Erik Nilsson is admitted to a large general hospital for a surgical procedure scheduled for early the next morning. He is 68 years old, and English is his second language. Although he can understand some words and phrases, his ability to speak in English is extremely limited. Erik is accompanied to the hospital by his daughter, Astrid, who can translate for Erik during the admission process. She tells Jackie, the healthcare professional conducting the interview, that her father lives with her and her family. Astrid says that she does not think he is especially worried about his surgery but did add that lately she has noticed that her father exhibited mood swings.

That evening, Erik speaks in an agitated manner, in Swedish, to another patient. Jackie, his evening healthcare professional, goes to Erik's bedside to calm him down and see what is wrong. He is gesturing and muttering to himself, quite loudly at times. Jackie notifies the physician on call. When the physician examines Erik, he still appears agitated but somewhat calmer. The attending practitioner orders a sedative and informs Jackie that he will check with her again in an hour. Erik falls asleep in a short while. The rest of the evening shift progresses unremarkably.

Jackie wakes Erik at about 6:00 a.m. and administers his preoperative medications. Erik is taken to surgery at 7:00 a.m. The surgery goes well, with no complications. Erik has an uneventful recovery and is returned to his unit at 2:00 p.m. His daughter and son-in-law are waiting to see him. Although he appears somewhat sleepy, Erik is mumbling to himself and gesturing with his hands. Neither his daughter nor his son-in-law can understand what he is saying. They try to visit with him briefly but finally leave, telling him to get some rest and they will return later.

Erik dozes off, but when he awakes, the unusual behaviors seem to increase. Erik's voice becomes louder. He then begins to appear very tense, grimacing and clenching his fists. When Jackie approaches him, he seems angry with her, and she is confused as to why. The nurse reports her concerns to her unit manager: "I'm not sure what's going on with Erik, but I feel somewhat frightened of him."

Jackie and the nurse manager decide that they both will go to Erik's room together to conduct a postoperative assessment. As they approach Erik's bedside, he begins shouting, trying to pull out his intravenous line and catheter, and attempting to leap out of the bed. He picks up a water bottle that was on his over-the-bed tray and throws it at the unit manager. It hits her on the arm, stunning her but not hurting her.

Staff arrive on the scene ready to assist in restraining Erik. In the meantime, a Swedish-language interpreter has come to the unit. After the interpreter is introduced, Erik seems to calm down considerably.

The on-call healthcare practitioner responsible for Erik's care arrives and, after reviewing the situation, orders medication to calm Erik. The interpreter tells Erik, in his own language, about the medication and why he is receiving it. Erik responds favorably to this and accepts the medication. A staff member is assigned to remain at Erik's bedside until he falls asleep. Soft restraints are made available at the bedside in case they are needed.

After this incident is under control, the unit manager, Jackie, and the other staff involved go to a conference room to review the episode. A plan is made to confer with the family about Erik's reported "mood swings," request a psychiatric evaluation, use Swedish-speaking personnel when available, and maintain close observation of the patient. Jackie asks the team why Erik behaved in this way.

The nurse manager may also tell Jackie, "Often patients will react aggressively but the staff has no sure way of knowing why this happens. It could be that the 'mood swings' mentioned by the daughter are connected to Erik's current behavior. It might be the unknowns of the hospital process or of what the findings from his surgery will indicate. The fact that Erik does not speak English well may increase what might be normal anxiety to a frightening level."

Michael Longfellow is a 60-year-old male patient who was admitted to the hospital after he fell and broke his hip. He had been helpless at home for several hours after the fall because his wife was away from the house. When she returned and found him, he was immediately brought to the hospital by ambulance. On the day of admission, surgical repair was performed.

After surgery, Michael was disoriented for several days. He was confused, belligerent, and had visual hallucinations. Medication for agitation was required some of the time. Michael's blood pressure and pulse rate were high. Eventually, his mental status cleared and the remainder of the postoperative period went smoothly. Michael's incision began healing and his vital signs became stable.

Pain management, however, remained a problem for Michael; it was difficult to develop a pain management regimen that enabled Michael to experience pain relief. He was unwilling to practice coughing or deep breathing as recommended because of reported pain. It was a constant struggle to assist him with ambulation exercises, although he had been informed of the dangers from immobility many times. He developed pneumonia and his hospitalization continued.

His wife and adult children rarely visited and were unwilling to talk with staff members. Michael reported that he had not worked for years and relied on his wife for much of his care and support. He gave vague reasons for this situation, stating that he had been laid off and that there were never any jobs in his field of employment.

The healthcare professional staff began to be concerned as time passed and Michael did not appear to be assuming responsibility for his recovery. He, on the other hand, was eager to return home and pressured his physician to let him go prematurely. The staff called a patient care conference to discuss the discharge plans for Michael.

During the conference, several of the healthcare professionals on the evening shift expressed concern that Michael would not be well taken care of if he were to return home at this time. They had met his wife because she visited in the evening after work. They described her as "cold" and "mean." They were sure that she would provide no assistance to Michael, who would be forced to fend for himself at home.

The night healthcare professionals described ongoing episodes of insomnia that the patient had experienced since his admission. One of the healthcare professionals had found Michael attempting to smoke in his room. She stated that he drank cup after cup of coffee whenever he could. She thought that he was simply a patient who was nonadherent with his treatment plan and should be discharged as soon as possible with home care assistance.

One of the healthcare professionals mentioned the possibility that Michael might have an alcohol use disorder. She cited his delirious episode after admission, his low pain tolerance, and the dysfunction in the family as possible indicators that he might have a substance use problem. The physician added that the hypertensive episode after surgery and the insomnia supported that assessment.

The social worker remembered that Michael's wife had bitterly discussed with her Michael's lack of employment and his previous falls. The social worker admitted that she had focused on the wife's hostility instead of on the possibility of an alcohol use disorder. She added that the behavioral habits of smoking and excessive coffee drinking have been linked in the literature to problem drinking.

It was agreed that the social worker would meet again with Michael's wife and discuss the possibility that Michael has an alcohol use disorder. With the information from that interview identifying Michael with a pattern of problem drinking, it was easier to approach Michael about his problem and he was, in fact, assessed and referred for treatment of an alcohol use disorder.

David Andrews, a single, 32-year-old man, has been admitted to the general surgery unit for a hernia repair. His healthcare professional, Bonnie Blake, introduces herself and welcomes him to the hospital. Bonnie is a recently divorced 28-year-old and has been a healthcare provider for about 6 months. She explains to David that she will need to ask a series of questions, some of which he may already have answered, but that she would like to hear his answers herself. David says he will be very happy to answer questions asked by such a cute healthcare provider. He tells Bonnie that he hopes she is his healthcare provider the whole time he is in the hospital and will meet his "every need, if you get what I mean!"

Discussion : How should Bonnie interpret David's last remark? It is hard to be sure of how to interpret the remark at this point. It is possible that this comment can be taken as harassment, but it is still too early to make a definitive judgement.

Bonnie begins her assessment by asking David ordinary questions such as his name, address, date of birth, and marital status. Each time he answers, David adds a short comment such as, "Yes, I already answered that one" or "Seems like you people could pass along information better; are you people all incompetent?"

Discussion : The best response to David's comments at this point is: "I do understand your frustration, there aren't too many more items." It is important to acknowledge that the process is cumbersome without taking sides or "scolding" the patient.

When asked the question about marital status, David replies, "I'm single, who wants to know?" and gives Bonnie a wink. He then asks her what her marital status is.

Discussion : The best response to David's comments at this point is: "That is not the purpose of this interview." Providers should be straightforward without being rude or flirty or creating a bargaining situation.

Bonnie is becoming increasingly uncomfortable and decides she needs to take a short break from this interaction. She tells David she needs to check on something and will be back as soon as she can. As she leaves the room, David calls out, "You hurry back, you sweet thing, I'll miss you while you are gone!"

Bonnie finds her supervisor and tells her that she is very uncomfortable with David. She asks if she can be reassigned to a different patient and let Joe, another provider on the unit, take over for her with David. The supervisor tells Bonnie that it would be better if she learned to manage patients with manipulative behaviors and that, for now, the assignments remain as they are. The supervisor does spend a bit more time with Bonnie and asks her what, specifically, is making the interview so uncomfortable and what she thinks would be the best thing to do about her discomfort.

On hearing her supervisor tell her that she will continue as David's healthcare provider, Bonnie's first reaction is to plead her case and ask her supervisor to reconsider.

Discussion : The supervisor's best response at this point is: "Tell me more about your feelings of discomfort." This will help Bonnie to focus on the feelings she is having about the situation and hopefully what is at the root of her discomfort.

Bonnie returns to the assessment room to continue the interview.

Discussion : The best way to resume the interview once Bonnie has returned to the assessment room is: "Sorry for the delay. Let's start where we left off." At least to begin with, it would be best for Bonnie to start with a clean slate and not address David's previous behavior. If it continues, then Bonnie will need to say something, but it would be best to first wait and see how things progress from the new starting point.