Issues in the measurement of violent incidents and the introduction of a new scale: the 'attacks' (attempted and actual assault scale)

A Study Into the Severity of Forensic and Civil Inpatient Aggression

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

How short should short-term risk assessment be? Determining the optimum interval for START reassessment in a secure mental health service

ACCESSIBLE SUMMARY

The Short-Term Assessment of Risk and Treatability (START) is a tool used in some mental health services to assess patients to see if they are at risk of violence, self-harm, self-neglect or victimization. The recommended time between assessments is 3 months but there is currently no evidence to show that this is best practice. We have investigated whether assessing at 1- or 2-month intervals would be more accurate and therefore facilitate more individualized risk management interventions. We found that many patients who were rated as low risk had been involved in risk behaviours before 3 months had passed; some patients who were rated at increased risk did not get involved in risk behaviours at all. Results are mixed for different outcomes but on balance, we think that the recommendation to conduct START assessment every 3 months is supported by the evidence. However, reassessment should be considered if risk behaviours are not prevented and teams should always consider whether risk management practices are too restrictive.

ABSTRACT

The Short-Term Assessment of Risk and Treatability (START) guides assessment of potential adverse outcomes. Assessment is recommended every 3 months but there is no evidence for this interval. We aimed to inform whether earlier reassessment was warranted. We collated START assessments for N = 217 adults in a secure mental health hospital, and subsequent aggressive, self-harm, self-neglect and victimization incidents. We used receiver operating characteristic analysis to assess predictive validity; survival function analysis to examine differences between low-, medium-, and high-risk groups; and hazard function analysis to determine the optimum interval for reassessment. The START predicted aggression and self-harm at 1, 2 and 3 months. At-risk individuals engaged in adverse outcomes earlier than low-risk patients. About half warranted reassessment before 3 months due to engagement in risk behaviour before that point despite a low-risk rating, or because of non-engagement by that point despite an elevated risk rating. Risk assessment should occur at appropriate intervals so that management strategies can be individually tailored. Assessment at 3-month intervals is supported by the evidence. START assessments should be revisited earlier if risk behaviours are not prevented; teams should constantly re-evaluate the need for restrictive practices.

Inpatient verbal aggression: content, targets and patient characteristics

Verbally aggressive behaviour on psychiatric wards is more common than physical violence and can have distressing consequences for the staff and patients who are subjected to it. Previous research has tended to examine incidents of verbal aggression in little detail, instead combining different types of aggressive behaviour into a single measure. This study recruited 522 adult psychiatric inpatients from 84 acute wards. Data were collected from nursing and medical records for the first 2 weeks of admission. Incidents of verbal aggression were categorized and associations with patient characteristics examined. There were 1398 incidents of verbal aggression in total, reported for half the sample. Types of verbal aggression were, in order of prevalence: abusive language, shouting, threats, expressions of anger and racist comments. There were also a large number of entries in the notes which did not specify the form of verbal aggression. Staff members were the most frequent target of aggression. A history of violence and previous drug use were consistently associated with verbal aggression. However, there were also some notable differences in patient variables associated with specific types of verbal aggression. Future studies should consider using multidimensional measures of verbal aggression.

The antecedents of violence and aggression within psychiatric in-patient settings

OBJECTIVE

To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings.

METHOD

Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data.

RESULTS

Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall.

CONCLUSION

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

Under the gaze of staff: special observation as surveillance

PURPOSE

This study explores the relationship of special observation (SO) to a range of patient, staff, and ward variables.

DESIGN AND METHODS

End-of-shift reports were completed by nurses on 136 acute mental health wards in England during 2004 and 2005.

FINDINGS

Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach). Significant relationships were found between SO and measures of ward surveillance, door locking, and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of staff without a nursing qualification were on duty.

PRACTICE IMPLICATIONS

Improved ward design, less reliance on unqualified staff, and greater use of surveillance measures may reduce the need for SO.

Violence against care workers in psychiatry: is prosecution justified?

The number of (severe) violent incidents against staff caused by psychiatric inpatients is high. Victims often do not report these incidents to the police, because of various reasons. But if they do report these incidents, the judicial authorities are often reluctant in prosecuting and convicting these patients. The central question in this article is 'in which cases is it appropriate to prosecute assaultive psychiatric patients?' In order to identify the influential factors in the decision in respectively reporting, prosecuting and convicting psychiatric patients who assault staff, a literature review has been performed. On the basis of this literature it is advised to report and investigate a case when the incident resulted in severe injury, the incident is a sexual offence, or when a patient repetitively causes violent incidents. Moreover, it appears that, although large amount of studies has been published on violence in psychiatry, the prosecution of violent psychiatric patients has hardly received any attention in the international literature. Empirical studies on this subject are suggested, in order to develop a uniform policy, which is embraced by all parties involved.

Potential severity of aggressive behaviour after acquired brain injury: implications for recording

Aggression is a consequence of acquired brain injury that may necessitate admission to neurobehavioural services. The 'Overt Aggression Scale - Modified for Neurorehabilitation' (OAS-MNR) is a valid, reliable means of capturing this. A criticism of observational rating scales is they do not reflect factors like intent to harm which results in recording anomalies. 'Attacks' has been proposed as a measure which achieves this within psychiatric settings. Principal goals of this study are to determine the usefulness of measuring similar concepts in neurobehavioural services and further validating both scales. A total of 1066 physical assaults were recorded in 6 weeks by 25 patients in an inpatient neurobehavioural programme using the OAS-MNR. Fifty incidents were also rated on Attacks. Convergent validity for using both measures in neurobehavioural services was found. Modifying OAS-MNR severity scores using one of two factors found to underlie Attacks produced an index that successfully discriminated incidents whose risk necessitated more intrusive intervention, which was not evident otherwise. Modifying scores that objectively reflect severity of physical assaults using measures of perceived intent should be a feature of observational recording scales such as the OAS-MNR. Ensuring robust inter-rater reliability will be essential in any development work.

The Quantification of Violence Scale: a simple method of recording significant violence

BACKGROUND

Although there are many rating scales recording the incidence and intensity of violence there are none that are specifically concerned with the measurement and assessment of severe violence.

AIMS

To develop a scale sensitive to variation centred on severe violence, establish its normative values, test its feasibility, and assess its reliability and validity in different populations.

METHOD

The Quantification of Violence Scale (QOVS) was developed in two stages. First, a list of 30 commonly experienced violent episodes in clinical psychiatric practice were evaluated and tested by weighting each episode by severity. Second, a numerical scale used to record the severity of the episode according to its degree of planning, intent and consequences. Violent episodes in two clinical populations were compared using the Modified Overt Aggression Scale (MOAS) and the preliminary version of the QOVS over periods up to 18 months, following which the numerical scale was developed.

RESULTS

Good (0.60-0.74) to Excellent (> 0.75) test-retest and inter-rater reliability agreement was obtained with both forms of the scale (intra-class correlations of 0.75 and 0.69 respectively), and similar agreement with MOAS scores was reached (0.67) in clinical populations. The scale was quick and easy to use in practice, and a score defining severe violence (9 on the numerical scale and 16 on the matched scale) was determined.

CONCLUSIONS

The QOVS, in its two forms, is a useful measure of recording significant violence in clinical and forensic practice.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Aggressive behaviour on acute psychiatric wards: prevalence, severity and management

AIM

This paper reports a study to investigate the nature and prevalence of inpatient aggressive behaviour directed at staff and other patients and, in the case of patient self-harm, the methods used by nursing staff to manage this.

BACKGROUND

Aggressive behaviour poses a threat to the physical and psychological health of psychiatric nursing staff. The fear that results from working in a climate of potential danger can also have a damaging impact on patient care.

METHODS

Nursing staff on five acute inpatient wards in one hospital in the United Kingdom collected data on aggressive incidents using the Staff Observation Aggression Scale - Revised during a 10 month period from June 2001 to April 2002.

RESULTS

There were 254 incidents of aggression recorded. Staff were most commonly targeted and were involved in 57 x 1% of incidents. The most frequent provocation of the aggression was the patient being denied something such as leave from the ward (29 x 5% of incidents). The most frequent means used by patients was verbal aggression (60% of incidents), the most frequent outcome for the victim was feeling threatened (59% of incidents), and verbal interventions were used most frequently to manage the aggressive behaviour (43 x 7%). Despite many incidents involving verbal aggression in both staff- and patient-targeted aggression, 35 x 9% of incidents involving staff and 25% of incidents involving other patients resulted in seclusion.

CONCLUSION

It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.

Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk

This study investigated the aggressive behaviour of all mentally ill patients within a whole psychiatric hospital with a catchment area of 325 000 inhabitants over a 1-year period (i) to assess the 1-year prevalence and characteristics of aggressive episodes and index inpatients, and (ii) to identify predictors of patients at risk by a multivariate approach. Staff Observation of Aggression Scale was used to assess aggressive behaviour. Characteristics of index inpatients were compared with those of non-index inpatients. Logistic regression analysis was applied to identify risk factors. A total of 171 out of 2210 admitted patients (7.7%) exhibited 441 aggressive incidents (1.7 incidents per bed per year). Logistic regression analyses revealed as major risk factors of aggression: diagnoses (organic brain syndromes OR = 3.6, schizophrenia OR = 2.9), poor psychosocial living conditions (OR = 2.2), and critical behaviour leading to involuntary admission (OR = 3.3). Predictors of aggressive behaviour can be useful to identify inpatients at risk. Nevertheless, additional situational determinants have to be recognized. Training for professionals should include preventive and de-escalating strategies to reduce the incidence of aggressive behaviour in psychiatric hospitals. The application of de-escalating interventions prior to admission might be effective in preventing aggressive behaviour during inpatient treatment especially for patients with severe mental disorders.

The Attempted and Actual Assault Scale (Attacks)

The Attempted and Actual Assault Scale (Attacks) was designed to record the nature and severity of inpatient assaults. To explore the psychometric properties of the Scale, a videotape of interpersonal assaults was compiled with clips from regular television broadcasts. During a meeting of the European Violence in Psychiatry Research Group (EVIPRG), 22 members from 14 different countries were instructed to rate the videotaped assaults on both the MOAS and the Attacks. Inter-rater reliability--in terms of intra-class correlation coefficients--was 0.70 for Attacks and 0.48 for MOAS severity scores. Attacks severity scores turned out to be significantly associated with the judgments of the raters about the severity of the observed assaults (Spearman's rho = 0.70). It is concluded that the psychometric properties of the newly developed Attacks are promising.