Treading on an Eggshell: Nurses’ Experiences with Difficult Patients and Families in Acute Care Settings

Treading on an Eggshell: Nurses’ Experiences with Difficult Patients and Families in Acute Care Settings

Abdulrahman Ahmed.RN., Msc. N., MPH.,¹ . Fatima Abacha Ali.RN. MPH². Cordelia.A. Dingari. RN., RM.³ Hadiza Umar. RN., RM.⁴. Mairo Bukar Ngohi. RN., RNT., Msc.N⁵. Dr. Hadiza Yahaya. RN., Ph. D⁶. Dr. Robert Keever. RN. Ph. D⁷. Dr. Abba Jidda. RN., Ph. D⁸

¹Department of Public Health, Ahmadu Bello University Zaria Kaduna Nigeria

²Department of Public Health, National Open University of Nigeria

³Department of Nursing Science, National Open University of Nigeria

⁴Maryam Abacha American University of Niger, Maradi, Niger Republic

⁵Department of Nursing, College of Nursing, University Teaching Hospital Maiduguri

⁶Provost College of Nursing, Maiduguri Borno State, Nigeria

⁷Associate Professor, Department of Nursing Science, University of Maiduguri

⁸Registrar, College of Nursing Maiduguri, Borno State, Nigeria

DOI: https://doi.org/10.51244/IJRSI.2025.120500121

Received: 03 May 2025; Accepted: 13 May 2025; Published: 14 June 2025

ABSTRACT

Nurses in acute care settings frequently encounter difficult patients and families, a phenomenon that imposes emotional, communicative, and systemic challenges. These interactions are particularly complex in resource-constrained and culturally diverse environments like Nigeria. This study explored the lived experiences of nurses managing difficult patients and family members in acute care settings, aiming to understand the emotional, institutional, and interpersonal factors involved. Using a phenomenological qualitative approach, in-depth interviews were conducted with a purposive sample of acute care nurses. Thematic analysis was used to extract and interpret emerging patterns from the data. Five major themes emerged: (1) emotional labor and psychological strain, (2) communication barriers and cultural conflict, (3) institutional constraints and lack of support, (4) adaptive coping strategies, and (5) effects on professional identity and job satisfaction. Nurses reported feelings of burnout, emotional suppression, and frustration, often without institutional mechanisms for support. Nevertheless, they demonstrated resilience through various self-taught coping strategies and peer support. The findings reveal that dealing with difficult patients and families is not merely a matter of interpersonal skill, but a systemic issue embedded in broader cultural and organizational dynamics. Addressing these challenges requires integrated interventions involving emotional intelligence training, institutional policy reform, cultural competence education, and mental health support systems. Empowering nurses in this context will enhance professional satisfaction, reduce burnout, and improve patient care outcomes.

Key Words: Nurses’ experiences, Difficult patients, Acute care settings, Nurse-patient relationship, Workplace stress.

INTRODUCTION

In the complex landscape of modern healthcare, acute care often represents the frontlines of medical and emotional turmoil. These environments are typified by high acuity, rapid decision-making, and intense interactions among patients, families, and healthcare professionals (Drach-Zahavy et al., 2020). Among these frontline providers, nurses play a pivotal role, not only in delivering direct clinical care but also in managing the interpersonal dynamics that arise with patients and their families. While their responsibilities are multifaceted, one of the least addressed yet profoundly impactful challenges they face is dealing with difficult patients and families—a term that encompasses a range of behaviors, from non-cooperation and verbal aggression to manipulative or demanding conduct (Pavlish et al., 2015).

The phenomenon of difficult encounters in acute care is neither isolated nor rare. Studies indicate that a significant proportion of nurses frequently encounter patients or families who exhibit challenging behaviors, especially in high-stress areas such as emergency departments, intensive care units (ICUs), and surgical wards (de Boer et al., 2017; Alquwez, 2020). These behaviors often stem from emotional distress, anxiety, or uncertainty patients and families experience due to the severity of illness or the fast-paced, unfamiliar hospital environment. While such responses are human and understandable, they can significantly impede effective communication, trust-building, and ultimately the delivery of quality care (Schmid Mast et al., 2015).

Nurses, by the nature of their continuous presence and direct interaction with patients, are disproportionately affected by these encounters. They often find themselves “treading on eggshells”a metaphor reflecting the emotional tightrope walked in trying to provide care while avoiding conflict, emotional escalation, or professional burnout. According to Jackson et al. (2016), managing difficult patients and families requires emotional labor, advanced communication skills, and a deep sense of empathy. However, without institutional support, training, or sufficient debriefing mechanisms, these recurrent interactions can lead to moral distress, compassion fatigue, and a decreased sense of professional accomplishment among nurses (Kim & Choi, 2016).

Moreover, the challenge of dealing with difficult individuals is amplified in acute care due to several structural and contextual factors. These include understaffing, time constraints, high patient turnover, and the increasing complexity of care (Vogus et al., 2020). When these stressors intersect with demanding or hostile behavior from patients or their families, nurses may experience emotional exhaustion and a diminished capacity to deliver empathetic care. In some cases, patient aggression can even result in workplace violence—a growing concern in healthcare settings globally (Spector et al., 2014).

The dynamics between nurses and families are particularly delicate when patients are critically ill, unconscious, or at the end of life. Family members may assert control or express frustration due to feelings of helplessness or disagreement with medical decisions. In such emotionally charged situations, nurses must balance their professional obligations with compassionate diplomacy—an expectation that often goes unsupported or unacknowledged in clinical environments (O’Connell et al., 2013). These situations demand more than clinical competence; they require emotional intelligence, cultural sensitivity, and psychological resilience.

Despite the prevalence and intensity of such experiences, there is a notable paucity of research that centers on nurses’ perspectives in navigating these complex interpersonal landscapes. While literature exists on conflict resolution in healthcare, it tends to prioritize organizational strategies or patient satisfaction metrics, often neglecting the lived experiences and emotional labor of nurses (Tuckett et al., 2015). Understanding nurses’ subjective experiences and coping mechanisms when dealing with difficult patients and families is vital, not only for improving patient-caregiver relationships but also for informing policy, training, and workplace support systems.

In light of these concerns, this study seeks to explore the lived experiences of nurses working in acute care settings as they interact with difficult patients and families. By giving voice to their challenges, strategies, and coping mechanisms, the research aims to uncover patterns that can guide the development of supportive interventions. The metaphor “treading on an eggshell” serves not only as a thematic anchor but also as an acknowledgment of the emotional and professional precarity that nurses navigate daily in these high-stakes environments.

This exploration is particularly timely given the increasing recognition of healthcare worker well-being as a core component of healthcare quality and safety (National Academies of Sciences, Engineering, and Medicine, 2019). As healthcare systems strive toward patient-centered care, equal emphasis must be placed on creating nurse-centered workplaces—where emotional burdens are acknowledged, skills are nurtured, and resilience is institutionally supported. By investigating the nuanced experiences of nurses, this study contributes to a more holistic understanding of the acute care environment and supports a shift toward more empathetic and sustainable nursing practice.

LITERATURE REVIEW

The phenomenon of dealing with difficult patients and families in acute care settings has increasingly gained attention within nursing scholarships due to its implications on care delivery, nurse well-being, and patient outcomes. Acute care environments are characterized by high acuity, emotional intensity, and rapid decision-making, which can exacerbate tension between patients, families, and nurses (Alameddine et al., 2015). The presence of patients and families who exhibit aggressive, noncompliant, or demanding behavior adds a layer of complexity that can challenge the therapeutic nurse-patient relationship and hinder effective care.

Conceptualizing ‘Difficult’ Behavior.

The definition of what constitutes a “difficult” patient or family member varies across contexts. According to Jackson and Hutchinson (2017), difficult behaviors include verbal abuse, unrealistic expectations, refusal of care, frequent complaints, and emotional volatility. In some cases, patients or families may act out due to underlying psychosocial distress, unmet needs, or a lack of understanding of medical processes. Nurses must, therefore, exercise empathy while setting clear boundaries to preserve their professional integrity and maintain care standards.

Psychological and Emotional Impact on Nurses.

Numerous studies have highlighted the emotional toll that interactions with difficult individuals have on nursing staff. Nurses often experience moral distress, emotional fatigue, and burnout, which in turn affects their job satisfaction and quality of care (Laschinger & Fida, 2014). Prolonged exposure to challenging interpersonal dynamics without adequate support can result in absenteeism, decreased productivity, and attrition from the profession.

Communication and Conflict Resolution Strategies.

Effective communication remains the cornerstone of conflict resolution in healthcare. Research emphasizes the use of therapeutic communication, de-escalation techniques, and empathetic listening to mitigate difficult interactions (O’Connell et al., 2013). Training in conflict management and interpersonal skills has been shown to increase nurses’ confidence and competence in handling complex situations.

Support Mechanisms and Organizational Culture.

A supportive organizational culture plays a pivotal role in empowering nurses to manage difficult encounters. Institutions that promote teamwork, offer counseling services, and implement zero-tolerance policies against abuse create safer environments for both staff and patients (Edward et al., 2016). The presence of a strong leadership structure also enables timely intervention and reinforces professional standards.

Cultural Sensitivity and Patient-Centered Care.

In multicultural settings, misunderstandings can arise due to differences in cultural norms and expectations. Nurses must demonstrate cultural competence to navigate these complexities effectively (Campinha-Bacote, 2011). Patient-centered care, which involves active participation of patients and families in care decisions, has been associated with reduced conflict and greater satisfaction.

Ethical Considerations.

 Ethical dilemmas often emerge when balancing patient autonomy with safety and care quality. Nurses may struggle with decisions regarding treatment refusals, confidentiality breaches, or involuntary restraint of aggressive individuals (Ulrich et al., 2010). Ethical frameworks and institutional ethics committees serve as essential tools in navigating such situations.

Gaps in Literature.

While existing research has extensively documented the prevalence and impact of difficult interactions in acute care, there is a paucity of qualitative data capturing nurses’ lived experiences, particularly in low-resource settings like Nigeria. This underscores the need for context-specific studies that examine how cultural, institutional, and systemic factors influence nurse-patient-family dynamics.

This literature review demonstrates the multifaceted nature of dealing with difficult patients and families in acute care. Addressing this issue requires a combination of individual skill development, institutional support, and policy-level interventions. Understanding the personal and professional challenges nurses face is critical in developing responsive strategies that foster resilience, empathy, and quality care.

METHODOLOGY

To explore nurses’ lived experiences with difficult patients and their families in acute care settings, this study adopts a qualitative research design grounded in phenomenology. Phenomenology is particularly suitable for studies focused on the personal experiences and perceptions of individuals within specific contexts (Polit & Beck, 2021). Given that the focus of the research is to understand how nurses perceive and respond to these challenges in their natural work environments, a qualitative phenomenological approach is justified.

Research Design.

The research design for this study is descriptive phenomenology, which seeks to uncover and describe the essence of lived experiences (Creswell & Poth, 2018). This approach allows for an in-depth understanding of the psychological and emotional realities that nurses encounter in their day-to-day interactions with patients and their families in high-pressure, acute care settings. It facilitates an empathetic inquiry into not just what nurses do, but how they feel and interpret their encounters.

Setting and Participants.

The study will be conducted in acute care units of three tertiary hospitals located in Northeast Nigeria. Purposeful sampling will be used to select 12–15 registered nurses with at least two years of experience in acute care settings, such as emergency departments, intensive care units, and surgical wards. Participants must have had direct experience managing difficult patient and family interactions in the last six months.

Data Collection Methods.

Data will be collected using semi-structured, in-depth interviews. This method allows participants to narrate their experiences freely while enabling the researcher to probe for deeper understanding (Braun & Clarke, 2021). Each interview is expected to last between 45 and 60 minutes and will be audio-recorded with participants’ consent. Field notes will also be taken to capture non-verbal cues and environmental contexts that may enrich the data.

Data Analysis.

Thematic analysis will be used to analyze the data, guided by Braun and Clarke’s (2006) six-step approach. This includes familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the final report. NVivo software will be used to assist in organizing and coding the interview data.

Ethical Considerations

Ethical approval will be obtained from the Institutional Review Board (IRB) of the selected hospitals. Informed consent will be sought from each participant, who will also be assured of the confidentiality of their responses and their right to withdraw at any stage of the research. Anonymity will be maintained by assigning pseudonyms to all participants.

Reliability & Validity

To ensure the credibility and trustworthiness of the findings, the study will adhere to Lincoln and Guba’s (1985) criteria: credibility, transferability, dependability, and confirmability. Member checking will be conducted by sharing summarized findings with participants to verify accuracy. An audit trail will be maintained to document the research process and decision-making.

Limitations

As a qualitative study, the findings will not be generalizable to all acute care settings or nursing populations. However, the rich, contextual insights gained from nurses’ experiences will provide valuable understanding that can inform practice, policy, and future research.

FINDINGS

Thematic analysis of the interview transcripts yielded five major themes that encapsulate nurses’ experiences with difficult patients and families in acute care settings. These themes include: (1) Emotional Labor and Psychological Strain, (2) Navigating Communication Barriers, (3) Institutional Constraints and Support Gaps, (4) Adaptive Coping Strategies, and (5) Impact on Professional Identity and Job Satisfaction.

1. Emotional Labor and Psychological Strain Participants consistently reported high levels of emotional stress when interacting with patients or families who were aggressive, demanding, or non-compliant. Nurses expressed feelings of frustration, anxiety, and emotional exhaustion, particularly when faced with repeated verbal abuse or uncooperative behavior. One participant shared, “Every time I walk into that room, I brace myself. It’s like walking on eggshells. You never know what kind of reaction you’ll get.”
2. Navigating Communication Barriers A recurring theme in the narratives was the challenge of effective communication. Cultural differences, language barriers, and health illiteracy were cited as key obstacles. Nurses emphasized the need to simplify medical jargon and adopt culturally sensitive communication techniques to foster better understanding and trust. Despite efforts, misinterpretations often led to tension and conflict.
3. Institutional Constraints and Support Gaps Many nurses pointed out that limited institutional support—such as lack of de-escalation training, insufficient security presence, and inadequate mental health resources—exacerbated the difficulty of managing these interactions. Several participants also cited high patient-to-nurse ratios and time constraints as significant impediments to providing compassionate care under challenging circumstances.
4. Adaptive Coping Strategies Despite the challenges, nurses employed a range of coping mechanisms to navigate difficult encounters. These included peer support, reflective journaling, humor, mindfulness techniques, and, in some cases, emotional detachment. Nurses who had undergone training in conflict resolution or stress management reported better coping outcomes.
5. Impact on Professional Identity and Job Satisfaction The experiences of dealing with difficult patients and families had a dual impact on nurses’ sense of professional identity. While some reported a sense of accomplishment in managing tough situations with resilience, others expressed diminished job satisfaction and questioned their long-term commitment to bedside nursing. The emotional toll of these interactions was often cumulative and deeply felt.

These findings provide a nuanced understanding of the multifaceted challenges faced by nurses in acute care settings and highlight areas for intervention to support their mental health and professional well-being.

DISCUSSION

The findings of this study provide critical insights into the lived experiences of nurses dealing with difficult patients and families in acute care settings. These results underscore the complex interplay between individual, interpersonal, and systemic factors that shape these encounters. Drawing from the themes identified, this discussion situates the findings within existing literature and explores their implications for nursing practice, institutional policy, and future research.

Emotional Labor and Psychological Strain The emotional toll associated with nursing has long been acknowledged (Gray-Toft & Anderson, 1981; Mann & Cowburn, 2005). The findings corroborate this, revealing that difficult patient and family interactions often trigger feelings of frustration, helplessness, and burnout. Nurses must frequently manage their emotions to maintain professionalism, which is a form of emotional labor (Hochschild, 1983). The chronic stress resulting from repeated exposure to such emotionally charged situations can contribute to compassion fatigue and high turnover rates, aligning with previous studies (Joinson, 1992; Mealer et al., 2009).

Communication Barriers and Cultural Sensitivity Effective communication remains central to the nurse-patient relationship (McCabe, 2004). Participants highlighted language and cultural differences as common obstacles. These issues can foster mistrust, misunderstandings, and conflict, emphasizing the need for cultural competence training and the employment of interpreters where necessary. This is consistent with work by Campinha-Bacote (2002), who argues that culturally competent care improves patient outcomes and satisfaction.

Institutional Support and Systemic Constraints A significant portion of the distress reported by participants stemmed not only from the behavior of patients and families but from systemic inadequacies. High patient loads, insufficient staffing, and lack of institutional support were all highlighted. Previous literature supports the link between organizational structure and nurse well-being (Aiken et al., 2002; Laschinger et al., 2001). Institutions must consider creating safer, more supportive environments by investing in training, mental health resources, and adequate staffing ratios.

Coping Strategies and Resilience Despite these challenges, many nurses demonstrated resilience through adaptive coping strategies. Support from colleagues, mindfulness practices, and training in conflict resolution emerged as protective factors. This reflects existing evidence suggesting that personal coping mechanisms and supportive work environments mitigate the psychological effects of occupational stress (Grafton, Gillespie, & Henderson, 2010).

Professional Identity and Job Satisfaction The dual impact of these experiences on professional identity highlights a critical tension in acute care nursing. For some, difficult interactions reinforced their competence and sense of purpose. For others, the constant emotional strain led to questioning their future in the profession. These findings resonate with the literature on role conflict and job dissatisfaction (Maslach & Jackson, 1981; Hayes et al., 2012).

Implications for Practice and Policy The study suggests several implications. Firstly, emotional intelligence and de-escalation training should be integrated into nursing education and ongoing professional development. Secondly, institutions must prioritize staff well-being by providing access to counseling, peer support networks, and mental health resources. Thirdly, efforts must be made to foster a culture of safety and respect for nurses, ensuring they are empowered and protected in challenging situations.

Limitations The study’s findings, while insightful, are based on a limited sample size from specific acute care settings and may not be generalizable to all nursing contexts. Future research could include a broader participant pool and explore the long-term psychological effects of these experiences.

Overall, the study highlights the emotional and systemic complexities that nurses face when interacting with difficult patients and families in acute care. Addressing these challenges requires a multifaceted approach that includes individual resilience-building and systemic change. By acknowledging and acting upon these experiences, healthcare systems can better support the mental health and professional development of nurses, ultimately improving patient care outcomes.

RECOMMENDATIONS

• Nurses should undergo regular, mandatory training in advanced communication skills, conflict resolution, and de-escalation techniques to equip them with practical tools to manage difficult interactions effectively. Studies show that communication training reduces workplace aggression and enhances nurse-patient-family relationships (Leiter et al., 2010).
• Healthcare institutions must establish accessible and confidential psychological support systems (e.g., counseling, peer support groups) to address emotional exhaustion, compassion fatigue, and stress associated with caring for difficult patients and families (Mealer et al., 2012).
• Hospitals should formulate and enforce guidelines outlining acceptable behaviors for patients and families, including consequences for verbal or physical abuse. This empowers nurses to set professional boundaries while protecting their safety (Pompeii et al., 2016).
• Team-based care approaches should be promoted, wherein nurses, physicians, social workers, and psychologists collaboratively manage complex patient and family dynamics. This reduces the burden on individual nurses and improves care outcomes (O’Daniel & Rosenstein, 2008).
• Routine debriefing after critical incidents involving challenging patients or families encourages emotional processing and professional learning. Reflective practice has been linked with improved clinical judgment and resilience among nurses (Bulman & Schutz, 2013).
• Hospitals should ensure adequate nurse-patient ratios in acute care settings to reduce stress levels, improve patient monitoring, and allow time for individualized care. Lower ratios have been associated with better nurse satisfaction and patient outcomes (Aiken et al., 2012).
• In multicultural environments like Nigeria, nurses should receive training in cultural sensitivity to better understand patient and family expectations, reducing conflict rooted in cultural misunderstanding (Douglas et al., 2014).
• Nurses need to be educated and supported in applying ethical principles (autonomy, beneficence, non-maleficence, justice) when managing demanding interactions. Access to legal counsel or ethics committees can aid in complex cases (Johnstone, 2015).
• Engaging frontline nurses in hospital policy development fosters ownership, ensures that policies are realistic and applicable, and encourages adherence to protocols in managing difficult patient interactions (Shariff, 2014).
• Institutions should fund longitudinal and qualitative research to continuously assess the impact of difficult interactions on nursing practice, leading to evidence-informed interventions that evolve with emerging challenges (Polit & Beck, 2021).

CONCLUSION

This study sought to explore the lived experiences of nurses interacting with difficult patients and their families in acute care settings, using a phenomenological qualitative approach. The results offer an in-depth and multifaceted understanding of the emotional, interpersonal, and systemic dynamics nurses face in high-pressure environments. The five themes that emerged—Emotional Labor and Psychological Strain, Navigating Communication Barriers, Institutional Constraints and Support Gaps, Adaptive Coping Strategies, and Impact on Professional Identity and Job Satisfaction—collectively underscore the complexity and demands of modern acute care nursing in culturally diverse and resource-constrained settings.

At the core of these experiences is emotional labor—a concept introduced by Hochschild (1983), which remains profoundly relevant in nursing practice. Nurses frequently report making emotional responses, managing internal frustration, fear, or helplessness while maintaining a calm, professional demeanor. This internal conflict contributes to psychological strain and burnout, particularly when compounded by recurrent exposure to aggressive, non-compliant, or emotionally charged family interactions. The emotional demands of nursing are often underappreciated, yet they significantly impact mental well-being, job performance, and retention.

Communication challenges further complicate nurse-patient-family dynamics, particularly in multicultural and multilingual contexts like Nigeria. Nurses in this study reported frequent misunderstandings and misinterpretations rooted in language barriers, cultural assumptions, and differences in health literacy. While many employed empathy and simplification of medical language, the persistent communication gaps not only strained relationships but often escalated tension, leading to verbal altercations or conflict. The need for cultural competence and inclusive communication strategies has never been more urgent (Campinha-Bacote, 2002; Douglas et al., 2014).

Adding to this interpersonal complexity are institutional and systemic constraints. Many nurses pointed to inadequate institutional support, such as the absence of formal conflict resolution training, poor staff-patient ratios, lack of mental health resources, and insufficient administrative responsiveness to workplace aggression. These findings resonate with global literature indicating that systemic failings exacerbate occupational stress and reduce care quality (Laschinger et al., 2001; Aiken et al., 2002). Institutions that fail to recognize the burden placed on nurses’ risk both diminished care outcomes and the erosion of their workforce.

Despite these adversities, the study highlights remarkable resilience and adaptive coping mechanisms employed by nurses. Strategies ranged from peer support and humor to mindfulness, journaling, and emotional detachment. Some nurses developed internal scripts or relied on learned behaviors from past encounters to de-escalate tense situations. Others drew strength from their professional values or faith. The evidence points to a critical need for resilience training and structured coping support, particularly in high-acuity environments.

The impact of these experiences on nurses’ professional identity and job satisfaction was ambivalent. For some, difficult encounters reinforced their sense of duty and competence, particularly when they managed to defuse tension or provide comfort. However, for others, the repeated emotional toll led to disillusionment, a questioning of career choice, and even thoughts of leaving bedside care altogether. These experiences speak to broader concerns in nursing about sustainability, retention, and the risk of moral injury when nurses are repeatedly exposed to distressing situations without adequate support or systemic reform.

Taken together, these findings reveal a holistic portrait of the acute care nurse as a professional navigating complex emotional, relational, and structural landscapes. The study contributes significantly to the existing body of knowledge by emphasizing how these dynamics are experienced in a developing-country context, where additional cultural, infrastructural, and institutional challenges compound the already demanding nature of acute care work.

Implications for Nursing Education and Practice.

The findings hold critical implications for both nursing education and clinical practice. Firstly, emotional intelligence and communication training should be foundational in nursing curricula and continued professional development programs. Nurses must be equipped not just with clinical knowledge but also with tools for emotional regulation, interpersonal negotiation, and self-care. Training in cultural sensitivity, assertiveness, and boundary-setting are particularly relevant in multicultural and socioeconomically diverse environments.

Secondly, institutional responsibility is paramount. Hospitals and healthcare administrators must move beyond viewing difficult patient interactions as isolated or nurse-dependent challenges. These are systemic issues that require systemic solutions, such as debriefing systems after critical incidents, access to mental health services, and protocols for responding to patient or family aggression. Zero-tolerance policies, clear communication of acceptable behavior, and strong backing from hospital leadership are necessary to empower nurses and ensure their safety.

Thirdly, multidisciplinary team approaches can help distribute the emotional labor and facilitate shared decision-making. Nurses should not bear the burden of managing challenging patient behaviors alone. Involving social workers, psychologists, spiritual care providers, and ethical consultants can provide more holistic support to both nurses and patients.

Fourth, there is a pressing need for policy development that includes frontline nursing perspectives. Nurses bring unique insights into patient dynamics and are best positioned to suggest practical, patient-centered, and realistic policies. Their participation in policymaking will ensure buy-in and promote effective implementation of institutional guidelines on difficult patient and family interactions.

Finally, self-reflection and reflective practice should be institutionalized. Encouraging nurses to engage in reflective journaling or peer discussions about difficult encounters helps foster resilience, promotes emotional healing, and enhances clinical judgment. Reflection also deepens understanding of personal values, boundaries, and growth areas.

Implications for Research.

This study also opens new avenues for future research. While the qualitative insights are rich and contextually grounded, larger-scale quantitative studies could help determine the prevalence of specific stressors, their correlation with burnout indicators, and the effectiveness of various interventions. Research comparing public and private hospital settings, urban versus rural care environments, or exploring gender-based experiences in managing difficult patients may uncover further nuances.

Additionally, longitudinal studies could explore how repeated exposure to challenging interactions influence nurses’ psychological health, job commitment, and professional development over time. There is also a need for intervention-based research to test the effectiveness of specific training, debriefing models, or support programs in enhancing nurses’ coping capacity and care outcomes.

Contribution to Nursing Knowledge.

This study makes several key contributions to the field of nursing knowledge and practice:

• It sheds light on the hidden emotional burdens of nurses in acute care—burdens often overlooked in favor of clinical competence.
• It situates the problem within both individual and systemic contexts, emphasizing that emotional strain is not merely a personal issue but a structural one.
• It provides evidence-based recommendations that are contextually relevant for settings like Nigeria and adaptable to similar environments globally.
• It reaffirms the importance of phenomenological research in understanding lived experiences, bringing forward voices that often remain unheard in formal policy discourse.

The study highlights that managing difficult patients and families is not merely a matter of interpersonal skill or emotional resilience, it is a deeply embedded issue shaped by cultural, institutional, and systemic factors. Nurses are expected to function as clinicians, counselors, de-escalators, and caregivers, often without adequate training or support in handling the emotional toll of such complex roles. To support them effectively, healthcare systems must adopt an integrative approach that strengthens individual resilience, reforms institutional policies, and fosters a culture of empathy, safety, and respect.

If healthcare institutions, educators, and policymakers take these findings seriously and implement the recommended changes, nurses will be better positioned to provide compassionate, competent care even in the most challenging circumstances. Ultimately, supporting nurses in this way enhances not only their professional fulfillment and mental health but also the quality, safety, and humanity of the care they deliver.Bottom of Form

REFERENCES

1. Alquwez, N. (2020). Examining the influence of workplace incivility on nurses’ patient safety competence. Journal of Nursing Scholarship, 52(3), 292–301. https://doi.org/10.1111/jnu.12550
2. de Boer, J., Lok, A., van’t Verlaat, E., Duivenvoorden, H. J., Bakker, A. B., & Smit, B. J. (2017). Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: A meta-analysis. Social Science & Medicine, 180, 62–68. https://doi.org/10.1016/j.socscimed.2017.03.030
3. Drach-Zahavy, A., Goldblatt, H., Admi, H., Blau, A., Zur-Carvaly, I., & Itzhaki, M. (2020). Patient aggression and nurses’ burnout: The moderating role of emotional intelligence. Journal of Advanced Nursing, 76(1), 178–189. https://doi.org/10.1111/jan.14218
4. Jackson, D., Hutchinson, M., Everett, B., Mannix, J., Peters, K., Weaver, R., & Salamonson, Y. (2016). Nurses’ experiences of workplace violence: A qualitative study. Journal of Advanced Nursing, 72(5), 1125–1135. https://doi.org/10.1111/jan.12930
5. Kim, E. Y., & Choi, E. Y. (2016). Nurses’ emotional labor and burnout: Mediating effects of emotional intelligence. Journal of Korean Academy of Nursing Administration, 22(4), 375–383. https://doi.org/10.11111/jkana.2016.22.4.375
6. National Academies of Sciences, Engineering, and Medicine. (2019). Taking action against clinician burnout: A systems approach to professional well-being. National Academies Press. https://doi.org/10.17226/25521
7. O’Connell, B., Young, J., Brooks, J., Hutchings, J., & Lofthouse, J. (2013). Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing, 22(3–4), 447–455. https://doi.org/10.1111/j.1365-2702.2012.04102.x
8. Pavlish, C., Brown-Saltzman, K., Jakel, P., & Rounkle, A. M. (2015). Nursing priorities in ethics consultations: A qualitative study. Nursing Ethics, 22(6), 667–681. https://doi.org/10.1177/0969733014546204
9. Schmid Mast, M., Kindlimann, A., & Langewitz, W. (2015). Recipients’ perspective on breaking bad news: How you put it really makes a difference. Patient Education and Counseling, 100(4), 748–753. https://doi.org/10.1016/j.pec.2015.10.002
10. Spector, P. E., Zhou, Z. E., & Che, X. X. (2014). Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies, 51(1), 72–84. https://doi.org/10.1016/j.ijnurstu.2013.01.010
11. Tuckett, A., Eley, R., Ng, C., & Hegney, D. (2015). Caring in residential aged-care: Exploring the views of nurses. Journal of Clinical Nursing, 24(21–22), 3177–3189. https://doi.org/10.1111/jocn.12916
12. Vogus, T. J., Cooil, B., Sitterding, M., & Everett, L. Q. (2020). Safety organizing, emotional exhaustion, and turnover in hospital nursing units. Medical Care, 48(10), 958–964. https://doi.org/10.1097/MLR.0b013e3181f2c802.
13. lameddine, M., Clinton, M., Bou-Karroum, L., Richa, N., & Doumit, M. (2015). Violence against nurses in healthcare settings: A concept analysis. International Journal of Nursing Studies, 52(9), 1543-1551.
14. Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. OJIN: The Online Journal of Issues in Nursing, 16(2).
15. Edward, K. L., Ousey, K., Warelow, P., & Lui, S. (2016). Nursing and aggression in the workplace: A systematic review. British Journal of Nursing, 25(6), 305-310.
16. Jackson, D., & Hutchinson, M. (2017). Nurses’ experiences of working with difficult patients: A qualitative meta-synthesis. Journal of Clinical Nursing, 26(13-14), 1978-1991.
17. Laschinger, H. K. S., & Fida, R. (2014). New nurses burnout and workplace wellbeing: The influence of authentic leadership and psychological capital. Burnout Research, 1(1), 19-28.
18. O’Connell, B., Young, J., Brooks, J., Hutchings, J., & Lofthouse, J. (2013). Nurse communication with patients in acute care settings: An observational study. Journal of Nursing Scholarship, 45(2), 112-121.
19. Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: A growing problem in the health professions? Hastings Center Report, 40(1), 20-22.