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Study Shows Intervention May Decrease Workplace Staff Injury Rates Due to Assaults in VA Community Living Centers

Persons with dementia in long-term care settings are at particularly high risk for exhibiting distress behaviors in dementia (DBD), such as physically and verbally aggressive behaviors, verbal agitation, and physically non-aggressive behaviors (i.e., pacing and wandering). Addressing DBD is part of a national VHA initiative to improve quality of care for persons with dementia in VA nursing homes, or Community Living Centers (CLCs). An interdisciplinary, person-centered, behavioral intervention for managing DBD, called STAR-VA, has been implemented in CLCs, with approximately17-21 CLC teams training annually between 2013 and 2018. The STAR-VA intervention helps staff have realistic expectations of residents with dementia; use effective verbal and non-verbal communication approaches; identify and change activators and consequences of distressed behavior; and facilitate individualized pleasant events. This study sought to describe the incidence of workplace disruptive behavior incidents and staff injury rates occurring in 120 VA CLCs (62 of which had completed STAR-VA training) from FY12-FY17 and to assess the association between STAR-VA implementation and workplace incidents. Outcome measures included staff injury due to assault and workplace disruptive behavior incidents (i.e., physical, verbal, and any workplace incident rate) occurring in the CLC, as well as therapeutic containment rates and resident-to-resident workplace incident rates. Workplace incident rates were gathered from VA’s Workplace Behavioral Risk Assessment (WBRA). The main independent variable was participation in the STAR-VA training program – and time since training.


  • The implementation of STAR-VA was significantly associated with lower staff injury rates due to assault, particularly following the first year of training, but was not associated with other reported workplace disruptive behavior incident rates. Verbal incident rates increased over time.
  • STAR-VA lowered agitation and target distress behavior frequency and severity among CLC residents with dementia.
  • Of total reported CLC workplace incidents from FY12-17 (21,056), 57% involved verbal incidents, 64% involved physical incidents, and 93% were initiated by a CLC resident.


  • The STAR-VA program has the potential to support a culture of safety within VA CLCs.


  • Investigators were unable to identify which CLC residents were involved in incidents or were present in multiple years of the data. Thus, it is unclear whether variations in workplace incident rates may be a function of resident turnover or reflect the impact of a small number of residents engaging in high numbers of behavior incidents.

This study was partly funded by HSR&D (IIR 17-046) and QUERI (PEC 16-353). Dr. Mohr is with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) in Boston, MA, and Dr. Curyto is part of the Center for Integrated Healthcare at VA Western New York Healthcare System

Mohr D, Curyto K, Jedele J, et al. Impact of STAR-VA on Staff Injury and Disruptive Behavior Reports in VA Nursing Homes. Journal of the American Medical Directors Association. August 30, 2021; online ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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