The participants will learn to recognise and respond to manipulation and drug-seeking behaviours while maintaining professionalism, empathy, and following clinical protocols.
- Participants brainstorm verbal and non-verbal cues that may indicate manipulative and drug-seeking behaviour.
- Review of clinical guidelines: group activity where participants review protocols for prescribing controlled substances in A&E settings.
You may wish to hand out the Sceptical Phrase Guide.
Scenario overview
Characters
Patient: Alex is a patient frequently presenting with various pains and requests for opioids.
Nurse: The nurse is responsible for conducting the assessment and managing the patient interaction. She denies the requested opioids and offers alternative solutions to the patient’s problem.
Background
A manipulative, drug-seeking patient in an Accident & Emergency exhibiting specific behaviours and verbal tactics aimed at obtaining prescription drugs. He is a repeat attender to the A&E department with similar problems.
The nurse checks his records, conduct assessment, firmly but compassionately refuses prescribing the opioids, and offers alternative solutions.
Setting
A&E triage room during a busy shift.
Roles Key Behaviours
Patient (Manipulative, Drug-Seeking): Behaviours: Use emotional manipulation tactics, such as guilt-tripping (“You don’t understand how much pain I’m in”) or exaggerating symptoms. Provide inconsistent or vague details about symptoms. Display frustration or agitation when their request is questioned, escalating to anger or pleading if refused. Ask for drugs by name, state allergies to non-addictive alternatives, use medical terms to appear credible.
Tone: Alternates between pleading, overly friendly, and frustrated/aggressive.
Attitude: Goal-oriented and determined to obtain opioids, potentially showing defiance or hostility when denied. May feign compliance with alternative solutions but continue to press for specific medications.
Nurse: Behaviours: Maintain a calm and professional demeanour, avoiding frustration or visible annoyance. Use direct but empathetic language to acknowledge the patient’s pain and concerns (e.g., “I can see you’re in a lot of discomfort, and I want to help you”). Conduct a thorough and objective assessment, referencing the patient’s records. Clearly and firmly explain why opioids are not an appropriate treatment option. Offer alternative solutions. Avoid engaging in argumentative or defensive behaviour.
Tone: Firm but empathetic. Calm and steady, even if the patient escalates their tone or behaviour.
Attitude: Patient-centred, while being mindful of the potential for manipulation. Resilient to pressure.
Simulation Flow
Setup
Arrange the triage room with a chair, a computer and basic medical tools.
Introduction
The role-players are briefed privately on the scenario and their roles.
Execution
The simulation begins with the nurse asking Alex about his symptoms and history while checking his records in the computer.
Alex responds in a detailed, exaggerated description of his symptoms. He is initially cooperative but becomes increasingly insistent on opioids, escalating emotionally if denied them. The nurse navigates the conversation, maintaining professionalism and offering alternative solutions.
Resolution
The nurse offers pain killers and resources for further care, such as information on local pain clinics, addiction services or support groups. The patient leaves.
By the end of the simulation the participants should be able to:
- Effectively manage manipulative behaviour in accordance with clinical guidelines
- Recognise verbal and non-verbal manifestations of drug seeking behaviour.
- Demonstrate the ability to maintain professional while showing empathy.
- Identify and understand the importance of medical records in monitoring repetitive manipulative behaviour.
Possible Distractors or Twists
- Patient escalation: Alex threatens to self-harm if opioids are not prescribed or feigns fainting.
- Family member involvement: A hypothetical family member calls during the simulation, pressuring the nurse to help Alex.
- Conflicting records: The nurse discovers discrepancies in Alex’s stated history and medical records.
- Self-reflection – the participants express their immediate emotional reactions to the simulation.
- Analysis - explore together what happened during the simulation and why.
- Highlight strengths and areas for improvement.
- Summarise main takeaways from the session.
Sceptical Phrase Guide
Telling someone "You are lying" directly can escalate tension, especially in sensitive situations. To express scepticism or address dishonesty in a non-confrontational way, you can use neutral, indirect or curiosity-driven language.
1. Ask for clarification or details
" Can you help me understand that a bit more?"
"I just want to make sure I’m clear on this; could you explain it again?"
2. Reflect discrepancies neutrally
"Something doesn’t quite add up here—can we go over it again?"
"I’m noticing a little difference between what you said earlier and now. Could you clarify for me?"
3. Reframe as a misunderstanding
"Maybe there’s been some miscommunication—can we check this together?"
"It seems like there might be some confusion. Let’s sort it out."
4. Focus on verifiable facts
"I have some records that show something a little different. Can you clarify for me?"
"I want to be on the same page, but this detail seems off—what’s your take on it?"
5. Use “I” statements
"I feel like there’s something missing here. Can you help fill in the gaps?"
"I’m having a hard time understanding this part. Can we talk it through?"