Mental Health Nursing

154 Acute Mental Health Nursing
under supervision by somebody who is trained in their use (e.g., clinical
psychologist, clinical nurse specialist).
The debate as to whether the clinical, ‘subjective’, or actuarial, ‘objective’,
approach is most relevant to clinical practice is complex. The reality
of clinical practice is that tests and scales can help to inform clinical
judgement, not replace it as ultimately people make decisions, not tests.
There is evidence to suggest that a combination of the clinical and actuarial
approach is warranted to structure clinicians’ risk judgements, as this
may be superior to unaided clinical judgement (McNiel and Binder, 1994;
Borum, 1996; Douglas et al., 1999). The Structured Clinical Judgement
Approach, as described by Hart (1998), attempts to bridge the gap
between the scientific (actuarial) approach and the clinical practice of risk
assessment. This approach emphasises the need to take account of past
history, objective measures, current presentation, context/environment and
protective factors, and recognises the reality that the process of clinical
risk assessment is a dynamic and continuous process which is mediated
by changing conditions (see Dolan and Doyle, 2000; Doyle, 2000).
Ultimately the method used by the mental health nurse to elicit information
and assess risk will depend upon the circumstances where the
assessment is being carried out, interdisciplinary arrangements, the time
constraints involved and the wishes of the person being assessed.
Managing violence risk
The management of risk to others encompasses clinical, health and
safety, and public protection (political) issues has to be balanced with the
rights of the individual. Indeed, this forms one of the most vociferous
debates concerning the radical changes introduced in the proposed reforms
to the Mental Health Act (DoH, 2000b) where individuals suffering from
a dangerous severe personality disorder who are considered to be a risk
to others can be admitted for compulsory treatment. Effective risk assessment
should therefore be part of risk management, and vice versa, and as
behaviour likely to cause harm to others may be symptomatic of many
disorders, it is unlikely to be susceptible to any single intervention.
Closely examining the factors which have contributed to past violent
behaviour should prove fruitful in identifying targets for treatment which
may reduce risk. For example, poor anger control – anger management;
substance abuse – drug/alcohol therapy; persecutory delusions – cognitive
and pharmacological interventions. In summarising the approaches
to managing violence risk, Harris and Rice (1997) distinguish between
several types of risk management intervention which take account of
both security and therapeutic interventions. These include interventions
that are as follows.