RISK ASSESSMENT TOOLS AVAILABLE TO INFORM A NURSE PRACTITIONER’S DETERMINATION OF TOLERABLE RISK by E. Ricki Smith PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING –FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA October, 2020 © E. Ricki Smith, 2020 ii Abstract Risk in health care, often discussed in terms of its tolerability, is an abstract term that is patient- and context-specific. An older adult living at risk can be someone falling frequently at home risking a fractured hip, to someone self-neglecting. Family Nurse Practitioners working in Primary Care are well-situated to support patients over time and to mitigate risk. A better understanding of the risk assessment tools available to inform a level of risk tolerability for Nurse Practitioners working in Primary Care may enhance clinical reasoning and enhance their comfort with the concept of risk, resulting in consistent care delivery for patients. Evidencebased literature highlights the complexity of both defining and assessing risk, which is further reflected within the assessment tools. For these reasons, the purpose of this integrative literature review is to provide recommendations, founded in current literature findings, regarding the comprehensive risk assessment tools used to inform a Nurse Practitioner’s determination of tolerable risk for community-dwelling older adults. A search of three databases, as well as hand searches, resulted in nine tools for analysis. The interpretation of the findings suggested that risk assessment tools varied in their approach to risk, with some focused preventatively on risk mitigation while others could be applied in real-time to assess the severity of a perceived risk. Each tool included elements of risk which together, comprise a comprehensive, holistic risk assessment to be considered in the ongoing assessment of tolerable risk. A positive risk-based approach is also a shift in risk perception that Nurse Practitioners are encouraged to consider. The implications for practice include how the described approaches guide decision-making and the definitions of tolerable and intolerable risk can steer the Nurse Practitioner’s care, as well as to inform future research and the development of new risk assessment tools. Keywords: Older adult, tolerable risk, intolerable risk, risk assessment tool(s), assessment iii Table of Conte nts Abstract .......................................................................................................................................... ii Table of Conte nts ........................................................................................................................................................ iii List of Tables ................................................................................................................................. v List of Abbre viations ................................................................................................................... vi Acknowle dge me nts...................................................................................................................................... vii Chapte r 1 - Introduction .............................................................................................................. 8 Chapte r 2 - Background ............................................................................................................. 10 Canada’s Aging Population........................................................................................................ 10 Long-te rm Care and Community He althcare in British Columbia ................................... 11 Defining Risk ........................................................................................................................... 15 Tolerable Risk ........................................................................................................................ 18 Ethical Principle s .................................................................................................................... 20 Capacity and Legislation ........................................................................................................ 23 Scree ning Tools.................................................................................................................................. 25 Compre he nsive ve rsus Focuse d Risk Assessme nt Tools .......................................................... 26 Relevance to Nurse Practitione r Practice ............................................................................. 26 Defining the Research Question ............................................................................................ 28 Chapte r 3 - Research Methods................................................................................................... 29 Se arch Strate gies ..................................................................................................................... 30 Inclusion and Exclusion Criteria ............................................................................................... 31 Se arch Results and Data Analysis ......................................................................................... 33 Chapte r 4 - Literature Findings..................................................................................................... 35 Study Ove rview ....................................................................................................................... 35 Type and Quality of Evide nce ............................................................................................................. 44 The Risk Assessme nt Tools ............................................................................................................. 46 Approach to Assessing Risk: Quantitative versus Qua litative .....................................................46 Type of Assessment Tool: Predictive versus Responsive ......................................................48 The Elements of Risk Being Assessed ............................................................................... 50 The Outcome Me asures ................................................................................................................... 55 How Risk is Viewed and Person-ce ntre d Care .................................................................................. 58 Chapte r 5 - Discussion and Recomme ndations............................................................................... 61 The Risk Assessme nt Tools ............................................................................................................. 61 Predictive versus Responsive Approaches as They Relate to Tolerable Risk .......................62 The Feasibility of the Tools ................................................................................................... 65 Elements of Risk: Function and Cognition ............................................................................68 Physica l Functioning and Health Conditions .........................................................................73 Outcome Me asures ...................................................................................................................... 74 Vie ws of Risk ........................................................................................................................... 75 Stre ngths and Limitations of the Literature Review ........................................................ 77 iv Implications for Practice ........................................................................................................ 79 Future Recomme ndations ............................................................................................................... 82 Chapte r 6 - Conclusion ............................................................................................................... 83 Appe ndix A: Search Terms ............................................................................................................ 84 Appe ndix B: Se arches by Database ........................................................................................... 85 Appendix C: Prisma Diagram ............................................................................................................ 86 Appe ndix D: An Ethical Approach to Managing Patie nts.............................................................. 87 Appe ndix E: Risk Support Manage me nt Plan ............................................................................... 88 Appe ndix F: Risk Assessment Framework: Ide ntifying Tolerable & Intole rable Risk Factors ............................................................................................................................................... 90 Appe ndix G: Assessme nt Workshee ts: Ide ntifying Actual Risks/Stre ngths ............................ 92 Appe ndix H: Levels of Research Evide nce .......................................................................................... 95 Appe ndix I: Literature Review Matrix ..................................................................................... 96 Appe ndix J: The Four Are as of Decision-making in Capacity Assessme nts .......................... 105 Appe ndix K: Copyright Permissions ....................................................................................... 106 Refe re nces ....................................................................................................................................... 107 v List of Tables Table 1 Inclusion and Exc lusion Criteria for Selection of Article ................................................33 Table 2 The Elements of Risk Assessed Within Each Tool, Framework or Guideline .................. 51 vi List of Abbre viations ADL – Activities of Daily Living BCCNM – British Columbia College of Nurses and Midwives BC Health Coalition and CCPA-BC - BC Health Coalition and Canadian Centre for Policy Alternatives – BC CINAHL – Cumulated Index to Nursing and Allied Health Literature CMA – Canadian Medical Association CNA – Canadian Nurses Association EMR - Electronic Medical Record iADL – Instrumental Activities of Daily Living MMSE – Mini Mental Status Exam MOH – Ministry of Health NACA - National Advisory Council on Aging PIE – Population, Intervention and Evaluation RAI-HC – Residential Assessment Instrument – Home Care ROC curves – Receiver operating characteristic curves WHO – World Health Organization vii Acknowle dge ments I would like to express my thanks to my advisory committee members, Shannon Freeman, PhD and Barb Nielsen, MSc NP(F) for their continued support, contributions and guidance throughout the development of this paper. I would also like to thank my family members, especially my husband, Shane, for their patience, love and support throughout the journey of completing my schooling and this project. It is also with great encouragement and support from my friends that I have successfully persevered in the program. 8 Chapte r 1 - Introduction Canadian older adults are living longer, as well as choosing to stay at home longer (Lee, Hillier, Lu, Martin, Pritchard, Janzen & Slonim, 2019), and with that, some are choosing to live at risk. “Older adults […] living at risk are usually identified as adults aged 60 years and older, who are living at home despite having economic, social or physical barriers that affect their overall independence, well-being and quality of life” (Berke, 2014, p. 1). Because people are living longer with chronic life-threatening diseases, and with an aging population, there is an increased demand for health care in the community (De Bono & Henry, 2016). Subsequently, Nurse Practitioners working in Primary Care are supporting an increasing number of communitydwelling older adults, with some living at risk. As providers supporting older adults in Primary Care, Nurse Practitioners are expected to discern between risks that are tolerable and those that are intolerable, as well as to understand how to proceed once the risks are identified as such. Determining when and how to intervene in a perceived risky situation is a challenging job for any Nurse Practitioner (Young & Everett, 2018). The concept of risk can be difficult to define and therefore, can be difficult to assess (Cott & Tierney, 2013). With the ambiguity of the concept of risk and its assessment, inconsistencies in risk management between Nurse Practitioners may result. It is because of this that a review of the available risk assessment tools was warranted. Through an integrative review of the literature, the project goal was to analyze risk assessment tools available to inform a Nurse Practitioner’s determination of tolerable risk for a community-dwelling older adult who is living at risk. 9 The following literature review will provide background information pertaining to the concept of risk and the older adult, the assessment tools used to assess risk, as well as the relevance to Nurse Practitioner practice. An overview of the pressures on British Columbia’s health care system will be discussed, highlighting the impacts for an older adult and the effects on a Nurse Practitioner’s practice. The underlying ethical principles, the concepts of personcentred care and decision-making capacity, the relevant legislation and the professional obligations of a Nurse Practitioner working in British Columbia will also be examined in relation to the assessment and management of a patient living at risk. A description of the literature search methods will be outlined and detail of the findings will ensue. The resulting nine articles will be analyzed for the types of tools described, the elements of risk captured within the tools, the tool outcome measures, the use of each tool in practice, as well as the views of, or approaches to, risk described in each tool. A discussion based on the literature findings and their relevance in the determination of tolerable risk will follow, concluding with recommendations for future Nurse Practitioner practice. 10 Chapte r 2 - Background The following section provides an overview of those concepts supporting the need for risk assessment tools that inform tolerable risk and their use by Nurse Practitioners in assessing community-dwelling older adults. Through a discussion of Canada’s population, the pressures on the health care system, and with the provision of relevant definitions, this chapter is a foundation upon which to demonstrate the importance of this project to Nurse Practitioner practice in British Columbia. The objective of this literature review is to analyze those tools available to Nurse Practitioners that inform clinical decision-making relating to older adults living at tolerable risk in the community. The chapter concludes with the presentation of the research question guiding this literature review. Canada’s Aging Population Statistics Canada (2019) states that “baby boomers” now account for the majority of older adults in Canada, noting that as of July 1, 2019, the Canadian population included 6,592,611 older adults. Of them, more than half of the people (51.1%) were born during the baby boom (1946 to 1965), with older adults accounting for 17.5% of the Canadian population on July 1, 2019 (Statistics Canada, 2019). As the population continues to age, it is predicted that by the year 2036, 25% of Canada’s population will include older adults (Canadian Medical Association [CMA], 2013). As such, this increase in the number of aging Canadians will impact both the health care system and the Nurse Practitioners. While increasing age is not synonymous with poor health outcomes, it is recognized that older adults have an increased risk of disability and/or chronic disease, as well as more visits to their Nurse Practitioner, more hospital admissions and longer stays in hospital than younger Canadians (CMA, 2013). 11 A large proportion of aging older adults wish to continue living in their own homes as long as possible (MacLeod & Stadnyk, 2015). An American study described that two-thirds of the population who require long-term care supports, live in the community with some degree of assistance, and live in a prolonged state of poor health prior to facility placement or death (Carey et al., 2008). It is therefore of consequence for Nurse Practitioners to consider the aging community-dwelling patient demographic in British Columbia as one that could increasingly require ongoing support in the primary care setting. Long-te rm Care and Community He althcare in British Columbia As the British Columbia population is aging and increasing in its numbers of older adults, the availability of health care resources to meet the needs of such an aging population should be considered. Specific to community-dwelling older adults, demand for long-term care facilities and the availability of community resources will be impacted not only by an increasing number of older adults, but also by British Columbia’s increased life expectancy, and by the prevalence of more older adults living with chronic health conditions (De Bono & Henry, 2016; Statistics Canada, 2020). In addition, between 2001 and 2009 access to long-term care facility beds in British Columbia dropped by 21% and access to home support services decreased by 30% (BC Health Coalition and Canadian Centre for Policy Alternatives [CCPA] – BC, 2012). A decrease in the availability of long-term care and community supports could negatively impact the increasing proportion of older adults requiring ongoing community-based care, and further increase the burden elsewhere in the health care system. Long-term care facilities “provide 24-hour professional supervision and care in a protective, supportive environment for people who have complex care needs and can no longer be cared for in their own homes or in an assisted living residence” (Government of British 12 Columbia [BC], 2020, para. 1). An individua l requiring long-term care in British Columbia has to meet certain eligibility requirements prior to being waitlisted for publicly subsidized placement in a long-term care facility (Government of BC, 2020); there is no option to preemptively put one’s name on a list in anticipation of requiring the support in the future. Such eligibility requirements stipulate that the individua l be a Canadian citizen, be a resident of British Columbia for a minimum of three months, be 19 years of age or older, be in need of long-term care services at the time of the assessment, and that they meet specific client characteristics and/or determined service needs (Government of BC, 2019). The eligibility criteria for client characteristics include severe, continuous behavioural issues, those who are moderately to severely cognitively impaired, and those who are either physically dependent or clinically complex in terms of medical care (Government of BC, 2019). The identified long-term care eligibility service needs include the need for 24-hour nursing care, as well as other long-term care facility services such as assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and grooming, as well as help with instrumental activities of daily living (iADLs) such as medication management, and support with finances (Government of BC, 2019), as examples. At the time of wait-listing, individuals are assessed by a trained health care provider using the Residential Assessment Instrument – Home Care (RAIHC) assessment tool, and qualification for long-term care facility placement is determined based on the above eligibility requirements (Government of BC, 2019). Community-dwelling older adults may or may not qualify for a long-term care facility bed based on the specific parameters listed above. If they qualify for wait-listing, then they commonly remain in community until a longterm care bed becomes available. Nevertheless, such older adults likely require some level of community support from both their Nurse Practitioner and the healthcare system alike while 13 living in community and/or awaiting placement. While age is not a requirement for health care supports, the average age of residents living in long-term care facilities in British Columbia in 2018 was 85 years old (Seniors Advocate British Columbia, 2018). Both publicly subsidized and privately funded community-based services are available to assist with healthcare needs in British Columbia. Publicly subsidized assistance is accessed through the health authority, is subsidized by the British Columbia Ministry of Health (MOH), is administered and delivered by the health authorities and other contracted providers, includes services such as home support, adult day services, and long-term care facilities, (Government of BC, 2020), and are available both on short- and long-term basis. The objectives of public home and community care programming include 1) helping an individua l remain independent and in their own home for as long as possible, 2) providing care at home when one would otherwise require admission to hospital or would stay longer in hospital, 3) providing assisted living and longterm care services for those who can no longer be supported in their home and 4) supporting a patient and their family at the end of life (Government of BC, 2020). The determination of which service needs are provided to an individua l is based on a formal assessment of needs using the RAI-HC (Government of BC, 2020). Private community-based health care services are accessed by the individua l directly from the service provider to determine the services that best meet their needs and preferences (Government of BC, 2020). Such services do not qualify for government financial assistance to individua ls or service providers (Government of BC, 2020), and can range from private home support services that visit throughout the day, to live-in care workers and private care homes offering varying levels of assistance. 14 Despite the availability of public and private support services to maintain an older adult’s independence in the community, many older adults choose to remain living at home without support. The cost, the desire for privacy, the wish to remain independent, as well as both the availability of resources and long wait times to access services may act as barriers to accessing public or private community health care services (Lee et al., 2019; Seniors First BC, 2020). Other obstacles to service access include gaps in services, wherein the needed service is unavailable, and unidentifie d care needs, further delaying access to the necessary supports. Since more restrictive changes to eligibility requirements for public long-term care facility placement and home support services were made in 2001, many older adults may wait until they are in crisis and admitted to hospital before they access the community services they require (BC Health Coalition and CCPA – BC, 2012). Such circumstances could result from when vulnerable older adults are living without the needed supports in community to continue living safely at home, or when the older adult experiences changes in their care needs during the facility placement wait-time. From clinical experience, I have witnessed long delays in both the community-based and long-term care facility placement access due to health care system difficulties with low staffing numbers, heavy workloads, long waitlists and unclear guidelines. There can also be effects on wait times due to miscommunication, differences in opinions regarding service needs and unmet expectations between patients, families and health care providers. De Bono and Henry (2016) describe how Canada’s aging population, the overcrowding of hospitals, shortages of long-term care facility beds and increased rates of chronic disease and disability result in more people accessing community home care services and choosing to spend their final months of life being cared for at home. As such, Nurse Practitioners can anticipate supporting this increasing patient demographic, as well as expect to encounter 15 more frequent situations of older adults choosing to live at-risk in the community in the near future. Reactive approaches to risk mitigation have previously led to unplanned medical crises with increased disease burden and a higher workload for the provider (Drubbel et al., 2012), therefore Nurse Practitioners working in Primary Care must anticipate supporting such older adults living at risk and become familiar with the tools to support the determination of tolerable risk. Defining Risk For the purpose of this literature review, living at risk is defined “as acting in a way that impacts the person (risk to self) or others (risk to others) in physical, emotional, or psychological ways” (Young & Everett, 2018, p. 314). “At risk” is suggestive of a chance of injury, suffering or harm to oneself or others. Risk itself is the degree of harm and probability of that harm occurring (Fraser Health Authority, 2011). Because the research question of this literature review aims to inform a Nurse Practitioner’s determination of tolerable risk, the concept of risk must be narrowed further. For the purpose of this paper, tolerable risk is defined as a risk that is consistent with past behaviour or actions, is acceptable and does not result in imminent harm to oneself or others. The word risk elicits a threat of a possible adverse outcome weighed against a potential benefit. In health care, risk can pertain to legal issues, medical ethics, personal values, and patient outcomes (Kane & Levin, 1998). To develop the definition of risk, an extensive review of the literature was conducted. The definitions of risk can vary between dictionaries. For example, when conducting an online search through Google.com, definitions of risk emphasize features of “hazards” or “exposure to danger” along with the possibility of an “adverse outcome”, “loss” or “injury”. Equally, among the definitions is the sense of uncertainty in which the risk is described, 16 using such terms as “possibility” or “suggested” to infer the ambiguity of outcomes tied to the concept of risk. Because risk involves the possibility of a negative outcome, few individua ls can clearly agree on what actions cross the line between those that are tolerable and those that are intolerable. Risk tolerance is personalized, and context-specific. How risk is perceived can vary between patients, their families and their Nurse Practitioner. It is a concept that is based on personal perception and values, and can lead to misunderstandings and friction between health care providers, patients and their families. Cott and Tierney describe an “underlying tension between professionals and family carers whose risk perspectives differ from those of the health professionals and who [may] have different priorities” (2012, p. 404). Risk is frequently referred to as a negative term, with health care providers being encouraged to mitigate, control and manage its effects (Berke, 2014). It is recognized that health care professionals focus more on risks that could threaten the health of an older adult, while the older adult focuses more on those risks that threaten personal wellbeing and the ability to remain living independently (Verver, Merten, Robben & Wagner, 2017). There is no consensus on how best to define and interpret risk, with some definitions based on values, others on objective observation, some on an estimation of probability and others on uncertainty (Sotic & Rajic, 2015). Along with aging inevitably comes some degree of change, often a deterioration, to one’s level of independence and, sometimes, an increased level of risk. As an example, a loss of independence could result from a deterioration in eyesight from glaucoma and an inability to drive. One adult may choose to rely on a friend for a weekly lift to the grocery store, increasing their dependence on others to meet this need, while another individua l may choose to continue driving despite waning eyesight and medical advice to desist. Similarly, an older adult may have 17 community health workers attending the home to assist with meal preparations and personal care due to their declining physical or cognitive function, while another older adult may refuse supports and begin to self-neglect. Changes in later life are unique to each individua l and to their social situation, and can lead to circumstances where the older adult is making decisions that others may find risky. Kane and Levin (1998) describe how competent decision-makers typically make autonomous choices about the risks they wish to accept based on weighing both the magnitude and likelihood of expected harms against the benefits associated with the decision. Older adults, however, often have a presumed level of vulnerability, wherein their choices are called into question by practitioners, families and friends. The prevalence of risk among older adults compared to the general population is unclear (MacLeod & Stadnyk, 2015). Risks pertaining to older adults with diminished cognitive abilities and/or increasing care needs are difficult to quantify in health care, further complicating its definition. Older adults choose whether or not to continue living independently as they age, potentially with compromised cognition, decreasing physical functioning or other risks factors. While some forms of risk, such as financial risk, can be calculated using mathematical calculations, the risk for the older adult who chooses to remain living at risk with such deficits, can be more abstract. Berke (2014) describes risks related to home and community-based services as particularly difficult to quantify and explain in comparison to those of a surgical procedure. Consider those patients contemplating a surgical procedure, they review the risks and benefits of the proposed surgery with the surgeon prior to providing informed consent for the procedure. Within the process of informed consent, the patient is offered measured, statistical data based on patient outcomes and those of the surgeon’s surgical history. A difference in the risk being discussed in this circumstance is that the decision is based on historical data with known outcomes. The older 18 adult, on the other hand, is often positioned to make a decision based on their values and perceived circumstances that could or could not happen. An additional layer of complexity to this results from the concept of power and control – wherein the power lies with the surgeon in hospital but returns to the older adult as an individual living in community. Tolerable Risk Risk for the older adult choosing to live independently in the community is often referred to in relation to its level of tolerance or acceptability. Risk falls across a spectrum, and is being further defined as either tolerable risk or intolerable risk. MacLeod and Stadnyk (2015) discuss how dictionary definitions of risk focus on harm, likelihood and uncertainty, which are unsuited for clinical situations in health care as they neglect to appreciate the positive outcomes of risk. The potential benefits of defining a risk as tolerable, is in allowing the older adult to feel supported in the maintenance of both their autonomy and independence. MacMillan (1994) describes how risk-taking is inherent to independence in everyday life and how allowing the older adult to take such risks enhances both their dignity and quality of life (as cited in Waring, 2000). Tolerable risk as it relates to the older adult is a concept situated in the theories of patient-centred care, autonomy and decision-making. In Weins’ (1993) description of a theoretical framework of patient autonomy for nursing, she defines autonomy as selfdetermination, where one has control over one’s life and has the freedom of choice. Decisionmaking being a key component of such autonomy. Equally, patient-centred care describes a philosophy in which the need for health care is to be more “explicitly centred on the needs of the individua l patient” (Kitson, Marshall, Bassett & Zeitz, 2012, p. 5). As an approach to risk management, patient-centred care has been described as the gold standard of geriatric care and 19 includes the development of individua l, goal-oriented care plans that are based on personal preferences (Lee et al., 2019). Further, patient-centred care values both autonomy and choice, and strives to advance healthcare safety, quality, care coordination and quality of life for older adults (Lee et al., 2019). Variation in risk tolerance is based on how tolerance itself is valued by either the older adult, a family member, a caregiver or a health care provider. Berke (2014) describes tolerable risk as being consistent with past behaviour, with no harm to others and without posing imminent life-threatening harm to self. Similarly, The Fraser Health Authority (2011) describes those risk factors that are not new, consistent with past behaviour and not causing harm as being tolerable. In contrast, intolerable risk, “involves dangerous behaviors or circumstances that can cause serious and imminent harm” (Culo, 2011, p. 425). Based on common themes describing tolerable risk in the literature, for this literature review three essential attributes associated with this concept are being used in its definition. The first, is an ability of the risk to be endured; for the risk to be understood as “tolerable”, it can be seen as neither negative nor positive, but deemed “acceptable” (Cott & Tierney, 2013; Fraser Health Authority, 2011; Savulescu, 2018). The second, is for the risk to be consistent with past behaviour (Cott & Tierney, 2013; Fraser Health Authority, 2011). The third and final attribute is for the risk to be free from imminent harm to one’s self or others (Cott & Tierney, 2013; Fraser Health Authority, 2011). Given these attributes, the conceptual definition of tolerable risk being used in this literature review is a risk that is consistent with past behaviour or actions, is acceptable and does not result in imminent harm to oneself or others. Conversely, an intolerable risk is one that is potentially harmful to oneself or others, wherein there is a new behaviour that 20 is unprecedented, inconsistent with past behaviour and results in harm (Fraser Health Authority, 2011). Ethical Principle s Many older adults choose to remain living at home despite significant risks to their overall health and welfare (Carey et al., 2008). Risks faced by community-dwelling older adults include but are not limited to frequent falls, self-neglect, non-compliance with medical advice, financial, physical, emotional and verbal abuses, living in unsuitable living conditions, and driving unsafely (Lee et al., 2019; Seniors First BC, 2020). The assessment of risk by the Nurse Practitioner consists not only of compiling objective data but also incorporates clinical reasoning, ethical principles and professional obligations. “Determining whether a given situation is too risky is challenging in terms of defining parameters, setting aside personal biases, and striving for objectivity” (Young & Everett, 2018, p. 315). Those ethical principles inherent to the concept of risk include 1) autonomy – a fundamental right to self-determination and freedom from interference of others, 2) beneficence – the act of doing good, and 3) non-maleficence – to do no harm (Baker, Camptom, Gillis, Kristjansson & Scott, 2007). One ethical conflict for the Nurse Practitioner is the balance between the promotion of an older adult’s independence and autonomy by allowing them to live their lives freely and under their own control, versus the need to act responsibly by promoting health and safety (non-maleficence) (Berke, 2014). Furthermore, the World Health Organization (WHO) outlines the goal for all health care professionals to encourage the independence of older adults (Berke, 2014). This overarching goal instills a sense of responsibility for the Nurse Practitioner trying to meet this target, weighing the threat of a perceived risk and compromised patient safety against the choices made by patients who wish to enact their autonomy and 21 maintain their independence in a risky situation. As Nurse Practitioners supporting older adults choosing to live at risk, an act of balancing these principles must ensue, that respects the freedom of the person, assures their best interest, and is driven by the goals of the competent older adult, while upholding professional obligations. Ethical principles underlie risk management and also inform the profession of nursing. Nursing standards of practice guide nursing care and are designed for Nurse Practitioners to: -Better understand their professional obligations -Support their own continuing competence and professional development -Explain what nursing is and what nurses do -Advocate for changes to policies and practices -Define and resolve professional practice problem -Include in nursing education courses/programs. (British Columbia College of Nurses and Midwives [BCCNM], 2012, p. 5) Within these standards, BCCNM identifies the standards of knowledge-based care and ethical practice, under which Nurse Practitioners are expected to make the patient the primary concern in providing nursing care, to set client-centred priorities when planning and providing care, as well as to provide care in a manner that preserves and protects client dignity (BCCNM, 2012). These standards align with the concept of patient-centred care which “emphasizes individua l preferences, goals and values as well as choice and autonomy, and aims to improve healthcare safety, quality, care coordination and quality of life for older adults” (Lee et al., 2019, p. 48). The Canadian Nurses Association (CNA) outlines statements of both aspirational and regulatory ethical values to be followed by all nurses in its Code of Ethics. The document includes 1) the promotion of safe, compassionate competent and ethical care, 2) the promotion of health and 22 wellbeing, 3) the promotion and respect of informed decision-making and 4) honouring dignity (CNA, 2017), as some of the values and ethical responsibilities to be upheld by all nurses. Upholding such values can sometimes feel in direct conflict with the ability to support a patient’s autonomy in a risky community-based living situation (Kane & Levin, 1998). The goal of the Nurse Practitioner in supporting older adults to live independently is not the elimination of risk itself, but involves discerning and achieving a tolerable level of risk. Furthermore, the Nurse Practitioner is often faced with weighing risks against an individua l’s right to make autonomous decisions when engaged in discussions about placement in a long-term care facility. Capable patients have the right to make choices for themselves (Young & Everett, 2018). If a patient rejects a proposed intervention, the Nurse Practitioner must then consider the potential harm to the patient, or others, and further consider the patient’s decisionmaking capacity regarding the activity in question (Young & Everett, 2018). The Nurse Practitioner is responsible to identify patients who choose to remain living in community at an intolerable risk and who may lack the capacity to safely make such a decision. The identification of such patients triggers the Nurse Practitioner to initiate the process for a formal capacity assessment. The decision of when to have a patient assessed and/or deemed incapable, for older adults living at an intolerable risk, ultimately lies with the Nurse Practitioner. The Nurse Practitioner must consider not only the concern of risk-taking as it relates to the physical safety of the older adult and others, but also consider the benefits gained by the older adult in choosing such a risk (Berke, 2014). The determination of incapability carries the significant consequence of removing the patient’s right to autonomously decide to continue living at risk. Nay (2002) highlights the delicacy of risk management well in stating that “overzealous risk management may protect a 23 physical body from bruising but it may also damage […] irreparably the already vulnerable human soul”, (as cited in Berke, 2014, p. 3). As Canada’s population ages, Nurse Practitioners supporting older adults in Primary Care will be required to navigate such circumstances in practice with increasing frequency. Capacity and Legislation Decision-making capacity is the ability to both understand information related to a decision and to appreciate the consequences of such a decision (Fraser Health Authority, 2011). Also referred to as a person’s capability or competency for decision-making, for the purpose of this paper, the term capacity will be used ongoing. The importance of understanding capacity as it relates to tolerable risk underpins when and how a Nurse Practitioner will intervene if an intolerable risk is identified. In British Columbia, Nurse Practitioners must complete courses through the MOH and must follow guidelines through the MOH and the Public Guardian and Trustee to qualify as a health care provider able to complete Financial Incapability Assessments and Incapability Assessments for Care Facility Admission (BCCNM, 2020). Without being qualified to complete such assessments, Nurse Practitioners must nonetheless be able to identify tolerable and intolerable risks, as well as to comprehend decision-making capacity. The identification of tolerable and intolerable risks allows the Nurse Practitioner to engage in personcentred dialogue with their patient to develop risk mitigation strategies. Understanding decisionmaking capacity ensures that patients requiring capacity assessments are properly identified and referred appropriately to the providers who carry out such tasks. Further to understanding and assessing an older adult’s level of risk and their capacity to make a decision, a Nurse Practitioner’s management of a patient who chooses to live at risk is 24 also guided by supporting legislation. The guiding principles of the Adult Guardianship Act section 2 include the following: (a) all adults are entitled to live in the manner they wish and to accept or refuse support, assistance or protection as long as they do not harm others and they are capable of making decisions about those matters; (b) all adults should receive the most effective, but the least restrictive and intrusive, form of support, assistance or protection when they are unable to care for themselves or their assets; (c) the court should not be asked to appoint, and should not appoint, decision makers or guardians unless alternatives, such as the provision of support and assistance, have been tried or carefully considered. As such, the legislation promotes risk tolerance, autonomy of person and a risk mitigation approach guided by the least invasive interventions. Because the concept of decision-making capacity often arises when discussing placement in a long-term care facility, the supporting legislation is also being reviewed. Part 3 of the Health Care (Consent) and Care Facility (Admission) Act (1996) now guides a Nurse Practitioner to obtain consent for facility admission prior to admission into long-term care. Section 21(1) notes that consent to admission to a care facility is achieved only if the following criteria are met: (a) the consent is given voluntarily, (b) the consent is not obtained by fraud or misrepresentation, (c) the adult is capable of making a decision about whether to give or refuse consent to admission, 25 (d) the adult has the information a reasonable person would require to understand that the adult will be admitted to a care facility and to make a decision, including information about (i) the care the adult will receive in the care facility, (ii) the services that will be available to the adult, and (iii) the circumstances under which the adult may leave the care facility, and (e) the adult has an opportunity to ask questions and receive answers about admission. Should the older adult be unable to meet these criteria for consent, and is not in agreement with facility placement, a capacity assessment is then completed to determine decision-making ability specific to admission into a long-term care facility. The language regarding the older adult having assumed capacity until proven otherwise from the Adult Guardianship Act (1996) persists throughout this legislation. “Only a medical practitioner or a prescribed health care provider may determine whether an adult is incapable of giving or refusing consent to admission to, or continued residence in, a care facility” (Health Care (Consent) and Care Facility (Admission) Act, 1996, section 26(1). Scre e ning Tools Generally, screening tools provide Nurse Practitioners with a relatively quick means of assessing a patient’s given risk for the development of a specific health condition and/or to monitor its progression, with both a high level of specificity and sensitivity. Validated screening tools provide Nurse Practitioners with a platform upon which to build their differential diagnoses and to support clinical reasoning by objectively measuring and predicting health issues or specific outcomes (Cott & Tierney, 2013). Given the complex nature of the concept of risk however, the ability to assess an older adult’s risk as either tolerable or intolerable is far less 26 clear. The perception of risk varies based on the risk type, the context of the risk, the individua l’s personality and the social context surrounding a given situation (Verver, Merten, Robben & Wagner, 2017). Further to this, one’s own attitudes, values, experiences and emotions influence an individua l’s perception of risk. Given such disparity, the concept of risk is less clearly defined as either tolerable or intolerable in a screening tool. Compre he nsive versus Focused Risk Assessment Tools Risk assessment tools in health care are numerous and are used to assess various aspects of health and wellness. As an example, an older adult’s balance and the risk of falling can be assessed using the Berg Balance Scale (Langley & Mackintosh, 2007). While this tool offers valuable information, and informs a Nurse Practitioner’s clinical picture of risk, focused risk assessment tools such as these inform only one aspect of risk. To rely on the focused risk assessment tools already available, such as the Berg Balance Scale, as a means of informing tolerable and intolerable risks, Nurse Practitioners would require the use of multiple tools and a significant amount of time to complete a comprehensive assessment. Because a perceived risk can result from any number of reasons, as with an older adult wandering and getting lost, or an older adult who self-neglects, a comprehensive risk assessment tool that focuses more broadly than on individua l risk factors is needed to capture as many facets of risk as possible. Therefore, comprehensive risk assessment tools informing tolerable and intolerable risks must consider the wide clinical picture of the older adult living in the community. Re le vance to Nurse Practitione r Practice Nurse Practitioners working in Primary Care are well-positioned to support Canada’s aging population, as older adults navigate their changing health care concerns. Nurse Practitioners have a continued role in supporting patients across the life span, therefore the care 27 of an aging population is relevant to practice. Not only is Canada’s population aging, but with it, the pressures on its health care system will also increase. As a means of anticipating such pressures, it is prudent for the Nurse Practitioner to consider this impact on its aging patients and to consider the expected barriers and outcomes, such as perceived risky situations, for communitydwelling older adults in relation to their ongoing health care needs. As providers, Nurse Practitioners can deliver better care to an aging population both in familiarizing themselves with the concepts of tolerable and intolerable risk, and in understanding the screening tools available to inform such risk. MacLeod and Stadnyk (2015) describe an increased awareness of risk assessment and management strategies through both an understanding of living at risk and the evaluation of risk status, as a means of supporting client choices when safety is concerned. In doing so, Nurse Practitioners can establish and uphold a standard of care for all community-dwelling patients supported in Primary Care, ensuring that all patients receive consistent information, support and care. Additionally, the availability of screening tools for the use by Nurse Practitioners may help inform a clinical picture and also can provide some level of guidance for decision-making to Nurse Practitioners less familiar with assessing risk. Nurse Practitioners hold the responsibility of knowing how to identify both a tolerable and an intolerable risk, and when to initiate the assessment of a patient’s decisionmaking capacity. Finally, in determining that a risk is tolerable, Nurse Practitioners are able to enact preventative, person-centred care with a focus on maintaining patient independence and upholding the autonomy of the older adults, as well as in the reduction of pressures and costs on the healthcare system. 28 Defining the Research Que stion In the interest of better-informing a Nurse Practitioner’s clinical decision-making regarding tolerable risk, and in providing continuity of care for patients, the concept of tolerable risk and its available assessment tools will be explored. By synthesizing the literature, it will narrow this knowledge gap by commenting on the quality of available risk assessment tools and by providing recommendations based on the findings of a literature review. In an effort to shed light on risk determination, an integrated literature review was conducted to answer the following question: What comprehensive risk assessment tools are available to inform a Nurse Practitioner’s determination of tolerable risk for a community-dwelling older adult who is living at risk ? This project will explore the tools available to Nurse Practitioners for assessing tolerable risk, as a means of both normalizing risk and supporting Nurse Practitioners when they are faced with contemplating risk and a patient’s capacity for decision-making. It is by increasing one’s understanding of the concept of tolerable risk that Nurse Practitioners can better determine how to balance and navigate dilemmas where an older adult’s decision may deviate from that which is traditionally perceived by others as lower risk. An assessment tool provides both objective and subjective data upon which to develop a clinical picture of risk, informing the balance between supporting the autonomy of the patient while upholding one’s professional obligations to maintain safety and manage risk. 29 Chapte r 3 - Research Methods The purpose of this integrative review was to describe and analyze the benefits and pitfalls of risk assessment tools available to Nurse Practitioners in terms of supporting their determination of tolerable risk in a given clinical situation. The following chapter will provide an overview of the methodology undertaken to acquire the foundational literature articles for review. A description of the databases selected, a discussion regarding the search methods and the rationale, as well as the accompanying results of the initial searches will follow. The integrative review method for summarization of literature allows for the amalgamation of findings from diverse methodologies to be synthesized and applied to clinical practice and evidence-based practice initiatives (Whittemore & Knafl, 2005). This approach suits this research question, as it aims to inform Nurse Practitioner decision-making based on recommendations within the relevant literature. Given the broad nature of the integrative review, the literature search needs to be well-defined and comprehensive. Recommended approaches by Whittemore and Knafl (2005) included in the described literature search are the use of computerized databases and hand searches, which were undertaken to inform this literature search. Given the breadth of the clinical question and the uncertainty I had regarding the availability of appropriate resources, three databases including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MedLine Ebsco and PsycINFO, were searched. The Cumulative Index to Nursing and Allied Health Literature is a comprehensive nursing and allied health-focused database, with literature covering nursing, biomedicine, health sciences librarianship, alternative and complementary medicine practices, and seventeen allied health profession topics (Ebsco, 2020a). MedLine Ebsco was created by the United States National 30 Library of Medicine, and provides biomedical and health literature covering research, policy issues, clinical practice and health care services (Ebsco, 2020b; Gray, Grove & Sutherland, 2017). PsycINFO was the third database chosen as it pertains specifically to psychology and the psychological aspects of medicine, psychiatry, nursing, physiology, education, pharmacology, linguistics, sociology, anthropology, business and law, with research in the behavioural and social sciences (American Psychological Association, 2020; Gray, Grove & Sutherland, 2017). PsycINFO was expected to produce articles highlighting a perspective that may otherwise be missed by focusing solely on those databases specific to nursing practice concerns. In addition, hand searches based on article reference lists, email communications with university professors, health authority websites and discussion with knowledgeable community members provided further articles integrated into the literature review. Se arch Strate gies The search strategies undertaken utilized a number of terms to capture the major concepts being reviewed within the proposed clinical question. Following the PIE (Population, Intervention and Evaluation) model for development of a research question, the major concepts were broken down based on the population, intervention and evaluation and searched accordingly. Broadly, the keywords and subject headings relating to the research question include: older adult, frailty, cognitive impairment, living at risk and risk assessment tools. The population of focus included older adults, with vulnerability or frailty which may require assessment of risk from a Nurse Practitioner while living in community (Appendix A). While the literature review focused on the assessment of risk, the aim was not to evaluate all risks and all assessment tools. The concept of “living at risk” was focused to capture either tolerable or intolerable risk for this patient demographic, as evidenced by the choice of search 31 terms in Appendix A. Culo (2011) describes how both the terms “risk” and “vulnerability” imply the possibility of experiencing an adverse outcome, which further informed the inclusion of “adverse outcome” within the search terms pertaining to the concept of living at risk. Additionally, as the question addresses evaluation tools used to assess a global picture of risk, synonyms of “assessment tool” were also integrated into the searches. Each set of terms was then searched jointly using the Boolean search method “AND” and carried out within the databases listed above (Appendix B) on Feb 18, 2020. In addition, independent searches within the website of all five of British Columbia’s health authorities was conducted. Each health authority website was searched using the terms “risk assessment tool”, “older adult risk assessment” and “living at risk” on April 21, 2020 in search of a tool meeting the inclusion and exclusion criteria discussed below. Inclusion and Exclusion Crite ria In addition to using the terms listed in Appendices A and B, the literature search was further narrowed based on inclusion and exclusion criteria, as depicted below in Table 1, to elicit the most relevant literature pertaining to the research question. Nurse Practitioners first became licensed to practice as advanced practice nurses in British Columbia in 2005. As a means of ensuring the clinical significance to Nurse Practitioner practice, only articles published in 2005 and beyond, were chosen as relevant to this integrative review. Only those articles available in the English language were chosen. The population in question focuses on older adults which are being defined as those 60+ years or older. The WHO (2019) provides no formal definition of old age, but does, however, note that most developed countries associate 65 years with the start of old age. Because articles were being chosen broadly and included some populations younger than 65 years, 60 was chosen as the age for this literature review. Another inclusion criterion was 32 that all articles include either an assessment tool, a guideline, a framework or a decision-making process with which to evaluate a level of risk. Because the term living at risk does not result in a specific outcome, such as a having a fall or sustaining financial abuse, the outcome measures included in the search were chosen as two or more broad terms resulting from any number of risk factors. These factors included adverse outcome, hospitalization, emergency room visits, institutiona lization, mortality and death. Tools assessing risk with no stated outcome measures were also included. Finally, because the population being discussed is specific to those living in community, those articles addressing risk in acute care settings or in relation to inpatient programming, as well as those for people in supportive housing, long-term care facilities or assisted living facilities were excluded. Because tolerable and intolerable risks can result from any number of actions or medical conditions, the assessment tools for inclusion in the literature review needed to be comprehensive and support the identification of tolerable vs. intolerable risk, based on the earlier definitions provided. Risk assessment tools targeting and/or measuring a single facet of risk such as falls, malnutrition, heart disease or caregiver burnout, as examples, are being eliminated with the inclusion and exclusion criteria, as well as with earlier definitions of risk. While these concepts are integral to a comprehensive risk assessment, their measurement in isolation negates what a comprehensive assessment aims to achieve by using one tool to assess and inform a fulsome clinical picture of either tolerable or intolerable risk. 33 Table 1 Inclusion and exclusion criteria for selection of articles Inclusion Criteria Exclusion Criteria -Articles published in 2005 and beyond -Study focused on non-community based settings such -Published in the English language as: inpatient programming, acute care setting, assisted -Older adults, 60+ yrs. living, long-termcare home and supportive housing -Includes an assessment tool, framework, guideline or decision-support strategy for assessing risk -Measures no outcomes –OR-Measures 2 or more of the following outcomes: adverse outcomes / institutionalization / hospitalization / visit to emergency room/ death/ mortality Risk factors influencing an older adult’s level of vulnerability include, but are not limited to, their social network, cognitive ability and health status (Seniors First BC, 2020). Specifically, those elements influencing vulnerability include financial security, advanced age, social isolation/caregiver support, substance use, functional decline, inadequate or unaffordable housing, mental and physical health status, medical comorbidities, polypharmacy, access to transportation and community supports, food security and nutrition, and marginalization based on culture and/or language (BC Guidelines, 2017; Seniors First BC, 2020), each of which informs a global picture of risk. Using these criteria as a guide, the articles chosen for review in this literature search aim to capture multiple facets of risk in one comprehensive assessment tool. Se arch Results and Data Analysis A total of 524 articles were retrieved during the database search. The inclusion and exclusion criteria were then applied to all 524 articles, resulting in 412 articles for further review. The articles were then screened based on a review of their title and abstract, as well as with the removal of duplicates, leaving 33 articles for full text review. Based on full text review, the 34 inclusion and exclusion criteria and the research question, nine articles were chosen to inform this literature synthesis. Appendix C delineates this literature search process using a Prisma diagram. The nine articles were initially analyzed using the Critical Appraisal Skills Programme checklists (2013) and the appraisal worksheets by Davies and Logan (2018), as a means of uncovering the most relevant evidence pertaining to the community-dwe lling older adult’s assessment of risk. The research question was then broken down further to inform the development of the literature matrix (Appendix I) and themes were developed based on the findings within the literature matrix. 35 Chapte r 4 - Literature Findings A critical analysis of the nine articles being used in the literature review follows. Discussion includes an overview of each article, their level of evidence, as well as themes within the literature outlining their key concepts, limitations and biases. Pertinent outcome measures relevant to the research question include the risk assessment tools themselves and the determination of risk level. Study Overview Nine articles met the criteria for this literature review (see Prisma diagram Appendix C). A short description of each article follows, highlighting the strengths and weaknesses of the tools, guidelines or frameworks. Because not all articles named a specific tool, those without an identified tool, such as those outlining an unnamed framework or a decision support strategy, will be further classified using the article’s description of the framework or decision support strategy as its tool name. Aliberti et al. (2019) describe a decision support strategy to estimate the interactions and impact of combining physical frailty and cognitive impairment without dementia on adverse health outcomes. Therefore, this tool will be addressed as Aliberti’s Decision Support Strategy moving forward. Aliberti’s Decision Support Strategy was analyzed using a prospective cohort study to estimate the effects of merging physical frailty and cognitive impairment without dementia on the risk of basic activities of daily living (ADL) dependence and death over 8 years among older independent adults (Aliberti et al., 2019). The outcome measures do not directly inform tolerable or intolerable risk in real-time. Using a representative population of 7,338 community-dwelling American older adults, the authors used previously validated definitions of physical frailty and cognitive impairment from the Health and Retirement Study to assess the 36 combined effects of such geriatric conditions on adverse health outcomes, disability and mortality for their target population (Aliberti et al., 2019). A formalized tool is not being used, however the article provides a rough approach to assessing the risk of adverse outcomes, and highlights aspects of an individua l’s health that should be included in consideration of such outcomes. Limitations were identified by the exclusion of eligible participants without physical measures, each of which was reduced through sensitivity analysis and in using sampling weights (Aliberti et al., 2019). Strengths include its longitudina l study and the representative sample of older adults living independently in the community (Aliberti et al., 2019). The Risk Instrument for Screening in the Community is a quick, comprehensive, subjective assessment of risk developed to identify a person’s 1-year risk of three outcomes: institutiona lization, hospitalization and death (O’Caoimh et al., 2015). The resulting score is assigned across the three outcomes based upon severity of concern and the caregiver networks’ ability to manage them (O’Caoimh et al., 2015). The tool was tested on a population of 801 community-dwelling adults over 65 years old, under follow-up by their public health nurse, in southern Ireland. Individua ls were excluded from the study if they were aged <65 years, currently a resident of institutional care such as a nursing home or other long-term care unit, or no longer under follow-up by the public health nurse. The Risk Instrument for Screening in the Community was compared to another subjective global assessment and frailty scale, the Clinical Frailty Scale, to determine its accuracy and predictive ability (O’Caoimh et al., 2015). The tool demonstrated satisfactory validity compared to the Clinical Frailty Scale, had excellent interrater reliability (Fleiss’ Kappa = 0.86-1.0), as well as internal consistency (Cronbach’s alpha coefficient =0.94) (O’Caoimh et al., 2015). In addition, validity testing is being undertaken in Australia, Northern Ireland, Portugal and Spain (O’Caoimh et al., 2015). Focusing on a 37 population-based health approach to the assessment of needs at an individua l, family and community level, the tool aligns favourably with the Nurse Practitioner’s role and approach to patient care in Primary Care. The tool holistically measures risk by including mental state, ADLs and medical problems, in the context of the caregiver network (O’Caoimh et al., 2015). Further, the use of a simple, subjective, five-point Likert scoring scale, from one (minimal and rare) to five (extreme and certain) is easy for individua ls to comprehend and for Nurse Practitioners to implement in practice. Data collection, based on a retrospective review of records, with some being incomplete, and sampling methods are limitations identified in the study (O’Caoimh et al., 2015). The reliability and validity of the Clinical Frailty Scale, scored by the public health nurse, was not examined, which may have contributed to bias (O’Caoimh et al., 2015). The tool does not assess real-time risk, nor does it address tolerable or intolerable risk. The Risk Instrument for Screening in the Community does, however, provide a quick, easy to use assessment tool that can be used by Nurse Practitioners working in Primary Care to inform a patient’s 1-year risk of institutiona lization, hospitalization and death. The Frailty Index based on Routine Health Care Data (Drubbel et al., 2012) is a tool with a focus on proactive, population-based care, used to predict the risk of adverse health outcomes for older adults. The goal of such a general frailty indicator is one that stratifies older patients based on their overall risk of adverse health outcomes, allowing general practitioners to focus care efforts to the patients at highest risk (Drubbel et al., 2012). The tool was used to screen for a predefined list of relevant health deficits including diseases, signs, symptoms, and psychosocial or functional impairments, with the proportion present informing the individua l’s Frailty Index score (Drubbel et al., 2012). A sample population of 1,679 community-dwelling older people were enrolled from an urban primary health care center where seven general practitioners cared 38 for 10,500 people in the Netherlands (Drubbel et al., 2012). As a predictor of adverse outcomes, the tool’s validity is supported with a deficit list similar but not equal to previous frailty indexes, as well as with a right-skewed distribution with women and older patients having higher frailty index scores (Drubbel, 2012). Strengths of the framework include the use of data that is readily available in the electronic medical record (EMR), and a sample of older patients taken from a large primary health care center without having the risk of selection bias, enabling broad generalizability to the community-dwelling older adult (Drubbel, 2012). Therefore, there is opportunity for application of the Frailty Index based on Routine Health Care Data as a risk stratification tool for Nurse Practitioners working in primary care practice. The limitations include the risk of missing information based on both how health conditions are captured within an EMR, and based on what information is presented to the Nurse Practitioner by the patient and subsequently captured on the chart. Therefore, the Frailty Index based on Routine Health Care Data is a tool that uses available data to help risk stratify a Nurse Practitioner’s patient panel of older adults to focus care efforts on those at highest risk of future adverse outcomes. The Early Risk Score (St. John & Montgomery, 2014) is designed to predict death or institutiona lization in community-living older adults. The Early Risk Score was tested for its correlation with other measures of health, using two original measures of frailty, developed in hospitalized older adults in the UK in 1962 – the brief measure of frailty and the Frailty Index. The Early Risk Score includes measures of disability and cognition, as well as forty self-reported health complaints, diseases, risk factors and impairments which are added and divided by the number of deficits considered to predict death or institutionalization (St. John & Montgomery, 2014). The tool was applied to a sample of 1,735 older adults residing in the community in Canada over five years (St. John & Montgomery, 2014). Strengths of the tool include reliable 39 and valid measures of health and well-being (St. John & Montgomery, 2014). Based on the findings of the study, the authors note that more recent sample settings and cohorts would help validate the tool and increase its generalizability (St. John & Montgomery, 2014). The tool is further limited by the inability to replicate the original risk score due to missing information and due to a lack of clarity regarding the original measurement of cognitive status. In addition, the Early Risk Score had a ceiling effect with the majority of patients with some level of disability all scoring high (St. John & Montgomery, 2014). Because the tool was developed to utilize routine data, and given that there is no defined health care provider listed as the prescribed user of this tool, Nurse Practitioners could apply this tool in practice to help predict adverse outcomes for the older adults in their care, and to inform a level of risk. The Elders Risk Assessment is a tool used to identify a population of community dwelling older adults at high-risk for hospitalization or emergency room utilization (Crane et al., 2010). The Elders Risk Assessment was used to demonstrate that readily accessible information within the EMR can be used to create an administrative index, and was tested using a sample of 12,650 community-dwelling older adults (Crane et al., 2010). Using a scoring system derived from data within the EMR of community-dwe lling older adults, a predictive index was established and validated (Crane et al., 2010). The Elders Risk Assessment used risk factors over the previous two years, which were assigned a score based on their regression coefficient estimate and a total risk score was created. This score was evaluated for sensitivity and specificity using receiver operating characteristic (ROC) curves (Crane et al., 2010). The tool is designed for use by primary care providers (Crane et al., 2010), including Nurse Practitioners. The strengths of the tool include its use of objective administrative data, and its ability to measure risk scores in real time (Crane et al., 2010). The authors note that limitations of the tool 40 include the risk of underreporting and the exclusion of functional-status measures (Crane et al., 2010). The Elders Risk Assessment is a tool used to predict older adults at highest risk of hospitalization and emergency room visits, which relies on risk factor data drawn from the EMR, and is appropriate for use by Nurse Practitioners working in Primary Care. The Decision-Making Process provides an overview of the concept of living at risk, discusses decision-making, the evaluation and assessment of risk, as well as addresses tolerable and intolerable risk, patient capacity and the implementation of a decision (Young & Everett, 2018). This is further broken down into an easy-to-follow flowchart (Appendix D). The DecisionMaking Process can be used by all members of the health care team, including the patient and family, to support ethically justifiable decisions about when and how to intervene when patients choose to live at risk (Young & Everett, 2018). The intended users of the tool are those team members who work with the patient and know them, and expressly includes Nurse Practitioners as one such health care provider. The article is not a validated study, but a “literature review informed by [British Columbia] legislation, based on bioethical principles of autonomy, non-maleficence, beneficence and justice” (Young & Everett, 2018, p. 315). Because the Decision-Making Process is directed to all members of the health care team, Nurse Practitioners can follow the process with a patient and family, and/or work through the process with other members of the health care team to inform decisions regarding an older adult living at risk. Further, without any defined outcome measures, the decision-making process is well-suited to informing tolerable risk, as its definition is not specific to a single adverse outcome. The strengths of this approach comprise the flow chart (Appendix D) which is easily followed, the sequential order of steps requiring completion, and the ease of revision after an intervention has been trialed. While tolerable and intolerable risks are addressed in the Decision-Making Process, 41 a lack of clear definitions or steps for the determination of either outcome is a limitation of the article. The Risk Support Management Plan (see Appendix E) is designed to provide a structured instrument inclusive of the necessary considerations to deliberate over when involved in risk management (De Bono & Henry, 2018). Specifically, the Risk Support Management Plan provides a method for supporting Canadian clients who choose to live at risk in their homes, for anticipating potential complications, and for informing the development of a contingency plan to mitigate concerns as they present themselves (De Bono & Henry, 2018). The framework also allows the Nurse Practitioner to set transparent and reasonable limits and justifications for why certain risk-taking behaviours might not be supported by health care providers and their organizations (De Bono & Henry, 2018). The authors discuss a shift in the approach to risk mitigation to one that is positive risk-based, and include a review time frame to remind the plan builders to set an appropriate review schedule (De Bono & Henry, 2018). “A positive risk-taking approach considers risk as having two potential outcomes: one that may […] benefit the client, and the other that may have harmful outcomes to the client and/or others with whom they come in contact” (De Bono & Henry, 2016, p. 215). The authors note that positive risk-based approaches to risk are relatively new in practice and that there are no vigorous systematic studies in the literature validating the effectiveness of such an approach (De Bono & Henry, 2018). The tool was presented using a fictitious palliative home-care case in Canada to demonstrate its use. The strengths of the tool include an easy-to-follow framework of decision-making steps, as well as four criteria to assist health care providers decide when, how and if a patient’s choice to live at risk can be supported, or not (De Bono & Henry, 2018). Limitations include the lack of systematic reviews supporting such a positive risk-based approach and that the tool is not 42 diagnostic of tolerable and intolerable risk. As demonstrated using the fictional case, this tool can be applied in clinical situations where a perceived risk is identified and risk mitigation strategies are discussed, similar to cases when a Nurse Practitioner would aim to determine a tolerable level of risk for a community-dwe lling older adult. With a focus on individua l preferences, goals and values, as well as on the concepts of choice and autonomy, the Person-Centred Risk Assessment Framework is a relatively new framework for managing risk among patients living with dementia in Primary Care (Lee et al., 2019). In this framework, the patient is engaged in the decision-making process regarding highrisk activities and in the development of surrogate solutions that could similarly meet the psychosocial need being achieved through the risky behaviour (Lee et al. 2019). A mixedmethods pilot study was conducted in Canada to test the Person-Centred Risk Assessment Framework in Primary Care, assessing 31 appropriate patients using the tool, with six health care providers and twelve patients and/or caregivers completing feedback surveys after piloting the framework. The pilot study qualitatively measured the feasibility of using the framework in Primary Care Collaborative Memory Clinics, using patient and health care provider satisfaction. No limits to its use in Primary Care could be appreciated. The Person-Centred Risk Assessment Framework used a proactive approach, wherein risks associated with dementia were assessed and managed early to avert crisis, unnecessary suffering and costly hospitalizations (Lee et al., 2019). Such an approach allowed older adults living with dementia to retain as much control over their lives as possible, through the identification of risky situations and the collaborative development of systems to manage risk, based on the person’s preferences (Lee et al., 2019). This personcentred approach is one of the study’s strengths. There is a lack of clarity, however, regarding what constitutes a person living with dementia. It is unclear how different degrees of cognitive 43 impairment could affect the framework’s application, highlighting a limitation of this tool. As such, the Person-Centred Risk Assessment Framework is a self-empowering tool used to guide the care being delivered to persons living with dementia, that is respectful of individua l needs and preferences, and that can be used by Nurse Practitioners in Primary Care. Finally, the Clinical Practice Guideline for risk assessment supports the identification of tolerable and intolerable risks and informs a patient’s decision-making ability (Fraser Health Authority, 2011). This guideline is not available to the public through the health authority website, it is intended for internal use only. Of the four goals stated in the Clinical Practice Guideline , the provision of a “standardized risk assessment process to determine tolerable and/or intolerable risk for vulnerable adults who are presenting at risk” (Fraser Health Authority, 2011, p. 1) most clearly addresses the question being tackled by this literature review. The Clinical Practice Guideline is a framework designed to be completed in addition to “each professional’s specific functional and/or psycho-emotional social assessment” (Fraser Health Authority, 2011, p. 6). The guideline follows sequential steps that guide a Nurse Practitioner through questions to ask themselves and the older adult in the assessment of risk. The Clinical Practice Guideline also notes that a risk assessment is a pre-requisite prior to the consideration of an incapability assessment (Fraser Heath Authority, 2011). Appendix F shows the risk assessment framework to be completed in the identification of tolerable and intolerable risk factors. Each risk is listed and evaluated by the individua l completing the form to determine whether it is new or pre-existing, what the consequences of each risk are, the mitigation strategies that have been tried and whether any were effective (Fraser Health Authority, 2011). The risks are then reviewed for intolerability using any of the following three criteria: 1) the adult has suffered actual harm and to whom (team, adult, family), 2) the adult exposes others to risk of harm or 3) the adult is engaging in 44 risky behavior they would normally have avoided (Fraser Health Authority, 2011). Both medical and psychologica l conditions that could impact decision-making ability are considered, mitigation strategies and expected outcomes are listed, as well as the reasons why a capacity assessment is, or is not, being contemplated (Fraser Health Authority, 2011). Beyond this, the Clinical Practice Guideline also includes assessments worksheets across the domains of nutrition, clothing, hygiene, safety, shelter, health care and finances for identifying actual risks and strengths in each area (Appendix G). These worksheets are to be used to create a care plan consistent with the person’s values, preferences, culture and beliefs (Fraser Health Authority, 2011). Strengths of this tool include clear definitions of tolerable and intolerable risk, the provision of standardized assessment tools to enhance a Nurse Practitioner’s assessment, the sequence of steps to follow in the assessment of risk and the use of fillable forms to guide the assessment process. Its limitation is the difficulty for Nurse Practitioners to access the Clinical Practice Guideline outside of the Fraser Health Authority. Type and Quality of Evide nce The type of evidence in this literature review includes articles published between 2010 and 2019, with the bulk being published in 2015 or later (n=5). Articles retrieved were from Canada, USA, and Europe, with the majority within Canada (n=5). All articles, except two, had author affiliation with a post-secondary education institute. Those articles outside these parameters include the Clinical Practice Guideline (Fraser Health Authority, 2011) and the Elder’s Risk Assessment index cohort study, through the Mayo clinic (Crane et al., 2010). Five research articles utilize cohort studies, two of which are retrospective (Crane et al., 2010; Drubbel et al., 2012) and three being prospective (Aliberti et al., 2019; O’Caoimh et al., 2015; St. John & Montgomery, 2014). Gray, Grove and Sutherland (2017) describe how levels of 45 research are reflected using a pyramid, with the highest degree of evidence (systematic reviews and meta-analyses) at the top on level I, while the weakest (opinions of expert committees and authorities) at the bottom on level VII. Based on the pyramid diagram in Appendix H, the levels of evidence for each article, along with greater detail of each article overview, is captured in the literature review matrix (Appendix I). Cohort studies provide level IV evidence, meaning that they provide limited evidence for changes in practice and that they typically involve newer areas of research (Gray, Groves & Sutherland, 2017). One article utilized a mixed method, quantitative and qualitative study design, level III evidence, to pilot study a risk assessment management framework (Lee et al., 2019). The remaining literature articles include non-experimental grey literature, of which there is one clinical practice guideline (Fraser Health Authority, 2011) one risk support management tool (De Bono & Henry, 2018), and an outlined process for decision-making as it pertains to living at risk (Young & Everett, 2019). Aliberti’s Decision Support Strategy (Aliberti et al., 2019), the Elders Risk Assessment (Crane et al., 2010), the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012), the Risk Instrument for Screening in the Community (O’Caoimh, et al., 2015) and the Early Risk Score (St. John & Montgomery, 2014) each outlined clear goals for the study, as mentioned in the article overview, and utilized all genders for sampling. The tools were developed using a range of cohort sample sizes, from 801 individua ls in the Risk Instrument for Screening in the Community (O’Caoimh, et al., 2015) to 12,650 subjects in the Elders Risk Assessment (Crane et al., 2010). The Person-Centred Risk Assessment Framework used a sample size of 297 patients in the pilot study, while a much smaller number of only six health care providers and twelve patients / families were interviewed to inform the qualitative results of the study (Lee et al., 46 2019), being another of the study’s limitations. The majority of the cohort samples reflect a diverse representation of community-dwe lling older adults (n=4), which applies broad generalizability of results. The Risk Instrument for Screening in the Community used a study cohort recruited from a population of older adults in Ireland that were referred to public health nurses for community-based follow-up (O’Caoimh, et al., 2015). This method of sampling has the potential to contribute to selection bias, as patients under public health nurse follow-up are already at higher risk of adverse outcomes than the general population (O’Caoimh et al., 2015). Finally, of the nine tools, the Decision-Making Process is the sole tool to directly include Nurse Practitioners as providers listed as intended users of this ethical approach to risk evaluation (Young and Everett, 2018). The Risk Assessment Tools The assessment tools are further being analyzed in terms of dominant themes, specifically the measures used in the tools, the predictive and responsive approach of the tools, the elements of risk included in each risk assessment tool, as well as risk mitigation strategies discussed. The risk assessment tools utilized in the nine articles include assessment tools, frameworks, guidelines and decision-support strategies. Approach to Assessing Risk: Quantitative versus Qualitative The approach to assessing risk varies across the literature, with some tools utilizing predictive scales as a means of calculating the likelihood of specific adverse outcomes, while others present frameworks to be followed, to those with more loosely suggested approaches and considerations to inform a Nurse Practitioner’s decision-making regarding risk. Of the nine tools, four aimed to determine risk using specific outcome measures that fall within the inclusion and exclusion criteria of this literature review. These include the Risk Instrument for Screening in the 47 Community (O’Caoimh, et al., 2015), the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012), the Early Risk Score (St. John & Montgomery, 2014), and the Elders Risk Assessment index (Crane et al., 2010). These tools quantitatively measure adverse outcomes using data relevant to the older adult’s clinical picture of health and wellness, and subsequently their level of risk. Further, the Elders Risk Assessment (Crane et al., 2010), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015), and the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012) each incorporate data taken from an EMR to inform a clinical picture of risk. Aliberti’s Decision Support Strategy describes an approach for Nurse Practitioners to consider in terms of risk of death and ADL dependence, as well as incorporating a quantitative assessment of both physical frailty and cognition for the older adult (Aliberti et al., 2019). The elements of risk prediction being addressed by each tool will be discussed in a succeeding section. The approach to risk assessment of the remaining four tools focused more on qualitative information. The Person-Centred Risk Assessment Framework provides a framework for health care professionals to engage with the older adult and their caregivers in a real-time discussion and assessment of risk, and to develop a positive person-centred care plan (Lee et al., 2019). Similarly, the Risk Support Management Plan suggests a two-part approach to help manage risk in the home, see Appendix E (De Bono & Henry, 2016). This is broken down further into the following steps: “1. Risk Identification 2. Risk Assessment 3. Creating a risk support management plan 4. Evaluating a risk support management plan” (De Bono & Henry, 2019, p. 216). The Person-Centred Risk Assessment Framework is specific to persons living with dementia, potentially limiting its generalizability to the broader population of older adults who may be living at risk. Because not all older adults living at risk live with cognitive impairment, a 48 tool specific to a population of older adults living with dementia excludes a proportion of adults for whom the tool could add value. Further, the Decision-Making Process incorporates a framework (Appendix D) and checklist of what clinicians should consider to make “ethically justifiable decisions about when and how to intervene when patients choose to live at risk” (Young & Everett, 2018, p. 315). The tool most specific to the research question being addressed by this literature review, the Clinical Practice Guideline , aims to “provide a standardized risk assessment process to determine tolerable and/or intolerable risk for vulnerable adults who are presenting at risk in Fraser Health” (Fraser Health Authority, 2011, p. 1). Type of Assessment Tool: Predictive versus Responsive A key difference in the approaches to assessing risk within the literature are those tools that are predictive of eventual adverse outcomes such as institutiona lization and death, versus those that can be used in real-time by a Nurse Practitioner to assess a perceived risk within a given clinical situation. Prediction is the act of projecting what will happen in the future, with preventive and therapeutic interventions being prescribed or suggested based on implic it or explicit expectations about future health outcomes (Janssens, 2020). For the purpose of this paper, predictive tools that aim to quantify the probability of future health outcomes based on a set of predictors include: The Risk Instrument for Screening in the Community, the Elders Risk Assessment, the Frailty Index based on Routine Health Care Data, the Early Risk Score and Aliberti’s Decision Support Strategy. Each tool describes either existing or new data to predict the future risk of adverse outcomes (O’Caoimh et al., 2015; Crane et al., 2010; Drubbel et al., 2012; Aliberti et al.’s, 2019). Such tools support risk stratification using a preventative health care approach. Their intended use, however, does not allow for use of these tools to be applied to 49 an immediate risky clinical scenario of an older adult choosing to live at risk, given their predictive nature. The tools being cited as responsive in this paper are those that are readily responsive to a stimulus (Merriam-Webster, n.d.), in this case, a perceived risk. Of the nine tools analyzed, four use a responsive approach to risk assessment, these include the Risk Support Management Plan (De Bono & Henry, 2016), the Clinical Practice Guideline (Fraser Health Authority, 2011), PersonCentred Risk Assessment Framework (Lee et al., 2019) and the Decision-Making Process (Young & Everett, 2018). The benefit of a responsive tool being that Nurse Practitioners supporting older adults in the community can inform their clinical decision-making regarding the determination of risk level immediately when a perceived risk is identified. The Person-Centred Risk Assessment Framework utilizes a framework that the Nurse Practitioner can apply directly to a clinical situation when there is a risk recognized. It is designed to act as a conceptual aid, working to help inform, not substitute, a Nurse Practitioner’s diagnosis and treatment plan (Lee et al., 2019). Similarly, the Risk Support Management Plan delivers a structured platform, with review schedule, for the necessary considerations to deliberate over when aiming to determine a risk management plan (De Bono & Henry, 2016). Another responsive tool that can be applied in real-time to an identified risk, the Decision-Making Process includes “analyzing the risks involved, considering all options available to reduce risks to a tolerable level, and implementing interventions based on the ethical principles of respect for autonomy, non-maleficence, beneficence, and justice” (Young & Everett, 2018, p. 318). Of the four goals outlined in the Clinical Practice Guideline, the most applicable in terms of it being a responsive assessment is that it “provide[s] a standardized risk assessment process to determine tolerable and/or intolerable risk for vulnerable adults” (Fraser Health Authority, 2011, p. 1), which can be applied 50 in real-time. This highlights the Clinical Practice Guideline’s applicability for use in the determination of tolerable risk for Nurse Practitioners and in answering the research question being posed in this literature review. Further to the tools being either predictive or responsive in their approach to risk, none of the nine tools are diagnostic of tolerable risk. The Decision Support Strategy (Young & Everett, 2018) does mention tolerable risk, however. In addition, the Clinical Practice Guideline (Fraser Health Authority, 2011) provides definitions of tolerable and intolerable risk, as well as presents three diagnostic criteria for the determination of intolerable risk. The subjective nature of risk supports how such tools are used to guide treatment decisions of the Nurse Practitioner, but not to be used in place of clinical judgement. The Elements of Risk Being Assessed The elements included in the assessment of risk within each of the risk assessment tools, frameworks and decision-support articles were further described by themes using the following six categories 1) health conditions and/or medications 2) level of function or frailty 3) cognition 4) caregiver support 5) psychological well-being 6) decision-making capacity, and 7) risk mitigation strategies, as seen in Table 2. Health conditions and/or medications pertain to the assessment of certain diseases that the patient may be diagnosed with, as well the analysis of either the types, or the numbers, of medications prescribed. Level of function and frailty refer to the assessment of a older adult’s ability to perform certain tasks, such as ADLs, iADLS and other objective measures of functioning. Cognition refers to the assessment of memory impairment. Assessment of caregiver support suggests the inclusion of important family or friends to the older adult, while psychological well-being refers to the older adult’s general outlook, values and wishes. Decision-making capacity refers to a formal assessment of the older adult’s ability to 51 decide whether or not to live at risk. Risk mitigation strategies refer to any approach that the Nurse Practitioner can use with an older adult, a family member or other health care professionals to engage in dialogue about risk reduction. Table 2: The elements of risk assessed within each tool, framework or guideline Health conditions and/or medications Aliberti’s Decision Support Strategy (Aliberti et al., 2019) Elders Risk Assessment (Crane et al., 2010) Risk Support Management Plan (De Bono & Henry, 2018) Frailty Index based on Routine Health Care Data (Drubbel, I. et al., 2012) Clinical Practice Guideline for Risk Assessment (Fraser Health Authority, 2011) Person-Centred Risk Assessment Framework (Lee et al., 2019) Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) Early Risk Score (St John & Montgomery, 2014) Decision-Making Process (Young & Everett, 2018) Level of function or frailty Cognition x x x Caregiver support Psychological well-being Decisionmaking capacity Risk mitigation strategies x x x x x x x x x x x x x x x x x X x x x x x Within these groupings, five of the nine tools utilize health conditions and/or medications in their determination of risk. The Elders Risk Assessment, the Early Risk Score, the Risk Instrument for Screening in the Community and the Frailty Index based on Routine Health Care Data discussed health conditions and medications as objective measures informing the older adult’s health deficits (O’Caoimh, et al., 2015; Drubbel et al., 2012; St. John & Montgomery, 2014; & Crane et al., 2010), while the Clinical Practice Guideline discussed medical conditions 52 and their potential impact on the older adult’s decision-making capacity (Fraser Health Authority, 2011). Level of function or frailty is addressed in four tools, with each article using a scale or a criterion for measurement. Aliberti’s Decision Support Strategy uses five frailty phenotype criteria including: 1) unintentiona l weight loss of 10% or greater in the previous 2 years or body mass index of less than 18.5 kg/m2; 2) exhaustion; 3) muscle weakness measured by grip strength using the CHS cutoff values; 4) slowness while walking 5) low levels of activity (Aliberti et al., 2019). The Frailty Index based on Routine Health Care Data also measured functional impairment within 140 chosen International Classification of Primary Care codes used to inform a holistic picture of the older adult’s health deficits (Drubbel et al., 2012), while the Risk Instrument for Screening in the Community subjectively measured ADL dysfunction as mild, moderate or severe (O’Caoimh et al., 2015). The Early Risk Score measured functional status using the Older Americans Resource Survey (St. John and Montgomery, 2014). Despite each tool measuring frailty using its own criterion, a relationship between frailty and certain risk factors is evidenced by its inclusion in each tool used to assess a level of risk. Cognition was addressed in four tools and was measured objectively using all, or portions of, the mini mental status exam (MMSE) in Aliberti’s Decision Support Strategy (Aliberti et al., 2019), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) and the Early Risk Score (St. John & Montgomery, 2014), whereas the Elders Risk Assessment (Crane et al., 2010) included a diagnosis of dementia as its measure of cognition. In addition, Aliberti’s Decision Support Strategy and the Risk Support Management Plan both highlighted the need for the assessment of cognition, in addition to physical abilities, as integral to the determination of risk (Aliberti et al., 2019; De Bono and Henry, 2019). Similar to cognition, the capacity of the 53 older adult to make a decision regarding the risk in question is addressed in just the Clinical Practice Guideline (Fraser Health Authority, 2011) and the Decision-Making Process (Young & Everett, 2018). Psychological well-being of the vulnerable adult was considered within four tools. The Frailty Index based on Routine Health Care Data and the Clinical Practice Guideline approached psychological well-being in terms of its impact on functional ability and the ability of the older adult to independently make decisions (Drubbel et al., 2012; Fraser Health Authority, 2011). Whereas the Decision-Making Process aimed to establish the nature of possible harm, either physical, emotional or psychologica l, incurred by a risky activity (Young & Everett, 2018). The Person-Centred Risk Assessment Framework described a different approach, by encouraging the Nurse Practitioner to determine if and how the risky behaviour meets an underlying psychological need of the patient (Lee et al., 2019). The authors went on to highlight love (unconditional acceptance), comfort (feeling close to others), identity (your story), occupation (activities with personal significance), inclusion (having a place in a group), attachment (emotional bonds) and environment (safety and security) as possible psychological needs being met by a risky behaviour (Lee et al., 2019). After determining the associated psychologica l need being met by the risky behaviour, the risk mitigation process proceeded to determine if other, less risky, options exist to fulfill such needs. Three tools included the caregiver as integral in their determination of risk and in its mitigation. The Clinical Practice Guideline included the caregiver’s availability, ability and willingness to support the older adult (Fraser Health Authority, 2011). Similarly, the Early Risk Score measured caregiver help with ADLs and iADLs objectively to inform the Frailty Index (St. John & Montgomery, 2014). Whereas the Person-Centred Risk Assessment Framework 54 suggested that the caregiver be included in the risk assessment dialogue to determine their perceived level of risk, in a given circumstance (Lee et al., 2019). The four articles using a responsive approach to risk, the Decision-Making Process, the Risk Support Management Plan, the Person-Centred Risk Assessment Framework and the Clinical Practice Guideline, addressed risk identification and mitigation strategies, whereas the five using a predictive approach to risk, the Elders Risk Assessment, the Early Risk Score, the Frailty Index based on Routine Health Care Data, the Risk Instrument for Screening in the Community and Aliberti’s Decision Support Strategy, did not. The Risk Support Management Plan however, focused solely on the risk in question and provided a framework within which to develop risk stratification strategies (De Bono and Henry, 2016), without the inclusion of the other elements categorized in Table 2. Of the nine tools reviewed, the Decision-Making Process (Young and Everett, 2018) and the Clinical Practice Guideline (Fraser Health Authority, 2011) were the two tools that directly address risk in terms of its tolerability. While the Clinical Practice Guideline informed intolerable risk with its criteria to consider, neither tool is diagnostic of tolerable risk. The Clinical Practice Guidelines did, however, provide a clear definition of tolerable risk which Nurse Practitioners can use to inform their clinical decision-making when faced with caring for an older adult living with a perceived risk. 55 Risk Mitigation. Further to the elements addressed in Table 2, the Risk Support Management Plan, the Clinical Practice Guideline, the Person-Centred Risk Assessment Framework and the Decision-Making Process go into detail regarding risk reduction strategies. The common themes pertaining to risk reduction include the identification of the risk/issue, the older adult’s understanding of the risk, the associated benefits of the risk, the type and degree of harm, caregivers, mitigation strategies including previous successes and failures, as well as a management plan and patient capacity (De Bono & Henry, 2016; Fraser Health Authority, 2011; Lee et al., 2019; Young & Everett, 2018). The Decision-Making Process presents a team-based approach whose main features are outlined in Appendix D, noting that the timing and sequence of each step can vary, but that all steps must be undertaken prior to making a decision regarding the risk in question (Young & Everett, 2018). Similarly, the Risk Support Management Plan provides a 4-step approach to guide dialogue with patients and families in making informed choices when they are choosing to live at risk in the community, as shown in Appendix E (De Bono and Henry, 2016). Although specific to older adults living with dementia, the PersonCentred Risk Assessment Framework also identifies the risk activity, the level of risk perceived, the unmet psychologica l need being fulfilled by the risk and a plan to engage in dialogue regarding risk mitigation strategies between the provider, patient and family (Lee et al., 2019). Finally, the Clinical Practice Guideline provides a guided interprofessional care planning process within its own risk assessment framework (Fraser Health Authority, 2011). The Outcome Measures In addition to analysis of the tools themselves, the outcome measures of each article also inform the approach to assessing tolerable risk. The five predictive tools, the Elders Risk Assessment, the Early Risk Score, the Frailty Index based on Routine Health Care Data, the Risk 56 Instrument for Screening in the Community and Aliberti’s Decision Support Strategy assessed risk as it relates to specific adverse outcomes, with hospitalization and death being the most common (Aliberti et al., 2019; O’Caoimh, et al., 2015; Drubbel et al., 2012; St. John & Montgomery, 2014; & Crane et al., 2010). Aliberti’s Decision Support Strategy measured ADL dependence and time to death (Aliberti et al., 2019), while the Frailty Index based on Routine Health Care Data measured visits to the emergency room and after-hours GP surgery visits, as well as mortality and nursing home admission (Drubbel et al., 2012). Similarly, the primary outcome described in the Elders Risk Assessment was the total number of emergency room visits and hospitalizations in the subsequent two years (Crane et al., 2010). The Risk Instrument for Screening in the Community tool assessed admission to long-term care, acute admissions to hospital and death as the outcome measures (O’Caoimh et al., 2015). While the Early Risk Score recorded death and nursing home admission over a 5-year period (St. John and Montgomery, 2014). In addition, the Elders Risk Assessment (Crane et al., 2010), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015), and the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012) each incorporated data taken from an EMR to inform a clinical picture of risk. While the facets of risk assessed in each tool are captured in Table 2, some standardized assessment tools were also incorporated into the assessment tools to objectively measure cognition and level of function. Aliberti’s Decision Support Strategy, the Risk Instrument for Screening in the Community and the Early Risk Score, as examples, objectively measured cognition and level of function using standardized assessment tools such as the MMSE, serial subtractions and muscle weakness by grip strength (Aliberti et al., 2019; O’Caoimh, et al., 2015; St. John & Montgomery, 2014). 57 The four remaining tools, the Decision-Making Process (Young & Everett, 2018), the Risk Support Management Plan (De Bono & Henry, 2016), the Person-Centred Risk Assessment Framework (Lee et al., 2019) and the Clinical Practice Guideline (Fraser Health Authority, 2011), did not gauge outcome measures with the use a specific risk assessment tool, however, they did suggest strategies for risk assessment and mitigation. The pilot study of the PersonCentred Risk Assessment Framework measured perceptions related to the use of the tool itself, using Likert scales to quantify overall satisfaction, ease of use, patient acceptability and feasibility in practice (Lee et al., 2019). As a conceptual aid, the Person-Centred Risk Assessment Framework suggested handling potential risks and harms using an approach that places the patient at the centre of the decision-making to make the condition less risky. If the risks “cannot be mitigated to reduce substantive risk, the next task is to determine the underlying psychosocial needs that are met by that particular activity and to work toward finding new meaningful activities that might fulfil those underlying psychosocial needs” (Lee et al., 2019, p. 48). The Decision-Making Process outlined a process incorporating a framework and checklist of what clinicians should consider to make ethically justifiable decisions about when and how to intervene when patients choose to live at risk (Young & Everett, 2018). Similarly, the Risk Support Management Plan argued for a positive risk-based approach and offered a tool to guide risk-management based on review of recent approaches in the literature about patients choosing to live at risk (De Bono & Henry, 2016). Of the remaining tools, the Clinical Practice Guideline was designed to provide a standardized risk assessment procedure to determine tolerable and intolerable risk (Fraser Health Authority, 2011). 58 How Risk is Vie wed and Pe rson-centre d Care How risk is viewed varies in the literature, with some following a more paternalistic, riskaverse approach wherein the providers are encouraged to mitigate or manage the risk, to those with a person-centred approach to risk where providers focus on patient values, holistic care and prioritize shared decision-making. None of the articles expressly promote a paternalistic approach to risk mitigation, however a holistic view of the older adult’s health and wellness is incorporated into the risk assessment in Aliberti’s Decision Support Strategy (Aliberti et al., 2019), the Elders Risk Assessment (Crane et al., 2010), the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012), the Risk Instrument for Screening in the Community (O’Caoimh, 2015) and the Early Risk Score (St. John & Montgomery, 2014), without mention of person-centred care or collaborative decision-making. The Elders Risk Assessment was developed to calculate the risk of specific adverse outcomes, aimed at the promotion of risk mitigation strategies earlier in the care planning for a vulnerable older adult (Crane et al., 2010). The Early Risk Score and Aliberti’s Decision Support Strategy include both cognition and physical assessment as a holistic picture of health and wellness, versus one in isolation in the assessment of risk (St. John & Montgomery, 2014; Aliberti et al., 2019). Such tools help to guide a Nurse Practitioner’s treatment decisions as they relate to certain adverse outcomes for the older adult. The goals described in the development of the Frailty Index based on Routine Health Care Data include the ability to guide practitioners in directing their care efforts to the patients at highest risk, making a shift toward more proactive, population-based care, while not directly focused on shared decision-making (Drubbel et al., 2012). Similarly, the Risk Instrument for Screening in the Community is an assessment tool that “incorporates mental state, ADLs and medical problems, in the context of the caregiver network. In this respect, it is a holistic measure, 59 incorporating more domains and contextualizing problems to create an individua lized measure of risk” (O’Caoimh, 2015, p. 7). Ethics and/or shared decision-making are addressed using a person-centred approach in the Risk Support Management Plan (De Bono & Henry, 2016), the Clinical Practice Guideline (Fraser Health Authority, 2011), the Person-Centred Risk Assessment Framework (Lee et al., 2019) and the Decision-Making Process (Young & Everett, 2018). Specifically, the approach to risk described in the Decision-Making Process is founded in the bioethical principles of respect for autonomy, non-maleficence, beneficence and justice, as well as being informed by relevant British Columbia legislation (Young & Everett, 2018). The Person-Centred Risk Assessment Framework is described as an inclusive opportunity to empower self-management, to gather perspectives of both the person living with dementia and their caregivers, as well as to reduce burden for caregivers and engage in conversation to increase understanding of potential risks (Lee et al., 2019). The Clinical Practice Guideline aimed to balance risk mitigation in the context of ethical decision-making principles (Fraser Health Authority, 2011). The five guiding principles underlying the Clinical Practice Guideline include 1) the vulnerable adult's quality of life is of principle consideration, 2) the team engages in culturally sensitive interventions, 3) the autonomy of the vulnerable adult is upheld, 4) previously established advanced care plan (verbal or written) guides the team’s interventions and 5) the social network / caregivers are key partners (Fraser Health Authority, 2011). While not expressly founded in ethical principles, De Bono and Henry (2016) argued for a positive risk-based approach and provided the Risk Support Management Plan to help manage risk in the home, applying these to a hypothetical end-of-life scenario. 60 Central to the discussion of living at risk, person-centred care and shared decisionmaking, is the concept of decision-making capacity. Throughout the discussion of choosing to live at risk, the ability of the older adult to independently decide whether or not to live at risk is either supported, opposed or mitigated by the Nurse Practitioner based on the older adult’s capacity to make that decision. Decision-making capacity is founded in ethics but also falls under the Adult Guardianship Act, which is British Columbia provincial legislation (Young & Everett, 2018). The Fraser Health Authority’s Clinical Practice Guideline (2011) and Young and Everett’s Decision-Making Process (2018) are the only two articles that address patient capacity. In summary, the dominant themes addressed in each tool’s approach to risk include how risk is viewed, the elements of risk being assessed, the usability of each tool as well as the ethical principles underpinning risk. 61 Chapte r 5 - Discussion and Recomme ndations The primary objective of this literature review was to examine risk assessment tools and guidelines that are available to Nurse Practitioners to support the determination of tolerable risk for older adults. The chapter that follows provides discussion of the literature as it relates to the significance in determining tolerable risk for a community-dwelling older adult. Additionally, strengths and limitations of the literature review, implications for Nurse Practitioner practice and future recommendations will also be discussed. An analysis of the available risk assessment tools is valuable to answer the research question in this literature review. The Clinical Practice Guideline (Fraser Health Authority, 2011) provided a useful framework, as well as clear definitions, upon which to build personcentred care plans and future risk assessment tools. The nine tools analyzed provided important information regarding the elements of risk to consider when Nurse Practitioners are determining if a perceived risk is either tolerable or intolerable. Through synthesis of the literature findings, the complexity of risk and the difficulty in both defining and assessing it in a clinical situation was made evident. The implications for Nurse Practitioner practice include a shift in thinking regarding risk and its assessment, as well as gaps in available tools and resources to inform a comprehensive clinical picture of an older adult living at risk, which provide opportunity for further study and leadership by Nurse Practitioners in the determination of tolerable risk. The Risk Assessment Tools The type of tools, the approaches to risk, the elements of risk assessed within each tool, the outcome measures and the view of risk each provide useful information from which the Nurse Practitioner can inform their decision-making regarding older adults living at risk. Each 62 contribute important pieces to a clinical picture of risk, that have the potential to impact the development of risk assessment tools in the future. Predictive versus Responsive Approaches as They Relate to Tolerable Risk The five predictive risk assessment tools, the Elders Risk Assessment (Crane et al., 2010), the Early Risk Score (St. John & Montgomery, 2014), the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) and the Decision Support Strategy (Aliberti et al., 2019) may be best suited to the early identification of future adverse outcomes, which could increase an older adult’s vulnerability to living at risk. This is because these tools aim to predict an eventual change in health status which could negatively impact one’s health and wellness, leading to hospitalization or institutiona lization, as examples, without the implementation of interventions which could otherwise help mitigate such an outcome. As described earlier, these risk assessment tools with measurable adverse outcomes (Aliberti et al., 2019; Crane et al., 2010; Drubbel et al., 2012; O’Caoimh et al., 2015; & St. John and Montgomery, 2014) are not intended to be used in a real-time assessment of risk. They are, however, focused so that the Nurse Practitioner can identify vulnerable and frail older adults early and implement a preventative approach to health care in the reduction of future adverse outcomes. Such an approach allows Nurse Practitioners to assess for common triggers identified in the literature which contribute to an older adult’s frailty and potentially, to experiencing increased adverse outcomes based on the assessed risk factor(s). The concept of frailty is closely related to the concept of living at risk, and its assessment similarly informs a Nurse Practitioner’s decision-making regarding focused, proactive health care interventions. Frailty is described as a state of functional impairment and increased 63 vulnerability caused by cumulative declines across various health care domains including medical, psychological, functional, medications and alcohol, as well as social and environmental (BC Guidelines, 2017). This concept of frailty is increasing in clinical importance with an aging population and a need for Nurse Practitioners to prevent late-life disability, resulting in improved quality of life for older adults and reducing health care costs (Costanzo et al., 2018). The benefits of risk assessment tools focusing proactively is that Nurse Practitioners can identify older adults for initial risk stratification, providing them with the opportunity to suggest rehabilitative actions and to implement preventive interventions, such as with a medication review, through an exercise program or with a referral to a community resource, to delay, avert or even reverse decline associated with frailty (BC Guidelines, 2017). Similar to the outcomes measured in the five cohort studies, frailty scales are strong predictors of future institutiona lization and mortality (BC Guidelines, 2017). The Elders Risk Assessment (Crane et al., 2010), the Early Risk Score (Drubbel et al., 2012), the Frailty Index based on Routine Health Care Data (St. John and Montgomery, 2014), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) and Aliberti’s Decision Support Strategy (Aliberti et al., 2019) were each tested using either a retrospective or prospective study approach to assess risk. Because they were not developed to be used in real-time, such an approach supports a preventative focus to risk mitigation, less so one that can be applied in an immediate clinically risky situation. While such tools have value for Nurse Practitioners identifying older adults susceptible to certain adverse outcomes, the intended purpose of projecting one or more future adverse outcomes, and not being diagnostic of tolerable risk, limits the tools’ use in the determination of tolerable risk. 64 Although the predictive tools were not explicitly developed to be applied in an immediate risky scenario, the elements included in the risk assessment tools (Table 2) comprise components of risk that Nurse Practitioners should consider and monitor as they support a population of older adults in Primary Care to mitigate risk early. In using a variety of risk assessment sources, the total elements of risk capture a comprehensive, holistic picture of risk that Nurse Practitioners can now reference and apply in a clinical scenario, despite lacking a formalized tool inclusive of all elements. The identification of risk adverse health outcomes also helps to target the delivery of specific preventative health interventions (Weathers et al., 2016). This allows Nurse Practitioners to implement measures early to prevent future decline and health complications. As an example, by identifying an older adult who is at risk of falls early, a referral to Occupational Therapy can be initiated and safety interventions such as grab bars installed in the home or fitting of a walker can be put in place to reduce the potential risk of falling. The determination of tolerable risk is better suited to those tools using a responsive approach to risk, as they allow the Nurse Practitioner to engage in dialogue and assessment of a risk at a point in time when the perceived risk is identified. The Clinical Practice Guideline “provide[s] a guided interprofessional care planning process in client situations that require […] informed decision making and care planning related to assumed risk” (Fraser Health Authority, 2011, p. 1). Similarly, the Person-Centred Risk Assessment Framework (Lee et al., 2019), the Decision-Making Process (Young & Everett, 2018) and the Risk Support Management Plan (De Bono & Henry, 2018) describe approaches that can be applied in practice once a risk is identified. Despite the ability of the four responsive tools to be used in real time, none of them provide a diagnostic algorithm to deduce tolerable risk. 65 The Feasibility of the Tools The usability of each tool in practice is also important to the research question. The feasibility of the risk assessment tools is influenced by the breadth and the quality of data availability, as well as by the ability to utilize the tool successfully in the appropriate clinical setting and with the intended patient population for the tool. Those risk assessment tools utilizing the older adult’s pre-existing health care data allow for a quantitative assessment of risk, however, they are limited by the availability of that data to the Nurse Practitioner. As discussed, the Elders Risk Assessment (Crane et al., 2010), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015), and the Frailty Index based on Routine Primary Care Data (Drubbel et al., 2012) each incorporate data taken from an EMR to inform a clinical picture of risk. While this provides objective, measurable data, it is limited by the availability of that data and relies on each Nurse Practitioner, and every member of the care team, to maintain the EMR to a similar standard. To inform clinical decision-making, a practice must consistently enter fully structured data, such as the problem list, allergies and prescriptions, using accepted coding standards, into an EMR as the principal method of record keeping (Hefford & Taylor, 2014). Also, this type of measure relies on a consistent usage, not only between providers, but also between provider clinics to predict the adverse outcomes being measured with each tool. Both the Early Risk Score (St. John & Montgomery, 2014) and the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) use self-reported, subjective data to quantify their picture of risk. While this does capture the subjective nature of risk as described earlier, it also has the potential for bias due to its subjectivity. As an example, a study of the inter-rater reliability between student public health nurses recently trained in the Risk Instrument for Screening in the Community, found that when high-risk cases were reviewed individually, the 66 training program was found to have affected individua l risk tolerance (Weathers et al., 2016). Further, due to its subjectivity, the training is thought to have affected risk tolerance, causing students to question “gut instincts” and subsequently leading to fluctuating scores (Weathers et al., 2019). Additional considerations for the risk assessment tools involves who the most appropriate provider is to conduct either a portion of, or the entire assessment, the time required to complete the assessment and the setting that is best-suited to complete the assessment. The use of standardized assessment tools was incorporated into the risk assessment process of some of the tools, such as Aliberti’s Decision Support Strategy (Aliberti et al., 2019), the Risk Instrument for Screening in the Community (O’Caoimh, et al., 2015), and the Early Risk Score (St. John & Montgomery, 2014). To ensure reliable outcomes with such measures, their implementation must be consistent between each patient encounter and between the providers using the tools. As an example, the BC Guideline for cognitive impairment (2016) provides a standardized MMSE resource with a script to be followed verbatim by the provider for every question, and clear criteria for scoring the tool, which must be followed by each practitioner to ensure validity of the tool. With practice and with the availability of the script to ensure consistent delivery between providers, Nurse Practitioners can become proficient in administering the assessment tool. Without the availability of such a script, there is freedom for the tool’s administrator to interpret the questions differently, or to unintentiona lly provide hints to the patient, potentially skewing the results and impacting the validity of the tool. It could be argued that to ensure validity of the results, such assessment tools are best completed by either a trained clinician such as an Occupational Therapist, or that the Nurse Practitioner have the appropriate training to implement 67 each tool correctly, in the assessment of risk, potentially limiting their use in a primary care setting. However, tools without such scripted assessments provide flexibility to support the Nurse Practitioner to use their own clinical judgement, as well as to rely on communication and established rapport with the patient to inform decision-making. It is tools such as the Decision Support Strategy (Young & Everett, 2018), the Risk Support Management Plan (De Bono & Henry, 2016), the Clinical Practice Guideline (Fraser Health Authority, 2011) and the PersonCentred Risk Assessment Framework (Lee et al., 2019) that act as guides to help inform Nurse Practitioner decision-making, versus tools lacking this flexibility with the use of standardized diagnostic assessments. Time requirements to complete an assessment must also be considered. The tools ranged between a 2 to 5-minute global subjective assessment of risk using the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015), to the Clinical Practice Guideline that was designed to be completed in addition to the provider’s functional or psychosocial assessment (Fraser Health Authority, 2011), increasing the time demands to inform a clinical picture of risk. Additionally, the Person-Centred Risk Assessment Framework pilot study identified time constraints to complete the tool “within the context of an already comprehensive clinic assessment” (Lee et al., 2019, p. 54) as a potential barrier, with home visits suggested as a mitigation strategy. Home visits could allow for a more fulsome clinical picture of risk by providing direct observation of both the physical environment and family supports, however, it does further limit the tool’s use to those providers willing to do home visits, and may require an additional visit to complete the assessment. The RAI-HC is such a tool that requires individua ls trained in its application to assess older adults in the home setting to determine service eligibility 68 for both publicly funded home support services and long-term care facility placement (Government of BC, 2020). Tools aimed at incorporating risk assessments into existing clinic encounters, such as with the Clinical Practice Guideline (Fraser Health Authority, 2011), give less of a priority on assessing risk as its own, independent health concern, than as with other medical conditions. The recommended assessment of frailty is through a comprehensive geriatric assessment, which can be resource intensive (BC Guidelines, 2017). It is understood that through a network of supports, patients with multiple health concerns that contribute to frailty, and subsequently those patients who could eventually also live at risk, can be managed in Primary Care, with recommendations for “rolling” assessments over multiple visits that target at least one area of concern, such as cognition, mood or nutrition, per visit (BC Guidelines, 2017). Elements of Risk: Function and Cognition Physical functioning and cognition were two elements most often identified as factors to be included in the determination of risk. Aliberti et al. (2019) and St. John and Montgomery (2014) both advocate for the inclusion of cognition and physical functioning as integral to the determination of risk. The purpose of including cognition and physical functioning varies between the tools. The Decision Support Strategy and the Early Risk Score both use cognition and physical functioning as predictors of adverse health outcomes, specifically ADL dependence and death (Aliberti et al., 2019), as well as institutiona lization and death (St. John & Montgomery, 2014). Whereas the Decision-Making Process (Young & Everett, 2018), the PersonCentred Risk Assessment Framework (Lee et al., 2019) and the Clinical Practice Guideline (Fraser Health Authority, 2011) consider cognition and physical functioning as they relate to the perceived risk and to the immediate risk mitigation strategies. The Frailty Index 69 based on Routine Health Care Data assesses a predefined list of relevant health deficits including “diseases, signs, symptoms, and psychosocial or functional impairments” (Drubbel et al., 2012, p. 301), without specifically discussing cognition. Cognition and physical function are however, integral to the identification of frail and vulnerable older adults (BC Guidelines, 2017), who would benefit from the preventative approach to care described earlier. The Risk Support Management Plan describes a risk management strategy without the use of a client-specific assessment tool and it refrains from addressing physical functioning, decision-making capacity or cognition altogether (De Bono & Henry, 2016). Further to the discussion of cognition, the Person-Centred Risk Assessment Framework is the one tool that is specific to people living with dementia (Lee et al., 2019). The reasoning for this being that much of the existing literature regarding risk focused on physical impairments and those people living with dementia did not necessarily fit into the criteria for those tools (Lee et al., 2019). Despite acknowledging that “dementia affects different people in different ways” (Lee et al., 2019, p. 48), what this tool does not do is provide a definition of dementia or address the degree of cognitive impairment for which its population is intended. Being a person-centred risk assessment framework, this tool does not objectively measure the older adult’s cognitive impairment. In this sense, the tool fails to address how its results could vary between individua ls with mild cognitive impairment to those whose cognitive impairment is severe. An individua l with severe dementia may be unable to participate in the subjective questioning of the assessment, incapable of verbalizing the psychosocial need being met by the risky activity, potentially impacting the effectiveness of the tool. Also, the tool is unclear as to whether a diagnosis of dementia is required or whether it is based on a subjective measure of some level of cognitive impairment by the assessor. Other tools have included objective measures of cognition, 70 such as with the use of the MMSE in Aliberti’s Decision Support Strategy and the Risk Instrument for Screening in the Community, however none are included in this tool to clarify how dementia is qualified. Despite being developed for persons living with dementia, and without outlined parameters for the target population, it may be questionable whether the framework could be applied to all older adults with and without dementia who are also living at risk. The focus of the Person-Centred Risk Assessment Framework for assessing this unique population also highlights a lack of tools for specialized populations in terms of living at risk. There is the understanding that certain physical risks and harms of activities are made riskier by the person living with dementia’s memory loss (Lee et al., 2019). Similarly, those with hoarding behaviours or with poorly managed mental health conditions, whose symptoms fall outside of physical impairments, may also be increasingly vulnerable to adverse outcomes in certain aspects of their physical and psychological well-being, due to their health condition. Because living at risk is such a broad concept, with a number of factors affecting one’s risk, it is worth questioning whether more disease-focused tools could support a more accurate clinical picture, or if comprehensive tools can provide a foundation upon which Nurse Practitioners can develop their clinical skills for risk assessment and mitigation. Capacity. The importance of understanding capacity as it relates to tolerable risk underpins when and how a Nurse Practitioner will intervene if an intolerable risk is identified. Of the nine tools, all but two include cognition or decision-making capacity as elements of the risk assessment. While not synonymous to one another, the terms cognition and capacity are closely tied together. An individua l with impaired cognition may still maintain their decisionmaking capacity however, decision-making capacity cannot be impaired without either a disease, 71 injury or treatment that affects cognition in some way (Karlawish, 2020). Under the Adult Guardianship Act section 3(1), until proven otherwise, “every adult is presumed to be capable of making decisions about personal care, health care, legal matters or about the adult's financial affairs, business or assets”. Capacity assessments are conducted by a qualified Nurse Practitioner or provider, if and when an individua l is thought to be at an intolerable risk and a decision is being made, or intervention is being suggested, that is contrary to the individua l’s expressed wishes. Capacity assessments cover four areas of decision-making which include understanding, expression of choice, appreciation and reasoning, as outlined in Appendix J. The National Advisory Council on Aging (NACA, 1993) highlights the following three complexities related to the use of capacity assessments: 1) capacity is not “all or nothing” and does not mean that a person is completely incompetent, 2) the testing today may not reflect the senior’s capacity next week, and 3) many capacity assessments don’t account for barriers that could impact the outcomes, such as education level, hearing and culture (as cited in Berke, 2014). In terms of mitigating such barriers, Young and Everett describe the initial establishment of patient capacity regarding the activity in question, by having the qualified Nurse Practitioner assess the patient’s ability to “understand the nature, degree and consequence of risk, [to] demonstrate preference [and to] act free of undue influence” (2018, p. 315). In consideration of a tolerable risk, it is only those risks deemed to be intolerable that could require a further assessment of decision-making capacity. A tolerable risk is one that is consistent with past behaviour or actions, is acceptable and does not result in imminent harm to oneself or others. “If there is no risk of harm to self or others it does not matter if the individua l is incapable” (Fraser Health Authority, 2011, p. 3). Further to an identified intolerable risk, the decision of how and when to intervene as a Nurse Practitioner is also driven by the older adult’s 72 decision-making capacity. It is therefore only after identifying a risk to be intolerable, that is one that is inconsistent with past behaviour or actions, is not acceptable and results in imminent harm to oneself or others, that a qualified Nurse Practitioner should consider doing a capacity assessment for the decision in question. The assertion of incapability can have devastating effects as it can potentially eliminate an individua l’s right to autonomous choice, therefore it should only be considered with trepidation and discretion (Fraser Health Authority, 2011). As a reference for Nurse Practitioners contemplating a patient’s capacity, the Clinical Practice Guideline discusses the concept as it relates to the evidence for decision-making ability and provides questions to determine whether an assessment is necessary (Fraser Health Authority, 2011). Some guiding questions used to determine the necessity of a qualified Nurse Practitioner’s initiation of a capacity assessment include “does it help solve the problem? will they accept support? whose interests are served by the assessment? what could they lose? ethical or legal substitute decision maker available?” (Fraser Health Authority, 2011, p. 7). The Nurse Practitioner must recognize that the aim is not to eliminate all risk, but to achieve a tolerable level of risk. Further, they must understand that risk can never be totally removed and that all people choose to live with some degree of risk (Young & Everett, 2018). For those actions deemed to be tolerable, only monitoring is required (Young and Everett, 2018), however if deemed to be intolerable and an intervention is indicated, the recommended intervention must satisfy certain criteria. Four criteria identified to finalize and validate a proposed plan include “the need for consensus from all stakeholders involved; that the plan be sustainably resourced; the plan must meet safety and professional standards; and finally, that it is supported legally” (De Bono & Henry, 2016, p. 218). Similarly, the Decision-Making Process describes ethical principles to be 73 upheld by a proposed intervention as one that 1) is effective, 2) is least intrusive, 3) is not causing greater harm than what it prevents, 4) is nondiscriminatory and 5) is fair (Young & Everett, 2018). Finally, the assessment of capacity of a “patient to understand and assume risks can take time, involve judgment, and require a large interdisciplinary team” (Young & Everett, 2018, p. 315). Physical Functioning and Health Conditions Finally, of the elements included in the risk assessment tools, level of functioning and physical health issues were addressed in six of the nine tools, as per Table 2. While these elements inform a clinical picture of tolerable and intolerable risk, they do not independently influence the older adult’s capacity for decision-making. A cognitively intact older adult may be completely dependent on others for all ADLs, increasing their vulnerability given the reliance on another individua l to maintain their day-to-day independence in the community. However, with a loss of the caregiver support due to unforeseen circumstances, and with a decision to remain living independently without the required support, the Nurse Practitioner’s role would involve risk mitigation strategies only. Despite differences in opinion, and even with the determination of risk intolerability, a Nurse Practitioner could not find the older adult incapable of deciding to remain in community without a mental illness, injury or disease affecting their cognition, in addition to the physical disabilities (Karlawish, 2020). Although the physical elements of a risk assessment do not independently inform an older adult’s decision-making capacity, they do provide an opportunity for Nurse Practitioners to engage in person-centred care planning that addresses goals of care and develops strategies to make risks more tolerable (Young & Everett, 2018; Lee et al., 2019). 74 Outcome Me asure s The subjective nature of risk makes it inherently difficult to quantify. The risk assessment tools that inform the outcome of tolerable risk include the Decision-Making Process (Young & Everett, 2018) as well as the Clinical Practice Guideline (Fraser Health Authority, 2011), as they directly address risk tolerability. Prior to determining whether a risk is tolerable or intolerable, the Decision-Making Process proposes an evaluation of the risk activity and for the health care team to determine if an intervention is required (Young & Everett, 2018). Intervention is triggered when a risk is identified as being “significant: that is, not a risk that is highly likely but with minor effect or a risk with major effect but so unlikely as to be merely theoretical” (Young & Everett, 2018, p. 317). The tool goes on to address whether the risk is deemed tolerable or intolerable, however no diagnostic criteria is offered to support such a determination (Young & Everett, 2018). Again, those risks deemed to be intolerable are then reviewed to ensure the intervention meets five ethical principles guiding the approach: 1) being effective, 2) being least intrusive, 3) not causing greater harm than it prevents, 4) being nondiscriminatory and 5) being fair (Young & Everett, 2018). Discussion of decision-making capacity follows in circumstances where an intervention is required, noting that the goal is not to remove risk entirely but to attain a tolerable level of risk (Young & Everett, 2018). Despite the acknowledgment of tolerable and intolerable risk within the tool, the Decision-Making Process fails to provide diagnostic criteria or direction of how best to determine this. Without defining risk tolerance or providing a framework to deduce whether a risk is tolerable or intolerable, Nurse Practitioners are left to rely on their clinical judgement and their experience with risk to make such a conclusion. The implications of this could contribute further to the ambiguity in the determination of risk for the older adult. 75 The Clinical Practice Guideline provides clear definitions outlining tolerable and intolerable risk. Tolerable risk involves risk factors that are not new, are consistent with past behaviour and do not result in harm (Fraser Health Authority, 2011). Whereas intolerable risks are those that are potentially harmful to oneself or others, wherein there is a new behaviour that is unprecedented, inconsistent with past behaviour and results in harm (Fraser Health Authority, 2011). While no tool is truly diagnostic of tolerable risk, it is with the clear definitions provided, in conjunction with clinical judgement, that Nurse Practitioners can engage with their patients with a goal to shift a given risk from intolerable to a level of tolerance or acceptability. This relies on clinical experience and a level of comfort of the Nurse Practitioner to feel confident in determining either tolerable or intolerable risk. Moreover, within the definitions of tolerable and intolerable risk, and the ability for modifications between the two types of risk, there is a reliance on the notion that families, patients and providers have the resources and the abilities to implement the interventions required to make the changes. Vie ws of Risk The views or approaches to risk inform the type of assessment tools that are best suited to support a Nurse Practitioner in determining tolerable risk in a given clinical scenario. The balance of ethical principles between justice and autonomy, against non-maleficence is central to discrepancies between the approaches to risk that are risk-averse, to those with a more progressive person-centred approach to risk. In health care, there is a desire to shift the thinking around the definition of risk from one that is negative and associated with failure. Berke (2014) describes a classic view of older adults who choose to either ignore medical advice, refuse facility placement or live within “unsuitable” housing conditions as being labelled one of noncompliance. The older adult who chooses to take a risk is often referred to as difficult, thereby 76 “emphasizing an attitude of intolerance of a client’s right to failure” (Berke, 2014, p. 2). Despite an apparent increase in frailty or vulnerability in the older adult, this does not, and should not, automatically negate the desire for the patient’s autonomy or independence in decision-making. Further, research in harm reduction has shown that some risk behaviours are in fact a matter of survival for some individua ls, as the only available strategy of coping with a more painful harm in their life such as a loss or trauma (De Bono & Henry, 2016). A risk averse approach prioritizes the ethical principle of non-maleficence over one legitimizing autonomy (De Bono & Henry, 2016). A shift in thinking is to look at risk in terms of its positive effects, however counterintuitive it may feel to Nurse Practitioners not trained in this approach. The goal of a positive risk-taking approach is to mutually develop a plan that meets the desired benefits of the patient, while aiming to minimize the negative consequences where possible (De Bono & Henry, 2016). As with the Person-Centred Risk Assessment Framework, its person-centred care approach explores the underlying psychological need being fulfille d by the risky behaviour or circumstance, as the basis upon which to develop risk mitigation strategies that could continue to satisfy that need, while lowering the safety risks (Lee et al., 2019). Focusing in such a way allows the risk assessment process to become less of an objective “ticky box” assessment and more a dialogue between patients and providers that addresses the risk, while continuing to uphold a patient’s autonomy. Along with the shift in thinking about risk, Nurse Practitioners also need to check their own biases and tolerance for risk. In the assessment of risk, Nurse Practitioners “should use objective and reliable evidence, eschewing speculation and emotion, and ensuring that the activity is actually harmful rather than merely offensive” (Young & 77 Everett, 2018, p. 317). A shift toward person-centred, holistic care will also influence the types and the focus of the risk assessment tools that are developed and tested in the future. The underlying thinking which guides advanced practice nursing arises from a nursing philosophy which differs from that of physicians. As primary care providers, Nurse Practitioners are “nurse[s] first and practitioners second” (Burgess & Purkis, 2010, p. 300). Nurse Practitioners function using a holistic lens, focusing on population-based health promotion and disease prevention strategies for patients (Burgess, Martin, & Senner, 2011; Weiland, 2008). This lens is also applied in the assessment of risk, wherein a holistic assessment is required to comprehensively assess all facets of risk. Nurse Practitioners are well-situated for assessing risk, which requires a holistic, person-centred approach and allows for the devotion of time and attention in a primary care setting. This methodology also lends itself to working within an interprofessional team, wherein diverse levels of knowledge and expertise contribute to shared knowledge and goals for a patient. The Nurse Practitioner’s foundational collaborative practice and holistic approach to health care prove to be invaluable in cultivating team relationships and subsequently, resulting in improved patient outcomes (Burgess, Martin, & Senner, 2011). Stre ngths and Limitations of the Lite rature Review A strength of the literature review is that it affirms the need for tools that support Nurse Practitioners’ decision-making process regarding older adults living at risk. “There is a critical need for feasible, effective ways of proactively assessing and managing risks […] with the aim of averting crises, and unnecessary suffering and costly healthcare service utilization” (Lee et al., 2019, p. 47). While the Clinical Practice Guideline (Fraser Health Authority, 2011) most closely informed a determination of tolerable and intolerable risk, no tool was diagnostic of tolerable risk, and the need for further research is evident. The search methodology was comprehensive, 78 using broadly-based databases to capture a comprehensive picture of risk. The nine articles referenced tools which were able to inform a Nurse Practitioner’s practice in support of older adults choosing to live at risk. Of the nine tools analyzed, five were Canadian, which can be applied in Canadian Nurse Practitioner practice. In using a variety of risk assessment sources, the total elements of risk capture a comprehensive, holistic picture of risk that Nurse Practitioners can now apply in a clinical scenario, despite lacking a formalized tool inclusive of all elements. The identification of the risk of adverse health outcomes also helps to target the delivery of specific preventative health interventions (Weathers et al., 2016). In knowing the definition of tolerable risk, Nurse Practitioners can begin to apply its definition in clinical scenarios where a perceived risk is identified, as a starting point for risk mitigation dialogue with patients and families. Finally, the lack of local policy provides opportunity for Nurse Practitioners to undertake the development of initiatives in the assessment of risk, such as the development of a clinical practice guideline at a local level or, more broadly, the advancement of provincial policy in British Columbia. A limitation of the literature review includes the fact that risk is difficult to define and subsequently, difficult to assess. MacLeod and Stadnyk (2014) describe how the breadth and inconsistencies in research findings regarding the definition, identification, perceptions, assessment and management of risk result in complexities in its application in clinical practice. The literature review resulted in a small number of tools for analysis and none of the articles focused on tolerable risk. Finally, there is a lack of studies replicating the findings for tools informing tolerable risk. 79 Implications for Practice The findings of the literature review have important implications for Nurse Practitioner practice and the determination of tolerable risk. Having a clear definition of tolerable risk and being aware of the goal to move perceived risks to a level of tolerability allows Nurse Practitioners to approach clinically risky situations using this lens. Also, by questioning whether an intervention is required for a perceived risk, and in understanding decision-making capacity, a Nurse Practitioner gains clarity on their role in the management of tolerable and intolerable risks, once identified. The risk assessment tools predictive of future adverse outcomes, The Elders Risk Assessment (Crane et al., 2010), the Early Risk Score (St. John & Montgomery, 2014), the Frailty Index based on Routine Health Care Data (Drubbel et al., 2012), the Risk Instrument for Screening in the Community (O’Caoimh et al., 2015) and Aliberti’s Decision Support Strategy (Aliberti et al., 2019), inform an older adult’s vulnerability to the development of certain health problems. Each draw attention to the elements of a patient’s health and wellness, as shown in Table 2, that could impact their level of risk in the future (Aliberti et al., 2019; Crane et al., 2010; Drubbel et al., 2012; O’Caoimh et al., 2015; St. John & Montgomery, 2014). Although the tools were not explicitly developed to be applied in an immediate risky scenario, the elements included in Table 2 comprise components of risk that Nurse Practitioners should consider and monitor as they support a population of older adults in Primary Care to mitigate risk early. In knowing the elements of risk to assess and monitor, Nurse Practitioners can begin to identify the older adult’s vulnerabilities and focus preventative interventions strategically to reduce future risks. Verver et al. describe how “preventative measures should not only focus on the medical or physical domain because older adults are likely to have other priorities to maintain self-reliance 80 and live independently” (2017, p. 338). In addition, the Nurse Practitioner can focus on each element of risk listed in Table 2 with an understanding of tolerable and intolerable risk, aiming to achieve a tolerable level of risk in each area where a perceived risk is identified. The preventative approach to healthcare with the older adult allows Nurse Practitioners to implement services and interventions early to reduce future adverse outcomes. Also, the use of an EMR in the Elders Risk Assessment, the Risk Instrument for Screening in the Community, and the Frailty Index based on Routine Health Care Data further supports the facilitation of such a preventative approach by easily capturing the required data in a system that is already accessed daily in a primary care clinic during patient encounters (Crane et al., 2010; Drubbel et al., 2012; O’Caoimh et al., 2015). The responsive frameworks and guidelines, the Decision-Making Process (Young & Everett, 2018), the Risk Support Management Plan (De Bono & Henry, 2016), the PersonCentred Risk Assessment Framework (Lee et al., 2019) and the Clinical Practice Guideline (Fraser Health Authority, 2011), with the intended application to assess an immediate perceived risk, are best suited to support the determination of an older adult’s tolerable risk, as they can be applied to a clinical scenario with an immediate perceived risk. The Decision-Making Process (Young & Everett, 2018), the Risk Support Management Plan (De Bono & Henry, 2016), the Person-Centred Risk Assessment Framework (Lee et al., 2019) and the Clinical Practice Guideline (Fraser Health Authority, 2011) do not describe a risk assessment tool that is completed as a one-page form, but suggest approaches that act as a guide, focusing on dialogue and shared decision-making between the Nurse Practitioner, the patient and the family. Each approach requires time to devote to these conversations, which highlights the need for health care providers to view and prioritize risk as an independent health issue. Similar to how a 81 diagnosis of hypertension is assessed and managed by a Nurse Practitioner, identifying risk as a health condition ensures that time is devoted to identifying the risk and to working through a mitigation strategy. This shifts from an approach which fails to prioritize the perceived risk by squeezing the discussion into an already full assessment for any other health issue. Further to the elements of risk named in the tools above, key concepts identified in the assessment of risk within the Risk Support Management Plan, the Decision-Making Process, the Person-Centred Risk Assessment Framework and the Clinical Practice Guideline include the identification of the perceived risk(s), the potential harm and who is affected, mitigation strategies including those previously tried and those available, safety planning, the need for and the type of intervention to reduce the risk and/or increase its tolerability, as well as decisionmaking capacity (De Bono & Henry, 2016; Fraser Health Authority, 2011; Lee et al., 2019; Young & Everett, 2018). These are elements for the Nurse Practitioner to consider when engaged in dialogue pertaining to a perceived risk with a patient and/or family. Additionally, the PersonCentred Risk Assessment Framework also addresses the psychosocial need being met by the perceived risk, further encouraging a person-centred approach to risk mitigation dialogue (Lee et al., 2019). In alignment with British Columbia legislation, should an intervention by the Nurse Practitioner be indicated, the intervention must be reviewed to ensure consensus from all stakeholders, as well as in terms of its ability to be effective and sustainably resourced, to be least intrusive, to not cause greater harm than it prevents, to be nondiscriminatory, to be fair, to meet safety and professional standards, and finally, that it is supported legally (De Bono & Henry, 2016; Young & Everett, 2018). 82 Future Recomme ndations Given the lack of diagnostic tools available to Nurse Practitioners to clarify their determination of tolerable risk, it is an area of research that remains available for further study. As such, developing and testing new risk assessment tools diagnostic of tolerable risk is an area of focus in which Nurse Practitioners can undertake their role as leaders and researchers. A call for validity and reliability of such tools can be achieved through replication and testing of the tools in the assessment of community-dwe lling older adults living at risk. Furthermore, while the tools discussed in the literature search are not diagnostic of tolerable risk, they do include a large number of elements for Nurse Practitioners to consider when supporting an older adult in Primary Care, that could paint a comprehensive picture of risk and subsequently, inform the development and testing of future risk assessment tools. 83 Chapte r 6 - Conclusion The literature review undertaken aimed to determine what risk assessment tools were available to inform a Nurse Practitioner’s determination of tolerable risk. Nine tools were retrieved and analyzed using the risk assessment tools, the outcome measures and the view of risk within each tool. Within the tools, key elements of an older adult’s health and wellness were identified as areas that Nurse Practitioners can focus their attention as a means of identifying risk factors early and focusing preventative health care practices to mitigate future risks. Four tools were able to be applied to clinical situations in a time when the perceived risk is identified, offering guidelines and decision-making processes for the Nurse Practitioner and the older adult to engage in person-centred risk mitigation dialogue. In clarifying the definitions of tolerable risk, intolerable risk and capacity, Nurse Practitioners can have an understanding of targets to aim for in discussion with older patients, and in gaining clarity regarding a Nurse Practitioner’s role in supporting this vulnerable population. No tool was diagnostic of tolerable risk, which leaves opportunity for Nurse Practitioners to engage in assessment tool development, policy development and research opportunities to fill this evidence gap. 84 Appe ndix A: Se arch Terms Crite ria Olde r Adult CINAHL Headings Older Adult* Older Person* Aged Elderly Me dline Older Adult* Older Person* Aged Elderly PsycINFO Older Adult* Older Person* Elderly Frailty Frail* Vulnerab* Cognitive Impairment Frail* Vulnerab* Cognitive Impairment Frail* Vulnerab* Cognitive Impairment Risk Assessment Tool Risk Assessment* Assessment Tool* Risk Estimat* Risk Assessment* Assessment Tool Risk Estimat* Risk Assessment* Assessment Tool Risk Estimat* Living at Risk Living at Risk Tolerable Risk Intolerable Risk Adverse Outcome* Living at Risk Tolerable Risk Intolerable Risk Adverse Outcome* Living at Risk Tolerable Risk Intolerable Risk Adverse Outcome* 85 Appe ndix B: Se arche s by Database Search Te rms Database ((Older adult*) OR (Older person*) OR (Aged) OR (Elderly) AND (Frail*) OR (Vulnerab*) OR (Cognitive impairment)) AND ((Risk Assessment*) OR (Risk Estimat*) OR (Assessment tool)) AND ((Living at Risk) OR (Intolerable risk) OR (Tolerable risk) OR (Adverse outcome) ((Older adult*) OR (Older person*) OR (Aged) OR (Elderly) AND (Frail*) OR (Vulnerab*) OR (Cognitive impairment)) AND ((Risk Assessment*) OR (Risk Estimat*) OR (Assessment tool)) AND ((Living at Risk) OR (Intolerable risk) OR (Tolerable risk) OR (Adverse outcome) ((Older adult*) OR (Older person*) OR (Elderly) AND ((Frail*) OR (Vulnerab*) OR (Cognitive impairment)) AND ((Risk Assessment*) OR (Risk Estimat*) OR (Assessment tool)) AND ((Living at Risk) OR (Intolerable risk) OR (Tolerable risk) OR (Adverse outcome) CINAHL Total Numbe r of Citations 95 Medline 377 PsycINFO 47 Total number of articles 519 86 Appe ndix C: Prisma Diagram Records identified through CINAHL (n =95) Records identified through Medline Ebsco (n = 377) Records identified through PsycINFO (n = 47) Records identified through other sources (n = 5) Total Articles Retrieved (n = 524) Exclusion Criteria: Date / Language / Age Records excluded 112 Article titles & abstracts assessed using inclusion / exclusion criteria (n = 412) Articles excluded, based on inclusion/exclusion 379 Removal of Duplicates (n = 33) Full Text Review Removed based on inclusion / exclusion criteria and definition of risk 24 Total number of studies included in literature review (n = 9) 87 Appe ndix D: An Ethical Approach to Managing Patie nts 1 1 From “ When patients choose to live at risk: What is an ethical approach to intervention?” by J. M. Young and B. Everett, 2018, BC Medical Journal, 60, p. 316. Copyright 2020 by https://www.bcmj.org. Reprinted with permission. 88 Appe ndix E: Risk Support Manage me nt Plan2 2 From “ A positive risk approach when clients choose to live at risk” by C. E. De Bono and B. Henry (2016). Current Opinion in Supportive and Palliative Care, 10, p. 216-217. Copyright 2016 Wolters Kluwer Health, Inc. Reprinted with permission. 89 90 Appe ndix F: Risk Assessment Frame work: Identifying Tole rable & Intole rable Risk Factors 3 PA RT A: IS THERE A CHANGE THAT MIGHT AFFECT DECISION MAKING ABILITY? o No – STOP! o Yes WHAT CHANGED? What are the actual current risk s? Pre- existing / New? What have been the consequences? What has been tried to mitigate the risk ? Previous assistance effective? Y/N o PreExisting o New o Worse o Aware o PreExisting o New o Worse o Aware o PreExisting o New o Worse o Aware o PreExisting o New o Worse o Aware Is the overall risk intolerable? o No o Yes (check all that apply): Explain: o Adult has suffered actual harm-to whom (team, adult, family) o Exposes others to risk of harm o Adult engaging in risky behavior they would normally have avoided To whom: (team, adult, family) ARE THERE MEDICAL CONDITIONS THAT MAY IMPACT DECISION MAKING ABILITY? o No o Yes (explain): ARE THERE PSYCHOSOCIAL CONDITIONS THAT MAY IMPACT DECISION MAKING ABILITY? o No o Yes (explain): WHAT CURRENT/NEW INTERVENTIONS ARE RECOMMENDED TO MITIGATE THE RISK? INSERT EXPECTED OUTCOME OF INTERVENTIONS · WERE THE RISKS MITIGATED SUCCESSFULLY WITH THE CURRENT INTERVENTIONS? No o Yes o If no proceed to PA RT B From “ Clinical Practice Guideline: Risk assessment – Identifying tolerable and intolerable risk factors and informing decision making ability” by Fraser Health Authority, 2011. Retrieved from http://gnabc.com/gnabcAdmin/wp-content/uploads/2014/04/RISK-Clinical-Practice-GuidelineMarch2014.pdf. Copyright 2011 Fraser Health. Reprinted with permission. 3 91 PA RT B: ARE YOU CONSIDERING A FORMAL INCAPABILITY ASSESSMENT? o No o Yes IF SO, WHY EXPECTED RESULTS: WHOSE INTERESTS ARE BEING SERVED? Adult’s Caregiv ers: Others (Substitute Decision Maker/family/friend): Care Name and Signature of T eam and Program: Team: Date: 92 Appe ndix G: Assessment Worksheets: Identifying Actual Risks/Stre ngths 4 Ke y: N/A – skill is not required to manage personal care requirements S - Satisfactory: fully independent or compensates for personal limitations (Appreciates need and accepts assistance) M - Marginal: could be a problemdepending on availability U - Unsatisfactory: no assistance available, resulting in unmet need D - Does not accept assistance resulting in an unmet need Personal Care A. Nutrition Self report Informant (if there is no neighbour, adult children/physician, significant other please indicate and draw a line) Behavioral evidence Self report Informant Behavioral evidence Self report Informant Behavioral evidence Able to store, prepare food Able to arrange for purchase of food Able to eat unassisted Knowledge of special dietary needs/restrictions Knows what to eat/has knowledge of nutrition I.e.: Canada food guide O ther: B. Clothing Able to dress/undress Clothes are adequate for weather O ther: C. Hygiene Able to wash/bathe Able to use bathroom Manages with incontinence Keeps clothes clean Keeps liv ing environment clean Personal grooming: teeth, hair, shaves Oral Health 4 From “ Clinical Practice Guideline: Risk assessment – Identifying tolerable and intolerable risk factors and informing decision making ability” by Fraser Health Authority, 2011. Retrieved from http://gnabc.com/gnabcAdmin/wp-content/uploads/2014/04/RISK-Clinical-Practice-GuidelineMarch2014.pdf. Copyright 2011 Fraser Health. Reprinted with permission. 93 O ther: D. Safety Sufficient mobility to meet needs/ Circumstances Self report Informant Behavioral evidence Does not exhibit life-threatening behavior (wandering, driving recklessly, provoking others? , medication abuse or misuse) Able to recognize and avoid hazards (handles cigarettes carefully, remembers to turn off stov e, manages meds, oxygen useappropriate) Able to handle emergencies (notification & evacuation, medical, fire, break-ins) Recognizes when others present a danger & takes precautions (careful when out alone at night, does not carry large sums, appropriate responses to solicitation of money ) O ther: E. Shelter Self - Informant Behavioral report evidence Able to find shelter that meets minimum personal needs Type of shelter is appropriate to needs (manages steps, lock s, has running water in bathroom and fridge for perishable food) Adequate temperature regulation /sanitation maintained within shelter Unsafe neighborhood/condition of shelter (i.e.: hoarding) O ther: F. Health Care Manages routine health problems Can follow medical treatment plan and manage meds (this can be with support serv ices/network ) Seek s medical care when needed Recognizes and alerts others to serious health problems Knows primary medical diagnosis and need for treatment Can communicate sy mptoms of illness Appropriate medication use and adherence O ther: Self - Informant Behavioral report evidence 94 G. Financial –Money Management A. Basic money management Pay bills, pay for services: Self - Informant Behavioral report evidence Manage income O ther: IF there is an Informant identified please describe the duration/nature of Contact (i.e. family, caregiver, physician, etc.): 95 Appe ndix H: Levels of Research Evide nce Level I: Systematic review and meta-analysis Level II: Randomized control trial or experimental study Level III: Quasiexperimental study Level IV: Descriptive correlational, predictive correlational and cohort studies Level V: Mixed methods systematic review and qualitative meta Level VI: Descriptive study and qualitative study Level VII: Opinions of expert committees and authorities From “ Burns and Groves’ T he practice of nursing research: Appraisal, synthesis, and generation of evidence, 8 th ed.” by J. R. Gray, S. K. Grove and S. Sutherland, 2013, St. Louis, Missouri: Elsevier. Copyright 2017 by Elsevier Inc. Reprinted with permission. Grey literature Fraser Health Authority Clinical Practice Guideline: Risk Assessment: Identifying tolerable and intolerable risk factors and informing Clinical Practice Guideline Responsive Predictive Retrospective cohort study Level IV Predictive vs. Responsive Study Design Level of Evidence Clinical Practice Guideline 2010 Use of an electronic administrative database to identify older community dwelling adults at high risk for hospitalization or emergency department visits: The elders risk assessment index Crane et al. Risk Tool Author (s) Title of Article Year of Publication Elders Risk Assessment Quality improvement process T he goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to riskstratify this heterogeneous population (identifying those patients most at risk for hospitalization) p 1 The primary aim of this study was to demonstrate that readily accessible information available in a provider’s electronic medical record could be used to identify a population of community dwelling older adults at high-risk for hospitalization or emergency room utilization. p. 2 Goal of the study 1. provide a guided interprofessional care planning process in client situations that require a informed decision making and care planning related to assumed risk. 2. Provide a framework & tool to guide care teams to identify, address & mitigate risk in the context of N/A Goal of the tool The Process See Appendices F & G 1. The issue - current risk(s) / new? / worse? / preexisting? 2. what has changed to trigger action/response? 3. Mitigation strategies previously tried / successes & failures 4. Ability, availability & willingness of supports 5. Vulnerable adult's understanding 6. Is there harm? what? to whom? Is it actual or perceived? caregiver burden? 7. Medical / psychosocial / Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. Date of birth, gender, marital status, race, and the number of hospital admission days in the prior two years. Comorbid medical illnesses included the presence or history of diabetes mellitus, coronary artery disease, congestive heart failure, stroke, chronic obstructive pulmonary disease, history of cancer, history of hip fracture, and dementia. These comorbidities were chosen via consensus discussion based on their known risk for recurrent hospitalizations and greater complexity of care (p. 2) Appe ndix I: Lite rature Review Matrix 1. what are the adult's values and beliefs? 2. Is the vulnerable adult experiencing risk of selfharm or self-neglect? 3. Is the vulnerable adult experiencing risk from others? 4. Is the vulnerable adult a risk to others? 5. Is the level of risk experienced intolerable? 6. Are we legally required to intervene? N/A Ethics Person-Centred Care Legislation Capacity 96 2011 decision making ability ethical decisionmaking principles 3. Provide a process that will support the individual, family & care providers who may be experiencing emotional & moral distress 4. Provide a standardized risk assessment process to determine tolerable and/or intolerable risk for vulnerable adults who are presenting at risk in Fraser Health Tolerable risk involves risk factors that are not new, are consistent with past behaviour and do not result in harm (Fraser Health Authority, 2011). Whereas intolerable risks are those that are potentially harmful to oneself or others, wherein there is a new behaviour that is unprecedented, inconsistent with past behaviour and results in harm Guiding principles - 1. Vulnerable adult's quality of life is of paramount consideration 2. T eam engages in culturally sensitive interventions 3. Autonomy of the vulnerable adult is upheld 4. Respect for the vulnerable adult's expressed choices / preferences 5. Previously established advanced care plan (verbal or written) guides the team’s intervention 6. Social network / caregivers are key partners (p. 4) psycho-emotional condition impacting decision-making ability? Is it reversible / permanent? 8. Mitigation strategies now 9. Evidence for decision-making capability - is an assessment necessary? (does it help solve the problem? will they accept support? whose interests are served by the assessment? what could they lose? ethical or legal substitute decision maker available?) (p. 6- 7) Capacity "No one is capable in every sphere of life" (p. 2) Decision-making ability and choosing to live at risk is not a test result or a diagnosis. T here is no evidence that scores from standard test of cognitive ability are a reliable indicator of capability or incapability. Most measures of cognitive status do not evaluate cognitive functions such as judgement and reasoning, which are relevant to capability and incapability. Questionable incapability is often reversible and illness can temporarily impair the adult's ability to make Adult Guardianship Act - and the presumption of capability (Section 3[1]) p. 3 7. Are there any support services/caregivers involved? 8. What are the caregiver’s values & beliefs? 9. What is the caregiver tolerance level for various risks? 10. Is the vulnerable adult going to deteriorate further without intervention? 11. Is the intervention consistent with the vulnerable adult's attitudes, beliefs, & preferences? (p. 5) 97 Prediction of Adverse Health Outcomes in Older People Using a Frailty Index Based on Routine Primary Care Data Drubbel et al. Frailty Index based on Routine Health Care Data Level IV Retrospective cohort study with a 2-year follow-up period Predictive To investigate if a Frailty Index based on the routine health care data of GPs can predict the risk of adverse health outcomes in communitydwelling older people A general frailty indicator could guide general practitioners (GPs) in directing their care efforts to the patients at highest risk A shift toward more proactive, population-based care is therefore essential (4–6). A general frailty indicator that stratifies older A Frailty Index screen for a predefined list of relevant “ health deficits” include diseases, signs, symptoms, and psychosocial or functional impairments. T he proportion of deficits present in an individual is the resulting FI score (p. 301) - selected 140 relevant ICPC coded items and a polypharmacy item. This selection was based on the literature on FI construction, data on age-related deficit prevalence and health burdens, and a consensus meeting with a local expert N/A decisions (p. 2) Appendix B: 1. What evidence suggests the need to assess their capability to make decisions based on answer to questions thus far? - Is a formal incapability assessment necessary? 2. Will a formal incapability assessment help solve the problem? 3. are there informal support and assistance options available? if so, what are they? 4. Is the adult willing to accept support & assistance regardless of risk or questionable capability status? 5. Whose interest is being served should a formal incapability assessment be suggested? 6. What could the person lose? 7. Is there an ethically and legally recognized substitute decision maker (p. 7) 98 O’Caoimh et al. Risk Instrument for Screening in the Community 2014 Level IV Prospective cohort study Level IV St John & Montgomery Validity of an early risk score for older adults Prospective cohort study Early Risk Score 2012 Predictive Predictive T he purpose of this study was to determine the accuracy and predictive ability of the RISC, scored by PHNs, to another subjective global assessment and frailty To determine if a risk score developed in hospitalized older adults in the UK in 1962 is correlated with other measures of health and if this risk score predicts death or institutionalization in community-living older adults. 1. To determine if a modified risk score developed in hospitalized older adults in the UK in 1962 is correlated with measures of health and frailty; 2. To determine if this risk score predicts death or institutionalization in community-dwelling older adults over a fiveyear period; and 3. To determine if a very straightforward modification considering age and gender further increases the predictive accuracy for death or institutionalization T he Risk Instrument for Screening in the Community (RISC) is a short (2–5 min), global subjective To determine if this risk score predicts death or institutionalization in communitydwelling older adults over a fiveyear period patients based on their overall risk of adverse health outcomes could guide general practitioners (GPs) in directing their care efforts to the patients at highest risk. p. 301 Demographic data and records the presence (yes or no responses) and magnitude (mild, moderate, severe) of concern across three domains: mental state, ADLs and medical state (p. 2). Two measures of frailty – the brief measure of frailty and the Frailty Index. Both of these measures were defined according to the original definitions. T he brief measure of frailty is a measure of disability and cognition, which is graded from 0 (no frailty) to 4 (severe frailty). T he Frailty Index is a tally of self-reported health complaints, diseases, risk factors and impairments. It measures 40 items, each scored 0 to 1. These are summed and divided by the number of deficits considered. (p. 112). Age, gender, living arrangement, education and selfrated health were all selfreported / ADL and iADL help / Life satisfaction (LS) was assessed using the Terrible– Delightful Scale / 2 measures of frailty / cognitive status, we considered the MMSE / Continence / functional status using the Older Americans Resource Survey (OARS) (p. 112-113) group of GPs. T hen: total selection and arrangement procedure resulted in an FI with 36 deficits (p. 302) T he RISC incorporates mental state, ADLs and medical problems, in the context of the caregiver network. It is a holistic measure, incorporating more N/A 99 2016 A positive risk approach when clients choose to live at risk: a palliative case discussion De Bono & Henry Risk Support Management Plan 2015 T he Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults Grey literature A risk support management tool developed by the T oronto Central Community Care Access Centre Responsive The article discusses recent approaches in the literature about clients who chose to live at risk in their homes. It argues for a positive risk-based approach and a tool to help manage risk in the home, and applies these to a hypothetical end-oflife scenario. p 214 scale, the Clinical Frailty Scale (CFS A tool to help manage risk in the home, and applies these to a hypothetical endof-life scenario. p 214 assessment of risk created to identify patients’ 1-year risk of three outcomes: Institutionalization, hospitalization and death T he Risk Instrument for Screening in the Community, to identify those at greatest risk of institutionalization, hospitalization and death p. 2 See Appendix E: Steps: identifying the major risk and why the client is choosing it - the healthcare team in consultation with the client must explore the following: consider the applicability of standard risk elimination strategies; explore risk mitigation or minimization possibilities; and develop a safety planning for the component elements of the risk that can neither be eliminated nor mitigated 2: risk management Two parts - Person-centered risk assessment and My Plan 1. Risk Identification 2. Risk Assessment 3. Creating a risk support management plan 4. Evaluating a Risk Support Management plan Based upon severity of concern and the caregiver networks’ ability to manage them, an overall global subjective assessment of risk score is then assigned to three adverse outcomes: institutionalization, hospitalization and death at 1 year from the date of assessment (p. 2) Research has shown that clients’ choosing to live with risk can in fact be instrumental in the way they manage their health and its effects on their lives [10]. For some, risk-taking can be viewed as a positive choice, permitting healthcare clients to have greater choice and control of their lives; in some cases, it can be their preferred way to discover new personal strengths and capabilities p. 215 The article discusses recent approaches in the literature about clients who chose to live at risk in their homes. It argues for a positive risk-based approach and a tool to help manage risk in the home, and applies these to a hypothetical end-oflife scenario (p 214). domains and contextualising problems to create an individualised measure of risk. 100 General values/principles 1. risk is a normal, everyday experience that can minimized, but not eliminated 2. risk outcomes are not always negative, risk taking can also have beneficial /positive outcomes 3. T hese behaviors can in fact be proportionally or functionally beneficial for that individual. T his insight is frequently viewed as counterintuitive to some healthcare professionals not trained in this approach. In that, what might readily be recognized as harmful or even irrational behavior (i.e., excessive drinking, recreational and illicit drug use), may actually be the only available strategy a client can use to mitigate a more painful harm in their life (i.e., trauma, loss, psychic pain). Unfortunately, a restrictive and riskaverse approach frequently overlooks or dismisses this reality. Ethically, a positive risktaking approach respects individual autonomy. It does this by engaging a capable client’s desire to live at risk as being motivated by a hopedfor outcome that is important and meaningful to the client p. 215 & 217 101 2018 When patients choose to live at risk: What is an ethical approach to intervention? Young & Everett DecisionMaking Process Grey literature A decisionmaking process - literature review informed by BC legislation, based on bioethical principles of autonomy, nonmaleficence, beneficence and justice Responsive A decision-making process Peer-reviewed article literature review informed by BC legislation, based on bioethical principles of autonomy, nonmaleficence, beneficence and justice p. 315 T he goal is not to remove all risk but to achieve a tolerable level of risk. Addressing tolerable and intolerable risk -If risk is deemed to be tolerable, no further action is needed beyond monitoring. If the risk is deemed intolerable and intervention is required, all options should be explored by the team and patient or substitute decisionmaker as appropriate, even when some options may seem extraordinary, A process can be used to make ethically justifiable decisions about when and how to intervene when patients choose to live at risk. A decision-making tool incorporates a framework and checklist of what clinicians should consider. P 315 See Appendix D The risk activity - establishing the nature of the possible harm (physical, emotional, or psychological) and the probability and severity of the harm. Consider awareness of their own personal biases and tolerance for risk. Decide if intervention is required - To trigger intervention, risk should be significant: that is, not a risk that is highly likely but with minor effect or a risk with major effect but so unlikely as to be merely theoretical. T he goal is not to remove all risk but to achieve a tolerable level of risk. Risk can never be totally eliminated and all persons choose to live with some degree of risk. (p. 317) T he intervention must: 1. Be effective 2. Be least intrusive 3. Not cause greater harm than it prevents 4. Be nondiscriminatory 5. Be fair -establishing patient capacity -Implementing the decision - The team should agree to follow the care plan so that the patient receives consistent care, and the care plan should be documented and re-visited when the patient’s condition changes (p. 318) If the patient or substitute decisionmaker agrees to the proposed intervention, it can be implemented. If the patient rejects the intervention, the team must establish whether the risk activity poses a risk only to the patient or Nonmaleficence, justice & autonomy. Autonomy - the process begins by considering the patient’s wishes and how these can be met in relation to the patient’s life context, goals, and values. If a decision is made to override the patient’s wishes, the onus is on health care providers to justify this decision. (p. 316-317) Despite the complexity involved when choosing the most appropriate intervention, a wellconsidered, ethically justifiable course of action must be taken. Failing to intervene is unjust because it leaves patients responsible for choices they may not be capable of making or allows health care providers to act on their own biases or fears (p. 318) clients are always presumed to be capable 4. risk and safety planning is best done collaboratively 5. not every risk-taking behaviour can be supported. (p. 216) 102 PersonCentred Risk 2019 When patients choose to live at risk: What is an ethical approach to intervention? Aliberti. et al. Aliberti’s Decision Support Strategy Mixed methods Level IV Prospective cohort study Responsive Predictive To estimate the effects of combining physical frailty and cognitive impairment without dementia on the risk of basic activities of daily living dependence and death over 8 years. this study explored previously validated operational definitions of physical frailty and CIND in the Health and Retirement Study (HRS), a representative sample of older Americans, to estimate the interactions and impact of combining these two geriatric conditions on adverse health outcomes, such as incident disability and mortality, among independent older adults. p. 478 T his study pilot-tested the person-centered risk Physical frailty was assessed according to the five frailty phenotype criteria originally constructed in the Cardiovascular Health Study (CHS) unintentional weight loss of 10% or greater in the previous 2 years or body mass index of less than 18.5 kg/m2; (2) exhaustion (3) muscle weakness measured by grip strength using the CHS cutoff values; (4) slowness while walking (5) low levels of activity. Cognition was evaluated using an approach for HRS selfrespondents. T he method includes the following cognitive tests: (1) immediate and delayed recall of 10 common nouns, (2) serial subtractions by 7, and (3) a backward count task from 20. T he PCRAF contributes to person-centered care with the A tool is not being used - the article provides a rough framework / approach to assessing the risk of adverse outcomes, and what should be included The personcentered risk outside standard budgets, or controversial (p. 317). A person-centered N/A to others as well. If the risk poses harm to others, the risks must be reduced to a tolerable level regardless of patient context or capacity as intolerable risk to others is never acceptable. If the activity poses a risk solely to the patient, patient capacity needs to be established regarding the activity in question. T his involves assessing the patient’s ability to: •Understand the nature, degree, and consequences of the risk. • Demonstrate preferences. • Act free of undue influence. (p. 317) 103 2019 Person-centered risk assessment framework: assessing and managing risk in older adults living with dementia Lee et al. Assessment Framework Level III assessment framework (PCRAF), a framework for managing risk among persons living with dementia (PLWD) in primary care. p 47 assessment framework (PCRAF) is a proactive approach that allows older adults living with dementia to retain as much control over their lives as possible, identifying risky situations and developing systems to manage risk. A personcentered approach to care, considered by many to be the gold standard for healthcare for older adults, emphasizes individual preferences, goals and values as well as choice and autonomy and aims to improve healthcare safety, quality, care coordination and quality of life for older adults. development of an individualized goal-oriented care plan based on the person’s preferences and ongoing review of the person’s goals and care plan, and care supported by an interprofessional team in which the person is an integral member. -Adult Guardianship Act approach to care, considered by many to be the gold standard for healthcare for older adults, emphasizes individual preferences, goals and values as well as choice and autonomy and aims to improve healthcare safety, quality, care coordination and quality of life for older adults (p 48) The PCRAF reflects a change in approach from considering ‘risk’ in absolute terms to better understanding vulnerability within the context of the situations that make a particular risky, and if possible managing potential risks and harms using an approach that places the person at the center of the decision-making to make the situation less risky. And if circumstances cannot be mitigated to reduce substantive risk, the next task is to determine the underlying psychosocial needs that are met by that particular activity and to work toward finding new meaningful activities that might fulfil those underlying psychosocial needs (p. 48) 104 105 Appe ndix J: The Four Areas of Decision-making in Capacity Assessments Decision-making ability Definition Sample que stions Understanding The ability to state the meaning of the relevant information (Eg. Diagnosis, risks and benefits of a treatment of procedure, indications and options of care). The ability to state a decision After disclosing a piece of information, pause and ask the patient: “can you tell me in your own words what I just said about [fill in the topic disclosed]?” “Based on what we’ve discussed about [insert the topic], what would you choose?” The ability to explain how information applies to oneself To assess appreciation of diagnosis: “Can you tell me in your own words what you see as your medical problem?” Expressing a choice Appreciation To assess appreciation of benefit: “Regardless of what your choice is, do you think that it is possible the medication can benefit you?” To assess appreciation of risk: “Regardless of what your choice is, do you think it is possible the medication can harmyou?” Reasoning The ability to compare information To assess comparative reasoning: and infer consequences of choices “How is X better than Y?” To assess consequential reasoning: “How could X affect your daily activities?” From “ Assessment of decision-making capacity in adults” by J. Karlawish, 2020, In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on Oct, 20, 2020.) Copyright © 2020 UpToDate, Inc. For more information visit www.uptodate.com. Reproduced with permission. 106 Appe ndix K: Copyright Pe rmissions Copyright Source Image Copyright Pe rmission Young, J.M & Everett, B. (2018). When patients choose to live at risk: What is an ethical approach to intervention? Brit ish Columbia Medical Journal, 60(6). 314-318. Figure 1: An ethical approach to managing patients Email response received September 13, 2020 from journal@doctorsofbc.ca (Tara) granting permission to use image with appropriate credit De Bono, C. E. & Henry, B. (2016). A positive risk approach when clients choose to live at risk: A palliative case discussion. Current Opinion in Supportive & Palliative Care 10(3): 214-220. Figure 1: Risk support management plan License Number: 4933200111431 License Date: October 20, 2020 Licensed Content Publisher: Wolters Kluwer Health, Inc. Burns and Groves’ The practice of nursing research: Appraisal, synthesis, and generation of evidence, 8th ed.” by J. R. Gray, S. K. Grove and S. Sutherland, 2013, St. Louis, Missouri: Elsevier. Figure 2.1: Levels of evidence Elsevier copyright permissions: https://www.elsevier.com/about/policies/copyright/permissions Fraser Health Authority. (2011). Clinical practice guideline: Risk assessment – identifying tolerable and intolerable risk factors and informing decision making ability. Retrieved from http://gnabc.com/gnabcAdmin/wpcontent/uploads/2014/04/RISKClinical-Practice-GuidelineMarch2014.pdf UpToDate From “ Assessment of decisionmaking capacity in adults” by J. Karlawish, 2020, UpToDate. Inc and/or its affiliates. Appendix A: Risk assessment framework Permission to use Elsevier book material such as figure, tables or text excerpts. Oct 20, 2020: If the amount of material you are using falls within the limits set out in the STM permissions guidelines, permission is automatically granted, and you are not required to request permission in writing. Please ensure you acknowledge the original source of the Elsevier material. Appendix B: Assessment worksheets Table 1: The decisionmaking abilit ies, their definit ions and questions to assess them Email response received Oct 23, 2020: “ Thanks for your email about getting copyright permission to use Fraser Health documents. You have permission to use the documents as long as they are attributed correctly to Fraser Health”. Tracy Barra-Navratil, MSN, RN Clinical Practice Consultant Professional Practice: Clinical Policy Office Fraser Health Authority www.uptodate.com Copyright @ 2020 UpToDate, Inc. granted Oct. 22, 2020 Figure(s): The decision-making abilit ies, their definit ions, and questions to assess them [100356] Topic: Karlawish J. Assessment of decision-making capacity in adults. Your rights are limited to this Dissertation only and the UpToDate material may not be reproduced in any other print, electronic, or CD/DVD publishing usage without the prior written consent of UpToDate, Inc. 107 References Adult Guardianship Act Aliberti, M. J. R., Cenzer, I. S., Smith, A. K., Lee, S. J., Yaffe, K., & Covinsky, K. E. (2019). Assessing risk for adverse outcomes in older adults: The need to include both frailty and cognition. Journal of the American Geriatrics Society, 67(3), 477-483. American Psychological Association (2020). APA PsycINFO. Retrieved from: https://www.apa.org/pubs/databases/psycinfo Baker, K., Camptom, T., Gillis, M., Kristjansson, J. & Scott, C., (2007). Whose life is it, anyway? Supporting clients to live at risk. Perspectives, 31(4), 19-24. British Columbia College of Nurses and Midwives (2020). Scope of practice for nurse practitioners. Retrieved from: https://www.bccnp.ca/Standards/RN_NP /StandardResources/NP_ScopeofPractice.pdf British Columbia College of Nurses and Midwives (2012). Professional standards for registered nurses and nurse practitioners. Retrieved from: https://www.bccnp.ca/Standards/RN_NP /StandardResources/RN_NP_ProfessionalStandards.pdf BC Guidelines (2016). Cognitive impairment: Recognition, diagnosis and management in Primary Care. Retrieved from: https://www2.gov.bc.ca/gov/content/health/practitioner -professional-resources/bc-guide lines/cognitive-impa irment BC Guidelines (2017). Frailty in older adults – early identification and management. Retrieved from: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guide lines/fra ilty -full_guide line.pdf 108 BC Health Coalition and Canadian Centre for Policy Alternatives – BC, (2012). Caring for BC’s aging population: Improving health care for all. Retrieved from: https://www.policya lternatives.ca/sites/default/files/uploads/publications/BC%20Office /2012/07/CCPABC-Caring-BC-Aging-Pop. pdf Berke, R. (2014). Older adults living at risk: Ethical dilemmas, risk, assessment and interventions to facilitate autonomy and safety. International Journal of Nursing Student Scholarship, 1, 1-12. Burgess, J., Martin, A., & Senner, W. (2011). A framework to assess nurse practitioner role integration in Primary Health Care. Canadian Journal of Nursing Research, 43(1), 22-40. Burgess, J. & Purkis, M. E. (2010). The power and politics of collaboration in nurse practitioner role development. Nursing Inquiry, 17(4), 297-308. Camptom, T., Gillis, M., Kristjansson, J., & Scott, C. (2007). Whose life is it, anyway? Supporting clients to live at risk. Perspectives, 31(4), 19-24. Canadian Medical Association (2013). Health and Health Care for an Aging Population: Policy summary of the Canadian Medical Association. Retrieved from https://www.cma.ca /sites/default/files/2018-11/CMA_Policy_Health_and_Health_Care_for_an_Aging -Population_PD14-03-e_0.pdf Canadian Nurses Association (2017). Code of Ethics for Registered Nurses. Retrieved from: https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-e dition -secure-interactive 109 Carey, E. C., Covinsky, K. E., Lui, L., Eng, C., Sands, L. P., & Walter, L. C. (2008). Prediction of mortality in community-living frail elderly people with long-term care needs. Journal of the American Geriatrics Society, 56(1), 68-75. Costanzo, L., Pedone, C., Cesari, M., Ferrucci, L., Bandinelli, S., & Incalzi, R. A. (2018). Clusters of functional domains to identify older persons at risk of disability. Geriatrics Gerontology International, 18, 685-691. Cott, C. A., & Tierney, M. C. (2013). Acceptable and unacceptable risk: balancing everyday risk by family members of older cognitively impaired adults who live alone. Health, Risk & Society, 15(5), 402-415. Crane, S. J., Tung, E. E., Hanson, G. J., Cha, S., Chaudhry, R., & Takahashi, P. Y. (2010). Use of an electronic administrative database to identify older community dwelling adults at high risk for hospitalization or emergency department visits: The elders risk assessment index. BMC Health Services Research, 10(338), 1-7. Critical Appraisal Skills Programme (CASP). (2013). 12 questions to help you make sense of a review. Retrieved from http://media.wix.com/ugd/dded87_ 342758a916222fedf6e2355e17782256.pdf Culo, S. (2011). Risk assessment and intervention for vulnerable older adults. BC Medical Journal, 53(8), 421-425. Davies, B., & Logan, J. (2018). Reading research: A user-friendly guide for health professionals (6th ed.). Toronto, ON: Elsevier. De Bono, C. E., & Henry, B. (2016). A positive risk approach when clients choose to live at risk. Current Opinion in Supportive and Palliative Care, 10(3), 214–220. doi: 10.1097/SPC.0000000000000223. 110 Drubbel, E., de Wit, N. J., Bleijenberg, N., Eijkemans, R. J. C., Schuurmans, M. J., & Numans, M. E. (2012). Prediction of adverse health outcomes in older people using a frailty index based on routine primary care data. Medical Sciences, 68(3), 301-308. doi:10.1093/Gerona/gls161 Ebsco (2020a). CINAHL database: The Cumulative Index to Nursing and Allied Health Literature. Retrieved from: https://www.ebscohost.com/nursing/products/c inahl -databases/the-cinahl-database Ebsco (2020b). Medline with full text: A leading source for full-text medical journals. Retrieved from: https://health.ebsco.com/products/medline-with-full-text Fraser Health Authority. (2011). Clinical practice guideline: Risk assessment – identifying tolerable and intolerable risk factors and informing decision making ability. Retrieved from http://gnabc.com/gnabcAdmin/wp-content/uploads/2014/04/RISK -Clinical-Practice-Guide line-March2014.pdf Government of BC (2019). Home and community care policy manual. Retrieved from: https://www2.gov.bc.ca/assets/gov/health-safety/home-community-care/ accountability/hcc-policy-manua l/6_hcc_polic y_manua l_chapter_6.pdf Government of BC (2020). Home & community care. Retrieved from: https://www2.gov. bc.ca/gov/content/health/accessing-hea lth-care/home-community-care Gray, J. R., Grove, S. K., & Sutherland S. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence (8 th ed.). St. Louis, Missouri: Elsevier. 111 Guidelines & Protocols Advisory Committee (GPAC). British Columbia Ministry of Health. (2017). BC guidelines: Frailty in older adults –early identification and management. Retrieved from https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc -guidelines/fra ilty-full_guide line.pdf Health Care (Consent) and Care Facility (Admission) Act (1996). Hefford, B., & Taylor, G. (2014). Your EMR: Why achieve meaningful use Level 3? BC Medical Journal. Retrieved from: https://www.bcmj.org/gpsc/your-emr-why-achieve-meaningful -use-level-3 Hoffman, T., Bennett, S., & Del Mar, C. (2017). Evidence-based practice across the health professions (3rd ed.). Australia: Elsevier. Janssens, A. C. J. W. (2020). Prediction research. Retrieved from: http://www.cecilejanssens.org /prediction-research-2/ Kane, R. A., & Levin, C. A. (1998). Who’s safe? Who’s sorry? The duty to protect the safety of clients in home- and community-based care. Generations, 22(3), 76-81. Karlawish, J. (2020). Assessment of decision-making capacity in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/assessment-of-dec ision-making-capac ity-in -adults?search=determining%20capacity&source=search_result&selectedTitle=1~150 &usage_type=default&display_rank=1 Kitson, A., Marshall, A., Bassett, K., & Zeitz K. (2012). What are the core elements of patient -centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing, 69(1), 4-15. 112 Langley, F. A. & Mackintosh, S. F. H. (2007). Functional balance assessment of older community dwelling adults: A systematic review of the literature. The Internet Journal of Allied Health Science and Practices, 5(4), 1-11. Lee, L., Hillier, L. M., Lu, S. K., Martin, S. D., Pritchard, S., Janzen, J., & Slonim, K. (2019). Person-centered risk assessment framework: Assessing and managing risk in older adults living with dementia. Neurodegenerative Disease Management, 9(1), 47-57. Merriam-Webster. (n.d.). Responsive. In Merriam-Webster.com dictionary. Retrieved July 15, 2020, from https://www.merriam-webster.com/dictionary/responsive MacLeod, H., & Stadnyk, R. L. (2015). Risk: ‘I know it when I see it’: How health and social practitioners defined and evaluated living at risk among community-dwe lling older adults. Health, Risk & Society, 17(1), 46-63. O’Caoimh, R., Gao, Y., Svendrovski, A., Healy, E., O’Connell, E., O’Keeffe, G., […] & Molloy, D. W. (2015). The Risk Instrument for Screening in the Community (RISC): A new instrument for predicting risk of adverse outcomes in community dwelling older adults. BMC Geriatrics, 15(92). 1-9. Savulescu, J. (2018). Golden opportunity, reasonable risk and personality responsibility for health. Journal of Medical Ethics, 44(1), 59-61. Seniors Advocate British Columbia (2018). Seniors at home & in long-term care: A 2017/2018 snapshot. Retrieved from: https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2018/09 /SeniorsatHomeandinLTC-rpt.pdf Seniors First BC (2020). Vulnerability. Retrieved from: http://seniorsfirstbc.ca/for -professionals/vulnerability/ 113 Sotic, A., & Rajic, R. (2015). The review of the definition of risk. Online Journal of Applied Knowledge Management, 3(2), 17-26. Statistics Canada (2019). Canada’s population estimates: Age and sex, July 1, 2019. Retrieved from: https://www150.statcan.gc.ca/n1/daily-quotidien/190930/dq190930a-eng.htm Statistics Canada (2020). Seniors and Aging: Statistics. Retrieved from: https://www.statcan.gc.ca/eng/subjects-start/seniors_and_aging St. John, P. D., & Montgomery, P. R. (2014). Validity of an early risk score for older adults. The Journal of the Royal College of Physicians of Edinburgh, 44, 111-115. University of Northern British Columbia (n.d.). Geoffrey R. Weller Library: Catalogue. Retrieved from: https://wizard.unbc.ca/search~S3?/yp/yp/1%2C23%2C23%2CB /eresource&FF=ypsycinfo&1%2C1%2C Verver, D., Merten, H., Robben, P., & Wagner, C. (2017). Perspectives on the risk for older adults living independently. British Journal of Community Nursing, 22(7), 338-345. Waring, A. (2000). Constructive risk in the care of the older adult: A concept analysis. British Journal of Nursing, 9(14), 916-924. Weiland, S., A. (2008). Reflections of independence in nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 20, 345-352. Weins, A. G. (1993). Patient autonomy in care: A theoretical framework for nursing. Journal of Professional Nursing, 9(2), 95-103. Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing 52(5), 546-553. doi:10.1111/j.1365-2648.2005. 03621.x Woodruff, J. M. (2005). Consequence and likelihood in risk estimation: A matter of balance in UK health and safety risk assessment practice. Safety Science, 43, 345-353. 114 World Health Organization (2019). Health statistics and information systems. Retrieved from: https://www.who.int/healthinfo/survey/age ingdefnolder/en/ Young, J. M., & Everett, B. (2018). When patients choose to live at risk: What is the ethical approach to intervention? BC Medical Journal, 60(6), 314-318.