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A tsunami of mental health challenges on the horizon is helping to bring PHC nursing leaders across the Auckland isthmus together. FIONA CASSIE finds out more about the resulting collaborative project to upskill primary health nurses in mental health and addiction.

Such thoughts used to tumble through the head of primary health nurse Jacqui McMahon when mental health or addiction issues were flagged by patients.

But now, she says, she feels quite comfortable to just come out and ask the questions, knowing that whatever the answer may be she can provide something to support them. It may be a brief intervention, pointing patients in the right direction for some self-learning resources or liaising and referring them on to the appropriate community or secondary services.

McMahon is one of the 24 nurses who last year completed the inaugural mental health and addictions credentialing programme for primary health care nurses that is being offered to nurses across metropolitan Auckland.

In a near unprecedented collaboration, the nursing leaders from the super city’s three district health boards (DHBs) and seven primary health organisations (PHOs) developed and delivered the education programme to prepare nurses for credentialing in mental health from the New Zealand College of Mental Health Nurses/Te Ao Māramatanga.

An independent evaluation found the pilot programme a success, with pre and post-programme surveys showing a surge in nurse confidence reflected in a 90 per cent jump in screenings, brief interventions and referrals by the nurses. More funding for the collaborative training model has been approved by the three DHBs for a further year, so two more cohorts can be trained with the first of those due to start in the spring.

Lois Boyd	Rachel Calverly	Rudy Bakker

Nurse leaders keen to collaborate

The project began with two of the city’s largest PHOs – ProCare (with around 600 nurses) and Waitemata (around 210 nurses) – coming together to discuss using some DHB funding earmarked for nurse workforce development for mental health and addictions in primary health care (PHC); probably building on a successful programme already offered by Northland’s Manaia PHO.

Rachael Calverley, director of nursing and workforce development for Waitemata PHO, says it didn’t seem sensible to duplicate education programmes across Auckland so a large meeting was held to bring together the three DHBs: Auckland, Waitemata and Counties-Manukau; and the remaining five PHOs: Alliance Health Plus, National Hauora Coalition, Auckland PHO, East Health Trust and East Tamaki Healthcare.

“That meeting discussed that practically and logistically a collaborative approach would be the most sensible way to do this,” says Calverley. And by aiming to have a cohort of 10 nurses from each of the three DHB regions, the programme should see a spread of nurses from across the seven PHOs serving the city.

Soon after, Calverley was asked to chair the collaborative project’s steering group made up of nurse leaders, senior mental health nurses and planners and funders drawn from across the DHBs and PHOs.

Fortnightly meetings followed, as Calverley believed the group needed to “drive hard and fast” to show getting an Auckland-wide programme off the ground was possible. “Above anything else we needed to demonstrate for the benefit of nursing – and obviously for patients by improving patient outcomes – that we could commit to this and work with a really collaborative approach.”

With a highly competitive primary health care sector in Auckland, and the complex logistics of bringing together people from across the super city, this was no easy ask, but Calverley says the nurses involved were keen to put all politics aside and demonstrate a great collaborative nursing leadership model. “Which I think we did,” she says, adding that all seven PH0s now have dedicated nursing leaders, unlike when she took up her role three years ago and PHO nursing leaders were few and far between.

Pivotal to making it work was also a project manager employed by ProCare, who “did a lot of the grunt work” and a colleague from Waitemata PHO’s Comprehensive Care Limited supported Calverley two days a week, but she emphasises that everybody contributed “a little bit of the pie”.

The Auckland programme, built on the initial MH credentialing programme delivered by Manaia PHO, comprised six study days delivered over six months and interspersed with five group supervision sessions and ongoing reflective practice.

The seven PHO nursing leaders were charged with promoting the programme – which was free to participants but did not pay for nursing cover during study days – to their nurses. It was also promoted to school and public health nurses.

The result was that, within about half a year of the collaborative project being agreed to, 27 nurses attended the six-month programme’s first study day in June 2015 at the Waitakere Hospital conference centre. Twenty-four of them completed the programme and have since gone on to seek credentialing from the college.

MH tsunami on the horizon

The Metro Auckland programme was a direct response to the Government’s call for moving health services closer to home through better integrated care, including primary care taking a greater role in mental health.

“I really think there is a huge tsunami of mental health and addiction challenges on the horizon for us,” says Calverley. “And all the literature supports that.”

She says physical wellbeing and health tends to be core business for nurses in general practice, and mental health and addictions are not always well understood or well attended to in primary health. But mental health issues are becoming increasingly prevalent and a “huge amount” of the work nurses do in areas like long-term conditions management involved dealing with related anxiety and depression. “For example, we know that approximately one in three people with diabetes and one in four with heart disease also suffer from depression.”

The programme’s aim was to give nurses increased skills, knowledge and confidence so they could also regard mental health as part of their core business.

Evaluation of the programme indicates it is making a difference, with nurses reporting picking up issues earlier and helping to prevent them developing into bigger problems and draining health resources, says Calverley. “And a number of the nurses have become the ‘go to’ person in the practice because of their extra knowledge and skill.”

Professional supervision and reflection

Gaining knowledge and skills is one thing, but building confidence is another and a key component of building confidence was the credentialing programme’s group supervision sessions, believes Calverley.

Coordinating the supervisors of the geographically based groups – all experienced MH nurses – was Rudy Bakker, a mental health nurse working for East Health PHO as its mental health and addictions coordinator

Bakker says that professional supervision was quite poorly understood to start with because, although firmly embedded in MH nursing, it was quite a foreign concept to most PHC nurses, with some assuming it was about supervising a particular procedure rather than reflecting on and developing their own practices.

The peer group supervision was slotted in between the study days with occasional one-on-one supervision if particular issues came up.
Bakker says the sessions were multi-faceted and included reflecting on how the theory they were learning on study days related to their day-to-day practice, discussing the management of particular patients or patient groups and the nurse’s own personal development.

An hour and a half was allocated for each supervision session, mostly held in the evenings after work, but often they ran on for two hours to give each nurse a share of the time.

Calverley says while there were some challenges initially with using a group model overall using the less expensive option of group rather than one-on-one supervision had been “reasonably effective”. “It gave them the chance to talk through some challenging situations and get that ongoing coaching and mentorship.”

Lois Boyd, the College of Mental Health Nurses’ board member with responsibility for credentialing, says feedback she has received is that exposure to supervision has been one of the standout parts of the credentialing programme, with some of the Manaia PHO nurses continuing to organise their own peer supervision.

Jacqui McMahon, an integrated care co-ordinator for East Health PHO working with patients in their homes, says she found the supervision a good opportunity to talk with others, brainstorm ideas for how to do things better next time and share the good outcomes as well.

Bakker sees the credentialing programme as filling a much-needed gap as mental health and addictions issues have always been ‘bubbling’ in practices, but offering early interventions was outside the comfort zone of some clinicians. The programme not only builds confidence, he says, but he is also aware of some nurses in his supervision group now being inspired to pursue postgraduate study in mental health. He also believes that it would be good if one day supervision was the norm for practice nurses as well as mental health nurses like himself.

Conclusion

After a slow start the interest in credentialing has started to pick up pace, with now 61 primary health nurses across the country credentialed in mental health by the college, says Lois Boyd.

Most of those have come through the three Manaia PHO cohorts and now the Metro Auckland programme, but a handful of individual nurses have successfully sought credentialing. Programmes are also underway or being considered in the Western Bay of Plenty and Hawke’s Bay.

Boyd says credentialing assessment is carried out by board volunteers and it is currently investigating funding options for supporting the positive increase in demand for credentialing.

Meanwhile the 80-page evaluation report on the Metro Auckland credentialing programme has been distributed widely to nursing groups and the Ministry of Health by Calverley. “It is a model that could be picked up and utilised and I hope it is,” she says.

Maybe now more primary health nurses will be comfortable to ask the questions and offer the early intervention that can make a difference to their patients.