Mental Health Nursing

152 Acute Mental Health Nursing
individual legal accountability is increased (Gupta, 1995) and their
professional judgement will inevitably be subjected to closer scrutiny, particularly
should things go wrong.
Clearly then, the knowledge, skills and experience that mental health
nurses possess are crucial to clinical interventions involved in the process
of assessing and managing risk.
Risk factors for violence
The factors that provide information about who in a given population is
going to be violent have been termed risk factors, which are measurable
factors that correlate with and precede the outcome of interest
(Kraemer et al., 1997), in this case violence. Increasing knowledge of what
factors best predict challenging/aggressive behaviour could help mental
health nurses to (1) recognise factors predictive/protective of violent and
aggressive behaviour; (2) identify targets for intervention and (3) equip
them with knowledge and skills to reduce risk to the service user, staff and
the public. This should also highlight training needs and areas where
improved approaches to care, treatment and management are required as,
until clinicians are better informed of the factors associated with violent
behaviour, there is little chance of improving the accuracy of risk assessments
(Monahan and Steadman, 1994).
There are many studies that have attempted to identify which factors
are most closely associated with an increased risk of violence from people
with mental disorder. However, the field has been blighted by a number
of problems and it is recognised that research in this area is flawed
with methodological shortcomings with little consistency in the research
approaches (Monahan, 1984). Despite the importance of the subject area
there are few consistent studies which investigate fully the heterogeneous
nature of violent behaviour in mental health services. However, a number
of large multi-factorial studies have explored risk factors for in-patient
violence (e.g., Crichton, 1995; Royal College of Psychiatrists, 1998;
Almvik et al., 1999); community violence (e.g. Klassen and O’Connor, 1988;
Swanson et al., 1990; Monahan et al., 2000); and differences between the
mentally disordered and non-mentally disordered in terms of which risk
factors predict violence (Bonta et al., 1998). The literature is far from consistent
in concluding the most valid risk factors for violence. However,
there is evidence that a number of characteristics relating to past history,
current functioning, protective influences and the individual’s
context/environment need to be taken into account when assessing violence
risk. These factors, derived from previous research, are summarised
in Table 7.2. Consideration of some or all these factors should make the
risk assessment process more systematic and transparent, while improving