of Mental Health Support Workers.

Barnaby Pace MNZPsS, Assoc.MNZCMHN

BSocSc(Hons), MSocSc(Hons), PGDipCBT, PGDipEd(AdEd)

Citation:

As a part of the ongoing investigation of how mental health support workers are perceived in a New Zealand context this paper explores the perceptions of healthcare professionals and service users. Both healthcare professionals and service users have a significant impact, and are impacted by this paraprofessional group. As such it is fundamental to include their viewpoint in order to develop a credible conceptualisation of the mental health support work role within New Zealand’s healthcare system.

Introduction
Contemporary research (Pace, 2009a) examining the role and function of support work has provided an initial conceptualisation for this developing mental health discipline. This conceptualisation suggests mental health support work to be a non-clinical profession. Logsdon and Davis (2004) echoed the perception viewing paraprofessionals as the first point in the continuum of healthcare services offered, providing further support for the conceptualisation of support work as a non-clinical profession. Pace (2009a) also identified primary roles of support and advocacy for mental health support workers as suggested within the job title form the principle function based on the successful development of therapeutic relationships with a strong emphasis on strengths-based practice and recovery principle. In order to continue the conceptual develop of the support work role additional avenues of investigation are required to ensure the credibility of the final conceptualisation. Pace (2009a) suggest the necessity for both healthcare professionals and mental health service users to be included in the development process as the support worker role impact significantly on two groups.

Professional Perceptions
Recent research conducted by Mackenzie (2006) offers an insight into the consideration of health care professional for the use of paraprofessional staff as a means of overcoming their increasing workload. Mackenzie delivers this consideration through the use of a well placed case study. Both managerial and practicing staff were engaged through the use of semi structured interviews to elicit their perceptions regarding the use of the paraprofessional. Mackenzie identified two areas of concern: 1. The potential for staff vulnerability and 2. Co-management of paraprofessionals by the health and voluntary organisations involved in service delivery. Such co-management could prove to be problematic if there was not an effective communication system in place to adequately manage non-registered and usually lesser trained paraprofessional staff. In line with the required management system Mackenzie’s review of relevant literature identified the implementation of a new role within existing health care structures to be potentially challenging. The discussion Mackenzie provides suggests, from a global perceptive, the need for further development of policy and codes of practice to adequately support and utilise these paraprofessionals in the health care system.

Edwards and Jahns (1990) considered the professionals primarily supervisors’ perceptions of paraprofessionals, as well as how the paraprofessionals perceived themselves as allied health care professionals. The results of this investigation revealed no major difference in the perceptions of either the paraprofessionals or supervising professionals on the majority of actual tasks performed. However, Edwards and Jahns did offer comment with regard to differences in perception of how tasks should ideally be performed. The author of this paper suggests that this difference in task performance could be the result of differing professional disciplines with potential differences in level and type of qualification, and overall competence. Smith, Prosser and Joomun (2007) also suggested the need to address issues, including level of qualification and expressed concerns regarding the supervision requirements of support workers; a concern not identified in Edwards and Jahns (1990) earlier work.

Service Users Perceptions
Through the evaluation of a new health initiative Smith, Prosser, & Joomun (2007) investigated service users’ perceptions of health support workers using focus group discussions and a series of semi-structured interviewes. The objective of the investigation was to determine the effectiveness and acceptability of services offered by support staff. The findings indicated that both service users and service visitors appreciated the involvement of the health support workers. Similarly in earlier research Corcoran (1985) investigated patient’s perceptions of paraprofessional and professional therapists. Corcoran suggested that the patients were more willing to seek help from paraprofessional then professional therapists, with areas such as trustworthiness and expertness showing no significant difference. Both articles offer strong support for the use and employment of paraprofessional staff, indicating, for the most part, that both service users and visitors are comfortable with their involvement in health and social services. The utilisation and potential benefits of paraprofessionals is further reflected in den Boer, Wiersma, Russo, and van den Bosch’s (2005), viewed from a managerial position

Like Mackenzie (2006), den Boer et al. (2005) examined the employment of paraprofessional as a means for a cost effective method to reducing the burden for health professionals, with particular reference to their effectiveness in the delivery of psychological treatments for depression and anxiety disorders. Within this study the focus was on perceptions of the service user, rather than the professional as was the case in Mackenzie (2006). Paraprofessionals involved within den Boer et al. were employed as mental health care workers, paid and voluntary, with no qualifications in regard to the delivery of psychological treatment. Analysis indicated no statistical difference between the delivery and effectiveness of treatment between professional and paraprofessional groups. However, the analysis of the preferred group from the client’s perspective favoured paraprofessionals supporting the earlier work of Corcoran (1985).

The objectives of the current investigation were to identify the role and function of mental health support workers as perceived by service users and healthcare professionals, and to identify the level of acceptance of paraprofessionals as members of the mental health care community.

Method
The research was based on a qualitative methodological approach utilising both focus groups and semi-structured interviews. Focus groups were held for health care professionals and individuals, semi-structured interviews for mental health services users. All participants were located in the Waikato region of New Zealand’s North Island. Four focus groups were run with registered health professionals. The focus group sessions ran for a duration of 45 minutes, consisting of twelve open-ended questions. Interviews were conducted by a service user who had been trained in the use of interview techniques. The rationale for this data collection approach was to minimise anxiety levels the services user may have experienced had the interviewer been a healthcare professional. The questions used both within the interviews and focus groups were similar in content to those used in Pace (2009b).

Table 1. Statistical information for discipline, registration period, and duration working for mental health services.

Sample Two consisted of 20 mental health service users who were currently engaging with a mental health service which employed mental health support workers as staff.

Table 2. Statistical information of current diagnosis and duration of mental illness.

Results
Sample One (Healthcare Professionals) Results

The data analysis suggested the following key themes as identified by healthcare professionals.

1. Rehabilitation

2. Care giving

3. Supporting activities of daily living

4. Advocating for clients

5. Level of skill/competence

Each will be discussed and illustrate with quotes where appropriate.

1. Rehabilitation
Many of the healthcare professionals considered support workers to be fundamental to the recovery/rehabilitation process, stipulating they were able to offer themselves as significant individuals in the service users’ life in the absence of family or friends.

“To help support the rehabilitation or recovery process and action the care plans we [Healthcare Professionals] set for them.”

“To make clients move forward … ensure they take their medication.”

2. Care giving
Perceptions surrounding the care or supportive nature of support work became polarised for the healthcare professional sample which resulted in this particular theme being divided into two components: 1. Care giving, and 2. Supporting activities of daily living. Care giving was viewed as a paternalistic model which removes the autonomy of the service user, suggesting support work is a ‘baby-sitting’ role.

“I can’t say that I know what support workers do. My opinion is that they should do more to care for the service users … such as cleaning their homes and making sure they shower daily… that type of task.”

“I believe that a key feature of the support role is to ensure clients live in a safe clean environment and provide for them accordingly.”

3. Supporting activities of daily living
In contract to the paternalistic model offered through care giving numerous references were given to the collaborative nature of support work, suggesting that the paraprofessional work along side rather than for the service user.

“… to walk beside the consumer and support and guide them when needed.”

4. Advocating for clients
Based on the experiences and contact with support workers professionals decided there was a strong emphases on the role of advocacy.

5. Level of skill/competence
With reference to the level of skill and competence perceived for mental health support workers a variety of views were expressed dependent on how their overall role was viewed, as stated in points two and three above. A clear division emerged from the narratives: those who perceived support workers to be under qualified and those who thought no qualification were needed.

“Support workers as a group need to be better qualified for the role which they have in the psychiatric sector.”

“Can the necessary skills and practice knowledge be taught at Certificate level and who is supervising their practice…or clinical responsibility?”

Sample Two (Service Users) Results
Analysis of Service User interviews revealed the following themes. Each will be discussed and illustrated with the use of quotes where appropriate.

1. Help to find employment

2. Assist in goal achievement

3. Care giving

4. Supporting activities of daily living

1. Help to find employment

Employment was identified as a significant function of the support work role with several of the research participant commenting on the value of have a support worker to guide them through the process of applying for work.

“I like it when [support workers] help me to get a job. When I’m working I feel so good and normal … you know … like I fit in.”

“[Support worker] came with me to an interview at [company]. I didn’t know what to say, but [support worker] helped me out.”

2. Assist in goal achievement

Goal completion was also identified as a significant function of the support worker’s role, ranging from short through to long-term goal development and implementation across a variety of domains.

3. Care giving

As with the Healthcare Professional, Service Users appeared polarized over the caregiver verse supportive nature perception of mental health support work. Several of the participants viewed support workers as a domestic aide who should perform tasks included meal preparation and house work.

“I think that its [support worker] job to look after me. Make sure that I tidy my flat and do the shopping and clean my room, bed, and stuff.”

4. Supporting activities of daily living

Contrary to the statements made in point three above, services users also viewed support workers as critical elements to their general well-being and ongoing recovery, viewing them in a more professional capacity.

“At times when I’m not well it’s good to know that [support worker] is going to be around to look after me. And my cat too.”

“I like knowing that [support worker] is there to support me through the dodge times… helps me to stay on the road, you know, ah.”

Discussion
What is of particular concern is the polarised view of the role and function of support work, from both the perception of the service users and healthcare professionals. Within both sample groups a large proportion viewed support work as similar to a caregiver role, whereby a support worker becomes a domestic aide. As a function of the support workers position, domestic duties performed in this manner would clearly undermine the recovery principles and strength-based focus central to mental health support work. What is clearly evident in the literature (Pace, 2009a) is that support workers are to work in collaboration with services users to assist them in becoming self-sufficient. Performed daily tasks and duties for service users may offer some benefits in the short-term but fail to do so over the long-term.

Apart from hindering the service user’s recovery, this caregiver perception also undermines and devalues the work mental health support workers engage in. As articulated in original conference presentation (Pace, 2007) which sparked the current research (Pace, 2009a, b), support workers can form a valuable source of information and support for healthcare professional if provided with the opportunity. The research presented at the 2007 New Zealand Collage of Mental Health Nursing Conference suggested that support workers are able to support health professionals through the sharing of resources, information and experience.

Issues regarding level of qualification and supervision of support workers were raised as a significant concern by healthcare professionals. Two issues were raised at polar ends of the same continuum. Healthcare professionals viewed either support workers as currently under qualified for their role and function in psychiatric care or that no such qualification is required. This immediately follows on from the professionals’ view of the support workers’ role and function. If focus is given to the concerns of support workers being under qualified, reference can be made to the discussion offered in Smith, Prosser, and Joomun, (2007), Mackenzie (2006), and Edwards and Jahns (1990), all of whom expressed similar educational concerns. In light of the low level of qualification required, discussions surrounding risk and clinical responsibility were entered into. Healthcare professionals demonstrated a degree of apprehension with reference to clinical ‘type’ duties and where clinical boundaries lie, particularly as support workers in New Zealand currently do not come under a registration body. Mackenzie (2006) also raised this as an area of vulnerability.

In addition to the qualifications required and as a potential solution to the clinical responsibility dilemma, a particular force was given to the supervision and its place in mental health support work. Recent research (Sutcliffe, 2007) has investigated this topic indicting that supervision can hold a critical role in the development, quality, and therapeutic engagement of staff towards service users. Sutcliffe does clearly state that in this instance support work is a non-clinical role. However, boundaries are often crossed (Pace, 2009a) making the role of supervision as described by Sutcliffe even more critical for the safety and well-being of professionals, support workers and service users.

These findings clearly indicate the need for mental health support workers as a group to improve their professional profile to ensure that both healthcare professionals and service users have a clearer understanding of support work and its position in the health sector. It also offers assistance for current discussion surrounding a registration process for mental health support workers as a means of minimising potential risk and increasing the profile and credulity of this fledging discipline. Further investigation is however required to determine what a registration body for support work may look like and its potential impact on the field.

Sutcliffe, R. (2007). What is the meaning of supervision for mental health support workers? A critical hermeneutic inquiry. Master of Health Science Thesis Auckland University of Technology, New Zealand.