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Aims and objectives: To gain insight into mental health staff’s perception of writing progress notes in an acute and subacute psychiatric ward context. Background: The nursing process structures nursing documentation. Progress notes are intended to be an evaluation of a patient’s nursing diagnoses, interventions and outcomes. Within this template, a patient’s status and the care provided are to be recorded. The therapeutic nurse–patient relationship is recognised as a key component of psychiatric care today. At the same time, the biomedical model remains strong. Research literature exploring nursing staff’s experiences with writing progress notes in psychiatric contexts, and especially the space given to staff–patient relations, is sparse. Design: Qualitative design. Methods: Focus group interviews with mental health staff working in one acute and one subacute psychiatric ward were conducted. Systematic text condensation, a method for transverse thematic analysis, was used. Results: Two main categories emerged from the analysis: the position of the professional as an expert and distant observer in the progress notes, and the weak position of professional–patient interactions in progress notes. Conclusions: The participants did not perceive that the current recording model, which is based on the nursing process, supported a focus on patients’ resources or reporting professional–patient interactions. This model appeared to put ward staff in an expert position in relation to patients, which made it challenging to involve patients in the recording process. Essential aspects of nursing care related to recovery and person-centred care were not prioritised for documentation. Relevance to clinical practice: This study contributes to the critical examination of the documentation praxis, as well as to the critical examination of the documentation tool as to what is considered important to document. [ABSTRACT FROM AUTHOR]

Background Biological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments. This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH. Methods In this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge. Results High triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients). Conclusion The triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio- psychosocial approach appears promising, but further research is necessary to refine and validate this method. [ABSTRACT FROM AUTHOR]

Abstract: Recently patients'' responsibility for and ownership of their own treatment have been emphasised. A literature search on patients'''' structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The present prospective naturalistic study comprised all involuntary and voluntary acutely admitted patients (n =489) to a psychiatric hospital during one year. Patients'' self-reported risks of violence and self-harm at admission and at discharge were compared with episodes recorded during hospital stay and 3months post-discharge. Patients'' predictions were significant concerning violent, suicidal and self-injurious behaviour, with AUC values of 0.73 (95%CI=0.61–0.85), 0.92 (95%CI=0.88–0.96) and 0.82 (95%CI=0.67–0.98) for hospital stay, and 0.67 (95%CI=0.58–0.76), 0.63 (95%CI=0.55–0.72) and 0.66 (95%CI=0.57–0.76) after 3months, respectively. Moderate or higher risk predictions remained significant in multivariate analysis, and risk of violence even after gender stratification. Self-harm predictions were significant for women. Moderate or higher risk scores remained significant predictors of violence one year post-discharge. Controlling for readmissions the results remained the same. Low sensitivity limits the clinical value, but relatively high positive predictive values might be clinically important. Still future research is recommended to explore if self prediction is a valid adjuvant method to established risk assessment procedures. [Copyright &y& Elsevier]

Objective. The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents. Background. Nurses in forensic settings are often confronted with patients’ aggression. Better collaboration between nursing staff and patients may improve patients’ ability to self manage aggression and contribute to a decrease in inpatient aggression. Design. Naturalistic one-way case-crossover design. Methods. The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a one-way case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during ‘Treatment As Usual’ with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents. Results. A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes. Conclusions. The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders. Relevance to clinical practice. This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression. [ABSTRACT FROM AUTHOR]

The Acute Project is a research project conducted on acute psychiatric admission wards in Norway. The objective is to develop and validate a structured, easy-to-use screening checklist for assessment of risk for violence in patients both during their stay in the ward and after discharge. The Preliminary Scheme 33 is a 33-item screening checklist with content domain inspired by the Historical-Clinical-Risk Management Scheme (HCR-20), the Brøset Violence Checklist, and eight risk factors extracted from the literature on risk assessment. The Preliminary Scheme 33 was designed and tested in two steps by a research group which includes the authors. The common aim of both steps was to develop this into a time economical, reliable, and valid checklist, in the first step in 2006 the predictive validity of the individual items was tested. The present work presents results from the second step, a study conducted to assess the interrater reliability of the 33 items. Eight clinicians working in an acute psychiatric unit volunteered to be raters and were trained to score the 33 items on a three-point scale in relation to 15 clinical vignettes, which contained information from 15 acute psychiatric patients' files. Analysis showed high interrater reliability for the total score with an intraclass correlation coefficient (ICC) of .86 (95% CI: 0.74-0.94). However, a substantial proportion of the items had medium to low ICCs. Consequences of this finding for further development of these items into a brief screen are discussed. [ABSTRACT FROM AUTHOR]

The article focuses on the validity and utility of risk assessment tools for violence in acute care settings. It mentions that risk assessment instruments concluded that the V-RISK-10 and the Broset Violence Checklist (BVC) provided the best assessment for violence risk in the acute care mental health setting; and also mentions the VRISK- 10 has shown significant predictive accuracy in general psychiatric acute wards.

The main scope of this paper is to delineate some findings from a review of the literature concerning the possible impact of delusions on violence toward others by psychiatric patients. According to this review, studies on a possible association between delusions and increased risk of violence are scarce, but steadily growing, and have shown some interesting results. However, since delusions are also common in nonviolent psychiatric patients, there is emerging evidence that our attention should be directed to specific hallmarks of delusions that indicate an increased risk of violence. Among the main findings of the present review are: the number of empirical studies were surprisingly low; about 80% of the studies were conducted during the last 8 years; and less than one third of the studies used a prospective design. Further findings were that persecutory delusions appear to increase risk of violence in some patients; co-occurence of persecutory delusions and emotional distress may increase risk of violence; and there is limited but tentative support to the existence of an association between symptoms of perceived threat and internal control override (TCO) and violence. [Copyright &y& Elsevier]

A sample of 39 patients who had committed serious violent acts toward others were assessed with the revised Symptom Checklist (SCL-90-R). The SCL-90-R is a self-report symptom inventory for the measurement of psychopathology in psychiatric and medical patients. In addition to the patients' self-report, an observer-rated SCL-90-R was obtained. This was accomplished by letting one pair of nurses complete SCL-90-R ratings for each patient. The first aim of the study was to compare the SCL-90-R self-report scores of the patient sample with the psychiatric inpatient norms [Derogatis LR (1992): Clinical Psychometric Research Inc]. Another purpose of this study was to explore possible trends of discordance between the observer ratings and the self-reports of the study group. Always considering the limitations of the small sample, it was nevertheless also of interest to look for possible sex differences and differences between violent subgroups and between diagnostic groups in the self-reported scores as well as in the observer ratings. The most striking findings of the present study were that the self-reported scores were lower than the inpatient norms for SCL-90-R and that the patients' self-reported levels of distress were significantly lower than those found in the observer ratings. Underreporting of psychopathology as a marker of violence risk is discussed in light of these findings. In this study, women reported higher distress levels than men in the Interpersonal Sensitivity symptom dimension. There were no significant differences concerning SCL-90-R ratings between patients who had committed homicide, attempted homicide, or physically assaulted another person in a serious but not life-threatening way. Aggr. Behav. 28:446–457, 2002. © 2002 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

While comorbidity of serious mental illness (SMI) and substance abuse increases violence risk, less is known about additional effects of multiple substance abuse. By using a check list, data on substance abuse, violence, diagnoses, and Perceived Threat Control Override symptoms (TCO) were extracted from electronic patient files in 146 male patients who were extensive users of acute psychiatric services. Variables that were significant in univariate analysis were entered into a stepwise multivariate regression analysis. Odds ratios for violence increased from 5.3 in patients who abused one substance to 153.4 with the abuse of four or five substances (Step 1). The effect was moderated in Step 2 by having a diagnosis of mood disorder (OR = .17). In Step 3, only a trend indicated that one TCO component, "others control my thoughts and feelings," increased the risk of violence (OR = 3.7). The positive effect sizes for polysubstance abuse were about two times larger in Step 3 than in Step 1. The findings indicate that including the number of abused substances may improve violence risk assessment in patients with SMI. [ABSTRACT FROM AUTHOR]

Abstract: Cross-sectional studies have reported an association between lipids and serotonin levels and aggression, but a literature search revealed a paucity of prospective studies. Subjects of the present naturalistic study were 254 of all (489) involuntary and voluntary acutely admitted patients to a psychiatric hospital during 1year. Serum lipids and platelet serotonin at admission were prospectively compared with recorded intra-institutional and 1-year post-discharge violence and self-harm. Total cholesterol had a significant negative relationship to inpatient suicidal behaviour and inpatient violent behaviour and to 3-month post-discharge violent behaviour. Triglycerides were a significant marker of inpatient self-mutilation and of self-mutilation in combination with suicidal behaviour at 3 and 12 months of follow-up. High-density lipoprotein (HDL) had a significant negative relationship to violence at 12-months, and to repeated violence in seven patients with two or more admissions. The post-discharge relationships between total cholesterol and violence and between triglycerides and self-harm remained significant even when controlling for other possible explanatory variables in a multivariate model. Results did not change after controlling for current medication at admission. There was no association between platelet serotonin and violence or self-harm. Future research may examine if lipid measurements add incremental validity to established clinical risk assessment procedures of violent and self-harm behaviour. [Copyright &y& Elsevier]

Abstract: In this study of 196 patients discharged from an acute psychiatric ward, 11 patients (6%) were identified as exhibiting repeated violence and having frequent readmissions. Compared with non-violent patients and those with only one violent post-discharge episode, repeatedly violent patients were significantly characterised by male gender, higher rates of previous threats of violence, lack of empathy, more severe violence during follow-up, and lower high-density lipoprotein levels. [Copyright &y& Elsevier]

Abstract: Violence risk assessment instruments are mainly based on historical and clinical risk factors. Biological factors have been related to violent behaviour but hardly used in risk assessment. A recent study indicated that both low total cholesterol (TC) and the patients’ own estimates about their risk of future violent behaviour, the Self-report Risk Scale (SRS), significantly predicted violent behaviour during hospital stay and the first 3 months after discharge from an acute psychiatric department. Our aim was to investigate whether combining three methods, a screening instrument for risk of violence (V-RISK-10), low TC and the SRS, into one multifaceted risk assessment model may enhance predictive validity. This prospective naturalistic study involved 134 of all (489) acutely admitted patients to a general psychiatric hospital during 1 year. Low TC, SRS and V-RISK-10 at admission were prospectively compared with recorded violence during hospital stay and the first 3 months after discharge. The multifaceted risk assessment model yielded a significant increase in explained variance beyond that of the V-RISK-10. AUC values were higher, but differences were not significant. The biopsychosocial approach to violence risk assessment seems promising, but further studies are needed to test the feasibility and predictive validity of multifaceted models. [Copyright &y& Elsevier]