Introduction

This chapter examines approaches that underpin risk assessment in contemporary mental health settings. It considers the skills that support good practice in risk assessment and management for mental health nurses and supports you to identify how you may learn about risk and contribute to risk assessment and management.

Risk assessment and management

Assessing and managing risk is an important skill within contemporary mental health nursing practice. Working with risk is a key feature of mental health policy (Department of Health (DH) 1999, DH 2006). It involves recognising, responding to and working with individuals to manage their own level of risk (DH 2004). It can also involve enabling people to take risks to work towards their recovery. This chapter examines risk in the context of mental health nursing practice and uses a scenario to help you explore this critically.

Risks in relation to mental health

Risk is most commonly understood in relation to the risks posed by people with mental health problems, either to themselves through self-harm, neglect or suicide or to others through violence. Identifying and assessing such risk is supported by a variety of risk assessment tools (examined briefly under the actuarial approach below). Within modern mental health services, professionals can often feel that their clinical abilities are judged by their ability to control and manage risk (Repper & Perkins 2003). This reflects the significant role risk has come to occupy within services. In order to understand this fully, it is important to consider the social and historical position of the concept of risk.

Following the advent of community care, people with mental health problems were more present within the community. Chapter 2 recognised that public perception of people with mental health problems is often lacking in understanding. Community care further highlighted this perception towards mental illness. This was exacerbated by a number of high-profile incidents of violence perpetrated by people with mental health problems. The manner in which the media reported such incidents has been identified as perpetuating a link between violence and mental illness (Paterson & Stark 2001). This culminated in a situation where the government, media and sections of the public perceived care in the community had failed.

Following these incidents the government introduced the need to conduct an inquiry into homicides committed by someone who has been diagnosed with mental health problems. This has been criticised as further perpetuating a stereotype linking violence with mental illness. Taylor and Gunn (1999) analysed homicide statistics between 1957 and 1995 (during a growth in community care) and found that the rate of homicides committed by people with mental health problems remained stable while the overall murder rate rose. Marsden's (2006) analysis of homicides committed by people with severe mental illness showed that these accounted for less than half a per cent of all homicides in England and Wales. This is not to deny the tragedy that each one of these statistics represents. However, it is important to critically explore where the culture of risk assessment and management in mental health arises from.

It is within this context that Care Programme Approach policy was developed, the government announced a review of the Mental Health Act and risk assessment was incorporated into mental Care Programme Approach policy. This has been perceived as fulfilling an agenda to increase surveillance and monitoring in the community (Morrall & Muir-Cochrane 2002).

A number of authors also point to the changing nature of risk within wider society. Beck (1992) suggests that we now all live in a ‘risk’ society in which risks are global and as a society we become pre-occupied with achieving safety and managing risk. Lupton (1999) also highlights how the meaning of risk has changed from previously being associated with opportunity and chance to being dominated by a view of safety and control.

For some mental health professionals the dominance of risk and concern with a perceived link between violence and mental illness has contributed to a culture of blame in mental health services. Practitioners fear that the consequences of their actions may result in a tragic event for which they are held to blame. This can contribute to defensive practice in which decisions are made based upon this fear and an avoidance of situations where people may be exposed to being able to take chances. At best this can lead to hindering the recovery journey and at worst it can lead to unnecessary deprivation of liberty and compromise of personal autonomy. The following discussion explores effective risk assessment and management and considers how this can be conducted to attempt to avoid defensive practice.

Risks to people with mental health problems

It has been highlighted that risk of violence and risk of suicide are important areas for the assessment of risk. However, these are often focused on at the expense of other risks that service users are commonly exposed to. People with mental health problems are at greater risk of poverty and unemployment than other sectors of the population (Office of the Deputy Prime Minister 2004).

There are potential risks posed in terms of social isolation, exploitation and risks posed by other service users and staff. Muir-Cochrane (2006) also examines the risk factors linked with developing physical health problems, particularly associated with schizophrenia. Chapter 2 highlighted that certain physical conditions are more common in people with mental health problems, representing increased risk to optimum physical health. There are also risks that are created by using mental health services; these are known as iatrogenic risks. The most common iatrogenic risks are the side effects and physical conditions, such as tardive dyskinesia, that may result from taking psychiatric medication. This highlights that the potential for risks associated with the experience of mental health problems are many and varied. It also recognises the need to examine the risks that the service user may be exposed to, which may fall outside the common factors highlighted in standardised risk assessment tools.

Risk assessment

Risk assessment has been defined as an examination of the context and the details of past risk incidents in the light of current circumstances. It entails the collection of information used to establish the likely occurrence of a future event and the impact and consequences of that event in terms of harms and benefits (Morgan 1998). In this respect there are two key aspects of the risk assessment process: identifying the potential consequences (the actions) and the potential likelihood of those consequences. It is important to bear in mind that risk can never be eliminated and it is very difficult to create accurate predictions for individuals (Royal College of Psychiatrists 2008). However, there is potential for practitioners and services to work in a way that helps to reduce the potential for risk.

There are two common types of risk assessment: actuarial and clinical. Actuarial approaches to risk assessment are based on statistical population information that is developed from research. They use this statistical information to make predictions in accordance with rules which are fixed (Buchanan 1999, Doyle & Dolan 2002). Risk assessment tools in mental health employ some actuarial measures. These include identifying issues such as unemployment and previous episodes of self-harm as risk factors for suicide, as population data suggest that these experiences are more common in people who have committed suicide.

Clinical risk assessment refers to the more informal judgements that clinicians make. Assessment of risk is based on the clinician's understanding of the individual, their circumstances and relationships. The professional is able to respond flexibly to this understanding; for Doctor (2004) this involves engaging in the inner world of service users.

Risk assessment is a dynamic process which most commonly makes use of both clinical and actuarial approaches to inform judgements about the level and nature of risk. There are no risk assessment tools that have been standardised nationally though some have been validated through research. The Royal College of Psychiatrists (2008) has called for better evidence to support the development of tools to aid practitioners in the assessment of risk. It is therefore important to familiarise yourself with the risk assessment tools used within your clinical placement setting.

The usefulness of risk assessment for the mental health nurse is in its attempt to understand behaviour associated with risk. In this respect, risk assessment becomes an assessment of a current situation rather than an accurate predictor of a future event. Factors that may be taken into consideration in understanding behaviour associated with a risk include the following:

Developing this assessment helps to identify whether risks are high, medium or low and therefore informs the development of a risk management plan.

Risk management

Good quality risk assessment is important for managing risk (Royal College of Psychiatrists 2008). Risk management entails the development of plans that identify responsibilities and actions (Morgan 2000). These plans may be aiming to support, minimise or respond to behaviours associated with risk. Similar to any other plan within mental health services, there should be a date for review and evaluation of the plan. Risk management incorporates the decision-making process in which decisions are made based on knowledge of the evidence, of service users and their social context, of the service users’ own experiences and the professionals’ clinical judgement (DH 2007). This underpins the varied resources that are drawn upon in order to make decisions within health care and acknowledges that this is necessary to attempt to build an understanding of the complex factors that influence an individual's behaviour and use these to inform management. Risk is a changing concept and it is important to recognise that by helping to decrease some risks, others may increase. For example:

Multidisciplinary team working

Inquiries into homicides have consistently highlighted problems with communication within and across teams. Multidisciplinary team working enables the sharing of information and a more holistic picture of the situation to be established. It is also important to promote clarity within the planning process to help ensure each member is clear about their roles and responsibilities. It enables professionals to share expertise and can help challenge the culture of blame as decisions are made as a team. Developing risk assessment and management as a team also allows individual practitioners to listen to different perspectives and gain support for the challenges of working with risk in complex situations.

Positive risk taking

The central role that risk occupies within mental health practice coupled with the concerns regarding the potential for defensive practice have contributed to a call for a broader conceptualisation and approach to risk. Therapeutic or positive risk taking redefines risk to recognise the potential for benefits, opportunities and growth to occur as a result of taking a risk. Positive risk taking acknowledges that there are times when we should support people to take a risk in order to help them reach their goals and work towards recovery. Taking risks is what enables anyone to achieve in life and learn from their mistakes. Starting a new relationship, going for a job interview and taking a driving test all involve taking a risk which may succeed and pay off, but may also result in a loss from which we can often learn and develop ways of coping when supported with this process. Positive risk taking involves working with individuals to identify the courses of action they have available and supporting them to make decisions. In order to make choices, sharing information and examining the potential costs and benefits are important. Positive risk taking incorporates many choices an individual can make. Positive risk taking in practice might result in the following:

Promoting positive risk taking involves many of the same approaches that contribute to effective risk assessment of known risks or perceived risk behaviours, such as therapeutic relationships with service users and their families, working as part of a team and developing relapse signatures and contingency plans. In addition, positive risk taking may be promoted through the following (Morgan 1998, 2000):

Positive risk taking has achieved support within more recent policy such as the ten essential shared capabilities (see Ch. 3) and the Department of Health's guide to best practice in risk assessment and management (DH 2007). These guidelines suggest that, in order to support positive risk taking, effective team working and clear documented plans are important (DH 2007). Team working and accessing supervision can be important for mental health nurses to gain support for enabling people to take therapeutic risks. An example can be seen in the following reflective learning exercise.

This chapter has provided an overview of risk assessment, management and therapeutic risk taking in contemporary mental health nursing practice. It has examined the significance of risk in relation to mental health services and suggested that this needs to be considered critically in relation to the social circumstances that have contributed to the situation. As mental health practitioners, it is important to situate an understanding of risk within the individual relationship that is developed with service users and to recognise the broader nature of risks that service users are exposed to.