What fields should be in the database?

The fields that comprise a database determine what information will be available for analysis later. The aim was to create as comprehensive as possible account of the events that were involved with the aggressive incidents observed in the records within the constraints of the records content and the aims of the research itself. A comprehensive database would then allow for events which are significantly

involved in violence to be found using Sequence Analysis. Any events which are irrelevant but included in the database would not emerge during Sequence Analysis so would not distort the results.

The literature review identified a number of variables and factors that are important when considering aggressive behaviour. These included personal factors such as gender, age, level of intellectual disability, mental health diagnosis and the presence of autistic spectrum disorders. Environmental factors such as setting events, reinforcing stimuli, provocation, frustration, hours of sleep, crowding, pain, number of

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qualified staff, location qualities, mood, time and day of the week and activity. Other risk factors were identified from research into forensic inpatient populations who aggress, and suggested dynamic factors such as a change in state, for example becoming confused or agitated.

Personal factors that were available in the records were age, gender, level of intellectual disability and presence of autistic spectrum disorders. These were identified and recorded in the participant database (see section 3.4.1).

The patient records allowed access to a number of the environmental and dynamic risk factors identified in the literature review as important. These were time of day, location, hours of sleep, levels of observation (related to crowding), mood, pain, activities and change of state. Fields were created in the database in order to capture these. Activities, which may cause environmental disturbance such as visits and outings were also recorded. The records also contained descriptions of the aggressive incidents, which held information that was potentially informative about provoking and frustrating events like cancellations and denial of requests, and other variables such as changes in state, so a field was created to hold a narrative of the incident.

There were a number of fields identified in the literature review as important for considering when examining aggressive behaviour that were not accessible through patient records. Information about staff qualifications and who was on shift at the time of aggression was not noted in the patient records and this information was not available to the researcher through other means. Information about the number of other service users and staff members present was also not available. This is due to the way patient records are constructed around an individual. Limited information is recorded about other service users in client records due to confidentiality issues.

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Therefore information about potential crowding factors was not available to the researcher.

Record keeping is done for a number of clinical, ethical and legal purposes. Research into clinical record keeping has suggested that this is influenced by the demands of the organisation and may inhibit the recording of the anything which goes

against the organisation’s purposes (Karkkainen, Bondas & Eriksson, 2005). There is

often an assumption that what has not been recorded has not happened, but there are a number of studies which suggest clinical records are often missing essential parts of information about client care and nursing activities (Adamsen & Tewes, 2000). De Marinis et al. (2010) found that only 40% of nursing activities were recorded in clinical records. Clinical records, due to the nature of the information required by organisations, can often exclude the caring part of nurse/service user interactions and record only concrete nursing care such as when someone was bathed or ate a meal (Kirrane, 2001).

There are also issues with the record keeping which means that although theoretically information should be present in the records, human error and memory means some information will not have been included. Record keeping is usually performed at the end of a shift when nurses and health care assistants may be tired. There has also been research which suggests some nurses hold negative attitudes towards clinical records, as they do not reflect the work they do or assist it (Lee, Yen & Ho, 2002). These negative attitudes and levels of tiredness may affect the accuracy or length of records. Nurses and health care assistants can only record what they see, and are also not permitted under record keeping guideline to record any subjective judgements about why an incident has occurred. Potentially, aggressive incidents may

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have gone unnoticed and unrecorded, as well as important information regarding the causes of incidents.

It is important to note here that while this thesis is investigating the sequence of aggressive incidents in people with intellectual disability, these sequences have been gleaned from observations made by care staff. There are benefits and limitations to using this type of information which will be discussed in more detail in the

conclusions chapter of this thesis.

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Figure 3.3

Fields Included in the Violent Incident Database.

Identifier Jane

Date of Incident 25/05/2007

Time of Incident 23:30

Day of Week Monday

Year of Birth 25/12/74

Location Corridor, Bedroom

Mood Prior to Incident AM Settled PM Agitated,

Upset

Preceding Event Visitor Yes, mother

Preceding Event Outing Yes, Drive to Shops

Preceding Event Cancellation No

Preceding Event Refused Medication No

Preceding Event Taken P.R.N Yes, Night P.R.N previous

evening

Preceding Event Had Request Denied No

Preceding Event Refused Something No

Incident Type Physical Aggression towards

Staff

What Happened Jane was agitated and was pacing her room shouting. She moved into the corridor and began to scream while pacing up and down the corridor circling her hands in the air. A staff member approached Jane, who she hit in the face

while circling her arms. Staff tried to verbally intervene with Jane’s but she refused to

lower her voice or go to her room. At this point she was physically escorted to her bedroom.

Duration 15 minutes

Outcome Verbal Intervention, Physical Escorting,

Consequences Calmed

Gender Female

Current Observation Level General Observation

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Contributors to Report KT

Source Reports Distress and Agitation Record, Running

Records

Misc. After her mother visited Jane became upset

and agitated. She was calmed somewhat by staff but had spent the afternoon agitated. Phone calls

My View Point Jane seemed to start having hallucinations after she saw her

mother – could this be a demonstration of her distress about her living situation? Did

the explanation given for staying in the unit satisfy her or was it unrelated.

Incident Information Type A