Mental health clinician training and experiences with utilization of advance statements in Victoria, Australia

Crisis plans in mental health: A scoping review

Crisis situations are frequent among people with mental health disorders. Several interventions have been developed to act in prevention, including crisis plans recognized as particularly effective in reducing coercive measures. In the literature, several models of crisis plans are proposed with similar aims and contents. Based on the methodology proposed by the Joanna Briggs Institute, a scoping review was conducted to map the state of knowledge on crisis plans in adult mental health settings. The literature search conducted on six databases (CINAHL, PubMed, Medline, EMBASE, PsychINFO and Cochrane) yielded 2435 articles. Of these, 122 full-text articles were assessed for eligibility, and 78 met the inclusion criteria. Studies were critically appraised using the Joanna Briggs Institute appraisal tools, and data were extracted by two independent reviewers. Content analysis identified a typology of crisis plans: (1) the legal crisis plan and (2) the formal crisis plan. Five modalities were identified for its completion: the sections, the moment, the completion steps, the people involved and the training of key actors. Most identified outcomes are consistent with the main purpose of the intervention, which is crisis prevention. However, the most identified outcomes focused on the service user's recovery and indicated that crisis plans could provide an opportunity to operationalize recovery in mental healthcare, thus suggesting an evolution in the aim of the intervention. Future research should further focus on the modalities of crisis plans to guide the implementation in clinical practice.

Promoting and hindering factors in the use of advance statements by Australian mental health clinicians

WHAT IS KNOWN ON THE SUBJECT?: Australia is a commonwealth of federated states and territories with each having unique mental health legislation. Victoria implemented advance statements based on legislation from overseas jurisdictions such as Scotland. The aim of this Victorian legislation was to underpin an individual's autonomy and decision-making in relation to treatment, particularly compulsory treatment. Advance statements allow individuals within the healthcare setting to document preferences for care and treatment during times of decompensated mental health, including informing nominated persons and preferences for recovery-oriented care; however, advance statements continue to attract barriers in their implementation and use. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This paper focuses on legislation within one jurisdiction, Victoria, highlighting that several barriers to uptake exist, including uncertainty around the legal status of advance statements, the ideal setting to implement advance statements and concern around perceived consumer capacity to contribute to developing advance statements. There are substantial differences of opinion regarding adherence to treatment and recovery preferences contained within the advance statement, especially when decisions are made in the context of decompensated mental health. The Theoretical Domains Framework (TDF) model has been used to formulate recommendations in several other health studies, but to date has not been used to provide recommendations for greater implementation of advance statements. Implementation science is a contemporary research translation movement that seeks to identify factors and strategies that influence the adoption and integration of interventions like advance statements in real world settings. For this study it has been useful to identify barriers, consider implementation strategies and link this with policy frameworks to support practice change. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our study revealed that real challenges exist for mental health clinicians in adopting advance statements despite them having a strong held intention to empower service users to play a greater role in their own treatment and care decisions. The facilitators identified in this study highlight the notion that advance statements, and the concept of supported decision-making are needed in contemporary mental health care. Implementation science can assist in identifying barriers and suggesting facilitators including enhanced training, incentivization of advance statement creation, and greater awareness of the overarching purpose and principle of advance statement creation. Continued support and training in implementing and maintaining advance statements is required if mental health clinicians are to drive the uptake of this important reform to mental health legislation. Training needs to be provided that will address attitudes, and strongly held beliefs that pose barriers to the use of advance statements.

ABSTRACT

INTRODUCTION: Advance statements, also known as advance directives or psychiatric wills, provide individuals the opportunity to document care and recovery preferences during a period of mental ill health. Although the use of advance statements has gained momentum, little research has explored the factors that promote or hinder further uptake.

AIM

To determine the factors that promote or hinder the uptake of advance statements.

METHOD

Cross-sectional online survey of healthcare workers (n = 190).

RESULTS

Promoting factors include high perceived value of advance statements, particularly their role in recovery focussed care, while hindering factors include disagreement or responsibility for advance statement creation and legal status.

DISCUSSION

This study indicates that several hindering factors or barriers to advance statement uptake remain, and until these factors are addressed future implementation is arguably hindered. In this paper, we have used the Theoretical Domains Framework (TDF) model to outline suggestions to address hindering factors to implementation and guide future implementation strategies for advance statement uptake and practice change.

IMPLICATIONS FOR PRACTICE

The ongoing uptake of advance statements requires tailored implementation strategies address hindering factors. Strong promoting factors, such as the shared belief in the advance statement model and its role in recovery focused care, should be considered a strong foundation for implementation strategies.

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.