Unearthing the conflicts between carer and custodian: implications of participation in Section 16 hearings under the Mental Health (Compulsory Assessment and Treatment) Act (1992)

Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers

BACKGROUND

Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences.

METHODS

The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software.

RESULTS

Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser.

DISCUSSION

Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness.

CONCLUSIONS

By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.

A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders

BACKGROUND

Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness.

METHODS

This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data.

RESULTS

Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy.

CONCLUSIONS

Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.

Improving the ability of mental health nurses to give second opinion in Judicial Reviews: an evaluation study

In New Zealand, concern has been expressed regarding the variable quality of second opinions given by health professionals assisting judicial decisions on the use of compulsory assessment and treatment under mental health legislation. This second opinion is mostly given by registered mental health nurses. An innovative education programme based on experiential learning and adult learning principles was developed to assist health professionals to effectively undertake this role. A mixed method pre-post test intervention research design was developed to evaluate the effectiveness of the programme in assisting health professionals to feel more competent in undertaking the role. Data from the participants (n= 112) was subjected to descriptive statistical analysis and a thematic analysis of open-ended questions. The findings suggested gains in all competencies following the education programme, although there was room for further improvement. These changes were sustained over time at the next occasion when the health professionals undertook the role. There is a need to nationally disseminate such educational innovations to assist more mental health nurses to maximize their input into judicial decisions, which have a marked impact on the lives of those service users involved.

Redressing the balance in mental health nursing education: arguments for a values-based approach

Evidence-based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self-examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.

Exploring the past: mental health nursing in Greece

This paper aims to explore the evolution of psychiatric nursing from the delayed organization of an asylum mental health system in Greece to the present. The care and custody of mental health patients which was in the hands of police at the first asylum passed to the hands of uneducated staff and gradually to the hands of qualified nurses. Severe overcrowding along with limited resources and low staff numbers resulted in the poor quality of living conditions. In this context, psychiatric nursing took its first steps in Greece, without realizing the inherent conflict in its dual role, that of care and social control. Counter to the handed-down cliché about psychiatric hospitals, nurses frequently put great effort into improving the living conditions of patients. However, the regulations of the institutions emphasizing the custodial role of nursing together with other structural factors of the psychiatric system impeded nurses' attempts to improve institutional care considerably. Nowadays, psychiatric hospitals are shrinking at a rapid pace, leaving behind them--as heritage for the psychiatric nurses who try to define their new role in community--the pioneers of psychiatric nursing's courage, ethos and respect for the psychiatric client.

Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992

The objectives of this research were to determine how many registered nurses are working as 'responsible clinicians', under what phases of the legislation they are functioning, and to describe the enabling processes and barriers to nurses undertaking this statutory role. An anonymous descriptive survey was distributed to the 11 nurses who were currently responsible clinicians as well as five senior nurses selected from each of the 21 District Health Boards and the Auckland Regional Forensic Psychiatry Services (n = 121). The response rate was 88.4% (n = 107). The survey questioned respondents on statutory roles currently undertaken. Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain it. They were also asked which competencies of the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions were analysed using content analysis. Of the approximately 395 responsible clinicians nationally, 11 (2.8%) are nurses. Most nurses viewed the role as legitimate. However, many were unaware of competencies for the role and credentialing processes, and were somewhat ambivalent about achieving the role due to current workload, role conflict and lack of remuneration. Competency deficits were highlighted. There are grounds to encourage nurses as responsible clinicians given the intent of the legislation. This will require the promulgation of appropriate mental health policy, and a concerted effort by major stakeholders in mental health service delivery.

The role of second health professionals under New Zealand mental health legislation

The development of generic statutory roles in mental health care has been the subject of discussion by New Zealand nurses for the past decade. One such role is that of second health professional in judicial reviews of civil commitment. Issues identified by New Zealand nurses have also been raised in England, where it seems that nurses are likely to assume the role of Approved Mental Health Worker under English mental health law. A survey of mental health nurses found that few had received any preparation for the role of second health professional and 45% did not feel adequately prepared for the role. Some of these issues are reflected in a New Zealand inquiry which resulted in the Ministry of Health developing a written report form for second health professionals. However, the form has the potential to reduce the mental health nursing role to a narrow legal role. Statutory roles such as that of second health professional challenge mental health nurses to critically reflect on the conceptual and ethical basis of their practice. While traditional concepts such as therapeutic relationships and advocacy need to be reviewed in light of these changes, nurses need to be vigilant in articulating the moral and clinical basis of their roles. The development of guidelines for he second health professional role is suggested as a way of supporting clinical practice in this area.

Advanced 'prescribing' of nurses' emergency holding powers under New Zealand mental health legislation

Since the mid-19th century doctors have exercised almost exclusive control in health professionals' decisions concerning compulsory assessment and treatment of the mentally ill. This control has the potential to compromise the legitimate professional practice of other mental health professionals. A new approach to mental health legislation has seen the involvement of a range of health professionals in legislated mental health roles, including the power of registered nurses to detain patients in hospital under Section 111 of the New Zealand Mental Health (Compulsory Assessment and Treatment) Act (1992). Under this Section a nurse who believes that a voluntary patient meets the legal criteria of the Act can independently detain the patient for a period of up to 6 hours, pending further assessment by a medical practitioner. However, anecdotal evidence and a clinical audit undertaken by the authors suggest some doctors 'prescribe' Section 111 at the time of admission. This practice instructs nurses to initiate Section 111 if particular voluntary patients choose to leave hospital. This study outlines practice issues resulting from 'prescribing' Section 111; provides a legal critique of medical practitioners' involvement in this practice; and makes recommendations for guidelines toward a more constructive use of Section 111.