Background
Methods
Eligibility criteria
Inclusion | Exclusion | |
---|---|---|
Sample/ Population | Studies that included mental health professional (MHP) participants: • Any member of staff responsible for risk assessment and risk management (i.e. mental health nurse, social worker, psychologist, occupational therapist and doctor/psychiatrist). • Mixed population (e.g. service users and MHP) studies were only included if the results were reported separately and data easily extractable. | • Studies that did not include MHPs (e.g. participants are all service users) • Studies conducted on students, trainees, peer support workers or those who are not responsible for risk assessment and risk management. |
Setting | Adult mental health services (both inpatient and outpatient services) in any geographical location | • Non-mental health related studies (i.e. physical health or learning disability). • Studies set in older adult, child and adolescent mental health services (CAMHS) or drugs/alcohol services. |
Phenomenon of Interest | Studies that reported on MHPs’ experiences and attitudes towards Shared Decision Making (SDM) in risk assessment (RA) and risk management (RM) with people with mental health problems. Studies that provided possible barriers and enablers to SDM in RA and RM as perceived by MHPs. For the purpose of this review: • For a decision to be a ‘shared’ decision it must include at least two participants (i.e. professional and service user), the sharing of information and a decision that is made and agreed upon by all parties • Based on Stacey et al’s (2015) ‘Three I’s Scale of Influence’ model, SDM requires all participants to be informed, involved and influential. Therefore, studies that discussed ‘working in collaboration’ or ‘service user involvement’ were included • Risk assessment may include statistical/actuarial tools, traditional clinical judgement or structured clinical judgement (combined) | |
Design of study | All study designs that produced original qualitative data, or mixed-methods studies that included a qualitative component | Studies that reported primarily quantitative data or where no qualitative analysis had been undertaken. |
Evaluation | Qualitative outcome methods that measured MHPs’: experiences of; attitudes towards; or perceived barriers and enablers to SDM in RA and RM | |
Research type | Original empirical studies. No restriction on publication status. | • Systematic reviews • Editorials • Opinion pieces • Letters and similar materials |
Language | Only studies written in English. |
Search strategy
Study selection
Data extraction
Quality appraisal
Data synthesis
Step 1: developing a coding manual
Step 2: pilot coding exercise
Step 3: coding papers and assessing reliability
Step 4: developing overarching themes
Step 5: mapping the COM-B model to the TDF domains
Step 6: sensitivity analysis
Results
Study selection
Quality appraisal
Study characteristics
Author (Year) | Research aim | Location | Population | Data collection method | Data analysis method | Quality rating |
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Coffey et al. (2017) [20] | To examine what patients, family members and workers say about risk assessment and management. | UK | N = 67 Community mental health teams Senior managers (N = 12); Senior practitioners (N = 27); Care coordinators (N = 28) | Semi-structured interviews | Thematic analysis | Key Paper |
Gunstone (2003) [70] | To explore the experiences and perceptions of community mental health workers in assessing and managing the risk of self-neglect or severe self-neglect in people with serious mental health problems. | UK | N = 7 Community mental health team and assertive outreach team Community mental health workers (N = 7) | Semi-structured interviews | Thematic content analysis | Satisfactory |
Holley et al. (2016) [72] | To explore how risk management practice impacts upon the implementation of recovery- oriented care within community mental health services. | UK | N = 8 Community mental health teams Social worker (N = 3); Occupational therapist (N = 1); Nurse (N = 2); Psychiatrist (N = 2) | Semi-structured interviews using vignettes | Grounded theory | Key Paper |
Langan (2008) [16] Linked publication (Langan and Lindow, 2004 [42]) | To explore how MHPs assessed risk to others and the extent to which they involved service users. To ascertain service users’ knowledge of, and involvement in, risk assessment. | UK | N = 46 Adult psychiatric inpatient setting Psychiatrist (N = 14); Nursing (N = 22); Social worker (N = 5); Psychologist (N = 2); Occupational therapist (N = 1); Unqualified (N = 2) | Semi-structured interviews | Thematic analysis | Key Paper |
Woods (2013) [63] | To identify and describe the nature and extent of current risk assessment and management approaches used in the adult inpatient mental health and forensic units | Canada | N = 48 Adult inpatient mental health and forensic units Psychiatric Nurse (N = 33); Registered Nurse (N = 2); Licensed Practical Nurse (N = 1); Special Care Aide (N = 7); Social Worker (N = 2); Student Nurse (N = 1); Other (N = 2) | Focus groups | Thematic analysis | Satisfactory |
Barnicot et al. (2017) [71] Linked paper (Insua-Summerhays et al., 2018 [77]) | To understand how staff and patients experience negotiating the balance between privacy and safety during decision-making about continuous observation. | UK | N = 31 Adult psychiatric inpatient setting Nursing (N = 9) Unqualified nursing staff (N = 12); Clinical team leader (N = 2); Ward manager (N = 3); Modern matron (N = 1); Consultant psychiatrist (N = 3); Consultant clinical psychologist (N = 1) | Semi-structured interviews | Thematic analysis | Key Paper |
Felton et al. (2018) [66] Linked paper (Felton et al., 2018) [78] | To examine MHPs’ experiences of potential contradictions between promoting recovery and managing risk in decision-making. | UK | N = 17 Acute inpatient ward and assertive outreach team Mental health nurse (N = 4); Ward charge nurse (N = 1); Consultant psychiatrist (N = 3); Community mental health nurse (N = 7); Community support worker (N = 1); Support worker team manager (N = 1) | Unstructured observations and semi-structured interviews | Case study theory building approach | Key Paper |
Awenat et al. (2017) [81] | To investigate the experiences and perceptions of staff working with in-patients who are suicidal | UK | N = 20 Adult psychiatric inpatient setting Qualified nurse (n = 8); Nursing assistant/support worker (N = 2); Psychiatry (N = 4); Allied health professional (N = 6) | Semi-structured interviews | Thematic analysis | Key Paper |
Sun et al. (2006) [67] | To explore and examine psychiatric nurses’ and patients’ perceptions of the care offered to patients with suicidal ideations on psychiatric wards | Taiwan | N = 15 Acute psychiatric ward and psychiatric stress ward Registered Nurses (N = 15) | Participant observation and semi-structured interviews | Grounded theory | Satisfactory |
Forsberg et al. (2018) [60] | To examine the processes involved in clinicians’ decision-making, specific to neuroleptic discontinuation. | UK | N = 12 Adult community mental health team, early intervention service or recovery team Psychiatrist (N = 5); Mental Health Nurse (N = 7) | In-depth interviews | Grounded theory | Satisfactory |
Vandewalle et al. (2019a) [82] | To uncover and understand the core elements of how nurses on psychiatric wards make contact with patients experiencing suicidal ideation. | Belgium | N = 19 Adult psychiatric wards Nurses (N = 19) | Semi-structured interviews | Grounded theory | Key paper |
Nielsen et al. (2018) [61] | To report on forensic mental health clinicians’ experiences of the clinician-patient alliance during mechanical restraint. | Denmark | N = 17 Forensic mental health setting: secure unit and rehabilitation unit Nurse Assistant (N = 1) Social and Healthcare Assistant (N = 8) Nurse (N = 8) | Focus groups | Thematic analysis | Satisfactory |
Nyman et al. (2020) [64] | To explore mental health nurses’ experiences of risk assessments within their care planning and management of risks for violence by forensic patients. | Sweden | N = 15 Forensic psychiatric Wards Mental Health Nurse (N = 15) | Focus groups | Content analysis | Satisfactory |
Rimondini et al. (2019) [65] | To investigate the critical issues and strategies related to psychiatric patients’ empowerment in risk management. | Italy | N = 95 Various mental health settings Psychiatric nurse (N = 67); Healthcare and Social Assistance Operator (N = 10); other mental health professional, e.g., Psychiatrists, clinical psychologists, (N = 18). | Focus groups | Content analysis | Key paper |
Vandewalle et al. (2019b) [83] | To uncover and understand the actions and aims of nurses in psychiatric hospitals during their interactions with patients experiencing suicidal ideation. | Belgium | N = 26 Adult psychiatric wards Nurse (N = 26) | Semi-structured interviews | Grounded theory and constant comparison analyses | Key paper |
Coffey et al. (2019) [62] | To explore participants’ views and experiences of care planning and co-ordination, safety and risk, recovery and personalisation, and the context within which these operated. | UK | N = 31 Acute inpatient ward Nurses, ward managers, occupational therapists, psychologists and psychiatrists (N = 31) | Semi-structured interviews | Framework method | Satisfactory |
Lees et al. (2014) [69] | To explore the experiences and needs that mental health care consumers had of suicidal crisis, the degree to which those needs were met, the role that mental health nurse engagement played in that context, and the key factors suggested to impact on the quality of care. | Australia | N = 11 Adult inpatient and community settings Mental Health Nurse (N = 11) | Semi-structured interviews | Critical discourse, constant comparative and content analysis | Satisfactory |
Hagen et al. (2017) [74] | To explore and compare therapists’ and mental health nurses’ experiences of caring for suicidal inpatients in light of ethics of care and ethics of justice. | Norway | N = 16 Inpatient psychiatric wards Psychiatrist (N = 4); Psychologist (N = 4); Mental Health Nurse (N = 8) | Semi-structured interviews | Systematic text condensation and theoretically scrutinized | Satisfactory |
Fletcher (1999) [68] | To identify the way nurses perceive the purpose, nature and meaning of constant observation. | UK | N = 12 Inpatient psychiatric wards Registered Nurses (N = 4); Enrolled Nurses (N = 2); Student Nurses (N = 2); Nursing Auxiliaries (N = 4) | Participant observations and interviews | Content analysis | Satisfactory |
Nolan and Quinn (2012) [73] | To explore the reality of the everyday practice of mental health social work professionals in managing the risks service users with mental health issues face and present. | UK | N= 7 Community mental health teams Social workers (N = 7) | Semi-structured interviews | Grounded theory and the constant comparative method | Satisfactory |
Coder reliability and sensitivity analysis
Data synthesis
SDM components
Barriers and enablers
TDF Domains | Themes | Awenat et al (2017) [81] | Barnicot et al (2017) [71] | Coffey et al (2017) [20] | Coffey et al (2019) [62] | Felton et al (2018) [66] | Fletcher (1999) [68] | Forsberg et al (2018) [60] | Gunstone (2003) [70] | Hagen et al (2017) [74] | Holley et al (2016) [72] | Langan (2008) [16] | Lees et al (2014) [69] | Nielsen et al (2018) [61] | Nolan and Quinn (2012) [73] | Nyman et al (2020) [64] | Sun et al (2006) [67] | Rimondini et al (2019) [65] | Vandewalle et al (2019a) [82] | Vandewalle et al (2019b) [83] | Woods (2013) [63] | No of studies by domain |
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Knowledge | Policy or guidelines | 2 | ||||||||||||||||||||
Memory, attention & decision processes | Type or level risk | 4 | ||||||||||||||||||||
Individual Factors | ||||||||||||||||||||||
Skills | Training (or lack of) | 10 | ||||||||||||||||||||
Adapting Language | ||||||||||||||||||||||
Social Influence | Risk Vs Recovery | 18 | ||||||||||||||||||||
Power or best interest | ||||||||||||||||||||||
Service user capacity/insight | ||||||||||||||||||||||
Risk averse team culture | ||||||||||||||||||||||
Therapeutic relationship | ||||||||||||||||||||||
Supervision | ||||||||||||||||||||||
Environmental context and resources | Lack of staff, time, resources | 12 | ||||||||||||||||||||
Setting or meeting forum | ||||||||||||||||||||||
Local policies and procedures | ||||||||||||||||||||||
Social professional role and identity | Not my role | 16 | ||||||||||||||||||||
My professional role and responsibility | ||||||||||||||||||||||
Decision shared with MDT | ||||||||||||||||||||||
Service user jointly responsible | ||||||||||||||||||||||
Beliefs about capabilities | Difficult/sensitive topic | 11 | ||||||||||||||||||||
Lack of confidence | ||||||||||||||||||||||
Resolving disagreements | ||||||||||||||||||||||
Level of agreement | ||||||||||||||||||||||
Beliefs about consequences | Fear of causing distress/harm | 10 | ||||||||||||||||||||
Disengagement | ||||||||||||||||||||||
Stigma and labelling | ||||||||||||||||||||||
Fear of blame/accountability | ||||||||||||||||||||||
Fear for personal safety | ||||||||||||||||||||||
Intention | Acceptance of current practice | 4 | ||||||||||||||||||||
Aspiration | ||||||||||||||||||||||
Goals | Not a priority | 13 | ||||||||||||||||||||
Obligatory reasons | ||||||||||||||||||||||
A shared decision | ||||||||||||||||||||||
To provide knowledge | ||||||||||||||||||||||
Improve RM or reduce risk | ||||||||||||||||||||||
Reinforcement | Value collaboration or SDM | 14 | ||||||||||||||||||||
Positive risk-taking | ||||||||||||||||||||||
Promote empowerment or recovery | ||||||||||||||||||||||
Empathy or compassion | ||||||||||||||||||||||
Emotions | Anxiety | 9 | ||||||||||||||||||||
Fear |
Capability
“The evidence we have is that it is worth giving most people a trial off the medication in order to see if their illness would be a relapsing recurring one” [60] p244)
“I think risk to other people tends to be thought of as being...You know, look at it historically and see what has happened before. Whereas, risk of suicide, although that’s important as well, tends to be more on how the patient feels, in terms of harming themselves, at that time. So, probably, risk to self is more centred on the patient” [16] p476)
“I have never done any training on this topic. I know that I may change my attitude towards the patients, but I don’t know how to do it” [65] p7)
“I ask patients how they feel about it when I talk to them about suicidality and how they prefer to have these interactions” [82] p2870)
Opportunity
“Every encounter with a patient should be made therapeutic … but it isn’t the primary purpose. The primary purpose is safety. I think the policy makes it very clear that safety trumps everything else” [77] p553)
‘ … risk dominated the decision-making of professionals to such an extent that it defined how service users were understood and treated with limited evidence of power-sharing and involvement of service users in decisions’ [66] p1142).
“If we indicate to patients that we are going to the seclusion room, then few patients say they’d “rather not”. But even when they say they’d “rather not”, we do it anyway, and then we emphasise, “Look, we want to protect you against your thoughts” [83] p1129)
“Of course it can get difficult if the service user says no, “I want, I want to do it my way now,“ Um, and then you have to have a very different conversation and you need to say that we feel collectively as a team that at this stage it’s still a risk” [72] p4)
“We can share the responsibility with the patient only when he has totally understood and accepted what is happening to himself, otherwise it is very difficult …” [65] p7)
“To my shame, there are cases that I follow that culture, that I hide that risk assessment or secret. Why? Because I want to protect the individual from the knowledge of that.., their illness that they have can be a risk to themselves or to the others. It’s a practice that I’m not very comfortable but nevertheless, I raise my hand and say I have” [20] p6)
“Rapport is key. .. it means I can get the information I need and that they’re more likely to actually tell me whether they’re still suicidal or not, and then from there we can work out what they need together” [69] p310)
“If you’re beginning to know a bit more about who they are, you might feel able to take greater therapeutic risks, in the hope of encouraging them to take responsibility” [71] p478)
“Sometimes I spend more time reporting than being present with the person. That is a shame! I sometimes wonder what is most important, “What I write down or what I really do with that person?”. Of course, I believe it is important that you write down things in case something happens, but I also believe that there are too many administrative tasks” [83] p1130)
“Formal ward round-based review meetings were named as a place for risks to be discussed although not necessarily in the presence of service users” [62] p12).
Motivation
“it was not clear how often the teams made decisions based on what they thought was appropriate for the client, rather than on the client’s personal and informed choice” [70].
“You know they [meaning colleagues] have a duty to protect the populous from risk. Sometimes that may not chime with the personal interest of the patient ...” [60] p243)
“Basically, it’s down to them to tell us … we’ve no other way really unless they already told their relative so they’re gonna have to be speaking about it” [81] p105)
‘ … although all participants are specialized in mental health nursing, one of them stated that she does not feel educated or confident enough to talk with patients about suicide, and another informant stated that there should be much more focus on caring for suicidal persons in the education’ [80] p33).
“Very difficult. Very difficult. He’ll deny many of the incidents that I’ve told you about. He’ll say that the police are wrong, that they were harassing him. That he didn’t do these things. That he’s not a risk to other people …. So it’s very, very difficult, yeah, to find any middle ground there really” [42] p18)
“Obviously, if they can acknowledge that there is a problem then we’re in a much better position to ensure that they put something in place which works” [42] p17)
“Sometimes we avoid involving patients in order to preserve his saneness. In the psychiatric field is difficult to evaluate how much information the patient may tolerate” [65] p7)
“the stigma of the mental health is still very prevalent in our society so by doing a risk assessment you more or less emphasise that stigma. .. You are a very risky person, you’re dangerous to yourself, and you’re dangerous to society, whereas this doesn’t go well with the recovery that we try to achieve for that person” [20] p8)
“Risk-taking and promoting an individual’s freedom is encouraged but you’re conscious of the fact that if someone gets hurt, it’s not just them. .. criticism will be levelled at each level within the authority” [73] p180)
“I’m quite open to change and including the person more in it, rather than it just being professionals talking about the risks” [16] p477)
‘… they had given little consideration to how they could directly and actively involve clients in the assessment and management of risk’ [63] p810).
“In order to take care of these suicidal patients, I try to build a trusting relationship with them. If I can build a good trusting relationship with them, they will trust me. They will give me the information I need and then we can explore their problems and try to help them to prevent future suicide attempts” [67] p687)
‘These nurses avoid imposing instant protection and instead engage in dialogue with patients that facilitates understanding of risks and potentially risky situations (e.g. taking a bath), the meaning that patients attach to risks and potentially risky situations, and what can be done to address risks’ [83] p1126).
“I think it’s more of a risk if it’s other people talking about them behind their back. I think the more that things can be out in the open, the less of a risk it is” [42] p14)
“The opportunity to interact is the ultimate. .. it’s a really important interaction... It can be the difference between life and death” [69] p309)
“if it is her wish to look after her finances then actually she is entitled and that needs to be explored very slowly with her [. . .] You can give her advice whether it’s a good decision or a bad decision but it’s her decision to take control of it” [72] p3)
“I feel it’s important to feel and show empathy. If you don’t have empathy, you have no way of realising the patients’ torment and discomfort, or how serious or how strongly they feel about attempting suicide” [67] p687)
“I think it’s scary because you don’t want to be the last person having that conversation and they do something. You don’t want to think you’ve done anything that could have erm, actually aggravated them or tipped them over the edge or you’ve said something that has made them think about something” [81] p106)