Managing risk

Dealing with challenging behaviour requires strategies for assessing, reducing and managing risks.

Assessing risks

Risk assessment means evaluating the likelihood and consequences of challenging behaviour, as well as identifying measures to help avoid, mitigate or control the risks.

Risk assessment should take account of personal (physical, emotional, cognitive), situational, or environmental factors which increase the likelihood of challenging behaviour. Personal factors can be either current (e.g. clinical presentation) or historical (e.g. a history of challenging behaviour), and they can work independently or in combination to increase the risk.

Sample risk assessment forms are available to assist with this process.

A formal risk assessment will not always be possible in all settings. For example, in fast paced emergency departments, admissions units or acute medical wards, patients are often in crisis and have only short stays, so there may not be time. In these environments staff should be able to recognise risk factors; quickly identify challenging situations; seek immediate information from the patient, carer and/or colleagues; dynamically assess the risks; and take action to minimise harm.

Reducing risks

To reduce the risks associated with challenging behaviour, staff need to identify and meet the individual psychological, emotional and physical care needs of the person. This often means taking time to talk to the patient. Dignity is important: the individual should be kept comfortable, they should be valued and respected, and they should have choices concerning their treatment and care where possible.

Flexibility in staff culture and habits is also essential. Tolerating certain behaviours rather than trying to control them may in some cases be more effective than specific preventive actions. Staff also need to be aware of the need to communicate with the patient in a sensitive way and of how their interaction can positively or negatively reinforce challenging behaviours.

A strategy for reducing risks also requires greater collaboration between colleagues to form a collective understanding of the person’s  behaviour, and what they all need to do to prevent the behaviours.  It also involves collaboration with other colleagues, services, and family networks. More practical strategies for emergency and long-term care can be found in the section on care strategies.

Better understanding

Staff who are routinely exposed to challenging behaviour can come to think of it as ‘just part of the job’. However, a crucial part of managing risk is understanding the reasons for the behaviour in order to implement immediate or long-term care strategies.

Some important questions to ask are:

‘What is causing the distress?’
‘What are we doing that is leading to this person’s distress?’
‘What can I/we as an organisation do differently?’

Staff sometimes record their observations on incident analysis ‘ABC charts’ used to capture:

    • Antecedents/triggers of the behaviour  
    • Behaviours of the individual at the time of the incident
    • Consequences of the incident

These sample behaviour analysis charts may be helpful.

Managing risks

In potentially harmful situations, staff should apply a combination of prevention, avoidance and de-escalation. Interventions such as physical restraint, pharmacological responses and seclusion should be used as a last resort only where this approach proves ineffective on its own, and always in conjunction with continued de-escalation. Some strategies for managing risks include:

  • Care planning informed by risk assessment, including what specific interventions may be required
  • De-escalation based on highly developed communication skills, empathy, non-confrontation, negotiation, compromise, distraction, and/or changes in staffing
  • ‘Do nothing’ in appropriate cases – such as a transitional period in care – where challenging behaviour is likely to settle down within a few days without intervention other than keeping the individual, staff and others comfortable and safe
  • ‘Leave and return’ where someone resists care at a certain time, unless a medical procedure/treatment or other essential care task is urgent
  • Better understanding and tolerance, particularly where challenging behaviours are difficult to stop (e.g. wandering or persistent vocalisation) but not offensive or harmful, including accommodation within the confines of the care environment and mitigation of the effects
  • Heightened observation that goes beyond therapeutic engagement, as determined by the level of risk, but which is not intrusive and respects the dignity and privacy of the individual
  • Physical and pharmacological intervention as short-term strategies for the immediate control of a dangerous situation, where de-escalation and non-pharmacological strategies have already been attempted. More detail is available in the section on physical intervention.
  • A post-incident review to identify any lessons learnt from a particular incident which should be documented in care plans and shared with all relevant staff involved in delivering care for the person.

More detail on these and other strategies can be found in the Care strategies and Physical intervention sections.

For further information on managing risks, please refer to the full guidance document.