When is Monitoring of Restraint Episodes Misleading? Disclosures. Objectives. APNA 27th Annual Conference Session 2012: October 10, 2013.

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1 When is Monitoring of Restraint Episodes Misleading? Joanne DeSanto Iennaco PhD, PMHNP BC, APRN Disclosures The speaker has no conflicts of interest to disclose Acknowledgement: The speaker was supported by CTSA Grant Number KL2 RR from the National Center for Research Resources (NCRR) and the National C enter for Advancing Translational Science (NCATS), components of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official view of NIH. Objectives At the conclusion of this program, the participant will be able to: Identify similarities and differences between patient aggression and worker aggression exposure rates. Describe measures providing retrospective reports of aggression vs. real time reporting of aggression. Identify ways to quantify success in de escalation of aggression and use this information to improve practice. Iennaco 1

2 Overview: Defining & Measuring Aggression Common Measures: Strengths and Limitations The Next step: Moving from restraint to successful de escalation Psychiatric settings routinely monitor the use of seclusion and restraint, using the data to track performance and reduce use of containment measures. As settings move to being restraint free an unintended consequence may be the perception that aggressive behavior is no longer a problem in a clinical setting. Defining & Measuring Aggression Defining Aggression Common rates to monitor Patient aggression rates Worker exposure rates What is the reality we are measuring? The aggression continuum Similarities and differences in patient vs. worker rates As settings move to being restraint free an unintended consequence may be the perception that aggressive behavior is no longer a problem in a clinical setting. Iennaco 2

3 Defining Aggression Using initiative Political leading to war or conflict Personality style At work, on the field, in competition Emotional states Strong, forceful Hostile Potentially or actually injurious or destructive Violent: greater severity forceful action Loss of self control Destructive force Common rates to monitor Patient aggression rates Worker exposure rates In a new era of restraint free practice, it is useful to consider how aggression in psychiatric settings is measured and the implications of this data. Patient aggression rates Physical restraint rates seclusion rates Incident report or Injury rates due to aggression Report, Chart Review Scales SOAS R PCC SR VIF Counts: using hand held counters Iennaco 3

4 Author (Year) Nijman 1999 Palmstierna 1987 Yudofsky 1986 Paxton Anslow1997 Measures of Patient Aggression Provides Rate? YES YES Scale Name Description/ Use Measures of Patient Aggression (N=26, 8 identify rate of aggression) SOAS-R: Staff Observation Aggression Scale-Revised. Severity scoring system validated w/visual Analogue Scale SOAS: Staff Observation Aggression Scale. Nurse records incidents immediately after violent event; YES OAS: Overt Aggression Scale. Objective rating of verbal and physical aggression. YES AIRF: Aggressive Incident Record Form. Uses OAS and info on antecedents to event Bowers 2006 Bowers 2002 Bjorkly 1996 Brizer 1987 YES PCC-SR: Patient Staff Conflict Checklist-Shift Report Uses OAS items to identify frequency of events YES Attacks: Attempted and actual assault scale Measures antecedent, severity management; Physical only YES REFA: Report form for Aggressive Episodes Measures aggression towards other persons (verbal, physical, ppts) YES SAAB: Scale for assessment of agitated and aggressive behavior Identifies initiator, target, severity and nature of event Worker exposure rates NCVS: National Crime Victimization Survey Incident reports Injury reports Workers comp records Scales VIF POPAS Counters All rely on workers identifying events Which events would you report? Measures of Staff Exposure/Effects Reference Rate? Scale Name & Description/Use Oud 2001 YES POPAS: Perception of Prevalence of Aggression Scale Arnetz YES 1998 Needham NO 2005 Lanza 1983 NO Freq of nurse experience in past year of 12 types of violence VIF: Violence Incident Form Report of incident after it occurs IMPACS: Impact of Patient Aggression on Carers Scale Measures adverse feelings after handling aggression Assault Response Questionnaire Social, emotional cognitive and biophysiologic of nurse response Poster 1996 NO APAQ: Attitudes towards patient assault questionnaire 31 items re safety staff performance and legal issues Whittington NO Strain Questionnaire 1992 Adapted from assault response questionnaire Jansen NO ATAS: Attitude toward aggression scale (ATAS) 1997 Attitude of nurse toward patient aggr; rated on 5 pt scale Petrie 2000 NO EAVS: Exposure to Aggression and Violence Scale Events, support (colleagues, managers); injuries sustained Iennaco 4

5 What is the reality we are measuring? The aggression continuum The similarities and differences in patient vs. worker rates In reality, aggressive behavior ranges from verbal to physical and the range of severity of behavior is wide. The aggression continuum Least aggressive Most aggressive Verbal aggression where would you place it? Are there more severe forms? Factors: specificity, personal Escalation of behavior Towards objects Towards self Towards others Physical forms Actions (flexing arms, pounding fist in hand.strike out) Objects....Weapons The Continuum of Aggression Iennaco 5

6 Similarities and differences in patient vs. worker rates Depends on what you want to learn about Very few measures offer information on both Patient rates offer information about risk factors, characteristics of events and patient Information on interventions used is not extensive Worker rates may vary Common Measures Measures: SOAS R, PCC SR, VIF, POPAS Strengths Measures can provide rates of patient aggression and rates of worker exposure Provide some information on characteristics of events Limitations Retrospective reporting required Tend to report major, more severe events Rates may assume universal worker exposure SOAS R Prevalence Precipitants Target of aggression Methods or means Consequences Interventions Severity score Can be used in many kinds of settings Has write in sections General types of events Ex: staff target vs. nurse, MD etc. Reporting tends to decrease over time More severe events reported No info about visitor events may be useful in acute care hospitals Assumes all workers equally exposed Iennaco 6

7 PCC SR Identifies # of events of each type each shift Mean unit rate of events w/comparison Includes problem behaviors that relate to nursing activities Hygiene or meal refusal Medication refusal Records frequency of difficult interactions Cannot link rate to individual or specific events, patients or staff Requires charge nurse awareness Requires worker communication about events Rates assume all workers are equally exposed Results in bias toward null when evaluating effects of exposure on health or work outcomes VIF Nature of incident: Precipitants Perpetrator (including staff and family) Event information Resulting actions and response Describe events r/t specific worker Prevalence of patient aggression Prevalence of worker exposure Excludes events with target of family, patient, other workers or persons Reports wane over data collecction Tendency to identify more severe events, missing lower level events Retrospective reporting POPAS Past year worker exposure Retrospective reporting Likely inaccurate over long period (12mos) More likely to report severe exposures, underestimate lower level Iennaco 7

8 Restraint or Seclusion reports Serious events documented Provides information on consequences Required reporting Assumes equal exposure of all workers Provides average unit rate of events Many factors affect results unit, job, shift Limited information on event trajectory or intervention Injury reports Documents serious events Identifies consequences of aggression Required reporting Some injuries are not reported Report focuses on worker injury vs. event Lacks information on event characteristics Lacks intervention information Next Steps Moving from restraint to successful de escalation Measuring successfully resolved events Determining best measures for use Using measures to spur practice improvement Identify thresholds specific to your needs Turning our perspective upside down: What helped to resolve events? What are worker and team strengths? Iennaco 8

9 Determining the best measures What is the goal? If intervening to reduce events Know baseline rate of events Benefits of measuring successfully resolved events Understanding our strengths: What works The ratio of resolved to unresolved events? Using measures to spur practice improvement Use of measures Quantitative data to inform: Care planning Milieu management Thank you! To contact me: Joanne DeSanto Iennaco PhD, PMHNP BC, APRN Yale University School of Nursing 400 West Campus Drive, Orange, CT Iennaco 9