Mary Chiarella

Assessing patient capacity to consent to treatment: an integrative review of instruments and tools.

AIMS AND OBJECTIVES To provide a narrative synthesis of research findings on instruments or tools designed to aid assessment of patient capacity to consent to treatment. BACKGROUND Capacity assessment is of significant priority within health care as a finding of incapacity is a vehicle for the removal of many of an individuals fundamental rights. Despite there being many instruments and tools available to aid health professionals in the assessment of patient capacity, there are no standardised guidelines from professional bodies that inform the assessment of mental capacity. DESIGN Integrative review. METHOD Primary studies of instruments or tools concerning assessment of patient capacity to consent to treatment, published in English in peer-reviewed journals between January 2005-December 2010, were included in the review. Review papers of capacity assessment instruments were included for years including and prior to 2006. RESULTS Nineteen instruments were found which assess patient capacity to consent. Key themes were identified in terms of capacity domains assessed, psychometric properties, instrument implementation, patient populations studied and instrument versus clinician judgement. CONCLUSION Despite a plethora of capacity assessment instruments and tools available, only a small number of instruments were found to have demonstrated both reliability and validity. Further research is required to improve the validity of existing capacity assessment instruments. RELEVANCE TO CLINICAL PRACTICE Increased attention to patient rights and autonomy arguably places a considerable burden on healthcare professionals to facilitate capacity assessments across a continuum of health care. Despite a plethora of capacity assessment instruments and tools being available to healthcare professionals, a comprehensive assessment requires time and is often difficult in the acute care setting. A strictly formulaic approach to the assessment of capacity is unlikely to capture specific individual nuances; therefore, capacity assessment instruments should support, but not replace, experienced clinical judgement.

Lessons learned from measuring safety culture: An Australian case study

BACKGROUND adverse events in maternity care are relatively common but often avoidable. International patient safety strategies advocate measuring safety culture as a strategy to improve patient safety. Evidence suggests it is necessary to fully understand the safety culture of an organisation to make improvements to patient safety. AIM this paper reports a case study examining the safety culture in one maternity service in Australia and considers the benefits of using surveys and interviews to understand safety culture as an approach to identify possible strategies to improve patient safety in this setting. SETTING the study took place in one maternity service in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure which was part of a major health reform agenda. The priorities of the reform included improving the quality of care and patient safety; and, creating a more efficient health system by reducing administration inefficiencies and duplication. DESIGN a descriptive case study using three approaches: FINDINGS the safety culture was identified to warrant improvement across all six safety culture domains. There was reduced infrastructure and capacity to support incident management activities required to improve safety, which was influenced by instability from the organisational restructure. There was a perceived lack of leadership at all levels to drive safety and quality and improving the safety culture was neither a key priority nor was it valued by the organisation. CONCLUSION the safety culture was complex as was undertaking this study. We were unable to achieve a desired 60% response rate highlighting the limitations of using safety culture surveys in isolation as a strategy to improve safety culture. Qualitative interviews provided greater insight into the factors influencing the safety culture. The findings of this study provide evidence of the benefits of including qualitative methods with quantitative surveys when examining safety culture. Undertaking research in this way requires local engagement, commitment and capacity from the study site. The absence of these factors is likely to limit the practicality of this approach in the clinical setting. SIGNIFICANCE the use of safety culture surveys as the only method of assessing safety culture is of limited value in identifying strategies to potentially improve the safety culture.

Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment: An integrative review

This integrative review aims to provide a synthesis of research findings of health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to or refuse treatment within the general hospital setting. Search strategies included relevant health databases, hand searching of key journals, ‘snowballing’ and expert recommendations. The review identified various knowledge gaps and attitudinal dispositions of health-care professionals, which influence their behaviours and decision-making in relation to capacity to consent processes. The findings suggest that there is tension between legal, ethical and professional standards relating to the assessment of capacity and consent within health care. Legislation and policy guidance concerning capacity assessment processes are lacking, and this may contribute to inconsistencies in practice.

Boundary violations, gender and the nature of nursing work:

Complaints against nurses can be made on several grounds and orders, including removal from the registry of nurses, can be made as a result of these complaints. Boundary violations generally relate to complaints around criminal charges, unsatisfactory professional conduct or professional misconduct or a lack of good character. This article explores the spectrum of boundary violations in the nurse–patient relationship by reviewing disciplinary cases from the New South Wales Nurses and Midwives Tribunal and Professional Standards Committees. The complaints spanned a spectrum of behaviours, from minor infringements such as inappropriate compliments to intimate touching and sexual intercourse. Furthermore, the majority of respondents were men, although men comprise a minority of the nursing profession. This phenomenon is discussed in terms of gender stereotyping and nursing work. In addition, the possibility that improved supervision may have gone some way to preventing the violations is explored.

Which tail wags which dog? Exploring the interface between professional regulation and professional education.

“An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society” (Cruess et al., 2004, p.74).

Workforce characteristics of privately practicing nurse practitioners in Australia: Results from a national survey.

Purpose Australian private practice nurse practitioner (PPNP) services have grown since legislative changes in 2010 enabled eligible nurse practitioners (NPs) to access reimbursement for care delivered through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). This article provides data from a national survey on the workforce characteristics of PPNPs in Australia. Method PPNPs in Australia were invited to complete an electronic survey. Quantitative data were analyzed using descriptive statistics and qualitative data using thematic analysis. There were 73 completed surveys. Conclusions One of the intentions of expanding access to MBS and PBS for patients treated by NPs was to increase patients’ access to health care through greater flexibility in the healthcare workforce. The results of this survey confirm that the workforce characteristics of PPNPs provide a potentially untapped resource to meet current primary healthcare demand. Implications for practice The findings of this study allow us to understand the characteristics of PPNP services, which are significant for workforce planning. The focus of PPNP practice is toward primary health care with PPNPs working predominantly in general practice settings. The largest age group of PPNPs is over 50 years and means a proportion will be retiring in the next 15 years.

Models of care choices in today’s nursing workplace: where does team nursing sit?

This paper provides an overview of the developmental history of models of care (MOC) in nursing since Florence Nightingale introduced nurse training programs in a drive to make nursing a discipline-based career option. The four principal choices of models of nursing care delivery (primary nursing, individual patient allocation, team nursing and functional nursing) are outlined and discussed, and recent MOC literature reviewed. The paper suggests that, given the ways work is being rapidly reconfigured in healthcare services and the pressures on the nursing workforce projected into the future, team nursing seems to offer the best solutions.

Documentation of Capacity Assessment and Subsequent Consent in Patients Identified With Delirium

BackgroundDelirium is highly prevalent in the general hospital patient population, characterized by acute onset, fluctuating levels of consciousness, and global impairment of cognitive functioning. Mental capacity, its assessment and subsequent consent are therefore prominent within this cohort, yet under-explored.AimThis study of patients with delirium sought to determine the processes by which consent to medical treatment was attempted, how capacity was assessed, and any subsequent actions thereafter.MethodA retrospective documentation review of patients identified as having a delirium for the twelve months February 2013 to January 2014 was undertaken. Inclusion and exclusion criteria were used; demographic and descriptive data collected. A total of n=1153 patients were identified with n=310 meeting inclusion criteria.ResultA random sample of one hundred patients were subsequently reviewed. One third of patients (n=33) had documentation relating to consent, while four patients had documentation relating to capacity. Median delirium duration was three days, with treatment refusal occurring in twenty-two patients and “duty of care” being used as an apparent beneficent related treatment framework in twelve patients.ConclusionsWhile impaired decision-making was indicated, the review was unable to indicate what patient characteristics flag the need for capacity assessment. Documentation relating to consent processes (whether patient or substitute) appeared deficient for this cohort.

Celebrating connecting with Communities: coproduction in global Primary Health Care

The rise of chronic diseases in many countries means that current models of care are inadequate for addressing population health needs. Primary health care (PHC) has a major role to play in health reforms as it can be the first level of contact of individuals with the national health system and constitutes the first element of a continuing health care process. Consequently, the development of PHC initiatives, which work co-operatively with communities to improve health, is of importance. Case studies included in a compendium of nurse and/or midwife-led PHC models compiled as part of a World Health Organisation (WHO) project identified strategies for enhancing how nurses can work with communities to improve health. A thematic analysis showed that one of the themes related to coproduction in health, and how nurses and midwives can be positioned to work with communities to jointly lead PHC. Coproduction describes an active relationship between health professionals and communities in which substantial resource contributions are made by all parties. While this was not the initial focus of this study, it was a key development and worthy of identification and exploration for the purpose of this paper. In most projects, the democratic engagement and empowerment of both staff and community was a key requirement for success. The achievement of health in projects based in coproduction of health was not considered to be the domain solely of health care professionals, planners and policy-makers. Commitment and motivation were essential, and were developed through culturally appropriate and sensitive engagement with communities. Health care organisations and professionals must experience a paradigm shift in both their approach to providing health care and in their understanding of health care communities as co-producers. The concept of community partnership, moving towards community control, will help to establish these models of PHC.

Who to turn to? 'Knowing the ropes' in an underbounded health care system.

Abstract This paper explores the impact of restructuring, conducted under the auspices of new public sector management, on the delivery of hospital based nursing care. Alderfer’s model of ‘overbounded’ and ‘underbounded’ systems is used to analyse the way in which the organisation and delivery of nursing care has changed. Nursing was traditionally organised in an overbounded system which nevertheless focussed clearly and primarily on the provision of excellence in patient care. Recent research and examples from case law illustrate how nursing has moved into an underbounded system, where lines of authority and accountability are crossed and blurred. This can lead to practices of ‘responsible subversion’ which leave nurses feeling dissatisfi ed, guilty and marginalised. New management models are required to address the multiple and competing authority relations and imprecise, incomplete and overlapping role definitions.