The Mental Capacity Act: a review of the current literature

What is the nature of Mental Capacity Act training and how do health and social care practitioners change their practice post-training? A narrative review

AIM AND OBJECTIVE

To identify training strategies and determine how registered health and social care practitioners change their practice after Mental Capacity Act training.

DESIGN

Narrative literature review.

DATA SOURCES

Seventeen databases were searched up to December 2019: CINAHL, Social Care Online, PubMed, Social Policy and Practice, Discover, MEDLINE, Science Direct, Ovid, 0of Science, British Nursing Index, DH-Data and King's Fund Library Catalogue.

REVIEW METHODS

Empirical studies of any design investigating Mental Capacity Act training were searched and screened. Data were extracted to a bespoke spreadsheet and quality assessed. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Of 162 papers identified, 16 were included comprising qualitative, quantitative and mixed-methods studies. Trainees valued interactive training with close alignment to practice. Training did not lead to demonstrable practice change. Barriers in the context and cultures of care environments were identified.

CONCLUSION

To facilitate application of Mental Capacity Act legislation, identified barriers should be addressed. Future training should be interactive, scenario-based and relevant to trainees' practice.

RELEVANCE TO CLINICAL PRACTICE

The Mental Capacity Act is widely misunderstood and implemented poor. Training is proposed as a solution, but the nature of training that will positively affect practice remains unknown. This review aims to address this gap in the evidence base. Interactive training, using scenarios that reflect practice complexities, has the most positive impact. Cultural norms in care environments may impede application of this legislation. The review has international relevance as there is a global imperative to adhere to the United Nations Convention on the Rights of Persons with Disabilities. The review will inform training design and delivery to ensure that people with impaired capacity to make decisions are given the best opportunity to act autonomously.

Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'

BACKGROUND

Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.

AIMS

To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.

METHOD

Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.

RESULTS

Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities.

CONCLUSIONS

The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.

DECLARATION OF INTEREST

D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

How do health and social care professionals in England and Wales assess mental capacity? A literature review

Purpose: To review evidence describing how health and social care professionals in England and Wales assess mental capacity, in order to identify ways to improve practice.Methods: A systematised literature review was completed. Electronic databases of published medical, health and social care research and gray literature were searched. Journal articles and research reports published between 2007 and 2018 were included if they met predefined eligibility criteria. Evidence from included studies was synthesized using thematic analysis.Results: 20 studies of variable methodological quality were included. The studies described assessments carried out by a range of multidisciplinary professionals working with different groups of service users in diverse care contexts. Four main themes were identified: preparation for assessment; capacity assessment processes; supported decision-making; interventions to facilitate or improve practice. There was a lack of detailed information describing how professionals provided information to service users and tested their decision-making abilities. Practice reported in studies varied in terms of its conformity to legal requirements.Conclusions: This review synthesized evidence about mental capacity assessment methods and quality in England and Wales and analyzed it to suggest ways in which practice might be improved.Implications for rehabilitationMental capacity assessment practice in England and Wales varies and is not always consistent with legal requirements, risking inconsistent and inaccurate judgements about capacity and exposure to legal action.Interventions have been developed to help professionals to engage in supported decision-making, and improve their mental capacity assessments and documentation in line with legal standards.These interventions include training and practical resources, such as assessment flowcharts, checklists and documentation aids. Such interventions would benefit from robust evaluation before they are implemented more widely.

Community nurse's knowledge, confidence and experience of the Mental Capacity Act in practice

The Mental Capacity Act (MCA) is statutory legislation introduced in 2007 to protect and empower people to make decisions for themselves and those who were deemed as unable to make choices would have decisions made on their behalf, often by health professionals. All health professionals must follow the guiding principles of this legislation. Yet a scrutiny report by the House of Lords concluded this legislation was under-used with a lack of knowledge among professionals regarding applying the legislation in practice. A review of the literature also supports these findings. A mixed method study was carried out among adult community nurses to explore if these findings were applicable within a health trust in the North West region. An electronic questionnaire (n=60), focus group (n=7) and a paired interview (n=2) were utilised to collect data regarding community nurse's experience and confidence of using the MCA in practice. Analysis identified key themes: training, knowledge and confidence among staff, working together with the wider multidisciplinary team, empowerment and improving documentation. While findings suggest clear examples of self-appraised confidence and excewllent patient care, there is also scope for development regarding the knowledge and utilisation of the MCA in the clinical practice of community nurses.