ORIGINAL ARTICLE
Rural nurses: a convenient co-location strategy for the rural mental health care of young people Rhonda L Wilson and Kim Usher
Aims and Objectives. The aim of this research was to understand new ways that young rural people with mental health problems could be helped at an early point in their mental health decline. Background. Rural nurses represent skilled mental health helping capital in their local communities, yet this important mental health helping resource, or helping capital, is both under-recognised and under-used in providing early mental health help in rural communities. In recent years international momentum has gathered in support of a paradigm change to reform the delivery of youth mental health services so that they align more closely to the developmental and social needs of young people with mental health problems. Design. A mixed methods case study design was used to explore the early mental health care needs of young rural people. Methods. A cross-sectional survey was conducted and data were analysed with descriptive techniques. In-depth interviews were conducted and the transcribed data were analysed using thematic techniques. Results. The results of this study demonstrate that in general rural people are willing to seek mental health care, and that rural nurses are well suited to provide initial care to young people. Conclusions. Non-traditional venues such as community, school and justice settings are ideal places where more convenient first conversations about mental health with young people and their families, and rural nurses should be deployed to these settings. Relevance to Clinical Practice. Rural nurses are able to contribute important initial engagement interventions that enhance the early mental health care for young people when it is needed.
What does this paper contribute to the wider global clinical community?
• Rural nurses are able to enhance •
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the mental health care of young rural people. Rural nurses are valuable rural clinicians because they are able to listen carefully, pay mindful attention, demonstrate authentic caring, engage emotionally, present with likeable traits (for example, casual age-appropriate fashionable clothing, similar interests, authenticity, gender) Rural nurses should be located in convenient places (for example, police stations, community welfare organisations and schools) for rural young people to access so they are ready to assist young people who are seeking mental health help.
Key words: case study, mental health, nurses, rural, young people Accepted for publication: 16 April 2015
Introduction It is well known that 75% of all adult mental health disorders have their onset prior to the age of 25 years (Kessler Authors: Rhonda L Wilson, RN, BNSc, MNurs (Hons), PhD, Lecturer, Mental Health Nursing, Indigenous Academic Advisor, School of Health, University of New England, Armidale, New South Wales; Kim Usher, RN, PhD, Professor, School of Health, University of New England, Armidale, New South Wales, Australia
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et al. 2005, Jones 2013), and that half of all lifetime mental health problems have an onset of 14 years of age or earlier (Kessler et al. 2005). The economic and human impact of these early adult experiences leaves young people at risk of Correspondence: Rhonda L Wilson, School of Health, University of New England, Madgwick Drive, Armidale, New South Wales 2350, Australia. Telephone: 61267733952. E-mail:
[email protected] twitter: @rhondawilsonmhn twitter: @kimusher3
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2638–2648, doi: 10.1111/jocn.12882
Original article
other long-term difficulties as a result of their mental illness, including personal, family, social, educational, financial and vocational consequences (Coughlan et al. 2013, . Unfortunately, the age-based classification systems for traditional mental health service provision is at odds with the developmental phases of adolescence and young adulthood, and this incongruence is a significant barrier for young people (Coughlan et al. 2013). In Australia in 2007, one in four young people aged 16– 24 years had experienced an anxiety, depression, or substance related disorder in the previous 12 months (National Mental Health Strategy 2009, Slade et al. 2009, Teesson et al. 2010). This is comparable to international morbidity rates, which report that young people first encounter a mental health problem during the ages of 12–25 years with approximately 20% of the world population in this age bracket affected (Kessler et al. 2005, Wei et al. 2013). Monitoring of the global burden of disease from 1990– 2010 has shown a steady increase in the burden of mental disorders which account for 74% of Disability-Adjusted Life Years (DALYs) of all 291 diseases measured globally (Murray et al. 2012). Murray et al. (2012) highlights a need for additional health system and health professional education investment because mental disorders currently rank in the top six DALYs growth demands internationally, and the trend is rising in conjunction with increases in the world population. Future demands for increased mental health care can be forecast based on large-scale research and ongoing longitudinal monitoring studies, and Murray and colleagues are continuing to build a global morbidity profile to inform health planning for the future (Murray et al. 2012). The prevalence of mental health disorders is such that the promotion and protection of mental health for young people is a global priority. This paper reports on research conducted in Australia that outlines ways in which rural nurses can contribute more effectively to the mental health care of rural young people.
Background A change in the paradigm underpinning the delivery of youth mental health has gathered momentum in recent times. Coughlan et al. (2011) challenge the traditional paradigm and have identified the need to reform youth mental health service delivery at an international level. Mental health experts across Australia, the United Kingdom and Ireland have banded together to call for a new approach to the delivery of mental health care for young people, and have developed an International Declaration on Youth Mental Health (Coughlan et al. 2011). As a result, mental © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2638–2648
Rural nurses and mental health care for youth
health experts are required to review the organisation of contemporary mental health service delivery and to develop new models of care in response to the targets of the Declaration’s associated action plan. This paper contributes to the call for improved youth mental health service delivery and suggests that the rural nursing workforce are important clinical assets, who are educationally prepared to take a more active role in the care of young people who require early mental health care. Age-based classifications have some limitations because human developmental phases and experiences vary considerably across the adolescent-young adult development spectrum. In particular, a gap has been identified for 16– 18-year-old people who do not always fit into the simplistic age-based categorisations because for some people in that age group, their lived experiences may include nontraditional lifestyles away from their families of origin. These young people may not neatly fit into either of the arbitrary mental health service streams, and are at risk of falling through service gaps (Coughlan et al. 2013). In contrast, young adults who are older than 18 years may live in dependent circumstances where they remain at home with their parents supporting them to various extents, and they find their circumstances at odds with the traditional adult mental health service stream provisions (Wilson 2007, Wilson et al. 2012). There is a need to adopt a young adult mental health service paradigm to better align services with the specific needs individual young people to aid the provision of appropriate mental health care, instead of continuing to use the traditional arbitrary age-based classification system as a criteria for service provision (Coughlan et al. 2013). Better initial treatment resulting from such a change offers considerable potential for improved health later in adult life. The mental health problems of young people have been identified as a health priority, with the highest prevalence of mental health problems and/or drug and alcohol problems found in the 12–24 year age group within the Australian population (Slade et al. 2009). The identification of emergent mental health problems is difficult as early signs and symptoms are often vague and easily misinterpreted as a difficult adolescent phase (ORYGEN Youth Health 2004). It has been recognised that the early treatment of mental health problems promotes recovery, while conversely the lack of early treatment results in slower recovery with less promising outcomes (Endacott et al. 2006). The duration of untreated mental health problems of young people in rural communities is known to be longer than for young urban people (Stain et al. 2010, Wilson et al. 2015). This disparity between the treatment of rural
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and urban young people has significant detrimental impacts on the longer term functional capacity, well-being and recovery of rural individuals, resulting in delayed social, educational and vocational developmental milestones of up to 10 years (Early Psychosis Writing Group 2010).
Mental health rural workforce The overall significant workforce shortage of specialist mental health professionals has meant that there is limited specialist mental health service provision in rural communities, and therefore limited access to professional help for mental health problems. However, a great deal of social capital exists in rural communities (Boyd et al. 2008). This social capital includes nurses who are the most plentiful providers of rural health services (Rajkumar & Hoolahan 2004). All registered nurses in Australia, similar to most other developed countries, are educationally and professionally prepared to provide initial mental health assessment and intervention to people with mental health problems (Happell et al. 2014). Rural nurses have been recognised as frequently operating as specialists in general care (Wilson 2007). These nurses represent skilled mental health helping capital in their local communities, yet this important mental health helping resource, or helping capital, is both underrecognised and under-used in providing early mental health help in rural communities. Many communities rely on the occasional visiting services by outreach mental health workers, and while this might provide a service opportunity to those consumers who have an established and enduring mental health problem, it is less likely to assist in the very early and emergent phases of mental health disorder. Visiting mental health workers are not locally embedded as rural social or helping capital and therefore are not privy to the unique networks and social structures within the local community where early detection is most likely to occur. Rural people are well known to value a close social proximity despite geographical distance (Boyd et al. 2008). Insiders within a rural community are distinctive participants within the social network of the community, while visiting outreach workers are not usually considered with the same regard as community insiders. In the rural context, these notions of insiders and outsiders are likely to impact on the degree of success of helping capital.
help for early mental health problems. Parents are the frequent helpers of their young adult offspring, and while they are frequently skilled in helping with the specific and unique needs of their adult or near-adult child; their helping can have the detrimental effect of containing emergent mental health problems within the family helping network for long periods of time (Wilson et al. 2012). When parents do seek help for their son or daughter, they have trouble identifying who is available to provide suitable assistance. Health care provision by professional mental health helpers is not immediately apparent to parents or young people, and so they continue to manage in a tenuous situation that is risk laden and escalating in terms of clinical complexity and recovery prognosis (Wilson 2009, Wilson et al. 2012).
Methods Research design A case study research design using mixed methods (Yin 2009) was chosen as an appropriate design to explore how young people with emergent mental health problems are helped. It was important to understand why there is an apparent delay in accessing mental health help by young rural people despite the general availability of nurses who represent professional mental health helping capital and who are the most abundant providers of services to rural people. Figure 1 provides a schematic overview of the QUAL-quan case study research design selected for this research, and demonstrates the chain of logic used to produce the reliable and trustworthy results of this research. Ethical approval to conduct the study was gained from the relevant committee (CEHR11-31, University of Canberra). A participant information sheet was developed and made available to potential participants. Completion of the survey was considered as implied consent. Signed consent forms were completed prior to all interviews. Participants were informed of their right to withdraw from the study.
Research question The research question was: What helps young rural people with emergent mental health problems?
Difficulty in seeking help
Setting
Previous research has demonstrated that young people and their families remain confused about where they might seek
The setting for this research was a rural and regional area of Northern New South Wales, Australia situated west of
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© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2638–2648
Original article
Rural nurses and mental health care for youth
Case study method research question: What helps young rural people with emergent mental health problems?
Underpinning theory: Social mental health helping capital - The sub set of social capital that is available in rural communities. These take the form of improving the mental health & well-being, or recovery of people vulnerable to mental health decline, & building resilience, robustness & protection from an insider/local position. (Stokols et al., 2013; Allen et al. 2012; Boyd et al. 2009).
Developing theory: Mental health helping capital already exists in rural communities (eg RNs). Mental health helpers should improve their understanding of help seeking vocabulary & characteristics. In doing so, help might be activated & achieved earlier
Context: Ecology of mental health in rural community
Revelatory case: Young rural people with emerging mental health problems in northern New South Wales, Australia.
Phenomenon: Beliefs, actions & behaviours that convey mental health helpfulness where people feel as though help has been achieved. Transactions & interactions of mental health helping.
quan data collection method 1: Online anonymous survey (survey monkey) (n81)
quan analysis: statistical analysis
Content
&
descriptive
QUAL data collection method 2: In-depth semi-structured interviews (n20)
QUAL analysis: Thematic analysis using computer assisted analysis – NVivo10 & traditional pen & paper
quan →QUAL intergration or merging of data. Interpretation of entire analysis.
Proposed theoretical propositions (Findings – conclusions drawn from & across QUAL & quan data): Improved model of mental health help provision for young rural people in northern New South Wales, Australia The primary recommendation from this research is to co-locate nursing assets in rural communities to places of convenient access for young people including police stations, schools and community organisations and in doing so, to promote the early engagement of young rural people into appropriate mental health care when it is required.
Figure 1 Schematic representation of case study mixed method research (Wilson, 2014a).
Rural nurses are ideal in rural settings because nurses contribute expertise by paying adequate attention, careful listening, provide authentic care which is mindfully present and understand the local context for young rural people. These nursing attributes are vital for instigating the first critical conversations and engaging young rural people and their families into meaningful and timely mental health care when it is needed.
the Great Dividing Range and midway between Sydney (NSW) and Brisbane (Qld), Australia. The region mirrors a NSW state health service region of 98,000 km2 (a land mass similar to that of South Korea) and a sparse population of approximately 200,000 people. Two large regional service centres dominate the region made up of many small © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2638–2648
towns and villages with large expanses of agricultural lands. The larger of the two regional centres contains a small public involuntary mental health hospital-based unit and the smaller regional centre has a very small public voluntary mental health hospital unit. The two main regional centres and one other smaller town operate public commu-
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nity based mental health services with outreach services provided to the outlying smaller communities. Transport between these communities is usually by private car with very limited public transport options available across the region. The agricultural sector is the dominant industry in the region which experiences a range of vulnerabilities including climate and market volatilities that have significant impacts on the population in the study region (Wilson et al. 2015).
Data collection In the first phase of the research, a cross-sectional survey developed specifically for the study was conducted. The survey was loaded onto a web-based survey data collection platform. Links to the survey were distributed using a social media strategy (Mannix et al. 2014) and distributed across
the rural health sector, and other rural industry, service and community sectors. A pilot study with nine respondents was compared to the actual survey results of 81 respondents to determine the reliability of the survey tool; the findings indicated moderate to strong strength of similarity was achieved across the two sample groups. The convenience sample (n = 81) was inclusive of a broad range of rural participants from relevant backgrounds (such as young people, families, health, community, education, justice and agricultural professionals), and across a full range of adult age groups. In phase two, in-depth interviews were conducted with 20 participants all of whom had personal experiences of caring for, a young person with a mental health problem or having been the recipient of care themselves as a young person. Table 1 describes the characteristics of the participant profile. In-depth interviews were conducted to further
Table 1 In-depth interview participant profile. Age: YA (60 years older adult); Personal experience: a personal experience of mental health problems during young adulthood either self, or close family member Age
Gender
Personal experience
60
Male Male
Personal experiences of mental health problems self
30–59
Female
30–59
Female
30–59
Female
>60