Volume 9, Number 2, July 1998

Examining the Need for Ethics Training for Hospital Support Staff in Direct Patient Contact

Richard Briggs, BA
Alberta Vocational College, Edmonton

One of the most enjoyable things about working in an operating room was listening to the jokes the doctors would send back and forth across the table. One of the more memorable ones went like this:

A surgeon walks into a patient's room, where her patient anxiously awaits the next day's scheduled operation. The man asked, almost hysterically, "Are you absolutely sure that this is the best possible way to treat me?" Puzzled, the doctor replies, "We sat down and discussed all of the best options. You asked for a second and third opinion, and you got it. We researched each possible procedure and, together, we decided that this was the best way to approach your problem. Has something happened to make you unsure of our joint decision?" The patient responded, with a concerned look on his face, "The lady who cleans my room says there's a much better way."

Many health care professionals underestimate the effect that a support worker can have on a patient. After all, why would a patient give the often misinformed ideas of a support worker as much weight as the ideas of the doctor? The answer is simple. Every person who comes into direct contact with a patient, from the receptionist at the admissions desk to the person who delivers the water jug in the afternoon, carries with them the badge of representing not only the hospital, but the whole medical profession. Studies have shown that one of the most powerful symbols of authority is the standard issue white lab coat worn by hospital staff at all levels. This fact is seldom acknowledged and not given adequate consideration in the initial orientation and training of support staff workers.

During resizing and restructuring, the healthcare industry must realize the increasing role of medical (e.g. respiratory therapists, etc.) and non-medical (e.g. dietary workers, etc.) support personnel and the resulting impact on patients. The range of direct patient care activities undertaken by support personnel is growing, but support workers are not being given adequate introduction to the basics of medical ethics. If you were to ask a dietary technologist to describe what patient advocacy implies, you would most likely get nothing more than a blank stare. It is essential that hospital support personnel, especially those in direct patient contact, be properly informed as to their ethical obligations and responsibilities in terms of patient care. This paper will suggest the context and procedure for the development and implementation of an introduction to medical ethics for support workers.

Objectives

Before beginning any large-scale training program, you have to establish the objectives of the training itself. This process involves both employer and employee. What concepts do the employers want the employees to learn? What concepts do the employees already understand? What concepts are most valuable, and therefore most viable in on-going, long-term programs? I believe there are five major objectives to be realized.

Objective 1: Traditional Principles of Ethics - Before applying ethics to a workplace situation, an employee must have a solid foundation in ethical principles. In some models of adult education, this type of background is called a fundamental skill. There are five traditional principles that I believe would be of value to the support staff worker. These are: autonomy, beneficence, non-maleficence, virtue and distributive justice. These concepts are well-known in ethics literature, but foreign to those not trained in ethics. The key to realizing this objective is the creation of a common glossary. The terms must be broken down and presented in a way that the employee will understand, using common language and simple explanations. Once the traditional principles have been discussed, more specific objectives can be met.

Objective 2: Patient Confidentiality - Legally, this is one of the most explosive issues in medical ethics. How much information regarding a patient's health is anyone entitled to? No hospital wants to find itself in the position of answering a lawsuit because a ward orderly has been reading a patient's chart without reason. Anyone with a background in ethics would not expect this to happen. However, without any knowledge of ethical principles, an employee may not know that this is an unethical act.

I say this because I have seen it. While I was working in the OR, I saw many famous people come through for elective and emergency surgery, as have most orderlies. When it was discovered that I was on shift during one celebrity's operation, I was berated with questions, including some from a member of the press. Because I was familiar with the idea of patient confidentiality, I didn't say anything. However, others who had been presented with similar opportunities were not so discreet. The disclosure of important information was not done out of malice for the individual; it was done out of ignorance of the basic concept of a patient's right to privacy.

"Studies have shown that one of the most powerful symbols of authority is the standard issue white lab coat worn by hospital staff at all levels." - Richard Briggs

Objective 3: Advocacy - We often hear the word "team" used to describe the body of employees working in a hospital setting. That team will often include support staff workers. I am not, by any means, suggesting that the support staff worker should be consulted before anything is done in terms of a patient's care program. Instead, I am suggesting that the orderly can serve a very specific role in patient advocacy, if that term can be defined as "serving as a voice for the voiceless." An example of this might be the use of certain equipment that an orderly might be involved in setting up. If the equipment is used in a way that varies from the design speculations, or if it is used in a way that is seen as detrimental to the patient (arms being pushed in an awkward position, etc.), the support staff worker should understand that his or her role in that patient's care is to point out the possible difficulty to someone in charge of the patient's care.

Objective 4: Informed Consent - The idea of informed consent is often difficult for support workers to grasp. It should be pointed out to the support worker that each patient goes through an exhausting series of diagnosis, tests and consultations before getting to the point of requiring hospitalization. Because of this, the patient and the doctor both have pretty good ideas of what is wrong and how to fix it. The support worker has no role in saying how a procedure works, or offering a second opinion. This limitation must be made clear from the start.

One thing that makes this a difficult consideration is gossip. Support workers will often overhear gossip regarding a doctor's abilities, or the effectiveness of a particular procedure. It should be made absolutely clear that the patient does not need to see eyes rolling at the mention of a doctor's name. The well-being of the patient is ultimately jeopardized when even the slight indication of a lack of faith comes to the surface.

Objective 5: Personal Judgment - One of the ideas behind the ethical principle of autonomy is that the support staff worker is an individual who is capable of making informed decisions and forming opinions. Support staff must be made aware that being armed with basic principles and specific responsibilities is the first step to empowerment. They should be able, upon completion of the program, to carry out their duties in an ethically sound manner. If everyone is carrying out their duties with a greater good in mind, and not simply performing a task for the sake of performance, the workplace is a very positive environment in which to work. This is one of the main goals of any training program.

Adult Education

It is essential that the facilitator for any training program be aware of a variety of learning styles and barriers that might present themselves in the case of adult learners. The individual support staff worker may have very little previous education, or he/she might have a graduate degree. English skills may vary from group to group as well, particularly in areas where immigrant workers are common. The program, then, should include a certain level of flexibility in its design. The facilitator will have to examine his/her students to decide how to approach each session.

To ensure comprehension at as many levels as possible, the terms used should be expressed in everyday English, and should reflect the realities of working in the hospital setting. Whenever possible, terms that are common to all areas of the hospital should be used in the training materials.

According to the literature that is currently available in the area of adult education, adults learn more effectively when they are interactive in the classroom. Hands-on experience enhances the learning environment. Therefore, the ideas covered in the classroom should be covered using quizzes and games, such as "Ethical Principle Jeopardy." This idea was used by Sue MacRae at Oak Forrest Hospital in Chicago, Illinois, and it has proven very effective. Role play would also serve to advance the concepts discussed in a more immediate and tactile manner.

Evaluation should be relatively broad-based. Testing knowledge in this sort of setting is an ineffective measure of progress. If the learner shows progress in his/her ability to act in an ethical manner and participate in an open discussion of workplace ethics, the program is a success.

Ethics training for support staff has never been a more crucial issue than it is in today's healthcare environment. As more support staff come into direct patient contact, hospital administrators must pro-actively ensure that the rights of the patient and the interests of the industry are protected to the greatest possible extent.

Acting Upon Alberta's Protection for Persons in Care Act

Jim Thomson, BA, BSW, RSW
Member, Alberta Association of Registered Social Workers

Alberta's Protection for Persons in Care Act was assented to on October 16, 1995 with the unanimous support of the Alberta Legislative Assembly. After extensive public consultation leading to amendments, the Act was proclaimed on January 5, 1998. The original name of the Act, the Vulnerable Person's Protection Act, was changed to its present name, which covers a broader range of persons in care. The Act's regulations may not be fully developed for some time.

There were at least five assumptions in news releases from the Legislative Assembly of Alberta leading up to the Act's proclamations:

• abuse is underreported,
• abuse is on the increase,
• there is hesitancy to report abuse for fear of negative consequences falling to the reporter (e.g. reduced job security),
• the protection and penalties built into the Act will result in more reporting of abuse and ultimately less abuse, and
• appropriate interventions will occur in cases of confirmed abuse.

Purpose of the Act

The main purpose of the Protection for Persons in Care Act is to protect the health, safety and well-being of adults who are being cared for in an "agency," defined in the Act as:

• an approved hospital as defined in the Hospitals Act,
• a lodge accommodation as defined in the Alberta Housing Act,
• a nursing home as defined in the Nursing Homes Act,
• a facility as defined in the Social Care Facilities Review Committee Act,
• any institution or organization designated by regulation as an agency.

The Act is intended to protect adults who must reside in a facility in order to receive the attention they need, such as people with physical disabilities, mental disabilities, or the elderly. Children are protected from abuse under the Child Welfare Act.

The Protection for Persons in Care Act placed a duty to report abuse on "every individual or service provider who has reasonable and probable grounds to believe there is or has been abuse against a client." "Client" is defined as "an adult who receives services from an agency." "Service provider" is defined as "a person who provides services to a client and is employed by or provides the services on behalf of an agency."

The Act requires an investigation into every reported case of abuse. It also provides specific protection from any form of retaliation directed towards individuals who report, in good faith, a case of abuse.

• intentionally causing bodily harm,
• intentionally causing emotional harm, including but not limited to, threatening, intimidating, humiliating, harassing, coercing, or restricting from appropriate social contact,
• intentionally administering or prescribing medication for an inappropriate purpose,
• subjecting to non-consensual sexual contact, activity or behaviour,
• intentionally misappropriating or improperly or illegally converting money or other valuable possessions,
• intentionally failing to provide adequate nutrition, adequate medical attention or other necessity of life without a valid consent.

Penalties and Protection

In addition to the penalties listed below, a person registered under an Act regulating a profession or occupation prescribed in the regulations, will also be subject to appropriate disciplinary action under their professional/occupational Act should they knowingly fail to report abuse. Failure to report abuse under Section 2(1) is an offence under the law and liable to a fine of not more than two thousand dollars and in default of payment, to imprisonment for a term of not more than six months. No action should be taken against a complainant unless the complaint is made maliciously or without reasonable and probable grounds [Section 3(1)]. The complainant can be anyone, including the abused client, an individual citizen, or a service provider or employee of an agency providing services to the abused client.

No agency should take adverse action against a service provider, an employee, or a client of an agency because that person is a complainant [Section 4(2) and Section 4(3)]. Violations of these two sections is an offence under the law and can result in:

• the case of an individual, a fine of not more than five thousand dollars,
• the case of an agency, a fine of not more than twenty-five thousand dollars.

As well, no action lies against an investigator appointed under Section 6 or a committee, body or person to whom a complaint is referred under Section 10, or a member, or former member of or a person employed or engaged by the committee or body, for anything done in good faith under this Act [Section 11(1)].

Confidentiality and Duty to Report Abuse

The duty to report applies even when the information on which the abuse belief is founded is confidential and its disclosure is prohibited under any other Act [Section 2(2)]. There are two exceptions to the duty to report. The first exception is information that is privileged as the result of a solicitor-client relationship [Section 2(3)]. The second exception involves the client themselves. A client "may" report an abuse against their person but is not required by the Act to report the abuse.

Clearly, one implication for anyone not in a solicitor-client relationship, and being asked by a client to keep information about to be shared confidential, is to qualify any prior agreement to confidentiality with a statement that specifically cautions the client that information which provides reasonable and probably grounds to believe that there is or has been abuse against the client must legally be reported.

This legal duty to report, however, applies only to abuse that occurred after the Act came into legal force, that is, January 5, 1998 and onwards [Section 2(6)].

Perhaps it goes without saying that because ethics and law are neither mutually exclusive nor synonymous, they can be intimately related as well as unrelated, if not sometimes incompatible. The new legal implications as a result of the Protection for Persons in Care Act far outweigh the new ethical implications. This is because the ethical implications surrounding abuse, as defined in the Act, largely existed prior to the Act.

In other words, prior to January 5, 1998, in many cases we had an existing ethical duty to report abuse as defined in the Act, even though we may not have had a legal duty in many cases. The new Act now complements any earlier ethical duty to report abuse with a new legal duty to report abuse.

Historically, staff in departments such as housekeeping, maintenance and food services, within larger agencies, could not always see an immediate relevance between their services to clients and healthcare ethics. They assumed healthcare ethics was only significant to physicians, nurses, rehabilitation staff, and other healthcare professionals. The Protection for Persons in Care Act serves to reinforce the relevance of healthcare ethics to all individuals and service providers, independent of the service they provide.

Despite the potential value of the Act, potential negative side effects may result. The Act includes a requirement for every new volunteer and every successful applicant for employment in an agency to provide a criminal records check. There is increasingly stiff competition for a limited number of volunteers. Additional prerequisites placed in front of new volunteers could lead to decreased motivations to consider, or continue volunteering even when they have nothing to fear from providing a criminal records check.

As well, it has not been clearly stated in the Act upon what information the criminal records check will be based. Some would argue that employers should only obtain a criminal records check response that relates directly to the issue of abuse. Other elements of a criminal record, depending on the nature of the offence(s), how long ago the offences(s) occurred, the frequency of the offences, the severity of the offence(s), and any mitigating contextual circumstances, may have little or no bearing on the issue of abuse or the job to be performed. Should an employer be informed of offences not related to abuse or that have little or no direct bearing on the job to be performed? And yet, if the non-abuse related criminal record is readily available, it could become a permanent barrier to many people obtaining future gainful employment in the human services field, human nature being what it is.

Some would argue that clients with the capacity to report abuse occurring to them have an ethical duty, if not a legal duty, to report the abuse. Knowingly withholding this information may well be placing other clients, served within the same agency, at risk from the offending person or persons.

Section 6(1) of the Act reads, "On receipt of a report of abuse to the Department of Community Development, the Department must, as soon as possible, refer the matter to the appropriate Minister for investigation." It is not yet clear what constitutes "receipt of a report of abuse." For example, can a report of abuse be received anonymously? The concern here is that if anonymous reports of abuse count as reports of abuse that must be investigated, many people will prefer to make anonymous reports and some may be made by someone who knows them to be false. But false reports of a client being abused, who does not have the capacity to speak for him or herself, are difficult to disprove unless the reporter admits to their falsehood. In these circumstances, the investigation will find the complaint is unfounded or the evidence is insufficient. The person who knows they were falsely accused should now ask. "What will happen to the record of this investigation that names and accuses me of an abuse but which could not be determined to have been made maliciously?" If retained, how secure will this record be? Who can have access to this record?

Naturally, an understanding of the significance of the Act should be integrated into all institutes of learning in their preparation of students for employment in agencies as defined in the Act.

• Every agency shall have a duty to protect the clients it serves from abuse and to maintain a reasonable level of safety for its clients.

• Every agency shall make the provisions of the Act available to service providers, employees and clients.

• Every agency must require that every successful applicant for employment and every new volunteer provide a criminal records check.

It will be interesting to see how these duties are interpreted in the investigator's report. Consider, for example, cases where it might be argued that an agency had not sufficiently prepared an employee, through necessary education and training, to safely perform the job duties as required. Could the investigators find primary liability against the agency and only secondary or a reduced liability against the employee?

For example, about fifty percent of all continuing care residents have combinations of behaviours that can include resistance to care, aggressiveness (verbal and physical), and agitation often as a complication of a dementia due to Alzheimer's Disease or multiple small strokes. The staff who expected to provide care to these residents need ongoing specialized education, training, and support in how to prevent and manage aggressive behaviour in a safe and constructive manner. Absence of such preparation could lead to preventable aggression by both residents and caregivers out of frustration or self-defence leading, in effect, to some forms of abuse or perceived abuse. Abuse under these circumstances may legitimately be accountable to the employer for knowingly not preparing their staff with skills required for such complex and demanding care.

To the credit of some agencies, required workshops on the prevention and management of aggressive behaviour are already made available to staff. As well, some agencies are incorporating in-depth information about the Protection for Persons in Care Act into their staff orientation sessions in order to fulfill their duty under Section 5(2).

The Alberta Government has established the following toll-free telephone line for reporting abuse: 1-888-357-9339. This toll-free telephone service will channel the investigation of a reported abuse to the appropriate government ministry responsible for the type of agency involved.

How this Act will affect Albertans, ethically and legally, will continue to be shaped by three primary factors:

• future regulations to the Act,
• recommendation precedents established by investigators,
• how and why Albertans make amendments to the Act.

These three factors should contribute to the safeguarding of each adult Albertan who at a point in their life if required to be in the care of other fellow Albertans.