A Todd, T Russ, O Ogundipe
‘adults with incapacity scotland act 2000, ’ ‘healthcare workers.’, ’ ‘information sheet, ’ ‘knowledge, ’ ‘understanding
A Todd, T Russ, O Ogundipe. A Survey of the Understanding of the Adults with Incapacity Act in an Edinburgh Teaching Hospital.. The Internet Journal of Law, Healthcare and Ethics. 2008 Volume 6 Number 2.
The Adults with Incapacity (Scotland) Act 2000 allows doctors and others to act on behalf of adult patients deemed incapable of making, communicating or understanding decisions, by reason of mental disorder or inability to communicate due to physical disability(1). Decisions should be in keeping with any known wishes of the patient and allow actions which are “reasonable in the circumstances to safeguard or promote the physical or mental health of the adult.” Any action must be intended to benefit the patient.
It is imperative for patient safety that those involved in the care of incapable adults are aware of the Adults with Incapacity Act, and that doctors authorising relevant forms in Scotland are fully aware of its indications and implications and their statutory responsibilities. In the authors’ experience, the Adults with Incapacity Act is not always well understood, and is sometimes confused with the Mental Health (Care & Treatment) (Scotland) Act 2003 which provides for the detention of people with a mental disorder.
Two years following the introduction of the Adults with Incapacity Act, a survey in the West of Scotland suggested that knowledge and understanding of the Act was poor(2). Seven years later, we examined whether knowledge and understanding of the Adults with Incapacity (Scotland) Act has improved. We also examined whether the provision of an information sheet improved basic understanding of the Act amongst healthcare workers or not.
The Royal Infirmary of Edinburgh is a tertiary hospital with teaching hospital status based in the South East of Scotland. Acute Medicine of the Elderly wards represent an area where the Adults with Incapacity (Scotland) Act 2000 was likely to be in use regularly, and so it was decided to survey this area.
A non-random selection of willing doctors, nurses and nursing auxiliaries working in the acute Medicine of the Elderly wards in the Royal Infirmary of Edinburgh was surveyed between July and August 2009. Each participant was asked to complete an anonymous questionnaire (see Appendix 1). In brief, this asked if he/she had heard of the Act, what was understood by it (as a free-text question) and how confident each participant felt with its use. Four knowledge-based questions in a true or false format were also included (Table 1).
Following completion of the first questionnaire, participants were given a one page information sheet about the Adults with Incapacity Act (Appendix 2). They were then asked to submit a repeat questionnaire at their convenience. Questionnaires were anonymous but coded so as to allow paired analyses which were conducted using paired t-tests.
Five nurses reported having had no training on the Act, three were self-taught and two had been taught at University. The remaining 14 had received training from the Health Board/Employer, the majority in an electronic format. Half of the nursing auxiliaries were aware of the Act, but none had had any formal training.
Some responses, however, suggested a poorer understanding, in addition to showing confusion with the Mental Health (Care & Treatment) (Scotland) Act 2003:
The Adults with Incapacity (Scotland) Act 2000 allows doctors to be advocates for the health of patients who are deemed incapable according to the specifications of the Act. It is a legal framework and it is imperative that doctors authorising or completing relevant forms (e.g. section 47 being the most commonly used part in acute hospitals – see Information Sheet in Appendix 2), as well as healthcare professionals caring for patients under the Act, are well aware of its indications and implications. There have been concerns that many years after the introduction of the Act there still appear to be suboptimal understanding of its central components (in relation to routine clinical practice). There is no evidence to suggest that this limited understanding is restricted to any particular hospital(s), institution(s) or region(s) in Scotland.
Whilst all doctors were aware of the Act in this study, it is concerning that three trained staff nurses reported that they had never heard of the Adults with Incapacity (Scotland) Act. For both doctors and nurses, it was noted that some of those who reported that they were aware of the presence of the Act still appeared to misunderstand its use.
Most nurses who were aware of the Act had received training from their employer, delivered electronically in most cases. This compared with only one third of doctors who had received training from the Health Board/employer. An electronic format of training potentially could serve as an easy to access component of introductory training in the Act. However, as with all aspects of on-line learning, safeguards are needed to ensure the training is effective and tailored to the specific needs of staff undertaking it.
Reassuringly, most doctors had a good basic level of knowledge about the Act and those who were less sure did not have false confidence in their ability. One would hope that the latter, in recognising this limitation, would seek advice from more experienced doctors as appropriate. While there was little change in doctors’ knowledge following provision of the information sheet, baseline levels were acknowledged to have been higher than in the other survey subgroups (with a cumulative score of 59 out of a possible 64 amongst the doctors). Improvement in knowledge following the provision of the information sheet was highly statistically significant for nurses and nursing auxiliaries.