Healthcare providers in the hospital setting are encountering increasing incidents of rude — and sometimes violent — patients and family.

“Hospitals are struggling with really demanding — even threatening — patients. We get people coming in saying, ‘You will do it. I’m a taxpayer and you work for me,’” says Richard C. Boothman, JD, executive director of clinical safety and chief risk officer at University of Michigan Health System in Ann Arbor.

The breakdown of paternalism and rise in patient autonomy is one contributing factor. “The old deference to doctors is breaking down, maybe for good reasons. But there is now a breakdown of respect,” says Boothman. “The incidence of threats is skyrocketing, and it’s truly disturbing.”

The problem is worst in the ED, due in part to escalating tensions amid crowding and lengthy waits. “We have preached to the general public that they need to be advocates for their own care,” says Boothman. “Sometimes we have 20 patients waiting for a bed — all of them thinking they need to advocate for themselves.” Some people do so in an inappropriate manner, with raised voices and threatening tones, he says.

“Now layer onto that a culture that is steadily getting more insistent, more violent, and less deferential to physicians,” says Boothman. The hospital recently held a grand rounds for the obstetrics/gynecology department on how clinicians can teach patients what their expectations are for their behavior.

At Springfield-based PeaceHealth Oregon, an Action Response Team (ART) was created in response to increasing concerns about patients who appear capable of violence. “The frequency is pretty surprising. We have at least one case a week,” says John Holmes, PhD, director of mission and ethics.

Clinicians call ART meetings, which include risk management, ethics, spiritual care, and nursing, if they have concerns about their safety for any reason. Common examples are verbally abusive patients with a documented history of violence, or patients who angrily demand a particular narcotic.

“Providers are under a lot of pressure to cut back on prescribing narcotics,” explains Holmes. “If a patient doesn’t get the answer they want, sometimes they decide to take matters in their own hands.”

Complex family dynamics sometimes escalate out of control. “People have different ideas about what’s best for the patient, and who should and shouldn’t be there when decisions have to be made,” says Holmes.

The team then comes up with a plan for that particular patient. “Security is involved, if necessary,” says Holmes. “Sometimes it’s just a matter of coming up with calming techniques to communicate with the patient.”

Address Root Cause

Autumn Fiester, PhD, executive director of the Penn Program for Clinical Conflict Management, says the key to managing verbally abusive patients or families is to “find the root cause and work to address it.” Fiester is director of education and faculty in the Department of Medical Ethics & Health Policy at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

“Verbal abuse and other types of challenging behavior should be seen as symptoms of a problem, not viewed as a problem in itself,” says Fiester. She says providers need the following two things:

  • a robust skill set in conflict resolution, and
  • dedicated personnel in the institution who can be brought in to help navigate situations that have turned into heated conflicts.

Philip M. Rosoff, MD, MA, professor of pediatrics and medicine at Duke University’s Trent Center for Bioethics, Humanities & History of Medicine in Durham, NC, says this is a complex issue that touches on many different aspects of medical care, in both the inpatient and outpatient arenas.

“Disruptive patients and families can be barred from the premises if their presence and behavior is believed to be threatening, or is otherwise disruptive,” says Rosoff. In his experience, hospital administrators sometimes go too far in their tolerance for bad behavior. “They give too much leeway, frequently in the name of good ‘customer relations,’” says Rosoff.

There can sometimes be a tension between the well-founded desire for hospitals to be welcoming places to patients and their families, and tolerating behavior that could prove to be threatening and dangerous.

“The most appropriate way to approach this challenge is to attempt to negotiate and compromise to accommodate the large variety of people who come to hospitals, but not lose sight of our duty to maintain a safe environment for all,” says Rosoff.

Clinical ethicists trained in conflict mediation can play crucial roles in addressing these issues, says Rosoff, “both in the moment and from an organizational perspective.”

Blair Henry, BSc, MTS, a senior ethicist at Sunnybrook Health Sciences Centre and assistant professor at the University of Toronto, Ontario, points to increasing incidents of healthcare providers being injured by violent patients. “The ethical quandary is a conflict between a duty to care vs. self-protection,” he says.

He recommends the following approaches:

  • ensure that policies address preventive strategies such as de-escalation and other violent behavior management techniques,
  • ensure signage is visible in common areas and treatment rooms outlining the need for respectful engagement between a patient and the staff, and
  • ensure that the causes of violent behaviors are considered.

“A policy needs to be careful about labelling people vs. behaviors,” says Henry. Underlying causes of violence may be related to alcohol or drugs, diseases, or mental health disorders.

“We need to balance the rights of a staff person to a safe work environment against the rights of the individual exhibiting the behaviors to receive care,” says Henry.

SOURCES

  • Richard C. Boothman, Executive Director of Clinical Safety/Chief Risk Officer, University of Michigan Health System, Ann Arbor. Phone: (734) 764-4188 ext. 44188. Email: boothman@med.umich.edu.
  • Autumn Fiester, PhD, Director, Penn Clinical Ethics Mediation Program/Faculty, Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. Phone: (215) 573-2602. Email: fiester@mail.med.upenn.edu.
  • Blair Henry, BSc, MTS, Senior Ethicist, Sunnybrook Health Sciences Centre, Assistant Professor, Department of Family and Community Medicine, University of Toronto, Ontario, Canada. Phone: (416) 480-6100 ext. 7178. Email: Blair.henry@sunnybrook.ca.
  • Philip M. Rosoff, MD, MA, Professor of Pediatrics & Medicine, Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, NC. Phone: (919) 668-9025. Fax: (919) 668-1789. Email: philip.rosoff@dm.duke.edu.