A concept analysis is an exercise designed to help a researcher become as familiar as possible with a concept. For the purposes of nursing, a concept might be related to health, managed care, or a var

Running head: Concept of Analysis of Risk

Concept Analysis of Risk

Risk in the Adolescent Population: Significance of the Concept

There is a preponderance of articles in the PubMed database using the term “risk” just in the title of the articles. The concept of risk was selected to help clarify this broad and widely utilized term. It is necessary to have an acceptable definition of the term risk and to identify the specific application of this term to its intended population. In planning education and interventions for the adolescent population it is important to expand the nurses understanding of risk and the associated decision making process. The term risk frequently is not defined and is used inconsistently and imprecisely in the medical and nursing literature.

Origin of Concept

The origins of risk date back to the 17th century with the French work risqué (Jacobs, 2000; Kettles, 2004; Shattell, 2004) . The original meaning of risk was to “gamble” and taking a gamble meant predicting the probability of an event occurring. This was utilized in the business world to include “commercial loss of insured property and goods” (Shattell, 2004, p. 12) . The business world also put an estimate on the gain and loss of an event occurring, connecting the definition to gamble. In the 19th century the word risk began to exchange its affiliation with gambling for gain (Jacobs, 2000) . “Taking a gamble meant the probability of an event occurring combined with magnitude of the loss or gain that could result” (Kettles, 2004, p. 485) . The healthcare field, especially in the area of epidemilogy, began to use the term to identify risk factors of disease. Consequently, the healthcare professionals began to study ways to prevent disease through the eradication of the risk factors.

Framework

The strategy of Walker and Avant (1995) was used in this concept analysis. This is a straightforward approach and has 8 steps in the process. These steps include: selection of concept, determination of the aims, identification of the uses, determination of attributes, the construction of a model case, and identification of related terms, description of the antecedents and consequences and empirical referents.

Definitions

There are several definitions of risk.

“Risk: 1. The possibility of suffering harm or loss; danger. 2. A factor, thing, element, or course involving uncertain danger; a hazard: “the usual risks of the desert: rattlesnakes, the heat, and lack of water. 3. The danger or probability of loss to an insurer. The amount that an insurance company stands to lose. 4. The variability of returns from an investment. The chance of nonpayment of a debt. 5. One considered with respect to the possibility of loss: a poor risk” (Webster's New Universal Unabridged Dictionary 2nd Edition, 1972, p.1565) .

Risk also includes some copyrighted materials, such as the card game, RISK and strategic board game, RISK. Attributes include a measurable uncertainty, usually related in statistical percentages and calculations. Society now associates risk with negative outcomes, especially in the healthcare field. Risk precedes the threat of the negative outcome. Individuals assessing risk must view the consequence as important and meaningful enough to have an impact on the judgments and decisions that must be made in relation to the risk taking.

Within healthcare, risk is the notion that extends the clinical view beyond the physical body and into the domain of the environment. Society and the medical community judge the amount of risk and regulate the environment to decrease the risk (Chater, 1999). This is exemplified by mandating car seat usage.

Attributes

Attributes of risk include a measurable uncertainty, usually related in statistical percentages and calculations. Society now associates risk with negative outcomes, especially in the healthcare field. “The concept of risk is about the uncertainty surrounding the translation of scientific knowledge into clinical practice” (Jacobs, 2000, p. 5). Risk precedes the threat of the negative outcome. Jacobs (2000) identifies three epidemiological conceptions of risk, absolute risk, relative risk and attributable risk. Individuals assessing risk must view the impact as important and meaningful enough to have an impact on the judgments and decisions that must be made in relation to the risk taking.

Model Case

Walker and Avant (1995) identified the next step in the analysis of risk as the construction of a model case. This model case includes the defining attributes of the concept.

A nineteen year-old female, who is attending the University of Memphis, with the genetic profile containing Hemoglobin (Hgb) Sickle Cell Trait (AS), is engaged to marry a young man. The young man is also a student at the University of Memphis. She has ask the young man to have genetic testing for the Hgb AS trait prior to their marriage. The young man’s test is positive for the trait. The couple each has childhood knowledge of a prior classmate with Sickle Cell Disease. They decide to have genetic counseling to determine their risk of having a child with the genetically acquired Sickle Cell Disease.

Closely Related Terms

There are several closely related terms found in the literature for the concept of risk. Vulnerability is described as a time when individuals may be in harms way (Jacobs, 2000). Susceptibility is a term used to determine that there is danger or harm that lurks in the future. This term can be used interchangeably with vulnerability but does not have the same attributes as risk (Jacobs, 2000). Wager is another closely related concept. This is the evidence or statistical odds of something going in a negative or positive way, generally associated with money (Jacobs, 2000). Risk estimation is another term used generically for risk factors (Kraemer, et al., 1997) . Weight of evidence, is a term often seen in the discussion of risk assessment (Weed, 2005) . Decision research is the amount and accuracy of the information gained to assess the risk of the decision (Ortendahl & Fries, 2006) . Noncompliance is also a related term or concept of risk. Chater states “ the notion of noncompliance has been classified as risk-taking behavior, which can be modified if the individual adheres to medical advise” (1999, p. 136) . Gamble is a closely related term with the assessment of loss and gains, such as gambling with your life savings or gambling with your health by smoking.

Antecedents

The one antecedent for risk is the cognitive ability to distinguish between two or more choices. If an individual is not able to use cognitive reasoning they will not have the skills to recognize or perceive the risk or potential harm. This is exemplified by a sexually active adolescent with sickle cell trait who does not understand the basic genetic implications of two traits have a 25% chance of conceiving a baby with sickle cell disease there is not a perceived risk. Another antecedent is prior knowledge of the possibility of harm. “Background knowledge is an important source of information in our thinking, reasoning and problem solving” (Huber, Wider & Huber, 1997) . Using the same example: the adolescent knows how the genetic disease is acquired and conceives a baby with sickle cell disease but has no knowledge of the consequences of the disease. There is no perceived risk in this decision.

The discussion now turns to the consequences of the concept of risk. Since risk involves a decision making process, the identification of risk guides the active decision making process. There can be political, economic, social and cultural forces that influence of concept of risk and the decision making process (Jacobs, 2000). Another consequence of risk is the possibility of harm and acknowledgement that harm could occur. There is also the recognition of the possibility of no harm, which could reinforce the negative behavior if nothing happens that is considered harmful. For example a patient has sickle cell disease and he never obtains routine care and rarely experiences pain episodes. He perceives his risk as very low for complications, but medically the risk is still very high. The end consequences are the chronic end organ damage that occurs without prophylactic routine care.

Empirical Referents

According to Kraemer, et al. (1997) “a risk factor is a measurable characterization of each subject in a specified population that precedes the outcome of interest (p. 2). The literature is filled with numerous empirical referents to the concept of risk. Many instances were seen with an assumed definition of risk imbedded in the articles (Maes & Leivens, 2002; Moran, el al., 2005; Newmark-Sztainer, Story, Dison & Murray, 1998) . Nursing literature is frequently used to measure negative health behaviors such as the percentage of adolescents who are smoking by the age of 14 years. Another behavior measured in the nursing literature is the percentage of adolescents engaging in unprotected sexual intercourse by the age of 14 years (Britto, et al., 1998; Clark, et al., 2005) . These are measuring the number of adolescents from the population engaged in behaviors that the healthcare profession has identified as risky. This falls contrary to the analysis that risk is cognitive, not behavioral. One study indicated that there is not association between risk factors and health behaviors (Manderbacka, Lundberg & Martikiainen, 1999) .

Pertinent to the discussion of risk and adolescents is the impact of timing for patient education. Health behaviors and genetic reproduction choices are difficult to affect change and healthy behaviors that are prescribed to decrease risk are not actually followed or the true impact of reproductive choices are not always recognized. Framing the risk as it relates to oneself verses a general risk may have more influence in the desired behavioral changes (Ortendahl & Fries, 2006) . The example shows the measurable outcomes and uncertainty: the possibility of a negative outcome with the impact of having a child with sickle cell disease.

According to Huber, et al. (1997), risk research has revealed that many more aspects are relevant in the perception and evaluation of subjective risk than the utility of the negative outcome and subjective probability. This view helps explain why some individuals who continue to choose what healthcare providers deem, as risky behaviors may not be perceived as a risk to the decision maker. This complex concept is determined, to a large degree, by the person who defines the risk (Woods, Reed & Collins, 2003) . One instrument in the limited literature review is the Behavioral Status Index, which has been used to facilitate the process of risk assessment in the mental health field, but it is only validated in the adult population (Woods, et al.) .

Relevance to Specific Population

The relevance of risk for the adolescent population pertains to the advances in healthcare research. There are several elements germane to the concept of risk. As more factors are being identified at an earlier age, the question is what to do with this information. By analysis, it has been determined that to have risk, prior knowledge is necessary to process the concept. The adolescent must have the cognitive ability to distinguish between two or more choices signifying the consequences of the decision. So patient education will be a necessary component that will be used in the decision making process. Using the case model example, several studies have indicated that there are certain factors, which influence parents more when deciding whether or not to have a child with a chronic illness. After pre-genetic testing it is not the precise numerical value of the risk but the long term burden associated with the risk (Turnpenny & Ellard, 2005) . This is where prior knowledge, personal experience and education may be the key to that decision making process. Risk information is about reviewing choice and empowering adolescents in their decision-making process (Rowan, 1996; Shiloh, Gerad & Goldman, 2006) .

More than a dozen qualitative factors have been identified as being influential in how people view risk (Rowan, 1996) . One overlaying factor is the concept of diminishing value of the risk assessment. This is a vital component to risk analysis. When benefits or negative outcomes occur in the future, the decision-making process becomes more difficult due to the limited immediate value to the decision to change behavior (Ortendahl & Fries, 2006) . This decision process is then influenced by the concept of time.

Furthermore, genetic testing will be moving into areas of pre-symptomatic diagnosis risk that will only be accessed by healthcare professionals. The challenges will be to meet the antecedents necessary for the adolescent to make decisions regarding possible health consequences from a concrete cognitive learning paradigm.

Another area of concern to the adolescent population is the ethical principles and pitfalls raised by the use of predictive testing. Information overload and parents’ request for information should not be confused with decision-making process and the assessment of risk/benefit ratios.

A final concern is the conflict with the high ideal of upholding the principle of individual autonomy; this may discourage testing unless medical intervention or screening is appropriate. Candid discussions are necessary to evaluate the mindset of the parents and to be watchful of the rights of adolescents as they enter into the adult decision making process involved with risk assessment and health behavior choices.

The understanding of the concept of risk is necessary to facilitate a personally informed and meaningful decision between a least two choices. This involves the amount and type of information provided to an adolescent that is essential in the decision process involving risk decisions. This concept then becomes crucial in the development of tailoring programs, education and interventions that meet the antecedents of risk in decision-making.

References

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Chater, K. (1999). Risk and representation: older people and noncompliance. Nursing Inquiry, 6, 132-138.

Clark, L. F., Miller, K. S., Nagy, S. S., Avery, J., Roth, D. L., Liddon, N. & Mukherjee, S. (2005). Adult identity mentoring: reducing sexual risk for African-American seventh grade students. Journal of Adolescent Health, 37, 337.e331-337.e310.

Huber, O., Wider, R. & Huber, O. W. (1997). Active information search and complete information presentation in naturalistic risky decision tasks. Acta Psychologica, 95, 15-29.

Jacobs, L. A. (2000). An analysis of the concept of risk. Cancer Nursing, 23(1), 12-19.

Kettles, A. M. (2004). A concept analysis of forensic risk. Journal of Psychiatic and Mental Health Nursing, 11, 484-493.

Kraemer, H. C., Kazdin, A. E., Offord, D. R., Kessler, R. C., Jensen, P. S. & Kupfer, D. J. (1997). Coming to terms with the terns of risk. Archives of General Psychiatry, 54(4), 337-343.

Maes, L. L., J. (2002). Can the school make a difference? A multilevel analysis of adolescent risk and health behavior. Social Science & Medicine, 56, 517-529.

Manderbacka, K., Lundberg, O. & Martikainen, P. (1999). Do risk factors and health behaviors contribute to self-ratings of health? Social Science & Medicine, 48, 1713-1720.

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Newmark-Sztainer, D., Story, M., Dison, L. B. & Murray, D. M. (1998). Adolescents engaging in unhealthy weight control behaviors:are they at risk for other health-compromising behaviors? AMerican Journal of Public Health, 88(6), 952-955.

Ortendahl, M. F., J. F. (2006). Discounting and risk characteristics in clinical decision-making. Medical Science Monitor, 12(3), 41-45.

Rowan, F. (1996). The high stakes of risk communication. Preventive Medicine, 25, 26-29.

Shattell, M. (2004). Risk: a concept analysis. Nursing Forum, 39(2), 11-17.

Shiloh, S., Gerad, L. & Goldman, B. (2006). The facilitating role of information provided in genetic counseling for counselees' decisions. Genetics in Medicine, 8(2), 116-124.

Turnpenny, P. E., S. (2005). Emery's Elements of Medical Genetics (12th ed.). Edinburgh: Elsevier Churchill Livingstone.

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Weed, D. L. (2005). Weight of evidence: a review of concept and methods. Risk Analysis, 25(6), 1545-1557.

Woods, P. R. C., M. (2003). The relationship between risk and insight in a high-security forensic setting. Journal of Psychiatic and Mental Health Nursing, 10, 510-517.