Part 2: Positive Risk Taking for the People you Support

There has been a lot of pressure in health, aged and social care to assess and manage ‘risks’.  A risk assessment can sometimes restrict or prevent people from doing the things they want to do or living where they want to live.  This is in contradiction to wider agendas of positive risk taking supported by government legislation and restrictive practices that limit individual’s quality of life. 

Care providers have both a duty to uphold the basic rights and freedoms of the people they support, and a duty of care to protect them from foreseeable harm. 

WATCH VIDEO: Positive Risk Taking NHS Clip 3 mins 53 seconds. 

What is Positive Risk Taking?

Risk enablement, also called positive risk taking, is a way of supporting people with a cognitive impairment such as dementia to participate in activities that involve risk. It is an approach that you can use in your work which helps to maintain peoples’ choice and control over activities.

Working with people with dementia means that you support them to make choices and decisions, while also having to make some of your own in the process. On the one hand, you must respect the preferences of the people you support and their right to make decisions and exercise control over their own lives. On the other hand, you have a duty of care to take reasonable actions to ensure safety and well-being. This does not mean you cannot support people to take risks. It means you need to enable risk taking whilst also respecting preferences and minimising potential harm.

Positive risk taking as a concept, offers a more sophisticated way of assessing and managing risks.  It is about taking risks to achieve personal positive outcomes.  The term positive is not about the risk itself, but rather about the outcome of the risk. 

Positive risk taking asks you to consider: How can I support a person with dementia who wants to participate in activities which involve risk, while reducing their potential for harm?”

Getting the balance

It is important to remember that there is a balance between respecting the rights of people living with dementia and safeguarding their wellbeing. Achieving this balance can be challenging.

People with dementia have the same right to take risks as any other member of society but often rely on others to support them to do so.

Everybody wants to be sure that the people they support are not harmed. However, when you work in a way that places more importance on protection and control, you become less likely to support risk-taking behaviour and you become ‘risk averse’. What also happens as a result of this pattern of work, is that the dignity, choice and independence of the people you support may be compromised. Figure 2 below helps to show this using a graph.

Figure 2. More protection means less choice.

What gets in the way of enabling risk for people with cognitive disabilities?

Sometimes, there are obstacles – real or perceived – that can get in the way of making risk enablement work. This may include:

  • Family and staff preferences: Family members and support workers can adopt an overprotective ‘parenting’ role. This approach, called paternalism, can influence choice and be restrictive, often limiting opportunities.  We also need to be careful that the language and the way we communicate.  For example, instead of saying ‘stay back the kettle is hot’ you could say ‘remember the kettle is hot’.
  • Core values: These can affect the quality of the support you provide. So, if protection is one of your core values, then you might be more likely to make decisions which are suited to you rather than the individual you support. For example, you might do all the cooking for fear of anyone getting burnt from using the hot stove. Remember, risk enablement requires balance.
  • Time: Sometimes we feel pressured for time. Enabling risk may require you to prioritise some aspect of your work over others. For example, on a given day, you may be required to spend more time filling out paperwork and this means you spend less time with the person you support. Shifting your thinking and planning will help you get the balance.
  • Risk Aversion/Blame Culture: Care staff are often concerned about being blamed or not supported by managers for positive risk taking, particularly if the person they support is hurt through an activity involving risk. Working through this resource will help you to learn how this worry might be managed by exploring the way your organisation supports risk enablement.
  • Lack of training: Learning about techniques to support people with cognitive disabilities, like learning about enabling risk, should be an ongoing part of your working life. Completing training like this is one way forward and will enable you to improve the quality of care you provide.
  • A lack of understanding between positive risk-taking and how this differs from ‘negligent’ practice.  It is important that people have a good understanding of relevant legislation related to:
    • Mental / Decision Making Capacity – there is a much higher threshold for judging a person as lacking the capacity to make a decision than is commonly thought.
    • Human Rights – protects everyone’s rights to liberty.
    • Equality / Anti-Discrimination – requires public bodies to ensure policies and practices do not have a disproportionately negative impact on people with a disability.

Achieving a balance between enabling risk and minimizing harm takes time, training, practice and reflection.  You have an important role in enabling the people you support to take risks so that they can have new experiences and become more engaged in their day-to-day lives. Supporting positive risk taking means that you support positive benefits like the ones outlined previously.

VIDEO 2: Louise and Shona Care Inspectorate 4mins 10 seconds

What happens over time when carers try to eliminate risk?

Risk can never be fully eliminated because risk also comes from not taking any risks at all.

A worker who adopts risk averse practice can diminish a person’s self-esteem, confidence and independence. There is also reduced opportunity for people being supported to learn and develop new skills. Unwanted physical and psychosocial outcomes can result.

A cycle of dependency is created when a risk averse approach is used. This means that the people you support are forced to rely on the support of others for their basic needs to be met.

Figure 3. Cycle of dependency is created when risk is eliminated.

When a worker does not enable risk, they actually encourage the person they support to become more dependent on others for help. Wanting to eliminate risk creates an environment where there are no opportunities for people with cognitive disabilities to have a chance to learn from either failure or success and they can therefore become more vulnerable.

Eliminating risk should not be a part of the way in which you provide support. Your role is to enable people with dementia to live an engaged life.

The concept of ‘positive risk taking’ is about sharing risk.  Making decisions and managing risks should be a shared decision, not a burden for a single individual.  Whatever condition people are living with, they still have strengths to call upon, their personal history and experiences, capabilities and wishes. 

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