Advance statements within the mental health setting
Creators: name: JAMES, Russell
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 420599
subject: Nursing not elsewhere classified

description: Aims
This thesis presents the findings of a mixed methods, multi-phase study set in Victoria, Australia. The study aimed to investigate Victorian mental health clinicians' understanding of advance statements since the implementation of the Victorian Mental Health Act 2014; identify factors that promote or hinder the establishment of advance statements; and deliberate the translation of the legislation to practice and develop recommendations for practice enhancement and sustained implementation. 

Background
Implemented in many jurisdictions globally, advance statements have been credited as a means of promoting and facilitating choice, empowerment, and autonomy for individuals accessing mental health services. As part of a suite of reform measures as part of the 2014 Victorian Mental Health Act, advance statements were embedded into legislation designed to convey individual preferences for treatment during times when the ability to communicate or make decisions may be impaired. The need to understand the role and scope of how advance statements can be effectively used within mental health services, and to identify the barriers of service in the implementation of this initiative, forms the overarching goals of this research study. This is the first study, mixed method explorative study designed to investigate the facilitating factors and barriers for implementing advance statements.  The study findings add a unique and valuable contribution to implementation practices and overcoming the potential for barriers to impact implementation practices.

Methods
Using a semi-structured interview based on the qualitative descriptive methodology, the first phase of this thesis gathered preliminary data from a key informant (n = 1) who headed the working group responsible for the implementation of advance statements in Victoria. Key findings from Phase One acknowledged the implementation of the advance statement model across Victoria was hindered by the disbandment of the project advisory group leading to individual services and organisations driving implementation efforts at local levels; inconsistencies relating to the quality of training provided to services and organisations; and a lack of evaluation and review of implementation and workability of the model used for advance statements. The findings from this phase informed the design of survey and interview instruments used in the second phase.

The second phase of this project sought to understand the knowledge and attitudes of Victorian mental health clinicians regarding the use of advance statements within the mental health setting. An online survey was disseminated to clinicians working in mental health services in Victoria through the Offices of the Chief Mental Health Nurse and Chief Psychiatrist. Snowball sampling was also employed to enhance response rates. A total of 190 clinicians completed the online survey, with results indicating high agreement with the need for advance statements in clinical practice. However, few participants (22%) had working experience of advance statements, particularly in the preparation phase.

Key findings from this phase indicate that support for the use of advance statements by mental health clinicians exists, but the knowledge and experience from clinical practice varies. There is widespread support for advance statements with participants viewing advance statements as positive tools which can benefit individuals and contribute to empowerment and autonomy whilst promoting recovery. The findings from Phase One and Two of the study have informed Phase Three, telephone interviews with mental health clinicians.

The final phase of this study explored clinician understanding and experience of advance statements. Fifteen (n = 15) semi-structured interviews with mental health clinicians from various settings in Victoria were conducted, identifying issues in implementation relating to the accessibility, communication, and clinician understandings of advance statements. The experiences of participants in this phase of the study indicate that more is needed to be achieved when implementing changes to legislation and practice. Participants highlighted that clinicians' knowledge of advance statements remains limited, however could be improved with better access to quality training and commitment from service leads to enable advance statement use within the practice setting. 

The process of eliciting narratives using interview was a major strength of this study. While some participants spoke of advance statements in a positive light, enabling service user's choice and forward planning with their key mental health worker to enable treatments and care, others mentioned problems. The themes revealed within the narratives support the importance of advance statements in contemporary mental health practice, the promotion of autonomy and empowerment for service users, as well as for sustained implementation and positivity of use. 

Recommendations
Several recommendations stem from this study's findings in relation to mental health practice, training and education, policy, and future research. The most pertinent of these was the integration of advance statements into routine mental health practice, and the need for greater training and education on advance statements for the wider mental health setting. Thus, a strength of this study has been that practical recommendations have been able to be made that relate directly to findings arising from participants working in contemporary practice settings.

Conclusions
As an explorative study, this thesis identifies several substantial issues in the implementation and use of advance statements within mental health settings in Victoria. The study revealed that the use of advance statements across Victoria is limited, with inadequacies in mental health clinician's knowledge, training, and practical experience in the use of advance statements. Despite this limited use of advance statements, they are viewed in a positive light from mental health clinicians as valuable tools which can be used to strengthen supported decision-making and engage individuals in treatment decisions. 

As advance statements slowly make their way into the clinical landscape, the mental health system faces a formidable challenge. If change and further implementation is not enacted, the promise of advance statements effectiveness risks becoming diminished, rather than the good faith invitation to dialogue that mental health legislation and informants interpret it to be. This thesis adds support for a greater ability to adopt advance planning measures within the clinical setting by engaging clinicians in the process to bolster the use and uptake of advance statements. In turn, providing sound representation of the identifiable issues facing advance statements, enabling recommendations for mental health practice, training, education, and policy.