7 top tips to Risk Enablement

I’d like to start this blog by asking you a simple question:

What are you doing right now?

Now, I know you’re reading an internet page but how? And what else? What brought you here? Maybe you’re sitting on a bus, reading this on your phone while balancing a takeaway coffee on your lap. Or maybe you are waiting for the casserole you put in the oven to cook and are enjoying a moment of quiet before the family come charging in, hungry for their tea.

Now – stop to consider if tomorrow someone told you that you could no longer do even just one element of what you’re doing now.

You can’t go on a bus by yourself.

You can’t use your cooker.

What would that mean to you? How would you feel – not just now but in a few weeks? What would be the potential impact on your mood? Your confidence? Your sense of self-identity?

What you are describing and feeling is at the heart of risk enablement. For although it seems like a complicated and, let’s face it, “risky” process, it is really just about seeing the bigger picture around what gives meaning and purpose to our lives:

“People with dementia often feel that dementia becomes the only thing others know about them. But they remain individuals in their own right and dementia is not the most important thing about them. Many are still able to do what they did before despite their life changing and some things becoming increasingly difficult to do.” (Alzheimer’s Society, 2010).

So, you have started the process of risk enablement by identifying the value of tasks and activities, using yourself as a case example. But what next? How can you support people living with dementia to take positive risks within their daily lives, whether you are a health or care practitioner, a friend or carer or you your self are living with dementia, risk enablement can seem like a daunting task, so with that in mind, here are seven top tips to help start the process.

  1. Start the conversation

Whilst risk management checklists and “safety first” approaches are often the norm, they are also one of the biggest barriers to empowering people with dementia (Department of Health, 2010). By talking about risk taking as a positive process, you can begin to create a culture of risk enablement.

  1. See the individual

Knowing what matters to the person living with dementia is the key to risk enablement. Be clear about who needs to be involved in the conversations and discussions. Try to avoid making generalisations and take an individualised approach (Joseph Rowntree Foundation, 2014).

  1. Acknowledge fear

Research has shown that your approach to risk is more likely to be based on your own culture and norms than on the actual probability of harm occurring (Department of Health, 2010). Positive risk taking requires trust & commitment so it is essential that we acknowledge our own fears and the fears’ of others.

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  1. Take a balanced view

It is easy to become focused on the physical domains of risks & worst case scenarios but risk enablement requires negotiation. Potential downsides of facilitating an activity or being involved in your favourite hobby must be weighed against the health benefits of engaging in an activity/occupation and the potential harm from withdrawing the task.

For staff, tools such as HEAT maps or personal risk portfolios can be a good starting point and can be found in the Department of Health document “Nothing ventured, nothing gained: risk guidance for dementia” on page 52

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Attached is a leaflet we designed to assist NHS staff clinical reasoning when faced with complex situations within acute/general hospital based practice http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4064579/274993%20Enablement%20Framework%20PROOF8.pdf

  1. Use a strengths based approach to finding solutions

Risk enablement is about supporting people living with dementia to take risks by creating plans to minimise or manage potential negative outcomes. Using a strengths based approach means all plans start from the point of “can do”, helping to lead you to a person-centred solution.

  1. Accept there is not always a perfect fit

Risk enablement is complex and not all risks can be managed or mitigated – and some risks are just “too risky”.

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  1. Remember to review

Risk enablement is an evolving process & what works today may not be the best solution tomorrow. But the cyclical process is essential to ensure that at every stage, the least restrictive solution is implemented:

“When the day comes that I have to start asking for help…[and]…if that independence is taken away…then I hope its only taken away from me in the right way…I would like to think that I could still be consulted and still have some say in my independence(Alzheimer’s Society, 2010).

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Reflection

I would welcome comments on my blog post, or you may want to consider;

  • What can we all do to support people living with dementia to take positive risks within their daily lives?
  • How do you ensure you know what matters to a person living with dementia?

 

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References

Alzheimer’s Society (2010) – “My name is not dementia”.

Department of Health (2010) – “Nothing ventured, nothing gained: risk guidance for dementia”. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215960/dh_121493.pdf

Joseph Rowntree Foundation (2014) – “How can ‘positive risk-taking” help build dementia friendly communities?”

Christine Steel

Christine Steel
AHP Consultant, NHS Greater Glasgow and Clyde
@Christineahp

Christine studied Occupational Therapy in Glasgow. After graduating with a BSc (Hons) degree, she began working as a Basic Grade OT within a busy acute hospital. Since then, Christine has worked in a range of clinical areas including adult community mental health, acquired brain injury & addictions and most recently was employed as a Practice Development Head OT within Glasgow’s North East mental health services (adult & over 65’s). Christine has been on secondment as an AHP Dementia Consultant since August 2010, with a particular focus on the care of people with dementia within acute hospital settings.

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11 thoughts on “7 top tips to Risk Enablement

  1. Fantastic blog Christine…..lovely clear messages we can all relate to…. What’s so helpful here is that you give us really practical steps we can follow and ideas we can use to think about this topic together …not just in our teams but …importantly….with our patients and their families.

    • Thanks Sandra. So hard to say it all in a short blog but really enjoyed writing it & hope it helps people to start supporting positive risk taking.

  2. Christine, I really enjoyed reading your blog, I connected with it.
    This is something I have had to come to terms with on a daily basis as a carer for my husband Archie, who has Semantic dementia.

    With semantic dementia, their is loss of conceptual knowledge,the person can get on with daily living but they don’t understand danger recognise risk ,understand language or the world about them.
    In the beginning it is more difficult as some people can still be working, they are fit and healthy and want to continue life as it’s always been.
    It is classed under the early onset dementias.

    For me as a carer, I was under extreme stress and pressure on a daily basis.
    I found it difficult to let go as I was protecting a vulnerable adult while enabling him to carry on with daily living, to help him have some quality of life.

    On the few occasions I did let go, because of my frustration and the extreme stress I was under, to my surprise it was OK and I felt immensely proud of what he had achieved, despite him not knowing how something worked. He did feel good when he could sneak one over me! I always acknowledged what he achieved with a smile and praise, despite how I felt inside.

    It was, however, a very different scenario when out and about, not understanding road signs or traffic signals putting us both at risk,that was extremely difficult.

    However, despite all of that I was able to do take calculated risks by fully understanding his condition and let him keep as much of his independence as long as possible, to retain his self esteem. But it was not easy.

    Now in the advanced stages it is more difficult to take any risk whatsoever. “Risk”. becomes ‘”protection of a vulnerable adult'”

    • Thanks for taking the time to reply Myra. Your experience really highlights the reality of risk enablement and how challenging but at the same time rewarding it can be. Laughed at your husband thinking he had one over on you – he sounds like such a character. Would value any tips from you as to how we AHPs could make risk enablement less stressful for families, friends and carers.

      • Thank you Christine for raising a very important topic and the tips offered are very helpful ! It is a challenging area to address at times as highlighted by Myra… I would like to share that I recently carried out a mountain biking assessment with a man with young onset dementia who generally has very limited communication skills. During this activity which he clearly enjoys, I learnt how aware he was of potential risk of traffic on the single track road, as he warned me of a car approaching from a distance using spontaneous and appropriate speech, and ensured he and I were positioned on the road safely…taking on the role as my carer. Devising the occupational therapy risk enablement plan for the support worker to follow as a guide provided his family and the private support agency information about level of risk and how to manage the risk in certain situations during this and other activities. A review process is now in place as changes occur in his condition.

  3. Christine, yes he always had a mischievous streak and still did until recently. My tips are trial and error but the main one for me is to let them do whatever they want, I had to as Archie can’t understand any language but he knows exactly what he wants to do and I couldn’t stop him. Pasna talked about her situation when the person she was working with was aware of risk of traffic. When I was driving the car Archie checked the side mirror every twist and turn I drove, also checked the speedometer to check my speed! was also very aware of the risk of traffic, but couldn’t follow the Highway Code or understand the traffic light system. Had he been involved in an accident he couldn’t describe what happened because of his poor communication and comprehension.
    Driving is a huge issue for people with dementia and difficult for the carer. That is something that should be looked at! I repeatedly asked our CPN to counsel Archie about stopping driving and she repeatedly told me it was the GPs responsibility. It was left to me! Such a hard thing to do to tell someone they could no longer drive.
    What a journey, you forget the bad times as you move into another phase with even more complex challenges.

    I would like to have more guidance about driving. The sooner a person with dementia is encouraged to talk about this the better and safer it is for everyone and less stress for the carer .Should be part of the Link Worker role, but maybe guidance would support the discussion!

    Would like to see this develop, maybe a nice leaflet about risk taking and advice on driving. Would be extremely valuable and useful
    I think it would help us as Carers.and maybe lesson the stress if talked about sooner.

    Such a complex area with a very complex disease.

    • Pasna – that is an amazing example and so fantastic to hear about someone being supported to maintain involvement in an activity which has inherent risks but yets brings such health benefits. Myra – your points about driving are interesting. I totally agree that when risks can’t be facilitated, there needs to be a process to ease the transition. And starting the conversation earlier so it is a staged process and not an all or nothing approach is definitely key.

  4. Pingback: Let’s Talk About Dementia – 2015 | Let's Talk about Dementia

  5. Thank you Christine, if only I had been able to show your blog to ‘professionals’ who thought it beneficial to keep my father in a Kirkton Chair for months and have no outside air for over 8 months. I was seen as troublesome and detrimental to his care. He was described at 93 and dying as ‘challenging’, ‘it’s the dementia’, ‘it’s the agitiation’. I came across the Alzheiimers Society Fix Dementia in Hospitals campaign. I even took an iPod to the hospital after watched the Henry Music and Memories film resented by Sally Magnusson at the University of Stirling, I was told the staff could not use it in case it was stolen. He sat in a chair underneath a TV set, members of staff in the ward watched… I didn’t quite understand their concerns. I hope you don’t mind my sharing this. If you wish to contact me to find out where he was I am happy to share this as I think some of your inspiration to these staff could literally help people survive and end their days in their home, and appropriate care setting with outdoor access or a hospice. Thanks again it cheered me up immensely.

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