Posted: September 19th, 2022

AMH

Assessment;

Critical Review

Assessment type;

Essay

Word limit/length; 2000 words

Overview

Risk assessment in mental health settings is one of the most challenging roles of the mental health professional. This assessment is designed to encourage you to explore the most recent evidence that informs best practice in conducting risk assessments in acute mental health
.

Learning Outcomes

This assessment task is aligned to the following learning outcomes:

2. Appraise a range of acute care conditions engagement and interventions

3. Appraise a range of complex acute care conditions engagement and interventions

4. Critically reflect on acute mental health risk factors, engagement, observation and interventions

Assignment details; VERY IMPOTANT FOR YOU TO FOLLOW

Write an essay that:

– Provides a brief overview of the type of risk assessments that are necessary to consider in acute mental health

– Critiques the effectiveness or accuracy of available risk assessment tools/methods

– Discusses how the risk assessment process could be improved or optimised, ensuring your arguments are evidence based

Assignment Rubric

1-
Criteria; Introduction & Conclusion

Mark; 12.5%;

Excellent introduction.

Clear and succinct.

Outstandingly written conclusion.

2-
Criteria; Succinct overview of all type of risk assessments conducted in the acute mental health setting

Mark; 25%;

Key risk assessments succinctly & outstandingly described.

3-
Criteria; Critiques the effectiveness or accuracy of risk assessment tools/methods and discusses how the risk assessment process could be optimised

Mark 50%

Outstanding critique of risk assessment approaches and how the process could be optimised.

Excellent incorporation of evidence and demonstration of understanding is clearly articulated.

4-
Criteria; Writing, grammar and referencing

Mark; 12.5%

Clear, crisp and coherent style.

Very well organised.

Free of grammar and spelling errors.

All citations follow required style.

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Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Investigating the Evidence for the Effectiveness of
Risk Assessment in Mental Health Care

Timothy Wand

To cite this article: Timothy Wand (2011) Investigating the Evidence for the Effectiveness
of Risk Assessment in Mental Health Care, Issues in Mental Health Nursing, 33:1, 2-7, DOI:
10.3109/01612840.2011.616984

To link to this article: https://doi.org/10.3109/01612840.2011.616984

Published online: 06 Jan 2012.

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Issues in Mental Health Nursing, 33:2–7, 2012
Copyright © 2012 Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2011.616984

Investigating the Evidence for the Effectiveness of Risk
Assessment in Mental Health Care

Timothy Wand, MHN RN NP DAS(Nurs) Grad. Dip.(MHN) MN(Hons)
Royal Prince Alfred Hospital, Emergency Department, Camperdown, Australia and University of Sydney,
Sydney Nursing School, Camperdown, Australia

Risk assessment pervades mental health care policy, practice,
and legislation. This paper aims to establish the research evidence
for the effectiveness of a risk assessment approach in mental health.
A search was conducted of the professional literature on risk as-
sessment in mental health, specifically seeking any research on the
effectiveness of risk assessment in reducing risk of harm to self
or others. The search found limited research on the effectiveness
of risk assessment. “Structured professional judgment” possibly
reduces aggression risk but there is no evidence that risk assess-
ment is effective in relation to self-harm or suicide reduction. The
implications for practice are discussed and alternatives to a risk
assessment approach are considered.

Evidenced Based Practice has been adopted globally and in
many specialties of health care, including nursing, psychology,
medicine, occupational therapy, and social work. The promi-
nence of Evidenced Based Practice has evoked controversy and
criticism, however, it continues to wield widespread influence
on health care policy and practice. Evidence Based Practice re-
lies on a hierarchy of evidence that enables clinicians to gauge
the strength of research findings in terms of efficacy or effective-
ness. Investigations providing the strongest levels of evidence
include meta-analyses, national clinical practice guidelines, and
systematic reviews of randomized controlled trials (RCT). A
single well-designed RCT provides moderate evidence, and the
weakest evidence is derived from non-randomized investiga-
tions, case studies, cohort studies, and qualitative or descriptive
studies. The lowest level of evidence is associated with the opin-
ion of authorities and/or reports of expert committees (Fisher &
Happell, 2009).

Risk assessment and management have become a central fo-
cus in mental health policy, practice and legislation. Due to the
dominance that risk assessment exerts in contemporary mental
health service provision, this paper investigates the available evi-

Address correspondence to Timothy Wand, Royal Prince
Alfred Hospital, Emergency Department, Missenden Road, Camper-
down, 2050 Australia, or University of Sydney, Sydney Nurs-
ing School, Mallet Street, Camperdown, 2050 Australia. E-mail:
timothy.wand@sswahs.nsw.gov.au

dence for the effectiveness of this approach in reducing risk; par-
ticularly in relation to risk of harm to self or others. A search of
the literature was conducted using PsycInfo, CINAHL, Medline,
and Google Scholar from the year 2000 to 2011. Key terms (e.g.,
risk assessment) and combinations of terms (e.g., risk assess-
ment and management, mental health, psychiatry, suicide, self-
harm, self-injury, psychosis, aggression, violence) were used.
Reports and consensus guidelines from professional bodies also
were considered. A systematic review was not possible given
paucity of studies evaluating the effectiveness of risk assess-
ment in mental health care. The majority of publications are
from the lowest level of evidence available. This paper presents
the research that is available investigating the effectiveness of
risk assessment as well as a general review and discussion of
the literature related to the topic. The implications for practice
and alternatives to a focus on risk assessment are considered.

PERSPECTIVES ON RISK ASSESSMENT IN MENTAL
HEALTH

In a report titled “Rethinking Risk to Others in Mental Health
Services” the UK Royal College of Psychiatrists (RCP; 2008)
expressed concern that a focus on risk assessment appears to
have had a negative impact on clinical practice, consumers, and
the public. The result is a culture of blame, leading to defensive
and overly coercive practices and policies that demonstrate little
understanding of the complexities inherent in clinical settings.
Furthermore, the RCP contend that as a negative consequence
of such policies and practices, consumers are subsequently less
likely to access services out of fear of further coercion (RCP,
2008).

Despite efforts made to improve awareness of mental health,
Lakeman (2006) reports that the public remains anxious about
mental illness and the perception remains that mental illnesses
are associated with dangerousness to self or others. Such pub-
lic perceptions continue to exert influence on policy and prac-
tice. Risk has therefore become an acceptable form of stigma
whereby “high-risk patients in the community” become a legiti-
mate source of moral concern (Undrill, 2007). These sentiments
are echoed by the RCP (2008) who state that due to a focus on

2

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 3

risk, people with mental illness are portrayed in a negative man-
ner and, typically, as dangerous. This is likely to contribute to
the continuing stigma of mental illness while the far greater
danger to the public is posed by people who misuse alcohol and
other drugs (RCP, 2008).

Crowe and Carlyle (2003) view risk assessment as an at-
tempt to control the actions and behaviours of consumers and
clinicians to best suit the needs of the organisation rather than
the interests of patients. Risk assessment is conceptualised by
Undrill (2007, page 294) as a “neurotic organisational attempt
to tame anxiety,” however Undrill contends that such defensive
practices generate further anxiety. Clinicians become anxious
about the risk management tools they are given, and then work
to reduce this anxiety by discharging their share of the risk.
Risk adversity then becomes responsibility adversity whereby
clinicians act out of fear of legal ramifications and/or fear of
failure at the expense of patient well-being (Undrill, 2007). Ac-
cording to Undrill (2007) risk assessment is a subjective, plas-
tic, and context-dependent statement that carries strong moral
overtones. However the policy and managerial tendency is for
implementing reductionist models and linear frameworks of un-
derstanding that fail to appreciate the degree of complexity and
randomness in the world.

AGGRESSION AND VIOLENCE RISK
The risk associated with violence and aggression in health

care is a subject that has undergone extensive exploration and
debate, particularly in the medical and nursing literature. The
debate concentrates on issues such as the purpose (to predict or
circumvent) and accuracy (actuarial or clinical) of risk assess-
ments. Actuarial risks are based on static or historical factors
statistically associated with increased risk, while clinical risk
assessment is usually based on unaided clinical judgment and
intuition (Lamont & Brunero, 2009). Clinicians however are
concerned with the reality of assessing and managing aggres-
sion and violence risk rather than the formal research task of
prediction (Doctor, 2004).

The clinical utility of violence risk assessment tools has
attracted particular scrutiny. Maden (2001) observes that most
violence risk assessment tools were developed on high-risk
populations, usually individuals who had already committed
serious offences. They were not designed to be applied to
the general population. Therefore attempts to apply violence
risk assessment tools developed in the forensic sector to
the wider population could result in inaccurate and overly
coercive interventions (RCP, 2008). Importantly, actuarial tools
developed from predictor variables do not necessarily reflect the
experiences of the individual (Crowe & Carlyle, 2003) and are
therefore the province of research rather than everyday clinical
practice (Undrill, 2007). Stein’s (2002) review of actuarial-
based tools used to aid the process of discharge risk assessment
in the UK surmised that there are inherent limitations in the
predictive power of these types of tools. This review expressed

reservations as to the ability of risk assessment tools to account
for the complexity and diversity of human behaviour. For
example, different tools may be required for males and females
as the predictor variables for one gender may differ from the
other. The transferability of actuarial tools from one setting to
another or one country to another also is doubtful (Stein, 2002).

The RCP contend there is an absence of research evidence
supporting the ability of violence risk assessment tools to re-
duce or prevent adverse events and that they provide a false
sense of security that risk has been adequately addressed (RCP,
2008). This claim is consistent with the UK National Institute
for Clinical Excellence (NICE; 2005) guidelines on the man-
agement of aggression and violence, which could recommend
no gold standard violence risk assessment tool. By illustration,
Hart, Michie, and Cooke (2007) evaluated the margins of error
at the group and individual level for risk estimates made using
two well-known actuarial risk assessment instruments: the Vio-
lence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, &
Cormier, 1998) and the Static-99 (Hanson & Thornton, 1999).
The VRAG is a 12–item test developed from a sample of pa-
tients released from a maximum-security psychiatric hospital
in Canada. The Static-99 is a 10-item test developed from four
diverse samples of offenders and forensic psychiatric patients
released from institutions in Canada and the UK. Results from
this evaluation indicated that the two tools had poor precision.
The margins of error for risk estimates made using the tools
were substantial, even at the group level. At the individual level,
the margins of error were so high as to render the test results
virtually meaningless. Hart et al. (2007) concluded that actuar-
ial risk assessment instruments cannot be used to estimate an
individual’s risk for future violence with any degree of certainty
and should be used with great caution or not at all.

Clearly however, risk assessment processes incorporate more
complex dynamics than just clinical experience and/or actuar-
ial based information. Subsequently an integrated framework
of structured professional judgment has developed as a mul-
tidisciplinary approach for reducing incidents of aggression
and violence in mental health. Structured professional judge-
ment involves consideration of known risk factors, professional
experience, and individual knowledge of the patient (Lamont
& Brunero, 2009). Operationalizing these principles, Abder-
halden, Needham, Dassen, Halfens, and Haug (2008) conducted
a RCT to assess whether structured risk assessment decreased
the incidence of violence and coercion in acute psychiatric set-
tings across Switzerland. The intervention consisted of three
elements: (1) a structured short-term risk assessment for every
new patient during the first three days of hospitalisation, (2)
discussion of preventative measures from a list provided on the
risk assessment form for high risk patients, and (3) in cases of
very high risk, teams were prompted to plan and implement
preventative measures. This process resulted in a significant re-
duction in severe events of patient aggression and also reduced
the need for coercive measures. The authors do note a number of
limitations to the study which might have increased the effect of

4 T. WAND

the intervention; however, findings indicate that action tailored
to the individual risk level may be a simple and cost effective
way of diminishing the problem of violent incidents in acute
psychiatric units.

Recently King, Yassi, Smailes, Lovato, and Koehoorn (2011)
investigated the effectiveness of a violence risk assessment alert
system in conjunction with existing violence prevention training
in a large acute care hospital in Canada. Although the alert sys-
tem was considered useful for identifying at risk patients, it had
no impact on the rate of violence during either the intervention
or post-intervention period compared with the pre-intervention
period. The authors posit that the alert system may have raised
staff anxiety, resulting in increased reporting of flagged patients.
The system also may have influenced the manner in which staff
interact with those patients identified as high risk, increasing
the likelihood the patient would become violent. In focus groups
conducted as part of the investigation, staff recognised that some
patients may be incorrectly identified as high risk based only on
past history and that flagging had the potential to stay with the
patient unnecessarily.

Related to violence risk, research on establishing a link with
psychosis and violence is also well represented in the literature.
The consensus from research in this field suggest strongly that all
acts of harm to others perpetrated by people with a mental illness
are not primarily related to their mental illness once substance
misuse is taken into account (Davidson, 2005; Elbogen & John-
son, 2009; RCP, 2008). This was highlighted by a meta-analysis
examining the association between psychosis and violence con-
ducted by Douglas, Guy, and Hart (2009). The study found
an overall association between psychosis and violence, which
was particularly strong when the comparison group consisted
of individuals without a mental disorder. However, compared to
individuals with externalizing psychopathology, psychosis did
not appear to further elevate the risk for violence while comorbid
substance-related disorder elevates the risk of violence substan-
tially. Therefore it is important to know whether a person with
either a psychotic illness or a substance-related disorder has a co-
occurring disorder, although the presence of psychosis should be
considered neither necessary nor sufficient for a determination
of high risk. This conclusion is based on the finding that the over-
all magnitude of the psychosis-violence association was small;
meaning that most violent individuals are not psychotic and most
psychotic individuals are not violent (Douglas et al., 2009).

Hiday (2006) identifies numerous confounding factors that
are minimised or neglected in studies undertaken to explore a
link between mental illness and violence. Hiday (2006) concurs
that once comorbid substance abuse and personality disorder
are taken into account, the contribution of psychosis to vio-
lence in the community diminishes dramatically. Furthermore,
people with mental illness are more likely to reside in violent
neighbourhoods and this could be a significant variable, rather
than a psychiatric diagnosis. Multiple studies provide evidence
that mental illness, substance abuse, and violence are frequently
associated with what are frequently called socially disorgan-

ised communities, which are environments characterised by
poverty, high unemployment, low education levels, resources
deprivation, physical deterioration, and breakdown in micro in-
stitutions, especially families. People with a mental illness who
grow up in these communities learn to be violent, just as oth-
ers in that environment learn that behaviour (Hiday, 2006). The
World Health Organisation (WHO; 2004) observes that anti-
social and suicidal behaviour have long been linked to strengths
or absences of social cohesion. Weak social controls and the
disruption of local community organisation have strong associ-
ations with increased rates of violent crime and suicide (WHO,
2004). Recognition that mental health problems occur univer-
sally, but are much more common among people with relative
social disadvantage (Herman & Jane-Llopis, 2005) therefore
requires a shift in policy, practice, and research away from a
narrow biomedical approach toward a broader health promotion
and public health perspective (Magyary, 2002; Wand, 2011).

SELF-HARM AND SUICIDE RISK
The terms self-harm and suicide are often used together,

and self-harm (such as low lethality overdose or self-inflicted
lacerations) is an established risk factor for suicide (Zahl &
Hawton, 2004). Nevertheless it is important to acknowledge that
self-harm is not necessarily synonymous with suicidal intent.
In reality most self-harm inflicts little actual harm and does not
come to the attention of mental health services. Some individuals
may initially state that their intentions were to die, however on
further exploration it can often be established that suicide was
not really the intended goal. The motivation for self-harm is
typically an expression of distress, anger, or a desire to escape
a troubling situation (Hawton & James, 2005).

Various studies and publications list an extensive number of
risk factors associated with suicide. Despite this, the prediction
of suicide reveals alarmingly low specificity. Static risk factors
may give an indication of an individual’s propensity for suicide
but they do not capture the fluctuating nature of risk. Multiple
risk factors are not always present in high-risk individuals and
only one or two risk factors may need to be present to a serious
degree to provide sufficient risk. Risk also can escalate rapidly
over a short period and alternatively, if the outcome is not fatal,
just as quickly subside (Bouch & Marshall, 2005). Furthermore,
most suicides occur in low risk groups for the simple reason that
they contain many more members than high risk groups and
there is no evidence that addressing risk factors as such has any
impact on survival (Undrill, 2007).

Harris and Hawton (2005) verify that studies attempting to
identify particular individuals who are more likely to die by
suicide have been largely unsuccessful primarily due to the low
prevalence even within high risk groups. Harris and Hawton
(2005) analysed the predictive value of the Beck Suicide Intent
Scale (SIS) based on clinical and demographic data on 4,156
individuals who had self-harmed. Thirty males (2.9%) and 24
females (1.7%) in this sample died by suicide but the positive

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 5

predictive value of the SIS was low (4%). The authors conclude
that it is not possible to use patient information (even infor-
mation shown to be strongly associated with suicidal intent) to
predict accurately which individual patients will die by suicide
and “highlights the dangers of a checklist-style approach” for
identifying at risk patients (Harris & Hawton, 2005).

Owens, Wood, Greenwood, Hughes, and Dennis (2005) at-
tempted to determine predictors of suicide by undertaking a
retrospective study with 976 consecutive patients attending a
large Emergency Department (ED) in the UK following nonfa-
tal self-poisoning. Their study found that suicide was related to
numerous factors evident at the time of self-poisoning but the
predictive values of patient characteristics that point to higher
than average risk are “just too poor to be useful” (Owens et al.,
2005). The researchers’ concluded that employing a high risk
strategy is a “hopeless” approach to suicide and self-harm re-
duction. Instead they suggest that government initiatives should
focus less on risk assessment and more on the assessment of
individual needs.

Kapur, Cooper, Rodway, Kelly, Guthrie, and Mackway-Jones
(2005) investigated the predictive value of risk assessments after
an episode of self-harm and compared assessments made by ED
staff with those made by psychiatric staff. They found that ED
staff were more likely than psychiatric staff to assess the risk
of repetition as high. For both groups however, most repetitions
were among people assessed as low or moderate risk. The pre-
dictive value of risk assessment after self-harm was low. These
authors believe that restricting intervention to people identified
as high risk, even assuming a completely effective intervention,
would prevent less than one fifth of repeat episodes.

Kapur (2005) contends that any predictability of the risk of
future suicidal behaviour following self-harm is problematic
because such events are statistically rare and assessment tools
are relatively crude. Nevertheless follow-up after self-harm and
suicidal behaviour is important and should be prompt. Strate-
gies that could be employed to improve follow-up include home
visits, the provision of printed information, and aftercare being
provided by the health professional who carried out the ini-
tial assessment (Kapur, 2005). The Royal Australian and New
Zealand College of Psychiatry (RANZP; 2004) practice guide-
lines on self-harm also advocate for early engagement of the
person and active follow-up. The RANZCP guidelines also rec-
ognize that the practice of asking individuals to enter into no
self-harm contracts or to guarantee or assure their safety is incor-
rectly thought of as an effective method for managing self-harm
risk and to protect the clinician from litigation. However these
guidelines state that there is no evidence that this or any form
of self-harm/suicide contract has any therapeutic benefit and is
potentially counter-therapeutic. This is supported by subsequent
examinations of this area that identify a lack of evidence for no
suicide or self-harm contracts, as well as confirming their lack
of medico-legal protection and potential to produce detrimen-
tal outcomes (Edwards & Harries 2007; Edwards & Sachmann
2010; McMyler & Pryjmachuk 2008). Kapur (2005) asserts that

reducing our preoccupation with risk assessment may actually
assist in improving the management of self-harm and suicide.
A shift from risk assessment to needs assessment is indicated
which aims to identify psychosocial factors that help to un-
derstand an act of self-injury or suicide and contributes to a
management plan (Kapur, 2005).

IMPLICATIONS FOR CLINICAL PRACTICE
The reality that the prediction of aggression and violence,

self-harm, and suicide by clinicians is poor raises serious ques-
tions about the integrity of mental health legislation, which in
most jurisdictions is based on a dangerousness standard of a risk
to self or others. In response, a growing number of clinicians
and academics have called for the abolition of separate men-
tal health legislation in favour of a generic mental incapacity
act (for examples see Dawson & Szmukler 2006; Large, Ryan,
Nielssen, & Hayes 2008; O’Brien, 2010; Ryan 2011; Wand &
Chiarella 2006). Concerns have been expressed about the pre-
ventative detention component of mental health legislation that
allows for apprehension of individuals in advance of violence
(a different standard applied to mental health treatment with-
out consent than to unconsented treatment for physical health
problems) and that separate mental health legislation framed
around a category of people and based on a risk criteria rein-
forces stigma and stereotypes about the characteristics of people
with mental illness. At least until a more accurate and equitable
legal resolution can be reached, Wand and Chiarella (2006) ar-
gue that it is imperative that current mental health legislation
maintain relevance in protecting the rights of consumers. This
is achieved by upholding the United Nations High Commission
for Human Rights (1991) and WHO’s (1996) principles of a
preference for community-based care, an emphasis on volun-
tary access to mental health services, and involuntary treatment
on the grounds of mental incapacity, only as a last resort and for
the shortest time possible.

The current discourse around a recovery orientation to men-
tal health service provision runs counter to the discourse on risk.
Parsons (2008) highlights the concept of “the dignity of risk”
and proposes that there is a double standard for people who are
diagnosed with a mental illness and those who are not. People
who are not diagnosed as mentally ill are able to make risky and
potentially self-defeating choices without intervention from
authorities, clinicians, or service providers wishing to protect
them from the consequences of their choices. The concept of the
dignity of risk acknowledges that accompanying every endeav-
our is the element of risk and that every opportunity for growth
carries with it the potential for failure. All people learn through a
process of trial and error and through taking risks. People often
learn as much from mistakes as from successes. When people
living with a mental illness are denied the dignity of risk, they are
being denied the opportunity to learn and recover. By supporting
dignity of risk, service providers and clinicians can help to com-
bat learned helplessness and bolster self-esteem, self-respect,

6 T. WAND

empowerment, and hope (Parsons, 2008). In Australia for
example, the Fourth National Mental Health Plan (2009–2014)
which adopts a population health perspective affirms that mental
health service providers should work within a framework that
supports recovery both as a process and as an outcome to
promote hope, well-being, and autonomy. In this current Plan
mental health clinicians are urged to recognise an individual’s
strengths including coping skills and resilience, and rights to
self-determination (Commonwealth of Australia, 2009).

Risk management must, therefore, move away from a focus
simply on assessment and instead on to therapeutic intervention
that recognises and promotes the patient’s strengths and sup-
ports recovery. The RCP (2008) assert that there is presently an
overemphasis on the use of “invalidated tick box” assessment
forms that are damaging to clinical practice and patient well-
being. The RCP report identifies the propensity for “locally de-
veloped assessment forms” to be produced as a means of “back
covering” in the event of an adverse incident and that this rep-
resents “a lazy and authoritarian approach to delivering health
care.” Contemporary formats for undertaking mental health as-
sessments are typically structured to seek out problems, illness,
and pathology in the individual. However, rather than producing
a comprehensive assessment, the profile of the individual ob-
tained is biased toward identifying only negative characteristics.
Some consideration of protective factors such as religious be-
liefs or concerns for family and friends or pets may occur; though
no attempt is usually made to balance an assessment with an ex-
ploration and documentation of the person’s strengths, abilities,
resources, coping skills, past successes, goals, hopes, and the
broader context of the individual’s life and social circumstances.
Further, Undrill (2007) argues that the amount of information
gathered during the typical assessment process is often super-
fluous to the current presentation and has the potential to over-
complicate clinical decision making. Undrill (2007) proposes
that a stance of “bounded rationality” may be more beneficial to
make decisions on less information rather than expend time and
energy on accumulating and documenting excessive amounts of
personal information that is of marginal utility.

WHAT IS THE ALTERNATIVE?
In contrast to a risk assessment focus, a substantial level

of interest has been generated in promoting the positive as-
pects of health and well-being, which concentrates on wellness
rather than illness (Parham, 2008). Research from the field of
positive mental health for example has been found to result in
impressive and enduring positive effects on multiple areas of
individual functioning and also has the dual effect of reducing
risk (Barry & Jenkins, 2007). Positive mental health acknowl-
edges that a mental illness or disorder may impede, but does
not preclude, positive emotion, engagement, purpose, positive
relationships, and positive accomplishments (Seligman, 2008).
Interventions adopting a positive mental health framework are
primarily concerned with building capacity and self-efficacy in

diverse areas of life and signal a shift from a disorder-focused
perspective to one that embraces psychological strengths and re-
silience. An emphasis on positive emotions, such as optimism,
promotes resilience, immunizes individuals against depression,
and enhances adaption to stressful life events (Magyary, 2002).
Building individual capacity also increases options available for
people to exercise more control over their own health and over
their environment to make choices conducive to health (Jane-
Llopis, Barry, Hosman, & Patel, 2005). This is compatible with
newer therapeutic approaches such as solution focused therapy
(SFT) that represent an alternative way of thinking and working
with people that is more optimistic, more enabling, and accepts
that individuals will ultimately make their own decisions. SFT
has broad utility for working with an array of mental health and
substance misuse problems and is increasingly popular across
a spectrum of health settings with a growing evidence base.
The SFT approach is based on solution building rather than
problem solving. Instead of a focus on problems, pathology
and risk, SFT utilises questions aimed at surfacing an individ-
uals strengths, abilities, resources, and the person’s vision for
the future; thereby helping the person to formulate solutions
to problems rather than dwell on problems themselves (Wand,
2010).

CONCLUSION
Despite the heavy emphasis on risk assessment in mental

health there is little evidence that this approach is effective in
reducing risk of harm to self or others. Moreover, there are in-
dications from the available research that a focus on risk assess-
ment has been ineffective in reducing self-harm and suicide risk
and that alternative approaches need to be considered. Risk as-
sessment is conceptualised as a managerially driven agenda that
has resulted in mental health service provision being consumed
by a state of nervous paternalism. The uncertainty with which
risk of harm to self or others can be anticipated by clinicians has
resulted in a culture of overly defensive practices and increased
use of coercion; whereby the fear of medico-legal reprisal takes
priority over the impact such intervention has on the individual.
This, in turn, has consequences for the establishment of positive
working relationships between clinicians and consumers and is
at odds with a recovery orientation. Organisations and health
authorities would be wise to invest more time and resources in
public awareness campaigns and initiatives that promote men-
tal health and well-being. There is a need to recognize from a
public, policy, practice, and research perspective that the root
cause of problems such as self-harm and suicide, aggression,
violence, and substance misuse are predominantly socially de-
termined and, as such, should be addressed by a broader public
health approach rather than through a narrow biomedical lens.

Declaration of interest: The author reports no conflicts of
interest. The author alone is responsible for the content and
writing of the paper.

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 7

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Hindawi Publishing Corporation
Nursing Research and Practice
Volume 2011, Article ID 650765, 4 pages
doi:10.1155/2011/650765

Research Article

Nurses’ Psychosocial Barriers to Suicide Risk Management

Sharon Valente

Research and Education, Department of Veterans Affairs, 11301 Wilshire Boulevard, Room 6235, Los Angeles, CA 90073, USA

Correspondence should be addressed to Sharon Valente, sharon.valente@va.gov

Received 24 December 2010; Accepted 25 March 2011

Academic Editor: Leana Ria Uys

Copyright © 2011 Sharon Valente. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Suicide remains a serious health care problem and a sentinel event tracked by The Joint Commission. Nurses are pivotal in
evaluating risk and preventing suicide. Analysis of nurses’ barriers to risk management may lead to interventions to improve
management of suicidal patients. These data emerged from a random survey of 454 oncology nurses’ attitudes, knowledge of
suicide, and justifications for euthanasia. Instruments included a vignette of a suicidal patient and a suicide attitude questionnaire.
Results. Psychological factors (emotions, unresolved grief, communication, and negative judgments about suicide) complicate
the nurse’s assessment and treatment of suicidal patients. Some nurses (n = 122) indicated that euthanasia was never justified
and 11 were unsure of justifications and evaluated each case on its merits. Justifications for euthanasia included poor symptom
control, poor quality of life, incurable illness or permanent disability, terminal illness, and terminal illness with inadequate
symptom control or impending death, patient autonomy, and clinical organ death. The nurses indicated some confusion and
misconceptions about definitions and examples of euthanasia, assisted suicide, and double effect. Strategies for interdisciplinary
clinical intervention are suggested to identify and resolve these psychosocial barriers.

1. Psychosocial Barriers to Suicide
Risk Management

Patients facing a life-threatening illness such as cancer
have an increased risk of suicide, and this study examines
the nurse’s psychosocial barriers to managing suicide risk.
Nurses have a major role to play in patient safety when
they recognize the warning signs, monitor the patient’s
emotional state, provide a therapeutic relationship, and take
precautions to prevent suicide. Although 70% of people warn
providers of their suicidal impulses, clinicians often fail to
take these warnings seriously [1]. Therapeutic intervention
can often effectively help alleviate the pain, symptoms, or
depression and reduce suicide risk. Psychosocial barriers
such as the nurse’s emotions, beliefs, knowledge, or attitudes
can impair risk management. This paper describes content
analysis of oncology nurses’ narratives about psychosocial
barriers in managing suicide risk.

People with cancer have higher than average rates of
suicide. Rates of suicide have been estimated to be as high
as 31.4/100,000 person-years among people with cancer
or AIDS. [2]. Misono et al. found an age-, sex-, and
race-adjusted rate of 31.4/100,000 person-years which is

almost twice the general suicide rate in the US which was
16.7/100,000 person-years. Men who were older and white
had higher suicide rates. Specific cancers had the highest
suicide risks (e.g., lung and bronchi cancers (standardized
mortality ratio (SMR) = 5.74; 95% CI, 5.30 to 6.22), stomach
(SMR = 4.68; 95% CI, 3.81 to 5.70), oral cavity and pharynx
(SMR = 3.66; 95% CI, 3.16 to 4.22), and larynx (SMR = 2.83;
95% CI, 2.31 to 3.44). Suicide is a sentinel event. Suicide
risk increases when cancer patients face diagnosis, disease
exacerbation, treatment failure, and advanced or terminal
stage of illness. An estimated 2–6% and an average of 3%
of terminally ill cancer patients commit suicide or request
assistance to do so [3]. A person’s threats of suicide may mean
that the person wants to escape from pain, fears, and misery
and they may consider suicide the only option. However,
therapeutic intervention can resolve some of the painful and
distressing symptoms.

2. Purpose

This paper reports the analysis of the psychosocial factors
(e.g., emotions, personal experiences, values, and judg-
ments) that oncology nurses identified as barriers to their

2 Nursing Research and Practice

management of suicide risk of a suicidal patient depicted in
a vignette. These data emerged from a study that examined
the oncology nurse’s attitudes and knowledge in managing
suicide risk.

3. Methods

Four hundred and fifty-four oncology nurses (37%) from a
national, random survey of 1200 Oncology Nursing Society
members in clinical practice provided informed consent and
agreed to participate. Clinical oncology nurses were selected
because they cared for patients with increased risk of suicide.
Six retired nurses declined to participate.

4. Instruments

Instruments included a demographic inventory, a vignette of
a suicidal patient with questions about nursing evaluation
and management, a quantitative instrument with 94 items
measuring attitudes toward suicide of the self, a loved one
and a stranger in various situations, and a Suicide Attitude
Questionnaire, a qualitative tool. The instruments were pilot
tested, revised, and given in random order to participants.
Participants used a confidential code and mailed back the
questionnaires.

5. Suicide Vignette

A case study of an oncology patient with suicidal signs (e.g.,
older, Caucasian, widower, depressed, talks about suicide,
gives away prized possessions, and has no reason to live)
was presented. It included questions about evaluating risk
assessment, evaluation, psychosocial assessments, suicide
risk factors, depression and anxiety ratings, goals and
interventions, skill, and knowledge. In the development of
these tools, both content validation and interrater reliability
were assessed. The procedure employing content experts
for content validation followed the usual protocol. A judge
panel of experts with advanced training in psychosocial
oncology and psychiatric nursing established content validity
and scoring. Test-retest (94%) was measured and inter-rater
reliability (96%) in scoring and data entry was accomplished
by having two people rate more than 25% of the vignettes.

Vignettes simulate a real situation and provide an effec-
tive research tool to elicit respondent’s attitudes, knowledge,
opinions, interventions, and respondent’s anticipated behav-
ior in the situation [4]. Outcomes assessment in psychiatric
postgraduate medical education: an exploratory study using
clinical case vignettes [4, 5], (Russell, 2007). Vignettes can
collect information simultaneously from a large sample,
manipulate variables, and avoid ethical problems that might
occur in observational studies [4]. Vignettes have served to
elicit diagnoses [6], pain [7], nursing knowledge [8], nursing
performance [9], infection control [10], ethical decisions
[11], and schizophrenia [12]. Expert panels have been used
to validate vignettes.

The Suicide Attitude Questionnaire (SAQ) is a qualita-
tive measure with items about care giving, ethical issues,

knowledge and assessment, and open-ended questions about
the difficulty responding to a patient who mentions suicide,
circumstances that would justify euthanasia, circumstances
under which a patient’s request for assistance should be
granted, concerns and conflicts, and questions about suicide
knowledge and suicide assessment skill. Questions about
euthanasia were added because the pilot study showed
that nurses were confused about this issue and needed
an opportunity to express these issues. Nurses answered
these questions and rated their skill and knowledge in
suicide assessment and management. Psychometrics for the
instruments are described in detail elsewhere [13].

6. Qualitative Data Analyses

Content analysis afforded a systematic approach for ana-
lyzing narrative texts into categories and making sense of
the data. All written narrative responses to SAQ items
were entered verbatim for each question and typed into
Word, a word processing program. We followed Wilson’s
(Wilson, 1989) procedures for semantic content analysis. We
identified the units of analysis as the respondent’s words. Our
unit of analysis were words (e.g., fear, not difficult), phrases
(e.g., fear of reprisal by family, fear of failure), or sentences
(e.g., due to chronic illness, my parent committed suicide)
that conveyed a unified idea. Six responses were not able to
be coded because they were vague or unclear.

The principle investigators trained the data analysis team
(e.g., experienced masters-prepared oncology nurses, an
oncology social worker, and a graduate nursing student) in
qualitative data analysis. The doctorally prepared principal
investigators had expertise in psychosocial oncology. After
the narrative data were entered in the computer and
verified, the data analysis team independently read the
narratives before meeting to discuss and identify categories.
We developed the preliminary categories from the data,
rationale, and illustrations to guide the coding. The entire
research team met to refine the directions for coding
until categories were accepted for coding the narratives.
After describing each category for coding, the research
team independently assigned the written narrative responses
to these categories before meeting to discuss our coding
and reach consensus. Final decisions about coding were
reached by consensus through discussion. The following
categories emerged: religious, spiritual, or other values and
beliefs; uncomfortable feelings; personal experiences with
suicide; inadequate skills, knowledge and experience (in
suicide evaluation and treatment); weight of professional
responsibility; not difficult to care for suicidal patients.

7. Results

7.1. Demographics. Of the total sample, 90.4% were women.
Seventy-seven percent (77%) were EuroAmerican, 7.1%
were African Americans, 7.1% were Asian Americans, 4.2%
were Latin Americans, and 2.1% identified themselves as
Canadians. The modal age was 40–49 with a range of 20 to
over 60 years old. Most of the sample had a diploma/AA

Nursing Research and Practice 3

or B.S. degree (38.4%) or an M.S. degree (55.9%). Most
nurses (89.1%) had worked more than 9 years in nursing.
Although most respondents were educated in the United
States (91.8%), some were educated in Canada or abroad. We
aimed for a sample of nurses in clinical practice. Most nurses
reported spending at least 50% per day in clinical practice.
Nearly 90% of nurses were close to one or more patients (x
= 6 who died in the year preceding the survey). Nearly all
nurses had taken courses in cancer; approximately 20% had
taken a course in suicide.

The main categories or core concepts that emerged from
the interviews and focus group included communication
barriers, judgments about suicide, unresolved grief, emo-
tions, inadequate knowledge, and justifications for euthana-
sia.

7.2. Communication Barriers. They emerged from the
nurses’ narratives about their difficulties caring for a suicidal
patient. Some nurses explained that they lacked the expertise
of psychiatrists and did not know what to say to a suicidal
patient (1) “I would say nothing to avoid making an error.”
Nurses also indicated they lacked skill and knowledge about
suicide risk assessment. (2) “I would not know what to ask
about suicide so I remain silent.” (3) Others feared that
asking about suicide risk might encourage suicidal acts. Some
nurses also reported that they did not know how to tell if the
patient was “serious” about these suicidal impulses and did
nothing while trying to figure out if the patient was serious.
Some nurses expressed conflicts between their roles in suicide
prevention and advocacy for the patient at end of life who
wanted to die with dignity. One nurse said, “I knew I should
sound the alarm when the patient talked about suicide but he
was dying and was exhausted by the treatments and wanted
to die in peace.”

7.3. Judgements about Suicide. Nurses reported that suicide
was “a coward’s way out” and some nurses identified religion
as the source of their values, but others described spiritual or
other beliefs that led them to judge suicide as wrong or bad.
Nurses expressed concern about what was morally right for
the patient within the limits of what was required by the legal
and professional guidelines. Some nurses worried about the
impact on the family and thought the patient was wrong for
harming the family. Examples of nurse’s narratives include
the following: (1) “I was reared with a strong religious
belief that ending one’s life should be prevented” and (2)
“Topic is taboo in society; my religious conviction—suicide
is wrong—a mortal sin.”

7.4. Unresolved Grief. Nurses drew on experience or lack
of experience in their own family or personal life and
shared personal experiences. When a family member had
committed suicide several nurses said that their reaction to
a family member’s suicide impaired their ability to care for
suicidal patients. Examples of nurses’ narratives included
the following: (1) “My grandmother committed suicide and
I had an uncle too.” (2) “A close relative of mine did
(committed suicide) for health reasons. Its very sad.”

7.5. Emotions. Nurses described unpleasant emotional
responses of varying or unspecified intensity (e.g., related to
fear and other feelings) that created difficulty. Examples of
nurses’ narratives include the following: (1) “Fear they will
commit suicide. I always think about the pain they must be
in and the level of that despair. Suffering is hard to watch.” (2)
“Fear of reprisal by patient/family.” (3) “Very uncomfortable
feeling.” Other comments included “fear that I’m unable
to help and the feeling that I’m a personal failure if the
patient commits suicide.” Some nurses reported “I’m just
uncomfortable with the subject.”

Inadequate Knowledge. I do not know the right thing
to say. Nurses highlighted deficits in their professional
experience, skill, knowledge, or abilities to care for suicidal
patients. The narrative was cognitive in tone and description.
Some nurses said that they lacked the skill and knowledge
to work with suicidal patients. They did not know how
to respond and wanted to avoid the risk of responding
incorrectly. In this category, respondents focused on suicide.
Examples from the nurses’ narratives included the following:
(1) “Sense of failure that I might not be able to “fix” things.
Its frightening; I’m not skilled at assessment and counseling
in this situation. Uncertainty about my own skill/knowledge
related to assessment.” (2) “Inadequate and ambivalent;
unfamiliar with suicide; no education.” (3) “Not knowing
how to help their helplessness, finding a way to reach them
and get them to see suicide as absolutely the last alternative.”
(4) “I don’t want to say the wrong thing.”

8. Circumstances That Justify Euthanasia

Asking about suicide in the context of end of life raises
issues about euthanasia. Nurses struggle to weigh patient
rights with their personal values and professional beliefs
about what is right. This is never an easy decision, as
nurses see patients suffer at end of life needlessly and those
who have intrusive interventions despite their wishes to the
contrary as well as patients who want to let nature take its
course. Nurses reported the circumstances that would justify
euthanasia. For nurses (n = 122) euthanasia was never
justified. Other nurses indicated that euthanasia could be
justified for poor symptom control or quality of life (not
terminally ill) (N = 61), terminal illness, impending death
with qualifiers (pain, QOL, end-stage disease) (N = 69);
patient autonomy (informed choice, living will) n = 30;
incurable illness/permanent disability n = 23; clinical death,
organ donor, vegetative state, flat EEG N = 15; terminal
illness (no qualifier) n = 14; not sure n = 11.

9. Discussion

The nurse’s concerns related directly to complex professional
and ethical issues that were embedded in the various
contexts of nursing care. Clinicians reported conflicts as
they considered their duties to safeguard life and to respect
the patient’s autonomy, yet they did not report considering
the patient’s capacity to exercise autonomy. Some believed
that their duty was to respect a patient’s right and freewill

4 Nursing Research and Practice

to choose suicide instead of a life-threatening disease (e.g.,
cancer or AIDS) that involved pain, fatigue, and unrelieved
suffering. On the other hand, nurses had a duty to protect
patients from harm.

Some nurses may not thoroughly consider the criteria
for rational thinking and voluntary, informed choice that
is necessary for autonomy. In some instances, suicidal pa-
tients lack capacity to exercise autonomy because a severe
psychiatric disorder such as major depression with cognitive
deficit undermines their ability to think clearly. However,
the striking fact is that nurses did not describe evaluating
rational thinking in their consideration of what justified
euthanasia.

Nurses rarely emphasized the constraints of their set-
tings. They struggled to describe their responses and actions
in the context of moral versions of the responsible nursing
role in situations where the nurses were not the arbiters of
power or decisions. In attempting to serve the best interests
of all involved, nurses face difficult ethical dilemmas. The
nurse’s strong support for the ethical principles of autonomy,
or free choice, and self-determination may conflict with
nonmaleficence, or the duty to prevent harm. When a patient
asks for the nurse’s assistance in dying, the nurse must
consider the conflicting ethical duties to prevent harm and
respect the patient’s choice. The ICN Code of Ethics states
that “the nurse takes appropriate action to safeguard the
individual when his care is endangered by any other person”
(ICN, p. XIII). In addition the nurse needs to consider
responsibilities to the family, hospital. Professional, legal, and
ethical implications arise when terminally ill patients request
euthanasia.

Acknowledgments

This material is the result of work supported with the
resources and use of the facilities at Department of Veterans
Affairs Greater Los Angeles Healthcare System. Supported
by the Oncology Nursing Foundation/Glaxo Wellcome Re-
search Grant.

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Volume 2011, Article ID 650765, 4 pages
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Research Article

Nurses’ Psychosocial Barriers to Suicide Risk Management

Sharon Valente

Research and Education, Department of Veterans Affairs, 11301 Wilshire Boulevard, Room 6235, Los Angeles, CA 90073, USA

Correspondence should be addressed to Sharon Valente, sharon.valente@va.gov

Received 24 December 2010; Accepted 25 March 2011

Academic Editor: Leana Ria Uys

Copyright © 2011 Sharon Valente. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Suicide remains a serious health care problem and a sentinel event tracked by The Joint Commission. Nurses are pivotal in
evaluating risk and preventing suicide. Analysis of nurses’ barriers to risk management may lead to interventions to improve
management of suicidal patients. These data emerged from a random survey of 454 oncology nurses’ attitudes, knowledge of
suicide, and justifications for euthanasia. Instruments included a vignette of a suicidal patient and a suicide attitude questionnaire.
Results. Psychological factors (emotions, unresolved grief, communication, and negative judgments about suicide) complicate
the nurse’s assessment and treatment of suicidal patients. Some nurses (n = 122) indicated that euthanasia was never justified
and 11 were unsure of justifications and evaluated each case on its merits. Justifications for euthanasia included poor symptom
control, poor quality of life, incurable illness or permanent disability, terminal illness, and terminal illness with inadequate
symptom control or impending death, patient autonomy, and clinical organ death. The nurses indicated some confusion and
misconceptions about definitions and examples of euthanasia, assisted suicide, and double effect. Strategies for interdisciplinary
clinical intervention are suggested to identify and resolve these psychosocial barriers.

1. Psychosocial Barriers to Suicide
Risk Management

Patients facing a life-threatening illness such as cancer
have an increased risk of suicide, and this study examines
the nurse’s psychosocial barriers to managing suicide risk.
Nurses have a major role to play in patient safety when
they recognize the warning signs, monitor the patient’s
emotional state, provide a therapeutic relationship, and take
precautions to prevent suicide. Although 70% of people warn
providers of their suicidal impulses, clinicians often fail to
take these warnings seriously [1]. Therapeutic intervention
can often effectively help alleviate the pain, symptoms, or
depression and reduce suicide risk. Psychosocial barriers
such as the nurse’s emotions, beliefs, knowledge, or attitudes
can impair risk management. This paper describes content
analysis of oncology nurses’ narratives about psychosocial
barriers in managing suicide risk.

People with cancer have higher than average rates of
suicide. Rates of suicide have been estimated to be as high
as 31.4/100,000 person-years among people with cancer
or AIDS. [2]. Misono et al. found an age-, sex-, and
race-adjusted rate of 31.4/100,000 person-years which is

almost twice the general suicide rate in the US which was
16.7/100,000 person-years. Men who were older and white
had higher suicide rates. Specific cancers had the highest
suicide risks (e.g., lung and bronchi cancers (standardized
mortality ratio (SMR) = 5.74; 95% CI, 5.30 to 6.22), stomach
(SMR = 4.68; 95% CI, 3.81 to 5.70), oral cavity and pharynx
(SMR = 3.66; 95% CI, 3.16 to 4.22), and larynx (SMR = 2.83;
95% CI, 2.31 to 3.44). Suicide is a sentinel event. Suicide
risk increases when cancer patients face diagnosis, disease
exacerbation, treatment failure, and advanced or terminal
stage of illness. An estimated 2–6% and an average of 3%
of terminally ill cancer patients commit suicide or request
assistance to do so [3]. A person’s threats of suicide may mean
that the person wants to escape from pain, fears, and misery
and they may consider suicide the only option. However,
therapeutic intervention can resolve some of the painful and
distressing symptoms.

2. Purpose

This paper reports the analysis of the psychosocial factors
(e.g., emotions, personal experiences, values, and judg-
ments) that oncology nurses identified as barriers to their

2 Nursing Research and Practice

management of suicide risk of a suicidal patient depicted in
a vignette. These data emerged from a study that examined
the oncology nurse’s attitudes and knowledge in managing
suicide risk.

3. Methods

Four hundred and fifty-four oncology nurses (37%) from a
national, random survey of 1200 Oncology Nursing Society
members in clinical practice provided informed consent and
agreed to participate. Clinical oncology nurses were selected
because they cared for patients with increased risk of suicide.
Six retired nurses declined to participate.

4. Instruments

Instruments included a demographic inventory, a vignette of
a suicidal patient with questions about nursing evaluation
and management, a quantitative instrument with 94 items
measuring attitudes toward suicide of the self, a loved one
and a stranger in various situations, and a Suicide Attitude
Questionnaire, a qualitative tool. The instruments were pilot
tested, revised, and given in random order to participants.
Participants used a confidential code and mailed back the
questionnaires.

5. Suicide Vignette

A case study of an oncology patient with suicidal signs (e.g.,
older, Caucasian, widower, depressed, talks about suicide,
gives away prized possessions, and has no reason to live)
was presented. It included questions about evaluating risk
assessment, evaluation, psychosocial assessments, suicide
risk factors, depression and anxiety ratings, goals and
interventions, skill, and knowledge. In the development of
these tools, both content validation and interrater reliability
were assessed. The procedure employing content experts
for content validation followed the usual protocol. A judge
panel of experts with advanced training in psychosocial
oncology and psychiatric nursing established content validity
and scoring. Test-retest (94%) was measured and inter-rater
reliability (96%) in scoring and data entry was accomplished
by having two people rate more than 25% of the vignettes.

Vignettes simulate a real situation and provide an effec-
tive research tool to elicit respondent’s attitudes, knowledge,
opinions, interventions, and respondent’s anticipated behav-
ior in the situation [4]. Outcomes assessment in psychiatric
postgraduate medical education: an exploratory study using
clinical case vignettes [4, 5], (Russell, 2007). Vignettes can
collect information simultaneously from a large sample,
manipulate variables, and avoid ethical problems that might
occur in observational studies [4]. Vignettes have served to
elicit diagnoses [6], pain [7], nursing knowledge [8], nursing
performance [9], infection control [10], ethical decisions
[11], and schizophrenia [12]. Expert panels have been used
to validate vignettes.

The Suicide Attitude Questionnaire (SAQ) is a qualita-
tive measure with items about care giving, ethical issues,

knowledge and assessment, and open-ended questions about
the difficulty responding to a patient who mentions suicide,
circumstances that would justify euthanasia, circumstances
under which a patient’s request for assistance should be
granted, concerns and conflicts, and questions about suicide
knowledge and suicide assessment skill. Questions about
euthanasia were added because the pilot study showed
that nurses were confused about this issue and needed
an opportunity to express these issues. Nurses answered
these questions and rated their skill and knowledge in
suicide assessment and management. Psychometrics for the
instruments are described in detail elsewhere [13].

6. Qualitative Data Analyses

Content analysis afforded a systematic approach for ana-
lyzing narrative texts into categories and making sense of
the data. All written narrative responses to SAQ items
were entered verbatim for each question and typed into
Word, a word processing program. We followed Wilson’s
(Wilson, 1989) procedures for semantic content analysis. We
identified the units of analysis as the respondent’s words. Our
unit of analysis were words (e.g., fear, not difficult), phrases
(e.g., fear of reprisal by family, fear of failure), or sentences
(e.g., due to chronic illness, my parent committed suicide)
that conveyed a unified idea. Six responses were not able to
be coded because they were vague or unclear.

The principle investigators trained the data analysis team
(e.g., experienced masters-prepared oncology nurses, an
oncology social worker, and a graduate nursing student) in
qualitative data analysis. The doctorally prepared principal
investigators had expertise in psychosocial oncology. After
the narrative data were entered in the computer and
verified, the data analysis team independently read the
narratives before meeting to discuss and identify categories.
We developed the preliminary categories from the data,
rationale, and illustrations to guide the coding. The entire
research team met to refine the directions for coding
until categories were accepted for coding the narratives.
After describing each category for coding, the research
team independently assigned the written narrative responses
to these categories before meeting to discuss our coding
and reach consensus. Final decisions about coding were
reached by consensus through discussion. The following
categories emerged: religious, spiritual, or other values and
beliefs; uncomfortable feelings; personal experiences with
suicide; inadequate skills, knowledge and experience (in
suicide evaluation and treatment); weight of professional
responsibility; not difficult to care for suicidal patients.

7. Results

7.1. Demographics. Of the total sample, 90.4% were women.
Seventy-seven percent (77%) were EuroAmerican, 7.1%
were African Americans, 7.1% were Asian Americans, 4.2%
were Latin Americans, and 2.1% identified themselves as
Canadians. The modal age was 40–49 with a range of 20 to
over 60 years old. Most of the sample had a diploma/AA

Nursing Research and Practice 3

or B.S. degree (38.4%) or an M.S. degree (55.9%). Most
nurses (89.1%) had worked more than 9 years in nursing.
Although most respondents were educated in the United
States (91.8%), some were educated in Canada or abroad. We
aimed for a sample of nurses in clinical practice. Most nurses
reported spending at least 50% per day in clinical practice.
Nearly 90% of nurses were close to one or more patients (x
= 6 who died in the year preceding the survey). Nearly all
nurses had taken courses in cancer; approximately 20% had
taken a course in suicide.

The main categories or core concepts that emerged from
the interviews and focus group included communication
barriers, judgments about suicide, unresolved grief, emo-
tions, inadequate knowledge, and justifications for euthana-
sia.

7.2. Communication Barriers. They emerged from the
nurses’ narratives about their difficulties caring for a suicidal
patient. Some nurses explained that they lacked the expertise
of psychiatrists and did not know what to say to a suicidal
patient (1) “I would say nothing to avoid making an error.”
Nurses also indicated they lacked skill and knowledge about
suicide risk assessment. (2) “I would not know what to ask
about suicide so I remain silent.” (3) Others feared that
asking about suicide risk might encourage suicidal acts. Some
nurses also reported that they did not know how to tell if the
patient was “serious” about these suicidal impulses and did
nothing while trying to figure out if the patient was serious.
Some nurses expressed conflicts between their roles in suicide
prevention and advocacy for the patient at end of life who
wanted to die with dignity. One nurse said, “I knew I should
sound the alarm when the patient talked about suicide but he
was dying and was exhausted by the treatments and wanted
to die in peace.”

7.3. Judgements about Suicide. Nurses reported that suicide
was “a coward’s way out” and some nurses identified religion
as the source of their values, but others described spiritual or
other beliefs that led them to judge suicide as wrong or bad.
Nurses expressed concern about what was morally right for
the patient within the limits of what was required by the legal
and professional guidelines. Some nurses worried about the
impact on the family and thought the patient was wrong for
harming the family. Examples of nurse’s narratives include
the following: (1) “I was reared with a strong religious
belief that ending one’s life should be prevented” and (2)
“Topic is taboo in society; my religious conviction—suicide
is wrong—a mortal sin.”

7.4. Unresolved Grief. Nurses drew on experience or lack
of experience in their own family or personal life and
shared personal experiences. When a family member had
committed suicide several nurses said that their reaction to
a family member’s suicide impaired their ability to care for
suicidal patients. Examples of nurses’ narratives included
the following: (1) “My grandmother committed suicide and
I had an uncle too.” (2) “A close relative of mine did
(committed suicide) for health reasons. Its very sad.”

7.5. Emotions. Nurses described unpleasant emotional
responses of varying or unspecified intensity (e.g., related to
fear and other feelings) that created difficulty. Examples of
nurses’ narratives include the following: (1) “Fear they will
commit suicide. I always think about the pain they must be
in and the level of that despair. Suffering is hard to watch.” (2)
“Fear of reprisal by patient/family.” (3) “Very uncomfortable
feeling.” Other comments included “fear that I’m unable
to help and the feeling that I’m a personal failure if the
patient commits suicide.” Some nurses reported “I’m just
uncomfortable with the subject.”

Inadequate Knowledge. I do not know the right thing
to say. Nurses highlighted deficits in their professional
experience, skill, knowledge, or abilities to care for suicidal
patients. The narrative was cognitive in tone and description.
Some nurses said that they lacked the skill and knowledge
to work with suicidal patients. They did not know how
to respond and wanted to avoid the risk of responding
incorrectly. In this category, respondents focused on suicide.
Examples from the nurses’ narratives included the following:
(1) “Sense of failure that I might not be able to “fix” things.
Its frightening; I’m not skilled at assessment and counseling
in this situation. Uncertainty about my own skill/knowledge
related to assessment.” (2) “Inadequate and ambivalent;
unfamiliar with suicide; no education.” (3) “Not knowing
how to help their helplessness, finding a way to reach them
and get them to see suicide as absolutely the last alternative.”
(4) “I don’t want to say the wrong thing.”

8. Circumstances That Justify Euthanasia

Asking about suicide in the context of end of life raises
issues about euthanasia. Nurses struggle to weigh patient
rights with their personal values and professional beliefs
about what is right. This is never an easy decision, as
nurses see patients suffer at end of life needlessly and those
who have intrusive interventions despite their wishes to the
contrary as well as patients who want to let nature take its
course. Nurses reported the circumstances that would justify
euthanasia. For nurses (n = 122) euthanasia was never
justified. Other nurses indicated that euthanasia could be
justified for poor symptom control or quality of life (not
terminally ill) (N = 61), terminal illness, impending death
with qualifiers (pain, QOL, end-stage disease) (N = 69);
patient autonomy (informed choice, living will) n = 30;
incurable illness/permanent disability n = 23; clinical death,
organ donor, vegetative state, flat EEG N = 15; terminal
illness (no qualifier) n = 14; not sure n = 11.

9. Discussion

The nurse’s concerns related directly to complex professional
and ethical issues that were embedded in the various
contexts of nursing care. Clinicians reported conflicts as
they considered their duties to safeguard life and to respect
the patient’s autonomy, yet they did not report considering
the patient’s capacity to exercise autonomy. Some believed
that their duty was to respect a patient’s right and freewill

4 Nursing Research and Practice

to choose suicide instead of a life-threatening disease (e.g.,
cancer or AIDS) that involved pain, fatigue, and unrelieved
suffering. On the other hand, nurses had a duty to protect
patients from harm.

Some nurses may not thoroughly consider the criteria
for rational thinking and voluntary, informed choice that
is necessary for autonomy. In some instances, suicidal pa-
tients lack capacity to exercise autonomy because a severe
psychiatric disorder such as major depression with cognitive
deficit undermines their ability to think clearly. However,
the striking fact is that nurses did not describe evaluating
rational thinking in their consideration of what justified
euthanasia.

Nurses rarely emphasized the constraints of their set-
tings. They struggled to describe their responses and actions
in the context of moral versions of the responsible nursing
role in situations where the nurses were not the arbiters of
power or decisions. In attempting to serve the best interests
of all involved, nurses face difficult ethical dilemmas. The
nurse’s strong support for the ethical principles of autonomy,
or free choice, and self-determination may conflict with
nonmaleficence, or the duty to prevent harm. When a patient
asks for the nurse’s assistance in dying, the nurse must
consider the conflicting ethical duties to prevent harm and
respect the patient’s choice. The ICN Code of Ethics states
that “the nurse takes appropriate action to safeguard the
individual when his care is endangered by any other person”
(ICN, p. XIII). In addition the nurse needs to consider
responsibilities to the family, hospital. Professional, legal, and
ethical implications arise when terminally ill patients request
euthanasia.

Acknowledgments

This material is the result of work supported with the
resources and use of the facilities at Department of Veterans
Affairs Greater Los Angeles Healthcare System. Supported
by the Oncology Nursing Foundation/Glaxo Wellcome Re-
search Grant.

References

[1] Institute of Medicine, Keeping Patients Safe: Transforming
the Work Environment of Nurses, National Academies Press,
Washington, DC, USA, 2004.

[2] S. Misono, N. S. Weiss, J. R. Fann, M. Redman, and B.
Yueh, “Incidence of suicide in persons with cancer,” Journal
of Clinical Oncology, vol. 26, no. 29, pp. 4731–4738, 2008.

[3] P. J. Miller and J. L. Werth, “Amicus Curiae Brief for the United
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Palliative Care, vol. 1, no. 4, pp. 7–33, 2006.

[4] J. C. Huffman, T. Petersen, L. Baer et al., “Outcomes
assessment in psychiatric postgraduate medical education:
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Psychiatry, vol. 34, no. 6, pp. 445–448, 2010.

[5] G. G. Harmandayan, “Outcomes assessment in psychiatric
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clinical case vignettes,” Gynecologic Oncology. In press.

[6] J. L. Temte and A. R. Zinkel, “The primary care differential
diagnosis of inhalational anthrax,” Annals of Family Medicine,
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[7] A. T. Hirsh, M. P. Jensen, and M. E. Robinson, “Evaluation of
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[8] J. M. Aflague and G. G. Ferszt, “Suicide assessment by
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[9] M. Wareing, “Using vignettes to explore work-based learn-
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1185–1188, 2010.

[10] B. Rios-Ellis, J. Frates, L. H. D’Anna, M. Dwyer, J. Lopez-
Zetina, and C. Ugarte, “Addressing the need for access to
culturally and linguistically appropriate HIV/AIDS prevention
for Latinos,” Journal of Immigrant and Minority Health, vol. 10,
no. 5, pp. 445–460, 2008.

[11] F. DeKeyser Ganz and C. F. Musgrave, “Israeli critical care
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[12] D. Razzouk, J. J. Mari, I. Shirakawa, J. Wainer, and D. Sigulem,
“Decision support system for the diagnosis of schizophrenia
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[13] S. M. Valente, “Oncology nurses’ teaching and support for
suicidal patients,” Journal of Psychosocial Oncology, vol. 25, no.
1, pp. 121–137, 2007.

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Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Investigating the Evidence for the Effectiveness of
Risk Assessment in Mental Health Care

Timothy Wand

To cite this article: Timothy Wand (2011) Investigating the Evidence for the Effectiveness
of Risk Assessment in Mental Health Care, Issues in Mental Health Nursing, 33:1, 2-7, DOI:
10.3109/01612840.2011.616984

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ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2011.616984

Investigating the Evidence for the Effectiveness of Risk
Assessment in Mental Health Care

Timothy Wand, MHN RN NP DAS(Nurs) Grad. Dip.(MHN) MN(Hons)
Royal Prince Alfred Hospital, Emergency Department, Camperdown, Australia and University of Sydney,
Sydney Nursing School, Camperdown, Australia

Risk assessment pervades mental health care policy, practice,
and legislation. This paper aims to establish the research evidence
for the effectiveness of a risk assessment approach in mental health.
A search was conducted of the professional literature on risk as-
sessment in mental health, specifically seeking any research on the
effectiveness of risk assessment in reducing risk of harm to self
or others. The search found limited research on the effectiveness
of risk assessment. “Structured professional judgment” possibly
reduces aggression risk but there is no evidence that risk assess-
ment is effective in relation to self-harm or suicide reduction. The
implications for practice are discussed and alternatives to a risk
assessment approach are considered.

Evidenced Based Practice has been adopted globally and in
many specialties of health care, including nursing, psychology,
medicine, occupational therapy, and social work. The promi-
nence of Evidenced Based Practice has evoked controversy and
criticism, however, it continues to wield widespread influence
on health care policy and practice. Evidence Based Practice re-
lies on a hierarchy of evidence that enables clinicians to gauge
the strength of research findings in terms of efficacy or effective-
ness. Investigations providing the strongest levels of evidence
include meta-analyses, national clinical practice guidelines, and
systematic reviews of randomized controlled trials (RCT). A
single well-designed RCT provides moderate evidence, and the
weakest evidence is derived from non-randomized investiga-
tions, case studies, cohort studies, and qualitative or descriptive
studies. The lowest level of evidence is associated with the opin-
ion of authorities and/or reports of expert committees (Fisher &
Happell, 2009).

Risk assessment and management have become a central fo-
cus in mental health policy, practice and legislation. Due to the
dominance that risk assessment exerts in contemporary mental
health service provision, this paper investigates the available evi-

Address correspondence to Timothy Wand, Royal Prince
Alfred Hospital, Emergency Department, Missenden Road, Camper-
down, 2050 Australia, or University of Sydney, Sydney Nurs-
ing School, Mallet Street, Camperdown, 2050 Australia. E-mail:
timothy.wand@sswahs.nsw.gov.au

dence for the effectiveness of this approach in reducing risk; par-
ticularly in relation to risk of harm to self or others. A search of
the literature was conducted using PsycInfo, CINAHL, Medline,
and Google Scholar from the year 2000 to 2011. Key terms (e.g.,
risk assessment) and combinations of terms (e.g., risk assess-
ment and management, mental health, psychiatry, suicide, self-
harm, self-injury, psychosis, aggression, violence) were used.
Reports and consensus guidelines from professional bodies also
were considered. A systematic review was not possible given
paucity of studies evaluating the effectiveness of risk assess-
ment in mental health care. The majority of publications are
from the lowest level of evidence available. This paper presents
the research that is available investigating the effectiveness of
risk assessment as well as a general review and discussion of
the literature related to the topic. The implications for practice
and alternatives to a focus on risk assessment are considered.

PERSPECTIVES ON RISK ASSESSMENT IN MENTAL
HEALTH

In a report titled “Rethinking Risk to Others in Mental Health
Services” the UK Royal College of Psychiatrists (RCP; 2008)
expressed concern that a focus on risk assessment appears to
have had a negative impact on clinical practice, consumers, and
the public. The result is a culture of blame, leading to defensive
and overly coercive practices and policies that demonstrate little
understanding of the complexities inherent in clinical settings.
Furthermore, the RCP contend that as a negative consequence
of such policies and practices, consumers are subsequently less
likely to access services out of fear of further coercion (RCP,
2008).

Despite efforts made to improve awareness of mental health,
Lakeman (2006) reports that the public remains anxious about
mental illness and the perception remains that mental illnesses
are associated with dangerousness to self or others. Such pub-
lic perceptions continue to exert influence on policy and prac-
tice. Risk has therefore become an acceptable form of stigma
whereby “high-risk patients in the community” become a legiti-
mate source of moral concern (Undrill, 2007). These sentiments
are echoed by the RCP (2008) who state that due to a focus on

2

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 3

risk, people with mental illness are portrayed in a negative man-
ner and, typically, as dangerous. This is likely to contribute to
the continuing stigma of mental illness while the far greater
danger to the public is posed by people who misuse alcohol and
other drugs (RCP, 2008).

Crowe and Carlyle (2003) view risk assessment as an at-
tempt to control the actions and behaviours of consumers and
clinicians to best suit the needs of the organisation rather than
the interests of patients. Risk assessment is conceptualised by
Undrill (2007, page 294) as a “neurotic organisational attempt
to tame anxiety,” however Undrill contends that such defensive
practices generate further anxiety. Clinicians become anxious
about the risk management tools they are given, and then work
to reduce this anxiety by discharging their share of the risk.
Risk adversity then becomes responsibility adversity whereby
clinicians act out of fear of legal ramifications and/or fear of
failure at the expense of patient well-being (Undrill, 2007). Ac-
cording to Undrill (2007) risk assessment is a subjective, plas-
tic, and context-dependent statement that carries strong moral
overtones. However the policy and managerial tendency is for
implementing reductionist models and linear frameworks of un-
derstanding that fail to appreciate the degree of complexity and
randomness in the world.

AGGRESSION AND VIOLENCE RISK
The risk associated with violence and aggression in health

care is a subject that has undergone extensive exploration and
debate, particularly in the medical and nursing literature. The
debate concentrates on issues such as the purpose (to predict or
circumvent) and accuracy (actuarial or clinical) of risk assess-
ments. Actuarial risks are based on static or historical factors
statistically associated with increased risk, while clinical risk
assessment is usually based on unaided clinical judgment and
intuition (Lamont & Brunero, 2009). Clinicians however are
concerned with the reality of assessing and managing aggres-
sion and violence risk rather than the formal research task of
prediction (Doctor, 2004).

The clinical utility of violence risk assessment tools has
attracted particular scrutiny. Maden (2001) observes that most
violence risk assessment tools were developed on high-risk
populations, usually individuals who had already committed
serious offences. They were not designed to be applied to
the general population. Therefore attempts to apply violence
risk assessment tools developed in the forensic sector to
the wider population could result in inaccurate and overly
coercive interventions (RCP, 2008). Importantly, actuarial tools
developed from predictor variables do not necessarily reflect the
experiences of the individual (Crowe & Carlyle, 2003) and are
therefore the province of research rather than everyday clinical
practice (Undrill, 2007). Stein’s (2002) review of actuarial-
based tools used to aid the process of discharge risk assessment
in the UK surmised that there are inherent limitations in the
predictive power of these types of tools. This review expressed

reservations as to the ability of risk assessment tools to account
for the complexity and diversity of human behaviour. For
example, different tools may be required for males and females
as the predictor variables for one gender may differ from the
other. The transferability of actuarial tools from one setting to
another or one country to another also is doubtful (Stein, 2002).

The RCP contend there is an absence of research evidence
supporting the ability of violence risk assessment tools to re-
duce or prevent adverse events and that they provide a false
sense of security that risk has been adequately addressed (RCP,
2008). This claim is consistent with the UK National Institute
for Clinical Excellence (NICE; 2005) guidelines on the man-
agement of aggression and violence, which could recommend
no gold standard violence risk assessment tool. By illustration,
Hart, Michie, and Cooke (2007) evaluated the margins of error
at the group and individual level for risk estimates made using
two well-known actuarial risk assessment instruments: the Vio-
lence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, &
Cormier, 1998) and the Static-99 (Hanson & Thornton, 1999).
The VRAG is a 12–item test developed from a sample of pa-
tients released from a maximum-security psychiatric hospital
in Canada. The Static-99 is a 10-item test developed from four
diverse samples of offenders and forensic psychiatric patients
released from institutions in Canada and the UK. Results from
this evaluation indicated that the two tools had poor precision.
The margins of error for risk estimates made using the tools
were substantial, even at the group level. At the individual level,
the margins of error were so high as to render the test results
virtually meaningless. Hart et al. (2007) concluded that actuar-
ial risk assessment instruments cannot be used to estimate an
individual’s risk for future violence with any degree of certainty
and should be used with great caution or not at all.

Clearly however, risk assessment processes incorporate more
complex dynamics than just clinical experience and/or actuar-
ial based information. Subsequently an integrated framework
of structured professional judgment has developed as a mul-
tidisciplinary approach for reducing incidents of aggression
and violence in mental health. Structured professional judge-
ment involves consideration of known risk factors, professional
experience, and individual knowledge of the patient (Lamont
& Brunero, 2009). Operationalizing these principles, Abder-
halden, Needham, Dassen, Halfens, and Haug (2008) conducted
a RCT to assess whether structured risk assessment decreased
the incidence of violence and coercion in acute psychiatric set-
tings across Switzerland. The intervention consisted of three
elements: (1) a structured short-term risk assessment for every
new patient during the first three days of hospitalisation, (2)
discussion of preventative measures from a list provided on the
risk assessment form for high risk patients, and (3) in cases of
very high risk, teams were prompted to plan and implement
preventative measures. This process resulted in a significant re-
duction in severe events of patient aggression and also reduced
the need for coercive measures. The authors do note a number of
limitations to the study which might have increased the effect of

4 T. WAND

the intervention; however, findings indicate that action tailored
to the individual risk level may be a simple and cost effective
way of diminishing the problem of violent incidents in acute
psychiatric units.

Recently King, Yassi, Smailes, Lovato, and Koehoorn (2011)
investigated the effectiveness of a violence risk assessment alert
system in conjunction with existing violence prevention training
in a large acute care hospital in Canada. Although the alert sys-
tem was considered useful for identifying at risk patients, it had
no impact on the rate of violence during either the intervention
or post-intervention period compared with the pre-intervention
period. The authors posit that the alert system may have raised
staff anxiety, resulting in increased reporting of flagged patients.
The system also may have influenced the manner in which staff
interact with those patients identified as high risk, increasing
the likelihood the patient would become violent. In focus groups
conducted as part of the investigation, staff recognised that some
patients may be incorrectly identified as high risk based only on
past history and that flagging had the potential to stay with the
patient unnecessarily.

Related to violence risk, research on establishing a link with
psychosis and violence is also well represented in the literature.
The consensus from research in this field suggest strongly that all
acts of harm to others perpetrated by people with a mental illness
are not primarily related to their mental illness once substance
misuse is taken into account (Davidson, 2005; Elbogen & John-
son, 2009; RCP, 2008). This was highlighted by a meta-analysis
examining the association between psychosis and violence con-
ducted by Douglas, Guy, and Hart (2009). The study found
an overall association between psychosis and violence, which
was particularly strong when the comparison group consisted
of individuals without a mental disorder. However, compared to
individuals with externalizing psychopathology, psychosis did
not appear to further elevate the risk for violence while comorbid
substance-related disorder elevates the risk of violence substan-
tially. Therefore it is important to know whether a person with
either a psychotic illness or a substance-related disorder has a co-
occurring disorder, although the presence of psychosis should be
considered neither necessary nor sufficient for a determination
of high risk. This conclusion is based on the finding that the over-
all magnitude of the psychosis-violence association was small;
meaning that most violent individuals are not psychotic and most
psychotic individuals are not violent (Douglas et al., 2009).

Hiday (2006) identifies numerous confounding factors that
are minimised or neglected in studies undertaken to explore a
link between mental illness and violence. Hiday (2006) concurs
that once comorbid substance abuse and personality disorder
are taken into account, the contribution of psychosis to vio-
lence in the community diminishes dramatically. Furthermore,
people with mental illness are more likely to reside in violent
neighbourhoods and this could be a significant variable, rather
than a psychiatric diagnosis. Multiple studies provide evidence
that mental illness, substance abuse, and violence are frequently
associated with what are frequently called socially disorgan-

ised communities, which are environments characterised by
poverty, high unemployment, low education levels, resources
deprivation, physical deterioration, and breakdown in micro in-
stitutions, especially families. People with a mental illness who
grow up in these communities learn to be violent, just as oth-
ers in that environment learn that behaviour (Hiday, 2006). The
World Health Organisation (WHO; 2004) observes that anti-
social and suicidal behaviour have long been linked to strengths
or absences of social cohesion. Weak social controls and the
disruption of local community organisation have strong associ-
ations with increased rates of violent crime and suicide (WHO,
2004). Recognition that mental health problems occur univer-
sally, but are much more common among people with relative
social disadvantage (Herman & Jane-Llopis, 2005) therefore
requires a shift in policy, practice, and research away from a
narrow biomedical approach toward a broader health promotion
and public health perspective (Magyary, 2002; Wand, 2011).

SELF-HARM AND SUICIDE RISK
The terms self-harm and suicide are often used together,

and self-harm (such as low lethality overdose or self-inflicted
lacerations) is an established risk factor for suicide (Zahl &
Hawton, 2004). Nevertheless it is important to acknowledge that
self-harm is not necessarily synonymous with suicidal intent.
In reality most self-harm inflicts little actual harm and does not
come to the attention of mental health services. Some individuals
may initially state that their intentions were to die, however on
further exploration it can often be established that suicide was
not really the intended goal. The motivation for self-harm is
typically an expression of distress, anger, or a desire to escape
a troubling situation (Hawton & James, 2005).

Various studies and publications list an extensive number of
risk factors associated with suicide. Despite this, the prediction
of suicide reveals alarmingly low specificity. Static risk factors
may give an indication of an individual’s propensity for suicide
but they do not capture the fluctuating nature of risk. Multiple
risk factors are not always present in high-risk individuals and
only one or two risk factors may need to be present to a serious
degree to provide sufficient risk. Risk also can escalate rapidly
over a short period and alternatively, if the outcome is not fatal,
just as quickly subside (Bouch & Marshall, 2005). Furthermore,
most suicides occur in low risk groups for the simple reason that
they contain many more members than high risk groups and
there is no evidence that addressing risk factors as such has any
impact on survival (Undrill, 2007).

Harris and Hawton (2005) verify that studies attempting to
identify particular individuals who are more likely to die by
suicide have been largely unsuccessful primarily due to the low
prevalence even within high risk groups. Harris and Hawton
(2005) analysed the predictive value of the Beck Suicide Intent
Scale (SIS) based on clinical and demographic data on 4,156
individuals who had self-harmed. Thirty males (2.9%) and 24
females (1.7%) in this sample died by suicide but the positive

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 5

predictive value of the SIS was low (4%). The authors conclude
that it is not possible to use patient information (even infor-
mation shown to be strongly associated with suicidal intent) to
predict accurately which individual patients will die by suicide
and “highlights the dangers of a checklist-style approach” for
identifying at risk patients (Harris & Hawton, 2005).

Owens, Wood, Greenwood, Hughes, and Dennis (2005) at-
tempted to determine predictors of suicide by undertaking a
retrospective study with 976 consecutive patients attending a
large Emergency Department (ED) in the UK following nonfa-
tal self-poisoning. Their study found that suicide was related to
numerous factors evident at the time of self-poisoning but the
predictive values of patient characteristics that point to higher
than average risk are “just too poor to be useful” (Owens et al.,
2005). The researchers’ concluded that employing a high risk
strategy is a “hopeless” approach to suicide and self-harm re-
duction. Instead they suggest that government initiatives should
focus less on risk assessment and more on the assessment of
individual needs.

Kapur, Cooper, Rodway, Kelly, Guthrie, and Mackway-Jones
(2005) investigated the predictive value of risk assessments after
an episode of self-harm and compared assessments made by ED
staff with those made by psychiatric staff. They found that ED
staff were more likely than psychiatric staff to assess the risk
of repetition as high. For both groups however, most repetitions
were among people assessed as low or moderate risk. The pre-
dictive value of risk assessment after self-harm was low. These
authors believe that restricting intervention to people identified
as high risk, even assuming a completely effective intervention,
would prevent less than one fifth of repeat episodes.

Kapur (2005) contends that any predictability of the risk of
future suicidal behaviour following self-harm is problematic
because such events are statistically rare and assessment tools
are relatively crude. Nevertheless follow-up after self-harm and
suicidal behaviour is important and should be prompt. Strate-
gies that could be employed to improve follow-up include home
visits, the provision of printed information, and aftercare being
provided by the health professional who carried out the ini-
tial assessment (Kapur, 2005). The Royal Australian and New
Zealand College of Psychiatry (RANZP; 2004) practice guide-
lines on self-harm also advocate for early engagement of the
person and active follow-up. The RANZCP guidelines also rec-
ognize that the practice of asking individuals to enter into no
self-harm contracts or to guarantee or assure their safety is incor-
rectly thought of as an effective method for managing self-harm
risk and to protect the clinician from litigation. However these
guidelines state that there is no evidence that this or any form
of self-harm/suicide contract has any therapeutic benefit and is
potentially counter-therapeutic. This is supported by subsequent
examinations of this area that identify a lack of evidence for no
suicide or self-harm contracts, as well as confirming their lack
of medico-legal protection and potential to produce detrimen-
tal outcomes (Edwards & Harries 2007; Edwards & Sachmann
2010; McMyler & Pryjmachuk 2008). Kapur (2005) asserts that

reducing our preoccupation with risk assessment may actually
assist in improving the management of self-harm and suicide.
A shift from risk assessment to needs assessment is indicated
which aims to identify psychosocial factors that help to un-
derstand an act of self-injury or suicide and contributes to a
management plan (Kapur, 2005).

IMPLICATIONS FOR CLINICAL PRACTICE
The reality that the prediction of aggression and violence,

self-harm, and suicide by clinicians is poor raises serious ques-
tions about the integrity of mental health legislation, which in
most jurisdictions is based on a dangerousness standard of a risk
to self or others. In response, a growing number of clinicians
and academics have called for the abolition of separate men-
tal health legislation in favour of a generic mental incapacity
act (for examples see Dawson & Szmukler 2006; Large, Ryan,
Nielssen, & Hayes 2008; O’Brien, 2010; Ryan 2011; Wand &
Chiarella 2006). Concerns have been expressed about the pre-
ventative detention component of mental health legislation that
allows for apprehension of individuals in advance of violence
(a different standard applied to mental health treatment with-
out consent than to unconsented treatment for physical health
problems) and that separate mental health legislation framed
around a category of people and based on a risk criteria rein-
forces stigma and stereotypes about the characteristics of people
with mental illness. At least until a more accurate and equitable
legal resolution can be reached, Wand and Chiarella (2006) ar-
gue that it is imperative that current mental health legislation
maintain relevance in protecting the rights of consumers. This
is achieved by upholding the United Nations High Commission
for Human Rights (1991) and WHO’s (1996) principles of a
preference for community-based care, an emphasis on volun-
tary access to mental health services, and involuntary treatment
on the grounds of mental incapacity, only as a last resort and for
the shortest time possible.

The current discourse around a recovery orientation to men-
tal health service provision runs counter to the discourse on risk.
Parsons (2008) highlights the concept of “the dignity of risk”
and proposes that there is a double standard for people who are
diagnosed with a mental illness and those who are not. People
who are not diagnosed as mentally ill are able to make risky and
potentially self-defeating choices without intervention from
authorities, clinicians, or service providers wishing to protect
them from the consequences of their choices. The concept of the
dignity of risk acknowledges that accompanying every endeav-
our is the element of risk and that every opportunity for growth
carries with it the potential for failure. All people learn through a
process of trial and error and through taking risks. People often
learn as much from mistakes as from successes. When people
living with a mental illness are denied the dignity of risk, they are
being denied the opportunity to learn and recover. By supporting
dignity of risk, service providers and clinicians can help to com-
bat learned helplessness and bolster self-esteem, self-respect,

6 T. WAND

empowerment, and hope (Parsons, 2008). In Australia for
example, the Fourth National Mental Health Plan (2009–2014)
which adopts a population health perspective affirms that mental
health service providers should work within a framework that
supports recovery both as a process and as an outcome to
promote hope, well-being, and autonomy. In this current Plan
mental health clinicians are urged to recognise an individual’s
strengths including coping skills and resilience, and rights to
self-determination (Commonwealth of Australia, 2009).

Risk management must, therefore, move away from a focus
simply on assessment and instead on to therapeutic intervention
that recognises and promotes the patient’s strengths and sup-
ports recovery. The RCP (2008) assert that there is presently an
overemphasis on the use of “invalidated tick box” assessment
forms that are damaging to clinical practice and patient well-
being. The RCP report identifies the propensity for “locally de-
veloped assessment forms” to be produced as a means of “back
covering” in the event of an adverse incident and that this rep-
resents “a lazy and authoritarian approach to delivering health
care.” Contemporary formats for undertaking mental health as-
sessments are typically structured to seek out problems, illness,
and pathology in the individual. However, rather than producing
a comprehensive assessment, the profile of the individual ob-
tained is biased toward identifying only negative characteristics.
Some consideration of protective factors such as religious be-
liefs or concerns for family and friends or pets may occur; though
no attempt is usually made to balance an assessment with an ex-
ploration and documentation of the person’s strengths, abilities,
resources, coping skills, past successes, goals, hopes, and the
broader context of the individual’s life and social circumstances.
Further, Undrill (2007) argues that the amount of information
gathered during the typical assessment process is often super-
fluous to the current presentation and has the potential to over-
complicate clinical decision making. Undrill (2007) proposes
that a stance of “bounded rationality” may be more beneficial to
make decisions on less information rather than expend time and
energy on accumulating and documenting excessive amounts of
personal information that is of marginal utility.

WHAT IS THE ALTERNATIVE?
In contrast to a risk assessment focus, a substantial level

of interest has been generated in promoting the positive as-
pects of health and well-being, which concentrates on wellness
rather than illness (Parham, 2008). Research from the field of
positive mental health for example has been found to result in
impressive and enduring positive effects on multiple areas of
individual functioning and also has the dual effect of reducing
risk (Barry & Jenkins, 2007). Positive mental health acknowl-
edges that a mental illness or disorder may impede, but does
not preclude, positive emotion, engagement, purpose, positive
relationships, and positive accomplishments (Seligman, 2008).
Interventions adopting a positive mental health framework are
primarily concerned with building capacity and self-efficacy in

diverse areas of life and signal a shift from a disorder-focused
perspective to one that embraces psychological strengths and re-
silience. An emphasis on positive emotions, such as optimism,
promotes resilience, immunizes individuals against depression,
and enhances adaption to stressful life events (Magyary, 2002).
Building individual capacity also increases options available for
people to exercise more control over their own health and over
their environment to make choices conducive to health (Jane-
Llopis, Barry, Hosman, & Patel, 2005). This is compatible with
newer therapeutic approaches such as solution focused therapy
(SFT) that represent an alternative way of thinking and working
with people that is more optimistic, more enabling, and accepts
that individuals will ultimately make their own decisions. SFT
has broad utility for working with an array of mental health and
substance misuse problems and is increasingly popular across
a spectrum of health settings with a growing evidence base.
The SFT approach is based on solution building rather than
problem solving. Instead of a focus on problems, pathology
and risk, SFT utilises questions aimed at surfacing an individ-
uals strengths, abilities, resources, and the person’s vision for
the future; thereby helping the person to formulate solutions
to problems rather than dwell on problems themselves (Wand,
2010).

CONCLUSION
Despite the heavy emphasis on risk assessment in mental

health there is little evidence that this approach is effective in
reducing risk of harm to self or others. Moreover, there are in-
dications from the available research that a focus on risk assess-
ment has been ineffective in reducing self-harm and suicide risk
and that alternative approaches need to be considered. Risk as-
sessment is conceptualised as a managerially driven agenda that
has resulted in mental health service provision being consumed
by a state of nervous paternalism. The uncertainty with which
risk of harm to self or others can be anticipated by clinicians has
resulted in a culture of overly defensive practices and increased
use of coercion; whereby the fear of medico-legal reprisal takes
priority over the impact such intervention has on the individual.
This, in turn, has consequences for the establishment of positive
working relationships between clinicians and consumers and is
at odds with a recovery orientation. Organisations and health
authorities would be wise to invest more time and resources in
public awareness campaigns and initiatives that promote men-
tal health and well-being. There is a need to recognize from a
public, policy, practice, and research perspective that the root
cause of problems such as self-harm and suicide, aggression,
violence, and substance misuse are predominantly socially de-
termined and, as such, should be addressed by a broader public
health approach rather than through a narrow biomedical lens.

Declaration of interest: The author reports no conflicts of
interest. The author alone is responsible for the content and
writing of the paper.

EVIDENCE OF EFFECTIVENESS OF RISK ASSESSMENT 7

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