In a healthcare setting, a multitude of ethical and moral challenges are often present when patients and families direct uncivil behavior toward clinicians and staff. These negative interactions may elicit strong social and emotional reactions among staff, other patients, and visitors; and they may impede the normal functioning of an institution. Ethics Committees and Clinical Ethics Consultation Services (CECSs) can meaningfully contribute to organizational efforts 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 may assist institutional leadership in evaluating and monitoring 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 Ethics Consultants 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.
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, 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 safe, humane, and compassionate care. They are therefore well-positioned to help identify gaps and shortcomings in institutional policies and procedures to effectively manage incivility. When warranted, 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, many 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.
#1 – Patient incivility
Mr. W. is an 80-year-old man with chronic 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 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.
#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 has 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 and their recommendations for transition to hospice. 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 ethnically biased 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. In the worst cases, 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 toward 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. Popular media hypothesize stress, substance use, and COVID-19 pandemic fatigue as possible factors.14 There is little dispute that incivility is a serious problem in healthcare settings, but should it be the responsibility of an institution’s CECS to address and/or mitigate 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 communication challenges that CECSs and Ethics Committees can help 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.
• Uncivil behavior can compromise both individual clinicians’ and healthcare institutions’ Duty to Care. 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. However, 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.15,16 Despite the 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. 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.17,18 Similarly, disparaging comments and overt aggression by patients’ relatives may be manifestations of their frustration, fear, anguish, helplessness, and despair. Patients, friends, and relatives are subject to social, situational, medical, or allocational vulnerability.19 Incivility may also stem from stress related to financial hardships. Despite the strong urge to respond with anger or moral outrage, clinicians have an ethical imperative to investigate the underlying causes of these conducts and remediate them to the extent possible.
• Uncivil behavior places “bystanders” at risk for harm or suboptimal 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 the healthcare provider’s ability to demonstrate respect for patient autonomy. Uncivil behavior can place a vulnerable patient’s autonomy at risk. Addressing disruptive behavior distracts clinicians from the essential responsibility to attend to patients’ goals, values, and preferences. Similarly, when caregivers assert themselves inappropriately, the focus shifts to the directives of the caregiver and a patient’s previously stated wishes are diluted. As our second case illustrates, Mrs C.’s daughter’s incivility toward the clinical team may have undermined her mother’s wish to return home.
• Uncivil behavior places healthcare providers at risk for moral distress. Directly or indirectly, incivility can physically and psychologically impact healthcare workers, leading 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.20
• 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. Discharge from an institution must include a medically safe plan, referrals to physicians/hospitals, and expedited access to medical records. Withholding or delaying standard of care treatment for an uncivil patient’s medical condition as punishment is never acceptable. In the case of Mr W. withholding or delaying pain medication after he insulted the nurse fails to meet the fundamental tenet of relieving suffering.
Addressing incivility: The case for involving ethics
The American Society of Bioethics and Humanities (ASBH) is a driving force in the professionalization of CECSs and Ethics Consultants21 by establishing roles and responsibilities,22 core competencies,23 quality attestation,24 and avenues for credentialing.25 While we do acknowledge that addressing incivility may not be a core responsibility of Ethics Committees or CECSs, we maintain that Ethics professionals have a responsibility and obligation within their institutions to assist when disruptive behavior adversely impacts care delivery and staff morale. As healthcare institutions confront increasing incivility by patients and caregivers, Ethics Committees and CECSs aspire to possess the knowledge, skills, and experience in organizational and clinical ethics which can allow them to play an active role on two fronts.23,26,27 First, they can work with an organization’s leadership to identify gaps and shortcomings in institutional policies and procedures. Second, Ethics can assist stakeholders in individual cases of patient/caregiver incivility.
Specific roles that ethics committees and clinical ethics consultation services can play on an organizational level
• Ethics Consultants can assist institutional leaders in assuring that incivility policies and procedures are ethically sound. While it is not the primary responsibility of Ethics Committees to draft and enforce incivility policies, Ethics can be instrumental in ensuring that these policies acknowledge the multifaceted ethical challenges related to patient/caregiver incivility and treat all stakeholders—including perpetrators—ethically and with respect.
• Ethics Consultants and Committees can provide staff education and training in recognizing, reporting and managing incivility. Historically, clinicians have commonly disregarded or overlooked their patients’ or caregivers’ behavior for the sake of professionalism.15 Many are reluctant to complain,20 believing that experiencing such behaviors is a rite of passage,28 that infractions can be handled internally without assistance,12 or that reporting is voluntary.29 Moreover, many staff possess limited knowledge of reportable event criteria.20 With their training in clinical ethics and mediation, CECSs can assist institutions in promoting a “speak up” culture.22,30 Senior Ethics Consultants can participate in institutional efforts to train and support staff at all levels to recognize and proactively address burgeoning issues and/or maladaptive behaviors that may devolve into incivility. Discussions facilitated by CECSs can raise awareness of clinical ethics issues related to incivility and encourage early identification and remediation of uncivil behavior through techniques such as mediation.
• Ethics Committees can play an important role in encouraging and promoting consistent and comprehensive documentation and review of incivility cases and procedures. It is vital that institutions understand not only the “what” and “when” of patient/family incivility, but the “why” and “how” that may have led to them. Comprehensive documentation and analysis of incidents of incivility can allow for ongoing reflection and review of behaviors and responses, which can help inform best practices going forward. The documentation that is required of Clinical Ethics Consultations may serve as a model for documenting and analyzing incidents of incivility. Unlike most clinical consultations, whose documentations are primarily data and treatment/procedure-driven, each ethics consultation entails documentation that incorporates an analysis of the ethical nuances and constituents’ perspectives.31 These ethics consultation notes are designed to enhance continuity, promote transparency, enable quality improvement, and facilitate longitudinal reviews.31,32 Through documentation, Ethics Consultants record the ethical analyses of specific cases while also ensuring multidisciplinary communication of ethical issues. Ethics Committees may therefore be helpful with establishing institutional procedures for reporting and reviewing all cases of incivility that require an institutional response. Reviews of incidents of incivility can be similar to an institution’s adverse events protocols and may help organizations identify institutional deficiencies for recognizing and addressing incivility, as well as suggest mechanisms for raising awareness of patients with a history of uncivil infractions, thus preventing recurrence and escalation.33,34
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, and security) 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 senior Ethics Consultants. Senior Ethics Consultants possess experience and training in diffusing emotionally charged encounters, and by employing their enhanced interpersonal skills, emotional intelligence, and empathy, they are therefore well-positioned to address incivility.35–37 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 focus and analysis without emotional distractions.38 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. Maintaining neutrality allows Ethics to support and guide, and to safeguard that all voices, viewpoints, and moral obligations are recognized and addressed.
• Substantiate whether this is a true case of incivility. Poor communication between the patients/families and providers may lead to a premature labeling of an encounter as “uncivil.”39 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.40 Offending behaviors should meet institutionally established and documented criteria for incivility. We are not suggesting that Ethics Consultant or CECS should be required to “officially” substantiate or “approve” each case of an institution’s procedural response to incivility. However, in cases of ambiguity or uncertainty, the involvement of Ethics can ensure that the process of substantiation is fair and includes full consideration of ethical issues, especially the clinicians’ and organization’s Duty to Care and the patient’s Autonomy.
• Attempt to determine the causes of the behavior. With a focus on an ethics facilitation approach, ASBH advocates that ethicists possess core ethics knowledge and be proficient in assessment, process, and interpersonal skills.27 We hypothesize that with advanced diagnostic listening techniques41 and familiarity with mechanisms of defense,37 senior Ethics Consultants are well equipped 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.37,38 For example, an Ethics Consultant may identify systemic issues such as staff shortages that may lead to unmet patient 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 perceived delay in management of 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 delays due to staffing levels 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 could be the most effective and ethically permissible practice change—rather than simply facilitating individual solutions for a specific case.
• Apply assessment, conflict resolution, mediation, and limit-setting techniques to help mitigate and remediate behavior. Mediation is specialized training in conflict management that focuses on better understanding stakeholders’ viewpoints and the root causes of disruptive behavior.28,42 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.43,44 By asking the question, “Why is the individual acting this way at this time?” ethicists can assist in interventions to address patient and family concerns, temper discontent, and rebuild the patient/provider relationship. For example, in the case of Mrs C’s daughter, the Ethics Consultant facilitated a meeting in which the daughter and staff were 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. Mediation was successful, and Mrs C’s daughter consented to her transfer to a regular hospital room where she received adequate symptom management and died surrounded by family.
• Confirm that the appropriate clinical services, mental health practitioners, and support services are involved. From their neutral and unbiased perspective, Ethics Consultants can identify gaps in care and support. Their knowledge of institutional practices, resources, and history can be applied without the emotional distractions that the healthcare team may be experiencing. In this way, Ethics Consultants can facilitate patient and family access to appropriate and comprehensive clinical and supportive resources.
• Ensure that clinicians and institutions recognize and respect ethical principles—even under difficult circumstances and with the most trying patients and families. In theory, clinicians generally agree that bioethical principles must be applied to all people in an equitable manner, but does this happen in practice? When confronted with patient or family incivility, staff members’ annoyance or anger may cause them to consciously or unconsciously disregard these principles. It is the responsibility of clinical Ethics practitioners to help ensure that ethical principles are not forsaken. Incivility does not occur in a vacuum, and in all but the most egregious and/or dangerous occurrences of incivility, it is necessary to try to understand the context and complexities surrounding the offending behavior in order to address it in a safe and ethical manner through respectful discussion and analysis. Ethics Consultants can help identify these complexities and enumerate the ethical duties, principles, and rights that apply to all parties, regardless of their status as victims or perpetrators.
When remediation fails—The continued role of ethics
Management of incivility as outlined above can be essential in remediation or avoiding escalation. Unfortunately, there are instances when standard avenues prove insufficient and more extreme measures are required. While CECSs should not be tasked with enforcing incivility policies, they can continue to play a vital role in the following manner:
• 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.
• Provide guidance in enforcing of consequences. 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 access be restricted. Ethics Consultants can assist their healthcare organizations in carefully balancing the ethical issues so that the safety needs of the patient, other patients, caregivers, visitors, and employees are considered in the difficult decision to terminate care. Institutions are ethically obligated to ensure that the patient continues to receive appropriate clinical care. This may require medically safe transfer, referrals to other physicians/hospitals, and sharing of medical records with the patient/surrogate’s consent. In the case of Mr W, numerous candid discussions and attempts to remediate his verbal and physical abuse were unsuccessful. The hospital leadership and clinical team agreed to formally discharge Mr W. This decision was not made lightly.
• Review for lessons learned. Ethics Consultants may be involved in review of whether hospital policies were appropriately and ethically administered, and that appropriate documentation was made. This may include ascertaining that offending behaviors met institutional criteria for incivility, that perpetrators had been made aware of the expectations and consequences for their behavior, that the rights and responsibilities of all parties involved were respected, and that ethical principles were upheld in the enforcing of consequences. Ethics Consultants may also play a role in analysis after the fact to identify potential improvements in policies and procedures, with a particular focus on any potential ethical implications.
Limitations to ethics 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 identifying gaps and deficiencies in 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 persist 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. Ethics Committees and CECSs can play important roles by raising and addressing ethical issues in developing and implementing such policies and procedures, as well as in training and supporting staff so that they are empowered to identity and address incivility.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health grant P30 CA008748 to Memorial Sloan Kettering Cancer Center and by the Ethics Committee at Memorial Sloan Kettering Cancer Center.
ORCID iDs
Liz Blackler
Louis P Voigt
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