The 'difficult' nurse-patient relationship: Development and evaluation of an e-learning package

Nurses in most clinical settings experience difficult 'nurse patient relationships' at various times. Attempts to describe and articulate how to manage such difficult relationships can be found, but often lay blame at the patient level and ultimately leave the nurse less confident to improve patient care. This study uses an action research approach in working with nurses in a generalist setting in developing an educational strategy that helped to improve their knowledge, skills and confidence in working within the 'difficult nurse patient relationship' paradigm. Through the experiential style learning methodology of scenario based learning and applying this via e-learning, an effective educational approach has been developed. Using a quasi-experimental design to evaluate the e-learning package, significant increases in knowledge, skill, confidence and reduced nurse stress as measured on the 'difficult patient stress scale' were shown. This approach allows nurses to reflect on their own behaviour and improve their ability to enhance patient care in difficult to manage nursing care situations. Keywords: nursing; nurse patient relationship; difficult patients; mental health liaison.

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Publication: Contemporary Nurse : a Journal for the Australian Nursing Profession
Author: Brunero, Scott; Lamont, Scott
Date published: June 1, 2010


Nurses frequently use the term 'difficult' to describe a range of behaviours that patients demonstrate. Primarily these behaviours are associated with some level of refusal and non adherence to nursing care. Often referred to as the 'difficult patient', it is a generally a term that encompasses a negative attitude solely toward the patient and even stigmatising the patient. Macdonald (2003) reports that nurses' inappropriately label patients which can lead to a global view of the patient which can compromise care. Given the very negative and one sided use of the term 'difficult patient' and its disproportionate sense of blaming the patient the term 'difficult nurse patient relationship' is used in this paper as to locate the behaviours displayed by both patient and nurse within a well defined area of the nursing literature (Laskowski, 2001; Macdonald, 2007; Stein-Parbury, 2005).

The term, 'difficult patient' is used primarily within the literature to describe patients who display a range of difficult to manage behaviours. Typical behaviours reported include; self harm, aggressive, demanding, attention seeking, dependent, splitting, deceptive, manipulative and disinhibited behaviours (Sharrock & Happell, 2001; Steinmiller, 1999). The literature contains in-depth reports of patient behaviour within the nurse-patient relationship but is scant on discussing how the nurse behaves when responding to these behaviours. In some of the earliest work on the topic, Groves (1978) suggested that these types of behaviours in patients develop a sense of helplessness in the helper, a tendency toward unconscious punishment of the patient, confrontation with the patient and the patient being excluded from care. Stein-Parbury (2005) argues that a nurses' own thoughts, feelings and attitudes can affect how they approach a nurse patient relationship. Typically nurses may parallel some of the behaviours of the patient, demanding more from the patient, approaching in an apprehensive or aggressive manner. Nurses may also retreat and start to avoid the patient in the hope of the patients behaviour decreasing; unwittingly the patient then increases their behaviour to gain the nurses attention. Gallop, Lancee, & Shugar (1993) argue that nursing staff report violence, self harm and treatment refusal as being associated with an inability to form a treatment alliance with the patient. Groves (1978) attempts to describe this group of patients as the 'hateful patient', not patients where there is a simple personality clash but for patients for whom clinicians dread to be involved in a therapeutic relationship with. Groves (1978) categorises these patients as 'dependent clingers, entitled demanders, manipulative help rejecters and self destructive deniers' but goes onto discuss how the emotions evoked in the clinician are directly relate to the behaviours of the patient. Whilst many of us behave within social norms whilst physically ill, some people may engage in behaviour that is not accepted as being socially desirable or behaviour that is not seen as acceptable by nursing and other health staff (Lamont & Brunero, 2009).

Difficult behaviours are often associated with distressed or frequent users of health services, who often have mental health problems (Brunero, Fairbrother, Lee, & Davies, 2007). Hahn et al. (1996) in a prevalence study of this patient group found mental illness to be twice as likely in patients identified as difficult. Patients who have a history of mood disorders may often present with insomnia, back pain, headaches and fatigue in a search for explanations for their low mood. Patients with anxiety disorders may present with multiple physical symptoms with a focus on cardiac symptoms. Patients with alcoholism and borderline personality disorder may also present with somatic complaints (Haas, Leiser, Magill, & Sanyer, 2005; Schafer & Nowlis, 1998). Certain disordered personality traits can cause problems within the nurse-patient relationship. People with personality disorders may be excessively dependent, demanding, manipulative or non compliant with nursing care (Haas et al., 2005; Macdonald, 2007). Patient groups can also include those with chronic pain, complex care needs, substance abuse, chronic fatigue syndrome, obsessive- compulsive disorder, or addiction to anxiolytics and analgesics drugs (Robinson-Wolf & Ronbinson-Smith, 2007).

The literature on interventions is less concise with a range of nursing management strategies proposed. Chitty and Maynard (1986) discuss a model to understand the meaning of manipulation in nursing care, through a process of self awareness, Chitty and Maynard (1986) base nursing interventions on a model of understanding issues such as; trust, security autonomy and control. Carol et al. (1997) in an exploratory descriptive study using focus groups (n = 53) of nurses, review nursing interventions for difficult to manage behaviours. The identifying themes of nursing practice included; getting the difficult patient label, difficult patient behaviours, reflecting on the label and passing it on, coping with a difficult patient, interventions that worked and interventions that did not work. Trimpey and Davidson (1998) and Nield-Anderson et al. (1999) suggest interventions such as; limit setting, understanding impulsivity, assertiveness, empathy, de-escalation techniques, maintaining consistency, avoiding power struggles and setting clear boundaries as effective nursing interventions. Hay and Passik (2000) suggest a symptom focused model of managing people with personality disorders in medical settings, which include aggression management strategies, staff education and staff support. Limit setting of behaviours is also reported by Sharrock and Rickard (2002) to be effective. Within a generalist rehabilitation setting, Sharrock and Rickard (2002) developed guidelines which draw on the concepts of limit setting difficult behaviour within a humanistic framework. Huffman, Theodore, Harley, and Lundy (2003) in a case series study paper, argue for the use of dialectic behaviour therapy. There is clearly a development need for nurses to work in nurse patient relationships that pose some degree of interpersonal difficulties. Models on how to build the capacity of nurses working in generalist settings in developing their knowledge, skills and confidence in managing difficult nurse patient relationships need to be further understood.


The aim of this project was to develop an educational approach that engaged nurses in an experiential learning experience about difficult nurse patient relationships, and strategies for managing these.


An action research approach underpinned the development of the project. Action research is a methodology where participants work collaboratively with a researcher to determine and enact solutions to research questions which confront them (Coghlan & Casey, 2001; Greenwood & Levin, 2005; Morton-Cooper, 2000). Hall (2006) suggests that action research responds to the values and problems of key stakeholders which are likely to form the change required. Action research involves an iteration of cycles of assessment, planning, acting, observing, reflecting. During this study a number of iterations occurred and so are expressed within distinctive phases within this paper.

Phase one established the extent of the problem and the learning need through the authors clinical work and clinical discussions with nursing staff using a focus group approach. Nolan and Grant (1993) suggest six key requirements are needed for action research to be successful; shared and explicit set of values acting as a guide for practice, recognition of the problems existence, common understanding of the problem, perceived need for change, a situation in which is seen to be amenable to change, focus on involvement and team building. These points were used as a guide in phase one to establish the extent of the problem and the learning need. Focus groups were chosen as a method of enabling participant empowerment to reflect, critique and develop knowledge in a safe questioning environment (Chin & Hamer, 2006; Hummelvoll & Severinsson, 2001). The facilitators asked participants to capture key ideas or words as opposed to sentences as a qualitative hermeneutic analysis approach would be undertaken to capture themes. This process of reflection and discussion is reported in the literature as collaborative enquiry (Chin & Hamer, 2006).

The second phase determined an educational methodology (case scenario based learning) and how the methodology would be delivered (e-learning). The third phase describes the dissemination and early evaluation of the educational tool, using a post test evaluation method. Ethics approval for the project was granted by the local human research ethics committee.


The authors identified an increase number of referrals to assist staff in the management of the 'difficult patient', with a number of particular clinical cases that lead to critical incidents. The general approaches and conceptualisations of nursing care planning to this group of patients were known to the authors. The ability to educate and build capacity and confidence in staff that did not have the skill in the nursing of this patient group was lacking. Within the mental health liaison nursing role, the authors were able to provide an in-service style of education to a limited number of nurses on the topic, but this 'in servicing' was not able to meet the demand and needs of all nursing staff at the study site.

Adapted form Noland and Grant's (1993) key points of action learning, a series of questions were put to a focus group (n = 8) of senior nurse educators, nurse managers registered nurses and nurse consultants, which lasted one and half hours The group were firstly asked: (1) To explore their beliefs and values of the patient group?; (2) Discuss the existence of the problem and any commonality in their understanding of the problem?; (3) Is there a demand for capacity building or preparing nurses to tackle the problem better and would they be willing?; and (4) How involved would nurses be prepared to be in the development of a strategy?

This process identified over 50 suggested action items which were synthesised, removing duplications, into 15 suggested action items and categorised under the following themes; blaming the patient, observing ones own emotional and behavioural response, develop interpersonal skills through experiential style learning and educational access to a majority of nurses. The key themes that the senior nurses expressed were patient focused, that is they were reporting the struggle with patients who displayed, demandingness, aggression, manipulation, non adherence with nursing advice and other similar behaviours. A common belief was one of 'blaming' the patient as the person who needed to change and that their inability to adapt to hospital life was the reason for their behaviour. A one sided view of the relationship between nurse and patient emerged, whilst the literature of the topic would suggest that both parties need to reflect and change (Sharrock & Rickard, 2002). The first element to creating a situation that was amenable to change was to engage nursing staff in a process of self reflection, or an ability to observe ones own emotional and behavioural responses. In this context this needs to be done in a nursing relationship that is characterised by individuals who display manipulative, demanding and aggressive type behaviours. The extent of the problem was discussed and staff reported that these behaviours came from a wide range of clinical specialties and clinical diagnostic groups (medical, surgical, orthopaedics, renal, emergency). The group reported that the use of role play and experiential type learning principles were required, as this is where the 'interpersonal skills' needed to interact with 'difficult patients' could be learnt. Whilst the 'in servicing' was seen as needed, the group reported that it was unable to access a great deal of the staff and what was needed was a way of extending both the clinical consultancy and educational work that was being undertaken by the mental health liaison nurse consultant. A way of achieving this was by the use of e-learning as a delivery method for education. With the findings from the focus group and a review of the literature the authors moved toward the development of an educational e-learning package, which was experiential in its learning methodology, and had wide range of accessibility to nursing staff.


Scenario based learning and e-learning

An expert in educational interactive multimedia was consulted, suggesting the use of 'scenario based learning' as the educational methodology, which is an experiential style learning method as suggested by the focus group. The benefits of e-learning methods are in its availability (24 h 7 d a week), number of people it can reach, novelty, perceived as innovative, useful when access to 'experts' is limited e.g. rural and remote areas, reusable, standardised, reduces traditional boundaries in learning, location, cost and can transgress economic and political boundaries (William, 1999). Some of the disadvantages are said to be its prescriptive nature, knowledge centred, post negotiation with the learner, a top-down learning and a submissive role of learner, although the disadvantages are challenged given the shift toward the use of scenario based learning as mentioned within the literature (Morales-Mann & Kaitell, 2001, Muirhead, 2007; William, 1999). By choosing scenario based learning and e-learning in combination the project would then go onto satisfy the themes generated by the earlier focus groups in phase 1.

Scenario based learning is a methodology which promotes deep learning and awareness by involving clinicians in realistic critical incidents. In these incidents clinicians are forced to consider a range of factors, make decisions and reflect on the potential outcomes of their choices. Scenariobased learning is similar to the experiential model of learning. Experiential learning models argue that learning occurs because we immerse ourselves in a situation where we need to perform, make decisions obtain feedback and then change our behaviour as the critical incident requires. It forces clinicians to draw on their knowledge and skills in a 'real' situation and deal with contingency factors that can arise in such incidents. In an e-learning environment, scenario based learning requires a selection of responses to move through learning modules. Scenario based learning asks the learner to apply knowledge relevant to that situation by making choices and attempting to follow a desirable path that demonstrates their ability to achieve a successful outcome (Morales-Mann & Kaitell, 2001; Muirhead, 2007). Instead of right and wrong answers there are success and failure paths. The modules describe a brief clinical situation, pose decision problems, and a request from the learner to select a behaviour (answer) that represents the best course of action in that situation. The aim for the learner is to negotiate a successful path through the learning modules. A typical decision path may occur like: (1) Choose a success or fail option at the start; (2) If clinician chooses a success option then proceed to next level; (3) If 'moderate' fail option chosen then receive feedback and remediation and proceed to next level; (4) If a disaster fail option chosen then receive feedback with some consequence and return to start; (5) This pathway is repeated until the learner follows the desired path (Collier, 2000; Delpier, 2006; Kolb & Kolb, 2005; Ritchie, 2006). Using this approach the clinical case of Rosie O'Grady is presented to the user (see Figure 1). Entitled the 'difficult nurse patient relationship' the nurse explores the presentation of Rosie O'Grady (fictional name) to an oncology unit. Rosie presents with varying behaviours that are often perceived to be challenging to manage from a nurse without mental health nursing skills. The nurse is taken through a three part scenario (taking approximately 60 min) with the nurse needing to answer reflective styled questions after each part (see Figure 2). At the end of the e-learning tool, the nurse watches video excerpts of Rosie, a nurse expert and a Professor of nursing reflecting on her nursing care (see Figure 3). (Visit the following link to complete the e-learning tool; http://www.

The writing of the case scenario was lead by the clinical content expert with regular reviews by an educationalist and a software developer. The educationalist ensured that the writing was aligned with scenario based learning principles and the consultations with the software developer ensured that the writing was deliverable on the screen. The case used was based on a typical clinical case observed in our roles in mental health liaison nursing. Mental health liaison nurses have had a long association with the management of diffi- cult nursing relationships behaviours (Sharrock and Happell, 2001). To maximise the learning opportunity, the case was taken further to include a broader range of issues, so the learner could be exposed to several key issues of the topic. Over several discussion group sessions, a nurse educator, clinical nurse specialist and a registered nurse developed the storyline for the care of the patient. Once a draft version of the case was developed, the educationalist then conducted a further review with a group of nurse who were not involved in the writing of the case. This group of nurses were taken through the case, with particular emphasis on the 'reality' of the clinical scenario now being proposed. Feedback was taken into account and some changes were made to match particular styles of language with the target audience of the e-learning package. Once the overall scenario was developed a specific 'script' was written that outlined in detail each part of the package, the various roles (patient, nurse), images required, and voice-overs written. On completion of the detailed script, a filming location was sought at the hospital and actors were auditioned. Once all the film, still photography and audio data were collected, it then went into post-edit production where the software developer took over the on screen development of the scenario. A further review was conducted after the initial post-edit production by an independent group of nurses who worked through the package, where some of the ordering of the package was changed.


Access to e-learning is primarily done via CD format, intranet or Internet. In this project all three options were used. CD's were produced as a means of locating the package in libraries and used as a way of presenting the learning package to other groups. In some of the clinical areas access to the intranet and Internet was restricted, so they used the CD for access. Both intranet access (through the hospital network) and internet access (MHCLNA, 2009) were made available.

At the study site nurses were invited via email to participate in an evaluation study of the e-learning tool. Using a quasi-experimental design an opportunistic sample n = 23 registered nurses were asked to complete the 'Difficult Patient Stress Scale' (Santammaria, 1996) after finishing the e-learning package, and for comparison n = 23 registered nurses were asked to complete the same questionnaire without being exposed to the e-learning package. The DPSS (Santammaria, 1996) gives six clinical scenarios where nurses have to rate their level of frustration toward the case on a 10 point scale of 1 = no frustration to 10 = high frustration. The nurses were also asked to rate their level of skill, knowledge and confi- dence on a 10-point scale (1 very little to 10 high level). Nurses were also asked 'How helpful was the e-learning experience?' and invited to give a text response. Significant differences between the intervention group and the control were noted for all items on the questionnaire (see Table 1). Table 2 reports the answers to the question 'How helpful was the e-learning experience?'. The comments were positive overall, highlighting the reflective nature of the package and the examples of how you can change you practice.

There are several unaccounted for variables that may limit results; length of nursing experience, unknown previous training, limited availability of validated evaluation tools, attitudes or staff beliefs toward difficult to manage behaviours and a lack of a matched control sample. Large multisite studies with a range of nurses who have different specialties are required to further understand the potential of this learning package. The audience was captive, having been invited to attend the session in a computer laboratory. In reality most nurses would probably complete this on a busy ward when time is limited and the possibility of being distracted is also likely.


The results of this study add further argument for the place of e-learning approaches within nursing education. Increasing nurse's knowledge, skills and confidence in this challenging area of nursing will hopefully serve to produce better patient outcomes. The reduction in stress scores for the nurses involved in delivering care to these patients may also have wider benefits to nurses work satisfaction and reduced stress related leave. The development part of the project may act as a guide for other educators who are pursuing a process by which to create e-learning materials.

E-learning in nursing is gaining ground with several publications of its use in a variety of clinical nursing specialities; psychiatric nursing (Shikiraishi, Norikane, & Majima, 2006; Simpson, Reynolds, Light, & Attenborough, 2008), surgical nursing (Maatsuda et al., 2006), patient- nurse communication (Katsuyama & Majima, 2006), nurse prescribing (Betts & Burgess, 2006), diversity health (Schitai, 2007). E-learning using scenario based methods have been reported by William (2006) with undergraduate paramedic students and Merrill (2005) in adult education. Rutledge, Barham, Wiles, and Benjamin (2008) used scenario based learning with undergraduates students who with patients of a culturally and linguistically diverse background. E-learning using problem based learning approaches have been reported by Kim, Koh, and Sun (2006) in first year undergraduate nursing students, Wong et al. (2008) with third year undergraduate nursing students and Majima and So (2006) and Lin, Chien, and Chang (2006) across a range of nursing specialities. Innovations in educational approaches will need to grow to meet the educational needs of healthcare professionals. Key issues of accessibility to education, cost effectiveness and standardised contents can be addressed by e-learning as an educational delivery mode. The use of experiential style learning methods such as scenario based learning and problem based learning will further the application of e-learning to a range of healthcare disciplines and specialities.


Overall the results showed a positive improvement in levels of stress, confidence, skill and knowledge post the use of the e-learning package. The comments suggest that nurses would like to see it available as a resource for the nursing teams. This project has developed the need to further explore how e-learning methodology can be used in educating nursing staff. The use of an e-learning approach with general nurses in understanding and managing difficult nurse patient relationships was positive, larger studies are required to confirm these findings.


Julie Smith, Peter Kandlbinder and Don Francis.


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Received 2 March 2009 Accepted 15 April 2010

Author affiliation:


Clinical Nurse Consultant, Mental Health Liaison Nursing, Prince of Wales Hospital, Sydney, NSW, Australia


Clinical Nurse Consultant, Mental Health Liaison Nursing, Prince of Wales Hospital, Sydney, NSW, Australia

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