Academic journal article Advances in Mental Health

Identifying Patients at Risk of Inpatient Aggression at the Time of Admission to Acute Mental Health Care. What Factors Should Clinicians Consider?

Academic journal article Advances in Mental Health

Identifying Patients at Risk of Inpatient Aggression at the Time of Admission to Acute Mental Health Care. What Factors Should Clinicians Consider?

Article excerpt

Introduction

Aggressive patient behaviour has become a major challenge for mental health staff working in acute inpatient units in Australia (Carr et al., 2008) and overseas (Cornaggia, Beghi, Pavone, & Barale, 2011; Papadopoulos et al., 2012; Vaaler et al., 2011). Verbal abuse and physical assault may lead to the demoralisation of staff and impact on the ability of health services to provide a safe and therapeutic environment for both patients and staff (Barlow, Grenyer, & Ilkiw-Lavalle, 2000). Staff are likely to resort to containment measures such as restraint, seclusion and enforced medications to manage violence and this in turn, can give rise to further violence (Bowers, 2014). Identification of high risk consumers and the provision of early de-escalation interventions are likely to reduce the need for coercion and other containment measures (Abderhalden et al., 2008; Chang et al., 2015). However, there continues to be a lack of agreement regarding the factors associated with increased risk of violence in inpatient settings (Newton, Elbogen, Brown, Snyder, & Barrick, 2012).

In early research, Monahan and Steadman (1994) categorised the risk factors for aggression into four domains; dispositional factors (such as age, gender, marital status and education), historical factors (such as psychiatric history, employment history and time in prison), contextual factors (such as lack of accommodation, current employment status, previous admissions, self-harm and aggression prior to admission) and clinical factors (type of admission, diagnosis, substance use and symptoms). The diversity of risk factors stems from differences in study settings, samples, study designs and measures (Newton et al., 2012; Vaaler et al., 2011). A key factor has been the lack of an accepted definition of what behaviours constitute aggression (Lozzino, Ferrari, Large, Neillsen, & de Girolamo, 2015). While some studies restricted the definition to include acts of 'physical violence to others' (Chang et al., 2015; Newton et al., 2012), other studies have including verbal threats, self-harm and property damage, in addition to physical violence (Amore et al., 2008; Foley et al., 2005). The lack of an acceptable definition for aggression has resulted in wide variation in the rates of aggression reported and difficulty reaching consensus on risk factors (Vaaler et al., 2011).

Violence among inpatients has been found to be frequently, but not consistently, associated with male gender, comorbid substance abuse, positive symptoms, schizophrenia, longer hospitalisation, lower educational attainment and history of violence prior to admission (Carr et al., 2008; Chang et al., 2015; Cornaggia et al., 2011; Dack, Ross, Papadopoulos, Stewart, & Bowers, 2013; Newton et al., 2012). Indeed, violence in the community prior to hospitalisation has been identified as one of the most consistent predictors of violence following admission (Amore et al., 2008; Foley et al., 2005). Foley et al. (2005) found that violence in the week prior to admission was a key predictor of post-admission violence, while Steinert (2002) noted that a history of violence in the month prior to admission increased the odds of being verbally and physically aggressive in hospital by a ratio of three and four times, respectively.

Identifying possible predictors of inpatient aggression allows clinicians to make better clinical decisions regarding risk management and patient treatment (Newton et al., 2012). Mental health staff have traditionally relied on clinical judgement to assess the risk of future violence (Clarke, Brown, & Griffith, 2010). However, emerging evidence suggests that structured assessments of violence risk (through the use of validated scales and questionnaires) are likely to be more accurate than clinical judgement (Clarke et al., 2010; Griffith, Daffern, & Godber, 2013). Against this backdrop, an increasing array of violence risk assessment measures has emerged. …

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