Evaluating the Interventions Implemented and Subsequent Outcomes Following a Moderate and High Score on the Dynamic Appraisal of Situational Aggression Risk Assessment Tool

Abstract

Aims

The Dynamic Appraisal of Situational Aggression (DASA) is one of a few instruments designed for the prediction of violence specifically for inpatient populations. It is important that risk assessment tools demonstrate clinical utility, and that barriers to successful implementation are addressed. If successful, the tool should not only predict risk, but lead to the utilisation of interventions intended to manage and reduce risk. The aim of this study is to learn more about the acceptability of the tool (adherence), it's outputs (nursing interventions), and the outcomes (inpatient aggression and violence). Understanding more about the relationship and processes between an intervention and its outcomes is a key step in intervention evaluation.

Methods

Data were collected over a three-month period within a medium secure forensic hospital. A total of 43 patients were included for analysis.

Categories of nursing intervention were coded and content analysis of electronic health records analysed. Incidents of aggression/violence to others was recorded as aggression to patient and aggression to staff. Data were gathered on the completion of the DASA score for all patients for each 24-hour period. A DASA score of 2–3 for moderate risk and ≥4 for high risk was used. The change in DASA score (before and after intervention) and frequency of incidents was calculated for each intervention implemented.

Results

The average adherence of the DASA tool was 58.82% (Range 1.09% - 90.02%). The most frequent intervention following a moderate and high DASA score was that no interventions were provided. The second most frequent outcome following a high score was a focussed discussion with the patient, the use of increased monitoring and the use of seclusion. For those patients that recorded a high score on the DASA tool, eight of those scores were followed by an incident of aggression (n = 8 / 50%). There was no statistically significant difference between the change in DASA scores between interventions implemented, for both high and moderate scores.

Conclusion

The ultimate goal of risk assessment is the management and prevention of risk. Thus, if a high score does not result in strategies for intervention, it renders the assessment process worthless. A recommendation for future clinical practice would be the systematic recording of interventions and risk management strategies when in receipt of a high score on the DASA. Greater operationalisation of risk management strategies and their ability to reduce aggression is needed to enhance risk assessment research and clinical practice.