Meaningful participation or tokenism for individuals on community based compulsory treatment orders? Views and experiences of the mental health tribunal in Scotland

BackgroundThe Mental Health (Care and Treatment) (Scotland) Act 2003 was considered as world leading when it was enacted due to its rights-based approach. Changes were made to encourage participation and enhance autonomy, including the Mental Health Tribunal for Scotland (the tribunal) replacing the Sheriff Court in making decisions about compulsory treatment.AimsTo explore the views of individuals on community based compulsory treatment orders (CCTOs) and independent advocates to assess whether participation in the tribunal is perceived as meaningful in practice.MethodA qualitative research design was adopted and semi-structured interviews were undertaken with 19 people with experience of being on a CCTO and eight mental health advocates in Scotland. The data were thematically analysed and explored using ethics of care principles.ResultsIndividuals faced barriers to participation, including mental distress, medication, and inaccessible communication, and both the tribunal process and outcome were important in shaping perceptions of fairness. A perceived unsuccessful outcome was found to undermine an ostensibly participatory process, and unequal power dynamics resulted in feelings of powerlessness.ConclusionsThe findings suggest that participation is often experienced as tokenistic in practice and that cultural change is required if people are to be meaningfully involved in tribunal proceedings

Are mental health tribunals operating in accordance with international human rights standards? A systematic review of the international literature

Mental health tribunals are responsible for making decisions about compulsory treatment for individuals considered a risk to themselves and others due to mental disorder. They are generally designed to provide safeguards for individuals subject to compulsory treatment by testing whether national legislative criteria and international human rights standards have been met. Despite this, they have been criticised for being dominated by the medical domain, focusing rigidly on legal criteria and for restricting human rights, including the rights to liberty and access to justice. As a result, questions have arisen over the extent to which mental health tribunals are in? deed operating in line with their legislative intentions and international human rights requirements. The aim of this systematic review was to synthesise international evidence on this and to assess the extent to which this is reflected in such literature. A systematic search of the literature was conducted on the 17 April 2018 for articles published between 2000 and 2018 in MEDLINE, CINAHL, PsychINFO, ASSIA and Web of Science. All study designs were included within this review, provided they reported empirical findings. Thirty?two studies met the inclusion criteria. Eight themes were identified across the literature and these were participation, information and understanding, patient representation, the power of the medical domain, feelings of powerlessness, perceptions of fairness, risk and the impact on relation? ships. The findings call into question whether mental health tribunals necessarily operate in compliance with international human rights standards. This article suggests that mental health tribunals may need to do more to safeguard legislative principles and human rights standards that promote patient autonomy

Supporting care home residents in the last year of life through ‘Needs Rounds’: Development of a pre-implementation programme theory through a rapid collaborative online approach

Background: Realist evaluation aims to address the knowledge to practice gap by explaining how an intervention is expected to work, as well as what is likely to impact upon the success of its implementation, by developing programme theories that link contexts, mechanisms and outcomes. Co-production approaches to the development of programme theories offer substantial benefits in addressing power relations, including and valuing different types of knowledge, and promoting buy-in from stakeholders while navigating the complex social systems in which innovations are embedded. This paper describes the co-production of an initial programme theory of how an evidence based intervention developed in Australia - called ‘Palliative Care Needs Rounds’ – might work in England and Scotland to support care home residents approaching their end of life. Methods: Using realist evaluation and iPARIHS (integrated Promoting Action on Research Implementation in Health Services) we sought to determine how contexts and mechanisms of change might shape implementation outcomes. Pre-intervention online interviews (n = 28) were conducted (February-April 2021), followed by four co-design online workshops with 43 participants (April-June 2021). The online interviews and workshops included a range of stakeholders, including care home staff, specialist palliative care staff, paramedics, general practitioners, and relatives of people living in care homes. Results: This methodology paper reports developments in realist evaluation and co-production methodologies, and how they were used to develop context, mechanisms, outcomes (CMOs) configurations, and chains of inference. The initial (pre-intervention) programme theory is used to illustrate this process. Two developments to iPARIHS are described. First, involving stakeholders in the collaborative co-design workshops created opportunities to commence facilitation. Second, we describe developing iPARIHS’ innovation component, to include novel stakeholder interpretations, perceptions and anticipated use of the intervention as they participated in workshop discussions. Conclusions: This rapid and robust co-production methodology draws on interactive collaborative research practices (interviews, workshop discussions of data, illustrative vignettes and visual methods). These innovative and engaging methods can be packaged for online processes to develop, describe and interrogate the CMOs in order to co-produce a programme theory. These approaches also commence facilitation and innovation, and can be adopted in other implementation science and realist studies

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study

Brendan McCormack - ORCID: 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Background Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this. Objective To co-design and implement a scalable UK model of Needs Rounds. Design A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework. Setting Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each. Participants Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings). Interventions (1) Monthly hour-long discussions of residents’ physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings. Main outcome measures A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement. Data sources Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members. Results The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents’ last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services’ complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality. Limitations COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost–benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care. Conclusions Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff.This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.https://doi.org/10.3310/KRWQ5829pubpu

The paradox of care and control: experiences of community based compulsory treatment orders in Scotland

The use of community based compulsory treatment orders for individuals experiencing mental distress is contentious. This is because they are fraught with tensions between care and control. They restrict liberty by mandating compliance with a range of conditions, including medication administration, attending specified services, and allowing professionals into the home space. Despite this, they were introduced in Scotland as part of a wider modernisation agenda, which has earned Scotland a worldwide reputation for leading the way in progressive mental health legislation. The unique Scottish approach is underpinned by rights and principles, which are designed to strengthen voice and choice and benefit ‘revolving door’ patients through access to treatment, and has been framed as a less restrictive option than hospitalisation. This thesis draws upon qualitative, semi-structured interviews with individuals, their relatives, and mental health advocates to explore whether experiences reflect the rights based intentions of the legislation. It specifically focuses on the named person provision, experiences of care and treatment, control and surveillance, and the mental health tribunal. A relational approach was adopted to examine how CCTOs are negotiated within the context of inter-personal and professional relationships. Furthermore, it uses the ethics of care as a normative model to assess the quality of care being provided, specifically drawing upon Tronto’s (1993, 2013) integrity of care framework to assess this. This thesis contends that the rights based intentions of the legislation are not being realised in practice and that paradoxically, a lack of control, hierarchies of power, and distrust overwhelmingly define experiences of compulsion. It argues that rights based frameworks can only go so far to benefit individuals and that an ethics of care is required to improve practice

Critical ethics of care in social work, transforming the politics and practices of caring

No abstract available

Negotiation of Safety in Inter-cultural Trauma Therapy: A Meta-ethnography of Qualitative Studies

Establishing psychological safety by increasing control and connectedness is often the first step in addressing traumatic distress in trauma therapy. Qualitative research suggests cultural differences between providers and clients may pose unique challenges to this process. The aim of this meta-ethnography was to understand how safety is negotiated within the therapeutic alliance in inter-cultural trauma therapy. Five databases were searched (MEDLINE, CINAHL, EMBASE, PsycINFO, and ASSIA) using a pre-planned search strategy in June 2021; this was further updated in June 2022. Sixteen studies were included in the review. The synthesis highlighted that safety is negotiated in a web of relationships that go beyond just the therapeutic dyad. Personal connection, non-verbal communication, tolerating discomfort, and sharing the role of an educator with the client were some of the strategies used by therapists to bridge cultural differences. These strategies created various cultural and role conflicts, which were managed by addressing stigma, clarifying roles (including interpreters’), and creating a work-life balance. Structural factors such as organisational protocols, lack of institutional support, cultural stigma, and the asylum-seeking process hindered the negotiation of safety. Based on this meta-ethnography, a framework was developed to help mental health professionals negotiate safety in inter-cultural trauma therapy