Understanding Clinicians' Use of Cues When Assessing the Future Risk of Violence: A Clinical Judgement Analysis in the Psychiatric Setting

An Ecological Model for High-Risk Professional Decision-Making in Mental Health: International Perspectives

Mental health professionals are frequently presented with situations in which they must assess the risk that a client will cause harm to themselves or others. Troublingly, however, predictions of risk are remarkably inaccurate even when made by those who are highly skilled and highly trained. Consequently, many jurisdictions have moved to impose standardized decision-making tools aimed at improving outcomes. Using a decision-making ecology framework, this conceptual paper presents research on professional decision-making in situations of risk, using qualitative, survey, and experimental designs conducted in three countries. Results reveal that while risk assessment tools focus on client factors that contribute to the risk of harm to self or others, the nature of professional decision-making is far more complex. That is, the manner in which professionals interpret and describe features of the client and their situation, is influenced by the worker's own personal and professional experiences, and the organizational and societal context in which they are located. Although part of the rationale of standardized approaches is to reduce complexity, our collective work demonstrates that the power of personal and social processes to shape decision-making often overwhelm the intention to simplify and standardize. Implications for policy and practice are discussed.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Clinical Reasoning in Physical Therapy: A Concept Analysis

BACKGROUND

Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research.

OBJECTIVE

The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research.

DESIGN/METHODS

The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified.

RESULTS

Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management.

LIMITATIONS

Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded.

CONCLUSIONS

A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.