Author: Georgia Geller
Geller, Georgia, 2017 Psychiatric risk assessment and management: an exploration of clinical perceptions, knowledges and attitudes existing within the context of risk, Flinders University, School of Nursing & Midwifery
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Risk assessment and management (RAM) is a significant part of everyday clinical practice. Risk in psychiatric settings usually means the avoidance of adverse events (e.g. aggression, absconding). As such, professionals seek to prevent negative outcomes for patients, staff, and the public through RAM. Overall, there is a lack of robust research about how RAM is conceptualised and understood by clinicians working in acute inpatient psychiatric settings. This study examines the issues facing health professionals in undertaking RAM, and investigates their perceptions, knowledge, and attitudes towards RAM, as well as the enablers of, and barriers to, RAM practices.
Using a case study approach (Yin 2014) in Stage One, 14 multidisciplinary mental health professionals participated in semi-structured interviews. A thematic model (Braun & Clarke 2006) was used to analyse the data. The themes provided a rich description of how clinicians specialising in mental health manage risk, and how RAM is integral to, and underpins all, clinical practice. Focused practice was considered important, and the purpose of RAM was to minimise risk – to ensure the safety of patients, staff, and visitors. Predicting risk behaviours was essential to the expert clinician. Clinicians identified a number of difficulties they encountered when attempting to predict risk – yet most were confident in their predictions. Experience, clinical knowledge of risk factors, and an “inner knowing” enhanced predictive confidence and were integral to this process.
RAM was considered to be everybody’s responsibility. Confusion about roles and task specificity, as well as legal and ethical issues, were identified. Clinicians also considered effective communication between clinicians, and towards patients, to be essential for risk assessment. However, opinion was divided. If done well, this promoted feelings of support and protection; if not, the potential for unsafe practice resulted. Staff considered that effective communication skills promoted therapeutic relationships and required patient and family input. These themes, together with other enablers of, and barriers towards, RAM will be presented and contextualised within notions of “risk”. The implications of these findings for clinical practice, including contemporary assessment practices, roles, and responsibilities will also be considered. Stage Two is a document analysis of key sources and draws on the work of Karppinen and Moe (2012), Prior (2003), and Smith (1984). The theoretical work on risk by Ulrich Beck (1992) and Anthony Giddens (1990), and Isabel Menzies’ (1960), were then applied to the findings of Stage One and Two.
Two key points emerged from this analysis. Firstly, notions of risk within mental health settings are socially-constructed through stereotypes about patients diagnosed with a mental illness, legal prescriptions, ethical guidelines, public health policy, and the institutional and bureaucratic culture of the organisation; mirroring what Beck refers to as “risk society”. Together, these socially-constructed factors interact with clinical knowledge and experience to constitute the core of psychiatric practice in this setting. As a consequence, I have argued in this thesis that the care plan of the patient is primarily concerned with the management of risk, and that RAM and the Recovery Framework, which underpins mental healthcare, cannot coexist.
Keywords: psychiatric risk assessment, psychiatric risk management, mental health nursing, risk theory
Subject: Nursing thesis
Thesis type: Doctor of Philosophy
Completed: 2017
School: School of Nursing & Midwifery
Supervisor: Dr. Julie Henderson