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Risk assessment and risk management

For the purposes of a textbook, or training event, the concepts of risk assessment and risk management can be analysed separately. However, in reality they are closely inter-linked – risk cannot be effectively managed until it has been clearly identified and defined; and when a risk is identified we instantly respond with considerations of how it is best managed. In recent years, there has been a shift of conceptual thinking, from a singular and static determination of dangerousness, to a more dynamic and changeable concept of risk (Rose 1998).

Risk assessment and management have become continuous elements of good clinical practice. This development has coincided with some of the consistent requirements emerging from the homicide inquiry reports, namely that:

high quality and up-to-date risk information is essential;

information needs to be shared as widely as possible between agencies and individuals, as appropriate; and

collaborative working between all individuals and organizations is crucial.

Risk assessment

A gathering of information and analysis of the potential outcomes of identified behaviours. Identifying specific risk factors of relevance to an individual and the context in which they may occur. This process requires linking historical information to current circumstances to anticipate possible future change. Specific categories and risk factors will be discussed in detail in the next section; here we will focus consideration more on the skills and general areas of assessment. There is no mystique about risk assessment, as with all other types of assessment it depends on the accessibility and quality of information gathered. To this end, it requires persistence in pursuit of the relevant information held at multiple sources. The skill lies more in the delicate manner and approach to enquiring after appropriate information from the service user, and all others with relevant knowledge to contribute. The basic skills include active listening, empathic understanding and reflective communication, supplemented by alert observation of the non-verbal cues or signs of change. Once information has been collected, the next skill required of the practitioner is that of reasoned analysis, towards the formulation of a plan of action. At this stage, accurate historical information needs to be evaluated against current patterns of behaviour. One previous incident, 20 years ago, does not necessarily indicate a high risk of reoccurrence; though such an eventuality should not be entirely ruled out. A repeated pattern of risk behaviours over time begins to present a stronger basis for predicting a reoccurrence. Never lose sight of the human potential to change behaviour patterns, even those that appear to be well established. The keys to a good assessment of risk are as follows.

Risk management

A statement of plans and an allocation of individual responsibilities for translating collective decisions into actions. This process should name all relevant people involved in the treatment and support including the service user and appropriate informal carers. It should also identify a review date for the assessment & management plan. Risk management receives far less attention in the literature than risk assessment. The last decade has seen an overall change of emphasis, not just for the concept of risk generally, but also risk management specifically. The latter has shifted from a means of trying to control the volume of medical negligence, to a clinical initiative for addressing potentially harmful outcomes for service users (Vincent 1997). Morgan (1998) suggests that clinical risk management is now focused on the interpretation and implementation of individualized care plans, through targeting treatment, care and support options to the issues identified in a comprehensive assessment (including risk assessment). In reality risk management is about actions, and the responsibilities for ensuring they are carried out and monitored as effectively as possible. Morgan and Hemming (1999) outline a structure for procedural risk management that stresses three levels of intervention:

preventative risk management (including attention to the working relationship, education and early warning signs of relapse);

management of escalating situations (including de-escalation techniques, rapid responses and crisis intervention); and

post-incident supportive management (including positive support for victims and a culture of learning rather than instant retribution through blaming). The effectiveness of risk management will be determined by the local team operational policies and daily procedures of clinical practice. The context that holds the most influence in this respect is that of team resources, space for imagination, reflection through individual and peer supervision, and attending to the tensions between the need for safety and least restriction of all people engaged in the process, not least the service user.

One of the key messages for all nursing staff and other mental health workers is the need to move away from an approach relying on the sole responsibility of individual practitioners. The need for collaborative approaches and collective responsibility cannot be over-emphasized. It is recommended that this method of working is supported by organizational management, policies and procedures emphasizing the concept of collective responsibility.

It is therefore vital that collaborative working takes place, where high quality information is shared and where colleagues use each other as sounding boards in order to check out thoughts, intuitive feelings, or concerns. In terms of good risk management practice, regular review at appropriate intervals is therefore required (Department of Health 1999a). ‘A collective approach should lead to collective responsibility in the event of “x”’. We need to learn the valuable lessons from what has gone wrong in the past, and the ‘near miss’ situations, in order that similar risks can be minimized in the future. The current patterns of investigation immediately set up anxieties in practitioners, even before the full facts have been established. A sense of ‘guilty until proven innocent’ is established. It is highly unlikely that this approach generates the necessary confidence of practitioners, either in their own abilities or in the support of the organizations. This approach may also seriously contribute to a more fearful, and consequently closed attitude towards reporting events that nearly became incidents.

Therefore, we should welcome a culture that strives to encourage and support a ‘blame-free, near-miss reporting’ mechanism, in order to develop the confidence to learn. This may require a more confidential set of arrangements to be established within or across organizations, enabling people to pass on important messages to the people who can ensure they are heard without any attachment of blame to those doing the reporting (unless serious negligence has arisen). Similar arrangements currently exist in the aviation industry to learn about near misses without targeting blame to individuals.

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