Personal (clinician) responses to risk

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Chapter 6 Personal (clinician) responses to risk

Within health care, clinicians are exposed to risks every day. Patients are exposed to risk, clinicians take risks and they sometimes put themselves at risk. Occasionally (perhaps often) clinicians feel that they carry all the risk or they find themselves saying, ‘We can’t take the risk’. Murphy (2002) comments, ‘Apart from the need to assess and manage risk, it also has an emotional component for all concerned and often a judgmental aspect.’¹ Undrill (2007) says, ‘Risk assessment has become a large and anxiety provoking part of the work of many psychiatrists.’²

Personal response to risk may vary from moment-to-moment and day-to-day. Sometimes it is easy to manage the risk and at other times clinicians may be more likely to avoid dealing with problems. In other situations, clinicians may be surrounded by so much risk that they become blasé about it.

The risk thermostat ³

The risk thermostat is a conceptual, qualitative model of how behaviour in risky situations is influenced by perceptions and attitudes. Cultural theory explains risk-taking behaviour by the operation of filters. It postulates that behaviour is governed by the probable costs and benefits of alternative courses of action which are perceived through filters formed from all the previous incidents and associations in the risk-taker’s life. This is shown diagrammatically in Figure 6.1.

Figure 6.1 The risk thermostat

Exercise 1

Below is a continuum which can be useful to consider when faced with a risk problem. The continuum characterises the alternative courses of action which will have been considered when risk decisions were taken previously. It allows for a consideration of where your risk thermostat is set at any given time and how the setting may change in different circumstances.

Imagine a recent episode in which you managed risk and ask yourself where you were on this continuum. Was the issue being managed by being risk-avoidant or risk-taking or was it being managed in a balanced way which required you or your team to be in the middle of the continuum?

Figure 6.2 Risk continuum

Most clinicians move up and down this continuum depending on many different factors. On the whole, it is easier to be risk-avoidant or blithely risk-taking. Sitting in the middle of the continuum (the preferred position) requires more effort, thought and interaction with the patient and their family. Setting the risk thermostat in the middle of the continuum may mean a slightly greater degree of anxiety on the part of the clinician as he/she will need to be more conscious of the possibility of an adverse outcome.

This is shown diagrammatically in Figure 6.3

Figure 6.3 Effort required depending on risk thermostat settings

In practice, it is more common to veer towards the risk-avoidant end of the continuum as this is driven not just by anxiety, but also high workload and limited knowledge base. Clinicians at the risk-taking end of the continuum are more likely to be working in situations where higher levels of risk are dealt with on a daily basis and they become desensitised to the level of risk; for example, crisis teams and inpatient units.

BOX 6.1 PRACTICE TIP

If individual clinicians feel or say that they are ‘carrying risk’ or feel burdened by the risk or say that they ‘can’t take the risk’, it usually means that they are not ‘managing the risk’ effectively.

Personal factors that may affect risk management

Most clinicians have learnt to identify and manage the personal factors that may affect risk management although they may be forgotten in the heat of the moment.

Here is a list of personal factors in the clinician which may affect the context of risk:

It is likely that these factors are additive.

Exploring personal factors in more detail

Fear/anxiety and emotional response to risk

Risk is synonymous with danger for many clinicians. If risk is perceived as dangerous, not as something to be assessed and managed with the patient, clinicians are likely to respond as if there is a personal threat. It may be in the form of danger from perceived attack, being stalked or from a fear of loss of registration if a suicide occurs. It is not only danger in the form of physical attack; personality disordered patients intrude on clinicians’ feelings and can affect the assessment. However, it would be wrong to ignore the fact that many clinicians are exposed to danger where there is a risk of personal harm. This can occur in many settings. The response to danger is invariably one of fear (‘survival anxiety’)⁴ but there may also be a loss of mental wellbeing from stress. Clinicians may also fear being blamed or fear personal and professional disgrace. If clinicians allow anxiety to affect risk management, it is likely that they will slip into secondary risk management (see glossary) which will have a ‘corrosive effect on the relationship between the clinician and patient’.⁵

The experience of fear/anxiety promotes an unconscious primitive defence designed to reduce clinician anxiety. The fight or flight response develops in which the patient can become the perceived threat. This is experienced either individually or at a staff group level. Because the defence is designed to protect the clinician as opposed to the patient, it will tend to promote a response of perceiving the patient as being the problem which precludes good risk and clinical management.

Patients can then be blamed (using externally directed hostility)⁶ for their problems or treated as consciously creating the problem. For example, ‘she’s just being manipulative’ or ‘he’s just personality disordered, not mentally ill’. Other common defences are to say, ‘it’s just a drug-induced psychosis’ or ‘this patient should be in forensics’. Anxious clinicians cannot reflect on what they are doing which will further reduce capacity for good risk assessment.

The task for individual clinicians and for clinical leaders is to create an environment in which risk assessment and management can occur whilst recognising the reality of risk posed to staff. When clinician anxiety is reduced, this will lead to an increased capacity to see the patient objectively and compassionately. Reduced clinician anxiety also reduces patient anxiety. This leads to better risk management. Clinician anxiety can be used as a tool to help assess the risk and as a tool to create dialogue within the team about risk; that is, using the fear of the clinician in group discussion as a tool to explore the likelihood of the risk occurring.

Competence and factual knowledge of clinician

• Clinician wisdom/experience

Increasing knowledge and experience would normally lead to an assumption that the capacity to manage risk would also be greater. This is usually the case but in those instances where team leaders or clinical leaders (e.g. consultant psychiatrists) are risk-avoidant, their seniority can cause substantial difficulties. Senior clinicians are sometimes risk-avoidant as a result of a patient having a bad outcome and the clinician being keel-hauled in a public setting, such as a coroner’s court. The best practice of confidential inquiries, peer review and individual supervision should limit this experience.

Mindset of clinician: ‘I should be able to save all of my patients’

To carry this mindset which has been described as an ‘over inflated concept of duty of care’⁷ is a recipe for burnout and rescuing behaviour on the part of the clinician. Although at times families, coroners and the media expect clinicians to prevent all suicides, this is not possible and the task is not to save all patients but to do the best within the limitations of the individual and the service.

Workload of clinician

• Energy/tiredness of clinician.

This point is self evident but can have a substantial effect on the capacity to manage risk. Making decisions at 3 a.m. is a different experience to making the same decisions at 3 p.m. Clinicians should be mindful of

BOX 6.2 PERSONAL RESPONSES TO RISK

Practice points

• If risk is managed by reducing clinician anxiety (secondary risk management), the risk to the patient may increase.

• If clinician/patient discomfort is reduced indiscriminately, opportunities for learning from and improving the symptoms may also be reduced.

• ‘In order to achieve therapeutic gain, it is sometimes necessary to take risks. A strategy of total risk avoidance can lead to excessively restrictive management, which may in itself be damaging to the individual.’⁸

the affect that their workload and tiredness is having on their decision-making.

Temperament (empathy, ability to tolerate distress)

• Proximity to the risk.

• Experience of patients having a bad outcome.

Within the mental health field, there is a wide variety of sub-specialities. Some clinicians are more able to care for some patients than others and it is important for them to be mindful of any personal characteristics which may affect decision-making in risky situations. Similarly, if clinicians have had a situation where there has been a bad outcome and that has had a substantial impact, consideration needs to be given to how this is affecting risk decision-making.

Finally, for some patients (not psychotic patients), it is often useful to sit with a certain degree of psychological tension as this will be the driver which helps them make necessary changes in their personal lives. It may well be important to support patients in this whilst recognising that both patients and clinicians may sit with a higher degree of risk for a period of time. This will be explored further in the clinical skills section of this book.

Related

Clinical Risk Management