Mental health nursing in New Zealand primary health care.

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1 Mental health nursing in New Zealand primary health care. O'Brien, Anthony J., Frances A. Hughes, and Jacquie D. Kidd. "Mental health nursing in New Zealand primary health care." Contemporary Nurse 21.1 (2006): 142. Academic OneFile. Web. 3 Oct Document URL Documents&type=retrieve&tabID=T002&prodId=AONE&docId=A &source=gal e&srcprod=aone&usergroupname=learn&version=1.0 Full Text:COPYRIGHT 2006 econtent Management Pty Ltd. ABSTRACT International literature and New Zealand health policy is giving increased emphasis to the role of the primary health care sector in responding to mental health issues. These issues include the need for health promotion, improved detection and treatment of mild to moderate mental illness, and provision of mental health care to some of those with severe mental illness who traditionally receive care in secondary services. These developments challenge specialist mental health nurses to develop new roles which extend their practice into primary health care. In some parts of New Zealand, this process has been under way for some time in the form of shared care projects. However developments currently are ad hoc. There is room for considerable development of specialist mental health nursing roles, including roles for nurse practitioners in primary mental health care. KEY WORDS mental health nursing; primary health care; New Zealand health policy; nurse practioners; mental health promotion and prevention INTRODUCTION Primary health care is an important setting in which to introduce treatment and care for people with mild and moderate mental illness, and to provide prevention and mental health promotion services. In addition, there is a developing body of literature that points to important reasons for providing care for some of those with severe mental illness within primary care settings (Hobbs, Wilson & Archie 1999; Lester 2005).The New Zealand Mental Health Strategy (Ministry of Health 1997) identifies two populations of people requiring involvement of health professionals. These are the 17% of the general population who experience lifetime prevalence of mild to moderate mental illness and who present to primary care, and the three percent of the population estimated to experience severe mental illness who need referral to specialist mental health services (Ministry of Health 1997). These two populations are not discrete. Individuals move between and out of groups as their needs change (Ministry of Health 2002a). Mental health promotion is a further area of mental health policy that seeks to address mental health needs at a population level (Ministry of Health 2001a). Primary health care plays a crucial role in mental health care but, to be effective, the sector needs to be strengthened in terms of its workforce, skill development and relationship with secondary services. This paper addresses the potential role of specialist mental health

2 nurses in primary health care. We argue that there is a range of possible roles for mental health nurses working with the populations identified above. Mental health nurses are challenged to redefine their range of clinical skills, and to develop new roles in response to changing perceptions of mental health needs and changes in models of service delivery. Greater commitment by service providers to the strategic implementation of the nurse practitioner role (Hughes & Carryer 2002) is necessary for nursing to realise its potential to contribute to population health gains. BACKGROUND Many of the most prevalent health problems seen in primary health care are chronic in nature. These chronic conditions include anxiety and depression, substance misuse and severe mental illness. They leave the individual and the family needing long-term support and care from their communities and the health system. Chronic conditions represent a growing proportion of the global burden of disease (WHO 2002) with mental disorder recognised as the leading cause of disability burden (Murthy & Bertolete 2001). Epidemiological studies estimate that between 10% and 50% of those presenting to primary care have a diagnosable mental disorder, although up to 50% of cases are not diagnosed by primary care physicians (Vazquez-Barquero, Herran & Simon 1999).There is now increasing recognition that mental health needs must be addressed in the primary sector (Jenkins & Strathdee 2000), and that nurses represent an important sector of the workforce in responding to the mental health needs of primary care consumers (Gournay 1999). Both internationally and within New Zealand, a range of models of mental health in primary health care have developed. The models focus on both the 'traditional' mental health consumer (the person with a long term mental illness) and primary care consumers with mild or moderate mental illness. The models include attachment of community mental health nurses to primary health care services (Hannigan 1999;Weaver, Patmore, Cunningham & Renton 1999); expansion of the role of primary care and community nurses to include mental health issues (Mead, Bower & Gask 1999; Sokhela 1999; Russell & Potter 2002) and development of nursing roles to meet the mental health needs of specific groups of consumers, e.g. women with postnatal depression (Davies, Howells & Jenkins 2003); people with unexplained physical symptoms (Lyles et al. 2003), people with severe and persistent mental illness (Bindman et al. 2001; Hobbs, Wilson & Archie 1999; Marion et al. 2004), and elderly people with depression (Saur et al. 2002). Some advanced practice models from the United States see the nurse practitioner providing a range of primary care health services to meet mental health consumers' physical health needs (e.g. Talley & Caverly 1994; Miller & Martinez 2003). Models of 'shared care' in which primary care and specialist mental health services negotiate joint care arrangements for mental health consumers have also been described (Lester 2005) and have been developing in New Zealand for several years (Ministry of Health 2002a; Nelson et al. 2003). Primary health care is not limited to intervention and treatment of existing mental health issues or to the provision of care through primary care services such as GP practices. The opportunity exists for experienced mental health nurses to deliver primary mental health care directly to the community as independent providers. The aim for such independent nurse providers is to assist communities, families and individuals to take control of and improve their own mental health, and to prevent mental illness (Ministry of Health 2004).

3 There is also the potential for mental health gains for Maori (indigenous people of New Zealand) through the involvement of specialist Maori mental health nurses in primary care settings. Literature supporting the development of primary mental health care for Maori (Ministry of Health 2002b) identifies the importance of non-clinical strategies, including ready access to primary health care, as vitally important in the quest for improved mental health for Maori. Improved access to effective primary mental health care has the potential to significantly decrease the acuity of the initial presentation to specialist mental health services, through earlier detection, culturally specific prevention strategies and health promotion activities which reflect the cultural identity of the community. Primary mental health care for Maori may include whanaungatanga (relationship building), whakapapa (ancestry), tikanga (cultural practices) and te reo (language), and be very effectively carried out in culturally appropriate environments, such as marae (meeting places), kohanga reo (language schools) and runanga (tribally based) organizations (Hamer et al. 2005). NEW ZEALAND HEALTH POLICY New Zealand has a range of health strategies within the overarching New Zealand Health Strategy (the Health Strategy).The Health Strategy, along with the Primary Health Care, Mental Health, Pacific and Maori Health Strategies and others, provide an overall framework as well as specific policy in priority areas. The Health Strategy's population focus, combined with the reinforcement of the public health system over the past five years, has implications for the care of people with enduring mental illness and for those presenting to primary care with mild to moderate mental disorders. Both primary health care and mental health are amongst the five service priority areas within the Health Strategy (Ministry of Health 2000). The Health Strategy anticipated fundamental reorganisation of the primary care sector and created 21 District Health Boards (DHBs) with responsibility for matching health needs to resources and service delivery in each region. A new provider of primary health care services, the Primary Health Organisation (PHO), was established to enable implementation of this strategy. PHOs are not-for-profit organisations funded by DHBs to provide primary health services to enrolled populations (Ministry of Health 2003).There are currently 79 PHOs providing health care for enrolled populations of 3.8 million or 93% of the population (Ministry of Health 2005a). Primary health care, including mental health, is integral to the implementation of the Health Strategy and is the focus of a separate policy document, the Primary Health Care Strategy (Ministry of Health 2001b). The Primary Health Care Strategy signalled a new direction for primary health care and placed a greater emphasis on health promotion, community involvement, preventive care, collaboration and teamwork, and better alignment and integration of existing services around community needs. As with the Health Strategy, the focus of the Primary Health Strategy is population health. The reorganisation of primary care changed the focus of this sector from predominantly private General Practitioner-led first contact service into a service with a broad preventative health focus, allowing different roles to develop. This new direction presents challenges for New Zealand's primary health care and community nursing workforce to 'critically evaluate and redefine the scopes of practice, address the current constraints to effective practice, and ensure that nurses are strong, effective and visible members of the primary health care workforce' (Ministry of Health 2003: vii). Within the Primary Health Care Strategy, nurses in advanced practice roles are seen as crucial to achieving improvements in the health status of specific populations (Ministry of Health 2003).

4 The development of a population-based health strategy also has implications for the development of mental health services and for the future roles of mental health nurses. Mental health policy has identified priority areas in both long-term and severe mental illness and mental health in primary care (Ministry of Health 1997, 2002a), with mental health in primary care one of the seven strategic directions of the National Mental Health and Addiction Plan (Ministry of Health 2005b). Similarly, Maori health has been identified as a priority area for health gain (Ministry of Health 2002c). Issues that need to be considered in implementing the Primary Health Care and Mental Health strategies are outlined in a further policy document, Primary Mental Health: A Review of Opportunities (Ministry of Health 2002a).This document notes that there have been a number of pilot initiatives to transfer lead care for those with severe and ongoing mental illnesses from specialist services to General Practitioners (GPs).There is interest from providers in a more co-ordinated approach to such developments, whilst recognising that those with high and complex mental health needs may not be best served in primary care settings. The document notes that 'the degree to which primary health care providers should be involved in providing mental health services to this group is not clearly identified nationally or internationally' (Ministry of Health 2002a: 13). In summary, New Zealand health policy in the past five years has developed around the concept of population-based health care with an emphasis on primary health care. While there remains a substantial role for specialist mental health services for people with the most severe and complex mental illnesses, new initiatives in primary health care provide challenges for nurses to develop new roles. The next section of the paper will review programmes of 'shared care', and research that addresses the issue of detection and treatment of mild to moderate mental illness in primary care. MENTAL HEALTH INITIATIVES IN PRIMARY CARE There have been a number of developments aimed at extending and improving mental health provision in primary care. These include programmes of shared care that aim to return consumers to primary care after a period of care in specialist mental health services, and greater detection and treatment of mental health problems in primary care populations. Shared care Shared care involves the development of a collaborative relationship between primary care and mental health services aimed at increasing the involvement of the primary care provider in mental health care. The review of mental health in primary care (Ministry of Health 2002a) outlined different models of relationships used internationally, noting that most have a mental health clinician in some way attached or linked to a primary care setting, though the structure, function and associated responsibilities of these arrangements varies. Four broad categories were identified: 1. Shifted outpatient clinics: visiting mental health clinicians provide clinics in primary care facilities. 2. Consultation liaison: mental health clinicians meet regularly with primary care providers to have input into the care of patients. 3. Locating a named mental health worker employed by mental health services in a primary care setting.

5 4. Co-location of specialist mental health services and primary care teams at same location with some boundary blurring. The focus of most New Zealand shared care projects is the population of people with severe mental illness, with the aim of either transition into primary care or shared responsibility for mental health care (Nelson et al. 2003). Improved physical health care is another aim of most projects. A range of models has been implemented, including consultation-liaison, shifted outpatient clinics and conjoint clinical care. The programmes were noted to have developed variations on the models described in the literature. Five programmes were pilots and others also had limited term funding, indicating that shared care relationships are not yet firmly established in New Zealand. Maori involvement was variable across the different programmes. Although improvement in physical health status was a goal of most programmes, few sought to measure improvement in physical health, with even fewer measuring health promotion or prevention. Of the 13 programmes reviewed by Nelson et al. (2003), 11 were actively providing shared care. Of these, five employed a mental health nurse in some role. The remaining programmes employed community mental health staff under generic descriptors. Significantly, Nelson et al. (2003) noted that in no programmes were mental health staff employed by primary care providers. The review commented on the importance of the role of mental health nurses in community mental health care and on the need to explore nurse-led initiatives in shared care programmes. Nurses play an important part in these projects but their role is not always visible in project descriptions. The variable nature of shared care programmes in New Zealand suggests that shared care has so far developed as a series of local initiatives, with no single model dominating. While this is consistent with the notion that new initiatives should be driven by local providers with support from central funding, there is a danger that, without a developed model of mental health nursing in primary care, the mental health nursing role will be left undefined or absent altogether. Identification of mental illness in primary health care Awareness of the prevalence of mental illness in the primary care population has been growing since the publication of epidemiological research in this area over a decade ago (Oakley-Browne, Joyce & Wells 1989). Specialist mental health services cater to only a small proportion of those with mental illness but, despite awareness of high rates of untreated mental illness, relatively low numbers of people present to primary care services specifically with mental health problems (MaGPIe Research Group 2003; 2004). This makes detection of mental illness in primary health care settings an important priority. New Zealand research suggests that, at least in the practices surveyed by the Mental Health and General Practice Investigation (MaGPIe) study, detection rates are high by international standards. GPs surveyed identified a diagnosable mental disorder in about one-third of patients, the most common disorders being anxiety, depression and substance misuse. There were high levels of comorbidity. In discussing these findings, the authors identify a number of structural barriers to identification and management of mental health issues in primary health care. These include the funding model of primary health care services (those surveyed were not PHOs) which results in relatively high direct costs to the consumer and time pressure on GPs and thus limits on the amount of time available for consultations. WORKFORCE IN PRIMARY HEALTH CARE

6 The change to a population health focus signals the need for a change in the 'number, mix, and distribution of the primary care workforce' (Ministry of Health 2001b: 22). This has implications for general practice, the setting in which most New Zealanders access firstcontact services. The current workforce does not reflect population needs, having developed largely in response to demand and to a range of unrelated incentives and initiatives. Planned workforce development is needed to address the priorities of the Primary Care and Mental Health Strategies. While this development will include enhancement of mental health assessment and intervention skills of current primary health care staff, the primary care sector cannot be expected to provide mental health services without partnerships with specialist mental health services. There is a danger of this occurring if funding incentives are not aligned with workforce skills and availability. This latter point is especially important for nurses as current funding for nursing is not specified within contracts and, unlike general practitioners, nurses are unable to claim on a fee-for-service basis. There are currently approximately 3000 nurses in New Zealand who identify mental health as their scope of practice (Nursing Council of New Zealand 2004). The current mental health nursing workforce is comprised of specialist practitioners, managing an already identified population groups within secondary and tertiary mental health services. As long as this group of nurses remains employed solely within the secondary and tertiary sectors, it has only a limited capacity to take a more 'hands on' role. However the mental health nursing workforce represents a considerable pool of skills that could assist in the development of mental health care in the primary sector. The review by Nelson et al. (2003) showed that nurses contributed to shared care programmes through their skills in assessment and intervention, case management, consultation and liaison, specialist advice and coordination, therapeutic interventions and education Our contention is that, in addition to the development of the skills of current primary health care staff, mental health nurses could contribute directly to mental health in primary health care by being employed within primary health care services to provide interventions such as those described by Nelson et al. (2003). These interventions could be provided to consumers in shared care programmes as well as to those presenting with mild or moderate mental illness. MENTAL HEALTH NURSING ROLES IN PRIMARY HEALTH CARE A range of models of mental health nursing in primary health care is described in the international literature. In reviewing these models in relation to the New Zealand context, it may be that none are directly applicable but all suggest possibilities for the development of mental health nursing in primary care. Mental health promotion Mental health promotion can occur as an integral component of general health care or as a specific activity by practitioners trained in interventions such as mental health education, stress management and cognitive intervention. For example, Naegle (2003: 217) describes 'culturally congruent parenting education and promotion of self esteem and selective preventative interventions such as elder support groups, respite for caregivers and health teachings'. These are all new areas for New Zealand mental health nurses as we face the challenges of service an ageing population.

7 Mental health care provided by primary health care nurses Most general practices in New Zealand employ practice nurses, practitioners with a generic nursing qualification but without specialist mental health nursing experience. Russell and Potter (2002) note that primary health care nurses (a group which includes practice nurses) made a distinction between interpersonal care (which they saw as part of their remit) and mental health care (which they did not see as part of their remit). Furthermore, Plummer, Gray & Gournay (2001) suggest that practice nurses are ill-prepared to assume mental health roles. Gournay (1999) suggests that for practice nurses to take on this role, closer linkage with mental health nurses in secondary services is important to develop skills and to receive appropriate clinical supervision. There is clearly a role for specialist mental health nurses in supporting generalist colleagues in developing mental health skills. Specialist mental health nursing roles in primary health care Internationally there has been interest in an extension of the mental health nursing role into primary care for some time. Different models are apparent in the US and the UK, with US practitioners extending their scope of practice to include the physical health care needs of mental health consumers (Bjorklund 2003;Talley & Caverly 1994), while British models include attachment of specialist mental health nurses to GP clinics where they provide specialist mental health care to those with serious mental illness as well as the primary care population with mild or moderate mental illness. Hannigan (1997) notes a lack of strategic planning of the expansion of mental health nursing into primary care in the UK. Anecdotally, we are aware that a small number of Primary Health Organisations in New Zealand have employed specialist mental health nurses but as yet there are no publications describing their roles. Community psychiatric nurse attachment to primary care In the UK, some community psychiatric nurses are employed by National Health Service Trusts to provide long-term care of the seriously mentally ill. Some of these nurses also have attachments to primary care where they provide a service to both the seriously mentally ill and to those with less severe mental illness. The literature on both the effectiveness of this model and nurses' satisfaction with it is mixed (Weaver et al. 1999). In particular, nurses surveyed by Secker, Pidd, Parham and Peck reported feeling 'torn by opposing demands of GPs and their employing trusts' (2000: 49). Some research reveals concerns that community psychiatric nurses working in this model have gradually given less emphasis to seriously mentally ill and have not always provided effective intervention for those with less severe mental illness (Gournay & Brooking 1994). However more positive outcomes have been reported in programmes provided by nurses trained in evidence-based approaches for defined illnesses (Gournay 1999). In addition to employment within primary care services and shared care roles, there is some literature describing mental health nursing roles with particular primary care populations such as the elderly (Suar et al. 2002) and in providing specific interventions such as behavioural psychotherapy (Newell & Gournay 1994). There is clearly a range of possible models that specialist mental health nurses can explore. While some of these models require only that primary care services develop roles for mental health nurses that use their existing skills (for example in cognitive therapy or supportive psychotherapy), others involve new roles in

8 which nurses work as autonomous practitioners within primary care. The next section considers the development of the nurse practitioner role in the New Zealand context. NURSE PRACTITIONER The development of the nurse practitioner role in New Zealand represents an opportunity for nurses to make a major contribution to achieving the goals of the Health Strategy and extending mental health services to populations which are currently underserved due to a shortage of specialist psychiatrists. The nurse practitioner in New Zealand is defined as 'the most advanced level of clinical nursing practice' (Hughes & Carryer 2002:3) and is a role aimed at improving access to health care and improving the health of populations. Following a recent change in prescribing regulations, nurse practitioners are able to prescribe autonomously (King 2005). The nurse practitioner role has been described as 'critical to the implementation of the (Primary Health Care) strategy' (King 2002: iii). Internationally, nurse practitioners have been shown to provide safe and effective care, providing clinical outcomes comparable to those of primary care physicians, and increased levels of consumer satisfaction (Hughes, Clark, Sullivan- Marks & Fairman 2002; Horrocks, Anderson & Salisbury 2002;Venning et al. 2000). Four models of nurse practitioner practice have been proposed (Hughes & Carryer 2002): Integrated nursing teams: A team of nurse practitioners provides a health service focusing on health promotion and disease prevention across the care continuum. Nurses' generic assessment and care coordination skills would enable appropriate clinical intervention and referral to other health professionals. A mental health nurse practitioner would contribute mental health expertise to the team, taking the lead clinical role for those consumers whose mental health needs were most prominent. This model could be adapted for Maori nurses to provide kaupapa Maori services for Maori populations. Nurse consultancy: The nurse practitioner works independently or in collaboration with other health professionals. In some cases the independent practitioner may refer to other disciplines. Nurse consultants could work within Primary Health organizations, discussing and advising on cases with other professionals, taking a clinical management role and liaising with specialist mental health services. Independent practice: Nurse practitioners are independently employed offering mental health services directly to the public. These can include counselling, medication management, cognitive and other psychological interventions, stress management and mental health promotion. Nurse practitioner specialist clinics: The nurse practitioner acts as the lead health professional in managing a specialist service for a specific population. A mental health specialist could provide a specialist service in areas such as early intervention, eating disorders, long term mental illness, forensic rehabilitation, drug and alcohol and others. The nurse practitioner role in New Zealand is in the early stages of implementation and has not yet been the subject of a comprehensive intersectoral strategy. The primary health care sector may provide the most exciting opportunities for the development of the nurse practitioner role as it is perhaps less likely to be restricted to traditional roles.

9 DISCUSSION Development of a specialist mental health nursing role in primary health care is one of a range of initiatives necessary to extend the mental health services provided in the primary sector, and to facilitate the transfer of some mental health consumers to the primary sector. The varying views on integration of primary and secondary care are illustrated by recent literature which argues, on the one hand, for greater use of the shared care model (Lester 2005) and, on the other, that mental health consumers are best served by separate mental health and primary services as long as there are good channels of communication between them (Burns 2005). The issue that needs to be debated is the capacity and capability of the general primary health care workforce to deliver on mental health needs of consumers and how this interfaces with the mental health specialist workforce. There is clearly scope for a specialist mental health nursing role alongside other mental health initiatives in primary care. At the very least, people with severe mental illness need a clearly identified contact within primary health care who has good relationships with mental health services. The nature and quality of that relationship or interface is important as the process of integrating mental health into primary health care requires close collaboration with existing primary health care personnel. Without training in mental health assessment and intervention, primary health care personnel may resist these functions or they may assume roles for which they are not trained. WHO (2001) has endorsed the model of co-location whereby mental health specialists work alongside primary health care staff. This approach in many ways pushes the boundaries of 'traditional working models' as it requires blurring of many traditional roles and systems. Research evidence and international opinion is clear that change is needed to address mental health issues in primary health care, but change in the nature of primary health care services is not something that is likely to be achieved quickly. Sartorius (1999) notes that there are a number of professional, social, administrative and personal barriers to extension of mental health services into primary health care. Mental health nurses will need both advanced clinical skills and skills in managing the barriers to implementation of new roles in order to pursue these new roles successfully. In the New Zealand context, they will also need to be supported by DHB providers and PHOs so that the expectations of all parties are reasonable and the demands for services manageable. The development of PHOs with responsibility for health outcomes for enrolled populations is a significant change in the health care environment and creates opportunities for mental health nurses to develop new roles that will assist PHOs in meeting their contractual responsibilities to health funders. The planned move to a capitation-funding model, together with the commitment within the Primary Health Care Strategy to an emphasis on health promotion and prevention, will require PHOs to provide services that have not traditionally been part of primary health care. Thus the historic culture of primary care will have to change to embrace this. The business model of primary health care, in which a service is owned and led by a GP supported by a practice nurse offering first contact care in 15 minute sessions, is inadequate to achieve the goals of the primary health care strategy, especially as it relates to mental health. It is clear that improvement in mental health requires a team of both mental health and generalist health practitioners working within a population health model. CONCLUSION

10 Mental health issues are prominent in primary health care populations and development of the primary health care workforce is essential to meet the range of needs identified in this paper. Two overlapping populations have been identified: those with severe mental illness and those with mild to moderate mental illness. In addition, mental health promotion can involve intervention before symptoms develop. Primary care services in New Zealand to date have been different from those in other Western countries in that services are provided, in the main, by general practitioners with little involvement of other specialist practitioners such as nurses. Changes in the funding, governance and reconceptualisation of primary care as primary health care have created opportunities for development of specialist mental health nursing roles in primary care. For too long, the primary care components of the mental health nurse have been under-emphasised, compared to their specialist role with mental health consumers. The potential for mental health nurses to become agents for the improvement of mental health of the population is enormous (Haber & Billings 1995). The international literature describes a range of possible initiatives including attachment of community mental health nurses to primary health care, shared care programmes such those already in place in a number of centres, employment of specialist nurses to work specifically with consumers with mental health issues, and independent practice. The further development of the nurse practitioner role in New Zealand could make a considerable contribution to addressing mental health issues in primary health care. Mental health funders and planners, service providers and the nursing profession need to take up the challenge of developing the mental health nursing role in primary care so that the mental health needs of the population, from mental health promotion to management of long term mental illness, are adequately addressed. Received 11 April 2005 Accepted 2 November 2005 References Bindman J, Goldberg D. Chisolm D, Amponsah S, Shetty G and Brown J (2001) Primary and secondary care for mental illness: impact of a link worker service on admission rates and costs. Journal of Mental Health 10(4): Bjorklund P (2003) The certified psychiatric nurse practitioner: Advanced practice psychiatric nursing reclaimed. Archives of Psychiatric Nursing XVII(2): Burns T (2005) Shared care, individual expertise. Advances in Psychiatric Treatment, 11, Davies B R, Howells S and Jenkins M (2003) Early detection and treatment of postnatal depression in primary care. Journal of Advanced Nursing 44: Gournay K (1999) 'Future role of the nurse in primary health care' in Tansella M and Thornicroft G (Eds) Common mental disorders in primary care. Essays in honour of Sir David Goldberg, pp , Routledge: London. Gournay K and Brooking J (1994) The CPN in primary care: An outcome study. British Journal of Psychiatry, 165:

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14 WHO (2001) Mental health policy and service guidance package: Organisation of services for mental health. Geneva: WHO. WHO (2002) The World Health Report Mental health--new understanding, new hope. Geneva: WHO. ANTHONY J. O'BRIEN Senior Lecturer School of Nursing University of Auckland, and Nurse Specialist, Liaison Psychiatry Auckland District Health Board Auckland, New Zealand FRANCES A. HUGHES Professor of Nursing, and Director Centre for Mental Health Research, Policy and Service Development University of Auckland Auckland, New Zealand JACQUIE D. KIDD Lecturer School of Nursing University of Auckland Auckland, New Zealand, and Primary Mental Health Practitioner Hamilton, New Zealand Gale Document Number:A Disclaimer: This information is not a tool for self-diagnosis or a substitute for professional care.