A community of practice intervention to increase education-focused mental health promotion actions among interdisciplinary professionals: a qualitative study
Ema Tokolahi
1 * , Deirdre Richardson 2 , Susan Bazyk 3
1
2
3
Abstract
Through a unique, inter-sectoral and interprofessional initiative, practitioners from education, health and social service sectors were invited to participate in communities of practice, facilitated online. The focus was on building workforce capacity to address the mental health needs of children and youth.
This paper explores interprofessional workforce development by translating knowledge from a mental health promotion initiative developed overseas into the Aotearoa New Zealand context.
Over a 6-month period, practitioners engaged in an iterative, capacity-building process, where they had access to the initiative materials and resources, shared practice stories, networked, and discussed barriers and facilitators for implementation. Qualitative thematic analysis was used to interpret data.
Members of the communities of practice engaged in storytelling and made sense of the initiative in relation to their previous knowledge and experiences: practice and thinking were validated. Mental health promotion was positioned as the responsibility of all sectors and the need for effective interprofessional collaboration was deemed essential. Furthermore, translation of the initiative into the bicultural context of Aotearoa New Zealand demanded and deserved sustained attention.
This study contributes interprofessional and inter-sectoral evidence for building workforce capacity to address the mental health needs of children and youth. Further research is warranted to investigate the outcomes for the children and youth served. Interprofessional communities of practice were shown to provide a sustainable mechanism by which knowledge can be received, transformed and translated into practice.
Keywords: collaborative practice, communities of practice, education, health promotion, interprofessional collaboration, knowledge translation, mental health, social services.
| WHAT GAP THIS FILLS |
| What is known about the topic: Mental health challenges pose a significant public health risk. There is a need to build workforce capacity to address the mental health needs of children and youth in order to promote positive outcomes in later life. |
| What this study adds: All sectors must take responsibility for promoting mental health in children and youth. This participatory action research study presents communities of practice as providing a sustainable mechanism by which international evidence can be received, transformed and translated into practice. |
Introduction
High rates of suicide and mental health issues impacting children and adults1,2 highlight the importance of taking an interprofessional and inter-sectoral approach – across education, health and social service sectors – to addressing the mental health needs of children and youth. Subsequently, there is a need to build the capacity of educators and non-teaching professionals in the school/classroom context, as part of a comprehensive strategy for addressing children’s mental health needs.
Background
In 2020, five Every Moment Counts (EMC) workshops were delivered, across Aotearoa New Zealand (hereafter, Aotearoa) to 358 delegates.3 Workshops targeted practitioners working with children and youth, who were seeking to promote participation and mental health throughout the day, particularly in school contexts (see www.everymomentcounts.org). These workshops offered an evidence-based, multi-tiered approach to mental health promotion and activities for building capacity of the children’s workforce. The implementation of the EMC workshops was unique as it brought together educators and non-teaching professionals, working in schools, hospitals, clinics and community settings. Delegates included general and special education teachers, resource teachers of learning and behaviour, counsellors, psychologists, nurses, social workers, occupational therapists, community youth providers, music therapists, psychiatrists and speech-language therapists. For the purposes of this article, the diverse members of this workforce are referred to as ‘practitioners’.
Aotearoa is a bicultural nation with a commitment to achieving equitable health and education outcomes for all, particularly for Māori, the Indigenous people of Aotearoa.4,5 There is the potential for cultural mismatch when importing an initiative from overseas.6 Additionally, there is the documented challenge that evidence-based interventions may be established as effective in research settings but may not always translate to real-world contexts, attributable to limited practical knowledge or support during implementation or lack of intervention fidelity.7 In this context, our team initiated interprofessional and inter-sectoral communities of practice as a potentially culturally responsive mechanism by which knowledge could be translated into the local context.
Methods
A participatory action research approach underpinned the design for this qualitative study 8 and approval was obtained from the Otago Polytechnic Research Ethics Committee (#843_2).
Recruitment
Practitioners from education, health and social service sectors were recruited into communities of practice, facilitated online. Invitations to participate were sent to delegates of the recent EMC workshops, who were encouraged to forward the invitation to colleagues; they were also posted on health workforce development sites and in the professional development adverts of a teaching publication.
Intervention
Initial plans for the communities of practice to be primarily conducted in person had to be adapted in response to the COVID pandemic. Subsequently, meetings occurred online and an online discussion board was created. Three communities were developed to loosely represent different geographical regions nationwide. These communities were intended to facilitate local networking; however, participants were able to attend whichever community meeting best suited their schedule. Each community held five meetings across a 6-month period, and attendance ranged between 2 and 11 participants at any one community meeting. Online capacity building webinars and materials9 focusing on EMC and a tiered approach to mental health served as the primary content, followed by discussions facilitated by experienced practitioners. Participants engaged in iterative action research cycles, where they had access to and discussed the initiative materials and resources, shared their own practice stories, networked and made connections, and discussed barriers and facilitators for implementation of knowledge into practice. Participants were encouraged to use relevant skills from the workshop and online content and to reflect on their application in practice.
Data collection and analysis
Meeting minutes were collected by the facilitator, summarised at the end of each meeting and approved by that community. These minutes provided the main data source for analysis. Initially, data from individual meetings were thematically analysed for broad brush themes and then a cross-comparative analysis across meetings was undertaken;10 feedback from this analysis was shared, amended (if required) and approved by each community at the start of the following meeting. A sixth meeting was held nationally for all community members to review and approve the final cycle of analysis. Therefore, analysis was inductive, ongoing, interactive and occurred concurrently over the 6-month period.
Results
A range of non-teaching practitioners (most commonly school-based occupational therapists and counsellors, community mental health practitioners, and public health nurses) participated in the communities of practice. The majority of participants identified as Tauiwi (non-Māori: New Zealand European citizens or immigrant to New Zealand from Europe and North America) and two identified as Māori. A consistent theme was that mental health promotion was positioned as the responsibility of all sectors and that the need for effective interprofessional and inter-sectoral collaboration was deemed essential. When making sense of their experiences, community members reflected on how mental health promotion, and the community of practice, impacted on their spheres of influence. Through reflection on thematic analysis it was determined the data could be best understood in the context of Bronfenbrenner’s ecological systems model. This model asserts the significance of interactions between layers of systems (micro, meso and macro) and has previously been found useful for guiding public mental health policy and practice.11
Micro sphere of influence
In community members’ personal sphere, value was clearly placed on the communities as a space for storytelling and making sense of the initiative in relation to their previous knowledge and experiences in the Aotearoa context. Current universal practices and thinking about children’s mental health needs were validated and extended in this space, even when these challenged current funding constraints.
Meso sphere of influence
Expanding the sphere of influence to those they work alongside, community members saw relationship networks as essential for enabling effective interprofessional and inter-sectoral collaboration. This was perceived as essential in order to authentically integrate what are currently fragmented services and genuinely embed family input. The need for a cultural shift in mindset was identified – in individuals, teams and school leadership – to empower practitioners to provide mental health promotion interventions at the universal level (as well as targeted and individual levels, which were more commonly accepted).
Macro sphere of influence
The bicultural context of Aotearoa recurrently demanded attention within the communities, with participants making amendments to use more culturally appropriate language (for example, replacing references to ‘recess’ with ‘break time’ and including Te Re Māori | Māori language), creativity in addressing legislative constraints, and tailoring the initiative to the physical, social, cultural and institutional needs of school environments, in order to achieve a better fit (for example, observing tikanga | cultural protocols during implementation). Policy-level and school-level leadership to drive a focus on promoting children’s mental health was highlighted as necessary to generate sufficient support (financially and culturally) to serve school communities at a universal level.
Discussion
Children’s mental health promotion was perceived as the responsibility of all sectors, with interprofessional collaboration deemed essential, and communities of practice offered a mechanism by which to reinforce and enhance universal-level practices in schools and communities. Opportunities to make change across expanding spheres of influence were identified and the context of Aotearoa required ongoing attention. Similar to previous research,12 the communities of practice in the current study facilitated the knowledge translation process, with opportunities for members to exchange learnings, test ideas, discuss ethical issues and synthesise relevant evidence informing their practice. Findings illustrated how, when translating knowledge into practice, change occurred across the micro to the macro spheres of influence for the practitioners. Previous research also found an ecological systems approach useful for determining knowledge translation in broader contexts.6,13 This is important to consider when planning how to embed mental health promotion initiatives into school and community contexts, signposting the need for policy-makers, leaders and practitioners to attend to each level of the system.
The ecological systems approach also provides a structure for adapting initiatives into a different cultural context.6 This process goes beyond translating words; it demands attention be paid to individuals’ personal beliefs and values, culturally specific protective and risk factors, and acknowledgement of differences in culture and health care systems.6,14 Culturally adapted initiatives often enhance outcomes for target populations. Importantly, they have also been shown to increase retention and recipient satisfaction.6 This process may be facilitated through a cyclic process of observe, ask, reflect and learn,14 which the communities in this study (unknowingly) implemented. Other models propose that modification of content and process should be undertaken in collaboration with members of the targeted community.6 This was integral to the communities in this study, with members already embedded in school and community environments. Thorough cultural adaptation processes will need to be undertaken, informed and started by the communities in the current study, for the EMC initiative to be appropriately translated into a credentialised training suitable for Aotearoa. Further research is recommended to ensure the adapted initiative achieves the intended aims for children and youth.
In this study, the value of interprofessional and inter-sectoral members integrated into each community of practice was highlighted as essential to sustainably promoting children’s mental health in school and community contexts. This was supported by international studies that value inter-sectoral collaboration in effective development and implementation of public health initiatives.15
Limitations
No teachers engaged in the communities of practice, a fact lamented by those who did. Having teachers involved may have yielded different findings and enhanced opportunities for genuine interprofessional and inter-sectoral collaboration to enhance members ability to impact on their ecological system. The pandemic prevented communities meeting in person: conducting them online may have enabled some to attend who may otherwise have been unable, and it may have impacted group dynamics and changed levels of participation, as many people were overwhelmed by online interactions at this time.
Data availability
The data that support the findings of this study are available from the corresponding author, [ET], upon reasonable request.
Declaration of funding
A Fulbright Specialist Award was granted to Dr Bazyk in 2019 and Otago Polytechnic (now Otago Polytechnic | Te Pūkenga) served as the host.
Acknowledgements
We would like to thank all the co-researchers who participated in each of the communities of practice, in particular our co-facilitators Dean Sutherland, Lucy Charles and Arul Hamil. The authors acknowledge the multiple groups across health and education that contributed resources and funding to make the initial Every Moment Counts workshop series happen, from which this research followed.
Author contributions
Ema Tokolahi: conceptualisation, methodology, formal analysis, writing – original draft, project administration, funding acquisition; Deirdre Richardson: conceptualisation, methodology, formal analysis, writing – review & editing, project administration, funding acquisition; Susan Bazyk: conceptualisation, methodology, writing – review & editing, funding acquisition.
References
1 Australian Bureau of Statistics. Suicides, Australia 2010. 2012. Available at https://www.abs.gov.au/ausstats/abs@.nsf/productsbytopic/7A5013A2773B6167CA2570A6008230C8?OpenDocument [cited 18 August 2020].
2 Ministry of Health. Suicide facts: 2015 data. 2015. Available at https://www.health.govt.nz/publication/suicide-facts-2015-data [cited 25 March 2019].
3 Tokolahi E, Fenwick J, Sutherland D, et al. Children’s mental health promotion: the need for inter-sectorial and inter-professional collaboration. Psychology Sch [in press]).
| Google Scholar |
4 Kenzie-Jones PR. Indigenous activism, community sustainability, and the constraints of CANZUS settler nationhood. Transmotion 2019; 5(1): 104-31.
| Google Scholar |
6 Marsiglia FF, Booth JM. Cultural adaptation of interventions in real practice settings. Res Soc Work Pract 2015; 25(4): 423-32.
| Crossref | Google Scholar | PubMed |
7 Barwick MA, Schachter HM, et al. Knowledge translation efforts in child and youth mental health: a systematic review. J Evid Based Soc Work 2012; 9(4): 369-95.
| Crossref | Google Scholar | PubMed |
8 Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health 2006; 60(10): 854-7.
| Crossref | Google Scholar | PubMed |
9 Nielson S, Bazyk S Building Capacity of School Personnel to Promote Positive Mental Health in Children and Youth. Mountain Plains Mental Health Technology Transfer Center Network; 2019. Available at https://mhttcnetwork.org/centers/mountain-plains-mhttc/product/building-capacity-school-personnel-promote-positive-mental [cited 21 August 2023].
10 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77-101.
| Crossref | Google Scholar |
11 Eriksson M, Ghazinour M, Hammarström A. Different uses of Bronfenbrenner’s ecological theory in public mental health research: what is their value for guiding public mental health policy and practice? Soc Theory Heal 2018; 16: 414-33.
| Crossref | Google Scholar |
12 Bazyk S, Demirjian L, LaGuardia T, et al. Building capacity of occupational therapy practitioners to address the mental health needs of children and youth: a mixed-methods study of knowledge translation. Am J Occup Ther 2015; 69(6): 6906180060p1.
| Crossref | Google Scholar | PubMed |
13 Caldwell SEM, Mays N. Studying policy implementation using a macro, meso and micro frame analysis: the case of the Collaboration for Leadership in Applied Health Research & Care (CLAHRC) programme nationally and in North West London. Heal Res Policy Syst 2012; 10(32): 1-10.
| Crossref | Google Scholar | PubMed |
14 Billekens P, Korfage IJ, Rietjens JAC, et al. Experiences of a nurse practitioner in the political, cultural and practice translation of a training program for advanced care planning (ACP) ‘Respecting Choices’ from the United States to the Netherlands. Support Palliat Care 2015; 5(Suppl 2): A46.
| Google Scholar |
15 Molina-Marín G, Ramírez-Gómez A, Oquendo-Lozano T. Inter-sectorial and inter-institutional cooperation and coordination in public health within the market model of the Colombian health care system, 2012-2016. Rev Salud Publica 2018; 20(3): 286-92.
| Crossref | Google Scholar | PubMed |
