At the Coalface: Mentoring the Health Promotion Role

At the Coalface: Mentoring the Health Promotion Role Robin Watts, Barbara Hughes, Kathy Mackay, Ann Bartlett 5th National Rural Health Conference Adelaide, South Australia, 14-17th March 1999 Robin Watts Proceedings

At The Coalface: Mentoring the Health Promotion Role Robin Watts, Barbara Hughes, Kathy Mackay, Ann Bartlett BACKGROUND History shows the present community health nursing service has evolved from the early Infant Health Service and the School Health Service where the targeted skill development areas were assessment, identification and to a lesser degree, health education. The current expanded role of community nurses is based on the delivery of primary health care. The three core activities in this area of service delivery are: assessment and care, early identification and intervention, and health promotion. Nurses have recognised the need for regular ongoing development of knowledge and skills in the first two core activities; however, health promotion has not received the same emphasis. IDENTIFICATION OF NEED The Eastern Perth Public and Community Health Unit (EPP&CHU) identified the need to provide further education and support to nurses, as they reoriented their role to focus on health promotion. Extensive consultation occurred with both administrators and clinical community nurses. A skill/knowledge assessment was conducted and the following issues were identified for further professional development: current information for special health issues; ability to identify areas of need; ability to plan and implement effective health promotion programs; and skills to develop and conduct program evaluation strategies. LEADERSHIP IN HEALTH PROMOTION WORKSHOPS The needs assessment resulted in the development of a two day workshop Leadership in Health Promotion. The expected outcomes were that participants would: be able to enhance their current knowledge and skills in planning and evaluation of health promotion programs; and show a higher level of self-efficacy in regard to health promotion. There have been a total of seven workshops conducted since October 1994. The process evaluations indicated that the participants were very satisfied with the course content and presentation. They also had a very positive attitude to the

health promotion aspect of their role. The immediate pre and post workshop impact evaluations demonstrated nurses had increased their knowledge base considerably in relation to program planning and evaluation. However outcome evaluation results six months later suggested that there had been a loss of knowledge regarding planning and implementation. Although participants stated they were confident (self-efficacious) and felt comfortable working in health promotion there was no evidence of this in their practice. The impression gained was that nurses were enthusiastic and maintained a positive attitude to implementing health promotion programs but seemed unable to move into the implementation stage. The evaluation also provides insight into the issues perceived by the participants as barriers to progressing their health promotion activities. These included: time constraints due to heavy case load; issues not seen as a priority; not all staff members had the same goal; financial restraints; and communities do not see the importance of health promotion programs. These findings supported a survey of community nurses conducted in 1995 1 which indicated that time constraints and other priorities acted as barriers to the nurses progressing health promotion activities. ORGANISATIONAL CHANGE Organisational change and continuous restructuring within the Health Department of Western Australia (HDWA), particularly in the last four years, has created a situation where field workers are not readily able to access support and assistance from experienced health practitioners. In the case of nursing, the organisational restructuring and career structure changes have resulted in the supervision and support previously provided by senior community nurses and regional health promotion professionals either being no longer available or difficult to access. The community nursing level 4 clinical position, previously used to provide clinical support, has been reoriented to a management role or, in many cases, abolished. The implementation of the level 3 position and the role of that position varies between health services. The structure and function of health promotion services have also been affected by the changes within the HDWA. Different structures have evolved across the various health services with new roles developing. These roles primarily focus on management, policy and program development, and training of assistants rather than direct service delivery. The changing role of Regional Health Promotion Officers across the Health Areas has made it difficult for nurses to obtain continuity and support as they develop their health promotion skills.

MENTORING Although there is debate about the specific definition of the term 'mentor', 2 there is agreement that mentoring is a developmental relationship consisting of two dimensions: an instrumental function such as coaching and psychosocial functions such as counselling. 3 The instrumental function emphasises role development. 4 Levinson 5 identified a mentor as: teacher, sponsor, guide, exemplar, counsellor and supporter. Anderson and Shannon, 6 enlarged on these roles by identifying specific behaviours for each role. These behaviours are: teach: model, inform, confirm/disconfirm, prescribe and question sponsor: protect, support, promote encourage: affirm, inspire, challenge counsel: listen, probe, clarify, advise befriend: accept, relate. All five roles were identified as relevant to this project. Vance 7 listed the benefits of a mentoring relationship as increased selfconfidence enhanced self-esteem, greater personal satisfaction, increased knowledge and skills and greater career satisfaction. Given the results of the six month follow up evaluations of the workshop participants ie loss of knowledge, continuing lack of self efficacy identified barriers to implementation, in the area of health promotion, we concluded that a mentoring program could well address these problems. A review by Pelletier and Duffield 8 indicated that other than their own research and Wright s work published in 1993, there were no reports of the incidence of mentoring in non-academic nursing settings in Australia. Even in respect to academic settings, only two studies were found. A further review of the literature between 1994-1998 indicates that this is still the case. Based on anecdotal information, the use of mentoring as an educational strategy has been confined to the novice nurse. In the practice arena the concept has been successfully implemented with new graduates from tertiary education programs to assist their entry into clinical nursing. However there appears to be no literature evaluating the use of mentoring to assist experienced nurses expand their role, although some studies have been conducted overseas. 9 AIM OF PROJECT The project aimed to trial the concept of a health promotion mentor for community health nurses. The role of this mentor was to assist community nurses incorporate health promotion program planning, implementation and evaluation skills into their practice.

METHOD Participants 5 th NATIONAL RURAL HEALTH CONFERENCE Fifteen community nurses from two workshop groups were approached to participate in the study, 13 agreed to participate (two had left community nursing) and 12 continued in the study. These nurses were working in metropolitan and several rural health services. Role of the Mentor Through identifying and addressing learning needs and skill development, the role of the mentor was to support course participants in incorporating health promotion into their practice by assisting them, as required, to: set priorities within their job responsibilities to ensure time is allocated to health promotion activities; refine the planning (including consideration of a range of implementation strategies) and evaluation components of the selected health promotion program; increase their knowledge and skills of the development, dissemination and implementation phases of health programs; identify and link into community resources relevant to these programs; use problem solving skills when confronted with barriers to implementing the program; and increase their confidence in their ability to conduct health promotion programs. Strategies The individual selected for the mentor role had a strong background in health promotion, a sound understanding of the community nurse s role and demonstrated practical skills in implementing health promotion programs. The mentor began by following up participants' progress since the Leadership in Health Promotion workshop and asking them to decide on a community based health promotion program for the purpose of this project. The mentor identified learning needs and supported them in dealing with issues arising from any of the stages of planning, developing, disseminating, implementing or evaluating the proposed project over a 12 month period. This support was provided through onsite contacts in person, frequent telephone, fax or mail contact (at least once a week). A health promotion manual on planning was developed to supplement the workshops and this was used as a mentoring tool during the project. Previous workshop participants formed the comparison group. This group was asked, as part of the usual workshop requirements, to identify a health promotion project for implementation in their community; however, they were not provided with dedicated support to implement their projects as were the mentored group. They were also required to complete the pre and post workshop impact survey related to various aspects of health promotion program planning. This information provided the data on which the groups were compared.

EVALUATION The study included process, impact and outcome evaluation strategies. 10 The latter focused on the progress or completion of the chosen community based health promotion project. The process evaluation employed a survey-datafeedback process. This approach enabled key stakeholders to generate information that was fed back into the process thereby allowing continuing development of the program. Data were collected from the various stakeholders in the project using a variety of data collection methods at various points in the 12 month period of the project. These stakeholders included the two groups of workshop participants, the mentor, associated health service supervisors and health promotion officers. Information on the workshop content and the teaching/learning process employed was also collected. Workshop participants completed a self-assessment of their knowledge of and self-efficacy in health promotion program planning on four occasions: at the beginning and end of the workshops then at the beginning and end of the study. This assessment consisted of a Likert Scale type questionnaire in which the participants rated their confidence, knowledge and skills in their ability to deal with all aspects of health promotion planning on a five point scale, and some open ended questions. As part of the process evaluation they also completed telephone interviews which included open-ended questions on progress with implementing the selected health promotion program, factors that facilitated progress and/or problems experienced, strategies employed to overcome barriers and reflections on the mentoring process. Supervisors completed a baseline and final questionnaire aimed at obtaining their views on the progress and outcomes of the projects, factors that influenced implementation and the usefulness or otherwise of the concept of a mentor in this situation. The mentor maintained field notes that formed the basis of case histories illustrating the progress of each project. Information obtained from discussions with health promotion officers from related public health units (key informants) were also incorporated into these field notes. FINDINGS The results have implications for community nurses as well as for health service managers, health promotion professionals and other community health staff. Is mentoring useful? The results indicated that the concept of mentoring in health promotion was beneficial to community nurses and they welcomed assistance to further develop their health promotion skills. Participants agreed the support given to them ensured they had incorporated a planned health promotion activity into their

practice. For many of them, mentoring provided the impetus and confidence to overcome barriers and develop programs and strategies to address health issues that they had been concerned about for a long time. In all cases participants indicated that involvement in the project made them take time out from busy clinical practice to meet with the mentor and plan the program of their choice. The majority of participants identified their need to refine the planning process, in particular their evaluation skills, and appreciated support in the field as they worked at their own pace to address these needs. What are the barriers to mentoring Time was the main barrier for both nurses and the mentor in this project. Nurses found it difficult even to arrange time for the on-site mentor visits. They were, however, unanimous that this is the most important aspect of the mentoring role. Without the on-site visits and regular contact it seems to be too hard to remain focused on health promotion even though they have the knowledge and skills. As one nurse stated "health promotion is the first thing to get dropped off in my workload. Organisational restructures, staff changes and additional role responsibilities resulted in participants moving out of the project and others having to defer strategies they had planned. Mentor role confusion was an issue for many of the participants. It was several months into the project before some nurses were clear about their involvement in the project and their relationship with the mentor. If mentoring is to support the development of knowledge and skills following an initial workshop, the concept needs to be included in the workshop. The mentoring process should then begin as soon as possible after completion of the workshop. Geographic work location is also an issue in mentoring. In this project the mentor was based in the metropolitan area and this restricted on-site contact for country participants. Given the importance assigned to on-site contact by participants, this will need to be addressed in implementing the project on a wider basis. REFERENCES 1. Bayly, L. & Mackay, K., Evaluation of key professionals' support for ' Be Active Together', 1995 Unpublished report, Perth: Public and Community Health Unit, East Metropolitan Health Area. 2. Hall, L., Mentoring relationships of New Zealand nurses: an empirical study (part 1), Collegian, 1997, 4:28-31. 3. Kram, K., Phases of the mentor relationship, Academy of Management Journal, 1983, 26:608-625. 4. Yoder, L., Mentoring; A concept analysis, Nursing Administration Quarterly, 1990, 15: 9-19. 5. Droste-Bielak, E., On being mentored: A personal experience, Nurse Educator, 1990, 15:3-4. 6. Anderson, E. & Shannon, A., Toward a conceptualization of mentoring, Journal of Teacher Education, 1988, 39:38-42.

7. Vance, C., 'The mentor connection', Journal of Nursing Administration, 1982, 12:7-13. 8. Pelletier, D. & Duffield, C., Is there enough mentoring in nursing, Australian Journal of Advanced Nursing, 1994, 11: 6-11. 9. L.Esperance, C., DiGregorio, R. & Wallerstedt, C., Preceptors in high-risk perinatal nursing for rural nurses: a pilot study, Journal of Continuing Education in Nursing, 1996, 27: 220-223. 10.Owen, J., Program evaluation: Forms and approaches. St. Leonards, Australia: Allen & Unwin, 1993.