Predicting Violence in the Individual Patient
By Gary Evans
Is it possible to assess whether a patient is a risk for committing an act of violence? Lynda Enos, RN, MS, COHN-S, CPE, an occupational health consultant in Oregon, thinks the evidence strongly supports the efficacy of patient assessment tools, and more hospitals should be using them.
Speaking in Austin at the annual conference of the Association of Occupational Health Professionals in Healthcare (AOHP), Enos recommended the Brøset Violence Checklist (BVC).1 The checklist was developed more than two decades ago for psychiatric facilities in Scandinavia but has been widely adopted in various healthcare settings.
“My passion is to be proactive on workplace violence,” Enos said. “I don’t think we can prevent [all] violence because we have a duty to care, and we can’t turn our patients away who are violent. However, can we be more proactive? What about assessing the patient for the risk of violence?
The BVC is a six-item checklist used to determine the patient’s potential for violence within the next 24 hours. The tool is used to assess three patient characteristics and three behaviors. Are these characteristics present or absent: boisterousness, confusion, and irritability? The three behaviors to look for are verbal threats, physical threats, and attacks on inanimate objects. Score 1 for each identified characteristic and behavior and add the total of all six measures. A score of 3 and above indicates the patient is likely to be violent in the next 24-hours. Zero through 2 scores indicate a low risk of violence over the same period.
“You might just use this in your emergency rooms, but it really needs to be everywhere,” Enos said. “The Brøset tool is one of the only validated tools to actually identify the risk of violence in the next 24 hours.”
The general recommendation is to conduct the assessment once per shift, so the tool relies on healthcare worker observation and compliance. Then there is the question of entering findings into the medical record and what specific measures should be recommended for caregivers.
Flagging the charts of potentially violent patients has been shown to prevent incidents, but it is controversial and could create stigma, Enos noted. Some hospitals use benign symbols or magnets, like the yin yang icon, on the room door to designate a potentially violent patient identified by the BVC. A common-sense approach would be for two caregivers to enter the room if the patient is designated as potentially violent. Given current staffing challenges, other tactics may be needed, depending on the local situation and facility.
Regardless, Enos and other AOHP speakers recommended forming a violence prevention committee to ensure occupational health and frontline workers are represented.
The Joint Commission’s new violence prevention standards for 2022 require a workplace violence committee “led by a designated individual and developed by a multidisciplinary team.”2
Michael Benedeck, BS, CHSP, WACH, senior director of loss control and nurse case management with the Illinois Health and Hospital Association, described his experience on a violence prevention committee.
“Knowing the departments where the incidents are occurring is very important,” Benedeck told AOHP attendees. “I made sure we captured that very succinctly, but I had trouble gaining traction.”
Since the ED was a hot zone, Benedeck tried to obtain buy-in there and generate data on incidents. “We began in the ER and reached out to the manager,” he said. “But what is really important is the frontline staff. For those of you who may be struggling, start where you find the data — where it points you — and then work from there and build something.”
Recruit committee members with a breadth of experience, Benedeck said, recalling a behavioral health nurse on the panel who traced violence in hospital units to medication delays in the ED.
“Always ask, ‘Why are these patients getting violent?’” Benedeck. “Was it a medication delay, withdrawal? We tried to tag the reasons.”
Committee discussions can circle into endless conversation about this complex problem, so create action items, assign the task, and then move on them, Benedeck advised.
- Clarke DE, Brown AM, Griffith P. The Brøset Violence Checklist: Clinical utility in a secure psychiatric intensive care setting. J Psychiatr Ment Health Nurs 2010;17:614-620.
- The Joint Commission. R3 Report: Workplace violence prevention standards. June 18, 2021.
Is it possible to assess whether a patient is a risk for committing an act of violence? An occupational health consultant in Oregon thinks the evidence strongly supports the efficacy of patient assessment tools, and more hospitals should be using them.
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