Cultural safety, diversity and the servicer user and carer movement in mental health research

Talking Circle for Young Adults (TC4YA) Intervention: A Culturally Safe Research Exemplar

BACKGROUND

: As a result of the intergenerational trauma impact and experience, Native Americans continue to exhibit trauma related issues such as high rates of substance use. After leaving high school, the pressures and stress of continuing an education, finding work/employment, and the responsibilities related to family and tribal community obligations result in the Native American young adult being more vulnerable to substance use.

OBJECTIVE

The purpose of this paper is to report findings of the Talking Circle intervention impact on the outcome variables of Native-Reliance, substance use, stress, and behavioral health, depression, and cumulative trauma.

METHODS

Native-Reliance was the theoretical underpinning for the study demonstrating culturally safe research. A pre-test/post-test one-group design was utilized to examine how the Talking Circle intervention influenced the outcome variables. 75 Native American participants, ages 18-24 participated in the Talking Circle intervention sessions. Baseline pre-intervention measures were completed and were repeated at 6-month post-intervention.

RESULTS

At 6-month post-intervention, Native-Reliance significantly revealed an increase of 40.55 (t = 22.13, p < .001), sources of stress (SS) revealed a significant decline of 3.68 (t= -18.39, p < .001), behavioral health issues (BH) showed a significant decline of 3.63 (t = -15.36, p < .001), substance related issues (SR) showed a significant decline of 3.57 (t = -15.24, p < .001), depression (PHQ-9) showed a significant decline of 4.85 (t = -17.02, p < .001), and cumulative trauma revealed a significant decline of 2.77 (t= -13.39, p < .001).

CONCLUSIONS

The use of a culturally safe Talking Circle intervention evidenced a research approach that resulted in the positive impact on reducing substance use and increasing the well-being of young Native American young adults.

IMPACT STATEMENT

Culturally safer intervention environments are conducive to results in outcomes that are positive and effective.

Clarifying Cultural Safety: its focus and intent in an Australian context

The nursing/midwifery professions are facing a sea change with the inclusion of cultural safety in the Code of Conduct for Registered Nurses (NMBA 2018a), the Code of Conduct for Midwives (NMBA 2018b), the Registered Nurse Accreditation Standards (Australian Nursing and Midwifery Accreditation Council [ANMAC] 2019) and the Midwife Accreditation Standards (ANMAC 2021). In this paper we focus on the theme of enabling cultural safety seeking to overcome the barrier of confusion surrounding it. The inclusion of cultural safety in codes and accreditation standards, highlights the pressing need for these professions to attain deep understanding of cultural safety so that clinicians and educators can confidently practice and teach in this area. This need is underscored by the context of heightened awareness, that developed amongst mainstream Australians with Black Lives Matter in 2020, of inequity including health inequity.Our concern as academics responsible for staff development, curriculum development and implementation in university Schools of Nursing/Midwifery is to enable and support the teaching and practice of cultural safety. Its focus on working in partnership, addressing power imbalances, racisms, and related systems of discrimination constitutes it as a vastly different model to cultural other-awareness and notions of cultural competency which have held sway on matters of culture in health service provision up to now. Our approach was to undertake a reflection on our combined decades of studying, leadership, teaching and practice of cultural safety, which consistently showed the confusion in Australia about the model overall and about the definition of culture underpinning it. This paper supports the profession by addressing the need to educate academics and clinicians on cultural safety itself and on the role of all nurses/midwives, Indigenous and non-Indigenous, in these endeavours. This paper encourages a coherent development and confident implementation of cultural safety curriculum and practice to meet current requirements.

Embedding lived experience expertise across the mental health tertiary education sector: An integrative review in the context of Aotearoa New Zealand

WHAT IS KNOWN ON THE SUBJECT?: An important step towards improving mental health outcomes is the realignment of tertiary mental health education and research in a way which places strategic value on experience-driven involvement in mental health and addiction-related care. One of the most widely recognized ways of achieving this is by increasing representation of individuals with first-hand experience of mental health and addiction distress (also known or referred to as Experts by Experience or EBE) within the tertiary sector. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Benefits of tertiary EBE representation such as improving student's preparedness for practice and the empowerment of mental health consumers are consistently reported throughout the literature. In striving towards these outcomes, it is crucial we remain mindful of relevant and often-reported hurdles such as stigma and improper implementation. By using Aotearoa New Zealand as a case study, the need for approaches to increasing EBE representation which is conscious of diverse cultural contexts, perspectives and identities is highlighted. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This review draws together a broad range of factors associated with improving clinical practice. These include the potential for EBE representation to improve outcomes for trainee clinicians, and the incorporation of consumer-driven perspectives into evidence-based practice. This review further highlights the need for EBE representation to be implemented in a way which is responsive to the cultural needs and nuances of mental health education and practice in Aotearoa New Zealand, and, similarly in other countries. ABSTRACT: Introduction There is potential value in increasing representation of expert by experience (EBE) involvement in mental health education sectors. This approach to improving mental health outcomes is here explored in the context of Aotearoa New Zealand's tertiary education sector. Aim/Question This review sought to identify potential outcomes, benefits and barriers associated with EBE representation in tertiary institutions, whilst critically analysing these strategies in the context of Aotearoa New Zealand's mental health education sector. Method Data retrieved from electronic databases were subjected to critical appraisal and thematic analysis. The integrative review drew from a final data set of 113 articles. Results An integrative review of our search results indicated that moving towards a tertiary mental health model in which lived experience plays a central role has the potential to benefit both teaching and research in the tertiary sector. Discussion The interplay between contemporary perspectives on tertiary EBE representation and the cultural needs and nuances of Aotearoa New Zealand's tertiary sector highlights the need for critical and careful approaches to EBE representation. Implications for clinical practice Findings surrounding tertiary EBE representation have direct implications for the training of mental health practitioners and the evaluation and development of clinical practice outcomes and procedures.

Turning the Tables: Power Relations Between Consumer Researchers and Other Mental Health Researchers

A crucial development resulting from consumer involvement in mental health services has been engagement as active participants in mental health research, often conducted in collaboration with mental health researchers representing the health disciplines (referred to in this paper as 'other' researchers). Despite progress in mental health consumer research, unequal power relations continue to pose a major barrier. Although power issues are discussed in the literature, there is little research from the perspective of other mental health researchers who have collaborated with consumers on research projects. This qualitative study explored other mental health researchers' perspectives on the role of power in collaborative research with consumers. Semi-structured interviews were completed with 11 other mental health researchers. Thematic analysis of the transcript version of interview recordings was conducted. The findings were grounded in 'the table' as a literal and metaphorical site of power relations. The umbrella theme was prominence and presence (of consumers) at the table, followed by subthemes on barriers (tokenism, undermined potential) and surmounting them through reworking power (critical mass and openness to power dynamics). Overall it was found that while there continue to be significant power-related barriers to further building of robust collaborative research with consumers in mental health, there are several avenues that should be considered, much more assertively, to disrupt and transcend them.

Men's and women's response to treatment and perceptions of outcomes in a randomized controlled trial of injectable opioid assisted treatment for severe opioid use disorder

Background

To test whether there are gender differences in treatment outcomes among patients receiving injectable opioids for the treatment of long-term opioid-dependence. The study additionally explores whether men and women have different perceptions of treatment effectiveness.

Methods

This study is a secondary analysis from SALOME, a double-blind, phase III, randomized controlled trial testing the non-inferiorirty of injectable hydromorphone to injectable diacetylmorphine among 202 long-term street opioid injectors in Vancouver (Canada). Given this was a secondary analysis, no a priori power calaculation was conducted. Differences in baseline characteristics and six-month treatment outcomes (illicit heroin use, opioid use, crack cocaine use, non-legal activities, physical and psychological health scores, urine positive for street heroin markers, and retention) were analysed by gender using fitted models. Responses to an open ended question on reasons for treatment effectiveness were explored with a thematic analysis.

Results

Men and women differed significantly on a number of characteristics at baseline. For example, women were significantly younger, presented to treatment with significantly higher rates of prior month sex work (31.5% vs. 0%), and used significantly more crack cocaine (14.71 vs. 8.38 days). After six-months of treatment there were no significant differences in treatment outcomes by gender, after adjusting for baseline values. For both men and women, improved health and quality of life were the most common reasons provided for treatment effectiveness, however women were more specific in the types of health improvements.

Conclusions

Despite presenting to treatment with vulnerabilities not faced to the same extent by men, at six-months women did not differ significantly from men in tested trial efficacy outcomes. While the primary outcome in the trial was the reduction of illicit opioid use, in the open-ended responses both men and women focused their comments on improvement in health and quality of life as reasons for treatment effectiveness. The supervised model of care with injectable medications provides a particularly suitable framework for providing care to opioid-dependent men and women not attracted or retained by other treatments. The absence of statistical differences reported in this secondary analysis may be due to lack of adequate statistical power to detect meaningful effects.

Trial registration

This trial is registered with ClinicalTrials.gov (NCT01447212) Registered: October 4, 2011 at the following link: https://clinicaltrials.gov/ct2/show/NCT01447212.

Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals

AIMS

To explore the perspectives of structurally vulnerable people who use drugs (PWUD) regarding: (1) the potential integration of harm reduction interventions (e.g. supervised drug consumption services, opioid-assisted treatment) into hospitals; and (2) the implications of these interventions for patient-centered care, hospital outcomes and drug-related risks and harms.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Thirty structurally vulnerable PWUD who had been discharged from hospital against medical advice within the past 2 years, and hospitalized multiple times over the past 5 years.

MEASUREMENTS

Semi-structured interview guide including questions to elicit perspectives on hospital-based harm reduction interventions.

FINDINGS

Participant accounts highlighted that hospital-based harm reduction interventions would promote patient-centered care by: (1) prioritizing hospital care access and risk reduction over the enforcement of abstinence-based drug policies; (2) increasing responsiveness to subjective health needs (e.g. pain and withdrawal symptoms); and (3) fostering 'culturally safe' care.

CONCLUSIONS

Hospital-based harm reduction interventions for people who use drugs, such as supervised drug consumption services and opioid-assisted treatment, can potentially improve hospital care retention, promote patient-centered care and reduce adverse health outcomes among people who use drugs.