Violence risk assessment and management with the HCR-20 in real-world clinical practice: a qualitative interview study

The Historical Clinical Risk-20 (HCR-20) risk assessment tool has been implemented into practice worldwide; however, we lack an understanding of whether its in-practice use aligns with its intended function and how risk assessment tools are being integrated with decision-making for risk management. We aimed to investigate how the HCR-20 (Version 3) is being used in real-world practice. We conducted semi-structured interviews with 21 psychiatrists and psychologists in secure mental healthcare. Interviews were analysed using thematic analysis. The results describe the intended and actual use of the HCR-20, the integration of the HCR-20 output with risk management and clinician’s views on the tool. Professionals believed that the HCR-20 and its guidance/standards were being fully adhered to, with variations found with the quality of delivery, multidisciplinary team involvement and the communication of risk as detailed in the HCR-20. Although the analysis identified different examples of HCR-20 use by individuals to inform clinical decision-making, active use of the HCR-20 to inform multidisciplinary team risk management strategies or case plans was absent. Participants recognised in-principle benefits of using a structured approach to assess risk and inform risk management clinical decision-making, however they also described in-practice impediments to those benefits being fully realised.