Staff Perceptions of Facilitators and Barriers to the Use of a Short- Term Risk Assessment Instrument in Forensic Psychiatry

Abstract

Prospective adverse events within forensic settings should be assessed using structured risk assessment instruments. Our aim was to identify the barriers and facilitators of a structured instrument for assessment of short-term risk within inpatient forensic psychiatric care. The instrument was piloted at a forensic psychiatric clinic. Three focus group interviews were conducted with staff. Content analysis revealed three main categories of barriers and facilitators for clinical use: implementation object, context, and users. Complexity of the instrument, insufficient continuous training and support, difficulties retrieving assessments on wards, and insecurity about translating assessments into actions were perceived barriers to clinical use. Routines for documentation improved communication and the inclusion of protective and short-term dynamic clinical factors were perceived as clinically relevant. Problem-solving ability, attitude, and motivation of staff were facilitating factors. Comprehensive risk assessment instruments require substantial support for staff to find them manageable. Systematic documentation is required to measure actual daily clinical use.

The Totalising Nature of Secure and Forensic Mental Health Services in England and Wales

“…Collaborative risk assessment and management have been recommended in health policy for over a decade in the UK ( 48 ). However, there is evidence that the extent to which patients are involved in risk assessment is suboptimal ( 49 , 50 ). Patients are often not aware of the content of their risk assessments let alone included in their development ( 51 ).…”

“…Collaborative risk assessment and management may also lead to patients taking increased accountability for their own recovery ( 60 ), and providing information on their internal mental states which are associated with risk ( 61 ). However, the research which has been conducted indicates that the extent to which collaborative risk assessment is occurring may be suboptimal ( 49 , 50 ). However, evidence of the value of collaborative care in evaluating risk in secure and forensic settings does exist, and remains a possible means of improving forensic care ( 62 ).…”

“…The phenomenon of accepted fictions can present in that staff may recognise that the basis for certain approaches may be predominantly administrative and have no scientific validity ( 42 ). Staff may also prefer to avoid potentially problematic conversations regarding risk and offending behaviour for fear of this damaging the therapeutic relationship ( 49 , 75 ). The process of developing therapeutic alliances, and experiencing trust or even rapport can also be problematic due to the restrictive nature of secure and forensic mental health services.…”

Mental health nurses' attitudes towards risk assessment: An integrative systematic review

“…However, this did not always happen (Gilbert et al, 2011; Woods, 2013). Staff tentatively suggested that the START had been used to inform decisions about risk management (Levin et al, 2018). Survey results indicated that one third of nurses agreed that an emphasis on the importance of risk assessment inherently reinforces risk averse practices, while slightly more, two in five, disagreed (Downes et al, 2016).…”

A critical ethnographic perspective on risk and dangerousness in forensic psychiatry

“…Risk assessment instruments can improve clinical decisions, increase transparency in decision making, and enhance communication within the health-care team (Levin et al, 2018). Although they are better at predicting the risk of violence than unstructured clinical judgement (Fazel et al, 2012), their use remains ethically complex, notably because they still cannot predict future acts of violence very well (Douglas et al, 2017).…”