Practicalities of HCR-20 implementation within secure psychiatric services

Abstract

The HCR-20 is established as the de-facto tool for the assessment of violence risk within forensic psychiatric services. Although much has been written about the value of the tool, less has been written about the practicalities of achieving meaningful completion of HCR-20 assessments at a service level. The present paper seeks to review recommendations within the literature and also those based upon the authors' own experiences in HCR-20 implementation, reviewing a number of the common issues and barriers encountered within the development of a strategic, service-level, approach to completion of the HCR-20. Possible solutions to these problems are also considered. We conclude that although there is not necessarily a single approach that is right for every service, certain principles need to be followed to ensure high quality assessments. Further, we develop a number of 'good practice points' which will be useful for services considering this issue on a strategic level, as well as commissioners evaluating the quality of HCR-20 completion within services.

Changing clinicians’ perceptions of the role that risk formulation and the HCR-20v3 play in the assessment and management of violence

“…The HCR-20 is used more routinely within forensic settings whereby risk to others is a key criterion for admission; however, this tool is also gaining empirical support for use within other psychiatric populations, including community settings where it can be used to predict violence post-discharge (Farrington et al , 2008; Douglas, Hart, Webster, Belfrage, Guy and Wilson, 2014; Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014; Strub et al , 2014; Doyle et al , 2014). Despite the wealth of literature on the high incidence of violence within mental health settings and the proven the clinical value of the HCR-20, Beazley et al (2017) noted that “cognitive distortions” exist as significant perceived barriers to the routine completion of HCR-20s (p.7). These “distortions” include the common perception that the completion of a HCR-20 takes considerable time and is regarded as a non-essential task in addition to clinical duties.…”

“…The importance of training provisions in the management of risk has been highlighted in best practice guidance (DoH, 2007a), the HCR-20 manual (Douglas, Hart, Webster, Belfrage, Guy and Wilson, 2014; Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014, p. 101) and is recommended in the trust’s local Clinical Risk Policy. Additionally, Beazley et al (2017) noted the importance of training provisions to clinicians who have had a limited prior opportunity to develop competencies of assessment and clinical formulation through experience, training and supervision. In response to this, many NHS trusts are incorporating HCR-20 training into their training packages, which is likely to result in variation, mirroring the wide variations in use and implementation of the HCR-20 tool itself (Beazley et al , 2017).…”

“…Additionally, Beazley et al (2017) noted the importance of training provisions to clinicians who have had a limited prior opportunity to develop competencies of assessment and clinical formulation through experience, training and supervision. In response to this, many NHS trusts are incorporating HCR-20 training into their training packages, which is likely to result in variation, mirroring the wide variations in use and implementation of the HCR-20 tool itself (Beazley et al , 2017). External HCR-20 training is unlikely to be utilised by services due to the resource required to fund such a strategy.…”

“…Additionally, the research focus has been within forensic services, despite the tool having wider applicability to other settings. With the barriers to completion noted by Beazley et al (2017), changing perceptions of the usefulness of the tool and its ability to impact the way an individual’s risk is managed are important to ensure that the added value of completing a HCR-20 is truly impacting the way clinicians formulate and manage risk in practice. Such research has the ability to guide how training is packaged and delivered and whether it is a worthwhile focus of service resources.…”

“…Additionally, comprehensive assessments using the HCR-20 are still viewed as time-consuming, which may not be undertaken by staff due to lack of confidence (Reynolds and Miles, 2009). The practical focus of the training which aimed to develop ability to complete a HCR-20 form on RiO was considered to be a key component in breaking down some of the barriers to completion and perception, such as regarding the tool as a non-essential task (Beazley et al , 2017).…”