Designing a novel post-incident intervention to address patient harassment of staff in VA primary care settings

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Project Background: Ninety-seven percent of women and 77% of men internal medicine physicians in a recent Veterans Affairs (VA) healthcare facility survey reported sexual harassment from patients. Staff may cope with patient-perpetrated harassment by omitting elements of care, rushing clinical tasks, and distancing from the patient emotionally and physically. Further, patient-perpetrated harassment is associated with decreased staff well-being and increased burnout and turnover, which are in turn associated with decreased quality of care, decreased patient satisfaction, and increased risk of medical errors. Secretary McDonough recently vowed to end all forms of harassment and discrimination at VA, and the new Deborah Sampson Act requires facilities to implement anti-harassment procedures. However, prior work indicates that VA lacks systematic, evidence-based interventions for responding to patient harassment of staff that anticipate harassment, stop the incident, communicate that harassment is unwelcome, facilitate incident reporting, and support affected staff. The goal of this pilot project is to design a novel intervention to guide immediate post- incident staff, clinic, and facility responses to patient-perpetrated sexual harassment of staff in primary care. Significance/Impact: The resulting intervention will address ORD Strategic Priority 4: actively promoting diversity, equity, and inclusion by communicating that VA does not tolerate harassment based on social identity characteristics. Additionally, it will contribute to HSR&D priority domain: Primary Care Practice and Complex Chronic Disease Management by offering support related to patient-perpetrated harassment that can “improve provider and staff morale,” improve staff-provider interactions, and increase quality of patient care. Innovation: This pilot project leverages a unique opportunity to respond to unprecedented leadership and policy support for interventions to address harassment at VA. The resulting intervention will fill a critical gap in procedures grounded in empirical data for responding to patient-perpetrated harassment and supporting VA staff, and will complement VA’s ongoing anti-harassment efforts. Our design process will be guided by an innovative framework that will ensure that the intervention fits with VA priorities and stakeholder needs. Specific Aims: The Specific Aims are to: 1) identify intervention components based on existing and ideal practices for responding to patient-perpetrated harassment of staff; and 2) refine the post-incident intervention through iterative stakeholder feedback. Methodology: Guided by a Steering Committee of operations partners, VA leadership, and subject matter experts, we will follow a step-based process of transcreation, i.e., co-designing interventions with stakeholders to fit with local contexts from the outset. We will focus on primary care settings, which have established rates of harassment and serve as the main port of entry into VA care. We will achieve Aim 1 by interviewing VA primary care providers (e.g., physicians, medical trainees), supervisors (e.g., primary care chiefs, fellowship preceptors), leaders (e.g., facility directors, fellowship directors), and other subject matter experts (e.g., ethicists, disruptive behavior committee members) (n = 30) to elicit current and desired staff, clinic, and facility procedures for responding to patient harassment and supporting affected staff. We will achieve Aim 2 by a) engaging an expert panel of Steering Committee members and Aim 1 staff participants (n = 12) in a modified Delphi process to build consensus on importance and feasibility of intervention components identified in Aim 1; and b) conducting interactive webinars with staff from Women’s Health Practice-Based Research Network sites to assess likelihood of intervention adoption and potential adoption barriers. Implementation/Next Steps: Following project completion, we will seek HSR&D funding to test the intervention in an effectiveness-implementation trial, with the ultimate goals of adaptation to other clinical settings and forms of patient-perpetrated bias (e.g., racial/ethnic discrimination) and dissemination.