Knowledge of Mental Capacity Issues in Community Teams for Adults with Learning Disabilities

Background The aim of this study was to evaluate the state of knowledge of mental capacity issues among health and social services professionals working in community teams supporting people with learning disabilities. Methods A structured interview was constructed around three scenarios, based on actual cases, concerning a financial/legal issue, a health issue and a relationships issue, as well as a set of ten ‘true/false’ statements. The interview aimed to elicit respondents’ understanding in relation, primarily, to assessment of capacity and best‐interests decision making. Forty interviews were conducted (two social workers and two health professionals from each of ten community teams). Most participants had attended training on the Mental Capacity Act (2005) . Results Performance of social services and health staff was similar throughout. Fourteen areas of concern were identified where there appeared to be significant gaps in knowledge. Conclusions Participants, particularly those who had experience of dealing with mental capacity issues, had good insight into the extent of their knowledge, and most participants said that the interview had made them aware of further training needs.     

The Mental Capacity Act 2005 and decision-making: advocacy

This article continues the series into the content and implications of the Mental Capacity Act 2005, which looks at the requirement to provide an independent mental capacity advocacy service in specified situations. The Act requires NHS organizations and local authorities to arrange for the appointment of an independent mental capacity advocate in the following situations: where serious medical treatment is being considered for a person who is incapable of making his or her own decisions, and where accommodation is being arranged by an NHS organization, or by a local authority, for a person who lacks the requisite mental capacity to give consent. Additional situations have been added by regulations and these include where there is a review of the accommodation arrangements (Reg. 3) or where an NHS body or local authority propose to take protective measures in relation to a person who lacks the requisite mental capacity (Reg. 4). The statutory duty does not apply if there is a person whom it would be appropriate to consult on a person's best interests, except in the case of protective measures being taken. The article considers the powers and the duties of the independent mental capacity advocate and applies the legal provisions to a practical situation.     

Mental capacity Act 2005: assessing decision-making capacity

In last month's article on the Mental Capacity Act 2005 Richard Griffith and Cassam Tengnah outlined the statutory principles and key powers that underpin the Act. This month's article considers one of the fundamental requirements of the Mental Capacity Act 2005, how and when should district nurses assess decision making capacity.     

Attitudes of Social Service Providers towards the Sexuality of Individuals with Intellectual Disability

Background The sexual lives of people with intellectual disability is made complex by the involvement and influence of social service providers, whose beliefs and values have a great impact on the support they provide. We hypothesized that social service providers’ role, educational level and service in which they worked could affect attitudes towards the sexual behaviour of individuals with intellectual disability. Materials and methods The current study describes attitudes of social service providers towards the sexuality of individuals with disability measured by 20 items of Sexuality and Mental Retardation Attitudes Inventory (SMRAI). This instrument was devised by Brantlinger [Mental Retardation (1983) Vol. 21, pp. 17–22] to assess the attitudes of the staff employed by organizations that supplied services to individuals with intellectual disability. Specifically, analysis of variance (type of service × professional role × education) was performed on participants’ scores. Results Results suggested that the social service providers participating in this research study tended to have moderately liberal attitudes. Educational level and role carried out did not produce differences in their attitudes. A significant difference emerged between those who operated in different services. It was especially the staff of the outpatient treatment services who revealed the most liberal and positive attitudes towards the sexuality of individuals with intellectual disability. Conclusions The data reported in the present study seem to underline some differences between the data collected from the Italian and the Anglo‐Saxon social service providers. Failure to record influences associated with the role carried out and previous training could be related to the different contextual differences. Results suggest that particular attention should be paid to the training of those who hold managerial posts in Italian residential services.     

Safeguarding people's rights under the Mental Capacity Act

People who lack capacity to make certain decisions have a statutory right to be represented by an independent mental capacity advocate (IMCA). However, there is concern among the organisations that provide IMCA services about the lower than expected number of referrals (instructions) by trusts in the NHS. The authors discuss possible reasons for the low instruction rate and how this could be improved. A case study of a woman with mental health problems is used to demonstrate how the role of the IMCA works in practice.     

Care adjustments for people with learning disabilities in hospitals

Health inequalities start early in life for people with learning disabilities. In the UK, they can arise from various barriers that people experience when trying to access care that should be appropriate, timely and effective. Inequalities in health care are likely to result in many NHS organisations breaching their legal responsibilities, as outlined in the Disability Discrimination Acts 1995 and 2005, the Equality Act 2010 and the Mental Capacity Act 2005 (Emerson and Baines 2010). This article seeks to help nurses, healthcare professionals and hospital managers ensure that better services are delivered by encouraging them to explore how reasonable adjustments can improve outcomes for people with learning disabilities.     

Consumer‐Directed Goal Planning in the Delivery of Assistive Technology Services for People who are Ageing with Intellectual Disabilities

Background A consumer‐directed service‐delivery approach to assistive technology and environmental modification intervention was examined with people who were ageing with intellectual disabilities. Material and Methods The intervention was based on a collaborative approach involving consumers, their social supports and service deliverers. Thirty individuals were randomly selected to receive the intervention from a sample of 75 community‐dwelling adults. Outcomes related to consumers’ and significant others’ perceptions of performance and satisfaction with goal attainment were assessed and the consumer‐directed goal planning process examined. Results Participants in the intervention group reported significantly higher levels of performance and satisfaction related to goals identified at baseline than participants in the control group. Two broad categories of goals were addressed during the intervention – basic self‐care goals and participation/environmental/systems level goals. A 98% direct agreement rate between consumer‐identified goals and goals addressed by service deliverers was found during the intervention. Of the environmental strategies employed during the intervention, assistive devices and systems level advocacy and action were the two most frequently used across goals. Conclusion Results provide evidence in favour of a consumer‐directed approach to assistive technology and environmental modification service delivery for consumers who are ageing with intellectual disabilities.     

Conflict of roles: A conflict of ideas? The unsettled relations between care team staff and independent mental health advocates

Drawing on a national study of independent mental health advocacy, we explored the social relations of independent advocacy. The study was commissioned by the Department of Health (England), and involved a case study design covering eight different geographies and service configurations, and interviews or focus groups with a total of 289 stakeholders across two phases of inquiry. This paper focused on the analysis of qualitative data relevant to the relationship between mental health‐care services and independent advocacy services, drawn from interviews with 214 participants in phase two of the study. Discussion of these particular findings affords insights into the working relations of independent advocacy within mental health services beset by reorganizational change and funding cuts, and increasing levels of legally‐sanctioned compulsion and coercion. We offer a matrix, which accounts for the different types of working relationships that can arise, and how these are associated with various levels of understanding of independent advocacy and appreciation for the value of advocacy. The discussion is framed by the wider literature on advocacy and the claims by practitioners, such as nurses, for an advocacy role as part of their professional repertoire.     

Mental Capacity Act 2005: statutory principles and key concepts

The Mental Capacity Act 2005 represents the most significant development in the law relating to people who lack decision making capacity since the Mental Health Act 1959 removed the states parens patriae jurisdiction preventing relatives, courts and government bodies consenting on behalf of incapable adults (F vs West Berkshire HA [1990]). The Mental Capacity Act 2005 impacts on the care and treatment provided by district nurses and it is essential that you have a sound working knowledge of its provisions and code of practice. In the first article of a series focusing on how the Mental Capacity Act 2005 applies to district nurse practice, Richard Griffith and Cassam Tengnah consider the principles and key concepts underpinning the Act.     

The Mental Capacity Act 2005 and decision-making: advance decisions

One of the crucial features of the Mental Capacity Act (MCA) 2005 was recognizing in a statute the ability of a person to refuse treatment at a subsequent time when he or she lacked the mental capacity to decide on treatment. This refusal, known as an advance decision or living will or advance refusal had been recognized at common law, i.e. judge-made law. This article, continuing the series on the MCA explains the statutory provisions, the specific requirements which must be satisfied if life-sustaining treatment is refused in advance and looks at a practical situation to illustrate the statutory provisions. The link between advance decisions are lasting powers of attorney is also discussed.     

The views and experiences of learning disability nurses concerning their advocacy education

A mixed methods project [Llewellyn, P., 2005. An investigation into the advocacy role of the learning disability nurse. University of Glamorgan, unpublished PhD Thesis] investigated the advocacy role of learning disability nurses. This paper discusses the section concerned with nurses' advocacy education. Focus groups, interviews and a questionnaire survey enabled nurses from a wide range of grades, seniority and experience to explore their received education in advocacy and their educational requirements concerning their advocacy role. Findings revealed that nurses' received education in advocacy varied according to the syllabus under which they qualified, with those whose education was influenced by the 1979 Jay Report having the highest incidence of advocacy training. Many learning disability nurses who had received theoretical education did not feel confident to advocate for their clients. Many were also unsure of their ability to access independent advocacy services and when it was permissible to do this. Nurse informants expressed a need for ongoing support and training in advocacy relating to The Human Rights Act (1998) and The Disability Discrimination Act (1995); and also specifically in relation to advocacy for clients within their own work area. Most nurses had definite ideas regarding how and by whom their advocacy education and training should be provided.     

The Mental Capacity Act 1: advance decisions

This is the first of a two-part unit on the Mental Capacity Act 2005. Part 1 outlines the act's key principles and implications. Healthcare professionals' responsibilities are examined in relation to advance decisions.     

Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature

Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self‐care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person‐centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.     

Decision-making support for inpatients with learning disabilities

Many people with learning disabilities are able to make their own healthcare decisions, but some lack the mental capacity to do so. This article discusses how the Mental Capacity Act can be used to guide decision-making for people with learning disabilities in hospital, and ensure all decisions are made in the patient's best interests.     

Including adults with intellectual disabilities who lack capacity to consent in research

The Mental Capacity Act 2005 has stipulated that in England and Wales the ethical implications of carrying out research with people who are unable to consent must be considered alongside the ethical implications of excluding them from research altogether. This paper describes the methods that were used to enable people with severe and profound intellectual disabilities, who lacked capacity, to participate in a study that examined their experience of receiving intimate care. The safeguards that were put in place to protect the rights and well-being of participants are described, and it is argued that the approaches used in this study met the requirements set out in the Mental Capacity Act 2005. Although this paper is based on research involving people with intellectual disabilities, it has implications for research involving other groups who may also lack capacity to consent, including people with mental health problems, head injuries and dementia.     

Assertive community treatment (ACT) case managers’ professional identities: A focus group study

Assertive community treatment (ACT) case managers provide healthcare services to people with severe and persistent mental illness. These case managers take on generic roles in multidisciplinary teams and provide all‐around services in the clients’ private homes. This focus group study aimed to gain insight into Danish ACT case managers’ professional identity work by examining their discussions of ethical dilemmas and collaboration in their everyday practice. Data were collected during five focus groups at three ACT teams in the North Denmark Region and subjected to discourse analysis emphasizing how identity work was accomplished through talk. The findings indicated that the case managers constructed professional identities by actively positioning themselves and the particular ACT approach in relation to other mental healthcare professionals and clients. They represented themselves as achieving better client‐related outcomes by being more assertive and persistent, and as responsible caregivers who provided the help that their clients needed when other services had failed to do so. They depicted their services as being focused on the clients’ well‐being, and their persistent efforts to establish and sustain interpersonal relationships with clients were an important part of their service. Basic nursing tasks were described as an important part of their everyday work, and even though such tasks were not distinctive for ACT case managers, the representations of their work seemed to give them a sense of worth as professionals and legitimized a unique role in the community mental healthcare services.     

Predictors and enablers of mental health nurses’ family‐focused practice

Family‐focused practice improves outcomes for families where parents have a mental illness. However, there is limited understanding regarding the factors that predict and enable these practices. This study aimed to identify factors that predict and enable mental health nurses’ family‐focused practice. A sequential mixed methods design was used. A total of 343 mental health nurses, practicing in 12 mental health services (in acute inpatient and community settings), throughout Ireland completed the Family Focused Mental Health Practice Questionnaire, measuring family‐focused behaviours and other factors that impact family‐focused activities. Hierarchical multiple regression identified 14 predictors of family‐focused practice. The most important predictors noted were nurses’ skill and knowledge, own parenting experience, and work setting (i.e. community). Fourteen nurses, who achieved high scores on the questionnaire, subsequently participated in semistructured interviews to elaborate on enablers of family‐focused practice. Participants described drawing on their parenting experiences to normalize parenting challenges, encouraging service users to disclose parenting concerns, and promoting trust. The opportunity to visit a service user's home allowed them to observe how the parent was coping and forge a close relationship with them. Nurses’ personal characteristics and work setting are key factors in determining family‐focused practice. This study extends current research by clearly highlighting predictors of family‐focused practice and reporting how various enablers promoted family‐focused practice. The capacity of nurses to support families has training, organizational and policy implications within adult mental health services in Ireland and elsewhere.     

Proposed changes to the Mental Health Act of England and Wales: research indicating future educational and training needs for mental health nurses

Proposed changes to the Mental Health Act (MHA) legislation in England and Wales have been identified as having significant impact upon both mental health service delivery and professional roles. Key issues being identified for both service delivery and professionals are the creation of approved mental health professionals (AMHP), increased demand upon community services and a potential negative impact upon the therapeutic relationship. Mental health nurses in particular have expressed their concerns, through their professional bodies, regarding the impact of the proposed MHA changes upon the therapeutic relationship. The aim of this article is to present findings from recently conducted research that explores experiences and perceptions of approved social workers (ASWs) regarding the impact of invoking the MHA upon the therapeutic relationship. These findings inform wider mental health nursing practice of essential skills and knowledge to protect and potentially enhance the therapeutic relationship while invoking MHA legislation. A questionnaire was distributed to ASWs working within the Trent region. The questionnaire included both closed and open questions inviting respondents to expand upon their experiences with the brief initial findings being earlier published. Semi-structured interviews with eight invited respondents to develop their responses were undertaken enabling an approach that was both conversational and emergent.     

Nurse‐led models of chemotherapy care: mixed economy or nurse–doctor substitution?

Aim. This paper reports a study exploring the perspectives of people affected by cancer (service users) and health care professionals’ about current medical consultant‐led services and the acceptability of a proposed nurse‐led ambulatory chemotherapy service. Background. A number of studies have evaluated a nurse‐led model of cancer care delivery but little work has been undertaken in chemotherapy settings. Furthermore, many of these studies give little information on how the perspective of users was incorporated in the design and evaluation of these services. Methods. Service users (n = 26) and health care professionals (n = 22) were recruited across the South East of England. A qualitative study was undertaken… Using a semi‐structured interview schedule, participants were asked to give their perceptions of current chemotherapy services and the potential of a nurse‐led service. A thematic analysis of data was undertaken. Findings. This paper focuses on the theme of the current and future context of a chemotherapy service. Three sub‐themes were identified: contextualizing roles, defining therapeutic outcomes, and demonstrating effectiveness. All interviewees saw this role as different but complementary to the role of medical staff. There were mixed opinions from service users and professionals on the acceptability of nurse‐led chemotherapy provision. In defining potential outcomes of nurse‐led care, service users described benefits in terms of service and economic outcomes. Professionals saw additional benefits in terms of patient‐based outcomes. Professionals and service users expressed the need for appropriate education of nurses for this role and rigorous evaluation of any new service before widespread implementation. Conclusions. Understanding the perspective of users is imperative when re‐designing cancer nursing services. Implementation of nurse‐led models in chemotherapy services should be preceded by staff education and followed by systematic evaluation.     

AN INVESTIGATION INTO THE PRACTICE AND BENEFITS OF STATUTORY AFTERCARE IN AN INNER CITY PSYCHIATRIC SERVICE

The implementation of statutory aftercare for psychiatric inpatients, as outlined in Section 117 of the Mental Health Act 1983 (England and Wales), was studied by examining current practice in an inner city psychiatric service. Seventy-seven per cent of patients received Section 117 aftercare; 56% of patients did not have an identified key worker. A significant proportion of those receiving statutory aftercare did not have evidence of adequate forward planning. General practitioners did not attend any meetings. Patients who had Section 117 aftercare were compared with those who did not. Using the Cox regression model, it was found there was no significant difference between these two groups in terms of time between discharge and first readmission, readmission rate, and length of first readmission.