Paper review: Health and social care practitioners experiences of assessing mental capacity in a community learning disability team

This paper, authored by Daniel Ratcliff and Melanie Chapman, was published in the British Journal of Learning Disabilities 2016 Vol 44 (4) p329-336

Introduction

This is an article which is very much located outside the ‘social work research’ space although it is occupied with a topic which is very much in our areas of interest, indeed, my own research is focussed on the Mental Capacity Act and ways of assessing it so there may be a tilt towards articles in this area. And this one has been enormously useful.

The premise of the paper is to look at the experiences of different professionals when undertaking the assessment task. It’s interesting to note that the study was undertaken by one practitioner (Ratcliff) and one academic (Chapman) working together. This adds another layer of interest to the paper and its analysis.

Methodology

The study was very much located within the qualitative space, exploring the experiences of eight professionals, from health and social care backgrounds, using semi-structured interviews which were then analysed using thematic network analysis.

All those interviewed worked within a community learning disability team and had done for at least seven years. In terms of professional breakdown, there were three nurses, a physiotherapist, a speech and language therapist and two social workers. All of the team members worked in the same team and had received the same in-house training.

The data, which was the transcribed interviews, was analysed using thematic network analysis. Thematic analysis looks at identifying common themes which emerge from the data and the researchers focussed on networks within the data which linked to the themes identified.

Context

The paper starts with a brief literature review relating to the current situation regarding the use of the Mental Capacity Act (2005) in England and Wales. It identifies, from previous research, that there are known variations in the quality of work around use of the MCA in practice including gaps in knowledge and lack of confidence in implementation of knowledge and that despite training, this had not, seemingly, led to improved practice.

The Mental Capacity Act (2005) while being generally acknowledged as a positive move in legislation relating to those whose capacity to make specific decisions may be doubted, has led to continuing conversations, over 10 years after implementation (which was in 2007) about the lack of embeddiness in health and social care services. The Act is used in all areas of health and social care practice (apart from under 16s) but it has been particularly used relating to adults with cognitive impairments, whether permanent or temporary. In terms of social work practice, this is most commonly identified in work with adults with learning disabilities and work with older adults where deteriorating cognitive functioning may be identified, for example, with some dementias.

Key learning points

The study identified five significant themes which emerged from the thematic analysis of the interviews.

  • Systematic barriers to assessment
  • Capacity assessment as a challenging process
  • Person-specific challenges
  • Protective practices
  • Protection of a fundamental human right

Basically, there were organisational and structural issues in place which might impede quality assessments. This could be about the workload pressure of staff or the ethical tensions between organisational need and outcome of specific assessments, particularly noted around attitudes towards risk

…there was service level pressure to ensure that risks of harm to individuals were limited as far as possible, thereby conflicting with the practice of positive risk taking and allowing capacitious individuals to make unwise decisions.

p332

There was also an expression that a ‘capacity assessment’ could take time and effort to ensure it was carried out in the best way, particularly with involvement of carers. While the legislation explicitly encourages family involvement it can be more challenging when there are differences around the decisions made.

Practitioners raised the challenge of difficult decisions where it was not a straightforward outcome but where there might be a different interpretation, for example, relating to specific decisions.

Participants noted that joint decision-making was helpful and support from other colleagues in thinking through the processes. They also said more specific guidance could be helpful.

There was a general positive response to the impact the MCA had made on practice. It had put into legislation, some of the importance of emphasising the individual and their human rights. There was a feeling it had improved practice and the rights of people who used the services they provided.

The researchers identified a ‘global theme’ which enveloped the data collected as ‘freedom to act versus restrictions on action’. Without understanding more about the coding process, I relate this back to the initial title, which summarises the experiences of those using the MCA in this setting.

Reflections and gaps

The study is acknowledged to be a small-scale study which has taken place within one team where professionals have worked with the same organisation and often with the same people (they have all been in the team for a minimum of seven years). This means there may be a further risk of extrapolating from this data where practises and the culture of the team and organisation may have embedded and reflected on the responses.

Language, attitudes and values can be shaped by the organisation as well as the individual attitude. The study does not reflect (possibly because it is not different and the same size was so small they could be identified) if the professional background of the interviewee was a factor in reflecting the differences.

It is useful to see practitioners directly involved in research, particularly noting the interviews were carried out by the practitioner. It would have been useful, although this might be for a longer piece, to know if he had links to the team in which the research was taking place. It makes no difference to the outcomes, but it an interesting context in which to place the research.

Use in practice

It is good to see an example of research of practice taking place involving a practitioner and academic working together, particularly as the issue is one that can have an impact on the way teams work.

There were a number of issues identified in the study that I can take with me to practice. One is about the usefulness of support. Often this can be looking at supervision and training but the key that this piece draws out is those informal conversations with colleagues, highlighting a need which emerges from the paper, for a consideration of peer groups among professionals. Personally, I’m wondering if there is a scope for multidisciplinary peer groups which a focus on learning from each others’ practice and reflecting on potential improvements in practice together, in my work setting.

Training is necessary for legal literacy but use of training can vary. It is worth considering how understanding and knowledge can be on a continuous basis rather than a snapshot in time. I come back to the peer support groups and wonder whether this is an aspect that can improve.

The paper talks about the need for organisational changes to ensure that there is sufficient time to ensure that work can happen in the best environment. This could be written about any aspect of health and social care and isn’t something we can often change as individuals. There is an aspect about usefulness of templates and examples which might be able to be shared to make the decision-making better informed. Perhaps sharing some model anonymised good practice examples which are referenced with up to date case law and research. Sometimes the time spent searching for new information can be saved if it is well-disseminated.

Conclusion

This is a useful study and a useful paper in all. As someone who has developed an interest both in how the MCA is used and understanding different research methodologies, it has been an interesting piece. The research is clearly explained and the gaps identified.

I think while the literature review is well-presented, the sample size is small but produces some useful content which reflects some of the previous research in the field. The commentary around the piece including the themes identified, in some ways seems more useful than the specific data. It is very useful to see practice-focussed research. I’d like to see more about any differences between professionals and how that links to attitudes to the legislation as well as the experiences of people who have differing levels of post-qualification experience.

Saying that, the paper is useful, particularly as the researchers identify explicitly, the potential use in practice. It does leave us begging a lot of questions for more research in this area though.

Author: Vicky

Social worker based in London

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