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The Organizational Sustainability of Pacific Mental Health Services in New Zealand: What Influences Success?
No full textINTRODUCTION
The growing burden of mental disorders in New Zealand as elsewhere is of particular concern to the health sector. In New Zealand, the over-representation of Pacific people in mental health statistics led to the establishment and growth of ethnic-specific services. Reforms and policy directives have changed the focus from growth to sustainability, without establishing a translational evidence-base that describes how organizational sustainability operates and is influenced in this context. An empirically grounded collective understanding of sustainability would provide services and stakeholders a common language base, thus, minimising ambiguities. This study sought to define organizational sustainability as it applied to the New Zealand Pacific mental health context and to develop a conceptual framework to help stakeholders identify the key factors that influence sustainability and are critical for success.
METHOD
A methodological framework was developed, combining the key elements of talanoa (a Pacific approach to dialogue and engagement), strengths-approach and narrative analysis. In-depth, face-to-face interviews were conducted with thirty-one senior Pacific mental health providers, policy makers and academics. Observation notes and key documents supplemented the interviews. Three key narrative analysis techniques - thematic, structural and interactional - were used to analyse the data. The collective story of organizational sustainability was categorised via themes and examined in light of the research questions.
RESULTS
Two conceptual frameworks for organizational sustainability were developed; one, embedded within a Pacific outrigger canoe image, while the second illustrated how the factors interacted. A guide to sustainability was also developed to translate the findings into a resource for services to address sustainability issues.
Participants sought to define organizational sustainability using their experiences and observations from the mental health sector. They struggled considerably with this task, raising concerns about the lack of dialogue in the sector. The reform environment within which the interviews occurred influenced participant definitions, thus, associating organizational sustainability with funding and performance reporting aspects.
The factors influencing sustainability were grouped in one of four categories: internal contextual factors, external contextual factors, over-arching factors and critical success factors. The internal factors were the Individual, the Team, the Leader, and the Organizational climate. Political and Financial factors comprised the external context. Culture, Hierarchies and Organizational Stigma were identified as the over-arching factors. The critical success factors were Effective communication, Shared values & beliefs, Stakeholder engagement & understanding, and Relationship strength.
CONCLUSIONS
Reforms and policy directives are pushing New Zealand Pacific mental health services to demonstrate sustainability, and are perceived as threats to service delivery. At its core, sustainability concerns the ability of an organization to maintain its activities at a certain rate or level, and can only be achieved if the challenges are examined via a systems approach to understand the key factors and their influence on sustainability. This study acknowledges the collective story of those working in the sector. The results indicate a need for Pacific mental health services to build resilience and flexibility to mitigate ill-effects, and generate their own solutions, which are strongly embedded in the cultural values underpinning their identity to deliver sustainable services for generations to come
The Organizational Sustainability of Pacific Mental Health Services in New Zealand: What Influences Success?
Full text linkINTRODUCTION
The growing burden of mental disorders in New Zealand as elsewhere is of particular concern to the health sector. In New Zealand, the over-representation of Pacific people in mental health statistics led to the establishment and growth of ethnic-specific services. Reforms and policy directives have changed the focus from growth to sustainability, without establishing a translational evidence-base that describes how organizational sustainability operates and is influenced in this context. An empirically grounded collective understanding of sustainability would provide services and stakeholders a common language base, thus, minimising ambiguities. This study sought to define organizational sustainability as it applied to the New Zealand Pacific mental health context and to develop a conceptual framework to help stakeholders identify the key factors that influence sustainability and are critical for success.
METHOD
A methodological framework was developed, combining the key elements of talanoa (a Pacific approach to dialogue and engagement), strengths-approach and narrative analysis. In-depth, face-to-face interviews were conducted with thirty-one senior Pacific mental health providers, policy makers and academics. Observation notes and key documents supplemented the interviews. Three key narrative analysis techniques - thematic, structural and interactional - were used to analyse the data. The collective story of organizational sustainability was categorised via themes and examined in light of the research questions.
RESULTS
Two conceptual frameworks for organizational sustainability were developed; one, embedded within a Pacific outrigger canoe image, while the second illustrated how the factors interacted. A guide to sustainability was also developed to translate the findings into a resource for services to address sustainability issues.
Participants sought to define organizational sustainability using their experiences and observations from the mental health sector. They struggled considerably with this task, raising concerns about the lack of dialogue in the sector. The reform environment within which the interviews occurred influenced participant definitions, thus, associating organizational sustainability with funding and performance reporting aspects.
The factors influencing sustainability were grouped in one of four categories: internal contextual factors, external contextual factors, over-arching factors and critical success factors. The internal factors were the Individual, the Team, the Leader, and the Organizational climate. Political and Financial factors comprised the external context. Culture, Hierarchies and Organizational Stigma were identified as the over-arching factors. The critical success factors were Effective communication, Shared values & beliefs, Stakeholder engagement & understanding, and Relationship strength.
CONCLUSIONS
Reforms and policy directives are pushing New Zealand Pacific mental health services to demonstrate sustainability, and are perceived as threats to service delivery. At its core, sustainability concerns the ability of an organization to maintain its activities at a certain rate or level, and can only be achieved if the challenges are examined via a systems approach to understand the key factors and their influence on sustainability. This study acknowledges the collective story of those working in the sector. The results indicate a need for Pacific mental health services to build resilience and flexibility to mitigate ill-effects, and generate their own solutions, which are strongly embedded in the cultural values underpinning their identity to deliver sustainable services for generations to come
Quality, Discrimination, and Participation in Mental Health Research
No full textThis study focuses on the issues underpinning non-clinical mental health research involving people with experience of mental illness. It examines a participatory action research project undertaken with the New Zealand Mental Health Commission as well as a systematic review of recent non-clinical mental health research, including New Zealand research. The systematic review focuses on the issues that researchers encounter when formulating their research - the ethical, methodological and research design issues that researchers have to address. An equally important issue is the role that people with experience of mental illness play in research. The findings focus on this, as well as the implications for the quality of mental health research, issues of discrimination, and the appropriate use of language in mental health research. This study queries whether people with experience of mental illness should be regarded as incompetent or incapable when seeking informed consent in mental health research, as well as questioning the appropriateness of trying to 'empower' people with experience of mental illness in the research process
Unpacking the black box of respite: A realist evaluation of a non-clinical crisis intervention
Full text linkThe prevalence of psychological distress and suicidality are issues of international concern. This concern includes discussion in both academic literature and the public sphere about the failure of existing services to adequately meet the needs of people experiencing acute distress and suicidal thoughts. Reflecting the medicalisation of distress and suicidality, discussion of these issues is heavily focussed on the need for an expansion and improvement of clinical services. Meanwhile, the role of non-clinical, community-based organisations in providing comprehensive support to people experiencing acute distress remains widely overlooked. Such services are scarce, and research into these services is even more so.
This thesis undertakes a realist evaluation of the Taranaki Retreat – a charitable organisation, staffed by non-clinical volunteers, which provides free respite for people who are experiencing distress and suicidal thoughts. Broadly, this thesis asks: How does respite function to support people experiencing a state of crisis? As a realist evaluation, it specifically asks: What are the key outcomes for service users of the Taranaki Retreat? What are the underlying mechanisms that generate these outcomes? And finally, What are the key contextual factors in which these mechanisms operate? By answering these research questions and developing theory at a middle-range of abstraction, this thesis aims to provide an explanation of how respite, as a non-clinical form of crisis intervention, functions to support people who are suicidal and/or acutely distressed. The purpose of developing such an explanation is to support the improvement of crisis intervention services.
Realist evaluation, which serves as the methodological framework of this thesis, is a form of theory-driven evaluation. Developing, testing, and refining a programme theory in this study involved a retroductive process over two phases of data collection and analysis. In phase one, an initial programme theory was abductively inferred following a review of related literature, interviews with the programme designers, and analysis of key policy and procedure documents. In phase two, that initial theory was deductively tested and inductively refined using data gathered from four qualitative methods: participant observation, a focus group with staff and volunteers, interviews with former guests, and a review of the case notes of those same guests. These different methods of data collection provided the diverse evidence needed for this approach and enabled triangulation of data.
The refined programme theory that emerged from the two phases of data collection and analysis identifies key outcomes of this intervention, and furthermore identifies five key mechanisms that, operating in different contexts, explain how these outcomes are generated. Three of the mechanisms relate to the fulfilment of previously unmet needs and can be collectively abstracted as ‘warmth’. The other two mechanisms relate to the removal of service users from agitating or unhelpful circumstances and can be abstracted as ‘quiet’. All five mechanisms primarily attend to secondary stressors, which are stressors arising from or exacerbated by the state of crisis itself. By removing the secondary stressors and, to a lesser extent, reducing the impact of initial stressors, these mechanisms generate five key outcomes for service users: reduced emotional distress, restored clarity of thought, reduced suicidality, restored sleep, and restored functioning. Collectively, these five outcomes constitute the resolution of a state of crisis (which can also be understood as the restoration of a state of affective and cognitive equilibrium). While the findings of this thesis indicate the ability of respite to facilitate a restored state of equilibrium, they also indicate that respite does not directly help service users develop additional coping skills or new interpretations of stressor events.
By developing a generative explanation of how respite functions to support people experiencing a state of crisis, this thesis contributes to the crisis intervention literature and also carries practical implications. First, the theory developed in this thesis demonstrates a ‘non-interventionist’ approach to crisis resolution, thereby challenging an implicit assumption in the literature that crisis resolution must be facilitated by an active interventionist (typically a health professional). Second, the prominence of the theme ‘genuine care’ within the refined theory highlights the importance of considering how people in crisis interpret the motivations of those around them. Third, this thesis illustrates that the ‘warmth’ mechanisms are enhanced by both the structure of charitable organisations as well as the use of non-professional volunteers. This serves as an argument against a trend in the literature towards promoting the formalisation of crisis resolution services along with the professionalisation of staff. Charitable organisations and non-professional volunteers should be viewed as not merely useful additions, but as bringing unique advantages that distinctly contribute to positive outcomes. Finally, the findings of this thesis suggest that the potential of respite to strengthen the spectrum of crisis responses should receive greater attention from policymakers. These findings furthermore point to the advantages of establishing crisis resolution services independently of mental health services
An Investigation Of Coercion And Autonomy In Medical Care. How much choice do patients really have?
No full textThe experience of coercion in health care is controversial. Coercion is likely to promote negative attitudes towards clinical care. People’s attitudes to health care potentially impacts on health outcomes and future interactions with the health system. In contrast, attending to patient autonomy is likely to enhance patients’ positive attitudes to healthcare. The relationship between coercion and autonomy is not entirely clear but intuitively coercive care seems to oppose the principle of autonomy. Similarly, possessing autonomy limits coercion.
Patient autonomy is heralded as an important concept in current medical practice. A detailed literature search failed to identify any previous study that considered the association of perceived coercion with autonomy preference. The majority of clinical studies on coercion have focussed on the experience of psychiatric patients whereas very few have considered the perception of coercion during medical admission, and none were found that related to coercion in a New Zealand medical setting.
Past psychiatric research has shown the perception of coercion is not exclusively associated with compulsory status and is actually more closely associated with procedural justice. It is likely, but previously unproven in a New Zealand context, that some medical patients will feel invalidated during admission and hence report their experience as coercive. This study attempts to understand the relationship between autonomy preference and perceived coercion. It also aims to measure the amount of perceived coercion reported by patients during a medical admission to a general hospital.
Perceived coercion and patient autonomy were measured in a cross-sectional survey of 86 general medical patients in the Medical Assessment and Planning Unit (MAPU) of a tertiary hospital in New Zealand. The socio-demographic characteristics of the sample, and perceived coercion and autonomy preferences, were evaluated using the “Admission Experience Survey” to measure the perception of coercion at admission, and the “Autonomy Preference Index” to measure the patients’ desire for information about their health status when making healthcare decisions.
Almost all survey participants showed a strong desire for information about their healthcare and treatment, although wide variations in their desire to make decisions about their health were apparent. Over one third of participants reported feeling coerced during their admission. No significant association between perceived coercion and autonomy preference was found.
This research shows that perceived coercion is not restricted only to psychiatric care and is relatively commonly reported by patients during medical admission. Confirmation that coercion exists in routine medical care may reflect on the persistence of paternalism in current general medical practice. The long term outcomes of patients who believe they were coerced during a medical admission are unknown but could influence the willingness of these patients to seek health care in the future
An Investigation Of Coercion And Autonomy In Medical Care. How much choice do patients really have?
Full text linkThe experience of coercion in health care is controversial. Coercion is likely to promote negative attitudes towards clinical care. People’s attitudes to health care potentially impacts on health outcomes and future interactions with the health system. In contrast, attending to patient autonomy is likely to enhance patients’ positive attitudes to healthcare. The relationship between coercion and autonomy is not entirely clear but intuitively coercive care seems to oppose the principle of autonomy. Similarly, possessing autonomy limits coercion.
Patient autonomy is heralded as an important concept in current medical practice. A detailed literature search failed to identify any previous study that considered the association of perceived coercion with autonomy preference. The majority of clinical studies on coercion have focussed on the experience of psychiatric patients whereas very few have considered the perception of coercion during medical admission, and none were found that related to coercion in a New Zealand medical setting.
Past psychiatric research has shown the perception of coercion is not exclusively associated with compulsory status and is actually more closely associated with procedural justice. It is likely, but previously unproven in a New Zealand context, that some medical patients will feel invalidated during admission and hence report their experience as coercive. This study attempts to understand the relationship between autonomy preference and perceived coercion. It also aims to measure the amount of perceived coercion reported by patients during a medical admission to a general hospital.
Perceived coercion and patient autonomy were measured in a cross-sectional survey of 86 general medical patients in the Medical Assessment and Planning Unit (MAPU) of a tertiary hospital in New Zealand. The socio-demographic characteristics of the sample, and perceived coercion and autonomy preferences, were evaluated using the “Admission Experience Survey” to measure the perception of coercion at admission, and the “Autonomy Preference Index” to measure the patients’ desire for information about their health status when making healthcare decisions.
Almost all survey participants showed a strong desire for information about their healthcare and treatment, although wide variations in their desire to make decisions about their health were apparent. Over one third of participants reported feeling coerced during their admission. No significant association between perceived coercion and autonomy preference was found.
This research shows that perceived coercion is not restricted only to psychiatric care and is relatively commonly reported by patients during medical admission. Confirmation that coercion exists in routine medical care may reflect on the persistence of paternalism in current general medical practice. The long term outcomes of patients who believe they were coerced during a medical admission are unknown but could influence the willingness of these patients to seek health care in the future
Science communication in risk management at a high-incidence location for suicide
Full text linkIt has been suggested that the role of robust scientific evidence in quality policy development is essential, but can vary on the basis of policy type and setting. These hypotheses and others were explored in a unique local case study dealing with risk management at a high-incidence location for suicide. Specifically, I examined the dynamic factors by which councillors regulated site access for public safety, journalists moderated relevant suicide reporting for public interest, and a science communicator with expertise in psychological medicine advised both groups. Scientific evidence guided public and private negotiations of a problem definition, solution approach, and philosophy of change; and the optimal utility of science in policy was eventually fulfilled in a precautionary suicide prevention approach by councillors and journalists, albeit with different conservative definitions of ‘cost-effective’ risk management. Findings supported an essential but variable role for science in policy – one influenced not only by policy type and setting, but also the management of expectations among decision-makers. Science communicators served as a resource for decision-makers, but ultimately definitions of cost-effective risk management were values-based judgements revealing not all decision-makers’ willingness to reject utilitarianism in the interest of a vulnerable few
Children, Social Media, and the Trouble with “Bullying”: A Child-Centred Investigation of Definitions
Full text linkBullying troubles parents, teachers, and children themselves. The emergence of bullying in children’s use of social media, often referred to as cyberbullying, has heightened concern for children’s social and emotional wellbeing. Bullying is troublesome in the context of how it is defined and identified in children’s social interactions with peers. The “trouble” with bullying for this thesis is that the common definitions and models of bullying are adult-generated and children’s perspectives are often missing in existing bullying literature. I have developed a child-centred approach to deconstruct assumptions in adult-generated definitions of bullying. I argue that marginalisation of children’s perspectives is a problem and present one approach to redressing the balance.
This thesis examines how children define bullying as a sense-making activity in the context of talking about their experiences of social media. It focuses on 11 – 13 year olds as a distinct social and emotional developmental stage, and a cohort for whom social media is becoming normal in their social world. Drawing on standpoint theory, social work theories, and childhood studies as a foundation, I developed a modified child-centred standpoint theory to critique the existing literature. The integrative research design I developed, including theoretical and analytic framework, supported an analysis of children’s methods for defining bullying to address this gap. The rich multimodal data set for this study was recorded at three schools in Wellington, New Zealand, designed to be consistent with ordinary classroom activities. The T-shaped analytic framework applies constructivist grounded theory for cross-sectional analysis of the data set, and ethnomethodology and membership categorisation analysis for granular analysis at key points.
My analysis revealed a distinctive interactional approach to making sense of bullying in participants’ accounts, in contrast with existing adult-generated definitions focused on behaviour or personality. Out of this analysis, I have developed a child-centred interactional model for defining bullying. This emergent model demonstrates the orderliness in children’s methods for defining bullying in the broader context of interactions that range from the playful to the conflictual and hurtful. This thesis offers new theoretical and methodological contributions to understanding this complex social phenomenon by placing children’s knowledges at the centre
Auto-mobile: Disabled Drivers in New Zealand
No full textMobility parking spaces can be found in cities and towns throughout New Zealand and in countries around the world. Despite this, there has been very little academic examination of the meaning or importance of driving for people with mobility impairments. What research exists on disabled drivers is almost entirely concerned with safety concerns of allowing disabled people to drive. Cars have been excluded from conceptions of assistive technology and the existing literature on driving and transport generally fails to acknowledge the fact that disabled people do drive cars. Following on from the assumption that disabled people do not drive, car-centric transport systems have even been presented as restricting disabled people’s mobility. A considerable volume of research has been published on transport as a social determinant of health, as well as its role in facilitating social participation and inclusion. This transport literature frames social participation and inclusion in terms of public transport, and acknowledges, but does not address, the inaccessibility of public transport for many disabled people. This thesis seeks to address the knowledge gap regarding social participation and inclusion among drivers with mobility impairments.
This thesis draws upon the author’s own experiences of being a disabled driver. It is written in the context of increasing concerns about global climate change and fluctuating (but rising) fuel prices, both issues which have put pressure on many people to reduce their car use. The aim of this qualitative study was to investigate the transport experiences of work-aged physically disabled drivers in New Zealand. Participants were recruited through the national issuer of mobility parking permits. In-depth interviews were conducted with 27 physically disabled drivers between the ages of 18-64 in New Zealand’s two largest urban centres, Wellington and Auckland, and in various parts of a semi-rural region, the Wairarapa.
The main barriers and enablers of car use identified were funding, the physical environment, and appropriate vehicle modifications. When unable to drive, participants relied on family or friends, as taxis were too expensive, and the alternative was being housebound. While some participants could and did use public transport, most could not, or would not due to their own or others’ bad experiences.
The participants saw cars as enabling them to perform tasks and social roles that they would not otherwise have been able to, due to the lack of other viable transport alternatives. Cars were also used as social and life markers, as driving could influence peoples’ identity and sense of self, including their perception of disability and ‘normality’. As modern societies are based around a system of ‘automobility’, disabled drivers found driving particularly meaningful because they were able to move around environments that are built for cars, in the same manner as non-disabled people, which made the world a less disabling place.
Overall, this thesis finds that cars play a vital role in improving social participation and inclusion for people with mobility impairments. This speaks to Amartya Sen’s capability approach whereby emphasis is placed on the ability to live a life ‘one has reason to value’. In order to achieve this life, people need to be able to access appropriate transport. On this view, present funding models in New Zealand, which create inequalities of access to appropriate transport on the basis of whether a person’s impairment(s) arose from illness or accident, need to be addressed. This study has shown that the voices of people with impairments provide rich insights into meanings of mobility, participation and disability
Coping has limits: 'Mixed Presenters' emergency department presentations for self-harm and other reasons
Full text linkSuicide is largely preventable, in part through effective emergency department (ED) care of people at risk of self-harm. Ample research on people presenting to ED for self-harm (including suicidal ideation, deliberate self-harm, and suicide attempts) exists, yet less is known about those who present also for other reasons within a short time of their self-harm visit. This information is important because ‘other’ ED presentations might indicate heightened future self-harm risk; ED patients presenting for other reasons might also be at risk of (oftentimes undetected) self-harm; and ED staff attitude, frequently negative for patients who present for self-harm, might represent a unique mind-set toward patients with these mixed or two-type presentations.
This research investigated ‘Mixed Presenters’, people who presented to one ED at least twice within 28 days, once for self-harm and once for another reason. It sought to answer the following questions: Who are Mixed Presenters? What is the future serious self-harm risk of Mixed Presenters compared to Self-harm Only Presenters? What characterises the ED management of Mixed Presenters? This mixed method study used ED data from another study (MISP), which facilitated the identification of Mixed Presenters. The qualitative part involved semi-structured interviews with 27 Mixed Presenters from three DHBs. For the quantitative part, data from 1921 patients, 1554 (80.4%) Mixed Presenters and 377 (19.6%) Self-harm Only Presenters, from eight DHBs were linked to admission and mortality datasets and were analysed using survival analysis to compare serious self-harm risk between the groups. The findings of the qualitative and quantitative studies were reported separately and then triangulated.
Mixed Presenters reported difficult life circumstances consisting of interwoven physical, mental health, and social struggles for which they received little help. The quantitative results showed Mixed Presenters to have a 60% reduced risk of future serious self-harm compared to Self-harm Only Presenters. Yet, interviews with Mixed Presenters revealed that the vast majority had a history of prior self-harm, were easily triggered to self-harm as a consequence of their life stressors, and on discharge from ED, nearly half were still at risk of self-harm. Mixed Presenters reluctantly sought ED care but acknowledged it provided safety. Many interviewees also disliked the ‘processing plant’ style in ED, where the focus was on risk assessment instead of their needs as people, and where some encountered judgemental staff.
These findings show that it is important for ED staff to identify Mixed Presenters. Hence, integrated care is required, which is patient-centred and identifies and addresses physical and self-harm needs simultaneously, and thus ultimately lessens the need for Mixed Presenters to return to ED. Opportunities for disclosure of self-harm could be increased by introducing routine self-harm screening of ED presentations related to substance misuse, degenerative physical health conditions, chronic pain, mental health issues, and trauma. Future research needs to explore Mixed Presenters’ ‘other’ visits, examine their long-term risk of self-harm, and explore support people’s and ED staff’s views on Mixed Presenters so their ED care can be enhanced. Whilst two ED presentations for self-harm incurred a significantly higher risk for future serious self-harm compared to mixed presentations, Mixed Presenters’ often complex life circumstances, frequently linked to chronic and or/high self-harm risk, make targeted ED support for these patients nevertheless imperative
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