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Inpatient aggression is common in forensic mental health settings, exposing staff and other patients to risk.
However, staff have limited guidance on preventing aggression and managing violent and aggressive behaviour without restrictive practices.
Dr. Tessa Maguire’s approach involves:
- better understanding patient aggression,
- assessing inpatient aggression,
- intervening at the individual level,
- intervening at the unit level, and
- using clinical reasoning to make informed decisions.
That was Dr. Maguire’s focus during her talk as part of the International Forensic Psychiatry Lecture Series.
Understanding Aggression
Frameworks can structure efforts to identify factors contributing to aggression and guide appropriate interventions. One such framework is The Model for Understanding Inpatient Aggression (MUIA) developed by Dr. Maguire and her colleagues.
The MUIA considers short- and long-term personal and contextual risk and protective factors. It also considers organizational factors, like policies and procedures, teamwork, and the physical environment. These factors can contribute to a patient’s state of mind. This temporary psychological state can indicate a high risk of aggressive behaviour in the near future.
“But what is novel about this model is it really encourages us to also think about the times when there has been successful de-escalation, the person hasn’t engaged in aggression, and they’ve gone through that recovery and that post-event phase,” Dr. Maguire said.
Assessing Inpatient Aggression
The National Institute for Health and Care Excellence (NICE) provides guidelines on Violence and aggression: Short-term management in mental health and community settings. NICE recommends actuarial prediction instruments — such as the Dynamic Appraisal of Situational Aggression (DASA) — instead of unstructured clinical judgment alone.
Distinguished Professor (Dr.) James Ogloff and Professor (Dr.) Michael Daffern developed the DASA to assess the likelihood of aggression in mental health inpatient settings.
A nurse notes whether seven items — irritability, impulsivity, unwillingness to follow directions, sensitivity to perceived provocation, negative attitudes, easily angered when requests are denied, and verbal threats — are present or absent. The total score indicates low, moderate, or high risk of violence.
Dr. Maguire said early intervention with least restrictive interventions (such as distraction and reassurance) should be encouraged to prevent aggression, rather than waiting until the patient reaches the high-risk band.
Individual-Level Intervention
Dr. Maguire researched whether clinicians selected different aggression prevention strategies to match the DASA level of risk. She studied files for 30 male and 30 female patients in three forensic acute units at a secure forensic mental health hospital.
In the patients’ first two months after admission, staff documented more interventions when DASA assessments were completed than when they were not.
The most commonly used intervention was medication as needed, followed by reassurance, distraction, limiting setting, one-on-one nursing, increased observation, and de-escalation. However, Dr. Maguire said she would have liked to have seen de-escalation used more often as opposed to medication as needed
She also found that the number of interventions increased with the level of risk. “You would really like to see more interventions applied early on, rather than waiting till the person hits that high-risk band.”
Dr. Maguire and her colleagues developed the Aggression Prevention Protocol (APP) to guide which interventions to use at different risk bands. Staff should use preventive interventions early, reserving more restrictive interventions for patients in the high-risk band.
Using the electronic DASA (eDASA) with the APP may improve risk assessment by helping to structure and coordinate the interventions that are already taking place in the setting.
After nurses were trained to use the DASA, they asked for prompts on when to re-administer it. This increased their use of the DASA. The eDASA also eliminated human error in calculating the final score.
After the introduction of the APP with the eDASA, nurses reduced the use of medications as needed and increased one-on-one time with patients, distraction, and reassurance. This reduced verbal aggression and the use of restrictive interventions.
Unit-Level Intervention
Dr. Maguire and her colleagues have been developing Safewards Secure, which builds on the original Safewards model for acute mental health inpatient services. It focuses on conflict, which may include aggression, self-harm, suicide, and absconding (being away without leave). It also focuses on containment and interventions staff can use to prevent conflict.
The original Safewards model identifies potential conflict by considering the patient community and characteristics, regulations, staff, physical environment, and factors outside the hospital.
However, results have been mixed when Safewards were implemented in forensic mental health settings.
Safewards Secure looks at the unique features of secure settings, including long-term therapeutic relationships with staff and the patient community. It also considers the regulatory framework for secure forensic mental health units.
These unique features have different potential sources of conflict than those found in non-forensic and non-secure settings. Safewards Secure considers these differences to provide a more comprehensive understanding of conflict and containment in forensic mental health settings.
Clinical Reasoning
Dr. Maguire and her colleagues have been developing a new version of the clinical reasoning cycle for forensic mental health nursing. As well as focusing on patients and recovery, the model has bias checks to highlight groupthink (poor decisions made to avoid disagreement) and ethical dilemmas.
“It really is designed to assist nurses to work collaboratively with [patients] and their supporters, counter bias, enhance critical thinking and clinical reasoning, and to enhance nursing practice,” Dr. Maguire said. “It also really does help with documentation, especially around when you’re having to make important decisions.”
For more details, watch the recording of the January 29, 2026, lecture, “Reducing Aggression and Use of Restrictive Practices in Forensic Mental Health.”
You can also join LinkedIn groups for DASA+APP Community of Practice, The Clinical Reasoning Cycle for Mental Health and Forensic Mental Health Nurses, and Safewards Secure Community of Practice.
Written by Virginia St-Denis and approved by Dr. Tessa Maguire.
