Risk is inherent in every occupational health (OH) consultation and underpins every recommendation made. However, in practice, risk is often treated as something to be minimised or avoided rather than actively managed. This tendency reflects a broader pattern of defensive practice within healthcare, where decisions are shaped not only by clinical reasoning but by perceived consequences and organisational culture (Catino, 2009; Doyle et al., 2025). Practitioners working within supportive environments are more likely to tolerate uncertainty and manage risk proportionately, whereas those operating within blame-oriented cultures are more likely to adopt risk-averse approaches (Catino, 2009; Boardman and Roberts, 2014).

This dynamic is particularly evident in mental health assessments. Compared with many physical health conditions, mental health presentations are characterised by greater variability, less predictable consequences, and a higher degree of interpretive judgement. Stigma and the perceived consequences of adverse outcomes can also increase practitioner anxiety and influence decision-making (Challinor et al., 2025; Fujimoto et al., 2025). As a result, risk-averse recommendations may be adopted as a default position, even where occupational evidence suggests that a more proportionate approach would be appropriate (NICE, 2022a; World Health Organization, 2022).

Within this context, risk should be understood as the probability of outcomes that may be either beneficial or adverse, rather than solely as the potential for harm (Department of Health, 2007; Wood et al., 2024). An exclusively harm-focused interpretation of risk can obscure the potential benefits of remaining in or returning to work. Positive risk-taking offers an alternative framework, emphasising the identification and management of risk in a way that maximises autonomy, function, and opportunity (Morgan, 2004; Department of Health, 2007).

Mental health and clinical uncertainty

Positive risk taking is relevant across OH practice, but its importance is most evident in mental health cases, where it is recognised as a core value of contemporary mental healthcare (Doyle et al, 2025; Teoh et al., 2023; Felton, 2017). These conditions involve greater uncertainty, greater variation in presentation, and lower practitioner confidence, which increase the likelihood that recommendations may have unintended consequences (Fujimoto et al., 2025; Challinor et al., 2025; NICE, 2022b).

Mental health conditions carry an occupational dimension that goes beyond symptom presentation. Evidence indicates that, most of the time, employment is associated with improved psychological health outcomes via mechanisms such as structure, role identity, social interaction, and sense of purpose (Waddell and Burton, 2006; WHO, 2022). These factors are directly relevant to OH assessment and advice.

The occupational impact of risk-averse practice

When OH practitioners take risk-averse approaches, recommending restriction or absence without adequately weighing occupational implications, the recommendation itself can directly contribute to poorer outcomes. Unnecessary restrictions or prolonged absences can reinforce avoidance, erode occupational identity, and delay recovery (Nieuwenhuijsen et al., 2014; Muntanelli and Silva-Junior, 2025).

In some cases, this approach may also function to defer, rather than resolve, complex decision-making, effectively shifting risk-based decisions to a later point or another practitioner, rather than actively managing them in the here and now. For practitioners, repeated reliance on cautious decision-making, driven by perceived consequences rather than clinical evidence and potential benefit, can undermine professional confidence and make considered judgment more difficult over time (Boardman and Roberts, 2014; Challinor et al., 2025). This suggests that risk-averse practices in OH may inadvertently undermine the very outcomes they seek to protect.

Professional confidence and decision making

OH practitioners may experience reduced confidence when assessing mental health presentations, reflecting the inherent complexity and uncertainty of these conditions (Fujimoto et al., 2025; Doyle et al., 2025; Teoh et al., 2023), yet confidence develops through repeated application of structured judgement in uncertain situations.

Risk-averse practice affects work outcomes by shaping how decisions are made in uncertain situations. In these situations, greater emphasis is placed on identifying and preventing potential harm, often at the expense of considering the occupational implications of restrictions or non-participation in work (Catino, 2009; Challinor et al., 2025). This may lead to recommendations that are broader and more restrictive, and less consistently anchored in functional assessment and employee capability (Catino, 2009; Serra et al., 2007).

This also affects the quality and practical value of OH advice. Recommendations that are not clearly grounded in functional capacity can introduce ambiguity into workplace decision-making and reduce the extent to which they are implemented consistently. This may contribute to unclear management pathways, increased reliance on continued absence or further referrals, and delayed progression towards defined occupational outcomes (CIPD, 2022; Hassard et al., 2024; SOM, 2022).

Positive risk taking in occupational health practice.

Positive risk taking provides a structured approach to decision-making in uncertain conditions and offers a framework that supports recovery, autonomy, and progression towards meaningful occupational outcomes (Department of Health, 2007; Morgan, 2004). Evidence indicates that outcomes improve when risk is explicitly identified, assessed, and documented rather than managed through defensive restriction (Catino, 2009; Wood et al., 2024). 

In OH, this involves articulating and acknowledging the presenting risks, their likelihood and impact, and the occupational implications of different options (Department of Health, 2007; NICE, 2022a).  This also includes considering how identified risks may be mitigated through adjustments, rather than defaulting to restriction or absence. It also requires a clear focus on functional capacity, ensuring that decisions are based on what the individual can do, rather than diagnosis alone.

In mental health assessments, this is grounded in functional assessment and risk formulation, including what the individual can do, the conditions required to support it, and the extent to which it can be maintained in a work setting. This involves understanding the factors contributing to the current presentation, including relevant background vulnerabilities, recent triggers, those that may be maintaining risk, and those that may mitigate or support recovery within the workplace (Fujimoto et al., 2025; Serra et al., 2007; Wood et al., 2024). This allows uncertainty to be managed within defined parameters rather than avoided.

This approach then supports the credibility of OH recommendations by ensuring that clinical reasoning is explicitly stated, structured, and grounded in the assessment. Decisions that are clearly reasoned and documented are more consistent, particularly in areas of uncertainty such as mental health conditions and assessment (Doyle et al., 2025; Wood et al., 2024).

The context in which symptoms occur is also critical in determining risk. The presence of a symptom alone does not necessarily indicate a high level of risk; rather, its meaning, severity, and impact on functioning must be considered. For example, experiences such as hallucinations do not, in themselves, indicate risk, but may become clinically significant depending on their content, the individual’s insight, and any associated behaviours. This reflects the principles of risk formulation, in which risk is understood through the interaction of factors rather than by individual symptoms in isolation (Royal College of Psychiatrists, 2016a; 2016b; Logan, 2014).

In practice, the reasoning underpinning a decision and recommendation should be clearly recorded in the clinical notes, including the risks considered, how they were assessed, and how they informed the advice given. The extent to which this is included within the report may vary, but sufficient clarity is required for employers to understand and implement the recommendation and outcome (Boardman and Roberts, 2014; NICE, 2022a).

In mental health assessments, conclusions are drawn from observable presentation, structured assessment, and practitioner interpretation, including the mental state examination, the individual’s account, risk formulation, relevant supporting evidence, and an assessment of consistency between reported symptoms, observed presentation, and functional impact (Wood et al., 2024; Doyle et al., 2025; Royal College of Psychiatrists, 2016a;2016b). Professional judgement therefore plays a central role in how information is applied, and the quality of reasoning and documentation becomes critical to the consistency and credibility of the outcome (Catino, 2009; Serra et al., 2007).

Conclusion

Risk is inherent in every OH recommendation, yet current approaches in mental health assessment often prioritise perceived safety, reflecting the influence of anticipated consequences on decision-making and contributing to more restrictive recommendations and reduced practitioner confidence (Challinor et al., 2025). This is not to suggest that risk should be disregarded or that individuals should return to work where it would be unsafe; rather, the aim is to ensure that risk is considered proportionately alongside the potential benefits of work.

The effectiveness of OH practice is closely linked to how risk is recognised, assessed, tolerated, documented, and incorporated into recommendations. Evidence indicates that outcomes are improved where risk is explicitly considered, proportionately assessed, and clearly documented, with occupational function remaining central to the decision-making process (Doyle et al., 2025; Waddell and Burton, 2006; WHO, 2022).

In practice, this requires OH practitioners to move beyond risk avoidance and adopt a structured approach to positive risk taking, explicitly balancing potential harms with the benefits of work engagement. This also requires practitioners to reflect on whether decisions are being driven by perceived risk or actual risk. When applied consistently, a positive risk-taking approach strengthens practitioner confidence and supports more effective occupational outcomes. It reflects the level of judgement, clarity, and accountability required for effective OH practice.

Reference List

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