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Policy into action : a case study of the educative efforts associated with the implementation of new… McFadyen, Carol Jean 2005

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POLICY INTO ACTION A CASE STUDY OF THE EDUCATIVE EFFORTS ASSOCIATED WITH T H E IMPLEMENTATION OF NEW H E A L T H C A R E LEGISLATION IN BRITISH COLUMBIA by CAROL JEAN M C F A D Y E N B.Sc.N. The University of Saskatchewan, 1968 M . A . The University of Victoria, 1993 A THESIS SUBMITTED IN PARTIAL F U L F I L M E N T OF T H E REQUIREMENTS FOR T H E D E G R E E OF DOCTOR OF E D U C A T I O N in T H E F A C U L T Y OF G R A D U A T E STUDIES (Educational Policy and Leadership)  Research Supervisory Committee Members: Thomas J. Sork Shauna Butterwick Michelle Stack  T H E UNIVERSITY OF BRITISH C O L U M B I A February 2005  © Carol Jean McFadyen, 2005  ABSTRACT The main goal of this study was to understand the role of education in public policy implementation through an exploration of how professional health care providers were educated about legislative change implemented in February 2000. Two key questions guided this study: First, what happened in the implementation phase of new health legislation in British Columb ia? Relative to this question, what did the government and professional health organizations do to educate professional health care providers? What challenges did they face? What do stakeholders think about the effectiveness and sufficiency of their educative efforts? The second key question was: What lessons can be learned about planning and implementing educational activities that inform professionals of legislative changes that affect their practice? The investigation focussed on'the three main areas of practice that were involved in educative initiatives related to the implementation of adult guardianship legislation. These included the Ministry of Health, the Public Guardian and Trustee Office, and several health care professional organizations. Fourteen participants representative of these areas were interviewed and documents utilized in their educative efforts were collected and analyzed. Several key findings emerged during the study. It became apparent that the government initiatives were responsible for the majority of education available to professional health care providers. Among the health care profession organizations, there were differences in educative initiatives as well as in their interpretation of the mandate for education of professional health care providers when legislation is implemented. There were differences in the educative efforts undertaken by the two separate government offices and each of them had very different impressions about their success. The Ministry of Health focus was on the Health Care Consent Act and that educative effort specifically targeted professional health care providers. The Public Guardian and Trustee Office focus was on the Adult Guardianship Act and that educative effort specifically targeted the ii  public but included professional health care providers. The latter initiative had significantly greater financial resources for education as well as an extended time period in which to offer and reinforce education. Participants who represented the Ministry of Health expressed concern that professional health care providers are not adequately informed about the full legislative package, whereas participants who represented the Public Guardian and Trustee Office expressed confidence that their educative work was successful. The particular legislation package that is the subject of this study is difficult and complicated; it consists of four different Acts and its effects include significant changes in the practice and power of health care providers. The findings highlight the politics of planning for education about legislation that originated from the grassroots in order to protect the vulnerable public and at the same time had implications for the practice of professional health care providers. These differing and sometimes competing interests, along with variation in resources and mandates, are two main policy influences that are in part addressed from the perspective of the power in planning literature.  "  The study offers conclusions and recommendations for how major policy change might be addressed in future. Recommendations are made to government policy makers, to health profession organizations, and for future research in the area of education about policy change. The study concludes with an exploration of its implications for the future work of this researcher.  TABLE OF CONTENTS ABSTRACT  II  LIST O F TABLES  VII  LIST O F FIGURES  VIII  ACKNOWLEDGEMENTS  IX  PREFACE  XI  C H A P T E R I:  INTRODUCTION  1  T H E LEGISLATION.  2  C O M P L E X I T Y O F CONSENT: A N ILLUSTRATIVE V I G N E T T E  3  Analysis of Vignette  Focus OF T H E  5  STUDY  6  A Complicated Context Research Questions and Methods.  6 9  O V E R V I E W O F CHAPTERS C H A P T E R II:  12  THE LEGISLATION  13  HISTORICAL SITUATION  13  The Health Care (Consent) and Care Facility (Admission) Act. The Representation Agreement Act. The Adult Guardianship Act The Public Guardian and Trustee Act. From the Perspective of the Professional Health Care Provider: Crucial Elements in the Legislation  17 21 25 27 28  S U M M A R Y : CONCERNS A B O U T T H E LEGISLATION  29  Adult Guardianship Act  30  Health Care (Consent) Act and Representation Agreement Act. C H A P T E R III:  31  THE LITERATURE  33  C O N C E P T U A L I Z I N G POLICY  33  IMPLEMENTATION  35  BARRIERS T O IMPLEMENTATION  41  T H E N E E D FOR EDUCATION  46  A D U L T E D U C A T I O N A N D POLICY IMPLEMENTATION  50  C O M M U N I T Y D E V E L O P M E N T A N D POLICY IMPLEMENTATION....  54  SUMMARY C H A P T E R IV:  56 RESEARCH METHODOLOGY  59  CASE STUDY  60  D A T A C O L L E C T I O N STRATEGIES  63  Interviews Selecting Participants The Interview Process Gathering Documents  63 64 66 69  D A T A ANALYSIS  69  RESEARCH ETHICS  71  Issues of Credibility ' Limitations  :  CHALLENGES  75  SUMMARY C H A P T E R V:  72 73  '. FINDINGS - T H E R O L E O F G O V E R N M E N T ORGANIZATIONS  MINISTRY O F H E A L T H A N D MINISTRY RESPONSIBLE FOR SENIORS  Train the Trainer. T H E PUBLIC G U A R D I A N A N D T R U S T E E OFFICE  Manager of Health Care Decisions. Adult Guardianship Implementation Team  76 78 78  86 89  90 93  iv  A T THE COMMUNITY LEVEL: ONE CLINICAL PRACTITIONER'S STORY. SUMMARY  99 :  103  CHAPTER VI: FINDINGS - THE ROLE OF HEALTH CARE PROFESSIONS  107  EDUCATIVE MANDATES.  108  INVOLVEMENT IN LEGISLATIVE PLANNING SOURCE OF INFORMATION ABOUT LEGISLATIVE CHANGE  111 112  MAJOR ISSUES IN THE LEGISLATION  113  EDUCATIONAL RESOURCES  114  EDUCATIONAL INITIATIVES  115  College of Physicians and Surgeons of British Columbia (CPSBC) Registered Nurses Association of British Columbia (RNABC) College of Dental Hygienists of British Columbia (CDHBC) College of Licensed Practical Nurses of British Columbia (CLPNBC) Board of Regulation for Social Workers (BRSW) British Columbia Society of Occupational Therapists (BCSOT) Physiotherapy Association of British Columbia (PABC)  115 118 119 121 121 123 124  OTHER EDUCATIVE INITIATIVES.  The Popular Media Medical Services Plan for Medical Practitioners Advocacy Groups. Representation Agreement Resource Centre (RARC) Health Association of British Columbia (HABC) SUMMARY  CHAPTER VII: DISCUS SION OF FINDINGS POLICY DEVELOPMENT  Competing Interests. The Politics of Policy Development. EDUCATION FOR IMPLEMENTATION  Competing Interests/Competing Mandates Competing Resources But What Happened to the Representation Agreement Act?  126  .'  126 127 127 127 128 128  132 133  133 134 136  13 7 141 146  POWER IN PLANNING  147  SUMMARY  152  CHAPTER VIII: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS PLANNING FOR EDUCATION INMAJOR PUBLIC POLICY CHANGE: CONCLUSIONS AND RECOMMENDATIONS  Conclusions Recommendations. SUGGESTIONS FOR A FUTURE APPROACH TO EDUCATION ABOUT MAJOR PUBLIC POLICY CHANGE  The Policy Change Itself. The Stakeholders (Learners) The Educative Process Larger Social-Political-Economic Context Assessment of Outcomes IMPLICATIONS FOR MY WORK AS A NURSE EDUCATOR.  APPENDIX A: EXCERPTS FROM "HOW CAN WE HELP?"  154 155  155 156 161  161 162 163 164 164 164  167  APPENDIX B: FLOW CHARTS FROM A PRIMER TO BRITISH COLUMBIA'S NEW HEALTH CARE CONSENT LEGISLATION 172 APPENDIX C: LETTER AND QUESTIONS MINISTRY OF HEALTH EMPLOYEE  175  APPENDIX D: LETTER AND QUESTIONS PUBLIC GUARDIAN AND TRUSTEE OFFICE EMPLOYEE .'. : 180 APPENDIX E: LETTER AND QUESTIONS: PROFESSIONAL ASSOCIATION EDUCATOR  185  APPENDIX F: CONSENT FORM  190  v  APPENDIX G: ACRONYMS  194  APPENDIX H: DOCUMENTS REVIEWED  196  APPENDIX I: PROFESSIONAL ORGANIZATION STANDARDS/MANDATES  201  REFERENCES  203  LIST OF T A B L E S  Table 1: Health Care Professions Represented in the Case Study.  LIST OF FIGURES Figure 1: Ambiguity-Conflict Matrix: Policy Implementation Process  48  viii  ACKNOWLEDGEMENTS Thank you to my Committee members for their ongoing encouragement and feedback throughout this process of research and writing. In particular, I thank my Committee Chair, Dr. Thomas Sork for his wisdom, Dr. Shauna Butterwick for her guidance, and Dr. Michelle Stack for her groundedness. I also thank the late Dr. Steven Salzberg for early contributions during his brief tenure as a Committee member. It is unfortunate that I cannot acknowledge the study participants by name, as I would want to publicly thank them for their contributions to this study and recognize the commitment and dedication of each of them to their work. Without exception, I was moved by and filled with respect for their devotion to the welfare of those who receive health care and those who administer that care. My unreserved appreciation goes to Gerrit Clements and to Dr. Robert Gordon, two of the main writers of the legislation, for their unfailing support beginning with my early intentions to explore the implementation of this adult guardianship legislation package, and continuing throughout the years that it took to complete the project. I thank Okanagan University College for supporting my study through a sabbatical as well as through the study grant process, a significant contribution that eased the accompanying financial burden. As well, I thank the University of British Columbia for their earlier support in providing me with Leadership Awards through the Department of Educational Studies. I was fortunate to have two special mentors throughout my study. Dr. Kyleen Myrah, a graduate of the 1997 EdD cohort, was generous in her assistance and unfailing in her encouragement. And, my dearest friend, Dr. Gail Prowse was a constant presence, always ready to offer her loving support, encouragement, inspiration, and a much-needed respite from my work.  ix  And last, but never least, I thank my children Kimberley and Scott for their love and their belief in me. I also thank my late husband Norm Reid for his inspiration and for encouraging me to enter the world of graduate study once again. The voice that was Heard On the wings of a Bird...  x  PREFACE The Doctor of Education in Educational Leadership and Policy program is designed to provide advanced preparation for education practitioners with leadership and policy responsibilities in both formal and nonformal settings. These settings include, among many others, the postsecondary sector, business and health organizations, unions and community groups, as well as the K-12 school system. The program is grounded in the belief that it is important for participants to engage in scholarly discourse about understanding, critiquing, and improving practice in educational settings. It was the elements of leadership and policy that attracted me to this program. As a nurse educator with many years of teaching as well as experience in both formal and informal leadership roles, I have always had a strong commitment to the importance of clearly articulated policy along with a well grounded philosophy of leadership. This program provided the opportunity to study with other teachers and leaders in education settings, while at the same time continuing my employment. As well, it offered enough flexibility for me to pursue my scholarly interests in law and ethics. The Ed.D. thesis is the report of research, which has allowed the student to give intensive study to a problem or set of circumstances in his or her practice. One part of the thesis may take the form of a document (or its equivalent in a non-print medium) of the kind commonly used in the field, such as a policy handbook or a particular policy statement, an action plan, a white paper, a curriculum or project design, a program evaluation, an institutional reorganization, a community development prospectus, or any other relevant innovative undertaking. If this is the case, the candidate must also provide as part of the thesis, documentation sufficient to allow others to follow the line of reasoning and evaluate the originality, usefulness and credibility of the work. xi  Evaluation of the thesis is based on both academic and professional norms. The former include, for example, the coherence and integrity of the argument, the adequacy of the research base, the quality of the analysis, and interpretation of relevant conceptual and theoretical work. The latter include the educational impact of the work, the level of insight and imagination applied to the issues being dealt with, the sensitivity to historical and local circumstances, and the feasibility and requisite support for recommendations.  1  M u c h of this information is taken from U B C (2000). Graduate study in the Department of Educational Studies. Vancouver, B C : Author. The information about evaluation of the thesis is taken from the Web site www.educ.ubc.ca/edst/  xii  C H A P T E R I: INTRODUCTION As the old man walked the beach at dawn, he noticed a young man ahead of him picking up starfish and flinging them into the sea. Finally, catching up with the youth, he asked him why he was doing this. The answer was that the stranded starfish would die if left until the morning sun. "But the beach goes on for miles and there are millions of starfish, " countered the other. "How can your efforts make any difference? " the young man looked at the starfish in his hand and then threw it to safety in the wave. "It makes a difference to this one, " he said. (Source unknown)  In the complex world of health care ethics, there is no single manner of action that will ensure dignity and regard without exception. I believe that each of us in health care can make a difference for those we encounter in the many interactions of our lives. I believe also that any effort we make to ensure autonomy for one person is potentially magnified and multiplied through subsequent encounters. I have taught health care law and ethics at all levels of the four-year nursing degree program as well as in six other health programs at Okanagan University College. For several years I was a member of the institutional Research Ethics Review Committee and enjoyed the opportunity to review research proposals for a wide variety of disciplines. As my involvement in health education and administration expanded beyond nursing to other educational programs, my interest in health care ethical and legal issues moved beyond the acute care institution to the broader community. Recently, I worked with community health representatives as a member of an ad hoc project committee and as Chair of the Central Okanagan Community Health Advisory Committee to the Okanagan Similkameen Health Region. Out of each of these experiences, new questions have arisen and my search has continued. In Nichomachean Ethics, Aristotle advised, "a well-schooled man [sic] is one who searches for the degree of precision in each kind of study which the nature of the subject at hand permits" (1094b, pp. 13-24, cited in Quinn and Smith, 1987, p. 53). 1  In all of these years as a nurse and as a teacher of nurses, I have struggled with the recurrent questions that surround issues of consent, confidentiality, autonomy, rights and responsibilities, allocation of resources, with the many conflicts and dilemmas that arise for patients and for their caregivers. But none of these have affected me more deeply than did the experience of living with and caring for my husband through his cancer diagnosis and eventual demise. The experience of supporting and caring for the man I loved as he made decisions about whether or not to accept treatment, as he attempted to understand his illness and his options, as he tried to explain his choices and wishes to health care professionals and to those who loved him, as he dealt with the realities and limitations of the health care system, as he died in the manner of his choosing, was the true source of my moral imperative to continue in my search for understanding and to attempt through my search to respond and uphold the rights of others in such circumstances. Recently I had the opportunity to complete a course in Health Law taught by a lawyer who was a major contributor to the new Adult Guardianship Legislation in British Columbia. As I studied and considered the new Health Care Consent Legislation implemented in February 2000,1 knew that I had found my research focus. I recognized that, to ensure that the intent of this legislation is fulfilled for the recipients of healthcare, its implementation must involve education of professional health care providers. My study sought to discover the educative efforts that did occur and to examine how they have played out to ensure that the intent of the legislation is understood and upheld. The Legislation Four new statutes came into effect in British Columbia on February 28, 2000. These laws Promote self-determination and autonomy for adults and create a comprehensive and integrated system of support and assistance for adults who need help in making decisions about their health, personal care, or financial matters, or who are abused or neglected." (A Health Care Provider's Guide to Consent to Health Care, February 15, 2000). 2  The new statutes, widely known as the "Adult Guardianship Legislation," include o  The Representation Agreement Act  o  The Adult Guardianship Act  o  The Health Care (Consent) and Care Facility (Admission) Act  o  The Public Guardian and Trustee Act  '  In the matter of adult abuse and neglect, there was no previous legislation addressing responsibilities and procedures for assisting adults who were abused, neglected, or selfneglecting. Previous to implementation of this legislation, professional health care providers were under 1  no legal obligation to follow any form of living will or advance directive. Therefore, in a nonemergency situation, if an adult became incapable of consent, health care providers turned to the next-of-kin or to the courts for the appointment of a committee. The individual who was ill and deemed incapable of making health care decisions had no legal control over who would make such decisions nor on what basis they would be made. At the same time, there existed the opportunity to appoint an enduring power of attorney. Under this law, a representative chosen in advance could make decisions about all matters other than personal health care should the elector become incapable of consent. To illustrate this field of relations in which decisions are made, the following vignette is presented.  Complexity of Consent: An Illustrative Vignette Julie Jones, age 76, suddenly develops an extremely severe headache with projectile vomiting, along with the inability to walk straight. Her husband John finds Julie resting in bed and when he speaks to her, her response is monosyllabic and her words are garbled. John notices In this paper, the term "health care provider" refers to the professional caregiver/provider, whereas the term "caregiver" refers to the non-professional health caregiver. This is consistent with the terminology in the adult guardianship legislation. 1  3  a bluish tinge to his wife's skin. Unable to rouse her more, he calls 911. The ambulance arrives, and the emergency workers transport Julie to hospital. John follows in his car. After a brief wait, the emergency physician sits down with John and lets him know that his wife appears to have bleeding in the brain. He seeks John's approval to do a CT (computed tomography) scan to establish a definite diagnosis. John is extremely upset and begs the physician to do everything possible to save his wife. While waiting for the CT scan to be completed, John phones his eldest and youngest daughters, who both live in the same town. Always protective of them and wanting to believe that nothing serious is happening, he tells them only that their mother is not well and is having tests at the hospital, and he asks them to join him when they can. An hour goes by, arid the physician informs John that during the CT scan, Julie suffered a major cerebrovascular accident (stroke), and has been placed on life support. He informs John that substantial damage has occurred to the cerebellum and the prognosis is grave - if she lives, Julie either will remain unconscious indefinitely or if she regains consciousness, it'is anticipated that she will be severely compromised mentally and physically. The eldest daughter arrivesfirstand she agrees with her father that Julie's life must be saved at all costs and regardless of the prognosis. Julie is moved to ICU and maintained on life support while preparations are made to evacuate the hematoma in her brain in an attempt to keep her alive. John has signed the consent for the surgical procedure. Two hours later, the youngest daughter arrives, having dealt with her responsibilities at work and arranged for someone to care for her children. She is devastated by the news about her mother and further by the decisions that have been made to keep her mother on life support and to intervene surgically. She reminds her father and sister that she is her mother's appointed Representative and she produces her copy of the Representation Agreement, which details that Julie does not wish to have her life prolonged by special measures in circumstances such as those that now prevail. She points out that it was because she was the only family member who agreed to uphold her mother's wishes to be 4  allowed to die with dignity and without interference that Julie selected the youngest daughter as her Representative.  Analysis of Vignette Prior to the implementation of this new legislation, there was no written law specifying what to do in an emergency situation, and the assumption was that life took precedence over quality of life. Therefore, it was expected that everything possible would be done to save the life of an unconscious person. It was not necessary for emergency staff to search for the existence or availability of a representative who could make decisions on behalf of the patient. In fact there was no formal recognition in law of advanced decision making such as a Representation Agreement. In practice, health care providers turned to a relative who accompanied the patient and felt particularly confident in accepting the direction of the patient's spouse. If the spouse consented to care as advised by the physicians, there was usually no issue and care proceeded. If it appeared that there was no hope and in particular if signs of brain death were present, the spouse was asked to sign a form approving removal of the patient from life support. The new legislation outlines specific procedures to be followed. The emergency room physician must inquire whether Julie has a Representation Agreement or a court-appointed committee of person. If an adult who is incapable of giving consent does not have a representative or committee of the person, a temporary substitute decision-maker (TSDM) must be appointed to provide substitute consent for each procedure or, in the absence of a spouse or near relative to perform this role, the health care provider must ask the Public Guardian and Trustee to authorize someone to make the decision, (see flowcharts - Appendix A and B). In this example, had the youngest daughter known that the situation was serious and that decisions were needed, she could have provided information over the telephone and presumably could have made a more timely arrival at the hospital.  5  Clearly Julie's health care providers have overlooked their obligations under the Act and her wish to die with dignity has already been compromised. The major changes that are embedded in this new legislation package relate to actions that professional health providers perform on a daily basis. These include but are not limited to: o  Seeking consent for health care  o  Assumption of capability of all adults  o  Establishing capacity to give or refuse consent  o  Adherence to pre-expressed wishes once an adult is assessed as incapable  o  Informing adults and their significant others about the opportunity to be heard in a Review process, once a temporary substitute decision maker is appointed  Additionally, professional health providers must be familiar with the legislation that allows for: o  Appointment of a temporary substitute decision maker  o  Making a Representation Agreement  o  Seeking protection for an adult when abuse or neglect is suspected.  New legislation affects every citizen in the province. Information must follow a path from government to health care providers at the institutional level as well as at the personal practice level. It must also be accessible to those whose lives will be impacted directly by the legislation, the general public.  Focus of the Study A Complicated Context I am concerned that health providers may not be aware of the new legislation. My concern arises both out of professional and personal experiences of health care issues. On an informal basis, I am aware that many health care providers as well as many members of the public are unaware of the significant changes in consent legislation under the Infants Act of 6  1993.1 therefore believe it safe to assume that they will be unaware of more recent legislation. As well, not many years ago, a landmark case of failure to adhere to legislation occurred in Nanaimo. A young man was sterilized with the consent of his mother and subsequently the Public Guardian Trustee successfully launched a wrongful action suit on his behalf (A.R. and P.G.T. v. Mclntyre, Oxley, Nanaimo Regional Hospital, and Crockett). Two of the lawyers who were involved both in writing and communicating the new legislation have indicated that health providers are not well informed about its contents. Although the new legislation facilitates personal choice about health care through its emphasis on autonomy, capability, and advanced decision-making, professional health providers may simply refuse to alter established practices or, if they are not familiar with the new legislation, they may by default preclude implementation of the patient's choices. Victims of abuse or self-neglect may be apprehended under the Mental Health Act, a proceeding that removes most personal choices and does not honour the intent of the Adult Guardianship Act to maintain maximum self determination and respect. I believe that I can bring these concerns forward through my involvement in research and dissemination of my findings. I am hopeful that through this work, the government as well as the health care professions might recognize the need for more effective education in both the professional and the public realm when legislative changes affect health care. This is the moral imperative for my work. While I believe legislation that clarifies consent and allows people to appoint representatives in advance is a significant forward step in protecting the right to selfdetermination, I also have serious concerns about the demands and challenges inherent in moving that legislation from the legislative context to the bedside. In this project I have explored the educative efforts associated with that transition. The purpose of this study was to discover how this new legislation was communicated to those whose work is most affected by it - more specifically, what initiatives were taken in 7  relation to educating professional health care providers about the legislation. In the case of this new health care legislation, the Ministry of Health (MoH) launched an education initiative in the fall of 1999. Health care constituencies throughout the province were invited to send representatives to a two-day "regional facilitator" session. In theory, each of these trained facilitators was expected to return to his or her jurisdiction and provide local education to other health care providers. Three of these sessions were offered, and approximately eighty people attended in total. As well, written information (A Primer to British Columbia's New Health Care Consent Legislation, March 2000,) was broadly distributed and placed on the Ministry website. Ministry consultants were made available to do workshops on location at the request of health care provider groups. Parallel to the initiatives launched by the Ministry of Health and Ministry Responsible for Seniors, the Office of the Public Guardian Trustee (OPGT) set up a Health Care Consent Planning Group. This group held information meetings throughout the province, but few health care providers attended. The efforts of the OPGT and of the MoH were not synchronized and their educative efforts were somewhat complicated by conflicting slants and advice (Personal communication, Gerrit Clements, fall 2002) . These issues among others were further explored 2  during the interview phase of the research. It is no straightforward or simple task to design and deliver effective educative efforts associated with any new legislation and in this case, there were a number of aspects that made for a complicated and contested process. First there were major upheavals in provincial health care Regionalization during this time, and people's work assignments changed frequently and sometimes drastically. Because of this upheaval, workers attending the training often had to pass on this task to others and they in turn had to struggle to catch up. In addition to the upheaval in  Gerrit Clements is a Special Health Care Consultant with the Ministry of Health. He has been involved with this legislation since its beginnings, as a member of the Joint Working Committee, as a writer of the legislation, and as an educator and consultant. 2  8  staffing there was the issue of varying resources that could be devoted to education leading to some professionals being well informed about the legislation and others less so. Larger hospitals, with their in-house risk management services, have the potential to be more successful in educating their professional health care employees about new legislation, while smaller hospitals and care facilities as well as the many health providers who practice privately do not have similar resources. Professional associations also play a role in keeping their members up to date but their mandates and resources also vary. Another complicating factor in this situation was the ongoing changes taking place in the legislation. Even if educative efforts have addressed the above issues and many health care providers are well informed about the legislation, there is the matter of ongoing power relations that are part of any decision making process in the health care field when it comes to patient care. In the complicated flux of clinical settings...respecting autonomy is considerably more problematic. Patients and their decisions are not patently and unequivocally autonomous; many parties participate in and influence the outcomes of decision-making processes; and decisions often evolve and appear rather than being formally and definitively made. Decisions, in other words, are contested, negotiated, and realized within the social and political dynamics that swirl around patients, families, and health care providers. Attention to context evokes the social and cultural forces that simultaneously anchor and constrain an individual's freedom to decide and to act. (Marshall, 2001, p. 141) Research Questions and Methods Problem  The main goal of this study was to explore how professional health providers were educated about this legislative change and what role was played by professional health organizations. My purpose was to understand o  The role of education in public policy implementation,  o  How professional health care providers become educated about legislative change.  9  o  The challenges associated with educating professional health care providers about new legislation.  o  The impact of various educative initiatives as perceived by the educators.  Research Questions Two research questions guided this study: 1. What happened in the implementation phase of new health legislation in BC? o  What did the government do to educate professional health care providers?  o  What response did the professional organizations make to educate the professional health care providers?  o  What do stakeholders think about the effectiveness and sufficiency of their educative efforts?  2. What lessons can be learned from this study about planning and implementing educational activities that inform professionals of legislative changes that affect their practice? Data collection methods included interviews and document analysis. My investigation focussed on three areas of practice that were involved with educative initiatives: the Ministry of Health, the Public Guardian and Trustee Office, and professional health care provider organizations. I interviewed several people from each of these areas. Documents utilized in their educative efforts were also collected and analyzed. This research project can contribute to a deeper understanding of the educative efforts that accompanied this new health care legislation. With this knowledge, more effective educative initiatives can be designed. Suggestions are made about sharing effective resources and strategies among the groups, as well as alternative approaches that could be used to educate professional health care providers about new legislation. The study concludes with  10  recommendations about the design of a comprehensive educative plan to accompany major public policy shift. Assumptions It was my assumption as I embarked on this research project that many health care providers are not aware of the new legislation. There are a number of possible mechanisms for accessing this information, including direct dissemination of information from the government, information gained through the media, and continuing education offered by the various professional organizations. For a variety of reasons, it is possible that individual health care providers have not accessed the information via any of these routes. This assumption arose out of informal questioning among physicians and nurses in my community and out of conversations with those who wrote the legislation. Until an event occurs that raises their level of consciousness, people often do not seek knowledge of specific legislation, relying instead upon habit and custom. Unless professional health care providers are familiar with the substance of this new legislation, they cannot practice effectively, legally, and with the potential positive influence upon adult patients that is made possible under the new Acts. As Gordon states, Clearly, the success of the Representation Agreement Act will depend very much upon the ability of both the public and key professionals such as social workers, physicians, nurses, lawyers and notaries to recognize the value of planning documents and advise their clients accordingly. ( 2 0 0 0 , p.7)  This surely is no less true of the success that accompanies implementation of the other three Acts. Further, it was my assumption that the educative information made available to each professional group of health providers varied significantly in form and amount. I was interested in this variation and in comparing the educative efforts launched by each of the professional groups.  11  Overview of Chapters This first Chapter has provided an introduction to the research topic along with the context for the legislation. A vignette was included to illustrate the potential for abuse of client rights when the legislated obligations of professional health care providers are not fulfilled. Recognizing that this failure to apply the legislation might result from a lack of information, I set out to find out how professional health care providers are informed about legislative change. My purposes and research questions are articulated, along with a very brief description of the research plan. In Chapter Two I describe the new legislation in more depth, highlighting changes from the perspective of the professional health care provider along with the impact of these changes on client care. In Chapter Three I review the literature from the perspective of education about legislative change. Barriers to successful implementation are addressed as well as educative efforts used in an attempt to break down these barriers. This chapter also includes a brief exploration of power in planning and community development literature. Chapter Four provides an overview of the research design. Interview and document analysis are discussed as they apply in case study research As well, research ethics and challenges inherent in this research are explored. Chapter Five and Six describe the findings of the research. Chapter Five focuses on education initiatives under the Ministry of Health and Ministry Responsible for Seniors and the Public Guardian Trustee Office. Chapter Six reports the findings related to education within professional organizations as well as some other educational initiatives related to this legislation. Chapter Seven provides further analysis and discussion of the key findings in relation to previous research and the literature. In Chapter Eight, a summary of the key findings is offered and policy, practice, and research implications are presented. Alternative approaches are offered for the enhancement of legislative success in the field of health care, and future research opportunities are suggested. I close with some personal reflections on the impact of this study on my practice. 12  C H A P T E R II: T H E LEGISLATION Historical Situation Initially, the idea of reforming consent legislation arose out of the concerns of citizens and community groups. These people were displeased with the lack of legislation in British Columbia to allow advanced selection of representation and choice making around health care so that incapability would not denigrate one's right to self-determination. In 1989 concerned citizens initiated an open participative process and in 1992 a formal partnership with Government ensured that involved citizens felt ownership around the five fundamental agreedupon principles of anticipated legislation: o  All adults have the right to autonomy and self-determination and the right to enjoy the fundamental rights and freedoms described in the Canadian Rights and  o  Charter of  Freedoms.  All adults are entitled to receive the most effective but the least restrictive, least intrusive, and least stigmatizing form of assistance, support or protection when they are unable to act independently, interdependently care for themselves or for their property andfinancialaffairs, particularly where there is a risk that the adult will be subjected to abuse or neglect,  o  All adults are entitled to the legal presumption that they are capable of making decisions and, where necessary, to support and assistance in order to understand and make informed decisions on their own behalf,  o  The use of court procedures and court orders appointing decision-makers or Guardians for adults should occur only as an absolute last resort and only after alternatives such as the provision of supports and assistance have been either attempted or carefully considered. 13  o  All procedures, protocols and other processes associated with the provision of support, assistance, or protection shall be intellectually, psychologically, physically, culturally, and financially accessible to all adults. (Joint Working Committee Report, September, 1992, pp. 3, 4).  The formal partnership known as the "Joint Working Committee" included equal representation from government (Interministry Committee on Issues Affecting Dependent Adults) and community (the Project to Review Adult Guardianship). Their written document "reflects the work and commitment of three thousand people province-wide" (see Appendix A excerpts from How Can We Help?, September, 1992). The Joint Working Committee Report became the basis for drafting new legislation. In July 1993 the draft Adult Guardianship legislation was passed with all party support. Attorney General Colin Gableman commented at that time that community involvement was crucial and must continue and also that he expected to hear from them again within a year with a set of amendments. During implementation of this package of legislation, the community voice arose out of a coalition of more than two hundred and sixty interest groups . 3  A timeline that illustrates the progress of the legislation from conception to implementation, along with the parties and premiers in power, is provided on the next page.  See Appendix A: Excerpts from How Can We Help? for an overview of the constituencies represented. This was truly a partnership between community and government. Some groups included: Aboriginal Nations Society, Alzheimer Society of BC, B C Federation of Labour, BC Retired Employees Association, BC Nurses Union, B C Health Injury Association, BC Medical Association, BC Friends of Schizophrenics, BC Association of Social Workers, Canadian Bar Association, Canadian Mental Health Association (BC division and its branches), Canadian Association for Community Living, College of Dental Surgeons, UBC Faculty of Law, Home Support Associations, Heart and Stroke Foundation of BC and the Yukon, Huntington Disease Resource Centre, Jewish Family Service Agency, Mental Health Services (MoH), Ministries of Attorney General, Health, Social Services and Housing, Labour and Consumer Services, RCMP, RNABC, Banks, Hospitals, Health Units, Churches, Seniors Networks, and many others too numerous to mention. An all-inclusive list can be found mHow Can We Help? (1992, pp. 86-91)  14  Premier (Party)  2003/.... Oct. '03 - Bill 44 - Changes to : ?: HCCAct  Campbell (Libera!) 2002/  CRNToolKitDistributed  2001 Dosanjh (N.D. P.) 2000  2000  I  MHI&r (N.D.P.) 1999-08-25 102000-02-24 1999  CRN Foundation established McLean Report  f  J]''  Jan. - PGT„hires Manager of Health Care Decisions Primer, Guide, Guidelines published Feb. - Adult Guardianship Legislation Enacted  1999/ /.. ..Train the Trainer Project - Fall  :  Clark (N.D.P.)  1996  1995/ Harcourt (N.D.P.)  1993/.;...... Draft legislation passed , Formal partnership with government -» Joint Working Committee "How Can We Help?" published Sept. '92  1991 t Johnson (S.C.) Vander Zalm(SC)  i  1986  Representation Agreement Resource Centre Incorporated PGT hires Director of Implementation for Adult Guardianship  1989  Coalition of Concerned Citizens initiate project to review Adult Guardianship  A long, slow climb on BC's Rocky Slopes 15  A very comprehensive analysis of the legislation can be found in The 2000 annotated Columbia  Representation Agreement Act, Adult Guardianship  British  Act and Related Statutes (Gordon,  2000) . The following discussion of the Acts is based upon Gordon's interpretations, and is 4  intended only to illustrate the significant changes in practice that are driven by these new laws. Each of these Acts is only partially in force and all are subject to ongoing revision. This in itself makes the education of professional health care providers more difficult and obviates the need for continuing educative efforts as revisions occur and as remaining sections come into force over time. Prior to the implementation of this legislation, consent to health care was subject to "a continued reliance on common law principles" (Gordon, 2000, p. 4). For those whose capacity to consent was questionable, health care was often delayed while the courts were tied up in review procedures primarily employed for the protection of the professional health care provider. The opportunity to make advance decisions about health care choices when capable in order to preserve autonomy even once incapacitated was not protected in the law, nor was it clear what responsibility professional health care providers had to follow or to override such directives. In these areas of health care, "it is generally recognized that ...there is widespread public and professional support for the kind of health care consent legislation that has been enacted in British Columbia" (p. 4). The common law paternalism of the past has been replaced with new legislation that is guided by the five principles referred to earlier in this-paper. The Health Care (Consent) and Care Facility  (Admission) Act is connected and  complementary to the other three Acts, but otherwise stands alone (Gordon, 2000, p. 6). To a  Dr. Robert Gordon is a Professor and the Director of the School of Criminology at Simon Fraser University. He was a member of the project to Review Adult Guardianship (1989-1993) and the provincial Joint Working committee on Adult Guardianship (1991 -1993), and was one of the drafters of British Columbia's new adult guardianship legislation. Since 1993, he has been an adult guardianship law consultant to the Public Trustee of BC and a member of the adult guardianship implementation team.  4  16  large extent, though they stand alone, the three other Acts serve to enhance and facilitate the application of the Health Care Consent statute. The Health Care (Consent) and Care Facility  (Admission)  Act  This Act applies to all people over 19 years of age. Those who are less than 19 years old are provided for under the Infants Act (RSBC, 1993). Previous to the implementation of this Act, there was no consent legislation - custom together with the Common Law was the basis for consent decisions. The Act is divided into five parts, each providing new direction for health care consent: Part I — Introductory  o  Provisions  Definitions are provided to clarify terms previously interpreted according to custom. Some of these terms, necessary for the application of the other parts of the Act, include: adult, review board, care facility, court, designated agency, guardian, major and minor health care, health care provider, representation agreement, representative, spouse, substitute decision maker.  o  The broad definition of health care applies only to voluntary admissions and the Act itself does not apply to certain experimental or controversial treatments.  o  Statutes listed in the Regulation define health care providers.  o  Major and minor health care is differentiated to guide the professional health care provider in non-emergency situations, where the procedure differs for obtaining consent to each of these categories of care.  o  The definition of spouse is expanded to include gay and lesbian partners as well as common-law marriages.  o  A very important element of the Act is that it "affirms the common law presumption that all adults are capable of making their own decisions...unless it can be shown that they are mentally incapable of making such decisions" and this 17  "will help to change the commonly held view that adults with disabilities are automatically incapable of making decisions about their lives" (Gordon, 2000, p. 91). It frees health care providers to assume capability unless evidence to the contrary can be provided, o  A very important revision to the Act that came into effect on October 1, 2003, clarifies that the Act does not apply to "the provision of professional services, care or treatment to a person for the purposes of sterilization for non-therapeutic reasons" (Bill 44 -2002 - s. 2 d).  Part 2 — Consent to Health Care o  The common law position, supportive of the right to autonomy, is entrenched and clarified in this section,  o  Consent can be given or refused on any grounds and the adult can choose any kind of health care that is available,  o  It is stated that, except under specific conditions, a care provider must seek consent prior to providing any health care,  o  It is the responsibility of the health care provider to seek a decision from the adult before seeking a substitute decision,  o  Consent must be based upon adequate information, provided by the health care provider.  o  When substitute decisions are made, pre-expressed wishes must be honoured,  o  The patient has the right to revoke consent at any time and this must be honoured unless immediate termination of care would pose a threat to the patient's health,  o  The elements of a valid consent are clearly stated and the duty of disclosure is clarified to include all of the information that a reasonable person in the patient's situation would wish to have. 18  o  The Act provides a cognitive test of incapability: to be deemed capable of consenting, the adult must demonstrate an understanding of the information provided and that the information applies to the adult's own situation.  o  The health care provider must make an effort to communicate in a manner appropriate to the skills and abilities of the adult and must utilize the services of the adult's relatives or friends to ensure accurate communication.  o  Consent may be expressed orally, in writing, or by inference.  o  The scope of consent is clarified as only to the specific health care outlined unless further unforeseen action becomes medically necessary and the adult is unable to consent.  o  The same rules apply to substitute consent as to consent given by the patient,  o  The Act clarifies what is an emergency and when care can be provided without the consent of the adult or of a substitute decision maker,  o  Bill 44, the Health Care (Consent) and Care Facility  (Admission) Act, in effect on  October 1, 2003, clarifies that A health care provider must not provide health care under section 12 if the health care provider has reasonable grounds to believe that the person, while capable...expressed an instruction or wish applicable to the circumstances to refuse consent to the health care. (Bill 44-2002-Section 12.1) o  Preliminary examination can be performed without informed consent if the adult or a substitute presents the adult for treatment.  o  In a non-urgent situation, major health care may be given to an adult who is not capable of consenting and does not have a pre-determined representative or substitute, if the health care provider follows a series of steps. This is one of the most important aspects of this new legislation, since it involves selecting a temporary substitute decision maker from a statutory list, and giving notice to the 19  adult and to anyone who accompanies the adult, of the decision(s) that have been made and of the mechanism for having such decisions reviewed within a period of 72 hours. Until April 2004, a Review Board option was available. Since then, the Review Board was disbanded and Health Authorities given notice that they are expected to provide for a review option mechanism, o  Minor health care can be provided under the same conditions as above by selecting a temporary substitute decision maker in the same manner and upon receiving his/her consent. Neither a waiting period nor a review is applicable here.  o  The qualifications of temporary substitute decision makers are set out. Authority under this category is for a period of only 21 days.  o  Temporary substitute decision makers cannot make certain kinds of controversial decisions. End of life decisions cannot be made unless the adult's health care providers agree with the decision and the decision is consistent with the adult's pre-expressed wishes or known beliefs and values (Gordon, 2000, p. 133). According to Clements (in Gordon, 2000, p. 135), this represents "a major advance for the ability of health care providers to make decisions regarding the cessation of treatment or non-use of available treatments without undue fear of legal repercussions." This significant change arises out of elements in all of the new Acts to ensure that there will always be a substitute decision maker who can weigh medical opinion and the patient's pre-expressed wishes, beliefs and values in making a decision. Any written documents in which the adult provided preexpression of wishes can be used to inform the temporary decision maker.  Part 3 - Admission to a Care Facility This part of the Act is not yet proclaimed. 20  Part 4 - Reviews and Appeals This part of the Act created the health Care and Care Facility Review Board. It was repealed as of April 2004. According to one of my participants, as of July 2004 only about half of the Health Authorities had created informal dispute resolution processes. Part 5 - General Provisions o  This section protects health care providers as well as others who are involved in substitute decision-making as long as they have "acted in good faith and used reasonable care" (Gordon, 2000, p. 154).  o  It also entitles a health care provider to rely upon information given to them by others during the course of choosing a temporary decision maker. The Representation Agreement Act  The Adult Guardianship Act and the Representation Agreement Act were drafted "to create consistency and to underscore the similarities between the two ways in which 'guardianship' may be created - one by the court, the other by the adult" (Gordon, 2000, p. 10). Although it came into effect along with the other three Acts on February 28, 2000, the Representation Agreement Act has been under more active ongoing review than have the other three. As of this writing, some changes have been made to this Act. The following analysis is based upon those pieces of the Act currently in effect. Part 1 - Introductory Provisions o  The Act begins with several definitions, many of which overlap with and are identical to those in the Health Care (Consent) and Care Facility (Admission) Act. Additionally, there are definitions that overlap with the Financial Institutions Act.  o  The Act applies only to adults 19 years of age or older.  21  o  The purpose of the Act is to provide a mechanism that allows adults to arrange in advance for management of health, personal, and financial matters, should the adult become incapable. This done, the court does not become involved in appointing substitute decision makers.  o  The Act is strong on its emphasis on the presumption of capability, thereby protecting the rights of adults with disabilities to make their own decisions about future matters.  o  There are provisions in the Act for determining incapability in differing circumstances. The standard (liberal) test of capability applies in s. 8, which describes preparation of a standard Representation Agreement. The tighter cognitive test in s. 10 offers complicated provisions for determining capability when an Enhanced Representation Agreement is chosen.  Part 2 - Parties, Terms, Formalities and Registration o  An adult can name anyone (including another adult, the Public Guardian and Trustee or a Financial Institution) as a representative.  o  More than one representative can be named and specific authority assigned to each of them. Alternates can also be named.  o  The representative(s) must accept the assignment by signing the Agreement and completing a prescribed certificate.  o  Standard provisions that may be assigned to a representative are outlined in s. 7, and capability to assign standard (low risk) provisions is virtually assumed. The test outlined for incapability allows for wide scope in who can assign representation. Because of this flexibility in the Act, people who are already experiencing some difficulty managing their affairs can make decisions about representation without the court becoming involved. 22  o  A representative cannot make decisions about controversial medical treatments nor about cessation of life support.  o  A monitor can be appointed to oversee decisions made by the representative.  o  S. 9 provides that special provisions may be assigned to a representative, but only if the adult consults with a lawyer who can establish that the adult is capable of understanding the nature and effect of the assigned authority. These special provisions inc lude the right to make decisions about controversial health care and end of life issues, along with any other decisions that are not prohibited by law.  o  These elements of the legislation at last give legal status to advance decisionmaking and pre-expression of wishes, both of which have previously had no legal support. Pre-selection of desired treatment can be based upon any number of factors including religious beliefs and values around end-of-life issues. This is the major contribution of this new Act - self-determination is ensured even after one becomes incapacitated.  o  The adult can elect or choose in writing not to elect a monitor. Under certain conditions, the Public Guardian Trustee may appoint a monitor.  o  Provision is made for the proper preparation, signing, and witnessing of the Agreement.  o  The adult must indicate when, and under what circumstances, the agreement will become effective.  Part 3 - Duties, Powers and Liability of Representatives and Monitors o  The representative is assigned certain responsibilities, including to act prudently, within the authority given in the agreement, and to the fullest possible extent, according to the pre-expressed or understood wishes of the adult.  23  o  The representative must adhere to the requirements regarding substitute decisionmaking as outlined in the HCCAct.  o  A representative who is uncertain about a decision may seek guidance from the court or the Public Guardian and Trustee.  o  The representative has the right to access all information about the adult that is necessary in making a decision, and the health care provider who supplies such information is absolved of any charges that confidentiality has been breached.  o  A monitor who has reason to believe that the representative is not performing in the best interests of the adult must inform the Public Guardian and Trustee.  o  The representative and the monitor have a duty of confidentiality toward the adult and they are protected from civil liability as long as their actions are consistent with the Act.  Part 4 - the Act allows for a capable adult to make changes to the agreement according to prescribed steps. o  Agreements are terminated under certain prescribed circumstances, such as the death of the adult or representative, or the dissolution of a marriage between the adult and the representative.  Part 5 - Objections, Investigations and Assistance o  Provides for any person to make a complaint to the Public Guardian and Trustee on any basis if there are questions about whether the adult is being properly represented.  o  The Public Guardian and Trustee can launch an independent investigation into the representation of the adult.  24  o  Under certain conditions, if the adult is incapable, the court may make an order altering the Representation Agreement but only if this order is in the adult's best interests and reasons for the order can be documented,  o  Representation Agreements that were made prior to the implementation of the Act, and that are consistent with the Act, are valid.  The Adult Guardianship Act At this time, only Parts 1,3, and 4 are in effect.  Part 1 - Definitions Part 3 - Support and Assistance for Abused and Neglected Adults o  Provides for support and assistance to adults 19 years of age and older who are abused or neglected and unable to seek assistance on their own.  o  The assistance is provided wherever the adult is abused or neglected, including the adult's or a relative's home, a public place, or a care facility,  o  Anyone who has information about abuse or neglect of an adult can report to a designated agency without fear of reprisal as long as the report is in good faith. The identity of the reporter is protected,  o  Designated agencies include local "community response networks" as well as regional health services,  o  There is no legal duty to report the abuse or neglect of an adult,  o  Reporting and/or assisting in an investigation cannot result in discrimination, discipline, or in dismissal from employment,  o  A designated agency must investigate any report of abuse or neglect and may take a variety of actions if there is a finding of abuse or neglect and may inform the Public Guardian and Trustee of the findings.  25  The designated agency must make every reasonable effort to interview the adult as well as anyone close to the adult who might assist. This includes health care providers and agencies that are associated with the adult. The designated agency may apply for a court order to enter the adult's premises and to have a health care provider enter the premises to examine the adult. The designated agency can take a wide range of available actions if the investigation reveals that there is abuse or neglect. These include: o  Referral to care  o  Report to the Public Guardian and Trustee  o  Assist the adult in obtaining a representative  o  Apply to have a person refrain from contact with the adult  o  Apply for a maintenance order  o  Specify support and assistance needed by the adult  The adult must be involved as much as possible in making decisions about how to stop the abuse or neglect and how to prevent it in future. If the adult refuses support and services and appears incapable of making such a decision, the Public Guardian and Trustee can be asked to make an assessment of the adult's incapability. If the refusing adult is deemed incapable, the designated agency may apply to the court for an authorization order. Within 72 hours of such an application, notice must be served on the adult, the adult's closest relative, the agency where the adult is receiving care, the Public Guardian and Trustee, the adult's designated representative or guardian, or any other person chosen to make decisions for the adult under the HCC Act, any person against whom an order is sought.  26  o  Remaining clauses deal with the process of holding a hearing and ordering care and protection for the adult,  o  A person from a designated agency may take steps to actively protect the adult in an emergency. These steps include removing the adult from unsafe premises, providing emergency health care, and informing the Public Guardian and Trustee that the adult's assets require protection,  o  Any party to the above proceedings can appeal an order to the Supreme Court.  Part 4 - Administrative and Miscellaneous Provisions o  The Public Guardian and Trustee is enabled to designate agencies and organize community response networks for protection of adults,  o  The Public Guardian and Trustee and designated agencies have the right to access any information that they need to carry out their duties in protecting adults from abuse and neglect, and are obligated to keep that information confidential. The Public Guardian and Trustee Act  This act replaces the Public Trustee Act. The main differences of interest to professional health care providers as outlined in Gordon (2000, p. 239) are: o  The new title which reflects "a more equitable focus on the personal guardianship and substitute decision making functions of the office."  o  The creation of an Investment Advisory Committee  o  Expanded powers to investigate and audit both trusts and the activities of persons holding powers of attorney, as well as representatives, decision makers, guardians, and committees,  o  The duties and responsibilities of the Public Guardian Trustee that affect professional health care providers in fulfilling their obligations have been outlined under the three Acts already reviewed. 27  From the Perspective of the Professional Health Care Provider: Crucial Elements in the Legislation Each of the four Acts described above contains elements that professional health care providers must know and understand to ensure that they are able to provide responsible care for clients. One element common to all of the Acts is that they apply only to adults over the age of 19. Other crucial elements are outlined below: The Health Care (Consent) and Care Facility (Admission) Act o  Legislation now exists to describe consent procedures and define valid consent  o  Definitions are articulated. For example, major and minor health care differentiated, spouse defined to include gay and lesbian and common-law partners  o  Capability is assumed unless proven otherwise  o  Consent for certain non-therapeutic procedures is not covered under this Act  o  Appointment of temporary substitute decision makers must follow a certain procedure and their authority is circumscribed  o  Pre-expressed wishes must be honoured  The Representation Agreement Act o  Allows adults to arrange in advance for management of health and personal matters  o  Capability is assumed  o  Powers of representatives differ in a standard and in an enhanced agreement  o  Agreements are terminated under certain specified circumstances  o  The representative must be given access to all information that applies in making a decision about consent  28  The Adult Guardianship Act o  Provides for support and assistance to adults who are abused or neglected or unable to seek assistance on their own  o  Assistance provided in any location where an adult is abused or neglected  o  Identity of reporter is protected as long as report given in good faith  o  Designated agencies have been appointed and are legally responsible to respond  o  Designated agencies have a wide range of available actions  o  The intent is to involve the adult as much as possible and to maximize selfdetermination, integrity, and respect  5  o  If an adult refuses services and appear incapable of making such a decision, the Public Guardian and Trustee can be asked to intervene and make an assessment  The Public Guardian and Trustee Act o  The PGT has expanded powers to investigate the activities of representatives, decision makers, guardians, and committees Summary: Concerns About the Legislation  As will become apparent in the Findings chapters, some of the delays that occurred between proclamation and implementation of the Adult Guardianship legislation package were the result of disagreement within and among the very groups who were responsible for its conception and development. The legislation is extremely complex and it was not accompanied by easy to follow, lock-step directions. Many advocacy groups were very worried about whether  This differs significantly from the Mental Health Act, which provides for a "person with a mental disorder...that renders that person incapable of associating with others, or unable to react appropriately to the environment" and who "must require psychiatric treatment, protection from self, or others must require protection from the person, or substantial physical or mental deterioration must be evident." Under this Act, any physician can complete a certificate and detain such a person for 48 hours. This certificate can be renewed upon examination and written report. Police can bring such a person into care as an emergency when the issue is safety. This Act removes selfdetermination for the period of certification, and does not reflect a primary intent of honouring integrity and dignity. Prior to implementation of the Adult Guardianship Act, the Mental Health Act was the primary tool for protection of people who were abused or neglected. As will be seen, the latter Act often remains the chosen route for professional • health caregivers who are unfamiliar with the Adult Guardianship Act. 5  29  people would be able to understand the intent behind the legislation and, given that they did understand, whether they would be able to apply it. There was not consistent agreement about how to make the legislation work at the front lines.  Adult Guardianship Act Near the time when this thesis was reaching its final stages, I had the unexpected good fortune of being offered an opportunity to speak with a clinical practice consultant for case management who has done extensive work with the Adult Guardianship Act-Part 3. This registered nurse, who I will refer to as Avery, was involved with a provincial working group and several smaller working groups under the PGT. Avery's association with these groups began in October of 2000 and continues to this day. The tasks in which Avery was engaged involved  operationalizing the legislation - "inventing the wheels and preventing the re-invention of those same wheels throughout the province. " Avery refers to the Adult Guardianship Act as the "AGA." Avery told me that it is not unusual for people who have not been educated about the  Adult Guardianship Act to choose the Mental Health Act as a default. The latter is  A comfortable tool... they've used it for years. There is sometimes a lack of experience in using the AGA. Personally, I feel that the AGA is a much more respectful legislative tool... it doesn't remove a person's capability the way that the Mental Health Act does... the approach that we take is to sort through the tools to find the one that is practical and preserves capability and integrity. The Mental Health Act is like a sledgehammer...you are capable or you are not capable. It's black or white. And if you are incapable under the Mental Health Act you have lost significant rights to self-determine and make your own decisions. Under AGA, there are shades of capability... a continuum.. .1 may not be able to manage my own financial affairs, but I may be able to decide to live at home alone and take that risk. It is a much more respectful place to support people.  When I asked Avery to identify the key factors in helping professional health care providers to sort among the tools, the response was immediate and passionate:  30  An understanding.. .to me, it's knowledge... and then experience secondarily. The more you use something, the more comfortable you become with it. When it's all new, it might appear to be very complex. The AGA has a lot of facets to it, and initially that may turn people off. But, education is the key...they need to understand and be supported as they learn.  It becomes obvious when summarizing the Acts and their relevance to professional health care, and when speaking with care providers about common concerns, that education of professional health care providers about the legislation is crucial if we expect them to honour its intent and apply its guidelines. Health Care (Consent) Act and Representation Agreement Act  In the fall of 1995, the Representation Agreement Resource Centre was incorporated as a charitable society. The purpose of this Centre is to assist people in understanding and implementing their own Representation Agreements. One concern was that the Health  Care  Consent legislation, which provides detailed instructions for appointing substitute decision makers, should have been enacted following the Representation  Agreement legislation to give  people enough time to prepare their representation agreements instead of risking'that the Health Care Consent Act be utilized as the default (Personal communication, Joanne Taylor, July 10, 2001) . In a conversation with Robert Gordon, he referred to the two pieces of legislation as 6  "symbiotic and interlocking"  (July, 2001) and suggested that the Health Care Consent  legislation will potentially be the context for ethical violation of the Representation  Agreement  Act. Essentially, the reason for his statement reflects the possibility that health care providers will move to the Substitute Decision Maker clauses in the Health Care Consent Act without first investigating whether the patient has made a Representation Agreement. This illustrates one  Joanne Taylor is the Executive Director of the Representation Agreement Resource Centre, set up in 1995 as an incorporated charitable society. RARC provides information and facilitation for people who wish to prepare Representation Agreements and also houses the Nidus Registry for those who wish to centrally register their Representation Agreements or Powers of Attorney. 6  31  reason why education of professional health care providers is imperative for the protection of the public. I asked Avery whether the education offered by the PGT included the other three Acts. Avery indicated that there were some one-day sessions that included all of the Acts, and that handouts were provided. "7found the information when the Representation  interesting, but there's a real gap between  Agreement ends and our caseload begins, " Avery stated. "It was  interesting, but not as pertinent as the Adult Guardianship  Act. People with a  Representation  Agreement don't usually end up in crisis... they don't appear in our caseload. They've planned out their lives and their life changes really well. "  The next chapter provides a review of the literature. Specific discussions in the literature about educative efforts attending legislative implementation are sparse. In her dissertation describing the implementation of similar legislation in the United States, Johnson (1995) found the same gap in her search of the literature. I hope that this project will make a contribution to that body of knowledge. The literature review defines several terms and discusses policy implementation with particular emphasis on barriers to implementation. Because in many settings, the process of planning for education appears to have been affected by power issues, I have also included a discussion of power in planning. A brief discussion of the community development literature is included because the approach used in some of the educative initiatives was considered by the educators to be a community development approach.  32  C H A P T E R III: THE LITERATURE Because this project was about efforts to educate professional health care providers when new legislation is implemented, I initially concentrated on an exploration of the literature that describes implementation of policy/legislation and the challenges that attend this stage of policy development. As is indicated in the literature, failure of the educative effort is only one of the factors that potentially affect the success of policy implementation. Conceptualizing Policy This is a case of investigating educative efforts in support of policy implementation. As one way in which policy is stated, legislation has statutory implications, but how is such policy conceptualized? Policy can be viewed as the expression of values that are incorporated into rules, and the impact of policy can be a function of the extent to which values are shared among the writers and the implementers, the clarity of the policy, as well as a number of variables in the policy context. These contextual variables can include situational issues and complexities, resource distribution, and the balance and fluctuation of power. Policy is "a set of claims about how the world should and might be.. .the operational statements of values" (Bowe & Ball with Gold, 1992, p. 13); "the programmatic activities formulated in response to an authoritative decision" (Matland, 1995, p. 154). Important to note is that while policies are descriptions of actions that should be taken in general, "practice is concerned with what should be done in a specific situation" (Wharf & McKenzie, 1998, p. 35). Therefore, both the input of practitioners during policy development and built-in flexibility at policy implementation can be important factors in policy success. Legislation  is the codification of statutory policy and, as Bowe, Ball, and Gold describe it,  "but one aspect of a continual process in which the loci of power are constantly shifting as the 33  various resources implicit and explicit in texts are recontextualized and employed in the struggle" (1992, p. 13). They go on to describe a view of "policy as discourse" (p. 13) with many variations that are dependent upon knowledge and practice and therefore subject to interpretation and change in the interval between legislation and implementation. Policy analysis, usually aimed at determining outcomes, is "a type of applied research and analysis conducted for policymakers to assist them in the decision-making process .. .can include an analysis of the impact of an existing policy, or an analysis of activities having a direct or indirect relationship to policy" (Gill & Saunders, 1997, p. 225). Policy implementation  is "what develops between the establishment of an apparent  intention on the part of government to do something, or to stop doing something, and the ultimate impact in the world of action" (O'Toole, 2000, p. 266). Wharf and McKenzie (1998, p. 73) describe implementation as "a powerful, but usually neglected stage in the policy process" and caution us that since it is almost certain that policy will be altered during its implementation, we should concentrate on how to ensure that these changes are "improvements rather than impediments to service." Believing that the majority of Canadian public policy is made by the "elite" members'of society (mainly middle-class men of Euro-Canadian descent), Wharf and McKenzie (2004, p. 11) recognize that policy-makers often lose interest at implementation, and that front line workers have a lot of discretion about how policy actually plays out at the point of impact. Implementation  research "concerns the development of systematic knowledge regarding  what emerges, or is induced, as actors deal with a policy problem" (O'Toole, 2000, p. 266). Exploring the connection between policy and research, Ozga describes policy as a process resulting from negotiation between competing groups (2000, p. 42), making it clear that policy text is not a "done deal" but rather a plan that is subject to change.  34  Implicit in all of these formulations of policy is the recognition that the original intent of policy may not be clearly articulated in its content and further that even when intent and content are clear, what happens to the policy at the implementation stage is subject to a wide variety of influences and effects. Dependent upon the orientation of the researcher, such variability in outcomes can be seen as positive or as negative. As experts at the frontlines, practitioners may be best qualified to influence the intent of policy, yet it is elected politicians who are given the power to develop policy at the statutory level. How that process plays out - whether or not at the development level, experts are included (the "bottom-up" format for policy development) can be a major predictor of policy outcomes. Wallace and Pocklington (1998, p. 8) encourage implementation studies that prevent "gaps between policy intention and practice" that result from the difficulties inherent in attempts of "groups at one system level [to] make policies on behalf of those at others levels". Education  involves knowing about, knowing how, knowing what to do - in the language  of Aristotle, epistome, techne, andphronesis.  (EDST 601, July 2000, class notes). Inherent in  this conception of education is the relationship between theory and practice known as praxis. To be successful, education for professional health care providers about new health care legislation would necessarily involve all three of these elements. Implementation According to the literature, it is rare that policy implementation fully succeeds (Elmore, 1978; McLanahan, 1980; Lomas, 1991; Levin, 2001). Elmore speaks disparagingly of "grand pretensions, faulty execution, puny results" (p. 186) in implementation efforts. Among the reasons for implementation difficulties are the varied interpretations of stakeholders, conflicts over values, and failure of strategies and instruments of implementation. Discretion and autonomy at the local implementation level can result in a great deal of variability in how a policy is implemented and it is obvious that such variability can increase when many 35  actors/stakeholders with differing ideologies and agendas are involved. Levin makes the point that legislative policies "are rarely clear and unambiguous" and in the specific settings where they are implemented, "the confusions are likely to be multiplied" (2001, p. 175). Further, he points out that policy involving many changes multiplies the difficulties of implementation. The legislation that is the subject of this project involves four new Acts which incorporate many changes in how health care consent is managed and affect many professional health care providers as well as individuals and families. The more complex the policy, the more crucial it is that stakeholders are familiar with its details. Conversely, the more complex the policy, the more difficult it is to read and the less likely that busy stakeholders will take the time to read and understand all of the nuances of the policy. Busy professionals, under pressure to increase productivity and at the same time to maintain their clinical competence, are unlikely to be aware of legislative changes unless such events are brought to their attention. Like the school system, the health care system is "large and decentralized" (Levin, 2001, p. 177) and therefore understanding and commitment to changes in policy may vary across the spectrum. Old habits, urgency in the immediate setting, and well-established values and routines all contribute to the exercise of discretion at the implementation level of policy in relatbn to education systems. Levin maintains, "the skills and attitudes of teachers would seem to be an absolutely critical factor in implementation" (2001, p. 177). No doubt the same is true of professional health care providers. Petr calls for a "model of implementation that is constructed from the consumer/client point of view" (1991, p. 68). Referring to the wide discretionary power that exists at the point of policy implementation, he posits that policy goals are much more likely to be achieved if stakeholders have direction in how to make policy work at the front lines. Mazmanian and  36  Sabatier (1989) support this view, further suggesting that increased specificity and prioritizing of statutory goals may lead to increased compliance. Petr speaks of assessing, rather than evaluating, implementation. "Implementation precedes outcome; implementation refers to what the agency is doing, while evaluation of outcome refers to the success or failure of those efforts" (1991, p. 70). In completing such an assessment, he describes two dimensions of implementation: degree of intent and degree of practice. To assess the degree of intent, agency documents must be obtained and analyzed and those delivering the training must be asked about their intent. Measuring the degree of practice involves assessing what was actually done to implement the intent (pp. 71,72). Petr's study included an assessment of how well front-line staff was educated about the policy to be implemented; information was gathered both from stakeholder reports and from agency documents. In their study of the implementation of four new statutes for the management of mentally ill offenders, Diamond, Cruser, Childs, Schnee, and Quinn discovered that a very low percentage of stakeholders were aware of the Statutes and even fewer were familiar with the details of the legislation. The study used "key informant interviews, document reviews, and a survey of knowledge and opinions" (1999, p. 333). Generally, they found few written materials along with a lack of familiarity among stakeholders about the Statutes. Few workers had received any formal training about the new legislation. After the findings of this study were reported, a county planning council was established with a mandate that included training for stakeholders. The authors "believe that the process of engaging people in the interviews, the surveys and the findings, validated their concerns and raised interagency awareness of common needs and interests previously unacknowledged" (p. 342). As they point out, "merely passing new laws and policies cannot effect change without awareness, information sharing, team building, and both lateral and vertical communication" (p. 343). 37  Ball points out that "some texts are never even read firsthand" (1994, p. 17) and that "solutions to the problems posed by policy texts will be localized and should be expected to display ad hocery and messiness" (p. 19). Many factors affect the actual application of policy, including but not limited to various representations by varied interests and actors, inequalities in the workplace, gatekeeper influences, contextual complexities, discretionary elements, and conflicts with other existing policies. If, as stated in Bowe and Ball with Gold, the Act is a '"working document' for politicians, teachers, the unions, and the bodies charged with responsibility for 'implementing' the legislation" (1992, p. 10), then it is essential that these stakeholders not only read the text, but read it with understanding and clarity and that they apply it through a process that ensures the understanding of those who must act upon the legislation. In the "context of practice," policy is "not simply received and implemented.. .rather it is subject to interpretation and then 'recreated'" (p. 22). O'Toole encourages ongoing research into matters of policy implementation, pointing out that "even as the researchers seem not to have solved the implementation puzzle, practitioners continue to find themselves enmeshed in the vexing challenges of converting policy intent into efficacious action" (2000, p. 265). He speaks of the "multiple institutional actors.. .whose cooperation and perhaps coordination are needed for implementation success" (p. 266). Clearly, unless those actors have a shared understanding of the policy intent, cooperation and coordination in its implementation are not possible. Mazmanian and Sabatier (1989, p. 266) describe the pessimism that has grown among practitioners and scholars as a result of repeatedly ineffective implementation efforts as "the pathos of implementation." In an effort to mitigate this pathos, they suggest several steps that can be utilized to increase the probability of success, even if conditions are not optimal. A summary of these steps follows:  38  o  At the Statute development stage, the use of learning, experiment, research and evaluation along with as much input from as many sources as possible;  o  Use of amendments to clarify ambiguous legislation.  o  Ongoing monitoring of implementation efforts along with periodic evaluation and reports to government leaders,  o  Identification and mobilization of an active supportive constituency that will monitor implementation,  o  To address apathy or even hostility among legislators during implementation, a "fixer" must be found and nurtured. A "fixer" is someone influential who will strongly support the legislation and give it priority,  o  Systematic monitoring and reviews must be completed either by sympathetic legislators or by external, impartial organizations, (pp. 275, 276)  Even with these steps in place, Mazmanian and Sabatier speak of "an implementation effort that goes against strongly held beliefs, long-standing practices, and potent political forces" (1989, p. 276) as "an uphill battle from start to finish" (p. 277). Certainly the legislation that is the focus of this study meets all of the criteria for an uphill battle. It is the first legislation that addresses issues of consent, advance decision-making and protection of adults from abuse and neglect. While many of the elements in the legislatio n parallel already established common practices, there are also many changes and additions that create complexity in roles and reduce the power of professional health care providers. In their paper that supports a democratic, "bottom-up" approach to implementation, deLeon and deLeon quote Mazmanian and Sabatier extensively, yet they utilize the work of Lester and Goggin (1981, p. 1) in their claim that Public policy implementation continues to hold much practical interest for policymakers [both] because it is a major stumbling block in the policy process 39  [and] .. .one of the most heavily utilized areas of policy analysis, (cited in 2002, p. 468)  It seems fair to suggest that unlike many others (Mazmanian & Sabatier, 1989; Wharf & McKenzie, 1998), deLeon and deLeon do not view implementation as in a state of pathos. Reassuring the reader that there are many examples of successful public policy implementation, deLeon and deLeon claim "the attention of both scholars and practitioners is focused on problems, that is, situations in which reality diverges from expectations. Problems cry out for explanations in a way that successes ordinarily do not" (2002, p. 477). My research project does not focus on problems, but rather on gathering information about process. Citing several examples of varying timeframes for implementation efforts, Mazmanian and Sabatier (1989, p. 277) reassure us that there is no "natural" progress from legislative development to implementation - progress varies significantly. Mazmanian and Sabatier (1989) have designed a checklist of questions that should be asked when planning for implementation. Included in the checklist are questions about the anticipated support of the organizations where the policy is to be implemented, opportunities for outside supporters to participate in implementation, the commitment of implementing officials to the Statutory objectives, their skills of implementation, as well as the probability that changes in socio-economic conditions and the short attention span of the media and the public might undermine implementation efforts. In their study of the response to new legislation regarding informed consent, Eijkman and Goaedhart (1996) discovered that Dutch dentists were not informed about the content and the background of the new legislation. Additionally, dentists related a number of perceived negative consequences and implications about the implementation of the new Act. Many of these were seen to arise out of a lack of clear understanding about the intent of the legislation. In this  40  implementation effort, education could possibly have clarified the intent and the content of the legislation and possibly reduced much of the negative outcomes. Although my literature search did not reveal much information about specific educative efforts directed toward stakeholders, it seems clear that this requirement is implicit in the implementation of new legislation. How else can the many uncertainties about practical application of legislative intent described above be addressed? Barriers to Implementation It is clear in the literature that implementation has been a "missing link" (Hargrove, 1975, as cited in deLeon and deLeon, 2002, p. 469) in the policy process for more than three decades. Before analyzing problems in the actual implementation of new policy, it is crucial that consideration be given to the policy itself. Involvement of the stakeholders in policy development can address many potential barriers in the implementation path "The best approach to developing realistic recommendations is to discuss preliminary recommendations with individuals who will have a role in the implementation of 'the real thing'" (Gill & Saunders, 1997, p. 232). However, as Wharf and McKenzie (1998) point out, this involvement must continue throughout the development and implementation phases of new legislation. There is potential for significant change in the socio-political realm when legislation is developed and implemented over a period of several years. "The pivotal assumption in implementation is that policy makers can be of one mind when it comes to operationalizing a policy, for at base, when multiple players are involved...implementation becomes a battle to determine a correct reading of the mandate and its accurate execution" (deLeon & deLeon, 2002, pp. 474, 475). Building on the work of Fullan (1991), Levin (2001) describes several barriers to implementation of new legislation in the field of education. These include:  41  o  Characteristics of the change - clarity, complexity, and degree of difficulty of the proposed change.  o  The setting - aspects of the organization, including the level of commitment by important actors, the skills of those involved, the resources allocated to support change, and the extent to which a given change fits the existing culture and structure.  o  The context - various other pressures either supporting or inhibiting implementation, (pp. 174, 175)  All of the barriers that Levin describes in the school system are found in the health care system. The specific settings require that local policy be developed to enable the legislation to be implemented. This policy must address the activities of all of the professional care providers who may be making decisions and having an impact on patients. The many steps involved in seeking consent, particularly substitute consent, and in clarifying the legalities around review of consent decisions, will complicate and extend the time required of the care providers. Four different Acts involve multiple changes in approach to the client as well as in the documentation of consent processes. The many stakeholders involved function in a variety of institutional settings as well as in private practice, necessitating changes in procedures at all locations. This reality also increases the discretionary power of the stakeholders since in some settings they are subject to the machinery of the organization as it sets policy and in others they must rely on their own understanding of the legislation to implement procedural guidelines. Reorganization and expansion of regions within the health care system means that as stakeholders move among settings, they may have to function under more than one set of policies and procedures. This reality is sure to lead to varied understandings and levels of commitmert to the policy intent. In reviewing legislative changes affecting education, Levin states that the "skills and attitudes of teachers would seem to be an absolutely critical factor in implementation" (2001, p. 42  177). Surely this is no less true of professional health care providers. In today's health care environment, with the emphasis on increased productivity accompanied by complaints of being overwhelmed, overworked, unappreciated, and burned out, attitudes toward new policies that are accompanied by new demands for education and change are even more likely to be negative. Citing the work of Chase (1979), a successful health care administrator in New York, Wharf and McKenzie (1998, p. 68) refer to the "three sources of obstacles [to implementation]: the operational demands required by the new policy, the nature and availability of resources and the need to share resources with other actors." The health care legislation required substantial change in the process of gaining consent. As well, it became apparent that educative efforts to enhance implementation success were significantly affected by the availability and distribution of resources. As Levin states, "resistance may not always be overt" (2001, p. 182). It would be easy for professional health care providers to quietly disregard many of the elements of the new legislation when seeking consent. To address some of the barriers to implementation, some authors promote the "bottomup" approach, in which the people responsible for applying policy are those who also develop that policy (Wharf & McKenzie, 1998; deLeon & deLeon, 2002). Such a "discursive, more democratic" (deLeon & deLeon, 2002, p. 478) approach allows for the voting public to contribute to decision-making about what is going to happen and how it will happen. In an unpublished paper about adult guardianship law reform in British Columbia, Gordon finds within the failure of full implementation success that there are three lessons for 7  law reformers. These include:  Dr. Robert Gordon was a member of the Project to Review Adult Guardianship and the Joint Working Committee, as well as a drafter of the adult guardianship legislation, a consultant to and member of the PGT adult guardianship legislation team. At the time that he wrote this unpublished paper, Gordon was convinced that the legislation would be abandoned and never implemented.  43  o  Keep the reforms small. Overwhelming changes in policy and practice result in slowed comprehension of the information, and are very expensive to implement,  o  Avoid delay once the Legislation  is passed. Delay causes a loss of momentum as a  result of decreased enthusiasm, allows for erosion of consensus among supporters, and opens the door to the introduction of new and conflicting agendas, o  Never trust politicians.  Initially, there was good faith and trust between the  community and government. Both groups worked collaboratively to develop the legislation. The process was "inclusive,  respectful, and empowering, " but in the  end, the politicians put a different political agenda ahead of their commitment to implement the legislation. (1999, pp. 25-31) Perhaps Gordon's rather cynical view of politicians at the time that he wrote this particular paper was a result of the very long delay in implementation, much of which was commonly attributed to the shift in equality of partnership described by Rutman (in Wharf & McKenzie, 1998). According to Rutman, "it is possible that earlier in the reform process the power dynamics were more balanced and that the issue of power, and power struggles, became more salient as the reform process unfolded and the community continued to demand equal participation" (p. 110). Rutman, who was a participant observer on the Office of the Public Guardian and Trustee policy committee, goes on to describe the various manifestations of the power imbalance. She describes the Public Trustee, who chaired the committee, as very influential in the committee process. As well, the committee members perceived that the information they were given was incomplete and slow to arrive. Probably the most significant "imbalance [was] in the resources that each 'side' had at its command" (p.l 10). Government members were paid for their time on the committee and had the necessary administrative support to complete their work as members. On the other hand, community participants were serving as volunteers, offering their time without compensation and sometimes even rescheduling their 44  responsibilities as employees in order to participate on the committee. The government also indicated that the original estimate of implementing the legislation, estimated at between three and five million dollars had increased to more than ten million dollars. This significant rise in associated costs was their excuse for reviewing all of the acts to determine whether costs could be reduced through gradual implementation without undermining the principles of the legislation. According to Rutman, community members were not in agreement with this estimate of implementation costs and the resulting delay in moving forward. The seeds of the adult guardianship legislation, planted early in the 1980's, found their roots in 1989 with the establishment of the Joint Working Committee, flowered into proclamation in 1994, but were not harvested until 2000. During this time period, five Premiers sat in the House, and three Attorney Generals controlled legislation. Many other political agendas demanded the attention of those who governed the province. Rutman muses, "what seems to be missing is the sense of personal commitment and passion that Colin Gabelman [BC attorney general] and Myrna Hall [BC Public Trustee], brought to the process" (1998, p. 106). Both of these leaders were in office when the legislation was first being developed and both were strong supporters. As well, with the passage of time, the process of co-creation that had guided the process of community working in equal partnership with government had evolved into a more consultative process. In the latter version of community participation, "for many government participants...partnership with community meant working with community 'advisors' who would provide feedback on the government's conceptualization and drafts of the new legislation" (p. 109). This sort of role change did not sit well with the community members, who often received completed versions of documents from government and perceived the expectation to be simply the provision of feedback. Such an altered role was unsettling and discouraging for  45  a group of community members who had dedicated many years of their lives to ensure the successful outcome of their legislative goal.  The Need for Education Many of the difficulties and barriers to implementation can be addressed, at least to some extent, through educative action during implementation. According to Levin, "the more novel or difficult the idea, the less likely it is to be implemented without learning on the part of the people involved" (2001, p. 183). He refers also to the importance of valuing learning and of commitment to change - both of which may well be influenced by professional associations. One of the strategies, or "policy levers" (p. 185) utilized by government is capacity building, which "involves various forms of training or skill development" (p. 186). In their discussion of the statutory variables that promote successful policy implementation, Meier and McFarlane emphasize the importance of stipulated decision rules and objectives for implementing agencies (1996, p. 287). The parallel to this requirement is written rules for consent and related matters. Although such statutory elements exist, it is essential for care providers to learn and understand the rules and objectives. How should this learning take place? Even more likely, rather than telling the stakeholder what to do, the policies "create circumstances in which the range of options available in deciding what to do are narrowed or changed, or particular goals or outcomes are set" (Ball, 1994, p. 19). Given such a situation, care providers must learn about the policies and develop processes to ensure adherence to the new mandate. Understanding is key to the enactment of texts. As Bowe and Ball with Gold point out, "the opportunity for re-forming and reinterpreting the text mean policy formation does not end with the legislative moment" (1992, p. 13). This recreation of policy that occurs in the "context of practice" (p. 22) is affected by the care providers' history, experiences, and values. Further to this, stakeholders implement 46  legislation with "a great deal of discretion and autonomy" (McLanahan, 1980, p. 357). Johnson (1995, p. 29) refers to other authors who have discussed the danger inherent in legislation that leaves the text ambiguous and open to the discretion and autonomous interpretation of professionals (Edwards, 1980; Hogwood & Peters, 1985). These writers point out that such textual ambiguity can lead to outcomes that may be either less than or different from the legislative intentions. DeLeon and deLeon refer to this as the problem of "administrative legitimacy," recognizing the reality that "statutory law cannot fully dictate administrative action, for every law or rule requires interpretation" (2002, p. 480) and they add that "these interpretive decisions of administrators.. .must have legitimacy, which in a democracy must derive in some way from the consent of the governed." Citing the "communicative rationality" of Habermas (1987), deLeon and deLeon promote a model of social discourse that mirrors deLeon and deLeon's description of operational participatory orientation, which "would include reaching back in the policy process framework to include the policy formulation deliberations as a means to help define policy goals by talking with the affected parties well before the policy is adopted by the authorized policy maker" (p. 483). Clearly it is crucial that a balance be struck allowing for the expertise and the autonomy of professionals to operate within the constraints of the legislation. Matland (1995, p. 160, cited in deLeon & deLeon, 2002, p. 485) offers an "ambiguity/conflict matrix" (see Figure 1) in which four cells illustrate the potential combinations when policy ambiguity is high or low and conflict is high or low. The adult guardianship legislation appears to fit into the "experimental implementation" cell, where ambiguity is high and conflict is (relatively speaking) low.  47  CONF1LICT  AMBIGUITY  Low  High  Low  Administrative Implementation  Political Implementation  High  Experimental Implementation  Symbolic Implementation  Figure 1: Ambiguity-Conflict Matrix: Policy Implementation Process (Matland, 1995, p. 160, as cited in deLeon & deLeon, 2002, p. 485). In this cell, "contextual conditions dominate the [implementation] process" (Matland, 1995, pp. 165, 166, cited in deLeon &deLeon, 2002, p. 486) and there is no significant discrepancy among the values of participants. The experimental implementation title refers to the general attitude that implementation is an experimental process that allows time for revisions and for learning to occur. Presumably, this would be a time in which educative efforts would be effective. It is disturbing to imagine the errors that could occur along with the potential for displacement of client values if every individual professional health care providers was to reform and re-interpret text on his or her own reading. It seems much more reasonable - indeed, safer - to imagine that such readings and interpretations would be guided by expertise. In the health care professions, the obvious source of this expertise should be found within the professional organization. According to Diamond et al., For effective [legislative] change to occur.. .those affected by the legislation must have adequate information about the change, issue and nature of the targeted arena...must be motivated and willing to make the change...need information, decision-making skills, feedback on performance, and informed, supportive, and flexible leadership." (1999, p. 330) All of these are essential requirements for the implementation of new consent legislation. More than minimal guidelines along with less discretionary judgement around implementation is a requirement supported as well by Helms and Henkin (1989). 48  •  Writing about the implementation of California's Children and Families First Act, Bodenhorn and Kelch (2001) emphasize the importance of educative strategies at both the planning and implementation phases. In her doctoral dissertation, Johnson (1995) describes the process used in the United States to implement the Patient Self Determination Act (PSDA), a piece of federal legislation with the major goal of enhancing the individual's control of medical decisions. The PSDA has several strong similarities to BC's adult guardianship legislation. Implementation of this new Act was accompanied by a federal mandate that in order to receive financial reimbursement from Medicare and Medicaid, institutions had to provide education to their staff and the general public about patient rights and advise patients of their right to consent or dissent to medical or surgical treatment, their right to have an advance directive, and to have the latter placed on their medical record (p. x). The federal government also required that States develop and provide in writing a description of their laws about advanced directives. Last, but certainly not least, the Act provided for a federal education program so that the public would have access to education outside of the medical institutions and providers of care. Even with the funding hammer poised and waiting, problems that had surfaced during legislative development reappeared in the implementation stage. These included issues such as appropriateness of patient decisions in particular medical circumstances, appropriate timing of implementing patient decisions, conflict between ethics and values of patients and care providers, and clarity of patient language, as well as complex problems of trust/distrust among all those concerned (p. xiv). What actually occurred during implementation of the PSDA was different than intended. In the end, funding was not tied to institutional efforts to inform and educate patients, nor was the federal public education initiative realized. Johnson believes that PSDA was founded on an inaccurate assumption. Prior to the legislation, patients were not participating actively and fully in health care decision-making and 49  they were not preparing advance directives with any regularity. The PSDA did not confer any new rights, but it was prescriptive in that it demanded that patient rights be communicated to patients and consistently upheld. The federal regulations that attended the implementation assumed that if patients were given information about PSDA on admission, their control of medical decisions would automatically be enhanced. Yet, the causal theory was never proven: "It was not known that the reason patients do not participate in health care decisions is that they don't know they have the right to [do so]" (p. xx). Johnson questions whether simply giving patients information on admission constitutes "education." She wonders whether such action enables people to "understand and participate...to the extent that they choose" (p. xxi). She expresses concern that the professional health care provider's ethical duty is not met when PSDA "is carelessly or thoughtlessly implemented [because] patients will be at risk of having treatment discontinued too soon, and health care proxies may make unilateral decisions without consideration of the patient's wishes" (p. xxii). One of the findings of Johnson's study was that "in-service training is a significant predictor of staff support of policy" (p. 96). As well, Johnson describes the process of implementing PSDA as "circular.. .As more patients develop advance directives, professionals, led by physicians, will have more experience in implementing them. Once a practice pattern is established, policy consistent with practice behaviour will follow" (p. 137). There are many parallels here that may apply to the adult guardianship legislation and these will be discussed in Chapter VII.  Adult Education and Policy Implementation Given the barriers to implementation that have been described, it seems reasonable to suggest that education may be one key to successful policy enactment. Theory about planning for adult education is therefore relevant to this study of policy implementation. Planning adult education is a political process. According to Fraser (1989, p. 167), "a matter is 'political' if it is contested across a range of different discursive arenas and among a range of different discourse  50  publics." In her discussion of the "struggle over needs," Fraser makes the claim that "needs talk functions as a medium for the making and contesting of political claims" (p. 161) and that "needs claims.. .tend to be nested, connected to one another in ramified chains of 'in-order-to' relations" (p. 163). Once we move beyond the general, or 'motherhood' statements about needs, we move into "thick" (p. 163) areas of controversy. For example, moving beyond the simplistic view that we all need shelter, how would we define shelter? For each of us, shelter constitutes a very different entity. So too does education. If we believe that knowledge is good.. .is power, how do we define what constitutes knowledge, and just as importantly, how do we define how to educate adults in order that they may attain knowledge? Educative efforts during implementation of new public policy are a form of adult education. In their discussions of planning for adult education, Cervero and Wilson (1994) provide a framework that is useful for the analysis of educative initiatives associated with the implementation of the adult guardianship legislation. Planning is described as "a social activity in which people negotiate with each other in answering questions about a program's form, including its purposes, content, audience, and format" (Goodson, 1991, cited in Cervero & Wilson, 1994, p. 28). 'Tower is the capacity to act" (p. 29) and arises out of the social context. Interests "direct the actions of planners" and "are motivations and purposes that lead people to actjin certain ways.. .are the human social purposes that give direction for acting in the world" (p. 29). Those who plan education have interests and are in power relationships that are "asymmetrical and complex" (p. xii). Negotiation must occur within the social context so that the varied interests and power relationships can be maintained, strengthened, or transformed. Cervero and Wilson claim "this model of planning as a social activity in which planners negotiate interests can improve practice in three ways." It can make sense of much of the apparent noise (contextual factors) of daily work; it identifies planning as a political activity; and it more clearly defines the ethical responsibilities of planners in determining whose interests will 51  be represented (1994, pp. 31, 32). As Forester points out, "ignoring the opportunities and dangers of an organizational setting [power and competing interests] is like walking across a busy intersection with one's eyes closed" (1989, p. 7). The education of adults is an awesome responsibility. As Cervero and Wilson point out, Planning practice matters in adult education because the programs will make the world a different place. People with particular sets of interests will have planned the programs...have selected certain purposes, content, audiences, and formats for the programs, thereby closing off other possibilities. Each educational program, then, makes a statement about the way the world ought to be... adult education cannot be a neutral activity.. .therein lies educators' central responsibility - namely, what kind of world will their practice shape? (1994, p. 5) In addition to the education and adult education literature, Cervero and Wilson credit professions outside of education for much of their inspiration and insights in developing the power in planning framework. Some of their resources included the social sciences and nursing. For the social-structural relationships of power, the literature of critical social theory was employed. They do not mention the literature of policy implementation in this wide scope of study. I have wondered whether they simply did not enter that field of literature or if they discovered, as I did, that there is little recognition of an education role in policy implementation. Reflecting upon the usefulness of social science research projects in the field of policy analysis, Ozga suggests, "we understand policy as involving negotiation, contestation, and a struggle between competing groups, as a process rather than an output" (2000, p. 42). In a later publication that addresses the struggle for knowledge and power in society, Cervero and Wilson (2001) emphasize a relational view of adult education in which power not only structures adult education but adult education plays a role in reproducing or changing power relations: This relational view requires that we ask that timeless political question about out efforts in adult education: Who benefits? Perpetually tied to this question is the ethical one: Who should benefit? The increasing importance  52  of adult education in the constitution of social, political, economic, and cultural life demands no less. (2001, p. 3) Further, they point out that "adults [adult learners]... enter this process [of adult education] marked by their location within larger systems of power and privilege that have shaped their experiences" (2001, p. 11). Clearly, then, negotiation of power and interests takes place not only among the educators but also among the learners and reciprocally among them all. An interesting political and ethical question that applies very much to this research project is ".. .what happens when adult educators meet real systems of power and privilege in our classrooms, institutions, and communities?" (p. 13). In order to practice, the adult educator must make a decision about who should benefit. This automatically makes education political and labels the educator a social activist (p. 13). It is when the question "who should benefit? " is addressed that reciprocal negotiation of power and interests is even more important. To fully understand the process of planning education, it is important to consider both the technicalrational process and the political process, since neither plays out in isolation. Writing about the success of continuing education programs, Ottoson (1995, 1997) makes the claim that immediate evaluation of such programs through questionnaires completed by the learners is not a reliable measure of success. Follow-up evaluation several months after the education program may indicate that very little application of learning has occurred. Ottoson asks, "what happened after the applause had faded?" (1997, p. 92). In the follow-up study of successful implementation of a new conceptual framework, researchers discovered that those who attended had individual differences among their experiences of the program that arose from their differing values, concerns, perceptions, circumstances, personal values and predispositions. These uniquely individual differences among learners as well as varied agendas, perceived power, pre-existing routines, resources, and other contextual factors in their organizations were all elements that affected implementation of the new model. Ottoson's more recent writings  53  (2000 a, b) further describe the contextual influences on application of continuing professional education and offer a theory for evaluation of continuing education programs that may be useful for the evaluation of educative efforts directed toward professional health care providers.  Community Development and Policy Implementation The adult guardianship legislation arose as a community initiative out of a perceived need to protect vulnerable adults and to enshrine their right to make decisions about their own health care. Another area that may help us to conceptualize the educative efforts made in this case study of implementation is the link between community development and education. As will be seen later, the Public Guardian and Trustee Office spearheaded efforts that were successful in developing and enhancing community strength. Community development has become a catch phrase for a variety of approaches to community initiatives in which the values of the target community should be central to the process. It is "the building of collective commitment, resources, and skills that can be deployed for purposive community change to build on community strengths and address community problems" (Vollman, Anderson, & McFarlane, 2002, p. 133). Minkler succinctly describes the community development process as "think globally, act locally, foster individual and community empowerment andfinallywork for social justice" (1994, cited in Vollman, Anderson, & McFarlane, 2004, p. 134). Steps in developing community include: o  Define the issue - what is it, what is known, who is affected.  o  Initiate the process - research, identify stakeholders, gather people to create commitment to action.  o  Plan community conversations - invite all stakeholders, develop formal and informal process to allow airing of all viewpoints.  o  Talk, discover, and connect - prepare handouts outlining the issue and why the community is mobilizing, make connections and seek support. 54  o  Create an asset map - develop lists and initiate relationships; communicate regularly.  o  Mobilize the community - bring people together to discuss, share, create a common vision, and plan.  o  Take action - involve and educate community members, help shape opinion, galvanize commitment.  o  Plan and implement community-driven initiatives to change and improve the situation, organize people, and sustain the efforts. (Vollman, Anderson, & McFarlane, 2004, pp.136, 137)  Some of the many positive consequences of using the community development approach might include: greater participation, expanded leadership base, strengthened individual skills, wide sharing of values and vision resulting in less conflict, tangible progress within a strategic agenda, more effective community organizations and institutions, and improved utilization of community resources (Vollman, Anderson, & McFarlane, 2004, p. 138). Describing a decision-making process for allocating funds to support health promotion initiatives, Bruce (1994) describes an applied community development approach. For community-based projects that the W.K. Kellogg Foundation supported, in which the focus "grow[s] out of concerns and priorities in the community - those that people who live there identify with, projects that they own and are willing to work on" (p. 45) Bruce posits that the best policy does not rise out of rooms full of experts but rather out of "lessons learned at the local or community level" - a lesson that policymakers must learn. He describes an approach to educate, inform, or influence policymakers at every level that incorporates the same kind of steps as those outlined above. First, you start where people are, and you proceed at their pace. Second, when a professional group or organization does start an activity in the community, it must be transferred to the community to be incorporated into 55  the lives of people and further sustained and continued. And.. .third.. .you never, ever do for the community what the community can do for itself, (p. 45)  Bruce and his staff determined that rather than funding large institutions such as universities, hospitals, and professional groups, Kellogg Foundation grants would be given to communities. They based this initiative on the realization that large formal organizations "love money.. .it is habit-forming.. .people become dependent on the habit and are devastated when grants expire" (1994, p. 45). Desiring to give money more wisely, to initiatives that would be sustainable without being dependent, the funding priorities were reset to reward Ideas that are so good that they will be enacted anyway, with or without a grant...[where] a little front-end money [would] assist a project in getting off to a better start, help build a better product, or help build the capacity of individuals to realize a stronger, healthier community." (p. 45)  Summary Examination of the literature reveals that problems in policy implementation are a common occurrence, particularly when the policy involves complex change and when there are multiple settings or actors involved in the application of policy. Frequently the policy text remains unexamined by those most affected in its implementation, and the combination of complexity and unfamiliarity often lead to resistance. A "bottom-up" approach of implementation, wherein stakeholders are involved both in policy writing and implementation, may facilitate policy success. Strategies to facilitate implementation may include stipulated rules and objectives provided by the government, along with education of all stakeholders about the intent and the goals of the policy. These two approaches may limit the extent to which text is altered at the front lines through the discretion and autonomy of stakeholders. Because professionals are seen to possess a great deal of expertise in their chosen fields, it often happens that policy-writers leave much to the interpretation and discretion of the professional. While this practice can add 56  strengths in its recognition of expertise, those strengths have the potential of outweighing the original policy intent. Again, the involvement of professionals in the discursive process of policy writing may capture the expertise both of the writers and the professionals in a way that reduces ambiguity and conflict at implementation. As well, this process can continue throughout implementation as the necessary revisions and adjustments are made with the cooperation of all those involved. In the United States, an effort to implement a federal Patient SelfDetermination Act met with resistance at the institutional level. Some of the difficulty in this initiative may have related to inaccurate assumptions underlying the Act and to difficulties in the educative efforts associated with its implementation. By its very nature policy planning is a political process, as is planning adult education. It is not any wonder that education related to policy implementation can be a political minefield. Planning as a social and a political activity involves negotiation of power and interests in which important decisions must be made. These decisions include answering the question, "who should benefit?" and "how can that benefit be realised?" Cervero and Wilson (1994, p. 5) would argue that this power that is located in planning has the capacity to "make the world a different place" through education and at the same time, to reproduce or change power relations. As is suggested by their worldview, education can be transformative, but in the broader context power issues may remain in spite of educative initiatives. Community development describes an approach to community initiatives in which the values of the community are central to the process. There are many advantages to the community in using this approach, including greater participation of community members, strengthened leadership base, strengthened individual skills, sharing of values which leads to reduced conflict, and improved utilization of resources. All of this describes an empowered community.  57  At every level in effecting policy, community development can operate effectively. In its process can be found the seeds and the content of new legislation, as well as the plans for successful implementation. Community development is a way of enhancing communication among stakeholders ranging from those at the top to those at the front lines where legislation affects practice. In the next Chapter, I outline the elements of this research project, beginning with methodology and a description of Case Study. Interview technique is discussed and described, followed by the research design and data analysis. Research ethics and the challenges inherent in this project complete the Chapter.  58  CHAPTER IV: RESEARCH METHODOLOGY My orientation to doing research about the implications of this legislation is twofold. I hope through this research to increase awareness within the professional health care provider groups about the implications of changing legislation. As well, I hope that out of this research will come direction about the needs for further education around new legislation in both the public and professional spheres. I am confident that members of the health care professions have a genuine commitment to responsible practice, but that they often fall short in their awareness and understanding of the legal parameters of practice. This confidence arises out of informal inquiry into people's awareness of the Infants Act enacted in 1993, which significantly changed consent law. I have found that members of the health professions are generally not well informed about this legislation. Recently I informally surveyed a group of twenty-eight registered nurses who are case managers in community health. I asked them about their familiarity with the adult guardianship le gislation. One indicated that she is familiar with the legislation, two had a "vague idea about the content, " several indicated that they may have had some orientation to the legislation but had not used it and therefore had lost the ability to do so, and all expressed concern about how to keep up with legislative changes when they have so much to read in order to maintain their knowledge about nursing itself. My analysis of the legislation illustrates areas of particular concern about the ethical implications of implementing this legislation. Whether and how these implications have been addressed through educative efforts made to date, both by the government and by the professions themselves, became apparent through the research project. In truth, the potential for public jeopardy arises out of the struggles of professional health care providers to keep abreast of new legislation, to understand it, and to adhere to their ethical obligation to respect all of the patient's  59  legal rights. At any one of those levels of understanding and of application, there are potential ethical implications. One of the ways that this research might be useful is if it "draw[s] attention to and challenge[s] the taken for granted or dominant assumptions informing policy" (Ozga, 2000, pp. 46, 47). It seems reasonable to expect professional health care providers to be aware of and supportive of legislation that protects their clients. This research seeks to discover how that awareness is achieved. In a sense, I believe that this research project has the potential of becoming an example of practical inquiry turning into formal research (Richardson, 1994, p. 7) and of contributing to the "epistemology of practice" (Noffke, 1993, p. 23). As mentioned in the Literature Review chapter, there is a very limited amount of literature about educative efforts made to enhance the implementation phase of public policy. Therefore a descriptive case study is an appropriate way to approach this subject. It is my sincere belief that this project will contribute to a greater awareness and understanding of the urgent need to provide professional health care providers with opportunities to be well informed about legislative change. My interest in ethics and in the law has spanned many years of study, teaching, research, and reflection. I believe that I possess an acute consciousness of ethical issues and I am committed to ongoing development of greater self-knowledge. I brought these traits to this research project. Case Study "[RJesearch is not the transmission of specialized data but, in style and content, a catalyst for critical consciousness" (Christians, 2000, p. 148). This case study will help us to better understand how to design/evaluate education regarding public policy, including conditions that support and inhibit the educational process. Through this work, the government and health care professions might recognize a need for further education in both the professional and the public realm when legislative changes are made which have the potential to affect health care. 60  Writing about how the policy process can be influenced by qualitative research, Rist claims that "there is a pressing need for information on the implementation process per se" and further that the "focus is on the day-to-day realities of bringing a new program or policy into existence.. .on the efforts made by the organization or institution to respond to the initiative.. .the expertise and qualification of those responsible for the implementation effort" (2000, p. 1008). In his discussions around accountability, Rist points out that qualitative research can effectively attend to "whether the original objectives and goals of the policy stayed in place through implementation" (p. 1009). My concern is that, without successful education for care providers, it is not possible for this health care consent policy to succeed. This research consists of a qualitative case study of the educative efforts made to inform professional health care providers about the new Health legislation in British Columbia. As Stake (2000) points out, "case study is not a methodological choice but a choice of what is to be studied" (p. 435). I believe that this project is an "instrumental case study" (p. 437) because it involved examining a case for the purpose of understanding the issue of education about new legislation - the particular instance being studied is intrinsic, however, in that I was interested in this case itself. I wanted very much to understand the stories of those involved in this particular case; beyond this case, I was also hopeful that this inquiry would contribute to a wider discussion about educative efforts that relate to new legislation. In his 1995 publication, The Art of Case Study Research, Stake offers an outline of how to approach the study of a single case. The first criterion for case selection: Should be to maximize what we can learn...we need to pick cases which are easy to get to and hospitable to our inquiry, perhaps for which a prospective informant can be identified and with actors willing to comment on certain draft materials. (Stake, 1995, p. 4) Stake also discusses the notion of 'progressive focusing' (1995, p. 9) which involves an emphasis on interpretation and flexibility as data is collected—a process that can contribute to  61  description of "those concerns and values recognized in the behaviour and language of the people being studied" (p. 42). Stake recognized that "all research is a search for patterns, for consistencies" (p. 44). Consistent with Stake's characteristics of qualitative case study (pp. 4748), in this research my intent was to understand the various efforts of those involved with education related to legislative changes and how they differ from others and might even contribute to one another. As a nurse and an educ ator myself, I have empathy for the challenges involved in professional continuing education and I sought to understand "actor frames of reference, value commitments" (p. 48) through a design that was emergent and responsive to the perceptions of the actors. Describing qualitative research, Merriam clarifies that "the key concern is understanding the phenomenon of interest from the participants' perspectives, not the researcher's...the emic, or insider's perspective, versus the etic, or outsider's view" (1998, pp. 6, 7). This describes my interest in seeking the perspectives of those who provided education about the new legislation their beliefs about how the education was offered and how successful it was. Consistent with other characteristics of qualitative research, as the researcher I was the primary instrument for data collection and analysis, and I collected data in the field where the participants are naturally located. Merriam describes a characteristic of qualitative research as "primarily employing] an inductive research strategy.. .builds abstractions, concepts, hypotheses, or theories rather than testing existing theory" (p. 7). Having found very little theory about the effect of education on implementation, I was unable to deduce hypotheses to guide the investigation; rather my inquiry was exploratory in nature. Outlined below is a discussion of my data collecting methods: interviews with key informants and document analysis. Collecting data for implementation research through interview and document analysis is supported in the writings of several authors (Ball, 1994; Diamond et al., 1999; McLanahan, 1980; Petr, 1991). 62  Data Collection Strategies Interviews An interview is "a conversation with a purpose" (Dexter, 1970, p. 135, cited in Merriam, 1998, p. 71). It allows us to "enter into the other person's perspective"(Patton, 1980, p. 196, cited in Merriam, 1998, p. 72). Merriam further states "[i] interviewing is necessary when we cannot observe behaviour, feelings, or how people interpret the world around them. It is also necessary to interview when we are interested in past events" (p. 72). Clearly, the best way to gain the perspective of educators about the legislation and its educative implications was to ask them. It seemed evident as well that asking in person would best allow me to clarify my questions and the participant to clarify his or her perceptions. Further, a minimally structured format allows the interviewee to "define the world in unique ways" (p. 74). Merriam suggests that the researcher can combine types of interviewing to achieve several purposes: standardized information, response to open-ended questions, and fresh insights along with new information (p. 75). In their discussion of new trends in interviewing, Fontana and Frey speak of creative interviewing, which has as its purpose the discovery of feelings and emotions as well as core knowledge (2000, p. 663). I think that this manner of interviewing was best to get at why the educators really believe that they were or weren't successful in carrying out their mandate. As much as possible, the engagement had to be "contextually grounded and jointly constructed by interviewer and respondent" (Schwandt, 1997, p. 79, as cited in Fontana & Frey, 2000, p. 663). Schwandt describes "four ways of defining (theorizing) the notion of interpretive understanding (Verstehen)" (2000, pp. 191, 192). The first, empathic identification, involves "getting inside the head of an actor" (p. 192). I am not convinced that this was always possible for me. My background as a nurse and a teacher helped me to understand where the participants are "coming from" but it may also confound my ability to stand outside of my own history. It 63  was an important consideration as I engaged with the participants. Phenomenological sociology aims to "grasp how we come to interpret our own and others' action as meaningful" (p. 192) in the intersubjective world. It was essential for me to remind myself to be aware of a tendency to think that I know what others mean by what they say, and that I understand their context. I took steps to elicit the meaning of words within contexts. Language games are unique to specific cultures. I am familiar with much of the health care culture, but not the culture of government. I had to work at understanding the language games that the participants play. "Interpretivists aim to reconstruct the self-understandings of actors engaged in particular actions" (p. 193). "[A]ctors' ways of making sense of their actions are constitutive of that action" (Giddens, 1993; Outhwaite, 1975, as cited in Lincoln & Guba, 2000, p. 193). My purpose was exactly as described - to achieve the two dimensions of interpretivistic verstehen - understand the actions of those who sought to educate and learn about the legislation through understanding how they make sense of their actions. The hermeneutic circle with its "hopping back and forth between the whole conceived through the parts" (Geertz, 1976/1970, as cited in Lincoln & Guba, 2000, p. 193) is a useful metaphor to describe what I anticipated doing during this research project. I think that it was also what actually happened during the interactions with key informants as we spoke of the legislation as a whole, its particular issues for professional health care providers, and the educative initiatives that related to some or all of these. Selecting Participants The educative efforts associated with implementation of this new legislation were concentrated within three major groups and so I sought to interview key informants from the Ministry of Health, the Public Guardian and Trustee, and Professional Organizations. Ministry of Health - launched a training initiative to prepare "regional facilitators " who would bring information back to professional health care providers in their constituencies. I used e-mail and telephone to initially contact the three people who did most of this teaching and I 64  asked them to participate in my research project. All of them agreed and each also had suggestions about contacts in the Public Guardian and Trustee office that they believed should be included in my research. "This is sometimes called the 'snowball method' of building up appropriate contacts " (Ozga, 2000, p. 85). I interviewed the three Ministry participants in person and completed a document analysis of materials offered at the training sessions and on the government website. I continue to maintain contact with all three and have communicated with them to follow up on questions and issues as they arose during the project and to keep informed about legislative changes that have occurred. Public Guardian and Trustee - launched initiatives to go to the communities throughout the province offering education to anyone who wanted to attend. I contacted three people who were responsible for these educative efforts and asked them to participate in my project. I interviewed two of them in person and one on the speakerphone and I completed a document analysis of materials offered during their presentations and on the website. A fourth participant was employed by both the Ministry of Health and the Public Guardian and Trustee during the development and implementation of the legislation and was therefore able to provide information about initiatives that originated in both areas. I also had an opportunity to interview a nurse who was active in some of the PGT groups that worked with some of the designated agencies during implementation of the Adult Guardianship Act requirements. I have kept in contact with the PGT participants to clarify issues that have arisen in the project and to keep informed about the legislation. Health Profession Organizations - 1 interviewed the Continuing Education Consultant (or equivalent) for several of the following professional health care groups to discover what specific education was offered to their members and I completed a document analysis of educational publications that they produced.  65  Selected professions included: o  Chiropractors  o  Dental Surgeons  o  Dental Hygienists  o  Licensed Practical Nurses  o  Massage Therapists  o  Occupational Therapists  o  Physical Therapists  o  Registered Psychiatric Nurses  o  Physicians and Surgeons  o  Naturopathic Physicians  o  Registered Nurses  *  o  Social Workers  *  * *  *  *  *  The above groups were selected from the listing of regulated health professionals who must comply with the Health Care (Consent) and Care Facility (Admission) Act found in A Primer to British Columbia's new Health Care Consent Legislation (March 2000, p. 12). I chose those Associations/Colleges that I believed have a formal member education function. Of the twelve contacted via e-mail, surface mail, and telephone, seven agreed to participate in the study - those are indicated with an asterisk (*). Others either did not respond to my attempts to contact them, or indicated that their profession had not offered education related to the legislation. The Interview Process I sent each potential participant an introductory letter describing this research project and I included the Consent Form as well as an Interview Guideline so that they would have a sense of what matters would be addressed in the interview. The actual Interview Guidelines for each group are included in Appendices C, D, and E. In the letter, I emphasized that as part of a 66  qualitative research interview, the questions were a guide only, and were not expected to restrict the conversation. Interviews took place over the twelve months from August 2003 to August 2004. Ten interviews took place in person in the actual work setting of the key informant. Scheduling and weather concerns necessitated telephone interviews for the others, during which the key informant was located in the workplace and I was in my home with a speakerphone and tape recorder. I was aware during those that the lack of non-verbal interaction may have reduced the opportunity for a more reflective and less structured process. To address this concern, I made sure that I allowed plenty of time for the interview, asked more than once whether there was anything else that the person wished to add or discuss, and followed up with a second contact via e-mail to offer the opportunity for additional input or conversation. Believing that it would be helpful for the participants to be prepared with a general idea of how the interview would progress, I included an outline o f possible questions with the letter of request. However, there were some disadvantages to this approach; some respondents seemed restricted or at least influenced by the questions and it was at times difficult to move into a more open-ended and reflective discussion of their participation in education. It seemed that this happened most with those who had been less involved in educative efforts. Contrarily, there were two who, though they had received the questions and the letter of request and had signed the consent form, were confused about which legislation I was studying. Both were prepared to discuss the Health Professions Amendment Act! In other cases, it was clear that having the questions had helped the informant to consider the information requested and to prepare for the interview. If I do a similar research project again, I will send guideline questions with the letter of request, but I would be inclined to reduce the number of questions and to make some of the questions less specific. Those that were more open-ended tended to elicit more conversation.  67  Each interview began with general questions around how the participant became involved in education about the legislation and the importance attached to this educative initiative. I asked the participant to tell me what major issues in the legislation were important for professional health care providers to understand. We then usually moved on to discussing goals of the educative initiative, the form taken, and the participant's perspective on the success of the education. I asked about resources and methodologies. As well, I encouraged exploration of how such initiatives might be approached differently in future, and of the relationship between education and the success of health policy. I frequently used validating phrases in the interviews. I would ask, "do you mean...?" or "can you say that another wayl" or even "would you please define what you mean by that phrase/term/word? " I also utilized the techniques of paraphrasing and of asking "can you say more about that? " or "how did you feel about that when it happened? " Reflecting feelings with phrases such as "it sounds like that was frustratingfor you " or "you seem excited about that idea " was effective in encouraging my participants to explore further and to increase the creativity that, as mentioned earlier, may have been somewhat stifled by the questions provided in the interview guideline. I took very brief notes on a template during the interviews, and tried to reflect upon and document my thoughts and reactions to the interviews immediately after they were completed. As indicated in the letter, I offered each participant of copy of the tape recording so that any concerns could be brought to my attention prior to using the data in the report. As well, the data analysis was offered for feedback before it became a permanent part of the thesis. All of the participants refused the copy of the recording; all indicated that they would welcome a copy of the data analysis when it was complete.  68  Gathering Documents In the letter as well as during the interview, I asked each participant for a copy of documents utilized in the education offerings. Several provided hard copies of documents at the time of the interview, while a few mailed them later. Many of the Ministry and PGT documents are available on the Web, and I copied them myself. The documents that I sought were "just about everything in existence prior to the research at hand" (Merriam, 1998, p. 113) in the hope that "the paper trail" might inform me about educative efforts in ways that interviewees could not or did not, and as well might have generated further questions. As Lincoln and Guba claim, "if an event happened, some record of it exists" (1985, p. 278). The documents helped validate and even enhanced some of the information gained during interviews. Authors consistently point out that one of the strengths of document analysis is its unobtrusiveness (Lincoln & Guba, 1995; Merriam, 1998; Marshall & Rossman, 1999). The gathering and analysis did not directly involve action on the part of participants and since the documents were developed prior to the research, there was no disturbance of the natural setting. Data Analysis Data analysis "involves making sense out of text.. .it is an ongoing process involving continual reflection about the data...asking analytic questions, and writing memos" (Creswell, 2003, p. 190). I used an informal variation of a "Document Summary Form" to "put the document in context, explain[s] its significance, and give[s] a brief summary" (Miles & Huberman, 1994, p. 55) as well as to record key ideas (Creswell, 2003, p. 190). Similarly, I utilized the essential elements of a template in the form of the "Contact Summary Sheet" to explore "the main concepts, themes, issues, and questions" revealed in the interviews (Miles & Huberman, 1994, p. 51). As Creswell claims, this assisted my work in a number of ways: it suggested new areas to explore in the next interview, revealed new areas to be coded, 69  summarized the interview to assist when I returned to the material at a later date, and furthered the data analysis (2003, p. 52). My research questions and more specifically my interview questions guided the selection of a "Start List" of codes for initial data analysis (Miles & Huberman, 1994, pp. 58, 59). As I collected data both in the form of documents and interviews, I began analysis concurrently through completion of a template based upon the questions and the start list. "Technical data" answered questions about what educative efforts were made and, as I anticipated, the "emergent intuitive" analysis revealed some sense of the actual commitment of each group to the educative process (Marshall & Rossman, 1999, p. 151). Codes changed and emerged as I worked with the data. I also employed inductive coding that emerged out of reflection during reading and rereading of data and field notes and to a limited degree, I used the "find" function in Word to seek coded materials. I utilized all three types of codes described by Miles and Huberman: descriptive, interpretive, and pattern codes (1994, p. 57). Pattern codes are also referred to as themes and issues in case study research (Creswell, 2003, p. 191). A series of eight steps describing the process of developing codes proved very useful. These steps were developed by Tesch (1990, pp. 142-145) and summarized by Creswell (p. 192): 1. Get a sense of the whole.. .read all the transcriptions carefully.. .jot down some ideas. 2. Pick one document or interview.. .read it and ask, "what is this about?" Think about underlying meaning.. .write thoughts in margin. 3. Make a list of all topics. Cluster together similar topics.. .form into columns. 4. Abbreviate the topics as codes and write the codes next to the appropriate segments of the text. See if new categories and codes emerge.  70  5. Find the most descriptive wording for topics and turn them into categories. Group topics that relate to each other to reduce total list. Draw lines to show interrelationships (patterns, themes, issues). 6. Abbreviate each category and alphabetize these codes. 7. Assemble the data material belonging to each category in one place and perform a preliminary analysis. 8. If necessary, recode existing data. What I found particularly fascinating in this process of constant comparison was the increasing emergence of themes each time I re-read an interview. Just when I thought that I had found all of the patterns among them, another read would reveal new connections among the key participant's responses and stories. This happened most in the materials arising out of the interviews with Government informants.  Research Ethics "The emergent design of a case study makes it difficult to assess, for example, potential harm to participants" (Merriam, 1988, p. 179). In fact, emergent design of any qualitative study makes many of the details of design difficult to articulate prior to the evolution of the study. In an interview, the responses of the interviewee are unpredictable. However, because my subjects are professionals and because they had the opportunity to validate and vet the information that I gathered and utilized, I did not anticipate particular concerns about revealing matters of potential harm. I did of course assure them in the consent form and again in person that anything could be deleted by their choice and/or they could withdraw at any time. Consistent with the information contained in the consent form, I assigned pseudonyms to each participant. Gender-neutral pseudonyms were used to make it less likely that the information and quotations can be recognized and attributed to a specific participant.  71  Issues of Credibility I sought and received permission to record all of the interviews and I invited those involved to apprise me of any concerns they had regarding my research. I offered the participants a copy of the tape recording to review. As well, both to reassure them about how their information was used and in order to validate the information, I offered them the opportunity to review and provide feedback on the data analysis before it became a permanent part of the thesis. Validity "refers not to the data but to the inferences drawn from them" (Hammersley & Atkinson, 1983, cited in Creswell & Miller, 2000, p. 125) and is a term that can be defined by "a confusing array of terms... including authenticity, trustworthiness, and credibility" (p. 124). Validity can be enhanced by "checking how accurately participants' realities have been represented in the final account" (p. 125). Lincoln and Guba (1985, p. 314) call this approach "member checking" and claim that it is "the most crucial technique for establishing credibility." Such approaches are also consistent with the feminist standpoint described by Ozga. "Feminist methodology is likely to involve interviewing...methods...involve personal interaction and negotiation about meaning." (2000, p. 84). No one chose to listen to the tape recording, but everyone indicated interest in reviewing the data analysis. I have also employed extensive use of quotations in my Findings chapters. Through providing the actual words and phrases chosen by the participants, quotations add rich detail to the Findings. Once the Findings chapters were drafted, I sent all participants a copy of the data that had been taken from their interviews and from the documents they had provided. Most ofthe participants responded with minor changes. These included corrections such as organization names, phrases or terms, facts, and dates. The response from three of the participants was not expected. Although I did not think that the material was particularly inflammatory, the three participants were extremely concerned about how I had utilized their information and in 72  particular, about the quotations that I had chosen from their interviews. They did not deny that they had said what was quoted or question accuracy of the material. However, the participants indicated that because they felt free in talking with me during the interviews, they may have said more than was wise, not miriking I would use certain pieces of the material.. .nor imagining that it was significant in my study. When they saw their words and thoughts in print, they were very concerned about how others might interpret what they had said. There was even concern expressed about job security. One participant withdrew consent until I was able to remove data that had been deemed unacceptable. I assured them that I was committed to honour the consent contract and that my studies were less important than their comfort with the possible outcomes of their participation. I met with one of them for several hours and went through the data sentence by sentence, communicated with the others by e-mail, then rewrote the data analysis and sent it to them again. They had further changes, which I responded to with a third version. At that point a great deal of the information had been removed and I was especially disappointed to have lost some very expressive quotations that I believed were highly illustrative of some of the frustrations and tensions that occurred during the implementation phase of this legislation However, it is essential that the researcher remain true to the contract with participants, even though as Ozga describes, "some methodological problems.. .may be raised by the nature of research on policy; because of the sensitivity of an issue, and difficulties about access to insider information" (2000, p, 82). As the researcher and the "outsider" it was critical that I honour the concerns of the participants, recognize the limitations on my understanding of their world and their realities, and give priority to their choices about the use of the data. Limitations "Biases that cannot be controlled should be discussed in the written report" (Diener & Crandall, 1978, p. 162, cited in Merriam, 1988, p. 182). Prior to the interviews, I explored again my value positions with regard to ethical decision making, advanced decision making, advanced 73  representative selection, and legal knowledge among professionals, and in the interviews I tried to avoid comments that revealed my biases. However, "the intuitive knowing that comes from experiences, reading, and reflection is not always reducible" (McFadyen Reid, 1993, p. 112). This was a limitation of the study, as it must be in any qualitative study. One bias that is probably obvious just by virtue of the case study cho sen is that I am supportive of the new legislation and I believe that it is in the best interests of everyone. I did find that on occasion, particularly during the early interviews, I would raise my eyebrows, roll my eyes, or otherwise indicate my bias when a comment was made that triggered an emotional response. For example, when all three of the educators who were involved in the Train the Trainer program indicated that educating physicians is a daunting task and is rarely achievable by anyone but another physician, I responded with non-verbal gestures that showed my concurrence. Subsequent to those events, I tried to monitor my behaviour more carefully and hold my emotions in check. I was successful in doing so most of the time. Other limitations of the study arise from the small sample, the quality of the questions, and the uncertainty about how openly the questions were answered. The study was limited to the first level of educative effort made to inform health care professionals about the new legislation. Certainly it could be considered a limitation of the study that I have chosen not to explore the efforts made by individual institutions, the employers of health care professionals, to educate their employees about the legislative change. This level of research would constitute a separate study involving analysis of the various efforts made by institutions of different sizes with differing mandates and resources. At the institutional level, part of the response to new legislation involves internal policy revisions as well as education of employees about how and why policy has changed. My study occurred at the level of government efforts to facilitate institutional implementation of the legislative changes and at the level of professional  74  organization efforts to educate all members of the profession regardless of their work environment. Challenges Although this project is descriptive and analytic rather than evaluative, I was concerned that it may be perceived as having an evaluative impact. Greene (1997) offers many worthwhile perspectives on the challenges faced when one moves into the political arena with evaluation in mind! She cautions that [Those] working in these politicized contexts must negotiate identities for themselves that maximize their credibility and potential effectiveness ... different grounds for negotiation ... lead to different...purposes and roles ... all are concerned with power and all are value based, (as cited in Greene, 2000, p. 982) Early on in the proposal stage, I was already aware I had chosen a project that involved tension between two government agencies. The Ministry of Health implemented the Facilitator Training initiative in direct contradiction to the advice of the Health Care Consent Planning Group (under the Public Guardian Trustee mandate). Both of these agencies were involved in educative initiatives at the same time, and I understood that their instruction was not always consistent. I had to be sensitive about the existence of this tension while at the same time seeking information about its sources and about the conflicting views of both agencies. As Greene states, there are "multiple, often competing, potential audiences .. .who have vested interests in the programs...[evaluators] must ...negotiate whose questions will be addressed and whose interests will be served" (2000, p. 982). Though there to critically analyze rather than to evaluate, I tried to take great care to honour these varied and sometimes competing interests as I moved among the participants. This demand was eased significantly through the evident respect for one another that was demonstrated by all of my participants. As questions arose about other educative efforts and the success of all educative efforts, there was no outright criticism of one another. Each key informant took care to honour the efforts of all participants and to focus on his or her own 75  efforts. Critical reflection was directed toward method rather than toward any person. As will be noted in the Findings Chapter V, there was some discrepancy between the stories told by the PGT participants and by the Ministry participants, in that only the latter referred to the tension between the two relative to how the education should be managed. Certainly it was also apparent that other agendas were at work when some of the participants chose to withdraw significant data because of concerns about the reactions of others when reading the Findings. "All...approaches advance certain ideals and values"(Greene, 2000, p. 985). Consistent with Greene's table (p. 984), I locate my work in the Interpretivist epistemology, promoting the values of understanding, contextualism, and personal experience, using case study and interview as the primary methods. My questions addressed how stakeholders experienced the educative efforts and to what extent and in what ways they perceived them to be meaningful. My emphasis is on a descriptive study of the educative response to new health legislation. I occupied an advantageous position by hearing from a diversity of stakeholders. From this vantage point and through critical analysis of the data, recommendations can be made for the facilitation and enhancement of professional care providers' responses to future legislative changes. Summary This chapter outlines the case study approach for my inquiry into the educative efforts associated with implementation of new legislation. Case Study is often used to maximize learning potential because of the attendant accessibility to materials and informants. Both materials and informants were available for this project. I used interviews to gather material from participants because I wanted to be able to explore the topic and allow the participants to lead the conversation so that I could draw upon their expertise. I wanted to understand what they chose to do in their educative efforts as well as to understand their perspective on the success of those efforts. My primary method of data analysis involved reading and re-reading the text of the interviews. I wanted to find what the participants had said in answer to my questions, and also to 76  discover what particular perspectives each had on the educative effort. I coded and clustered topics and categories in order to analyze the data. Each time I read the transcripts and each time I added to the scope of my literature search, more themes and clusters emerged. The next two chapters will provide my analysis of the data collected during interviews with representatives of three groups. Both chapters will address two of the research questions: o  What happened in the implementation phase of new health legislation in BC?  o  What do stakeholders think about the effectiveness and sufficiency of their educative efforts?  Chapter V addresses interviews with representatives from the Ministry of Health and the Public Guardian and Trustee Office as well as the documentation related to educative efforts associated with implementation of the Adult Guardianship legislation. This chapter addresses the research question: What did the government do to educate professional health care providers? Chapter VI provides a discussion of interviews with representatives of health care profession organizations, and of the documentation related to educative efforts that they made. This chapter addresses the research question: What response did the professional organizations make to educate professional health care providers?  77  CHAPTER V: FINDINGS - THE ROLE OF GOVERNMENT ORGANIZATIONS It is self-evident that in order to have its intended effect, legislation must be communicated to those it affects and it must be understood. After more than a decade of effort by hundreds of British Columbians and after several delayed implementation dates, parts of the Adult Guardianship legislation came into effect on February 28, 2000. The intent of these four Acts was to "promote self-determination and autonomy for adults and create a comprehensive and integrated system of support and assistance for adults who need help in making decisions about their health, personal care, or financial matters, or who are abused or neglected" (A Health Care Provider's Guide to Consent to Health Care, February 15, 2000). This Chapter addresses three of the research questions: o  What happened in the implementation phase of new health legislation in BC?  o  What did the government do to educate professional health care providers?  o  What do stakeholders think about the effectiveness and sufficiency of their educative efforts?  Ministry of Health and Ministry Responsible for Seniors I was fortunate to have the opportunity to speak with three people who worked in the Ministry of Health and Ministry Responsible for Seniors during the development of the legislation and through to its implementation. Two of the key informants wrote much of the legislation and the third led the Ministry's initiative to provide education for professional health care providers. I have assigned to these participants the pseudonyms: Mel, Leslie, and Pat. On February 24, 2000, Alan Moyes sent a letter to all Health Sector Colleges and 8  Professional Licensing Bodies. The letter clarified the most important elements of the four Acts  Alan Moyes was the Director of Legislation and Professional Regulation in the Ministry of Health and Ministry Responsible for Seniors.  78  and briefly indicated which parts of the Acts were to be implemented on February 28 and which parts were to be delayed. The letter directed recipients to the Public Trustee website for copies of unofficial consolidated versions of the Acts, and was accompanied by two copies of the Health Care (Consent) and Care Facility (Admission) Act, the Health Care Consent Regulation A Primer to British Columbia's New Health Care Consent Legislation: The Health Care (Consent) and Care Facility (Admission) Act, and two brochures related to health care consent and the Review Board. As well, it referred to the Ministry website for downloading Guides including the Primer, the detailed guide A Health Care Provider's Guide to Consent to Health Care, and Practice Guidelines for Determining Incapability to Consent to Health Care. The letter recognized that some professional bodies intended to publish articles about the Consent Act and invited them to contact Pieter de Groot , for comments on draft material prior to publication 9  and/or to participate in workshops or seminars. Gerrit Clements has been involved with this legislation from its origin, and his mandate 10  includes education of health care providers in the form of written publications, workshops, teleconferences, and consultation. In the early years of drafting the legislation, Clements was encouraged to travel as part of his education portfolio but more recently, budget considerations have forced him to remain in his Victoria office and to be available to travel only to those constituents who are able to reimburse his travel costs. Leslie pointed out that while the new Health Care Consent Act was largely a formalization of the law reflective of Common Law practice, several provisions addressed issues for the first time. These included differentiation between major and minor health care, definition of what constitutes an emergency or urgently required health care, and the presumption of capability. A significant and extremely important piece of the legislation addresses decisions about Pieter de Groot was the Manager of Adult Guardianship Legislation in the Ministry of Health and Ministry Responsible for Seniors. Gerrit Clements is a Special Health Law Consultant with the Ministry of Health and Ministry Responsible for Seniors. 9  1 0  79  incapability to make health care consent decisions, how the patient and significant others are informed about such a decision, the appointment of temporary substitute decision makers, and how that decision can be formally reviewed. It is probably this important new content that caused the most concern and resistance to the new legislation on the part of health providers. N o longer could they proceed on the presumption that as health care professionals, they were experts not only in medicine but also in choosing the best option for individuals in making decisions about their care. This approach to health care decision-making became illegal with the implementation of legislated guidelines. Failure to adhere to these guidelines can result in legal action against the professional health care provider, however adherence can and does complicate and prolong the consent process. To mitigate this reality, the approach used by the Ministry in its educative efforts was to emphasize how the legislation clarifies the process of informed consent and protects the adherent care providers against claims of negligence or assault. Clements was heavily involved in the development of the Health Care Provider's Guide and recently in its revision to update sections relevant to ongoing legislative changes. This guide, available only in hard copy, was to be placed on the Ministry of Health and Public Guardian Trustee websites but according to Pat, a lack of funds prevented this from happening. Both Leslie and Pat expressed their disappointment that this has not occurred. Both felt strongly that websites are the best venue for making materials readily and generally accessible. In the words of Pat, one of my participants from the Ministry, We found what was important was that we provide adequate education materials to the facilitators...and that information would be available on the Internet...readily available to them. Not all of the information is on the internet.. . 1 don't think that the links were in a format that makes it easy to find either...I was disappointed in the end that we didn't get the full information and the Health Care Provider's Guide on the website in a format that people could go to it. The Ministry placed an individual in the position of Manager of Implementation of Adult Guardianship legislation. Primarily that person was considered the manager of implementing the 80  Health Care (Consent) and Care Facility (Admission) Act. His responsibilities related mainly to ensuring that professional health care providers were familiar with the legislation and were able to implement it into their workplaces. Pat indicated,  We were really concerned with the health care consent legislation...because the PGT had different interests and concerns...in particular protecting the well-being of people who are in dependent situations... and our overriding concern was really broader... the legislation was applicable to all people and had to be workable for all.. .patients and health care professionals... that created some stresses along the way. Although keenly aware that the legislation impacted all British Columbians, the mandate was clear that only health care professionals would be targeted for this education. Even at that, it was a daunting task, with some nine thousand physicians and thirty-three thousand nurses as well as many thousand other health care professionals spread across eighteen regions in the province. And so was born the Training for Regional Facilitators, a program based upon the Train the Trainer model. This program will be described later in this Chapter. 11  The Ministry of Health Steering Committee for the Adult Guardianship legislation recognized early on that there would be a crucial need for education - that in fact, education would be "critical to its success " (Rob Gordon, Personal Communication). According to Gordon, new legislation is usually associated with some degree of educative effort and different ministries choose different models for addressing this need. In fact, he indicated that the Train the Trainer model had been utilized successfully to educate social workers when the Child, Family, and Community Services Act changes came into effect in 1995/96.1 was unsuccessful in locating any written information about that initiative, but did speak with one person who confirmed that a three-day training program occurred throughout the province at that time. The  "Train the Trainer" is an approach to education that involves training facilitators who then carry information to various audiences. The facilitator training consists of two major elements: the information to be transmitted to other audiences, and the methodology to be applied in transmitting the information. 1 1  81  training was offered to social workers and other staff members on location and was considered to have been successful. The extent to which it utilized the Train the Trainer model is unclear. The long delay between proclamation of the Adult Guardianship legislation in 1993 and its implementation in 2000 resulted in a loss of momentum along with a decrease in available resources for implementation. Interest in education waned as people began to doubt that the legislation would ever come into force. During this time tension arose between the Ministry of Health and the Public Guardian Trustee. In the Ministry, interest in the legislation was focussed on.health issues while the Public Trustee Office interest was directed mainly toward the protection and abuse-prevention elements. Both had an education mandate; each functioned independently of the other to some extent, yet there was collaboration through an inter-rninistry working committee as well as through other joint ventures. Still, Mel stated, "there were some  tensions between the two... there was in-house conflict and it comes down to personalities quit  often, which was very unfortunate.. .certain styles sometimes rubbed people the wrong way...th I saw as one of the difficulties in the process." As I listened to the participants, the source of tension seemed most often to arise out of the difference in perceived mandates of the two government sectors: the PGT Office was concerned about protection of the vulnerable and therefore wanted to ensure that they and their families and caregivers were fully aware of the protective and empowering elements within the legislatio n; the Ministry of Health was most concerned with how to ensure that the legislation was understood by, and workable for, health care professionals. The Health Care (Consent) and Care Facilities (Admission) Act Planning Group advised against the Train the Trainer model, believing that it would not be possible to get the message out to professional health care providers in this manner and in particular, that physicians would not attend such trairiing sessions. They were firm in their conviction that who delivers the message is of primary importance, and that in the case of physicians, to be seen as credible the 82  message must come either from a peer or from an expert in the legislation. It seems that this disagreement in approach to education was a major source o f tension between people working with the Ministry o f Health and with the Public Guardian and Trustee office. A theme that repeated itself regularly as I spoke with writers o f the legislation was that the complexity o f the legislation makes it difficult to understand and to interpret, let alone to teach. Therefore, it is very ambitious and possibly unreasonable to expect that people who may have no background in law could attend a two day workshop and not only learn enough to understand the legislation personally but to teach it to other care providers representative o f various health professions. T o assist in familiarizing people with the  Health Care (Consent) and Care Facility  (Admission) Act, the Ministry prepared "A Primer to British Columbia's New Health Care Consent Legislation "  (March,  2000). This  document clearly outlines the requirements o f each  section o f the A c t in language that is easy to understand. A s well, it highlights the presumption of capability and consent rights, both elements that had not previously been set out in legislation. Scope o f consent, unexpected treatment, substitute consent, incapability, treatment without a patient's consent, and various safeguards are also elements that are thoroughly addressed with references to the specific sections o f the A c t as well as brief references to the other three Acts in the A d u l t Guardianship package. Issues attending the appointment and scope o f the Temporary Substitute Decision-Maker are clarified, as is the role o f A d v a n c e d Directives. T h e Primer lists all o f the regulated health professional groups who must comply with the A c t . Finally, it provides three flow charts that outline the process o f consent in each type o f care situation. These can be easily reproduced and were used as posters i n the health care setting. Hundreds o f the posters were produced b y the Ministry and distributed to health care settings.  Close to the time when the legislation was to be implemented, the Ministry and the Public Guardian Trustee Office worked together to produce guidelines and brochures for  83  professional health care providers as well as for the public. Out of that collaborative effort came "A Health Care Provider's Guide to Consent to Health Care" (February 15, 2000). While much of the content is similar to that of the Primer (from which it was derived), this document provides more detail regarding substitute decision-making and the mechanisms of the Health Care Review Board. As well, contained in Appendix E is the "Practice Guidelines for Determining Incapability to Consent to Health Care" (February 15, 2000), a document prepared with extensive input from the Incapability Assessment Steering Committee. For the first time in British Columbia, this document provides comprehensive, step-by-step guidelines for the assessment of capability, documentation of the process, and for communication to ensure that the adult understands the proposed health care. Forms requesting Review are provided along with contact information for the Review Board, the Ministry of Health, and the Public Guardian and Trustee. On occasion, prior to the implementation of the legislation, two of its writers went out to hospital regions to talk about the legislation. They were even able to return to the same setting in some instances. According to Leslie, "the great majority (in attendance at these sessions) are always nurses. ..nurses are head and shoulders above the rest, including physicians." With the passage of time and the reduction in resources, the Ministry was unable to support this outreach approach to education on an ongoing basis. However, in the words of Leslie, "I still do it but the policy now is that we look at each request and I don't think we have ever turned any down over the last couple of years, but the health authorities or RNABC or whoever is still going to have to pay for the cost of my travel. " In this conversation, it was obvious that there was some discrepancy between the beliefs of the Ministry of Health and the Public Guardian Trustee Office with regard to their responsibilities for education. As will be seen later in this chapter, the P G T folks consider their mandate to include everyone, including health care professionals. The Ministry of Health participants seemed to think that it was their sole responsibility to educate the 84  latter group and that time and cost constraints were major limiting factors in the extent of their mandate. Pat indicated that They [the PGT] got a lot of money from us... so they did a lot of travelling. There is no doubt that although it is clearly our obligation, the PGT has always taken a more expansive view of both their mandate as well as how the mandate generally should be carried out. They have spent a lot of time and money on that and they deserve a lot of credit. With some reluctance, the two legislation writers joined the Train the Trainer project. One person I interviewed had significant concerns about two aspects of this project. First, most of the trainers were hospital-based people, mainly nurses and social workers. Very few physicians became trainers, yet as Mel pointed out: There was a significant shift in terms of how health care consent was dealt with...it very greatly reduced the decision-making powers of health care professions with regards to deciding what health care would be provided to an individual... there was really a very strong focus in the legislation to give the decision-making powers back to individuals and if the individual is not capable, to the individual's substitute decision-maker.  It is well known among professional health care providers that physicians are not inclined to accept training from nurses or social workers - in that reality rested a significant weakness of the training approach. Realistically, physicians are the primary care providers who require written evidence of patient consent. As well, they are the ones who at least four of my participants found most resistant to the Consent legislation. It creates additional work for them when they consider the complexities of determining incapacity, appointing a temporary substitute decision maker, and waiting for a period of review. It also significantly reduces their power and authority. Leslie said that Physicians in particular, in general, have not responded well...generally physicians see the requirement to obtain consent as a nuisance. Fm sure you've seen the literature that talks about how, unless you are a doctor, you don't understand what is actually being proposed anyway. So why waste time? Now that is the extreme version of course, way over in rightfield,and most physicians don't have views that extreme. They don't deal with things legal to begin with...I spoke at rounds and they nearly lynched me even 85  though I was only the messenger. They passed a motion to call on the government to rescind the legislation. Mel described the failure to educate physicians through the Train the Trainer initiative this way: "very few of them [trainers] would be physicians... and there is a pecking order in the health care professions... So you've got people at the end of the feeding tray trying to train all these people at the top end. I thought that was a mistake. " According to Pat, physicians still often leave it to nurses to obtain consent for medical and surgical interventions. This occurs even though it is every professional health care provider's individual responsibility to get consent for proposed care. This requirement addresses the reality that one care provider cannot reliably predict and explain the intentions of another. Consent obtained by a third party is not considered to be a valid consent. A second concern related to the complexity of the legislation and to the ongoing changes that were anticipated. The probability of inaccuracy creeping into the training sessions caused serious reservations about effectiveness. Mel emphasized "the trainer's credibility...was a problem... it's passing from one to another...so the probability of inaccuracy is extremely high... and if you don't get it right, and you don't know that you are getting it wrong, then a whole mess can occur. " Train the Trainer In the fall of 1999, an invitation was sent out to all of the Health Regions inviting them to send representatives to one of three Train the Trainer sessions. These were two day seminars held at a hotel in Vancouver. The Ministry funded travel costs and accommodation but did not pay replacement costs for substitutes in the workplace. Approximately eighty people attended the Train the Trainer workshop. The first day was fully devoted to the Health Care (Consent) and Care Facility (Admission) Act. On the second day, Representation Agreements were discussed along with Advance Directives and temporary  86  substitute decision-makers. The role of the Public Guardian and Trustee as a decision-maker of last resort and the process of appeal through the Review Board were included in the second afternoon. Several resources were provided for the facilitators, including the Primer, Flow Charts, a draft of the Practice Guidelines for Determining Incapability to Consent to Health Care, along with the highlights of the legislation. The majority of these resources were prepared by the Public Guardian and Trustee of BC; some by the Ministry of Health. All of the resources offered contact addresses, websites, and telephone numbers for further information. A series of overhead transparency masters were included in each facilitator's kit, so that they each could prepare a presentation utilizing those. All materials were available for copying without copyright restrictions. In addition to the handouts provided at the workshop, the Ministry mailed out multiple copies to each of the facilitators after the workshops had been completed. The Primer was (and still is) available on the Ministry website but for some reason, the more detailed Health Care Provider's Guide to Consent to Health Care along with the Guidelines for Determining Incapability have never been placed on the website. The people who I interviewed from the Ministry and the PGT office believe this to be an unfortunate oversight. Pat suggests that these two documents were not included because of a lack of resources in the Ministry of Health website office and Communications Branch. According to Pat and Mel, probably the greatest strength in the Train the Trainer workshops came from the expertise of the presenters who were involved. Pieter de Groot of the Ministry organized, coordinated, and facilitated the entire effort, utilizing inter-Ministry and inter-agency groups for ideas. Two of the people who wrote the legislation, Gerrit Clements and Rob Gordon led the majority of the sessions. As well, Giuseppe (Joe) Scaletta spoke about 12  At the time that he participated in the Train the Trainer workshops, Giuseppe Scaletta was Coordinator, Elderly Outreach Service for the Capital Health Region. As a member of the Steering Committee for Incapability Assessment under the Adult Guardianship Act, he was also involved in developing the practice guidelines for incapability assessment under the Health Care (Consent) and Care Facility (Admission) Act. 1 2  87  incapability and Alan Tuokko described the function of the Review Board. Jay Chalke 13  14  described the Review Board role as decision-makers of last resort. For a short period following the Train the Trainer sessions, two of the Ministry trainers were available to attend training in the regions and to offer their support and assistance. Pat describes this as a community development approach, believed to be most effective in supporting the communities to recognize and meet their particular needs for education about the legislative changes. Very quickly, however, funds to support this extended service disappeared and the Ministry representatives were moved on to other assignments. It was suggested by all three of the Ministry key participants that funds were diverted to the PGT office and away from the Ministry. Although they did not suggest a reason for this, it may have been because the PGT office was seen as having the greatest ongoing educative mandate as well as responsibility for the bulk of the legislation. The Ministry people expressed frustration over their lack of ongoing resources, as they believed that their continued presence and availability could have supported a more successful training effort in the regions. They indicated that the facilitators who were trained in the sessions generally expressed a positive response to the legislation and their greatest concerns seemed to relate to the complexity of the substitute decision-making process. It was in this latter area that the Ministry experts could have best supported community facilitators with return visits. It seems that the Ministry let them down in meeting their need for support and encouragement through ongoing contact with the original trainers. In addition to this lack of ongoing support, the organization of BC's health care system was experiencing frequent and significant change. Many of the facilitators, already expected to add to their regular workload this additional and extensive responsibility of training their professional colleagues in complex legislative change, found themselves moved into different regional  1 3  1 4  Alan Tuokko worked with the Public Guardian and Trustee Office. Jay Chalke was, and still is, the Public Guardian and Trustee of British Columbia.  districts and often into different roles soon after the Train the Trainer sessions occurred. Among the many changes that were occurring was the reduction of fifty-two Regional health authorities at the end of 2001 to one provincial and five geographic Health Authorities. As Mel put it, "I think that what happened for many people was that their positions disappeared so they stacked the training material on the desk and walked away. " Leslie indicated When I look at the list of people that we trained back then the great majority has gone on to a lot of things and I've never been advised of anybody else taking their places. If we hadn't been in such turmoil it might have worked. On the other hand, I heard years ago that the experience in Ontario was that after five years, it was felt that about 50% of the professionals knew about the legislation...and they thought that was good!"  The Public Guardian and Trustee Office The government of the day gave to the Office of the Public Trustee, associated with the Ministry of the Attorney General, the mandate and budget to implement the Adult Guardianship legislation. Early in the implementation planning process, those responsible for the Guardianship Implementation Project consulted regularly with the diverse working groups who had been actively involved with development of the legislation. Those groups represented many constituencies including health care providers, social service providers, professional associations, advocacy groups, and the public. While there was not complete unanimity about how best to educate professional health care providers, people in the Office of the Public Trustee and in the Ministry of Health worked cooperatively in their efforts to fulfill their particular educative roles. In 2000, when the legislation came into effect, the Office of the Public Trustee became the Public Guardian and Trustee of British Columbia. I was able to interview three people from the Public Guardian and Trustee Office, as well as a fourth who had done contract work during the development and implementation of this legislation. These participants are referred to as  89  Mel, Cameron, Sidney, and Lyle. A fifth participant had been involved with some of the working groups under the PGT that planned for establishing communication among designated agencies after the legislation was implemented. This participant, represented by the pseudonym Avery, was also active in establishing protocols to enable utilization of the Adult Guardianship Act by case managers and professional health care providers working in community settings. Manager of Health Care Decisions Six weeks prior to the implementation date, the Office of the Public Trustee hired an individual as Manager of Health Care Decisions, with the responsibility to develop policies around how decisions would be made by that office under the new legislation. Very quickly this position evolved into having combined responsibility for Assessment Investigation Services and Health Care Decisions. A team was formed to carry out this work. The team consists of the Manager and seven regional consultants, all located in Vancouver, and one assessment investigator worker located in Victoria. The consultants travel for major decisions requiring on site assessment. Their policy is to make every effort to find a family member or friend who is qualified and willing to make decisions for the person. To that eiid, their assessment involves information gathering, seeking out family and friends, and in the final instance when all other avenues are exhausted, they attempt to make decisions in the person's best interests. In the latter case, they search out any information from family, friends, and acquaintances that may help to make decisions based upon the person's values and wishes. As the decision maker of last resort, the team seeks first to find a qualified substitute decision maker, and most often are successful. If they must make a decision on behalf of someone, members of the team go to great lengths to advocate for the client's prior capable expressed wishes. For example, Lyle told the following story: One of our downtown eastside guys was living in a certain residence that had a building manager. So I asked him to describe the client... what do you know about him? "Well, he got into a car accident once and he fired his  90  physiotherapist after two sessions - he said he could make it on his own. " So if you put the word "independent" into the mix, it would be fair. Dependence on others...he hated it. That's what we took out of it.  The Manager of this service saw education as inherent in the Health Care Decisions Team mandate. For health caregivers and for members of the public to know when to call upon the PGT office, it is necessary to know how the legislation directs the consent process. Three sets of constituents require this information: the developmentally disabled community, the long-term care system, and the acute hospital system. In each of these constituencies there are people affected both personally and professionally. As soon as the team began their work in the province, it became apparent to them that to fulfill their mandate of protecting people's rights, it would be necessary not only to educate the general public but also to play a role in ongoing education of professional health care providers. To operationalize the services of the Assessment Investigations and Health Care Decisions Team, the Team Manager offered presentations that included both information about their services and the legislative parameters around those services. These presentations were offered to all three constituencies in communities across the province. Initially contacts and arrangements to provide these presentations were made through some of the advisory and planning groups associated with the legislation. For example, the Health Care (Consent) and Care Facility (Admission) Planning Group offered opportunities to make contacts and set up venues. The BC Association for Community Living also welcomed the involvement of the PGT in an educative role. Although formal registration data has not been maintained, attendance at these community sessions consisted mainly of family members, social workers, and community workers. Very few other health care professionals were in attendance. The Team Manager has also arranged to attend various gatherings of physicians, such as the annual ethics conference, the College of Physicians and Surgeons annual education meeting, and the BCMA conference. Usually a booth is set up with pamphlets and information about the  91  legislation as well as the services of the PGT Office. A representative is present to answer questions. Whenever they have an opportunity to speak to professional health care providers, the team emphasizes how the new legislation makes the caregiver role easier. Examples include how the temporary substitute decision-maker list may prevent disagreements among family members and how clear it is that in urgent or emergency situations, the caregiver has the right to make decisions on behalf of the adult who is not able to make the decision. In the legislation it is now clear that the "urgent or emergency" category includes not only saving life, but also preventing emotional or mental distress and alleviation of severe pain. In all of their presentations, the team emphasizes the capability content of the legislation - the principle that adults are presumed capable until the contrary is demonstrated - to make their own decisions, including advance decisions while capable, and their right to have such choices respected whenever the need arises. Because it is not the mandate of the Health Care Decisions Team to be proactive as educators or to offer advice, they see their educative role as solely responsive. They do not offer to do educational sessions, nor do they advertise sessions. When asked to do so, they will go to a community and will encourage them to invite other groups to attend the sessions. One of the strongest and most effective points that Lyle makes when he speaks to professional health caregivers is to emphasize s. 33 (1) of the Health Care (Consent) Act. This section states "[n] o action may be brought or continued against a person for any act or omission in the performance of a duty or the exercise of a power or function under this Act if the person has acted in good faith and used reasonable care." As Lyle reminds the listeners, "you get protection from s. 33, but you only get there by adhering to s. 1 to s. 32 inclusive. " This, he states, gets people's attention!  92  Adult Guardianship Implementation Team In 1995, the Public Trustee appointed a Director of Implementation for Adult Guardianship. This person had the responsibility to plan for implementation of all four of the Acts. This was to include advising on the drafting of regulations, developing policy, writing information documents, and educating community groups, health care professionals, and government employees about the legislation. Originally, an implementation budget of 1.1 million dollars was provided and the Office of the Public Trustee worked collaboratively with the Ministry of Health in relation to those elements of the legislation that were the main concern of the latter. Out of this collaboration evolved a loose and overlapping division of educative work around the legislation - the Ministry focus was on health care consent in general, while the focus of the Office of the Public Trustee was on the Representation Agreement Act, the Public Guardian and Trustee Act, and the Adult Guardianship Act, with an emphasis and increasingly strong focus on Part 3 of the Adult Guardianship Act: Support and Assistance for Abused and Neglected Adults. Contractors assisted with the preparations for implementation through completion of various pieces of work identified by the Planning Groups, Task Groups, and internal staff. To determine how best to approach their education mandate, the Implementation Team sought advice from the groups who needed the information, many of whom were represented on the Planning Groups and had been involved in developing the legislation over many years. Sidney indicated that these groups offered ideas around both content and process for the educative work, suggesting "how to say things in a way that was respectful, supportive, andfollowed the principles of the legislation. " Legislation provides broad guidelines, and the people representing those likely to be most affected by it participated by advising on the Regulations, policy guidelines, and public information brochures. Sidney pointed out that these folks were able to  93  Advise how it would play out in their daily lives... or change the way they do things...It was important to work in a consensual way to bring many perspectives together and achieve a common understanding of how the legislation would work. In the beginning, ifyou went around the table and there were 10 people there, there might be 10 different perspectives about how they saw it working. Our goal was to work toward a common understanding and consensus about how regulations and policy would play out, and ultimately that the legislation would work well for everyone. To take legislation that is written in broad terms and figure out how it will work in the actual setting, it is necessary to have all those affected come together and figure out how to put it into operation while honouring the principles of the legislation and the goals that people wanted to achieve. Many brief public information documents were produced with the intent that each would focus on one piece of the legislation and would convert the necessary legalese to more reader-friendly language. A list of these documents can be found in Appendix H. At the same time, under the mandate of the Adult Guardianship Act, this implementation team was actively encouraging communities throughout the province to form Community Response Networks and to work with the Designated Agencies who would respond to situations of abuse or neglect. Under the new legislation, it is the official role of the Public Guardian and Trustee to designate agencies. Such Designated Agencies are required to respond to reports of abuse. They include the five Regional Health Authorities, the Ministry of Children and Family Development, and Community Living Services for adults who are eligible for their services. All are encouraged to be part of the Community Response Networks along with other people and organizations who work together to ensure an appropriate and coordinated response to adult abuse, neglect, and self-neglect. Sidney recalled that it "the challenge to communicate in a meaningful and practical way with staff throughout the province seemed, at first, very daunting. " Letters went out to all of the Chief Executive Officers ofthe Health Authorities who were the potential designated agencies asking them to identify a staff member as a liaison with the implementation team. Throughout this time, health regions underwent a number of  94  reorganization efforts and this was a further challenge to communication. The implementation team encouraged each of the then eighteen regional Health Authorities to select representatives from continuing care, mental health, and licensing, acute hospitals and care facilities, as well as others who they believed might encounter situations of abuse and neglect. A significant number of the liaison staff were home and community care nurses, social workers, and mental health workers. These staff members became the means of communication with the health regions, provided invaluable advice for implementation and education, and were key in arranging for educational sessions that would be provided by the implementation team. They also participated in the development of policies, procedures, and guidelines that would assist the health authorities in the development of their own internal policies. Sidney pointed out that With the implementation of the legislation and the new mandated role as Designated Agency, Health Authorities realized that they needed to update their policies and procedures to include possible use of the Adult Guardianship Act, Part3, and to outline how it would work in light of their current mandate and the other pieces of legislation that would affect them. For the first time, Health Authorities were mandated by law to respond when they discovered situations of abuse or neglect, or when such situations were reported to them. In the past, staff had responded, but if their offers of support were refused, they did not have the mandate or tools to go further. The new legislation gave them many new tools to offer support. At first, some aspects of the legislation were viewed with some trepidation. But staff began to see that they could do something about situations that had frustrated them in the past. All of these efforts occurred over four years prior to the actual implementation of the legislation, and during this time several implementation dates came and went without anything actually happening. Sidney pointed out that "for some folks who had been working on this legislation for years this was a source of some frustration. " Although it was potentially a discouraging time, morale was sustained by the success in community building as evidenced by the growing number of vibrant Community Response Networks in the province and by the encouragement of the Planning Group who pointed out that it would take more than legislation alone to keep people safe. 95  Beginning in 1996, and escalating in late 1999, the Adult Guardianship implementation team began making the rounds of the province, first with general information about the legislation and then with presentations that evolved into more specific content over the years. Sidney explained that training was designed around the specific audience and based upon input from participants. Overheads and handouts were utilized and lots of question time was provided. As well, training was geared to how staff practice would have to change, or how the legislation would impact adults' lives in British Columbia. Sidney describes how Initially the focus was on Part 3 in general, then on dynamics of abuse and neglect in communities if they wanted that information, then on to incapability assessment practice guidelines, and on developing interagency protocols between police and Designated Agencies. Sessions were offered for staff of Health Authorities and Ministry of Children and Family Development - Community Living Services, and other CRN members. A flyer template was developed and provided to the key contacts in Health Authorities, and others in the community, who arranged for the room, coffee and supplies, and most importantly, circulated the flyer to ensure good attendance. The implementation team was able to cover the cost of room rental, muffins and lunch for the attendees, while costs of staff attendance were borne by the employers. The first round of workshops in 1996 was a one-day introduction to the four Acts with some case examples and group work to illustrate and apply the legislation. In many instances, there were more than one hundred people in attendance. The Team attempted to respond to each and every inquiry and request for education. Groups requesting workshops included churches, advocacy organizations, seniors groups, brain injury organizations, and professional associations, in addition to staff of Home and Community Care, Mental Health, and Community Living Services. Sidney and Cameron describe many reasons why they believe that these educative efforts were successful. First of all, they 'Svent to where the people were, had as many as they could get  96  into the room, anyone who would come, all in the room together. Everyone who had an interest was welcome to attend. " Those who did attend included social workers from Community Living Services, community care nurses, social workers from hospitals, mental health workers from community, and all kinds of other community groups, as well as people more personally affected by the legislation. Many heard the message and therefore there was a better understanding throughout the community. Participants were connected to one another in the training sessions and this assured them not only that no one individual was responsible for educating all others, but also that there were others to contact and consult with as they began to work with the legislation. As well, the team tried to make the material interesting, using handouts, slides and overheads, as well as multiple presenters with varying expertise. "They saw it, heard it, and we left behind our educational materials to take home and refer to in their work. " Sidney emphasizes that adequate time was left for questions at the end of each session and when questions and issues were raised that the team hadn't yet considered, it lead to further research and refinement of the presentations. "As well, " she states, "the team always made a point of  getting back to anyone whose question hadn't been answered during the presentation. " Many o the key contacts who attended these sessions became integral members and in many cases, leaders for the Community Response Networks. Teleconferences were held over a number of years during which practice issues were raised and discussed, further training was provided, and relationship building continued. In 2000, a large session was held in Vancouver to assist staff of Designated Agencies to work with the legislation. The session, called "Sorting out the Options" utilized a woman's story and provided the opportunity to see how a typical situation might evolve and how to use the legislation in a manner that can give an adult the least intrusive support, respecting and honouring her wishes and the principles of the legislation. In addition to a multitude of brochures, The CRN Tool Kit - Building Community Capacity to Respond to Adult Abuse, Neglect & Self-Neglect in BC was ready for distribution in 97  the fall of 2001. This large, ten-part document provides a step-by-step guide for the establishment of Community Response Networks. Its preparation involved many of the early CRNs in the province as well as the members of the Abuse, Neglect and Self-Neglect Planning Group and many of the other planning and working groups related to the development and implementation of Part 3 of the Adult Guardianship Act. It was put together by the Adult Guardianship Implementation Team, working with representatives from community. On the advice of the Planning Group, the Implementation Team was able to provide small grants to communities to support them in forming their Community Response Networks. This has proven to be a wise approach. Cameron stated: Planning group members felt that community organizations are used to having next to nothing and can sometimes feel shut out of the process because of all these other bigger players. So when we grant money to start the development process, they felt that it should be given to non-profit groups. Because not only will they feel that they are part of it and like they have an equal voice, but they also know how to make a little bit of money go a long way... With more than fifty CRNs now up and running throughout the province, a new Foundation has been created. The CRN Foundation, bom out of the last Implementation dollars for CRNs, has the mandate of coordinating raising money to support all CRNs. On September 11, 2003, the day that the Public Guardian and Trustee Jay Chalke announced that he was contributing the final instalment to the Foundation, he received a standing ovation for his efforts and commitment on behalf of CRNs. Although ongoing funding is of concern, people also recognized that they have the power to carry on and to move forward with the momentum that they had gained from creating their own networks both locally and provincially. At the time of writing, the CRN network and the Foundation are continuing to grow and flourish through their own creative efforts and province-wide participation under the leadership of a part-time Executive Director.  98  It seems that the CRNs themselves are now helping to provide ongoing education within their communities. As membership changes, mostly as a result of people changing jobs and locations, new members come on board and need to be trained in the legislation and its application. The creativity of volunteers, who belong to the CRNs along with the agency people, has resulted in many exciting and original efforts to inform the community about abuse and neglect. Cameron describes their efforts to educate others as All about portraying this and getting community conversation going about a really tough topic... in one community a seniors' counsellor has written a script about a daughter who was financially abusing her Mum with a power of attorney... it's really a powerful venue. Also to help sustain the knowledge in the communities, the implementation team is hoping to produce a video on Part 3 of the Adult Guardianship Act, to be accompanied by a handbook and the set will be used to provide orientation and information for new members of communities and CRNs. There will no longer be the same level of budget to sustain provincewide training visits out of the PGT Office.  At the Community Level: One Clinical Practitioner's Story Early in 2000, when the legislation was implemented, the implementation team sent out a province-wide invitation inviting Health Authorities to name facilitators who would assume the task of operationalizing the Adult Guardianship Act - Part 3. Avery believes that this invitation got lost in the paper shuffle for several months, and it resurfaced in the fall of 2000. Avery, who had attended some of the education that had been offered by the PGT in provincial communities, agreed to join the provincial working group that was assigned the task of working with designated agencies and respondents to develop policy that would help implement the legislation at the front lines. Avery describes the PGT's invitation this way: "They offered to assist in coordinating communication and, I think, to prime the pump and get people rolling, because it's totally daunting to implement legislation at the front lines. "  99  Avery, along with one other facilitator from their community, started out by reviewing the Adult Guardianship Act and participating in teleconferences - "huge ones, lots of them, two, three, four hours long.. .facilitated by the Implementation Team " to discuss the policies that each community had developed and to share their work. Commenting on the success of this initiative, Avery recalls that You could hear the energy as people shared in the teleconferences...they found a way to make a piece of legislation that is pretty dry reading come alive! People said things like, 'that sounds like something we've experienced. Can I tell you about it?' And then, we would all listen so ' intently... and we would learn from one another.  This first effort by the communities took a varying amount of time. Avery, who did the work off the comer of an overloaded desk, took about ten months to get policy in place for the local community. Some of the larger regions had designated writers and not only completed their task sooner, but led the effort. The smaller communities welcomed their leadership and willingness to share. Avery expresses even more passion about a second task that originated out of this same commitment and involved working with the Justice Department to establish procedures for responding to situations of abuse or neglect when both case managers and police are involved. This working group met in person and included case managers, police, and representatives of the Public Guardian and Trustee as well as the Attorney General's office. When a situation of abuse or neglect arises, "police come in very much from a criminal offence perspective. Health clinicians come in from a 'preserving the relationship 'perspective, so we clash in the field. " Avery went to four or five meetings in Vancouver, and believes that his effort has come out extremely well. "We spoke different languages from the beginning. They didn't understand nurse-speak and we didn't understand police-speak, but we made huge gains and I think learned a real respect for each other and where we were coming from. "  100  Describing more specifically the effect of these meetings, Avery claims that "it established a respect and trust that when it comes to the AG A, it's the health care responder who needs to be in charge in the field - the police officer role is to aid and assist, but not to take charge. It's hard for them to let go of that control. " To broadcast these achievements beyond the umbrella group, a number of memos were issued by the RCMP Superintendent and the Attorney General. As well, the RCMP and the PGT issued a bulletin announcing the agreed-upon framework. Inservice sessions were held in community police offices. Avery describes how after this first step was achieved at the provincial level, each community had to assume the task of local protocol development. There isn't one formula that works for everyone. In our community, we established a Community Action Plan. At a central workshop, all case managers developed an Action Plan for their own community settings. In it, they identified contact people, and established a timeline and deadlines for meeting with these contacts. Community Action Plans varied. For example, some managers dropped by the local police station with muffins and said, 'Hi - remember me? I'm the case manager here. Can we chat about how we will work together under the Adult Guardianship Act?' this works for you if you're in a rural area — you can have a 20-minute conversation about: 'if I'm in the field, I might need you. Here's what the AG A says I need to do, and here's what it says I might need from you.' It made clinicians feel comfortable to establish those relationships before they were needed. In Avery's community, the case managers did the same kind of work with financial institutions and Justices of the Peace so that they would know what to do if they suspected a situation of abuse or neglect. Some arranged for a "breakfast with the bankers " to achieve their communication goals. Ideas for these creative encounters came from the Implementation Team, provincial partners, and from case managers themselves. The designated responders in Avery's community include case managers, mental health clinicians, and social workers with the Ministry of Children and Families. They have been meeting together to find common ground within the Adult Guardianship Act and to share ideas about its application.  101  I asked Avery to comment on the Community Action Plan vis a vis the Community Response Networks. Avery clarified that the Community Action Plans were just a strategy to make links, and to help the CRNs work. In Avery's community, the CRN movement has been very effective in some locales and not at all effective in others. Some communities reject the provincial template provided in the CRN Tool Kit and just do not choose to develop under that model. Avery believes that Whether CRNs develop according to the provincial plan reflects the flavour of the community, its values, and its leadership. And this is not a bad thing. The Community Development theory supports each community developing their response capacity according to their own values.  As Avery is both a member of the PGT working groups and a registered nurse who has a leadership role in community care, I thought that it would be revealing to ask for an opinion about educative responsibilities when new legislation is implemented. Avery was not aware of any other sources of education besides the PGT initiatives. The RNABC was described as Not a strong educational leader in the Adult Guardianship legislation. The odd article appeared in Nursing BC, but it was a superficial report of the facts only. If you wanted in-depth information, you had to figure out for yourself where to get it. Avery seemed somewhat hesitant to comment on the responsibility of professional health provider organizations to provide education about legislative change, responding to that question with "I don't know. ..I think professional associations should keep up with legislative issues. ..I see reporting it as different than educating. " Avery was unaware of any educative initiatives launched by the Ministry of Health when this legislation was implemented, but had only positive comments regarding the PGT initiatives. "The PGT leadership is stellar... they keep people engaged with the legislation. " After Avery indicated that "it is critical that staff understand an Act that is directly applicable to their work, such as the AGA. The front lines have to be informed, " I persisted in  102  seeking a comment about who should be responsible for providing education to professional health care providers when new legislation is implemented. Avery replied,  I think it belongs higher up. To ensure internal consistency, the provincial role is to provide a complete package with good standards for the way that the Act should be applied. Consistent, equitable standards...practice guidelines. We need an interpretation in a nursing voice...what does the legislation mean for families, for nurses? What is my role...how can I use this to enhance my nursing care? Avery clarified that what is needed is not specific procedures for the application of the legislation, but rather that which was provided through the PGT initiatives: "The PGT didn't tell us what to do, but clarified intent, definitions, principles underlying the Act. That's what I go back to in a real case situation, not to a piece ofpaper [procedure]. " Avery's beliefs about education and about making this legislation continue to live through care providers were summarized this way: Education does not have to be formal, but has to be ongoing. We are thinking of establishing a quarterly case review in our community, with an AG A focus, to keep all of the communities involved and share knowledge with those who haven't had the experience. We will involve all of the disciplines and will possibly assign the presentation to a different locale each time. This will be an effort at keeping people current with the intent and principles of the legislation. Community development appears to be alive and well in Avery's health care community. Summary And so it is clear that an implementation phase lasting for several years led to a variety of outcomes. Some were beneficial - others were not. This prolonged time line allowed for community coalitions and planning groups to have very significant influence on legislative planning. As well, it provided time for government agencies to prepare regulations and many documents that would enhance implementation efforts. However, several of those most heavily  103  involved in preparing and implementing the four Acts experienced disappointment, frustration, and exhaustion as promised dates came and went without implementation. The government invested a considerable amount of resources to augment the success of the Adult Guardianship legislation package. There appears to be some question about how and where these funds were concentrated. Much greater resources and efforts were expended by the Public Guardian and Trustee office to ensure successful implementation of the Adult Guardianship Act itself than were spent to support the other three Acts. Resources and time were much more limited in the Ministry of Health initiative and there are many questions about the success of their one major effort - the Train the Trainer program. This program may have been negatively affected by a number of events that occurred outside of the educative process itself. Professional health care providers were under significant stress as a result of sweeping reforms that were occurring in health care regionalization. Many of the facilitators were attempting to add an educative responsibility to an already over-extended portfolio. Health care providers did not necessarily respond positively to education that was offered by those below them in the professional hierarchy. Certainly the legislation created a contested space in that it was developed by and for the grassroots, but it had major implications for professional health care providers. There were competing interests between the vulnerable public, whose need to increase their agency was addressed by the legislation, and the professional health care providers, who lost much of their power in the consent process and who also were expected to follow a much more complex process of getting consent. It was also apparent in the interviews that issues of power had an effect on the educative process launched by both government agencies. One PGT participant spoke of the necessity to frame the legislation in a way that highlighted its positive effects on the role of the professional caregiver, and even to employ a veiled threat when indicating that a section was there for the 104  protection of professionals was only effective if all of the other sections were honoured. Several participants acknowledged that attendance of health care professionals at all educative offerings was sparse. And, clearly the statement by Leslie that expressed a fear of being "lynched" by a group of physicians during an education session, was an expression of power wielding. Participants from the PGT office are generally very pleased with the effectiveness of their educative efforts and have utilized an approach that promotes networking and supports ongoing education. As they point out, sufficiency is probably an unreachable goal, but their efforts to supplement knowledge and update community care providers will continue in spite of significant budgetary reduction. It is clear from Avery's comments that the efforts made by the PGT Implementation Team were effective at the community level and that they effectively engaged frontline workers in operationalizing the Adult Guardianship Act - Part 3. As well, Avery describes ongoing efforts to keep the legislation alive and to ensure that responders throughout the community continue to apply the intent and the principles of the Act. Participants from the Ministry of Health remain very concerned about the level of knowledge among professional health care providers. In general, they do not believe that their efforts were effective nor sufficient and some are seriously concerned about possible effects of this lack of information now and as the legislation evolves. As was pointed out by Mel, "we live in Canada, and so the likelihood of a lawsuit is lower than in some other settings, but that is what it might take to make the point... and that is not what we want!" In the next chapter, the educative efforts made by seven health care professions will be described. The third research question is addressed: o  What response did the professional organizations make to educate health care providers?  I contacted representatives of twelve health care professions and seven agreed to participate in the research project. When possible, I interviewed each of them in their work  105  setting. Time and weather constraints necessitated that a few interviews were completed via speakerphone. I asked each participant for copies of documents that were used in their educative initiatives. The next chapter also includes a brief discussion of some other educative initiatives related to the adult guardianship legislation.  106  CHAPTER VI: FINDINGS - THE ROLE OF HEALTH CARE PROFESSIONS Twelve health care profession associations and/or colleges were contacted via e-mail, telephone, and letter to request participation in this research. Some were contacted several times without response and two responded with refusals, indicating that their groups had not been involved in any educative effort related to the legislation. The following discussion arises out of interviews held with representatives of seven organizations, as well as a document submission from an eighth organization. The health care professions represented, along with gender-neutral pseudonyms assigned to the participants, are described in Table 1. This Chapter addresses two of the research questions: o  What response did the professional organizations make to educate the professional care providers?  o  What do stakeholders think about the effectiveness and sufficiency of their educative efforts?  At the end of this Chapter there is a brief description of several educative initiatives launched by other organizations in the province and described by the participants who represented both government and professional organizations. Several general themes emerged when I interviewed representatives of professional organizations. These themes will be grouped and explored first, followed by a discussion of educative initiatives launched by each individual professional organization.  107  Table 1: Health Care Professions Represented in the Case Study  Group Physicians  Legislative  Acronyml  Body  Designation  Medical Prof.  CPSBC  Act  College  Information re Membership  AGM  Publications Implementation Detailed summary  Mandatory  Yes  Quarterly  HPA Fall 2004  (Taylor)  Nurses (Reg.) Act  Nurses (Tony)  HPA Fall 2004  Dental  Health  Hygienists  Professions  RNABC Association  Mandatory  Yes  CDHBC College  Mandatory  Health  Practical Nurses  Professions  (Francis)  Act  College  Social Workers Regulatory  Workers  all 4 Acts with  Quarterly  web addresses  Article  1995,96,2000  Teleconferences Sept. 2000  Revised Guidelines  Nov. 1999  Three times  Copies of PGT  Annual  per year  brochures sent  June "Update"  to all members  mailing  Nil  Nil  Adult Guardianship  Fall 2001  CLPNBC Mandatory  Nil  BRSW  Social  Spring '00  Overview of 4 Acts  Bimonthly  Act  (Wynn)  Method  Bulletin x 3-4 Optional  per year  Optional  Quarterly  Act  (Chris)  BCASW Association  Act Summary Occupational  Health  Therapists  Professions  (Lin)  Act  Quarterly  BCSOT Society  Optional  Yes  Newsletter x 10 annually  COTBC College  Physio-  Health  CPTBC  therapists  . Professions  College  (Lane)  Yes  Quarterly  Mandatory  Act  Winter 2000  Quarterly  Spring 2004  Quarterly  (update)  PABC Association  Newsletter Optional  Yes  x10 annually  At AGM  e-mail list  Educative Mandates In the province of British Columbia, most health professions fall under the Health Professions Act. This includes all of the health professions represented in my data, with the exception of Social Workers, Registered Nurses, and Physicians. The latter two will come under  108  that Act in the fall of 2004. According to the Health Professions Act, the Duties and Objectives of a College of Health Professionals include: o  To establish, monitor and enforce standards of practice to enhance the quality of practice and reduce incompetent, impaired or unethical practice amongst registrants.  o  To establish and maintain a continuing competency program to promote high practice standards among registrants. (RSBC 1996, C.183, s.16, 2, d, e)  As well as referring to the Health Professions Act Duties and Objectives, several of the health care professional groups further clarify the continuing knowledge mandate of members. Excerpts from their documents can be found in Appendix I. RNABC is the regulatory body for registered nurses in B.C. As such its mandate includes helping registrants to maintain currency about health care legislation. Standard 1.2 of the Standards for Registered Nursing Practice in British Columbia states: Functions within the legally recognized scope ofpractice  of nursing and within all relevant  legislation.  In order to do this a registered nurse must keep current regarding legislative changes. As will become evident later in this chapter, RNABC communicates with all registrants to keep them up to date as the legislation is developed and comes into effect. Participants whose professional associations do not have the educative mandate indicated instead that this mandate rests with the Colleges under the Health Professions Act. Membership in the various Colleges is obligatory in order to practice as a health care professional while membership in the Associations is optional. Wynn, from the College of Dental Hygienists (CDHBC) described their mandate as "absolutely critical... any thing to do with protection legislation  of the public or consent or any such  certainly falls under our umbrella rather than our professional  would be our prime responsibility  association  and it  to guide. "  109  Taylor, the representative of the BC College of Physicians and Surgeons (BCCPS), confirmed that the College mandate includes making sure that members are adhering to legislative changes and that those members do depend upon the College for information about how to keep current regarding such matters. However it is up to the individual physician to follow up on information provided. "Unequivocally, the sphere of their practice,  they have an obligation  to do that within  " Taylor stated.  The Physiotherapy Association of BC (PABC) is a professional association without mandatory membership. Its interests in education relate mainly to the needs of the practitioner rather than to protection of the public. The latter mandate is that of the College of Physical Therapists of BC (CPTBC). According to the PABC representative Zane, there is a close and harmonious relationship between these two groups and they often work collaboratively to ensure that members have access to information through more than one route. Lin, the BC Society of Occupational Therapists (BCSOT) representative indicated that there is still some uncertainty about the division of educative mandates between them and the recently formed College of Occupational Therapists of BC (COTBC). In most cases, professional interest and public interest are congruent and it is therefore appropriate that the two bodies operate jointly. Although she recognized that the College has a mandate related to ensuring that members are informed about legislative change, Francis, the College of Licensed Practical Nurses of BC (CLPNBC) representative indicated that at this time there is no mechanism in place to meet this mandate. Currently they are in the process of developing such a mechanism and it is part of the vision of the recently appointed Executive Director to launch an ambitious ongoing education program. Francis indicated that with the rapidly broadening Licensed Practical Nursing scope of practice, the College has many educational initiatives in the planning stages.  110  The Board of Registration for Social Workers (BRSW) has that profession's mandate for client protection and therefore an obligation to alert members when legislative changes have the . potential to impact social workers. Although believing that it would be desirable for the BRSW to carry their mandate further and to actively educate members about such matters, Chris pointed out that the difficulty lies in financial resources. Social workers are not highly paid, nor is their continuing education usually supported by employers in the form of paid leave and/or paid registration for courses. Another significant issue in keeping practicing social workers educated is that there is no general mandatory registration for them. All who are employed by government are exempt from mandatory membership in the regulatory body, although they may join voluntarily. All representatives agreed that as members of a profession, there is a huge onus on the individual to meet professional standards, and all of them have standards that make reference to maintaining currency about legislation affecting the provision of health care.  Involvement in Legislative Planning In each interview, I asked the participant whether any representative from that profession had been involved in the development of the legislation. While only three indicated that their profession had consultative involvement, two others indicated that they would have appreciated being involved. The CPSBC, the RNABC, and the CDHBC all responded to early drafts ofthe Acts with written feedback. As well, the CPSBC had an active role in drafting some of the legislation and since its implementation their involvement has continued to affect some of the amendments that have been implemented. Taylor said, "in my experience whenever there is legislation  relative to us we are part of the consultation process. They will usually share their  draft legislation  and advise us as things are moving along through the legislative process and  look for feedback, and they get it. "  111  RNABC also potentially has input to legislative change through their regular interaction with the Chief Nursing Officer of BC, a government representative for nursing. The three organizations that were involved with the Health Care Consent legislation have continued their active involvement with the Health Professions Amendment Act (HPAA), indicating that they are generally satisfied with their opportunity to influence legislation as it evolves. Lin indicated that occupational therapists would like to have "direct input into legislative changes " through collaboration in problem solving. "You know that is step one consultation at the beginning rather than planning education about things that we may feel are  inappropriate. " Yet, as Lin pointed out, time and financial constraints on some of the professions with smaller memberships and fewer central staff makes it difficult to respond to requests for input, sometimes exacerbated by requests for turnaround time that are unrealistic because they do not allow the opportunity to poll members nor to prepare an informed response. The more recent tendency of the government to post draft bills on their websites and invite feedback via that mode has exacerbated this problem because usually even less time is allowed for the organization to provide a response based upon a membership poll. Source of Information about Legislative Change At the time that the legislation came into effect in February of 2000, all of the health sector Colleges and professional Licensing Bodies were on a Ministry of Health mailing list. I was able to obtain a copy of a letter that went out on February 24, 2000 from the office of Director of Legislation and Professional Regulation, Alan Moyes, informing them that the Health Care (Consent) and Care Facility (Admission) Actwas to be proclaimed on February 28. That letter  clarified which sections of all four Acts were to come into effect and highlighted the major elements of the new legislation from the perspective of health providers. The PGT and Ministry of Health website addresses were included along with information about the kinds of documents that could be downloaded. Included in the mailing were two hard copies of the Health Care 112  (Consent) and Care Facility (Admission) Act, the Health Care Consent Regulation, the Primer, and two brochures related to health care consent and the Review Board. The letter also offered consultative services for any professions who intended to publish articles about the legislation, along with an offer to participate in workshops and seminars. The name of the adult guardianship manager was provided, along with his telephone and fax numbers and an e-mail address. Moyes asked that recipients of the letter inform their members about the implementation of the legislation. In the fall of 2003, a letter was sent out from the Deputy Minister of Health Services indicating that amendments to the legislation can be found in Bill 44, and that these amendments were to be effective on October 1, 2003. The letter provided website addresses for the Queen's Printer where both the Act and the Bill can be located. Social worker organizations did not receive the correspondence described above. According to Chris (BRSW), their government mailings normally come only from the Ministry of Children and Families. However, they do receive Law Society bulletins about legislative matters and as well are members of voluntary groups of Health Regulatory and Health Profession organizations, where legislative change is usually on the agenda.  Major Issues in the Legislation I asked participants for their views on the major issues that professional health care providers needed to understand about the legislation at the time that it came into effect. While most indicated that much of the legislation was a continuation of usual practice supported in Common Law, several recognized that a major change was the legal definition of capacity to consent, attended by the expectation that all adults are capable of consent unless incapability can be demonstrated. Along with this goes the need for professionals to understand the process of getting consent from a capable adult as well as from a substitute decision maker. In the case of Social workers, Chris pointed out that a major interest was in the process of developing 113  Representation Agreements along with the social worker's role in that process. The Adult Guardianship Act - Part 3 is a crucial piece of legislation for many social workers, but as near as I can understand, their access to education about that legislation has been largely through presentations under the PGT Office.  Educational Resources All of the professions that provided information to their members utilized the PGT and Ministry documents, brochures, and websites. Most of the professional publications related to this legislation referred the reader to those resources. A lack of funds creates a true dilemma for the professions whose numbers are smaller, who have less central office staff, and who do not have mandatory membership in their organization. An additional challenge for some, such as social workers and licensed practical nurses, is the lack of employer financial support for continuing education along with lower pay scales in comparison to those of some other more lucrative health profession positions. In this regard, Lin indicated that occupational therapists would welcome government funding for continuing education, in addition to printed resources. As well, they would appreciate being able to partner with government representatives to bring education to the membership. Lin described such an arrangement with BC Risk Management. "A fellow comes regularly to workshops that we do... he brings a really useful perspective into our discussions about the legal liabilities. We could hire a lawyer to do that but we don't have the resources. " As will be evident in the following section, the professions who made the greatest effort toward educating their membership are those with the larger memberships, central offices that have larger staff, and mandatory membership. The Ministry of Health and the Public Guardian Trustee Office offered their support and assistance in educating members of health professions about the new legislation. The RNABC took advantage of this offer, as did the CPSBC. 114  Educational Initiatives To a very large extent, educational initiatives launched by the health care profession organizations consisted of information on their websites, in their newsletters, and at their annual meetings. I was able to obtain copies of a number of publications that were provided, many of which had input from representatives of the PGT Office or the Ministry of Health. This section will summarize the efforts of those professions who participated in this study. College of Physicians and Surgeons of British Columbia (CPSBC)  Representatives of the CPSBC were actively consulted during the development of the legislation and as usual, the Registrar and two or three members were involved as advisors and readers of the early drafts. Normally unless there are particular concerns about elements of developing legislation, the consultative process occurs within this circle and does not expand to the 8800 members of the College. Taylor, the participant representing the CPSBC, indicated that they do not go to the membership Unless there were concerns that we couldn't address... that became most obvious with the early drafts of the Health Professions Act which were a source of great concern to us and when we couldn't get the response that we sought, we did make it widely known what was happening and the profession reacted accordingly.  The College takes very seriously its obligation to inform members of new legislation and at the same time, individual physicians are expected to keep current with such changes. Information is provided in the newsletter, called the Quarterly, which is sent out in hard copy and placed on the website, www.cpsbc.ca. The Spring 2000 Quarterly contained a lengthy article "The New Adult Guardianship Legislation. " Additionally, the complete text of the March 2000 Primer was, and still is, available on the website. The Winter 2001 Quarterly contained an updated summary of the Health Care (Consent) Act along with downloadable substitute decision maker forms. In this article, emphasis was on how to determine capability and incapability, when consent is not necessary, how to obtain substitute decision makers, and when to enlist the PGT 115  Office. As well, it included a list of procedures to which substitute decision makers cannot consent. This edition also contained a summary of the disciplinary action against Dr. Oxley in the case mentioned on page 7. It is interesting to note, and it may be of concern, that there is no table of contents at the beginning of the Quarterly. Therefore, readers must scan the full document to discover its contents. Taylor indicated that physicians are expected to read the full contents of the publication but that some may focus most on the "Discipline" section. I noted when I reviewed the last several Quarterlies that as of the Fall 2003 edition, a statement at the end of the publication reads as follows: "This bulletin is forwarded to every practitioner registered with the College. Decisions of the College on matters of standards, policies, and guidelines are published in this bulletin. The College therefore assumes that each practitioner is aware of these matters." Clearly, this constitutes notice to all registered physicians that they are responsible and accountable for maintaining currency with respect to matters of standards and policy. The CPSBC Policy Manual is available on the website along with updates of policies that are affected by legislative change. There is an Annual Meeting as well as an Ethics Conference each year. At both events, Kerry Baisley of the PGT office, along with other members of the Assessment Investigations Services and Health Care Decisions Team has distributed informational brochures and answered questions at a PGT booth. As well, on two or three occasions presentations have been made at the Ethics Conference by Gerrit Clements, a Special Health Law Consultant from the Ministry of Health. In the past year, Baisley has met with physicians at the CPSBC office to seek additional ways of getting information out to all physicians. Presentations at Medical Grand Rounds have been unsuccessful. According to Taylor, most physicians are unable to spare the time that such a presentation demands. In talking about this effort, Taylor said, 116  You know it is not a big draw...Social workers, nurses, and others attend, but very few docs... it is very hard to put that [the legislation] in a light that is going to appeal to people. Most doctors of course know their obligations to have this information before them, but they sort of wait until the critical last minute and they are confronted with the problem and then they go looking for it.  Taylor indicated that when physicians are confronted with questions that they are unable to answer or concerns about the consent process, they usually call the office of the CPSBC. Initially, when the legislation was first proclaimed, the office received many calls. More recently, these calls have virtually ceased. This has led Taylor to conclude that the message has gone out successfully and that there is no need to change their method of educating physicians about legislative change. Taylor also expressed genuine appreciation and respect for the people working with the consent legislation in both the Ministry of Health and the Public Guardian and Trustee Office. Physicians have been given ample opportunity for input both prior to and since proclamation, and Taylor has also found that both offices "bend over backward  to clarify issues and address  problems that arise within the CPSBC. When I asked specifically about the related legislation, the Representation and the Adult Guardianship  Agreement Act  Act, Taylor was less enthusiastic:  That can of worms...I've spent a lot of time with these people trying to understand what applies where and even they can't convey it to me. They just leave me baffled. They are really hamstrung, as you are well aware, with the fact that they government hasn't passed legislation in the anticipated way...that it took parts out and tacked bits on...left one Act dependent on the interpretation from another.. .you'd have to work on it full time to figure it out I guess.  This confusion within the medical cadre about much of the legislation gives rise to serious concern, particularly when one considers Taylor's response when asked about the relationship between education and the success of health policy:" I think it a fundamental element, you may as well not bother... implementation is doomed without it, I think."  If those  117  responsible for that education are not clear on the intent and the content of the legislation, it is highly unlikely that practicing physicians have been educated about it. Registered Nurses Association  of British Columbia  (RNABC)  In the Spring of 1992, the Nursing BC journal contained an article by the Executive Director indicating how registered nurses could participate in the proposed Adult Guardianship legislation. The article summarized the discussion paper How Can we Help? produced by the Joint Working Committee, pointing out that registered nurses were represented both on that Committee as well as at the forums that were held throughout the province. Registered nurses were encouraged to continue attending public meetings hosted by the Joint Working Committee, to offer their own feedback individually and to provide feedback to the RNABC office. A contact name, address, and telephone number was provided for the Project to Review Adult Guardianship. In August of that same year, RNABC produced a written response to the discussion paper. The Executive Summary indicated that RNABC represents more than 34,000 nurses throughout the province, many of whom are directly involved in caring for adults whose independence or autonomy may be compromised or challenged...Because nurses are often the first care providers to become aware of problems associated with an adult person's capacity to make decisions, they are very interested in any proposed changes to legislation related to this issue. RNABC emphasized the importance of involving nurses in making decisions about competence, incompetence and guardianship. (RNABC, 1992) In March 1996, a teleconference was held for registered nurses in ten sites throughout the province. This offered the opportunity to hear Rob Gordon and Gerrit Clements describe the proposed legislation. The teleconference was 1.5 hours in length. Subsequently, a number of nurses signed up for a full day conference on the legislation that was held following the A G M in April 1996. This conference offered several speakers, each of which gave a 20 to 30 minute presentation addressing one aspect of the legislation.  118  In 1999, RNABC revised the Overview of Legislation  Relevant to Nursing Practice  and  distributed the revised version in Nursing BC and on the website. This document provides a brief summary of some 35 Acts and Codes applicable to nurses in their practice. Included in the 1999 version were the four Acts to be in force February 28, 2000. It remains available on the website www.mabc.ca. When the legislation was finally proclaimed in 2000, RNABC revised the Nursing Practice  Guideline: Informed Consent (Pub. No. 359, September 2000) and distributed these in  Nursing BC. As well, all Guidelines are available on the website. The Guideline on Informed Consent is very comprehensive, offering highlights of the legislation including advocacy, nurses' role in consent, a description of what constitutes informed consent for adults and children, and nurse actions relevant to consent. Resources, all available in the RNABC library, are listed. These include the Primer and the Health Care Provider's  Guide described earlier. In this  Guideline it is clear that registered nurses are expected to follow the relevant legislation and the applicable Acts are listed. Nurses are referred to their agency policies for consent and referral procedures. Tony, the RNABC participant, indicated that with the infrastructure already in place, registered nursing is well situated for educating members about legislative change. The resources provided by government for supplementary material are also very helpful as are the speakers who so willingly participate in planned educative sessions. Tony indicated that RNABC will "continue with its current educative mandate when it comes under the Health Professions  Act  and is renamed the College of Registered Nurses of BC. " College of Dental Hygienists  of British Columbia  (CDHBC)  Wynn, who represented the CDHBC, assured me that the government is reliable in seeking information from them when proposing legislation that will affect dental hygienists. Wynn did not recall being involved in the development of the Adult Guardianship package, but 119  did receive the letter from Alan Moyes indicating that the legislation was to be implemented on February 28, 2000. Upon receiving this information, the Registrar and the Deputy Registrar reviewed the legislation to determine its impact on members. It appeared to them that the greatest impact would be on those dental hygienists working in residential care and long term care facilities. As the regulatory body, the CDFLBC focus is on public protection and it is apparent that they take this obligation very seriously. As Wynn stated, "it would be absolutely critical that anything to do with protection of the public, or consent of any type... that legislation falls under our umbrella rather than our professional responsibility  association  certainly  and it would be our prime  to guide."  This responsibility is met through the Registrant's Handbook, a comprehensive document that is provided to every registrant and updated annually in June. Every five years a complete new version is printed and mailed out. Upon receiving the notice from Alan Moyes, the Ministry website was accessed and information documents about the legislation were printed. With permission, some of that information was duplicated and provided to the registrants along with interpretation guidelines, which constitute directions for practitioners. The colour-coded package of material is sent out with a cover memo and a Schedule of Amendments listing all of the revisions and indicating where to place them in the Handbook. In this case, a copy of the brochure "B.C.'s New Adult Guardianship Laws: Supporting Self-Determination for Adults in British Columbia: Consent to Health Care " was included in the package. Had the legislative changes resulted in a more "direct" or urgent effect on the practice of members the newsletter Access, published three times annually, would have been used to alert everyone to the information. To draw attention to a topic, the information is printed on coloured flyers that are inserted into the newsletter and flagged with  "MUSTREAD".  120  Wynn does not believe that the government should be responsible to ensure that professional health care providers are informed about new legislation beyond notifying the regulatory body of proposals and changes. In Wynn's opinion, the CDHBC has a legislated mandate to protect the public and one of the ways of doing so is to provide information to registrants in a timely and effective manner. College of Licensed Practical  Nurses of British Columbia  (CLPNBC)  Registration with the CLPNBC is obligatory for all practical nurses that are actively practicing as nurses. Additionally, some belong to the Licensed Practical Nurses Association of British Columbia (LPNABC) and many to a union such as the Health Employees Union. This triple membership is costly for a group of health care providers who are at the lower ends of the professional pay scale. As a result, membership in the LPNABC is not strong. Although the mandate to protect the public and therefore to provide information about legislative change rests with the CLPNBC, at the time of my interviews, they were not yet organized to meet this mandate. However, they were in a planning mode and considering a variety of models for ongoing educative work. In many settings, licensed practical nurses function under the supervision of registered nurses. It is therefore fair to assume that they would take direction from the registered nurse in matters of health care consent. However, in many extended care facilities LPNs have become the primary care providers and even leaders of the nursing team - their practice responsibilities and accountabilities are expanding. Since all nurse-patient interactions should be based upon patient consent that is implied, verbal, or written, it is important that all health care providers understand the parameters of legal consent. Board of Regulation for Social Workers (BRSW)  The BRSW would not expect to have direct communication from the Ministry of Health when health legislation changes. Normally their legislative connection is to the Ministry of 121  Children and Families. The Registrar considers it her responsibility to monitor the media and Law Society bulletins for information about legislative changes that may affect social work practice. As well, she regularly attends meetings of the Registrars and Directors of Professional Organizations and of the Health Regulatory Organizations. Often it is in these latter venues that she learns of legislative changes. The BRSW Registrar is the main professional employee of that organization, whose mandate is public protection. There are many exemptions to mandatory registration in this regulatory body. For example, social workers employed by government are not obligated to belong to BRSW. This includes all those who work for the Health Authorities and for the Ministry of Children and Families. Chris indicated, "these exemptions probably reflect the prevailing  view that the employer has vicarious responsibility  for the actions of the employee. "  It is therefore a common assumption that the employer is responsible for ensuring that employees are duly informed of legislation affecting practice. As has been mentioned previously, social workers were well represented in all of the education sessions offered by the Ministry of Health and the Public Guardian Trustee Office. Various interview participants also indicated that they viewed social workers in large facilities as the care providers who usually assist with the health care consent process when there are questions around capability and availability of substitute decision makers. The BRSW sends out a bulletin two to three times a year to all registrants. Chris was not employed by the BRSW in the year 2000 at the time that this legislation was implemented and was unable to find a record of any information that went out in the bulletin with regard to the Adult Guardianship legislation. However, Chris did receive several telephone calls from members inquiring about their responsibilities relative to Representation Agreements. Membership in the British Columbia Association of Social Workers (BCASW) is entirely voluntary. In their quarterly publication, Perspectives,  the BCASW published an article about 122  the new Adult Guardianship Part 3 legislation (Leaney, 2001, pp. 14-15). The author, an active member of the Adult Guardianship Implementation Project, wrote the article in her capacity as Chair of the Perspectives Editorial Board. It provides guidance for social workers in their efforts to support abused or neglected adults, and also directs them to the website www.trustee.bc.ca for additional information. Chris believes that it is "crucial" for health care professionals to keep up to date about  legislative change. "People need to understand to overcome resistance. To buy in, they need to  see the value to clients, to their role as professionals, and they need to know what resource available. " Chris recognized that in the field of social work, there is a "gap between what is desirable and practical. " Because registration is not mandatory for all practicing social workers and because they are a generally poorly paid group without employer support for continuing education, it is difficult to conceive a reliable method of ensuring that such a mandate is met.  British Columbia Society of Occupational Therapists (BCSOT) At the time that this new legislation was proclaimed, the occupational therapists in BC were experiencing a major change in their own legislated mandate. The College of Occupational Therapists (COTBC) became functional in July of 2000. Since that time, the BCSOT and the COTBC have been working out their particular functions. Clearly it is the COTBC who has the regulatory function and the BCSOT has the interest of the practitioner as its priority. However, Lin pointed out that the interests of the public and of the practitioner are essentially the same and therefore the two organizations have been working very closely together. According to Lin, no educational initiative was launched relative to this legislation. She believes that the necessary education for the 70 to 75 % of occupatioml therapists who work for public sector employers would have occurred in the workplace or through the information loop involving the particular Ministry associated with their work. As well, legislative changes, along  123  with Ministry website addresses for more information, are flagged in the newsletter put out by the BCSOT ten times annually. The BCSOT and the COTBC share their Annual Meeting in order to provide an opportunity for members to access both organizations in one day. The session begins with an open forum in the morning, an appropriate venue for raising legislative changes along with other issues that may affect practice. Lin indicated that not only is there some confusion about mandates between their regulatory group and their professional group, but that the Ministries are also often confused about who should be contacted when input is needed or change occurs. As well, Lin believes that government often does not allow enough time for organizations to participate in consultative processes and as a result, their voice is silenced. Clarity around roles, lengthened timelines, and resources that support input from voluntary organizations would go a long distance to enhancing the quality of legislative efforts and ensure greater buy-in from affected professional groups. Lin stated that The earlier people are involved in a process, the more ownership develops...and the more committed people will be to assisting with education around the issue...In terms of educating the public about how to ensure that their rights are acknowledged and respected by health care professions, having the professions working with the government on how to get the message out to people is probably the most effective thing to do. Physiotherapy  Association  of British Columbia  (PABC)  Membership in the PABC is voluntary, yet about 80% of practicing physiotherapists belong to this association. Membership is tied into practice liability insurance, and this is believed to be a mitigating factor for the high membership fee. As well, there is a fee differential of 50 % for registration in some continuing education courses when the registrant is a PABC member.  124  The PABC produces a newsletter annually. According to Zane, it is likely that the new legislation was noted in that newsletter as well as at the Annual General Meeting. However, I was unable to obtain evidence of either event. The CPTBC produces a Quarterly newsletter, sent to members in hard copy and available online at www.cptbc.org. The Winter 2000 edition offered an article about the rights of adults to make their own health care decisions. The article named the four new Acts, summarized the rights of adults, described the responsibilities of health care providers, and provided links to www.hlth.gov.bc.ca/cpa/publications/index.html and to lpieter.degroot@moh.hnet.bc.ca, along with telephone numbers for consultation. In the Spring 2004 edition, a brief summary of Bill 44 is provided along with website addresses for the Queen's Printer version of this amendment bill. Zane indicated that formal education of many physiotherapists about the legislation would have occurred in the workplace. I have to be honest - as time went on, it drifted off the radar. At first everybody was very hot that we had to change how we practiced, and get permissions from different sources. I remember being told distinctly that every time we recorded or documented on the chart, we had to state that permission/consent was obtained from the patient for treatment. It has now disappeared and nobody worries about it.  When questioned about how education for the membership could be best achieved, Zane replied, There is certainly a gap - a knowledge gap. I think it should be more formal. There is an interesting sort of dichotomy here - many members feel that they don't want to pay for professional education, that it should be provided free of charge by the association or by the College. They only want to participate in [pay for] the kind of education that will enhance their practice and promote their professional development. When it comes to these professional issues, they become reluctant to pay. Sometimes we piggyback onto the AGM ...if it happens to be a hot topic... usually those courses attached to the AGM are either free or very low cost to attract as many people as possible.  125  Zane pointed out: If we get quality instructors to address... issues, they like to be paid and are not going to do it free of charge. We want to give them the education, we understand the need, understand the legislation, we recognize that therapists need to be educated in this area - who is going to pay for it? I hate to think that education always boils down to money, but in some cases it does. Zane's closing comment indicated optimism for future involvement in continuing education of physiotherapists. Speaking of the cooperation between the PABC and the CPTBC, Zane described a "very harmonious relationship " out of which collaborative educative initiatives are likely to arise. Other Educative Initiatives  In addition to those offered by the Ministry of Health, the Public Guardian Trustee Office, and the various health profession organizations, a number of other initiatives were launched by a variety of public and private organizations. The Popular Media During the time that the legislation was being discussed within the Joint Working Committee and during its subsequent development, there were occasional articles in newspapers across the province. These articles generally discussed the draft provisions of the legislation and often were published primarily to announce public forums. Because this legislation was developed over a long period of time - from its inception in 1989, until its implementation in 2000, and also because it was accompanied by many false starts and changes, it was perceived by many to be an unlikely reality. As a result, interest waned in many groups - the working groups, the writers of the legislation, the implementation groups, health care providers, and even the public began to doubt its eventual success.  126  Medical  In the Physician's  Services Plan for Medical  Practitioners  Newsletter published by the Medical Services Plan, under the Ministry  of Health and Ministry Responsible for Seniors, an announcement of the new Legislation for Consent to Health Care was published in the summer of 2000. The announcement discusses only the Health Care Consent Act but it does refer to the other applicable Acts and provides the PGT website for further information, as well as the Ministry website for copies of the Primer and the Health Care Provider's  Guide. Advocacy  Groups  Several Advocacy Groups, most of whom were also involved with the Joint Working Committee, provided education for their members. Among these was the British Columbia Association for Community Living and also the British Columbians for People with Disabilities. These efforts were directed to clients and their families rather than to professional health care providers. A major concern of several Advocacy Groups is that the Representation  Agreement  Act allows for the possibility that people who may not be capable could be manipulated into preparing a Representation Agreement for the purposes of the self proclaimed Representative rather than for the good of the elector. Their educative efforts were in part an attempt to mitigate this possibility through education of potential advocates. Representation  Agreement Resource Centre  (RARC)  Incorporated in 1995, the Representation Agreement Resource Centre is a non-profit voluntary service that offers information and facilitation for people who wish to prepare Representation Agreements. The RARC has provided many opportunities for members of the community to become educated about Representation Agreements. According to the 2002 Annual Report, 56 information sessions were provided for approximately 1300 people. In addition, telephone calls were fielded and consultations provided for many people, a significant percentage of them health care professionals. Along with two partners, the RARC has launched 127  the Nidus Registry, an electronic service allowing people to register their Representation Agreements so that health care institutions can have direct access to the wishes of those who choose to make advance selection. RARC maintains a website that provides many resources relative to the Adult Guardianship legislation, including some specifically directed toward professional health care providers.  Health Association of British Columbia (HABC) In 2000, HABC put out a video recording titled "The New Adult Guardianship Legislation - Health Care Consent." This 26-minute tape provides an overview of the Acts, and is narrated by several of the legislation writers and other principals in its development. The intent was to offer professional health care providers an opportunity to view the tape during quiet times in their workplace. It was considered by some of my participants to be more effective as a sleeping aid than as an educative aid!  Summary Without exception, participants who represented professional health organizations agreed that the relationship between education and the success of health policy is critical. In order to be guided by it, people need to understand the philosophy and reasoning behind policy. Health care professionals also must understand the value for their clients. Role clarification and access to resource materials are crucial to policy success. No doubt the delayed implementation of the Adult Guardianship legislation had some , negative impact on the educative impetus of the health profession organizations. Invited to participate in the planning, some chose to do so while others did not. Repeatedly, word of impending implementation reached the professional organization offices but the expected date came and went and implementation was stalled. People began to doubt the reality that this legislation would ever make it off the table. Information about it began to elicit a "ho-hum" response from many. 128  The health professions as units were not invited to the Train the Trainer program. They were, however, sent notice of the implementation date along with documents and brochures as well as an offer to assist in educating members. Some took advantage of resources and others did not. A few members of the health professions attended educative sessions offered by the various groups working out of the PGT office. However, in most cases their education was directed at their work as individuals or at a small number of workers within their work setting. Their mandate did not include general education of professional health care providers. Relative to the total number of professional health care providers in the province, it appears that only a minute number attended those sessions. Only one of the participants indicated that the professional organization assumes this ongoing educative responsibility as primarily theirs. Within other professions, there was confusion about where the mandate lies. Overall it was seen as the responsibility of the individual professional health care providers to ensure that changes in legislation affecting practice are known and understood. However, for many reasons what this entails may not be realistic. Several observations can be made about the role of professional bodies in the educative process related to legislative change. These include: o  Most agree that when membership in the professional organization is mandatory, that organization has some responsibility for notifying registrants of legislative change. The responsibility of the registrant varies with the organization, but most indicate that each individual professional has the responsibility to follow up notification of changes with an effort to become educated.  129  o  The professions that have more members and larger central office staff are able to provide more educative resources than are those with fewer members and small central office staff.  o  If mandatory registration is not a requirement for a profession, there is no established method of ensuring that members of that profession have access to information about legislative change.  o  Some of the professional groups are at the lower end of health provider pay scales and do not enjoy the support of employers for continuing education leave and subsidization. This perpetuates their distance from educative resources.  o  Most of the professional health care provider organizations would participate in legislative development if they were given enough time and in the case of smaller groups, some government resources.  o  All of the organizations appreciate being on a regular mailing list and an e-mail server list so that government initiatives related to legislative change arrive in their office in a timely fashion. Some indicated that there is confusion among their organizations and within the government about which particular organization should be contacted.  o  Most organizations recognized that the major change in the legislation was the presumption of capability. The process of getting consent required education.  o  All of the professions appreciate and utilize government documents that provide information about legislative change and impact.  o  Power and its negotiation are again evident in some of the data offered by professional care providers. Physicians, long recognized as the most powerful group in the health care professions, feel confident that they will be consulted when legislative change is being considered, and that their feedback will drive 130  revisions when they disagree with legislation. Groups of professionals that are smaller in number or lower in the hierarchy have less confidence that their voices are heard as well as fewer resources to effect an influence on legislation, o  The smaller professional groups would welcome government assistance with resources to enhance their educative capability around legislative change,  o  Specific educative initiatives made within professiona 1 organizations vary widely. Of particular concern is the reality that there is no mechanism for tracking the effect of these efforts. No one knows whether or not health care providers are assuming individual responsibility to self-educate about legislative change. Everyone recognizes that professional health care providers have very challenging mandates to remain current and competent in their specific caregiver skills. Do they also take the time to learn about the law?  The following chapter will further discuss the challenges and perceived impact of educative efforts made by government and by health profession organizations from the perspective of other research and key concepts that have guided the analysis with particular attention given to the politics of planning and implementing educational activities.  131  CHAPTER VII: DISCUSSION OF FINDINGS In this chapter I discuss the challenges and perceived impact of the educative efforts made by government and professional organizations. These findings will be examined from the perspective of other research and key concepts that have guided the analysis with particular attention given to the politics of planning and implementing educational activities. I began this study with the assumption that most educative efforts related to new health care legislation would originate within the various health care provider professional organizations. Aware that there were also educative initiatives offered under the Ministry of Health and the Public Guardian and Trustee, I developed a research plan that involved data gathering in all three venues. I wanted to find out what happened when new health care legislation was implemented in February 2000; what efforts were made to educate professional health care providers about the new laws and what the stakeholders believe about the impact of those efforts. I was surprised to discover that the government initiatives were responsible for the majority of education available to health care providers. I also discovered that there were differences in the efforts undertaken by the two separate government offices and that each of them had very different impressions about their success. Among the health care profession organizations, there were differences in educative initiatives as well as in their interpretation of the mandate for education of professional health care providers when legislation is implemented. These findings highlight the politics of planning for education about legislation that originated from the grassroots in order to protect the vulnerable public and at the same time had implications for the practice of health care providers. Earlier conceptualizations of policy implementation are lacking in that they do not address the politics and complexities that are inherent in this important phase of legislation. The particular legislation package that is the subject of this study is difficult and complicated; it consists of four different Acts and its effects 132  include significant changes in the practice and power of health care providers. From the perspective of the complexity of interests served, it is not surprising that the process of implementation was contested. Consideration must be given to the effects of competing interests combined with differing resources and mandates between the Public Guardian and Trustee (PGT) Office, representative of the public interest, and the Ministry of Health, representative of health care providers, as well as among the health care provider organizations. These differing and sometimes competing interests, along with the variation in resources and mandates, are two main policy influences that can in part be addressed from the perspective of the power in planning literature. Policy Development  Competing Interests This legislation found its roots in the public domain. A group of concerned citizens wanted to protect the rights of all adults to make choices about their health care. In particular, they were concerned about the rights of those who traditionally were seen as incapable of making their own decisions and who, as a result, were often treated in a paternalistic fashion. The efforts of these concerned citizens led to a province-wide initiative through which the lay public as well as health care providers were invited to participate in developing a new package of adult guardianship legislation. The new legislation departs significantly from the status quo. Two major constituencies were affected: the powerful and the relatively powerless, i.e. health care providers - in particular, physicians, and the public - i n particular, those with mental and physical disabilities who are now able to have a voice in their care. The Representation Agreement Act and certain sections of the Health Care (Consent) Act reduce the power of the health care provider and shift that power to those who previously may have been assumed incapable or to others who must be appointed according to new guidelines. Physicians, the group of health care providers generally seen as 133  those who wield great power in health care, are greatly affected by this power shift. Not only do they lose much of their discretionary power in determining incapability, but they also gain responsibility for a more complex and burdensome process of obtaining informed consent. As Wharf and McKenzie point out, we must "recognize the realities of the work life of first-line practitioners who in many instances regard new policies as unnecessarily adding to and complicating a crisis-ridden work environment" (2004, p. 82). The Politics  of Policy  Development  Fraser describes the "discourse sense [of politics] in which something is 'political' if it is contested across a range of different discursive areas and among a range of different publics" (1989, p. 166) and further states that "the relative power of various publics... determines the outcome of struggles over the boundaries of the political" (p. 167). This legislation is noteworthy in that it shifts power away from those who have been considered the powerful. The intent and the content of the legislation contributed to a contested space in which different and competing interests exist in the public arena and in the (health care) professional arena. This legislation, fraught with issues of power and politics, would seem to have its best hope for success if founded in a "bottom-up" or "backward-mapping" approach to policy (see deLeon & deLeon, 2002; Wharf & McKenzie, 1998). While this approach is more timeconsuming in that it involves consultation and negotiation of varied interests, some believe that its democratic character is more likely to result in acceptance at the implementation stage, especially if implementation is also oriented from the bottom up . The Joint Working 15  Committee and the Planning Groups who developed the adult guardianship legislation package were reflective of such a bottom-up approach to legislative planning. However, it would seem In this approach to policy-making, policy originates with practitioners and "the problem-solving ability of complex systems depends not on hierarchical control but on maximizing discretion at the point where the problem is most immediate" (Elmore, 1982, p. 21, as cited in Wharf & McKenzie, 1998, p. 69). Those who promote such an approach to policy development and implementation point out that practitioners are more likely to be committed to policies that they have had some input into shaping rather than to those that have come down from above and that add further to their weighty responsibilities. 1 5  134  that those members from the public arena might have provided a more democratic perspective than did those involved as health care provider representatives. If that is not the case, why did the educators meet with such resistance at implementation? (see comments by Mel, Leslie, Alex, and Taylor). A time-consuming approach that requires consultation with varied interest groups and stakeholders, the bottom-up model of policy planning and implementation cannot be realized through one representative who speaks for several thousand. Yet, involving health care providers in active debate about proposed legislation is challenging when so many more pressing issues compete for their attention. During the time that this legislation was being developed, ongoing and significant changes were occurring in the provincial organization of health care services. Such changes demand the attention and consume the energy of physicians and of other professional health care providers. In addition to the complexities of health care organizational changes and the crises attending lengthening waitlists and reduced resources, the rapid expansion of medical knowledge strains the attention and time of these groups. The College of Physicians and Surgeons (CPSBC) was represented at the table where this legislation was being developed. Other health care professions also had some, though limited, input into the development process. What seems most significant, however, is that even when a representative of a group of professional health care providers participates in developing legislation, the actual implementation of that legislation may still be fraught with problems. Although it is critical to the success of new policy that all stakeholders have involvement in planning as well as implementation (see Ball, 1992 and 1994; deLeon & deLeon, 2002; Gill & Saunders, 1997; Johnson, 1995; Levin, 2001; Mazmanian & Sabatier, 1989; Wharf & McKenzie, 1998, 2004), many of the health care provider organizations were not involved in developing the legislation. Several were invited to the table, but not all were given the opportunity and sufficient time to become fully engaged. The only organization that sent a representative to planning meetings was the CPSBC. Others, such as the Registered Nurses Association of BC (RNABC) 135  and the College of Dental Hygienists of BC (CDHBC), responded with written submissions. Taylor, the participant who represented the CPSBC, was specific in recognizing that the Ministry of Health and the Public Guardian and Trustee Office were straightforward and responsive to concerns expressed by the CPSBC representative during legislative development and revision. Several of the smaller organizations were unable to send a representative to the planning table because they do not have the financial and human resources to support such involvement. At the same time, participants who represented some of these smaller organizations also felt that because they are seen as less powerful than other professional caregivers, their input is devalued. Clearly, the differences in power and influence that are perceived among professional health care providers in the health care arena are also played out in the legislative process of development. Education for Implementation The hierarchical structures of health care played a key role in this legislative implementation, a reality that needs to be considered in future legislative change. Such a hierarchy has an influence on the roles and expectations of health care professionals about their involvement as part of the larger policy landscape. Educative efforts related to new health care legislation is a form of adult education. In relation to this legislative package, two major constituencies required information about the four new Acts - professional health care providers and the lay public. The latter group includes those who are vulnerable and those who are personally or professionally associated with the vulnerable public. This new legislation was written at the urging of the lay population and with the intention of protecting the vulnerable. Significantly, the greatest educative efforts made during implementation were also directed toward those most associated with the vulnerable population - their personal and professional caregivers. The broader scope of health care providers including those in the acute care setting - who, in order to honour the right to self-determination, 136  must be familiar with both the Health Care Consent Act and the Representation  Agreement  Act,  were offered far less opportunity to familiarize themselves with the intent and the content of the legislation. Cervero and Wilson (1994, 1996, 2001) offer a conceptualization of planning for education that moves beyond the classical, naturalistic, and critical views of program planning. While the latter three views do offer insights into the planning process, they are seen as dichotomous in their views of planner discretion and structural constraints. Seeking to integrate these two concepts, Cervero and Wilson describe planning as a social activity in which varied interests (interpersonal and institutional) and power relationships give rise to the structure of the program through a process of negotiation. 'This negotiation is expressed in every practical judgment made in creating any educational program, including its purposes, content, audience, and format" (1994, pp. 30, 31). The authors claim that this model of planning improves practice because it makes sense of the varied and mundane daily activities involved in planning, highlights the political nature of planning, and most importantly, because it articulates the ethical responsibility inherent in deciding among competing interests (pp. 31, 32). When the time came to implement the Adult Guardianship package of legislation, the two government bodies had different views about who needed information and what information they needed. As well, professional health care organizations responded to the educative demands of the legislation in diverse ways that highlight competing interests within that arena. Competing Interests/Competing Ministry  Mandates  of Health and Ministry Responsible for Seniors  It was clear to the three participants from the Ministry that their educative mandate applied to professional health care providers. Unless those responsible for implementing the legislation understood and supported the intent, its success was doomed. The Manager of Implementation of Adult Guardianship was primarily concerned with ensuring the success of the 137  Health Care (Consent) and Care Facility  (Admission) Act. This involved attempting to make the  information available to well over forty thousand physicians and nurses as well as thousands of other health care professionals throughout the province. Although the Planning Group advised against the model chosen to educate professional health care providers, the Ministry proceeded with their plan to utilize a Train the Trainer approach. And, although they were not convinced that it would ultimately lead to success, two writers of the legislation agreed to participate in training the facilitators. Both were concerned about the complexity of the legislation and the potential for inaccurate transmission by trained facilitators as well as the likelihood that physicians, the caregivers whose role in consent was significantly altered by the legislation, would not recognize the trained facilitators as credible resources. Wilson and Cervero describe power as the capacity to act in a social context and recognize that the program planner operates within a context where power necessitates the negotiation of interests. Further, they clearly indicate that ".. .traditional planning tasks.. .[are] centrally involved in who has the power to represent which interests" and "the instrumental tasks.. .tell planners what to do.. .and also.. .are the activities within which planners negotiate power and interests" (1996, p. 91). It would seem that the Manager of Implementation for the Ministry of Health held enough power in that position to override the advice of the Planning Group as well as that of individuals involved in developing the legislation. According to Mel, there were personality conflicts and differing styles among those with the mandate for education and this may have further contributed to tension as well as confounded the successful negotiation of competing interests. Participants from the Ministry were much more forthcoming than were those from the PGT Office in recognizing that disagreement did occur between them and that rather than resolving their differences and negotiating a new approach that modified the interests of both, the Ministry remained firm in its chosen educative plan. 138  The Public  Guardian  and Trustee Office  As part of the responsibility for implementing all four Acts, the Director of Implementation for Adult Guardianship was given the responsibility to plan for educating community groups, health care professionals, and government employees. Recognizing that the Ministry of Healthfocuswas on health care consent, the Director of Implementation put the PGT Office focus on the other three pieces of legislation, emphasizing in particular the Adult Guardianship  Act - Part 3. This was consistent with the mandate of the Public Guardian and  Trustee - protection of the vulnerable public. True to the history of this legislation, the PGT staff sought and followed the advice of the people who had been involved in its development. These concerned groups gave direction that was consistent with the principles of the legislation and guided the Implementation Team as they developed educative materials and planned the process of engaging with the public. Guidelines for implementation were developed in consultation with representatives of the community and some of the health care professions. Many authors support this as an effective approach to avoiding misinterpretation of text and/or failure to adhere to new policy (see deLeon & deLeon, 2002; Johnson, 1995; Levin, 2001; Meier & McFarlane, 1995; Petr, 1991). Parallel to their educative planning efforts, the Implementation Team was actively encouraging and supporting communities to develop Community Response Networks. Out of this initiative arose participants who were willing to assist in planning for education sessions that would be provided by the Implementation Team. Consistent with the advice offered by their various participants, the Implementation Team made a series of visits to communities throughout the province to offer general information about the legislation and later, to provide specific guidance around implementation. Attendance was broad in scope; some health care providers were present along with people who were more personally affected by the legislation. However, overall these sessions attracted few 139  health care providers employed in acute care settings or in practices not associated with community care. Just prior to the implementation date, the PGT Office hired a Manager of Health Care Decisions. This person saw education as a key component of success in protecting the vulnerable public during the consent process. The acute hospital system was a constituent in this mandate, along with the developmentally disabled community and the long-term care community. Although they are not active solicitors of education opportunities, the team welcomes opportunities to address health care provider organizations and groups about the consent and guardianship legislation. Health Profession  Organizations  Some health care provider organizations did not receive an invitation to be involved or to respond to the developing legislation. There seems to be some confusion among the organization membership and at the government level about the mandates of some of the organizations, in part as a result of a blurring of accountabilities between Associations and Colleges. There is also some confusion within some of the organizations about their mandate to educate members. Generally, where membership is required in order to practice, to inform the member when new legislation is enacted is seen as part of the mandate of the organization. At the same time, the extent of that mandate is variable. Some organizations provided written information to members, along with directions to further resources on websites. Others, such as the RNABC, CDHBC, and CPSBC, flagged the information and emphasized its significance. It is apparent that in certain cases, some health care professional organizations can and do involve their members actively in legislative development and implementation. Representing the CPSBC, Taylor indicated that legislative drafts are made widely known within the profession when issues within them are of great concern and legislators are not responding as desired. The Health Professions Act (HPA), which sets the mandate and practice parameters for most of the 140  health care professions in British Columbia, was cited as one example of legislation that was taken to the CPSBC membership for their active involvement. The membership of the RNABC was also actively engaged in responding to drafts of the HP A legislation. Tony from the RNABC indicated that there is a communication plan and education plan that has been developed specifically for legislation such as the HP A that is "directly related to us. " In other matters such as the adult guardianship legislation, the role of the RNABC is to 'facilitate education sessions. " Tony indicated, "it is not our mandate to help members to be informed of health care  legislation  that may affect them " and pointed out that one of the standards (see Appendix I) requires members to function within the legal scope of practice and within relevant legislation. One concern that is not addressed by any of the health care provider organizations is how to ensure that members are accountable for maintaining currency with regard to legislative change. Once the health care provider is licensed to practice, assessment of safety to practice consists of member reports about hours worked in the profession, self and peer evaluation, voluntary activities and in some professions, evidence that ongoing education has been undertaken. The responsibility for ongoing competence is addressed in the Codes of Ethics and is a matter of individual accountability. Competing Ministry  Resources  of Health  Participants indicated that although the government dedicated significant resources to the development and implementation of the adult guardianship legislation package, as the time of the actual implementation date came closer there were limited funds available for educating professional health care providers. Only one person was employed to oversee the education of many thousands of health care professionals throughout the province. Unlike the Office of the Public Guardian and Trustee, the Ministry of Health did not have a team dedicated to ensuring successful implementation of the legislation. Although earlier on one of the drafting lawyers was 141  supported and funded in travelling throughout the province as part of his education portfolio, that funding ceased shortly after the legislation was implemented. Funds became so limited that even computer technology conversion work necessary to mount documents such as the Health Care Provider's Guide on the Ministry website was determined to be beyond the budget. Against the advice of the Health Care (Consent) and Care Facility  (Admission)  Act  Planning Group, the Ministry went ahead with its Train the Trainer project. Some of my research participants indicated that they believed this project was doomed from the start. It did not take into account a number of obvious issues, including the critical importance of educating health care providers about this legislation, ongoing upheavals in the health care delivery system, the complexity of the legislation, and possibly most important of all, the essential credibility of the educator at the frontlines. It is critical that those who educate professionals do so in a manner that develops understanding, and not just in rote fashion (see Johnson, 1995; Levin, 2001). Very soon after the legislation was implemented, the Ministry moved its Manager of Adult Guardianship Legislation out of that portfolio and on to a completely different assignment. At the same time, funds for ongoing education of any kind were disappearing. All research participants who represented the Ministry expressed the belief that funds were diverted from them to the PGT office. It was clear that all would have welcomed more time and more resources to extend their educative endeavour through ongoing sessions that would reinforce and strengthen the outcomes of the Train the Trainer initiative and enhance the distribution of materials among health care providers. It seemed evident to me that any ongoing speaking engagements undertaken by Ministry folk are indicative of their individual passion and support for the legislation rather than of the Ministry's dedication to an educative mandate. As Wharf and McKenzie (1998) point out, without such dedication to the legislative cause, educative efforts would have terminated abruptly.  142  The Public Guardian  and Trustee Office  As indicated earlier, the Office of the PGT was given the mandate and budget to implement the Adult Guardianship legislation. According to the participants who represented the PGT office, although there was not complete unanimity between them and the Ministry about how to educate professional health care providers, the two constituencies did work cooperatively to fulfill their particular educative roles. Five years before implementation of the legislation, this office was able to hire a Director of Implementation for Adult Guardianship as well as, six weeks prior to implementation, a Manager of Health Care Decisions. With an overall budget of 1.1 million dollars and a wide scope of responsibility, the Director of Implementation was able to contract for assistance with preparation of documents and plans for their work. Consistent with advice found in the literature (see deLeon & deLeon, 2002), groups that had been involved in developing the legislation as well as groups that would need the information were consulted for advice and guidance. Community building was an important focus for the Implementation Team, and that effort achieved two purposes: it put in place a framework for disseminating information as well as an ongoing network to support the mandate of the Adult Guardianship  Act. Their budget was  healthy enough to allow for allocation of small grants to support communities throughout the province in building their local response networks. Study participants from the PGT office as well as the one community participant were unreserved and unanimous in stating that they believe their educative efforts were successful. They attribute their success to the consultation process, their willingness to go to the communities as needed, their network building, and to the quality of the presentations that they developed. Consistent with claims in some of the literature (see Johnson, 1995; Wharf & McKenzie, 1998), one of my participants also gave credit to the positive impact of the delay in implementation, which allowed time to develop regulations and guidelines for implementation. 143  Although province-wide training will no longer be sustained within the PGT Office budget, the newly formed Community Response Network (CRN) Foundation is making ongoing efforts to keep people updated through a teleconferencing network. Plans are also underway to develop a program of orientation tothe Adult Guardianship Health Profession  Act for newly hired staff.  Organizations  None of the health profession organization participants indicated that their organizations dedicate substantive resources to education about legislative change. Some of the smaller organizations have virtually no resources for education and unless registration is mandatory, no way to even ensure that contact is made with all members of that profession. All of the organizations indicated that they provided information to their members by referencing the PGT and Ministry websites and publications. Opportunities to partner with government representatives for education are generally welcomed as long as the cost is borne by the government. The greatest educative efforts were made by the three organizations that have the largest number of members along with mandatory registration. Both of these elements support a more substantial resource base for education. In spite of numerous efforts to inform them about the Health Care (Consent) and Care Facility (Admission) Act, the participant who represented the College of Physicians and Surgeons of BC admitted that physicians were not showing much interest and were inclined to wait until they need it before seeking information from the CPSBC office. Participants from both the Ministry and the PGT Office reinforced this belief. Various opportunities in varied settings have attracted only a few physicians. It is reasonable to question whether, without any background information about the legislation, physicians really can be relied upon to recognize the need for consultation when it arises in the practice setting. There are many possible explanations for what some participants saw as a lack of interest among physicians in becoming 144  educated about the legislative change. It could be a form of covert resistance (see Levin, 2001) or indicative of their own overriding values and beliefs (see Bowe & Ball with Gold, 1992; Johnson, 1995; McLanahan, 1980) pr reflective of a lack of motivation (see Diamond et al., 1999). Alternatively, this perceived lack of interest in the legislation might be a function of the limits of time for the vast range of issues and expanding knowledge that they must respond to on an ongoing basis or a lack of awareness of the importance of this particular training. Whatever accounts for their perceived lack of interest in becoming educated about the legislation, certainly there is potential for the exercise of their power to override the intent of the legislation. Of even greater concern is the lack of physician familiarity with the Agreement Act and the Adult Guardianship  Representation  Act. According to Taylor, the participant who called  them a "can of worms" there is much confusion about these pieces of legislation. Both the Registered Nurses Association of BC and the College of Dental Hygienists of BC took care to inform all of their members about the new legislation. Of serious concern is the lack of a model for ongoing education of Licensed Practical Nurses (LPNs). As a group whose practice responsibilities and accountabilities are rapidly expanding, LPNs should have ongoing and reliable access to changes in legislation. Francis assured me that a model for continuing education of LPNs is being developed. When there are changes in legislation that are applicable to their practice, professions who work across Ministry borders can easily be overlooked. The Board of Regulation for Social Workers (BRSW) would not expect to receive direct communication about legislative change within the Ministry of Health. As well, the many social workers employed by government are not required toregisterwith BRSW. Bulletins sent out by the BRSW would be directed only to their members, leaving those not registered without access to announcements of legislative change. Although social work was the profession most often represented at education sessions offered by the Ministry and the PGT, Chris worries that many members of the profession do not 145  know about the legislation and therefore are unaware of the resources available to them in helping their clients. Their relatively low pay scale along with a general lack of employer support for ongoing education is a combination that raises further concerns about access to updated legislative change. Occupational therapists and physiotherapists share the need for access to financial resources that would support the dissemination of information about legislative change. But What Happened to the Representation  Agreement Act?  The Ministry of Health made an attempt to educate health care providers about the Health Care (Consent) Act. The three participants who I spoke with do not feel confident about the success of that effort. Further, they believe that the lack of funds for ongoing support and enhancement of the educative effort has been a serious barrier to success. Occasionally, a Ministry representative responds to a request from an organization or an institution to speak about the legislation, but only if the visit is funded by the inviting organization. Some health care providers attended the sessions offered by the PGT Team and therefore may be well informed about the Adult Guardianship  Act. Fortunately, the Manager of the Health  Care Decisions Team has supplemented the educative effort and sees that team's mandate as inclusive of caregivers as well as the general public. No one initiative has focussed on all of the legislation and certainly the piece that seems to have been generally overlooked is the Representation  Agreement Act. Implemented in 2000  along with the others, this huge and complex Act has probably been the most controversial. The McLean Report (2002) was commissioned to critique the Act and to suggest revisions, but the legislation has never reappeared on the government agenda for amendment. Uncertainty about this legislation, which mainly applies to its standard and enhanced conditions and to the issue of power of attorney, is probably the reason that it has not been well publicized. Yet, it is the piece of legislation that allows all citizens of British Columbia to make their own choices in advance 146  about who will make decisions on their behalf. These decisions may apply to health care, personal care, and financial matters.  Power in Planning This legislation was created and occurred within a contested space, wherein representatives of the community and the interests of its vulnerable members initiated changes in legislation that would ultimately alter the roles and responsibilities of professional health care providers. The resulting tensions are related to a number of power issues. The PGT Office educators generated educative needs by consulting with the same constituencies who spearheaded the legislation and therefore their educative target was conceived to protect the vulnerable population. Inevitably that meant their focus became the Adult Guardianship Act. The Ministry wanted to ensure that professional health care providers understood how to gain informed consent under the new legislation and they therefore focussed on the Health Care (Consent) and Care Facility (Admission) Act. Both of these choices are supported in Fraser's (1989) description of how political decisions may be grounded in needs claims. These need claims "tend to be nested, connected to one another in ramified chains of 'in-order-to' relations" (p. 163) and unravelling such chains reveals who established the needs, how the needs have been interpreted, by whom, and according to whose perspective and interests, as well as in what form of discourse. Involvement of professional health care providers in making decisions about whose interests needed to be served, with what information, and in what manner, may have facilitated the success of governmental educative efforts. The social activity of planning involving negotiation about purposes, content, audience, and format as described by Cervero and Wilson (1994) was illustrated in the actions of the Adult Guardianship Team in the PGT office. It seems that in the planning of the Ministry's educative initiative, negotiation of interest and power was a more subtle process and that the decision was made to proceed in a certain way without taking into account all of the nuances, interests, and 147  perspectives. As a model that is familiar and cost-effective, and has often been used successfully to educate large numbers of people, Train the Trainer may have appeared to be the obvious choice for this huge educative undertaking. As a tried and true method, Train the Trainer can be a successful community-building tool and it is reasonable to imagine that it could work when educating professional health care providers about new legislation. The plan to utilize this approach was conceived without support from any of the Planning Groups, from the PGT Office, or from legislative experts. If "power is the capacity to act" (p. 29), then apparently the Manager of Adult Guardianship for the Ministry possessed sufficient power to override the advice of others. And, if interests direct planners and cause them to act in certain ways (p. 29) then that same person's interest in Train the Trainer must have been very strong. Once they realized that the Train the Trainer project was going to proceed, several of the experts who had been associated with the legislation during its development got on board in an attempt to make it a success. Soon after the series of training workshops was completed, the Manager was relocated within the Ministry and the funding supporting education was significantly reduced. No one made the suggestion that either of those occurrences was related to the outcomes of the Train the Trainer initiative. In fact, the success of that initiative has never been objectively evaluated. To be fair to the Ministry in their decision about an educative approach, it must be recognized that the majority of funds were apparently directed to the PGT Office and this may have been a primary factor in deciding how best to approach the education of a huge number of professional health care providers. A second important consideration was the shortage of time available for education of professional health care providers after the fall of 1999 announcement that the legislation would be implemented in February of 2000. On the basis of such restrictions in resources and time, a decision was made about who should know and what they should know.  148  Discussing the ethical dimensions of deciding whose interests matter, Sork makes the claim that If negotiating power and interests are the central features of program planning, then great care must be taken not only to recount details of the negotiations but also to reveal the moral and ethical justifications for actions taken. An ethically sensitive planning practice must not only acknowledge that an ethical issue was confronted but also be accountable for decisions made and actions taken in relation to the issue. (Sork, 1996, p. 86) I was not able to establish clearly the justification for decisions that were made in this educative endeavour. It was apparent that the Ministry had the responsibility to educate health care providers about the Health Care (Consent) and Care Facility  (Admission) Act, while the  PGT Office held overall responsibility for implementing all four Acts. What became clear during this research project, however, was that the Ministry made only one significant attempt to initiate education of health care providers, offering direct education to only a handful of "facilitators" and left ongoing education and support in their hands. In some ways this made sense, given the sheer numbers of professionals, the roles of professional organizations, and the differences among responsibilities within that constituency. The success of efforts made by those facilitators was compromised by a number of factors, including upheavals in provincial health care organization, issues of hierarchy and credibility within the health care professions, and the complexity of the legislation. As well, they were quickly and effectively abandoned by the Ministry of Health educators once their training had taken place. Several research participants, including Pat, Leslie, and Mel, believe that if there had been funds to support ongoing work with the facilitators, Train the Trainer would have proven to be more effective. Pat believes a "major shortfall"  in the success of the Ministry effort was the lack of ongoing contact with facilitators to  support them in their presentations and with professional organizations to support them in preparing educative journal articles and offering workshops.  149  Although Ministry participants made thinly veiled suggestions that were indicative of tension between the Ministry and the PGT Office, no one from the PGT Office concurred. Certainly the Ministry initiative was seen by its representatives to have suffered from diversion of implementation funds to the PGT, and this became more obvious when the PGT was able to continue educative efforts long after the Ministry's focus had moved in other directions. Recognizing that health care professionals must understand the legislation in order to know when to call in the PGT Office, the Manager of Health Care Decisions has made an effort to include them in any educative sessions offered by that team. The PGT Office staff made an ambitious undertaking to educate the vulnerable public and their personal and professional caregivers. However, those efforts evolved into a focus on only one of the Acts, leaving the others within their mandated responsibility largely disregarded. The basis for this decision to remain true to their interest in one Act and one audience is not clearly articulated and therefore not apparent. Through their successful efforts at implementing the Adult Guardianship  Act, they did meet the major mandate of the Public Guardian and  Trustee Act, which requires establishment of Community Response Networks and Designated Agencies. Implementation of the Health Care (Consent) Act and the Representation  Agreement  Act has not included a significant educative aspect. The "dominant power relations [were] reproduced" (Cervero & Wilson, 1996, p. 93) and the PGT Office remained true to its mandate of protecting the vulnerable public and true to their commitment to the Planning Groups. What remains unclear is who will assume responsibility for protecting all of the public through ensuring that everyone is aware of the right to make advance decisions and to give informed consent. Well before Cervero and Wilson described their model of planning for education, Elmore wrote about the conflict and bargaining that occurs when social policy is implemented. He spoke of the reality that "one can't expect individuals to respond to new policies unless they are 150  predisposed to do so [and] policy does not exist in any concrete sense until implementers have shaped it and claimed it for their own" (1978, p. 216). Describing implementation as a process of conflict and bargaining among stakeholders, Elmore acknowledges the exercise of both formal and informal power as well as varied interests leading to outcomes that may differ significantly from the original policy. Although the physicians in the province were probably the group of health care providers most actively represented in the development and early revision of the legislation, that representation did not involve consultation with the membership in their organization. People who sought to provide education to frontline physicians keenly felt their resistance. It was virtually impossible to garner their attention for more than a few minutes at a time (see comments of Leslie, Mel, and Pat) and usually when the legislation was presented, the information was not well received. When Leslie spoke with one group of physicians, their reaction was so negative that it resulted in a motion to call on the government to rescind the legislation. As Lyle indicated, one effective strategy in gaining the attention of health care providers is to remind them that the legislation has built-in protection from legal action, but that protection applies only if the caregiver has adhered to the legislation itself. This approach, employing the power of law, capitalizes on the interest of professional health care providers to protect themselves from the threat of lawsuits - a strong policy lever indeed. It must also be recognized that education about legislative change is in competition with the demands upon professional caregivers to remain current in new knowledge and skills related more directly to health care. A review of the Okanagan Similkameen Health Region policy on Consent (revised November 2003) reveals a document that is twenty-four pages long and incorporates the major directives of the Health Care (Consent) Act. Although reference is made to the  Representation  Agreement Act, no detail is provided about the latter piece of legislation. Without knowledge and understanding about the content and intent of those two legislative pieces, it is difficult to 151  conceive how health care providers would interpret and apply the policy. It is also difficult to imagine that they would have the time or inclination to read such a lengthy policy prior to obtaining consent. No consent form can possibly relate the intent and content of this complex legislation. Therein lies the potential for following traditional consent procedure and overlooking the changes driven by the new legislation. Summary A variety of educative efforts were initiated to support implementation of the adult guardianship legislation. These efforts originated in two different Ministry areas as well as in various health profession organizations. Overall, the greatest of these efforts were made by the Public Guardian and Trustee Office to familiarize the vulnerable population and their caregivers with the Adult Guardianship Act. Participants representing the PGT Office indicate satisfaction with their educative efforts while those representing the Ministry of Health express serious concerns about the success of their efforts to educate professional health care providers. None of the participants claim to have made significant efforts at providing education around the Representation Agreement Act. Adult education is planned in a social context that involves power struggles and negotiation of competing interests. The findings of this research project indicate that power prevailed in some contested spaces, there was minimal negotiation of interests, and the choices made for government education initiatives ensured that the interest of the vulnerable public and their caregivers were addressed most effectively. Health profession organizations do not have a clear mandate to ensure that members are educated about legislative change. At most, their mandate is to inform members that changes have occurred and to offer information about resources that the members can access if they so choose. There is no mechanism in any of the organizations for holding members accountable to maintaining currency. Only by default are members found to be negligent in their knowledge 152  unfortunately, once sanctions become necessary, mistakes have already occurred. "Compassion with competence.. .that is the need and where either is missing little good will be done" (Hellegers, source unknown). The final chapter summarizes the findings of this research study in relation to the goals, and outlines conclusions arising out of the study. A model for planning education related to major public policy change is offered to illustrate how addressing the purpose, content, audience and format of the education program should include consideration of several contextual issues. Recommendations are made to policy makers and health profession organizations about ways to enhance the effectiveness of education offered to health care providers about new legislation. Suggestions are offered for future research studies that may address assessment of the implementation efforts related to this legislation. The chapter ends with a discussion of implications for my practice as a nurse educator.  153  CHAPTER VIH: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS The main goal of this study was to understand the role of education in public policy implementation through an exploration of how professional health care providers were educated about legislative change implemented in February 2000. Two key questions guided this study. First, I wanted to know what happened in the implementation phase of new health legislation in British Columbia. Relative to this question, I wanted to know what the government and the professional health organizations did to educate professional health care providers, what challenges they faced, and what stakeholders think about the effectiveness and sufficiency of their educative efforts. Second, I wanted to discover what lessons can be learned about planning and implementing educational activities that inform professionals of legislative changes that affect their practice. My investigation focussed on the three main areas of practice that were involved in educative initiatives related to the implementation of adult guardianship legislation. This legislation was a package of four acts intended to protect the rights of adults who require health care or protection from abuse. Included were the Health Care (Consent) and Care (Admission) Act, the Representation  Agreement Act, the Adult Guardianship  Facility  Act, and the Public  Guardian and Trustee Act. The three main areas of practice that were involved in educative initiatives related to implementation included the Ministry of Health, the Public Guardian and Trustee Office, and several health care professional organizations. I interviewed people from each of these areas. I also collected and analyzed documents utilized in their educative efforts. Once again, I want to remind the reader of how uniquely complex this legislation package is, in that it contains four separate pieces of interlocking legislation and it has different and significant effects on the public and on professional health care providers. Therefore, it is more demanding in terms of educative efforts than are most general policy changes. It may be 154  that these unique demands were not fully recognized and taken into account when education was planned and the more traditional approaches were utilized.  Planning for Education in Major Public Policy Change: Conclusions and Recommendations The fact that government and health professional organizations have had little experience with implementation of such complex legislative packages makes this legislation a useful test case for the effectiveness of educative efforts associated with major public policy change. Conclusions  The study revealed that the Ministry of Health and the Public Guardian and Trustee Office were responsible for most of the education that was offered to professional health care providers. The Ministry of Health focus was on the Health Care (Consent) and Care  Facility  (Admission) Act, while the Public Guardian and Trustee educators focussed largely on the Adult Guardianship  Act. As a result, those professional health care providers who did access  government-provided education were not likely to gain an understanding of the full legislation package. The Ministry of Health effort consisted of two Train the Trainer workshops, attended by approximately eighty people in total from across the province, who were then expected to carry the information back to their workplaces. The participants who represented the Ministry do not believe that this was an effective mode of education and two of them expressed fear that frontline health care providers are riot well informed about the intent and the content of the legislation. Both believe that the Train the Trainer approach was inappropriate given the complexity of the legislative package and the lack of credibility of trained facilitators. They expressed the fear that it will take a serious case of negligence to awaken health care professionals to the need for becoming educated about this legislation. The Public Guardian and Trustee Office educators are satisfied that their educative efforts have been efficient and effective. However, their focus was on the vulnerable public along with their personal and 155  professional caregivers, leaving a very large majority of professional health care providers outside of the targeted audience. Health profession organizations made varied efforts to inform their members about the legislation. The repeated delays in implementation may have caused a somewhat "ho-hum" approach to this effort. As well, mandates of some organizations are unclear. At best, their mandate is to inform members of legislative change; standards and ethical codes hold the individual professional health care provider accountable for adhering to the law. There is no organization that has a mechanism for holding the individual member accountable to read the information that is provided. Participants from professional organizations and from government indicated strong support for the Internet as the best vehicle for providing access to information about specific policy change and guidelines. Access to ongoing education and information about policy is essential as new health care providers enter practice areas and as legislation is revised. Recommendations  To enhance the success of future educational initiatives undertaken to inform professionals of legislative changes that affect their practice, I offer the following recommendations. In presenting these recommendations I am fully aware that they would have to be implemented in a complex socio-political-economic context and that the potential for controversy about the philosophical underpinnings of policy, along with multiple perspectives and power relationships, would influence whether or not these recommendations would even be possible, let alone be fully implemented. I recommend: To Government Policy  Makers  1. That government should provide supportive funding where it is needed to facilitate the involvement of representatives from all affected health profession groups in discussion about legislative changes. 156  2.  That government, in collaboration with health profession organizations, should clarify the mandate of those organizations, specifying registration/licensing requirements of practitioners as well as the responsibility of the organization to provide their members with information and education about legislative change. The only way to ensure that all professional health care providers are apprised of legislative change is when registration is mandated and there is clear articulation of the organization's responsibility for providing such information.  3. That government should give health profession organizations sufficient time to poll their membership in order to provide a response and advice based upon an inclusive process. 4. That, when health legislation is changed, government should provide resources that would supplement continuing education funds and enable health profession organizations to offer inclusive education to their membership. In determining the level of funding and resources that are needed, it is essential that consideration be given to the complexity of the policy change. 5. That government should plan education of health professionals in collaboration with representatives of health profession organizations. Planning education about policy change is complex and political and must involve negotiation about many contextual issues, including the scope of the change, the intent and content, resources for implementation, and environmental issues and complexities. 6. That education about new legislation should be offered through a lens that highlights the positive effects on the health care provider role. 7. That the success of educative efforts related to policy implementation should be assessed and this should include interviews of stakeholders and document (guidelines, policies, and procedures) analysis.  157  To Health Profession  Organizations  1. That on behalf of professional health care providers, health profession organizations should demand central involvement in development and implementation of health care legislation. This could be facilitated through creation of policy-making groups of health professionals and the public at the community level. 2. That health profession organizations should lobby for supportive funding from government when needed to facilitate their representation in discussions about legislative changes. 3. That health profession organizations should seek government cooperation in specifying their mandate for registration/licensing of practitioners as well as clarifying the responsibility of the organizations to provide information about legislative change to members. 4. That, as crucial players in determining the success of health policy, professional health care providers should demand that their organizations are proactive in providing education prior to and during implementation. 5. That health profession organizations should lobby for government resources to supplement continuing education funds and enable them to offer inclusive education to their membership. In determining the level of funding and resources that are needed, it is essential that consideration be given to the complexity of the policy change. 6.  That professional health care providers should be held accountable for understanding the effect of new legislation on their practice. Within health profession organizations where registration is required, a process for that accountability should be developed.  To Health Profession  Educators  1. That health profession educators include in the curriculum a full review and discussion of the legislation related to health care. It is critical that this education be approached from 158  the perspective of understanding the philosophy and intent behind the policy, and not just as information. Education, by definition, consists of knowing about, knowing how, and knowing what to do. Guidelines for application at the front lines should be part of the curriculum content. 2. That health profession educators impress upon their students the importance of maintaining and updating their knowledge of health care legislation. 3. That health profession educators encourage students to be socially and politically active, to lobby for involvement in health legislation, and to utilize their professional expertise to influence legislation. For Future  Research  What hath policy wrought? Having tasted of the fruit of the tree of knowledge, the implementer can only answer, and with conviction, it depends...(Pressman & Wildavsky, 1979, as cited in Ottoson, 1995, p. 1) Government educators who participated in the interviews during this study did not believe that professional health care providers are adequately informed about the legislation. Together with informal feedback from health care providers as well as the potential for misapplication of legislation described by Avery, this should be enough to suggest that the educative efforts related to implementation of the Adult Guardianship  legislation have been less  than fully successful at educating all professional health care providers. To my knowledge, no assessment or evaluation of the implementation of this legislation has been undertaken. What follows are suggestions for undertaking such research: 1. Professional health care providers should be interviewed and surveyed to assess their familiarity with the legislation as well as how effectively it is being applied. This research should address several settings where professional health care providers are employed: institutions of varying sizes and mandates; private health care providers; all professions named in the legislation. 159  2. Policies and procedures that direct processes for gaining informed consent, dealing with advanced care choices, and protecting adults from abuse should be analyzed for their consistency with the intent and content of the new legislation. 3. Facilitators who attended the Train the Trainer workshops should be surveyed to determine their efforts related to the legislation as well as the challenges and success that they have experienced. 4. Surveys of those who attended the educative sessions offered under the PGT teams would assess the perceived success of their approach and the outcomes of their educative efforts. For Future  Researchers  The literature reveals very little research about educative efforts associated with policy implementation. I believe this to be a rich source of research opportunities, and I offer a few suggestions that might assist others who choose such a study in the future. First, I suggest that the invitation to participate in such research be accompanied by a very general guideline for the research questions. Detailed interview guidelines such as the ones that I sent to my prospective participants had the effect of curtailing and constricting some of the conversations. It would have been useful i f I had left the parameters of the interview more fluid so that participants felt free to explore their memories more freely and express the issues that stood out most for them as they recalled the process of educating health care professionals. When there are multiple perspectives represented about what works and why it works, it can be hard to sort among those perspectives. Added to that one must be sensitive to the political tensions that may exist among participants, to the unknown factors that may influence their answers, and to their angst about how the researcher characterizes their contributions. When I returned the data analysis to the study participants, most indicated that it had been utilized accurately and appropriately. However, there were a few who had very real and compelling 160  concerns about how I had characterized their contributions, even though they agreed that the data was accurate as it was quoted. Some had not expected that I would use certain comments, as their interpretation of the study questions had assumed a narrower focus. Some revealed that the interview was an opportunity for them to explore their memory and reflect on the events that transpired, yet when they saw their words in print, they became concerned about the possible impact of revealing certain information and perspectives. It was necessary for me to offer reassurance about my commitment to the parameters within the Consent Form and to prove that commitment by editing and re-editing the content of the analysis until they were comfortable with it. That did take a lot of time and a lot of patience, but it was very clear to me that my first obligation was to my participants. As well, this experience impressed upon me once again the importance of offering participants the opportunity to approve how their information is interpreted and utilized.  Suggestions for a Future Approach to Education about Major Public Policy Change Upon reflection on these findings along with the literature that describes policy implementation strategies and the literature that describes the planning process for adult education, a number of insights arise about considerations during the negotiation phase of planning for education related to legislative implementation. In the case of this health policy implementation effort, addressing the purpose, content, audience and format of the education program should have included consideration of several contextual issues.  The Policy Change Itself The uniqueness and complexity of this legislative change should give rise to special considerations for education. With four interlocking and individual Acts, the legislation is best understood as a package rather than in separate pieces. Added to the complexity of the legislation is the reality that it has a significant impact on the habits, routines, and power of professional health care providers. The procedures for determining capability, gaining informed 161  consent, and for appointing substitute decision makers are detailed and time consuming and differ from those formerly considered acceptable. Further added to the burden of enhanced complexity is the reduction in power of health care providers, particularly that of physicians. As well, the legislation now demands that health care providers adhere to the wishes of their patients, wishes that may be expressed in advance and in a variety of formats. Given that these changes have a major impact on the professional health care provider context and may even offer new challenges to their professional values, acceptance and support of these key stakeholders is critical to the success of the legislation. Without such acceptance and support, the interi of the legislation may not be realized and front line resistance can lead to reduced compliance and even to failure. Added to all of these complexities is the likelihood that legislation involving so much change and so much controversy will be subject to ongoing revision, giving rise to the need for health care providers to remain flexible and responsive to those changes. The Stakeholders  (Learners)  In response to such complex legislation, educative efforts must be directed to a very broad audience consisting of many thousands of stakeholders. It is critical that the legal profession understands the legislation so that they can guide and support the public as well as professional health care providers in carrying out the intent. The public must learn about the legislation so that citizens can advocate for their rights and for the rights of others. Home caregivers, both family and employees, must understand the legislation and how it impacts the vulnerable population. And of course, professional health care providers must be involved in planning for who needs to be educated and how best to achieve that goal. Consideration must be given to the categories of health care providers affected, to their status, and to the power and hierarchical issues inherent in the health care field. As described earlier, it is critical that those offering education are seen as credible by the learners. It is just as critical that those receiving the education understand both the intent and the content of the legislation. The literature shows that 162  the best way to achieve such congruency is through a bottom-up approach to legislative development and implementation. However, this approach must utilize participants who are truly representative of their professional group so that the membership is actively engaged in the process and so that they have the opportunity to table their concerns and have them addressed.  The Educative Process Planning for the educative process should be coordinated so that leaders are in touch with representatives who are familiar with the legislation as well as those who are familiar with the professional health care provider issues that relate to the legislation. It is crucial that these planners determine the critical mass that needs to be educated in order to raise the general level of awareness. This determination could be made during the evaluative phase of a previous policy implementation effort. Ideally negotiations that determine the purpose, content, audience, and format would occur in such a manner that the interests of all stakeholders are represented. Government must be prepared to allocate funding for the whole of the policy cycle, inclusive of development, implementation, and evaluation of implementation success as well as ongoing support of education when policy is revised. It is important that health profession organizations are supported in their educative efforts and this support should include the provision of printed materials whose quality, readability, and availability meets standards as indicated by representatives of those health professionals. These materials should be available on the Internet as well as in hard copy. It is critical that the educative mandates of professional organizations be clarified and that those mandates are understood by government and by professional health care providers. Any process for maintaining ongoing competency of professional health care providers should be broadened in scope to include measures that are sensitive to legislative change.  163  Larger Social-Political-Economic Context Contemplation of legislation that will change the rights and responsibilities of care recipients and professional health care providers must be reflected against societal trends and it must be recognized that those trends progress at varying rates within both groups. In the case of this legislation, the rights of care recipients to be self-governing were recognized and honoured. However, the agency of professional health care providers was altered significantly and, in many ways, their responsibilities were extended. These changes occurred parallel to a major upheaval in the organization of the health care delivery system, during which many health care providers were reassigned to different roles and responsibilities within their organizations. Organizational boundaries changed more than once, as did organizational charts and lines of responsibility. Within this shifting and evolving system, facilitators were expected to educate others across the care provider hierarchy. The current state and potential impact of the larger social-political-economic context must be considered in the process of planning education about changing legislation.  Assessment of Outcomes It is critical that educative efforts be evaluated so that the success of policy can be assessed and so that future educative efforts can benefit from what is learned about outcomes. Such assessment should consider the response of stakeholders both in the professional and public arenas. Changes in frontline policy and procedure can be tracked and reflected against intent and content of the legislation. And of course, the knowledge of professional health care providers can be assessed. It would be important to seek feedback from care providers about the source of their information so that connections can be made to specific educative efforts. Implications for my Work as a Nurse Educator As described in Chapter I of this document, health law and ethics have always been central to my research and teaching interests. As a result of this research project,! am further 164  convinced of the compelling need to educate students in the health professions about the law and about the ethical implications of understanding and applying the law, both for the protection of client rights and the protection of health care provider rights. But just as important is our influence on students to maintain and continually update their knowledge of health care legislation and to lobby for access to legislative development and information through their professional organizations. As nurse educators, we are preparing our students to be social and political activists. What better example can we use than this? The responsible and accountable professional health care provider would want to adhere to the law and also to use earned professional expertise to influence the law in the interest of both clients and health care providers. Since beginning this research project, and whenever I have the opportunity to speak to groups of nurses, I have increased my emphasis on new health care legislation and on the importance of staying up to date with health law. One of my professional goals is to continue to seek opportunities to spread the word about health legislation among all levels of affected professional health care providers. As well, I look forward to publishing the findings of this research project. Health professions need to start thinking more about ongoing/continuing education. What can be expected; what is expected; what is occurring; how can this be assessed; what constitutes accountability? I will continue to ask these questions through the dissemination of my research. It is also my goal to become more directly involved with my own health professional organization, the Registered Nurses Association of British Columbia - soon to become the College of Nurses of British Columbia. My goal there will be to foster a program that demands ongoing accountability of registered nurses in maintaining currency of their understanding of legal practice expectations.  165  And last, but certainly not least, the community service element of my work as an educator will be met in part through offering public information sessions about the full adult guardianship legislation package. I firmly believe that all citizens should know their rights in making choices about health care and that making choices in advance can ensure that their wishes and values will be respected under all circumstances. A society cultivates whatever is honoured there. It is important for us to know what we honour. (Plato)  166  APPENDIX A: EXCERPTS F R O M "HOW C A N W E HELP?"  THE JOINT WORKING COMMITTEE  MEMBERS:  Mr. Al Etmanski Executive Director, Planned Lifetime Advocacy Network  Mr. Gerrit Clements Special Health Law Consultant Ministry of Health  Dr. Robert.Gordon Associate Professor Simon Fraser University  Dr. Garry Curtis Executive Director, Policy, Planning and Legislation Division Ministry of Health  Ms. Pearl McKenzie Executive Director, North Shore Community Services  Ms. Myrna Hall Public Trustee  SECRETARIAT:  Ms. Chloe Lapp Project Director, Project to Review Adult Guardianship  -Mr. Mark G . Perry Policy Analyst, Office of the Public Trustee  168  PROJECT TO REVIEW ADULT GUARDIANSHIP CHAIRS Dr. Stephen Kline, Chair Mr. Jim Pozer, Vice Chair PROJECT TO REVIEW ADULT GUARDIANSHIP WORKING GROUP CHAIRS Ms. Jo Dickey, Personal Supports Mr. Al Etmanski, Co-Chair, Personal Supports Mr. Hugh McLellan, Future Planning Mr. Greg Steele, Court Processes Dr. Allan Posthuma, Capacity and Needs Mr. Al Etmanski, Co-Chair, Capacity and Needs Ms. Pearl McKenzie, Assistance and Advocacy Ms. Pearl McKenzie, Abuse, Neglect and Self-Neglect Mr. Bill Trott, Co-Chair, Consent to Health Care Mr. Darren Kopetsky, Co-Chair, Consent to Health Care PROJECT TO REVIEW ADULT GUARDIANSHIP TASK GROUP CHAIRS Dr. Robert Gordon, Chair, Ad ministration Task Group Ms. Wendy Baker, Co-Chair, Issues and Strategy Task Group Ms. Kathy Hamilton* Co-C^airi Issues and Strategy Task Group Ms. Jane Holland. Chair, Education & Research Task Group  Ms. Myrna Hall, Chair Public Trustee Mr. ^drew3utlei;, Director, Cohtiriuin^.C^rj; Division, Miiiiitry of Health Mr. Gerrit pemen|5, .Special Health Law Cdnsultant, Mirustry of Heaftfv Dr. Garry >jCiutt»s; Executive Direetor, Policy, Planning and Lt:gislaUprL Ministry of''Health' Ms. Pat Giichrist, Regional Director, Alcohol and TJmg Proparris, Ministry of Health Ms. Paula Grant* Regional Director, Community Support Services Division, Ministry of Social Services ...... f^Joha the Elderly, Mental Health Services, Ministry offMealth Ms. Juhe:;Lake;f, Deputy Public Trustee Dr. Jacquelyn Nelson, Policy Analyst, Ministry of Attorney General Mr. Mack Perry, Policy Analyst, Office 6f the Public Trustee Ms. Ami Rate!, Policy Amlyst^jM  169  Dr. Diane Rothnn, Director, Health Services, B.C. Corrections, Ministry of Attorney General Ms. Zena Simces Katz, Director, Policy; Planning and Communications, Office of the Public Trustee Mr. Glen Timbers, Director, Community Care Facilities Branch  RESEARCH OFFICERS  Ms. Barbara Lindsay, Project to Review Adult Guardianship Dr. Jacquelyn Nelson, Ministry of Attorney General Ms. Ann Ratel, Ministry of Attorney General ADMINISTRATIVE STAFF Kelly Weilbacher, Project to Review Adult Guardianship . Yukari Okuma, Office of the Public Trustee Mary Sue, Office of the Public Trustee  APPENDIX B: F L O W CHARTS F R O M A PRIMER T O BRITISH COLUMBIA'S NEW H E A L T H C A R E CONSENT LEGISLATION  172  APPENDIX II: CONSENT IN URGENT* OR* EMERGENCY HEALtH CARE SITUATIONS^ r Health care* required, without delay, to „ - preserve life or :*preventsenousphysical/mental hamkorw/ - alleviate severe pain UJ  I  Is 12(D(a))  Adult capable-  H C P B forms opinion  re: adult's. •• capability/incapability  hudllli care decision followed  'Adult incapable due to ••• - impairment by drugs/alcohol • - unconsaousness/semi-consaousness for any reason T  • or otherwise incapable ls.12(1)(b))  If possible, HCP checks for existence/availability of representative or court-appointed committee of person GO  ra  If representative/committee is available »follow that person's decision J f|tw|p>*a  [s 1Z(1)(Q] If not available  i:tf possible/practicable, HCP obtains second opinion from another HCP re: need for •< • health care and adult's incapability  S aeecnd cjAte sifeSrwsi is «SfW«. V to matefiwiteikiMtojjwicfc«,  l'»*«i^alW«^^^^iwmi«!«iW  PKwtyAa  1*  173  A P P E N D I X II: C O N S E N T IN MAJOR HEALTH C A R E * F O R I N C A P A B L E A D U L T S (ss,l4»nd 18} H C P " proposes rna)or health carejTl  C  T  ls.6(aMl Adult capable •  HCP forms opinion capability/incapability  is mm Adult incapable  3  ' Confirm whether representative. ^or committee or" person exists^ |i :  ;  f  >  f  ^  f i ) — • ( adult's decision followed J  (If representative/committee' T. 'Jisavailable:- .'•.: tollrjwthatperaon's decision; ;  Is U(lHe)(t>H<Dl  Is 111  none exists or is not available iCP determines winch family tmberis avaiJableiand qualifies to be chosen as TSDM*"  :  ts.16(t)mi tf TSDM unavailable or unqualified, request Public Guaidian and Trustee*™ to authorize a TSDM,  HCPchoosesiaiTSDM, Dr: ls.16(1)(2)J  is.imi : TSDM makes decision 1S.19J  *-  • .:r  • *  ! - r ^ s to i t a w s ! rov*w w**iin «*? tiar**""""  Q  J.  i (tj^witaic2i_«F^i  5———a—  i  *«}*;» 72 nwtts •  ,  ,  &iaHf*>eferon  „  s  %  | J  hec*thi»flt,' , •raiptovttttS " Heat*  •' \4| .  *vsWtsaita C a n Fiwa»r(>fis«r}9 t^:axmrisBieegtS>atiAet,i» *»sr» m «<t*) i¥«w»,mUtat ef in&x> or *S» SMssw.HesgiCmw«#MrJ*!:ffra« and >*»^:i^.aB^fv3j?^eaw;i: > &«tuMf ta*Ktt4 tirn>s«S5.*ai tc PKJVK/B c««5 arty *f&ev jwsss> ««*s-- f<«s « * » » t i lo/utirnktm V/JH.nfcftr, ps^/.Si«f^or.«^,:«enya(5(>:s tmSt: am ar.rf & *<oai*«<¥*> ,, -' oisa «Ja*eo" »y oraasp&n to (J» ai*i9 or potman a « s a « * » * * « l tr A*. A r M ) .SMrttat* Md.<7«MeM Xixi-j:ts t.,s5ar«ttV topaSS, i  1  i  ftrtifc Gumttn TivsSmi > K * AI GxiuBtartininbati. TH>arti, oVtiuHo Batfe«»tV S m s w r ^^tixj aw« f-«?r-i»VMt ? i ?fte iioars af srwtee Stefidw io Fmtoy, fH» a ns. • A £0 P L « fc/»/%*• -VL-.  *T 3.-I'Kfi "  Sara iB .-1 r£v"> c il r, . /I ^ / • j y  1i  i  3 fists" to 4a  CTDaKtito.  174  APPENDIX C: LETTER AND QUESTIONS MINISTRY OF HEALTH EMPLOYEE  Dear Ministry of Health Employee: My name is Carol McFadyen. I am writing to ask you to participate in a research project titled "Policy into Action: A Case Study of the Educative Efforts associated with the Implementation of new Health Care Legislation in British Columbia". This study is both descriptive and analytic. The purpose is to understand: o  The role of education in public policy implementation.  o  The challenges associated with educating professional care providers about new legislation.  o  The study will describe what happened in the implementation phase of new health legislation in BC. Research questions include:  o  What did the government do to educate professional care providers?  o  What did the professional associations do to educate the professional health cafe providers?  o  What can we learn from what the government and each of the professional organizations did in response to this legislation?  I am an Associate Professor of Nursing at Okanagan University College and a Doctoral student at University of British Columbia. For many years my area of scholarly and teaching interest has been health law and ethics. I have completed all of the courses for the doctoral degree and this research project is the final step in the program. This research project will culminate in a written thesis and possibly will generate some scholarly journal articles. At your convenience, might I meet with you for approximately 1 A hours, first to chat l  about the project and then to interview you about your involvement in educating health care providers? I enclose a list of the kinds of questions that I would like to ask, to help clarify my purpose. I must emphasize however that this is a qualitative research project and therefore we need not feel limited to address each of these questions exactly as they are written. I anticipate 176  Policy into Practice Interview Guideline: Ministry of Health Employees 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.  Please describe how you were assigned the mandate of educating health care providers about the new health legislation. At that time, what was your perspective about the major issues that professional health care providers needed to understand in relation to the new legislation? Please tell me about any other educative initiatives relative to this legislation that you were aware of in the province. What is your view about best practice for professional health care providers in keeping current regarding health legislation changes? Please describe the Ministry's education initiative for this legislation. What were your goals in that educative effort? What were you seeking to accomplish? Did you provide any documents or other forms of educative materials for the use of your audience? Would you be willing to provide me with copies of those? What resources did you have to help you plan the methodology and carry out this education initiative? Please describe the facilitator training sessions. How did you ensure that as many care providers as possible received information about the new legislation? Did you have any concerns about this project? If so, would you please elaborate? What is your perspective on the success of the educative initiative that you were involved in? Please explain. What observations did you make about the facilitators that you trained? If you were to be involved in future educative initiatives relative to health legislation changes, would you approach the situation any differently? Do you have any other comments or suggestions about continuing education of professional health care providers relative to legislative change? What do you think is the relationship between education and the success of health policy? Roles,goals,limits?  179  APPENDIX D: LETTER AND QUESTIONS PUBLIC GUARDIAN AND TRUSTEE OFFICE EMPLOYEE  Dear Public Guardian and Trustee Office Employee: My name is Carol McFadyen. I am writing to ask you to participate in a research project titled "Policy into Action: A Case Study of the Educative Efforts associated with the Implementation of new Health Care Legislation in British Columbia". This study is both descriptive and analytic. The purpose is to understand: o  The role of education in public policy implementation.  o  The challenges associated with educating professional care providers about new legislation.  o  The study will describe what happened in the implementation phase of new health legislation in BC. Research questions include:  o  What did the government do to educate professional care providers?  o  What did the professional associations do to educate the professional care providers?  o  What can we leam from what the government and each of the professional organizations did in response to this legislation?  I am an Associate Professor of Nursing at Okanagan University College and a Doctoral student at University of British Columbia. For many years my area of scholarly and teaching interest has been health law and ethics. I have completed all of the courses for the doctoral degree and this research project is the final step in the program. This research project will culminate in a written thesis and possibly will generate some scholarly journal articles. At your convenience, might I meet with you for approximately 11/2 hours, first to chat about the project and then to interview you about your involvement in educating members of the community? I enclose a list of the kinds of questions that I would like to ask, to help clarify my purpose. I must emphasize however that this is'a qualitative research project and therefore we need not feel limited to address each of these questions exactly as they are written. I anticipate 181  Policy into Action Interview Guideline: Public Guardian and Trustee Office Employee 1. Please tell me your perspective on the importance of public education regarding health legislation changes. 2. Please describe how you were assigned the mandate of educating members of the community about the new health legislation. 3. What was your view at that time about the major issues that professional health care providers needed to understand in relation to the new legislation? 4. Please tell me about any other educative initiatives relative to this legislation that you were aware of in the province. 5. What were your goals in that educative effort? W h were you seeking to accomplish? 6. Did you provide any documents or other forms of educative materials for the use of your audience? Would you be willing to provide me with copies of those? 7. What resources did you access to help plan the methodology and carry out this education initiative? 8. Please describe the community education sessions. 9. How did you ensure that as many members of the public as possible received information about the new legislation? 10. Were there any professional health care providers in attendance at your sessions? If so, do you know how many? Were they specifically invited or did they attend as members of the public? 11. Did you have any concerns about this project? If so, would you please elaborate? 12. What is your perspective on the success of the educative initiative that you were involved in? Please explain. 13. If you were to be involved in future educative initiatives relative to health legislation changes, would you approach the situation any differently? 14. Do you have any other comments or suggestions about education relative to legislative change? 15. What do you think is the relationship between education and the success of health policy? Roles, goals, limits? at  184  APPENDIX E: LETTER AND QUESTIONS: PROFESSIONAL ASSOCIATION EDUCATOR  Dear Professional Association Educator: My name is Carol McFadyen. I am writing to ask you to participate in a research project titled "Policy into Action: A Case Study of the Educative Efforts associated with the Implementation of new Health Care Legislation in British Columbia". This study is both descriptive and analytic. The purpose is to understand: o  The role of education in public policy implementation.  o  The challenges associated with educating professional care providers about new legislation.  o  The study will describe what happened in the implementation phase of new health legislation in BC. Research questions include:  o  What did the government do to educate professional care providers?  o  What did the professional associations do to educate the professional care providers?  o  What can we learn from what the government and each of the professional organizations did in response to this legislation?  I am an Associate Professor of Nursing at Okanagan University College and a Doctoral student at University of British Columbia. For many years my area of scholarly and teaching interest has been health law and ethics. I have completed all of the courses for the doctoral degree and this research project is the final step in the program. This research project will culminate in a written thesis and possibly will generate some scholarly journal articles. At your convenience, might I meet with you for approximately 1 !/2 hours, first to chat about the project and then to interview you? I enclose a list of the kinds of questions that I would like to ask, to help clarify my purpose. I must emphasize however that this is a qualitative research project and therefore we need not feel limited to address each of these questions exactly as they are written. I anticipate that, with your greater knowledge of professional continuing 186  Policy into Action Interview Guideline: Professional Association Educator 1. The new Health Care Consent and related Acts legislation was implemented in February of 2000. When legislative changes are pending or occurring, how do you and your Professional Association know about them? 2. What is your source of information about new legislation? 3. As far as you know, was any member of your Association involved or influential in the drafting of this legislation? 4. What was your view at that time about the major issues that professional health care providers needed to understand in relation to the new legislation? 5. Does you mandate as a Professional Association include helping members to maintain currency about health care legislation that may affect them? 6. Please tell me about any educative initiatives relative to this legislation that you were aware of in the province. 7. What is your view about the obligation of professional health care providers to keep current regarding health legislation changes? 8. Was your Association involved in launching any educative initiative about the new legislation for the members of your Association? If so, would you please describe that initiative to me? 9. What were your goals in that educative effort? What were you seeking to accomplish? 10. Did your Association provide any documents or other forms of educative materials for the use of your members? Would you be willing to provide me with copies of those? 11. What resources were you able to access from outside your professional association to help you in educating your members? 12. How did you ensure that as many of your members as possible received information about the new legislation? 13. What is your perspective on the success of any educative initiative that your association launched? Please explain. 14. If you were to be involved in future educative initiatives relative to health legislation changes, would you approach the situation any differently? 15. What do you think about the role of Professional Associations when new legislation is brought into play? 16. Do you have any other comments or suggestions about continuing education of professional health care providers relative to legislative change? 17. What do you think is the relationship between education and the success of health policy? Roles, goals, limits?  189  APPENDIX F: CONSENT F O R M  APPENDIX G: A C R O N Y M S  Acronyms Found in this Document A G A Adult Guardianship Act BCASW British Columbia Association of Social Workers BCCPS British Columbia College of Physicians and Surgeons BCSOT British Columbia Society of Occupational Therapists BRSW Board of Regulation of Social Work CDHBC College of Dental Hygienists of British Columbia CLPNBC College of Licensed Practical Nurses of British Columbia C O T B C College of Occupational Therapists of British Columbia CPTBC College of Physical Therapists of British Columbia H A B C Health Association of British Columbia H C C A Health Care Consent Act HPAA Health Professions Amendment Act L P N A B C Licensed Practical Nurses Association of British Columbia PABC Physiotherapy Association of British Columbia PGT Public Guardian Trustee R A R C Representation Agreement Resource Centre R N A B C Registered Nurses Association of British Columbia  APPENDIX H : DOCUMENTS REVIEWED  Documents Reviewed: Public Guardian and Trustee Office o  Adult Guardianship Legislation: Selective Proclamation Highlights. June 29, 1999.  o  Health Care (Consent) and Care Facility (Admission) Act RSBC 1996 Chapter 181 As Amended, Printed June, 1999.  o  The Representation Agreement: A brief guide. October 1999.  o  Community Response Network (under the auspices of Kelowna Community Resources and the Crisis Line). Last printed 05/05/04  o  A Guide for Developing Protocols: Community Protocols, Interagency Protocols, Agency Protocols (Draft, February 4, 2003)  o  Information for Financial Institutions on the Adult Guardianship Act: Part 3 Support and Assistance for Abused and Neglected Adults, March 7, 2001, www.trustee.bc.ca  o  Designated Agencies and Police Working Together - A Provincial Policy Framework Related to the Adult Guardianship Act, Part 3 Support and Assistance for Abused and Neglected Adults, Working Document, April 18, 2002  o  Financial Inquiries by a Designated Agency and Investigations by the Public Guardian and Trustee, Adult Guardianship Act, Part 3 Support and Assistance for Abused and Neglected Adults, July 24, 2001.  o  Protocols to Guide a Coordinated Community Response: Everyone Has a Role to Play, no date.  o  Designated Agencies and Police Working Together - Inter-Agency Protocols Related to the Adult Guardianship Act, Part 3, June 13, 2002.  o  Protocol Development Template: What might Protocols Contain? 197  o  The CRN Tool Kit: Building Community Capacity to Respond to Adult Abuse, Neglect & Self-Neglect in BC, Fall 2001.  o  Who We Are: Public Guardian and Trustee of British Columbia, January 2000.  o  Update from the Adult Guardianship Implementation Project - April, 2000, www.trustee.bc.ca  o  It's Your Choice: A Guide to making a Representation Agreement, September 2000.  o  BC's New Adult Guardianship Laws: Supporting Self-Determination for Adults in British Columbia: Planning for Your Future; So You've Been Asked to be a Representative or Monitor; Consent to Health Care; Substitute consent to Health Care; Being a Temporary Substitute Decision-Maker Under the Health Care (Consent) and Care Facility (Admission) Act; Health Care and Care Facility Review Board: Providing Safeguards; Protecting Adults from Abuse, Neglect, and Self-Neglect; Support and Assistance for Abused and Neglected Adults, www.trustee.bc.ca  o  Adult Guardianship Act Part 3 Support and Assistance for Abused and Neglected Adults: A Guide for Communities, Revised January, 2001.  o  Ministry of Attorney General Information Bulletin: Report on Legal Planning Tools Released, March 12, 2002  o  Representation Agreement Act RSBC Chapter 405 As Amended, Printed May 10, 2002 from www.trustee.bc.ca  o  Plan Now to Protect Your Future, October 2001.  o  How You Can Help People Manage Finances and Legal Matters when They Cannot Manage on Their Own, October 2001.  198  The Representation Agreement Resource Centre: o  Health Care Decisions: Your Rights and the New Law, February 2001.  o  An Update on Representation Agreements, April 2001.  o  RARC Fact Sheet, December 2001.  o  News Update, March, 2002, www.rarc.ca  Other Resources: Community Coalition for the Implementation of Adult Guardianship (Fall, 1995). Guardianship news. Vancouver, BC: The Notary Foundation. The Peoples' Law School (October, 2001). Power ofAttorney, www.publiclegal.bc.ca The Kelowna Daily Courier (December, 2000). Abuse of seniors targeted. Birrell, M. (April, 2000). Vision comes to fruition The Scrivener, 9(1), p. 10. Hardy, G. M. (April, 2000). Public legal education at the grass-roots level. The Scrivener, 9(1), pp. 12-13. Etmanski, A. (April, 2000). Legislation befitting a new millennium. The Scrivener, 9(1), pp. 1517. Taylor, J. (April, 2000). Representation Agreement Resource Centre. The Scrivener, 9(1), pp. 18-19. Gordon, C. (April, 2000). The promise of Representation Agreements. The Scrivener, 9(1), p. 20. Wilson, V. (April, 2000). Representation Agreements are for everyone! The Scrivener, 9(1), pp. 22-28. Stewart, D. (April, 2000). The rocky road to a Representation Agreement. The Scrivener, 9(1), pp. 34-35. Sue, M., Leaney, A., & Derkach, L.(April, 2000). February 28, 2000: Day one of BC's New Adult Guardianship legislation. The Scrivener, 9(1), pp. 37-38.  199  Todd, T. (April, 2000). Representation Agreement overview. The Scrivener, 9(1), pp. 39-47. Sloan, J. (April, 2000). The issue of capacity. The Scrivener, 9(1), p. 48. Donnelly, M. (April, 2000). Viewpoint: Health care professionals: Benefits and concerns. The Scrivener, 9(1), p. 49. Paul, G. (April, 2000). Viewpoint: Clinical Social Worker: Acting properly is easier with a Representation Agreement in place. The Scrivener, 9(1), p. 50. Beddows, D., & Fulton, P. (April, 2000). If I were asked to be the Representative or a Monitor, would I agree? The Scrivener, 9(1), P. 51. The Ministry of Health: New legislation for consent to care. Summer, 2000. The Medical Services Plan for Medical Practitioners. The Ministry for Children and Families Child Protection Division (October, 1999). Practice guidelines for managing critical health care decisions including advance health care directives.  200  APPENDIX I: PROFESSIONAL ORGANIZATION STANDARDS/MANDATES  201  Professional Organization Standards/Mandates: o  Registered Nurses Association ofBC: •  Standard I: Responsibility and Accountability •  o  College of Dental Hygienists ofBC: •  Practice Standards: •  •  Dental hygienists must obtain informed consent from the client or the client's representative before providing any services, by physical indication or verbal statement, following applicable laws. (See the following policies in Tab 7:- Informed Refusal to Consent, Consent of Minors to Treatment, and the summary of BC's New Adult Guardianship Laws). (CDHBC website http://www.cdhbc.bc.ca/) (The reader is provided a link to BC's New Adult Guardianship Laws)  Board of Registered Social Workers ofBritish Columbia: •  Standards of Practice Handbook: •  o  1. A dental hygienist must obtain informed consent from the client or the client's representative before initiating dental hygiene care.  Policy: •  o  Functions within the legally recognized scope of practice of nursing and within all relevant legislation. (Pub. 128, 2003, p. 6).  Social Workers maintain current knowledge of policies, legislation, programs and issues related to the community, its institutions and services in their areas of practice, (http://www.brswbc.bc.ca/)  College ofPhysicians and Surgeons ofBritish Columbia: •  Code of Ethics: •  The Code is an ethical document. Its sources are the traditional codes of medical ethics such as the Hippocratic Oath as well as developments in human rights and recent bioethical discussion. Legislation and court decisions may also influence medical ethics. Physicians should be aware of the legal and regulatory requirements for medical practice in their jurisdiction. 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