Abstract
The focus on the effectiveness of delivery of mental health care to indigenous people in New Zealand and Australia over the last decade has brought the issues of clinical practice outcome measurement, patient consultation, and cultural safety to centre stage. Quality of care and self management of illness are a priority for all mental health services and patients, with national standards being articulated in various policy, standards and competency documents.
Ascertaining the degree to which quality improvement and monitoring systems are enhancing professional practice and patient outcomes for indigenous people, however, is hindered by the difficulty of measuring such concepts. Furthermore, knowing how quality of care affects outcomes for patients is also problematic, especially when processes to identify the role of the patient in self-management of mental illness are poorly defined. Perhaps even more difficult is the measurement of patient and family involvement in the planning and delivery of care, factors that are now understood to be critical to outcomes for both New Zealand and Australia's indigenous and Pacific peoples. Measurement of how clinical practice influences the degree to which patients are actively engaged in the management of their illness is particularly challenging when cultural factors come into play, especially those factors that affect and influence intervention for any person's mental health condition toward recovery [1–15].
Culturally based mental health services in Australia
The majority of Australia's mental health services are not geared to incorporate cultural presentations and assessment, or self-management plans, let alone the culturally safe admission to hospital where the process of self-care can be nurtured. Major issues for Aboriginal Australians accessing mainstream and Aboriginal mental health services appear to be: (i) the need for mainstream services to be culturally sensitive and holistic; (ii) the need for self-determination; (iii) the need for non-Aboriginal workers to acknowledge historical factors relevant to social and cultural marginalization; (iv) the need for appropriate services available for critical incident review of those factors affecting families, persons and communities; (v) the need to develop special places of healing for indigenous people; and (vi) the need for appropriate training in Aboriginal culture and history for non-Aboriginal workers [16].
Aboriginal mental health information
The National Aboriginal and Torres Strait Islander Clearinghouse for indigenous health status claims that very little health information is currently available specifically for Aboriginal and Torres Strait Islanders [17]. For instance, it is still not possible to report on an equity target for mental health that includes Aboriginal and Torres Strait Islander people as a special needs group, due to fully validated data not being provided by State and Territory governments [18]. The identification of indigenous people in hospital records data is still incomplete and ranges from between 55% and 100% accuracy; the accuracy of records varies between regions.
Health statistics identify causes of death and incidence rates for physical health problems but there are no separate reliable data on incidence rates for mental health disorders [17]. Furthermore, reporting the rates of mental illness/disorder for the general population does not include problems that the indigenous community experiences, because it obscures relevant data [19]. There are figures that differentiate between non-Aboriginal and Aboriginal and Torres Strait Islanders on suicide rates, alcohol and substance abuse, injuries and violence to women, which offer some indication of the levels of emotional hardship, lived and experienced; but nothing definitive is compiled [20].
There is an embarrassing shortage of indigenous mental health nurses and an ongoing need to improve links between indigenous-specific services (such as Aboriginal-controlled health services) and mainstream services. The cultural competency and epidemiological awareness of non-indigenous workers continues to be an area of ongoing concern [4]. Cultural safety and awareness, as outlined by Ramsden [21] is an area of concern for many indigenous mental health workers, as well as their non-indigenous counterparts. This may especially be the case for Aboriginal people who have been estranged from their culture for whatever reason, recently identified as Aboriginal or Torres Strait Islander, or where they have grown up predominantly in the mainstream system.
The currently agreed set of national performance indicators identify that further research and development are required in Aboriginal communities in relation to the usefulness of self reported health status as a valid and reliable indicator of indigenous mental health. Given the way indigenous Australians interact culturally, incorporating a belief in kinship, story telling, community and spirituality, the development of process indicators that support personal interaction in clinical practice is essential to ensure that there has been an attempt to engage the patient and their family at a cultural and clinical level. Information is also needed on how Aboriginal people deal with emotional crises individually and collectively as part of their kinship structure [2, 4]. It is conceivable that such information will assist to manage the trajectory of the illness.
Culturally based mental health services in New Zealand
Aboriginal people represent 2.1% (476 900) of the Australian population [22] whereas Mâori people represent 14.5% of the New Zealand population, but experience mental health issues at a rate disproportionate to the non-Mâori population. Half of all Mâori experience mental health disorders during their lives, with the most common lifetime conditions being anxiety, substance misuse, and mood disorders. To care successfully for Mâori people in mental health services, nursing staff need to be conversant with, and sensitive to, the cultural needs of indigenous patients and the processes by which such cultural needs can best be met [8, 23].
Te reo is recognized as an official language of New Zealand's multicultural society and this is a unifying and empowering situation for Mâori. In respect to indigenous mental health services in New Zealand, there are currently more than 61 Mâori non-government mental health service providers and all health services now have access to Kaumatua (male and female elders); Kuia (wise elder woman) and Koroua (male elders) as consultants [8]. Structures to meet the mental health needs of Australian indigenous people are still developing, albeit at a slower rate than in New Zealand.
Mâori experience in the development of Mâori-led and -managed mental health services has proliferated over the last few years, particularly since the first set of health reforms in the early 1990s. Nevertheless, the number of Mâori who are trained and experienced in mental health service delivery at all levels is significantly lower than for non-Mâori [8]. The same can be said for the Australian mental health service landscape, where indigenous mental health workers are still by far in the minority.
In New Zealand the need for culturally appropriate and safe mental health care is widely recognized, especially in light of the disproportionate number of indigenous Mâori diagnosed with mental illness in New Zealand. Mâori admission and readmission rates to psychiatric services are also higher than for the general New Zealand population [24]. Mâori, however, are making more progress than Australian Aboriginal and Torres Strait Islander people towards ensuring that culturally appropriate mechanisms for the treatment of Mâori are introduced into health services. This is a potentially useful reference point for the Australian indigenous groups and mental health nurses and health workers. The New Zealand processes include Mâori-specific services that work with Mâori patients to assist them to self-manage their illness.
Mental health research and clinical practice priorities
The current priority areas for mental health research in both New Zealand and Australia include: (i) measuring the incidence and prevalence of different mental health problems (epidemiology); (ii) measuring the costs of treating patients with different types of mental health problems (casemix); and (iii) developing and assessing measures of mental health outcome, and quality and best practice [4, 25].
In Australia, however, the statistics as previously mentioned for indigenous mental health are more unreliable than in New Zealand. In New Zealand epidemiological and casemix development work has been done with Mâori. Although outcome measures of quality represent the desired end results of health care, validated process of care measures provide an important additional element to quality improvement efforts, as they illuminate exactly which provider actions could be changed to further improve patient outcomes. [26]
Role of process measures in the assessment of quality patient care
There is no doubt that quantitative and qualitative assessment of the process of care provided to patients is essential in determining why certain outcomes are achieved. The process indicators described here provide a sense of indigeneity (indigenousness) that the currently used mainstream process indicators of mental health care do not. This is particularly the case for the virtually non-existent guidelines and tools used in the mental health treatment of Australian indigenous people. The clinical (process) indicators are a strong example of how to involve patients in their own care but also in the involvement of their kin and community.
It has been recognized that outcome (an improvement in health) does not always justify the means. As Disley, from the New Zealand Mental Health Commission, has commented, ‘people can have very negative experiences between presenting and leaving the health service, despite overall achievement of better health’ [27]. Conversely, patients can be provided with the same broad category of care (e.g. both receive the same number of hours of counselling as determined by casemix measurement system) but experience vastly differing outcomes.
Written process measures provide information that is actionable; that is, they identify what is being done well, how to do it, and what needs continuous improvement. When process measures are developed so that they accurately reflect the care that clinicians are delivering, clinicians also feel accountable for them [1].
Process measures have particular relevance in the mental health context. Kingi and Durie have commented on this issue, stating that factors such as the cultural appropriateness of processes used to deliver care may significantly influence the outcome for Mâori patients [28]. In relation to Pacific peoples, Lui argues, ‘there is a need to develop measurement tools that are relevant, meaningful, and specific to Pacific peoples. The tools must measure outcomes, must be simple, and must take into account the processes, which is possibly more important to Pacific peoples than the outcome’[29]. While recognizing that perceived ‘patient satisfaction’ with services may not necessarily relate with positive patient outcomes and recovery,. Bridgman et al. argue that it is clear that the way in which services are delivered to patients will affect their recovery and their ability to engage in the process of care delivery [30]. Process factors that are reported to be central to patient recovery include culturally appropriate care, wellness-oriented care, patient participation in the planning and review of their care, and communication and consultation with whanau (family) [2, 9, 12].
Mental health nursing clinical indicators
Clinical indicators are measures of the ongoing or continuous processes that occur between the health worker, the patient and their family during an episode of care in a health service. They can be used to identify potential underlying factors in the process of care that may account for variance in patient outcomes. The two commonly reported types of clinical indicators reported in literature are sentinel events (serious, unacceptable, and often-avoidable aspects of care, or professional status) [31], and rate-based indicators (patient care events that may indicate a quality issue that requires review over a period of time and for which a certain rate of occurrence is acceptable) [31].
The O'Brien et al. study, summarized in this section, further classified a new criterion called ‘critical events’ as non-sentinel, rate-based clinical indicators that are considered crucial to achievement of practice standards that, if not achieved, identify a need for immediate rectification of the inherent practice [1, 2]. The O'Brien et al. study was funded by the Health Research Council of New Zealand to develop clinically and culturally valid indicators for the Australian and New Zealand College of Mental Health Nurse’ (ANZCMHN) 1995 Standards of Practice for mental health nursing in New Zealand [1, 2].
These standards require the mental health nurse to: (i) ensure her/his practice is culturally safe; (ii) establish partnership as the basis for therapeutic relationships with patients; (iii) provide nursing care that reflects contemporary nursing practice and is consistent with the therapeutic plan; (iv) promote health and wellness in the context of her/his practice; (v) be committed to ongoing education and contribute to the continuing development of the theory and practice of mental health nursing; and (vi) be a health professional who demonstrates the qualities of identity, independence, authority, and partnership [32].
To redress the aforementioned disproportionate rates of mental illness experienced by New Zealand's Mâori, that study used a bicultural research approach in an effort to ensure that the resultant process measures were both clinically and culturally valid. The bicultural focus of the research involved Mâori consultation and ongoing support with the project, Mâori membership on the research team, use of appropriate data collection and analysis methods for Mâori, the preservation of Mâori language, and the development of generic and Mâori-specific clinical indicators [1, 2]. These steps were taken to ensure that the unique perspectives of both Mâori and non-Mâori nurses and patients were sought when identifying those pivotal nursing practices that must be achieved for professional practices standards to be met.
Summary of the research design
The project used a four-stage research design that included (i) focus groups of expert Mâori and non-Mâori mental health nurses to generate statements of best mental health nursing practice; (ii) Delphi surveys to prioritize and validate the statements [33]; (iii) a pilot study and (iv) national audit of patient case notes to further validate and assess the interrater reliability of the clinical indicators [34]. A professional practice audit questionnaire made up from items unobservable in patient case notes was also trialled [35]. The project had ethical clearance from all participating District Health Board human ethics committees and Massey University human ethics committee. Participants gave informed consent and patient anonymity was preserved.
Outputs of the study included a set of patient notes clinical indicators that enable mental health nursing practice to be assessed by auditing the nursing documentation in patient case notes for occurrences of the practices described by the indicators [1, 2]. Nursing practices that are essential to achievement of professional practice standards that were not considered to be observable in case-note documentation were incorporated into a nursing survey instrument that purports to measure professional practice standards of nurses (mental health workers) [36].
In the national field study, the clinical indicators and questionnaire were applied in 11 government-funded mental health services throughout New Zealand. A total of 327 case notes were audited using a draft version of the Patient Notes Clinical Indicator (CNCI) Audit Booklet [37]. The rules specified in the accompanying guidebook [38] were used to guide researcher judgement regarding proof of occurrence.
Results
The results from the national field study indicated a wide variation in the degree to which the nursing practices inherent in the clinical indicators were being achieved, the range being as great as 0–100% for some clinical indicators. For example, CNCI 6 (Goals are set and reviewed in partnership with tangata whaiora) was achieved 69.8% of the time in the national field study overall; but it occurred 93.5% of the time in one service and only 33.3% of the time in another. (The term tangata whaiora refers to all patients of the mental health service. The term Mâori tangata whaiora refers to patients of Mâori ethnicity.)
Two clusters of clinical indicators from the national field study focused on patient recovery and cultural safety. They have been selected for further analysis in this paper because they typify the way that process issues have been said to influence patient outcomes [2, 27, 29]. The findings described here clearly demonstrate that the way in which services are delivered to patients impacts upon their ability to engage in the treatment processes, and ultimately in their recovery. This is especially the case for patients of Mâori and Pacific ethnicity in New Zealand, where the integrity of the process of care is critical to the outcome. The findings also illustrate the value of process measures in assessing clinical practice improvement programmes but particularly highlight the importance of culturally appropriate processes, and patient and family involvement in the self care dialogue.
Recovery-focused care
In the O'Brien et al. national field study, evidence of a recovery-based relapse prevention programme was evidenced in only 18.5% of files [2]. Available health and social resources were used to support tangata whaiora in the community 78.9% of the time. Nurses were in collaboration with significant others in providing wellness education on 29.2% of occasions. Mental health promotion education that focused on strengths and wellness was recorded as being provided 48% of the time. A mental health promotion intervention focusing on personal issues occurred in 54.4% of the files surveyed. There was a partnership between the nurse and the multidisciplinary team on 68.7% of occasions.
Cultural safety
In the O'Brien et al. national field study, evidence that tangata whaiora were given a choice of whether they wanted their cultural issues addressed was documented in 34.3% of the files surveyed during the national field study [2]. This result flags a need to offer a choice on a further 65.7% of occasions. Of the 75 files in which patients had identified specific cultural issues, thereby requiring the implementation of the linking clinical indicator ‘if tangata whaiora has identified specific cultural issues, then access to relevant cultural support is provided for all issues’, the nurse had provided relevant cultural support for the identified issues 72% of the time.
Evidence of Mâori cultural assessment as having been conducted for Mâori tangata whaiora was found in only 22.9% of occasions, indicating that in 77.1% of files the patients had not received a Mâori cultural assessment. A Mâori mental health nurse and/or cultural advisor had been consulted regarding care of Mâori tangata whaiora and/or whanau 64.7% of the time. Only 22.7% of Mâori patients were given a choice of having a Mâori mental health nurse as an advocate.
The mental health nurse observed and supported Mâori tikanga/kawa (protocols/procedures) in only 43.9% of the applicable files. The use of rongoa (traditional medicine) was found in 18 patient files, in which the nurse had supported the patient in its use on (n = 14) 77.8% of occasions. Deficits in the provision of culturally safe practice were identified in 44 files, and these deficits were rectified only 25% of the time (n = 11), indicating that on 75% of occasions there was no documented evidence of remedial action being taken when deficits in culturally safe practice were identified.
Discussion
Culturally sensitive clinical indicators, as developed by O'Brien et al. [37, 38] provide mental health professionals with a quality mechanism to assess the effectiveness of the processes of clinical nursing care provided. The ability of nursing managers and clinicians to identify areas in which service delivery is not meeting standards, as well as areas of exemplary practice and patient engagement, is critical to the effective allocation of resources to areas that most require support. Furthermore, knowledge of the quality of the processes of care delivery may provide valuable insight into variance in patient outcomes measures for which similar casemix inputs were received. Indeed, it is also apparent that such measures have enormous cross-disciplinary relevance in the provision of mental health care.
It is clear that the major deficits in clinical indicator achievement in the O'Brien et al. study were related to the provision of culturally and legally safe care that is recovery focused and based on therapeutic relationships with patients [1]. Cultural issues, patient rights, and recovery focus have been major areas of New Zealand's mental health policy development in recent years and should, therefore, have resulted in higher levels of achievement of related clinical indicators. Yet, there is only partial evidence from the national field study that the competencies and practices inherent in such policies are being incorporated into the practice of mental health nurses in any consistent fashion.
It also appears that nurses aim to provide care associated with clinical priorities, but not with a particular focus on meeting any predetermined professional benchmark in the delivery of that care. This type of care is very reactive and not necessarily planned or proactive; thus there is a continued need for quality of care improvement. Improvements in care, however, can occur only if appropriate measures are taken to support standards of practice and national benchmarks for mental health nursing. Such mechanisms of support are mainly concerns for funding agencies, educators and managers of facilities and nursing staff.
Conclusion
Despite the recent proliferation of national standards and policies in New Zealand regarding mental health-care requirements, there was only partial evidence in the O'Brien et al. study that the competencies and practices inherent in such policies are being incorporated into the practice of mental health nurses in any consistent fashion [1]. Attention to underlying causes of poor achievement of process factors such as recovery-focused care is likely to positively impact on patient outcomes and ultimately patient recovery.
A national benchmarking scheme to systematically measure process factors in mental health service delivery would enable long-term tracking of clinical nursing practice and comparisons between services. Such systems would have great relevance for current efforts to increase professional sensitivity to indigenous and minority ethnic patients of mental health services. Process measures can also guide the mental health worker in their interactions with patients and enable a self-care dialogue to be promulgated. An education programme for mental health nurses and other mental health professionals, centered around culturally and clinical valid clinical indicators such as those broadly and specifically described here, would promote the philosophical underpinnings of recovery-oriented care that is appropriate to the cultural requirements of mainstream and indigenous client groups.
One mental health service in New Zealand has already experienced improvements in their registered nurses clinical practice, and in patient outcomes such as reduced readmission, seclusion, and absence-without-leave rates, as a result of an education programme centered on the clinical indicators described in the present paper [39].
Clinical indicators, as measures of the process of clinical care, fill the gaps in knowledge between casemix and outcome measures. They also provide another means of tracking the long-term relationship between the patient and service provider. Process measures enable a much greater understanding of the quality of the actual care being provided to patients in an episode of care, and whether practice is occurring at levels required by legal and professional standards. Ultimately, however, the measurement of process indicators is relevant only if it leads to improved long-term health outcomes. Thus, outcome and process measures go hand in hand. Future research is planned to examine the link between improved achievement of process measures of care and patient outcomes in mental health.
The applicability and universality of the O'Brien et al. clinical indicators applied to the international mental health sector [1, 35–37], now need to be determined. Could the tools described here be modified for appropriateness to the Australian context and beyond? What are the culturally valid indicators of quality care for indigenous people in other countries? Identification of specific clinical indicators for indigenous populations aids mental health workers by giving them the tools by which to measure their own clinical practice alongside professional and national standards of practice, and to identify areas in which improvements can be made for the ultimate benefit of our mental health patients.