A Shared Mental Health Care Model at Whitehorse Hospital, Yukon:
A First Nations and Medical Perspective

T. Lynn Scott
R.N., Scarborough Regional Nursing, Centennial College, 1975
B.S.W., Ryerson University, 1996

Thesis Submitted in Partial Fulfillment Of
The Requirements For The Degree Of
Master of Social Work

The University of Northern British Columbia
October 2008

© T. Lynn Scott, 2008

1*1

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ii

ABSTRACT
This research presents a Shared Mental Health Care model for Whitehorse General
Hospital that successfully merges medical and Aboriginal health and healing practices within
the mental health program. This blended model encourages a collaborative approach that
supports the key concepts and principles of the national Shared Care model. This research
explores the Whitehorse Hospital mental health program from employee participant views,
perspectives, and experiences. A significant number of strengths are identified within the
mental health program, along with suggestions for change and improvement. Results are
descriptive in nature and positively reflect on program components. The research reveals that
a collaborative Shared Care model does operate successfully at Whitehorse Hospital, and
complements the medical and First Nations programs, as the way forward.

iii

TABLE OF CONTENTS
Abstract

11

Table of Contents

in

Chapter One

Chapter Two

Introduction

1

Purpose and Objectives of Research Study

2

The Personal Context
Role of Whitehorse General Hospital
Chapter Outlines

3
4
4

A Review of the Literature
Shared Mental Health Care
Historical Background
Collaborative Mental Health Care
Other Shared Mental Health Care Models
Shared Mental Health Care Reform
Barriers to Implementation of Shared Mental Health Care
Shared Mental Health Care Key Concepts
Collaboration
Support and education
Maximizing resources in underserved populations
Case management
Implementation Shared Care Projects and Initiatives
Shared Care in Aboriginal/Northern Territorial Communities
Aboriginal Health and Healing
Historical Background
Barriers to First Nations Health Practices
Key Concepts of the Aboriginal Model
Holistic health and healing
Aboriginal world view
Collaboration and consensus
Aboriginal healing methods and practices
Holistic Health and Wellness Frameworks
Integration of Aboriginal and Medical Models

7
7
10
11
12
14
15
15
17
19
20
21
24
25
25
28
29
29
30
31
31
33
34

Chapter Three

Whitehorse General Hospital

39

Chapter Four

Methods
Purpose and Objectives of Research Study
Participant Sample
Interview Sites
Data Interview Process
Data Collection
Demographics

45
46
46
47
48
53
53

iv

Focus groups and individual interview methods
Methological Design Changes
Data Analysis Process
Trustworthiness of Results and Conclusions
Ethical Considerations

55
60
61
62
65

Chapter Five

Results
67
Matrix # 1: Key Themes by Model
67
Matrix # 2: Key Themes by Model and Discipline
70
Matrix # 3 : Vision Statement Results
75
Vision Statement Priorities
78
Matrix #4: Comparison of Key Concept & Vision Statements 79
Comparison of Discipline Groups
82
Collaboration and communication
82
Expanded mental health program
83
Support and education
83
Safety issues
84
Possible Limitations of the Data Results
85
Shared Mental Health Care Vision at Whitehorse Hospital
87
# 1 : Collaboration
88
# 2: Holistic health, healing, and methods
90
# 3: Separate mental health unit/day hospital/outpatient clinic 91
# 4: Expanded mental health program
92
# 5 : Support and education
93
# 6: Case management and Shared Care plans
94
# 7: Other priorities
95

Chapter Six

Implications for Social Work Practice
Common Themes in the Research
Collaborative and Holistic Health Approach to Social Work
Personal and Professional Impact of Research
Research Implications for Social Work Practice
Relevance for Future Social Work Research

References
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10

97
98
100
102
105
107
110

Whitehorse Hospital Approval Letter
Yukon Scientist and Explorers Permit
Participant Summary Sheet and Consent Form
Participant Information Education Package
Participant Interview Guide Qeustionnaire Package
Matrix # 1: Key Concept Themes and Model
Matrix # 2: Key Concept Themes by Model and Discipline
Matrix # 3: Vision for Shared Care at Whitehorse Hospital
Matrix # 4: Key Concept and Vision Statement Verification
General Mental Health Intake Form Draft: First Nations

126
127
128
130
140
148
154
164
165
166

TABLES
Table 1

Participant Recruitment

50

Table 2

Thematic Matrix

52

Table 3

Demographics

54

Table 4

Participant Data Summary Tool

55

Table 5

Interview Method

59

Table 6

Summary Key Concept Themes by Model

68

Table 7

Summary Key Themes by Model and Discipline

72

Table 8

Matrix # 3 Simplified

76

Table 9

Vision Statement Priorities

77

Table 10

A Shared Mental Health Care Vision for
Whitehorse General Hospital

88

1
CHAPTER ONE
INTRODUCTION
Shared Mental Health Care is a progressive mental health care concept that has
changed how mental health services are delivered to clients across Canada, and around
the world. This collaborative and consultative approach brings together family
physicians, psychiatrists, and mental health professionals to provide a more accessible,
effective, comprehensive, and quality mental health service. The College of Family
Physicians of Canada and the Canadian Psychiatric Association described this
collaborative approach in a joint position paper, Shared Mental Health Care in Canada
(Kates, Craven, Bishop, Clinton, Kraftcheck, LeClair, et al., 1997). Shared Mental
Health Care is defined as follows:
"... a process of collaboration between the family physician and the
psychiatrist that enables responsibilities of care to be apportioned
according to the treatment needs of the patient at different points in time
in the course of a mental health problem and the respective skills of the
family physician and the psychiatrist" (p. 10).
The goal of the Shared Mental Health Care (or Shared Care) approach is to
improve the working relationship of health care professionals who work in the area of
mental health. This is achieved through improved communication and shared
responsibility of mutual mental health clients. Collaboration is considered to be a critical
key concept of Shared Care, as is support and education. The sharing of information and
educational opportunities were also promoted to improve the knowledge, skill level, and
confidence of family physicians. Maximizing available resources is another key concept
of Shared Care, especially important for smaller and rural communities. There is strong
support for communities to implement a Shared Mental Health Care model, in terms of

2
its effectiveness, and better use of available mental health resources. This approach
provides for a more coordinated and comprehensive mental health program that would
improve access, quality of care, and service delivery. The key concepts, of collaboration,
support and education, maximizing resources, and case management are considered to be
essential components to implementing a successful Shared Care model.
At Whitehorse General Hospital, Yukon, a model of Shared Care exists. This
mental health program consists of two separate, but parallel components. First, the
medical mental health program involves the family physician, nurses, mental health
nurses, and a consulting psychiatrist. The second component is a First Nations health
program that delivers a holistic health and cultural component to Aboriginal patients,
while in hospital. These two distinct programs operate independently of each other, and
at the same time deliver excellent patient care.
Purpose and Objectives of Research Study
The purpose of this research is to determine if a Shared Mental Health Care model
for Whitehorse General Hospital operates, and if so would it continue to be reflective of
both medical and First Nations culture and values. The objectives of this research are:
1. To describe the mental health care program, in relation to the Shared Care and
Aboriginal health models
2. To increase awareness and understanding of the First Nations and Medical
components of the mental health program, and how they collaborate,
complement, and support one another
3. To explore how the Shared Care model works, and the degree to which it is
complementary to the First Nations practices of the mental health program

3

4. To present an improved Shared Mental Health Care program for Whitehorse
General Hospital, Yukon, one that uniquely incorporates First Nations
philosophical, cultural and traditional healing practices
The Personal Context
My purpose and vision to see a successful Shared Care model at Whitehorse
Hospital comes from a strong personal interest and commitment to mental health clients,,
a passion for the concept of Shared Care, and a desire to share this information with
others who work in the field of mental health. In my previous role as Whitehorse
Hospital mental health nurse, I was acutely aware that there was a lack of information
among staff as to what the two programs did, and a need for role clarification.
My personal involvement with this mental health program created some minor
challenges for me in my role as both a researcher and co-worker. This relationship was
unique, as I had professional and some personal relationships with participants. There
were benefits to my dual role. My intimate knowledge of the mental health program, my
social work and nursing background and experiences, and my theoretical constructs were
all elements that I believe contributed to the high quality of data and the positive results
for this project. To address the possibility of an ethical dilemma, every attempt was
made to acknowledge and minimize potential bias, during the planning, preparation, data
collection, and data analysis phases. It was critical to me that I maintain an objective
stance, be vigilant, and very aware of possible ethical dilemmas that could arise. To
differentiate, in my role as researcher, I was very clear that this study was based on
participant perspectives, and not my own personal views.

Role ofWhitehorse General Hospital
As a researcher I was given permission and formal approval (see Appendix 1) to
conduct research on site at Whitehorse Hospital with access to hospital staff, and during
their regularly scheduled work hours. The role of Whitehorse Hospital administration

was very positive, and with strong support for my studies, and my thesis project, they
encouraged me to proceed, even though my Masters degree was in social work, and I had
been working at the hospital as a registered nurse. I believe there was relevance to the
hospital in my capacity as a nurse, or as a social worker. Politics was not a major issue in
this study, given that the study itself was an internal one, and did not involve any external
agencies. My proposal was submitted and approved by senior administration, and also
reviewed informally, and accepted by the newly formed Whitehorse General Hospital
Ethics Committee (2003). Another formal submission for this research project was to the
Yukon Scientists and Explorers Permit (see Appendix 2). Approvals were granted by this
Yukon agency, and also the University of Northern British Columbia Ethics Review
Committee.
Chapter Outlines
A brief description of the contents of this thesis report is outlined here. Chapter
One provides the introduction, and an overview of this document. Chapter Two follows,
with an extensive literature review of the Shared Care and Aboriginal health models.
Historical information, key concepts, and relevant Canadian and international literature is
also discussed for these two models, as well as the emerging acceptance and integration
of holistic health into mainstream medical programs and facilities, such as Whitehorse
Hospital. Considerable support for these models extends to an integration of holistic
health concepts within a medical model framework. Chapter Three provides a brief

5

summary of the services Whitehorse Hospital currently provides. Chapter Four presents
the research methodology. This study will use a descriptive thematic method of inquiry,
and a content and comparative analysis approach. Key concepts of the Shared Care and
Aboriginal models frame the methodological process. They include: collaboration;
support and education; maximizing resources; case management; collaboration and
consensus; holistic health and healing; and Aboriginal healing methods. The focus of
inquiry was the mental health program, specifically an examination of the strengths, areas
to improve, and solutions for change. Participants' views and perspectives were critical
in exploring these areas. Participants, who were also employees, were from a variety of
professional disciplines, health care services, and all directly or indirectly involved with
mental health clients. It should be mentioned the term discipline, in this research paper,
refers to employees who work in a specific professional occupation, with the exception of
the support group who consist of health professionals and providers. Also, the term
'medical' refers to all disciplines, other than First Nations health, and who work within
the medical system.
The research also explored participants' vision or ideas for a future model of
Shared Care. A three step process was used in this research. The first step was to gather
support for my Shared Care project. In the second step, participants attended an
information education session, followed by a third step where participants completed
interview questionnaires. Data collection was done using focus groups and individual
interviews, and with strong participation evident in this study. Chapter Five presents the
results of this research study with data summarized and analyzed by model, participant
discipline, key concepts, and vision statements. Comparisons and contrasts explored

6
similarities and variations across the data, and among discipline groups. All data results
point to a participant driven vision of a Shared Mental Health Care model for Whitehorse
Hospital. Chapter Six discusses the implications for social work practice, and presents
research conclusions, common themes in the study, and a collaborative and holistic health
approach to social work. The impact of this research is explored in personal and
professional terms, as well, as the relevance of this study for future research initiatives.

7

CHAPTER TWO
A REVIEW OF THE LITERATURE
Introduction
This chapter will examine key concepts and relevant Canadian, and international
literature regarding Shared Mental Health Care and Aboriginal health. A historical
overview of both models is presented in this chapter, and discussion on the emerging
acceptance, and integration of holistic health into mainstream medical programs and
facilities.
Shared Mental Health Care
Historical Background
The Shared Mental Health Care model was created in 1997, by members of the
Canadian General Practitioners Association, and the Canadian Psychiatric Association.
A critical need and definitive gap was identified in the way mental health services were
delivered to clients in Canada. As a result of collaborative efforts of both professional
associations, a 'National Conjoint Committee on Mental Health Care' was formed, and a
solution proposed to address these issues, and was called Shared Mental Health Care.
This concept was promoted as a new model for mental health service delivery. The
Shared Mental Health Care in Canada - Position Paper, described the mental health
situation at that time (Kates, Craven, Bishop, et al., 1997). Issues and concerns were also
expressed in this document with clear resolutions. The need to establish and strengthen
the working relationship between the family physician and psychiatrist was considered to
be an important component of Shared Care. This collaborative approach would be
expected to encourage and support a Shared Care model, improve the mental health

8

services and systems, and contribute to a more comprehensive and coordinated mental
health delivery system. These positive changes would assist health care professionals to
better navigate the mental health system to access mental health services for their clients.
A national Collaborative Working Group on Shared Mental Health Care (Canadian
Psychiatric Association and College of Family Physicians of Canada, 2002) was then
created to further develop and expand the Shared Care model. The Working Group's
objectives included: to share information on Shared Care projects with other health
professionals across Canada; integrate and incorporate Shared Care into university
academic residency programs; encourage continuing educational opportunities for family
physicians; develop strategies for underserved and rural populations; lobby for Shared
Care funding; and develop a national implementation research strategy for Shared Care
projects. Results of these initiatives were published in the Shared Mental Health Care in
Canada Current Status, Commentary, and Recommendation (Canadian Psychiatric
Association and College of Family Physicians of Canada, 2000). This report provided
background information and suggestions to plan, develop, and implement a Shared Care
model. A key informant survey of 350 health care professionals suggested that a
majority of participants had increased awareness, interest, and an acceptance of the
Shared Care model. An inquiry into Shared Care initiatives and projects was also
conducted. This study showed strong support for this approach, which was clearly
evident in the reported number of Shared Care projects already in existence. Updates
from the Collaborative Working Group provided additional recommendations (Canadian
Psychiatric Association and College of Family Physicians of Canada, 2002, 2003). They
included: training practitioners in the Shared Care model, and integrating Shared Care

9
principles into mental health policy and reform. Guidance and assistance on the
implementation of Shared Care initiatives was also presented for practitioners and policy
makers. Definite support and a desire to share information among Canadian health care
professionals were also clear objectives of the Working Group. Two valuable reports
show this commitment and their achievements. The document Shared Mental Health
Care in Canada: A Compendium of Current Projects (Kates & Ackerman, 2002) report
provided a compilation of Shared Care projects across Canada with over 100 initiatives
documented in the first five years of Shared Care. Numerous project descriptions
assisted others to implement Shared Care models. The second report, Shared Mental
Health Care: A Bibliography and Overview (Craven & Bland, 2002) summarized critical
issues regarding the Shared Care model. This document showed a strong need for
collaboration between family physicians, and psychiatrists. Also presented are different
theoretical perspectives, models, and educational training initiatives. Challenges,
barriers, and evaluation research methods were also presented. This comprehensive
overview is an excellent document that encourages others to understand the value, and
the challenges of implementing a Shared Care model.
Communication is critical for psychiatrists, family physicians, and mental health
professionals to exchange and update information on Shared Care. The annual national
conference on Shared Care has been in existence since 2000. This event is strongly
supported by health care professionals across Canada. Yukon is represented at this
conference with various Whitehorse Hospital and community representatives attending,
including myself. A Shared Care Newsletter (2007) and Shared Mental Health Care
Website (2008) keep members up to date. The Shared Care website provides information

10
on Shared Care, background history, current resources, and publications from Canada,
and around the world. Also showcased, are excerpts from the national Shared Care
conferences.
Collaborative Mental Health Care
Shared Care continued to evolve, and in 2003 expanded to include not only
psychiatrists and family physicians, but other professional disciplines (Kates, 2006).
Representatives from twelve Canadian associations came together to form partnerships
and created a working committee to further the work of Shared Care. Professionals
included: social work, psychology, nursing, occupational therapy, pharmacy, dietetics,
national mental health organizations, and continued participation from members of the
College of Family Physicians of Canada, and the Canadian Psychiatric Association
(Canadian Collaborative Mental Health Initiative, 2006). This consortium received
funding from the Health Care Transition Fund (Health Canada, 2007) to develop the
Canadian Collaborative Mental Health Initiative. Their objectives included: to improve
the overall mental health of Canadians; increase collaboration among health care
professionals; and the inclusion of consumers, families and caregivers within the Shared
Care model. This successful group of health care professionals achieved many of their
objectives. These include: a published research series on collaborative health; a charter
mandate that was created, based on consultations with health care professionals,
caregivers, and Aboriginal groups across Canada; and toolkits developed for specific
target groups to assist with the planning, and implementation of collaborative community
initiatives (Canadian Collaborative Mental Health Initiative, 2006, May; Kates,
Ackerman, Crustola, & Mach, 2006). Also published was a second compendium, the

11
Resource Guide II, which is an updated status report of nearly 100 Shared Care and
collaborative projects across Canada (Canadian Collaborative Mental Health Initiative,
2005, December). As a result of the excellent work of the Canadian Collaborative
Mental Health consortium, Shared Care has now been widely recognized and
acknowledged among health care professionals across the country. In addition,
considerable financial support was received from the federal Primary Health Care
Transition Fund, which produced hundreds of provincial and territorial Shared Care
initiatives (Health Canada, 2007). The concept of Shared Care evolved to a new level,
and included a name change. The term Shared Mental Health Care was replaced by
Collaborative Mental Health Care. This created some confusion. For example, the
Shared Care website (2008) clearly identified 'Shared Mental Health Care in Canada' at
the top of the web page, and just below was an announcement for the '2008 Collaborative
Mental Health Care Conference'. Despite the desire by some to change the name, many
community initiatives in the Resource Guide II (Canadian Collaborative Mental Health
Initiative, 2005, December) are titled Shared Care.
Other Shared Mental Health Care Models
Shared care has been associated with other names. Historically, Craven and
Bland (2002) trace the origins of shared and collaborative care to the United Kingdom.
This older term is called 'shifted out-client', and was used when discharged hospital
clients are shifted to community care with virtually no significant difference in client
service delivery. In the United States there is a mental health concept called, 'carve-out
to collaboration'. The American Academy of Family Physicians endorsed this model,
which supports mental health professionals working within family physician clinics

12
(White, 1997). The community consultation-liaison program (CLIPP) is another version
of Shared Care that is now widely accepted in Australia, and the United Kingdom. This
integrated and consultative model is where mental health professionals provide support
and education to family physicians, and to their mental health clients (Bower & Sibbald,
2000; Meadows, 1998; Willis, Condon, & Litt, 2000). Craven and Bland (2002) and
Ungar and Hoffman (1998) describe the concept of split-care, as a mental health
approach. This concept refers to a consultation process where the client visits the family
physician and psychiatrist separately, and with no verbal communication between
disciplines. The Shared Care model is now slowly replacing the split-care model.
Shared Mental Health Care Reform
The Canadian federal government now strongly supports an integrated and
collaborative practice with mental health professionals, as part of an interdisciplinary
team (Canadian Mental Health Commission, n.d.; Health Canada, 2002; Health Council
of Canada, 2006; Kirby & Keon, 2006; Romanow, 2002). Interdisciplinary is one term
that defines different health care professionals working together in partnership, as they
apply methods of their respective disciplines to their practices. They can include: social
workers, psychologists, nurses, family physicians, and psychiatrists (Chisholm, 2001;
Craven & Bland, 2002; Gagne, 2005; Kates, Crustola, Farrar, & Nikolaou, 2002). Gagne
(2005) and Hoekstra (2001) also included the client as part of the interdisciplinary team.
Primary health care reforms are becoming more common. Health Canada (2007, March)
supports primary care initiatives in the area of mental health. The term 'primary health
care' is defined as the first contact by a consumer to a health care service, institution, or
professional. A family physician, nurse, pharmacist, dietician, for example, would be

13
considered first contact, as well as a clinic, hospital, or telephone health help line
(Canadian Collaborative Mental Health Initiative, 2006; Gagne, 2005; National Primary
Health Care Awareness Strategy, 2005). This concept of primary health care is based on
shared responsibilities among health care professionals, who provide flexible and varied
services, and use a client centered or consumer approach (Gagne, 2005). A
multidisciplinary team based approach is the stated goal for primary health care in
Canada (Health Council of Canada, 2006).
Canadian provinces have also initiated mental health reforms with progressive
changes in the area of mental health and addictions, and with a shift towards a
collaborative systems framework. There is now strong support for coordinated and
integrated partnerships within the health system. This collaborative and client centered
approach is supportive of a Shared Care model (Alberta Alcohol and Drug Abuse
Commission, 2005; Alberta Provincial Mental Health Planning Project, 2004). GrahamWalker (2000, March 7, March 28) states that Nova Scotia has made similar progress in
the area of mental health reform by restructuring a fragmented and inaccessible mental
health system in Halifax. Ontario has implemented mental health reforms. The Ontario
Ministry of Health and Long Term Care published two reports on mental health reform,
Mental Health: 2000 and Beyond. Strengthening Ontario's Mental Health System
(Newman, 1998), and Making it Happen. Operational Frameworkfor the Delivery of
Mental Health Services and Supports (Ontario Ministry of Health, 1999). This province
also supports a collaborative and coordinated mental health care system, and is one that
supports a holistic concept within mental health.

14
Strong support also exists for a shifting paradigm towards a more collaborative
and consultative model, by the World Health Organization, and United Nations General
Assembly. Clear recommendations include an integration of psychiatry and mental
health within primary health care settings, and an established need for a multisectoral and
interdisciplinary approach across organizations. Increased knowledge for mental health
professionals, and university curriculum changes in the area of mental health are also
supported (World Health Organization, 2001b). This highly respected international
organization now provides their endorsement for a Shared Care model. The World
Health Organization (1990, 1999, 2001b, 2002a) is a strong advocate for mental health,
as is evident in their many publications. In 1991, the United Nations General Assembly
(as cited in WHO, 2001b) adopted and endorsed similar principles to improve and protect
mental health service delivery with an emphasis on community care.
Barriers to Implementation of Shared Mental Health Care
Support definitely exists for a Shared Care model. There are, however, potential
barriers and obstacles that could impact on the implementation of Shared Care initiatives.
Positive change towards mental health reform can be challenging. Issues include: a
fragmented mental health system; fee-for-service issues for psychiatrists and family
physicians, where joint consultations are not allowed; negative attitudes towards Shared
Care; confidentiality among disciplines; and decreasing numbers of health care
professionals (Kates, Craven, Bishop, et al., 1997; Romanow, 2002). Indications show
that despite the barriers, the acceptance of the Shared Care model is moving forward,
resulting in positive change (Canadian Psychiatric Association and College of Family
Physicians of Canada, 2003).

15
Shared Mental Health Care Key Concepts
The key themes of Shared Mental Health Care are critical to the foundation of this
model. These concepts o f collaboration', 'support and education', and 'maximizing
resources' are recommended when planning and implementing Shared Care initiatives.
Collaboration
The most important key concept necessary to the success of a Shared Care
approach is collaboration. This term is defined in the literature as a collaborative process,
where family physicians and psychiatrists, through improved communication and
consultation, share responsibility for the care of mental health clients. This occurs within
a collaborative and coordinated mental health system (Canadian Psychiatric Association
and College of Family Physicians of Canada, 2000; Kates, Craven, Bishop, et al., 1997).
Gagne (2005) states that collaboration is defined from a primary health care perspective,
as "two or more primary health care providers working together with consumer, family,
and caregiver for purposes of improving health outcomes and system capacity" (p. 61).
Collaboration between family physicians and psychiatrists is the critical component
required for Shared Care success. Typically, the first contact for clients into the mental
health system is with the family physician, as 35% to 50% of clients seek help for their
mental health problems (British Columbia Provincial Government, 1998; Chisholm,
2001; Gagne, 2005; Health Canada, 2002; Hill, Levitt, Chambers, Cohen & Underwood,
2001; Kates, 2002; Kates, Craven, Bishop, et al., 1997; Kates, Craven, Crustola, et al.,
1997). Other studies suggest a higher figure of 60% to 84% (Arboleda-Florez &
Saraceno, 2001; Canadian Collaborative Mental Health Initiative, 2006). A report from
Health Canada (2002) suggests that mental health affects all Canadians in some way with

16
20% of Canadians experiencing a mental illness in their life, and 90% impacted indirectly
through a family member or significant other. Considering that family physicians are
most often the first contact for clients accessing mental health care services, there is a
critical need to strengthen the working relationship between family physicians and
psychiatrists (Canadian Psychiatric Association and College of Family Physicians of
Canada,, 2000, 2003; Kates, Crustola, et al., 2002). Communication is encouraged
between these two disciplines to encourage and support this collaborative relationship
(British Columbia Provincial Government, 1998; Canadian Psychiatric Association and
College of Family Physicians of Canada, 2000; Kates, 2002; Kates, Craven, & Bishop, et
al., 1997). The literature strongly supports the collaborative concept, where the
psychiatrist provides consultative services within the family physicians office (Canadian
Psychiatric Association and College of Family Physicians of Canada, 2000; Ungar &
Hoffman, 1998). As a result, this mutual relationship shifts to a stronger and more
consultative arrangement. The family physician would then have improved mental health
knowledge and skills to better manage mental health clients, and access the needed and
available resources (Canadian Psychiatric Association and College of Family Physicians
of Canada, 2000; Kates, Craven, Bishop, et al., 1997; Ungar and Hoffman, 1998). There
is substantial support for a collaborative model, especially one that includes not only
family physicians and psychiatrists, but mental health professionals, especially within
primary care clinics. It is suggested that social workers, nurses, psychiatrists, and family
physicians be included as part of the interdisciplinary mental health team, and work in
collaborative partnership together (Borsellino, 1999; Chisholm, 2001; College of Family
Physicians & Royal College of Physicians and Surgeons of Canada, 2006; Gagne, 2005;

17
Kates, Crustola, et al., 2002; Manzer, 2001; McCann & Baker, 2002; Webber & Wills,
1997). Kates (2002) suggests that there is a "continuum of care that flows with other
specialized services" (pg. 1). This is important, as 40% of clients access services through
mental health professionals (Kates, 2002). Gagne (2005) presents detailed statistics and
percentages on client access. This author suggests clients consult their family physician
(45%), psychiatrist (25%), psychologist (23%), social worker (21%), religious advisors
(8%>), and nurses (6%). A coordinated and comprehensive mental health care system
involves strong relationships, and the commitment of all mental health care professionals
to support a collaborative approach. This is critical to the success of a Shared Care
program (Canadian Psychiatric Association and College of Family Physicians of Canada,
2000; Helm, 2000; Kates, 2002; Kates, Craven, Bishop, et. al., 1997; Romanow, 2002;
Ungar & Hoffman, 1998).
Support and education
'Support and education' is one of the key concepts and founding principles of the
Shared Mental Health Care model. This concept is identified in the literature as 'support
and education', and in this paper I will use this term as one phrase. This collaborative
approach presents unique opportunities when knowledge is shared between the family
physicians and psychiatrists (Canadian Psychiatric Association and College of Family
Physicians of Canada, 2000; Kates, 2002; Ungar & Hoffman, 1998; Wysong, 1999).
Kates, Craven, Bishop, et al. (1997), Manzer (2001), and Ungar and Jarmain (1999)
suggest collaborative, joint clinical consultations with the psychiatrist, family physician,
and the client. This exchange of mental health information within the primary care clinic
improves the family physician's knowledge and expertise with mental health clients

18
(Kates, Craven, Bishop, et al., 1997; Leverette & Parker, 1999). Continuing medical
education is available for family physicians, and is strongly encouraged. Theory based
mental health modules, practical placements in psychiatric areas, and specialist
psychiatric training are now widely available to family physicians (Canadian Psychiatric
Association and College of Family Physicians of Canada, 2000; Kates, Craven, Bishop,
et. al., 1997; Meadows, 1998). Collaborative educational outreach programs are also
available. The national ACCESS program provides psychiatric support and education
through clinical case reviews, interactive workshops, and telephone support with
psychiatrists (Ungar, 1996). The Enhanced Mental Health Skills Program is a
mentorship program where psychiatrists provide support and education to family
physicians in British Columbia. This initiative is aimed at increasing the competency and
skill level of family physicians, especially those in rural and remote settings, and where
there is a lack of mental health services (Kates & Ackerman, 2002). A major shift has
occurred with the integration of Shared Care approaches into university residency
training, and curriculum programs. Psychiatric residents now train in primary care clinics
and family physicians train in psychiatric settings (Bland & Galarneau, 2001; Canadian
Psychiatric Association and College of Family Physicians of Canada, 2000; GrahamWalker, 2000, April; Leverette & Parker, 1999; Ungar & Hoffman, 1998; World Health
Organization, 2001b). An increasing number of mental health educational resources are
available across Canada, such as clinical case conferences, educational programs, and
mental health workshops, and many are offered through telehealth (Canadian Psychiatric
Association and College of Family Physicians of Canada, 2000, 2002; Gagne, 2005;
Kates & Ackerman, 2002). Federal reports have encouraged telehealth initiatives (Health

19
Canada, 2002; House of Commons Canada, 1995). The British Columbia Provincial
Government (2007) has recently published the Family Physician Guide. This booklet
focuses on mental health and addictions, and includes one chapter dedicated to Shared
Care. This guide strongly encourages collaborative relationships between family
physicians and psychiatry. The Shared Care concept has been endorsed by the federal
government. The British Columbia Medical Association and the College of Family
Physicians of British Columbia also extend support to Shared Mental Health Care models
(British Columbia Provincial Government, 2007). An innovative mentoring program, the
Collaborative Mental Health Care Network, extends support and education to Ontario
family physicians via telephone and email. This new concept has received overwhelming
support from physicians with approvals from the Ontario College of Family Physicians
Association (Hunter, Gingrich, Rochman, Silveira, & Salach, 2007). Other resources are
available world wide on the internet. A mental health educational series, Practice
Essentials, is available to assist Australian family physicians to treat and manage mental
health clients (Medical Journal Australia, 1998). This program is also available to
Canadian health care professionals on the Shared Care Website (2008).
Maximizing resources in underservedpopulations
The Shared Care model clearly benefits and supports mental health services
within small, remote, and rural communities. These services are often underserved due to
a lack of psychiatrists and mental health professionals. Consulting psychiatrists from
tertiary centers provide mentorship, education, and support to family physicians, thereby
maximizing existing resources effectively. University psychiatric residency placements
also support rural communities (Canadian Psychiatric Association and College of Family

20
Physicians of Canada, 2000; Hodges, 2001; Kates, Craven, Bishop, et al., 1997;
Romanow, 2002; Ungar; 1996). Borsellino (1999), the Canadian Psychiatric Association
and College of Family Physicians of Canada, (2000), and Webber and Wills (1997)
suggest greater collaboration between mental health professionals and nurses to improve
skills and mental health knowledge. Allied professionals, such as social workers, are also
encouraged to support interdisciplinary collaboration within a Shared Care framework
(Canadian Psychiatric Association and College of Family Physicians of Canada, 2000;
Hodges, 2001; Kates, Craven, Bishop, et al, 1997; Romanow, 2002; Ungar, 1996).
Implementing Shared Care initiatives and strategies in rural and remote areas in Canada
ensures that communities maintain acceptable standards of care, and maximize available
mental health services and resources. This results in a cost effective, efficient, and
effective mental health service (British Columbia Provincial Government, 1998;
Canadian Psychiatric Association and College of Family Physicians of Canada, 2000;
Kates, Craven, Bishop et al., 1997; Romanow, 2002; Ungar & Hoffman, 1998).
Case management
Another key concept of Shared Care is case management, but for reasons
unknown, this component was not included in the literature. Considering the importance
of using a collaborative or interdisciplinary approach in case management, I have
included this as a Shared Care key concept in this research study. Baldwin and Woods
(1994) state that there is no clear definition for case management, but there is discussion
on case managers, their roles, and components of this concept. There is an identified
need for case management for clients and their families, as they navigate the mental
health care system. Words to describe this system include: a 'fragmented', 'confusing', a

21
'maze', a 'duplication of services', and 'fend for themselves', as explained by clients and
consumers (Baldwin & Woods, 1994; Durban, Goering, Wasylenki & Roth, 1997; Helm,
2000; Romanow, 2002). The need for a case manager is crucial, and is where one person
is responsible for the coordination of client care. Helm (2000) considers case
management as a critical component of community care, but is concerned, because 50%
of mental health professionals are transient. This author suggests the family physician be
delegated as case manager to conduct assessments, provide counselling and support, and
coordinate client programs. Social workers are also considered as case managers within
primary care settings (Canadian Association of Social Workers, 2003). Meadows (1998)
reports on the successful Australian CLIPP program, where mental health nurses are used
in a similar capacity. Romanow (2002) suggests the case manager "guides individual
clients through the various aspects of the health care system and co-ordinates all aspects
of their care" (p. 122). One case management initiative that is supported by the federal
government is a national electronic record (Health Canada, 2002; House of Commons
Canada, 1995), which collaboratively connects health care professionals who share a
mutual client.
Implementation of Shared Mental Health Care Projects and Initiatives
There have been a variety of Shared Mental Health Care initiatives and projects
implemented in the majority of Canadian provinces, since its inception in 1997. The
Collaborative Working Group provided suggestions for implementing Shared Care
initiatives (Canadian Psychiatric Association and College of Family Physicians of
Canada, 2000). They include: a review of existing mental health services, support for a
collaborative approach among mental health professionals, and identifying effective

22

strategies for underserved and Aboriginal communities. All are considered to be
essential components of a Shared Care model. Prior to implementation, a review of
similar Canadian projects is recommended and beneficial (Canadian Collaborative
Mental Health Initiative, 2005, December; Kates & Ackerman, 2002). A significant
number of Shared Care initiatives have been integrated into mental health services within
family physician clinics. The most common practice is for mental health professionals
and psychiatrists to regularly visit primary care clinics to conduct client mental health
assessments, and follow up. In these programs, the psychiatrist typically has a consulting
role with the mental health clinician, and joint consultations with the family physician.
Support and education is also provided in these meetings (Graham-Walker, 2000, March
7, March 28; Kates & Ackerman, 2002; Kates, Craven, Crustola, et al., 1997; McMaster
University, 2007). Many clinics have hired mental health professionals and integrated
this collaborative mental health service within their primary care clinics (GrahamWalker, 2000, March 7, March 28; Wysong, 1999). The Hamilton-Wentworth, Ontario,
HSO mental health program (Kates, Craven, Crustola, et al., 1997) was one of the first to
successfully integrate Shared Care into two primary care clinics. A family physician,
psychiatrist, and mental health counselor work in collaboration together in the
community clinic, and with telephone support. Mental health professionals conduct
preliminary assessments on site, and a consulting psychiatrist regularly visits the clinic,
depending on need. McMaster University (2007) reports that the HSO Shared Care
program continues to expand and integrate mental health services within 145 primary
care clinics, and is strongly supported by all health professionals.

23

Shared care has been implemented with success using an interdisciplinary and
collaborative approach in hospitals. The North York General Hospital in Ontario set the
precedent as one of the first hospitals to implement a Shared Care model. The major
focus for this program is the collaborative relationship between family physicians and the
mental health system. As well, this hospital changed recruitment policies to ensure that
those hired support a Shared Care model (Ungar & Jarmain, 1999). Manzer (2001)
reports on the success of the St. Joseph's Hospital in Toronto, Ontario. This program
focused on a collaborative approach with client pre-assessments by the mental health
clinician, then joint consultations with the clinician, psychiatrist, and client. The family
physician is supported by the team and initiates client treatment plans (Manzer, 2001).
Successful Shared Care approaches have also been implemented in hospital emergency
departments. In these institutions, mental health nurses collaborate and coordinate with
hospital health care providers to facilitate admissions, and follow up with discharge
planning. Successful programs are in existence in New Brunswick and Yukon (Canadian
Collaborative Mental Health Initiative, 2005, December). Hospitals are also providing
outreach mental health services to community clinics. The Ottawa Hospital, in Ontario
established two community outreach clinics for client discharge follow up, and for other
students who access university campus services (Kates & Ackerman, 2002). Outreach
psychiatric services extend to hospitals in rural and remote Ontario communities, through
university affiliations. For example, a University of Toronto Shared Care initiative
provides mental health services to Sault Ste. Marie, Ontario. University psychiatrists
assist hospital and community psychiatrists with client consultations, and provide support
and education (Kates & Ackerman, 2002). Kates and Ackerman (2002), Kates, Craven,

24

Crustola, et al. (1997), and McMaster (2007) suggest rural outreach programs have been
found to decrease the workload of the resident psychiatrist, and improve knowledge and
skill levels of the family physician. As a result, family physicians' report they are more
prepared to manage severely mentally ill clients in a clinic setting.
Shared Care in Aboriginal and Northern Territorial Communities
First Nations communities have begun to incorporate and integrate Shared Care
models into their mental health programs. A collaborative mental health program, in
Calgary, Alberta is a well organized community based First Nations program (Pace,
2007). This collaborative model consists of twelve family physicians, two First Nations
physicians, and one resident First Nation psychiatrist. Telephone consultation and
telehealth is also available. Collaboration between elders, a psychologist, clients, and
their families also occurs. The Ohsweken Mental Health program in Northern Ontario is
another example. This community based program integrates concepts of the Shared Care
model within their service (Wieman, 2001). This program has a crisis response team that
includes: a social worker, nurses, a consulting psychiatrist, and a resident First Nations
psychiatrist. Culturally sensitive Aboriginal holistic health and healing methods, and
traditional beliefs and practices are all key components of this mental health program.
This interdisciplinary model supports consultations with traditional healers and social
workers. There is acknowledgement that there are few Aboriginal Shared Care programs.
Kamil (2004) suggests First Nations communities have yet to 'experience' Shared Care.
There is the potential, however, to encourage and advocate to First Nations communities
about the tremendous benefits of Shared Mental Health Care programs (Canadian
Collaborative Mental Health Initiative, 2005, May; Kamil, 2004; Wiemen, 2001). The

25
northern territories are beginning to explore Shared Care initiatives. Four collaborative
First Nations community initiatives are identified in the Resource Guide II. One of these
programs is the 'Yukon First Nations Health Program', which is integrated within the
Whitehorse Hospital mental health program (Canadian Collaborative Mental Health
Initiative, 2005, December).
Aboriginal Health and Healing
Historical Background
Federal initiatives, historically, have focused on policy and process aspects of
Aboriginal health. There has now been a shift and a move forward, as the federal
government has taken a leading role in Aboriginal reform. Critical Aboriginal health
issues have been explored, and there is strong support with identified solutions, from all
levels of government. This involves: First Nations; Inuit; Metis; federal, provincial, and
territorial governments; and Aboriginal organizations. This collaborative effort is evident
in the many reports and documents on issues of Aboriginal health. The Royal
Commission on Aboriginal Peoples (1991, 1993, 1996) was created to examine these
concerns. National roundtable discussions, presentations, and public consultations took
place in many cities across Canada, resulting in two critical documents. The first report,
Gathering Strength (1991) identified inequities in health standards between Aboriginal
and non Aboriginal Canadians. Recommendations in this report include a shift in
strategy from a 'piecemeal to holistic' approach to Aboriginal health and healing, and an
acknowledgement of the importance of cultural and traditional health and healing
methods. The Path to Healing report (1993) followed, with recommendations to address
Aboriginal inequalities using a holistic health approach within an integrated health and

26
social service system. Expectations were that positive change would result and
relationships would improve between Canadian and Aboriginal communities. More
importantly the health and social status of Aboriginal people would be enhanced. Four
commissioned reports were published, based on the Path to Healing (1993) roundtable
consultations. Holistic health and healing was a common theme throughout these
discussions. Clear definitions of healing within a holistic health framework model are
presented, specifically in two of these reports. Healing processes for the individual,
family, and community are also considered important within a well integrated holistic
system (Krawll, 1999; Lane, Bopp, Bopp, & Norris, 2002). The House of Commons
(1995) created a federal committee to conduct further consultations among Aboriginal
and federal health organizations, and communities. This committee published a report
called, Towards Holistic Wellness: Aboriginal People's. Report of the Standing
Committee on Health, 31. As a result of this document, Aboriginal people were given the
opportunity to define health, healing, and wellness from their perspectives and views.
This report also recommended the need for a holistic health approach with an integration
of traditional healing methods into western practices of medicine. A collaborative
approach to health is one that is acknowledged in the Future of Health Care in Canada
report, as one that reflects community needs (Romanow, 2002). Holistic health was also
an accepted theme for the future of health care. As a result of the collaborative efforts
among all levels of government and Aboriginal communities, the national Blueprint on
Aboriginal Health. A 10 Year Transformative Plan (2005) was created to address
Aboriginal health issues. This document defines Aboriginal health, as the "collective
vision for First Nations people is to be served by their own distinct yet coordinated health

27
system, which ensures a full continuum of services, a wholistic approach to health, and
the integrity of traditional healing practices" (p. 9). Several reports that contributed to the
development of this Blueprint on Aboriginal Health (2005) focused specifically on
holistic health and healing, and the need to address and improve Aboriginal health
services, and systems. These documents included: the First Nations Health Report Card
(Gideon, 2005), the First Nations Health Action Plan (Assembly of First Nations, 2004),
and the First Nations Holistic Policy and Planning Model, Draft 4 (Assembly of First
Nations, 2005). Federal first ministers who participated in these meetings (2004, 2005),
not only acknowledged this Blueprint on Aboriginal Health (2005), but committed 700
million dollars for initiatives. Health Canada (2007-2008) was committed to work in
partnership with First Nations and Inuit communities and leaders to develop a strategic
plan to improve Aboriginal health outcomes. This process would ensure availability and
access to quality health care services, and provide a 'coordinated continuum' of service
delivery (First Nations Inuit Health, 2007). The Aboriginal Healing Foundation (n.d.)
was also actively involved in the promotion and support of Aboriginal healing initiatives
and strategies. This federally funded organization focused on impacts of residential
school system traumas and abuses, rebuilding health processes, and 'intergenerational
separation'. Funding is available for community awareness and educational initiatives on
the impacts of residential schools, traditional cultural and heritage projects, and a variety
of holistic health and healing initiatives, which have been published in a three volume
report (Aboriginal Healing Foundation, 2006). The Institute of Aboriginal People's
Health is one of the thirteen Canadian Institutes of Health Research (2006) that strongly
supports research initiatives to address immediate and long term health issues, and

improves the overall health of Aboriginal people. Partnerships and the sharing of
research activities are also important (Canadian Institutes of Health Research, 2006;
Health Canada, 2007-2008). The National Network for Aboriginal Mental Health
Research (2006) works in partnership with Aboriginal people and groups, and provides
research opportunities, and training. Health research is critical in addressing Aboriginal
health issues, and improving health outcomes.
Barriers to First Nations Health Practices
Despite the fact that great progress has been made by First Nations and federal
government leaders and community members on holistic models of health and practice,
there remain a number of barriers that can impact on successful program outcomes.
Credibility of First Nations healers and a lack of acceptance by society are two such
concerns (House of Commons, 1995; Waldram, Herring, & Young, 1995). Social issues,
such as substandard housing and unemployment are still evident with gaps and systemic
issues identified (Schmidt, 2000). There are also decreasing numbers of available
Aboriginal healers and resources, and financial concerns in funding these Aboriginal
healing practices (House of Commons, 1995). Efficacy and validity issues, a lack of
definition and standards, and poor funding for traditional medicines are serious concerns
(Waldram, et al., 1995). The House of Commons (1995), Report of the Standing
Committee on Health suggests that effective solutions for change focus on promoting
health and wellness in Aboriginal communities. Consultative and collaborative models
of practice, community partnerships, and the development of a national action plan
among all levels of governments are all approaches that could potentially reduce the
barriers. The development of the national Blueprint on Aboriginal Health 10 Year Plan

29
(2005) is also a step forward. Results are not yet known as to whether there are
successful outcomes from this action plan.
Key Concepts of the Aboriginal Model
Holistic health and healing
Holistic health is consistently defined in the literature as an 'interconnectiveness'
or 'interdependence' that involves the 'whole' person. This holistic concept includes the
physical, mental, emotional, and spiritual components of the individual. According to
some Aboriginal concepts, these key elements are required to maintain balance and
harmony to achieve optimum health and well being for individuals, families, and
communities. This definition of holistic health also includes social, cultural, economic,
political, geographical, and environmental factors (Bopp & Bopp, 1997; Canadian
Association of Social Workers, 2003; Cross, Earle, Echo-Hawke Solie, & Manness,
2000; Hart, 2000; Hollow Water First Nations, 1999; Kassi & Walker, 2002; Krawll,
1999; Lane, Bopp, et. al., 2002; Smye & Mussell, 2001). The holistic health concept is
strongly supported by all levels of government (Assembly of First Nations, 2005;
Blueprint on Aboriginal Health, 2005; Canadian Institute Health Research, 2006; House
of Commons Canada, 1995; Royal Commission on Aboriginal Peoples, 1991, 1993,
1996). Holistic health is an accepted concept in Yukon First Nations communities
(Jensen & Johnson, 1998). The Government of Yukon (2003) also supports holistic
health as the "physical, mental, emotional, social, and spiritual well being of residents of
Yukon in harmony with their physical social, economic, and cultural environments" (p.
2). Council of Yukon First Nations (2001) describes health as "a wholistic view that
promotes and recognizes all aspects related to the wellbeing of nation, communities,

30

family and individuals" (p. 1). Kenny (2004) supports the holistic health definition, and
includes the past, present, and future within the healing process. A New Zealand Maori
holistic health model, Te Whare Tapa Wha health, was developed in 1994 by Dr. Mason
Durie (as cited in New Zealand Childcare Association, n.d.). He described the holistic
model as the four walls of a house, which includes: taha tinana (the physical side), taha
hinengaro (thoughts and feelings), taha wairua (the spiritual side), and taha whanau
(family). Each dimension is then necessary for the individual's overall health and wellbeing. Family is also included as a holistic concept by the Yukon Registered Nurses
Association (2005).
Aboriginal world view
It is important to note in the literature, reference is made to an Aboriginal world
view. This concept is viewed as a set of beliefs and value systems, which explains the
essence of a culture, while connecting people and communities (Government of Yukon,
1998; Jensen & Johnson, 1998). Dr. Brant Castellano (2004), a highly respected
Mohawk woman, and retired Professor Emeritus of Trent University, defines the concept
of 'world view' as a tree rooted and supported in the earth, and is shared to community
members through language, ceremony, and family. Kenny (2004) defines Aboriginal
world view principles as: cultural practices, holistic health, spirituality, and an
"interconnected web of life" with a "belief in adaptability and change" (pg. 8). The
Government of Yukon (1998) describes elders as respected and important to Yukon First
Nations culture, as they share world views through oral history, and storytelling. An
elder is defined as "someone who has lived a good life, has acquired wisdom, displays
qualities of kindness, patience, and fairness" (p.27).

31
Collaboration and consensus
Aboriginal people and communities have used ancient methods of collaboration
and consensus for centuries, especially for community decision making (Aboriginal
Healing and Wellness Strategy, 2001; Simpson, 2000a). The Canadian government
supports collaboration and partnerships, as is evident in the many roundtable discussions
and consultations on Aboriginal health (Royal Commission, 1991, 1993). These
collaborative efforts resulted in progressive Aboriginal health reforms (Blueprint on
Aboriginal Health, 2005; House of Commons Canada, 1995; Kenny, 2004; Lane, Bopp,
et al., 2002; Royal Commission Aboriginal Peoples, 1991, 1993). A collaborative and
participatory healing approach is crucial to create the structures necessary for healing that
strengthen the capacity of a community to support its people (Aboriginal Healing and
Wellness Strategy, 2001). Lane, Bopp, et al. (2002) agree, and suggest that collaborative
partnerships are critical among Aboriginal communities and leaders. These essential
support systems indicate a shared common vision towards an integrated holistic system.
Collaborative efforts improve access to more available resources, so individuals, families,
and communities are able to heal (Aboriginal Healing Foundation, 2006). Cross, et al.
(2000) support this collaboration, and extend this concept to include agencies and
professionals. A collaborative model of alternative dispute resolution, or circle
sentencing, is a common practice used within the Yukon justice system (Government of
Yukon, 2001).
Aboriginal healing methods and practices
Aboriginal or 'traditional' knowledge is defined as a process that is understood to
be an accumulation of knowledge, information, social values and attitudes, experiences,

32
teachings, and storytelling. Individuals, communities, and their environments are
actively involved in this process, as traditional knowledge is collected over time, and
passed on from generation to generation (Emery, 2000; Jalan, 1993; Petch, 2000;
Simpson, 2000a). Brant Castellano (2004) believes in the concept of traditional teachings
using music, stories, and ceremonies to share this information. Castellano (2004) cites
elder Peter Waskahat who strongly supports the "connections between land, family,
spirituality, values, and every day living" (p. 100). Bopp and Bopp (1997) suggest using
symbolism with traditional healing, and say for every illness there is a 'blessing' and a
'message' to learn by, with the focus on health. Aboriginal healing methods and
practices are part of the healing process to promote health and well being. The medicine
wheel is one tool that is used, by some First Nations, for individual healing (Assembly of
First Nations, 2005; Bopp & Bopp, 1997; Bopp, Bopp, Brown, Lane, 1985; Cross, et al.,
2000; Hart, 2001; Hollow Water First Nation, 1999; Royal Commission, 1993). The
Sacred Tree booklet defines the medicine wheel as an ancient north and south American
symbol that is used in a variety of ways to 'interrelate' with the four elements of holistic
health, and to promote an individual's ability to heal, grow, and change (Bopp, Bopp, et
al., 1985). Bopp and Bopp (1997) describe the medicine wheel as a tool that is based on
the holistic concepts that represents balance leading to wholeness, meaning healing of the
whole person, family, and the community. The Sacred Tree (Bopp, Bopp, Brown, et al.,
1985) and medicine wheel tool are used as healing approaches, by the Yukon First
Nations Health program at Whitehorse Hospital.
Sharing and healing circles have been a part of Aboriginal culture for many years,
and they continue to be a popular healing method (Government of Yukon, 2001; Hart,

33

2000; Hollow Water, 1999; Simpson, 2000a). Aboriginal medicine is another healing
approach that is an integral part of indigenous cultures, and used for social, religious, and
medicinal reasons (Waldram, et al., 1995; World Health Organization, 2001a).
Aboriginal healers administer these traditional medicines, and also specialize in different
areas of practice. Involvement of elders, the community, and the environment are
considered to be necessary and critical components in Aboriginal healing methods (Bopp
& Bopp, 1997; Government of Yukon, 1998; Hollow Water, 1999; House of Commons
Canada, 1995; Lane, Bopp, et al., 2002; Native Law Centre Canada, 1996; Simpson,
2000a). The World Health Organization (2000, 2001a, 2002b, 2004) defines standards,
guidelines, and strategies on proper uses of traditional medicines, and healing methods.
Issues of standards of safety, efficacy, quality control, and traditional and herbal products
are addressed in these reports.
Holistic Health and Wellness Frameworks
It is important at this point to present an overview of Aboriginal health and
healing frameworks. The literature suggests healing first begins within the individual
(Bopp & Bopp, 1997; Krawll, 1999; Lane, Bopp, et al., 2002). The Alberta Mental
Health Board (2006), Assembly of First Nations (2005), and Bopp and Bopp (1997)
suggest that the individual's healing journey extends to family relationships, and links to
their community, social networks, and resources. Community based holistic healing
models suggest collaborative and integrated systems begin with the individual, and then
expands to others, resulting in a positive healing effect for the community (Aboriginal
Healing Foundation, 2006; Bopp & Bopp, 1997; Lane, Bopp, et al., 2002). Cross, et al.
(2000) describes a 'relational model' of healing that involves the mind-body-spirit

34

connection, the family, and the social and cultural context of their community.
Traditional knowledge and past wisdoms are also critical (Bopp & Bopp, 1997), as well
as traditional healers, and Aboriginal healing practices within community based programs
(Cross, et al., 2000; Hollow Water First Nations, 1999). The Aboriginal Healing
Foundation (2006) presents an excellent description of a 'community based healing
journey' model for survivors of residential schools. This program includes: increased
awareness and educational programs; knowledge of residential schools, and the related
impacts; increased support of available resources; and collaboration with community
leaders and organizations.
Integration of Aboriginal and Medical Models
There has been a significant shift in attitude within the federal government and
the medical community, towards an acceptance and integration of the concept of holistic
health and wellness. The medical definition of 'health' has been revised from illness and
absence of disease to a more positive and broader view of holistic health and wellness.
The Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health (Miller &
Keane, 1997), states that 'health' is a "relative state in which one is able to function well
physically, mentally, socially, and spiritually"... and "within the environment in which
one is living" (p. 697). Individual responsibility and preventative care are also
considered components of health. This expanded definition of holistic health has been
used by the World Health Organization (1946), for over 50 years.
The federal government is very supportive of an integrative approach, shifting
towards a more culturally appropriate holistic health model of service delivery. Federal
documents strongly support the need to reorganize existing health and social service

35
delivery systems, and incorporate and integrate traditional Aboriginal healing approaches
and practices within mainstream medical systems (Aboriginal Healing and Wellness
Strategy, 2001; House of Commons, 1995; Royal Commission on Aboriginal Peoples,
1991). Community based traditional holistic healing frameworks include integrated
healing methods into cultural wilderness camps (Hollow Water First Nations, 1999;
Lane, Bopp, et al., 2002), and long term residential treatment (Hill, 2003; Royal
Commission on Aboriginal Peoples, 1991, 1996; Smye & Mussell, 2001). Rural
Canadian nursing stations have successfully integrated Aboriginal health and healing
practices into medical models of treatment with 76 remote and rural nursing stations,
providing a holistic and integrated service (Aboriginal Wellness Strategy, 2001; Health
Canada, 2007-2008). Health Canada (2007, March) also extends considerable support for
First Nations and Inuit community programs that incorporate traditional methods of
practice. For example, funding is provided for transportation to the nearest approved
traditional healer.
Professional associations from the social work, nursing, and family physician
disciplines have progressed towards an acceptance and integration of holistic health
concepts into their professional practices (Canadian Association Social Workers, 1998;
Patterson, 1998). The Guidelines for Ethical Practice for social workers' includes 'social
well-being' in the definition of health (Canadian Association of Social Workers (2005b).
Hart (2001) stresses the importance of awareness of Aboriginal culture within a social
worker's practice. Two position papers on Aboriginal health provide recommendations
for professionals. The Canadian Medical Association (2002) supports the document
Health of Aboriginal Peoples, and encourages physicians to have an improved acceptance

36
and understanding of Aboriginal health concepts, and to integrate these concepts into
their medical practice. The Guide for Health Professionals Working with Aboriginal
Peoples (Smylie, 2001) is another position paper that provides a series of guidelines and
recommendations. Community based health care and prevention based programming are
some initiatives suggested. This guide was endorsed by the College of Family
Physicians, Assembly of First Nations, and the Aboriginal Health Issues Committee,
which consisted of a group of health care professionals, established for this report. It is
important to note that representatives on this committee consisted of physicians and
nurses from Ontario, Quebec, Nunavut, and Northwest Territory.
There are also an increasing number of successful Aboriginal health programs
integrated and positioned within acute care hospital settings across Canada that provide
holistic health and healing services to Aboriginal clients. Other community based
programs have collaborative affiliations with hospitals, and provide direct in-client
services. A number of hospitals in Canada offer Aboriginal health programs as part of
their service. They include: Calgary Health Region (n.d.); Nanaimo Regional General
Hospital (Vancouver Island Health Authority, n.d.); Prince George Regional Hospital
(Northern Health, n.d.); Regina Qu'Appelle Health Region (n.d.); Royal Jubilee Hospital
(Vancouver Island Health Authority, n.d.); Whitehorse Hospital (Hogan, 2002); and the
Winnipeg Regional Health Authority (n.d.). These hospital programs offer access to a
wide range of services, such as, health promotion; advocacy; support to clients and
families while in hospital; language and interpreters; supportive counselling; Aboriginal
healing methods; liaison among client, hospital staff, community, and other health care
professionals; referrals; and coordination of discharge planning. A number of Aboriginal

37
health programs also provide cross cultural workshops to health care professionals,
community outreach services, and act as resource centers to rural communities.
Aboriginal ceremonies within hospitals in Saskatchewan and Manitoba are an accepted
practice, where administrators compromise on the no smoking policy, by allowing
ceremonial sweetgrass within the hospital (Jalan, 1993; Waldram, et al., 1995).
The federal government has made a very clear and strong commitment to endorse
comprehensive holistic health and wellness practices integrated into mainstream medical
systems (Browne, Fiske, & Thomas, 2000; House of Commons Canada, 1995; Royal
Commission of Aboriginal Peoples, 1991, 1996; Waldram, et al., 1995). Lane, Bopp, et
al. (2002) state that "what is needed is the creation of an integrated holistic system that
provides critical pathways for healing, personal growth and learning, leading to a
significant improvement in social, economic, and political life of the person, family and
community" (p. 57). The Assembly of First Nations (2005) and Lane, Bopp, et al. (2002)
suggest a blending of traditional and medical models into existing medical programs.
Commissioned reports suggest positive outcomes result when the two models are merged,
especially in the planning, development, and implementation phases of community health
programs (Helin, 1993; Jalan, 1993; O'Neil, 1993; Proctor, 1993). Petch (2000), Procter
(2000), and Simpson (2000a) identify components of Aboriginal and medical or western
models, and compare and contrast these views. Procter (2000) suggests the need to
continue to legitimize and verify traditional knowledge. Petch (2000) and Procter (1993)
support a new framework using the strengths of both models to 'blend' and integrate both
cultures of the Aboriginal and medical model. This new approach is described as a
'superholistic model' (Petch, 2000).

38

Summary
This comprehensive literature review has presented a historical overview, and a
brief summary of the key concepts of both the Aboriginal and Shared Care models.
There is clearly strong support for a collaborative approach that integrates holistic health
within medical models of care. This information provides critical information needed to
move forward and fully understand this research project, and the impacts on the
Whitehorse General Hospital.

39

CHAPTER THREE
WHITEHORSE GENERAL HOSPITAL
Whitehorse General Hospital in the Yukon Territory is a 49 bed community
hospital that provides acute care services to a Yukon population of 32,714 (Government
of Yukon, 2007), and parts of northern British Columbia, and Alaska. The majority of
Yukon residents live in the city of Whitehorse, and within fourteen rural, and First
Nations communities. In 1992, the Canadian government transferred responsibility for
all Yukon health and social services to the Government of Yukon (1998, 2002). The
Whitehorse General Hospital was the one exception. As part of this devolution process,
the hospital became a private corporation, governed by a board of directors. A First
Nations health program was created shortly thereafter. A committee was formed to
monitor and provide direction to this new program with the Council of Yukon First
Nations appointing four hospital trustees to this board. An elder working group was later
appointed in 1995 to discuss traditional medicines, and consult on the development of a
First Nations healing room, which opened in 1999. The First Nations health program
incorporates holistic health values and beliefs that are reflective of Yukon First Nations
cultural and healing practices (Hogan, 2002). The Whitehorse General Hospital (2002)
describes the First Nations health program mission as follows:
"We advocate for First Nations people at Whitehorse Hospital to ensure
quality and culturally sensitive holistic health care " (p. 1).
This comprehensive program provides services to all Aboriginal clients at
Whitehorse Hospital, as well as providing outreach to rural Yukon First Nations
communities.

40
First Nations health and social liaison workers (7 FTE) offer a range of services,
and in many areas of the hospital and community. They include: information and
education; health promotion; interpretive services; support and advocacy; liaison with the
client, medical staff, and communities; mental health; child life work; and discharge
plans (Hogan, 2000). A popular First Nations cross cultural workshop is available for
family physicians, and medical staff. Aboriginal healing methods are an accepted
practice at Whitehorse Hospital with variations depending on the specific beliefs and
practices of the fourteen Yukon First Nations. Ceremonies, prayers, traditional foods and
medicines, and use of the First Nations healing room are all a part of a client's overall
hospital experience, and care. Collaboration, communication, consensus, relationships,
and a sense of community are not only principles of the Aboriginal model, but are critical
components of the mental health program at Whitehorse Hospital.
The second component of the mental health program at Whitehorse Hospital
involves the medical system. The family physician is the first contact for clients who are
in crisis, and require assessment, and treatment. Mental health clients are cared for in the
hospital emergency department, or admitted to the west (or medical) unit, where there are
17 acute care beds with seven identified as mental health. Consultations also occur with
family physicians, regarding direct admission from one of the four family practice clinics.
It is not common for mental health clients to be admitted to the east (or surgical) unit.
The family physician is often the case manager for their clients', as they assume primary
care responsibility, and coordinate care. A consulting psychiatrist (.25 FTE) visits
Whitehorse Hospital weekdays to see referred mental health clients for individual
consultation, as well as offering education, guidance, and support to family physicians

41
and mental health nurses, both in person, and via telephone. Clients can also be referred
for consultation to the psychiatrist's office within the community. Joint consultations are
not conducted with the psychiatrist, family physician, and client in Yukon, due to billing
regulations. Visiting specialists, such as a child psychiatrist, have occasionally provided
consultative services to clients admitted to Whitehorse Hospital, on request. Family
physicians also consult regularly with psychiatric specialists in Alberta and British
Columbia, especially when caring for youth, or if a client is being transferred out of the
Yukon for long term assessment and treatment. Whitehorse Hospital is considered to be
an acute care center with mental health clients admitted for short term duration. Two
mental health registered nurses (2 FTE), work as part of the west unit team. They cover
12 hour days, and 7 days per week, caring for mental health clients within the Hospital.
Their role includes: conducting of mental health assessments, crisis intervention work,
counseling and support, case management, and discharge planning for all referred mental
health clients. Another role of the mental health nurse is to ensure the legal process is
followed for all committed clients under the Yukon Mental Health Act (Government of
Yukon, 2002). The mental health nurse works collaboratively and in consultation with
all health and social service professionals who work directly and indirectly with mental
health clients at Whitehorse Hospital. They also provide consultative services to health
professionals in the rural communities. Registered nurses in the emergency department,
and registered nurses and licensed practical nurses on the west unit are responsible for the
physical, mental, emotional, and spiritual care of mental health clients, when the mental
health nurses or First Nations liaison workers are not available.

42
There are two qualified social workers who work with clients at Whitehorse
Hospital. The First Nations social worker is responsible for liaison with hospital and
community supports, and the coordination of discharge planning for all Aboriginal
hospital clients, including mental health. A second social worker is responsible for all
other hospital clients with the exception of mental health, as this is primarily the
responsibility of the mental health nurses. However, on occasion, this social worker has
assisted and supported the mental health nurse, as needed.
Several critical reports helped to improve and strengthen the Whitehorse Hospital
mental health program. The Final Report of the Task Force on Hospital and Community
Based Mental Health Services (Whitehorse General Hospital, 1999) showed that the
mental health program met its objectives of assessment, crisis management, stabilization,
and discharge planning. This Task Force report recommended increased collaboration,
and a sharing of information among stakeholders. The first suggestion identified by the
Task Force was to implement Whitehorse Hospital's version of Shared Care plans. These
case management plans (Pasquali, 1998) were developed based on mutual mental health
clients who accessed both community and hospital mental health services. This plan was
coordinated by either the family physician or community mental health clinician. The
client Shared Care plans consisted of a brief summary of diagnosis, issues of concern,
and likely presentation to the emergency department. Clinical interventions, medications,
community supports, and other relevant information were also included in this plan. It is
unclear as to whether the hospital Shared Care plan is associated with the national Shared
Mental Health Care model, as the name is the same. I was not able to find out where the
Shared Care name originated. Another consideration is that the Shared Care model does

43

not include client care plans or case management within the key concepts of this
approach. The second Task Force recommendation was the community mental health
Next Working Day Service (Government of Yukon, 1999). This initiative was
implemented for clients who present to the emergency department in crisis, but not
requiring admission. Both initiatives were successful, however, the Shared Care plans
were considered to be outdated and inconsistent.
Whitehorse Hospital continues to be progressive in its vision to improve mental
health service delivery. A second formal assessment and review of the mental health
program was conducted by the Mental Health Evaluation and Community Consultation
Unit (MHECCU) from the University of British Columbia (Chan & Noone, 2001). This
critical evaluation report resulted in significant changes to the Whitehorse program. The
first implemented recommendation was the expanded role of the mental health nurse to
include assessment, consultation, and crisis intervention services to clients in the
emergency department. A preliminary evaluation of this service was conducted (Scott,
2001), and results showed overwhelming support for this initiative. This expanded
mental health nurse role, and the use of emergency department Shared Care plans, are but
two components of the Shared Mental Health Care model that fit with the national Shared
Care philosophies of collaboration, and maximizing resources in underserved areas.
The Whitehorse General Hospital Accreditation Survey Report (Canadian Council
on Health Services Accreditation, 2004) acknowledged significant progress in the area of
mental health following the MHECCU review, and provided further recommendations.
They included progressive policy and practice initiatives that were implemented to
address safety issues, and other client and staff concerns. These improvements include:

44

the creation of an ethics committee; the hiring of a consulting then a part time psychiatrist
(.25 FTE) was hired; and renovations to the seclusion room were completed to ensure
client safety. Several areas to be addressed in the immediate future include: another
safety issue, for example, when confused and mentally ill clients are mixed with acute
care clients on the west unit, and in the emergency department. A timely service is also
acknowledged as an issue in the emergency department, with a suggestion to assess the
effectiveness of this service holistically. There has been considerable progress in the
positive changes to the mental health program at Whitehorse Hospital with ongoing
improvements in service delivery. Administrators continue to assess the effectiveness of
mental health services with the goal of ensuring a comprehensive and successful mental
health program.
The next step in this research process is the focus of participant views and
perspectives for a Shared Care model.

45
CHAPTER FOUR
METHODS
Introduction
This research explored how a Shared Mental Health Care model operates within the
Whitehorse General Hospital mental health program. The focus of inquiry was on
participants' observations, perspectives, viewpoints, and experiences as they examined
the mental health program. A descriptive thematic qualitative approach was used in this
study. Patton (1990) defines a thematic strategy as "common themes and relationships
emerging from and related to the context within which it exists" (p. 51). Themes are also
determined as data is reduced to specific categories (Coleman & Unrau, 1996; Krueger &
Casey, 2000; Seidman, 1998). Thematic tools were created to structure this process.
Matrix tables framed the critical key concepts of the Aboriginal and Shared Care models
(Coleman & Unrau, 1996; Miles & Huberman, 1994; Patton, 1990; Rubin & Babbie,
1997). The participant interview guide questionnaire was structured in this same format,
and found to be invaluable during data collection, and analysis. The participant
information education package presented relevant information on the Shared Care and
Aboriginal models, as well as provided a step by step format that guided participants
through the methodological process (Rubin & Babbie, 1993, 1997). Data collection
involved three methods, which consisted of focus groups, individual interviews, and
participants completing questionnaires themselves. This qualitative research design also
included a holistic component that examined the 'whole' context of the research to better
reflect First Nations concepts, perspectives, and practices (Janesick, 1998; Kenny, 2004;
Patton, 1990).

Purpose and Objectives of Research Study
The purpose of this research is to determine if a Shared Mental Health Care model
for Whitehorse General Hospital operates, and if so would it continue to be reflective of
both medical and First Nations culture and values. This study has four objectives:
1. To describe the mental health care program, in relation to the Shared Care and
Aboriginal health models
2. To increase awareness and understanding of the First Nations and Medical
components of the mental health program, and how they collaborate,
complement, and support one another
3. To explore how the Shared Care model works, and the degree to which it is
complementary to the First Nations practices of the mental health program
4. To present an improved Shared Mental Health Care program for Whitehorse
General Hospital, Yukon, one that uniquely incorporates First Nations
philosophical, cultural and traditional healing practices
Participant Sample
The participant sample in this study consisted of all employees who were directly
or indirectly involved with mental health clients at Whitehorse Hospital. Participant
discipline groups included: senior administration; middle management; clinical case
managers; family physicians, and the psychiatrist; First Nations health, including one
First Nations social worker; west unit registered nurses, and licensed practical nurses;
emergency department registered nurses; a mental health nurse; and an east unit
registered nurse. Support staff included: a dietician; pharmacist; physical therapist;
housekeeping; security; dietary aids; maintenance; administrative assistants, and one

47

social worker who support but are not responsible to the mental health program.
Unfortunately, the laboratory and radiology departments were not represented in this
sample, due to availability, and time constraints.
A 'Participant Summary Sheet and Consent Form' (see Appendix 3) was
reviewed and completed by all participants prior to data collection. This form provided
participants with an overview of the research questions, explanation of the use of the
results, informed consent, confidentiality, and care and disposal of research materials
(Patton, 1990; Rothery, 1996; Rubin & Babbie, 1997). No names were revealed with
data categorically coded, and analyzed according to discipline group. Consent forms
were completed by all participants.
Considerable thought was given whether to include clients as a participant group.
Although, this would have added an interesting dimension to the study, it was decided not
to involve clients and their families, because this research focused specifically on
Whitehorse Hospital employees and their views, perspectives, and involvement within
the mental health program. As well, the focus of inquiry was predominantly on issues
related to the areas of collaboration, support and education, maximizing resources, case
management, and holistic health and healing, and an exploration of the First Nations
health program and practices.
Interview Sites
Focus groups and individual interviews were conducted on site at Whitehorse
Hospital, so as to provide easier access, increased comfort, and maximum participant
involvement. Various site locations were used in and around the hospital. The majority
of interviews were conducted in the report room on the west unit. This area is where the

48

largest concentration of staff works. Staff rest areas in their respective work place were
also popular venues. Middle management and senior administration preferred their own
offices as interview sites. The First Nations boardroom was used for two focus groups.
The hospital cafeteria, a bench outside on hospital grounds, the local coffee shop, and
another work place were alternative sites. Senior administrators supported my request to
conduct all interviews at Whitehorse Hospital, when units were not busy. Participants
were informed of this approval and authorization, but were consciously aware of taking
time away from their work. Many participants completed interviews on their meal
breaks, or on their own time.
Data Interview Process
Step 1 Gathering support
This process occurred in three phases. These steps included: 1) gathering support
and inviting participants to take part in my research project; 2) attending an information
education session; and 3) the completion of an interview questionnaire. The first step in
this interview process was the gathering of support for my project with recruitment
selection within specific identified discipline groups (Janesick, 1998). In the preparation
phase of this study, all staff who worked directly and indirectly with mental health clients
in various areas of Whitehorse Hospital were approached. A brief informal overview of
the study and research process was provided to potential participants, and if interested,
they were asked to attend an information education session, followed by the completion
of an interview questionnaire. Flexible times and days were offered for these meetings at
respective work sites. It was not known which participants would be involved, as this
would depend on level of interest, workload, and whoever was on shift on any given day.

Expressions of support were received from potential participants with only three
declining to participate, with thanks. Discussions were highly effective, and gathered not
only support for the research study, but also for the Shared Care model.
Step 2 Information education session
The information education session was the second component of the data
collection process. An overview of the Shared Care and Aboriginal models was provided
to participants. Historical background and key concepts of each model were reviewed,
and how they are integrated within the acute care setting of Whitehorse Hospital.
Collaborative practice and the possibilities of a Shared Care model at Whitehorse
Hospital were also discussed. A 'Participant Information Education Package' (see
Appendix 4) was made available to all those who attended the information education
sessions to assist in completion of the participant questionnaire. This package was
identical to the information presented, and was well received by participants. Only those
participants who attended the information education sessions could complete the
interview questionnaire. As a result of gathering support for this thesis project, the
participant recruitment and attendance at the information education sessions was
considered a success. Results were impressive with 63% of participants' having
completed questionnaires. Table 1 shows that strong support exists for this project.

50
Table 1
Participant Recruitment
Gathering Support

Over 100

Attended Information
Education Sessions

Number Participant
Responses

85

54

Step 3 Participant interview questionnaires
The third step in this data interview process was completion of the 'Participant
Interview Guide Questionnaire' (see Appendix 5). This tool was based on an interview
guide format, using a thematic method of inquiry (Coleman & Unrau, 1996; Huberman &
Miles, 1998; Rubin & Babbie, 1997; Seidman, 1998). This framework was developed
using a structured, step by step interview format with a specific list of topics and
questions to guide the interview. This process encouraged sufficient detail and allowed
participants to express their own views and in their own words. The interview guide
allowed the researcher the flexibility to informally gather the information, and ensured all
participants received the same inquiry process, and were asked the same questions, in
essentially the same sequence, and with adequate information (Rubin & Babbie, 1993).
Questions were clear, easy to understand, and open ended, allowing for description and
quality data (Coleman & Unrau, 1996; Rubin & Babbie, 1997; Seidman, 1998). The
expectation was that the participant interview questionnaire would explore and achieve
the objectives of this research study. A one page summary started the interview process
with specific instructions to assist participants with completion of the interview tool.
Handouts in this package (see in Appendix 5) provided background information on the
specific questions and topics for participants to refer to. The participant package

51
consisted of three parts. The first inquiry was the 'description of the Whitehorse Hospital
mental health program'. One of the handouts summarized the different disciplines, their
roles, and the services they provide to mental health clients. Participants were given the
opportunity to comment and update. The second inquiry, 'what are we doing now?'
allowed participants to discuss possible elements of Shared Mental Health Care within
the existing mental health care program. A handout was provided on this question also,
summarizing Shared Care at Whitehorse Hospital. The next set of questions focused
specifically on the key concepts of the Shared Mental Health Care and Aboriginal
models, in relation to the Whitehorse Hospital mental health program. A thematic matrix
style approach (see Table 2) organized and framed the key concepts of both models,
which helped to structure participant responses (Coleman & Unrau, 1996; Miles &
Huberman, 1994; Rubin & Babbie, 1997).

Table 2
Thematic Matrix
Shared Mental Health Care Model
Key Concepts
I Collaboration

Strengths
I

What Would You Like
to See Different
I

Solutions & Suggestions
for Change
I
I

Support/Education
Maximizing Use
of Resources
Case Management

Aboriginal Health Model
Key Concepts
Collaboration and
Consensus
Holistic Health and
Healing
Aboriginal Healing
Methods/ Practices

Strengths

What Would You Like Solutions & Suggestions
to See Different
for change

This matrix table presents the Shared Care and Aboriginal model key concepts, as
described in Table 1. This thematic interview format used a modified version of the
SWOT analysis to answer the third part of the questionnaire, 'how are we doing now?'
Idaho State University Pocatello (2006) defines SWOT as "a strategic planning tool,
useful for planning and decision making at multiple levels within an institution,
organization or business" (p. 1). This model is appropriate for this study, but somewhat

restrictive and negative, as it addresses, 'strengths, weaknesses, opportunities, and
threats' (Danca, n.d.; Krueger 1988; Westhues, Lafrance, & Schmidt, 2001). This SWOT
analysis was adapted for this study with the focus on 'strengths', 'what would you like to

53
see different', and 'suggestions and solutions for change'. Using this thematic technique
encouraged positive data results for changes in the mental health program, and reflected a
strengths perspective (DeJong & Miller, 2000), and a solution focused approach (DeJong
& Berg, 2002). There are intentional overlaps placed in the key concept thematic format.
The two questions, 'what would you like to see different?', and 'suggestions and
solutions for change' were similar, but different, and presented a more positive approach
to the data results. Participants would describe what they would like to see different,
rather than focus negatively on the mental health program. The third component of the
participant interview guide questionnaire consisted of three vision questions. They were:
'what would a Shared Mental Health Care model at Whitehorse Hospital look like in the
future?'; 'what Shared Mental Health Care components would you like to see
implemented?', 'what is your vision?', and all rated in terms of priority. A 'questions,
comments, suggestions' page, was also included in this package. All participants
received the same information and instructions either individually or in focus groups.
This ensured the consistency of the data across disciplines and methods. The interview
guide was piloted with a registered nurse colleague, who was not involved in the study
(Janesick, 1998). No major revisions were required at that time.
Data Collection
The data collection process took place over a period of four months, and with the
majority of participant questionnaires received within the first six weeks of the study.

54
Demographics
Table 3
Demographics
Years Worked at
Whitehorse Hospital

1-4

= 7

5-10

=16

11-15 = 31

Age

Gender

Race

< 29 = 3

M = 15

Caucasian

30-44

=15

45-55 =23

38

16-20 = 0
21-25 = 6

>55 = 10

=

46

Aboriginal =

6

Aboriginal/
Caucasian =

1

Aboriginal/
Black
=

1

>30= 2
Note. Respondents = 54 with 2 not completing the age category

The majority of participants, 71% (38) were between the ages of 30 and 55 with
approximately two thirds female, and one third male. All but eight participants are
Caucasian. It is expected the majority would have a relatively good working knowledge
of the Whitehorse Hospital mental health program, as 90% (47) of participants worked at
the hospital between 5 and 20 years, and two had over 30 years service. Only seven
participants had less than 4 years service.
A 'Participant Data Summary Tool' was created (see Table 4) to assist in the
organization of participant information. This non specific data was categorized according
to participant number, discipline, interview method, and site. This form also included:
data quality, appropriateness, gaps, variables, specific quotes, and important comments.

55
Table 4
Participant Data Summary Tool
Participant #
and Discipline

Interview
Method and
Location Site

Data
Appropriate Gaps/
Variables,
Quality / Relevant Incomplete Quotes, Journal
of the Data
Notes,
Comments

This summary data form was found to be invaluable, and referred to frequently
throughout the methodological process. Quantitative numbers were easily extrapolated
when analyzing demographics, disciplines groups, site locations, and interview methods.
Focus groups and individual interview methods
Participant interviews were conducted at Whitehorse Hospital to gather the
necessary information required for this study. Participants were offered a choice of
interview method, and whether to attend a focus group, an individual interview with the
researcher, or complete the questionnaire themselves. The focus group approach
consisted of a specific group of two to six persons coming together to discuss and explore
their thoughts, views and perspectives on a common topic (Krueger & Casey, 2000;
Patton, 1990). Individual interviews followed a very similar process with the same
standardized interview guide format, but with just the participant, and the researcher.
There was consistency, and little variation occurred across methods. Participants were
also given the opportunity to attend the focus groups or an individual interview either in
two separate sessions, a combination of both methods, or they could complete the
questionnaire themselves. These sessions did not have to run concurrently or on the same

56
day. This design change was effective in allowing for maximum participation in this
study. Participant focus groups and individual interviews were conducted with each
session taking approximately 30 to 45 minutes, followed by a question and answer
period. The time frame was the same for the presentation of the information education
sessions, and the completion of the questionnaires. Participants' respective worksites
were visited on average three to five times per week to make arrangements, conduct
individual interviews and focus groups, and follow up inquiry as to the completion of the
questionnaires. Some of these visits were during my regularly scheduled workday as a
nurse at the hospital, but during my scheduled meal breaks. A variety of dates and times,
and various interview locations, were made available. The flexibility and availability of
myself, as the researcher, was crucial in conducting the focus groups and individual
interview process. I endeavoured to establish rapport and an element of trust with
participants. As a result, relationships were able to develop within a supportive and
respectful environment (Fontana & Frey, 1998; Janesick, 1998). Every effort was made
to ensure maximum participation, and as little disruption as possible. At no time was
client care compromised in any way. All of these factors contributed to high respondent
numbers, critical to the success of this project.
The senior administrators at Whitehorse Hospital were the first discipline group to
receive the information education focus group session. Discussion followed the
presentation. Verification was provided that the participant sample would be inclusive
only of Whitehorse Hospital personnel. Also discussed, an inquiry as to the name for this
project, whether it was to be Shared Mental Health Care or collaborative care. A
unanimous decision supported a Shared Mental Health Care model at Whitehorse

57

Hospital. It was suggested this concept "fits in nicely with the future direction of the
hospital". Positive feedback and support was extended, with an endorsement from senior
administrators to proceed with staff focus groups and individual interviews.
The west unit was the second focus group to receive the information education
session. This group was multidisciplinary in nature, and included west unit registered
nurses and licensed practical nurses, and the hospital support staff discipline. This focus
group was important, as it was the first employee interviews. Informal evaluation
discussions were conducted following the information education session. Feedback was
requested, and received. The focus group process was considered to be a good
experience. Participants reported positively on the information they were given in the
presentation and summary handouts, which they described as comprehensive and
appropriate. Participants did say they needed time to process the information received,
and preferred to complete their questionnaires at a later date. They also requested
additional information to assist with completion of their questionnaires, specifically, the
detailed information education package I referred to in my presentation notes. I
subsequently provided this more detailed package (see Appendix 4) to all participants,
including the senior administration group, to ensure all received the same information.
No revisions or changes were required from the feedback.
Multidisciplinary focus groups continued on the west unit. During these sessions
participants were presented with the information education sessions. Focus groups were
a preferred method of choice by these participants with six being conducted at the
beginning of data collection. Single discipline focus groups were also conducted at the
same time in other areas of the hospital with several groups preferring to complete the

58
information education session followed by the questionnaires in one session. Mid way
through data collection, there was a notable shift in research method. Participant
preference was then for individual interviews for both the information education sessions,
and the questionnaire interviews. Almost all of the individual interview participants
preferred to complete their questionnaires themselves, returning them sporadically,
depending on hospital activity. Towards the end of data collection, gentle reminders
were provided to the remaining participants with the offer of support and assistance, or
the option of attending a focus group. As a result, this method was again popular with
four focus groups arranged towards the end of the study. Data collection was complete
when all disciplines were represented with sufficient numbers in all categories, and 54
respondents in this survey (Rubin & Babbie, 1993, 1997). Table 5 summarizes the
interview methods and represents participants who completed questionnaires.

Table 5
Interview Method
Discipline

Senior
Administration

Information Education
Sessions
Focus
Individual
Group
Interview

Questionnaires
Focus
Group

Individual Participant
Interview Complete

3

2

1

Middle
Management

2

2

Clinical Care
Managers

3

3

Physicians

5

2

1

1

First Nations
Health

4

Emergency Room
Registered Nurses

2

3

2

1

West Unit
Registered Nurses

5

5

10

Mental Health
Nurses

1

1

East Unit
Registered Nurses

1

1

5

4
2

Licensed Practical
Nurses

6

4

Support staff

6

6

2

3

7

Participant
Numbers

31

23

17

8

29

Note. Total respondents = 54; The physician group, includes psychiatrist

2

Table 5 clearly shows the majority of participants (48), preferred attending focus
groups to receive the information education sessions. A smaller number of participants,
(17), attended focus groups to complete their questionnaires. A large number (29),
preferred to complete the questionnaire component individually, and a small number
completed with the researcher. Most participants attended separate focus group sessions
for the information education session, and questionnaire. Although, some participants,
(18), preferred to complete both components in the same session, either in focus groups
or individual interviews. This complete approach was preferred by specific discipline
groups, such as family physicians, First Nations, and senior administration, possibly as
they were more available during the day. Strong support for this study was received by
all participant discipline groups.
Methodological Design Changes
It should be mentioned that decisions had been made to change the
methodological design in this research study, prior to data collection. The original
participant sample included only those employees who provided direct services to mental
health clients. There were four specific focus groups that would have included: family
physicians, and the psychiatrist; First Nations health workers; the staff on the west unit,
which included registered nurses, licensed practical nurses, and the mental health nurses;
and management. I had become aware that the shared Care model had expanded to
include other health care professionals, such as social workers. There was also
considerable interest to attend in this study. As a result, the participant sample was
expanded to all staff that provided direct and indirect care and services to mental health
clients. Methodological design changes in the interview method were then necessary to

61
reflect increased numbers in the participant sample. Also, the need for a more flexible
approach was evident. A shift from the original design plan of four centralized focus
group locations to varied participant locations of work was required. A decision was
made to allow participants a choice in method between focus groups or individual
interviews. The interview method was then changed. Participants were given the choice
whether to attend a focus group, have an individual interview with the researcher, or
complete the questionnaire themselves. The participant interview questionnaire guide
was also revised slightly to present a more structured and simplified approach to
accommodate participants who would complete the questionnaire themselves, and ensure
a standard is maintained across disciplines, and methods. All methodological changes
were reviewed and supported by Whitehorse Hospital senior administration.
Data Analysis Process
In preparation for data analysis, activities were conducted to organize and manage
the data, supporting this process. A systematic and structured data management and
analysis framework was created for this study. This format clearly guides this rigorous
and disciplined process (Coleman & Unrau, 1996; Patton, 1990). Huberman and Miles
(1998) provided an excellent framework used in this study. They describe three 'sub
processes' that include data reduction (manage the data), data displays (organize and
structure the data), and verification of conclusions (interpretation from data displays).
The first step in the data management process was to gather, organize, and manage all
relevant data (Coleman & Unrau, 1996; Patton, 1990). A physical and electronic filing
system was created with a back up data system (Huberman & Miles, 1998; Patton, 1990).
All participant interview responses were transcribed, and typed into data display

62
documents that were created to organize and reduce the data (Miles & Huberman, 1994).
These data sets were grouped according to discipline, location of work, key concepts, and
vision statement categories. A process of content analysis was used to identify patterns,
and key themes within the data, and define categories within a 'conceptual framework'
(Krippendorff, 1980; Patton, 1990). Thematic results were then put into matrices
(Huberman & Miles, 1998; Patton, 1990; Seidman, 1998). Vision statement data was
categorized in the same way using a similar process. The next analytical step was to
interpret the data, and verify conclusions. Observation of regularities, similarities,
differences, relationships, connections, and theoretical constructs was used. These tactics
were central to the identification and summarizing of the key themes in the matrix charts
(Coleman & Unrau, 1996; Mertens, 2005; Miles & Huberman, 1994; Patton, 1990; Rubin
& Babbie, 1997). A colour coded marking system was used with each colour delegated
to one of the seven vision statement categories, including subgroups. Counting
techniques were utilized to then determine priority vision statements (Krippendorff,
1980; Patton, 1990). Comparisons and contrasts of key concept and vision statement data
were conducted, including counting tactics to verify participant vision statements. This
data was entered into matrix tables. Analysis of all data was important to present an
improved Shared Care model for Whitehorse Hospital.
Trustworthiness of Results and Conclusions
Judging the quality of the data was essential in this research project with
credibility as the most important and critical indicator (Coleman & Unrau, 1996;
Mertens, 2005; Patton, 1990). There are a number of elements that are required to ensure
a credible study. A thoroughly researched methodological plan was necessary, as well as

63
the development of a structured data management and analysis framework, both adding
to the credibility of this research. Comparing and contrasting themes, and using different
methods of thematic inquiry, resulted in the presentation of appropriate and accurate
quality data results. Specific thematic matrix tools also structured, and validated the data.
The participant information education package (Appendix 4), and the participant
interview questionnaire package (see Appendix 5), and participant guided participants
through the data collection process, especially the key concept forms. The participant
data summary form (Table 4), and matrix # 1, # 2, #3, graphs (Appendix 6, 7, 8
respectively) summarized the key concept data into structured themes, and guided the
data management and analysis process.
A number of strategies and tactics to validate the credibility of this research study
were used in this paper. Sufficient and 'thick' detailed description of thoughts, feelings,
relationships, experiences, and context are balanced with credible explanation, and
participant summary responses. Perspectives and views of participants are clearly
presented within the thematic matrix results (Denzin, 1998; Patton, 1990). Audit trails,
via hard copy, and electronically were an integral part of the methodological process
(Coleman & Unrau, 1996; Patton, 1990). The data management and analysis plan is a
perfect example of an audit trail. Quotes, metaphors, and tests for completion have also
added to the credibility of this research (Coleman & Unrau, 1996; Patton, 1990).
Member checks (Janesick, 1998; Mertens, 2005; Patton, 1990) were completed with
participants who provided emails for results on their consent form. Prolonged and
substantial time at the interview site with participants (Coleman & Unrau, 1996; Janesick,
1998; Mertens, 2005) was another strategy used. I had purposefully visited the research

64
site during data collection, until I had sufficient representation in all discipline areas.
This process over time with the use of journal notations was consistently transparent in
tracking methodological changes. Results of this study are beneficial to other small
community based hospitals that have mental health programs that include both medical
and Aboriginal components. Authentic and fair representation (Mertens, 2005; Patton,
1990) of participant responses is presented as a balanced view of their perspectives,
values, and beliefs. This is crucial in ensuring an accurate description of this research
study, which is presented in this report. Mertens (2005) cites Guba and Lincoln (1989)
who describes the concept of 'ontological authenticity' or the "degree to which
participant's conscious experience of the world becomes more informed" (p. 256).
Participants not only became more informed about Shared Care, but strongly supported
this model at Whitehorse Hospital. Maintaining objectivity in this study was critical.
This ensured the research represents participant perspectives, and not my own
assumptions or viewpoints (Mertens, 2005; Patton, 1990). Distance from participants
during data collection was a key theme adhered to throughout the entire methodological
process (Coleman & Unrau, 1996; Guba & Lincoln, 1994). The rigorous and structured
methodological process of this research study presents credible and trustworthy results
and conclusions. Analytical strategies and techniques used an adequate and consistent
level of appropriate data, and the variety of interview methods used supports and
confirmed the research findings (Coleman & Unrau, 1996; Mertens, 2005; Patton, 1990).
A 'logical chain of evidence' was utilized in this study, and presented in this methodical
report (Guba and Lincoln, 1994; Mertens, 2005; Miles & Huberman; 1994).

65
Ethical Considerations
Ethical processes were followed during preparation, data collection, analysis, and
the writing of this report. An ongoing and conscious awareness of the potential for bias
and researcher effects was an integral and essential part of the research process. Every
effort was made to minimize these possibilities. An open and honest approach, the
sharing of my personal information, qualifications, and experiences is presented in this
report, which ensured credibility, and validated myself as a researcher. Considering, I
had personal and professional relationships with participants it was important to ensure
an accurate portrayal of the participant data is represented in an objective, neutral, and
unbiased way. It was essential that my position or standpoint, as a researcher to
participants, be reciprocal, and based on an equal position during data collection
(Mertens, 2005). These ethical considerations were integrated throughout the research
process, which ensured the research data and conclusions to be representative of
participant viewpoints in a fair and objective way. Anonymity, confidentiality, and safe
keeping of participant interview materials processes were also ethical issues adhered to.
Ethical conduct and research principles were an integral part of this study, and guided
this research project during preparation, data collection, data management, and the
analysis phases. A number of ethical research documents were reviewed concerning the
protection of indigenous knowledge, traditional medicines, and traditional practices
(Aboriginal Healing Foundation, 2000; Brascoupe' & Mann, 2001; Canadian Institutes
Health Research, 2002, 2007; Emery, 2000; Hill, 2003). Also critical to this academic
study, a review of ethical research guidelines was conducted, and referred to during the
research process. Publications include: the Canadian Association of Social Workers,

66
'Code of Ethics' (2005); the Association of Canadian Universities for Northern Studies
(2003); Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans
(Canadian Institutes of Health Research, 1998, 2000, 2002, 2005); and University of
Northern British Columbia's Policies and Procedures General Research Ethics (1995,
2005). It is important to note this research project was reviewed by the ethics committees
of the University Northern British Columbia, and informally by Whitehorse General
Hospital.
Summary
The research method used for this study has been outlined in this chapter. The
results of this study will show if a Shared Mental Health Care model would be successful,
and this discussed in the next chapter.

CHAPTER FIVE
RESULTS
Introduction
This research examines the Whitehorse Hospital mental health program, and
specifically the medical and First Nations health programs. Key concepts of the
Aboriginal and Shared Care models are presented from participant perspectives, in terms
of strengths, areas to improve, and solutions for change. Results are descriptive, and
reflect a vision for change, towards a Shared Care model. A thematic content analysis
strategy identifies important themes within the data, which was entered into matrix tables
(Krippendorff, 1980; Patton, 1990). Themes were categorized by Shared Care and
Aboriginal models, participant discipline groups, and locations. Vision statement data
was analyzed with critical themes emerging. A comparative analysis was conducted with
key concept themes, models, disciplines, and vision statement data. Thematic comments
were counted and framed within vision statements. These strategies assisted to verify,
and confirm data results. A Shared Mental Health Care vision for Whitehorse Hospital
emerged from the data, based on participant perspectives.
Matrix # 1: Key Concept Themes by Model
Matrix # 1 (see Appendix 6) clearly identifies support for major concepts within
the data, based on identified themes of the Shared Care and Aboriginal health models.
Matrix results present a majority of comments with equal representation of participant
responses in all key concept areas. Critical information identifies strengths, what
participants would like to see different, and solutions and suggestions for change. Table
6 presents a brief summary of key themes by model.

68

Table 6
Summary Key Concept Themes by Model

Shared Mental Health Care
Key Concepts
Collaboration

Support and
Education

Maximizing
Use of
Resources

Case
Management

What Would You Like Solutions/ Suggestions
See Different
for Change
- Improve
- Separate mental
communication
health unit
- Increase psychiatric - Mental health nurse
services
24/7 in emergency
and west units
- Improve educational - Mandatory mental
opportunities for: all
health in bi-annual
staff and new nurses
hospital days
- Psychiatrist and
mental health nurse
in-services
- Record telehealth
- Peer support
- Utilization of
- Mental health nurse
- Expanded mental
existing mental
24/7
health program and
health resources
- Second psychiatrist
staffing
- Psychiatrist support - Mental health
- Separate mental
and consultation to
health unit with
education sessions
family physicians
trained staff
to improve staff
- Expanded role of
- Mental health clinic
knowledge and
mental health nurse
with addiction/detox
skills
to emergency
- Mental health
department
multidisciplinary
rounds and clinical
case presentations
- Training in Shared
- Multi-disciplinary
- Shared care plans
approach to develop
Care plans
- Client history
Shared Care plans
- Mental health and
- Communicate
- Meditech care plans
First Nations client
Shared Care plans
- Review/ update at
record notations
exist
3-6 months by case
- Improve, update,
manager
and maintain plans
- Cultural component
- Psychiatrist and
physician - eligible
for fee for service

Strengths
- Collaboration
- Communication
among mental
health team and
family physicians
- Mental health
workshops, and
training
- Telehealth

Note. MH team consists of Mental Health Nurses and Psychiatrist; Meditech is Whitehorse Hospital
electronic client record

69
Aboriginal Health
Cey Concepts
Collaboration
and
Consensus

Holistic
Health and
Healing

Aboriginal
Healing
Methods and
Practices

What Would You Like Solutions/ Suggestions
Strengths
To See Different
for Change
- Collaboration
- Improve
- First Nations and
- First Nations health
collaboration
mental health staff
program
work collaboratively
- Improve
together to:
- First Nations health
communication,
communicate and
workers
specifically
report both verbal
reports of client
- First Nations health
and written client
information
health have
assessments and
excellent
- Expand First
information
Nations
staffing
communication, and
service, so more
emotional support to
- Expand First
available and
clients and families
Nations coverage to
accessible
weekends and nights
- Adolescent mental
health
- First Nations health
- Improve mental
information, tours,
- Discharge planning
health skills of
and pamphlets
- Knowledge of
First Nations
available resources
workers
- Integrate residential
- Need increased
school component
First Nation
into mental health
cultural information
intake assessment
- Focus on residential
school and related
social issues
- Strong personal
- Increased education - Educational training
belief in 'whole
in all areas first
- Holistic health
person', holistic
pamphlets on
nations health
health approach to
First Nations culture
program
healing
- Traditional
practices, such as
spiritual, traditional
medicine and foods,
elder support
- Healing room

- Improved
understanding
Aboriginal healing
methods, including
access and
utilization

Note. Meditech refers to Whitehorse Hospital electronic client record.

- Educational
sessions in First
Nations healing
methods, for all
staff
- First Nations
holistic health and
healing pamphlets
and tours
- Integrated holistic
health center

70

Matrix # 2 shows that participant data results overwhelmingly support a Shared
Care model for Whitehorse Hospital, one that incorporates components of Aboriginal
health. Considerable strengths are identified within the data, indicating a well supported
mental health program. These strengths show success, but there is also an
acknowledgment and desire for positive change. This is clearly evident in the excellent
suggestions and solutions identified for change. Matrix 1 presents a general and overall
summary of the participant data based on key concept themes. This approach not only
supports the key concept themes revealed, but presents additional specific information on
the participant data, reflective of the discipline, and triangulating the data. Further
analysis of the data by discipline and model was then conducted.
Matrix # 2: Key Themes by Model and Discipline
The second matrix (see Appendix 7) looks at participant discipline data from
differing viewpoints and perspectives. Key themes were explored within the Shared Care
and Aboriginal health models, and categorized by discipline group. Clear patterns and
views became evident with different priorities emerging with respect to strengths, what
participants would like to see different, and suggestions for change in the Whitehorse
Hospital mental health program. Table 7 presents a summarized version of Matrix # 2. It
is important when reading this table to note specific variations in discipline groups.
Middle management and west unit registered nurses, include other related health care
professionals clustered together to ensure confidentiality and anonymity. Family
physicians and the psychiatrist are referred to separately in other sections of this paper,
but in this chapter, both discipline groups are classified as 'physicians'. This allows for
confidentiality of the psychiatrist, and is appropriate as they attended the family

71
physician focus group. The First Nations health discipline group consists of staff from
the Yukon First Nations health program. Also, refer to Table 7, 'Note', for further
details. Questions may arise, as to why the east unit (surgical) was not included in this
study. A decision was made by the east unit clinical care manager that this area would
not participate in this survey, due to the new bed allocation system, and very few mental
health clients admitted to that unit. Table 7 presents key theme data, by model and
discipline for both the Shared Care and Aboriginal health models.

72
Table 7
Summary Key Themes by Model and Discipline
Discipline
Senior
Administration

Shared Care
- Collaboration is a strength, but
acknowledged a need to do more
- Support and education identified
as strength, as well as need for
increased training, and staff
development

Aboriginal Health
- Strong well accepted First
Nations health program
- Improve collaboration - provide
more support, no "road blocks"
- Educational programs for all
staff in holistic health, healing,
methods
- Explore traditional medicines fit
with medical system
- Integrated holistic health center

Middle
Management

- Support and education critical in
area of staff development

- Well accepted program
- Need for supportive counselling
training for First Nations staff

First Nations

- Strength is collaboration
between First Nations, and
mental health
- Need improved communication
between First Nations and west
unit regarding client charting
- Expand First Nations health staff
- Coordinated, well staffed mental
health clinic using Shared Care

- Strong Aboriginal health and
healing methods, especially
healing room, spiritual practices
- Need for education and access
to resources
- Revise mental health intake
form to reflect residential school
survivor issues

Physicians

- Overwhelming support for
collaborative effort of mental
health nurses
- Increased psychiatrist services
- 24/7 mental health nurse
- Critical issue - mixed mental
health unit solution a separate
mental health unit and day clinic

- Excellent First Nations health
program
- Aboriginal holistic health and
healing practice component
supported with interest and a
desire to learn more

- Mental health education — topics

include: Mental Health Act;
disorders, improve telehealth
- Local family physician funding
opportunities in mental health
- Develop Shared Care plans, be
more available & fee for service

73
Emergency
Department
Registered
Nurses

- Strong support for mental health
nurse in emergency department
- Need to expand mental health
nurse to 24/7, and be available
full time emergency department
- Mental health education - high
risk issues, and for new nurses
- Drop in clinic to decrease
emergency department workload
- Existing Shared Care plans good
but require consistent updating

- Very positive comments for first
nations health program,
- Strong support for First Nations
healing methods, especially
traditional medicines and meals,
elder participation, and
residential school healing
initiatives.

West Unit
Registered
Nurses

- Strong support for Shared Care
- Multidisciplinary cooperation
with family physicians, and
mental health nurses
- Mental health nurse is resource
- Need additional mental health
education and training sessions
- Mandatory biennial hospital
education days - incorporate
mental health
- Formal relationships with
university psychiatric resident
- Expand mental health programincreased psychiatrist; and
mental health nurse 24/7

- Strong personal belief and
acceptance of holistic health and
healing concepts
- Aboriginal healing methods
strongly supported by majority
- Need to improve verbal
communication in area of client
assessment and reporting
- Positive comments for First
Nations child support worker,
and discharge planning social
worker

West Unit
Licensed
Practical
Nurses

- Need for full time psychiatrist,
specific to Whitehorse Hospital,
for clients, and staff training
- Limited client Shared Care plans
- Need to communicate plan to
staff and update regularly
- Educational mental health
conferences, workshops,
training, and repeat them

- Strong support for collaboration
with disciplines working
together, and sharing
information
- Holistic health concept of
healing is an excellent strength
- Desire for increased awareness,
and education on First Nations
health program

74
Support

- Strong support for collaborative
and multidisciplinary approach
with mental health nurses, family
physicians, psychiatrist, and
support staff
- Expand mental health program
with additional psychiatrist, and
mental health nurses
- Explore psychiatrist resident
- Multidisciplinary client meetings
with flexible dates, times
- Improve communication - due to
potential safety issues
- Excellent workshops in mental
health - need training expanded

- Strong support for First Nations
health program, specifically the
sharing of information, and the
healing room
- Request for more information on
First Nations healing practices
and healing room tours

Note. Middle management includes clinical care managers, education, quality assurance; west unit registered
nurse includes: mental health nurse and east unit registered nurse; physician group, includes the
psychiatrist

Matrix # 2 presents similar themes, as in matrix # 1. Results in Table 7 show
considerable strengths in the key concept data. These strengths are balanced with areas
to improve. Collaboration among all disciplines is considered to be a strong focus of the
mental health program, as is support and education. Expanding the mental health
program to include increased psychiatric and mental health nurse services are identified
as a priority for many discipline groups. Also, very important is a separate mental health
area for clients, as well as educational opportunities that improve the knowledge and skill
level of all hospital employees. The First Nations health program is described as being
well accepted, by many participants, and this result is strongly reflected in participant
responses. There is also a definite and clear need for additional information about the
First Nations health program. The important issue for senior administration and middle
management is staff education and development, but from a broader perspective, and
reflective of their supervisory roles. The support discipline identified the need for

75

education for all staff involved or associated with mental health clients in their work and
duties. They identify specific issues related to collaboration, communication, support and
education, and staff safety. Numerous solutions are suggested by this group. The next
step in this research process is to examine participants' shared visions.
Matrix # 3: Vision Statement Results
The results of vision statement data present clearly defined themes that emerge
from three specific vision questions. They include: "what would a shared mental health
care model at Whitehorse Hospital look like in the future?", "what is your vision?", and
"if the mental health program were to be expanded, what would your priority be?"
Participants identified one to four vision statements, with several including two
comments within one vision statement. Results show a high number of participants, (43
or 79%) responding to the vision category section of the questionnaire. Matrix # 3 was
then created to present a vision for Shared Mental Health Care at Whitehorse General
Hospital (see Appendix 8 for details). All participant vision statements were numerically
ranked, according to priority and vision. Four vision statements identify five critical
themes in the data. They include: separate mental health unit; expanded mental health
service; outpatient clinic; day and hospital based program; separate addictions and
medical detoxification area; support and education; and Shared Care plans. An 'other'
category includes comments important to mention, but did not rank high enough to score
on the matrix. A decision was made to separate vision statements from matrix data
results. This was done to ensure vision statements were prioritized to present the future
direction of the mental health program at Whitehorse Hospital. Table 8 presents a

simplified version of Appendix 8 with participant vision statement priorities that are
calculated in percentages.
Table 8
Matrix # 3 Simplified

Vision

Vision Statement

Vision One

Separate mental health unit

Participant Response %

53

Expanded mental health program

Vision Two

First Nations health program

39

Mental health nurse

32

Other disciplines

25

Psychiatrist

18

Day hospital

27

Expanded mental health program
Mental health nurse

25

Other disciplines

13

Support and education

13

Vision Three

Support and education

20

Vision Four

Mental health nurses

35

Note. Percentages are based on Matrix # 3; Less than 10 comments are not included in this table,
except for vision # 4; in vision statement # 4 this number is rated six out of 17 respondents.

Table 8 clearly presents all vision statements. The majority of participants (80%,
or 156 out of 193) completed vision statements # 1 and # 2 categories. The analysis of
matrix # 3 posed several questions. These include: whether to use only the priority # 1

vision statements; a combination of vision statements # 1 and # 2; or the total number of
the four vision statements. The most appropriate conclusion that represents participant
views is to use vision statement # 1, with variations. My decision was based on
prioritized participant responses that present a clear shared vision for the Whitehorse
Hospital mental health program. Table 9 reflects these six vision statement priorities.
Table 9
Vision Statement

Priorities

Priority

Vision Numbers

#1

Separate Mental Health Unit

#2

Expand Mental Health program

25^

Mental health nurse

27

First Nations health

18

Other disciplines

17

Psychiatrist

11

Recreation activity

5

#3

Outpatient clinic and day hospital

22

#4

Support and education

10

#5

Case management and Shared Care plans

8

#6

Separate medical detoxification and addictions area

7

Note. Percentages include combined vision statements # 1 and # 2 and 80% of all respondents;
separate mental health unit is vision statement # 1, as identified by 25 of 53 respondents;
support and education includes vision statements # 1, # 2, # 3.

Vision Statement Priorities
Clustering of this data was relatively simple, as vision statements were clear, and
presented in six general categories. An 'other' category was created for statements that
were important, but did not fit. Also notable, vision statement data was analyzed after
key concept data, so as not to influence vision priorities. The first vision statement
priority in this study was clearly identified, as a separate mental health facility. Results
show overwhelming support for this concept with the majority (53%) of participants
identifying this as their first vision. This statement is also listed as the first priority,
because of the high participant numbers (23) in vision statement # 1. The expanded
mental health program for Whitehorse Hospital is identified as the second priority.
Participants suggest improvements and changes in all areas of the mental health program.
The majority of comments focused on increasing staffing levels for the mental health
program. Participant support is listed in percentages for this expanded model. This
includes: the First Nations health program (39%); mental health nurses (37%); other
disciplines (25%); and the psychiatrist (18%). This priority is listed as the second vision
statement, as participant support is strong with nearly half (45%) of vision # 1 and # 2
comments included in this section. I decided not to separate the specific elements of this
expanded mental health program, as numbers were consistently high across all vision
statements, as represented in the final totals. The third priority for a Shared Care vision
for Whitehorse Hospital consisted of strong support for a hospital based outpatient and
day clinic. This priority, when vision statement # 1 (23%) and vision statement # 2
(27%) are merged is rated by participants as being important. Support and education is
identified as the fourth priority, as the majority of participants identify this concept in

79
vision statement # 3 (20%), and numbers are consistent in vision # 2 (13%), and vision #
1 (9%). Case management or Shared Care plan is the fifth priority acknowledged by
participants. This area did not rate as high as others, but deserves to be mentioned. The
sixth priority, also did not rate high in the numbers, and includes a separate medical
detoxification, and addictions area. Several references were made for this separate unit to
be located within the hospital, and follow a 'best practices' detoxification protocol.
Matrix # 4: Comparison of Key Concept and Vision Statement Data
Participants clearly stated and prioritized vision statements. The question is,
whether priority visions are rated consistently across all data results. A comparison of
vision statement priorities with key concept themes by model (Matrix #1), key concept
themes by discipline (Matrix # 2), and vision statement data (Matrix # 3) was then
conducted. The first step in this analytical process was to numerically count comments
within the data display summaries, with respect to strengths, what participants would like
to see different, and suggestions or solutions for change, taking into consideration
concept overlaps. The seven vision statement categories were delegated using a colour
coded system, which assisted in the data analysis process. All participant responses in
the data display summaries and vision statement categories were counted. This technique
helped to visualize key themes in both sets of data, which further validated the findings
(Patton, 1990; Miles & Huberman, 1994). Matrix # 4 presents this information, and
displays the results framed by the vision statement priorities.
A 'Key Concept and Vision Statement Analysis Verification' tool was created in
Matrix # 4 (see Appendix 9). This table verifies the key concept data, and also provides a
comprehensive overview of the identified vision statements within the key concepts

80

framework. It should be noted, the theme collaboration, which includes both Shared Care
and Aboriginal health programs, is not evident in the vision statement priorities (Matrix #
3). The key concepts of holistic health and healing, and Aboriginal healing methods are
not listed either. Considering these key concepts are identified in high numbers within
the Matrix # 1 and # 2 data displays, they are included in this comparative analysis. The
results in Matrix # 4, show there are a considerable number of comments in the strengths
category (239), what participants would like to see different (470), and solutions and
suggestions for change (296) categories. This indicates sufficient detailed responses and
shows strong support for all identified key concepts, and vision statement results. Key
concepts are identified in this matrix, as collaboration, holistic health and healing,
Aboriginal healing methods, support and education, and case management concepts.
There is also an expectation for positive change, as participants identify what they would
like to see different. These areas include: collaboration, holistic health and healing,
Aboriginal healing methods, support and education, and an expanded mental health
program, specifically mental health nurses, and the psychiatrist. A number of excellent
solutions and suggestions for change are presented in this matrix, especially in the area of
collaboration, holistic health and healing, Aboriginal methods, support and education;
and expanding the mental health nurse program.
Results clearly show collaboration is the most important concept to participants,
which is evident not only in the number of comments (205) that is indicated consistently
in the data, with the exception of the vision statements. Holistic health and healing, and
Aboriginal methods also received a consistently high number of responses (201). This
concept is identified as a major strength, and there is a clear need and desire to learn more

81
about these Aboriginal key concepts. The concept of support and education (189)
received considerable discussion with a substantial number of comments on this issue.
Mental health nurses (88) are identified as the next priority. Shared Care plans (73), the
psychiatrist (59), and the First Nations health program (42) followed. A separate mental
health unit (42), as well as an expanded mental health program that includes other
disciplines (39), are also identified priorities. An outpatient clinic and day hospital, also
received notable mention. Recreational activities, and a separate medical detoxification
and addictions area, received the fewest comments.
Analysis of Matrix # 4, presents a separate mental health unit as priority # 1. This
concept is clearly identified in vision statement data, but is not consistently represented in
the key concept data, as only 42 comments were reported. Priority # 2 is presented as an
expanded mental health program. This area was consistently presented across matrix
tables, with the mental health nurse as the priority. The psychiatrist holds a higher rank
in the matrix data compared to vision statements, and numbers are relatively consistent
for First Nations health, and other disciplines. An outpatient clinic day hospital is ranked
as vision statement priority # 3, whereas in the data it is ranked considerably lower.
Support and education is ranked exceptionally high in terms of participant comments, yet
in vision statements, it is rated priority #4. There is a definite need to continue existing
educational programs, but expand in this area. A considerable number of comments on
case management and Shared Care plans are provided in the data, whereas this is rated as
priority # 5 in the vision statements. A separate medical detoxification and addictions
area, and recreational activities are ranked lower, at six and seven. Matrix # 4 clearly
shows what is important to participants, especially in the improvements for change

82
category. Vision statements should be respected, as this is a vision for the future of
mental health care at Whitehorse Hospital.
Comparison of Discipline Groups
Critical and common themes are identified within the data, specific to discipline
groups. Matrix # 2 was examined and data display summaries of the nine discipline
groups were analyzed. Relationships, comparisons, similarities, and differences were
explored (Coleman & Unrau, 1996; Miles & Huberman, 1994; Patton, 1990; Rubin &
Babbie, 1997). Different priorities and mental health issues were revealed for the
discipline groups, with respect to strengths, what they would like to see different, and
suggestions for change. Issues include: collaboration and communication; expanding the
mental health program; support and education; and safety issues, which supports the need
for a mental health area, which is separate from acute care services.
Collaboration and communication
All discipline groups expressed overwhelming support for collaboration. This
key concept is considered to be a strength, and by all disciplines, especially among the
mental health nurse and psychiatrist. Collaboration is also suggested as an improvement
with the majority of discipline groups. Another important suggestion is to expand the
mental health program. Communication is an identified area to improve for several
discipline groups. One example noted was some misunderstanding between the west
unit, and First Nations health staff about client reporting issues. The west unit registered
nurses and licensed practical nurses prefer to use verbal reports and updates, whereas
First Nations health workers utilize chart records for their communication. An awareness
and discussion of reporting preferences could be all that is needed to not only improve

83
communication, but the relationship between the two discipline groups. There were no
major differences between west unit registered nurses, and west unit licensed practical
nurses. The same is also noted for the physician group, which includes the psychiatrist
and family physicians. The psychiatrist arrived at the focus group a little late, and this
allowed family physicians an opportunity to discuss specific issues related to their
discipline. There were no differences in physician comments before or after the
psychiatrist attended. Comments appeared to be open and honest throughout. A large
number of participants in the support discipline group expressed serious concern in the
area of communication, relating to personal safety. Strong statements were cited in the
'what would you like to see different' section, followed by excellent solutions and
suggestions for change, which are detailed further on in this chapter.
Expanded mental health program
An expanded mental health program is presented in the data results. The majority
of disciplines overwhelmingly suggest increased services of the mental health nurse with
a 24 hour service, and an expanded role to the emergency department. Psychiatric
services would also be more available, with an increase to full time staffing. It is also
recommended the First Nations health program expand their coverage and services to
also provide 24 hours per day, and 7 day per week coverage.
Support and education
All discipline groups present positive comments for existing support and
educational programs offered at Whitehorse Hospital. Participants also provide excellent
suggestions to improve and expand training and education. In addition, west unit
registered nurses, licensed practical nurses, and physicians agree that the psychiatrist

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should be more available for consultation, and provide educational sessions to west unit
staff. Senior administrators are supportive of hospital educational programs, and suggest
additional opportunities for the mental health nurses. Emergency nurses provide
solutions of peer mentoring and skills training to improve confidence levels in the area of
mental health. The support group, on the other hand, address educational issues in terms
of hospital security and client safety.
Safety issues
The majority of participant discipline groups identify safety concerns with
specific reference to mental health clients admitted to the acute care service on the west
unit. A separate mental health unit is identified as a solution by the majority of
disciplines to address this concern. The issue of safety was strongly identified by the
support group with one key difference. The majority of the support discipline group
expressed concern for their own personal safety. A lack of communication, and not being
aware of potentially high risk mental health clients in this groups' workplace are the
specific issues.
Participant comments were usually related to their specific work location, their
clients' needs, and the services they provide. For example, the majority of nurses on the
west unit suggest a separate mental health unit, as they work in a mixed (acute care and
mental health) unit setting, whereas the emergency department registered nurses prefer an
outpatient clinic, and day hospital based program. Also, the west unit registered nurses
and licensed practical nurses are not as clear on the role of the First Nations workers, and
request clarification. In contrast, the emergency department registered nurses had greater
awareness and knowledge about the role of the First Nations health program. This

85
reflects on relationships, as the First Nations health workers work more closely with
emergency staff than the west unit, especially in arranging follow up, and referral
services for their clients. Physicians also had very positive remarks about the First
Nations health program, especially in reference to their clients in the emergency
department. Physicians also identified an issue of compensation for their time involved
in the development and updating of client Shared Care plans. This is the only group that
is not paid for their participation, whereas other disciplines attend on their regularly
scheduled work day. Residential school issues were raised by two disciplines. The
emergency department registered nurses say residential school healing initiatives are an
identified strength. The First Nations group suggests training of staff in this area, and
recommends that residential school assessments are conducted with the inclusion of
attendance, intergenerational histories, social concerns, and emotional issues. One
solution identified by the First Nations group is to integrate this residential assessment,
and incorporate a cultural component into a mental health intake and assessment form
(see Appendix 10).
Possible Limitations of the Data Results
Several issues, considered as possible limitations, emerged in this research study.
The first consideration was that the participant interview questionnaire was presented in
two different formats. The structured key concept thematic tool was one type used,
where participants commented specifically on the strengths, what they would like to see
different, and suggestions for change about the mental health program. The other format
was a descriptive inquiry as to participant vision statements about the future of the mental
health program. The two different interview formats, as well as three different

86
questionnaire methods could present possible limitations. On the other hand, the
methodology was used consistently across all methods. Another possible issue was
electronic recording of the focus groups, which was not done in this study. This could
have added additional background information that could have possibly influenced the
results. Considering individual interviews were not taped, this was the reason why this
was not done. A third possibility is that too much information was provided in the
participant interview guide questionnaire package. The concern is that the handout could
possibly lead the participant in the direction to support a Shared Care model. This was
not considered likely, as the more informed participants were the better they understood
the information, and the expectations required to complete the questionnaires. The
inclusion of clients in the participant sample was seriously considered, and clearly the
client perspective is missing from this study. This was a serious concern for one
participant from the support discipline group. This issue was discussed at length. The
concern was summarized as follows: it is critical that the client be a part of the
collaborative process, especially if the mental health program were to be expanded. I
agreed with this statement. After considerable thought however, I stood by my decision
not to include clients in this study. My reasons remained the same. The focus of the
study would have shifted from a descriptive to evaluation approach, and also Odata
collection was already in progress. Another issue was the three questionnaires, of which
two were missing, and one was partially complete. All three participants had received
information education sessions, followed by an individual interview. This is where my
very detailed journal notes were helpful, and their comments were included in the data,
and considered to be an important part of the methodological process. Language was a

87

possible issue to four participants, for whom English was a second language. These
participants were approached (as all were), and I inquired if assistance or clarification of
the questions was required. Two participants admitted they might have trouble putting
their thoughts into words. One received clarification and completed the questionnaire
themself, and the second received an individual interview. Responses from all four
participants were excellent with rich descriptive data presented. There were no apparent
differences in the quality of their data responses compared to their respective discipline
groups. There was one exception, as one participant provided limited data, but the
responses received were of good quality. I did question later, whether there could have
been more information had I interviewed participants themselves or conducted focus
groups. Reflecting on this, I do not think I would have done anything different.
Shared Mental Health Care Vision at Whitehorse Hospital
A future vision for a Shared Mental Health Care model at Whitehorse Hospital is
strongly supported by an overwhelming majority of participants with results consistent
across the data. The final step in this data analysis process is to identify participants'
vision of a Shared Care model from their perspective. Table 10 presents an outline of the
key summary points in this Shared Care vision.

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Table 10
A Shared Mental Health Care Vision for Whitehorse General Hospital
# 1

Collaboration

#2

Holistic health, and healing, including Aboriginal methods

#3

Separate mental health unit with day hospital and outpatient clinic

#4

Expand mental health program
Mental health nurse
First Nations health
Psychiatrist

#5

Support and education

#6

Case management and Shared Care plans

#7

Separate medical detoxification and addictions area

# 1: Collaboration
The key concept of collaboration is listed in the data as a significant strength to
the mental health program. Participant comments overwhelmingly state there is
collaboration, cooperation, and good communication among mental health nurses, family
physicians, the psychiatrist, and the First Nations health program. The mental health
nurses and psychiatrist are also seen as excellent supports to family physicians, and
nurses in the emergency department, and west unit. Collaboration is identified as a
strength, but this concept is also considered to be an area to improve, specifically the
communication of mental health clients who are potentially presenting safety concerns,
and reporting verbal and written client record notations. Suggestions clearly support a

89
separate mental health unit, and that mental health nurses be available to the emergency
department and the west unit 24 hours per day, and 7 days per week. Considerable
support is extended by participants in the area of Aboriginal collaboration and consensus.
There is also strong support extended to First Nations health workers. Data clearly
identifies this discipline group has excellent communication skills, as they interact and
provide emotional support with clients and their families. Other collaborative strengths
within the First Nations health program include: adolescent mental health care, discharge
planning, and knowledge of available resources. Participants provide clear direction on
solutions and suggestions to improve communication and collaboration. It is suggested
First Nations and mental health work more collaboratively together with improved
communication, specifically in the area of sharing and reporting of client assessments,
issues of concern, treatment and discharge planning, and other relevant information.
Another recommendation is the integration of a First Nations component into the mental
health intake process, which begins with the client's point of entry to the hospital. This
assessment (see Appendix 10) would determine First Nations status, and whether a client
is a residential school survivor. Also included would be incorporation of social concerns
and stressors, abuse issues, and these elements are also important in the discharge
planning process for clients.
In the area of collaboration, participant responses identify similar issues in this
category that overlap with other key concepts of support and education, and maximizing
resources. A collaborative effort is required for the maximization of existing and
available resources. This concept is critical to rural and remote Canadian communities.
The utilization of existing mental health services and resources at Whitehorse Hospital is

90
strongly presented in the data, as a strength. Support is strong for the collaborative
approach. This includes: improved communication, and supportive consultations
between the psychiatrist and family physician. Other collaborative strategies to
maximize resources include: an expanded mental health program, specifically extending
the mental health nurse role to the emergency department; and a second psychiatrist
would also improve the service. Another strategy to maximize resources is to have a
separate mental health unit, and a mental health clinic is also suggested.
# 2: Holistic health, healing, and methods
All participant disciplines consider the First Nations health program a strong, well
supported, and accepted program at Whitehorse Hospital. Participants do suggest the
need for increased understanding of the role and responsibilities of First Nations workers,
especially by west unit participants. Strong links to the community are considered to be
strengths, especially in arranging follow up, and referral services for emergency
department clients. First Nations and holistic health and healing methods are also
considered strengths, and this is consistently supported by participants across the data.
This concept is suggested as an integral part of the health and well being of First Nations
clients. Participants comment on personal preferences. Many state they have a "strong
belief in the whole person", and that holistic health and healing is a "wonderful approach
for treating the whole person". There is also strong support among participants for the
holistic health concept of the physical, mental, emotional, and spiritual healing, and
extending this concept to all hospital clients. The healing room, spiritual practices,
traditional foods, the medicines program, and elder support are considered strengths
within the First Nations health program. Tours of the healing room, and holistic First

91
Nations pamphlets, are some of suggestions for change. Participants have a strong desire
and interest to learn more about the First Nations health program. They suggest
additional educational opportunities for hospital staff in all areas of the First Nations
health program, but especially access and utilization, and Aboriginal healing practices.
Another important recommendation is to integrate a residential school component into
the mental health intake and assessment form. This would highlight residential school
attendance, and resulting social problems, as well as family and intergenerational issues.
# 3: Separate mental health unit with day hospital and outpatient clinic
The next priority in this study is a separate mental health facility. Participants
envision this unit to be an area separate from acute care clients, and the current mixed
ward. They suggest this mental health program is a separate unit, but in association with
Whitehorse Hospital, and one that includes an addictions and detoxification service. A
number of participants suggest the 'Thompson Center', which is an existing and vacant
structure adjacent to the hospital, and accessible via a locked hallway. Participants
provide very specific details for this separate mental health area. This unit would be a
multidisciplinary, well staffed, and properly trained unit that would operate seven days
per week, and 24 hours per day. This unit would include a consulting psychiatrist, First
Nations health, and mental health nurses. Other disciplines included are social work,
occupational therapy, and physical therapy. Structured activities and recreational
programs are also included. Participants' envision a strong First Nations presence within
this separate mental health facility. Support also exists to incorporate other programs
within this mental health unit. They include: a day clinic; day programs; a drop in; a
medical detoxification unit; a separate smoking area; activities; elder participation; and

92
access to other hospital services. Numerous participant comments refer to a
multidisciplinary and integrated medical and First Nations mental health unit. This
center would provide a comprehensive, and all inclusive holistic mental health service.
# 4: Expanded mental health program
An expanded mental health program for Whitehorse Hospital is identified as the
next priority, and rated as high by the majority of participants. The most important
component in expanding this program was the need to increase the staffing for mental
health nurse services to a minimum of 12, but preferably 24 hour day coverage, and 7
days per week. Participants suggest this would ensure weekends, sickness days, and
statutory holidays were covered. This improved service would ensure all clients and staff
have access to a consistent, and available, mental health nurse service. Other suggestions
by participants for the expanded role of the mental health nurse include: to work in the
emergency department on a permanent basis; operate a mental health clinic; and conduct
regular staff training. Also, identified by a significant majority is to expand the role and
services of the First Nations health program. Participants clearly support this program
with a need for additional First Nations health workers to be trained in mental health, and
staff levels be increased, so this service could be more available and accessible to the
hospital with a weekend, and night coverage. It was suggested this expanded First
Nations service could be integrated into an outpatient clinic, or a separate mental health
unit. A First Nations holistic health and healing center was also suggested, where
traditional health and healing methods would be offered with ceremonies, spiritual work,
and workshops on First Nations concepts. A number of disciplines identified the need to
increase the psychiatrist services for hospital client consultations, and family physician

93
support. This expanded role would also enable the psychiatrist to provide staff education
to ensure all disciplines associated with the mental health program are adequately trained.
Participant comments in this category, also suggest expanding the mental health program
to include other disciplines, such as a social worker, and a mental health family
physician. These professionals would work in partnership with other disciplines, already
involved in the mental health program, including the First Nations, and mental health
workers.
# 5: Support and education
Expanding on the existing educational mental health programming is a key
suggestion by a high majority of participants. The goal for many is to have educated,
well trained staff, who are specialized in the area of mental health. There are a number of
strengths presented in the data that support the existing educational workshops and
training. Non violent crisis intervention, CPR, telehealth, and First Nations cross cultural
training are some of the programs identified as excellent, and available to staff. There is
also a clear need to improve educational opportunities, and have workshops available for
all staff, including the support discipline. Participant solutions include: incorporating the
mental health and First Nations health program into the bi-annual mandatory hospital
education days; recording and taping of telehealth programs; a peer support and
mentoring program; and a variety of mental health in-services provided by the mental
health nurse, and psychiatrist. Educational modules and online self study are alternative
ideas. Specific suggestions for these topics include: psychiatric disorders, identification
of symptoms, medications and treatments; practical ways to deal with high risk mental
health clients; mental health and safety issues; and addictions. Other suggestions are for

the mental health nurses and the psychiatrist to present clinical case presentations, mservices, and conduct multidisciplinary mental health rounds. This would improve the
knowledge, education, skill level, and provide support to general duty staff. Also listed
as priorities, are the orientation of new staff to mental health, and a workshop on the
Yukon Mental Health Act (Government of Yukon, 2002). Another priority is to expand
mental health education to all First Nations health workers to improve knowledge and
skills in the area of mental health.
# 6: Case management and Shared Care plans
Shared care plans or case management are acknowledged in the data by
participants. This area did not rate as high as others, but considering this concept was
consistently presented in the data display summaries, it deserves to be mentioned.
Support definitely exists for mental health client Shared Care plans. There is an
acknowledgement these plans exist, and suggestions are clear. There is a need for
training on how Shared Care plans are developed to ensure effectiveness. Also important
to participants is to share and communicate that there is a client plan in place. Shared
care plans are described by several respondents as 'ancient'. Strong support exists for
client care plans to be regularly updated and maintained by the mental health nurses, and
on all clients who regularly access mental health services. Also suggested:
multidisciplinary rounds, which would involve the client in the development of their
Shared Care plan; a case manager responsible for an update review of the client plans
quarterly, or every six months; place the plan on the hospital electronic meditech client
system, so all staff involved are aware of the plan; and incorporate a cultural component
into the Shared Care plan. Historical and current client records, mental health nurse, and

95
First Nations health staff notations are all identified as case management strengths. An
important recommendation is to include in the mental health intake assessment First
Nations components of status, residential school abuses, and associated issues.
# 7: Other priorities
Several priority themes did not rate high in number, but were consistently
mentioned in the data. A separate medical detoxification and addictions area were
identified in this category. A majority of participant comments suggested that addictions
services be included as part of the separate mental health unit with some saying an
addictions unit should be located within the hospital. This would accommodate mental
health clients with addiction problems. The remaining priority themes include:
collaboration, consensus, and partnership; holistic health; client focused collaborative
consultations with a steering committee; safety policy; in and out-client therapy;
discharge planning; and a female counsellor to address women's emotional and mental
health issues, such as abuse and rape. One participant suggested "one holistic health
vision for all with a First Nations and medical approach to healing". I am confident the
summary of the Shared Mental Health Care visions that I have presented here will
encourage future discussion among participants.
Summary
Results presented in this chapter clearly support a Shared Mental Health Care
model, and vision for Whitehorse Hospital. Data analyzed represents participant data that
contributed to this vision. A Shared Care model is supported with an integration of both
medical and First Nations health models, and is incorporated throughout the entire mental
health program. Participant priorities clearly envision a future Shared Care model with a

96
strong collaborative and holistic approach to health and healing. A separate mental
health unit with a day hospital, and outpatient clinic, is the highest priority. An expanded
mental health program, specifically the services of the mental health nurse, First Nations
health, and the psychiatrist are described as critical to the future success of the mental
health program. Support and education, and case management or Shared Care plans are
also of high importance, followed by a separate medical and detoxification area. This
vision positively reflects on the future of the mental health program at Whitehorse
Hospital, and also impacts on implications for social work practice.

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CHAPTER SIX
IMPLICATIONS FOR SOCIAL WORK PRACTICE
Research Conclusions
The Whitehorse Hospital Shared Mental Health Care model is one that is strongly
supported by research participants from all disciplines, and at all levels. This vision
clearly shows support for a collaborative mental health model, complementing the
medical and First Nations holistic health components. The primary focus for participants
in this study is a separate mental health unit with a day hospital and clinic. Strong
support also exists for a second vision for an expanded mental health program with
increased services and staffing, specifically, the mental health nurse, First Nations health
workers, and the psychiatrist. The strengths of the mental health program showed
overwhelming support for the concepts and themes of collaboration, holistic health, and
Aboriginal healing methods. Support and education, client Shared Care plans or case
management, and a separate addictions area were also identified as clear priority areas for
participants. Results in this study show a definite commitment to the Whitehorse
Hospital mental health program by participants. This is evident in the participant
numbers with 53 completed interview guide questionnaires. The data was descriptive
and detailed with clear representation by all disciplines with sufficient data in all
categories. The collective shared and common experiences (Patton, 1990; Schwandt,
1997) among participants involved with the mental health program were forthcoming,
and with tremendous support. This reflected on a commitment of the staff at Whitehorse
Hospital to work together to create a Shared Care vision for the mental health program.
Participants identified a great number of strengths within the program. This is balanced

98
by a need to improve this service. Many suggestions and solutions were identified to
address these issues. A Shared Care model is definitely supported in the data results.
The purpose and objectives of this research study have been achieved. It has been
determined there is a Shared Mental Health Care model in existence at Whitehorse
Hospital. This is clearly a successful collaborative program that supports both the First
Nations and medical approaches within a Shared Care perspective. This is evident in the
matrix key concept data. Some inconsistencies around communication and safety
concerns do need to be addressed, but the results from this report will likely initiate
positive change. There is a clear need for program description of Whitehorse Hospital's
existing services, and this is presented in Chapter Three, and throughout the data. It is
important for all involved to be aware of the different program components, the staff
involved, and their roles. It is evident from participant responses that there is an
increased awareness, and a greater understanding of the components of the Aboriginal
and Shared Care models, and how they fit within the Whitehorse Hospital medical and
First Nations health programs. Research statements definitely address the question, as to
whether a Shared Care model exists at Whitehorse Hospital, and it clearly does. A vision
for a new and improved Shared Mental Health Care model for Whitehorse General
Hospital, Yukon is one that uniquely incorporates both medical and, First Nations
cultural and holistic health and traditional healing practices.
Common Themes in the Research
Key themes in this research were explored. Collaboration is a recurrent theme in
this research study. A collaborative model is described in the Shared Care literature as,
encouragement and support for the working relationship between the family physician,

99
psychiatrist, and mental health professionals. This partnership works towards improved
communication and consultation. This collaborative model is one that, if all
professionals are in agreement, can successfully coordinate a multidisciplinary group of
health and social service professionals, and as a result effectively maximize mental health
service delivery. A shared responsibility is critical for the caring of mutual mental health
clients, leading towards a more comprehensive approach to mental health service care
(Canadian Psychiatric Association and College of Family Physicians of Canada, 2000;
Kates, Craven, Bishop, et al., 1997). Another critical theme that is strongly supported in
the literature and throughout this research study is the concept of the holistic health
model. Collaboration, consensus, and partnerships are also strong component of
Aboriginal principles, as well as relationships, and a sense of community. The focus on
an acknowledgement and acceptance of the Aboriginal holistic health and healing
concept is considered to be the cornerstone for change, and is supported by all levels of
governments. This is a positive shift towards an integration of holistic health beliefs and
practices into all aspects of the medical model (Aboriginal Healing and Wellness
Strategy, 2001; Lane, Bopp, et al., 2002). Yukon Territory is no exception. There is
strong support for the concept of Aboriginal health and healing from this territorial
government, the Whitehorse Hospital board of directors, and senior administration. This
is evident in the creation of the Whitehorse Hospital First Nations health program. There
is a successful integration of Aboriginal health and healing, cultural approaches,
philosophies, and traditional healing methods into all aspects of the Whitehorse mental
health program, which is clearly supported in the research results. This type of
collaborative model has shown a recent increase in Shared Care initiatives across Canada,

100
including the northern territories (Canadian Collaborative Mental Health Initiative, 2005,
December). A Shared Care model is in existence at Whitehorse General Hospital, and
according to participants, is a successful collaborative effort (Scott, 2002).
Collaborative and Holistic Health Approach to Social Work
Collaboration is a key social work principle and value, where stakeholders work
together to develop partnerships, and collectively share resources and responsibilities of
mutual clients (Barter, 1996; Hart, 2001). Barter (1996) also suggests that a collaborative
framework is a 'critical theme' for social work practice, and there needs to be a
commitment by stakeholders to work together. Collaboration was also a key theme
among social workers at a Canadian Association of Social Workers (2001) forum in
Montreal, Quebec. This conference was considered to be a historic event, where social
workers from the areas of practice, education, and regulation came together for the first
time. The document, Toward Sector Collaboration, presented a summary of discussions
that took place at this conference. Many identified issues that impact on the social work
profession include: financial constraints, changes in the delivery of social programs and
services, world events, and globalization. This collaborative sector approach charted a
new path forward for the profession and addressed priorities and strategies for the three
areas of social work. MacKenzie Davies (2005) describes the possibilities of an
interprofessional approach to social work practice, education, and research. This author
is editor of the Journal of the Ontario Association of Social Workers Newsmagazine.
This magazine devoted an entire issue to the theme of interprofessional collaboration,
which is now suggested to be the preferred term, rather than interdisciplinary. ShekterWolfson (2005) defines the term interprofessional practice as "occasions when two or

101
more professions learn from and about each other to improve collaboration and the
quality of care" (p.l). Shekter-Wolfson (2005) suggests that as social workers 'move
forward' in the profession we are positioned as a 'natural fit' to collaborate with other
health care professionals, and their mutual clients.
Collaborative practice is a key component in a joint position paper by the Alberta
Association of Registered Nurses (n.d.), which involves the provincial registered nurses
association, licensed practical nurses association, and the registered psychiatric nurses
association. Collaborative practice is a working relationship and environment, for the
benefit of clients and workers. Two former, Toronto, Ontario, nursing college programs,
Centennial and George Brown Colleges, have merged and work collaboratively, and in
partnership with Ryerson University (2006-2007) to offer undergraduate degrees in
nursing. These programs utilize resources and share classes of both colleges. This
program initiative is a relatively new concept across Canada. A note of interest is that
Centennial College is where I received my nursing college diploma, and my social work
undergraduate degree was with Ryerson University. As of 2005, this university now
offers a collaborative nursing program. The University of Toronto (n.d.), faculty of
social work, offers interdisciplinary collaborative graduate degree programs. The
University of Northern British Columbia (n.d.) school of social work program is quite
unique, as collaboration is promoted, especially in remote areas, northern, and in
Aboriginal communities. This is evident in the commitment by this university to support
a collaborative, interdisciplinary, and holistic approach within social work education, and
practice. Holistic health is a critical component of social work practice. Medical
definitions of health now include a holistic component, which involves all parts of the

individual, including their family, social, and environmental aspects (Miller & Keane,
1997). Saleebey (1992) suggests social workers' reflect on a client's issue from a
'strengths' perspective, which is to focus on the concept of health and wellness, rather
than disease. This approach also looks at a holistic view of the client in the bigger
context of the individual's life, and their community support systems.
Highly respected Aboriginal scholars (Brant Castellano, 2004; Hart, 2001;
Simpson, 2000b) write about the importance of understanding, accepting, and integrating
holistic health concepts into medical systems. New frameworks are now being created
that represent the strengths of both cultures and models (Petch, 2000). It is clear, in the
data, there is strong support for an integration of the holistic health model within
Whitehorse Hospital mental health program, and there is also a definite need and desire
of all participant disciplines to learn more about the First Nations holistic health program
and practices. A critical concept of the Whitehorse Hospital's Shared Care model is that
the two distinct First Nations and medical components complement one another. The
utilization of the strengths of both programs with an integration of the Aboriginal and
medical components, form the foundations for a strong, and sustainable mental health
program.
Personal and Professional Impact of Research
The common themes of collaboration and holistic health have major implications
for social work practice. Incorporating themes of collaboration, partnerships, and
principles of holistic health and healing should be an integral part of a social worker's
practice. Janesick (1998) suggests a researcher explore how their ideology fits within
their practice framework. This research study has challenged my principles and beliefs,

103
and caused me to examine my personal and professional practices. My methodological
ideology has strong roots in the medical model, as I have been a registered nurse for
many years. As I moved into the social work profession, with an undergraduate degree in
1996, my philosophical views shifted to a more social and environmental approach with a
strong interest in holistic health. A personal learning objective began, over ten years ago,
when I started working with Yukon First Nations communities. My understanding of
holistic health and healing concepts from a First Nations perspective improved, and I was
able to put the theory I had learned into practice. I also explored my theoretical
constructs taking University of Northern British Columbia, Masters level social work
courses, which again challenged my personal values and beliefs, as a registered social
worker, and a nurse. An awareness of this in my role as researcher, as well as my
intimate knowledge of the mental health program, my social work and nursing
background and experiences, and my theoretical constructs were all elements of
consideration in this report.
The Shared Mental Health Care collaborative model seemed a natural fit with my
social work and nursing background. Having been introduced to the Shared Care model
by a Whitehorse family physician, and attending the national Shared Care conferences, I
was committed to examining how this approach would fit within Whitehorse Hospital. I
was inspired by one Canadian psychiatrist, Dr. Nick Kates, who led the initiative for
Shared Mental Health Care. His participation and contribution to the comprehensive
Shared Mental Health Care in Canada, joint position paper (Kates, Craven, Bishop, et
al., 1997), and continued work with the Collaborative Working Group has been
admirable. Dr. Kates is a strong advocate for Shared Mental Health Care, and continues

104
his work today through the Canadian Collaborative Mental Health Initiative (2006). As a
result of Dr. Kate's unwavering dedication and commitment to Shared Mental Health
Care he has inspired many health care professionals, including myself. In Yukon, there is
considerable support now for the collaborative Shared Care approach from within the
medical community, government, Whitehorse Hospital, and the participants in this study
who now strongly support this concept. Northern territorial Shared Care initiatives have
now begun with Whitehorse Hospital being one such program (Canadian Collaborative
Mental Health Initiative, 2005, December).
The holistic health principles and practices are an integral and critical part of my
professional practice as a social worker. Hart (2001) suggests social workers incorporate
holistic health into their own practices, especially if working with Aboriginal clients.
This author also suggests social workers personally explore their own physical, mental,
emotional, and spiritual aspects of themselves. Strategies such as these, would not only
create a better understanding of Aboriginal beliefs and values, but also improve the
relationship between social worker, and client. Mr. Hart speaks from a personal
viewpoint, as he is of First Nations ancestry, and a social worker. I agree with Hart's
approach. I myself have examined holistic health concepts in relation to my social work
practice. I believe in the holistic model of health that considers the different parts of the
individual, including the physical, mental, emotional, spiritual, social, and their
environment, and the family and community in which the client lives. You must have all
these elements in order to be healthy, whole, and in balance. Hart (2000) describes the
'helping process', as stages of development. They include: healthy relationships; the
sharing of knowledge and information; and using specific techniques, such as the

105
medicine wheel, ceremonies, rituals, and elder advice and participation, in healing
approaches. I concur with Hart, and suggest these stages are critical to optimum health. I
have benefited personally and professionally, and felt honoured to have been asked to
participate in a number of First Nations ceremonies within Whitehorse hospital, in my
role as mental health nurse. Professional associations are suggesting their members
integrate holistic health into professional practice (Hart, 2001; Smylie, 2001). It is the
strength and commitment of all health care professionals involved in these processes, to
move positively forward, and towards equality of health among Canadians. This
approach would then support the integration of holistic health principles into mainstream
medical systems, and social work practices. An integrated medical and holistic health
model of social work practice is achievable, desirable, and beneficial for both health care
professionals, and clients in any cross cultural setting. I believe an integrated model
begins with having a better understanding, and acceptance of Aboriginal cultural and
healing methods working with Yukon First Nations communities, and the Whitehorse
Hospital First Nations health program. I challenge all social workers to examine their
holistic health beliefs, and integrate this concept into their professional practice. My
personal, professional, and academic experiences, as well as analyzing the results of this
research study have contributed to my now unique collaborative and holistic health
approach to social work practice.
Research Implications for Social Work Practice
Another journey that I have taken, as a result of this research study, is a
methodological one. Patton (1990) states "critical and creative thinking" (p. 434) is
addressed through qualitative inquiry. In my pursuit for a step by step qualitative

106
process, I came to the realization I had to be creative, as there were no clear, concrete, or
systematic social work frameworks that would assist me to manage and analyze the
research data for this study. Tutty, Rothery, and Grinnell (1996) provide descriptive
explanations as to what to do, but no specific information on how to conduct data
management and analysis, from a social work perspective.
Rubin & Babbie (1997) calls the methodological process, (as cited by Lofland &
Lofland, 1995), a 'terminological jungle' (p. 6). This very accurate term, (as cited by
Rubin & Babbie, 1997) described my thoughts, as I reviewed the many different
approaches, models, theories, and texts. A descriptive phenomenological approach
(Patton, 1990) was considered for this research study, but a more structured and
systematic approach was what I was looking for. This personal preference was likely due
to my medical background. The grounded theory model (Huberman & Miles, 1998;
Miles & Huberman, 1994; Strauss & Corbin, 1998) was also considered for this study, as
it provided a detailed and clear 'how to' approach to data management and analysis, but
this model was not appropriate for this study. This methodological detour of mine was
beneficial in that a number of approaches were reviewed for consideration in this
research study, and may be useful in future studies. The concern remains however, that
there is no clear, step by step social work model from which researchers like myself,
would benefit. Harrison (1994) suggests there is no specific social work model, but there
is an integration of other research models that reflect social work perspectives, and
approaches. I realized I needed to put my social work hat on, and reevaluate the purpose
of the study and my research question, and have a more conscious awareness of my social
work and nursing theoretical constructs. As I continued to review the literature, I began

107
to get a clearer picture of the analytical process I would use in this study. The first
challenge for me was develop a framework, which I could work within, so a personalized
data management and analysis framework was developed. My decision in the end was to
incorporate parts of the social work and medical models using a descriptive thematic
inquiry and comparative analysis process. The different theoretical perspectives and
views assisted me to frame and structure an individual approach that contributed to the
methodological process. This framework incorporates, integrates, and blends together
different theoretical approaches and strategies from a variety of disciplines, and is
supportive of my medical and social work background, as well my interest in psychology
and education. The lack of a clearly defined social work model of practice could be
considered beneficial, as social workers do have the flexibility and creativity to develop a
critical model appropriate for their specific practice. This personal approach could assist
their clients by using an all encompassing, collaborative, and more holistic model of
service delivery. Concerns do exist, however that with no clearly defined social work
model, there is a lack of credibility, and validation from other professions. Perhaps, the
standardization of social work practice, verification of credentials, strong provincial and
territorial social work organizations, and a more involved and powerful Canadian
Association of Social Workers lobby group would give credibility to a well deserved
profession.
Relevance for Future Social Work Research
The impact of this research study clearly shows an accepted and well integrated
medical and Aboriginal model within a small community hospital. This Shared Mental
Health Care model in Yukon was one of the first precedent setting programs of its kind

108
that involved a community hospital in the Northern territories, and a model for other
hospitals to follow in similar settings.
This research study explores and describes the existing mental health programs,
and outlines strengths, areas to improve, and solutions and suggestions for change by
employees. A vision for a future mental health program is also presented, based on
participant perspectives. The next phase of this research project is to give clients an
opportunity to do the same. This would result in a more comprehensive vision for the
mental health program at Whitehorse Hospital, and be representative of all those involved
from a consumer, community, or a professional capacity. Vision statement priorities
would then be the basis for program changes and policy development. Proposals
submitted and a detailed implementation plan would be the next steps. Future change is
inevitable, and a true vision, based on participants' views and ideals, would strengthen
the mental health program, maximize available services, and promote a comprehensive
and complete medical and holistic mental health service, one that is beneficial to, and
supported by clients, staff, management, and hospital board of directors, and Yukon
communities.
Summary Conclusion
It is the reality of a vision for a Shared Mental Health Care model at Whitehorse
General Hospital that started this methodological journey. It is also my passion for the
mental health clients, and the mental health program that has propelled and energized me
throughout this methodological journey to the completion of this thesis report. This
research provides participants and employees of the Whitehorse Hospital with an
increased awareness and understanding of the two major components of the mental health

109
program. This knowledge brings together medical and First Nations cultural concepts,
and principles of holistic health and healing. The collective descriptive experiences, and
comments among participants involved with the mental health program clearly show that
the strengths of the mental health program are considerable, and reflect the desire and
commitment of all staff to work together towards positive change, supportive of the many
identified solutions for change. This research paper positively describes the collaboration
of the First Nations and medical programs of the Whitehorse Hospital mental health
program. This successful blended model integrates and incorporates First Nations
cultural traditions and beliefs, and a holistic approach to health and healing, thus being
complementary and supportive of a unique Shared Care model. The results of this study
confirm this is a strong and well supported mental health program, and is one that reflects
on the health care professionals who deliver this service. There is obvious commitment,
enthusiasm, dedication, and support by the Whitehorse Hospital staff participants for an
improved mental health program with an identified vision for the future. There is a
unique Shared Mental Health Care model at Whitehorse General Hospital, Yukon.

110
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APPENDIX 3
PARTICIPANT SUMMARY SHEET & CONSENT FORM
A Shared Mental Health Care Model at Whitehorse General Hospital
My name is Lynn Scott and I am a graduate student at the University of Northern British
Columbia working on my thesis towards a Masters degree in social work. I currently work casual
as a registered nurse on the West unit, and if you recall, have previously worked as mental health
nurse. I continue to have a personal interest in the field of mental health and the success of the
mental health program at Whitehorse Hospital. So, I am asking you to participate in this study.
Shared Mental Health Care (Shared Care) is a relatively new and innovative health care concept
bringing together family physicians, psychiatrists, mental health nurses, and nurses. This new
approach brings a collaborative and comprehensive approach to mental health care. I believe
Whitehorse Hospital has a Shared Mental Health Care program, what with the expanded role of
the mental health nurses seeing mental health clients in the emergency department, and the
continued use of 'Shared Care plans in the emergency department. These components of the
Whitehorse mental health program fit nicely into the national strategy of the Shared Care model.
The purpose of this research project is as follows: to present a general description of the mental
health program from participant perspectives; show how the First Nations and medical models
collaborate, complement and support one another, incorporating national Shared Care principles;
and finally, based on participant responses, present a new and improved Shared Mental Health
Care model, reflective of First Nations cultural and healing practices, for Whitehorse Hospital.
In this descriptive and thematic qualitative study I will personally select participants, depending
on their interest in the mental health program, and availability. Participants will be assigned to
specific focus groups depending on profession and occupation. The four groups will include the:
First Nations health program; medical staff; Physicians; and Administration. Participation will be
voluntary and you may withdraw at any time without a reason, and without penalty. Information
received during focus group interviews will be kept confidential specifying no names, and will be
coded according to group, allowing for candid expression of thoughts and feelings. The
information you provide will be used toward my Masters of social work thesis, and it may also be
used in scholarly papers or journals. Tapes will be transcribed then erased. All written interview
materials and notes will be shredded within two years following acceptance of the thesis.
Common themes shared in the focus groups and interviews will be summarized, and inserted as
tables in the paper. Authorization will be requested if specific quotes are used. The attached
consents will be reviewed prior to the interview.
If you have any problems or concerns with this process, please contact myself at the numbers
listed below. You can also contact my supervisor, Dr. Glen Schmidt, 250-960-6519, or Dr. Max
Blouw, Vice President Research, University of Northern British Columbia, 250-960-5820).

So, I am asking you to participate in this study and I encourage you to ask questions and share
comments during the focus group interviews. Should you have any additional comments
following the interviews, please feel free to call or email. I would be very interested in what you
have to say. Thank you very much for your time.
Sincerely, Lynn Scott Tel: 867-634-2138 (home); 393-8722 (west unit); Scotts@northwest.net

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CONSENT
Focus Group Interview Participant
Interview Group:
Participant #:

1. I understand that Lynn Scott is conducting a study for thesis completion towards a Masters of
social work degree at the University of Northern British Columbia. The topic of research project
is:

A Shared Mental Health Care Model at Whitehorse General Hospital

2. I understand that I have been asked to participate in focus groups and interviews to discuss
the mental health program at Whitehorse Hospital. This interview will last for approximately 1 Vi
hours, and my participation is voluntary. I may withdraw at any time.

3. I understand and agree that the information I will provide to Lynn Scott during the focus
groups will be respected, and remain confidential and private at all times. I understand this
information will be recorded, kept under lock and key, and deleted and shredded within two
years of the completion of this thesis project.

I agree to participate in this study and have received and read the Participant Summary Sheet

Print name:
Signature:

Date:

Please complete if you would you like to receive a copy or email of the results of this paper?
Yes

Telephone number and/or Email address:

APPENDIX 4
PARTICIPANT INFORMATION EDUCATION PACKAGE
SHARED MENTAL HEALTH CARE at WHITEHORSE GENERAL HOSPITAL
1. OUTLINE FOCUS GROUP/INDIVIDUAL INTERVIEW PROCESS
>

HELLOS/ INTRODUCTIONS/ PASTRIES

>

PARTICPANT PACKAGE - Consent

2. PURPOSE - GOALS - OBJECTIVES
PURPOSE: OF MY THESIS
> Present a Shared Mental Health Care Model for Whitehorse General Hospital
> Incorporate national Shared Mental Health Care principles and key concepts
> Reflects First Nations principles and values, and
> Represent a territorial and northern perspective (northern territories)
MY GOALS: FOR THIS STUDY
> Increase awareness and understanding of the Aboriginal model, the Shared Mental
Health Care model, and integrated medical and Aboriginal models of health care
> Present an overall description of the mental health program at Whitehorse Hospital
from participant perspectives
> Explore how the Whitehorse Hospital's First Nations and medical programs operate
independently, as well as collaborate, complement, and support one another, using
principles of the national Shared Mental Health Care model.
> Present a vision for a new and improved Shared Mental Health Care model for
Whitehorse General Hospital, Yukon, which uniquely incorporates First Nations
philosophical, cultural and traditional healing practices.

MY OBJECTIVES - for this study
> When this study is complete, I will proceed with writing up the research report, to
complete my thesis for my Masters degree in social work
> Present a proposal to the Collaborative Working group, so as to apply for funding to
implement the vision of a Shared Mental Health Care program at Whitehorse
Hospital

3. INFORMATION and EDUCATION
• Shared Mental Health Care healing Model
• Aboriginal health and healing health Model
• Integrated medical and Aboriginal Models in health care

I NEED YOUR INPUT-HOW CAN WE MAKE OUR MENTAL HEALTH PROGRAM
BETTER?

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1.

SHARED MENTAL HEALTH CARE MODEL

Question
Have you heard about Shared Mental Health Care-also known as Shared Care/Collaborative care?
Definition
"A 'process of collaboration', where family physicians and psychiatrists, through improved
communication and consultation, share responsibility for the care of mental health clients,
ultimately providing a collaborative and comprehensive approach to mental health care" (Kates,
Craven, etal., 1997).
Historical Background
• Many reports have been published by family physicians expressing frustration and
concern when accessing mental health care services for their clients - communication
issues; access mental health services; lack of respect and support
• In 1997, the Canadian Psychiatric Association and the Canadian General Practitioners
association identified a need and a very definite gap in the services provided to mental
health clients.
• In 2000, representatives from both associations published a Joint Task Force Position
Paper Report, (Kates, Craven, Bishop, et al, 2000), and proposed a solution they called
'Shared Mental Health Care', bringing together family physicians, psychiatrists, and
mental health professionals to provide a more comprehensive delivery of service, thereby
improving access and quality of care to mental health clients (Kates & Craven, 2000).
Collaborative Working Group (2000) outlined Shared Care principles and key concepts
... Suggestions for Implementation
4 A review of existing mental health services
4 support for a collaborative approach among mental health professionals
•Jr- The need to define effective strategies dealing with underserved, rural
and isolated communities, including Aboriginal populations.
•

Shared Care has now expanded further to involve groups other than family physicians
and psychiatrists. A national collaborative Shared Mental Health Care Project (2002)
working group has been established and represents many Canadian associations including
social workers, occupational Therapists, mental health nurses, mental health,
psychologists, nurses, psychiatrists, family physicians.

•

World Health Organization
• 'Health Systems: Principled Integrated Care' (2003) - Report suggests:
health systems be based on core principles of primary health care
•
Mental health: New Understanding, New Hope. (2001)
> This report suggests a shift towards a Shared Mental Health Care model
> Recommendations include:
• A consultative approach
• Integration of psychiatry and mental health within primary care
health care settings
• Increasing the knowledge base of professionals
• Changing university curriculum to reflect mental health
services
• Improved access to mental health services with decreased
stigma.

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Key Concepts of Shared Mental Health Care (Shared Care):

1. Collaborative/Consultative Approaches
•
•
•
•
•
•

Original goal - of Shared Care is to improve the working relationship between family
physicians and psychiatrists; and mental health professionals
Objective - to do this it is suggested professionals meet in the family physicians'
office, thereby increasing client's access to mental health services
Professionals working with mental health clients work in collaboration with one
another
Communication
Relationships
Integrate primary care and mental health services

2. Education and support
•
•
•
•
•

In-services, workshops
Education modules
Telehealth, online modules
Clinical training
Peer mentoring

3. Maximizing Use ofresources/Underserved Populations
•
•
•

Effective and better use of available mental health resources.
This approach provides for a more comprehensive program that is better coordinated
and improves access and service delivery
Result is better cost effective measures and a much more efficient health care system.

4. Case Management (client care plans) - not defined as a key concept by the Joint Task
Force, but included in this thesis report

5. Client/ Client Centered focus - Recent key concept of Shared Mental Health Care

133
IMPLEMENTATION of Shared Mental Health Care projects A Compendium of Current Projects (Kates & Ackerman, 2002), describes over 100 Shared
Care projects across Canada,
Suggestions to implement a Shared Care model (Collaborative Working Group, 2000):
• A visiting psychiatrist consult, mentor, and provide advice and supervision to family
physicians working in smaller and rural communities
• Greater collaboration between mental health nurses and general duty nurses
• Encourage professionals such as social workers, psychiatrists, nurses, and family
physicians collaborate and work in partnership together

1. COLLABORATIVE MODELS
•

Hamilton-Wentworth HSO, Mental Health program in Ontario - (Kates, Craven, et.al.
1997).
• One of the first in implementing a collaborative Shared Care model
• Successful integration of mental health and primary care, program consists of:
> Mental health counsellors in each of the Family Practice clinics with a
psychiatrist visiting the clinics every 1 - 3 weeks, depending on need
> The family physician, mental health counselor, & psychiatrist work
collaboratively together by telephone, with the physician supported by
the psychiatrist in person.

4* North York General Hospital in Ontario (Ungar & Jarmain, 1999)
• One of the first - a community hospital that implemented Shared Care concepts:
> A collaborative relationship between family physicians and mental health
system
> Systemic changes, within hospital, include a change in their mission
statement and recruiting strategy. For example, when a vacancy became
available for a psychiatrist, they hired one that would support the new
Shared Care model.

2. PSYCHIATRIC OUTREACH
4t Psychiatric Outreach, mental health Evaluation and Community Consultation Unit
(MHECCU), Department of Psychiatry, University of British Columbia
• Psychiatrist services - if none available in community or "need to
augment their available psychiatric care. By providing:
Direct consultation to clients
- Indirect - discussion/consultation with referring family physician
education models
Clinical case reviews
- Client group - children, youth, their families, adults, and elderly

134
3. MENTAL HEALTH CLINICS
ik Adult Outpatient Psychiatric Clinic, Mental Health program, Sault Area Hospitals
• Goal - to improve access and predictability of specialized psychiatric care
for remote and underserved northern Ontario communities
- reduce inappropriate admissions
• Plan - visiting psychiatrist - consultation, support, and education
- community nurse specialist
• Results — family physician is "willing" and able to manage severely
mentally ill clients in an outpatient setting
4* Urgent Consultation Clinics, Ottawa Hospital (General Campus, Civic Campus)
• Referrals for in clients, and by family physician clinics/offices
• Urgent consultation clinics to provide rapid access to psychiatric care for
clients, and following discharge
• Converted long term day treatment program (4-6 months) to an acute day
hospital program (4 weeks)
4. CASE MANAGEMENT (SHARED CARE PLANS
<t ACCESS - a national program of education and consultation in psychiatry, North
York Hospital, ON, that focuses on developing client care plans for psychiatric
clients.
<k NDCL (New Dimensions in Community Living) program - provides intensive
case management services to clients with severe and persistent mental illness who
have experienced difficulty using services in the past. Program provides
emotional and medical support and activities of daily living programs.
5. EDUCATION
• Universities: British Columbia, Alberta, Toronto, Queens and Dalhousie
Universities have encouraged psychiatry and family medicine departments
to take the lead in developing Shared Care models
• A major shift is the approach to training and education where psychiatric
residents train in primary care clinics and practices, and vise versa.
• Curriculum changes to integrate the Shared Care model.
• Focus on improvement of communication skills and collaboration between
the two disciplines.
• One Shared Care project involved a component of education and training
for child care providers to improve their ability to identify child care
issues, treatment options, and interviewing techniques
6. OTHER INITIATIVES ACROSS CANADA - Calgary, Edmonton, Vancouver
7. World - Around the world, Australia, UK, US, the model of Shared Care has been
implemented in a variety of ways

ABORIGINAL MODEL
Historical
Federal Government Reports/ Documents —policy, procedure, process oriented
«Sfe Royal Commission on Aboriginal Peoples
• 'Gathering Strength' (1991)
• Defines Aboriginal concept of holistic health
• Discusses inequities in health standards of Aboriginals
• Acknowledges Aboriginal cultural and traditional healing practices
• 'Path to Healing'(1993)
• Goal of Royal Commission - to integrate the holistic health approach into
health and social areas
4* House of Commons of Canada (1995) - Towards Holistic Wellness: Aboriginal People's
• Components of Aboriginal wellness - mental, physical, spiritual, environmental
• Towards Holistic Wellness document
• Role of Community; Wellness approach - incorporates traditional with
western approaches; and consider integration of Aboriginal and Western
models of wellness
4> Institute of Aboriginal People's Health Research - 1 of11 Institutes that are part of the
Canadian Institutes of Health Research
Aboriginal Reports/Documents
4* Aboriginal Healing Movement
*l* Started in early 1980's with the focus on alcohol and an awareness of much larger
problems - addictions, parenting, anger issues, residential school syndrome
• Viewed as a movement and also as healing initiatives and Aboriginal programs and
activities
• Foundations of healing
• Holistic health principles as physical, mental, spiritual, and environmental
components of wellness but also include political, economical, social, and
cultural elements
• Healing comes from within
• Healing of the individual and community interrelated
• Overcoming past oppressions, abuses
• Towards holistic wellness
• Role of Community - the community defines the problem and solutions
" Wellness - need to incorporate traditional and western approaches to healing
• Integration of Aboriginal and Western practices
• Funding of community proj ects
*4t Aboriginal Healing and Wellness Strategy (2001)

•
•

Funds projects for Aboriginals by Aboriginals and must include Aboriginal health
and healing practices when planning primary health programs
Royal Commission recommends 'Strengthening the Journey' as a service delivery
model to address Aboriginal health and healing issues

4» National Network for Aboriginal Mental Health Research (NNAMHR)
*t* Assists Aboriginal people with Aboriginal research opportunities

136

Key Concepts of the Model
1. Holistic Health and Healing
Definition of the holistic concept of health is consistent across the literature - and includes
4* Body, Mind, and Spirit, and
4* Physical, Emotional, Mental, Spiritual, supported by:
• Royal Commission on Aboriginal Peoples
• House of Commons of Canada - Towards holistic Wellness: the Aboriginal
People
• Aboriginal Healing Movement
• Aboriginal world view
Other Terms
4* "Whole health"
"interconnectedness" ..."interdependence"
4*- Inclusion of the social and cultural components
4* Maintain balance and harmony within the individual, family and community

Council of Yukon First Nations
4* "The approach and vision of health is a wholistic view that promotes and recognizes all
aspects related to the wellbeing of nation, communities, family and individuals".

2. Collaboration, consensus, and Partnerships
4* Historically, Aboriginal people and communities have used a collaborative or consensus
approach for centuries, decisions made with all in agreement
4* Federal government supports concepts of collaboration and partnerships when conducting
national consultations with Aboriginal communities and groups
4> The Institute of Aboriginal People's Health strategic plan (2006) suggests partnerships
and the sharing of Aboriginal knowledge when conducting research

3. Aboriginal Healing Methods and Practices
- Holistic health and healing
- Healing Process - Restoring balance
- Sharing and/or healing circles
- Medicine wheel based on holistic health
- Environment
- Community involvement
- Wilderness camp
- Traditional or Aboriginal healers and medicines
- Elder involvement necessary for healings

World Health Organization support for Aboriginal medicines and traditional healing
sit Proper Use of Traditional, Complementary and Alternative Medicine (2004)
4* Traditional Medicine Strategy 2002-2005 (2002) - definitions of traditional medicine:
suggest integration traditional medicine with national health care systems
4* Traditional Medicine & Complementary/Alternative Medicines (2001)
4* Training Traditional health Practitioners in Primary Health Care Guidelines (1995)

137

4) Community Wellness Framework Models
'Strengthening the Journey Model - called Aboriginal Circle of Care (Aboriginal Healing and
Wellness Strategy, 2001)
«4 An Aboriginal Circle of Care - is a supportive, safe, inclusive, accessible environment;
staff as role models; and relationships
4i Balance - emphasis on physical, mental, emotional and spiritual balance; cultural
teaching and spiritual development; strong and positive sense of identity
4> Integrated interventions that incorporate interventions from the 'two worlds' an ethic of
choice and self responsibility
4 Community development and empowerment with centers
4- Recommended by the Royal Commission Aboriginal Peoples
4- Holistic model uses sharing Aboriginal knowledge and integrated into community
nursing stations
'Circle of Life' Yukon Model of Health and Healing (Kassie, 2002)
Jk A health promotion booklet on cancer prevention (Kassi & Walker, 2002). This holistic
tool is used so as to reduce the risk of cancer by looking positively at the spirit, mind,
body, heart. The Circle of Life tool was developed using First Nations beliefs of holistic
health, focusing on the mind, body, heart, and spirit in order to maintain harmony and
balance for good health.
'•4- This book is one of the few that have been published for Yukoners by Yukoners.
4 This model could easily be implemented into western or medical models.
4 The Circle of Life tool would provide an excellent opportunity for social workers and
other professionals to encourage their clients or clients to explore strengths and solutions
to mend their mind, body, heart, or spirit.
The Medicine Wheel - The Sacred Tree booklet (Bopp, Bopp, Brown, Lane, 1985)
*b Funding for booklet provided by: national Native Alcohol and Drug Abuse program of
Health and Welfare Canada
4* Ancient symbol of the universe and individual journeys around the medicine wheel
*4 Used by many native people of North and South American as teachings about the life of
the sacred tree, including the life of the people, including Yukon
<fc Principles - Four Aspects of our nature - physical, mental spiritual, emotional; Four
Great Meanings of the Sacred Tree - wholeness, protection, nourishment, growth; Four
seasons; Four races; Four directions; Four elements;
Aboriginal Healing Foundation (May, 2000)
s4 Supports Aboriginals in building/reinforcing sustainable healing processes for the legacy
of physical abuse and sexual abuse in residential schools, including intergenerational
«4 Facilitate the healing process by helping Aboriginal people help Ethical Guidelines:
published for Aboriginal communities doing healing work
Active Yukon Projects - (10) funded by the Aboriginal Healing Foundation
4t Intensive Therapeutic Community Healing Project - Kwanlin Dun First Nations:
therapeutic program, blend of Western and First Nations philosophies for a holistic
4t Teslin Tlingit Council's Healing Strategy - Conference on residential schools Jan 05.
Healing strategy - 4 healing workshops (anger management, family violence, addictions
awareness, and spirituality.

138

INTEGRATION of ABORIGINAL and MEDICAL MODELS of HEALTH CARE
Key concepts
1) Holistic health — New Definitions of Health
slfc 'Encyclopedia and Dictionary ojMedicine, nursing, and Allied health' (1997)
- "a relative state in which one is able to function well physically, mentally, socially,
and spiritually" and "within the environment in which one is living" (Miller & Keane,
1997)
4* World Health Organization (1946)
- "health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity
". This definition has not been amended since 1948
4* Yukon Health Act - supports the principles of holistic health as a state of "physical,
mental, emotional, social and spiritual well being of residents of Yukon in harmony with
their physical social, economic and cultural environments".

2) Acceptance of Aboriginal Health andHealing Practices
4* Shift within the federal government and the medical community towards
4* Royal Commission (1991) and House of Commons Canada (1995)
4* Associations - Canadian Medical Association, Canadian Association of Social Workers,
British Nursing Association
• A shift in attitude towards an acceptance of the holistic health model of practice
• Committed to acceptance and to encourage integration of Aboriginal holistic
practices incorporated into medical, social work, and nursing practices.

3). Integration of Aboriginal Health and Healing methods with the Medical Model
4* Rural and Remote nursing stations have integrated Aboriginal health and healing
practices into medical models of treatment in the north
4* Health programs within hospitals - they operate within acute care centers using a holistic
health care approach to care and provide a variety of services to First Nations clients.
••• Aboriginal Health Program, Calgary Health Region, AB
••• Fort Qu'Appelle Indian Hospital (Health Canada)
• Aboriginal Liaison program. Tillicum Haus', Nanaimo Regional Hospital, BC
• Aboriginal Health program, Prince George Regional Hospital, BC
••• Aboriginal Health Services program', Winnipeg, MN
• First Nations health program, Whitehorse General Hospital, Whitehorse
<& Winnipeg, Nanaimo, Calgary and Whitehorse programs provide support, access,

information and education, referrals and discharge planning
4* Whitehorse and Calgary programs also providing cross cultural workshops to hospital
staff
4* Regina Fort Qu'Appelle Hospital also provides services to non Aboriginals. .

139
COLLABORATIVE/ SHARED CARE/ INTERDISCIPLINARY PRACTICE - new buzz word
4- Collaborative Nursing Practice in Alberta. Joint document supports nursing associations
*t* Working together, mutual respect, a collaborative working environment for
nurses/clients
4

Collaborative Nursing Degree program - Ryerson University - starting in 2005
• Two Toronto Colleges merged with University, and developed partnerships

4» Collaborative Graduate/Masters Social Work programs - University of Toronto,
Interdisciplinary programs 1 .Addictions, 2.Ethics and Pluralism, 3.Womens Studies
4

University of Northern British Columbia - Social Work program - Mission statement
• Collaboration - supporting Northern/remote areas, Aboriginal and cultural issues
• Acknowledgment of a holistic, interdisciplinary and activist nature of social work

4

Canadian Association of Social Workers
• Purpose and objective - (1/8) Collaborate, strengthen and unify the SW
profession

4

Health Council of Canada. Annual Report. (2006). Health Care Renewal in Canada.
• Team based multidisciplinary care for primary health care in Canada
•J* National Electronic Patient Record

COLLABORATIVE - Projects in Yukon
4 Collaborative Wound Conference - Sept 2004 - Multidisciplinary approach - wound care
4- Collaborative Palliative care Project - Home care, Cont care, Therapies, WGH pharmacist
4 Collaborative Chronic Disease - (diabetes
) - - Telehealth with communities
Collaborative BC/YT Initiative
- Mental health/addictions - funded by Primary Health Care Transition Fund'
4 Multidisciplinary approach - collaboration and ability to work together
4- Improve Access
4 Decrease burden on family physician
4 strengthen community links, including Rural and Urban
4 Improve Best Practices
4* Maximize resources to ensure sustainability (caveat)
PHASE I - Completed:
4* Yukon Drug Strategy Assessment Community Resources - (Kramer, Oct 04)- Benchmark
4* Provide education, information, training - WGH Mental Health Nurses attended
• Mental health screening workshop - Nov 04; Motivation counseling - Jan 05
4> Stakeholders Steering Committee meeting — (Hospital spokesperson attended)

4* Planned: Peer mentoring; distance education and consultation with experts; client based
case conferencing - meetings and common record called 'continuous record of care'
* Participating YT Communities - WH, HJ, WL, DC, Old Crow
Collaborative Community Health Centre proposal by Yukon Registered Nursing Association
4 Registered nurse Practitioners provide health care as they do in the Yukon communities
4- Other services suggested - Therapies, mental health

APPENDIX 5
PARTICIPANT INTERVIEW GUIDE QUESTIONNAIRE PACKAGE
WHAT ABOUT *OUR* SHARED MENTAL HEALTH CARE MODEL
for WHITEHORSE GENERAL HOSPITAL
- DESCRIPTION OF WGH MENTAL HEALTH PROGRAM - S e e Handout #1
• Overview Current Whitehorse Hospital's mental health program
• What is your job? Any corrections, additions

2. WHAT ARE WE DOING NOW??? - See Handout #2
• Shared Care and Aboriginal models of health care
3.

HOW ARE WE DOING NOW??? - See Handout #3
a Strengths?
a What Would You Like to See Different?
• Solutions and suggestions for change?

QUESTIONS:
4. WHAT WOULD A SHARED MENTAL HEALTH CARE MODEL at WGH LOOK LIKE
IN FUTURE??? - See Handout #4
• What Would You Like To See???
• What is YOUR vision???

5. IF OUR MENTAL HEALTH PROGRAM WERE TO BE EXPANDED???
• What Would Your Priority Be? Number please
• What SMHC components would you like to see implemented?
1.
2.
3.
QUESTIONS????? PLEASE ASK! COMMENTS SUGGESTIONS - Handout #5

141

Handout # 1 - CURRENT DESCRIPTION WGH MENTAL HEALTH PROGRAM
- a descriptive inquiry - any changes, corrections, additions???
> First Nations Health Program liaison workers
• Program developed
by elders
• First Nations liaison workers are all Aboriginal clients
• Program incorporates Aboriginal holistic health values and taking into consideration,
physical, emotional, cultural, spiritual needs of the client
• Provides information, support, education, advocacy, discharge planning, liaise
between client and medical staff
• Aboriginal healing methods - traditional medicines, traditional diets
• First Nations healing room - open to all
>

Medical program - mental health nurses - two
• Assessment, crisis intervention, discharge planning for all referred (physician or
nurse), and suicidal in-client and emergency department mental health clients
• Mental health screening tools used (depression, alcohol, suicide)
• Work collaboratively with consulting psychiatrist, family physicians, First Nations
liaison workers, nurses, and support staff
• Provide support and education to staff
• Shared Care plans or case management plans
• Yukon Mental Health Act - ensuring process is followed for all committed clients

>

Family physicians
• Key contact, and often first contact for client in crisis or requiring treatment
• Case manager
• Co-ordinates client care

>

Nurses
• Physical care
• Emotional care when mental health nurse not available or off duty

>

Consulting psychiatrist
• Assessment and consultation of mental health clients within hospital
• Support to family physicians and mental health nurses

Medical supports - direct and regular contact with mental health clients
> Administrative assistants - main contact for mental health clients
> Dietary - deliver dietary trays to all mental health clients
> Housekeeping - of client rooms, hallways, seclusion room as required
> Clinical care managers - administration
> Pharmacy - dispenses drugs and client information
>

>
>
>

Dietician — discusses dietary issues with special diet clients

Admission / discharge - admit mental health clients to emergency, observation of lobby
Security - Respond to code yellow; accompanying clients for smokes
Social worker - collaborative support and advice to mental health nurses, First Nations
Health program, and hospital staff
> Quality assurance - risk management
> Mental health care team (former) - now part of acute care quality assurance team

142
Handout # 2

Shared Mental Health Care & First Nations Models
WHAT ARE WE DOING NOW? In terms of OUR Shared Care model

Collaboration

Communication, relationships
Collaboratively work together (family physician, psychiatrist, mental
health nurse, First Nations, emergency department registered nurses,
occupation and physical therapies, administrative assistants,
admission and discharge, housekeeping, dietary, pharmacy, lab,
senior admin
Interdisciplinary team meetings - weekly rounds
National Ambulatory Care Reporting System —analysis admission
and emergency visits/classification of diseases
Quality Assurance Teams
Collaborative Initiatives Whitehorse Hospital involved in
- PARTY- youth alcohol prevention program, involves
education, ambulance, and RCMP; and Safe Grad
- Palliative/Home Care project
- BC/YT collaborative initiative - Addictions/Mental health
- Substance Abuse Prevention Coalition (SAPC) WGH major
partner outreach van - sharps, equipment

Support/ education

Tele health sessions
Hospital education sessions
- Non violent crisis intervention
- Mental health risk management assessment
- First Nations cross cultural workshop

Maximizing use
of resources

Mental health nurse expanded role to see mental health clients in
Emergency department
- Decrease workload on family physician
- Increase access and continuity of client care

Case management

Interdisciplinary team meetings - discharge planning
- Client Shared Care plans in emergency
- Expanded Shared Mental Health Care plans - piloted, and
supported by medical staff, and family physicians and clients

Holistic health and
healing

Principles of wholeness and balance
- Physical, mental, emotional, and spiritual
Acceptance - by medical community

Collaboration and

Communication

consensus

Relationships

Sense of community
Aboriginal healing
methods

Integration of First Nations practices at WGH
- Traditional medicines/foods
- Ceremonies on ward and in First Nations healing room
Healing room open to all
Healing methods vary among First Nations

Case Management

Strengths

SHARED MENTAL HEALTH CARE

Maximizing Use of Resources

Support/Education

Collaboration

Handout # 3
What Would You Like
To See Different?

HOW ARE WE DOING?
Solutions and/Suggestions
for Change

143

FIRST NATIONS MODEL

Aboriginal healing methods/
practices

Holistic health and healing

Collaboration and consensus

Handout # 3
Strengths

What Would You Like
To See Different?

HOW ARE WE DOING?
Solutions /Suggestions
for Change

144

145

Handout #4

possibilities A SHARED CARE MODEL FOR WGH
suggestions
based on implementation projects across Canada

1. COLLABORATION
• Continue to communicate, consult, and work collaboratively together, sharing
information and knowledge among all health professionals who provide physical,
emotional, mental, spiritual, social, and environmental care to our mental health clients
• Encourage mental health team professionals, such as social workers, First Nations workers,
nurses, psychiatrists, family physicians to collaborate and work in partnership with client s
2. MENTAL HEALTH OUT PATIENT CLINIC
• 0900 - 1100 hours daily, including weekends
• A private Emergency department mental health office for consultation
• Urgent Drop in Clinic/Urgent Consultation
• Day Hospital program
• Possibility of: Groups
• The mental health outpatient clinic would be an excellent follow up for physicians,
especially when it is evenings or weekends.
• This should decrease repeat visits to the emergency department, and decrease admissions,
and improve safety concerns with mental health clients in Emergency department
3. MEDICAL DETOXIFICATION
• Medical management for client care for withdrawal to alcohol and/or drugs
• Client support and education
• Referrals to appropriate community resources
4. EXPAND MENTAL HEALTH NURSE ROLE
• Continue to see all mental health clients presenting in emergency in collaboration
with Emergency Physician and nurses
• Responsibility for new mental health out client clinic. This service would provide
assessment, crisis intervention, counseling support, discharge planning for referred mental
health clients, for:
Clients seen in emergency department overnight and requiring follow up but not admission
Referred from family physician's office - to prevent admission
Clients requiring 1-3 follow up sessions to prevent admission
5. EXPAND ROLE OF PSYCHIATRIST. OR SECOND '/2 TIME PSYCHIATRIST
• Augment existing psychiatric services
• Continue to support the primary psychiatrist for client consultation
• Continue to support and educate family physicians, mental health nurses, and hospital staff
working with mental health clients
6. EXPAND ROLE OF MENTAL HEALTH PROFESSIONALS:
• Mental health professionals - social workers, First Nations Liaison Workers, nurses, to care
for the physical, emotional, mental, spiritual needs of the mental health clients; and
participate in inpatient and outpatient programming.
• Some hospitals have added a Community nurse Practitioner to assist the Emergency
department with assessments mental health clients

146

7. SHARED CARE PLANS
• Develop Expanded Shared Care plans for all identified clients who access Whitehorse
Hospital mental health and emergency department services on a regular basis
• Emergency Admission form could be flagged by the Admissions & Discharge staff using
the confidential Meditech computer system, so all staff would be aware of a SCP on file
• The full document would remain confidential in Meditech computer system, and in
hard copy in a specifically coded envelope on the Clients Chart with access would
be to Emergency Physicians, family physicians, emergency department and west unit nurses,
other staff deemed appropriate
• Family physician directives included
• Client involvement and support
8. SUPPORT AND EDUCATION OPPORTUNITIES
• Tele health - make more accessible and available (i.e. Onsite WGH)
• Training modules (Mheccu) - "Enhanced Skills program" for Family Physicians', UBC
• ACCESS - Canadian psychiatric education modules for family physicians
• Education - expand knowledge base of professionals working with mental health clients.
Provide educational sessions to staff, workshops, inservices, and mental health days on
Topics such as: Psychiatric diseases, treatments, risk assessments, crisis intervention
techniques, Anger management techniques, conflict resolution, solution focused
supportive counselling, etc...by mental health nurse, psychiatrist, mental health experts
• Consultation via telephone with experts
• Clinical Training
• Orientation of new staff to mental health (i.e. mental health Act)
• Peer Mentoring - for example - nurses, mental health nurses and First Nations Liaison
Workers spend time in each others work areas
• Solution Focused Crisis Intervention supportive Counselling
• Residency programs - Family Practice, Psychiatric residency
9. COORDINATOR FOR EXPANDING SHARED CARE PROGRAM AT WGH
• Coordinate and implement Shared Mental Health Care Model initiatives for the at WGH
mental health program
• Work collaboratively with other relevant Yukon projects and initiatives, for example -the
collaborative BC/Yukon mental health/addictions initiative
• Develop specific process to evaluate the changes as they are implemented, to determine
effectiveness and whether or not changes to process or implementation need to be revised.
10. STEERING COMMITTEE
• Provide support and direction to Coordinator of Shared mental health program
• Monitor progress of initiative and target dates are followed
• Report to, gather information, update progress, and advise on Shared Care initiatives to senior
administration and WGH Hospital Board of Directors

147
Handout # 5 QUESTIONS?????

PLEASE ASK!!!!!... COMMENTS

SUGGESTIONS

COLLABORATION

STRENGTHS

• Collaboration is a significant
strength to mental health program
• Cooperation and good
communication among mental health
nurse, physicians, psychiatrist
• Mental health nurse/ psychiatrist
seen as excellent supports to family
physicians and nurses in west unit &
emergency department. They provide
knowledge, expertise, and share
information to both client and staff
• Acknowledgement and strong
support there is collaboration &
cooperation among all staff who work
within a multidimensional system
• Very good to excellent
collaboration with physicians, mental
health nurses, and psychiatrist
• Experienced family physicians
• Mental health nurse assessing
clients and sharing information in
emergency department
• Very good to excellent
communication system
• "Staff development is almost
always collaborative approach"

Shared Mental Health Care
• Could be more. Need improved
collaboration, and improved
communication
• Need for increase in psychiatric
services, so clients are seen without
delays, "in a timely fashion", and not
kept in hospital longer than necessary
• Increase availability of mental
health nurse services, for nights, and
when mental health nurse if vacation,
ill, etc.
• Separate mental health clients
from acute care settings, as well as
palliative, maternity, pediatrics, and
intensive care

WHAT WOULD YOU LIKE TO SEE
DIFFERENTLY

148

• Separate mental health unit
• Mental health nurses staffed
and available 24/7
• A second psychiatrist attached
to the hospital
• A separate mental health unit,
with secure area, at Thompson
Centre, "that will incorporate
addictions, detox and mental health
clients under one umbrella"

SOLUTIONS & SUGGESTIONS
FOR CHANGE

MATRIX # 1: KEY CONCEPT THEMES BY KEY CONCEPT AND MODEL

APPENDIX 6

MAXIMIZING
RESOURCES

SUPPORT AND
EDUCATION

•

•

•

•

•

•
•

•

•

Very good utilization of existing
mental health resources,
specifically psychiatrist and
mental health nurses
Psychiatrist provides client
consultation and support to family
physician, and mental health
nurses Services
Mental health nurse expanded
role to assess and assist clients in
crisis in Emergency department
Appropriate use of staff skills

Support of existing educational
workshops, training, telehealth
sessions on mental health
Training is available, specifically
the non violent crisis intervention
workshop, and First Nations
health cross cultural training
Telehealth is available
Mental health nurse provides
support and guidance to all staff
and Family Physicians
Case histories well documented

•

•

•

•

•

•

•
•

•

Expanded mental health program
- Additional mental health nurses
would provide coverage 24 hour
per day, and 7 days per week
Psychiatrist services - increase
from current 25%
2nd psychiatrist to improve
service
Ensure mental health nurse
available to west unit and
Emergency department so
adequate coverage and will fit
with First Nations and Shared

Clear need identified to improve
educational opportunities,
especially to nurses and new
nurses
Telehealth - times not preferable
Lackof Inservices, workshops
and proper training in mental
health issues for all nurses, but
especially for new nurses to
Territory.
Areas identified - mental health
risk assessments, illnesses,
medications, out of control
emergency clients, and mental
health Act
Not being paid for educational
sessions

•

•

•

•

•

•

•

•

•
•
•

•

149
Telehealth - Record sessions,
and prefer University British
Columbia sessions
Orienting new staff
Peer support and mentoring
Incorporate mental health into
bi-annual hospital staff
educational days
Variety mental health inservices from psychiatrist and
mental health nurse
Lunch/Learn mental health inservices
Conduct a mental health Day
conference/ symposium - for
hospital, and community
Mental health rounds with
mental health nurse
participation
Mental health nurse position 24/7, or 12 hour days, 7 days
per week, and on call at night
Hire 3 rd part time mental health
nurse or Psychiatric social
worker to cover
2nd psychiatrist - for
Interdisciplinary rounds,
clinical case presentations
quarterly, case rounds by
psychiatrist, mental health
nurses, and Physicians
In-services by mental health

CASE MANAGEMENT

•

•

•

•

An acknowledgement and
strength that some client care
plans are in use
Support definitely exists for
existing Shared Care plans for
mental health clients"
Mental health nurse records,
history, and old chart
Interdisciplinary team meetings
for client rounds, case
•

•

•

•

•

•

•

Education and training on how to
do case management plans to
ensure effectiveness
Need to regularly update,
improve, and maintain, what
several participants call "ancient"
Shared Care plans
Need to share and communicate
there is a specific client plan in
place. Not always communicated

Care models
Fewer admissions if seen by
mental health nurse in emergency
department
Improve and increase knowledge,
education, and skills of mental
health workers, if separate unit,
will be critical
Develop a more formal
relationship with a university
Separate mental health from acute
care - "mix of acute and
psychiatric clients is not working"

•

•

•

•

•

•

•
•

•

•

150
nurse, psychiatrist, social
worker
A separate mental health unit
with trained staff, activities
and elder participation
Mental health clinic separate
but in association with
Whitehorse Hospital and
include: detoxification,
addictions, and mental health
Psychiatric resident
Mental health clinic separate
from the hospital, reference to
Thompson Centre, with mental
health, addictions, and detox
under one umbrella.
A common room with arts,
crafts, and activities, and
elder participation
A mental health consumer
driven steering committee with
accountability
Multidisciplinary rounds, which
involve the client in the
development of the Shared Care
plan
Mental health weekly rounds,
perhaps following west unit
client rounds
Determine who is responsible
as case manager
Case manager is responsible for

•

conferences
Historical charts, current client
records, and mental health nurses
and First Nations health staff
notations, are identified as case
management strengths.

•

•

•

•

that there is a plan
Request medical plan of care and
Discharge plan be written down
Involve all relevant staff, client,
and their family in case
management
Mental health weekly rounds,
perhaps with west unit client
rounds, and at a better time where
all disciplines can attend
Staff could include cultural
component - is not evident in
staff reports on client records
•

•

•

•

151
an update review of client plans
quarterly or every six months
Input plan on the hospital
electronic Meditech client
system, so all staff involved are
aware of the plan
Include a cultural component to
the plan
Payment to family physicians
and psychiatrist for their time
commitment for initiation and
review of all client Shared Care
plans
Training in case management
so that it is done effectively
Shared Care plans

COLLABORATION
AND CONSENSUS

Aboriginal

•
•

•

•

•

•

•

"Aboriginal Model is
collaboration"
Considerable support is extended
to concept of Aboriginal
collaboration and consensus.
Strong support extended by
participants to First Nations
health Workers
Data clearly identifies the First
Nations health program discipline
group has very good to excellent
communication skills, as they
provide emotional support and
interact with clients, and their
families.
"Child support worker excellent
with First Nations adolescents
with mental health issues"; Very
good social worker Discharge
planning,
Knowledgeable of resources
"Excellent bridge between
hospital and community"

STRENGTHS

WHAT WOULD YOU LIKE TO SEE
DIFFERENTLY
• Could be more collaboration, and
communication
• First Nations and mental health
working together on client Shared
Care plans, and discharge
planning
• First Nations liaison workers need
to be more available and
accessible, especially on
weekends, and nights
• More of the First Nations health
workers educated in mental health
issues, and counselling, and not
one specializing in mental health
• Residential school history for the
client with their family history
integrated into the mental health
system

SOLUTIONS & SUGGESTIONS
FOR CHANGE
• First Nations mental health work
more collaboratively together
with improved communication,
specifically in the area of client
assessments, reporting of
information, treatment and
discharge planning
• Communicate/report assessment
and valuable information of
"clients health and what is
necessary for healing" "Everyone
sit down and share info"
• First Nations staff levels are
increased, so service is more
available/ accessible / expanded
weekend/ night coverage
• Education appears to be a priority
• All First Nations health workers
improve knowledge and skills in
mental health
• Increased First Nations cultural
information, pamphlets, and tours
• Integrate residential school
component into mental health
intake/assessment form. This
highlights attending residential
school, resulting social issues,
family, intergenerational history

152

HEALING
METHODS AND
PRACTICES

HOLISTIC
HEALTH AND
HEALING

•
•
•

•

•

•

•

•

Participants express strong
support and an interest in this
program
Strong support for the healing
room
Traditional spiritual practices
Traditional foods and medicines
Elder support and supply
medications

Strong support for holistic health
concept of the physical, mental,
emotional, and spiritual healing
Participants state, they have a
"strong belief in the whole
person", and holistic health and
healing is a "wonderful approach
for treating the whole person".
Healing room, traditional foods,
residential school assessments

•

•

•

•

•

•

More information and education
on First Nations culture,
traditional healing, and holistic
health and healing concepts,
including residential school
survivors
Clarification of First Nations
health Worker role with regards to
holistic health and healing
program, and in general
Encourages increased education
for hospital staff in all areas of
First Nations health programs,
specifically cultural information
and understanding First Nations
healing practices,
Request educational sessions, so
participants will have a better
understanding of First Nations
healing methods, including access
and utilization.
Use of the healing room more
often
Acknowledgement and concern
expressed what can and should be
Shared, in terms of Aboriginal
practices
•

•

•

•

•

•

Tours of the healing room,
holistic First Nations pamphlets,
and educational programs on
holistic health and healing for all
staff
An integrated holistic health
center, educate and increase
understanding of access and
utilization of healing room
Educational sessions on
traditional healing methods and
First Nations medications
Increase staffing for First Nations
health program

153
First Nations health educational
programs on holistic health and
healing for all staff
Integrated holistic health center

MIDDLE
MANAGEMENT

SENIOR ADMIN

•
•

•

•
•

•

•

•

•

•

•

•

PARTICIPANT GROUP

Major strength identified - support and education,
specifically staff development education
Supportive of collaborative approach
Suggest increased collaboration, and a greater role
for communication
Expand mental health nurse staffing to 24/7 and to
be more available in emergency department
Safety concerns for clients on integrated west unit
Expand mental health program - Thomson Center

The most important strength for this group is
collaboration. They acknowledge collaboration
has improved, but admit the need to do more
"Some do some don't, there are those people who
collaborate, they work together, but others just
give the info".
Collaboration, education, and knowledge should
be shared among disciplines, so more staff are
educated in mental health
Support and education identified as a strength, but
need for increased staff development training
Specific training topics include: mental health
issues and disorders; assessment skills, how to
deal with clients in crisis; client care/ treatment in
hospital; case management; team building skills
Solutions identify need - interdisciplinary mental
health rounds, clinical case presentations by
mental health nurse, psychiatrist, family physician

SHARED CARE

•

•

•

•

•

•

•

•

•

First Nations health is a strong program - "well
accepted by all"
More training to "better understand the gaps they are
bridging"
There is an identified need for supportive counselling
training for all First Nations workers

First Nations health program is considered a strength,
and well accepted by staff and community
Improve collaboration - provide more support for the
First Nations program with "no road blocks"
support is strong for educational programs on First
Nations holistic health and traditional practices and
suggest education in this area be provided to all staff
Holistic healing methods - need to improve, saying "it
happens and accepted by some, not all staff.
Need to explore how traditional medicines fit with
western medications and within the medical model.
Strong support exists for an integrated holistic health
center.

ABORIGINAL HEALTH

MATRIX # 2: KEY THEMES BY MODEL AND DISCIPLINE

APPENDIX 7

154

Collaboration is a strength between First Nations
health workers and mental health team, but this
could improve regarding a clients admission,
discharge, and therapeutic support plan
Suggestion the mental health team, incorporate
into the mental health assessment tool, (starting in
the emergency department), issues of residential
school survivor, generational abuse issues, and the
resulting trauma and abuses suffered
One area of concern was the need for improved
communication between First Nations health and
west unit health workers. First Nations health
workers say they feel "devalued", as medical staff
do not read their client records
There is a need for a mental health clinic, with a
well staffed unit with a coordinator and
psychiatrist. This mental health clinic would work
"within a Shared Care model", and be willing to
encourage further collaboration between First
Nations health program and the mental health
staff. Activities, a recreation program, a living
area, and visiting elders would be components of
this new program - "like it used to be"
Collaboration exists, especially between family
physicians, psychiatrist, and mental health nurses
Overwhelming support for collaborative approach
in Shared Care model. Comments: collaborative
model include: "excellent", and "the fact is there is
collaboration, especially with the psychiatrist,
mental health nurses, and nursing staff
Suggestions for an expanded mental health
program. Psychiatrist considered a valuable

FIRST NATIONS

PHYSICIANS

•
•

•

•

•

•

•
•

Very strong support exists by the physician group for
the First Nations health program, which they describe
as "outstanding"
Strong support for First Nations interventions
First Nations healing methods and practices are also
strongly supported with a definite interest and desire
to learn more on the many aspects of holistic health
and healing that are delivered by the First Nations
health program.

Strong support for the Aboriginal model
Strong support for healing room to conduct
"traditional spiritual practices to facilitate supportive
counselling healing with the client and family"
Cross cultural workshop not enough for hospital staff,
need for further education and access to available
resources - healing room, residential school survivor
videos, Aboriginal magazines
Education and information to hospital staff on First
Nations residential school survivor and how to
support this client population is also considered to be
important
Suggestions for a revised mental health intake form
that would reflect and integrate residential school
survivor issues, intergenerational concerns, and
traumas associated with attendance at residential
schools. For example, include: First Nations status,
identification of Residential school survivor abuses,
current social stressors, such as poverty, housing,
alcohol, and plan of action for discharge and referrals
(see Appendix 10). Training was also suggested to
implement this new intake process.

155

resource, but there is a need to increase psychiatric
services up from the current .25% staffing.
Suggest expand mental health nurse to 24 hour/7
day coverage. It "can't work any better when
available"
Important to all physicians is Shared Care and
client discharge planning. Suggest these plans
"need to be more available, especially in the ER"
[Emergency department], and this department
should be involved
Concern regarding the current billing system in
Yukon, as the psychiatrist, and family physician
cannot bill for the same client meeting.
A critical issue identified as a priority by all
members of this discipline group, is having a
mixed unit with mental health and acute care
clients on the same west unit.
Solution identified is a day clinic area with
recreation services for mental health clients.
Suggesting a day area with recreational services like "how it used to be"
Support and education are clearly important to this
group, suggestions include : training nurses on the
Yukon mental health Act, changes in how
telehealth services are delivered - improve times
and record sessions
Local mental health education available for family
physicians
Funding available for case management and
educational opportunities as it is for salaried
employees. Suggest "salary as possible alternative
for case management", or payment for developing
and updating client Shared Care plans

•

Desire/interest to learn more about First Nations
program and methods, but understand limits of
reporting, and sensitivity of sharing this information

156

EMERGENCY
DEPARTMENT
REGISTERED
NURSES

The emergency department registered nurses
discipline group, identify one clear strength as the
mental health nurse role in the emergency unit.
Strong support to expand the mental health
program. Specifically, there is a need to increase
services of the psychiatrist
Need to increase mental health coverage to 24
hour, 7 days per week, to respond to emergency
department needs as required, which they are
"currently not able to do". Suggest increase
staffing of mental health nurses so they would be
available to respond to client needs in emergency
department, as sometimes clients are "lost in the
system", as mental health nurse is not available
Considerable support for a "drop in clinic", which
would decrease the emergency department
workload
Support for separate mental health unit with
reference to this unit being located at the
Thompson Centre.
Need for support and education. Topics suggested
include: mental health practice issues, "what to
say" to mental health clients if they are "suicidal",
and a better understanding of the Mental Health
Act. Suggest peer mentoring with mental health
nurse
Finally, existing Shared Care plans for clients in
the emergency department are described as
"good", but require regular and consistent
updating. As well there needs to be a
determination of who is responsible for this

157
First Nations health program and mental health nurses
"share the workload" and "both are very helpful"
Strong support for the holistic concept, and suggest
using this concept for all clients
Strong support for the First Nations program,
including positive comments on elder participation
and traditional medications and meals
An identified strength is the residential school healing
initiatives

WEST UNIT
REGISTERD
NURSES, includes
mental health
registered nurse, &
east unit registered
nurse

All participants in this group express strong
support for the Shared Care collaborative model.
Comments include: there is "multidimensional
cooperation", "mental health nurses seen as strong
resource", and "our strongest strength is our GP
[family physician] with nursing staff, and mental
health nurse - respect, trust and communication"
Strong support for relationship between family
physicians, nursing staff, and mental health nurses
Key theme with this discipline group is expansion
of mental health program. Specifically,
Increase the psychiatrist services from existing
.25% to 50%, preferably full time
Expanding coverage of the mental health nurse to
minimum 12, preferable 24 hours per day, seven
days per week, including vacation, stat holidays,
and illness or education
Support and education is another key concept with
considerable attention. Numerous remarks from
this group suggest additional staff education and
training sessions. Topics identified are listed as:
the Yukon Mental Health Act; mental health
disorders; therapeutic management; Alcohol,
drugs, and withdrawal; how to deal with out of
control clients; case management techniques;
Peer mentoring and cross training in mental health
services and First Nations program- a number of
comments received.
Mental health nurse and psychiatrist provide
inservices.
Mental health educational seminars, a mental
health day, a symposium, with some suggesting
inclusion of the community.

Strong support exists for the First Nations health
program. Comments such as "quite unique the
program we have up here", and Whitehorse Hospital
is "tolerant and welcoming" in terms of Aboriginal
practices, express their support. The concept of
holistic health and healing and Aboriginal healing
methods was strongly supported by a number of
participants. Many expressed personal beliefs and an
acceptance of the holistic health concept, using terms,
"whole person", "interconnectedness", and a healing
of the emotional, mental, spiritual aspects of an
individual, as well as the physical.
Some comments on good communication, but others
express concern of a lack of communication,
specifically in the area of reporting client assessments
and their health and healing
Need to expand the First Nations program, so service
is more available on days, weekends, and nights
Suggestion the First Nations health program be
actively involved in the healing methods in the areas
of Detox, Addictions, and mental health
Need for role clarification of First Nations health
Workers
Positive comments by this group were extended to the
First Nations child support worker and First Nations
discharge planning social worker
Strong need expressed for increased staff education
and information sessions on First Nations traditional
healing, medicines, and methods
Suggest increased mental health education programs
for First Nations staff
Use/ accessibility of the healing room is considered a
great strength for clients, there is desire to know more

158

•

•

•

•

•

•

Strong support for mandatory mental health
educational days be incorporated into the regular
hospital educational days "just like we have CPR
day" (cardiopulmonary resuscitation).
Several suggestions for the hospital to maximize
resources and "develop a formal relationship with
a university", so psychiatric residents can do
practical placements at Whitehorse Hospital, and
in northern and rural settings.
Yukon registered nurses association provide
educational funding; and Whitehorse Hospital has
been very supportive of continuing education, and
suggest education should include case
management
Strong support for case management, which is
viewed in the well documented chart case notes
and mental health assessment records
Strong support for Shared Care plans that are in
existence, but need to be updated regularly
mental health assessment tools - considered an
educational strength

159

LICENSED
PRACTICAL
NURSES WEST
UNIT

•

•

•

•

•

•

Very strong focus on working together, sharing of
information and working collaboratively with
family physicians and mental health nurse
The major issues for this licensed practical nurse
discipline group are the need for a full time
psychiatrist, and case management
The first need is for a full time psychiatrist who is
more available for in hospital clients, and also
available for staff in-services and workshops
The second need identified by this group is for a
full time psychiatrist, specifically for Whitehorse
Hospital. This position would not only increase
access to psychiatric services for clients, but
educational opportunities would be more readily
available to staff.
Another major issue for this group is Shared Care
plans. There is acknowledgement of a limited
number of Shared Care plans for those clients who
regularly access mental health services at
Whitehorse hospital. Suggestions for change were
clear. They include: Shared Care plans should be
noted or displayed on the meditech system; note
on the hospital outpatient form; review quarterly;
use these plans for clients frequenting the
emergency department; increase the number of
Shared Care plans in existence.
Education is also an issue. Topics suggested
include: psychiatric medications, street drugs,
mental health issues. Suggestions also include:
mental health clinical rounds, workshops,
conferences. It was also mentioned educational
sessions be repeated so more staff can attend, and
the conference be open to the community

Strong support for collaboration and consensus,
specifically the sharing of information
There is very strong support for the First Nations
health program by the licensed practical nurse group
Strengths were identified that focus on collaboration
and consensus. For example, there is a very strong
belief within this participant group that everyone
should "focus on working together and sharing
information".
The holistic health concept of healing was also
identified as an excellent strength and a strong belief
in the "Circle of Life" tool, used by the First Nations
health program, and considered a strength in healing
of the "spirit, mind, heart". One suggestion to
improve, and Shared by a number of participants, is to
increase awareness as to what the First Nations
program is all about.
The First Nations program is described as
"invaluable", but there is still a desire by this group
for more information.
Suggestion for cross training with First Nations
program
Desire for increasing awareness of what the role
clarification, and to increase their awareness and role
clarification and unsure what First Nations health
program is all about

160

SUPPORT

Strong support exists for collaboration,
specifically the collaborative approach with
physicians, the psychiatrist, mental health nurses,
and support staff
In this support discipline category, there were
numerous solutions and suggestions for change
from this group, especially around collaboration,
communication, support and education, and safety
issues.
Strong support for using the multidisciplinary
team approach, especially for mental health
rounds, with mental health nurse present, and
client discharges discussed at that time,
suggestions include: accommodate all disciplines
in client rounds by being "time flexible", and
include notification and "liaise with retail
pharmacist on discharge planning, so they know
medication changes and why"; include "Pastors
involved in discharge planning", as they are often
the community support counselors; and strong
support for medical plans of care, as "discharge
planning very valuable to staff
Explore psychiatric residency programs
There are many suggestions to expand the mental
health program and provide additional mental
health nurse and psychiatrist services.
There were two major issues identified by this
group, the need for improved communication with
regards to safety concerns, and the need for
increased education and support. The first issue
was consistent throughout the support data
responses, and identified by many participants, is
the issue of poor communication resulting in
•

•

•

•

•

161
Strong support for First Nations health program,
especially the sharing of information
A strength of this program is First Nations healing
practices and methods, and the First Nations healing
room
Request from many in this group, for a description as
to what the First Nations program is all about, and
role clarification, as to "what they are doing and
why", and about First Nations healing practices used.
Suggestions for more information on the First Nations
health program, in the form of pamphlets, and tours of
the healing Room. .
Suggest asking for the smoke detector to be removed
prior to smudging or sweetgrass ceremonies

•

•

•

•

potentially unsafe working situations.
This disciplines primary concern is a lack of
information about possible safety issue, as a result
of poor communication not Shared by nursing
Staff to support Workers. This leads to concern
due to their client contact in their everyday work
activities. Concern is staff are interacting with
mental health clients, and do not know the client is
or may be unpredictable or aggressive in their
behaviour. As a result, they may be at risk of
harm or injury.
Specific comments include: the "only indication of
mental health concerns with client is no sharps or
in seclusion room - over time may figure it out for
self; "not knowing that client is mental health";
"not getting enough about client"; and being
"misinformed or not informed at all".
The support discipline group, provide numerous
positive solutions For change to improve safety in
the workplace. Some of these excellent
suggestions include: "communicate client issues
that potentially present safety concerns"; "if client
a concern or unpredictable - meditech"; "ask to
remove smoke detectors for smudging or when
using sweet grass"; a specific "client gown to
prevent mistaken identify"; a "high guard rail by
river"; install "panic buttons", and have a "secure
area for mental health", and a "mental health
facility". Suggest every support staff person
should go through training
The second major issue for the support discipline
group is education and training. Participants
strongly support and identify, as a strength, the

162

•

•

educational training and workshops available
They provide a number of solutions to improve
their knowledge and skill level. They include: "the
need for mental health information on at risk
clients", "improve knowledge and skill level of
workers", "training specific for difficult
situations", such as "when a client grabs you", and
what to say and "how to talk to mental health
clients". They also suggest "ALL" support staff,
including security have opportunity to take these
courses and are replaced so are able to do so", and
regular mental health educational sessions with
mental health nurse and psychiatrist during "lunch
and learns".
Many positive comments and strong support for
mental health education and support, specifically,
non violent crisis intervention, cross cultural
course are mandatory programs with annual paid
Hospital education days. Conflict Resolution
courses are now available and completed by some
staff.

163

APPENDIX 8
MATRIX # 3: VISION FOR SHARED CARE AT WHITEHORSE HOSPITAL
VISION

VISION

VISION

VISION

#1

#2

#3

#4

23

2

16

11

17

-OTHER DISCIPLINES
(social worker, Family
Physician, Therapies)

11

- PSYCHIATRIST

8

-RECREATION ACTIVITY

3

2

OUTPATIENT CLINIC &
DAY HOSPITAL
BASED PROGRAM

10

12

SUPPORT & EDUCATION

4

SEPARATE MENTAL
HEALTH UNIT
EXPAND Mental health
program services
- MENTAL HEALTH
NURSES

TOTAL

25

6

34

1

1

19

6

3

20

3

11

1

6

2

3

27

6

9

1

20

4

4

3

11

6

1

2

9

OTHER (see details below)

4

2

3

2

11

TOTALS*

106

50

20

17

193

-FIRST NATIONS
HEALTH PROGRAM

CASE MANAGEMENT/
SHARED CARE
PLANS

SEPARATE MEDICAL
DETOX/ADDICTIO
NSAREA

1

Note. Totals do not reflect the total number of respondents, as some participants included 2 items in thenvision # 1, with one exception 23 respondents clearly identified separate mental health unit under
vision # 1; vision # 1, # 2, # 3, # 4 are actually vision statements ranked as priorities.

2

91

65
28
55
STRENGTHS - 239

222

1

2

1

4

3

1

23

14

3

10

9

2

2

5

5

2

14

8

9

12

COL

90
109
49
81
SEE DIFFERENT 470

3

1

10

2

0

13

8

18

9

4

1

2

2

11

18

4

15

9

19

26

1

10

20

10

3

62

11

9

CM

7

17

2

8

7

3

8

8

6

6

2

21

5

1

2

2

11

11

CM

72
88
55
SOLUTIONS - 296

1

3

10

2

52

16

4

SOLUTIONS
S/E
M/R

1005

10

35

45

73

19

39

59

42

88

189

201

205

TOTAL

Note. Other disciplines includes: social worker, family physician, physical and occupational therapy; COL - Collaborative; S/E - Support and education;
M/R - Maximizing resources; CM - Case management; See Different - What would you like to see different; Solutions - Solutions/suggestions for change

TOTALS

1

1

- RECREATION/ACTIVITIES

CASE MANAGEMENT/SHARED
CARE PLANS
SEPARATE MENTAL HEALTH
UNIT
OUTPATIENT CLINIC & DAY
HOSPITAL BASED PROGRAM
SEPARATE MEDICAL DETOX/
ADDICTIONS AREA

1

- OTHER DISCIPLINES

2

29

2

7

32
3

12

83

SEE DIFFERENT
COL S/E
M/R

2

2

1

47

2

- PSYCHIATRIST

- FIRST NATIONS HEALTH

- MENTAL HEALTH NURSES

SUPPORT & EDUCATION
EXPAND MENTAL HEALTH prog

14

50

HOLISTIC HEALTH, HEALING

13

12

2

39

CM

STRENGTHS
COL S/E
M/R

MATRIX # 4: KEY CONCEPT AND VISION STATEMENT ANALYSIS VERIFICATION

KEY CONCEPTS
COLLABORATION
(Shared Care and Aboriginal Health)

APPENDIX 9

165

APPENDIX 10
GENERAL MENTAL HEALTH INTAKE FORM DRAFT: FIRST NATIONS

A. STATUS
• First Nations
• Inuit
• Metis
B. RESIDENTIAL SCHOOL SURVIVOR ABUSE
• Emotional Trauma
• Sexual Abuse
• Physical Abuse
• Starvation
• Racism
C. CURRENT SOCIAL STRESSORS
• Poverty
• Sexual Abuse
• Physical/Emotional Abuse
• Alcohol/Drugs
• Family Violence
• Inadequate Housing
• FASD
• Unresolved trauma
• Intergenerational Survivor
D. PLAN OF ACTION/REFERRALS FOR FIRST NATION AND MENTAL
HEALTH STAFF
• Admit and plan
• Discharge Referrals

Note. This is a suggested Intake form by one participant in this study