Positive risk management: Staff perspectives in acute mental health inpatient settings

A systematic review of policy and clinical guidelines on positive risk management

BACKGROUND

National policies and guidelines advocate that mental health practitioners employ positive risk management in clinical practice. However, there is currently a lack of clear guidance and definitions around this technique. Policy reviews can clarify complex issues by qualitatively synthesising common themes in the literature.

AIMS

To review and thematically analyse national policy and guidelines on positive risk management to understand how it is conceptualised and defined.

METHOD

The authors completed a systematic review (PROSPERO: CRD42019122322) of grey literature databases (NICE, NHS England, UK Government) to identify policies and guidelines published between 1980 and April 2019. They analysed the results using thematic analysis.

RESULTS

The authors screened 4999 documents, identifying 7 eligible policies and 19 guidelines. Qualitative synthesis resulted in three main themes: i) the conflicting aims of positive risk management; ii) conditional positive risk management; and iii) responsible positive risk management.

CONCLUSIONS

Analysis highlighted discrepancies and tensions in the conceptualisation of positive risk management both within and between policies. Documents described positive risk management in different and contradictory terms, making it challenging to identify what it is, when it should be employed, and by whom. Five policies offered only very limited definitions of positive risk management.

Contemporary perceptions and meanings of 'the medical model' amongst NHS mental health inpatient clinicians

Debates within health care and public spheres have, at times, created a seeming 'divide' between biological and psychosocial determinants and management of mental health difficulties. The phrase 'medical model' is often held up as an example and is sometimes used pejoratively to infer over-reliance on biology and medication. Our objective was to explore inpatient mental health clinicians' perceptions of the definition and the application of a 'medical model' in contemporary mental health care. In this qualitative study, eighteen clinicians working in adult inpatient teams participated in three mixed focus groups. Data were analysed using framework analysis. Three core themes were identified: (i) power of a 'medical model' and authority of the medic; (ii) responsibility within, and reliance on, a 'medical model'; and (iii) integrated models of contemporary mental health care. Subthemes arose around organisational culture and low resources affecting the power of a 'medical model' and the value of multidisciplinary and person-centred approaches. The findings highlight the importance of recognising inter-professional dynamics and power gradients in mental health teams and organisations, as we begin to move towards more integrated models of collaboration and distributed leadership within the NHS.