- Email: [email protected]
Knowledge of Section 23 of the Mental Health Act
Australasian Emergency Nursing Journal (2006) 8, 149—155
Knowledge of Section 23 of the Mental Health Act Russell Boyd, FACEM ∗, Sharon Semmler, MBBS Emergency Department, Lyell McEwin Health Services, Haydown Road, Elizabeth Vale, SA 5112, Australia KEYWORDS Mental health; Emergency Department; Police; Ambulance; Section 23
Summary Objectives: Section 23 of the Mental Health Act of South Australia contains legislation entitling members of the police force to apprehend and transfer for medical opinion, members of the public who are perceived to be suffering from mental illness. The objective of this study was to evaluate knowledge of Section 23 of the Mental Health Act amongst police, ambulance, emergency medical and nursing staff. Methods: A structured questionnaire was developed and distributed to a total of 214 police, ambulance and ED staff. The study was undertaken from December 2002 to April 2004. A combination of face-to-face and postal administration was used. Data was collated using Microsoft excel software. Results: The overall response rate was 89%. Knowledge concerning the proscribed detention and transfer powers available to the police and ambulance officers was best amongst police officers. There was a general misconception that persons held under Section 23 must be taken to an Emergency Department. There was a general desire to ensure written documentation was produced especially amongst the ED staff. Pre-qualification training concerning Section 23 is poor especially amongst medical staff. Conclusions: Knowledge of Section 23 of the Mental Health Act of South Australia was variable with the police officers showing the best knowledge. Teaching for medical staff concerning mental health legislation was poor. A clear desire for further teaching about mental health legislation was identified in all groups and should be enacted. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Current Mental Health legislation in South Australia1 as in most Australian states, bears ∗
Corresponding author. Tel.: +61 08 818123 9000; fax: +61 08 8182 9179. E-mail address: [email protected] (R. Boyd).
great similarity to the precursors of the Mental Health Acts of England. In particular, both contain legislation entitling members of the relevant police force to apprehend and transfer for medical opinion, members of the public who are perceived to be suffering from mental illness. These powers date historically from the English Vagrancy acts of 1714 and 1744 that allowed a police constable on
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.12.001
150 the order of two magistrates to lock up a ‘‘lunatic pauper’’ in a secure place. Section 23 of the Mental Health Act (SA) is designed to enable members of the police force to forcibly detain individuals who are felt to be, in the opinion of the police officer, suffering from ‘‘a disorder of the mind’’. This power specifically entitles the police to detain individuals not only in public places but also enable them to break into private residences. There is no definitive medical definition of ‘‘disorder of the mind’’ in the act and as such it is interpreted to include all higher cognitive dysfunction be that organic or non-organic. The Act also entitles ambulance officers to forcibly transfer such individuals at the request of the police. The individual must be taken as soon as is practicable to an unspecified location in order to be examined by a registered medical practitioner. The act also includes provisions for the detention and transfer of individuals who are currently under the jurisdiction of sections of the Mental Health Act who have absconded or defaulted from the terms of their treatment or detention orders. The act has been revised on several occasions most recently in 1993, however the wording is still very general in nature, as is evidenced by the term ‘‘disorder of the mind’’. Work from the UK2 suggests that knowledge of the specifics of these types of powers (included under section 136 of the Mental Health Act England and Wales) amongst most professional groups who regularly use said Mental Health Act is in fact poor. Anecdotal evidence in South Australia would seem to confirm this observation and a detailed literature search revealed no evidence of comparable research into current levels of knowledge amongst the relevant professional groups within Australia as a whole. Some limited work has been performed with mental health nurses in New Zealand and has highlighted some issues within the relevant legislation.3 The aim of this study was to ascertain current levels of knowledge concerning Section 23 of the Mental Health Act in South Australia among the various professional groups who do in fact use this act on a regular basis. In addition we also wished to identify key areas for future education and training amongst these various professional groups.
Methods This study was a cross sectional survey of volunteers from the police, ambulance, emergency nursing and medical staff in South Australia. All groups were
R. Boyd, S. Semmler included as they are actively involved in the implementation and discharge of this particular section of the Mental Health Act. The study was conducted in the period from December 2004 to April 2004. Ethics approval was sought and obtained from the North West Adelaide Research and Ethics Committee. The questionnaire was designed by an ED peer group consisting of ED registrars, staff specialists, nurses and a former consultant psychiatrist. It was structured to elicit discrete Yes/No responses to a sequence of 37 questions concerning 15 discrete areas that Section 23 covers within the Mental Health Act. An additional four questions were placed at the end of the questionnaire to elicit Yes/No discrete answers to question concerning the individual’s previous training and future needs for training in respect to the Mental Health Act. The questionnaire is included as Appendix A. Relevant sections of the Mental Health Act of South Australia (1993) were studied during question development. All attempts possible were made to produce definitive questions with minimal ambiguity but the relevant act is worded so as to be open to interpretation. The group acknowledged this potential for ambiguity. Therefore, to ensure a perspective other than that of ED personnel, the completed questionnaire was reviewed and revised by a recent Consultant Psychiatrist and past member of The Guardianship Board of South Australia with a view to establishing maximal clarity, and minimal ambiguity. Revisions, as provided by the expert opinion of our guardian ship colleague, were incorporated into the revised final draft of the questionnaire. The Guardianship Board acts as an appeal body in cases of misapplication or uncertainty over interpretation of the Mental Health Act. Participation in the survey was voluntary. The questionnaire was distributed by hand or by post. The questionnaire was distributed to 89 members of the northern metropolitan division of the South Australian Police Force (SAPOL). This was undertaken during mandatory update training and was completed anonymously on an individual basis. Individuals were given a questionnaire and asked to complete them immediately upon on receipt. All South Australian Ambulance Service (SAAS) Paramedic and Intensive Care Paramedic officers from two metropolitan ambulance stations were distributed surveys by hand via their station manager. The survey was again completed anonymously on an individual basis. Thirty-eight questionnaires were distributed to ambulance officers. The sur-
Knowledge of Mental Health Act (Section 23) vey was also distributed by hand to all consenting nursing staff at the annual state ED nursing conference. Again, individuals were asked to complete the survey on an individual basis immediately upon on receipt of the questionnaire. Fifty-eight questionnaires were distributed to emergency nurses. The questionnaire was completed on an individual basis and returned anonymously. All of the above questionnaires were distributed by hand but were completed outwith the presence of the distributor and authors. The survey was administered by post to all ED registrars registered for advanced emergency medicine training in South Australia, with a second blanket follow-up mailing to increase the response rate. Respondents were asked to complete the questionnaire without use of reference texts. A total of 33 questionnaires were given to ED medical officers. Respondents were asked to refrain from completing a further survey if they had already completed one to avoid result duplication. Data was collected and collated on Microsoft Excel software.
Results Two hundred fourteen questionnaires were distributed. A total of 193 replies were collected with an overall response rate of 89%. One hundred percent of SAPOL officers, 82% of SAAS officers, 83% of ED nurses and 79% of ED medical staff participated in the project. Section 23 of the Mental Health Act of South Australia covers proscribed powers for both Police and Ambulance officers. The police powers were recognised by all SAPOL officers and by 94% of SAAS officers, 94% of nursing and 96% of medical staff. The Ambulance officer powers were recognised by 83% of SAAS officers, 55% of SAPOL officers, 69% of nursing and 73% of medical staff. Apprehension powers rest only with police officers and this was identified by 100% of police officers. Current legislation also empowers police officers to force entry to any premises in order to apprehend a person. This was correctly identified in 74% of cases by the SAPOL officers. Section 23 does not set any age limits and potentially covers the entire age spectrum. This was correctly identified by 90% of SAPOL officers but by only 50% of emergency doctors and 40% of emergency nurses (55% in SAAS officers). In addition no history of diagnosed mental illness need be present for the legislation to be enacted. This was identified correctly by 80% of police officers, 85% of ED
151 doctors but only 44% of ED nurses and 45% of SAAS officers. The Mental Health Act of South Australia identifies that to enact Section 23 the member of the public apprehended, must be exhibiting ‘‘any form of disorder of the mind’’. This was correctly stated by 51% of SAPOL and SAAS officers. Medical and nursing staff identified this in 58% and 44% of respondents. In addition, the act states the person apprehended must be deemed to be at risk to either themselves or others. Ninety-four percent of SAPOL officer and 84% of SAAS officer replies correctly identified this. Ninety-four percent of nursing staff but only 69% of medical staff identified this. Section 23 contains provisions to cover forced apprehension of persons already detained under other sections of the Mental Health Act. These cover the forced return of persons who have absconded from treatment centres whilst still detained and also persons who are failing to comply with the terms of their treatment orders in the community. This was identified correctly by 90% of police officers with reference to absconded patients and 69% of cases with reference to patients failing to adhere to their community treatment order. Amongst emergency doctors only 64% correctly identified the powers with reference to absconded patients and only 35% identified the powers with reference to treatment order failures. In nursing staff, 88% of staff identified the police powers with reference to absconded patients but only 52% identified the powers with reference to failure of compliance with community treatment orders. Responses suggest that it is poorly known to where apprehended persons should be taken. Only 60% of SAPOL officers correctly identified that persons can be taken to a medical practitioner regardless of actual location. The most popular but incorrect response was in fact that persons should be taken direct to an Emergency Department. A similar response was present with the SAAS officers and indeed only 69% of emergency doctors were indeed correct with the next most popular response again incorrectly stating conveyance to an Emergency Department (42%). Emergency Nurses incorrectly felt the Emergency Department was the preferred site in 45% of cases with only 31% correctly identifying the stipulation of any location being suitable for medical review. Section 23 of the Mental Health Act of South Australia states only, that assessment must be made by a registered medical practitioner, and does not include any other mental health workers or specialists in that assessment need. The emergency doctors identified this correctly in 92% of cases
152 with the emergency nurses correct in 81% of cases. SAPOL officers responded correctly in 70% of cases. SAAS officers identified this correctly in 58% of cases. The act identifies that police merely need to transfer the person to a site to be seen by a medical practitioner and does not stipulate that they need stay once they have arrived at that site. Ninety percent of the police officers questioned, incorrectly stated they believed they had to stay with said person until that person was formally detained or released by the treating medical officer. Only 8% of nursing and 46% of medical staff felt SAPOL officers had to stay after completing the transfer. In addition, the act states police may stay and render any assistance felt necessary if asked by the receiving site. This is in fact not a statutory obligation, but 91% of police officers answered that they felt it was a compulsory part of their responsibilities to stay and assist if asked. No formal written documentation concerning the enactment of Section 23 of the Mental Health Act of South Australia is required to be produced for either the receiving site or the person apprehended. The police officers questioned identified this correctly in 78% and 91% of cases, respectively. Emergency doctors and nurses were aware of this in only 36% and 17% of cases, respectively. On questioning, 46% of SAPOL officers felt written documentation would be desirable whilst 85% of emergency doctors and 96% of emergency nurses felt written documentation would be desirable. In terms of training, 91% of SAPOL officers and 77% of SAAS officers receive training concerning Section 23 of the Mental Health Act in the prequalification phase of training. Only 8% of emergency doctors and 19% of emergency nurses stated that they had received training concerning this section during their pre-registration training. Furthermore, only 19% of emergency doctors and 40% of emergency nurses stated they had had received training concerning Section 23 during their postregistration training. Twenty-five percent of SAPOL officers and 33% of SAAS officers stated that they had received post-graduation training. There was a general identification for a need for continued training regarding Section 23 with a mean of 89% being in favour of this need across all groups.
Study limitations The Mental Health Act has deliberately been written so as to be open to interpretation on various points. As such it is extremely difficult to create
R. Boyd, S. Semmler unambiguous questions or questions with discrete yes or no answers. Thus, although a past member of the guardianship board was involved in reviewing and refining the questionnaire the questions may not have been truly without ambiguity. The survey was administered in a non-uniform fashion depending on the access to the target audience. This varied from direct person to person contact with the SAPOL officers to mailing for the medical officers. This may have introduced some degree of bias as the more open conditions for the medical and SAAS officers may have allowed greater time for reflection or access to written materials. In addition, the questionnaire was of course voluntary and bias may have existed as only ‘‘interested’’ respondents provided replies. The respondents may have had particular views or levels of knowledge in the field. As yet there has been no way to measure if this study has external reliability as no previous work is available from other states in Australia and the previous UK work is based on a different mental health act although it does share core principles.
Discussion We have identified that in general, knowledge concerning Section 23 is better in South Australia than in the UK.2 This is evident with the SA police correctly identifying Section 23 as an act that empowers police officers alone to apprehend as opposed to their UK counterparts who identified their version as a police apprehension power in only 56% of cases. There are however, still specific areas that would suggest some problems either in dissemination of knowledge or interpretation of the actual act itself. Nearly all police officers, medical and nursing staff identified that the person apprehended should be deemed to be at risk to themselves or others. This seems to be at odds with the finding that only 50% of police officers felt a person needed to have a disorder of the mind to be covered by the act. This may reflect the somewhat grey nature of the wording contained within the act. The Act as pertains to South Australia states that any person deemed to be suffering from a disorder of the mind, regardless of its potential cause can be apprehended. The Act as applies to South Australia would appear to be written from an all-encompassing viewpoint including both organic and non-organic brain disorders. Our responses would appear to indicate there is moderately good knowledge concerning the main
Knowledge of Mental Health Act (Section 23) function of Section 23. However, knowledge concerning secondary powers namely the apprehension of absconded patients or patients who have failed to comply with community treatment is poorer across all groups with the highest scores again with the police officers. This may be explained partly by the fact that emergency department staff does not usually have detailed involvement in community treatment. Section 23 of the Mental Health Act of South Australia does not require any formal written documentation to be produced either for the police, receiving unit or the apprehended person. This appears to be in contrast to what most medical and nursing staff believe to be so. Our survey suggests that there is a perceived need for some form of documentation especially amongst the health care professionals however there appears some reticence amongst the SAPOL officers. The misconception that all persons apprehended under Section 23 of the Mental Health Act of South Australia must be taken to an Emergency Department is of particular note. This was strongest amongst the police and nursing staff. The act states that a patient is to be taken as soon as practicable to a medical practitioner for assessment. In rural or country areas this, by necessity, may not be an Emergency Department and our responses may reflect the urban site used for the police officer survey although few major differences overall do exist.4 Emergency Departments have historically not been designed or funded for the assessment and often prolonged stays associated with this complex group5 , many of whom may not have any treatable mental illness. This appears to mirror work in the UK.3 The increasing trend to the care of mental illness in the community without the corresponding increase in acute community mental health services has led to the police force6 and as demonstrated by this paper, the emergency department to become the receiving area for acute community crisis care or enforcement of failed community treatment orders. This has been demonstrated in South Australia in particular with Kalucy et al showing a 10-fold rise in mental health presentations in general, to the emergency department of a major South Australian teaching hospital7 over a 10-year period. The current move from institutional care to community care does not appear to have been effective with emergency departments becoming the fallback safety net for self and police referred cases.8 The results from our survey would appear to confirm that either by default or misinterpretation Emergency Departments are becoming the defacto community crisis care resource.
153 Emergency departments are by consensus inappropriate areas for caring for agitated or at risk clients9 and as a rule have received little additional resources for such a 10-fold increase in client numbers.7 Finally, the results concerning training are noteworthy. Only 8% of emergency medical and only 19% of emergency nursing staff state that they had received specific training on this section of the Mental Health Act during their undergraduate careers. Postgraduate training would appear not to be much better, with only 19% of emergency department doctors stating they had received training. This paucity of training clearly identifies an area for improvement in emergency department training schedules. This questionnaire does not demonstrate any direct deficit in patient care or evidence of harm but does demonstrate that there are considerable differences between professional groups in their interpretation of the act and their ability to put it into practice. This may reflect poor training, historical attitudes or that the act itself is vague and open to interpretation.
Conclusion Knowledge of Section 23 of the Mental Health Act of South Australia was variable with the police officer group showing the best levels of knowledge. These variations may reflect different knowledge levels or different interpretations of the Act itself. There is an overall desire for the introduction of formal documentation to the use of the act. There were near universal calls for increased training concerning the act.
Acknowledgements We would like to greatly thank all the members of SAPOL, SAAS and the Emergency Departments surveyed during this study for their help and cooperation. We would also like to thank Dr. John Cooper-Smart for his invaluable advice and analysis of the questionnaire. We would like to thank Ms. Jackie Wilton for her assistance with data entry and analysis. Contributions: RB was responsible for the original concept and initial research proposal, RB and SS submitted ethics applications, produced the questionnaire. SS distributed the questionnaire. RB and SS analysed the data and wrote the draft paper.
154
Appendix A. Section 23 Mental Health Act of South Australia Questionnaire form Questionnaire Please answer in the Yes or No box on the attached anonymous answer sheet (1) Section 23 of the Mental Health Act of SA specifically covers the rights and responsibilities of Police only? (2) Section 23 of the Mental Health Act of SA specifically covers the rights and responsibilities of Police and Ambulance Officers? (3) Does Section 23 enable the following to independently apprehend a person (a) South Australian ambulance officers? (b) Volunteer ambulance officers, e.g. St. John’s? (c) Police officers? (d) Social workers? (e) Mental health nurses? (4) Section 23 relates only to the following people (a) Those older than 18 years? (b) Those with a diagnosed mental illness, e.g. schizophrenia/depression? (c) Those showing any form of disorder of the mind? (d) Those considered only to be a threat to themselves or others? (5) Section 23 of the Mental Health Act of SA also (a) Enables police officers to return detained patients who have left a treatment centre unlawfully? (b) Enables police officers to return mental health patients to a treatment centre who have failed to comply with treatment? (6) People apprehended under this section of the Mental Health Act must be taken to (a) A police station? (b) A psychiatric unit? (c) An emergency department? (d) A medical practitioner? (7) The patient must be taken to that place (a) Within 24 h? (b) Within 4 h? (c) As soon as is practicable? (8) The person apprehended must be examined by (a) A registered Mental Health Nurse? (b) A registered specialist in psychiatry? (c) Any grade of psychiatrist? (d) A registered Medical Practitioner? (9) A member of the police force has the right to break into any premise under this Act to apprehend a person?
R. Boyd, S. Semmler (10) An ambulance officer has the right to break into any premise to apprehend a person? (11) An ambulance officer (a) Can apprehend a person using this section independently of the police? (b) May only forcibly convey a person if summoned by the police? (c) May not use reasonable force even if necessary? (12) Once the patient has arrived at a medical assessment area (a) Police and ambulance officers have completely discharged their duties and are free to leave? (b) Must remain until the person apprehended is formally released or detained? (c) If requested must render such assistance to the assessing centre as may be necessary to assess the patient? (13) Section 23 of the Mental Health Act (a) Does not relate to detained patients under the Mental Health Act? (b) Relates to detained patients who are being transferred? (c) Relates to detained patients who abscond? (14) Written documentation of some type is required to enforce this section? (15) The person apprehended must be given written confirmation of their apprehension under this section of the Mental Health Act? (16) Were you taught about this Section of the Mental Health Act? (a) During initial basic training? (b) Since you have left basic training? (17) Do you agree formal documentation should be introduced for this section of the Mental Health Act? (18) Do you agree there is a need for regular training in the use of this section of the Mental Health Act?
References 1. Mental Health Act of South Australia 1993. Adelaide: South Australian Parliament Publication; 1993. 2. Lynch RM, Simpson M, Higson M. Grout P Section 136. The Mental Health Act 1983: Levels of knowledge among accident and emergency doctors, senior nurses and police constables. Emerg Med J 2002;19:295—300. 3. Farrow T, McKenna B, O’Brien A. Advanced ‘‘prescribing’’ of nurses emergency holding powers under New Zealand mental health legislation. Int J Mental Health Nurs 2002;11:164—9. 4. Caldwell T, Jorm A, Dear K. Suicide and mental health ion rural, remote and metropolitan areas in Australia. MJA 2004;181:S10—4. 5. Royal College of Psychiatrists. Report of a joint working party of the royal college of psychiatrists and the British Associ-
Knowledge of Mental Health Act (Section 23) ation for Accident and Emergency Medicine. London: RCP; 1996. 6. Prior C. Peace of mind? Police Rev 1999;107:16—7. 7. Kalucy R, Thomas L, King D. Changing demand for mental health services in the emergency department of a public hospital. Aust N Z J Psychiat 2004;39:74—8.
155 8. Perry A, Hatfield B, Spurrell B. Specialist service use following psychiatric emergency presentation: an 18 month followup study. Health Social Care Community 2002;10(6):457—63. 9. Hatfield B, Spurrell M, Perry A. Characteristics of patients presenting for emergency psychiatric assessment at an English hospital. Psychiat Serv 2003;54(2):240—5.
Knowledge of Section 23 of the Mental Health Act Russell Boyd, FACEM ∗, Sharon Semmler, MBBS Emergency Department, Lyell McEwin Health Services, Haydown Road, Elizabeth Vale, SA 5112, Australia KEYWORDS Mental health; Emergency Department; Police; Ambulance; Section 23
Summary Objectives: Section 23 of the Mental Health Act of South Australia contains legislation entitling members of the police force to apprehend and transfer for medical opinion, members of the public who are perceived to be suffering from mental illness. The objective of this study was to evaluate knowledge of Section 23 of the Mental Health Act amongst police, ambulance, emergency medical and nursing staff. Methods: A structured questionnaire was developed and distributed to a total of 214 police, ambulance and ED staff. The study was undertaken from December 2002 to April 2004. A combination of face-to-face and postal administration was used. Data was collated using Microsoft excel software. Results: The overall response rate was 89%. Knowledge concerning the proscribed detention and transfer powers available to the police and ambulance officers was best amongst police officers. There was a general misconception that persons held under Section 23 must be taken to an Emergency Department. There was a general desire to ensure written documentation was produced especially amongst the ED staff. Pre-qualification training concerning Section 23 is poor especially amongst medical staff. Conclusions: Knowledge of Section 23 of the Mental Health Act of South Australia was variable with the police officers showing the best knowledge. Teaching for medical staff concerning mental health legislation was poor. A clear desire for further teaching about mental health legislation was identified in all groups and should be enacted. © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Current Mental Health legislation in South Australia1 as in most Australian states, bears ∗
Corresponding author. Tel.: +61 08 818123 9000; fax: +61 08 8182 9179. E-mail address: [email protected] (R. Boyd).
great similarity to the precursors of the Mental Health Acts of England. In particular, both contain legislation entitling members of the relevant police force to apprehend and transfer for medical opinion, members of the public who are perceived to be suffering from mental illness. These powers date historically from the English Vagrancy acts of 1714 and 1744 that allowed a police constable on
1574-6267/$ — see front matter © 2006 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.aenj.2005.12.001
150 the order of two magistrates to lock up a ‘‘lunatic pauper’’ in a secure place. Section 23 of the Mental Health Act (SA) is designed to enable members of the police force to forcibly detain individuals who are felt to be, in the opinion of the police officer, suffering from ‘‘a disorder of the mind’’. This power specifically entitles the police to detain individuals not only in public places but also enable them to break into private residences. There is no definitive medical definition of ‘‘disorder of the mind’’ in the act and as such it is interpreted to include all higher cognitive dysfunction be that organic or non-organic. The Act also entitles ambulance officers to forcibly transfer such individuals at the request of the police. The individual must be taken as soon as is practicable to an unspecified location in order to be examined by a registered medical practitioner. The act also includes provisions for the detention and transfer of individuals who are currently under the jurisdiction of sections of the Mental Health Act who have absconded or defaulted from the terms of their treatment or detention orders. The act has been revised on several occasions most recently in 1993, however the wording is still very general in nature, as is evidenced by the term ‘‘disorder of the mind’’. Work from the UK2 suggests that knowledge of the specifics of these types of powers (included under section 136 of the Mental Health Act England and Wales) amongst most professional groups who regularly use said Mental Health Act is in fact poor. Anecdotal evidence in South Australia would seem to confirm this observation and a detailed literature search revealed no evidence of comparable research into current levels of knowledge amongst the relevant professional groups within Australia as a whole. Some limited work has been performed with mental health nurses in New Zealand and has highlighted some issues within the relevant legislation.3 The aim of this study was to ascertain current levels of knowledge concerning Section 23 of the Mental Health Act in South Australia among the various professional groups who do in fact use this act on a regular basis. In addition we also wished to identify key areas for future education and training amongst these various professional groups.
Methods This study was a cross sectional survey of volunteers from the police, ambulance, emergency nursing and medical staff in South Australia. All groups were
R. Boyd, S. Semmler included as they are actively involved in the implementation and discharge of this particular section of the Mental Health Act. The study was conducted in the period from December 2004 to April 2004. Ethics approval was sought and obtained from the North West Adelaide Research and Ethics Committee. The questionnaire was designed by an ED peer group consisting of ED registrars, staff specialists, nurses and a former consultant psychiatrist. It was structured to elicit discrete Yes/No responses to a sequence of 37 questions concerning 15 discrete areas that Section 23 covers within the Mental Health Act. An additional four questions were placed at the end of the questionnaire to elicit Yes/No discrete answers to question concerning the individual’s previous training and future needs for training in respect to the Mental Health Act. The questionnaire is included as Appendix A. Relevant sections of the Mental Health Act of South Australia (1993) were studied during question development. All attempts possible were made to produce definitive questions with minimal ambiguity but the relevant act is worded so as to be open to interpretation. The group acknowledged this potential for ambiguity. Therefore, to ensure a perspective other than that of ED personnel, the completed questionnaire was reviewed and revised by a recent Consultant Psychiatrist and past member of The Guardianship Board of South Australia with a view to establishing maximal clarity, and minimal ambiguity. Revisions, as provided by the expert opinion of our guardian ship colleague, were incorporated into the revised final draft of the questionnaire. The Guardianship Board acts as an appeal body in cases of misapplication or uncertainty over interpretation of the Mental Health Act. Participation in the survey was voluntary. The questionnaire was distributed by hand or by post. The questionnaire was distributed to 89 members of the northern metropolitan division of the South Australian Police Force (SAPOL). This was undertaken during mandatory update training and was completed anonymously on an individual basis. Individuals were given a questionnaire and asked to complete them immediately upon on receipt. All South Australian Ambulance Service (SAAS) Paramedic and Intensive Care Paramedic officers from two metropolitan ambulance stations were distributed surveys by hand via their station manager. The survey was again completed anonymously on an individual basis. Thirty-eight questionnaires were distributed to ambulance officers. The sur-
Knowledge of Mental Health Act (Section 23) vey was also distributed by hand to all consenting nursing staff at the annual state ED nursing conference. Again, individuals were asked to complete the survey on an individual basis immediately upon on receipt of the questionnaire. Fifty-eight questionnaires were distributed to emergency nurses. The questionnaire was completed on an individual basis and returned anonymously. All of the above questionnaires were distributed by hand but were completed outwith the presence of the distributor and authors. The survey was administered by post to all ED registrars registered for advanced emergency medicine training in South Australia, with a second blanket follow-up mailing to increase the response rate. Respondents were asked to complete the questionnaire without use of reference texts. A total of 33 questionnaires were given to ED medical officers. Respondents were asked to refrain from completing a further survey if they had already completed one to avoid result duplication. Data was collected and collated on Microsoft Excel software.
Results Two hundred fourteen questionnaires were distributed. A total of 193 replies were collected with an overall response rate of 89%. One hundred percent of SAPOL officers, 82% of SAAS officers, 83% of ED nurses and 79% of ED medical staff participated in the project. Section 23 of the Mental Health Act of South Australia covers proscribed powers for both Police and Ambulance officers. The police powers were recognised by all SAPOL officers and by 94% of SAAS officers, 94% of nursing and 96% of medical staff. The Ambulance officer powers were recognised by 83% of SAAS officers, 55% of SAPOL officers, 69% of nursing and 73% of medical staff. Apprehension powers rest only with police officers and this was identified by 100% of police officers. Current legislation also empowers police officers to force entry to any premises in order to apprehend a person. This was correctly identified in 74% of cases by the SAPOL officers. Section 23 does not set any age limits and potentially covers the entire age spectrum. This was correctly identified by 90% of SAPOL officers but by only 50% of emergency doctors and 40% of emergency nurses (55% in SAAS officers). In addition no history of diagnosed mental illness need be present for the legislation to be enacted. This was identified correctly by 80% of police officers, 85% of ED
151 doctors but only 44% of ED nurses and 45% of SAAS officers. The Mental Health Act of South Australia identifies that to enact Section 23 the member of the public apprehended, must be exhibiting ‘‘any form of disorder of the mind’’. This was correctly stated by 51% of SAPOL and SAAS officers. Medical and nursing staff identified this in 58% and 44% of respondents. In addition, the act states the person apprehended must be deemed to be at risk to either themselves or others. Ninety-four percent of SAPOL officer and 84% of SAAS officer replies correctly identified this. Ninety-four percent of nursing staff but only 69% of medical staff identified this. Section 23 contains provisions to cover forced apprehension of persons already detained under other sections of the Mental Health Act. These cover the forced return of persons who have absconded from treatment centres whilst still detained and also persons who are failing to comply with the terms of their treatment orders in the community. This was identified correctly by 90% of police officers with reference to absconded patients and 69% of cases with reference to patients failing to adhere to their community treatment order. Amongst emergency doctors only 64% correctly identified the powers with reference to absconded patients and only 35% identified the powers with reference to treatment order failures. In nursing staff, 88% of staff identified the police powers with reference to absconded patients but only 52% identified the powers with reference to failure of compliance with community treatment orders. Responses suggest that it is poorly known to where apprehended persons should be taken. Only 60% of SAPOL officers correctly identified that persons can be taken to a medical practitioner regardless of actual location. The most popular but incorrect response was in fact that persons should be taken direct to an Emergency Department. A similar response was present with the SAAS officers and indeed only 69% of emergency doctors were indeed correct with the next most popular response again incorrectly stating conveyance to an Emergency Department (42%). Emergency Nurses incorrectly felt the Emergency Department was the preferred site in 45% of cases with only 31% correctly identifying the stipulation of any location being suitable for medical review. Section 23 of the Mental Health Act of South Australia states only, that assessment must be made by a registered medical practitioner, and does not include any other mental health workers or specialists in that assessment need. The emergency doctors identified this correctly in 92% of cases
152 with the emergency nurses correct in 81% of cases. SAPOL officers responded correctly in 70% of cases. SAAS officers identified this correctly in 58% of cases. The act identifies that police merely need to transfer the person to a site to be seen by a medical practitioner and does not stipulate that they need stay once they have arrived at that site. Ninety percent of the police officers questioned, incorrectly stated they believed they had to stay with said person until that person was formally detained or released by the treating medical officer. Only 8% of nursing and 46% of medical staff felt SAPOL officers had to stay after completing the transfer. In addition, the act states police may stay and render any assistance felt necessary if asked by the receiving site. This is in fact not a statutory obligation, but 91% of police officers answered that they felt it was a compulsory part of their responsibilities to stay and assist if asked. No formal written documentation concerning the enactment of Section 23 of the Mental Health Act of South Australia is required to be produced for either the receiving site or the person apprehended. The police officers questioned identified this correctly in 78% and 91% of cases, respectively. Emergency doctors and nurses were aware of this in only 36% and 17% of cases, respectively. On questioning, 46% of SAPOL officers felt written documentation would be desirable whilst 85% of emergency doctors and 96% of emergency nurses felt written documentation would be desirable. In terms of training, 91% of SAPOL officers and 77% of SAAS officers receive training concerning Section 23 of the Mental Health Act in the prequalification phase of training. Only 8% of emergency doctors and 19% of emergency nurses stated that they had received training concerning this section during their pre-registration training. Furthermore, only 19% of emergency doctors and 40% of emergency nurses stated they had had received training concerning Section 23 during their postregistration training. Twenty-five percent of SAPOL officers and 33% of SAAS officers stated that they had received post-graduation training. There was a general identification for a need for continued training regarding Section 23 with a mean of 89% being in favour of this need across all groups.
Study limitations The Mental Health Act has deliberately been written so as to be open to interpretation on various points. As such it is extremely difficult to create
R. Boyd, S. Semmler unambiguous questions or questions with discrete yes or no answers. Thus, although a past member of the guardianship board was involved in reviewing and refining the questionnaire the questions may not have been truly without ambiguity. The survey was administered in a non-uniform fashion depending on the access to the target audience. This varied from direct person to person contact with the SAPOL officers to mailing for the medical officers. This may have introduced some degree of bias as the more open conditions for the medical and SAAS officers may have allowed greater time for reflection or access to written materials. In addition, the questionnaire was of course voluntary and bias may have existed as only ‘‘interested’’ respondents provided replies. The respondents may have had particular views or levels of knowledge in the field. As yet there has been no way to measure if this study has external reliability as no previous work is available from other states in Australia and the previous UK work is based on a different mental health act although it does share core principles.
Discussion We have identified that in general, knowledge concerning Section 23 is better in South Australia than in the UK.2 This is evident with the SA police correctly identifying Section 23 as an act that empowers police officers alone to apprehend as opposed to their UK counterparts who identified their version as a police apprehension power in only 56% of cases. There are however, still specific areas that would suggest some problems either in dissemination of knowledge or interpretation of the actual act itself. Nearly all police officers, medical and nursing staff identified that the person apprehended should be deemed to be at risk to themselves or others. This seems to be at odds with the finding that only 50% of police officers felt a person needed to have a disorder of the mind to be covered by the act. This may reflect the somewhat grey nature of the wording contained within the act. The Act as pertains to South Australia states that any person deemed to be suffering from a disorder of the mind, regardless of its potential cause can be apprehended. The Act as applies to South Australia would appear to be written from an all-encompassing viewpoint including both organic and non-organic brain disorders. Our responses would appear to indicate there is moderately good knowledge concerning the main
Knowledge of Mental Health Act (Section 23) function of Section 23. However, knowledge concerning secondary powers namely the apprehension of absconded patients or patients who have failed to comply with community treatment is poorer across all groups with the highest scores again with the police officers. This may be explained partly by the fact that emergency department staff does not usually have detailed involvement in community treatment. Section 23 of the Mental Health Act of South Australia does not require any formal written documentation to be produced either for the police, receiving unit or the apprehended person. This appears to be in contrast to what most medical and nursing staff believe to be so. Our survey suggests that there is a perceived need for some form of documentation especially amongst the health care professionals however there appears some reticence amongst the SAPOL officers. The misconception that all persons apprehended under Section 23 of the Mental Health Act of South Australia must be taken to an Emergency Department is of particular note. This was strongest amongst the police and nursing staff. The act states that a patient is to be taken as soon as practicable to a medical practitioner for assessment. In rural or country areas this, by necessity, may not be an Emergency Department and our responses may reflect the urban site used for the police officer survey although few major differences overall do exist.4 Emergency Departments have historically not been designed or funded for the assessment and often prolonged stays associated with this complex group5 , many of whom may not have any treatable mental illness. This appears to mirror work in the UK.3 The increasing trend to the care of mental illness in the community without the corresponding increase in acute community mental health services has led to the police force6 and as demonstrated by this paper, the emergency department to become the receiving area for acute community crisis care or enforcement of failed community treatment orders. This has been demonstrated in South Australia in particular with Kalucy et al showing a 10-fold rise in mental health presentations in general, to the emergency department of a major South Australian teaching hospital7 over a 10-year period. The current move from institutional care to community care does not appear to have been effective with emergency departments becoming the fallback safety net for self and police referred cases.8 The results from our survey would appear to confirm that either by default or misinterpretation Emergency Departments are becoming the defacto community crisis care resource.
153 Emergency departments are by consensus inappropriate areas for caring for agitated or at risk clients9 and as a rule have received little additional resources for such a 10-fold increase in client numbers.7 Finally, the results concerning training are noteworthy. Only 8% of emergency medical and only 19% of emergency nursing staff state that they had received specific training on this section of the Mental Health Act during their undergraduate careers. Postgraduate training would appear not to be much better, with only 19% of emergency department doctors stating they had received training. This paucity of training clearly identifies an area for improvement in emergency department training schedules. This questionnaire does not demonstrate any direct deficit in patient care or evidence of harm but does demonstrate that there are considerable differences between professional groups in their interpretation of the act and their ability to put it into practice. This may reflect poor training, historical attitudes or that the act itself is vague and open to interpretation.
Conclusion Knowledge of Section 23 of the Mental Health Act of South Australia was variable with the police officer group showing the best levels of knowledge. These variations may reflect different knowledge levels or different interpretations of the Act itself. There is an overall desire for the introduction of formal documentation to the use of the act. There were near universal calls for increased training concerning the act.
Acknowledgements We would like to greatly thank all the members of SAPOL, SAAS and the Emergency Departments surveyed during this study for their help and cooperation. We would also like to thank Dr. John Cooper-Smart for his invaluable advice and analysis of the questionnaire. We would like to thank Ms. Jackie Wilton for her assistance with data entry and analysis. Contributions: RB was responsible for the original concept and initial research proposal, RB and SS submitted ethics applications, produced the questionnaire. SS distributed the questionnaire. RB and SS analysed the data and wrote the draft paper.
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Appendix A. Section 23 Mental Health Act of South Australia Questionnaire form Questionnaire Please answer in the Yes or No box on the attached anonymous answer sheet (1) Section 23 of the Mental Health Act of SA specifically covers the rights and responsibilities of Police only? (2) Section 23 of the Mental Health Act of SA specifically covers the rights and responsibilities of Police and Ambulance Officers? (3) Does Section 23 enable the following to independently apprehend a person (a) South Australian ambulance officers? (b) Volunteer ambulance officers, e.g. St. John’s? (c) Police officers? (d) Social workers? (e) Mental health nurses? (4) Section 23 relates only to the following people (a) Those older than 18 years? (b) Those with a diagnosed mental illness, e.g. schizophrenia/depression? (c) Those showing any form of disorder of the mind? (d) Those considered only to be a threat to themselves or others? (5) Section 23 of the Mental Health Act of SA also (a) Enables police officers to return detained patients who have left a treatment centre unlawfully? (b) Enables police officers to return mental health patients to a treatment centre who have failed to comply with treatment? (6) People apprehended under this section of the Mental Health Act must be taken to (a) A police station? (b) A psychiatric unit? (c) An emergency department? (d) A medical practitioner? (7) The patient must be taken to that place (a) Within 24 h? (b) Within 4 h? (c) As soon as is practicable? (8) The person apprehended must be examined by (a) A registered Mental Health Nurse? (b) A registered specialist in psychiatry? (c) Any grade of psychiatrist? (d) A registered Medical Practitioner? (9) A member of the police force has the right to break into any premise under this Act to apprehend a person?
R. Boyd, S. Semmler (10) An ambulance officer has the right to break into any premise to apprehend a person? (11) An ambulance officer (a) Can apprehend a person using this section independently of the police? (b) May only forcibly convey a person if summoned by the police? (c) May not use reasonable force even if necessary? (12) Once the patient has arrived at a medical assessment area (a) Police and ambulance officers have completely discharged their duties and are free to leave? (b) Must remain until the person apprehended is formally released or detained? (c) If requested must render such assistance to the assessing centre as may be necessary to assess the patient? (13) Section 23 of the Mental Health Act (a) Does not relate to detained patients under the Mental Health Act? (b) Relates to detained patients who are being transferred? (c) Relates to detained patients who abscond? (14) Written documentation of some type is required to enforce this section? (15) The person apprehended must be given written confirmation of their apprehension under this section of the Mental Health Act? (16) Were you taught about this Section of the Mental Health Act? (a) During initial basic training? (b) Since you have left basic training? (17) Do you agree formal documentation should be introduced for this section of the Mental Health Act? (18) Do you agree there is a need for regular training in the use of this section of the Mental Health Act?
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Knowledge of Mental Health Act (Section 23) ation for Accident and Emergency Medicine. London: RCP; 1996. 6. Prior C. Peace of mind? Police Rev 1999;107:16—7. 7. Kalucy R, Thomas L, King D. Changing demand for mental health services in the emergency department of a public hospital. Aust N Z J Psychiat 2004;39:74—8.
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