Risky business!


Among the papers in this issue that I found particularly engaging is Vallenga et al.’s (2008) report of their longitudinal action research project (pp. 261–272). The aim was to increase awareness of the decisions healthcare workers made about interventions that reduced risk for people with epilepsy and intellectual disability who were residents in a long stay institution. Risk management in such circumstances involves really tricky decision-making. Taking risks can involve exposing an individual to dangerous situations: on the other hand, measures that are overly protective can impose restrictions that are experienced by the individual as being detrimental to quality of life. The purpose of the research was to engage healthcare workers by utilizing the cyclical, reflective processes of action research to generate change in decision-making, care planning and delivery. There already was a desire for change within the healthcare worker team – an important prerequisite for undertaking successful action research!

During the research, which was conducted in the Netherlands, nurses and nursing assistants gained understanding about the analysis and evaluation inherent in decision-making about the risks to which residents were exposed. At the beginning of the research there was a lack of consensus about the extent to which residents should be protected by interventions: however, utilizing the cycles of action research, reflection, discussions and questions were generated. Decision-making about risk often involved uncertainty because a positive outcome was never a guarantee. Interesting questions were posed about risk management vs. risk elimination, about dignity associated with risk taking and about the impact on people with disabilities. In questioning the preconditions of nurses’ decision-making, the researchers enabled a shift from a problem-based approach to acknowledgement of the possibilities for individual residents. During the 22-month period over which the research was conducted, care-giving became more client-centred, and with decisions made in the context of a resident’s individual situation. Healthcare workers began to be less reactive when incidents occurred, instead considering risk minimization measures that were suited to a resident’s wishes. Emphasis shifted to client autonomy and self-determination by gaining an understanding through dialogue of client wishes and preferences.

Engaging healthcare workers in the reflective processes that characterize action research created change to practice. Importantly, the changes in the approach to decision-making about risk management were sustained, as demonstrated by an evaluation 6 months after completion of the research. For me, what is clearly demonstrated in this paper is the building of relationships between people that underpins the action research process. To do this requires the development of an environment that facilitates collaborative learning where responsive processes are established with improved abilities to improve decision-making through the sharing of information, communication and understanding.