NURSES’ PERCEPTION OF THE USE OF THE DYNAMIC...

Nurses' Perception of the Use of theDynamic Appraisal of Situational Aggression(DASA) in an Emergency Psychiatric Setting

Item Type text; Electronic Dissertation

Authors Underwood, Stacy

Publisher The University of Arizona.

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Download date 02/07/2018 17:04:06

Link to Item http://hdl.handle.net/10150/624529

http://hdl.handle.net/10150/624529

NURSES’ PERCEPTION OF THE USE OF THE DYNAMIC APPRAISAL OF

SITUATIONAL AGGRESSION (DASA) IN AN EMERGENCY PSYCHIATRIC

SETTING

by

Stacy Lynn Underwood

________________________ Copyright © Stacy Lynn Underwood 2017

A DNP Project Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements

For the Degree of

DOCTOR OF NURSING PRACTICE

In the Graduate College

THE UNIVERSITY OF ARIZONA

2 0 1 7

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THE UNIVERSITY OF ARIZONA GRADUATE COLLEGE

As members of the DNP Project Committee, we certify that we have read the DNP Project

prepared by Stacy Lynn Underwood entitled “Nurses’ Perception of the Use of the Dynamic

Appraisal of Situational Aggression (DASA) in an Emergency Psychiatric Setting” and

recommend that it be accepted as fulfilling the DNP Project requirement for the Degree of

Doctor of Nursing Practice.

_________________________________________________________ Date: April 6, 2017 Michelle Kahn-John, PhD, RN, PMHNP-BC, GNP

_________________________________________________________ Date: April 6, 2017 Kathleen Insel, PhD, RN

_________________________________________________________ Date: April 6, 2017 Donna McArthur, PhD, APRN, FNP-BC, FAANP, FNAP Final approval and acceptance of this DNP Project is contingent upon the candidate’s submission of the final copies of the DNP Project to the Graduate College. I hereby certify that I have read this DNP Project prepared under my direction and recommend that it be accepted as fulfilling the DNP Project requirement.

_________________________________________________________ Date: April 6, 2017 DNP Project Director: Michelle Kahn-John, PhD, RN, PMHNP-BC, GNP _________________________________________________________ Date: April 6, 2017 Kathleen Insel, PhD, RN

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STATEMENT BY AUTHOR

This DNP Project has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.

Brief quotations from this DNP Project are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his or her judgment the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author.

SIGNED: __Stacy Lynn Underwood_______________

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ACKNOWLEDGMENTS

I would like to thank my wonderful committee for all their encouragement and support

throughout my long journey to the DNP. Their extensive knowledge of the nursing field,

research, and practice, has been invaluable to me during this process. If not for them, I would not

be finishing the program today.

I would also like to acknowledge Connections Arizona and Dr. Robert Williamson for

allowing me to develop the DNP project within the facility. In addition, I would like to thank

Josh Leslie PA-C, Amanda Johnson-Wo PA-C, Yolanda Bough RN, Brian Montgomery RN,

Julie Curtain RN, Amber Segal RN, Angela Goettl Crisis Worker, Shane Curtis and all the RN’s

who chose to participate in the project for their participation, support and encouragement.

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DEDICATION

I would like to dedicate this DNP project to all of those people instrumental in the

development, positive influence and encouragement that led to the completion of the project.

Most of all, the completion of the project ant the DNP degree is dedicated to my mother, father,

and sister who have always been my strongest supporters and cheerleaders throughout my life.

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TABLE OF CONTENTS8

LIST OF FIGURES ......................................................................................................................... 8

LIST OF TABLES .......................................................................................................................... 9

ABSTRACT .................................................................................................................................. 10

INTRODUCTION ....................................................................................................................... 12

Background and Significance ..................................................................................................... 12

Local Problem .............................................................................................................................. 16

Purpose ......................................................................................................................................... 19

Study Questions ........................................................................................................................... 19

Literature Review ........................................................................................................................ 20

Framework and Theoretical Underpinnings ............................................................................ 26

METHODS ................................................................................................................................... 28

Setting ........................................................................................................................................... 28

SAUPC’s Implementation of the DASA .................................................................................... 29

Current DNP Project – Planning Phase .................................................................................... 32

Recruitment of RN Study Participants .......................................................................... 34

Informed Consent ............................................................................................................ 34

Participant Privacy and Confidentiality of Data .......................................................... 35

Ethical Issues .................................................................................................................... 35

Measures ........................................................................................................................... 35

Method of Evaluation ...................................................................................................... 36

Analysis ............................................................................................................................. 36

Planning the Intervention – “Plan” of PDSA ............................................................................ 36

RESULTS ..................................................................................................................................... 37

Analysis of the PDIQ, “Study” ................................................................................................... 37

Descriptive Statistics ....................................................................................................... 37

Research Questions ......................................................................................................... 38

Research question 1. ............................................................................................ 38


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TABLE OF CONTENTS – Continued




Gender. ...................................................................................................... 41

Years of experience as an RN. ................................................................. 42

Level of education. .................................................................................... 43

Years at SAUPC. ....................................................................................... 44


DISCUSSION ............................................................................................................................... 45

PDSA “Act” .................................................................................................................................. 45

Strengths and Limitations .......................................................................................................... 49

CONCLUSIONS .......................................................................................................................... 51

APPENDIX A: DISCLOSURE STATEMENT ........................................................................... 53

APPENDIX B: DEMOGRAPHIC INFORMATION .................................................................. 55

APPENDIX C: POST DASA IMPLEMENTATION QUESTIONNAIRE - PDIQ .................... 57

APPENDIX D: PROCESS FLOW SHEET ................................................................................. 60

REFERENCES ............................................................................................................................ 62

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LIST OF FIGURES

FIGURE 1. Box Plot of the DASA Usefulness Score by Gender ............................................ 42

FIGURE 2. Box Plot of the DASA Usefulness Score by Level of Education .......................... 44

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LIST OF TABLES

TABLE 1. Frequency Table of Level of Agreement with the Statement, “The DASA was effective in identifying potentially aggressive/violent behaviors in patients.” ...... 38

TABLE 2. Frequency Table of Level of Agreement with the Statement, “The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.” ............................................................................................... 39

TABLE 3. Frequency Table of Level of Agreement with the Statement, “The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.” .............................................................................. 40

TABLE 4. Frequency Table of Level of Agreement with the Statement, “I believe using the DASA decreased the episodes of seclusion and restraint.” .................................. 40

TABLE 5. Frequency Table of Level of Agreement with the Statement, “I would like to continue to use the DASA as a violence risk assessment tool.” ............................ 45

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ABSTRACT

Background: The use of the Dynamic Assessment of Situational Aggression (DASA) in acute

psychiatric settings to identify aggressive and/or violent patients upon admission.

Objective: Determining nurses’ perception of the usefulness of the Dynamic Assessment of

Situational Aggression (DASA) in a psychiatric emergency room setting.

Theoretical Background: Langley, Nolan, Nolan and Provost’s (2009) Model for Improvement,

which incorporates Deming’s Plan-Do-Study-Act (PDSA) cycle, was utilized as the

theoretical framework to guide this DNP project.

Setting: An adult psychiatric emergency room in urban Phoenix, Arizona.

Measurement: A six-item survey questionnaire measured on a five-point Likert scale ranging

from “Strongly Disagree” (1) to “Strongly Agree” (5) describes and measures nurses’

perception on the usefulness of the DASA. An additional question explored the influence

of static nursing factors (gender, years of experience, level of education, years at the

facility), on nurses’ perception of the usefulness of the DASA.

Results: Overall, nurses (90%) of the study participants perceived the DASA to be effective in

identifying aggressive violent patients and 70% of the participants would like to continue

to use the DASA. Static nursing factors showed no difference in nurses’ perception of

usefulness.

Limitations: Further exploration in similar settings such as regular emergency departments and

psychiatric emergency and crisis settings are recommended. In this study only nursing

perception was explored. Analysis of the validity of the DASA tool in the psychiatric

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emergency room setting in addition to nursing perceptions would be more beneficial in

determining the DASA’s true usefulness.

Conclusion: The results of this DNP project demonstrate that nurses at the SAUPC perceive the

DASA to be a useful addition to their admission assessment. Overall nursing response

was positive and the SAUPC seclusion and restraint committee recommended

incorporating the DASA into the triage nursing admission assessment.

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INTRODUCTION

Background and Significance

According to the United States Bureau of Justice’s National Crime Victimization Survey

findings from 1993-2009, “In 2009, an estimated four violent crimes per 1,000 employed persons

age 16 or older were committed while the victims were at work or on duty” (Harrel, 2011, p. 1).

Of the occupations measured, medical professionals (physicians, nurses, technicians, and

other/medical occupations) experienced workplace violence at a rate of 6.5 per 1,000 employed

persons, whereas mental health professionals and other mental health occupations experienced

incidents of violence at a rate of 20.5 per 1,000 employed persons (Harrel, 2011). The prevalence

of threats and assaults by patients were reported highest from physicians, nurse practitioners, and

nurses working on inpatient units and in psychiatric emergency rooms (Privitera, Weisman,

Cerulli, Tu, & Groman, 2005). Due to the high incidence of patient aggressive and violent

behaviors that occur in psychiatric settings, the ability to identify, predict the occurrence of these

behaviors, and intervene to prevent patient aggression and violence is important for overall

patient and staff safety.

Historically, tools to assess risk of violence were developed and tested on prisoners and

forensic (criminal) psychiatric patients prior to release or discharge into the community (Barry-

Walsh, Daffern, Duncan, & Ogloff, 2009). As such, these instruments are standardized and focus

on static risk factors that do not change based on mental state. In some psychiatric settings, more

specifically forensic, these standardized risk assessment tools are effective, but in the

crisis/emergency psychiatric settings, where rapid assessment and management are critical in

mitigating patient and staff safety, the tools may not have clinical utility (Sands, Elsom, Gerdtz,

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& Khaw, 2012). For this reason, research has focused on the difference between the prediction of

imminent aggression, short-term aggression, and long-term predictors, with a concentration on

more dynamic risk factors (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Bjorkly, Hartvig,

Braur, & Moger, 2009; Chapman, Perry, Styles, & Combs, 2009; Clarke, Brown, & Griffith,

2010; Kling et al., 2006; Ideker, Todicheeney-Mannes, & Kim, 2011; McDermott & Holoyda,

2014). Static risk factors (fixed) are defined as events occurring in the past that may influence a

patient’s current behavior (i.e., history of violence, arrests, history of abuse), whereas dynamic

risk factors are contextual, situational, and temporal variables (substance intoxication, emotional

state, support) that are changeable (Eccleston & Ward, 2004). Although historical factors are

helpful in determining risk, studies have found that dynamic, generally observable factors, such

as behavior, appearance, speech, and thought process, are more predictive of violent behavior

(McNiel, Gregory, & Lam, 2003; Sands, Elsom, Gerdtz, & Khaw, 2012).

The ability to determine who will or will not engage in violent acts in a psychiatric

emergency setting is currently beyond our reach. Through research and an awareness of a

combination of empirically supported risk factors, a practitioner may make a reasoned judgment

as to the chance that a psychiatric patient will become violent (Mullen & Oglaff, 2008, as cited

in Allnut et al., 2010). Early identification and rapid assessment of potentially violent and

aggressive patients, whether due to involuntary status, psychosis, or other factors, allows for the

implementation of interventions that can decrease the occurrence of violence (Bowers et al.,

2011). The identification of risk factors for violence during the initial assessment processes

enhances the possibility for prevention (Sands, 2007). Therefore, identifying and utilizing a tool

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that allows for rapid assessment by facility first responders, such as a registered nurse, should

allow for timely implementation of appropriate interventions with high-risk patients.

Defining aggression and violence is difficult. In a literature review and meta-analysis,

aggression was defined by type from physical only, verbal only, both verbal and physical,

towards objects, toward staff, and other combinations of these behaviors (Bowers et al., 2011).

The National Institute for Health Care Excellence (NICE, United Kingdom), indicates

“Violence and aggression refer to a range of behaviors or actions that can result in harm,

hurt or injury to another person, regardless of whether the violence or aggression is

physically or verbally expressed, physical harm is sustained or the intention is clear”

(2015, p. 6).

The NICE definition views violence/aggression as interchangeable, provides a general

characterization of violent and aggressive behaviors, and is therefore used for the purpose of the

project.

In both emergency and psychiatric settings, the risk of admitting violent and potentially

violent patients is high. In many cases, information about the patient’s history and reason for

presentation is limited. Binder and McNiel (1999) interviewed medical directors from 20

different psychiatric emergency rooms throughout the United States. These interviews revealed

that it is difficult to determine the etiology of violent behaviors of unfamiliar patients, difficult to

obtain accurate vital signs, or obtain appropriate laboratory tests (breathalyzer, urine drug

screen). More recent research supports early assessment indicating that violence risk assessment

during triage instead of during primary assessment addresses the period of high risk, which is

within the first 1-2 hours upon arrival to a facility (Daniel, Gerdtz, Elsom, Knott, Prematunga, &

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Virtue, 2015). Further, most patient presentations were not amenable to direct questioning

supporting the use of a behavioral based assessment (Daniel et al., 2015). The most commonly

used protocol for acutely violent patients was restraint and medication (Binder & McNiel, 1999;

Roberts, Crompton, Milligan, & Grooves, 2009; Wale, Belkin, & Mood, 2011). For this reason,

although used as a last resort, elevated seclusion and restraint rates are common. Data from the

Centers for Medicare & Medicaid Services (CMS) Hospital Compare Inpatient Psychiatric

Facility Quality Reporting Program (2014) indicate national average for physical restraint are

0.39 hours overall rate per 1000 patients, and 0.2 hours overall rate for seclusion. Older data in a

congressional report from the United States General Accounting Office, GAO, (1999) found

among five state hospital systems, the rates of seclusion and restraint varied widely. Seclusion

episodes ranged from 0.6-41.8 per 1000 patient days and seclusion episodes ranged from 0.2-

29.1 per 1000 patient days (GAO, 1999).

The use of seclusion and/or restraint (Daniel et al., 2015) is used in emergency rooms and

psychiatric facilities to manage acute aggressive and/or violent behaviors and is surrounded by

controversy (Downey, Zun, & Gonzales, 2007; Georgieva, Mulder, & Noorthoorn, 2012;

Huckshorn, 2014; Wieman, Camacho-Gonsalves, Gonsalves, Huckshorn, & Leff, 2014). Due to

the increased risk of physical harm and psychological trauma to the patients and staff secondary

to seclusion and restraint episodes (Knox & Holloman, 2012; LeBel, Duxbury, Putkonen,

Sprague, Rae, & Sharpe, 2014; Moran, Cocoman, Scott, Matthews, Staniuliene, & Valimaki,

2009; Steinert, Berger, Psych, Schmidt, & Gebhardt, 2007) the practice of seclusion and restraint

is closely regulated and considered acceptable only as a last resort (Knox & Holloman, 2012;

Vollmer et al., 2011). Utilizing assessment tools early in the assessment process that identify

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aggressive and violent behaviors that commonly lead to seclusion and restraint, have the

potential to impact seclusion and restraint rates, staff/patient safety, and improve the assessment

process.

Local Problem

The Southern Arizona Urgent Psychiatric Center (SAUPC), located in a large metro area,

is a freestanding psychiatric room/observation unit with a recliner/bed capacity of 50 that

provides crisis psychiatric services to the greater Phoenix area. Like many acute care settings

where patients are in crisis, decreasing the occurrence of violent and aggressive behaviors toward

staff and peers is a goal (Chapman, Perry, Styles, & Combs 2009; Ideker, Todicheeney-Mannes,

& Kim, 2011; Kling et al., 2006).

The practice of seclusion and restraint is a highly scrutinized practice in the psychiatric

community (Georgieva, Mulder, & Noorthoorn, 2012). Concerns regarding seclusion and

restraint are addressed at the SAUPC by the Seclusion & Restraint (S&R) Committee, which

consists of members of the facilities multidisciplinary team (Medical Director, Director of

Nursing, Director of Operations, Compliance Officer, a Nurse Practitioner, Charge RN, Staff

RN, Lead Behavioral Health Specialist, Behavioral Health Specialist, a Social Worker, a

Rehabilitation Support Specialist and Admissions Coordinator) on a monthly basis. The purpose

of the meeting is to review episodes of seclusion, restraint, incidences of violence on the unit,

and develop ways to decrease the incidence of seclusion and restraint events and increase safety

during these events. Due to a recent upward trend of patients presenting with violent and

aggressive behavior and a subsequent increase in the incidence of seclusion and restraint events,

the SAUPC Seclusion and Restraint Committee determined that intervention was required. A

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quality improvement project, utilizing the Model for Improvement as a guideline, was developed

and implemented. The Model for Improvement, developed by Langley, Nolan, Nolan, and

Provost (2009), is a framework that acknowledges the complexity of relationships and their

influence on care delivery while taking into account variation, knowledge, and psychology. The

theory is implemented using Deming’s Plan-Do-Study-Act (PDSA) cycle. The S&R Committee

decided to implement a new violence risk assessment during the initial admission process at the

SAUPC in hopes to improve their assessment of potentially violent patients and decrease

emergency seclusion and restraint. As part of the implementation-planning phase, violence risk

assessment tools were researched, and two were chosen and presented to the S&R Committee at

the SAUPC.

The SAUPC provides all staff members with CPI (Crisis Prevention Intervention) non-

violent crisis intervention training on a yearly basis. Crisis Prevention Intervention is a behavior

management philosophy, considered to be the worldwide standard for crisis prevention and

intervention. CPI utilizes a holistic approach to defuse escalating, aggressive, and violent

behaviors, while maintaining the therapeutic relationship (Crisis Intervention Prevention, 2016).

In addition, should a patient’s behavior escalate to the point of actually attempting to harming

self or others, CPI incorporates and teaches safe appropriate time limited practices for physically

holding a patient. Despite the use of CPI methods by all staff, some patients still require

seclusion and/or restraint. Review of the SAUPC seclusion and restraint monthly state report

(summary of de-identified patient seclusion and restraint information) revealed that the facility

has a high incidence of seclusion and restraint episodes that occur within the first 60 minutes of

the patient being brought to the facility-either by crisis team, police, ambulance, or walk-up (B.

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Montgomery, Nurse Manager SAUPC, personal communication, May 10, 2016). This finding is

consistent with literature that indicates that the first 1-2 hours of admission in an emergency

room is the period of highest risk for a behavioral emergency (Daniels et al., 2015). As violent

and aggressive behaviors lead to increased risk of injuries for staff and patients and increased

risk of seclusion or restraint, the S&R Committee concluded a rapid and effective manner in

which to assess patients upon admission was needed to address the upward trend of S&R. The

absence of a formal or evidenced based violence risk assessment at the SAUPC supported the

implementation of a violence risk assessment at admission for every patient entering the SAUPC.

The S&R Committee at the SAUPC selected the Dynamic Assessment of Situational Aggression

(DASA) for implementation. The DASA and the process of selection are further described in the

literature review.

The DASA was implemented from June 15, 2016 through October 15, 2015. During this

period, greater than 4000 patients were screened by nurses, at the point of initial contact, upon

admission to the SAUPC. The principle investigator for this project is a Doctor of Nursing

practice student, a practicing Psychiatric Nurse Practitioner, and was naturally selected by the

S&R committee to be the lead for the development and implementation of the planned quality

improvement project. The S&R committee decision to implement the use of the DASA by nurses

at the SAUPC, provided the opportunity for the principle investigator of this project to conduct a

doctor of nursing practice quality improvement project.

The Dynamic Assessment of Situational Aggression (DASA) has been utilized in various

psychiatric settings that include, psychiatric intensive care units, voluntary, and involuntary

inpatient units (Ogloff & Daffern, 2006; Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Chu,

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Thomas, Ogloff, & Daffern, 2011; Dumais, Larue, Michaud, & Goulet, 2012; Griffith, Daffern,

& Godber, 2013). To date, there have been no studies published in the literature that include the

use of the DASA instrument in the United States, or in a freestanding psychiatric emergency

room.

Purpose

The purpose of this DNP project is to determine nurses’ perception of the usefulness of

the DASA in a psychiatric emergency room. By increasing awareness of dynamic behavioral risk

factors (dynamic) and early identification/prediction of potentially aggressive/violent behaviors,

it was hypothesized that nurses would perceive the DASA useful during their initial assessment.

Study Questions

Utilizing a self-report questionnaire completed by the nurses who utilized the DASA

during SAUPC’s implementation, the following study questions were addressed:

1. Do nurses perceive the DASA to be effective in identifying potentially aggressive/violent

patient’s behaviors?

2. Do nurses perceive the use of the DASA increases their awareness of the behaviors

(negative attitudes, impulsivity, irritability, verbal threats, sensitive to perceived

provocation, easily angered when requests are denied, unwillingness to follow directions)

that indicate a patient’s increased risk for aggressive/violent behavior?

3. For patients that nurses perceive are at risk of violent/aggressive behaviors, does the

DASA trigger an initiation of an intervention by the nurse?

a) And if so, what interventions were used?

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4. Do nurses perceive a decrease in seclusion and restraint episodes as a result of the use of

the DASA?

a) Which behaviors reported by nursing lead to an episode of seclusion and/or

restraint?

5. Is nurse gender, years of experience as a nurse, level of education, and/or years at the

facility, associated with the nurses’ perception of the usefulness of the DASA?

6. Do nurses want to continue to use the DASA as a violence assessment tool in the

psychiatric emergency room setting?

Literature Review

A literature search was conducted to find research conducted on violence risk

assessement and on seclusion and restraint practices. Electronic databases including PubMed

(Med-Line), PsychInfo (ProQuest), and CINAHL were searched. Search terms included,

violence, risk assessment, seclusion and restraint, psychiatric hospital, emergency room, violence

prevention, and nursing assessment. Once brief risk assessments were identified research

specifically related to those tools was searched. Only articles related to violence risk assessment,

seclusion and restraint, emergency room, and pyschiatric settings were used.

Consistent with research, violence or threatening violence, agitation, and disorientation

(Kaltiala-Heino, Tuohimaki, Korkeila, & Lehtinen, 2003; Larue, Dumais, Drapeau, Menard, &

Goulet, 2010; Knox & Holloman, 2012; Keski-Valkama, Sailas, Eronen, Koivisto, Lonnqvist, &

Kaltaiala-Heino, 2010; Vruwink et al., 2012) involuntary status (Iozzino, Ferrari, Large,

Nielssen, de Girolamo, 2015; Gergiev, Vesselinov, & Mulder, 2012; Taylor et al., 2012; van de

Sande et al., 2013; Vruwink et al., 2012), psychotic symptoms and paranoid behaviors

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(Geogieva, Vesselinov, & Mulder, 2012; Taylor et al., 2012; van de Sande et al., 2013), and

recent alcohol or drug abuse (Iozzino, Ferrari, Large, Nielssen, & de Girolamo, 2015; Witt, van

Dorn, & Fazel, 2013) are the most frequent contributing factors leading to seclusion and restraint

at the SAUPC. Research indicates that the use of systematic, structured, violence risk assessment

have led to a decrease in patient seclusion and restraint episodes (Abderhalden, Needham,

Dassen, Hlfens, Haug, & Fisher, 2008; van de Sande et al., 2011).

Standard violence risk assessments developed in the forensic (criminal) setting, which

focus on non-changing static factors, are limited in usefulness in the crisis/emergent psychiatric

setting (Sands, Elsom, Gerdtz, & Khaw, 2012). Structured clinical tools/instruments that

consider dynamic factors in addition to static risk factors have shown success in assessing for

aggression and potential violent behaviors in patients (Amlik & Woods, 2000; Ogloff & Daffern,

2006; Bjorkly, Harvig, Heggen, Brauer, & Moger, 2009; Chu, Thomas, Ogloff, & Daffern,

2011). Multiple studies have evaluated the validity (how well the assessment or tool measures

what it intends) of various tools in the psychiatric intensive care unit and on inpatient voluntary

and involuntary psychiatric units (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Bjorkly,

Harvig, Heggen, Brauer, & Moger, 2009; Clark, Brown, & Griffith, 2010, Dumais, Larue,

Michaud, & Goulet, 2012; McDermott & Holoyda, 2014). Based on supporting research and

level of appropriateness for the SAUPC, the Broset Violence Checklist (BVC), and the Dynamic

Appraisal of Situational Aggression (DASA), were selected to be reviewed by the S&R

Committee. In addition, existing studies that mention nursing perception on the use of the

different violent risk assessments mention the need for the investigation of violence assessment

in the psychiatric emergency and crisis settings. A brief description of each assessment tool is

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provided with a final summation of the reasons the S&R committee selected the DASA for the

SAUPC quality improvement project.

The Broset Violence Checklist (BVC) is a six-item structured clinical tool, completed by

the nurse to assess for potential patient violence within the following 24-hours of assessment

(Almvik & Woods, 1999). It has been extensively studied in inpatient psychiatric settings and

with varying populations (Almvik & Woods, 1999, Aberhalden et al., 2004, 2006, 2008;

Bjorkdahl, Olsson, & Palmstierna, 2006; Clark, Brown, & Griffith, 2010; Yao, Li, Arthur, Hu,

An, & Cheng, 2014). The tool, which takes less than one minute to complete, utilizes six items to

assess patient characteristics; confusion, irritability, boisterousness, verbal threats, physical

threats, and attacks on objects (Almvic & Woods, 1999). The presence of two or more of the

behaviors indicates a higher likelihood that a patient may become violent. Previous studies

(Almvic & Woods, 1999; Almvik, Woods & Rasmussen, 2000; Almvik et al., 2007; Vaaler et

al., 2011) demonstrated within the first 72-hours post admission, that the tool is more reliable

than clinical judgment or intuition, for predicting violent episodes. The BVC showed, with 63%

accuracy that violence will occur within the next 24-hours, and had 92% accuracy in predicting

violence will not occur. In addition, they found that using the instrument during admission

resulted in 41% reduction in severe aggressive events and a 27% reduction in the need for

seclusion and restraint measures. A more recent study evaluated the ability of the BVC to help

staff on a psychiatric intensive care unit identify potential violence and explored its utility in

implementing interventions that eliminate or reduce the impact of violence and behaviors (Clark,

Brown, & Griffith, 2010). Results among patients who consented to the study, revealed that on

Day 1 of admission, involuntary (those on a mental health hold) patients scored higher on the

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screen than voluntary patients did, female scores were higher than male scores, irritability was

the most predictive in BVC scores, and seclusion rates decreased “dramatically” over the three-

month study period (Clarke, Brown, & Griffith, 2010). Nurses completing the BVC were

provided questionnaires about its use and found that the nurses felt the tool was easy to use, took

approximately 1-2 minutes to complete and was easy to understand (Clarke, Brown, & Griffith,

2010). Scoring of the BVC was also consistent between staff completing the instrument (Clarke,

Brown, & Griffith, 2010). Despite the positive results, it was noted that the sample size of

patients in the study and the nurses completing the questionnaires was small, was not

consistently used by all staff, and hence, the results were not generalizable. The BVC was also

well received and appeared to be a great choice for the setting. Although all six items are

dynamic in nature and relate to violence, not all were amenable to intervention, redirection by

staff members, or treatment planning (Ogloff & Daffern, 2006). Studies explored the ability of

the BVC to encourage the use of least restrictive measures. One occurred on a small (11-bed)

PICU that had a small sample size (Clark, Brown, & Griffith, 2010) and the other study,

conducted on regular inpatient psychiatric wards, focused on applicability, validity, and

acceptability in a Chinese population (Yao, Li, Arthur, Hu, An, & Cheng, 2014).

Due to the BVC’s, lower ability to accurately predict the occurrence of violence in the

following 24-hours (63% vs. 70% for the DASA), and the absence of impulsivity as a risk factor,

the BVC was not chosen for the SAUPC implementation project.

The Dynamic Appraisal of Situational Aggression (DASA) is a brief structured violence

instrument developed to assist in the assessment of imminent aggression (within the next 24-

hours). The DASA assessment, consisting of seven items, draws two items from the HCR-20

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(negative attitudes and impulsivity), two items from the BVC (irritability and verbal threats), and

three items (sensitive to perceived provocation, easily angered when requests are denied, and

unwillingness to follow directions), from the authors of the DASA’s research (Ogloff & Daffern,

2006). The items were chosen because they are each independently related to imminent

aggression (Ogloff & Daffern, 2006). In addition, these seven items were found to increase

predictive validity and lead to identifiable variables which staff may target for intervention, in

turn, enabling the prevention of aggressive acts (Ogloff & Daffern, 2006, p. 809). Studies have

shown the DASA to have moderate to strong predictive ability (Ogloff & Daffern, 2006, Barry-

Walsh, Daffern, Duncan, & Ogloff, 2009; Chu, Thomas, Ogloff, & Daffern, 2011). As with the

other studies, scores were more accurate in identifying imminent aggression in patients than with

unaided clinical judgment (Griffith, Daffern, & Godber, 2013). In addition, the DASA has been

able to identify aggressive events that occurred early in a patient’s admission and prior to

psychiatric evaluation (Chan & Chow, 2014). In terms of usefulness, nursing response to the

DASA was generally positive with the exception of one study that found nurses did not perceive

the DASA to be an improvement on their own clinical judgment (Daffern et al., 2009). Another

usefulness and predictive validity study was conducted in a 12-bed psychiatric intensive care unit

in a psychiatric hospital in Quebec, Canada (Dumais et al., 2012). The study found that the

nurses’ clinical judgment was comparable to the DASA for prediction of patient aggression. In

addition, staff generally considered the DASA relevant to their practice and was useful for

preventing the escalation of aggressive behaviors. Most recently, a study was completed in

which the DASA was implemented on mental health units in the Finnish healthcare system

(Lantta, Daffern, Kontio, & Valimaki, 2015). Generally, many nurses found the DASA was

25

quick and easy to complete, generated information sharing among staff, was suitable for both

experienced and inexperienced staff, and facilitated admission assessment (Lantta et al., 2015).

Of the nurses with a negative response to the DASA, the researchers found that the use of a

structured assessment was not always positively received, that many nurses did not believe that

the DASA instrument was better able to predict violent/aggressive behaviors, and that they

preferred to rely on their own clinical judgment (Lantta et al., 2015).

Overall, the DASA was chosen by the SAUPC Seclusion & Restraint Committee because

it can be completed quickly (Dumais et al., 2012; Griffith, Daffern, & Godber, 2013; Lantta et

al., 2015; Vojt, Marshall, & Thompson, 2010), has been found to have a moderate to strong

predictive ability (Barry-Walsh, Daffern, Duncan, & Ogloff, 2009; Chu, Thomas, Ogloff, &

Daffern, 2011; Ogloff & Daffern, 2006), does not require verbal patient interview, has no

restrictive user requirements, is used in an 24-hour context, was found useful in similar settings

(Dumais et al., 2009; Lantta et al., 2015), and encourages the initiation of preventive measures to

decrease the potential of patient violence/aggression (Barry-Walsh, Daffern, Duncan, & Ogloff

2009; Chu, Thomas, Ogloff, & Daffern, 2011; Griffith, Daffern, & Godber, 2013; Ogloff &

Daffern, 2006). In addition the SAUPC Seclusion & Restraint Committee concluded that the

DASA’s inclusion of impulsivity was crucial to assessing potential violence/aggression.

Investigative data on impulsivity and aggression suggests aggression can manifest in two forms,

“manipulative, cold, premeditated, executively complex, antisocial agression versus impulsive,

hot, executively simple aggression” (Singh, Serper, Reinharth, & Fazel, 2011, p. 910). The

SAUPC Seclusion and Restraint Committee members felt that much of the violent and

aggressive behaviors were reactive and impulsive in nature and immediately assessing for

26

impulsive behaviors was of high importance. Research indicates that aggression is impulsive,

reactive, is strongly influenced by perception and is one of the most common and difficult to

predict (Quanbeck et al, 2007; McDermott, Quanbeck, Busse, Yasso, & Scott, 2008). The intent

of the SAUPC Seclusion and Restraint Committee to implement the DASA for use by RN’s as

an assessment of patient risk for becoming violent would enhance staff (MD, NP, PA, behavioral

health techs, recovery support specialists, and crisis workers) ability to intervene and prevent

future violence, aggression, and subsequent seclusion and restraints.

Framework and Theoretical Underpinnings

Determining the usefulness of a violence assessment tool falls into the realm of quality

improvement. Improvement theory and continuous quality improvement methods were used to

guide the completion of the DNP project. Langley, Nolan, Nolan and Provost’s (2009) Model for

Improvement, which incorporates Deming’s Plan-Do-Study-Act (PDSA) cycle, was utilized as

the theoretical framework to guide this DNP project. The Model for Improvement describes four

components that underlie improvement. The first component is appreciation of a system, which

acknowledges the complex nature of the relationships (between care providers) and components

(treatments, procedures) involved in delivery of care and understanding of the dependence on

each other (Institute for Healthcare Improvement, 2016). The second component is an

understanding of variation (between hospitals, units, staffing, etc.) and how that influences

outcomes. The third component is a theory of knowledge leading to predictions about the results

of a change. The final component is psychology. For the purposes of improvement, psychology

represents the understanding of how people interact with the system and each other (Institute for

27

Healthcare Improvement, 2016). Addressing all four components in a quality improvement effort

leads to successful improvement.

The PDSA suggests a systematic approach to formulating a plan for change and

determining whether the change is an improvement in an actual work setting (Institute for

Healthcare Improvement, 2016). The model provides the ‘roadmap’ by identifying three

questions focused on the aim of the change, quantitative measurements to assess change, and

select changes, as well as the PDSA cycle to test the change and implement and spread the

change. During the planning stage, the aim or goal/purpose is determined, a theory or prediction

is formulated, measures for success are defined, and a plan made for implementing the change

(The W. Edwards Deming Institute, 2016). In the Do state, the change is implemented. In the

Study stage, outcomes are evaluated to determine the success of the change and areas for

improvement are identified. The Act stage ends the cycle, integrates what was learned from

process, and aims, methods, and original theories or predictions can be adjusted. The cycle is

then repeated if needed to further refine additional aspects of quality improvement.

The “Aim” for this DNP is to determine the nurses’ perception of the usefulness of the

DASA in the identification of potentially aggressive/violent patients. Data will be collected with

the use of questionnaires completed by nurses who participated in completing the DASA during

the SAUPC’s implementation period (Summer/Fall of 2016). Descriptive statistics and

correlational analyses to determine the relationship between responses on the items and outcome

variables were used to evaluate whether nurses’ perceived the DASA to be useful. The selected

change is based on nursing perception of the DASA’s usefulness and their desire to continue to

use the assessment.

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METHODS

Setting

The vision of the SAUPC is “To provide high quality behavioral health care that is

person-centered, evidence-based and culturally sensitive, that expects recovery from mental

illness” (connectionsarizona.com). The facility focuses on providing access to care for everyone

(adults age 18 and older) regardless of his or her, race, color, sex, national origin, disability

religion, sexual orientation, or ability to pay. The vision incorporates the belief that psychiatric

hospitalization can be avoided with appropriate intervention, which includes collaboration with

“community partners” (e.g., police, emergency departments, jails, family, behavioral health

providers, medical providers). Effective collaborative with community partners facilitates

successful patient outcomes. In addition, if hospitalization is required, length of stay can be

shortened with aggressive, tailored and early assessment and/or intervention.

The SAUPC facility services approximately 900 patients per month 36% of who are

voluntary and 64% involuntary. The unit accepts patients 24-hours a day, 365 days a year. The

focus is on crisis observation and stabilization. A disciplinary team consisting of social workers,

behavior health specialists (BHS), unit coordinators, RN’s, PA’s, NP’s, and MD’s collaborate to

provide therapeutic support, evaluation, and treatment to the community. Patients are evaluated

and the need for further psychiatric care, whether voluntary or involuntary, is determined.

Patients who are deemed appropriate for discharge are provided appropriate community referrals.

The majority of the patient population comes from Maricopa County in Southern Arizona.

Patients access the facility on a walk-up basis, transfer from emergency rooms and hospitals, via

police, and crisis intervention. No patient is turned away.

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The observation unit has two levels of care, which consists of 50 reclining chairs, 10 of

which are in a separate area and reserved for highly acute patients. Forty of the recliners are in a

large open area (room) with two sections; male and female. Multiple BHS staff are assigned to

areas of the room to continuously monitor, assess, and engage with patients. The size (number of

chairs) on the male or female side fluctuates based on the patient population. Along one wall,

there are several interview, quiet, and group rooms. There are individual bathrooms and showers.

The higher acuity side of the unit is also divided into two sections, male and female. BHS to

patient ratio (2 BHS to 10 patients) is increased allowing for a higher level of observation if

needed. Currently there is no set criterion for placement in this section other than provider and

charge nurse choice. Both areas are connected to the nursing/staff station, which looks onto both

sections of the observation unit. Cameras are placed throughout the facility and an emergency

alert system is in place. Staff members are also required to carry a hand held radio throughout

their shift.

SAUPCP’s Implementation of the DASA

To provide a clear background for the DNP project, the implementation of the DASA and

the process of that implementation at the SAUPC will be described. The unit and patient specific

data collected during the SAUPC implementation of the DASA will not be utilized in this

project. This study will focus on surveying nurses at the SAUPC to assess their perceived

usefulness of the DASA in a psychiatric emergency setting.

The SAUPC utilized the Institute for Healthcare Improvement PDSA Worksheet to

implement the use of the DASA in the summer/fall of 2016. The worksheet was useful in

identifying the tasks that were required to initiate the intended change and identified a task

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completion deadline. The implementation of the DASA on the unit required the completion of

the following tasks; making copies of the DASA collection sheet, placing the DASA in the

nursing admission packet, setting up a DASA training schedule for nursing staff, and the

establishment of a start and end date for data collection. Once the plan was set in place the

prediction and measures section of the PDSA worksheet was completed.

Upon implementation of the DASA at the SAUPC, the Chief Medical Officer and the

Seclusion and Restraint committee required the DASA in every nursing assessment packet to be

completed by all nursing staff admitting patients to the facility. All nursing staff participated in a

15-minute power point training session to describe the purpose of the DASA. Handouts were

provided after the power point presentation and training session. Question and answer, with

interactive and guided completion was provided (Griffith, Daffern, & Godber, 2013). The

admission process flow to include the DASA was reviewed as well (Appendix D). Training

sessions occured 15 minutes prior to each 12-hour shift report. Nursing staff who did not attend

the training session met individually with their charge nurse, or the nursing director prior to

using the instrument. Each nursing staff member who participated in the admission process

completed the DASA instrument form.

The SAUPC is staffed 24-hours a day and 365 days a year. Each 24-hour day has a 7 am

to 7 pm shift and a 7 pm to 7 am shift. There is a front end crew (Sunday, Monday, Tuesday and

every other Wednesday) and back end crew (Thursday, Friday, Saturday, and every other

Wednesday). Six nurses are scheduled per shift. Of the six nurses, four participate in the

admission process. See Appendix E for process flow chart. Upon admission to the 24-hour unit,

the DASA was completed during the initial nursing assessment.

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The DASA includes seven items: negative attitudes, impulsivity, irritability, verbal

threats, sensitive to perceived provocations, easily angered when requests are denied, and

unwillingness to follow directions. Each item is scored for its presence or absence upon

admission. It is recommended that a score of 0 reflects a low risk of violence, a score of 1-3

suggests that risk for violence is moderate and preventative measures should be taken, a score of

4 or 5 indicates that risk is high, and a score of 6 or 7 indicates very high risk of imminent

aggression (Ogloff & Daffern, 2006). The nurse, using judgment (based on their own knowledge

and experience), assigns a risk level of High, Moderate, or Low. The items on the DASA are all

independently moderately related to aggression within the following 24-hours with an area under

the curve value of AUC > 0.70 (Ogloff & Daffern, 2006). Once the nurses completed the DASA

and assigned a risk level, they used critical thinking and clinical judgment to further determine

the need for intervention. The next section on the DASA form was completed to report the type/s

of interventions used, record whether or not the patient became violent, report if the patient

required or did not require seclusion and/or restraint, and describe the behavior that lead to the

seclusion and/or restraint. Per request from the S&R committee, the DASA form also recorded

the patient placement on the Observation Unit (OBS 1) or the higher acuity (OBS 2).

Nurses completed the DASA collection form as part of the admission packet when each

patient was admitted to the facility. The nurse wrote their name on the DASA collection form

and attached a patient admission sticker. Upon completion, the DASA collection form was

removed from the nursing assessment and placed in the identified/labeled folder designated for

all DASA collection forms. The time between completion of the form and an episode of violence

was reviewed. When the data was entered into Microsoft Excel, all patient indentifiers were

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eliminated to ensure privacy and confidentiality. For data entry purposes, the DASA collection

forms were organized by nurse name. An Excel sheet was created for each nurse to capture the

elements of the DASA, interventions used, occurrence of and seclusion/and or restraint event,

and behavior that led to the event. Final results were not connected to any specific nurse. Only

information from the DASA assessment forms were entered into the excel data set. The

occurrence and time of a seclusion and/or restraint episode was subsequently obtained from

seclusion and restraint data managed by the Director of Nursing. The monthly seclusion and

restraint data was also obtained from the Director of Nursing records and as the final report

reveals results only, no patient information is attached to this information. The DASA data forms

were stored in designated boxes in the cabinet behind the admission coordinators desk. Forms

were then removed, divided by nurse, numbered and then entered by Phoenix Facility designated

staff. The final resting place for the physical DASA data collection sheets was in the locked

office of the Quality Assurance Officer. Data was collected starting on June 15, 2016 through

October 15, 2016. Nurses completed approximately 4000 DASA data collection sheets. A post

implementation questionnaire was distributed to all nurses who completed the DASA and was

the basis of the DNP project. The Quality Assurance Officer of the SAUPC analyzed the data

from the DASA collection sheet. Before making any final decisions about the DASA, the

Seclusion and Restraint Committee reviewed the results of the current DNP quality improvement

project.

Current DNP Project – Planning Phase

Prior to developing the plan in the PDSA cycle, the purpose or aim must be determined

(Institute for Healthcare Improvement, 2016). The purpose of this project is to determine the

33

nurses’ perception of the usefulness of the DASA during the admission process (point of first

patient contact) to identify potentially aggressive/violent behaviors. In doing so, it was

hypothesized that the nurses would endorse perceiving an increased awareness of these behaviors

and would report that timely and appropriate interventions were used to prevent

aggressive/violent behavioral acts. The study purpose is also consistent with the Institute of

Medicine’s (IOM) six main “Aims of Improvement” which indicate that an improvement be safe,

effective, patient centered, timely, efficient, and equitable (Institute for Healthcare Improvement,

2016). The study questions guiding the DNP project provided specific, measureable components

that were analyzed, and results obtained to determine nurses’ perception of the usefulness of the

DASA.

In order to enact the plan, an effective team that includes members such as system

leadership (administrators), technical expertise (person who knows the subject and is an expert in

methods, measurement tools and clinical implications), and day-to-day leadership (physicians,

NP, PA, nurses, and frontline workers), who are familiar with the processes involved in the

change or improvement was formed (Institute for Healthcare Improvement, 2016). As the S&R

committee is integral to the process of ensuring patient and staff safety, has members from all

levels of the system, and has the ability to implement changes in direct patient care, the S&R

team was determined to be an effective team to lead the PDSA with the goal of implementing the

DASA at the SAUPC. The principal investigator of the DNP project is a practicing Psychiatric

Nurse Practitioner and an employee at the SAUPC. She provided expertise and leadership to the

S&R committee in the PDSA process. The principal investigator presented the additional aim for

her DNP project focusing on the nurse perceptions of the usefulness of the DASA. She received

34

full support for the above-described project. For the purpose of the DNP project, the principal

investigator served as the clinical leader, day-to-day leader, and technical expert. The sponsor of

the S&R team is the chief medical officer.

All team members were fully invested in the proposed DNP project and determined that it

aligned well with the facility’s mission to provide evidenced based care. Leaders of each

discipline of the interdisciplinary team (members of the committee) were engaged in providing

feedback about the purpose and aim of the project.

Recruitment of RN Study Participants

Although each nurse was required to complete the DASA instrument form, only those

nurses who wished to participate in the DNP project participated in completion of the Post

DASA Implementation Questionnaire (PDIQ). All nursing staff were made aware that they were

not required to participate in the completion of the Post DASA Implementation Questionnaire

and that participation had no effect on their job status. A disclosure statement was provided with

each study questionnaire (Appendix D).

Informed Consent

Each nurse completing the DASA at the SAUPC was given a PDIQ packet. The packet

consisted of a disclosure statement (Appendix A) informing them of their rights as a participant

in the study, a demographics page (Appendix B) requesting information about gender, degree,

years of experience, and years at the facility, as well as the questionnaire itself (Appendix C). By

completing and turning in the questionnaire, the nurse provided consent.

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Participant Privacy and Confidentiality of Data

Once IRB approval was attained, the PDIQ packet was distributed to nurses who

completed the DASA. In addition, information regarding the nurses, years of experience as a

nurse, nurse gender, time as a nurse in psychiatry, amount of time working for the facility, and

level of education (associates vs. bachelors) was obtained for sample description as well as to

determine relationships between the demographics and the five study questions which address

the association of factors on nursing perception (Appendix B). The principal investigator was the

only person to collect and enter data related to the PDIQ. The collected PDIQ packets were

stored in a file managed by the principal investigator and placed in the Director of Nursing’s

locked office.

Ethical Issues

The DNP project received approval from the University of Arizona’s Human Subjects

Protection Program and the Institutional Review Board (IRB). A letter approving the description

of the SAUPC implementation of the DASA was obtained and filed with University of Arizona’s

IRB. This is a quality improvement project and the Determination of Human Subjects form was

completed and submitted to the IRB. As the DASA is copyrighted, the manual for administration

and scoring of the DASA was purchased from the Centre for Forensic Behavioral Science, prior

to the Phoenix Facility starting their implementation. The purchase of the manual provides

permission from the authors to use the instrument.

Measures

Each nurse who completed the DASA assessment was asked to complete a PDIQ with

questions matching the initial study questions. The questions on the PIDQ are directly related to

36

the aim of the DNP project. Only nurse participants who had completed the DASA during the

implementation of the DASA at the SAUPC were invited to participate in this study.

Method of Evaluation

Post DASA Implementation Questionnaires completed by nurses were evaluated

(Appendix C). There are five survey items each measured on a five-point Likert scale ranging

from “Strongly Disagree” (1) to “Strongly Agree” (5) which describe and measure nurses’

experience using the DASA. A demographic questionnaire explored the association of static

nursing factors (gender, years of experience, level of education, years at the facility), on nurses’

perception of the usefulness of the DASA.

Analysis

The PDIQ data for the DNP project, including participant demographic information was

entered into SPSS based on questionnaire number. Participant demographic data was included to

provide a clear description of the participants (Appendix B). Once the study questionnaire was

completed and entered into SPSS, descriptive statistics, specifically central tendencies and

percentages, were used. In addition, correlational analyses were completed to determine the

relationship between responses on the items and outcome variables of interest.

Planning the Intervention – “Plan” of PDSA

The methods section reflects the ‘Plan’ section of the PDSA and outlines the step-by-step

process by which the nurses’ perception of the usefulness of the DASA was measured.

This investigator hypothesized that nurses would indicate that the DASA is useful in

identifying violent/aggressive behaviors, would report an increased awareness of

violent/aggressive behaviors, and report that using the DASA triggered them to implement an

37

intervention to decrease aggressive/violent patient behaviors. In addition, it was hypothesized

that nurses would report a decrease in the incidence seclusion/restraint in the SAUPC. The ‘Do”

section of the PDSA is reflected by a step by step discussion of all activities involved in the

evaluation of the nurses’ perception of the usefulness of the DASA via the PDIQ. A discussion

of the outcomes of the PDIQ and how they compared with the initial hypothesis is reflected in

the ‘Study’ section of the PDSA. The ‘Act’ section of the PDSA is reflected in the SAUPC’s

decision to recommend the addition of the DASA to the nursing initial assessment. In

conclusion, the results of the questionnaire analysis are presented alongside limitations of this

project, future directions for quality improvement, research in the emergency psychiatric setting,

and implications for nursing practice

RESULTS

Analysis of the PDIQ, “Study”

Descriptive Statistics

During the four-month SAUPC implementation of the DASA, a total of 25 nurses

completed the DASA during their initial admission assessment. Secondary to some of the

SAUPC study participants being pool, agency, or regular staff leaving employment, a total of 20

registered nurses participated in this study representing an 80% response rate. Among the 20

study participants, nine (45%) were female and 11 (55%) were male. The distribution of level of

education was five (25%) Associate Degree Nurse (AN); 12 (60%) Bachelor of Science in

Nursing (BSN), and three (15%) Master of Science in Nursing (MSN). The average (and

standard deviation) number of years of experience as a registered nurse was 8.72 (8.18) and the

range was 0.80 to 30.00. The DASA Usefulness (USE) score was computed as the average of

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questions 1, 2, 3, 4 and 6 from the study survey. Cronbach’s alpha for the USE score was 0.98,

indicating excellent reliability. The average (and standard deviation) USE score was 4.13 (1.02)

and the range was 1.00 to 5.00. Considering the average was well above the midpoint of 3.00, on

average the study participants considered the DASA to be very useful.

Research Questions

Research question 1. Do nurses perceive the DASA to be effective in identifying

potentially aggressive/violent patient’s behaviors?

Table 1 shows the frequency distribution of the level of agreement with the statement

“The DASA was effective in identifying potentially aggressive/violent behaviors in patients”.

Considering 18 (90%) of the study participants either agreed or strongly agreed with the

statement, the answer to the research question is, the majority of nurses perceive the DASA to be

effective in identifying potentially aggressive/violent patient’s behaviors.

TABLE 1. Frequency Table of Level of Agreement with the Statement, “The DASA was effective in identifying potentially aggressive/violent behaviors in patients.”

Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Neutral 1 5.0 5.0 10.0 Agree 5 25.0 25.0 35.0 Strongly Agree 13 65.0 65.0 100.0 Total 20 100.0 100.0

Research question 2. Do nurses perceive the use of the DASA increases their awareness

of the behaviors (negative attitudes, impulsivity, irritability, verbal threats, sensitive to perceived

provocation, easily angered when requests are denied, unwillingness to follow directions) that

indicate a patient’s increased risk for aggressive/violent behavior?

39


“The DASA increased my awareness of behaviors that indicate a patient may become

violent/aggressive”. Considering 17 (85%) of the study participants either agreed or strongly

agreed with the statement, the answer to the research question is, the majority of nurses perceive

the DASA increases the nurse’s awareness of the behaviors (negative attitudes, impulsivity,

irritability, verbal threats, sensitive to perceived provocation, easily angered when requests are

denied, unwillingness to follow directions) that indicate a patient’s increased risk for

aggressive/violent behavior.

TABLE 2. Frequency Table of Level of Agreement with the Statement, “The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.”

Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Disagree 1 5.0 5.0 10.0 Neutral 1 5.0 5.0 15.0 Agree 9 45.0 45.0 60.0 Strongly Agree 8 40.0 40.0 100.0 Total 20 100.0 100.0

Research question 3. For patients that nurses perceive are at risk of violent/aggressive

behaviors, does the DASA trigger an initiation of an intervention by the nurse?


“The DASA triggered me to initiate an intervention to prevent patient escalation to further

violent/aggressive behaviors.” Considering 17 (85%) of the study participants either agreed or

strongly agreed with the statement, the answer to the research question is, the vast majority of

nurses perceive that for patients that nurses perceive are at risk of violent/aggressive behaviors,

the DASA triggers an initiation of an intervention by the nurse.

40

TABLE 3. Frequency Table of Level of Agreement with the Statement, “The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.”


Research question 4. Do nurses perceive a decrease in seclusion and restraint episodes

as a result of the use of the DASA?

Table 4 shows the frequency distribution of the level of agreement with the statement “I

believe using the DASA decreased the episodes of seclusion and restraint.” Considering 15

(75%) of the study participants either agreed or strongly agreed with the statement, the answer to

the research question is, a significant majority of nurses perceive a decrease in seclusion and

restraint episodes as a result of the use of the DASA.

TABLE 4. Frequency Table of Level of Agreement with the Statement, “I believe using the DASA decreased the episodes of seclusion and restraint.”


Research question 5. Is gender, years of experience as a nurse, level of education,

and/or years at the facility, associated with the nurses’ perception of the usefulness of the

DASA?

41

Gender. The natural choice for comparing a continuous variable (e.g., DASA Usefulness

score) between two independent groups (e.g., males and females) is the independent samples t-

test. Prior to conducting the analysis, the assumptions for the independent samples t-test were

evaluated. The first assumption is that there are no outliers in the continuous variable (e.g., USE)

for either group (e.g., males versus females). This assumption was evaluated by inspection of

box plots of the USE score, separately for males and females. The second assumption is that the

continuous variable has a normal distribution for both groups. This assumption was evaluated by

inspection of histograms of the continuous variable, separately for each group. The third

assumption, homogeneity of variance, is that the variance of the continuous variable is the same

for both groups. This assumption was evaluated using the Levene’s test Results of the

assumption testing indicated both the normality and constant variance assumptions were

violated. Consequently, the independent samples t-test was inappropriate. Therefore, the non-

parametric equivalent of the independent samples t-test, the Mann-Whitney U test was used to

compare the median USE score between males and females. The Mann-Whitney U test was

appropriate because this test does not require normal distributions or homogeneity of variance.

Figure 1 is a box plot of the USE score, separately for males and females. The median USE score

for females (5.00) and males (4.2) was not statistically significantly different, U = 47.00; z = -

0.20; p = 0.85. In summary, this study did not show any evidence to suggest the perceived

usefulness of the DASA is different for male and female RN’s.

42

FIGURE 1. Box Plot of the DASA Usefulness Score by Gender. (The median Usefulness score, 5.00 (females) versus 4.20 (males) not statistically significantly different. Mann-Whitney U test: U = 47.00; z = -0.20; p = 0.85.)

Years of Experience as an RN. The natural choice for comparing two continuous variables

(e.g., USE versus years of experience as an RN) is the Pearson’s correlation coefficient. The

assumptions for Pearson’s correlation were evaluated prior to conducting the analysis. The

assumption that there are no extreme outliers was evaluated by inspection of box plots for the

two variables. The assumption that the two variables have a normal distribution was evaluated by

inspection of histograms separately for each variable. The linear relationship and homogeneity of

variance assumptions were evaluated by way of inspection of a scatter plot between the two

43

variables. The results of these evaluations indicated both the normality and linearity assumptions

were violated. Therefore, the Pearson’s correlation statistic was inappropriate. Consequently, the

non-parametric equivalent of the Pearson’s correlation statistic, Spearman’s rho was used

instead. Spearman’s rho was appropriate because it does not require normal distributions or

linear relationships. The results showed there was not a statistically significant correlation

between USE and years of experience as an RN, rs(18) = -0.35; p = 0.13. It was concluded that

there is no relationship between the perceived usefulness of the DASA and years of experience

as an RN.

Level of education. The natural choice for comparing a continuous variable (e.g., DASA

Usefulness score) between three or more independent groups (e.g., levels of education) is a one-

way analysis of variance (ANOVA). Analysis of variance requires the same assumptions as the

independent samples t-test. As discussed above, the assumptions for the independent samples t-

test were not satisfied and therefore, the assumptions for ANOVA were also not satisfied.

Consequently, ANOVA was inappropriate for evaluating the relationship between USE and level

of education. Therefore, the non-parametric equivalent of the ANOVA, the Kruskal-Wallis test

was used. The Kruskal-Wallis test was appropriate because this test does not require normal

distributions or homogeneity of variance. Figure 2 is a box plot of the USE score, separately for

each level of education AN (n = 5), BSN (n = 12), and MSN (n = 3). The median USE score for

AN (4.60), BSN (4.30), and MSN (4.20) was not statistically significantly different, X2(2) =

0.19; p = 0.91. In summary, this study did not show any evidence to suggest the perceived

usefulness of the DASA is different for RN’s with different levels of education.

44

FIGURE 2. Box Plot of the DASA Usefulness Score by Level of Education.

Years at SAUPC. As discussed above for the comparison of USE versus years of

experience as an RN, the natural choice for comparing two continuous variables (e.g., USE

versus years at UPC) is the Pearson’s correlation coefficient. However, as discussed previously,

the normality assumption for the USE score was violated. Therefore, Pearson’s correlation

statistic was inappropriate and Spearman’s rho was used instead. The results showed there was

not a statistically significant correlation between USE and years at UPC, rs(18) = 0.30; p = 0.20.

45

It was concluded that there is no relationship between the perceived usefulness of the DASA and

years at UPC.

Research question 6. Do nurses want to continue to use the DASA as a violence

assessment tool in the psychiatric emergency room setting?

Table 5 shows the frequency distribution of the level of agreement with the statement “I

would like to continue to use the DASA as a violence risk assessment tool.” Considering 14

(70%) of the study participants either agreed or strongly agreed with the statement, the answer to

the research question is, a significant majority of nurses want to continue to use the DASA as a

violence assessment tool in the psychiatric emergency room setting.

TABLE 5. Frequency Table of Level of Agreement with the Statement, “I would like to continue to use the DASA as a violence risk assessment tool.”

Frequency Percent Valid Percent Cumulative Percent Strongly Disagree 1 5.0 5.0 5.0 Neutral 5 25.0 25.0 30.0 Agree 7 35.0 35.0 65.0 Strongly Agree 7 35.0 35.0 100.0 Total 20 100.0 100.0

DISCUSSION

PDSA “Act”

Although studies specific to the use of the DASA queried nursing opinion about their use

and satisfaction with the scale (Dumais et al. 2012, Laffern et al. 2015, Lantta et al. 2015), there

are no known studies that focus solely on nursing perception and usefulness. Results from the

statistical analysis of the PIDQ supports the hypothesis that, of the nurses completing the PIDQ,

(USE) score of 4.12 on the Likert scale 1-5, did find the DASA useful for identifying potentially

violent and aggressive patients upon admission to the SAUPC and would like to continue to use

46

the DASA in their nursing assessment. These results are consistent with previous findings

indicating that nurse’s response to using the DASA were mostly positive (Dumais et al., 2012,

Laffern et al., 2015). Comments written in the suggestions portion of the PIDQ describe the

DASA as a “simple and effective way to quantify risk,” and “It identified most of the people who

had problems before acting out on the unit,” and “early intervention increased safety for patients

and staff.” The comments by the nurses are consistent with previous findings in which nurses

reported that the DASA, provided an objective assessment of patient behaviors, and encouraged

them to perform an intervention to prevent further episodes of acting out on the unit (Dumais et

al., 2012). Overall, it appears that nurses who participated in this study felt that the DASA did

increase their awareness of aggressive behaviors and encouraged pre-emptive interventions to

prevent episodes of violent behavior not only during the admission but also once on the unit.

One area not studied in the previous literature is nursing static factors such as gender,

years of experience, years at the facility, level of education and the influence these may have on

nursing perception of the DASA. No statistically significant difference was found based on years

of experience, years at the facility, or level of education in the sample. Of note, the participants

in this study produced an almost equal distribution of male (11) versus female (9) nurses to

compare results across gender. Statistically no difference was found for gender related to the

perception of the DASA’s usefulness in the SAUPC setting. This finding is consistent with the

results in a study conducted in 2015 in which the gender of the person observing an aggressive

act does not appear to have an effect on the manner in which the person perceives the aggressor

or the aggressive act (Way, 2015). In a prior study by Steven-Williams (2002) when men and

women perceive an act to have the same level of aggression they do not differ in their views

47

about acceptability of a behavior. In the case of the study participants and the DASA, based on

this premise, both male and female nurses’ perception of patient behavior in relation to the seven

behavioral items on the DASA, are making equally objective reports of these behaviors and

therefore supports the lack of statistical difference between the genders in perception.

The premise of the DNP project is based on nursing perception of whether the DASA is

useful at increasing awareness of dynamic risk factors and early identification of aggressive

violent behaviors. In addition, one of the purposes of the DASA is to trigger an intervention to

decrease the likelihood that the patient will become aggressive/violent and, for the purpose of the

SAUPC implementation, decrease the use of seclusion and restraint. While completing the

PIDQ, nurses identified the most commonly used interventions when a patient exhibited the

scored behaviors in the DASA. Of the written responses received, one of the most common

interventions was medication administration. Requesting the presence of a provider (MD, NP,

PA) at the back door (of the facility where patients are dropped off) was the second most

common intervention. Due to the multidisciplinary nature of the team at the SAUPC, a

psychiatric provider is available to participate in the admission process if required and upon

request of the admitting nurse. A recent study investigated the interventions utilized by staff on

adult inpatient psychiatric unit in Finland. The intervention nurses reported using most

frequently in the study was prn medication (Kaunomaki, Jokela, Kontio, Laiho, Sailas, &

Lindberg, 2017). Of note, discussion with the psychiatrist was used only three times during the

six-month study period, as they (the psychiatrists) were overburdened by other duties therefore

leaving no remaining time to participate in preventative actions (Kaunomaki et al., 2017). The

psychiatrist’s inability to participate in prevention during the study is quite different than at the

48

SAUPC. The most likely reason for this difference is the crisis focus at the SAUPC, which

allows for provider involvement and is considered an intervention based on nursing report. The

ability of the nurse to request provider presence and assistance during the initial admission

assessment is a unique “intervention” to the SAUPC that can validate nursing assessment and

promote targeted and expedited interventions to minimize aggressive and threatening behavior

by patients. It allows for timely administration of medication, seclusion and/or restraint, if

necessary, and provider/patient interaction prior to the patient being brought into the unit milieu.

Overall, nursing responses on the PDIQ demonstrates that the DASA did encourage initiation of

preventive interventions, which further support previous research findings (Barry-Walsh et al.,

2009, Chu et al., 2011, Griffith et al. 2013, Ogloff & Daffern, 2006).

Despite completion of the DASA and identification of potentially aggressive/violent

behaviors, the SAUPC did have episodes of seclusion and restraint. Although the reduction of

seclusion and restraint was not the focus of this project, nurses’ perception of a decrease in

seclusion and/or restraint as a result of the DASA was explored. Seventy-five percent (75%) of

nurses completing the PIDQ indicated that they perceived a decrease. Of the behaviors that led to

the episodes that did occur, nurses reported that threatening violence, agitation, substance abuse,

and involuntary status were behaviors that led to an episode of seclusion and/or restraint. Of

note, the contributing factors, involuntary status (Iozzino et al., 2015, Gergieve et al., 2012),

substance abuse (Iozzino et al. 2015, Witt et al. 2013), agitation and threatening violence

(Kaltiala-Heino et al., 2003, Larue et al, 2010, Vruwink et al., 2012), reported by the nurses are

have been identified in the literature. Review of the seclusion restraint data from the SAUPC

indicates that during the time frame in which the DASA was implemented seclusion and restraint

49

rates did decrease by approximately 32% (B. Montgomery, Nurse Manager SAUPC, personal

communication, March 30, 2017). The SAUPC is currently analyzing data from their

implementation and no correlation has been made between the use of the DASA and the

decrease. It would be appropriate to speculate though, that this was a contributing factor based

on prior research indicating that violence risk assessment leads to reduced seclusion and restraint

episodes (Abderhalden et al., 2008; van de Sande et al., 2011).

The results from the DNP project were presented to the Seclusion & Restraint Committee

at the SAUPC. Due to the positive response from the nursing staff, it was determined that,

despite not having completed the analysis from the SAUPC implementation of the DASA, the

DASA would be incorporated into the initial nursing assessment. Future cycles are being

considered to include expanding the use of the DASA in nursing shift assessments. In addition,

as there is no restriction on discipline or level of education for those completing the DASA, other

disciplines, specifically the BHS, using the DASA as part of their shift assessment to better

manage and monitor patient behavior, is being contemplated. Exploration the use of the DASA

as a component of admission criteria for the higher acuity side of the observation unit at the

SAUPC, is under consideration as well.

Strengths and Limitations

Strengths of this DNP project are reflected in the strong support provided by the facility

and management team. Nurses as well as the interdisciplinary team as a whole had a strong buy

in to the implementation of the project and a vested interest in its success. The use of the PDSA

provided a clear roadmap and common goal for the facility’s desire to utilize evidenced based

tools to improve violence assessment and decrease seclusion and restraint rates. This study, led

50

by an experienced/practicing Psychiatric NP with an abundance of experience, has provided

insights and nuances into the improvement of practice and patient outcomes in a highly

specialized psychiatric practice setting. The project offers the first of its kind on nurses’

perceptions on the use of the DASA in the psychiatric emergency room setting. The project is

specifically relevant to clinicians in emergent psychiatric healthcare settings and provides critical

elements to guide and promote practice change and transformation thereby, improving patient

outcomes and enhancing quality healthcare delivery. It provides evidence and process based

quality improvement guidelines to be used by practicing healthcare providers for violence risk

assessment and empowers the behavioral health team to optimize their delivery of care in this

setting. Finally, this project has broad impact as it benefits patients, staff, and the healthcare

system and could potentially transform healthcare on a wider level.

There are a number of limitations that should be noted in this study. First, the DNP

project was completed in a very specialized setting, a psychiatric crisis facility, and therefore

may not be generalizable to other psychiatric settings. The sample size (20 participants) is very

small therefore; the negative or null findings may be related to a small sample size to detect a

relationship if one exists. Methodological quality of the design of a study is also an important

consideration and in the case of this DNP project, a limitation. It is accepted that the higher the

level of evidence, the better the recommendation and applicability to patient care (Johns Hopkins

Medicine, n.d.). Using the Johns Hopkins Evidence Level and Quality guide, this DNP project

falls into the non-research Level 5 B (Good quality) category of evidence based practice (Johns

Hopkins Medicine, n.d.). Finally, throughout the SAUPC implementation process, the nursing

staff was very enthusiastic about the use of the DASA. Many expressed a desire to participate in

51

the DNP project and were invested in the success of this writer. This investment may contribute

some bias, despite the completion of the PIDQ being anonymous.

CONCLUSIONS

The results of this DNP project demonstrate that nurses at the SAUPC perceive the

DASA to be a useful addition to their admission assessment. Overall nursing response was

positive and the SAUPC seclusion and restraint committee decided to recommend incorporation

of the DASA into the initial nursing admission assessment. Future research to validate the DASA

in the emergency psychiatric setting should be explored. Alternative interventions to decrease

aggressive and violent behaviors during admission that do not rely so heavily on medications

and/or seclusion and restraint should be considered. Nursing perceptions should continue to be

included in research design. Exploration of other disciplines incorporating the DASA into their

shift assessment would be beneficial in further validation and widespread use of this quick,

simple and effective instrument.

Advanced practice nurses are in a position today to effect change in the daily practice of

nursing. Disseminating and implementing nursing knowledge to use in practice are part of the

eight DNP Essentials that are the cornerstone of practicing at the doctoral level (AACN, 2006).

Using a quality improvement theory practice model (Model for Improvement and the PDSA) this

DNP project demonstrates the identification of problem (SAUPC’s lack of a evidence based

assessment), research on an evidenced based intervention (the DASA), the implementation of

that assessment (description of the SAUPC’s implementation), perception of the assessment by

those using it (PDIQ results and analysis), and the final outcome (overall positive response by

nurses and recommendation to include in initial nursing assessment). This DNP project has

52

generated new knowledge in a specific context, the psychiatric emergency room, and provides a

framework for replication in other similar settings where violent and aggressive patients may be

encountered. Finally, the DNP project demonstrates the ability of a nursing leader to work within

a facility to engage management and all patient care disciplines to work toward a common goal,

which effects an improvement in overall provision of care and safety.

53

APPENDIX A:

DISCLOSURE STATEMENT

54

Nurses Perception of the Usefulness of the Dynamic Assessment of Situational Aggression (DASA) in and Emergency Psychiatric Setting

Stacy Underwood, NP The purpose of this study is to determine the usefulness of the DASA in a psychiatric emergency room setting. It is hoped that by increasing awareness of behavioral risk factors (dynamic) and early identification/prediction of potentially aggressive/violent behaviors, it is hoped that staff will implement appropriate and timely interventions that will increase patient and staff safety. If you choose to take part in this study, you will be asked to complete a post data collection survey. It will take approximately 10 minutes to complete this survey. There are no foreseeable risks associated with participating in this research and you will receive no immediate benefit from your participation. Survey responses are anonymous. If you choose to participate in the study, you may discontinue participation at any time without penalty. In addition, you may skip any question that you choose not to answer. By participating, you do not give up any personal legal rights you may have as a participant in this study. An Institutional Review Board responsible for human subjects’ research at The University of Arizona reviewed this research project and found it to be acceptable, according to applicable state and federal regulations and University policies designed to protect the rights and welfare of participants in research. For questions about your rights as a participant in this study or to discuss other study-related concerns or complaints with someone who is not part of the research team, you may contact the Human Subjects Protection Program at 520-626-6721 or online at http://rgw.arizona.edu/compliance/human-subjects-protection-program. For questions, concerns, or complaints about the study, you may call Stacy Underwood, NP, at (917) 848-7929 or mailto:[email protected]. By taking this survey you agree to have your responses used for research purposes.

55

APPENDIX B:

DEMOGRAPHIC INFORMATION

56

PARTICIPANT INFORMATION SHEET

Gender Male Female

Highest Level of Education: _______________________

Role at UPC: RN

Shift: FED FED BED BEN Pool

Years spent as an RN: _____________

Years spent as a Psychiatric RN:____________

Years at this facility: _______________

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APPENDIX C:

POST DASA IMPLEMENTATION QUESTIONNAIRE - PDIQ

58

Post Dynamic Assessment of Situational Aggression Implementation Questionnaire – Nursing Did you utilize the DASA during your initial contact and assessment of patients during the two-week study period? YES NO 1. The DASA was effective in identifying potentially aggressive/violent behaviors in patients.

1 Strongly Disagree

2 Disagree

3 Neutral

4 Agree

5 Strongly

Agree

2. The DASA increased my awareness of behaviors that indicate a patient may become violent/aggressive.

1 Strongly Disagree

2 Disagree

3 Neutral

4 Agree

5 Strongly

Agree

3. The DASA triggered me to initiate an intervention to prevent patient escalation to further violent/aggressive behaviors.

1 Strongly Disagree

2 Disagree

3 Neutral

4 Agree

5 Strongly

Agree

3a. What intervention did you find most effective for preventing further behaviors?

4. I believe using the DASA decreased the episodes of seclusion and restraint.

1 Strongly Disagree

2 Disagree

3 Neutral

4 Agree

5 Strongly

Agree

4a. For patients who experienced and episode of seclusion

and/or restraint, what, per your experience was the most common behavior?

59

5. I would like to continue to use the DASA as a violence risk assessment tool.

1 Strongly Disagree

2 Disagree

3 Neutral

4 Agree

5 Strongly

Agree

Suggestions/Comments?:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for your participation, Stacy Underwood, NP

60

APPENDIX D:

PROCESS FLOW SHEET

62

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