Originally published in AJDC June/July 2019 Vol 8 No 3
Jo Croft explores the benefits of a ‘can do’ rights-based approach to care planning and risk management to facilitate an active lifestyle for people living with dementia and shares an example of a positive risk assessment tool
At the heart of any quality service providing care to people living with dementia is a passion for delivering holistic care which responds to the needs of the individual. Person-centred care planning is by no means a new concept, but taking this a step further to ensure we are taking a ‘rights-based’ approach to care planning for those living with dementia is what provides genuine choice and agency and that requires us to make a commitment to actively listen to our clients (Pieters-Hawke 2018). The objective is to provide empowerment and a ‘can do’ emphasis in care planning by enabling and supporting a culture which maximises the quality of daily life for our clients and continues to provide them with a sense of purpose.
Most care providers and practitioners working with people who are living with dementia would argue they are already providing clients with maximum choice and agency, but in reality this is a very challenging task and one we frequently fail to deliver as fully as we intend. In the main this is because, as well as promoting independence and choice, we have a legal and moral duty to protect those in our care from foreseeable harm and this causes an inevitable tension between the risks and benefits of the ‘can do’ approach.
Research suggests that care providers and practitioners are often risk averse (Royal College of Nursing 2013) and are inclined to lean towards protectionism in their delivery of care. So whilst most of us would like to think we give our clients choice, in reality many care providers and practitioners limit choice due to fear of causing unintended harm.
There is a tipping point where protection becomes restraint and this doesn’t have to be overt or physical. Depriving someone of their liberty can be as subtle as a gently but firmly applied coercion on the part of the care giver. Exactly where the tipping point is can be subjective and confusing and care givers need guidance and support to ensure a balanced and positive approach to risk management is maintained. Therefore, providing them with a positive risk assessment tool which can be used within the care plan can give the necessary guidance.
The nursing and allied health professions have long recognised the importance of risk assessment tools with regards to physical health and wellbeing. For example, the use of risk assessment tools in planning and management of pressure ulcer and malnutrition prevention are not only commonplace but have become an essential and expected part of care planning. Living an active life inevitably involves risk-taking, as it is not possible to eliminate risk altogether. If we are to maximise the lived experience of our clients, which will be unique to each individual and situation arising (Croft 2018), we must also realise that risk management is a fundamental part of our role in planning activities for our clients and should be exercised with similar skill.
Positive risk-taking tool
The Colten Care Positive Risk Assessment Tool (pictured below right) provides a framework which aims to remove subjectivity and help the practitioner to plan care based upon the principles of defensible decision making. The purpose of the positive risk-taking tool is to support the practitioner’s professional integrity and confidence when making care-related decisions which involve an element of risk. It aims to uphold the rights of the individual to make choices, whilst simultaneously protecting the interests of the individual client and enhancing client confidence in the practitioner.
The tool was developed by UK aged care provider Colten Care Ltd and is used in its care homes with residents living with dementia or who otherwise have reduced mental or physical capacity. It has been informally externally validated by the Mental Capacity Lead for Dorset County Council UK and received positively by several Care Quality Commission Inspectors, but has not been formally validated.
When using the tool it is essential the rights of the individual are upheld by ensuring the client’s wishes and opinions are clearly documented and taken into account, irrespective of their level of capacity and insight. This is to ensure that the care provider fully listens to and aims to understand the client’s point of view. Often the view of the risks associated with an activity will differ greatly between the care provider and the client, but when deciding how to minimise the risks, the care provider will be better able to recognise potential problems if they have fully explored the client’s aspirations and associated understanding, or lack thereof.
It is equally important to involve the client’s relatives and representatives in discussions to ensure a balanced approach and outcome are reached and that all interested parties are in agreement with the care plan. Relatives can exert a lot of influence over their loved ones, which may have either a positive or a negative influence on the ambitions of the client depending on their own attitude to risk.
However, they are often the people who know the client best and can give context to the aspirations of the client and their support is invaluable.
The Colten Care Positive Risk Assessment Tool incorporates, and is based upon, the following key elements (Dix & Smith 2009):
- Description of the identified risk (usually an activity which the resident wishes to partake in).
- The nature of the risk (what it is about the particular activity which has the potential to cause harm).
- An exploration of the potential benefits to taking the risk (weighing up the potential benefits and harms of exercising one choice of action over another, whilst reflecting the aspirations of the resident in accordance with their aspirations, values and beliefs. We must remain focused on the desires of the client, which is to support them to live life their way, not ours, so far as is practicable).
- A record of any advice given by the person supporting the resident to make a decision (eg nurse or other health or social care practitioner and the involvement of family or other representatives as appropriate, as they may wish to be present during the discussion and their views need to be considered and appropriately responded to as well. It is important to recognise that this is a collaborative process).
- Measurement of the risk (using a simple but robust risk-rating table).
- Identification and agreement with the resident or their representative of any control measures required to help reduce the level of risk. (Use all available resources to minimise potential harm and ensure the least restrictive options are identified and implemented. This will require some lateral thinking and teamwork and needs to be specific to the individual and their particular circumstances).
- Evidence of consent (with reference to your local statutory legislation).
The outcomes from the positive risk assessment and, in particular, the control measures will need to be cross-referenced with any other relevant aspect of the care plan. The plan will need to be communicated to everyone involved, reviewed regularly and evaluated (which is in line with the nursing process). It may of course, need to be rewritten as the needs and abilities of the client, and therefore the measure of risk, change over time.
The Colten Care Positive Risk Assessment Tool included alongside this article shows how the tool could be used, loosely based upon a recent case study but fictionalised for client confidentiality:
It is important to note that the Risk Score is calculated and recorded as a ‘before and after’ measure. That is, before control measures have been identified and after they have been put into place. This demonstrates that due diligence has been observed in the management of the risk, by selecting appropriate and effective control measures. The Colten Care Risk Calculator is shown to the right.
It is important to note that at every stage of the risk assessment process the emphasis is on encouraging the resident to express their views and exercise their choices, enabling them to grow in confidence and gain as much independence as possible. Where the resident lacks insight into their capabilities and physical and mental limitations, it is the role of the care practitioner to explore the gap between the resident’s perception of the risk and the actual level of risk. Furthermore, where the risk score is medium to high, it is recommended that the control measures to reduce the risk be agreed and documented in conjunction with other members of the multidisciplinary team including, where appropriate, the resident’s named nurse, GP, physiotherapist or mental health practitioner, thus spreading the responsibility for decisions made.
If, instead of putting limits on people, we explore possibilities in all of our discussions relating to individual care planning and we champion the pursuit of fulfilling goals and aspirations for our clients, positive benefits for them will inevitably result and they will be able to continue to enjoy hobbies and activities which they have participated in prior to coming into care. By using the Positive Risk Assessment Tool and putting Positive Risk Assessments in place, Colten Care clients living in our dedicated dementia communities continue to enjoy a wide range of activities. These include cooking, gardening, horse riding, swimming, playing golf and even hot air balloon rides and many other fulfilling activities that most of us would take for granted.
The Colten Care Positive Risk Assessment Tool can help care providers and practitioners to promote a ‘can do’ rights-based approach and to challenge the negative connotations surrounding the concept of risk, so often thought of in terms of danger and damage limitation. Professionally, these need replacing with a culture of enablement and support with as few restrictions as possible. It supports us to fulfil our duty of care to protect our residents from foreseeable harm whilst bringing the metaphorical scales of choice and independence vs safety into balance. It helps the staff who support our clients to overcome the fear factor of being held to account if things should go wrong, as it provides evidence of a carefully thought out strategy which is legally defensible and well documented. This, is turn, provides reassurance to relatives and builds trust.
The importance of training staff to use a positive risk assessment tool as part of the individual care plan cannot be stressed enough, as it helps to remove fear of doing the wrong thing and supports the creation of a culture of positive risk management and values. For this reason, Colten Care has developed a tool which is neither complicated nor legalistic for the user (although it is robust if applied correctly). It is very simple to use on an individual basis whenever a client wishes to undertake an activity which has an element of risk and which has not already been covered by another form of commonly used risk assessment within the care plan.
Providing high-quality dementia care requires dedication on the part of care providers and practitioners. The 21st International Dementia Conference held in Sydney in June 2018 was entitled ‘Mission Impossible: Truth and Lies in the Age of Choice’. Fortunately, as discussed and explored at this very inspiring conference, the mission is not an impossibility, though it is a challenging one. John Swinton, Professor in Practical Theology and Pastoral Care in the School of Divinity, Religious Studies and Philosophy at the University of Aberdeen summed up the challenge perfectly in his description of dementia care, not as a mission impossible, but certainly as a story of truth and lies: “The lie: the ‘person’ disappears once they have dementia and that a life without memory is no life at all. The truth: people living with dementia can have a good life” (Swinton 2018).
And it is our mission to support them individually in every way we can to make that possible, for as long as possible and as well as possible.
Accessing the risk tool and calculator
The author is happy to forward copies of the Colten Care Positive Risk Assessment Tool and The Colten Care Risk Calculator to individuals upon request. Email Jo Croft at JoCroft@ColtenCare.co.uk
Jo Croft is a Registered Nurse with over 25 years’ experience in aged care home management both in Australia and the UK. She currently works as a Quality Manager for Colten Care Ltd, a care provider in southern England with 20 nursing and residential care homes, including five dedicated dementia communities, providing care to over 1000 residents
Colten Care Ltd (2016) Person Centred Risk Assessment Tool (Version 2).
Croft J (2017) Enabling positive risk-taking for older people in the care home. Nursing & Residential Care 19(9) 515-519.
Croft J (2018) International Dementia Conference – Mission Impossible? Truth and Lies in the Age of Choice. Sydney 7-8 June 2018. Leaders in the Field Agenda Item 4: Enabling positive risk taking – a framework for supporting choice and an active lifestyle within the care home setting. 2018. Sydney: HammondCare.
Dix M, Smith S (2009) Managing risk positively: a guide for staff in health and social care. Available at: http://bit.ly/2vyI8Cw.
Pieters-Hawke S (2018) International Dementia Conference – Mission Impossible? Truth and Lies in the Age of Choice. Sydney 7-8 June 2018. Leaders in the Field Agenda Item 1: Dementia and human rights – rising to the challenge. Sydney: HammondCare.
Royal College of Nursing (2013) RCN Congress and Exhibition Liverpool 21-25 April 2013. Agenda Item 25: A risk worth taking? Older People’s Forum. London: Royal College of Nursing.
Swinton J (2018) International Dementia Conference – Mission Impossible? Truth and Lies in the Age of Choice. Sydney 7-8 June 2018. Plenary Agenda Item: Taking time for those things that the world considers trivial: choosing to be with and for people living with dementia. Sydney: HammondCare.