1. Hench, Christine MSW

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Home care providers with any length of experience will have encountered patients who are uncooperative, hostile, or even combative. There are many reasons for such behavior, but they are all symptoms of feeling unsafe and devalued. For the purposes of this commentary, unsafe is a feeling that something bad, physically or emotionally, will happen. Feeling devalued means seeing oneself as being unlovable and unimportant.


A few of the many reasons patients may feel unsafe and devalued are:


* Pain and other symptoms of illness,


* Fear of the unknown/fear of death,


* Mental illness,


* A history of being emotionally or physically abused or neglected,


* Disability (e.g., a person with autism may perceive her environment as unpredictable and frightening; a person with an intellectual disability may not understand what you are doing or saying),


* A chaotic home life/unpredictability,


* Loss of control over one's life,


* High turnover of healthcare providers, and


* A history of uncaring healthcare providers



Home care providers, of course, cannot make these problems disappear. They can, however, create a positive relationship in which the patient feels safe and valued during their visit. To do this, use the following tools: eyes, words, presence, and touch.


Your eyes must be warm. Always. Even if you have just been cursed, or worse. If your eyes convey fear, disgust, or harshness, there is no hope for the relationship.


Your words must be uplifting. Always. Even if the patient is hostile, you must find something positive to say. Try "I've been looking forward to seeing you all week." Your words cannot be demanding, demeaning, or authoritarian.


Presence has two meanings. It means being together for no other purpose than enjoying each other's company. One way to do this is to talk about something you know the person cares about (a pet, sports, etc.) for several minutes before you start your examination.


Another meaning of presence is body language. Do not fold your arms across your chest or stand over the patient. Open your arms. Sit in a chair or on the edge of the bed. Convey openness, not authority.

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The last tool, touch, if properly used, is the most powerful of the four. This is especially true for chronically sick people who are rarely touched. The hands are usually safe and a good place to start. Lightly rub or massage the hands each time you meet the patient. The power of touch is unparalleled in its ability to connect two people. Keep in mind; if the patient is a survivor of sexual assault, and you are the same gender of the perpetrator, it would likely be unwise to use touch. Any touch that may be interpreted as sexual must not be used. Consider the age, gender, and sexual preference of the patient before deciding whether or not to use touch; if you find you are not able to use touch in order to connect, you will have to make strong use of your other tools.


Here are some other tips that will help your patient feel safe and valued.


Minimize demands and maximize praise. Make requests. Instead of saying "turn over," try "I'd like to take a look at your rash. Could you turn over for me?" Instead of "goodbye," say "It has been great to see you today! I can't wait until I come back next week." For a person who feels devalued, there is no such thing as too much praise. If a patient is being uncooperative or aggressive, make no mention of it. Focus on the positive.


Just as we feel unsettled without our smart phones, your patients have the same need to know their schedule. Try to make your appointments on the same day of each week. Write the date of your next visit on the patient's calendar. If the patient cannot read, put a symbol such as a red cross on the calendar.


Change can make people feel unsafe, especially if they have no choice in the matter. Altering the frequency of your visits or having another healthcare provider take over for you are things that may cause your patient to feel unsafe or devalued. Telling the patient you have been seeing twice a week that you will not be seeing them the next week takes thought and compassion. Possible ways to help are to let the patient know ahead of time, tell the patient something appealing about the new provider ("He loves football, too!"), and let the new care provider know the patient's likes and dislikes.


Using these tools, you may see a positive change in patients. People with backgrounds of chaos, abuse, neglect, and substance abuse will respond more slowly. Even when the patient does not respond in the way you had hoped, you will still have helped the patient experience feeling safe and valued during your time together.