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The Broset violence checklist (BVC)

Article in Acta psychiatrica Scandinavica. Supplementum · February 2002

DOI: 10.1034/j.1600-0447.106.s412.22.x · Source: PubMed

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The Brøset violence checklist (BVC)

Introduction

The Brøset violence checklist (BVC) was developed from the empirical work of Linaker and Busch- Iversen (1). During their study at the Regional Secure Unit at Brøset, Norway, Linaker and Busch-Iversen examined all the daily reports during a 5-year period. They found that 56 different forms of behaviour were recorded during a 24-h period prior to a violent incident occurring.

The six most frequent behaviours that occurred were confusion, irritability, boisterousness, phys-ical threats, verbal threats and attacking objects.

Entering these six behaviours into a logistic regression analysis showed that all were predictive of violence.

These six behaviours were consequently devel-oped into the BVC, which measures confusion, irritability, boisterousness, physical threats, verbal threats and attacking objects (2, 3). Each of the six items on the BVC is scored for their presence (1) or absence (0). For well-known patients an increase in the behaviour described above is scored as 1, whereas the habitual behaviour while being non-violent is scored as 0. The sum of scores is then totalled. Interpretation of the scoring is given as follows: a sum of 0 suggests that the risk of violence is small; scores of 1 and 2 suggest that the risk of violence is moderate and preventive meas-ures should be taken; and scores of 3 and more indicate that the risk of violence is very high, immediate preventive measures are required and plans for handling an attack should be activated.

Figure 1 provides an example of a BVC scoring sheet.

Predictive ability of the BVC

One published study is available that reports on the sensitivity, specificity and inter-rater reliability of the BVC (4) and this study will be summarized.

However, the reader is directed towards the main published paper for specific details and tabulated data. Many studies are currently underway and these will be reported on later in this paper.

Almvik et al. (4) studied 109 patients (52 men and 57 women) admitted to four acute wards at four different psychiatric hospitals in central and southern Norway, during a 2-month period in the spring of 1997. Patients were rated using the BVC on admission and for three consecutive days on each of the three nursing shifts. Violent incidents were recorded using the staff observation aggres-sion scale (SOAS) (5). Twelve patients were repor-ted to have been involved in a total 34 violent incidents (four males and eight women). Data were missing for one reported incident, therefore 33 violent incidents were analysed. The distribution of scores between the violent and not violent was found to be significant, indicating that the

Woods P, Almvik R. The Brøset violence checklist (BVC) Acta Psychiatr Scand 2002: 106 (Suppl. 412): 103–105.

ª Blackwell Munksgaard 2002.

Objective: The Brøset violence checklist (BVC) is a short-term violence prediction instrument assessing confusion, irritability, boisterousness, verbal threats, physical threats and attacks on objects as either present or absent. The aim of this paper is to describe the evolution and usefulness of the BVC.

Method: This paper reviews studies on the BVC and discusses implications for further research.

Results: Empirical research has shown that it has moderate sensitivity and high specificity with an adequate inter-rater reliability.

Conclusion: The BVC is a useful instrument for predicting inpatient violence within the next 24-h period. The psychometric properties of the instrument are satisfactory. Results from ongoing studies will give important information on cultural differences, the validity of the BVC in less well staffed wards, the clinical use of the checklist and its ability to predict violence throughout all the hospital stay.

Phil Woods1, R. Almvik2

1Florence Nightingale School of Nursing and Midwifery, Kings College London, UK and 2Norwegian University of Science & Technology and, Forensic Psychiatric Unit Brøset, Trondheim, Norway

Key words: Brøset violence checklist; sensitivity;

specificity; predictive validity; violence prediction; risk assessment

Phil Woods, Kings College London, Kneesworth House Hospital, Bassingbourn-cum-Kneesworth, Royston, Hertfordshire SG8 5JP, UK

This paper, in its preliminary version, was read at the 2nd European Congress on Violence in Clinical Psych-iatry symposium 'Violence in public health and victims' perspective', Stockholm, Sweden, 28–30 June 2001

Acta Psychiatr Scand 2002: 106 (Suppl. 412): 103–105 Printed in UK. All rights reserved

Copyright ª Blackwell Munksgaard 2002

ACTA PSYCHIATRICA

SCANDINAVICA

ISSN 0065-1591

non-violent patients scored significantly lower on the BVC than did the violent patients (t ¼ )8.881, df ¼ 64.394,P < 0.001, 95%CI ¼ )2.67 to)1.69).

For a score of 2 or more on the BVC relative to an incident occurring in the next 24-h period, the sensitivity was 0.63 and specificity was 0.92. The AUC was found to be 0.82 (SE ¼ 0.04; 95% CI 0.75–0.89; P < 0.001). Overall the results are reported to indicate that a score of 2 or more predicts a violent event in the next 24-h period.

Inter-rater reliability of the BVC

Almvik et al. (4) also reported inter-rater reliability for the BVC (N ¼ 39). Kappa values were reported as: confused j ¼ 0.91; irritable j ¼ 0.68; boister-ousj ¼ 0.61; verbally threateningj ¼ 0.48; phys-ically threatening j ¼ 0.66; and attacking objects j ¼ 1.00. The kappa value for the total BVC score was 0.44. Percentage exact rater agreement were reported as: confusion 97% agreement (one pair of raters not agreeing); irritable 90% agreement (four pairs of raters not agreeing); boisterous 90% agree-ment (four pair of raters not agreeing); verbally threatening 95% agreement (two pairs of raters not agreeing); physically threatening 97% agreement (one pair of raters not agreeing); and attacking objects 100% agreement.

Discussion

Within psychiatric inpatient units it is unfeasible to give vast time commitments to regular monitoring of potentially violent behaviour, therefore a clear need exists for a quick and easy-to-use instrument to predict risk. One the fundamental advantages of using the BVC in everyday clinical practice comes from the 5 min that it takes to complete. More-over, when predictive instruments are to be used to assist the decision-making process, they have to be empirically sound, reliable and theoretically grounded (6).

Results of empirical work surrounding the BVC seem to indicate that it is a useful instrument in predicting violence within the next 24-h period.

Furthermore, its psychometric properties are satis-factory. The BVC is discriminating the violent from the not-violent over the next 24-h period. More specifically, the BVC is 63% accurate in predicting that violence will occur within the next 24 h; and 92% accurate in predicting that violence will not occur. For the BVC’s purpose it can be argued that selecting a cut-off score of 2 yields acceptable results in terms of sensitivity and specificity.

In conclusion, it appears that the applicability of the BVC is promising for the prediction of viol-ence. More studies are currently being undertaken

THE BRØSET VIOLENCE CHECKLIST – BVC ©

The BVC is a short checklist to help in prediction of violent behaviour during the following 24 hours. The items in the BVC have all shown a high correlation with violent behaviour.

Patient’s project no:

Filled in by: Day one, dayshift Date:

To be filled in before 10 a.m.

Confused

Irritable

Boisterous

Physically threatening

Verbally threatening

Attacking objects

SUM:

Gender: Male: Female: Involuntary admitted? Yes No Age: < 20 years; 20–30 years; 31–40 years; 41–50 years; >50 years

Directions for use:

Each of the six items is scored numerically for their presence (1) or absence (0) during the observation time preceding the scoring.

For previously unknown patients the items are scored as present or not.

For well-known patients an increase in the behaviour described by the item is scored as 1, but the patient’s usual level of the behaviour while being non-violent is scored as 0.

The total score is the sum in one column.

Patient’s name: Date of birth:

Fig. 1. The Brøset violence checklist.

Table 1. Current and planned BVC studies

Study site Type of unit Time scale

Innherred Hospital, Norway Acute Finished PST Østmarka, Norway Acute Finished RiTø, Psyk. avd. ;sg<rd, Norway Acute To be decided RiTø, Psyk. avd. ;sg<rd, Norway Geriatric Finished Oslo Kommune, Ullev<l Sykehus, Norway Geriatric Finished PST Østmarka, Norway Geriatric To be decided PST Brøset, Norway Forensic Finished NPS, Rehab 3, Norway Forensic Finished Eastern Healthboard, Dublin, Ireland Acute ⁄ ICU Finished Z@rich, Switzerland Acute Autumn 2001 ⁄Winter 2002 Beroendecentrum, Sweden Substance abuse Spring 2002 Karolinska Institute, Sweden Forensic and acute Spring 2002

Woods and Almvik in order to further examine its constructs: reliab-ility, applicability and validity. Presently validation studies are planned or already running in a number of European countries. Results from these studies will inter alia give important information on cultural differences, the validity of the BVC in less well staffed wards and the psychometric properties of the instrument. Studies will also examine the clinical use of the checklist, and its ability to predict violence throughout all the hospital stay, or over a longer time period.

Table 1 summarizes ongoing BVC studies.

References

1. Linaker OM, Busch-Iversen H. Predictors of imminent violence in psychiatric inpatients. Acta Psychiatr Scand 1995;92:250–254.

2. Almvik R, Woods P. The Brøset violence checklist (BVC) and the prediction of in-patient violence: some preliminary results. Psychiatric Care 1998;5:208–211.

3. Almvik R, Woods P. Predicting inpatient violence using the Brøset violence checklist (BVC). Int J Psychiatric Nurs Res 1999;4:498–505.

4. Almvik R, Woods P, Rasmussen K. The Brøset violence checklist (BVC): sensitivity, specificity and inter-rater reli-ability. J Interpersonal Violence 2000;15:1284–1296.

5. Palmstierna T, Wistedt B. Staff observation aggression scale, SOAS. Presentation and evaluation. Acta Psychiatr Scand 1987;76:657–663.

6. Woods P, Reed V, Robinson D. The behavioural status index: therapeutic assessment of risk, insight, communi-cation and social skills. J Psychiatric Mental Health Nurs 1999;6:79–90.

The Brøset violence checklist

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