Is a patient, family member, or other visitor being rude or disrespectful to clinicians? It’s happening more frequently, says Mary Faith Marshall, PhD, FCCM, co-director of the Center for Biomedical Ethics and Humanities at Charlottesville-based University of Virginia.

“We make sure there is institutional attention to that. As far as we’re concerned, it’s not okay,” says Marshall.

Clinicians often felt they had no recourse if a patient or family behaved disrespectfully. “For a long time, the thinking was — with nursing staff especially — that we just need to suck it up,” says Marshall. A different set of rules might apply to patients who are decisionally incapable. However, disrespectful behavior was happening with patients and families for all kinds of reasons. “Our thinking is that you don’t get to come act in ways you wouldn’t be able to do outside the hospital, just because you are ill,” says Marshall. “We are approaching close to a zero-tolerance policy for that.”

If a person is acting in an unacceptable manner, hospital security notifies the person that if he or she interferes with patient care, he or she will be asked to leave. If it happens again, the person is asked to leave for 24 hours. “If it happens a third time, they don’t get to come back,” says Marshall.

Law enforcement have gotten involved in several recent cases. “The unit managers are learning that this is the institution’s approach,” says Marshall.

Patient Satisfaction Scores

Patients always are given a brochure on their rights and responsibilities, based on The Joint Commission guidelines. Often, patients focus only on the rights, and ignore the fact that they also have responsibilities.

“That’s the piece that everybody forgets,” says Lucia D. Wocial, PhD, RN, FAAN, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health in Indianapolis.

Overemphasis on patient satisfaction scores is one underlying factor. “Part of the unruly behavior stems from reimbursement that’s tied to patient satisfaction,” says Wocial. “Clinicians misunderstand what that means.”

Some believe that in order to get good satisfaction scores, they have to acquiesce to everything that a patient or family demands. “And that’s actually not true. To tolerate bad behavior is a mistake,” says Wocial.

Virtually all patients and family members at the hospital are in crisis for one reason or another. “But clinicians need to be reminded that they owe the same duty to themselves that they owe to patients. Clinicians deserve respect,” says Wocial.

Few would argue that point. Still, sending the message to people, “Visiting is a privilege. If you can’t abide by our rules, you are no longer welcome here,” is an unenviable task.

“Nobody wants to kick a family out. But it’s not being mean — it’s holding them to a standard. The fact is, being on property, for nonpatients, is a privilege,” says Wocial. She suggests reminding unruly individuals that they are in a public place where healing needs to take place, and if they can’t contribute to a healing environment, they cannot be present.

There are limits to patients’ autonomy. “Autonomy isn’t ‘I get what I want.’ Clinicians need to be reminded of what, in nursing, we call ‘everyday ethical comportment,’” says Wocial.

Organizations need to remind staff that patient satisfaction doesn’t mean letting people do whatever they want, argues Wocial: “That, for me, is a professional ethics issue.”

Be Aware of Policies

Many clinicians are unaware of what existing hospital policies have to say regarding behavior of patients and visitors. “In fact, policies are there to support you when things are not going well,” says Wocial. “For instance, our organization’s visitor policy gives quite a lot of latitude to a bedside nurse who feels that people are being disruptive.”

Policies on visitation typically define visiting hours, who may come, and when visiting may be restricted, particularly during infectious disease outbreaks.

An “open access” policy contributes to misunderstandings. On one occasion, a family member brought bedding to sleep on the floor of the ICU, making it difficult for nurses to get to the patient’s IV pump. “That’s a safety issue,” says Wocial. “‘Open access’ doesn’t mean everything is acceptable.”

Another family set up a cook stove in the waiting room. “I get that you are from out of town and hotels are expensive. We understand all that and we feel badly,” says Wocial. “But that doesn’t mean you may claim chairs in the lounge and literally camp out there for days.”

Clinicians need skills to de-escalate. “Nobody goes a day without some kind of conflict, but conflict management is a skill that is rarely taught,” says Wocial. “Security doesn’t need to be called every time.”

Learning how to navigate conflict is an essential skill, says Wocial, “if we in healthcare want to effectively address the incivility that feels omnipresent both in the hospital and in society at large.”

Wocial suggests quietly, respectfully telling patients, “You may not yell at me, throw things at me, or threaten me,” “I’m not sure you realize this, but you are talking very loudly,” or “Please tone it down.”

“And if that doesn’t work, there needs to be a mechanism to back it up,” says Wocial.

SOURCES

  • Mary Faith Marshall, PhD, FCCM, Director, Program in Bioethics/Co-Director, Center for Biomedical Ethics and Humanities, University of Virginia, Charlottesville. Phone: (434) 924-1934. Fax: (434) 982-3971. Email: mfm@virginia.edu.
  • Lucia D. Wocial, PhD, RN, Nurse Ethicist, Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis. Phone: (317) 962-2161. Email: lwocial@iuhealth.org.