Mental Health in Tertiary Curricula for Dietitians: Phase 2 · Consultant Dietitian B. Health Sc (Nutr&Diet) (Hons); B. Bus (Mktg) Project Managers: Dietitians Association of Australia

Mental Health in Tertiary Curricula for Dietitians: Phase 2

FINAL REPORT 30 June 2009 Contact for Liaison: Ms Annette Byron Professional Services Manager Dietitians Association of Australia 1/8 Phipps Close, DEAKIN ACT 2600 Phone: (02) 6163 5200 Fax: (02) 6282 9888 E-mail: [email protected]

Mental Health in Tertiary Curricula for Dietitians: Phase 2 – Final Report June 2009 2

Table of Contents Contributors and Acknowledgments ................................................................... 4 Executive Summary .............................................................................................. 6 1.0 Introduction ................................................................................................... 8 2.0 Aims & Objectives ........................................................................................ 9 3.0 Project Methodology .................................................................................... 10 3.1 Background .......................................................................................... 10 3.2 Methodology flow-chart ...................................................................... 10 3.3 Data collection and review .................................................................. 11 3.3.1 Review phase 1 materials ....................................................... 11 3.3.2 Online survey .......................................................................... 11 3.3.3 Literature searches ................................................................. 12 3.3.4 Consultation with key stakeholders ......................................... 12 3.4 Resource Development ....................................................................... 13 3.4.1 Case studies ........................................................................... 14 3.3.2 Mental Health and Wellbeing Decision Tree ........................... 15 3.4.3 Critical Incident Reflection Tool .............................................. 16 3.4.4 Critical Incident Audio Vignettes and Scripts .......................... 17 3.4.5 Short Video Clips (DVD) ......................................................... 18 3.4.6 Webpresent – audio presentation of roadshow session ......... 18 3.4.7 MHANDi .................................................................................. 18 3.3.8 Mental Health and Wellbeing Roadshow ................................ 21 3.5 Dissemination ...................................................................................... 25 4.0 Deliverables (summary) ............................................................................... 25 4.1 Deliverable one - MHANDi ..................................................................... 25 4.2 Deliverable two Case studies ................................................................ 26 4.3 Deliverable three CIRT .......................................................................... 27 4.4 Deliverable four MH&W Resources Package ........................................ 28 5.0 Conclusion .................................................................................................... 29 6.0 Recommendations ....................................................................................... 29 7.0 References .................................................................................................... 31


List of Appendices

I Summary of online survey results ....................................................... A2

II Example results of the mental health literature & resources search .. A7

III Case Study Example .......................................................................... A8

IV Mental Health and Wellbeing Decision Tree ...................................... A12

V Critical Incident Reflection Tool .......................................................... A13

VI Critical Incident Vignette Script with mentoring prompts (example) ... A15

VII MHANDi .............................................................................................. A20

VIII Mental Health and Wellbeing Session Plan ........................................ A21

Mental Health and Wellbeing PowerPoint Presentation ..................... A24


Contributors and Acknowledgements Project Team Project Leader: Susan Ash, PhD, FDAA

Associate Professor Institute of Health and Biomedical Innovation School of Public Health Queensland University of Technology

Project Officer: Kerryn Dowding, APD Consultant Dietitian

B. Health Sc (Nutr&Diet) (Hons); B. Bus (Mktg) Project Managers: Dietitians Association of Australia (DAA)

Annette Byron, APD Professional Services Manager, DAA Acknowledgements Department of Health and Ageing, Mental Health Workforce Division Mental Health in Tertiary Curricula for Dietitians Project Steering Committee DAA National Office staff DAA Dietetics Standards & Accreditation Committee Mental Health Interest Group and Committee Members Project stakeholders and participants Abbreviations APD – Accredited Practising Dietitian APS – Australian Psychological Society CODSR – Council on Dietetic Standards Recognition DAA – Dietitians Association of Australia DSAAC – Dietetic Standards and Accreditation Committee MHANDi – Mental Health and Nutrition and Dietetic Information MHIG – Mental Health Interest Group QUT – Queensland University of Technology


Mental Health in Tertiary Curricula for Dietitians Phase 2 Project Steering Committee

Kay Gibbons, FDAA Manager, Nutrition and Foodservices DSAAC - Chair Royal Children’s Hospital Melbourne, Victoria Achamma Joseph, APD Community Nutritionist CODSR Queensland Health Townsville, QLD Mari Eronen, APD Private Practice Dietitian Canberra Shane Jeffery, APD Specialist Dietitian Eating Disorder Services Royal Brisbane and Women’s Hospital Brisbane, QLD Jan Plain, APD Senior Dietitian MHIG convenor Macquarie Hospital Sydney, NSW Jane Shakespeare-Finch, PhD Lecturer Psychologist, APS Member School of Psychology and Counselling Queensland University of Technology Noel P Muller Mental Health Council

Consumer Advocate Annette Byron, APD Professional Services Manager Dietitians Association of Australia


Executive Summary The Mental Health Tertiary Curricula for Dietitians Project (2007-2009) was funded by the Department of Health and Ageing as part of the Mental Health in Tertiary Curricula Program. This funding program aims to enhance the mental health skills of the newly graduating health workforce by expanding the mental health components of undergraduate health training. Dietitians are involved with mental health issues through clinical, community and food service roles. Phase 1 of the Mental Health Curricula for Dietitians Project highlighted the importance of mental health issues across the spectrum of dietetic practice, identified the core knowledge and skills related to mental health required for early career practitioners and revised National Competency Standards for Entry Level Dietitians (ELC) to incorporate mental health. This project, the Mental Health Curricula for Dietitians Project: Phase 2 was designed to support the universities operating DAA accredited nutrition and dietetic programs in Australia to implement revised entry-level curricula and improve practical training in mental health. The project has provided the opportunity for DAA to share the process used to revise the competencies, develop tools and resources to assist with entry-level training and also provide continuing professional development for existing practitioners and dietetic educators. Project activities have included consulting with stakeholders; collecting information and resources for Mental and Health and Nutrition and Dietetic Information (MHANDi); developing teaching tools such as the Critical Incident Reflection Tool (CIRT), Mental Health and Wellbeing Decision Tree, cases studies and vignettes, Mental Health and Wellbeing Resources Package DVD & USB; and the national DAA Mental Health and Wellbeing Roadshow. The Roadshow provided an opportunity to showcase the resources and demonstrate their application. Consultation with key stakeholders was extremely productive. Feedback about the tools and resources has been very positive from the universities, steering committee and DAA Mental Health Interest Group (MHIG). The universities were very enthusiastic about the project resources and believed they will be useful in teaching and practicum. All universities could identify areas where they could incorporate the project tools and resources into their curriculum. Phase 2 of the Mental Health in Tertiary Curricula for Dietitians Project has provided the opportunity for DAA to develop mental health related tools and resources specifically for dietitians. This project has assisted stakeholder groups in a variety of ways. In particular, the tools and resources developed will help:

§ Universities implement the mental health content of the revised National Competency Standards for Entry Level Dietitians (2009).

§ Dietetic educators (clinical supervisors and educators) provide individualised practical training and assessment for dietetic students working with clients with mental health issues

§ Students and beginning practitioners build their knowledge and skills about working with clients with mental health issues by accessing MHANDi

§ Dietetic mentors to provide constructive feedback and mentoring with respect to mental health for beginning practitioners


§ Promote mentoring, continuing professional development and reflective practice in mental health throughout the dietetics profession.

§ Focus entry-level practitioners on holistic care by highlighting the importance of mental health in everyday dietetic practice,

§ Guide future professional development activities in mental health § Highlight areas where advocacy is needed for nutrition in mental health

This project has provided universities and the dietetics profession with innovative tools and resources to assist dietitians and dietetic students to work more effectively with clients with mental health issues. The project has also raised awareness about the importance of mental health issues in everyday dietetic practice. In the longer term it is anticipated that this will improve dietetic education and professional development and consequently nutrition services and outcomes for clients with mental health issues.


1.0 Introduction The 2006 Federal Budget included $1.9 billion for a mental health reform package to improve services for people with a mental illness, their families and carers. This funding also represented the Australian Government’s commitment to the Council of Australian Governments National Action Plan on Mental Health. As part of this package, the Mental Health in Tertiary Curricula Program included approximately $5.6 million over 5 years to enhance the mental health skills of the newly graduating health workforce by expanding the mental health components of undergraduate health training. The Dietitians Association of Australia (DAA) was previously funded under the Mental Health in Tertiary Curricula Program to identify the current and future needs of dietitians in relation to mental health issues; review Entry Level Competencies for Dietitians and supporting documents in relation to mental health; and review the DAA course accreditation requirements to include a minimum mental health component. A subsequent project, Mental Health Curricula Project for Dietitians: Phase 2, has been funded under the same Program through the Australian Government Department of Health and Ageing to share the learnings from the first project with other disciplines and to assist the universities operating the 17 nutrition and dietetic programs accredited by DAA in Australia to deliver revised curricula.

2.0 Aims & Objectives Project aims

• Develop tools to assist universities to implement the mental health content of the Entry Level Competencies for Dietitians.

• Develop the capacity of dietetic educators to provide practical training and assessment for dietetic students working with clients with mental health issues.

The project has addressed project aims and objectives and met all of the required project deliverables. The project was underpinned by a comprehensive implementation outlined in the flowchart on page 10. A summary of outcomes follows.


Table 1: Project objectives Objectives Outcome Identify and assess key materials to support entry-level dietetic training in mental health issues

MHANDi

Develop a sustainable delivery system for materials that is accessible and maintains currency

MHANDi

Develop and implement a reflective practice tool to support entry level dietetic practice with clients with mental health issues

CIRT Vignettes Vignette Scripts

Develop materials to enhance consumer engagement in entry level training and increase student understanding of engaging with consumers

Case studies MHANDi

Review data derived from critical incident interview to develop exemplar case studies about clients with mental health issues

Case studies

Identify practical strategies for entry level dietitians to use with clients and carers with mental health issues

Case studies MHANDi

Table 2: Project deliverables Deliverables Outcome Dynamic CD or web-based resource of user-friendly mental health and nutrition information, research and resource materials to be used for teaching, patient education and professional development

MHANDi

Practical training and assessment tools for dietetic students working with clients with mental health issues

CIRT, Case studies

Practical training and assessment methods for supervisors assessing student dietitians working with clients with mental health issues

CIRT, Case studies Mental Health & Wellbeing Roadshow

Resources to assist universities incorporate the revised mental health related content of the Entry level Competencies for Dietitians into entry level dietetic curricula

MHANDi Mental Health & Wellbeing Resources Package (Data stick including case studies, CIRT, Vignettes, Scripts & DVD of video clips)


3.0 Project Methodology 3.1 Background Following the success of Phase 1 of the Mental Health in Tertiary Curricula Project, a second project was planned to support universities operating nutrition and dietetic programs in Australia to implement the revised curricula requirements. In Phase 2: Mental Health Curricula Project for Dietitians the learnings from the first project were to be disseminated, and strategies implemented to address the development of competencies across the domains of clinical practice, community health and food service in classroom theory and on practical placement (also referred to as practicum), The flow chart below summarises the planned activities of the project. 3.2 Methodology Flow Chart


3.3 Data Collection and Review 3.3.1 Review of Phase 1 Materials One of the aims of this project was to utilise the rich data generated from Phase 1 and translate this information into tools and resources to assist universities training dietitians. Prior to collecting additional data, Phase 1 materials such as critical incident interview transcripts and analysis, stakeholder survey, scoping survey and steering committee minutes were reviewed. The Critical Incident interview transcripts in particular provided the basis for the development of the Critical Incident Reflection Tool (CIRT), case studies, vignettes and some of the practical tips and strategies. 3.3.2 Online Survey An online survey of DAA members was conducted (Mental Health Resources Survey) in October 2008 to determine whether the proposed Mental Health and Nutrition & Dietetic Information (MHANDi) webpage was required; and if it would be supported by members and universities. The survey also provided data to inform MHANDi design and delivery and engaged key stakeholders such as universities and the Mental Health Interest Group (MHIG). There were 230 survey responses, which represents a response rate of 6.5%. This response rate was double the previous survey and was slightly less than the average number of responses of online surveys conducted by DAA during the previous two years. Key results from the survey include:

- Over two-thirds of respondents reported their entry level preparation was poor or below average for dealing with mental health issues

- 82% of respondents indicated they worked in mental health. However, approximately half of respondents work less than four hours per week in the area.

- Depression remains the most frequent mental health issue that respondents encounter in their practice (two thirds of respondents encounter this issue in their practice frequently or very frequently).

- 87% of respondents feel they are not provided with adequate resources and training to effectively work with clients with mental health issues.

- Nearly three quarters of respondents who searched for nutrition and dietetic information related to mental health in the past year were only able to access some of the information they were searching for or not able to access what they were looking for easily.

- Respondents identified easy access to resources about nutrition and mental health issues (such as information on drug-nutrient interactions), practice guidelines, on-going research, journal articles and CPD workshops were essential supports for practitioners of all levels.

- 93% of respondents rated the proposed MHANDi resource as useful/very useful.

For a detailed summary of results refer to Appendix I


3.3.3 Literature searches Literature searches were conducted to inform the development of the Mental Health Resources Survey (refer to Progress Report 1, Appendix D1) and the structure and types of resources to be contained in MHANDi (refer to Progress Report 1, Appendix E1). Additionally, mental health and nutrition resources and literature were searched and collated as part of the development of MHANDi. The results of these searches are available on the MHANDi webpage on the DAA website. See Appendix II. 3.3.4 Consultation with Key Stakeholders Consultations with stakeholders in universities, the steering committee and practitioners in the DAA Mental Health Interest Group were a key part of the project. Stakeholders have provided valuable feedback about draft resources and the direction of the project. Engaging key stakeholders to support and adopt project resources was an effective strategy to increase the reach of the project. For a more detailed discussion of each consultation refer to Progress Report 2. Steering Committee The steering committee provided feedback on project progress and resources at three intervals, including a face-to-face meeting in late January 2009. Key feedback from the committee included:

- Using the term ‘mental health and wellbeing’ and focusing on wellbeing rather than mental illness

- Ensure clients in the case study examples are not identified as their diagnosis - Reducing the number of MHANDi sections to ensure project met deadlines - Practical tips and strategies for working with clients with mental health issues,

in particular, focusing on the importance of listening and ‘just being there’ for clients

- Feedback from roadshow participants indicated that dietitians need more training in practical strategies for working with clients with mental health issues. The steering committee considered the following ideas for future projects:

o Review and expand the MIND Essentials resource (Hunter Institute of Mental Health). This resource focuses on practical information and strategies for nurses but could be extended to cater for allied health professionals. The resource could then be the basis for multidisciplinary training workshops to facilitate interdisciplinary communication and networks.

o Consider ways to effectively communicate and work with key stakeholders of the mental health team on a national, state, community level to advocate for expansion of the nutrition workforce in mental health and highlight the contribution that dietitians make to mental health care.


o Extend the skills and knowledge of mental health team members about the role of nutrition in mental health. In the first instance, it might be possible to develop a program of ‘Nutrition First Aid’ based on the concepts of Mental Health First Aid.

o Consider ways to advocate to other members of the mental health team, including general practitioners and psychiatrists, about when and how to refer clients on mental health medications to dietitians.

Mental Health Interest Group (MHIG) The DAA Mental Health Interest Group was formed as a result of the first Mental Health in Tertiary Curricula for Dietitians project. The Project Officer has worked with the MHIG to promote the project and develop the online survey and MHANDi. Key outcomes of this collaboration include:

- Collation of resources for MHANDi (e.g. professional development section, useful links section)

- Development of resources for MHANDi (e.g. documents such as ‘Nutritional implications of mental health medications’ and ‘Nutrition issues and mental health’)

- Review of resources for MHANDi (e.g. review of practical tips and strategies) - Promotion of roadshow to MHIG members and DAA members resulting in

over 500 roadshow registrations - Mental Health First Aid professional development sessions - Establishing a committee member position for MHANDi to ensure its long

term viability - Planning and prioritising the development of future MHANDi resources (e.g.

research updates and nutrition resources for case workers).

Universities Teleconferences were held in February to gain feedback from the universities about the pilot tools (MHANDi, Critical Incident Reflection Tool, Mental Health & Wellbeing Decision Tree, Case Studies and Vignettes) and the design of the Mental Health and Wellbeing Roadshow. Universities were enthusiastic about the project resources and believed they would be useful in teaching and practicum. All universities identified areas where they could incorporate the project tools and resources into their curriculum. Key feedback from the universities included:

- MHANDi will be a great resource for students, universities and the profession - CIRT will be a useful tool for student and supervisors on placement (with

some minor amendments). Several universities expressed interest in being involved in trialling and evaluating the tool.

- Mental Health and Wellbeing Decision Tree will be useful as a teaching tool in conjunction with the case studies. Several constructive suggestions were


made about the order of decision tree. The project team has incorporated these suggestions in the final version of the tool.

- The case studies will be useful to highlight mental health issues in subjects such as Nutritional Counselling or Communication or Dietetics. Most stakeholders were pleased with format of the cases. Some stakeholders preferred more detail. The cases have been revised to incorporate this feedback.

- The Mental Health and Wellbeing Roadshow will be a valuable activity for all dietitians to attend, in particular supervisors and students. Universities were committed to promoting the event throughout their networks.

- Create a DVD/webpresent of the roadshow so that universities can run training sessions with their students.

3.4 Resource Development The Mental Health and Wellbeing Resources Package consists of:

1. Case studies including questions to stimulate discussion 2. Mental Health and Wellbeing Decision Tree 3. Critical Incident Reflection Tool 4. Critical Incident Audio Vignettes 5. Short video clips of mental health consumers speaking about their experience

with mental illness (DVD) 6. Audio presentation (Webpresent) of the Mental Health & Wellbeing Roadshow

session 7. MHANDi - Mental Health and Nutrition and Dietetic Information

The majority of these tools were developed from data collected in Phase One. Consultations with key stakeholders as described above, informed the development, review and promotion of the tools. These tools are intended for use during classroom teaching, practicum and professional development. A limited quantity of USB (data) sticks & DVDs containing resources 1-6 will be provided to universities, DAA branches and DAA members. In addition, these resources will be available to download via MHANDi on the DAA webpage. It is anticipated the tools of the Mental Health and Wellbeing Resources Package will enable students, dietitians who mentor, supervise or teach students and entry level dietitians to work more effectively with clients with mental health issues. A discussion of each of the individual components of the package follows.


3.4.1 Case Studies Ten case studies (refer to Appendix III for example cases) provide a set of realistic examples for students to explore the implications of mental health issues on nutrition therapy in a classroom setting and also gain practice applying the Mental Health and Wellbeing Decision Tree and CIRT. The aim is to teach students and entry level practitioners about decision making and reflective practice so they are empowered to work more effectively with clients with mental health issues. The case studies highlight a range mental health and nutrition issues in a variety of settings (e.g. hospital inpatients and outpatients, community health, home visits and private practice) with a variety of clients (teenager, adult, elderly, clients from Aboriginal and Torres Strait Islander background, culturally and linguistically diverse backgrounds, low income or living on a pension, and a carer). The case studies are based on situations shared by new graduates in the Critical Incident Interviews in Phase 1. The cases highlight the importance of holistic care, by focusing on mental health and wellbeing and client interaction rather than medical nutrition therapy. The case studies include questions to stimulate group discussion about mental health and wellbeing issues, answer prompts and links to relevant resources such as video clips, MHANDi and MIND Essentials. As each university has different course structure, these case studies will assist universities integrate mental health issues into their curriculum in a way to suit their needs. They are designed so that they can be used either in a classroom setting in clinical nutrition or nutrition counselling/communication subjects or in a tutorial setting on practicum. The cases can also be combined with film clips, Mental Health and Wellbeing Decision Tree and Critical Incident Reflection Tool if preferred. The key innovation of these case studies is the practical focus on ‘social, mental health and wellbeing issues’. The aim of which is to promote holistic care for all clients, not just clients with diagnosed mental health issues. These case studies also provide an example format for universities wishing to develop additional mental health and wellbeing cases studies in the future.


3.4.2 Mental Health and Wellbeing Decision Tree The aim of the Mental Health and Wellbeing Decision Tree is to develop entry level dietitian’s decision making skills in cases involving mental health and wellbeing issues. It focuses practitioners on the client’s needs whilst ensuring they remain within their scope of practice. Refer to Appendix IV for a copy of the tool. The tool was developed from the DAA Scope of Dietetic Practice Decision Tree (DAA, 2006). An additional tool was required because the existing decision tool did not help practitioners to decide what they could do practically to assist clients with mental health issues, whilst still remaining within their professional scope of practice. The tool is holistic in nature and focuses on mental health and wellbeing, rather than mental illness. For example, it can help inexperienced dietitians decide how they can help a client who may be temporarily experiencing a mental health issue or dealing with difficult life circumstances, whilst still remaining within their dietetic scope of practice. The decision tree is designed to be used in conjunction with the DAA Scope of Practice Decision Tree, CIRT and case studies. Feedback about the tool from roadshow respondents indicates the tool will be useful for student and entry level practitioners, because more experienced practitioners intuitively follow the decision making process of the tool. In particular, the tool will assist beginning practitioners evaluate their case management skills in complex cases involving mental health and wellbeing issues. Evaluating the effectiveness of this tool is not in the scope of this project.


3.4.3 Critical Incident Reflection Tool The Critical Incident Reflection Tool (CIRT) provides a way for students (or entry level dietitians) and their supervisors to debrief about working with clients with mental health issues in a practical empowering manner. It is a structured debriefing tool which enables practitioners to distinguish their underlying knowledge and skills with respect to mental health and also identify gaps and support needs. Refer to Appendix V for a copy. The CIRT was adapted from the critical incident interview schedule developed by Patricia Benner in the mid 1980’s. Benner, a nursing researcher, pioneered this approach, which is used throughout the health sciences to distinguish the features of competent practice. This technique is used to bring to the surface ‘tacit knowledge’, that is, knowledge, techniques and attitudes that underlie performance but cannot be easily explained or identified by practitioners (Ash et al, 1992). After developing the CIRT and modifying it based on feedback from the steering committee, the tool was piloted with nine QUT students and their supervisors during February – April 2009. Focus groups were held with students during and after their practical placements. Initial feedback indicated that the students felt the tool was beneficial, but they needed more explanation about when to use the tool. After completing their practicum the students indicated that they found the tool very useful towards the end of their placements. In particular, they found it opened up new areas of feedback with their supervisors. The student’s main recommendation was to ensure the tool is incorporated into assessment. Appendix V contains summary of the benefits the tool provides for each of the relevant user groups. The key difference of the CIRT to other debriefing tools is that it focuses on the dietitian’s experience of the session/situation prior to evaluating the case and client management. It allows practitioners to express their feelings and emotions about a situation which may have been challenging, confronting or distressing before reflecting on nutrition care plan and client interactions. Reflective practice is an important part of professional practice and case management. Students and practitioners are skilled at identifying where they ‘went wrong’ or how they can improve their practice, however, they are not as proficient at identifying what they do well. Therefore, the CIRT does not focus on what ‘went wrong’ because this information is always shared in the course of the discussion (without the supervisor asking). The CIRT can be applied to a variety of cases and situations, not just those involving mental health issues. The broad applicability of the tool will promote the adoption of the tool by students, universities, entry level practitioners and experienced dietitians.


The CIRT will be a valuable addition to practical training for students and supervisors and create opportunities for dialogue about working with clients with mental health issues. This tool will also be useful in mentoring, in particular for beginning practitioners participating in the provisional Accrediting Practicing Dietitian program. Feedback from roadshow indicated that the CIRT will also be useful for dietitians in private practice as a self-reflection tool. The CIRT will be evaluated by the project team in a follow-on project. 3.4.4 Critical Incident Audio Vignettes & Scripts The Critical Incident Audio Vignettes are short (3-4 minute) audio clips demonstrating how to use the CIRT. The vignettes are based on the transcripts of the Critical Incident Interviews conducted in Phase 1. Volunteers (QUT students and DAA members) were recruited through Expression of Interest emails to participate in taping the vignettes. The ten vignettes were recorded in February at QUT by QUT Teaching and Learning Support Services. The audio vignettes have two aims. Firstly, to demonstrate how easy the CIRT is to use, by providing examples of students and supervisors using the tool to debrief. Secondly, the vignettes provide examples about how a beginning practitioner may feel after experiencing a challenging situation with a client with mental health issues. The accompanying vignette scripts give suggestions about how mentors may be able to provide support. Refer to Appendix VI for an example of a vignette script with prompts for mentors. In particular, the clips will be useful for mentors and beginning practitioners/students who were not able to attend the Mental Health and Wellbeing Roadshow The vignettes will be available for download via the MHANDi webpage and on the USB stick. Promoting the CIRT is a key strategy to help improve reflective practice and professional development in mental health. The vignettes will be a useful promotional tool to demonstrate how easy and time efficient the tool is to use.


3.4.5 Short Video Clips (DVD) Feedback from university stakeholders highlighted the importance of using a variety of media to assist teaching regarding mental health. In particular, it was identified that short video clips about signs and symptoms of common mental illnesses and consumers talking about their experiences living with mental illness would be useful teaching tools. Therefore, a variety of clips were sourced from non-government organisations based in Australia (Beyond Blue and SANE) and overseas (Freedom from Fear [US]; Like Minds, Like Mine [NZ]). Permission was obtained from Beyond Blue and SANE to reproduce the clips onto a DVD for teaching purposes. This DVD will be distributed to universities with the Mental Health and Wellbeing Resources Package USB stick. These clips will also be available for download via the MHANDi website. In addition, MHANDi will also contain links to video clips from relevant websites. To maintain currency, the links on the MHANDi website will be reviewed and updated on an annual basis. 3.4.6 Webpresent - Audio Presentation of Roadshow Session A web-present is a combination of audio recording of a session that is synchronised with the PowerPoint presentation. Members who could not attend the Mental Health and Wellbeing Roadshow expressed interest in accessing a copy of the web-present for this session. Universities also believed it would be a useful resource for teaching as well. Some universities are planning to use the resource to run their own version of the roadshow with their students. The value of the web-present, is that it expands the reach of the roadshow and also provides a permanent resource for members to access. In particular, the descriptions of how to use the Mental Health and Wellbeing Decision Tree and Critical Incident Reflection Tool will be particularly useful for beginning practitioners and mentors. 3.4.7 MHANDi Mental Health and Nutrition and Dietetic Information (MHANDi) has been a joint initiative of the Mental Health Curricula Project and the Mental Health Interest Group (MHIG). MHANDi is a dynamic knowledge network about mental health for dietitians, universities and nutrition and dietetic students. MHANDi is designed to be an “ongoing work in progress” which relies primarily on the contribution of members. It is located on the DAA website on the MHANDi page.


Development of MHANDi MHANDi has evolved from an idea to a dynamic resource in less than twelve months. Results from the 2008 Mental Health Resources Survey highlighted that easy-to- access, relevant information about nutrition and mental health were not readily available to DAA members.After conducting an online survey, a literature search was carried out to inform MHANDi design. Refer to Progress Report 1, Appendix E1 for further details. Subsequently, it was decided MHANDi be a web-based information knowledge network located on the DAA website. Refer to Appendix VII for access details. Initially, MHANDi was planned to encompass six major topics as shown in the illustration below. The current MHANDi resource is not as extensive as originally proposed, because it was not feasible to create such an extensive resource from scratch within the tight project timeframes and limited volunteer resources. Therefore, after the first steering group teleconference, MHANDi was scaled back to include four major sections: 1. Understanding mental health 2. Services and resources 3. Learning tools 4. Professional development opportunities Members from the MHIG assisted with resource collection, creation and review in sections 1, 2 and 4. Refer to Progress Report 2 for further detail about this process. Section 3 contains the tools of the Mental Health and Wellbeing Resources Package. This version of MHANDi will provide dietitians with a wealth of information that they have not previously had access to. Feedback from the universities indicates that this version of MHANDi will be an extremely valuable tool for students, staff and dietitians. Following is a brief outline of each section: Understanding mental health The information in this section gives a broad overview of issues related to mental health. It is not intended to be a substitute for lecture content. Topics in this section include:

§ Mental health issues in Australia § Nutrition issues and mental health (including the impact of medications) § The mental health care team & referrals § Practical strategies and tips


Services & resources (by state) This section has the following information for each state and territory:

§ Mental health emergency contacts § Links to government and non-government mental health services; § Links to descriptions of state mental health systems, programs and policies § Links to nutrition/ lifestyle programs for mental health consumers

Learning tools This section contains the tools of the Mental Health and Wellbeing Resources Package which includes:

§ Mental Health and Wellbeing Decision Tree § Critical Incident Reflection Tool (CIRT) § 10 x audio Critical Incident Vignettes (CIV) § 10 x CIV scripts with mentoring prompts § Film clips of consumers discussing their experiences of living with mental

illness § 10 x case studies with questions and learning prompts and links to resources

Professional development opportunities § CPD Sessions (sessions or courses less than 1 day); § Short Courses § Tertiary courses § E-learning / web based learning § Mental Health related conferences

Useful mental health and wellbeing links This section contains over 30 categories of links to information on variety of mental health and related issues including:

§ Anxiety, Bipolar Disorder, Depression, Schizophrenia, Suicide and Dementia § Domestic Violence, Substance Abuse, Homelessness, Food Security &

mental health, Palliative Care, Trauma & Torture § Aboriginal and Torres Strait Islanders, Multicultural Mental Health and much

more. MHANDi in the future It is anticipated that information about research and evidence (section 6) and mental health and dietetic practice (section 7) will come online in the next 12 – 18 months. A MHIG volunteer is currently collating journal articles into a database and this facility is expected to be available by the end of 2009. The MHIG is also plans to develop resources aimed at consumers in the future. Sustainability issues In total, the MHIG has allocated three dedicated volunteers to MHANDi including: 1. MHANDi coordinator (committee member) 2. Research coordinator (committee member)


3. MHANDi assistant coordinator Two out of the three positions report directly to the Interest Group committee, which meets on a monthly basis. This structure will provide volunteers with support and a reporting mechanism to ensure MHANDi is reviewed on an ongoing basis. For the next twelve months, the project officer will continue as the MHANDi coordinator on a volunteer basis. In that timeframe she will train the assistant coordinator, who will then fill the MHANDi coordinator position. The MHIG and the Project Team have highlighted the need to monitor the viability of volunteers maintaining the webpage. It is suggested that the MHIG undertake a brief review after 12 – 18 months of maintaining MHANDi. In the medium term, the MHIG has indicated they may apply for grants to assist with the maintenance and expansion of the webpage. Over the long term, it may be necessary to source ongoing funding or affiliation with a university or research centre, as discussed in Progress Report 2. Difficulties & action to overcome difficulties As mentioned previously, the scope of the MHANDi resource was underestimated by the project team. In particular, many resources included in MHANDi had to be developed from scratch. As such, parts of the MHANDi webpage are still under construction. In particular, the Understanding Mental Health and Learning Tools sections still have resources to be uploaded in the near future. It is anticipated these sections will be completed by the end of June 2009. As discussed earlier, MHANDi has been designed and promoted as an “on-going work in progress”. MHANDi is live and DAA members are able to access the information currently available 3.4.8 Mental Health and Wellbeing Roadshow The Mental health and wellbeing is every dietitian’s business roadshow was held in seven capital cities throughout Australia during late April 2009. The event was a practical session aimed at all members, because mental health issues are a part of everyday dietetic practice. However, the key target audience was dietitians who mentor, supervise or teach students. To maximise attendance, the event was promoted to all DAA members, because most dietitians mentor, supervise or teach students. Development The aim of the roadshow was to demonstrate to participants how to use the tools of the Mental Health and Wellbeing Resources Package to enhance reflective practice and professional development in mental health. Therefore the majority of the session involved practical activities using the tools of the package.


Feedback from key stakeholders (DAA members in the online surveys, new graduates, Mental Health Interest Group and universities) also indicated that it was important to include an information based section about a mental health topic. Therefore, an introductory session of Mental Health First Aid was been included to raise awareness about a valuable training opportunity. Refer to Appendix VIII for a copy of the roadshow PowerPoint presentations and session plan. Promotion for the roadshow commenced in mid February via DAA national and state weekly email newsletters. Teaser lines such as “Have your sessions been sidetracked because a client is unresponsive or appears depressed?” were very effective in promoting the session to a wide variety of participants. Special emails before the registration closing date were also important reminders. The roadshow was featured on the cover of the DAA March newsletter and universities promoted the roadshow to their supervisor and student networks. Evaluation The Mental health and wellbeing is every dietitian’s business roadshow was the most successful DAA national roadshow to date. Over 500 participants registered with over 95% of registrants attending the sessions. This response was double the forecasted figures for attendance. In addition, evaluation data from 369 participants (response rate, 75%) indicates that over 40% of roadshow participants either work in a university or supervise or mentor students. Overall, this was a very successful result and indicates the interest dietitians have in mental health and that the project reached the target audience. A variety of delivery methods including a case study, small group discussion, large group discussion, role plays, audio and video clips as well as lecture style presentation. The combination of these methods resulted in an interactive session that participants commented was “very well organised and interactive”. In particular, participants found the case study, group work and role play activity useful.


Overall, participants rated the roadshow 7.7 on a scale of 1-10, with 10 being excellent. Unsurprisingly, MHANDi rated as the most useful tool (8.5/10) followed by the Critical Incident Reflection Tool (7.9/10). Participants intended to use both these tools in their practice in the future. Table 2: Summary of Evaluation Results from Mental Health & Wellbeing Roadshow

Location CIRTDecisionTree Case Vignette MHANDi MHFA Overall

Brisbane 7.7 6.7 6.8 6.7 8.3 7.1 7.3Hobart 7.8 6 7.7 7.3 8.5 7.8 8.1Melb 8.1 6.9 7.8 7.4 8.2 5.4 7.7Sydney 7.8 7.1 7.7 7.6 8.6 8.7 7.8Canberra 7.7 6.9 7.7 7.4 8.5 8.3 7.5Adelaide 7.6 6.8 6.8 6.9 8.8 8.2 7.5Perth 8.3 7.5 7.5 7.3 8.5 8.4 8.1

7.9 6.8 7.4 7.2 8.5 7.7 7.7 Evaluation results were reviewed immediately to improve the following day’s session. After the Brisbane session, feedback indicated that the participants felt the session was too rushed and did not focus enough on practical strategies. Therefore, the session was modified to focus on two questions from the case study rather than the five questions that were initially planned. Also, more time was allotted to discuss practical strategies. Mental Health First Aid (MHFA) presenters also modified their presentation to include a practical activity. The improvement in evaluation results for the MHFA towards the end of the roadshow reflects these changes. Overall, participants reported that the roadshow sessions, were useful despite not being what they expected. In particular, dietitians in private practice (not supervising students) were expecting more focus on advanced management strategies for clients with mental illness. This is an area which requires more attention; however it was not in the scope of this project. However, private practitioners were impressed by the flexibility of the CIRT and its usefulness as a self reflection tool. Participants also noted that it would be great if it were possible to hold a Mental Health and Wellbeing Roadshow on an annual basis. Difficulties & action to overcome difficulties As discussed in Progress Report 2, the tight project timeframes did not allow for visits to Darwin and other regional centres such as Wollongong. Videoconferencing was planned as a substitute for the Roadshow but it became apparent that this style of presentation would not suit the interactive nature of the presentation. However, the Mental Health and Wellbeing Resources Package USB contains a web-present session of the roadshow along with additional resources. Therefore, branches, workplaces and individuals will have the resources necessary to experience a version of the roadshow themselves.


3.5 Dissemination Dissemination of Phase 1 Outcomes Dissemination of Phase 1 project outcomes has occurred throughout the course of this project. Key activities included:

• Articles in DAA National Newsletter • Teleconferences sessions with each university • Summary emails to Mental Health Interest Group members • Newsletter article to Mental Health Council • Launch of Revised Competency Standards for Entry-Level Dietitians at DAA

2009 Conference Other activities planned include:

• A poster presentation at the 10th International Mental Health Conference (August 2009)

• Presentation at the Allied Health Professions Australia Conference (October 2009)

• Submission of journal articles for publication (2009) Dissemination of Phase 2 Outcomes Dissemination of Phase 2 outcomes have primarily occurred during the project. Key activities include:

• Mental Health and Wellbeing Roadshow • Poster presentation at the DAA 2009 Conference • Articles in DAA National Newsletter • Teleconferences sessions with each university

Other opportunities for dissemination will occur after the project completion, including:

• Article in DAA National Newsletter • Article in Mental Health Council Newsletter • Letter to each university summarising project outcomes and distributing the

Mental Health and Wellbeing Resources Package • Summary report to Mental Health Interest Group members via the List –Serve • Presentation at the Allied Health Professions Australia Conference • Submission of journal articles for publication (2010) • Presentation at the Allied Health Educators Conference (2010)

Additional opportunities for dissemination of project results will arise, after project tools and resources are evaluated,


4.0 Deliverables 4.1 Deliverable one Dynamic CD or web-based resource of user-friendly mental health and nutrition information and resource materials to be used for teaching, patient education and professional development. The development and implementation of Mental Health and Nutrition and Dietetic Information (MHANDi) webpage is a significant achievement of the Mental Health Curricula Project (Phase 2) and the DAA Mental Health Interest Group. MHANDi is a dynamic knowledge network about mental health for dietitians, universities and nutrition and dietetic students. MHANDi is designed to be an “ongoing work in progress” which relies primarily on the contribution of members. It is located on the DAA website on the MHANDi page. See Appendix VII MHANDi will not be as extensive as originally proposed, due to tight project timeframes and limited volunteer resources. Therefore, the current version of MHANDi includes five sections:

• Understanding mental health • Services and resources • Learning tools • Professional development opportunities • Useful mental health and wellbeing links

This version of MHANDi will provide dietitians with a wealth of information to which they have not previously had access. Feedback from the universities and DAA members indicates that this version of MHANDi will be an extremely valuable tool for students, staff and dietitians. It is anticipated that information about mental health and dietetic practice and research and evidence will come online in the next 12 – 18 months. A MHIG volunteer is currently collating journal articles into a database and this facility is expected to be available by the end of 2009. The MHIG is also plans to develop resources aimed at consumers in the future. Below is an illustration of what MHANDi will evolve to in the future.


4.2 Deliverable two Practical training and assessment tools for dietetic students working with clients with mental health issues A suite of training and assessment tools have been developed for dietetic students working with clients with mental health issues. (For further discussion refer to Deliverable Four on page 28). These tools include:

- Case studies - Mental Health and Wellbeing Decision Tree - Critical Incident Reflection Tool

In particular, ten case studies covering a range of mental health issues including depression, bipolar disorder, schizophrenia and dementia (refer to Appendix III), provide a set of realistic examples for students to explore the implications of mental health issues on nutrition therapy. These case studies are designed to be applied with the Mental Health and Wellbeing Decision Tree and the Critical Incident Reflection Tool in a classroom or practicum tutorial setting. The aim is to teach students and entry level practitioners about decision making and reflective practice so they are empowered to work more effectively with clients with mental health issues. The key innovation of these case studies for nutrition and dietetics is the practical focus on ‘social, mental health and wellbeing issues’. The aim of which is to promote holistic care for all clients, not just clients with diagnosed mental health issues. It is also anticipated that universities will use these case studies for assessment purposes. The Mental Health and Wellbeing Decision Tree is a practical tool which supports students’ clinical decision making. It is intended to be implemented prior to practicum, to help prepare students for situations they may encounter when working with clients with mental health issues. It is envisaged this tool will also be useful during practicum when students and supervisors debrief about demanding cases involving mental health issues. The tool can assist students identify areas where their case management skills (from a holistic / mental health and wellbeing perspective) could be improved. The Critical Incident Reflection Tool was also developed to assist practical training for students and beginning practitioners working with clients with mental health issues and also support supervisors and mentors. A discussion follows in the next section.


4.3 Deliverable Three Practical training and assessment methods for supervisors assessing student dietitians working with clients with mental health issues. The Critical Incident Reflection Tool (CIRT) was developed to improve practical training and assessment for students and supervisors working with clients with mental health issues. Much of the learning in professional training occurs on practical placements, where students have to apply and translate the knowledge and skills they learn in coursework to situations with individual clients. The revised National Competency Standards for Dietitians (2009) do not require this because working with clients with diagnosed mental health issues is an advanced specialist practice area. It is not feasible to expect beginning practitioners acquire specific clinical skills for working with clients with mental health issues. However, it is feasible and necessary for beginning practitioners to learn how to apply their existing knowledge and skills (particularly in communication and nutritional counselling) when mental health issues may arise in general dietetic practice. The CIRT is a tool that assists students and supervisors debrief and reflect on situations involving mental health issues. Debriefing and reflective practice are common strategies used in professional training to help students consolidate knowledge, transfer knowledge from supervisor to student and informally assess student learning and competence. Cases that involve mental health issues are usually complex and require more advanced case management skills. Invariably students/beginning practitioners require additional support and training when working with these clients. The CIRT provides a structured efficient way to conduct an in-depth debrief, whilst also consolidating existing knowledge and transferring knowledge from supervisor to student. The CIRT is differs from existing debriefing methods in that it allows students to express their feelings and emotions about a situation prior to evaluating the case management aspects of the case. It focuses on eliciting student’s underlying skills and knowledge and then integrating new knowledge (e.g. suggestions from the supervisor) with the student’s existing knowledge. The CIRT is also a practical reflective practice training tool. Reflective practice is a key skill which enables students to make the transition to entry-level practitioner and beyond. Students who find reflective practice difficult can use this tool to help guide their personal reflective practice. Reflective practice is an important skill when working with clients with mental health issues, because each situation and client is very individual, so the ‘one-size fits all’ approach is not appropriate. For example,


reflective practice is useful for students to identify situations where the most appropriate action for a client may be to refer them to a psychologist or their doctor for treatment of their mental health issues. Beginning practitioners sometimes do not have the clinical judgement (which is only gained with experience and reflective practice) to realise this. In summary, the CIRT is a practical training tool for students and supervisors in working with clients with mental health issues. The CIRT debrief can also be used to gauge a student’s competence with managing a client with a mental health issue. Additionally, the CIRT is also useful tool for practitioners generally working with clients with mental health issues. 4.4 Deliverable Four Resources to assist universities incorporate the revised mental health related content of the Entry Level Competencies for Dietitians into entry level dietetic curricula. Mental Health and Wellbeing Resources Package A suite of tools and resources has been developed and collated to assist universities incorporate the mental health related content into entry level dietetic curricula. These resources include:

- Case studies (with questions, discussion prompts and links to relevant resources)

- Mental Health and Wellbeing Decision Tree - Critical Incident Reflection Tool - Critical Incident Audio Vignettes - Vignette Scripts with prompts for mentors - Film clips of consumers speaking about their experience of mental illness - MHANDi webpage which incorporates links to information and resources

about mental health issues, practical strategies and tips for working with clients with mental health issues and information about advocacy strategies

These tools will be used in classroom teaching, practicum and professional development. The resources will be provided to universities on a DVD (film clips) and USB data stick (remaining resources) and via MHANDi on the DAA webpage. As each university has different course structure, the various tools and resources provide universities the flexibility to integrate mental health and wellbeing into their existing curriculum, as appropriate. All universities have indicated areas where they could incorporate the project tools and resources into their curriculum. To promote and assist the implementation of these tools, the ‘Mental Health and Wellbeing is every dietitian’s business’ training roadshow was held in capital cities throughout Australia. The aim of the roadshow was to demonstrate to participants (particularly dietitians supervising or mentoring students and universities) how to use the tools of the Mental Health and Wellbeing Resources Package to enhance reflective practice and professional development in mental health. With over 500 participants, it was the most successful DAA national roadshow to date.


5.0 Conclusion Phase 2 of the Mental Health in Tertiary Curricula for Dietitians Project has provided the opportunity for DAA to develop mental health and wellbeing related tools and resources specifically for dietitians. This project has assisted stakeholder groups in a variety of ways. In particular, the tools and resources developed will help:

§ Universities implement the mental health and wellbeing content of the revised National Competency Standards for Entry Level Dietitians (2009).

§ Dietetic educators (clinical supervisors) provide individualised practical training and assessment for dietetic students working with clients with mental health and wellbeing issues

§ Students and beginning practitioners build their knowledge and skills about working with clients with mental health and wellbeing by accessing the MHANDi webpage

§ Dietetic mentors to provide constructive feedback and mentoring with respect to mental health and wellbeing for beginning practitioners

§ Promote mentoring, continuing professional development and reflective practice in mental health and wellbeing throughout the dietetics profession.

§ Highlight the importance of mental health and wellbeing issues in everyday dietetic practice, focus entry-level practitioners on holistic care

§ Guide future professional development activities in mental health and wellbeing

§ Highlight areas where advocacy is needed for nutrition in mental health and wellbeing

6.0 Recommendations Recommendations arising from the project include the following: Project resources

§ DAA undertake a comprehensive communication strategy to promote the Mental Health and Wellbeing Resources Package to universities, dietetic educators and clinical supervisors

§ DAA consider ways of incorporating the Critical Incident Reflection Tool into DAA programs, such as the Accredited Practising Dietitian program, and in DAA publications, such as the Private Practitioner’s Manual.

§ DAA continue the development of MHANDi to facilitate ease of access to resource materials.

§ DAA reviews how the Mental Health Interest Group may contribute to the long term sustainability of MHANDi, and what resources will be needed to maintain and expand MHANDi.


Evaluation/Research § DAA support the evaluation of the tools of Mental Health and Wellbeing

Resources package, in particular the Critical Incident Reflection Tool, MHANDi and the Mental Health and Wellbeing Decision Tree.

Further training and professional development

§ DAA continue professional development opportunities in mental health for existing practitioners, particularly around practical strategies for working with clients with mental health issues and specific nutritional management issues for clients with mental illness.

§ DAA promotes Mental Health First Aid as a valuable training opportunity for dietitians

§ DAA undertake multidisciplinary training initiatives such as joint professional development sessions with other allied health professions (such as social work and occupational therapy).

§ DAA supports members with an interest in mental health and wellbeing by continuing to support the DAA Mental Health Interest Group.

Advocacy and workforce development

§ DAA advocates for the role of dietitians in mental health care via national, state channels.

Dissemination

§ DAA continues to consolidate links with the mental health sector through participation in the Mental Health Council of Australia.

§ DAA disseminates the experience gained during the project, and the outcomes of the process, to key stakeholders in the mental health sector and in other health disciplines.


7.0 References Ash, S., Gonzi, A. & Hager, P. (1992). Combining research methodologies to develop competency-based standards for dietitians: a case study for the professions. National Office of Overseas Skills Recognition Research Paper No. 6, DEET. Canberra: Australian Government Publishing Service. Dietitians Association of Australia. (2008). Mental Health in Tertiary Curricula Project: Phase 2 Progress Report 1. Canberra: DAA. Dietitians Association of Australia. (2009). Mental Health in Tertiary Curricula Project: Phase 2 Progress Report 2. Canberra: DAA. Dietitians Association of Australia. (2009). National Competency Standards for Entry Level Dietitians 2009. Canberra: DAA. Dietitians Association of Australia. (2006). Scope of Dietetic Practice, September. 2006. DAA. URL (accessed May 30, 2009).

Documents

Mental Health in Tertiary Curricula for Dietitians: Phase 2 · Consultant Dietitian B. Health Sc (Nutr&Diet) (Hons); B. Bus (Mktg) Project Managers: Dietitians Association of Australia