Developing diversity in the workforce

Published in Kai Tiaki: Nursing New Zealand 1410.10 (Oct 2008): p23(1).

Identifying barriers, opportunities and strategies to integrate and develop a diverse health workforce was the aim of a workshop at the recent Diversity Forum in Auckland.

“Capitalising on a diverse health workforce” was hosted by the Centre for Asian and Migrant Health Research at the Auckland University of Technology (AUT) and opened by dean of the Faculty of Health and Environmental Sciences at AUT’s North Shore campus, Max Abbott. He recounted how pivotal overseas health professionals were to his recovery during a recent hospital stay.

Nurse consultant-recruitment at North Shore Hospital, Waitemata District Health Board (DHB), Carat Frankson, identified some bottlenecks to the registration of overseas nurses, in particular passing the International English Language Testing System (IETLS) exam, getting a job offer and finding employment opportunities for spouses. Other bottlenecks included organising passports and visas, selling and buying houses, finding schools, living costs, climate, separation from family, loss of familiar surroundings, religious practices, cultural backgrounds and the financial costs of moving from one country to another. Strategies the DHB provided in order to embrace a diverse nursing workforce included:

  • coaching, support, mentorship and supervision in the work environment;
  • introduction to the New Zealand cultural context and context of nursing at the DHB;
  • education in the principles of the Treaty of Waitangi; and
  • education in the values of the Waitemata DHB: integrity, compassion, openness, respect and customer focus.

The process could be mutually beneficial, Frankson said. “It is our responsibility to introduce and support new recruits into the New Zealand way of life, offering them cultural support. Incorporating and including immigrants into our communities is a responsibility we all share.” White these health professionals benefitted our workforce, they could also benefit other areas of society, eg schools, Libraries, universities, community centres, religious centres and the legal system, she said.

Auckland DHB clinical nurse educator, Roanne Crane’s presentation on integrating overseas-trained health professionals into the DHB identified some of the issues facing overseas registered nurses, such as Language, manoeuvring through the New Zealand registration process, socialisation, cultural differences, unprincipled agents and assumptions/racism.

Reducing health inequalities

Workforce development consultant at Counties Manukau DHB, Elizabeth Ryan, discussed the increasing demand for health services. The population was ageing, with the number of people over 65 projected to more than double between 2001 to 2021; a third of deaths occurring everyday in Counties Manukau were from potentially preventable conditions; and workforce demand would outstrip supply, with shortages nationally of up to 40 percent predicted by 2021, including in South Auckland. Having an ethnically diverse workforce was a key strategy in reducing inequalities in health, she said. The workforce needed to reflect the community being served in order to deliver quality health services in a culturally-appropriate manner. Ethnic matching was associated with greater patient satisfaction and better patient-reported outcomes.

She highlighted initiatives such as increasing the number of high school students studying health courses, with an emphasis on Maori and Pacific students, increasing numbers pursuing health at mid-career level, especially males/ Maori and Pacific people, collecting accurate demographic data, developing an affirmative action policy and the pilot programme which wilt see around 50 Pacific-Island trained nurses gain registration in New Zealand annually over the next three years.

Meeting the challenge of institutionalised racism was tackled by Auckland University researcher Nicola North. Of note was the complex and subtle set of skills that international medical graduates (IMGs) and international registered nurses(IRNs) needed to acquire, eg understanding cultural differences, familiarity with the culture of the new community of practice, fluency with the nuances of professional communication, and understanding the behaviour and values expected. To meet the challenge, North suggested several factors needed to be addressed: self-reflection as a society, a focus on immigration and settlement structures and processes, even-handed behaviour from registration councils, finding employment, smoothing the process of joining the new practice community and, lastly, getting real. “We need to acknowledge we need IMGs and IRNs more than they need us,” she said.

In the final part of the workshop, the group considered the question: What would a health system that capitalised on its diversity look like? Answers included:

  • recognising skills and supporting people financially;
  • ensuring the health workforce reflects the population demographics;
  • passing on success stories to the media;
  • rewarding and acknowledging cultural competence;
  • fostering diversity at all levels, including around decision-making, to develop new ideas and treatments;
  • consolidating, streamlining and integrating information systems to free up funding for initiatives;
  • growing the inter-cultural communication capacity of the entire workforce, eg educating people about how to deriver bad news to patients;
  • including diversity at art education levels;
  • focusing on areas of under-representation and targeting them specifically; and
  • ensuring support mechanisms are developed to take into account cultural differences, eg around employee disputes.

New York author Margaret Visser argues that change and diversity are necessary to human growth and evolution: “Machines like, demand, and produce uniformity. But nature loathes it: her strength lies in multiplicity and in differences. Sameness, in biology, means fewer possibilities and, therefore, weaknesses.” (1)

Reference

(1) Visser, M. (1999) Much depends on dinner:. The extraordinary history and mythology, allure and obsessions, perils and taboos, of an ordinary meal. New York: Grove Press.

Indians in New Zealand and the story of my family’s arrival

The Indian community is a growing minority in New Zealand, making up the second largest group in the category ‘Asian’ after Chinese communities.

You can watch a short video (4.38), excerpted from the TV Series Here to Stay about Indians in New Zealand. by clicking on the link. I talk about my parents’ decision to migrate and the experience of arrival: Ruth DeSouza: Arriving in New Zealand.

I’ve also provided a very brief background of Indian migration to New Zealand from an article I wrote: DeSouza, R. (2006). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, 20 (1&2), 159-170.

The 2006 Census found that European New Zealander’s make up 67.6% of the population of people in New Zealand, 14.6 % of people as Māori. Pacific Peoples make up 6.9% of the population, Asians 9.2% and Middle Eastern, Latin American & African people 0.9%. The Census also found that 11.1% of people identified themselves as New Zealanders (Statistics New Zealand, 2006). Within the Asian group, Indians had the highest percentage increase in population between 2001 and 2006  increasing from 62,190    to 104,583 a 68.2% increase. The previous Census of 2001, found that Indian-New Zealanders were highly qualified and more likely to receive income from wages and salaries than the total New Zealand population and as likely as the overall New Zealand population to receive income from self-employment thus Indians have the second highest median annual income among the Asian ethnic groups, are involved in white collar employment and, at 77%, had the highest labour force participation rate of all the Asian ethnic groups (Statistics New Zealand, 2002a).  A relatively high level of home ownership (41%) was also found. This profile of Indian New Zealanders is a recent development, early Indian migration was primarily derived from two rural areas of India, Gujarat and Punjab, and arrivals were mainly traders, farmers, artisans or small businessmen (Tiwari, 1980).

The Indian connection with New Zealand began in the late 1800s through Lascars (Indian seamen) and Sepoys (Indian soldiers) on British East India Company ships that brought supplies to the Australian convict settlements. The earliest Indian to arrive in New Zealand is thought to have jumped ship in 1810 to marry a Mâori woman. The Indians that followed came mainly from Gujarat and Punjab, areas of India which had been exposed to emigration, and were driven by economic factors. Initially Indians were considered British subjects and could enter New Zealand freely. This changed with the passing of the Immigration Restriction Act 1899.

Indian migration increased until 1920, when the New Zealand Government introduced restrictions under a ‘permit system’ (Museum of New Zealand: Te Papa Tongarewa, 2004). In 1926, the White New Zealand League was formed as concern grew about the apparent threat that Chinese and Indian men appeared to present in terms of miscegenation and alien values and lifestyle. Discrimination against Indians manifested in restrictions around joining associations and accessing amenities such as barbers and movie theatres. By 1945, families (mostly of shopkeepers and fruiterers) were getting established and marriages of second-generation New Zealand Indians were occurring. As well as Gujuratis and Punjabis, smaller numbers of Indians came from locations such as Fiji, Africa, Malaysia, the Caribbean, North America, the United Kingdom and Western Europe. The proportion of Fiji-born Indian immigrants to New Zealand rose significantly as a result of the Fijian coups of 1987 and 2000 (Swarbrick, 2004).

How to conquer anxiety and even enjoy giving a presentation

Published in Kai Tiaki: Nursing New Zealand 13.10 (Nov 2007): p20(2).

It is 11 years since my first conference presentation and I remember that day vividly. I had prepared carefully for the presentation; friends and family came to support me; but a tricky question at the end of my presentation took me by surprise: “Ruth, thanks for that interesting presentation. How does what you say relate to postmodemism?” I was mortified and fudged an answer. It’s a wonder that anyone presents realty! Why would you expose yourself in this way and what is the purpose of a presentation?

In this article I attempt to summarise some of my learning and share some strategies and ideas, in the hope of prompting readers to consider embracing the performance that is presenting. I am going to ask you first to think about who was the best speaker you have ever heard and what was good about them. Now, think about what presenting might have to offer you. Why should nurses think about presenting or public speaking? It is a good career move. The pay off is personal satisfaction, peer esteem and building your career. It is a good skill to develop–you might need to present research at a conference, in-house or at an interview. These experiences help you become a better presenter and increase your visibility.

Conferences, for example, provide an important arena and opportunity for people to exchange views and communicate with each other. They are also useful for linking up with the people who are most interested in your work.

What makes a good speaker?

What makes a good speaker? In my view, a good speaker begins and ends their presentation strongly; you are hooked from the first word to the last, by their brilliance, humour, wisdom, provocation and ability to entertain. They also know how to tell good stories, but they never read from their speech. They capture your attention because, not only do they know their own work, they also have a clear message.

So how does one go about speaking? I have developed as a presenter over the years from being flustered and over-prepared, to having far too much to say, to now beginning to feel natural and comfortable when I present at a conference or gathering of peers.

When I was a group therapist and facilitator, I had to speak to several people at a time and this helped me grow in confidence as a speaker. Then I was asked to facilitate a function attended by 250 people. This prompted me to do a Toastmasters course, where I learned how to recover from mistakes in a presentation. I also realised that when I was anxious, I lost my ability to be natural and humorous, but if I could manage my anxiety, then all would be well

In terms of conference presentations, I prepared by reading previous papers and began networking, so I got to know other people in my research field, which helped me realise I had something to offer.

Preparation crucial

Preparation is crucial to presenting well Three aspects need to be addressed: the purpose, structure and content of your presentation. In considering purpose, it is important to know the key messages you want to convey. It might help to start at the end and work backwards–every presentation needs a destination. Then consider what you need to say to assist the listener to get those key messages. Is there a context you need to introduce? How much can you assume your audience will know already? So to the structure. I tend to work on the basis of four parts to a presentation: the introduction, the body, the guts and the conclusion.

The purpose of the introduction is to motivate the audience, which you can do by having a warm up or a question. I also use this part to introduce myself and define the problem or issue, and set the scene. Then you can introduce the context, such as terminology and earlier work. At this point, I would also emphasise what your work contributes to the topic or area, and provide a road map of where your presentation is going. This normally takes around five minutes. The next part of the presentation outlines some big picture results or themes and why they are important. This is followed by the “guts” of what you want to say, where you present one key result, carefully and in-depth.

The conclusion is where many presenters (including myself) run out of steam. The conclusion involves rounding off your presentation neatly and linking everything you’ve said. This can be a good time to mention the weaknesses of your work, and it can help manage questions at the end. It is good to find a way to indicate the presentation is over. I do this by thanking the audience and asking if there are any questions.

Now to the content. Many people use PowerPoint presentations. Use slides like make up–sparingly and simply: common advice is don’t have too much on them; and don’t have too many. (I’m still working on this one.) Six words per bullet point and a maximum of six bullet points per slide is recommended.

The slides are merely an adjunct to your talk, so please don’t read them word for word (my pet hate). The purpose is to highlight key points for the audience and to prompt the speaker. In considering the number of slides to have, keep in mind that each slide takes about a minute and a hail or two minutes to read and fully understand?? If you have 87 slides for a 25-minute talk, like someone I was on a panel with recently, you are likely to overwhelm your audience. Take care with formatting your slides and make sure the spelling is correct. Lastly, be sure you’ve saved your presentation to two types of media. Practise your presentation, ask for a second opinion and get some feedback. Practising helps fine tune your timing.

On the day itself, make sure you are prepared and took and feet good. Ensure you take the media you are going to use and take a hard copy of the presentation to refer to. Say your presentation out loud. At the venue expect nothing to work and scope the technology. Address your anxiety. I do this by practising my presentation, going for a brisk walk and taking deep breaths. I also like to get to the venue early and mingle with those attending the conference, so I can develop some allies in the audience. Focus on being yourself and focus on giving.

Connecting with the audience

Now to the actual presentation. Make sure you project your voice to the very back of the room. It is important to know the audience and pitch your message accordingly. Make eye contact if possible–this is easier if you had time to meet people beforehand. Find a way to involve the audience and make sure you have a good opening. Use repetition to reinforce your message: tell them what you are going to tell them; tell them; then tell them what you told them, but repeat it in different ways. Make sore you are standing in the right place so you aren’t blocking your slides or other visual aids.

Remember that once you get involved in what you have to say, then the nervousness will go away. Don’t be afraid to pause, and you can pause for emphasis. If you get stuck, just move on to the next part of your presentation (others won’t notice). Be spontaneous, considerate and inclusive. I like to move around and I tend to focus on entertaining. If you can generously link in with what previous speakers have said, or affirm later speakers for continuity and reinforcement, that is all to the good. Whatever you do, don’t go over time.

Congratulations, you’ve finished. Now, let’s talk about feedback and questions. Feedback is critical to Learning how to improve your talk and for future presentations. Solicit feedback, if it isn’t freely given, but be prepared for some negative comments! Ask for written feedback, if appropriate.

Managing questions is important. Repeat the question so everyone can hear. It is important to be both prepared and polite. Keep your answers short where possible. If you get drawn into a Long discussion with a questioner, for the sake of your audience, offer to discuss the issue tater. Don’t be afraid to say that you don’t know. Find a way to turn criticism into a positive statement, eg “thanks for mentioning that, it’s given me something to think about”, rather than being defensive.

Different types of questions

In my experience there are four types of question: the genuine request; the selfish question (which is realty about the questioner saying “Look at me”); the malicious question (which is designed to expose you); and the question that has absolutely nothing to do with your presentation and makes you wonder if you and the questioner were in the same venue!

Presenting requires a delicate balance–preparation is important but so is being yourself and being spontaneous. It is important to have content and structure, but the more you have of both, the less room you have for questions and spontaneity. It is important to be inclusive, but be careful with humour and jokes or your own stories, unless you can Link them with your talk well. Lastly, be entertaining, know your material, keep it simple, be prepared, be creative and have fun!

Advice to a student nurse

My response to  a student nurse who was haunted by questions about becoming a nurse. Published in Kai Tiaki: Nursing New Zealand 13.1 (Feb 2007): p4(1).

I was pleased to see [x} letter, Questions haunt nursing student, in the December/ January 2006/2007 issue of Kai Tiaki Nursing New Zealand (p4). The questions she has reflected on indicate she is going to be an amazing nurse.

I believe nursing is both an art and a science, and our biggest tools are our heart and who we are as human beings. I was moved by her letter and thought I’d share my thoughts. The questions she posed were important because the minute we stop asking them, we risk losing what makes us compassionate and caring human beings.

Let me try to give my responses to some of the questions Lisa raised–I’ve been reflecting on them my whole career and continue to do so.

1) Can a nurse “care” too much?

Yes, when we use caring for others as a way of ignoring our own “issues”. No, when we are fully present in the moment when we are with a client.

2) Don’t patients deserve everything I can give them?

They deserve the best of your skills, compassion and knowledge. Sometimes we can’t give everything because of what is happening in our own lives, but we can do our best and remember we are part of a team, and collaborate and develop synergy with others, so we are resourced and can give our best.

3) How do I protect myself and still engage on a deeper level with the patient?

I think we have to look after our energy and maintain a balance in our personal lives, so we can do our work weft. We also need healthy boundaries so we can have therapeutic communication.

4) How do I avoid burnout?

Pace yourself, get your needs met outside work, have good colleagues and friends, find mentors who have walked the same road to support you. I’ve had breaks from nursing so I could replenish myself.

5) Why can’t I push practice boundaries, when I see there could be room for adjustment or improvement?

I think you can and should, but always find allies and justification for doing something. Sometimes you have to be a squeaky wheel

6) Isn’t it okay to feet emotionally connected to the patient?

Yes, it is okay to feel emotionally connected to the patient, but we also have to remember that this is a job and our feelings need transmutation into the ones we live with daily.

7) Don’t I need to continually ask questions, if nursing is to change, or will that just get me fired?

Yes, you do have to ask questions but it is a risky business. Things don’t change if we don’t have pioneers and change makers.

8) Finally, am I just being a laughable year-one student with hopes and dreams, and in need of a reality check?

No, your wisdom and promise are shining through already and we want more people like you. Kia Kaha!

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.

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