Luz Semeah is a Health Science Specialist, Diane Cowper- Ripley is Director, Magaly Freytes and Huanguang Jia are Research Health Scientists, all at the Center of Innovation on Disability and Rehabilitation Research (CINDRR) at the North Florida/South Georgia Veterans Health System (NF/SGVHS) in Gainesville, Florida. Colleen Campbell is a Licensed Clinical Social Worker, and Connie Uphold is a Health Scientist at CINDRR and the Associate Director of Implementation and Outcomes Research at the Geriatric Research Education and Clinical Center at NF/SGVHS. When this article was written, Destiny Hart was a Research Assistant at CINDRR and is currently a Student at the University of Florida in Gainesville. Diane Cowper-Ripley is an Affiliated Associate Professor in the Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida. Colleen Campbell is an Instructor at the University of Central Florida School of Social Work. Huanguang Jia is a Professor at the College of Public Health and Health Professions and Connie Uphold is an Associate Professor in the Department of Aging and Geriatrics Research, College of Medicine; both at the University of Florida. Correspondence: Luz Semeah (luz.semeah@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
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
