Staff Observation Aggression Scale-Revised Research Articles

The Aggression Observation Short Form Identified Episodes Not Reported on the Staff Observation Aggression Scale-Revised

The purpose of this study is to evaluate the underreporting of violence and aggression on the Staff Observation Aggression Scale-Revised (SOAS-R) when compared to a simpler assessment: the Aggression Observation Short Form (AOS). During a period of one year, two open and two closed wards gathered data on both the SOAS-R and the AOS for all of their patients. The 22-item SOAS-R is to be filled out after each violent episode. The 3-item AOS is to be filled out during each shift and should also record the absence of violence. The SOAS-R registered 703 incidents and the AOS registered 1,281 incidents. The agreement between the SOAS-R and the AOS was good (kappa = 0.65, 95% CI = 0.62–0.67). Among the 1,281 AOS episodes, 51% were also registered on the SOAS-R. For the 176 AOS episodes with harm, 42% were also registered on the SOAS-R. We found 44% missing registrations on the AOS, primarily for open wards and for patients with short admission lengths. Standard instruments such as the SOAS-R underreport aggressive episodes by 45% or more. Underreporting can be reduced by introducing shorter instruments, but it cannot be completely eliminated.

Sensitivity and specificity of the Brøset Violence Checklist as predictor of violence in forensic psychiatry

Background: Violence and aggressive behavior within psychiatric facilities are serious work environment problems, which have negative consequences for both patients and staff. It is therefore of great importance to reduce both the number and the severity of these violent incidents to improve quality of care. Aims: To evaluate the specificity and sensitivity of the Brøset Violence Checklist (BVC) as a predictor of violent incidents for Danish forensic psychiatry patients. Method: A total of 156 patients were assessed three times daily with the BVC for 24 months. All aggressive or violent incidents were recorded using the Staff Observation Aggression Scale-Revised (SOAS-R). SOAS-R scores of 9 or more defined violent incidents. Data were analyzed using standard logistic regression models as well as models incorporating a random person effect. We used receiver operating curve (ROC) analysis to evaluate different BVC thresholds. Results: Of a total of 139,579 BVC registrations we found 1999 scores above 0 and 419 violent incidents. The BVC score was a strong predictor of violence. For the standard cut-off point of 3, specificity was 0.997 and sensitivity was 0.656. For the general risk of violence seen in this study, the risk of violence given a BVC score > 3 (positive predictive value) was 37.2%, and the risk of violence given a BVC score < 3 (negative predictive value) was 0.1%. Conclusion: The BVC showed satisfactory specificity and sensitivity as a predictor of the short-term risk of violence against staff and others by patients in a forensic setting.

1385 – Characteristics of the aggressive in-patient in a forensic psychiatric hospital in denmark: using the staff observation aggression scale - revised(SOAS-R)

To investigate the characteristics of the aggressive in-patient in a Danish forensic hospital. The study was conducted in a forensic psychiatric setting at Psychiatric Centre Sankt Hans. It utilizes data from the three year period between 2008 and 2010. Staff Observation Aggression Scale - Revised (SOAS-R) is used to examine all aggressive incidents during the period mentioned. 212 patients were admitted between 2008 and 2010, the majority of which being mainly men (98.6%) with a diagnosis within ICD10 F20-F29 (79.7%). In total there were 1507 recorded aggressive incidents, and 63.2% of the patients were registered with at least one incident of aggression. Ethnic minorities were overrepresented in comparison to the background population (37.3% vs. 9.5%). We found that Danish-born patients were more frequently aggressive compared to ethnic minorities (OR 1.8 p = 0.029), and that alcohol/substance abuse was a predictor of aggression (OR 3.47 p =< 0.001). According to age we found that the aggressive patient was significant younger compared to the non-aggressive patient (p = 0.043). Aggression is a prevalent phenomenon in a forensic psychiatry setting. Patients with at least one aggressive incident as recorded in the SOAS-R are characterized by being male, Danish and abusing. In addition schizophrenia is the most frequent diagnosis in forensic psychiatry at Psychiatric Center Sankt Hans.

1446 – Perspectives on staff factors and aggression in a forensic psychiatric setting in denmark: using the staff observation aggression scale- revised (SOAS-R)

To illustrate different perspectives on staff factors and aggression in forensic psychiatry. The study was conducted in a forensic psychiatric setting at Psychiatric Centre Sankt Hans. It utilizes data from the three year period between 2008 and 2010. Staff Observation Aggression Scale - Revised (SOAS-R) is used to examine aggressive incidents during the period mentioned. Out of 244 employees in a three year period and based on 1507 incidents, 91.6 % have registered at least one aggressive incident. The primary target for aggression was the staff in 64.4 % of the incidents. 74.8 % of the staff were women and the majority of the staff were RN and nurse-aids. According to gender differences we found no significant differences in reported incidents (OR 1.27 p = 0.818). Regarding the severity score there were no significant gender differences (p = 0.41). The length of employment has no impact on the severity score (p = 0.269). We found a minor but significant negative correlation (r = -0.262 p = < 0.01) between length of employment and the number of reported aggressive incidents. Our findings show that the staff is the primary target of aggression, and the majority of the staff is experiencing aggression as part of the job. We found no significant differences related to the gender of the staff, but we found that length of employment has an impact on the numbers of reported aggressive incidents, indicating underreporting and possibly cultural adaptation to some extent.

1442 – Severity of aggression in a forensic in-patient hospital in denmark: using the staff observation aggression scale - revised (SOAS-R)

To illustrate the targets and the severity of the aggressive incidents in a forensic psychiatric setting. The study was conducted in a forensic psychiatric setting at Psychiatric Centre Sankt Hans. It utilizes data from the three year period between 2008 and 2010. Staff Observation Aggression Scale Revised (SOAS-R) is used to examine all aggressive incidents during the period mentioned. 212 patients were admitted between 2008 and 2010. The majority being mainly men (98.6 %) with a diagnosis within ICD10 F20-F29 (79.7 %). In total there were 1507 recorded aggressive incidents of whom 63.2 % were registered with at least one aggressive incident. The most prevalent trigger of aggression was related to patients being denied something (45.9 %) and the staff is the primary target of the aggressions in 64.4 % of the incidents. Mean severity score we found to be 10.12 (SD 4.84). According to the severity of the aggressions, we found 61.5 % of the reported incidents, with a severity score ≤ 9, symbolizing more severe aggression. We found abusive patient to be significantly more aggressive (OR 3.47 p = < 0.001), but no difference in the severity score between the abusive patient and the non- abusive patient was found (p = 0.28). Aggression is a prevalent phenomenon in a forensic psychiatric setting in Denmark. The Majority of the aggressive incidents are characterized by being severe, but not necessarily related to abuse. The staff was the primary target of the aggressions.

Assessing Aggressive Behavior in Forensic Psychiatric Patients: Validity and Clinical Utility of Combining Two Instruments

Accurate observation of aggressive behavior among forensic psychiatric patients requires valid instruments. This study examines the validity and clinical utility of combining the social dysfunction and aggression scale (SDAS) and staff observation aggression scale revised (SOAS-R). Nurses weekly obtained SDAS scores of 127 patients, resulting in 6.124 assessments. Aggressive incidents were documented by the SOAS-R. Internal consistency, subscale structure, interobserver reliability of the SDAS, and convergent validity with SOAS-R were analyzed. A three-factor solution was found. Interobserver reliability was moderate, and good convergent validity was found. The SDAS, in conjunction with the SOAS-R, monitors changes in aggressiveness and may contribute to the prevention of aggressive behavior.

Determinants of Seclusion After Aggression in Psychiatric Inpatients

Some aggressive incidents in psychiatric wards result in seclusion, whereas others do not. We used the Staff Observation Aggression Scale-Revised and the mental health trust's database to identify determinants that predicted seclusion after aggression. These consisted of demographic, diagnostic, contextual, and aggression characteristics and were analyzed in a multilevel logistic regression. This showed associations between seclusion and aggression for the following: younger age, involuntary status, history of previous aggression, physical or dangerous violence, aggression being directed against objects, and a more severe incident. Thus, seclusion after aggression appears to be mainly predicted by aggression itself.

Factors affecting assessment of severity of aggressive incidents: using the Staff Observation Aggression Scale – Revised (SOAS‐R) in Japan

The aim of this study is to investigate factors associated with overall judgements of aggression severity as provided by ward nurses, using the Japanese-language version of the Staff Observation Aggression Scale - Revised (SOAS-R). Nurses who observed 326 aggressive incidents involving psychiatric inpatients at five mental health facilities in Japan provided their assessments of the incident severity both on the established rating scale, the SOAS-R, and on a visual analogue scale (VAS), a one-item scale to indicate overall aggression severity. To evaluate the factors influencing the VAS severity scores, a multiple regression analysis was performed, in which consumer, nurse and ward characteristics were added consecutively, along with SOAS-R severity scores as independent variables. SOAS-R scores explained 17.6% of the VAS severity scores. Independently from the SOAS-R scores, the gender and age of the aggressive consumers (adjusted R(2) = 10.0%), as well as the gender of the nurses who reported the aggression (adjusted R(2) = 4.1%), each explained VAS severity score to a significant degree. Apart from the SOAS-R scores, consumer and nurse characteristics appeared to influence the overall judgements of severity of aggressive incidents, which may be connected to decisions about the use of coercive measures, such as seclusion/restraint or forced medication.

Aggressive behaviour of inpatients with acquired brain injury

To study the prevalence, nature and determinants of aggression among inpatients with acquired brain injury. Patients with acquired brain injury often have difficulty in controlling their aggressive impulses. A prospective observational study design. By means of the Staff Observation Aggression Scale-Revised, the prevalence, nature and severity of aggressive behaviour of inpatients with acquired brain injury was assessed on a neuropsychiatric treatment ward with 45 beds. Additional data on patient-related variables were gathered from the patients' files. In total, 388 aggressive incidents were recorded over 17 weeks. Of a total of 57 patients included, 24 (42%) patients had engaged in aggressive behaviour on one or more occasions. A relatively small proportion of patients (n=8; 14%) was found to be responsible for the majority of incidents (n=332; 86%). The vast majority of aggression incidents (n=270; 70%) were directly preceded by interactions between patients and nursing staff. In line with this, most incidents occurred at times of high contact intensity. Aggressive behaviour was associated with male gender, length of stay at the ward, legal status and hypoxia as the cause of brain injury. Aggression was found to be highly prevalent among inpatients with acquired brain injury. The results suggest that for the prevention of aggression on the ward, it may be highly effective to develop individually tailored interventions for the subgroup with serious aggression problems. Insight into the frequency, nature and determinants of aggressive behaviour in inpatients with acquired brain injury provides nurses with tools for the prevention and treatment of aggressive behaviour.

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics

BackgroundThe aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance.MethodsIn 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed.ResultsThe global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents.ConclusionsIn a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients.Trial registrationsNCT00184119/NCT00184132

The assessment of imminent inpatient aggression: a validation study of the DASA-IV in Scotland

Inpatient aggression in psychiatric settings poses a serious management problem. This study reports the findings of a prospective pilot study on the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA-IV), a structured risk assessment tool for imminent aggression. The study was conducted in the State Hospital, the high secure psychiatric hospital for Scotland and Northern Ireland. The outcome data were aggressive incidents recorded on the Staff Observation Aggression Scale – Revised (SOAS-R) and incidents noted on the hospital's online recording tool. All measures were completed by nursing staff as part of their daily clinical routine to ensure ecological validity. The DASA-IV was found to be of moderate to good predictive power. Limitations and suggestions for further research are outlined, and the potential for implementation of the tool is discussed.

J12 Aggression among institutionalized patients with huntington's disease

BackgroundTo monitor and improve quality of care, all incidents in our nursing home are registered and evaluated. Incidents like aggression, falls, and choking may have serious consequences for the patient...

Gewalt und Aggression in Pflege- und Betreuungsberufen – Ein Literaturüberblick

For many people working in the care sector, aggression and violence are part of their everyday working life. In order to obtain an overview of the occurrence of violence and aggression in care-related jobs, the current literature on this topic has been analysed. Most published studies are in English and refer to psychiatric facilities. There are fewer analyses of facilities that provide care for the elderly, and facilities that look after people with disabilities have been analysed even less frequently. The German as well as the English literature provides no clues as to the valid prevalence rates in the various fields of the health sector. It is particularly difficult to comment on the prevalence rates because different tools have been used to collect the information. In addition, the definitions of violence and aggression used differ from study to study. In the present article, we introduce fourteen tools that have been developed to record aggressive behaviour towards others. The choice of the tools should be based on the choice of the target group. There are hints indicating that the Staff Observation Aggression Scale-Revised (SOAS-R) is the most suitable tool to record aggressive behaviour prospectively across all fields in the health care sector.

The Correspondence Between the Staff Observation Aggression Scale-Revised and Two Other Indicators for Aggressive Incidents

Previous research has shown good psychometric properties of the Staff Observation Aggression Scale-Revised (SOAS-R). However, it has never been investigated what proportion of aggressive incidents occurring in facilities is documented with the SOAS-R. Furthermore, if incidents are underreported, the consequences for the categorization of clients into aggressive and nonaggressive subgroups based on the SOAS-R are unknown. To examine this, in four inpatient psychiatric facilities for adults with mild intellectual disabilities, aggressive incidents were documented with the SOAS-R and two other indicators of aggressive incidents: the daily staff reports on clients' behavior and reports on of the use of restraints. Less than half of the incidents documented with the staff and restraint reports were also documented with the SOAS-R. On the other way around, however, it was also found that a substantial proportion of incidents reported on SOAS-R forms were not documented in the daily staff reports, which points to a more general problem of underreporting aggressive behavior. Apart from that, categorization of clients into an aggressive and a nonaggressive subgroup with SOAS-R data collected during 1 month or longer corresponded largely with the categorization based on both other indicators. This study showed that underreporting of aggressive incidents is likely to occur with the SOAS-R, making the instrument less suitable to assess absolute aggression incidence in facilities. Still, the SOAS-R seems a good instrument to categorize clients into aggressive and nonaggressive subgroups. Ways to improve the compliance of the ward team to document all aggressive incidents are addressed in the Discussion section of this article.

Pilot Study Evaluating the Effect of Massage Therapy on Stress, Anxiety and Aggression in a Young Adult Psychiatric Inpatient Unit

The aim of the present pilot study was to examine the effectiveness of a relaxation massage therapy programme in reducing stress, anxiety and aggression on a young adult psychiatric inpatient unit. This was a prospective, non-randomized intervention study comparing treatment as usual (TAU) with TAU plus massage therapy intervention (MT) over consecutive 7 week blocks (May-August 2006). MT consisted of a 20 min massage therapy session offered daily to patients during their period of hospitalization. The Kennedy Nurses' Observational Scale for Inpatient Evaluation (NOSIE), the Symptom Checklist-90-Revised (SCL-90-R), the State-Trait Anxiety Inventory (STAI) and stress hormone (saliva cortisol) levels were used to measure patient outcomes at admission and discharge from the unit. The Staff Observation Aggression Scale-Revised (SOAS-R) was used to monitor the frequency and severity of aggressive incidents on the unit. There was a significant reduction in self-reported anxiety (p < 0.001), resting heart rate (p < 0.05) and cortisol levels (p < 0.05) immediately following the initial and final massage therapy sessions. Significant improvements in hostility (p = 0.007) and depression scores (p < 0.001) on the SCL-90-R were observed in both treatment groups. There was no group x time interaction on any of the measures. Poor reliability of staff-reported incidents on the SOAS-R limited the validity of results in this domain. Massage therapy had immediate beneficial effects on anxiety-related measures and may be a useful de-escalating tool for reducing stress and anxiety in acutely hospitalized psychiatric patients. Study limitations preclude any definite conclusions on the effect of massage therapy on aggressive incidents in an acute psychiatric setting. Randomized controlled trials are warranted.

Incidence, types and characteristics of aggressive behaviour in treatment facilities for adults with mild intellectual disability and severe challenging behaviour

Inpatient aggression in treatment facilities for persons with intellectual disability (ID) can have aversive consequences, for co-clients and staff, but also for the aggressors themselves. To manage and eventually prevent inpatient aggressive incidents, more knowledge about their types and characteristics is necessary. In four facilities, totalling 150 beds, specialized in the treatment of adults with mild ID or severe challenging behaviour, aggressive incidents were registered during 20 weeks using the Staff Observation Aggression Scale-Revised. Characteristics of auto-aggressive and outwardly directed incidents and differences in their incidence in male and female clients in these facilities were compared. During the observation period of 20 weeks, 639 aggressive incidents were documented. Most of these (71%) were outwardly directed, predominantly towards staff, while most of the remaining incidents were of an auto-aggressive nature. Of the 185 clients present during the observation period, 44% were involved in outwardly directed incidents (range per client 1-34), and 12% in auto-aggressive incidents (range per client 1-92). Auto-aggressive and outwardly directed incidents differed regarding source of provocation, means used during the incident, consequences of the incident and measures taken to stop the incident. The proportion of men and women involved in each type of incident was comparable, as well as the majority of the characteristics of outwardly directed incidents caused by men and women. Although approximately half of all clients were involved in aggressive incidents, a small minority of clients were responsible for the majority of incidents. Therefore, better management and prevention of aggressive incidents for only a small group of clients could result in a considerable overall reduction of aggressive incidents in treatment facilities. Comparability of aggressive behaviour in these facilities shown by men and women and differences in characteristics of auto-aggressive and outwardly directed incidents are discussed.

Assessing risk for imminent violence in the elderly: the Brøset Violence Checklist

The Brøset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. It is hypothesised that an individual displaying two or more of these behaviours is more likely to be violent in the next twenty-four hour period. This study aims to test the validity of the instrument in geriatric settings and to report on the predictive value of an easy-to-use risk assessment instrument. Eight thousand eight hundred and thirty-five BVC observations were completed in two psychogeriatric wards (n = 42 patients) and two special care units for patients with dementia (n = 40 residents). To measure violent incidents the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R). This study disclosed that patients in geriatric wards and residents in nursing homes who are aggressive have higher BVC scores than the non-violent subjects indicating that the BVC does predict violent episodes in these settings. From a clinical perspective, it is most important that a prediction aid has good sensitivity, so that most cases are detected and have a high negative predictive value so that most non-cases on the measure are indeed non-cases. Our results indicate that the BVC was able to achieve this goal.

Effects of a psychiatric intensive care unit in an acute psychiatric department

Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients. Controlled studies evaluating the effects of the procedure are lacking. The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit (PICU) and not in a psychiatric acute department. In a naturalistic study, one group of consecutively referred patients had access only to the PICU, the other group to the whole acute unit. Data were obtained for 56 and 62 patients using several scales. There were significant differences in reduction of behaviour associated with imminent, threatening incidents (Broset Violence Checklist), and actual number of such incidents (Staff Observation Aggression Scale-Revised) in favour of the group that was treated in a PICU. The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents.

Challenging behaviour in the elderly—monitoring violent incidents

To explore the frequency and nature of violent incidents in psychogeriatric wards and nursing homes in terms of type and severity of incidents, what provoked the incidents, and what kind of measure was needed to stop the aggression. Aggressive behaviour of the study group was monitored using the Staff Observation Aggression Scale-Revised (SOAS-R( in two Norwegian nursing homes and two geriatric psychiatric wards for a period of three months. Severity of incidents were monitored with the built-in severity scoring system in SOAS-R. During the study period 32 out of the 82 patients were reported to be violent. The majority of the incidents were generated by a minority of the patients. Physical injury to the staff as a consequence of the aggression was extremely rare. Situations where the client was denied something were the most provocative ones and a substantial number of incidents occurred at bath/shower times. Talking to the patient was the most frequent measure used to stop the aggression, but more intrusive measures were also used. A substantial proportion of the incidents were associated with personal care tasks, suggesting a crucial role for communication difficulties and a focus for staff training. We suggest that personal care situations should be added to the variable list in future research.

Prediction of aggression on a locked psychiatric admissions ward.

The present study evaluates the accuracy of clinical and archival predictors of patients' aggressive behaviour on a locked admissions ward. Over a 9-month period, staff members estimated the likelihood that patients would become aggressive during their stay in the ward. These unaided clinical assessments were obtained with Visual Analogue Scales (VASs) administered before the end of the first full day of admission. Archival predictions were based on demographic variables (e.g. gender, number of previous admissions, diagnosis) derived from patients' admission forms. Aggressive behaviour was recorded with the Staff Observation Aggression Scale-Revised (SOAS-R). Clinical predictions of aggression were found to be moderately accurate. On the basis of clinical estimates, 75% of the patients were correctly classified as becoming aggressive or not. Although a body of evidence indicates that unaided clinical prediction of violent recidivism after hospital discharge does not perform well, it may be quite accurate in estimating short-term aggression risks during acute psychiatric admission.