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.
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. DB may represent a symptom of a health problem. Further, patients who are refused care because of DB may pose a threat to the community if their medical conditions are not treated or managed properly.
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).8,21Although 13% may seem small, the incidents may have lasting financial and emotional distress. Risk factors associated with DB include medication nonadherence, history of drug and alcohol use, disappointment with care, history of violence, and untreated mental health concerns.19,24,25 Also, unmarried and young patients are more likely to display violence against health care workers.26
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.
