Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Cynthia D. Connelly, PhD, RN, FAAN, Chairperson; Jane M. Georges, PhD, RN, Committee Member; Christine Nibbelink, PhD, RN, Committee Member; Julie Graham, PhD, APRN, ACCNS-AG, Committee Member


difficult patient, qualitative, therapeutic engagement, altruism


Background: Nurses provide care for patients they classify as “difficult.” The phenomenon of the difficult patient is described in nursing research and is associated with a broad spectrum of behaviors ranging from non-compliant to physical violence. Despite the recommendation from bioethicists that the etiology is multifactorial, nursing research focuses on interventions to manage the patient’s behaviors. Locating the source of the difficult patient only within the patient control may create an environment where the nurse is socialized to take an authoritarian approach to care without reflection on the nurse/patient relationship dynamics. An extended exploration was needed to understand the influence of the difficult patient within the context of the nurse/patient relationship and the impact on care delivery.

Purpose/Aims: The purpose of this study was to describe how acute care hospital nurses made decisions and delivered nursing care in the context of the difficult patient.

Methods: A qualitative descriptive study using a constructivist approach was used. Informants were acute care hospital nurses with experience providing nursing care to difficult patients. Purposeful sampling with maximum variation sampling was used to select informants with diverse characteristics. Data collection included individual, semi-structured interviews, and document review of nursing notes of patients described as difficult. The sample size was seven registered nurses and thirty-seven documents. Data analysis was completed using inductive thematic analysis.

Findings: The difficult patient was described with the theme the Spectrum of the Difficult Patient. Nurse decision making in the context of the difficult patient was expressed with the themes Navigating Control and Limit Setting, Effects of Violence, Understanding and Altruistic Care, Respecting Autonomy and Moral Distress, and Role Support.

Potential Implications: Repeated exposure to difficult behaviors remains a role dissatisfier. This study presented an evolving nursing understanding of the potential for biased provision of care with the use of stigmatizing label. The social context of providing nursing care to a difficult patient is changing from an authoritarian approach to one of altruistic collaboration. Further professional development in therapeutic engagement was identified as a need. Organizations can decrease the burden of care to difficult patients through resource allocation and structural support with embedded clinical role models.

Document Type

Dissertation: USD Users Only



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