Paula Scholte

Congratulations to Paula Scholte, CHT, a recipient of the 2008 Wesley Watkins Scholarship Award

“Managing the Difficult Dialysis Patient”

Managing the difficult dialysis patient can be a challenging situation not only for the health care professional, but also for the other patients that co-exist within the renal unit. An important skill for the renal technician to have is understanding and a general idea of to deal with difficult dialysis patients, whether being from a clinical or behavioural perspective. This essay will discuss managing the difficult dialysis patient from a behavioural perspective, knowing and implementing de-escalation techniques to help mange the difficult dialysis patient.

The process of adjusting to an illness can be quite daunting and the feeling of uncertainty would be one of the emotions a renal patient would face on a day to day basis, the patient can experience a range of emotions before accepting and challenging the changes to their health and lifestyle.(1)

I commenced as a haemodialysis technician, 2002. Having the understanding and knowledge of renal disease and being aware of the ramifications and the psychosocial issues that can derive from kidney failure, knowing this has been an advantage to myself and the patients I care for when dealing with a difficult dialysis patient.

Patients once diagnosed require a lot of emotional support to assist to the lifestyle changes that need to occur and adjusting to haemodialysis. Adjustment includes diet variations and restrictions, medication adherence, fluid restrictions and most importantly a positive attitude.

The term “difficult dialysis patient” can be categorised as many different aspects such as non-compliance to treatment in a clinical perspective, or as a behavioural perspective. From a professionals point of view aggression can be perceived as violence and harm to others and recognised as a difficult behaviour.(2) Whereas from a renal patients perspective it is their way of expressing their emotions in the trauma they are experiencing. Anger often follows denial and once acceptance of the chronic illness occurs it is easier for a patient to adapt to changes that need to occur within their life, hence a smoother dialysis session and a co-operative patient. Patients that require renal replacement therapy may develop difficult behaviours due to stressors that are caused by illness.(3)

Managing difficult behaviour in patients must be approached with sensitivity and individuality. As discussed earlier, patients may display difficult behaviour due to the changes taking place in their lives, dialysis patients have a tendency to attend dialysis with frustration, and un-cooperative behaviour due to their chronic illness.(4) The healthcare professional requires the knowledge and the skill to deal with frustrated patients, without this skill, the slightest trigger can exacerbate the frustration even more. To alleviate and help the difficult patient through their frustration, strategies such as listening, treating the patients as individuals and not just a number in the dialysis group, making them feel secure with on going education, as well as taking an interest in them as a person. If the patient recognises that staff possesses these skills and education, this may help alleviate some of their fears and possible root causes of their inappropriate behaviour. Managing techniques such as being firm and polite, when compromising with a difficult patient ensure to stay with in your limits, and ensure safety for yourself and the patient and other patients within the renal unit. Reassurance and explaining with a calm approach and encouragement can be an advantage. The health care team can provide support in terms of specialised help from outside sources such as social workers, psychologists and assistance from pastoral care services. Identifying and recognising triggers of difficult behaviour, implementing and knowing de-escalation techniques can be an advantage to the multidisciplinary team to manage and improve patient care. Harmony and understanding are the perfect benchmark!!!!


  • (1) Terrill, B. 2002, Renal Nursing — A Practical Approach, Australian Health Education Systems PTY LTD, Australia
  • (2) Daugirdas, J. Blake, P. & Ing, T. 2007, Handbook of Dialysis, 4th ed. Lippincott, USA
  • (3) Thomas, N. 1997. Renal Nursing, 2nd ed. Baillier Tindall, Elsevier
  • (4) Daugirdas, J. Blake, P. & Ing, T. 2007, Handbook of Dialysis, 4th ed. Lippincott, USA

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