Category: Education

How do we teach ethics? Intersectionality, care failure and moral courage

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As a clinician and educator, I have long been interested in how to prepare  nurses for professional practice. Schon uses a metaphor of terrain made up of high, hard ground overlooking a swamp  which Street (1991) has extended to nursing practice. While some clinical problems can be resolved through theory and technique (on hard ground), messy, confusing problems in swampy ground do not have simple solutions, but it is critically important  to practice that they are resolved. One way in which I have attempted to open up and create new collective reflective spaces is through using  forum theatre to facilitate reflection and culturally safe practice.

It is the swampy ground that interests me, where utilitarian, techno-rational solutions are limited. As pressure  increases in under-graduate nursing curricula,  having the time to develop skills and capacities  for negotiating ethical relationships  can be compromised. Simultaneously the concept of  intersectionality, offers an intervention to challenge a reductionist focus on a single axis of difference within a largely white feminist nursing frame. Can  the concept of intersectionality  be integrated  into nursing in ways that are true to the politics that black feminists aspired to?   In this article written with colleagues at Abertay University, Scotland we  begin to examine these issues as part of a larger conversation.

Ion, R., DeSouza, R., Kerin, T., Teaching ethics: Intersectionality, care failure and moral courage, Nurse Education Today (2017), doi:10.1016/j.nedt.2017.12.023

Highlights

  • Provides a critical discussion of ethics teaching arguing that it must recognise frameworks from outside the Anglo-European tradition.
  • Drawing on examples of care failure, racism and sexism, argues that there is evidence that some nurses struggle to practice in accordance with ethical guidance.
  • Identifies intersectionality, the culture of practice and moral courage as fundamental to enabling nurses to practice in accordance with ethical guidance.
  • Presents a case for an approach to applied approach ethics education, which recognises the complexity and diversity of practice.

Introduction

Ethical practice is an unambiguous requirement for nurses and midwives in guidance from across the world (ICN 2012). As a profession characterised by its often intimate involvement with vulnerable others and where matters of life and death and all points in between are at stake, it is right and proper that our respective professional organisations should set out clear expectations for practitioners. In this paper we argue that while an expectation of ethical nursing is commendable, its realisation in the real world is often far from straightforward. In doing this we address three issues. First, we draw attention to some every-day and some less common ethical dilemmas which nurses encounter – we argue that these constitute complex problems, which are further compounded by situational and cultural factors. Second, we expose the reality of unethical practice, arguing that it may be more common than the profession would like to believe. Finally, we consider the role of education in preparing and supporting the nursing and midwifery workforce. We argue for a reinvigorated approach to ethics education, which takes account of the reality of contemporary nursing and recognises the complexity of practice – here we pay particular attention to intersectionality, power, oppression and moral courage. We conclude by presenting some thoughts on how this might be operationalised in curricula.

Every-day and unusual problems.

While some ethical issues may be less common than others, nurses are faced with real world ethical dilemmas on a daily basis. By ethical, we mean decisions about how to engage with others, or respond to situations where action or omission might adversely impact some aspect of another’s experience. Ethical problems do not just involve the interface between nurses, patients, families and communities, but also extend to inter-staff relationships, and relationships between staff and organisations. Examples might include questions about how best to secure the consent of a patient with dementia in order to assist with personal care, to decisions about sharing information with a patient about a poor prognosis, or whistleblowing when faced with care failure. We contend that these negotiations require a complex blend of technical skill, knowledge and sensitivity. It is perhaps easier to see the ethical challenges, which might be raised in the breaking of bad news, or when considering whistleblowing – few would dispute the difficulties associated with these scenarios, but an ethical dimension may be less immediately obvious in the former, but much more frequently encountered case of consent to personal care. With a little examination, however, if we recognise that personal care involves an intimacy, which is defined by multiple factors including age, gender, culture, class, sexuality and previous experience, the issue becomes less opaque. To understand the complexities of providing personal carefully, and to deliver it professionally, requires significant knowledge of all of these areas, as well as the ability to deploy that knowledge, and a concomitantly high level of technical skill. Personal care is not a task, it is an action loaded with significance for both the recipient and the caregiver and is embedded in relationships shaped by social, cultural and historical factors. Similar points might be made about the use of restraint in mental health settings. An instrumental view of this intervention might frame it as a technical skill requiring training in physical procedure and some knowledge of risk. This would be to overlook the huge personal significance that should be attached to the act of preventing a fellow human being from retaining control of their body and movements – action which is a legal expression of power over another, and which in other circumstances would be considered to be a case of assault. Few would argue that this intervention should be used sparingly, but for front line staff it may sometimes be the only option. In these circumstances, while adherence to policy and guidance is critical, the extent to which these can ever address the complexity and sensitivities involved in exerting physical power over another is questionable – in our view action in this context also requires an ability to draw on and apply a deep ethical knowledge.

Similarly, while policy can guide those nurses who provide care for hostile combatants in a military situation, or with prisoners in high security settings, or in the complex and politically charged area of refugee health care in detention centres, its application requires both an understanding of, and an ability to operationalise, ethical thinking. Schon’s (1987) metaphor of the world of professional practice resembling terrain made up of high, hard ground overlooking a swamp is useful here. As, Street (1991) observes, there are some clinical problems that can be resolved through theory and technique (on hard ground), while messy, confusing problems in swampy ground do not have simple solutions, but their resolution is critical to practice.

Evidence of unethical practice.

Given then the importance assigned by the profession to ethical practice and the potential challenges to its realisation in the often messy clinical world, it makes sense to take stock and reflect on the extent to which we can be confident that nurses practice ethically and manage ethical problems with confidence. Evidence of racism, gender discrimination and care failure tell us that this may not always be the case and that we have good reason to be concerned about the ability of some nurses and midwives to practice according to ethical guidance. With regard to racism, DeSouza’s (2014) study of the maternity experiences of Korean new mothers in New Zealand and Mapedzahama’s (2012) study of black African nurses working in Australia shows that racism is experienced both as a care recipient and as a colleague. A similar picture emerges regarding gender diversity. Discussing the situation in the United States and Canada, Kellett and Litton (2016) argue that many educational programmes have failed to grasp this agenda and thereby fail to adequately prepare students for the world of practice.

In relation to care failure, Reader & Gillespie (2013), noted evidence of patient neglect and poor care across a range of settings in Australia, Europe and North America. These included failure to meet essential care needs, and examples of abuse and neglect. We should be concerned about the extent to which those who participate in failures of this type understand the requirement for ethical practice. In addition, a review by Jackson et al. (2014) indicates many of those who witness poor care, make the decision to let it go without censure or sanction. Although this may be understandable in some circumstances, for example, where these is a genuine fear that harm may come to the whistle-blower, inaction of this type is surely not underpinned by a recognisable ethical framework, nor is it in keeping with professional guidance. In light of the above, we contend that, there is reason to believe that some nurses struggle to practice in accordance with professional guidance in this area.

Education and the ethics agenda.

Our focus here is on the role of education in the development and maintenance of ethical practice. However, educational preparation can only play a part in this process. Registrants will spend the great majority of their time in practice and it is therefore imperative that care is taken to ensure that, as far as is possible, the practice environment is one in which doing the ‘right thing’ is always the easier option. Given this, what then can education do?

It is conceivable, although hopefully very unlikely, that some nurses consciously select to behave unethically in spite of a detailed understanding of the field and their responsibilities to patients, carers and colleagues. We consider these individuals to be rogue practitioners who have no place in the profession – the role of education here is to try to identify and screen out such people at the earliest point possible – we accept that while this is desirable the extent to which it is achievable is questionable.

It may be that some others who breach ethical guidance were fully prepared in their undergraduate studies for the challenges they might face, but that time has somehow diluted and dissipated this preparation. If this is the case, then educators need to consider how they might work with students to ensure that learning occurs but, equally importantly, that it is maintained and built upon in the years after registration. It is also possible that initial preparation programmes failed to deliver on the ethics agenda – either through significant omission, or by delivery in a manner, which framed ethics as an abstract subject without a clear practical application. The challenge here is to for educators to deliver ethics teaching in a way which resonates with the reality of practice and which is clearly of practical benefit to students. The principle in these circumstances should be to create an ethics, which empowers nurses to do the right thing, rather than one, which constrains them from doing the opposite.

What might an education in applied ethics for nurses look like?

The extent to which educational programmes address ethics is probably dependent to some extent on faculty make up. Where individuals have an interest in the topic, it is likely to prosper. Conversely, where this is not the case, its treatment is likely to be more cursory. Some version of Kant’s categorical imperative, the utilitarianism of John Stuart Mill, virtue ethics and the principles of autonomy, beneficence, non- maleficence and justice are likely to be present in most courses, albeit to a greater or lesser extent. There is no question that all have much to offer, but nursing is a global profession and our major cities are culturally diverse. Add to this, the equally heterogeneous health workforce, and it becomes clear that the ability to work with complexity, ambiguity and uncertainty in a culturally safe way may require considering ethical frameworks from other locations if we are to avoid the pitfall of assuming that the common ethical frameworks of Western Europe and North America make sense to populations whose belief systems were forged elsewhere. Assuming therefore, that a commitment to common ethical framework will suffice may be fundamentally flawed – educators need to prepare nurses for a world, which will require them to draw on knowledge of a range of philosophical ideas, including those outside Anglo-European traditions in order to determine the appropriate course of action in a given situation.

As well as taking this broader perspective, educators also need to consider the growing interest in making gender, race and class central to equity agendas in health. Typically, the reductionist single focus of biomedicine has privileged these social structures in isolation from each other viewing them as parallel, rather than as being mutually constitutive and maintaining each other. Derived from African American theorising and activism, the view that systems of oppression are interlocking assumes that attempts to dislodge one axis of oppression will impact on another. Given we all occupy positions in society that privilege particular identities whether gender, race, or class, intersectionality is a prompt to consider how these positions influence and affect one another and where power lies (or doesn’t lie). It is not enough to merely look outside ourselves for explanation; we must also examine our own complicity in oppression. This examination must consider individual and institutional raced, classed, and gendered identities and how they impact on the work we do (Van Herk et al. 2011). In our view, educational programmes should provide space for critical review of staff and student individual gender, race, and class identities, as well as how our intellectual and political institutions and their agendas reinforce or diminish those identities in both the academy and in the clinical setting. Our point here is that ethical practice requires an awareness of the multifaceted nature of power and disadvantage, which cannot be found in more traditional one-dimensional accounts of health inequality.

Ethical practice requires action as well as the ability to recognize difficulties and dilemmas. Roberts (2016) has noted that inaction in the face of poor care is often justified by explanations, which focus on situational factors. Drawing on Sartre’s notion of freedom, he argues that these justifications do not stand up and that we are fundamentally free to act, albeit with consequences, if we chose to do so. Here inaction is a choice which is freely made and which privileges the needs of the self over ethical action. For many, the idea of sacrificing self-interest in preference to speaking out against injustice is understandably frightening and plays into the kind of hero stereotype which few can live up to. These fears may be particularly acute in the current economic circumstances where concerns about job security are widespread. If then we are to expect nurses to manage complex ethical problems and to be accountable for these we need to ensure that our educational programmes do more than just provide theoretical understanding. They must seek to equip practitioners with the moral courage and personal resilience required to do the right thing in difficult circumstances – specifically to take action based on one’s ethical beliefs in the knowledge that some adverse personal outcome might result. While we offer no template for how this might be done, as this will be dependent on circumstance, need and resources, it is clear that it cannot occur in isolation. Drawing on the work of Gallagher (2011) moral courage is most likely to be demonstrated when the desire of the individual to do the right thing is matched by a practice culture where doing so is the easier option. Educators must then work with their clinical partners to ensure that students are only placed in environments which have an explicit commitment to ethical practice, and where this is demonstrated through the attitudes and behaviours of all staff and in the leadership style of managers. Without this, we run the risk of expecting ordinary people to behave heroically in the kind of toxic environments, which were described by Francis (2015) in his reflections on care failure in the UK.

Conclusion

While ethical practice lies at the heart of good nursing care, evidence of poor care, racism and sexism suggest that some nurses fail to live up to the standards set by the profession. There may be a number of reasons for this, including both the complex nature of care and the diverse populations which nursing serves. Elements of educational preparation may also be flawed. We have argued that in order to address this agenda, educators need to deliver ethics teaching in a manner, which recognises this complexity and diversity. To do this, they must to move away from a mono-cultural approach, which privileges the Anglo-European tradition. This revised approach should consider the issue of intersectionality – a perspective that provides space to consider issues such as power and control in health, social and structural inequities in practice and in education, and the role of class, gender, ethnicity and age in the development of health problems and the experience of health care.

Simply educating nurses about ethics will not on its own solve the problem. We also need to help practitioners to develop their capacity to make ethical decisions and to take action to the basis of these. Ultimately, the environments in which nurses work need to be places which welcome critical reflection and value open discussion. If these things can be achieved, then practicing ethically by managing the everyday and sometimes extraordinary moral dilemmas, which face nurses, may become an easier option.

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What can The Handmaid’s Tale teach us about intersectionality in institutional life?

Margaret Atwood’s The Handmaid’s Tale focuses on women living in a theocratic totalitarian regime in a newly created dystopian, pronatalist society called Gilead. The regime attributes declining fertility to women’s rights, same sex relationships and an environment damaged beyond repair, which it solves with  the creation of a society predicated on women stratified into their biological destinies to reproduce (Handmaids) or to fulfil household obligations in the private sphere (Marthas). The women are all white, and the story is told through Offred, the plucky white narrator enslaved in a white male supremacist society, where all the people of color have been banished to ‘the colonies'(we are also left uncertain about whether this includes indigenous peoples).  Margaret Attwood doesn’t need to attend to characters of color in the book because in a matter of sentences we already know that they are not included in this new world. This lets Attwood off the hook for engaging with with characters of color in the novel. However, critiques of the book from an intersectional perspective have noted that the narrative banishment comes to extrapolate white women’s experiences as representative of the experiences of all women, even though many of the exploitative and cruel mechanisms to curtail maternity and bodily autonomy used on the white women were used specifically against women of colour in actual North American history that underpins the life of the author and the novel. Or were used on enslaved Africans in the United States including public lynchings and being named after their owners.

The television version attempts to address the invisibility and exclusion of the book where people of color were banished or exterminated. People of colour are visible on screen, as loving husbands, loyal running mates, a daughter, a housekeeper.  The women of color characters are dispersed through the stratified roles of Handmaids or Marthas which also assumes levels of social mobility. But these characters are merely backdrop cardboard cutouts, holograms, one-dimensional, devoid of depth in this white supremacist tale. Characters like Luke and Moira don’t get to explore their racial identities, much less how religious totalitarianism would specifically affect their racialised experiences. In ignoring racism, the show misses an opportunity to show how racism would manifest and evolve in a puritanical theocracy. In the show, The Handmaid’s Tale assumes that racism has been solved or that it is trumped by gender in the cause of preserving fertility. But there is a lost opportunity to consider ‘racist sexism’, that is how policies and practices that discriminate against women, also discriminate in different ways against racialised women. It also fails to acknowledge that America has always been a dystopia for people of color or that American dystopia is founded on anti-Black violence.. It appears on the surface that all subjects other than the commanders and their wives are treated in much the same way as each other. Seemingly the biblical rules of law are applied equally for transgressions. But Bastien asks: 

Are white Commanders and their wives really okay with having a handmaid of color? Is there a caste system for handmaids of color in which some are considered more desirable than others? Do Commanders of color have the same privileges as their white counterparts? If Gilead is meant to imagine a possible future for America, how could deeply entrenched racial dynamics disappear?

In this color-blind, post-racial idyll, there are people of color, but they are hollow and we know nothing about them, past or present. Evan Narcisse suggests it is like the comment made when you’re a non-white person in a predominantly white institution: “When I look at you, I don’t see a marginalised/minority person, I just see a person.” Although meant kindly, in its unmarked privilege it erases the fact of your difference and what it means to inhabit your body and your life. Whiteness is still the unacknowledged default. As Stephanie Brown observes, the men in power are white, as are most of the women. It’s important though that we care about all of this in real life, not just as fiction, as Berlatsky notes:

Because fictional tyrannical dystopias are primarily envisioned as affecting white people, it can be harder to see negative policies that oppress others. At the point where the fictional metaphor matters more than the current reality, something’s gone terribly wrong.

Several critics suggest that The Handmaid’s Tale represents a failure of intersectionality. The term ‘intersectionality’ originates in African American theorising and activism, and is most commonly associated with work by Kimberle Crenshaw and Patricia Collins. It describes how systems of oppression are viewed as interlocking. Therefore, attempts to dislodge one axis of oppression will impact on another. Globally, the term intersectionality is being appropriated as a way to activate attempts to address issues of under-representation in institutions without reverting to a single focus lens on issues such as gender, race, class, or sexuality. Intersectionality provides an understanding that identities can be simultaneously privileged and marginalised, depending on social context. Consequently we are all interpellated differently by racism and sexism through a ‘matrix of domination’ (Collins, 1990).  For example, I can be a migrant woman of color who is marginalised through sexism and racism, but I am also privileged through class position, education, able body and heterosexuality. 

Intersectionality is being introduced into diversity initiatives in Universities and is gaining momentum in the Science, Technology, Engineering, Maths and Medicine disciplines (STEMM) disciplines. Intersectionality is seen as a strategy  for addressing the barriers to success and to widen and increase participation by women, working class, indigenous and ethnic minority groups, in order to leverage a diversity dividend. The use of an economic metaphor valorises innovation and economic competitiveness, rather than attempting to address a pressing social justice. Metaphors to account for inequities and the underrepresentation of groups in STEMM disciplines include the old boys club, the glass ceiling and the leaky pipeline. These metaphors also guide the strategies developed to address these failures of inclusion and their limitations. Merely creating a pipeline and applying force to propel people forward does not guarantee an increase numbers (Núñez, 2014). In the case of a pipeline, we know that it leaks at various stages and is still designed for an implicit ideal input, consequently women and ethnic minorities are more likely than white men to leak out. We also know that the leaking is progressive, so the farther along the pipeline, the fewer these groups are in number (Clark Blickenstaff*, 2005). Merely focusing on increasing or diversifying the supply hides the real issue which is at the ‘demand’ end of things, that is, the organization and the need for it to change (Riegle‐Crumb, 2009, p. 4). Similarly, the metaphor of the glass ceiling assumes the barriers facing marginalised groups are a one dimensional insurmountable barrier experienced at the ‘top’, when in fact marginalised identities experience discrimination and ‘hurdles’ throughout their careers (Husu, 2001, p. 177). Instead the analytic of intersectionality is being vaunted as an antidote to under-representation.

Diversity management is fast becoming a feature of the public image of the corporatised entrepreneurial academy. Standing in for structural or organisational change, diversity risks reproducing the issues I’ve identified in the screen version in the Handmaid’s Tale. Damon Williams suggests there are several political, social and economic imperatives for Universities to respond to diversity. In its place in the knowledge based global economy, it must respond to changing demographics and meet the need for creative and capable students and also demonstrate the viability and vibrancy of diversity. The diversity management strategies it employs range from access and equity; to creating a multicultural and inclusive campus climate; enhancing domestic and international diversity research and scholarship and preparing students for a diverse and global world (Damon Williams, p.19). However, the emphasis on diversity as a way of increasing numbers and improving Human Resources, is often not supplemented with an explicit engagement with the systems of power and inequality that structure the processes of knowledge production. Consequently, the white, elite and middle class structures and structural arrangements that reproduce inequality remain both invisible and intact (Dill & Zambrana, 2009). The neoliberal assumption of an asocial and ahistorical individualised world of meritocracy, means sometimes ignoring racism and sexism (Ong, Wright, Espinosa, & Orfield, 2011). Unmarked white, masculine values and norms instituted through colonial processes of political, cultural, and military dominance favor dominant epistemologies which claim universal truths that overlook social locations and identities (Carlone & Johnson, 2007).

The Handmaid’s Tale is being flagged as a universal wake-up call, about a white feminist dystopia. But as critics note, this ‘feminist’ rallying point ignores enduring prior calls by indigenous and women of color and is a failure of intersectionality. The assumption of a post-racial, ahistorical world limits the possibilities of imagining alternative futures for people of color, in a time of Turnbull, Trump, Macron and Trudeau. Similarly efforts in academia to engage with ‘diversity’ without attention to intersectionality and attending to systems of power and inequality, risks positioning people of color as economic resources who are mere backdrop in a white supremacist institution.

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Using forum theatre to facilitate reflection and culturally safe practice in nursing

Unpublished manuscript for those who might be interested. Cite as: DeSouza, R. (2016, July 16). Using forum theatre to facilitate reflection and culturally safe practice in nursing [Web log post]. Retrieved from: http://www.ruthdesouza.com/2016/07/16/using-forum-theatre-for-reflective-practice/

High quality communication is central to nursing practice and to nurse education. The quality of interaction between service users/patients and inter-professional teams has a profound impact on perception of quality of care and positive outcomes. Creating spaces where reflective practice is encouraged allows students to be curious, experiment safely, make mistakes and try new ways of doing things. Donald Schon (1987) likens the world of professional practice to terrain made up of high hard ground overlooking a swamp. Applying this metaphor in Nursing, Street (1991) contends that some clinical problems can be resolved through theory and technique (on hard ground), while messy, confusing problems in swampy ground don’t have simple solutions but their resolution is critical to practice.

Rocks Philip Island
Rocks Philip Island

Australian society has an Indigenous foundation and is becoming increasingly multicultural.In Victoria 26.2 percent of Victorians and 24.6 per cent of Australians were born overseas, compared with New Zealand (22.4 per cent), Canada (21.3 per cent), United States (13.5 per cent) and The United Kingdom (10.4 per cent). Australia’s multicultural policy allows those who call Australia home the right to practice and share in their cultural traditions and languages within the law and free from discrimination (Australia Government, 2011, p. 5). Yet, research highlights disparities in the provision of health care to Culturally and Linguistically Diverse (CALD) groups and health services are not always able to ensure the delivery of culturally safe practice within their organisations (Johnstone & Kanitsaki, 2008).

An important aspect of cultural safety is the recognition that the health care system has its own culture. In Australia, this culture is premised on a western scientific worldview. Registered nurses (RNs) have a responsibility to provide culturally responsive health care that is high quality, safe, equitable and meets the standards expected of the profession such as taking on a leadership role, being advocates and engaging in lifelong learning. RNs who practice with cultural responsiveness are able to ‘respond to the healthcare issues of diverse communities’ (Victorian Department of Health [DoH], 2009, p. 4), and are respectful of the health beliefs and practices, values, culture and linguistic needs of the individual, populations and communities (DoH, 2009, p. 12).

Culturally competent nursing requires practitioners to provide individualised care and consider their own values and beliefs impact on care provision. Critical reflection can assist nurses to work in the swampy ground of linguistic and cultural diversity. Reflection involves learning from experience: not simply thinking back over an event, but developing a conscious and systematic practice of thinking about experience in order to learn and change future behaviour. Critical reflection involves challenging the nurse’s understanding of themselves, their attitudes and behaviours in order to bring their views of practice and the world closer to the complex reality of care. This kind of process facilitates clinical reasoning, which is the thinking and decision-making toward undertaking the best-judged action, enhancing client care and improve practitioner capability and resilience.

Didactic approaches impart knowledge and provide students with declarative knowledge but don’t always provide the opportunity to practice communication techniques or to explore in depth the attitudes and behaviours that influence their own knowledge. Drama and theatre are increasingly being used to create dynamic simulated learning environments where students can try out different communication techniques in a safe setting where there are multiple ways of communicating. A problem based learning focus allows students to reflect on their own experiences and to arrive at their own solutions, promoting deep learning as students use their own experiences and knowledge to problem solve.

In 2015 I developed and trialed a unit for students at all three Monash School of Nursing and Midwifery campuses in their third year. The aim of the unit was to provide students with resources to understand their own culture, the culture of healthcare and the historical and social issues that contribute to differential health outcomes for particular groups in order to discern how to contribute to providing culturally safe care for all Australians. The unit examined how social determinants of health such as class, gender, race, sexual orientation, gender identity; education, economic status and culture affect health and illness. Students were invited to consider how politics, economics, the social-cultural environment and other contextual factors impacted on Aboriginal and Torres Strait Islander and Culturally and Linguistically Diverse (CALD) communities. Students were asked to consider how policy, the planning, organisation and delivery of health and healthcare shaped health care delivery.

The unit was primarily delivered online but a special workshop was offered using Forum theatre developed by Augusto Boal in partnership with two experienced practitioners Azja Kulpińska and Tania Cañas. Forum theatre is focused on promoting dialogue between actors and audience members, it promotes transformation for social justice in the broader world and differs from traditional theatre which involves monologue. Simulated practices like Forum theatre allow students to address topics from practice within an educational setting, where they can safely develop self-awareness and knowledge to make sense of the difficult personal and professional issues encountered in complex health care environments. This is particularly important when it comes to inter-cultural issues and power relations. Such experiential techniques can help students to gain emotional competence, which in turn assists them to communicate effectively in a range of situations.

Students were invited to identify a professional situation relating to culture and health that was challenging and asked to critically reflect on the event/incident focusing on the concerns they encountered in relation to the care of the person. Through the forum theatre process they were asked to consider alternative understandings of the incident, and critically evaluate the implications of these understandings for how more effective nursing care could have been provided. Through the workshop it was hoped that students could then review the experience in depth and undertake a process of critical reflection in a written assessment by reconstructing the experience beyond the personal. They were encouraged to examine the historical and social factors that structure a situation and to start to theorise the causes and consequences of their actions. They were encouraged to use references such as research, policy documents or theory to support their analysis and identify an overarching issue, or key aspect of the experience that affected it profoundly. Concluding with the key learnings through the reflective process, the main factors affecting the situation, and how the incident/event could have been more culturally safe/competent. Students were asked to develop an action plan to map alternative approaches should this or a similar situation arise in the future.

Forum theatre has been used in nursing and health education to facilitate deeper and more critical reflective thinking, stimulate discussion and exploratory debate among student groups. It is used to facilitate high quality communication skills, critical reflective practice, emotional intelligence and empathy and appeals to a range of learning styles. Being able to engage in interactive workshops allows students to engage in complex issues increasing self-awareness using techniques include physical exercises and improvisations.

My grateful thanks to two Forum Theatre practitioners who led this work with me:

Azja Kulpińska is a community cultural development worker, educator and Theatre of the Oppressed practitioner and has delivered workshops both in Australia and internationally. She has been a supporter of RISE: Refugees, Survivors and Ex-Detainees and for the last 3 years has been co-facilitating a Forum Theatre project – a collaboration between RISE and Melbourne Polytechnic that explores challenging narratives around migration, settlement and systems of oppression. She is also a youth worker facilitating a support group for young queer people in rural areas.

Tania Cañas is a Melbourne-based arts professional with experience in performance, facilitation, cultural development and research. Tania is a PhD candidate at the Centre for Cultural Partnerships, VCA. She also sits on the International PTO Academic Journal.
She has presented at conferences both nationally and internationally, as well as facilitated Theatre of the Oppressed workshops at universities, within prisons and youth groups-in in Australian, Northern Ireland, The Solomon Islands, The United States and most recently South Africa. For the last 2.5 years has been working with RISE and Melbourne Polytechnic to develop a Forum Theatre program with students who are recent migrants, refugees and asylum seekers.

References

  • Australian Government. (2011). The People of Australia: Australia’s Multicultural Policy, Retrieved from https://www.dss.gov.au/sites/default/files/documents/12_2013/people-of-australia-multicultural-policy-booklet.pdf
  • Boud, D., Keogh, R. and Walker, D. 1985. Reflection: Turning experience into learning. London: Kogan Page.
  • Gibbs, G. 1988. Learning by doing: A guide to teaching and learning methods. Oxford: Oxford Further Education Unit.
  • Johns, C. 1998b. Illuminating the transformative potential of guided reflection. In Transforming Nursing Through Reflective Practice (eds). C. Johns and D. Freshwater. Oxford: Blackwell Science. 78-90.
  • Johnstone, MJ. & Kanitsaki, O. (2008). The politics of resistance to workplace cultural diversity education for health service providers: an Australian study. Race Ethnicity and Education 11(2) 133-134
  • McClimens, A., & Scott, R. (2007). Lights, camera, education! The potentials of forum theatre in a learning disability nursing program. Nurse Education Today, 27(3), 203-9. doi:10.1016/j.nedt.2006.04.009
  • Middlewick, Y., Kettle, T. J., & Wilson, J. J. (2012). Curtains up! Using forum theatre to rehearse the art of communication in healthcare education. Nurse Education in Practice, 12(3), 139-42. doi:10.1016/j.nepr.2011.10.010
  • Nursing and Midwifery Board of Australia (2006). National competency standards for the registered nurse, viewed 16 February 2014: www.nursingmidwiferyboard.gov.au.
  • Nursing and Midwifery Board of Australia (2008). Code of professional conduct for nurses in Australia, Nursing and Midwifery Board of Australia, Canberra.
  • Schön, D.A. 1987. Educating the Reflective Practitioner. San Francisco: Jossey Bass.
  • Street, A. 1990. Nursing Practice: High Hard Ground, Messy Swamps, and the Pathways in Between. Geelong: Deakin University Press.
  • Turner, L. (2005). From the local to the global: bioethics and the concept of culture. Journal of Medicine and Philosopy. 30:305-320 DOI: 10.1080/03605310590960193
  • Victorian Department of Health. (2009). Cultural responsiveness framework Guidelines for Victorian health services, Retrieved from http://www.health.vic.gov.au/__data/assets/pdf_file/0008/381068/cultural_responsiveness.pdf
  • Wasylko, Y., & Stickley, T. (2003). Theatre and pedagogy: Using drama in mental health nurse education. Nurse Education Today, 23(6), 443-448. doi:10.1016/s0260-6917(03)00046-7
  • Also see DeSouza, R (2015). Communication central to Nursing Practice. Transforming the Nations Healthcare 2015, Australia’s Healthcare News.

Improving collaboration between nursing professionals and support workers in the New Zealand mental health system– A position paper

In 1998 I began teaching the first mental health support work cohorts in New Zealand at Unitec Institute of Technology. I had the privilege of working with Maori and Pacific mental health workers, peer support workers and consumer providers until 2005. I wrote this position paper for the Australian and New Zealand College of Mental Health Nurses way back in 2003. I have taken it out of the vault in case it is of use. I have listed more up to date references at the end of the document for those who might want to do some further reading.

EXECUTIVE SUMMARY

The Mental Health Commission (1997) states that mental health is the concern of all. Support workers are a reality of today’s mental health system in New Zealand and this paper looks at their relationship with community mental health nurses. This paper is a response to the major changes in mental health care in New Zealand over the last decade, which have dramatically altered the landscape of the mental health workforce. It seems timely to look at a way forward and to develop guidelines for nurses working with support workers in the community. In this paper “support workers” include community support workers and consumers as providers and the term “nurses” refers to community mental health nurses.

No one group can meet the needs of consumers. Together these two groups can provide complimentary services to improve client care but a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. The changes in the socio-political context of mental health care in New Zealand are challenging nurses to re-define their scope of practice. These developments and their implications are summarised and options for the nursing profession are discussed and recommendations given.

ISSUES

Competition for funding

The creation of the Regional Health Authorities (RHA) in 1991 was part of a new system of purchasing health services which replaced Area Health Boards (Yegdich & Quinn, 1996). This new funder /purchaser /provider system encouraged competition between providers and led to many new services entering the health sector. These included non-governmental services who were now able to compete directly with Crown Health Enterprises (CHE), previously there was an obligation for boards to concentrate funding on their own services (Yegdich & Quinn, 1996). In 1996 the new coalition government initiated another review of the health system leading to funding being centralised under the Transitional Health Authority (THA). Competition for central funding begs the question of whether competing services with different philosophies and types of workers can cooperate with each other. When community support services were established in Auckland there was antagonism from nurses as these new services were seen as better resourced, with lower caseloads and were seen to be eroding the role of the professional nurse.

Culturally appropriate parallel services

The changes in funding have also lead to the development of specialised Maori and Pacific Island support work services. In Auckland, the Maori community support work (CSW) service has dramatically reduced the rate of admission and re-admission for Maori . Previous statistics had shown that Maori were entering the mental health system at the same rates as non-Maori but required longer stays and more frequent re-admissions (Te Puni Kokiri, 1993). Increased numbers of immigrants and refugees from Africa, Asia and Eastern Europe have led to the formation of specialised mental health services, for example the Refugees As Survivors (RAS) centre. However, a disadvantage of parallel services is that nurses in main stream services lose the opportunity to develop specialised skills for working with cultures other than their own.

Case management

Case management originated in the United States in the 1980’s in the context of deinstitutionalisation, normalisation and the development of community mental health centres (Sledge, Astrachan, Thompson, Rakfeldt & Leaf, 1995; Willis & Morrow, 1995). It was seen as a way of improving the connections between services and linking both clinical and rehabilitation services together to ensure that “severely mental ill” clients received adequate services (Sledge, et al. 1995). Versions of case management are used in New Zealand although little has been written about the experience locally. Universal agreement has not been achieved regarding the scope of practice of case managers and the level of education required. The assumption that nurses are the most suitable group to provide case management services is being challenged by the emergence of support work services and parallel ethnic mental health teams.

Role change

Yegdich and Quinn (1996) have observed that the role of nurses has extended with the move from institution to community. Needs of clients now include housing, income, employment and social networks. However, an audit of community services in Auckland found that the dominant activity of nurses was crisis intervention (Yegdich & Quinn, 1996). Support work services have evolved in recognition of the gaps in community care provision. This movement to the community has also resulted in an increased emphasis on tertiary prevention, rehabilitation and recovery. New postgraduate training courses in mental health nursing have been developed as a result of a growing dissatisfaction with comprehensive nurse training and what is seen as inadequate preparation for working in this area (Ministry of Health, 1996). This is also important from a case management perspective particularly as broader skills are necessary for this role, for example knowledge of community resources.

Changing relationship with consumers

The consumer movement is influencing the movement of mental health service delivery from a medical to psychosocial rehabilitation model (Worley, 1997). New opportunities have arisen for consumers to interact with policy makers, professionals and others from a position of strength. Consumer operated programmes and initiatives have been developed due to the dissatisfaction with clinical mental health services. Consumers have found consumer-staffed organisations more empathetic, tolerant and understanding because of their own struggles with psychiatric disability (Worley, 1997). Consequently, guidelines have been developed as a result of increased consumer participation in professionally run mental health agencies (Ministry of Health, 1995). This has also led to changes in relationships between consumers and professionals. There is growing recognition on the part of professionals of the value of experiential knowledge and what consumers have to offer other consumers.

Safety and extended roles

  • Assessment by a nurse is required to detect changes in the mental state of a client. Where a support worker is the predominant contact, changes may be missed particularly if they have no clinical experience or assessment skills. In an article about extended roles, Rieu (1994) stated that discussion about accountability (“professional” and “legal”) and competency is needed. Other questions that need to be addressed include:
  • What preparation and training are support workers given?
  • What supervision do they get and how are they regulated?
  • How well are they resourced and supported?
  • Is their scope of practice clearly defined?

ADDRESSING THE ISSUES

Recognising the strengths of support workers

Support workers are seen as filling the gaps in community care, particularly in terms of work with clients with complex needs not met within the reductionist medical model (Davies, Harris, Roberts, Mannion, McCosker & Anderson, 1996). Other advantages include breaking the barrier of client-worker distance, providing a bridge between clients and mainstream staff and providing a role model for clients of similar background (Davies et al., 1996). Studies have shown that support workers are considered more effective than health professionals for several groups with varying mental health needs (Davies et al., 1996; Grant, Ernst, Streissgut, Phipps & Gendler, 1996). These include abused women, who have viewed the health system as sexist, fragmented and professionals as judgemental and insensitive (Davies et al., 1996). Other studies have shown that chronically drug-dependent women have become distrustful of “helping” agencies and in turn many professionals see these women as a hopeless population (Grant et al., 1996). They describe an advocacy model of case management using support workers, who worked intensively with women, who used drugs or alcohol heavily during their pregnancies and were alienated from community services. This alienation increased the risk of delivering children with serious medical, developmental and behavioural problems. It also prevented them from seeking assistance from agencies that were designed to help them. These ‘advocates’ were support workers experienced in social services with high-risk populations, had a variety of life experiences and came from a similar cultural background to their clients. They were seen as positive role models, providing hope and motivation. It was found after one year that clients now engaged with treatment agencies, decreased drug use, increased use of birth control and increased their involvement with supportive and skill building groups, such as parenting classes (Grant, et al., 1996).

Training and education of nurses

Nursing training must incorporate concepts such as recovery and consumer perspectives. Nurses need to be supported to work as case managers and build on their roles as more than adjuncts to the medical model. Mental health nurses working in the community must clarify their current roles and define what pathways they will follow.

Diversity in the workforce to provide culturally appropriate services

Reviews have shown that there are a paucity of culturally safe services for Maori and Pacific people (Ministry of Health, 1997). Furthermore, the provision of resources and devolution of resources have not supported other views of mental illness (Mental Health Commission, 1996). “Moving Forward” (Ministry of Health, 1997) national objectives states more trained mental health workers are needed before culturally appropriate services can be provided by mainstream and kaupapa Maori mental health services. A better partnership is needed between education and health sectors so that training can be specifically targeted to Maori. The Pacific Island objective also recommends that work be done so that mental health services become more responsive to the diverse needs of Pacific peoples. The national objectives recommend educating consumers as providers, community support workers and Maori and Pacific Island workers.

Better cooperation with ethnic support workers

In an Australian article, Fuller (1995) argued that health care practices by professionals continue to be predominantly monocultural despite recognition of the need to be responsive to the culturally diverse population. Fuller added that different ethnic groups practice illness prevention and health promotion differently. Some prefer direct, practical and immediate assistance from the Western care system rather than long term strategies. Fuller argued that nurses could not attain all the necessary cultural knowledge to provide total care to clients without a partnership with cultural intermediaries. According to Fuller, this expectation would result in lists of stereotypical traits being produced rather than an improved understanding of clients individual needs. Fuller added that the values and assumptions of primary nursing with contradictory notions of empowerment and autonomy have resulted in rigid professional boundaries which restrict multi-disciplinary team work, thereby increasing the need for an ethnic support worker.

Alternative structures and models

The Ministry of Health (1997) recommends that mental health promotion and prevention for Maori and Pacific Islanders be strengthened. They suggest using traditional (Pacific and New Zealand) structures to promote mental health including circulating Pacific language descriptions of key western mental illnesses. In addition, the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996) suggested that Maori consumers become integrated into the provider culture of mental health services, so services reflect the wealth of Maori consumer experience. This is in line with the request by Maori consumers to have more Maori community support workers, patient advocates and crisis teams. This leads on to the next area for discussion about who can best provide services for those with mental health needs. Takeuchi, Mokuau & Chun (1992) found that the establishment of parallel services improved mental health for minorities and led to an increase in their use.

Multiskilled, multidisciplinary and comprehensive

According to Øvretveit (1993), it is rare that one profession alone is able to meet the needs of a person with a social or health need. Usually the skills and knowledge of a range of specialists are beneficial and coordination is crucial to prevent costs of duplication and staff frustration. This is echoed by the Report of the National Working Party on Mental Health Workforce Development (Ministry of Health, 1996). It suggests that the best way to deliver mental health services to consumers is by having a team of multi-skilled and multi disciplinary workers. This team would be able to address the many facets of care required by sufferers of mental illness and would include community support workers as well as Maori and Pacific Island workers. “Moving Forward’s” National objectives are to increase the Maori and Pacific Island mental health workforce. In addition, a flexible system is required where a case manager might need to spend more time with someone as the nature of mental illness changes rapidly.

A proposed model of cooperation

The mental health of consumers will be maximised if professionals and support workers are able to work in partnership and combine their skills, knowledge, life experience and expertise in a coordinated way. This would ensure that services are respectful, relevant, flexible, responsive and effective and that they are available to consumers to reduce the barriers that prevent them from achieving their full health potential. The framework for community service delivery for people with mental health problems needs to be comprehensive, health promoting and collaborative; a partnership that is committed to client empowerment and the elimination of barriers to access (Association of Ontario Health Centres, 1994).

RECOMMENDATIONS

Several recommendations are proposed:

Liaison

  • Adopt protocols for networking within all services so that inter-agency cooperation is maximised and clients receive a seamless service.
  • Improve the interface between clinical, cultural and psychosocial models to increase understanding and collaboration from both perspectives.

Training 

  • Educate support workers to understand the role of the nurse but not to the extent that traditional healing structures are negated in favour of psychotherapeutic methods.
  • Formalise traditional roles into the mental health system, for example the role of Kaumatua (Street & Walsh, 1996).
  • Train nurses in cultural and psychosocial models.

Role and Scope of practice

  • Develop job descriptions for support workers in cooperation with nurses to prevent role ambiguity, promote job satisfaction and decrease discontent.
  •  Support and safeguard support workers to ensure that their role does not compromise the safety of clients and staff or the role of the nurse.
  • Use nurses appropriately and ensure that they are not substituted by support workers for fiscal or political reasons.
  • Define core competencies for support workers at a national level and ensure on-going monitoring of standards.

Alternatives to the medical model

  • Recognise that the clinical model has limitations and cannot meet the needs of all clients.
  • Increase familiarity with alternative models of mental health amongst nurses, for example recovery and cultural models.
  • Review and clarify the role of nurses working in mental health.

Cultural safety 

  • Acknowledge the importance of spiritual issues, land rights, whanau reconstruction and physical health (Street & Walsh, 1996).
  • Resource nurses appropriately for the cultural component of their work.
  • Involve nurses in developing appropriate policy and healthcare services to Maori and ethnic minorities in New Zealand (Street & Walsh, 1996).
  • Familiarise nurses with the work of ethnic mental health workers and Maori support work services.

Consumer participation/consumer focused

  • Recognise the experiential and personal knowledge of consumers.
  • Ensure that consumers are key players in planning and accountability structures which are linked to outcome measures.

CONCLUSION

This paper has shown how support workers can reach clients who are lost to or fearful of the mental health system, whether this is because of social, ethnic or cultural reasons. In an evolving mental health system moving from institutionalisation to community-based care, these new roles provide a bridge between the clinician and the consumer. No one group can meet all the needs of consumers. Support workers can widen the focus of the mental health system in a way that better meets the needs of clients in the community at large, whatever their background. Friction has existed between nurses and support workers, the former often viewing the latter as eroding their role and of being unskilled. Alternatively support workers have sometimes viewed nurses as part of a system that they see as having failed them. Support workers are seen by some as being a political solution to eroded health care funding. Although there are several issues requiring on-going discussion, not least the legal and ethical requirements for support workers and their regulation, a synergy exists between nurses and support workers and together they can provide complimentary services to improve client care. For this to be successful a model of cooperation is necessary and further clarification of roles and overlap is required. Effective teamwork between nurses and support workers in the mental health community in New Zealand must occur so that the care delivered is flexible and responsive to the needs of consumers and their families. A guiding framework of principles for working in harmony should be developed.

REFERENCES

Association of Ontario Health Centres (1994). Response to: “Implementation Vision” – Mental Health Reform. Toronto: Association of Ontario Health Centres

Davies, J; Harris, M; Roberts, G; Mannion, J; McCosker, H & Anderson, D. (1996). Community health workers’ response to violence against women. Australian and New Zealand Journal of Mental Health Nursing,5, 20-31.

Fuller, J. (1995). Challenging old notions of professionalism: how can nurses work with paraprofessional ethnic health workers? Journal of Advanced nursing, 22, 465-472.

Grant, T.M.; Ernst, C.C.; Streissgut, A.P.; Phipps, P.& Gendler, B. (1996).When case management isn’t enough: a model of paraprofessional advocacy for drug and alcohol abusing mothers. Journal of Case Management, 5, 1, , 3-11.

Mental Health Commission (1997). Discrimination against people with experience of mental illness: Discussion paper for the mental health commission. Wellington: Mental health commission.

Ministry of Health (1995). A guide to effective consumer participation in mental health services. Wellington: Ministry of Health.

Ministry of Health (1996). Towards better mental health services: The report of the national working party on mental health workforce development. Wellington: Ministry of Health.

Ministry of Health (1997). Moving forward: The National Mental Health Plan for more and better services. Wellington: Ministry of Health.

Øvretveit, J. (1993). Coordinating community care. Open University press: Buckingham. Rieu, S. (1994). Error and trial: the extended role dilemma. British Journal of Nursing, 3, 4, 168-174.

Street, A & Walsh, C. (1996). Community nursing issues in Maori Mental Health. Australian and New Zealand Journal of Mental Health Nursing, 5, 54-62. Te Puni Kokiri (1993).

Nga Ia O Te Oranga Hinengaro Maori trends in Maori Mental Health: A discussion document. Wellington: Te Puni Kokiri. Worley, N. (1997). Mental health nursing in the community. .Mosby: St Louis.

Yegdich, T & Quinn, J. (1996). Community mental health nursing. In Clinton, M & Nelson, S (Ed), Mental health & Nursing practice, (p335-353). Sydney: Prentice Hall.

 

More recent references

Annadale, M., & Instone, A. (2004). Sei Tapu: Evaluation of the National Certificate in Mental Health Support Work. Wellington, New Zealand: Platform.

Barber, K. F. M. (2015). Realising Our Best Intentions: Vision, Values and Voice in Community Non-government Organisations of the Aotearoa$\backslash$ New Zealand Mental Health Sector. University of Waikato. Retrieved from https://waikato.researchgateway.ac.nz/handle/10289/9989

Cheng, R., & Smith, C. (2009). Engaging people with lived experience for better health outcomes: Collaboration with mental health and addiction service users in research, policy, and …. Toronto, Ontario: Minister’s Advisory Group,. Retrieved from https://www.researchgate.net/profile/Christopher_Smith27/publication/260589695_Engaging_People_with_Lived_Experience_for_Better_Health_Outcomes_Collaboration_with_Mental_Health_and_Addiction_Service_Users_in_Research_Policy_and_Treatment/links/0f317531a029393ce7000000.pdf

Hatcher, S., Mouly, S., Rasquinha, D., & Miles, W. (2005). Improving recruitment to the mental health workforce in New Zealand. Of New Zealand. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/Improving-Recruitment-to-the-Mental-Health-Workforce-in-New-Zealand-2005.pdf

Hennessy, J. L., Smythe, L., Abbott, M., & Hughes, F. A. (2016). Mental Health Support Workers: An Evolving Workforce. Workforce Development Theory and Practice in the Mental Health Sector, 200.

 

Hennessy, J. L. (2015). The contribution of the mental health support worker to the mental health services in New Zealand: an Appreciative Inquiry approach. Auckland University of Technology. Retrieved from https://aut.researchgateway.ac.nz/handle/10292/9192

McMorland, J., Kukler, B., Murray, L., & Warriner, R. (2008). Partnerships in Development: developments in mental health service provision in New Zealand. A case study. New Zealand Journal of Employment Relations (Online), 33(1), 19.

Morrison, N., & Ronan, K. (2002). Assessment of Core Competency Status and Work Environment of Residential Mental Health Support Workers. The Australian Journal of Rehabilitation Counselling, 8(02), 114–126.

Morrison, N. (2000). Assessment of competency status of residential mental health support workers: a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Psychology at Massey University. Massey University. Retrieved from http://mro.massey.ac.nz/handle/10179/6018

 

O’Neil, P., Bryson, J., Cutforth, T., & Minogue, G. (2008). Mental health services in Northland. Industrial Relations Centre, Victoria University of Wellington, July, 2–3.

O’Hagan, M. (2001). Recovery Competencies for New Zealand Mental Health Workers. Retrieved from http://eric.ed.gov/?id=ED457512

Pace, B. (2009b). Organisational views of the mental health support worker role and function. Unpublished Paper. Waikato Institute of Technology, New Zealand. Retrieved from http://www.psychosocial.com/IJPR_14/Organizational_Views_Pace.html

Pace, B. (2009a). How New Zealand community mental health support workers perceive their role. Journal of Psychosocial Rehabilitation. Vol 13 (2). 5. Retrieved from http://www.psychosocial.com/IJPR_13/New_Zealand_Comm_Mental_Health_Pace.html

Pace, B. (2010). Exploring support work: Examining the role of mental health support workers in New Zealand (p. 159). Wellington, New Zealand: B. Pace.

Pace, B. (2009). A practical guide to mental health support work (p. 94). Wellington, New Zealand: B. Pace.

Reeves-Timms, H. (2011). Diploma in action: Making a difference when working with tangata whai ora. Retrieved from http://repository.digitalnz.org/system/uploads/record/attachment/508/diploma_in_action___making_a_difference_when_working_with_tangata_whai_ora.pdf

Rangiaho, A. (2003). Te Puawaitanga o Te Oranga Hinengaro-An evaluation of the Natioonal Certificate in Mental Health Support Work from a Maori perspective. Wellington, New Zealand: Mental Health Support Work.

Scott, A. (2015). Gaining acceptance: Discourses on training and qualifications in peer support. New Zealand Sociology, 30(4), 38.

Southwick, M., & Solomona, M. (2007). Improving Recruitment and Retention for the Pacific Mental Health Workforce. Auckland: The National Centre of Mental Health Research and Workforce Development. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/improving-recruitment-and-retention-for-the-pacific-mental-health-workforce-feasibility-study.pdf

Sutcliffe, R. (2007). What is the meaning of supervision for mental health support workers? A critical hermeneutic inquiry. Retrieved from https://aut.researchgateway.ac.nz/handle/10292/88

Taylor, G. E. (2015). Who cares about carers? Experiences of community mental health support workers from a feminist perspective. University of Waikato. Retrieved from http://researchcommons.waikato.ac.nz/handle/10289/9649

 

Scott, A. L., Doughty, C., & Kahi, H. (2011). Peer Support Practice in Aotearoa New Zealand. Retrieved from http://ir.canterbury.ac.nz/handle/10092/5258

Te Ararau, K. P. (n.d.). Māori mental health workforce development. Networknorth.org.nz. Retrieved from http://www.networknorth.org.nz/file/NRWorkforceDevelopment/KeyDocsAndLinks/ktpabook.pdf