Handover | Issue 40 - September 2017

Early in 2014, educators from the Faculty of Health at Whitireia New Zealand in Porirua, began an extensive exercise to increase the focus on co-existing problems (CEP) across the Whitireia nursing and mental health programmes.

One catalyst for this was the publication of the joint mental health and addiction workforce development centre’s Te Whare o Tiki: Co-Existing Problems Knowledge and Skills Framework. The faculty wanted to build their own capacity and then find ways to integrate CEP learning into programmes so students learned of its importance and would be better equipped for working with people who have both addiction and mental health problems.

Good pre-existing relationships with Te Pou and Matua Raki were built upon and Suzette Poole (clinical lead, Te Pou) and Ashley Koning (project lead, Matua Raki) agreed to provide a series of tailored workshops for students in the nursing and mental health programmes. This was done as part of the workshop provided by Te Pou and Matua Raki to help develop more person-centred, wellbeing oriented, CEP responsive mental health and addiction services.

The training was based on the knowledge and skills described in Te Whare o Tiki and linked to the learning outcomes of Let’s get real. It was designed to help students understand just how prevalent CEP is, the impact it has for people and various intervention models to address it. The workshops were both effective and popular, and by late 2015 demand for them was increasing, so Suzette and Ashley offered to hold a train the trainer workshop to equip Whitireia educators to teach CEP knowledge and skills themselves.

Whitireia Faculty and Graduate - Catherine Fuller, Loom-Linda Tasi, Dianne McKellar, Wendy Trimmer, Vicky Jennings.

The CEP train the trainer workshop occurred in early 2016, and was attended by representatives from all Whitireia nursing programmes as well as the Bachelor of Health Science (Paramedic) programme.

“The intention was to build CEP responsiveness and capability within the faculty and for the faculty to then incorporate CEP teaching within all its programmes,” says Wendy Trimmer, academic leader at Whitireia.

“It was a challenge as less than half of the faculty staff had worked in specific mental health and addiction areas before.”

Educators completed self-assessments around the CEP knowledge and skills outlined in Te Whare o Tiki and then began work on professional development plans for themselves and their programmes based on identified needs. Group work was then done to produce an action plan to make broader curriculum changes.

To support this work Matua Raki provided several written publications and participants were also given a USB device with access to the CEP 101 e-learning course and many other electronic resources.

“The train the trainer workshop was evaluated and all respondents said it was relevant to their practice and that their confidence level had increased in this subject area following the workshop,” says Wendy.

Catherine Fuller co-ordinates the New Entry to Specialist Practice Nursing (NESP Nursing) mental health and addiction nursing programme and is part of a team with Wendy and other nurse educators (Vicky Jennings and Loma-Linda Tasi mentioned below) working with faculty staff and overseeing CEP integration. She says the workshop was beneficial and that she has used many of the resources and techniques covered by Suzette and Ashley.

“Probably one of the key principles is to allow people the ability to critically analyse what they are doing in their clinical practice in CEP terms. I work mostly with registered nurses and we’ve been able to use Te Whare o Tiki to make the critical links between clinical practice and their teaching and to use the new resources they now have.”

She says one of the ways in which that works, is that as students rotate through different clinical areas, Te Whare o Tiki helps them recognise the different areas of knowledge they need to work confidently with people accessing that level of care through primary and secondary services.

“In the CEP workshops we now hold, we use context-based learning scenarios and we’ve just started doing simulated workshops to be able to safely formulate and assess nursing care plans.”

But it’s also important the students are equipped to translate their new knowledge to whichever setting they may be working in – community, primary or acute inpatient.

“We want to ensure that when they meet someone with CEP they’re able to support them, assess them, focus on their strengths and their recovery, regardless of the setting,” says Catherine.

Vicky Jennings is a nurse educator working in the Whitireia Bachelor of Nursing programme and says she now has the information and resources she needs to focus on CEP at an undergraduate level in a really foundational way.

“Those of us who are experienced in mental health have become CEP champions within our teams. The benefit of having the training is that we can contact Matua Raki and Te Pou when we need further information and support ourselves.

“We work on this with our individual programmes, because each is different and has a different approach. CEP integration is an agenda item at our mental health and addiction strand meetings, so we discuss what we’re doing and share ideas.

I expect the new graduates will have awareness about mental health and addiction, and be able to integrate those foundational skills into their nursing practice no matter what area of nursing they work in.”

Loma-Linda Tasi is a nurse educator in the Bachelor of Nursing Pacific programme. The addiction aspects of CEP are of particular interest to her because of her background in the smokefree sector. But she says the high prevalence of CEP, and disproportionately high levels of addiction and mental health among Pasifika people, are important areas of learning for the students she teaches.

She also found the train the trainer workshop immensely valuable.

“What was great is that it broke everything down in a way that made it easy for us to select what was relevant for our papers, to see what was do-able at the time, and to be able to plan ahead.”

She gives Te Whare o Tiki to all her students, but also works with many of the other provided resources in her teaching – especially those around understanding the addiction sector in New Zealand, guidelines for parents (see Working with families and whānau and the guide to brief intervention).

“My main role is to link all the concepts into their training, looking at the competencies and helping them identify that the workforce itself, is not all registered nurses. A big challenge for student nurses is what their scope of practice will be and look like – and many have not come across mental health and addiction much before.”

Dianne McKellar graduated from the Whitireia Bachelor of Nursing programme in 2016 and now works in the Neuroscience Ward at Wellington Hospital. She says, like many other students, mental health, addiction and CEP were not special interests when she began her training.

“But from the get-go we were told CEP was going to be woven through everything and we quickly came to understand that, no matter where we ended up as nurses, CEP was going to be a big factor in our work. This and the workshops opened up a stark reality for a lot of us and created an awareness that really makes a difference to my nursing practice.”

Dianne became so interested in the amount of people with CEP and how their issues were being addressed, that one of her chosen essay topics was the lack of access for people with addiction and mental health problems in New Zealand.

“This became kind of huge for me because I started to see that, despite all the work going on to try and rectify this lack of access, the problem remains significant here and internationally.”

Dianne’s essay was received well and upon her tutor Agustilia Rodrigues’ suggestion, will be published in the Whitireia Health Journal in late 2017. She says she is really grateful for Agustilia’s support, guidance and encouragement. She also says the CEP training and research has really made her think about her role as a nurse and as an advocate working in an acute setting with people who typically have brain or spinal injuries.

“Where I work I can’t fix problems as such, but I’m now super aware of what else might be going on for a person and what I can do in the short term to make a difference. I have noticed people coming through with alcohol problems, tobacco addiction or experiencing mental health problems. So, it’s given me the sense that it’s not just about looking at the person on the surface.”

She believes this ‘big picture’ holistic approach means that even if immediate solutions for people are not found, connections might still be made for people so they get the support they need into the future. The faculty at Whitireia are proud of what’s been achieved in a few short years, but will continue to work on CEP integration from undergraduate right through to Master’s level. Critical analysis of every programme will continue so there is consistency and a clear learning pathway around CEP. 

“It’s something we will do over time, but it won’t be that difficult to achieve considering how far we’ve already come and because the changes being made are so fully supported by all our mental health streams,” says Catherine Fuller.

Whitireia continues to have a close working relationship with Te Pou and Matua Raki, and follow-up meetings between the organisations have been scheduled to keep momentum going.

“It is wonderful to see how staff have embraced this initiative,” Wendy Trimmer says.

“It means we are all working to be part of the CEP solution, ensuring students are prepared for practice with the knowledge, clinical assessment and decision-making skills; and attitudes to work with people who have co-existing problems.