Combating racism in healthcare

Nurse Leader Insider, November 16, 2017

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Nurse managers and their staff often face racism in the work place. In 2013, Minority Nurse reported that almost half of minority nurses said they experienced barriers in their career because of their race and educational background. In addition to institutional barriers, there is also the problem of patient racism, where patients refuse care based on the race or ethnicity of the provider. As a nurse, you might be put in the unenviable position of deciding how to handle one of these situations. Do you refuse care to the patient? Do you acquiesce to the patient’s unreasonable demand?

A Cautionary Tale

Plainfield Healthcare Center was faced with a similar dilemma, when some residents of the facility refused care from nonwhite staff members. The center had a policy of honoring such racial preferences, citing the patient’s right to select their providers.

For Brenda Chaney, a CNA at Plainfield Healthcare Center, this caused issues with both her workplace experience and patient safety. Patients verbalized their preference on a regular basis, causing distress and a hostile work environment for Chaney. Additionally, the policy created safety risks for the patients; Chaney shared one such situation: after finding that a patient fell and couldn’t get up, instead of assisting the patient herself, she had to hunt for nonblack staff members to help the resident return to her bed.

Chaney responded to a call one morning from a resident who was struggling to get out of bed. The patient refused her help, and when she eventually helped another staff member with the patient, the staff member reported that Chaney used profanity when helping the patient. After investigating the complaint, they found no evidence to substantiate the complaint, and the resident’s roommate heard no profanity during the incident. Despite this, Chaney was still terminated.

After her termination, Chaney filed a lawsuit under Title VII of the Civil Rights Act of 1964, where she alleged that Plainfield Healthcare Center’s adherence to resident’s racial bias was illegal and contributed to a hostile work environment. The suit was supported by the Equal Employment Opportunity Commission. After an appeals process, the 7th U.S. Circuit Court of Appeals sided with Chaney and found the practice of allowing patients to refuse care based on race in violation of Title VII. Both parties eventually settled the case, with Chaney receiving $150,000 settlement.

Preventative Measures

The New England Journal of Medicine published an article that provides some useful information about how to handle patient racism. The authors point out that there are a number of concerns to take into account, both legally and ethically. The situation pits a number of rights and laws against each other, including the patient’s right to refuse medical care, laws that require hospitals to provide medical care in emergency situations, and employment rights that dictate that hospitals cannot make staff decisions based on race. Nurses that have been reassigned based on a patient’s racial demands have successfully sued their employers, but if a patient doesn’t receive proper medical attention in a timely manner, facilities are equally liable.

The journal lays out five factors to consider when faced with this difficult situation:

  • The patient’s medical condition: If the patient is unstable, treat the patient right away, regardless of the patient’s preference. It is possible that their current condition is impairing their mental faculties.
  • The patient’s decision-making capacity: Try to assess if the patient is capable of making decisions for themselves; psychosis or dementia are important factors to consider. If the patient lacks decision-making capacity, try to persuade the patient to reconsider their request.
  • Reasons for the request: If there are clinical or ethnically appropriate reasons for reassigning staff, that should be taken into consideration. For example, if there are language barriers or religious concerns, it might be reasonable to accommodate the patient.
  • Effect on the provider: Always take into account the effect a decision might have on the employee. "For many minority health care workers, expressions of patients' racial preferences are painful and degrading indignities, which cumulatively contribute to moral distress and burnout," according to the article. Always try to support staff when possible, and discuss their preferences when deciding how to respond.
  • Options for responding: In some situations, staffing might dictate your decision. If the department is understaffed and you cannot provide proper coverage by reassigning, try to persuade the patient.

If faced with a non-emergency situation and a patient is deemed capable of making decisions, the article suggests that it may be best to suggest that the patient seek care elsewhere; though that also has its risks depending on the availability of other treatment.

For more information on this difficult issue, including a useful decision-making tool, read the New England Journal of Medicine’s full article.

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