By Stacey Kusterbeck
For hospitals attempting to address workplace violence, the focus typically is on concrete interventions: Providing de-escalation training, adding metal detectors, or bolstering security. What is less well-understood are the ethical implications of violence.
“Oftentimes, the clinicians who are confronted with the violence feel alone. Physically, they may be alone in a room with somebody who is being violent. But clinicians are often morally alone, as well,” says Tim Lahey, MD, MMSc, HEC-C, director of clinical ethics at University of Vermont Medical Center.
Clinicians struggle with competing obligations — to the patient, and to keep themselves safe from harm. “Clinicians can feel divided. They have the natural human instinct to be safe and remove themselves from that threat. But they have a bedrock belief that they should provide needed care and should be in a therapeutic relationship with this person also,” explains Lahey.
In this ethically complex situation, clinicians may experience guilt for “abandoning” the patient/physician relationship. “Clinicians are in this horrible bind, where they might feel obligated to subjugate their natural instinct to feel safe, or they may honor their natural instinct to feel safe. And then they feel guilty — that they are a bad nurse or doctor. It’s that conflict of moral obligations that is the space for ethicists to help,” asserts Lahey.
Instead of leaving clinicians to struggle with all this alone, ethicists can offer assistance proactively. Ethicists discuss the violence in terms of ethical principles. “We can explain, for instance, that the clinicians’ professional obligation to help somebody does have limits,” says Lahey. Ethicists can help clinicians focus on their duty to provide the standard of care, and to avoid conflict, and to protect a safe work environment. “Ethicists aren’t the only resource for clinicians managing violence in the hospital,” Lahey acknowledges. Employee assistance programs or peer support programs can help clinicians with the fallout of violence when it occurs. However, there also is a need to address violence on a systemwide level. Ethicists can do that by helping to update policies and identifying ways to reduce the likelihood of threats. “By virtue of bridging individual clinical situations and institutional policy, we can help institutions bring to bear the types of team responses that can help clinicians not feel so alone,” says Lahey.
Ethicists routinely consult on cases where a patient’s medical condition leaves few good treatment options. Clinicians accept that if the prognosis is poor, technology only allows them to help in certain ways. Lahey says that this is an ideal jumping-off point for ethicists to talk about workplace violence. Ethicists can explain that similar limitations exist for patients acting out violently in a healthcare setting. “Sometimes clinicians can have unrealistic expectations of themselves — that when someone is swinging a fist at them, that they can magically restore the therapeutic alliance,” explains Lahey.
Ethicists can help to disavow clinicians of this notion. During consults, it is part of the ethicist’s role to help people recognize when ideal outcomes are not possible and to identify outcomes that actually are achievable.
In the case of violent patients, ethicists can help clinicians focus on what is possible. That could mean de-escalating conflicts and addressing reasonable patient requests in non-stigmatizing ways. At the same time, clinicians must maintain healthy boundaries (such as withdrawing non-urgent care if patients are threatening).
Ethicists can bring home the message that each episode of violence, or potential violence, requires individualized team care. “Bread-and-butter clinical ethics work involves bringing together the right stakeholders around a given case to discuss what the right way forward looks like,” says Lahey.
This expertise proved vital when clinicians at University of Vermont Medical Center were struggling with how to manage violent encounters. Lahey brought together a multidisciplinary team on how clinicians should balance competing values in this situation. “Much of that work included listening to stakeholders,” recalls Lahey. Nurses talked about what they needed in terms of institutional support. Security described what they do to de-escalate patients. Patient representatives discussed ways healthcare workers sometimes can escalate conflicts unintentionally.
“That’s what ethicists can do. We don’t have to be experts in all of those realms or have the time to do all the work. But if we can help to convene the conversations, and guide that process of bringing in those sources of expertise, then suddenly we have a team on the bedside,” says Lahey.
When policies on workplace violence are being developed, input is needed from security, chaplains, social workers, and psychiatrists. “Those are the same people who can provide the direct, hands-on support that clinicians need — who are going to be helping with a violent person in the emergency department,” says Lahey.
Some clinicians accept violence as being part of the job, which likely leads to burnout. The team approach implemented by Lahey circumvents this. If a clinician knows that security has de-escalation skills, that psychiatry is available to reduce patients’ agitation, and that ethicists affirm that the clinician can step away from care until they can be safe, burnout becomes less likely. “Suddenly, now the clinician has backup,” says Lahey. “The moral decisions are not something they have to tangle with on their own. Instead, they are doing so with a group of trusted peers.”
Ethics expertise is valuable before, during, and after violent incidents. “Sometimes the needed intervention happens before violence happens. Sometimes it happens in the moment, when somebody has been hit and we are deciding whether we can still provide medical care despite the risk,” says Lahey. In other cases, a healthcare provider needs counseling or psychological help to debrief after a violent incident.
For ethicists, getting involved in efforts to address workplace violence is part of a bigger picture. It can alert hospital leaders to the importance of ethics work. “Most healthcare institutions have a violence problem, and are trying to figure out how to deal with it. If the ethicists help to bring the team together, the institution may be more interested in supporting that ethicist,” suggests Lahey. It also is an opportunity to demonstrate the return on investment of ethics, from a financial standpoint. “Ethicists almost never make institutions money. We don’t bill. But we do save a lot of money. We help institutions avoid lawsuits, or the delivery of unnecessary end-of-life care. In the case of violence, we help avoid the many costs of nursing burnout and attrition,” Lahey argues.
Ethicists also can make sure that workplace violence policies are followed consistently. “Ethicists can encourage data collection on activation of behavioral event response teams to monitor for hidden bias,” says Lucia Wocial, PhD, FAAN, RN, HEC-C, senior clinical ethicist and assistant director at the John J. Lynch Center for Ethics at Medstar Washington Hospital Center.
For instance, ethicists can determine if there are a disproportionate number of calls for minority patients. Some electronic record systems flag a patient as potentially violent. These flags may stay in the chart indefinitely, despite resolution of the event that provoked the violence. “This stigmatizes patients and family members, and may result in substandard care,” warns Wocial.
REFERENCE
- Pilcher F, Shubkin CD, Marcolini E, et al. Ethical responses to violence toward health care workers. J Hosp Med 2024; Apr 2. doi: 10.1002/jhm.13355. [Online ahead of print].
For hospitals attempting to address workplace violence, the focus typically is on concrete interventions: Providing de-escalation training, adding metal detectors, or bolstering security. What is less well-understood are the ethical implications of violence.
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