Eighty-one clinicians, including nurses, social workers, occupational therapists, psychologists, dieticians, and pharmacists, participated over the five sessions of focus groups. Attendance at these sessions was not required, and therefore the sample of participants was self-selected. No participants had a prior relationship with the first author. Summary tables of the participants’ professions and their years of clinical experience are available elsewhere [17].
Each participant was assigned a unique number identifier, consisting of the month and date of their training session and the order in which they joined on that day. For example, the participant labelled 05-24-16 attended the session held on May 24 and joined after participant 05-24-15. These identifiers are used in the supporting quotes that follow.
The themes from the discussions are grouped below into barriers, facilitators, and hypothetical facilitators—solutions that participants proposed but that are not current facilitators. Their subthemes were coded to domains within the TDF. These themes, subthemes, and domains are summarized in the leftmost three columns of Table 1.
The dataset of anonymized focus group transcripts is available in the Federated Research Data Repository at https://doi.org/10.20383/102.0358.
Barriers
We identified several barriers clinicians faced that hindered them from consistently giving involuntary patients complete rights information.
Clinicians receive inadequate training on the Mental Health Act generally and rights notification specifically
This theme falls under the TDF domains of Knowledge, Skills, Social/Professional Role, and Beliefs about Capabilities (see Table 1).
Some clinicians felt they lacked the training to give complete and consistent rights information confidently (or “perceived competence” within the Beliefs about Capabilities domain). Several participants also expressed uncertainty about the process involved in helping patients exercise some of their legal rights. That is, although they knew they had to give rights information, many expressed a lack of process knowledge—that is, how to give rights information (“Knowledge” in the TDF). Some clinicians who work in units with slower patient turnover reported that the lack of opportunities to practise giving rights information contributed to their lower confidence:
07-17-08 (nurse): [There’s] just no real formal training on the Mental Health Act. […] So it’s sort of like coming to an environment where you’re doing more of the, like, education around that, like, first certification and just kind of trying to figure it out as you’re going.
***
07-27-10 (nurse): On our inpatient units, we don’t… we don’t give the rights as much, and so the nurses would be even less familiar with, like, doing a Form 13, because it’s only required there once per month, theoretically, whereas on our assessment unit, the flow of patients was much quicker through there, so they would be giving it more often. So I think, um, nurses on our inpatient units just don’t have… like, it’s not a priority because they are not as familiar with it.
***
07-27-12 (nurse): I’m a psych nurse, personally, so, I mean, I’m familiar with Form 13, but some of the language is confusing. So if you’re reading it, and you’re just, like, “You have the right to appeal to a judge,” and they’re like, “How do I do that?” Or whatever it is, like, we might not be able to, like, articulate that, or even have the knowledge to be able to go beyond what’s actually written. […] Maybe you are just saying this verbatim, because you’re, like, “Well, I know this is my job, I’m supposed to tell patients this,” and then it’s confusing to them and they’re, like, “OK, well, now I have all this information, but I don’t actually know how to access that.”
***
07-17-02 (nurse): Clinicians may not feel comfortable giving the rights because they might not feel comfortable with having the knowledge of what to do once they’ve given the right. So what’s the next step when the client does say, “Well, I want to talk to a lawyer. I want to exercise my right to have a review panel”? I think sometimes clinicians might not know what that next step is, so they might be… just kind of avoid the conversation, almost, to avoid having to get into that part of it. So I think sometimes it’s just a lack of knowledge, I guess is what it comes down to.
They also commented that specific training on the rights notification process itself was nonexistent (falling under the Skills domain of the TDF), and they reported differences in the level of formal training on the Mental Health Act among different types of health professionals (for example, registered nurses generally receive less training on the legislation compared with registered psychiatric nurses):
05-29-12 (nurse): I think when you look around, our staff makeup… is the different education backgrounds that we come from. Some are RNs [registered nurses], some are RPNs [registered psychiatric nurses], some have been around for 20 years, 30 years, some for two years. And I think the big thing is, like, there’s not a lot of emphasis on the Mental Health Act. I know in my RPN program, we had a semester, we had a full course on it, but that’s very few and far between. I’ve noticed that some of the schools, like, when you get new grads, they’ve never even gone over a Form 13. And that’s not something that’s included and part of our initial orientation either. […] I think something like that would be more useful to get clinicians and make sure that we are providing consistent rights and reading the rights to the patients.
***
07-27-10 (nurse): Pretty much all of our education as nurses, RPNs and RNs, is, like, there’s, like, really no, like, Form 13 education. […] There’s no, like, going in depth into actually understanding what it means. […] If they want a review panel, you would fill out the review panel form. We don’t actually really, like, describe what a review panel is or, like, what the real process is behind it. So it’s, like, a lack of education for all staff.
Although most participants felt that giving rights information was within their scope of practice (Social/Professional Role in the TDF), some questioned whether this task was appropriate for clinicians without legal training:
07-27-o9 (nurse): I don’t think I’d be able to speak to sort of, like, the human rights law associated with involuntary certification and ramifications of that. I don’t have the legal training. Just like we wouldn’t expect a lawyer to come in and do… complete a nursing pass that they’ve never done or had training on.
At the time of admission, patients are not receptive to new information
This theme falls under the TDF domains of Environmental Context and Resources, Beliefs about Capabilities, Optimism, and Beliefs about Consequences (see Table 1).
Participants reported that patients were often too ill to be cognitively able to understand or remember rights information when they were admitted, a factor within the Environmental Context and Resources domain:
05-29-02 (nurse): A lot of times our clients, like, their cognitive capacity to understand the Mental Health Act and how it works is quite limited, and even when we do our best to try and explain it at a level that they understand, we have clients, you know, applying for review panels thinking that that’s their ticket out of hospital and that’s gonna get them housing faster, so not really understanding, and it’s hard to kind of, I don’t know, explain it at a level that they’re gonna kind of understand and makes sense to them.
***
05-24-16 (nurse): I had to do a Form 13 yesterday. You know, sometimes people are just so unwell at the point that you’re doing it that it just goes over their head.
***
07-27-12 (nurse): Well, obviously in mental health, there’s varying levels of acuity, […] so when a patient comes in, they’re maybe withdrawing from drugs or maybe psychotic or agitated. That might not be necessarily the right time for them to be receptive to feedback, or they just can’t, like, mentally process what you’re talking about.
The assumption that a patient would not understand the information may discourage some clinicians from giving patients rights information. In other words, clinicians were pessimistic (TDF domain of Optimism) that they would be able to convey information in a way patients would understand, given their mental state (TDF domain of Beliefs about Abilities).
05-24-06 (nurse): Some people just assume that they won’t understand the rights, and so they’re not done.
Similarly, some clinicians believe that giving rights information to patients who are already angry about being detained will further upset or agitate them (TDF domain of Beliefs about Consequences).
07-17-01 (nurse): I’ve been working in psychiatric nursing all my career, and for me the number one barrier is the assumption that patients won’t understand, we’re going to upset them, you know, we’ll increase their agitation, you know, because then they will want, you know, their rights to be exercised immediately, and then we don’t have the resources to fulfill that right immediately.
***
06-12-01 (nurse): Sometimes the patients are… when they come in, they don’t want to be in, so they’re quite angry. So to tell them that they’re… what their rights are would be quite detrimental—just anger provoking. When we do read them the rights with that paper, we have to read it aloud to them. I find it’s too long, and they either lose interest or, again, they get angry. […] And, I mean, honestly yeah, the nurses are all, “Yeah, I don’t want to do it because I don’t want to provoke” whatever.
The tool used to communicate rights information to patients (Form 13) is inadequate
This theme falls under the TDF domains of Environmental Context and Resources, Beliefs about Capabilities, and Beliefs about Consequences (see Table 1).
Several participants said that a major barrier to effective communication about rights with involuntary patients was the long, overly complex language on Form 13 (an element of their Environmental Context and Resources). Not only did participants feel unable to interpret this information in a way patients could understand (TDF domain of Beliefs about Capabilities), but many of them believed that the legal nature could breed mistrust between the patient and the treatment team (TDF domain of Beliefs about Consequences):
05-29-20 (nurse): That form is really wordy. So it’s really hard for me to give a Sparks Notes version of that form, so that’s one thing.
***
06-12-03 (occupational therapist): I feel like the Mental Health Act, it’s written out for clinicians, not for patients, so we’re essentially just regurgitating information that could be stigmatizing towards clients, so as soon as you say, like, “Your rights have been taken away,” or whatever it may be, that’s a trigger, that’s gonna escalate them, they’re not going to retain any of that information.
***
06-12-05 (nurse): It uses legal jargon. I just had a conversation with a patient just before coming here, and seeing the legal jargon and stuff like that, he automatically assumed “If my lawyer’s not here, if I don’t have a lawyer present, I’m not signing anything. I don’t care what you tell me it’s about. I’m not.”
***
07-27-03 (nurse): Well I think all of the language in Form 13, it’s just not really accessible to a lot of patients, especially if there’s a language barrier, a literacy barrier, anything, it’s totally not accessible. That’s sort of my main observation of it.
Many patients don’t speak English
This theme falls primarily under the TDF domain of Environmental Context and Resources (see Table 1).
Participants frequently mentioned that their patients came from many cultural and linguistic backgrounds but Form 13 is available only in English. Not having means to communicate rights information in other languages—an issue within the TDF domain of Environmental Context and Resources—was a barrier for many of the clinicians.
05-24-06 (nurse): I find, obviously, the language barrier, like, the biggest barrier for me. […] Because, again, you have to wait, get a translator to do that, and then things just get lost in the clutter. So I think that’s a big thing.
***
05-29-11 (nurse): [A barrier to giving rights information is the] language barrier because, you know, here, there’s a lot of different languages. This [Form 13] is only English, and then you have to translate verbally in that language.
***
07-27-01 (nurse): With the population I work with at [site redacted] and geri[atric] psych[iatry], people are coming in with dementia, delirium, so they may not understand. So a lot of times I’m having family members sit in while I read it. And we have a lot of people who don’t speak English. That seems to be the majority rather than the minority, so it’s a real issue. You’re explaining to family and they’re translating it.
Clinicians said that even when interpreters were available, their focus was usually on conveying treatment information and not rights information.
05-24-00 (nurse): Like, they have interpreters when they’re having their assessments with their physician, but I don’t know then if that [rights information] would be something that would be highlighted to the physicians to discuss when the interpreter’s around.
Beyond language, different cultural understandings of mental illness and the health care system presented barriers as well:
05-29-15 (nurse): I worked in emergency, and we saw patients who had been brought in from the airport. And this was a big issue. It was culture. It was… not just this… the simpler barriers of language and time changes and things like that, but it was it was definitely culture. It was respect. There were a lot of things… So for the emergency setting, I think those were barriers, definitely.
Clinicians have many competing priorities in the admission process, which can be busy and chaotic
This theme falls under the TDF domains of Environmental Context and Resources and Social/Professional Role (see Table 1).
Several participants described the involuntary admission process as being hectic, with many forms that have to be completed, a factor in the TDF domain of Environmental Context and Resources. The amount of information that the patient has to process about their reason for detention and their diagnosis or proposed treatment may already be overwhelming, and clinicians facing a heavy workload with many responsibilities may consider giving rights information a lower priority compared with these clinical details (TDF domain of Social/Professional Role).
05-29-03 (occupational therapist): I think often it’s sort of offered as part of the admission process, and there’s a lot of processes that have to go on at admission day, so I think time is limited, and that’s a big barrier.
***
06-12-08 (nurse): I think for me, my own experience, a barrier to providing rights advice is often a lot of the Mental Health Act information is distributed during admissions, and if an admission comes in at 2:00 in the morning, there’s no way there’s gonna be ample time or appropriate time to discuss it, so it kind of gets left to the wayside in hopes that the day nurse next day will carry it on, and if that’s not communicated effectively, it just kind of gets pushed and pushed and pushed along until someone’s like, “Oh my god—this hasn’t been discussed at all.”
***
07-17-01 (nurse): Usually it’s the nurses who are dealing with the triage and the assessment are the ones to be dealing with that [rights information] most often. And so at the back of your head, you’re thinking, “Oh, I have two more patients to see, I have three more…” I feel the time factor can play a role in that.
Clinicians face pressure from other staff not to give rights information in an understandable way
This theme falls under the TDF domains of Social Influences and Environmental Context and Resources (see Table 1).
Some clinicians acknowledged a conflict of interest that may prompt them to give patients rights information in a way that doesn’t necessarily encourage understanding. When patients choose to exercise their rights, such as when they apply for a review panel hearing, they initiate legal processes that demand staff time and resources (TDF domain of Environmental Context and Resources). As a result, some clinicians face social pressure from their colleagues (TDF domain of Social Influences) to downplay rights information, and there appears to be an organizational culture to see review panel hearings as a burden rather than as a therapeutic opportunity to further a patient’s sense of procedural justice.
07-27-14 (social worker): I think that the staff […] have a tendency to do things that are required of them in this regard but not necessarily to go above and beyond that, to actually help someone understand, as opposed to just going through the motions of showing them a list of their rights and asking them if they have any questions. But again, if they’re not in a state of mind to process a lot of information in that exact moment, then there might not be another opportunity that presents itself for patients to really ask those questions and really understand what their rights are. And I think there’s a certain, like, intention behind that as well, to be honest. Review panels take a lot of work and time, and sometimes they’re perceived as a barrier to, again, from a paternalistic point of view, achieving and executing a care plan or a treatment plan that the care team specifically—often the psychiatrist—has in mind, right? So I think there’s that side of the equation as well.
***
06-12-12 (nurse): The other thing we see is, when you’re offering something like “You have the right to a review panel.” Physicians don’t want review panels. They take up a lot of time. They take up a lot of work. So they’re going to… you know, the information that the patient’s getting, maybe they’re glazing over that part about review panel because they don’t want to have to spend the X amount, you know. So to me that is a direct conflict of interest.
The clinical workflow doesn’t facilitate follow-up and accountability
This theme falls under the TDF domains of Environmental Context and Resources, Social Influences, and Social/Professional Role (see Table 1).
The Mental Health Act requires only that patients be notified of their rights if they are transferred between facilities and not when they are transferred between units at the same facility. When a patient arrives at a unit, clinicians assume that if a Form 13 appears in their file, they have been told about their rights, but whether the patient has in fact been explicitly told and whether they have understood is not always clearly documented.
07-17-02 (nurse): We send them up [to the inpatient unit] with the forms that have been signed, so if the Form 13 has been signed, then I think that that would communicate to the inpatient unit that this has been communicated to the person. And if it’s not signed, then I think it would communicate to the inpatient unit that they may need to provide that information. But there’s no direct, formal communication to say, “Hey, we informed them of their rights” or anything like that.
Whether patients have received and understood rights information is also poorly communicated and documented over shift changes:
07-27-06 (nurse): I think what participant number two [07-27-02, a nurse] said in terms of, like, the ability to communicate fluidly with your colleagues around the status of the patient and what their rights […] like, what the conversation has been so far, we don’t have great systems to document that well. […] It’s just fragmented, and there’s not a really clear system in place for clinicians to understand what the conversation has been, and especially when there’s shift change at minimum, you know, twice a day […] so systems for clinicians, and we only have… We have the Form 13—that’s the only resource we have to go off of.
When patients refuse to hear about their rights when they arrive, or if they appear not to understand, the Mental Health Act says that they must be offered rights information again later in their stay. Clinicians acknowledge, however, that they have no standard systems to track which patients need their rights repeated and when. This lack of tracking and accountability systems reflect a problem within the TDF domain of Environmental Context and Resources as well as a social or organizational culture that has not prioritized creating such systems (TDF domain of Social Influences).
05-24-16 (nurse): People are coming in and maybe they’re not in a state of mind where they’re able to hear and understand the information that you’re providing, and then, um, and then it’s sort of losing track of that, I think, and not revisiting it at a time when they’re more able to hear that information and understand that information.
***
06-12-05 (nurse): Sometimes passing along to our cohorts about what we’ve been able to accomplish for that kind of discussion or not isn’t really written down, so somebody’s attempted but then that person goes off for the next three days, and that nurse isn’t back to check in for the next little bit, so it gets lost in translation there. Yeah. People will see you’ve attempted and assumed that an attempt means a full conversation when it was just an attempt.
***
05-29-16 (nurse): Sometimes if someone isn’t wanting to [hear rights information], like, you’d write, you know, “Patient declined to hear,” or whatever, but then it doesn’t get followed up with or, you know, it kind of gets put away because that check box is now checked.
Because any number of clinicians may give patients rights information, participants said that uncertainty about whose responsibility it was (TDF domain of Social/Professional Role) led to further confusion.
06-12-08 (nurse): Back in the day when we did have primary nursing in more acute settings, I feel like information was way more consistent, but now that that’s not a scenario that we have anymore, I do think that kind of hinders having consistent advice being provided.
***
07-17-05 (social worker): I think clinicians assume the doctor has talked to the patient about being certified. Sometimes with patients who don’t know they’re certified, we’ve gone and done all these forms, and there’s a miscommunication of who’s actually told the patient what’s going on.
The organization doesn’t give staff enough resources and support
This theme falls under the TDF domains of Environmental Context and Resources and Social/Professional Role (see Table 1).
One clinician recalled her experience working in another province where the resources devoted to record keeping allowed for more accountability. In BC, where historically resources had not been allocated to auditing patient files, clinicians may not complete the forms, including Form 13, with as much care.
06-12-05 (nurse): I started practising in Alberta first before coming out here, and I was used to a system where, like, health records and so on and so forth were actually in charge of receiving the forms and ensuring that the dates and everything made sense, whereas here it seems quite strange to me that we complete them, they go in the back of the chart, and unless somebody asks to go to review panel, it’s not being reviewed or seen, so things can have lapsed or not have made sense. Sometimes you go quite far back and realize, OK, you know, actually, the forms were messed up six months ago, and you’re not actually certified. All these different things, so, yeah, it’s just kind of interesting that, yeah, they do it completely different than here.
Some clinicians cited a general lack of organizational support and staff needed to truly answer patients’ questions about their rights and their concerns about their involuntary hospitalization (TDF domain of Environmental Context and Resources):
06-12-03 (occupational therapist): At times we could not have enough staff or just things are busy, so getting the accurate explanation of the Mental Health Act might be challenging.
***
06-12-02 (social worker): If we were concerned about it, we could put on more staff. There could be more staff. So on any given day, there really is not adequate staff. And management could make the choice to change that, or not. So given at the start of every day, there’s not adequate staff, then people are trying to get all those things done, and of course my colleagues have discussed some of the difficulties with that. […] I get a lot of concerns [from patients] about, say, how long does somebody have to remain certified, and then people will naturally tend to go off on that tangent. So very time consuming, because I don’t want to escalate the patient and make things worse, so I might end up being a half an hour going over a form with them.
Finally, some participants suggested that the problem of clinicians failing to give involuntary patients consistent and complete rights information reflected their part (TDF domain of Social/Professional Role) within a paternalistic system that devalued patients’ rights and prioritized expedience over the patient experience, from police apprehension through to discharge.
07-27-13 (social worker): My impression is that it’s not necessarily prioritized as, like, a primary responsibility. I think that there’s not the, like, culture or the systemic support to help maybe prioritize rights advice in hospital… maybe the support that we need to be able to do that more effectively. I think sometimes there’s maybe a bit of a, like, some of it’s, like, about stigma. Some of it’s about attitudes, maybe, that clinicians might have around, like, their patients or perceptions around, like, what asking for information about your rights and, like, maybe some of the judgments that go on around that. I think we have some paternalistic attitudes in psychiatry, and so I think that influences maybe some of… I think that is a barrier.
***
07-17-07 (nurse): I don’t think the system is actually providing any support, specific support towards that [giving patients rights information. […] My experience was the other day working with a person that there are other systems involved—like, I mean, police is involved, I’m involved, ambulance is involved, and I’m trying to provide… like, I’m using least intrusive… and explaining everything, but the officer is standing there. She must be having a crunch by the time she has stepped forward and said, “That’s it, I’m handcuffing the patient, we’re going.” Which I totally understand. I’m not saying it from the point of criticism. But I’m saying that sometimes it’s a multifactorial situation, and it’s not that easy that we would, say, I would walk towards my patient and I say, there are so many other things in the background that it does play its own role. That it should be addressed as a whole. But definitely, I mean, my experience, it’s a system issue.
Facilitators
Although most of the participants’ comments related to barriers to giving patients rights information, some did mention factors that supported this behaviour.
A team approach allows clinicians to learn from one another about the Mental Health Act and about the rights-notification process
This theme falls under the TDF domains of Social/Professional Role and Social Influences (see Table 1).
Some clinicians reported learning from more experienced colleagues about the Mental Health Act (thus help defining their Social/Professional Role, per the TDF), which helped increase their confidence in giving rights information to involuntary patients.
05-24-16 (nurse): A facilitator for that [being confident in giving rights information] is every work environment that I’ve been in, people are super supportive in helping you with those things, so having other nurses there to help is good.
***
06-12-08 (nurse): I think just having experienced colleagues, you know, for situations where questions come up and you’re not sure how to answer them or for newer staff who are not sure when to approach a patient so that they’d be open and able to understand information and getting advice from colleagues about that could be something that supports that information getting distributed.
Several participants said that different members of the treatment team can remind one another of the responsibility of giving rights information to ensure that it is done (TDF domain of Social Influences).
05-24-12 (nurse): I think we… in hospital, it gets overlooked sometimes because we’re in such a rush, especially when it’s, like, admission, […] but I think it’s really important that we just kind of, like, you know, like, clinician to clinician to remind ourselves, like, what we’re really doing for these clients and that they really… they need to know their rights. And just kind of thinking about putting ourselves in their shoes. If we were admitted, of course, we’d want to know.
***
06-12-05 (nurse): Usually I find that our physicians are trying to complete this process together, like, so acknowledging and talking about their rights as a part of, already, when certification’s completed, […] so it’s not just myself alone with the patients. The doctor’s also involved. So I find that helpful.
***
07-17-05 (nurse): And I think maybe asking the doctor, “Have you explained this or not?”
07-17-02 (nurse): “Would you like me to explain this?”
07-17-05 (nurse): Yeah, exactly. They’re time-pinched, too.
Having one person take responsibility for rights information clarifies clinicians’ roles and increases accountability
This theme falls under the TDF domains of Social/Professional Role and Intentions (see Table 1).
A primary nursing model, where each patient is assigned a nurse who is primarily responsible for their care, clarifies that giving rights information is that nurse’s responsibility (that is, their Social/Professional Role in the TDF). A nurse who serves as coordinator in a unit may also regularly review patient files to ensure that each patient has been given their rights information when they are receptive to it. This clarity in role reinforces the clinician’s intent (TDF domain of Intentions) to give rights information.
05-29-17 (nurse): Well, I’m coordinator on the fourth floor, and so I do an audit, three to four days, or maybe a week, after the person has been admitted, and I go and I look and see a lot of times the client refused to sign. So ideally they’re a little bit more settled, so sometimes then I take the form and I go back and sort of continue that work.
***
06-12-10 (research assistant): I work primarily upstairs, um, where each patient has a primary nurse that they’re working with, so mainly having it be, like, the job of one person instead of hoping that somebody in the group has done something about it. The primary nurse of the patient would check in with them and make sure they understand that.
***
06-12-12 (nurse): We do do primary nursing upstairs, so generally the primary nurse, it’s their responsibility to have that conversation, the rights advice conversation with the client, because they have the most rapport developed already.
Accreditation processes remind clinicians of the importance of giving rights information to involuntary patients
This theme falls under the TDF domains of Social/Professional Role, Reinforcement, Goals, Behavioural Regulation, and Environmental Context and Resources (see Table 1).
One clinician stated that when their facility underwent an accreditation process, it reinforced the need for consistently completing the forms as required by the Mental Health Act. An external organization auditing and evaluating the facility’s practices (TDF domains of Environmental Context and Resources and Behavioural Regulation) based on a set of standards (TDF domain of Goals) reminded clinicians of the consequences of not fulfilling their legal obligations to give patients rights information (TDF domain of Reinforcement) and reminded them of their responsibility (TDF domain of Social/Professional Role).
07-27-10 (nurse): Something like being accredited through Accreditation Canada, as one of the other participants was saying, really pushed us to understand, like, “Oh, we have this gap in our care and we hadn’t recognized it before” […] Like that Form 13s need to be happening consistently, every single time that someone is either certified or if they have, like, that change in consciousness or cognitive ability, where those major changes are occurring, that we should be also doing it at those points.
Checklists remind clinicians of their rights-notification responsibilities
This theme falls under the TDF domains of Social/Professional Role and Environmental Context and Resources (see Table 1).
At one of the sites where we conducted focus groups, clinicians said that they had developed a series of checklists (thus introducing a tool to their environment—TDF domain Environmental Context and Resources) to delineate clinicians’ responsibilities within the involuntary admission process (that is, defining their Social/Professional Role) and sample forms to increase the likelihood that the Mental Health Act forms, including Form 13, would be completed as the legislation requires.
06-12-12 (nurse): We created a Mental Health Act checklist. So basically the checklist was to clarify who’s responsible to do what forms and when. The checklist is accompanied with an SOP, a standard operating procedure, which staff can use to help guide them. It’s just a little bit more detail. But the checklist breaks down what forms are needed, and we ask for the date, and then who was the person that signed that. […] It’s worked really well for our unit. It’s caught a lot of errors, generally from the community, where there’s a lot of errors coming in for certification, and then it also keeps track of who’s doing what when and whose responsibility. Because a lot of times with paperwork, it’s, like, “Oh, well, I don’t do that—that’s not my job.” We have it explicitly kind of broken down—whose job is it to do what.
At other sites, clinicians suggested using checklists to document whether patients had received and understood their rights information and to communicate this information to their colleagues across shift changes.
07-27-02 (nurse): We do have kind of this mental health form checklist that prints out with the chart packs. I don’t know if we could do some kind of, um, tweaking to it where, under the Form 13, like, if they refuse to sign, like, someone could make a note, like, “Refused to sign” or “Did not appear to understand—follow up.” And it could be something that is that communication tool.
***
05-24-16 (nurse): In your Kardex [medical information system for nursing staff to communicate] and in your charting and stuff you should be sharing… or documenting whether or not information has been shared and what information needs to be revisited, but then it’s the carrying over of that information I think… It’s good and fine to put it in a Kardex one day, but then if it hasn’t been done again, is it going to be in the Kardex the next day? And so… and maybe if there was some sort of a formal way of documenting that.
One participant said that a poster may also remind clinicians to give rights information to involuntary patients.
07-17-07 (nurse): I think partially what can help me is just having a poster as a reminder. […] It would be this as a reminder in the unit, you know, having that every time I pass by it, even if I have a glance at it, I would just, “Oh, OK, I should remember.” I should remember, you know, just to explain the rights of the patient to the patient when they are involuntary.
Hypothetical facilitators
During the discussion participants also suggested services or programs that did not exist but could facilitate their task of giving rights information to involuntary patients.
A legal or advocacy service that clinicians could contact with questions about the Mental Health Act would allow clinicians to better help patients exercise their rights
This theme falls under the TDF domains of Knowledge, Social/Professional Role, and Environmental Context and Resources (see Table 1).
Several participants said that they would appreciate a service staffed by lawyers or legal advocates well versed in the Mental Health Act (thus adding to their Environmental Context and Resources) that they could freely consult to answer their own or patients’ questions relating to the legislation (TDF domain of Knowledge). Some participants understood that as clinicians, they could not be expected to be experts on the law (TDF domain of Social/Professional Role) but they expressed a reluctance to contact legal professionals directly, owing to cost.
07-17-01 (nurse): When Riverview [psychiatric hospital] was fully functioning […] there was a direct call to Riverview review panel there, and they have that patient rights department, where you just call in, and patients… they can speak directly to the patient as well, so that system was there, where you have direct contact to the review panel or patient rights advocacy at Riverview Hospital.
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07-17-02 (nurse): Yeah. I wonder if a service like that, that would have to almost act like a consultation service where things get a little bit more in-depth, where it is beyond our ability to explain, you know, where it becomes a little bit more legal, a service like that would probably be helpful, where we can almost call in and receive for ourselves or for our clients some advice around, “OK here’s a really good question that I don’t know the answer to,” and maybe somebody who has some legal background might be able to answer it for us. That would be, I think, a helpful service.
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07-27-10 (nurse): the thing that I would like to see, like someone like CLAS [Community Legal Assistance Society] or another organization is to basically have, that almost like an open line of communication, so that you have, like, access to someone that you’re not, um, feeling like you’re taking up their time for free asking questions about, you know, like, “My patient is asking me this, how do I figure this out?” […] Like, an open email that gets answered every day or something like that, so that you’re not feeling like you’re taking up a lawyer’s time, because it’s like… that’s, like, I think one of the sort of, like, rumours or ideas that lawyers, like, they’re so expensive, it’s like, why would you call a lawyer—maybe, like, you’ll get charged.
Regular, open information sessions for patients would give them opportunities to learn about their rights when they are ready to receive the information
This theme falls under the TDF domain of Environmental Context and Resources (see Table 1).
Some participants suggesting reviving old or revising existing group programs (thus adding to the Environmental Context and Resources) to offer patients other means of learning about their rights beyond the rights notification required during the admission process. These programs would give clinicians an opportunity to convey rights information when patients may be more receptive to it.
05-29-10 (recreational therapist): I used to work at Riverview way back 20 years ago, and MPA [an advocacy and empowerment group for people with mental illness, known at the time as the “Mental Patients’ Association” and now known simply as the MPA Society] did a lot of the advocacy, and we… they had a coffee program, and clients could come when they were ready to come and seek that… advice or that support. It’d be kinda cool to have something like that monthly here or something, where if somebody wants to know more information, they could come, so it’s not, like… Like, I think when you take it to the unit, then it’s kind of being forced on them, but it’s almost better when they are coming themselves to find out the information. It’s more like you have this opportunity, you can go down and you can find it, and I think it’s empowering the clients a little bit more when you have something that’s more like on a drop-in basis or something like that.
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07-27-14 (social worker): We have a group program, and we could easily facilitate someone coming in and presenting on these issues, yeah, and helping clients have the space and time to actually contemplate and think about and ask questions. As opposed to the sometimes rushed clinical process after the context of a psychiatric appointment that’s, like, very short.