Risk Assessment: Articles Review

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Risk Assessment Articles

I am going to discuss and analyse the efficiency and the effectiveness that current risk assessments used in hospitals have, on addressing violent and aggressive behaviour of patients towards health care workers. My main viewpoint, from researching various journals and articles on this topic, is that while risk assessments play a crucial role in implementing a reduction in occupational violence overall, assessments need to be continuously updated and improved to make a large difference in the reduction of violence. Tools that are commonly used range from Alert systems, alert forms, protective behaviour and the HCR-20 tool that uses historical data from the patient and other data to predict violent behaviours. I take the viewpoint the wholistic approach used within risk assessments of these types lies in the HCR-20 tool and this will be discussed within my essay. There are also other factors to be considered when addressing violence and that lies with society and their attitudes towards combating this behaviour that affects many Health care workers in Australia and overseas. The harmful effects that violence and aggressive behaviour have on the health of workers within this sector, is strikingly alarming and thus counselling and training should be always implemented by their employers.

An example of when crucial risk assessments were not implemented, created a devasting effect for the Alfred hospital in Melbourne and especially the victim being a nurse for the hospital. A severe breach of the OHS Act occurred at the Alfred hospital whereby a nurse was physically assaulted by a patient known to be violent that had many incidents of violent behaviour towards nurses. The Alfred Hospital was fined $25,000 as this institution failed to provide information, instruction, and necessary training for staff. No information was given to staff about patient behaviour concerns that they could be at risk of injury to employees. There were also no mechanical restraints used or staff having any duress alarms. ANMF worked with health services to upgrade their systems for preventive action and additional tools needed to reduce occupational violence and aggression, and to be continuously improved (ANMF, 2019). This is a prime example of when alert alarms should have been implemented for staff to remain safe and not subjected to violent behaviour.

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Since 2015, the ABC reported that $20 million plus dollars has been allocated to spending on protective vests, and alert alarms in Victoria hospitals due to an increase on hospital staff from violence, aggressive and threating behaviour and is definitely on the rise especially around major events and special times of the year such as the New year’s eve period (ABC News, 2015). These are disturbing facts and the question is then, how can we put in place better risk assessment procedures? occupational violence, measures put in place, but nothing addressed about preventing violence from patients in this study. Alert duress alarms, vests, etc are useful in addressing the significant increase in occupational violence. but only one step in the right direction.

There is evidence to suggest from the article by Mathew Large, Department of mental health services, along with, Christopher Ryan from the Uni of Sydney show that ‘’violence risk assessment has not been shown to reduce violence.’’(Large & Ryan, 2014). Many thousands of studies have been done on violence risk assessments in health care settings like hospitals generally at the front line in an emergency apartment, aged care facilities and mental health units within hospitals. However, it was found that only two studies have shown evidence that a reduction in violence occurred and they argued that violence risk assessment does not lead to a significant reduction of occupational violence and aggression (Large & Ryan,2014). Of these studies, one being the:’Van De Sande study (2011)’, there were 2 experimental wards of the hospital that noted every patients every day with 2 risk assessments scales and then 2 assessment scales on weekly basis. During this period, staff in these experimental wards were represented by a specialist nurse and risk assessment expert panel assigned to ongoing clinical supervision. As a result, there was evidence that violent episodes towards staff decreased but unfortunately, not such a significant difference when compared to other wards that were assigned clinical supervision, during this intervention period (Large & Ryan 2014). This article shows that ongoing training in dealing with aggression and violent behaviour needs to be done and constantly improved if we are to reduce occupational violence in our workplaces, especially staff in health care systems.

During 2003 and 2004 in Australia, a study of the effectiveness of an Alert assessment form used as part of the Alert system was done in a large acute care hospital, to identify potential patients with an elevated chance to have violent behavioural tendencies. In the study, 117 violent patients’ charts were compared to 161 nonviolent patients’ charts. It was noted in the article by Kling et al, that the ‘Broset Violence Checklist and used the Alert System Risk Induction {M55 form}. The form included a notification system, ie flagging, to inform health care workers about a potential patients’ risk for violence and aggressive behaviour. It was found that the Alert system needed to be utilised in an appropriate time frame (Kling et al, 2006). Even though the appropriate protocol was implemented with the alert system, , there was still a high proportion of violent behaviours and attacks from patients towards workers even after being flagged. Maybe this was due to reporting only of that day in hospital that they were aggressive and did not have a full, accurate history of these patients.

Workers using these forms all agreed that the Alert System process was difficult to use and procedures that needed to be adhered to, were not followed and thus were inconsistent affecting the efficiency of the use of the Alert system. As the perception of the patients and staff personal tolerance of violent behaviour are dependent on the particular person, the results are also flawed and not accurate. Other factors to consider in establishing the accuracy of these forms to be used for analysing a patient’s potential violence. is that some forms were only partially completed or not even filled out at all due to workers busy schedule (Kling et al, 2006). Health care workers, especially those in a frontline role in a hospital, also have to use their own clinical judgement when assessing a patient who presents to them as time is crucial when identifying persons displaying violent behaviour.

In conclusion, further research of risk assessments, into the predictors of violent and aggressive behaviours, needs to be established to become an effective preventative measure to reduce occupational violence towards health care workers. I believe that we need to promote preventative measures of understanding violence in general and what a society can do to establish better behavioural ways towards another fellow person. Addressing children and teens within schools, workplaces and within homelife, needs to be a focal point of establishing socially acceptable behaviours. In addition to this, anger- management courses for children, carers, teachers, parents, all cultures and genders, and work place staff should be the norm to address society’s responses to violence, how to detect violence , triggers that create violent behaviours, mental health assessments, counselling services, medication, training on assisting fellow staff when caught in these situations dealing with difficult and challenging behaviours.

It appears that after my research, the most effective risk assessment tool that seems to take a wholistic approach towards detecting and addressing occupational violence is the HCR-20 tool which is defined as ‘The HCR-20 tool. A specific definition of how this works is ‘’the HCR-20 comprises 20 items and is divided into three sections; the first section, the Historical or “H” section comprises 10 items scored from data obtained from multiple sources and can be described as anchoring risk assessments. Although many of the factors on the “H” subscale are enduring, there is the possibility of “new historical items” emerging, for example, if a person assessed later develops a substance use problem.’ (McCallum & Eagle, 2015).

‘The second section, the Clinical or “C” section, comprises five items concerned with dynamic/current risk factors with the presence and intensity of these factors possibly varying the level of risk (Webster et al., 1997). The final section, the Risk Management or “R” section consists of five items and is most concerned with forecasting an individual’s ability to cope with future circumstances. These factors are also dynamic and are cited by Webster et al. (1997) as perhaps presenting the greatest challenge to clinicians undertaking a HCR-20 because of their speculative nature.’ (McCallum & Eagle, 2015). This tool represents a wholistic approach in assessing risks associated with occupational violence and I would agree that this is the best way to implement safer and less harmful violence towards health care workers.

In conclusion to all of these articles about using risk assessment tools to help curb violence and aggression towards health care workers, it is nicely summed up by John McCallum and Kerri Eagle who point out in their journal, stating ‘Such approaches should increase the level of reassurance for clients, carers, families, mental health professionals and the wider public that everything clinically possible is being attempted to minimize the occurrence of violent tragedies involving mental health clients.’ (McCallum & Eagle, 2015). By using these various tools, protective vests, alert alarms and M55 forms and the HCR-20 tool, all need to undergo continuous improvement and regular updating. Therefore, these risk assessment tools, especially the HCR-20 tool, provide essential guards to improving management of violent behaviours towards workers in health care professions, especially frontline staff in hospitals.


  1. ABC Premium News, Victorian hospital staff to get duress alarms, protective vests after ‘unacceptable’ rise in violence in ABC News, 2015
  2. https://www.abc.net.au/news/2015-12-28/hospital-staff-to-get-duress-alarms-protective-vests/7056644
  3. Kling,R et al. Use of a violent risk assessment tool in an acute care hospital and the effectiveness in identifying violent patients. BA AAOHN JOURNAL NOVEMBER 2006, VOL. 54, NO. 11
  4. [bookmark: _Hlk35255949]Large, M & Ryan, C. Violence risk assessment has not been shown to reduce violence. Australian and New Zealand journal of psychiatric. (January 2015) https://www.researchgate.net/publication/263396942_Violence_risk_assessment_has_not_been_shown_to_reduce_violence_Letter
  5. McCallum, J & Eagle, K. Risk Assessment: A Reflection on the Principles of Tools to Help Manage Risk of Violence in Mental Health, Justice Health and Forensic Mental Health Network, Blacktown, NSW, Australia, Psychiatry, Psychology and Law, 2015 Vol. 22, No. 3, 378387, http://dx.doi.org/10.1080/13218719.2014.959155


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