Seeing the cage: stigma and its potential to inform the concept of the difficult patient

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.