Shouldering the role of key health professional for individuals detained on a community treatment order in Malta : mental health nurses’ experience

Abstract

Background: Community Treatment Orders (CTOs) were introduced locally when the Mental Health Act was revised in 2012 and are being increasingly used in practice. Nurses are usually the appointed Key Health Professionals (KHPs) for individuals detained on CTOs. Although nurses are important stakeholders within this scheme no actual exploration of how they are coping with challenges incurred from the responsibilities of the role of KHP for individuals on a CTO has been done. Aim: This study aimed to explore the meaning that Mental Health nurses (MHNs) attribute to the experience of caring for individuals detained on a CTO. The objectives of this study were to explore the views of MHNs on CTO’s framework, identify the challenges faced by MHNs whilst caring for individuals on CTO, explore how these challenges influenced care provision, explore how they coped with emerging challenges, and identify ways to support them in their role as KHPs. Design & Method: A qualitative approach was utilised following the Interpretative Phenomenological Analysis (IPA) principles. A purposive sample of seven Mental Health Nurses acting as KPHs for individuals on a CTO were recruited. Semi-structured interviews were conducted and transcribed verbatim. Data was analysed using IPA methodology. Results: Three superordinate themes emerged namely: “Paving through Responsibilities”, “Targeting the Challenges”, and “Attempts at Maintaining Balance”. The first super-ordinate theme “Paving through Responsibilities” produced two sub- themes, “Juggling between Care and Control” and “Therapeutic Relationship is Key”. The participants imparted how they regarded the CTO as a measure to support, protect and ensure treatment compliance for patients with severe mental illness. However, participants described that combining care with coercion led to ethical dilemmas, especially when enforcing treatment. To cope with these difficulties and safeguard the therapeutic relationship, participants tried to direct any conflicts regarding treatment to the administrator of the CTO. They also empathized with and guided patients to focus on their recovery process. Furthermore, unease about possible litigation and blame was evident and to safeguard themselves, the participants tended to focus more on their legal responsibilities than their caring role. The second super-ordinate theme “Targeting the Challenges” produced three sub- themes mainly “Involvement in Care Decisions”, “Resources” and “Validation and Understanding”. The participants shared their views on how the existing clinical practices are affecting care provision, the service users, and themselves as KHPs. The difficulties experienced by MHNs resulted from the complexity of their role, patient-related aspects, procedural issues, and system insufficiencies, which left the participants feeling unsupported and burdened with all the caring and legal responsibilities. Moreover, findings hinted that care planning within the local care context is focused on risk and is gripped by a blaming culture leading the participants to experience persistent emotional distress and exposing them to higher burnout risks. The final superordinate theme “Attempts at Maintaining Balance” produced two sub- ordinate themes, “Support Systems” and “Hear Us Out”. Effective dynamics and cultures within the team and reflective practice were regarded as major support structures and helped participants to cope with difficulties. Moreover, participants regarded relatives as partners in care and viewed their contribution as essential for both themselves as KHPs and for patients’ recovery process. Conclusion: MHNs described that caring for patients within CTO’s framework is indeed a complex and challenging endeavour. Participants described how the coercive aspect and legal obligations challenged their caring role and the therapeutic relationship. Furthermore, the study’s results showed that work approaches and systems’ culture could influence the provision of care and professionals’ psychological well-being. Recommendations from these findings point to a need for change in the present modus operandi and the availability of more support for MHNs to deal with challenges within the CTO framework, which will ultimately result in improved patient care outcomes.