Is there a Role for Ethics in Addressing Healthcare Incivility?

Abstract

In a healthcare setting, a multitude of ethical and moral challenges are often present when patients and families direct uncivil behavior towards clinicians and staff. These negative interactions may elicit strong social and emotional reactions among staff and other patients and visitors, and they may impede the normal functioning of an institution. Ethics Committees and Clinical Ethics Consultation Services (CECSs) can play a vital role in implementing policies and procedures to effectively manage incivility through two distinct, yet inter-related channels. First, given their responsibility to promote a humane, respectful and professional climate, many CECSs and Ethics Committees work closely with institutional leadership to create, evaluate, disseminate, and monitor incivility policies and procedures. Second, when confronted with individual incidents of patient/family incivility, Ethics Consultants can and often do work with all stakeholders to address and mitigate potentially deleterious impacts. This manuscript presents an overview of the multifaceted ethical implications of incivility in the healthcare environment, discusses the inherent qualifications of CECSs for assisting in the management of incivility, and proposes specific mitigating actions within the purview of CECSs and Ethics Committees. We also invite healthcare organizations to harness the skills and reputation of their CECSs and Ethics Committees in confronting incivility through comprehensive policies, procedures, and training.

INTRODUCTION

In recent years, healthcare settings have witnessed tremendous rises in uncivil behavior perpetrated by patients and their surrogates.¹ In addition to impeding the normal functioning of an institution, these hostile behaviors can present multiple ethical and moral challenges as they elicit strong social and emotional reactions among staff and other patients and visitors. Within healthcare organizations, Ethics Committees and Clinical Ethics Consultation Services (CECSs) often work closely with leadership to promote a professional environment for the delivery of a safe, humane, and compassionate care.They are therefore well-positioned to assist in devising and implementing policies and procedures to effectively manage incivility. In certain cases, Ethics Consultants should work with stakeholders to address individual incidents of patient/family incivility. With their specialized training in ethics, law, societal norms, communication, and mediation, Ethics Consultants are uniquely positioned to meaningfully contribute to organizational efforts to address incivility and facilitate conflict resolution that ensures that all involved parties are treated in an ethically appropriate manner.

Case #1 – Patient Incivility:

Mr. W. is an 80-year-old man with multiple myeloma, for which he requires hemodialysis thrice weekly at an outpatient dialysis center. Throughout his illness and care, Mr. W. has demonstrated a longstanding pattern of manipulative behavior and difficult relationships with healthcare providers and staff. Several staff are uncomfortable being alone with Mr. W. In the past month, his behavior has escalated to include disregard of safety protocols (such as refusal to wear a mask), insulting staff, throwing objects, and making disparaging remarks about other patients, for which the security team was called three times. Mr. W has refused psychiatric referral. His oncologist and nephrologist concur that there is no element of delirium or severe cognitive impairment, and note that his worsening behavior is voluntarily, in that he is able to conform his behavior to expectations with some staff and when security officers are present.

Case #2 – Family Member Incivility:

Mrs. C. is a 64-year-old woman with recurrent ovarian cancer who has consistently expressed her desire to return home regardless of her prognosis. She was recently admitted to the ICU for rectal bleeding, hemorrhagic shock and delirium. Although her condition has improved to allow for transfer from the ICU to a regular room, she had not regained decision making capacity. Mrs. C’s daughter, her primary healthcare agent, has been dismissive of the multiple specialists involved in her mother’s care. She calls the ICU multiple times each day, demanding to speak to an “American-born” attending physician. Multiple hospital staff report that she uses profane and offensive language – including racist and ethnic comments. Numerous attempts by clinical and support staff to stifle these exasperating actions have been unsuccessful.

INCIVILITY IN THE HEALTHCARE SETTING: AN INCREASING PROBLEM

‘Incivility’ is defined as an act of verbal, nonverbal, physical, or social media intimidation or abuse.² It may entail insulting, racist, sexist, lewd, derogatory, threatening or otherwise inappropriate language, symbols, gestures, imagery, intimidation (using proximity), or overt aggression. Worst-case, incivility may escalate to hostile and aggressive interactions, or even violent physical assaults.³ Airlines, fast food venues, retailers, small businesses, and restaurants all report significantly higher rates of verbal abuse and physical violence towards staff.⁴ This behavior appears to be increasingly acceptable, even encouraged, in certain arenas of our society and has seeped into aspects of healthcare.^{3, 5–8}

Both clinical and nonclinical healthcare staff have recently experienced increases in uncivil behavior perpetrated by patients and their surrogates.¹ In the United States (US), healthcare workers face more direct verbal and physical assaults than any other groups, and they are disproportionally victims of aggravated assaults, shootings and other serious acts of violence.^{9, 10} Studies of non-psychiatric healthcare settings reveal that nurses, patient care technicians (PCTs), physicians, and trainees all report increases in verbal and physical abuse, with nurses and PCTs experiencing the highest rates of victimization.^{7, 11–13}

INCIVILITY IS AN ETHICAL ISSUE

It is beyond the scope of this paper to comprehensively analyze the societal underpinnings for this increase in incivility, but there is little dispute that it is a serious problem in healthcare settings. But should an institution’s CECS be responsible for addressing and/or mitigating incivility? We maintain that while responding to uncivil behavior on the part of patients and caregivers does not fall squarely within the traditional Bioethics wheelhouse, these unfortunate incidents are often manifestations of ethical conflicts or challenges that CECSs and Ethics Committees can help to identify and mediate in compassionate and effective ways. The role of Ethics Consultants is not to condone, rationalize, or quell instances of incivility, but rather to ensure that all constituents – even uncivil ones – are respected and that patient care is not compromised.

Incivility and its repercussions pose multifaceted ethical challenges within a healthcare setting and require analysis and consideration.

• Both an individual clinician’s and a healthcare institution’s Duty to Care can be compromised by uncivil behavior. Healthcare providers and their institutions are bound by legal and moral standards to act in an appropriate, ethical and fair manner to all patients – even those who act uncivilly. Despite professional obligation to treat unpleasant, hostile, and even potentially dangerous patients, even the most altruistic healthcare providers are not impervious to the effects of witnessing or experiencing uncivil behavior. Acts of verbal, nonverbal, physical, or social media intimidation or aggression can irreparably damage the therapeutic patient-provider relationship and jeopardize clinically appropriate care and health outcomes.^{14, 15} On an institutional level, leadership is confronted with the need to judiciously create policies and procedures that protect the institution and all who enter its doors, while at the same time guaranteeing clinically appropriate care and preserving the dignity of patients and families who exhibit uncivil behavior.

• Duty to Care obligates clinicians and support staff to recognize that uncivil behaviors may be the manifestation of underlying and/or potentially corrigible physiological, psychological, or psychosocial challenges. These can include (but are not limited to) psychiatric illnesses, treatment side-effects, disease progression, pain, and cognitive dysfunction.^{16, 17} Similarly, disparaging comments and overt aggression by patients’ relatives may be manifestations of their frustration, fear, anguish, helplessness, and despair. Patients who experience such complications and their friends and relatives are subject to social, situational, medical, or allocational vulnerability.¹⁸ Despite the strong urge to respond with anger or moral outrage, clinicians have a moral imperative to investigate the underlying causes of these conducts and remediate them accordingly.

• Uncivil behavior places “bystanders” at risk for harm or sub-optimal care. When healthcare providers are forced to divert finite resources (such as time and emotional and intellectual bandwidth) to manage incidents of incivility, other patients, families and staff suffer. As noted in the case of Mr. W., his maladaptive behaviors require additional staff to attend to his needs, thereby shortchanging or delaying the care of other patients. Moreover, verbal and physical aggressions can create chaotic and toxic healthcare settings – not the inclusive, welcoming, serene, and healing environments desired by patients and clinicians.

• Incivility may threaten patient autonomy. Uncivil behavior can place a vulnerable patient’s autonomy at risk by creating barriers to their care. As our second case illustrates, Mrs. C.’s daughter’s incivility toward the clinical team may have impeded her incapacitated mother’s wishes to return home.

• Uncivil behavior places healthcare providers at risk for moral distress. Directly or indirectly, incivility can physically and psychologically impact healthcare workers, which may in turn lead to compassion fatigue, workplace dissatisfaction, and/or suboptimal performance. Clinicians who receive racist, sexist or demeaning/derogatory comments are more likely to withdraw from clinical roles, be less attentive to learning, and experience increased emotional burdens and self-doubt compared to colleagues who were not subjected to these invectives.⁷ Uncivil behavior has been demonstrated to result in an increase in absenteeism, thoughts about leaving the healthcare profession, and staff turnover.¹⁹

• Responses to incivility must be fair, proportional, and just. Careful ethical scrutiny must be applied to institutional responses to incivility. Behavioral expectations and consequences for offending conduct must be consistent regardless of one’s financial, celebrity, insurance, or other status. At the same time, consequences for uncivil behavior must be both proportional and clinically sound. Thresholds for “firing” patients should be carefully considered and take into account the potential risks to the patient. Withholding, delaying, or minimizing standard or proven treatment for an uncivil patient is never acceptable. In the case of Mr. W., denying or delaying pain management after he insulted the nurse might fail the fundamental tenet of moral integrity.

ADDRESSING INCIVILITY: THE CASE FOR INVOLVING ETHICS

As healthcare institutions confront increasing rates of incivility by patients and caregivers, Ethics Committees and CECSs possess the knowledge, skill sets and experience in both organizational and clinical ethics which can allow them play an active role on two fronts. First, they can work with an organization’s leadership to create ethically-sound institutional policies and procedures. Second, Ethics can assist stakeholders in individual cases of patient/caregiver incivility.

Specific Roles that Ethics Committees and CECSs Can Play on an Organizational Level:

• Bioethicists can assist institutional leaders in the development of incivility policies and procedures. Ethics Committees can be instrumental in ensuring that these policies acknowledge the ethical challenges related to patient/caregiver incivility and treat all stakeholders - including perpetrators - ethically and with respect.

• With their training in clinical ethics and mediation, CECSs can assist institutions in promoting a “speak up” culture. Similar to the guidance that they provide on ethics-related issues, Ethics Consultants can provide training and support that empowers staff at all levels to proactively and compassionately address burgeoning issues and/or maladaptive behaviors that may devolve into incivility. Historically, clinicians have commonly disregarded or overlooked their patients’ or caregivers’ behavior for the sake of professionalism.¹⁴ Many are reluctant to complain¹⁹, believing that experiencing such behaviors is a rite of passage²⁰, that infractions can be handled internally without their assistance¹², or that reporting is voluntary²¹. Moreover, many staff possess limited knowledge of reportable event criteria.¹⁹ Routine, institution-wide, multidisciplinary programing and discussions can raise awareness and encourage early identification and remediation of uncivil behavior.

• Ethics Committees can play an important role in establishing and promoting consistent and comprehensive documentation and review of incivility cases and procedures. Analysis and documentation are integral – and required – components of the ethics consultation process. Bioethicists therefore may be helpful with establishing institutional procedures for reporting and reviewing all cases of incivility that require an institutional response. Examination of reported incidents of incivility can be similar to an institution’s adverse events protocols and may help identify mechanisms for flagging patients with a history of uncivil infractions and preventing recurrence and escalation.^{22, 23}

Specific Roles that Ethics Consultants Can Play with Individual Cases on a Local Level:

Members of an institution’s multidisciplinary support team (including Patient Representative/Advocate, Psychiatry, Social Work, Spiritual Care, Security, and Law Enforcement) possess the tools to mediate aggression while supporting patients and caregivers. However, there are situations where clinical and/or support teams may request assistance from Ethics Consultants, who are trained to diffuse these emotionally charged encounters and are well-positioned to address incivility.²⁴ When asked to participate in individual cases of patient/family incivility, the Ethics Consultant’s primary responsibilities should be the following:

• Maintain positions of neutrality. Ethics Consultants are trained to set personal beliefs and interests aside to allow for a focus and analysis without emotional distractions.²⁵ Consultants are usually not personally or professionally connected to either patients or family members, nor are they the recipients or witnesses of the uncivil behavior. Ethics is notably positioned to offer support and guidance and to safeguard that all voices and viewpoints are recognized to ensure that the moral obligations of all parties are addressed.

• Substantiate whether this is a true case of incivility. Poor communication between the patients/families and providers may lead to a premature labelling of an encounter as ‘uncivil.’²⁶ In the era of patient-centered care, patient (and caregiver) self-advocacy should be expected. Staff must be careful not to mischaracterize an intense manifestation of self-advocacy as incivility.²⁷

• Attempt to determine the causes of the behavior. With a focus on an ethics facilitation approach, the American Society of Bioethics (ASBH) advocates that ethicists possess core ethics knowledge and be proficient in assessment, process and interpersonal skills.²⁸ Ethics Consultants have the moral capacity and fortitude to engage in uncomfortable conversations. Without condoning uncivil behavior, they may be helpful in illuminating its underlying causes. A thoughtful ethical analysis may pinpoint specific causes, ease tensions, and reestablish a working patient-provider relationship.²⁵ For example, an Ethics Consultant may identify systemic issues such as staff shortages that may lead to unmet patients’ needs. Mrs. C.’s daughter’s vituperations and demands on hospital staff - while inexcusable in tone and tenor - may be indicative of her distress from a delay in symptom management for her mother’s agonal breathing. In a situation like this, an Ethics Consultant possesses the institutional knowledge and legitimacy to both respond to Mrs. C.’s daughter and call attention to how treatment delays due to staff attrition may have contributed to the daughter’s growing frustration. For the long-term well-being of patients, families and staff, recognizing and addressing such systemic issues would be the most effective and ethically permissible practice change - rather than simply facilitating individual solutions at local level.

• Apply assessment, conflict resolution, mediation, and limit-setting techniques to help mitigate and remediate behavior. Mediation is specialized training in conflict management that focus on better understanding stakeholders’ viewpoints and the root causes of disruptive behavior.^{29, 30} Assessment and mediation skills help Ethics Consultants identify and address the multitude of concerns raised by uncivil behavior and to provide resources for resolving conflict.³¹ By asking the question, “Why is the individual acting this way at this time?” ethicists can assist in interventions to address the patient’s and family’s concerns, tamper discontent, and rebuild the patient/provider relationship. For example, in the case of Mrs. C’s daughter, the Ethics Consultant may facilitate a meeting in which the daughter and staff are given an uninterrupted opportunity to voice their concerns and define interests and priorities regarding the patient with the goal of finding common ground and identifying mutually acceptable approaches going forward.

• Confirm that the appropriate clinical services, mental health practitioners and support services are involved. Ethics Consultants can facilitate patient and family access to appropriate and comprehensive clinical and supportive care.

• Assure relevant ethical principles are identified and adhered to. In a system-wide context, ethicists can credibly articulate the ethical complexities surrounding patient/family incivility. For individual cases, an Ethics Consultant’s analysis can identify the duties, principles, and rights that apply to all parties involved. They can therefore ensure that institutional procedures and policies are fairly and ethically created and implemented, and that all parties (regardless of their status as victims or perpetrators) are treated fairly and objectively.

When remediation fails - the continued role of Ethics:

Prevention of incivility is essential. Healthcare organizations and their leaders have a moral obligation to promote a climate of transparency where employees feel protected. They must shield both staff and patients and their caregivers against microaggressions and less subtle forms of abuse that can create unsafe environments, which in the very worst of cases may deteriorate into physical violence. Unfortunately, there are instances when standard avenues for conflict resolution are insufficient and more severe measures are required. In such cases, CECS can continue to play a vital role in the following manner:

• Ensure that protocols are followed. Ethics Consultants can safeguard that hospital policies are appropriately and ethically administered and well documented. This may include ascertaining that offending behaviors meet institutionally-documented criteria for incivility, that perpetrators have been made aware of the expectations and consequences for their behavior, and that the rights and responsibilities of all parties involved are respected.

• Offer Staff Support. Under the unfortunate circumstances when physical, emotional or moral injury is sustained by the staff or institution, Ethics Consultants - in concert with institutional services such as Social Work, employee health, peer groups, and Employee Assistance Programs - can provide support and debriefings to those affected.

• In the rare cases of patient discharge or revoking family visiting privileges, provide guidance as needed. The goals of an incivility policy are de-escalation and remediation of offending behaviors and continued patient care. Some egregious cases, however, require that the patient be discharged from care or a caregiver’s presence restricted. Healthcare organizations must carefully balance the safety needs of the patient, other patients, caregivers, visitors, and employees against the difficult decision to terminate care. Institutions are ethically obligated to ensure that the patient continues to receive comparable clinical care, which may require medically safe transition, referrals to physicians/hospitals, and access to medical records. In the case of Mr. W, numerous candid discussions and attempts to remediate his verbal and physical abuse directed towards hospital staff and other patients were unsuccessful. Hospital leadership and clinical team agreed to formally discharge Mr. W. This decision was not made lightly.

LIMITATIONS TO ETHCIS INVOLVEMENT IN INCIVILITY

It is not always necessary or appropriate for CECSs and Ethics Committees to be involved in incivility-related cases. Some manifestations of incivility are beyond remediation and place others at risk for significant harm. Security and law enforcement resources must be available as necessary to maintain safety. CECSs and Ethics Committees can and should play a role in devising how institutional policies, procedures, personnel and other resources are developed and implemented, but they must also be prepared to cede involvement when the situation warrants. Deploying Ethics Consultants in appropriate incivility-related situations requires additional time and resources. We recognize that institutions with small CECSs may not have the resources to manage significant additional responsibilities regarding patient or family incivility. Finally, some Ethics Consultants will require supplementary or enhanced training to appropriately address these new responsibilities.

CONCLUSION:

Insufficient institutional policies and procedures to consistently address workplace violence, bullying, and incivility persists in many health care institutions. Sound organizational ethics mandates comprehensive policies which codify acceptable behavior for patients, visitors, and staff as well as organizational responses to unacceptable behavior. These policies are needed to establish accountability and consistency, which are essential for the ethical management of incivility. They are also vital for recognizing and managing staff distress, mistrust, and burnout. With adequate policies and commensurate training that appropriately utilize Ethics Committee and CECSs, staff are empowered to identity and address incivility.