Navigating challenging patient situations

FigureThe administrative supervisor, the nurse leader present in hospitals on the evening, night, and weekend shift, serves as the on-site hospital representative for all issues that daytime hospital personnel or departments typically manage.1 A patient representative addresses patient and family concerns during the day, but the administrative supervisor handles these issues on the evening, night, and weekend shifts. The administrative supervisor utilizes effective communication, along with problem-solving and conflict resolution approaches, when dealing with these circumstances, and occasionally will enlist the assistance of the administrator on call to help resolve an issue.2 Staff seek assistance from the administrative supervisor with patient and family complaints because staff recognize the value of the administrative supervisor's presence, particularly how patients and families respond differently to “someone in a white coat.”3 Direct care nurses confirm that supervisors use problem-solving and communication skills to address issues efficiently.1 The concept of human experience in healthcare is often misunderstood. At its very core are the lived experiences of the human beings, known as patients, that healthcare is here to serve, and the lived experiences of the healthcare professionals themselves.4 This latter part is often overlooked or minimized. As healthcare professionals serving in the role of administrative supervisors, there are many moments where there's a call to action and an immediate need to respond in this intersection of human experiences of both the patients and the care providers. Understanding the nuances of these moments can lead to more effective and empathetic connections with patients, team members, and colleagues. Every interaction can significantly impact the lives of the humans in our midst. Thus, this article will explore five challenging patient and family situations that an administrative supervisor might be expected to face, as well as offer possible solutions designed to manage these highly impactful events. The administrative supervisors contributing these accounts work at hospitals in the northeastern region of the US. VERBALLY ABUSIVE MOTHER While working one Sunday as nursing administrative supervisor at a 622-bed American Nurses Credentialing Center (ANCC) Magnet® university medical center, I was called by the pediatric ED team for assistance with a patient's mother. The team explained that the mother was verbally abusive and that they were concerned about potential escalation to physical harm and feared for their safety. A staff member had called security, but the team didn't get the support they felt they needed. I remember walking briskly to the ED and thinking: How do I keep the patient safe? How do I keep my staff safe? How can I de-escalate the situation? Who should I have ready on speed dial? I called security on my way to the pediatric ED requesting that they be there to back me up. I even remember removing my necklace and putting it in my pocket because I was afraid the patient's mother might grab it and break it based on the team's description of the imminent threat. The mother had stormed out of the pediatric ED into the waiting room, where, upon my arrival, I found her loudly cursing and yelling. She was being verbally aggressive and calling me names as I continued to approach her in a calm but firm way. I first asked her to lower her voice and use appropriate language for a hospital. I then pointed to the two very large posters in the lobby and asked the mother to read them aloud. She cooperated and read the following message out loud to me. “This is a place of healing. We are committed to a culture where all are treated with respect and compassion. Aggressive or disruptive behavior will not be tolerated. Examples of disruptive behavior include threats (verbal or physical), use of abusive or foul language, failure to respond to staff instructions, physical assault, other behaviors that disrupt or distract from the healing environment. Acts of aggression or disruption may result in removal from the facility and may be subject to further action. Leadership supports team members in taking all actions necessary in accordance with our policies, practices, and laws to ensure a safe and healing environment.” I asked the woman if she felt that she was following our hospital guidelines and rules set forth by the sign. After reading this out loud, the mother started to cry and break down. I sat next to her and held her hand. Her daughter was in our pediatric emergency psychiatric services, and she was feeling overwhelmed and unsure of how to handle or manage the situation. I explained that, according to our policy, she shouldn't be permitted to stay and visit. But I also understood her pain and her daughter's need for her mother's presence and support. I felt that this mother wasn't a true threat to our staff; she had just let her emotions get the best of her. I contracted with the mother that there was to be no inexcusable behavior from this point forward and that this was her final warning. I requested she apologize to myself, the security staff, and the pediatric ED team for her actions. I informed her that if I was to be called down again regarding her behavior that I would have no choice but to ask her to leave. I then had her wait in the lobby while I went back into the pediatric ED to tell the team the game plan. The team seemed upset that I was allowing this mother back to visit. I used this as an opportunity to mentor and coach the team to be empathetic and look at things through a different lens, the patient's lens. The patient was a 12-year-old girl who needed her mom. We needed to offer that mother a second chance so that we could do right by our patient. Throughout the remainder of my shift, I made additional rounds to the pediatric ED to support the staff and check on the patient and mother until the patient was transferred to another facility. Additionally, I discussed this situation with the security officers, requesting that they increase their presence in the pediatric ED to ensure ongoing safety and support. The role of the administrative supervisor is to maintain homeostasis in chaos, offer clarity, and always prioritize our patients' and team members' safety. In most cases, it's a balancing act and requires critical-thinking skills, situational awareness, and strong leadership to overcome these challenges. Wearing the supervisor hat can put us in some difficult—even scary and dangerous—situations, but when we maintain composure, exude confidence, and have a plan, we can successfully diffuse even the most tense situations. CARDIAC ARREST ON DAY OF DISCHARGE As a night-shift administrative manager at a 177-bed ANCC Magnet community hospital, I was working the day shift one Saturday when a code blue was called. Responding to the unit, I discovered that the patient had COVID-19 and was scheduled to be discharged that day. During the resuscitation, the patient's wife arrived on the unit and approached the room asking what was happening. This obviously wasn't the best timing for her to discover her husband in cardiac arrest. I explained to the wife that there was an emergency in progress and asked one of the staff members to escort her to the visitor lounge. One of the providers was informed that the patient's wife had arrived, and he and I went to speak with her. When the provider told the wife that her husband was in cardiac arrest, she shouted, “He was supposed to be discharged today!” She had last seen her husband the night before and had spoken to him that morning. The woman had told her husband that she was going to shower and then come to the hospital. She was extremely upset because, if she had come earlier, she would've seen her husband before this event. The provider left to return to the resuscitation, and I remained with the patient's wife, offering her support. I asked if there was anyone we could call, but she made phone calls herself. The unit staff called a social worker for additional support, and I remained as much as I could. During this time, I dealt with other issues, including a call from MRI regarding a patient who needed to be monitored by a nurse. Upon the provider's return, he explained to the patient's wife that the resuscitation had been in progress for a prolonged amount of time and asked whether the efforts should be continued. After the wife agreed to ceasing resuscitation efforts, we were informed that the patient had regained ROSC (return of spontaneous circulation). However, the patient coded again in the ICU and passed away. The wife expressed her thanks for our efforts and support. I usually work at night, and when we have codes, there are no family members present. This was one of the first codes during which I offered active support to the patient's family. It's so important to designate at least one staff person to provide support to families. I was so thankful that the social worker joined me to provide additional assistance. It's so difficult to find the right words to say; sometimes silence can be awkward yet much needed. PHYSICAL ALTERCATION BETWEEN PATIENTS As I arrived for my night shift as administrative supervisor at a 150-bed rehabilitation hospital, I noticed a security officer running from the acute care hospital to our facility. Upon entering the building, I learned that two patients on the 12-bed locked brain injury unit had a physical altercation with each other. I immediately proceeded to that unit. At our facility, a code gray is activated and announced via the overhead speaker system to signal both actual and perceived threats of violence involving patients, families, or staff. This code ensures an immediate response from security, the administrative supervisor, and nurse managers or charge nurses from other units and alerts others to avoid the area to minimize potential escalation. In this case, a code gray had already been called, so the day supervisor, charge nurses from the other three units, and a security officer from the acute care hospital were already on the unit. The staff reported that the altercation began with a verbal dispute between the two patients. The argument then escalated, and one patient “swung first,” physically assaulting the other patient, which resulted in a “brawl in the hallway.” The staff had to physically separate the two patients. On the locked brain injury unit, patients interact multiple times a day, such as when walking around the unit or in physical therapy. These young adult men had impulse-control issues and weren't fond of each other. Immediately after the incident, actions were taken to ensure safety and prevent further conflict. One patient was moved to another unit, and the aggressor patient was assigned a Crisis Prevention Institute (CPI)-trained 1:1 sitter and remained on the locked brain injury unit. Both patients' physical therapy schedules were adjusted to avoid further interactions. The attending physician notified both patients' families of the incident. Following any workplace violence event, a postvention learning tool is utilized to analyze the triggers, interventions, and outcomes, as well as to identify opportunities for improvement. The findings for this incident noted that the aggressor had displayed agitation and was pacing the hallways prior to the altercation. This behavior should've been reported to the RN earlier, which might've allowed for timely intervention. Possible measures, such as redirecting the patient to his room, could have de-escalated the situation. After a review of this incident, a positive outcome for the safety of the staff and patients was that a security officer is now present at the rehab hospital 24 hours a day. Additionally, I initiated a code lavender following this event to support the well-being of the staff involved. This protocol aims to help staff reduce stress and includes support from the hospital chaplain, along with the provision of a snack cart and a wellness cart stocked with tea and essential oils. Staff members were encouraged to complete a report of injury or illness (ROII) form to document any physical or psychological effects and ensure that they could access follow-up care if needed. DELAY IN PATIENT DISCHARGE One Saturday evening, as I arrived for my night shift as an administrative supervisor at a 793-bed ANCC Magnet university medical center, I quickly got a report from the day supervisor on my service line. After receiving report, I overheard the other supervisors dealing with an issue involving a patient who wasn't on my service line. Because I had finished getting the report, I volunteered to go to that unit and help resolve the issue. When I arrived, I learned that the patient had undergone surgery a few days prior and that the covering resident had told the patient that he would be discharged that morning. However, the attending physician had visited the patient soon after and requested that physical therapy evaluate the patient before discharge to ensure that the patient could ambulate with his walker. Despite multiple attempts, the nursing staff was unable to reach physical therapy, which delayed the patient's discharge. After numerous hours of waiting, the patient was upset, and he had taken it upon himself to walk around with his walker. The patient also felt that the staff was dismissive of his concerns. I listened to the patient's and his wife's concerns and apologized for the delays. I noted that the assigned nurse was a travel nurse who was unsure about what to do and that the charge nurse was busy at the moment, so I decided to handle the problem. To start, I provided the patient and his wife with some snacks from the pantry to eat while I tried to reach out to the physician. Upon further exploring the situation, I noticed that the staff had been trying to contact the attending physician who visited the patient that morning. The problem was that he wasn't the on-call physician for the weekend; therefore, he wasn't receiving any of the phone calls. I reached out to the on-call covering physician, explained the delay in discharge, and provided the physician with an updated patient assessment. The covering physician was comfortable with sending the patient home after discussing the patient's status. To ensure that the patient and his wife were fully prepared for discharge, I worked with the travel nurse to review the discharge instructions. I then transported the patient in a wheelchair to his car and spoke to guest services to validate the patient's wife's parking pass. Although the patient and his wife were upset with the delay in discharge, they were very appreciative that they finally could go home. Looking back, I believe the way this situation was handled offered many learning opportunities. Upon arrival, I quickly assessed the patient and saw that he already met his physician's requirement of walking around with an assistive walker. I gave the patient and his wife something to eat because they never ate dinner. I called the operator to verify the physician's phone number was correct, and that's when I found out that the staff had been calling the incorrect number. After assessing the situation, I could expedite the already delayed discharge. I also spoke to the staff and educated them about the importance of escalating concerns to the administrative supervisors early on whenever there's an issue to avoid further exacerbation of the problem. Overall, the situation highlights the importance of patient-centered care, active listening, and effective communication in healthcare delivery, along with the important role administrative supervisors have in service recovery. ASSAULT BY SECURITY OFFICER At the end of the night shift on an early Monday morning at a 503-bed ANCC Magnet hospital, there was an altercation in the psychiatric ED between a patient and a security officer. The police department brought the patient in on an involuntary commitment for a suicide attempt. According to the staff, the patient had been verbally escalating during this time and was extremely oppositional. The staff placed the patient in four-point restraints and, minutes later, an altercation ensued. The patient spit on the security officer and made racial slurs toward him. It was at this time that the officer escalated and assaulted this patient, punching the patient three times in the face. The patient was taken immediately to the medical ED for evaluation and treatment. In addition, the security officer's supervisor quickly removed the security officer from this situation. After the altercation, as administrative supervisor, I met with the security officer while my colleague debriefed with the staff in the psychiatric ED. During this meeting, the security officer expressed deep remorse and devastation for his behavior and reaction. He explained that he had never acted this way in his 20-year career as a hospital security officer, and he was deeply embarrassed. He couldn't even explain his behavior and stated that he really didn't remember and just saw red. I sent the security officer home following this event and placed him on administrative leave pending investigation. After the security officer was dismissed for the night and the staff were debriefed, the physician and I connected with the patient's father and informed him of the altercation. This conversation was after from our The patient's father was for our and apologized on his The next day, the department with the security officer and offered him services from our The security officer the offer and began Following this incident, security leadership a system in the psychiatric ED that allowed to care for our psychiatric a The security also the of their rounds in the psychiatric ED. 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