The mental health clinical nurse specialist and the "difficult" patient: evolving meaning.

Twelve mental health clinical nurse specialists (CNSs) working in outpatient mental health settings were interviewed and asked to describe situations where they had experienced difficult client behavior. Study data, analyzed via the grounded theory method, revealed the basic social process of Evolving Meaning. Evolving Meaning signifies change over time, based on both Enhancing Experience and Expanding Understanding. The phases of Personal Meaning, Negotiating Meaning, and Illuminating Meaning were recognized as central to the basic social process of Evolving Meaning. The study findings emphasized the importance of the nurse-client relationship process. Although the CNS participants did describe client behavior that created difficulty for them, the CNS-client relationship was viewed as being interactive and subsequently, difficult behavior was viewed within the context of that relationship. Clinical supervision was recognized as an essential component of outpatient mental health CNS practice, even by the more experienced study participants. In this study, positive components of clinical supervision included validation, insight, and system support. A surprising finding of the study was the intrusive behavior of clients, including stalking of some CNSs, their family members, or both.