Addressing Mistreatment of Providers by Patients and Family Members as a Patient Safety Event Free

We conducted a single-center interventional study at a 213-bed university-based tertiary care children’s hospital in the northeastern United States between November 2018 and December 2019, which used two cross-sectional evaluations: before and after the intervention.

Nursing and physician leadership collaborated to develop the intervention strategy, which used the existing safety culture and treated mistreatment by patients and family members as an adverse patient safety event.³⁵  Our intervention included interprofessional training, modification of the patient safety incident reporting system, and development of a response protocol with escalation algorithm (Supplemental Information 1), which was based on recommendations of the US Occupational Safety and Health Administration.^33,34 

Between November 2018 and February 2019, we invited residents, faculty, and nurses to a 1-hour interprofessional educational training using the ERASE” framework (Expect, Recognize, and Address mistreatment, Support team members, and Encourage a positive culture) framework, which has previously been shown to improve provider knowledge and confidence in handling mistreatment by patients and family members.³⁶  The training was led by faculty with expertise in addressing mistreatment (K.M.W. and M.G.] and delivered in 3 sessions and 1 grand rounds, which included discussion of the interventional strategy and reporting of mistreatment through the electronic reporting system and response protocol. All sessions were recorded so that they could be accessed later.

We modified the hospital’s electronic safety incident reporting software RL Solutions to include reporting and tracking of mistreatment by patients or family members, as well as by other staff members. Quality and safety leadership and operational and physician leaders reviewed each report, after which they took actions to resolve the issue or further track for repeat events. Written feedback about each event was provided to the involved staff through e-mail, and a summary of the events and actions taken was provided monthly for unit staff meetings. Summary data of event frequency was distributed monthly to the children’s hospital leadership.

Before the intervention, we sent an anonymous Qualtrics survey to all faculty, nurses, and residents (pediatrics, combined internal medicine and pediatrics, and child psychiatry) in the children’s hospital through e-mail between November 2018 and January 2019 (Supplemental Information 2). The survey included multiple choice questions and open text responses for descriptive data. We sent a second survey to evaluate the effects of the intervention between June 2019 and September 2019 (6–8 months later), which was identical except for additional questions identifying the training sessions on mistreatment that the participant attended and assessing the participant’s knowledge of addressing mistreatment. We designed the surveys after a review of the literature, basing them on the Medical School Graduation Questionnaire from the Association of American Medical Colleges.⁵  We obtained content validation through reviews by departmental and hospital leadership and the Vice Chair of Diversity and Inclusion in the Department of Pediatrics. We pilot tested and revised the survey on the basis of feedback from faculty, trainees, and nurses. For both pre- and postintervention surveys, we sent the original invitation and 4 reminder e-mails. The study was reviewed by the university human investigative committee and was considered exempt.

Knowledge was operationalized as knowing that the organization has policies (yes/no) and a standardized approach to address mistreatment (yes/no). Self-efficacy was operationalized as (agree or strongly agree and disagree or strongly disagree) with the statements, “I intervene effectively when I am mistreated by patients or family members,” or, “I intervene effectively when I witness staff or trainees being mistreated by patients or family members.” Experiences of mistreatment were further subcharacterized by type (verbal threat, threat of physical harm, physical harm, or offensive behavior or remark made by patients or family members [based on gender, ethnicity/race, age, appearance, sexual orientation, disability, language proficiency, or other]) and frequency (a few times a year, a few times a month, or a few times a week). Frequent mistreatment was defined as occurring a few times a month or a few times a week.

Participants’ characteristics were summarized using descriptive statistics, such as count (percent) and mean (SD), and were stratified by role (faculty, nurse, resident) and evaluation period (pre- and postintervention). Unadjusted between-group comparisons (by role or by training, yes/no) were implemented using the χ² or Fisher’s exact test for all binary outcomes of interest describing knowledge, self-efficacy, and reporting of different types of mistreatment behaviors. To increase the response rate, we allowed our participants to choose to remain anonymous, which allowed a mixture of the same and new participants at follow-up. Therefore, the impact of the intervention on the outcomes of interest was only formally assessed descriptively at follow-up by comparing responses before and after the intervention. Follow-up survey data were analyzed using multivariable logistic regression to investigate the association between receiving training and the outcomes of interest, adjusting for role, gender, race, and ethnicity. Results were summarized using adjusted odds ratios (ORs) and surrounding 95% confidence intervals (CIs). Hypothesis testing was performed at the two-sided α-level of <.05 and for statistical trends, at the two-sided α ≤ .10. However, to draw conclusions, we relied not only on the P values^37,38  but also on the combination of the effect sizes (differences in percentages and ORs) and sampling variability (95% CIs), not discounting practically or clinically meaningful differences. SAS version 9.4 software (SAS Institute, Cary, NC) was used for the statistical analyses.

We received 309 finished preintervention surveys from 72 faculty, 191 nurses, and 46 residents, representing 39.1%, 27.1%, and 59.7%, respectively, of the total 835 HCPs eligible to participate (overall response rate, 37.0%). The characteristics of HCPs, by role who participated in the survey and eligible HCPs are shown in Table 1. The majority of respondents were female (208, 81.3%), White (214, 88.4%), and non-Hispanic (197, 83.5%). More children’s hospital faculty (48, 92.3%) who participated in the survey self-identified as White compared with all eligible faculty (127, 68.7%; P = .002). The residents were the youngest group, followed by nurses, with 35 (83.3%) and 53 (35.3%) reporting an age <31 years, respectively.

Of the HCPs, 214 (69.5%) had experienced verbal threats or intimidation from patients or family members within the previous year, with 70 (23.1%) and 35 (11.6%) experiencing the threat of and actual physical harm, respectively. Most of the HCPs reported that mistreatment was frequent, defined as occurring a few times a month or a few times a week; frequent verbal threat, physical threat, and physical harm were reported by 202 (65.6%), 67 (22.1%), and 34 (11.2%) of HCPs, respectively.

The types of mistreatment experienced by HCPs, by role, are shown in Fig 1. Residents were more likely than faculty or nurses to experience verbal threats (P < .05). Nurses were more likely than faculty to experience physical harm (P < .05). Offensive behavior or comments from patients and family members were most commonly based on age (85, 28.5%), gender (85, 28.5%), ethnicity or race (55, 18.5%), and appearance (43, 14.6%). Representative behaviors and comments are shown in Supplemental Table 4. Comments related to age were primarily based on being perceived as too young for patient care responsibilities (eg, “I was ‘fired’ as the RN due to looking ‘too young’”), whereas those related to appearance often focused on the provider being attractive (eg, “Referred to as Barbie doll” or “pretty”). Sex-based discrimination was most commonly associated with female gender, ranging from inappropriate sexual comments from male patients to not being acknowledged as a physician or being treated differently than male colleagues. The prevalence of the offensive behaviors varied depending on the role of the HCP. Faculty and residents were more likely to experience offensive behaviors based on gender than nurses (P < .001). Residents were more likely to experience offensive behaviors based on age than faculty or nurses (P < .001) and on appearance than nurses (P < .05). There was no difference across provider roles in the prevalence of offensive behavior based on ethnicity or race.

Of the 309 HCPs, 85 (27.6%) reported receiving training in the past on how to intervene or respond when patients or family members mistreat HCPs. Compared with the nurses, fewer residents reported receiving training (6 [13.0%] vs 61 [31.9%], respectively; P = .011), whereas 18 (25.3%) faculty reported receiving training. Only 78 (25.4%) HCPs knew that there were institutional policies about mistreatment by patients and family members (Table 2). The majority of HCPs believed that they could intervene effectively when they were the targets of or witnessed mistreatment by patients and family members (194 [63.6%] and 200 [65%], respectively). However, residents were less likely to report being able to intervene effectively than nurses when experiencing mistreatment (P < .001) and either faculty or nurses when witnessing mistreatment (P < .001).

After the intervention, 244 HCPs finished the second survey. Estimates of quantitative differences in demographic composition of samples (before and after) relative to each other did not reach notable effect sizes and statistical differences. In the postintervention survey, 84 (34.4%) HCPs reported receiving training (eg, ERASE) during the study period; in the baseline survey, 85 (27.6%) HCPs had reported receiving training, which was not specified, before the ERASE curriculum was made available. Overall, after intervention, there appeared to be an increase in training reported by faculty (35 [46.7%] vs 18 [25.4%]) and residents (21 [67.7%] vs 6 [13.0%]). In addition, a higher proportion of HCPs reported that there were departmental or hospital policies about mistreatment by patients and family members compared with baseline (106 [43.4%] vs 78 [25.4%]) (Table 2). HCP reports of effectiveness in addressing mistreatment when they were the targets were similar before and after intervention (Table 2). However, after intervention, more residents reported having effectively addressed mistreatment when they witnessed it (16 [51.6%] vs 18 [39.1%]). The types of mistreatment reported by HCPs after intervention are shown in Supplemental Table 5.

Eighty-four (34.4%) of the 244 HCPs reported that they received training on addressing mistreatment by patients and family members (Table 3). HCPs who received training had a higher odds of reporting knowledge of mistreatment policies (OR, 2.7; 95% CI, 1.38–5.32) and having a standardized approach to addressing mistreatment (OR, 4.43; 95% CI, 2.03–9.67). Furthermore, they had a higher odds of reporting having experienced offensive behavior based on gender (OR, 2.91; 95% CI, 1.24–6.82), ethnicity or race (OR, 2.11; 95% CI, 0.96–4.61), and appearance (OR, 2.53; 95% CI, 1.09–5.88). Training was associated with a meaningful increase in self-efficacy, as the odds of intervening effectively when mistreated or when witnessing such behaviors were almost 2 times greater if a respondent was exposed to training.

HCP reporting of mistreatment events in the patient safety incident reporting system before and after the intervention (which was initiated mid-November 2018) is shown in Fig 2. The comparison of preintervention (October 2017 to November 2018) with postintervention (December 2018 to December 2019) revealed a threefold increase in reports of mistreatment by patients and family members per month from a mean (SD) of 3.3 (2.7) to 9.4 (5.0; P < .001). Reports of mistreatment per month by patient family members increased from a mean (SD) of 0.5 (0.9) to 3.5 (2.4; P < .001).

We found that the majority of pediatric HCPs in our tertiary care children’s hospital reported experiencing mistreatment by patients and family members; verbal threats and offensive behaviors or comments based on female gender, younger age, ethnicity or race, and appearance were most common but varied by provider role. The high prevalence of mistreatment of HCPs is concerning because it is associated with provider burnout,^6–8  decreased patient satisfaction,¹³  and adverse events and medical errors.^9,10,14,22  Pediatric residents were at high risk of experiencing mistreatment, which runs counter to regulatory standards regarding the clinical learning environment.³⁹  The prevalence of mistreatment of pediatric residents by patients and family members in our study was greater than the 18% reported Kemper and Schwartz,⁸  which may be related to their study’s narrower focus on types and sources of mistreatment. In contrast, the prevalence of gender discrimination from patients and family members experienced by pediatric residents in our study was similar to that reported by Hu et al⁷  in surgical residents (44%). Why residents may be more vulnerable than nurses or faculty to experiencing mistreatment by patients and families is unclear but could be related to factors such as long work hours, frequency of patient interactions, or status as trainees. Additionally, the low response rate of nurses may introduce nonresponse bias, making a comparison between them and the other provider groups less reliable. However, the high prevalence of resident mistreatment reinforces the need for bystander training of faculty and nurses who work most closely with them.

Interprofessional training of HCPs on addressing mistreatment was associated with an increased odds of knowledge of policies and a standardized approach to as well as self-efficacy in addressing mistreatment when experienced or witnessed, which was measured at least 6 months after the training. Our finding adds to those of previous studies on the short-term effectiveness of bystander training³⁶  and suggests long-term outcome benefits. HCPs who completed training had a higher odds of reporting having experienced offensive behaviors, especially based on gender, race/ethnicity, and appearance. This finding is most likely due to enhanced awareness of mistreatment, as recognition of microaggressions based on these characteristics was specifically addressed in the curriculum.

Our integrated organizational strategy included training, expansion of the system used for patient safety event reporting, and a response protocol. Postintervention, HCPs reported mistreatment by patients and family members more frequently. Although it is possible that the increase in incident reports of mistreatment reflects an increase in the number of events, it is more likely due to increased awareness of mistreatment and an enhanced safety culture that promotes event reporting. We specifically addressed barriers to HCP reporting of mistreatment by patients and family members, such as fear of reprisal²⁶  and beliefs that mistreatment is “part of the job”³²  and not associated with personal injury.^30,31  Furthermore, the clear collaboration between physician and nursing leadership and frequent feedback were critical in demonstrating institutional commitment to addressing and eliminating mistreatment of HCPs.

Several important limitations in our study design include potential nonresponse bias, particularly given the low response rate among nurses. The fact that fewer faculty self-identified as not White in our survey population than in the total eligible population likely underestimates the prevalence of discrimination based on race in the children’s hospital. Furthermore, potential differences appear to exist with respect to the race and gender composition by type of HCP between the pre- and postintervention samples, but because our adjusted analysis of outcomes of interest was performed only on the postintervention sample, the potential impact of these between-sample differences on the outcomes was limited by the analytical approach. Although we attempted to minimize nonresponse bias by making all surveys anonymous, we were only able to describe the change in our outcomes of interest before and after the intervention. However, our effect sizes (changes in outcomes) were practically meaningful and significant, and our analysis of the follow-up responses corroborated the positive association between being exposed to the organizational strategy to combat HCP mistreatment by patients and family members and increased knowledge, self-efficacy, and incident reporting. Our ability to detect the specific effects of training was decreased because multiple changes were made, including incident reporting and the response protocol.

We demonstrate the effectiveness of an integrated institutional strategy that treats mistreatment of HCPs as a patient safety event, an approach that can be adopted by other institutions. Although we focused on mistreatment by patients and family members in this study, we have since expanded the program to address mistreatment of HCPs by other staff members, with additional education on addressing discrimination based on race and ethnicity. Additional studies should be undertaken to demonstrate whether this strategy results in improvement in patient quality care metrics and HCP well-being.