Journal of Psychiatric and Mental Health Nursing, 2014, 21, 618–627
Mental health promotion in comprehensive schools A . M . O N N E L A 1 M n S c , P. V U O K I L A - O I K K O N E N 2 T. H U R T I G 3 P h D & H . E B E L I N G 4 M D P h D
Ph D,
1
Psychiatric Nurse/Team Coordinator, Social- and Healthcare, City of Oulu, Oulu, Finland, 2Principal Lecturer, Diaconia University of Applied Sciences, Oulu, Finland, 3Adjunct Professor, Postdoctoral Researcher, Department of Child Psychiatry, Institute of Health Sciences, University of Oulu, University Hospital of Oulu, Oulu, Finland, and 4Professor of Child Psychiatry, Department of Clinical Medicine, Child Psychiatry, University of Oulu, Child Psychiatry, Oulu University Hospital, Oulu, Finland
Keywords: child and adolescent mental
Accessible summary
health, comprehensive schools, intervention, mental health nursing,
•
mental health promotion, school health services Correspondence: A. M. Onnela Social- and Healthcare City of Oulu Tuirantie 5, 90500 Oulu Finland E-mail: [email protected] Accepted for publication: 26 December 2013 doi: 10.1111/jpm.12135
• •
A participatory action research study on the development of a professional practice model of mental health promotion in a comprehensive school. Model was developed in collaboration with interest groups, students and parents. Interventions were developed on universal, selective and indicated levels.
Abstract The purpose of this paper is to describe a participatory action research process on the development of a professional practice model of mental health nurses in mental health promotion in a comprehensive school environment in the city of Oulu, Finland. The developed model is a new method of mental health promotion for mental health nurses working in comprehensive schools. The professional practice model has been developed in workshops together with school staff, interest groups, parents and students. Information gathered from the workshops was analysed using action research methods. Mental health promotion interventions are delivered at three levels: universal, which is an intervention that affects the whole school or community; selective, which is an intervention focusing on a certain group of students; and indicated, which is an individually focused intervention. All interventions are delivered within the school setting, which is a universal setting for all school-aged children. The interventions share the goal of promoting mental health. The purposes of the interventions are enhancing protective factors, reducing risk factors relating to mental health problems and early identification of mental health problems as well as rapid delivery of support or referral to specialized services. The common effect of the interventions on all levels is the increase in the experience of positive mental health.
Introduction Child and adolescent mental health has become a great concern for healthcare providers in recent years. Alternative approaches to mental health promotion are required to accomplish a significant change in the emotional and behavioural problems of children. Early interventions and preventive measures are attracting increasing attention as ways to improve immediate and long-term mental health in these age groups (Stallard et al. 2008). Mental health pro618
motion interventions aim at providing individuals, families and societies with the knowledge, skills and resources needed to promote mental health (Lavikainen et al. 2004). Mental health promotion interventions delivered in school settings have as their aim preventing mental disorders from developing (Stallard et al. 2008) The spectrum of students has become more diverse, which creates a need for mental health know-how in schools. Children need support for their issues in schools, which are a good environment to carry out supportive measures (Lönnqvist 2005). © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
There is also a need to develop a nursing practice model to meet the increasing needs of school health care to deal with mental health issues (Woodhouse 2010). In Oulu, Finland, eight mental health nurses were hired for mental health promotion work in the primary healthcare environment in the context of comprehensive schools. Their professional practice model was developed in workshops in which the nurses participated together with their collaboration networks, including multiprofessional teams, school staff, students and parents. The developed interventions were based on existing knowledge from studies and previous health promotion projects on effective mental health promotion. The mental health promotion model was developed using participatory action research approach. This paper aims to describe the mental health promotion constructional model and the interventions developed for comprehensive schools.
Mental health promotion Mental health promotion is about enhancing positive emotion and optimal functioning. Health is not only the absence of illness but rather a means to harness the resources of individuals and societies and the factors that make life good (Power 2010, Kobau et al. 2011). Promotion enhances personal abilities to achieve good selfesteem, well-being and social inclusion. (Power 2010). The concept of health promotion has its roots in the 1970s. The foundations of health promotion are in the change of perception of determinants of health to include health behaviour, social factors, biological factors and health care versus the previous perception that health was reliant on available health care. Another factor that contributed to the development of the health promotion concept was the emergence of a new approach to health education in the 1970s that included the concepts of empowerment, informed decision making and social determinants of health (Cattan & Tilford 2006). The Ottawa Charter from 1986 and Alma Ata conference in 1978 emphasize the role of primary health care, flexible systems and education in health promotion. The Ottawa Charter obligates for health promotion to be facilitated in a school, home, work and community settings and for the role of the health sector to move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services (WHO 1986). The Alma Ata conference states that the national health systems need to bring health care close to where people live and work in coordination with other service providers (WHO 1978). Mental health promotion enhances communal assets in order to prevent mental illness and promote the well-being and quality of life of people. Health-enhancing © 2014 John Wiley & Sons Ltd
public policies, creation of supportive environments, and enhancement of community actions and development of health services are ways to implement mental health promotion (Kobau et al. 2011). Mental health promotion in schools includes information and training on self-harm, social skills, stress, coping skills, school bullying and understanding mental well-being and understanding of diversity. The nurses working in schools are the tools that put these actions into practice (Woodhouse 2010). Mental health promotion of children and adolescents should not be detached from the community but a function of the community. Stallard et al. (2008) agrees in his study that early interventions and preventive measures are ways to improve immediate and long-term mental health of children and adolescents (Stallard et al. 2008). Högnabba (2011) and Taggart & McKendry (2009) state in their studies that early interventions promote feelings of control, strengthen a person’s capacity to deal with adversity and prevent anxiety, depression and behavioural problems (Taggart & McKendry 2009, Högnabba 2011). The important role of parents needs to be recognized in the mental health promotion of children and adolescents. It is effective to promote the mental health of children and adolescents in schools, but in order to be able to make a lasting and embedded difference in the mental status of children and adolescents methods to promote the mental health of whole families need to be developed. As many mental health problems are inherited and unhealthy lifestyles are learned from the parents, it is significant to attempt to promote the mental health of parents and societies (Solantaus & Paavonen 2009). Kavanagh et al. (2009) has also found that enhancing coping skills, providing knowledge and strengthening resilience and psychosocial activity of children and adolescents promotes mental health (Kavanagh et al. 2009). Taggart & McKendry (2009) and Woodhouse (2010) have stated that mental health promotion programmes should include promotion of emotional stability through concepts of self-esteem, empowerment, coping skills and social skills (Taggart & McKendry 2009, Woodhouse 2010) and offer methods and knowledge to improve and maintain positive mental health (Lavikainen et al. 2004).
Mental health promotion interventions on universal, selective and indicated levels in the context of comprehensive schools Mental health promotion interventions in schools include universal, selective and indicated interventions. The universal approach includes the whole school as a setting for mental health promotion (Stallard et al. 2008). Universal interventions are delivered on various levels and have a 619
A. M. Onnela et al.
whole-school focus. The school environment is improved by educating school staff on mental health issues and providing skills allowing them to identify, intervene and cope with different emotional and behavioural needs (Licence 2004). At schools ‘low threshold’ places provide easy access to mental health care for students and reduce the stigma related to seeking help for mental health problems. Low threshold places are services that are easily accessible to students in their own environment and do not require an appointment or referral. The effect of universal interventions is the reduction of stigmatization associated with mental health illnesses. Interventions taking place in school environment and culture and involving the school staff are effective in promoting mental health of the whole school community through promoting feelings of belonging, togetherness and trust (Licence 2004). A selective approach affects a specific group, e.g. a subgroup of adolescents at risk of developing mental health problems (Lind 2007). Selective interventions focus on groups of students or families at enhanced risk of developing mental health problems. Such groups may include participants with problems in social skills, poor self-esteem or depressive symptoms. The groups provide empowering peer support and a chance to share similar experiences. The effects of selected interventions are the reduction of disruptive behaviour, decrease of depressive symptoms and an enhanced feeling of togetherness. Interventions targeted at families affect the ways in which families feel, think, communicate and behave. This enhances parents’ experience of understanding their adolescent’s needs and provides an understanding of the families’ resources (Wyn et al. 2000). Indicated interventions are targeted at individual students with emerging symptoms and their families (Puskar & Bernardo 2007). The purpose of indicated interventions is early identification of mental health problems and rapid delivery of support or referral to specialized services. Mental health problems can be reduced in the long run through effective early identification. Another purpose of all interventions is to reduce risk factors that might impact the development of mental health problems and to enhance protective factors. The aim of the mental health promotion interventions is empowerment and improving of social, emotional and problem-solving skills. The effect of interventions at all levels is the increased experience of positive mental health (Onnela 2012). Indicated interventions are individually focused interventions that aim to provide support for students displaying some symptoms of mental health problems in order to prevent more severe symptoms or disorders from developing. Indicated interventions have the purpose of changing the cognition, attitude, beliefs, 620
actions and behaviour of an individual in a therapeutic conversation (Puskar & Bernardo 2007). It is important to include parents in the intervention. Multiprofessional assessment improves early identification and expedites referral to specialized mental health care. The effects of indicated interventions are the reduction of disciplinary referrals, depressive symptoms and referrals to specialized mental health care. There is also improvement in coping skills and school attendance. Indicated interventions strengthen a person’s capacity to deal with adversity and prevent anxiety and behavioural problems (Taggart & McKendry 2009). Promotion of compliance with regimen and generalization of compliance to several settings are also effects of interventions. (Weist et al. 2003). Interventions can be used to strengthen an individual’s resilience, which is not something that a person either has or does not have; it develops through learned cognitions and behaviour. Personal strengths act as barriers against development of mental problems and adversity as well as enhancement of resilience. Strengths such as optimism, coping skills and positive self-esteem can be found, enhanced and harnessed through interventions (Power 2010). In addition to interventions that are individually focused, interventions directed at families are effective because well-functioning, healthy families are able to support well-functioning, healthy individuals. A wellfunctioning family and a sense of strong parenting are mediators of positive mental health for children. The communities where families live should be strengthened as well in order to improve the well-being of individuals (Power 2010).
School as a setting for mental health promotion Finnish students are ranked high internationally according to level of academic skills but do not enjoy going to school (Punamäki et al. 2011). School satisfaction of Finnish students’ is poorer than the international average in all age groups. At the age of 15, only 11 percent of girls and 9 percent of boys enjoy going to school. The reason for dissatisfaction is likely to be the social atmosphere in the schools. Students feel that the school climate is negative, and nearly 30 percent of ninth-grade boys and 42 percent of ninth-grade girls feel that relations to peers are poor (Kiilakoski & Oksanen 2011). Positive mental health is related to school satisfaction. A poor school climate enhances feelings of stress and fatigue in students (Honkinen 2010). On the other hand, the social capital that schools provide plays an important role in academic success and © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
mental health. Social capital is affected by trust, good social networks and a feeling of togetherness. Belonging to a school community where a child or adolescent feels equity and peer support prevents school violence (Punamäki et al. 2011). School violence has increased in recent years in Finland, and 8 percent of Finnish students experience bullying on a weekly basis (Luopa et al. 2007). Many visible problems in schools such as large group sizes, inequality of resources and school bullying increase the risk of school violence (Punamäki et al. 2011). There is good reason that mental health promotion interventions should be carried-out in schools. Schools are arguably the only universal setting for children and adolescents. In addition, the years of attending comprehensive schools are the time when emotional and behavioural needs increase, but also when they can be influenced. Young people spend a large proportion of their days in school, and interactions with school staff and peers are bound to have an effect on their emotional well-being. Mental health promotion interventions emphasize a feeling of togetherness in schools through promoting feelings of security and trust towards peers and staff, good communication and positive self-esteem that is enhanced by participation in school activities. The interventions are also focused on students who are at risk of dropping out of school and becoming socially alienated (Patton et al. 2000). The underlying idea is that mental health promotion is a basic function of schools (Wyn et al. 2000).
Aim and research questions Research aim: to investigate current practices in relation to mental health promotion in comprehensive schools and to develop a professional practice model for mental health interventions in practice using an action research approach. Research question is: What kind of mental health promotion interventions were developed according to existing knowledge from studies and good practice in comprehensive schools? How the professional practice model was developed using action research methods?
invited to share knowledge on their viewpoints, knowledge and perceptions of the developed interventions. Because action research is carried out in real-world circumstances and involves close and open communication among the people involved, the researchers must pay close attention to ethical considerations in the conduct of their work. During workshops, the relevant persons, committees and authorities were consulted, and the principles guiding the work were accepted in advance by all. All participants were allowed to influence the work and their viewpoints were respected. The development process was visible and open to suggestions from workshop participants (Winter 1996).
Participatory action research approach According to Genat (2009), participatory action research draws theoretically on the concepts of symbolic interactionism. Action research is used in real situations, and this professional practice research study is based on developing process action research that is defined as the ‘learning by doing’ approach (Genat 2009) and for solving challenges occurring in professional practice (Levin 2012). According to Carr (2011), one strength when using action research is that this ethical, activist dimension of knowledge production is both explicit and essential (Carr 2011). There is a dual commitment in action research to study a system and concurrently to collaborate with members of the system in changing it into what is jointly regarded as a desirable direction. As a process, a group of people identify a problem, do something to resolve it, see how successful their efforts were, and if not satisfied, try again (Levin 2012). In this case, there were mental health nurses with their collaborators in health centres, schools and hospitals, in addition to which also students with their parents participated. While this is the essence of the approach, there are other key attributes of action research that differentiate it from common problem-solving activities that we all engage in every day (O’Brien 2001, Potvin et al. 2010).
Participatory action research process
Ethical issues The written agreement on the development process between the City of Oulu and Diaconia University of Applied Sciences was signed on 17 April 2011. The participants in the development process were informed (oral informed consent) that action research method would be applied also during the development process and the results would be published. All participants were aware of their participation in the research process. Participants were © 2014 John Wiley & Sons Ltd
According to O’Brien (2001), much of the researcher’s time is spent on refining the methodological tools to suit the exigencies of the situation, and on collecting, analyzing, and presenting data on an ongoing, cyclical basis (O’Brien 2001). In the development process, there were nine workshops where the mental health promotion model was discussed, developed and reflected. People from previous health promotion projects in northern Finland were invited to the first workshop to share knowledge of health promotion working practices 621
A. M. Onnela et al.
and material developed in the projects. Previous studies on mental health promotion interventions were also studied. Knowledge of workable interventions was gathered and developed further in the workshops. Participants in the workshops produced knowledge on workable mental health promotion according to their perceptions, professional experience and needs. The interventions were developed using knowledge and material produced in previous health promotion projects and previous studies taking into account the knowledge produced in the workshops. The interventions were then delivered in the schools followed by another workshop to further develop the interventions according to feedback from the participants. Workshops were chosen as the method for gathering data because it supports the ‘learning by doing’ approach of participatory action research. Mental health promotion in schools requires the collaboration of people from many sectors of community social, health, and education services and, most importantly, the collaboration of students and parents. Workshops are a convenient platform for all participants to share and develop knowledge on mental health promotion. A steering group was chosen to follow and evaluate the development process in between the workshops. The steering group consisted of directors and coordinators in the health sector who did not participate in the workshops. The mental health nurses were given assignments in between the workshops to help evaluate the model (Table 1). Mental health nurses were chosen as the operators of the interventions in schools due to the fact that a separate allowance from the community budget was allocated for preventive mental health services in the health sector. In addition, mental health nurses also have diverse know-how on mental health. The participants in the workshops comprised school staff, interest groups, parents and students. School staff including principals, teachers, study advisors, counsellors, school nurses and schools psychologists were invited to the second and ninth workshop to share ideas on the needs that schools have and their ideas of functional methods of mental health promotion in a school setting. Most importantly, the parents and students were invited to attend the second and ninth workshop to share their needs and anticipations for the mental health promotion model. Invitations were sent to the students and parents through the student and parents’ association, who then chose their participants. Collaborative networks such as child welfare services, family counselling centres and child psychiatry were invited to the fourth workshop to strengthen public services and sharing of information. All workshops were based on voluntary participation. Furthermore, data were collected in workshops to develop mental health promotion in action. 622
Together with the school staff and students, the mental health nurses assessed how workable the developing model was. Furthermore, the data were analyzed, and new questions were asked for reflection in workshops (Winter 1996). The interventions were delivered in six comprehensive schools and two special education schools that were chosen as pilot schools in the city of Oulu. The comprehensive schools have grades ranging from first to ninth grade. Interventions were delivered in all grade levels. The two special education schools are characterized by offering education to children with special needs such as behavioural problems and learning disabilities. The special educations schools also provide education from grade one through nine. The data consisted of the information produced in the workshops and assignments in between workshops by the mental health nurses. The written material produced in all the workshops acted as the entire data that was analysed using content analysis. Phrases that described mental health interventions were chosen from the data. Each workshop acted as an analysis stage (or document). New data from each workshop were built upon knowledge from previous workshops. The final data were a comprehensive professional practice model of mental health promotion that was constructed based on the workshops (Fig. 1).
Results The result of the participatory action research process is the professional practice model of mental health nurses in comprehensive schools that is based on the interventions created during the participatory action research process in the workshops. The interventions were developed according to knowledge produced in the workshops. The structures for all the interventions are substantially the same. There is always an instructor and an objective for the intervention and it is based on active doing that corresponds to the developmental stage of the children or adolescents. The focus and aim of the intervention is always mental health promotion. A few examples of interventions on universal, selected and indicated levels in comprehensive schools are described here (Table 2). All the interventions take place within the school community, which enables the promotive actions to take place on all levels of activity. In action, the interventions that are delivered on a universal level reach the whole school community: students and school staff. Mental health kiosks are a whole school event where stands are placed in the school lobby or cafeteria and the school mental health nurse distributes information pamphlets and tests about mental health. Students are able to visit the stands to receive infor© 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
Table 1 Workshops Workshop
Participants
Aim
Outcome
1st starting point
People from previous health promotion projects + mental health nurses
List of existing good practices in accordance to the aim of the new working life model.
2nd ideation
School counsellors, principals, school psychologists, study advisors, school nurses, students and parents + mental health nurses Directors and coordinators of the health sector
Mapping of existing good practice = > assignment between workshops: what good practices exist? New ideas for the basis of the model= > assignment between workshops: what needs exist in relation to the aim of the model? Monitoring the advancement of the development process, setting a goal for the advancement Planning the model = > assignment between workshops: notes on positive and negative aspects to the developing model
Steering group
3rd designing
Mental health nurses
4th integration and collaboration
People from public services ex. child welfare, child psychiatry, family counselling centres +mental health nurses
Linking of the model to other public services = > assignment between workshops: Listing of new collaborative networks and evaluation of the model Evaluation
5th school meeting
Teachers + mental health nurses
6th school meeting
Teachers + mental health nurses
7th clarifying the model
Mental health nurses
Comments of the model in comprehensive schools = > assignment between workshops: evaluation of the comments by mental health nurses Comments of the model in comprehensive schools = > assignment between workshops: evaluation of the comments by mental health nurses Development of model according to meetings with the school staff = > assignment between workshops: what effects can be seen from the interventions? Evaluation
Steering group
Steering group 8th clarifying the model
Mental health nurses
9th approving the model
Parents, students, collaborators, mental health nurses, steering group
Steering group
© 2014 John Wiley & Sons Ltd
Development of model according to feedback from school staff = > assignment between workshops: what effects are perceived Approving the model
Final evaluation
Defining the aim for the model/action
Evaluation and approval of the aims for the model and good practices to be used in the model (1) Evaluation of the model using SWOT (2) Evaluation of the development process and workability of the model in action (1) Listing of most important collaborative networks (2) Evaluation of multiprofessional collaboration cross-sectorally using SWOT 1 evaluation of workability, and cross-sectoral collaboration Feedback from schools = > recording of necessary changes to the model
Feedback from schools = > recording of necessary changes to the model
Evaluation of the whole model using SWOT
1 listing perceived effects of the model. Evaluation of the model using SWOT, (evaluating have the threats and weaknesses decreased to the prior SWOT) Final version of the model to be presented to the public (1) Evaluation of the methods of instilling the model to the schools (2) Evaluation of the development process
623
A. M. Onnela et al.
Figure 1 Action research process
Table 2 Interventions Universal intervention
In action
Whole school events
‘Mental health rally’ – checkpoints where students discuss mental health issues in groups together with the mental health nurse In ‘mental health kiosk’ – stands in the school lobby where information pamphlets and tests are distributed. Students visit the stands to receive information about mental health issues and to test their knowledge Walk-in times where a mental health nurse is available without appointment or referral Staff meetings
Sharing of knowledge
‘Low threshold’-places Education of school staff Selective interventions Classroom interventions Groups Indicated interventions Support for students and families
Lessons on ex. taking care of mental health, substance abuse, stress, friendship, social skills, crisis, interactional skills, classroom environment ART (aggression replacement treatment), mastery of life skills, social skills Supportive and solution focused dialogue with student or families Parent consultation Assessment with multiprofessional team
mation about mental health issues and to test their knowledge. The event is also a good opportunity for the students to talk to the school mental health nurse without fear of being labelled. Visitors from different communal services are also present at the rally. The event is a good opportunity for municipal services, such as youth services and sports and recreation services, to showcase their activities for children and adolescents. The education of school staff takes place in school meetings. The meetings can be held for the entire school staff or the student services team consisting of the school principal, school nurse, school psychologist and curator. The purpose is to increase knowledge of how to identify students with incipient symptoms of mental health problems in order to provide help quickly, how to deal with the challenges of having a student with mental health problems in the classroom and how to promote mental health in school. On a selective level, the interventions are delivered to classrooms and selected groups. Classroom interventions are lessons taught by the school mental health nurse 624
together with the teacher on mental health issues. The subjects for the lessons include how to take care of mental health, substance abuse, stress, friendship, social skills, crisis, interactional skills and classroom environment. The content is customized for each grade to suit the developmental stage of the students. The interventions are integrated into the curriculum. The classroom interventions can be delivered over one or several lessons depending on the subject and classroom. Interventions in a classroom environment usually demand several lessons. A group for learning social skills meets 10 times at a fixed time and place. The group has six to eight participants and two instructors, one being the school mental health nurse and the other a member of the school staff, such as a teacher. The aim of the group is to learn and practice social skills with active methods such as acting, games, drawing and crafting. The practicing of social skills in the group supports a regimen of compliance. Indicated interventions are delivered to individual students with a low level of symptoms and their families. They © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
are delivered through supportive and solution-focused dialogue sessions with the school mental health nurse during the school day. The school mental health nurse meets with the student or the whole family 1–5 times. This is based on aiming at finding solutions and moving forward in the challenging situation through resource-focused conversation. The inclusion of parents is necessary for elementary level students. Adolescents often prefer to discuss personal matters with a reliable adult other than parents, but also benefit from inclusion of parents in the intervention.
Validity Decisions were made about the direction of the study, and the probable outcomes are collective. Researchers were explicit about the nature of the research process from the beginning, including all personal biases and interests. According to Levin (2012), action research can be evaluated by using trustworthiness (Levin 2012). Data collection and analysis occurred simultaneously in construction of the mental health promotion model. Furthermore, the processlevel relationship between data collection and analysis stimulates communication between participants. This was initiated during data collection in workshops by sharing information from participants and sharing new information from their viewpoints. The developed model was reflected on by school staff, parents and students who were not involved in the development process. A reflective journal was used to write down the data collected in workshops, working with hypotheses, and themes that emerged. In workshops, the participants described their natural settings at schools. All data were collected by authors (A.O. and P.V-O.). At least one follow-up contact was made in a symposium to persons who participated in the workshops. Municipal decision-makers also took part in the symposium. In the symposium, the model of mental health was reflected on and further development needs and embedding processes were decided (Lincoln & Guba 1985). All produced data were compared with existing research based on sound methods of mental health promotion interventions. Also adding to validity is the reflection on produced data by all participants. Validity is increased through coherence, which in this case means that enough data were produced to develop a comprehensive understanding of mental health promotion interventions. The knowledge produced was cumulated from the data produced in the workshops.
Discussion The outcome of the participatory action research process was a professional practice model for mental health nurses © 2014 John Wiley & Sons Ltd
in the context of comprehensive schools. The professional practice model consists of the interventions that were developed during the action research process in workshops. The interventions were developed in correspondence to existing knowledge from studies and previously developed experience-based intervention methods and good practice. Some interventions were excluded from the model according to knowledge produced in the workshops. Prior to the development of the new model, mental health nurses’ point of focus in their work was long-lasting individual therapeutic relationships in child and adolescent mental health care. In the workshops, knowledge was produced that school community-level and group-level interventions are more effective in improving mental health of students through prevention of bullying, increasing knowledge and participation of students and improving school and classroom environment. Although individual-focused interventions were not excluded, they were modified to be solution-focused short interventions that were based on the needs of the students. It was important to involve the collaborative networks as well as students and parents in the development process so that the developed interventions answered to their needs. The development of mental health promotion interventions systematically in collaboration with interest groups increases the know-how of mental health promotion of the entire community. Universal interventions developed in the process include mental health rallies, mental health kiosks, low threshold places and education of school staff. They all have the aim of increasing knowledge of mental health issues and promoting skills in self-care. Selective level interventions include classroom interventions and selected groups. They also have the aim of increasing knowledge on mental health and skills in self-care. They also provide peer support and a collective sense of belonging. Individual interventions comprise support for students and families in solutionfocused dialogue with the aim of empowerment. The group for learning social skills promotes social skills and provides peer support. The indicated interventions offer individuals methods and knowledge to improve and maintain positive mental health. Whole-school events, such as the mental health rally, improve the school environment and culture. There are many practical challenges to meet before mental health promotion is consistently practiced in schools. School health care in Finland already has a strong foothold in screening and early intervention of somatic illnesses. Early interventions of mental health problems need to be incorporated into the school healthcare system to be in accordance with a holistic view of health care. School staff and healthcare providers need to tighten their collaboration and broaden their view to gain a 625
A. M. Onnela et al.
comprehensive understanding of the well-being of students. Interventions need to be developed further, and more research on mental health promotion interventions and their effects is needed. The shift of thinking from illness management to promotion of mental health has already lead to changes in primary health care. A change in culture is called for to move on from problem-oriented thinking to a positive and empowering approach on mental health. There is also the need to improve student satisfactions levels in Finnish schools despite superior academic performance. The professional practice model can be used in development of mental health promotion interventions in communities as well as in participatory development projects in healthcare systems. The developed interventions are also of value to clinical nursing practice. Participatory action research approach enables partners to involve in the development of professional practice; it focuses on change, collaboration and participation. All participants are actively involved in the developing process and the results are drawn together. The key to this approach is the role of the researcher as a facilitator, interlocutor and interpreter. According to Genat (2009), participatory action research builds local theory and knowledge and positions local participants as advocates for new ways of understanding the phenomenon. (Genat 2009). However, professional practice development is never truly finished, which means that professional practice should be accountable to continue the process further to the implementation process (Walsgrove & Fulbrook 2005). Gaining insights and planning the
References
action are two of the main purposes of being engaged in action research; in this paper, the process is described to confirm the quality of results (Koshy 2005). A recommendation for further development of the mental health promotion model is to improve the collaboration between healthcare services and school services that support the easy access to care for students. The mental health status of children and adolescents is similar throughout Europe and new ways to promote mental health on an international level therefore need to be developed. The idea that mental health promotion is everybody’s responsibility needs to be embedded into the school policy. The expertise that mental health nurses provide in schools is a valuable asset that should be considered. It is important to develop interventions and mental health promotion models together with interest groups, such as school staff, parents, students and healthcare services in the context where the action takes place. Collaboration enhances the initialization of the interventions and supports the instilling of the interventions as part of school function. The student involved in the intervention is always a part of the community, which is why the indicated interventions also affect the community and the universal interventions affect individual students. There is a shift of perspective from an illness and problem perspective to a health and empowerment perspective. This creates a need to measure the effects of interventions designed to empower and increase health. Further research is needed on the effects of the interventions especially from the viewpoint of students and school staff.
Kavanagh J., Oliver S., Lorenc T., et al. (2009)
Licence K. (2004) Promoting and protecting the
School-based cognitive – behavioral interven-
health of children and young people. Child:
tions: a systematic review of effects and inequalCarr J. (2011) Activist research and city politics: ethical lessons from youth-based public scholar-
ities. Health Sociology Review 18, 61–78. Kiilakoski T. & Oksanen A. (2011) Cultural and peer influences on homicidal violence: a Finnish
ship. Action Research 10, 61–78. Cattan M. & Tilford S. (2006) Mental Health Promotion a Lifespan Approach. Open University
perspective. New Directions for Youth Develop-
Inquiry. Sage Publications, Beverly Hills, CA, USA. Lind C. (2007) The power of adolescent voices: co-researchers in mental health promotion.
ment 129, 31–42. Kobau R., Seligman M.E.P., Peterson C., et al.
press, Buckingham, Great Britain.
Care, Health and Development 6, 623–635. Lincoln Y.S. & Guba E. (1985) Naturalistic
Educational Action Research 15, 3.
Genat B. (2009) Building emergent situated
(2011) Mental health promotion in public
Lönnqvist J. (2005) Tee hyvä sijoitus, anna aikaa
knowledges in participatory action research.
health: perspectives and strategies from positive
lapselle. Available at: http://www.ktl.fi/portal/
Action Research 7, 101–115.
psychology. American Journal of Public Health
suomi/julkaisut/kansanterveyslehti/
8, e1–e9.
lehdet_2005/9_2005/paakirjoitus/ (accessed 6
Högnabba S. (2011) Etelä-Suomen Lapsen ääni – kehittämisohjelman 2009–2011 loppuarviointi. Available
at:
http://www.lapsenaani.fi/
Koshy V. (2005) Action Research for Improving Practice, In: A Practical Guide. Paul Chapman
MATERIAALI/Lapsen%20%C3%A4%C3
Publishing,
%A4ni%20koko%20raportti%20
London, England.
loppuarviointi%2031%2010%2011.pdf (accessed 22 December 2011).
Thousand
Oaks,
New
Delhi,
Lavikainen J., Lahtinen E. & Lehtinen V. (2004)
October 2008). Luopa P., Pietikäinen M. & Jokela J. (2007) Koulukiusaaminen
peruskoulun
yläluokilla
2000–2007. Ministry of Education Publication, Helsinki, Finland.
Mielenterveystyö Euroopassa, In: Sosiaali-ja
O’Brien R. (2001) An Overview of the Methodo-
terveysministeriö. Publications of the Ministry
logical Approach of Action Research. In:
ongelmia
of Social Affairs and Health, Helsinki, Finland.
Theory and Practice of Action Research (ed
nuoruudessa. Lääketieteellinen Aikakauskirja
Levin M. (2012) Academic integrity in action
Richardson, R.), Universidade Federal da
Honkinen P-L. (2010) Lapsuusiän käytöshäiriöt ennustavat
elämänhallinan
Duodecim 126, 5–6.
626
research. Action Research 10, 2133–2149.
Paraíba,
João
Pessoa,
Brazil.
Available
© 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
at:
http://www.web.ca/∼robrien/papers/arfinal
.html (Accessed 20 January 2002). Onnela A. (2012) Mental health promotion inter-
kannanottoja. Available at: http://www.acadsci .fi/kannanottoja/koulusurmat.pdf
(access
18
Weist M.D., Goldstein A., Morris L., et al. (2003) Integrating expanded school mental health programs and school-based mental health centers.
October 2012).
Psychology in the Schools 3.
ventions in school health care: a systematic lit-
Puskar K.R. & Bernardo L.M. (2007) Mental
erature review. Master thesis: University of
health and academic achievement: role of school
WHO (1978) Declaration of Alma-Ata Interna-
Oulu, Department of Nursing Science.
nurses. Journal for Specialists in Pediatric
tional Conference on Primary Health Care,
Nursing 12, 215–223.
Alma-Ata, 1978. Available at: http://www.searo
Patton G.C., Glover S., Bond L., et al. (2000) The Gatehouse Project: a systematic approach to
Solantaus T. & Paavonen J.E. (2009) Vanhempien
mental health promotion in secondary schools.
mielenterveyshäiriöt
The Australian and New Zealand Journal of
ongelmat.
ja
lasten
Lääketieteellinen
psykiatriset Aikakauskirja
Duodecim 125, 1839–1844.
Psychiatry 34, 586–593.
.who.int/LinkFiles/Health_Systems_declaration _almaata.pdf (accessed 29 November 2012). WHO (1986) The Ottawa charter for health promotion.
Available
at:
http://www.who.int/
healthpromotion/conferences/previous/ottawa/
Potvin L., Bisset S.L. & Waltz L. (2010) Participa-
Stallard P., Simpson N., Anderson S., et al. (2008)
tory Action Research: Theoretical Perspectives
The FRIENDS emotional health prevention pro-
en/index3.html (accessed 28 November 2012).
on the Challenge if Research Action. In: The
gramme – 12 month follow-up of a universal
Winter R. (1996) Some principles and procedures
Sage Handbook of Qualitative Methods in
UK school based trial. European Child and
for the conduct of action research. In:
Health Research (eds Bourgeault, I., Dongwall,
Adolescent Psychiatry 17, 283–289.
New
R.
&
de
Vries,
R.),
Sage
Publications,
USA. Power A.K. (2010) Transforming the nation’s health: next steps in mental health promotion. American Journal of Public Health 12, 2343–
Taggart L. & McKendry L. (2009) Developing a
Directions
in
Action
Research
(ed
Zuber-Skerritt, O.), Falmer Press, London.
mental health promotion booklet for young
Woodhouse A. (2010) Is there a future in mental
people with learning disabilities. Learning Dis-
health promotion and consultation for nurses?
ability Practice 10, 27–32.
Contemporary Nurse 34, 177–189.
Walsgrove H. & Fulbrook B. (2005) Advancing
Wyn J., Cahill H., Holdsworth R., et al. (2000)
the clinical perspective: a practice development
MindMatters, a whole-school approach pro-
Punamäki R., Tirri K., Nokelainen P., et al. (2011)
project to develop the nurse practitioner role in
moting mental health and wellbeing. The Aus-
Koulusurmat Yhteiskunnalliset ja psykologiset
an acute hospital trust. Journal of Clinical
tralian and New Zealand Journal of Psychiatry
taustat ja ehkäisy. Suomalaisen tiedeakatemian
Nursing 14, 444–455.
34, 594–601.
2346.
© 2014 John Wiley & Sons Ltd
627
Mental health promotion in comprehensive schools A . M . O N N E L A 1 M n S c , P. V U O K I L A - O I K K O N E N 2 T. H U R T I G 3 P h D & H . E B E L I N G 4 M D P h D
Ph D,
1
Psychiatric Nurse/Team Coordinator, Social- and Healthcare, City of Oulu, Oulu, Finland, 2Principal Lecturer, Diaconia University of Applied Sciences, Oulu, Finland, 3Adjunct Professor, Postdoctoral Researcher, Department of Child Psychiatry, Institute of Health Sciences, University of Oulu, University Hospital of Oulu, Oulu, Finland, and 4Professor of Child Psychiatry, Department of Clinical Medicine, Child Psychiatry, University of Oulu, Child Psychiatry, Oulu University Hospital, Oulu, Finland
Keywords: child and adolescent mental
Accessible summary
health, comprehensive schools, intervention, mental health nursing,
•
mental health promotion, school health services Correspondence: A. M. Onnela Social- and Healthcare City of Oulu Tuirantie 5, 90500 Oulu Finland E-mail: [email protected] Accepted for publication: 26 December 2013 doi: 10.1111/jpm.12135
• •
A participatory action research study on the development of a professional practice model of mental health promotion in a comprehensive school. Model was developed in collaboration with interest groups, students and parents. Interventions were developed on universal, selective and indicated levels.
Abstract The purpose of this paper is to describe a participatory action research process on the development of a professional practice model of mental health nurses in mental health promotion in a comprehensive school environment in the city of Oulu, Finland. The developed model is a new method of mental health promotion for mental health nurses working in comprehensive schools. The professional practice model has been developed in workshops together with school staff, interest groups, parents and students. Information gathered from the workshops was analysed using action research methods. Mental health promotion interventions are delivered at three levels: universal, which is an intervention that affects the whole school or community; selective, which is an intervention focusing on a certain group of students; and indicated, which is an individually focused intervention. All interventions are delivered within the school setting, which is a universal setting for all school-aged children. The interventions share the goal of promoting mental health. The purposes of the interventions are enhancing protective factors, reducing risk factors relating to mental health problems and early identification of mental health problems as well as rapid delivery of support or referral to specialized services. The common effect of the interventions on all levels is the increase in the experience of positive mental health.
Introduction Child and adolescent mental health has become a great concern for healthcare providers in recent years. Alternative approaches to mental health promotion are required to accomplish a significant change in the emotional and behavioural problems of children. Early interventions and preventive measures are attracting increasing attention as ways to improve immediate and long-term mental health in these age groups (Stallard et al. 2008). Mental health pro618
motion interventions aim at providing individuals, families and societies with the knowledge, skills and resources needed to promote mental health (Lavikainen et al. 2004). Mental health promotion interventions delivered in school settings have as their aim preventing mental disorders from developing (Stallard et al. 2008) The spectrum of students has become more diverse, which creates a need for mental health know-how in schools. Children need support for their issues in schools, which are a good environment to carry out supportive measures (Lönnqvist 2005). © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
There is also a need to develop a nursing practice model to meet the increasing needs of school health care to deal with mental health issues (Woodhouse 2010). In Oulu, Finland, eight mental health nurses were hired for mental health promotion work in the primary healthcare environment in the context of comprehensive schools. Their professional practice model was developed in workshops in which the nurses participated together with their collaboration networks, including multiprofessional teams, school staff, students and parents. The developed interventions were based on existing knowledge from studies and previous health promotion projects on effective mental health promotion. The mental health promotion model was developed using participatory action research approach. This paper aims to describe the mental health promotion constructional model and the interventions developed for comprehensive schools.
Mental health promotion Mental health promotion is about enhancing positive emotion and optimal functioning. Health is not only the absence of illness but rather a means to harness the resources of individuals and societies and the factors that make life good (Power 2010, Kobau et al. 2011). Promotion enhances personal abilities to achieve good selfesteem, well-being and social inclusion. (Power 2010). The concept of health promotion has its roots in the 1970s. The foundations of health promotion are in the change of perception of determinants of health to include health behaviour, social factors, biological factors and health care versus the previous perception that health was reliant on available health care. Another factor that contributed to the development of the health promotion concept was the emergence of a new approach to health education in the 1970s that included the concepts of empowerment, informed decision making and social determinants of health (Cattan & Tilford 2006). The Ottawa Charter from 1986 and Alma Ata conference in 1978 emphasize the role of primary health care, flexible systems and education in health promotion. The Ottawa Charter obligates for health promotion to be facilitated in a school, home, work and community settings and for the role of the health sector to move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services (WHO 1986). The Alma Ata conference states that the national health systems need to bring health care close to where people live and work in coordination with other service providers (WHO 1978). Mental health promotion enhances communal assets in order to prevent mental illness and promote the well-being and quality of life of people. Health-enhancing © 2014 John Wiley & Sons Ltd
public policies, creation of supportive environments, and enhancement of community actions and development of health services are ways to implement mental health promotion (Kobau et al. 2011). Mental health promotion in schools includes information and training on self-harm, social skills, stress, coping skills, school bullying and understanding mental well-being and understanding of diversity. The nurses working in schools are the tools that put these actions into practice (Woodhouse 2010). Mental health promotion of children and adolescents should not be detached from the community but a function of the community. Stallard et al. (2008) agrees in his study that early interventions and preventive measures are ways to improve immediate and long-term mental health of children and adolescents (Stallard et al. 2008). Högnabba (2011) and Taggart & McKendry (2009) state in their studies that early interventions promote feelings of control, strengthen a person’s capacity to deal with adversity and prevent anxiety, depression and behavioural problems (Taggart & McKendry 2009, Högnabba 2011). The important role of parents needs to be recognized in the mental health promotion of children and adolescents. It is effective to promote the mental health of children and adolescents in schools, but in order to be able to make a lasting and embedded difference in the mental status of children and adolescents methods to promote the mental health of whole families need to be developed. As many mental health problems are inherited and unhealthy lifestyles are learned from the parents, it is significant to attempt to promote the mental health of parents and societies (Solantaus & Paavonen 2009). Kavanagh et al. (2009) has also found that enhancing coping skills, providing knowledge and strengthening resilience and psychosocial activity of children and adolescents promotes mental health (Kavanagh et al. 2009). Taggart & McKendry (2009) and Woodhouse (2010) have stated that mental health promotion programmes should include promotion of emotional stability through concepts of self-esteem, empowerment, coping skills and social skills (Taggart & McKendry 2009, Woodhouse 2010) and offer methods and knowledge to improve and maintain positive mental health (Lavikainen et al. 2004).
Mental health promotion interventions on universal, selective and indicated levels in the context of comprehensive schools Mental health promotion interventions in schools include universal, selective and indicated interventions. The universal approach includes the whole school as a setting for mental health promotion (Stallard et al. 2008). Universal interventions are delivered on various levels and have a 619
A. M. Onnela et al.
whole-school focus. The school environment is improved by educating school staff on mental health issues and providing skills allowing them to identify, intervene and cope with different emotional and behavioural needs (Licence 2004). At schools ‘low threshold’ places provide easy access to mental health care for students and reduce the stigma related to seeking help for mental health problems. Low threshold places are services that are easily accessible to students in their own environment and do not require an appointment or referral. The effect of universal interventions is the reduction of stigmatization associated with mental health illnesses. Interventions taking place in school environment and culture and involving the school staff are effective in promoting mental health of the whole school community through promoting feelings of belonging, togetherness and trust (Licence 2004). A selective approach affects a specific group, e.g. a subgroup of adolescents at risk of developing mental health problems (Lind 2007). Selective interventions focus on groups of students or families at enhanced risk of developing mental health problems. Such groups may include participants with problems in social skills, poor self-esteem or depressive symptoms. The groups provide empowering peer support and a chance to share similar experiences. The effects of selected interventions are the reduction of disruptive behaviour, decrease of depressive symptoms and an enhanced feeling of togetherness. Interventions targeted at families affect the ways in which families feel, think, communicate and behave. This enhances parents’ experience of understanding their adolescent’s needs and provides an understanding of the families’ resources (Wyn et al. 2000). Indicated interventions are targeted at individual students with emerging symptoms and their families (Puskar & Bernardo 2007). The purpose of indicated interventions is early identification of mental health problems and rapid delivery of support or referral to specialized services. Mental health problems can be reduced in the long run through effective early identification. Another purpose of all interventions is to reduce risk factors that might impact the development of mental health problems and to enhance protective factors. The aim of the mental health promotion interventions is empowerment and improving of social, emotional and problem-solving skills. The effect of interventions at all levels is the increased experience of positive mental health (Onnela 2012). Indicated interventions are individually focused interventions that aim to provide support for students displaying some symptoms of mental health problems in order to prevent more severe symptoms or disorders from developing. Indicated interventions have the purpose of changing the cognition, attitude, beliefs, 620
actions and behaviour of an individual in a therapeutic conversation (Puskar & Bernardo 2007). It is important to include parents in the intervention. Multiprofessional assessment improves early identification and expedites referral to specialized mental health care. The effects of indicated interventions are the reduction of disciplinary referrals, depressive symptoms and referrals to specialized mental health care. There is also improvement in coping skills and school attendance. Indicated interventions strengthen a person’s capacity to deal with adversity and prevent anxiety and behavioural problems (Taggart & McKendry 2009). Promotion of compliance with regimen and generalization of compliance to several settings are also effects of interventions. (Weist et al. 2003). Interventions can be used to strengthen an individual’s resilience, which is not something that a person either has or does not have; it develops through learned cognitions and behaviour. Personal strengths act as barriers against development of mental problems and adversity as well as enhancement of resilience. Strengths such as optimism, coping skills and positive self-esteem can be found, enhanced and harnessed through interventions (Power 2010). In addition to interventions that are individually focused, interventions directed at families are effective because well-functioning, healthy families are able to support well-functioning, healthy individuals. A wellfunctioning family and a sense of strong parenting are mediators of positive mental health for children. The communities where families live should be strengthened as well in order to improve the well-being of individuals (Power 2010).
School as a setting for mental health promotion Finnish students are ranked high internationally according to level of academic skills but do not enjoy going to school (Punamäki et al. 2011). School satisfaction of Finnish students’ is poorer than the international average in all age groups. At the age of 15, only 11 percent of girls and 9 percent of boys enjoy going to school. The reason for dissatisfaction is likely to be the social atmosphere in the schools. Students feel that the school climate is negative, and nearly 30 percent of ninth-grade boys and 42 percent of ninth-grade girls feel that relations to peers are poor (Kiilakoski & Oksanen 2011). Positive mental health is related to school satisfaction. A poor school climate enhances feelings of stress and fatigue in students (Honkinen 2010). On the other hand, the social capital that schools provide plays an important role in academic success and © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
mental health. Social capital is affected by trust, good social networks and a feeling of togetherness. Belonging to a school community where a child or adolescent feels equity and peer support prevents school violence (Punamäki et al. 2011). School violence has increased in recent years in Finland, and 8 percent of Finnish students experience bullying on a weekly basis (Luopa et al. 2007). Many visible problems in schools such as large group sizes, inequality of resources and school bullying increase the risk of school violence (Punamäki et al. 2011). There is good reason that mental health promotion interventions should be carried-out in schools. Schools are arguably the only universal setting for children and adolescents. In addition, the years of attending comprehensive schools are the time when emotional and behavioural needs increase, but also when they can be influenced. Young people spend a large proportion of their days in school, and interactions with school staff and peers are bound to have an effect on their emotional well-being. Mental health promotion interventions emphasize a feeling of togetherness in schools through promoting feelings of security and trust towards peers and staff, good communication and positive self-esteem that is enhanced by participation in school activities. The interventions are also focused on students who are at risk of dropping out of school and becoming socially alienated (Patton et al. 2000). The underlying idea is that mental health promotion is a basic function of schools (Wyn et al. 2000).
Aim and research questions Research aim: to investigate current practices in relation to mental health promotion in comprehensive schools and to develop a professional practice model for mental health interventions in practice using an action research approach. Research question is: What kind of mental health promotion interventions were developed according to existing knowledge from studies and good practice in comprehensive schools? How the professional practice model was developed using action research methods?
invited to share knowledge on their viewpoints, knowledge and perceptions of the developed interventions. Because action research is carried out in real-world circumstances and involves close and open communication among the people involved, the researchers must pay close attention to ethical considerations in the conduct of their work. During workshops, the relevant persons, committees and authorities were consulted, and the principles guiding the work were accepted in advance by all. All participants were allowed to influence the work and their viewpoints were respected. The development process was visible and open to suggestions from workshop participants (Winter 1996).
Participatory action research approach According to Genat (2009), participatory action research draws theoretically on the concepts of symbolic interactionism. Action research is used in real situations, and this professional practice research study is based on developing process action research that is defined as the ‘learning by doing’ approach (Genat 2009) and for solving challenges occurring in professional practice (Levin 2012). According to Carr (2011), one strength when using action research is that this ethical, activist dimension of knowledge production is both explicit and essential (Carr 2011). There is a dual commitment in action research to study a system and concurrently to collaborate with members of the system in changing it into what is jointly regarded as a desirable direction. As a process, a group of people identify a problem, do something to resolve it, see how successful their efforts were, and if not satisfied, try again (Levin 2012). In this case, there were mental health nurses with their collaborators in health centres, schools and hospitals, in addition to which also students with their parents participated. While this is the essence of the approach, there are other key attributes of action research that differentiate it from common problem-solving activities that we all engage in every day (O’Brien 2001, Potvin et al. 2010).
Participatory action research process
Ethical issues The written agreement on the development process between the City of Oulu and Diaconia University of Applied Sciences was signed on 17 April 2011. The participants in the development process were informed (oral informed consent) that action research method would be applied also during the development process and the results would be published. All participants were aware of their participation in the research process. Participants were © 2014 John Wiley & Sons Ltd
According to O’Brien (2001), much of the researcher’s time is spent on refining the methodological tools to suit the exigencies of the situation, and on collecting, analyzing, and presenting data on an ongoing, cyclical basis (O’Brien 2001). In the development process, there were nine workshops where the mental health promotion model was discussed, developed and reflected. People from previous health promotion projects in northern Finland were invited to the first workshop to share knowledge of health promotion working practices 621
A. M. Onnela et al.
and material developed in the projects. Previous studies on mental health promotion interventions were also studied. Knowledge of workable interventions was gathered and developed further in the workshops. Participants in the workshops produced knowledge on workable mental health promotion according to their perceptions, professional experience and needs. The interventions were developed using knowledge and material produced in previous health promotion projects and previous studies taking into account the knowledge produced in the workshops. The interventions were then delivered in the schools followed by another workshop to further develop the interventions according to feedback from the participants. Workshops were chosen as the method for gathering data because it supports the ‘learning by doing’ approach of participatory action research. Mental health promotion in schools requires the collaboration of people from many sectors of community social, health, and education services and, most importantly, the collaboration of students and parents. Workshops are a convenient platform for all participants to share and develop knowledge on mental health promotion. A steering group was chosen to follow and evaluate the development process in between the workshops. The steering group consisted of directors and coordinators in the health sector who did not participate in the workshops. The mental health nurses were given assignments in between the workshops to help evaluate the model (Table 1). Mental health nurses were chosen as the operators of the interventions in schools due to the fact that a separate allowance from the community budget was allocated for preventive mental health services in the health sector. In addition, mental health nurses also have diverse know-how on mental health. The participants in the workshops comprised school staff, interest groups, parents and students. School staff including principals, teachers, study advisors, counsellors, school nurses and schools psychologists were invited to the second and ninth workshop to share ideas on the needs that schools have and their ideas of functional methods of mental health promotion in a school setting. Most importantly, the parents and students were invited to attend the second and ninth workshop to share their needs and anticipations for the mental health promotion model. Invitations were sent to the students and parents through the student and parents’ association, who then chose their participants. Collaborative networks such as child welfare services, family counselling centres and child psychiatry were invited to the fourth workshop to strengthen public services and sharing of information. All workshops were based on voluntary participation. Furthermore, data were collected in workshops to develop mental health promotion in action. 622
Together with the school staff and students, the mental health nurses assessed how workable the developing model was. Furthermore, the data were analyzed, and new questions were asked for reflection in workshops (Winter 1996). The interventions were delivered in six comprehensive schools and two special education schools that were chosen as pilot schools in the city of Oulu. The comprehensive schools have grades ranging from first to ninth grade. Interventions were delivered in all grade levels. The two special education schools are characterized by offering education to children with special needs such as behavioural problems and learning disabilities. The special educations schools also provide education from grade one through nine. The data consisted of the information produced in the workshops and assignments in between workshops by the mental health nurses. The written material produced in all the workshops acted as the entire data that was analysed using content analysis. Phrases that described mental health interventions were chosen from the data. Each workshop acted as an analysis stage (or document). New data from each workshop were built upon knowledge from previous workshops. The final data were a comprehensive professional practice model of mental health promotion that was constructed based on the workshops (Fig. 1).
Results The result of the participatory action research process is the professional practice model of mental health nurses in comprehensive schools that is based on the interventions created during the participatory action research process in the workshops. The interventions were developed according to knowledge produced in the workshops. The structures for all the interventions are substantially the same. There is always an instructor and an objective for the intervention and it is based on active doing that corresponds to the developmental stage of the children or adolescents. The focus and aim of the intervention is always mental health promotion. A few examples of interventions on universal, selected and indicated levels in comprehensive schools are described here (Table 2). All the interventions take place within the school community, which enables the promotive actions to take place on all levels of activity. In action, the interventions that are delivered on a universal level reach the whole school community: students and school staff. Mental health kiosks are a whole school event where stands are placed in the school lobby or cafeteria and the school mental health nurse distributes information pamphlets and tests about mental health. Students are able to visit the stands to receive infor© 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
Table 1 Workshops Workshop
Participants
Aim
Outcome
1st starting point
People from previous health promotion projects + mental health nurses
List of existing good practices in accordance to the aim of the new working life model.
2nd ideation
School counsellors, principals, school psychologists, study advisors, school nurses, students and parents + mental health nurses Directors and coordinators of the health sector
Mapping of existing good practice = > assignment between workshops: what good practices exist? New ideas for the basis of the model= > assignment between workshops: what needs exist in relation to the aim of the model? Monitoring the advancement of the development process, setting a goal for the advancement Planning the model = > assignment between workshops: notes on positive and negative aspects to the developing model
Steering group
3rd designing
Mental health nurses
4th integration and collaboration
People from public services ex. child welfare, child psychiatry, family counselling centres +mental health nurses
Linking of the model to other public services = > assignment between workshops: Listing of new collaborative networks and evaluation of the model Evaluation
5th school meeting
Teachers + mental health nurses
6th school meeting
Teachers + mental health nurses
7th clarifying the model
Mental health nurses
Comments of the model in comprehensive schools = > assignment between workshops: evaluation of the comments by mental health nurses Comments of the model in comprehensive schools = > assignment between workshops: evaluation of the comments by mental health nurses Development of model according to meetings with the school staff = > assignment between workshops: what effects can be seen from the interventions? Evaluation
Steering group
Steering group 8th clarifying the model
Mental health nurses
9th approving the model
Parents, students, collaborators, mental health nurses, steering group
Steering group
© 2014 John Wiley & Sons Ltd
Development of model according to feedback from school staff = > assignment between workshops: what effects are perceived Approving the model
Final evaluation
Defining the aim for the model/action
Evaluation and approval of the aims for the model and good practices to be used in the model (1) Evaluation of the model using SWOT (2) Evaluation of the development process and workability of the model in action (1) Listing of most important collaborative networks (2) Evaluation of multiprofessional collaboration cross-sectorally using SWOT 1 evaluation of workability, and cross-sectoral collaboration Feedback from schools = > recording of necessary changes to the model
Feedback from schools = > recording of necessary changes to the model
Evaluation of the whole model using SWOT
1 listing perceived effects of the model. Evaluation of the model using SWOT, (evaluating have the threats and weaknesses decreased to the prior SWOT) Final version of the model to be presented to the public (1) Evaluation of the methods of instilling the model to the schools (2) Evaluation of the development process
623
A. M. Onnela et al.
Figure 1 Action research process
Table 2 Interventions Universal intervention
In action
Whole school events
‘Mental health rally’ – checkpoints where students discuss mental health issues in groups together with the mental health nurse In ‘mental health kiosk’ – stands in the school lobby where information pamphlets and tests are distributed. Students visit the stands to receive information about mental health issues and to test their knowledge Walk-in times where a mental health nurse is available without appointment or referral Staff meetings
Sharing of knowledge
‘Low threshold’-places Education of school staff Selective interventions Classroom interventions Groups Indicated interventions Support for students and families
Lessons on ex. taking care of mental health, substance abuse, stress, friendship, social skills, crisis, interactional skills, classroom environment ART (aggression replacement treatment), mastery of life skills, social skills Supportive and solution focused dialogue with student or families Parent consultation Assessment with multiprofessional team
mation about mental health issues and to test their knowledge. The event is also a good opportunity for the students to talk to the school mental health nurse without fear of being labelled. Visitors from different communal services are also present at the rally. The event is a good opportunity for municipal services, such as youth services and sports and recreation services, to showcase their activities for children and adolescents. The education of school staff takes place in school meetings. The meetings can be held for the entire school staff or the student services team consisting of the school principal, school nurse, school psychologist and curator. The purpose is to increase knowledge of how to identify students with incipient symptoms of mental health problems in order to provide help quickly, how to deal with the challenges of having a student with mental health problems in the classroom and how to promote mental health in school. On a selective level, the interventions are delivered to classrooms and selected groups. Classroom interventions are lessons taught by the school mental health nurse 624
together with the teacher on mental health issues. The subjects for the lessons include how to take care of mental health, substance abuse, stress, friendship, social skills, crisis, interactional skills and classroom environment. The content is customized for each grade to suit the developmental stage of the students. The interventions are integrated into the curriculum. The classroom interventions can be delivered over one or several lessons depending on the subject and classroom. Interventions in a classroom environment usually demand several lessons. A group for learning social skills meets 10 times at a fixed time and place. The group has six to eight participants and two instructors, one being the school mental health nurse and the other a member of the school staff, such as a teacher. The aim of the group is to learn and practice social skills with active methods such as acting, games, drawing and crafting. The practicing of social skills in the group supports a regimen of compliance. Indicated interventions are delivered to individual students with a low level of symptoms and their families. They © 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
are delivered through supportive and solution-focused dialogue sessions with the school mental health nurse during the school day. The school mental health nurse meets with the student or the whole family 1–5 times. This is based on aiming at finding solutions and moving forward in the challenging situation through resource-focused conversation. The inclusion of parents is necessary for elementary level students. Adolescents often prefer to discuss personal matters with a reliable adult other than parents, but also benefit from inclusion of parents in the intervention.
Validity Decisions were made about the direction of the study, and the probable outcomes are collective. Researchers were explicit about the nature of the research process from the beginning, including all personal biases and interests. According to Levin (2012), action research can be evaluated by using trustworthiness (Levin 2012). Data collection and analysis occurred simultaneously in construction of the mental health promotion model. Furthermore, the processlevel relationship between data collection and analysis stimulates communication between participants. This was initiated during data collection in workshops by sharing information from participants and sharing new information from their viewpoints. The developed model was reflected on by school staff, parents and students who were not involved in the development process. A reflective journal was used to write down the data collected in workshops, working with hypotheses, and themes that emerged. In workshops, the participants described their natural settings at schools. All data were collected by authors (A.O. and P.V-O.). At least one follow-up contact was made in a symposium to persons who participated in the workshops. Municipal decision-makers also took part in the symposium. In the symposium, the model of mental health was reflected on and further development needs and embedding processes were decided (Lincoln & Guba 1985). All produced data were compared with existing research based on sound methods of mental health promotion interventions. Also adding to validity is the reflection on produced data by all participants. Validity is increased through coherence, which in this case means that enough data were produced to develop a comprehensive understanding of mental health promotion interventions. The knowledge produced was cumulated from the data produced in the workshops.
Discussion The outcome of the participatory action research process was a professional practice model for mental health nurses © 2014 John Wiley & Sons Ltd
in the context of comprehensive schools. The professional practice model consists of the interventions that were developed during the action research process in workshops. The interventions were developed in correspondence to existing knowledge from studies and previously developed experience-based intervention methods and good practice. Some interventions were excluded from the model according to knowledge produced in the workshops. Prior to the development of the new model, mental health nurses’ point of focus in their work was long-lasting individual therapeutic relationships in child and adolescent mental health care. In the workshops, knowledge was produced that school community-level and group-level interventions are more effective in improving mental health of students through prevention of bullying, increasing knowledge and participation of students and improving school and classroom environment. Although individual-focused interventions were not excluded, they were modified to be solution-focused short interventions that were based on the needs of the students. It was important to involve the collaborative networks as well as students and parents in the development process so that the developed interventions answered to their needs. The development of mental health promotion interventions systematically in collaboration with interest groups increases the know-how of mental health promotion of the entire community. Universal interventions developed in the process include mental health rallies, mental health kiosks, low threshold places and education of school staff. They all have the aim of increasing knowledge of mental health issues and promoting skills in self-care. Selective level interventions include classroom interventions and selected groups. They also have the aim of increasing knowledge on mental health and skills in self-care. They also provide peer support and a collective sense of belonging. Individual interventions comprise support for students and families in solutionfocused dialogue with the aim of empowerment. The group for learning social skills promotes social skills and provides peer support. The indicated interventions offer individuals methods and knowledge to improve and maintain positive mental health. Whole-school events, such as the mental health rally, improve the school environment and culture. There are many practical challenges to meet before mental health promotion is consistently practiced in schools. School health care in Finland already has a strong foothold in screening and early intervention of somatic illnesses. Early interventions of mental health problems need to be incorporated into the school healthcare system to be in accordance with a holistic view of health care. School staff and healthcare providers need to tighten their collaboration and broaden their view to gain a 625
A. M. Onnela et al.
comprehensive understanding of the well-being of students. Interventions need to be developed further, and more research on mental health promotion interventions and their effects is needed. The shift of thinking from illness management to promotion of mental health has already lead to changes in primary health care. A change in culture is called for to move on from problem-oriented thinking to a positive and empowering approach on mental health. There is also the need to improve student satisfactions levels in Finnish schools despite superior academic performance. The professional practice model can be used in development of mental health promotion interventions in communities as well as in participatory development projects in healthcare systems. The developed interventions are also of value to clinical nursing practice. Participatory action research approach enables partners to involve in the development of professional practice; it focuses on change, collaboration and participation. All participants are actively involved in the developing process and the results are drawn together. The key to this approach is the role of the researcher as a facilitator, interlocutor and interpreter. According to Genat (2009), participatory action research builds local theory and knowledge and positions local participants as advocates for new ways of understanding the phenomenon. (Genat 2009). However, professional practice development is never truly finished, which means that professional practice should be accountable to continue the process further to the implementation process (Walsgrove & Fulbrook 2005). Gaining insights and planning the
References
action are two of the main purposes of being engaged in action research; in this paper, the process is described to confirm the quality of results (Koshy 2005). A recommendation for further development of the mental health promotion model is to improve the collaboration between healthcare services and school services that support the easy access to care for students. The mental health status of children and adolescents is similar throughout Europe and new ways to promote mental health on an international level therefore need to be developed. The idea that mental health promotion is everybody’s responsibility needs to be embedded into the school policy. The expertise that mental health nurses provide in schools is a valuable asset that should be considered. It is important to develop interventions and mental health promotion models together with interest groups, such as school staff, parents, students and healthcare services in the context where the action takes place. Collaboration enhances the initialization of the interventions and supports the instilling of the interventions as part of school function. The student involved in the intervention is always a part of the community, which is why the indicated interventions also affect the community and the universal interventions affect individual students. There is a shift of perspective from an illness and problem perspective to a health and empowerment perspective. This creates a need to measure the effects of interventions designed to empower and increase health. Further research is needed on the effects of the interventions especially from the viewpoint of students and school staff.
Kavanagh J., Oliver S., Lorenc T., et al. (2009)
Licence K. (2004) Promoting and protecting the
School-based cognitive – behavioral interven-
health of children and young people. Child:
tions: a systematic review of effects and inequalCarr J. (2011) Activist research and city politics: ethical lessons from youth-based public scholar-
ities. Health Sociology Review 18, 61–78. Kiilakoski T. & Oksanen A. (2011) Cultural and peer influences on homicidal violence: a Finnish
ship. Action Research 10, 61–78. Cattan M. & Tilford S. (2006) Mental Health Promotion a Lifespan Approach. Open University
perspective. New Directions for Youth Develop-
Inquiry. Sage Publications, Beverly Hills, CA, USA. Lind C. (2007) The power of adolescent voices: co-researchers in mental health promotion.
ment 129, 31–42. Kobau R., Seligman M.E.P., Peterson C., et al.
press, Buckingham, Great Britain.
Care, Health and Development 6, 623–635. Lincoln Y.S. & Guba E. (1985) Naturalistic
Educational Action Research 15, 3.
Genat B. (2009) Building emergent situated
(2011) Mental health promotion in public
Lönnqvist J. (2005) Tee hyvä sijoitus, anna aikaa
knowledges in participatory action research.
health: perspectives and strategies from positive
lapselle. Available at: http://www.ktl.fi/portal/
Action Research 7, 101–115.
psychology. American Journal of Public Health
suomi/julkaisut/kansanterveyslehti/
8, e1–e9.
lehdet_2005/9_2005/paakirjoitus/ (accessed 6
Högnabba S. (2011) Etelä-Suomen Lapsen ääni – kehittämisohjelman 2009–2011 loppuarviointi. Available
at:
http://www.lapsenaani.fi/
Koshy V. (2005) Action Research for Improving Practice, In: A Practical Guide. Paul Chapman
MATERIAALI/Lapsen%20%C3%A4%C3
Publishing,
%A4ni%20koko%20raportti%20
London, England.
loppuarviointi%2031%2010%2011.pdf (accessed 22 December 2011).
Thousand
Oaks,
New
Delhi,
Lavikainen J., Lahtinen E. & Lehtinen V. (2004)
October 2008). Luopa P., Pietikäinen M. & Jokela J. (2007) Koulukiusaaminen
peruskoulun
yläluokilla
2000–2007. Ministry of Education Publication, Helsinki, Finland.
Mielenterveystyö Euroopassa, In: Sosiaali-ja
O’Brien R. (2001) An Overview of the Methodo-
terveysministeriö. Publications of the Ministry
logical Approach of Action Research. In:
ongelmia
of Social Affairs and Health, Helsinki, Finland.
Theory and Practice of Action Research (ed
nuoruudessa. Lääketieteellinen Aikakauskirja
Levin M. (2012) Academic integrity in action
Richardson, R.), Universidade Federal da
Honkinen P-L. (2010) Lapsuusiän käytöshäiriöt ennustavat
elämänhallinan
Duodecim 126, 5–6.
626
research. Action Research 10, 2133–2149.
Paraíba,
João
Pessoa,
Brazil.
Available
© 2014 John Wiley & Sons Ltd
Mental health promotion in comprehensive schools
at:
http://www.web.ca/∼robrien/papers/arfinal
.html (Accessed 20 January 2002). Onnela A. (2012) Mental health promotion inter-
kannanottoja. Available at: http://www.acadsci .fi/kannanottoja/koulusurmat.pdf
(access
18
Weist M.D., Goldstein A., Morris L., et al. (2003) Integrating expanded school mental health programs and school-based mental health centers.
October 2012).
Psychology in the Schools 3.
ventions in school health care: a systematic lit-
Puskar K.R. & Bernardo L.M. (2007) Mental
erature review. Master thesis: University of
health and academic achievement: role of school
WHO (1978) Declaration of Alma-Ata Interna-
Oulu, Department of Nursing Science.
nurses. Journal for Specialists in Pediatric
tional Conference on Primary Health Care,
Nursing 12, 215–223.
Alma-Ata, 1978. Available at: http://www.searo
Patton G.C., Glover S., Bond L., et al. (2000) The Gatehouse Project: a systematic approach to
Solantaus T. & Paavonen J.E. (2009) Vanhempien
mental health promotion in secondary schools.
mielenterveyshäiriöt
The Australian and New Zealand Journal of
ongelmat.
ja
lasten
Lääketieteellinen
psykiatriset Aikakauskirja
Duodecim 125, 1839–1844.
Psychiatry 34, 586–593.
.who.int/LinkFiles/Health_Systems_declaration _almaata.pdf (accessed 29 November 2012). WHO (1986) The Ottawa charter for health promotion.
Available
at:
http://www.who.int/
healthpromotion/conferences/previous/ottawa/
Potvin L., Bisset S.L. & Waltz L. (2010) Participa-
Stallard P., Simpson N., Anderson S., et al. (2008)
tory Action Research: Theoretical Perspectives
The FRIENDS emotional health prevention pro-
en/index3.html (accessed 28 November 2012).
on the Challenge if Research Action. In: The
gramme – 12 month follow-up of a universal
Winter R. (1996) Some principles and procedures
Sage Handbook of Qualitative Methods in
UK school based trial. European Child and
for the conduct of action research. In:
Health Research (eds Bourgeault, I., Dongwall,
Adolescent Psychiatry 17, 283–289.
New
R.
&
de
Vries,
R.),
Sage
Publications,
USA. Power A.K. (2010) Transforming the nation’s health: next steps in mental health promotion. American Journal of Public Health 12, 2343–
Taggart L. & McKendry L. (2009) Developing a
Directions
in
Action
Research
(ed
Zuber-Skerritt, O.), Falmer Press, London.
mental health promotion booklet for young
Woodhouse A. (2010) Is there a future in mental
people with learning disabilities. Learning Dis-
health promotion and consultation for nurses?
ability Practice 10, 27–32.
Contemporary Nurse 34, 177–189.
Walsgrove H. & Fulbrook B. (2005) Advancing
Wyn J., Cahill H., Holdsworth R., et al. (2000)
the clinical perspective: a practice development
MindMatters, a whole-school approach pro-
Punamäki R., Tirri K., Nokelainen P., et al. (2011)
project to develop the nurse practitioner role in
moting mental health and wellbeing. The Aus-
Koulusurmat Yhteiskunnalliset ja psykologiset
an acute hospital trust. Journal of Clinical
tralian and New Zealand Journal of Psychiatry
taustat ja ehkäisy. Suomalaisen tiedeakatemian
Nursing 14, 444–455.
34, 594–601.
2346.
© 2014 John Wiley & Sons Ltd
627
![[Health promotion: Mental health promotion].](/assets/img/hold.png)
