Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward

Raija Kontio,Jenni Kaunomäki,Tero Laiho,Markus Jokela,Nina Lindberg,Eila Sailas

doi:10.1186/s12913-016-1942-0

Abstract

BackgroundPatient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. A constant worry of staff is that the results of risk assessments would not be used. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were.MethodsThe data were collected in a naturalistic setting during a 6-month period in a Finnish psychiatric admission ward with a total of 331 patients with a mean age of 42.9 years (SD 17.39) suffering mostly from mood, schizophrenia-related and substance use disorders. The total number of treatment days was 2399. The staff assessed the patients daily with the Dynamic Appraisal of Situational Aggression (DASA), which is a structured violence risk assessment considering the upcoming 24 h. The interventions in order to reduce the risk of violence following a high DASA total score (≥4) were collected from the patients’ medical files. Inductive content analysis was used.ResultsThere were a total of 64 patients with 217 observations of high DASA total score. In 91.2% of cases, at least one intervention aiming to reduce the violence risk was used. Pro re nata (PRN)-medication, seclusion and focused discussions with a nurse were the most frequently used interventions. Non-coercive and non-pharmacological interventions like daily activities associated significantly with the decrease of perceived risk of violence.ConclusionIn most cases, a high score in violence risk assessment led to interventions aiming to reduce the risk. Unfortunately, the most frequently used methods were psychopharmacological or coercive. It is hoped that the findings will encourage the staff to use their imagination when choosing violence risk reducing intervention techniques.

Highlights

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units
Thirty-one (9.4%) patients were discharged from the ward or transferred to another ward before the afternoon Dynamic Appraisal of Situational Aggression (DASA) scoring
Interventions regulated by the Finnish Mental Health Act, Pro re nata (PRN)-medication, and focused discussion with nurse were not significantly associated with a lower DASA total score on the following day (Table 3)

Summary

Introduction

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were. In a Finnish nationwide interview study, as many as 8% of psychiatric staff reported experiencing violence from patients at least once a week and 16% one to three times per month [2]. A number of structured clinical risk assessment tools have been developed and they have proved to be substantially more accurate than unaided clinical judgments [15,16,17]

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