Risk management : an investigation into nurses response to risk presented by people with severe mental health problems
In the last few years clinical risk assessment and management in people with severe mental
health problems has become a national agenda following various critical incidents reported in
national confidential enquiries (Sheppard 1996, Bloom-Cooper 1996, Ritchie 1994) and the
media. Evidence from previous studies suggested that nurses' risk assessment and
management practices have not been fully explored although the risk assessment and
management practices of other professionals such as doctors and psychologists have been
explored (Modestine 1989, Lidz et al).
The aim of this study was to explore how nurses managed risk presented by people with severe
mental health problems.
Data collection involved a mixed approach of both qualitative and quantitative methods in a
three stage process. Stage I involved the review of a number of case notes (N=300), 150 case
notes from the community and 150 case notes from the in-patient services. Gaps in the case
notes reviewed led to a stage II of the study in an attempt to understand the nurses risk
assessment and management practices from their point of view. Stage II of the study involved
an interview with qualified nurses (N=10) in the UK, 5 participants from the community and 5
participants from the in-patients services. Following the data collection and analysis in both stages one and two of the study the researcher believed that an international focus and
perception of factors that influenced the risk assessment and management agenda and
practices would be useful for comparison and learning. This therefore led to a stage III of the
study which involved the collection of data through an interview process with international
experts in clinical risk assessment and management and a group of clinicians and managers
from two different clinical settings in the United States. The data from the case notes reviewed
was analysed using Statistical Package for Social Sciences version 12 and contents analysis
was used to analyse the data collected from the interviews.
The major findings from the case notes reviewed showed that the community patients were
more likely to have risk assessments completed with a total of 101 out of 150 completed risk
assessments. Nineteen (19) patients on level 3 CPA did not have completed risk assessments.
One hundred and thirteen (113) out of 150 patients had risk management plans and only 47 out
of 150 patients had risk relapse plans completed. The in-patients case notes reviewed showed
that only 74 out of 150 patients had risk assessments completed on admission. Only 21 out of
43 formal (detained under the Mental Health Act 1983) patients had risk assessments
completed on admission. Sixteen (16) patients on level 3 CPA did not have completed risk
assessment. Ninety two (92) patients had risk management plans with only 35 risk relapse
Major findings from the interviews showed that nurses risk assessment and management
practices were diverse and inconsistent with varied perceptions of responsibilities and practices.
Evidence of diffusion of responsibility within the in-patient services indicated that high risk
patients admitted formally (under the Mental Health Act 1983) did not have risk assessments completed on admission. The perception of the 'blame culture' within the organisation hindered
the completion of risk assessment, management and relapse plans.
The interviews with the participants from the United States demonstrated that risk assessment
and management was very much team focused with professionals developing and using
creative ways of engaging high risk patients who presented a risk to themselves and others. A
standardised risk assessment tool approved by the State in which the study was conducted, and
used by all the mental health facilities was perceived to be protective against litigation by the
Recommendations for practice included a review of risk assessment and management training
for nurses at both pre and post registration levels to include strong emphasis on responsibilities
and communication. National Health Service Trust hospitals to introduce robust mechanisms for
monitoring risk assessment and management practices to ensure that risk assessment and
management practices are viewed by the professionals as a dynamic and not a static process.
National Health Service Trust hospitals should address the perception of the 'blame culture' and
the diffusion of responsibility and promote life-long learning cultures to enhance risk assessment
and management practices. National Health Service Trust Boards to support clinicians
especially nurses in developing creative ways of engaging high risk patients who present a risk
to themselves and others.