Coming Together to Improve Quality: Piloting the Staff Observed Aggression Scale

By Ivy Zang, MPH, RN

Aggressive acts color daily life on inpatient psychiatric units. Name-calling, violence-threatening, wall-punching, food-throwing, and head-banging characterize the inpatient milieu at times. Although incidents that result in restraint and seclusion or cause injury are both documented in reports, what about all the aggressive acts that never lead to restraint or injury? Some of those actions are described in varying detail in nursing progress notes. Often, however, they are seen as an unremarkable and expected part of the milieu that is not passed on to other staff members or the medical record. Is there a way to accurately measure the level of and changes in aggression on inpatient units, with the hope of reducing the number and intensity of these events?

In June, NB2 and SB2 piloted the Staff Observed Aggression Scale-Revised (SOAS-R), with the dual goals of measuring the frequency and severity of all aggressive incidents occurring on the units, while determining if the SOAS-R is the right aggression-measuring tool to use at McLean Hospital. Dr. Henk Nijman developed the SOAS-R in the Netherlands in 1999. It has since been validated in numerous countries, with many different inpatient psychiatric populations. We aimed to determine if the SOAS-R accurately captures the different kinds of aggression that occur at McLean Hospital, and if staff members can quickly and effectively use the tool to document incidents.

The form has five check-off columns that record provocation of aggressive incident, means, target, consequences for the victim, and actions taken by staff to minimize the aggression. The SOAS-R also contains a visual analog scale, which staff members use to record a subjective rating of aggression severity.

At the end of May, as we prepared to launch the pilot program, we ran group and individual educational sessions, during which nursing staff on all shifts were encouraged to fill out an SOAS-R form for a recent incident of aggression. Staff members needed minimal instruction to fill out the forms, and reported that the tool appeared easy to use. However, they voiced dissatisfaction with the limited options provided by Nijman in the “measures to stop the aggression” column. We added five additional measures to the tool, based on staff suggestions and the primary standards of care for patients on NB2 and SB2.

The SOAS-R pilot was launched on NB2 and SB2 on June 1st. We framed the project as an opportunity for nursing staff to quantitatively show the intensity of their workload to the rest of the McLean community, and to help staff identify potential areas for improvement. On both units, staff members were immediately responsive, and a majority filled out the forms during the first eleven days of the month.

At the end of August, we conducted a group session with NB2 and SB2 staff members to discuss their experiences with the tool. Feedback was mostly positive, and nurses on SB2 offered their reactions. Ginybel Belgira described the SOAS-R as “fine and easy to use.” Amanda Casparriello reported that the tool “only takes 30 seconds” to use. Jill Standish said that the forms “made a lot of us think about the day-in, day-out stuff that we take for granted.” Jill identified an unexpected benefit to the tool, noting that if we continue to take aggression in the milieu for granted, we will not work to minimize it.

Despite the generally positive feedback, NB2 and SB2 staff members discovered a number of shortcomings with Nijman’s tool when used in practice. Due to Nijman’s limited options for provocation, staff frequently checked “other” and described the provocation in a detailed narrative, thereby losing the efficiency and simplicity intended by the tool’s designer. Staff members identified that Nijman’s vocabulary and formatting made the form tedious to use. The complicated phrasing led to a frequent misreading of “consequences for the victim” as “consequences for the patient.” Staff members also cited multiple aggressive incidents that took place on units that did not fit into the confined spaces of the form.

Using data analysis and feedback from the inpatient staff, we have revised the form, which will be released in August. “Staff redirection” as a provocation and “non-verbal aggression” as a means have been added to the form, and the formatting and vocabulary have been simplified for easier use. To encourage sustained enthusiasm for the second stage of the pilot, weekly updates will be posted for unit staff.

Only with research is effective change possible. Thank you to all the wonderful staff on SB2 and NB2 for their enthusiasm and willingness to try something new.