Abstract
The phenomenon of the difficult patient is well known to nurses. Nursing research concerning this phenomenon is limited. The existing research focuses primarily on describing the characteristics of the difficult patient and tends to locate the problem within the patient. This has resulted in a perpetuation of the phenomenon of the difficult patient and has created a cage effect in which nurses' thinking about this phenomenon rests. The purpose of this article is to explore the concept of the difficult patient. The specific aims are to describe the attributes of the concept; arrive at a tentative definition; summarize the findings of a critical review of the nursing research on the concept, conducted within the framework of Goffman's conceptualization of stigma (Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Simon & Schuster; 1963.); and discuss the utility of Goffman's work to further illuminate our understanding of the difficult patient. Particular emphasis was placed on the implications for nursing research. Clinical implications are also included.
This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:
1. Explain the concept of the difficult patient, historically and currently.
2. Discuss the various research studies that have shed light on difficult patients as they relate the concept to stigmatization.
3. Describe the concept of the difficult patient from a nursing perspective.
Difficult is a word that has a disturbing ring to it. When it is used to describe a patient it takes on a host of negative connotations. This concept is used on a regular basis by nurses, who share a certain common understanding in describing the patient as difficult.1 Concepts that become common parlance among nurses warrant exploration and description. Exploration of this term will lead to knowledge about and understanding of it. This knowledge will add to the discipline by raising consciousness regarding the effects of the widespread use of this stigmatizing term.
The literature concerning the difficult patient focuses on describing characteristics that result in patients being labeled difficult. These characteristics include "demanding, complaining, frustrating, time-consuming, requesting often, calling frequently, manipulative, female, impolite, unreasonable and uncooperative."2 The concept of stigma appears in the literature on difficult patients. Describing a patient as difficult is considered to be a stigmatizing act.1-7
The concept of the difficult patient is not new in the nursing literature. It has been the subject of at least 2 books, by Ujhely8 and by Stockwell,9 and countless articles in the nursing, nonresearch literature. A recent review of this literature confirms the continuance of the trend.7,10-18 A common thread in this literature is the description of the characteristics of the difficult patient, followed by suggestions on how to respond. In contrast, the nursing research literature in the past 15 years includes only 9 studies of the concept. It would seem at first glance that the subject is of little significance to nursing since there are so few studies. The proliferation of articles in the nonresearch literature is an indication that the concept is ever present but that it is seen as a problem that resides in the patient and that nurses already know the solution. A series of interventions is suggested in this literature, such as get to know the patient, listen, work on your communication, admit your negative feelings and get on with giving good care, set limits, allow the patient some control, do better assessments to uncover problems, acknowledge what the patient says, contract, use a consistent approach, reach out to the patient, and accept patients as they are.6,7,10-13,15-18 Despite the mention of these interventions there is almost no evidence in the difficult patient literature about whether or not they work. The perpetuation of this concept without a sound research base provided the impetus for writing this article. The belief by nurses that being difficult resides within the patient has placed nurses' thinking about the concept in a cage. This article is intended to expose the dimensions of this cage and perhaps even expand them.
The specific aims of this article are to describe the attributes of the concept of the difficult patient; arrive at a tentative definition of this phenomenon; summarize the findings of a critical review of the nursing research on the concept conducted within the framework of Goffman's conceptualization of stigma19; discuss the utility of Goffman's work to further illuminate our understanding of the difficult patient; and finally to discuss the implications for nursing research and practice.