Risk Management among Older People - Essay Example

?[Question 3] Social Work: Risk Management among Older People Assessment of risk is central to all social work, with the best strategies being soughtcontinually to undertake it. The concept of risk in the society has become a subject of dominance in the political and social landscape. The importance of risk in society thus rightfully calls for studies into it. This study will explore the concept of risk, the social workers duty and reasons for engaging in risk assessment and the theories and approaches used in risk assessment. All of these will be in relation to a special category of service users; older people, where the discussion will lead to the establishment of the best range of methods utilised in risk assessment in this group. What is Risk? In the social context of the word, it is appreciated that the concept of risk is a much contested issue, but at the same time a much highlighted issue in society (Calder 2008, p. 40). McDonald (2010, p. 99) argues that risk is quite a serious societal issue as demonstrated by more emphasis being placed in distribution of risks than in distribution of wealth. McDonald then explores several perspectives of the definition/concept of risk in the society as it relates to social work, beginning with the widely accepted legal view that risk is the likelihood of an event occurring and the existence of a duty of care that is owed to those who might be affected (in this case the elderly) by reasonably foreseeable consequences of another party’s actions (100). Another perspective of risk is the actuarial notion, where it is the probability of occurrence of certain events based on statistical analyses of whole populations or subgroups, where in this case we have the older people sub-group. McDonald also discusses the social constructivist aspect of risk, where certain risks have been granted cultural acceptance based on different societal dynamics. An example concerning older people is where certain risk-taking behaviours are out of question in a manner different to young people who may not be limited by such events. For instance, although the risk of injury from engaging in sport is present for all sub-groups, older people are more constrained from it differently from young people. Across all these concepts of risk, it is discernible that the shared characteristic is in the probability of an event occurring, and for the purposes of social work, an opportunity to pre-empt the event from occurring which forms a vital dimension of social work. The functional definition is that risk involves calculation of probability of and description of the likelihood of a future event given certain conditions, while at the same time recognising duty of care. Risk assessment is an issue related to the probabilistic aspect of the social workers knowledge base; hence it involves balancing out the outcomes for the service user in question (Hawkes 2003, p. 6). The role of the social worker here is to assess the probability of significant harm occurring, or assess that which has already occurred in a bid to prevent further/future harm from occurring. Assessment of risk occupies a pivotal position in social work since it occurs at the initial point of contact between the service user and the social worker, and hence the effectiveness of intervention mechanisms depends to a large extent on the outcomes of the risk assessment. Social Worker Duty, Reasons for Risk Assessment and Obsession with Risk Assessment The reasons behind the obsession of social work with risk assessment can be traced from the trends in the wider society. McLauglin (2008, pp. 3-6) first establishes that there is an ongoing preoccupation with risk in the society and its minimisation, with the primary concern of the contemporary society shifting from being after something good to instead preventing the worst (tendency towards self-limitation as opposed to pursuing self realisation). This shift is being driven by a shift from natural hazards to man-made ones especially in the developed world, where for example an older person may not be in risk of starvation but at risk from manufactured uncertainties arising from technological innovations. Another aspect of the self-limitation concept in societal risk is that it is to a large extent based on a culture of fear, where the perceived risk is much greater than the actual risk. The other notable aspect of this contemporary risk discourse is that at risk individuals are presented as being powerless in the face of pertinent danger. In the midst of this social construction of risk-limitation, social work policy is also impacted in a major way with the central theme thus being risk minimization. The obsession of social work with risk assessment is therefore a direct product of the society’s perceptions of being at risk and needing to be aided from it. In such a situation, the first action that social workers undertake is to establish the level of risk the service user is in and then take the necessary measures. A consequence of this for instance among older people is that they may be denied the help required to live at home due to the fear that it is an environment in which they will be at risk. After establishing the reasons behind society’s obsession with risk, the next step is to establish the reasons behind the emphasis placed on risk assessment. Here, it is observed that risks are a potential and serious source of likelihood of harm which results in an undesirable thing, and thus need to be managed properly and adequately. Such risk management is dependent on effective risk assessment. As Kerr et al (2005, pp. 32-33) state, assessment is the first action undertaken by a social worker on the service user groups. It is necessary in establishing the intervention that needs to be implemented by the social worker and thus plays a central role between the service user and the entire social work system in terms of eligibility. With time, risk assessment has gained a significant role in the determination of priority for intervention. Risk assessment enables the social worker to determine the individual who is at most risk and thus structure the provision of social work services in (Bostock et al. 2005, p. 20; Carr 2004, p. 20). It has become a primary duty for the social worker to conduct a risk assessment due to the much criticized resource-led nature of social services as they centre on the need to determine eligibility in terms of the individual who is at greatest risk. Kerr et al. (2005, 35) argues that risk management is a core distinction among social workers, which translates to the preceding risk assessment being hugely influential. The next issue for discussion is why social workers need to control risks among the service users. This raises fundamental questions that have created a debate in terms of whether social work should be geared towards needs assessment or towards risk assessment. Whereas there are a sizeable number of individuals who would concur with Martin (2008, p. 8) that assessment is rightfully inclusive of both needs and risk assessment, there is debate on which should be the primary driver of assessment. Much of such debate is due to the fact that control of risks is accompanied by sometimes drastic measures such as removing an elderly individual from home or separating a child from the parents. It is, however, necessary to know that social work makes an effort to control risks due to its being more of a priority since the individual in question may be in the face of a negatively life-changing event. Use of Theory in Assessment of Old People by Social Workers According to Watson and West (2006, p. 20), use of formal theories in social work practice is particularly relevant since it helps in understanding social work and guides engagement with the service users. Here, the theories applicable in social work can be categorized into two; grand theories and middle-level theories. Middle level theories are more specified and directed to social work practice and include; theories on society, social policy, family, individuals, motivation and change. The authors argue that formal theories provide a starting point for the social worker, who would then be required to incorporate these into the particular situation as they rarely relate to precise situations. There are several theories in social work that can be applied in risk assessment among the elderly. One of these is the person-in-environment theory, which appreciates the interacting influence of individual capacities and needs and the specific demands and opportunities of the environment. In this approach, the social worker identifies the individual’s transactions with the environment and the impact of the environment on the client or client systems (Greene 2008, pp. 134-135). In terms of elderly clients, the assessment by the social worker should thus be aimed at analysing how the client relates with the individuals around them, for example the immediate family, and how the family in turn interacts with the client. Assessment in this manner may help the social worker gain insights into risks may be in the path of the client as a result of their environment and the people around them. Instances of abuse and neglect can be discerned from the client’s interaction with the people around them. Neglect may be in the form of not ensuring that the client’s environment is free from hazards. The main advantage of adopting this theory is that it enables the risk assessment to discern the life space of clients and the multiple sources of influence at play for the old individual and as a result implement the best intervention strategies. Another theory that can be utilised in risk assessment of elderly clients is the resilience theory. According to Ungar (2008, pp. 6-7), resilience theory focuses on the processes behind positive adaptation and development in the face of adversity and disadvantage. It is thus related to the person-in-environment model where, in this case relating to adapting well to adversity in the ecological context. Social work practice based on resilience derives from engaging the client from the strengths perspective. Here, risk assessment is a critical aspect if at all the client engagement is to head towards resilience. For instance, assessment of the elderly based on strengths follows the pattern of leading the client from the problem-saturated side to appreciation of the client’s strengths. The client is assessed in a manner involving analysis of the environmental strengths and personal strengths versus the environmental and personal obstacles. The structure of the risk assessment based on this theory involves questions that gather information on the survival of the old client up to the moment of assessment, highlighting availability of support from individuals in the client’s environment, seeking to know the positive aspects of client’s life during exceptions of suffering, the possibilities that would translate to a better situation and lastly esteem-based inquiry (VanBrenda 2001, pp. 205-206). Some of the advantages that accompany this theoretical approach include the alleviation of the debate on emphasis on risks since this model highlights the client’s strengths in the face of the risks. Another advantage is that it serves as a form of early intervention since the process of risk assessment is accompanied by strengthening the client. Methods and approaches used in Risk Assessment It is a consensus that assessment is central to effective social work practice. It includes a range of activities from basic observation and judgment deduction resulting from the context of the first meeting with the client to more formal frameworks of undertaking assessment. It is the first step in social work practice, with its purpose being helping the social worker to understand the client’s situation. It is the gateway to helping social workers identify areas for potential intervention and help build a rationale intervention in the future. One aspect of risk assessment is the importance of the social worker’s approach, which influences the effectiveness of the entire process and helps determine how the clients themselves may contribute to the assessment process. Watson and West (2006, p. 30) identify the four underlying steps that are common in all approaches of assessment; preparation to meet the client, the actual meeting where a relationship is built and relevant information gathered, reflection and analysis of the information gathered by the social worker and lastly implementation of action. For risk assessment, the standard approach is to identify the hazards, determine who may be harmed and in what ways, evaluate the risks and decide on the precautions, record the findings and use them to inform intervention and lastly review the risk assessment with an aim of updating it where necessary. In recent times, assessment has gradually shifted from being needs-based to being risk-based, where the social worker undertakes the assessment with the focus being on the hazard at hand to the client. Much criticism has accompanied this shift, including the view that it has narrowed down from being holistic to focusing on a single issue. The result of risk assessment is also an issue of concern since it may focus efforts on what should be avoided (emphasis on the negative) rather than building on the positive in terms of what can be done. Watson and West (2006, p.40) discuss three models through which risk assessment can be approached. The first one is the question model, which is based on the social workers employing a set of questions to collect information from rather passive clients. In this model, the social worker is the expert with the ability to interpret data and establish the service user’s needs and risks. It follows the traditional and perhaps outdated model of social work professionalism in which the social worker wields all the power and plays the larger active role while the service user remains in the background. It is agreed that this approach is counteractive to efforts towards empowerment of the service users and thus should be limited. It is, however, crucial to realise that social workers still need to collect information from their clients and thus not possbile to totally do away with this model. The next approach is based on the procedural model which is centred on completion of a number of checklists to determine whether the potential client is eligible to access the social work services. In this assessment model, the power lies in the checklist designer, with the social worker being relegated to gathering information while the service user still remains in the background. The main advantage of this approach is on its ability to optimise social work services to the available resources which largely depends on the collection of facts from the service users. It, however, insubordinates the client in relation to the process of gathering information and may fail to address pertinent problems which might not be covered in the formulated checklists. The last model is the exchange approach, which appreciates the view that clients are of importance to social work practice as they can be viewed as self-experts; bearing fundamental knowledge about their lives and the environments in which they are in. This form of risk assessment is geared towards establishing a relationship that enables the service user to identify their strengths and weaknesses as well as the opportunities and threats in their environment. It is an assessment model that places the client in the midst of assessment and thus empowers them to have significant input in the intervention that follows the assessment. Whether in terms of needs or risks, this assessment model provides the service users with an opportunity to impact their own lives, which has become the mainstay of current assessment and intervention efforts (Barry 2007; Trevithick 2001, p. 140). All the common avenues through which risk assessment is undertaken can be seen to follow one of these approaches, with the central issue being power-play within social work practice; the procedural model grants power to the social work system while the exchange approach grants power to the service user. How Old People’s Risk Assessment is done in Social Work Client-centred Risk Assessment Patient-centred approach in all forms of social work has received much emphasis and support with wide consensus being that it is the best approach to social practice. According to the Centre for Policy on Ageing (CPA 2008, P. 1) client-centred approaches in social work refer to avenues through which social service is commissioned, provided and organized in a manner that listens to the service user and helps them live in the community according to their choice. Here, resources are utilised in a flexible manner to be personalised to an individual’s perspective in a bid to adjust social services to suit the individual rather than fitting the person into pre-existing models of services (Patmore and McNulty 2005, p. 3). Galloway (2010, p. 16) directly defines this concept as expressed in several different terms; client-centred, patient-centred, personalised care or individualised care, as the treatment of people as individuals and provision of opportunities to such individuals to make choices about their health. Dowling et al. (2006 p. 3) traces the origins of person-centred approach to the works of Carl Rogers, who extensively explored the concept of person-centred psychotherapy. Since Roger’s era of influence, the concept gained gradual but significant growth in social work first being through normalisation-where long stay homes for the disabled were being closed down in the 1970s with emphasis being placed on ordinary living. The turn of the new millennium so person-centred approach gain weight in instruction of people with learning difficulties, and has since revolutionised social work care. Before client-centred risk assessment and management among the old service users and their carers can be discussed, it is perhaps necessary to establish the reasons as to why it has been given much emphasis especially since the dawn of the new millennium when national policy has leaned majorly towards its promotion (Dowling et al. 2006, p. 1). Galloway (2010, p. 9) explains the issue of ageism, where an individual is discriminated against based on their age. It was not uncommon for such discrimination to be practiced a few years ago, with some of its manifestations including; lower standard of services; deny to access of services while being told that some of their problems are directly related old age; and finally not being involved in the decision-making process on the basis of old age. Galloway (10) further explains that the elderly members of society are subjected to stereotypes- incontinence, confusion and lack of contribution to society- and labels such as the derogatively used term geriatric, besides names such as coffin-dodgers. It can thus be appreciated that the elderly people have had to undergo particularly difficult situations and thus were in need of a responsive social practice system that came in the form of the client-centred model. A key issue in older people’s social work is respect/dignity, where the NFS Standard 2 (2001, p. 65) argues that older people and their carers have not always been treated with requisite dignity and respect besides their being denied involvement in risk assessment and decision-making. Client-centred social work also arose for the older people due to the realisation that organisational structures acted to impede the provision of coordinated care personalised to the older people. The client-centred approach currently in use in the UK is based on the Single Assessment Plan (SAP) which was introduced in the National Service Framework for Older People in 2001 as the Standard 2: Person centred care. According to CPA (2008, p. 1) the aim of the SAP is to ensure that social care practice treats older people as individuals, enabling them to make choices about their own care. The decision to form the SAP was informed by the realisation that older people bear needs that are wide-ranging and thus require that the stakeholder agencies cooperate and collaborate to ensure that assessment and the subsequent care planning are ultimately effective. In the typical exchange approach explained earlier, NFS Standard 2 (2001, p. 65) explains that older people and their carers should be involved in their own assessment so as properly assess their complex needs and thus result in care provision that enables them to function independently and prevent the commonplace premature admission to residential care homes. The NFS Standard 2 (2001, p. 66) explains that client-centred assessment for the older people involves three fundamental tenets; appropriate personal and professional behaviour by social workers handling older people; systematic inquiry into the views of the service users and carers; lastly, provision of sufficient information to the older people and their carers so as to ensure they are significantly involved in assessment and decision-making about their own care. An important concept in client-centred approach to older people social work involves home-based care; hence the assessment should rightfully involve the carer to ensure that the patient-in-environment risks are taken care of. Besides the SAP approach, CPA (2008, p. 2) also discusses the Common Assessment Framework (CAF) for adults that is also used for social work among in the UK. Here, the artificial older age boundary is targeted for removal so as to allow for the provision of continuity in person-centred assessment and care throughout an individual’s adult life. One of the reasons behind this development is the appreciation of the difficulty in having separate approaches for adults especially when an individual bears multiple needs and thus would have to navigate through different systems. As can be discerned from the SAP framework, risk assessment is based on the principles of being person-centred, encouraging independence, respect of dignity and confidentiality and lastly promotion of self-determination. Some of the areas in which risks may manifest for the old service user and their carers include the home conditions, physical health, financial ability, diet, mobility, availability of vital medication and mental health. It is the duty of the social worker to undertake effective patient-centred risk assessment based on the best available evidence so as to ensure that old service users and their carers receive the best possible services. An area in the risk assessment for older people that deserves particular mention is mental health risks. According to Nicholls (2006, p. 21), older individuals with mental health needs require similar skills as any other risk assessment, and social work on them is based on same principles of a client-centred approach. They have a right to correct standards of assessment and social care services as other categories of individuals at risk. Important considerations here are that older people bearing mental health needs have higher vulnerability, anxiety, confusion, and perhaps a history of being dismissed as mentally ill. To offset these, it is the responsibility of social workers to conduct assessment as they would any other individual; honestly, openly, with respect and the necessary social work empathy. The social worker still has the responsibility to assess their independence ability and not assume they are incapable unless proven otherwise. Carers play a pivotal role in the risk assessment of such individuals. Social Worker Skills for Older People and Service User Involvement Effective communication skills are crucial in helping to make the service users at ease, gather the necessary information and empower them to feel integrated in the risk assessment. Communication is thus central to successful client-centred risk-assessment, and involves effective listening skills since the views of the old person and helper are to be part of the assessment (Watson and West 2006, pp. 44-47). Negotiation skills are also of utmost importance in client-centred approach since they allow the social worker to balance off legal/ethical/experiential requirements with the wishes and input of the service users. To empower them, negotiation seeks out the commonalities rather than the differences in views (47). Decision-making skills cannot be done away with in any social work; the worker has to decide who to involve in the client-centred risk assessment, the relevance of the information and the course of action (48). Besides the just discussed people skills, risk assessment with older people and their carers also requires practical skills such as securing and coordinating resources and problem-solving skills (Kerr et al. 2005, p. 43). As already discussed, client-centred approach is based on the concept of involving the service users in the risk assessment. It is imperative that the social worker appreciates the knowledge of the situation according to the old person and the carer. Thus, the social worker should seek this information for example through enquiry of the potential hazards within the environment for both the old person and the carer. The required historical information can also be sought from the two parties, besides arriving at conclusions and decisions with them. Documentation of the risk assessment can also involve incorporating the care giver’s and old person’s own words, stories, goals and feedback. Another aspect of involvement is empowering the two parties with the necessary information (financial, legal among others) on the situation so as to enable them make informed contributions to the risk assessment, besides ensuring that every decision/resolution arrived at is communicated to them (NASW 2010, P. 37). Reflection and Recommendations on Risk Management in Old People There are three general approaches to assessment that can be applied to risk assessment among old people; a questions approach, a procedural approach and an exchange approach. The first two grant power to the social work system and away from the service user (old person) and thus go against the efforts of service user empowerment. The third approach-exchange- places focus on the old individual during assessment and the subsequent steps of intervention. The widely supported client-centred approach to social work is clearly based on this model. The client-centred approach seeks to customise social work efforts beginning with risk assessment on the old person, seeking their input, providing them with sufficient information, involving them in the decision-making process, treating them with respect and dignity at all times and thus promoting independence to the individual’s level best. This, in personal view, is the correct way to go about risk assessment and the subsequent risk management among older people. The Common Assessment Framework (CPA 2008, p. 2) is also a commendable effort since it maintains involvement of the service user (older people and their carers) and identifies that complex needs and risks make it difficult to access convenient and effective social work services. A recommendation informed by reflection based on this analysis/study is that there are still many players in the issue of older people’s social services; the social worker, the government, the older people and their carers, social work agencies, social work scholars, the healthcare industry, and old people’s forums among others all of whose views need to be considered. It is perhaps advisable that any revisions made on the SAP or any new policies for older people’s care under consideration should involve all of these stakeholders in order to generate the most formidable risk assessment framework based around the service user that will stand the test of time. Conclusion People live in societies where a heightened sense of risk pervades, and social work thus has to respond to this situation by focusing on risk assessment. Older people are a respected group in social work, and efforts directed to them should treat them appropriately. A method of risk assessment highlighting the central role of older people and their carers is the best approach available so far since it results in the attractive client-centred approach to social work. Upon reflection on the study, my opinion is that client-centred approach is the most effective to risk assessment and intervention among older people. It is recommended that future updates on the current policy in care for old people or establishment of new policy should involve all the relevant stakeholders so as to generate the highest quality framework for assessment and management of older people’s risk. References Barry, M 2007, Effective approaches to risk assessment in social work: An international literature review, Scottish Executive Social Research, UK. Bostock, L Bairstow, S, Fish, S & Macleod, F 2005, Managing risk and minimising mistakes in services to children and families, SCIE, London. 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