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Occupational Hazard: Disruptive Behavior in Patients
While private or other public health care organizations can refuse to care for patients who have displayed disruptive behavior (DB), the VA Response to Disruptive Behavior of Patients law (38 CFR §17.107) prohibits the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) from refusing care to veterans who display DB.1 The VHA defines DB as any behavior that is intimidating, threatening, or dangerous or that has, or could, jeopardize the health or safety of patients, VHA staff, or others.2
VA Response to DB Law
The VA Response to Disruptive Behavior of Patients requires the VHA to provide alternative care options that minimize risk while ensuring services; for example, providing care at a different location and/or time when additional staff are available to assist and monitor the patient. This can provide a unique opportunity to capture data on DB and the results of alternative forms of caring for this population.
The reason public health care organizations refuse care to persons who display DB is clear: DBs hinder business operations, are financially taxing, and put health care workers at risk.3-10 “In 2009, the VHA spent close to $5.5 million on workers’ compensation and medical expenditures for 425 incidents–or about $130,000 per DB incident (Hodgson M, Drummond D, Van Male L. Unpublished data, 2010).” In another study, 106 of 762 nurses in 1 hospital system reported an assault by a patient, and 30 required medical attention, which resulted in a total cost of $94,156.8 From 2002 to 2013, incidents of serious workplace violence requiring days off for an injured worker to recover on average were 4 times more common in health care than in other industries.6-11 Incidents of patient violence and aggression toward staff transcend specialization; however, hospital nurses and staff from the emergency, rehabilitation and gerontology departments, psychiatric unit, and home-based services are more susceptible and vulnerable to DB incidents than are other types of employees.8,10-19
Data reported by health care staff suggest that patients rather than staff members or visitors initiate > 70% of serious physical attacks against health care workers.9,13,20-23 A 2015 study of VHA health care providers (HCPs) found that > 60% had experienced some form of DB, verbal abuse being the most prevalent, followed by sexual abuse and physical abuse.20 Of 72,000 VHA staff responding to a nationwide survey, 13% experienced, on average, ≥ 1 assault by a veteran (eg, something was thrown at them; they were pushed, kicked, slapped; or were threatened or injured by a weapon).8,21
To meet its legal obligations and deliver empathetic care, the VHA documents and analyzes data on all patients who exhibit DB. A local DB Committee (DBC) reviews the data, whether it occurs in an inpatient or outpatient setting, such as community-based outpatient clinics. Once a DB incident is reported, the DBC begins an evidence-based risk evaluation, including the option of contacting the persons who displayed or experienced the DB. Goals are to (1) prevent future DB incidents; (2) detect vulnerabilities in the environment; and (3) collaborate with HCPs and patients to provide optimal care while improving the patient/provider interactions.
Effects of Disruptive Behavior
DB has negative consequences for both patients and health care workers and results in poor evaluations of care from both groups.27-32 Aside from interfering with safe medical care, DB also impacts care for other patients by delaying access to care and increasing appointment wait times due to employee absenteeism and staff shortages.3,4,20,32,33 For HCPs, patient violence is associated with unwillingness to provide care, briefer treatment periods, and decreases in occupational satisfaction, performance, and commitment
Harmful health effects experienced by HCPs who have been victims of DB include fear, mood disorders, anxiety, all symptoms of psychological distress and posttraumatic stress disorder (PTSD).10,22,30,34-36 In a study of the impact on productivity of PTSD triggered by job-related DB, PTSD symptoms were associated with withdrawal from or minimizing encounters with patients, job turnover, and troubles with thinking
Reporting Disruptive Behavior
The literature suggests that consistent and effective DB reporting is pivotal to improving the outcome and quality of care for those displaying DB.37-39 To provide high-quality health services to veterans who display DB, the VHA must promote the management and reporting of DB. Without knowledge of the full spectrum of DB events at VHA facilities, efforts to prevent or manage DB and ensure safety may have limited impact.7,37 Reports can be used for clinical decision making to optimize staff training in delivery of quality care while assuring staff safety. More than 80% of DB incidents occur during interactions with patients, thus this is a clinical issue that can affect the outcome of patient care.8,21
Documented DB reports are used to analyze the degree, frequency, and nature of incidents, which might reveal risk factors and develop preventive efforts and training for specific hazards.8,39 Some have argued that implementing a standardized DB reporting system is a crucial first step toward minimizing hazards and improving health care.38,40,41
When DB incidents were recorded through a hospital electronic reporting system and discussed in meetings, staff reported: (1) increased awareness of DB; (2) improved ability to manage DB incidents; and (3) amplified reporting of incidents.38,41,42 These findings support similar results from studies of an intervention implemented at VA Community Living Centers (CLCs) from 2013 to 2017: Staff Training in Assisted Living Residences (STAR-VA).4,12,19 The aim of STAR-VA was to minimize challenging dementia-related DB in CLCs. The intervention initially was established to train direct-care, assisted-living staff to provide better care to older patients displaying DB. Data revealed that documentation of DBs was, the first step to ensuring staff and patient safety.18,40
VHA Reporting System
In 2013, the VA Office of Inspector General (OIG) found no standardized documentation of DB events across the VA health care system.42 Instead, DB events were documented in multiple records in various locations, including administrative and progress notes in the electronic health record (EHR), police reports, e-mails, or letters submitted to DBC chairs.42 This situation reduced administrators’ ability to consider all relevant information and render appropriate decisions in DB cases.42 In 2015, based on OIG recommendations, the VHA implemented the Disruptive Behavior Reporting System (DBRS) nationwide, which allowed all VHA staff to report DB events. The DBRS was designed to address factors likely to impede reporting and management of DB, namely, complexity of and lack of access to a central reporting system.43,44 The DBRS is currently the primary VHA tool to document DB events.
The DBRS consists of 32 questions in 5 sections relating to the (1) location and time of DB event; (2) reporter; (3) disrupter; (4) DB event details; and (5) the person who experienced (experiencer) the event. The system also provides a list of the types of DB, such as inappropriate communication, bullying and/or intimidation, verbal or written threat of physical harm, physical violence, sexual harassment, sexual assault, and property damage. The DBRS has the potential to provide useful data on DB and DB reporting, such as the typical staff entering data and the number and/or types of DB occurring.
The DBRS complements the preexisting VHA policies and committees for care of veterans who display DB.1-3,14,21,24,25 The VHA Workplace Violence Prevention Program (WVPP) required facilities to submit data on DB events through a Workplace Behavioral Risk report. Data for the report were obtained from police reports, patient safety reports, DBC records, and notes in the EHR. Following implementations of DBRS, the number of DB events per year became a part of facility performance standards.
VHA is creating novel approaches to handling DB that allow health care workers to render care in a safe and effective manner guided by documented information. For example, DBCs can recommend the use of Category I Patient Record Flags (PRFs) following documented DB, which informs staff of the potential risk of DB and provides guidance on protective methods to use when meeting with the patient.2,21,24 A survey of 140 VA hospital chiefs of staff indicated that DBC procedures were related to a decrease in the rates of assaults.1 Additionally, VA provides training for staff in techniques to promote personal safety, such as identifying signs that precede DB, using verbal deescalation, and practicing therapeutic containment.
Resistance to Reporting
Many health care employees and employers are reticent to report DBs.22,31,43,45-48 Studies suggest health care organizations can cultivate a culture that is resistant to reporting DB.49,50 This complicates the ability of the health care system to design and maintain safety protocols and safer treatment plans.3,41,51 Worldwide, < 30% of DBs are reported.47 One barrier may be that supervisors may not wish to acknowledge DBs on their units or may not provide sufficient staff time for training or reporting.31,46,47 HCPs may worry that a DB report will stigmatize patients, especially those who are elderly or have cognitive impairment, brain injury, psychological illness, or developmental disability. Patients with cognitive conditions are reportedly 20% more likely to be violent toward caregivers and providers.31 A dementia diagnosis, for example, is associated with a high likelihood for DB.30,52 More than 80% of DB events displayed by patients with dementia may go unreported.26,31,50,52
Some clinicians may attribute DB to physiologic conditions that need to be treated, not reported. However, employers can face various legal liabilities if steps are not taken to protect employees.47,51 Federal and state statutes require that organizations provide a healthy and safe employment environment for workers. This requires that employers institute reasonable protective measures, such as procedures to intervene, policies on addressing DB incidents, and/or training to minimize or deescalate DB.51,53 Also, employees may sue employers if security measures are inadequate or deficient in properly investigating current and past evidence of DB or identifying vulnerabilities in the workplace. Unwillingness to investigate DB and safety-related workplace concerns have contributed to increased workplace violence and legal liability.52,53 The mission of caring and trust is consistent with assuring a safe environment.
Training and Empathetic Care
To combat cultural resistance to reporting DBs, more and perhaps different contextual approaches to education and training may be needed that address ethical dilemmas and concerns of providers. The success of training relies on administrators supporting staff in reporting DB. Training must address providers’ conflicting beliefs and assist with identifying strategies to provide the best possible care for patients who display DB.1,38 HCPs are less likely to document a DB if they feel that administrators are creating documentation that will have negative consequences for a patient. Thus, leadership is responsible for ensuring that misconceptions are dispelled through training and other efforts and information on how reported DB data will be used is communicated through strategic channels.
Education and training must consider empathic care that attempts to understand why patients behave as they do through the information gathered.55 Empathy in health care is multifaceted: It involves comprehending a patient’s viewpoint, circumstances, and feelings and the capacity to analyze whether one is comprehending these accurately in order to demonstrate supportive care.54,55
Improving patient and staff interaction once a problematic behavior is identified is the aim of empathic care. Increasing empathic care can improve compassionate, patient-centered interactions that begin once the patient seeks care. This approach has proven to decrease DB by patients with dementia and improve their care, lessen staff problems during interactions, and increase staff morale.20 Experts call for the adoption of an interpersonal approach to patient encounters, and there is evidence that creating organizational change by moving toward compassionate care can lead to a positive impact for patients.54,55
Future Studies
There are growth opportunities in utilization of the DBRS. Analysis of the DBRS database by the VA Central Office (VACO) showed that the system is underutilized by facilities across the VA system.56 In response to this current underutilization, VACO is taking steps to close these gaps through increasing training to staff and promotion of the use of the DBRS. A 2015 pilot study of VHA providers showed that > 70% of providers had experienced a DB as defined by VHA, but only 34% of them reported their most recently experienced DB within the past 12 months.20 Thus, DBRS use must be studied within the context that patient-perpetrated DB is underreported in health care organizations.5,9,29,41,43,57,58 Studies addressing national DBRS utilization patterns and the cost associated with implementing the DBRS also are needed. One study suggests that there is an association between measures of facility complexity and staff perceptions of safety, which should be considered in analyzing DBRS usage.57 Studies addressing the role of the DBRS and misconceptions that the tool may represent a punitive tool also are needed. VHA should consider how the attribution “disruptive behavior” assigns a negative connotation and leads HCPs to avoid using the DBRS. Additionally, DB reporting may increase when HCPs understand that DB reporting is part of the comprehensive, consultative strategy to provide the best care to patients.
Conclusion
Accurate reporting of DB events enables the development of strategies for multidisciplinary teams to work together to minimize hazards and to provide interventions that provide for the safe delivery of health care to all patients. Improving reporting ensures there is an accurate representation of how disruptive events impact care provided within a facility—and what types of variables may be associated with increased risk for these types of events.
Additionally, ensuring that reporting is maximized also provides the VHA with opportunities for DBCs to offer evidence-based risk assessment of violence and consultation to staff members who may benefit from improved competencies in working with patients who display DB. These potential improvements are consistent with the VHA I CARE values and will provide data that can inform recommendations for health care in other agencies/health care organizations.
Acknowledgments
This work was supported by the Center of Innovation on Disability and Rehabilitation Research (CINDRR) of the Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs.
1. Hodgson MJ, Mohr DC, Drummond DJ, Bell M, Van Male L. Managing disruptive patients in health care: necessary solutions to a difficult problem. Am J Ind Med. 2012;55(11):1009-1017.
2. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2010-053. Patient Record Flags. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341 Published December 3, 2010. Accessed March 29, 2019.
3. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2012-026. Sexual Assaults and Other Defined Public Safety Incidents in VHA Facilities. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2797. Published September 27, 2012. Accessed March 29, 2019.
4. Curyto KJ, McCurry SM, Luci K, Karlin BE, Teri L, Karel MJ. Managing challenging behaviors of dementia in veterans: identifying and changing activators and consequences using STAR-VA. J Gerontol Nurs. 2017;43(2):33-43.
5. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228.
6. Phillips JP. Workplace violence against health care workers in the United States. NEJM. 2016;374(17):1661-1669.
7. Janocha JA, Smith RT. Workplace safety and health in the health care and social assistance industry, 2003–07. https://www.bls.gov/opub/mlr/cwc/workplace-safety-and-health-in-the-health-care-and-social-assistance-industry-2003-07.pdf. Published August 30, 2010. Accessed February 19, 2019.
8. US Department of Labor, Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. https://www.osha.gov/Publications/OSHA3826.pdf. Published December 2015. Accessed February 19, 2019.
9. US Department of Labor, Occupational Safety and Health Administration. Prevention of Workplace Violence in Healthcare and Social Assistance. Occupational Safety and Health Administration, https://www.govinfo.gov/content/pkg/FR-2016-12-07/pdf/2016-29197.pdf. Accessed January 20, 2017.
10. Gerberich SG, Church TR, McGovern PM, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med. 2004;61(6):495-503.
11. Sherman MF, Gershon RRM, Samar SM, Pearson JM, Canton AN, Damsky MR. Safety factors predictive of job satisfaction and job retention among home healthcare aides. J Occup Environ Med. 2008;50(12):1430-1441.
12. Karel MJ, Teri L, McConnell E, Visnic S, Karlin BE. Effectiveness of expanded implementation of STAR-VA for managing dementia-related behaviors among veterans. Gerontologist. 2016;56(1):126-134.
13. US Department of Labor, Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work. https://www.bls.gov/news.release/archives/osh2_11192015.htm. Published November 19, 2015.
14. Beech B, Leather P. Workplace violence in the health care sector: A review of staff training and integration of training evaluation models. Aggression Violent Behav. 2006;11(1):27-43.
15. Campbell CL, McCoy S, Burg MA, Hoffman N. Enhancing home care staff safety through reducing client aggression and violence in noninstitutional care settings: a systematic review. Home Health Care Manage Pract. 2014;26(1):3-10.
16. Gallant-Roman MA. Strategies and tools to reduce workplace violence. AAOHNJ. 2008;56(11):449-454.
17. Weinberger LE, Sreenivasan S, Smee DE, McGuire J, Garrick T. Balancing safety against obstruction to health care access: an examination of behavioral flags in the VA health care system. J Threat Assess Manage. 2018;5(1):35-41.
18. Elbogen EB, Johnson SC, Wagner HR, et al. Protective factors and risk modification of violence in Iraq and Afghanistan war veterans. J Clin Psychiatry. 2012;73(6):e767-e773.
19. Karlin BE, Visnic S, McGee JS, Teri L. Results from the multisite implementation of STAR-VA: a multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans. Psychol Serv. 2014;11(2):200-208.
20. Semeah LM, Campbell CL, Cowper DC, Peet AC. Serving our homeless veterans: patient perpetrated violence as a barrier to health care access. J Pub Nonprofit Aff. 2017;3(2):223-234.
21. Hodgson MJ, Reed R, Craig T, et al. Violence in healthcare facilities: lessons from the Veterans Health Administration. J Occup Environ Med. 2004;46(11):1158-1165.
22. Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: findings from an Australian study. J Adv Nurs. 2006;55(6):778-787.
23. Barling J, Rogers AG, Kelloway EK. Behind closed doors: in-home workers’ experience of sexual harassment and workplace violence. J Occup Health Psychol. 2001;6(3):255-269.
24. Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med. 2015;58(11):1194-1204.
25. Sippel LM, Mota NP, Kachadourian LK, et al. The burden of hostility in U.S. veterans: results from the National Health and Resilience in Veterans Study. Psychiatry Res. 2016;243(suppl C):421-430.
26. Campbell C. Patient Violence and Aggression in Non-Institutional Health Care Settings: Predictors of Reporting By Healthcare Providers [doctoral dissertation]. Orlando: University of Central Florida; 2016.
27. Galinsky T, Feng HA, Streit J, et al. Risk factors associated with patient assaults of home healthcare workers. Rehabil Nurs. 2010;35(5):206-215.
28. Campbell CL. Incident reporting by health-care workers in noninstitutional care settings. Trauma, Violence Abuse. 2017;18(4):445-456.
29. Arnetz JE, Arnetz BB. Violence towards health care staff and possible effects on the quality of patient care. Soc Sci Med. 2001;52(3):417-427.
30. Gates D, Fitzwater E, Succop P. Relationships of stressors, strain, and anger to caregiver assaults. Issues Ment Health Nurs. 2003;24(8):775-793.
31. Brillhart B, Kruse B, Heard L. Safety concerns for rehabilitation nurses in home care. Rehabil Nurs. 2004;29(6):227-229.
32. Taylor H. Patient violence against clinicians: managing the risk. Innov Clin Neurosci. 2013;10(3):40-42.
33. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. The Joint Commission releases results of surveys of the VA health care system. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2808. Updated August 5, 2014. Accessed February 19, 2019.
34. Büssing A, Höge T. Aggression and violence against home care workers. J Occup Health Psychol. 2004;9(3):206-219.
35. Geiger-Brown J, Muntaner C, McPhaul K, Lipscomb J, Trinkoff A. Abuse and violence during home care work as predictor of worker depression. Home Health Care Serv Q. 2007;26(1):59-77.
36. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59-66.
37. Petterson IL, Arnetz BB. Psychosocial stressors and well-being in health care workers: the impact of an intervention program. Soc Sci Med. 1998;47(11):1763-1772.
38. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-680.
39. Arnetz JE, Hamblin L, Russell J, et al. Preventing patient-to-worker violence in hospitals: outcome of a randomized controlled intervention. J Occup Environ Med. 2017;59(1):18-27.
40. Elbogen EB, Tomkins AJ, Pothuloori AP, Scalora MJ. Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination. J Am Acad Psychiatry Law. 2003;31(1):58-64.
41. Winsvold Prang I, Jelson-Jorgensen LP. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Geriatr Nurs. 2014;35(6):441-447.
42. US Department of Veterans Affairs, Office of Inspector General. Healthcare inspection: management of disruptive patient behavior at VA medical facilities. Report No. 11-02585-129. https://www.va.gov/oig/pubs/VAOIG-11-02585-129.pdf. Published Mrach 7, 2013. Accessed February 21, 2019.
43. Lipscomb J, London M. Not Part of the Job: How to Take a Stand Against Violence in the Work Setting. Silver Spring, MD: American Nurses Association; 2015.
44. May DD, Grubbs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs. 2002;28(1):11-17.
45. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? J Gerontol Soc Work. 2014;57(5):460-477.
46. Brennan C, Worrall-Davies A, McMillan D, Gilbody S, House A. The hospital anxiety and depression scale: a diagnostic meta-analysis of case-finding ability. J Psychosom Res. 2010;69(4):371-378.
47. McPhaul K, Lipscomb J, Johnson J. Assessing risk for violence on home health visits. Home Healthc Nurse. 2010;28(5):278-289.
48. McPhaul KM, London M, Murrett K, Flannery K, Rosen J, Lipscomb J. Environmental evaluation for workplace violence in healthcare and social services. J Safety Res. 2008;39(2):237-250.
49. Kelly JA, Somlai AM, DiFranceisco WJ, et al. Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers. Am J Public Health. 2000;90(7):1082-1088.
50. Pawlin S. Reporting violence. Emerg Nurse. 2008;16(4):16-21.
51. Brakel SJ. Legal liability and workplace violence. J Am Acad Psychiatry Law. 1998;26(4):553-562.
52. Neuman JH, Baron RA. Workplace violence and workplace aggression: evidence concerning specific forms, potential causes, and preferred targets. J Manage. 1998;24(3):391-419.53. Ferns T, Chojnacka I. Angels and swingers, matrons and sinners: nursing stereotypes. Br J Nurs. 2005;14(19):1028-1032.
54. Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract 2002;52(suppl):S9-S12.
55. Lee TH. An Epidemic of Empathy in Healthcare: How to Deliver Compassionate, Connected Patient Care That Creates a Competitive Advantage. Columbus, OH: McGraw-Hill Education; 2015.
56. US Department of Veterans Affairs, Veterans Health Administrastion. Veterans Health Administration workplace violence prevention program (WVPP): disruptive behavior reporting system utilization report. Published 2017. https://vaww.portal2.va.gov/sites/wvpp/Shared%20Documents/DBRS%20Utilization%20Reports/FY2017%20DBRS%20Quarterly%20Utilization%20Report%20(Quarter%201).pdf. [Source not verified.]
57. Campbell CL, Burg, MA, Gammonley D. Measures for incident reporting of patient violence and aggression towards healthcare providers: a systematic review. Aggression Violent Behav. 2015;25(part B):314-322.
58. Carney PT, West P, Neily J, Mills PD, Bagian JP. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25(6):457-461.
While private or other public health care organizations can refuse to care for patients who have displayed disruptive behavior (DB), the VA Response to Disruptive Behavior of Patients law (38 CFR §17.107) prohibits the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) from refusing care to veterans who display DB.1 The VHA defines DB as any behavior that is intimidating, threatening, or dangerous or that has, or could, jeopardize the health or safety of patients, VHA staff, or others.2
VA Response to DB Law
The VA Response to Disruptive Behavior of Patients requires the VHA to provide alternative care options that minimize risk while ensuring services; for example, providing care at a different location and/or time when additional staff are available to assist and monitor the patient. This can provide a unique opportunity to capture data on DB and the results of alternative forms of caring for this population.
The reason public health care organizations refuse care to persons who display DB is clear: DBs hinder business operations, are financially taxing, and put health care workers at risk.3-10 “In 2009, the VHA spent close to $5.5 million on workers’ compensation and medical expenditures for 425 incidents–or about $130,000 per DB incident (Hodgson M, Drummond D, Van Male L. Unpublished data, 2010).” In another study, 106 of 762 nurses in 1 hospital system reported an assault by a patient, and 30 required medical attention, which resulted in a total cost of $94,156.8 From 2002 to 2013, incidents of serious workplace violence requiring days off for an injured worker to recover on average were 4 times more common in health care than in other industries.6-11 Incidents of patient violence and aggression toward staff transcend specialization; however, hospital nurses and staff from the emergency, rehabilitation and gerontology departments, psychiatric unit, and home-based services are more susceptible and vulnerable to DB incidents than are other types of employees.8,10-19
Data reported by health care staff suggest that patients rather than staff members or visitors initiate > 70% of serious physical attacks against health care workers.9,13,20-23 A 2015 study of VHA health care providers (HCPs) found that > 60% had experienced some form of DB, verbal abuse being the most prevalent, followed by sexual abuse and physical abuse.20 Of 72,000 VHA staff responding to a nationwide survey, 13% experienced, on average, ≥ 1 assault by a veteran (eg, something was thrown at them; they were pushed, kicked, slapped; or were threatened or injured by a weapon).8,21
To meet its legal obligations and deliver empathetic care, the VHA documents and analyzes data on all patients who exhibit DB. A local DB Committee (DBC) reviews the data, whether it occurs in an inpatient or outpatient setting, such as community-based outpatient clinics. Once a DB incident is reported, the DBC begins an evidence-based risk evaluation, including the option of contacting the persons who displayed or experienced the DB. Goals are to (1) prevent future DB incidents; (2) detect vulnerabilities in the environment; and (3) collaborate with HCPs and patients to provide optimal care while improving the patient/provider interactions.
Effects of Disruptive Behavior
DB has negative consequences for both patients and health care workers and results in poor evaluations of care from both groups.27-32 Aside from interfering with safe medical care, DB also impacts care for other patients by delaying access to care and increasing appointment wait times due to employee absenteeism and staff shortages.3,4,20,32,33 For HCPs, patient violence is associated with unwillingness to provide care, briefer treatment periods, and decreases in occupational satisfaction, performance, and commitment
Harmful health effects experienced by HCPs who have been victims of DB include fear, mood disorders, anxiety, all symptoms of psychological distress and posttraumatic stress disorder (PTSD).10,22,30,34-36 In a study of the impact on productivity of PTSD triggered by job-related DB, PTSD symptoms were associated with withdrawal from or minimizing encounters with patients, job turnover, and troubles with thinking
Reporting Disruptive Behavior
The literature suggests that consistent and effective DB reporting is pivotal to improving the outcome and quality of care for those displaying DB.37-39 To provide high-quality health services to veterans who display DB, the VHA must promote the management and reporting of DB. Without knowledge of the full spectrum of DB events at VHA facilities, efforts to prevent or manage DB and ensure safety may have limited impact.7,37 Reports can be used for clinical decision making to optimize staff training in delivery of quality care while assuring staff safety. More than 80% of DB incidents occur during interactions with patients, thus this is a clinical issue that can affect the outcome of patient care.8,21
Documented DB reports are used to analyze the degree, frequency, and nature of incidents, which might reveal risk factors and develop preventive efforts and training for specific hazards.8,39 Some have argued that implementing a standardized DB reporting system is a crucial first step toward minimizing hazards and improving health care.38,40,41
When DB incidents were recorded through a hospital electronic reporting system and discussed in meetings, staff reported: (1) increased awareness of DB; (2) improved ability to manage DB incidents; and (3) amplified reporting of incidents.38,41,42 These findings support similar results from studies of an intervention implemented at VA Community Living Centers (CLCs) from 2013 to 2017: Staff Training in Assisted Living Residences (STAR-VA).4,12,19 The aim of STAR-VA was to minimize challenging dementia-related DB in CLCs. The intervention initially was established to train direct-care, assisted-living staff to provide better care to older patients displaying DB. Data revealed that documentation of DBs was, the first step to ensuring staff and patient safety.18,40
VHA Reporting System
In 2013, the VA Office of Inspector General (OIG) found no standardized documentation of DB events across the VA health care system.42 Instead, DB events were documented in multiple records in various locations, including administrative and progress notes in the electronic health record (EHR), police reports, e-mails, or letters submitted to DBC chairs.42 This situation reduced administrators’ ability to consider all relevant information and render appropriate decisions in DB cases.42 In 2015, based on OIG recommendations, the VHA implemented the Disruptive Behavior Reporting System (DBRS) nationwide, which allowed all VHA staff to report DB events. The DBRS was designed to address factors likely to impede reporting and management of DB, namely, complexity of and lack of access to a central reporting system.43,44 The DBRS is currently the primary VHA tool to document DB events.
The DBRS consists of 32 questions in 5 sections relating to the (1) location and time of DB event; (2) reporter; (3) disrupter; (4) DB event details; and (5) the person who experienced (experiencer) the event. The system also provides a list of the types of DB, such as inappropriate communication, bullying and/or intimidation, verbal or written threat of physical harm, physical violence, sexual harassment, sexual assault, and property damage. The DBRS has the potential to provide useful data on DB and DB reporting, such as the typical staff entering data and the number and/or types of DB occurring.
The DBRS complements the preexisting VHA policies and committees for care of veterans who display DB.1-3,14,21,24,25 The VHA Workplace Violence Prevention Program (WVPP) required facilities to submit data on DB events through a Workplace Behavioral Risk report. Data for the report were obtained from police reports, patient safety reports, DBC records, and notes in the EHR. Following implementations of DBRS, the number of DB events per year became a part of facility performance standards.
VHA is creating novel approaches to handling DB that allow health care workers to render care in a safe and effective manner guided by documented information. For example, DBCs can recommend the use of Category I Patient Record Flags (PRFs) following documented DB, which informs staff of the potential risk of DB and provides guidance on protective methods to use when meeting with the patient.2,21,24 A survey of 140 VA hospital chiefs of staff indicated that DBC procedures were related to a decrease in the rates of assaults.1 Additionally, VA provides training for staff in techniques to promote personal safety, such as identifying signs that precede DB, using verbal deescalation, and practicing therapeutic containment.
Resistance to Reporting
Many health care employees and employers are reticent to report DBs.22,31,43,45-48 Studies suggest health care organizations can cultivate a culture that is resistant to reporting DB.49,50 This complicates the ability of the health care system to design and maintain safety protocols and safer treatment plans.3,41,51 Worldwide, < 30% of DBs are reported.47 One barrier may be that supervisors may not wish to acknowledge DBs on their units or may not provide sufficient staff time for training or reporting.31,46,47 HCPs may worry that a DB report will stigmatize patients, especially those who are elderly or have cognitive impairment, brain injury, psychological illness, or developmental disability. Patients with cognitive conditions are reportedly 20% more likely to be violent toward caregivers and providers.31 A dementia diagnosis, for example, is associated with a high likelihood for DB.30,52 More than 80% of DB events displayed by patients with dementia may go unreported.26,31,50,52
Some clinicians may attribute DB to physiologic conditions that need to be treated, not reported. However, employers can face various legal liabilities if steps are not taken to protect employees.47,51 Federal and state statutes require that organizations provide a healthy and safe employment environment for workers. This requires that employers institute reasonable protective measures, such as procedures to intervene, policies on addressing DB incidents, and/or training to minimize or deescalate DB.51,53 Also, employees may sue employers if security measures are inadequate or deficient in properly investigating current and past evidence of DB or identifying vulnerabilities in the workplace. Unwillingness to investigate DB and safety-related workplace concerns have contributed to increased workplace violence and legal liability.52,53 The mission of caring and trust is consistent with assuring a safe environment.
Training and Empathetic Care
To combat cultural resistance to reporting DBs, more and perhaps different contextual approaches to education and training may be needed that address ethical dilemmas and concerns of providers. The success of training relies on administrators supporting staff in reporting DB. Training must address providers’ conflicting beliefs and assist with identifying strategies to provide the best possible care for patients who display DB.1,38 HCPs are less likely to document a DB if they feel that administrators are creating documentation that will have negative consequences for a patient. Thus, leadership is responsible for ensuring that misconceptions are dispelled through training and other efforts and information on how reported DB data will be used is communicated through strategic channels.
Education and training must consider empathic care that attempts to understand why patients behave as they do through the information gathered.55 Empathy in health care is multifaceted: It involves comprehending a patient’s viewpoint, circumstances, and feelings and the capacity to analyze whether one is comprehending these accurately in order to demonstrate supportive care.54,55
Improving patient and staff interaction once a problematic behavior is identified is the aim of empathic care. Increasing empathic care can improve compassionate, patient-centered interactions that begin once the patient seeks care. This approach has proven to decrease DB by patients with dementia and improve their care, lessen staff problems during interactions, and increase staff morale.20 Experts call for the adoption of an interpersonal approach to patient encounters, and there is evidence that creating organizational change by moving toward compassionate care can lead to a positive impact for patients.54,55
Future Studies
There are growth opportunities in utilization of the DBRS. Analysis of the DBRS database by the VA Central Office (VACO) showed that the system is underutilized by facilities across the VA system.56 In response to this current underutilization, VACO is taking steps to close these gaps through increasing training to staff and promotion of the use of the DBRS. A 2015 pilot study of VHA providers showed that > 70% of providers had experienced a DB as defined by VHA, but only 34% of them reported their most recently experienced DB within the past 12 months.20 Thus, DBRS use must be studied within the context that patient-perpetrated DB is underreported in health care organizations.5,9,29,41,43,57,58 Studies addressing national DBRS utilization patterns and the cost associated with implementing the DBRS also are needed. One study suggests that there is an association between measures of facility complexity and staff perceptions of safety, which should be considered in analyzing DBRS usage.57 Studies addressing the role of the DBRS and misconceptions that the tool may represent a punitive tool also are needed. VHA should consider how the attribution “disruptive behavior” assigns a negative connotation and leads HCPs to avoid using the DBRS. Additionally, DB reporting may increase when HCPs understand that DB reporting is part of the comprehensive, consultative strategy to provide the best care to patients.
Conclusion
Accurate reporting of DB events enables the development of strategies for multidisciplinary teams to work together to minimize hazards and to provide interventions that provide for the safe delivery of health care to all patients. Improving reporting ensures there is an accurate representation of how disruptive events impact care provided within a facility—and what types of variables may be associated with increased risk for these types of events.
Additionally, ensuring that reporting is maximized also provides the VHA with opportunities for DBCs to offer evidence-based risk assessment of violence and consultation to staff members who may benefit from improved competencies in working with patients who display DB. These potential improvements are consistent with the VHA I CARE values and will provide data that can inform recommendations for health care in other agencies/health care organizations.
Acknowledgments
This work was supported by the Center of Innovation on Disability and Rehabilitation Research (CINDRR) of the Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs.
While private or other public health care organizations can refuse to care for patients who have displayed disruptive behavior (DB), the VA Response to Disruptive Behavior of Patients law (38 CFR §17.107) prohibits the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) from refusing care to veterans who display DB.1 The VHA defines DB as any behavior that is intimidating, threatening, or dangerous or that has, or could, jeopardize the health or safety of patients, VHA staff, or others.2
VA Response to DB Law
The VA Response to Disruptive Behavior of Patients requires the VHA to provide alternative care options that minimize risk while ensuring services; for example, providing care at a different location and/or time when additional staff are available to assist and monitor the patient. This can provide a unique opportunity to capture data on DB and the results of alternative forms of caring for this population.
The reason public health care organizations refuse care to persons who display DB is clear: DBs hinder business operations, are financially taxing, and put health care workers at risk.3-10 “In 2009, the VHA spent close to $5.5 million on workers’ compensation and medical expenditures for 425 incidents–or about $130,000 per DB incident (Hodgson M, Drummond D, Van Male L. Unpublished data, 2010).” In another study, 106 of 762 nurses in 1 hospital system reported an assault by a patient, and 30 required medical attention, which resulted in a total cost of $94,156.8 From 2002 to 2013, incidents of serious workplace violence requiring days off for an injured worker to recover on average were 4 times more common in health care than in other industries.6-11 Incidents of patient violence and aggression toward staff transcend specialization; however, hospital nurses and staff from the emergency, rehabilitation and gerontology departments, psychiatric unit, and home-based services are more susceptible and vulnerable to DB incidents than are other types of employees.8,10-19
Data reported by health care staff suggest that patients rather than staff members or visitors initiate > 70% of serious physical attacks against health care workers.9,13,20-23 A 2015 study of VHA health care providers (HCPs) found that > 60% had experienced some form of DB, verbal abuse being the most prevalent, followed by sexual abuse and physical abuse.20 Of 72,000 VHA staff responding to a nationwide survey, 13% experienced, on average, ≥ 1 assault by a veteran (eg, something was thrown at them; they were pushed, kicked, slapped; or were threatened or injured by a weapon).8,21
To meet its legal obligations and deliver empathetic care, the VHA documents and analyzes data on all patients who exhibit DB. A local DB Committee (DBC) reviews the data, whether it occurs in an inpatient or outpatient setting, such as community-based outpatient clinics. Once a DB incident is reported, the DBC begins an evidence-based risk evaluation, including the option of contacting the persons who displayed or experienced the DB. Goals are to (1) prevent future DB incidents; (2) detect vulnerabilities in the environment; and (3) collaborate with HCPs and patients to provide optimal care while improving the patient/provider interactions.
Effects of Disruptive Behavior
DB has negative consequences for both patients and health care workers and results in poor evaluations of care from both groups.27-32 Aside from interfering with safe medical care, DB also impacts care for other patients by delaying access to care and increasing appointment wait times due to employee absenteeism and staff shortages.3,4,20,32,33 For HCPs, patient violence is associated with unwillingness to provide care, briefer treatment periods, and decreases in occupational satisfaction, performance, and commitment
Harmful health effects experienced by HCPs who have been victims of DB include fear, mood disorders, anxiety, all symptoms of psychological distress and posttraumatic stress disorder (PTSD).10,22,30,34-36 In a study of the impact on productivity of PTSD triggered by job-related DB, PTSD symptoms were associated with withdrawal from or minimizing encounters with patients, job turnover, and troubles with thinking
Reporting Disruptive Behavior
The literature suggests that consistent and effective DB reporting is pivotal to improving the outcome and quality of care for those displaying DB.37-39 To provide high-quality health services to veterans who display DB, the VHA must promote the management and reporting of DB. Without knowledge of the full spectrum of DB events at VHA facilities, efforts to prevent or manage DB and ensure safety may have limited impact.7,37 Reports can be used for clinical decision making to optimize staff training in delivery of quality care while assuring staff safety. More than 80% of DB incidents occur during interactions with patients, thus this is a clinical issue that can affect the outcome of patient care.8,21
Documented DB reports are used to analyze the degree, frequency, and nature of incidents, which might reveal risk factors and develop preventive efforts and training for specific hazards.8,39 Some have argued that implementing a standardized DB reporting system is a crucial first step toward minimizing hazards and improving health care.38,40,41
When DB incidents were recorded through a hospital electronic reporting system and discussed in meetings, staff reported: (1) increased awareness of DB; (2) improved ability to manage DB incidents; and (3) amplified reporting of incidents.38,41,42 These findings support similar results from studies of an intervention implemented at VA Community Living Centers (CLCs) from 2013 to 2017: Staff Training in Assisted Living Residences (STAR-VA).4,12,19 The aim of STAR-VA was to minimize challenging dementia-related DB in CLCs. The intervention initially was established to train direct-care, assisted-living staff to provide better care to older patients displaying DB. Data revealed that documentation of DBs was, the first step to ensuring staff and patient safety.18,40
VHA Reporting System
In 2013, the VA Office of Inspector General (OIG) found no standardized documentation of DB events across the VA health care system.42 Instead, DB events were documented in multiple records in various locations, including administrative and progress notes in the electronic health record (EHR), police reports, e-mails, or letters submitted to DBC chairs.42 This situation reduced administrators’ ability to consider all relevant information and render appropriate decisions in DB cases.42 In 2015, based on OIG recommendations, the VHA implemented the Disruptive Behavior Reporting System (DBRS) nationwide, which allowed all VHA staff to report DB events. The DBRS was designed to address factors likely to impede reporting and management of DB, namely, complexity of and lack of access to a central reporting system.43,44 The DBRS is currently the primary VHA tool to document DB events.
The DBRS consists of 32 questions in 5 sections relating to the (1) location and time of DB event; (2) reporter; (3) disrupter; (4) DB event details; and (5) the person who experienced (experiencer) the event. The system also provides a list of the types of DB, such as inappropriate communication, bullying and/or intimidation, verbal or written threat of physical harm, physical violence, sexual harassment, sexual assault, and property damage. The DBRS has the potential to provide useful data on DB and DB reporting, such as the typical staff entering data and the number and/or types of DB occurring.
The DBRS complements the preexisting VHA policies and committees for care of veterans who display DB.1-3,14,21,24,25 The VHA Workplace Violence Prevention Program (WVPP) required facilities to submit data on DB events through a Workplace Behavioral Risk report. Data for the report were obtained from police reports, patient safety reports, DBC records, and notes in the EHR. Following implementations of DBRS, the number of DB events per year became a part of facility performance standards.
VHA is creating novel approaches to handling DB that allow health care workers to render care in a safe and effective manner guided by documented information. For example, DBCs can recommend the use of Category I Patient Record Flags (PRFs) following documented DB, which informs staff of the potential risk of DB and provides guidance on protective methods to use when meeting with the patient.2,21,24 A survey of 140 VA hospital chiefs of staff indicated that DBC procedures were related to a decrease in the rates of assaults.1 Additionally, VA provides training for staff in techniques to promote personal safety, such as identifying signs that precede DB, using verbal deescalation, and practicing therapeutic containment.
Resistance to Reporting
Many health care employees and employers are reticent to report DBs.22,31,43,45-48 Studies suggest health care organizations can cultivate a culture that is resistant to reporting DB.49,50 This complicates the ability of the health care system to design and maintain safety protocols and safer treatment plans.3,41,51 Worldwide, < 30% of DBs are reported.47 One barrier may be that supervisors may not wish to acknowledge DBs on their units or may not provide sufficient staff time for training or reporting.31,46,47 HCPs may worry that a DB report will stigmatize patients, especially those who are elderly or have cognitive impairment, brain injury, psychological illness, or developmental disability. Patients with cognitive conditions are reportedly 20% more likely to be violent toward caregivers and providers.31 A dementia diagnosis, for example, is associated with a high likelihood for DB.30,52 More than 80% of DB events displayed by patients with dementia may go unreported.26,31,50,52
Some clinicians may attribute DB to physiologic conditions that need to be treated, not reported. However, employers can face various legal liabilities if steps are not taken to protect employees.47,51 Federal and state statutes require that organizations provide a healthy and safe employment environment for workers. This requires that employers institute reasonable protective measures, such as procedures to intervene, policies on addressing DB incidents, and/or training to minimize or deescalate DB.51,53 Also, employees may sue employers if security measures are inadequate or deficient in properly investigating current and past evidence of DB or identifying vulnerabilities in the workplace. Unwillingness to investigate DB and safety-related workplace concerns have contributed to increased workplace violence and legal liability.52,53 The mission of caring and trust is consistent with assuring a safe environment.
Training and Empathetic Care
To combat cultural resistance to reporting DBs, more and perhaps different contextual approaches to education and training may be needed that address ethical dilemmas and concerns of providers. The success of training relies on administrators supporting staff in reporting DB. Training must address providers’ conflicting beliefs and assist with identifying strategies to provide the best possible care for patients who display DB.1,38 HCPs are less likely to document a DB if they feel that administrators are creating documentation that will have negative consequences for a patient. Thus, leadership is responsible for ensuring that misconceptions are dispelled through training and other efforts and information on how reported DB data will be used is communicated through strategic channels.
Education and training must consider empathic care that attempts to understand why patients behave as they do through the information gathered.55 Empathy in health care is multifaceted: It involves comprehending a patient’s viewpoint, circumstances, and feelings and the capacity to analyze whether one is comprehending these accurately in order to demonstrate supportive care.54,55
Improving patient and staff interaction once a problematic behavior is identified is the aim of empathic care. Increasing empathic care can improve compassionate, patient-centered interactions that begin once the patient seeks care. This approach has proven to decrease DB by patients with dementia and improve their care, lessen staff problems during interactions, and increase staff morale.20 Experts call for the adoption of an interpersonal approach to patient encounters, and there is evidence that creating organizational change by moving toward compassionate care can lead to a positive impact for patients.54,55
Future Studies
There are growth opportunities in utilization of the DBRS. Analysis of the DBRS database by the VA Central Office (VACO) showed that the system is underutilized by facilities across the VA system.56 In response to this current underutilization, VACO is taking steps to close these gaps through increasing training to staff and promotion of the use of the DBRS. A 2015 pilot study of VHA providers showed that > 70% of providers had experienced a DB as defined by VHA, but only 34% of them reported their most recently experienced DB within the past 12 months.20 Thus, DBRS use must be studied within the context that patient-perpetrated DB is underreported in health care organizations.5,9,29,41,43,57,58 Studies addressing national DBRS utilization patterns and the cost associated with implementing the DBRS also are needed. One study suggests that there is an association between measures of facility complexity and staff perceptions of safety, which should be considered in analyzing DBRS usage.57 Studies addressing the role of the DBRS and misconceptions that the tool may represent a punitive tool also are needed. VHA should consider how the attribution “disruptive behavior” assigns a negative connotation and leads HCPs to avoid using the DBRS. Additionally, DB reporting may increase when HCPs understand that DB reporting is part of the comprehensive, consultative strategy to provide the best care to patients.
Conclusion
Accurate reporting of DB events enables the development of strategies for multidisciplinary teams to work together to minimize hazards and to provide interventions that provide for the safe delivery of health care to all patients. Improving reporting ensures there is an accurate representation of how disruptive events impact care provided within a facility—and what types of variables may be associated with increased risk for these types of events.
Additionally, ensuring that reporting is maximized also provides the VHA with opportunities for DBCs to offer evidence-based risk assessment of violence and consultation to staff members who may benefit from improved competencies in working with patients who display DB. These potential improvements are consistent with the VHA I CARE values and will provide data that can inform recommendations for health care in other agencies/health care organizations.
Acknowledgments
This work was supported by the Center of Innovation on Disability and Rehabilitation Research (CINDRR) of the Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs.
1. Hodgson MJ, Mohr DC, Drummond DJ, Bell M, Van Male L. Managing disruptive patients in health care: necessary solutions to a difficult problem. Am J Ind Med. 2012;55(11):1009-1017.
2. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2010-053. Patient Record Flags. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341 Published December 3, 2010. Accessed March 29, 2019.
3. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2012-026. Sexual Assaults and Other Defined Public Safety Incidents in VHA Facilities. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2797. Published September 27, 2012. Accessed March 29, 2019.
4. Curyto KJ, McCurry SM, Luci K, Karlin BE, Teri L, Karel MJ. Managing challenging behaviors of dementia in veterans: identifying and changing activators and consequences using STAR-VA. J Gerontol Nurs. 2017;43(2):33-43.
5. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228.
6. Phillips JP. Workplace violence against health care workers in the United States. NEJM. 2016;374(17):1661-1669.
7. Janocha JA, Smith RT. Workplace safety and health in the health care and social assistance industry, 2003–07. https://www.bls.gov/opub/mlr/cwc/workplace-safety-and-health-in-the-health-care-and-social-assistance-industry-2003-07.pdf. Published August 30, 2010. Accessed February 19, 2019.
8. US Department of Labor, Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. https://www.osha.gov/Publications/OSHA3826.pdf. Published December 2015. Accessed February 19, 2019.
9. US Department of Labor, Occupational Safety and Health Administration. Prevention of Workplace Violence in Healthcare and Social Assistance. Occupational Safety and Health Administration, https://www.govinfo.gov/content/pkg/FR-2016-12-07/pdf/2016-29197.pdf. Accessed January 20, 2017.
10. Gerberich SG, Church TR, McGovern PM, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med. 2004;61(6):495-503.
11. Sherman MF, Gershon RRM, Samar SM, Pearson JM, Canton AN, Damsky MR. Safety factors predictive of job satisfaction and job retention among home healthcare aides. J Occup Environ Med. 2008;50(12):1430-1441.
12. Karel MJ, Teri L, McConnell E, Visnic S, Karlin BE. Effectiveness of expanded implementation of STAR-VA for managing dementia-related behaviors among veterans. Gerontologist. 2016;56(1):126-134.
13. US Department of Labor, Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work. https://www.bls.gov/news.release/archives/osh2_11192015.htm. Published November 19, 2015.
14. Beech B, Leather P. Workplace violence in the health care sector: A review of staff training and integration of training evaluation models. Aggression Violent Behav. 2006;11(1):27-43.
15. Campbell CL, McCoy S, Burg MA, Hoffman N. Enhancing home care staff safety through reducing client aggression and violence in noninstitutional care settings: a systematic review. Home Health Care Manage Pract. 2014;26(1):3-10.
16. Gallant-Roman MA. Strategies and tools to reduce workplace violence. AAOHNJ. 2008;56(11):449-454.
17. Weinberger LE, Sreenivasan S, Smee DE, McGuire J, Garrick T. Balancing safety against obstruction to health care access: an examination of behavioral flags in the VA health care system. J Threat Assess Manage. 2018;5(1):35-41.
18. Elbogen EB, Johnson SC, Wagner HR, et al. Protective factors and risk modification of violence in Iraq and Afghanistan war veterans. J Clin Psychiatry. 2012;73(6):e767-e773.
19. Karlin BE, Visnic S, McGee JS, Teri L. Results from the multisite implementation of STAR-VA: a multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans. Psychol Serv. 2014;11(2):200-208.
20. Semeah LM, Campbell CL, Cowper DC, Peet AC. Serving our homeless veterans: patient perpetrated violence as a barrier to health care access. J Pub Nonprofit Aff. 2017;3(2):223-234.
21. Hodgson MJ, Reed R, Craig T, et al. Violence in healthcare facilities: lessons from the Veterans Health Administration. J Occup Environ Med. 2004;46(11):1158-1165.
22. Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: findings from an Australian study. J Adv Nurs. 2006;55(6):778-787.
23. Barling J, Rogers AG, Kelloway EK. Behind closed doors: in-home workers’ experience of sexual harassment and workplace violence. J Occup Health Psychol. 2001;6(3):255-269.
24. Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med. 2015;58(11):1194-1204.
25. Sippel LM, Mota NP, Kachadourian LK, et al. The burden of hostility in U.S. veterans: results from the National Health and Resilience in Veterans Study. Psychiatry Res. 2016;243(suppl C):421-430.
26. Campbell C. Patient Violence and Aggression in Non-Institutional Health Care Settings: Predictors of Reporting By Healthcare Providers [doctoral dissertation]. Orlando: University of Central Florida; 2016.
27. Galinsky T, Feng HA, Streit J, et al. Risk factors associated with patient assaults of home healthcare workers. Rehabil Nurs. 2010;35(5):206-215.
28. Campbell CL. Incident reporting by health-care workers in noninstitutional care settings. Trauma, Violence Abuse. 2017;18(4):445-456.
29. Arnetz JE, Arnetz BB. Violence towards health care staff and possible effects on the quality of patient care. Soc Sci Med. 2001;52(3):417-427.
30. Gates D, Fitzwater E, Succop P. Relationships of stressors, strain, and anger to caregiver assaults. Issues Ment Health Nurs. 2003;24(8):775-793.
31. Brillhart B, Kruse B, Heard L. Safety concerns for rehabilitation nurses in home care. Rehabil Nurs. 2004;29(6):227-229.
32. Taylor H. Patient violence against clinicians: managing the risk. Innov Clin Neurosci. 2013;10(3):40-42.
33. US Department of Veterans Affairs, Office of Public and Intergovernmental Affairs. The Joint Commission releases results of surveys of the VA health care system. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2808. Updated August 5, 2014. Accessed February 19, 2019.
34. Büssing A, Höge T. Aggression and violence against home care workers. J Occup Health Psychol. 2004;9(3):206-219.
35. Geiger-Brown J, Muntaner C, McPhaul K, Lipscomb J, Trinkoff A. Abuse and violence during home care work as predictor of worker depression. Home Health Care Serv Q. 2007;26(1):59-77.
36. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59-66.
37. Petterson IL, Arnetz BB. Psychosocial stressors and well-being in health care workers: the impact of an intervention program. Soc Sci Med. 1998;47(11):1763-1772.
38. Arnetz JE, Arnetz BB. Implementation and evaluation of a practical intervention programme for dealing with violence towards health care workers. J Adv Nurs. 2000;31(3):668-680.
39. Arnetz JE, Hamblin L, Russell J, et al. Preventing patient-to-worker violence in hospitals: outcome of a randomized controlled intervention. J Occup Environ Med. 2017;59(1):18-27.
40. Elbogen EB, Tomkins AJ, Pothuloori AP, Scalora MJ. Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination. J Am Acad Psychiatry Law. 2003;31(1):58-64.
41. Winsvold Prang I, Jelson-Jorgensen LP. Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes. Geriatr Nurs. 2014;35(6):441-447.
42. US Department of Veterans Affairs, Office of Inspector General. Healthcare inspection: management of disruptive patient behavior at VA medical facilities. Report No. 11-02585-129. https://www.va.gov/oig/pubs/VAOIG-11-02585-129.pdf. Published Mrach 7, 2013. Accessed February 21, 2019.
43. Lipscomb J, London M. Not Part of the Job: How to Take a Stand Against Violence in the Work Setting. Silver Spring, MD: American Nurses Association; 2015.
44. May DD, Grubbs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs. 2002;28(1):11-17.
45. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? J Gerontol Soc Work. 2014;57(5):460-477.
46. Brennan C, Worrall-Davies A, McMillan D, Gilbody S, House A. The hospital anxiety and depression scale: a diagnostic meta-analysis of case-finding ability. J Psychosom Res. 2010;69(4):371-378.
47. McPhaul K, Lipscomb J, Johnson J. Assessing risk for violence on home health visits. Home Healthc Nurse. 2010;28(5):278-289.
48. McPhaul KM, London M, Murrett K, Flannery K, Rosen J, Lipscomb J. Environmental evaluation for workplace violence in healthcare and social services. J Safety Res. 2008;39(2):237-250.
49. Kelly JA, Somlai AM, DiFranceisco WJ, et al. Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers. Am J Public Health. 2000;90(7):1082-1088.
50. Pawlin S. Reporting violence. Emerg Nurse. 2008;16(4):16-21.
51. Brakel SJ. Legal liability and workplace violence. J Am Acad Psychiatry Law. 1998;26(4):553-562.
52. Neuman JH, Baron RA. Workplace violence and workplace aggression: evidence concerning specific forms, potential causes, and preferred targets. J Manage. 1998;24(3):391-419.53. Ferns T, Chojnacka I. Angels and swingers, matrons and sinners: nursing stereotypes. Br J Nurs. 2005;14(19):1028-1032.
54. Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract 2002;52(suppl):S9-S12.
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56. US Department of Veterans Affairs, Veterans Health Administrastion. Veterans Health Administration workplace violence prevention program (WVPP): disruptive behavior reporting system utilization report. Published 2017. https://vaww.portal2.va.gov/sites/wvpp/Shared%20Documents/DBRS%20Utilization%20Reports/FY2017%20DBRS%20Quarterly%20Utilization%20Report%20(Quarter%201).pdf. [Source not verified.]
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58. Carney PT, West P, Neily J, Mills PD, Bagian JP. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25(6):457-461.
1. Hodgson MJ, Mohr DC, Drummond DJ, Bell M, Van Male L. Managing disruptive patients in health care: necessary solutions to a difficult problem. Am J Ind Med. 2012;55(11):1009-1017.
2. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2010-053. Patient Record Flags. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2341 Published December 3, 2010. Accessed March 29, 2019.
3. US Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2012-026. Sexual Assaults and Other Defined Public Safety Incidents in VHA Facilities. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2797. Published September 27, 2012. Accessed March 29, 2019.
4. Curyto KJ, McCurry SM, Luci K, Karlin BE, Teri L, Karel MJ. Managing challenging behaviors of dementia in veterans: identifying and changing activators and consequences using STAR-VA. J Gerontol Nurs. 2017;43(2):33-43.
5. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228.
6. Phillips JP. Workplace violence against health care workers in the United States. NEJM. 2016;374(17):1661-1669.
7. Janocha JA, Smith RT. Workplace safety and health in the health care and social assistance industry, 2003–07. https://www.bls.gov/opub/mlr/cwc/workplace-safety-and-health-in-the-health-care-and-social-assistance-industry-2003-07.pdf. Published August 30, 2010. Accessed February 19, 2019.
8. US Department of Labor, Occupational Safety and Health Administration. Workplace violence in healthcare: understanding the challenge. https://www.osha.gov/Publications/OSHA3826.pdf. Published December 2015. Accessed February 19, 2019.
9. US Department of Labor, Occupational Safety and Health Administration. Prevention of Workplace Violence in Healthcare and Social Assistance. Occupational Safety and Health Administration, https://www.govinfo.gov/content/pkg/FR-2016-12-07/pdf/2016-29197.pdf. Accessed January 20, 2017.
10. Gerberich SG, Church TR, McGovern PM, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med. 2004;61(6):495-503.
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