An Exploration of Barriers and Facilitators to Risk Assessment in Mental Health Professionals
The decisions made by Mental Health Professionals (MHPs) are of utmost significance for providing the highest quality care to service users. The assessment of risk is one of the pivotal processes that MHPs undertake frequently, as per government policy guidelines, and in order to safeguard patients and the public. Although Risk Assessment Proformas (RAPs) consume a proportion of MHP time and resources, very little research has been undertaken to address factors that might affect their most optimal utilisation in practice. Previous literature suggests that medical decisions, like decision making of other kinds, is fraught with difficulty including being susceptible to the influence of cognitive biases, pre-decisional affect, overconfidence, and subjectively held attitudes towards organisational policies and regulations. Specifically, the presentation of risk information can influence decisions. It has also been suggested that anxiety has the capacity to elicit risk aversive responses, and that overconfidence and negative attitude may lead to complacency in undertaking policy-led responsibilities and produce non-compliance for the same. However, much of what is known about medical decision making has been gleaned from outside of context of mental health. As such, the current programme of research aimed to explore decision making in mental health settings and with a view to raise awareness of the complexity of decision making amongst MHPs. The implementation of quantitative and qualitative techniques (studies 1 and 2) revealed negative attitudes from psychiatrists towards Risk Assessment Proformas (RAPs), which are essentially structured decision making aids. Psychiatrist, compared to other MHPs, spent less time completing RAPs, which may reflect their differing attitudes towards their usefulness, something that was consistently emphasised during in-depth qualitative exploration. It was also found that experience was an additional differentiating factor between MHPs. Relationships between experience and other factors such as anxiety, confidence and complacency were found via conversations with MPHs, experience members of staff being less inclined to provide comprehensive and detailed accounts of service user risk in RAPs. This is problematic since although there is, in the UK, a policy led requirement that RAPs are completed for each service user, it is clear that there are inter-professional variations in how RAPs are being used and this acts to inhibit the best information sharing between all those involved in patient care. Following previous work in the area of cognitive bias and its influence upon general and medical decisions, a clinical vignette was also developed (study 3) to establish whether the presentation of risk information influences psychiatric admission decisions. The current findings supported previous work in that decisions were susceptible to the framing effect. The findings here, and previously in the literature, reveal a necessity for MHPs to be informed of bias in decision making in an attempt to improve objectivity in risk assessment practices. The unearthing of the framing effect also further signals the need for proper use of RAPs, where many MHPs may not be using them to their full potential - i.e. an aid to the systematic consideration of a range of information about a service user. The final part of the thesis (study 4) turned to the piloting of an educational module incorporating content around the factors affecting decision making in an attempt to raise awareness amongst MHPs. The rationale being better awareness of the complexity of decision making may act to enhance decision making processes. Pre and post intervention analyses revealed an improvement of baseline to follow-up knowledge of decision making bias and statistical concepts and this knowledge was maintained to a moderate level at four weeks follow-up. Although individuals maintained their susceptibility to the framing effect, the bias was less prevalent in those who knew of its presence before taking part in the study. Overall the findings give some support to the use of education as an approach to raising awareness about decision making processes in MHPs, although what remains to be seen is whether such education acts to bring about changes in behaviour - for example, different use of RAPs. The PhD programme suggests that MHPs are just as susceptible to cognitive biases, such as the framing effect, as has been demonstrated in both general population and other groups of health practitioners. At the same time, attitudes to RAPs differ depending on exact job role, which psychiatrist being least likely to spend time on their completion and reporting them as a tool for noting decisions reached as opposed to an aid to the process. This acts reduce the quality and quantity of reported information shared with colleagues about a service user. It is possible that MHP behaviour aligns with general attitude-behaviour models, such as the Theory of Planned Behaviour. As such, whilst the current work has demonstrated that educational interventions may act to improve awareness of decision making processes and their influences, further research would benefit from considering if these types of approach affect actual behaviour. For example, improved used of RAPs as decision-aids, reduced susceptibility to framing effects, consciousness around how information is represented in RAPs given knowledge of how the information may be used by others.