Research Seeks to Understand Patient Aggression

What you don’t know can hurt you.

That’s the motto behind an effort at New Hampshire Hospital (NHH) to study violence and aggression in the hospital, understand the variables associated with its occurrence, and design an intervention to diminish its occurrence.

At the 2016 IPS: The Mental Health Services Conference this past October, Lisa Mistler, M.D., M.S., who directs the research effort at NHH along with Matthew Friedman, M.D., Ph.D., presented statistics that paint a dismal picture: the mental health profession is second only to law enforcement with regard to workplace violence. Between 2005 and 2009, 20.5 mental health professionals per 1,000 were the victims of workplace violence, according to the National Crime Victimization Survey. Law enforcement had a rate of 47.7 per 1,000 professionals, and transportation professionals trailed mental health with 12.2 per 1,000 professionals.

In an interview with Psychiatric News, Mistler said formal research on violence on psychiatric units has been hampered by the lack of a standard definition for what constitutes violence. Much research has tended not to include verbal assaults, for instance, since they don’t result in physical injuries.

But verbal assaults are common and among the most damaging forms of assault, she said.

“In the available measures there is no way to capture verbal assaults by patients who are manic or otherwise very ill,” she said. “Some researchers simply put it aside because there are no obvious sequelae. But that’s not true. It’s hard to get a flavor of the intensity of verbal assaults. People are worn down hearing themselves denigrated day after day. It’s related to low morale, people calling in sick, and a high turnover rate.”

A survey of staff about what they considered the most important issues needing research was revealing. “To a person, staff cited violence and aggression,” she told Psychiatric News. “Our frontline mental health nurses and professionals who work face to face with patients are at risk all the time.”

After some trial and error, Mistler and colleagues developed a modified version of the Staff Observed Aggression Scale (SOAS), a four-question instrument (including an assessment of verbal aggression) that is now incorporated into the report that nursing staff complete on every patient at the end of every shift.

Mistler has also partnered with Dror Ben-Zeev, Ph.D., of Dartmouth University to experiment with technology-assisted interventions for research. One example is “Project Pause,” which is examining whether a smartphone app can predict violence among a select group of acutely ill patients.

During the research phase, patients carried smartphones (with cameras and games disabled) for seven days. Every two hours, the app prompted them to answer questions about how they felt. The phones could detect ambient sounds (for example, patients screaming or talking to themselves) and track the location and movement of patients.

Ultimately, Mistler and Friedman aim to compare these self-assessment data with violent incidents and restraint and seclusion reports to determine whether the self-assessment tool has predictive value.

The project has already provided some preliminary findings suggesting temporal relationships between delusions and violent ideation, property damage, and physical aggression and between such factors as noise on the unit and opportunities for physical activity and changes in rates of violent ideation.

“We want to use those findings and design an intervention to see whether we can affect the rates of aggression and violence,” Mistler said. “Ideally, we would like to feed the information back to nurses in real time. That is the ultimate goal—moment-by-moment assessment with the capacity to intervene in a timely manner.”

Importantly, Mistler and staff at NHH hope to form a consortium with other psychiatric hospitals to share information and data as well as best practices for reducing aggression and violence. Interested parties should email Mistler at [email protected]. ■