VOL: 97, ISSUE: 25, PAGE NO: 37
David Pratt, BSc, DipCMHN, RMN, is specialist research nurse, Affinity Healthcare, Darlington
Risk assessment has become a key component of mental health services in recent times and the importance of good practice in this arena is not in dispute. However, the process is by no means easy and nurses are beginning to voice concerns over the difficulties and ethical dilemmas they face when incorporating the activity into their daily working practice.
At a recent course for community psychiatric nurses (CPN) on risk management, participants described some of the problems. Nurses who had first-hand experience of investigations and inquiries gave disturbing accounts of the line of questioning and feelings of isolation while living through these events. Several talked about former colleagues who had decided to leave the service or had emotional problems as a direct result of the inquiry process. One CPN said he had felt ‘like the accused’ because he had failed to carry out a formal risk assessment on a client who was later involved in a major incident.
Psychiatric nurses are finding it difficult to please everyone. While trying to give patients the best possible care, they are under increasing pressure from employers, the public and the law. The threat of litigation is creating anxieties that may lead nurses to rethink their approach to care because they know they will be punished if they get it wrong (Aleszewski, 1998).
In this post-institutional era policies are being driven by sensationalised media coverage rather than by service users, informal/formal carers or health care professionals. Shaughnessy (1998) states that tabloid newspapers are ‘putting pressure on the government to bring in all these measures that are about protecting the public, not about protecting people with mental health problems, and it’s the media that has created this obsession with public safety. So the main issues now are all about locking up the wards again and how they are going to control people in the community. It’s not about care in the community; it’s about control.’
Morrall (1998) would agree that risk management in this context is all about social control.
With the advent of the Care Programme Approach, the cornerstone of which concerns perceived risk (Department of Health, 1996), supervision registers, supervised discharges and section 117s, local policies and procedures direct mental health teams to address risk factors and record this information contemporaneously in care plans and case notes (UKCC, 1998). These directives would be ignored at the individual practitioner’s peril, according to Roy (1997), who encapsulated the conundrum when he stated:
‘The individual clinician is well advised to consider the personal risks of clinical practice in the same way as one would ensure adequate insurance and pension arrangements for one’s home and family. Medical records, including good note-keeping and communication, are the key to effective risk management. Issues relating to the general attitude and approach of clinical staff, particularly doctors, towards patients and carers are a growth area for complaints and dissatisfaction.’
However, there is a danger of decisions on risk management being taken out of context and separated from clinical assessment, and with this there is the potential for psychiatric services to be swamped by the bureaucratic administration inherent in such an approach. Even more worrying is the probability that mental health nurses will feel duty-bound to prioritise their time, dealing with the management of people deemed to be ‘at risk’ in an attempt to control future behaviours, as opposed to concentrating on therapy and the individual care of their patients.
In other words, an overemphasis on risk assessment and management could have a direct impact on nurse/patient relationships if practitioners focus their interventions on these issues to the detriment of psychosocial interventions.
Holloway (1997) states that patients will benefit from a heightened awareness of risk management. The above analysis, if correct, may contradict this.
As training in this area increases, which it surely must, the expectations of patients, carers, employing authorities and the public will weigh heavily on the shoulders of clinicians who are already overworked and under stress as a consequence of existing pressures.
The consensus of opinion in the group of CPNs who attended my course was that busy mental health nurses may well choose the path of least resistance, which could be detrimental to clients. Unless additional resources are provided to meet the increasing burden, individual practitioners might easily settle for the ‘safest’ options, very few of which are likely to include clients’ and carers’ autonomy and increased choice.
Every mental health professional walks the tightrope in a world in which blame and culpability await anybody who cannot prove that every stone was turned, every ‘i’ dotted and ‘t’ crossed regarding any violent incident or dangerous behaviour that could potentially have been avoided, according to Prins (1996).
Nurses are very aware of the importance of risk assessment and management, and realise that they must, with the use of evidence based tools, attempt to quantify the probability of future behaviours to ensure that informed decisions about tomorrow are made today (Rose, 1998). However, we are also entitled to point out the difficulties of embracing an approach that requires so much extra work, particularly with regard to its administration.
I have read countless articles and chapters and have discussed and debated issues of risk management with peers and lecturers. Despite this, I could not confidently predict the dangerousness of individual patients.
Predicting behaviour will never be an exact science because of the many variables involved when dealing with complex individuals in environments and circumstances which are impossible to control.
Inquiries are always ‘wise after the event’ and can make fools out of the most experienced practitioners.
Unfortunately, psychiatry and the justice system speak different languages, leading practitioners to feel increasingly vulnerable in a developing culture of blame and litigation.
If mental health practitioners are to feel safe and secure in their working environment in today’s climate, they must be given a platform on which to highlight the grey areas in this black-and-white world, particularly to the people who set the psychiatric care agenda.
I consider myself to be an experienced mental health nurse, but could never feel confident enough to predict the future behaviours of my clients.
And I am in good company, as the late Patrick McGrath, for many years medical superintendent at Broadmoor Hospital, Crowthorne, once said: ‘Half of my patients could be discharged, the problem is, I could not say which half.’ (Prins, 1996).