When the minister of health and the minister of mental health and addictions recently announced it had amended B.C.’s Mental Health Act to create a new pathway that allows nurse practitioners to certify involuntary admission and detention, we became concerned.
As nurses working in mental health and substance use, we have been paying close attention to the NDP government's response to the drug poisoning crisis — a crisis responsible for the death of close to 12,000 people in B.C. since 2016.
Central to the NDP’s current response is a commitment to enacting legislative amendments and introducing policies to involuntarily admit and detain people who use substances under B.C.’s Mental Health Act.
This commitment remains despite the appointment of David Eby — a civil-rights lawyer — as the province’s premier, as well as strong opposition from researchers, Indigenous leaders, nurses, advocates in the fields of mental health and substance use, people and families with lived and living experience, B.C.'s Representative for Children and Youth, and B.C.'s chief coroner to a first bill — Bill 22 — focusing on youth who use substances.
The number of people admitted and detained against their will under B.C.’s Mental Health Act has been steeply rising in B.C., reaching 20,000 in 2020 alone. Moreover, B.C. does not currently report the number of people who are certified under the Mental Health Act due to their use of substances.
A recently released position statement by Pivot Legal Society notes that this practice exists and warns of its expansion in the current political context. This echoes findings of a recent study, which found that substance use accounted for the greatest increase in involuntary hospitalizations in B.C. between 2008 and 2018. As the authors of this study note, “increasing admissions for substance use is concerning given the absence of treatment guidelines and legal frameworks surrounding involuntary treatment of substance use in B.C., and the limited evidence of the benefits of involuntary care for substance use.”
We agree with those who immediately raised doubts about the framing of this new nursing pathway as a solution to address emergency room wait times and delays in accessing mental health care.
We are also alarmed by the NDP’s persistent framing and normalizing of involuntary hospitalization as a “needed response” to the mental health crisis and, increasingly, to the drug poisoning crisis.
As Health Minister Adrian Dix pointed out in the news release announcing the new pathway, “Nurse practitioners are critical to our health-care system, particularly for the delivery of care to rural and Indigenous communities, seniors and people requiring mental-health and addictions care.”
Tasking nurse practitioners who most often work in primary care settings with admitting and detaining patients against their will and without adequate community-based services for voluntary care before admission and after discharge from hospital raises serious ethical implications. This is because involuntary hospitalization can cause significant health harms (e.g. increased overdose risks) and social harms (e.g. loss or housing and employment).
These harms, which disproportionally affect people who experience systemic racism and colonial violence in health care, can be further amplified by rights violations, the breakdown of trust and therapeutic relationships, and subsequent care avoidance. Available evidence also points to the ineffectiveness and inappropriateness of involuntary care for people who use substances.
Practicing at full scope and with sufficient resources, nurse practitioners can have a critical role in scaling up and supporting low-barrier and voluntary mental health and substance use care, including safe supply prescribing. As primary care providers, nurse practitioners are well positioned to fill long-standing service gaps by providing health-care services and programs that are person-centred, trauma-informed, culturally safe and rights-based. They can also contribute to improving population-level mental health by engaging in prevention, early intervention and mental health promotion.
As noted by the Nurses and Nurse Practitioners of British Columbia in their position statement on involuntary and coercive psychiatric treatment: “A lack of sufficient voluntary, prevention-based community services, including structural factors (such as the degradation of the social safety net and inadequate access to safe and secure housing) have contributed to an increased reliance on involuntary psychiatric treatment and emergency services/law enforcement.
"Strengthening and integrating accessible, preventative community mental health services is an urgent nursing priority. Similarly, strengthening the social safety net and addressing core housing needs is mandatory to help prevent mental and physical deterioration and support health and well-being.”
Nurse practitioners, and nurses more generally, are essential, highly skilled members of the health-care workforce. There are ample opportunities to leverage nursing roles in expanding mental health and substance use care, yet we must ensure that nurses’ work in this context is being used for good, not harm.
We urge elected officials, policymakers and nurse practitioners to approach B.C.’s expanded pathway to involuntary hospitalization with caution, and to continue focusing on addressing long-standing gaps in voluntary and equity-informed approaches that meet people where they are at.