Difficult dental patients: a grounded theory study of dental staff's experiences

The concept of the "difficult" patient is prevalent across various healthcare settings, including medicine, mental health, and dentistry. While prevalence estimates vary, a significant portion of patients are perceived as "difficult." However, there's a lack of concrete definitions, and previous research often focuses on inherent patient problems, neglecting the complex interplay between patient, caregiver, and clinical context. In mental healthcare, "difficult" patients are associated with specific diagnoses and behaviors. In medicine, psychosomatic symptoms and personality disorders are often cited. In dentistry, aggressive behaviors and anxiety negatively impact dentists' well-being. Recent studies highlight the importance of complexity and the triadic relationship between caregiver, patient, and context. This study addresses the gap in understanding the dental staff's experiences with "difficult" patients, aiming to create a conceptual framework outlining their characteristics, effects on staff, and coping strategies, emphasizing the right to good health and equal care.

Existing literature reveals a lack of consensus on defining "difficult" patients, with terminology ranging from "hateful" to "challenging." Research in other healthcare fields has linked "difficult" patients to specific diagnoses (e.g., paranoid psychosis, chronic depression) and behaviors (e.g., demanding, manipulative, aggressive). In medicine, psychosomatic symptoms and personality disorders are frequently cited characteristics of "difficult" patients. Studies have demonstrated that "difficult" patients in medicine induce frustration and negative emotions in healthcare providers, potentially leading to diagnostic errors and reduced patient satisfaction. Similar findings are reported in mental healthcare, where stress and frustration are common among caregivers. In dentistry, while "difficult" patients are known to be a stress factor, their overall effects on the dental staff and interactions remain unclear. Previous studies emphasize the influence of dentists' intuition and judgment on treatment outcomes and the importance of therapist-patient relationships in shaping dental care. However, existing literature often adopts a one-sided perspective, placing the responsibility solely on the patient. The present study challenges this perspective, acknowledging the intricate dynamics involved.

This study employed a grounded theory approach, suitable for exploring human social processes and generating new theories from data. Ten participants (five dentists, two dental hygienists, and three dental nurses) from nine different clinics in the Västra Götaland region of Sweden were interviewed. The interviews, lasting 25-60 minutes, used a conversational style with three guiding questions: 1. Characteristics of "difficult" patients; 2. How these patients affect caregivers; 3. Caregivers' coping strategies. Interviews were audio-recorded, transcribed verbatim, and analyzed using open line-by-line coding, followed by clustering into categories and identifying a core category. Theoretical sampling was employed to ensure data saturation. The analysis was conducted by two authors with supervision from a senior author, with all authors considering potential biases. Ethical approval was obtained from the Swedish Ethical Review Authority.

The core category emerging from the data was "balancing subjective difficulties." This encompasses seven interrelated lower-level categories describing patient characteristics, their impact on staff, and staff strategies. **Patient characteristics** included "showing interaction difficulties" (communication barriers, lack of respect/trust, non-compliance) and "having bio-psycho-social complexity" (personality factors, mental/physical disorders, socioeconomic conditions). **Patient affecting abilities** included evoking negative emotions (frustration, anger, anxiety) and behaviors in the staff, hampering self-esteem and job satisfaction, and impairing life/health. **Staff problem-solving strategies** focused on "activating internal and external resources" (self-reflection, professional attitude, team collaboration) and "creating adaptive treatment relations" (getting to know the patient, balancing professional/personal interactions, patient-centered approach). The "balancing subjective difficulties" core category highlights the dynamic interplay between patient factors, caregiver abilities, and contextual conditions (e.g., time). The framework illustrates how caregivers actively modify their own experiences and use resilience strategies to manage challenging encounters. The study shows that what constitutes a "difficult" patient is subjective and context dependent.

This study provides a nuanced understanding of "difficult" dental patients, moving beyond a simple patient-centric view to encompass the complex interaction between patient, caregiver, and context. The findings challenge the notion of inherent "difficult" patient traits and emphasize the dynamic interplay of patient characteristics, staff perceptions, and coping mechanisms. The concept of "balancing subjective difficulties" highlights the active role of caregivers in managing their emotional and professional responses. The staff's use of personal and professional resources to build adaptive treatment relationships aligns with the growing emphasis on person-centered care in dentistry. The study's findings suggest that sufficient time and support are crucial for caregivers to effectively manage challenging interactions. By acknowledging the subjective nature of "difficult" patient encounters, this study provides a framework for improved training and support for dental professionals. The study suggests that successful management of "difficult" patients depends not just on the patients themselves but on a combination of patient traits, staff resources, and contextual factors like time.

This study offers a novel understanding of "difficult" dental patients, emphasizing the dynamic interplay between patient characteristics, staff perceptions, and coping strategies. The core category, "balancing subjective difficulties," highlights the active role of caregivers in navigating these interactions. Future research should focus on strategies for building and maintaining adaptive treatment relationships, exploring potential preventive behaviors and factors enhancing resilience among dental professionals. This would contribute to improved patient care and a more supportive work environment. Further research should explore specific interventions to promote resilience and improve communication skills within the dental profession.

The study's qualitative nature, using a theory-generating approach and subjective data, limits the generalizability of findings. The data were collected from a single public dental health institution in Sweden. Focusing solely on the dental staff's perspective limits the understanding of the patient experience. The term "difficult" patient, while used in clinical practice, may be subjective and require further refinement. The translation of qualitative data from Swedish to English may have resulted in subtle nuances being lost. These aspects should be taken into consideration when interpreting the results.