An international comparison of legal frameworks for supported and substitute decision-making in mental health services

There have been important recent developments in law, research, policy and practice relating to supporting people with decision-making impairments, in particular when a person’s wishes and preferences are unclear or inaccessible. A driver in this respect is the United Nations Convention on the Rights of Persons with Disabilities (CRPD); the implications of the CRPD for policy and professional practices are currently debated. This article reviews and compares four legal frameworks for supported and substitute decision-making for people whose decision-making ability is impaired. In particular, it explores how these frameworks may apply to people with mental health problems. The four jurisdictions are: Ontario, Canada; Victoria, Australia; England and Wales, United Kingdom (UK); and Northern Ireland, UK. Comparisons and contrasts are made in the key areas of: the legal framework for supported and substitute decision-making; the criteria for intervention; the assessment process; the safeguards; and issues in practice. Thus Ontario has developed a relatively comprehensive, progressive and influential legal framework over the past thirty years but there remain concerns about the standardisation of decision-making ability assessments and how the laws work together. In Australia, the Victorian Law Reform Commission (2012) has recommended that the six different types of substitute decision-making under the three laws in that jurisdiction, need to be simplified, and integrated into a spectrum that includes supported decision-making. In England and Wales the Mental Capacity Act 2005 has a complex interface with mental health law. In Northern Ireland it is proposed to introduce a new Mental Capacity (Health, Welfare and Finance) Bill that will provide a unified structure for all substitute decision-making. The discussion will consider the key strengths and limitations of the approaches in each jurisdiction and identify possible ways that further progress can be made in law, policy and practice.

Differences Between Irish and Australian Psychiatric Nurses' Family Focused Practice in Adult Mental Health Services

Psychiatric nurses’ practice with parents who have mental illness, their children and families is an important issue internationally. This study provides a comparison of Irish and Australian psychiatric nurses’ family focused practices in adult mental health services. Three hundred and forty three nurses across Ireland and 155 from Australia completed the Family Focused Mental Health Practice Questionnaire. Cross-country comparisons revealed significant differences, in terms of family focused skill, knowledge, confidence and practice. Australian psychiatric nurses engaged in higher family focused practice compared to Irish nurses. The comparative differences between countries may be attributable to differences in training, workplace support and policy.

Assessment Work of Paramedics on the Front lines of Emergency Health Services

This article draws on an institutional ethnographic inquiry into the work of paramedics and the institutional setting that organizes and coordinates their work processes. Drawing on over 200 hours of observations and over 100 interviews with paramedics (average length of 18 minutes) and other emergency medical personnel, this article explores the standard and not so standard work of paramedics as they assess and care for their patients on the front lines of emergency health services. More specifically, I focus on the multiplicity of interfacing social, demographic, locational, situational, and institutional factors that shape and organize the work of paramedics. In doing so, this article provides insights into how paramedics orient to the social context in which their work occurs and contrasts this actual work with how their work is institutionally reported and made visible; what gets counted institutionally is not necessarily the same as what counts for the paramedics. This article problematizes this demarcation between what is known institutionally and “systematic practices of ‘not knowing’” (DeVault, 2008, p. 290).

Street Medicine – Assessment Work Strategies of Paramedics on the Front lines of Emergency Health Services

This article is based on an institutional ethnographic inquiry into the work of paramedics and the institutional setting that organizes and coordinates their work processes in a major City in Canada. Drawing on over 200 hours of observations and over 100 interviews with paramedics (average length of 18 minutes) and other emergency medical personnel, this article explores the standard and not so standard work of paramedics as they assess and care for their patients on the front lines of emergency health services. The multiplicity of interfacing social, demographic, locational, and situational factors that shape and organize the work of paramedics are analyzed. In doing so, this article provides insights into the complex work of an understudied yet ever-important profession in healthcare.

Mental Health Nurses' Family Focused Practice with Parents who have Mental Illness, their Children and Families in Adult Mental Health Services in Ireland

Introduction: While it is recommended that mental health professionals engage in family focused practice (FFP), there is limited understanding regarding psychiatric nurses’ practice with parents who have mental illness, their children and families in adult mental health services.

Methods: This study utilized a mixed methods approach to measure the extent of psychiatric nurses’ family focused practice and factors that predicted it. It also sought to explore the nature and scope of high scoring psychiatric nurses’ FFP and factors that affected their capacity to engage in FFP. Three hundred and forty three psychiatric nurses in 12 mental health services throughout Ireland completed the Family Focused Mental Health Practice Questionnaire (FFMHPQ). Fourteen nurses who achieved high scores on the FFMHPQ also participated in semi-structured interviews.

Results: Whilst the majority of nurses were not family focused a substantial minority were. High scoring nurses’ practice was complex and multifaceted, comprising various family focused activities, principles and processes. Nurses’ capacity to engage in FFP was determined by their knowledge and skills, working in community settings and own parenting experience.

Conclusions: Generally, low levels of family focused practice suggest the need for organizations to develop and implement guidelines, policies and training to support mental health professionals to adopt a whole family approach.

Patterns and predictors of help-seeking contacts with health services and general practitioner detection of suicidality prior to suicide: a cohort analysis of suicides occurring over a two-year period

Background: Contact with primary care and psychiatric services prior to suicide may be considerable, presenting
opportunities for intervention. However, there is scant knowledge on the frequency, nature and determinants of
contact.
Method: Retrospective cohort study-an analysis of deaths recorded as suicide by the Northern Ireland Coroner’s
Office linked with data from General Practice patient records over a 2 year period
Results: Eighty-seven per cent of suicides were in contact with General Practice services in the 12 months before
suicide. The frequency of contact with services was considerable, particularly among patients with a common
mental disorder or substance misuse problems. A diagnosis of psychiatric problems was absent in 40 % of suicides.
Excluding suicide attempts, the main predictors of a noted general practitioner concern for patient suicidality are
male gender, frequency of consultations, diagnosis of mental illness and substance misuse.
Conclusions: Despite widespread and frequent contact, a substantial proportion of suicidal people were
undiagnosed and untreated for mental health problems. General Practitioner alertness to suicidality may be too
narrowly focused.

A systematic review of evidence-based assessment practices by allied health practitioners for children with cerebral palsy

AIM: The routine use of psychometrically robust assessment tools is integral to best practice. This systematic review aims to determine the extent to which evidence-based assessment tools were used by allied health practitioners for children with cerebral palsy (CP).

METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols 2015 was employed. A search strategy applied the free text terms: 'allied health practitioner', 'assessment', and 'cerebral palsy', and related subject headings to seven databases. Included articles reported assessment practices of occupational therapists, physiotherapists, or speech pathologists working with children with CP aged 0 to 18 years, published from the year 2000.

RESULTS: Fourteen articles met the inclusion criteria. Eighty-eight assessment tools were reported, of which 23 were in high use. Of these, three tools focused on gross motor function and had acceptable validity for use with children with CP: Gross Motor Function Measure, Gross Motor Function Classification System, and goniometry. Validated tools to assess other activity components, participation, quality of life, and pain were used infrequently or not at all.

INTERPRETATION: Allied health practitioners used only a few of the available evidence-based assessment tools. Assessment findings in many areas considered important by children and families were rarely documented using validated assessment tools.

A critical analysis of Child and Adolescent Mental Health Services policy in England, 2000‐2015

Policy in Child and Adolescent Mental Health (CAMH) in England has undergone radical changes in the last 15 years, with far reaching implications for funding models, access to services and service delivery. Using corpus analysis and critical discourse analysis, we explore how childhood, mental health, and CAMHS are constituted in 15 policy documents, 9 pre‐2010, and 6 post 2010. We trace how these constructions have changed over time, and consider the practice implications of these changes. We identify how children’s distress is individualised, through medicalising discourses and shifting understandings of the relationship between socioeconomic context and mental health. This is evidenced in a shift from seeing children’s mental health challenges as produced by social and economic inequities, to a view that children’s mental health must be addressed early to prevent future socio‐economic burden. We consider the implications CAMHS policies for the relationship between children, families, mental health services and the state. The paper concludes by exploring how concepts of ‘parity of esteem’ and ‘stigma reduction’ may inadvertently exacerbate the individualisation of children’s mental health.

Are mental health services getting better at responding to abuse, assault and neglect?

Objective To determine whether staff responses to abuse disclosures had improved since the introduction of a trauma policy and training programme. Method The files of 250 clients attending four New Zealand mental health centres were audited. Results There was a significant improvement, compared to an audit prior to the introduction of the policy and training, in the proportion of abuse cases included in formulations, and, to a lesser extent, in treatment plans. There was no significant improvement in the proportion referred for relevant treatment, which remained at less than 25% across abuse categories. The proportion of neglect disclosures responded to was significantly lower than for abuse cases. Fifty percent of the files in which abuse/neglect was recorded noted whether the client had been asked about previous disclosure, and 22% noted whether the client thought there was any connection between the abuse/neglect and their current problems. Less than 1% of cases were reported to legal authorities. People diagnosed with a psychotic disorder were significantly less likely to be responded to appropriately. Conclusion Future training may need to focus on responding well to neglect and people diagnosed with psychosis, on making treatment referrals, and on initiating discussions about reporting to authorities.

Validating A knowledge transfer framework in health services

The study of knowledge transfer (KT) has been proceeding in parallel but independently in health services and in business, presenting an opportunity for synergy and sharing. This paper uses a survey of 32 empirical KT studies with their 96 uniquely named determinants of KT success to identify ten unique determinants for horizontal knowledge transfer success. These determinants, the outcome measure of Knowledge Use, and separate explicit and tacit transfer flows constitute the KT Framework, extending the work of previous KT framework authors. Our Framework was validated through a case study of the transfer of clinical practice guideline knowledge between the cardiac teams of selected Ontario hospitals, using a survey of senders and receivers developed from the KT literature. The study findings were: 8 of 10 determinants were supported by the Successful Transfer Hospitals; and 4 of 10 determinants were found to a higher degree in the Successful than non-Successful transfer hospitals. Taken together, the results show substantive support for the KT Framework determinants, indicating aggregate support of 9 of these determinants, but not the 10th - Knowledge Complexity. The transfer of tacit knowledge was found to be related to the transfer of the explicit knowledge and expressed as the transfer or recreation of resource profile and internal process tacit knowledge, where this tacit transfer did not require interactions between Sender and Receiver. This study provides managers with the building blocks to assess and improve the success rates of their knowledge transfers.