P39
MANAGING CHALLENGING PATIENTS ON THE DIALYSIS UNIT
Andre, T, Miller, C
Department of Nephrology and Transplantation, Guy’s and St Thomas’ NHS Foundation
Trust
PROBLEM: Over the last ten years incidences of verbal and physical aggression by patients towards
NHS staff has increased. This presents a particular problem in dialysis units where patients are regular
attendees receiving life sustaining treatment. Managing these behaviours is vital to ensure that
treatment is delivered safely and effectively. These behaviours can also result in increased stress
amongst staff and anxiety in other patients. The use of security staff is now common place in UK
dialysis units which is costly to the health economy and generally undesirable in a clinical setting.
AIMS: The overall aim was to introduce a psychological approach to managing challenging patient
behaviours and to eliminate the need for regular security staff attendance in the dialysis unit. This
would be achieved by:
1. involvement of doctors, nurses, psychologists, social workers and security staff, in implementing
a new approach
2. support and training for nurses in the practical aspects of managing challenging behaviours on a
daily basis
3. patient involvement in the new approach and resulting treatment plan
DESIGN: Following consultation with the team a new approach to managing challenging behaviours
was agreed. Central to this new approach was the development of a series of workshops for dialysis
nurses focussing on:
 anger management
 managing anxiety
 communication strategies
 confidence building
A voluntary peer support group for the nurses was also offered. The workshops and support group
were facilitated by the renal clinical psychologist. In depth discussions by the psychologist with a
particularly challenging patient revealed his desire to change his management plan with regard to
security staff attendance. A care plan was negotiated to support the gradual reduction and eventual
removal of security staff in the dialysis unit.
FINDINGS: 100% (37) of the nurses in the dialysis unit attended the workshops, of these 79%
reported increased levels of confidence and competence in managing challenging behaviours.
Feedback included the importance of peer support; the usefulness of open discussion regarding
strategies and solutions; the importance of caring for one self in managing personal stress; the impact
on learning through role play. Following these workshops and in negotiation with the clinical team
and patients, the Head of Security withdrew her staff from the dialysis unit.
CONCLUSIONS: A whole team approach, including input from security staff, can be effective in
managing challenging behaviours proactively. Nurses need to feel supported by management and
empowered by attending skill development workshops. Nurses gain further skill development through
peer support. Communication regarding challenging patients can be improved throughout the team by
mutual agreement on common goals and involvement from challenging patients in treatment plans.
RELEVANCE: In recent years managing challenging patients on the dialysis unit has focussed on
behaviour contracts and implementation of various degrees of security measures. While this may have
a place in certain situations there are other solutions to this issue. Using a psychological approach,
staff can be empowered to manage challenging patients holistically with the support and input of the
whole team. Involving patients in the behavioural aspects of their treatment plans is vital.