_{Published October 22, 2021}

In my colleague Jonathan Kruskal’s article, we learned about health care professionals as “second” victims of medical errors and how we can support them. Here, we will focus on the “first” victim, or the patient who has experienced such an error. Historically, quality efforts in health care have focused on the reduction of errors causing physical harm to patients. Only recently has the scope widened to include non-physical or emotional harm.

Patients are known to frequently experience emotional harm when interacting with the health care system through violations to their dignity. Emotional harm from disrespect to a patient’s dignity can, in turn, lead to a loss of trust. Patients may therefore cease to fully engage with health care providers. This interferes with future care and with our efforts to fully integrate patients as members of the health care team.

As informed team members who are actively involved in their care, patients are known to make critical contributions to their safety and play a vital role in team success. Like clinical staff, patients will only feel comfortable to participate, ask questions, and speak up about concerns in a psychologically safe environment based on a culture of respect and trust. The need to address emotional harm in patients is therefore twofold: to avoid non-physical harm to patients and to avoid its consequences, including a loss of trust, so that patients continue to be fully engaged in their care.

How Common Is Emotional Harm? 

Evidence in the literature raises the concern that patients may suffer emotional harm more frequently than physical harm and that its incidence is currently underreported. Underreporting may be due to clinical staffs’ lack of awareness about the concept of non-physical or emotional harm and its reportability. A study from 2004, for example, details how a group of providers aimed to develop patient-centered typologies of medical errors. During this work, providers discovered that 70% of patient-reported harmful events in the primary care setting related to emotional harm. If this estimate is correct and non-physical harm events were reported in the future, this would more than double the number of departmental quality assurance-related incident reports.

What Are the Causes of Emotional Harm?

Emotional harm is mainly caused by failing to be patient-centered, which can include disregarding patients’ expressed wishes, delaying care, and communicating ineffectively, either due to insufficient interpreter resources for non-English-speaking patients or other factors. The Joint Commission views patient-centered care as an important element of safe, quality care. Patient-centered care encourages “the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.” Patients and their care suffer when previously made decisions are not honored. A delay in care (such as postponing a non-urgent interventional radiology procedure for an emergency add-on case) is understandable to clinical staff, and to some degree, to most patients. However, repeated cancellations or rescheduled procedures will make patients feel insignificant and that they are not receiving the care they need in a timely fashion. Ineffective or infrequent communication with the patient, such as not updating them on changes in diagnostic or treatment plans, or NPO status, causes additional harm.

Other drivers of emotional harm include disrespectful communication/treatment, minimizing patients’ concerns, violating patients’ privacy, failing to care for personal possessions, and prejudice or discrimination. Disrespectful communication among staff is a frequent occurrence in health care. A recent survey by the Institute for Safe Medication Practices showed that disrespectful behaviors were observed by 70% of staff multiple times a year. Patients are exposed to this behavior indirectly when observing staff or can be an active participant in a disrespectful encounter.

What Are the Manifestations of Emotional Harm?

Emotional harm can be conceptualized as harm to a patient’s ‘dignity,’ which can be caused by failing to demonstrate adequate ‘respect’ for the patient as a person (dignity being defined as the intrinsic, unconditional value of an individual, and respect being defined as the actions that honor and acknowledge dignity). Patients can experience insults to their dignity as frustration, anger, belittlement, sadness, disrespect, violation, anxiety, worry, and a loss of trust in the clinician and the patient-provider relationship. The severity of emotional harm can range from mild to severe. Severe cases represent up to a quarter of total cases and may require patients to undergo therapy to deal with the trauma from the event.

What Is the Impact of Emotional Harm on Patients?

Emotional harm impacts patients on multiple levels. The effect of emotional harm on the individual patient can be serious; sometimes, it’s described as worse than physical injury. Emotional harm can lead to a loss of trust in health care providers, and patients may choose to transfer their care to another institution. Alternatively, it may lead to a loss of trust in health care in general, with the patient foregoing needed health care in the future. In a 2018 survey by the Betsy Lehman Center for Patient Safety, 66% of patients reported losing trust in the health care system after a medical error. Patients reported foregoing future care, with 34–67% avoiding the physician, facility, or health care overall, even six years after the event. This can lead to delays in diagnoses and treatments and result in adverse patient outcomes.

Emotional harm, whether of a patient or team member, comes at a great cost to health care teams. In staff members, disrespectful treatment has been shown to lead to a decrease in the ability to function, affecting procedural performance, as well as diagnostic abilities. Teamwork is also influenced by disrespected individuals being less willing to utilize team functions, such as information sharing and help-seeking. The latter also applies to patients being treated disrespectfully. Patients may be unwilling to share important health information with the team or voice observations that could lead to the prevention of medical errors.    

How Can We Prevent Emotional Harm?

To prevent emotional harm in health care and to harvest the full potential of patients as team members, several improvement efforts are needed. Patient and staff education about the nature and importance of emotional harm must be mandatory to encourage the reporting of these events, so that effective countermeasures can be introduced and tested for efficacy.

Staff communication training and individual feedback are also important countermeasures. Staff communication training needs to focus on active listening, or making the patient feel heard, by rephrasing/summarizing the patient’s statements and reflecting them to the patient to ensure an accurate understanding. Additional measures include explicitly asking for and following the patient’s stated preferences or explaining when and why this is not possible and offering alternatives. Closed-loop communication is vital to keep the patient updated on developments in their care and continuously engaged in shared decision-making, should new information become available.

Lastly, individual feedback to staff who were involved in an emotionally harmful event will be key and likely successful in preventing future instances. Towbin et al., in an effort to improve disrespectful communication, were able to demonstrate an increase in positive interactions from 48% to 90% after providing feedback to staff. Feedback was shared with individuals about the events they were involved with and anonymized among the group to maximize learning.

In conclusion, by increasing awareness of emotional harm as a frequently occurring, preventable medical error, and providing staff with communication training and individual feedback, this newly recognized concept will hopefully soon be eliminated.