This social-cultural history explores the changing context, culture, and identity of psychiatric nurses working in New Zealand public mental hospitals between 1939 and 1972. Primary documentary sources and oral history interviews provided the data for analysis. The thesis is divided into two periods: 1939 to 1959 when asylum-type conditions shaped the culture of the institutional workforce, and 1960 to 1972 when mental health reform and nursing professionalisation challenged the isolation and distinct identity of mental hospital nurses. Between 1939 and 1959 the introduction of somatic treatments did not substantially change nursing practice in mental hospitals. Overcrowding, understaffing and poor resources necessitated the continuance of custodial care. The asylum-type institutions were dependent on a male attendant workforce to ensure the safety of disturbed male patients, and the maintenance of hospital farms, gardens, and buildings. Although female nurses provided all the care and domestic work on the female side, the belief that psychiatric nursing was physically demanding, potentially dangerous, and morally questionable, characterised the work as generally unsuitable for women. Introduction of psychiatric nursing registration which was a move toward professionalisation did little to change the dominance of a male, working-class culture. From 1960 to 1972 psychiatric nurses’ identity was contested. New therapeutic roles created the possibility of the nurses becoming health professionals. Their economic security and occupational power, however, was tied to an identity as unionised, male workers. As psychiatric nurses were drawn closer to the female-dominated nursing profession through health service changes and nursing education reform, both men and women acted to protect both their working conditions and their patients’ welfare. To achieve these ends, they employed working-class means of industrial action. By accepting the notion that psychiatric nurses’ identity was socially constructed, this thesis provides an interpretation that goes beyond the assumption that nursing is a woman’s profession. Instead, it presents psychiatric nursing as a changing phenomenon shaped by contested discourses of gender, class and professionalisation. Nursing in public mental hospitals attracted ordinary men and uncommon women whose collective identity was forged from the experience of working in a stigmatised role.

Background: There is a high rate of mental disorders among general practice attendees that is associated with substantial morbidity, disability and global burden. As a consequence GPs play a pivotal role in ensuring that patients with mental disorders are recognised and optimally treated. While there is little doubt of the role GPs play in managing mental illness in general practice the literature suggests a proportion of patients will go unrecognised or else be inadequately diagnosed and in some instances inadequately treated by their GP. The known problems of under diagnosis of mental disorders has been seen until recently to be a problem of GP knowledge and skill, which has led to the close scrutiny of GP performance in this field. In response to this close scrutiny has been the development of a wide range of physician education programs aimed to improving the clinical performance of GPs. However, more recently it has been acknowledged that reasons for low recognition and inadequate treatment of mental disorders in general practice is not only the GPs lack of skill and knowledge, but instead involves a complex interplay of GP, patient and systemic factors unique to GPs, their patients and the general practice setting. Therefore there is a growing interest in research to not only explore ways to improve the clinical performance of GPs, but to also gain a better understanding of the range of issues that GPs are confronted with when managing mental disorders in general practice. Aim: There were two aims of this research: 1) examine GP attitudes, reported confidence and behaviour pertaining to the detection, diagnosis and management of mental illness in general practice (Study One); and 2) describe the epidemiology of depression in general practice and investigate symptom attribution styles as it relates to depression (Study Two). Methodology: In Study One 800 randomly selected rural and urban GPs in the North Island were invited to complete the Attitudes, Reported Confidence and Behaviour Questionnaire Revised (ARCBQ-R). The ARCBQ-R had been previously piloted and reliability and validity issues addressed and published elsewhere. In Study Two, 15 general practices were randomly selected from a database of Auckland General Practices, of which 35 consecutive general care attendees were recruited from each of the 15 general practices. Consenting patients completed a self report questionnaire on mood and health and a computerised version of the Composite International Diagnostic Interview (CIDI) questionnaire (depression module only). Results: Study One: Four hundred and sixteen (52%) GPs completed the ARCBQ-R. GPs are confronted with a wide range of mental disorders in their day-to-day practice, with a predominance of depression and anxiety. GPs were most confident in detecting, diagnosing and treating depression and were most confident in prescribing antidepressants, particularly SSRIs for depression and anxiety. GP confidence in detection, diagnosis and treatment of mental illness was influenced by a number of GP factors such as: interest in mental health, previous mental health training, gender and exposure to mental disorders in their practice. Systemic and patients factors were also reported to influence the way in which GPs recognise and manage mental disorders in their practice. Only a small proportion of GPs reported to use solely DSM-IV or ICD-10 classifications when making a diagnosis, and the majority relied on informal ways to diagnose mental disorders in their patients, which raises questions about the appropriateness of formal diagnostic classifications in general practice. Training needs for this group of GPs involved both treatment and diagnostic issues pertaining to more complex disorders. GPs believed that shared care of mental disorders is the most effective way to provide optimal care for patients. However a number of issues pertaining to availability and assessibility of secondary mental health services along with structural issues such as cost, time and extended consultations in general practice must be addressed before this model of care can work to its full potential. Study Two: A total of 475 general practice attendees agreed to take part in this study. Approximately 20% of general practice attendees met DSM-IV criteria for major depression in the last 12 months and 12% for major depression with a recency of '1 month to less than 2 weeks'. Just under 5% of the sample met DSM-IV criteria for dysthymia, of which 80% had comorbid major depression. A greater proportion of participants who were divorced or separated, unemployed or looking for work, younger in age, of Maori ethnicity and had a history of mental illness met criteria for DSM-IV major depression. Compared to non-depressed participants, depressed participants in this study reported significantly more missed work or social activity in the last year due to emotional problems. With the aid of two screening questions for depression, GPs in this study accurately identified 75% of depressed general practice attendees. The most common attribution style amongst general practice attendees was a normalising attribution style. Patient attribution styles was not found to influence the level of depression detection by GPs, instead past and current illness profiles influenced GP detection rates of depression. Conclusion: The current research findings report figures and trends consistent with overseas studies, not only demonstrating the high prevalence of mental illness, particularly that of depression present in general practice attendees, but the many issues that shape mental health care in general practice. Inline with Klinkman's 'Competing Demands Model' GPs perform three important functions: 1) to identify mental disorders in the community; 2) directly provide mental health care to patients; and 3) a referral agent to secondary mental health services. Like Klinkman's model, results derived from the two studies suggest GPs attitudes towards mental health will shape the level of involvement across these three functions. Results derived from 'Study One' and 'Study Two' extends on Klinkman's model to incorporate 'shared care' as a potential model for managing more severe complex disorders. However, before such a model of 'shared care' can be implemented it is essential that accessibility and communication channels between primary and secondary sectors are improved, and structural funding arrangements including the appropriate remuneration for GPs time is addressed. In reality not all GPs will be interested in managing mental illness in their practice and therefore will not have the motivation to acquire and maintain a level of knowledge sufficient to work with patients with mental illness, whether it be in the capacity of 'shared care' or solely the responsibility of the GP. However, it is not unreasonable to expect GPs to have the necessary skills and ability to at least detect and diagnose mental illness in their patient population, and if necessary refer patients on to secondary mental health services. Prerequisite training in mental health, training in diagnostic classifications along with considerations around their appropriateness in general practice, a sound knowledge of patient risk factors for mental illnesses and established networks with secondary mental health services is necessary before GPs can successfully fulfill these roles.

The purpose of this qualitative research project has been to explore what social inclusion means to people with an enduring mental health problem. A review of the general literature on social inclusion revealed that little research has been conducted in relation to mental health, particularly in New Zealand. Even fewer studies have investigated the meanings that people with severe and enduring mental health problems place on their experiences. A life story narrative approach was employed in order to explore the experience of social inclusion and enduring mental health problems. Data were collected by way of unstructured, individual interviews with five users of mental health services living in supported housing in a small rural New Zealand town. Thematic analysis was carried out on the narratives, identifying six major themes. The findings indicated that, for this group of service users, social inclusion means having someone to love, something to do and somewhere to live. They want relationships with family and friends, to engage in recreational or leisure activities, to be employed, to have financial security, and to have safe and comfortable housing. The major barriers to achieving these are stigma and discrimination. New Zealand’s mental health services have adopted a recovery approach to mental health. Whereas social inclusion has a broad political and social focus that places responsibility for reducing social exclusion on society, recovery focuses on individuals’ personal journeys towards mental health and well-being. Despite international recognition of the value of social inclusion, New Zealand’s mental health services have not yet embraced it, although policy advisory organisations such as the Mental Health Commission state its aims as desirable for services. However, the concept of recovery sits within the framework of social inclusion and is an integral part of it. Mental health nurses need to understand what social inclusion means to people who experience it, so that they are able to empower them to make a positive contribution to their community, as citizens, friends, family members, employees and neighbours.

Despite nurses having legitimate ethical rights and responsibilities, they are often constrained in practice from acting in ways they believe to be morally correct. This thesis presents a qualitative exploration of factors that influenced eight newly graduated nurses as they endeavoured to practice ethical mental health nursing in New Zealand. Data was gathered from in depth interviews with the participants and analysed using a thematic analysis method. A critical lens was employed to view the data so as to make visible aspects of the social and political context within which the participants were situated. The participants? moral practice was profoundly influenced by a number of relational experiences they had. These relationships were then determinants in their moral development, professional socialization and their ability to practice in accordance to their moral beliefs. Key aspects of these relationships were their experiences with nursing education and the influence of the organisations where they worked. Recommendations are made to both areas to enable and support moral nursing practice for new graduate mental health nurses. New graduate nurses inherently desire to practice in a way that honours the client and is therefore inherently ethical. Moral nursing practice is an everyday occurrence that must be situated in a culture of respect and regard for both clients and nurses. New graduate nurses have much to offer the profession and the tangata whaiora of the mental health services. They must be valued and supported to act in accordance to their moral ideals.

This research is about the facilitation of taha wairua (spirituality) in mental health services. This research has been guided by kaupapa Maori frameworks and aimed to answer three questions: · Whether taha wairua, supported by matauranga Maori can be verified as a valid concept for use in mental health services · How Maori cultural and clinical workers facilitate taha wairua within a kaupapa Maori approach, and, · How the use and influence of taha wairua facilitates the inclusion of matauranga Maori. The increasing acceptability of alternative and holistic approaches to healing often with a spiritual component deserves serious consideration, especially within the area of mental health services. The literature shows that indigenous views of health and healing are valid and deserve recognition and acceptance in mental health services. The Treaty of Waitangi, the founding document of New Zealand, underpins Maori rights to the facilitation of taha wairua practices in Western health systems. Current New Zealand mental health policy and legislation provide strategies to progress the facilitation of Maori healing interventions in mental health services. It is noticeable, however, that these strategies are not built on the Treaty of Waitangi but are built on health disparities. The literature also supports the concept that there is a place in the recovery process for both spirituality and religious beliefs, and Western and cultural interventions. The data illustrate how tikanga Maori either practised solely in its natural form or within the framework of Maori models of health is beneficial to health outcomes for tangata whai ora and whanau when supported by the facilitation of taha wairua. The research data provided the foundation for components that can produce a framework for the facilitation of the concept of taha wairua within the scopes of practice of kaimahi Maori in mental health services. Some standards for best practice in supporting taha wairua within the cultural component of all Maori working in mental health have also been proposed. Maori do not have the critical mass to achieve all that has been raised in this research, and the principle of collective responsibility needs to be applied to provide the necessary resources and support to achieve implementation of Maori healing frameworks to facilitate taha wairua in mental health services. It is hoped the knowledge gained from this research will be useful to policy makers and managers in gaining insight into the benefits of healing for tangata whaiora, whanau and kaimahi Maori through the provision of appropriate cultural interventions and in providing an appropriate environment to enable physical and spiritual healing to take place. It is also hoped Maori too will find this research of benefit, particularly to inform scopes of practice, thereby providing potential for new ways to achieve best practice cultural and clinical practice.

No description available.

No description available.

No description available.