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 .     

Qualitative exploration of stakeholders’ perspectives of involuntary admission under the Mental Health Act 2001 in Ireland

There is international interest in, and continued concern about, the potential long‐term impact of involuntary admission to psychiatric institutions, and the effect this coercive action has on a person's well‐being and human rights. Involuntary detention in hospital remains a controversial process that involves stakeholders with competing concerns and who often describe negative experiences of the process, which can have long‐lasting effects on the therapeutic relationship with service users. The aim of the present study was to explore the perspectives of key stakeholders involved in the involuntary admission and detention of people under the Mental Health Act 2001 in Ireland. Focus groups were used to collect data. Stakeholders interviewed were service users, relatives, general practitioners, psychiatrists, mental health nurses, solicitors, tribunal members, and police. Data were analysed using a general inductive approach. Three key categories emerged: (i) getting help; (ii) detention under the Act; and (iii) experiences of the tribunal process. This research highlights gaps in information and uncertainty about the involuntary admission process for stakeholders, but particularly for service users who are most affected by inadequate processes and supports. Mental health law has traditionally focussed on narrower areas of detention and treatment, but human rights law requires a greater refocussing on supporting service users to ensure a truly voluntary approach to care. The recent human rights treaty, the UN Convention on the Rights of Persons with Disabilities, is to guarantee a broad range of fundamental rights, such as liberty and integrity, which can be affected by coercive processes of involuntary admission and treatment.     

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.     

Police and mental health clinician partnership in response to mental health crisis: A qualitative study

Police officers as first responders to acute mental health crisis in the community, commonly transport people in mental health crisis to a hospital emergency department. However, emergency departments are not the optimal environments to provide assessment and care to those experiencing mental health crises. In 2012, the Northern Police and Clinician Emergency Response (NPACER) team combining police and mental health clinicians was created to reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services. The aim of this study was to describe the perceptions of major stakeholders on the ability of the team to reduce behavioural escalation and improve the service utilization of people in mental health crisis. Responses of a purposive sample of 17 people (carer or consumer advisors, mental health or emergency department staff, and police or ambulance officers) who had knowledge of, or had interfaced with, the NPACER were thematically analyzed after one‐to‐one semistructured interviews. Themes emerged about the challenge created by a stand‐alone police response, with the collaborative strengths of the NPACER (communication, information sharing, and knowledge/skill development) seen as the solution. Themes on improvements in service utilization were revealed at the point of community contact, in police stations, transition through the emergency department, and admission to acute inpatient units. The NPACER enabled emergency department diversion, direct access to inpatient mental health services, reduced police officer ‘down‐time’, improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition.     

Operationalizing autonomy: solutions for mental health nursing practice

The new Mental Health Act (2001) became a law on 1 November 2006. The new Act, reflective of international legislative norms, outlines an agenda for the mental health services in Ireland which, in part, aims to maximize patient autonomy. This paper seeks to contextualize autonomy within nurse-patient interactions in the mental health care setting. The acceptance of autonomy as an unconditional principle, as outlined within traditional bioethics, is challenged. The paper draws on the social critique of normative ethics and suggests an alternative framework within which to operationalize patient autonomy. The authors conclude that a broader, more contextualized perspective on autonomy would more suitably inform mental health nursing. Narrative ethics and a framework of 'protective responsibility' are offered as an alternative to more traditional approaches. Practice-based initiatives to maximize patient autonomy and facilitate-reasoned ethical decision making are outlined.     

重性精神疾病患者非自愿治疗应急处置机制研究

“非自愿治疗”是精神卫生法实施中的关注焦点。精神障碍的特殊性使精神疾病患者在发病状态下精神能力受损,无法理智/合理地作出决策或控制自身行为,常需要予以人身自由限制,以及采用其他非自愿的医疗措施。针对河南省重性精神疾病管理治疗工作的社区精神卫生服务状况,建立重性精神疾病患者非自愿治疗的应急处置机制,为基层医疗卫生机构建立提前介入预防处置机制提供有益的策略依据。     

Risky business: Lived experience mental health practice,nurses as potential allies

Mental health policy includes a clear expectation that consumers will participate in all aspects of the design and delivery of mental health services. This edict has led to employment roles for people with lived experience of significant mental health challenges and service use. Despite the proliferation of these roles, research into factors impacting their success or otherwise is limited. This paper presents findings from a grounded theory study investigating the experiences of Lived Experience Practitioners in the context of their employment. In‐depth interviews were conducted with 13 Lived Experience Practitioners. Risk was identified as a core category, and included sub‐categories: vulnerability, ‘out and proud’, fear to disclose, and self‐care. Essentially participants described the unique vulnerabilities of their mental health challenges being known, and while there were many positives about disclosing there was also apprehension about personal information being so publically known. Self‐care techniques were important mediators against these identified risks. The success of lived experience roles requires support and nurses can play an important role, given the size of the nursing workforce in mental health, the close relationships nurses enjoy with consumers and the contribution they have made to the development of lived experience roles within academia.     

Lived experience in teaching mental health nursing: Issues of fear and power

Australian mental health policy clearly articulates recovery focus as the underpinning of mental health services. Barriers to achieving a recovery focus are identified in the literature, with negative attitudes of health professionals receiving particular attention. The involvement of people with lived experience of significant mental health challenges and mental health service use is essential to enhancing more positive attitudes. Lived‐experience involvement in the education of nurses is evident; however, it is generally limited and implemented on an ad hoc basis. Overall, there is a paucity of literature on this topic. A qualitative exploratory study was undertaken to elicit the views and perceptions of nurse academics and lived‐experience educators about the inclusion of lived experience in mental health nursing education. One major theme to emerge from the research was issues of fear and power, which included three subthemes: facing fear, demystifying mental illness, and issues of power. Lived‐experience involvement has an important role to play in the education of nurses in addressing fear and demystifying the experience of mental illness. The power that lived‐experience educators exercised in their roles varied considerably, and for many, was limited. Therefore, the effectiveness of lived‐experience involvement requires a more equitable distribution of power.     

综合干预对急诊科护士心理健康状况的影响

目的探讨综合干预对提高急诊科护士心理健康水平的效果。方法采取改善： 工作环境、规范抢救流程、实行责任组长负责制、学习法律法规、成立心理支持小组、运用激励机制等措施进行干预,在实施干预前后运用症状自评量表对38名急诊科护士进行测试。结果急诊科护士的心理健康状况较一般人群差,突出表现为躯体化、人际关系、抑郁、焦虑、恐怖和强迫;经综合干预后,能有效缓解心理压力。结论应重视急诊科护士心理健康状况,并给予相应干预,能有效地缓解急诊科护士的心理压力,提高其心理健康水平。     

How involuntary commitment impacts on the burden of care of the family

Little research has examined how, or if, involuntary commitment has impacted on the burden experienced by the family. This paper reports a qualitative study which explored how involuntary commitment under the Mental Health Act (MHA) 2000 in Queensland, Australia impacted on families of people with mental illness. Family members of a person with a mental illness, under involuntary commitment at the time or in the previous 12 months, participated in focus groups. Thematic analysis was used to determine the themes. It was apparent from the views of the family that the use of the involuntary commitment was influenced greatly by the pressures experienced by the mental health services (MHS). The MHA did little to assist the family in gaining access to MHS. It was not until after the family made repeated attempts that they were taken seriously. Often the family had few options other than to use deceit and threats to obtain the necessary treatment required. In view of this, the inherit nature of what involuntary commitment implies for persons under it, such as refusing treatment and management difficulties, indicates the family with such an individual experience more hardship in trying to obtain assistance for that person. Thus, the MHA in Queensland has not met its goals of increasing access to MHS. Family members perceive that they were not being listened to and their concerns were not acted upon. The current culture of the MHS appears to serve, to a large degree, to estrange the family from the consumer making relationships difficult and time-consuming to repair. The mental health profession is urged to consider the culture within their workplace and move towards constructive involvement of the family.     

A conversation: challenging the relevance and wisdom of separate mental health legislation

This paper explores the dilemmas encountered by mental health nurses when working with mental health legislation. The concerns and considerations of an expert mental health nurse, complemented by the opinion of an expert in health-care and legal issues are presented. It is argued that there is currently a distorted perception with regard to the function and sentiment of mental health legislation, and this paper aims to restore balance in interpreting and working with such law. Viewing mental health legislation primarily as a mechanism for involuntary hospitalization effectively removes any power or recourse given to mental health consumers by the law. Principles of mental health care and legislation are examined as well as the relationship the law has with dangerousness to self or others and mental ill health. A dialogue is established between the two authors to assist the exploration of these legal and clinical issues. The continued relevance of specific mental health legislation is brought into question. It is proposed that the existence of such legislation constitutes discrimination and contributes to stigma associated with mental illness. An alternative legislation for all circumstances where an individual is deemed incompetent is proposed as the most significant step towards mainstreaming of mental health care and an end to discrimination.     

New directions in mental health practice with older people: Canadian strategies for mental health reform

Aim and objective.  The purpose of this article is to draw attention to problems in the Canadian health system that must be overcome if Canada is to ensure that older people can access the services they need.
Background.  Projections suggest that 20% of Canadians will be aged 65+ by 2021. If current prevalence rates for mental illness continue, this will result in a significant increase in the number of older Canadians with or at risk for mental illness and mental health problems.
Design.  Findings of the final report of the Standing Committee on Social Affairs, Science and Technology are summarized and related to the intended role and primary strategy of the proposed Canadian Mental Health Commission.
Methods.  The relevance of the Interprofessional Education for Collaborative Patient-Centred Practice initiative launched by Health Canada is then considered in light of the intention that the Commission adopt collaboration with relevant stakeholders as its primary strategy for achieving mental health reform.
Conclusions.  Fragmentation in service delivery must be overcome if older Canadians are to receive age appropriate mental health services when and where they need them. Yet there is little evidence that the degree of interprofessional collaboration required can be achieved.
Relevance to clinical practice The reforms advocated by the Senate Committee are widely embraced but evidence is needed on how mental health and other professionals can best learn to work together in the interests of older people and other mental health consumers.     

Co‐responding police–mental health programmes: Service user experiences and outcomes in a large urban centre

As police officers are often the first responders to mental health crises, a number of approaches have emerged to support skilled police crisis responses. One such approach is the police–mental health co‐responding team model, whereby mental health nurses and police officers jointly respond to mental health crises in the community. In the present mixed‐method study, we evaluated outcomes of co‐responding team interactions at a large Canadian urban centre by analysing administrative data for 2743 such interactions, and where comparison data were available, compared them to 16 226 police‐only team responses. To understand service user experiences, we recruited 15 service users for in‐depth qualitative interviews, and completed inductive thematic analysis. Co‐responding team interactions had low rates of injury and arrest, and compared to police‐only teams, co‐responding teams had higher overall rates of escorts to hospital, but lower rates of involuntary escorts. Co‐responding teams also spent less time on hospital handovers than police‐only teams. Service users valued responders with mental health knowledge and verbal de‐escalation skills, as well as a compassionate, empowering, and non‐criminalizing approach. Current findings suggest that co‐responding teams could be a useful component of existing crisis‐response systems.     

Review article: Interventions for people presenting to emergency departments with a mental health problem: A systematic scoping review

The number of people presenting to EDs with mental health problems is increasing. To enhance and promote the delivery of safe and efficient healthcare to this group, there is a need to identify evidence‐based, best‐practice models of care. This scoping review aims to identify and evaluate current research on interventions commenced or delivered in the ED for people presenting with a mental health problem. A systematic search of eight databases using search terms including emergency department, mental health, psyc* and interventions, with additional reference chaining, was undertaken. For included studies, level of evidence was assessed using the NHMRC research guidelines and existing knowledge was synthesised to map key concepts and identify current research gaps. A total of 277 papers met the inclusion criteria. These were grouped thematically into seven domains based on primary intervention type: pharmacological (n = 43), psychological/behavioural (n = 25), triage/assessment/screening (n = 28), educational/informational (n = 12), case management (n = 28), referral/follow up (n = 36) and mixed interventions (n = 105). There was large heterogeneity observed as to the level of evidence within each intervention group. The interventions varied widely from pharmacological to behavioural. Interventions were focused on either staff, patient or institutional process domains. Few interventions focused on multiple domains (n = 64) and/or included the patient's family (n = 1). The effectiveness of interventions varied. There is considerable, yet disconnected, evidence around ED interventions to support people with mental health problems. A lack of integrated, multifaceted, person‐centred interventions is an important barrier to providing effective care for this vulnerable population who present to the ED.     

Police and mental health responses to mental health crisis in the Waikato region of New Zealand

New Zealand police report a high level of involvement with people in mental health crisis, something that has been reported in the international literature in recent decades. Involvement of police represents a coercive pathway to care and is likely to be associated with use of force. The aim of this study was to investigate the clinical, legal, and social characteristics of individuals subject to police response in the Waikato region of New Zealand. Data were also collected on characteristics of police response, including use of force, time of day, and disposition. Use of force, most commonly use of handcuffs, occurred in 78% of cases involving police. The study showed that Māori were overrepresented in police responses, but no more likely than Europeans to experience use of force. Almost half those subject to police response were not subsequently admitted to hospital, raising questions about the need for and nature of police response in these cases. Because mental health nurses are often part of police response, nurses need to take cognisance of their relationship with police and contribute to any initiatives that can reduce coercion in the pathway to care, and improve service users' experience in mental health crises.     

The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

BACKGROUND: There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.     

心理干预对康复期精神分裂症患者心理健康状况的影响

目的探讨心理干预对康复期精神分裂症患者心理健康状况的影响。方法对52例康复期精神分裂症患者在常规药物治疗和护理的基础上进行心理干预,观察6w。心理干预前及干预6w末采用症状自评量表评定患者的心理健康状况,并与国内成人常模进行对比分析。结果康复期精神分裂症患者心理干预前症状自评量表各因子分均显著高于国内成人常模（P〈0．01）;心理干预6w末除偏执因子分无显著变化外,其他各因子分均较心理干预前有显著性下降（P〈0.01～0．05）,与国内成人常模比较,除恐怖因子分有显著性差异（P〈0．05）外,其他各因子分均无显著性差异（P〉0．05）。结论心理干预能显著改善精神分裂症患者的心理健康状况,提高其人际交往能力和生活质量。