Introduction
In Ireland, the Mental Health Act 2001 (Department of Health and Children, 2001) was implemented in November 2006 and has resulted in many changes to the mental health services. These changes commenced with the enactment of the Act by the Houses of the Oireachtas (Parliament) on 8th July 2001, and were fully implemented in November 2006. The purpose of the Act was to bring Ireland into line with international practice, in particular the United Nations Convention on Human Rights, to which Ireland is a signatory (United Nations, Secretariat Centre for Human Rights, 1991; United Nations, 2006). Previous studies have reported some practical difficulties for the professionals involved. We wished to examine the experiences of nursing staff and the impact of the Act on clinical nursing practice since its implementation.
The process of involuntary admission in particular has undergone extensive change, and including the automatic review of involuntary admission orders by Mental Health Tribunals within 21 days of the involuntary admission (Kelly, Reference Kelly2007). The Mental Health Commission was established to oversee this process and to ensure that the rights of detained persons are upheld at all times.
The Mental Health Act 2001 has received a varied response from the professionals on whose clinical practice it has impinged. In a study conducted in 2007 examining the impact of the Act on psychiatrists, psychiatrists described negative aspects including increased workload, conflicts with patients and difficulties arising from the adversarial nature of mental health tribunals (particularly in interactions with solicitors) (Jabbar et al. Reference Jabbar, Kelly and Casey2010). They have described specific difficulties in the process and nature of the tribunals, the involuntary admissions process, resource issues, stigma, and the legal position of children and adolescents (Jabbar et al. Reference Jabbar, Kelly and Casey2010). Many of these problems had been predicted by psychiatrists before the Act was implemented (Ganter, Reference Ganter2005; Kelly & Lenihan, Reference Kelly and Lenihan2006), although the prediction that it would impact on numbers of involuntary admissions has not been realised (Nwachukwu et al. Reference Nwachukwu, Crumlish, Heron and Gill2010).
General practitioners, as the registered medical practitioners who are most commonly involved in the second step of the process of involuntary admissions, have similarly described a number of difficulties, in particular describing an increase in paperwork related to involuntary admissions and limited training in the Act (Jabbar et al. Reference Jabbar, Doherty, Aziz and Kelly2011).
Patients’ attitudes were explored in a study on 81 patients in Dublin, where 27.5% experienced a negative impact on the relationship with their family and 15% reported a positive impact (O’Donoghue et al. Reference O’Donoghue, Lyne, Hill, Larkin, Feeney and O’Callaghan2010). A majority agreed that their admission had been necessary.
The attitudes of nursing staff have not been examined to date. We wished to examine the experiences of nursing staff and the impact of the Act on clinical nursing practice since its implementation.
Methods
We sent questionnaires to 600 psychiatric nurses in the greater Dublin area. These questionnaires were distributed along the chain of command (i.e. from the Directors of Nursing to the nurses who report to them) and were returned to our research office. As there is no precedent in the international literature for assessing the impact of legislation on nursing practise, it was not possible to use a validated instrument. We used a questionnaire previously used by the authors in the assessment of the attitudes of psychiatrists (Jabbar et al. Reference Jabbar, Kelly and Casey2010) and GPs (Jabbar et al. Reference Jabbar, Doherty, Aziz and Kelly2011) to the Mental Health Act, and adapted it as appropriate to nursing staff. We had consulted widely with a number of Directors of Nursing regarding the questions included.
The questionnaire was composed of the following questions:
1. What grade are you? Clinical Nurse Manager, Community Psychiatry Nurse, Staff Nurse or Student.
2. Where do you work? In an acute hospital unit, in a day hospital, in the community or other?
3. What training in the Mental Health Act did you receive? Standard 2-day course, standard 2-day course with updates, e-learning or other.
4. Has the Mental Health Act changed your overall workload?
5. Has the Mental Health Act changed the amount of time you spend with patients?
6. Have there been any changes in the pattern of attention given to patients (e.g. patients who are not involuntary being sidelined, etc.)?
7. Has the Mental Health Act affected your relationship with patients?
8. Have you experienced any difficulties with the Mental Health Act?
Respondents were also provided with a ‘free-text’ area to allow for additional comments at the end of the questionnaire.
Statistical analysis
Statistical analysis was performed using SPSS. Univariate analysis was performed using χ 2 test. The comments in the ‘free-text’ area were grouped into themes by consensus of the researchers.
Results
We received responses from 317 nurses of the 600 questionnaires sent, giving a response rate of 52.8%. These respondents comprised 50.9% (n=162) staff nurses, 27% (n=86) clinical nurse managers, 9.7% (n=31) community mental health nurses, 2.8% (n=9) clinical nurse specialists, 5.7% (n=18) students and 3.8% (n=12) others.
More than half of the respondents (n=181; 57.3%) stated that they worked in an acute psychiatric unit, 22.5% (n=71) worked in the community, 7.9% (n=25) worked in a day hospital and 12.3% (n=39) worked elsewhere.
The majority of respondents (n=292; 92.1%) stated that they had received some training in the Mental Health Act 2001. Of them, 81.1% (n=257) had attended the standard 2-day course provided by the HSE, and 13 had received some additional updates; 4.1% (n=13) had received their training as part of their nursing training in college; and 6.9% (n=22) had received training via e-learning.
Respondents reported changes in working practise since the implementation of the Act, which they attribute to the Act, with a majority describing increased workload (56%; n=178) and 23% (n=73) reporting a change in the amount of time available to spend with patients. Of the respondents, 36.5% (n=115) reported having experienced difficulties with the Act.
The ‘free-text’ comment area was utilised by 57.5% (n=183) respondents. Of these, the majority (n=140; 76.5%) were negative, with 14.2% (n=26) making neutral comments and 9.3% (n=17) making positive comments. When these negative comments were further divided by theme, 10 distinct themes emerged, and the increased amount of paperwork engendered by the Act was the most widespread theme cited in 60% of the negative comments. The other themes and their frequency are reported in Table 1.
Table 1 Negative themes in nurses’ comments regarding the Mental Health Act 2001
There were no significant differences in the Mental Health Act Training received by those nurses working in acute psychiatric units as opposed to those working elsewhere (p=0.436), as shown in Table 2. However, there were significant differences in a number of other responses between the two groups (Table 2). Nurses working in an acute admission unit were significantly more likely to report an increased workload as a result of the Act, and were also more likely to report a change in the time spent with patients. They were more likely to report a change in the pattern of attention given to patients (33.7% v. 11%) with an odds ratio of 2.5 (confidence interval 1.29–5.84) as a result of the Act, and more likely to report difficulties (46.1% v. 23.9%) with an odds ratio of 2.7 (confidence interval 1.67–4.47). Of those respondents who made comments, most were of a negative theme; however, there remained significant differences between the two groups. Respondents describing themselves as nurse managers were significantly more likely to have received adequate formal training (χ 2=11.2; p=0.024) and to report difficulties with the Act (51.2% v. 31.2%; χ 2=10.653; p=0.001). There were no other significant differences between nurse managers and more junior staff.
Table 2 Differences in responses to questions on the Mental Health Act 2001 from nurses working in acute units and in the community
Discussion
The Act has brought Ireland in line with international practice (United Nations, Secretariat Centre for Human Rights, 1991; United Nations, 2006) and the process of involuntary admission been revolutionised to ensure that the rights of detained persons are upheld at all times. In a study of 81 Dublin patients who had been admitted under the Act, a majority agreed afterwards that their admission was necessary, indicating some satisfaction with the process (O’Donoghue et al. Reference O’Donoghue, Lyne, Hill, Larkin, Feeney and O’Callaghan2010). While our results show that the majority of nurses received adequate training in the Mental Health Act, they also show that the Act has created a number of difficulties reported by a minority of nurses, including increased paperwork, a change in the time available for patients and difficulties arising from the greater legal emphasis, which has been placed on involuntary admission. These difficulties are reported most frequently in admission units. This is to be expected, as staff in acute admission units have the most number of dealings with the Act.
The higher proportion of difficulties reported by nurse managers compared with nurses of other grades may be seen to represent the degree of responsibility and additional workload experienced by this group in relation to the Act.
The findings of this study are in keeping with the literature which has examined the experiences of other professionals. Like the psychiatrists studied (Jabbar et al. Reference Jabbar, Kelly and Casey2010), the nurses reported difficulties with increased workload, a legal emphasis being brought into clinical practise, problems arising from the detention of minors, and doubts about whether or not the process is in the best interest of the patient. The chief difficulties cited by psychiatrists that were not mentioned by nurses were the implications for resources and various practical difficulties relating to Mental Health Tribunals (Jabbar et al. Reference Jabbar, Kelly and Casey2010). Other commentators have also drawn attention to the matter of resources (Ní Mhaoláin & Kelly, Reference Ní Mhaoláin and Kelly2009). Like the nurses, general practitioners reported increased paperwork as one of the most significant difficulties, and suggested that more training is required. They also raised concerns about transporting patients to the hospital, and about the detention of minors (Jabbar et al. Reference Jabbar, Doherty, Aziz and Kelly2011). The proportion of negative remarks are consistent across the literature with 70% of psychiatrists (Jabbar et al. Reference Jabbar, Kelly and Casey2010), 88% of general practitioners (Jabbar et al. Reference Jabbar, Doherty, Aziz and Kelly2011), and in this study 76.5% of nursing staff who made free-text comments (i.e. 44% of the total sample) reporting negative experiences of the Act.
However, despite its shortcomings, the Act improves Ireland’s compliance with international human rights standards (United Nations, Secretariat Centre for Human Rights, 1991). In addition, one survey of consultant psychiatrists found that, whereas the care of voluntary patients had declined following the introduction of the Act, the care of involuntary patients had improved (O’Donoghue & Moran, Reference O’Donoghue and Moran2009). Some of the nurses surveyed in this study reported some benefits of the legislation. Of the GPs in another study, 33% believed that the care of patients was improved by the Act (Kelly et al. Reference Kelly, O’Sullivan, Finegan, Moran and Bradley2011). Unfortunately, there is a paucity of international literature regarding the effect of changes in mental health law on nurses.
The limitations of this study include the simplicity of the questionnaire, which results in limited background information regarding the respondents (age, sex, duration of experience, etc.). This, however, may be regarded as one of the advantages of the study, as we hypothesised that nursing staff are more likely to complete a single page document owing to competing demands in their time. To clearly quantify the proportion of nurses who had difficulty with the Act, we used the question: ‘Have you experienced any difficulties with the Mental Health Act?’, which may have introduced bias – another limitation of this paper. The distribution of the questionnaire along the chain of nursing command may potentially have introduced a selection bias, as the questionnaire may have been less likely to be distributed in units where less training was available.
The small proportion of respondents (52.8%), although similar to other studies examining the experiences of professional groups to the Mental Health Act, may reflect selection bias. Furthermore, we would like to emphasise that only 57.5% of the respondents completed the ‘free-text’ section, and that there may be bias inherent in the self-selection of participants who chose to make a comment.
The absence of validated instruments is another limitation of this study. It is regrettable that there are no validated instruments that would have suited our purposes in the design of this study. However, we used adapted versions of instruments used by the authors in other professional groups in examining their experiences of the same piece of legislation.
Conclusion
Similar to other professions, nurses have experienced significant practical difficulties with the Mental Health Act since its implementation. When the problems encountered by the relevant groups of psychiatrists (Jabbar et al. Reference Jabbar, Kelly and Casey2010; Kelly et al. Reference Kelly, O’Sullivan, Finegan, Moran and Bradley2011), general practitioners (O’Donoghue & Moran, Reference O’Donoghue and Moran2009; Jabbar et al. Reference Jabbar, Doherty, Aziz and Kelly2011) and nurses are considered, policymakers can perhaps incorporate these into the future amendments to the Act. Given that a large number of nurses, particularly more senior nursing staff, reported an increase in paperwork, a solution may lie in the area of workforce planning to ensure that staff have adequate time for clinical and administrative duties. We hope this will ultimately provide an Act that, as well as protecting the rights of psychiatric patients, will also promote efficient practice, which is in the best interest of patients.
Acknowledgements
The authors would like to acknowledge all the respondents, and the Directors of Nursing who facilitated the dissemination of the questionnaire. In particular, they would like to thank Mr Michael Shasby, who undertook the co-ordination of the distribution of the questionnaires. They are grateful to the editors and peer-reviewers for their helpful comments and suggestions.
