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The challenges of using structured risk assessment instruments in forensic psychiatric care
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The purpose of psychiatric forensic care is to provide treatment for mentally ill offenders and to prevent future acts of violence and other adverse events. During care, the type of restrictions of freedom, the patient’s continuous need for involuntary treatment and readiness for discharge, are continuously evaluated based on the assessment of risk the patient pose to themselves and others as well as the progress achieved with treatment. The use of structured risk assessment instruments is recommended in clinical guidelines to assess such risks. However, unstructured clinical assessments, considered to be less valid, are often used in clinical practice. There is insufficient research evidence concerning several aspects related to the clinical use of structured risk assessment instruments in terms of guiding the planning and realization of care and risk management interventions. There is also a lack of knowledge about what patients themselves perceive to be mediating factors for their use of violence. Overall aim: The overarching aim of this thesis was to investigate the implementation and use of structured risk assessment instruments to prevent violence and other adverse events in forensic settings and to improve understanding of the factors that influence such events among forensic patients.

Methods: Several methods were used for data collection and data were analysed by different types of content analysis. In the first paper, a systematic review of previous research studies on implementation determinants for structured risk assessment instruments in forensic settings was conducted to investigate implementation determinants for such instruments. The second paper evaluates a pilot project of the implementation of a structured risk assessment instrument at a forensic clinic in Östergötland using focus group interviews with staff members who had used the instrument. Their perceptions of the instrument and barriers and facilitators to its implementation and clinical use were investigated. The third paper investigated the actual clinical use of structured risk assessments to guide the planning and realization of care and risk management interventions documented in forensic patients’ records. In the fourth paper, patient perspectives of factors increasing and decreasing the risk for violence were investigated by individual semi-structured interviews with forensic patients.

Results: There is a wide variety of determinants for the implementation and clinical use of structured risk assessment instruments, which make such missions complicated. The determinants relate to the characteristics of the implementation object, characteristics of users, the inner setting in which the implementation occurs and the implementation process. Limiting the need to change current routines, and hence the strain on the organization by reducing complexity, and the need for resource allocation seem especially important. Most of the planned risk management interventions in structured risk assessments were realized according to patient records. However, structured risk assessments largely overlap with unstructured risk assessments in terms of planned care and risk management interventions. Noteworthy, most of the interventions realized were not documented as planned. Forensic patients described several risk factors that increased and decreased their use of violence. These factors related to themselves, external influences, social and relational aspects and situational factors. Most patient accounts of mediating factors overlapped with those listed in commonly used risk assessment instruments and previous research. Additional factors identified by patients related to the outer context and interpersonal aspects.

Conclusions: There are many barriers and facilitators to the implementation and use of structured risk assessment instruments, implying the need for a multifaceted approach to address determinants at several system levels. Considering the clinical context is important when selecting a structured risk assessment instrument to be implemented, but also the complexity of the instrument, the required change of routines and the provision of continuous resources and interventions to achieve and maintain clinical use. Despite the many barriers, there is evidence of clinical use of both unstructured clinical and structured risk assessments in terms of informing and guiding care and risk management interventions. The large overlap, however, makes it difficult to draw definite conclusion about which type of assessment actually influenced the interventions that were realized. Realized care and risk management interventions are most often not documented as planned. This increases the risk of subjective decisions and provision of interventions, which also make such interventions difficult to evaluate. Forensic patients are actively managing their risk of violence and are capable of identifying and communicating many different mediating factors for their violence risk. They are knowledgeable and important stakeholders and should be involved in their own risk assessments, as well as in research.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 95
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1666
National Category
Nursing Psychiatry
Identifiers
URN: urn:nbn:se:liu:diva-156726DOI: 10.3384/diss.diva-156726ISBN: 9789176851203 (print)OAI: oai:DiVA.org:liu-156726DiVA, id: diva2:1315312
Public defence
2019-06-04, Belladonna, Campus US, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2019-05-13 Created: 2019-05-13 Last updated: 2019-05-17Bibliographically approved
List of papers
1. Structured Risk Assessment Instruments: A Systematic Review of Implementation Determinants
Open this publication in new window or tab >>Structured Risk Assessment Instruments: A Systematic Review of Implementation Determinants
2016 (English)In: Psychiatry, Psychology and Law, ISSN 1321-8719, E-ISSN 1934-1687, Vol. 23, no 4, p. 602-628Article in journal (Refereed) Published
Abstract [en]

Research-based structured risk assessment instruments (SRAIs) can improve violence risk assessment and clinical judgements in mental health and correctional services. Practical challenges of implementing SRAIs have led to calls for more research to understand the determinants influencing this process. Studies describing determinants for SRAI implementation in psychiatric, correctional, or community in-patient settings were systematically reviewed. Findings were analysed according to the Consolidated Framework for Implementation Research. A total of 11 studies were included. Four types of main implementation determinants were found: characteristics of the SRAI; users of the SRAI; inner setting; and process. Findings underscore the importance of applying a multifactorial approach to the implementation of SRAIs to address many different barriers and facilitators. More stringent research is needed to obtain more solid evidence of factors that impede or enable SRAI implementation, especially regarding patient perspectives and outer setting determinants. Constructing shared concepts of determinants across research fields could further aid information transferences.

Place, publisher, year, edition, pages
Routledge, 2016
Keywords
determinants; implementation; structured risk assessment; systematic review; violence
National Category
Pediatrics
Identifiers
urn:nbn:se:liu:diva-131922 (URN)10.1080/13218719.2015.1084661 (DOI)000383249100010 ()
Available from: 2016-10-13 Created: 2016-10-11 Last updated: 2019-05-13
2. Staff Perceptions of Facilitators and Barriers to the Use of a Short- Term Risk Assessment Instrument in Forensic Psychiatry
Open this publication in new window or tab >>Staff Perceptions of Facilitators and Barriers to the Use of a Short- Term Risk Assessment Instrument in Forensic Psychiatry
2018 (English)In: Journal of Forensic Psychology Research and Practice, ISSN 2473-2850, Vol. 18, no 3, p. 199-228Article in journal (Refereed) Published
Abstract [en]

Prospective adverse events within forensic settings should be assessed using structured risk assessment instruments. Our aim was to identify the barriers and facilitators of a structured instrument for assessment of short-term risk within inpatient forensic psychiatric care. The instrument was piloted at a forensic psychiatric clinic. Three focus group interviews were conducted with staff. Content analysis revealed three main categories of barriers and facilitators for clinical use: implementation object, context, and users. Complexity of the instrument, insufficient continuous training and support, difficulties retrieving assessments on wards, and insecurity about translating assessments into actions were perceived barriers to clinical use. Routines for documentation improved communication and the inclusion of protective and short-term dynamic clinical factors were perceived as clinically relevant. Problem-solving ability, attitude, and motivation of staff were facilitating factors. Comprehensive risk assessment instruments require substantial support for staff to find them manageable. Systematic documentation is required to measure actual daily clinical use.

Place, publisher, year, edition, pages
Routledge, 2018
Keywords
tructured risk assessment;START; implementation;clinical use of researchevidence
National Category
Psychiatry
Identifiers
urn:nbn:se:liu:diva-154051 (URN)10.1080/24732850.2018.1466260 (DOI)000452643000001 ()
Available from: 2019-01-24 Created: 2019-01-24 Last updated: 2019-05-13
3. Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records
Open this publication in new window or tab >>Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records
2019 (English)In: International Journal of Law and Psychiatry, ISSN 0160-2527, E-ISSN 1873-6386, Vol. 64, p. 71-82Article in journal (Refereed) Published
Abstract [en]

Both structured and unstructured clinical risk assessments within forensic care aim to prevent violence by informing risk management, but research about their preventive role is inconclusive. The aim of this study was to investigate risk management interventions that were planned and realized during forensic care by analysing patient records. Records from a forensic clinic in Sweden, covering 14 patients and 526 months, were reviewed. Eight main types of risk management interventions were evaluated by content analysis: monitoring, supervision, assessment, treatment, victim protection, acute coercion, security level and police interventions. Most planned risk management interventions were realized, both in structured and clinical risk assessments. However, most realized interventions were not planned, making them more open to subjective decisions. Analysing risk management interventions actually planned and realized in clinical settings can reveal the preventive role of structured risk assessments and how different interventions mediate violence risk.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Risk assessment, Risk management, Forensic care, Violence risk
National Category
Forensic Science
Identifiers
urn:nbn:se:liu:diva-156724 (URN)10.1016/j.ijlp.2019.02.003 (DOI)000470949900009 ()31122642 (PubMedID)2-s2.0-85062027323 (Scopus ID)
Available from: 2019-05-13 Created: 2019-05-13 Last updated: 2019-07-15Bibliographically approved

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