Abstract
This is an outcome project paper on “Administration Guest Syndrome” common in patients and which nurses are constantly confronted with as they in the daily undertakings. The paper includes a diagnostic tool that can be used by other health care professionals in identifying the syndrome. With the support of appropriate literature, the paper has discussed a nursing protocol that can help deal with the syndrome. Various desired outcomes have been pointed, the stressors that are likely to be associated with the response pattern, and the nursing interventions that can be used to handle the stressors. The outcomes are based on ideal timing, skills and staffing.
Introduction and presentation of Syndrome
Patients put in situations that are out of their control, respond to their problems in varied ways at the busy Cardio-thoracic step-down unit where I work. Ideally, most of them stick to the plan. Some, however, respond differently. Venting out negative feelings through complaints, remaining sad or withdrawn, and verbalizing frustration are some of the acceptable way’s patients responded which I identified. Some of the less desirable responses identified were the incessant use of the call light, coercive behavior, and expectation by the patient to have their every wish catered for. These types of patients are often referred to as “administrative guests” since they are often calling administrative offices to complain about the care they are receiving as a way of coping with their illness. This manipulative and demanding behavior is an undesirable pattern of response and is often not part of the medical diagnosis. The same type of behavior would most likely be witnessed if the same patient had a different medical problem.
Desired and Realistic Treatment Outcomes
The project seeks to diagnose these types of responses supported by appropriate literature. Its purpose is to help nurses deal with these types of negative patient responses more effectively. A nursing protocol will consequently be developed that will help treat the stated response patterns. Desired outcomes are based on ideal staffing, time and skills. The desired outcome is that the patient will be able to more effectively cope with their current health condition, verbalize and show an acceptance of changes in the daily routines, reduce the use of call bell for unnecessary demands and stop jeopardizing the health care provider’s job status by constant complains to administrators.
Diagnostic Tool for Identification of “Administrative Guest Syndrome”
The following tool can be used by nurses to identify the “Administration Guest Syndrome” in patients.
“Administration Guest Syndrome” is present if a patient has at least three out of the following characteristics:
- Patient underwent unplanned emergency surgery (True_________ False________)
- Patient’s family has unrealistic goals and outcomes (True______ False________)
- Patient’s Family makes unrealistic demands (True______False_________)
- Patient presses the call bell as soon as caregiver leaves the room (True________False______)
- Patient acts friendly to caregiver but files complain to supervisor (True______False_______)
- Same complain filed for different healthcare providers (True _______False________)
- Patient does not make progress in past few days (True______ False_______)
- At least twice, patient or family called administration (True______ False________)
- Patient is apprehensive and denies anxiety related to current condition (True______ False_______)
There were many characteristics that were more incidental and really diagnostic but by going over my simple diagnostic tool, I decided to eliminate questions that lead to persistent false-negative results. It is my thought that the family of the patient has significant input on the diagnosis of such a syndrome. I believe in the holistic approach of the care process thus the reason for the decision to include the patient’s family in my project since I am treating the person as a whole.
Literature Review on Administration Guest Syndrome
Research
In a study conducted by Yardley et.al (2009), showing the relevance between staff training and the quality of spiritual care they provide, it was obvious that many health care professionals often face incredible difficulties when it comes to spiritual care delivery while maintaining personal borders and overcoming their own obstacles. This particular study is a qualitative one utilizing structured patient interviews that offers training suggestions and opinions. It’s also observed in this study that patients often appreciate staff who inquire about their spiritual needs and engage in spiritual conversations. The results of this research reveal that patients expect spiritual care as a non-judgmental, integrated approach to their individuality. It is clear from this study that health care providers need to get more engaged in and to do so willingly in discovering the spiritual needs of patients. The “Administrative Guest” which is the subject of this paper can significantly benefit from being actively listened to and being offered spiritual support as part of the care plan.
A different study carried out by Torres (2009) differs from the previous one since it measures how the rapid cycle process helps in the reduction of patient use of the call bell and improves patient satisfaction. This study has its background from a steady decline in patient satisfaction scores. It is a very interesting study since more and more facilities in recent days correlate their services with patient satisfaction survey results. In addition to the patient survey, the study engaged staff members in the collection of data and tracking the frequency and nature of call bells. Consequently, proper interventions and action plans were initialized to reduce call bells and improve future scores on surveys. In addition, promptness in response to call bells led to a major increase in patient satisfaction from 57th to 74th percentile (Torres, 2009). This study, which was more statistically measured, reveals that the “Administrative Guest” uses the call bell consistently at particular times more than at others. It is thus suggested that patient complaints to supervisors can be prevented by conducting an analysis of what and exactly when the patient is more likely to require any type of assistance.
Spirituality
A study was carried out by Griffin and Yancey (2007) with a focus on nurses who take care of patients in highly technical surgical environments and their ability to provide spiritual care competently. The challenge to this study was that patients in this type of environment often face stressors such as uncertainty and the possibility of negative outcomes. This article talks about the transition theory which is explained as increased vulnerability and disrupted reality which leads to feelings of loss of control, hopelessness, powerlessness and anger. The researchers who conducted this qualitative study also focused on examining health-related issues of patients undergoing surgery and later developed the “Five level Continuum of Relationships” which is helpful to nurses in understanding the feelings of the patient. This study proves that faith and trust in the caregiver get established when the nurse addresses the spiritual needs of the patient. There is an evident line between the spiritual wellness and despair of the client and it is, as stated by this study, in the caregiver’s hands to promote a smoother transition between the two. The final results of this study prove that nurses can enhance the spiritual well-being of the patient and the path through the surgical experience by paying attention to and recognizing the patient’s transitional experiences and by providing supportive and holistic care.
A different study was carried out by, Musgrave addressing the differences among traditional, secular and religious oncology nurses in Israel. This study was based on their inherent, external religious natures, their well-being, spirituality, and their attitudes on spiritual care (Musgrave, 2004). This particular research was conducted as a comparative and descriptive study. Mailed questionnaires were completed by nurses and the result indicated a more positive outlook to spiritual care among the secular nurses compared to the religious ones.
An obvious weakness of this study was that it was conducted in Israel and it focused on only one particular religious group. In a conclusion, it was found that nurses need to assess their own spiritual self-awareness and attitudes toward spiritual care in order to provide a holistic approach.
Both studies conclude that patients need to be treated as a whole and the holistic approach is generally promoted. In order to promote a person’s own well-being, all aspects of life need to be addressed and recognized which is proved in the above studies. These aspects of life include intrapersonal relationships and spiritual wellness. As shown by the second study, spiritual well-being is not necessarily related to the person’s religious beliefs. Thus, in order to be spiritually competent, a caregiver does not really have to be a religious person. In relation to “Administration Guest Syndrome” Is it crucial for nurses to recognize the patient and their families and their spiritual despair in a timely manner in order to go ahead with planned interventions that would improve their spiritual well-being.
Discharge planning
Bauer et.al (2009) conducted studies on the best methods of the discharge planning process for patients. This study was specifically based on discharge processes that included frail older adults and their families. The study revealed that there is a significant link between the level of anxiety related to discharge and the complaints and dissatisfaction from services received during the patient’s stay. This particular study was designed as a literature review related specifically to effective discharge planning. In a conclusion, it is strongly suggested that in order to carry out effective discharge planning, members of a multidisciplinary team need to be involved. This particular study found that the patient’s family needs to be included and addressed way before the official discharge day. There is also a need for ongoing communication between family and staff reassurance of ongoing support after discharge. Also noteworthy in this study was that the perception of the principal family caregiver of a patient of the effectiveness of the discharge process determines how the bulk of care received will be graded in future satisfaction surveys and agendas. There is also a significant direct correlation between the quality of discharge planning and readmission to the hospital often due to lack of teaching and reevaluation of taught material.
Different research about patient choices of discharge planning was conducted by Birmingham (2009). The purpose of this study was to describe steps in offering patients’ choices in the discharge planning process while ensuring that the patient maintains a sense of control about his/her situation and that the best choice is made as a rehabilitation step. The major key to this study was offering proper education about all available options. Prior to offering choices, a patient needs to undergo a functional screening in order to be offered only those options that are realistic. A major weakness of this study is the lack of a cognitive function assessment in the patient choice portion. The strongest part of this study was offering patients and their family’s options to choose from thus giving them a sense of control.
The first study clearly states that the patient’s family needs to be involved in discharge planning. Majority of complaints from the family of a patient that has “Administration Guest Syndrome” are often regarding decisions that were made without the family’s input. The discharge process is anxiety provoking subject as stated by both mentioned studies, thus, the sooner the patient and family are updated on what option is more realistic for them, the more time they have to adjust to change and start the copying process.
The second study pays a lot of attention to patient choice in the discharge process. In spite of its weakness, it makes a lot of sense in giving back the patient the control of the situation he or she lost on admission. The patient with “Administration Guest Syndrome” often makes complains and calls supervisors as a result of a loss of control and feeling of powerlessness. Thus, by taking action, an individual with this syndrome gets the feeling of winning.
Culture
Jotkowitz, Clarkfield and Glick (2005) conducted a study about modern Jewish ethical perspectives on care of patients with dementia. This particular study is very helpful to all healthcare providers because it helps them understand the conflicts that arise when a patient becomes demented and requires skilled nursing care round the clock. This study revealed the obligation that children had towards their aging parents which were catered for in the Jewish law. The study clearly describes the proper ethical response to difficult areas for families to face such as truth-telling, transfer to a skilled nursing facility, artificial nutrition and end-of-life care. The study finds solutions for problems that are created when modern trends clash with the Jewish tradition.
Another research conducted by Kappeli (2000) studied the influence of Jewish and Christian religions on coping mechanisms. The main focus was on the effect of religiosity on patients’ ability to face cancer. This study was very structured because it contained intensive methodological experimentation and inductive research methods were used such as unstructured interviews and patient diaries. The surprising conclusion of this study was that Jewish and Christian patients utilized the same religious motives. The difficulty of talking about religion by healthcare providers such as nurses is revealed in this study yet the study also shows that the same has great potential for healing and improving coping mechanisms thus deserves, the same support as other clearer methods.
Both studies are dealing with the often-vague topics of culture and religiosity. A patient who has “Administration Guest Syndrome” can significantly benefit from moral and religious support if recognized by nurses in a timely fashion. Sometimes a difficult patient just wants to be heard and has no one serious to talk to. This type of individual can often benefit from clergy and pastoral care. Patients feel greatly respected when their religious and cultural preferences are recognized. The studies also reveal that taking care of demented individuals is very difficult for staff members working for only a few shifts in a row but for family members, it has significant changes especially when they face issues such as the end of life care, transfer to a nursing home and artificial feeding. A lot of grief and negative energy comes from the patient’s family members who are forced to deal with this type of agonizing decision mentioned in the first study. As a result, children often feel guilty and take this on staff members such as nurses by making unrealistic requests and demanding consistent answers from all members of the health team.
Nursing Strategy to Ameliorate “Administration Guest Syndrome”
The Desired Outcome
After the nursing intervention, the patient will cope better with their current health condition. There are stressors that must be removed and weaknesses distanced in order that the desired outcome may be achieved.
Stressor: increased anxiety level
The nursing intervention intended to weaken this particular stressor is actively listening to the patient. This indicates that the nurse is present, interested, has time and has respect for the patient (Bryant, 2009). Another quite simple nursing intervention is providing an explanation about any plans to carry out the action as this can cause a significant decrease in verbalized and expressed feelings of anxiety. One particular study done showed that the eighty-five percent of patients who experienced the highest anxiety level was due to lack of information related to upcoming tests and procedures (Cossette, 2009).
Implementing methods of therapeutic communications such as encouraging the patient to verbalize their fears and restating their feelings is a nursing intervention that can significantly help in fortifying defense (Palmer, 2007). Furthermore, a patient who appears to be overly anxious cannot advance and consume new information due to anxiety as the major barrier. Nurses who utilize relaxation techniques acceptable by the patient should communicate this in the shift report as well as during multidisciplinary rounds so that everyone is aware of the patient’s anxiety and all team members are able to utilize techniques that work for this individual either by listening, letting the patient vent or by simply taking time to sit with the patient (Edwards, 2008).
Stressor: an altered sense of control
Several nursing interventions can be used to reduce this stressor: getting the patient involved as much as possible in decision making will help the patient combat expressed a feeling of powerlessness (Cossette,2009). The patient can be offered options such as time (within a reasonable range) of certain tests as well as a choice of activities such as ambulation or nap (Hayhurst, 2009). The nurse’s analysis of what worked for this individual in the past and implementing it can help the patient to cope better with this stressor. Many times, by using open questions, a better rapport and communication is established which enables the caregiver to carry out better interventions. As a result, the patient is able to regain the feeling of control and power over the care received (Lau-Walker, 2009).
Expected Outcome
After the nursing intervention, the patient will become more comfortable with his/her nursing care so that there are fewer complaints to the administration.
Stressor: change of environment
The nursing intervention that will significantly reduce this particular stressor is orienting the patient and his/her family to the healthcare team and unit routines from the beginning of admission (Lutfey. 2005). In addition, it is important that the role of each caregiver from the multidisciplinary team be explained and introduced to the highly demanding patient in order to decrease any unrealistic expectations (Lutfey, 2005).
Furthermore, nursing interventions that enhance the patient’s own defense mechanism in order to cope with such stressors are taking the patient complaints seriously and expressing the will to take corrective action in order to make the patient feel respected (Giffors 2010). Another intervention that would assist in helping the patient to understand that certain actions are done in order to promote healing and the reasoning behind them should be explained before the patient makes complaints to the supervisor. For example, early blood draws and daily weights should be explained as promoting earlier blood transfusion before the patient is the symptomatic and proper dosing of diuretic medication (Webel, 2007).
Contributing Stressor: Fear of possibly less than expected outcome
The nursing interventions that would alleviate this stressor is exploring feelings about previous hospital experiences (Cossette, 2009), encouraging patient’s own decision making (Palmer, 2007), avoiding false reassurance and explaining side effects (Luthy 2009), allowing patients to seek experts and second opinion as well as enable the patient’s will of rights (Aiken 2007).
Desired Outcome
Reduction in call bell use and unnecessary demands.
Contributing stressor 1: Feelings of uncertainty
Nursing interventions that would help reduce this stressor include conducting hourly rounds to check for pain, potty and position. This is proven to reduce amounts of call lights at the same time and lesser complaints of unanswered and ignored bells (Edwards, 2008). Delegating to ancillary staff appropriate tasks in order to prevent the patient from abusing call bells and nurse’s time is another intervention that would help. (Giffors, 2010). Another intervention would be the use of open-ended questions when performing teaching which provides an opportunity for asking questions at the right time and also offering help when present in a patient’s room and expressing availability (Lau-Walker, 2009).
Contributing Stressor 2: Conflict between family members concerning discharge plans
The nursing interventions that would help address this would be encouraging the patient to designate one person to handle important decision making in health care proxy (Aiken 2007), identifying which family members cause an increased amount of stress as stated by the patient and approaching them in a professional manner (Hayhurst, 2009), involving supervisors when less than expected patient and family behaviors are observed (Edwards, 2008) and avoiding conflict and verbal confrontations which can easily turn into a shouting match between anxious, angry patient and caregiver (Bryant, 2009. The last two interventions will reduce anger significantly.
Conclusion
Many registered nurses are forced to deal with patients who have “Administration Guest Syndrome”. It is very difficult to take care of this type of patient because of his/her frequent complaints to supervision. This syndrome can be very devastating to all staff members as well as to the patient because staff tends to get burned out over time. Many of the above-mentioned interventions can be optimized when incorporated quickly enough before the escalation of the situation. Many times, nurses’ awareness helps as this syndrome is controlled, tamed and the patient has better outcomes.
References
Aiken, J. (2007). Outdated and irrelevant? Rethinking the Library Bill of Rights – does it work in the real world?. American Libraries, 38(8), 54-56.
Bauer, M., Fitzgerald, L., Haesler, E., & Manfrin, M. (2009). Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence. Journal of Clinical Nursing, 18(18), 2539-2546.
Birmingham, J. (2009). Patient choice in the discharge planning process. Professional Case Management, 14(6), 296-311.
Bryant, L. (2009). The art of active listening. Practice Nurse, 37(6), 49-52.
Cossette, S., D’Aoust, L., Morin, M., Heppell, S., & Frasure-Smith, N. (2009). The systematic development of a nursing intervention aimed at increasing enrollment in cardiac rehabilitation for acute coronary syndrome patients. Progress in Cardiovascular Nursing, 24(3), 71-79.
Edwards, C. (2008). Using interdisciplinary share governance and patient rounds to increase patient safety. MEDSURG Nursing, 17(4), 255-257.
Gifford, J., Husain, N., Dinglas, V., Colantuoni, E., & Needham, D. (2010). Baseline quality of life before intensive care: A comparison of patient versus proxy responses. Critical Care.
Griffin, A., & Yancey, V. (2009). Spiritual dimensions of the perioperative experience. AORN Journal, 89(5).
Hayhurst, C. (2009). Help your patients make the right choices. PT in Motion, 1(1), 18-24.
Jotkowitz, A., Clarfield, A., & Glick, S. (2005). The care of patients with dementia: a modern Jewish ethical perspective. Journal of the American Geriatrics Society, 53(5), 881-884.
Käppeli, S. (2000). Between suffering and redemption: religious motives in Jewish and Christian cancer patients’ coping. Scandinavian Journal of Caring Sciences, 14(2), 82-88.
Lau-Walker, M., Cowie, M., & Roughton, M. (2009). Coronary heart disease patients’ perception of their symptoms and sense of control are associated with their quality of life three years following hospital discharge. Journal of Clinical Nursing, 18(1), 63-71.
Lutfey, K. (2005). On practices of ‘good doctoring’: reconsidering the relationship between provider roles and patient adherence. Sociology of Health & Illness, 27(4), 421-447.
Luthy, C., Cedraschi, C., Pautex, S., Piguet, V., & Allaz, A. (2009). Difficulties of residents in training in end-of-life care. A qualitative study. Palliative Medicine, 23(1), 59-65.
Musgrave, C., & McFarlane, E. (2004). Intrinsic and extrinsic religiosity, spiritual well-being, and attitudes toward spiritual care: A comparison of Israeli Jewish oncology nurses’ scores. Oncology Nursing Forum,, 31(6), 1179-1183.
Palmer, J. (2007). Decreasing anxiety through patient education. Plastic Surgical Nursing, 27(4), 215-220.
Torres, S. (2007). Process improvements. Rapid-cycle process reduces patient call bell use, improves patient satisfaction, and anticipates patient’s needs. Journal of Nursing Administration, 37(11), 480-482.
Webel, A., Frazier, S., Moser, D., & Lennie, T. (2007). Daily variability in dyspnea, edema and body weight in heart failure patients. European Journal of Cardiovascular Nursing, 6(1), 60-65.
Yardley, S., Walshe, C., & Parr, A. (2009). Improving training in spiritual care: a qualitative study exploring patient perceptions of professional educational requirements. Palliative Medicine, 23(7), 601-607.