Accepted: 11 October 2017

DOI: 10.1111/jocn.14107

ORIGINAL ARTICLE

Risk assessment and subsequent nursing interventions in a

forensic mental health inpatient setting: Associations and
impact on aggressive behaviour

Tessa Maguire BN, RN MMentHlthSc FBS, Clinical Nurse Consultant1,2 | Michael Daffern
MPsych Clin, PhD Professor of Clinical Forensic Psychology1,2 | Steven J Bowe PhD, Bed
se Maths, MMed. Stats, Senior Research Fellow3 | Brian McKenna RN, PhD, Professor in
Forensic Mental Health1,4

1
Centre for Forensic Behavioural Science,
Swinburne University of Technology,
Melbourne, Vic., Australia
2
Victorian Institute of Forensic Mental
Health, Forensicare, Melbourne, Vic.,
Australia
3
Faculty of Health, Biostatistics Unit,
Deakin University, Melbourne, Vic.,
Australia
4
School of Clinical Sciences, Auckland
University of Technology, Auckland, New
Zealand
Correspondence
Tessa Maguire, Centre for Forensic
Behavioural Science, Swinburne University
of Technology, Clifton Hill, Vic, Australia.
Email: tessa.maguire@forensicare.vic.gov.au
Aim and objectives: To examine associations between risk of aggression and nurs-
ing interventions designed to prevent aggression.
Background: There is scarce empirical research exploring the nature and effective-
ness of interventions designed to prevent inpatient aggression. Some strategies may
be effective when patients are escalating, whereas others may be effective when
aggression is imminent. Research examining level of risk for aggression and selection
and effectiveness of interventions and impact on aggression is necessary.
Design: Archival case file.
Methods: Data from clinical files of 30 male and 30 female patients across three
forensic acute units for the first 60 days of hospitalisation were collected. Risk for
imminent aggression as measured by the Dynamic Appraisal of Situational Aggres-
sion, documented nursing interventions following each assessment, and acts of
aggression within the 24-hours following assessment were collected. Generalised
estimating equations were used to investigate whether intervention strategies were
associated with reduction in aggression.
Results: When a Dynamic Appraisal of Situational Aggression assessment was com-
pleted, nurses intervened more frequently compared to days when no Dynamic
Appraisal of Situational Aggression assessment was completed. Higher Dynamic
Appraisal of Situational Aggression assessments were associated with a greater
number of interventions. The percentage of interventions selected for males dif-
fered from females; males received more pro re nata medication and observation,
and females received more limit setting, one-to-one nursing and reassurance. Pro re
nata medication was the most commonly documented intervention (35.9%) in this
study. Pro re nata medication, limit setting and reassurance were associated with an
increased likelihood of aggression in some risk bands.
Conclusions: Structured risk assessment prompts intervention, and higher risk rat-
ings result in more interventions. Patient gender influences the type of interven-
tions. Some interventions are associated with increased aggression, although this
depends upon gender and risk level.

J Clin Nurs. 2018;27:e971–e983. wileyonlinelibrary.com/journal/jocn © 2017 John Wiley & Sons Ltd | e971
e972 | MAGUIRE
Relevance to clinical practice: When structured risk assessments are used, there is
greater likelihood of intervention. Intervention should occur early using least restric-
tive interventions.
KEYWORDS
aggression management, forensic mental health, intervention, mental health nursing, nursing,
risk assessment
1 | INTRODUCTION
Aggression occurs frequently in inpatient mental health settings,
resulting in multiple adverse consequences for patients, staff, as well
as for the milieu and operation of the unit (Bowers et al., 2011; Cut-
cliffe & Riahi, 2013; Daffern, Howells, & Ogloff, 2007; Daffern,
Maguire, Carroll, & McKenna, 2015; Davidson, 2005; Duxbury,
Hahn, Needham, & Pulsford, 2008; Needham et al., 2004). There
may also be undesirable outcomes for patients who engage in
aggression, including being subject to restrictive practices such as
sedation, seclusion or restraint (Daffern et al., 2015).
2 | BACKGROUND
2.1 | Nursing interventions designed to reduce
aggression
There has been limited investigation into the impact of nursing inter-
ventions that are used to prevent and manage aggression (Irwin,
2006), and little guidance as to the most effective methods, resulting
in uncertainty for nurses (Stevenson, Jack, O’Mara, & Le Gris, 2015).
Therefore, the selection and implementation of preventative strategies
often occur in the absence of a framework that would assist in provid-
ing pre-emptive and targeted interventions before the aggression
becomes imminent (Taylor et al., 2011). Without a systematic
approach, the interventions used may lack consistency, or be unsuit-
able for the patient or the situation (Daffern et al., 2007), and may lead
to the use of reactive and restrictive practices (Taylor et al., 2011).
Some commonly used nursing interventions include increased
observations, one-to-one engagement with a nurse, reassurance, dis-
traction techniques (including sensory modulation), limit setting, ver-
bal de-escalation and the use of pro re nata (PRN) medication
(Department of Health, 2013; MacNeela et al., 2010; NICE, 2015).
Some interventions such as limit setting have been associated with
an increased risk of aggression (Bjørkly, 1999; Sheridan, Henrion,
Robinson, & Baxter, 1990) and the manner in which limits are set
may influence how patients respond to this intervention (Lancee,
Gallop, McCay, & Toner, 1995; Maguire, Daffern, & Martin, 2014).
Often these interventions are poorly defined (e.g., de-escalation and
limit setting; Irwin, 2006; Johnson & Hauser, 2001; Maguire et al.,
2014; Roberton, Daffern, Thomas, & Martin, 2012), leading to the
possibility of inconsistent application of the intervention, where
ET AL.
What does this paper contribute to the wider
global clinical community?
• Few studies have examined the impact of aggression risk
assessment on nursing initiated preventative interven-
tions within mental health settings.
• We examined the use of the Dynamic Appraisal of Situa-
tional Aggression, and interventions nurses documented
to prevent aggression, and the impact of these interven-
tions on aggressive behaviour in male and female foren-
sic mental health inpatients.
• Results suggest that structured assessment may prompt
nurses to intervene, different interventions are used for
males and females, and more interventions are applied
with higher risk patients.
• Greater consideration is required when selecting inter-
ventions to prevent aggression. Attention should be
given to risk level and patient gender, with early inter-
vention and least restrictive strategies used before
patient’s risk escalates.
nurses may be applying the same intervention but in different ways.
Furthermore, although some of these interventions have been sub-
ject to empirical investigation, each intervention is rarely investigated
independently, leading to uncertainty in determining the impact of
any one intervention. For example, Bobier et al. (2015) examined the
introduction of sensory modulation; however, the introduction of
sensory modulation was one of a range of interventions (including
personal safety assessment tools) that were introduced as part of an
organisation-wide restraint and seclusion reduction initiative.
Evaluation of nursing interventions is typically achieved through
scrutinising medical records. However, there are limits to this
approach. Documentation has been noted to be vague in relation to
the recording of the specific details of interventions provided (Hale,
Thomas, Bond, & Todd, 1997; Martin & Street, 2003; Mullen,
Drinkwater, & Lewin, 2013). Furthermore, the rationale for choosing
and enacting the intervention, and outcomes arising from the inter-
vention may be unclear or absent (Curtis, Baker, & Reid, 2007;
O’Brien & Cole, 2004). For example, a nursing file note stating “pa-
tient was de-escalated” may not adequately describe the actual
MAGUIRE ET AL.
practice, which may make it difficult for others to replicate or to
know which elements of the intervention were effective.
Another limitation has been the absence of regard for gender dif-
ferences when considering the type and effectiveness of nursing inter-
ventions used to prevent aggression (Nicholls, Brink, Greaves, Lussier,
& Verdun-Jones, 2009). Certain interventions may be more frequently
offered to male or female patients or may be more readily accepted by
either males or females. For example, some studies have reported that
sensory modulation was used more by female patients (Bobier et al.,
2015; Novak, Scanlan, McCaul, MacDonald, & Clarke, 2012) whilst
another study found that PRN medication was administered nearly
twice as often to male patients (Nicholls et al., 2009). There is little
advice offered in the literature differentiating the effectiveness, appli-
cation or selection of interventions for male and female patients.
Proactive approaches should be used to ameliorate risk (Taylor
et al., 2011) and these strategies should be used in a manner that is
suitable for the patient and their level of risk. The principles of preven-
tion outlined by the World Health Organization (WHO) (Krug, Dahl-
berg, Mercy, Zwi, & Lozano, 2002) classify interventions according to
three levels: primary, secondary and tertiary. Primary prevention
approaches include interventions aimed at preventing aggression
before it develops. Secondary prevention approaches are recom-
mended when aggression is considered to be imminent, and tertiary
interventions are used when aggression is occurring and needs to be
controlled to reduce its harmful effects. Priority should be given to
interventions that prevent aggression from occurring in the first
instance, using primary intervention strategies (Krug et al., 2002).
Due to the risks (e.g., physical injury, positional asphyxia, the
experience of trauma) that are associated with some of the tertiary
interventions commonly used to manage aggression (e.g., rapid tran-
quilisation, restraint and seclusion), the National Institute of Clinical
Excellence’s (NICE) guidelines for the short-term management of vio-
lence and aggression suggest that these practices should only be
considered once other interventions (such as de-escalation) have
failed to effectively calm the person (NICE, 2015).
Internationally, there is increasing pressure to reduce the use of
restrictive practices. It is now widely acknowledged that these prac-
tices are not therapeutic (Department of Health, 2013; Finke, 2001;
LeBel & Goldstein, 2005), have the potential to cause physical and
psychological harm (Bonner, Lowe, Rawcliff, & Wellman, 2002; Lam,
2002; Ryan & Happell, 2009; Sullivan et al., 2005) and may inadver-
tently encourage rather than prevent aggression (Daffern et al., 2007).
Tertiary interventions (that may involve the use of restrictive prac-
tices) should therefore only be used as a last resort after other inter-
ventions have been offered, tried and excluded (McKenna, Furness, &
Maguire, 2014). However, what constitutes last resort is often unclear
(Riahi, Thomson, & Duxbury, 2016). The Royal Australian and New
Zealand College of Psychiatrists (2010) have commented on the lack
of staff knowledge and skills in the use of nonrestrictive interventions.
Other researchers have highlighted that there is currently limited
research and evaluation of aggression prevention interventions (Fos-
ter, Bowers, & Nijman, 2007; Kynoch, Wu, & Chang, 2010). As a result,
aggression is often managed in a reactive and uncoordinated manner.
| e973
2.2 | Risk assessment instruments
The assessment of an individual’s risk of aggression is considered
an important skill for forensic mental health nurses, along with the
implementation of evidence-based interventions following assess-
ment (Bowring-Lossock, 2006; Martin et al., 2013; McKenna,
Maguire, & Martin, 2016). There are several risk assessment instru-
ments that have demonstrated validity with regard to predicting
imminent aggression in the inpatient setting. The Brøset Violence
Checklist (BVC) and the Dynamic Appraisal of Situational Aggres-
sion (DASA) are valid instruments that have been recommended by
NICE (2015); these instruments are conceptually and structurally
similar and often used by nurses. Both the BVC and DASA are
quick and easy to use. Each incorporates dynamic items (including
some overlapping items) allowing the possibility of regular and
timely assessment of fluctuating risk levels, which can then prompt
the intervention to prevent aggressive behaviours (Chu, Daffern, &
Ogloff, 2013).
Several studies have investigated the psychometric properties of
the BVC (Almvik, Woods, & Rasmussen, 2000; Bjorkdahl, Olsson, &
Palmstierna, 2005; Hvidhjelm, Sestoft, Skovgaard, & Bue Bjorner,
2014; Yao et al., 2014) and the DASA (Barry-Walsh, Daffern, Duncan,
& Ogloff, 2009; Chu et al., 2013; Dumais, Larue, Michaud, & Goulet,
2012; Griffith, Daffern, & Godber, 2013; Vojt, Marshall, & Thomson,
2010). Two cluster randomised controlled trials have demonstrated
that the use of the BVC resulted in less aggression and a decreased
use of restrictive practices (e.g., seclusion, mechanical restraint and the
forced injection of medication) (Abderhalden et al., 2008; van de
Sande et al., 2011). In the van de Sande et al. (2011) study, experi-
mental wards had a significantly lower number of aggressive incidents
and a lower number of patients engaging in aggression following intro-
duction of the BVC. Some possible reasons for the results were noted;
risk assessment led to earlier identification of imminent aggression,
leading to “more focused discussions on how to deal with observed
changes in risks, such as timely verbal de-escalation, behavioural limit
setting, close observation and reintegration to the ward after seclu-
sion” (p. 474).
Although the predictive validity of the BVC and DASA are estab-
lished and the impact of the BVC on aggression and the use of
restrictive practices have been demonstrated, there has been no
study focusing specifically on the DASA and nursing interventions,
including (i) whether the use of the DASA encourages nurses to
modify their response and initiate interventions to prevent aggres-
sion; (ii) whether different levels of assessed risk are associated with
different interventions; and (iii) the effectiveness of these nursing
interventions for patients at different levels of risk. There also
remains uncertainty about the impact of both measures on nursing
initiated interventions and the effectiveness of specific interventions
at different risk levels for males and females. One of the main chal-
lenges facing nurses in providing care following risk assessment
involves the planning and implementation of interventions that are
designed to reduce the risk, while also trying to avoid the use of
restrictive practices.
e974 | MAGUIRE
2.3 | Aim of the study
The aim of this study was to investigate what nursing interventions
were used to prevent aggression in male and female inpatients in a
forensic inpatient setting. It also sought to determine whether com-
pletion of a structured aggression risk assessment instrument (DASA)
and the risk bands it yields is associated with initiation of more or
different aggression prevention interventions. This study was also
designed to examine the effectiveness of interventions at different
levels of DASA risk (low, moderate and high), and establish whether
there are interventions that are more effective at different risk levels
for males and females.
3 | METHOD
3.1 | Setting and participants
Data were collected in a statewide inpatient forensic mental health
service in Victoria, Australia, the Thomas Embling Hospital (TEH). The
hospital has 116 beds and provides assessment and treatment for
patients who have been found not guilty by reason of mental impair-
ment, patients who may be sentenced or on remand from prison and
who require mental health inpatient assessment and treatment and
patients who may be considered high risk of offending who are
referred from civil mental health services. Thirty male and 30 female
patients admitted to the acute mental health units (there are two 15-
bed male acute units with a total of 30 beds, and one 10-bed female
unit) between 2009–2013 and who remained in the hospital for at
least 60 days were randomly selected for inclusion. The sample size
was selected to provide a large enough number of patients and days
of observation (3,600 patient days) and included an equal number of
males and female patients so that comparisons between genders were
possible. The data set used for this study has been described in an ear-
lier paper (Maguire et al. 2017), which focused on the predictive valid-
ity of DASA; however, the focus of this study is associated with
nursing interventions and their impact on aggression, which has not
previously been reported.
3.2 | Instruments
3.2.1 | The dynamic appraisal of situational
aggression
Dynamic Appraisal of Situational Aggression contains seven items:
negative attitudes, impulsivity, irritability, verbal threats, sensitivity
to perceived provocation, easily angered when requests are denied
and unwillingness to follow directions. These items are all indepen-
dently moderately related to aggression within 24 hr following the
DASA assessment (AUC > 0.70) (Ogloff & Daffern, 2006). The DASA
takes approximately five minutes to complete and the assessments
involve a nurse trained in the use of the DASA scoring each item for
its presence or absence in the 24 hr prior to assessment (Daffern
et al., 2009). DASA items are then totalled to determine the
ET AL.
likelihood of imminent aggression, and a final risk rating is translated
into one of three risk bands, low (0), moderate (1–3) and high (4 or
greater) (Maguire et al. 2017). The bands serve as a guide for inter-
preting the scores and assist in indicating the level of risk (Ogloff &
Daffern, 2004). The DASA, while identifying patients who are at
imminent risk of aggression, currently does not provide any proce-
dures or guidance about interventions following the DASA assess-
ment. At TEH, the DASA assessment is generally scored each day at
around midday to handover the DASA assessment and for the nurs-
ing team to discuss possible intervention strategies.
3.3 | Ethical issues
Access to conduct the study was granted by the Forensicare Opera-
tional Research Committee. Ethical approval to conduct the study
was granted by the Swinburne University of Technology Human
Research Ethics Committee (SUHREC) (SHR Project 2014/199). The
study was conducted in compliance with the ethical guidelines of
the Declaration of Helsinki (World Medical Association, 2001). No
ethical issues were encountered during the study.
3.4 | Data collection
Patient demographic information was gathered from patient files, as
was the data for the first 60 days of admission. The following informa-
tion was collected: (i) DASA scores on each day of each participant’s
hospital stay, (ii) the nursing interventions that were documented in
the following 24 hr after the DASA assessment prior to any act of
aggression (if one occurred) and (iii) if aggression occurred in the sub-
sequent 24 hr. Aggression was documented and categorised according
to the following groupings: (i) raised voices/verbal aggression/verbal
altercation/threats, (ii) hitting/pushed another person, (iii) use of
weapon or physical threats to attack another person, or an attack on
another person, and (iv) throwing, striking, kicking/hitting or damaging
objects/furnishings/fittings (Royal College of Psychiatrists, 2007). Any
questions about the classifications for aggression were discussed by
TM and MD until a consensus was reached.
3.5 | Data analysis
Statistical analyses were conducted using the Statistical Package for
Social Sciences version 23 (SPSS, Chicago, IL, USA). Cross-tabulations
that report proportions and frequencies were used to explore associa-
tions between patients who received an intervention and whether
they went on to engage in aggression; however, due to the correlated
nature of the data, any further statistical inference was made using
binary generalised estimating equation (GEE) models with the binomial
family and logit link with an exchangeable working correlation matrix.
The GEE models were undertaken to evaluate the relationship
between the use of intervention strategies and aggression. The seven
intervention strategies were binary variables (Yes/No) and GEE mod-
els are reported as odds ratios (OR). Odds ratios were generated from
the exponentiated values of the beta estimates of the binary GEE
MAGUIRE ET AL.
models. Due to the exploratory nature and the use of multiple GEE
models, the level of significance (a) was set to a value of .05.
4 | RESULTS
4.1 | Demographic and clinical characteristics of
participants
The mean age of the sample was 36.8 years (SD = 10.4, ranging
from 22–68); for males, the mean age was 34.5 (SD = 10.3, ranging
from 22–68), and the mean age for females was 39.2 (SD = 10.2,
ranging from 26–68). Diagnoses were as follows: schizophrenia 70%
(n = 42), schizoaffective disorder 13.3% (n = 8), first-episode psy-
chosis 5% (n = 3), major depressive disorder 3.3% (n = 2), personality
disorder 3.3% (n = 2), schizophreniform 1.7% (n = 1), organic psy-
chosis 1.7% (n = 1) and bipolar disorder 1.7% (n = 1).
4.2 | Aggression
There were 546 days from a total possible 3,600 patient days when
some form of aggression occurred meaning patients did not engage
in aggressive behaviour on 84.8% of days. When aggression was
documented, 79.9% incidents (n = 436) were categorised as raised
voices/verbal aggression/verbal altercation/threats; 11.7% (n = 64)
were categorised as throwing, striking, kicking/hitting or damaging
objects/furnishings/fittings; 6.4% (n = 35) were classified as hitting/
pushing another person, and 2% (n = 11) were incidents involving
the use of a weapon or threatening, or attacking another person.
4.3 | Nursing interventions
In total, there were 1,257 patient days when interventions were
documented and 2,041 interventions were documented (1 to a maxi-
mum of six interventions daily). Nurses most commonly documented
80
70
60
% of interventions
50
40
30
20
10
0
Medication Reassurance Observations Distraction Limit setting 1-1 nursing De-escalation
FIGURE 1 Percentage of interventions
by gender
| e975
that they had provided one type of intervention in the 24 hr follow-
ing DASA assessment and prior to an act of aggression (n = 754;
36.9%), followed by two interventions 29.6% (n = 604), three inter-
ventions 20.9% (n = 426), four interventions 8% (n = 164), five inter-
ventions 3.7% (n = 75) and six interventions <1% (n = 18). The most
commonly documented intervention was PRN medication 35.9%
(n = 733), followed by reassurance 18.1% (n = 369), distraction
10.9% (n = 223), limit setting 10.5% (n = 214), one-to-one nursing
9.7% (n = 198), increased observations 9.1% (n = 185) and de-esca-
lation 5.8% (n = 119).
Figure 1 reports the percentage of interventions that were pro-
vided to males and females. Patients are reported multiple times in
any or all of the three DASA bands (low, moderate, high). Pearson’s
chi-squared tests were considered to explore associations in both
Figure 1 and Table 1 but are not reported because these tests do
not account for the correlated nature of these data. In Figure 1,
there does not appear to be an association between gender and the
use of distraction, or for gender and de-escalation. A possible associ-
ation appears to exist between gender and limit setting, with more
females receiving limit setting as an intervention than males. There
also appears to be an association between gender and one-to-one
nursing, with more females receiving one-to-one nursing than males.
Likewise, there appears to be an association between gender and
reassurance, with more females receiving reassurance than males.
More males received PRN medication than females. However, there
also appears to be a possible association between gender and obser-
vations, with more males receiving observations than females.
4.4 | DASA assessments
There were 2,175 DASA risk assessments completed (60.4%, from a
possible 3,600 patient days). The DASA ratings in order from highest
number to lowest number recorded were DASA 0 (n = 1,300), DASA
1 (n = 225), DASA 2 (n = 201), DASA 3 (n = 123), DASA 7
Males Females
68.9
65.1
54.8
51.8 53.3 51.5
48.2 48.5 50 50
45.2 46.7
34.9
31.1
n = 733 n = 369 n = 183 n = 199 n = 214 time n = 198 n = 108
Interventions
e976 | MAGUIRE ET AL.

T A B L E 1 Proportions of reported acts of patient aggression following an intervention

Males Females

Intervention Aggression n Proportion, %* Aggression n Proportion, %*

Limit setting
Low Band No 519 6.4 No 742 5.1
Yes 17 11.8 Yes 22 27.3
Moderate Band No 241 17.8 No 255 22.7
Yes 34 29.4 Yes 21 42.9
High Band No 151 49.0 No 110 52.7
Yes 26 65.4 Yes 37 54.1
Medication
Low Band No 434 5.3 No 708 4.8
Yes 102 11.8 Yes 56 17.9
Moderate Band No 171 21.1 No 230 23.0
Yes 104 16.3 Yes 46 30.4
High Band No 87 52.9 No 90 51.1
Yes 90 50.0 Yes 42 56.1
Reassurance
Low Band No 494 6.5 No 694 5.3
Yes 42 7.1 Yes 70 10.0
Moderate Band No 236 16.9 No 234 21.8
Yes 39 33.3 Yes 42 38.1
High Band No 147 49.0 No 119 50.4
Yes 30 63.3 Yes 28 64.3
Distraction
Low Band No 516 6.4 No 735 5.6
Yes 20 10.0 Yes 29 10.3
Moderate Band No 246 18.7 No 259 23.2
Yes 29 24.1 Yes 17 41.2
High Band No 161 52.8 No 127 52.0
Yes 16 37.5 Yes 20 60.0
De-escalation
Low Band No 523 6.5 No 742 5.7
Yes 13 7.7 Yes 22 9.1
Moderate Band No 262 18.7 No 265 24.2
Yes 13 30.8 Yes 11 27.3
High Band No 170 51.2 No 141 51.8
Yes 7 57.1 Yes 6 83.3
Observations
Low Band No 492 6.5 No 752 5.7
Yes 44 6.8 Yes 12 8.3
Moderate Band No 250 19.2 No 263 24.0
Yes 25 20.0 Yes 13 30.8
High Band No 170 51.8 No 137 51.1
Yes 7 42.9 Yes 10 80.0
One-one
Low Band No 508 6.3 No 724 5.7
Yes 28 10.7 Yes 40 7.5

(Continues)
MAGUIRE ET AL. | e977

TABLE 1 (Continued)
Males Females

Intervention Aggression n Proportion, %* Aggression n Proportion, %*

Moderate Band No 247 18.6 No 259 23.6
Yes 28 25.0 Yes 17 35.3
High Band No 164 50.6 No 131 51.1
Yes 13 61.5 Yes 16 68.8

*Patients are reported multiple times in any or all of the three Dynamic Appraisal of Situational Aggression bands (Low, Moderate, High).

(n = 109), DASA 4 (n = 85), DASA 5 (n = 77) and a DASA score of 6
(n = 53). According to the specified DASA risk bands, 59.8%
(n = 1,300) were low DASA ratings (DASA score of 0), 25.2%
(n = 549) were moderate DASA ratings (DASA score of 1-3) and
14.9% (n = 324) were high DASA ratings (DASA scores 4–7). When
a DASA was completed, there was a total of 1,347 patient days
when there were no documented interventions, either documented
as planned following the DASA assessment or in the subsequent
24 hr. Of these, 71.6% (n = 964) of these ratings were in the low
DASA band, 20.6% (n = 278) were in the moderate DASA band, and
7.8% (n = 105) were in the high-risk band (including 29 ratings of a
DASA score of 7, where no intervention was documented).
Out of the 1,257 times when interventions were documented, a
DASA risk assessment had been completed and nursing staff then
documented intervention strategies to prevent aggression a total of
828 times. As the data reported are correlated, such that a patient is
counted on more than one occasion, chi-squared tests from GEE
models were used. GEE model results suggest there was a significant
association between DASA completions and interventions provided,
(v2 (1) = 21.35, p < .0001), whereby the patients who had a DASA
assessment (38.0%) had more interventions provided as compared to
those without a DASA assessment (30.2%). Males had more docu-
mented interventions (40.33%, n = 726) than the females (29.50%,
n = 531), v2(1) = 3.05, p = .081).
4.5 | Interventions provided at different risk bands
There were 2,175 occasions when a DASA was recorded. As the
DASA band level increased so did the percentage of interventions pro-
vided within the DASA bands, with the low band at 25.8% (n = 336),
the moderate band at 49.5% (n = 273) and the high DASA band at
67.6% (n = 219). Results from a GEE model (n = 2,175) suggest there
was a significant association between the DASA bands and the inter-
ventions provided (v2(2) = 110.64, p < .0001). There were more inter-
ventions provided as the level of risk increased. Figure 2 shows the
number of interventions that were provided per DASA risk band.
4.6 | Examining the effectiveness of interventions
at different DASA bands
Using cross-tabulation, the difference between those patients identi-
fied as having the intervention and then engaging in aggression were
compared for each DASA band (results are displayed in Table 1).
Exploratory descriptive results suggested that higher proportions of
females who were offered limit setting in the low and moderate
bands subsequently engaged in aggression. Higher proportions of
males and females in the low DASA band engaged in aggression
after being offered medication, and higher proportions of both males
and females in the moderate-risk band engaged in aggression follow-
ing reassurance. To draw further inference on these possible associa-
tions, usual chi-squared tests were deemed inappropriate due to the
correlated nature of these data. Hence, binary GEE models were
performed and are displayed as odds ratios (OR) in Tables 2 and 3.
Each of the seven intervention strategies displayed were analysed as
separate models. In the low-risk band, limit setting was significant,
meaning there was an increased likelihood of aggression for females
when limit setting was used. Medication was also significant in the
low-risk band; therefore, there was also an increased likelihood of
aggression for males and females when PRN was administered in the
low-risk band. In the moderate-risk band, there was an increased
likelihood of aggression for females when limit setting was used.
Reassurance was also significant for both males and females in the

250
Number of intervenons

201

200
158

150
112
96

87

82

100
68

56
52

52
49
46
39
36

35
34
30
28

50
23
19

14

0
PRN Reassurance Limit seng One-One Distracon ObservaonsDe-escalaon
F I G U R E 2 Interventions per Dynamic Intervenons
Appraisal of Situational Aggression band DASA low band DASA moderate band DASA high band
e978 | MAGUIRE ET AL.

T A B L E 2 Separate generalised
Males Females
estimating equation models for the seven
95% CI 95% CI interventions documented in the low
OR p OR p
Dynamic Appraisal of Situational
Limit setting 1.585 0.567 4.283 .363 4.178 1.156 15.104 .029*
Aggression band by males (n = 30) and
No limit setting 1 1 females (n = 30)
Medication 2.025 1.122 3.654 .019* 4.275 1.711 10.679 .002*
No medication 1 1
One-one 1.568 0.473 5.197 .462 1.226 0.476 3.157 .674
No one-one 1 1
Reassurance 1.009 0.272 3.747 .989 1.838 0.969 3.485 .062
No reassurance 1 1
Distraction 0.868 0.331 2.278 .774 1.767 0.691 4.521 .235
No distraction 1 1
De-escalation 0.877 0.157 4.852 .877 1.378 0.429 4.425 .590
No de-escalation 1 1
Observation 1.023 0.336 3.111 .968 1.607 0.385 6.707 .515
No observations 1 1

*<.05.

T A B L E 3 Separate generalised
Males Females
estimating equation models for the seven
95% CI 95% CI interventions documented in the moderate
OR p OR p
Dynamic Appraisal of Situational
Limit setting 1.863 0.576 6.025 .299 2.411 1.045 5.562 .039*
Aggression band by males (n = 27) and
No limit setting 1 1 females (n = 27)
Medication 0.786 0.416 1.488 .460 1.115 0.541 2.299 .769
No medication 1 1
One-one 1.379 0.688 2.675 .379 1.548 0.771 3.109 .219
No one-one 1 1
Reassurance 2.423 1.144 5.135 .021* 2.092 1.291 3.388 .003*
No reassurance 1 1
Distraction 1.302 0.434 3.910 .638 2.018 0.899 4.533 .089
No distraction 1 1
De-escalation 1.677 0.690 4.073 .254 1.209 0.403 3.629 .735
No de-escalation 1 1
Observations 1.011 0.350 2.914 .984 1.646 0.577 4.695 .352
No observations 1 1

*<.05.

moderate band, with an increased likelihood of aggression. There moderate and high) for males and females to determine whether
were no significant results for the high-risk band. there may be interventions that are more effective at preventing
aggression in different risk bands.

5 | DISCUSSION
The aim of this study was to elucidate the nursing interventions that
were used to prevent aggression in male and female patients in an
acute forensic setting, whether different and more interventions
were associated with higher risk levels, and whether these interven-
tions prevented aggression. This study also aimed to examine the
effectiveness of interventions at different levels of risk (low,
5.1 | Nursing interventions
This study offers an insight into the types of interventions used to
prevent aggression in a forensic inpatient setting. The use of PRN
medication was the most commonly documented intervention, con-
sistent with studies by Haw and Wolstencroft (2014) and Richardson
et al. (2015). PRN medication may have been the most common
type of intervention documented as there are more stringent
MAGUIRE ET AL.
requirements in regard to documentation of medication, whereas
psycho-social interventions such as those that involve engagement
may be documented less reliably. While the use of PRN medication
can be an effective intervention, it is generally considered that medi-
cation should be used after other nonpharmacological interventions
have failed, due to potential side effects (Usher & Luck, 2004). Possi-
ble reasons for the use of PRN over other interventions may include
the pressures on nurses due to the nature of busy inpatient wards
where PRN medication may be favoured over more time-consuming
interventions (Barlow, 2014).
5.2 | Interventions per risk band
As the DASA score increased so did the number of interventions
that were documented, which corresponds with the intention of the
DASA, which is to assist in prompting clinicians to start planning and
providing suitable interventions to reduce the risk of aggression
(Ogloff & Daffern, 2004). While the literature describing interven-
tions for preventing aggression and/or restrictive interventions often
mentions the need to use several interventions (e.g., Bowers et al.,
2015; Gaskin, Elsom, & Happell, 2007; NICE, 2015; Stewart, Van der
Merwe, Bowers, Simpson, & Jones, 2010), little attention has been
paid to which interventions should be used, in which combination,
whether males and females should be cared for differently with
regard to aggression prevention and when interventions should be
initiated. As seen in this study, the majority of interventions are pro-
vided once behaviour reaches a threshold within the high-risk band.
While it seems reasonable that there would be more interventions
applied in the high-risk band, it may be more effective to intervene
earlier to prevent the aggression risk from escalating (Krug et al.,
2002). Intervening early may also increase the efficacy of interven-
tions as the patient may be more receptive (Fluttert et al., 2008).
When a person is assessed as being in the high-risk DASA band,
they are already in a state of irritability and disagreeableness (Barry-
Walsh et al., 2009), which may impact on their willingness to engage
in the intervention.
5.3 | Comparing the interventions provided for
males and females
Our findings suggest there were differences between males and
females in relation to the type of interventions provided. Similar
to the findings by Nicholls et al. (2009), there was a tendency to
provide males in this study with more restrictive interventions;
more PRN medication was administered to males as compared to
females, and they were also more likely to be subjected to
increased observations. While the reasons for this discrepancy are
unclear, others have noted that these differences are explained by
males being perceived to be more dangerous (Wynn, 2002).
Females in this study were more likely than the males to receive
one-to-one nursing, reassurance and limit setting, which by their
very nature involve a more interpersonal approach and have an
emphasis on communication. This may be because female forensic
| e979
patients are perceived as less dangerous than their male counter-
parts, or perhaps as being more receptive to interpersonal
approaches.
5.4 | Impact of nursing interventions
Some interventions were associated with an increased likelihood of
aggression, but none that prevented aggression. For males in the
low-risk band, the use of PRN medication was associated with an
increased likelihood of subsequently engaging in aggression. In the
moderate-risk band for males, the use of reassurance as an interven-
tion was also associated with being more likely to engage in aggres-
sion. For females in the low-risk band, PRN medication was also
associated with being more likely to engage in aggressive behaviour,
along with limit setting. In the moderate band, the use of the inter-
ventions reassurance and limit setting was all associated with a
female being more likely to engage in aggression. Inpatient, aggres-
sion may in part be associated with the quality of the interaction
between staff and patients (Lancee et al., 1995), and in particular,
limit setting has been linked with aggressive responses from patients,
which may in part be due to the manner in which limits have been
set. For example, a more authoritarian style of limit setting may
engender a hostile response from patients, whereas limit setting
using an authoritative approach may enhance positive outcomes
(Maguire et al., 2014). Patients may also view limit setting as an
intervention that is more restrictive in nature; as such, this interven-
tion should be reserved for when the level of risk has escalated and
is imminent rather than when the person is presenting in the low-
and moderate-risk bands.
While assessment can alert nurses to imminent risk, preventing
patients from engaging in aggressive behaviour will often require
nursing intervention along with certain resources and/or procedures
(Kling, Yassi, Smailes, Lovato, & Koehoorn, 2010), which might
include additional staff to facilitate interventions such as close obser-
vations, equipment for distraction or space on the unit suitable for
engaging in one-to-one nursing, distraction techniques and de-esca-
lation. However, the engagement and selection of appropriate inter-
ventions (from primary to tertiary) for patients who present as a risk
of engaging in aggression remains a significant challenge for nurses
working in the acute inpatient setting.
This study found that the impact of interventions differs for male
and female patients. The differences could be due to how the inter-
vention is performed, and when the intervention is applied (is an
intervention such as limit setting being applied too early, e.g., when
someone is in the low-risk band when primary interventions should
be instigated, or perhaps they are initiated too late, such as the use
of reassurance in the moderate DASA band when this intervention
may have been more successful when a person was at low risk). The
lack of empirical research along with a lack of clear definitions of
interventions, and clear procedures that articulate how to success-
fully apply these nursing interventions for males and females at dif-
ferent risk levels, is hampering preventative action (Barlow, 2014;
Johnson & Hauser, 2001; Roberton et al., 2012).
e980 | MAGUIRE
Following the DASA assessment, a plan needs to be made about
how to prevent aggression, taking into account knowledge of what
works for each patient, with regard to his or her gender and risk
level. Patient preferences may also be usefully considered although
this was not a focus of this study. When the DASA was first devel-
oped, guidance suggested the intensity of the interventions should
correspond with the level of risk (Ogloff & Daffern, 2006). The
DASA instrument in its current form does not provide any sugges-
tions or framework in regard to what might be suitable nursing inter-
ventions at each DASA risk band. However, a framework including
primary, secondary and tertiary prevention linked to DASA risk
bands may enhance the use of the DASA, providing structure for
nursing intervention.
In the light of our findings, perhaps the focus may need to be on
engaging patients and applying primary interventions (such as one-to-
one nursing, distraction techniques and reassurance) in the low-risk
band. In the moderate DASA risk band, interventions might also
include the use of de-escalation techniques as indicated (and possibly
distraction techniques and one-to-one nursing). Finally, for patients
who are assessed as being in the high DASA band, tertiary interven-
tions (along with primary and secondary interventions) might include
the use of PRN medication, increased observation and limit setting.
These are more restrictive interventions and should be used only
after other less restrictive interventions have been tried and when
risk of aggression is imminent. The more restrictive interventions such
as the use of PRN medication, increased observations and limit set-
ting appear unsuitable when a patient is presenting as low or moder-
ate risk. These interventions are restrictive and may be viewed as
unnecessary and provocative by patients at low risk. They should be
used after other less restrictive (primary and secondary) practices
have been attempted. Attention should also be given to the choice
and application of interventions in the moderate-risk band. In this
study, limit setting (for females) and reassurance for males and
females were associated with an increased risk of aggression.
5.5 | Completion of risk assessment
Despite risk assessment being considered an important aspect of
forensic mental health nursing (McKenna et al., 2016), and a require-
ment for all patients admitted to the acute units in this service, on
40% of the days in this study a DASA was not completed. Compet-
ing demands for nurses, documentation not being completed, and
staff not valuing structured risk assessment may explain this result.
Identifying when patients might be at risk of engaging in aggressive
behaviour is an important component of forensic mental health nurs-
ing practice and should be done using an evidence-based approach
(Bowring-Lossock, 2006). Further research is required to understand
why risk assessments are not completed when required.
5.6 | Limitations
The most significant limitation of this study was its reliance on docu-
mented notes as the means of collecting the data for nursing
ET AL.
interventions and acts of aggression. Using this methodology, we
may not have provided a comprehensive representation of the care
that was provided, and may have failed to capture some of the other
factors that influence aggression and its prevention (e.g., staffing,
ward milieu). The reporting of nursing interventions and aggression
is reliant on the quality of the documentation, and it is likely that
both nursing interventions and aggression were underreported.
Another limitation is that patient risk levels may have changed from
the time of the DASA assessment, to the time that the intervention
was applied, which may mean some of the interventions were actu-
ally appropriate if the person’s risk had increased. The modest num-
ber of patients in this study and the forensic mental health setting
may also limit the generalisability of these results to other hospital
settings.
6 | CONCLUSION
Although numerous interventions for managing aggression are men-
tioned in the literature and documented in practice, some interven-
tions appear contraindicated for males and females assessed as low
to moderate risk of aggression. Further, these results suggest that
there is no particular intervention that is particularly effective for
preventing aggression for patients at high risk of imminent aggres-
sion; it is likely that a combination of various interventions is
required to prevent aggression for high-risk patients (e.g., offering
reassurance, providing PRN medication and observing and engaging
with the patient). This is reflected by the higher number of interven-
tions being initiated for patients who are assessed in the moderate-
to high-risk bands. Gender may have an influence on the type of
interventions provided. To improve patient care and prevent inpa-
tient aggression, attention needs to be directed towards improving
the interventions designed to reduce aggression and the use of
restrictive interventions. Early intervention should be a priority.
7 | RELEVANCE TO CLINICAL PRACTICE
Findings from this study can be used to enhance clinical practice in
several ways. Given the importance of assessing for risk of imminent
aggression, patients in the acute inpatient setting should have a daily
risk assessment completed by nurses. Once a risk assessment has
been completed, a plan should be developed about how to manage
the risk; this should take into account the patient’s gender and risk
level. Consideration needs to be given to the type of intervention
and how it is applied (e.g., how reassurance is provided, and how
limits are set—this requires elucidation of best practice and consis-
tency in implementation). As noted, many of the commonly sug-
gested interventions are not defined clearly and practice can vary
considerably (Roberton et al., 2012). Staff training in relation to the
details of the interventions and when to apply interventions could
possibly enhance the effectiveness, consistency and documentation
of these interventions. Consideration also needs to be given to
MAGUIRE ET AL.
intervening as early as possible and in the least restrictive manner,
using primary, secondary and tertiary interventions according to risk
level. Early intervention may be more successful at averting aggres-
sion as patients may be more receptive, although care should be
given not to intervene with low-risk patients using restrictive/ter-
tiary strategies.
ACKNOWLEDGMENTS
The authors would like to acknowledge Forensicare’s support for TM
through the further study incentive scheme. We are also very grate-
ful for the ongoing support and assistance from Ms. Jo Ryan,
Director of Nursing at Forensicare and Mr. Murray Bruce for his
insightful comments on an early draft.
CONTRIBUTIONS
Substantial data analysis, manuscript preparation: TM; statistical
analysis, manuscript preparation and revision: MD, SB, BM.
AUTHORSHIP
All authors listed met the criteria according to the guidelines of the
International Committee of Medical Journal Editors and are in
agreement with the manuscript.
CONFLICT OF INTEREST
The authors report no financial support or conflict of interest.
ORCID
Tessa Maguire http://orcid.org/0000-0002-1050-6094
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How to cite this article: Maguire T, Daffern M, Bowe SJ,
McKenna B. Risk assessment and subsequent nursing
interventions in a forensic mental health inpatient setting:
Associations and impact on aggressive behaviour. J Clin Nurs.
2018;27:e971–e983. https://doi.org/10.1111/jocn.14107