The incident reporting form used in this study was developed from the Staff Observation Scale - Revised (SOAS-R). SOAS-R is easy and quick to fill in, can be used without previous training, and has been shown to give a valid approximation of the severity of aggressive incidents [5, 10]. In 1987, Palmstierna and Wistedt constructed the Staff Observation Scale to monitor frequency, nature and severity of aggressive incidents which are damaging or threatening to objects or humans in psychiatric wards [11]. The scale was revised in 1999, forming the currently used SOAS-R [5], and is used in psychiatric settings worldwide [12]. The SOAS-R report form is completed when a staff member observes aggressive behaviour on the part of a patient. It consists of five columns (categories), and each column comprises several options to characterise the actual incident. Several options can be marked in each column. The five columns have the following themes: 1) The provocation that leads to the aggressive incident; 2) The means used by the aggressor during the incident; 3) The target of aggression; 4) The consequences for victims; and 5) The immediate measures taken to stop or control aggressive behaviour.
In the original SOAS, the severity scores were developed based on face-validity [11], while in SOAS-R the scoring system was further developed and designed statistically to increase the validity [5, 13]. A total score system was developed to rate overall severity of an aggressive incident [5]. Each option in the columns was given a score, and the column score equalled the highest scoring option of each column. The total severity score was derived by adding the five column scores. The SOAS-R total severity score ranges from 0 to 22 points, with scores of 0–7 indicating mild, 8–15 moderate, and 16–22 severe severity [12]. A SOAS-R severity score of 9 or more includes all incidents where physical pain or injury is inflicted. A score of 9 or more also includes all physical attacks causing fear of harm to the victim, as well as attacks with dangerous objects directed at a person [14].
In addition to the five columns, a 100-mm Visual Analogue Scale (VAS) is often added to the SOAS-R form to judge the severity of the incident [5]. The VAS is found to be suitable for assessment of subjective phenomena [15], and has also been validated for assessing occupational stress [16]. On the VAS, the worker marked the severity of the aggression on a scale ranging from “not severe at all” (at the 0-end of VAS) to “extremely severe” (at the 100-end of the VAS).
Setting
Emergency primary care in Norway is organized as casualty clinics or as part of a regular general practitioner’s surgery. Many of the units are small, isolated and geographically distant from the hospital. The number of staff on duty varies from one to several persons, mainly physicians (mandatory) and nurses. The physicians primarily see patients at the clinic, but they also conduct home visits and participate on site in emergencies outside hospitals. The clinics provide walk-in services, and as a matter of policy, they are easily accessible to the public. They give care to all persons in need who reside within a defined geographical area. The clinics handle all types of medical emergencies, and are gatekeepers for all kinds of secondary medical and psychiatric care. Most patients are treated at the clinic without further referral to secondary care.
Development of the pilot version of the SOAS-RE
A number of adjustments were made to adapt the SOAS-R to the setting of emergency primary health care (SOAS-RE). The changes were based on input from nurses and doctors working in emergency primary health care. Background questions included location for the incident (clinic, phone, home visit/emergency call out); the worker’s age, occupation, gender, whether the worker was alone on duty; and information about the aggressor’s gender, mental health and present drug or alcohol use or presence of influences from these.
New options were added in each of the existing columns and an additional column was added based on findings from qualitative studies on factors influencing workplace violence in emergency primary health care [17, 18]. In column 1 (Provocation of aggressive behaviour), the new options “the person had to wait”, “the person disagreed about assessment/advice” and “involuntary assessment of health condition” were added. In column 2 (Means used by the aggressor), “used/had weapon” and “used/ had pointed weapon” were added. In column 3 (Target of aggression), “physician”, “nurse”, “ambulance personnel”, “security guard”, and “police” were added. In column 4 (Consequences for victim) “psychological/emotional stress”, and “needs to be taken off duty” were added. In column 5 (Measures to stop aggression) “withdrew from situation/ended call”, “complied with the person’s wish”, and “asked the person to leave the site” were added. The new and sixth column was used for information about persons involved to stop the aggression. This information was judged as valuable to complete the description of the aggressive episode, but was not included in the severity scoring system. Contrary to the traditional psychiatric inpatient setting where only nursing staff is involved in handling an incident, the emergency primary health care setting includes different persons or occupations, like physicians, nurses, ambulance personnel, security guards, police, other patients and next-of-kin.
The scores ranged from 0 to 2 (first column (Provocation)), 0 to 3 (second column (Means used)), 0 to 4 (third column (Target of aggression), 0 to 9 (fourth column (Consequence(s) for victim)). All SOAS-RE severity scores were assigned based on the scores used in SOAS-R and an adjustment of these after a discussion in the project group about the relative severity of each item. In the fourth column, the new option “psychological/emotional stress” was assigned the SOAS-RE severity score 4. As damaged objects were considered less severe than psychological/emotional stress, the existing item “objects damaged” was assigned the SOAS-RE severity score 2, as opposed to severity score 4 in SOAS-R. The scores of the fifth column (Measure(s) to stop aggression) ranged from 0 to 4. All items in column 6 had a severity score of 0 and were therefore not added to the SOAS-RE severity score but used only for factual information about the incident. Thus, the possible range of the SOAS-RE total severity score was 0–22 points.
Sample
In validation studies, it is recommended that more than 100 recordings be included [19]. Based on one per thousand contacts with threatening behaviour in casualty clinics [20] and about 300 contacts per thousand inhabitants per year [21], we estimated that the casualty clinics recruited to document incidents had to cover more than 300,000 inhabitants. Information about the study was given at emergency primary health care conferences. Eleven emergency primary care clinics self-recruited to the study, but one of the clinics did not send in any forms during the study period. The remaining ten clinics were geographically spread throughout Norway and covered a total population of 1.3 million inhabitants. The observation period was 12 months (2016).
Procedure
Before the data collection started, a sub-investigator visited all the casualty clinics and gave verbal and written instructions to the contact person at the clinic on how to conduct the collection of data. The contact person was given the following instruction: “After an aggressive incident, the health worker involved in the aggressive situation should complete the SOAS-RE form. Then, the severity of the aggressive incident should be assessed by VAS scale ranging from “not severe at all” (left end, 0 mm) to “extremely severe” (right end, 100 mm). The contact person collects the anonymously completed forms and forwards them to the National Centre for Emergency Primary Health Care.” The contact person was given the responsibility for informing the colleagues and making sure that the form was used after incidents. The sub-investigator had email communication with the contact persons each month to remind them about the data collection and to confirm whether there had been any incidents the previous month.
After receiving the form, the researchers calculated a total severity score based on predefined scores for each item. Neither the contact person nor the worker received information about how the SOAS-RE severity scores were calculated.
Statistical analyses
Background characteristics are given as mean, standard deviation (SD) and percentages. Mean SOAS-RE and VAS severity scores, SD and 95% confidence interval (CI) are presented for each column and for each group of items holding the same SOAS-RE value. Variance analyses were used to test gender and age differences of the victims in SOAS-RE severity score and in VAS severity score. Linear regression analysis was performed to evaluate the relative impact each of the five SOAS-RE columns had on the VAS score. The association between SOAS-RE severity score and VAS severity score was calculated by the Pearson correlation coefficient. Items that were associated with higher VAS scores were identified, and the severity scoring system could eventually be improved.