Pregnant with possibility: Migrant motherhood in New Zealand

First published in Mindnet  Issue 6 – Winter 2006

When my family arrived in New Zealand in 1975 there were very few people from Goa living here. We quickly got know every Goan in the country and, in hindsight, this connection provided me with an early interest in and focus on both maternal mental health and migrant mental health. Two Goan women we knew developed mental health problems that were devastating for themselves and their families. For one, it led to suicide and for another a lifelong history of mental illness and loss. Hardly good outcomes! This was a time when it was hard to maintain our culture. Thankfully, the more recent shift in focus to encompass settlement rather than just immigration will further enhance the well-being of ethnic communities in New Zealand.

There are still large research, policy and practice gaps in the area of migrant motherhood, which I’d like to address in this article. I’d like to start by highlighting the significance of migrant motherhood, which has potentially long term and wide ranging impacts on members of a family. I’ll then talk about the changing demographics of New Zealand society and suggest that health workers need to broaden their focus for working with New Zealand’s increasing diversity and develop culturally safe ways of working with migrants and their families. Lastly, I’ll share my experiences of research with migrant mothers from different ethno-cultural communities.

When migrants “cross borders they also cross emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. Boundaries are crossed when new identities and roles are incorporated into life” (Espín, 1997, p.445). Border crossing can involve trauma related to migration and a psychic split (Mohamed & Smith, 1999).

Migration policies favour women (and families) of childbearing age, so it is no surprise that having a baby is a common aspect of a woman’s settlement experience. Motherhood and migration are both major life events. They present opportunities but incur the risk of mental health problems, more so when they are combined. Many cultures and societies have developed special perinatal customs that can include diet, isolation, rest and household help. But these traditional and specific practices and beliefs that assist in the maintenance of mental health can be lost in migration (Kruckman, 1992). Women are separated from their social networks through migration and must find new ways to recreate these rituals or lose them (DeSouza, 2002). Research suggests that the loss of support, protective rituals and supportive networks compounded by a move to a nuclear family-model can result in isolation and postnatal depression (PND) (Barclay & Kent, 1998; Liamputtong, 1994).

Access to help and support can be impeded if the mother has language and communication problems.

Migrant mothers sometimes face additional cultural and social demands and losses that include the loss of lifestyle, control, sense of self and independence, family and friends, familiar birthing practices and care providers.

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

In a study of 119 pregnant immigrant women in Canada, Zelkowitz et al., (2004) found that the transitions associated with migration placed women at higher risk of depression. Forty-two percent of participants scored above the cut-off for depression. Depressive symptoms were associated with poorer functional status and more somatic symptoms. Depressed women reported a lack of social support, more stressful life events and poorer marital adjustment. In Australia, Liamputtong and Naksook (2003) found that Thai women who became mothers in Australia had several main concerns, including social isolation, different childrearing and child disciplinary practices, and the desire to preserve their culture. Findings of isolation, loneliness and negotiating between traditional and Western childbirth rituals are common in these studies and were significant issues in my own New Zealand research (DeSouza, 2006c). This research strongly suggests that migrant mothers, regardless of origin, benefit significantly from effective and familiar social support networks.

Psychiatric illness occurring at this time can have an adverse effect not only on the woman herself but also on her relationships, family, and the future development of her infant. The impact on a child of a mother’s depression can include behavioural problems, relationship problems and cognitive deficits. Research shows that infants who had a mother who was depressed in its first year of life are more likely to develop cognitive deficits and behavioural problems than infants whose mothers were not depressed in that first year (Beck, 1998).
A review by Goodman (2004) of literature from 1980 to 2002 found 20 research studies that included incidence rates of paternal depression during the first year postpartum. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.

Changing demographics

Many societies are grappling with issues of citizenship and participation in the context of globalisation, increased migration and increasing diversity. In Europe, one in every fifteen people was born overseas, in the US it rises to one in eight and in New Zealand it is one in five (DeSouza, 2006a). This presents unique challenges and opportunities for service providers to develop skills and competence for working with this diversity, especially as migration is going to be a key source of population increase. Census projections to 2021 suggest that Māori, Pacific and Asian populations will grow at faster rates than the European population but for different reasons. The Asian population is expected to more than double mainly due to net migration gains while Māori and Pacific people’s increases will be due to their higher fertility rates (Statistics New Zealand, 2005).

The Asian community has the highest proportion of women (54%), followed by Māori and Pacific (53% each) and European (52%) (Scragg & Maitra, 2005). Asian women are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups and to some degree this is a reflection of migration policy with Asian women using the opportunity to study or work. It is thought that 23% of New Zealand females were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands (Statistics New Zealand, 2005). The 2001 Census revealed growing numbers of Māori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), despite the dominance of the European/Pākehā who make up 79.6% of the population. In the period between 1991-2001, women originating from the Republic of Korea have increased 23 times from 408 to 9,354, women from China have quadrupled from 4,620 to 20,457 and women from South Asia have doubled in the same time period. Women from Africa (primarily South Africa, Zimbabwe and Somalia) have quadrupled in number (Statistics New Zealand, 2005). This has significant implications for the development and delivery of health services to women.

Cultural competence?

Working on a postnatal ward of a women’s hospital several years ago led me to question whether cultural safety had prepared the nursing and midwifery workforce for working with ethnic diversity1. Cultural safety, which refers to the experiences of the client, and cultural competence, which focuses on the practitioner and their capacity to improve health status by integrating culture into the clinical context, have been gaining prominence, but what do they actually mean?

The introduction of the Health Practitioners Competence Assurance Act 2003 has meant an additional responsibility to ensure the cultural competence of health practitioners. Cultural competence can be defined as “the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, Green, & Carrillo, 2002). Cultural competence includes not only the interpersonal relationship (for example, training and client education) but also the organisational (for example, involving community representatives) and the systemic (for example, providing health information in the appropriate language, collecting ethnicity data).

The New Zealand Medical Council recently consulted its members on cultural competence (The New Zealand Medical Council, 2005). The consultation document includes a proposed framework and says that cross-cultural doctor-patient interactions are common, and doctors need to be competent in dealing with patients whose cultures differ from their own.

It cites the benefits of cultural competence as:

  • Developing a trusting relationship;
  • helping to get more information from patients;
  • improving communication with patients;
  • helping to resolve any differences;
  • increasing concordance with treatment and ensuring better patient outcomes; and
  • improved patient satisfaction.

For cultural competence to occur there is a need for the voices of ethnic communities to be considered in service development, policy and research. Despite the long histories of migration to New Zealand, ethnic communities have been absent from discussions of nation building and health care policy (DeSouza, 2006b). This has in part been due to the relatively small numbers of migrants from non-traditional source countries until the early 1990s, which meant that that the concerns of a relatively homogenous Pākehā people were reflected in policy (Bartley & Spoonley, 2004). This monoculturalism continues to be challenged by the increased prominence of Māori concerns since the 1970’s and increasing attention to biculturalism and health outcomes for Māori. Developments have also occurred with regard to Pacific peoples, largely around health disparities, but this concern has not been extended to ethnic communities despite their increasing visibility in long and short-term migration statistics. This is partly due to an assumption of a ‘health advantage’ of immigrants on the basis of current migration policy, which selects healthy people. However, evidence is growing that this advantage declines with increasing length of residence in a receiving country (Johnstone & Kanitsaki, 2005).

Cultural safety

When Britain assumed governance of its new colony in 1840, it signed a treaty with Māori tribes. Te Tiriti O Waitangi/The Treaty of Waitangi is today recognised as New Zealand’s founding document and its importance is strongly evident in health care and social policy. As an historical accord between the Crown and Māori, the treaty defines the relationship between Māori and Pākehā (non-Māori) and forms the basis for biculturalism.

Durie (1994) suggests that the contemporary application of the Treaty of Waitangi involves the concepts of biculturalism and cultural safety, which are at the forefront of delivery of mental health services. This means incorporating “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9) into the care that is delivered. There is an expectation that mental health staff in New Zealand ensure care is culturally safe for Māori (Mental Health Commission, 2001). Simply put, “unsafe practitioners diminish, demean or disempower those of other cultures, whilst safe practitioners recognise, respect and acknowledge the rights of others” (Cooney, 1994, p.6). The support and strengthening of identity are seen as crucial for recovery for Māori along with ensuring services meet Māori needs and expectations (Mental Health Commission, 2001). Cultural safety goes beyond learning about such things as the dietary or religious needs of different ethnic groups; it also involves engaging with the socio-political context (DeSouza, 2004; McPherson, Harwood, & McNaughton, 2003). However, critics suggest that cultural safety needs to encompass new and growing ethnic communities. Whilst in theory cultural safety has been expanded to apply to any person or group of people who may differ from the health professionals because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997), in practice the focus remains on the relationship between Pākehā and Māori, rather than migrants (DeSouza, 2004) and other communities (Giddings, 2005).

Expanding the bicultural to a multi-cultural framework is necessary without removing the special status of tangata whenua. New Zealand’s reluctance to encompass multiculturalism as a social policy framework has been shaped by two key factors, according to Bartley and Spoonley (2004). The first is the location of historical migration source countries such as the United Kingdom and Ireland, which shaped the development of activities and concerns (as they argue, racist and Anglo centric assumptions of a colonial New Zealand) and, secondly the rise in concerns over indigenous rights and the Treaty of Waitangi, which have precluded discussion around nation and nationality. Thus while countries such as Canada and Australia were developing multicultural policies, New Zealand was debating issues of indigeneity and the relationship with tangata whenua. As a result, New Zealand has yet to develop a locally relevant response to cultural diversity (multiculturalism) that complements or expands on bicultural and Treaty of Waitangi initiatives (Bartley & Spoonley, 2004).

Need for a migrant health agenda

It is, I hope, clear by now that there is a need to develop a migrant mental health agenda, yet much of the previous New Zealand research has omitted the experiences of migrant mothers. The Centre for Asian and Migrant Health Research at AUT University and Plunket have begun a collaborative project with funding from the Families Commission and Plunket volunteers to understand the experiences of migrant mothers from the United Kingdom, the United States, South Africa, Palestine, Iraq, China, India and Korea, which it is hoped will assist in the development of services and policy.

There is a misguided view that migrants do not experience compromises in their health status despite the changes in income and social support and the new stressors they encounter, which can lead to cumulative negative effects and the need to access mental health services. The neo-liberal trajectory that our society has taken has precluded an interest in the wellbeing of migrants who often face culture-related barriers in using mental health care services. Other than a literature review produced by the Mental Health Commission (Mental Health Commission, 2003), which recommended that mental health services become more responsive to Asian people, there has been little in the way of strategic or long term planning with most of the developments in this area coming from the community and voluntary sector.

Conclusion

Migrants face additional stressors that can increase their need for mental health services. Migration can be a traumatic life event. Becoming a mother in an unfamiliar country adds to this already traumatic event, leading migrant mothers to be more at risk of experiencing depression or other mental health issues. Yet, research on the migrant experience in New Zealand is limited and studies on postnatal depression have excluded migrants in the past.

As the number and diversity of migrants increase, their well-being becomes an increasingly important issue for policy makers and health professionals. The time is right to begin a dialogue about how mental health services can work effectively with this diversity. Migrant mothers hold the key to a family’s future well-being and so are an important group for us to understand and support. In the absence of policy there is a need to advocate for migrant mental health service development, building on the many grassroots initiatives that are already occurring. Beyond this, further discussion is needed as to how cultural competency and cultural safety can be applied to migrant populations.

1. ‘Ethnic’ is a term devised by the Department of Ethnic Affairs and refers to people who are neither Pakeha, Maori or Pacific).

References

Barclay, L., & Kent, D. (1998). Recent immigration and the misery of motherhood: a discussion of pertinent issues. Midwifery, 14, 4-9.

Bartley, A., & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi revisited: perspectives on the Treaty of Waitangi (2nd ed., pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beck, C. T. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27(1), 43-44.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Retrieved 27th April, 2005, from www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf

Cooney, C. (1994). A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.

DeSouza, R. (2002). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Massey University, Albany, New Zealand.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R. (2006a, May 26th). Cultural Diversity and Context: Responding to the needs of ‘This Child” in “This Family”. Paper presented at the 5th Annual Child Law Conference, Lexis Nexis, Auckland.

DeSouza, R. (2006b). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, In press.

DeSouza, R. (2006c). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Auckland, NZ: Muddy Creek Press.

Durie, M. (1994). Whaiora: Maori health development. Auckland; Oxford: Oxford University Press.

Espin, O. M. (1997). The role of gender and emotion in women’s experience of migration. Innovation: The European Journal of Social Sciences, 10(4), 445-455.

Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 2-35.

Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.

Kohen, D. (2001). Psychiatric services for women. Advances in Psychiatric Treatment, 7, 328-334.

Kruckman, L. D. (1992). Rituals and support: An anthropological view of postpartum depression. In J. A. Hamilton & P. N. Harberger (Eds.), Postpartum psychiatric illness: a picture puzzle (pp. 137-148). Philadelphia: University of Pennsylvania Press.

Liamputtong, P. (1994). Asian mothers, Australian birth: pregnancy, childbirth, and childrearing: the Asian experience in an English-speaking country. Melbourne: Ausmed Publications.

Liamputtong, P., & Naksook, C. (2003). Life as mothers in a new land: The experience of motherhood among Thai women in Australia. Health Care Women International, 24(7), 650-668.

McPherson, K. M., Harwood, M., & McNaughton, H. K. (2003). Ethnicity, equity and quality: Lessons from New Zealand. Quality & Safety in Health Care, 12(4), 237-238.

Mental Health Commission. (2001). Cultural Assessment Processes for Maori – Guidance for Mainstream Health Services. Wellington: Mental health commission.

Mental Health Commission. (2003). Mental Health Issues for Asians in New Zealand: A Literature Review. Wellington: Mental health commission.

Mohamed, C., & Smith, R. (1999). Race in the therapy relationship. In M. Lawrence, M. Maguire & J. Campling (Eds.), Psychotherapy with women: feminist perspectives (pp. 134-159). New York: Routledge.

Ramsden, I. (1997). Cultural Safety: Implementing the concept – The Social Force of Nursing and Midwifery. In P. T. Whaiti, M. McCarthy & A. Durie (Eds.), Mai i rangiatea (pp. 113-125). Auckland, NZ: Auckland University Press and Bridget Williams Books.

Statistics New Zealand. (2005). Focusing on women. Retrieved 25th January, 2005, from www.stats.govt.nz/analytical-reports/children-in-nz/growing-ethnic-diversity.htm

The New Zealand Medical Council. (2005). Assuring Medical Practitioners’ Cultural Competence (draft document for consultation). Retrieved 3rd May, 2005, from www.mcnz.org.nz/portals/1/news/culturalcompetence.pdf

Zelkowitz, P., Schinazi, J., Katofsky, L., Saucier, J. F., Valenzuela, M., Westreich, R., et al. (2004). Factors Associated with Depression in Pregnant Immigrant Women. Transcultural Psychiatry, 41(4), 445-464.

Researching the Health Needs of Elderly Indian Migrants to New Zealand

DeSouza, R. (2006). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, 20 (1&2), 159-170.

The older adult population in New Zealand is increasing and becoming more ethnically diverse. With this change comes a requirement for health and social service professionals to become more knowledgeable about the cultural needs of their clients and to provide care that is cognisant of language, culture and religion. Indians have a long history of settlement in New Zealand; however this has not been reflected in policy or service provision. The reasons for this include a focus on the bicultural relationship with indigenous Mâori and a relatively small Indian population. The Immigration Act 1987 has led to an increase in the cultural diversity of migrants and the number of Indians. Policy has not kept pace with demographic changes and there is a need to develop the health sector to work with Indians and other migrants. This article begins by tracing the changing demographics of age and ethnicity in New Zealand and the relationship with migration policy. Indian history, settlement and health in New Zealand are explored then a brief overview of existing research is presented along with the identification of gaps and recommendations for an expansion of current health research and practice agendas such as cultural safety and ethnicity data collection.

Keywords: Indians, health, settlement, Asian, older adults, New Zealand

Migrant Populations

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

The art of walking upright here

Is the art of using both feet.

One is for holding on.

One is for letting go. (Colquhoun, 1999, p.32)

Glenn Colquhoun’s poetry captures the challenge dislocation from home and family. The migrant or refugee has to somehow hold on to their legacy and their heritage whilst simultaneously letting go of those things that cannot be maintained in a new country. They must let go to create new lives, so they can stake a new claim of belonging; a new place to stand.

One in five New Zealanders was born overseas. This rises to one in three in Auckland. For many, migration is seen as a way of obtaining a better life, particular for ones children. Whilst many migrants make informed decisions, this needs to be seen as a continuum between full choice and no choice. This can been viewed as a ‘pull’ effect (migrants are drawn to a new country for the opportunities available) or a ‘push’ effect (the motivation is simply to leave where they are). Migrants can be defined as people who were born in one country and then move to another under an immigration programme. In New Zealand this consists of three main streams:

  •  Skilled/Business: Which relates to attracting migrants with qualifications and skills, or the potential to create business opportunities in New Zealand.
  • Family sponsored: Where New Zealand citizens or permanent residents can sponsor family members to the country.
  • Humanitarian: This includes refugees and allows for family members to be granted residence if there are serious humanitarian concerns.

Refugees that have resettled in New Zealand mostly originate from Africa, the Middle East, South East Asia and Eastern Europe. Refugees differ from voluntary migrants because they were forced to leave their home and have little if any choice in selecting their destination. They are at the extreme end of the ‘push’ effect, often having fled from situations of conflict and human right abuses. This has important implications for the provision of  health care, as they might not have had access to preventative and treatment services. Most refugees arriving in New Zealand will spend six weeks at the Mangere Refugee Reception Centre (MRRC) in South Auckland. There are estimated to be 20.6 million refugees and displaced people in need of protection and help (UNHCR, 2003). Currently New Zealand accepts a United Nations-mandated quota of 750 refugees per year, plus approximately the same number again of asylum seekers. Asylum seekers are people seeking refugee status without legal documentation. They often experience depression, hopelessness and helplessness related to stress and socio-economic deprivation. Even where migration is an informed choice, the result can still be isolation and loss of financial independence. Before migration, one often only considers the positives; it can be difficult to understand the adjustment that is required and to come to terms with the losses of family, friends, culture and familiarity.

In this chapter I present a view of cultural safety and how it is relevant to health from the perspective of a migrant with a view to informing those who will be caring for the needs of migrants and refugees. I will briefly review the history and tensions around migration and migrants. Anecdotes from my clinical experience are woven through the text to present multiple layers to reflect the complexity of the experience and reflective questions are posed to increase self-awareness. I conclude by offering a range of strategies for working with diversity.

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