One step at a time

Mike Titterton  is an independent consultant, researcher
and trainer. He works in the UK and in eastern Europe, where he has
been project manager for EU programmes in health and social
care.

In the UK risk has been placed higher up the agenda in work with
children and vulnerable adults. Changes have been taking place in
the legal context, in terms of new legislation and the impact of
human rights issues.(1) Concerns about the use of restraint, for
example in the care of older people, have been expressed in
parliament.(2)

At the same time, worries about the protection of children and
vulnerable adults have been reflected in inquiries into incidents
across the UK.(3) Health and welfare professionals are increasingly
in the harsh glare of the media due to their risk decisions.

In welfare settings, risk-taking can be defined as a course of
purposeful action based on informed decisions concerning the
positive and negative outcomes of types and levels of risk
appropriate in certain situations.

Dilemmas arise over the choices that vulnerable people and their
carers face between options that entail benefits and harm. No easy
solution or “one-size-fits-all” approach exists for resolving these
dilemmas.

The Prams model (person-centred risk assessment and management
system) is a framework for the consideration of these risks,
options and dilemmas.(4) It was developed for the assessment and
management of risk in community and residential contexts. Key steps
are presented here to guide the taking of risks in welfare
settings, based on this model.

Set out your risk policy
This consists of spelling out a risk-taking policy at
the level of the agency and the care unit or community team. This
sets out the main principles that will guide risk-taking. It is
worth involving all staff and managers as well as users and family
carers where possible, in order to broaden the ownership of risk
issues.

Assess the risk
An assessment should be made of: the nature of the
risk activity and the reasons for undertaking it; where the risk
activity will take place, and when; the likelihood and type of
benefits and harms for the individual, staff, the local community
and the service the practitioner represents.

Discuss the risk
It is important to discuss the risk with the
individual as well as other staff as appropriate. Time can be spent
talking through the risks involved, the advantages and
disadvantages and agreeing as far as possible broad limits for the
risk decision. This is a chance to evaluate how strongly the person
feels about taking the risk.

Make the decision
The decision to proceed with the risk should be made
as far as possible by the individual, after consultation and
discussion with the care professional and others. Where vulnerable
individuals are competent to make a decision, they should be
empowered to take that decision themselves. If all goes well, the
discussion and the risk decision is recorded. If an individual is
judged not to be competent to take a decision, steps should be
taken to check why this is the case. A decision has to be made
about whether an advocate or someone else should be involved in the
risk decision. It may be appropriate to involve relatives if the
individual agrees.

Draw up a plan
This step involves setting up a risk management plan.
The key elements of the plan should include: who has been
consulted; responsibilities for implementation; steps to be taken
to minimise possible harms; steps to be taken to enhance possible
benefits; timescale; when intervention should occur and how;
milestones for success or failure; and record-keeping
arrangements.

Reach a consensus
Check that all parties to the risk decision have been
consulted. This will include final discussions of the decision and
trying as far as is possible to reach a consensus on an agreement
of the risk decision. Where this proves impossible to secure
everyone’s agreement, these disagreements can be recorded.

Manage the risk
Too often insufficient attention is given to the
management of risks. It is essential to set out the key actions
designed to minimise each type of harm identified by the risk
assessment. It is also important not to neglect the benefits that
the assessment will have identified above. Steps that will increase
the likelihood of positive outcomes should now be proposed.

Make arrangements
Arrangements for monitoring, reviewing and the keeping
of records have to be specified and the other activities mentioned
in steps five and seven need to be organised. It should be a
requirement to ensure that these are in place first before
risk-taking occurs.

Take the risk
The individual begins the process of undertaking the
risk identified and discussed in steps two to four. It is now
important to monitor how the individual is doing and how he or she
is coping. It may be that some adjustments are required to minimise
harm or maximise benefits.

Review and reflect
A review is essential and an agreed date should be
set.
If there is a satisfactory outcome, care practitioners should learn
from this success, along with the person concerned. The
questions
they should ask are: what went well and why?

If there is an adverse outcome, again it is essential to learn from
the problems. This is an important part of the learning process for
all those involved. The need for discussion and agreement on how to
avoid future adverse outcomes is paramount. Support needs to be
provided both for the staff involved and the individual.

While the dreams of individuals in terms of taking more risks have
to be respected, a dose of realism is required. The individual and
the care professional may well make mistakes. They both need
encouragement and motivation if they are to learn from their
mistakes. Starting small, in other words, beginning with slow but
steady actions with limited and achievable goals helps build up the
confidence of the vulnerable individual. Just as important, they
can build up the confidence of the care professional too. 

Training and learning
The author has provided questions about this article
to guide discussion in teams. These can be viewed at
www.communitycare.co.uk/prtl and individuals’ learning from the
discussion can be registered on a free, password-protected training
log held on the site. This is a service from Community Care for all
GSCC-registered professionals.

Abstract
The author presents key steps to guide care
professionals and service users in taking risks. The steps are
derived from a systematic approach called Person-centred Risk
Assessment and Management System, developed by the author for the
assessment and management of risk in community and residential
settings.

References
(1) G Davidson, M McCallion, M Potter, Connecting
Mental Health and Human Rights, Northern Ireland Human Rights
Commission, 2003
(2) House of Commons health select committee, Elder Abuse, Second
report of session 2003-4, Stationery Office, 2004
(3) Scottish Work Services Inspectorate, Report of the Inspection
of Scottish Borders Council Social Work Services for People
affected by Learning Disability, Scottish executive, 2004
(4) M Titterton, Risk and Risk Taking in Health and Social Welfare,
Jessica Kingsley, 2005

Further information

• A Alaszewski, J Harrison, J Manthorpe, Risk, Health and
  Welfare, Open University Press, 1998
• H Kemshall, J Pritchard (eds), Good Practice in Risk Assessment
  and Management, Volume 1, Jessica Kingsley, 1996 and Volume 2,
  1997

Contact the author
By e-mail at: miketitterton@blueyonder.co.uk