EDUCATION & TRAINING Knowledge of mental health legislation in junior doctors training in psychiatry {

statutory managers’ Mental Health Act. will medical time, the likelihood of trainees getting involved in situations where they have to demonstrate the knowledge of the Act. trainee psychiatrists know about mental health legislation in England and Wales. psychiatry trainees, assess the trainees’ involuntary admissions of 5(2), 2 and 3 of the Mental 1983 Aims and method To assess junior doctors’ knowledge of the procedures involved in involuntary admission of patients detained under Sections 5(2), 2 and 3 of the Mental Health Act 1983. A semi-quantitative research study of junior trainees afﬁliated to two psychiatry training schemes was carried out. Results Trainees’ knowledge of professionally relevant sections of the Mental Health Act was patchy. Knowledge correlated signiﬁcantly with experience in clinical practice and with experience of using mental health legislation. Surprisingly, in-service training in mental health legislation had no effect on participants’ knowledge. Clinical implications Lack of knowledge and understanding raises the possibility of inappropriate use of the mental health legislation. This threatens patients’ fundamental rights and can lead to complaints or litigation. There is a clear need to address this at an early stage in psychiatry training. Declaration of interest None.

The Mental Health Act 1983 is an important piece of legislation used frequently in psychiatric practice. There has been concern over an apparent lack of knowledge of mental health legislation among medical practitioners, including psychiatrists. [1][2][3] In his study on non-consultant psychiatrists, Humphreys 4 reported that only 28% were able to give the correct title and year of the Mental Health (Scotland) Act 1984. Furthermore, in a study on consultant psychiatrists, only 10% of the sample were able to give the statutory definition of the term mental disorder. 5 In a survey of Section 12(2)-approved medical practitioners in the West Midlands (England), only a third of respondents correctly identified the four legal categories of mental disorder and none was able to define the term mental disorder as used in the Mental Health Act. 6 In another study on psychiatry trainees in Ireland, 7 patchy knowledge of procedures in compulsory admissions is reported.
Although most of the clinical work pertaining to the use of Mental Health Act is the responsibility of senior trainees or consultant psychiatrists (in particular, approved clinicians as established by the 2007 reforms of the Mental Health Act 1983 and doctors approved under Section 12 of the Act), [8][9][10] junior psychiatry trainees also come across situations where they have to demonstrate competence in mental health legislation. Trainees carry out most emergency psychiatric assessments as a consequence of their routine clinical duties, although frequently the final decision to use the Mental Health Act is taken by their supervising senior. Junior psychiatry trainees also frequently come across clinical situations where they might have to detain a patient using Section 5(2), which permits short-term detention in emergency situations. Emergency detention orders are commonly initiated by the most inexperienced trainee psychiatrists, often outside normal working hours and with less immediate access to the advice of a specialist senior colleague. 11,12 In addition, junior trainees are required to prescribe medication, review patients asking to leave the ward and even organise the transfer of patients to medical or other psychiatric units. When the patients involved are (or may be) detained under the Mental Health Act, these decisions necessarily demand knowledge of the relevant legislation. Junior trainees may also be involved in mental health review tribunals and statutory managers' hearings, which all require them to have adequate knowledge of the Mental Health Act.
As the 2007 amendments to the Mental Health Act 1983 are likely to increase the workload for healthcare staff, extra resources will be required to provide additional medical time, increasing the likelihood of trainees getting involved in situations where they have to demonstrate the knowledge of the Act. 13 Despite this, there has been little systematic research into what trainee psychiatrists know about mental health legislation in England and Wales. We therefore conducted a semi-quantitative research study in junior psychiatry trainees, the aim of which was to assess the trainees' knowledge of the procedures involved in involuntary admissions of patients detained under Sections 5(2), 2 and 3 of the Mental Health Act 1983 (as amended in 2007). It is important to recognise that this paper relates to the Mental Health Act in England and Wales only.

Method
The semi-quantitative research study was conducted through a face-to-face, standardised, open-ended, semistructured interview of junior doctors training in psychiatry. Interviewing offers the flexibility to react to the respondent's situation, probe for more detail, seek more reflective replies and ask complex questions. 14 The face-to-face interview format was adopted so as to ensure that the participants did not refer to the Act for completion of the questionnaire and to discourage guessing.
Trainees in psychiatry posts form two groups, junior trainees (foundation trainees year 2 (FY2), specialty trainees years 1-3 (ST1-3) and senior trainees (specialty trainees years 4-6 (ST4-6)). 15 Junior psychiatry trainees in England and Wales formed the target population. One hundred junior trainees affiliated to two psychiatry training schemes in the north-west of England formed the accessible population for this study. Of these 100 trainees, convenience sampling was used and 60 trainees volunteered to participate in the face-to-face interview. These included 9 FY2, 18 ST1, 16 ST2 and 17 ST3 trainees. Of the participants, 37 were male and 23 were female.
Participants were interviewed by two authors (O.W. and N.J.) using an open-ended instrument (details available from the authors on request) designed specifically for the purpose of testing the trainees' knowledge of Sections 5(2), 2 and 3 of the Mental Health Act. Draft instruments were critically reviewed by senior trainees and consultants and then pre-tested with a small sample of trainees. This was to ensure content validity of the measurement. The content validity is concerned with adequacy of coverage of the content area being measured and is crucial for tests of knowledge. 16 There are no totally objective methods of ensuring the adequate content coverage of an instrument. Experts in the area are called on to analyse the items' adequacy in representing the hypothetical content universe in the correct proportion.
The instrument used had three parts; part one about Section 5(2) had 12 items and parts two and three (about Section 2 and Section 3 respectively) each had 8 items. In addition, information was collected on demographic characteristics, number of Section 5(2) orders implemented, years of experience in psychiatry, training level (grade) and examination status of the participants. Participants were asked whether they had received specific training in the use of the Mental Health Act and what had been their main source of information. Each interview took approximately 45 min to complete. To decrease interviewer bias, the two interviewers were trained and the interview process was rehearsed before the formal study. Responses were written down verbatim. Data were scored with the help of purposedesigned guide to produce quantitative data. This guide included questions and example answers as well as listing possible acceptable answers. All the variables and responses were analysed using SPSS (version 16.0.1) software for Windows.

Results
Of the 100 trainees invited to participate, 60 volunteered and completed the study. The groups' male:female ratio and experience in psychiatry were: FY2 -3 men and 6 women, mean 3.56 months of experience (s.d. = 1.01); ST1 -10 men and 8 women, 11.39 months of experience (s.d. = 5.35); ST2 -11 men and 5 women, 28.88 months of experience (s.d. = 6.65); ST3 -13 men and 4 women, 39.71 months of experience (s.d. = 11.98). The absolute numbers and percentages of correct answers for the four groups of trainees at different levels of seniority are presented below. Specific questions related to basic knowledge of the three sections were analysed on an individual basis.

Section 5(2)
As can be seen in Table 1, senior trainees were more likely to know that Section 5(2) applies to an informal hospital in-patient (w 2 (3,60) = 20.10, P50.0005), but there was no significant difference in the number of correct answers provided between those who had received formal training as part of workplace induction (26 correct out of 39) and those who had not (16 correct out of 21; w 2 (1,60) = 0.59, P = 0.443). Of the 32 trainees who had sat at least one part of the formal examinations organised by the Royal College of Psychiatrists, 28 answered correctly, compared with only 14 of the 28 who had sat no exam (w 2 (1,60) = 10.00, P50.0005).
Senior trainees were more likely to be correct in terms of their knowledge as to which professionals can authorise detention under Section 5(2) (w 2 (3,60) = 11.77, P50.01), but there was no significant difference as regards training -34/ 39 v. 21/21 respectively for those who had and those who had not received formal training (w 2 (1,60) = 2.94, P = 0.087). Of the 32 trainees who had sat at least one part of the formal examinations, 30 answered correctly, not significantly different from the 25 of the 28 who had sat no exam (w 2 (1,60) = 0.39, P = 0.533).

Section 2
In respect of questions related to Section 2 ( Table 2), there was no significant difference between trainees of different seniority in their knowledge of the core function of the section (w 2 (3,60) = 6.91, P = 0.075) or between those who had received formal training (37/39) and those who had not (18/21; w 2 (1,60) = 1.50, P = 0.221). All 32 trainees who had sat at least one part of the formal College examinations answered correctly, but of the 28 who had not sat a College exam, only 23 knew the correct answer (w 2 (1,60) = 6.23, P50.05).
To further analyse differences in knowledge in trainees at different levels of experience, simple numerical scores were calculated for the three sections by adding together the number of correct categorical answers in each group of questions. Analysis of variance conducted on these composite scores revealed that the levels of knowledge about all three sections differed significantly between trainees of different seniority. Regarding Section 5(2), mean scores were: 9.00 (s.d. = 2.84) for FY2, 10  Comparisons were also made between those trainees who had received formal training in mental health legislation through the induction training on taking up their posts in a National Health Service (NHS) trust. Of the 60 trainees, 39 had received such training and 21 had not. Whether or not participants had received such training had no statistically significant effect on scores on Section 2 (F(1,58) = 0.68, P = 0.795) or Section 3 (F(1,58) = 0.56, P = 0.457), but there was a trend for a group difference in scores for Section 5(2) questions (F(1,58) = 3.87, P = 0.054). Examination of the scores revealed that those who had not received formal training in mental health legislation actually had higher mean scores (14.90, s.d. = 4.16) than the trainees who had received such training (12.49, s.d. = 4.73).
Finally, there were strong correlations between scores on all three sections (and overall) and both clinical experience in months and the number of Section 5(2) orders implemented (Table 4). There was, not surprisingly, a

Discussion
This study revealed potentially serious inadequacies in psychiatry trainees' knowledge of key mental health legislation. This is worrying given that the doctors concerned in most cases would have dealt frequently with patients detained under Sections 5(2), 2 and 3 and should be familiar with the various statutory requirements. However, it is reassuring that the knowledge increases with experience, unlike what was shown in previous studies, which had noted no change regardless of experience. 4,5 Lack of knowledge and understanding raises the possibility of inappropriate use of the Mental Health Act. This is particularly relevant to Section 5(2). Inappropriate use of the Act threatens patients' fundamental rights and can have important consequences for the doctors involved and their employers, potentially leading to patient complaints or litigation. 17 Lack of emphasis on education and training in mental health law are possible explanations that can account for deficiencies in knowledge. 12,18 The findings from our study clearly show that the limited training received on taking an NHS trust post (induction) is not sufficient. Another area of concern is that doctors are not tested for competencies with regard to applying law. Membership exams do not test the candidates' knowledge of mental health legislation. Even formal Section 12 approval of psychiatrists does not include formal testing in mental health legislation. It is important to bear in mind that the Royal College of Psychiatrists' curriculum defines competencies that psychiatrists have to acquire and demonstrate in their day-to-day clinical practice. Trainees are required to maintain and apply an adequate and up-to-date knowledge of legislation that is relevant to any aspect of their professional practice, including patient care, the rights of patients, their relatives and carers, and research. 19,20 There must, therefore, be increased emphasis on the importance of training in mental health law and its clinical implications. Trainees should be encouraged to attend formal training courses run by the employing trust, professional bodies or educational institutions. It may also be sensible to focus such training on the specific needs of trainees. Training sessions should be included in their teaching and academic programmes. Research has suggested that acquisition and retention of knowledge is best achieved through active use of the Mental Health Act. 21,22 This needs to be reflected in the type and nature of training courses developed. Suggestions include small-group or workshop teaching with the opportunity to discuss real-life situations, applying the Mental Health Act in case vignettes, observing consultants on Mental Health Act assessments, and attending courses. Such training should not be confined to those individuals seeking statutory approval. It is important and would be timely to explore ways of improving matters and not only to formalise training for psychiatry trainees but also to test their competencies. There is a clear need to address this at an early stage in psychiatric training.

Strengths and limitations
This is the first study in England which looks at psychiatry trainees' knowledge of mental health law through a face-to-face interview. In contrast to studies from other countries it is concerned not only with legal knowledge but with procedures as well.
The limitations to the approach taken in this study largely relate to the response rate. Difficulties with responses have been noted in previous studies. 5,7,23 With a response rate of 60%, it is likely that our study accurately represents what this group of psychiatric trainees know about one specific area of current mental health legislation. Moreover, the concerns raised should be considered seriously given the likelihood that non-participating psychiatric trainees may have poorer knowledge than the ones who volunteered to participate. It is possible that our results cannot be generalised to other geographical areas; however, there is no evidence to support this concern and it is difficult to identify how this sample might differ from trainees in other parts of England and Wales. No comparisons can be drawn to other countries as legislation varies significantly from one to another. Another possible limitation is that, in the analyses reported here, all the questions asked were considered equally important. This approach was thought more appropriate than potentially highly subjective weighting systems, but it does mean that rather more obscure issues may have been unduly prioritised. It also limits the conclusions that may be drawn from the data and the extent to which specific recommendations can be made to address the apparent lack of knowledge.