“ERASE”-ing Mistreatment by Patients

Transcript

• 00:13Hi, my name is Doctor Kirsten Wilkins.
• 00:15I'm a professor in the Department of
• 00:17Psychiatry and I'm also Director of
• 00:19Medical Student Education and Psychiatry.
• 00:21I work clinically as a geriatric psychiatrist
• 00:23at the VA Connecticut Healthcare System
• 00:25and I'm pleased today to talk to you
• 00:27about erasing mistreatment by patients.
• 00:31Our learning objectives for today
• 00:33will be to discuss the prevalence
• 00:35and impact of mistreatment by
• 00:37patients on healthcare workers in the
• 00:39learning and clinical environments,
• 00:41identify potential barriers to
• 00:43addressing mistreatment by patients,
• 00:45recognize the different forms that
• 00:47patient mistreatment can take,
• 00:49and finally to apply at least
• 00:52three practical strategies for
• 00:53addressing mistreatment by patients.
• 00:56So first, a definition,
• 00:57what do we mean by mistreatment?
• 01:00In this talk, we'll focus
• 01:02specifically on verbal mistreatment,
• 01:03and the AA MC has defined
• 01:05mistreatment as any behavior,
• 01:07any behavior,
• 01:08intentional or unintentional,
• 01:10that shows disrespect for the dignity of
• 01:13others and unreasonably interferes with
• 01:15the learning process or clinical care.
• 01:17And we focus on verbal mistreatment
• 01:19as opposed as opposed to physical
• 01:21mistreatment in this video
• 01:23because in our experience,
• 01:24verbal mistreatment is a lot more
• 01:26common and insidious and people are
• 01:29often lacking in guidance or policies
• 01:31or procedures to help us determine
• 01:34how to respond when this occurs.
• 01:36The literature is rapidly growing
• 01:38in this area and I just would like
• 01:40to share a few take home points.
• 01:42Mistreatment and harassment
• 01:44by patients is unfortunately a
• 01:45common experience in healthcare,
• 01:47especially for women and people of color.
• 01:50Mistreatment and harassment can have
• 01:52a significant psychological impact and
• 01:54especially when endured over a lifetime,
• 01:56physiological impact.
• 01:59Healthcare workers often report
• 02:01uncertainty with how to address
• 02:02these situations when they occur,
• 02:04and unfortunately,
• 02:05those of us that work as supervisors
• 02:08don't always address it either.
• 02:10So given its prevalence and impact,
• 02:12why aren't we doing enough about it?
• 02:16I think we have to acknowledge
• 02:17there are some very real barriers to
• 02:20addressing mistreatment by patients.
• 02:21One we may not even recognize
• 02:23that mistreatment has occurred.
• 02:25Sometimes it can be quite subtle and
• 02:27if we aren't used to experiencing it,
• 02:29it may not be something that
• 02:31registers as mistreatment if we're a
• 02:32bystander or a targeted individual.
• 02:36Often times when we are mistreated by a
• 02:38patient, there's a freeze response and we
• 02:40don't really know what to say in the moment.
• 02:41This is very common and not having the
• 02:44language or a script to call on can make
• 02:47it very difficult to respond in the moment.
• 02:49Lack of time is often cited by staff members
• 02:52as a reason that they don't intervene.
• 02:54There's a sense of a very busy day in a
• 02:57in clinic or hospital rounds, and if I
• 02:59do make an intervention with a patient,
• 03:01how long is this going to take me?
• 03:04There's also an understandable fear that
• 03:06if I do address mistreatment by patients,
• 03:08the patient may escalate,
• 03:10become agitated or aggressive.
• 03:11And certainly we don't want that.
• 03:14There is a common fear of damaging
• 03:17the therapeutic alliance.
• 03:18As healthcare workers,
• 03:19we always want to help take care
• 03:21of our patients and we want them
• 03:22to come back for care.
• 03:23And sometimes there may be a fear that
• 03:25if we intervene when they mistreat us,
• 03:27that we may fracture that relationship.
• 03:30And lastly,
• 03:31many healthcare workers report that they
• 03:33aren't clear that they're going to get
• 03:35support from the institution or from
• 03:37their supervisors if they were to intervene.
• 03:40So let's introduce the erase framework
• 03:42as a stepbystep model for how to
• 03:45intervene with patient mistreatment.
• 03:47First,
• 03:48we have to expect that these things
• 03:50will happen and prepare accordingly.
• 03:52The R is for recognize the mistreatment.
• 03:56The A is to address the situation
• 03:59in real time.
• 04:00The CS is to seek support if you've
• 04:02been mistreated or support the targeted
• 04:05individual if you're a bystander.
• 04:07And the final E is to establish
• 04:08and encourage a positive culture.
• 04:10So let's take each of these step by step.
• 04:13How do we expect and prepare?
• 04:15Well,
• 04:16Attending workshops like erase training
• 04:18or bystander training and rehearsing
• 04:20exact language that you would say
• 04:22in the moment can be very helpful.
• 04:24As I mentioned earlier,
• 04:25it's very common that people have
• 04:26a freeze response when a patient
• 04:28says something biased or offensive.
• 04:30So thinking in advance about how
• 04:32you might respond can be helpful
• 04:34to prepare you for that moment.
• 04:36It's really important for those of
• 04:38us that work in supervisory roles
• 04:40to establish a safe and positive
• 04:42learning and clinical care environment.
• 04:44And by that we mean providing some
• 04:47anticipatory guidance to those
• 04:48trainees or junior staff members that
• 04:50may be new to our clinical setting.
• 04:53Anticipatory guidance might sound
• 04:54something like this from Wheeler
• 04:56and colleagues.
• 04:57It's important to us that everyone
• 04:59feel comfortable and supported here.
• 05:01I wish that expressions of bias never
• 05:03occurred, but unfortunately they do.
• 05:05Patients and families may be the source.
• 05:07I may be the source as well.
• 05:09I want to know when you're not
• 05:11feeling comfortable or supported.
• 05:12This really lays a nice groundwork
• 05:14for your your clinical team,
• 05:15your educational team,
• 05:16and hopefully opens the door for folks
• 05:19to feel comfortable talking about
• 05:21these incidents when they occur.
• 05:22The are of a race stands for
• 05:25recognizing mistreatment.
• 05:26Sometimes mistreatment is very obvious,
• 05:28and anyone in earshot
• 05:29would say that's not okay.
• 05:31Things like derogatory language,
• 05:33racial slurs and hate speech,
• 05:36aggressive behavior and tone,
• 05:37and sexual inappropriateness can all
• 05:39at times be very obvious and overt.
• 05:42Sometimes mistreatment is not as obvious.
• 05:45Some of our healthcare workers colleagues
• 05:49experience microaggressions regularly.
• 05:50Others may not experience them.
• 05:52If you're somebody that
• 05:54doesn't experience them,
• 05:55it really is incumbent upon you to
• 05:56be more attuned to the experience of
• 05:58others and to educate yourselves on
• 06:00how microaggressions can take place and
• 06:02manifest in the clinical care setting.
• 06:05Those problematic compliments
• 06:06that patients sometimes give us,
• 06:08that may be well intended but
• 06:10don't always feel very good when
• 06:12they when they're received by us.
• 06:14And sexual inappropriateness
• 06:15can be sometimes very overt,
• 06:17as I mentioned earlier,
• 06:18or it can be a little more subtle.
• 06:22So the A of a race stands for
• 06:24addressing it in real time.
• 06:25Well, what does that look like?
• 06:27It's important to emphasize that there's no
• 06:29one right way to respond in all settings.
• 06:32One must take into account their
• 06:34sense of safety in the moment,
• 06:35their comfort level with the patient,
• 06:37their personality style,
• 06:39the amount of time they have,
• 06:41the acuity of the situation, etcetera.
• 06:42And it's important to note that many
• 06:44of the strategies that we will discuss
• 06:46today will be appropriate for whether
• 06:48you are a bystander or a target, either.
• 06:50One might choose to respond in the moment,
• 06:53And we acknowledge that sometimes you may
• 06:55choose not to respond in the moment at all.
• 06:58You may just not have the emotional energy,
• 07:00bandwidth or time,
• 07:01or feel safe speaking up in the moment.
• 07:04And if you don't speak up in the moment,
• 07:06don't beat yourself up afterward.
• 07:08We would encourage you to still seek support
• 07:10and talk about this with trusted colleagues.
• 07:13Some other things to consider when
• 07:15you address mistreatment in real time.
• 07:17First,
• 07:18what is the purpose of this intervention?
• 07:21Sometimes when we address mistreatment,
• 07:22we're really wanting to just
• 07:24put a stop to the behavior.
• 07:25Other times mean we may want to use this
• 07:28opportunity to educate or explain to a
• 07:31patient why their behavior is problematic.
• 07:33Sometimes when we intervene,
• 07:35it's not because we think the
• 07:37patient is going to change.
• 07:38The patient may have dementia or delirium,
• 07:40they may be intoxicated,
• 07:41and it may not be a time to have an
• 07:44educational conversation with them.
• 07:46But we may want to intervene
• 07:47anyway because it sends a message
• 07:49to everyone else in the mill,
• 07:50you,
• 07:50other patients,
• 07:51staff members that what we just heard is
• 07:55really not consistent with the values
• 07:57of our institution and it's not okay.
• 08:00You want to also consider what's
• 08:01your relationship with the person.
• 08:03Is this someone that you've been
• 08:05seeing for several years and you
• 08:06have a good relationship and and
• 08:08therapeutic rapport with them?
• 08:10You may be able to have a really
• 08:12serious but but meaningful conversation
• 08:14about why something really isn't okay.
• 08:16If it's someone you've just met
• 08:18for the very first time,
• 08:19you may not be as sure what
• 08:22their response will be.
• 08:23What's the context or setting?
• 08:25Context or setting,
• 08:26don't excuse mistreatment by patients,
• 08:28but it may help us better prepare
• 08:30for how do we want to intervene?
• 08:33And lastly, what is your approach?
• 08:35Although the things that patients
• 08:38say may sometimes rise in us a
• 08:40lot of powerful emotions,
• 08:42it's important that we try to do our very
• 08:44best to maintain a professional demeanor
• 08:46and treat the patient with respect.
• 08:48And if we aren't able to do so because
• 08:50we have been so hurt or we're so upset,
• 08:52then that's a wonderful time for our
• 08:54colleagues who are bystanders to become
• 08:57upstanders and intervene on our behalf.
• 08:59So let's go through some three common
• 09:02problem examples of mistreatment by
• 09:04patients and some suggested interventions,
• 09:06Problem #1, derogatory language.
• 09:08Some examples are listed here.
• 09:11In this case,
• 09:12anyone in earshot's going to recognize
• 09:14this is mistreatment and it's not okay.
• 09:16And so a suggested intervention in
• 09:18this case is to set clear limits.
• 09:20Some sample language is provided here,
• 09:23some of which can be used whether
• 09:25you're the target or a bystander.
• 09:26We expect both patients and staff to
• 09:28be treated with respect in this clinic.
• 09:30We can't tolerate that kind of language.
• 09:33Mr. X, we're only trying to help you
• 09:35and that's really hard to do when you
• 09:37talk to our team members like that or
• 09:39when you use hurtful language like that.
• 09:42And we really like the use of
• 09:43the the term we in these kind of
• 09:46interventions because it signals this
• 09:48is the institution's recommendations
• 09:50or or rules here.
• 09:51This is not just one person being sensitive.
• 09:54This is something that's really
• 09:56inconsistent with the values of our
• 09:58institution and we can't tolerate that
• 10:00problem. Example #2 Microaggressions.
• 10:02Some examples listed here and there
• 10:05are numerous in the literature
• 10:07and numerous that our healthcare
• 10:09worker colleagues have experienced.
• 10:11For example,
• 10:12a patient may repeatedly address
• 10:13female staff as honey or sweetie,
• 10:15or referring to the male staff by
• 10:18their appropriate name or title.
• 10:19Or a patient may assume that a social
• 10:22worker or psychologist of color is
• 10:24a member of custodial services.
• 10:26In this case,
• 10:27education and explanation could be
• 10:29a helpful intervention as opposed
• 10:31to ignoring it,
• 10:32laughing it off or just moving on.
• 10:35But to actually address it,
• 10:37in the first example, one might say,
• 10:39as I introduce myself,
• 10:40I go by a B in the clinic and I appreciate
• 10:43you using my professional title.
• 10:45I want to be sure to use your
• 10:47preferred name as well.
• 10:48What do you prefer to be called?
• 10:50Or in the second example,
• 10:52a bystander could become an
• 10:53upstander and say something like
• 10:55as their name tag says,
• 10:56Jay is a social worker and a really
• 10:59important member of your healthcare team.
• 11:00The custodial service people wear
• 11:02royal blue shirts and they don't
• 11:03participate in healthcare appointments.
• 11:07Problem #3.
• 11:09Those quote complimentary comments.
• 11:12Most of us would agree that patients
• 11:14don't have any ill intent when they
• 11:16compliment us on our appearance
• 11:17or make assumptions about our
• 11:19skills based on our appearance.
• 11:21For example, I'm so lucky to have
• 11:23such a good looking nurse or I'm
• 11:24so glad to have an Asian clinician.
• 11:26You're also smart.
• 11:28However, continued stereotypes and
• 11:31objectifying comments can sort of
• 11:33chip away at professional boundaries
• 11:35between healthcare workers and patients,
• 11:37and they can serve serve to
• 11:39objectify or demean people,
• 11:40which is not helpful for
• 11:41the clinical care setting.
• 11:43And so in this case,
• 11:44a suggested intervention might
• 11:46be redirection or reframing.
• 11:48Mr.
• 11:49Why A/B is a really smart and skilled nurse.
• 11:51That's far more important than her looks.
• 11:53A bystander might say in the first example,
• 11:56if you were the targeted person,
• 11:58you might say missus D More important
• 11:59than my looks is that I take
• 12:01really good care of my patients.
• 12:03Now let's focus on what brings you in today.
• 12:05Again, a reframing followed by a redirection.
• 12:08Or in the last example,
• 12:10a target or bystander might say,
• 12:12our staff come from a diverse
• 12:13array of backgrounds.
• 12:14We're all exceptionally qualified
• 12:16to participate in your care.
• 12:19Unfortunately, we recognize that sometimes
• 12:21patients don't respond to feedback
• 12:23and they may continue mistreatment.
• 12:25In this case, involve a
• 12:27supervisor and seek backup.
• 12:29No one comes to work to be abused,
• 12:30and no one should have to
• 12:33tolerate harassment or abuse.
• 12:34It's okay to take a time out
• 12:36and step away from the patient,
• 12:38assuming they're medically and
• 12:39psychiatrically stable and there
• 12:41are no acute safety concerns.
• 12:43It's appropriate to say Mr.
• 12:44M's ex.
• 12:45We're going to need to terminate
• 12:47this conversation or the appointment,
• 12:49as we can't provide good care
• 12:51for you without mutual respect.
• 12:52Will return in an hour if
• 12:54it's an inpatient visit or if
• 12:56it's an outpatient visit.
• 12:57You'll need to reschedule this appointment,
• 12:59and we expect that we'll be
• 13:00mutually respectful next time.
• 13:04The S of a race is support,
• 13:06seeking it if you've been targeted
• 13:08by mistreatment and providing it.
• 13:09If you're a bystander,
• 13:12a simple checkin can go a long way.
• 13:14Everyone has different
• 13:15responses to these things.
• 13:16Some people may be very upset,
• 13:18others may not be quite as upset,
• 13:20and so we don't want to make
• 13:22assumptions about how somebody
• 13:23feels after an encounter like this.
• 13:25But just asking an individual or as part
• 13:27of your team debrief and acknowledging
• 13:29that was a difficult encounter.
• 13:31How is everyone feeling right now?
• 13:34It's important to involve the
• 13:36targeted individual in decision
• 13:38making about next steps.
• 13:39Sometimes the temptation is,
• 13:41as a supervisor to remove
• 13:43somebody from the care of a
• 13:45patient that has mistreated them.
• 13:46But we hear from our trainees
• 13:48and junior staff that sometimes
• 13:49this serves to further disempower
• 13:50them and that they would actually
• 13:52like to be part of that process.
• 13:54As a supervisor, you might then say,
• 13:56I can understand how continuing
• 13:57to work with Mr.
• 13:58Z could be difficult.
• 14:00We have a couple of options,
• 14:02and I'd like to hear which
• 14:03one feels right to you.
• 14:05Therefore,
• 14:05you include them in the conversation
• 14:07and empower them to help make a
• 14:09decision about what happens next.
• 14:10Would they like to continue to care
• 14:12for the patient with appropriate
• 14:13supervision or a chaperone in the room?
• 14:15Or do they feel that the
• 14:16relationship has been so fractured
• 14:18that they're really unable to
• 14:19provide care for the individual?
• 14:23And lastly, support is an
• 14:25opportunity to empower people to
• 14:27report and share these incidents,
• 14:29as well as speak up when it happens to them,
• 14:32a bystander might say to a colleague
• 14:33after an episode of mistreatment.
• 14:35Supervisors want to hear
• 14:36when these things happen.
• 14:37It's important that everyone feels
• 14:39supported and comfortable here.
• 14:41Or supervisor might say I'm
• 14:42glad you told me and I want you
• 14:44to feel empowered to speak up
• 14:45even when I'm not in the room.
• 14:47Please know that you'll always
• 14:48have my support and institutions
• 14:50may also have local reporting
• 14:52mechanisms for extra support or
• 14:54requesting training for a team.
• 14:58The final E is to encourage or
• 15:00establish a positive culture.
• 15:01How do we do that? Well,
• 15:03having trainings like a race or other
• 15:06bystander trainings for all members of the
• 15:08healthcare team can be very important.
• 15:10This is not just an issue for doctors,
• 15:12nurses. It really impacts everyone on
• 15:16the team. Educating, our colleagues,
• 15:19educating yourselves.
• 15:20Again, if something like microaggressions
• 15:22is not something you experience regularly,
• 15:24learning about them and how they can
• 15:26manifest and how you can be an effective
• 15:28upstander or bystander is really important.
• 15:30Learning about the impact of implicit
• 15:32bias on care and the impact of
• 15:34racism in the clinical care setting.
• 15:38As we mentioned earlier,
• 15:40setting up expectations at the
• 15:41beginning of a rotation or when
• 15:43you're welcoming junior staff to
• 15:44the team can be very helpful.
• 15:46And then regularly checking in with
• 15:47them and discussing these concerns,
• 15:49making it clear this is something
• 15:51that the team wants to help solve.
• 15:52This is not an individual problem,
• 15:54this is a team problem.
• 15:57And it's important to make sure that all
• 15:59healthcare workers know who they can go to,
• 16:01who are the point people,
• 16:02and who are the resources if they
• 16:04don't feel like they're getting
• 16:05that sort of support that they
• 16:07need from their immediate team.
• 16:09And lastly,
• 16:09institutions should think about policies,
• 16:12codes of conduct,
• 16:13procedures for reporting verbal
• 16:15mistreatment by patients,
• 16:16as well as signage to help promote a
• 16:19culture of inclusivity and support.
• 16:22One example of a sign that has been used
• 16:24at the VA mental health clinic is this one,
• 16:25which spells out specifically the
• 16:27kinds of things that won't be tolerated
• 16:30and notes that this is a place of
• 16:31healing and these kinds of things are
• 16:33not congruent with a place of healing.
• 16:37So let's review the erase framework.
• 16:40First, we will expect that unfortunately
• 16:42these events will likely continue to happen,
• 16:44and let's be prepared to deal with them.
• 16:47Second, we want to recognize the
• 16:49mistreatment and again make a
• 16:51concerted effort to consider the
• 16:53experiences in the viewpoints of
• 16:54all members on the healthcare team.
• 16:56The A is for addressing the situation
• 16:59in real time whenever possible.
• 17:02CS is for seeking support if you've
• 17:04been targeted or supporting your
• 17:06colleagues if you've been a bystander.
• 17:08And the final E is to establish and
• 17:11encourage a positive culture where
• 17:12this issue is addressed, talked about,
• 17:15and institutional policies are enacted
• 17:18to help support healthcare workers.
• 17:21I'd like to acknowledge my colleagues
• 17:23who cocreated a race with me,
• 17:24Doctor Callie Cyrus and Doctor
• 17:26Matthew Goldenberg.
• 17:27I'd also like to acknowledge and
• 17:29thank the VA Mental Health Anti
• 17:31Racism Coalition and the Yale,
• 17:33Connecticut Older Adult Collaboration
• 17:35for Health Coach 4M.
• 17:37Thank you.