Dynamic Appraisal Of Situational Aggression Research Articles

The risk assessment of imminent inpatient aggression: A cross-cultural validation study of the dynamic appraisal of situational aggression in Estonia.

The reason for this study was void of a data-driven imminent risk assessment instrument for aggression in psychiatry clinics in Estonia. The predictive accuracy of the observer-rated Dynamic Assessment of Situational Aggression (DASA) has been repeatedly demonstrated. However, the research gap remains regarding a deeper conceptual understanding of the underlying latent structure of the DASA. Comprehensively evaluate the psychometric properties of the Estonian DASA version for cross-cultural clinical use. We used a prospective repeated measure design and collected 6097 risk evaluations from 381 adult inpatients, 151 of whom committed 1013 aggressive incidents during the study. The Estonian DASA version has acceptable inter-rater reliability (Kendall's τ = 0.74) and is a useful instrument with excellent predictive validity (AUC = 0.86) for identifying potentially aggressive inpatients. In our sample, the DASA has a bi-factorial structure which explains 83% of the total variance. The adapted DASA has acceptable validity and reliability indices for measuring imminent aggression risk in adult inpatient units. Evidence-based risk assessment of aggression in psychiatric clinics enhances recognition of the signs of potentially aggressive behaviour in order to apply preventive actions and reduce aggression, thereby improving the quality of the care provided.

An assessment of interventions following moderate and high scores on the dynamic appraisal of situational aggression risk assessment tool in a forensic mental health unit

ABSTRACT The Dynamic Appraisal of Situational Aggression (DASA) provides a quick and systematic assessment of short-term violence risk. Risk assessment should be closely aligned to management and result in interventions aimed to reduce risk. The aim of this study was to investigate what interventions followed a moderate/high DASA score and whether they reduced risk. The impact of staff training was also assessed. The study was a retrospective analysis of health records within a medium secure hospital over 6 months. Data was gathered on tool adherence and interventions that were used to reduce risk following a moderate/high score. The change in DASA score following the intervention was recorded. There were 70 patients covering 8224 bed days. There were 24 occasions where a moderate score led to an intervention (n = 24/40%), and 26 occasions for a high score (n = 26/87%). A moderate score was mostly followed by no intervention (n = 35/59%), a high score was mostly followed by seclusion (n = 9/29%). The intervention that led to the largest reduction in DASA score was pro re nata medication following a moderate score and seclusion following a high score. The training of staff led to a reduction in tool adherence and increased intervention use. These results support the need for combining the DASA assessment with operationalised systems to link assessment with risk prevention to help reduce aggression and restrictive practices.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AimThe research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression). BackgroundPreventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions. MethodsData were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted. ResultsThree themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) ‘who watches the watchers’, were identified by the experts as well as areas to enhance EPAs prior to introduction into practice. ConclusionsEPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

A Quality Improvement Approach to Violence Reduction: Standardizing the Risk Identification Process.

The impact of aggressive and violent behaviors directed toward staff in psychiatric facilities has layers of implications tied to recruitment and retention, cost, quality and safety. Increased patient aggressive behaviors contributed to staff dissatisfaction and high turnover rates, triggering an analysis of current aggression management approaches. The Plan-Do-Study-Act quality improvement method was used for this project. The Dynamic Appraisal of Situational Aggression (DASA) risk assessment tool was implemented. Daily aggression risk identification increased by 69%, and aggressive incidents toward staff and patients decreased by 64% and 28%, respectively, when the tool was completed more consistently. Surveys revealed acceptance of the tool by nurses. Quality improvement statistical tools supported evidence-based strategies. A risk for aggression assessment laid the foundations for implementing strategies for reducing aggression and violence.

Using the Dynamic Appraisal of Situational Aggression (DASA) to assess the impact of unit atmosphere on violence risk assessment.

Research suggests that the Dynamic Appraisal of Situational Aggression (DASA) is a useful risk assessment instrument to identify individuals who might be at risk of aggression in mental health inpatient units. Although, risk assessment research has typically focused on an individual's risk of aggression, recent research has begun exploring whether the DASA could be used to assess the likelihood that a group of patients would be aggressive. While the DASA was useful for assessing whether an individual was likely to be aggressive, the group average score was not a useful indicator for the likelihood of aggression once the individual DASA score was taken into consideration. Unexpectedly, patients who were assessed as high risk on the DASA were more likely to be aggressive on settled units compared to unsettled units, which included other individuals whose risk was elevated. There is not enough evidence to suggest that the group DASA average improves the identification of aggression above the individual DASA score. INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an inpatient aggression risk assessment instrument. Recently, research explored whether the unit atmosphere, as indicated by a unit's average DASA score, was related to inpatient aggression risk, but failed to control for individual risk. Investigate whether the DASA unit average score or an interaction between the unit average and an individual patient's DASA score was related to the likelihood that an individual would act aggressively. Cox regression with repeated assessments and recurrent events was used to analyse 11,243 DASA risk assessments of 113 inpatients collected via retrospective file review. The unit DASA average score was not related to aggression towards staff. There was a negative interaction between the individual and the unit DASA average scores when identifying patient-to-patient aggression; high-risk patients engaged in less aggression when the unit average was heightened relative to units with lower DASA average scores. It is possible that there were more nursing interventions and/or patients engaged in greater self-regulation on unsettled units, thus reducing aggression. Currently, there is insufficient evidence to suggest that the unit average score should be used to supplement individual DASA scores to identify aggression risk.

Investigating the dynamic nature of multiple risk assessment instruments in a forensic mental health hospital.

Readministration of multiple risk assessment instruments to determine the risk of aggression over the short, medium, and long term is common practice in many forensic mental health settings. Justification for the repeated administration and use of multiple instruments is based on purported differences in discriminative validity of risk factors according to whether they are characterized as static, stable, or acute, and the composition of these tools, in terms of the relative balance of different types of risk factors, which can impact the discriminative validity of these instruments over different follow-up periods. However, research has yet to determine whether the use of multiple and repeated administration of risk assessment instruments improves identification of risk, and it may be the case that the heavy burden on service providers to administer multiple instruments is unwarranted. In this study, time-dependent cox regression with repeated assessments and recurrent events was used to investigate the dynamic nature and incremental validity of the dynamic appraisal of situational aggression (DASA), short-term assessment of risk and treatability (START), and HCR-20v3, which were repeatedly rated on a sample of forensic mental health inpatients (N = 240) over a 2-year period. Results suggest that using the rolling mean or the most recent risk assessment yielded the most accurate characterization of change in aggression risk. Repeated administration of dynamic risk instrument instruments improved the identification of aggression beyond the initial risk assessment. Although static, stable, and acute factors were significantly related to aggression, the combination of data from multiple risk assessment instruments may not result in clinically meaningful improvements in risk identification. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence

IntroductionPatient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings. MethodsThis quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation. ResultsViolent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation. DiscussionUsing an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.

Relationship Between the Dynamic Appraisal of Situational Aggression (DASA) Score and Incidents of Aggression Within 24 Hours in Patients in a Psychiatric Intensive Care Setting

The Dynamic Appraisal of Situational Aggression (DASA) is a risk assessment instrument developed in 2006 to assess the likelihood of a patient engaging in violence within 24 hours in a psychiatric inpatient environment. The aim of this study was to investigate whether DASA scores predict incidents of violence, restraints and seclusion in a 24-hour period on a psychiatric intensive care unit (PICU). This study also aimed to identify a meaningful DASA score which would suggest a high risk of an incident of violence occurring within 24 hours on a PICU. For two months, data collected for every inpatient on PICU were: daily DASA scores, incidents of violence, physical restraint or seclusion and whether the patient was deemed appropriate to transfer from PICU to an acute ward. Receiver operating characteristic (ROC) curves assessed the ability of DASA scores to predict incidents. Higher DASA scores were significantly associated with decreased odds of a patient being deemed fit for transfer to an acute ward and with increased odds of an incident of violence, seclusion or restraint within 24 hours. With a DASA score of 4 or above, there is a 16% probability there will be an incident of violence, 21% probability of seclusion and 11% probability of restraint within 24 hours. The DASA score can be used to predict incidents of violence, seclusion and restraint in the following 24 hours in a PICU setting.

Prevalence and forms of aggressive behavior among patients admitted to an acute psychiatric ward

IntroductionAggressive behavior is frequently associated with acute psychiatric admission. Several studies highlight the increased risk of aggression in certain psychiatric disorders.ObjectivesThe aim of the study was to explore the extent of aggressive behavior, its various manifestations, and its association with gender, age, and diagnosis among patients admitted to an acute psychiatric ward.MethodsPatients admitted to our acute psychiatric ward in a three months period were included and the Dynamic Appraisal of Situational Aggression - Inpatient Version (DASA-IV) questionnaire was administered in the first seven days after admission for all patients.ResultsA total of 290 patients, 153 men and 137 women, with a mean age of 46.9 years (SD=17.5) participated in the study. Men were overrepresented among patients who showed aggressive behavior (p=.008). There was no correlation between age and DASA-IV score (p=.259). 40% of patients (N=116) did not show aggression, while 60% (N=174) experienced some form of aggression. Of those who exhibited some form of aggressive behavior, 94% had only low, 4% had high, and 2% had extremely high levels of aggression. Aggression was most common in patients with intellectual disabilities, dementia, and bipolar disorder.ConclusionsAccording to our findings the majority of the acutely admitted psychiatric patients shows no or only low level of aggression. There were also differences in the forms and extent of aggressive behavior between the diagnostic groups. Risk assessment is important because it provides an opportunity for early detection and prevention, and the development of personalized treatment plans.DisclosureNo significant relationships.

Establishing best practice in violence risk assessment and violence prevention education for nurses working in mental health units

ObjectivesTo explore and evaluate extant and potential methods used in risk assessment and aggression prevention training. This study was also designed to consider the most appropriate method for educating nurses in use of a novel risk assessment instrument linked to a structured nursing intervention protocol (the electronic application of the Dynamic Appraisal of Situational Aggression and Aggression Prevention Protocol). BackgroundOrganisational and personal concerns have led to the development of training programs designed to prevent and manage aggression in mental health units. DesignThis descriptive qualitative study explored experts’ opinions about effective training approaches. MethodsData were collected via focus groups (a total of four discrete groups), with each of the four focus groups repeated after four weeks. A semi-structured guide was used to guide the focus group discussions. ResultsSeventeen experts with experience coordinating and facilitating training in prevention and management of aggression in mental health units in New Zealand and Australia participated in this study. Three themes emerged from the data 1) existing training can be “like pulling teeth without anaesthetic” 2) the need to “breathe life” into the training and 3) a vision of the “gold standard” for practice and training. ConclusionsTraining is optimal when it is place-based, responsive to local needs and inclusive of relevant clinical, cultural, consumer/carer and contextual factors. Training may benefit from a focus on the application of the knowledge, skills and attitudes learnt and there is a need for ongoing reinforcement of training in the clinical setting, beyond initial introduction and provision of information and orientation to relevant skills.

Implementation of the dynamic appraisal of situational aggression in inpatient mental health.

To implement structured violence risk assessment (VRA) using the Dynamic Appraisal of Situational Aggression (DASA) on a 25-bed, adult, inpatient psychiatric unit. Inpatient DASA screening for 13 weeks with nursing communication orders (NCOs) to highlight patients at high risk for violence. Pre/posttests measured registered nurse (RN) knowledge and perceptions of the DASA. DASA completion rate equaled 81.8% with an NCO issue rate of only 32.8%. RN perceptions of the DASA were positive, and knowledge of structured violence risk assessment increased. Structured violence risk assessment with the DASA is feasible and well-accepted on psychiatric units.

An observational study of a cross platform risk assessment mobile application in a forensic inpatient setting

Consumer-focused healthcare mobile applications have seen widespread adoption in recent years. Enterprise mobile applications in hospital settings have been slower to gain traction. In this study we examine the Dynamic Appraisal of Situational Aggression: Inpatient version (DASA), a short-term risk assessment tool which is well validated and widely used in the prediction of violent incidents, within an inpatient forensic setting. The application was piloted over a period of three months, collecting 847 total DASA scores on 21 different patients. Time stamping allowed for accurate correlation between risk assessment scoring and the violent risk incidents. The internal validity of the app was measured using Cronbach's alpha and was calculated at 0.798 indicating good internal validity. Using violent incidents as the dependent factor and the total DASA score as the independent factor, predictive validity of the app was calculated at 0.85, p = 0.007. The use of this application in a forensic setting was successful with good internal and predictive validity. A major benefit of this form of data collection was the electronic time stamping so that the correlation between risk estimation and events could be more closely correlated. Deployment of such an application in a general hospital setting would bring its own challenges but would be useful in other types of risk assessment and screening tools.

Factors Affecting the Success of Psychiatric Nurses in Conducting Risk Assessment of Violence Behavior

Background: Patient violence behavior in psychiatric services is a challenge for health care providers.Violence behavior can affect patients themselves, other patients and staff including nurses and affect thequality of service. Psychriatic nurses can play roles in conducting risk assessment of violence behaviors toreduce impact and make appropriate decisions.Purpose: This systematic review aims to find out the factors that influence the success of psychiatric nursesin conducting risk assessment of violence behavior.Method: This systematic review begins with making questions by the PICO method, identification,eligibility, article inclusion criteria selection, screening and appraisal. Search articles through the databaseof Science Direct, Pubmed and Ebsco with a time span from 2009-2019. And continue with PRISMA flowdiagram and JBI critique tool up to get 13 articles that relevant to be analyzed be systematic review.Result and Discussion: Reviews are carried out on articles that fit the inclusion criteria. Factors thatinfluence the success of psychiatric nurses in conducting risk assessment of violence behavior are trainingand continuing education, self-confidence, understanding early warning signs/alert systems, understandingthe causes of violence and the use of violence risk assessment tools) such as the Brøset Violence Checklist(BVC) and Dynamic Appraisal of situational Aggression (DASA)Conclusion: Psychiatric nurses still need continuing education and training in understanding the early signsof a patient’s violence behavior and the use of assistive devices in the form of risk assessment of violencebehavior to increase the confidence of nurses and assist in making appropriate decisions.

Diagnostic Sensitivity of the Dynamic Appraisal of Situational Aggression to Predict Violence and Aggression by Behavioral Health Patients in the Emergency Department

IntroductionThe Dynamic Appraisal of Situational Aggression (DASA) is an assessment tool that has been validated to predict violent or aggressive behavior in psychiatric inpatient settings. Its validity has not been established for use in the emergency department. MethodsThe DASA was implemented within the electronic health record of an academic medical center with inpatient psychiatric services. A retrospective analysis was conducted using Spearman rank-correlation coefficients to compare a final risk score with the subsequent occurrence of violence or aggression, defined as the use of hard leather physical restraints or the administration of intramuscular sedative medication. A receiver operating characteristic curve was used to summarize the predictive accuracy of the tool to assess aggression in behavioral health patients in the emergency department. ResultsA total of 3,433 scores were analyzed, representing 1,548 patients. The DASA had predictive validity with increasing scores comparing all tested cutoff scores against incidence of violence and aggression. The area under the curve comparing scores of 0 versus more than 0 was 0.79. The median time to subsequent aggression was 110 minutes. DiscussionThe DASA has predictive validity for use in evaluating behavioral health patients in the ED setting in an urban academic medical center. The tool is capable of predicting violence or aggression within a time frame conducive to the implementation of noninvasive measures. The DASA should be tested in other ED settings to further establish its predictive validity.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit.

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.

Imminent Aggression in Female Forensic Inpatients: A Study Assessing the Predictive Validity of the Dynamic Appraisal of Situational Aggression: Women’s Version (DASA: WV)

Despite high rates of aggression on female psychiatric inpatient units and research to suggest that risk factors for violence may be different for men and women, violence risk assessment instruments are typically developed and validated through research on male populations. The current study tested a female-specific modification to an existing risk assessment instrument, the Dynamic Appraisal of Situational Aggression: Women’s Version (DASA:WV). The modification involved addition of two factors taken from the Female Additional Manual used in conjunction with the HCR-20 (Covert/Manipulative Behaviour and Low Self-Esteem) and a rating of ward atmosphere to the original DASA. Nursing staff on a high secure female forensic unit rated patients on the DASA:WV at the end of each shift and recorded incidents of verbal aggression and physical aggression against others, objects, and self in the subsequent 24-hr period. Hierarchical (multilevel) logistic regression was employed in the statistical analysis to account for the incorporation of multiple repeated measures for each participant. While the evidence for the predictive validity of the DASA for aggression in a female forensic population was strengthened, the hypothesis that the DASA:WV would significantly improve predictive validity for female patients was not supported.

Risk prediction using natural language processing of electronic mental health records in an inpatient forensic psychiatry setting.

Instruments rating risk of harm to self and others are widely used in inpatient forensic psychiatry settings. A potential alternate or supplementary means of risk prediction is from the automated analysis of case notes in Electronic Health Records (EHRs) using Natural Language Processing (NLP). This exploratory study rated presence or absence and frequency of words in a forensic EHR dataset, comparing four reference dictionaries. Seven machine learning algorithms and different time periods of EHR analysis were used to probe which dictionary and which time period were most predictive of risk assessment scores on validated instruments. The EHR dataset comprised de-identified forensic inpatient notes from the Wilfred Lopes Centre in Tasmania. The data comprised unstructured free-text case note entries and serial ratings of three risk assessment scales: Historical Clinical Risk Management-20 (HCR-20), Short-Term Assessment of Risk and Treatability (START) and Dynamic Appraisal of Situational Aggression (DASA). Four NLP dictionary word lists were selected: 6865 mental health symptom words from the Unified Medical Language System (UMLS), 455 DSM-IV diagnoses from UMLS repository, 6790 English positive and negative sentiment words, and 1837 high frequency words from the Corpus of Contemporary American English (COCA). Seven machine learning methods Bagging, J48, Jrip, Logistic Model Trees (LMT), Logistic Regression, Linear Regression and Support Vector Machine (SVM) were used to identify the combination of dictionaries and algorithms that best predicted risk assessment scores. The most accurate prediction was attained on the DASA dataset using the sentiment dictionary and the LMT and SVM algorithms. NLP, used in conjunction with NLP dictionaries and machine learning, predicted risk ratings on the HCR-20, START, and DASA, based on EHR content. Further research is required to ascertain the utility of NLP approaches in predicting endpoints of actual self-harm, harm to others or victimisation.

Predictive power of the DASA-IV: Variations in rating method and timescales.

This project evaluated the predictive validity of the Dynamic Appraisal of Situational Aggression - Inpatient Version (DASA-IV) in a high-secure psychiatric hospital in the UK over 24hours and over a single nursing shift. DASA-IV scores from three sequential nursing shifts over a 24-hour period were compared with the mean (average of three scores across the 24-hour period) and peak (highest of the three scores across the 24-hour period) scores across these shifts. In addition, scores from a single nursing shift were used to predict aggressive incidents over each of the following three shifts. The DASA-IV was completed by nursing staff during handover meetings, rating 43 male psychiatric inpatients over a period of 6months. Data were compared to incident reports recorded over the same period. Receiver operating characteristic (ROC) curves and generalized estimating equations assessed the predictive ability of various DASA-IV scores over 24-hour and single-shift timescales. Scores from the DASA-IV based on a single shift had moderate predictive ability for aggressive incidents occurring the next calendar day, whereas scores based on all three shifts had excellent predictive ability. DASA-IV scores from a single shift showed moderate predictive ability for each of the following three shifts. The DASA-IV has excellent predictive ability for aggressive incidents within a secure setting when data are summarized over a 24-hour period, as opposed to when a single rating is taken. In addition, it has moderate value for predicting incidents over even shorter timescales.

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour.

To examine associations between risk of aggression and nursing interventions designed to prevent aggression. There is scarce empirical research exploring the nature and effectiveness of interventions designed to prevent inpatient aggression. Some strategies may be effective when patients are escalating, whereas others may be effective when aggression is imminent. Research examining level of risk for aggression and selection and effectiveness of interventions and impact on aggression is necessary. Archival case file. Data from clinical files of 30 male and 30 female patients across three forensic acute units for the first 60days of hospitalisation were collected. Risk for imminent aggression as measured by the Dynamic Appraisal of Situational Aggression, documented nursing interventions following each assessment, and acts of aggression within the 24-hours following assessment were collected. Generalised estimating equations were used to investigate whether intervention strategies were associated with reduction in aggression. When a Dynamic Appraisal of Situational Aggression assessment was completed, nurses intervened more frequently compared to days when no Dynamic Appraisal of Situational Aggression assessment was completed. Higher Dynamic Appraisal of Situational Aggression assessments were associated with a greater number of interventions. The percentage of interventions selected for males differed from females; males received more pro re nata medication and observation, and females received more limit setting, one-to-one nursing and reassurance. Pro re nata medication was the most commonly documented intervention (35.9%) in this study. Pro re nata medication, limit setting and reassurance were associated with an increased likelihood of aggression in some risk bands. Structured risk assessment prompts intervention, and higher risk ratings result in more interventions. Patient gender influences the type of interventions. Some interventions are associated with increased aggression, although this depends upon gender and risk level. When structured risk assessments are used, there is greater likelihood of intervention. Intervention should occur early using least restrictive interventions.

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 60days of each patient's file was reviewed to identify daily DASA scores and subsequent risk-related nursing interventions and aggressive behaviour within the following 24hours. 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.