risk assessment mental health nursing

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Article contents

Learning objectives, case vignette, meaning of risk and related concepts, risk assessment framework, conclusions, author contributions, declaration of interest, risk assessment in clinical practice: a framework for decision-making in real-world complex systems.

Published online by Cambridge University Press:  29 September 2022

Risk assessment in clinical practice is often characterised as a process of analysing information so as to make a judgement about the likelihood of harmful behaviour occurring in the future. However, this characterisation is brought into question when the evidence does not support the current use of risk assessment approaches to predict, or provide probability estimates of, future behaviour in a way that is usable in single instances arising in individual cases. This article sets out a broader and more clinically applicable description of risk assessment which takes account of the wider influences on how this clinical activity takes place. In so doing, it provides a framework to guide clinicians, researchers and authors of practice guidance who are interested in improving approaches to risk assessment.

After reading this article you will be able to:

• explain the concept of risk as it applies to clinical practice

• recognise that risk assessment is much more than gathering and interpreting information to make judgements about future harm

• understand the wider psychological, interactional and system influences on risk assessment in a way that informs better practice.

Clinical risk assessment in the field of mental health is usually conceptualised as a process carried out by clinicians which involves the explicit analysis of pertinent information about a patient to reach a judgement on whether the patient will go on to act in a way that is harmful to themselves or others. This conceptualisation imagines an objective process disconnected from the real-world context in which the assessment occurs. A more informed perspective should delineate the way such judgements may be reached and the influence on doing so of the wider context in which the clinical encounter occurs. This article offers such a perspective in a way that encourages clinicians, organisations and researchers to approach risk assessment differently.

The risk assessment framework described below starts with a description of information gathering. The risk assessor needs to be familiar with factors that have been found to be associated with harm to self or others. These have been described extensively elsewhere (e.g. American Psychiatry Association 2016 ; Franklin Reference Franklin, Ribeiro and Fox 2017 ) and will not be rehearsed here. The focus of this article is more on how this information should be interpreted in the context of making clinical decisions, and the importance of recognising the impact of broader interpersonal and organisational issues on the day-to-day practice of risk assessment ( Fig. 1 ). Drawing on the empirical evidence base and on clinical experience, we will demonstrate that clinical risk assessment should not be seen as an objective analysis of risk factors to make a prediction about whether or not the patient is going to harm themselves or others in order to decide what to do to prevent that outcome. Rather, it should be seen as a process of gathering and interpreting information in the context of interpersonal relationships to guide collaborative decision-making that aims to improve patient well-being while reducing the likelihood of harm to self or others.

FIG 1 Risk assessment framework.

In academic and practice guidance the notion of risk is often examined in a way that is somewhat removed from real-world clinical practice (Nathan Reference Nathan, Gabbay and Boyle 2021b ). Key points raised in this article will be examined with reference to practice by using a case vignette that involves possible future harm. Rather than presenting only a patient profile, the following vignette describes a broader set of processes that are often neglected in risk assessment guidance and research and that will be explored in this article.

At the request of the hospital medical team, a liaison psychiatry practitioner Amy assessed Tom, a 37-year-old male who had been deemed medically fit following treatment for an overdose of medication and alcohol. Amy elicited a history of alcohol misuse, depressive symptoms and relationship breakdown. Tom said that he wanted to come into hospital for help to stop drinking. On the basis of her assessment of Tom's ongoing depressive symptoms, his social isolation and the level of his hopelessness and despondency, Amy was concerned about the risk to self and she thought that a brief crisis admission should be considered even though she was mindful that there were no vacant beds in the local psychiatric unit. Nevertheless, according to the local protocol for patients thought to need hospital admission, Amy made a referral to the home treatment team that acted as the ‘gatekeepers’ for acute in-patient services. A member of that team undertook an assessment and concluded that the primary problem was alcohol misuse, which was not a reason for admission to a psychiatric unit. When this was explained to Tom, he became angry and he said that if he was not admitted to hospital he would go out and throw himself off a motorway bridge.

To effectively undertake risk-related activities (such as risk assessment and management), we need to be sure that we agree on the meaning of the term ‘risk’. Formal definitions of risk in the context of mental health service provision refer to a future harmful event and generally incorporate its severity, imminence and likelihood or probability. However, we cannot take for granted that the notion of ‘risk’ is applied consistently in clinical practice. A phenomenological analysis of the Royal College of Psychiatrist's report on the assessment and management of risk to others (Royal College of Psychiatrists 2016 ) found that ‘risk’ was used in a way that conveys variable meanings (e.g. harm, the possibility of harm, characteristics of possible harm, a state with changeable potential for harm, and different states of potential harm) (Nathan Reference Nathan, Gabbay and Boyle 2021b ). Given the potential for protean interpretations of ‘risk’, we believe it is essential that clinicians, academics and authors of practice guidance are clear about their use of this term. In this article, the term risk is used to describe the ‘possibility of harm’. This conveys that something may occur without necessarily suggesting that it is likely to occur (i.e. it is ‘possible’ but not necessarily ‘probable’) and it leaves room for the further characterisation of the possibility.

To be able to characterise future harmful events, it is first necessary to commit to the types of event under consideration. Guidance does not usually describe this step, but it would seem reasonable to at least consider types of harm suggested by expressed intentions (e.g. Tom's statement about throwing himself off a bridge), a recurrence of harm that has occurred before (e.g. an overdose), other forms of the same category of harm (i.e. other suicidal behaviours) and other categories of harm given a particular mental state (e.g. harm to others linked to Tom's angry hostility). Risk assessment convention dictates that the possibility of any identified plausible future harmful events occurring should be delineated. Therefore, clinicians need to understand different ways of describing the delineation ( Box 1 ) and ensure that their use of a chosen descriptor is valid.

BOX 1 Meaning of risk, prediction, probability and related terms

Risk – The possibility of harm

Prediction – A commitment to a specified future outcome

Probability :

• Classic probability – The fraction of the total number of possibilities of equal likelihood in which the outcome occurs

• Frequentist probability – The frequency of an outcome over a long-run series of event occurrences

• Subjectivist probability – The degree of belief that a specified outcome will occur

Uncertainty – Known and unknown characteristics of the future in which the outcome occurs

Propensity – A property that is causally responsible for the long-run frequency

A judgement about whether an event may occur in the future could be presented as a dichotomous prediction, i.e. that harm will or will not occur. Alternatively, judgements about the future could be categorised (e.g. low, medium or high risk). However, such categorical approaches have limited utility in informing clinical decisions so as to meaningfully reduce infrequent high-harm events (Mulder Reference Mulder, Newton-Howes and Coid 2016 ).

Classic probability

The chance of a possible event occurring can also be characterised in terms of probability, which is used to describe the relative frequency of an event. This classic interpretation of probability is the fraction of the total number of possibilities of equal likelihood in which the event occurs (e.g. a 1/6 probability of tossing a three with a fair die). Since the assessment of possible future harm in clinical scenarios such as the case vignette described above does not involve a fixed number of outcomes of equal likelihood, classic probability is not applicable.

Frequentist probability

A related interpretation of probability is the frequentist view, which represents probability as a ‘long-run frequency over a large number of repetitions of an experiment’ (Blitzstein Reference Blitzstein and Hwang 2019 ). This would produce the same probability of tossing a three with a fair die, but it could also be used to reach an informed probability for an outcome when rolling an unfair die (i.e. where the possibilities are not equally likely). Clinical scenarios such as the one presented in the vignette are unique instances that cannot be replayed. Thus, even putting aside the obvious ethical objections, allowing a series of instances to play would not be the same as rolling the same die in an unchanging environment. Therefore, frequentist probability is meaningless in a unique clinical situation. However, there remains a question about the applicability to practice of data-sets from comparable groups of patients. For instance, in relation to a discrete outcome such as suicide, one could use the positive predictive value of a suicide risk assessment model derived from group-level data as the probability of a patient identified as ‘high risk’ subsequently dying by suicide. However, once it is recognised that a patient presentation at a point in time is a unique instance and that the patient's future will be influenced by a unique set of countless environmental and psychological factors in constant interplay, the limitations of using a data-set to inform decision-making in a single clinical encounter become apparent (Nathan Reference Nathan, Gabbay and Boyle 2021b ).

Uncertainty

Economists have long recognised that probability in the classic or frequentist sense cannot be used for decision-making in the context of a single unique instance (Sakai Reference Sakai 2016 ). Frank Knight reserved the term ‘risk’ for those scenarios in which the probability distribution of the outcome is known, and instead used the term ‘uncertainty’ for those scenarios in which the situation is so unique that probability distributions are not available (Sakai Reference Sakai 2016 ). Critically in the context of mental health risk assessments, Knightian uncertainty seems more applicable since we cannot reliably distinguish what will occur from what will not occur. This uncertainty has two underlying components: epistemic uncertainty, resulting from a lack of knowledge, and aleatory uncertainty, resulting from random or chance events (Large Reference Large, Ryan and Carter 2017 ). If it is accepted that one cannot accurately determine much of what is going to happen in the future (including events that might have a bearing on the occurrence of harm-related outcomes), then it follows that much of the uncertainty about a particular future harm-related outcome is aleatory (Large Reference Large, Ryan and Carter 2017 ). The vignette illustrates that in such clinical settings the uncertainty arises in a scenario involving agents making interdependent choices with strategic dimensions. This raises as yet unanswered questions about whether game theory modelling might offer greater insights into likely outcomes. To do so, account would need to be taken of the role of emotions in decision-making.

Subjective probability

Another interpretation of probability that does not rest on an imagined or actual series of trials is subjective probability. In this case, probability is conceptualised as a feature of the person undertaking the assessment rather than of the real world and is quantified on a scale of the degree of belief (Biedermann Reference Biedermann, Bozza and Taroni 2017 ). For instance, in the case vignette above, Amy felt that Tom should have a brief crisis admission, whereas the home treatment team practitioner felt otherwise. This discrepancy in opinion could be understood as arising owing to differences in both Amy's and the home treatment team practitioner's prior assumptions. Amy may have recently seen a very similar patient who subsequently died by suicide, therefore leading her to believe that Tom is presenting as higher risk warranting admission.

One may also consider the properties of the entity that are causally responsible for the long-run frequency (such as the physical property of a rolled die). This is known as propensity. The propensity notion has advantages over the frequentist perspective because it can be used for a single event. Its use in mental health scenarios would also encourage a focus on the mental processes (the properties that are causally responsible for action) and, by extension, on consideration of factors that might influence these processes. In this way, talk of propensity shifts the focus from abstract disembodied concepts (such as probability) to the mind of the person.

Information gathering

Risk assessment should not be seen as a stand-alone clinical activity. It is heavily dependent on a comprehensive psychiatric assessment, which involves integrating information from an interview with, and examination of, the patient together with data from other sources (e.g. personal and professional informants, and the available records). Certain parts of that assessment are especially pertinent to judgements about the possibility of harm. These include psychological, behavioural or environmental occurrences, which have been found in group-level quantitative studies to be associated with an increased likelihood of future harm to self or others (American Psychiatry Association 2016 ; Franklin Reference Franklin, Ribeiro and Fox 2017 ). For instance, these studies have demonstrated that some of the elements contained in the case vignette are associated with an increased likelihood of suicide: these include a history of overdose, comorbid psychiatric disorder, alcohol misuse, relationship breakdown and feelings of hopelessness.

Special attention should be given to the characteristics of violent or suicidal ideation (e.g. frequency and intensity) and associated behaviours (e.g. intent, planning, actions) (Borges Reference Borges, Nazem and Matarazzo 2019 ). Suicidal ideation refers to thoughts about ending one's life, which may be categorised as ‘active’ (i.e. thoughts, and a plan, to die) or ‘passive’ (i.e. thoughts to die, but no plan) (Turecki Reference Turecki, Brent and Gunnell 2019 ). Although the clinician should pay attention to any statements suggesting a pattern of thinking, feeling and planning that is relevant to the potential for future harmful actions, it should also be recognised that internal experiences relevant to future actions are not experienced as circumscribed and unchanging entities in the way descriptors such as active or passive ideation suggest. Similarly, taking a phenomenological approach to explore mind-based correlates of disturbed behaviour is likely to lead to a more fine-grained and case-specific causal understanding of the behaviour than is possible when working just at the level of diagnosis or symptoms (Nathan Reference Nathan, Whyler and Wilson 2020 ).

If an assessment entailed merely compiling a list of case-based factors that theoretically may increase the likelihood of a high-harm outcome, it would be of limited use for decision-making in an individual scenario (American Psychiatric Association 2016 ). Instead, the relevance of these factors should be understood in the context of the person's current experiences and triangulated with other sources of information, such as a collateral history from a family member. Moreover, the assessment should attempt to uncover underlying psychosocial processes that explain how the factors interact to influence this person's behaviour (as explained below).

Interpretation

Despite the identification of factors that predict suicide or serious violence, it has not been possible to translate this literature into clinically useful predictive tools (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). Although a meta-analysis of prospective studies predicting suicide following self-harm found four risk factors with robust effect sizes (previous self-harm, suicidal intent, physical health problems and male gender) they were ‘unlikely to be of much practical use because they are comparatively common in clinical populations’ (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). The study's authors, who also reviewed a range of risk scales, concluded that ‘the idea of risk assessment as prediction is a fallacy and should be recognised as such’. Another meta-analysis concluded that no unique set of risk factors could be reliably linked to an outcome of suicide, with predictive ability found to have not improved over the past 50 years (Franklin Reference Franklin, Ribeiro and Fox 2017 ). There are a number of reasons. First, risk factors are non-specific and are shared by many individuals; for instance, the presence of mental illness is considered a risk factor for a suicide, despite the fact that most people with mental illness will not die by suicide (Franklin Reference Franklin, Ribeiro and Fox 2017 ). Second, suicide risk is influenced by a complex combination of interacting factors, with each individual factor only having a weak association with the rare outcome of suicide (Zortea Reference Zortea, Cleare and Melson 2020 ). Third, although clinicians are tasked with determining risk over periods of hours or days, most studies are not focused on acute or short-term prediction and therefore, unsurprisingly, longer follow-ups within studies did not improve prediction power and, in some cases, significantly weakened it (Ribeiro Reference Ribeiro, Franklin and Fox 2015 ). It should be mentioned, though, that a case has been made for the use of probability scores from a risk assessment tool to complement an individual needs-based assessment, although how the clinician uses the scores requires further empirical examination.

Believing that it is possible to categorise patients accurately may even be harmful. Potential problems include unnecessarily applying more restrictive approaches to all those categorised as ‘high risk’ and directing resources away from the ‘low-risk’ groups despite these groups containing most of those who go on to die by suicide (because they are much larger in absolute terms) (Mulder Reference Mulder, Newton-Howes and Coid 2016 ). Additional problems may arise as a consequence of an innate tendency of humans to automatically assign people to broad categories and then to make predictions about them on the basis of the assigned category rather than person's unique characteristics (Liberman Reference Liberman, Woodward and Kinzler 2017 ). In the risk assessment/management context, this may lead to the clinician inflexibly adhering to beliefs about the patient's assigned risk categorisation even in the light of emerging evidence to the contrary. As will be discussed below, such inflexibility can encourage a countertherapeutic stance. In forensic mental health services, risk categorisation is still used, but its effectiveness in reducing violence remains to be determined (Challinor Reference Challinor, Ogundalu and McIntyre 2021 ).

Uncertainty versus predictions and probabilities

Although there may be an emerging consensus that categorical prediction has no place in an individual clinical risk assessment in general psychiatric settings (e.g. Graney Reference Graney, Hunt and Quinlivan 2020 ), there remains a question about the role of probabilistic approaches. In other fields, such as economics and geopolitics, it has been demonstrated that the practice of actively thinking probabilistically is associated with more accurate subjective probability estimates of future events (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ). However, there is a difference between improving the accuracy of these estimates and the use of the estimates to inform clinical decisions. To use a probability estimate to inform a categorical decision (e.g. to admit the patient or not) requires a threshold to be applied, which inevitably turns the estimate into a category (and therefore subject to the problems of using predictive categories).

The concept of ‘uncertainty’, which acknowledges that the probabilities of the outcomes are unknown or meaningless (Park Reference Park and Shapira 2017 ), more accurately represents the realm in which mental health clinicians undertake risk assessments and it encourages a focus on reducing uncertainty rather than predicting outcomes or quantifying the probability of their occurrence. Accepting that we are dealing with Knightian uncertainty, in that the probability distribution of future harmful events in the case of a given patient is unknown, reduces our need to think of the future in terms of predictions and probabilities. The focus should then shift from trying to compute the likelihood of outcomes to instead concentrating on characterising future scenarios of interest and the circumstances that would appreciably increase the likelihood of harm. In the psychiatric context, this can be facilitated by formulation, which brings together relevant factors in a way that produces an explanatory framework for the behaviour of interest. This is commonly done by assigning factors different explanatory functions, such as predisposing, precipitating, perpetuating and protective. Using formulation as an explanatory framework and scenarios to speculate about the future are important steps in approaches to risk assessment and management in forensic settings. Formulations can be further enhanced by exploring the proximal mental processes that are hypothesised to cause the behaviour (i.e. the propensity) (Nathan Reference Nathan, Whyler and Wilson 2020 ). Existing explanatory models of suicidal and violent behaviour can serve as evidence-based frameworks to assist the clinician (Klonsky Reference Klonsky 2018 ) ( Box 2 and Table 1 ). Such models describe how combinations of many risk factors create pathways towards the emergence of harmful ideation and behaviour, and reserve particular focus, as a result of being set within the ideation-to-action framework, on the factors that govern the transition from ideation to action (Zortea Reference Zortea, Cleare and Melson 2020 ).

BOX 2 Explanatory frameworks of proximal mental processes related to suicidal behaviour

Interpersonal theory of suicide (IPTS) (van Orden Reference van Orden, Witte and Cukrowicz 2010 ) – Thwarted belongingness (unmet need to belong) and perceived burdensomeness (perception of being a burden to others) lead to suicidal desire. Exposure to painful and provocative events (e.g. childhood adversity, adult trauma, self-injury) causes habituation to fear and pain, which can result in the capability to enact suicide.

Integrated motivational-volitional model (IMV) (O'Connor Reference O'Connor and Kirtley 2018 ) – A tripartite model in which (1) the pre-motivational phase, comprising life circumstances and events, provides a contextual background for (2) the motivational phase, when defeat and humiliation appraisals lead to a state of entrapment in which suicidal behaviour is seen as a salient solution to life circumstances and suicidal ideation and intent develop, followed by (3) the volitional phase, in which the suicidal behaviour occurs. Progression through these phases is influenced by moderators (e.g. social problem-solving, memory biases and rumination, thwarted belongingness, burdensomeness, social support).

Three-step theory (3ST) (Klonsky Reference Klonsky 2018 ) – Step 1: the combination of pain that is experienced as punishing (particularly psychological pain consequent on aversive stimuli, such as conflict, loss, physical ill health) and hopelessness (about the pain diminishing) lead to suicidal ideation; step 2: suicidal ideation is heightened by disrupted connectedness (primarily to other people, but also to a job, project, interest, etc.); and step 3: progression from ideation to action depends on suicide capacity, which is made up of the dispositional (e.g. pain sensitivity), acquired (e.g. habituation to experiences associated with pain) and practical (e.g. knowledge of and access to lethal means).

Fluid vulnerability theory (FVT) (Rudd Reference Rudd and Ellis 2006 ) – Takes account of the variable nature of suicide risk over time (such as rapid changes in ideation) by delineating chronic and acute suicide risk. Acute episodes of risk are time-limited and driven largely by situation and contextual variables (e.g. severity and mix of current symptoms, life stressors, substance misuse, access to method). Chronic (or baseline/residual) risk describes an enduring individual vulnerability for suicidality or an acute risk episode and is based on a disparate range of factors, including adversity, genetic history, biology/physiology, and cognitive, affective and motivational dispositions.

TABLE 1 Explanatory framework of mental processes related to violent behaviour

Making use of case-based explanatory models

Although clinical experience suggests that the explanatory models (or elements thereof) often have utility in explaining a single instance of behaviour, a model should not be seen to have universal applicability and there should not be indiscriminate top-down imposition (Hjelmeland Reference Hjelmeland and Loa Knizek 2019 ). Furthermore, just because a model may represent a parsimonious theory to understand the behaviour in a way that guides clinical decision-making does not mean that it leads to highly accurate predictions of future behaviour (Klonsky Reference Klonsky, Saffer and Bryan 2020 ). Analysis of previous suicidal, self-harm or aggressive behaviours should inform the explanatory processes that are relevant to this case. This can be done using a chain analysis, which involves a collaborative exploration with the patient of the vulnerability factors and prompting events for, and the consequences of, the target thoughts/behaviour (Borges Reference Borges, Nazem and Matarazzo 2019 ). The use of such explanatory models can be illustrated in the context of the vignette presented above. It turned out that Tom's feelings of hopelessness and despondency tended to become more intense when the relationship problems were such that he could not see a way out of his predicament and an end to his anguish. If Amy was familiar with the evidence-based explanatory frameworks related to suicidal behaviour (and in particular the integrated motivational-volitional model), then she would be more likely to ask relevant questions and to explore further for other relevant processes (e.g. defeat and humiliation). Tom may, in response, feel reassured that his problems are being properly understood and he may be left with more insight into why he sometimes experienced thoughts of ending his life (which otherwise may have felt frighteningly unpredictable).

Even with the use of an agreed model to characterise possible future scenarios, within- and between-assessor differences may contribute to variability among assessor judgements. For example, affective processes, which may change over time in the same individual, have a strong influence on risk perception (through the automatic deployment of the affect heuristic). Thus, clinicians’ feelings (as distinct from their knowledge) about an intervention are liable to influence their perception of its effectiveness (including in relation to managing the potential for harm). Risk perception may also be dependent on the readiness with which examples relevant to the scenario under consideration come to mind (i.e. the availability heuristic), which is liable to differ depending on the assessor's previous experience. Assessors should be aware of the potential for biased judgements and the need to resist automatic risk categorisations in favour of a detailed analysis with the intention of reducing uncertainty.

As well as the effect of heuristics on decision-making, certain practitioner characteristics have been shown to contribute to better judgement formation. Subject-matter expertise is necessary, but not sufficient (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ). For instance, an individual's willingness to accept the role of change and the potential to cultivate this type of judgement formation, together with active open-mindedness, are associated with better judgements about future events (Tetlock Reference Tetlock, Mellers and Scoblic 2017 ).

Decision-making

Although any categorical or dimensional outputs of risk assessment methods may not be usable in individual instances of clinical decision-making, the constituent elements of the risk assessment may still have some utility for risk management. Risk management involves addressing current modifiable factors that the explanatory formulation suggests increase the likelihood of high-harm behaviour, including any specific treatment needs (e.g. depression or substance misuse) (Large Reference Large, Ryan and Carter 2017 ). Ways of bolstering factors that the formulation suggests reduce the likelihood of future harm should be explored with the patient. The management plan should also consider early warning signs for a high-risk mental state and steps to be taken in this event. Specific safety or crisis plans (which focus on stressors, warning signs, self-management strategies, social support and crisis resources) have been shown to reduce subsequent suicidal behaviours (e.g. Nuij Reference Nuij, van Ballegooijen and de Beurs 2021 ).

Although it has to be accepted that the current empirical evidence undermines the case for the routine clinical use of categorical risk predictions, it does leave an outstanding question about how clinicians should take account of risk when faced with options that can only be implemented in categorically distinct forms. In the vignette presented above, one of the issues under consideration was admission to hospital. Clinical experience would suggest that the decision is often framed as being dependent on whether or not the patient is going to imminently act on urges to cause harm (to self in the vignette) but, as has been explained, this cannot be accurately predicted. It is possible to conceive the use of a probability estimate, but it would require the data-set from which the estimate is drawn to be relevant to the scenario (i.e. from a sample of patients assessed following an overdose rather than an in-patient sample about to be discharged). Also, to use a number from a continuous scale to make a categorical decision requires the establishment of thresholds (with or without the scope for justified discretion). Before introducing such an approach, further empirical testing would be necessary.

An alternative approach would be to use the unique case-based explanatory formulation in collaboration with the patient to consider the factors that increase the likelihood of the behaviour and potential ways to address modifiable factors so as to reduce that likelihood. It would still be necessary to come to a categorical decision, but this approach has the advantage of focusing attention on what can be done to adjust the modifiable circumstances (and this may include the use of therapeutic skills during the assessment), which in turn may assist the clinician in combatting their own automatic and biased categorical assumptions.

It needs also to be recognised that in practice the system places demands on the clinician that are sometimes in competition. Although the imperative to help the patient's emotional well-being may not conflict with the requirement to reduce the likelihood of high-harm outcomes, sometimes it does. For example, although admission may be thought necessary to manage dangerous levels of self-harm, in some cases the in-patient environment may exacerbate some of the underlying processes contributing to self-harm. For example, the use of medication and/or physical restrictions to address acute mental state changes may reinforce certain pre-existing processes contributing to a tendency to self-harm (such as difficulties understanding and reflecting on the mental states of others, which may lead to a dependence on the overt physical representations of the intentions of others provided by medication and physical restrictions). Therefore, the clinician needs to consider the possibility that the way of managing the potential for harm in the short term (i.e. admission) will further compromise the patient's well-being. Also, there may be service-level pressures (which can be manifest in interpersonal tension between ‘referrers’ and ‘gatekeepers’) to avoid admission, which are often related to the need to manage a finite resource under pressure. Thus, the clinician's final decision is influenced by judgements about future unpredictable harms and benefits within a complex system of pressures and relationships.

Interaction

If risk assessment is framed solely as a process of gathering and interpreting information about the patient to reach a judgement about the possibility of future adverse incidents, then the discussion with the patient is liable to become transactional, in that the primary goal is to elicit information. To the contrary, the interaction should be seen as an opportunity to reach a shared understanding of risk and to positively influence the patient's mental state and their representations of mental healthcare professionals in a way that may have a bearing on their future behaviour (including behaviour that has the potential to harm themselves or others). The clinician should adopt a compassionate and collaborative stance in which they actively and supportively listen with the aim of enhancing understanding (or reducing uncertainty) rather than reaching a categorical position about risk (Large Reference Large, Ryan and Carter 2017 ).

There may be a legitimate difference of view between the clinician and patient about the next steps (e.g. whether to admit a patient who is feeling suicidal), but the clinician needs to be careful that their explanation for their decision does not constitute invalidation of the patient's experiences. The false belief that the patient can be definitely allocated to a risk category may lead the clinician to have an undue sense of confidence in their judgement, and then convey this false confidence to the patient in a way that invalidates the patient's experiences and feelings. There is empirical evidence to show that a collaborative assessment that emphasises respect, compassion, curiosity, a desire to help, flexibility and the relational nature of the assessment is associated with symptom reduction and patient self-enhancement (e.g. Durosini Reference Durosini and Aschieri 2021 ) and it has been proposed that a positive therapeutic relationship may reduce risk (Royal College of Psychiatrists 2016 ).

Learning and investigating

The approach to learning from untoward incidents is relevant to the practice of risk assessment because in making decisions in acute psychiatric scenarios, clinicians are influenced not only by the clinical information available to them, but also by the wider context in which they practice (Nathan Reference Nathan and Wilson 2021a ). Such learning, typically through investigations, takes a deterministic perspective that does not readily apply within complex systems (such as mental health services), in which the underlying determinants of change are uncertain and non-stationary.

Although scrutinising the past in light of the outcome seems the best way to reach an explanation of why the outcome occurred, it can lead to problems when judging whether the decision was the correct one or not. The usual approach to investigating an incident (e.g. by an internal investigation, an external review or the coronial process) is to work back from the outcome to identify factors and decision points that appear to have a causal link with the outcome. This approach encourages decision-making to be tested in light of the outcome, i.e. would the outcome have been different if a different decision had been made? It is well recognised that looking back from the outcome makes the assessor susceptible to hindsight bias, which leads to an overestimation of the foreseeability of the outcome (Roese Reference Roese and Vohs 2012 ) and that the resulting investigations can contribute to a culture in which clinicians feel that they are liable to be blamed for unpredictable outcomes (Munro Reference Munro 2019 ). However, more fundamentally, the decision maker is in effect being tested against a standard that is almost impossible to meet. Not only do they not know the outcome, but as articulated above the empirical evidence also suggests that even if they had fully considered the relevant risk factors, that outcome would have been nigh on impossible to predict in an individual case. Another way of illustrating the contradiction is to consider the decision not only in light of actual events but also in the counterfactual scenario in which the outcome did not occur. Concluding that it was reasonable in the latter scenario but not in the former means that the clinician is placed in the unenviable position of being assessed by a standard that is not known at the time of making the decision and only becomes known after a future unlikely and unpredictable outcome has occurred (Bhandari Reference Bhandari, Thomassen and Nathan 2022 ).

What is the relevance of this to practice? At the time of making a critical clinical decision, as well as thinking about the possibility of future harm enacted by the patient, clinicians’ decisions are also influenced by an in-the-moment contemplation of an unfavourable future appraisal of their decision-making in the event of a serious adverse event occurring (even though the event is unlikely) (Nathan Reference Nathan and Wilson 2021a ). The issues can be illustrated by a development of the scenario presented in the vignette above. Although Amy remained of the view that admission was indicated, there had been previous tension between her and the home treatment practitioner and she did not have the confidence to contest the decision to decline admission. She also had on her mind thoughts about a member of her team who was still off work for stress due to the experience of the way she was questioned in both an internal investigation and coroner's inquest in a separate case 6 months before. When Amy told Tom that he had to go home, he abruptly left the hospital. In Amy's clinical entry she justified her decision not to pursue the option of admission by stating that although Tom ‘threatened’ to throw himself off a motorway bridge this appeared to be for ‘secondary gain’ (to secure admission) and she thought that because he was talking about events in the future the risk of suicide was not high. Thus, although in reality clinicians are unable to reliably predict the outcome, they are prone to hold in mind an approach that relies on a deterministic predictive model (in which an outcome is an inevitable result of the antecedent causes), further encouraging the spurious categorisations of patients as high or low risk, the use of such categorisation to allocate resources and the adoption of defensive practices (Munro Reference Munro 2019 ). Amy would, she thought, have felt more able to take a different approach to the dilemma she faced if it was clear to her that in the event of a future untoward incident, the investigation would not use the outcome as a basis for judging her actions and account was taken of the real-time complexity of the situation. She would have felt less motivated to use a spurious risk categorisation to defend herself against what she imagined, from the perspective of a hindsight-armed investigator or coroner, could look like a ‘missed opportunity’. More importantly, by feeling able to acknowledge with Tom (and in her clinical entry) that she remained concerned about the risk, the encounter would have been more validating and there would have been greater opportunity for the collaborative exploration of alternative options to admission, which as noted above may have reduced risk.

Therefore, the issue is not just agreeing how to conceptualise risk assessment, but also agreeing how to conceptualise the system in which the risk assessment activity occurs. Rather than conceptualising a deterministic system (i.e. one in which the future state of every aspect of the system can be described), risk assessment should be characterised as an informed process to reduce uncertainty within a complex system of unknowable future states. More research is needed before firm recommendations can be given about alternative models to learn from adverse incidents, but possible approaches include appraising any decision of interest in light of a counterfactual scenario in which the outcome did not occur, appraising decisions against pre-agreed standards, appraising decisions without knowledge of the outcome and/or focusing on potential latent factors (i.e. systems, processes and training) rather than just linear cause-and-effect ones (Bhandari Reference Bhandari, Thomassen and Nathan 2022 ).

As yet, it has not been possible to produce a method for an individual clinician to accurately predict whether or not the patient they are assessing at a single point in time will go on act in a way that seriously harms themselves or others in the near future. It remains to be determined whether the alternative approach of attempting to apply a quantitative estimate to possible future events has applicability in such a single instance. Given that a person's future behaviour is dependent on the interplay over time between their actions (which are in turn dependent on innumerable and often unknowable mental processes) and the environment in which they will exist (which takes the form of a complex and dynamic system of other unpredictable and interdependent agents), it seems unlikely that accurately foretelling a single person's future will be possible anytime soon. In the meantime, a faith in this possibility can interfere with the goal of risk assessment, which should be to inform clinical decisions with the aim of reducing the likelihood of future serious harm while at the same time improving patient health and well-being. Oversimplified categorical judgements are not just liable to be wrong. The rigid and overconfident adherence to such judgements can also undermine the therapeutic potential of the assessment.

An awareness of the factors that have been found at a group level to be associated with an increased likelihood of harmful events is still important. Armed with such an awareness the clinician can reach an informed conclusion about the type of harm that the risk management plan should address and can engage the patient in a discussion about strategies to address those factors that are modifiable. However, the success of new models of risk assessment will not merely be a function of the components of those models. Attention also needs to be paid to clinician-based and system-based issues that have a bearing on the implementation of the model. If, as the empirical evidence suggests, humans are naturally inclined to categorise and to be subject to unthinking biases in forming judgements about the future, then attention also needs to be given to enhancing the psychological competencies of risk assessors and incident investigators, so that they are more able to resist these inclinations and remain actively open-minded. Furthermore, for as long as the wider system takes a deterministic approach in judging previous decisions in light of an adverse outcome, then clinicians (who, the empirical evidence suggests, have an eye to the anticipated findings of such investigations in their day-to-day practice) will find it difficult to lose faith in the deterministically informed assumption that the future can be read. Developing, implementing and researching risk assessment requires clarity about the goal of this clinical activity, its meaning in real-world settings (which should take into account the wider system as well as the individual clinical encounter) and the human factors that can interfere with the achievement of the goal.

R.N. conceived the article and was responsible for the figure and table. R.N. and S.B. reviewed the relevant literature and drafted and edited the manuscript.

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Select the single best option for each question stem

a frequentist probability is the long-run frequency over a large number of repetitions of an experiment

b classic probability is the fraction of the total number of possibilities of different likelihoods in which the event occurs

c classic probability is directly relevant to clinical risk assessments

d the term ‘uncertainty’ applies when the probability distribution of the outcome is known

e subjective probability is equivalent to propensity.

a risk assessment should not be seen as a stand-alone clinical activity

b a phenomenological approach is likely to produce a more case-specific understanding than a diagnostic approach

c risk factors should be understood in the context of the person's current experiences

d it is good practice to seek information from a range of sources

e all suicidal ideation can be defined as either passive or active.

a the use of risk assessment tools enables clinicians to predict future violent and suicidal acts

b the idea of risk assessment as prediction is fallacy

c risk factors tend to occur very rarely in clinical practice

d serious harm outcomes are common in psychiatric practice

e risk categorisation is unlikely to be harmful.

a the availability heuristic refers to the influence on probability judgements of the readiness with which relevant examples come to mind

b affective processes within the assessor may influence the perception of risk

c assessors should ignore their own potential biases when undertaking risk assessments

d active open-mindedness is associated with better judgements about future events

e assessors’ willingness to accept the role of change is associated with better judgements about future events.

a hindsight bias refers to the tendency to retrospectively underestimate the foreseeability of a known outcome

b concluding that a decision was incorrect in light of the actual adverse outcome but would have been correct if that outcome had not occurred is a good way of testing clinical decision-making

c deterministically judging clinical decisions in the knowledge of the outcome generally proves helpful in learning from adverse outcomes

d when making decisions in acute psychiatric scenarios, clinicians are liable to contemplate an unfavourable appraisal of their decisions in the event of an adverse outcome

e risk assessment in practice should depend on a deterministic conceptualisation of reality.

MCQ answers

1 a c 2 e c 3 b c 4 c 5 d

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• Volume 30, Issue 1
• Rajan Nathan (a1) and Sahil Bhandari (a2)
• DOI: https://doi.org/10.1192/bja.2022.67

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• Research article
• Open access
• Published: 25 November 2021

Mental health professionals’ perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

• Nafiso Ahmed   ORCID: orcid.org/0000-0001-6732-1317 1 ,
• Sally Barlow 1 ,
• Lisa Reynolds 2 ,
• Nicholas Drey 3 ,
• Fareha Begum 1 ,
• Elizabeth Tuudah 4 &
• Alan Simpson 4 , 5 , 6  

BMC Psychiatry volume  21 , Article number:  594 ( 2021 ) Cite this article

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Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals’ perspectives.

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were ‘power and best interest’ (social influences) and ‘my professional role and responsibility’ (social/professional role and identity). Key enablers were ‘therapeutic relationship’ (social influences) and ‘value collaboration’ (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components ‘opportunity’ and ‘motivation’.

The review highlights the need for further empirical research to better understand current practice and mental health professionals’ experiences and attitudes towards shared decision-making in risk assessment and risk management.

Peer Review reports

In mental health services, Shared Decision Making (SDM) is a means of delivering recovery orientated care through involving individuals in decisions about their care. For a decision to be ‘shared’ it must involve: at least two participants, the sharing of information, and a decision that is made and agreed upon by all parties [ 1 ]. These criteria are reflected in a shared decision model [ 2 ], which proposes that SDM occurs when all participants are informed, involved, and influential in the decision-making process. It is, however, emphasised that the three SDM components are on a sliding scale of influence that is dependent on context, capacity and desire to influence [ 2 ].

In shared decision-making, the aim is to recognise and utilise the unique expertise of healthcare professionals and services users to produce better decisions, and potentially better outcomes. While healthcare professionals may be experts in diagnosis, aetiology, prognosis, treatment options, and outcome probabilities [ 3 ]; service users are experts about the impact of the condition on their lives, their preferences, their personal attitudes towards risks, and often know what works best for them regarding their condition and treatment [ 4 ].

Studies report positive effects of SDM interventions on patient outcomes within different mental health populations. A randomised control trial (RCT) for people with depression reported a positive impact on patient participation in treatment decision-making and patient satisfaction [ 5 ]. Another RCT of an intervention for people with schizophrenia found SDM improved social recovery [ 6 ]. A pilot trial of a SDM intervention with veterans with post-traumatic stress disorder (PTSD) found positive impacts on patients’ receptivity to evidence-based treatment [ 7 ]. In contrast, some studies report no significant effect of SDM on clinical outcomes for people with severe mental illness [ 8 ] and depression [ 9 ], although they acknowledge that further long-term work may be needed to detect an effect.

Shared decision-making is endorsed and advocated in international healthcare policy [ 10 , 11 ]. Research has found that both service users and professionals support SDM. A qualitative research synthesis examining stakeholders’ attitudes towards SDM in mental health reported that service users valued their voice being heard, listened to, and supported to express themselves in encounters with professionals [ 12 ]. Several barriers to SDM were identified from the service user’s perspective, including feelings of perceived inadequacy, fear of being judged and a lack of trust. Barriers to SDM for professionals included: the service user lacking cognitive capacity or insight; where stigma negatively influenced the service user’s attitude towards SDM; and the professional’s own attitudes, motivation, willingness, empathy, and ability to engage and implement SDM. Professionals also highlighted challenges surrounding the competing priorities of their role, mainly them being accountable and responsible for managing risk.

Implementing SDM may pose challenges when there are concerns about the potential risks to self or others [ 13 , 14 ]. In these circumstances, mental health professionals (MHP) may not feel able to engage service users in decisions about their care. Potential barriers cited in the literature include inadequate training in suicide prevention [ 15 ]; fears about negative adverse reaction from individuals who pose a risk to other [ 16 ] and the ‘blame culture’ observed in mental health care [ 17 ], whereby MHPs are increasingly fearful of culpability and litigation. It has been suggested that this has resulted in more defensive or risk-averse practice intended to prevent harm [ 18 , 19 ].

Risk in mental health care is often used to refer to the possibility of an adverse event, outcome or behaviour arising from the unwanted actions of the service user [ 20 , 21 ]: notably risk of harm to self, others, or both, and may include self-harm, suicide, or violence. Risk also signifies the vulnerabilities that a person with mental illness may be exposed to, such as side effects from medication, exploitation, victimisation, bullying, and discrimination [ 22 , 23 ]. These risks occur frequently but are considered less in the assessment and management of risks [ 24 ].

Risk Assessment (RA) and Risk Management (RM) are the mechanisms used by MHPs to identify and minimise risk. There are three main approaches to assessing risk in mental health care: unstructured clinical judgement, actuarial methods and structured clinical judgement [ 25 ]. Unstructured clinical judgement typically involves professionals making judgements based on their clinical experience, opinion, intuition or ‘gut feeling’. Actuarial methods provide the assessor with a statistical means to combine information and calculate risk [ 26 ]. The subjective nature and poor predictive accuracy of these approaches have resulted in recommendations for them not to be used on their own in clinical practice [ 27 ]. Structured clinical judgement is considered the best approach to assessing risk [ 28 ]; this involves the use of a standardised RA tool to aid a professional in their clinical judgement [ 25 ].

Nonetheless, studies have found wide variability in the methods used to assess risk in UK mental health services [ 29 ] and forensic services in Australia and New Zealand [ 30 ]. These studies agree that a more consistent approach to RA is needed in mental health services. A multitude of evidence-based guidance is available to help standardise the process and support professionals in their assessment of risk [ 28 , 31 , 32 , 33 ]. A model for assessing suicidality, for example, provides guidance on the importance of language, the structure of the clinical interview, questioning, actuarial tools and risk categorisation [ 31 ].

Risk management is informed by the RA and includes the key actions or strategies that are designed to prevent or limit undesirable outcomes. Strategies may include treatment, supervision (i.e. help with planning daily activities), or monitoring (i.e. identifying and looking out for early warning signs) [ 28 ]. Several RM and safety planning interventions have been developed that can be used to mitigate, contain or improve RM [ 34 , 35 , 36 ].

The need to involve service users in the RA and RM process has been advocated in current professional guidance, policy, and research [ 28 , 33 , 37 ]. Involving service users is a means of minimising the gap between professionals and service users’ perspectives of risk [ 38 , 39 ] and thus, ensuring that the plan developed meets the individual’s needs [ 33 ]. This can lead to more accurate prediction and management of risk. Another potential benefit of involvement is that the individual is empowered to take responsibility for their choices, which can be a motivator for change [ 40 ]. It has been suggested that service user involvement can improve confidence and self-management skills, which may have long term impacts on reducing dependency on services, thereby increasing cost-effectiveness [ 37 ].

The UK Department of Health (DH) best practice guideline, specifically recommends SDM. Studies have shown, however, that service users are often unaware that a RA has taken place [ 41 , 42 ].

Although Higgins, Doyle [ 24 ] found that more than three-quarters of MHPs reported ‘always’ involving service users in risk assessment (77.8%) and safety planning (78.4%), only 50% of the respondents reported that they ‘always’ informed service users about their risk level, while only 43% of the respondents reported that they ‘always’ developed a shared responsibility with the service user for safety. Despite professionals reporting a high rate of service user involvement, these findings suggest that SDM is not routinely nor fully implemented.

A recent systematic review of mixed methods studies explored the service users’ perspective of helpful RM practices within mental health services [ 43 ]. Two categories of beneficial RM practices were identified: interpersonal relationships and communication; and agency and autonomy. A key finding was that trust fosters openness in relationships and enables discussion of risks, especially when service users felt that their distress was understood or their accounts were validated by professionals. Service users preferred professionals to maintain responsibility for RM initially but that eventually (at their own pace) they wished to regain control.

Other systematic reviews in this field have focused on interventions that promote SDM in RA and RM in forensic mental health settings [ 36 , 44 ]. A qualitative synthesis of research examining professionals attitudes towards SDM in the broader field of mental health exists [ 12 ], however, the authors acknowledge that the rigour of a full systematic review was not adopted. There is currently no systematic review of MHPs’ experiences and attitudes towards implementing SDM in the assessment and management of risk. A synthesis of studies will improve our understanding of the discrepancies in reported practice and identify factors that may help or hinder its implementation. The specific review question was:

What do mental health professionals perceive as the barriers and enablers to SDM in RA and RM?

This review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 45 ]. The protocol is registered on PROSPERO (CRD42016050457).

Eligibility criteria

The SPIDER framework (sample, phenomenon of interest, design, evaluation, research type) was used to specify eligibility criteria [ 46 ]. An additional S was added to capture the ‘setting’ criterion of adult mental health services. The SPIDER framework is a tool for developing a search strategy that has been designed from the PICO tool, specifically for reviews that aim to synthesise qualitative and mixed-method research studies. Due to limited resources, only studies written in English were included in the review. Table  1 lists the inclusion and exclusion criteria.

Search strategy

The EBSCOhost and Ovid Online platforms were used to search six electronic bibliographic databases: MEDLINE; EMBASE; PsycINFO; CINAHL; AMED and Internurse. Databases were searched from inception. The last search was completed on the 4th December 2019.

The search strategy used a combination of medical subject headings (MeSH) and free text key terms related to concepts of ‘mental health’, ‘health professionals’, ‘experiences’, ‘shared decision making’, ‘risk assessment’ and ‘risk management’. A full electronic search strategy is presented in Additional file 1 .

Two grey literature databases were also searched for relevant unpublished empirical research studies; Bielefeld Academic Search Engine (BASE) and Open Grey. Citation chaining was performed on all articles selected for inclusion to identify further studies of interest, and this involved searching the reference lists (backward chaining) and using Google Scholar to identify and review papers that had cited the included articles (forward chaining).

Study selection

Search results were imported into a systematic review management software EPPI-reviewer 4 [ 47 ] and duplicates removed. Two-stage screening was undertaken: stage 1 screened the titles and abstracts of studies against the eligibility criteria; stage 2, further assessed full-text of potential studies against the eligibility criteria. Study authors were contacted if more information was needed.

To minimise risk of bias, two authors (NA and FB) independently assessed titles and abstracts, and subsequently, full-text articles. A full-text review was carried out if at least one of the reviewers believed that the study met the inclusion criteria at the title and abstract screening stage. At full-text review, any discrepancies regarding eligibility were resolved by consensus and in consultation with a third author (AS/LR). Also, studies were included only once if they had multiple articles. The original or most relevant to the review question was used as the primary article for the study’s results.

The ‘Three I’s Scale of Influence Model’ [ 2 ] was used as a framework for study selection. Studies that reported on a least one of the three components (informed, involved and influential) of SDM in RA and RM were included. Stacey, Felton [ 2 ] definitions of the SDM components can be found in Additional file 2 .

Data extraction

An electronic data extraction form was devised and piloted on two of the included studies. The following data items were extracted: author(s), publication year, research question/aim, geographical location, sample size, setting, data collection, and method of analysis. The entire results sections, including direct quotations and author interpretations were imported directly into NVivo 11 software [ 48 ]. For studies with multiple publications, results were extracted and collated from all the linked reports but only one publication was used as the source of study results. Data extraction was carried out by the first author (NA) and cross-checked by a second author (SB): disagreements were resolved through discussion.

Quality appraisal

Dixon-Woods, Shaw [ 49 ] prompts were used to assess the quality and relevance of individual studies within this review. These prompts focus on the universal features of qualitative research and have been devised to ‘sensitise appraisers to the various dimensions of articles that require evaluation’ (p224). Two reviewers (NA and AJ or UF – see acknowledgements) read the papers independently and answered a series of questions on the quality appraisal checklist (e.g., Are the research questions clear?). They recorded their response as Yes (Y), No (N), Can’t tell (−). A rating system was then used to categorise the papers: Key paper (meets all quality criteria and clearly fits with review question); Satisfactory (meets most quality criteria and fits well to review question); Unsure (mixed responses to quality criteria and lack of clarity regarding relevance to review question); and Poor (does not meet quality criteria) [ 50 ]. No studies were excluded based on methodological quality; however, a sensitivity analysis (described below) was conducted to see the impact of removing lower-rated studies on the review findings. Any disagreements were discussed in full, and a rating was agreed (Additional file 3 ).

Data synthesis

The Theoretical Domains Framework (TDF) was used to explore the factors that influence the implementation of SDM in RA and RM with individuals with mental illness. The TDF is a behaviour change framework developed by a group of experts to simplify and integrate the large number of psychological theories relevant to behaviour change [ 51 ]. The TDF has been used by researchers across a range of healthcare settings to identify determinants of behaviour, namely the barriers and enablers to implementation, and to inform intervention design [ 52 ]. The original TDF has 12 domains derived from 33 health and social psychology theories and 128 key theoretical constructs. The framework was later validated and refined by Cane, O’Connor [ 52 ] to include 14 theoretical domains. The revised version of the framework was used in this review, Cane et al. (2012) definition of each domain is presented in (Additional file 2 ).

The Capability, Opportunity, and Motivation (COM-B) model was then used to condense the relevant TDF domains into three components that interact to predict behaviour. The model was developed as part of the broader framework of the behaviour change wheel [ 53 ] and provides a basis for intervention design. Each component of the COM-B model is divided into sub-components that capture important distinctions. Capability can be physical (e.g. skills) or psychological (e.g. interpersonal skills and knowledge) and represents an individual’s capacity to carry out the behaviour. Opportunity can be physical (e.g. environmental factors) and social (e.g. social influences) and is defined as all the factors that lie outside the individual that influence the behaviour. Motivation can be reflective (e.g. beliefs, intentions) or automatic (e.g. emotions) and characterises the brain processes that drive behaviour [ 53 ]. The most relevant TDF domains and linked components that are likely important to changing behaviour were identified [ 52 ].

The data synthesis process drew on established analysis methods recommended in the TDF guidelines [ 54 ], and used in previous studies applying the TDF [ 55 , 56 , 57 ]. Data synthesis involved the following six stages:

Step 1: developing a coding manual

A coding guide was developed based on the definitions of the three components of SDM [ 2 ], and the 14 domains and 84 constructs from Cane, O’Connor [ 52 ]. To provide guidance and confidence that a piece of text represents a domain, statements of how the domain applies to the research context were also included in the coding guide.

Step 2: pilot coding exercise

To ensure consistency between coders and refine the coding guideline, two coders (NA and ET) jointly coded the extracted findings from two randomly selected included papers. Any disagreements were discussed until consensus was reached; where consensus could not be reached a third researcher was consulted. The final version of the coding guide is included in Additional file 2 .

Step 3: coding papers and assessing reliability

Two researchers (NA and ET) independently coded the extracted findings from the remaining included papers using the coding guideline and via NVivo 11 software [ 48 ]. Findings relating to the target behaviour were coded to the SDM components [ 2 ], whereas potential barriers and enablers identified within the included papers were coded to the 14 domains of the TDF [ 52 ]. For example, the statement ‘“[the risk assessment is] one thing … you never discuss with service users just in case it alarms them”’ was coded to the ‘informed’ component and the ‘beliefs about consequences’ domain. If the participant’s response or the author’s interpretation represented more than one TDF domain, the text was coded to multiple domains. For example, “You know that you’re going to have suicide risk but you think well, the psychologists will deal with that bit … so to want to deal with it, even as part of the overall care, I think you’d want some type of supervision” was coded to both “social professionals’ role and identity” and “social influences”.

Inter-coder reliability was assessed by calculating the percentage agreement/disagreement (prior to consensus being reached), to measure consistency in coding within and across domains [ 58 ]. Reliability between two coders is considered acceptable if percentage agreement > 60% is achieved [ 54 ]. Discrepancies in coding were addressed by NA and ET with a consensus reached by discussion. AS was available to resolve any disputes over discrepancies; however, this was not required.

Step 4: developing overarching themes

Data within the domains were further analysed by the lead researcher (NA) using thematic synthesis [ 59 ]. Text coded into each domain were compared across papers, and findings representing similar ideas were grouped together. An overarching theme was then generated to categorise the initial themes. The overarching themes represent the specific factor perceived to influence SDM in RA and RM. For example, findings that suggest rapport, alliance or connection facilitate discussion about risk with service users were categorised as ‘therapeutic relationship’.

Step 5: mapping the COM-B model to the TDF domains

The relevant TDF domains were matched to the COM-B components [ 53 ]. The lead researcher (NA) drew on the links between the TDF domains and COM-B components identified by a group of experts in a consensus exercise reported in Cane, O’Connor [ 52 ]. The most relevant TDF domains (and themes within) were identified based on a frequency count of studies by domain. The TDF domains (and themes within) identified in at least 60% ( n  = 11) of the included studies were considered salient in understanding the target behaviour.

Step 6: sensitivity analysis

A sensitivity analysis was carried out to determine whether the methodological quality of studies impacted on the findings of the review. The results from the lowest-rated studies were removed from the synthesis to see if this influenced the key themes originally identified. No studies were excluded based on methodological quality.

A total of 8211 papers were yielded in the databases searches; and 1420 additional papers were included from other sources. After the removal of duplicates, a total of 8652 papers were eligible for screening. Following title and abstract screening, 8491 papers were excluded, and 161 full text papers were reviewed; 134 papers were excluded at full-text, and 20 studies (reported in 27 papers) met the inclusion criteria for this review. The PRISMA diagram of study selection can be seen in Fig.  1 .

A PRISMA flow diagram detailing the search strategy and results (Moher et al., 2009) [ 45 ]

All papers gained the rating of either key paper ( n  = 9) or satisfactory ( n  = 11). Papers were rated satisfactory if they did not meet all of the quality criteria and/or did not clearly fit with the review question. For example, papers that reported on specific risk decisions i.e. decision-making regarding neuroleptic medication [ 60 ]; specific RM practices i.e. clinician-patient alliance during mechanical restraint [ 61 ]; or contained very limited findings relevant to the review question [ 62 ] were rated satisfactory. Quality appraisal of the included studies can be seen in Additional file 3 .

Study characteristics

Over half of the included studies were conducted in the UK ( n  = 11), two in Belgium and the remaining studies in Australia, Canada, Taiwan, Denmark, Sweden, Italy, and Norway. The papers were published between 1999 and 2019 and were predominantly qualitative in design ( n  = 18). Semi-structured interviews were the most common data collection method ( n  = 15); four studies utilised focus groups [ 61 , 63 , 64 , 65 ]; and one used in-depth interviews [ 60 ]. Three studies used unstructured observation in addition to semi-structured interviews [ 66 , 67 , 68 ]. One study surveyed participants before conducting the qualitative interviews [ 69 ], and one described using a mixed-methods approach [ 65 ] comprising of focus groups and a quantitative analysis technique (i.e., inductive content analysis). Their findings, however, included several illustrative quotes that were deemed relevant to the review question.

Over half of the studies gathered data from adult psychiatric/forensic inpatient settings. ( n  = 12). Other settings included adult community mental health teams ( n  = 4) or both inpatient and community mental health settings ( n  = 4).

The included studies focused on a range of risk issues including suicidality ( n  = 7); risk to others [ 16 ]; self-neglect [ 70 ] and violence [ 64 ]. Two of the studies explored safety and risk within the broader topic of care-planning [ 20 , 62 ]. Other studies explored specific RM practices [ 61 , 65 , 68 , 71 ]; the tension between promoting recovery and managing risk [ 66 , 72 ]; and risk-minimisation and risk-taking [ 73 ]. One study examined clinicians’ perspectives of supporting service users who wished to discontinue from medication, which is a form of risk-taking [ 60 ]. Several of the included studies [ 16 , 20 , 66 , 71 , 74 ] had multiple publications from the same study [ 42 , 75 , 76 , 77 , 78 , 79 , 80 ]. The characteristics of the included studies are summarised in Table  2 .

Coder reliability and sensitivity analysis

Interrater agreement between the two coders across the three SDM components and 14 TDF domains ranged from 83.1 to 100%. For the sensitivity analysis, removing all the studies that gained an overall ‘satisfactory’ rating [ 60 , 61 , 62 , 63 , 64 , 67 , 68 , 69 , 70 , 73 , 74 ] resulted in one domain (knowledge) no longer being relevant. The same salient TDF domains were identified, with the addition of ‘beliefs about consequences’ and ‘emotions’. The findings of the sensitivity analysis demonstrated that the exclusion of these studies would have had a small impact on the overall findings.

The following section begins by summarising study findings relating to the components of SDM. Then, the key barriers and enablers within each of the TDF domains and COM-B components are summarised.

SDM components

None of the included studies directly referred to the term SDM in RA and RM with individuals with mental illness. However, all studies reported on at least one component of the ‘Three Is of Influence’ SDM model [ 2 ].

The ‘informed’ component was identified in several of the included studies. Professionals spoke openly about not discussing risk with service users; that RA was undertaken without the service user’s knowledge; and that the content of the RA was not always shared with the individual [ 16 , 20 , 62 , 63 , 66 , 81 ]. Conversely, in describing RM practices, professionals emphasised the importance of providing information to service users during observation and mechanical restraint [ 61 , 71 , 82 ]. In a study about forensic mental health services, professionals believed that keeping the service user informed and prepared before meetings, as well as discussing risk factors contributed to forming a trusting relationship [ 64 ].

In other studies, professionals acknowledged that they do not generally involve service users in the RA process [ 16 , 20 , 63 , 64 ], some reported involving service users for obligatory, and information gathering purposes [ 20 , 67 , 70 , 82 ]. Others believed it was important to involve and collaborate with service users in RM planning [ 64 , 65 , 83 ] for reasons discussed later.

The ‘influence’ component was also mapped to findings within this review. Some professionals described the need to make decisions on behalf of the service user [ 66 , 70 , 72 , 83 ], thus inhibiting the service user’s influence in the RA and RM process. Other professionals valued collaborating with service users and supporting their choice in decisions that involved risk [ 60 , 64 ]. Positive risk-taking was encouraged to support service users’ influence in decision-making [ 66 , 71 , 72 , 73 ].

Barriers and enablers

Through the use of the TDF [ 52 ], potential barriers and enablers to the SDM components in RA and RM were identified. Barriers and enablers ranged across twelve domains: knowledge, skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; reinforcement; intentions; goals; memory, attention and decision processes; environmental context and resources; social influences; and emotions . Relevant domains, and the how they relate to barriers and enablers are presented in Table  3 .

TDF domains (and the themes within) were then mapped to COM-B components and sub-components (Fig.  2 ). Based on a frequency count of studies by domain (Table 3 ), the most relevant domains were: social influences ( n  = 18); social/professional role and identity ( n  = 16); reinforcement ( n  = 14); goal ( n  = 13); environmental context and resources ( n  = 12) and beliefs about capabilities ( n  = 11). The key barriers were ‘power and best interest’ ( n  = 11) and ‘my professional role and responsibility’ ( n  = 12). The key enablers were ‘therapeutic relationship’ ( n  = 12), and ‘value collaboration’ ( n  = 11). The key barriers and enablers linked with TDF domains: ‘social influences’, ‘social/professional role and identity’ and ‘reinforcement’. The salient TDF domains (and barriers and enablers within) matched COM-B components: ‘opportunity’ and ‘motivation’.

TDF domains mapped to COM-B components and sub-components

Below, is a summary of the review findings of the barriers and enablers matched to TDF domain and COM-B component. Both first-order (direct quotations) and second-order (authors interpretation) themes are presented using illustrative quotations. Direct quotes have been presented in italics.

Professionals referred to policy and legislation in guiding them in supporting service users’ influence in decision-making or risk-taking [ 73 ]. In a study about service users who wish to discontinue taking neuroleptic medication [ 60 ], professionals working in early intervention services demonstrated openness towards supporting discontinuation and said that this was guided by their understanding of the National Institute for Health and Care Excellence (NICE) guidelines and research:

“The evidence we have is that it is worth giving most people a trial off the medication in order to see if their illness would be a relapsing recurring one” [ 60 ] p244)

Memory, attention and decision processes

Professionals’ implementation behaviours may have been influenced by the type of risk identified. In Langan [ 16 ], professionals believed that service users were less involved in a discussion about risk to others than risk to self:

“I think risk to other people tends to be thought of as being...You know, look at it historically and see what has happened before. Whereas, risk of suicide, although that’s important as well, tends to be more on how the patient feels, in terms of harming themselves, at that time. So, probably, risk to self is more centred on the patient” [ 16 ] p476)

In other studies, individual factors were key in determining service users’ readiness to be released from mechanical restraint [ 61 ]; and if risk-taking could be supported [ 60 , 73 ].

Some professionals attributed their reluctance to discussing suicide with service users to lack of formal training [ 69 , 74 , 81 , 83 ] . Limited training was also considered a barrier to engaging service users in RM:

“I have never done any training on this topic. I know that I may change my attitude towards the patients, but I don’t know how to do it” [ 65 ] p7)

Some professionals’ believed that additional training in risk would enhance their practice in caring for suicidal service users [ 69 ]. In a study about risk to others [ 16 ], a psychiatrist explained how training in RA and RM enabled him to discuss risk openly with a service user:

Professionals described adapting the language of risk to aid them in communicating with service users. In Langan and Lindow [ 42 ], professionals questioned the helpfulness in using the term risk: “I mean, I don’t like to use terms like ‘risk’ in that sense, but I mean I think he does accept that there are concerns about his behaviour” [ 42 ] p16). Instead, they reported using terms such as “early warning signs” or “relapse indicators” to facilitate discussion about risk with service users.

In a study about suicidal ideation, nurses reported adapting their communication to align with the service user’s communication preferences [ 82 ]:

“I ask patients how they feel about it when I talk to them about suicidality and how they prefer to have these interactions” [ 82 ] p2870)

Professionals also reported adapting their communication style with individuals who wished to discontinue taking neuroleptic medication [ 60 ]. The communication style that they adopted, i.e. collaborative or coercive, was based on their judgement of the risk factors and perceived outcome. Other professionals were reported to have used euphemistic language to avoid open dialogue about suicide with service users, : “oh, well, you know, if you’re not feeling right” [ 81 ] p105)).

Opportunity

Social influences.

The tension between managing risk and promoting recovery resulted in professionals experiencing role conflict [ 20 , 64 , 72 , 73 , 74 , 83 ]. Findings indicate that RM practices influence other aspects of care including therapeutic relationships, decision-making, and recovery [ 64 , 65 , 72 , 74 , 78 ]. In a study about continuous observation [ 71 , 77 ], a professional explained that while developing a therapeutic relationship with the service user was important, the utmost priority was maintaining safety:

“Every encounter with a patient should be made therapeutic … but it isn’t the primary purpose. The primary purpose is safety. I think the policy makes it very clear that safety trumps everything else” [ 77 ] p553)

Findings suggest that the pressure of managing risk could lead to power imbalances that inhibit service users’ involvement or influence in the decision-making process:

‘ … risk dominated the decision-making of professionals to such an extent that it defined how service users were understood and treated with limited evidence of power-sharing and involvement of service users in decisions’ [ 66 ] p1142).

Some professionals reported using coercion [ 68 ] to maintain the service users safety:

“If we indicate to patients that we are going to the seclusion room, then few patients say they’d “rather not”. But even when they say they’d “rather not”, we do it anyway, and then we emphasise, “Look, we want to protect you against your thoughts” [ 83 ] p1129)

Decisions about risk are sometimes made by professionals in what they believe to be the service user’s best interest [ 16 , 20 , 60 , 65 , 66 , 70 , 71 , 72 , 74 ]:

“Of course it can get difficult if the service user says no, “I want, I want to do it my way now,“ Um, and then you have to have a very different conversation and you need to say that we feel collectively as a team that at this stage it’s still a risk” [ 72 ] p4)

Factors relating directly to the service user, such as insight or mental capacity impede on the SDM components in RA and RM [ 42 , 60 , 61 , 65 , 70 , 71 , 72 , 73 , 83 ]:

“We can share the responsibility with the patient only when he has totally understood and accepted what is happening to himself, otherwise it is very difficult … ” [ 65 ] p7)

A risk-averse team culture was highlighted as a barrier to positive risk-taking [ 72 , 73 ] and the sharing of risk information with service users:

“To my shame, there are cases that I follow that culture, that I hide that risk assessment or secret. Why? Because I want to protect the individual from the knowledge of that.., their illness that they have can be a risk to themselves or to the others. It’s a practice that I’m not very comfortable but nevertheless, I raise my hand and say I have” [ 20 ] p6)

Some professionals’ reluctance to talk openly about suicide or trauma was reinforced in team culture [ 81 , 83 ]. In a study about service users who wished to discontinue from neuroleptic medication, professionals spoke about the change in service culture [ 60 ]. With the ‘old’ culture described as less acceptant of discontinuation and service users influence in the decision-making process.

Developing a therapeutic relationship and trust enabled professionals to facilitate discussion about risk with service users [ 16 , 69 , 82 ], as well to collaborate in RM [ 71 ] and gather information for RA purposes [ 67 ]:

“Rapport is key . .. it means I can get the information I need and that they’re more likely to actually tell me whether they’re still suicidal or not, and then from there we can work out what they need together” [ 69 ] p310)

Others felt that knowing the service user enabled them to support positive risk-taking:

“If you’re beginning to know a bit more about who they are, you might feel able to take greater therapeutic risks, in the hope of encouraging them to take responsibility” [ 71 ] p478)

A good therapeutic relationship was reported to be beneficial in challenging situation, for example, communicating negative decisions to service users [ 64 ]. Therapeutic trust and alliance were also viewed as critical strategies in engaging service users in RM [ 61 , 65 ].

Conversely, where the quality of the therapeutic relationship was less than ideal, it was considered a barrier to involving service users in RA and RM. Staff acknowledged that they were more likely to err on the side of caution with RM with service users that were less well known [ 71 ]. In other studies, professionals recognised that the therapeutic relationship may be better with one professional compared to another and that this could impact on the service user’s openness about risk and engagement in RM [ 61 , 77 ]. Authors concluded that professionals lack of interaction with service users and distance from their subjective experience suggest a relational distance [ 66 ]. In a study about the risk to others, professional’s tentativeness in language, for example, “I try to discuss risk with him” , was attributed to the quality of therapeutic relationship [ 42 ].

Supervision was considered essential and beneficial to support discussing risk, such as suicidality, with service users [ 69 , 81 , 83 ]; and perceived as an enabler to engaging service users in RM [ 71 , 77 ]:

Environmental context and resources

Professionals reported that they did not have the time or opportunity to get to know or directly relate to service users [ 65 , 66 , 71 ]. High caseloads, staff shortages, lack of training and resources were highlighted as factors that impede practice [ 63 , 66 , 69 ]. For example, in Forsberg, Tai [ 60 ], the pressure of increased caseloads, administration and service targets were reported as barriers to supporting service users to discontinue from medication. In a study about suicidal ideation, a nurse reported:

“Sometimes I spend more time reporting than being present with the person. That is a shame! I sometimes wonder what is most important, “What I write down or what I really do with that person?”. Of course, I believe it is important that you write down things in case something happens, but I also believe that there are too many administrative tasks” [ 83 ] p1130)

In Felton, Repper [ 66 ], professionals recognised that most of their time was spent in an office and that this caused a spatial distance between themselves and service users. Professionals were critical of organisational requirements to persistently document risks [ 82 ] and the amount of screening and assessments they needed to do for service users at risk of suicide. Instead, they questioned the value of these tasks as they believed it limited their time to meaningfully engage with service users.

Findings indicate that the setting or meeting structure used to discuss and make decisions about risk may impede on the service user’s involvement or influence in the process [ 62 , 66 ].

“Formal ward round-based review meetings were named as a place for risks to be discussed although not necessarily in the presence of service users” [ 62 ] p12).

Nurses reported the difficulty in communicating risk with service users when they were not invited to the RA meeting or not directly involved in developing the RA [ 64 ], and they believed that this hindered their ability to promote the service users participation in decisions. Professionals also highlighted that if the environment or setting was inappropriate, for example unsafe, noisy and distracting, this could impact on the service users’ involvement in RM [ 65 , 77 ].

Local policies and procedures were considered an aid to communication about risk with service users. In Langan [ 16 ], a voluntary sector organisation reported that their local policies encourage openness between professionals and service users about risk. Specifically, it was a requirement for professionals to complete RA forms jointly with service users, or the voluntary organisation operated an open access policy where individuals could freely access any information about their risks.

Social/professional role and identity

Findings indicate that professionals retain responsibility for managing risk [ 16 , 20 , 63 , 65 , 66 , 70 , 71 , 72 , 74 ], which may be influencing the service users involvement in the RA and RM process.

Findings mapped to this domain were associated with data within the ‘social influences’ domain, for example, professionals making decisions in the best interest of the service user or conforming to their teams’ risk averse culture. In Holley, Chambers [ 72 ], professionals described making decisions on behalf of service users by drawing on their professional knowledge and expertise for managing risk.

In many of the included studies, decision-making regarding risk was described as a team responsibility with little mention of the service user’s input [ 66 , 67 , 70 , 72 ]. In a study about service users who self-neglect, the author concluded that:

“it was not clear how often the teams made decisions based on what they thought was appropriate for the client, rather than on the client’s personal and informed choice” [ 70 ].

Professionals’ responsibility for reducing risk of harm to the individual and others conflicted with their intention to work collaboratively with the service user:

“You know they [meaning colleagues] have a duty to protect the populous from risk. Sometimes that may not chime with the personal interest of the patient ...” [ 60 ] p243)

Findings indicate that therapeutic engagement with individuals at risk of suicide was not always prioritised by nurses or realised by other MHP’s as part of their role [ 69 , 81 ]. For some, facilitating discussion about suicidality or trauma was considered the responsibility of the psychologist or psychiatrist [ 81 , 83 ] . For others, the service user was responsible for initiating discussion about suicidality:

“Basically, it’s down to them to tell us … we’ve no other way really unless they already told their relative so they’re gonna have to be speaking about it” [ 81 ] p105)

Beliefs about capabilities

Conversations with service users about risk and therapeutic risk-taking were described as difficult [ 16 , 66 , 81 ]. Some professionals lacked confidence in approaching the topic of ‘risk to others’ with service users [ 16 ], whereas others expressed a lack of confidence about how to talk with service users about suicide [ 81 ]. Professionals highlighted the need for more training on suicidality in their education:

‘ … although all participants are specialized in mental health nursing, one of them stated that she does not feel educated or confident enough to talk with patients about suicide, and another informant stated that there should be much more focus on caring for suicidal persons in the education’ [ 80 ] p33).

They acknowledged that risk information might not be shared with service users because of potential disagreements [ 20 ]. In a study about the risk to others, reaching a mutual agreement with an individual who disagreed with their identified risks was described as challenging:

“Very difficult. Very difficult. He’ll deny many of the incidents that I’ve told you about. He’ll say that the police are wrong, that they were harassing him. That he didn’t do these things. That he’s not a risk to other people …. So it’s very, very difficult, yeah, to find any middle ground there really” [ 42 ] p18)

When the service user and professional had conflicting viewpoints about discontinuation from medication, this impeded on the service user’s influence in the process [ 60 ]. The professional, instead, attempted to increase the service user’s agreement with their perspective.

On the other hand, the level of agreement about risk was highlighted as an enabler to involving service users in RM:

“Obviously, if they can acknowledge that there is a problem then we’re in a much better position to ensure that they put something in place which works” [ 42 ] p17)

Beliefs about consequences

Professionals expressed a range of views about the potential consequences of involving service users in the RA and RM process. Many were concerned that discussing risk with a service user or involving them in RM would cause the individual distress or harm [ 16 , 20 , 81 , 82 ]:

“Sometimes we avoid involving patients in order to preserve his saneness. In the psychiatric field is difficult to evaluate how much information the patient may tolerate” [ 65 ] p7)

Some professionals believed that discussing risk with others could be damaging to their therapeutic relationship with the service user and lead to disengagement [ 16 ] . Others were worried that involving service users in RA would reinforce stigma:

“the stigma of the mental health is still very prevalent in our society so by doing a risk assessment you more or less emphasise that stigma. .. You are a very risky person, you’re dangerous to yourself, and you’re dangerous to society, whereas this doesn’t go well with the recovery that we try to achieve for that person” [ 20 ] p8)

Professionals also feared negative consequences for themselves by discussing risk with service users. In Awenat, Peters [ 81 ], following a suicide, professionals were worried about being blamed for negligence. This resulted in them recording detailed information to clear themselves of blame should a suicide occur, as well as cautious discussions with service users in case they disclosed suicidal ideation. Similarly, in other studies, professionals highlighted the need to document decisions accurately and follow protocol to protect themselves from blame should their decision be questioned [ 74 , 83 ]. Professionals who encouraged risk-taking [ 73 ] or supported a service user’s wish to discontinue from medication [ 60 ] were also fearful of being blamed if negative outcomes occurred as a result of their decision.

“Risk-taking and promoting an individual’s freedom is encouraged but you’re conscious of the fact that if someone gets hurt, it’s not just them. .. criticism will be levelled at each level within the authority” [ 73 ] p180)

In other studies, fear of being blamed influenced the decision-making process and resulted in professionals adopting defensive or restrictive approaches [ 71 , 83 ].

Professionals’ concern for their personal safety acted as a barrier to both discussing ‘risk to others’ with service users [ 16 ] and involving service users in RM [ 65 ].

Some professionals were resigned to their current practice of not involving service users in the RA and RM process [ 20 ]. Others were willing to move towards involving service user more in the process:

“I’m quite open to change and including the person more in it, rather than it just being professionals talking about the risks” [ 16 ] p477)

Nonetheless, professionals’ aspirations for greater service user involvement in RA and RM did not necessarily reflect practice [ 72 ]:

‘Whilst everyone considered openness a good idea in principle, practice had not always caught up with aspirations’ [ 16 ].

The extent to which professionals consider the SDM components important in the RA and RM process influenced their implementation behaviour. For example, involving service users in RA and RM was not considered a priority for some professionals:

‘… they had given little consideration to how they could directly and actively involve clients in the assessment and management of risk’ [ 63 ] p810).

For others, interpersonal engagement with service users at risk of suicide was not prioritised [ 69 ] and discussion about suicidal ideation was considered counterproductive [ 68 ]. Obligatory reasons for involving service users in RA and RM practices, i.e. for assessment and information gathering purposes, were provided by professionals in several studies [ 20 , 61 , 63 , 65 , 67 , 70 , 74 , 82 , 83 ]:

“In order to take care of these suicidal patients, I try to build a trusting relationship with them. If I can build a good trusting relationship with them, they will trust me. They will give me the information I need and then we can explore their problems and try to help them to prevent future suicide attempts” [ 67 ] p687)

Forming agreements with service users (or a shared-decision) was considered an important step in the RM process [ 61 , 82 , 83 ]. In several studies, professionals emphasised the importance in openly communicating about risk, as well as providing the service user with knowledge and information about their risk [ 16 , 65 , 71 , 83 ]:

‘These nurses avoid imposing instant protection and instead engage in dialogue with patients that facilitates understanding of risks and potentially risky situations (e.g. taking a bath), the meaning that patients attach to risks and potentially risky situations, and what can be done to address risks’ [ 83 ] p1126).

Professionals acknowledged that RM was more likely to be helpful or effective if the service user was involved in the RA process [ 16 , 61 , 65 , 67 , 69 , 71 , 82 , 83 ]:

“I think it’s more of a risk if it’s other people talking about them behind their back. I think the more that things can be out in the open, the less of a risk it is” [ 42 ] p14)

Reinforcement

Professionals emphasised the importance in communicating to service users about their risk [ 72 ], as well as encouraging service users to talk about their distress or suicidality [ 81 , 82 , 83 ].

“The opportunity to interact is the ultimate. .. it’s a really important interaction.. . It can be the difference between life and death” [ 69 ] p309)

Some believed that RM was more likely helpful if service users were involved in decision-making [ 71 ]. Others valued supporting choice and collaboration, and this guided their interaction with service users who wished to discontinue from medication [ 60 ]. Positive risk-taking encouraged some professionals to support the service user’s choice or influence [ 61 , 62 , 71 , 72 , 73 ].

Professionals were motivated to support service users’ influence and positive risk-taking as this favoured autonomy, empowerment, and recovery [ 65 , 66 , 72 , 73 , 82 ]:

“if it is her wish to look after her finances then actually she is entitled and that needs to be explored very slowly with her [. . .] You can give her advice whether it’s a good decision or a bad decision but it’s her decision to take control of it” [ 72 ] p3)

Professionals stressed the importance in demonstrating empathy, compassion and instilling hope [ 67 , 69 , 77 , 82 , 83 ]. They believed that empathy supported service user to work through their distress and talk about suicidal feelings:

“I feel it’s important to feel and show empathy. If you don’t have empathy, you have no way of realising the patients’ torment and discomfort, or how serious or how strongly they feel about attempting suicide” [ 67 ] p687)

Professionals expressed negative emotions that impact on the assessment and management of risk with individuals with mental illness. In Barnicot, Insua-Summerhayes [ 71 ], anxiety in preventing harm and about being blamed may have influenced decision-making around continuous observation and led to restrictive practices. The possibility of a negative outcome from supporting a service user to discontinue from medication triggered anxiety in professionals [ 60 ]. While approaching the issue of risk created anxiety for some professionals [ 20 , 66 , 80 ], others expressed fear in approaching sensitive topics such as risk to others [ 16 ] or suicidal risk [ 69 , 80 , 81 ]. For example, a professional described their concern about possibly being the last person to have spoken to someone who takes their own life:

“I think it’s scary because you don’t want to be the last person having that conversation and they do something. You don’t want to think you’ve done anything that could have erm, actually aggravated them or tipped them over the edge or you’ve said something that has made them think about something” [ 81 ] p106)

The findings of this review indicate that SDM is not a term commonly used in mental health services when exploring processes of RA and RM. The components of SDM (i.e. informed, involved and influential) are referred to but are not being implemented consistently in the RA and RM process. MHPs spoke openly about not discussing risk with service users, involving service users in the process, or supporting their influence in decision-making about risk. This is in line with studies of service user accounts of RA and RM [ 20 , 38 , 42 ], where it was found that service users were often unaware of the RA and RM plan.

Through the use of the TDF [ 52 ], this systematic review has provided a comprehensive understanding of the perceived barriers and enablers to the SDM components in RA and RM from the literature. The salient COM-B components (and linked TDF domains) identified from the findings of this review were social and physical opportunity (i.e. ‘social influences’ and ‘environmental context and resources’), which refer to the social, cultural, and environmental influences on behaviour; and reflective and automatic motivation (i.e. ‘social/professional role and identity’, ‘beliefs about capabilities’, ‘goals’ and ‘reinforcement’), which characterise the cognitive processes that drive behaviour.

Mental health policy at an international level recommends that the processes of RA and RM are collaborative, person-centered and based on SDM [ 28 , 33 , 84 ]; however, there were many factors identified in this review that potentially impede on practice.

Managing risk and delivering recovery-orientated care were experienced as competing priorities that led to practice dilemma. The tension was believed to arise from organisational expectations, legal responsibilities, and contradictory frameworks of practice. Policy guidelines emphasise protection, harm minimisation, public safety, and duty of care. At the same time, they recommend recovery-orientated care based upon the components of SDM, positive risk-taking, therapeutic relationships, and empowerment. Our findings show professionals acknowledged the primacy of RM and the impact this had on other aspects of care including therapeutic relationships, and positive risk-taking. Boardman and Roberts [ 37 ] argue that it is possible to strike a balance between managing risk and delivering recovery-orientated care. They propose shifting towards a ‘person-centred’ approach to assessing and managing risk, based on SDM and collaborative safety planning.

Reluctance to talk about suicidality with service users or to support positive risk-taking were believed to be reinforced in a risk-averse team culture. Simpson [ 85 ] reported similar findings and highlighted the need for a ‘safe’ environment for professionals to openly discuss and disclose uncertainties, challenges, and alternative treatment options within the team. In addition, the findings of this review suggest that professionals tried to make decisions about risk with the service users’ best interests in mind, but at times this was the professionals’ interpretation of best interests and not necessarily the service users’. This is problematic as a capacitous service user is the expert on their own best interests, and even when not capacitous their wishes and views ought to be taken into account. Factors relating directly to the service user, such as capacity and insight, were considered barriers to discussing risk and collaborating with the service user in RM planning, thus impeding best interest decisions. It has been argued that paternalistic approaches to decision-making can cause practice conflicts between the ethical principles of autonomy on the one hand, and beneficence and non-maleficence on the other [ 86 ]. In mental health care, decision-making can be justified in terms of respecting the service user’s choice (autonomy), the professional’s duty to promote good (beneficence) or to prevent harm (non-maleficence) [ 86 ]. Paternalistic approaches may conflict with the autonomy of a non-capacitous service user, when decisions are made based on the professional’s interpretation of the best interests of the service user [ 87 ]. Experiencing a mental health crisis can lead to diminished capacity and competency to make a decision and in these circumstances, paternalistic interventions have been justified on the basis of the requirements of beneficence or non-maleficence [ 88 ]. Breeze [ 87 ] argues that the assessment of rationality or competency has the potential to be subjective and value-laden and although paternalism maybe justified in some situations, it should be exercised with caution. For example, where there is a disagreement between the professional and service user about what is considered ‘best interest’, it should not be assumed that the service user’s view is irrational or wrong, indeed S. 1 [ 4 ] Mental Capacity Act (2005) states that ‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision’ [ 89 ].

Developing a therapeutic relationship and gaining trust enabled professionals to engage service users in a discussion about suicidality, as well as promote positive risk-taking and collaboration in RM. A recent review of service users’ perspectives of helpful RM practices [ 43 ] found that interpersonal relationship and communication aided RM to be inclusive for service users, and trust was considered to nurture open discussion about risk. In a study about risk-taking and recovery [ 90 ], service users also reported that therapeutic relationships developed trust, and this led to more collaborative discussion and decision-making.

Study findings suggest that professionals may be retaining responsibility for assessing and managing risk and thus limiting the extent to which service users are genuinely informed, involved or influential in the process. Negative beliefs about consequences inhibited professionals from implementing SDM in RA and RM. On the one hand, professionals were concerned that discussing risk could cause the service user distress, to disengage from services or to feel stigmatised. On the other hand, professionals were fearful of being blamed or investigated for negative outcomes from supporting risk-taking, i.e. service user who wished to discontinue taking medication, or discussing suicidality. Fear of blame led professionals to accurately document decision-making to protect themselves should their decision later be questioned, as well as cautious discussion with service users about suicidal thoughts. A culture of blame and risk aversion continues to pervade mental health services [ 91 ] that is said to derive from bureaucratic management styles, perception of failure, political pressures and media influences [ 17 , 92 ]. In a qualitative study, professionals expressed concern about restrictive practices potentially being eliminated as they felt that this would make it difficult to maintain safety [ 93 ], they were also concerned about being blamed when a negative event occurred.

Beliefs about consequences provoked negative emotions for some professionals who expressed fear and anxiety about preventing harm. Supervision was highlighted as a potential aid in discussing suicidal thoughts with service users. Tragic incidents can occur even after careful decision-making and thus professionals can expect to be accountable for decision-making and its implementation but not outcomes that they have no control over [ 94 ]. For MHPs to move away from paternalism and towards promoting SDM, change needs to occur at an organisational level [ 37 ]. Professionals need to know that they have managerial and institutional support, especially in situations where negative beliefs about consequences occur. It has been suggested that developing therapeutic risk-taking in practice requires organisations to support professionals by creating safe spaces to hold uncertainty, multidisciplinary working, shared responsibility, and supervision [ 88 ]. Institutional fear of things ‘going wrong’ is perhaps not helped by anxieties over the hyperbolic media coverage that can emerge when tragedies do occur [ 95 ]. The media’s negative portrayal of mental illness and misleading association with violence [ 96 , 97 ] may contribute to the continuing stigma of mental illness; the preoccupation with RM in mental health care; and misconstrued perceptions of the actual risk posed towards others by individuals with mental illness. In reality, 11% of all homicide convictions in the UK, during 2007–2017, were patient homicides, i.e. people in contact with mental health services in the 12 months prior to the offence [ 98 ].

A lack of confidence in discussing certain types of risks with service users was reported. For example, professionals expressed concern about approaching the topic of ‘risk to others’, and uncertainty in how to initiate discussions about suicide with service users. In mental health care, it is recognised that RA and RM practices focus on ‘dramatic risks’ that involve harm to self or others [ 37 ], however, these extreme harms relate to a minority of people in contact with mental health services [ 98 ]. Dixon [ 38 ] compared service users’ and professionals’ ratings of risk and found that service users identified more risks in relation to their vulnerability, such as self-neglect and suicide, than professionals did. In contrast, professionals identified more risks than service users in relation to risk of harm to others. A collaborative safety planning approach would broaden the focus on risk to include the service users perspectives and consideration of everyday risks that are common but less considered in the assessment and management of risk [ 37 ]. Changing the language of risk and basing discussions on safety-concerns offer an alternative way of involving service users’ in managing their own safety and opens discussion about risk [ 99 ].

In the current review, professionals questioned their ability to resolve disagreements with service users about risk to others. Consequently, conversations about risk with service users were described as difficult. A systematic review of services users’ perceptions of RM found that people’s desire for honesty and collaboration was fulfilled when they felt listened to, despite disagreements. Furthermore, some services users recognised disagreements as an authentic part of therapeutic relationships [ 43 ].

As found in the broader recovery-focused care-planning and coordination literature [ 75 ], high caseloads, staff shortages and a lack of resource were highlighted as factors that impede on practice. Professionals reported limited time or opportunity to support positive risk-taking or to meaningfully engage with service users. Also, insufficient training on RA and RM negatively impacted on professionals’ ability to talk openly about risk. In one of the included studies, a professional who had received RA training reported that it enabled him to face his fear in discussing risk openly with an individual who had previously damaged his office [ 16 ]. Higgins, Doyle [ 24 ] research findings indicate the need for training to enable professionals to adopt a collaborative RA and safety planning approach. They propose training delivered at undergraduate and postgraduate level that includes the skills necessary to engage service users and carers in the RA and safety planning process [ 24 ].

Professionals’ behaviours were guided by their perceived outcomes of implementing the SDM components in RA and RM. For some professionals, involving service users in RA and RM was not always a priority. Others, however, were motivated to involve service users for obligatory reasons, as well as to provide the service users with knowledge and understanding of risks and to collaborate in reducing risks. Similar to the findings of Kaminskiy, Senner [ 12 ] qualitative synthesis, this review found support from MHPs for the idea of implementing SDM or working in collaboration with service users. Professionals’ emphasised the importance in communicating risk with service users, promoting empowerment and demonstrating empathy. Some described adjusting their language to facilitate discussions about risk, while others expressed aspiration towards involving service users in future RA and RM practices, though it was recognised that aspiration may have not yet influenced practice.

Strengths and limitations

This is the first systematic review of evidence reporting MHPs’ experiences and attitudes towards SDM in RA and RM, which uses both the TDF and COM-B model to synthesise findings. The synthesis was informed by several psychological theories of behaviour change and empirical findings of included studies. However, this review is not without limitation. First, the review focused on MHPs’ experiences of SDM in RA and RM: thus, the service users’ perspective was not examined, however, a recent mixed-studies systematic review explored helpful RM practices from the service users’ viewpoint [ 43 ]. Secondly, despite conducting systematic searches, SDM is not a well-indexed term, and researchers have varying interpretations of the concept: therefore, our search strategy may have inadvertently missed relevant studies. To capture relevant studies in our searches, we used MeSH terms for SDM and included additional free text key terms related to the concept of SDM (e.g., service user involvement, patient-centred and recovery). Thirdly, it is important to note that the decision to conduct a qualitative systematic review was derived from the findings of a scoping search, which indicated that qualitative methods dominated this field of research. A quantitative survey study [ 24 ] was identified, however, but excluded on the review’s eligibility criteria. Although the key focus of Higgins, Doyle [ 24 ] study was to explore mental health nurses’ practices and confidence in RA and safety planning, there was a small amount of data relevant to the findings of this review (i.e. stakeholders’ involvement in the RA and RM process). Lastly, the wide variation in methods employed in qualitative research poses challenges in the assessment of quality and synthesis of findings for the purpose of a review [ 49 , 100 ]. Indeed, the present review included studies that differed significantly in design, data collection, and analysis method. Also, qualitative research is often criticised for lack of generalisability. Therefore, the strength of recommendation that can be made from the evidence included in this review is limited. Future reviews may wish to further develop the themes identified in this review by sourcing data from quantitative work.

The findings of this review indicate that there may be limited SDM in RA and RM with individuals with mental health problems. Langan and Lindow [ 42 ] reported this over 15 years ago, and despite policies endorsing SDM it, largely, is not happening. This review identifies some of the key issues that may be underpinning this lack of action and warrant further intervention and investigation.

Through the use of the TDF and COM-B model, this review explored MHPs’ perceived barriers and enablers to SDM in RA and RM. Key barriers were ‘power and best interest’ and ‘my professional role and responsibility’, whereas key enablers were ‘therapeutic relationship’ and ‘value collaboration’. These barriers, enablers and TDF domains matched COM-B components ‘opportunity’ and ‘motivation’.

The finding from the present study contributes to existing knowledge of SDM by providing insight into MHPs’ perceived barriers and enablers to implementing SDM in RA and RM. Consistent with a qualitative synthesis study that examined attitudes towards SDM in the broader field of mental health [ 12 ], a lack of capacity was identified as a barrier to SDM in RA and RM. Although justified in some situations, mental capacity fluctuates with time and research indicates that most psychiatric in-patients are capable of making key treatment decisions [ 101 ]. There are also methods that can be used to incorporate service users’ views, such as decision aids, advance directives and advocacy. Therefore, diminished capacity alone should not be reason to exclude the service user from the RA and RM process, as the service user may still be able to offer valuable insight into their perspective and experiences with risk that can inform the RM plan. The present study also highlights the importance of the therapeutic relationship in facilitating discussions about risk with service users, which corroborates findings from a previous systematic review of service users’ perspectives of RM [ 43 ]. Therefore, increasing professionals’ opportunity to develop the therapeutic relationship may influence their motivation to implement SDM in RA and RM.

The findings of this review highlight a complex range of social, cultural and environmental factors that together influence SDM in RA and RM. This information will be relevant to policymakers and practitioners and can also be used to develop targeted interventions aimed at changing practice in this challenging area. However, these findings are based on a small number of studies that are heterogeneous in aim and objective. Furthermore, none of the included studies directly investigated SDM in RA and RM with individuals with mental illness. Therefore, further extensive work is needed to better understand how best to implement SDM in RA and RM so that all parties feel comfortable. A qualitative study by the lead author, directly investigating the barriers and enablers to SDM in RA and RM, is currently underway and has been developed from the findings of this review. The benefits of implementing SDM in RA and RM planning is also insufficiently researched. It is important to build an evidence base on the impact, as well as the acceptability and feasibility of a collaborative approach.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Abbreviations

Shared Decision Making

Mental Health Professional

Risk Assessment

Risk Management

Department of Health

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International prospective register of systematic reviews

Sample, Phenomenon of Interest, Design, Evaluation, Research type

Bielefeld Academic Search Engine

Theoretical Domains Framework

Capability, Opportunity, Motivation to Behaviour

United Kingdom

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Acknowledgements

I would like to thank Dr. Afnan Aljaffary, and Dr. Una Foye for their support with appraising the quality of studies within this review.

This research was part of a PhD funded by City, University of London, and East London NHS Foundation Trust. Neither funding body had a role in the design of the study, data collection, analysis, interpretation of data or writing the manuscript.

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Lisa Reynolds

Centre for Health Services Research, School of Health Sciences, City University of London, Northampton Square, London, EC1V 0HB, UK

Nicholas Drey

Health Service and Population Research, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF, UK

Elizabeth Tuudah & Alan Simpson

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NA contributed to the design of study, conducted the searches, screening, quality appraisal, data extraction, analysis, synthesis, drafted and edited the manuscript. AS contributed to the design of the study, supported screening, analysis, synthesis, and revised the manuscript. SB contributed to the design of the study, supported data extraction, screening and revised the manuscript. LR contributed to the design of the study, supported screening, and revised the manuscript. ND advised and revised the manuscript. FB supported title and abstract, and full text screening. ET contributed to the analysis and interpretation of data. All authors have read and approved the final version of the manuscript.

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Ahmed, N., Barlow, S., Reynolds, L. et al. Mental health professionals’ perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review. BMC Psychiatry 21 , 594 (2021). https://doi.org/10.1186/s12888-021-03304-0

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Assessing and managing risk in mental health services

How mental health practitioners can manage risk including self-harm and harm to others.

Best practice in managing risk: the assessment and management of risk to self and others in mental health services

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Organisations, care teams and individual practitioners should review their current practice against the principles in this guidance and consider ways of applying them in daily practice.

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Examination of risk assessment tools developed to evaluate risks in mental health areas: A systematic review

Affiliations.

• 1 Department of Nursing, Psychiatric Nursing, Health School,  Batman University, Batman, Turkey.
• 2 Department of Psychiatric Nursing, Faculty of Health Sciences, Uskudar University, Istanbul, Turkey.
• PMID: 33538023
• DOI: 10.1111/nuf.12557

The purpose of this research was to identify and examine risk assessment tools evaluating at least two risk dimensions to evaluate the risk assessments of patients in mental health areas in a more comprehensive and standard manner. This systematic review was prepared according to the PRISMA guidelines. The databases to be scanned and the keywords to be entered were identified before scanning the literature. The keywords risk assessment, risk management, mental health, psychiatry, risk assessment scales, and risk assessment tools were scanned. The CINAHL, EMBASE, PsycInfo, Medline, APA PsycNET, Science Direct, Pubmed, ProQuest, and Google Scholar databases were searched. All full-text articles published between December 30th, 1970, and January 1st, 2020, were examined. A total of 7385 papers were investigated using the keywords listed above, and 18 studies meeting the inclusion criteria were identified. The tools involved were SPC, FACE, Clinical Risk Management, Threshold Assessment Grid, Risk Assessment for People with Mental Health Problems, Psychogeriatric and Risk Behavior Assessment Scale, Sainsbury Risk Assessment Tool, Risk Assessment Management and Audit Systems, Generic Integrated Risk Assessment for Forensic Environments, FRAME, Brief Risk Assessment, Clinical Assessment of Risks to Self & Others, RIO, The Risk Assessment and Management, Risk Assessment and Management Self-Efficacy Study, Galatean Risk and Safety Tool, Short-Term Assessment of Risk and Treatability, and Psychiatric Risk Assessment Scale.

Keywords: mental health; psychiatry; risk assessment; risk assessment tool.

© 2021 Wiley Periodicals LLC.

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Mental health professionals’ perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

Nafiso ahmed.

1 Centre for Mental Health Research, School of Health Sciences, City University of London, Northampton Square, London, EC1V 0HB UK

Sally Barlow

Lisa reynolds.

2 School of Nursing, Midwifery and Allied Health, Buckinghamshire New University, 106 Oxford Rd, Uxbridge, UB8 1NA UK

Nicholas Drey

3 Centre for Health Services Research, School of Health Sciences, City University of London, Northampton Square, London, EC1V 0HB UK

Fareha Begum

Elizabeth tuudah.

4 Health Service and Population Research, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK

Alan Simpson

5 South London and Maudsley NHS Foundation Trust, Maudsley Hospital, 111 Denmark Hill, London, SE5 8AZ UK

6 Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, James Clerk Maxwell Building, King’s College London, 57 Waterloo Road, London, SE1 8WA UK

Associated Data

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals’ perspectives.

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were ‘power and best interest’ (social influences) and ‘my professional role and responsibility’ (social/professional role and identity). Key enablers were ‘therapeutic relationship’ (social influences) and ‘value collaboration’ (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components ‘opportunity’ and ‘motivation’.

The review highlights the need for further empirical research to better understand current practice and mental health professionals’ experiences and attitudes towards shared decision-making in risk assessment and risk management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-021-03304-0.

In mental health services, Shared Decision Making (SDM) is a means of delivering recovery orientated care through involving individuals in decisions about their care. For a decision to be ‘shared’ it must involve: at least two participants, the sharing of information, and a decision that is made and agreed upon by all parties [ 1 ]. These criteria are reflected in a shared decision model [ 2 ], which proposes that SDM occurs when all participants are informed, involved, and influential in the decision-making process. It is, however, emphasised that the three SDM components are on a sliding scale of influence that is dependent on context, capacity and desire to influence [ 2 ].

In shared decision-making, the aim is to recognise and utilise the unique expertise of healthcare professionals and services users to produce better decisions, and potentially better outcomes. While healthcare professionals may be experts in diagnosis, aetiology, prognosis, treatment options, and outcome probabilities [ 3 ]; service users are experts about the impact of the condition on their lives, their preferences, their personal attitudes towards risks, and often know what works best for them regarding their condition and treatment [ 4 ].

Studies report positive effects of SDM interventions on patient outcomes within different mental health populations. A randomised control trial (RCT) for people with depression reported a positive impact on patient participation in treatment decision-making and patient satisfaction [ 5 ]. Another RCT of an intervention for people with schizophrenia found SDM improved social recovery [ 6 ]. A pilot trial of a SDM intervention with veterans with post-traumatic stress disorder (PTSD) found positive impacts on patients’ receptivity to evidence-based treatment [ 7 ]. In contrast, some studies report no significant effect of SDM on clinical outcomes for people with severe mental illness [ 8 ] and depression [ 9 ], although they acknowledge that further long-term work may be needed to detect an effect.

Shared decision-making is endorsed and advocated in international healthcare policy [ 10 , 11 ]. Research has found that both service users and professionals support SDM. A qualitative research synthesis examining stakeholders’ attitudes towards SDM in mental health reported that service users valued their voice being heard, listened to, and supported to express themselves in encounters with professionals [ 12 ]. Several barriers to SDM were identified from the service user’s perspective, including feelings of perceived inadequacy, fear of being judged and a lack of trust. Barriers to SDM for professionals included: the service user lacking cognitive capacity or insight; where stigma negatively influenced the service user’s attitude towards SDM; and the professional’s own attitudes, motivation, willingness, empathy, and ability to engage and implement SDM. Professionals also highlighted challenges surrounding the competing priorities of their role, mainly them being accountable and responsible for managing risk.

Implementing SDM may pose challenges when there are concerns about the potential risks to self or others [ 13 , 14 ]. In these circumstances, mental health professionals (MHP) may not feel able to engage service users in decisions about their care. Potential barriers cited in the literature include inadequate training in suicide prevention [ 15 ]; fears about negative adverse reaction from individuals who pose a risk to other [ 16 ] and the ‘blame culture’ observed in mental health care [ 17 ], whereby MHPs are increasingly fearful of culpability and litigation. It has been suggested that this has resulted in more defensive or risk-averse practice intended to prevent harm [ 18 , 19 ].

Risk in mental health care is often used to refer to the possibility of an adverse event, outcome or behaviour arising from the unwanted actions of the service user [ 20 , 21 ]: notably risk of harm to self, others, or both, and may include self-harm, suicide, or violence. Risk also signifies the vulnerabilities that a person with mental illness may be exposed to, such as side effects from medication, exploitation, victimisation, bullying, and discrimination [ 22 , 23 ]. These risks occur frequently but are considered less in the assessment and management of risks [ 24 ].

Risk Assessment (RA) and Risk Management (RM) are the mechanisms used by MHPs to identify and minimise risk. There are three main approaches to assessing risk in mental health care: unstructured clinical judgement, actuarial methods and structured clinical judgement [ 25 ]. Unstructured clinical judgement typically involves professionals making judgements based on their clinical experience, opinion, intuition or ‘gut feeling’. Actuarial methods provide the assessor with a statistical means to combine information and calculate risk [ 26 ]. The subjective nature and poor predictive accuracy of these approaches have resulted in recommendations for them not to be used on their own in clinical practice [ 27 ]. Structured clinical judgement is considered the best approach to assessing risk [ 28 ]; this involves the use of a standardised RA tool to aid a professional in their clinical judgement [ 25 ].

Nonetheless, studies have found wide variability in the methods used to assess risk in UK mental health services [ 29 ] and forensic services in Australia and New Zealand [ 30 ]. These studies agree that a more consistent approach to RA is needed in mental health services. A multitude of evidence-based guidance is available to help standardise the process and support professionals in their assessment of risk [ 28 , 31 – 33 ]. A model for assessing suicidality, for example, provides guidance on the importance of language, the structure of the clinical interview, questioning, actuarial tools and risk categorisation [ 31 ].

Risk management is informed by the RA and includes the key actions or strategies that are designed to prevent or limit undesirable outcomes. Strategies may include treatment, supervision (i.e. help with planning daily activities), or monitoring (i.e. identifying and looking out for early warning signs) [ 28 ]. Several RM and safety planning interventions have been developed that can be used to mitigate, contain or improve RM [ 34 – 36 ].

The need to involve service users in the RA and RM process has been advocated in current professional guidance, policy, and research [ 28 , 33 , 37 ]. Involving service users is a means of minimising the gap between professionals and service users’ perspectives of risk [ 38 , 39 ] and thus, ensuring that the plan developed meets the individual’s needs [ 33 ]. This can lead to more accurate prediction and management of risk. Another potential benefit of involvement is that the individual is empowered to take responsibility for their choices, which can be a motivator for change [ 40 ]. It has been suggested that service user involvement can improve confidence and self-management skills, which may have long term impacts on reducing dependency on services, thereby increasing cost-effectiveness [ 37 ].

The UK Department of Health (DH) best practice guideline, specifically recommends SDM. Studies have shown, however, that service users are often unaware that a RA has taken place [ 41 , 42 ].

Although Higgins, Doyle [ 24 ] found that more than three-quarters of MHPs reported ‘always’ involving service users in risk assessment (77.8%) and safety planning (78.4%), only 50% of the respondents reported that they ‘always’ informed service users about their risk level, while only 43% of the respondents reported that they ‘always’ developed a shared responsibility with the service user for safety. Despite professionals reporting a high rate of service user involvement, these findings suggest that SDM is not routinely nor fully implemented.

A recent systematic review of mixed methods studies explored the service users’ perspective of helpful RM practices within mental health services [ 43 ]. Two categories of beneficial RM practices were identified: interpersonal relationships and communication; and agency and autonomy. A key finding was that trust fosters openness in relationships and enables discussion of risks, especially when service users felt that their distress was understood or their accounts were validated by professionals. Service users preferred professionals to maintain responsibility for RM initially but that eventually (at their own pace) they wished to regain control.

Other systematic reviews in this field have focused on interventions that promote SDM in RA and RM in forensic mental health settings [ 36 , 44 ]. A qualitative synthesis of research examining professionals attitudes towards SDM in the broader field of mental health exists [ 12 ], however, the authors acknowledge that the rigour of a full systematic review was not adopted. There is currently no systematic review of MHPs’ experiences and attitudes towards implementing SDM in the assessment and management of risk. A synthesis of studies will improve our understanding of the discrepancies in reported practice and identify factors that may help or hinder its implementation. The specific review question was:

What do mental health professionals perceive as the barriers and enablers to SDM in RA and RM?

This review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 45 ]. The protocol is registered on PROSPERO (CRD42016050457).

Eligibility criteria

The SPIDER framework (sample, phenomenon of interest, design, evaluation, research type) was used to specify eligibility criteria [ 46 ]. An additional S was added to capture the ‘setting’ criterion of adult mental health services. The SPIDER framework is a tool for developing a search strategy that has been designed from the PICO tool, specifically for reviews that aim to synthesise qualitative and mixed-method research studies. Due to limited resources, only studies written in English were included in the review. Table  1 lists the inclusion and exclusion criteria.

Inclusion and exclusion criteria based on SSPIDER

Search strategy

The EBSCOhost and Ovid Online platforms were used to search six electronic bibliographic databases: MEDLINE; EMBASE; PsycINFO; CINAHL; AMED and Internurse. Databases were searched from inception. The last search was completed on the 4th December 2019.

The search strategy used a combination of medical subject headings (MeSH) and free text key terms related to concepts of ‘mental health’, ‘health professionals’, ‘experiences’, ‘shared decision making’, ‘risk assessment’ and ‘risk management’. A full electronic search strategy is presented in Additional file 1 .

Two grey literature databases were also searched for relevant unpublished empirical research studies; Bielefeld Academic Search Engine (BASE) and Open Grey. Citation chaining was performed on all articles selected for inclusion to identify further studies of interest, and this involved searching the reference lists (backward chaining) and using Google Scholar to identify and review papers that had cited the included articles (forward chaining).

Study selection

Search results were imported into a systematic review management software EPPI-reviewer 4 [ 47 ] and duplicates removed. Two-stage screening was undertaken: stage 1 screened the titles and abstracts of studies against the eligibility criteria; stage 2, further assessed full-text of potential studies against the eligibility criteria. Study authors were contacted if more information was needed.

To minimise risk of bias, two authors (NA and FB) independently assessed titles and abstracts, and subsequently, full-text articles. A full-text review was carried out if at least one of the reviewers believed that the study met the inclusion criteria at the title and abstract screening stage. At full-text review, any discrepancies regarding eligibility were resolved by consensus and in consultation with a third author (AS/LR). Also, studies were included only once if they had multiple articles. The original or most relevant to the review question was used as the primary article for the study’s results.

The ‘Three I’s Scale of Influence Model’ [ 2 ] was used as a framework for study selection. Studies that reported on a least one of the three components (informed, involved and influential) of SDM in RA and RM were included. Stacey, Felton [ 2 ] definitions of the SDM components can be found in Additional file 2 .

Data extraction

An electronic data extraction form was devised and piloted on two of the included studies. The following data items were extracted: author(s), publication year, research question/aim, geographical location, sample size, setting, data collection, and method of analysis. The entire results sections, including direct quotations and author interpretations were imported directly into NVivo 11 software [ 48 ]. For studies with multiple publications, results were extracted and collated from all the linked reports but only one publication was used as the source of study results. Data extraction was carried out by the first author (NA) and cross-checked by a second author (SB): disagreements were resolved through discussion.

Quality appraisal

Dixon-Woods, Shaw [ 49 ] prompts were used to assess the quality and relevance of individual studies within this review. These prompts focus on the universal features of qualitative research and have been devised to ‘sensitise appraisers to the various dimensions of articles that require evaluation’ (p224). Two reviewers (NA and AJ or UF – see acknowledgements) read the papers independently and answered a series of questions on the quality appraisal checklist (e.g., Are the research questions clear?). They recorded their response as Yes (Y), No (N), Can’t tell (−). A rating system was then used to categorise the papers: Key paper (meets all quality criteria and clearly fits with review question); Satisfactory (meets most quality criteria and fits well to review question); Unsure (mixed responses to quality criteria and lack of clarity regarding relevance to review question); and Poor (does not meet quality criteria) [ 50 ]. No studies were excluded based on methodological quality; however, a sensitivity analysis (described below) was conducted to see the impact of removing lower-rated studies on the review findings. Any disagreements were discussed in full, and a rating was agreed (Additional file 3 ).

Data synthesis

The Theoretical Domains Framework (TDF) was used to explore the factors that influence the implementation of SDM in RA and RM with individuals with mental illness. The TDF is a behaviour change framework developed by a group of experts to simplify and integrate the large number of psychological theories relevant to behaviour change [ 51 ]. The TDF has been used by researchers across a range of healthcare settings to identify determinants of behaviour, namely the barriers and enablers to implementation, and to inform intervention design [ 52 ]. The original TDF has 12 domains derived from 33 health and social psychology theories and 128 key theoretical constructs. The framework was later validated and refined by Cane, O’Connor [ 52 ] to include 14 theoretical domains. The revised version of the framework was used in this review, Cane et al. (2012) definition of each domain is presented in (Additional file 2 ).

The Capability, Opportunity, and Motivation (COM-B) model was then used to condense the relevant TDF domains into three components that interact to predict behaviour. The model was developed as part of the broader framework of the behaviour change wheel [ 53 ] and provides a basis for intervention design. Each component of the COM-B model is divided into sub-components that capture important distinctions. Capability can be physical (e.g. skills) or psychological (e.g. interpersonal skills and knowledge) and represents an individual’s capacity to carry out the behaviour. Opportunity can be physical (e.g. environmental factors) and social (e.g. social influences) and is defined as all the factors that lie outside the individual that influence the behaviour. Motivation can be reflective (e.g. beliefs, intentions) or automatic (e.g. emotions) and characterises the brain processes that drive behaviour [ 53 ]. The most relevant TDF domains and linked components that are likely important to changing behaviour were identified [ 52 ].

The data synthesis process drew on established analysis methods recommended in the TDF guidelines [ 54 ], and used in previous studies applying the TDF [ 55 – 57 ]. Data synthesis involved the following six stages:

Step 1: developing a coding manual

A coding guide was developed based on the definitions of the three components of SDM [ 2 ], and the 14 domains and 84 constructs from Cane, O’Connor [ 52 ]. To provide guidance and confidence that a piece of text represents a domain, statements of how the domain applies to the research context were also included in the coding guide.

Step 2: pilot coding exercise

To ensure consistency between coders and refine the coding guideline, two coders (NA and ET) jointly coded the extracted findings from two randomly selected included papers. Any disagreements were discussed until consensus was reached; where consensus could not be reached a third researcher was consulted. The final version of the coding guide is included in Additional file 2 .

Step 3: coding papers and assessing reliability

Two researchers (NA and ET) independently coded the extracted findings from the remaining included papers using the coding guideline and via NVivo 11 software [ 48 ]. Findings relating to the target behaviour were coded to the SDM components [ 2 ], whereas potential barriers and enablers identified within the included papers were coded to the 14 domains of the TDF [ 52 ]. For example, the statement ‘“[the risk assessment is] one thing … you never discuss with service users just in case it alarms them”’ was coded to the ‘informed’ component and the ‘beliefs about consequences’ domain. If the participant’s response or the author’s interpretation represented more than one TDF domain, the text was coded to multiple domains. For example, “You know that you’re going to have suicide risk but you think well, the psychologists will deal with that bit … so to want to deal with it, even as part of the overall care, I think you’d want some type of supervision” was coded to both “social professionals’ role and identity” and “social influences”.

Inter-coder reliability was assessed by calculating the percentage agreement/disagreement (prior to consensus being reached), to measure consistency in coding within and across domains [ 58 ]. Reliability between two coders is considered acceptable if percentage agreement > 60% is achieved [ 54 ]. Discrepancies in coding were addressed by NA and ET with a consensus reached by discussion. AS was available to resolve any disputes over discrepancies; however, this was not required.

Step 4: developing overarching themes

Data within the domains were further analysed by the lead researcher (NA) using thematic synthesis [ 59 ]. Text coded into each domain were compared across papers, and findings representing similar ideas were grouped together. An overarching theme was then generated to categorise the initial themes. The overarching themes represent the specific factor perceived to influence SDM in RA and RM. For example, findings that suggest rapport, alliance or connection facilitate discussion about risk with service users were categorised as ‘therapeutic relationship’.

Step 5: mapping the COM-B model to the TDF domains

The relevant TDF domains were matched to the COM-B components [ 53 ]. The lead researcher (NA) drew on the links between the TDF domains and COM-B components identified by a group of experts in a consensus exercise reported in Cane, O’Connor [ 52 ]. The most relevant TDF domains (and themes within) were identified based on a frequency count of studies by domain. The TDF domains (and themes within) identified in at least 60% ( n  = 11) of the included studies were considered salient in understanding the target behaviour.

Step 6: sensitivity analysis

A sensitivity analysis was carried out to determine whether the methodological quality of studies impacted on the findings of the review. The results from the lowest-rated studies were removed from the synthesis to see if this influenced the key themes originally identified. No studies were excluded based on methodological quality.

A total of 8211 papers were yielded in the databases searches; and 1420 additional papers were included from other sources. After the removal of duplicates, a total of 8652 papers were eligible for screening. Following title and abstract screening, 8491 papers were excluded, and 161 full text papers were reviewed; 134 papers were excluded at full-text, and 20 studies (reported in 27 papers) met the inclusion criteria for this review. The PRISMA diagram of study selection can be seen in Fig.  1 .

A PRISMA flow diagram detailing the search strategy and results (Moher et al., 2009) [ 45 ]

All papers gained the rating of either key paper ( n  = 9) or satisfactory ( n  = 11). Papers were rated satisfactory if they did not meet all of the quality criteria and/or did not clearly fit with the review question. For example, papers that reported on specific risk decisions i.e. decision-making regarding neuroleptic medication [ 60 ]; specific RM practices i.e. clinician-patient alliance during mechanical restraint [ 61 ]; or contained very limited findings relevant to the review question [ 62 ] were rated satisfactory. Quality appraisal of the included studies can be seen in Additional file 3 .

Study characteristics

Over half of the included studies were conducted in the UK ( n  = 11), two in Belgium and the remaining studies in Australia, Canada, Taiwan, Denmark, Sweden, Italy, and Norway. The papers were published between 1999 and 2019 and were predominantly qualitative in design ( n  = 18). Semi-structured interviews were the most common data collection method ( n  = 15); four studies utilised focus groups [ 61 , 63 – 65 ]; and one used in-depth interviews [ 60 ]. Three studies used unstructured observation in addition to semi-structured interviews [ 66 – 68 ]. One study surveyed participants before conducting the qualitative interviews [ 69 ], and one described using a mixed-methods approach [ 65 ] comprising of focus groups and a quantitative analysis technique (i.e., inductive content analysis). Their findings, however, included several illustrative quotes that were deemed relevant to the review question.

Over half of the studies gathered data from adult psychiatric/forensic inpatient settings. ( n  = 12). Other settings included adult community mental health teams ( n  = 4) or both inpatient and community mental health settings ( n  = 4).

The included studies focused on a range of risk issues including suicidality ( n  = 7); risk to others [ 16 ]; self-neglect [ 70 ] and violence [ 64 ]. Two of the studies explored safety and risk within the broader topic of care-planning [ 20 , 62 ]. Other studies explored specific RM practices [ 61 , 65 , 68 , 71 ]; the tension between promoting recovery and managing risk [ 66 , 72 ]; and risk-minimisation and risk-taking [ 73 ]. One study examined clinicians’ perspectives of supporting service users who wished to discontinue from medication, which is a form of risk-taking [ 60 ]. Several of the included studies [ 16 , 20 , 66 , 71 , 74 ] had multiple publications from the same study [ 42 , 75 – 80 ]. The characteristics of the included studies are summarised in Table  2 .

Characteristics of included studies

Coder reliability and sensitivity analysis

Interrater agreement between the two coders across the three SDM components and 14 TDF domains ranged from 83.1 to 100%. For the sensitivity analysis, removing all the studies that gained an overall ‘satisfactory’ rating [ 60 – 64 , 67 – 70 , 73 , 74 ] resulted in one domain (knowledge) no longer being relevant. The same salient TDF domains were identified, with the addition of ‘beliefs about consequences’ and ‘emotions’. The findings of the sensitivity analysis demonstrated that the exclusion of these studies would have had a small impact on the overall findings.

The following section begins by summarising study findings relating to the components of SDM. Then, the key barriers and enablers within each of the TDF domains and COM-B components are summarised.

SDM components

None of the included studies directly referred to the term SDM in RA and RM with individuals with mental illness. However, all studies reported on at least one component of the ‘Three Is of Influence’ SDM model [ 2 ].

The ‘informed’ component was identified in several of the included studies. Professionals spoke openly about not discussing risk with service users; that RA was undertaken without the service user’s knowledge; and that the content of the RA was not always shared with the individual [ 16 , 20 , 62 , 63 , 66 , 81 ]. Conversely, in describing RM practices, professionals emphasised the importance of providing information to service users during observation and mechanical restraint [ 61 , 71 , 82 ]. In a study about forensic mental health services, professionals believed that keeping the service user informed and prepared before meetings, as well as discussing risk factors contributed to forming a trusting relationship [ 64 ].

In other studies, professionals acknowledged that they do not generally involve service users in the RA process [ 16 , 20 , 63 , 64 ], some reported involving service users for obligatory, and information gathering purposes [ 20 , 67 , 70 , 82 ]. Others believed it was important to involve and collaborate with service users in RM planning [ 64 , 65 , 83 ] for reasons discussed later.

The ‘influence’ component was also mapped to findings within this review. Some professionals described the need to make decisions on behalf of the service user [ 66 , 70 , 72 , 83 ], thus inhibiting the service user’s influence in the RA and RM process. Other professionals valued collaborating with service users and supporting their choice in decisions that involved risk [ 60 , 64 ]. Positive risk-taking was encouraged to support service users’ influence in decision-making [ 66 , 71 – 73 ].

Barriers and enablers

Through the use of the TDF [ 52 ], potential barriers and enablers to the SDM components in RA and RM were identified. Barriers and enablers ranged across twelve domains: knowledge, skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; reinforcement; intentions; goals; memory, attention and decision processes; environmental context and resources; social influences; and emotions . Relevant domains, and the how they relate to barriers and enablers are presented in Table  3 .

TDF domain mapped to the barriers and enablers

Reference: [ 42 , 75 – 80 ]

TDF domains (and the themes within) were then mapped to COM-B components and sub-components (Fig.  2 ). Based on a frequency count of studies by domain (Table ​ (Table3), 3 ), the most relevant domains were: social influences ( n  = 18); social/professional role and identity ( n  = 16); reinforcement ( n  = 14); goal ( n  = 13); environmental context and resources ( n  = 12) and beliefs about capabilities ( n  = 11). The key barriers were ‘power and best interest’ ( n  = 11) and ‘my professional role and responsibility’ ( n  = 12). The key enablers were ‘therapeutic relationship’ ( n  = 12), and ‘value collaboration’ ( n  = 11). The key barriers and enablers linked with TDF domains: ‘social influences’, ‘social/professional role and identity’ and ‘reinforcement’. The salient TDF domains (and barriers and enablers within) matched COM-B components: ‘opportunity’ and ‘motivation’.

TDF domains mapped to COM-B components and sub-components

Below, is a summary of the review findings of the barriers and enablers matched to TDF domain and COM-B component. Both first-order (direct quotations) and second-order (authors interpretation) themes are presented using illustrative quotations. Direct quotes have been presented in italics.

Professionals referred to policy and legislation in guiding them in supporting service users’ influence in decision-making or risk-taking [ 73 ]. In a study about service users who wish to discontinue taking neuroleptic medication [ 60 ], professionals working in early intervention services demonstrated openness towards supporting discontinuation and said that this was guided by their understanding of the National Institute for Health and Care Excellence (NICE) guidelines and research:

“The evidence we have is that it is worth giving most people a trial off the medication in order to see if their illness would be a relapsing recurring one” [ 60 ] p244)

Memory, attention and decision processes

Professionals’ implementation behaviours may have been influenced by the type of risk identified. In Langan [ 16 ], professionals believed that service users were less involved in a discussion about risk to others than risk to self:

“I think risk to other people tends to be thought of as being...You know, look at it historically and see what has happened before. Whereas, risk of suicide, although that’s important as well, tends to be more on how the patient feels, in terms of harming themselves, at that time. So, probably, risk to self is more centred on the patient” [ 16 ] p476)

In other studies, individual factors were key in determining service users’ readiness to be released from mechanical restraint [ 61 ]; and if risk-taking could be supported [ 60 , 73 ].

Some professionals attributed their reluctance to discussing suicide with service users to lack of formal training [ 69 , 74 , 81 , 83 ] . Limited training was also considered a barrier to engaging service users in RM:

“I have never done any training on this topic. I know that I may change my attitude towards the patients, but I don’t know how to do it” [ 65 ] p7)

Some professionals’ believed that additional training in risk would enhance their practice in caring for suicidal service users [ 69 ]. In a study about risk to others [ 16 ], a psychiatrist explained how training in RA and RM enabled him to discuss risk openly with a service user:

Professionals described adapting the language of risk to aid them in communicating with service users. In Langan and Lindow [ 42 ], professionals questioned the helpfulness in using the term risk: “I mean, I don’t like to use terms like ‘risk’ in that sense, but I mean I think he does accept that there are concerns about his behaviour” [ 42 ] p16). Instead, they reported using terms such as “early warning signs” or “relapse indicators” to facilitate discussion about risk with service users.

In a study about suicidal ideation, nurses reported adapting their communication to align with the service user’s communication preferences [ 82 ]:

“I ask patients how they feel about it when I talk to them about suicidality and how they prefer to have these interactions” [ 82 ] p2870)

Professionals also reported adapting their communication style with individuals who wished to discontinue taking neuroleptic medication [ 60 ]. The communication style that they adopted, i.e. collaborative or coercive, was based on their judgement of the risk factors and perceived outcome. Other professionals were reported to have used euphemistic language to avoid open dialogue about suicide with service users, : “oh, well, you know, if you’re not feeling right” [ 81 ] p105)).

Opportunity

Social influences.

The tension between managing risk and promoting recovery resulted in professionals experiencing role conflict [ 20 , 64 , 72 – 74 , 83 ]. Findings indicate that RM practices influence other aspects of care including therapeutic relationships, decision-making, and recovery [ 64 , 65 , 72 , 74 , 78 ]. In a study about continuous observation [ 71 , 77 ], a professional explained that while developing a therapeutic relationship with the service user was important, the utmost priority was maintaining safety:

“Every encounter with a patient should be made therapeutic … but it isn’t the primary purpose. The primary purpose is safety. I think the policy makes it very clear that safety trumps everything else” [ 77 ] p553)

Findings suggest that the pressure of managing risk could lead to power imbalances that inhibit service users’ involvement or influence in the decision-making process:

‘ … risk dominated the decision-making of professionals to such an extent that it defined how service users were understood and treated with limited evidence of power-sharing and involvement of service users in decisions’ [ 66 ] p1142).

Some professionals reported using coercion [ 68 ] to maintain the service users safety:

“If we indicate to patients that we are going to the seclusion room, then few patients say they’d “rather not”. But even when they say they’d “rather not”, we do it anyway, and then we emphasise, “Look, we want to protect you against your thoughts” [ 83 ] p1129)

Decisions about risk are sometimes made by professionals in what they believe to be the service user’s best interest [ 16 , 20 , 60 , 65 , 66 , 70 – 72 , 74 ]:

“Of course it can get difficult if the service user says no, “I want, I want to do it my way now,“ Um, and then you have to have a very different conversation and you need to say that we feel collectively as a team that at this stage it’s still a risk” [ 72 ] p4)

Factors relating directly to the service user, such as insight or mental capacity impede on the SDM components in RA and RM [ 42 , 60 , 61 , 65 , 70 – 73 , 83 ]:

“We can share the responsibility with the patient only when he has totally understood and accepted what is happening to himself, otherwise it is very difficult … ” [ 65 ] p7)

A risk-averse team culture was highlighted as a barrier to positive risk-taking [ 72 , 73 ] and the sharing of risk information with service users:

“To my shame, there are cases that I follow that culture, that I hide that risk assessment or secret. Why? Because I want to protect the individual from the knowledge of that.., their illness that they have can be a risk to themselves or to the others. It’s a practice that I’m not very comfortable but nevertheless, I raise my hand and say I have” [ 20 ] p6)

Some professionals’ reluctance to talk openly about suicide or trauma was reinforced in team culture [ 81 , 83 ]. In a study about service users who wished to discontinue from neuroleptic medication, professionals spoke about the change in service culture [ 60 ]. With the ‘old’ culture described as less acceptant of discontinuation and service users influence in the decision-making process.

Developing a therapeutic relationship and trust enabled professionals to facilitate discussion about risk with service users [ 16 , 69 , 82 ], as well to collaborate in RM [ 71 ] and gather information for RA purposes [ 67 ]:

“Rapport is key . .. it means I can get the information I need and that they’re more likely to actually tell me whether they’re still suicidal or not, and then from there we can work out what they need together” [ 69 ] p310)

Others felt that knowing the service user enabled them to support positive risk-taking:

“If you’re beginning to know a bit more about who they are, you might feel able to take greater therapeutic risks, in the hope of encouraging them to take responsibility” [ 71 ] p478)

A good therapeutic relationship was reported to be beneficial in challenging situation, for example, communicating negative decisions to service users [ 64 ]. Therapeutic trust and alliance were also viewed as critical strategies in engaging service users in RM [ 61 , 65 ].

Conversely, where the quality of the therapeutic relationship was less than ideal, it was considered a barrier to involving service users in RA and RM. Staff acknowledged that they were more likely to err on the side of caution with RM with service users that were less well known [ 71 ]. In other studies, professionals recognised that the therapeutic relationship may be better with one professional compared to another and that this could impact on the service user’s openness about risk and engagement in RM [ 61 , 77 ]. Authors concluded that professionals lack of interaction with service users and distance from their subjective experience suggest a relational distance [ 66 ]. In a study about the risk to others, professional’s tentativeness in language, for example, “I try to discuss risk with him” , was attributed to the quality of therapeutic relationship [ 42 ].

Supervision was considered essential and beneficial to support discussing risk, such as suicidality, with service users [ 69 , 81 , 83 ]; and perceived as an enabler to engaging service users in RM [ 71 , 77 ]:

Environmental context and resources

Professionals reported that they did not have the time or opportunity to get to know or directly relate to service users [ 65 , 66 , 71 ]. High caseloads, staff shortages, lack of training and resources were highlighted as factors that impede practice [ 63 , 66 , 69 ]. For example, in Forsberg, Tai [ 60 ], the pressure of increased caseloads, administration and service targets were reported as barriers to supporting service users to discontinue from medication. In a study about suicidal ideation, a nurse reported:

“Sometimes I spend more time reporting than being present with the person. That is a shame! I sometimes wonder what is most important, “What I write down or what I really do with that person?”. Of course, I believe it is important that you write down things in case something happens, but I also believe that there are too many administrative tasks” [ 83 ] p1130)

In Felton, Repper [ 66 ], professionals recognised that most of their time was spent in an office and that this caused a spatial distance between themselves and service users. Professionals were critical of organisational requirements to persistently document risks [ 82 ] and the amount of screening and assessments they needed to do for service users at risk of suicide. Instead, they questioned the value of these tasks as they believed it limited their time to meaningfully engage with service users.

Findings indicate that the setting or meeting structure used to discuss and make decisions about risk may impede on the service user’s involvement or influence in the process [ 62 , 66 ].

“Formal ward round-based review meetings were named as a place for risks to be discussed although not necessarily in the presence of service users” [ 62 ] p12).

Nurses reported the difficulty in communicating risk with service users when they were not invited to the RA meeting or not directly involved in developing the RA [ 64 ], and they believed that this hindered their ability to promote the service users participation in decisions. Professionals also highlighted that if the environment or setting was inappropriate, for example unsafe, noisy and distracting, this could impact on the service users’ involvement in RM [ 65 , 77 ].

Local policies and procedures were considered an aid to communication about risk with service users. In Langan [ 16 ], a voluntary sector organisation reported that their local policies encourage openness between professionals and service users about risk. Specifically, it was a requirement for professionals to complete RA forms jointly with service users, or the voluntary organisation operated an open access policy where individuals could freely access any information about their risks.

Social/professional role and identity

Findings indicate that professionals retain responsibility for managing risk [ 16 , 20 , 63 , 65 , 66 , 70 – 72 , 74 ], which may be influencing the service users involvement in the RA and RM process.

Findings mapped to this domain were associated with data within the ‘social influences’ domain, for example, professionals making decisions in the best interest of the service user or conforming to their teams’ risk averse culture. In Holley, Chambers [ 72 ], professionals described making decisions on behalf of service users by drawing on their professional knowledge and expertise for managing risk.

In many of the included studies, decision-making regarding risk was described as a team responsibility with little mention of the service user’s input [ 66 , 67 , 70 , 72 ]. In a study about service users who self-neglect, the author concluded that:

“it was not clear how often the teams made decisions based on what they thought was appropriate for the client, rather than on the client’s personal and informed choice” [ 70 ].

Professionals’ responsibility for reducing risk of harm to the individual and others conflicted with their intention to work collaboratively with the service user:

“You know they [meaning colleagues] have a duty to protect the populous from risk. Sometimes that may not chime with the personal interest of the patient ...” [ 60 ] p243)

Findings indicate that therapeutic engagement with individuals at risk of suicide was not always prioritised by nurses or realised by other MHP’s as part of their role [ 69 , 81 ]. For some, facilitating discussion about suicidality or trauma was considered the responsibility of the psychologist or psychiatrist [ 81 , 83 ] . For others, the service user was responsible for initiating discussion about suicidality:

“Basically, it’s down to them to tell us … we’ve no other way really unless they already told their relative so they’re gonna have to be speaking about it” [ 81 ] p105)

Beliefs about capabilities

Conversations with service users about risk and therapeutic risk-taking were described as difficult [ 16 , 66 , 81 ]. Some professionals lacked confidence in approaching the topic of ‘risk to others’ with service users [ 16 ], whereas others expressed a lack of confidence about how to talk with service users about suicide [ 81 ]. Professionals highlighted the need for more training on suicidality in their education:

‘ … although all participants are specialized in mental health nursing, one of them stated that she does not feel educated or confident enough to talk with patients about suicide, and another informant stated that there should be much more focus on caring for suicidal persons in the education’ [ 80 ] p33).

They acknowledged that risk information might not be shared with service users because of potential disagreements [ 20 ]. In a study about the risk to others, reaching a mutual agreement with an individual who disagreed with their identified risks was described as challenging:

“Very difficult. Very difficult. He’ll deny many of the incidents that I’ve told you about. He’ll say that the police are wrong, that they were harassing him. That he didn’t do these things. That he’s not a risk to other people …. So it’s very, very difficult, yeah, to find any middle ground there really” [ 42 ] p18)

When the service user and professional had conflicting viewpoints about discontinuation from medication, this impeded on the service user’s influence in the process [ 60 ]. The professional, instead, attempted to increase the service user’s agreement with their perspective.

On the other hand, the level of agreement about risk was highlighted as an enabler to involving service users in RM:

“Obviously, if they can acknowledge that there is a problem then we’re in a much better position to ensure that they put something in place which works” [ 42 ] p17)

Beliefs about consequences

Professionals expressed a range of views about the potential consequences of involving service users in the RA and RM process. Many were concerned that discussing risk with a service user or involving them in RM would cause the individual distress or harm [ 16 , 20 , 81 , 82 ]:

“Sometimes we avoid involving patients in order to preserve his saneness. In the psychiatric field is difficult to evaluate how much information the patient may tolerate” [ 65 ] p7)

Some professionals believed that discussing risk with others could be damaging to their therapeutic relationship with the service user and lead to disengagement [ 16 ] . Others were worried that involving service users in RA would reinforce stigma:

“the stigma of the mental health is still very prevalent in our society so by doing a risk assessment you more or less emphasise that stigma. .. You are a very risky person, you’re dangerous to yourself, and you’re dangerous to society, whereas this doesn’t go well with the recovery that we try to achieve for that person” [ 20 ] p8)

Professionals also feared negative consequences for themselves by discussing risk with service users. In Awenat, Peters [ 81 ], following a suicide, professionals were worried about being blamed for negligence. This resulted in them recording detailed information to clear themselves of blame should a suicide occur, as well as cautious discussions with service users in case they disclosed suicidal ideation. Similarly, in other studies, professionals highlighted the need to document decisions accurately and follow protocol to protect themselves from blame should their decision be questioned [ 74 , 83 ]. Professionals who encouraged risk-taking [ 73 ] or supported a service user’s wish to discontinue from medication [ 60 ] were also fearful of being blamed if negative outcomes occurred as a result of their decision.

“Risk-taking and promoting an individual’s freedom is encouraged but you’re conscious of the fact that if someone gets hurt, it’s not just them. .. criticism will be levelled at each level within the authority” [ 73 ] p180)

In other studies, fear of being blamed influenced the decision-making process and resulted in professionals adopting defensive or restrictive approaches [ 71 , 83 ].

Professionals’ concern for their personal safety acted as a barrier to both discussing ‘risk to others’ with service users [ 16 ] and involving service users in RM [ 65 ].

Some professionals were resigned to their current practice of not involving service users in the RA and RM process [ 20 ]. Others were willing to move towards involving service user more in the process:

“I’m quite open to change and including the person more in it, rather than it just being professionals talking about the risks” [ 16 ] p477)

Nonetheless, professionals’ aspirations for greater service user involvement in RA and RM did not necessarily reflect practice [ 72 ]:

‘Whilst everyone considered openness a good idea in principle, practice had not always caught up with aspirations’ [ 16 ].

The extent to which professionals consider the SDM components important in the RA and RM process influenced their implementation behaviour. For example, involving service users in RA and RM was not considered a priority for some professionals:

‘… they had given little consideration to how they could directly and actively involve clients in the assessment and management of risk’ [ 63 ] p810).

For others, interpersonal engagement with service users at risk of suicide was not prioritised [ 69 ] and discussion about suicidal ideation was considered counterproductive [ 68 ]. Obligatory reasons for involving service users in RA and RM practices, i.e. for assessment and information gathering purposes, were provided by professionals in several studies [ 20 , 61 , 63 , 65 , 67 , 70 , 74 , 82 , 83 ]:

“In order to take care of these suicidal patients, I try to build a trusting relationship with them. If I can build a good trusting relationship with them, they will trust me. They will give me the information I need and then we can explore their problems and try to help them to prevent future suicide attempts” [ 67 ] p687)

Forming agreements with service users (or a shared-decision) was considered an important step in the RM process [ 61 , 82 , 83 ]. In several studies, professionals emphasised the importance in openly communicating about risk, as well as providing the service user with knowledge and information about their risk [ 16 , 65 , 71 , 83 ]:

‘These nurses avoid imposing instant protection and instead engage in dialogue with patients that facilitates understanding of risks and potentially risky situations (e.g. taking a bath), the meaning that patients attach to risks and potentially risky situations, and what can be done to address risks’ [ 83 ] p1126).

Professionals acknowledged that RM was more likely to be helpful or effective if the service user was involved in the RA process [ 16 , 61 , 65 , 67 , 69 , 71 , 82 , 83 ]:

“I think it’s more of a risk if it’s other people talking about them behind their back. I think the more that things can be out in the open, the less of a risk it is” [ 42 ] p14)

Reinforcement

Professionals emphasised the importance in communicating to service users about their risk [ 72 ], as well as encouraging service users to talk about their distress or suicidality [ 81 – 83 ].

“The opportunity to interact is the ultimate. .. it’s a really important interaction.. . It can be the difference between life and death” [ 69 ] p309)

Some believed that RM was more likely helpful if service users were involved in decision-making [ 71 ]. Others valued supporting choice and collaboration, and this guided their interaction with service users who wished to discontinue from medication [ 60 ]. Positive risk-taking encouraged some professionals to support the service user’s choice or influence [ 61 , 62 , 71 – 73 ].

Professionals were motivated to support service users’ influence and positive risk-taking as this favoured autonomy, empowerment, and recovery [ 65 , 66 , 72 , 73 , 82 ]:

“if it is her wish to look after her finances then actually she is entitled and that needs to be explored very slowly with her [. . .] You can give her advice whether it’s a good decision or a bad decision but it’s her decision to take control of it” [ 72 ] p3)

Professionals stressed the importance in demonstrating empathy, compassion and instilling hope [ 67 , 69 , 77 , 82 , 83 ]. They believed that empathy supported service user to work through their distress and talk about suicidal feelings:

“I feel it’s important to feel and show empathy. If you don’t have empathy, you have no way of realising the patients’ torment and discomfort, or how serious or how strongly they feel about attempting suicide” [ 67 ] p687)

Professionals expressed negative emotions that impact on the assessment and management of risk with individuals with mental illness. In Barnicot, Insua-Summerhayes [ 71 ], anxiety in preventing harm and about being blamed may have influenced decision-making around continuous observation and led to restrictive practices. The possibility of a negative outcome from supporting a service user to discontinue from medication triggered anxiety in professionals [ 60 ]. While approaching the issue of risk created anxiety for some professionals [ 20 , 66 , 80 ], others expressed fear in approaching sensitive topics such as risk to others [ 16 ] or suicidal risk [ 69 , 80 , 81 ]. For example, a professional described their concern about possibly being the last person to have spoken to someone who takes their own life:

“I think it’s scary because you don’t want to be the last person having that conversation and they do something. You don’t want to think you’ve done anything that could have erm, actually aggravated them or tipped them over the edge or you’ve said something that has made them think about something” [ 81 ] p106)

The findings of this review indicate that SDM is not a term commonly used in mental health services when exploring processes of RA and RM. The components of SDM (i.e. informed, involved and influential) are referred to but are not being implemented consistently in the RA and RM process. MHPs spoke openly about not discussing risk with service users, involving service users in the process, or supporting their influence in decision-making about risk. This is in line with studies of service user accounts of RA and RM [ 20 , 38 , 42 ], where it was found that service users were often unaware of the RA and RM plan.

Through the use of the TDF [ 52 ], this systematic review has provided a comprehensive understanding of the perceived barriers and enablers to the SDM components in RA and RM from the literature. The salient COM-B components (and linked TDF domains) identified from the findings of this review were social and physical opportunity (i.e. ‘social influences’ and ‘environmental context and resources’), which refer to the social, cultural, and environmental influences on behaviour; and reflective and automatic motivation (i.e. ‘social/professional role and identity’, ‘beliefs about capabilities’, ‘goals’ and ‘reinforcement’), which characterise the cognitive processes that drive behaviour.

Mental health policy at an international level recommends that the processes of RA and RM are collaborative, person-centered and based on SDM [ 28 , 33 , 84 ]; however, there were many factors identified in this review that potentially impede on practice.

Managing risk and delivering recovery-orientated care were experienced as competing priorities that led to practice dilemma. The tension was believed to arise from organisational expectations, legal responsibilities, and contradictory frameworks of practice. Policy guidelines emphasise protection, harm minimisation, public safety, and duty of care. At the same time, they recommend recovery-orientated care based upon the components of SDM, positive risk-taking, therapeutic relationships, and empowerment. Our findings show professionals acknowledged the primacy of RM and the impact this had on other aspects of care including therapeutic relationships, and positive risk-taking. Boardman and Roberts [ 37 ] argue that it is possible to strike a balance between managing risk and delivering recovery-orientated care. They propose shifting towards a ‘person-centred’ approach to assessing and managing risk, based on SDM and collaborative safety planning.

Reluctance to talk about suicidality with service users or to support positive risk-taking were believed to be reinforced in a risk-averse team culture. Simpson [ 85 ] reported similar findings and highlighted the need for a ‘safe’ environment for professionals to openly discuss and disclose uncertainties, challenges, and alternative treatment options within the team. In addition, the findings of this review suggest that professionals tried to make decisions about risk with the service users’ best interests in mind, but at times this was the professionals’ interpretation of best interests and not necessarily the service users’. This is problematic as a capacitous service user is the expert on their own best interests, and even when not capacitous their wishes and views ought to be taken into account. Factors relating directly to the service user, such as capacity and insight, were considered barriers to discussing risk and collaborating with the service user in RM planning, thus impeding best interest decisions. It has been argued that paternalistic approaches to decision-making can cause practice conflicts between the ethical principles of autonomy on the one hand, and beneficence and non-maleficence on the other [ 86 ]. In mental health care, decision-making can be justified in terms of respecting the service user’s choice (autonomy), the professional’s duty to promote good (beneficence) or to prevent harm (non-maleficence) [ 86 ]. Paternalistic approaches may conflict with the autonomy of a non-capacitous service user, when decisions are made based on the professional’s interpretation of the best interests of the service user [ 87 ]. Experiencing a mental health crisis can lead to diminished capacity and competency to make a decision and in these circumstances, paternalistic interventions have been justified on the basis of the requirements of beneficence or non-maleficence [ 88 ]. Breeze [ 87 ] argues that the assessment of rationality or competency has the potential to be subjective and value-laden and although paternalism maybe justified in some situations, it should be exercised with caution. For example, where there is a disagreement between the professional and service user about what is considered ‘best interest’, it should not be assumed that the service user’s view is irrational or wrong, indeed S. 1 [ 4 ] Mental Capacity Act (2005) states that ‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision’ [ 89 ].

Developing a therapeutic relationship and gaining trust enabled professionals to engage service users in a discussion about suicidality, as well as promote positive risk-taking and collaboration in RM. A recent review of service users’ perspectives of helpful RM practices [ 43 ] found that interpersonal relationship and communication aided RM to be inclusive for service users, and trust was considered to nurture open discussion about risk. In a study about risk-taking and recovery [ 90 ], service users also reported that therapeutic relationships developed trust, and this led to more collaborative discussion and decision-making.

Study findings suggest that professionals may be retaining responsibility for assessing and managing risk and thus limiting the extent to which service users are genuinely informed, involved or influential in the process. Negative beliefs about consequences inhibited professionals from implementing SDM in RA and RM. On the one hand, professionals were concerned that discussing risk could cause the service user distress, to disengage from services or to feel stigmatised. On the other hand, professionals were fearful of being blamed or investigated for negative outcomes from supporting risk-taking, i.e. service user who wished to discontinue taking medication, or discussing suicidality. Fear of blame led professionals to accurately document decision-making to protect themselves should their decision later be questioned, as well as cautious discussion with service users about suicidal thoughts. A culture of blame and risk aversion continues to pervade mental health services [ 91 ] that is said to derive from bureaucratic management styles, perception of failure, political pressures and media influences [ 17 , 92 ]. In a qualitative study, professionals expressed concern about restrictive practices potentially being eliminated as they felt that this would make it difficult to maintain safety [ 93 ], they were also concerned about being blamed when a negative event occurred.

Beliefs about consequences provoked negative emotions for some professionals who expressed fear and anxiety about preventing harm. Supervision was highlighted as a potential aid in discussing suicidal thoughts with service users. Tragic incidents can occur even after careful decision-making and thus professionals can expect to be accountable for decision-making and its implementation but not outcomes that they have no control over [ 94 ]. For MHPs to move away from paternalism and towards promoting SDM, change needs to occur at an organisational level [ 37 ]. Professionals need to know that they have managerial and institutional support, especially in situations where negative beliefs about consequences occur. It has been suggested that developing therapeutic risk-taking in practice requires organisations to support professionals by creating safe spaces to hold uncertainty, multidisciplinary working, shared responsibility, and supervision [ 88 ]. Institutional fear of things ‘going wrong’ is perhaps not helped by anxieties over the hyperbolic media coverage that can emerge when tragedies do occur [ 95 ]. The media’s negative portrayal of mental illness and misleading association with violence [ 96 , 97 ] may contribute to the continuing stigma of mental illness; the preoccupation with RM in mental health care; and misconstrued perceptions of the actual risk posed towards others by individuals with mental illness. In reality, 11% of all homicide convictions in the UK, during 2007–2017, were patient homicides, i.e. people in contact with mental health services in the 12 months prior to the offence [ 98 ].

A lack of confidence in discussing certain types of risks with service users was reported. For example, professionals expressed concern about approaching the topic of ‘risk to others’, and uncertainty in how to initiate discussions about suicide with service users. In mental health care, it is recognised that RA and RM practices focus on ‘dramatic risks’ that involve harm to self or others [ 37 ], however, these extreme harms relate to a minority of people in contact with mental health services [ 98 ]. Dixon [ 38 ] compared service users’ and professionals’ ratings of risk and found that service users identified more risks in relation to their vulnerability, such as self-neglect and suicide, than professionals did. In contrast, professionals identified more risks than service users in relation to risk of harm to others. A collaborative safety planning approach would broaden the focus on risk to include the service users perspectives and consideration of everyday risks that are common but less considered in the assessment and management of risk [ 37 ]. Changing the language of risk and basing discussions on safety-concerns offer an alternative way of involving service users’ in managing their own safety and opens discussion about risk [ 99 ].

In the current review, professionals questioned their ability to resolve disagreements with service users about risk to others. Consequently, conversations about risk with service users were described as difficult. A systematic review of services users’ perceptions of RM found that people’s desire for honesty and collaboration was fulfilled when they felt listened to, despite disagreements. Furthermore, some services users recognised disagreements as an authentic part of therapeutic relationships [ 43 ].

As found in the broader recovery-focused care-planning and coordination literature [ 75 ], high caseloads, staff shortages and a lack of resource were highlighted as factors that impede on practice. Professionals reported limited time or opportunity to support positive risk-taking or to meaningfully engage with service users. Also, insufficient training on RA and RM negatively impacted on professionals’ ability to talk openly about risk. In one of the included studies, a professional who had received RA training reported that it enabled him to face his fear in discussing risk openly with an individual who had previously damaged his office [ 16 ]. Higgins, Doyle [ 24 ] research findings indicate the need for training to enable professionals to adopt a collaborative RA and safety planning approach. They propose training delivered at undergraduate and postgraduate level that includes the skills necessary to engage service users and carers in the RA and safety planning process [ 24 ].

Professionals’ behaviours were guided by their perceived outcomes of implementing the SDM components in RA and RM. For some professionals, involving service users in RA and RM was not always a priority. Others, however, were motivated to involve service users for obligatory reasons, as well as to provide the service users with knowledge and understanding of risks and to collaborate in reducing risks. Similar to the findings of Kaminskiy, Senner [ 12 ] qualitative synthesis, this review found support from MHPs for the idea of implementing SDM or working in collaboration with service users. Professionals’ emphasised the importance in communicating risk with service users, promoting empowerment and demonstrating empathy. Some described adjusting their language to facilitate discussions about risk, while others expressed aspiration towards involving service users in future RA and RM practices, though it was recognised that aspiration may have not yet influenced practice.

Strengths and limitations

This is the first systematic review of evidence reporting MHPs’ experiences and attitudes towards SDM in RA and RM, which uses both the TDF and COM-B model to synthesise findings. The synthesis was informed by several psychological theories of behaviour change and empirical findings of included studies. However, this review is not without limitation. First, the review focused on MHPs’ experiences of SDM in RA and RM: thus, the service users’ perspective was not examined, however, a recent mixed-studies systematic review explored helpful RM practices from the service users’ viewpoint [ 43 ]. Secondly, despite conducting systematic searches, SDM is not a well-indexed term, and researchers have varying interpretations of the concept: therefore, our search strategy may have inadvertently missed relevant studies. To capture relevant studies in our searches, we used MeSH terms for SDM and included additional free text key terms related to the concept of SDM (e.g., service user involvement, patient-centred and recovery). Thirdly, it is important to note that the decision to conduct a qualitative systematic review was derived from the findings of a scoping search, which indicated that qualitative methods dominated this field of research. A quantitative survey study [ 24 ] was identified, however, but excluded on the review’s eligibility criteria. Although the key focus of Higgins, Doyle [ 24 ] study was to explore mental health nurses’ practices and confidence in RA and safety planning, there was a small amount of data relevant to the findings of this review (i.e. stakeholders’ involvement in the RA and RM process). Lastly, the wide variation in methods employed in qualitative research poses challenges in the assessment of quality and synthesis of findings for the purpose of a review [ 49 , 100 ]. Indeed, the present review included studies that differed significantly in design, data collection, and analysis method. Also, qualitative research is often criticised for lack of generalisability. Therefore, the strength of recommendation that can be made from the evidence included in this review is limited. Future reviews may wish to further develop the themes identified in this review by sourcing data from quantitative work.

The findings of this review indicate that there may be limited SDM in RA and RM with individuals with mental health problems. Langan and Lindow [ 42 ] reported this over 15 years ago, and despite policies endorsing SDM it, largely, is not happening. This review identifies some of the key issues that may be underpinning this lack of action and warrant further intervention and investigation.

Through the use of the TDF and COM-B model, this review explored MHPs’ perceived barriers and enablers to SDM in RA and RM. Key barriers were ‘power and best interest’ and ‘my professional role and responsibility’, whereas key enablers were ‘therapeutic relationship’ and ‘value collaboration’. These barriers, enablers and TDF domains matched COM-B components ‘opportunity’ and ‘motivation’.

The finding from the present study contributes to existing knowledge of SDM by providing insight into MHPs’ perceived barriers and enablers to implementing SDM in RA and RM. Consistent with a qualitative synthesis study that examined attitudes towards SDM in the broader field of mental health [ 12 ], a lack of capacity was identified as a barrier to SDM in RA and RM. Although justified in some situations, mental capacity fluctuates with time and research indicates that most psychiatric in-patients are capable of making key treatment decisions [ 101 ]. There are also methods that can be used to incorporate service users’ views, such as decision aids, advance directives and advocacy. Therefore, diminished capacity alone should not be reason to exclude the service user from the RA and RM process, as the service user may still be able to offer valuable insight into their perspective and experiences with risk that can inform the RM plan. The present study also highlights the importance of the therapeutic relationship in facilitating discussions about risk with service users, which corroborates findings from a previous systematic review of service users’ perspectives of RM [ 43 ]. Therefore, increasing professionals’ opportunity to develop the therapeutic relationship may influence their motivation to implement SDM in RA and RM.

The findings of this review highlight a complex range of social, cultural and environmental factors that together influence SDM in RA and RM. This information will be relevant to policymakers and practitioners and can also be used to develop targeted interventions aimed at changing practice in this challenging area. However, these findings are based on a small number of studies that are heterogeneous in aim and objective. Furthermore, none of the included studies directly investigated SDM in RA and RM with individuals with mental illness. Therefore, further extensive work is needed to better understand how best to implement SDM in RA and RM so that all parties feel comfortable. A qualitative study by the lead author, directly investigating the barriers and enablers to SDM in RA and RM, is currently underway and has been developed from the findings of this review. The benefits of implementing SDM in RA and RM planning is also insufficiently researched. It is important to build an evidence base on the impact, as well as the acceptability and feasibility of a collaborative approach.

Acknowledgements

I would like to thank Dr. Afnan Aljaffary, and Dr. Una Foye for their support with appraising the quality of studies within this review.

Abbreviations

Authors’ contributions

NA contributed to the design of study, conducted the searches, screening, quality appraisal, data extraction, analysis, synthesis, drafted and edited the manuscript. AS contributed to the design of the study, supported screening, analysis, synthesis, and revised the manuscript. SB contributed to the design of the study, supported data extraction, screening and revised the manuscript. LR contributed to the design of the study, supported screening, and revised the manuscript. ND advised and revised the manuscript. FB supported title and abstract, and full text screening. ET contributed to the analysis and interpretation of data. All authors have read and approved the final version of the manuscript.

This research was part of a PhD funded by City, University of London, and East London NHS Foundation Trust. Neither funding body had a role in the design of the study, data collection, analysis, interpretation of data or writing the manuscript.

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• Cross-sectional analysis of healthcare worker mental health and utilisation of a digital mental health platform from 2020 to 2023
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• http://orcid.org/0000-0003-2175-0196 Anish K Agarwal 1 , 2 ,
• Lauren Southwick 1 , 2 ,
• Arthur Pelullo 2 ,
• Haley J McCalpin 2 ,
• Rachel E Gonzales 1 , 2 ,
• David A Asch 3 ,
• Cecilia Livesey 4 ,
• Lisa Bellini 3 ,
• Rachel Kishton 2 , 4 ,
• Sarah Beck 2 ,
• Raina M Merchant 1 , 2
• 1 Department of Emergency Medicine , University of Pennsylvania , Philadelphia , Pennsylvania , USA
• 2 Center for Health Care Transformation and Innovation , University of Pennsylvania , Philadelphia , Pennsylvania , USA
• 3 Department of Medicine , Perelman School of Medicine , Philadelphia , Pennsylvania , USA
• 4 Department of Psychiatry , Perelman School of Medicine , Philadelphia , Pennsylvania , USA
• Correspondence to Dr Anish K Agarwal; anish.agarwal{at}pennmedicine.upenn.edu

Background Healthcare worker (HCW) anxiety and depression worsened during the pandemic, prompting the expansion of digital mental health platforms as potential solutions offering online assessments, access to resources and counselling. The use of these digital engagement tools may reflect tendencies and trends for the mental health needs of HCWs.

Objectives This retrospective, cross-sectional study investigated the association between the use of an online mental health platform within a large academic health system and measures of that system’s COVID-19 burden during the first 3 years of the pandemic.

Methods The study investigated the use of Cobalt, an online mental health platform, comprising deidentified mental health assessments and utilisation metrics. Cobalt, serves as an online mental health resource broadly available to health system employees, offering online evidence-based tools, coaching, therapy options and asynchronous content (podcasts, articles, videos and more). The analyses use validated mental health assessments (Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and post-traumatic stress disorder (PTSD)) alongside publicly available COVID-19 data. Statistical analyses employed univariate linear regression with Stata SE Statistical Software.

Results Between March 2020 and March 2023, 43 308 independent user sessions were created on Cobalt, a majority being anonymous sessions (72%, n=31 151). Mental health assessments, including PHQ-4, PHQ-9, GAD-7 and primary care-PTSD, totalled 9462 over the time period. Risk for self-harm was noted in 17.1% of PHQ-9 assessments. Additionally, 4418 appointments were scheduled with mental health counsellors and clinicians. No significant associations were identified between COVID-19 case burden and Cobalt utilisation or assessment scores.

Conclusion Cobalt emerged as an important access point for assessing the collective mental health of the workforce, witnessing increased engagement over time. Notably, the study indicates the nuanced nature of HCW assessments of anxiety, depression and PTSD, with mental health scores reflecting moderate decreases in depression and anxiety but signalling potential increases in PTSD. Tailored resources are imperative, acknowledging varied mental health needs within the healthcare workforce. Ultimately, this investigation lays the groundwork for continued exploration of the impact and effectiveness of digital platforms in supporting HCW mental health.

• Mental health
• Healthcare quality improvement

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Data are available on reasonable request. Data are available on request with appropriate protocols and permissions.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjoq-2024-002896

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Mental health strain persists among healthcare workers including anxiety and depression, which have worsened during and beyond the pandemic.

WHAT THIS STUDY ADDS

A cross-sectional approach to understanding the associations between an external strain and how healthcare workers use a digital mental health platform and their assessment scores.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

In the evolving landscape where health systems are attempting to support and improve the mental health of the workforce, many have launched online platforms for resources. These platforms may provide insight into the scope of the problem and its trajectories over time.

Introduction

Rates of anxiety and depression among healthcare workers (HCWs) remain high. 1–3 The importance of preserving HCW mental health has gained significant attention, including from the US surgeon general and the National Academy of Medicine. 4 5 One approach to support the workforce at scale has been the rapid development and deployment of digital technologies such as online mental health platforms, applications and even chatbots. 6–8 These platforms may provide a strategy and venue for individual HCWs to complete mental health assessments, access asynchronous related content (eg, podcasts, literature and videos) and connect to individualised expert mental healthcare to initiate mental health counselling or therapy.

Digital programmes offer an additional advantage in that they make it easier to measure use in real time. The objective of this study was to investigate the use of a web-based mental health platform (named Cobalt) across a large, academic health system within the context of COVID-19 case burden, hospitalisations and mortality. The hypothesis was that increasing COVID-19 case burden, hospitalisations and mortality would be associated with higher collective levels of HCW anxiety, depression and platform utilisation.

We conducted a retrospective cross-sectional study of HCW mental assessments and utilisation data of ‘Cobalt’, a mental health platform at the University of Pennsylvania Health System. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for observational studies. 9

Created in the early stages of the COVID-19 pandemic, Cobalt is an online resource available to all health system employees and functions as a web-based platform that curates mental health content. 8 Users navigating to Cobalt can complete mental health assessments related to anxiety, depression and post-traumatic stress disorder (PTSD) using validated and brief online tools. The platform then provides individual HCWs with links to evidence-based individual or group-based tools and resources and access to coaching and professional therapy using a stepped model of care. Effectively, Cobalt provides a centralised source for HCWs seeking mental health or well-being care to find and use resources for support on their own and also offers the opportunity for individuals to schedule time with mental health experts for one-on-one appointments, peer support or group sessions.

Individual Cobalt users can navigate to the web homepage and choose to proceed anonymously to navigate asynchronous content or identify themselves via name, phone number or email address to connect with psychiatrists, clinical psychologists and other expert mental healthcare. Users can remotely access online content related to mental health, schedule therapy, peer-to-peer support, coaching sessions or appointments with a trained mental health professional.

Cobalt mental health assessment data (eg, assessments of anxiety, depression and PTSD) were aggregated and accessed. HCW privacy remains paramount to Cobalt, and to this investigational study, particularly when related to mental health data. Thus, this university IRB-approved study and approach did not identify individual user-level information.

Measures and outcomes

The Cobalt measures included validated mental health assessments: depression (Patient Health Questionnaire-4 and 9 (PHQ-4 and PHQ-9)), anxiety (Generalised Anxiety Disorder-7 (GAD-7)) and post-traumatic stress disorder (primary care PSTD screen (PC-PTSD)). 1 10–12 We also assessed publicly available COVID-19 data including documented case counts, mortality and hospitalisations using the Centers for Disease Control and Prevention (CDC) COVID Data Tracker. 13 The primary outcomes were aggregated mental health assessment scores and platform utilisation (eg, number of user sessions, appointments made and completed). Anonymous sessions from the same user were possible and counted separately. Cobalt functionality used PHQ-4 as an initial depression and anxiety screen which then triages those with moderate or high scores to complete the PHQ-9 or GAD-7 assessment.

Data analysis and statistical methods

Linear regression analyses were conducted to analyse the association between COVID-19 case counts and the number of user-initiated sessions, assessment scoring, and appointments made and completed. Analyses were performed using Stata SE Statistical Software: Release V.18.0 (StataCorp).

Cobalt utilisation and mental health assessments

Between March 2020 and March 2023, there were 43 308 distinct user sessions accessing the Cobalt platform with an average of 1170 (SD 550.5) monthly user sessions. Of these, 31 151 (71.9% were anonymous user sessions) with an average of 865 anonymous user sessions per month and 113 non-anonymous user sessions per month. In total, the users completed 9462 mental health assessments including the PHQ-4 (n=2762, 29.2%), PHQ-9 (n=2398, 25.3%), GAD-7 (n=2327, 24.6%) and PC-PTSD (n=1975, 20.9%). Over the study analysis period, there were 409 assessments endorsing the risk for self-harm of those individuals completing the PHQ-9, question 9 (17.1%) and in total, there were 4418 appointments made with a mental health professional. Figure 1 displays depression, anxiety and PTSD assessments and regional COVID-19 case burden over time, from May 2020, when the first county-level data were available, to June 2022.

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Regional COVID-19 case burden and mental health assessments. Figure 1 displays monthly variation in COVID-19 case count across five counties within the health system’s geography and median scores of depression (PHQ-4, PHQ-9), anxiety (GAD-7) and PTSD (PC-PTSD) assessments completed on Cobalt. Assessment volume is indicated by indicator size. GAD-7, Generalised Anxiety Disorder-7; PC, primary care; PHQ-4, Patient Health Questionnaire-4; PTSD, post-traumatic stress disorder.

Depression, anxiety and PTSD

The PHQ-4 was implemented and used during the first 29 months of Cobalt’s launch. During this period, the total average PHQ-4 score was categorised as mild with a mean score 5.4 (SD 3.3). PHQ-9 and GAD-7 were used throughout the entire period (March 2020–March 2023). The PHQ-9 had a total average in the moderate range of 10.7 (SD 5.7). Among those indicating risk for self-harm, the final question of the PHQ-9, the overall mean score was higher (15.9, SD 6.0). GAD-7, on average, was at a moderate level with a total mean of 10.2 (SD 5.2). PC-PTSD was used during the first 29 months and had a low total mean (mean 1.9, SD 1.4). Figure 1 displays variation assessments over time.

Mental health assessments and COVID-19 case burden

Using publicly available COVID-19 regional and state case burden including case counts, hospitalisations and ICU admissions, we investigated the association between COVID-19 data and Cobalt accounts, mental health assessment scores and instances of risk for self-harm (question 9 on the PHQ-9). We found no significant associations between account creation on Cobalt or the number of assessments completed with regional or state COVID-19 burden. There was a trend towards significant association indicating more regional and state hospitalisations with more assessments completed (p=0.07 and 0.05, respectively). Anxiety, depression and risk for self-harm scoring were not associated with COVID-19 burden. We did find a significant association between state hospitalisations and number of appointments made (p=0.012). Figure 2 displays the trends in PHQ-9 median scores and COVID-19 cases across time (March 2020–March 2023), with the presence or absence of suicidal ideation in PHQ-9 results depicted in separate figures. Among PHQ-9 respondents with the risk for self-harm, there was a general trend of increased median scores occurring 1–2 months after a hospital case peak.

Median depression (PHQ-9) Scores, risk for self-harm and COVID-19 case burden. Figure 2 displays median monthly depression scores (PHQ-9) among healthcare workers indicating risk for self-harm and those who were not against COVID-19 hospitalisations and ICU admissions. PHQ-4, Patient Health Questionnaire-4.

HCW mental health plays a crucial role in healthcare delivery and patient care, with literature highlighting increased rates of burnout, workforce attrition and deteriorating mental health. 14 15 As health systems implement mechanisms to broadly support their employees, understanding these strategies and the evolving needs of the workforce is imperative. This study focuses on the utilisation of a health system-wide web-based mental health platform, yielding four key findings.

First, Cobalt offers a potential strategy to assess, at a high level, the collective mental health of a segment of the workforce. The analysis reveals a growth in engagement, measured by the number of unique sessions, with variations in assessments related to depression, anxiety and risk for self-harm. Over the 3-year study period, approximately 1200 users per month engaged with Cobalt. A key finding is that a large majority (72%) were anonymous. To our knowledge, this is one of earlier investigations studying this intersection of public health burden, digital health platforms and the mental health of the workforce over time. Notably, these results suggest that these platforms may serve a dual purpose by providing a real-time, broad assessment of a system’s workforce mental health while preserving privacy and confidentiality. While lacking granularity at the role or division level, these findings offer insights into how health systems can navigate HCW mental health in the digital era. The impact and effectiveness of these platforms over time remain an area for future exploration.

Second, the use of Cobalt was not significantly linked to prominent markers of the pandemic case burden at regional, city or state levels. Although trends indicated increased completion of mental health assessments during periods of high case burden, these did not reach statistical significance. Limitations in the analysis include the influence of other stressors outside patient care, such as racial injustice and political unrest, as well as a host of personal factors at the individual level. Additionally, the nuanced emotional reactions to a case surge may manifest at varying times for individuals. Recognising these complexities is essential for a comprehensive understanding.

Third, using validated mental health assessments across this cohort, median HCW depression and anxiety remained in the moderate range over the study period. Additionally, as anxiety and depression scores slowly lowered, we identified signals of potentially increasing severity of PTSD using the PC-PTSD assessment. These data are aggregated and anonymous, so these findings cannot be interpreted as repeat assessments of individuals. Rather, as intended in the study design, to more broadly understand the group at large. A global improvement of anxiety and depression with a potential increase in individuals potentially experiencing PTSD aligns with mental health reactions to other catastrophic events. Within the context of the pandemic waves, the initial uncertainty and fears may have driven anxiety and depression, and as the public focus shifted, PTSD may rise in the face of the workforce emotionally processing their experiences. While the PC-PTSD assessment is not tailored for HCWs experiencing moral distress, no other current validated tool exists for this population and should be further investigated. The finding does identify early signals for health systems to help guide specific resources to supporting individuals with anxiety and depression versus those with PTSD in healthcare settings.

Fourth, Cobalt’s continuous engagement and outreach can inform a learning health system (LHS) approach towards maintaining a healthy workforce, lowering barriers to mental healthcare, protecting privacy and reducing stigma. Stein et al underscore the critical importance of LHS to harness data to advance, personalise and integrate in clinically meaningful ways. 16 As many health systems grapple with continued workforce shortages and high rates of mental health challenges, the exploration of the adoption and utilisation of these platforms’ usage would provide valuable insights.

Limitations

This study has several important limitations. It reports aggregated data across roles within a large healthcare system and due to the anonymity built into the system, it does not provide demographic or individual-level data. Importantly, a single individual accessing Cobalt anonymously for separate sessions at different times would be counted multiple times in this analysis. It also reports cross-sectional information from a single health system, though over a significant period of time. The mental health assessments used within this platform are validated but do not provide diagnostic capacity for mental health disorders. Additionally, the assessments do not provide a full description of the complexities of mental health, symptoms of depression, anxiety or PTSD, but rather assist in triage and identifying individuals at risk. COVID-19 case data, even from a robust source like the CDC, does not fully reflect the burden as testing capacity and requirements fluctuated through the years of the study and do not capture home test results. Finally, the sample accessing and completing the assessments presents selection bias and may not be entirely generalisable to the entire healthcare workforce. The study also has strengths in using these validated mental health assessments over a broad sample of HCWs over the first 3 years of the pandemic.

In this retrospective cross-sectional study, we do not find significant associations between COVID-19 case burden, the use of a mental health platform or mental health assessment scores. We identify variations in depression and anxiety scores over time indicating moderate levels across the workforce and persistent levels of suicidal thoughts. Finally, the use of a web-based mental health platform serves as an important resource for HCWs and one that is consistently used.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study was approved by the University of Pennsylvania Institutional Review Board (#848844).

Acknowledgments

Dr Merchant is the PI of NIH NHLBI R01HL1-141844, NIH/DHHS R01 MH127686 and NIH K24 HL157621.

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X @AgarwalEM

Contributors AA was responsible for design, execution and draft of the manuscript. AA is the corresponding and guarantor author. AP was responsible for data analysis. HJM was responsible for data analysis. REG was responsible for data collection and execution. DAA provided manuscript revisions and oversight. CL was responsible for Cobalt design and manuscript revision. LB was responsible for Cobalt design and manuscript revision. SB was responsible for Cobalt design and manuscript revision. RK and CL were responsible for Cobalt design and manuscript revision. LS was responsible for study design and execution. RMM was responsible for study design, execution and manuscript preparation.

Funding This study was funded by National Institute of Mental Health (R01MH127686).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Suicide Prevention: Suicide Assessment and Intervention Training for Mental Health Professionals

This full-day training is designed to increase knowledge and improve the skills and confidence of clinicians and others who find themselves identifying high-risk youth and adults, and planning for their care. Participants will learn about the scope of the problem, review current information on suicide risk factors, and examine personal reactions to dealing with suicidal behaviors. Best practices in risk assessment will be presented and attendees will learn techniques for eliciting suicidal ideation. Issues relative to liability management and planning for intervention will be presented. Research on the effectiveness of this training demonstrates significant gains in knowledge and confidence. The training, which was approved in 2015 by the SPRC Best Practices Registry for Suicide Prevention, is based on current best practices and reflects the training objectives in the 2012 National Strategy for Suicide Prevention.

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‘I hope the next Darzi report will be a positive story about NHS progress’

STEVE FORD, EDITOR

• You are here: Opinion

‘What the Calocane case tells us about contemporary mental health services’

17 September, 2024 By Chris Hart

How could this happen? That’s a question many have asked since it became known that Valdo Calocane, a highly vulnerable man with a serious mental illness, and history of violence, was left free and untreated before going on to kill three people in Nottingham.

Louis Appleby, who leads the National Suicide Prevention Strategy for England and directs the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, put a different – essential – question on X (formerly Twitter).

“Arguably, there’s no more important task for clinicians than preventing homicides caused by someone’s mental illness”

He asked: “Much discussion about benefits of outreach teams in mental health. And promises to ‘learn the lessons’ from the Nottingham tragedy – a phrase that infuriates families. But the real question is why we unlearned past lessons and what this tells us about future safety.”

That is because there was nothing new in this shocking case. And the painful lessons had had to be learned 30 years ago.

Mr Calocane was diagnosed with paranoid schizophrenia in June 2020. Three years later he fatally stabbed students Barnaby Webber and Grace O’Malley-Kumar and school caretaker Ian Coates, then seriously injured three others after driving Mr Coates’ van at them.

Detained under the Mental Health Act four times in two years, Mr Calocane was not attending appointments and remained non compliant with medication when discharged from mental health services back to his GP in September 2022.

This seems extraordinary, to the degree that one might think it’s an isolated case. But it’s not.

Arguably, there’s no more important task for clinicians than preventing homicides caused by someone’s mental illness. So, this tragedy raises profound questions about the state of mental health care today.

It must always be remembered that people with a mental illness are far more likely to be victims of violence rather than perpetrators, and the number of homicides perpetrated by people with a mental illness has always been relatively low.

However, numbers of homicide related to mental illness have more recently been contested and are even more difficult since NHS funding of research was cancelled in 2019.

The National Confidential Inquiry into Suicide and Homicide (NCISH) reported an average of 60 homicides per year perpetrated by people with a serious mental illness from 2009 to 2019.

However, Julian Hendy, who founded hundredfamilies.org after his own father was killed by a man with a psychotic illness, claims mental health services frequently – and sometimes deliberately – minimise the problem of violence in mental health patients, particularly homicides, and estimate patient homicides at an average of 120 per year.

This discrepancy is, in part, because the NCISH only includes cases where the perpetrator was in contact with secondary mental health services in the 12 months before the offence, and excludes cases where perpetrators later took their own life as well and, therefore, wasn’t charged or convicted.

Also, the NCISH counts the number of convicted perpetrators rather than victims. The number of victims is higher, as there are always cases of multiple homicide – as in Nottingham.

The Care Quality Commission ’s (CQC) interim report into Mr Calocane’s care and treatment, which was published earlier this year, highlighted “errors, omissions and misjudgements”.

They also sampled 10 different patients’ records and noted examples of risk assessments “minimising or omitting key details”, as had been the case with Mr Calocane.

Significant concerns were highlighted in the following areas of care:

• Assessing and managing risk in the community
• Care planning, and the involvement of families
• Discharge planning.
• Medicines management
• Managing people who find it difficult to engage with services
• Clinical decision making around detaining patients under the Mental Health Act

Following publication of the report, there was no shortage of criticism of the trust as well as suggestions for how to prevent further tragedies, including the re-establishment of assertive outreach teams, better use of community treatment orders, a focus on severe mental illness, and a better balance of patient autonomy and stigma against safety and risk.

All eminently sensible, practical and often evidence based. But why weren’t they in place in Nottingham? And if they were everywhere else, why was it not identified as a clear outlier and steps taken to bring it into line with the rest of the country?

“Following publication of the report, there was no shortage of criticism of the trust as well as suggestions for how to prevent further tragedies”

Because it wasn’t an outlier, but acting in common with most mental health services.

The CQC’s first report into Nottinghamshire Healthcare NHS Foundation Trust noted: “Like many other mental health services across the country, mental health services at NHFT were in high demand, with long waiting lists for community mental health teams, difficulties in accessing crisis care and lack of access inpatient beds.

“A lack of oversight for people on waiting lists and too many patients without a care coordinator was putting them, and the public, at risk of harm.”

These are systemic, deep rooted problems. The picture across all mental health services is disturbing, with the independent inquiry into the deaths of more than 2,000 mental health patients under the care of Essex Partnership University NHS Trust or its predecessors the most extreme.

To understand how we got here, however, we must look back at why services such as assertive outreach teams were established.

The 1980s saw the rise of patient advocacy and campaigning groups, particularly hostile to the large psychiatric hospitals still dominating the provision of services for those with mental health problems.

Between 1968 and 1981, there were 24 major inquiries into allegations of abuse and/or ill treatment, including a series of deaths by suicide at Warlingham Park. Many revealed systemic abuse and cruelty.

This fed into a wider, growing consumer rights movement, focus on individual freedoms and the Thatcher government’s aim to cut health service spending.

Alongside advances in drug treatments and the reforms of the 1959 Mental Health Act, this all fuelled a rapid – broadly welcomed – shift to community based care.

The 87,396 available beds in NHS hospitals in 1980 had shrunk by more than 50% by 1993-94, with only 27,000 available in 2012. The promised funding for community mental health services, however, failed to materialise.

While the deficiencies in 1980s hospital care were obvious and highlighted, their virtues were underrated and often dismissed, including being a place of safety for the most vulnerable. By the early 1990s, new scandals were rocking the world of psychiatry.

The highest profile of these concerned Christopher Clunis, a 29-year-old man with a long history of mental illness, non compliance with treatment and not attending appointments, previously detained under the Mental Health Act and with a history of violence.

In December 1992, he stabbed Jonathan Zito to death in a London tube station due to his mental illness.

The Ritchie Inquiry (1994), which reviewed Mr Clunis’ care, described a “catalogue of failure and missed opportunity”, concluding the “more disturbed Christopher Clunis became, the less effective was the care he received”.

Alongside other serious events – including Ben Silcock, another man diagnosed with schizophrenia, jumping into the lion’s den at London Zoo – this  lodged in the public consciousness, with far reaching, positive consequences, partly due to the tireless campaigning of Jayne Zito, Jonathan’s widow.

After its 1997 election victory, Labour introduced national service frameworks (NSF) in the NHS, providing funding for specific targets.

The NSF for mental health recognised that “of the 15,000 people in England with severe and enduring mental illness, between 14 and 200 per 100,000 were difficult to engage.

“They are a diverse group, more likely to live in inner city areas, to be homeless, and to be over-represented in suicide, violence and homicide”.

The NSF legislated for assertive outreach as a “form of intensive case management” to ensure “mental health services stay in contact with people with severe and enduring mental illness, especially individuals who are assessed as at risk of harm themselves or of posing a risk to others”.

“It was ironic that an unintended consequence of the greater specialisation of community mental health teams was greater fragmentation”

To make this initiative work, innovative change was required to both clinical practice and the systems and structures that supported it.

For example, nurses at Lambeth’s award winning community team at Lewin Road, devised the first zoning system to rate the risk of each patient, with specific standards for addressing the risk eg ‘red zone’ patients having to be seen each day, with a cohesive plan for what would be done and ways to track their progress or lack of it.

Caseloads were limited to enable staff to carry out this intensive work, clinical supervision and reflective practice was put in place alongside extended multi professional clinical reviews. Shifts were planned and daily objectives evaluated. Robust clinical leadership was seen as essential.

Dual diagnosis teams were established for people with psychotic disorders who were also misusing substances, ensuring another at risk group didn’t continue to fall through gaps in services with tragic consequences.

It was ironic, therefore, that an unintended consequence of the greater specialisation of community mental health teams, such as early intervention services for people with psychosis, home treatment teams, crisis services etc, was greater fragmentation.

This structural weakness was blown apart when, in 2010, a Conservative government was elected and ‘austerity’ was their response to the banking crash of 2008-09, paving the way for the long-held Tory objective of shrinking the state, with huge reductions in public spending.

Mental health services suffered the double whammy not only of having their own funding cut but also being expected to respond to the psychological and emotional impact on the wider population of cuts in local authority spending, wage stagnation and job insecurity.

Research for Community Care revealed that, between 2010 and 2015, mental health funding was reduced by 8.25%, with community teams overall losing 5% of their budgets while referrals increased by 20%.

A further 2,100 inpatient beds were cut. At the same time, local authority spending on working age adults with mental health needs fell by 13.2% in real terms (McNicoll 2015). Assertive outreach teams lost an astonishing 56% of their budgets.

Having inherited from Labour a mental health nursing workforce of 40,810 in 2010, the Conservative’s austerity programme saw it drop to 36,054 by 2016, only returning to 2010 levels in 2023, though with significant vacancies among that number.

Community teams merged, had bigger caseloads, lost experienced staff, and posts requiring two to three years post-reg experience were opened to newly qualified staff.

Clinicians appointed into management posts had far less experience than their predecessors of a decade ago, with their successors further disadvantaged by having to learn from those relatively inexperienced managers.

Investment in often ambitious training programmes that had marked the 2000s, including in risk assessment, were cut back. Even when their funding was retained, freeing up staff to attend was increasingly difficult.

In this economic climate, admission criteria for community teams, initially about maintaining fidelity to the teams’ core function but which could be problematic, were increasingly used as a rationale for excluding people.

The reductions in inpatient beds saw ‘gatekeeping’, or decisions about who could be admitted to hospital, become a euphemism for locking the gates and letting in as few people as possible.

“The Friday morning ritual of ward nurses being instructed to go through their patient lists to discharge the least unwell is well established”

Over the years, nurses in inpatient units struggling with demand had gone along with deeply troubling practices, eg unwell patients being moved in the middle of the night from one ward to another to ‘make space’ for someone requiring admission.

That morphed into moving patients to different hospitals or forcing people to sleep in chairs in day rooms.

Now, the Friday morning ritual of ward nurses being instructed to go through their patient lists to discharge the least unwell people is well established.

It’s always tempting to point the finger of blame at individual clinicians. In the case of Mr Calocane, the full review into his treatment and care will undoubtedly raise many uncomfortable issues about practice.

But it’s clear there is a political and structural context to the tragic events that unfolded, which are mirrored across the country.

What is happening at an organisational level? Within a team? And how does that impact individual clinicians?

For example, how do trust board members needing to meet savings targets rationalise the risks in merge three community mental health teams into two with all the implications eg increased caseloads, less time for clinicians with patients, longer waiting times to be seen and assessed?

What philosophy do senior managers adopt when they cut back on education in risk assessment? At times it seems to be, ‘Well, nothing’s gone wrong yet…’

What’s the decision making process in a team that has to balance seeing at risk patients on current caseloads with the demands of assessing new referrals? What’s said about what’s missed when a new assessment of a complex patient is completed in thirty minutes?

How is decision making affected for clinicians in a discussion about risk with a patient? Should I ask that question? Should I probe into that thinking? What will I do if I get a worrying answer?

How is the risk assessment documented when the clinician thinks admission is required but there is no bed available or a ‘bed manager’ has vetoed that decision without seeing the patient?

How does it affect a community practitioner who thinks a patient needs to be seen every day but knows that cannot happen?

This has been an incremental process over 14 years. But one that wears people down.

Will the nurse who flatly refuses to transfer patients to a different ward against that patient’s will until instructed to do so, or the clinician who argues patients need admission but is overruled, continue to do the same every time they have that opinion? Of course, they don’t.

What was once unacceptable to clinicians or a team gradually becomes the norm.

The effects go yet deeper. Avoiding detailed assessments, not studying the theory and practice related to risk, not doing the hard yards to engage with reluctant patients or provide the psychoeducation that can promote better understanding for individuals about their mental health problems, abandoning the structures that not only support best practice but help develop it, all create skills’ deficits and a lack of opportunity to develop knowledge and establish high standards the whole team adhere to.

Instead, community teams often report huge levels of stress. Often there’s an underlying anxiety about being the last person to see an ‘at risk’ patient in case there’s a serious incident.

“Most, if not all, of these tragedies will highlight the problems faced by both inpatient and community services”

This has changed the culture in many mental health services. Lower standards are accepted.

Clinicians rationalise the situations they find themselves in, using arguments of patient choice, the right to refuse treatment – completely valid in themselves but ignoring the counter argument for patients having the right to receive treatment, even if they don’t want it, if it means addressing a life-changing deterioration in their mental health or is a matter of theirs or others’ safety.

What we can be pretty sure of is this: in the next 12 months somewhere between 60 and 120 people will be killed by a person with a mental illness. And our current mental health service provision is ill equipped to prevent this from happening.

Most of those homicides will not generate national media coverage, their numbers won’t be aggregated, the cases analysed collectively and themes extrapolated.

Most, if not all, of these tragedies will highlight the problems faced by both inpatient and community services but it’s highly unlikely lessons will be learned across services.

The crisis in our prisons has – finally – dominated headlines but that facing mental health services is no less serious. There are few short term fixes. A coherent, national strategy is required.

The CQC’s recommendations are predictable and can be summarised as ‘ensuring’ (a word that occurs in almost all recommendations) all elements are addressed where deficiencies were found in the treatment and care of Mr Calocane or the wider patient group reviewed.

What’s missing, however, is how this will be done. Referring people who find it difficult to engage with services to non existent teams for ‘assertive and intensive support’ is magical thinking. Robust policies and processes for discharge are meaningless without staff equipped to enact them.

It doesn’t address funding, resources, the huge education and training programme required – not just in knowledge and clinical skills but leadership and management.

It doesn’t look at how effective systems and structures can be established or how to generate the cultural and ideological change needed to promote reflection, supervision, multi-professional team working, or the sticks and carrots that enable trusts to provide sufficient beds, community teams with manageable caseloads and services that are not fragmented and exclusive but cohesive and inclusive.

There are changes teams can make eg using zoning, improving supervision and reflective practice, clinical reviews etc, and trusts can change the climate within their services but this is going to take national leadership from the government, and money.

Admittedly, it was a healthier economic climate in the 1990s, but we brought about positive change in the wake of tragedy.

There is nothing stopping us from doing it now other than a lack of ambition and imagination.

Chris Hart, author of A Pocket Guide to Risk Assessment and Management in Mental Health (Second Edition) and independent nurse consultant and director of The Reducing Deaths in Custody Programme

Appleby L et al (2022) The National Confidential Inquiry into Suicide and Safety in Mental Health . Annual Report: UK patient and general population data, 2009-2019, and real time surveillance data. 2022. University of Manchester.

Care Quality Commission (2024) Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust: Part 2.

Department of Health (1999) A National Service Framework for Mental Health . London: HMSO.

Hart C (2023) A Pocket Guide to Risk Assessment and Management in Mental Health (Second Edition). London: Routledge.

McNicoll A (2015) Mental health trust funding down 8% from 2010 despite coalition’s drive for parity of esteem : Community Care (20.03.2015).

Ritchie JH, Dick D and Lingham R (1994) The Report of the Inquiry into the Care and Treatment of Christopher Clunis. London: HMSO.

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• Open access
• Published: 17 September 2024

Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review

• Bente Hamre Larsen 1 ,
• Dagrunn Nåden Dyrstad 2 ,
• Helle K. Falkenberg 3 , 4 ,
• Peter Dieckmann 2 , 5 , 6 &
• Marianne Storm 1 , 7 , 8  

BMC Medical Education volume  24 , Article number:  1019 ( 2024 ) Cite this article

Metrics details

Interprofessional assessment and management of health needs for older adults living at home can help prioritize community service resources and enhance health, yet there is a shortage of professionals with the necessary competencies. Therefore, support and training for healthcare professionals in community settings to assess older adults’ health with the aim of for health promotion are needed.

To identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home.

A systematic literature search of the Cinahl, Medline, Academic Search Ultimate, Scopus, Embase, and British Nursing Index databases was performed. We considered studies focusing on the training of healthcare professionals in assessing a single or multiple health needs of older adults aged 65 and above living at home. We considered studies published between 1990 – and March 2024. The review evaluated qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. A quality appraisal was conducted via the Mixed Methods Appraisal Tool (MMAT).

Twenty-three studies focused on training healthcare professionals to assess health needs and plan care for older adults living at home were included. The majority of the included studies combined teacher-driven pedagogical approaches consisting of educational sessions, written materials or e-learning, and more participant-engaging pedagogical approaches such as knowledge exchange or various forms of interactive learning. Healthcare professionals were trained to detect and manage single and multiple health needs, and some studies additionally incorporated interprofessional collaboration. Healthcare professionals were satisfied with the training content and it increased their confidence and competencies in health needs assessment and care planning for older adults. Moreover, some studies have reported that training interventions foster the implementation of new and effective ways of working and lead to positive outcomes for older adults.

Healthcare professionals were satisfied with a combination of participant-engaging and teacher-driven pedagogical approaches used to train them in assessing health needs and planning care for older adults living at home. Such training can lead to enhanced assessment skills and facilitate improvements in practice and health promotion for older adults. Future research is recommended on interprofessional simulation training for conducting structured and comprehensive health needs assessments of older adults living at home, as well as on the implementation of such assessments and health-promoting interventions.

Peer Review reports

Introduction

The globally growing and diverse aging population will impact the sustainability of healthcare systems and the independent living of older adults. To support the health needs of older adults, the World Health Organization (WHO) underscores the necessity of effectively training the healthcare workforce [ 1 , 2 ]. However, the complexity of health needs in older adults, coupled with an increased risk of frailty and adverse health outcomes, challenges the provision of tailored care [ 3 ]. Healthcare professionals in homecare settings are well-positioned to assess the health needs of home-living older adults [ 4 , 5 ] and facilitate the interprofessional management of these needs within the community [ 5 ].

Health needs assessment should offer a comprehensive understanding of individuals’ physical, mental, and social health needs, and address the constantly changing needs with increasing age. The assessments aim to identify those who can benefit from healthcare services, such as health education, disease prevention, treatment, and rehabilitation [ 6 ]. The assessment can help set service priorities and allocate service resources effectively, guide clinical decision-making [ 7 ] and design targeted, health promoting interventions [ 4 , 7 , 8 , 9 ] to prevent or delay frailty [ 10 ], enhance overall outcomes for those with complex health needs [ 11 ] and enable them to remain at home for as long as possible [ 12 ]. Given its importance, the task of health needs assessment, is becoming increasingly crucial in homecare settings [ 13 ]. However, there is a scarcity of adequately trained professionals proficient in conducting interprofessional health needs assessments [ 4 , 5 , 9 , 14 , 15 ], including depression [ 16 ], cognitive function [ 17 ], social needs [ 18 ], sensory function (i.e. hearing and vision) [ 19 ], geriatric healthcare [ 20 , 21 ], and multidimensional frailty [ 22 , 23 ]. Frailty, as a dynamic state, affects an individual who experiences losses in one or more domains of human functioning (physical, mental, social) that are caused by the influence of a range of variables, and which increase the risk of adverse outcomes [ 24 ].

A comprehensive understanding of how to train healthcare professionals in health needs assessment of the physical, mental, and social health needs of older adults living at home is crucial. This review understands training as “planned and systematic activities designed to promote the acquisition of the knowledge, skills, and attitudes” [ 25 , p77]. Training can take place as “on-the-job training,” with practicing tasks with a mentor or receiving feedback, or through “off-the-job training,” in a classroom setting with lectures, discussions, and exercises [ 26 ]. It is essential to consistently update and expand knowledge and skills throughout healthcare professionals’ careers [ 27 ]. Mentorship and support are highly valued as pedagogical approaches [ 28 ]. Another approach is implementing interprofessional team-based training [ 29 ] focused on health needs assessment for older adults, which can be complemented by practical, supervised training with a mentor in real-world settings [ 9 ]. Interprofessional simulation training can support healthcare professionals developing communication and collaborative skills and improving patient outcomes [ 2 ]. Additionally, opportunities to share and exchange experiences and new learning with peers and seniors, along with tailored, role-focused teaching, are effective approaches training strategies in community healthcare [ 30 ]. Practical training through simulation, case studies, and role-playing influences skill development by creating experiences that promote individual understanding and learning [ 31 ] and it is based on Vygotsky’s sociocultural learning theory [ 32 ]. Tailored simulation training in use of systematic assessment tools enhanced nurses’ competencies to assess and treat complex symptoms among older adults in long-term care facilities [ 33 ].

Therefore, this scoping review aimed to identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home. Three research questions guided the review: (1) what pedagogical approaches are used when training healthcare professionals to assess the health needs of older adults living at home, (2) what is the content and foci in the health needs assessment training provided in the studies, and (3) what are the outcomes of training reported by healthcare professionals and older adults living at home?

Scoping review design

This study followed the Joanna Briggs Institute (JBI) methodology [ 34 ] for conducting and reporting scoping reviews built on Arksey and O’Malley’s framework [ 35 ]: (1) Define and align the objectives (2) develop and align the inclusion criteria with the objectives (3) describe the planned approach to evidence searching, selection, data extraction, and presentation of the evidence (4) search for the evidence (5) select the evidence (6) extract the evidence (7) analyze the evidence (8) present the results (9) summarize the evidence in relation to the purpose of the review, draw conclusions and note the implications of the findings [ 36 ]. In addition, the PRISMA-ScR [ 37 ] was used as a checklist to report the scoping review data charting, data synthesis and presentation of the data (Additional file 1).

Selection of studies

To be eligible for inclusion in the review, the study had to focus on the training of healthcare professionals in assessing physical, mental and social health needs [ 24 ], specifically assessing frailty, physical function, depression, cognition, social health, and sensory function of older adults aged 65 and above living at home [ 38 ]. Healthcare professionals from diverse fields were included, whether engaging in one-to-one interactions where individual healthcare professionals work directly with patients or working collaboratively in interprofessional teams of members from different professional backgrounds [ 29 ]. The review included qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. The inclusion and exclusion criteria are specified in Table  1 below.

Search strategy

The authors and an experienced research librarian collaboratively developed the search strategy and search terms. The search strategy followed the recommendation of JBI [ 34 ]. In June 2022, a limited search of PubMed and CINAHL was conducted to identify relevant articles. To develop a more comprehensive search strategy, we subsequently analyzed the titles and abstracts of the retrieved papers, as well as the index terms used to describe the articles. A systematic literature search was performed on October 6, 2022, in the CINAHL (EBSCO), MEDLINE (EBSCO), Academic Search Ultimate (EBSCO), Scopus (Elsevier), Embase (OVID) and British Nursing Index (ProQuest) databases. The updated search was conducted on the 7th of March 2024. The search terms employed in the different databases to represent training healthcare professionals to assess health needs in older adults living at home are described in Table  2 . We considered studies published between 1990 – and March 2024. Ultimately, the reference lists of all included studies were reviewed to identify any additional studies aligned with the scoping review’s aim.

Identification and selection of studies

The search yielded a total of 2266 records. The study selection process is illustrated in Fig.  1 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [ 39 ]. The search results were uploaded into the citation management system EndNote, where duplicates were removed. A total of 1722 records remained for screening. We used the web application Rayyan [ 40 ] to screen studies for inclusion or exclusion. The screening involved all the authors working in pairs, independently assessing eligibility on the basis of the inclusion and exclusion criteria. Discrepancies were resolved through discussions until consensus by all authors in arranged meetings.

All the records were independently screened by the authors (BHL, DND, HKF, PD and MS), and 1452 records were excluded. Two hundred seventy abstracts were reviewed in blinded pairs, leading to the exclusion of 212 records. Next, the full texts of 58 studies were read. This process resulted in the exclusion of 38 studies whose reasons are provided in the flow chart. The remaining 20 studies were included in this review (Fig.  1 ).

The primary reason for exclusion was the lack of content related to training in health needs assessment  ( n  = 13) or incorrect populations ( n  = 12). Eight studies were excluded because they focused on training for medical or bachelor’s degree students. Additionally, four publications were not peer-reviewed studies ( n  = 4).

BHL and MS independently screened the reference lists from the 20 included studies to identify additional eligible studies. After all the blinded titles were read, 28 titles of records were identified for abstract review. Following this, 22 titles were excluded, leaving 6 abstracts included in the full-text examination. The full-text reading further excluded four studies because they did not focus on training in health needs assessment. Finally, two studies [ 41 , 42 ] were added to this scoping review, resulting in a total of 22 included studies.

An updated search was conducted on the 7th of March 2024, including publications from 2022 to 2024, following the procedure above. After removing duplicates, 173 titles and abstracts were screened for eligibility. The full texts of nine articles were read. Six studies were excluded because they did not include training for healthcare professionals. One had incorrect population, and the others were in a language other than English. This led to the inclusion of one new study [ 43 ], bringing the total number of included studies for the scoping review to 23.

Search results, study selection and inclusion process [ 39 ]

Extraction and analysis of the data

In line with the updated JBI methodological guidelines for scoping reviews [ 34 ], we extracted and coded descriptive details from the 23 included records. The extraction table covered the publication year, country of origin, study purpose, research design, study population, context/setting, training intervention content and assessment tools, pedagogical approaches and training duration, and outcomes for healthcare professionals and older adults. A test was conducted to ensure that the coauthors were aligned in their understanding of what type of data to extract for the table. Feedback from the test guided essential refinements to the extraction table before the authors collaborated to extract and organize pertinent information. We applied a basic thematic analysis to code the data and identify, analyze, and interpret patterns, ultimately deriving themes that addressed our research questions [ 44 , 45 ]. The analysis utilized NVivo 12 Pro software [ 46 ].

Quality appraisal

We performed a quality evaluation of the included studies via the Mixed Methods Appraisal Tool (MMAT) in blinded pairs. This tool is designed for a structured and standardized evaluation of methodological quality and risk of bias in systematic reviews that include qualitative, quantitative, and mixed methods studies [ 47 ]. Although quality evaluation is optional in a scoping review, it can provide valuable insights [ 48 ] and enhance the interpretability of the included studies [ 49 ].

All studies were evaluated according to five quality criteria specific to each research design (qualitative, quantitative descriptive, nonrandomized, randomized, and mixed methods studies). Each criterion received a response score of either “Yes,” indicating that the study met the quality criteria, or “No,” indicating that it did not meet the quality criteria or that it was unclear (see Table  4 ). It is discouraged to calculate an overall score. Any disagreements in scoring were resolved through discussion. The quality scores were not used to exclude articles from the review; instead, they were reported and discussed [ 49 ].

In accordance with the JBI scoping review guidance [ 44 ], the extracted data are presented in a table format (Tables  3 and 5 ) and a narrative summary is provided to respond to the three research questions. Table  3 provides a description of the study characteristics, while Table  5 outlines overarching categories along with relevant extracted information [ 44 ].

Characteristics of the included studies

Table  3 shows that the 23 studies were published between 1990- and 2023. Eight studies were conducted in the United States [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 ], three in Canada [ 55 , 56 , 57 ], three in Australia [ 58 , 59 , 60 ], three in the United Kingdom [ 41 , 61 , 62 ], and one each in Ireland [ 63 ], Italy [ 64 ], Brazil [ 65 ], France [ 66 ], Singapore [ 67 ], and Belgium [ 68 ].

Ten studies meticulously examined training interventions tailored for primary nurses [ 43 , 50 , 51 , 54 , 55 , 60 , 61 , 63 , 66 , 68 ], one study specifically targeted the training of community health workers [ 65 ] and another presented an educational session tailored for case managers and agency supervisors [ 42 ]. The remaining studies indicated that training was provided to interprofessional teams or various distinct professions, such as nurses, physical therapists, occupational therapists, general practitioners, social workers and psychologists [ 16 , 41 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 67 ]. The study participants were in home healthcare or primary/community care [ 16 , 41 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 68 ], community and social services [ 42 , 64 ], mental health care [ 61 ], eldercare centers/daycare [ 67 ], residential settings [ 58 , 59 , 64 ], hospitals [ 53 , 56 ], rehabilitation [ 56 ] and acute care [ 61 ].

Quality evaluation results

The quality appraisal procedure revealed variations in the quality of the 23 included studies. The detailed quality evaluation results for each study are presented in Table  4 , and an overview of the methodological quality criteria is presented in Additional file 3.

Each study was evaluated on five criteria appropriate to its study design category. Overall, only one study, which was a mixed methods study, met al.l five quality criteria in the MMAT [ 62 ]. Additionally, one mixed methods study met four criteria [ 61 ], and another met three criteria [ 65 ]. The most common criterion that mixed methods studies failed to meet was 5.2: whether the different components of the study were effectively integrated to answer the research question. Among the quantitative randomized studies, one study met four quality criteria [ 50 ], whereas the other was of low quality, meeting only one criterion [ 59 ]. None of these studies met the quality criterion for proper randomization. In the quantitative nonrandomized studies, six met four criteria [ 41 , 55 , 56 , 58 , 64 , 68 ], one met three [ 63 ], and one met only one criterion [ 16 ], indicating low quality. All studies met the criterion regarding whether the intervention was administered as intended. The most common criteria they failed to meet were 3.3: whether there were complete data and 3.4: whether confounders were accounted for in the study design and analysis. Among the descriptive studies, seven met four criteria [ 42 , 43 , 54 , 57 , 60 , 66 , 67 ], one met three criteria [ 53 ], and two met only one criterion [ 51 , 52 ], demonstrating low quality.

The majority of these studies met the criterion regarding whether the measurements were appropriate. However, the criterion most studies did not meet (only one out of ten) was whether the risk of nonresponse bias was low. Notably, no qualitative methods studies were included in our scoping review.

Training interventions in assessment of older adults living at home

The next section presents a narrative overview of three major themes related to the three research questions. The themes concerned the training provided for healthcare professionals in assessing the physical, mental, and social health needs of older adults living at home: pedagogical approaches, content and foci of health needs assessment training for healthcare professionals and outcomes and evaluation of health needs assessment training for healthcare professionals and older adults living at home. The findings are summarized in Table  5 [ 44 ].

Pedagogical approaches

The included studies employed diverse pedagogical approaches to train healthcare professionals in assessing the health needs of older adults living at home. The spectrum of pedagogical approaches observed in the studies was categorized into teacher-driven and participant-engaging pedagogical approaches. Twenty-one studies [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ] combined teacher-driven and participant-engaging pedagogical approaches, reflecting a multifaceted training strategy. Mayall et al. [ 41 ] opted for a more singular pedagogical approach, exclusively relying on lecture-based education, whereas the training method used in the Piau et al. [ 66 ] study remained unspecified. The training interventions varied in duration, from one-hour sessions [ 68 ] to an ongoing training program spanning 21 months [ 57 ]. In two studies, the specific duration of the training interventions was not specified [ 53 , 57 ]. The most common duration for training was 4–8 h [ 16 , 43 , 50 , 52 , 54 , 56 , 58 , 59 , 62 , 67 ].

Teacher-driven pedagogical approaches

Almost all studies utilized teacher-driven pedagogical approaches, including educational sessions, written materials or e-learning [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. Educational sessions were evident in 14 studies [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 65 ], providing healthcare professionals with information about relevant topics through lectures [ 16 , 41 , 42 , 51 , 62 , 64 , 65 ], slides [ 16 , 64 ] and instructions [ 50 , 52 , 53 ], as well as demonstrations of the use of assessment tools [ 41 , 42 , 51 , 56 , 58 , 59 ]. Additionally, Abbasi et al. [ 57 ] and Quijano et al. [ 42 ] offered ongoing sessions during the post training implementation period.

Written materials were provided to the participants in nine studies [ 16 , 42 , 50 , 52 , 54 , 58 , 59 , 63 , 64 ]. This included training manuals containing examples and case studies [ 58 , 59 ], written documents about the training pack and the assessment forms [ 63 ], course textbooks and instruction manuals [ 64 ], educational materials including the program manual and articles [ 42 ], a CD-ROM (a data-disc for computer) containing written educational material [ 52 ] and toolkits derived from the educational material [ 16 , 50 , 54 ]. Brown et al. [ 54 ] reported that toolkits included key intervention components for seamless application of learned concepts [ 54 ]. Furthermore, some described follow-up emails to provide participants with information post training [ 50 , 54 ].

E-learning as a preplaying online module or videoclip appeared in nine studies [ 16 , 42 , 43 , 50 , 53 , 54 , 61 , 64 , 68 ]. Naughton et al. [ 61 ] delivered prerecorded lectures [ 61 ], Landi et al. [ 64 ] used video recordings presenting real cases to test participants’ assessments- and decision-making skills, and Quinlan and Ryer [ 43 ] offered online modules on aging epidemiology, fall risk factors, and age-friendly health systems [ 43 ]. Participants watched video recordings portraying late-life depression [ 42 , 53 , 54 ], and patient interactions illustrating approaches to depression assessment [ 50 , 54 , 68 ] via standardized questions and follow-up questions [ 16 ]. Professional actors were used in three studies [ 16 , 53 , 68 ].

Participant-engaging pedagogical approaches

The majority of the included studies utilized participant-engaging pedagogical approaches involving knowledge exchange or various forms of interactive learning [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ].

Sixteen studies employed various forms of knowledge exchange such as discussion, questioning and coaching, between training participants and teachers [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. Peer-to-peer learning and dialog facilitated the exchange of knowledge and insights [ 65 ], which enriched the overall learning experience [ 61 ]. The participants were included in discussions following lectures [ 55 ], after watching scripted videos [ 53 ], and during patient case reviews [ 56 , 67 ]. Additionally, three studies included both discussions and allowed participants questions [ 52 , 54 , 68 ]. Discussions allowed participants to delve into case management techniques [ 51 ], explore experiences related to assessing the health of older adults [ 54 , 60 , 64 ] and solve problems and discuss alternative strategies regarding depression screening [ 54 ]. A few studies have provided ongoing coaching in the post training phase to support healthcare professionals in applying newly acquired skills [ 42 , 55 , 57 ]. This included three months of feedback and support [ 42 ], mentorship for skill integration [ 57 ], and a six-month collaborative approach between resource staff and case managers involving home visits and clinical consultations [ 55 ].

Interactive training was employed in fifteen studies through skills training, role-playing, simulations, and hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ]. Skill training allows nurses to practice patient interviews and assessments and receive instructor feedback [ 54 ]. The participants practiced by assessing their colleagues’ health and responding to assessment [ 16 , 51 ], with faculty staff offering assistance, encouragement, and feedback throughout [ 51 ]. Landi et al. [ 64 ] provided practice exercises followed by presentations, and Quinlan and Ryer [ 43 ] provided a virtual training session in motivational interviewing technique and assessment. Roleplay as a teaching strategy was used to address practical aspects of administering depression screening [ 50 , 52 , 60 ], and Butler and Quayle [ 63 ] incorporated case scenarios, roleplay, and practical skills training for assessing depression in older adults [ 63 ]. Simulation training was used to immerse participants in the experience of living with sight and hearing impairments performing everyday tasks such as filling out forms or managing medications using sight impairment spectacles. Training was followed by a debriefing session [ 62 ]. Hands-on training in the assessment of older adults’ health in real-world settings was conducted in ten studies [ 42 , 51 , 54 , 55 , 57 , 58 , 59 , 60 , 64 , 65 ]. Healthcare professionals gained clinical experience through assessments of home dwelling older adults [ 55 , 58 , 59 , 60 , 64 , 65 ] and through participation in a rotational preceptorship for community health nurses. This enabled them to practice newly acquired assessment skills and collaborate in a real-life setting [ 51 ]. Additionally, two other studies emphasized practical training in communication with other professionals in real-world settings [ 58 , 59 ], while Brown et al. [ 54 ] encouraged participants to practice assessments in a real-world setting between educational sessions.

Content and foci of health needs assessment training for health care professionals

All the included studies offered insights into the content and foci of health neesd assessment training interventions for healthcare professionals. The studies were divided into those aimed at training healthcare professionals to understand and assess either single or multiple physical, mental, and social health needs in older adults living at home. Additionally, some training sessions focused on interprofessional collaboration.

Single health need assessment training

The focus of twelve studies involved enhancing the skills of healthcare professionals in assessing, planning and conducting interventions for a specific, single health need in older adults, with each addressing either the assessment of mental or physical health [ 16 , 41 , 43 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 63 , 68 ]. Two of these studies [ 43 , 62 ] focused solely on physical health factor training. Smith et al. [ 62 ] emphasized training in assessing and detecting sight and hearing impairments without specifying whether any assessment tools were used [ 62 ]. Quinlan and Ryer [ 43 ] provided fall risk assessment training, which included the use of assessment tools to evaluate the physical function of older adults and to assess their home environments. The other ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused on training to assess depression in older adults living at home. The training encompassed understanding and detecting the condition, and all of them included the use of assessment tools. Van Daele et al. [ 68 ] included skills such as actively listening to patients and motivating them to seek expert assistance when needed. Delaney et al. [ 16 ] incorporated skills in asking follow-up questions, and Mellor et al. [ 59 ] offered training in appropriate communication with older adults to identify masked, early signs of depression.

Multiple health needs assessment training

Eleven studies [ 42 , 50 , 51 , 55 , 56 , 57 , 61 , 64 , 65 , 66 , 67 ] described training interventions for healthcare professionals aimed at assessing, planning, and conducting interventions for multiple health needs in older adults living at home. The training content ranged from learning to performing a holistic health assessment of older adults encompassing physical, mental, cognitive, and social factors [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] to a more nuanced assessment of two or three of these factors [ 50 , 65 , 67 ]. All studies described the use of assessment tools or checklists. A holistic assessment and understanding of older adults’ health context and needs enables interventions to be tailored to their health and care needs, priorities, and levels of frailty [ 57 ]. Within the realm of holistic assessment, only two of these studies addressed alcohol and medication usage [ 55 , 56 ], whereas two other studies focused on evaluating sensory status [ 57 , 66 ]. For studies with more nuanced assessment training, three studies [ 42 , 50 , 67 ] primarily tailored their training to focus on depression assessment and intervention in older adults, but Quijano et al. [ 42 ] also included training in assessing general physical health status, social function, and cognitive function. Sin et al. [ 67 ] included dementia assessment and Bruce et al. [ 50 ] addressed factors that commonly complicate depression in homecare patients, such as health conditions, disability in activities of daily living, and cognitive function. The training included how to ask follow-up questions and observe nonverbal language [ 50 ]. Neto et al. [ 65 ] provided training for healthcare professionals in rural areas to screen for geriatric risk factors such as caregiver overburden, general health, social health, risk of falling, or difficulties in activities of daily living.

Interprofessional collaboration and communication skills in health needs assessment training

Beyond the focus on training for assessing the health needs of older adults, sixteen studies [ 42 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 , 68 ] have incorporated training elements to increase interprofessional collaboration and communication skills among healthcare professionals. Health needs assessment training for interprofessional teams was evident in eight of the included studies [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Two studies [ 58 , 59 ] outlined an advanced session to teach skills for interacting with other healthcare providers, including general practitioners and mental health specialists, whereas Couser et al. [ 51 ] stressed the importance of effectively communicating the assessment results to physicians and other healthcare providers. Training in writing referrals was emphasized in ten studies [ 42 , 50 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 68 ]. In addition, Stolee et al. [ 55 ] trained healthcare professionals in writing reports and making recommendations to the referring case manager. Only two studies [ 61 , 65 ] included collaboration with family in their training programs. Naughton et al. [ 61 ] designed training programs to support healthcare professionals in navigating the complexities of collaboration with multidisciplinary teams, older adults, and their families. They also developed a network among nurses to facilitate the exchange of expertise, experience, and innovative ideas [ 61 ]. Neto et al. [ 65 ] aimed to increase the capacity of care workers to effectively collaborate with family caregivers and social services for dependent older adults in rural areas. Stolee et al. [ 55 ] provided training for case managers to extend this knowledge to their teams and strengthen connections with specialized geriatric services. Similarly, Abbasi et al. [ 57 ] emphasized team-based care delivery training, with active and holistic discussions among patients, caregivers, and interprofessional teams. Diverse skill sets within teams can effectively meet the holistic care needs of patients. In parallel, Piau et al. [ 66 ] focused on training nurses to collaborate with general practitioners to develop comprehensive care plans. Landi et al. [ 64 ] trained case managers who collaborated in supervised teams to assess older adults and present care plans. They watched videos of simulated team discussions to enhance their understanding of the assessment process and teamwork [ 64 ].

Evaluation and outcomes of health needs assessment training for healthcare professionals and older adults

All of the studies provided insight into the experiences or outcomes of healthcare professionals participating in the training interventions. This included their satisfaction and experiences with health needs assessment training, improved confidence and competencies in health assessment and care planning and shifts in work practices. Additionally, some studies have reported outcomes for older adults following health needs assessment training, such as appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. The evaluation of these outcomes relied to a small extent on models or frameworks, with only three studies incorporating them [ 43 , 61 , 62 ]. Smith et al. [ 62 ] utilized Kirkpatrick’s four-level training evaluation model to assess the relevance and impact of educational intervention. Naughton et al. [ 61 ] adopted Alvarez et al.’s (2004) framework of an integral model of training evaluation and effectiveness. Quinlan and Ryer [ 43 ] presented their findings following the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework.

Healthcare professionals’ satisfaction and experiences with assessment training

Ten studies provided insights into healthcare professionals’ experiences with participating in training interventions [ 16 , 41 , 43 , 54 , 55 , 56 , 60 , 61 , 62 , 65 ], where most of the participants expressed satisfaction with both the content and format of the courses. The participants in Brymer, Cormack and Spezowka [ 56 ] expressed a high level of satisfaction with the presenter’s content, pacing, and format, and in Mayall et al. [ 41 ], the training met the participants’ needs and expectations. The participants in Naughton et al. [ 61 ] particularly valued the peer-to-peer learning aspect, whereas Smith et al. [ 62 ] emphasized the effectiveness of simulations. Neto et al. [ 65 ] rated classroom sessions and supervised home visits very positively and found them useful. Furthermore, participants in four of the studies [ 16 , 60 , 61 , 65 ] offered suggestions to enhance the number of educational sessions. They suggested allocating more time for training [ 16 , 65 ], a greater focus on skills training [ 60 , 61 ], additional training in managing complex and technically challenging issues [ 65 ] and incorporating more time for case studies and discussions [ 16 ].

Improved confidence and competence in health assessment and care planning

Improvements in assessment competencies following training interventions among healthcare professionals were reported in nineteen studies [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Among these, nine studies explicitly reported increased confidence among healthcare professionals in assessing older adults’ health needs [ 16 , 41 , 54 , 55 , 58 , 59 , 63 , 67 , 68 ]. The health need sassessment and use of assessment tools or checklists led to the identification of health needs. Quinlan and Ryer [ 43 ] noted that without screening in a fall prevention program, the identification of fall risk among older adults would be missed. Piau et al. [ 66 ] noted that a high proportion of assessments effectively identified frailty and suggested interventions and referrals. One comment was that they “were previously skirting around the problem, now asked about mental health directly” [ 61 , p. 33]. Naughton et al. [ 61 ] reported that performing a comprehensive geriatric assessment helped when raising issues with general practitioners because they were talking about their language. Nunn, Annells and Sims [ 60 ] acknowledged the use of Geriatric Depression Screening (GDS) tool raised awareness of depression. A total of 62.5% felt that the GDS helped identify depression that might otherwise be overlooked, but some questioned its universal usefulness [ 60 ]. Abbasi et al. [ 57 ] reported that having an evaluation framework helped healthcare professionals guide meaningful measures [ 57 ]. Conversely, some participants also expressed that they relied more on observation than direct questions when assessing depression [ 54 ]. According to Landi et al. [ 64 ], careful assessments is deemed essential for effective care planning, and Stolee et al. [ 55 ] emphasize the critical role of assessment training in identifying health needs and equitably distributing community service resources. Two studies reported one year of retention of knowledge and skills without the inclusion of a refresher course [ 54 , 62 ].

Twenty studies documented a better understanding of appropriate interventions and referrals [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. According to Delaney et al. [ 16 ], 50% of the participants noted that a key aspect they learned was understanding the significance of the assessment results and the corresponding interventions [ 16 ]. The participants in the study by Neto et al. [ 65 ] demonstrated significantly improved capacity in responding to the health and care needs of older adults. The participant reported increased confidence in making referrals and consulting resources [ 51 ], increased knowledge about managing depression, making referrals, and accessing available local services [ 41 ] and enhanced self-efficacy in providing care for older adults [ 16 , 58 ]. Nunn, Annells and Sims [ 60 ] reported that 50% of participants felt prepared to address older adults’ depression after training. Smith et al. [ 62 ] observed increased referral practices and improved ability to advise patients about sensory services, whereas Mellor et al. [ 59 ] noted a slight increase over time in specialist referrals, and senior staff reported increased confidence in interacting with health specialists.

Shift in healthcare professionals’ work practices after assessment training

The training intervention resulted in either a change or potential for change in work practices in ten studies [ 16 , 42 , 43 , 52 , 53 , 55 , 57 , 62 , 63 , 64 ]. Butler and Quayle [ 63 ] reported that prior to receiving training, nurses did not utilize any formal assessment measures to screen for depression in older adults. However, following training, some nurses continue to use screening measures for depression in their clinical practice [ 63 ]. Similarly, case managers in Stolee et al. [ 55 ] stated that the major change in their assessment practice was greater consistency in the use of assessment tools. Smith et al. [ 62 ] reported a shift in practice toward incorporating more detailed information about patients’ impairments and implementing supportive strategies, and in Marcus et al. [ 53 ], communication of depression screening results to patients, physicians, or mental health specialists became a standard protocol.

Landi et al. [ 64 ] reported that training was proven feasible and may be implemented on a broader scale, and Luptak et al. [ 52 ] outlined an implementation period of the ADAPT—Assuring Depression Assessment and Proactive Treatment protocol for depression care in rural healthcare—with the potential to achieve the outlined goals in various clinical settings [ 52 ]. Delaney et al. [ 16 ] reported that project participants were interested in implementing the program in their homecare setting and developed a train-the-trainer model. Abbasi et al. [ 57 ] provided results and experiences regarding the Seniors Community Hub (SCH) through the ADKAR (awareness, desire, knowledge, ability, reinforcement) evaluation framework to assist others interested in implementing a similar integrated care model [ 57 ]. Quinlan and Ryer [ 43 ] stated that fall assessment practices are currently implemented and continuous; similarly, Quijano et al. [ 42 ] reported that depression interventions continue to be offered by participating agency offices. On the other hand, Butler and Quayle [ 63 ] noted the challenge of implementing assessment tools due to competing demands such as holidays, working part-time or being too busy, and Sin et al. [ 67 ] outlined one participant with difficulties in applying new knowledge owing to manpower shortages and constraints in time and space.

Outcomes for older adults following the health needs assessment training

Seven studies [ 42 , 43 , 50 , 53 , 57 , 66 , 68 ] detailed outcomes for older adults following health needs assessment training for healthcare professionals. These outcomes included appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. Bruce et al. [ 50 ] highlighted that depressed older adults in the intervention group were more likely to receive appropriate referrals for mental health evaluation [ 50 ], aligning with findings where a minimal intervention significantly increased the detection of depression and further referrals to general practitioners [ 68 ]. The findings in two studies demonstrated that patients were referred to tailored resources designed to address their identified problems [ 53 , 57 ]. Furthermore, Quijano et al. [ 42 ] revealed that older adults’ awareness of seeking help and the significance of physical activity for maintaining health improved. Quinlan and Ryer [ 43 ] stated that after providing care plans to 83 older adults, most implemented fall prevention strategies during a two-week follow-up call with 29 older adults, with only one fall reported. Piau et al. [ 66 ] identified the main causes of frailty and reported effective intervention recommendations and referrals [ 66 ]. Most physicians in Stolee et al. [ 55 ] reported better general function for older adults due to comprehensive geriatric assessment. Findings in two studies [ 42 , 57 ] documented reductions in depression severity at the follow-up assessment due to appropriate referrals and interventions [ 42 , 57 ], and significantly more older adults felt better and experienced pain reduction, followed by increased activity [ 42 ]. Additionally, Abbasi et al. [ 57 ] reported a slight improvement in health-related quality of life, including mobility, usual activities, pain/discomfort, and anxiety and depression, suggesting enhanced function [ 57 ].

This scoping review provides insights into training interventions for healthcare professionals assessing the physical, mental, and social health needs of older adults living at home. The analysis of 23 studies revealed that nearly all training interventions used a multifaceted training strategy combining teacher-driven and participant-engaging pedagogical approaches to teach healthcare professionals theoretical and practical knowledge. Health needs assessment training focuses on the skills needed to conduct single or multiple health needs assessments in older adults. Interprofessional collaboration was an essential part of most training interventions. Multiple studies noted that participants were satisfied with the training content and had increased confidence and competencies in health needs assessment and care planning. Studies have also reported a shift in work practices for health care professionals and some included results have shown improved health outcomes for older adults.

Our study revealed that most of the included studies blended the use of teacher-driven and participant-engaging pedagogical approaches [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. These approaches provide participants with confidence and competencies in health needs assessment [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Skilled healthcare professionals are crucial in facilitating the implementation of health assessments for older adults [ 69 ]. Lectures can be highly effective for learning, especially when they stimulate thinking and active engagement. Their effectiveness depends on the lecturer’s skill and can be improved by incorporating learner feedback, performance results, self-reflection, and peer feedback [ 70 ]. Another way to improve lecture quality is by including interactive elements such as practical skill training, following John Dewey’s “learning by doing” philosophy [ 32 ]. In our review, we identified fifteen studies that utilized participant-engaging approaches such as skills training, role-playing, simulations, hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ], and sixteen studies employed discussion, questioning and coaching [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. The integration of teacher-driven sessions, interactive training, and knowledge exchange resembles simulation training, which typically includes briefing, simulation exercises, and debriefing phases. These phases allow participants to reflect, enhance their learning, and deepen their educational experience [ 71 ]. Debriefing is a valuable tool for reflecting on and discussing experiences in training and real-world settings. This helps individuals and teams identify strengths, areas for improvement, and lessons learned, thereby enhancing learning and future performance [ 72 ]. However, effective debriefing relies on facilitators with strong skills to maximize learning outcomes [ 73 ].

The WHO advocates interprofessional simulation training to enhance healthcare professionals’ competencies and improve patient outcomes [ 2 ]. Even if several studies combined teacher-driven approaches, interactive training and knowledge exchange, our review included only one study utilizing simulation training [ 62 ]. Health needs assessment training for interprofessional teams was evident in eight of the studies included in our review [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Such training has been proven to provide valuable insights into the health of older adults, leading to improved care delivery [ 74 , 75 ], improved patient outcomes [ 76 ] and reduced hospitalization [ 74 ]. It can improve conflict management skills and team functioning [ 76 ] and play a critical role in equitably distributing community service resources [ 55 ]. Interprofessional simulation training is an engaging method for training clinical skills, procedures, teamwork, and communication in a safe, realistic environment [ 77 ]. It promotes critical thinking, reflection [ 78 ], and effective learning [ 79 ] enhancing the application of knowledge in clinical practice [ 80 ]. The use of participant engaging pedagogical approaches aligns with the sociocultural view of training, which emphasizes active engagement and collaboration in the learning process. It enables knowledge exchange and reflection, and participants can integrate their experiences with new information, internalize it, and construct new knowledge [ 32 , 81 ]. Practical training such as simulations, can push participants out of their comfort zones, foster collaborative learning and enrich the educational experience [ 82 ]. However, to achieve optimal learning, it is crucial to balance skill development with an appropriate level of challenge as learners acquire new concepts. At the same time, temporary support from more experienced learners should be available. This balance is known as the zone of proximal development, which represents the space between a learner’s current skill level and their potential skill level with guidance. Tasks within this zone promote growth [ 83 ].

Our review reports a distinction in training content with a focus on assessing single versus multiple health needs in older adults. Ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused solely on assessing depression. There is a strong correlation between late-life depression and reduced quality of life, as well as comorbidities such as physical illness, disability [ 58 , 84 ] and physical frailty [ 85 , 86 ]. However, single health need assessment training may inadvertently lead to the overlooking of broader health needs among older adults. A multiple health assessment of older adults is recommended [ 7 ], as it can serve as the foundation for developing holistic interventions to enhance overall health [ 10 , 12 , 87 , 88 , 89 ], promote health [ 90 ], foster positive health behaviors [ 91 ], and reduce frailty [ 92 , 93 ]. Our review included eight studies [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] providing training in physical, cognitive, mental, and social health needs assessment, alongside care planning on the basis of these assessments. Research indicates that both healthcare professionals and frail older adults participating in an interdisciplinary care approach were satisfied with the improved structure of care and appreciated the emphasis on health promotion [ 94 ]. On the other hand, a comprehensive health needs assessment is a multifaceted and complex intervention, with uncertainties surrounding its effectiveness and underlying mechanisms [ 95 ]. Some research findings indicate that there is no conclusive evidence that it reduces disability, prevents functional decline [ 96 ], impacts mortality, or supports independent living in older adults [ 97 ]. These results underscore the complexity and challenges in conducting and implementing comprehensive health needs assessments and tailoring interventions to promote health in older adults.

Our review revealed that almost all [ 16 , 41 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 66 , 67 , 68 ] health needs assessment training programs included the use of assessment tools or checklists, leading to the identification of health needs. Only one of these studies reported that participants relied more on observation than on direct questioning when assessing depression [ 54 ]. Additionally, another study found that healthcare professionals using assessment tools felt that this approach led to asking overly personal and intrusive questions without first establishing trust or explaining the purpose of the assessment [ 98 ]. On the other hand, some older adults reported that using assessment tools made it difficult to discuss issues outside the predefined domains of the comprehensive health needs assessment [ 99 ]. Research indicates that current assessment practices heavily rely on professional judgment and intuition, and healthcare professionals in community settings often lack adequate knowledge and training regarding the health needs assessment of older adults [ 22 , 100 ]. This can be seen as problematic because these professionals are ideally positioned to assess older adults early in their health trajectories [ 105 ]. Proper assessment in these settings can facilitate the early recognition of functional decline [ 101 , 102 ] and vulnerability, enable timely intervention to mitigate frailty’s adverse effects [ 105 ], and support effective care planning [ 64 ]. Even if several healthcare professionals have endorsed the integration of frailty assessment tools into primary care [ 22 ], they need a simple, efficient assessment tool [ 105 ] that empowers them to identify older adults’ health needs [ 9 , 88 , 103 , 104 ]. This is particularly critical due to the essential role that assessments play in equitably distributing community service resources [ 105 ]. As such, this review underscores the importance of educating healthcare professionals in community care to effectively assess the physical, mental, and social health needs of older adults. Furthermore, understanding the learning process of healthcare professionals [ 78 ], evaluating the effects of training [ 106 ], and establishing evidence-based standards for skills training are crucial for high-quality teaching [ 107 ]. Additionally, further research is necessary to assess the feasibility, effectiveness, and acceptability of interprofessional interventions targeting multiple health needs aimed at health promotion [ 90 ] and experiences using comprehensive health assessment tools [ 108 ].

Methodological considerations

This review included studies employing various methods to obtain comprehensive insights into training healthcare professionals in assessing the health needs of older adults living at home [ 47 ]. We utilized a validated mixed-methods appraisal tool to assess the quality of the included studies [ 47 , 49 ]. We did not include reporting on screening questions regarding the clarity of the research question or whether the collected data addressed the research questions, as our review focused exclusively on empirical studies. Additionally, we chose not to calculate an overall score from the ratings of each criterion, as this practice is discouraged. We provide an overview of each study’s quality by presenting the ratings of each criterion [ 49 ]. Our findings revealed that only one study met all the quality criteria, fifteen studies met four criteria, three studies met three criteria, and four studies met only one criterion. High-quality studies employ rigorous and robust methods, leading to reliable and valid findings [ 109 ]. While most studies met 3–4 quality criteria, they provide a relatively strong evidence base and offer valuable insights, although some concerns remain. Several studies did not meet the quality criteria for nonresponse bias or complete outcome data. It is crucial to describe and evaluate a low response rate for its potential impact, as this can limit the generalizability of findings [ 110 ]. Many studies also failed to account for confounders in their design and analysis. Confounding factors may bias results by distorting the interpretation of findings [ 49 ], masking actual associations or creating false associations, potentially leading to incorrect conclusions [ 111 ]. The randomization of study subjects and rigorous statistical analyses can mitigate the impact of confounding variables [ 112 ]. Nonetheless, conducting a quality assessment increases awareness of these biases and limitations, thereby enhancing our confidence in the study findings.

Strengths and limitations

Our scoping review has several limitations. Initially, our search strategy involved the use of six databases and various relevant search terms related to training healthcare professionals in assessing the health needs of older adults. We excluded gray literature to focus on mapping existing published research and identifying any research gaps. The search was conducted by an experienced librarian. Despite our efforts to comprehensively map the research literature, we may have overlooked some studies. Second, our exclusion criteria, which encompassed, for example, general practitioners, students, and institutional settings, restricted the scope of the study. Additionally, we focused on health needs assessment, excluding studies that assessed the environment, an important factor in enabling older adults to stay at home as long as possible. However, based on the findings and limitations of the included studies, we believe our review provides valuable insights into the research context. These findings can inform future research, practice, policymaking, and the development of training programs for healthcare professionals in community settings to assess older adults’ health needs.

Healthcare professionals require training in assessing physical, mental, and social health needs in older adults living at home to ensure tailored interventions that enhance their health and independence. Our study revealed that healthcare professionals were satisfied with the combination of participant-engaging and teacher-driven pedagogical approaches when training in physical, mental, and social health needs assessment. Such training is beneficial and strengthens healthcare professionals’ confidence and competency in assessment and care planning for older adults living at home. Additionally, some studies reported that following health needs assessment training, there was a shift in work practices and improved health outcomes for older adults. We suggest that health needs assessment training programs are valuable for improving health and care for older adults living at home and contribute to increased sustainability in healthcare.

Furthermore, we propose additional research on interprofessional simulation training for the structured assessment of multiple health needs in older adults, ensuring comprehensive coverage of all significant health issues in these assessments. We also recommend research on the implementation of such assessments and health promoting interventions.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors express gratitude to librarian Kari Hølland, Division of Research, Stavanger University Library for performing the systematic literature searches.

This article stems from the research project “More good days at home - Advancing health promoting practices in municipal healthcare services for older recipients of homecare” (HEIME), specifically related to Work Package 3, “Simulation and training for health needs assessment in home-living older adults”. HEIME is funded by the Research Council of Norway (grant 320622), University of Southeastern-Norway, University of Stavanger, Stavanger, Horten, Porsgrunn and Nome municipality (2021–2025). Dr. Grethe Eilertsen is the project director. Drs. Siri Tønnessen, Anette Hansen and Professor Marianne Storm are the principal researchers and work package leaders.

Open access funding provided by University of Stavanger & Stavanger University Hospital

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Faculty of Health Sciences, Department of Public Health, University of Stavanger, Postbox 8600, Stavanger, 4036, Norway

Bente Hamre Larsen & Marianne Storm

Faculty of Health Sciences, Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway

Dagrunn Nåden Dyrstad & Peter Dieckmann

National Centre for Optics, Vision and Eye Care, Faculty of Health and Social Sciences, University of South-Eastern Norway, Kongsberg, Norway

Helle K. Falkenberg

USN Research Group of Older Peoples’ Health, University of South-Eastern Norway, Drammen, Norway

Center for Human Resources and Education, Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark

Peter Dieckmann

Department of Public Health, Copenhagen University, Copenhagen, Denmark

Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway

Marianne Storm

Research Department, Research Group of Nursing and Health Sciences, Stavanger University Hospital, Stavanger, Norway

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All authors (BHL, DND, HKF, PD and MS) contributed to the design and development of the study, research questions, and literature search. BHL conducted the literature search in collaboration with MS and research librarian. All authors participated in the screening and quality assessment processes. Data analysis and manuscript writing and preparation was led by BHL in collaboration with MS. All authors were involved in reading, commenting and reviewing the text, and approving the final manuscript.

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Correspondence to Bente Hamre Larsen .

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Larsen, B.H., Dyrstad, D.N., Falkenberg, H.K. et al. Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review. BMC Med Educ 24 , 1019 (2024). https://doi.org/10.1186/s12909-024-06014-9

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Received : 28 June 2024

Accepted : 11 September 2024

Published : 17 September 2024

DOI : https://doi.org/10.1186/s12909-024-06014-9

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