Presented by: Dr Jo Preston, Dr Iain Wilkinson, Jackie Lelkes – Senior Lecturer, University of Brighton, Dr Alice O’Connor – Teaching Fellow, East Surrey Hospital
Broadcast Date: 24th September 2019
Iain: Four square step test
Jackie: Therapy cat
- Develop an understanding of the factors that influence decision making in cases of complexity and high risk.
- Develop an understanding of the importance of avoiding risk averse practice.
- To know what a defensible risk is.
- To consider the use of positive risk assessment tools to support decision making and risk taking.
- To understand that risk is a key part of person centred care, and hence an opportunity to tailor care.
- To recall the importance of the Mental Capacity Act in risk assessments.
- To explore how your own attitude to risk influences the care you deliver.
Risk can mean many things in health and social care. A formal definition is:
A risk is the likelihood that a hazard will actually cause its adverse effects, together with a measure of the effect. (Health and Safety Executive)
For example, there are 8 domains of risk management according to the American Society for Healthcare Risk Management (ASHRM).
- Clinical & Patient Safety
- Human Capital
- Legal & Regulatory
- Environmental and Infrastructure-Based Hazards.
Therefore there is risk present in each of these areas. There is risk involved in making a diagnosis and getting it wrong. There are degrees of risk with each and every test / procedure / tablet / diagnosis / hands-on moment with our patients. It’s sort of knowing what you don’t know.
However, we are not really going to talk about any óf those areas, but more about a broad framework about risk as a concept that you can apply to a number of situations.
Terms like ‘positive risk taking’ and ‘risk enablement’ help us to take account of potential benefits as well as disadvantages when assessing risk.
Managing risk is one of the most difficult and complex areas of practice. It involves juggling empowerment with a duty of care and, when it is not addressed appropriately, the consequences can be catastrophic, yet according to case law:
It is… the essence of humanity that adults are entitled to be eccentric, entitled to be unorthodox, entitled to be obstinate, entitled to be irrational. Many are.
Notions of risk are socially constructed and not context specific. However, they are often presented as a technical or scientific fact, which can be assessed by professionals. This process, though, is an opaque one which is invisible to critical analysis.
If practitioners are able to relinquish their expert status, and view risk through the lens of human rights, they may be able to approach the use of risk assessment tools as a participative means of gathering information to inform decision making and take the role of advocate or facilitator in supporting the person to make difficult decisions about their situation. Organisations play their part in changing the language and understanding of risk, to support their staff in making good decisions instead of eliminating risk altogether, and in moving away from seeing risk purely from the viewpoint of organisational liability.
White, E, Assessing and Responding to Risk, Chapter 6: Cooper, A and White, E (eds) “Safeguarding Adults Under the care Act 2014” Jessica Kingsley publishing, 2017
Gardner provides the following features judged high-risk in contemporary Western society:
- A single event catastrophe – rather than the same things dispersed over time;
- Novel or unusual risks, especially if we do not understand them and cannot see how to reverse the effects of something going wrong;
- Lack of personal control, especially if it affects us and we do not choose to engage the risk;
- The involvement of children or a personally identifiable victim, rather than just a statistic;
- Effects that harm some people in society but benefit others whilst generating fear
- Risks that are managed by institutions we do not trust or have a poor record of managing this kind of thing; and
- Immediate threats that loom larger in contrast to those in the future, although we worry about spoiling things for future generations.
Gardner, D (2008) Risk: The science and politics of fear, London: Virgin Books
Any risk-related decision is likely to be acceptable if
- It conforms with relevant guidelines and law.
- It is based on the best information available.
- It is documented.
- The relevant people are informed.
As decisions for many health and social care practitioners are concerned with the social rather than the physical world and individuals have their own perceptions of social reality, the basic elements that are required to come to an informed decision on risk are not ‘out there’ and are always “subjective, relative and debatable”.
Guido M. J. van de Luitgaarden. 2009. Evidence-Based Practice in Social Work: Lessons from Judgment and Decision-Making Theory. British Journal of Social Work (2009) 39, 243–260. doi:10.1093/bjsw/bcm117
A client-centered approach to care means that the client’s views, experiences, interests and safety are central to the process of assessment and intervention, in contrast to a paternalistic approach to health care where the client’s wishes might be overturned or overridden for the sake of their safety.
‘The concept of risk assessment in care should be a simple one, but all practitioners are different which can result in bias and differences of interpretation. We can strive to reduce risk but it is inevitable that things will sometimes go wrong. A positive risk-taking culture looks beyond the potential physical effects of risk, such as falling over or of getting lost, to consider the mental aspects of risk, such as the effects on wellbeing or self-identity if a person is unable to do something that is important to them.’
Bates and Limbery (2011) identify how the personality of individual workers affects how they think about and address issues of risk – this can be impacted by a lack of resources available to support the person. They describe scarcity (at its worst) as evoking feelings of fatalism, blame and victim thinking, while for other individuals, limited resources stimulate their creativity and intelligence and risk-taking evokes feelings of exhilaration.
Bates P. and Lymbery, M. 2011 cited in Taylor, R. Hill, M. & McNeill, F. ed. 2011. Early Professional Development for Social Workers. British Association of Social Workers. ISBN-10: 1861780842
Professionals can minimise the risk of harm in their minds for a number of other reasons including burnout or compassion fatigue. For example, Ruth Hardy (2017) in an article in Community Care identified how practitioners working with sex offenders can find that they have been “brutalised” by reading court papers and can start to minimise offences.
Person-centred approach to risk management: Positive risk taking.
The balance of risk and benefit will be unique to each individual and each particular situation. There is no one-size-fits-all solution, and a balanced approach will only be achieved through discussing and exploring the individual’s priorities and expectations.
- Look to the person to offer solutions to the risks rather than imposing solutions;
- Look to the difference between feeling safe and being safe to establish what feeling safe looks like from the individual perspective;
- Work with people to identify the personal strategies they have in place to minimise risk;
- Challenge the underlying causes of the risk to try and prevent it happening again;
- Provide the necessary information to enable the person to make an informed decision;
- Build a relationship of trust;
- Contextualise behaviour –know about the person’s history and social environment, their previous experience of risk, what has and has not worked in previous situations;
- Include people who are important to the individual (consider issues of consent);
- Inventiveness is sometimes overlooked yet it can counteract the tendency for risk assessment to be mechanical and formulaic, and is becoming increasingly important when responding to people with complex needs. (‘Creativity’ cited within the Care Act 2014);
- A fresh perspective can sometimes address the problem with unexpected solutions;
- Proportionality – the time and effort spent on managing a risk should match the severity of that risk. The approach should also explore the consequence of not taking the risk in question, such as loss of autonomy or restriction of choice.
Bates P.and Lymbery, M. 2011 cited in Taylor, R. Hill, M & McNeill, F. ed. 2011. Early Professional Development for Social Workers. British Association of Social Workers. ISBN-10: 1861780842
Consider these four key questions to support positive risk assessments:
- Can the person’s safety be promoted without interfering with the benefits they gain from the situation or infringing their rights?
- Are there ways in which to change the situation to reduce the risk to acceptable levels, whilst still respecting their choices and promoting their quality of life? (DH, 2010)
- Accepting that some things can go wrong – what could go wrong, and how could you respond in that case? Who can help support with the consequences and associated fear or guilt? (Morgan, S and Williamson, T, 2014)5
- Are you in a position where collectively the different people, professionals and organisations involved support a joined-up understanding of the person, what is important to them and what the risks are?
One tool that helps in this process is the The Colten Care Positive Risk Assessment (PRA) tool. It is used to inform complex decision making and is an integral part of a resident’s care plan.
It incorporates the following key elements:
- Description of the identified risk (usually an activity which the resident wishes to partake in)
- The nature of the risk (what it is about the particular activity which has the potential to cause harm)
- An exploration of the potential benefits to taking the risk, as identified by the resident, in accordance with their values and beliefs
- A record of any advice given by the person supporting the resident to make the decision (such as the nurse or care practitioner)
- A measurement of the risk
- Identification and agreement with the resident of any control measures required to help reduce the level of risk
- Cross-referencing with any other relevant aspect of the care plan
- Evidence of consent
A decision can be considered defensible if co-professionals would have made the same decision under the same circumstances.
Carson, D. (1996). Risking legal repercussions. In H. Kemshall & L.Pritchard (Eds.), Good practice in risk assessment and management (Vol. 1, pp. 3–12). London: Jessica Kingsley
Defensible decision making involves recording a clear rationale for all the decisions made and the discussions that led to the decisions, including reference to relevant legislation such as the Mental Capacity Act or the Human Rights Act.
In his seminal work ‘The human error’ Reason, J. (1990) defines error and mistakes as:
“a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency”
According to Sicora (2017) admitting you are wrong should be easier but is often associated with shame.
Sanders et al (2011) research in Accident and Emergency Departments, found that nurses and other practitioners preferred not to reveal their mistakes, or admitted that they had even lied or deceived others in order to hide their own sense of inadequacy and avoid shame.
Sicora (2017) argues that even though criticism can be used in a constructive way, as a developmental tool to improve practice, it is often felt by the practitioner as an ‘attack’ influencing and impacting upon their self-worth and confidence, and therefore often elicits a defensive reaction rather than listening. If practitioners accept that it is very likely that errors will occur then this diminishes the sense of shame and feelings of inadequacy.
Risk Averse Practice:
“There is a risk that all professionals involved with treating and helping that person…may feel drawn towards an outcome that is more protective of the adult and thus, in certain circumstances, fail to carry out an assessment of capacity that is detached and objective”
The term ‘risk aversion’ refers to the ‘manifestation of people’s general preference for certainty over uncertainty, and for minimising the magnitude of the worst possible outcomes to which they are exposed’ (Kolakowski 2011, p204)
Whilst all agencies talk about the ‘dignity of risk’, the day-to-day management of hospital and social care organisations can easily favour a risk-averse approach in which professionals’ practice is defensive, rather than making decisions in which they can justify their approach and support risk taking as well as risk minimisation.
In research undertaken with OTs in an acute care setting the following factors were highlighted as impacting on risk averse practice:
- Clinical knowledge and confidence
- Teamwork, which can be associated with ‘shared risk taking’
- Concerns over litigation
- Interprofessional tensions where risk was perceived in different ways by members of the team
- Lack of mechanisms to manage different perspectives of risk within teams – linking to the importance of being assertive and advocating for the individual and ‘group think’ to minimise conflict
Atwal, A., Wiggett, C., & McIntyre, A. (2011). Risks with Older Adults in Acute Care Settings: Occupational Therapists’ and Physiotherapists’ Perceptions. British Journal of Occupational Therapy, 74(9), 412–418. https://doi.org/10.4276/030802211X13153015305510
NHS Knowledge Skills Framework
- Core 1 Level 3
- Core 2 Level 1
- Core 3 Level 2
- Core 4 Level 1
- HWB2 Level 2
- HWB3 Level 2
- HWB4 Level 2
- 1:3. Ethical and legal requirements, Mental capacity
- 1:4. Keeps practice up to date through learning and teaching
- 2:7. Works effectively as a team member: Interaction with colleagues
- 4:18. Safety and quality: Recognises and works within limits of personal competence.
- 4:19. Safety and quality: Makes patient safety a priority in clinical practice (Causes of impaired performance, error or suboptimal patient care).
Core Medical Training
- Time management and decision making
- Decision making and clinical reasoning
- The patient as central focus of care
- Prioritisation of patient safety in clinical practice
- Complaints and medical error
- Personal behaviour
- Core competence: Maintaining an ethical approach
- Core competence: Making decisions
- Core Competence: Maintaining performance, learning and teaching
Geriatric Medicine Specialty Training
- 4. Time management and decision making
- 5. Decision making and clinical reasoning
- 6. The patient as central focus of care
- 7. Prioritisation of patient safety in clinical practice
- 12. Relationships with patients and communication within a consultation
- 14. Complaints and medical error
- 19. Legal framework for practice
- 24. Personal behaviour