4. ASSESSING AGGRESSION
An integral part of all de-escalation models is assessment. Knowing when a patient is likely to become violent is imperative to enacting de-escalation strategies, but often, the details of aggression assessment are left out of the broader context of a de-escalation framework. Berg, Bell, and Tupin (2001) propose a linear de-escalation framework that contains assessments for “potential violence” and “imminent violence.”They argue that, prior to diagnosing aggression, it is important to determine the immediacy of the threat. In a literature review regarding risk assessment tools in emergency department settings, Calow et al. (2016) discusses nine different tools, the three most commonly used being the STAMP violence assessment framework, the Brøset Violence Checklist, and the M55 Violence Risk Assessment Tool. Calow et al. organizes the tools according to their intended setting – emergency department or inpatient.
4.1 Berg, Bell, and Tupin
Berg, Bell, and Tupin (2001) identify three stages of aggression: potential violence, imminent violence, and emergent violence. The authors quip, “Clearly, while one is being choked is not the time to gather data about why one is being choked.” For this reason, only potential and imminent violence require assessment protocols.
4.1.1 Potential Violence
Berg, Bell, and Tupin emphasize the need for staff consultation with colleagues, in order to prevent denial of aggression symptoms, identify unintentionally provocative behavior on the part of staff, and keep a de-escalation team informed. Consistent consultation should occur simultaneous to the identification of potentially violent patients via background checks, and violence histories. Historical data not only provides information on who is likely to be aggressive, but what their potential triggers might be.
The authors list the following as additional risk factors for aggression in the healthcare setting: alcohol or substance abuse, low staffing, untrained security personnel, lack of emergency devices, and environmental concerns (e.g., unpleasant conditions, furniture that can be used as a weapon).
4.1.2 Imminent Violence
Certain behavioral warning signs signal to staff that violence may be imminent. This includes agitated behavior (e.g., pacing), use of threats, aggressive body language (e.g., opening and closing of fists), pupil dilation, standing too close, impulsiveness, an immediately recent episode of violent behavior, and demonstrations of fear and apprehension. Berg, Bell, and Tupin (2001) state that spoken threats in the form of yelling, name calling, or cursing are the most common precursors to physical violence.
4.2 Calow et. al
Calow et al. (2016) conducted a 13-paper literature review on aggression assessments. They identify themes from assessments used in both ED and inpatient settings.
4.2.1 Emergency Department
The authors identified three risk assessment tools used in the ED setting: the STAMP violence assessment framework, Assessment, Behavioral Indicators, and Conversation (ABC), and the five attributes of caring to avert violence (be safe, available, respectful, supportive, and responsive). Collectively, these tools identified high-risk behaviors as staring/glaring at the caregiver, increased volume or hostile tone, anxiety, mumbling, pacing, aggressive statements, belligerence, clenched fists, demanding attention, irritability, and general hostility. The STAMP tool was used most often in the ED setting, and has been validated as an effective tool.
4.2.2 Inpatient Care
Calow et al. identified six risk assessment tools used in the inpatient setting that cover a range of possible risk factors, including patient behavior, history of violence, psychopathology and current demonstrations of psychosis, and intoxication and substance abuse. The behaviors identified as possible precursors to violence in the inpatient setting were consistent with those described for the ED. The Brøset Violence Checklist, a six-item tool that includes confusion, irritability, boisterousness, verbal threat, physical threat, and attack on objects, was the most commonly used aggression risk assessment tool. It demonstrates the best validity and reliability. The M55 Violence Risk Assessment, the third most commonly used assessment alongside STAMP and Brøset, has mixed validity results.