568227 research-article2015
APY0010.1177/1039856214568227Australasian PsychiatryWand et al.
Australasian
Psychiatry
Psychiatric services
Surveying clinician perceptions of risk assessment and management practices in mental health service provision
Australasian Psychiatry 2015, Vol 23(2) 147–153 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214568227 apy.sagepub.com
Timothy Wand Associate Professor, University of Sydney and Sydney Local Health District, Concord, NSW, and; Nurse Practitioner, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Sophie Isobel Grad Cert, Child and Family Health, Clinical Nurse Consultant, Quality and Research, Sydney Local Health District, Concord, NSW, Australia
Kate Derrick Grad Cert, Mental Health, Clinical Nurse Consultant, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Abstract Objectives: This study aimed to survey multidisciplinary mental health staff on their perceptions of risk assessment and management practices in a local health district in Sydney. Methods: The research team developed the risk assessment and management survey (RAMS) which was distributed to staff across the district from November 2013 to January 2014. Results: A total of 340 RAMS were distributed and 164 were returned (48% response rate). There was considerable agreement that risk assessment and management is essential to maintaining safety and delivering good mental health care, and respondents reported high levels of confidence in their judgement when carrying out such practices. Respondents identified organisational pressure in relation to risk assessment and management but also felt supported. However, 65% of respondents considered that there ‘is good evidence that risk assessment and management practices are effective in reducing risk in mental health care’, when this is not the case. Conclusion: The confidence that clinicians placed in risk assessment and management practices (despite an absence of evidence) is disconcerting. Given the dominance of risk assessment and management, health services mandating such practices have a duty to inform employees of the current evidence base for this approach in reducing risk. Keywords: risk assessment and management, culture of blame, risk aversion, dignity of risk, attitude of health personnel
R
isk assessment and management dominates mental health policy and practice. Such practices encompass the determination of risk factors, recording identified risks (typically documented in a pro-forma assessment), stratifying the level of risk, and re-evaluating risk on a periodic basis.1 In addition, in most jurisdictions, mental health legislation and decisions about involuntary detention are based on dangerousness criteria of risk of harm to self or others.2 However, there is growing recognition that despite the heavy influence of risk assessment and management in mental health care there is presently an absence of research evidence to support the effectiveness of this clinical framework in reducing risk.3–9 While evidently of no significant clinical value, it is argued that risk assessment and management is a form
of contemporary governance10 representing a neurotic, organisational attempt to control anxiety.11 Power describes ‘the risk management of everything’ as a response to the functional and political imperative to maintain myths of control and manageability. Professional judgement is therefore displaced by more
Corresponding author: Timothy Wand, Associate Professor, University of Sydney and Sydney Local Health District, Nurse Practitioner, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia. Email: [email protected]
147
Australasian Psychiatry 23(2)
‘defendable processes’ that aim to establish distance from the potential negative consequences of being ‘responsible and answerable’.12
further ensure anonymity of participants. Data were analysed using SPSS.
There is a vast body of literature on the topic of risk assessment and management in mental health. However, there has been little research exploring the perspectives of mental health staff in working within a risk assessment and management framework. A study involving interviews with community mental health nurses in the UK reported that participants considered risk assessment tools to be too mechanical, behaviourally reductive and dehumanising. There was also a view that formalised risk assessment and management procedures prioritised ‘safety’ and ‘avoiding blame’ over an individual’s personal development.13 In another qualitative study, multidisciplinary staff identified the purpose of risk assessment and management practices as having a ‘preventative function’ in keeping people and the community safe. Participants recognised a tension between managerial and therapeutic concerns. A tendency for risk aversion (with associated negative consequences for patients) and a ‘blame culture’ was also identified.14
Results
The risk assessment and management survey The present study involved distributing a survey across an inner city local health district in Sydney, Australia, that aimed to explore clinicians’ perceptions of working within a risk assessment and management framework. The research team developed the risk assessment and management survey (RAMS) which consisted of 16 statements derived from key words, themes and phrases distilled from the relevant literature. The RAMS development process also involved obtaining feedback from multidisciplinary colleagues and a biostatistician who examined the RAMS for face validity prior to ethics committee submission. Participants were asked to rate their level of agreement with each statement from strongly disagree to strongly agree. These statements were scored on a Likert Scale from 1 to 6, with 6 being most positive.
A total of 340 RAMS were distributed and 164 returned (48% response rate); 45% of respondents were female, 30.5% male and 23.8% did not indicate a gender. There was representation from a range of disciplines, settings and years experience (see Table 1). Just over 60% of respondents were nurses, while 15.4% were medical staff. Table 2 indicates that respondents generally agreed that risk assessment and management practices make a difference to the outcomes for consumers, and were reassured by such practices. There were also high levels of agreement that risk assessment and management is essential to maintaining safety and delivering good care. High levels of confidence in their judgement were also expressed by respondents when carrying out risk assessment and management practices. Somewhat paradoxically, respondents identified organisational pressure and a ‘culture of blame’ around risk assessment and management, and of being left to feel responsible following an adverse event, but felt supported by the mental health service. Respondents recognised consideration of the potential medico-legal ramifications for decisions made about an individual’s level of risk and a tendency to employ more coercive measures when there is uncertainty.
Discussion
Method
Findings from this short survey demonstrate that multidisciplinary staff associate risk assessment and management practices with delivering safe and effective mental health care. A high level of confidence in undertaking such practices was also evident. However, there is growing recognition that despite acknowledged risk factors for harmful acts such as suicide and violence, there is no evidence that identifying and responding to risk factors is useful in predicting, preventing or reducing risk of harm.4,6,8 Moreover, risk assessment is plagued by high rates of false-positive findings, which has implications for restrictions on individual freedom.6
Surveys were distributed from November 2013 to January 2014 by individual research team members who attended team meetings at inpatient and community health settings. Staff were briefed on the study and given an explanation of the clinical risk assessment and management practices the survey referred to. Copies of the RAMS were handed out individually. An information sheet emphasising the voluntary nature of the survey and an envelope were attached to each RAMS. Clinicians were invited to leave completed surveys in a designated envelope in a staff common area, or return surveys to the investigators via the internal mail system. All surveys were individually numbered in order to obtain a response rate, but were not distributed in numerical order to
Restrictive practices such as involuntary hospitalisation, restraint, sedation and seclusion pose competing risks, placing both patients and staff at risk of injury. Perceptions of coercion also have a negative impact on individual experiences of mental health care,15 and as a consequence of such practices people are less likely to access services out of fear of coercion.16 Given that the risk assessment tools that clinicians are required to use when making decisions about the level of intervention are without an established evidence base, patients and clinicians are potentially being placed at unnecessary risk of injury. Work health and safety laws require organisations to provide information, training and uphold the safety and wellbeing of employees. Health services
148
Wand et al.
Table 1. Characteristics of RAMS respondents (n=164) Gender
%(N)
Male Female
40 (50) 60(75)
Occupation
%(N)
Occupational therapist Psychologist Psychiatry registrar Psychiatry consultant Registered nurse Nurse specialist Nurse consultant Social worker Other
3 (5) 7 (11) 6 (10) 9 (15) 57 (91) 3 (4) 3 (5) 9 (14) 3 (5)
Area of practice
% (N)
Community Consultation-liaison Inpatient Community/inpatient split
46 (65) 6 (9) 43 (61) 5 (7)
own interests over the welfare of patients. The absence of any certainty around the assessment of risk also questions the validity of the dangerousness criteria and preventative detention mechanisms embedded within current mental health legislation.2,8 A blame culture is a prominent theme in the research and discourse around risk assessment and management in mental health, and this theme was met with significant levels of agreement from respondents. As an example, a UK Royal College of Psychiatrists report titled Rethinking risk to others raised concerns about a culture of blame and the proliferation of invalidated tick box assessment forms that are produced as a means of ‘back covering’ and that represent ‘a lazy and authoritarian approach to delivering health care’.16 This reinforces the proposition that risk assessment and management practices are a form of secondary risk management, whereby policies and processes are instituted at the organisational level to create a perception of control, to avoid responsibility and protect reputations.10–12 Undrill argues that risk in mental health has become a contemporary form of stigma through its association with dangerousness.11 Conversely, rather than viewing risk negatively, there is recognition that therapeutic or positive risk-taking13 and allowing individuals the ‘dignity of risk’ is an important component of the recovery process.8
Limitations
Years working in mental health Range Mean Median
0.5–50 12 8
Missing demographic data
% (N)
Gender Profession Years of practice Area of practice
24 (39) 2 (4) 40 (60) 13 (22)
therefore have a duty to inform clinicians regarding the lack of available evidence for risk assessment and management practices, due to the influence this has on clinical decision making and the subsequent safety implications. The lack of foreseeability and the fluctuating nature of risk is manifest in the level of agreement from respondents to the RAMS that medication, hospitalisation and Mental Health Act certification are often utilised when there is uncertainty about an individual’s perceived risk. This, coupled with the high number of respondents who agreed that they reflect on the potential medico-legal ramifications, indicates that clinicians are routinely placed in the position where they are shouldered with the dilemma of choosing between the protection of their
This was a small study conducted across one health service and the response rate was modest. However, to the best of our knowledge this is the only published study to have surveyed clinicians’ perceptions of working within a risk assessment and management framework.
Conclusion Evidence-based practice is central to contemporary healthcare delivery. Disconcertingly, despite an absence of evidence, risk assessment and management practices dominate mental health service provision and consume considerable time and resources. Mental health clinicians are therefore presently required to make decisions about how to respond to the assessment of risk from an inherently flawed approach. The lack of any real certainty around risk of harm has the potential to lead to the greater use of restrictive interventions, which places patients and staff at increased risk of injury. It also risks individuals avoiding healthcare out of fear of coercion. Under current work health safety principles, health services therefore have a duty to inform clinicians that they are working within a framework for which there is no evidence base. Assessing an individual’s clinical circumstances is undoubtedly an important task, but the present preoccupation with the negative connotation of risk inhibits the establishment of positive working relationships between clinicians and consumers and is inconsistent with the promotion of recovery.
149
Australasian Psychiatry 23(2)
Table 2. Findings from the risk assessment and management survey (RAMS) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
1. The risk assessment forms and tools we are provided with make a discernable difference to the outcomes for consumers. 2. Risk assessment and management practices provide me with reassurance that risk has been adequately addressed. 3. Risk assessment and management is essential for maintaining safety of consumers and staff. 4. I have confidence in my judgement when carrying out risk assessment and management practices. 5. Assessing and managing risk makes me nervous. 6. I worry about the decisions I have made about an individual’s level of risk, even after I have finished work for the day.
23.3 42.4%
11.0
27.0
23.9 57.6%
6.7
18.9 35.4%
9.8
25.6
29.3 64%
9.1
0.6
3.8 4 1.449
3.7 8.6%
3.7
9.8
25.0 90.9%
56.1
0.6
5.2 6 1.136
5.5 9.1%
3.0
16.5
48.8 89.7%
24.4
1.2
4.8 5 1.055
18.9 50.7%
15.9
27.4
18.9 49.3%
3.0
3.2 3 1.444
17.7 46.4%
11.6
31.7
17.6 53.6%
4.3
3.3 4 1.484
8.0
*
3.6 4 1.445
6.7
1.2
0.6
15.9 17.1
Mean median SD
(Continued)
150
Wand et al.
Table 2. (Continued) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
7. I often reflect on the potential medico-legal ramifications for me with the decisions I make about an individual’s level of risk 8. There is organisational pressure around the assessment and management of risk. 9. A culture of blame exists around the assessment and management of risk in mental health services. 10. I feel supported by the mental health service in decisions I make about risk. 11. Following an adverse event mental health staff are left feeling responsible for inaccurate assessment and management of risk. 12. Mental health staff resort to increased medication administration when there is uncertainty about an individual’s level of risk.
11.6 28%
10.4
30.5
22.0 72%
19.5
4.3 12.2%
6.7
19.5
34.2 87.2%
33.5
0.6
4.8 5 1.168
9.1 26.8%
12.8
26.2
29.3 72%
16.5
1.2
4.2 4 1.375
9.8 22.6%
11.0
32.3
36.0 76.2%
7.9
1.2
4.2 4 1.158
7.9 28%
14.0
31.2
27.4 71.4%
12.8
0.6
4.0 4 1.346
12.8 34.8%
17.7
25.0
32.9 64%
6.1
1.2
3.9 4 1.290
6.1
*
4.1 4 1.456
1.2
4.9
1.8
6.1
4.3
Mean median SD
(Continued) 151
Australasian Psychiatry 23(2)
Table 2. (Continued) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
*
Mean median SD
13. Mental health staff are inclined to use hospitalisation in response to uncertainty about an individual’s level of risk. 14. Mental health staff are inclined to use Mental Health Act certification and community treatment orders in response to uncertainty about an individual’s level of risk. 15. There is good evidence that risk assessment and management practices are effective in reducing risk in mental health care. 16. Risk assessment and management is central to the delivery of good mental health care.
9.1 25%
12.2
23.2
36.6 74.4%
14.6
0.6
4.2 5 1.315
10.4 26.9%
12.8
32.9
25.6 72.5%
14.0
0.6
4.1 4 1.304
12.2 33.5%
14.0
21.4
25.6 65.3%
18.3
1.2
4.0 4 1.522
5.5
8.5
17.1
28.0
37.2
3.7
3.7
7.3
3.7
17.7%
82.3%
4.7 5 1.377
*Missing values.
Disclosure
References
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
1. Holmes A. Is risk assessment the new clinical model in public mental health? Australas Psychiatry 2014; 22: 307–308.
Ethical considerations
2. Large M, Ryan CJ, Nielssen OB, et al. The danger of dangerousness: Why we must remove the dangerousness criterion from our mental health system. J Med Ethics 2008; 34: 877–881.
Ethical approval for the study was obtained from the local health district human research ethics committee.
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Wand et al. 3. Large M, Sharma S, Cannon E, et al. Risk factors for suicide within a year of discharge from psychiatric hospital: A systematic meta-analysis. Aust NZ J Psychiatry 2011; 45: 619–628. 4. Large M and Ryan C. Suicide risk assessment: Myth and reality. Int J Clin Pract 2014; 68: 679–681. 5. Paton MB, Large M and Ryan C. Debate: Clinical risk categorisation is valuable in prevention of suicide and violence-No. Australas Psychiatry 2014; 22: 10–12. 6. Ryan C, Nielssen O, Paton M, et al. Clinical decisions in psychiatry should not be based on risk assessment. Australas Psychiatry 2010; 18: 398–403. 7. Troquete NAC, Van den Brink RHS, Beintema H, et al. Risk assessment and shared care planning in out-patient forensic psychiatry: Cluster randomised controlled trial. Br J Psychiatry 2013; 202: 365–371. 8. Wand T. Investigating the evidence for the effectiveness of risk assessment in mental health care. Issues Mental Health Nurs 2012; 33: 2–7. 9. Wand T and Large M. Evidence is lacking for the usefulness of violence risk assessment. Br J Psychiatry 2013; 202: 468.
10. Crowe M and Carlyle D. Deconstructing risk assessment and management in mental health nursing. J Adv Nurs 2003; 43: 19–27. 11. Undrill G. The risks of risk assessment. Adv Psychiatr Treat 2007; 13: 291–297. 12. Power M. The risk management of everything. Rethinking the politics of uncertainty. London: Demos, 2004. 13. Godwin PM. ‘You don’t tick boxes on a form’: A study of how community mental health nurses assess and manage risk. Health Risk Soc 2004; 6: 347–360. 14. Muir-Cochrane E, Gerace A, Mosel K, et al. Managing risk: Clinical decision-making in mental health services. Issues Mental Health Nurs 2011; 32: 726–734. 15. Katsakou C, Bowers L, Amos T, et al. Coercion and treatment satisfaction among involuntary patients. Psychiatr Serv 2010; 61: 286–292. 16. Royal College of Psychiatrists. Rethinking risk to others in mental health services. Final Report of a Scoping Group. London: Royal College of Psychiatrists, 2008.
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APY0010.1177/1039856214568227Australasian PsychiatryWand et al.
Australasian
Psychiatry
Psychiatric services
Surveying clinician perceptions of risk assessment and management practices in mental health service provision
Australasian Psychiatry 2015, Vol 23(2) 147–153 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214568227 apy.sagepub.com
Timothy Wand Associate Professor, University of Sydney and Sydney Local Health District, Concord, NSW, and; Nurse Practitioner, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Sophie Isobel Grad Cert, Child and Family Health, Clinical Nurse Consultant, Quality and Research, Sydney Local Health District, Concord, NSW, Australia
Kate Derrick Grad Cert, Mental Health, Clinical Nurse Consultant, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Abstract Objectives: This study aimed to survey multidisciplinary mental health staff on their perceptions of risk assessment and management practices in a local health district in Sydney. Methods: The research team developed the risk assessment and management survey (RAMS) which was distributed to staff across the district from November 2013 to January 2014. Results: A total of 340 RAMS were distributed and 164 were returned (48% response rate). There was considerable agreement that risk assessment and management is essential to maintaining safety and delivering good mental health care, and respondents reported high levels of confidence in their judgement when carrying out such practices. Respondents identified organisational pressure in relation to risk assessment and management but also felt supported. However, 65% of respondents considered that there ‘is good evidence that risk assessment and management practices are effective in reducing risk in mental health care’, when this is not the case. Conclusion: The confidence that clinicians placed in risk assessment and management practices (despite an absence of evidence) is disconcerting. Given the dominance of risk assessment and management, health services mandating such practices have a duty to inform employees of the current evidence base for this approach in reducing risk. Keywords: risk assessment and management, culture of blame, risk aversion, dignity of risk, attitude of health personnel
R
isk assessment and management dominates mental health policy and practice. Such practices encompass the determination of risk factors, recording identified risks (typically documented in a pro-forma assessment), stratifying the level of risk, and re-evaluating risk on a periodic basis.1 In addition, in most jurisdictions, mental health legislation and decisions about involuntary detention are based on dangerousness criteria of risk of harm to self or others.2 However, there is growing recognition that despite the heavy influence of risk assessment and management in mental health care there is presently an absence of research evidence to support the effectiveness of this clinical framework in reducing risk.3–9 While evidently of no significant clinical value, it is argued that risk assessment and management is a form
of contemporary governance10 representing a neurotic, organisational attempt to control anxiety.11 Power describes ‘the risk management of everything’ as a response to the functional and political imperative to maintain myths of control and manageability. Professional judgement is therefore displaced by more
Corresponding author: Timothy Wand, Associate Professor, University of Sydney and Sydney Local Health District, Nurse Practitioner, Mental Health Liaison, Emergency Department, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia. Email: [email protected]
147
Australasian Psychiatry 23(2)
‘defendable processes’ that aim to establish distance from the potential negative consequences of being ‘responsible and answerable’.12
further ensure anonymity of participants. Data were analysed using SPSS.
There is a vast body of literature on the topic of risk assessment and management in mental health. However, there has been little research exploring the perspectives of mental health staff in working within a risk assessment and management framework. A study involving interviews with community mental health nurses in the UK reported that participants considered risk assessment tools to be too mechanical, behaviourally reductive and dehumanising. There was also a view that formalised risk assessment and management procedures prioritised ‘safety’ and ‘avoiding blame’ over an individual’s personal development.13 In another qualitative study, multidisciplinary staff identified the purpose of risk assessment and management practices as having a ‘preventative function’ in keeping people and the community safe. Participants recognised a tension between managerial and therapeutic concerns. A tendency for risk aversion (with associated negative consequences for patients) and a ‘blame culture’ was also identified.14
Results
The risk assessment and management survey The present study involved distributing a survey across an inner city local health district in Sydney, Australia, that aimed to explore clinicians’ perceptions of working within a risk assessment and management framework. The research team developed the risk assessment and management survey (RAMS) which consisted of 16 statements derived from key words, themes and phrases distilled from the relevant literature. The RAMS development process also involved obtaining feedback from multidisciplinary colleagues and a biostatistician who examined the RAMS for face validity prior to ethics committee submission. Participants were asked to rate their level of agreement with each statement from strongly disagree to strongly agree. These statements were scored on a Likert Scale from 1 to 6, with 6 being most positive.
A total of 340 RAMS were distributed and 164 returned (48% response rate); 45% of respondents were female, 30.5% male and 23.8% did not indicate a gender. There was representation from a range of disciplines, settings and years experience (see Table 1). Just over 60% of respondents were nurses, while 15.4% were medical staff. Table 2 indicates that respondents generally agreed that risk assessment and management practices make a difference to the outcomes for consumers, and were reassured by such practices. There were also high levels of agreement that risk assessment and management is essential to maintaining safety and delivering good care. High levels of confidence in their judgement were also expressed by respondents when carrying out risk assessment and management practices. Somewhat paradoxically, respondents identified organisational pressure and a ‘culture of blame’ around risk assessment and management, and of being left to feel responsible following an adverse event, but felt supported by the mental health service. Respondents recognised consideration of the potential medico-legal ramifications for decisions made about an individual’s level of risk and a tendency to employ more coercive measures when there is uncertainty.
Discussion
Method
Findings from this short survey demonstrate that multidisciplinary staff associate risk assessment and management practices with delivering safe and effective mental health care. A high level of confidence in undertaking such practices was also evident. However, there is growing recognition that despite acknowledged risk factors for harmful acts such as suicide and violence, there is no evidence that identifying and responding to risk factors is useful in predicting, preventing or reducing risk of harm.4,6,8 Moreover, risk assessment is plagued by high rates of false-positive findings, which has implications for restrictions on individual freedom.6
Surveys were distributed from November 2013 to January 2014 by individual research team members who attended team meetings at inpatient and community health settings. Staff were briefed on the study and given an explanation of the clinical risk assessment and management practices the survey referred to. Copies of the RAMS were handed out individually. An information sheet emphasising the voluntary nature of the survey and an envelope were attached to each RAMS. Clinicians were invited to leave completed surveys in a designated envelope in a staff common area, or return surveys to the investigators via the internal mail system. All surveys were individually numbered in order to obtain a response rate, but were not distributed in numerical order to
Restrictive practices such as involuntary hospitalisation, restraint, sedation and seclusion pose competing risks, placing both patients and staff at risk of injury. Perceptions of coercion also have a negative impact on individual experiences of mental health care,15 and as a consequence of such practices people are less likely to access services out of fear of coercion.16 Given that the risk assessment tools that clinicians are required to use when making decisions about the level of intervention are without an established evidence base, patients and clinicians are potentially being placed at unnecessary risk of injury. Work health and safety laws require organisations to provide information, training and uphold the safety and wellbeing of employees. Health services
148
Wand et al.
Table 1. Characteristics of RAMS respondents (n=164) Gender
%(N)
Male Female
40 (50) 60(75)
Occupation
%(N)
Occupational therapist Psychologist Psychiatry registrar Psychiatry consultant Registered nurse Nurse specialist Nurse consultant Social worker Other
3 (5) 7 (11) 6 (10) 9 (15) 57 (91) 3 (4) 3 (5) 9 (14) 3 (5)
Area of practice
% (N)
Community Consultation-liaison Inpatient Community/inpatient split
46 (65) 6 (9) 43 (61) 5 (7)
own interests over the welfare of patients. The absence of any certainty around the assessment of risk also questions the validity of the dangerousness criteria and preventative detention mechanisms embedded within current mental health legislation.2,8 A blame culture is a prominent theme in the research and discourse around risk assessment and management in mental health, and this theme was met with significant levels of agreement from respondents. As an example, a UK Royal College of Psychiatrists report titled Rethinking risk to others raised concerns about a culture of blame and the proliferation of invalidated tick box assessment forms that are produced as a means of ‘back covering’ and that represent ‘a lazy and authoritarian approach to delivering health care’.16 This reinforces the proposition that risk assessment and management practices are a form of secondary risk management, whereby policies and processes are instituted at the organisational level to create a perception of control, to avoid responsibility and protect reputations.10–12 Undrill argues that risk in mental health has become a contemporary form of stigma through its association with dangerousness.11 Conversely, rather than viewing risk negatively, there is recognition that therapeutic or positive risk-taking13 and allowing individuals the ‘dignity of risk’ is an important component of the recovery process.8
Limitations
Years working in mental health Range Mean Median
0.5–50 12 8
Missing demographic data
% (N)
Gender Profession Years of practice Area of practice
24 (39) 2 (4) 40 (60) 13 (22)
therefore have a duty to inform clinicians regarding the lack of available evidence for risk assessment and management practices, due to the influence this has on clinical decision making and the subsequent safety implications. The lack of foreseeability and the fluctuating nature of risk is manifest in the level of agreement from respondents to the RAMS that medication, hospitalisation and Mental Health Act certification are often utilised when there is uncertainty about an individual’s perceived risk. This, coupled with the high number of respondents who agreed that they reflect on the potential medico-legal ramifications, indicates that clinicians are routinely placed in the position where they are shouldered with the dilemma of choosing between the protection of their
This was a small study conducted across one health service and the response rate was modest. However, to the best of our knowledge this is the only published study to have surveyed clinicians’ perceptions of working within a risk assessment and management framework.
Conclusion Evidence-based practice is central to contemporary healthcare delivery. Disconcertingly, despite an absence of evidence, risk assessment and management practices dominate mental health service provision and consume considerable time and resources. Mental health clinicians are therefore presently required to make decisions about how to respond to the assessment of risk from an inherently flawed approach. The lack of any real certainty around risk of harm has the potential to lead to the greater use of restrictive interventions, which places patients and staff at increased risk of injury. It also risks individuals avoiding healthcare out of fear of coercion. Under current work health safety principles, health services therefore have a duty to inform clinicians that they are working within a framework for which there is no evidence base. Assessing an individual’s clinical circumstances is undoubtedly an important task, but the present preoccupation with the negative connotation of risk inhibits the establishment of positive working relationships between clinicians and consumers and is inconsistent with the promotion of recovery.
149
Australasian Psychiatry 23(2)
Table 2. Findings from the risk assessment and management survey (RAMS) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
1. The risk assessment forms and tools we are provided with make a discernable difference to the outcomes for consumers. 2. Risk assessment and management practices provide me with reassurance that risk has been adequately addressed. 3. Risk assessment and management is essential for maintaining safety of consumers and staff. 4. I have confidence in my judgement when carrying out risk assessment and management practices. 5. Assessing and managing risk makes me nervous. 6. I worry about the decisions I have made about an individual’s level of risk, even after I have finished work for the day.
23.3 42.4%
11.0
27.0
23.9 57.6%
6.7
18.9 35.4%
9.8
25.6
29.3 64%
9.1
0.6
3.8 4 1.449
3.7 8.6%
3.7
9.8
25.0 90.9%
56.1
0.6
5.2 6 1.136
5.5 9.1%
3.0
16.5
48.8 89.7%
24.4
1.2
4.8 5 1.055
18.9 50.7%
15.9
27.4
18.9 49.3%
3.0
3.2 3 1.444
17.7 46.4%
11.6
31.7
17.6 53.6%
4.3
3.3 4 1.484
8.0
*
3.6 4 1.445
6.7
1.2
0.6
15.9 17.1
Mean median SD
(Continued)
150
Wand et al.
Table 2. (Continued) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
7. I often reflect on the potential medico-legal ramifications for me with the decisions I make about an individual’s level of risk 8. There is organisational pressure around the assessment and management of risk. 9. A culture of blame exists around the assessment and management of risk in mental health services. 10. I feel supported by the mental health service in decisions I make about risk. 11. Following an adverse event mental health staff are left feeling responsible for inaccurate assessment and management of risk. 12. Mental health staff resort to increased medication administration when there is uncertainty about an individual’s level of risk.
11.6 28%
10.4
30.5
22.0 72%
19.5
4.3 12.2%
6.7
19.5
34.2 87.2%
33.5
0.6
4.8 5 1.168
9.1 26.8%
12.8
26.2
29.3 72%
16.5
1.2
4.2 4 1.375
9.8 22.6%
11.0
32.3
36.0 76.2%
7.9
1.2
4.2 4 1.158
7.9 28%
14.0
31.2
27.4 71.4%
12.8
0.6
4.0 4 1.346
12.8 34.8%
17.7
25.0
32.9 64%
6.1
1.2
3.9 4 1.290
6.1
*
4.1 4 1.456
1.2
4.9
1.8
6.1
4.3
Mean median SD
(Continued) 151
Australasian Psychiatry 23(2)
Table 2. (Continued) Statements Disagree about risk strongly=1 assessment and management
Disagree Disagree a Agree a somewhat=2 little=3 little=4
Agree Agree somewhat=5 strongly=6
*
Mean median SD
13. Mental health staff are inclined to use hospitalisation in response to uncertainty about an individual’s level of risk. 14. Mental health staff are inclined to use Mental Health Act certification and community treatment orders in response to uncertainty about an individual’s level of risk. 15. There is good evidence that risk assessment and management practices are effective in reducing risk in mental health care. 16. Risk assessment and management is central to the delivery of good mental health care.
9.1 25%
12.2
23.2
36.6 74.4%
14.6
0.6
4.2 5 1.315
10.4 26.9%
12.8
32.9
25.6 72.5%
14.0
0.6
4.1 4 1.304
12.2 33.5%
14.0
21.4
25.6 65.3%
18.3
1.2
4.0 4 1.522
5.5
8.5
17.1
28.0
37.2
3.7
3.7
7.3
3.7
17.7%
82.3%
4.7 5 1.377
*Missing values.
Disclosure
References
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
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Ethical considerations
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