Harassment and discrimination from patients

Not all of the harm patients and visitors cause is physical. A patient who makes sexual comments to a young personal support worker every time she enters his room, a visitor who refuses to let a Black nurse care for his mother, a patient who calls a gay porter names in the elevator, a family that photographs staff and posts the pictures online with abusive comments: these are harassment, and in many cases discrimination. They are common in healthcare, they are badly under-reported, and they wear staff down over time in ways that can be as damaging as an assault. This lesson covers what the law requires, how staff can respond in the moment, and how the hospital supports them.

What harassment from patients looks like

Surveys of healthcare staff consistently find that harassment from patients and visitors is widespread. The most common forms are:

• Sexual harassment: comments about appearance or bodies, sexual jokes and propositions, requests for unnecessary intimate care, touching, grabbing, exposure, and following staff or contacting them outside work.
• Racist and other discriminatory abuse: slurs, insults, and comments about a worker's race, ethnicity, accent, religion, gender identity, sexual orientation, age or disability.
• Refusal of care based on identity: demanding a different nurse or physician because of race, religion, accent or appearance.
• Bullying and intimidation: repeated insults, belittling, threats to complain or sue, and filming or photographing staff without consent to intimidate them.
• Online harassment: posting staff names, photos or false claims on social media.

Some patients who behave this way have conditions that affect their judgment, such as dementia, brain injury, delirium or mania, and sexual disinhibition is a recognized symptom of several of them. That changes how the hospital responds, as with physical violence, but it does not mean staff have to accept the behaviour, or that it is not harmful to them.

What the law requires

The OHSA defines workplace harassment as engaging in a course of vexatious comment or conduct against a worker in a workplace that is known or ought reasonably to be known to be unwelcome, and it includes workplace sexual harassment. The definition covers harassment by anyone, including patients and visitors. Employers must have a written harassment policy, reviewed every year, and a program to implement it that includes measures and procedures for workers to report incidents to someone other than the person responsible if that person is the harasser, how incidents and complaints will be investigated and dealt with, how information will be kept confidential, and how the worker and the alleged harasser will be told the results. Employers must investigate incidents and complaints in a way that is appropriate in the circumstances.

The Ontario Human Rights Code adds a separate duty. Employers must maintain a workplace free from harassment and discrimination on the grounds the Code protects, such as race, ancestry, place of origin, colour, ethnic origin, creed, sex, sexual orientation, gender identity, age and disability. Human rights decisions have found that this duty includes taking reasonable steps when the harassment comes from clients or customers. A hospital that tells a nurse to ignore racist abuse from a patient, or quietly reassigns staff to meet a patient's racist demand, can breach the Code.

Responding in the moment

Staff often freeze when a patient says or does something offensive, partly from surprise and partly because they are trained to be caring and patient. Having a few practised responses makes it easier to act. A simple approach has three steps: name the behaviour, set the limit, and redirect to the care.

The tone is calm and matter-of-fact, not angry. The aim is not to win an argument or teach a lesson, but to stop the behaviour and get on with care. If the behaviour continues, the worker leaves the room, makes sure the patient is safe, and tells the charge nurse.

For patients with dementia or other conditions affecting judgment, the same approach is used more gently and with more redirection: a firm, kind "No, Mr. Kaplan", moving his hand away, and turning his attention to something else. The behaviour is recorded on the ABC chart described in Lesson 4, because it may have a cause, such as boredom, a misunderstanding of what care is happening, or a medication, that the team can address.

The response ladder

When harassment continues, the hospital takes escalating steps, from the least to the most restrictive, until it stops. Northbridge's procedure follows a ladder:

• The worker sets a limit in the moment, as above, and reports it.
• The charge nurse or manager talks with the patient, explains that the behaviour is not acceptable and what will happen if it continues, and documents the conversation. A conversation with someone in authority stops a large share of harassment.
• A flag and care plan tell other staff about the behaviour and set precautions, such as two staff for intimate care or the door left open.
• A written behaviour agreement sets out expectations and consequences, signed or acknowledged by the patient.
• A senior review of further options, such as transfer of care to another unit or facility where that is clinically safe, or, for outpatients, care at another site.
• For visitors, restrictions on visiting, supervised visits, or removal by security, and police involvement for conduct that is criminal, such as sexual assault or threats.

Throughout, the patient continues to receive the care they need. A hospital does not deny necessary treatment as a punishment. But how, where and by whom that care is given can change.

Requests for a different caregiver

Patients sometimes ask for a different nurse or physician. Some requests are reasonable: a woman who has experienced sexual violence asking for a female caregiver for intimate care, a patient who wants a caregiver who speaks their language, or a patient who has lost trust in a particular worker after a conflict. Others are discriminatory: refusing a caregiver because of their race, ethnicity, religion or accent.

Northbridge's policy distinguishes between the two. Requests based on a patient's own needs, such as trauma, religious modesty for intimate care, language or a breakdown in the relationship, are accommodated where possible. Requests based on a caregiver's race, ethnicity, religion, accent, sexual orientation or similar characteristics are not honoured, except in an emergency when delay would harm the patient, and are handled by the charge nurse or manager, not by the worker who was rejected. The manager speaks with the patient, explains the hospital's position and the qualifications of the assigned caregiver, and documents the conversation. The worker is told what happened and is offered the choice of whether to continue caring for the patient, but is never quietly removed to satisfy a discriminatory demand.

Filming and online harassment

Phones have added a new kind of harassment. Patients and visitors sometimes film staff during tense moments, then post the video with names and abusive comments, or threaten to. Northbridge's policy allows patients to record their own conversations with clinicians about their care, which can help them remember information, but does not allow filming of staff without consent to intimidate them, filming of other patients, or filming in areas where privacy is expected. Staff who are being filmed can say calmly that they do not consent and ask the person to stop, then call the charge nurse if it continues. If staff find themselves named or pictured in abusive posts, they report it to their manager; the hospital's communications and legal teams can ask platforms to remove content that breaches their rules, and security or police are involved when posts include threats or personal details such as a home address.

Reporting and patterns

Harassment from patients is reported through the same system as physical violence, with its own categories so that patterns can be seen. Joanne reviews the categories each quarter:

from collections import Counter

reports = [  # (category, unit, patient had cognitive impairment?)
    ("sexual comment", "4 West", False), ("racist remark", "Emergency", False),
    ("sexual touching", "Birch", True), ("refused caregiver", "3 East", False),
    ("sexual comment", "Birch", True), ("racist remark", "Emergency", False),
    ("filming", "Emergency", False), ("sexual comment", "4 West", False),
    ("racist remark", "4 West", False), ("sexual touching", "4 West", True),
]
cats = Counter(c for c, _, _ in reports)
units = Counter(u for _, u, _ in reports)
impaired = sum(1 for *_, imp in reports if imp)
print("by category:", ", ".join(f"{c} {n}" for c, n in cats.most_common()))
print("by unit:    ", ", ".join(f"{u} {n}" for u, n in units.most_common()))
print(f"patient had cognitive impairment: {impaired} of {len(reports)}")

by category: sexual comment 3, racist remark 3, sexual touching 2, refused caregiver 1, filming 1
by unit:     4 West 4, Emergency 3, Birch 2, 3 East 1
patient had cognitive impairment: 3 of 10

The numbers are small, and Joanne knows from the staff survey that most harassment is never reported. Even so, the review shows something useful: racist remarks cluster in the emergency department, where waits are long and staff change constantly, and sexual comments and touching on 4 West mostly come from patients without cognitive impairment. That second finding led to a change: charge nurses on 4 West now speak to patients the first time a report is made, rather than waiting for a pattern.

Supporting staff

The harm of harassment builds up. A nurse who hears a racist remark once may shrug it off; a nurse who hears them every week, and sees nothing done, may leave. Support includes:

• Managers who believe staff, act quickly and visibly, and tell staff what was done.
• A clear message, repeated often, that staff do not have to tolerate abuse as part of the job.
• Time away from the patient, and the choice not to continue caring for them where that is safe.
• Access to peer support, the employee and family assistance program and, for racism, support from colleagues and networks who share the experience.
• Protection from retaliation for reporting, including from patients who threaten to complain.