Risk and Risk Taking in Health and Social Welfare

Mike Titterton

• Publisher: Jessica Kingsley Publishers
• Year: 2004
• Print ISBN: 9781853024825
• eBook ISBN: 9781846421136
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

How can a social worker assess the risk that an older person with dementia faces? How would a nurse or housing support worker decide on the balance between danger and safety? In cases of potentially serious harm, as in the examples of abused children or sex offenders, can risk taking work? In this practical and accessible book, Mike Titterton offers an innovative model of risk work in health and social care. He argues that a thoughtful risk-taking approach can lead to empowerment and greater independence for vulnerable individuals.

The author explores the dilemmas frequently faced when working with older people, homeless persons, and people with physical or learning disabilities or with mental illness, and proposes a systematic framework for assessing and managing the risks involved. He also discusses contemporary theories and definitions of risk, and identifies the essential skills needed by professionals, with an emphasis on developing creative approaches to practice.

Offering a wealth of case studies, examples of good practice and a clear overview of the legislative framework, this book is an invaluable resource for social work, health and housing practitioners, trainers and policy makers.

Chapter 1

What is Risk and Risk Taking?

Introduction

One of the major changes in health and social welfare of late is the growing emphasis on risk and the development of a risk-taking approach in working with vulnerable people. In this chapter the concepts of ‘risk’ and ‘risk taking’ are examined. Different perceptions of risk and understandings of these concepts are also considered. It is evident that conceptions of these notions have been changing and it is useful to chart some of these changes, as far as they affect practice in health and social care, and to identify some of the key influences on these shifts. A positive view of risk is argued for, one which promotes the idea of risk as an essential ingredient for improving the quality of life.

First of all, the literature is reviewed and the development of academic and practical understandings of the concepts of ‘risk’ and ‘risk taking’ is described. A definition is then put forward, based on the consideration of the arguments contained within the literature and one which resonates with professionals’ perceptions of the issues. Then recent thinking on these notions, as reflected in recent studies, is examined and some of the pressing issues which arise for welfare professionals and vulnerable people are considered.

Risk and welfare professionals

There are numerous pressures on welfare professionals to go for a ‘safety first approach’ rather than a ‘risk-taking approach’ in their work with clients. The pressures on a profession such as nursing have been discussed by various writers, including Crosland (1992); Young (1994); Cook and Procter (1998); and Alaszewski, Harrison and Manthorpe (1998). Cook and Procter point to the problem created by the ‘vague professional guidance about reasonable risk taking’ which nurses receive (1998, p.279). The tensions this creates are reflected in the new Code of Professional Conduct for nurses, for example, in directivies concerning ‘protecting and supporting [the] health’ of individuals, and providing ‘safe and competent care’ (Nursing and Midwifery Council 2002).

These tensions have been inherited from the way directives in the former Code were interpreted (UKCC 1992, 1996). The Code has in the past been used to justify the premium which nurses have traditionally placed upon safety. However writers such as Crosland, Cook and Procter and Alaszewski et al. argue that the Code does allow for the empowerment of patients and service users. As Cook and Procter write, it ‘also justifies the incorporation of risk taking into clinical practice if the intended outcome is the patient’s best interest’ (1998, p.279).

This creates a dilemma for nurses, since the Code appeared to justify practice which emphasises supervision and safety on the one hand, and practice which promotes patient autonomy and independence on the other. This fundamental dilemma can, as Cook has perceptively written elsewhere, lead to nurses ‘avoiding risk taking altogether’ (1996, p.12). Alaszewski et al. (1998) have considered the preparation of nurses for risk assessment and management, finding little evidence of systematic work, with views of risk that differed according to the types of service user involved; this study will be referred to again.

However, such codes are not set in tablets of stone: they need to change and reflect the search for better practice within the nursing profession. An example is given in Chapter 3 of a group of nurses who have tried to develop risk-taking practice within the framework laid down by the UKCC. Social workers as a profession in the UK now at last have Social Care Councils (Social Services Council in Scotland). Social workers have to work within a looser professional framework, which at present consists of legislation and policies laid down by the councils who are responsible for the regulation of practice. This framework is examined in Chapters 2 and 4. Nonetheless, social workers face major dilemmas in the course of their professional practice, as will be emphasised throughout this book.

Apart from the pressures generated by concerns over regulation and professional ethics, there are other pressures on care workers from families, carers and other professionals. Care workers and nurses come to place an absolute priority on safety; their fear is that they will be seen as bad workers or to have failed in their role if a person is injured or injures himself/herself while under their care. This leads to the attitude that vulnerable people need to be protected from activities which may be dangerous, and leads in turn to an emphasis on the use of restraint. The use of restraint is widespread and can be subtle as well as obvious (this point is considered again in the next chapter).

This has often led to the adoption of the ‘safety first approach’ in the health and social services. As one care worker has noted: ‘We’re often expected to simply “wrap people up in cotton wool” – to keep them safe and sound, away from any possible harm’ (training participant, Shetland). The problem with this sort of ‘safety first’ approach is:

•it ignores the other needs of vulnerable people

•it denies them the right to choice and self-determination

•it leads to a loss of a sense of self-esteem and respect

•it can lead to a form of institutionalisation with the loss of individuality, volition and an increase in dependence

•at its worst, it can lead to the abuse of vulnerable people.

This approach also has a questionable legal basis, for example in the case of the restraint of an individual, as will be seen in the following chapter. The cost of a ‘safety first’ approach in terms of the loss of self-care skills, dignity, self-worth and levels of functioning – and independence – can be a heavy one. Moreover it is possible to argue that caring practice based on this approach is counter to good practice. Practitioners have a responsibility to attend to physical, psychological and emotional well-being.

As the nurses who run V Ward at Seacroft Hospital have written, ‘“total safety” can only exist in an environment of “total control”: such an approach would deny people “basic and important human rights: the right to choice, the right to self-determination, the right to privacy, the right to take risks”’ (Nursing Development Unit Seacroft Hospital, n.d.). Good health, they suggest, can only be enjoyed in ‘an environment which promotes happiness through respect for the dignity and rights of each individual’.

Professionals working with vulnerable people must be prepared to accept the challenge of finding imaginative answers to the problem of the balance between danger and safety. The discussion in this book promotes the development of a ‘risk-taking approach’ which:

•celebrates the taking of risks as a way of enhancing people’s lives

•recognises the importance of psychological and emotional needs, as well as physical needs

•promotes choice and autonomy for the individual

•values the individual, irrespective of whether they live in community or institutional settings

•promotes the rights of vulnerable people and their carers, while accepting that these will sometimes be in conflict.

One of the most difficult things to achieve is the shifting of ingrained professional attitudes. The dominance of the safety-first approach in health and social care can be challenged however. Some examples of welfare professionals who have attempted to change professional and lay attitudes are considered later in this text.

Defining and conceptualising ‘risk’

Ideas about risk can be traced back through history. One derivation for the word for ‘risk’ is, Alison Norman (1988) suggests, from the Greek word ‘rhiza’ for cliff. This refers to the hazardous journeys undertaken by sailors in Ancient Greece, out of the safety of their home port through the potentially treacherous waters around the coasts, and at the mercy of the sea gods and goddesses. The challenges of sailing in such waters are captured by ancient Greek writers, as in the story of Odysseus, who was a great adventurer and voyager. This is an evocative notion and helps to capture the double-sided meaning of the term: the sailors face potential hazards in setting out, but there are rewards for them when they reach the other parts of the Mediterranean, where they exchange goods and reap the benefit of having taken the risk. This can be a handy metaphor when thinking about risk taking and vulnerable people, especially for trainers.

For some authors, risk has always been central to professions like social work (Alaszewski et al. 1998; Brearley 1982; Manthorpe et al. 1995, p.20; Parton 1996) and to the health care professions (Heyman 1998). For others, risk remains a contested and multifaceted concept (Stevenson 1999b). One problem is that ‘risk’ in the care of vulnerable people is typically taken to mean the threat to the well-being or welfare of the individual, their relatives and members of the public and staff. The concept is often interpreted as dealing with the probability of an unfortunate incident occurring. Such incidents result from a conjunction of circumstances which may have harmful consequences. According to writers such as East (1995), the likelihood of such an incident occurring represents its risk.

Perceptions of risk have been changing however. Two influential writers deserve to be highlighted in this respect. The first is Alison Norman, whose work has helped to redefine the relation between risk and rights and has challenged ageism in work with older people. A key development has been the changing perception that risk is ‘not, as it is often taken to be, an evil in itself ’ (Norman 1988, p.82). According to Norman, people take risks every moment of their lives, ‘weighing the likely danger of a course of action against the likely gain’ (1988, p.82). However as Norman (1980, 1988) has noted, this negative view of risk can also be accompanied by stereotypes and prejudices about old age and old people.

In her seminal text, Rights and Risk, published in 1980, she raised some core issues to do with civil liberty in old age. One of the key questions posed was: ‘How does one balance the risks of institutionalisation (of older persons) against the risks of remaining independent?’ (p.13). Here the focus was on older people and their rights, with a strong plea for rights to be respected. These are themes which were later developed in her research into the provision of longstay care for people with severe dementia (Norman 1987). While the 1980 document and the latter research provided food for thought, little in the way of guidance was provided for professionals.

This was a challenge taken up by Paul Brearley, who has written extensively on social work with older people. In his writings (e.g. 1979, 1982) he has been particularly influential in shaping professional views of risk and in providing a framework for understanding and assessing it. Again Brearley takes as his starting point the critique of ageism. He develops a cogent argument for letting older people take gambles; risk taking should be recognised as important for the quality of life. This applies to all contexts of living, whether residential or non-residential. Brearley explicitly rejected the conflation of the term ‘risk’ with ‘hazard’ in an influential analysis (Brearley 1982; Carson 1995; Pilgrim and Rogers 1996).

Questions of individual risk and protection present complex problems. The duty of the practitioner to protect the older person is not clear, he or she contends. He or she has then to take into account the possibility of danger to his or her own personal and professional reputation, as well as the potential danger to others, and then to the person perceived to be ‘at risk’. Brearley argued that better analytical tools were required by practitioners, ones which would allow for assessing hazards, dangers and strengths of a particular situation; thus the risks of action or inaction could be properly weighed up. However some of the assumptions underlying Brearley’s own framework have been criticised by Macdonald and Macdonald (1999). Brearley’s pioneering work in the assessment of risk is returned to in Chapter 5.

The Centre for Policy on Ageing has been a lively source of commentary on the issue of risk. It was commissioned by the Department of Trade and Industry Consumer Safety Unit to carry out a study into aspects of risk taking and safety for older people; this was published under the title Living Dangerously by Deirdre Wynne-Harley (1991). This took up themes from earlier work done under the auspices of the Centre for Policy on Ageing, including the discussion document by Norman (1980) and Home Life, which set out a code of practice for residential care (Centre for Policy on Ageing 1984). This emphasised the right of the individual to choice and risk taking in whatever setting they lived in. This work was endorsed as guidance by the Department of Health and Social Security and has since been updated (Centre for Policy on Ageing 1996, 1999).

For the Living Dangerously study, 150 interviews were conducted with individuals and groups of people aged over 60, and further questionnaires given to another 80 persons, most of whom were living independently. The study sought ‘to examine risk taking in the context of daily life’ (Wynne-Harley 1991, p.2), using information from the interviews and questionnaires, and views were sought from policy makers and practitioners in health, social welfare and safety, as well as families as supporters of older people. In the study, the concept of ‘voluntary risk taking’ was unpacked. A distinction was drawn between ‘involuntary risk’ which might result from a wide variety of sources, including ‘from failures in any of a range of services’ (1991, p.1). On the other hand:

voluntary risk taking can only occur when the risks have been identified, enabling individuals to make personal choices about types and levels of risk which are appropriate in certain situations. This then becomes an informed decision. (1991, p.4)

Early discussions with the sample of older persons showed that they tended to hold images which conformed to stereotypes and media images: risk was rarely seen as a ‘corollary of choice’ which could influence the quality of life. However, by the end of the study half the sample saw risk taking as an important element in lifestyle and nearly half saw risk taking as justified to maintain independence in old age. In her study of the risks older people can face, Wynne-Harley writes: ‘Risks and risk taking are commonly seen in a negative light. For example, a thesaurus identifies risk with hazard, menace, peril and danger’ (1991, p.1; see also Douglas 1992 and Prins 1996). Equally it can be argued that an ‘over-cautious life style can bring its own hazards’, so an appropriate balance between risk and safety is desirable (1991, p.1).

Like Norman and Brearley, Wynne-Harley identifies ageist attitudes as a key problem militating against the rights of older people. Many old people have low expectations and a low sense of worth. They share the prevalent negative attitudes to old age. In doing this, they may ‘accept the right of those who are younger to make decisions for them, to reduce their autonomy, to eliminate choice and risk from their lives’ (1991, p.27). The report concluded that ‘reasonable, informed and calculated risk taking plays an important part in contributing to the quality of life for young and old; this is a matter of choice, demonstrating an individual’s right to self-determination and autonomy’ (1991, p.29).

This theme was taken up by another valuable report, issued this time by Counsel and Care, What If They Hurt Themselves, published in 1992. This was a discussion document on the uses and abuses of restraint in residential care and nursing homes for older people. The concern f...

Table of contents

• Cover Page
• Of Related Interest
• Title Page
• Copyright
• Contents
• Acknowledgements
• Preface
• Introduction
• 1. What is Risk and Risk Taking?
• 2. Rights, Responsibilities and the Law
• 3. Exploring Welfare Dilemmas
• 4. Principles, Policies and Models
• 5. Risk Assessment
• 6. Risk Management
• 7. Linking Risk Assessment and Management
• 8. Training Professionals and Laypersons in Risk Taking
• Conclusion
• Appendix 1: Assessing Risk of Serious Harm in Health and Social Care Settings: The Examples of Child Protection and Sex Offenders
• Appendix 2: Risk Assessment and Management Plan (Example)
• Appendix 3: Sample Case Studies
• Appendix 4: A Note on Health and Safety Issues
• References
• Subject Index
• Author Index