'When you're it': a qualitative study exploring the rural nurse experience of managing acute mental health presentations.

INTRODUCTION: A higher proportion of chronic mental illness is reported for populations residing in inner and outer regional (IOR) areas when compared to major cities in Australia. Conversely, fewer mental health professionals work in IOR areas when compared to major cities indicating poorer access to services for rural populations. Rural emergency departments (EDs) and urgent care centres (UCCs) deliver a broad range of services. Often they are the first point of care for consumers experiencing acute mental health issues. Rural nurses working in EDs and UCCs require a diverse clinical skill set to manage complex presentations, often with limited support and resources. Developments in telehealth services have reportedly improved access for rural consumers. It is known that nurses report a lack of skills and confidence when managing mental health presentations. Despite these challenges, there is little documented regarding the experience of generalist nurses managing acute mental health presentations in rural hospitals that have limited support of community mental health teams and no onsite inpatient mental health facilities. METHODS: A qualitative study was conducted to explore the experience of rural nurses in managing acute mental health presentations within an emergency context. An interview guide developed from the literature was used to explore issues of experience, safety, knowledge and clinical confidence. Thirteen rural generalist nurses from one rural emergency department and two rural UCCs located in south-west Victoria participated in a semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Transcriptions were thematically analysed by applying an inductive descriptive approach. RESULTS: The majority of participants were experienced generalist registered nurses with no formal qualifications in mental health. Two participants had some clinical experience in mental health and drug and alcohol. Themes elicited from data analysis and discussion between the researchers were (1) 'we are the frontline', (2) 'doing our best to provide care', (3) 'complexities of navigating the system', and (4) 'thinking about change'. Findings indicated that rural generalist nurses deliver the majority of care to mental health consumers in EDs and UCCs. Local mental health clinicians and emergency service providers offer limited support, with a reliance on telephone triage for after-hours assessment. Multiple challenges were cited including coordinating the transfer of consumers to inpatient facilities and feeling inadequately supported. Irrespective of these challenges, nurses reported delivering the best possible care to consumers despite reporting a lack of knowledge and skills. Recommendations for improving the delivery of care included increasing access to emergency mental health training and receiving more support from local mental health teams. The need for more rural mental health facilities was also discussed. CONCLUSIONS: The findings from this study suggest generalist nurses are the frontline providers of care for mental health consumers in rural EDs and UCCs. Nurses feel ill-equipped for assessing and managing mental health presentations, relying heavily on local mental health teams and telephone triage who provide limited onsite support. The need to support nurses through training and mentoring relationships with community mental health teams is highlighted by this study in conjunction with improving the delivery of mental health services in rural areas.

Mental health academics in rural and remote Australia.

CONTEXT: The significant impact of mental ill health in rural and remote Australia has been well documented. Included among innovative approaches undertaken to address this issue has been the Mental Health Academic (MHA) project, established in 2007. Funded by the Australian Government (Department of Health), this project was established as a component of the University Departments of Rural Health (UDRH) program. All 11 UDRHs appointed an MHA. Although widely geographically dispersed, the MHAs have collaborated in various ways. The MHA project encompasses a range of activities addressing four key performance indicators. These activities, undertaken in rural and remote Australia, aimed to increase access to mental health services, promote awareness of mental health issues, support students undertaking mental health training and improve health professionals' capacity to recognise and address mental health issues. MHAs were strategically placed within the UDRHs across the country, ensuring an established academic base for the MHAs' work was available immediately. Close association with each local rural community was recognised as important. For most MHAs this was facilitated by having an established clinical role in their local community and actively engaging with the community in which they worked. In common with other rural health initiatives, some difficulties were experienced in the recruitment of suitable MHAs, especially in more remote locations. The genesis of this article was a national meeting of the MHAs in 2014, to identify and map the different types of activities MHAs had undertaken in their regions. These activities were analysed and categorised by the MHAs. These categories have been used as a guiding framework for this article. ISSUES: The challenge to increase community access to mental health services was addressed by (i) initiatives to address specific access barriers, (ii) supporting recruitment and retention of rural mental health staff, (iii) developing the skills of the existing workforce and (iv) developing innovative approaches to student placements. Strategies to promote awareness of mental health issues included workshops in rural and remote communities, specific suicide prevention initiatives and targeted initiatives to support the mental health needs of Indigenous Australians. The need for collaboration between the widely dispersed MHAs was identified as important to bridge the rural divide, to promote project cohesiveness and ensure new ideas in an emerging setting are readily shared and to provide professional support for one another as mental health academics are often isolated from academic colleagues with similar mental health interests. LESSONS LEARNED: The MHA project suggests that an integrated approach can be taken to address the common difficulties of community awareness raising of mental health issues, increasing access to mental health services, workforce recruitment and retention (access), and skill development of existing health professionals (access and awareness). To address the specific needs and circumstances of their community, MHAs have customised their activities. As in other rural initiatives, one size was found not to fit all. The triad of flexibility, diversity and connectedness (both to local community and other MHAs) describes the response identified as appropriate by the MHAs. The breadth of the MHA role to provide university sponsored educational activities outside traditional student teaching meant that the broader health workforce benefited from access to mental health training that would not otherwise have occurred. Provision of these additional educational opportunities addressed not only the need for increased education regarding mental health but also reduced the barriers commonly faced by rural health professionals in accessing quality professional development.