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Risk and Reward
Assessment of risk should form part of any health and social care assessment, and I want to include in this article some pointers as to what makes for an effective risk assessment. The QCS policies and procedures provide templates for assessment of the health and social care of service users including risk factors. Why do we assess risk? Certainly not to eliminate it, that would be virtually impossible, unless we lock someone in a room and observe them closely 24 hours a day. If we were to do that, then there is another risk we have created, that is the risk of losing an independent and fulfilling life. So what we are seeking to do by assessing risk is to form the basis of a plan that will allow us to manage risk. As a number of blogs written on the QCS website have said, the importance of using assessments is not to stop people doing things, but rather enabling them to do things safely.
So before we start our risk assessment, we need to identify the types of risk we are concerned with. Mental health services often categorise these as the risk of harm to oneself, the risk of harm to others, and then the risk of harm by others. I’ll say something about each of these.
Harm to oneself
When we look at this heading we think about acts of self-harm that are deliberate. However, self-harm can be wider than that and can include unintentional self-neglect such as not eating properly or not looking after oneself. Another common mistake is to think that deliberate self-harm is about trying to kill yourself. Deliberate self-harm can take many forms such as cutting.
Harm to others
This is the area of risk that concerns practitioners most, how would we feel if someone in our care harmed someone else? I think the high profile that harm to others gets, has got a lot to do with media portrayals of people with major mental health problems. However the reality is that amongst people with mental health problems the risk of harm to others is less than the risk of self-harm.
Harm by others
This is an area of risk that can be overlooked. Here we are considering issues around vulnerability, including vulnerability to abuse, which can be financial, physical, sexual or emotional. That abuse can come from strangers, or even from families. We need to think about potential abuse by health and social care services, and the recent examples where this has been exposed. We also need to think about more ‘low level’ risks’ such as the risk of losing independence or self-confidence. This is the risk that services pose when their practice becomes too defensive.
Positive risk taking
Much of the focus of discussion about risk in mental health is about high level risk. These are the risks that hit the headlines and have the most awful consequences. The problem with too much focus on risk being about severe harm is that adds to the stigma that surrounds mental health. We should think about all levels of risk. That will encourage us to think about the idea of risk taking being positive.
The QCS Risk Taking Policy explores the issue of how taking risks can be positive. Think about you own life. Many of the decisions we make on a day to day basis involve some risk. We make a positive decision to do something because of the benefits we think we will gain. Sometimes it is a mistake, and we learn from that and re-evaluate our risk taking strategy for the future. The same choices should apply for the people we are working with. However, we do have a duty of care to people who are vulnerable. Some of the people we work with may lack the mental capacity to make those decisions involving risk. This is where the practitioner becomes involved in managing risk.
Think of the analogy of a washing line. If we think about a washing line and at one end someone is given complete freedom to make risky decisions, this may well end up in the person being harmed or harming someone else. At the other end of the washing line – the ‘safety at all costs’ end- we may impose so many restrictions on someone’s choices they are not able to do anything they might enjoy. So effective risk management is about knowing the place on the washing line that allows someone to make choices safely. To take the analogy one step further it is about putting some washing pegs in place (or control measures) to minimise the risk of harm.
What do we mean by control measures? These would include things such as a contingency plan. If something happens what can we have in place to minimise harm. That might be an early review of medication, or bringing someone back from leave at home. This is where we would also think about protective factors that can help keep someone safe, such as the support of family members. In thinking about networks of support one of the keys to good risk management is having the support and co-operation of other workers and other agencies around you. Assessing and managing risk is done best with others. One of the fears that workers have is if something goes wrong they will get the blame, and so sometimes stick to the ‘safest end’ of the washing line. Sharing risk decisions with others allows us come to a balanced decision. Managers have their part to play too, through supervision. Being able to sound out your decision making with managers and colleagues improves our decision making and our confidence.
No easy solutions
Management of risk can never be scientifically accurate. Risk assessment tools and forms can guide your assessment – but those assessments will be determined by the worker who compiles them. Finally, a quick summary of points to improve those assessments:
- Share your assessment information with colleagues and manager and other agencies (keeping in mind confidentiality policies)
- Record your decision making and involve service users in that decision making
- Think about risk in its widest sense – not just the severe end of the spectrum. That will help in positive risk taking.