Chapter 7 Systemic aspects of risk assessment and management
Risk is never limited to the patient. Clinicians, family, the wider community, other health services and so on will all be involved. At its simplest level, risk will be managed between one individual clinician and the patient but this is an unusual situation. More commonly the potential consequences of an adverse outcome will be felt by a much wider selection of people and they are likely to become involved in some way in the assessment and management of the risk. Family and friends are often vital informants who will help identify early warning signs and triggers for risk behaviours.
Multidisciplinary team (MDT) dynamics affecting risk assessment and management
Group cohesiveness
Within a mental health team, there is likely to be more than one clinician involved in the care of a patient and even if there is only one clinician directly involved, the patient’s care will be discussed in a MDT format. The cohesiveness or otherwise of the staff group can have a large bearing on risk management. Group cohesiveness can break down for several different reasons, such as weak leadership or one clinician holding a grudge against another. Any psychological process affecting an individual clinician can also affect the MDT as a group. As is the case with individual staff, the capacity of the group to think and reflect may be impaired in a setting of risk and perceived danger.1
For example, if the psychiatric registrar is anxious about the care of the patient, this may make other clinicians anxious and the whole team becomes risk-avoidant. This will then need to be managed as a team problem. Conversely, if the MDT is supportive, anxiety will be lower and the risk thermostat for the team will be set differently.
Another influence on group decision-making is the concept of ‘groupthink’.2, 3 Groupthink is a type of thought exhibited by group members who try to minimise conflict and reach consensus without critically testing, analysing and evaluating ideas. Individual creativity, uniqueness and independent thinking are lost in the pursuit of group cohesiveness. During groupthink, members of the group avoid promoting viewpoints outside the comfort zone of consensus thinking. Groupthink may cause groups to make hasty, irrational decisions where individual doubts are set aside for fear of upsetting the group’s balance. Groupthink is more likely to occur in situations in which there is directive leadership, the group perceive themselves as being under stress from external threats or where there are excessive difficulties in the decision-making tasks. Moral dilemmas are also likely to invoke groupthink.
