You walk into a patient room at the beginning of your shift. The atmosphere is tense, the conversation is uneasy. You don't understand what you're doing wrong until the patient asks to be assigned another nurse because she or he is uncomfortable with your race. Unfortunately, this is a situation some nurses know all too well.
While health care professionals are bound by multiple codes of conduct prohibiting discrimination against patients, what protection do we have against patients’ discriminatory acts toward us? In certain circumstances (for example, because of trauma or cultural beliefs), it's appropriate to heed patient requests to change providers, but some situations involve requests based on racial bias. While the true motivation behind requests may be difficult to pinpoint, those on the receiving end can usually identify racial bias when they experience it.
According to an article by Paul-Emile, “Patients’ Racial Preferences and the Medical Culture of Accommodation” (UCLA Law Review, 2012), it is no secret that hospitals often comply with patients’ requests for providers based on racial preferences. Her examination of statutes and laws concludes that antidiscrimination policies—which may be seen as conflicting with the ethical principle of respect for patient autonomy, among other considerations—do not prohibit the practice of yielding to such requests. However, as reported by Reddy in the January 22 Wall Street Journal, hospitals may begin providing clearer guidance in this area, as evidenced by a 2017 Penn State College of Medicine patient rights policy update. The policy states that, with some case-by-case exceptions, “requests for changes of provider… based on… race, ethnicity, religion, sexual orientation or gender identity will not be honored.”
This institution's policy change is a step in the right direction. But how should a nurse respond if faced with such a request? At a time when patient satisfaction affects many aspects of how we provide care, nurses can be placed in a challenging situation. In current practice, the solution usually involves intervention from management or a supervisor in finding a compromise. These “compromises” often feel like lose-only situations for nurses. When one opts for appeasement by yielding to the patient's wishes, it sends a message that racism is acceptable as long as you're not feeling well. Through legitimizing the patient's request for different staff, we condone the patient's behavior. In this situation, the nurse's qualifications do not matter—in the eyes of the patient, the nurse is of a race the patient can't trust.
A policy such as the one at Penn State aimed at prohibiting a patient's discriminatory behavior offers a guideline for what was previously a gray area of personnel judgment. It communicates that such behavior will not be tolerated. Unfortunately, it does not fully resolve the problem. If the nurse continues taking care of the patient despite the refusal, the patient may see that as simply following the rules of the hospital, not a direct reprimand of her or his racist behavior. On the other hand, if the nurse declines to take care of this patient, the patient gets what she or he wanted in the first place—a staffing change. It's also important to consider the emotional repercussions for the nurse who will spend the remaining hours of the shift with a patient who sees the nurse through the lens of racism. From ethical questions to staffing ratios, the complexity of this problem is profound on many levels.
But what if we look at this policy in a different light? The continued care from this nurse provides an opportunity for exposure, a chance to indirectly influence a person's deep-seated assumptions. The nurse's compassionate care may help the patient see that this “stranger” of a different race is as human as the patient is. This may in turn help to break down fixed racial biases in the patient and those around her or him.
While we can continue to look for ways to practically address this issue at the bedside, unless we find a cure for racism itself, this will continue to be a problem. Until then, I believe nurses will continue to take the high road. It is not easy, but the positive impact may be greater than we know.