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Evaluating the Interventions Implemented and Subsequent Outcomes Following a Moderate and High Score on the Dynamic Appraisal of Situational Aggression Risk Assessment Tool
- Alexander Challinor, Patrick Briggs, Faye Brennan, Charles Daniels
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S47
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Aims
The Dynamic Appraisal of Situational Aggression (DASA) is one of a few instruments designed for the prediction of violence specifically for inpatient populations. It is important that risk assessment tools demonstrate clinical utility, and that barriers to successful implementation are addressed. If successful, the tool should not only predict risk, but lead to the utilisation of interventions intended to manage and reduce risk. The aim of this study is to learn more about the acceptability of the tool (adherence), it's outputs (nursing interventions), and the outcomes (inpatient aggression and violence). Understanding more about the relationship and processes between an intervention and its outcomes is a key step in intervention evaluation.
MethodsData were collected over a three-month period within a medium secure forensic hospital. A total of 43 patients were included for analysis.
Categories of nursing intervention were coded and content analysis of electronic health records analysed. Incidents of aggression/violence to others was recorded as aggression to patient and aggression to staff. Data were gathered on the completion of the DASA score for all patients for each 24-hour period. A DASA score of 2–3 for moderate risk and ≥4 for high risk was used. The change in DASA score (before and after intervention) and frequency of incidents was calculated for each intervention implemented.
ResultsThe average adherence of the DASA tool was 58.82% (Range 1.09% - 90.02%). The most frequent intervention following a moderate and high DASA score was that no interventions were provided. The second most frequent outcome following a high score was a focussed discussion with the patient, the use of increased monitoring and the use of seclusion. For those patients that recorded a high score on the DASA tool, eight of those scores were followed by an incident of aggression (n = 8 / 50%). There was no statistically significant difference between the change in DASA scores between interventions implemented, for both high and moderate scores.
ConclusionThe ultimate goal of risk assessment is the management and prevention of risk. Thus, if a high score does not result in strategies for intervention, it renders the assessment process worthless. A recommendation for future clinical practice would be the systematic recording of interventions and risk management strategies when in receipt of a high score on the DASA. Greater operationalisation of risk management strategies and their ability to reduce aggression is needed to enhance risk assessment research and clinical practice.
A Pilot Study of Service Utilisation Pathways of Patients With Distinct Psychotic and Antisocial Typologies
- Alexander Challinor, Neil Meggison, Jonathon Whyler, Phoebe Cresswell, Leah Evans, Michael Bingley, Praveen Somarathne, Jodi Thompson, Dawn Washington, Taj Nathan
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S45
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Aims
There is a developing body of research that suggests that there may be distinct categories of patients that can explain the relationship between psychosis and antisocial behaviours. Specifically, three pathways of offending, antisocial behaviour and psychosis have been described and there is an evolving empirical evidence base to suggest that these pathways are aetiologically distinct. Firstly, there is a pathway for early-start offenders, which have been identified as those with psychosis preceded by Conduct Disorder (SZ + CD). Secondly, a group that start to display antisocial behaviours in parallel to the onset of psychosis (SZ-AS). The third group involves those with a long history of a psychotic disorder and no history of antisocial behaviours, who will present to services following a first conviction for non-violent or violent crime (SZ). The authors hypothesise that each typology will utilise services differently throughout the clinical trajectory. This pilot study aimed to (i) examine the concurrent validity of the antisocial behaviour and psychosis typologies, and (ii) examine differences in the service utilisation patterns of patients between these groups.
MethodsThe sample consisted of adult male patients admitted to low and medium secure forensic hospitals within the Northwest of England. A total of 90 patients were used.
A categorisation checklist was developed, and the typology of patients determined from data collected from electronic health records. Data were collected on patient demographics, psychiatric diagnosis, aetiological factors, and service utilisation. Two researchers reviewed the data and determined the typology. Statistical analysis aimed to assess the difference in aetiological variables between the typologies and examine the relationship with how each typology utilised services.
ResultsThis study provided further evidence of distinguishing characteristics emphasising typology heterogeneity.
The CD-SZ group were more likely to have utilised mental health services <18 years (70%, p = 0.062), and to have used services preceding a diagnosis of psychosis (60%, p = 0.011). Following the onset of a psychotic disorder, the AS-SZ and SZ groups had a higher proportion that used general adult psychiatry services (p = 0.031), with CD-SZ coming in to contact with forensic psychiatry services and criminal justice services earlier and more frequently.
ConclusionThis study demonstrates that each typology has a different clinical trajectory through mental health services. This provides further empirical evidence towards different clinical typologies and trajectories of individuals with psychosis and anti-social behaviour. Understanding more about how these typologies utilise services will enable clinicians to introduce interventions help develop effective management plans that address the distinct characteristics of each typology of offender with psychosis.
A literature review for the introduction of psychiatric simulation to University of Liverpool Medical School
- Alexander Challinor, Declan Hyland
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S129
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The aim of this review is to systematically investigate simulation in psychiatry to enable the evidence based introduction of psychiatry simulation into the undergraduate curriculum at the University of Liverpool.
BackgroundTransformations in the structure of psychiatric delivery and reductions in funding to mental health care have limited the availability of direct patient clinical experiences for medical students. Experiential learning through simulation can be utilised as a powerful pedagogical tool and provide exposure to a broad range of psychopathology.
Although psychiatric skills and knowledge are gained from the current University of Liverpool undergraduate curriculum, there is no specific well-designed psychiatry simulation.
MethodThe author searched MEDLINE, EMBASE and PsycINFO databases for studies that met the inclusion criteria. Search terms included ‘simulation (psychiatry or ‘mental health’). Studies were also searched using snowballing via citation tracking within the databases.
Inclusion criteria comprised studies of an educational intervention that involved simulation. The intervention had to be utilised within the field of psychiatric teaching.
ResultThe literature review illustrated the dearth of studies analysing role-playing (RP) and/or simulated patients (SP) in psychiatry with it typically encountered as part of the more general communication skills curriculum. Studies analysing SP and RPs demonstrate how they build on the social context of learning alongside drawing on a range of educational theories, including experiential learning. However, studies show that well-designed simulation training should encompass more facets of learning to be transformative, specifically reflecting upon ones experiences alongside understanding and interpreting this new knowledge, allowing it to guide future actions and change practice.
Studies analysing virtual-reality in psychiatry are limited but demonstrate significant improvements in students’ acquisition of key psychiatric skills and exposure to psychopathology. More studies are needed to evaluate the efficiency and cost-effectiveness of virtual-reality over more traditional methods.
Despite the increase in simulation teaching within psychiatry, and the expansion of innovative simulation approaches in other specialties, there was limited use of novel approaches found within the studies analysing psychiatric simulation. There were studies evaluating novel approaches to psychiatry simulation outside of the undergraduate curriculum.
ConclusionWhilst there are barriers to overcome in simulation training, these are primarily logistical and are clearly outweighed by the educational gain demonstrated throughout this review. Simulation training in psychiatry has often remained limited to traditional communication-oriented scenarios using RP or SP. A greater emphasis on furthering the advancement and integration of more innovative approaches into psychiatric undergraduate teaching is needed.