VOL: 101, ISSUE: 33, PAGE NO: 35
Lesley Murphy, BSc, RNLD, RMN, Dip CLDN, Cert CBT, is clinical nurse specialist;
Lorna Cox, RN (mental health), is senior staff nurse; Danny Murphy, RN (mental health), is senior staff nurse; all at the intellectual and developmental disability service, the State Hospital, CarstairsLesley Murphy, BSc, RNLD, RMN, Dip CLDN, Cert CBT, is clinical nurse specialist;
The State Hospital is a national resource for Scotland and Northern Ireland providing high security services for patients with mental disorder. This includes specialist services for male patients with a primary diagnosis of learning disabilities, who represent around 12 per cent of the current inpatient population.
These patients need high security conditions, due to their behaviour. The hospital aims to deliver care while maintaining safety for patients, staff and the public. Risk assessment therefore has a significant role in patient care and management. The system used is dynamic risk assessment and management (DRAMS). Data regarding its reliability and predictive ability has been documented by Lindsay et al (2004).
Risk assessment is an important aspect of care and treatment for all client groups. It can be used to ascertain an individual's current presentation, or to inform a variety of decisions such as appropriate placements, levels of supervision and staffing, and appropriate treatment programmes. Risk assessment is generally considered under the two broad categories of static/historical risk factors and dynamic/proximal risk factors.
Rationale for using DRAMS
DRAMS was developed in response to a clinical problem faced by the clinical team in the learning disabilities unit in the State Hospital. While developing and implementing positive behavioural programmes with patients with learning disabilites, it was found that acute risk situations frequently arose, sometimes resulting in serious incidents. This made it difficult to maintain the positive programme. Rather than introducing penalties that would prevent individuals from accessing positive outcomes, it was thought that the implementation of a parallel dynamic risk assessment could enable the positive programme to be temporarily suspended until the level of dynamic risk had decreased. In effect, individuals would not lose any rewards they had gained, but would not be able to access them or gain further rewards until it was safe to do so.
It was thought that if a sufficently simple system could be developed, it could be used collaboratively with patients to explain why the positive programme was suspended. This might also help them to understand why certain procedures were being followed and decisions made. The use of a simple assessment tool might also encourage individuals to consider their own behaviour, and through support, reflect on their current level of risk. In this way it would serve as a method of positive feedback as dynamic risk levels decrease.
Additionally, staff often use intuitive knowledge of individuals to identify and manage dynamic risk. If this knowledge could be made more clear and accessible, it might make it easier to share with other staff groups working with patients who have learning disabilities. Another advantage might be to engage patients in difficult discussions.
Description of DRAMS
From the literature on dynamic risk, several major variables were extracted and these were in turn subdivided into specific items making up the general variable (Box 1, p36). Each item is arranged along a continuum from 'no problem' to 'severe problem'. This is worded so that it can be understood by patients, while a traffic light analogy is used to further promote the tool's useability and their understanding and collaboration. Green lights cover the two least problematic categories, amber covers the intermediate categories and red lights cover the categories associated with the greatest risk.
In addition, with regard to certain items such as violence to others, drug and solvent abuse and excessive opportunities for victim access (in the case of sex offenders), a 'stop' sign has been introduced. In these cases, once the patient has moved back into the less risky categories, he may still not be given access to his daily routines until the staff group are satisfied that the level of risk has indeed subsided to acceptable levels.
The DRAMS can be scored by item, by category and as a total score. However, it should be remembered that the DRAMS has been developed as a collaborative tool and it is best used with individual participants.
In order to evaluate the introduction of DRAMS, a satisfaction questionnaire was devised by the clinical nurse specialist and issued to 10 staff working on the unit. The questionnaire included a number of questions on the user-friendliness of the tool and its relevance to patient management and progress, and usefulness in planning individual programmes. The use of focus groups was another method that could have been used to evaluate the tool, however it was felt that the use of an anonymous questionnaire was more likely to generate accurate and honest answers from participants.
All 10 staff members participating in the evaluation were clinically experienced and familiar with the use of unit-based rating scales. Before it was introduced they were given basic guidance (a one-hour training session) orienting them to the assessment tool and the items it contains. Results of the evaluation focus on staff opinion on the usefulness of the tool. The staff involved were selected based on a cross-section of people with different levels of experience, training, ability and knowledge. They were fairly representative of the wider group of nurses working in the unit.
Findings from the questionnaires
Attitudes to introducing a new tool
With a staff/patient ratio of 5:26, there were concerns about finding time to carry out DRAMS with the patients. However, the tool was generally welcomed by nurses. Responses from the questionnaires indicate that, in general, DRAMS was considered to be a helpful and useful addition to the programming and running of the unit (Box 2).
A few participants noted that their ability to focus their care had increased as a result of using DRAMS to assess patients. For example, comments on the questionnaires included:
- 'It helps us to focus with the patient on what the real issues are;'
- 'Before DRAMS it was easy to get side-tracked into other issues, not completely relevant to the actual incident.'
Acute dynamic risk situations arise frequently within the unit and can result in necessary limits being placed on patients' activities and the facilities accessible to them. Often in this situation, the patient concerned accuses staff of being unnecessarily harsh on them. This discussion is often used to minimise the incident and avoid personal responsibility. The focus then becomes, for example, the restrictions rather than addressing risk and its management. This emphasises the benefits of DRAMS as a collaborative tool and supports the rationale for developing the system.
There were also some good examples of collaborative working and joint decision-making, and staff commented that:
- 'Sometimes the patient makes decisions about how best to manage the situation to keep him and others safe. It's good when that happens because there is agreement rather than staff being accused of being unnecessarily restrictive;'
- 'When we make joint decisions with the patient, he is more willing to work with it and accept responsibility for it.'
Another positive outcome for staff was the number of opportunities DRAMS created, such as a point of contact on a weekly basis. They also mentioned that the tool helped them to justify decisions made, and gave them time with patients to discuss issues with them.
The use of DRAMS created further opportunities to detect potential problems 'through discussing different aspects or issues that patients or staff may have been unaware of in a totally non-confrontational way and resolve these issues with advice and support'. Staff also mentioned that DRAMS 'enabled more full discussion of moods and reactions, allowing patients time to think of alternatives to their usual reactions or inaction'.
Challenges of using the tool
Throughout the project several concerns about the use of DRAMS were highlighted. Staff were enthusiastic about the tool's potential contribution, yet the length of time it took to collate the data, and to develop guidelines and training to enable staff to use the tool competently were a source of frustration.
The importance of the time taken to complete DRAMS was evident and there were some difficulties in filling out the assessment when an individual was extremely agitated. Staff noted that it was difficult to engage collaboratively with patients to complete DRAMS immediately before, during and after a significant aggressive incident.
However, it was noted that in the few hours following an incident it is possible to use the DRAMS as this is when clients and staff are reflecting on the relevant issues and circumstances pertinent to the incident.
Appearance of the tool
The tool was devised in such a way as to aid understanding for all patients on the unit, including those with the lowest levels of intellectual ability. It was generally thought to be a good visual aid for some patients - although not every patient felt the visual aid was appropriate. One patient claimed the pictorial representation of traffic lights was childish and this did hinder communication at times. This issue could be addressed in two ways - either by encouraging the patient to see beyond the pictorial representation and explaining why the analogy is used, or simply by removing or changing the pictorial representation for more able patients.
Staff highlighted an important ethical dilemma relating to the use of DRAMS, emphasising, as one noted: 'We want to avoid patients feeling punished for being open and honest.'
This dilemma arose because the patients were encouraged to be open and honest about their thoughts. The staff were concerned that a patient may reveal risky thoughts and then have restrictions placed on him as a result. Since the patient would not have acted on these thoughts at the time, this could be viewed as punitive. However, if no restrictions were placed on the patient and he went on to act on his thoughts then this could be viewed as negligence.
Some future developments in training for staff were identified and the following suggestions were made:
- 'We need a manual to be developed to help staff understand how to use the tool;'
- 'You could have a handbook giving more detail with categories, it would give more clarity when different members of staff are completing DRAMS.'
It is anticipated that future training will be provided on interpretation of the results, developing a scoring chart and guidelines for using DRAMS.
The DRAMS assessment system has been developed to assess dynamic risk. It has become apparent that it is a relatively user-friendly tool, and staff reports are favourable.
The information presented here simply reflects the initial findings from the pilot project. Extended use of the DRAMS will offer more substantial data and it is anticipated the system will be subject to greater scrutiny as it becomes part of a more detailed research project. The sample used in the audit is small (n=10) and therefore the findings are not generalisable.
- This article has been double-blind peer-reviewed.
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