Roger Almvik

Fifteen years of research with the Staff Observation Aggression Scale: a review

Objective:  Research on the prevalence and causes of in‐patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

The Brøset Violence Checklist Sensitivity, Specificity, and Interrater Reliability

The Brøset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects as either present or absent. It is hypothesized that an individual displaying two or more of these behaviors is more likely to be violent in the next 24-hour period. All 109 consecutive referrals to four psychiatric inpatient acute units during a 2-month period were included in the study. Ratings were performed at the time of admission and three times a day for each patient—once for each working shift. Interrater reliability was adequate. Thirty-four separate incidences of violence occurred. Comparisons between ratings performed in the 24-hour interval before the incident and all other ratings suggested moderate sensitivity and good specificity of the instrument. It is concluded that the BVC is a useful instrument in predicting violence within the next 24-hour period and that the psychometric properties of the instrument are satisfactory.The Broset Violence Checklist (BVC) assesses confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects as either present or absent. It is hypothesized that an individual displaying two or more of these behaviors is more likely to be violent in the next 24-hour period. All 109 consecutive referrals to four psychiatric inpatient acute units during a 2-month period were included in the study. Ratings were performed at the time of admission and three times a day for each patient—once for each working shift. Interrater reliability was adequate. Thirty-four separate incidences of violence occurred. Comparisons between ratings performed in the 24-hour interval before the incident and all other ratings suggested moderate sensitivity and good specificity of the instrument. It is concluded that the BVC is a useful instrument in predicting violence within the next 24-hour period and that the psychometric properties of the instrument are satisfactory.

Predictive Validity and Other Psychometric Properties of the Short-Term Assessment of Risk and Treatability (START) in a Norwegian High Secure Hospital

Short- to medium-term risk assessment in psychiatric hospitals is a topic of clinical relevance that deserves attention from the research community. In this paper, the Short Term Assessment of Risk and Treatability, or START (Webster, Martin, Brink, Nicholls, & Middleton, 2004), a new structured instrument for judgment of dynamic risk and treatment factors is briefly described. Internal reliability properties are analyzed and the predictive validity for severe violence in a Norwegian high secure psychiatric hospital is investigated. The results indicate that the START has promise as a valid tool for short-term violence risk assessment. The authors make an argument for the importance and relevance of dynamic risk and strength factors in the short to medium term.

The Brøset violence checklist (BVC)

Objective:  The Brøset violence checklist (BVC) is a short‐term violence prediction instrument assessing confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. The aim of this paper is to describe the evolution and usefulness of the BVC.

A European perspective on psychiatric nursing and violent incidents: management, education and service organisation

The topic of violent incidents and its importance to inpatient psychiatric nursing practice is well recognised in the academic literature. However the awareness and profile of the issue in different European countries is highly variable. In this paper five European countries are compared: Italy, Norway, the Netherlands, Sweden and the UK. Contextual factors are likely to determine the perception, recognition and acknowledgement of the problem. Those described in detail here are the organisation of psychiatric inpatient services, the training of psychiatric nurses, and the methods used by those nurses to control and contain disturbed patients. For each of these factors large variations exist between the countries considered. The conclusion is drawn that there is much scope for useful comparative research.

Mechanical restraint in psychiatry: preventive factors in theory and practice. A Danish-Norwegian association study.

PURPOSE To examine how potential mechanical restraint preventive factors in hospitals are associated with the frequency of mechanical restraint episodes. DESIGN AND METHODS This study employed a retrospective association design, and linear regression was used to assess the associations. FINDINGS Three mechanical restraint preventive factors were significantly associated with low rates of mechanical restraint use: mandatory review (exp[B] = .36, p < .01), patient involvement (exp[B] = .42, p < .01), and no crowding (exp[B] = .54, p < .01). PRACTICE IMPLICATIONS None of the three mechanical restraint preventive factors presented any adverse effects; therefore, units should seriously consider implementing these measures.

Implementation of the Short Term Assessment of Risk and Treatability (START) in a Forensic High Secure Unit

Our objective was to describe and analyze the implementation process of the Short Term Assessment of Risk and Treatability in a forensic high secure unit in Norway. A stepwise implementation procedure was used and an educational package on practical use of the START in the clinic was developed. A questionnaire about START was given to the staff at the end of the first implementation phase and semi-structured qualitative interviews with staff on the content of security decision processes were carried out. Also, a log of the actual number of completed START scorings was made, including the number of ratings and the regularity of these ratings finished within this time frame. After six months’ implementation the questionnaire showed that 74% of the staff agreed that the evaluations made on the basis of START were interdisciplinary. Seventy-three percent also agreed that START contributed significantly to a more systematic risk assessment and management, and 79% said the START was useful as a tool in risk assessments and treatment planning. Informants from the interview study described how the START structured their clinical judgement. At the same time, the START fulfilled their wish to address both the patients’ strengths and risks. The START continued to be in regular use after the more intensive implementation process.Our results indicate that the implementation of START had led to interdisciplinary security decisions with a broader perspective of the patients’ situation.

Comparing the effect of non-medical mechanical restraint preventive factors between psychiatric units in Denmark and Norway.

Abstract Background: The use of mechanical restraint (MR) is controversial, and large differences regarding the use of MR are often found among countries. In an earlier study, we observed that MR was used twice as frequently in Denmark than Norway. Aims: To examine how presumed MR preventive factors of non-medical origin may explain the differing number of MR episodes between Denmark and Norway. Methods: This study is a cross-sectional survey of psychiatric units. Linear regression was used to assess the confounding effects of the MR preventive factors, i.e. whether a difference in the impact of these factors is evident between Denmark and Norway. Results: Six MR preventive factors confounded [∆exp(B)> 10%] the difference in MR use between Denmark and Norway, including staff education (− 51%), substitute staff (− 17%), acceptable work environment (− 15%), separation of acutely disturbed patients (13%), patient–staff ratio (− 11%), and the identification of the patients crisis triggers (− 10%). Conclusions: These six MR preventive factors might partially explain the difference in the frequency of MR episodes observed in the two countries, i.e. higher numbers in Denmark than Norway. One MR preventive factor was not supported by earlier research, the identification of the patients crisis triggers; therefore, more research on the mechanisms involved is needed. Clinical implications: None of the six MR preventive factors presents any adverse effects; therefore, units in Denmark and Norway may consider investigating the effect of implementing, the identification of the patients crisis triggers, an increased number of staff per patient, increased staff education, a better work environment and reduced use of substitute staff in practice.

Assessing living skills in forensic mental health care with the behavioural status index: A European network study

Abstract Assessment of living skills and violence risk in forensic psychiatric patients is a priority for clinicians. Suitably fine-grained instruments are rare. The goal of this study was to compare a norm-based psychometric assessment battery (the Behavioural Status [BEST] Index) with known valid instruments. Parallel cohort studies were undertaken in four European countries. Inpatients from 24 forensic psychiatric clinics were assessed three times using five instruments measuring living skills, psychological symptoms, aggression, and violence risk. Positive clinical changes were noted in insight, empathy, and some behaviors related to communication and living skills, with little change in violence risk, which was low to medium for most patients. Clinical congruence was observed between logically cognate items of the BEST Index and comparison instruments. Evidence for the scientific and clinical utility of the BEST Index as an effective tool for forensic psychiatric practice is discussed.

Selecting and Monitoring Living Skills in Forensic Mental Health Care: Cross-Border Validation of the BEST-Index

Background: Assessment of living skills and violence risk in forensic psychiatric patients is a priority for clinicians. Suitably fine-grained instruments are rare.Aim: We cross-validate a norm-based psychometric assessment battery (the Behavioral Status Index [BEST-Index]) against known valid instruments. Method: Parallel cohort studies were undertaken in five European countries. Inpatients (N = 231) from 24 forensic psychiatric clinics were assessed three times, using five instruments measuring living skills, psychological symptoms, aggression, and violence risk. Results: Positive clinical changes were noted in communication and living skills, with little change in violence risk, which was low to medium for 90 percent of patients. Clinical congruence was observed between logically cognate items of cross-validators and the BEST-Index. Discussion: Evidence for the scientific and clinical utility of the BEST-Index as an effective guideline for treatment priorities and outcomes is discussed.