risk assessment made easy the bröset violence checklist...

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Risk assessment made easy The Bröset Violence Checklist

(BVC)

Roger Almvik, Dr. Philos Research Director, RN, RMN,PhD

Centre for Research and Education in Forensic Psychiatry St. Olavs hospital, Forensic department Bröset, Trondheim

Norwegian University of Science & Technology,Faculty of Medicine

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Learningobjec-ves

•  Reflectonthebasicunderlyingprinciplesofviolenceriskassessment

•  DevelopawarenessofBVCintheassessmentofimminentviolence

•  Considertheevidencetosupportitsvalidity• TobeawareofRosenborgTrondheimFC

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Introduc-on

•  InstrumentaBontoaidintheassessmentprocessshouldbeapartofeverydayclinicalpracBce.

•  AllmembersoftheinterprofessionalteamhaveanimportantparttoplayincollecBngclinicallyrelevantdatatoassistidenBfyingintervenBonsandcontributetoclinicaldecision-making.

•  Assessingtheriskofviolencetoself,othersorpropertyisanimportantaspect

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Introduc-on

•  WhentheseformsofviolenceoccurtheyhavethepotenBaltoimpactonboththeclinicalstaffandthehealthenvironmentaswellascosts

•  Thereisextensiveresearchthatconsistentlyshowssuperiorriskdecision-makingwhenstructuredclinicaljudgementisused.

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Introduc-on

•  ResearchoninstrumentdevelopmenthasamassedovertheyearstothecurrentdatewhereclinicianshaveabaKerytochoosefrom.

•  OneshorttermviolencepredicBoninstrumentthatisreceivingconsiderableinterestistheBrøsetViolenceChecklist(BVC).

•  TodateabodyofresearchexistsonitsusefulnessandimplementaBoninclinicalpracBce,mostrecentlyfromrandomizedcontrolledtrials.

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Background (for being here ?)

NICE guidance NG10, on the short term management of violence and aggression, recommends using an actuarial prediction instrument such as the BVC (Brøset Violence Checklist) or the DASA-IV (Dynamic Appraisal of Situational Aggression - Inpatient Version), rather than unstructured clinical judgement alone, to monitor and reduce incidents of violence and aggression and to help develop a risk management plan in inpatient psychiatric settings.

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Center for Clinical Guidelines (DK)

Conclusions/recommandations: ü Standardised risk assessment tools can be

used to predict aggressive and violent behaviour

ü MHC staff should use the BVC in their clinical work in adult inpatient services

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Riskassessment

•  RiskassessmentneedstobesystemaBcandbasedonthepopulaBonundergoingassessment;withidenBfiedriskfactorsrequiredtobebrokendownintomoremanageablecomponents,furtherassessedthrougheffecBvetreatmentplanningandoutcomesevaluatedthroughrecovery

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Growth of Risk Assessment

•  Monahan (1981) – 5 studies •  Early 1990s – handful of instruments •  Today – too many instruments ?! •  1998 – first publication on BVC •  1999 – first publication on HCR-20 •  Today

› 150+ disseminations on HCR-20 › Estimated 300 SPJ disseminations › Estimated 600 disseminations, generally

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SPJ studies over time (Guy 2008)

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SPJ Decision Steps (HCR-20 Version 3, Douglas et al., 2013)

1 •  Gather relevant information

2 •  Determine presence of risk factors

3 •  Determine relevance of risk factors

4 •  Develop formulation of violence risk

5 •  Develop primary scenarios of violence

6 •  Develop case management plans

7 •  Develop final risk judgments

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Brøset Violence Checklist - BVC

Ø  A risk assessment tool hitting the Bull’s eye ?

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Brøset Violence Checklist (BVC) History and Background

ü Developed at R.S.U. Bröset based on data from forensic inpatients.

ü  Extensively tested out on acute wards, nursing homes and geriatric wards in Norway

ü  Extensive validation studies in various settings nationwide as well as international

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Brøset Violence Checklist

Six variables/behaviours: ®  Confused ®  Irritable ®  Boisterous ®  Physically threatening ®  Verbally threatening ®  Attacking objects

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Interpretation and operationalisation •  Confused - Appears obviously confused and disorientated. May be

unaware of time, place or person. •  Irritable - Easily annoyed or angered. Unable to tolerate the

presence of others. •  Boisterous - Behaviour is overtly "loud" or noisy. For example

slams doors, shouts out when talking etc. •  Physically threatening - Where there is a definite intent to

physically threaten another person. For example the taking of an aggressive stance; the grabbing of another persons clothing; the raising of an arm, leg, making of a fist or modelling of a head-butt directed at another.

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Interpretation and operationalisation

•  Verbally threatening - A verbal outburst which is more than just a raised voice; and where there is a definite intent to intimidate or threaten another person. For example verbal attacks, abuse, name-calling, verbally neutral comments uttered in a snarling aggressive manner.

•  Attacking objects - An attack directed at an object and not an individual. For example the indiscriminate throwing of an object; banging or smashing windows; kicking, banging or head-butting an object; or the smashing of furniture.

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BVC – Form (example) Filled in by:

DAY ONE DAYSHIFT date To be filled in before.....

Confused

Irritable

Boisterous

Verbal threatening

Physical threatening

Attacking objects

SUM

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Interpretation of BVC score

Score Risk

Sum = 0 Risk of violence is small

Sum = 1-2 The risk of violence is moderate, Preventative measures should be taken

Sum = > 2 The risk of violence is high. Preventative measures should be taken and plans about how to manage an attack made.

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hKp://goo.gl/fc9Co

HowtousetheBVC

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TheApp23

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Research ?

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Plenty !

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Russia

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Japan……

第35回日本看護学会論文集 - 論題一覧 - 抄録集演題・論文集論題一覧 ...暴力発生の状況と

Broset Violence Checklistによる予測の予備的検討―: 元・東京都立松沢病院 下里誠二東京都立松沢病院 相馬厚・釜英介・薄田恒夫・北野進・石川博康 key word：精神障害者，暴力，短期予63.p.186～187 暴力を繰り返す患者への看護 ...

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Nurses and research…………. Professor C. Pirquet (Vienna 1927):

”one cannot think of nurses doing scientific research – their ability to think originally are more seldom than in men”

Chief medical officer Wyller (Oslo 1918):

”The knowledge that are forced into the nurses is completely dead ballast – their brain is not capable of receiving it”

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China

Acceptability and psychometric properties of Brøset Violence Checklist in psychiatric care settings in China; X . Yao et al in Journal of Psychiatric and Mental Health Nursing, 2014

BVC provides nurses with a quick and easily administered method to screening out patients with violence potential, thus allowing for early intervention. Feedback from the nurses was quite encouraging and the further use of BVC seems promising.

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Evidence on effects •  Abderhalden et al in BJP (2008): Introducing twice daily

staff measures on risk assessment (BVC Swiss version) –  41 % reduction in severe violent incidents –  27 % reduction in the use of coercive measures

•  Van de Sande et al in BPJ (2011): Implementing regular risk and violence assessment –  68 % reduction of aggressive incidents –  45 % reduction of time in seclusion

•  Hvidhjelm et al in PhD thesis, Uni of Copenhagen (2015) –  48 % reduction in violent incidents

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Lockertsen, Ø. (2012); Master thesis

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Nurses assessment of the BVC

ü  95,8 % thinks that the use of BVC rarely or never increase the use of coercive measures

ü  75 % describes increased insight in to the pt’s risk for violence, but not necessarily more insight in to pt’s vulnerability

ü  83,4 % reports that BVC is used activily in the daily risk assessment routines

ü  68,5 % reports that BVC makes them better in risk prediction ü  67,6 % reports that the use of BVC often or always leads to early

inteventions

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References•  Abderhalden,C.,Needham,I.,Miserez,B.,Almvik,R.,Dassen,T.,Haug,H.J.,

&Fischer,J.E.(2004).PredicBnginpaBentviolenceinacutepsychiatricwardsusing theBrøset-Violence-Checklist:amulBcentreprospecBvecohort study.JournalofPsychiatricandMentalHealthNursing,11(4),422-427.

•  Abderhalden,C.,Needham,I.,Dassen,T.,Halfens,R.,Haug,H.J.,&Fischer,J.(2006).PredicBnginpaBentviolenceusinganextendedversionoftheBrøset-Violence-Checklist: instrument development and clinical applicaBon. BMCPsychiatry,6:17

•  Abderhalden,C.,Needham, I.,Dassen,T.,Halfens,R.,Haug,H.J.,&Fischer,J.E. (2008). Structured risk assessment and violence in acute psychiatricwards: randomised controlled trial. Bri;sh Journal of Psychiatry, 193(1),44-50.

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References

•  Almvik,R.,&Woods,P.(1998).TheBrøsetViolenceChecklist(BVC)andthepredicBonofinpaBentviolence:somepreliminaryresults. PsychiatricCare,5(6),208-211.

•  Almvik, R., & Woods, P. (1999). PredicBng inpaBent violence using theBrøsetViolenceChecklist(BVC). Interna;onalJournalofPsychiatricNursingResearch,4(3),498-505.

•  Almvik,R.,Woods,P.,&Rasmussen,K.(2000).TheBrøsetViolenceChecklist(BVC): SensiBvity, specificity and inter-rater reliability. Journal ofInterpersonalViolence,15(12),1284-1296.

•  Almvik, R., & Woods, P. (2003). Short-term risk predicBon: the BrøsetViolence Checklist – Research in Brief. Journal of Psychiatric andMentalHealthNursing,10(2),236-238.

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References

•  Almvik,R.,Woods,P.,&Rasmussen,K. (2007).Assessing risk for imminentviolenceintheelderly:TheBrosetViolenceChecklist. Interna;onalJournalofGeriatricPsychiatry,22(9),862-867.

•  Björkdahl, A., Olsson, D., & PalmsBerna, T. (2006). Nurses’ short-termpredicBonofviolenceinacutepsychiatric intensivecare. ActaPsychiatricaScandinavica,113(3),224-229

•  Clarke,D.E.,Brown,A.M.,&Griffith,P.(2010).TheBrøsetViolenceChecklist:clinicaluBlityinasecurepsychiatricintensivecaresenng.JournalofPsychiatricandMentalHealthNursing,17,614–620.

•  Linaker,O.M.,&Busch-Iversen,H.(1995).PredictorsofimminentviolenceinpsychiatricinpaBents.ActaPsychiatricaScandinavica,92(4),250-254.

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References

•  Needham,I.,Abderhalden,C.,Meer,R.,Dassen,T.,Haug,H.J.,Halfens,R.J.,&Fischer,J.E.(2004).TheeffecBvenessoftwointervenBonsinthemanagementofpaBentviolenceinacutementalinpaBentsenngs:reportonapilotstudy.JournalofPsychiatricandMentalHealthNursing,11(5),595-601.

§  Nijman,H.L.I.,Muris,P.,Merckelbach,H.L.G.J.,PalmsBerna,T.,Wistedt,B.,Vos, A.M., van Rixtel, A., & Allertz, W. (1999). The Staff ObservaBonAggressionScale-RevisedSOAS-R.AggressiveBehavior,25(3),197-209.

§  Ogloff, J. D., & Daffern, M. (2006). The dynamic appraisal of situaBonalaggression: An instrument to assess risk for imminent aggression inpsychiatricinpaBents.BehavioralSciencesandtheLaw,24,799-813.

•  Palmstierna, T., & Olsson D. (2007). Violence from young women involuntarily admitted for severe drug abuse. Acta Psychiatr Scand, 115(1), 66-72

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References•  van de Sande, R.et al (2011). Aggression and seclusion on acute psychiatric

wards: effect of short-term risk assessment. Bri;sh Journal of Psychiatry,199(6),473-478.

•  Vaaler, A.E., et al. (2011). Short-term predicBon of threatening and violentbehaviour in an Acute Psychiatric Intensive Care Unit based on paBent andenvironmentcharacterisBcs.BMCPsychiatry,11:44

•  Woods,P.,&Almvik,R.(2002).TheBrøsetViolenceChecklist(BVC).ActaPsychiatricaScandinavica,106(suppl.412),103-105.

•  Woods,P.,Ashley,C.,Kayto,D.,&Heusdens,C.(2008).PiloBngviolenceandincidentreporBngmeasuresononeacutementalhealthinpaBentunit.IssuesinMentalHealthNursing,29(5),455-469

•  YaoX1,LiZ,ArthurD,HuL,AnFR,ChengG.(2014):AcceptabilityandpsychometricproperBesofBrøsetViolenceChecklistinpsychiatriccaresenngsinChina.JPsychiatrMentHealthNurs.

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Conclusion•  TheBVChasagrowingevidencebasetosupportitsvalidity

•  AssessingapaBentsriskofviolenceusingastandardizedmeasureismoreaccuratethanusingsolelysubjecBvejudgements

•  TheBVCallowsforreflecBonandstandardizaBonofthebehavioursandcharacterisBcstypicalofviolentincidents(OgloffandDaffern2006)

•  BVCiseasytoincorporateintodailyrouBnes

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Contact information

roger.almvik@ntnu.no

www.riskassessment.no