Positive risk-taking in intermediate care: a study of risk-related decision making in occupational therapy

Abstract

Intermediate care services support people at the interface between hospital and home and its services are mostly accessed by older adults with complex needs. There are many risks associated with discharging older adults from hospital to home. Employing positive risk-taking in occupational therapy intermediate care interventions is necessary to ensure safety and autonomy. In this context, it is likely that positive risk-taking barriers can impact discharge decisions, especially those made by students of occupational therapy or newly qualified practitioners who have been shown to be more risk averse than experienced practitioners. This research investigated the effect strength of positive risk-taking barriers at different levels of occupational therapy experience in relation to discharging older adults from hospital to home in occupational therapy intermediate care and other occupational therapy community services. To achieve this, a scoping review, a consensus study by Nominal Group Technique (NGT) and a factorial survey were undertaken. A scoping review of twenty-five articles (n=25) investigated the common areas of risk and their characteristics from an occupational therapy intermediate care perspective. It found ten risk domains: falls, discharge, practice errors, activities of daily living, pressure care, frailty management, patient handling, loneliness, nutritional care and language barriers. Three risk characteristics were identified, these were, ‘risk awareness and identifying risk’, ‘decision-making under risk’ and ‘improving safety’. Additionally, it was found that risk control, reconciliation with occupation, and facilitation of positive risk-taking were implicit and not directly addressed within the literature. The Nominal Group Technique (NGT) convened experienced intermediate care occupational therapists to determine the most prevalent risks and barriers to positive risk-taking. Nineteen (n=19) areas of risk and sixteen (n=16) positive risk-taking barriers were identified. ‘Falls’ and ‘Comorbidities’ were rated the most common areas of risk. ‘Different risk perception for organisations/providers’ was rated the highest positive risk-taking barrier. Based on the findings from the scoping review and the NGT, vignettes were constructed to approximate occupational therapy intermediate care discharge to home scenarios and the prevalent responses were organised into positive risk-taking barriers and facilitators. The factorial survey was employed to investigate the barriers to positive risk-taking at different levels of experience. Seventy-four (n=74) participants self-categorised their older adult occupational therapy experience into Novice, Semi-expert, Expert before answering a total of 281 vignettes. Those barriers that were found to be statistically significant in reducing the likelihood to recommend a home discharge for an older adult were ‘No Support’, Novices (β = -.315, p=0.002), Semi-experts (β = -.313, p=0.001) Experts (β = -.254, p=0.009); ‘Limited Capacity’, Novices (β = -.305, p<0.003), Semi-experts (β = -.254, p=0.006) Experts (β = -.376, p=0.001) and ‘Blame Culture’ Semi-experts (β = -.240, p=0.010). Novices were found to be less likely to recommend a home discharge by comparison, Semi-experts were the group most affected by the ‘Blame Culture’ factor and Experts considered the ‘Limited Capacity’ factor as the most relevant in this context. These findings are important to direct future research and could be used as a targeted approach to training occupational therapists at pre-registration level, inform intermediate care practice and benefit occupational therapists who are new to discharge risk assessment and positive risk-taking