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The Racist Patient—Revisited Joni M. Brady, MSN, RN, CAPA POSTANESTHESIA PAIN MANAGEMENT ROUNDS became unusually challenging one day when encountering Mr. B., a 52-year-old Caucasian male seen on postoperative day 1 after a cervical decompression procedure. A pre-visit review of the electronic health record (EHR) revealed that this patient had a decade-old diagnosis of failed back syndrome with multiple spine surgeries and an associated history of opioid misuse 8 years before admission. His EHR medication reconciliation screen indicated no currently prescribed opioids at home; and, despite increasing opioid dosages in combination with scheduled nonopioid adjuvants since surgery concluded, documented pain reports remained well above the patient’s stated comfort-function goal level. Before seeing a patient, I typically discuss plan of care progress with the clinical nurse assigned to his/her care. It quickly became apparent from talking with Mr. B.’s nurse that the patient was engaging in some complex and concerning behaviors. The next report came from an Acute Pain Service colleague, a US citizen and native Ethiopian anesthesiologist who when entering Mr. B.’s room earlier that morning to perform a postanesthesia rounding visit experienced overt racism. On introducing himself to the patient, Mr. B. ordered the anesthesiologist out of the room and was heard to say, ‘‘I didn’t ask for you so just get out. I said I only want Americans taking care of me!’’ A novice clinical nurse witnessed this event and was clearly upset by the patient’s rejection of the anesthesiologist coupled with engagement in racist behaviors toward other hospital staff members in her presence.

Joni M. Brady, MSN, RN, CAPA, consultant and Pain Management Nurse, Nursing Administration, Inova Alexandria Hospital, Alexandria, VA. Conflict of interest: None to report. Address correspondence to Joni M. Brady, 4320 Seminary Road, Alexandria, VA 22304; e-mail address: joni.brady@ inova.org. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.03.008

Journal of PeriAnesthesia Nursing, Vol 29, No 3 (June), 2014: pp 239-241

Few characteristics cut closer to the core than one’s culture, ethnicity, race, and personal identity. The expression of racism in its many forms is fundamentally discriminatory and very personal. Racism occurs when an individual thinks of him/herself as superior and chooses to label and reject engagement with another person based solely on differences in human characteristics. In subsequent days from our initial meeting, this patient’s observed racist behavior continued to negatively impact care efficiency, delivery, length of stay, and staff morale. For example, after making a plan with the patient to have an expert investigate his demonstrably upsetting concerns about neuropathic lower extremity symptoms, Mr. B. would not accept specialist care later that day from an American board–certified neurologist based solely on his race. In each case described, the physician respectfully left Mr. B.’s room and removed himself from the patient’s care team. And although the surgical unit care team’s composition was racially and ethnically diverse, accommodations were made to limit caregivers to Caucasians only. Consequently, the same four nurses were assigned to this patient through to discharge on postoperative day 8.

Crossing the Cultural Line This scenario represents a seemingly rare patient occurrence, but its emotionally charged nature and the events that unfolded throughout the week caused me to wonder about best practice recommendations for this type of uncomfortable encounter. The surgeon and his assistant were surprised by the patient’s in-hospital behavior and expressed appreciation for the team’s support, while the palliative care team worked with our anesthesia pain team during the postoperative phase to manage his opioid escalation in the presence of a history of misuse. One thought was recurrent: Do the dynamics of racism in a health care delivery setting have the propensity to become minimized or overlooked? This spirit of inquiry led to a literature search that uncovered the article titled ‘‘The Racist Patient’’1 in which its author, Dr. Jain, critically reflects on a patient encounter in which he

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was angrily challenged by a patient to go home to his birth country. The doctor’s admittedly human response was to feel hurt and he then became atypically reactive to a racist comment that spurred the return of painful memories surrounding childhood name calling. Physician responses to Jain’s commentary included beliefs that the patient should know that these comments were offensive and inappropriate, thereby giving them less meaning.2 Providers are often unprepared to handle degrading patient encounters, and health care institutions have a responsibility to prepare for and address difficult, drug-seeking, and dangerous behaviors through the deployment of an interprofessional team that uses a coordinated care approach to develop a patient behavioral agreement contract.3 Most literature on disruptive behavior in hospitals discusses untoward behaviors found within the health professional care team impacting patient safety4 or identified disparities in access to US health care that disproportionately and negatively affect minority populations.5,6 Patients considered to be ‘‘difficult’’ have most often been studied from the physician perspective7 or when asked to report the occurrence of a discriminatory experience with access to or during care delivery,5 further limiting our understanding on how best to manage the racist patient. The nursing literature on this topic was limited and dated, offering little direction on how to handle patients’ racist behavior in the workplace. Daum8 addressed nursing management strategies for the antisocial disruptive patient, including judicious staff assignments and an established patient-staff behavioral agreement with compliance monitoring, whereas Campbell and Anderson9 discussed implementation of a systemic patient care agreement documentation process within a behavioral health setting. The paucity of evidence highlights a gap in nursing knowledge needed to drive best practice for this challenging patient cohort, and perhaps illuminates nurse satisfaction implications as evidenced by the comments of several direct care nurses involved in Mr. B.’s case. Each nurse commented on his ‘‘ugly language,’’ and all reported feelings of powerlessness and despair such as, ‘‘I left work after that 12-hour shift and felt so emotionally exhausted, I called my friends and cancelled

JONI M. BRADY

our dinner plans because I knew I wouldn’t be very good company after dealing with his behavior all day. All I wanted was quiet.’’ Martin10 cited key influences tied to nurses’ knowledge that impact culturally competent patient care, such as individual civil rights, existing policies and legislation (governmental/nongovernmental agencies and accrediting bodies), demographic shifts, and practice guided by professional nursing organization recommendations. I could tell from our daily conversations surrounding Mr. B.’s pain management plan that clinical nurses repeatedly assigned to his care were struggling with negative feelings about the patient and the nursing care experience. After discussing the situation with the unit nurse manager and elevating the case to a nursing administrator for review, the staff was invited to attend team debriefing sessions facilitated by an employee assistance program professional. The debriefing sessions allowed for safe experiential dialog and event processing and were reportedly deemed therapeutic and well accepted by members of the clinical care team.

Establishing Neutral Space Any examination of racism will surely produce a spectrum of human emotions and uncover peoples’ painful experiences as perpetrated by another who believed in human superiority versus the concept that all humans were created equal. Although controversial patient behavior is destined to occur in practice, the reality for health care providers is that we are educated and trained to treat all persons in our care with dignity and respect, regardless of their beliefs or culture. The purpose of this discussion was to share, inform, and recommend more research to be performed in this area because, in reality, a patient may be admitted for a procedure or surgery on any given day espousing a racist belief system. The United States, an experimental cultural melting pot established less than 300 years ago, has grappled with institutionalized racism throughout its history. Continued global migration patterns and changing national demographics continue to foster growth in US population diversity and support an increasingly diverse US health care workforce. The Institute of Medicine, with its focus on provision of culturally competent care, seeks care that is respectful and responsive to

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individual patient’s values, needs, and preferences.11 The Transcultural Nursing Society promotes global understanding of cultural diversity and asserts that ‘‘Actions related to ethnocentrism, lack of awareness and moral blindness perpetuate and exacerbate healthcare inequities.’’12 Again, these perspectives focus on the patient experience, leaving the opportunity to explore the effect of a patient’s overt racism on the provider team and optimal ways in which to de-escalate and address racist patient care demands. O’Reilly13 advises health care facilities to establish policies that address discriminatory patient requests, particularly when demands are based on ethnicity or race. Ethical and legal experts recommend refusal of racist requests because although patients have the right to refuse interventional medical treatment, they do not have the right to demand a specified kind of treatment when the request is rooted in hatred. Furthermore, alterations in an organization’s typical work flow, scheduling, and care delivery processes may jeopardize patient safety. Although

the American Hospital Association lacks a policy to address patients’ racial demands, the American Medical Association’s House of Delegates adopted a 2009 policy urging hospitals to adopt uniform guidelines to address racially motivated health professional abuse.13 After numerous ‘‘tough love’’ conversations with Mr. B. during his hospitalization, it seemed that his aberrant behavior was often emboldened by our acquiescence. As suggested before, involvement of hospital ethics and legal departments can serve to establish a written action plan should this type of patient present for treatment and require a mutual contractual care agreement. Finally, if confronted with a similar patient scenario, it is recommended that nursing management teams actively support the staff through scheduled professional debriefing sessions that promote effective coping strategies, and management teams should engage in strategic interprofessional team development to prepare for any racist patient–related actions required in the future.

References 1. Jain SH. Comments and responses: The racist patient. Ann Intern Med. 2013;158:632. 2. Sahai SK. Comments and responses: The racist patient. Ann Intern Med. 2013;159:228. 3. Nardone DA. Comments and responses: The racist patient. Ann Intern Med. 2013;158:632. 4. Grenny J. Crucial conversations: The most potent force for eliminating disruptive behavior. Health Care Manag. 2009;28: 240-245. 5. Shavers VL, Fagan P, Jones D, et al. The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public Health. 2012;102:954-966. 6. L^e Cook B, McGuire T, Zuvekas S. Measuring trends in racial/ethnic health care disparities. Med Care Res Rev. 2009; 66:23-48. 7. Fiester A. ‘‘Difficult’’ patient reconceived: An expanded moral mandate for clinical ethics. Am J Bioeth. 2012;12:2-7.

8. Daum A. The antisocial disruptive patient: Management strategies. Nurs Manage. 1994;25:46-51. 9. Campbell DB, Anderson BJ. Setting behavioral limits. Am J Nurs. 1999;99:40-42. 10. Martin MB. Transcultural advocacy and policy in the workplace. J Nurses Prof Dev. 2014;30:29-33. 11. Paul-Emile K. Patients’ Racial Preferences and the Medical Culture of Accommodation. Available at: http:// www.uclalawreview.org/pdf/60-2-3.pdf. Accessed March 7, 2013. 12. The Transcultural Nursing Society. Human Rights Position Statement: Introduction (2). Available at: http://tcns.org/ Humanrights1.html. Accessed March 7, 2013. 13. O’Reilly KB. Drawing the Line on Racially Motivated Patient Demands. Available at: http://www.amednews.com/ article/20130304/profession/130309980/7/. Accessed March 4, 2013.