Violence Reduction in Neurology. Clinician Safety References Brasic JR. Clinician safety. Grand Rounds, Kirby Forensic Psychiatric Center, Wards Island,

Violence Reduction in Neurology

Clinician Safety References

• Brasic JR. Clinician safety. Grand Rounds, Kirby Forensic Psychiatric Center, Wards Island, New York, May 23, 2002 [videotape]

• Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005 Available at: http://www.emedicine.com/neuro/topic713.htm.• Brasic JR, Fogelman D: Clinician safety. Psychiatric Clinics of North

America 1999;23(4):923-940

Victims of Patient Assault

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005 . Available at http://www.emedicine.com/neuro/topic713.htm.

Crilly, et al.: Violence towards emergency department nurses by patients. Accid Emerg Nurs 2004; 12: 67-73

• Physicians

• Nurses

• Social workers

• Allied health personnel

• Emergency teams

• Administrators

• Law enforcement

• Corrections

• Other patients

• Visitors

Violence in Schizophrenia

• Four times more common than in people without mental illness• Psychotic symptoms• Alcohol abuse• Psychopathy• Antisocial personality disorder• Special education

Abu-Akel A, Abushua'leh K: 'Theory of mind' in violent and nonviolent patients with paranoid schizophrenia. Schizophrenia Res 2004; 69: 45-53

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htmWalsh E, et al. Predicting violence in schizophrenia: a prospective study. Schizophrenia Res 2004;67:247-252

Violence in Hospitalized Male Patients With Paranoid Schizophrenia

• Alcohol abuse• Drug abuse• Good ability to infer cognitive mental

states of others• High hostility • Poor empathy• Youth


Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm

Violence in First Episode Psychosis • Involuntary admission• Drug abuse• Poor insight• High psychopathology

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htmFoley, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Res 2005; 72: 161-168

Research Review • Avoid apparent wrongdoing• Misinterpretations• Misconstrued conclusions• Required in 2005

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Foley, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Res 2005; 72: 161-168

Hypotheses

• Violent patients have medical disorders (eg, metabolic, toxic)• Violent patients have substance abuse• Violent patients have reduced empathy• Violent patients have learning disorders• Violent patients have paranoid schizophrenia

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm

Goals

• To measure medical disorders(eg, metabolic, toxic)

• To measure substance use • To measure empathy• To measure learning disorders • To measure psychiatric disorders

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.

Subjects

• Probability sampling• Statistical theory applies• Can generalize to total population

• Nonprobability sampling (Cochran, 1977)•Cannot generalize to total population

Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Brašic, et al. Quality assurance of the community placement of institutional residents. German Journal of Psychiatry 2002;5(4):95-114 http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-quality.pdfBrasic, et al., Psychoactive Medication Quality Assurance Rating Survey (PQRS). Journal of Developmental and Physical Disabilities 1997;9:311-336Cochran WG. Sampling Techniques, 3rd ed New York: John Wiley & Sons, 1977

http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-quality.pdf

Subjects

• Probability sampling• Total population (Brasic et al, 2002)• Simple random sample of ten percent

(Brasic et al, 1997)• Need for probability sampling (Cochran, 1977)• Generalize to total population



Subjects

• Nonprobability sampling (Cochran, 1977)• Readily accessible (Cochran, 1977)• Haphazard selection (Cochran, 1977)• “Typical” units (Cochran, 1977)• Volunteers (Cochran, 1977)• Cannot generalize to total population


http://www.emedicine.com/neuro/topic713.htm


Consent From Patients•Institutional Review Board

• Justify need to provide for the safety of patients and staff

• Admission protocol• Written informed consent (Brasic, 2003; Brasic and Davis, 1998 )• Record (Audio [Video] tape, CD, DVD) the consenting

procedure (Brasic, 2003; Brasic and Davis, 1998 )

Brasic JR: Pervasive developmental disorder: autism. eMedicine Pediatric Journal [serial online]. November 3, 2003. Available at: http://www.emedicine.com/ped/topic180.htm. Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm. Brasic JR, Davis E: Obtaining informed consent for research from persons with Parkinson’s disease and movement disorders. Movement Disorders 1998;13 (supplement 2):206 [abstract]

Consent From Staff• Institutional Review Board

• Justify need to provide for the safety of patients and staff

• Employment application include study protocol• Written informed consent (Brasic, 2003; Brasic

and Davis, 1998 )• Record (Audio [Video] tape, CD, DVD) the consenting procedure (Brasic, 2003; Brasic and Davis, 1998 )

Brasic JR: Pervasive developmental disorder: autism. eMedicine Pediatric Journal [serial online]. November 3, 2003. Available at: http://www.emedicine.com/ped/topic180.htm. Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Brasic JR, Davis E: Obtaining informed consent for research from persons with Parkinson’s disease and movement disorders.

Movement Disorders 1998;13 (supplement 2):206 [abstract]

Subjects Baseline Assessment

• On admission (for control nonviolent patients)• Research team independent of clinical and

administrative hierarchy • All patients• A simple random sample of 10% of all patients


Subjects Acute Assessment

• Perpetrator patients• Immediately after violent episodes• Research team independent of clinical and

administrative hierarchy


Subjects Follow-up Assessment

• Perpetrator patients• After intervention (eg, training, education, behavior modification, medication) for violent episodes• Research team independent of clinical and

administrative hierarchy


Tools to Measure Patient Characteristics

• Substance abuse, current and past• Criminal record, current and past• Violence, current and past• Employment status• Demographic Coding Form (Brasic, 2003, 2004)


Brasic JR. Documentation of demographic data. Psychological Reports 2003;93:151-152Brasic JR. Documentation of ethnicity. Psychological Reports 2004;95:859-861Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.

Tools to Assess Patients• Hostility Scale (hostility, suspiciousness, and uncooperativeness items)

of the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962)

• Negative Symptom Scale (flat affect, emotional

withdrawal, and motor retardation items of the BPRS) (Overall and Gorham, 1962)• Positive Symptom Scale (concept disorganization,

hallucinatory behavior, and unusual thoughts items of the BPRS) (Overall and Gorham, 1962)

• Empathy tasks (Abu-Akel and Abushua’leh, 2004)

• Modified Overt Aggression Scale (Kay et al, 1988)

• Maudsley Violence Questionnaire (Walker, 2005)

Abu-Akel A, Abushua'leh K: 'Theory of mind' in violent and nonviolent patients with paranoid schizophrenia. Schizophrenia Res 2004; 69: 45-53Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm. Foley, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Res 2005; 72: 161-168

Kay SR, et al., (1988) Profiles of aggression among psychiatric patients. I. Nature and prevalence. J Nervous Mental Disease, 1988;176: 539-546 Overall JE, Gorham DR. 1962. The Brief Psychiatric Rating Scale. Psychol Rep 10:799-812Walker JS. The Maudsley Violence Questionnaire: initial validation and reliability. Personality and Individual Differences 2005;38:187-201

Tools to Measure Staff Characteristics

• Substance abuse, current and past• Criminal record, current and past• Violence, current and past• Employment status• Age• Gender• Length of employment• Training in management of violence• Demographic Coding Form (Brasic, 2003)


Brasic JR. Documentation of demographic data. Psychological Reports 2003;93:151-152Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Crilly, et al: Violence towards emergency department nurses by patients. Accid Emerg Nurs 2004; 12: 67-73

Debriefing of Patient• Immediately after violent incident• Interviewer unfamiliar with patient• Interviewer from outside team for study only• Do not blame patient• Maintain polite, neutral, calm demeanor• Record (Audio [Video] tape, CD, DVD) interview for blind

rating by outside colleagues unfamiliar with patient• Ask open-ended questions• Elicit detailed description of incident• Precipitating events• Cognitive awareness of injury• Intent to perpetrate violence



Treatment of Patient• Immediately after violent incident• Physical examination of patient• Therapy for acute injuries• Do not blame patient• Maintain polite, neutral, calm demeanor• Record (Audio [Video] tape, CD, DVD) examination of patient for blind

rating by outside colleagues unfamiliar with patient• Immediate toxicology• Immediate basic metabolic profile• Immediate hematological profile• Treatment plan for posttraumatic stress disorder and other

anxiety disorders• Observe closely to prevent further violence

Brasic JR: Pervasive developmental disorder: autism. eMedicine Pediatric Journal [serial online]. November 3, 2003. Available at: http://www.emedicine.com/ped/topic180.htm. Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Brasić JR, Davis E: Obtaining informed consent for research from persons with Parkinson’s disease and movement disorders.


Debriefing of Staff• Immediately after violent incident• Interviewer unfamiliar with staff• Interviewer from outside team for study only• Do not blame staff• Maintain polite, neutral, calm demeanor• Record (Audio [Video] tape, CD, DVD) interview for blind rating by

outside colleagues unfamiliar with patient• Ask open-ended questions• Elicit detailed description of incident• Precipitating events• Cognitive awareness of injury• Intent to perpetrate violence



Treatment of Staff

• Immediately after violent incident• Physical examination of staff• Therapy for acute injuries• Do not blame staff• Maintain polite, neutral, calm demeanor• Record (Audio [Video] tape, CD, DVD) examination of

patient for blind rating by outside colleagues unfamiliar with staff

• Treatment plan for posttraumatic stress disorder and other anxiety disorders

• Observe closely to prevent further violence



Debriefing of Unit

• Immediately after violent incident• Mental health clinicians (consultation-liaison psychiatrist,

psychologist, nurse, social worker) unfamiliar with unit• Do not blame staff• Maintain polite, neutral, calm demeanor• Ask open-ended questions• Elicit detailed description of incident• Precipitating events• Cognitive awareness of injury• Intent to perpetrate violence



Treatment of Unit

• Immediately after violent incident• Mental health clinicians (consultation-liaison psychiatrist,

psychologist, nurse, social worker) unfamiliar with unit• Do not blame staff• Maintain polite, neutral, calm demeanor• Express concern for welfare of members of unit• Identify posttraumatic stress disorder (PTSD) and other

sequelae of incident• Institute group counseling• Institute individual treatments for staff with PTSD• Protect unit from future violence



Mathematical Modeling

• Poisson distribution, a mathematical model for rare events

• Models of airplane crashes, automobile accidents• Clustering of events in time and space• Seasonal variation• Temporal variation, eg, evenings, nights, weekends• Nursing unit variation, eg, admission, maximal

security, violent patients• Staff variation, eg, students, new staff

Abu-Akel A, Abushua'leh K: 'Theory of mind' in violent and nonviolent patients with paranoid schizophrenia. Schizophrenia Res 2004; 69: 45-53Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Foley, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Res 2005; 72: 161-168

Statistical Analysis

• Nonparametric tests for categorical data (clinical data, demographic data, empathy scores)

between violent and nonviolent patients using baseline assessments• Logistic regression models to predict violence on

clinical data, demographic data, empathy scores, involuntary admission status, employment status, insight

Abu-Akel A, Abushua'leh K: 'Theory of mind' in violent and nonviolent patients with paranoid schizophrenia. Schizophrenia Res 2004; 69: 45-53Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online]. 2005. Available at: http://www.emedicine.com/neuro/topic713.htm.Foley, et al. Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Res 2005; 72: 161-168

Clinical Trials For Patient Assault on Staff

• Baseline assessment• Intervention

• Staff training• Patient training

• Follow-up assessment


Program to ReduceViolence in Neurology

• Prepare manual to detail procedures to minimize violence• Present nationally and internationally• Publish results


Documents

Violence Reduction in Neurology. Clinician Safety References Brasic JR. Clinician safety. Grand Rounds, Kirby Forensic Psychiatric Center, Wards Island,