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International Journal of Mental Health Nursing (2014) 23, 336–343
doi: 10.1111/inm.12063
Feature Article
Clinical responsibility, accountability, and risk aversion in mental health nursing: A descriptive, qualitative study Jenni Manuel1 and Marie Crowe2 1
Canterbury District Health Board, and 2Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand
ABSTRACT: A number of recent, highly-publicized, perceived health-care service failures have raised concerns about health professionals’ accountabilities. Relevant to these concerns, the present study sought to examine how mental health nurses understood clinical responsibility and its impact on their practice. A descriptive, qualitative design was used, and a convenience sample of 10 mental health nurses was recruited from specialist inpatient and outpatient mental health settings in Canterbury, New Zealand. Data were collected using semistructured interviews, and the transcriptions were analysed using an inductive, descriptive approach. Three major themes were identified: being accountable, fostering patient responsibility, and shifting responsibility. Being accountable involved weighing up patients’ therapeutic needs against the potential for blame in an organizational culture of risk management. Fostering patient responsibility described the process of deciding in what situations patients could take responsibility for their behaviour. Shifting responsibility described the culture of defensive practice fostered by the organizational culture of risk aversion. The present study highlighted the challenges mental health nurses experience in relation to clinical responsibility in practice, including the balancing required between the needs of patients, the needs of the organization, and the perceived need for self-protection. KEY WORDS: accountability, clinical responsibility, defensive practice, mental health nursing, qualitative study, risk aversion.
INTRODUCTION The present study focused on the important contemporary issue of nursing responsibility. This qualitative study explored the views of practicing nurses, highlighting matters of accountability and ownership of responsibility in a context of prevailing risk-management cultures in services. Peplau (1999) reported that when the term ‘responsibility’ surfaced in the nursing literature in the 1970s, it Correspondence: Jenni Manuel, Mental Health Division, Canterbury District Health Board, 97 Cashmere Road, Christchurch, New Zealand. Email: [email protected] Jenni Manuel, MHSc RN. Marie Crowe, PhD RN. Accepted January 2014.
© 2014 Australian College of Mental Health Nurses Inc.
referred to one being: ‘reliable, trustworthy and doing what was expected; a kind of moral and personal liability was implied’ (Peplau 1999, p. 20). However, the concept of responsibility has evolved over time to be more closely associated to the concept of accountability. A more contemporary definition states that clinical responsibility refers to the ‘tasks or functions that an employer, professional body, court of law or some other recognised body can legitimately demand from a health professional’ (Department of Health 2010, p. 16). Accountability, more specifically, describes the potential for disciplinary action occurring if one fails to exercise their clinical responsibilities (Department of Health 2010). The notion of responsibility and accountability in clinical practice is particularly relevant, due to a number of
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recently-publicized, perceived service failures in health care. An example of this is a recent inquiry that took place into the care provided by the Mid-Staffordshire National Health Service Foundation Trust between 2005 and 2009 in the UK (Francis 2013). The events that led to this inquiry included high mortality rates and public outcry about poor standards of care. Specific recommendations to nursing were made regarding the need for a culture of care and compassion that lead to public commentaries about nursing training being overly theoretical (Hayter 2013). The inquiry identified multiple issues relating to institutional cultures focused on doing the systems business, rather than focusing on patients’ best interests (Francis 2013). The report recommendations included that further provision should be made to ensure that those who care for patients are properly accountable for what they do (Francis 2013). Inquiries in other countries have come to similar conclusions. In Australia, a number of inquiry recommendations have focused on the lack of reporting concerns about patient care and safety. A study that examined multiple examples of significant health-care failures in various Western countries noted that the causes and characteristics of such failures were strikingly similar across different countries (Walshe & Shortell 2004). Given these countries had different ways of organizing and funding health care, it was surmised by those authors that the problem might be inherent in health-care culture. Cultures of secrecy, self-protection, and institutional defensiveness were questioned as potential areas of focus (Walshe & Shortell 2004). Brunton (2005) noted that inquiries have played an important role in the design of mental health policy and in shaping mental health service delivery, both in New Zealand and elsewhere. Because mental health lacks high status and popularity among politicians (and perhaps the general public), major policy changes have occurred in response to inquiries triggered by some newsworthy incident, revelation, or a level of public disquiet that makes an issue politically sensitive. A main theme of inquiries over time has been the need for an accountability framework to provide clear direction and leadership (Brunton 2005). Most inquiries that have occurred during the advanced liberal political ethos of the late 20th and early 21st centuries have focused on accountability, who or what is responsible for the newsworthy incident, and how the risk of a recurrence could be mitigated through risk-management strategies (Crowe & Carlyle 2003). Despite the attention healthcare service failures have received internationally, and the subsequent focus on © 2014 Australian College of Mental Health Nurses Inc.
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health-care professionals’ accountability, there is limited literature that explores the topic. Cultures of selfprotection and organizational defensiveness have been identified as potential factors in inquiries; however, this notion has received relatively little attention in the literature. Additionally, there is no research available that is specific to the topic in the context of mental health nursing. Therefore, the aim of the present study was to explore this topic from the perspective of mental health nurses.
METHODS Design This qualitative study design utilized a descriptive, general, inductive approach. This approach is a wellconsidered combination of sampling, data collection, and analysis techniques (Sandelowski 2000). This approach is less theoretical than some, which can be considered an advantage, as it allows for findings to emerge from the raw data without being restricted by imposed methodologies or predetermined theories (Thomas 2003). The inductive element of data analysis is consistent with Strauss and Corbins’s (1998) description: ‘The researcher begins with an area of study and allows the theory to emerge from the data’ (p. 12). This approach was a good fit with the aim of the present study, which was to identify mental health nurses’ understandings and experiences of clinical responsibility. Although descriptive, general, inductive approaches are less theoretical than other qualitative designs, it was still important to consider the underlying theory and assumptions that were relevant to the study. Interpretivism (Denzin & Lincoln 2000), and the theoretical positioning of the researchers (Caelli et al. 2003), were relevant factors to this design. Given that this was a descriptive study, the interpretation was low inference, in that the findings were not described in terms of a conceptual or philosophical framework (Sandelowski 2000). However, it did involve a degree of interpretation, as this cannot be avoided based on the underlying assumptions of interpretivism as a basis for qualitative research. The research question was developed in response to questions that were circulating in the researcher’s clinical practice area about who held clinical responsibility for particular aspects of care. The researcher held the prior assumptions that risk assessment and management have a strong influence on mental health practice, and that mental health nurses experience varying levels of anxiety regarding clinical responsibility in practice.
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Participants A convenience sample of mental health nurses working in local mental health inpatient and outpatient services was recruited via advertisement in nursing staff rooms. Ten participants responded to the advertisements from acute, youth, and rehabilitation inpatient mental health wards, as well as youth and adult community mental health services. All participants were registered nurses; there were no other selection criteria.
Data collection Semistructured interviews were the means of data collection, as they are considered the most appropriate form of enquiry when participants’ perspectives about a particular topic are sought (Crouch & McKenzie 2006). This type of interview is organized around a set of predetermined questions, with the flexibility of following participants’ responses when further avenues of enquiry emerge from the dialogue (Whiting 2008). The interviews were based on the following questions: (i) What is your understanding of the term ‘clinical responsibility’?; (ii) Tell me about the areas of clinical practice you have responsibility for; (iii) How do you feel about your current levels of responsibility within your practice?; and (iv) How do you think your perceptions of ‘clinical responsibility’ influence your decision-making in practice? The audio-recorded interviews were between 40 and 60 min in length. The interviews were later downloaded, and then transcribed verbatim, providing written data ready for analysis.
Data analysis Thematic analysis was chosen for this study, as it fits with the general, inductive approach, and provides a structured process of analysis. Having a clear process for the analysis, such as this, enables the researcher to increase the accuracy in the interpretation of qualitative information (Boyatzis 1998). The data were read a number of times, and a synopsis for each transcript was written, allowing for familiarity to the data. Key points made by participants were identified, pulled out, and given brief descriptions. This process of labelling narrative is described as ‘naming it’ by Boyatzis (1998). The next step involved comparing and looking for similarities, which resulted in emerging themes being identified. The final step involved combining and cataloguing related themes together to produce the major themes.
Ethics The present study received ethical approval from the Regional Health and Disability Ethics Committee. Infor-
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mation sheets were provided to all potential participants, and signed, informed consent was obtained. The researcher did not work within the areas sampled, but did work in a local, clinical area, resulting in some participants having a prior working relationship with the researcher. This was raised on the information sheet as a potential issue, and participants were encouraged not to volunteer if they felt uncomfortable about knowing the researcher. For the transcription of audio-tapes, the typist signed a confidentiality agreement. Participants’ names and identifying details were removed from records prior to analysis, and special consideration was given to the use of narratives. Parts of narrative were removed to ensure participant, other staff, and patient confidentiality.
Rigour The trustworthiness of the research process was established using the guidelines of Guba and Lincoln (1989). The first author independently analysed the data, and both authors got together to integrate the interpretation of data. The findings were corroborated at two research presentations, at which feedback was invited from mental health nurses. The nurses who attended these attested that the findings were congruent with their experiences of clinical responsibility. Transferability was addressed by providing sufficient background information regarding the study to enable the reader to determine the relevance of the findings to their own practice. Dependability and confirmability were ensured by providing sufficient information about the research process, and the use of quotes to provide evidence of findings to enable an audit trail of the process.
RESULTS Ten participants were recruited and interviewed. Three themes emerged from the data to describe the participants’ perceptions and experiences of clinical responsibility: being accountable, fostering patient responsibility, and shifting responsibility.
Being accountable This theme referred to the participants taking responsibility for their practice, which involved weighing up the patients’ therapeutic needs against the potential for blame in the organizational culture of risk management. Being accountable could be defined as acknowledging the decisions one has made, and being able to provide a rationale for why a decision was made. It describes the process of being answerable to one’s actions, as described by this participant: © 2014 Australian College of Mental Health Nurses Inc.
CLINICAL RESPONSIBILITY AND ACCOUNTABILITY It’s putting your hand up and accepting that you basically take responsibility for the things that you do, and don’t expect to be able to pass the buck if things get tough or you’re uncomfortable.
This participant described being answerable for one’s decisions as something that is both professional and personal: Even if you feel you’ve done everything that you should have done, and you look back and you can’t see anything that was particularly remiss on your part . . . you’d still feel a certain amount of responsibility; it’s a kind of personal level of responsibility, because you’re looking after that patient, and something went wrong or something happened.
Being accountable was regarded as being not only a personal obligation, but also something that required active consideration of the rationale for one’s actions:
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Fostering patient responsibility The participants described another aspect of clinical responsibility as fostering patient responsibility. This appeared to have both therapeutic and punitive elements. This theme involved encouraging the patient to adhere to social or cultural expectations for acceptable behaviour. It described the participants’ belief that patients needed to take responsibility for the choices they made. While the nurses described an attitude of wanting to help the patient, they also described not being willing to be accountable for their behaviour: There is a point where you can’t take responsibility for somebody else’s behaviour, so you can only do everything that you can in order to help that person.
I’m very comfortable documenting what my clinical rationale is, and as long as I always have a sound clinical rationale underpinning my intervention and I can justify that and that’s very clear, then I’m ok.
While expecting that most patients take responsibility for their behaviour, the participants also revealed that the degree to which they fostered patient responsibility was dependent on a range of factors. One participant described basing this decision on the patient’s diagnosis:
Most of the participants regarded being accountable as a response to some adverse event, and associated it with blame:
I think it depends very much on what illness they’re presenting with, as to what level of self-responsibility I think they should have.
I guess I would feel really responsible if I felt that some of the things I have done weren’t appropriate, or perhaps putting it another way, I hadn’t done all the things I should of (sic) done, then I would be a lot more selfblaming, and I would feel more responsible and accept whatever came out of that process, whatever inquiry took place or whatever.
Participants described making a differentiation between behaviours they regarded as ‘bad’ (under the patient’s control) or ‘mad’ (outside the patient’s control): I’d never get the police involved if the patient assaulted me if they were psychotic and unwell, but if it was intentional and they were not psychotic and in their right mind and punched me, I would involve the police.
Balancing the needs of the patient with the organization’s culture of risk management was an active and considered process that continually influenced the participants’ practice:
Some of the participants described this process of fostering responsibility as a process of providing the patient with alternatives:
I see that accountability again is about what’s in the patients’ best interests, and I guess in terms of risk management, you know weighing that up between wanting to cover yourself and wanting to do what’s right for the patient.
For me, the responsibility is more around, I don’t even know how to explain it . . . it’s working with them to foster that sense of being able to start to take on board some ideas and some ways of being that might, you know, enable them to manage better stress or whatever.
Being accountable identified the active process with which the participants engaged, in an effort to balance the patients’ needs in an organizational climate in which they felt they would be blamed if an adverse event occurred. In the nurses’ descriptions, accountability was explained as being aware that their practice could come under scrutiny and appeared to be associated with the possibility of a life-threatening event occurring, rather than something related to day-to-day practice.
The shift in being accountable for one’s practice and fostering responsibility was associated with behaviours that were regarded as violent or aggressive, or self-harming. The participants described these behaviours as within the patients’ control:
© 2014 Australian College of Mental Health Nurses Inc.
We almost lost her six times, five or six times, while she was with us, and not one of those times was I thinking ‘Bugger, it was my fault’. No, I always thought ‘What a shame that you’ve made this decision’.
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This theme explored how the nurses described fostering patient responsibility. The participants appeared to be suggesting that their perception of patient responsibility was determined by a judgment call they made in relation to whether patients’ behaviour was ‘mad’ or ‘bad’. If it was regarded as ‘bad’ behaviour, then the patient was expected to take responsibility for this, but if the behaviour was judged to be ‘mad’, then the patient could not be expected to take responsibility. It was interesting that a number of participants suggested that self-harm was within patients’ control, and they should, therefore, be responsible for stopping it.
Shifting responsibility Shifting responsibility described the culture of defensive practice fostered by the organizational culture of risk management, and the strategies the participants used to manage this. It described the actions nurses undertook to ensure their rationales for actions were recorded, and the activities they undertook to shift the responsibility of decisions to others. The strategies involved in shifting responsibility included using written over verbal communication, referring the decision to a psychiatrist, or referring the decision to a team. The following participant’s quote captured the uneasy nature of this theme: I think that our (district health board) is very risk averse. We’re very much into . . . butt covering, when our practice is driven by fear, rather than the patient’s best interest.
These participants described ensuring decisions were written down as one strategy for covering themselves. The following participant described a response to a sudden death: There’s a lot of blame that often gets pointed towards nurses, and words like ‘negligence’ are bandied around. So there is definitely the feeling that, should my notes need to go somewhere, I want to know that I have documented as thoroughly as possible the situation and my assessment.
The participants used their documentation, including nursing notes, to cover themselves in case something happened to the patient: I’m always conscious that, ultimately, it’s what’s written down that carries the weight.
Other participants described giving the decision to psychiatrists to make, rather than taking on the responsibility themselves: If there’s like a major change in presentation or major change in risk factor, I probably would consult with the
J. MANUEL AND M. CROWE doctor, if I was unsure, yeah, just to protect my butt basically, not for anything else.
Others felt that consultation with other members of the team in relation to risky decisions was another way to avoid blame: If there’s a risky decision to be made, I think you’re foolish to try and make it without consulting somebody else.
The organization had implemented multisectorial, complex case conferences where risk was addressed. The following participant felt that such initiatives were intended for the organization to mitigate their risk, rather than the needs of the patient: I’ve been involved in a case where this young person had borderline personality disorder risky, risky behaviours. There was a complex case conference around her, and you know complex case conferences are always about risk and management and about how we show that we’ve done everything to manage her risk. It’s more about being able to say we have done whatever we could to manage the risk. They’re not really about the young person themselves.
The participants suggested that the organization was more concerned about possible outcomes from having their policies audited than on the quality of patient care. This potential for external audit had led to a ‘tick-box’ mentality, where the completion of paperwork was valued more highly than other aspects of care: You know, it’s all this ticks and charts, and stuff like that.
DISCUSSION The main finding that emerged from this study was that the mental health nurses regarded clinical responsibility as a process of balancing patients’ needs, the needs of the health-care organization to manage risk, and their own need for self-protection from blame in the event of an adverse outcome. While acknowledging that they were accountable for their practice, the participants regarded clinical responsibility as something adverse and something to be avoided by either shifting responsibility on to the patient or the psychiatrist. The concept of risk management is a construct at the core of contemporary, advanced liberal societies. Through the process of modernization and the advancement of science and technology, we are exposed to increasing amounts of information that has led to increasing emphasis on risk (Beck 1992). Such emphasis on risk does not actually equate to increased dangers or hazards, © 2014 Australian College of Mental Health Nurses Inc.
CLINICAL RESPONSIBILITY AND ACCOUNTABILITY
but it does lead to expectations regarding the need to control and prevent risk in the future (Giddens 1999). Risk management involves a calculation of potential danger. It has resulted in a society where danger is defined in order to protect the public good, and the incidence of blame is a by-product of arrangements to ensure that members adhere to strategies put in place to manage the danger (Douglas 1994). If a person is deemed to be in some way negligent, it is perceived as an attack against the public good. The concept of a risk society, as described by Beck (1992), has particular relevance to the area of psychiatry. Psychiatry claims expertise in human conduct, which places an expectation that those that practice it have responsibilities in the management of related risks (Rose 1996). This is driven by the historical context in which psychiatry is practiced in a culture of blame; where any tragedy is viewed as something that could have been avoided. Dangerousness, which has previously been viewed as part of an individual’s anti-social pathology, is now viewed as something that is measurable and predictable (Rose 1996). This, in conjunction with the societal perception that mental illness predicts violence and the political reframing of suicide as a social issue, rather than an individual phenomenon (Rogers & Pilgrim 2010), creates a strong onus on mental health clinicians to effectively manage risk. Such pressure has led to risk management becoming a leading discourse in contemporary practice (Crowe & Carlyle 2003; Stickley & Felton 2006; The Ministry of Health 1998). This is consistent with the findings of the present study, which identified the discourse of risk management as having a profound influence on mental health nursing practice, and a distinct influence on how nurses perceive clinical responsibility. Despite the fetishized preoccupation with risk in contemporary mental health settings, there is no evidence that the processes employed to assess and mitigate risk have had any discernible effect on suicide rates or violent incidents in mental health services. First, there is an increasing body of literature that suggests that the accurate prediction of risk in psychiatry is impossible (Large et al. 2011; Mulder 2011; Windfuhr & Kapur 2011). When a clinician fails to make an accurate assessment of risk, she or he is regarded as negligent, and therefore, accountable for failing to uphold the public good (Crowe & Carlyle 2003). In addition to this, it is not clear why defensive practices, such as ticking boxes to identify that a patient was observed, or holding meetings to discuss risk, as described by the nurses in the present study, are sanctioned from either a professional or organizational perspective when there is no evidence that they are effective. © 2014 Australian College of Mental Health Nurses Inc.
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There is also strong argument that such a preoccupation with risk management is countertherapeutic and carries various costs to services users, mental health clinicians, and services (Szmukler & Rose 2013). The findings of the present study reiterate this point, in that they demonstrate the discursive influence of risk management leading to non-therapeutic defensive practices, such as focusing on documentation or referring decision-making to a psychiatrist. The nurses also described a process of calculating decisions in practice, based on wanting to protect themselves from blame against what they perceived as being in the best interests of the patients. Another New Zealand study found that, among psychiatrists and psychiatric nurses, defensive practice was perceived as being widespread in mental health settings (Mullen et al. 2008). Mullen et al. (2008) also found that nurses felt more vulnerable in practice than psychiatrists. The authors suggested that this might be associated with more regulated protocols for nurses and a perceived lack of support in the event of an adverse outcome. This level of defensiveness is curious in a country such as New Zealand, where there is no-fault legislation, which means that practitioners are seldom sued (Mullen et al. 2008). This might indicate that the pervasiveness of defensive practice is not necessarily promulgated through legal systems or professional organizations, but is engendered by characteristics of the broader system, such as organizational managers, coroners, the media, and government health departments (Krawitz & Batcheler 2006). The participants attributed a level of responsibility to consumers for safety. One of the more significant changes in mental health care over the past 40 years has been the increasing expectation that consumers have a more active role in treatment and decision-making (Lammers & Happell 2003; Tomes 2006). In contemporary times, the recovery model is offered as a basis for consumer-driven mental health care. The essence of this model is that consumers are in control of their own treatment (Mead & Copeland 2000). Within this framework, individuals are accountable for their own behaviour and decisions, not unlike anyone else (Mead & Copeland 2000). Mead and Copeland (2000) argued, from the consumer perspective, that risk is inbuilt in the experience of life, and that it remains up to the consumer to make choices about taking risks, and not up to the health professional to protect them. However, in the psychiatric domain, the wider public tend to perceive psychiatric consumers as incapable of holding responsibility for their own conduct, which leaves mental health clinicians with a sociallymandated protection role. As described in the present
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study, a point of controversy is created in the requirement of mental health nurses to facilitate the recovery model, as well as serving the wider public and organizational interests in risk management (Chiplin et al. 1998). Interestingly, in the present study, the nurses’ descriptions also indicated an attempt to assuage their vulnerability for blame by abdicating responsibility to the patient. The potential to be held accountable for failing to protect the public good through insufficient or inadequate risk management underpinned the tactics that the participants indicated that they used to shift the responsibility to others less vulnerable to potential outcomes: psychiatrists and patients.
Study limitations Recruitment bias was possible, given that the participants were self-selected by volunteering to take part in the study, and their views and experiences need to be understood as a consequence of this. The research was undertaken at one site; however, the literature supports the findings having wider relevance. It is also acknowledged that the researcher’s professional identity might have been influential in generating the findings.
Conclusion Bellack (2006) noted that health professionals, family members, and consumers have different priorities in treatment, as well as different underlying values based on different perspectives, which require evaluation when deliberating on a person’s ability to retain responsibility in treatment. What seems to have usurped this is the emphasis placed on risk management by the organizations that deliver mental health care, coupled with society’s insistent need for protection. At even the most basic level, there is little or no evidence that policies, protocols, and clinical interventions that focus purely on risk management are clinically effective. This leads to the need to question whose interests are really being served by mental health services (Rogers & Pilgrim 2010). As suggested by Crowe and Carlyle (2003), the mental health nursing profession needs to carefully examine its role in perpetuating the discourse of risk management at the expense of its espoused therapeutic responsibilities.
REFERENCES Beck, U. (1992). Risk Society: Towards a New Modernity. London: Sage Publications Inc. Bellack, A. (2006). Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophrenia Bulletin, 32 (3), 432–442.
J. MANUEL AND M. CROWE Boyatzis, R. E. (1998). Transforming Qualitative Information. California: Sage Publications Inc. Brunton, W. (2005). The place of public inquiries in shaping New Zealand’s mental health policy 1858–1996. Australia and New Zealand Health Policy, 2, 24–40. Caelli, K., Ray, L. & Mill, J. (2003). ‘Clear as mud’: Toward greater clarity in generic qualitative research. International Journal of Qualitative Methods, 2 (2), article 1. Chiplin, J., Bos, V., Harris, C. & Codyre, D. (1998). Clinical Accountability within the Mental Health Sector: The Results of A Review Conducted on Behalf of the Mental Health Commission. Wellington: The Mental Health Commission. Crouch, M. & McKenzie, H. (2006). The logic of small samples in interviewed based qualitative research. Social Science Information, 45 (4), 483–499. Crowe, M. & Carlyle, D. (2003). Deconstructing risk assessment and management in mental health nursing. Journal of Advanced Nursing, 43 (1), 19–27. Denzin, N. & Lincoln, Y. (Eds) (2000). Handbook of Qualitative Research, 2nd edn. Thousand Oaks, CA: Sage Publications. Department of Health (2010). Responsibility and Accountability Best Practice Guide–Moving on from New Ways of Working to a Creative, Capable Workforce. London: Department of Health. [Cited 14 January 2013]. Available from: URL: http://www.rcpsych.ac.uk/pdf/Responsibility%20 and%20Accountability%20Moving%20on%20for%20 New%20Ways%20of%20Working%20to%20a%20Creative, %20Capable%20Workforce.pdf Douglas, M. (1994). Risk and Blame: Essays in Cultural Theory. London: Routledge. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive Summary. London: The Stationary Office. Giddens, A. (1999). Risk and responsibility. The Modern Law Review, 62 (1), 1–10. Guba, E. & Lincoln, Y. (1989). Fourth Generation Evaluation. Thousand Oaks, CA: Sage Publications. Hayter, M. (2013). The UK Francis Report: The key messages for nursing. Journal of Advanced Nursing, 69 (8), 1–3. Krawitz, R. & Batcheler, M. (2006). Borderline personality disorder: A pilot survey about clinician views on defensive practice. Australasian Psychiatry, 14 (3), 320–322. Lammers, J. & Happell, B. (2003). Consumer participation in mental health services: Looking from a consumer perspective. Journal of Psychiatric and Mental Health Nursing, 10, 385–392. Large, M., Sharma, S., Cannon, E., Ryan, C. & Neielssen, O. (2011). Risk factors for suicide within a year of discharge from psychiatric hospital: A systematic meta-analysis. Australian and New Zealand Journal of Psychiatry, 45 (8), 619–628. Mead, S. & Copeland, M. (2000). What recovery means to us. Community Mental Health Journal, 36 (3), 315–328. Mulder, R. (2011). Problems with suicide risk assessment. Australian and New Zealand Journal of Psychiatry, 45 (8), 605–607. © 2014 Australian College of Mental Health Nurses Inc.
CLINICAL RESPONSIBILITY AND ACCOUNTABILITY Mullen, R., Admiraal, A. & Trevena, J. (2008). Defensive practice in mental health. Journal of the New Zealand Medical Association, 121 (1286), 85–91. Peplau, H. (1999). The psychiatric nurse–accountable? To whom? For what? Perspectives in Psychiatric Care, 35 (3), 20–25. Rogers, A. & Pilgrim, D. (2010). A Sociology of Mental Illness: Fourth Edition. Berkshire, UK: McGraw-Hill. Rose, N. (1996). Psychiatry as a political science: Advanced liberalism and the adminstration of risk. History of Human Sciences, 9 (2), 1–23. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing, 23, 334–340. Stickley, T. & Felton, A. (2006). Promoting recovery through therapeutic risk taking. Mental Health Practice, 9 (8), 26–30. Strauss, A. & Corbins, J. (1998). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications.
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343 Szmukler, G. & Rose, N. (2013). Risk assessment in mental health care: Values and costs. Behavioural Sciences and the Law, 31 (1), 125–140. The Ministry of Health (1998). Guidelines for Clinical Risk Assessment and Management in Mental Health Services. Wellington, New Zealand: The Ministry of Health. Thomas, D. (2003). A general inductive approach for qualitative data analysis. American Journal of Evaluation, 27, 237–246. Tomes, N. (2006). The patient as a policy factor: A historical case study of the consumer/survivor rights movement in mental health. Health Affairs, 25 (3), 720–729. Walshe, K. & Shortell, M. (2004). When things go wrong: How health care organisations deal with major failures. Health Affairs, 23 (3), 103–111. Whiting, L. (2008). Semi-structured interviews: Guidence for novice researchers. Nursing Standard, 22 (23), 35–40. Windfuhr, K. & Kapur, N. (2011). Suicide and mental illness: A clinical review of 15 years’ findings from the UK national confidential inquiry into suicide. Bristish Medical Bulletin, 100, 101–121.
International Journal of Mental Health Nursing (2014) 23, 336–343
doi: 10.1111/inm.12063
Feature Article
Clinical responsibility, accountability, and risk aversion in mental health nursing: A descriptive, qualitative study Jenni Manuel1 and Marie Crowe2 1
Canterbury District Health Board, and 2Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand
ABSTRACT: A number of recent, highly-publicized, perceived health-care service failures have raised concerns about health professionals’ accountabilities. Relevant to these concerns, the present study sought to examine how mental health nurses understood clinical responsibility and its impact on their practice. A descriptive, qualitative design was used, and a convenience sample of 10 mental health nurses was recruited from specialist inpatient and outpatient mental health settings in Canterbury, New Zealand. Data were collected using semistructured interviews, and the transcriptions were analysed using an inductive, descriptive approach. Three major themes were identified: being accountable, fostering patient responsibility, and shifting responsibility. Being accountable involved weighing up patients’ therapeutic needs against the potential for blame in an organizational culture of risk management. Fostering patient responsibility described the process of deciding in what situations patients could take responsibility for their behaviour. Shifting responsibility described the culture of defensive practice fostered by the organizational culture of risk aversion. The present study highlighted the challenges mental health nurses experience in relation to clinical responsibility in practice, including the balancing required between the needs of patients, the needs of the organization, and the perceived need for self-protection. KEY WORDS: accountability, clinical responsibility, defensive practice, mental health nursing, qualitative study, risk aversion.
INTRODUCTION The present study focused on the important contemporary issue of nursing responsibility. This qualitative study explored the views of practicing nurses, highlighting matters of accountability and ownership of responsibility in a context of prevailing risk-management cultures in services. Peplau (1999) reported that when the term ‘responsibility’ surfaced in the nursing literature in the 1970s, it Correspondence: Jenni Manuel, Mental Health Division, Canterbury District Health Board, 97 Cashmere Road, Christchurch, New Zealand. Email: [email protected] Jenni Manuel, MHSc RN. Marie Crowe, PhD RN. Accepted January 2014.
© 2014 Australian College of Mental Health Nurses Inc.
referred to one being: ‘reliable, trustworthy and doing what was expected; a kind of moral and personal liability was implied’ (Peplau 1999, p. 20). However, the concept of responsibility has evolved over time to be more closely associated to the concept of accountability. A more contemporary definition states that clinical responsibility refers to the ‘tasks or functions that an employer, professional body, court of law or some other recognised body can legitimately demand from a health professional’ (Department of Health 2010, p. 16). Accountability, more specifically, describes the potential for disciplinary action occurring if one fails to exercise their clinical responsibilities (Department of Health 2010). The notion of responsibility and accountability in clinical practice is particularly relevant, due to a number of
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recently-publicized, perceived service failures in health care. An example of this is a recent inquiry that took place into the care provided by the Mid-Staffordshire National Health Service Foundation Trust between 2005 and 2009 in the UK (Francis 2013). The events that led to this inquiry included high mortality rates and public outcry about poor standards of care. Specific recommendations to nursing were made regarding the need for a culture of care and compassion that lead to public commentaries about nursing training being overly theoretical (Hayter 2013). The inquiry identified multiple issues relating to institutional cultures focused on doing the systems business, rather than focusing on patients’ best interests (Francis 2013). The report recommendations included that further provision should be made to ensure that those who care for patients are properly accountable for what they do (Francis 2013). Inquiries in other countries have come to similar conclusions. In Australia, a number of inquiry recommendations have focused on the lack of reporting concerns about patient care and safety. A study that examined multiple examples of significant health-care failures in various Western countries noted that the causes and characteristics of such failures were strikingly similar across different countries (Walshe & Shortell 2004). Given these countries had different ways of organizing and funding health care, it was surmised by those authors that the problem might be inherent in health-care culture. Cultures of secrecy, self-protection, and institutional defensiveness were questioned as potential areas of focus (Walshe & Shortell 2004). Brunton (2005) noted that inquiries have played an important role in the design of mental health policy and in shaping mental health service delivery, both in New Zealand and elsewhere. Because mental health lacks high status and popularity among politicians (and perhaps the general public), major policy changes have occurred in response to inquiries triggered by some newsworthy incident, revelation, or a level of public disquiet that makes an issue politically sensitive. A main theme of inquiries over time has been the need for an accountability framework to provide clear direction and leadership (Brunton 2005). Most inquiries that have occurred during the advanced liberal political ethos of the late 20th and early 21st centuries have focused on accountability, who or what is responsible for the newsworthy incident, and how the risk of a recurrence could be mitigated through risk-management strategies (Crowe & Carlyle 2003). Despite the attention healthcare service failures have received internationally, and the subsequent focus on © 2014 Australian College of Mental Health Nurses Inc.
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health-care professionals’ accountability, there is limited literature that explores the topic. Cultures of selfprotection and organizational defensiveness have been identified as potential factors in inquiries; however, this notion has received relatively little attention in the literature. Additionally, there is no research available that is specific to the topic in the context of mental health nursing. Therefore, the aim of the present study was to explore this topic from the perspective of mental health nurses.
METHODS Design This qualitative study design utilized a descriptive, general, inductive approach. This approach is a wellconsidered combination of sampling, data collection, and analysis techniques (Sandelowski 2000). This approach is less theoretical than some, which can be considered an advantage, as it allows for findings to emerge from the raw data without being restricted by imposed methodologies or predetermined theories (Thomas 2003). The inductive element of data analysis is consistent with Strauss and Corbins’s (1998) description: ‘The researcher begins with an area of study and allows the theory to emerge from the data’ (p. 12). This approach was a good fit with the aim of the present study, which was to identify mental health nurses’ understandings and experiences of clinical responsibility. Although descriptive, general, inductive approaches are less theoretical than other qualitative designs, it was still important to consider the underlying theory and assumptions that were relevant to the study. Interpretivism (Denzin & Lincoln 2000), and the theoretical positioning of the researchers (Caelli et al. 2003), were relevant factors to this design. Given that this was a descriptive study, the interpretation was low inference, in that the findings were not described in terms of a conceptual or philosophical framework (Sandelowski 2000). However, it did involve a degree of interpretation, as this cannot be avoided based on the underlying assumptions of interpretivism as a basis for qualitative research. The research question was developed in response to questions that were circulating in the researcher’s clinical practice area about who held clinical responsibility for particular aspects of care. The researcher held the prior assumptions that risk assessment and management have a strong influence on mental health practice, and that mental health nurses experience varying levels of anxiety regarding clinical responsibility in practice.
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Participants A convenience sample of mental health nurses working in local mental health inpatient and outpatient services was recruited via advertisement in nursing staff rooms. Ten participants responded to the advertisements from acute, youth, and rehabilitation inpatient mental health wards, as well as youth and adult community mental health services. All participants were registered nurses; there were no other selection criteria.
Data collection Semistructured interviews were the means of data collection, as they are considered the most appropriate form of enquiry when participants’ perspectives about a particular topic are sought (Crouch & McKenzie 2006). This type of interview is organized around a set of predetermined questions, with the flexibility of following participants’ responses when further avenues of enquiry emerge from the dialogue (Whiting 2008). The interviews were based on the following questions: (i) What is your understanding of the term ‘clinical responsibility’?; (ii) Tell me about the areas of clinical practice you have responsibility for; (iii) How do you feel about your current levels of responsibility within your practice?; and (iv) How do you think your perceptions of ‘clinical responsibility’ influence your decision-making in practice? The audio-recorded interviews were between 40 and 60 min in length. The interviews were later downloaded, and then transcribed verbatim, providing written data ready for analysis.
Data analysis Thematic analysis was chosen for this study, as it fits with the general, inductive approach, and provides a structured process of analysis. Having a clear process for the analysis, such as this, enables the researcher to increase the accuracy in the interpretation of qualitative information (Boyatzis 1998). The data were read a number of times, and a synopsis for each transcript was written, allowing for familiarity to the data. Key points made by participants were identified, pulled out, and given brief descriptions. This process of labelling narrative is described as ‘naming it’ by Boyatzis (1998). The next step involved comparing and looking for similarities, which resulted in emerging themes being identified. The final step involved combining and cataloguing related themes together to produce the major themes.
Ethics The present study received ethical approval from the Regional Health and Disability Ethics Committee. Infor-
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mation sheets were provided to all potential participants, and signed, informed consent was obtained. The researcher did not work within the areas sampled, but did work in a local, clinical area, resulting in some participants having a prior working relationship with the researcher. This was raised on the information sheet as a potential issue, and participants were encouraged not to volunteer if they felt uncomfortable about knowing the researcher. For the transcription of audio-tapes, the typist signed a confidentiality agreement. Participants’ names and identifying details were removed from records prior to analysis, and special consideration was given to the use of narratives. Parts of narrative were removed to ensure participant, other staff, and patient confidentiality.
Rigour The trustworthiness of the research process was established using the guidelines of Guba and Lincoln (1989). The first author independently analysed the data, and both authors got together to integrate the interpretation of data. The findings were corroborated at two research presentations, at which feedback was invited from mental health nurses. The nurses who attended these attested that the findings were congruent with their experiences of clinical responsibility. Transferability was addressed by providing sufficient background information regarding the study to enable the reader to determine the relevance of the findings to their own practice. Dependability and confirmability were ensured by providing sufficient information about the research process, and the use of quotes to provide evidence of findings to enable an audit trail of the process.
RESULTS Ten participants were recruited and interviewed. Three themes emerged from the data to describe the participants’ perceptions and experiences of clinical responsibility: being accountable, fostering patient responsibility, and shifting responsibility.
Being accountable This theme referred to the participants taking responsibility for their practice, which involved weighing up the patients’ therapeutic needs against the potential for blame in the organizational culture of risk management. Being accountable could be defined as acknowledging the decisions one has made, and being able to provide a rationale for why a decision was made. It describes the process of being answerable to one’s actions, as described by this participant: © 2014 Australian College of Mental Health Nurses Inc.
CLINICAL RESPONSIBILITY AND ACCOUNTABILITY It’s putting your hand up and accepting that you basically take responsibility for the things that you do, and don’t expect to be able to pass the buck if things get tough or you’re uncomfortable.
This participant described being answerable for one’s decisions as something that is both professional and personal: Even if you feel you’ve done everything that you should have done, and you look back and you can’t see anything that was particularly remiss on your part . . . you’d still feel a certain amount of responsibility; it’s a kind of personal level of responsibility, because you’re looking after that patient, and something went wrong or something happened.
Being accountable was regarded as being not only a personal obligation, but also something that required active consideration of the rationale for one’s actions:
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Fostering patient responsibility The participants described another aspect of clinical responsibility as fostering patient responsibility. This appeared to have both therapeutic and punitive elements. This theme involved encouraging the patient to adhere to social or cultural expectations for acceptable behaviour. It described the participants’ belief that patients needed to take responsibility for the choices they made. While the nurses described an attitude of wanting to help the patient, they also described not being willing to be accountable for their behaviour: There is a point where you can’t take responsibility for somebody else’s behaviour, so you can only do everything that you can in order to help that person.
I’m very comfortable documenting what my clinical rationale is, and as long as I always have a sound clinical rationale underpinning my intervention and I can justify that and that’s very clear, then I’m ok.
While expecting that most patients take responsibility for their behaviour, the participants also revealed that the degree to which they fostered patient responsibility was dependent on a range of factors. One participant described basing this decision on the patient’s diagnosis:
Most of the participants regarded being accountable as a response to some adverse event, and associated it with blame:
I think it depends very much on what illness they’re presenting with, as to what level of self-responsibility I think they should have.
I guess I would feel really responsible if I felt that some of the things I have done weren’t appropriate, or perhaps putting it another way, I hadn’t done all the things I should of (sic) done, then I would be a lot more selfblaming, and I would feel more responsible and accept whatever came out of that process, whatever inquiry took place or whatever.
Participants described making a differentiation between behaviours they regarded as ‘bad’ (under the patient’s control) or ‘mad’ (outside the patient’s control): I’d never get the police involved if the patient assaulted me if they were psychotic and unwell, but if it was intentional and they were not psychotic and in their right mind and punched me, I would involve the police.
Balancing the needs of the patient with the organization’s culture of risk management was an active and considered process that continually influenced the participants’ practice:
Some of the participants described this process of fostering responsibility as a process of providing the patient with alternatives:
I see that accountability again is about what’s in the patients’ best interests, and I guess in terms of risk management, you know weighing that up between wanting to cover yourself and wanting to do what’s right for the patient.
For me, the responsibility is more around, I don’t even know how to explain it . . . it’s working with them to foster that sense of being able to start to take on board some ideas and some ways of being that might, you know, enable them to manage better stress or whatever.
Being accountable identified the active process with which the participants engaged, in an effort to balance the patients’ needs in an organizational climate in which they felt they would be blamed if an adverse event occurred. In the nurses’ descriptions, accountability was explained as being aware that their practice could come under scrutiny and appeared to be associated with the possibility of a life-threatening event occurring, rather than something related to day-to-day practice.
The shift in being accountable for one’s practice and fostering responsibility was associated with behaviours that were regarded as violent or aggressive, or self-harming. The participants described these behaviours as within the patients’ control:
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We almost lost her six times, five or six times, while she was with us, and not one of those times was I thinking ‘Bugger, it was my fault’. No, I always thought ‘What a shame that you’ve made this decision’.
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This theme explored how the nurses described fostering patient responsibility. The participants appeared to be suggesting that their perception of patient responsibility was determined by a judgment call they made in relation to whether patients’ behaviour was ‘mad’ or ‘bad’. If it was regarded as ‘bad’ behaviour, then the patient was expected to take responsibility for this, but if the behaviour was judged to be ‘mad’, then the patient could not be expected to take responsibility. It was interesting that a number of participants suggested that self-harm was within patients’ control, and they should, therefore, be responsible for stopping it.
Shifting responsibility Shifting responsibility described the culture of defensive practice fostered by the organizational culture of risk management, and the strategies the participants used to manage this. It described the actions nurses undertook to ensure their rationales for actions were recorded, and the activities they undertook to shift the responsibility of decisions to others. The strategies involved in shifting responsibility included using written over verbal communication, referring the decision to a psychiatrist, or referring the decision to a team. The following participant’s quote captured the uneasy nature of this theme: I think that our (district health board) is very risk averse. We’re very much into . . . butt covering, when our practice is driven by fear, rather than the patient’s best interest.
These participants described ensuring decisions were written down as one strategy for covering themselves. The following participant described a response to a sudden death: There’s a lot of blame that often gets pointed towards nurses, and words like ‘negligence’ are bandied around. So there is definitely the feeling that, should my notes need to go somewhere, I want to know that I have documented as thoroughly as possible the situation and my assessment.
The participants used their documentation, including nursing notes, to cover themselves in case something happened to the patient: I’m always conscious that, ultimately, it’s what’s written down that carries the weight.
Other participants described giving the decision to psychiatrists to make, rather than taking on the responsibility themselves: If there’s like a major change in presentation or major change in risk factor, I probably would consult with the
J. MANUEL AND M. CROWE doctor, if I was unsure, yeah, just to protect my butt basically, not for anything else.
Others felt that consultation with other members of the team in relation to risky decisions was another way to avoid blame: If there’s a risky decision to be made, I think you’re foolish to try and make it without consulting somebody else.
The organization had implemented multisectorial, complex case conferences where risk was addressed. The following participant felt that such initiatives were intended for the organization to mitigate their risk, rather than the needs of the patient: I’ve been involved in a case where this young person had borderline personality disorder risky, risky behaviours. There was a complex case conference around her, and you know complex case conferences are always about risk and management and about how we show that we’ve done everything to manage her risk. It’s more about being able to say we have done whatever we could to manage the risk. They’re not really about the young person themselves.
The participants suggested that the organization was more concerned about possible outcomes from having their policies audited than on the quality of patient care. This potential for external audit had led to a ‘tick-box’ mentality, where the completion of paperwork was valued more highly than other aspects of care: You know, it’s all this ticks and charts, and stuff like that.
DISCUSSION The main finding that emerged from this study was that the mental health nurses regarded clinical responsibility as a process of balancing patients’ needs, the needs of the health-care organization to manage risk, and their own need for self-protection from blame in the event of an adverse outcome. While acknowledging that they were accountable for their practice, the participants regarded clinical responsibility as something adverse and something to be avoided by either shifting responsibility on to the patient or the psychiatrist. The concept of risk management is a construct at the core of contemporary, advanced liberal societies. Through the process of modernization and the advancement of science and technology, we are exposed to increasing amounts of information that has led to increasing emphasis on risk (Beck 1992). Such emphasis on risk does not actually equate to increased dangers or hazards, © 2014 Australian College of Mental Health Nurses Inc.
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but it does lead to expectations regarding the need to control and prevent risk in the future (Giddens 1999). Risk management involves a calculation of potential danger. It has resulted in a society where danger is defined in order to protect the public good, and the incidence of blame is a by-product of arrangements to ensure that members adhere to strategies put in place to manage the danger (Douglas 1994). If a person is deemed to be in some way negligent, it is perceived as an attack against the public good. The concept of a risk society, as described by Beck (1992), has particular relevance to the area of psychiatry. Psychiatry claims expertise in human conduct, which places an expectation that those that practice it have responsibilities in the management of related risks (Rose 1996). This is driven by the historical context in which psychiatry is practiced in a culture of blame; where any tragedy is viewed as something that could have been avoided. Dangerousness, which has previously been viewed as part of an individual’s anti-social pathology, is now viewed as something that is measurable and predictable (Rose 1996). This, in conjunction with the societal perception that mental illness predicts violence and the political reframing of suicide as a social issue, rather than an individual phenomenon (Rogers & Pilgrim 2010), creates a strong onus on mental health clinicians to effectively manage risk. Such pressure has led to risk management becoming a leading discourse in contemporary practice (Crowe & Carlyle 2003; Stickley & Felton 2006; The Ministry of Health 1998). This is consistent with the findings of the present study, which identified the discourse of risk management as having a profound influence on mental health nursing practice, and a distinct influence on how nurses perceive clinical responsibility. Despite the fetishized preoccupation with risk in contemporary mental health settings, there is no evidence that the processes employed to assess and mitigate risk have had any discernible effect on suicide rates or violent incidents in mental health services. First, there is an increasing body of literature that suggests that the accurate prediction of risk in psychiatry is impossible (Large et al. 2011; Mulder 2011; Windfuhr & Kapur 2011). When a clinician fails to make an accurate assessment of risk, she or he is regarded as negligent, and therefore, accountable for failing to uphold the public good (Crowe & Carlyle 2003). In addition to this, it is not clear why defensive practices, such as ticking boxes to identify that a patient was observed, or holding meetings to discuss risk, as described by the nurses in the present study, are sanctioned from either a professional or organizational perspective when there is no evidence that they are effective. © 2014 Australian College of Mental Health Nurses Inc.
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There is also strong argument that such a preoccupation with risk management is countertherapeutic and carries various costs to services users, mental health clinicians, and services (Szmukler & Rose 2013). The findings of the present study reiterate this point, in that they demonstrate the discursive influence of risk management leading to non-therapeutic defensive practices, such as focusing on documentation or referring decision-making to a psychiatrist. The nurses also described a process of calculating decisions in practice, based on wanting to protect themselves from blame against what they perceived as being in the best interests of the patients. Another New Zealand study found that, among psychiatrists and psychiatric nurses, defensive practice was perceived as being widespread in mental health settings (Mullen et al. 2008). Mullen et al. (2008) also found that nurses felt more vulnerable in practice than psychiatrists. The authors suggested that this might be associated with more regulated protocols for nurses and a perceived lack of support in the event of an adverse outcome. This level of defensiveness is curious in a country such as New Zealand, where there is no-fault legislation, which means that practitioners are seldom sued (Mullen et al. 2008). This might indicate that the pervasiveness of defensive practice is not necessarily promulgated through legal systems or professional organizations, but is engendered by characteristics of the broader system, such as organizational managers, coroners, the media, and government health departments (Krawitz & Batcheler 2006). The participants attributed a level of responsibility to consumers for safety. One of the more significant changes in mental health care over the past 40 years has been the increasing expectation that consumers have a more active role in treatment and decision-making (Lammers & Happell 2003; Tomes 2006). In contemporary times, the recovery model is offered as a basis for consumer-driven mental health care. The essence of this model is that consumers are in control of their own treatment (Mead & Copeland 2000). Within this framework, individuals are accountable for their own behaviour and decisions, not unlike anyone else (Mead & Copeland 2000). Mead and Copeland (2000) argued, from the consumer perspective, that risk is inbuilt in the experience of life, and that it remains up to the consumer to make choices about taking risks, and not up to the health professional to protect them. However, in the psychiatric domain, the wider public tend to perceive psychiatric consumers as incapable of holding responsibility for their own conduct, which leaves mental health clinicians with a sociallymandated protection role. As described in the present
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study, a point of controversy is created in the requirement of mental health nurses to facilitate the recovery model, as well as serving the wider public and organizational interests in risk management (Chiplin et al. 1998). Interestingly, in the present study, the nurses’ descriptions also indicated an attempt to assuage their vulnerability for blame by abdicating responsibility to the patient. The potential to be held accountable for failing to protect the public good through insufficient or inadequate risk management underpinned the tactics that the participants indicated that they used to shift the responsibility to others less vulnerable to potential outcomes: psychiatrists and patients.
Study limitations Recruitment bias was possible, given that the participants were self-selected by volunteering to take part in the study, and their views and experiences need to be understood as a consequence of this. The research was undertaken at one site; however, the literature supports the findings having wider relevance. It is also acknowledged that the researcher’s professional identity might have been influential in generating the findings.
Conclusion Bellack (2006) noted that health professionals, family members, and consumers have different priorities in treatment, as well as different underlying values based on different perspectives, which require evaluation when deliberating on a person’s ability to retain responsibility in treatment. What seems to have usurped this is the emphasis placed on risk management by the organizations that deliver mental health care, coupled with society’s insistent need for protection. At even the most basic level, there is little or no evidence that policies, protocols, and clinical interventions that focus purely on risk management are clinically effective. This leads to the need to question whose interests are really being served by mental health services (Rogers & Pilgrim 2010). As suggested by Crowe and Carlyle (2003), the mental health nursing profession needs to carefully examine its role in perpetuating the discourse of risk management at the expense of its espoused therapeutic responsibilities.
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