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Exploring Community Treatment Orders: An Institutional Ethnographic Study Open Access


Other title
Type of item
Degree grantor
University of Alberta
Author or creator
Snow, Nicole
Supervisor and department
Dr. Janet Rankin, Nursing, University of Calgary
Professor Gerald Robertson, Law, University of Alberta
Dr. Wendy Austin, Nursing, University of Alberta
Examining committee member and department
Dr. Gerri Lasiuk, Nursing, University of Alberta
Dr. Derek Truscott, Psychology, University of Alberta
Dr. Peter Bartlett, Law, University of Nottingham
Faculty of Nursing

Date accepted
Graduation date
Doctor of Philosophy
Degree level
Community Treatment Orders (CTOs) involve mandated community treatment for individuals with severe, persistent mental disorders. The use of CTO legislation in Newfoundland and Labrador (NL), Canada is explored in this study through institutional ethnography (IE). This method is used by researchers seeking to elucidate everyday life experiences that occur within an institution. According to IE, the everyday work of individuals is coordinated and organized by social structures and discourses known as ruling relations that are inherent within an institution. These ruling relations exist often without our overt knowledge or awareness. One of the main findings in this study is that CTOs are socially organized to focus on legal issues of public safety and accountability. Worries about the possible risks to the public of severe, persistent mental illness supersede the therapeutic implications of the CTO. While health professionals’ activation of the CTO proceeds as though it is focused on treatment and recovery, the therapeutic interests are subordinate to the politico-legal interests of government. Informants in this study included family members, nurses and other healthcare team staff, managers, bureaucrats, and legal experts who had experience with CTOs. Data were collected through interviews and document review and examined for evidence of the social web of practices (ruling relations). The actual process of using the CTO legislation was mapped, highlighting the many points at which decisions were being made based on varying interpretations of the legislation. A number of disjunctures, or moments of incongruousness, were found. What the informants described as actually happening with the use of CTO legislation was sometimes in conflict with what they expected to happen, or with what the legislation identified as “suppose to happen”. Nurses’ professional ideology was also challenged in that nurses’ “therapeutic” actions often resulted in practices organized by the legislation that were at odds with the interests of patients and their families. The results of this study offer important insights about the use of CTOs in NL and should be of considerable interest to nurses and other health professionals, advocacy groups, families, and individuals with mental health concerns. It is hoped that increasing awareness to these social structures and disjunctures will foster a greater understanding of the challenges facing mental health nursing practice.
Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
Citation for previous publication
Snow, N. & Austin, W. J. (2009). Community treatment orders: The ethical balancing act in community mental health. Journal of Psychiatric and Mental Health Nursing, 16, 177-186.

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