Risk assessment and risk management: Developing a model of ...

Copyright © eContent Management Pty Ltd. Advances in Mental Health (2013) 11(2): 157–162.

Risk assessment and risk management: Developing a model of shared learning in clinical practice KATE DEUTER*, PHILIP GALLEY+, ANDREW CHAMPION!, ANDREA GORDON#, TONY HALCZUK**, ADRIAN JACKSON++, ANNETTE JONES##, LESLEY LEGG!, JULIE MURISON!!, CONRAD NEWMAN***, NICHOLAS PROCTER* AND PENNY WILLIAMSON* *School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; +Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local, Bedford Park, SA, Australia; !Southern Mental Health, Southern Adelaide Local Health Network, Bedford Park, SA, Australia; #School of Nursing and Midwifery, Division of Health Sciences, Sansom Institute for Medical Research, University of South Australia, Adelaide, SA, Australia; **Mental Health Triage Service, Adelaide Metro Mental Health Service, Eastwood, SA, Australia; ++Hallet Team, Eastern Community Mental Health Centre, Eastern Mental Health Service, Tranmere, SA, Australia; !!Eastern Assessment Crisis Intervention Service (EACIS), Eastern Mental Health Services, College Park, SA, Australia; ##Safety and Quality Unit, Mental Health Services, Glenside, SA, Australia; ***Department of Psychiatry, Flinders University, Bedford Park, SA, Australia

Abstract: Effective risk assessment and risk management is an important component of clinical mental health practice and is vital to people in crisis and at risk of an adverse outcome. This discussion paper reflects on key findings from a symposium addressing clinical risk assessment and risk management processes and methods. The focus of the symposium centred on the importance of shared learning in clinical practice to enable practitioners to reflect and learn from one another in relation to the complexities of modern-day mental health practice and the implications of the various mental health reform agendas to the provision of clinical care and treatment. The symposium provided an opportunity for clinicians to critically present and discuss risk assessment and risk management practices in an endeavour to develop a systematic approach to the effective assessment and management of suicide, aggression and violence in a range of mental health settings. Key findings from the symposium are discussed against a backdrop of contemporary literature in the field and form a practical framework for the assessment and management of risk regarding suicide, aggression and violence.

Keywords: risk assessment, risk management, clinical practice, suicide, aggression, violence

D

espite extensive research conducted to date, risk remains a poorly defined and understood concept in mental health (Pfohl, 1978; Rose, 1998; Woods, 2012). Within mental health practice, risk has been associated with the notion of ‘dangerousness’ (Crichton, 2001) and is applied across multiple contexts such as suicide, aggression and violence (Woods, 2012). One of the prime requirements of mental health services, particularly in recent years has been the assessment and safe management of risk behaviours such as self-harm, substance abuse and violent behaviour (Lamont & Brunero, 2009). Generally there appears to be agreement that consumers’ risk behaviours should be assessed and managed as clinically indicated (Coffey, 2009). Risk assessment methodology is an expanding contemporary area of practice with a focus on concepts of validity and reliability (Kettles, 2004). Such concepts

whilst important do not however sit alone in the risk assessment and management sphere. Other, perhaps less publicised issues such as the health risks faced by mental health consumers resulting from metabolic syndrome and polypharmacy are critical considerations for clinicians. So too, how people’s lives are affected by receiving mental health treatment is also pivotal to the way clinicians think about their approach to risk and care delivery. A shift towards community mental health care presents new challenges in the assessment and management of ongoing risk behaviours of people who may be seen as ‘unpredictable’ and ‘dangerous’ to themselves and others (Coffey, 2009; Lamont & Brunero, 2009). Concurrently, suicide has emerged as a particularly significant aspect of risk assessment and management. Approaches to risk assessment appear to be divided between

Volume 11, Issue 2, February 2013

ADVANCES IN MENTAL HEALTH

157

Kate Deuter et al.

what is seen as heuristic and unstructured clinical judgement, versus a structured clinical judgement approach. A major problem that remains for clinicians is the dichotomous view taken of risk assessment and risk management, where many clinicians appear to view the completion of a risk assessment as a complete process, as opposed to its part within a dynamic formulation approach to managing risk. The Royal College of Psychiatrists (2008) suggest that in clinical practice the relationship between risk assessment and risk management is limited and that the translation from assessment to a formalised plan is lacking. They further suggest that there is a burgeoning culture of ‘file and forget’ in risk assessment and risk management which would suggest that the benefits to the consumer are not evident. This may be in part due to governance that an assessment is completed, but little governance of what happens following this. Throughout the risk management process clinicians need to move dynamically and collaboratively from assessment to formulation of assessment, to management interventions and monitoring, potentially returning to assessment to form fresh judgement, to make new formulations and interventions dependent on the variables that are presented to the clinical scenario; all of which may affect the risk potential. As new dynamic variables materialise, the course of the risk management process can alter. A practice of continuous, collaborative review and monitoring is essential to the risk management process. Risk management plans are often documented in clinical files, to be quickly superseded by new information that arrives through various sources. This often requires changes to the plan, a source of tension for clinicians with competing demands, leaving them understandably vulnerable to criticism when things go wrong. In an attempt to further investigate and address these issues, the Shared Learning in Clinical Practice Team was formed, and a Risk Assessment and Risk Management Symposium was planned and conducted. FORMULATION OF THE GROUP AND SYMPOSIUM Collaboration was formed between members of the University of South Australia’s (UniSA) Mental Health and Substance Abuse Research

158


Group, and the South Australian Department of Health’s Acute Unit Matters. The Acute Unit Matters initiative commenced in August 2009 with the aim of strengthening the capacity of acute units, psychiatric intensive care and new Intermediate Care Centres, to provide care and treatment to those consumers who are most unwell, by focussing on seven ‘acute priority areas’: use of outcome measures; induction, capability and competence; supporting reform; assessment and care planning; stepping up and stepping down; working with comorbidities and, funding for innovation. The scope of the initiative was broadened in early 2011 to include community-based acute services, given their integral role in consumer and carers’ experience of acute care. Convenors of these two groups then formed a planning team consisting of researchers from UniSA and interested clinicians (psychiatrists, nurses and social workers) from SA Health to form the Shared Learning in Clinical Practice Team. The Risk Assessment and Risk Management Symposium was held in March 2011 in response to an expressed overwhelming need from clinicians within South Australian mental health services for such events and initiatives to share key learning in practice strategies. The day was broadly separated into two themes: (i) what we have learnt about risk assessment and management when there are less than desirable outcomes; and (ii) what we have learnt about risk assessment and management when there are positive outcomes. One hundred and twenty people attended the symposium and comprised a range of front-line mental health clinicians and practitioners. Key speakers included the Deputy State Coroner and the Chairperson of Suicide Prevention Australia, who spoke on crisis response and the role of emergency services and first responders to suicide and suicide attempts. A keynote address by a senior South Australian forensic psychiatrist also outlined a view of risk assessment and management. Other topics presented included adverse and sentinel events, consumer and carer engagement, emergency departments, services for older people, challenges of cultural competency in suicide risk assessment, rural and remote mental health services, the role


© eContent Management Pty Ltd

Risk assessment and risk management

of local hospitals and mental health telephone triage services. A panel discussion was undertaken at the conclusion of each of the two sessions that included speakers from the respective sessions, as well as two mental health consumers to allow audience members to pose risk assessment and risk management questions with a process enquiry emphasis. Attendees were invited to reflect on their experience of the symposium via completion of an anonymous evaluation form. The following clinical practice recommendations are drawn from the relevant key points and reflections of both symposium presenters and attendees and are framed within contemporary thinking in the field. CLINICAL PRACTICE RECOMMENDATIONS Diagnosis and treatment in the context of engagement … today’s symposium has made me re-think very differently about how I not only assess, but engage clients in a different manner. I hope that in the future I can do better and more aware and useful risk assessments … (Attendee)

There are numerous reasons why we undertake risk assessment – outcomes of adverse event reviews, a method of communicating to others, or as a framework to assist in countering ‘heuristic biases’ (errors of judgement or cognitive shortcuts to which all human decision making is prone). Too often though, our focus in mental health is narrowed by thinking of risk rather than of the holistic care and engagement, collaboration, therapy, and addressing social and other stressors. Our current focus is one of ‘surveillance’ – of involuntary treatment, observation and medication. Overwhelmingly, feedback from the symposium attendees acknowledged the usefulness of the clinical information presented, in particular messages communicating that risk assessment and risk management are not just about risk of harm to self or others – but developing a therapeutic relationship with the consumer through engagement. Importantly, this information was seen as highly applicable to everyday practice. Methods of consumer engagement in acute psychiatric care have come under intense scrutiny in recent times in order


for optimal care and recovery-based treatment to be achieved. This has led to various ways to improve clinical assessment and therapeutic engagement in mental health settings. Engagement has long been cited as a crucial component of mental health practice. It involves healthcare professionals spending quality time with consumers and aims to empower them to actively participate in their care (Pereira & Woollaston, 2007). Evidence however reveals the limited input consumers and carers have in managing their risk (Langan, 2008). It has also been identified that consumers reject service based on lack of therapeutic engagement from clinicians. This then raises the question ‘how do clinicians engage consumers, even those who are reluctant to engage, in order to facilitate face-to-face assessment and assess risk?’ The Aeschi Working Group is an international collaboration of mental health clinicians and researchers dedicated to improving clinical suicide prevention by developing and promoting patientoriented models of understanding suicidal behaviour. It is widely accepted that the most important clinical aspect of reducing potential danger and risk is to make an accurate diagnosis of the psychiatric problem and institute timely and adequate treatment. This is also echoed in the Aeschi Working Group Guidelines for Clinicians (2011) which states ‘a psychiatric diagnosis is an integral part of the assessment interview and must adequately be taken into consideration in the planning of further management of the patient’. However, the group have argued that current emergency room and clinic approaches to suicidal patients are too ‘unempathic’ and (therefore) unhelpful to succeed in ‘drawing out patient’s accounts of extreme pain and suffering in such a way so that the nature of their experience becomes clear and a therapeutic alliance established’. In response, they propose a number of key principles to assist the clinician in risk assessment and risk management within the context of forming a therapeutic alliance with the suicidal person: (i) The clinician’s task is to reach, together with the patient, a shared understanding of the patient’s suicidality; (ii) The clinician should be aware that most suicidal patients suffer from a state of mental pain or anguish and a total loss of self-respect;



159

Kate Deuter et al.

(iii) The interviewer’s attitude should be nonjudgemental and supportive; (iv) The interview should start with the patient’s self-narrative; (v) The ultimate goal must be to engage the patient in a therapeutic relationship. Thus, future models are needed to conceptualise suicidal behaviour via a framework that enables the patient and clinician to reach a shared understanding of the patient’s suicidality. These guiding principles resonated with the clinicians of the Shared Learning in Clinical Practice Team. A consensus opinion was that these principles should be incorporated into clinical practice in South Australia’s mental health system. It’s not just about likelihood … thinking about concurrent levels of risk and the clarity of risk. The overall risk could remain high while the day to day risk might be low … (Attendee)

A common mistake in assessing risk is to simply look at the ‘likelihood’ of a person acting in a dangerous manner. To some extent, the prediction of the likelihood of harm and injury is a core activity of risk assessment (Millar & Sands, 2012). However, a thorough assessment includes consideration of other factors including imminence (how soon they are likely to act), magnitude (how serious are the likely consequences if they do act), and frequency (how often they are likely to act in a dangerous manner). Scott and Resnick (2006) offer a useful framework for conducting a violence risk assessment by dividing the concept of ‘dangerousness’ into the following five components: (i) the magnitude of potential harm that is threatened; (ii) the likelihood that a violent act will occur (here they argue it is important to ‘clarify the seriousness of the person’s intent to cause harm. A person’s past history of acting on violent thoughts is the best predictor that the violent intentions will be undertaken’); (iii) the imminence of the harm (i.e., is the person threatening harm in the next 10 hours or the next 10 days?); (iv) the frequency of behaviour (defined as the number of times a particular act has occurred over a specified period of time – the greater the frequency of an aggressive

160


act, the higher the risk that the behaviour will reoccur in the future); and (v) situational factors that increase the risk of future violence (e.g., association with a criminally offending peer group, lack of financial resources and housing, easy access to weapons, and exposure to alcohol or illicit substances) (Scott & Resnick, 2006, p. 599). Norko and Baranoski (2005) also add that imminent risk of violence may be more closely aligned with acute psychiatric symptoms, while longer-term risk has a stronger association with historical variables. Get it ‘Write’ … to think, learn and listen – review my practice and that of our team, it’s not just another piece of paper to fill out … (Attendee) … noting that the understanding of the integrity of what risk management is about has been somewhat lost (‘show your working out’) with many clinicians as they translate it to filling in a form as a task … (Attendee)

Completing a risk assessment form does not of itself improve consumer care if it does not inform risk management. It is important to not only document findings and recommendations, but also to document the ‘thinking’ and ‘reasoning’ behind opinions. Simply stating ‘low suicide risk’ without explaining how that judgement was made is insufficient. Clinicians should document a reasonable and complete thought process and clinical considerations – in addition to a final decision (Simpson & Stacy, 2004). Simon (2009) highlights an absence of the process of analysis and synthesis in completing suicide risk assessment forms. It is critical therefore, that clinicians document in a way that others will understand how such a conclusion was reached. This can be achieved by identifying, prioritising and integrating risk and protective factors into an overall assessment of a person’s suicide risk (Simon, 2009). Who are you trying to protect? … focus on the client and how/why he/she needs protecting is best practice so keep doing what we are doing and build on this … (Attendee)

Risk assessment and risk management have emerged as highly ‘anxiogenic’ for those carrying



Risk assessment and risk management

it out (Undrill, 2007; Weintraub Brendel, Wei, & Edersheim, 2010). Such anxiety can result in behavioural changes in those conducting an assessment, even leading to unintended adverse outcomes for consumers. At worst, behavioural change manifests as ‘expert judgement (which) shrinks to an empty form of dependable compliance’ (Undrill, 2007, p. 294). Risk should primarily (but not exclusively) be viewed in terms of risk faced by the consumer (Mulder, 2011). This then makes way for a consensual process; one in which the consumer and clinician work side-by-side towards a shared understanding and management of risk. Risk assessments are valuable; however, they are also vulnerable professional decisions in the face of uncertainty (Undrill, 2007). Furthermore, potentially dangerous people can engender strong emotional reactions in others. Mental health workers have a responsibility to monitor their own reactions. Rather than be fearful of their emotions, such reactions can assist in diagnostic considerations. Another issue relating to risk assessment is that of the multidisciplinary team versus lone clinicians. Murphy, Kapur, Webb, and Cooper (2011) compared risk assessments by psychiatrists and mental health nurses following an episode of selfharm. The study showed that doctors and nurses based their risk assessment on almost identical criteria, but doctors were five times more likely to admit to hospital, raising issues of conservative treatment because of perception of carrying responsibility. Seeking consultation and support from co-workers can assist to make rational decisions in risk assessment and management rather than emotive impulsive decisions in an effort to reduce personal distress. FUTURE DIRECTIONS … risk assessment is a key part of the provision of good services. It needs to be given far more time and consideration. This leads to good management practices and communication between a diversity of people … (Attendee)

Risk assessment and risk management are fundamental to – without being conceptually


separate from – the practice of mental health care and are likely to remain core activities of clinical practice in the future (Coffey, 2009). Therefore, it is vital that clinicians keep themselves informed and up-to-date so that the potential to address avoidable complications of risks associated with mental health can be addressed and managed, but also to illuminate the very real limitations of this practice. It was acknowledged during the symposium that adverse events, whilst tragic, represent a very small percentage of contacts within mental health services. This indicates the very effective job clinicians undertake in managing people with severe mental illness and, in all likelihood, preventing future adverse events. Whilst such positive outcomes are clearly encouraging, existing clinicians and new entrants to the field must be adequately educated, resourced and supported to develop their practice. Training in first response is beneficial to both the responder and the person in crisis. Yet, as the chairperson of Suicide Prevention Australia highlighted during the symposium, the professional groups who most commonly respond to suicide attempts (ambulance personnel, police, doctors, generalist nurses) receive little basic training in risk assessment and management strategies. Furthermore, as Snowden (1997) states, high quality clinical training requires well resourced mental health services: without this, no amount of training in risk assessment and risk management will make a difference. One such group requiring further training and support are mental health triage clinicians who take suicide and high risk calls. The symposium identified the need for special support to ensure their resilience as first responders; realistically, this is beyond what employee assistance programmes can provide. This is also likely to apply to some extent in other areas of crisis mental health work. Consumers need an emergency and crisis response model and need a treatment and recovery pathway; concurrently clinicians working in mental health also need systems that maintain their resilience and improve their effectiveness. To support their colleagues and achieve the best clinical outcomes, clinicians need to be sharp, well trained and have a heightened index of suspicion for risk, and be aware of the



161

Kate Deuter et al.

broader social context that suicide occurs in. The components to maintaining resilience and improving effectiveness are being developed, but require further consideration, as does the prerequisite skills and attitude necessary to work with at risk people in the community. The final panel discussion at the March 2011 Symposium also involved an impassioned plea for engaging Aboriginal and Torres Strait Islander people more effectively in mental health services, along with recognition of the often untapped potential of non-Government organisation services in acute service delivery. The Shared Learning in Clinical Practice Team will be continuing their partnership in planning symposia, supporting reflective practice and leading practice development initiatives. As part of this process, the South Australian Department of Health’s Acute Unit Matters will become known as Acute Matters, to reflect the fact that the scope of the initiative goes beyond in-patient settings and that the shared learning focus is on areas pivotal to successful mental health service delivery. The Shared Learning in Clinical Practice Team will also work to ensure that its initiatives are targetted in such a way as to maximise involvement and benefits for front-line mental health clinicians and practitioners. REFERENCES Aeschi Working Group. (2011). Meeting the suicidal person. The therapeutic approach to the suicidal patient: New perspectives for health professionals. Retrieved from http://www.aeschi-conference.unibe.ch/Guidelines_ for_clinicians.htm Coffey, M. (2009). Treating violence: A guide to risk management in mental health violence risk assessment and management – Book review. Journal of Psychiatric and Mental Health Nursing, 16, 860–864. Crichton, J. (2001). Risk perceptions of mental health nursing. Risk Management, 3, 39–46. Kettles, A. M. (2004). A concept analysis of forensic risk. Journal of Psychiatric and Mental Health Nursing, 11, 484–493. Lamont, S., & Brunero, S. (2009). Risk analysis: An integrated approach to the assessment and management of aggression/violence in mental health. Journal of Psychiatric Intensive Care, 5, 25–32.

162


Langan, J. (2008). Involving mental health service users considered to pose a risk to other people in risk assessment. Journal of Mental Health, 17, 471–481. Millar, R., & Sands, N. (2012). ‘He did what? Well that wasn’t handed over!’ Communicating risk in mental health. Journal of Psychiatric and Mental Health Nursing. [Epub ahead of print]. doi:10.1111/j.1365-2850.2012.01948.x Mulder, R. (2011). Problems with suicide risk assessment. Australian and New Zealand Journal of Psychiatry, 45, 605–607. Murphy, E., Kapur, N., Webb, R., & Cooper, J. (2011). Risk assessment following self-harm: Comparison of mental health nurses and psychiatrists. Journal of Advanced Nursing, 67, 127–139. Norko, M. A., & Baranoski, M. V. (2005). The state of contemporary risk assessment research. Canadian Journal of Psychiatry, 50, 18–26. Pereira, S., & Woollaston, K. (2007). Therapeutic engagement in acute psychiatric inpatient services. Journal of Psychiatric Intensive Care, 3, 3–11. Pfohl, S. J. (1978). Predicting dangerousness. Lexington, MA: Lexington Books. Rose, N. (1998). Living dangerously: Risk thinking and risk management. Mental Health Care, 1, 263–266. Royal College of Psychiatrists. (2008). Rethinking risk to others in mental health services. Final report of a scoping group (Report CR150). London, England: Author. Scott, C. L., & Resnick, P. J. (2006). Violence risk assessment in persons with mental illness. Aggression and Violent Behavior, 11, 598–611. Simon, R. I. (2009). Suicide risk assessment forms: Form over substance? The Journal of the American Academy of Psychiatry and the Law, 37, 290–293. Simpson, S., & Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicide risk assessment. Journal of Psychiatric Practice, 10, 1–5. Snowden, P. (1997). Practical aspects of clinical risk assessment and management. British Journal of Psychiatry, 170, 32–34. Undrill, G. (2007). The risks of risk assessment. Advances in Psychiatric Treatment, 13, 291–297. Weintraub Brendel, R., Wei, M. H., & Edersheim, J. G. (2010). An approach to the patient in crisis: Assessments of the risk of suicide and violence. Medical Clinics of North America, 94, 1089–1102. Woods, P. (2012). Risk assessment and management approaches on mental health units. Journal of Psychiatric and Mental Health Nursing. [Epub ahead of print]. doi:10.1111/jpm.12022 Received 07 June 2012


Accepted 29 January 2013
