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Abstract
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orkplace violence is a significant challenge in the health care industry. Even before the COVID-19 pandemic, the US Bureau of Labor Statistics calculated that workplace violence in health care was 5 times higher than in all other industries and accounted for 73% of all workplace violence injuries. Experiences of violence and abuse also contribute to burnout and clinical staff leaving the medical professions.
The epidemic of workplace violence has prompted the use of harsh responses that include "behavior contracts" (sometimes called "behavioral agreements") that can undermine a hospital's commitment to providing evidence-based, patient-centered care. There is no national repository of data on the use of behavior contracts, or on hospital policies, but in our experience as clinical ethics consultants, and through discussions with colleagues nationally, we have observed that hospitals increasingly try to manage so-called difficult patients and families through behavior contracts that impose paternalistic limits and punitive consequences on patients for a wide range of behaviors. Yet behavior contracts pose serious ethical challenges, especially when unilaterally imposed on patients whose behavior is upsetting and disrespectful but not unsafe. Moreover, the evidence supporting the efficacy of contracts is lacking.
Behavior contracts are used in a variety of health care contexts to promote patient adherence with treatment, including smoking cessation, weight loss, substance use disorder rehabilitation, and psychiatric treatment. A Cochrane systematic review found that evidence of their effectiveness at improving adherence is limited and mixed; it did not find evidence from randomized clinical trials outside of this context.1 Indeed, we could find no empirical evidence to support or challenge the effectiveness of behavior contracts as a tool for addressing the problems of undesirable patient or family behaviors, patient-staff conflicts, and workplace violence in health care. Absent such evidence, health care institutions committed to evidence-based medicine and workplace safety might hesitate before using these contracts. When viewed alongside the ethical considerations, which have been extensively explored in the bioethics literature,2-4 we argue that the lack of supportive evidence generates an ethical imperative to reconsider their use altogether. Such reconsideration should include internal audits of how and when they are used, address the lack of institutional transparency and accountability about their use, and impose consistency and ethical safeguards. Based on our own experience, and that of many colleagues, we suspect that institutions that engage in this kind of self-reflection will find worrisome disparities in their use of behavior contracts.5
Behavior contracts raise concerns about justice in health care. Fiester and Yuan2 noted that behavior contracts treat a range of potential offenses, including rudeness, interference with treatment, and threats and violent assault, as similarly problematic, requiring similar solutions. As an example, the consensus recommendations of the Florida Academic Healthcare Patient Safety Organization for the management of patient behavior issues, behavior agreements, and dismissal list behaviors as disparate as failing to comply with medical treatment, speaking in a loud voice, rude behavior, and physical abuse of medical staff. While these are all concerning behaviors, they do not all rise to the same level of concern. Nonviolent, unpleasant interactions can be distressing, but treating all offenses alike fails the test of formal justice, which requires treating like situations alike, and unlike situations differently. The lack of differentiation in defining what constitutes "disruptive," "difficult," and violent behaviors results in both ethical inconsistency and a lack of ethical proportionality. ...
Language: en |