Risk assessment made easyThe Bröset Violence Checklist(BVC)Roger Almvik, Dr. PhilosResearch Director, RN, RMN,PhDCentre for Research and Education in Forensic PsychiatrySt. Olavs hospital, Forensic department Bröset, TrondheimNorwegian University of Science & Technology,Faculty of Medicine1

2Learning objec-ves Reflect on the basic underlying principles of violencerisk assessment Develop awareness of BVC in the assessment ofimminent violence Consider the evidence to support its validity To be aware of Rosenborg Trondheim FC2

3Introduc-on InstrumentaBon to aid in the assessment processshould be a part of everyday clinical pracBce. All members of the interprofessional team have animportant part to play in collecBng clinically relevantdata to assist idenBfying intervenBons and contributeto clinical decision-making. Assessing the risk of violence to self, others orproperty is an important aspect3

4Introduc-on When these forms of violence occur they have thepotenBal to impact on both the clinical staff and thehealth environment as well as costs There is extensive research that consistently showssuperior risk decision-making when structured clinicaljudgement is used.4

5Introduc-on Research on instrument development has amassedover the years to the current date where clinicianshave a baKery to choose from. One short term violence predicBon instrument that isreceiving considerable interest is the Brøset ViolenceChecklist (BVC). To date a body of research exists on its usefulness andimplementaBon in clinical pracBce, most recently fromrandomized controlled trials.5

Background (for being here ?)NICE guidance NG10, on the short termmanagement of violence and aggression,recommends using an actuarial predictioninstrument such as the BVC (Brøset ViolenceChecklist) or the DASA-IV (Dynamic Appraisal ofSituational Aggression - Inpatient Version), ratherthan unstructured clinical judgement alone, tomonitor and reduce incidents of violence andaggression and to help develop a risk managementplan in inpatient psychiatric settings.6

Center for Clinical Guidelines (DK)Conclusions/recommandations:ü Standardised risk assessment tools can beused to predict aggressive and violentbehaviourü MHC staff should use the BVC in theirclinical work in adult inpatient services7

8Risk assessment Risk assessment needs to be systemaBc and based onthe populaBon undergoing assessment; with idenBfiedrisk factors required to be broken down into moremanageable components, further assessed througheffecBve treatment planning and outcomes evaluatedthrough recovery8

Growth of Risk Assessment Monahan (1981) – 5 studiesEarly 1990s – handful of instrumentsToday – too many instruments ?!1998 – first publication on BVC1999 – first publication on HCR-20Today› 150 disseminations on HCR-20› Estimated 300 SPJ disseminations› Estimated 600 disseminations, generally9

SPJ studies over time (Guy)10

SPJ Decision Steps(HCR-20 Version 3, Douglas et al.)1 Gather relevant information2 Determine presence of risk factors3 Determine relevance of risk factors4 Develop formulation of violence risk5 Develop primary scenarios of violence6 Develop case management plans7 Develop final risk judgments11

Brøset Violence Checklist - BVCØ A risk assessment toolhitting the Bull’s eye ?12

Brøset Violence Checklist (BVC)History and Backgroundü Developed at R.S.U. Bröset based on data from forensicinpatients.ü Extensively tested out on acute wards, nursing homesand geriatric wards in Norwayü Extensive validation studies in various settingsnationwide as well as international13

Brøset Violence ChecklistSix variables/behaviours: Confused Irritable Boisterous Physically threatening Verbally threatening Attacking objects14

Interpretation andoperationalisation Confused - Appears obviously confused and disorientated. May beunaware of time, place or person. Irritable - Easily annoyed or angered. Unable to tolerate thepresence of others. Boisterous - Behaviour is overtly "loud" or noisy. For exampleslams doors, shouts out when talking etc. Physically threatening - Where there is a definite intent tophysically threaten another person. For example the taking of anaggressive stance; the grabbing of another persons clothing; theraising of an arm, leg, making of a fist or modelling of a head-buttdirected at another.15

Interpretation andoperationalisation Verbally threatening - A verbal outburst which is more than just araised voice; and where there is a definite intent to intimidate orthreaten another person. For example verbal attacks, abuse, namecalling, verbally neutral comments uttered in a snarling aggressivemanner.Attacking objects - An attack directed at an object and not anindividual. For example the indiscriminate throwing of an object;banging or smashing windows; kicking, banging or head-butting anobject; or the smashing of furniture.16

BVC – Form (example)Filled in by:DAY ONEDAYSHIFTTo be filled in before.ConfusedIrritableBoisterousVerbal threateningPhysical threateningAttacking objectsSUM17date




Interpretation of BVC scoreScoreSum Risk0Risk of violence is smallSum 1-2The risk of violence is moderate, Preventativemeasures should be takenSum 2The risk of violence is high.Preventative measures should be taken andplans about how to manage an attack made.21

23The App23

Research ?24

Plenty !25


Japan 第35回日本看護学会論文集 - 論題一覧 - 抄録集演題・論文集論題一覧 .暴力発生の状況とBroset Violence ��東京都立松沢病院 �英介・薄田恒夫・北野進・石川博康 .186 187 暴力を繰り返す患者への看護 .27

Nurses and research .Professor C. Pirquet (Vienna 1927):”one cannot think of nurses doing scientificresearch – their ability to think originally are moreseldom than in men”Chief medical officer Wyller (Oslo 1918):”The knowledge that are forced into the nurses iscompletely dead ballast – their brain is notcapable of receiving it”28


ChinaAcceptability and psychometric properties of Brøset ViolenceChecklist in psychiatric care settings in China; X . Yao et al in Journalof Psychiatric and Mental Health Nursing, BVC provides nurses with a quick and easily administered method toscreening out patients with violence potential, thus allowing for earlyintervention. Feedback from the nurses was quite encouraging and thefurther use of BVC seems promising.30



Evidence on effects Abderhalden et al in BJP : Introducing twice dailystaff measures on risk assessment (BVC Swiss version)– 41 % reduction in severe violent incidents– 27 % reduction in the use of coercive measures Van de Sande et al in BPJ : Implementing regularrisk and violence assessment– 68 % reduction of aggressive incidents– 45 % reduction of time in seclusion Hvidhjelm et al in PhD thesis, Uni of Copenhagen – 48 % reduction in violent incidents33

Lockertsen, Ø. ; Master thesis34

Nurses assessment of the BVCü 95,8 % thinks that the use of BVC rarely or never increase the useof coercive measuresü 75 % describes increased insight in to the pt’s risk for violence, butnot necessarily more insight in to pt’s vulnerabilityü 83,4 % reports that BVC is used activily in the daily riskassessment routinesü 68,5 % reports that BVC makes them better in risk predictionü 67,6 % reports that the use of BVC often or always leads to earlyinteventions35

36References Abderhalden, C., Needham, I., Miserez, B., Almvik, R., Dassen, T., Haug, H.J.,& Fischer, J.E. . PredicBng inpaBent violence in acute psychiatric wardsusing the Brøset-Violence-Checklist: a mulBcentre prospecBve cohort study.Journal of Psychiatric and Mental Health Nursing, 11(4), 422-427. Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H.J., & Fischer, J.. PredicBng inpaBent violence using an extended version of the BrøsetViolence-Checklist: instrument development and clinical applicaBon. BMCPsychiatry, 6:17 Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H.J., & Fischer,J.E. . Structured risk assessment and violence in acute psychiatricwards: randomised controlled trial. Bri;sh Journal of Psychiatry, 193(1),44-50.36

37References Almvik, R., & Woods, P. (1998). The Brøset Violence Checklist (BVC) and thepredicBon of inpaBent violence: some preliminary results. Psychiatric Care,5(6), 208-211. Almvik, R., & Woods, P. (1999). PredicBng inpaBent violence using theBrøset Violence Checklist (BVC). Interna;onal Journal of Psychiatric NursingResearch, 4(3), 498-505. Almvik, R., Woods, P., & Rasmussen, K. . The Brøset Violence Checklist(BVC): SensiBvity, specificity and inter-rater reliability. Journal ofInterpersonal Violence, 15(12), 1284-1296. Almvik, R., & Woods, P. . Short-term risk predicBon: the BrøsetViolence Checklist – Research in Brief. Journal of Psychiatric and MentalHealth Nursing, 10(2), 236-238.37

38References Almvik, R., Woods, P., & Rasmussen, K. . Assessing risk for imminentviolence in the elderly: The Broset Violence Checklist. Interna;onal Journalof Geriatric Psychiatry, 22(9), 862-867. Björkdahl, A., Olsson, D., & PalmsBerna, T. . Nurses’ short-termpredicBon of violence in acute psychiatric intensive care. Acta PsychiatricaScandinavica, 113(3), 224-229 Clarke, D.E., Brown, A.M., & Griffith, P. . The Brøset Violence Checklist:clinical uBlity in a secure psychiatric intensive care senng. Journal ofPsychiatric and Mental Health Nursing, 17, 614–620. Linaker, O.M., & Busch-Iversen, H. (1995). Predictors of imminent violence inpsychiatric inpaBents. Acta Psychiatrica Scandinavica, 92(4), 250-254.38

39References Needham, I., Abderhalden, C., Meer, R., Dassen, T., Haug, H.J., Halfens, R.J.,& Fischer, J.E. . The effecBveness of two intervenBons in themanagement of paBent violence in acute mental inpaBent senngs: reporton a pilot study. Journal of Psychiatric and Mental Health Nursing, 11(5),595-601.§ Nijman, H.L.I., Muris, P., Merckelbach, H.L.G.J., PalmsBerna, T., Wistedt, B.,Vos, A.M., van Rixtel, A., & Allertz, W. (1999). The Staff ObservaBonAggression Scale-Revised SOAS-R. Aggressive Behavior, 25(3), 197-209.§ Ogloff, J. D., & Daffern, M. . The dynamic appraisal of situaBonalaggression: An instrument to assess risk for imminent aggression inpsychiatric inpaBents. Behavioral Sciences and the Law, 24, 799-813. Palmstierna, T., & Olsson D. . Violence from young womeninvoluntarily admitted for severe drug abuse. Acta Psychiatr Scand,115(1), 66-7239

40References van de Sande, al . Aggression and seclusion on acute psychiatricwards: effect of short-term risk assessment. Bri;sh Journal of Psychiatry,199(6), 473-478. Vaaler, A.E., et al. . Short-term predicBon of threatening and violentbehaviour in an Acute Psychiatric Intensive Care Unit based on paBent andenvironment characterisBcs. BMC Psychiatry, 11:44 Woods, P., & Almvik, R. . The Brøset Violence Checklist (BVC). ActaPsychiatrica Scandinavica, 106 (suppl. 412), 103-105. Woods, P., Ashley, C., Kayto, D., & Heusdens, C. . PiloBng violence andincident reporBng measures on one acute mental health inpaBent unit. Issuesin Mental Health Nursing, 29(5), 455-469 Yao X1, Li Z, Arthur D, Hu L, An FR, Cheng G.: Acceptability andpsychometric properBes of Brøset Violence Checklist in psychiatric caresenngs in China. J Psychiatr Ment Health Nurs.40

41Conclusion The BVC has a growing evidence base to support itsvalidity Assessing a paBents risk of violence using astandardized measure is more accurate than usingsolely subjecBve judgements The BVC allows for reflecBon and standardizaBon ofthe behaviours and characterisBcs typical of violentincidents (Ogloff and Daffern) BVC is easy to incorporate into daily rouBnes41