Bloom's taxonomy-Can evidence-based teaching improve junior medical officers' knowledge of the mental health and guardianship acts?

OBJECTIVE: To determine whether a brief educational intervention for Junior Medical Officers (JMOs), using teaching methods aimed at achieving higher outcomes on Bloom's Taxonomy, significantly improved participant confidence and knowledge in decision making about restrictive care. METHOD: JMOs received a teaching session on restrictive medical and mental health care. Groups were randomly assigned to either sessions including a component of modern pedagogical interventions (Think-Pair-Share and SNAPPS), or sessions including a control period focusing on reviewing a condensed summary of relevant information. Pre- and post-intervention measures were recorded for subjective self-ratings of confidence and scores on standardized clinically relevant extended matching questions (EMQs). RESULTS: There was no difference in subjective confidence improvement between groups; however, the group receiving the modern pedagogical intervention demonstrated significantly greater objective performance on knowledge-based EMQs. CONCLUSIONS: A brief modern pedagogical intervention using interactive teaching methods shows promise for improving knowledge of restrictive care and the Mental Health and Guardianship Acts. In the control group, similarly increased confidence in knowledge did not equate to increased competence on a knowledge assessment. Refurbishing educational interventions presents opportunities for improving clinical outcomes and engaging junior doctors in psychiatry.

Working alongside next of kin to enhance discharge: A quality improvement collaboration to co-design discharge for mental health patients.

OBJECTIVES: Mental health (MH) patients seen in the emergency department (ED) setting are often viewed in isolation, outside of the context of their loved ones, the next of kin (NOK). This is especially problematic when a patient is detained under the mental health act. This project aimed to improve this engagement. METHODS: A sense of urgency was created from a guiding coalition of the local MH and ED executive of a rural hospital. The vision was communicated to the team for action. This was then institutionally incorporated as best practice during a 3 month trial. RESULTS: NOK were engaged more frequently as a result of this quality improvement strategy, rising to 90.8% (2021) from 63.2% (2020) compared to the previous year χ2 (1, N=166) =18.75, p = .000015. Admissions for all MH patients from the emergency department fell to 28.3% (2021) from 39% (2020) χ2 (1, N=652) =8.32, p = .0039. CONCLUSIONS: Working with NOK is a best practice strategy that was embraced by clinicians when highlighted. This resulted in less restrictive practice and more community treatment. Creating a frame for the patient that is standardised, provides containment and co-designs future health care is beneficial.

Use of a quality improvement strategy to increase drug and alcohol consultation and care opportunities for mental health inpatients in rural and remote New South Wales.

PROBLEM: Mental health inpatients have high rates of co-morbid substance use disorders which may exceed 50% in addition to the presenting complaint(s). Treating teams may prioritise, and substance use disorders are often not addressed. SETTING: Dubbo inpatient mental health units. KEY MEASURES FOR IMPROVEMENT: Rates of drug and alcohol consult of inpatients. DESIGN: Retrospective audit of all inpatient records for mental health units at Dubbo Hospital (May-October period 2018 and 2019) following the intervention. Qualitative reflections of clinical staff were also included. STRATEGIES FOR CHANGE: From early 2019, the problem was communicated with staff via education and open discussion. Modelling of the expected numbers of referral was understood as manageable within existing resources. The agenda of the morning meeting then always included an item that asked all team members to identify and refer a person if they needed drug and alcohol care. EFFECT OF CHANGE: Consultation by the drug and alcohol clinical nurse consultant increased from 48 of 228 (21%) patients in the 2018 period to 83 of 232 (35.8%) patients in the 2019 period. LESSONS LEARNT: The community and inpatient multidisciplinary team can correctly inform and increase drug and alcohol referral for mental health inpatients.

Use of a quality improvement strategy to introduce co-design of the mental health discharge plan in rural and remote New South Wales.

PROBLEM: Patients have not traditionally partnered in the design of their discharge plans, with discharge summaries at times not completed. In rural settings, discharge planning communicates care to a complex geographic area with fragmented resources. Patients may also be socially disadvantaged, with relatives and friends sometimes excluded. DESIGN: Situational analysis and liaison with key partners occurred in the months prior to the core project. Opportunities for improvement were noted. An audit of all discharges in May 2020 was planned to assess rates of discharge completion, co-design and inclusion of next of kin. Qualitative feedback was also noted from staff. SETTING: Dubbo inpatient mental health units (Gundaymarra and Barraminya). KEY MEASURES FOR IMPROVEMENT: Rates of discharge summary completion, co-design of discharge plan, engagement of next of kin. Qualitative measures included reflections of clinical staff involved. STRATEGY FOR CHANGE: Junior doctors were key in facilitating each patient to co-design their discharge plan and collaborate with all biological and psychosocial treatments and providers in a forum for open discussion. The inclusion of nominated next of kin was core. EFFECTS OF CHANGE: Discharge summary completion rates were high; co-design of discharge plans occurred frequently; and next of kin were involved with few exceptions. The adoption of the person as expert in modifying their plan became a norm. Medical staff wanted this care frame for each person. LESSONS LEARNT: Engaging patients and their next of kin directly in their discharge planning improves care opportunities in a rural setting, as well as understanding for all parties. This approach also prioritises the process of discharge completion.

Should we be Royal?

OBJECTIVE: Our college name The Royal Australian and New Zealand College of Psychiatrists (RANZCP) and Crest (Coat of Arms) are echoes of our colonial past, which create a barrier to an inclusive 21st-century Australasian psychiatry. Two hundred and fifty years after European settlement, this article reviews the colonial legacy, the evolution of the college and the process by which the prefix 'Royal' came to be attached. This is now an anachronism that symbolically undermines our mission to create a fully inclusive psychiatry for all Australians and New Zealanders, from indigenous people across the spectrum of cultures drawn from recent migrations within our complex multicultural society. CONCLUSION: As psychiatrists, it is time to modernise and reinvent the college name and Crest. We will be a healthier and more inclusive community of practice without the 'Royal' prefix, and with a new symbol for our college that embodies our values and vision.

Development of a joint mental-health and drug health assessment unit and short-stay unit.

OBJECTIVES: There is emerging interest in models of care that focus on assessment and brief inpatient treatment (two to three days) including psychiatric emergency care centre units and short-stay units in Australia. We present the development of a functionally integrated Missenden Assessment Unit and six-bed short-stay unit in the new Professor Marie Bashir Centre at Royal Prince Alfred Hospital in inner-city Sydney. The focus was on collaboration between emergency, drug and alcohol and mental-health services in developing the short-stay unit and Missenden Assessment Unit with joint admission and resource use. We outline the models of care and findings from the 2016 evaluation following the initial two years of operation and consider ongoing challenges. CONCLUSION: The Missenden Assessment Unit provides an alternative point of presentation for mental-health drug and alcohol patients. The short-stay unit provides coordinated, therapeutic interventions. The Missenden Assessment Unit/short-stay unit reduced the burden of presentations to the emergency department while providing the opportunity for training and collaboration. Further refinement of the models of care should occur with policy development and via research.

Outcomes of mentoring programs in psychiatry training: a literature review.

OBJECTIVES: This literature review aimed to outline the evidence regarding the outcomes of formal mentoring programs for training psychiatrists. METHODS: An electronic search of Ovid MEDLINE, EMBASE, Ovid PsycINFO and The Cochrane Library was conducted. RESULTS: A total of 17 articles fulfilled inclusion criteria. Positive outcomes of mentorship include promotion of research, perpetuation of further mentorship, increased perceived support and enhancement of teaching skills. One article reported a negative outcome. CONCLUSIONS: Current evidence regarding mentorship in psychiatry is limited and there is a lack of clarity regarding the relationship between positive outcomes and mentorship. Components of the included programs may act as confounders. Mentorship, protected teaching time, and didactic teaching may be important to encourage research. Other potential benefits of mentorship include enhanced career guidance, perceived support, and enriched teaching skills.

Transgender ward allocation in single-sex mental health wards: contemporary considerations.

OBJECTIVES:: Allocation of transgender patients to single-sex mental health wards in Australasia can be a complex and challenging decision in the absence of adequate awareness, education and policy that prioritize consumer safety and preference. It is a point of care that can go wrong for a transgender person. We examine relevant literature, law and existing principles of care and offer an approach. CONCLUSION:: Transgender individuals experience an excess health burden and have difficulties that are poorly understood by many health practitioners. This is partly the result of both informational and institutional biases. Relevant legal frameworks, while supportive, are still to be translated into policy. We suggest a framework that canvasses the needs of various stakeholders and considers them equally in the decision-making process.

The possible role of the psychiatrist: The lesbian, gay, bisexual, and transgender population in India.

Sweeping social change is occurring in India with regard to the proposed transgender legislation and the enshrinement of associated rights. This progressive legislative change occurs as existing Indian law is profoundly reshaped by the judiciary with regard to other members of this sexually diverse group, the lesbian, gay, bisexual, and transgender (LGBT) group. Now as a group of immense interest within high-income countries, this article through Government, legal, and medical literature, explores the possible population of interest in India, relevant law and associated health disparities. The author considers the evidence of a mental health burden, among the estimated 45.4 million LGBT people in 2011. The complex contribution of psychiatrists is noted, and a prism for care delivery is suggested. The underlying goal of lower morbidity for the entire LGBT community is through enhanced care opportunities, understanding, and reduced societal discrimination.

Psychiatric advance directives in Australian mental-health legislation.

OBJECTIVE: Following the recent widespread reform of mental-health legislation in Australia, psychiatric advance directives (PADs) have now been incorporated in four jurisdictions. We contextualise the potential role for PADs within the Australian legal framework and note their varying introduction across jurisdictions, with a focus on progressive legislation in the Australian Capital Territory (ACT). CONCLUSION: The formal recognition of PADs effectively shifts the trajectory of mental-health law towards a stronger recognition of consumer autonomy, albeit to varying degrees across jurisdictions. The most inspiring of these changes may be seen in the ACT Act, where an innovative framing of PAD provisions creates a safe space for clinicians and patients to engage, build therapeutic alliances and develop appropriate frameworks for further change.

Primary evidence of seton therapy at Tarban Creek, New South Wales, 1839.

OBJECTIVE: We aimed to find and explore the earliest available New South Wales asylum medical records to identify any management or therapeutic data that might be of interest to the psychiatric field. CONCLUSIONS: The earliest known existing records of New South Wales asylum data are from Tarban Creek Asylum. After almost two centuries the preserved records allow insight into treatment used in early colonial Australia, including the scarcely remembered seton therapy. This finding highlights the importance of preserving historical records. It also demonstrates the necessity and/or evolving wish within the colony to care for patients with perceived mental health difficulties based on a shared medical culture inherited from techniques used in Britain.

When should I attempt my centrally administered summative assessments in the RANZCP competency-based training program?

OBJECTIVE: To provide information relevant to decision-making around the timing of attempting the centrally administered summative assessments in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) 2012 Fellowship Program. METHODS: We consider the new Competency-Based Fellowship Program of the RANZCP and its underlying philosophy, the trainee trajectory within the program and the role of the supervisor. The relationship between workplace-based and external assessments is discussed. The timing of attempting centrally administered summative assessments is considered within the pedagogical framework of medical competencies development. RESULTS: Although successful completion of all the centrally administered summative assessments requires demonstration of a junior consultant standard of competency, the timing at which this standard will most commonly be achieved is likely to vary from assessment to assessment. There are disadvantages attendant upon prematurely attempting assessments, and trainees are advised to carefully consider the requirements of each assessment and match this against their current level of knowledge and skills. CONCLUSIONS: Trainees and supervisors need to be clear about the competencies required for each of the external assessments and match this against the trainee's current competencies to assist in decision-making about the timing of assessments and planning for future learning.

Marriage equality is a mental health issue.

OBJECTIVE: We aim to review marriage equality in New Zealand and Australia and critically evaluate the health impact of such a legal change. METHOD: We undertook a review of the literature using the search terms "marriage equality", "same sex marriage" and "gay marriage" in combination with "health", "wellbeing", "psych*", "mental illness" and "distress". This search included medical literature, legal literature and mass media. RESULTS: This review indicates that Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) people disproportionately face negative health stressors and negative health events compared with the general population and this is related to the stress of being a stigmatised minority group. The evidence strongly supports the proposition that marriage equality is related to improved health outcomes. A diverse range of professional health groups advocate for the legislative progression to marriage equality. The authors found no evidence that marriage equality harms opposite-sex marriage. CONCLUSION: Marriage equality is still lacking in Australia and as a positive correlate of health should be strongly supported.