Assessment and Management of Violence Risk for Psychiatric General Adult In-patient Units: the Application of a New Evidence Based Assessment Tool on Violence Risk of In-patient

Abstract Description

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Authors (including presenting author) :

CHAU, L.S. (1); CHOI, T.H.W. (1); LAI, K. L. (1); LEUNG, C.Y. (1); NG, K. (1) (2); WONG, C.Y. (1)

Affiliation :

(1) Department of Psychiatry, Shatin Hospital, (2) Department of Psychiatry, Prince of Wales Hospital

Introduction :

Patient aggression is common in clinical practice. 90% of psychiatric nurses face workplace violence, which brings along with negative impacts on various parties (Rippon, 2000; Sands et al., 2009). Discouragement of patients’ recovery, extension on the length of stay and unpleasant hospitalization experience are resulted. Further it causes injury on duty (IOD), high turnover rate and lawsuits to healthcare professionals (Griffith et al., 2013; Needham et al., 2005; Duxbury & Whittington, 2005; Rippon, 2000). Precise assessment of violent risk is vital in prevention; however, pre-existing instrument was loosely-structured and not validated. Dynamic Appraisal of Situation Aggression – Inpatient Version (DASA-IV), a validated instrument to predict risk of violence in next 24 hours (Griffith et al., 2013), along with a structured multi-disciplinary approach in the management of violence were introduced to the in-patient units of Shatin Hospital (SH).

Objectives :

The objectives were as follows: 1. To introduce a systemic early warning of violence risk to in-patient setting based on an evidence-based assessment tool; 2. To reduce the incidence of workplace violence, restraint and injury on duty; 3. To enhance multi-disciplinary communication on the management of patient’s violence, no longer limited between nurses and doctors only; 4. To strengthen nursing staff’s skills on assessment and management of patients with violence risk; 5. To promote patient’s satisfaction in hospital.

Methodology :

A four-month pilot study in one of the acute admission ward of SH was started in August 2016. DASA-IV was then implemented to the psychiatric general adult in-patient units of SH in January 2017. Three training workshops were held to explain the use and application of DASA-IV to nursing staff. To enhance the inter-rater reliability, a video training material was produced to demonstrate and discuss how to assess and rate the violent risk with the application of DASA-IV. A pretest-posttest design was adopted to access both nursing and allied health staff’s attitude towards the handling of violent patient in the working place. Two sets of questionnaires were distributed in January 2017 and January 2019. A statistical review was conducted to identify the incidence of restraint, IOD and compliance rate

Result & Outcome :

DASA-IV showed a positive impact on staff’s attitude towards handling of violent patients. Most of the nursing staff reflected that they had substantial gain from the training program and became more confident to assess the risk of violence by using DASA-IV. They reflected that DASA-IV facilitates a better identification of risk, early prediction and enhanced communication between disciplines. In 2018, the annual incidence of IOD decreased by 100% and the episodes of restraint also decreased by 36.7%. The compliance rate of DASA-IV was over 95%. With the use of DASA-IV, the assessment of patient’s violence risk was evidence-based. Nursing staff were able to classify the risk of violence in the next 24 hours, leading to an early induction of preventive measures to attain harm reduction in a multi-disciplinary approach. The use of DASA-IV had been integrated into the daily practice of nurses with a remarkable compliance rate. It promoted a safe working environment to healthcare professionals with the reduction of IOD incidence. DASA-IV successfully facilitated the management of violence in psychiatric in-patient setting. It promoted patient’s satisfaction in hospital with the reduction of restraint rate. DASA-IV is a structured and validated assessment tool in the management of violence. With the application of DASA-IV, nursing staff were able to classify the risk of violence and to provide early prevention. It promoted a safe working environment to staff and also satisfaction in hospital to patient.