Risk analysis: An integrated approach to the assessment and management of aggression/violence in mental health

Inter-rater reliability of the occupational violence risk assessment tool for emergency departments

BACKGROUND

The three-item occupational violence (OV) risk assessment tool was developed and validated for use in emergency departments (EDs). It prompts review of each patient's aggression history, behaviours, and clinical presentation. However, confidence around representativeness and generalisability are needed before widescale adoption; hence we measured the inter-rater reliability of the tool among a large group of emergency nurses.

METHODS

A cross-sectional study was conducted between Sep 2021 and Jan 2022. Nurses were directed to a website that hosted an e-learning module about the tool. They were asked to apply the tool to two video scenarios of typical patient presentations. Demographic data, including years of emergency experience, were collected to contextualise their responses. Gwet's Agreement Coefficients (AC1) were calculated to determine inter-rater reliability.

RESULTS

There were 135 participants: typically female, under the age of 40 years, with more than 3 years of emergency nursing experience. Overall, there was excellent inter-rater agreement (AC1 =0.752, p = 0.001). This was consistent when years of ED experience was stratified: 0-2 years, AC1 = 0.764, p = 0.002; 3-5 years, AC1 = 0.826, p = 0.001; 6-10 years, AC1 = 0.751, p < 0.001; 11-15 years, AC1 = 0.659, p = 0.004; ≥ 16 years, AC1 = 0.799, p < 0.001.

CONCLUSION

The three-item OV risk assessment tool has excellent inter-rater reliability across a large sample of emergency nurses.

Validity and reliability of the novel three‐item occupational violence patient risk assessment tool

Aim

To develop and psychometrically test an occupational violence (OV) risk assessment tool in the emergency department (ED).

Design

Three studies were conducted in phases: content validity, predictive validity and inter‐rater reliability from June 2019 to March 2021.

Methods

For content validity, ED end users (mainly nurses) were recruited to rate items that would appropriately assess for OV risk. Subsequently, a risk assessment tool was developed and tested for its predictive validity and inter‐rater reliability. For predictive validity, triage notes of ED presentations in a month with the highest OV were assessed for presence of OV risk. Each presentation was then matched with events recorded in the OV incident register. Sensitivity and specificity values were calculated. For inter‐rater reliability, two assessors—trained and untrained—independently assessed the triage notes for presence of OV risk. Cohen's kappa was calculated.

Results

Two rounds of content validity with a total of N = 81 end users led to the development of a three‐domain tool that assesses for OV risk using aggression history, behavioural concerns (i.e., angry, clenched fist, demanding, threatening language or resisting care) and clinical presentation concerns (i.e., alcohol/drug intoxication and erratic cognition). Recommended risk ratings are low (score = 0 risk domain present), moderate (score = 1 risk domain present) and high (score = 2–3 risk domains present), with an area under the curve of 0.77 (95% confidence interval 0.7–0.81, p < .01). Moderate risk rating had a 61% sensitivity and 91% specificity, whereas high risk rating had 37% sensitivity and 97% specificity. Inter‐rater reliability ranged from 0.67 to 0.75 (p < .01), suggesting moderate agreement.

Conclusions

The novel three‐domain OV risk assessment tool was shown to be appropriate and relevant for application in EDs. The tool, developed through a rigorous content validity process, demonstrates acceptable predictive validity and inter‐rater reliability.

Impact

The developed tool is currently piloted in a single hospital ED, with a view to extend to inpatient settings and other hospitals.

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.

Construct validity of the Mechanical Restraint - Confounders, Risk, Alliance Score (MR-CRAS): a new risk assessment instrument

Background: A new short-term risk assessment instrument, the Mechanical Restraint - Confounders, Risk, Alliance Score (MR - CRAS) checklist, including three subscales with altogether 18 items, has been developed in close collaboration with forensic mental health nurses, psychiatrists' etc., and shows evidence of being comprehensible, relevant, comprehensive and easy to use for assessing the patient's readiness to be released from mechanical restraint. Aim: The aim of this study was to investigate whether the subscales: confounders, risk and parameters of alliance constituted separate subscales and needed further revisions. Materials and methods: MR - CRAS was field-study tested among nurses, nurse assistants and social and health care assistants in 13 Danish closed forensic mental health inpatient units, and a Mokken analysis of scalability and a Spearman correlation analysis were performed. Results: MR - CRAS was completed by clinicians in 143 episodes of mechanical restraint, representing 88 patients, with a mean duration of 63.25 hours. Most patients were younger men, diagnosed within the schizophrenia spectrum. One-third of the patients had repeated mechanical restraint episodes ranging between 2 and 8 episodes. MR - CRAS and especially the parameters of alliance were perceived as usable for assessment of the patient's readiness to be released from mechanical restraint. The psychometric analyses showed that the three subscales were unidimensional. Conclusions: The study shows evidence of the construct validity of MR - CRAS among clinicians at closed forensic mental health inpatient units. MR - CRAS contributes with a common language and structured, systematic and transparent observations and assessments on an hour by hour basis during mechanical restraint.

The effect of a workplace violence training program for generalist nurses in the acute hospital setting: A quasi-experimental study

BACKGROUND

Workplace violence prevalence has attracted significant attention within the international nursing literature. Little attention to non-mental health settings and a lack of evaluation rigor have been identified within review literature.

OBJECTIVES

To examine the effects of a workplace violence training program in relation to risk assessment and management practices, de-escalation skills, breakaway techniques, and confidence levels, within an acute hospital setting.

DESIGN

A quasi-experimental study of nurses using pretest-posttest measurements of educational objectives and confidence levels, with two week follow-up.

SETTING

A 440 bed metropolitan tertiary referral hospital in Sydney, Australia.

PARTICIPANTS

Nurses working in specialties identified as a 'high risk' for violence.

METHOD

A pre-post-test design was used with participants attending a one day workshop. The workshop evaluation comprised the use of two validated questionnaires: the Continuing Professional Development Reaction questionnaire, and the Confidence in Coping with Patient Aggression Instrument. Descriptive and inferential statistics were calculated. The paired t-test was used to assess the statistical significance of changes in the clinical behaviour intention and confidence scores from pre- to post-intervention. Cohen's d effect sizes were calculated to determine the extent of the significant results.

RESULTS

Seventy-eight participants completed both pre- and post-workshop evaluation questionnaires. Statistically significant increases in behaviour intention scores were found in fourteen of the fifteen constructs relating to the three broad workshop objectives, and confidence ratings, with medium to large effect sizes observed in some constructs. A significant increase in overall confidence in coping with patient aggression was also found post-test with large effect size.

CONCLUSIONS

Positive results were observed from the workplace violence training. Training needs to be complimented by a multi-faceted organisational approach which includes governance, quality and review processes.

Risk assessment practice within primary mental health care: A logics perspective

From the 1980s onwards, discourses of risk have continued to grow, almost in ubiquity. Ideas and practices of risk and risk aversion have extended to UK mental health care where services are expected to assess and manage risks, and high-quality clinical assessment has been revised to incorporate risk assessment. This article problematises practices of risk assessment in mental health provision, focussing on the base-rate problem. It presents an analysis of audio recordings of risk assessments completed within a primary care mental health service. The analysis is informed by a critical logics approach which, using ideas from discourse theory as well as Lacanian psychoanalysis, involves developing a set of logics to describe, analyse and explain social phenomena. We characterise the assessments as functioning according to social logics of well-oiled administration and preservation, whereby bureaucratic processes are prioritised, contingency ironed out or ignored, and a need to manage potential risks to the service are the dominant operational frames. These logics are considered in terms of their beatific and horrific fantasmatic dimensions, whereby risk assessment is enacted as infallible (beatific) until clients become threats (horrific), creating a range of potential false negatives, false positives and so forth. These processes function to obscure or background problems with risk assessment, by generating practices that favour and offer protection to assessors, at the expense of those being assessed, thus presenting a challenge to the stated aim of risk assessment practice.

Developing a guideline for structured content and process in mental health nursing handover

The process of handover has received recent attention within Australian health care, as evidence linking patient safety with the quality of handover emerges. Such links between clinical handover and patient safety have been reported elsewhere in the literature, where it is posited that the safe care of patients relies not only on the expertise and judgment of individual clinicians, teamwork, and effective management, but hinges to a large extent on the quality of information transferred from team to team. The present qualitative, descriptive study used participant observations, focus groups, and interviews to investigate the nursing handover in two acute mental health inpatient units in New South Wales, Australia. Data collected as part of that investigation contributed to the development of a handover guideline that incorporates the key components of structure, content, and leadership. The research indicated a link between these components, and further revealed the necessity to have other forums, such as supervision and clinical review, to ensure that handover serves its intended purpose in an efficient manner.

Risk tools for the prediction of violence: 'VRAG, HCR-20, PCL-R'

Many instruments have been introduced as measures of violence risk prediction. Studies on risk assessment displayed two major approaches - clinical risk evaluation and actuarial measures - and three tools were mostly used: (1) Violence Risk Appraisal Guide, (2) Historical-Clinical-Risk-20 item scale and (3) Psychopathy Checklist-Revised. Although these tools are commonly used in clinical practice, they differ in their uses, benefits and limitations, and their ability to predict future violence. Subsequently, this paper aim to provide the readers an in-depth description that specifies these aspects, as well as a comparison of these tools in order to help readers decide which tool to use.

Investigating the evidence for the effectiveness of risk assessment in mental health care

Risk assessment pervades mental health care policy, practice, and legislation. This paper aims to establish the research evidence for the effectiveness of a risk assessment approach in mental health. A search was conducted of the professional literature on risk assessment in mental health, specifically seeking any research on the effectiveness of risk assessment in reducing risk of harm to self or others. The search found limited research on the effectiveness of risk assessment. "Structured professional judgment" possibly reduces aggression risk but there is no evidence that risk assessment is effective in relation to self-harm or suicide reduction. The implications for practice are discussed and alternatives to a risk assessment approach are considered.

The clinical reality of implementing formal risk assessment and management measures within high secure forensic care

This paper describes the successful implementation of a formal violence risk assessment and management strategy within a high secure forensic care facility. The aim of the implementation was to ensure that each patient had a formal violence risk assessment and management plan that was shared and applied to clinical practice by the patient's clinical team. The process as a whole, from risk assessment to risk management including appropriate care and treatment documentation, is outlined. In this way, this paper also describes the difficulties and problems encountered within the organizational reality of implementation projects. Suggestions and recommendations on how to avoid and manage these are made.