Introduction

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.

Methods

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).

Figure 1

Table 1: Knowledge-based true/false statements

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.

Results

Who was aware of the Adults with Incapacity (Scotland) Act? Forty-eight people participated in the study, comprising eighteen doctors, twenty-four nurses and six nursing auxiliaries. All doctors, twenty-one nurses (87.5%) and three auxiliaries (50%) were aware of the Act (Figure 1, below).

Figure 2

Where had participants obtained their knowledge? Two doctors had received no training on the Act, and five reported they were self-taught. The remaining 11 doctors had all received face-to-face teaching, six from their Employer/Health Board and five at University.

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.

What is understood by The Adults with Incapacity (Scotland) Act? Responses to this were variable. While some showed an accurate interpretation of the Act, the majority showed a more basic level of understanding. For example, one respondent answered:

“[The Act] allows treatments to be given to patients who lack capacity to make a decision regarding this.” (Doctor 1)

Some responses, however, suggested a poorer understanding, in addition to showing confusion with the Mental Health (Care & Treatment) (Scotland) Act 2003:

“[The Act is] a form signed to over-ride [patients who cannot make decisions] for their best interests so that health care professionals can make their decisions for them or detain them in hospital”. (Nurse 1)

“If adults don’t have capacity a doctor can fill in a form which lets a relative make decisions in the best interest of the patient”. (Nurse 2)

Knowledge-based assessment. The responses to the four knowledge-based true/false statements (listed in Table 1) are shown in Table 2. Knowledge was generally good amongst the doctors surveyed, with all participants recognising the important difference between the Adults with Incapacity (Scotland) Act and Mental Health (Care & Treatment) (Scotland) Act. Knowledge regarding the role of relatives in decision making was however poor for all groups, but particularly amongst the nurses surveyed.

Figure 3

Table 2: Responses to knowledge based questions

For doctors, did confidence levels correlate with knowledge? As shown in Figure 2 (below), all doctors who felt fully confident in using The Adults with Incapacity Act answered all questions correctly. Almost half of the doctors did not feel confident in using the Act despite answering all questions correctly. The two doctors who had only answered two questions correctly recognised that they were not confident with the Act.

Figure 4

Did the information sheet make a difference to knowledge of The Act? Two doctors, three nurses and one nursing auxiliary did not complete the second questionnaire and so their initial results were excluded from the following results. This left a total of 42 participants, representing a return rate of 87.5% for the second questionnaire. Cumulative data is shown in Table 3 (and individual results in Appendix 3). Paired t-tests were then used to compare and assess significance between pre- and post- information sheet answers to the knowledge-based questions. For both nurses and nursing auxiliaries, the improvement in scores was highly significant with p=0.0001 and p=0.0042 respectively. There was no significant improvement for doctors (p=0.1881), although it was recognised that their baseline knowledge was already high.

Figure 5

Table 3: Cumulative correct responses

Discussion

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.

Limitations of the study: This study used a relatively small sample size and was performed in one particular division of the hospital so may therefore not reflect the hospital as a whole. Although junior and senior medical and nursing staff were represented in the survey, we did not officially record the grade of subjects to encourage participation. In an ideal situation participants would have completed the second questionnaire several days after having been given the information sheet, so as better to assess retention of the information. Due to time constraints this was not possible, and we relied on asking participants to complete the second questionnaire in their own time before returning the form. Future work could be done to re-assess whether participants in a similar study retain the information over the intermediate to longer term.

Conclusions and Further Thoughts: Understanding and knowledge levels of the Adults with Incapacity (Scotland) Act are variable amongst healthcare professionals. It is important that all nurses and doctors working within Medicine of the Elderly divisions (and indeed other clinical medical and surgical areas of practise that care for individuals that may be required to use the Act on a regular basis) have adequate understanding of relevant areas of the Act that relate to their clinical practice. The provision of a simple information sheet appears to be a useful tool in improving the knowledge and understanding of the basic principles of the Act amongst healthcare workers. Following this finding, an electronic package, easily accessible to all professions might be an ideal, cost-effective format for the delivery of initial basic training. Finally, it should be considered a duty for health professionals to be able to communicate accurate information about the Act to patients and their relatives.

Figure 6

Appendix 1: The questionnaire

Figure 7

Appendix 2: The information sheet

Figure 8

Appendix 3: Reponses to knowledge-based questions before (Part 1) and after (Part 2) provision of the information sheet.