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.
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.
