Changing clinicians’ perceptions of the role that risk formulation and the HCR-20v3 play in the assessment and management of violence
| Date | 11 November 2019 |
| DOI | https://doi.org/10.1108/JFP-05-2019-0019 |
| Published date | 11 November 2019 |
| Pages | 212-227 |
| Author | Emma Elizabeth Covernton,Amy Moores,Joseph Aaron Lowenstein |
| Subject Matter | Health & social care |
Changing clinicians’perceptions of the
role that risk formulation and the
HCR-20v3 play in the assessment
and management of violence
Emma Elizabeth Covernton, Amy Moores and Joseph Aaron Lowenstein
Abstract
Purpose –The assessment and management of risk towards others is an integral part of clinical practice,
particularly in forensic and other psychiatric settings. Version 3 of the HCR-20 is the latest version of a
comprehensive set of professional guidelines based on the Structured Professional Judgement model. It is
the most widely used and best validated tool available to assess risk of violence; however, clinicians perceive
it as an additional task with limited clinical usefulness, which requires undergoing expensive training and takes
considerable time to implement. The paper aims to discuss these issues.
Design/methodology/approach –Training was delivered to 148 clinicians to improve perceptions with
regard to risk formulation and the HCR-20v3 as an effective and clinically useful tool in generating individual
and robust care plans to minimise risk of violence.
Findings –Results indicated significant score increase post-training, indicating higher regard for the HCR-20
in terms of its usefulness, anticipated impact upon working, anticipated impact upon managing risk, ease of
completion and perceived relevance to clinical practice. This was also consistent with qualitative feedback
indicating improved risk management and care planning with reference to how learning would support
respective roles. Feedback also highlighted the added value of certain aspects of the training provided, which
may be useful to consider when designing HCR-20 training packages.
Research limitations/implications –This study demonstrates the importance of engaging clinicians in
bespoke training on the practicalities of HCR-20 completion and the fundamentals of risk formulation.
Practical implications –This study highlights the importance of incorporating a training package for staff of
all disciplines in changing perceptions of risk management tools and thus their use in the practical
management of violence. The useful aspects of training may assist changing perceptions of the role that risk
formulation and the HCR-20v3 play in the assessment and management of violence.
Originality/value –This research suggests that if this can be done successfully, it may lead to a change in
the perception of the role that the HCR-20v3 can play in assessing risk of violence and generating meaningful
management plans to reduce the future likelihood of violence.
Keywords Risk management, Risk assessment, Staff training, HCR-20v3, Staff perceptions,
Risk formulation
Paper type Research paper
Introduction
The HCR-20 is a Structured Professional Judgement (SPJ) tool that bridges the gap between
assessing risk of future violence and formulating individualised robust management strategies to
reduce the likelihood of occurrence (Douglas, Hart, Webster, Belfrage, Guy and Wilson, 2014;
Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014).
Following profess ional consultatio n, version 3 now incorp orates concepts of ri sk formulation
and scenario plann ing as part of the SPJ approach aiming to make the complet ion of a
Received 15 May 2019
Revised 15 August 2019
Accepted 19 August 2019
Emma Elizabeth Covernton,
Amy Moores and Dr Joseph
Aaron Lowenstein are all based
at STRIVE Team, Dorset
HealthCare University NHS
Foundation Trust,
Poole, UK.
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VOL. 21 NO. 4 2019, pp. 212-227, © Emerald Publishing Limited, ISSN 2050-8794 DOI 10.1108/JFP-05-2019-0019
HCR-20 more dynamic, practical and accessible (Logan, 2014; Douglas, Hart, Webster,
Belfrage, Guy and Wilson, 2014; Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014).
For professionals, this means being able to generate feasible plans in order to try to
manage risk-related behaviour in the short term and facilitate change in the long term (Lewis
and Doyle, 2009; Logan, 2014). These changes have resulted in the HCR-20v3 tool being
more detailed and systematic, and it has subsequently shown to be more clinically useful
(Bjorkly et al., 2014).
The HCR-20 is used mo re routinely withi n forensic setting s whereby risk to oth ers is a key
criterion for admission; however, this tool is also gaining empirical support for use within other
psychiatric pop ulations, including community s ettings where it can be used to predic t violence
post-discharge ( Farrington et al. , 2008; Douglas, Har t, Webster, Belfra ge, Guy and Wilson,
2014; Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014; Strub et al., 2014; Doyle
et al., 2014). Despite the wealth of literature on the high incidence of violence within mental
health settings and the proven the clinical value of the HCR-20, Beazley et al. (2017) noted
that “cognitive distor tions”exist as significant perceived barriers to the routine completion
of HCR-20s (p.7). These “distortions”include the common perception that the completion of a
HCR-20 takes considerable time and is regarded as a non-essential task in addition to clinical
duties. These views are particularly likely in settings whereby risk to others is not a primary
concern, such as no n-forensic servic es. Another potent ial barrier relate s to individuals wh o
have been within the c are system for a substantial perio d of time. Such individuals may alre ady
have a comprehensive up-to-date case summary which includes a comprehensive risk
assessment and inf ormed management plan; hence, clinic ians are less likely to see the added
value of completing a HCR-20.
Education and training are considered an important component in overcoming these barriers by
shifting perceptions, improving knowledge and promoting skills to be used in practice.
Professionals are expected to be competent in risk assessment, even if they have little formal
training (Schwartz and Park, 1999). The emphasis in healthcare is often to train staff to enable
them to deliver high-quality care as well as to make them feel valued, invested in and confident in
the work they are doing (DoH, 2016; Jabbal, 2017).
Specific to mental health and secure settings, studies have shown that engaging in training for
tools such as the St ructured Assessment of Vio lence Risk in Youth (SAVRY; Bo rum et al., 2010)
and the Youth Level of Se rvice/Case Manage ment Inventory (YLS/ CMI; Hoge and Andrew s,
2002) can result in a shift in perceptions to recognise the usefulness of these SPJ tools to
formulate risk in comparison to a quantifying algorithmic tool (Guy et al., 2014). Training in SPJ
approaches, in general, can result in significant improvements in knowledge, practical skills and
confidence in assessing risk violence (Storey et al., 2011). In a study by McNie l et al.,
self-assessment of perceived competence in terms of ability to accurately assess patients’risk
of violence, knowledge about violence and working with violent patients, and ability to manage
patients’risk of violence were all shown to significantly improve, following a 5-h workshop on
evidence-based assessment and management of risk, violence and suicide. Interestingly, this
study also found tha t delivering trai ning leads to objecti ve improvements in the systematic
identification and documentation of formulation factors (McNiel et al., 2008). Other studies have
also shown that specific HCR-20 training can improve quality of, clinician knowledge
of and practical ski lls to complete effect ive and relevant HCR- 20s (Reynolds and Mile s, 2009;
Walker et al., 2013).
The importance of training provisions in the management of risk has been highlighted in best
practice guidance (DoH, 2007a), the HCR-20 manual (Douglas, Hart, Webster, Belfrage, Guy and
Wilson, 2014; Douglas, Shaffer, Blanchard, Guy, Reeves and Weir, 2014, p. 101) and is
recommended in the trust’s local Clinical Risk Policy. Additionally, Beazley et al. (2017) noted the
importance of training provisions to clinicians who have had a limited prior opportunity to develop
competencies of assessment and clinical formulatio n through experience, training and
supervision. In response to this, many NHS trusts are incorporating HCR-20 training into their
training packages, which is likely to result in variation, mirroring the wide variations in use and
implementation of the HCR-20 tool itself (Beazley et al., 2017). External HCR-20 training is
unlikely to be utilised by services due to the resource required to fund such a strategy. To the
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