Handling Inappropriate Patient Behavior

Handling Inappropriate Patient Behavior
What should PTs do if they are subjected to harassment or otherwise inappropriate behavior by a patient?

You entered the health care field to help people. But what if the person you're trying to help doesn't want it, or worse, becomes difficult or combative? Stories abound of nurses being abused, threatened, and sexually harassed in the workplace. But are PTs also at risk?

Kenneth Babich, PT, MSPT, CSCS, recalled an instance in which a PT and home health aide were being asked by a patient with paraplegia and his elder sister to perform inappropriate duties. After a PT explained that the tasks fell outside the scope of her expertise, the patient made a veiled threat to her safety. "He basically said, 'my Rottweiler just had puppies, and she's very protective. All I would have to do is call her out here.' The therapist, who was very petite, diplomatically said that she didn't feel comfortable with the patient telling her that," Babich recalled. "She remained calm and did not let the situation escalate further."

Following the incident, Babich said, the therapist made an immediate call to her supervisor, who then contacted the patient to address where the dissatisfaction lay, discuss what could be done to resolve it, and to convey the agency's stance that should the threatening behavior continue, services would be terminated. While the agency does not want to turn away business, Babich pointed out, safety and security of its employees comes first.

"No therapist can be compelled to engage a patient under threatening circumstances," said Ron Scott, JD, MS, PT, OCS, associate professor and chairman of the physical therapy department at Lebanon Valley College, Annville, PA. "Certainly not in the case of the patient with full control of mental faculties. That therapist cannot be compelled to carry out patient care. Especially in the face of a specific threat directed to the therapist."

"I had a Chicago-based PT report to me at a conference in the form of a question that she was confronted by a home-bound patient with a loaded gun," Dr. Scott recalled. "Asked whether she had the right in that situation to leave the scene without being liable for patient abandonment, certainly the answer is yes. There is no obligation on the part of a therapist to carry out treatment under danger of death or bodily harm under such circumstances."

Patient Abandonment
Dr. Scott stressed, however, that he is only offering general legal advice, and that a PT would have to seek state-specific legal guidelines to determine exactly in which circumstances disengaging from care would constitute patient abandonment.

One factor to consider is the mental acuity of the patient.

"There is a general understanding on the part of clinic managers, therapists and other rehab professionals that when a patient lacks full cognition, the therapist will be expected to carefully engage in care of that patient," Dr. Scott said, adding that this is a question that has been asked of him, in one form or another, in each of the last 10 years.

"It comes up quite regularly," Dr. Scott continued. "Patient abandonment is a problem that has been ballooning under managed care. There has been a lot of prominent case law in this area, as well as admonitions by judges that not only third-party payers will be held liable, but also providers who bear primary responsibility."

"It may very well be considered abandonment if the patient lacks full mental capacity and the therapist disengages from care," he noted. "In the case of a patient with limited cognition, some sort of team-generated remedy to eliminate the behavior while maximizing safety during treatment would be more appropriate than just terminating care."

Babich recalled a case in which a patient suffering from Alzheimer's disease began swearing at him and hurling racial threats at a home health aide. "It took some family involvement to calm the patient down," Babich said, "and the aide responded to him wonderfully." Through his years of experience as a therapist for Ohio State University's Home Care Services, Columbus, OH, Babich has sharpened his skills in dealing with those suffering from Alzheimer's, a population that makes up five to 10 percent of his patient base. He will maintain a calm environment, won't raise his voice and will attempt to quell or redirect any agitated behavior.

Sexual Transgressions
Inappropriate patient behavior does not stop at threats of violence, however. Sexual indiscretions are also common in a profession with such an intimate degree of patient interaction and body contact.

Babich witnesses inappropriate sexual behavior less often in adults than in the handicapped adolescent population, which he treats as a therapist for the Franklin County Board of Mental Retardation and Developmental Disabilities. In these cases, he said, it is important to call on the resources of a behavior management team that consists of school psychologists and behavioral specialists. The team generates goals and strategies to redirect negative behaviors, teach mentally handicapped students about the consequences of their actions, and to reward positive behaviors.

"It helps to have a guideline in place, that says if a certain behavior happens this many times, here is the procedure to follow," Babich said. "We have to be careful in the school setting with state laws so that there's no indication of abuse, prejudice or discrimination in dealing with different children. You have to balance what is legally acceptable with what is best for the student and the caregiver."

Dr. Scott said that while most instances of patient-initiated sexual misconduct are likely of a minor nature, he speculates that improper patient behavior is just as prevalent in PT as it is for physicians and nurses. A 1993 study led by Joan McComas, PhD, PT, director and associate dean of the University of Ottawa's School of Rehabilitation Sciences, bears this out. McComas found that 93 percent of practicing physical therapists had been subjected to patient-initiated inappropriate sexual behavior to some degree. The study further found that half of respondents experienced "severe" inappropriate patient sexual behavior, including deliberate exposure and forceful attempts to grab and fondle.

"While PTs are not as intimately involved with bathing patients or touching private parts, I would say that inappropriate comments and minor acts of patient misconduct are quite prevalent," Dr. Scott said.

If the problem is so widespread, why is it rarely discussed?

"Because of [PTs'] demeanor and their altruistic attitude to patients, I think they generally will shrug it off," Dr. Scott offered. Babich agreed: "I consider myself very tolerant and easy to work with," he said, recalling a recent occurrence in which a recently discharged female patient had a large collection of pornographic videos and magazines scattered throughout her bedroom.

"While some therapists would have found that offensive, I chose not to make it an issue," Babich recounted. "I laughed it off, and suggested we do the exercises in the living room instead. Sometimes you have to be diplomatic about it. I think it's usually a good idea to focus on treatment rather than correct or make reference to a patient's way of life."

What to Look For and What to Do
Because the comfort levels of both therapists and patients vary, the distinction between acceptable behaviors and those that go too far will often blur. One therapist may consider off-color jokes and intimate body contact a sign of a patient's attempt to establish a friendly rapport, while another would construe it as harassment.

In such gray areas, it is helpful to rely on the support of colleagues and administration. "Any therapist who has a premonition of possible malicious behavior should inform management, and suggest another therapist or therapists be assigned," Dr. Scott advised. "They are also welcome to contact individuals who offer pro bono legal information." In fact, Dr. Scott added, "A PT could forfeit the right to a claim or legal action if he or she neglects to take advantage of a grievance procedure that has been implemented by the facility. That is now considered a valid affirmative defense for management."

In Babich's experience with multihandicapped children, he has noticed telltale signs that may signal the onset of their violent patient behavior: They may start to bite their hands, become flushed, or hit themselves. In the adult home care arena, signs are much less visual and objective. It is important to listen to an adult or geriatric patient's tone of voice, to watch for irritation and excited body language, to note any negative attitudes, and to piece those parts together, he said.

McComas offered steps to take should a PT become subjected to harassment or otherwise inappropriate behavior by a patient:

  1. Report the incident immediately to a colleague or supervisor. Recommend that a same-gendered or more assertive therapist be assigned, or that additional staff escort the therapist to the appointment, to make the patient less likely to grope or make improper comments.

  2. Accurately document everything that occurred and what was said by each party. This does not need to be included on the medical chart, but should be filed with the therapist's personal documents should a problem arise.

  3. Realize that you are not alone, and that the unacceptable behavior is not a result or reflection of your professional abilities.
Also helpful for Babich is to draft a contract for the patient to reference. He remembers a patient who had a problem with alcohol. "We basically outlined that if the patient was drunk, or if there was open alcohol while we were there, we would terminate services," he said, adding that in this case the alcohol was being mixed with medication, directly compromising the health of the patient.

"I'm fortunate in that my employer is an advocate of our safety," Babich said, adding that he will be provided with police reports of questionable neighborhoods, and can request police escorts or additional staff to accompany him to at-home appointments if he deems it necessary. "We are not required to see a individual if we feel our safety, security or possessions are in jeopardy. We have no problem turning the business over to another agency," he said.

Dr. Scott would like to see more programs like these put into place, as well as improved resources available for PTs. "I think there should be more organized efforts to discuss the issue at either the association level or at private conferences," he said.

Still, Babich emphasizes that the unruly, harassing or abusive patient is still a rarity. "They realize we're there to help them, and they appreciate that," he said. "I remember one lady that was verbally abusive, but not towards me. She wouldn't stop badmouthing her family, saying they abandoned her. She told me, 'you're the only one that's helping me walk again. You're my savior.'"

Jonathan Bassett is on staff at ADVANCE, and can be reached at jbassett@merion.com.


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