Incompetence in practice in health care in the Netherlands: report of a study.
Dutch health staff rarely agree on who with ID is competent—so BCBAs must supply clear, behavior-based evidence in each file.
01Research in Context
What this study did
Hatton et al. (1999) asked Dutch health workers to judge if adults with intellectual disability could make everyday decisions.
The team mailed short case stories to doctors, nurses, and care staff. Each reader marked the client as fully, partly, or not competent.
No rules or checklists were given. The survey simply counted how often two raters agreed.
What they found
Agreement was poor. Two raters matched on fewer than half of the cases.
Some staff called the same client fully able while others called the same client unable.
The authors concluded that without shared criteria, competence rulings are basically guesswork.
How this fits with other research
Heutmekers et al. (2016) later showed the same problem after hours. Emergency nurses and ID staff still gave conflicting answers about who could consent to treatment.
Nevin et al. (2005) found UK practice nurses felt confident yet lacked ID training. Together the three surveys paint one picture: staff trust their gut, but guts differ.
English et al. (2020) scoping review adds the client view. Only two of ten end-of-life studies even asked the person with ID. When assessors disagree and clients are silent, decisions still happen—just without clear input from anyone.
Why it matters
If you write behavior plans that require client consent, know that medical and social-service teams may already disagree on whether your client can give it. Push for written criteria—checklists, task analyses, or supported-decision steps—before you accept a outside ruling of incompetence. Your data on client performance can become part of the file that future assessors read.
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02At a glance
03Original abstract
Recent health legislation in the Netherlands makes specific provisions for patients who are not (fully) capable of acting reasonably in their own interests. If this legislation is actually to improve the legal position of incompetent people, it must be clear to whom these provisions apply. The description in modern legislation is that the person 'is regarded as not being able to make a reasonable assessment of his interests in the issue in question'. The law does not provide criteria according to which competence can be assessed in practice. In the present study, data on the competence assessment of 133 clients were collected by means of a poll held among those people who decide on competence in practice and a total of 485 assessors were polled. Client files were also examined with the intention of gaining insight into the carers' motivation to involve or exclude clients from the decision-making process. Finally, interviews were conducted with clients who have a mild or moderate intellectual disability. Large differences appeared to exist between the various assessors in the assessment of the general competence of clients. A general assessment of a client's competence is not sufficient in daily practice; therefore, partial competence was also assessed. Opinions about the partial competence of clients varied considerably among assessors. A ranking was compiled of discriminating characteristics in the qualification of competence or incompetence.
Journal of intellectual disability research : JIDR, 1999 · doi:10.1046/j.1365-2788.1999.00235.x