When patient advocacy turns to bullying…how should healthcare providers respond? This article explores the ethical dilemma of coercive behavior, specifically bullying, by patients, families and substitute decision-makers, that is directed towards providers and healthcare support workers. We discuss some of the contributing societal and environmental factors, the ethical implications for healthcare leaders and suggest some practical options for managing bullying situations in hospitals.
Many thanks to my co-author Dr. Dave Neilipovitz.
A 35 year old man is referred to a neurologist for upper extremity weakness and tingling. He requests a certificate saying he is unable to work. After comprehensive testing and consultation with a colleague, the neurologist can find no underlying medical issue and refuses the request. The patient threatens to “come after” the doctor, her family and staff if she won’t complete the certificate, calling her office daily, and escalating his threats.
An 85 year old woman is admitted with a hip fracture. The family tells the surgeon “that we will be watching.” Even after explanations about the operating room booking priority system for urgent surgery, they threaten to call the media if the patient does not have her surgery “immediately.” Two hours later, they email their Member of Parliament, copying the hospital CEO and several media outlets, complaining about ageism and poor treatment of their elderly relative.
A 70 year old man is brought to the Emergency Department with a stroke. After providing care to treat his stroke and therapy to try to prevent future strokes, the medical team approaches the family about sending the patient to a stroke care rehabilitation facility (which is standard of care.) The family insists the patient remain in acute care and refuses to sign any referral papers. Each time the discharge team presses the issue over the next several weeks, the patient’s daughter calls the local television station and newspapers, complaining that her father is being “dumped to a nursing home.”
Intimidation and outright bullying of caregivers by patients or their families is an unpopular topic in today’s consumer-focused healthcare environment, however it is an emerging and increasingly prevalent concern. The impact of bullying is not yet fully explored, but it is recognized as a leading contributor to provider burnout, staff absenteeism, post-traumatic stress disorder, and ironically, as increasing adverse events for patients. While many constituencies are passing legislation to deal with physical violence against workers, the focus is on harassment from coworkers (lateral violence), and little is being done to address the problem of bullying by patients, families or their substitute decision makers (PFSDs).
This article explores the ethical dilemma of coercive behavior, specifically bullying, by PFSDs, that is directed towards providers and healthcare support workers. We discuss some of the contributing societal and environmental factors, the ethical implications for healthcare leaders and suggest some practical options for managing bullying situations in hospitals.
What is bullying behaviour?
Adapting from Powell, we define bullying as occurring when PFSDs use offensive, intimidating, malicious or insulting behaviour, along with a misuse of power, to undermine, defame or abuse the recipient, with the intention of forcing their will on the recipient. Bullying rarely involves overt physical threats; rather it typically includes verbal abuse and various other forms of reputational intimidation, including litigation or complaints to the hospital administration, media and higher government officials. An emerging form of bullying is through social media and/or using online rating systems to broadcast negative reviews – thus punishing health providers who do not accommodate the wishes of PFSDs.
The goals of the bullying can vary, but typically are those of obtaining unwarranted clinical management or preferential treatment. Unwarranted management includes medical care, treatments or investigations that are not indicated, have no proven benefit, are not funded by medical insurers, or do not follow the expressed wishes of the patient or their legally defined substitute decision-maker. Preferential treatment includes the desire to jump queues in obtaining care from various clinics/medical specialists, investigations, procedures or surgery; or to receive care in a location that is not required or the norm (e.g. intensive care unit, hospital, etc.). In essence, the expectation is for service that is different from the standard of medical and hospital care.
Bullying vs. Anger/Frustration
Illness places patients in a vulnerable situation where they often feel they have little control. They may be in pain, afraid of their prognosis, worried about their mobility/independence, and/or be under considerable economic strain. These factors contribute to situations where PFSDs may behave in uncharacteristic ways, due to their anger and frustration, often resulting in yelling or abuse.
Through their training, most healthcare providers learn at least the basics of working effectively with angry and frustrated individuals. Healthcare administrative leaders also receive training in conflict resolution and managing difficult situations. In general, the consensus seems to be that managing these difficult situations is an unfortunate part of the job; providers are largely responsible for dealing with it but should do so with dignity and respect. Unfortunately, in recent years, we have seen increasing incidence of overtly coercive behaviours that cross the line from anger and frustration to overt bullying.
A 2007 US study found high rates of coercive and threatening behaviour by patients in primary care. Although the study was small, 85% of primary care physicians reported being verbally abused with 61% reporting bullying behaviour and a further 41% acknowledging the need for police or security to remove a patient from their office. Cook et al surveyed internal medicine specialists, who reported that roughly three quarters of internists had experienced emotional abuse with over 25% of them having been physically abused. Although the literature does provide some information on physical abuse of physicians, particularly those who care for patients with mental illness, information on other forms of bullying is lacking or limited. Anecdotally however, most health care providers can recount examples of coercive behaviors.
Why is bullying on the rise?
The past two decades have brought widespread changes in consumer expectations regarding healthcare. This rise in expectations coincided with a relative reduction in the availability of resources to meet those expectations, inevitably leading to conflict when PFSDs are dissatisfied with the level of care or priority they receive.
In addition, people have easy, but unfiltered, access to information about illnesses and potential treatments, sometimes leading to incorrect conclusions. Also, compared to even a decade ago, it is easy to voice dissatisfaction, broadly and unrestrained, via social media – where aggressive behaviour and harassment is on the increase. While organizations are constrained from responding by privacy legislation, the Internet is an environment where people can say anything about anybody. Often as not, once the media gets involved, perception becomes reality and the grievance is judged in ‘the court of public opinion.’
Leaders have legal and ethical obligations to address the issue
While front line providers are experiencing increasing bullying and incivility, healthcare leaders are faced with an increasingly urgent need to address the situation. Most Canadian provinces and U.S. states have legislation requiring that organizations protect workers from workplace violence, including bullying. Healthcare employers are liable for harassment by patients, not just from other employees and have a legal responsibility to ensure that they provide a safe work environment.
Bullying presents an ethical challenge for leaders. While patient/family experience is a priority, the behaviour of bullying PFSMs unavoidably affects the care of other patients, either by diverting resources or through creating an unpleasant care environment. Bullying leads to negative health-related outcomes for providers, including reduced mental health-related quality of life. Finally, coping with bullying behaviours creates internal conflict as providers try to balance their duties to patients, customer service goals and reasonable expectations for personal safety and security. Absenteeism, provider burnout and other symptoms of unrelieved stress in the healthcare workplaces have become rampant, increasing costs and affecting providers’ ability to provide care. Leaders cannot ignore the impact of bullying and have an obligation to act.
This ethical obligation is referenced in the Canadian College of Health Leaders Code of Ethics, which states that the member shall:
- Employ sound management practices, including prudent use of resources
- Promote ethical conduct and best practices for discussing and addressing ethical issues and concerns
- Promote a healthy work environment that is safe and harassment-free, and that stimulates and makes the best use of employee skills, knowledge and experience
- Promote a safe environment for disclosure of ethical issues
Similar obligations are included in the Code of Ethics for The American College of Health Executives.
Do patients have ethical obligations and duties as well?
Much has been written about provider obligations and duties of care, particularly in an environment focused on improving patient experience yet little is written on patient obligations. However, increasingly, physicians, leaders and ethicists are suggesting that patients, and by extension their families, also have duties and obligations. Evans suggests that patients have the “negative duties of avoiding either uncivil behaviour or needless waste,” in addition to accessing healthcare responsibly.
Suggested guidelines/actions for addressing bullying, harassment and abusive behaviour
What is the best response when PFSMs engage in overt bullying behaviour? In our experience, the suggested action of calling security/police or discharging the patient from one’s care rarely have satisfactory outcomes. These actions remove the difficult individual(s) but do not address the conflict. It is also not an option for certain situations in which the patient cannot be safely discharged or transferred elsewhere. Although it is important to recognize that sometimes negative behavior can be due to factors beyond the control of the individual (e.g. fear, mental health issues, cognitive impairment, drugs, etc.), regardless of the cause, bullying behavior needs to be managed. Well planned and thoughtfully curated responses can minimize emotional reactions and ensure standardized, evidence based actions. In our organization we have employed a broad set of strategies that we attempt to customize to the individual situation. Our goal is always the same: to find the most appropriate treatment for the patient but address the bullying behaviour. Our recommendations are to:
- Evaluate the situation thoroughly and objectively to determine what may have triggered the undesirable behaviour. While bullying and abuse is never appropriate, often there are reasons for the behaviour that may warrant remedial action.
- Avoid labeling the PFSMs, either verbally or in the record, with any negative labels such as difficult, demanding, unreasonable or similarly subjective judgment, as they will invariably influence how all subsequent caregivers will interact with the PFSMs.
- Implement regular and well documented multidisciplinary team meetings to ensure good communication between providers.
- Involve specialized experts such as ethics, chaplaincy, psychology, legal and social work sooner rather than later, discussing broadly to be sure all perspectives are being considered.
- Develop a formal, written care plan and then stick to it. This plan is aided by bringing in a professional from outside the immediate clinical care team, such as professional practice or administrative expert; they can be helpful with objectivity, in developing consistent messaging, ensuring standardized care, improving institutional awareness and implementing escalation strategies.
- Begin with the traditional options for managing the situation, attempting to de-escalate the situation by acknowledging if mistakes or errors have occurred, along with addressing legitimate concerns – but concurrently setting boundaries, clarifying expectations, offering appropriate choices and setting up a realistic care plan.
- Consider using an Acceptable Behaviour Agreement (ABA). ABA’s for PFSMs are intended to clearly explain what aspects of the behaviour are inappropriate, describe the impact on others (including impact on patient care) and specifically detail potential outcomes if their behaviour continues.
- Engage Employee/Physician Assistance Programs as needed and encourage physicians, nurses and other health professionals to consult with their respective professional organizations.
- Document all interactions and responses carefully and objectively.
Organizational responses to bullying behaviour
While the above guidelines can go a long way towards helping clinical teams in addressing bullying behaviour, the growing prevalence of bullying and threatening behaviour by PFSMs suggests that the issue is no longer just for the clinical team and managers to solve. Instead, the issue also needs corporate attention, with commitment of resources, and senior management involvement.
An important first step is for organizations to strongly consider creating a formal Behavioral Management Team (BMT). The composition of the BMT can vary but should include committed representatives from various medical disciplines (e.g. internal medicine, psychiatry, critical care, surgery, etc.), nursing, social work, discharge planning, behavioural health, psychology, risk management, legal, ethics, and selected other professionals. The value of a BMT is that they can develop and maintain expertise in supporting the care team with these challenging situations. Some organizationshave found them highly successful and they also help front line caregivers feel supported and less alone.
A second step is for senior management team of the hospital to become actively involved in the issue of PFSMs bullying, with explicit commitment. There needs to be a true willingness to address this issue even though there is a potential for negative consequences, at least in the short term (e.g. negative media coverage). A coordinated plan, including consideration of likely media responses, will support employee/physician engagement and facilitate communication with PFSMs in such situations.
A final but very important step is to change the culture around the issue of PFSM bullying. While employees and physicians are often explicitly encouraged to report bullying behaviours, they are also implicitly incentivized to “let it go”. The let-it-go culture is reinforced by many factors but all have similar theme – there is a belief that nothing good will come of trying to tackle it. Fears over the potential problems that will arise from confronting the situation, such as negative publicity, disparaging ratings, complaints to professional colleges, inflammatory media and other negative outcomes, need to be overcome by a change of culture. The targets of bullying need to know that they will be supported and defended, and that their actions will make a difference.
The issue of bullying is an emerging issue that is likely to become a more significant problem in the future. Not only is the impact on health professionals profound, but the impact onto others is also substantial. Failure to address the issue will have consequences, including organizational reputation, provider engagement, legal implications and potential adverse events. We recommend that hospitals address the issue pre-emptively before they are forced to do so through further legislation or provider burnout/disengagement.