Nurses' Perception of the Use of theDynamic Appraisal of Situational Aggression(DASA) in an Emergency Psychiatric Setting
Item Type text; Electronic Dissertation
Authors Underwood, Stacy
Publisher The University of Arizona.
Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.
Download date 02/07/2018 17:04:06
Link to Item http://hdl.handle.net/10150/624529
NURSES’ PERCEPTION OF THE USE OF THE DYNAMIC APPRAISAL OF
SITUATIONAL AGGRESSION (DASA) IN AN EMERGENCY PSYCHIATRIC
SETTING
by
Stacy Lynn Underwood
________________________ Copyright © Stacy Lynn Underwood 2017
A DNP Project Submitted to the Faculty of the
COLLEGE OF NURSING
In Partial Fulfillment of the Requirements
For the Degree of
DOCTOR OF NURSING PRACTICE
In the Graduate College
THE UNIVERSITY OF ARIZONA
2 0 1 7
2
THE UNIVERSITY OF ARIZONA GRADUATE COLLEGE
As members of the DNP Project Committee, we certify that we have read the DNP Project
prepared by Stacy Lynn Underwood entitled “Nurses’ Perception of the Use of the Dynamic
Appraisal of Situational Aggression (DASA) in an Emergency Psychiatric Setting” and
recommend that it be accepted as fulfilling the DNP Project requirement for the Degree of
Doctor of Nursing Practice.
_________________________________________________________ Date: April 6, 2017 Michelle Kahn-John, PhD, RN, PMHNP-BC, GNP
_________________________________________________________ Date: April 6, 2017 Kathleen Insel, PhD, RN
_________________________________________________________ Date: April 6, 2017 Donna McArthur, PhD, APRN, FNP-BC, FAANP, FNAP Final approval and acceptance of this DNP Project is contingent upon the candidate’s submission of the final copies of the DNP Project to the Graduate College. I hereby certify that I have read this DNP Project prepared under my direction and recommend that it be accepted as fulfilling the DNP Project requirement.
_________________________________________________________ Date: April 6, 2017 DNP Project Director: Michelle Kahn-John, PhD, RN, PMHNP-BC, GNP _________________________________________________________ Date: April 6, 2017 Kathleen Insel, PhD, RN
3
STATEMENT BY AUTHOR
This DNP Project has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.
Brief quotations from this DNP Project are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his or her judgment the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author.
SIGNED: __Stacy Lynn Underwood_______________
4
ACKNOWLEDGMENTS
I would like to thank my wonderful committee for all their encouragement and support
throughout my long journey to the DNP. Their extensive knowledge of the nursing field,
research, and practice, has been invaluable to me during this process. If not for them, I would not
be finishing the program today.
I would also like to acknowledge Connections Arizona and Dr. Robert Williamson for
allowing me to develop the DNP project within the facility. In addition, I would like to thank
Josh Leslie PA-C, Amanda Johnson-Wo PA-C, Yolanda Bough RN, Brian Montgomery RN,
Julie Curtain RN, Amber Segal RN, Angela Goettl Crisis Worker, Shane Curtis and all the RN’s
who chose to participate in the project for their participation, support and encouragement.
5
DEDICATION
I would like to dedicate this DNP project to all of those people instrumental in the
development, positive influence and encouragement that led to the completion of the project.
Most of all, the completion of the project ant the DNP degree is dedicated to my mother, father,
and sister who have always been my strongest supporters and cheerleaders throughout my life.
6
TABLE OF CONTENTS8
LIST OF FIGURES ......................................................................................................................... 8
LIST OF TABLES .......................................................................................................................... 9
ABSTRACT .................................................................................................................................. 10
INTRODUCTION ....................................................................................................................... 12
Background and Significance ..................................................................................................... 12
Local Problem .............................................................................................................................. 16
Purpose ......................................................................................................................................... 19
Study Questions ........................................................................................................................... 19
Literature Review ........................................................................................................................ 20
Framework and Theoretical Underpinnings ............................................................................ 26
METHODS ................................................................................................................................... 28
Setting ........................................................................................................................................... 28
SAUPC’s Implementation of the DASA .................................................................................... 29
Current DNP Project – Planning Phase .................................................................................... 32
Recruitment of RN Study Participants .......................................................................... 34
Informed Consent ............................................................................................................ 34
Participant Privacy and Confidentiality of Data .......................................................... 35
Ethical Issues .................................................................................................................... 35
Measures ........................................................................................................................... 35
Method of Evaluation ...................................................................................................... 36
Analysis ............................................................................................................................. 36
Planning the Intervention – “Plan” of PDSA ............................................................................ 36
RESULTS ..................................................................................................................................... 37
Analysis of the PDIQ, “Study” ................................................................................................... 37
Descriptive Statistics ....................................................................................................... 37
Research Questions ......................................................................................................... 38
Research question 1. ............................................................................................ 38
Research question 2. ............................................................................................ 38
7
TABLE OF CONTENTS – Continued
Research question 3. ............................................................................................ 39
Research question 4. ............................................................................................ 40
Research question 5. ............................................................................................ 40
Gender. ...................................................................................................... 41
Years of experience as an RN. ................................................................. 42
Level of education. .................................................................................... 43
Years at SAUPC. ....................................................................................... 44
Research question 6. ............................................................................................ 45
DISCUSSION ............................................................................................................................... 45
PDSA “Act” .................................................................................................................................. 45
Strengths and Limitations .......................................................................................................... 49
CONCLUSIONS .......................................................................................................................... 51
APPENDIX A: DISCLOSURE STATEMENT ........................................................................... 53
APPENDIX B: DEMOGRAPHIC INFORMATION .................................................................. 55
APPENDIX C: POST DASA IMPLEMENTATION QUESTIONNAIRE - PDIQ .................... 57
APPENDIX D: PROCESS FLOW SHEET ................................................................................. 60
REFERENCES ............................................................................................................................ 62
8
LIST OF FIGURES
FIGURE 1. Box Plot of the DASA Usefulness Score by Gender ............................................ 42
FIGURE 2. Box Plot of the DASA Usefulness Score by Level of Education .......................... 44
9
LIST OF TABLES
TABLE 1. Frequency Table of Level of Agreement with the Statement, “The DASA was effective in identifying potentially aggressive/violent behaviors in patients.” ...... 38
TABLE 2. Frequency Table of Level of Agreement with the Statement, “The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.” ............................................................................................... 39
TABLE 3. Frequency Table of Level of Agreement with the Statement, “The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.” .............................................................................. 40
TABLE 4. Frequency Table of Level of Agreement with the Statement, “I believe using the DASA decreased the episodes of seclusion and restraint.” .................................. 40
TABLE 5. Frequency Table of Level of Agreement with the Statement, “I would like to continue to use the DASA as a violence risk assessment tool.” ............................ 45
10
ABSTRACT
Background: The use of the Dynamic Assessment of Situational Aggression (DASA) in acute
psychiatric settings to identify aggressive and/or violent patients upon admission.
Objective: Determining nurses’ perception of the usefulness of the Dynamic Assessment of
Situational Aggression (DASA) in a psychiatric emergency room setting.
Theoretical Background: Langley, Nolan, Nolan and Provost’s (2009) Model for Improvement,
which incorporates Deming’s Plan-Do-Study-Act (PDSA) cycle, was utilized as the
theoretical framework to guide this DNP project.
Setting: An adult psychiatric emergency room in urban Phoenix, Arizona.
Measurement: A six-item survey questionnaire measured on a five-point Likert scale ranging
from “Strongly Disagree” (1) to “Strongly Agree” (5) describes and measures nurses’
perception on the usefulness of the DASA. An additional question explored the influence
of static nursing factors (gender, years of experience, level of education, years at the
facility), on nurses’ perception of the usefulness of the DASA.
Results: Overall, nurses (90%) of the study participants perceived the DASA to be effective in
identifying aggressive violent patients and 70% of the participants would like to continue
to use the DASA. Static nursing factors showed no difference in nurses’ perception of
usefulness.
Limitations: Further exploration in similar settings such as regular emergency departments and
psychiatric emergency and crisis settings are recommended. In this study only nursing
perception was explored. Analysis of the validity of the DASA tool in the psychiatric
11
emergency room setting in addition to nursing perceptions would be more beneficial in
determining the DASA’s true usefulness.
Conclusion: The results of this DNP project demonstrate that nurses at the SAUPC perceive the
DASA to be a useful addition to their admission assessment. Overall nursing response
was positive and the SAUPC seclusion and restraint committee recommended
incorporating the DASA into the triage nursing admission assessment.
12
INTRODUCTION
Background and Significance
According to the United States Bureau of Justice’s National Crime Victimization Survey
findings from 1993-2009, “In 2009, an estimated four violent crimes per 1,000 employed persons
age 16 or older were committed while the victims were at work or on duty” (Harrel, 2011, p. 1).
Of the occupations measured, medical professionals (physicians, nurses, technicians, and
other/medical occupations) experienced workplace violence at a rate of 6.5 per 1,000 employed
persons, whereas mental health professionals and other mental health occupations experienced
incidents of violence at a rate of 20.5 per 1,000 employed persons (Harrel, 2011). The prevalence
of threats and assaults by patients were reported highest from physicians, nurse practitioners, and
nurses working on inpatient units and in psychiatric emergency rooms (Privitera, Weisman,
Cerulli, Tu, & Groman, 2005). Due to the high incidence of patient aggressive and violent
behaviors that occur in psychiatric settings, the ability to identify, predict the occurrence of these
behaviors, and intervene to prevent patient aggression and violence is important for overall
patient and staff safety.
Historically, tools to assess risk of violence were developed and tested on prisoners and
forensic (criminal) psychiatric patients prior to release or discharge into the community (Barry-
Walsh, Daffern, Duncan, & Ogloff, 2009). As such, these instruments are standardized and focus
on static risk factors that do not change based on mental state. In some psychiatric settings, more
specifically forensic, these standardized risk assessment tools are effective, but in the
crisis/emergency psychiatric settings, where rapid assessment and management are critical in
mitigating patient and staff safety, the tools may not have clinical utility (Sands, Elsom, Gerdtz,
13
& Khaw, 2012). For this reason, research has focused on the difference between the prediction of
imminent aggression, short-term aggression, and long-term predictors, with a concentration on
more dynamic risk factors (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Bjorkly, Hartvig,
Braur, & Moger, 2009; Chapman, Perry, Styles, & Combs, 2009; Clarke, Brown, & Griffith,
2010; Kling et al., 2006; Ideker, Todicheeney-Mannes, & Kim, 2011; McDermott & Holoyda,
2014). Static risk factors (fixed) are defined as events occurring in the past that may influence a
patient’s current behavior (i.e., history of violence, arrests, history of abuse), whereas dynamic
risk factors are contextual, situational, and temporal variables (substance intoxication, emotional
state, support) that are changeable (Eccleston & Ward, 2004). Although historical factors are
helpful in determining risk, studies have found that dynamic, generally observable factors, such
as behavior, appearance, speech, and thought process, are more predictive of violent behavior
(McNiel, Gregory, & Lam, 2003; Sands, Elsom, Gerdtz, & Khaw, 2012).
The ability to determine who will or will not engage in violent acts in a psychiatric
emergency setting is currently beyond our reach. Through research and an awareness of a
combination of empirically supported risk factors, a practitioner may make a reasoned judgment
as to the chance that a psychiatric patient will become violent (Mullen & Oglaff, 2008, as cited
in Allnut et al., 2010). Early identification and rapid assessment of potentially violent and
aggressive patients, whether due to involuntary status, psychosis, or other factors, allows for the
implementation of interventions that can decrease the occurrence of violence (Bowers et al.,
2011). The identification of risk factors for violence during the initial assessment processes
enhances the possibility for prevention (Sands, 2007). Therefore, identifying and utilizing a tool
14
that allows for rapid assessment by facility first responders, such as a registered nurse, should
allow for timely implementation of appropriate interventions with high-risk patients.
Defining aggression and violence is difficult. In a literature review and meta-analysis,
aggression was defined by type from physical only, verbal only, both verbal and physical,
towards objects, toward staff, and other combinations of these behaviors (Bowers et al., 2011).
The National Institute for Health Care Excellence (NICE, United Kingdom), indicates
“Violence and aggression refer to a range of behaviors or actions that can result in harm,
hurt or injury to another person, regardless of whether the violence or aggression is
physically or verbally expressed, physical harm is sustained or the intention is clear”
(2015, p. 6).
The NICE definition views violence/aggression as interchangeable, provides a general
characterization of violent and aggressive behaviors, and is therefore used for the purpose of the
project.
In both emergency and psychiatric settings, the risk of admitting violent and potentially
violent patients is high. In many cases, information about the patient’s history and reason for
presentation is limited. Binder and McNiel (1999) interviewed medical directors from 20
different psychiatric emergency rooms throughout the United States. These interviews revealed
that it is difficult to determine the etiology of violent behaviors of unfamiliar patients, difficult to
obtain accurate vital signs, or obtain appropriate laboratory tests (breathalyzer, urine drug
screen). More recent research supports early assessment indicating that violence risk assessment
during triage instead of during primary assessment addresses the period of high risk, which is
within the first 1-2 hours upon arrival to a facility (Daniel, Gerdtz, Elsom, Knott, Prematunga, &
15
Virtue, 2015). Further, most patient presentations were not amenable to direct questioning
supporting the use of a behavioral based assessment (Daniel et al., 2015). The most commonly
used protocol for acutely violent patients was restraint and medication (Binder & McNiel, 1999;
Roberts, Crompton, Milligan, & Grooves, 2009; Wale, Belkin, & Mood, 2011). For this reason,
although used as a last resort, elevated seclusion and restraint rates are common. Data from the
Centers for Medicare & Medicaid Services (CMS) Hospital Compare Inpatient Psychiatric
Facility Quality Reporting Program (2014) indicate national average for physical restraint are
0.39 hours overall rate per 1000 patients, and 0.2 hours overall rate for seclusion. Older data in a
congressional report from the United States General Accounting Office, GAO, (1999) found
among five state hospital systems, the rates of seclusion and restraint varied widely. Seclusion
episodes ranged from 0.6-41.8 per 1000 patient days and seclusion episodes ranged from 0.2-
29.1 per 1000 patient days (GAO, 1999).
The use of seclusion and/or restraint (Daniel et al., 2015) is used in emergency rooms and
psychiatric facilities to manage acute aggressive and/or violent behaviors and is surrounded by
controversy (Downey, Zun, & Gonzales, 2007; Georgieva, Mulder, & Noorthoorn, 2012;
Huckshorn, 2014; Wieman, Camacho-Gonsalves, Gonsalves, Huckshorn, & Leff, 2014). Due to
the increased risk of physical harm and psychological trauma to the patients and staff secondary
to seclusion and restraint episodes (Knox & Holloman, 2012; LeBel, Duxbury, Putkonen,
Sprague, Rae, & Sharpe, 2014; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimaki,
2009; Steinert, Berger, Psych, Schmidt, & Gebhardt, 2007) the practice of seclusion and restraint
is closely regulated and considered acceptable only as a last resort (Knox & Holloman, 2012;
Vollmer et al., 2011). Utilizing assessment tools early in the assessment process that identify
16
aggressive and violent behaviors that commonly lead to seclusion and restraint, have the
potential to impact seclusion and restraint rates, staff/patient safety, and improve the assessment
process.
Local Problem
The Southern Arizona Urgent Psychiatric Center (SAUPC), located in a large metro area,
is a freestanding psychiatric room/observation unit with a recliner/bed capacity of 50 that
provides crisis psychiatric services to the greater Phoenix area. Like many acute care settings
where patients are in crisis, decreasing the occurrence of violent and aggressive behaviors toward
staff and peers is a goal (Chapman, Perry, Styles, & Combs 2009; Ideker, Todicheeney-Mannes,
& Kim, 2011; Kling et al., 2006).
The practice of seclusion and restraint is a highly scrutinized practice in the psychiatric
community (Georgieva, Mulder, & Noorthoorn, 2012). Concerns regarding seclusion and
restraint are addressed at the SAUPC by the Seclusion & Restraint (S&R) Committee, which
consists of members of the facilities multidisciplinary team (Medical Director, Director of
Nursing, Director of Operations, Compliance Officer, a Nurse Practitioner, Charge RN, Staff
RN, Lead Behavioral Health Specialist, Behavioral Health Specialist, a Social Worker, a
Rehabilitation Support Specialist and Admissions Coordinator) on a monthly basis. The purpose
of the meeting is to review episodes of seclusion, restraint, incidences of violence on the unit,
and develop ways to decrease the incidence of seclusion and restraint events and increase safety
during these events. Due to a recent upward trend of patients presenting with violent and
aggressive behavior and a subsequent increase in the incidence of seclusion and restraint events,
the SAUPC Seclusion and Restraint Committee determined that intervention was required. A
17
quality improvement project, utilizing the Model for Improvement as a guideline, was developed
and implemented. The Model for Improvement, developed by Langley, Nolan, Nolan, and
Provost (2009), is a framework that acknowledges the complexity of relationships and their
influence on care delivery while taking into account variation, knowledge, and psychology. The
theory is implemented using Deming’s Plan-Do-Study-Act (PDSA) cycle. The S&R Committee
decided to implement a new violence risk assessment during the initial admission process at the
SAUPC in hopes to improve their assessment of potentially violent patients and decrease
emergency seclusion and restraint. As part of the implementation-planning phase, violence risk
assessment tools were researched, and two were chosen and presented to the S&R Committee at
the SAUPC.
The SAUPC provides all staff members with CPI (Crisis Prevention Intervention) non-
violent crisis intervention training on a yearly basis. Crisis Prevention Intervention is a behavior
management philosophy, considered to be the worldwide standard for crisis prevention and
intervention. CPI utilizes a holistic approach to defuse escalating, aggressive, and violent
behaviors, while maintaining the therapeutic relationship (Crisis Intervention Prevention, 2016).
In addition, should a patient’s behavior escalate to the point of actually attempting to harming
self or others, CPI incorporates and teaches safe appropriate time limited practices for physically
holding a patient. Despite the use of CPI methods by all staff, some patients still require
seclusion and/or restraint. Review of the SAUPC seclusion and restraint monthly state report
(summary of de-identified patient seclusion and restraint information) revealed that the facility
has a high incidence of seclusion and restraint episodes that occur within the first 60 minutes of
the patient being brought to the facility-either by crisis team, police, ambulance, or walk-up (B.
18
Montgomery, Nurse Manager SAUPC, personal communication, May 10, 2016). This finding is
consistent with literature that indicates that the first 1-2 hours of admission in an emergency
room is the period of highest risk for a behavioral emergency (Daniels et al., 2015). As violent
and aggressive behaviors lead to increased risk of injuries for staff and patients and increased
risk of seclusion or restraint, the S&R Committee concluded a rapid and effective manner in
which to assess patients upon admission was needed to address the upward trend of S&R. The
absence of a formal or evidenced based violence risk assessment at the SAUPC supported the
implementation of a violence risk assessment at admission for every patient entering the SAUPC.
The S&R Committee at the SAUPC selected the Dynamic Assessment of Situational Aggression
(DASA) for implementation. The DASA and the process of selection are further described in the
literature review.
The DASA was implemented from June 15, 2016 through October 15, 2015. During this
period, greater than 4000 patients were screened by nurses, at the point of initial contact, upon
admission to the SAUPC. The principle investigator for this project is a Doctor of Nursing
practice student, a practicing Psychiatric Nurse Practitioner, and was naturally selected by the
S&R committee to be the lead for the development and implementation of the planned quality
improvement project. The S&R committee decision to implement the use of the DASA by nurses
at the SAUPC, provided the opportunity for the principle investigator of this project to conduct a
doctor of nursing practice quality improvement project.
The Dynamic Assessment of Situational Aggression (DASA) has been utilized in various
psychiatric settings that include, psychiatric intensive care units, voluntary, and involuntary
inpatient units (Ogloff & Daffern, 2006; Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Chu,
19
Thomas, Ogloff, & Daffern, 2011; Dumais, Larue, Michaud, & Goulet, 2012; Griffith, Daffern,
& Godber, 2013). To date, there have been no studies published in the literature that include the
use of the DASA instrument in the United States, or in a freestanding psychiatric emergency
room.
Purpose
The purpose of this DNP project is to determine nurses’ perception of the usefulness of
the DASA in a psychiatric emergency room. By increasing awareness of dynamic behavioral risk
factors (dynamic) and early identification/prediction of potentially aggressive/violent behaviors,
it was hypothesized that nurses would perceive the DASA useful during their initial assessment.
Study Questions
Utilizing a self-report questionnaire completed by the nurses who utilized the DASA
during SAUPC’s implementation, the following study questions were addressed:
1. Do nurses perceive the DASA to be effective in identifying potentially aggressive/violent
patient’s behaviors?
2. Do nurses perceive the use of the DASA increases their awareness of the behaviors
(negative attitudes, impulsivity, irritability, verbal threats, sensitive to perceived
provocation, easily angered when requests are denied, unwillingness to follow directions)
that indicate a patient’s increased risk for aggressive/violent behavior?
3. For patients that nurses perceive are at risk of violent/aggressive behaviors, does the
DASA trigger an initiation of an intervention by the nurse?
a) And if so, what interventions were used?
20
4. Do nurses perceive a decrease in seclusion and restraint episodes as a result of the use of
the DASA?
a) Which behaviors reported by nursing lead to an episode of seclusion and/or
restraint?
5. Is nurse gender, years of experience as a nurse, level of education, and/or years at the
facility, associated with the nurses’ perception of the usefulness of the DASA?
6. Do nurses want to continue to use the DASA as a violence assessment tool in the
psychiatric emergency room setting?
Literature Review
A literature search was conducted to find research conducted on violence risk
assessement and on seclusion and restraint practices. Electronic databases including PubMed
(Med-Line), PsychInfo (ProQuest), and CINAHL were searched. Search terms included,
violence, risk assessment, seclusion and restraint, psychiatric hospital, emergency room, violence
prevention, and nursing assessment. Once brief risk assessments were identified research
specifically related to those tools was searched. Only articles related to violence risk assessment,
seclusion and restraint, emergency room, and pyschiatric settings were used.
Consistent with research, violence or threatening violence, agitation, and disorientation
(Kaltiala-Heino, Tuohimaki, Korkeila, & Lehtinen, 2003; Larue, Dumais, Drapeau, Menard, &
Goulet, 2010; Knox & Holloman, 2012; Keski-Valkama, Sailas, Eronen, Koivisto, Lonnqvist, &
Kaltaiala-Heino, 2010; Vruwink et al., 2012) involuntary status (Iozzino, Ferrari, Large,
Nielssen, de Girolamo, 2015; Gergiev, Vesselinov, & Mulder, 2012; Taylor et al., 2012; van de
Sande et al., 2013; Vruwink et al., 2012), psychotic symptoms and paranoid behaviors
21
(Geogieva, Vesselinov, & Mulder, 2012; Taylor et al., 2012; van de Sande et al., 2013), and
recent alcohol or drug abuse (Iozzino, Ferrari, Large, Nielssen, & de Girolamo, 2015; Witt, van
Dorn, & Fazel, 2013) are the most frequent contributing factors leading to seclusion and restraint
at the SAUPC. Research indicates that the use of systematic, structured, violence risk assessment
have led to a decrease in patient seclusion and restraint episodes (Abderhalden, Needham,
Dassen, Hlfens, Haug, & Fisher, 2008; van de Sande et al., 2011).
Standard violence risk assessments developed in the forensic (criminal) setting, which
focus on non-changing static factors, are limited in usefulness in the crisis/emergent psychiatric
setting (Sands, Elsom, Gerdtz, & Khaw, 2012). Structured clinical tools/instruments that
consider dynamic factors in addition to static risk factors have shown success in assessing for
aggression and potential violent behaviors in patients (Amlik & Woods, 2000; Ogloff & Daffern,
2006; Bjorkly, Harvig, Heggen, Brauer, & Moger, 2009; Chu, Thomas, Ogloff, & Daffern,
2011). Multiple studies have evaluated the validity (how well the assessment or tool measures
what it intends) of various tools in the psychiatric intensive care unit and on inpatient voluntary
and involuntary psychiatric units (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Bjorkly,
Harvig, Heggen, Brauer, & Moger, 2009; Clark, Brown, & Griffith, 2010, Dumais, Larue,
Michaud, & Goulet, 2012; McDermott & Holoyda, 2014). Based on supporting research and
level of appropriateness for the SAUPC, the Broset Violence Checklist (BVC), and the Dynamic
Appraisal of Situational Aggression (DASA), were selected to be reviewed by the S&R
Committee. In addition, existing studies that mention nursing perception on the use of the
different violent risk assessments mention the need for the investigation of violence assessment
in the psychiatric emergency and crisis settings. A brief description of each assessment tool is
22
provided with a final summation of the reasons the S&R committee selected the DASA for the
SAUPC quality improvement project.
The Broset Violence Checklist (BVC) is a six-item structured clinical tool, completed by
the nurse to assess for potential patient violence within the following 24-hours of assessment
(Almvik & Woods, 1999). It has been extensively studied in inpatient psychiatric settings and
with varying populations (Almvik & Woods, 1999, Aberhalden et al., 2004, 2006, 2008;
Bjorkdahl, Olsson, & Palmstierna, 2006; Clark, Brown, & Griffith, 2010; Yao, Li, Arthur, Hu,
An, & Cheng, 2014). The tool, which takes less than one minute to complete, utilizes six items to
assess patient characteristics; confusion, irritability, boisterousness, verbal threats, physical
threats, and attacks on objects (Almvic & Woods, 1999). The presence of two or more of the
behaviors indicates a higher likelihood that a patient may become violent. Previous studies
(Almvic & Woods, 1999; Almvik, Woods & Rasmussen, 2000; Almvik et al., 2007; Vaaler et
al., 2011) demonstrated within the first 72-hours post admission, that the tool is more reliable
than clinical judgment or intuition, for predicting violent episodes. The BVC showed, with 63%
accuracy that violence will occur within the next 24-hours, and had 92% accuracy in predicting
violence will not occur. In addition, they found that using the instrument during admission
resulted in 41% reduction in severe aggressive events and a 27% reduction in the need for
seclusion and restraint measures. A more recent study evaluated the ability of the BVC to help
staff on a psychiatric intensive care unit identify potential violence and explored its utility in
implementing interventions that eliminate or reduce the impact of violence and behaviors (Clark,
Brown, & Griffith, 2010). Results among patients who consented to the study, revealed that on
Day 1 of admission, involuntary (those on a mental health hold) patients scored higher on the
23
screen than voluntary patients did, female scores were higher than male scores, irritability was
the most predictive in BVC scores, and seclusion rates decreased “dramatically” over the three-
month study period (Clarke, Brown, & Griffith, 2010). Nurses completing the BVC were
provided questionnaires about its use and found that the nurses felt the tool was easy to use, took
approximately 1-2 minutes to complete and was easy to understand (Clarke, Brown, & Griffith,
2010). Scoring of the BVC was also consistent between staff completing the instrument (Clarke,
Brown, & Griffith, 2010). Despite the positive results, it was noted that the sample size of
patients in the study and the nurses completing the questionnaires was small, was not
consistently used by all staff, and hence, the results were not generalizable. The BVC was also
well received and appeared to be a great choice for the setting. Although all six items are
dynamic in nature and relate to violence, not all were amenable to intervention, redirection by
staff members, or treatment planning (Ogloff & Daffern, 2006). Studies explored the ability of
the BVC to encourage the use of least restrictive measures. One occurred on a small (11-bed)
PICU that had a small sample size (Clark, Brown, & Griffith, 2010) and the other study,
conducted on regular inpatient psychiatric wards, focused on applicability, validity, and
acceptability in a Chinese population (Yao, Li, Arthur, Hu, An, & Cheng, 2014).
Due to the BVC’s, lower ability to accurately predict the occurrence of violence in the
following 24-hours (63% vs. 70% for the DASA), and the absence of impulsivity as a risk factor,
the BVC was not chosen for the SAUPC implementation project.
The Dynamic Appraisal of Situational Aggression (DASA) is a brief structured violence
instrument developed to assist in the assessment of imminent aggression (within the next 24-
hours). The DASA assessment, consisting of seven items, draws two items from the HCR-20
24
(negative attitudes and impulsivity), two items from the BVC (irritability and verbal threats), and
three items (sensitive to perceived provocation, easily angered when requests are denied, and
unwillingness to follow directions), from the authors of the DASA’s research (Ogloff & Daffern,
2006). The items were chosen because they are each independently related to imminent
aggression (Ogloff & Daffern, 2006). In addition, these seven items were found to increase
predictive validity and lead to identifiable variables which staff may target for intervention, in
turn, enabling the prevention of aggressive acts (Ogloff & Daffern, 2006, p. 809). Studies have
shown the DASA to have moderate to strong predictive ability (Ogloff & Daffern, 2006, Barry-
Walsh, Daffern, Duncan, & Ogloff, 2009; Chu, Thomas, Ogloff, & Daffern, 2011). As with the
other studies, scores were more accurate in identifying imminent aggression in patients than with
unaided clinical judgment (Griffith, Daffern, & Godber, 2013). In addition, the DASA has been
able to identify aggressive events that occurred early in a patient’s admission and prior to
psychiatric evaluation (Chan & Chow, 2014). In terms of usefulness, nursing response to the
DASA was generally positive with the exception of one study that found nurses did not perceive
the DASA to be an improvement on their own clinical judgment (Daffern et al., 2009). Another
usefulness and predictive validity study was conducted in a 12-bed psychiatric intensive care unit
in a psychiatric hospital in Quebec, Canada (Dumais et al., 2012). The study found that the
nurses’ clinical judgment was comparable to the DASA for prediction of patient aggression. In
addition, staff generally considered the DASA relevant to their practice and was useful for
preventing the escalation of aggressive behaviors. Most recently, a study was completed in
which the DASA was implemented on mental health units in the Finnish healthcare system
(Lantta, Daffern, Kontio, & Valimaki, 2015). Generally, many nurses found the DASA was
25
quick and easy to complete, generated information sharing among staff, was suitable for both
experienced and inexperienced staff, and facilitated admission assessment (Lantta et al., 2015).
Of the nurses with a negative response to the DASA, the researchers found that the use of a
structured assessment was not always positively received, that many nurses did not believe that
the DASA instrument was better able to predict violent/aggressive behaviors, and that they
preferred to rely on their own clinical judgment (Lantta et al., 2015).
Overall, the DASA was chosen by the SAUPC Seclusion & Restraint Committee because
it can be completed quickly (Dumais et al., 2012; Griffith, Daffern, & Godber, 2013; Lantta et
al., 2015; Vojt, Marshall, & Thompson, 2010), has been found to have a moderate to strong
predictive ability (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Chu, Thomas, Ogloff, &
Daffern, 2011; Ogloff & Daffern, 2006), does not require verbal patient interview, has no
restrictive user requirements, is used in an 24-hour context, was found useful in similar settings
(Dumais et al., 2009; Lantta et al., 2015), and encourages the initiation of preventive measures to
decrease the potential of patient violence/aggression (Barry-Walsh, Daffern, Duncan, & Ogloff
2009; Chu, Thomas, Ogloff, & Daffern, 2011; Griffith, Daffern, & Godber, 2013; Ogloff &
Daffern, 2006). In addition the SAUPC Seclusion & Restraint Committee concluded that the
DASA’s inclusion of impulsivity was crucial to assessing potential violence/aggression.
Investigative data on impulsivity and aggression suggests aggression can manifest in two forms,
“manipulative, cold, premeditated, executively complex, antisocial agression versus impulsive,
hot, executively simple aggression” (Singh, Serper, Reinharth, & Fazel, 2011, p. 910). The
SAUPC Seclusion and Restraint Committee members felt that much of the violent and
aggressive behaviors were reactive and impulsive in nature and immediately assessing for
26
impulsive behaviors was of high importance. Research indicates that aggression is impulsive,
reactive, is strongly influenced by perception and is one of the most common and difficult to
predict (Quanbeck et al, 2007; McDermott, Quanbeck, Busse, Yasso, & Scott, 2008). The intent
of the SAUPC Seclusion and Restraint Committee to implement the DASA for use by RN’s as
an assessment of patient risk for becoming violent would enhance staff (MD, NP, PA, behavioral
health techs, recovery support specialists, and crisis workers) ability to intervene and prevent
future violence, aggression, and subsequent seclusion and restraints.
Framework and Theoretical Underpinnings
Determining the usefulness of a violence assessment tool falls into the realm of quality
improvement. Improvement theory and continuous quality improvement methods were used to
guide the completion of the DNP project. Langley, Nolan, Nolan and Provost’s (2009) Model for
Improvement, which incorporates Deming’s Plan-Do-Study-Act (PDSA) cycle, was utilized as
the theoretical framework to guide this DNP project. The Model for Improvement describes four
components that underlie improvement. The first component is appreciation of a system, which
acknowledges the complex nature of the relationships (between care providers) and components
(treatments, procedures) involved in delivery of care and understanding of the dependence on
each other (Institute for Healthcare Improvement, 2016). The second component is an
understanding of variation (between hospitals, units, staffing, etc.) and how that influences
outcomes. The third component is a theory of knowledge leading to predictions about the results
of a change. The final component is psychology. For the purposes of improvement, psychology
represents the understanding of how people interact with the system and each other (Institute for
27
Healthcare Improvement, 2016). Addressing all four components in a quality improvement effort
leads to successful improvement.
The PDSA suggests a systematic approach to formulating a plan for change and
determining whether the change is an improvement in an actual work setting (Institute for
Healthcare Improvement, 2016). The model provides the ‘roadmap’ by identifying three
questions focused on the aim of the change, quantitative measurements to assess change, and
select changes, as well as the PDSA cycle to test the change and implement and spread the
change. During the planning stage, the aim or goal/purpose is determined, a theory or prediction
is formulated, measures for success are defined, and a plan made for implementing the change
(The W. Edwards Deming Institute, 2016). In the Do state, the change is implemented. In the
Study stage, outcomes are evaluated to determine the success of the change and areas for
improvement are identified. The Act stage ends the cycle, integrates what was learned from
process, and aims, methods, and original theories or predictions can be adjusted. The cycle is
then repeated if needed to further refine additional aspects of quality improvement.
The “Aim” for this DNP is to determine the nurses’ perception of the usefulness of the
DASA in the identification of potentially aggressive/violent patients. Data will be collected with
the use of questionnaires completed by nurses who participated in completing the DASA during
the SAUPC’s implementation period (Summer/Fall of 2016). Descriptive statistics and
correlational analyses to determine the relationship between responses on the items and outcome
variables were used to evaluate whether nurses’ perceived the DASA to be useful. The selected
change is based on nursing perception of the DASA’s usefulness and their desire to continue to
use the assessment.
28
METHODS
Setting
The vision of the SAUPC is “To provide high quality behavioral health care that is
person-centered, evidence-based and culturally sensitive, that expects recovery from mental
illness” (connectionsarizona.com). The facility focuses on providing access to care for everyone
(adults age 18 and older) regardless of his or her, race, color, sex, national origin, disability
religion, sexual orientation, or ability to pay. The vision incorporates the belief that psychiatric
hospitalization can be avoided with appropriate intervention, which includes collaboration with
“community partners” (e.g., police, emergency departments, jails, family, behavioral health
providers, medical providers). Effective collaborative with community partners facilitates
successful patient outcomes. In addition, if hospitalization is required, length of stay can be
shortened with aggressive, tailored and early assessment and/or intervention.
The SAUPC facility services approximately 900 patients per month 36% of who are
voluntary and 64% involuntary. The unit accepts patients 24-hours a day, 365 days a year. The
focus is on crisis observation and stabilization. A disciplinary team consisting of social workers,
behavior health specialists (BHS), unit coordinators, RN’s, PA’s, NP’s, and MD’s collaborate to
provide therapeutic support, evaluation, and treatment to the community. Patients are evaluated
and the need for further psychiatric care, whether voluntary or involuntary, is determined.
Patients who are deemed appropriate for discharge are provided appropriate community referrals.
The majority of the patient population comes from Maricopa County in Southern Arizona.
Patients access the facility on a walk-up basis, transfer from emergency rooms and hospitals, via
police, and crisis intervention. No patient is turned away.
29
The observation unit has two levels of care, which consists of 50 reclining chairs, 10 of
which are in a separate area and reserved for highly acute patients. Forty of the recliners are in a
large open area (room) with two sections; male and female. Multiple BHS staff are assigned to
areas of the room to continuously monitor, assess, and engage with patients. The size (number of
chairs) on the male or female side fluctuates based on the patient population. Along one wall,
there are several interview, quiet, and group rooms. There are individual bathrooms and showers.
The higher acuity side of the unit is also divided into two sections, male and female. BHS to
patient ratio (2 BHS to 10 patients) is increased allowing for a higher level of observation if
needed. Currently there is no set criterion for placement in this section other than provider and
charge nurse choice. Both areas are connected to the nursing/staff station, which looks onto both
sections of the observation unit. Cameras are placed throughout the facility and an emergency
alert system is in place. Staff members are also required to carry a hand held radio throughout
their shift.
SAUPCP’s Implementation of the DASA
To provide a clear background for the DNP project, the implementation of the DASA and
the process of that implementation at the SAUPC will be described. The unit and patient specific
data collected during the SAUPC implementation of the DASA will not be utilized in this
project. This study will focus on surveying nurses at the SAUPC to assess their perceived
usefulness of the DASA in a psychiatric emergency setting.
The SAUPC utilized the Institute for Healthcare Improvement PDSA Worksheet to
implement the use of the DASA in the summer/fall of 2016. The worksheet was useful in
identifying the tasks that were required to initiate the intended change and identified a task
30
completion deadline. The implementation of the DASA on the unit required the completion of
the following tasks; making copies of the DASA collection sheet, placing the DASA in the
nursing admission packet, setting up a DASA training schedule for nursing staff, and the
establishment of a start and end date for data collection. Once the plan was set in place the
prediction and measures section of the PDSA worksheet was completed.
Upon implementation of the DASA at the SAUPC, the Chief Medical Officer and the
Seclusion and Restraint committee required the DASA in every nursing assessment packet to be
completed by all nursing staff admitting patients to the facility. All nursing staff participated in a
15-minute power point training session to describe the purpose of the DASA. Handouts were
provided after the power point presentation and training session. Question and answer, with
interactive and guided completion was provided (Griffith, Daffern, & Godber, 2013). The
admission process flow to include the DASA was reviewed as well (Appendix D). Training
sessions occured 15 minutes prior to each 12-hour shift report. Nursing staff who did not attend
the training session met individually with their charge nurse, or the nursing director prior to
using the instrument. Each nursing staff member who participated in the admission process
completed the DASA instrument form.
The SAUPC is staffed 24-hours a day and 365 days a year. Each 24-hour day has a 7 am
to 7 pm shift and a 7 pm to 7 am shift. There is a front end crew (Sunday, Monday, Tuesday and
every other Wednesday) and back end crew (Thursday, Friday, Saturday, and every other
Wednesday). Six nurses are scheduled per shift. Of the six nurses, four participate in the
admission process. See Appendix E for process flow chart. Upon admission to the 24-hour unit,
the DASA was completed during the initial nursing assessment.
31
The DASA includes seven items: negative attitudes, impulsivity, irritability, verbal
threats, sensitive to perceived provocations, easily angered when requests are denied, and
unwillingness to follow directions. Each item is scored for its presence or absence upon
admission. It is recommended that a score of 0 reflects a low risk of violence, a score of 1-3
suggests that risk for violence is moderate and preventative measures should be taken, a score of
4 or 5 indicates that risk is high, and a score of 6 or 7 indicates very high risk of imminent
aggression (Ogloff & Daffern, 2006). The nurse, using judgment (based on their own knowledge
and experience), assigns a risk level of High, Moderate, or Low. The items on the DASA are all
independently moderately related to aggression within the following 24-hours with an area under
the curve value of AUC > 0.70 (Ogloff & Daffern, 2006). Once the nurses completed the DASA
and assigned a risk level, they used critical thinking and clinical judgment to further determine
the need for intervention. The next section on the DASA form was completed to report the type/s
of interventions used, record whether or not the patient became violent, report if the patient
required or did not require seclusion and/or restraint, and describe the behavior that lead to the
seclusion and/or restraint. Per request from the S&R committee, the DASA form also recorded
the patient placement on the Observation Unit (OBS 1) or the higher acuity (OBS 2).
Nurses completed the DASA collection form as part of the admission packet when each
patient was admitted to the facility. The nurse wrote their name on the DASA collection form
and attached a patient admission sticker. Upon completion, the DASA collection form was
removed from the nursing assessment and placed in the identified/labeled folder designated for
all DASA collection forms. The time between completion of the form and an episode of violence
was reviewed. When the data was entered into Microsoft Excel, all patient indentifiers were
32
eliminated to ensure privacy and confidentiality. For data entry purposes, the DASA collection
forms were organized by nurse name. An Excel sheet was created for each nurse to capture the
elements of the DASA, interventions used, occurrence of and seclusion/and or restraint event,
and behavior that led to the event. Final results were not connected to any specific nurse. Only
information from the DASA assessment forms were entered into the excel data set. The
occurrence and time of a seclusion and/or restraint episode was subsequently obtained from
seclusion and restraint data managed by the Director of Nursing. The monthly seclusion and
restraint data was also obtained from the Director of Nursing records and as the final report
reveals results only, no patient information is attached to this information. The DASA data forms
were stored in designated boxes in the cabinet behind the admission coordinators desk. Forms
were then removed, divided by nurse, numbered and then entered by Phoenix Facility designated
staff. The final resting place for the physical DASA data collection sheets was in the locked
office of the Quality Assurance Officer. Data was collected starting on June 15, 2016 through
October 15, 2016. Nurses completed approximately 4000 DASA data collection sheets. A post
implementation questionnaire was distributed to all nurses who completed the DASA and was
the basis of the DNP project. The Quality Assurance Officer of the SAUPC analyzed the data
from the DASA collection sheet. Before making any final decisions about the DASA, the
Seclusion and Restraint Committee reviewed the results of the current DNP quality improvement
project.
Current DNP Project – Planning Phase
Prior to developing the plan in the PDSA cycle, the purpose or aim must be determined
(Institute for Healthcare Improvement, 2016). The purpose of this project is to determine the
33
nurses’ perception of the usefulness of the DASA during the admission process (point of first
patient contact) to identify potentially aggressive/violent behaviors. In doing so, it was
hypothesized that the nurses would endorse perceiving an increased awareness of these behaviors
and would report that timely and appropriate interventions were used to prevent
aggressive/violent behavioral acts. The study purpose is also consistent with the Institute of
Medicine’s (IOM) six main “Aims of Improvement” which indicate that an improvement be safe,
effective, patient centered, timely, efficient, and equitable (Institute for Healthcare Improvement,
2016). The study questions guiding the DNP project provided specific, measureable components
that were analyzed, and results obtained to determine nurses’ perception of the usefulness of the
DASA.
In order to enact the plan, an effective team that includes members such as system
leadership (administrators), technical expertise (person who knows the subject and is an expert in
methods, measurement tools and clinical implications), and day-to-day leadership (physicians,
NP, PA, nurses, and frontline workers), who are familiar with the processes involved in the
change or improvement was formed (Institute for Healthcare Improvement, 2016). As the S&R
committee is integral to the process of ensuring patient and staff safety, has members from all
levels of the system, and has the ability to implement changes in direct patient care, the S&R
team was determined to be an effective team to lead the PDSA with the goal of implementing the
DASA at the SAUPC. The principal investigator of the DNP project is a practicing Psychiatric
Nurse Practitioner and an employee at the SAUPC. She provided expertise and leadership to the
S&R committee in the PDSA process. The principal investigator presented the additional aim for
her DNP project focusing on the nurse perceptions of the usefulness of the DASA. She received
34
full support for the above-described project. For the purpose of the DNP project, the principal
investigator served as the clinical leader, day-to-day leader, and technical expert. The sponsor of
the S&R team is the chief medical officer.
All team members were fully invested in the proposed DNP project and determined that it
aligned well with the facility’s mission to provide evidenced based care. Leaders of each
discipline of the interdisciplinary team (members of the committee) were engaged in providing
feedback about the purpose and aim of the project.
Recruitment of RN Study Participants
Although each nurse was required to complete the DASA instrument form, only those
nurses who wished to participate in the DNP project participated in completion of the Post
DASA Implementation Questionnaire (PDIQ). All nursing staff were made aware that they were
not required to participate in the completion of the Post DASA Implementation Questionnaire
and that participation had no effect on their job status. A disclosure statement was provided with
each study questionnaire (Appendix D).
Informed Consent
Each nurse completing the DASA at the SAUPC was given a PDIQ packet. The packet
consisted of a disclosure statement (Appendix A) informing them of their rights as a participant
in the study, a demographics page (Appendix B) requesting information about gender, degree,
years of experience, and years at the facility, as well as the questionnaire itself (Appendix C). By
completing and turning in the questionnaire, the nurse provided consent.
35
Participant Privacy and Confidentiality of Data
Once IRB approval was attained, the PDIQ packet was distributed to nurses who
completed the DASA. In addition, information regarding the nurses, years of experience as a
nurse, nurse gender, time as a nurse in psychiatry, amount of time working for the facility, and
level of education (associates vs. bachelors) was obtained for sample description as well as to
determine relationships between the demographics and the five study questions which address
the association of factors on nursing perception (Appendix B). The principal investigator was the
only person to collect and enter data related to the PDIQ. The collected PDIQ packets were
stored in a file managed by the principal investigator and placed in the Director of Nursing’s
locked office.
Ethical Issues
The DNP project received approval from the University of Arizona’s Human Subjects
Protection Program and the Institutional Review Board (IRB). A letter approving the description
of the SAUPC implementation of the DASA was obtained and filed with University of Arizona’s
IRB. This is a quality improvement project and the Determination of Human Subjects form was
completed and submitted to the IRB. As the DASA is copyrighted, the manual for administration
and scoring of the DASA was purchased from the Centre for Forensic Behavioral Science, prior
to the Phoenix Facility starting their implementation. The purchase of the manual provides
permission from the authors to use the instrument.
Measures
Each nurse who completed the DASA assessment was asked to complete a PDIQ with
questions matching the initial study questions. The questions on the PIDQ are directly related to
36
the aim of the DNP project. Only nurse participants who had completed the DASA during the
implementation of the DASA at the SAUPC were invited to participate in this study.
Method of Evaluation
Post DASA Implementation Questionnaires completed by nurses were evaluated
(Appendix C). There are five survey items each measured on a five-point Likert scale ranging
from “Strongly Disagree” (1) to “Strongly Agree” (5) which describe and measure nurses’
experience using the DASA. A demographic questionnaire explored the association of static
nursing factors (gender, years of experience, level of education, years at the facility), on nurses’
perception of the usefulness of the DASA.
Analysis
The PDIQ data for the DNP project, including participant demographic information was
entered into SPSS based on questionnaire number. Participant demographic data was included to
provide a clear description of the participants (Appendix B). Once the study questionnaire was
completed and entered into SPSS, descriptive statistics, specifically central tendencies and
percentages, were used. In addition, correlational analyses were completed to determine the
relationship between responses on the items and outcome variables of interest.
Planning the Intervention – “Plan” of PDSA
The methods section reflects the ‘Plan’ section of the PDSA and outlines the step-by-step
process by which the nurses’ perception of the usefulness of the DASA was measured.
This investigator hypothesized that nurses would indicate that the DASA is useful in
identifying violent/aggressive behaviors, would report an increased awareness of
violent/aggressive behaviors, and report that using the DASA triggered them to implement an
37
intervention to decrease aggressive/violent patient behaviors. In addition, it was hypothesized
that nurses would report a decrease in the incidence seclusion/restraint in the SAUPC. The ‘Do”
section of the PDSA is reflected by a step by step discussion of all activities involved in the
evaluation of the nurses’ perception of the usefulness of the DASA via the PDIQ. A discussion
of the outcomes of the PDIQ and how they compared with the initial hypothesis is reflected in
the ‘Study’ section of the PDSA. The ‘Act’ section of the PDSA is reflected in the SAUPC’s
decision to recommend the addition of the DASA to the nursing initial assessment. In
conclusion, the results of the questionnaire analysis are presented alongside limitations of this
project, future directions for quality improvement, research in the emergency psychiatric setting,
and implications for nursing practice
RESULTS
Analysis of the PDIQ, “Study”
Descriptive Statistics
During the four-month SAUPC implementation of the DASA, a total of 25 nurses
completed the DASA during their initial admission assessment. Secondary to some of the
SAUPC study participants being pool, agency, or regular staff leaving employment, a total of 20
registered nurses participated in this study representing an 80% response rate. Among the 20
study participants, nine (45%) were female and 11 (55%) were male. The distribution of level of
education was five (25%) Associate Degree Nurse (AN); 12 (60%) Bachelor of Science in
Nursing (BSN), and three (15%) Master of Science in Nursing (MSN). The average (and
standard deviation) number of years of experience as a registered nurse was 8.72 (8.18) and the
range was 0.80 to 30.00. The DASA Usefulness (USE) score was computed as the average of
38
questions 1, 2, 3, 4 and 6 from the study survey. Cronbach’s alpha for the USE score was 0.98,
indicating excellent reliability. The average (and standard deviation) USE score was 4.13 (1.02)
and the range was 1.00 to 5.00. Considering the average was well above the midpoint of 3.00, on
average the study participants considered the DASA to be very useful.
Research Questions
Research question 1. Do nurses perceive the DASA to be effective in identifying
potentially aggressive/violent patient’s behaviors?
Table 1 shows the frequency distribution of the level of agreement with the statement
“The DASA was effective in identifying potentially aggressive/violent behaviors in patients”.
Considering 18 (90%) of the study participants either agreed or strongly agreed with the
statement, the answer to the research question is, the majority of nurses perceive the DASA to be
effective in identifying potentially aggressive/violent patient’s behaviors.
TABLE 1. Frequency Table of Level of Agreement with the Statement, “The DASA was effective in identifying potentially aggressive/violent behaviors in patients.”
Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Neutral 1 5.0 5.0 10.0 Agree 5 25.0 25.0 35.0 Strongly Agree 13 65.0 65.0 100.0 Total 20 100.0 100.0
Research question 2. Do nurses perceive the use of the DASA increases their awareness
of the behaviors (negative attitudes, impulsivity, irritability, verbal threats, sensitive to perceived
provocation, easily angered when requests are denied, unwillingness to follow directions) that
indicate a patient’s increased risk for aggressive/violent behavior?
39
Table 2 shows the frequency distribution of the level of agreement with the statement
“The DASA increased my awareness of behaviors that indicate a patient may become
violent/aggressive”. Considering 17 (85%) of the study participants either agreed or strongly
agreed with the statement, the answer to the research question is, the majority of nurses perceive
the DASA increases the nurse’s awareness of the behaviors (negative attitudes, impulsivity,
irritability, verbal threats, sensitive to perceived provocation, easily angered when requests are
denied, unwillingness to follow directions) that indicate a patient’s increased risk for
aggressive/violent behavior.
TABLE 2. Frequency Table of Level of Agreement with the Statement, “The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.”
Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Disagree 1 5.0 5.0 10.0 Neutral 1 5.0 5.0 15.0 Agree 9 45.0 45.0 60.0 Strongly Agree 8 40.0 40.0 100.0 Total 20 100.0 100.0
Research question 3. For patients that nurses perceive are at risk of violent/aggressive
behaviors, does the DASA trigger an initiation of an intervention by the nurse?
Table 3 shows the frequency distribution of the level of agreement with the statement
“The DASA triggered me to initiate an intervention to prevent patient escalation to further
violent/aggressive behaviors.” Considering 17 (85%) of the study participants either agreed or
strongly agreed with the statement, the answer to the research question is, the vast majority of
nurses perceive that for patients that nurses perceive are at risk of violent/aggressive behaviors,
the DASA triggers an initiation of an intervention by the nurse.
40
TABLE 3. Frequency Table of Level of Agreement with the Statement, “The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.”
Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Disagree 1 5.0 5.0 10.0 Neutral 1 5.0 5.0 15.0 Agree 9 45.0 45.0 60.0 Strongly Agree 8 40.0 40.0 100.0 Total 20 100.0 100.0
Research question 4. Do nurses perceive a decrease in seclusion and restraint episodes
as a result of the use of the DASA?
Table 4 shows the frequency distribution of the level of agreement with the statement “I
believe using the DASA decreased the episodes of seclusion and restraint.” Considering 15
(75%) of the study participants either agreed or strongly agreed with the statement, the answer to
the research question is, a significant majority of nurses perceive a decrease in seclusion and
restraint episodes as a result of the use of the DASA.
TABLE 4. Frequency Table of Level of Agreement with the Statement, “I believe using the DASA decreased the episodes of seclusion and restraint.”
Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Disagree 1 5.0 5.0 10.0 Neutral 3 15.0 15.0 25.0 Agree 6 30.0 30.0 55.0 Strongly Agree 9 45.0 45.0 100.0 Total 20 100.0 100.0
Research question 5. Is gender, years of experience as a nurse, level of education,
and/or years at the facility, associated with the nurses’ perception of the usefulness of the
DASA?
41
Gender. The natural choice for comparing a continuous variable (e.g., DASA Usefulness
score) between two independent groups (e.g., males and females) is the independent samples t-
test. Prior to conducting the analysis, the assumptions for the independent samples t-test were
evaluated. The first assumption is that there are no outliers in the continuous variable (e.g., USE)
for either group (e.g., males versus females). This assumption was evaluated by inspection of
box plots of the USE score, separately for males and females. The second assumption is that the
continuous variable has a normal distribution for both groups. This assumption was evaluated by
inspection of histograms of the continuous variable, separately for each group. The third
assumption, homogeneity of variance, is that the variance of the continuous variable is the same
for both groups. This assumption was evaluated using the Levene’s test Results of the
assumption testing indicated both the normality and constant variance assumptions were
violated. Consequently, the independent samples t-test was inappropriate. Therefore, the non-
parametric equivalent of the independent samples t-test, the Mann-Whitney U test was used to
compare the median USE score between males and females. The Mann-Whitney U test was
appropriate because this test does not require normal distributions or homogeneity of variance.
Figure 1 is a box plot of the USE score, separately for males and females. The median USE score
for females (5.00) and males (4.2) was not statistically significantly different, U = 47.00; z = -
0.20; p = 0.85. In summary, this study did not show any evidence to suggest the perceived
usefulness of the DASA is different for male and female RN’s.
42
FIGURE 1. Box Plot of the DASA Usefulness Score by Gender. (The median Usefulness score, 5.00 (females) versus 4.20 (males) not statistically significantly different. Mann-Whitney U test: U = 47.00; z = -0.20; p = 0.85.)
Years of Experience as an RN. The natural choice for comparing two continuous variables
(e.g., USE versus years of experience as an RN) is the Pearson’s correlation coefficient. The
assumptions for Pearson’s correlation were evaluated prior to conducting the analysis. The
assumption that there are no extreme outliers was evaluated by inspection of box plots for the
two variables. The assumption that the two variables have a normal distribution was evaluated by
inspection of histograms separately for each variable. The linear relationship and homogeneity of
variance assumptions were evaluated by way of inspection of a scatter plot between the two
43
variables. The results of these evaluations indicated both the normality and linearity assumptions
were violated. Therefore, the Pearson’s correlation statistic was inappropriate. Consequently, the
non-parametric equivalent of the Pearson’s correlation statistic, Spearman’s rho was used
instead. Spearman’s rho was appropriate because it does not require normal distributions or
linear relationships. The results showed there was not a statistically significant correlation
between USE and years of experience as an RN, rs(18) = -0.35; p = 0.13. It was concluded that
there is no relationship between the perceived usefulness of the DASA and years of experience
as an RN.
Level of education. The natural choice for comparing a continuous variable (e.g., DASA
Usefulness score) between three or more independent groups (e.g., levels of education) is a one-
way analysis of variance (ANOVA). Analysis of variance requires the same assumptions as the
independent samples t-test. As discussed above, the assumptions for the independent samples t-
test were not satisfied and therefore, the assumptions for ANOVA were also not satisfied.
Consequently, ANOVA was inappropriate for evaluating the relationship between USE and level
of education. Therefore, the non-parametric equivalent of the ANOVA, the Kruskal-Wallis test
was used. The Kruskal-Wallis test was appropriate because this test does not require normal
distributions or homogeneity of variance. Figure 2 is a box plot of the USE score, separately for
each level of education AN (n = 5), BSN (n = 12), and MSN (n = 3). The median USE score for
AN (4.60), BSN (4.30), and MSN (4.20) was not statistically significantly different, X2(2) =
0.19; p = 0.91. In summary, this study did not show any evidence to suggest the perceived
usefulness of the DASA is different for RN’s with different levels of education.
44
FIGURE 2. Box Plot of the DASA Usefulness Score by Level of Education.
Years at SAUPC. As discussed above for the comparison of USE versus years of
experience as an RN, the natural choice for comparing two continuous variables (e.g., USE
versus years at UPC) is the Pearson’s correlation coefficient. However, as discussed previously,
the normality assumption for the USE score was violated. Therefore, Pearson’s correlation
statistic was inappropriate and Spearman’s rho was used instead. The results showed there was
not a statistically significant correlation between USE and years at UPC, rs(18) = 0.30; p = 0.20.
45
It was concluded that there is no relationship between the perceived usefulness of the DASA and
years at UPC.
Research question 6. Do nurses want to continue to use the DASA as a violence
assessment tool in the psychiatric emergency room setting?
Table 5 shows the frequency distribution of the level of agreement with the statement “I
would like to continue to use the DASA as a violence risk assessment tool.” Considering 14
(70%) of the study participants either agreed or strongly agreed with the statement, the answer to
the research question is, a significant majority of nurses want to continue to use the DASA as a
violence assessment tool in the psychiatric emergency room setting.
TABLE 5. Frequency Table of Level of Agreement with the Statement, “I would like to continue to use the DASA as a violence risk assessment tool.”
Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Neutral 5 25.0 25.0 30.0 Agree 7 35.0 35.0 65.0 Strongly Agree 7 35.0 35.0 100.0 Total 20 100.0 100.0
DISCUSSION
PDSA “Act”
Although studies specific to the use of the DASA queried nursing opinion about their use
and satisfaction with the scale (Dumais et al. 2012, Laffern et al. 2015, Lantta et al. 2015), there
are no known studies that focus solely on nursing perception and usefulness. Results from the
statistical analysis of the PIDQ supports the hypothesis that, of the nurses completing the PIDQ,
(USE) score of 4.12 on the Likert scale 1-5, did find the DASA useful for identifying potentially
violent and aggressive patients upon admission to the SAUPC and would like to continue to use
46
the DASA in their nursing assessment. These results are consistent with previous findings
indicating that nurse’s response to using the DASA were mostly positive (Dumais et al., 2012,
Laffern et al., 2015). Comments written in the suggestions portion of the PIDQ describe the
DASA as a “simple and effective way to quantify risk,” and “It identified most of the people who
had problems before acting out on the unit,” and “early intervention increased safety for patients
and staff.” The comments by the nurses are consistent with previous findings in which nurses
reported that the DASA, provided an objective assessment of patient behaviors, and encouraged
them to perform an intervention to prevent further episodes of acting out on the unit (Dumais et
al., 2012). Overall, it appears that nurses who participated in this study felt that the DASA did
increase their awareness of aggressive behaviors and encouraged pre-emptive interventions to
prevent episodes of violent behavior not only during the admission but also once on the unit.
One area not studied in the previous literature is nursing static factors such as gender,
years of experience, years at the facility, level of education and the influence these may have on
nursing perception of the DASA. No statistically significant difference was found based on years
of experience, years at the facility, or level of education in the sample. Of note, the participants
in this study produced an almost equal distribution of male (11) versus female (9) nurses to
compare results across gender. Statistically no difference was found for gender related to the
perception of the DASA’s usefulness in the SAUPC setting. This finding is consistent with the
results in a study conducted in 2015 in which the gender of the person observing an aggressive
act does not appear to have an effect on the manner in which the person perceives the aggressor
or the aggressive act (Way, 2015). In a prior study by Steven-Williams (2002) when men and
women perceive an act to have the same level of aggression they do not differ in their views
47
about acceptability of a behavior. In the case of the study participants and the DASA, based on
this premise, both male and female nurses’ perception of patient behavior in relation to the seven
behavioral items on the DASA, are making equally objective reports of these behaviors and
therefore supports the lack of statistical difference between the genders in perception.
The premise of the DNP project is based on nursing perception of whether the DASA is
useful at increasing awareness of dynamic risk factors and early identification of aggressive
violent behaviors. In addition, one of the purposes of the DASA is to trigger an intervention to
decrease the likelihood that the patient will become aggressive/violent and, for the purpose of the
SAUPC implementation, decrease the use of seclusion and restraint. While completing the
PIDQ, nurses identified the most commonly used interventions when a patient exhibited the
scored behaviors in the DASA. Of the written responses received, one of the most common
interventions was medication administration. Requesting the presence of a provider (MD, NP,
PA) at the back door (of the facility where patients are dropped off) was the second most
common intervention. Due to the multidisciplinary nature of the team at the SAUPC, a
psychiatric provider is available to participate in the admission process if required and upon
request of the admitting nurse. A recent study investigated the interventions utilized by staff on
adult inpatient psychiatric unit in Finland. The intervention nurses reported using most
frequently in the study was prn medication (Kaunomaki, Jokela, Kontio, Laiho, Sailas, &
Lindberg, 2017). Of note, discussion with the psychiatrist was used only three times during the
six-month study period, as they (the psychiatrists) were overburdened by other duties therefore
leaving no remaining time to participate in preventative actions (Kaunomaki et al., 2017). The
psychiatrist’s inability to participate in prevention during the study is quite different than at the
48
SAUPC. The most likely reason for this difference is the crisis focus at the SAUPC, which
allows for provider involvement and is considered an intervention based on nursing report. The
ability of the nurse to request provider presence and assistance during the initial admission
assessment is a unique “intervention” to the SAUPC that can validate nursing assessment and
promote targeted and expedited interventions to minimize aggressive and threatening behavior
by patients. It allows for timely administration of medication, seclusion and/or restraint, if
necessary, and provider/patient interaction prior to the patient being brought into the unit milieu.
Overall, nursing responses on the PDIQ demonstrates that the DASA did encourage initiation of
preventive interventions, which further support previous research findings (Barry-Walsh et al.,
2009, Chu et al., 2011, Griffith et al. 2013, Ogloff & Daffern, 2006).
Despite completion of the DASA and identification of potentially aggressive/violent
behaviors, the SAUPC did have episodes of seclusion and restraint. Although the reduction of
seclusion and restraint was not the focus of this project, nurses’ perception of a decrease in
seclusion and/or restraint as a result of the DASA was explored. Seventy-five percent (75%) of
nurses completing the PIDQ indicated that they perceived a decrease. Of the behaviors that led to
the episodes that did occur, nurses reported that threatening violence, agitation, substance abuse,
and involuntary status were behaviors that led to an episode of seclusion and/or restraint. Of
note, the contributing factors, involuntary status (Iozzino et al., 2015, Gergieve et al., 2012),
substance abuse (Iozzino et al. 2015, Witt et al. 2013), agitation and threatening violence
(Kaltiala-Heino et al., 2003, Larue et al, 2010, Vruwink et al., 2012), reported by the nurses are
have been identified in the literature. Review of the seclusion restraint data from the SAUPC
indicates that during the time frame in which the DASA was implemented seclusion and restraint
49
rates did decrease by approximately 32% (B. Montgomery, Nurse Manager SAUPC, personal
communication, March 30, 2017). The SAUPC is currently analyzing data from their
implementation and no correlation has been made between the use of the DASA and the
decrease. It would be appropriate to speculate though, that this was a contributing factor based
on prior research indicating that violence risk assessment leads to reduced seclusion and restraint
episodes (Abderhalden et al., 2008; van de Sande et al., 2011).
The results from the DNP project were presented to the Seclusion & Restraint Committee
at the SAUPC. Due to the positive response from the nursing staff, it was determined that,
despite not having completed the analysis from the SAUPC implementation of the DASA, the
DASA would be incorporated into the initial nursing assessment. Future cycles are being
considered to include expanding the use of the DASA in nursing shift assessments. In addition,
as there is no restriction on discipline or level of education for those completing the DASA, other
disciplines, specifically the BHS, using the DASA as part of their shift assessment to better
manage and monitor patient behavior, is being contemplated. Exploration the use of the DASA
as a component of admission criteria for the higher acuity side of the observation unit at the
SAUPC, is under consideration as well.
Strengths and Limitations
Strengths of this DNP project are reflected in the strong support provided by the facility
and management team. Nurses as well as the interdisciplinary team as a whole had a strong buy
in to the implementation of the project and a vested interest in its success. The use of the PDSA
provided a clear roadmap and common goal for the facility’s desire to utilize evidenced based
tools to improve violence assessment and decrease seclusion and restraint rates. This study, led
50
by an experienced/practicing Psychiatric NP with an abundance of experience, has provided
insights and nuances into the improvement of practice and patient outcomes in a highly
specialized psychiatric practice setting. The project offers the first of its kind on nurses’
perceptions on the use of the DASA in the psychiatric emergency room setting. The project is
specifically relevant to clinicians in emergent psychiatric healthcare settings and provides critical
elements to guide and promote practice change and transformation thereby, improving patient
outcomes and enhancing quality healthcare delivery. It provides evidence and process based
quality improvement guidelines to be used by practicing healthcare providers for violence risk
assessment and empowers the behavioral health team to optimize their delivery of care in this
setting. Finally, this project has broad impact as it benefits patients, staff, and the healthcare
system and could potentially transform healthcare on a wider level.
There are a number of limitations that should be noted in this study. First, the DNP
project was completed in a very specialized setting, a psychiatric crisis facility, and therefore
may not be generalizable to other psychiatric settings. The sample size (20 participants) is very
small therefore; the negative or null findings may be related to a small sample size to detect a
relationship if one exists. Methodological quality of the design of a study is also an important
consideration and in the case of this DNP project, a limitation. It is accepted that the higher the
level of evidence, the better the recommendation and applicability to patient care (Johns Hopkins
Medicine, n.d.). Using the Johns Hopkins Evidence Level and Quality guide, this DNP project
falls into the non-research Level 5 B (Good quality) category of evidence based practice (Johns
Hopkins Medicine, n.d.). Finally, throughout the SAUPC implementation process, the nursing
staff was very enthusiastic about the use of the DASA. Many expressed a desire to participate in
51
the DNP project and were invested in the success of this writer. This investment may contribute
some bias, despite the completion of the PIDQ being anonymous.
CONCLUSIONS
The results of this DNP project demonstrate that nurses at the SAUPC perceive the
DASA to be a useful addition to their admission assessment. Overall nursing response was
positive and the SAUPC seclusion and restraint committee decided to recommend incorporation
of the DASA into the initial nursing admission assessment. Future research to validate the DASA
in the emergency psychiatric setting should be explored. Alternative interventions to decrease
aggressive and violent behaviors during admission that do not rely so heavily on medications
and/or seclusion and restraint should be considered. Nursing perceptions should continue to be
included in research design. Exploration of other disciplines incorporating the DASA into their
shift assessment would be beneficial in further validation and widespread use of this quick,
simple and effective instrument.
Advanced practice nurses are in a position today to effect change in the daily practice of
nursing. Disseminating and implementing nursing knowledge to use in practice are part of the
eight DNP Essentials that are the cornerstone of practicing at the doctoral level (AACN, 2006).
Using a quality improvement theory practice model (Model for Improvement and the PDSA) this
DNP project demonstrates the identification of problem (SAUPC’s lack of a evidence based
assessment), research on an evidenced based intervention (the DASA), the implementation of
that assessment (description of the SAUPC’s implementation), perception of the assessment by
those using it (PDIQ results and analysis), and the final outcome (overall positive response by
nurses and recommendation to include in initial nursing assessment). This DNP project has
52
generated new knowledge in a specific context, the psychiatric emergency room, and provides a
framework for replication in other similar settings where violent and aggressive patients may be
encountered. Finally, the DNP project demonstrates the ability of a nursing leader to work within
a facility to engage management and all patient care disciplines to work toward a common goal,
which effects an improvement in overall provision of care and safety.
53
APPENDIX A:
DISCLOSURE STATEMENT
54
Nurses Perception of the Usefulness of the Dynamic Assessment of Situational Aggression (DASA) in and Emergency Psychiatric Setting
Stacy Underwood, NP The purpose of this study is to determine the usefulness of the DASA in a psychiatric emergency room setting. It is hoped that by increasing awareness of behavioral risk factors (dynamic) and early identification/prediction of potentially aggressive/violent behaviors, it is hoped that staff will implement appropriate and timely interventions that will increase patient and staff safety. If you choose to take part in this study, you will be asked to complete a post data collection survey. It will take approximately 10 minutes to complete this survey. There are no foreseeable risks associated with participating in this research and you will receive no immediate benefit from your participation. Survey responses are anonymous. If you choose to participate in the study, you may discontinue participation at any time without penalty. In addition, you may skip any question that you choose not to answer. By participating, you do not give up any personal legal rights you may have as a participant in this study. An Institutional Review Board responsible for human subjects’ research at The University of Arizona reviewed this research project and found it to be acceptable, according to applicable state and federal regulations and University policies designed to protect the rights and welfare of participants in research. For questions about your rights as a participant in this study or to discuss other study-related concerns or complaints with someone who is not part of the research team, you may contact the Human Subjects Protection Program at 520-626-6721 or online at http://rgw.arizona.edu/compliance/human-subjects-protection-program. For questions, concerns, or complaints about the study, you may call Stacy Underwood, NP, at (917) 848-7929 or mailto:[email protected]. By taking this survey you agree to have your responses used for research purposes.
55
APPENDIX B:
DEMOGRAPHIC INFORMATION
56
PARTICIPANT INFORMATION SHEET
Gender Male Female
Highest Level of Education: _______________________
Role at UPC: RN
Shift: FED FED BED BEN Pool
Years spent as an RN: _____________
Years spent as a Psychiatric RN:____________
Years at this facility: _______________
57
APPENDIX C:
POST DASA IMPLEMENTATION QUESTIONNAIRE - PDIQ
58
Post Dynamic Assessment of Situational Aggression Implementation Questionnaire – Nursing Did you utilize the DASA during your initial contact and assessment of patients during the two-week study period? YES NO 1. The DASA was effective in identifying potentially aggressive/violent behaviors in patients.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly
Agree
2. The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly
Agree
3. The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly
Agree
3a. What intervention did you find most effective for preventing further behaviors?
4. I believe using the DASA decreased the episodes of seclusion and restraint.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly
Agree
4a. For patients who experienced and episode of seclusion
and/or restraint, what, per your experience was the most common behavior?
59
5. I would like to continue to use the DASA as a violence risk assessment tool.
1 Strongly Disagree
2 Disagree
3 Neutral
4 Agree
5 Strongly
Agree
Suggestions/Comments?:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for your participation, Stacy Underwood, NP
60
APPENDIX D:
PROCESS FLOW SHEET
61
62
REFERENCES
American Association of Colleges of Nursing. (2006). Essentials of doctoral education for advanced nursing practice. Retrieved from http://www.aacn.nche.edu/dnp/Essentials.pdf
Abderhalden, C., Needham, I., Dassen, T., Hakfens, R., Haug, H., & Fischer, J. (2008). Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. British Hournal of Psychiatry, 193(1), 44-50.
Abderhalden, C., Needham, I., Dassens, T., Halfens, R., Haug, H., & Fischer, J. (2006, Apr 25). Predicting inpatient violence using and extended version of the Broset-Violence-Checklist: instrument development and clinical application. BMC Psychiatry, 6, 17.
Abderhalden, C., Needham, I., Miserez, B., Almvik, R., Dassen, T., Haug, H., & Fischer, J. (2004, Aug). Predicting inpatient violence in acute psychiatric wards using the Broset-Violence-Checklist: a multicenter prospective cohort study. Journal of Psychiatric Mental Health Nursing, 11(4), 422-427.
Allnut, S., O'Driscoll, C., Ogloff, J., Daffern, M., & Adams, J. (2010). Clinical Risk Assessment & Management: A Practical Manual for Mental Health Clinicians. Syndey, NSW: Justice Health.
Almvic, R. & Woods, P. (1999, Jan). Predicting inpatient violence using the Broset Violence Checklist (BVC). International Journal of Psychiatric Nursing Research, 4(3), 498-505.
Almvik, R., Woods, P., & Rasmussen, K. (2007). Assessing risk for imminent violence in the elderly: the Broset Violence Checklist. International Journal of Geriatric Psychiatry, 22, 862-862.
Almvik, R., Woods, R., & Rasmussen, K. (2000). The Broset Violence Checklist: sensitivity, specificity, and interrater reliability. Journal of Interpersonal Violence, 15, 1284-1296.
Barry-Walsh, J., Daffern, M., Duncan, S., & Ogloff, J. (2009). The prediction of imminent aggression in patient with mental illness and/or intellectual disability using the Dynamic Appraisal of Situational Aggression instrument. Australian Psychiatry, 17(6), 493-496.
Binder, R. & McNiel, D. (1999). Contemporary practices in managing acutely violent patients in 20 psychiatric emergency rooms. Psychiatric Services, 50(12), 1553-1554.
Bjorkdahl, A., Olsson, D., & Palmstiema, T. (2006, Mar). Nurses' short-term prediction of violence in acute psychiatric intensive care. Acta Psychiatry Scand., 113(3), 224-229.
63
Bjorkly, S., Harvig, P., Heggen, F., Brauer, H., & Moger, T. (2009). Development of a brief screen for violence risk (V-Risk_10) in acute and general psychiatry: An introduction with emphasis on findings from a naturalistic test of terrater reliability. European Psychiatry, 24, 388-394.
Bowers, L., Stewart, D., Papadopoulos, C., Dack, C., Ross, J., Khanom, H., & Jeffery, D. (2011, May). Inpatient violence and aggression: a literature review. Institute of Psychiatry Kings College London, Section of Mental Health Nursing. London: Institue of Psychiatry Kings College. Retrieved from http://www.kcl.ac.uk/ioppn/depts/hspr/research/ciemh/mhn/projects/litreview/LitRevAgg.pdf
Centers for Medicare & Medicare Services. (2012, May 14). HCAHPS fact sheet.
Chan, O. & Chow, K. (2014). Assessment and determinants of aggression in a forensic psychiatric institution in Hong Kong, China. Psychiatry Research, 220, 623-630.
Chapman, R. P. (2009). Predicting patient aggression against nurses in all hospital areas. British Journal of Nursing, 18(8), 476-483.
Chu, C., Thomas, S., Ogloff, J., & Daffern, M. (2011, August). The short-term to medium-term predictive accuracy of static and dynamic risk assessment measures in a secure forensic hospital. Assessment, XX(X), 1-13.
Clarke, D., Brown, A., & Griffith, P. (2010). The Broset Violence Checklist: clinical utility in a secure psychiatric intensive care setting. Journal of Psycniatric and Mental Health Nursing, 17, 614-620.
Crisis Intervention Prevention. (2016). Retrieved March 02, 2016, from Crisis Intervention Prevention (CPI): www.crisisprevention.com/About-CPI
Daniel, C., Gerdtz, M., Elsom, S., Knott, J., Prematunga, E., & Virtue, E. (2015). Feasibility and need for violence risk screening at triage: an exploration of clinical process and public perceptions in on Austrialian emergency department. Emergency Medicine Journal, 32, 457-462.
Downey, L., Zun, L., & Gonzalez, S. (2007). Frequency of alternative to restraints and seclusion and use of agitation reduction techniques in the emergency room. General Hospital Psychiatry, 29(5), 470-474.
Dumais, A., Larue, C., Michaud, C., & Goulet, M.-H. (2012). Predictive validity and psychiatric nursing staff's perception of the clinical usesfulness of the french version of the Dynamic Appraisal of Situational Aggression. Issues in Mental Health Nursing, 33, 670-675.
64
Eccleston, L. & Ward, T. (2004). Assement of dangerousness and criminal responsibility. In W.O. Levensky, Handbook of Forensic Psychology (pp. 85-104). London: Elsevier.
Georgieva, I., Mulder, C., & Noorthoorn, E. (2013, Jan 30). Reducing seclusion through involuntary medication: a randomized clinical trial. Psychiatry Res., 205(1-2), 48-53.
Georgieva, I., Vessenlinov, E., & Mulder, C. (2012, Nov). Early detection of risk factors for seclusion and restraint: a prospective study. Early Interventional Psychiatry, 6(4), 415-22.
Griffith, J., Daffern, M., & Godber, T. (2013). Examination of the predictive validity of the Dynamic Appraisal of Situationa Aggression in two mental health units. Journal of Mental Health Nursing, 22, 485-492.
Grol, R., Bosch, M., Hulscher, M., Eccles, M., & Wensing, M. (2007). Planning and Studying improvement in patient care: The use of theoretical perspectives. The Milbank Quarterly, 85(1), 93-138.
Harrel, E. (2011). Workplace violence 1993-2009. Bureau of Justice Statistics. Washington DC: U.S. Department of Justice Office of Justice Programs.
Huckshorn, K. (2014, Nov). Reflections on the use of restraint and seclusion: a 10-year update. Psychosocial Nurse Mental Health Services, 52(11), 3-3.
Ideker, K. T.-M. (2011, February 8). A confrimatory study of violence risk assessment toll (M55) and demographic predictors of patient violence. Journal of Advanced Nursing, 2455-2462.
Institute for Healthcare Improvement. (2016, February). Across the chasm: six aims for changing the healthcare system. Retrieved January 29, 2016 from Institute for Healthcare Improvement, www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingtheHealthCareSystem.aspx
Institute for Healthcare Improvement. (2016). How to improve. Retrieved January 29, 2016, from Institute for Healthcare Improvement: www.ihi.org/resources/Pages/Howtoimprove/ScienceofimprovementHowtoImprove.aspx
Iozzino, L., Ferrari, C., Large, M., Nielssen, O., & de Girolamo, G. (2015, June 10). Prevalence and risk factors of violence by psychiatric acute inpatients: a systematic review and meta-analysis. PLOS ONE, 1-18.
65
Johns Hopkins Medicine. (n.d.). Johns Hopkins nursing evidence based practice: Appendix C: Evidence level and quality guide. Retrieved from http://www.hopkinsmedicine.org/evidence-basedpractice/_docs/appendix_c_level_quality_guide.pdf
Kaltiala-Heino, R., Tuohimaki, C., Korkeila, J., & Lehtinen, V. (2003, Mar-Apr). Reasons for using seclusion and restraint in psychiatric inpatient care. Internaltion Journal of Law Psychiatry, 26(2), 139-149.
Kaunomaki, J., Jokela, M., Kontio, R., Laiho, T., Sailas, E., Lindberg, N. (2017). Interventions following high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward. BMC Health Serv Res, 17(1) 26,
Keski-Valkama, A., Sailas, E., Eronen, M., Koivisto, A., Lonnqvust, J., & Kaltiala-Heino, R. (2010, Apr). The reasons for using restraint and seclusion in psychiatric inpatient care: a nationwide 15-year study. Nordic Journal of Psychiatry, 64(2), 136-144.
Kling, R., Corbiere, R., Morrison, G., Craib, K., Yassi, A., Sidebottom, C., . . . Saunders, S. (2006, Nov). Use of a violence risk assessment tool in an acute care hospital: effectiveness in identifying violent patients. AAOHN J., 54(11), 481-487.
Knox, D. & Holloman, G. (2012, Feb). Use and avoidance of seclusion and restraint: consensus statement from the Americanfor emergency psychiatry project Beta seclusion and restraint workgroup. West Journal of Emergency Medicine, Feb(1), 35-40.
Langley, G., Nolan , K., Nolan, T., Norman, C., & Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition ed.). San Francisco: Jossey-Bass Publishers.
Lantta, T., Daffern, M., Kontio, R., & Valimaki, M. (2015, July/August). Implementing the Dynamic Appraisal of Situational Aggression in mental health units. Clinical Nurse Specialist, 230-243.
Larue, C., Dumais, A., Drapeau, A., Menard, G., & Goulet, M. (2010, Dec). Nursing practices recorded in reports of episodes of seclusion. Issues in Mental Health Nursing, 31(12), 785-792.
LeBel, J., Duxbury, J., Putkonen, A., Sprague, T., Rae, C., & Sharpe, J. (2014, Nov). Multinational experiences in reducing and preventing the use of seclusion and restraint. Journal of Psychosocial Nursing Mental Health Services, 52(11), 22-29.
McDermott, B. (2008). Examining the role of static and dynamic risk factors in prediction of inpatient violence: variable and person-focused analysis. Law and Human Behavior, 32(4), 325-338.
66
McDermott, B. A. (2014). Assessment of aggression in inpatient settings. CNS Spectrum, 19, 425-431.
McDermott, B., Quanbeck, C., Busse, D., Yasso, K., & Scott, C. (2008). The accuracy of risk assessment instruments in the prediction of impulsive versus predatory aggression. Law and Human Behavior, 26(6), 759-777.
McNiel, D., Gregory, A., & Lam, J. (2003). Utility of decision support tools for assessing acute risk for violence. Journal of Consulting and clinical Psychology, 71, 945-953.
Moran, A., Cocoman, A., Scott, P., Matthews, A., Staniuliene, V., & Valimaki, M. (2009, Sep). Restraint and seclusion; a distressing treatment option? Journal of Psychiatric Mental Health Nursing, 16(7), 599-605.
National Institute for Health and Care Excellence. (2015, May). Violence and aggression: short-term management in mental health, health and community settings. Retrieved from National Institue for Health and Care Excellence: https://www.nice.org.uk/guidance/ng10/chapter/introduction
Ogloff, J. & Daffern, M. (2006). The Dynamic Appraisal of Situational Aggression: An instrument to assess risk for imminent aggression in psychiatric inpatients. Behavioral Sciences and the Law, 24, 799-813.
Privitera, M., Weisman, R., Cerulli, C., Tu, X., & Groman, A. (2005). Violence toward mental health staff and safety in the work environment. Occupational Medicine, 55, 480-486.
Quanbeck, C., McDermott, B., Scott, G. et al. (2007). Categorization of assaultive acts committed by chronically aggressive state hospital patients. Psychiatric Services, 58(4), 521-528.
Roberts, D., Crompton, D., Milligen, E., & Groves, A. (2009). Reflections on the use of seclusion: in an acute mental health facility. Journal of Psychosocial Nursing Mental Health Services, 47(10), 25-31.
Sands, N. (2007). An ABC approach to assessing the risk of violence at triage. Australasian Emergency Nursing Journal, 10, 107-109.
Sands, N., Elsom, S., Gerdtz, M., & Khaw, D. (2012). Mental health-related risk factors for violence: using the evidence to guide mental health triage decision making. Journal of Psychiatric and Mental Health Nursing, 19, 690-701.
Singh, J., Serper, M., Reinharth, J., & Fazel, S. (2011). Structured assessment of violence risk in schizophrenia and other psychiatric disorders: a systematic review of the validity, reliability, and item content of 10 available instruments. Schizophrenia Bulletin, 37(5), 899-912.
67
Steinert, T., Bergbauer, G., Schmid, P., & Gebhardt, R. (2007, Hun). Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates. Journal of Nervous Mental Disorders, 195(6), 492-496.
Stewart-Williams, S. (2002). Generd, the perception of aggression and the overestimation of gender bias. Sex Roles, 46 (5/6), 177-189.
Taylor, K., Mammen, K., Barnett, S., Hayat, M., Dosreis, S., & Gross, D. (2012, May-Jun). Characteristics of patients with histories of multiple episodes of seclusion and restraint events during a single psychiatric hospitalization. Jounal of American Psychiatric Nurses Association, 18(3), 159-165.
The W. Edwards Deming Institute. (2016). Deming.org. Retrieved January 25, 2016, from https://www.deming.org/theman/theories/pdsacycle
United States General Accounting Office (GAO). (1999, Sept 7). Improprer restraint or seclusion uses places people at risk. Retrieved Aug 10, 2016, from U.S. Government Accoutability Office: www.gao.gov/products/HEHS-99-176
Vaaler, A., Iversen, V., Morken, G. et al. (2011). Short-term prediction of threatening and violent behavior in an acute psychiatric intensive care unit based on patient and environment characteristics. BMC Psychiatry, 11, 44.
van de Sande, R., Nijman, H., Noorthoorn, E. et al. (2011). Aggression and seclusion and acute psychiatric wards: effect of short-term risk assessment. British Journal of Psychiatry, 199(6), 473-478.
Vojt, G., Marshall, I., & Thompson, L. (2010). The assessment of imminent inpatient aggression: A validation study of the DASA in Scotland. Journal of of Forensic Psychiatry & Psychology, 1, 1-12.
Vollmer, T. E. (2011, Spring). The association for behavior analysis international position statement on restratin and seclusion. Behaviorl Analysis, 34(1), 103-110.
Wale, J., Belkin, G., & Moon, R. (2011). Reducing the use of seclusion and restrain in psychiatric emergency and adult in-patient services - Improving patient centered care. The Permanente Journal, 15(2), 57-62.
Way, J. (2015). Effects of gender and aggression type on perceptions of aggressive behaviors at work. http://scholarcommons.usf.edu/etd/5608.
Wieman, D., Camacho-Gonsalves, T., Huckshorn, K., & Leff, S. (2014, Mar 1). Multisite studey of an evidence-based practice to reduce seclusion and restraint in psychiatric inpatient facilities. Psychiatric Services, 65(3), 345-351.
68
Witt, K., van Dorn, R., & Fazel, S. (2013). Risk factors for violence in psychosis: Systematic Review and meta-regression analysis of 110 studies. PLOS One, 8(2), 1-15.
World Health Organization. (2002). World report on violence and health: summary., (pp. 1-54). Geneva.
Yao, X., Li, Z., Arthur, D., Hu, L., An, F., & Cheng, G. (2014). Acceptability and psychometric properties of Broset-Violence-Checklist in psychiatric care settings in China. Journal of Psychiatric Mental Health Nursing, 21(9), 848-855.
Top Related