Here is the text of the presentation given by Brendan Broderick at the 20th Anniversary Discussions In Disability conference held at the George Moore Auditorium, UCD O’Brien Centre for Science, UCD in July 2016.
In this presentation I want to set out the co-ordinates within which we seek to navigate risk.
The key messages I will be promoting are:
- Primarily we need to be addressing the issue of a life worth living – and looking at risk within this frame. A relevant observation here is the comment some years back of a participant in a staff induction programme who, having turned 50, decided to treat himself to a once-in-a-lifetime experience: a parachute jump. On arrival at the parachute centre, he was startled to find three individuals with significant physical disability preparing to share this thrill-seeking experience. His richly ironic comment “that’s real risk assessment – because them fellows [the guides] don’t take chances” gets to the core of risk planning in the context of a life worth living;
- A life worth living is a multidimensional, complex, incident- and encounter-packed experience. Hopefully there’s more going on than can be written up;
- In some ways risk can be viewed as the oxygen of life;
- Safety first – but not safety only;
- What kind of life is left if we edit out surprise, adventure, serendipity? This is not to urge intuitive, give-it-a-lash impulsivity, but it is to caution that responsible risk-focused thinking and risk consciousness does not always have to conform to formal, team-based, documented approaches, although there certainly are scenarios and decisions which require such rigour.
The challenge and anxiety for the individual with a disability is whether he or she is going to be able to stake out a life worth living in a space easily dominated by a service provider increasingly preoccupied with parallel and layered compliance accountabilities. It would be naive to assume that the odds are stacked in favour of the individual.
Some believe that it is possible to reduce life to an ordered series of static freeze-framed moments, each of which can be comprehensively scanned for risk, with each discrete risk identified becoming the subject of team-based risk assessment, resulting in documented protocols that anticipate every bounce of the ball. Seamus Heaney’s phrase about a dream of order comes to mind.
Translated into practice, this orientation generates a parody of a life worth living, a slow-motion existence keeping pace with the system’s capacity to generate the defensive documentation that keeps it safe in its various accountabilities.
A life worth living is not some classical symphony where each separate note is carefully scored in advance. It has more in common with a jazz ensemble – musical themes developed imaginatively, intuitively, by people with a shared understanding and shared sympathies, people who are making music in the moment, where there is space and leeway for individuals to express themselves, producing by times sublime passages, felicitous errors, some bum notes and the occasional discordant sound. This is our guiding metaphor for what we are trying to create in our organisation. I use the word create deliberately. Fundamentally this is creative work, not a technocratic engineering enterprise underpinned by a suite of Standard Operating Procedures.
John Armstrong, the Australian Social Role Valorisation consultant, summarised this cogently at the HSE “Summit” in Croke Park last year when he contrasted complicated and complex enterprises. Complicated work is where the heart of the matter is precision: there is an objectively correct answer and an identifiably correct/best way of doing things. This reflects the thinking and work practices in aeronautics, pharmaceutical engineering, neurosurgery, intensive care medicine, petrochemical engineering. Complex enterprises on the other hand, have at their heart the acquisition of insight and the exercise of judgment, subjective judgment. These are ideal types. In the impure world in which we live we straddle and weave between complicated and complex. The contention is that ultimately and fundamentally our sphere of practice is more complex than complicated.
Where does risk fit into all of this? What is the relationship between risk and life? Life is inherently uncertain. Operating in the shadow of duty of care, we are prone to acquiring control-orientated mindsets. We view uncertainty negatively, a zone replete with largely nasty possibilities. However, what hollowed out, short-changed lives would each of us have if we sought to nullify uncertainty? The same implications hold for those we support. The challenge is to reframe uncertainty as an entwining of both positive and negative.
Safety is the bottom line. However, it is not the ultimate aspiration and cannot be the exclusive point of reference when supporting people to access a good life – safety first, by all means, but not safety only. Uncertainty and risk are ever-present. Eradicate them and one inadvertently cuts off the oxygen of life. There is a deep-seated paradox at the heart of the safety-at-all-costs quest. Risk cannot be eradicated. When we seek to create risk-sterilised environments, we end up introducing enormous opportunity-cost risks, and a whole host of other poorly-recognised risks: the risk of being locked within a life-wasting regime; increased risk of different kinds of neglect and abuse, even increased risks to particular kinds of infections.
Lives worth living involve elements of surprise, adventure, taking advantage of the current, getting into the traffic, responding to the breaking ball.
Our risk-scanning sensors and our risk-management skills are vital life-preserving, life-enhancing adaptive capacities. But they do need to be focused, and focused proportionately, on the right targets, not squandered on plausible but ultimately inconsequential sources of risk. While every moment, every scenario is teeming with theoretical risk possibilities, the vast majority of these will need to be spontaneously, implicitly negotiated. If we seek to adopt a consciously considered approach to every potential risk, our risk-navigational systems will overload and crash.
What’s involved in competently and responsibly managing risk? What does effective risk management look like? It needs to be open, mindful (conscious, not locked onto automatic pilot mode), alive to the dialogue of opportunity-opportunity cost, fit-for-purpose. By fit-for-purpose I mean that the approach to risk management does not unnecessarily compromise or otherwise drain value from the life being lived out. Fit-for-purpose risk management can keep up with the life being lived. It does not seek to unnecessarily slow down or freeze life to accommodate arbitrary requirements of the risk management system. Crucially this implies that most effective approaches to risk management will be done ‘live’, as things are happening. Effective risk managers are people who can spontaneously profile the shifting figure-ground risk dimensions in dynamically unfolding situations. There is a significant improvisational element involved. While this can be caricatured as making it up as we go along, it’s the improvisation of the musician acutely aware of the melodic and harmonic parameters within which he is operating. Drain risk management of this improvisational quality and the life being lived reverts and degrades to slow-motion, set-piece deliberation.
Are there occasions when the Big Set-piece MDT Process is necessary/does add value? Yes:
- When a very significant stepped change is being contemplated, e.g. a major strategic change in medication regime, someone moving from a 24 x 7 situation to independent or semi-independent living;
- When there is a line of action being considered which involves great hazards, ones which could hugely set back progress which has been made with the individual;
- Where there is a divergence of opinion among key stakeholders about an important course of action;
- Where restrictive practices are in use or being contemplated.
Some parting observations
Isn’t it interesting that nobody ever asks us whether we are too risk-averse, whether we might be risk-obsessed to the point of it becoming a self-defeating fetish (from the perspective of the individual we are supporting)?
We might profitably risk-assess our risk orientation and associated processes, and review whether they are adding value to or draining value from the lives of individuals we purport to support in their yearning for a life worth living.
We might also profitably review whether the growing scale of our investment in exhaustive, panoramic documentation is adding or eroding value – and while we’re at it we might also check out whether our belief that documented material is a sound touchstone for validating the lived reality experienced by individuals dependent on services holds up.
We might also risk-assess whether our growing-like-topsy policy landscapes are overwhelming staff and service users in their levels of detail and elaboration, and constraining staff at all levels from exercising appropriate discernment and judgment.
We need to create a new culture around risk, one in which we are as prepared to hold one another accountable for what we have failed to do as we are to hold one another accountable when we have not been as painstaking in our analysis of risk as we ought to have been. This new culture would recognise that heavy costs are incurred by any unbalanced position on risk.