Violence risk assessment: combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study

BACKGROUND

Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions.

METHODS

A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC).

RESULTS

Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent.

CONCLUSIONS

This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Risk management of hydrogenation station PPP project based on 3D framework-A case study in China

Renewable hydrogen energy has received growing attention due to the energy shortage and increasing CO2 emissions. With these issues in mind, renewable hydrogen has become an important component of future energy systems in many countries, especially in the transportation sector. However, the shortage of hydrogenation station and the risks associated with their construction have become an urgent issue for the development of hydrogen energy transportation. To better implement the hydrogenation station project, a risk management framework is proposed for risk control. First, a comprehensive risk index system is developed, using a weighting method based on the G1 method and the C-OWA operator. Second, a grey fuzzy synthetic assessment method is applied to evaluate the risk based on the 3D risk assessment framework. Finally, risk is assigned to different participants and actionable measures are proposed. This paper summarizes the obstacles to the development of hydrogen energy transportation, highlights the potential of hydrogen energy development, and suggests workable solutions for the use of hydrogen energy in the future transportation industry.

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings

INTRODUCTION

Violence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so.

METHODS

CINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken.

RESULTS

Eight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area.

DISCUSSION

There is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.

Mental health professionals' perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

BACKGROUND

Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals' perspectives.

METHODS

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

RESULTS

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were 'power and best interest' (social influences) and 'my professional role and responsibility' (social/professional role and identity). Key enablers were 'therapeutic relationship' (social influences) and 'value collaboration' (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components 'opportunity' and 'motivation'.

CONCLUSION

The review highlights the need for further empirical research to better understand current practice and mental health professionals' experiences and attitudes towards shared decision-making in risk assessment and risk management.

The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms "HCR-20" and "HCR 20", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the "presence of risk factors" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps ("scenario planning" and "management") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

Examination of risk assessment tools developed to evaluate risks in mental health areas: A systematic review

The purpose of this research was to identify and examine risk assessment tools evaluating at least two risk dimensions to evaluate the risk assessments of patients in mental health areas in a more comprehensive and standard manner. This systematic review was prepared according to the PRISMA guidelines. The databases to be scanned and the keywords to be entered were identified before scanning the literature. The keywords risk assessment, risk management, mental health, psychiatry, risk assessment scales, and risk assessment tools were scanned. The CINAHL, EMBASE, PsycInfo, Medline, APA PsycNET, Science Direct, Pubmed, ProQuest, and Google Scholar databases were searched. All full-text articles published between December 30th, 1970, and January 1st, 2020, were examined. A total of 7385 papers were investigated using the keywords listed above, and 18 studies meeting the inclusion criteria were identified. The tools involved were SPC, FACE, Clinical Risk Management, Threshold Assessment Grid, Risk Assessment for People with Mental Health Problems, Psychogeriatric and Risk Behavior Assessment Scale, Sainsbury Risk Assessment Tool, Risk Assessment Management and Audit Systems, Generic Integrated Risk Assessment for Forensic Environments, FRAME, Brief Risk Assessment, Clinical Assessment of Risks to Self & Others, RIO, The Risk Assessment and Management, Risk Assessment and Management Self-Efficacy Study, Galatean Risk and Safety Tool, Short-Term Assessment of Risk and Treatability, and Psychiatric Risk Assessment Scale.

Structured Professional Judgment to Assist the Evaluation and Safety Planning of Suicide Risk: The Risk of Suicide Protocol (RoSP)

Background: The Risk of Suicide Protocol (RoSP) is a structured professional judgment (SPJ) scheme designed in line with NICE guidelines to improve clinicians' ability to evaluate and manage suicide risk. Aims: This study aimed to evaluate the efficacy of RoSP in two settings: (1) unexpected deaths of people in the community who were known to mental health services; and (2) an inpatient hospital specializing in the assessment and treatment of patients with personality disorder. Method: In Study 1, information from a database of unexpected deaths (N = 68) within an NHS health board was used to complete a RoSP assessment (blind to cause of death) and information from the Coroner's Court was used to assign people to suicide vs. natural causes/accidental death. In Study 2, patients (N = 62) were assessed on the RoSP upon admission to hospital and their self-injurious behaviors were recorded over the first 3 months of admission. Results: (1) Evaluations using RoSP were highly reliable in both samples (ICCs 0.93-0.98); (2) professional judgment based on the RoSP was predictive of completed suicide in the community sample (AUC = 0.83) and; (3) was predictive of both suicide attempts (AUC = 0.81) and all self-injurious behaviors (AUC = 0.80) for the inpatient sample. Conclusion: RoSP is a reliable and valid instrument for the structured clinical evaluation of suicide risk for use in inpatient psychiatric services and in community mental health services. RoSP's efficacy is comparable to well-established structured professional judgment instruments designed to predict other risk behavior (e.g., HCR-20 and the prediction of violence). The use of RoSP for the clinical evaluation of suicide risk and safety-planning provides a structure for meeting NICE guidelines for suicide prevention and is now evidence-based.

Engaging with nurses to develop an occupational violence risk assessment tool for use in emergency departments: A participatory action research inquiry

BACKGROUND

Early detection of occupational violence (OV) risk factors could facilitate timely and appropriate management of patients in the emergency department. For this purpose, an OV risk assessment could be useful and best initiated at triage.

AIMS

To understand the need for and determine potential utility and desirable components of an OV risk assessment tool; and to determine specific challenges to its implementation if appropriate.

METHODS

A participatory action research was conducted. Data were collected through focus groups and semi-structured interviews. Thematic analysis was done inductively and collaboratively using Braun and Clarke's technique.

FINDINGS

Six themes were identified from triage nurses (N = 15) pertaining to: i) OV risk assessment; ii) communication of OV risk; iii) clinical implications of risk assessment; iv) tool attributes; v) future implementation challenges; vi) unintended consequences.

CONCLUSION

The development of an OV risk assessment tool is supported, but with very specific attributes. Findings herein also have implications on the implementation and evaluation of this tool in emergency settings.

SÉCuRE: A clinical tool for comprehensively assessing home safety of people with mental illness

Introduction

People with severe mental illness benefit from a growing number of measures aimed at supporting independent housing. The purpose of the study was to develop a comprehensive home safety assessment tool.

Method

The tool's elaboration was done in three phases. The planning phase was intended to circumscribe the phenomenon, providing input for the development phase, which consisted of creating and enhancing the tool's prototypes. The evaluation phase then featured the tool's translation validity (relevance, exhaustiveness, clarity, and apparent clinical utility), with four successive rounds of expert consultation ( n = 20). Changes were made to the tool according to the experts' suggestions.

Findings

The proposed tool, SÉCuRE, adopts a structured professional judgment approach that is designed to be used collaboratively and interprofessionally, with a specific role for occupational therapists. It aims to systematize the assessment of contributive factors (risk and protective), all stakeholders' expectations and needs and the identification of potential ethical issues. The findings supported the translation validity and acceptance of the tool by clinicians.

Conclusion

SÉCuRE was developed to assist with clinical judgment regarding home safety interventions. It is hoped that its use may ultimately foster home safety in the context of recovery.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

An Etiological Approach to Sexual Offender Assessment: CAse Formulation Incorporating Risk Assessment (CAFIRA)

PURPOSE OF REVIEW

Case formulations (CF) have been the cornerstone of effective practice in clinical psychology since the 1950s and now form one of the core competencies in clinical and forensic assessment. The use of CFs within forensic settings is becoming more relevant when working with offenders who have experienced significant trauma, suffered from personality disorder, and have displayed sexually abusive behavior. Furthermore, most North American and European jurisdictions insist that expert witnesses adopt an idiosyncratic approach to risk assessment and consider the characteristics of the individual as part of a wider formulation of the problem behavior. This article focuses specifically on CF incorporating risk assessment procedures of sexual offenders.

RECENT FINDINGS

While empirical support for the use of risk analysis and formulation in managing offending behavior generally, and sexual offending behavior in particular, is limited, there is mounting evidence to suggest that CF can improve understanding of an individual's problem sexual behaviors. We argue that by integrating risk formulations into the CF provides a conceptually robust link between the etiologically development of the problem sexual behavior and effective assessment and risk management of sexual offenders. As forensic treatment programs increasingly moved toward strength-based approaches, in keeping with the Risk-Need-Responsivity principles Andrews and Bonta (2004), and the Good Lives Model Ward and Stewart (Prof Psychol Res Pract 34:353-60, 2003) of offender rehabilitation, the use of CFs in the assessment, treatment, and management of sexual offenders is indispensable. We present an etiological framework for understanding risk in an individual sexual offender by integrating a case formulation model to include the use of (static, stable, and acute) actuarial and clinical risk assessment measures as well as protective risk factors, referred to as the CAse Formulation Incorporating Risk Assessment (CAFIRA) model.

Predicting aggressive behaviour in acute forensic mental health units: A re-examination of the dynamic appraisal of situational aggression's predictive validity

In the present study, we explored the predictive validity of the Dynamic Appraisal of Situational Aggression (DASA) assessment tool in male (n = 30) and female (n = 30) patients admitted to the acute units of a forensic mental health hospital. We also tested the psychometric properties of the original DASA bands and novel risk bands. The first 60 days of each patient's file was reviewed to identify daily DASA scores and subsequent risk-related nursing interventions and aggressive behaviour within the following 24 hours. Risk assessments, followed by documented nursing interventions, were removed to preserve the integrity of the risk-assessment analysis. Receiver-operator characteristics were used to test the predictive accuracy of the DASA, and generalized estimating equations (GEE) were used to account for repeated risk assessments, which occurs when analysing short-term risk-assessment data. The results revealed modest predictive validity for males and females. GEE analyses suggested the need to adjust the DASA risk bands to the following (with associated odds ratios (OR) for aggressive behaviour): 0 = low risk; 1, 2, 3 = moderate-risk OR, 4.70 (95% confidence interval (CI): 2.84-7.80); and 4, 5, 6, 7 = high-risk OR, 16.13 (95% CI: 9.71-26.78). The adjusted DASA risk bands could assist nurses by prompting violence-prevention interventions when the level of risk is elevated.

Measurement of Change in Dynamic Factors Using the START:AV

Historical approaches to violence risk assessment emphasized prediction of future violence and focused on static or historical risk factors. Consideration of dynamic factors as part of a comprehensive violence risk assessment approach may allow practitioners to better tailor treatment and risk management strategies. Limited research exists on whether risk assessment instruments can detect change in dynamic factors over time. The Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) is a relatively new risk assessment instrument that considers both Vulnerabilities and Strengths on factors that are purportedly dynamic in nature. This study examined changes in START:AV factors between initial and follow-up assessments conducted approximately three months later as part of a pilot implementation at three juvenile justice residential facilities in a Southern state. Overall, findings revealed significant item-level changes on several factors, as well as reliable changes in total scores for 28% (reliable change index; 95% confidence interval) of adolescents.

A Literature Review of the Utility of Selected Violence and Sexual Violence Risk Assessment Instruments

The rationale for this article is to comprehensively outline and describe the strengths and weaknesses of various risk assessment instruments/tools relevant to the evaluation of sexually violent and violent offenders. The author will briefly discuss ethical obligations the forensic mental health professional (FMHP) must consider when conducting risk assessments.

Predicting Aggressive and Disruptive Behavior in Referred 6- to 12-Year-Old Boys

The authors investigated the predictive and incremental validity of the Early Assessment Risk List for boys (EARL-20B; Augimeri, Koegl, Webster, & Levene, 2001), a structured clinical checklist designed for the professional judgment of risk for aggressive and disruptive behaviors and risk/needs factor-based management of this risk. Seventy-six boys consecutively referred to child psychiatric outpatient clinics in mid-Sweden were evaluated according to the EARL-20B and with independent (not EARL-20B-based) clinical evaluations. The participants were prospectively followed after 6 and 30 months. EARL- 20B-based assessments were positively and moderately associated with aggressive (reactive and proactive aggression) and disruptive behavior (conduct problems and DSM-IV Conduct Disorder) at both subsequent evaluations. Clinical evaluations made without the instrument were not as consistently associated with outcome. Incremental predictive validity over unstructured clinical evaluations and Conduct Disorder at baseline suggested promising clinical utility. The checklist might be used to support clinical decision making for referred boys at risk for continued antisocial behavior.

Covert and Implicit Influences on the Interpretation of Violence Risk Instruments

Forensic mental health practitioners are frequently asked to estimate the risk of future violence. Legal decisions concerning the sentencing, management and disposition of offenders often rely on the advice of such testimony. The burgeoning use of violence risk instruments in these settings undoubtedly injects a level of scientific rigour into forensic evaluations for courts and tribunals. Yet scrutiny of the inherent limitations of both risk instruments and the inferences and formulations drawn from them are often veiled by the discipline's endorsement for such approaches. Misconceptions about the validity and dependability of present-day risk assessments and expert infallibility persist. The furtive influences that shape both the (mis)interpretation and miscommunication of risk instruments in legal settings necessitate discussion.

How Veterans Health Administration Suicide Prevention Coordinators Assess Suicide Risk

This cross-sectional study was designed to examine the suicide risk assessment practices of Suicide Prevention Coordinators (SPCs) within the Veterans Health Administration. Specifically, this study sought to (1) identify factors SPCs consider most important in assessing risk and patient priority; (2) measure the level of consistency and agreement between SPCs in assessing suicide risk and prioritizing cases; and (3) measure individual SPC consistency between cases. SPCs (n = 63) responded to online survey questions about imminent and prolonged risk for suicide in response to 30 fictional vignettes. Combinations of 12 acute and chronic suicide risk factors were systematically distributed throughout the 30 vignettes using the Fedorov () procedure. The SPCs were also asked to identify the level of priority for further assessment both disregarding and assuming current caseloads. Data were analysed using clinical judgement analysis. Suicidal plan, β = 1.64; 95% CI (1.45, 1.82), and preparatory behaviour, β = 1.40; 95% CI (1.23, 1.57), were considered the most important acute or imminent risk factors by the SPCs. There was less variability across clinicians in the assessment of risk when alcohol use (p = 0.02) and hopelessness (p = 0.03) were present. When considering acute or imminent risk factors, there was considerable variability between clinicians on a vignette-by-vignette basis, median SD = 0.86 (range = 0.47, 1.13), and within individual clinicians across vignettes, median R²  = 0.80 (0.49, 0.95). These findings provide insight into how this group of providers think about acute and chronic risk factors contributing to imminent suicide risk in Veterans. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Identifies factors that practitioners consider most important in suicide risk assessment Discusses how to distinguish between chronic and acute risk for suicide Identifies factors that lead to more consistent clinical judgments.

There is more to risk and safety planning than dramatic risks: Mental health nurses' risk assessment and safety-management practice

Risk assessment and safety planning are considered a cornerstone of mental health practice, yet limited research exists into how mental health nurses conceptualize 'risk' and how they engage with risk assessment and safety planning. The aim of the present study was to explore mental health nurses' practices and confidence in risk assessment and safety planning. A self-completed survey was administered to 381 mental health nurses in Ireland. The findings indicate that nurses focus on risk to self and risk to others, with the risk of suicide, self-harm, substance abuse, and violence being most frequently assessed. Risk from others and 'iatrogenic' risk were less frequently considered. Overall, there was limited evidence of recovery-oriented practice in relation to risk. The results demonstrate a lack of meaningful engagement with respect to collaborative safety planning, the identification and inclusion of protective factors, and the inclusion of positive risk-taking opportunities. In addition, respondents report a lack of confidence working with positive risk taking and involving family/carers in the risk-assessment and safety-planning process. Gaps in knowledge about risk-assessment and safety-planning practice, which could be addressed through education, are identified, as are the implications of the findings for practice and research.

Measures for screening for intimate partner violence: a systematic review

WHAT IS KNOWN ON THE SUBJECT?: Intimate partner violence (IPV) has a significant impact on the onset, duration and recurrence of mental health problems. Prevalence rates of IPV are significantly higher in mental health services, but the studies are limited. Accurate assessment of IPV is important for decision making in risk assessment and safety planning within mental health nursing. Psychometrically tested tools are the most accurate way to identifying all areas of IPV abuse: physical, sexual and psychological. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Ten IPV screening tools were identified in healthcare and three tools; Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK) were identified as having strong psychometric values as they assessed all areas of IPV and were validated against an appropriate reference standard. None of the three IPV tools identified (WAST, AAS, HARK) were tested on men or in mental health settings impacting the gender sensitivities of the tools and the reliability of the prevalence rates of IPV in mental healthcare. Over seventy percent of the studies reviewed were conducted in America this impacts the cultural sensitivities of the IPV tools. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: IPV screening needs to be incorporated as a priority in mental health services in order to reduce the morbidity and mortality issues associated with this abuse. Psychometric tools to screen for IPV need to be incorporated to assist mental health professionals in decision making in risk assessment and safety planning. Further research is needed to improve the psychometric properties of IPV tools in mental health settings, to ensure they are culturally and gender sensitive.

ABSTRACT

Objective Intimate partner violence (IPV) is a public health priority due to the physical and mental impacts it has on health. No existing reviews have focused on the psychometric properties of IPV screening tools used to screen men and women within a mental health context. This review aimed to identify the best psychometrically tested screening tools available to assess all areas of IPV in men and women in mental health setting. Method Databases psycArticles, PsycINFO, Social Science, CINAHL, PubMed and Cochrane were searched from their starting date through to July 2015. Eligible studies were published in peer-reviewed publications in English. Results Thirty-six studies met the inclusion criteria. Ten IPV screening tools were identified. Three tools assessed all areas of IPV and were validated against an appropriate reference standard. One study tested IPV screening tool in a mental health setting. Conclusion Mental health nurses need to incorporate a psychometrically tested IPV tool as part of risk assessment and safety planning for clients. This review identified three tools that are suitable for identifying IPV in a mental health context. However, further research is necessary to validate IPV screening tools that are culturally sensitive and have been validated with men and women.

Survey of mental health nurses' attitudes towards risk assessment, risk assessment tools and positive risk

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and safety planning are a core aspect of the role of the mental health nurse. Conflicting views exist on the value of risk assessment tools. Few studies have examined mental health nurses' attitudes towards risk, including use of tools and the role of positive risk in recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Mental health nurses view risk assessment as a core dimension of their role and not merely an exercise to fulfil organizational clinical safety and governance obligations. The majority of nurses hold positive attitudes towards therapeutic or positive risk, and consider creative risk taking as vital to people's recovery. The majority of nurses believe that risk assessment tools facilitate professional decision making, however, some are concerned that tools may negatively impact upon therapeutic relationships. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ongoing education on the use of risk assessment tools is required to minimize views that their use is incompatible with therapeutic engagement, and to enable nurses to develop confidence to engage with positive risk and to allow service users make decisions and take responsibility.

ABSTRACT

Introduction Risk assessment and safety planning are considered core components of the role of the mental health nurse; however, little is known about nurses' attitudes towards risk assessment, use of tools to assess risk or therapeutic risk taking. Aim This study aimed to explore mental health nurses' attitudes towards completing risk assessments, use of tools as an aid, and therapeutic or positive risk. Method An anonymous survey which included 13 attitudinal statements, rated on a five-point Likert scale, was completed by 381 mental health nurses working in adult services in Ireland. Findings Findings indicate strong support for the practice of risk assessment in mental health practice. The vast majority of nurses believe that risk assessment tools facilitate professional decision making; however, there is concern that the use of these tools may negatively impact upon therapeutic engagement with service users. The majority of participants have positive attitudes towards therapeutic risk, believing that service users have the right to take informed risks in the context of recovery-orientated care. Discussion The provision of education on the use of risk assessment tools within the context of engagement may help minimize views that the use of assessment tools are incompatible with therapeutic engagement.

Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR-20

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR-20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3-month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR-20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item-outcome analysis revealed that impulsivity, negative attitudes, and non-compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients.

Risk assessment by client and case manager for shared decision making in outpatient forensic psychiatry

BACKGROUND

In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning.

METHODS

In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied.

RESULTS

Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60-0.80).

CONCLUSIONS

In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry.

Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting

Research is sparse on how clinicians' judgement informs their violence risk assessments. Yet, determining preferences for which risk factors are used, and how they are weighted and combined, is important to understanding such assessments. This study investigated clinicians' use of static and dynamic cues when assessing risk in individual patients and for dynamic cues considered in the recent and distant past. Clinicians provided three violence risk assessments for 41 separate hypothetical cases of hospitalized patients, each defined by eight cues (e.g., psychopathy and past violence severity/frequency). A clinical judgement analysis, using regression analysis of judgements for multiple cases, created linear models reflecting the major influences on each individual clinician's judgement. Risk assessments could be successfully predicted by between one and four cues, and there was close agreement between different clinicians' models regarding which cues were relevant for a given assessment. However, which cues were used varied between assessments: history of recent violence predicted assessments of in-hospital risk, whereas violence in the distant past predicted the assessed risk in the community. Crucially, several factors included in actuarial/structured risk assessment tools had little influence on clinicians' assessments. Our findings point to the adaptivity in clinicians' violence risk assessments, with a preference for relying on information consistent with the setting for which the assessment applies. The implication is that clinicians are open to using different structured assessment tools for different kinds of risk assessment, although they may seek greater flexibility in their assessments than some structured risk assessment tools afford (e.g., discounting static risk factors).

KEY PRACTITIONER MESSAGE

Across three separate violence risk assessments, clinicians' risk assessments were more strongly influenced by dynamic cues that can vary over time (e.g., level of violence) than by static cues that are fixed for a given individual (e.g., a diagnosis of psychopathy). The variation in the factors affecting risk assessments for different settings (i.e., in hospital versus in the community) was greater than the variability between clinicians for such judgements. The findings imply a preference for risk assessment strategies that offer flexibility: either using different risk assessment tools for different purposes and settings or employing a single tool that allows for different inputs into the risk assessment depending upon the nature of the assessment. The appropriateness of these clinical intuitions about violence risk that are implied by our findings warrants further investigation.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

Risk assessment and absconding: perceptions, understandings and responses of mental health nurses

AIMS AND OBJECTIVES

This paper reports mental health nurses' perspectives of absconding. The aims of the study were to explore nurses' perceptions of risk assessment and management practices regarding absconding from acute inpatient psychiatric settings, and their affective responses when patients absconded.

BACKGROUND

Nurses are directly involved in managing the risk of patients leaving hospital while acutely unwell, as well as dealing with the implications of an absconding event. However, despite their key role, few studies have explored nurses' perceptions of absconding.

DESIGN

An interpretive inquiry was undertaken using a systematic thematic approach.

METHODS

Mental health nurses (n = 11) from three acute inpatient mental health units in Australia took part in semi-structured interviews, with a focus on the nurses' experiences of working with patients who had absconded. Data were analysed using systematic thematic coding procedures.

RESULTS

Nurses' assessment of a patient's risk of absconding involved the use of clinical judgement, focusing on markers of absconding including the patient's history and clinical presentation. The acuity of the perceived risk determined the type of risk management strategy implemented, which could include support, observation and/or the use of containment procedures. Nurses responded with a myriad of affective reactions when patients absconded depending on their assessment of the patient's risk.

CONCLUSIONS

Support and debriefing is required for mental health nurses following an absconding event. Additional research is vital to identify alternative absconding assessment and management strategies to ensure the best possible outcome for patients and nurses.

RELEVANCE TO CLINICAL PRACTICE

Mental health nurses play a central role in risk assessment and management for absconding, with fear of repercussions a significant consequence for them. This research highlights the importance of both clinical judgment and standardised instruments in assessing absconding risk. Further research is needed to identify alternative evidence-based absconding management strategies to support nursing practice.

The Diagnostic Efficiency of the Extended German Brøset Violence Checklist to Assess the Risk of Violence

Background and Purpose: The prevention of aggression and violence of patients is part of the challenge for the psychiatric inpatient care. Resources needed are a systematic risk assessment and taking preventive measures according to the risk. The extended Brøset Violence Checklist (BVC-CH) is an assessment instrument for the short-term assessment of the risk of violence for physical attacks toward medical staff and other patients. Until now, the instrument was only validated in the context of the development phase of the instrument. The aim of this study was to investigate how valid the BVC-CH scale is for adult psychiatry in acute inpatient care facilities. Methods: In a prospective cohort study, 232 consecutively admitted patients were assessed using the BVC-CH. The calculation of the predictive values was based on a contingency table. The discriminatory power of the instrument and the determination of the cutoff point were done using the receiver operating characteristic (ROC) curve analysis. Physical attacks were registered with the Staff Observation of Aggression Scale–Revised (SOAS-R). Results: The sensitivity was 58.8% and the specificity was 96.8% by a cutoff point of ≥7. By choosing a cutoff point of ≥6, the sensitivity was 64.7% and the specificity was 95.1%. A value of .93 was determined for the area under the curve receiver operating characteristic (AUCROC). Conclusions: Overall, the BVC-CH is a valid instrument for the short-term prediction of physical attacks. Further research of the BVC-CH is recommended but in particular for the cutoff point.

Risk assessment and management approaches on mental health units

This exploratory and descriptive study took place in one Canadian province. The study aimed to: (1) to identify and describe the nature and extent of current risk assessment and management approaches used in the adult inpatient mental health and forensic units; and (2) to identify good practice and shortfalls in the nature and extent of the approaches currently utilized. Data were collected from 48 participants through nine focus groups. Participants reported that they used a clinical approach to risk assessment. They had also not considered risk assessment and management as a proactive structured process. Education and training was also limited and skills were developed over time through practice. Five keys issues are discussed as important: reliance on clinical judgement alone is not the best choice to make; the need to consider risk as a whole concept; risk management being more reactive than proactive; education and training; and client involvement in risk assessment.

Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services

BACKGROUND

The START and SAPROF are newly developed fourth generation structured professional judgement instruments assessing strengths and protective factors. The DUNDRUM-3 and DUNDRUM-4 also measure positive factors, programme completion and recovery in forensic settings.

METHODS

We compared these instruments with other validated risk instruments (HCR-20, S-RAMM), a measure of psychopathology (PANSS) and global function (GAF). We prospectively tested whether any of these instruments predict violence or self harm in a secure hospital setting (n = 98) and whether they had true protective effects, interacting with and off-setting risk measures.

RESULTS

SAPROF and START-strengths had strong inverse (negative) correlations with the HCR-20 and S-RAMM. SAPROF correlated strongly with GAF (r = 0.745). In the prospective in-patient study, SAPROF predicted absence of violence, AUC = 0.847 and absence of self-harm AUC = 0.766. START-strengths predicted absence of violence AUC = 0.776, but did not predict absence of self-harm AUC = 0.644. The DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales also predicted in-patient violence (AUC 0.832 and 0.728 respectively), and both predicted in-patient self-harm (AUC 0.750 and 0.713 respectively). When adjusted for the HCR-20 total score however, SAPROF, START-S, DUNDRUM-3 and DUNDRUM-4 scores were not significantly different for those who were violent or for those who self harmed. The SAPROF had a significant interactive effect with the HCR-dynamic score. Item to outcome studies often showed a range of strengths of association with outcomes, which may be specific to the in-patient setting and patient group studied.

CONCLUSIONS

The START and SAPROF, DUNDRUM-3 and DUNDRUM-4 can be used to assess both reduced and increased risk of violence and self-harm in mentally ill in-patients in a secure setting. They were not consistently better than the GAF, HCR-20, S-RAMM, or PANSS when predicting adverse events. Only the SAPROF had an interactive effect with the HCR-20 risk assessment indicating a true protective effect but as structured professional judgement instruments all have additional content (items) complementary to existing risk assessments, useful for planning treatment and risk management.

The role of psychopathic traits and substance abuse in predicting violent victimization in patients with schizophrenia spectrum disorders

We examined the relationship between psychopathic traits and substance abuse and violent victimization in 94 community patients meeting DSM-IV criteria for schizophrenia spectrum disorders in contact with public mental health services in Victoria, Australia. Data on violence and victimization were collated from multiple sources and combined to categorize patients into victims of serious violence (VV; n = 74) and those who were not victims of serious violence (NVV; n = 20) groups. The VV group had higher rates of unemployment and previous violence but did not differ from the NVV on current symptom ratings. The VV group has significantly higher substance abuse and psychopathy scores, but only psychopathy score significantly contributed to the prediction of victimization. All psychopathy facets were reasonably good predictors of victimization status, but the antisocial facet contributed most to the prediction of victimization. A better understanding of the role and contribution of antisocial (particularly psychopathic) traits in violent victimization in mentally ill populations is needed to better inform community management plans.

Early detection of risk factors for seclusion and restraint: a prospective study

AIM

The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint.

METHODS

Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis.

RESULTS

The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%).

CONCLUSION

Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.

Assessment of moral judgment and empathy in young sex offenders: a comparison of clinical judgment and test results

Professional decision making in forensic clinical practice may have lifelong consequences for offenders. Although information on moral development is important for prediction of reoffending and referral to adequate treatment, conclusions regarding moral development are still largely based on unstructured clinical judgment instead of assessment instruments. For this study, the authors examined to what extent unstructured clinical judgment of both moral judgment and victim empathy concurred with test results in a group of young sex offenders. Moral judgment was measured with the Sociomoral Reflection Measure-Short Form (SRM-SF), whereas victim empathy was measured with an extended version of the Basic Empathy Scale (BES). No significant associations were found between clinical judgment of moral judgment and the mean scores on the SRM-SF. However, clinical judgment of victim empathy was significantly associated with victim empathy on the Victim Empathy Scale but not consistently in the expected direction. Juvenile sex offenders, who were judged by clinicians to show little victim empathy, displayed lower mean scores on the Victim Empathy Scale than juvenile sex offenders who were evaluated to lack victim empathy or to have intact victim empathy. This study showed unstructured clinical judgment of moral development not to concur with test results. To improve decision-making processes regarding moral development, clinicians are advised to rely on instruments that assess moral development to inform clinical judgment. Further research is needed to examine which predictions are more accurate and to establish the predictive validity of moral development evaluations.

Criminally violent victimisation in schizophrenia spectrum disorders: the relationship to symptoms and substance abuse

Background

Violent victimisation among people with major mental illness is well-documented but the risk factors for criminal violent victimisation are not well understood.

Methods

We examined the relationship between illness-related variables, indices of substance abuse and previous history of violence in a sample of 23 male criminally violently victimized and 69 non-criminally violently victimized male patients with DSM-IV-TR diagnoses of schizophrenia and schizoaffective disorder that were resident in the community and in contact with public mental health services in Victoria Australia. Data on criminal victimisation was acquired from the police database.

Results

Demographic, a history of violence or illness-related variables did not distinguish between those had been the victim of a violent crime and those who had not. Our data indicated that drug abuse was a key factor in distinguishing between the groups, but the age of onset of substance abuse was not a significant factor. Scores on measures of drug abuse were modest predictors of criminal victimisation status in our Receiver Operator Characteristic analyses.

Conclusion

Overall, our findings suggest that substance abuse (particularly drug abuse) is a key predictor of violent victimisation based on criminal statistics. The latter has implications for mental health professions involved in the care planning and community management of patients with major mental illness and work points to the importance of substance abuse treatment in the prevention of victimisation as well as violence perpetration.

The application of a violence risk assessment tool among Chinese psychiatric service users: a preliminary study

The Violence Risk Screening-10 (V-RISK-10) is one of the few instruments available for evaluating violence risk among general psychiatric service users. This naturalistic prospective study involved 376 inpatients in a general psychiatric hospital in Beijing and intended to determine whether this brief instrument could be applied to a sample of Chinese consumers and whether its predictive properties could be retained. Risk assessment at admission was compared to the record of aggression and violence during the first month of hospitalization. During the research period, 108 of the 376 consumers caused 265 incidences of aggression. Receiver operating characteristics for the V-RISK-10 Chinese version yielded an area under the curve of 0.63. Its sensitivity/specificity was 0.80/0.38 and the corresponding positive/negative predictive value was 0.34/0.82. Intraclass correlation coefficient for the whole instrument was 0.89. Compared to the results of the original V-RISK-10, its predictive accuracy was lower. However, with some modification, the V-RISK-10 still shows promise as an instrument for use in daily practice in Chinese clinical settings.

Moral judgment of young sex offenders with and without intellectual disabilities

This study examined differences in moral judgment between juvenile sex offenders with and without intellectual disabilities. The Sociomoral Reflection Measure-Short Form (SRM-SF) was used to assess moral judgment, and was extended with questions referring to general sexual situations and to the offenders' abuse victim(s). Juvenile sex offenders with and without ID significantly differed in moral judgment stage regarding general life, sexual and own abuse victim situations. Juvenile sex offenders with ID generally showed stage 2 moral reasoning, which indicated that their justifications for moral decisions were dominated by instrumental and pragmatic reciprocity, whereas juvenile sex offenders without ID used reasons and justifications representing transitional moral stage 2/3 moral judgment, indicating that the maintenance of interpersonal relationships was considered to a certain extent in their justifications for moral decisions. Future research should examine to what extent moral judgment of offenders with ID should be targeted in treatment.

Aggression in psychiatry wards: a systematic review

Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal aggression, but the level of general health is significantly lower in nurses who report 'frequent' exposure to violent incidents, and there is disagreement between patients and staff concerning predictors of these episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words "aggress*" (aggression or aggressive) "violen*" (violence or violent) and "in-patient" or "psychiatric wards", and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.

V-RISK-10: Validation of a Screen for Risk of Violence After Discharge from Acute Psychiatry

Background

Current violence risk assessment instruments are time-consuming and mainly developed for forensic psychiatry. A paucity of violence screens for acute psychiatry instigated the development and validation of the V-RISK-10. The aim of this prospective naturalistic study was to test the predictive validity of the V-RISK-10 as a screen of violence risk after discharge from two acute psychiatric wards.

Methods

Patients were screened with V-RISK-10 before discharge, and incidents of violence were recorded 3, 6, 9 and 12 months after discharge. A total of 381 of the 1017 patients that were screened completed the follow up.

Results

The ROC-AUC values for any violent behaviour were 0.80 and 0.75 (p < 0.001) for the 3 and 12 months follow-up periods, respectively, and significant for both genders. The most accurate risk estimates were obtained for severe violence. For persons without a known history of violence prior to the screening, AUCs were 0.74 (p = 0.004) and 0.68 (p = 0.002).

Conclusions

Results indicate that the V-RISK-10 is a valid and clinically useful screen for violence risk after discharge from acute psychiatry, and even significant for patients without a known previous history of violence.

Retrospective analysis of absconding behaviour by acute care consumers in one psychiatric hospital campus in Australia

Absconding is increasingly being recognized as a problem within mental health settings with significant risks for consumers. This study examines absconding behaviours across three acute care wards within an Australian psychiatric hospital campus over a 12-month period. A descriptive statistical analysis determined the rate of absconding from 49 consumers who absconded 64 times. The absconding rate was 13.33% (absconding events), with most absconding events arising from males diagnosed with schizophrenia (57.14%) aged between 20 and 29 years, and with 62.50% of absconding events occurring whilst consumers were on their first 21-day detention order. Nearly half of all absconding events were by consumers who had absconded previously, with the highest proportion of events occurring during nursing handover. A profile of people who abscond, time of day of absconding, legal status and repeated absconding behaviours are described. The emergent profile of consumers who absconded within this study bears some similarities to that described in overseas research, although in this study consumers were slightly older and 25% of absconders were female. Of particular interest are findings that identify the timings of absconding events in relation to a consumer's legal status. Implications for practice, including assessment of risk of absconding and management, are considered.

Preventing aggressive incidents and seclusions in forensic care by means of the 'Early Recognition Method'

OBJECTIVE

The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents.

BACKGROUND

Nurses in forensic settings are often confronted with patients' aggression. Better collaboration between nursing staff and patients may improve patients' ability to self manage aggression and contribute to a decrease in inpatient aggression.

DESIGN

Naturalistic one-way case-crossover design.

METHODS

The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a one-way case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during 'Treatment As Usual' with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents.

RESULTS

A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes.

CONCLUSIONS

The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders.

RELEVANCE TO CLINICAL PRACTICE

This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression.

Zoning: focused support: a trust wide implementation project

Applying pragmatic risk management procedures to facilitate the sharing of clinical knowledge in and across mental health teams. Abstract Zoning: focused support is pragmatic risk management support procedure that enhances adherence to operational policies, provides a forum in which staff can receive support and visually facilitates the sharing of clinical knowledge. This paper presents a 3-year multi-method management project that sought to introduce zoning principles into all teams of an inner city Mental Health NHS Trust. By changing the language and culture of the organization findings indicate that there has been a positive attitudinal shift in how the approach is perceived. It is considered to be of value to staff, service users and their families and 73% of teams are now using it routinely.

Role of the forensic psychiatric nurse

Abstract The article clarifies the role of the forensic psychiatric nurse (FPN) and challenges interchangeable terms confusing forensic and correctional nursing. It addresses the varied venues where the FPN may assess the patient (victim or perpetrator) and gather evidence that may influence conviction, sentencing, recidivism, treatment, and prevention. In depth knowledge of medical and psychiatric nursing as well as the criminal justice system is germane to competent advanced practice forensic nursing. An analogy is drawn between the forensic assessment for risk of violence which is commonly performed by psychiatric nurses in Emergency Departments and the collection and preservation of evidence by medical nurses in Emergency Departments. Both instances require evidence-based techniques and a familiarity with forensic procedures and are often performed by nurses who are not specifically trained in these areas. A case analysis demonstrates the value of an in depth and broad assessment of victim and perpetrator. Evidence based training and the application of structured clinical judgment used in the evaluation of victims and perpetrators make it possible for the FNP to provide expert testimony and to make recommendations for treatment.