Mental health service users experience increased risk in relation to a number of specific problems, including an increased risk of suicide, self-injury, neglect, exploitation (physical, financial or sexual) and violence towards others.
VOL: 99, ISSUE: 09, PAGE NO: 44
Anthony Harrison, MSc, DipN, RMN, is consultant nurse (liaison psychiatry), Avon and Wiltshire Mental Health Partnership NHS Trust, Bath
Risk assessment is linked to the practice of risk management, whereby a mutually agreed plan, aimed at reducing identified risks, is negotiated with the individual concerned. The plan incorporates specific therapeutic strategies and is a collaborative, interactive and dynamic process rather than something that is ‘done to’ the person. Although risk assessment is a core nursing skill, it needs to occur within the multi-professional context and involves other relevant disciplines.
Overview of the risk assessment process
Risk should be gauged in the context of a broader, holistic appraisal of the person. This should include physical, psychological, sociological and spiritual dimensions and take account of the interplay between all these factors.
Risk assessment provides useful information when devising care plans. It also has an impact on psychotherapeutic issues such as engagement with the person and concordance with treatment. A number of key principles underpin this approach to risk:
- Risk cannot be eliminated, as there is no such thing as a completely risk-free situation. Outcomes are not easily predicted. The nursing goal is the minimisation of risk and the prevention of harm or further harm.
- Risk is a dynamic process, influenced by any number of variables within a given situation. Risk fluctuates and is influenced by the experiences, perceptions and interactions that the individual is subject to at any point in time. Therefore, risk management plans must be constantly evaluated and amended.
- ‘Risk factors’ are based on population studies and do not necessarily allow practitioners to identify risks in a particular individual. For example, although males are statistically more likely to commit suicide, an individual man receiving care may not automatically be at increased risk of suicide simply because of his gender.
- Research suggests engagement and psychological support are key nursing strategies for reducing risk. Empathy, active listening and involvement in care planning can reduce self-harming behaviour (Jones, 2000).
- Training, ongoing education and clinical supervision increase the effectiveness of clinical work and risk assessment practice.
Assessing suicide risk
There is a known link between self-harm and suicide, with one per cent of individuals going on to commit suicide in the 12 months following an episode of self-harm (Hawton and Fagg, 1988). Engaging the patient in a risk assessment before formulating a care plan is, therefore, a nursing priority. Such an assessment is informed by a knowledge of factors relating to increased risk of suicide (Box 1).
An empathic and nonjudgemental attitude can encourage the person to express information that is crucial for determining the true level of risk. The issue of confidentiality needs to be addressed early on, with the nurse explaining the limits of confidentiality and how he or she will use the information gained.
A thorough history is essential and information can be gained from the person’s partner, GP and friends. Focusing questions on what triggered the current crisis is a useful way of clarifying personal risk indicators, as is an understanding of how the person usually deals with stressful situations. The 24-48 hours prior to the crisis is often a critical time in terms of risk, and information about this period can significantly assist in making judgements about the level of ongoing risk. Key personal, social and clinical information (Box 2) is recorded and shared within the clinical team in order to pinpoint key risk areas, as well as factors that may decrease risk. Finally, a timeframe is identified within which risk is likely to be increased, sometimes referred to as short, medium and long-term risk.
Bird, L., Faulkner, A. (2000)Suicide and Self-harm. London: The Mental Health Foundation.
Department of Health (2002)National Suicide Prevention Strategy for England. London: DoH.
Morgan, S. (2000)Clinical Risk Management. London: The Sainsbury Centre for Mental Health.
O’Rourke, M., Bird, L. (2001)Risk Management in Mental Health. London: The Mental Health Foundation.
Hawton, K., Fagg, J. (1988)Suicide and other causes of death following attempted suicide. British Journal of Psychiatry; 152: 3, 359-366.
Jones, J. (2000)Psychiatric inpatients’ experience of nursing observation. Journal of Psychosocial Nursing; 38: 12, 10- ‘20.