Abstract
In a recovery focussed mental health service the aim is for patients to be involved in all aspects of their care (Scottish Government, 2012). Within mental health care, risk is incorporated in policy and procedures guiding Mental Health nurses’ practice. Earlier studies have shown that while mental health nurses felt strongly in support of risk assessment, many were strongly resistant to patients being involved in completing risk assessments. There is little evidence to suggest why this resistance exists, whether mental health nurses feel risk assessing is detrimental to therapeutic interactions or a barrier to recovery focussed care (Downes et al., 2016).Aims:- The aim of this project is to explore mental health nurses’ attitudes to risk assessment and how that affects recovery focussed care.
Methods This research was conducted as a mixed method project involving three individual studies to give an overall picture and triangulate evidence to cover the aims of the research.
Study one was completed by the collation of quantitative data. The data was taken at a single time point from all current nursing documentation in three under 65 acute psychiatric wards within an NHS health board. This served to survey frequency of risk assessment completion and involvement of service users within the process. The study also looked at whether the risk assessment documentation was revisited within the suggested time frames. The information was collated in a simple table format to affirm completion and service-user involvement, and to give context to the subsequent research studies.
Studies two and three were completed using a qualitative design to draw out the experiences and views of the registered nurses (study two) and patients (study three) on the wards. Invitations were sent to all current registered nurses and all current acute inpatients regardless of gender, diagnosis or length of service/admission. All participants were adults aged 18 to 65. All patients were deemed to have capacity to participate by their designated psychiatric consultant. Data were then gathered by individual single round semi-structured interviews. All data was transcribed verbatim from audio recordings and a thematic analysis was carried out by the research team. After care was available for anyone who potentially identified any additional needs following the interviews.
Findings Study one showed that patients are frequently not actively being involved in the risk assessment process with 30% of patients having no risk assessment paperwork completed. Of those completed, 66% indicated that there was no patient involvement in the assessment process, 72% were not completed on time and 83% had not been reviewed since completion. Initial interviews with nursing staff identified that possible reasons for this include lack of time, avoidance of difficult conversations, and a lack of perceived value to the documentation. Interviews with service-users showed a strong wish to be involved in the risk assessment and the care pathway, however the study also indicated that patients had limited awareness that there were risk assessment documents completed regarding their care. The results also showed that patients feel they are not listened to and that they benefit more from their peers on the ward than they do from interactions with nursing staff.
Conclusion
Many papers written on risk assessment claim that by being involved in the process the patient experiences a range of outcomes including feeling listened to (Sweeney et al 2014), developing trust for the nurse (Downes et al 2014) and gaining sympathetic support (Department of Health 2007). Most papers such as the work of Hseoi and colleagues (2015), Deuter and colleagues (2013) and Neech and colleagues (2018) take a more negative approach to the risk assessment process and look at the detriments of risk assessing in more detail than they do the overall benefits with particular attention payed to the difficulties in completing the documentation. This study has highlighted that the nursing staff themselves may be a contributing factor to the recovery focus of risk assessment on the mental health wards due to avoidance of difficult conversations, fear of aggression or lack of value to the process of risk assessing.
There needs to be a cultural shift around viewing risk assessment as a negative conversation to a recognition of the individual's strengths. Risk assessment should no longer be a tool that is viewed as invaluable and restrictive and should be taken forward as a collaborative tool that embraces all aspects of the individual's experiences as a means of planning future care to allow the individual to move forward.
Recommendations
Drawing on the findings of the three studies that took place the project drew three key recommendations.
1.As mental health drivers remove the center of care from in-patient services and place a greater emphasis on community based care it is highlighted that there is a need for the documentation used in care to change to accommodate and strength the change of emphasis. It is recommended that further research take place to streamline the paperwork used in Mental Health nursing into a continuous care record that follows the patient seamlessly through their journey.
2.It was highlighted that there was a lack of training and arguably this lack of understanding could contribute to the lack of value placed on the risk assessment documentation. It is recommended that the NHS trust in the study incorporates more robust training around risk assessment and risk management.
3.It was identified by both nursing staff and patients that there is a lack of collaborative working within the inpatient ward in the studied trust. It is recommended that research into collaborative working between the nurse and the patient is carried out with a view to making nursing documentation person centered and less objective.
| Date of Award | 22 Jan 2021 |
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| Original language | English |
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| Supervisor | Kate Smith (Supervisor) & Penny Woolnough (Supervisor) |