Use of advance directives to promote supported decision-making in mental health care: Implications of international trends for reform in New Zealand.

Advance directives are advocated, in many jurisdictions, as a way to promote supported decision-making for people who use mental health services and to promote countries' compliance with their obligations under the United Nations Convention on the Rights of Persons with Disabilities. The United Nations Convention on the Rights of Persons with Disabilities promotes the use of tools to further personal autonomy which would include integrating the use of advance directives into mental health law, to clarify the effect (or force) an advance directive carries when its maker comes under the relevant mental health legislation. In addition, securing the active use of advance directives requires adoption of certain supportive practices and policies within health services. Here, we discuss a number of approaches taken to advance directives in revised mental health legislation, and the associated practices we think are required.

Community treatment orders in New Zealand: regional variability and international comparisons.

OBJECTIVES: Community treatment orders (CTOs) have been used in New Zealand since 1992 and are now used in most Commonwealth countries. There is little research on the rate of use of CTOs in New Zealand. This study compares the prevalence of CTO use across New Zealand's 20 health districts and makes comparisons with international prevalence rates. METHODS: New Zealand Ministry of Health reports provided data on rates of CTO use in New Zealand between 2005 and 2011. International rates were obtained from published reports and academic literature on CTO use. RESULTS: Rates of CTO use in New Zealand show marked and persistent regional variation over the period of data collection. National average rates increased from 58 per 100,000 in 2005 to 84 per 100,000 in 2011. Rates of use of CTOs are increasing internationally. New Zealand's CTO use is high by international comparisons. CONCLUSIONS: New Zealand's high and increasing rate of CTO use by international standards raises questions about the delivery and functioning of mental health services, and about mental health service users' experience of mental health care. The high rate of CTO use needs to be addressed as a human rights issue as well as a clinical issue.

Taser use on individuals experiencing mental distress: An integrative literature review.

WHAT IS KNOWN ABOUT THE SUBJECT?: People experiencing mental distress have a high rate of contact with police in community crisis events. Police use a continuum of responses when managing situations involving agitation, aggression and behavioural problems. People experiencing mental distress have been subjected to Tasers as part of the police response. Following a number of deaths and numerous reports of injuries, concerns have been raised about the safety of Tasers. WHAT THIS PAPER ADDS?: Police use of Tasers in mental health crises is relatively common. Tasers are used in a range of settings including public places, private residences and healthcare facilities. People experiencing mental distress may be subjected to more use of Tasers than the general population. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals need to work with police towards greater understanding of the needs of people experiencing mental distress and to promote the use of non-coercive interventions in mental health crisis events. Mental health researchers need to explore the qualitative experiences of people who are Tasered, to provide an evidence base for Taser use with people experiencing mental distress. ABSTRACT: Introduction Conducted electrical weapons, or "Tasers," are currently used by over 15,000 law enforcement and military agencies worldwide. There are concerns regarding the effectiveness, potential for harm and overuse with people experiencing mental distress. Aim To explore the literature about police use of Tasers with people experiencing mental distress. Method An integrative review was undertaken, and qualitative and quantitative analytical approaches were used. Results Thirty-one studies were included. Of all recorded usage, overall prevalence of Taser use on people experiencing mental distress was 28%. This population appears to experience higher Taser usage than the general population. Discussion There are substantial gaps in the research literature particularly with respect to the decision-making processes involved in deploying Tasers on this population and the physical and psychological consequences of Taser use in this context. Implications for practice Police use of Tasers in mental health crises is relatively common and occurs in a variety of environments including mental health settings. Mental health professionals need to work with police towards greater understanding of the needs of people with mental illness and to promote the use of non-coercive interventions in mental health crisis events.

Capacity, consent, and mental health legislation: time for a new standard?

Recent international reforms in mental health legislation have introduced a capacity test as a criterion for civil commitment. There are proposals that a common test of incapacity should apply in both mental and physical health under a single legislative framework for all cases in which the normally accepted standard of informed consent for treatment is not met. Capacity is a complex concept, but can be reliably assessed in clinical practice. Nurses need to be involved in the policy debate about capacity and consent in mental health care.

Don't go there - It's not a nice place: Older adults' experiences of delirium.

Delirium is a common neuropsychiatric disorder that causes fluctuations in consciousness and attention, impairments in cognitive functioning and information processing, and changes in how individuals perceive what is going on around them. Delirium is associated with increased mortality, ongoing impairment in cognitive functioning, and a high possibility of discharge to residential care. The experience of delirium may be distressing for the patient and their family. Despite the frequency of delirium in hospitalized elderly patients, there is a dearth of literature that examines their experience of this phenomenon, and how it affects individuals as they continue their lives. This study uses descriptive qualitative methodology to explore the question: 'What is the experience of delirium for older adults during hospitalisation?' Data were collected from older adults who had received hospital care in a tertiary general hospital setting. Seven participants were recruited between January and June 2017. Semi-structured individual interviews were used to gather data which was analysed using content analysis. Four themes were identified. These were sense of confusion, disrupted sense of autonomy, perceptual disturbances, and emotional response. Participants exercised agency in the way they responded to these experiences. The study highlighted the need for delirium prevention, and education to improve nurses' recognition, understanding, and management of delirium. In particular, there is a need for nurses to attend to the psychological and emotional experience of delirium.

Metabolic monitoring in New Zealand district health board mental health services.

AIM: To audit New Zealand district health boards' (DHBs) metabolic monitoring policies in relation to consumers prescribed second-generation antipsychotic medications using a best practice guideline. METHODS: Metabolic monitoring policies from DHBs and one private clinic were analysed in relation to a best practice standard developed from the current literature and published guidelines relevant to metabolic syndrome. RESULTS: Fourteen of New Zealand's 20 DHBs currently have metabolic monitoring policies for consumers prescribed antipsychotic medication. Two of those policies are consistent with the literature-based guideline. Eight policies include actions to be taken when consumers meet criteria for metabolic syndrome. Four DHBs have systems for measuring their rates of metabolic monitoring. There is no consensus on who is clinically responsible for metabolic monitoring. CONCLUSIONS: Metabolic monitoring by mental health services in New Zealand reflects international experience that current levels of monitoring are low and policies are not always in place. Collaboration across the mental health and primary care sectors together with the adoption of a consensus guideline is needed to improve rates of monitoring and reduce current rates of physical health morbidities.

Registered nurses as responsible clinicians under the New Zealand Mental Health (Compulsory Assessment and Treatment) Act 1992.

The objectives of this research were to determine how many registered nurses are working as 'responsible clinicians', under what phases of the legislation they are functioning, and to describe the enabling processes and barriers to nurses undertaking this statutory role. An anonymous descriptive survey was distributed to the 11 nurses who were currently responsible clinicians as well as five senior nurses selected from each of the 21 District Health Boards and the Auckland Regional Forensic Psychiatry Services (n = 121). The response rate was 88.4% (n = 107). The survey questioned respondents on statutory roles currently undertaken. Respondents were asked whether the responsible clinician role was a legitimate one for nurses and whether they were motivated to attain it. They were also asked which competencies of the role they believed they met, their perceptions of credentialing processes and the educational requirements needed to achieve the role. A descriptive statistical analysis was undertaken and open-ended questions were analysed using content analysis. Of the approximately 395 responsible clinicians nationally, 11 (2.8%) are nurses. Most nurses viewed the role as legitimate. However, many were unaware of competencies for the role and credentialing processes, and were somewhat ambivalent about achieving the role due to current workload, role conflict and lack of remuneration. Competency deficits were highlighted. There are grounds to encourage nurses as responsible clinicians given the intent of the legislation. This will require the promulgation of appropriate mental health policy, and a concerted effort by major stakeholders in mental health service delivery.

Mental health nursing in New Zealand primary health care.

International literature and New Zealand health policy is giving increased emphasis to the role of the primary health care sector in responding to mental health issues. These issues include the need for health promotion, improved detection and treatment of mild to moderate mental illness, and provision of mental health care to some of those with severe mental illness who traditionally receive care in secondary services. These developments challenge specialist mental health nurses to develop new roles which extend their practice into primary health care. In some parts of New Zealand this process has been under way for some time in the form of shared care projects. However developments currently are ad hoc. There is room for considerable development of specialist mental health nursing roles, including roles for nurse practitioners in primary mental health care.

Discourse analysis of newspaper coverage of the 2001/2002 Canterbury, New Zealand mental health nurses' strike.

In late 2001 Canterbury, New Zealand mental health nurses undertook a variety of strike actions after stalled industrial negotiations with the local district health board. One response to these actions was the temporary reduction of many of the regions metal health services. Unsurprisingly, the print media responded by publicizing the crisis in mental health services on an almost daily basis. This paper reports on subsequent research into these print media representations of the industrial disputes, identifying themes of juxtaposed but largely deprecatory images of both mental health nursing and of consumers of services. Some professional nursing voices were given print space during the strike; however, these were largely incorporated into existing discourses rather than offering a nursing viewpoint on the strike. We, therefore, conclude by suggesting organizational efforts to focus on ways of ensuring that mental health nurses are seen as a legitimate authority by the media.

The New Zealand development and trial of mental health nursing clinical indicators--a bicultural study.

This paper describes the development and validation of bicultural clinical indicators that measure achievement of mental health nursing practice standards in New Zealand (ANZMCHN, 1995, Standards of practice for mental health nursing in New Zealand. ANZCMHN, Greenacres). A four-stage research design was utilised including focus groups, Delphi surveys, a pilot, and a national field study, with mental health nurses and consumers as participants. During the national field study, consumer files (n=327) from 11 District Health Boards, and registered nurses (n=422) completed an attitude questionnaire regarding the regularity of specific nursing and service activities. Results revealed a variation in the mean occurrence of the clinical indicators in consumer case notes of 18.5-89.9%. Five factors with good internal consistency, encompassing domains of mental health nursing required for best practice, were derived from analysis of the questionnaire. This study presents a research framework for developing culturally and clinically valid, reliable measures of clinical practice.

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.

Clinical indicators as measures of mental health nursing standards of practice in New Zealand.

This paper discusses the utility of Consumer Notes Clinical Indicators (CNCI) as a means to monitor mental health nursing clinical practice against the Australian and New Zealand College of Mental Health Nurses' (ANZCMHN) Standards of Practice for mental health nursing in New Zealand. CNCI are statements describing pivotal mental health nursing behaviours for which evidence can be found in the nurses' case notes. This paper presents 25 valid and reliable CNCI that can be used to monitor mental health nursing practice against the ANZCMHN's Standards of Practice for mental health nursing in New Zealand. The bicultural clinical indicators were generated in focus groups of Maori and non-Maori mental health nurses, prioritized in a three-round reactive Delphi survey of expert mental health nurses and consumers, pilot tested, and applied in a national field study. This paper reports the development and validation of the CNCI, for which achievement is assessed by an audit of the nursing documentation in consumer case notes. The CNCI were tested in a national field study of 327 sets of consumer case notes at 11 District Health Board sites. The results of the national field study show wide variation in occurrence of individual indicators, particularly in the areas of informed consent, information about legal rights, and provision of culturally safe and recovery-focused care. We discuss the implications of using the CNCI to assess the professional accountability of mental health nurses to provide quality care. Recommendations are made regarding the application of the clinical indicators and future research required, determining appropriate benchmarks for quality practice. The CNCI could be adapted for application in other mental health nursing and other mental health professional clinical settings.

Initiating committal proceedings "just in case" with voluntary patients: a critique of nursing practice.

Voluntary patients entering mental health units retain the right to accept or refuse treatment, including ongoing admission, as they see fit. However the nature of acute mental distress means that some patients have fluctuations in their mental status and competency to make informed decisions. Inpatient mental health nurses face the ongoing challenge of practising in a way that balances the requirement to support and promote the autonomy of voluntary patients with the need, occasionally, to take actions which although they may appear paternalistic are needed to protect those patients or other people. Anecdotal evidence together with a clinical audit undertaken by the authors suggest that the practice of nurses requesting that doctors sign medical certificates which are then placed on patients' files 'just in case' they are needed has become a mechanism by which a minority of nurses deal with such challenges. A conceptual analysis of these issues indicates that such a practice is both legally questionable and ethically inappropriate. We suggest an alternative framework for practice that is legally and ethically preferable for both nurses and patients.

Police use of TASER devices in mental health emergencies: a review.

The proliferation of TASER devices among police forces internationally has been accompanied by concerns about injuries and health effects, and about the use of TASER devices on vulnerable populations such as people with mental illness. TASER devices have generated a flood of research studies, although there remain unanswered questions about some of the key issues. This paper outlines the introduction of TASER devices to policing and their subsequent widespread adoption. The paper considers the role of police in mental health emergencies with a particular focus on use of TASER devices. Some factors contribute to the special vulnerability of people with mental illness to the effects of TASER devices. The paper also reviews research into use of TASER devices and raises issues about conflict of interest in research into TASER devices. We conclude that TASER devices look set to play a significant role in policing in the future. We make suggestions for a future research programme, and suggest guidelines for publication of papers in which there may be a conflict of interest.

Use of Tasers on people with mental illness A New Zealand database study.

BACKGROUND: In 2006-2007 New Zealand police deployed the Taser X26 electro-muscular incapacitation device for a twelve month trial across four police districts. Criteria for use of the Taser included "individuals in various states of mental health crisis". AIMS: To provide a descriptive analysis of the use of Tasers by the New Zealand police; to identify those incidents that involved people in mental health emergencies; and to compare this use with that which occurred in incidents of criminal arrest. METHOD: Descriptive analysis of the police Tactical Operations Database. RESULTS: Tasers were deployed on a total of 141 people in 124 events, and discharged 19 times. Of the 141 subjects, 30 (21%) involved people in mental health emergencies. Tasers were more than twice as likely to be discharged at mental health emergencies (8 of 30; 27%) than at criminal arrests (11 of 111; 10%) (X(2)=5.69; df=1; p=0.017). There were two incidents that involved a Taser being used as part of police response to in-patient mental health services and two incidents involving mental health community residential accommodation. CONCLUSIONS: Introduction of Tasers into policing in New Zealand will disproportionately impact on people with mental illness. Guidelines are needed to manage the future use of Tasers in mental health emergencies.