The Role of Risk in the Acute Care of Older Adults

RISK AND RESPONSIBILITY: THE ROLE OF RISK IN THE ACUTE CARE OF OLDER ADULTS
By Dr. Gillian Stockwell-Smith, RN, MN, MAP (Hons), PhD; Menzies Health Institute Queensland, Griffith University, Queensland, Australia

Key highlights:

• Risk assessments conducted in hospital during a period of sickness and recovery can have a considerable impact on an older adults care choices.
• It is not uncommon for age stereotyping to dominate and for health professionals to dismiss the decisionmaking capacity of cognitively intact frail older people, thereby excluding them from important discussions and decisions about their future care and care settings.
• Health professionals tend to adopt a risk averse approach when assessing older adults, with a focus on weaknesses and inabilities, the primary concern being the prevention of adverse events within the hospital and on discharge.
• A commitment to supporting an older adult to make care-related decisions should be demonstrated by encouraging, rather than restricting, their capacities and wellbeing, as well as by taking into account outcomes such as dignity, rights, freedom and privacy.
• Practical suggestions on improving professional team decision-making capacity include: (1) routinely reviewing the outcomes from previous risk management decisions prior to making a new risk decision, and (2) finding a common language or common goal in relation to patient safety and risk management, both within and across healthcare organisations.

Introduction
One of the major issues regarding risk and older people is the need to find a balance between conflicting expectations, fulfilling organisational and professional risk management obligations and promoting an older adults right to independence and autonomy (Berke, 2014). Risk assessments conducted in hospital during a period of sickness and recovery can have a considerable impact on the living arrangements of older adults, specifically whether they are permitted to return home or are admitted to residential aged care (Faulkner, 2012). Therefore, risk assessment should not be treated as a substitute for clear and rigorous thinking, despite what the actions of some healthcare professionals might suggest (Carson & Bain, 2008).

How risk is defined in acute care
In hospital settings, there is a strong discourse regarding patient safety in relation to risk and the prevention of adverse events (Rowland & Kitto, 2014). Risk originally meant calculating the probabilities of events, both positive and negative (Barry, 2007; Carson & Bain, 2008). However, as a society, we have become preoccupied with harm and hazards (Powell, Wahidin, & Zinn, 2007). While there is no broadly recognised definition of risk, risk is commonly perceived in negative terms and associated solely with the chance of an adverse outcome or event occurring (MacLeod, 2013). In contemporary western society, risk has become a broad concept that extends over a wide range of social practices that have a negative impact on autonomy and choice for older adults (Powell et al., 2007). This is evident is an overarching emphasis on the professional role in identifying and mitigating the personal risks associated with an older adults declining functional abilities and cognitive skills (Cott & Tierney, 2013).

Current risk management practice in acute care
Risk assessments of older people in the hospital commonly occur during a time of crisis, a fall resulting in harm or general deconditioning due to ill health, and are thus reactive rather than proactive (Barry, 2007). In such scenarios health professionals tend to overstate risk in order to protect themselves and their patients from harm (MacLeod, 2013), and curtail risks through avoidance strategies such that restricting choice and activities takes priority over patient choice and dignity (Digby, Lee, & Williams, 2017). In most acute healthcare settings health professionals are required to identify, assess and manage risk for older adults’ while negotiating and reconciling divergent issues of safety and autonomy (MacLeod & Stadnyk, 2015). Tensions are exacerbated when differing views on the degree and likelihood of risk are expressed by clinicians, family members and older adults (Rush, Kjorven, & Hole, 2016). Establishing the older adult’s capacity to make and implement decisions is considered an essential component of risk assessment (Culo, 2011). Cognitive impairment (delirium and/or dementia) can result in fluctuating or lack of decision making capacity, but the majority of older adults retain full capacity to make decisions regarding their ongoing care and living arrangements (Carson & Bain, 2008). If an older adult has the mental capacity to make a decision, and chooses voluntarily to live with a level of risk, they are entitled to do so (Skills for Care, 2011). However, it is not uncommon for age stereotyping to effectively dismiss the decision making capacity of cognitively intact frail older people thereby excluding them from important discussions and decisions about their future care and care settings (Carson & Bain, 2008). Organisational factors are considered to have a considerable impact on health professional risk practices. A pervasive culture of defensiveness, fed by litigation and inquiries, in health care policy and practice has been blamed for a reduction in professional autonomy with health professionals more preoccupied with avoiding criticism and protecting their professional practice than in making appropriate decisions for patients (Barry, 2007; Carson & Bain, 2008). Consequently health professionals tend to adopt a risk averse approach with a focus on the older adults weaknesses and inabilities, the primary concern being the prevention of adverse events within the hospital and on discharge (Rowland & Kitto, 2014).

The way forward?
For some years now a more positive approach to risk has been recommended (Barry, 2007; Carson & Bain, 2008; Rowland & Kitto, 2014). New models of consumer directed care in disability and community aged care services have provided consumers with greater levels of choice and control over their care and services. The values of choice and control that these models promote denotes the need for professional and organisational change in the way risk is understood, managed and negotiated with the person using the service (Faulkner, 2012; Skills for Care, 2011). A commitment to supporting an older adult to make care related decisions should be demonstrated by encouraging rather than restricting their capacities and wellbeing and taking into account outcomes such as dignity, rights, freedom and privacy (Rowland & Kitto, 2014). Carson and Bain (2008) maintain the vast majority of risk decisions taken by professionals in health settings lead to benefits, and consider that the more this is appreciated organisationally the more likely it is that a positive culture of risk management will develop. Barry (2007) recommends health professionals adopt a practice of constant and critical review, with risk assessment as a tool to complement professional judgement, rather than an end in itself. Carson and Bain (2008) offer practical suggestions on improving professional team decision making capacity which include routinely reviewing the outcomes from previous risk management decisions prior to making a new risk decision for a patient/client. The focus of this reflective practice is on identifying the success or harm that resulted from the decision, providing praise or counselling to clinical team members and concluding with ‘lessons learnt’ so as to learn from past mistakes (Carson & Bain, 2008). It is also apparent there are difficulties in finding a common language or common goal in relation to patient safety and risk management, both within and across healthcare organisations (Rowland & Kitto, 2014). The development of a shared organisational vocabulary of risk and risk taking terminology, a common language and common goals of risk identification and management, will go a long way to improving the quality of risk communication within an organisation and inclusion and choice for older adults (Carson & Bain, 2008).

For further reading:

• Barry, M. (2007). Effective Approaches to Risk Assessment in Social Work. Retrieved from Victoria Quay, Edinburgh:
• Berke, R. (2014). Older Adults Living At Risk: Ethical dilemmas, Risk, Assessment and Interventions to Facilitate Autonomy and Safety. 2014, 1.
• Carson, D., & Bain, A. (2008). Professional Risk and Working with People : Decision-Making in Health, Social Care and Criminal Justice. London, UNITED KINGDOM: Jessica Kingsley Publishers.
• Cott, C. A., & Tierney, M. C. (2013). Acceptable and unacceptable risk: balancing everyday risk by family members of older cognitively impaired adults who live alone. Health, Risk & Society, 15(5), 402- 415. doi:10.1080/13698575.2013.801936
• Culo, S. (2011). Risk assessment and intervention for vulnerable older adults. BCMJ, 53(8), 421-425.
• Digby, R., Lee, S., & Williams, A. (2017). The experience of people with dementia and nurses in hospital: an integrative review. Journal of Clinical Nursing, 26(9-10), 1152-1171. doi:10.1111/jocn.13429
• Faulkner, A. (2012). The Right to Take Risks: Service Users’ Views of Risk in Adult Social Care. Retrieved from York:
• MacLeod, H. (2013). Understanding risk: Health professionals' decision making with frail community dwelling older adults. (Master of Science), Dalhousie University, Halifax, Nova Scotia, http://hdl.handle.net/10222/42707.
• MacLeod, H., & Stadnyk, R. L. (2015). Risk: ‘I know it when I see it’: how health and social practitioners defined and evaluated living at risk among community-dwelling older adults. Health, Risk & Society, 17(1), 46-63. doi:10.1080/13698575.2014.999749
• Powell, J., Wahidin, A., & Zinn, J. (2007). Understanding risk and old age in western society. International Journal of Sociology and Social Policy, 27(1/2), 65-76. doi:doi:10.1108/01443330710722760
• Rowland, P., & Kitto, S. (2014). Patient safety and professional discourses: implications for interprofessionalism. Journal of Interprofessional Care, 28(4), 331-338. doi:10.3109/13561820.2014. 891574
• Rush, K. L., Kjorven, M., & Hole, R. (2016). Older Adults’ Risk Practices From Hospital to Home: A Discourse Analysis. The Gerontologist, 56(3), 494-503. doi:10.1093/geront/gnu092 Skills for Care. (2011). Learning to live with risk, an introduction for service providers. (DS026). Leeds: S
• kills for Care Retrieved from www.skillsforcare.org.uk.

Dr. Stockwell-Smith is a registered nurse and works with older people in hospital, community and residential aged care settings in the United Kingdom and Australia for over thirty years. She is currently a research fellow in sub-acute and aged care nursing with Griffith University and Gold Coast Hospital and Health Service.

Excerpted as reprint from the IPA Bulletin, Volume 35, Number 1
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