National Development and Implementation of a Democratized Disruptive Behavior Reporting System in Health Care.

INTRODUCTION: Workplace disruptive behavior/ violence (WDBV) is underreported in health care. This study evaluated a 7-year implementation of the Disruptive Behavior Reporting System (DBRS), the most robust consolidated WDBV reporting system developed in the United States within the Veterans Health Administration (VHA). METHODS: After implementation of the system, implementation success was measured in real time by number of reports, types of staff entering reports, time to review the reports and time between when the incident occurred and report entry. RESULTS: Over the seven years since implementation, there has been a significant increase in reporting within DBRS with more than 50,000 reports in fiscal year (FY) 2021 up from 0 to 2014. Types of staff reporting increased to 67 from 54. The median number of days to review events in FY19 Q2 was 4.79 days and the report latency has almost completely disappeared. DISCUSSION: DBRS was designed to democratize reporting so staff can report WDBV anytime and anywhere playing a large role in the successful implementation. The increase in total number of reported events is an indication of the success of the system as it captures data historically lost due to underreporting. CONCLUSION: DBRS development and implementation showcases how information systems can empower front-line personnel to voice behavioral safety concerns.

Workplace violence prevention standardization using lean principles across a healthcare network.

Purpose The purpose of this paper is to describe the process used to standardize a Workplace Violence Prevention Program (WVPP) within a five-hospital healthcare system in Veterans Health Administration (VHA). Design/methodology/approach A description of the lean process improvement principles, used to bring the WVPP into compliance with Occupational Safety and Health Administration (OSHA) and other agencies through streamlining/standardizing processes. Findings There was significant standardization in both the threat assessment and education arms of the WVPP. Compliance with all major US Department of Labor OSHA requirements, as well as substantial time savings, were realized as part of this process improvement. Originality/value VHA is leading the way in inter/multidisciplinary assessment and mitigation of workplace violence, however, there are significant competing demands on staff time. This first ever use of lean principles to streamline processes around workplace violence prevention freed up clinician time for care while improving internal and external customer satisfaction, representing a major step forward in workplace violence risk mitigation.

Anger and suicidality in veterans: Impact of postseparation time and combat.

OBJECTIVE: The study investigated the association over time between the rates of anger/hostility and suicidality in post-9/11 veterans as a function of time following separation from the military and combat exposure. METHOD: Structured clinical interviews were conducted with N = 2,580 Iraq/Afghanistan-era U.S. military veterans serving since 9/11/01. For each participant, a postseparation interval was calculated as the time between military separation and the clinical interview, with a range of up to 9 years. Combat exposure was assessed using a three-level categorical proxy derived from the Combat Exposure Scale indexing levels of none, below, and above median exposure. Three separate estimates measuring anger/hostility and three separate measures of suicidality were modeled variously across separation intervals and levels of combat exposure. RESULTS: In bivariate analyses, higher levels of combat exposure were associated with overall significantly higher levels of both anger/hostility and suicidality. Based on multivariable analyses, rates in measures indexing suicidality among veterans did not decrease as a function of the number of years postseparation. In contrast, rates in measures indexing anger/hostility among veterans endorsing above-median levels of combat exposure decreased significantly with increasing time since separation. Nonetheless, even at longer time points, both suicidality and anger/hostility remained elevated among respondents endorsing above-median combat exposure. CONCLUSIONS: These findings illustrate the importance of implementing suicide prevention and anger management programs for postseparation adjustment as well as for the period beyond the immediate postseparation, with particular attention paid to the level of combat exposure experienced. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Managing disruptive patients in health care: necessary solutions to a difficult problem.

BACKGROUND: We sought to describe the components and processes in a violence risk assessment and management system, including electronic record requirements in the Veterans Health Administration (VA). We present information on system-level variation among program elements and their association with perceived and measured effectiveness. METHODS: We conducted a cross-sectional survey of Chiefs of Staff (COS) at 140 VA hospitals across the United States about specific disruptive behavior program elements, such as committee processes, patient referrals, and outcome patterns. We assessed COS perceived effectiveness of the processes. We compared COS perceptions with employee-reported assault-related incident rates and workers compensation lost time claim rates for assault-related injuries for 2009 and 2010. RESULTS: We found the violence risk assessment and management system is heavily used, often with guidance to provide police protection for providers. COS respondents were generally satisfied with design and performance of the system. Committee processes and perceptions of effectiveness were associated with reduction in assault-related incident rates. CONCLUSIONS: VA's system was considered effective by system owners and users may be effective at reducing assaulted-related injuries.

Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans.

BACKGROUND: This study investigates the empirical association between psychosocial protective factors and subsequent suicidal ideation in veterans. METHODS: We conducted a national longitudinal survey in which participants were randomly drawn from over one million U.S. military service members who served after September 11, 2001. Data were provided by a total of 1090 veterans representative of all 50 states and all military branches in two waves of data collection one year apart (79% retention rate). RESULTS: In chi-square analyses, psychosocial protective factors at wave 1 (employment, meeting basic needs, self-care, living stability, social support, spirituality, resilience, and self-determination) were significantly related to lower suicidal ideation at wave 2. In multivariable analyses controlling for covariates at wave 1 including suicidal ideation, the total number of protective factors endorsed at wave 1 significantly predicted reduced odds of suicidal ideation at wave 2. In multivariable analysis examining individual risk and protective factors, again controlling for covariates, results showed that money to cover basic needs and higher psychological resilience at wave 1 were associated with significantly lower odds of suicidal ideation at wave 2. LIMITATIONS: The study measured the link between psychosocial protective factors and suicidal ideation but not suicide attempts, which would be an important next step for this research. CONCLUSIONS: The results indicate that psychosocial rehabilitation and holistic approaches targeting financial well-being, homelessness, resilience, self-care, social support, spirituality, and work may offer a promising avenue in both veteran and non-veteran populations for treatment safety planning as well as suicide risk management and prevention.

Imagery rehearsal therapy for posttraumatic nightmares in U.S. veterans.

Imagery rehearsal therapy (IRT) may help reduce residual nightmares and posttraumatic stress disorder (PTSD) symptoms in veterans after trauma-focused PTSD treatment. Fifteen male U.S. veterans with PTSD and trauma-related nightmares, who had not previously completed trauma-focused PTSD treatment, attended 6 IRT group sessions. No benefits were observed immediately posttreatment. At 3- and 6-month follow-up, however, trauma-related nightmare frequency (nights/week) decreased (p < .01). The number of trauma-related nightmares/week (p < .01), number of total nightmares/week (p < .05), and PTSD symptoms (p < .05) also decreased at 3 months. The overall F test for time was significant (p < .05) for nightmare severity and fear of sleep. No effects were found on measures of the impact of nightmares, sleep quality, or depression. Clinical and research implications are discussed.

Protective mechanisms and prevention of violence and aggression in veterans.

Although a subset of Iraq and Afghanistan Veterans show aggression toward others after they return home from military service, little is known about protective mechanisms that could be bolstered to prevent violence. A national longitudinal survey was conducted between 2009 and 2011 using a random sample of veterans who served in Operation Iraqi Freedom or Operation Enduring Freedom. One thousand and ninety veterans, from 50 states representing all military branches, completed 2 waves of data collection, 1 year apart (retention rate = 79%). The final sample resembled the U.S. military post 9/11 in terms of age, sex, ethnicity, geography, and service branch. Protective mechanisms in socioeconomic (money to cover basic needs, stable employment), psychosocial (resilience, perceiving control over one's life, social support), and physical (healthy sleep, no physical pain) domains were examined. We found these protective mechanisms predicted decreased aggression and violence at follow-up, particularly among higher risk veterans. Multivariable analyses confirmed that protective mechanisms lowered violence through their interaction with risk factors. This study identifies protective mechanisms related to decreased community violence in veterans and indicates that rehabilitation aimed at improving socioeconomic, psychosocial, and physical well-being has potential promise to reduce aggression and violence among veterans after returning home from military service.

Screening for violence risk in military veterans: predictive validity of a brief clinical tool.

OBJECTIVE: Violence toward others is a serious problem among a subset of military veterans. The authors evaluated the predictive validity of a brief decision support tool to screen veterans for problems with violence and identify potential candidates for a comprehensive risk assessment. METHOD: Data on risk factors at an initial wave and on violent behavior at 1-year follow-up were collected in two independent sampling frames: a national random-sample survey of 1,090 Iraq and Afghanistan veterans and in-depth assessments of 197 dyads of veterans and collateral informants. Risk factors (lacking money for basic needs, combat experience, alcohol misuse, history of violence and arrests, and anger associated with posttraumatic stress disorder) were chosen based on empirical support in published research. Scales measuring these risk factors were examined, and items with the most robust statistical association with outcomes were selected for the screening tool. Regression analyses were used to derive receiver operating characteristic curves of sensitivities and specificities, with area under the curve providing an index of predictive validity. RESULTS: The resultant 5-item screening tool, called the Violence Screening and Assessment of Needs (VIO-SCAN), yielded area-under-the-curve statistics ranging from 0.74 to 0.78 for the national survey and from 0.74 to 0.80 for the in-depth assessments, depending on level of violence analyzed. CONCLUSIONS: Although the VIO-SCAN does not constitute a comprehensive violence risk assessment and cannot replace fully informed clinical decision making, it is hoped that the screen will provide clinicians with a rapid, systematic method for identifying veterans at higher risk of violence, prioritizing those in need a full clinical workup, structuring review of empirically supported risk factors, and developing plans collaboratively with veterans to reduce risk and increase successful reintegration in the community.