my life, my risk€¦ · guesswork) about whether or not an adverse event is likely to happen by...
TRANSCRIPT
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P R O F E S S O R C H A R L O T T E C L A R K E
MY LIFE, MY RISK
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WORKSHOP IN OUTLINE
1. What do we mean by risk?
2. What’s so hard about risk management?
3. How can we understand risk differently?
4. How can risk taking enhance quality of life?
5. How can we do risk management differently?
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INSTRUCTIONS!!
• You need 2 or more pieces of post-it note paper
•And a pen!
•On each side of paper you will need to write a symbol and a few words...
• There is very little space and little time – so write small, think quick!!
• This is fun – but important
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PART 1
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MARY & FRED
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MARY & FRED
Carers help Mary
bed
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MARY & FRED
Carers help Mary
to bed
• No evening time together
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MARY & FRED
Carers help Mary
to bed
• No evening time together
Move house
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MARY & FRED
Carers help Mary
to bed
• No evening time together
Move house
• None in area
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MARY & FRED
Carers help Mary
to bed
• No evening time together
Move house
• None in area
Bed downstairs
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MARY & FRED
Carers help Mary
to bed
•No evening time together
Move house
•None in area
Bed downstairs
•Can’t have church meetings in house
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MARY & FRED
Carers help Mary to bed
• No evening time together
Move house • None in
area
Bed downstairs
• Can’t have church meetings in house
Respite care for Fred’s surgery
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MARY & FRED
Carers help Mary to bed
• No evening time together
Move house • None in
area
Bed downstairs
• Can’t have church meetings in house
Respite care for Fred’s surgery
• Mary never goes home again
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APPROACHES TO RISK
• An objective approach, quantifying risk by
calculating the statistical probability of particular
(and usually adverse) events occurring
• Risk calculation is based on the belief that we can make objective, rational judgments (as opposed to intuition or
guesswork) about whether or not an adverse event is likely
to happen by calculating the event's statistical probability.
• A subjective approach, focusing on what
risk means to different people
• Influenced by culture, power, regulation, questions about ‘in whose interests’.
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Risk / Harm management
Vulnerable people
Risk enablement / positive risk taking
Vulnerable situations
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IF SOMEONE ASKED MY ADVICE ABOUT WHAT
RISKS AND DILEMMAS THERE ARE FOR PEOPLE
LIVING AND WORKING WITH DEMENTIA
I WOULD SAY ...
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CLARKE, KEADY , WILK INSON
DILEMMAS IN RISK MANAGEMENT IN DEMENTIA CARE
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STUDY 1
• Questionnaire survey in England, Wales and
Scotland concerning risk management practices.
• 46 responses obtained.
• Responses to:
• “Providing services for any client group can create risk
dilemmas in which service providers find themselves with
difficult decisions to make about care. Please describe some of the risk dilemmas that you and your organisation
are faced with – you may use (anonymous) case examples
to describe these”.
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RISK & INDEPENDENCE
• “Encouragement of independence always results in increased risk to the individual”
• “Perceptions of what constitutes acceptable risk can often be problematic between managers, staff and family carers – family carers need to keep the person with dementia ‘safe and looked after”
• “Quality of life versus safety, such as walking about the home – activities the resident enjoys”
• “Restraint and restriction of personal freedom are a daily dilemma”.
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RISK & RESOURCE
• “Keeping people at home when there isn't a residential resource available”
• Lack of resources, especially in terms of staffing, can “prevent effective and constructive risk taking”
• “We have 1:1 care and focus on what each individual client wishes to do, for example, we had a male client who became extremely restless if he was unable to go outside, we are in the fortunate position that he was able to leave the building any time with a volunteer for an enjoyable walk around the park”
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ORGANISATIONAL RISK MANAGEMENT
• Health and safety legislation “can inhibit proactive practice as nurses fear litigation”
• “Difficulties about making decisions about care and the dilemma regarding appropriate representation (no real advocacy service available)”
• “There is a tendency by purchasers to remove the person rather than the 'risks' involved. Clients are disempowered and their rights as citizens denied due to medicalising dementia and collusion of social services.”
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KEY MESSAGES
• In day to day decision making situations, the dilemmas faced by many of the respondents concerned balancing independence and autonomy with exposure to potential harm.
• Maintaining safety and protection from harm is, in the view of some respondents, insufficient.
• The dilemmas faced by practitioners and service managers in risk assessment in dementia care are indeed complex, and profoundly influence the nature of care available to people.
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STUDY 2
• Collaborative learning group, addressing risk
management in dementia care
• Approx. 20 practitioners
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SEEKING CERTAINTY
• How to respond in situations fraught with uncertainty!
• How to work with complexity
• Risk-adversity: ‘tick-box’ thinking
• Enabling ‘risky’ activities
• Risk repair – by practitioners & people with dementia
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JUDGMENTS
• Making judgments – being judged
• Making judgments for fear of being judged
• Working with multiple views of the ‘right’ thing to do
• How to gather and interpret information to inform judgments
• Keeping the person central for person-centred care
Needs / wishes of person
Self as practitioner
Employing institution
Society / community
Family members
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TEAM WORKING
• Conflicting views between colleagues, between
professions & between sectors
It’s a social
problem
It’s a cultural
issue
It’s your problem
It’s the family..
It’s a medical problem
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RISK – SCOPE OF RESPONSIBILITIES
‘Risks are inherent in social care, as in everyday life.
Those leading and governing a service manage the
risks in their service in a systematic way which is
embedded in a culture focused on the safety,
welfare and quality of life for people using the
service.’
Health Information and Quality Authority 2013)
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PART 2
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ROLES IN RISK MANAGEMENT (ALASZEWSKI ET AL 1998)
• Risk is a hazard
• and the practitioner is a hazard manager
• Risk is potentially empowering
• and the practitioner is a risk facilitator
• Risk is a dilemma
• and the practitioner is an dilemma negotiator
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EXAMPLES OF YOUR ROLE AS: - A HAZARD MANAGER - A RISK FACILITATOR
- A DILEMMA NEGOTIATOR
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TWO MOTHERS
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TWO MOTHERS
‘My mum, while she still had some mental capacity, said to me:
So what if I go out. If I get lost, someone will help me home. If I walk in front of a bus so be it let nature take its course.
We put Mum's physical safety ahead of her freedom. She is now in a Care Home. We felt we had no choice .’
http://forum.alzheimers.org.uk/showthread.php?63715-Risk-averse-carers-hasten-dementia-decline
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RISK: QUALITY OF LIFE OR PHYSICAL SAFETY?
• Creating ‘silent harms’ (Clarke et al 2011)
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RISK: QUALITY OF LIFE OR PHYSICAL SAFETY?
• Creating ‘silent harms’ (Clarke et al 2011)
• Managing risk by attending to physical safety only
can lead to (Titterton 2005):
• Ignoring other needs
• Denying right to choice and self-determination
• Loss of a sense of self-esteem and respect
• A form of institutionalisation with loss of individuality, volition
and increase in dependence
• At its worst, can lead to abuse of vulnerable people.
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MAINTAINING WELLBEING FOR OLDER PEOPLE
• Re-narrating life
• Social networks
• Having a purpose
• Finding a meaning to day to day life
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Vulnerability of individual,
social or physical environment
Being perceived to be ‘At Risk’
May result in heightened surveillance,
altered freedoms, altered place of ‘home’
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Time reference
back Person privileged
Time reference
forward
Dementia
privileged
Lay-Professional Time Framing
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Time reference back
Person privileged
Time reference
forward Dementia privileged
Lay-Professional Time Framing
Information ‘provided’
about dementia
Information ‘elicited’
about the person
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TEMPORAL ACCOUNTING: BALANCING LOSS AND ASPIRATION
Facing a diminishing
future? E.g. loss of influence & power, loss of faith in society
Aspirations for the future e.g.
political motivation to
improve services
Sense of loss – societal e.g. loss of respect from
others
Individual aspirations e.g.
self-determination
Sense of loss – individual e.g.
loss of health & abilities,
bereavement
Moyle W., Clarke C.L. et al. (2010) Older people maintaining mental health well-being through resilience: an appreciative inquiry study in four countries. Journal of Nursing and Healthcare in Chronic Illness 2;113-121.
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• The dual-ality of risk
• Harm vs. enhancing QoL
• ‘Subject of society’ vs. providing leadership
• Individual ‘at risk’ vs. ‘society as risk’
• Temporal accounting
• Changing ‘life goals’
• Diminishing concern for self & enhancing concern for
community / society
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IN ORDER TO PREVENT SILENT HARMS, I WOULD ADVISE A COLLEAGUE OR FAMILY MEMBER TO...
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TAKING A RISK?
‘Quite simply, risk taking is sometimes a
duty.
Not taking a risk can be bad
professional practice.
Often the real problem is that too few,
not too many, risks are taken.’
Carson & Bain 2008
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PART 3
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PRINCIPLES OF A LEGISLATIVE FRAMEWORK (CARSON & BAIN 2008; CLARKE ET AL. 2011)
1. When undertaking a risk assessment, the law may
specify the criteria to be taken into account.
2. The law requires you to consider whose values are
to be taken into account in assessing risk.
3. Consider your own professional responsibility under
the law of negligence: make decisions and act in
a way that is demonstrably consistent with what a
responsible body of your colleagues would do.
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OUTCOMES VS PROCESS??
A good process will,
hopefully very infrequently,
still lead to harm being incurred.
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SUPPORTING QUALITY OF LIFE THROUGH POSITIVE RISK TAKING
• Enable people to manage uncertainty rather than create certainty - to avoid unnecessary dependence and risk avoidance
• Effective advocacy of the views of the person with dementia – involve them in decisions about risk taking or risk avoiding
• Ensure that assessment includes psycho-social and emotional wellbeing as well as physical safety
• Ensure that there is good communication within and between services.
• Review regularly – people and contexts change!
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FRAMEWORK FOR RISK ASSESSMENT & MANAGEMENT (CLARKE ET AL 2011)
1. Identify risks in the life-context of personal biography & everyday life
2. Identify risk perspectives
3. Weighting of risks
4. Identify current and past strategies for managing risks
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PERSONAL RISK PORTFOLIO (NOTHING VENTURED, NOTHING GAINED. DH 2010)
High
QoL
Low QoL
High risk Low risk
of Harm of Harm
Stop
Substitute
Balance
carefully
Continue
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THINK OF A CURRENT RISK ISSUE FOR SOMEONE LIVING WITH DEMENTIA. ASSESS WHETHER TO: - CONTINUE - BALANCE CAREFULLY - SUBSTITUTE - STOP WHY? HOW?
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Risk identification
Risk assessment
Risk treatment
Risk monitoring
Risk reporting
RISK MANAGEMENT CYCLE (HEALTH INFORMATION AND QUALITY AUTHORITY 2013)
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NO EASY ANSWERS!
‘There is a delicate balance to
draw between empowerment,
safeguarding choice and
managing risk.’ Addendum for Dementia Risk / Benefit Assessment and Management
Tools (DHSSPSNI 2010)
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SOME VEXING ISSUES
• The role of protection - A mandate from society? • Which both enables and disables?
• Maintaining independence vs engaging in risky behaviours? • Risk experts – self management and non-compliance?
• Who assumes / relinquishes responsibility for protecting safety / promoting autonomy? • Individualisation of responsibility?
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A N D O N E T H A T C A N H A V E A N E N O R M O U S
I M P A C T O N Q U A L I T Y O F L I F E
RISK MANAGEMENT IS ONE OF THE MOST COMPLEX ASPECTS OF
PROFESSIONAL PRACTICE