nissan risk management case study

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Nissan: Recovering Supply Chain Operations

By: Shikha Aggarwal, Manoj Kumar Srivastava

Nissan's resilience strategy had been considered an exemplary response to the triple disaster in Japan in March 2011. The Japanese automobile industry made their respective recovery efforts to resume…

• Length: 6 page(s)
• Publication Date: May 30, 2016
• Discipline: Operations Management
• Product #: W16331-PDF-ENG

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Nissan's resilience strategy had been considered an exemplary response to the triple disaster in Japan in March 2011. The Japanese automobile industry made their respective recovery efforts to resume production and delivery of vehicles after suffering damage from an earthquake, tsunami, and a nuclear crisis, but it took months before they could reach pre-disaster levels of operations. Nissan's resilience practices and supply chain disruption management were acknowledged as superior to those of their peers and were appreciated by experts and analysts. Nonetheless, it took Nissan more than a month to resume production, and each day of lost production cost Nissan $25 million.

Shikha Aggarwal is affiliated with Management Development Institute. Manoj Kumar Srivastava is affiliated with Management Development Institute.

Learning Objectives

The case can be used in graduate-level business courses in supply-chain management, operations management, and strategic management. It can also be used in a post-graduate course on risk management. The case provides an opportunity for students to understand the concept of supply-chain resilience; identify potential disruptions in a global supply-chain network; analyze the best design-disruption fit in a supply chain; understand operations strategies to manage supply-chain disruptions; formulate improvement strategies for building robustness; and understand reconciliation of supply-chain capabilities with vulnerabilities.

May 30, 2016

Discipline:

Operations Management

Geographies:

Industries:

Automotive industry

Ivey Publishing

W16331-PDF-ENG

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Teaching Resources Library

Nissan Motor Company Ltd.: Building Operational Resiliency

David Simchi-Levi

William Schmidt

Aug 27, 2013

Japan’s March 11, 2011 Great Tōhoku earthquake and tsunami was among the most damaging natural disasters on record. This case examines the organizational structure and operational decisions that allowed Nissan Motor Company to recover from the disaster more rapidly than its peers. In doing so, Nissan was able to increase production and capture market share from its slower-to-recover competitors.

Learning Objectives

To facilitate a discussion on how one of the world’s biggest car companies was able realize a faster time-to-recovery through superior supply chain visibility, rapid response efforts, and flexible supply allocation and production decisions.

Appropriate for the Following Course(s)

operations management, supply chain management, strategy

Nissan Motor Company LTD.: Building Operational Resiliency 

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Nissan Case Study in Organizational Behaviour Perspectives

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Case study: How Nissan promotes sustainability across its supply chain

Nissan is a leading global Japanese automobile manufacturer headquartered in Nishi-ku, Yokohama, Japan. Nissan seeks to achieve sustainable growth built on a foundation of mutual trust with its business partners and, accordingly, listens closely to and works with its suppliers as equal partners, developing and maintaining cooperative and competitive relations that enable it to implement best practices.

This case study is based on the 2021 Sustainability Report by Nissan , prepared in accordance with the GRI Standards, that can be found at this link . Through all case studies we aim to demonstrate what CSR/ ESG/ sustainability reporting done responsibly means. Essentially, it means: a) identifying a company’s most important impacts on the environment, economy and society, and b) measuring, managing and changing.

Nissan seeks to establish a sustainable supply chain, with due regard to human rights and the environment.     Tweet This! In order to promote sustainability across its supply chain Nissan took action to:

• implement CSR Guidelines for Suppliers
• promote environmental sustainability
• evaluate, monitor, and audit suppliers’ sustainability practices

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Please subscribe to the SustainCase Newsletter to keep up to date with the latest sustainability news and gain access to over 2000 case studies. These case studies demonstrate how companies are dealing responsibly with their most important impacts, building trust with their stakeholders (Identify > Measure > Manage > Change).

With this case study you will see:

• Which are the most important impacts (material issues) Nissan has identified;
• How Nissan proceeded with stakeholder engagement , and
• What actions were taken by Nissan to promote sustainability across its supply chain

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What are the material issues the company has identified?

In its 2021 Sustainability Report Nissan identified a range of material issues, such as climate change, occupational health and safety, air quality, resource dependency, learning and development. Among these, promoting sustainability across its supply chain stands out as a key material issue for Nissan.

Stakeholder engagement in accordance with the GRI Standards              

The Global Reporting Initiative (GRI) defines the Principle of Stakeholder Inclusiveness when identifying material issues (or a company’s most important impacts) as follows:

“The reporting organization shall identify its stakeholders, and explain how it has responded to their reasonable expectations and interests.”

Stakeholders must be consulted in the process of identifying a company’s most important impacts and their reasonable expectations and interests must be taken into account. This is an important cornerstone for CSR / sustainability reporting done responsibly.

Key stakeholder groups Nissan engages with:   

To identify and prioritise material topics Nissan engaged with its stakeholders through the following channels:

What actions were taken by Nissan to promote sustainability across its supply chain ?

In its 2021 Sustainability Report Nissan reports that it took the following actions for promoting sustainability across its supply chain:

• Implementing CSR Guidelines for Suppliers
• Compliance: Complying with laws, preventing corruption, etc.
• Safety and Quality: Ensuring the safety and quality of products and services, etc.
• Human Rights and Labour: Prohibition of child labour and forced labour, complying with working hours and remuneration laws, etc.
• Environment: Environmental management, reducing greenhouse gas emission and industrial waste volumes, and managing chemical substances, etc.
• Information Disclosure: Open and impartial communication with stakeholders, etc.
• In addition, suppliers are requested to undergo assessments by third parties. The guidelines mandate that suppliers comply with laws and regulations. If suppliers are found to be in a state of non-compliance, the guidelines prescribe required responses, such as filing a report immediately, conducting an investigation and formulating corrective measures. In the case of a non- compliance incident, Nissan will take firm action based on its regulations and do everything necessary to prevent a recurrence. In fiscal 2020 no human rights violations, such as discrimination, occurred, and no supplier was found to be at serious risk of forced labour or child labour.
• Promoting environmental sustainability
• Nissan has shared its environmental philosophy and environmental action plan with suppliers since the mid-1990s. To improve environmental performance throughout the supply chain jointly with suppliers, Nissan first published the Nissan Green Purchasing Guidelines in 2001 and has actively promoted environmental activities at suppliers in line with these guidelines since then. After Nissan and Renault integrated their technical standards for management of chemical substances in fiscal 2016, a revised version of the guidelines was published in January 2017. Furthermore,
in August 2018, based on the midterm environmental action plan, Nissan Green Program 2022 (NGP2022), Nissan revised the content of the guidelines, adding requests that suppliers undertake their own environmental activities. Additionally, in May 2019, in order to strengthen management of environment-impacting substances, Nissan added requirements dealing with supplier self-diagnosis of environment-impacting substance management and related topics, which all suppliers are asked to follow. The Nissan Green Purchasing Guidelines are part of the detailed explanation in the environment-related section of the Renault-Nissan CSR Guidelines for Suppliers. Environmental activities undertaken with suppliers involve the core components of compliance with environmental regulations and Nissan’s basic environmental principles, along with activities to reduce the burden on the environment. As for the former, in response to global trends in such regulations as the European Union’s Registration, Evaluation, Authorization and Restriction of Chemicals (REACH) Regulation and the European Reusability/Recyclability/ Recoverability (RRR) Directive, Nissan has added new items to the list of banned substances and globally expanded component data management. When selecting suppliers for new models, Nissan checks their management of and activities regarding environmentally hazardous substances, informing them of specific actions needed to comply with the REACH Regulation and requesting their compliance.  Based on the NGP2022, Nissan holds annual environmental briefing sessions and has since fiscal 2012 conducted surveys to ascertain CO2 emissions, water usage, waste production and other data related to its burden on
the environment. To further enhance its activities in this area, in fiscal 2014 Nissan adopted the supply chain programme run by CDP, an international environmental NPO that manages a global system for disclosing corporations’ environmental impact and strategies. In fiscal 2020, based on these surveys, Nissan continued encouraging some suppliers to improve their environmental activities.
• Evaluating, monitoring, and auditing suppliers’ sustainability practices
• Nissan has been confirming suppliers’ acceptance of the Renault-Nissan CSR Guidelines for Suppliers and check their environmental management systems and their willingness to advance environmental activities with it at the time of supplier selection. Among newly selected suppliers in fiscal 2020, 100% of them met both Nissan’s social standards and basic environmental principles. In 2016 the Renault-Nissan alliance began third-party assessment of suppliers’ sustainability activities to raise standards through mutual confirmation. When results do not meet Alliance standards, suppliers are asked to draw up plans for improvement. Nissan then monitors their implementation. In fiscal 2020, Nissan held a seminar for suppliers, where
a rating organisation spoke to them directly on how to answer assessment questions and formulate improvement plans. By now, more than 90% of Nissan’s purchase demands are covered by a third-party assessment. Nissan also conducts sustainability training in its purchasing department to ensure that employees conduct checks of suppliers’ sustainability activities in their daily work. If there are issues with the supply of parts and materials, they may lead to problems not only for Nissan’s production but also supply chain as a whole. Nissan therefore positioned the following measures as part of sustainability activities: (1) confirming supply risks
under normal circumstances; (2) following up annually on quality, cost, delivery, development, management, sustainability, and risk (QCDDMSR) performance and (3) working with suppliers to craft response plans for natural disasters to ensure production continuity or early restoration of capacity. Nissan monitors compliance from the perspective of supplier management, constantly assessing the situation at each supplier based on a range of factors. When high risk is identified, Nissan works with the supplier to rapidly draft and implement countermeasures. In fiscal 2020 there were no suppliers whose compliance was problematic, and no supplier contract was terminated for such a reason.

Which GRI Standards and corresponding Sustainable Development Goals (SDGs) have been addressed?

The GRI Standards addressed in this case are:

1) Disclosure 308-1 New suppliers that were screened using environmental criteria

2)  Disclosure 308-2 Negative environmental impacts in the supply chain and actions taken

3) Disclosure 414-1 New suppliers that were screened using social criteria

Disclosure 308-1 New suppliers that were screened using environmental criteria does not correspond to any SDG.

Disclosure 308-2  Negative environmental impacts in the supply chain and actions taken does not correspond to any SDG.

Disclosure 414-1 New suppliers that were screened using social criteria corresponds to:

• Sustainable Development Goal (SDG) 5 : Gender Equality
• Targets: 5.2
• Sustainable Development Goal (SDG) 8 : Decent Work and Economic Growth
• Targets: 8.8
• Sustainable Development Goal (SDG) 16 : Peace, Justice and Strong Institutions
• Targets: 16.1

78% of the world’s 250 largest companies report in accordance with the GRI Standards

SustainCase was primarily created to demonstrate, through case studies, the importance of dealing with a company’s most important impacts in a structured way, with use of the GRI Standards. To show how today’s best-run companies are achieving economic, social and environmental success – and how you can too.

Research by well-recognised institutions is clearly proving that  responsible companies can look to the future with optimism .

7 GRI sustainability disclosures get you started

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• Formulate in group exercises your plan for action. Begin taking solid, focused, all-round sustainability action ASAP. 
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See upcoming training dates. References:

This case study is based on published information by Nissan, located at the link below. For the sake of readability, we did not use brackets or ellipses. However, we made sure that the extra or missing words did not change the report’s meaning. If you would like to quote these written sources from the original please revert to the following link:

https://www.nissan-global.com/EN/DOCUMENT/PDF/SR/2021/SR21_E_All.pdf

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Dubai’s Extraordinary Flooding: Here’s What to Know

Images of a saturated desert metropolis startled the world, prompting talk of cloud seeding, climate change and designing cities for intensified weather.

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By Raymond Zhong

Scenes of flood-ravaged neighborhoods in one of the planet’s driest regions have stunned the world this week. Heavy rains in the United Arab Emirates and Oman submerged cars, clogged highways and killed at least 21 people. Flights out of Dubai’s airport, a major global hub, were severely disrupted.

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Heavy rain there is rare, but not unheard-of.

On average, the Arabian Peninsula receives a scant few inches of rain a year, although scientists have found that a sizable chunk of that precipitation falls in infrequent but severe bursts, not as periodic showers.

U.A.E. officials said the 24-hour rain total on Tuesday was the country’s largest since records there began in 1949 . But parts of the nation had experienced an earlier round of thunderstorms just last month.

Oman, with its coastline on the Arabian Sea, is also vulnerable to tropical cyclones. Past storms there have brought torrential rain, powerful winds and mudslides, causing extensive damage.

Global warming is projected to intensify downpours.

Stronger storms are a key consequence of human-caused global warming. As the atmosphere gets hotter, it can hold more moisture, which can eventually make its way down to the earth as rain or snow.

But that doesn’t mean rainfall patterns are changing in precisely the same way across every corner of the globe.

In their latest assessment of climate research , scientists convened by the United Nations found there wasn’t enough data to have firm conclusions about rainfall trends in the Arabian Peninsula and how climate change was affecting them. The researchers said, however, that if global warming were to be allowed to continue worsening in the coming decades, extreme downpours in the region would quite likely become more intense and more frequent.

The role of cloud seeding isn’t clear.

The U.A.E. has for decades worked to increase rainfall and boost water supplies by seeding clouds. Essentially, this involves shooting particles into clouds to encourage the moisture to gather into larger, heavier droplets, ones that are more likely to fall as rain or snow.

Cloud seeding and other rain-enhancement methods have been tried across the world, including in Australia, China, India, Israel, South Africa and the United States. Studies have found that these operations can, at best, affect precipitation modestly — enough to turn a downpour into a bigger downpour, but probably not a drizzle into a deluge.

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One recent study of Sharjah , the capital of the third-largest emirate in the U.A.E., found that the city’s rapid growth over the past half century had made it vulnerable to flooding at far lower levels of rain than before.

Omnia Al Desoukie contributed reporting.

Raymond Zhong reports on climate and environmental issues for The Times. More about Raymond Zhong

Nissan Company’s Constraint Management Case Study

Generating value.

A. When discussing the Nissan case study, it is important to mention that the company placed emphasis on diversity, with offices including employees of numerous cultures and nationalities and extensive experiences in the overseas operations. Moreover, Nissan implemented a build-to-order and build-to-stock approach in order to streamline the processes and simplify the products manufactured. According to the beliefs of the management, the adoption of the build-to-stock and order strategy made a positive influence on the increase in sales.

Compared to key competitors, Nissan introduced a simplified line of products with a view to compliment the key strategies (Schmidt & Simchi-Levi, 2013). Therefore, this allowed the company to overcome unpredictable challenges and change the way Nissan usually responded to emergencies and risks.

Nissan also focused on the importance of the supply chains within the context of increased globalization of the automotive industry. Importantly, Nissan leveraged a decentralized structure of supply chains and later imposed central control and coordination in cases of crises (Schmidt & Simchi-Levi, 2013). Apart from contributing to the developing of the corporate culture, the flexible organization of the supply chain was efficient in the process of management of the major global operations through the valuing of the executive team.

One of the critical components of operations management functions is the production of vehicles that are of high quality but reasonably priced. In addition, it enables the company to ensure the rewarding customer experience by furnishing considerate customer care and manufacturing reliable and environmentally friendly cars that correspond with client’s needs (Schmidt & Simchi-Levi, 2013). Moreover, the enterprise cherishes and promotes the diversity. The multi-nationality that characterizes its workforce allows meeting the requirements of the diverse markets in which Nissan functions.

• Trying to become more competitive in the automotive market that offers very vast competitive opportunities is hard for many companies. According to the research conducted by Toma and Marinescu (2013), Nissan used 13 cross-functional areas that represent the core of the company’s functional spheres. Following the logic of the cross-functional areas, Nissan focused on the global strategy that accounts for the quick expansion of the process of globalization. Therefore, Nissan has to be a proactive multinational and transnational company that has considerable resources (Toma & Marinescu, 2013) for sustaining a competitive advantage in the automotive industry where every manufacturer is faced with great struggle and thus the requirement to implement global strategies for competitive advantage to at least survive.
• Service operations and manufacturing operations have both similarities and differences. The main distinction lies in the tangibility of the output. In the first case, the output is intangible (for instance, purchasing a vehicle from Nissan and its maintenance). In the second case, operations produce physical goods (for example, car manufacturing). Nissan brings value to the clients by addressing all the customers’ needs so that they do not have to turn to other companies for service provision (Pyzdek & Keller, 2014). The main similarity between the two categories is that labor and location are needed for both of them.

To achieve the competitive edge, Nissan has decentralized the supply chain structure. At the time of the natural disasters, the company was already prepared to mitigate the possible disruptions through strong central control and coordination (Hill, Hult, Wickramasekera, Liesch, & Mackenzie, 2016). This strategy enabled the enterprise to recover from the crisis faster than the rivals and bring the value to the clients rapidly. As stated by the company CEO, “most of the steps we have taken in response to the March 11 disaster have been continuations of strategies priorities and plans that were already in place” (Schmidt & Simchi-Levi, 2013, p. 7). Therefore, the emergency response strategy was centered on the decentralization of supply chain.

Theories and Techniques

MRP calculations must be accompanied by the development of product structure, building a gross requirement plan, as well as building a net requirement plan. MRP is a dynamic system that changes according to how company changes. The calculations for gross to net for MRP is the following: Gross Requirements – On Hand Inventory = Gross Requirements. The input files needed for a successful MRP are master production schedule, production cycle, bill of materials, customer focus, and supplier lead times.

It should be noted that PERT (Program/Project Management and Review Technique) places emphasis on timeframe and planning. CPM (Critical Path Method) centers on the cost (O’Brien & Plotnick, 2015). In terms of the company under analysis, the first system would be more advantageous since the occurrences that took place were unpredictable. In addition, this approach enables determining the minimum amount of time needed to furnish the task as well as the activity in general. Regarding CPM, Nissan could utilize it in everyday occupations or when cutting down the expenses in particular project parts.

The steps of forecasting can be concluded to the following: defining the operation that needs it, determining the items, and specifying the timeframe (range of the forecast). Then, Nissan could choose the approach and utilize a qualitative method to produce the new commodity. Regarding top-selling product line, the enterprise will be able to address clients’ requirements better. It will be achieved through ensuring supply chain visibility. The major risks and reduction practices can be concluded to two main categories. They are currency fluctuations and financial risks (Abe & Ye, 2013). The company could employ flexibility in manufacturing decisions and decentralization to remit the possible negative manifestations (Mahutga, 2012).

Priority rules usually dictate the sequence in which jobs are works. Priority rules make job-processing times and due dates crucial information pieces. There are four types: “first come, first served” (FCFS), shortest processing time (set), the critical ratio (CR), and earlier due date (EDD). Earlier due date can be the most effective priority rule for Nissan since it implies that jobs are processed in accordance with due dates, with the earliest due dates first. Because the company is trying to become more sustainable and operate within the just-in-time framework, it can be useful to fulfill tasks that have the earliest due dates to ensure that customers remain satisfied.

Theory of constraints (TOC) is associated with the process of mitigation and identification of bottlenecks within systems. The five steps of the TOC process include the following:

• Identifying constraints within the system – finding the part within the process that limits the goal from being achieved;
• Deciding on how to exploit the identified constraints – using improvements to get the most out of the existing resources (Dettmer, 2000);
• Subordinating other components to the decision – adjusting the rate of activities to support the decision;
• Elevating the constraints – considering further actions for eliminating the constraint;
• Going back to the step 1 in the case if the constraint has been broken at previous steps – avoiding the constraint in the future (Goldratt, 1999).

According to the case study by Schmidt and Simchi-Levi (2013), Nissan experienced some financial difficulties in the process of risk management, which suggests that this area could benefit from the application of the theory of constraints. However, supply chain management is the most challenging process, with which Nissan has to deal, so it is important for the company to identify the constraints within the process and decide how to elevate them for achieving maximum performance.

There are seven steps that companies can use for developing a cohesive forecasting system: identifying the utilization of the forecast, selecting items for the projection, determining the timeline, choosing a forecasting model, gathering data, forecast creating, and implementation. In the case of Nissan, it can use quantitative prediction that is based on the history of sales to input into the forecast. A forecasting system can bring positive results with regards to reducing waste and only producing as many products as customers will be willing to buy.

Risks associated with the effectiveness of the supply chain are differentiated into two categories: internal and external risks. With regards to external supply chain risks, there are the following types:

• demand risks, which occur when there is unpredictable or misunderstood demand of customers;
• supply risks, which are caused by the interruptions in product flow within the supply chain;
• environmental hazards that occur externally in the supply chain and are usually associated with social, governmental, or economic factors;
• business risks, which are caused by factors such as the processes within supplier companies and their stability with regards to management or finance;
• plant hazards, which are caused by the circumstances within the physical facilities (Identifying supply chain risks, n.d.).

Internal supply chain risks are easier for companies to manage because they are usually within the control of the business. Five types of internal supply chain risks are the following:

• manufacturing risks, which occur as results of processes’ and operations’ disruptions;
• business risks, which take place due to the disruptive changes in personnel or management as well as the shifts in the ways suppliers and purchases communicate;
• control hazards, which occur due to the inadequate planning procedures and the lack of effective management;
• risks of mitigation and contingency that are caused by the absence of alternative solutions in cases when something does not go the right way;
• cultural risks, which occur as results of the cultural tendencies of businesses to delay or hide negative information, which contributes to the slower reactions of companies to emergencies (“Identifying supply chain risks,” n.d.).

Supply chain resilience is targeted at risk reduction and can be used by companies even in cases of natural disasters. With regards to resilience, a company should regionalize. Regionalization is often effective in helping a company reduce costs and contain the impact of natural disasters to a specific geographic region (Chopra & Sodhi, 2014). By implementing the regionalization approach towards the distribution of manufacturing facilities of Nissan, the company will be able to design a cohesive plan for the mitigation of natural disaster risks since usually one region is more prone to such incidents than others. For example, through identifying the most disaster-prone areas on the map, Nissan will give more priority to those regions to respond to risks as quickly as possible.

Just-in-time (JIT) is a manufacturing and inventory strategy that companies use for increasing efficiency and decreasing waste by receiving goods only when they are needed in the process of production (“Just in time – JIT,” n.d.a). Toyota Production System (TPS) is based on making vehicles that customers order in the most efficient way for delivering them as quick as possible (Toyota, 2017). TPS aligns with the ideas of just-in-time inventory and lean.

Lean manufacturing is an approach that is based on finding the most efficient approach for removing any wasteful steps that do not add value to the end product (MT Team, 2017). All three concepts are related in a way that they enable manufacturers to focus on efficiency and removal of waste without compromising the quality of the end product. On the bright side, JIT, TPS, and lean reduce inventory costs; on the downside, it requires manufacturers to be extremely accurate when forecasting demand.

With regards to Toyota, just-in-time, TPS, and lean encouraged the company to pull materials forward when they were needed, with components produced and received in small lots. On the other hand, the overall system was not risk-free (Schmidt & Simchi-Levi, 2013). For instance, if there were disturbances in the information or material flow, the manufacturing stages can be significantly undermined.

Total quality management (TQM) is an approach towards management for achieving long-term success through ensuring customer satisfaction (ASQ, 2017). Seven TQM tools include check sheets, scatter diagrams, cause-and-effect diagrams, Pareto charts, flowcharts, time-function maps, value-stream maps, and process charts. In the case of Nissan, the management can use time-function maps to identify processes that limit the company from achieving an effective just-in-time framework of manufacturing. Process charts, on the other hand, can be used by Nissan to distinguish between processes that add value to the just-in-time framework as well as those that only produce waste.

Data Analysis

The process map for the new model of X-trail SUVs is presented in the diagram below. The process map can be used for multiple purposes. First, an operations manager can use this value map for checking the current state of the production process. Second, it can be used for assessing the future possibilities. Third, it can be used for complying with the requirements that arise during the process.

X-trail SUV Process Map

Causes of partners’ struggle are shown in the diagram above; the most prominent are complexity, high costs, and lack of available resources. The constraints partners experience can be mitigated when Nissan addresses the mentioned causes.

According to the calculations above, the two locations got almost equal scores. Although, since the rental and labor costs as well as taxes are lower in South Carolina, it will be a rational decision for Nissan to open a plant there because labor productivity is lower only by two points.

D. Using the ABC inventory classification can allow a business regular its cost control of the materials stored in warehouses. Within the model, materials that make up 70% or more fall under the A category, 20% and below fall under the B category, while materials that are 10% and below in total value fall under the C category. Thus, the framework suggests that even though there are more of some materials, they have less quality compared to those of greater need but of less stock available.

The application of the ABC inventory matrix will allow Nissan to generate a cohesive framework for determining on which materials to focus and on which to not. The calculations for the annual dollar volume, percentage of annual dollar value, and the assigned category for each item are presented in the table below:

Sustainability

• Triple Bottom Line (TBL) is an accounting framework that includes tree performance dimensions: social, environmental, and financial (Slaper & Hall, 2011). Three Ps are the dimensions of the TBL: people, planet, and profits (Slaper & Hall, 2011). To enhance operations management in Toyota, the management should address its three dimensions. First, there should be a shift of focus on the fair treatment of employees by enacting favorable practices. Second, Toyota should implement sustainable practices and reduce its environmental impact. Such practices can range from recycling programs to the usage of only sustainable materials (“Triple bottom line,” n.d.). Third, the company should align its financial bottom line with the sustainable practices and social responsibility since the largest consumer demographic is willing to pay for sustainable goods (“Triple bottom line,” n.d.).
• The ISO 14000 standards provide manufacturers with measurements for dealing with their environmental impact by integrating the environmental considerations into the production process. With regards to Toyota Motor Corp., the company identified hundreds of substances and chemicals that the suppliers must not use in their manufacturing process (Gilbert-Miller, n.d.). The alignment with the ISO 14000 standards allows the company to follow the Triple Bottom Line framework to promote the agenda of sustainability and social responsibility to show customers that Toyota cares about reducing the environmental impact associated with the process of vehicle manufacturing.
• Integration of corporate social responsibility in a technology-oriented company comprises of knowledge exchange with customers, maintaining sustainable agreements with suppliers, developing employee code of conduct concerning ethics and knowledge dissemination, protecting the interest of the company with regards to protecting the corporate government decisions, and creating a social action plan to benefit local communities (Guadamillas-Gomez, Donate-Manzanares, & Skerlavaj, 2010). Among the mentioned principles, exchanging knowledge with suppliers and customers is the most effective since it will allow the company understand the demands of the public with regards to vehicle manufacturing and get an idea about what suppliers can and cannot do to adhere to the practices of environmental sustainability and social responsibility.

Abe, M., & Ye, L. (2013). Building resilient supply chains against natural disasters: The cases of Japan and Thailand. Global Business Review, 14 (4), 567-586.

ASQ. (2017). What is total quality management (TQM)? Web.

Chopra, S., & Sodhi, M. (2014). Reducing the risk of supply chain disruptions . Web.

Dettmer, W. (2000). Constraint management. Tuscon, AZ: Quality America Inc.

Gilbert-Miller, S. (n.d.). ISO 14000 becomes a prerequisite for suppliers to stay in the game . Web.

Goldratt, E. (1999). Theory of constraints. Great Barrington, MA: North River Press.

Guadamillas-Gomez, F., Donate-Manzanares, M., & Skerlavaj, M. (2010). The integration of corporate social responsibility into the strategy of technology-intensive firms: A case study. Proceedings of Rijeka School of Economics, 28 (1), 9-34.

Hill, C., Hult, T., Wickramasekera, R., Liesch, P., & Mackenzie, K. (2016). Global business today . New York, NY: McGraw-Hill.

Identifying supply chain risks . (n.d.). Web.

Just in time – JIT. (n.d.). Web.

Mahutga, M. (2012). When do value chains go global? A theory of the spatialization of global value chains. Global Networks, 12 (1), 1-21.

MT Team. (2017). Lean manufacturing: Working more efficiently . Web.

O’Brien, J., & Plotnick, F. (2015). CPM in construction management (8th ed.). New York, NY: McGraw Hill.

Pyzdek, T., & Keller, P. (2014). The six sigma handbook (4th ed.). New York, NY: McGraw Hill.

Schmidt, W., & Simchi-Levi, D. (2013). Nissan Motor Company Ltd.: Building operational resiliency . Web.

Slaper, T., & Hall, T. (2011). The triple bottom line: What is it and how does it work? Web.

Toma, S-G., & Marinescu, P. (2013). Global strategy: The case of Nissan Motor Company. Procedia Economics and Finance, 6 , 418-423.

Toyota. (2017). Toyota production system . Web.

Triple bottom line . (n.d.) Web.

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IvyPanda. (2022, December 6). Nissan Company's Constraint Management. https://ivypanda.com/essays/nissan-companys-constraint-management/

"Nissan Company's Constraint Management." IvyPanda , 6 Dec. 2022, ivypanda.com/essays/nissan-companys-constraint-management/.

IvyPanda . (2022) 'Nissan Company's Constraint Management'. 6 December.

IvyPanda . 2022. "Nissan Company's Constraint Management." December 6, 2022. https://ivypanda.com/essays/nissan-companys-constraint-management/.

1. IvyPanda . "Nissan Company's Constraint Management." December 6, 2022. https://ivypanda.com/essays/nissan-companys-constraint-management/.

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IvyPanda . "Nissan Company's Constraint Management." December 6, 2022. https://ivypanda.com/essays/nissan-companys-constraint-management/.

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• Published: 24 April 2024

Management of pediatric vanishing testes syndrome based on pathological diagnosis: a single-center retrospective study

• Chang-Kun Mao 1 ,
• Yuan-Fang 2 &
• Yong-Sheng Cao 1  

Scientific Reports volume  14 , Article number:  9437 ( 2024 ) Cite this article

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• Medical research

This study aims to explore the optimal management strategy for pediatric vanishing testes syndrome (VTS) based on pathological characteristics. We retrospectively analyzed clinical data and pathological results of children with unilateral VTS who underwent surgical treatment at our center from July 2012 to July 2023. The children were categorized into the testicular excision group and testicular preservation group based on the surgical approach. Clinical characteristics and outcomes were compared between the two groups. Pathological examination results of excised testicular tissues were collected and analyzed, and long-term follow-up was conducted. A total of 368 children were included in this study. The age of the children at the time of surgery was 27 months (range, 6–156). Among them, 267 cases (72.6%) had VTS on the left side, and 101 cases (27.4%) on the right side. There were no statistically significant differences (P > 0.05) in age, affected side, contralateral testicular hypertrophy (CTH), testicular location, and preferred surgical incision between the testicular excision group (n = 336) and the testicular preservation group (n = 32). In the preservation group, two children experienced scrotal incision infections, showing a statistically significant difference compared to the excision group (P < 0.05). Pathological examination of excised tissues revealed fibrosis as the most common finding (79.5%), followed by vas deferens involvement (67%), epididymis involvement (40.5%), calcification (38.4%), and hemosiderin deposition (17.9%). Seminiferous tubules (SNT) was present in 24 cases (7.1%), germ cells (GC)in 15 cases (4.5%), and ectopic adrenal cortical tissue(EACT) in 1 case (0.3%). VTS belongs to a type of non-palpable testes (NPT) and requires surgical exploration. Considering the risk of scrotal incision infection after preserving atrophic testicular remnants and the unpredictable malignant potential, we recommend excision.

Introduction

Cryptorchidism or undescended testis is one of the most common congenital anomalies in male newborns, with an incidence of 1.0–4.6% in full-term infants and up to 45% in premature infants 1 . For ease of surgical management, clinical practice often categorizes testes as palpable or non-palpable, with approximately 20% falling into the non-palpable category 2 . Vanishing testes syndrome (VTS) is one of the reasons of non-palpable testes (NPT) in children, characterized by the discovery of blind-ended spermatic vessels or nodules with unidentifiable normal testicular morphology during surgical exploration 1 , 2 , 3 . However, consensus on the optimal diagnostic and therapeutic approaches for VTS remains elusive. Some scholars previously advocated for surgical excision of testicular remnants, positing that residual testicular tissues may harbor germ cells (GC) and seminiferous tubules (SNT) with potential malignant transformation risks 4 , 5 . Nevertheless, recent research has presented an alternative perspective, suggesting that excision may not be imperative, given the relatively low incidence of GC and SNT, coupled with insufficient robust evidence indicating a continued presence of GC and SNT leading to potential malignant risks 3 , 6 . To delve further into this matter, the current study conducts a retrospective analysis of clinical and pathological data from 368 cases of unilateral VTS treated at our center over the past 11 years, aiming to provide additional data support for the diagnosis and treatment of VTS.

Materials and methods

We conducted a retrospective analysis of case data for children with unilateral VTS who underwent surgical treatment at our center from July 2012 to July 2023, utilizing the electronic medical records system. Inclusion criteria comprised initial diagnosis of cryptorchidism, with surgical confirmation of blind-ended spermatic vessels or identification of atrophic nodules during exploration. Exclusion criteria encompassed a history of surgery on the affected side for undescended testis, testicular torsion, or incarceration related to inguinal hernia, all of which could lead to an NPT. A detailed dataset was constructed by carefully reviewing clinical records, surgical records, and pathological data for each patient.

Preoperative ultrasound and definition of testicular hypertrophy

All patients underwent preoperative ultrasound examination of the scrotum or inguinal region to detect NPT. Simultaneously, the maximum longitudinal diameter of the contralateral testis was measured to assess whether it was hypertrophic. We utilized a criterion of 1.6 cm for testicular diameter in patients under 36 months as the threshold for defining testicular hypertrophy 3 , 7 .

Surgical management

Prior to the commencement of surgical exploration, a thorough physical examination was conducted under general anesthesia to ensure that the patients met the inclusion criteria. If palpable cord-like tissue or atrophic remnants are detectable in the inguinal or scrotal region, inguinal or scrotal incision exploration is the preferred approach. If no structures are palpable, or if there is contralateral inguinal hernia present, laparoscopic exploration is the first choice. During laparoscopic exploration, if no intra-abdominal testis is found, and the spermatic cord enters the closed internal ring, exploration of the inguinal or scrotal region is performed. At the distal end of the spermatic cord, a small fibrotic remnant is identified, with no visible normal testicular tissue. If macroscopically abnormal intra-abdominal testicular remnants are discovered during laparoscopic examination, we advocate for their removal. During the procedure, communication with the parents was reiterated to inform them about the testicular development, and based on parental choice, patients were categorized into the testicular excision group or preservation group. All excised residual specimens underwent histological examination with hematoxylin and eosin (H&E) staining.

Statistical analysis

Statistical analyses were performed using SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY, United States). Continuous variables were presented as mean ± standard deviation (SD) or mean (min–max), and categorical variables were presented as n (%). Comparisons were made using chi-squared or Fisher’s exact tests for categorical variables. All tests were two-tailed. A significance level of P  < 0.05 was considered statistically significant.

Ethical approval

This study obtained approval from the Ethics Committee of Anhui Provincial Children’s Hospital (Approval No. 116123S21), ensuring the privacy and confidentiality of all data. Patient participation was voluntary, and informed consent was obtained from parents prior to their children’s involvement, documented through signed informed consent forms. All the procedures involving human participants followed in the study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This study included a total of 368 pediatric patients with VTS. The mean age of the patients at the time of surgery was 27 months (range, 6–156). Among them, 267 cases (72.6%) had VTS on the left side, and 101 cases (27.4%) on the right side. Thirty-three cases were concurrently associated with contralateral undescended testis or inguinal hernia. Color Doppler ultrasound revealed atrophic nodules in 102 cases (27.7%), with 16 located in the inguinal region and 86 within the scrotum. In 263 cases (71.5%) of patients under 36 months, 172 cases (65.4%) exhibited contralateral testicular hypertrophy (CTH), with ultrasound longitudinal diameters exceeding 1.6 cm. A total of 206 cases (56%) opted for laparoscopic exploration, including 18 cases with contralateral inguinal hernia. The remaining 162 cases (44%) preferred inguinal or scrotal incision exploration.

Based on parental choices during surgery, 336 patients chose testicular excision, while the remaining 32 opted for testicular preservation. Comparative analysis of data between these two groups, including patient age, affected side, CTH, testicular position, and preferred surgical incision, showed no significant differences ( P  > 0.05) in these aspects (Table 1 ). However, it is noteworthy that in the preservation group, two cases, aged 22 months and 30 months respectively, experienced scrotal incision infections postoperatively, showing statistical significance ( P  < 0.05). All patients did not undergo contralateral testicular orchidopexy.

Figure  1 illustrates an atrophic nodule retrieved from the left inguinal incision, where the spermatic vessels and vas deferens were absent, replaced by fibrotic strands (Fig.  1 ). Excision and pathological examination were performed. Results from H&E staining revealed fibrosis in 267 cases (79.5%), vas deferens involvement in 225 cases (67%), epididymis involvement in 136 cases (40.5%), calcification in 129 cases (38.4%), and hemosiderin deposition in 60 cases (17.9%) (Fig.  2 ). Multiple pathological components were found in 83.9% (282/336) of the excised tissue in the excision group. Additionally, 24 specimens (7.1%) showed the presence of SNT, while 15 specimens (4.5%) exhibited GC. Furthermore, one specimen revealed ectopic adrenal cortical tissue (EACT) (Fig.  3 ). An atrophic nodule retrieved from the left scrotal incision, showing the presence of spermatic vessels and vas deferens but lacking normal testicular parenchyma. After consulting with the parents, the remnant was preserved (Fig.  4 ).

Atrophic nodule extracted via left inguinal incision.

The pathological composition of VTS.

The pathological microscopic images of the excised tissue with H&E staining, captured under a × 200 magnification. ( A ) Ectopic adrenal cortex components are observed adjacent to the epididymal duct. ( B ) Iron-hemosiderin deposition and calcification are visible within the fibrous tissue. ( C ) Large and primitive germ cells are seen between the supporting cells of convoluted seminiferous tubules. ( D ) Underdeveloped, small convoluted seminiferous tubules.

Atrophic nodule retrieved from the left scrotal incision.

Through outpatient follow-up examinations, with an average follow-up time of 40 months (range, 3–120), no abnormal development or testicular torsion was observed in the contralateral testis. Among the 32 patients in the preservation group, ultrasound examinations did not detect any malignant transformations, and no cases required secondary surgical excision.

Currently, the guidelines of the European Association of Urology categorize undescended testes into palpable and non-palpable types for clinical management. Among the 20% of NPT, 50–60% are intra-abdominal, canalicular, or peeping (right inside the internal inguinal ring), while the remaining 20% may be absent, 30% atrophied or underdeveloped, and sometimes include cases of ectopic testicles 1 . A retrospective review of clinical cases reveals that VTS is the fundamental cause in 35–69% of clinically NPT 8 , 9 , 10 . Therefore, some scholars consider that VTS is one of the reasons for the inability to palpate the testicle and recommend explaining this to all patients and their families before surgery 10 .

Due to the lack of consensus, various definitions of VTS exist in the literature 3 , 4 , 5 , 11 , 12 . The common feature is the presence of NPT, with only residual structures detected during surgical exploration. In this study, we adopt the definition of VTS as a congenital disease where normal testicular tissue is not identifiable by the naked eye after clinical exploration of the NPT 3 , 6 , 13 . This includes the presence of testicular remnants, nodules, or tissues adjacent to the testis/testicular side at the end of the spermatic cord. Although the etiology, pathological tissue composition, and prognosis of VTS may differ from those of surviving undescended testes 5 , 6 , VTS is considered a result of prenatal or late gestational vascular thrombosis, torsion, or endocrine abnormalities 5 . However, recent studies strongly support the theories of vascular accidents and prenatal torsion, rather than endocrine diseases 14 . Our study consistently observes and supports this theory, as fibrosis, malnutrition-induced calcification, hemosiderin deposition, and the presence of macrophages in the excised residual tissues indicate vascular accidents 4 , 15 , 16 . Additionally, VTS is more common on the left side, as reported in previous studies 3 , 4 , 5 , 6 , 16 . He et al. 16 suggest that it is challenging to explain this significant lateralization with endocrine factors. The potential reasons include anatomical relationships between the left testicular vein and the left renal vein, leading to vascular occlusion secondary to abnormal renal activity 5 . Furthermore, the earlier descent of the left testis during fetal development may be another contributing factor 15 , 16 .

Preoperative imaging examinations are unable to determine the presence of the testes 17 . Although ultrasound is a non-invasive tool, it is time-consuming, expensive, and lacks accuracy in detecting the presence or location of intra-abdominal testes in non-palpable cases 1 , 18 . However, Press et al. 19 found that ultrasound can detect 84.8% of NPT, including 12.1% with atrophic nodules. These results can impact surgical planning, avoiding unnecessary laparoscopic explorations. In our study, ultrasound is cost-effective (approximately $13), and all patients underwent preoperative ultrasound examinations. The ultrasound results revealed 102 cases (27.7%) with atrophic nodules, including 16 cases in the inguinal region and 86 cases in the scrotum. When ultrasound cannot detect the testes, parents are informed of various possibilities and corresponding treatment methods for the presence of NPT. Another essential role of ultrasound is detecting CTH. Unlike measuring tools such as calipers, ultrasound can exclude interference from the epididymis, scrotal skin, and adjacent soft tissues during the measurement, making it considered the best tool for assessing testicular size in the pediatric population 20 . Although CTH often indicates ipsilateral testicular atrophy, ultrasound is often challenging in determining the location of atrophic nodules 16 . Therefore, CTH has no impact on the decision-making for NPT management, consistent with the results of Wei et al. 21 . Another study’s findings indicate that regardless of ultrasound results, over 80% of surgeons choose laparoscopic exploration as the initial step in diagnosing and treating NPT, while less than 20% of participants opt for inguinal/scrotal approaches as the primary choice for NPT. Supporters of this approach believe that, as only 14–32% of patients have an intra-abdominal testis, this incision allows for easier detection of the testis, potentially avoiding the need for laparoscopic exploration 22 . However, if there is suspicion of a nodular lesion on the same side and CTH is present on the contralateral side, the option of scrotal incision and excision of the nodule can be considered to confirm testicular disappearance, thus obviating the need for laparoscopic exploration 1 . In our study, 206 cases (56%) of patients who did not initially exhibit cord-like structures or atrophic remnants in the inguinal or scrotal region underwent initial laparoscopic exploration. Additionally, 162 cases (44%) with detected nodules in the inguinal or scrotal region underwent direct inguinal or scrotal exploration and residual excision. This surgical approach is considered to have potential certainty for the diagnosis and treatment of testicular disappearance 23 .

Past studies have debated whether atrophic testicular nodules need to be excised. Unlike undescended testes, congenital undescended testes increase the risk of future malignancies 24 . However, the etiology of VTS differs from congenital undescended testes, and therefore, the risk of future malignant tumors may also differ 6 . So far, there has been only one isolated report of intratubular germ cell neoplasia (ITGCN) in residual testicular ducts in a 9-year-old child, but it lacked immunohistochemical support 25 . The controversy over whether to excise atrophic nodules arises from different reported rates of GC occurrence 3 , 4 , 5 , 10 , 16 and the subsequent risk of malignancy.A large-scale retrospective study conducted until now indicated an overall incidence rate of 3.1% for GC and 6.6% for SNT 16 . However, a recent systematic review revealed that the overall incidence rate of GC is 5.3%, and SNT is 10.7% 6 . In our study, considering the potential medical disputes associated with excising testicular tissues and the unpredictable malignant potential of retaining atrophic testicular nodules, parents were allowed to observe the atrophy of the testicles during surgery and choose between excision and fixation. Based on this, we divided the patients into excision and fixation groups. There were no significant differences between the two groups in terms of patient age, affected side, CTH, testicular location, and preferred surgical incision. However, the fixation group had two cases of postoperative scrotal incision infections, which showed statistical significance. In the excision group, we found an SNT occurrence rate of 7.1% and a GC occurrence rate of 4.5%. Postoperative follow-up did not reveal abnormal development or torsion of the contralateral testicle. In the fixation group, no malignant conditions were detected by ultrasound, and there were no cases requiring a second excision surgery. At the same time, we observed that 336 cases (91.3%) of patients underwent excision surgery, a relatively high proportion that may reflect a preference for surgical interventions within parents. Despite our efforts to provide objective information regarding treatment options, we cannot rule out the potential influence of personal preferences within the medical team and concerns from parents about future risks on the decision-making process. Interestingly, in this study, we discovered a case of EACT. First discovered by Morgagni in 1740 26 , EACT can be found anywhere along the migration path from the urogenital ridge during embryonic development. While descriptions of EACT have been reported in the abdomen, broad ligament, testicles, spermatic cord, kidneys, and retroperitoneum 11 , it is rarely reported in atrophic testicular nodules. Although the number of reported cases is limited, EACT is generally accepted to have malignant potential 11 , 27 , thus recommending excision.

By reviewing the literature, the low occurrence rates of SNT and GC and insufficient evidence supporting the continuous existence of future malignant potential lean towards the argument that surgical excision is unnecessary 3 , 6 , 10 . However, this overlooks the clinical significance of surgical procedures. VTS is a type of NPT, often requiring surgical exploration to determine the presence of viable testes. Considering the risk of scrotal incision infections after retaining atrophic nodules and the unpredictable malignant potential, even if the likelihood of malignancy is extremely low, parents find it difficult to accept. Therefore, we recommend excision.

Despite providing valuable data, this study has some limitations. Firstly, it has the limitations inherent in retrospective research, such as information completeness and selection bias. Secondly, the identification of SNT and GC in this study relied on H&E staining and lacked immunohistochemical results. Additionally, the follow-up period in this study was relatively short, requiring long-term follow-up of the malignant potential after retaining atrophic testicular nodules. Therefore, future prospective randomized controlled studies with long-term follow-ups will be more valuable.

In conclusion, in this study, SNT was found in 24 cases (7.1%) of excised atrophic remnants, GC in 15 cases (4.5%), and EACT in 1 case (0.3%). Although there is not sufficient robust evidence to prove the sustained malignant potential of GC and SNT over time, considering that VTS is a type of NPT requiring surgical exploration, and taking into account the risk of incision infection and the unpredictable malignant potential after retaining atrophic testicular remnants, which, even if low, is difficult for parents to accept, we recommend excision.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Vanishing testes syndrome

Contralateral testicular hypertrophy

Seminiferous tubules

Ectopic adrenal cortical tissue

Non-palpable testes

Hematoxylin and eosin

Standard deviation

Intratubular germ cell neoplasia

Radmayr, C. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology guidelines. J. Pediatr. Urol. 13 (5), 550. https://doi.org/10.1016/j.jpurol.2017.06.012 (2017).

Article   PubMed   Google Scholar  

Boehm, K. et al. Contralateral testicular hypertrophy is associated with a higher incidence of absent testis in children with non-palpable testis. J. Pediatr. Urol. 19 (2), 214.e1-214.e6. https://doi.org/10.1016/j.jpurol.2022.11.006 (2022).

Gao, L., Tang, D. & Gu, W. Histopathological features of vanishing testes in 332 boys: What is its significance? A retrospective study from a tertiary hospital. Front. Pediatr. 10 , 834083. https://doi.org/10.3389/fped.2022.834083 (2022).

Article   PubMed   PubMed Central   Google Scholar  

Nataraja, R. M. et al. Is routine excision of testicular remnants in testicular regression syndrome indicated?. J. Pediatr. Urol. 11 (3), 151.e1–5. https://doi.org/10.1016/j.jpurol.2015.01.018 (2015).

Article   CAS   PubMed   Google Scholar  

Bader, M. I. et al. The testicular regression syndrome–do remnants require routine excision?. J. Pediatr. Surg. 46 (2), 384–386. https://doi.org/10.1016/j.jpedsurg.2010.11.018 (2011).

Nataraja, R. M. et al. Presence of viable germ cells in testicular regression syndrome remnants: Is routine excision indicated? A systematic review. Pediatr. Surg. Int. 34 (3), 353–361. https://doi.org/10.1007/s00383-017-4206-0 (2017).

Berger, C. et al. Nonpalpable testes: Ultrasound and contralateral testicular hypertrophy predict the surgical access, avoiding unnecessary laparoscopy. J. Pediatr. Urol. https://doi.org/10.1016/j.jpurol.2017.10.010 (2018).

Igarashi, A. et al. Surgical exploration for impalpable testis: Which should be first, inguinal exploration or laparoscopic abdominal exploration?. J. Pediatr. Surg. 53 (9), 1766–1769. https://doi.org/10.1016/j.jpedsurg.2017.10.046 (2017).

Mizuno, K. et al. Feasible etiology of vanishing testis regarding disturbance of testicular development: Histopathological and immunohistochemical evaluation of testicular nubbins. Int. J. Urol. 19 (5), 450–456. https://doi.org/10.1111/j.1442-2042.2011.02951.x (2012).

Woodford, E. et al. Is excision of testicular nubbin necessary in vanishing testis syndrome?. J. Pediatr. Surg. 53 (12), 2495–2497. https://doi.org/10.1016/j.jpedsurg.2018.08.011 (2018).

Pathak, M. et al. Testicular remnant “nubbin” and incidental ectopic adrenal cortical rests: A case series and systematic review. J. Pediatr. Urol. 16 (5), 627–634. https://doi.org/10.1016/j.jpurol.2020.07.011 (2020).

Van Savage, J. G. Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome. J. Urol. 166 (4), 1421–1424. https://doi.org/10.1097/00005392-200110000-00060 (2001).

Law, H. et al. Histopathological features of testicular regression syndrome: Relation to patient age and implications for management. Fetal Pediatr. Pathol. 25 (2), 119–129. https://doi.org/10.1080/15513810600788806 (2006).

Kraft, K. H. et al. Histological examination of solitary contralateral descended testis in congenital absence of testis. J. Urol. 187 (2), 676–680. https://doi.org/10.1016/j.juro.2011.10.021 (2011).

Pirgon, Ö. & Dündar, B. N. Vanishing testes: A literature review. J. Clin. Res. Pediatr. E 4 (3), 116–120. https://doi.org/10.4274/Jcrpe.728 (2012).

Article   Google Scholar  

He, T. Q. et al. Testicular regression syndrome: A retrospective analysis of clinical and histopathological features in 570 cases. Front. Pediatr. 10 , 1006880. https://doi.org/10.3389/fped.2022.1006880 (2022).

Hrebinko, R. L. & Bellinger, M. F. The limited role of imaging techniques in managing children with undescended testes. J. Urol. 150 (2 Pt 1), 458–460. https://doi.org/10.1016/s0022-5347(17)35510-6 (1993).

Tasian, G. E. & Copp, H. L. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: A systematic review and meta-analysis. Pediatrics 127 (1), 119–128. https://doi.org/10.1542/peds.2010-1800 (2010).

Press, B. H. et al. Heresy—Is there a role for ultrasound in management of the non-palpable testicle?. J. Pediatr. Urol. https://doi.org/10.1016/j.jpurol.2023.08.032 (2023).

Diamond, D. A. et al. Comparative assessment of pediatric testicular volume: Orchidometer versus ultrasound. J. Urol. 164 (3 Pt 2), 1111–1114. https://doi.org/10.1097/00005392-200009020-00048 (2000).

Wei, Y. et al. Testicular hypertrophy as predictor of contralateral nonpalpable testis among Chinese boys: An 18-year retrospective study. Arch. Pediatrie 27 (8), 456–463. https://doi.org/10.1016/j.arcped.2020.08.006 (2020).

Article   CAS   Google Scholar  

Mah, L. W., Durbin-Johnson, B. & Kurzrock, E. A. Non-palpable testis: Is management consistent and objective?. J. Pediatr. Urol. 16 (1), 62–68. https://doi.org/10.1016/j.jpurol.2019.11.015 (2019).

Snodgrass, W. T., Yucel, S. & Ziada, A. Scrotal exploration for unilateral nonpalpable testis. J. Urol. 178 (4 Pt 2), 1718–1721. https://doi.org/10.1016/j.juro.2007.05.089 (2007).

Pettersson, A. et al. Age at surgery for undescended testis and risk of testicular cancer. N. Engl. J. Med. 356 (18), 1835–1841. https://doi.org/10.1056/NEJMoa067588 (2007).

Rozanski, T. A., Wojno, K. J. & Bloom, D. A. The remnant orchiectomy. J. Urol. 155 (2), 712–713 (1996).

Schechter, D. C. Aberrant adrenal tissue. Ann. Surg. 167 (3), 421–426. https://doi.org/10.1097/00000658-196803000-00017 (1968).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Jain, S. H. et al. A patient with ectopic cortisol production derived from malignant testicular masses. Nat. Clin. Pract. Endoc. 4 (12), 695–700. https://doi.org/10.1038/ncpendmet0985 (2008).

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C.-K.M designed the study and collect the data. Y.-F. analyzed the pathological data. Y.-S.C conducted statistical analyses. All the authors were involved in writing and reveiwing the manuscript as well as preparing the figures.

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Mao, CK., Yuan-Fang & Cao, YS. Management of pediatric vanishing testes syndrome based on pathological diagnosis: a single-center retrospective study. Sci Rep 14 , 9437 (2024). https://doi.org/10.1038/s41598-024-59583-6

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• Published: 23 April 2024

Interrater reliability of the violence risk assessment checklist for youth: a case vignette study

• Anniken L. W. Laake 1 , 2 ,
• John Olav Roaldset 2 ,
• Tonje Lossius Husum 1 ,
• Stål Kapstø Bjørkly 3 ,
• Carina Chudiakow Gustavsen 4 &
• Øyvind Lockertsen 1 , 2  

BMC Psychiatry volume  24 , Article number:  303 ( 2024 ) Cite this article

Metrics details

Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12–18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions.

A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities ( N  = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC).

Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent.

Conclusions

This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Peer Review reports

While evaluations of an individual’s risk for violent behavior were traditionally developed within and for forensic settings [ 1 ], the need for assessing violence risk has been identified in additional settings where management of violent behavior commonly occurs [ 2 , 3 ]. Violence risk assessments are increasingly conducted in multiple contexts of healthcare and other public services [ 3 , 4 ], including mental healthcare [ 2 ] and emergency departments [ 5 , 6 ]. As the settings in which violence risk assessments are utilized expand, the need emerges for tools tailored to target populations and the evaluation of their psychometric properties.

Institutions providing healthcare and social services for youth commonly face challenges related to aggression and violence. In youth psychiatric units, inpatient violence is a substantial concern, negatively impacting the wellbeing of both patients and staff [ 7 ]. For instance, a chart review study in an inpatient psychiatric unit for adolescents showed that aggressive or violent behavior requiring intervention were recorded for 28.4% of inpatients [ 8 ]. Further, child protective services (CPS) is identified as one of the public services at highest risk of encountering violent behavior from youth [ 9 ]. Thus, these are settings with a need for available resources to identify, prevent and manage violence risk. The ability to accurately identify individuals at high risk for violent behavior facilitates implementation of interventions to prevent violence from occurring [ 4 , 10 , 11 , 12 ], and aids decision-making related to patient treatment [ 13 , 14 ]. Further, routinely assessing violence risk in inpatient psychiatric settings can help de-escalate aggressive behavior [ 15 ] and can reduce use of coercive measures, promoting a safer environment for patients and staff [ 16 , 17 , 18 , 19 ].

Violence risk assessments for youth

For children and adolescents, assessing violence risk require distinct situational and intrapersonal considerations (e.g. school setting; caretaker situation; cognitive developmental stage; psychiatric diagnostics), and assessments for adults can not readily be generalized to youth [ 1 , 20 ]. Violence risk assessment tools specifically for youth have been developed and validated for various settings, with the Structured Assessment of Violence Risk in Youth (SAVRY) [ 21 ] and Youth Level of Service/Case Management Inventory (YLS/CMI) [ 22 ] among the most commonly researched [ 23 , 24 ]. These instruments are comprehensive, time consuming to administer, and may require specific training to utilize [e.g. 25 , 26 ]. In facilities commonly required to make judgments about violence risk, such as emergency departments and acute psychiatric institutions, structural and contextual aspects like scarcity of time and staff resources influence the ability to routinely conduct in-depth violence risk assessments [ 27 , 28 ].

For adults, several shorter violence risk screeners, such as V-RISK-10 [ 29 ], have been designed to rapidly identify individuals at high risk for violence. In situations where comprehensive assessments are not feasible, these brief instruments can be used to quickly identify high-risk individuals and guide initial decisions about the need for more comprehensive risk assessments or implementation of immediate interventions [ 30 , 31 ]. However, in comparison to adult populations, the development of violence risk screening instruments for youth is lagged. In lieu of available instruments tailored to youth, providers have in some instances used tools designed for adult populations, such as V-RISK-10 [ 32 ].

Violence risk assessment checklist for youth aged 12–18 (V-RISK-Y)

The V-RISK-Y is a violence risk screening tool for youth aged 12 to 18, based on the V-RISK-10 screener. The instrument is designed to be time-efficient, self-explanatory, and possible to use without prior training [ 32 ]. As such, it caters to institutions providing 24-hour care, where acute evaluations are conducted, and where staff trained in risk assessment may not readily be available.

V-RISK-Y was piloted in an emergency psychiatric unit for youth in Norway [ 32 ]. Results indicated good predictive validity for violent events during the youth’s hospital stay, with Area Under the Curve of the Receiver Operating Characteristics (AUC) of a high value of 0.762 for the sum score of V-RISK-Y. Interrater reliability for V-RISK-Y was assessed in the pilot by scoring of case vignettes. As measured by intraclass correlation coefficient (ICC), interrater reliability for individual items was poor to fair, and the ICC for the sum score was 0.51. The pilot version of V-RISK-Y included relevance scores for each of the 12 items, but as the relevance scores were perceived as confusing by participants it was hypothesized that they contributed to low ICC values [ 32 ]. Because V-RISK-Y is a new instrument, there is a need to establish psychometric properties of the screening in relevant settings and with a larger sample size.

• Interrater reliability

While knowledge about interrater reliability is essential for evaluating the validity of a scale, reporting of interrater reliability in psychometric studies is commonly neglected [ 33 ]. For violence risk assessment, concordance between participants in assessing violence risk has been associated with predictive validity [ 34 ]. McNiel and colleagues (2000) assessed interrater reliability and predictive validity for risk assessments in an inpatient psychiatric unit and found that predictive validity of assessed risk significantly improved with agreement between participants.

Previous studies on interrater reliability for violence risk assessments have commonly utilized the interrater correlation coefficient (ICC) as reliability measure [e.g. 29 , 35 , 36 ], which indicates the variation between raters measuring the same individuals [ 37 ]. A study on V-RISK-10 assessed interrater reliability in an in-patient psychiatric setting, and included ratings for 73 acute psychiatric patients from 25 participants [ 29 ]. ICC values indicated good interrater reliability for the sum score, fair for the Low-Moderate-High risk level, and for single items ICC ranged from poor to good [ 29 ]. In a systematic review of psychometric properties of violence risk assessments for youth, ICC estimates for SAVRY and YLS/CMI indicated fair to excellent interrater reliability across published studies [ 38 ]. Given the lack of established violence risk screening instruments for youth, interrater reliability of violence risk screeners for youth has not been assessed other than in the V-RISK-Y pilot study.

The main objective of the present study was to assess the interrater reliability of V-RISK-Y in facilities where youth receive psychiatric in- and outpatient care, as well as acute child protective services institutions. A secondary aim was to assess whether there are differences in interrater reliability between types of youth facilities, or between types of staff in these institutions.

Design, setting and participants

This study was designed as a case vignette study, where staff from mental health and child protective services ( N  = 163) rated V-RISK-Y for three written cases. Vignettes simulate real life and allows for controlling included variables, ensuring all participant responses are based on the exact same information [ 39 ]. The design circumvents ethical and practical challenges which commonly arise when including vulnerable individuals in research [ 40 ], and thus is beneficial for initial assessment of an instrument. Generalizability is one of the major criticisms of this methodology as the complexities of real life can be difficult to capture in a written scenario [ 39 , 40 ].

Participants were recruited among staff from youth facilities participating in an ongoing V-RISK-Y multicenter study in Norway and staff from youth psychiatric units participating at a V-RISK-Y seminar in Sweden. Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics (REK ID: 218444).

Sample characteristics are illustrated in Table  1 . Participants included psychologists ( n  = 15), physicians ( n  = 18), as well as staff members with other professions ( n  = 106). Staff other than physicians and psychologists consisted of professions that do not require postgraduate education, including nurses, social workers, social educators, and youth workers. Only staff in direct contact with youth were included (i.e. administrative staff was not included).

The Norwegian youth facilities consisted of four acute psychiatric units ( n  = 72) providing in-patient services, and four acute child protective services (CPS) institutions ( n  = 52) providing residential care. CPS institutions are custodial institutions for acute placement of youth without satisfactory home conditions [ 41 ], and staff at these institutions largely consist of social workers and youth workers.

Participants from Sweden included staff from six child and adolescent psychiatric units ( n  = 39). These units consisted of facilities providing outpatient mental health services as well as units for inpatient acute psychiatric care for children and adolescents.

Measures consisted of printed copies of V-RISK-Y and three case vignettes. Materials were developed in Norwegian and translated to Swedish in collaboration with Swedish mental health professionals.

V-RISK-Y consists of 12 items: V1) Prior and/or current acts of violence; V2) Prior and/or current threats of violence; V3) Prior and/or current alcohol or substance abuse; V4) Prior and/or current severe symptoms of mental health disorders; V5) Disruptive, impulsive behaviour/Behavioural disorder; V6) Poor insight into the mental disorder and/or behaviour; V7) Suspicion; V8) Demonstrates lack of empathy; V9) Unrealistic planning; V10) Future stressful situations; V11) Prior and/or current severe trauma; and V12) The youth and parents/guardians’ perception of risk. Each item is rated according to their presence as “No”, “Moderate/Maybe”, “Yes”, or “Don’t Know”. The level of violence risk, “Low”, “Moderate”, or “High” is categorically indicated by the rater based on item scores combined with clinical judgment, following the structured professional judgment (SPJ) tradition [ 42 ]. The relevance scores previously included are removed from the current version. If feasible, the screening should be scored interdisciplinary. It is recommended to do the scoring upon the initial contact with the youth, such as after the intake interview, without the youth or their parents/guardians present.

The case vignettes were each approximately one page. Vignette summaries are included in Appendix 1. Cases were developed by clinicians and researchers experienced in violence risk assessment and youth psychiatry, and designed to reflect cases commonly encountered in youth psychiatric units and CPS institutions. While no psychiatric diagnoses were specified or fully described in the cases, the description of Case 1 (Farhad) alludes to autism specter disorder, Case 2 (Peter) describes antisocial behavior and symptoms of behavioral disorders, and Case 3 (Jeanette) indicates a depressive reaction. To reflect a clinical setting where information about youth might be lacking at intake, each case was designed with incomplete information to allow for the “don’t know” response to be an appropriate score for some items.

Researchers visited each youth facility interested in participating and gave an introduction of the development and structure of V-RISK-Y. Because V-RISK-Y is designed to be self-explanatory, no in-depth training in scoring the instrument was provided. Staff who agreed to participate were given writeups of the cases and V-RISK-Y forms and asked to independently rate each case to the best of their ability in one sitting. Ratings were conducted anonymously, without the researchers present. While no specific time limit was given for rating the cases, participants typically spent a total of 15 to 30 min completing the scorings.

Statistical analyses

Statistical analyses were conducted in Stata Statistical Software 17.0. Statistical significance level was set to 0.05 for all levels. Interrater reliability was assessed by estimating the intraclass correlation coefficient (ICC) for the 12 V-RISK-Y individual items, the sum score, and the risk level (Low-Moderate-High). ICC values range from 0 to 1, and interrater reliability is typically interpreted as low for values below 0.50, moderate for values between 0.50 and 0.75, good for values between 0.75 and 0.90, and excellent for values above 0.90 [ 37 ]. Because of clustering of data due to shared environmental and individual factors among participants, ICC was estimated based on multilevel statistical models which account for homogeneity [ 43 ], using the estat icc command.

The risk level was scored on an ordinal scale, as Low (1), Moderate (2) and High (3). V-RISK-Y items were also interpreted on an ordinal scale as “No” (0), “Don’t Know” (1), “Moderate/Maybe” (2), and “Yes" (3). “Don’t know” ratings were weighted as 1 and included in item analyses, which was also the method for analyses in the recent pilot study on V-RISK-Y [ 32 ]. Accounting for their ordinal properties, ICC for these variables was calculated based on multilevel ordered logistic regression [ 44 ]. For the sum score variable (range 0–36), mixed linear regression was used to estimate ICC [ 45 ].

Analyses were conducted for the overall data, and stratified analyses were conducted for type of institution and type of profession. As there is overlap in responsibilities of psychologists and physicians in the participating facilities, these professions were combined and compared to the other professions to increase statistical power.

For ten submitted forms, the full V-RISK-Y scoring was missing, and these ratings were excluded. All ten excluded ratings were for Case 3, Jeanette. There were no more than three missing values for any included V-RISK-Y ratings. Given the low number of missing scores in the included ratings, as displayed in Table  2 , missing values were not replaced.

Table 2 shows the frequency of scores for each V-RISK-Y item by case. The mean sum score for the cases was 24.43 [SD = 2.74] for Case 1, 27.99 [SD = 3.12] for Case 2, and 16.15 [SD = 5.00] for Case 3.

Results for analyses of interrater reliability for the overall data and stratified analyses for the types of youth facilities are presented in Table  3 . For the overall data, interrater reliability is excellent for V1 (Violence), good for V2 (Threats), moderate for V3 (Substance abuse), poor for V4 (Severe mental health symptoms), moderate for V5 (Disruptive behavior), good for V6 (Insight), poor for V7 (Suspicion), good for V8 (Empathy), moderate for V9 (Unrealistic plans) and V10 (Future stress), good for V11 (Trauma) and poor for V12 (Own perception). ICC estimates remained identical when type of institution and profession was controlled for in the mixed model. For stratified analyses, confidence intervals are wide and overlapping for all individual items.

Interrater reliability for types of youth facilities

Interrater reliability is good for V-RISK-Y sum score, and excellent for the Low-Moderate-High risk level across type of facility. For the acute psychiatry group, interrater reliability is excellent for V1, good for V2, moderate for V3, poor for V4, good for V5, moderate for V6, poor for V7, good for V8 and V9, moderate for V10, good for V11, and poor for V12.

For the CPS institutions, interrater reliability is excellent for V1 and V2, good for V3, poor for V4, moderate for V5 and V6, poor for V7, excellent for V8, moderate for V9, poor for V10, good for V11, and poor for V12.

For the Swedish units, interrater reliability is good for V1, excellent for V2, moderate for V3, poor for V4, good for V5, excellent for V6, poor for V7, excellent for V8, good for V9, moderate for V10, good for V11, and moderate for V12.

Interrater reliability for professional groups

Results for interrater reliability for the professional groups are presented in Table  4 .

Across the professional groups, interrater reliability is good for the sum score and excellent for the Low-Moderate-High risk level. For the physician/psychologist group, ICC values did not compute for items V1 and V8. Interrater reliability is excellent for V2, moderate for V3, poor for V4, excellent for V5 and V6, poor for V7, excellent for V9, moderate for V10, excellent for V11, and moderate for V12.

For the other professions, interrater reliability is excellent for V1 and V2, moderate for V3, poor for V4, moderate for V5 and V6, poor for V7, excellent for V8, moderate for V9, poor for V10, moderate for V11, and poor for V12.

Results indicate overall good interrater reliability for V-RISK-Y, and moderate to good interrater reliability for most individual items. These findings are comparable to interrater reliability for other youth violence risk assessments tools [ 38 ], as well as for V-RISK-10 [ 29 ], a recommended violence risk screener for adults utilized internationally [ 31 ]. There were few differences in interrater reliability between the youth facilities included in the study, which is promising for the potential utility of V-RISK-Y across settings where violence risk screening of youth is needed. No major differences in interrater reliability were found between Swedish and Norwegian units, implying that the level of agreement between staff at youth facilities in Sweden and Norway is similar.

Sum score and risk level

The interrater reliability for the sum score is consistently high, indicating agreement between participants on the sum of present risk factors presented in the cases. Results indicate good interrater reliability for the sum score of V-RISK-Y, and excellent for the Low-Moderate-High risk level across all types of facilities. Similarly, interrater reliability for the sum score is good, and excellent for the Low-Moderate-High risk level across the professional groups. These results are encouraging, as it indicates that there is overall agreement on the risk level assigned to the cases based on the V-RISK-Y scoring. These results lend support to the SPJ tradition in which V-RISK-Y is developed, demonstrating high agreement of the discretionary risk assessment guided by scoring the instrument [ 46 ].

Single items

For most single items, interrater reliability is consistently moderate to good across all groups. For items representing static risk factors, such as V1 (Violence) and V2 (Threats), interrater reliability is good to excellent. For V3 (Substance abuse), interrater reliability is good for CPS institutions while moderate for the other types of facilities. These items are likely relatively easy to score provided the availability of relevant information.

The poorest interrater reliability is found for V4 (Severe symptoms of mental health disorder), where ICC is close to zero across all groups. In the V-RISK-Y pilot study, which also assessed interrater reliability with case vignettes, the ICC value of 0.66 for V4 indicates moderate interrater reliability [ 32 ]. Characteristics of the case vignettes could provide one possible explanation of the low reliability measure for this item. Few typical symptoms of mental health disorders were described in the cases, and there was no mention of previous or current psychiatric diagnoses. The first case of Farhad describes a condition that could be compatible with autism specter disorder, where challenges in communication and social interactions are highlighted. For the second case, Peter, behavioral issues are the most prevalent. The third case of Jeanette describes symptoms that can be seen as a depressive reaction, where a change in mood and behavior has occurred following negative experiences. Another explanation for discrepant findings of interrater reliability for V4 could be that the scoring instructions are unclear or too broad. For V-RISK-10, interrater reliability for V4 was good, with ICC value of 0.70 for single measures and 0.83 for average measures [ 29 ]. It is possible that this item is harder to score for youth than it is for adults. The pilot study [ 32 ] and the V-RISK-10 study [ 29 ], which both found higher ICC values for V4, were conducted in acute psychiatric inpatient units only. In this study, interrater reliability was not higher for the acute psychiatric units as compared to the other youth facilities, so the differences cannot readily be explained by differences in types of institutions. The V-RISK-10 study was conducted in a naturalistic setting, and the discrepancies between these findings could imply difficulties in scoring this item for a vignette as compared to in-person cases. However, another V-RISK-10 study assessing interrater reliability through a case vignette design with 15 vignettes and eight raters yielded similar results [ 13 ].

Interrater reliability for item V7 (Suspicion) was poor across all groups. The description of V7 is largely based on exhibited behavior, which can be difficult to judge from a vignette without relying on behavioral observations. In the V-RISK-Y pilot, however, interrater reliability for this item was good, with an ICC estimate of 0.76 [ 32 ].

Interrater reliability is moderate for V10 (Stress exposure) for all types of facilities, except for the CPS institutions where it is poor. Further, interrater reliability for V10 is lower for professions other than psychologists and physicians. It is possible that these differences could reflect that staff groups have different ways of assessing stressful situations. Physicians and psychologists in the psychiatric units are typically responsible for treatment, whereas other staff groups are more present in the institutional environment outside of treatment sessions. These findings could also be impacted by most staff from the other professions group being from the CPS institutions. Possibly, staff in psychiatric units for youth have different ways of assessing stressful future situations as compared to CPS staff. Differences in ways of thinking about future stress may for instance be due to institutional characteristics, where the relatively closed environment of an inpatient unit might be perceived as mitigating stressful situations as compared to a more open residential setting. Interrater reliability for this item was good (ICC = 0.76) in the pilot study [ 32 ], which was conducted in a psychiatric unit.

For V12 (User perception), one of the items novel to V-RISK-Y, interrater reliability was poor to moderate for all groups. This finding is comparable to the pilot study, where ICC for this item was 0.35 [ 32 ]. This item was included in V-RISK-Y based on findings that patients’ own perception of violence risk is significantly associated with actual risk [ 47 ]. Patients’ own perception is not commonly included in existing screenings and assessments of violence risk [e.g. 48 ], and potentially represents a new way of thinking about risk assessments which may make it difficult to score. Further, this item is challenging to score based on the provided case vignettes, where there was little information about the youth or parents’ perceived risk of violence. A study conducted in a naturalistic setting, where the youth and their guardians could be asked about risk perception, might yield better interrater reliability for this item.

In the V-RISK-10 study where interrater reliability was assessed in a naturalistic setting, some items were found to have poor interrater reliability, including item V7 (Suspiciousness) and V10 (Future stressful situations). However, in subsequent research on predictive validity of V-RISK-10, items with low interrater reliability were still found to have high predictive validity [e.g. 49 , 50 ], and the items are kept in the instrument. Before deciding what to do with items with low interrater reliability, results from this study must be seen in relation to findings from ongoing efforts to validate V-RISK-Y, and be compared to items’ contribution to predictive validity of the instrument.

Limitations and future research.

There are some limitations in the study design that may have impacted results, which should be considered in future research on psychometric properties of V-RISK-Y. The case vignette design allows to control for the information provided to score each case. However, while efforts were made to design vignettes resembling clinical cases, a case vignette design does not reflect a naturalistic setting. Only a narrow range of scenarios are represented in the included vignettes, which do not cover complexities and diversity of real-life contexts. These limitations impact the generalizability of the findings to settings outside of theoretical case scorings. Case vignettes are commonly used in violence risk assessment trainings for skill development [e.g. 51 , 52 ]. It is possible that the cases would be better suited for a training purpose than realistic assessment of interrater reliability. Nevertheless, the good interrater reliability found for the sum score and the Low-Moderate-High risk level lend support for continuing research efforts on the current version of V-RISK-Y. It would also be of interest to conduct a naturalistic study of interrater reliability as was done for V-RISK-10.

Demographic information about participating staff was not collected in the present study. Thus, findings cannot be interpreted in relation to demographic variables such as work experience, age or sex. These variables should be included in future research to enable more distinguished comparisons between included staff groups, which particularly would be of interest because V-RISK-Y is developed to be easy to use for all clinical staff.

The design of this study included only three cases and a high number of participants. In studies with low between-rater variance, which may be the case when all participants are in similar work environments, precision of ICC is facilitated by a high number of raters and a low number of cases [ 53 ]. It is likely that the large confidence intervals for the estimated ICC values and the inability to compute ICC for some items in the stratified analyses on profession reflects the design of a high rater to case ratio. A study with a different setup, where more cases are scored by fewer participants, could mitigate this issue and allow for further assessment of discrepancies in interrater reliability found in stratified analyses.

In this study, cases were scored individually by the participants. The recommendation for V-RISK-Y is interdisciplinary rating when possible. Further research should assess whether interdisciplinary versus individual scoring influences the psychometric properties of V-RISK-Y. In this study, as well as in the pilot, “Don’t know” scores are coded as 1 and included in the ordinal scale of the single items, based on findings on V-RISK-10 showing that don’t know scores should be counted toward risk [ 54 ]. To date, there is no research exploring whether the same argument holds true for V-RISK-Y, which should be assessed in future studies.

Results from this initial study on interrater reliability for V-RISK-Y are promising. While poor interrater reliability was found for some of the risk items, the overall agreement on sum of present risk factors and risk level is high. Findings indicate acceptable interrater reliability for V-RISK-Y across different types of youth facilities where the objective of identifying violence risk commonly occur, namely acute psychiatry, outpatient psychiatry, and child protective services. Given limitations in the study design, findings should be cautiously interpreted, and generalizability to naturalistic settings cannot be readily assumed. This is the first interrater reliability study of the current version of the V-RISK-Y, and an important step in establishing the psychometric properties of this instrument. Research on V-RISK-Y is still in its early stages, and there is a need for further studies to assess its psychometric properties in naturalistic settings.

Data availability

The datasets analyzed in the current study are not publicly available and cannot openly be shared due to privacy laws and restrictions in ethical approval. Data are available from the authors upon reasonable request.

Borum R. Assessing violence risk among youth. J Clin Psychol. 2000;56(10):1263–88.

Article   CAS   PubMed   Google Scholar  

Haque Q. Implementation of violence risk assessment instruments in mental healthcare settings. International perspectives on violence risk assessment. 2016:40–52.

Scott CL, Resnick PJ. Violence risk assessment in persons with mental illness. Aggress Violent Beh. 2006;11(6):598–611.

Article   Google Scholar  

Singh JP, Grann M, Fazel S. A comparative study of violence risk assessment tools: a systematic review and metaregression analysis of 68 studies involving 25,980 participants. Clin Psychol Rev. 2011;31(3):499–513.

Article   PubMed   Google Scholar  

Cabilan C, Eley R, Snoswell C, Jones AT, Johnston AN. Inter-rater reliability of the occupational violence risk assessment tool for emergency departments. Australasian Emerg care. 2023;26(1):54–8.

Article   CAS   Google Scholar  

Sammut D, Hallett N, Lees-Deutsch L, Dickens GL. A systematic review of violence risk assessment tools currently used in emergency care settings. J Emerg Nurs. 2022.

Atkins R. The association of personality type in childhood with violence in adolescence. Res Nurs Health. 2007;30(3):308–19.

Baeza I, Correll CU, Saito E, Amanbekova D, Ramani M, Kapoor S, et al. Frequency, characteristics and management of adolescent inpatient aggression. J Child Adolesc Psychopharmacol. 2013;23(4):271–81.

Article   PubMed   PubMed Central   Google Scholar  

Svalund J. Vold Og Trusler Om Vold i offentlig sektor. Oslo: Fafo; 2009.

Google Scholar  

Doyle M, Dolan M. Violence risk assessment: combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. J Psychiatr Ment Health Nurs. 2002;9(6):649–57.

Douglas KS, Kropp PR. A prevention-based paradigm for violence risk assessment: clinical and research applications. Criminal Justice Behav. 2002;29(5):617–58.

Skeem JL, Monahan J. Current directions in violence risk assessment. Curr Dir Psychol Sci. 2011;20(1):38–42.

Bjørkly S, Moger TA. A second step in development of a checklist for screening risk for violence in acute psychiatric patients: evaluation of interrater reliability of the preliminary scheme 33. Psychol Rep. 2007;101(3suppl):1145–61.

PubMed   Google Scholar  

Swanson JW. Preventing the unpredicted: managing violence risk in mental health care. Psychiatric Serv. 2008;59(2):191–3.

Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, et al. Preventing and de-escalating aggressive behavior among adult psychiatric patients: a systematic review of the evidence. Psychiatric Serv. 2017;68(8):819–31.

Hirsch S, Steinert T. Measures to avoid coercion in psychiatry and their efficacy. Deutsches Ärzteblatt International. 2019;116(19):336.

PubMed   PubMed Central   Google Scholar  

Abderhalden C, Needham I, Dassen T, Halfens R, Haug H-J, Fischer JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry. 2008;193(1):44–50.

van de Sande R, Nijman H, Noorthoorn E, Wierdsma A, Hellendoorn E, Van Der Staak C, et al. Aggression and seclusion on acute psychiatric wards: effect of short-term risk assessment. Br J Psychiatry. 2011;199(6):473–8.

Hvidhjelm J, Sestoft D, Skovgaard LT, Rasmussen K, Almvik R, Bue Bjorner J. Aggression in psychiatric wards: effect of the use of a structured risk assessment. Issues Ment Health Nurs. 2016;37(12):960–7.

Kleeven AT, de Vries Robbé M, Mulder EA, Popma A. Risk assessment in juvenile and young adult offenders: predictive validity of the SAVRY and SAPROF-YV. Assessment. 2022;29(2):181–97.

Borum R. Manual for the Structured Assessment of Violence Risk in Youth (SAVRY). 2006.

Hoge RD, Andrews DA. Youth level of service/case management inventory 2.0 (YLS/CMI 2.0): User’s manual. Multi-Health Systems Toronto, Ontario, Canada; 2011.

Vincent GM, Drawbridge D, Davis M. The validity of risk assessment instruments for transition-age youth. J Consult Clin Psychol. 2019;87(2):171.

Shepherd SM, Luebbers S, Ogloff JR. Are youth violence risk instruments interchangeable? Evaluating instrument convergence in a sample of incarcerated adolescent offenders. J Forensic Psychol Pract. 2014;14(4):317–41.

Hoge RD. The Youth level of service/Case management inventory. Handbook of violence risk assessment. Routledge; 2020. pp. 191–205.

Borum R, Lodewijks HP, Bartel PA, Forth AE. The structured assessment of violence risk in youth (SAVRY). Handbook of violence risk assessment. Routledge; 2020. pp. 438–61.

Connors MH, Large MM. Calibrating violence risk assessments for uncertainty. Gen Psychiatry. 2023;36(2).

Davis S. Violence by psychiatric inpatients: a review. Psychiatric Serv. 1991;42(6):585–90.

Bjørkly S, Hartvig P, Heggen F-A, Brauer H, Moger T. Development of a brief screen for violence risk (V-RISK-10) in acute and general psychiatry: an introduction with emphasis on findings from a naturalistic test of interrater reliability. Eur Psychiatry. 2009;24(6):388–94.

Rotter M, Rosenfeld B. Implementing a violence risk screening protocol in a civil psychiatric setting: preliminary results and clinical policy implications. Commun Ment Health J. 2018;54:245–51.

Anderson KK, Jenson CE. Violence risk–assessment screening tools for acute care mental health settings: literature review. Arch Psychiatr Nurs. 2019;33(1):112–9.

Roaldset JO, Gustavsen CC, Lockertsen Ø, Landheim T, Bjørkly SK. Validation of a violence risk screening for youth in psychiatric inpatient care-A pilot study of V-RISK-Y. Front Psychiatry. 2023;14:1210871.

Tinsley HE, Weiss DJ. Interrater reliability and agreement. Handbook of applied multivariate statistics and mathematical modeling: Elsevier; 2000. pp. 95–124.

McNiel DE, Lam JN, Binder RL. Relevance of interrater agreement to violence risk assessment. J Consult Clin Psychol. 2000;68(6):1111.

Douglas KS, Belfrage H. Interrater reliability and concurrent validity of the HCR-20 Version 3. Int J Forensic Mental Health. 2014;13(2):130–9.

Lodewijks HP, Doreleijers TA, De Ruiter C, Borum R. Predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) during residential treatment. Int J Law Psychiatry. 2008;31(3):263–71.

Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–63.

Koh LL, Day A, Klettke B, Daffern M, Chu CM. The predictive validity of youth violence risk assessment tools: a systematic review. Psychol Crime Law. 2020;26(8):776–96.

Gould D. Using vignettes to collect data for nursing research studies: how valid are the findings? J Clin Nurs. 1996;5(4):207–12.

Evans SC, Roberts MC, Keeley JW, Blossom JB, Amaro CM, Garcia AM, et al. Vignette methodologies for studying clinicians’ decision-making: Validity, utility, and application in ICD-11 field studies. Int J Clin Health Psychol. 2015;15(2):160–70.

Greger HK, Myhre AK, Lydersen S, Jozefiak T. Previous maltreatment and present mental health in a high-risk adolescent population. Child Abuse Negl. 2015;45:122–34.

Scurich N. An introduction to the assessment of violence risk. International perspectives on violence risk assessment. 2016:3–15.

Asparouhov T, Muthen B. Multilevel mixture models. Adv Latent Variable Mixture Models. 2008:27–51.

Vermunt JK. Mixed-effects logistic regression models for indirectly observed discrete outcome variables. Multivar Behav Res. 2005;40(3):281–301.

Bravo G, Potvin L. Estimating the reliability of continuous measures with Cronbach’s alpha or the intraclass correlation coefficient: toward the integration of two traditions. J Clin Epidemiol. 1991;44(4–5):381–90.

Hart SD, Douglas KS, Guy LS. The structured professional judgement approach to violence risk assessment: Origins, nature, and advances. The Wiley handbook on the theories, assessment and treatment of sexual offending. 2016;2:643– 66.

Skeem JL, Manchak SM, Lidz CW, Mulvey EP. The utility of patients’ self-perceptions of violence risk: consider asking the person who may know best. Psychiatric Serv. 2013;64(5):410–5.

Lockertsen Ø, Procter N, Vatnar SKB, Færden A, Eriksen BMS, Roaldset JO, et al. Screening for risk of violence using service users’ self-perceptions: a prospective study from an acute mental health unit. Int J Ment Health Nurs. 2018;27(3):1055–65.

Eriksen BMS, Bjørkly S, Færden A, Friestad C, Hartvig P, Roaldset JO. Gender differences in the predictive validity of a violence risk screening tool: a prospective study in an acute psychiatric ward. Int J Forensic Mental Health. 2016;15(2):186–97.

Roaldset JO, Hartvig P, Bjørkly S. V-RISK-10: validation of a screen for risk of violence after discharge from acute psychiatry. Eur Psychiatry. 2011;26(2):85–91.

McNiel DE, Chamberlain JR, Weaver CM, Hall SE, Fordwood SR, Binder RL. Impact of clinical training on violence risk assessment. Am J Psychiatry. 2008;165(2):195–200.

Storey JE, Gibas AL, Reeves KA, Hart SD. Evaluation of a violence risk (threat) assessment training program for police and other criminal justice professionals. Criminal Justice Behav. 2011;38(6):554–64.

Saito Y, Sozu T, Hamada C, Yoshimura I. Effective number of subjects and number of raters for inter-rater reliability studies. Stat Med. 2006;25(9):1547–60.

Eriksen BMS, Dieset I, Lockertsen Ø, Roaldset JO. The risk of not knowing–A predictive validity study of the Don’t know scores on a violence screen in acute psychiatry. Psychiatry Res Commun. 2022;2(4):100076.

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Acknowledgements

We are truly grateful for the indispensable statistical support provided by Professor Emeritus Petter Laake of the University of Oslo, Faculty of Medicine, Department of Biostatistics. Staff at all participating institutions in Norway and Sweden are thankfully acknowledged for their contributions to data collection and administration of the study.

The study is funded by Oslo University Hospital and Oslo Metropolitan University.

Open access funding provided by OsloMet - Oslo Metropolitan University

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Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway

Anniken L. W. Laake, Tonje Lossius Husum & Øyvind Lockertsen

Oslo University Hospital, Centre for Research and Education in Forensic Psychiatry, Oslo, Norway

Anniken L. W. Laake, John Olav Roaldset & Øyvind Lockertsen

Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway

Stål Kapstø Bjørkly

Department of Child and Adolescent Psychiatry, Oslo University Hospital, Oslo, Norway

Carina Chudiakow Gustavsen

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Contributions

ØL and JR were responsible for data collection. ØL, JR, CG, and SB contributed to developing the case vignettes used in the study. AL performed the data analysis and drafted the original manuscript. All authors contributed substantially to the content and revising of the manuscript.

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Correspondence to Anniken L. W. Laake .

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Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics (REK ID: 218444). Informed consent was obtained from all participants.

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Appendix: case vignettes

Case 1: farhad [ 15 ].

Farhad is referred for assessment of behavioral disorder. He struggles with schoolwork and in social interactions with peers. As a young child (6–8 years), he kicked and hit his peers, without anyone getting physically hurt. At 13, he attacked a teacher who suggested he received special education, resulting in the teacher sustaining a concussion. He is easily upset, particularly if he feels misunderstood, devalued, or struggles to express himself. At home, he spends most of his time in front of the computer. During initial contact, he seems disinterested in engaging in conversation, and is annoyed when staff asks him questions. Peers are uneasy around him. He does not understand that others get upset when he hits or kicks them, and says it’s their fault for treating him unfairly.

Case 2: Peter [ 17 ]

Peter struggles to adhere to rules and structure and demonstrates lack of respect for authorities. In school, he once lifted a teacher out of the classroom and locked the door. At home he is aggressive and destructive, and his parents often give in to what he wants out of fear that he will destroy things or hurt them. Peter describes his parents as weak. He does not get along with his peers, but has a few younger friends. He stays out late, and drinks alcohol on the weekends. He recently physically assaulted someone for calling him gay. He wants to move out from his parents house and become rich.

Case 3: Jeanette [ 15 ]

Jeanette has always been ambitious in school, but lately she’s been reluctant to go to school and her grades have dropped. Upon her parents’ separation one year ago, Jeanette started spending less time at home and started going to the mall. A few weeks ago she got drunk with her friends, and was the victim of an attempted rape. She did not tell her parents about this incident. She is normally good with her younger siblings, but recently she yelled at her little brother when he entered her room and threatened to hit him. Her mother has noticed that Jeanette has started self-harming by cutting her wrists. In the initial contact, she seems resigned, and lets her mother answer for her.

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Laake, A.L.W., Roaldset, J.O., Husum, T.L. et al. Interrater reliability of the violence risk assessment checklist for youth: a case vignette study. BMC Psychiatry 24 , 303 (2024). https://doi.org/10.1186/s12888-024-05746-8

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Received : 18 December 2023

Accepted : 08 April 2024

Published : 23 April 2024

DOI : https://doi.org/10.1186/s12888-024-05746-8

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