Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Thomas, Sage
Master of Science in Nursing - MSN
University of British Columbia
Background: Worldwide, mental health and substance use (MHSU) disorders are the primary contributors to disability among children and youth and typically have an early age of onset. In rural communities, children and youth may experience compounding barriers to accessing MHSU care. Nurses may be the first point of contact and key support for rural children and youth needing MHSU care. However, the experiences of nurses regarding rural child and youth MHSU care in community settings in BC is understudied. Research Question: What can be learned from rural nurses about child and youth MHSU care in community settings in British Columbia, Canada? Methodology: This qualitative study used an interpretive descriptive approach to understand rural nurses' insights. Actively licensed or registered nurses who work in a rural and/or remote community setting in British Columbia with children and/or youth (up to age 25 years) were included using purposive and snowball sampling recruitment strategies. Data were collected through semi-structured interviews informed by the “Knowing the Rural Community” nursing framework (the Framework) and Community Health Nurses of Canada (CHNC) standards of practice. Data Analysis: Reflexive thematic analysis and interpretive description were used to code and develop themes. Results: Participants (n=11) worked in a range of settings, from outpost nursing to an outreach clinic. Eight of the nurses provided generalist care with MHSU care embedded within broader nursing care, while three nurses worked as MHSU specialists. Three themes were constructed from the data about what can be learned from rural nurses about child and youth MHSU care: child and youth MHSU was more bound to the rural and remote context than adults; MHSU care was more than just MHSU care; and rural nurses were clear on what supported them to provide child and youth MHSU care. Discussion: Rural nurses may play a pivotal role in early MHSU intervention among children and youth. Their unique positions as initial points of contact could enable them to build trust and facilitate early identification and treatment of MHSU issues. Additionally, rural nurses are well-positioned to support rural-centric approaches to MHSU care, leveraging their familiarity with local community contexts.
THE NURTURE STUDY: THE VITAL ROLE OF NURSES FOR UNDERSTANDING AND RESPONDING TO THE UNIQUE RURAL MENTAL HEALTH AND SUBSTANCE USE EXPERIENCES OF CHILDREN AND YOUTH by Sage Thomas B.S.N., University of Manitoba, 2013 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE COLLEGE OF GRADUATE STUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2024 © Sage Thomas, 2024 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: THE NURTURE STUDY: THE VITAL ROLE OF NURSES FOR UNDERSTANDING AND RESPONDING TO THE UNIQUE RURAL MENTAL HEALTH AND SUBSTANCE USE EXPERIENCES OF CHILDREN AND YOUTH submitted by Sage Thomas in partial fulfillment of the requirements for the degree of Master of Science in Nursing Examining Committee: Dr. Elizabeth Keys, School of Nursing Supervisor Dr. Nelly D. Oelke, School of Nursing Supervisory Committee Member Dennis Jasper, School of Nursing Supervisory Committee Member Dr. Saima Hirani, The University of British Columbia (Vancouver) Additional Examiner iii Abstract Background: Worldwide, mental health and substance use (MHSU) disorders are the primary contributors to disability among children and youth and typically have an early age of onset. In rural communities, children and youth may experience compounding barriers to accessing MHSU care. Nurses may be the first point of contact and key support for rural children and youth needing MHSU care. However, the experiences of nurses regarding rural child and youth MHSU care in community settings in BC is understudied. Research Question: What can be learned from rural nurses about child and youth MHSU care in community settings in British Columbia, Canada? Methodology: This qualitative study used an interpretive descriptive approach to understand rural nurses' insights. Actively licensed or registered nurses who work in a rural and/or remote community setting in British Columbia with children and/or youth (up to age 25 years) were included using purposive and snowball sampling recruitment strategies. Data were collected through semi-structured interviews informed by the “Knowing the Rural Community” nursing framework (the Framework) and Community Health Nurses of Canada (CHNC) standards of practice. Data Analysis: Reflexive thematic analysis and interpretive description were used to code and develop themes. Results: Participants (n=11) worked in a range of settings, from outpost nursing to an outreach clinic. Eight of the nurses provided generalist care with MHSU care embedded within broader nursing care, while three nurses worked as MHSU specialists. Three themes were constructed from the data about what can be learned from rural nurses about child and youth MHSU care: child and youth MHSU was more bound to the rural and remote context than adults; MHSU care iv was more than just MHSU care; and rural nurses were clear on what supported them to provide child and youth MHSU care. Discussion: Rural nurses may play a pivotal role in early MHSU intervention among children and youth. Their unique positions as initial points of contact could enable them to build trust and facilitate early identification and treatment of MHSU issues. Additionally, rural nurses are well-positioned to support rural-centric approaches to MHSU care, leveraging their familiarity with local community contexts. v Lay Summary Mental health and substance use (MHSU) disorders are a major cause of disability in children and youth worldwide, often starting early in life. In rural areas, accessing MHSU care can be particularly challenging due to things like a lack of services and travel distances. Nurses often serve as the first point of contact and primary support for rural children and youth. This study explored the experiences of rural nurses in British Columbia to understand their role in MHSU care. The findings highlighted how child and youth mental health is closely connected to the rural community, that MHSU care involves more than just treating disorders, and that rural nurses need support to provide this care. Rural nurses may have a role in early intervention and in tailoring MHSU services to rural communities’ unique needs. Understanding these experiences can help improve MHSU care for children and youth in rural communities by adequately supporting rural nurses in their roles. vi Preface Chapter 1, 3, and 5 are original, independent, and unpublished works by the author, Sage Thomas (ST). Chapter 2 has been submitted to Rural and Remote Health for publication, currently under peer-review. ST identified the research question, conceptualized and designed the literature review, conducted screening and data extraction of all articles, and led data analysis and manuscript writing. Elizabeth Keys (EK) assisted ST in conceptualising and designing the literature review, conducted screening, assisted ST with analysis, and provided critical feedback for the manuscript drafts. Nelly D. Oelke (NO) assisted ST with analysis and provided critical feedback for the manuscript drafts. Dennis Jasper (DJ) assisted ST with screening and provided critical feedback for the manuscript drafts. Michelle Pavloff (MP) reviewed and provided critical feedback on the manuscript drafts. I would also like to acknowledge Marina Ovsenek Manning (MOM) (undergraduate research assistant) who assisted with screening. Thomas, S., Oelke, N. D., Jasper, D., Pavloff, M., & Keys, E. Rural mental health and substance use nursing: A mapping review, submitted to the Rural and Remote Health Journal, March 2024. Chapter 4 is prepared as a manuscript for publication with Global Qualitative Nursing Research. ST identified the research question, conceptualized the study design, created the data collection tools, collected all data, and led data analysis and manuscript writing. EK assisted ST with conceptualizing the study design, creating the data collection tools, data analysis, and manuscript vii writing. NO and DJ assisted ST with conceptualizing the study design, data analysis, and manuscript writing. I would like to acknowledge MP for providing valuable input into using the Framework for the semi-structured interview guide. Thomas, S., Oelke, N. D, Jasper, D., & Keys, E. The NURTURE study: An interpretive description of the vital role of nurses for understanding and responding to the unique rural mental health and substance use needs and experiences of children and youth, in preparation for submission to the Global Qualitative Nursing Research journal, target Generative AI was not used for any aspects of this work. This study was granted ethical approval by the University of British Columbia Behavioural Research Ethics Board – Certificate Number: H23-00823. viii Table of Contents Abstract.........................................................................................................................................iii Lay Summary.................................................................................................................................v Preface............................................................................................................................................vi Table of Contents........................................................................................................................viii List of Tables...............................................................................................................................xiii Acknowledgements.....................................................................................................................xiv Dedication.....................................................................................................................................xv Chapter 1: Introduction…………………....................................................................................1 1.1 Introduction..........................................................................................................................1 1.2 Background..........................................................................................................................1 1.2.1 Child and Youth Mental Health and Substance Use.......................................................1 1.2.2 Barrier to Accessing Rural Mental Health and Substance Use Care..............................4 1.2.3 Community Health Nurses and Standards of Practice....................................................5 1.2.4 Knowing the Rural Community: A Framework for Nursing Practice in Rural and ………. Remote Canada (The Framework)..................................................................................7 1.3 Knowledge Gap and Research Question..............................................................................7 Chapter 2: Literature Review - A Mapping Review of Rural Mental Health and Substance Use Nursing....................................................................................................................................9 2.1 Introduction..........................................................................................................................9 2.2 Methods..............................................................................................................................10 2.2.1 Mapping Review……………………….………..........................................................10 2.2.2 Search Strategy and Article Selection..……..…...........................................................11 ix 2.2.3 Synthesis………………...............................................................................................12 2.3 Results................................................................................................................................12 2.3.1 Rural People – Rural and Remote Nursing Interactions…...........................................14 2.3.1.1 Preparedness for Role and Practice Implications…............................................17 2.3.2 Community..........................……………………..........................................................18 2.3.2.1 Social Determinants of Health…........................................................................21 2.3.3 Rural Context………………........................................................................................22 2.3.4 Larger Society……...………........................................................................................23 2.4 Discussion..........................................................................................................................25 2.4.1 Framework and Literature Integration……………………..........................................25 2.4.2 Rural-Centric Approach……………..……………………..........................................26 2.5 Future Research.................................................................................................................26 2.6 Strengths and Limitations..................................................................................................28 2.7 Conclusion.........................................................................................................................29 Chapter 3: Research Methods....................................................................................................30 3.1 Study Aims...................................................................................................................….30 3.2 Theoretical Framework......................................................................................................30 3.3 Methodology......................................................................................................................32 3.3.1 Interpretive Description….……………………….......................................................32 3.3.1.1 Theoretical Underpinnings of Interpretive Description.........................................33 3.3.2 Data Collection….……………………….....................................................................35 3.3.2.1 Semi-structured Interviews…………………………............................................35 3.3.3 Participants and Recruitment….……...….....................................................................36 x 3.3.3.1 Inclusion Criteria………...…………………………............................................36 3.3.3.2 Exclusion Criteria………...………………………...............................................37 3.3.3.3 Sampling Methods and Recruitment.………...………..........................................37 3.3.3.4 Sample Size……...………...………………..………............................................38 3.3.4 Data Analysis….……...….............................................................................................39 3.3.4.1 Reflexive Thematic Analysis and Interpretive Description...................................40 3.3.5 Quality……………………...….……...….....................................................................41 3.3.5.1 Quality Measures………....…………………………............................................41 3.3.5.2 Reflexivity and Positionality………...……………...............................................42 3.3.5.3 Applied Researcher Accountability..………..………............................................43 3.3.6 Ethical Considerations………………...….……...…....................................................45 3.3.7 Data Management Plan………...……...….....................................................................46 3.3.8 Knowledge Translation…......................….....................................................................47 3.4 Conclusion……………………...……...…...........................................................................48 Chapter 4: The NURTURE Study: An interpretive description of the vital role of Nurses for Understanding and Responding To the Unique Rural mental health and substance use needs and Experiences of children and youth...........................................................................49 4.1 Introduction........................................................................................................................49 4.2 Research Aim.....................................................................................................................50 4.3 Methods..............................................................................................................................50 4.3.1 Theoretical Framework….……………………............................................................50 4.3.2 Interpretive Description….…………………...............................................................51 4.3.3 Participants and Procedures.…….……………............................................................51 4.3.3.1 Participants and Recruitment…………………….................................................51 xi 4.3.3.2 Sample Size…………………………....................................................................52 4.3.4 Data Collection and Analysis.…….…………….…....................................................53 4.3.5 Quality and Rigour.…….……………….....................................................................54 4.4 Results................................................................................................................................55 4.4.1 Theme 1: Children and Youth Were More Bound to the Rural and Remote Context ........ Than Adults and Thus, Their Mental Health was More Tethered to This Context......57 4.4.1.1 Everybody Knowing Everyone…………...…………….......................................58 4.4.1.2 Peer, Family, and Community Norms or Standards ………….............................59 4.4.1.3 Navigating the (Un)available Resources…….… …………….............................59 4.4.1.4 Leaving to Grow…………………………………...………….............................60 4.4.2 Theme 2: MHSU Care was More Than Just MHSU Care............................................61 4.4.2.1 Developing Trust and Safety Between Rural Children and Youth and the …………. Healthcare System.................................................................................................62 4.4.2.2 Facilitating Continuity of Care…………………...………..….............................65 4.4.2.3 Advocating for Equitable Access to MHSU Resources……...….........................66 4.4.3 Theme 3: Rural Nurses Were Clear on What Supports Child and Youth MHSU Care…………………………………………………………………………………...68 4.4.3.1 Embracing Rural Nurse Qualities and Ways of Being……..................................68 4.4.3.2 Having Enough Time to Care…………….……..…………….............................70 4.4.3.3 Access to Practice Support…..…………………………...……............................71 4.4.3.4 Knowing the Community………...…………………………................................73 4.4.3.5 Being Part of a Cohesive, Supportive Team…….………….…............................75 4.4.3.6 Effective Communication and Collaboration Across Health Systems..................78 xii 4.5 Discussion..........................................................................................................................79 4.5.1 The Role of Rural Nurses in Early Intervention…………...........................................80 4.5.2 The Role of Rural Nurses in Supporting Rural-centric Approaches to MHSU Care...81 4.6 Limitations and Future Research.......................................................................................82 4.7 Conclusion…………………….........................................................................................83 Chapter 5: Conclusion.................................................................................................................85 5.1 Implications for Nurses in Canada..........................................................................……...85 5.2 Recommendations..............................................................................................................86 5.2.1 Nursing Practice……………………………………….................................................87 5.2.2 Nursing Education……………………………………….............................................88 5.2.3 Nursing Administration...............……………...……...................................................89 5.2.4 Nursing Research...………………………....................................................................90 5.2.5 Rural Health Policy………………………....................................................................91 5.3 Summary............................................................................................................................92 Bibliography.................................................................................................................................93 Appendices..................................................................................................................................117 1234Appendix A: Literature Search Strategy…………………………..………………………117 1234Appendix B: Prisma Flow Diagram………………………………………………...……..122 1234Appendix C: Data Extraction Table………………………………………..………….......123 1234Appendix D: Semi-structured Interview Guide……………………………………..….…160 1234Appendix E: Recruitment Materials…………………………….…………….…………..162 1234Appendix F: Consent Form……………………………………….……….………………169 xiii 1234Appendix G: Child & Youth MHSU Resources as Described by Rural British Columbia 1234Nurses……………….……….……………………………………………….….………..174 Appendix H: The Framework………………………………...…………………………...177 xiv List of Tables Table 1: Mapping Review Study Countries and Practice Settings…………...............................13 Table 2: Characteristics of Participants’ Nursing Practice…………………...............................57 Table 3: MHSU Approaches to Care as Described by Participants……......................................72 xv Acknowledgements Completing this thesis has been a journey filled with challenges and growth, and I am deeply grateful to the people who have supported and guided me along the way. First and foremost, I want to extend my heartfelt thanks to my thesis supervisor, Elizabeth Keys. Thank you for your thorough, kind, and consistent support. Your grounding presence and skillful guidance have provided me with the encouragement and confidence I needed to persevere through this degree. I am also very thankful for the mentorship and support from Nelly D. Oelke and Dennis Jasper. Your combined expertise and thoughtful feedback have been instrumental in shaping this work. Thank you to Michelle Pavloff for your invaluable assistance with the mapping review and your guidance in using the Framework. I would also like to thank the rural nurse participants who contributed to this study. I am profoundly grateful for your time, dedication to the work, and invaluable input. To my family and friends, thank you for your unwavering love and support. Lastly, I would like to thank UBC Okanagan for the scholarships that have funded my studies. Your generosity allowed me to focus on my research and complete this thesis. xvi Dedication To all the rural children, youth, families, and communities: you deserve access to great care, no matter where you live. And to our rural healthcare providers: my deepest gratitude goes to you. 1 Chapter 1: Introduction 1.1 Introduction Rural nurses provide direct care to children and youth across many community settings (Canadian Public Health Association, 2010), but very little is known about the mental health and substance use (MHSU) care they provide, which may be explicit or embedded throughout more general practice. While the term “rural” can mean different things to different people, for this thesis, unless otherwise stated, rural will be defined as rural, remote, and Indigenous communities with populations of less than 10,000 people (Canadian Association for Rural and Remote Nursing (CARRN), 2020; du Plessis et al., 2001). Rural communities have fewer resources compared to urban centres, are geographically isolated or semi-isolated, and their economies are typically based on natural resources (CARRN, 2020; Kulig et al., 2008). The knowledge gap about rural child and youth MHSU nursing that exists in the literature about Canadian communities limits the opportunity for rural nurses to provide high-quality, equitable MHSU care to children and youth; health systems to leverage valuable practice insights and knowledge from these rural nurses; and rural nurses to access appropriate supports and resources to bolster their rural practice. 1.2 Background 1.2.1 Child and Youth Mental Health and Substance Use Mental health, the psychological and emotional well-being of a person, is an integral dimension of one’s overall health (World Health Organization (WHO), 2022a). Mental health influences an individual’s capacity to cope, live a life of purpose, and engage in their community. Mental health challenges include diagnosed disorders such as major depressive disorder and generalized anxiety disorder (Ferro et al., 2021), as well as states of distress and 2 altered functioning, and do not preclude someone from having positive mental health (WHO, 2022a). Risk factors that contribute to poor mental health include individual, social, and structural factors such as genetics, interpersonal violence (WHO, 2022a), and racism (Fante-Coleman & Jackson-Best, 2020). Conversely, protective factors that contribute to positive mental health include individual, social, and structural factors such as emotion regulation skills, healthy relationships (WHO, 2022a), and equitable access to care (King et al., 2022). These factors also influence an individual’s substance use (Substance Abuse and Mental Health Services Administration, 2019). Substance use is the consumption of drugs, alcohol, and other substances, and exists on a continuum from beneficial use (i.e., where the person experiences positive effects), to casual use (i.e., non-problematic, recreational use), problematic use (i.e., the person starts experiencing ill effects), and chronic dependence (i.e., substance use disorder) (Health Officers Council of British Columbia, 2005). Someone with concurrent MHSU challenges, where a person has both mental health challenges and a substance use disorder, may experience compounding barriers to care, such as stigma and fragmented care, leading to worse functioning and poorer quality of life (Jenkins et al., 2022). Globally, MHSU disorders are the main contributor to disability among children and youth (Erskine et al., 2015), often beginning at a young age. Research indicates that 34.6% of youth with a mental health issue experience it by age 14, with the prevalence increasing to 48.4% by age 18, and 62.5% by age 25 (Solmi et al., 2022). Further, compared to other age groups, children and youth have the poorest mental health, and youth aged 15-24 years have the highest rates of substance use or abuse (Pearson et al., 2013). In addition, the COVID-19 pandemic has exacerbated youth MHSU challenges (Vaillancourt et al., 2021). Canadian youth have reported a decline in their overall mental health since before the pandemic, with only 42% of youth 3 reporting “positive mental health” (i.e., rating their mental health as “good” or “very good”) in 2020, compared to 62% in 2018 (Findlay & Arim, 2020). Children and youth may have unearned disadvantages related to multiple, compounding systemic factors, leading to disproportionately high rates of MHSU disorders (Canadian Mental Health Association (CMHA), 2022; Fante-Coleman & Jackson-Best, 2020; Guruge & Butt, 2015; Kim, 2019; Tilleczek et al., 2014). Racialized youth tend to experience higher rates of MHSU disorders compared to their non-racialized peers (Fante-Coleman & Jackson-Best, 2020). Although Canada does not collect statistics about the prevalence of MHSU challenges in Black children and youth, American statistics show that close to 50% of Black youth experience mental health challenges by the age of 18, with additional barriers to accessing mental health care, such as racism and poverty (Fante-Coleman & Jackson-Best, 2020). Indigenous youth, including First Nations, Inuit, and Metis youth, experience mental health challenges five to six times higher than the non-Indigenous Canadian population (Giroux & Sauve, 2017). Suicide is the leading cause of death for Indigenous youth, compared to accidental death as the leading cause of death for non-Indigenous youth (Giroux & Sauve, 2017). The reasons for these staggering differences are complex and intertwined with ongoing experiences related to historical and systemic trauma that includes (but is not limited to) the intergenerational effects of residential schools, poverty, and racism (Carrier et al., 2022). Two-spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual orientation and gender diverse (2SLGBTQIA+) youth experience suicidality at fourteen times the rate compared to heterosexual and cisgender youth (CMHA, 2022). About half of immigrant and refugee (newcomer) families may face financial insecurity during the first five years of living in Canada (British Columbia Child and Youth Advocacy 4 Coalition, 2011). This instability, along with significant factors such as racism and adjusting to a new culture, put newcomer youth at higher risk of mental health challenges (Hilario et al., 2014). Because these unearned disadvantages are related to multiple, compounding factors, it is important to use an intersectional approach when considering youth MHSU (CMHA, 2022; Khan et al., 2018). Intersectionality is a way of looking at the multiple, overlapping systems or societal norms that interact to inequitably advantage or disadvantage an individual, their family, or community, such as racism, homophobia, transphobia, ableism, sexism, or settler colonialism (Nixon, 2019). For example, an Indigenous youth who is part of the 2SLGBTQIA+ community and experiences racism, homophobia or transphobia, and lives in poverty has a greater, unearned risk of an MHSU disorder related to these systemic factors (CMHA, 2022). If this youth lived in a remote First Nation’s community, their MHSU care could be impacted by factors such as stigma, healthcare staffing shortages, and the availability of MHSU services (Pijl et al., 2022). 1.2.2 Barriers to Accessing Rural Mental Health and Substance Use Care Over 80% of children and youth with MHSU challenges may experience barriers to accessing care (Youth Mental Health Canada, 2019), such as stigma and lengthy waitlists (Canadian Association of Mental Health (CAMH), 2019), financial insecurity and fragmented care (Moroz et al., 2020), or a lack of youth-friendly services (Hawke et al., 2019). Access to care is further diminished in rural areas (CMHA, 2009), with few or no MHSU supports or services (Canadian Institute for Health Information (CIHI), 2019), including less access to harm reduction resources (Parker et al., 2012). Harm reduction, the philosophy and practice of nonjudgmentally supporting people at any stage of their substance use to minimize harms (Dubois, 2017), is an integral element of best practices in substance use treatment (Kerber et al., 2020). Rural people who use substances face a 30-50% higher risk of a fatal toxic drug poisoning 5 (overdose) compared to urban people who use substances (Hu et al., 2022), so it is crucial that rural people – including children and youth – can access timely and appropriate harm reduction supports (Pijl et al., 2022) and other appropriate MHSU care. If children and youth with MHSU disorders are left unsupported or inadequately treated, they have a heightened risk of death due to toxic drug poisoning (British Columbia Coroners Service, 2023), suicide (Ackerman & Horowitz, 2022), developing chronic MHSU disorders (Malla et al., 2018; Wiens et al., 2020), poorer mental and physical health outcomes (Patel et al., 2007), and an increased risk of housing insecurity, imprisonment, and sexual exploitation (Miller, 2009). The cost of MHSU challenges to the Canadian economy, including health care and criminal justice costs, reduced quality of life, and lower levels of productivity, is approximately $90 billion per year across all age groups (CAMH, 2019). While this potential toll on young people, their families, communities, and society is immense, these adverse outcomes are highly preventable with robust and timely treatment (McGorry & Mei, 2018). To mediate these inequitable MHSU outcomes in rural regions, Community Health Nurses (CHNs) may have a role in facilitating or providing appropriate and comprehensive MHSU care (McAllister, 2019). 1.2.3 Community Health Nurses and Standards of Practice CHNs are highly credible and trusted healthcare providers embedded within the healthcare system throughout urban and rural communities in Canada (Canadian Public Health Association, 2010). CHNs work in community-based settings, supporting the health of individuals and communities across the continuum of health promotion to illness prevention and recovery (Community Health Nurses of Canada (CHNC), 2019). CHNs support children, youth, and their families in a variety of practice environments, including schools, community-based 6 clinics, on the streets, and in Indigenous communities (Canadian Public Health Association, 2010), and often work directly with unfairly disadvantaged children and youth, their families, and their communities (McAllister, 2019). The CHNC Professional Practice Model & Standards of Practice (CHNC Standards) guide CHN practice and specifically refer to the practice of Registered Nurses (RNs) (CHNC, 2019). The CHNC Standards define the core elements of CHN practice, which can occur in home health, primary care, public health, and other generalist or specialty community roles. CHN practice can be very specific (e.g., running immunization clinics), or broad (e.g., working as a combined home care, public health, and primary care nurse in Indigenous communities) using a holistic lens to care for the individual, family, and community over the lifespan. Since the CHN scope of practice is holistic, it includes mental health, no matter the role (CHNC, 2019). The CHNC Standards include (a) health promotion; (b) prevention and health protection; (c) health maintenance, restoration, and palliation; (d) professional relationships; (e) capacity building; (f) health equity; (g) evidence-informed practice; and (h) professional responsibility and accountability (CHNC, 2019). The CHNC Standards have recently been updated to include considerations for cultural safety, Indigenous ways of knowing, and health equity (Belita et al., 2021). Due to the exploratory nature of this study to look at rural nurses working in community settings, in this thesis I have purposefully considered CHNs to include all nurses (i.e., licensed practical nurses (LPNs), nurse practitioners (NPs), RNs, and registered psychiatric nurses (RPNs)) who work in rural community settings. Although the CHNC Standards (CHNC, 2019) are specific to RN practice, all professional nursing standards of practice in British Columbia (British Columbia College of Nurses and Midwives (BCCNM), 2024a; 2024b, 2024c) are congruent with the CHNC Standards (CHNC, 2019). 7 Given their extensive involvement in child and youth health settings (Canadian Public Health Association, 2010), their ability to provide care spanning health promotion to illness prevention (CHNC, 2019), and existing connections within communities, CHNs are optimally positioned to support and increase access to high-quality and equitable MHSU care (McAllister, 2019). This care potential extends to rural communities, where an estimated 10.8% of Canadian nurses support the health of isolated populations (CARRN, 2020). However, CHN practice in the rural context has not been well-documented, thus the Knowing the Rural Community: A Framework for Nursing Practice in Rural and Remote Canada (CARRN, 2020), or the Framework, could help to contextualise rural CHN practice (Appendix H). 1.2.4 Knowing the Rural Community: A Framework for Nursing Practice in Rural and Remote Canada The Framework was developed by CARRN (2020) as a specific resource to support the professional practice of all regulated nurses working in rural communities, and includes considerations related to rural people (including rural and remote nursing interactions), community, rural context (including the determinants of health), and larger society. The Framework (CARRN, 2020) assists rural nurses to account for the multi-layered, rural context across nursing education, clinical practice, policy, and research. The theoretical underpinnings of the Framework (CARRN, 2020) are explored in chapter 4. 1.3 Knowledge Gap & Research Question Research is available regarding general rural mental health nursing, however, research related to rural Canadian child and youth MHSU nursing has not been explored and/or systematically described. Further, there is no apparent qualitative research specifically looking at community nursing practice settings. This gap limits understanding of and the future 8 opportunities for Canadian CHNs to contribute to optimal, integrated MHSU care for children and youth across community healthcare settings in rural areas. My thesis project addresses this knowledge gap by asking the following research question: What can be learned from rural nurses about child and youth MHSU care in community settings in British Columbia, Canada? By exploring the experiences of rural CHNs, their valuable practice insights will be leveraged with the aim of better supporting CHNs to provide high-quality and equitable MHSU care to rural Canadian children and youth. Following this introductory chapter that has provided background information on rural child and youth MHSU and rural nursing in community-based settings, chapter 2 presents a comprehensive mapping review of rural MHSU nursing internationally. Due to a paucity of literature in community practice settings and with child and youth populations, this review includes all nursing practice settings and all age groups. Chapter 3 outlines the methodology used in this study, interpretive description (Thorne, 2016); this detailed chapter was necessary because chapter 4, which describes the study’s findings, is formatted as a manuscript and thus is confined by word limits that restrict extensive methodological descriptions. Chapter 5 concludes this thesis by discussing the implications of the findings for nurses in Canada, recommendations, and a summary. Due to the manuscript format, there is some repetition of methodological details between chapters 3 and 4. 9 Chapter 2: Literature Review – A Mapping Review of Rural Mental Health and Substance Use Nursing 2.1 Introduction According to CARRN (2020), approximately 10.8% of Canadian nurses worked in rural locations in 2016. Rural regions have been defined in Canada as communities with populations of less than 10,000 people (CARRN, 2020; du Plessis et al., 2001), although rural is inconsistently defined across the literature in different countries (Cosgrave et al., 2018; Cree et al., 2021). Rural nurses provide care in various settings, such as public and community health, inpatient units, emergency departments, long-term care, outreach, and outpatient settings (CARRN, 2020). However, rural settings often have limited access to resources and specialists compared to urban settings, varying levels of communication technology, and greater susceptibility to environmental disasters (CARRN, 2020). Rural nurses typically have a broader scope of practice than their urban counterparts, as they are presented with a range of healthcare concerns and diverse populations (MacLeod et al., 2019). While some rural nurses specialize in MHSU care (e.g., MHSU prevention, harm reduction, treatment, and health promotion), most have a multi-layered, generalist practice, working in multiple settings (e.g., hospitals and primary care) (MacLeod et al., 2022). Within Canada, an estimated 20% of the population experiences an MHSU disorder, such as generalized anxiety disorder or major depressive disorder, in any one year (CMHA, 2021). People living in rural regions tend to have disproportionately higher rates of mental illness (Beks et al., 2018) and poorer mental health outcomes (Perkins et al., 2019) than those in urban areas. Further, rural people in some regions, such as rural British Columbia, Canada, face a 30-50% higher risk of a fatal toxic drug poisoning (i.e., drug overdose) compared to urban areas (Hu et 10 al., 2022). Moreover, rural residents typically face greater stigma related to mental health (Mental Health Commission of Canada (MHCC), 2020) and substance use (Ezell et al., 2021). Compounding these inequities, MHSU services may be absent, difficult to access, or inadequate (Matsea et al., 2018; MHCC, 2020). In this context, rural nurses are often the first point of contact and the primary professional support for those with mental health challenges, across healthcare settings (MacLeod et al., 2022). International research has been conducted on rural MHSU nursing, highlighting the difficulties of working in isolation with limited resources (Crowther & Ragusa, 2011; Kadar et al., 2020; MacLeod et al., 2022). However, no literature reviews have been published on rural MHSU nursing; greater insight is needed into the practice realities of rural nurses, as the health of rural communities is deeply connected to their work (MacLeod et al., 2019). Thus, the aim of this mapping review was to answer the research question: What is the current state of evidence on rural mental health and/or substance use nursing? To improve insight into this practice area, the literature was organized and synthesized according to the professional practice framework for rural nursing practice, the Framework (CARRN, 2020; Pavloff et al., 2022). The Framework (CARRN, 2020) was developed to support rural nursing education, clinical practice, policy, and research (CARRN, 2020), and has not been examined within MHSU research. Thus, this review aimed to map the rural MHSU nursing literature to the Framework (CARRN, 2020), to expand our understanding of this valuable practice area and explore the congruence between the literature and the Framework. 2.2 Methods 2.2.1 Mapping Review The depth and scope of rural MHSU nursing literature internationally was unclear, and 11 therefore, a mapping review (Booth, 2016) was chosen to guide a systematic exploration of the literature. For this review paper, a mapping review was defined as a broad overview of the research topic that examines what is known by “categorizing, classifying, characterizing patterns, trends or themes” (Booth, 2016, p. 14). This mapping review may then serve as a foundation to conduct a systematic review or primary research study to explore the identified knowledge gaps (Booth, 2016) on rural MHSU nursing. In this study, five mapping review steps (Booth, 2016) were followed: (1) identifying the search strategy (Appendix A); (2) conducting the literature search; (3) conducting the article selection process; (4) extracting and analysing the data; and (5) presenting the data. 2.2.2 Search Strategy and Article Selection The databases of CINAHL, Medline, and PyscINFO (all via EBSCOhost) were used to search for articles that addressed the research question from May to August 2023. Searches were conducted utilizing standardized search headings and keyword searches based on the concepts of “nursing” AND “rural” AND “mental health” AND “substance use”, and the search strategy was developed in consultation with academic librarians. Boolean operators (AND/OR) were used to retrieve relevant articles. Inclusion criteria included any date range; language (English); qualitative, quantitative, or mixed-method scholarly (peer-reviewed) or research articles; articles that included considerations about rural and/or remote regions, mental health and/or substance use care, and nursing (i.e., LPN, RN, or RPN) practice considerations. Exclusion criteria included grey literature, articles about NPs due to differences in scope of practice, and intervention studies that did not describe current nursing practice. In total, 6111 articles (CINAHL, n=811; Medline, n= 3216; PsycINFO, n=2084) were imported into Covidence (2023), a literature screening and data extraction tool, and 1368 12 duplicate articles were removed. Next, the titles and abstracts of 4743 articles were screened, excluding 4541 articles. Then, 202 full-text articles were independently assessed by two reviewers (ST and EK or DJ) for eligibility, excluding 155 articles for (a) study design (n=48), (b) study population (n=31), (c) not empirical evidence (n=27), (d) not differentiating nurses from other populations (n=18), (e) not including MHSU considerations (n=19), and (f) not differentiating rural from urban data (n=12) (Appendix B). Data on study characteristics and any data relating to rural nurses’ involvement with MHSU care were manually extracted from 47 articles; these articles ranged from 2012-2023. Data were managed in a Microsoft Word table and NVivo 14 (Lumivero, 2023), and extracted into relevant Framework (CARRN, 2020) categories (Appendix C). 2.2.3 Synthesis The included articles were synthesized, first describing the study characteristics (i.e., type of research design, country, healthcare setting, and participant characteristics). Results from individual studies were deductively mapped to the Framework (CARRN, 2020; Pavloff et al., 2022) categories: (a) rural people – rural and remote nursing interactions, (b) community, (c) rural context, and (d) larger society, starting with a focus on the micro level (i.e., rural and remote nursing interactions) and expanding to the macro level (i.e., larger society). Results were compared and contrasted to see how they fit with the Framework (CARRN, 2020). 2.3 Results In total, 47 studies related to rural MHSU nursing were examined, comprised of 7 mixed-methods, 28 qualitative, and 12 quantitative studies. In these studies, researchers analysed data from primary data sources (i.e., surveys, questionnaires, focus groups, and/or semi-structured interviews) and secondary data sources (i.e., document analyses). The studies were conducted in 13 many different countries and practice settings (Table 1). Table 1 Mapping Review Study Countries and Practice Settings Characteristic n % Study country Australia United States Canada South Africa Cameroon Greece Guatemala Indonesia Ireland Kenya Mongolia Poland Scotland St. Kitts & Nevis Sweden Tanzania 15 8 31.9 17 7 5 1 1 1 1 1 1 1 1 1 1 1 1 14.9 10.6 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 2.1 Practice settings Hospital Primary care Community mental health Community health Emergency departments Urgent care centres Long-term care Mental health Other (nursing station, obstetrics, education, or not specified) Schools Home care Hospice/palliative/end-of-life care Indigenous communities Remote practice Maternal-child health Mobile mental health unit Substance abuse program 14 11 7 7 6 4 29.8 23.4 14.9 14.9 12.8 8.5 3 3 3 3 2 2 2 2 1 1 1 6.4 6.4 6.4 6.4 4.3 4.3 4.3 4.3 2.1 2.1 2.1 14 The studies examined or included mental health considerations (n=22), both MHSU considerations (n=21), or substance use considerations (n=4) within rural nursing practice. The vast majority of nurses in the studies, where demographic information was included, were women, RNs, with an age range of 21-70 years. Data were synthesized into four overarching themes within the Framework (Pavloff et al., 2022): rural people, community, rural context, and larger society. The “rural people” theme was further divided into rural and remote nursing interactions, and preparedness for practice and role implications. 2.3.1 Rural People – Rural and Remote Nursing Interactions Rural nurses are part of the community, serving the people they live amongst. Within the Framework (Pavloff et al., 2022), the rural nursing role is described as complex and generalist, requiring a versatile, prepared, culturally safe nurse to work in a dual role (i.e., where their personal and professional roles overlap). Over one-third of the studies reflected this multifaceted rural nursing role (Beks et al., 2018; Burch & Stoeckel, 2021; Cosgrave et al., 2018; Crowther & Ragusa, 2014; Dube & Uys, 2015; Happell et al., 2012; Jahner et al., 2020; Jansson & Graneheim, 2018; Jones & Quinn, 2021; Kadar et al., 2020; Kenny & Allenby, 2013; Kidd et al., 2012; McCullough et al., 2012; Mendenhall et al., 2018; Stryker et al., 2022; Whiteing et al., 2021; Wolf & Delao, 2013), with 15 of the studies speaking to the generalist and multiskilled approach that is required for rural MHSU care (Ambikile et al., 2021; Beks et al., 2018; Burch & Stoeckel, 2021; Cosgrave et al., 2018; Crowther & Ragusa, 2014; Jones & Quinn, 2021; Kadar et al., 2020; Kenny & Allenby, 2013; Kidd et al., 2012; MacLeod et al., 2022; Mendenhall et al., 2018; Stanisławska et al., 2015; Wand et al., 2021; Whiteing et al., 2021; Wolf & Delao, 2013). Many of the nurses reported having to contend with a high workload (Burch & Stoeckel, 2021; Cosgrave et al., 2018; Happell et al., 2012; Jansson & Graneheim, 2018; Kenny & Allenby, 15 2013; Mpheng et al., 2022; Wand et al., 2021), and subsequently, the MHSU needs of some rural people (Kenny & Allenby, 2013) were harder to address or prioritize. Little time was left to devote to the nursing team’s or community’s mental health education needs (Wand et al., 2021; Whiteing et al., 2021). In addition, the generalist role was associated with increased responsibilities (Burch & Stoeckel, 2021; Cosgrave et al., 2018; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; Kidd et al., 2012; Ratter, 2023; Whiteing et al., 2021) in the context of a changing healthcare landscape, which included rising substance use, increased youth mental health challenges (Beks et al., 2018), and increasingly complex care needs (Beks et al., 2018; Burch & Stoeckel, 2021; Jansson & Graneheim, 2018; Jones & Quinn, 2021; Kidd et al., 2012). Nine of the studies also indicated that rural nurses face a significant risk of violence in their nursing interactions due to patient mental health, substance use, or other reasons (Gohar et al., 2020; Jacob et al., 2022; Jahner et al., 2020; Jahner et al., 2022; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; MacLeod et al., 2022; McCullough et al., 2012; Whiteing et al., 2021). Some rural nurses may have access to law enforcement support for violence intervention (Dube & Uys, 2015), while other nurses may be unable to involve police or other emergency services due to a lack of these services, leaving the nurses to handle the violent situation with inadequate care (Whiteing et al., 2021). In three studies (Gohar et al., 2020; Jacob et al., 2022; McCullough et al., 2012), workplace culture was reported to compound and contribute to the risk of violence against rural nurses through complacency or normalizing workplace violence. Workplace violence was exacerbated for rural nurses whose personal and professional lives intersect (dual role), as some rural nurses in smaller communities feared being targeted outside of the work setting by people who had been aggressive in the past (Jacob et al., 2022). The dual nursing role was also noted to add to ethical dilemmas and complicate an already 16 multilayered rural role (Cosgrave et al., 2018; Jahner et al., 2022; Kenny & Allenby, 2013; Whiteing et al., 2021). However, in one study (Wideman et al., 2020), most rural home visit nurses felt capable of navigating their dual role, such as seeing the rural people they work with in the community, outside of their practice interactions. Four of the studies described the importance of collaboration, highlighting the positive impact of partnerships between nurses and Indigenous workers (McCullough et al., 2012), families (Mpheng et al., 2022), and other community members (Beks et al., 2018; McCullough et al., 2012). In several studies, the nurses’ role was described as being part of an interprofessional team to provide rural MHSU care (Beks et al., 2018; Burch & Stoeckel, 2021; Jansson & Graneheim, 2018; Jones & Quinn, 2021; Lamba & Aswani, 2012; Mpheng et al., 2022; Peritogiannis et al., 2022; Wand et al., 2021). One study identified that the rural school nurse role was not well recognized as supporting child and youth mental health, and thus there were missed opportunities for collaboration (Ratter, 2023). Burch and Stoeckel (2021) describe how some school nurse’s offices are places children and youth may go to feel safe when experiencing physical or mental health issues. Nurses in one study (Wand et al., 2021) described how beneficial it was to have a mental health nurse embedded within rural emergency departments for collaborative, integrated mental health care. Further, one study (Beks et al., 2018) emphasized the need to understand the community’s concerns related to mental health and partner with community services to address these concerns. Cultural safety and trust were underexplored facets of nursing practice. Only three studies underscored the importance of culturally safe care (Cole & Bondy, 2020; McCullough et al., 2012; Whiteing et al., 2021), and the need for adherence to cultural safety policies and access to cultural safety training (Whiteing et al., 2021). The need for trust to 17 facilitate care between rural nurses and the people they work with (Stanisławska et al., 2015; Stryker et al., 2022), including youth (Wilson & Usher, 2015), was also noted. For example, nurses in one study (Stryker et al., 2022) describe how confianza, an Indigenous Guatemalan concept, is translated to trust in English; however, culturally defined, it is really “a trust based on respect and the duty to honor an interpersonal relationship” (p. 1647) and is pivotal to facilitating mental health care. 2.3.1.1 Preparedness for Practice and Role Implications The nurse’s experience of “being prepared” is a consideration of the Framework (Pavloff et al., 2022), but it is necessary to expand on it here as this facet was described in twenty studies, and nurses’ personal experiences may influence their nursing interactions or capacity to do their job (Ambikile et al., 2021; Beks et al., 2018; Burch & Stoeckel, 2021; Cosgrave et al., 2018; Dube & Uys, 2015; Gohar et al., 2020; Jahner et al., 2020; Jansson & Graneheim, 2018; Kadar et al., 2020; Kenny & Allenby, 2013; Keugoung et al., 2013; Kidd et al., 2012; MacLeod et al., 2022; McCullough et al., 2012; Mpheng et al., 2022; Ratter, 2023; Stryker et al., 2022; Wand et al., 2021; Whiteing et al., 2021; Wolf & Delao, 2013). Many rural nurses in the reviewed studies expressed a lack of MHSU experience, training, or knowledge (Ambikile et al., 2021; Beks et al., 2018; Burch & Stoeckel, 2021; Cosgrave et al., 2018; Dube & Uys, 2015; Gaffey et al., 2016; Jones & Quinn, 2021; Kadar et al., 2020; Kenny & Allenby, 2013; Keugoung et al., 2013; Kidd et al., 2012; MacLeod et al., 2022; McCullough et al., 2012; Mendenhall et al., 2018; Mpheng et al., 2022; Pattison-Sharp et al., 2017; Ratter, 2023; Whiteing et al., 2021; Wolf & Delao, 2013), and reported low confidence providing mental health care (Ambikile et al., 2021; Beks et al., 2018; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; Kidd et al., 2012; Ratter, 2023; Stryker et al., 2022). Rural nurses in one study (Mpheng et al., 2022) identified that they lacked 18 the counselling skills needed for comprehensive mental health care. Moreover, some nurses were coping with stress, burnout (Cosgrave et al., 2018; Gohar et al., 2020; Jacob et al., 2022; Jahner et al., 2022; McCullough et al., 2012; Singh et al., 2015; Whiteing et al., 2021), feelings of being undervalued in their role (Crowther & Ragusa, 2014; Ratter, 2023), and other distressing emotions (Jahner et al., 2020; Jahner et al., 2022; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; Kidd et al., 2012; Stryker et al., 2022). However, five studies (Beks et al., 2018; Burch & Stoeckel, 2021; Cole & Bondy, 2020; Jahner et al., 2022; Whiteing et al., 2021) noted that rural nurses are resilient and that they worked hard to provide good care despite the challenges these nurses and the rural people they worked with faced. This commitment to provide care supported the mental health of the communities that rural nurses are a part of. These findings highlight the complexity of the multiskilled, generalist rural nurse role. Rural nurses, balancing their dual roles of community member and caregiver, may feel unprepared for but committed to delivering MHSU nursing care, and this reality may be affected by rural community considerations. 2.3.2 Community The Framework (Pavloff et al., 2022) considers community to include the political, cultural, social, and economic context that healthcare is situated within, including access to care. Nearly three-quarters of the studies underscored the challenges faced by rural nurses and their communities, with inadequate and/or poor access to healthcare resources described in most studies (Ambikile et al., 2021; Beks et al., 2018; Burch & Stoeckel, 2021; Cosgrave et al., 2018; De Kock & Pillay, 2016, 2018; Dube & Uys, 2015; Etter et al., 2019; Happell et al., 2012; Jahner et al., 2020; Jahner et al., 2022; Jansson & Graneheim, 2018; Jones & Quinn, 2021; Kadar et al., 2020; Kenny & Allenby, 2013; Keugoung et al., 2013; Kidd et al., 2012; Lamba & Aswani, 19 2012; MacLeod et al., 2022; McCullough et al., 2012; Mendenhall et al., 2018; Mpheng et al., 2022; Nankivell et al., 2013; Pattison-Sharp et al., 2017; Ratter, 2023; Searby & Burr, 2021; Stanisławska et al., 2015; Stryker et al., 2022; Sutarsa et al., 2021; van Rooyen et al., 2019; Wand et al., 2021; Whiteing et al., 2021; Wideman et al., 2020; Wilson & Usher, 2015; Wolf & Delao, 2013). These deficient healthcare resources included absent or insufficient security measures (Beks et al., 2018; Jahner et al., 2020; Kidd et al., 2012; MacLeod et al., 2022; McCullough et al., 2012; Whiteing et al., 2021), a lack of funding (Mpheng et al., 2022; Nankivell et al., 2013; Stanisławska et al., 2015), a lack of facilities and/or services (Burch & Stoeckel, 2021; Cosgrave et al., 2018; Kadar et al., 2020; Lamba & Aswani, 2012; Mendenhall et al., 2018; Nankivell et al., 2013; Ratter, 2023; Stryker et al., 2022; van Rooyen et al., 2019; Wilson & Usher, 2015) or limited service hours (Jones & Quinn, 2021), inadequate equipment (Jahner et al., 2020; Wolf & Delao, 2013) or mental health screening tools (Ambikile et al., 2021; Ratter, 2023), absent MHSU policies (Cree et al., 2021; Dube & Uys, 2015), inadequate access to training (Cosgrave et al., 2018; Kadar et al., 2020; Keugoung et al., 2013; Kidd et al., 2012; MacLeod et al., 2022; Mendenhall et al., 2018; Ratter, 2023; Wand et al., 2021; Whiteing et al., 2021; Wolf & Delao, 2013), limited access to medications (Mpheng et al., 2022; Pattison-Sharp et al., 2017; van Rooyen et al., 2019), fewer or a lack of cultural resources (Etter et al., 2019; Rieckmann et al., 2016; Whiteing et al., 2021), inadequate staffing (e.g., inadequate baseline staff and/or no specialized, onsite MHSU support) (Ambikile et al., 2021; Beks et al., 2018; De Kock & Pillay, 2016, 2018; Dube & Uys, 2015; Happell et al., 2012; Jahner et al., 2020; Kadar et al., 2020; Keugoung et al., 2013; Kidd et al., 2012; Lamba & Aswani, 2012; MacLeod et al., 2022; Mendenhall et al., 2018; Mpheng et al., 2022; Nankivell et al., 2013; Whiteing et al., 2021; Wolf & Delao, 2013), insufficient time to complete their work (Burch & 20 Stoeckel, 2021; Cosgrave et al., 2018; MacLeod et al., 2022; Wand et al., 2021; Whiteing et al., 2021) or to access peer support (Ratter, 2023), a lack of (or delayed) critical incident debriefing (Gohar et al., 2020; Jahner et al., 2022; Whiteing et al., 2021), and deficits in leadership support (Jahner et al., 2022; Kenny & Allenby, 2013; McCullough et al., 2012; Whiteing et al., 2021). A lack of resources can create challenges for nurses when addressing the social determinants of health that may impact MHSU (Burch & Stoeckel, 2021; Stryker et al., 2022). Additional challenges that impacted access to MHSU care included difficulty referring or supporting rural people through complex mental health systems (Beks et al., 2018; Dube & Uys, 2015; Stryker et al., 2022), transferring people to a higher level of care outside of the community (Beks et al., 2018; Etter et al., 2019; Jansson & Graneheim, 2018; MacLeod et al., 2022; Stryker et al., 2022; Wolf & Delao, 2013), helping people access mental health care via telephone (Beks et al., 2018; Jansson & Graneheim, 2018; Wideman et al., 2020), or accessing mental health assessments after business hours (Beks et al., 2018). Jones and Quinn (2021) describe the challenges that the interprofessional care team, including nurses, may face when providing substance use care in remote communities, including no pharmacy, limited nursing station hours, and the need for people to travel out of community for opioid use disorder treatment initiation (e.g., buprenorphine-naloxone). These systemic challenges contribute to an uncoordinated system of care, where MHSU care (Dube & Uys, 2015) and physical health care (Nankivell et al., 2013) are absent or fragmented. Limited onsite or community support was identified to be a significant barrier to providing quality MHSU care in some studies (Beks et al., 2018; Cosgrave et al., 2018; Jansson & Graneheim, 2018; Ratter, 2023; Stryker et al., 2022; van Rooyen et al., 2019). Further, eleven of the studies found that many rural nurses worked in isolation within their clinical practice setting, where they may be one of a few or the only healthcare provider on 21 shift (Happell et al., 2012; Jahner et al., 2020; Jahner et al., 2022; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; Kidd et al., 2012; MacLeod et al., 2022; Ratter, 2023; Whiteing et al., 2021; Wideman et al., 2020; Wolf & Delao, 2013). In contrast to the many challenges that rural nurses and their communities face, two studies reported that some nurses felt well-supported by leadership (i.e., received psychological workplace support, such as debriefing, after an extremely distressing incident) (Jahner et al., 2020) or had adequate peer support to navigate MHSU care in their practice setting (Jansson & Graneheim, 2018). In one study, leadership support, peer mentorship, and past experience with teaching helped improve nurse self-efficacy for providing mental health education (i.e., postpartum depression education) (Link et al., 2019). These findings suggest that rural nurses and their communities face significant challenges when trying to provide or access MHSU care, including a range of insufficient or absent resources. These varying challenges are important to understand because rural healthcare systems are a part of, and integral to, rural communities. 2.3.2.1 Social Determinants of Health Seven studies included data about the nurse’s perspectives on the social determinants of health, such as income, housing, or food insecurity, in relation to MHSU experiences. In three studies (Baker & Showalter, 2018; Stryker et al., 2022; Wideman et al., 2020), nurses expressed an awareness that rural peoples’ MHSU challenges can be in response to or influenced by the social determinants of health such as poverty, interpersonal stress, or familial factors, thus requiring support that is tailored to the person’s multifaceted experience. Two studies (Happell et al., 2012; Nankivell et al., 2013) commented on how rural people with mental health challenges experienced financial insecurity and subsequently had difficulty accessing physical health care. 22 Burch and Stoeckel (2021) described how school nurses were aware that child and youth MHSU challenges were related to the social determinants of health, such as poverty and housing insecurity, and some nurses and school staff tried to alleviate stress related to food insecurity by providing free lunches, doing the student’s laundry, or helping them with hygiene. In addition, geographic isolation may have intensified stress related to the social determinants of health, such as poverty (Wideman et al., 2020). Nurses in one study (Trop et al., 2018) thought that adversity (e.g., living in harsh environments) can make rural peoples’ mental health more resilient than urban people. Although only a limited number of studies included data on the social determinants of health in the context of rural MHSU nursing, these facets are important to consider here to demonstrate how rural nurses may intervene upstream to support rural people facing complex challenges. 2.3.3 Rural Context Rural context refers to the geographical, climate, and historical environment in which rural healthcare services are embedded (Pavloff et al., 2022). In eighteen of the studies, the rural context was described by nurses as an important consideration when providing MHSU care. For example, working in remote and sparsely populated areas meant that nurses often worked in geographical isolation (Beks et al., 2018; Cosgrave et al., 2018; Happell et al., 2012; Jahner et al., 2020; Jansson & Graneheim, 2018; Kidd et al., 2012; MacLeod et al., 2022; Ratter, 2023; Whiteing et al., 2021; Wideman et al., 2020) or they had to travel far to provide care (Burch & Stoeckel, 2021). Some nurses worked in remote, mountainous regions (Peritogiannis et al., 2022), while others worked in locations that were only accessible via air (Etter et al., 2019; Jahner et al., 2020). Prohibitive geographical distance was also a barrier for rural people who were needing to access MHSU services outside of their community (Jones & Quinn, 2021; 23 Nankivell et al., 2013; Stryker et al., 2022; van Rooyen et al., 2019; Wideman et al., 2020; Wilson & Usher, 2015). A lack of, or unreliable, internet access or cell phone coverage in the area prevented some rural people from accessing telehealth MHSU care (Searby & Burr, 2021; Wideman et al., 2020). Five studies briefly described rural climate considerations, including poor road (MacLeod et al., 2022; van Rooyen et al., 2019; Wideman et al., 2020) or weather conditions (MacLeod et al., 2022; Wilson & Usher, 2015), or extreme weather events such as flooding (Happell et al., 2012), that compound these geographically isolated rural environments. None of the studies discussed the impact of climate change on rural MHSU nursing. Nurses in two studies described the importance of knowing local current and historical community issues as part of the context of rural peoples’ mental health (Beks et al., 2018; Burch & Stoeckel, 2021). For example, rural school nurses were aware that youth they worked with were negatively affected by significant family issues such as abuse, homelessness, and substance abuse (Burch & Stoeckel, 2021). Taken together, these findings highlight the geographical and climate challenges that impact healthcare access within the rural context as well as the importance of exploring the rural community’s history. 2.3.4 Larger Society Larger society refers to societal values and beliefs, and includes social justice and health equity considerations (Pavloff et al., 2022). Nineteen studies identified health inequity considerations related to “larger society” that become apparent when comparing rural to urban communities. Five studies highlighted the disproportionate mental health challenges in rural compared to urban communities, with fewer healthcare providers or services (e.g., specialized services or psychiatric beds) to meet this greater need (Beks et al., 2018; Cosgrave et al., 2018; De Kock & Pillay, 2016, 2018; MacLeod et al., 2022). Two studies found significant inequities 24 between rural and urban communities, where there are fewer mental health nurses in rural regions of Australia (Sutarsa et al., 2021) and fewer nurses staffed in rural Indigenous substance use programs in the United States (Rieckmann et al., 2016) compared to urban regions. In two studies (Happell et al., 2012; Nankivell et al., 2013), nurses felt that rural communities face greater barriers (i.e., staffing and service shortage, geographic, and economic) when rural people try to access physical health care, compared to urban communities. Additionally, fourteen studies identified that mental health stigma was a pervasive issue in rural communities (Beks et al., 2018; Etter et al., 2019; Happell et al., 2012; Kenny & Allenby, 2013; Keugoung et al., 2013; Kidd et al., 2012; Lamba & Aswani, 2012; MacLeod et al., 2022; Mendenhall et al., 2018; Mpheng et al., 2022; Nankivell et al., 2013; Stryker et al., 2022; van Rooyen et al., 2019; Wand et al., 2021). Stigma was described as being directed toward rural people with mental health challenges from rural nurses (Beks et al., 2018; Kenny & Allenby, 2013; van Rooyen et al., 2019) or other community members (Happell et al., 2012; Mendenhall et al., 2018; Mpheng et al., 2022; Nankivell et al., 2013; Stryker et al., 2022; van Rooyen et al., 2019; Wand et al., 2021), toward rural nurses from urban healthcare providers when training in cities (Kidd et al., 2012), and from community members toward rural mental health nurses (MacLeod et al., 2022). In six studies, stigma toward rural people with mental health challenges was noted to limit their engagement with health services (Happell et al., 2012; Mendenhall et al., 2018; Nankivell et al., 2013; Stryker et al., 2022; van Rooyen et al., 2019) or impede comprehensive care (Mpheng et al., 2022). While many of the studies included “larger society” considerations including rural MHSU inequity and stigma, nurses in only one study (Wand et al., 2021) described the role for mental health nurses in decreasing stigma against the people they care for. 25 2.4 Discussion 2.4.1 Framework and Literature Integration This mapping review provided an overview of rural MHSU nursing in comparison with the Framework (CARRN, 2020). The Framework (CARRN, 2020) provided a multilayered approach for reviewing the literature and helped to scaffold this mapping review so that the findings could be systematically described. While the findings from the literature are largely congruent with the Framework (CARRN, 2020), meaning that all of the findings fit under one or more categories of the framework, and no new categories were required to account for the literature findings, some challenges were encountered. Organizing the findings for the “determinants of health” category was complex, given that this category influenced multiple framework categories but appeared most connected to “Place: Rural Context” due to being placed close to this category in the Framework. Although the theme of “being prepared” is included in the Framework (CARRN, 2020), it would be helpful to embed an additional circle of “Rural Nurse” or “Rural Nursing” parallel to “Rural People”, with “Rural and Remote Nursing Interactions” connecting the circles. This would strengthen the emphasis on the rural nurse being an integral person within the healthcare relationship and highlight the importance of preparedness for the role, as reflected in the literature. There was a lack of literature in the current mapping review about climate change considerations related to MHSU nursing. Although the theme of weather is included in the Framework (CARRN, 2020), climate change and climate change hazards are not discussed. Considering climate change hazards (i.e., flooding and wildfires) disproportionately impact rural communities, including rural people’s mental health (Longman et al., 2023), this is an important 26 facet to include in the framework (i.e., under “Place: Rural Context”) (CARRN, 2020). Overall, the Framework (CARRN, 2020) provided a useful, comprehensive structure to organize and synthesize the literature on rural MHSU nursing. 2.4.2 Rural-Centric Approach This mapping review highlighted the challenges nurses face in delivering high-quality MHSU care in rural areas. The broader literature on rural nursing reflects the review findings that rural MHSU nurses often work as multiskilled generalists, in dual roles and in resource- and infrastructure-limited environments (Pavloff et al., 2022). Perkins et al (2019) reinforce these findings that rural communities face unique and complex challenges that are distinct from urban areas, such as limited access to resources, lower population density, and greater social and geographical isolation. To address these challenges, authors (Perkins et al., 2019) advocate for applying a rural-centric approach rather than replicating urban-centric approaches. A rural-centric approach accounts for the distinct characteristics and needs of rural communities when designing and implementing research, policies, programs, and services. For example, a rural-centric approach is place-based, looking at each unique rural context in a holistic manner to develop MHSU services along with rural residents, compared to top-down models that are used in urban communities (Perkins et al., 2019). Oelke and Lints-Martindale (2020) emphasize that it is crucial to meaningfully involve people who live in rural areas, including Indigenous peoples and people with lived mental health experience, in identifying and implementing changes needed to improve rural mental health care. It is also necessary to partner with rural nurses and other healthcare providers to co-design rural MHSU services (Perkins et al., 2019). 2.5 Future Research Nurses play a crucial role in healthcare systems worldwide and constitute the largest 27 workforce in this industry (WHO, 2022b). However, MacLeod et al (2022) highlight a concerning trend: rural communities face a significant shortage of nurses compared to urban communities. Rural nurses are also at risk of experiencing excessive stress and burnout (Cosgrave et al., 2018; Jahner et al., 2020; Whiteing et al., 2021), which may lead to their departure from rural communities, or nursing altogether (Mannix, 2021). Given the disproportionate impact of mental health issues on rural populations (Beks et al., 2018), it is crucial to address these issues. Thus, to support rural MHSU nursing, future research should (a) look at how to attract, retain, and train nurses in rural areas to address the shortage of human resources (Kadar et al., 2020; Kenny & Allenby, 2013; McCullough et al., 2012), (b) develop sustainable support mechanisms for nurses, including ongoing, local education (Beks et al., 2018; Jansson & Graneheim, 2018; Kadar et al., 2020; Kenny & Allenby, 2013; Kidd et al., 2012), and (c) facilitate collaboration between nurses and their communities (Beks et al., 2018; Kadar et al., 2020; McCullough et al., 2012). Additionally, while most of the studies included mental health (n=22) or MHSU (n=21) considerations, few studies included substance use-only considerations (n=4). Since rural communities may face disproportionate rates of toxic drug poisonings and greater access to care difficulties compared to urban communities (Hu et al., 2022), research focusing on rural substance use nursing could be beneficial for supporting rural people who use substances. Moreover, while six studies included child and youth MHSU considerations (Burch & Stoeckel, 2021; Cree et al., 2021; Etter et al., 2019; Pattison-Sharp et al., 2017; Ratter, 2023; Wilson & Usher, 2015), only three studies specifically focused on child and youth MHSU nursing practice (Burch & Stoeckel, 2021; Pattison-Sharp et al., 2017; Ratter, 2023), an underexplored and valuable research area. While these three studies were conducted with school nurses, studying 28 other community practice settings where nurses work with children and youth would help to understand how rural nurses support child and youth MHSU care in diverse settings. Further, future rural research should be more inclusive of cultural diversity, including Indigenous peoples (McCullough et al., 2012), and gender diversity, including two-spirit, transgender, nonbinary, genderqueer, agender, and other gender-diverse individuals (Hankivsky & Mussell, 2018). 2.6 Strengths and Limitations There were several limitations with this mapping review. One limitation was that a small number of databases were searched (i.e., CINAHL, Medline, and PsycINFO), although these are the key databases for MHSU studies. Additionally, no single international definition of “rural” exists, so this could lead to variable ways of interpreting the concept; relevant studies that did not use the term “rural” could have been excluded. The search strategy only included English words. Therefore, only studies conducted in English were accessed, potentially excluding relevant studies in different languages. Study quality using a validated checklist was not assessed. Although mapping reviews do not require study quality assessments (Booth, 2016), it would have increased the rigour of this review. However, by conducting a thorough search of databases and including multiple reviewers at the screening stages, the rigour of the review process was high. This mapping review has several noteworthy strengths. It is the first review to examine the rural MHSU nursing evidence. This is particularly important because rural communities face unique challenges related to MHSU and access to care, yet this has been underexamined. In addition, a mapping review approach was a good fit since there is a pre-existing framework for examining the literature with rigorous methods (Booth, 2016). Additionally, the Framework (CARRN, 2020) is a robust and practical nursing framework that supported a comprehensive 29 literature review. 2.7 Conclusion Through this mapping review, the international research on rural MHSU nursing was synthesized, providing insight on the complex, under-resourced reality of nursing practice in rural areas (Beks et al., 2018; Jansson & Graneheim, 2018). Rural nurses are multiskilled generalists (Beks et al., 2018; Kadar et al., 2020; Kenny & Allenby, 2013; Kidd et al., 2012; MacLeod et al., 2022), and may lack specialized MHSU training (Beks et al., 2018; Kadar et al., 2020; Kenny & Allenby, 2013; Kidd et al., 2012; MacLeod et al., 2022; McCullough et al., 2012). Their nursing practice may be embedded in isolation, both in workplace settings and geographical regions (Jahner et al., 2020; Jansson & Graneheim, 2018; Kenny & Allenby, 2013; Kidd et al., 2012; MacLeod et al., 2022). Despite these obstacles, rural nurses continue to work hard to improve the mental health of the rural people in their care (Beks et al., 2018; Burch & Stoeckel, 2021; Cole & Bondy, 2020; Jahner et al., 2022; Whiteing et al., 2021). This mapping review provides a critical starting point for examining the current state of knowledge about rural MHSU nursing compared with the Framework (CARRN, 2020). It establishes the groundwork for future research, aiming to understand and enhance MHSU nursing care in rural communities. 30 Chapter 3: Research Methods 3.1 Study Aims My thesis project explored the experiences of nurses who work with rural Canadian children and youth in community practice settings (i.e., CHNs), with the aim of leveraging their practice insights and knowledge toward high-quality and equitable MHSU care. I answered the following research question: What can be learned from rural nurses about child and youth MHSU care in community settings in British Columbia, Canada? 3.2 Theoretical Framework To answer this practice-oriented research question, I used an interpretive description methodology (Thorne, 2016) guided by a theoretical framework comprised of the CHNC Standards of Practice (CHNC, 2019) and the Framework (Pavloff et al., 2022). The CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) are theoretically congruent and complementary to one another. They have been developed from nursing practice theory and knowledge, including principles of accessibility, client participation, health promotion, appropriate skills and technology, and intersectoral cooperation from primary care (CARRN, 2020; CHNC, 2019). Both advocate for holistic, collaborative, and person-centred care nested within the community context, with an emphasis on the health of all people, from individuals to populations (CARRN, 2020; CHNC, 2019). Moreover, they were both informed by an ecological or contextual approach, the social determinants of health, and principles of social justice and health equity. They guide nursing practice, policy, education, and research (CARRN, 2020; CHNC, 2019). The CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) differ in complementary ways that assisted with broadening the view of my project, that neither CHNC 31 Standards (CHNC, 2019) nor the Framework (CARRN, 2020) alone would sufficiently accomplish. The CHNC Standards include harm reduction considerations (CHNC, 2019), a crucial philosophy and ways of providing substance use care (Dubois, 2017). The CHNC Standards also specifically examine and expand upon community practice settings (CHNC, 2019). In contrast, the Framework includes all nursing practice settings, from community to acute and emergency care (CARRN, 2020). The Framework (CARRN, 2020) focuses on the rural context, while the CHNC Standards were developed for use in any rural or urban community practice setting (CHNC, 2019). Further, the CHNC Standards’ emphasis is on nursing practice, and while it does include considerations for geography and the broader context (CHNC, 2019), it is not as in-depth about these considerations as the Framework (CARRN, 2020); in the Framework, the nursing interaction is a significant yet small part of the larger ecosystem that care is nested within. To develop a comprehensive understanding of rural community health nursing regarding child and youth MHSU care, the CHNC Standards (CHNC, 2019) and Framework (CARRN, 2020) provided valuable theoretical scaffolding. The CHNC Standards helped to enhance understanding of the CHN role (CHNC, 2019), while the Framework helped to better situate this work within the rural context (CARRN, 2020). Moreover, using the Framework (CARRN, 2020) helped to extend the work of other nurse scholars (e.g., Pavloff et al., 2022) by considering the Framework in the child and youth MHSU context. Together, the CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) helped to explore and expand on the nursing role while upholding the significance and relevance of the rural context, informing both data collection and analysis. Using both the CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) to guide my thesis research allowed me to bring the understudied areas of 32 community nursing practice and rural nursing practice together to look at child and youth MHSU care. The theoretical underpinnings of the CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) align well with my nursing practice-oriented thesis methodology, interpretive description (Thorne, 2016). The CHNC Standards, the Framework, and interpretive description all overlap in their attention to context, collaboration, person-centred care, and their aims of enhancing pragmatic, socially just care (CARRN, 2020; CHNC, 2019; Thorne, 2016). The CHNC Standards, the Framework, and interpretive description were developed from and for the nursing profession, informed by nursing theory and knowledge (CARRN, 2020; CHNC, 2019; Thorne, 2016). 3.3 Methodology 3.3.1 Interpretive Description Interpretive description was developed to answer qualitative research questions that seek to address practice-specific knowledge gaps or queries (Thorne et al., 1997; Thorne et al., 2004; Thorne, 2016). This applied qualitative design was born out of the nursing profession and is theoretically flexible and highly attuned to context (Thorne, 2016). This methodology is optimal to answer my research question: by exploring the qualitative experiences of rural nurses regarding child and youth MHSU community care, I transformed what can be learned from these nurses into clinically relevant knowledge for the rural practice setting. By asking what can be learned, I moved into an active position of applying the knowledge that is shared by the participants, reflecting the practical nature of this methodology that is grounded in and useful for the health sciences professions, and oriented toward knowledge translation (Thorne, 2020; Thorne, 2016). 33 3.3.1.1 Theoretical Underpinnings of Interpretive Description My interpretive descriptive study used philosophical perspectives aligned with nursing knowledge and practice (Chiu et al., 2022; Thorne et al., 1997; Thorne, 2016). Nursing is an applied discipline: a practical science primarily focused on caring for the health of individuals and populations, not on theorizing (Thorne et al., 1997; Thorne et al., 2016). When nurse researchers theorize, it is typically to advance clinical knowledge (Thorne et al., 2016; Thorne, 2016). Nursing is concerned with the objective and subjective; nurses must see the patterns of health and illness that occur across groups while always tending to the specificity of the individual in front of them (Thorne et al., 1997; Thorne, 2016). This weaving between the broad and the specific is characteristic of nursing (Thorne et al., 1997; Thorne et al., 2016). Nurses understand the significance of context, providing clinical care in the patient’s complex biopsychosocial matrix (Thorne et al., 1997; Thorne, 2016). Further, the nursing discipline is adaptable and pragmatic, seeking applied knowledge with the understanding that “truth” may change depending on the circumstances and knowledge development (Thorne et al., 1997). Finally, nursing is situated within past and present knowledge, with an awareness that this history will shape future knowledge (Thorne et al., 2016). These components of nursing philosophy are what comprise interpretive description. Interpretive description is rooted in constructivist epistemology, seeing multiple ways of knowing as valid and valuable (Thorne, 2016). Constructivism understands truth as the socially constructed, subjective experiences of participants, co-developed with researchers, and embedded within context; conversely, positivism espouses that truth is one external, discoverable reality that is best revealed through impartial observation and experimentation (Given, 2008). A constructivist philosophy is necessary to create space for the diverse perspectives of rural CHNs, 34 co-creating what can be learned from them while recognizing the context in which their experience is situated. Constructivism infuses the interpretive description methodology via its methods (e.g., semi-structured interviews and focus groups) to collaboratively develop an understanding of participants’ viewpoints (Thorne, 2016). Interpretive description, as its name suggests, is from an interpretive paradigm that focuses on understanding phenomena through the perspectives of individuals in their real-life contexts (Weaver & Olson, 2006) and it is concerned with a degree of explanation that can lend the findings well to clinical application (Thorne et al., 2004; Thorne, 2016). By asking “what can be learned” from rural CHNs regarding child and youth MHSU care, the co-constructed data was interpreted and oriented toward clinical relevance. This interpretive, constructivist philosophy underlies interpretive description's central principles. The central principles of interpretive description helped to guide me through study design and implementation (Thorne, 2016). The principles of interpretive description studies are that they (a) are carried out in the participant’s natural environment, accounting for the ethical and well-being aspects of the participant’s involvement in the study; (b) recognize and uphold that participant experience is central to applied practice knowledge; (c) seek to understand and utilize both shared and unique participant experiences of the phenomena; (d) acknowledge that certain issues transcend a specific time and context, while also recognizing that one must attend to the time and context in which human experiences take place; (e) recognize that the participant’s subjective experience and the essence of their experience are integrated; (f) acknowledge that, although there may be contradictions, “reality” is comprised of multiple ways of knowing and experiencing; and (g) recognize the inherent connectedness between the participant and researcher, understanding that they inevitably affect each other (Thorne, 2016). Notably, 35 researchers are encouraged to be adaptive and utilize the full menu of design methods, such as components of other methodologies, data collection methods, and approaches, in a purposeful, rationalized, and explicit manner (Thorne, 2016). In this thesis project, I leveraged the theoretical flexibility of interpretive description (Thorne, 2016) to utilise the CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020). 3.3.2 Data collection In interpretive description, data are viewed as “constructed” rather than “collected”, reflecting the interpretive paradigm by highlighting the researcher’s active role in choosing what counts as data and are subsequently analysed as such (Thorne, 2016). I collected and analysed data concurrently, as per interpretive descriptive studies, so that data collection and analysis were enriched through this iterative process (Thorne, 2016). Data were collected through semi-structured interviews so that subjective experience could be explored in the context the phenomena were situated in (Thorne et al., 2004; Thorne, 2016). 3.3.2.1 Semi-Structured Interviews Semi-structured interviews were the primary data source to flexibly explore nurse experiences (Thorne, 2016). Interviewing is a process where a researcher asks a participant questions to elicit information or co-create a participant’s experience of something (Sahlstein Parcell & Rafferty, 2017). Semi-structured interviews are interviews using a flexible interview guide (i.e., the interview questions can be changed or more questions added). They allowed for more responsivity to participants and aligned with interpretive description studies (Thorne, 2016). Interviews were conducted virtually using the University of British Columbia’s (UBC) approved videoconference platform (Zoom) and were audio-recorded. Semi-structured interviews were conducted with the key elements of interviewer presence and patience, creating 36 a supportive yet neutral space for participants to elaborate about their experiences (Thorne, 2016). The semi-structured interview guide was developed from the CHNC Standards (CHNC, 2019) and the Framework (Pavloff et al., 2022), and tailored using a strengths-based approach (Gottlieb, 2012). CHNs were asked to describe their experiences of supporting child and youth MHSU care (see Appendix D). Questions and prompts were used to encourage in-depth responses about the MHSU care provided and how rural contextual factors influence care. CHNs were asked to describe the larger rural environment related to this MHSU care, including the community, rural context, and larger society that their practice is situated in, to develop a fulsome, ecological understanding of their nursing practice. 3.3.3 Participants and Recruitment 3.3.3.1 Inclusion criteria All types of actively regulated or licensed nurses (i.e., LPNs, NPs, RNs, and RPNs) who self-identified as currently working in a rural region of British Columbia with children and youth, in community practice settings, who speak and read English, and consent to an interview, were eligible for this study. All nurse types were included so that various facets of the nursing discipline could be explored in the rural context, understanding that scope of practice differences exist between different nurse-types (BCCNM, 2024a; 2024b, 2024c). Nurses were able to self-define whether they work in a rural community because there is no consensus for a single definition of rural (Kulig et al., 2008), thus leaving room for various nurse definitions of rural within this exploratory study. Nurses who identified that they provide specific MHSU care and those who identified that they provide generalist community care were both included in the study, maximizing sample variation and therefore understanding of diverse experiences of the 37 phenomena (Hirschkorn et al., 2022; Thorne, 2016), with the aim of better understanding the bounds and constructs of MHSU care. 3.3.3.2 Exclusion criteria Non-nurses (e.g., physicians, community health workers, counsellors) and unregulated nurses (i.e., nurses who are not actively licensed or registered) were excluded from this study. 3.3.3.3 Sampling methods and Recruitment I utilized purposive and snowball sampling in line with interpretive descriptive studies (Thorne, 2016). Purposive sampling involves recruiting participants with specific and relevant characteristics or experiences to the study (Palinkas et al., 2015); I used purposive sampling based on the inclusion criteria (above). I achieved purposive sampling by using the recruitment strategies listed below. In addition, snowball sampling involves recruiting participants via participant acquaintances (Parker et al., 2020); I asked each study participant if they knew anyone else who may be interested in the study and sent them an email link to forward to any potential participants. To maximize efficiency in reaching CHNs in rural British Columbia, I used a multi-modal recruitment strategy that was refined with input from my supervisory committee. I leveraged the networks of my supervisory committee, including my committee member Dr. Nelly Oelke who is well-connected to rural communities via the Rural Coordination Centre of British Columbia. I shared recruitment materials through my supervisory committee’s professional networks, including the Rural Coordination Centre of British Columbia and social media channels, as well as through professional networks via established email distribution lists, such as national (i.e., CHNC and CARRN) and provincial (i.e., Nurses and Nurse Practitioners of British Columbia) professional nursing associations. Recruitment strategies were responsive to 38 the sample I had; I purposefully used certain recruitment strategies to get maximum variation across different aspects (i.e., geographical regions and generalist vs MHSU specialist practice) (Schreier, 2018). I developed inclusive recruitment materials to try to encourage potential participants who have unearned disadvantages to apply, such as those who identify with typically underrepresented nursing groups (e.g., male nurses, gender diverse nurses), as well as those who face systemic barriers of discrimination and/or racism (e.g., 2SLGBTQIA+ individuals, or Indigenous, black, and other people of colour (IBPOC)) (see Appendix E: Recruitment Materials). Additionally, participants were offered honoraria ($40 e-gift card). 3.3.3.4 Sample size In interpretive descriptive studies, sample sizes usually range from 5-30 participants but can vary considerably outside these bounds and depend on the nature of the phenomena being studied and the subsequent rationale that the researcher provides to justify the sample size (Thorne, 2016). In contrast to well-studied research topics that likely require a larger sample size, small sample sizes can be appropriate for under-studied research topics (Thorne, 2013). Given that my thesis topic is an under-studied phenomenon, I anticipated needing to interview approximately 10-15 participants to meaningfully interpret practice-useful data (Thorne, 2016) of child and youth MHSU community nursing in rural British Columbia. Although this smaller sample size does not do justice to the potential variation and inherent complexity (Thorne, 2013) of rural child and youth MHSU nursing, I accounted for this limitation by using the concept of information power (Malterud et al., 2016). Information power specifies that a smaller sample size can be used when there is adequately rich data, significant to the study’s aims; information power is in place of the concept saturation (Malterud et al., 2016). I used the information power 39 elements of (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy (Malterud et al., 2016) to justify my final sample size. My study’s aim is specific: child and youth nursing, rural nursing, and MHSU nursing are all specialised nursing practices, and the confluence of these three concepts creates a narrower study aim. Similarly, my sample of nurses who work with children and youth in rural communities, regarding MHSU care, is specific. I used a composite theoretical background (i.e., CHNC Standards (CHNC, 2019) and Framework (CARRN, 2020)) for my study; if I was not using an explicit theoretical framework, a larger sample size would be required (Malterud et al., 2016). Further, I interviewed participants in a focused and engaging manner to develop high-quality dialogue, justifying the use of a smaller sample. My experiences as a nurse working in community MHSU settings helped me to build rapport and engage in high-quality dialogue. Finally, by using reflexive thematic analysis (TA) (see section 3.3.4) (Braun & Clarke, 2020) I analysed the data in depth, increasing the likelihood of information power so that a smaller sample size was adequate (Malterud et al., 2016). This sample size helped me to balance the need for adequate depth and richness of data to reach information power (Malterud et al., 2016) with the scope and time constraints of completing a Master’s thesis. 3.3.4 Data analysis Once data were collected through semi-structured interviews, they were transcribed into text form (Sahlstein Parcell & Rafferty, 2017) using the transcription function in Zoom. I then reviewed and corrected the transcriptions as needed to ensure that I was adequately familiar with the data, as recommended by Thorne (2016) and Braun and Clarke (2020). Then, I used NVivo 14 (Lumivero, 2023) to help code the data. 40 3.3.4.1 Reflexive Thematic Analysis and Interpretive Description While interpretive description offers a broad and flexible methodology, it does not prescribe a particular type of analysis (Thorne, 2016). Therefore, I used reflexive TA to guide the analysis (Braun & Clarke, 2021a), with interpretive description providing the overall analytical aim toward clinical applicability (Thorne, 2016). Reflexive TA is an analytical method specifically used in qualitative research (Braun & Clarke, 2020). The philosophies of reflexive TA and interpretive description are compatible. Both see researcher positionality as a crucial element to account for and utilise in the research (Braun & Clarke, 2020; Thorne, 2016). Reflexive TA and interpretive description both stress the importance of flexibility, context, and theory (Braun & Clarke, 2020; Thorne, 2016). Further, both emphasise the need for the researcher to become sufficiently familiar with the data, beyond surface impressions, to proficiently move the data into higher levels of abstraction (Braun & Clarke, 2019; Thorne et al., 2004). In reflexive TA, it is integral to be explicit about the underlying theory and philosophy of the research project, as congruency between these elements and the type of TA is necessary (Braun & Clarke, 2019). I used reflexive TA from a constructionist philosophy (Braun & Clarke, 2021b) to analyse interview data, exploring what can be learned from CHN experiences of providing MHSU care of children and youth. The six phases of reflexive TA guided my analysis, with the understanding that these phases are to support the process rather than be followed inflexibly (Braun & Clarke, 2020). These phases included (a) data familiarisation; (b) systematic data coding; (c) constructing initial themes; (d) developing and reviewing themes; (e) refining, defining, and naming themes; and (f) writing the report/manuscript (Braun & Clarke, 2020). 41 In reflexive TA, data familiarisation is an extensive, reflective process (Braun & Clarke, 2020), as it is in interpretive description (Thorne, 2016). After extensive and reflective data familiarisation, I engaged in the iterative reflexive TA phases that included coding the transcripts, inductively generating initial themes describing what can be learned from CHN experiences, reviewing, developing, refining, and naming themes (Braun & Clarke, 2021b). Themes can include both semantic or explicit and latent or underlying meanings (Braun & Clarke, 2021b). I reviewed, discussed, and refined themes during data analysis meetings with my supervisory team. Rural clinical nursing application was considered throughout theme development (Thorne, 2016). Reflexive TA (Braun & Clarke, 2020), combined with interpretive description (Thorne, 2016), provided a strong analytical framework, supporting the construction of key findings about rural child and youth MHSU nursing care in community settings in BC. 3.3.5 Quality 3.3.5.1 Quality Measures To advance nursing research, it is integral to ensure that rigorous, high-quality studies are conducted (Thorne, 2016). I used the quality measures suggested by Thorne (2016) in this thesis project: (a) epistemological integrity, (b) representative credibility, (c) analytic logic, and (d) interpretive authority. Epistemological integrity refers to researchers being consistent with and explicit about their epistemology, as in, how truth may be generated from the study's design (Thorne, 2016). I have demonstrated this by clearly articulating the epistemological alignment (i.e., a constructivist approach) between my theoretical underpinnings, methodology, and results. Representative credibility means coherence between the study findings and methods; I achieved this through the recommended strategies of maximal variation (i.e., by interviewing nurses who provide specific MHSU care and those who provide generalist nursing care) and sustained 42 engagement (i.e., through ongoing engagement with my supervisory committee) (Thorne, 2016). Analytic logic means that inductive reasoning is made visible throughout the research report so that readers can verify the researcher’s reasoning. I demonstrated this by ensuring I thoroughly documented an audit trail of analytical decisions, by presenting the findings at various conferences, and during discussion of preliminary themes with my supervisory committee (Thorne, 2016). Interpretive authority refers to the researcher being trustworthy in their data analysis, using transparent reflexivity to account for the researcher’s positionality and subjectivity. This was demonstrated by using memos, field notes, and identifying my position in the research report (Thorne, 2016). 3.3.5.2 Reflexivity & Positionality Reflexivity in an ongoing, dimensional, and reflective exercise in which researchers use their self-awareness and metacognition to think about, assess, and evaluate how their own context and internal experiences affect the qualitative research process from beginning to end (Olmos-Vega et al., 2022). Researcher positionality is the worldview that a researcher holds, that is, their underlying ontological and epistemological position, and socio-political context they are situated in (Holmes, 2020). Reflexivity and positionality are crucial to interpretive description (Thorne, 2016) and reflexive TA (Braun & Clarke, 2021a). By being reflexive, the researcher can gain insight into how their positionality acts like a lens that they see through, shaping the questions that are asked and the ways that research is conducted and interpreted (Braun & Clarke, 2021a; Holmes, 2020; Thorne, 2016). Further, acknowledging the researcher’s subjectivity aligns with a constructivist ontology because the researcher is seen as having a particular understanding rather than an objective stance (Olmos-Vega et al., 2022). 43 My experiences working as a CHN with people across the lifespan, including children and youth, in rural contexts developed my drive to better understand CHN practice. Further, my difficulty accessing child and youth MHSU resources specific to the rural community setting underscored my interest in this under-researched and under-resourced practice area. Due to my positionality, my assumptions were that other CHNs provide MHSU care to children and youth in rural settings, whether specialist MHSU care or within their generalist nursing practice, and that these CHNs have experiences that would be beneficial for the broader nursing community to understand and learn from. I was motivated to learn how we can support these nurses to improve care or access to care for rural children and youth. Further, my lens comes from being a queer, gender-diverse, white settler with a history of working in rural Indigenous and non-Indigenous settings, and urban community settings. It was important to me to conduct this thesis project with cultural humility, the process of reflexivity of any personal or systemic cultural biases I may have, along with engaging meaningfully and respectfully with participants and community members (First Nations Health Authority, 2022). It was also integral for me to include equity considerations through this thesis project that the CHNC Standards and Framework assisted me with (CARRN, 2020; CHNC, 2019). 3.3.5.3 Applied Researcher Accountability Due to the applied purpose of interpretive description studies, Thorne (2016) highlights that applied researchers must also ensure that high-quality, ethical studies are conducted due to the nature of applied research. The research findings may be used in or influence practice and have effects (positive or negative) outside of generating theory. There is potential to cause harm to people through the misapplication of research findings or applying findings that are not trustworthy, a critical ethical consideration (Austin, 2013; Thorne, 2016). By using the additional 44 quality measures of moral defensibility, disciplinary relevance, pragmatic obligation, contextual awareness, and probable truth (Thorne, 2016), I have accounted for the multilayered contexts (i.e., disciplinary, social, and historical) that this qualitative research project is situated in. For moral defensibility, or the justification of why one is engaging with participants and how the findings may benefit the clinical populations to which they are applicable; the findings from my thesis project have the potential to contribute to improved MHSU care for children and youth living in rural regions. For disciplinary relevance, I have situated the study within the nursing discipline and rationalized why it is important to further nursing science in such a way (Thorne, 2016); I have used the CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020), and extended what can be learned from rural nurses about child and youth MHSU nursing care. In addition, I have worked in multiple rural communities as a generalist and MHSU specialist RN with children and youth in community practice settings and understood this research gap to be a relevant and meaningful project based on my own experiences and my colleagues’ feedback. Pragmatic obligation is the understanding that research findings may be used in practice before they are tested or “proven”, and I have been mindful of this. There is a low likelihood that the knowledge gained from my study will drastically change practice, so there is a lower chance of causing harm. Instead, it will help to inform a better understanding of the previously invisible work that many CHNs already do. Researchers must also have contextual awareness (Thorne, 2016); I have demonstrated this by situating my findings in the nursing discipline, time (2024), and rural Canadian society. Lastly, findings that are deemed credible and useful may be probable truths (Thorne, 2016); I recognize that even the most compelling findings may turn out to be untrue. To support these quality measures, and to foster and strengthen my accountability, I consulted with my supervisory committee. I met with my 45 supervisor every 1-4 weeks and my supervisory committee every 3-4 months. By engaging with my supervisory committee, I meaningfully engaged in support to ensure that I conducted this thesis project in an ethical manner. 3.3.6 Ethical Considerations While ethical considerations are integral to quality measures (Thorne, 2016), additional key considerations include ethical approval, informed consent, risk of harm or benefits, and confidentiality (Research Ethics Board (REB), 2022). Ethical approval was granted by UBC’s research ethics board (ID #H23-00823). Informed consent, the participant’s permission to involve them in research, is an integral part of ethical research; I ensured that I had consent from participants that was voluntary, informed, and revisited throughout the research process (Research Ethics Board, 2022). To start, I emailed participants a link to an online consent form that they could electronically sign (Appendix F) before the interview. On Zoom, before the interview began, I reviewed key points about the study and confirmed that they had reviewed and signed the consent form. I offered to provide a copy of the consent form, although no participants wanted to review the consent form again. I asked them if they had any questions about the consent form or research process and no participants had any questions about the form or process. If there had been any questions I could not address on my own, I would have reached out to my Principal Investigator for the participant’s questions to be adequately answered before continuing with the interview. If the participant had any concerns or complaints about their rights as a research participant and/or their experiences while participating in this study, I would have directed them to contact the Research Participant Complaint Line in the UBC Office of Research Services or the UBC Okanagan Research Services Office. I obtained written and verbal consent before starting the interview. I explained to the participant that their engagement in the study was 46 completely voluntary and they could choose to stop participating for any reason, if they decided, until data analysis was completed. No participants stopped the interview or withdrew from the study. In terms of risks of harm and benefits, the research was anticipated to have low physical, emotional, and social risks, and there were no direct benefits to participating in this research. The probability and magnitude of potential harms from participating in this research was not greater than what was encountered by rural community nurses in their everyday life related to this research and was likely even lower risk than what rural nurses encounter in their everyday work settings. Further, participants were considered to have low vulnerability due to their professional training and supports available (e.g., employee family assistance programs, counselling through extended benefits). 3.3.7 Data Management Plan To maintain ethical standards, a data management plan was developed to protect and uphold study data confidentiality. This plan is required to be explicit about the collection, safeguarding, storage, and destruction of data, to support the integrity of the research process (Zozus, 2017). Semi-structured interview data were recorded and saved in a password-protected location using UBC servers located in Canada. All participant identities are confidential. Participants were assigned a participant ID number and only the participant ID was recorded in the transcription, data files, and interview notes. Given the high sample specificity, participant IDs were removed from the quotes so that individual quotes could not be tracked or cross-referenced, to protect confidentiality (Damianakis & Woodford, 2012); participant IDs were tracked before removing the IDs, to ensure representation. Participants were able to withdraw until data analysis had been completed. No participants withdrew from the study, but if they had withdrawn, all associated 47 data collected would have been immediately destroyed. After completing data analysis, the participant’s de-identified and analysed data were used in the study. Study data are being securely stored until five years after publication, and after that date, it will be destroyed. 3.3.8 Knowledge Translation There is a critical knowledge gap about Canadian child and youth MHSU nursing in rural community settings; my findings address this knowledge gap. Closing this gap has started to develop a clearly articulated CHN role in supporting community-based child and youth MHSU care in Canada, including recommendations for supporting and optimizing this role, informing competency updates and practice changes for CHNs, and informing nurse training and professional development (e.g., conference workshops, undergraduate nursing curricula, and/or CHN entry to practice competencies). Potential target audiences include nurses, program managers, policymakers, nursing education programs, and nursing program accreditation boards. To conduct a collaborative and clinically relevant thesis project, I formed partnerships with professional nursing organizations (i.e., CARRN), to facilitate meaningful and purposeful integrated knowledge translation with the nursing profession. To facilitate knowledge translation, an advisory board was planned. This proved not to be feasible, however, I consulted one rural mental health nursing content expert in an advisory role. They specifically advised on chapter 2’s data analysis, comparison of literature review findings with the Framework (CARRN, 2020), and manuscript writing, as well as informed the thesis project’s semi-structured interview guide based on the Framework. For end-of-project knowledge translation, I presented at the 2023 British Columbia Rural Health Research Exchange conference and the 2024 UBC Okanagan Interdisciplinary Student Health Conference. Further, I will publish my thesis in an open-access repository (i.e., UBC Circle) and disseminate the study findings to CARRN, CHNC, and to rural 48 nurse participants who expressed interest in reading the study findings. I submitted one manuscript (Chapter 2) to Rural and Remote Health and I expect to submit the study findings (Chapter 4) to a peer-reviewed journal. 3.4 Conclusion Children and youth are disproportionately affected by MHSU challenges compared to other age groups in Canada (Pearson et al., 2013), with rural children and youth, including other individuals with unearned disadvantages, experiencing greater challenges accessing the MHSU care that they need (CIHI, 2019; CMHA, 2009). CHNs, who provide care from health promotion to illness prevention, work with children and youth throughout the health system (CHNC, 2019). However, there is a knowledge gap about rural child and youth MHSU nursing care in community settings; this qualitative thesis project was a necessary step to start to address this significant knowledge gap. Interpretive description was an ideal qualitative methodology to conduct this project due to its foundations in nursing, focus on context, and purpose of developing clinically relevant information (Thorne, 2016). The CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) broadened the lens of this project by including key considerations about community health nursing and rural nursing. By analysing data from semi-structured interviews with CHNs in rural communities using reflexive TA (Braun & Clarke, 2020) and interpretive description (Thorne, 2016), this methodology helped me to answer the question, “What can be learned from nurses about child and youth MHSU care in rural community practice settings in British Columbia, Canada?” The following chapter presents study findings and is formatted as a manuscript for submission to a peer-review journal. 49 Chapter 4: The NURTURE Study: An interpretive description of the vital role of Nurses for Understanding and Responding To the Unique Rural mental health and substance use needs and Experiences of children and youth 4.1 Introduction Worldwide, MHSU disorders are the primary contributors to disability among children and youth (Erskine et al., 2015) and typically have an early age of onset: 34.6% of youth with a mental health challenge experience it by age 14 years, 48.4% by age 18 years, and 62.5% by age 25 years (Solmi et al., 2022). Moreover, children and youth with MHSU challenges are at an increased risk of suicide (Ackerman & Horowitz, 2022), chronic MHSU conditions (Malla et al., 2018; Wiens et al., 2020), homelessness, incarceration, and exploitation (Miller, 2009). Compounding the high rates, early onset, and adverse outcomes of MHSU challenges, children and youth living in rural areas face multiple barriers, such as long waitlists, stigma (CAMH, 2019), financial insecurity, fragmented care (Moroz et al., 2020), extensive travel (Sinclair, 2020), and a lack of youth-friendly MHSU services (Hawke et al., 2019) or a lack of MHSU services in general (CIHI, 2019). The potential burden of untreated MHSU challenges on children, youth, their families, and communities is substantial; however, comprehensive and timely MHSU support may prevent these adverse outcomes (McGorry & Mei, 2018). Rural communities may not have adequate MHSU supports and services, including harm reduction resources, despite the reality that rural people who use substances face higher rates of death from toxic drug poisonings (i.e., drug overdoses) (Hu et al., 2022) and are the leading cause of death in young people aged 10-18 years in British Columbia, Canada (British Columbia Coroners Service, 2023). Rural and remote communities are defined here as geographically isolated, poorly resourced, and/or with smaller populations (CARRN, 2020). 50 To address the inequitable barriers to care in rural regions, CHNs may play a role in supporting child and youth MHSU care (McAllister, 2019). CHNs provide care in diverse community-based practice settings, supporting the health of individuals and communities across the continuum of health promotion to illness prevention and palliation (CHNC, 2019). Given their trusted position and integration within the community, rural CHNs (hereto referred to as rural nurses) may play a crucial role in providing healthcare to children and youth, yet there is limited understanding of their provision of MHSU care in community settings. Previous research focused on school nurses and does not include other settings such as primary care clinics or outpost nursing stations (Burch & Stoeckel, 2021; Pattison-Sharp et al., 2017; Ratter, 2023). This gap hinders knowledge sharing among rural nurses and the healthcare system that could improve the delivery of high-quality MHSU care to rural children and youth, and limits awareness of what supports rural nurses in providing this care. 4.2 Research Aim This research project aimed to answer the question: What can be learned from rural nurses about child and youth MHSU care in community settings in British Columbia, Canada? 4.3 Methods 4.3.1 Theoretical Framework The CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) comprised the guiding theoretical framework for this study, rooted in the nursing practice theory principles of accessibility, client participation, health promotion, appropriate skills and technology, and intersectoral cooperation. Both advocate for equitable, holistic, and person-centred care nested within the community context, with an emphasis on the health of all people (CARRN, 2020; CHNC, 2019). The CHNC Standards uniquely contribute harm reduction considerations and a 51 focus on community practice settings (CHNC, 2019), while the Framework extends to all nursing practice settings with a specific focus on the rural context (CARRN, 2020). Together, they provided a comprehensive scaffold for understanding rural community health nursing regarding child and youth MHSU care. Moreover, this composite theoretical framework aligned well with this study’s interpretive description methodology (Thorne, 2016), emphasizing context, collaboration, person-centred, pragmatic, and socially just care, all developed from and for the nursing profession, informed by nursing theory and knowledge (CARRN, 2020; CHNC, 2019; Thorne, 2016). 4.3.2 Interpretive Description This study used interpretive description methodology, an applied qualitative research design meant to address practice-specific knowledge gaps or queries (Thorne et al., 1997; Thorne et al., 2004; Thorne, 2016). This theoretically flexible and context-attuned methodology (Thorne, 2016) was optimal to answer the research question. By exploring what can be learned from the qualitative experiences of rural nurses regarding child and youth MHSU community care, their practice insights could be transformed into practical, clinically relevant knowledge for the rural practice setting. 4.3.3 Participants and Procedures 4.3.3.1 Participants and Recruitment Participants for this study were recruited through purposive and snowball sampling (Palinkas et al., 2015; Parker et al., 2020), targeting actively regulated or licensed nurses working in rural British Columbia with children and youth in community settings. All nurse types (LPNs, NPs, RNs, and RPNs), nurses providing both specific MHSU care and generalist care, and nurses in a variety of geographical locations were interviewed to ensure diverse care 52 experiences were included (Hirschkorn et al., 2022; Thorne, 2016). Recruitment materials were distributed to rural nurses via professional networks, social media channels (including an online paid advertisement on Facebook), email distribution lists, and nursing groups. Potential participants completed a Qualtrics eligibility and online consent form, outlining the study’s purpose, protocol, and participant rights, and ST contacted eligible participants. Verbal consent was affirmed prior to beginning the interview. Participants were offered honoraria in the form of a $40 e-gift card. 4.3.3.2 Sample Size In interpretive descriptive studies, sample sizes typically range from 5-30 participants, contingent upon the research focus and rationale provided by the researchers (Thorne, 2016). For under-studied topics like rural child and youth MHSU nursing in community practice settings, a smaller sample size of approximately 10-15 participants was anticipated to yield meaningful, practice-useful data. Although this smaller sample size would not capture the full variation and inherent complexity (Thorne, 2013) of rural child and youth MHSU nursing, this limitation was accounted for using the concept of information power (Malterud et al., 2016). Information power specifies that a smaller sample size can be used when there is adequately rich data relevant to the study’s purpose, and considers factors such as study aim, sample specificity, theory use, dialogue quality, and analysis strategy (Malterud et al., 2016). The specific aim and sample of this study allowed for a narrow focus, while the use of a composite theoretical background (i.e., CHNC Standards (CHNC, 2019) and Framework (CARRN, 2020)) grounded this study in rural community health nursing. Efforts to promote high-quality dialogue and analyse the data in depth further supported the adequacy of the sample size, ensuring sufficient depth and richness of data to reach information power (Malterud et al., 2016). 53 4.3.4 Data Collection and Analysis In interpretive description, data are viewed as “constructed” rather than “collected,” emphasizing the researcher’s active role in choosing what constitutes relevant data, subsequently informing the analysis process (Thorne, 2016). Data collection and analysis occurred concurrently so that both processes were iteratively enriched by the other (Thorne, 2016). Data were collected through semi-structured interviews, conducted virtually using UBC’s approved videoconference platform (Zoom). Interviews were audio-recorded to capture participants’ narratives comprehensively. The semi-structured interview guide (Appendix D), developed from the Framework (Pavloff et al., 2022) and the CHNC Standards of practice (CHNC, 2019), prompted participants to describe their experiences of supporting child and youth MHSU care in rural community settings. Questions encouraged in-depth responses regarding MHSU care provision and the influence of rural contextual factors, including the community, rural context, and larger society, to develop a fulsome, ecological understanding of their nursing practice. Once data were collected via semi-structured interviews by the first author, ST, using Zoom’s auto-transcription function, ST reviewed and corrected transcripts as needed for data accuracy and familiarization (Braun & Clarke, 2020; Thorne, 2016). NVivo 14 (Lumivero, 2023) was used to code and organize the data. Reflexive TA (Braun & Clarke, 2020) and interpretive description (Thorne, 2016) both supported data analysis. The qualitative analysis method for this study was comprised of reflexive TA (Braun & Clarke, 2020) and interpretive description (Thorne, 2016). Reflexive TA (Braun & Clarke, 2020) offered specific guidance on analysis methods while interpretive description provided the overall analytical aim of clinical applicability (Thorne, 2016). The philosophies of reflexive TA and interpretive description are compatible. Both approaches emphasize researcher positionality, 54 theoretical flexibility, the importance of context, and the use of theory (Braun & Clarke, 2020; Thorne, 2016). Further, both highlight the importance of data familiarization beyond surface impressions to move the data into higher levels of abstraction (Braun & Clarke, 2019; Thorne et al., 2004). In reflexive TA, it is integral to be explicit about the underlying theory and philosophy of the research project, as congruency between these elements and the type of TA is necessary (Braun & Clarke, 2019). We used reflexive TA from a constructionist philosophy (Braun & Clarke, 2021b) to analyse interview data, exploring what can be learned from CHN experiences of providing MHSU care of children and youth. The six phases of reflexive TA guided the analysis, with the understanding that these phases are meant to support the process rather than be rigidly followed (Braun & Clarke, 2020). These phases included (a) data familiarisation; (b) systematic data coding; (c) constructing initial themes; (d) developing and reviewing themes; (e) refining, defining, and naming themes; and (f) writing the report/manuscript (Braun & Clarke, 2020). Themes were reviewed for clinical applicability, asking “so what?” when thinking about the data in relation to rural clinical nursing practice (Thorne, 2016). Reflexive TA (Braun & Clarke, 2020), in conjunction with interpretive description (Thorne, 2016), provided a robust framework for analysing the data, supporting the construction of key findings that illuminate the nursing practice experiences of CHNs regarding child and youth MHSU care in a rural community setting. 4.3.5 Quality and Rigour To ensure rigorous and high-quality nursing research, Thorne’s (2016) measures were adopted: epistemological integrity, representative credibility, analytic logic, and interpretive authority. Epistemological integrity was maintained by aligning the study’s design with a 55 constructivist approach, ensuring that the research methodology was in harmony with this philosophical foundation. Representative credibility was achieved through maximal variation by interviewing nurses who provided specific MHSU care and generalist care. Moreover, this study strove for analytic logic through the research report and audit trail, enhancing the trustworthiness of the findings. Further, interpretive authority involved transparent reflexivity, facilitated by the use of memos and field notes by ST, and subsequent discussion with supervisory committee for interpreting the findings. In addition, this study also accounted for the elements of applied researcher accountability, including attention to moral defensibility, disciplinary relevance, pragmatic obligation, contextual awareness, and probable truth (Thorne, 2016). The researchers understood the potential impact of research findings on practice and situated the findings in the nursing discipline and the contemporary context of specific rural Canadian communities. By adhering to these principles throughout the research process, ethical considerations were thoroughly integrated at every stage of the process. Finally, ethical approval was granted by UBC Okanagan’s Behavioural Research Ethics Board (ID #H23-00823). 4.4 Results Eleven rural nurse participants who worked with children and/or youth in rural and remote community practice settings were interviewed, including RNs (n=8), NPs or RPNs (n=3). To protect confidentiality, only general sample characteristics are presented (i.e., not stratified according to nursing type or location) (Table 2). Nurses were able to self-define whether they worked in a rural community, and this led to a considerable range of population sizes. Although some nurses worked in communities with larger populations they also served outlying rural areas (hub and spoke model), all shared commonalities in terms of resource deficits, transportation challenges, and geographical distance from major centres, as aligned with core rural features 56 Table 2 Characteristics of Participants’ Nursing Practice Characteristic n % Nurse type RN NP or RPN 8 3 72.7 27.3 MHSU is one part of their nursing practice (MHSU-plus) or MHSU is their specific practice (MHSU-only) MHSU-plus 8 72.7 MHSU-only 3 27.3 Practice type Remote practice 4 36.4 Primary care or public health 4 36.4 Rural MHSU 3 27.3 Live in or travel to community Live in community 6 54.5 Travel to community 5 45.5 Ages worked with All ages 9 81.8 Youth to young adult 2 18.2 Community size Population of a few hundred 4 36.4 Population of 5,000-15,000 5 45.5 Population of 50,000-100,000 2 18.2 (CARRN, 2020). These rural nurses described a range of mental health challenges, seen more commonly in youth (ages 13 to 25 years) compared to children (ages 12 years and under), including depression, anxiety, suicidal ideation, self-harm, anorexia, bulimia, paranoia, and psychosis. All of the rural nurses saw youth for substance use-related concerns or knew about the substances that youth in their communities used, with youth most often using alcohol, cannabis, or nicotine, and some youth using stimulants (e.g., methamphetamine or cocaine), opioids, or psychedelic mushrooms. All of the nurses identified social determinants of health that underlie or influence rural youth MHSU, including gender, sexuality, historical and ongoing trauma, culture, racism, 57 education, social support, housing, income and financial insecurity. The COVID-19 pandemic, the ongoing toxic drug crisis, and rural community isolation were also noted to contribute to MHSU challenges among youth. Looking at the social determinants of health […] I've like recognized it kind of everywhere in everybody's care, and so applying that to youth: most often […] the youth in my practice I see are affected on multiple levels, on like lacking in social determinants of health. So access to […] safe housing, having […] those strong family units, […] lack of access to social supports and education, so a few of them aren't attending school, […] lack of access to longitudinal primary care. Three themes were developed from the data: (a) children and youth were more bound to the rural and remote context than adults and thus, their mental health was more tethered to this context; (b) MHSU care was more than just MHSU care; and (c) rural nurses were clear on what supports child and youth MHSU care. 4.4.1 Theme 1: Children and Youth Were More Bound to the Rural and Remote 2345678 Context Than Adults and Thus, Their Mental Health Was More Tethered to This 2345678 Context Nurse participants described how rural and remote contexts were important to the wellbeing of all rural people. However, since children and youth tend to have less agency than adults, this decreased autonomy uniquely tethered the child or youth’s mental health to the rural community. Rural children and youth may be particularly affected by (a) everybody knowing everyone; (b) peer, family, and community norms or standards; (c) navigating the (un)available resources; and (d) the need to leave the community to grow. 58 4.4.1.1 Everybody Knowing Everyone Rural nurses repeatedly talked about how everybody knows everyone and is affected by whatever happens in the community. This interconnectedness was particularly true in the smaller or more remote communities. The familiarity among community members could pose particular challenges for children and youth seeking privacy in their healthcare. As one participant stated, “one of the hard things is that everybody's your cousin, everybody's your aunt, and everybody's your uncle, so who do you talk to that's gonna keep it just to you and not talk to everybody about it?” There may be fewer confidential places that youth can go for MHSU support, more limits around confidentiality, and a greater chance that they (or their families) are related to or connected in various ways to the providers they have access to. While this sense of community can cultivate feelings of belonging, it can also compound difficulties for youth if there is a lack of confidentiality, anonymity, and MHSU stigma. I think there's so much stigma like I know that you can get birth control now at [the local pharmacy], but you have no anonymity there. You have to make an appointment and then there's […] not even a room, there's just a kiosk and somebody else can be buying hair dye and listening to you. Or like in the condom aisle, you know. And so […] there's no anonymity, […] your mom probably knows the people who are working behind the desk, so that's [...] the challenge around seeking confidential care. Stigma can exacerbate the challenges of accessing MHSU care, potentially making it even more difficult for youth to access the MHSU care that they need from the limited available services. 59 4.4.1.2 Peer, Family, and Community Norms or Standards The nurse participants spoke about how children and youth may be more highly influenced by their peer groups, families, and communities due to fewer social influences than if they lived in urban or more populated places. If the youth was surrounded by peers, family, or community members who hold negative norms or low standards for what is possible, the youth may internalize these standards and maintain a shared sense of hopelessness or normalized mental ill health. Because there's such a small group of kids in each age group, […] you can't really choose your friends. […] Whether you agree with the lifestyle they're living or not, they're kind of your friends, right? So like certain kids who maybe seem like they [want to] go to university or strive to do well in school, […] it almost seems like they kinda hold themselves back because this is their peer group and a lot of their peers don't really care. So then […] the standard is not super high. […] And when your […] peers are maybe into […] substance use, or whatever lifestyle they're living, I think it's easier to slide into that, because those are who you're surrounded by all the time and looking […] to fit in. Conversely, if the community was tight-knit or had a strong cultural identity, this may support the youth’s sense of belonging and mental wellbeing. For example, one nurse stated “I think the fact that it is such a tight-knit community is very helpful for children to feel like they belong, and that they're not alone.” The influence of these standards or norms may be heightened in more remote or less populated communities. 4.4.1.3 Navigating the (Un)available Resources Several rural nurse participants highlighted how there were limited opportunities for children and youth in their communities, and that transportation posed a significant barrier to access the 60 available resources. Compared to urban communities, some rural communities had fewer recreational or MHSU resources that supported youth wellbeing such as swimming lessons or psychological assessments. Transportation barriers exacerbated these resource limits; youth may have lacked access to a vehicle, a driver’s license, or a ride. Some of the nurses noted that even when public transportation was available, it was inadequate due to insufficient operating hours or failing to reach outlying areas where some youth lived. There's no real bus service, so, for example, if somebody wants to stay after school, then how are they gonna get home? They'll either hitchhike [...], which is less safe now, especially in the wintertime when it gets dark pretty quick [...]. The buses […] don't serve the [community] in the way that if you were in [...] an urban centre you could go off, and [...] go to swimming practice, or you could go meet your friends downtown, or you could go do other things. And there's [...] more opportunity for sure. I think [...] that the loneliness and isolation is hugely due to transportation. They don't have their own cars. Cars are too expensive. And most live way off in [geographically distant area] or way off somewhere else. To overcome these challenges, some organizations offered transportation support, such as financial coverage, or virtual MHSU support to attend healthcare appointments. 4.4.1.4 Leaving to Grow Nurse participants shared that some rural youth needed to leave their home community to pursue further education, find a career, or access appropriate MHSU support. However, this departure disconnected youth from their familiar support networks and cultural norms. And so there's definitely challenges [...] with kids who are growing up in these remote, small places. [...] Growing up in the community can be great when things are good in the 61 family, and when they're young, but teens and early young adults, […] can have [...] a harder time of where do I fit in life, and where do I go? ‘Cause there's a struggle if this is home, and this is where my family is [...] but when they are wanting to seek higher education, different jobs, how do I fit in in a big city, but wanting to go home, but those jobs aren't there? So in that teen, young adult age, trying to figure out where to be in life, I think, is harder. [...] Say you want to seek higher education, but you have to travel a long way for that, [...] that's a lot more culture shock than somebody who's in [a larger city] going to Vancouver [...] and it's further distance, too. This challenge was particularly acute for youth in remote communities as some youth needed to move away permanently to access MHSU care. I think, with mental health, a lot of the youth that are having issues or have had issues, they get transported […] out of the community, and then they tend to stay with family out of the community because they need more resources. The nurse participants pointed out how facets of the rural environment such as community connectedness, culture and norms, and resource and transportation unavailability played a crucial role in shaping child and youth mental health. 4.4.2 Theme 2: MHSU Care Was More Than Just MHSU Care The rural nurse participants described a broad range of MHSU nursing care for children and youth, primarily youth, including MHSU crisis intervention, assessment, counselling, treatment, harm reduction, case management, and referral to a higher level of care. Their versatile nursing approaches also extended beyond what is formally thought of as MHSU care to include strategies aimed at promoting safety within the healthcare system and navigating its 62 complexities. Underlying these efforts was the prevailing mistrust in the health system among some rural youth and families that nurses work with. Intergenerational trauma secondary to the […] residential schools is like [the] definition of determinants of health at play. One thing that […] I've noticed […] is that because of like fear and the experiences that people have had with […] their traumas, they often fear our systems. Recognizing this challenge, rural nurses employed strategies aimed at developing trust and safety between rural children and youth and the healthcare system, facilitating continuity of MHSU care, and advocating for equitable access to MHSU resources. This emphasis on trust-building and navigating the healthcare system underscored the vital role of rural nurses in ensuring effective MHSU care for children and youth, particularly in regions with limited resources and support services. 4.4.2.1 Developing Trust and Safety Between Rural Children and Youth and the ……………...Healthcare System Rural nurse participants emphasized aspects of relational care as central for establishing trust and safety with children and youth, recognizing that the need for relational approaches was intensified in some of the more remote or resource-deficient settings. Since nurses were the first point of contact with the healthcare system for some children and youth and one of few formal supports in their rural communities, cultivating trust became even more crucial; there were few or no alternative options for MHSU care. There's a lack of […] resources […] and supports in rural [communities], so you really have to get creative and you have to build solid relationships so that your clients connect 63 with you and come to you for appointments and the injections and things like that, so a lot of relationship building. Multiple nurses underscored that creating a safe, confidential space for children and youth was an essential way to support trust and open communication. Kids want to be seen in person, […] there’s a real safety when they’re in a room that their parents have never been in before, or that they’re not gonna get walked in on, and they can do whatever. You learn so much just in that like hangout period, where they’re playing with something or they’re drawing on something, […] and then they like drop you those little nuggets about […] what they’re actually feeling. They need the space and time to do that. Additionally, two nurses highlighted the importance of supporting children or youth to lead their care decisions, recognizing the challenges they faced in trusting external resources, such as a suicide hotline. I normally talk about what what’s going on for them? […] What have they tried before? What resources have worked for them? Do they know about Foundry? […] What do they want most? […] What would their step one be? And then trying to facilitate that, whether it’s […] connecting them with […] a counsellor [at] Foundry […], or […] trying to pave the way calling with them sometimes, because it’s always scary to call a suicide hotline or any kind of outside number, like it’s hard to trust, really hard to trust, especially when you’re a teenager, to admit that you need some help. […] I’m really letting them drive what they need […] and being open to them not being ready for it ‘cause […] it’s really up to them. But just knowing that […] here’s all the things, and sometimes all the things 64 can be overwhelming. So […] what’s one thing you wanna do? […] How can we make that happen? Moreover, four nurses described strategies to instill hope and possibilities in youth, such as encouraging career exploration and validating one’s reactions to traumatic experiences. [In] our positions, we had to have […] lived experience to be able to take this role, and I use that to be able to support the youth, to […] normalize it for them, and […] to see that there is hope on the other side. You can achieve things even when you've gone through, […] some severe whatever, and you've had your own challenges. There is hope. You can continue, like you can do the work. Community programs and initiatives were described as potential avenues to visibly demonstrate healthcare providers’ safety for children or youth. And so there's […] visible support, […] like we as the providers go, and we wear the T-shirts and show our faces, and let the people take pictures of us and say who we are, […] and then that, in hopes, will trickle to the patients, especially the young folks, to know that their providers are safe. Another nurse described a program that aimed to decrease fear in the health system: I started a program where the […] daycare kids like as young as 3 to 6, I have a day where I've had them come in and sort of take away the fear that they have of nurses, doctors in the hospital, like showing them how certain things are done, […] like vitals, machines, or a cast, or an X-ray or drawing blood, just to sort of make that different for them, because they're overhearing historically how the treatment was for their [Indigenous] culture, and so a lot of them are quite afraid of what's going on. And then also the fear around, oh, so and so was here, and they got shipped off. That's very scary 65 for kids. They don't wanna be shipped off. They wanna be where their family is. So just sort of explaining that to them a little better in the […] child lens. By prioritizing relationship building, rural nurses not only cultivated trust but helped children and youth to empower themselves in their healthcare journeys, potentially improving their future interactions with the healthcare system. 4.4.2.2 Facilitating Continuity of Care To ensure continuity of MHSU care in rural communities with limited resources, rural nurses adopted multifaceted approaches. Some of the nurses described how they integrated care by offering support that addressed the physical and mental health care needs during interactions with youth. Teenagers are coming into immunizations, and so talking about HPV [human papillomavirus] and […] how important that is, and then […] what else is going on for them in their lives, and kind of one-stop shopping it […] and knowing that our door is always open, they can come in whenever. Leveraging their familiarity with the community, rural nurses provided tailored care that was responsive to the specific needs of children and youth, sometimes stepping beyond their usual roles to provide comprehensive support. Additionally, they collaborated with various health and social service providers to bridge gaps in service. For example, one participant stated, “like all rural nurses, [rural MHSU nurses] have to kind of fill every gap.” By proactively sharing relevant background information about youth between care providers who may be unfamiliar with the community and extending their reach to support rural clients admitted to urban hospitals, nurses enhanced the quality of MHSU care and minimized the risk of rural children and youth slipping through the cracks or receiving inadequate care. 66 We do daily meetings with acute care for anyone who's [admitted] for their mental health and substance use issues so that we can make that connection and eliminate some of the gaps of them maybe going to the hospital, [and] us in rural communities not knowing. So now we all know, because we have a […] daily meeting. So we hope the person consents, and then you can form a relationship. Sometimes […] I'm supported to go meet them in the hospital, make a connection in person. […] I could speak to a youth […] or young adult who is really high risk […] in a hospital setting, make that connection so that I can support them when they're back rural. 4.4.2.3 Advocating for Equitable Access to MHSU Resources Rural nurse participants described advocacy strategies that could play a pivotal role in improving child or youth access to MHSU resources. Nurses actively engaged in advocating for resources and services to address systemic barriers. They participated in regional committees, communicated the realities of their rural communities’ needs, and pushed for fair allocation of resources. For the treatment beds, there's a regional bed committee that I was never a part of, and then somebody sent me a link, and then I was able to go to a zoom call and tell them, ‘hey, guys […] this is the reality of my folks here’. […] That communication […] really […] does improve the knowledge and the understanding […] and it helps our clients be able to access care in a fair sort of way […] when people in urban settings have a better idea of what they're facing. Their advocacy efforts extended to ensuring timely access to care for children and youth, such as advocating for nurses in high schools to provide non-judgmental support and information. 67 I found that hardly anybody has a doctor, and so […] my big push lately has been to try and provide timely access […] for teens. […] I'm advocating for public health nurse presence, or some kind of presence in the […] high school, so that that kids can come and they have access to say, birth control, or […] if they've got STIs, or if they've got other challenges. […] I would love to be able to provide more opportunities for kids to be able to ask questions with no judgment and health advice [...] and have [...] a constructive and a good relationship with people in the healthcare system, because when you have good interactions, it paves the way to be able to have better interactions later, and to be able to ask for help later when you need it. Rural nurses also facilitated transitions from acute care to substance use treatment by advocating for seamless transfers between care levels and providing logistical support, thereby increasing the likelihood of successful health outcomes. If [youth] are hospitalized with anything related to their substance use, and they want treatment, we can really push […] the acute care end to say […] ’They really want to go. We've worked with them. This is their opportunity. And […] let us help’ and as soon as we say we can help, the acute care […] doctors will sign anything, psychiatrists will sign anything if you're offering to […] take the bulk of that referral […] and complete it. So often we'll do that when our clients are in hospital like ‘let us do the work’ and let's get them in so that they can go from the hospital to treatment and have a good […] chance of success. Rural nurses highlighted that advocacy work addressing the social determinants of health was part of the nursing role and part of MHSU care. Through these advocacy efforts, nurses worked 68 to bridge the gap between available services and the diverse needs of rural children and youth, ultimately enhancing the overall MHSU care landscape and health of rural communities. The biggest challenge […] I see is that there's no emergency housing for youth here whatsoever. […] If they're in an unsafe position, there's nowhere to go. […] [So] learning how to advocate for these changes […] has been super beneficial for me. […] I've tried to […] find the […] channels to advocate for change within [health authority] and basically it's “go to your manager, […] make the suggestion, and then the manager will take it to […] the steps above them”. And then […] what gets lost in the process? What gets lost in translation, you know? And so that's […] another reason why I found connecting with BCNU [British Columbia Nurses Union] and learning how these advocacy pieces work [necessary], and […] connecting with MLAs [Member of Legislative Assembly] and being able to say […] “this is what we really need here”. […] I do believe it is […] part of MHSU work. 4.4.3 Theme 3: Rural Nurses Were Clear on What Supports Child and Youth MHSU 2345678 Care. To support rural child and youth MHSU care, nurse participants reflected on key aspects that facilitated this care, including (a) embracing rural nurse qualities, (b) having enough time to care, (c) access to practice support, (d) knowing the community, (e) being part of a cohesive and supportive team, and (f) effective communication and collaboration across health systems. 4.4.3.1 Embracing Rural Nurse Qualities and Ways of Being Rural nurse participants described core qualities and ways of being that helped them to navigate, support, or carry out child and youth MHSU care. These qualities are more about how nurses provided care rather than what care was provided. They approached their work with 69 authenticity and relatability, establishing connections with youth, as one nurse noted “I just try to be authentic and try to support them with as much as I know how to do.” Nearly all of the nurse participants described how their own lived experiences related to MHSU deepened their empathy and understanding, enhanced rapport building, or guided effective care strategies for children, youth, and families. I've had lived experience […] with mental health and addictions as a youth. So I think […] having lived experience has helped me a lot, just to understand better […] what needs to be addressed […] with the patients […]. It just gives you a different […] understanding of the situations that people are coming from. Another participant described that: It helps [that] I had a background myself, and being like a pretty troubled youth, and more in that direction of like suicidal ideation, self-harm, and I got through it. So being able to share that with teens being like, “you know what, I did this stuff”, I think that actually helps a lot to build rapport and also to know where they're coming from. Further, some of the nurses noted the importance of a harm reduction approach or philosophy of practice, of holding a nonjudgmental attitude and meeting youth where they are to help create a safe and supportive environment. This approach was particularly important in rural and remote communities that had limited confidential spaces. I meet the youth where they're at to kind of reduce any barriers that way. A lot of the youth have trust issues, and so it's hard to get them to come into facility […] so oftentimes I will meet them at a local park or at a local restaurant. A lot of the meetings happen in my vehicle so that they have a safe place where they know people aren't gonna overhear them, but yet it doesn't have the stigma of accessing mental health supports. 70 In addition, two rural nurses described how a strengths-based perspective supported MHSU care. I think that the important part is, I don't have to have all their answers. I have to let go of fixing it, I just have to convince them that they matter. They matter to me, and they matter […] in the world, and […] there's lots of people […] who think that they matter as well. And it's hard for some kids who don't have a lot of people who care about them […] to think that anybody else thinks that they do. Some of the rural nurses shared that flexibility, resourcefulness, and creativity were important qualities for navigating the constraints of rural healthcare systems. [It’s] hard to find the resources to support somebody when they're not living in urban centres with access to more things to do with […] gender identity issues, sexual health clinics, things like that. So again, that's another piece of us having to be creative is finding those resources, finding those online resources, being up with that stuff ourselves so we can support our youth because it's […] definitely an issue, and then that also contributes to them using substances and drinking alcohol and things to cope and manage the way that they're feeling. Overall, these qualities and ways of being enabled rural nurses to deliver compassionate, holistic, and effective MHSU care that addressed the unique needs of children and youth in rural communities. 4.4.3.2 Having Enough Time to Care Time was highlighted as a key care facilitator when working with children and youth. Nearly half of the rural nurses talked about the importance of having enough time to provide MHSU care. Three nurses noted that having time for care was one strength of their remote communities. 71 The advantage of working in this really small community, and compared to where I've worked in busy, bigger emergency departments, is […] we have more time. And so […] I'm not getting pulled to look after other people so much, so I could sit and listen, and I'll just say, […] tell me more about that, and that feels good, right? ‘Cause I think […] people wanna be heard and have somebody to just talk to and feel like they're getting heard. […] I can have the time to do that, and that feels good to be able to have that time. Some of the nurses commented on how a lack of time hindered their ability to access education or collaborate with local support. I would love to have […] more education in the child and youth stuff and […] if I take time to figure out what I should take, […] then I can probably pitch it, and […] it will probably be supported. But that's like off the side of my desk while I'm also the only person [in this role]. 4.4.3.3 Access to Practice Support All of the rural nurse participants shared a range of resources that supported MHSU care, including resources for children, youth, and their families, and resources to inform or guide nursing practice (Appendix G). The topics included immediate virtual support and MHSU information for children, youth, families, and care providers; and child and youth MHSU nursing practice support. All of these resources were free and accessible with an internet or phone connection. Some of the rural nurse participants talked about approaches to practice that supported their MHSU practice with children and youth (Table 3). In addition to these approaches, nurses spoke about considering perspectives from a wide variety of sources on topics for their practice, like parenting, trauma, and mindfulness. 72 Table 3 MHSU Approaches to Care as Described by Participants Approach Description Cognitive behavioural therapy Cognitive behavioural therapy is an MHSU treatment that supports people to change negative thought patterns or behaviours to improve their mental wellbeing (e.g., Friedberg et al., 2020). Harm reduction Substance use harm reduction is a philosophy and approach that aims to decrease harm from substance use, substance-related policies, and laws (Harm Reduction International, 2024) by meeting a person wherever they’re at and providing person-centred support, education, and resources (Smyth, 2017). Harm reduction is also an effective approach for sexual health and other health and social behaviours (e.g., Smyth, 2017). I'm […] pretty liberal in my beliefs on harm reduction like, in our community, there is quite a […] push against prescribing different types of OAT [opioid agonist therapy] medications to treat opiate use. […] We very much understand that it's still a struggle, […] I just much prefer people get all of their opiates from the pharmacy, at a known dose, […] and you know for sure what's in it. So […] you reduce your risk of death and overdose, and then if people have a steady access to opiates from a safe, reliable source, like the pharmacy, […] then they have time and breathing space in their life […]. So then they can start to heal a little bit and focus on healing and getting safe […]. And so I'm […] very open to harm reduction and open to […] always learning more about it to help people. Because I know […] there's not one answer for every person to help, right? So some more options we can offer to help people the more successful they'll be hopefully. […] I actually […] couldn't even imagine doing work coming from another perspective, because […] I wouldn't know any different. Because you can tell people to stop doing drugs and get an apartment but it doesn’t work that way. Motivational interviewing Motivational interviewing is a collaborative approach that supports people to identify, enhance, and act on their own motivations for change (e.g., Naar & Suarez, 2021). With my practice, I focus on […] doing motivational interviewing, trying to see where […] they do want to 73 Approach Description grow, the things that they do want to achieve, and kind of working on their quality of life at home until they can kind of make those changes. And I've seen very positive results that way. Polyvagal theory Polyvagal theory is a way for people to conceptualise and work with the nervous system that helps to increase feelings of safety and regulation (e.g., Dana, 2021; Porges, 2022). Trauma-informed practice Trauma-informed practice is a strengths-based approach that focuses on creating safety in healthcare interactions through the principles of trauma awareness, safety and trust, autonomy and collaboration, and resiliency and skill-building (e.g., Poole et al., 2016). I took like a full-day course […] that was [about] trauma-informed care, and I found that super helpful […]. It was [provided by] somebody who was sort of trained in this, who came and gave information […] about trauma-informed care, specifically how for children, […] how childhood adverse events affect people later in life. And that was super helpful because it gave me a different perspective. And right away, when I was taking that education, […] I was reflecting […] on many situations in life of […] work and […] also other life outside of work about how I've seen that things that happen to people, especially in childhood, but sometimes later as well, adverse life events, then, can affect […] people later […] especially with turning to addictions, maybe to mental health diagnoses, etc., […] whether it's anxiety, PTSD, substance use, all sorts of things. […] Ongoing education is important because people come up with new techniques and new research and all that kind of stuff. 4.4.3.4 Knowing the Community Rural nurses shared that their MHSU work was facilitated by knowing the client, family, and community. Although having a dual role may have been challenging, it helped some nurses to understand the child or youth’s life context and humanized their care encounters. 74 And quite often the kids that are presenting, […] if they're coming in for alcohol abuse, […] we know the community, and we know their family, and you know it's like a generational thing like you just seen their [parent] the week before, for like abuse or detox, you know, stuff like that. So that's kind of an interesting aspect, just the fact that […] you know their family and kind of the history of their family in that as well. […] It kind of opens your eyes up more to what they are facing, makes you a little bit more empathetic, […] just with what they're going through on their day-to-day. I think, when you're in a bigger centre, and you see a kid come in for that, […] you hear what they're telling you there and now, but […] when you're [in the rural community] and […] you see them day to day around the community, and you know what else they're facing, it […] makes you relate to them a little bit more on a deeper level. Additionally, one rural nurse noted that knowing support persons from the community could have increased the likelihood of youth engaging with those supports if the nurse vouched for them. Knowing like the drug and alcohol counselors for youth, or the school counselors, or […] child and youth mental health, like knowing them, so when you're referring them, you can say, ‘hey, […] I know this guy, he's so awesome, he'll come to you and work with you at school’. So like knowing the roles of the people you're referring them to, not just like blindly giving them a phone number, like get to know the people who are supporting the youth so you have a personal opinion when you're selling the youth to accessing [them]. I really feel that that's helpful. But that […] comes with time and experience and getting to know the community and those other people supporting youth, because […] then you hope that their chances of connecting […] are higher. 75 4.4.3.5 Being Part of a Cohesive, Supportive Team Some rural nurse participants described how different facets of a supportive team helped their nursing practice: co-worker support, adequate and regular staffing, leadership support, counselling, and immediate consultation. Co-worker support included immediate critical incident debriefing, especially after challenging and emotionally demanding situations such as youth overdoses or assaults; regular team check-ins; a willingness to help colleagues; and support to think creatively through resource-limited situations. Recently, [we had a critical incident] and the […] follow up of that was quite a lot of like team support, and debriefing from that. We have a lot of kids that […] repeatedly overdose or are victims of varying types of assault, and we tend to see them quite promptly after. So […] we just make sure to always have someone [for debriefing], like we have [a] group chat. And so we do a lot of debriefing […] right away. There's no like, let's book a [critical incident stress debrief] next month, […] it's like right now, anybody needs to call anytime like outside work, whatever, come over, or do you need dinner? […] We have just kind of like a no holds bar policy, […] if somebody needs something as a like a co-worker provider, […] just call. Almost half of the rural nurses underscored the challenges of working in isolation or the effects of an inconsistent team. A regular and adequately staffed team better facilitated continuity of care, co-worker support, and safety. More regular staffing makes a difference. When we're all travel nurses, there is no team. Sometimes you’ll meet other travel nurses, and […] right away, you have each other's backs, but it's not the same as an actual regular team. 76 If there's someone that's in a mental health crisis and they need to go to higher level of care, we're waiting for a plane to come, and it can take a day or 2 or 3. And so with the staffing that we have, I could be awake for 48 hours watching this patient by myself, and then leaving the community without a nurse. One rural nurse linked insufficient staffing with the potential to negatively impact continuity of care and subsequently, the development of trust between nurses and youth. It's really nice when […] there's […] continuity of care up here… but that is a staffing issue. But you know, when there is like the same staff, and you can build that trust with them over a series of years in that community, and they know, okay, you're a person I can talk to, and that's safe. But when there's always new staff like travel nurses coming in, or travel doctors, […] each time they have their guards up a bit, […] and you have to slowly break those down again. So yeah, that's a big struggle in the rural communities, just having that continuity of care to kind of build that trust with teenagers. In addition to the necessity of adequate staffing, nurses shared how valuable it was to be supported by responsive, communicative leadership that advocated for nurses’ well-being and supported Indigenous culture in the workplace. It's a lovely place and very well supported like […] management and administration is just amazing for us there. […] [Health authority] recognizes the Indigenous culture and supports it. […] The administrator will check in with us like every 2 hours to make sure that we're not burning out, our mental health is not being affected, and that we have the supports that are needed. And [they] will either […] drive [themself] in or fly in the next day, if we need it. [They’ll] make the doctors get involved as well where the doctors are 77 gonna have to do a 4-hour shift of staying up all night […] if we're […] hitting a wall. Yeah, so I feel very supported that way. One example of more formal support was having an organization set up counselling that the healthcare team could access in the workplace. One nurse stated “we actually have […] a day set aside for […] counsellors coming in […] to provide individual counselling to all of us, […] because we get vicarious trauma working with clients in this [work].” In contrast, another nurse noted that there was private counselling available through extended benefits, but it may have been insufficient: “there's counselling through my benefits, but it's only goes up to like $900 a year to do private counselling, so it's challenging.” Rural nurses identified immediate consultation for child and youth MHSU care as another feature of a supportive team. Few of the nurses had access to immediate consultation, and the ones who did were from larger rural centres. Now I have a really experienced, dedicated team of nurse practitioners for immediate consultation, so that has been a wonderful change. When I first started with this organization […] I only had access to virtual consults for physicians that were not immediately available. So that's been great, just having more immediate support. One nurse identified that the lack of immediate consultation was a barrier to providing effective care for youth in crisis. This challenge is exacerbated by the complex clinical support hierarchy and geographical separation from key knowledge coordinators. But it's been challenging because the team leads, they're busy, […] and the on-site team leads don't have specific knowledge, and so then they have to dig to somebody else, right? There's that hierarchy, of like, who I can access. And then our main knowledge 78 coordinators are out of [city], so then it means sending an email or asking for a meeting, and meanwhile you're trying to support these youth in crisis. Overall, nurses underscored the value of and need for consistent staffing, supportive leadership, and readily accessible consultation to enhance the work environment and ensure continuity of MHSU care. 4.4.3.6 Effective Communication and Collaboration Across Health Systems All of the nurses spoke about the lack of rural MHSU resources for all rural people broadly or for children and youth specifically. When the appropriate resources existed, nurses described siloed services and fragmented communication, highlighting the need for effective communication and collaboration across all health system levels. There are programs and services that we know nothing about. We don't hear anything about it. Or we maybe get like an email, and […] other people get presentations and things like that which we don't get here. And so that, I think is a bit problematic. Effective communication improved awareness of, access to, and collaboration with resources that supported rural child and youth MHSU. This morning I was connecting with [a nurse] up at the hospital […] to look at wound care, because a lot of our clients who come in for their [harm reduction supplies], […] they're like, well, I need antibiotic cream because look at my hands or look at [my] trench foot, or whatever. […] So I connected with [specific nurse] to say, hey, if you provide […] these items, we can make up the kits and then put them out […] when we're doing harm reduction and walkarounds. And when […] we're giving people what they need, […] they're gonna trust us more, and […] if we can give them something so they don't have to go to the hospital, we save $700 every time, right? So [another nurse]’s 79 gonna connect with [local service] cause they've got better stuff, and then hopefully, […] they can give us the stuff, and it's not a big deal, and then we're working, not in silos. Further, understanding and supporting the rural reality was an important facet of health system communication between urban and rural settings. I'm not sure that [urban intake clinician] understands the reality of [rural] clients. […] Like what does it mean when you're living in a trailer with no electricity, and you don't have cell phone coverage? […] So when I'm interacting with services and they're telling me that my clients need to engage in lower-level services before they can access like treatment programs, […] I'm like, what lower-level services are you talking about? They're talking to me, like that's it. […] So I think the rural reality is hard to understand unless you are part of that experience. These rural nurses offered valuable insights about child and youth MHSU care, drawing on their deep understanding of the unique challenges, strengths, and realities of their rural and remote communities. They weaved insights that helped to better understand their nursing practice, including the embeddedness of child and youth mental health in their rural context, the expanded role nurses had within MHSU care, and a deep awareness of what supported their practice. From the individual nurse to the broader health systems level, these nurses worked hard to care, connect, and advocate for better MHSU care for rural children and youth. 4.5 Discussion In this study, we aimed to explore what can be learned from rural nurses regarding child and youth MHSU care in community practice settings in British Columbia. Our findings shed light on some of the dynamics of rural nursing practice in the context of child and youth MHSU, offering unique perspectives related to rural MHSU care. Specifically, this study delineates the 80 importance of the rural nurse-client (i.e., child, youth, and family) relationship for building trust in the health system and facilitating access to care, especially when nurses are adequately supported and resourced. Since practical considerations are emphasized as a critical part of interpretive description, two key points that are relevant to nursing practice are discussed: the role of rural nurses in early intervention and in supporting rural-centric approaches to MHSU care. 4.5.1 The Role of Rural Nurses in Early Intervention Rural nurses can play a pivotal role in early intervention, the early identification and treatment of MHSU challenges (McGorry & Mei, 2018) among children, youth, and families in rural communities. Early intervention is not commonly a routine part of MHSU care (McGorry et al., 2018). Since rural nurses may serve as the first professional point of contact (MacLeod et al., 2022), this provides a unique opportunity for relationship and trust-building from the outset in children and youth’s healthcare interactions. This early engagement is crucial, as research underscores the early onset of MHSU challenges in youth (Solmi et al., 2022). Early psychosis intervention studies indicate that recognizing and addressing MHSU challenges in their beginning stages can lead to better outcomes and reduced long-term MHSU impacts compared to treatment-as-usual (Correll et al., 2018). Early intervention approaches also show promising results when extended to non-psychotic disorders such as depression (Davey & McGorry, 2019). As explored in theme 1, that child and youth MHSU is more bound to the rural context, the potential familiarity that rural nurses have with their clients and local communities could help them to assess the psychosocial context of children and youth and recognize early signs and symptoms of MHSU challenges. Their understanding may extend beyond clinical symptoms and a narrower understanding of MHSU care to include building trust between children, youth, and 81 the health system; facilitating continuity of care; and advocating for MHSU resources, as described in theme 2. This understanding could facilitate comprehensive individual and systems-level MHSU care (Mpheng et al., 2022). However, to intervene early, rural nurses need to be supported, as identified in theme 3, by sufficient staffing levels, appropriate supports and resources, and adequate training (Mpheng et al., 2022). For example, Cusack et al. (2017) describe how comprehensive supports, such as access to proper training and education, are needed for nurses to provide comprehensive mental health care, including early intervention. In rural communities where there may be substantial staffing and resource inadequacies, this comprehensive support may need to include additional facets, such as virtual support and 24-hour helplines for MHSU care (Novak Lauscher et al., 2023). In addition to rural nurses’ potential role in early intervention, they could have a role in supporting rural-centric approaches to care (Perkins et al., 2019). 4.5.2 The Role of Rural Nurses in Supporting Rural-Centric Approaches to MHSU …………Care Rural communities encounter distinct and complex challenges such as limited or absent services and geographical isolation (CARRN, 2020). Recognizing the necessity of properly supporting rural mental health care, Perkins et al. (2019) outline the importance of rural-centric approaches compared to adopting urban-centric approaches. Rural-centric approaches, grounded in the unique characteristics of rural communities, emphasize place-based, integrated, and community-engaged service development (Perkins et al., 2019). Rural nurses could have an important role in supporting rural-centric approaches to MHSU care for children and youth. Through their potential sensitivity to the psychosocial context of their clients and communities, as discussed in theme 1, rural nurses are likely more aware of what MHSU supports and 82 resources are needed, compared to resources developed by urban health services. Moreover, in alignment with theme 2, rural nurses may need to advocate for their role to be adaptable and responsive to community needs (i.e., rural-centric), encompassing a broader scope of practice compared to their urban counterparts. For example, this could include integrating counselling support within nursing practice (BCCNM, 2023; MacLeod et al., 2022) in communities with few or no counselling supports or working across health promotion and illness prevention with children, youth, and families rather than focusing primarily on immunizations in a public health nurse role (Burch & Stoeckel, 2021). Furthermore, as discussed in theme 3, supporting rural nurses in their practice is essential for implementing rural-centric MHSU services. Rural nurses may need the time to get to know their communities, especially if they are new to the community (Kulig et al., 2018); the team and community support to collaborate on service development or provision (Beks et al., 2018; Etter et al., 2019); and improved communication across local and non-local health systems (Sutherland et al., 2020) to leverage available resources to create and adapt services. These necessary supports can provide the foundation for nurses to advocate for and deliver context sensitive MHSU care to children and youth in rural areas. 4.6 Limitations & Future Research While this qualitative study offers valuable insights into the role of rural nurses in supporting MHSU care of rural children and youth, there were multiple limitations. First, the study sample consisted primarily of nurses from rural and remote regions of British Columbia, Canada, potentially limiting the transferability of the study findings to other regions in Canada or worldwide. Additionally, the sample size was relatively small and homogenous, which may have restricted the breadth and depth of perspectives included in the study. Despite these limitations, this study contributes to the growing body of literature on rural child and youth MHSU nursing 83 and provides a foundation for further research in this important area of healthcare. Future research should continue to expand our understanding of rural child and youth MHSU nursing care. Studies that meaningfully involve rural children, youth, and families could provide valuable firsthand insights about MHSU care in rural areas. Studies with more diverse samples are also needed to ensure a broader representation of rural nurses, including men, gender-diverse individuals, and nurses from various geographic regions. Examining whether nurses from different backgrounds hold unique perspectives or employ distinct strategies in MHSU care delivery could inform the development of tailored MHSU supports and interventions. Additionally, understanding how nurses can actively engage in rural health policy development and advocacy efforts is essential, requiring exploration of barriers, facilitators, and strategies for nurse involvement in policy-making processes. By addressing these research gaps, we can enhance the capacity of rural nurses to support MHSU care and contribute to positive health outcomes for children and youth in rural areas. 4.7 Conclusion The prevalence and early onset of MHSU disorders present significant challenges for children and youth globally (Erskine et al., 2015; Solmi et al., 2022), with rural communities facing additional barriers to accessing care (Moroz et al., 2020; Sinclair, 2020). This study aimed to learn from rural nurses about MHSU care for children and youth in community settings, describing the pivotal role rural nurses can play in providing comprehensive MHSU care and highlighting the support needed for their practice. Further research is needed to better understand MHSU care provision aimed at addressing the unique needs of rural communities. This study underscores the importance of supporting rural nurses, recognizing their invaluable expertise in understanding and improving MHSU care of children and youth. 84 Chapter 5: Conclusion Chapter 4 contained the manuscript for this thesis study. Since this manuscript was tailored toward a more global audience, implications for nurses in Canada and recommendations for nursing practice, education, administration, and rural health policy are described below. This chapter ends with this thesis’ summary. 5.1 Implications for Nurses in Canada The results of this study hold implications for nurses across Canada, particularly those practicing in rural and remote regions and in community practice settings. First, the exploration of rural nurses’ roles in supporting MHSU care in this thesis underscores the relevance of the CHNC Standards (CHNC, 2019) to NP, RN, and RPN practice; since no LPNs were interviewed, this is a knowledge gap that warrants further exploration. The CHNC Standards (CHNC, 2019) are congruent with LPN, NP, RN, and RPN professional standards (BCCNM, 2024a; 2024b, 2024c), and thus, it may be useful to consider updating the CHNC Standards to guide all types of regulated nurses working in community practice settings, keeping in mind differences in scope of practice. The CHNC Standards emphasize the provision of holistic, client-centred care within diverse community settings (CHNC, 2019); rural nurses can use these standards to support their nursing practice. In particular, as described in theme 2: MHSU care was more than just MHSU care, an expanded vision of MHSU nursing care in rural communities can be supported by the health promotion, prevention and health protection, capacity building and health equity standards (CHNC, 2019). Building trust in the health system among rural children, youth, and families is a health promotion and illness prevention activity, as described by theme 2: MHSU care is more than just MHSU care subtheme developing trust and safety between rural children and youth and the healthcare system. Promoting trusting relationships early along children and youth’s 85 health journeys may increase their likelihood of engaging in the health system when they need care (Valenti et al., 2020). Moreover, nurses aligned with the capacity-building standard by collaborating with children and youth, families, and caregivers to empower themselves beyond the care barriers, using their available strengths and resources (Mendenhall et al., 2020). Finally, rural nurses identified many determinants of health that impact children and youth’s MHSU. They worked at creatively addressing these determinants of health, strived to provide culturally safe and destigmatizing care, and identified ways to advocate for fair allocation and appropriate access to MHSU resources; this work is supported by the health equity standard (Community Health Nurses of Canada, 2019). Furthermore, this study highlights the relevance of the Framework (Pavloff et al., 2022) in research. The Framework (Pavloff et al., 2022) was useful for guiding a comprehensive literature review (Chapter 2) and developing a multilayered and rural-relevant semi-structured interview guide. The Framework (Pavloff et al., 2022) could also be used by rural nurses to guide the delivery of MHSU services for children and youth in rural communities, as outlined in the discussion document by CARRN (2020). By accounting for the Framework’s (Pavloff et al., 2022) considerations of rural people, community, rural context (including the determinants of health), and larger society in their practice, nurses can address the unique care realities inherent in providing MHSU care in rural settings, thereby optimizing health outcomes for rural children, youth, and families. 5.2 Recommendations The overall aim of this thesis was to explore what could be learned from rural nurses about child and youth MHSU nursing care. Since interpretive description emphasizes the practice-based implications of research, key recommendations for nursing practice, nursing 86 education, nursing administration, and rural health policy are included, based upon the study findings, to support rural Canadian MHSU nursing practice for children and youth in community settings. 5.2.1 Nursing Practice Key nursing practice recommendations for enhancing child and youth MHSU care in rural communities include strengthening continuity of care, reducing MHSU stigma, forming interdisciplinary and community partnerships, and incorporating MHSU screening and early intervention within care. As highlighted in theme 1 (subthemes navigating the (un)available resources and leaving to grow), continuity of care can be particularly challenging in rural communities due to factors such as geographic isolation and limited resources (MacLeod et al., 2022). Nurses can play a key role in ensuring effective care coordination and follow-up through advocacy and engaging in policy (Kulig et al., 2004). Further, active efforts to reduce stigma around MHSU are essential in encouraging children, youth, and their families to seek help and engage with available services (Radez et al., 2021). These efforts could include strategies such as talking to children, youth, and their families in an open and nonjudgmental way about MHSU (Radez et al., 2021) and providing community education (Childs et al., 2021). Additionally, as explored in theme 3 (subtheme knowing the community), fostering strong partnerships with other clinicians, schools, families, and community organizations could help nurses to create a supportive and cohesive network for child and youth clients (Ratter, 2023). Finally, as discussed in chapter 4, implementing routine MHSU screening and early intervention can help nurses to identify and address MHSU issues at an earlier stage, improving long-term mental and physical health outcomes for rural children and youth (Correll et al., 2018). By integrating these 87 strategies, nurses may be able to substantially improve child and youth MHSU care in rural communities. 5.2.2 Nursing Education Recommendations for nursing education emphasize the need for developing specialized programs and ongoing training that equips rural nurses with the necessary skills to address child and youth MHSU care effectively, as described in theme 3 (rural nurses were clear on what supports child and youth MHSU care). These programs could be integrated into diploma, undergraduate, graduate, and post-graduate certificate programs. It is important for this education to be tailored to the unique challenges of rural healthcare environments and include components on cultural safety (Curtis et al., 2019), intersectionality (Hankivsky & Mussell, 2018), and trauma-informed care (CARRN, 2020). Specialized training programs should also focus on enhancing the nurses’ ability to identify and address MHSU challenges early and effectively (McGorry & Mei, 2018). In addition, educating nurses on how to form strong partnerships with local schools, families, and community organizations as described by theme 2 (subtheme knowing the community) could help to foster a supportive network for child and youth clients, promoting a holistic and community-centred care model (Ratter, 2023). Further, it is crucial to ensure that nurses can access professional development opportunities relevant to the evolving needs of rural child and youth MHSU care, such as workshops, online courses, and seminars that provide up-to-date knowledge and practical skills (Kverno & Kozeniewski, 2016). Finally, training in the use of telehealth technologies, including familiarization with real-time virtual consultation, is also important to overcome geographical barriers and provide timely and less expensive MHSU care (Novak Lauscher et al., 2023). By providing ongoing and relevant rural 88 MHSU training to nursing students and regulated nurses, rural child and youth MHSU nursing care can be optimised. 5.2.3 Nursing Administration Recommendations for nursing administrators include facilitating team relationships (Beks et al., 2018), providing access to immediate MHSU practice support (Cosgrave et al., 2018; Novak Lauscher et al., 2023), and ensuring that rural nurses have adequate support for their mental health (Jahner et al., 2022). Nursing administrators could facilitate opportunities for rural nurses and their teams to build strong relationships among themselves and with their communities (Beks et al., 2018), and this may be particularly relevant for nurses who are new to the community (Kulig et al., 2018). Building these connections enhances collaboration, trust, and the overall effectiveness of care delivery (Johnston et al., 2021). Additionally, as described in theme 3 (subtheme access to practice support), access to immediate MHSU practice support must be prioritized for rural nurses and their healthcare teams, such as real-time virtual support (immediate consultation), ensuring that nurses have the necessary resources to handle complex cases and emergencies effectively (Novak Lauscher et al., 2023). Finally, as explored in chapter 4, it is vital that rural nurses receive adequate support for their mental health as they may encounter challenging situations that are taxing on their well-being, such as workplace violence, toxic drug poisonings, and traumatic incidents (Gohar et al., 2020; Jahner et al., 2022). This support may include things such as critical incident stress debriefing (Gohar et al., 2020; Jahner et al., 2022), access to counselling support (Duhoux et al., 2017), and case consultations that focus on navigating the moral or ethical challenges (Maben et al., 2018). By equipping rural nurses with the support, knowledge, and skills they need, they can be supported to deliver high-quality care to their communities (Jahner et al., 2022). 89 5.2.4 Nursing Research Nursing research should prioritize effective nursing education and practice support development, specific to rural child and youth MHSU nursing, while also engaging diverse perspectives related to this type of care. Theme 3 (rural nurses were clear on what supports child and youth MHSU care) underpins the importance of better understanding nursing education and practice supports. Jenkins et al. (2022) demonstrated the positive impact of a one-day concurrent disorder training, finding that the intervention was effective for improving nurse and student nurse’s knowledge and attitudes about concurrent disorder care. Similar studies tailored to different rural contexts and guided by the Framework (CARRN, 2020) could provide valuable insights into what content and frequency of trainings, educational supports, and resources are most beneficial for improving rural nurse competency in child and youth MHSU care. Additionally, research should focus on factors that enhance rural nurse wellbeing, either integrated within the aforementioned studies, or studied separately. Rural nurses may face challenging experiences such as suicides, overdoses, and violence and this extends to child and youth MHSU (Jahner et al., 2020). Understanding the types of support that improve rural nurse wellbeing and retention from individual to systems-level interventions is essential, given the high turnover rates in the nursing profession (Flaubert et al., 2021). Finally, meaningful engagement of rural nurses, children, youth, and families, including those with overlapping unearned disadvantages, should also be a cornerstone of rural child and youth MHSU nursing research (Thorne, 2016). The Framework (CARRN, 2020) could also guide participatory research that includes people with lived experiences that are reflective of and responsive to the unique realities of rural MHSU (Boydell et al., 2021; Vaughn & Jacquez, 2020). 90 5.2.5 Rural Health Policy Rural health policies must be rural-centric, tailored to the rural and remote context and developed in collaboration with rural people, to address the complex healthcare challenges (e.g., fragmented and inadequate access to care) faced by rural communities (Kulig et al., 2009; Perkins et al., 2019). Theme 1 (children and youth were more bound to the rural and remote context than adults and thus, their mental health was more tethered to this context) speaks to the importance of considering the rural context for rural health policy. Specific policy measures aimed at strengthening rural healthcare, such as health system policies that support care integration between local (within rural) and non-local (rural to urban) health systems (Sutherland et al., 2020) are needed to reduce rural health inequities (Kulig et al., 2004), as described in theme 2 (subtheme facilitating continuity of care) and 3 (subtheme effective communication and collaboration across health systems). For example, policies that facilitate care between rural and urban communities could address issues such as time-consuming or confusing referral processes, tenuous professional relationships between rural and urban care providers, and disjointed health information due to multiple electronic health records (Sutherland et al., 2020). In addition, to support rural-centric health policy, rural nurses should be educated and supported to participate in the health policy cycle (i.e., analysis, design, implementation, and evaluation) (Kulig et al., 2004). Their close relationships with their rural communities and unique insights are invaluable for shaping policies that affect the health of rural communities (Kulig et al., 2004), including child and youth MHSU. This involvement could help to ensure that rural voices are heard and included in broader health policy discussions related to child and youth MHSU, ultimately leading to more effective and contextually appropriate health services (Kulig et al., 2004). Incorporating these recommendations into nursing practice, nursing administration, and health 91 policy is essential to enhance MHSU nursing care for children and youth in rural Canadian communities. 5.3 Summary In conclusion, this thesis underscored the vital role of rural nurses in understanding and supporting MHSU care for children and youth in rural Canadian communities. Three themes were constructed from the rural nurses’ practice insights: (a) children and youth were more bound to the rural and remote context than adults and thus, their mental health was more tethered to this context; (b) MHSU care was more than just MHSU care; and (c) rural nurses were clear on what supports child and youth MHSU care. These insights underscored the complex role that rural nurses have in supporting child and youth MHSU care in community settings. The CHNC Standards (CHNC, 2019) and the Framework (CARRN, 2020) both align with and could further support rural nursing in this practice area. However, additional recommendations could be implemented to enhance rural child and youth MHSU nursing, such as specialized training (Cosgrave et al., 2018), strong team relationships (Beks et al., 2018), adequate mental health support (Jahner et al., 2022), and nurse involvement in rural-centric health policy (Kulig et al., 2004). Embracing, leveraging, and thoroughly supporting rural nursing expertise may lead to significant improvements in MHSU care, thereby enhancing the wellbeing of children, youth, families, and rural communities. 92 Bibliography Ackerman, J. P., & Horowitz, L. M. (2022). Youth suicide prevention and intervention: Best practices and policy implications (1 ed.). 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CRC Press. https://doi.org/10.1201/9781315151694 116 Appendix A Literature Search Strategy Data Base Concepts MESH or equivalent terms Search Strategy Number of Articles Identified CINAHL EBSCO Concept 1: nursing (MH "Nurses+") OR (MH “Nursing+) [mesh] S1: (MH "Nurses+") OR (MH “Nursing+) OR 238,896 Keywords: nurse or nursing or nurses S2: nurse or nursing or nurses 2,184,847 Concept 2: rural (MH "Rural Health Centers") OR (MH "Hospitals, Rural") OR (MH "Rural Population") OR (MH "Rural Health Services") OR (MH "Rural Health Nursing") OR (MH "Rural Areas") OR (MH "Rural Health") [mesh] S3: (MH "Rural Health Centers") OR (MH "Hospitals, Rural") OR (MH "Rural Population") OR (MH "Rural Health Services") OR (MH "Rural Health Nursing") OR (MH "Rural Areas") OR (MH "Rural Health") 53,493 Keywords: rural or remote or isolated or regional or small town S4: rural or remote or isolated or regional or small town 630,675 Concept 3: mental health (MH "Mental Health") OR (MH "Community Mental Health Services+") OR (MH "Mental Health Services+") OR (MH "Mental Health Care (Saba CCC)+") [mesh] S5: (MH "Mental Health") OR (MH "Community Mental Health Services+") OR (MH "Mental Health Services+") OR (MH "Mental Health Care (Saba CCC)+") 142,496 Keywords: mental health or mental illness S6: mental health or mental illness 510,597 117 Data Base Concepts MESH or equivalent terms Search Strategy Number of Articles Identified or mental disorder or psychiatric illness or mental disorder or psychiatric illness Concept 4: substance use (MH "Substance Use Disorders+") S7: (MH "Substance Use Disorders+") 186,973 Keywords: substance use or substance abuse or drug use or drug abuse or dependence or addiction S8: substance use or substance abuse or drug use or drug abuse or dependence or addiction 193,700 Nursing MH OR Keywords S9: S1 OR S2 1,028,765 Rural MH OR Keywords S10: S3 OR S4 242,325 Mental Health MH OR Keywords S11: S5 OR S6 287,757 Substance Use MH OR Keywords S12: S7 OR S8 276,546 Mental Health OR Substance Use S13: S11 OR S12 528,000 Nursing AND Rural AND (Mental Health OR Substance Use) S14: S9 AND S10 AND S13 1,708 S15: Limiters – Narrow by Language: - English; Research Article 900 811 MEDLINE EBSCO Concept 1: nursing (MH "Nurses+") OR (MH "Nurse's Role") OR (MH "Nursing Staff+") OR (MH "Nursing+") [mesh] S1: (MH "Nurses+") OR (MH "Nurse's Role") OR (MH "Nursing Staff+") OR (MH "Nursing+") 392,629 Keywords: nurse or nursing or nurses S2: nurse or nursing or nurses 1,119,202 Concept 2: rural (MH "Rural Population") OR (MH "Rural Nursing") OR (MH "Rural Health") S3: (MH "Rural Population") OR (MH "Rural Nursing") OR 101,200 118 Data Base Concepts MESH or equivalent terms Search Strategy Number of Articles Identified OR (MH "Rural Health Services+") [mesh] (MH "Rural Health") OR (MH "Rural Health Services+") Keywords: rural or remote or isolated or regional or small town S4: rural or remote or isolated or regional or small town 1,901,215 Concept 3: mental health (MH "Mental Health") OR (MH "Mental Health Services+") OR (MH "Community Mental Health Services") [mesh] S5: (MH "Mental Health") OR (MH "Mental Health Services+") OR (MH "Community Mental Health Services") 158,911 Keywords: mental health or mental illness or mental disorder or psychiatric illness S6: mental health or mental illness or mental disorder or psychiatric illness 598,799 Concept 4: substance use (MH "Substance-Related Disorders+") S7: (MH "Substance-Related Disorders+") 308,359 Keywords: substance use or substance abuse or drug use or drug abuse or dependence or addiction S8: substance use or substance abuse or drug use or drug abuse or dependence or addiction 606,040 Nursing MH OR Keywords S9: S1 OR S2 1,126,699 Rural MH OR Keywords S10: S3 OR S4 1,901,215 Mental Health MH OR Keywords S11: S5 OR S6 641,835 Substance Use MH OR Keywords S12: S7 OR S8 764,927 Mental Health OR Substance Use S13: S11 OR S12 1,321,635 119 Data Base Concepts MESH or equivalent terms Search Strategy Number of Articles Identified Nursing AND Rural AND (Mental Health OR Substance Use) S14: S9 AND S10 AND S13 4,673 S15: Limiters - Narrow by Language: English; Research Article 3,216 3,216 PsycINFO EBSCO Concept 1: nursing DE "Nurses" OR DE "Nursing" [mesh] S1: DE "Nurses" OR DE "Nursing" 50,930 Keywords: nurse or nursing or nurses S2: nurse or nursing or nurses 194,325 Concept 2: rural (DE "Rural Environments" OR DE "Rural Health") [mesh] S3: (DE "Rural Environments" OR DE "Rural Health") 22,847 Keywords: rural or remote or isolated or regional or small town S4: rural or remote or isolated or regional or small town 159,055 Concept 3: mental health DE "Mental Health" OR DE "Mental Health Programs" OR DE "Mental Health Services" OR DE "Community Mental Health Services" OR DE ("Community Mental Health") OR DE "Mental Health Personnel" [mesh] S5: DE "Mental Health" OR DE "Mental Health Programs" OR DE "Mental Health Services" OR DE "Community Mental Health Services" OR DE ("Community Mental Health") OR DE "Mental Health Personnel" 158,462 Keywords: mental health or mental illness or mental disorder or psychiatric illness S6: mental health or mental illness or mental disorder or psychiatric illness 858,691 Concept 4: substance use DE "Substance Use Disorder" OR DE "Substance Related and Addictive Disorders" S7: DE "Substance Use Disorder" OR DE "Substance 10,930 120 Data Base Concepts MESH or equivalent terms Search Strategy Number of Articles Identified Related and Addictive Disorders" Keywords: substance use or substance abuse or drug use or drug abuse or dependence or addiction S8: substance use or substance abuse or drug use or drug abuse or dependence or addiction 284,823 Nursing MH OR Keywords S9: S1 OR S2 194,325 Rural MH OR Keywords S10: S3 OR S4 159,055 Mental Health MH OR Keywords S11: S5 OR S6 858,691 Substance Use MH OR Keywords S12: S7 OR S8 284,824 Mental Health OR Substance Use S13: S11 OR S12 1,061,195 Nursing AND Rural AND (Mental Health OR Substance Use) S14: S9 AND S10 AND S13 4,170 S15: Limiters - Narrow by Language: - English; Research Article 2,430 2,084 Inclusion and Exclusion Criteria INCLUSION EXCLUSION Any date range Grey literature Language: English Articles about nurse practitioners Empirical Articles (qualitative, quantitative, or mixed-methods studies) Intervention studies that do not describe current nursing practice Articles about rural and/or remote regions, mental health and/or substance use care, and nursing (licensed practical nurses, registered nurses, or registered psychiatric nurses) 121 Appendix B PRISMA Flow Diagram Records identified from: CINAHL (n=811) MEDLINE (n=3216) PsycINFO (n=2084) Records removed before screening: Duplicate records removed (n=1368) Records screened (n=4743) Records excluded (n=4541): • Study design • Study population • Not empirical evidence • Does not differentiate nurses from other populations • Did not include mental health or substance use considerations • Did not differentiate rural from urban data Articles sought for full-text retrieval (n=202) Articles not retrieved (n=0) Full-text articles assessed for eligibility (n=202) Full-text articles excluded (n=155): • Study design (n=48) • Study population (n=31) • Not empirical evidence (n=27) • Does not differentiate nurses from other populations (n=18) • Did not include mental health or substance use considerations (n=19) • Did not differentiate rural from urban data (n=12) Studies included in review (n=47) Mixed methods (n=7) Qualitative (n=28) Quantitative (n=12) Identification of studies via databases and registers Identification Screening Included 122 Appendix C Data Extraction Table Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Ambikile et al. (2021) Country: Tanzania Practice setting(s): hospitals and health centres MHSU To assess nurses' and midwives' awareness of intimate partner violence (IPV)-related mental healthcare and associated factors to encourage care provision. Quantitative. Cross-sectional survey. Purposive sample. Nurses and midwives from hospitals and health centres in the seven districts of Tanzania's Mbeya region; remote areas. Rural nurses: n=568. Cross-sectional, anonymous, self-administered survey developed based on the 2013 WHO IPV Clinical and Policy Guidelines. In hospitals, higher professional nursing and midwifery education (adjusted odds ratio [AOR]: 1.207; 95% confidence interval [CI]: 0.787, 1.852; p = .045) and extensive work experience (AOR: 1.479; 95% CI: 1.009, 2.169; p = .007) correlated with increased recognition of IPV-related mental health disorders. Conversely, in health centres, government ownership (AOR: 3.526; 95% CI: 1.082, 11.489; p = .037) and having a mental health resource person (AOR: 3.251; 95% CI: 1.184, 8.932; p = .036) were correlated with increased recognition of One limitation was that the understanding of IPV-related mental disorders among nurses and midwives was gauged by asking participants to select disorders from a provided list, which may not fully capture their awareness. The assessment of screening tool availability relied on written responses, lacking physical verification. Important factors like coordination and supervision in mental health services were not explored, potentially impacting IPV-related mental healthcare delivery. 123 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations IPV-related mental health disorders. Participants' responses may have been influenced by social desirability, posing a limitation. Baker and Showalter (2018) Country: USA Practice setting(s): Did not specify aside from women’s health settings SU To understand smoking among women in rural Central Appalachia. Qualitative. Content analysis. Purposive sample. Rural nurses: n=15 Semi-structured small focus group and individual interviews. The study identified the themes: reasons for smoking, reasons for quitting, barriers to quitting, and perceptions of current interventions. It emphasized the significant influence of the rural social setting on smoking habits, including the presence of smokers in social networks and mixed attitudes towards smoking risks. Recognizing this strong social influence is crucial for effective women's health promotion in the area. The most notable study limit is the purposive sample. While efforts were made to select nurses from various counties and age groups, the study's university setting might have led to a bias in participant selection, potentially resulting in higher-than-average education levels among the nurses sampled. Beks et al., 2018 Country: Australia To explore the experience of rural nurses in managing acute mental Qualitative. Inductive descriptive approach Purposive sample. One-page demographic questionnaire; Semi-The study identified four key themes: "we are the frontline," "doing our best to provide care," "complexities of The sample composition depended on nurses' responses to the study invitation, 124 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Practice setting(s): Emergency department and urgent care centres MHSU health presentations within an emergency context. with principles of naturalistic inquiry. Rural generalist nurses: n=13 structured interviews. navigating the system," and "thinking about change." Rural generalist nurses primarily deliver care to mental health consumers in emergency departments and urgent care centers. Limited support is provided from local mental health clinicians and emergency service providers, often resorting to telephone triage after hours. Additional challenges include coordinating patient transfers to inpatient facilities and feeling inadequately supported. Regardless, nurses strive to deliver the best possible care, in spite of reporting skill and knowledge deficits. potentially overlooking novice nurses. Their inclusion could have provided valuable insights into assessing the efficacy of undergraduate mental health training for rural generalist practice readiness. Burch and Stoeckel (2021) Country: USA To explore the challenges rural school nurses face in Colorado. Qualitative. Descriptive phenomenological study. Purposive sample. Rural school nurses: n=9 Semi-structured interviews. Three themes were identified: (1) rural school nurses’ efforts to meet students’ extensive physical and mental health issues, (2) school Study limitations included a small, homogeneous sample from a limited, high-poverty area. Future research should 125 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Practice setting(s): Schools MHSU nurses struggle to help rural students in extreme poverty, and (3) communication challenges experienced by rural school nurses. involve qualitative studies exploring rural school nurses' roles and potential contributions, gathering perspectives from educators, school board members, and administrators. Cole and Bondy (2020) Country: Canada Practice setting(s): Nurse setting not specified MH To explore rural clinicians’ understanding of farmers’ mental health and well-being, current health services, and potential responses. Qualitative. Purposive and snowball. Rural mental health nurses: n=4. (and family physicians: n=5) Semi-structured interviews. This study included three main themes: 1) farming as a unique subculture; 2) farming involved both benefits and challenges for health; and 3) farmers rarely seek care. This study had a small sample size and its findings may not be applicable to other farmers in different regions. Cosgrave et al. (2018) Country: Australia To identify work challenges negatively affecting the job satisfaction of early career Qualitative. Purposive. Rural community mental health workers: n=25 Semi-structured interviews. The study revealed that factors diminishing job satisfaction among early career rural-based CMH professionals also impact all rural CMH professionals, with Recall bias may affect the career reflections of health professionals who work in CMH for 5 years, compared to their first few years. 126 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Practice setting(s): Community mental health MH community mental health (CMH) professionals working in rural Australia. Of this sample, rural registered nurses: n=6 greater impact in more remote areas. Early career professionals facing rural health challenges alongside sector-specific constraints experience compounded negative effects on job satisfaction. This likely contributes to the high levels of dissatisfaction and turnover among Australia's rural-based early career CMH professionals. This limitation was particularly notable for RA4 (remote regions) participants; hence the inclusion criteria were relaxed for the RA4 participants. Cree et al. (2021) Country: USA Practice setting(s): emergency departments MH To understand factors associated with whether United States (US) emergency departments (EDs) had a pediatric mental health care policy. Quantitative. Cross-sectional survey analysis. Purposive. Nurse managers reported whether their hospitals had a policy to care for children with social/mental health concerns (n = 3612). Analyzed data from the National Pediatric Readiness Project, a nationally representative cross-sectional survey of US EDs. Overall, pediatric mental health policies were in 46.2% of EDs. Urban areas had a pediatric mental health policy more often than remote (PR, 0.4; CI, 0.3–0.5), rural (PR, 0.7; CI, 0.6–0.7), and suburban (PR, 0.7; CI, 0.6–0.8) areas. The ED ability to provide mental health care may not be captured by the presence of a pediatric mental health policy. The survey questions lacked depth. ED policies may have changed since 2013. The study’s cross-sectional design limits causal or 127 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations directional understanding. ED managers may misreport the presence of ED policies. Crowther and Ragusa (2014) Country: Australia Practice setting(s): Community mental health MHSU To explore the effects of mental policy changes and the curtailment of mental health nursing education on the realities of working as a mental health nurse in rural and remote locations in New South Wales, Australia. Qualitative. Grounded theory approach. Purposive. Rural or remote mental health nurses: n=32. Focus groups: n=5. Findings indicated feelings of nostalgia and remorse about former (compared to current) mental health nursing. Nurses longed for past mental health hospital work and were uncertain about whether their knowledge and skills were sufficient for today’s mental health nursing environment. No limitations section. Mapping review authors noted that there was no demographic information included and this study was conducted in one region of Australia so may not reflect the experiences of nurses from other regions in Australia or worldwide. De Kock and Pillay (2016) Country: South Africa To fill knowledge gaps with regard to mental health nurse (MHN) human Quantitative. Data from 98% of South African PRPHCs: n= 160 Primary and secondary data analysis looking at MHN human resources in PRPHCs. The findings suggest a distressing shortage of MHNs in South Africa’s rural public areas. Only 62 (38.7%) of the 160 facilities employ MHNs, a total of 116 MHNs. Even though the findings could be interpreted as representative because 98% of the sample’s facilities participated in the 128 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Practice setting(s): primary health care centres. MH resources in South Africa’s public rural primary health care (PRPHC) settings. These MHNs serve an estimated population of more than 17 million people, suggesting that MHNs are employed at a rate of 0.68 per 100 000 population in South Africa’s PRPHC areas. audit, the results should be regarded as a guide for further, comprehensive enquiries. With the time elapsed since the start of the audit, the authors, while making every effort to maximise the inclusivity of facilities, cannot claim that an exhaustive list of health facilities was included because some facilities may have been added or removed by provincial departments. This limiting factor, together with the rural population’s calculation that was based on primary and secondary data collection suggests a tentative 129 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations interpretation of findings. De Kock and Pillay (2018) Country: South Africa Practice setting(s): primary health care centres. MH To provide a situation analysis of South Africa’s PRPHC mental health human resources and services. Quantitative descriptive. Data from n= 160 (98.3%) of South African rural PRPHC facilities. Primary and secondary data analysis looking at mental health human resources in rural primary health facilities, MH nurses (MHNs), clinical psychologists, MH medical doctors (MHMDs) and psychiatrists. Results indicate the following clinicians work in rural primary healthcare settings at rates per 100,000 people: MHNs (0.68), clinical psychologists (0.47), MHMDs (0.37) and psychiatrists (0.03). The following percentages of facilities do not have these clinicians employed or features: psychiatrists (96%), MHMDs (81%), clinical psychologists (64%), MHNs (61%), specialist MH outreach services (69%), MH multidisciplinary teams (78%). Despite auditing 160 health facilities (98%), the lack of clear provincial and national PRPHC documentation may have resulted in institution omissions. The absence of recent official records suggests caution in interpreting the population relying on these facilities, even though the calculation used primary and secondary sources. Dube and Uys (2015) Country: South Africa To determine the practices of primary health care nurses in the management of psychiatric patients in Mixed-methods. Purposive. Rural professional nurses: n=32 Rural staff nurses: n=15 Quantitative questionnaire to determine psychiatric nursing practice. The findings indicated that in 83.3% of the sites, treatments are not reviewed semi-annually; there were no local psychiatric emergency drug administration protocols; and psychiatric Patient’s satisfaction with the service were not evaluated at any of the study sites. 130 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Setting(s): primary health care clinics MHSU primary health care clinics in one of the rural districts in South Africa. Qualitative: semi-structured interviews with primary care nurses. Record review of patient records. patients did not receive medication education at any of the study sites. Etter et al. (2019) Country: Canada Setting(s): Indigenous community. MHSU To describe a community-specific and culturally coherent approach to youth mental health services in a small and remote northern Indigenous community in Canada's Northwest Territories, under the framework of ACCESS Qualitative. Community mapping design. Ulukhaktok, Northwest Territories (NWT) youth mental health services. Community mapping. The local team in Ulukhaktok identified gaps in youth programming and mental wellness services through community mapping. No limitations section. This study was conducted in one NWT region in Canada, and its process or findings may not be applicable to other regions or communities. 131 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Open Minds (ACCESS OM), a pan-Canadian youth mental health research and evaluation network. Gaffey et al. (2016) Country: Ireland Practice setting(s): Hospital and community mental health. MH To assess current knowledge and attitudes of Irish mental health professionals to the concept of recovery from mental illness. Mixed Methods. Descriptive survey design. Entire rural mental health practitioner population. Rural mental health practitioners: n=176 Of these, rural nurses: n=118 Descriptive survey: the Recovery Knowledge Inventory. When comparing recovery scores to Cleary & Dowling (2009), or comparing recovery scores to levels of experience, no significant differences were discovered. Improved recovery scores were associated with working in dual settings, training, and being a non-nurse. Training emerged as the strongest predictor of better recovery knowledge. The study was conducted in 2013, so the recovery knowledge and attitudes may have changed between that date and the study publication date. Additionally, there are likely other factors in explaining knowledge and attitudes toward recovery not considered in the regression model. Further, to prevent participant recognition from their quotes, qualitative analysis was conducted 132 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations without pairing the quotes with demographic information, and thus, prevented different demographic categories from being compared. Finally, since data were collected through self-reporting questionnaires, the potential for reporting bias exists. Gohar et al. (2020) Country: Canada Practice setting(s): Hospital and long-term care facilities. MH To identify and understand the factors associated with sickness absence among nurses and personal support workers (PSWs) through several experiences while Qualitative descriptive. Purposive. Rural (northern) nurses (Registered Nurses (n=6) and Registered Practical Nurses (n=4)), PSWs (n=5, and key informants (n=5). Focus groups. Four themes included: occupational/organizational challenges, physical health, emotional toll on mental well-being, and northern-related challenges. Staffing shortages were a key factor that led to sickness absences. Since this is a qualitative study, its findings may not be transferable to other regions, although other northern regions may face similar challenges. Biases may have been introduced by using thematic analysis. Not all informants could attend the focus groups, so their 133 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations investigating if there are northern-related reasons to explain the high rates of sickness absence. perspective may be missed. Happell et al. (2012) Country: Australia Setting(s): community mental health MH To identify the activities that nurses in community mental health services undertake. Qualitative. Purposive. Rural mental health nurses (n=38) from community (n=11), acute inpatient (n=17), or both (n=2) settings. Semi-structured focus groups. The main themes include: stigma of mental illness, barriers to accessing physical health care services, nurse adaptations under demands, and community and integration towards better overall health. No limitations section. Mapping review authors note that this study is from one region of rural Australia; thus the findings may not be generalizable to other rural regions globally. Jacob et al. (2022) Country: Australia Setting(s): emergency department (ED) To explore and understand rural ED nurses’ views on the daily experience and impact of violence, and its perpetrators. Qualitative. Phenomenology. Purposive. Rural ED nurses (n=14). Semi-structured focus groups. Violence was ongoing and significantly affected rural ED nurses. The nurses anticipate, tolerate, and have to manage violence in the workplace. The qualitative results may have limited generalisability. 134 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations MHSU Jahner et al., 2020 Country: Canada Setting(s): Acute care, primary care, community health, home care, hospice/palliative/end-of-life care, long-term care, mental health, other (e.g., nursing station, obstetrics, education) MHSU To explore the distressing experiences encountered by rural/remote nurses and their perception of organizational support. Qualitative. Cross-sectional design with thematic analyses. Purposive. Rural and remote nurses: n=3822 A pan-Canadian survey (with closed- and open-ended questions) of nurses in rural and remote practice. The three major themes related to rural and remote nurses experiences of distressing events included: involvement in profound events of death/dying, traumatic injury, and loss; experiencing or witnessing severe violence and/or aggression; and failure to rescue or protect patients or clients. The three major themes relating to organizational support included: feeling well supported in the work setting with debriefing and reliance on informal peer support; lack of acknowledgment and support from leaders on the nature and impact of distressing events; and barriers influencing access to adequate mental health services in Since data were collected via written responses, the depth of responses may have been limited, compared to data collection via interviews. 135 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations rural and remote practice settings. Jahner et al. (2022) Country: Canada Setting(s): acute care hospitals MHSU To explore how Registered Nurses (RNs) in rural practice deal with psychologically traumatic events when living and working in the same rural community over time. Qualitative. Constructivist grounded theory. Purposive and theoretical. Rural Registered Nurses (n=19). Semi-structured interviews. Participants experienced many trauma-related events and were mainly worried about these events impacting them lifelong. Participants coped by staying strong (i.e., being supported by others, finding internal strength, trying to let go of the past, and by being transformed over time), and this helped participants to weather future traumatic events. The sample did not include nurses who previously left the job or were on stress/medical leave related to traumatic events. The small sample size limits the results transferability. Nurses may have been triggered by talking about or processing traumatic events, although participants were informed of this risk beforehand, and provided support resources. Results may not be transferable to rural nurses who are not part of the community they serve, as this study explored rural nursing practice of nurses who were 136 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations integrated within their communities. Jansson & Graneheim, 2018 Country: Sweden Setting(s): Community mental health MH To describe nurses’ experiences of assessing suicide risk in specialised mental health outpatient care in rural areas in Sweden. Qualitative. Descriptive design; qualitative content analysis using an inductive approach. Purposive sample. Enrolled nurses: n=4 Registered nurses: n=8 Semi-structured individual interviews that were subjected to qualitative content analysis. The results indicated that the nurses experienced distress stemming from a sense of powerlessness. They voiced feelings of doubt and isolation, grappling with ethical issues and organisational challenges. Participants were chosen by colleagues, and interviewers had dual roles. The participant group uniformity presents a possible limitation. Nurses with less than 1 year of experience in assessing suicidality were omitted, yet their insights could have been valuable for a comprehensive understanding. Jones and Quinn (2021) Country: Canada Setting(s): Indigenous community SU To describe a buprenorphine-naloxone induction in the North. Qualitative Case report. Rural nurse involvement is described. Narrative case report. Case report about a 50-year-old female patient with opioid use disorder in a remote community. The article reviews this patient’s treatment options and access along with healthcare provider collaboration. No limitations section. Mapping review authors note that this is one case report and thus its generalizability is limited. 137 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Kadar et al., 2020 Country: Indonesia Setting(s): Community mental health. MH To examine the practice of mental health staff delivering mental health programs in community centers in one sub-district area in Indonesia; majority (88.5%) of staff surveyed were rural nurses. Quantitative. Audit to evaluate the current practice of mental health staff. Purposive sample. Rural nurses: n=23 Physiotherapist: n=1 Midwives: n=2 Surveys. The questionnaires were adapted from Mental Health Law No. 18 and Community Mental Health Nursing Program. While the majority of healthcare personnel adhered to governmental directives regarding mental health services, such as offering health education, early detection, counseling, monitoring pasung practice, medication compliance, and rehabilitation programs, this study did not delve into the specifics of their actions. It's possible that staff members lack adequate knowledge and skills in mental health care. None of the staff had undergone formal mental health training, and there were no comprehensive guidelines for their guidance. Moreover, community health centers faced constraints including limited staffing, funding, and facilities. No limitations section. Mapping review authors noted that this study did not specify information about the role of the rural nurses compared to the other healthcare staff. Health care workers (HCWs) from one region were included in the study; including HCWs from across the country would be more inclusive. 138 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Kenny & Allenby, 2013 Country: Australia Setting(s): Hospitals MH To examine issues that rural nurses face in the provision of psychosocial care in Victoria, Australia. Qualitative. Interpretive descriptive design with data analysis based on Attride-Stirling’s (2001) approach to thematic analysis. Snowball sampling; information was distributed through a chief nurse network who then held information sessions to recruit study participants. Rural nurses: n=22 Four Focus groups: two with six participants and two with five. Five main themes were identified: constructive relationships, professional isolation, multiskilling expectations, client interaction, and competing demands. The reality that rural nurses face for psychosocial care provision is reflected in the overarching theme of “Managing multiple roles, demands and relationships”. The study findings may not be transferable to other regions or the larger nursing workforce. Keugoung et al. (2013) Country: Cameroon Setting(s): Primary care. MHSU To describe the characteristics of suicide and assess the capacity of health services at the district level in Cameroon to deliver quality mental health care. Mixed-methods. Purposive. Rural nurses (n=15). Documentary review of medical archives, semi-structured interviews of relatives of suicide completers, focus groups of health committee members, A minority of the nurses (2/15) were able to name three or more depression symptoms and had awareness that depression is a risk for suicide. None of the nurses had any specific mental health training or supervision. No limitations section. Mapping review authors note that the sample size is small and this study is limited to one rural region of Cameroon, thus it may not be generalizable to other areas or true of other nurse populations. 139 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations and a survey of nurses. Kidd et al., 2012 Country: Australia Setting(s): Emergency department (ED) MHSU To explore the experiences of general nurses working in rural hospital settings, with regards to their ED responsibilities; part of the exploration included mental health practice. Mixed-methods. Two-stage approach. Questionnaire: Purposive sampling. Rural ED nurses: n=53 Focus groups: Convenience sampling. Rural ED nurses: n=17 First stage: Questionnaires (including five point likert scales and open-ended fields) and second stage: two focus groups, framed directly from the questionnaire results. The study found that nurses lacked confidence due to the irregular nature of their work and the diverse cases they encountered, leading to 'skills rusting'. They felt the need for diverse specialization but lacked confidence, especially in mental health, due to isolation and inadequate training. Although there are good emergency training programs for rural nurses, access is limited due to various constraints. No limitations section. Mapping review authors noted that this study was conducted within one rural region and may not be transferable to rural nurses in other regions. Lamba and Aswani (2012) Country: St. Kitts and Nevis Setting(s): hospital and To describe the burden of psychiatric disease and mental health services available on the Caribbean island of Nevis. Qualitative. Case Study. Hospital and clinic records, unpublished psychiatric case information, and experience of primary health Hospital and clinic record and report analysis; unpublished information pertaining to psychiatric case anaylsis; personal The island of Nevis’ mental health services are free, and include a psychiatrist and two psychiatric nurses (twice per week, from Saint Kitts) and local primary care providers (emergency, urgent, and inpatient care). Records to identify epidemiological and census data were of limited availability. 140 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations community health clinics. MHSU care providers (n=2). experience of primary health care providers integrated in the analysis. Depression, schizophrenia, and drug-induced psychosis were the most prevalent presentations. Link et al. (2019) Country: USA Setting(s): hospital MH To survey perinatal nurses’ self-efficacy in postpartum depression teaching, self-esteem, stigma and attitudes toward seeking help for mental illness. Quantitative. Cross-sectional, descriptive, correlational study. Convenience. Rural perinatal hospital nurses (n=38). Self-report survey. The results found that perinatal nurses’ postpartum depression teaching behaviors correlated to: postpartum depression teaching self-efficacy related to postpartum; supervisor social persuasion; prior teaching mastery; and vicarious experiences of observing peers teach about postpartum depression. This study was limited by the small convenience sample, and thus the findings may not be generalizable. There may have been significant difference in study response rate between perinatal nurses who did and did not respond to the survey. MacLeod et al., 2022 Country: Canada Setting(s): Acute care, primary care, To explore the characteristics and context of practice of registered nurses (RNs), licensed practical nurses (LPNs), Quantitative. Cross-sectional survey. Systematically stratified target sample. Regulated nurses in rural and remote areas: n=3822 Nursing Practice in Rural and Remote Canada pan-Canadian cross-sectional survey; Only a small percentage of nurses (9.8%) were mental health-only nurses, and those nurses were mostly RPNs. For nurses whom mental health was one part of their practice (mental health-plus), they The main limitations stem from the national survey's cross-sectional design, its broad scope, and the limited number of mental health-related variables in the 141 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations community health, long-term care, home care, hospice/end-of-life/palliative care, mental health, other (not specified); multiple practice settings MHSU and registered psychiatric nurses (RPNs) in rural and remote Canada, who provide care to those experiencing mental health concerns. included 24-item Job Resources in Nursing (JRIN) Scale and the 22-item Job Demands in Nursing (JDIN) Scale. typically worked in both hospital and primary care settings as generalists. Both mental health-only and mental health-plus nurses experienced moderate levels of job resources and demands. Over half of the nurses faced violence recently, especially LPNs. Nurses frequently commented on the difficulties in accessing specialized mental health services predominantly in Indigenous communities or remote regions. original survey tool. This analysis might have underestimated the proportion of rural and remote nurses delivering mental health care, as they may not have categorized 'mental health' as a distinct area of practice. McCullough et al., 2012 Country: Australia Setting(s): Remote areas, community health MHSU To identify and describe hazards within the Remote Area Nurse (RAN) workplace from the perspective of experienced RANs. Qualitative. The Delphi method. Purposive sample. Expert RANs: n=10 Panel nomination was based on extended length of practice as a The Delphi method: three rounds of questionnaires which progressively refined knowledge and opinion with the aim to reach consensus This study shows that RANs face diverse hazards from various sources, with environmental hazards complicated by their remote living and practice locations. Complex community relationships, lack of experience, and organizational support Bias may exist in the Delphi study panel selection. 142 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations RAN, geographical representation and active involvement in the RAN community. from the participants. contribute to increased violence risk. 'Major' or 'extreme' risks include clinic maintenance and security, patient care at staff residences, RAN inexperience, intoxicated clients with mental health issues, and a work culture tolerating verbal abuse. Management inaction and inadequate recognition of violence risks by employers are also significant hazards. Mendenhall et al. (2018) Country: Kenya Setting(s): primary care MHSU To investigate nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. Qualitative. Convenience. Nurses from three hospitals, public urban (n=20), private urban (n=20), and public rural (n=20). Semi-structured interviews. Nurses considered mental health services a priority and thought that integrating them into primary care could shield them from competing health concerns, financial obstacles, stigma, and social issues. While many nurses deemed this integration acceptable and viable, limited provider knowledge, particularly in rural regions, and a scarcity of Since this is a qualitative, cross-sectional design, there may be limited transferability about task-sharing in Kenya in general. 143 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations specialists, posed barriers. Mpheng et al. (2022) Country: South Africa Setting(s): Community health MH To explore and describe the views of healthcare practitioners on the aspects that hinder providing comprehensive care for mental healthcare users (MHCUs), the role players needed to execute comprehensive care and what can be done to improve comprehensive care for MHCUs in the community setting in one of the subdistricts of the North West Qualitative. Qualitative descriptive design. Purposive. Rural nurses (n=19) and medical doctor (n=1). Semi-structured interviews. Four major themes included: healthcare practitioners’ understanding of comprehensive care to MHCUs; barriers to comprehensive care to MHCUs; stakeholders needed for providing comprehensive care to MHCUs; and suggestions for comprehensive care improvement to MHCUs. The aim was to involve all members of the MDT in the study, but not all members (i.e., psychologists, social workers, psychiatrists, and other mental healthcare professionals) were available due to COVID-19 restrictions. Consequently, data collection only involved hospital-based members (i.e., professional nurses and one medical doctor). This situation posed a challenge, leading the researcher to revise the data collection method from focus group interviews to individual interviews 144 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations province (NWP), South Africa (SA) conducted over the phone. Nankivell et al. (2013) Country: Australia Setting(s): Hospital and community mental health MH To explore nurses’ views and perceptions to identify (1) orientation of nurses to human rights, and (2) access of consumers with serious mental illness (SMI) to general practitioner services. Qualitative. Purposive. Nurses from regional and rural settings (n=38). Focus groups. The study highlighted notable issues regarding service users' access to physical healthcare. Nurses seldom broached the topic of human rights, and when they did, it wasn't seen as a strategy to improve access to much-needed physical healthcare services for consumers with SMI. Two main factors contributing to poor access to physical healthcare services were identified: clinical and attitudinal barriers. Mapping review authors noted that this study is from one region in Australia and thus its findings may not be generalizable to other regions globally. Pattison-Sharp et al. (2017) Country: USA Setting(s): Schools SU To (1) describe the context within which school nurses encounter student opioid prescriptions; (2) assess school nurses’ Mixed-methods. Cross-sectional survey design with closed and Convenience. School nurses; urban (n=371) and rural (n=251). Online survey. A significant portion of school nurses (40.3%) had come across students with opioid prescriptions, yet only a small percentage (3.6%) had naloxone available for potential overdoses. A majority of school nurses The authors couldn't determine the exact number of school nurses who received the survey, so the true response rate remains unknown. Therefore, it's unclear how representative 145 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations preferences for training and student education; and (3) explore urban–rural differences in school nurses’ experiences and training preferences. open-ended questions. (69.9%), particularly those in rural areas, believed students would benefit from opioid education (74.9% vs. 66.6%, p = 0.03). Additionally, most school nurses (83.9%) expressed interest in receiving training related to opioids. the survey results are for the Carolinas or other states. This lack of data could pose a risk of selection bias. Moreover, coding bias may have been introduced from only one coder reviewed all qualitative responses. Peritogiannis et al. (2022) Country: Greece Setting(s): Mobile mental health units (MMHU) MH To explore the differences among two MMHUs, one being run by a university general hospital (MMHU UHA) and the other being run by a nongovernmental organization (MMHU I-T). Quantitative. Two-tailed z-test for independent proportions and t-test for independent samples. Purposive. Compared rural MMHU in Greece, which employ rural mental health nurses (n=7). Chart review of patient information from two rural MMHU. Staffing composition differences were found between MMHU UHA (i.e., more medical and nursing staff), and MMHU I-T (i.e., more psychologists, social workers and health visitors). For MMHU I-T, patients were significantly older than MMHU UHA patients (mean age 64.5 vs. 55.3 years) with more elderly patients receiving treatment (56.5% vs. 20%). Both MMHU provided home-based care to a similar The study results could inform clinical practice in rural areas, the findings may not generalize to other rural regions in Greece. Variations in resources and staffing levels among different MMHUs, including those in public hospitals and those run by NGOs, may affect the applicability of the findings. Additionally, certain aspects of care, such as patient symptoms 146 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations proportion of patients. For MMHU UHA, a significantly higher percentage of patients with schizophrenia attended it, whereas significantly more patients with affective disorders, anxiety disorders and organic brain disorders attended the MMHU I-T. and hospitalizations, were not addressed in this study. Ratter (2023) Country: Scotland. Setting(s): Schools MH To explore the experiences and perceptions of a small school nursing team of the support they receive to deliver emotional and mental health interventions. Qualitative. Rural or remote school nurses (n=4). Questionairre and semi-structured interviews. Peer support was seen as a key facilitator and training was also considered crucial, but time constraints hindered both. Additionally, limited access to support services for children and youth, coupled with a lack of recognition and understanding of participants' roles by others, added to the challenges of delivering emotional and mental health interventions. The limited sample size restricted the diversity of ages, experiences, and perspectives, thereby limiting the generalizability of the findings and the ability to draw conclusions. Although all participants were women, this reflects the composition of the school nursing workforce. 147 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Rieckmann et al. (2016) Country: USA Setting(s): Substance abuse programs MHSU To study American Indian and Alaska Native (AIAN) substance abuse treatment provider and program characteristics between urban and rural communities. Quantitative. Cross-sectional survey design. Stratified sample. Clinical administrators and other senior clinical staff from substance abuse treatment programs serving AIAN communities: n=192. Online or telephone survey. Rural programs were less likely to have nurses, traditional healing consultants, or ceremonial providers on staff, consult external evaluators, use strategic planning for program quality improvement, offer pharmacotherapies, pipe ceremonies, or cultural activities. They were also less likely to participate in research or program evaluation studies but more likely to employ elders as traditional healers, offer AA-open group recovery services, and collect data on treatment outcomes. Greater receptivity to EBTs was associated with larger clinical staff, presence of addiction providers, directors perceiving a gap in EBT access, and collaboration with stakeholders to improve service access. This study heavily depended on the reports of program staff, which may not fully represent the insights and experiences of all staff members. Programs that didn't participate could differ from those included. Cross-sectional non-experimental studies like this one lack the ability to analyze changes over time or factors influencing program, staff, and service delivery beyond association. 148 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations However, programs providing early intervention services showed lower openness. Searby and Burr (2021) Country: Australia Setting(s): Did not link the setting type to the rural nurse’s data. MHSU To explore the perspective of alcohol and other drug nurses about telehealth during COVID‐19, including rural nurses. Qualitative description. Purposive sample with maximum variation. Alcohol and other drug nurses: n=19 Semi-structured interviews. Study participants faced hurdles in transitioning to telehealth methods. Overcoming challenges such as perceived loss of therapeutic communication, assessing risks like domestic violence, and addressing the needs of marginalized consumer groups is crucial for telehealth to succeed in alcohol and other drug treatment. Nevertheless, telehealth proved to be a beneficial addition to current practices for nurses serving consumers in regional or remote areas, or for those who preferred this mode of service delivery. The sampling method used in this study resulted in a large number of participants from New South Wales, Australia, with no representation from other Australian states and territories. While workforce data indicate that most Australian nurses in alcohol and other drug settings are in New South Wales, the lack of representation and subjective nature of participants' experiences mean the findings may not represent all alcohol and other drug nurses across Australia. Similarly, despite 149 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations efforts to recruit from New Zealand, only one participant was from there, possibly due to poor engagement with professional organizations or ongoing COVID-related lockdowns. Singh et al. (2015) Country: Australia Setting(s): Mental health MH To investigate the extent to which mental health nurses employed within rural and metropolitan areas of Australia are affected by burnout. Quantitative. Cluster-sampling, cross-sectional study. Representative sample of the population framework. Rural and urban nurses: n=319 Survey: The Maslach and Jackson Burnout Inventory (MBI) and a demographic questionnaire. The MBI has 22 items designed to assess three aspects of the burnout syndrome: emotional exhaustion, depersonalisation and This study's findings show that mental health nurses in both urban and rural Australia experience burnout. Lately, job dissatisfaction due to work stress is rising among rural nurses. The findings are limited to mental health nurses in the four Australian states studied. Caution is advised in interpreting the results without a longitudinal study. Additionally, the use of self-report measures may pose limitations due to potential social desirability bias and self-disclosure concerns. 150 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations personal accomplishment. Stanisławska et al. (2015) Country: Poland Setting(s): Primary health care centres SU To show the problem of alcoholism in a rural area and the role of a family nurse. Quantitative. Purposive. Rural family nurses: n=50 Rural care recipients: n=100 Questionnaire. In the rural areas, men consumed alcohol more frequently than women. Most villagers understood alcoholism, knew how to assist addicted individuals, and were familiar with the concept of codependency. Family nurses in these areas took steps to promote health and address alcohol-related issues among their patients. They collaborated with other primary healthcare team members to ensure comprehensive care was provided. No limitations section. Mapping review authors noted that it was unclear what questions were asked and whether the questions gave sufficient depth to understand the nurse’s role in prevention, assessment, and treatment of alcohol use disorder. Stryker et al. (2022) Country: Guatemala To describe the experience of primary care nurses treating depression in Mixed-methods. Quantitative: Purposive. Survey of rural nurses: n=22 Cross-sectional survey with closed- and open-ended Guatemalan primary care nurses described culturally contextual depression symptoms, community-related socioeconomic factors To maintain confidentiality, this study didn't link survey responses to individuals or clinical locations. While 151 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Setting(s): Primary care MH rural Guatemala. descriptive statistics. Qualitative: thematic analysis. Focus groups of rural nurses: n=16 questions and focus groups. contributing to depression, and treatment preferences. Challenges in connecting patients to mental health care were noted due to limited referral options and privacy concerns. Nurses stressed the importance of community education on depression and the need for additional mental health resources to enhance their ability to identify and treat depression. responses were generally consistent, the design limited understanding regional differences' impact on the explanatory model of disease in Guatemala. Data collection occurred during two staff meetings, potentially missing perspectives of absent nursing staff. The study did not employ a validated burnout screening tool, and cross-cultural validation has not been done in Guatemala. Instead, a screening questionnaire was developed with input from bicultural WK staff members. The insights provided by nurses working for a private non-profit may not be 152 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations generalized to those in the Guatemala’s public health system. Sutarsa et al. (2021) Country: Australia Setting(s): N/A MH To understand whether there are spatial inequities of mental health nurses (MHNs) in rural and remote Australia Quantitative. Cross-sectional analysis of spatial distribution of MHNs per 100,000 people. Purposive. The National Health Workforce dataset (NHWDS) including local government areas (n=544). Analysis of the publicly available 2017 NHWDS. Our study illustrates the disparity in mental health nurse distribution between urban and rural/remote areas. No limitations section. Mapping review authors noted that this study may not reflect spatial inequities of other rural regions worldwide. Trop et al. (2018) Country: Mongolia Setting(s): Clinic or hospital MHSU To explore health care providers' perspectives on postpartum depression (PPD) in Mongolia. Qualitative. Purposive. Healthcare providers that work with urban and rural clients (n=15); included nurse-midwives (n=5), and a family clinic nurse (n=1). Semi-structured interviews and focus groups. Most providers acknowledged some basic knowledge of PPD but had limited experience with PPD patients. They primarily described signs and symptoms based on their own observations rather than patient reports. Providers generally viewed PPD as a complex condition influenced by obstetric, psychological, The data were gathered from a small sample of providers in Ulaanbaatar, limiting generalizability to other regions or countries. Research on rural providers' perspectives is warranted. Qualitative methodology limitations, such as group dynamics and 153 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations socioeconomic, and cultural factors. Traditional concepts of PPD, such as "sav khuurukh," were commonly cited. While providers had varied opinions on where women seek help for PPD, they generally agreed that patient-provider discussions are crucial for identification. However, such discussions are rare due to providers' lack of confidence, training, time constraints, and other barriers. social desirability biases, may have influenced responses. Focus groups comprised homogeneous groups of providers, with separate interviews for those with unique views. Different administrators led discussions, potentially affecting participant responses and inter-rater reliability. van Rooyen et al. (2019) Country: South Africa Setting(s): Primary healthcare facilities To explore and describe experiences of persons living with severe and persistent mental illness (SPMI) and those of their families in Qualitative. Descriptive, exploratory design. Convenience sampling to select the healthcare facilities and purposive to to recruit participants. Persons living with SPMI Unstructured interviews. Two main themes included primary healthcare access challenges and the inadequate mental healthcare provision. Originally, the plan was to conduct unstructured individual interviews at the homes of individuals living with SPMI and their families. However, some potential participants' homes in deep rural areas were 154 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations MH rural South Africa. (n=18) and family members (n=11). inaccessible due to lack of roads. As a result, the study was limited to accessible rural areas, potentially missing certain viewpoints from eligible participants. Wand et al. (2021) Country: Australia Setting(s): Emergency department (ED) MHSU To explore mental health liaison nurses' (MHLNs) experiences of working in the emergency department (ED) of two rural Australian settings. Qualitative. Purposive. Rural MHLNs (n=12). Semi-structured interviews. Participants highlighted several advantages of integrating MHLNs within the ED team. They also acknowledged some challenges related to changing thinking and practice and offered suggestions for enhancing mental healthcare in the ED. This evaluation only included two rural emergency settings and may not reflect the broader rural context. Further investigation is needed to determine the model's broader applicability, as its key principles and governance may not be suitable for all EDs. Whiteing et al. (2021) Country: Australia To delineate the practice of rural and remote nurses in Australia. Qualitative. Multiple case study design. Purposive. Rural and remote nursing documents (n=42), rural Content analyses of nursing documents and online questionnaires, and semi-The major themes included “a medley of preparation for rural and remote work”; “being held accountable”; “alone, with or without someone”; and Being qualitative research, the findings of this study may not apply to other regions in Australia or abroad. Participants were recruited 155 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations Setting(s): hospital, remote practice setting, community, multiple sites, other MHSU nurses: online questionnaire (n=75) and interviews (n=20). structured interviews. “spiralling well- being.” Despite various strategies, challenges such as isolation, stress, burnout, and organizational commitment persist for rural and remote nurses. Professional development courses and graduate certificates, while beneficial, have yet to alleviate these issues. through communication via Executive Directors of Nursing (EDoN), but the researcher was unsure if all RNs or only some facilities were contacted, potentially introducing bias. The code of conduct for nurses replaced several documents examined in phase I, and the effectiveness of the new code, focusing more on nurses' cultural practices, was not evaluated in this study, suggesting a need for future research. Another limitation is the lack of perspectives from different stakeholders, such as students, other nurses, and managers, which 156 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations could be addressed in future research. Wideman et al. (2020) Country: USA Setting(s): Maternal child health home visits MHSU To explore how family and community characteristics affected rural nurse home visiting. Qualitative. Case file review. Purposive. Rural families: n=433 Member checking with rural nurses: n=3 Content analysis of rural nurse home visitation files supplemented by quantitative descriptions of the study counties and member checking. While concerns of families served, such as mental health, may not be specific to rural areas, challenges in accessing resources and meeting various needs were distinct. Nurses adjusted engagement and service strategies accordingly. The study relied solely on nurse case notes, which may vary in content, potentially impacting the coding process and the emergence of themes. Interviewing families or using validated diagnostic instruments could have provided additional insights into mental health disorders or substance abuse, but these were not employed. The study was conducted in three counties, limiting the generalizability of the findings, as rural demographics can differ significantly. Additionally, the data are nearly a decade 157 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations old, which may affect their relevance. Wilson and Usher (2015) Country: Australia Setting(s): N/A MH To understand new ways that young rural people with mental health problems could be helped at an early point in their mental health decline. Mixed-methods. Convenience sampling for the survey, purposeful for the interviews. For survey: Rural participants from diverse backgrounds: n=81 For interviews: rural people with personal experiences of caring for, a young person with a mental health problem or having been the recipient of care themselves as Cross-sectional survey and semi-structured interviews. This study shows that rural individuals are generally open to seeking mental health care, and rural nurses are suitable for providing initial care to young people. The survey had a small sample size, with fewer males than females participating. The questionnaire design also posed limitations as it aimed to gather descriptive and open-ended responses, limiting statistical analysis. Additionally, no test-retest was conducted on the pilot survey. Recruitment was convenience-based and purposeful in both phases of the mixed-method study, as random sampling is not always feasible in human research. 158 Authors, Country, & Setting Purpose Research Design Sample Data Collection Studies Main Findings Limitations a young person: n=20 Wolf and Delao (2013) Country: USA Setting(s): emergency department (ED), critical access hospitals MH To identify the educational needs of emergency nurses in rural and critical access (limited service) hospitals. Qualitative. Qualitative descriptive design. Purposive. Rural or critical access nurses: n=33 Focus groups. Participants highlighted the need for additional education in caring for critically ill patients, those who have had bariatric surgery, geriatric patients, individuals with traumatic injuries, and those with mental health issues. Themes included educational isolation and resource scarcity. Study limitations include a self-selecting sample and the influence of the focus group format on participants' responses, thus potentially limiting the generalizability of the findings to all emergency nurses in rural or critical access hospitals. 159 Appendix D Semi-Structured Interview Guide Main Questions Probing Questions 1. To start, could you tell me about your current nursing role? [rural people] a) How long have you practiced in this area? [rural people] b) What are the age ranges of the children and/or youth you typically work with? [rural people] c) How do you work with children and youth? [rural people] d) What setting or settings do you work in? [community] e) Could you describe your community? [community] a. What makes your community rural? [place: rural context] 2. What are some examples of child or youth mental health or substance use needs or experiences you see in your practice? [rural people] a) Do you notice any patterns or trends in the past few years, and if so, what do you notice? [community, rural people] a. (If they answer about mental health, ask about substance use after and vice versa). b. (If they answer about one age group, e.g., younger children, ask about other age groups, e.g., youth). 3. Tell me about how you respond to these MHSU care needs that your rural clients present with? [community, rural people] a. What helps you respond to or provide this care? b. What are some of the challenges that you encounter when trying to provide this care? c. Tell me about your experiences or thoughts on harm reduction in your practice? 4. Tell me about your opportunities to collaborate with other sectors in your work with MHSU care? [community] a. Could you talk about a time when you were involved in a significant incident regarding child and youth MHSU care, and how other people in the community responded to the work you were doing? [community] 5. How do you see the social determinants of health at play with child and youth MHSU? [Place: rural context; larger society] a. In your practice where do you see inequities, and how do you address them or how do you wish you could address them? b. How do you see children and/or youth’s identities impacting their MHSU experiences? c. What is the impact of living rural on these social determinants of health regarding MHSU care? 6. I’m using this next question so that other nurses can understand a day in the life of a rural community nurse a. What defines the complex and important role of a rural community health nurse working with child and youth MHSU? 160 Main Questions Probing Questions who works with this population. 7. If you could wave a magic wand and change anything to improve this type of care, what would this look like? 8. That was the end of the formal questions. Is there anything we missed or anything else you would like to share about your experiences? 161 Appendix E Recruitment Materials 162 163 164 165 166 167 168 Appendix F Consent Form Study Title: NURTURE: the vital role of Nurses for Understanding and Responding To the Unique Rural mental health and substance use Experiences of children and youth Study Team: Principal Investigator: Dr. Elizabeth Keys, Faculty of Health and Social Development, UBC Okanagan. Phone: 250-807-8344; email: elizabeth.keys@ubc.ca Supervisory Committee Member: Dr. Nelly Oelke, Faculty of Health and Social Development, UBC Okanagan; email: nelly.oelke@ubc.ca Supervisory Committee Member: Dennis Jasper, Faculty of Health and Social Development, UBC Okanagan; email: dennis.jasper@ubc.ca MSN Student researcher and primary contact: Sage Thomas, Faculty of Health and Social Development, UBC Okanagan; email: sathomas@mail.ubc.ca Purpose of the study: This study forms part of the requirements for the Master of Science in Nursing degree, thesis project. This study will explore the experiences of nurses who work with rural children and youth in community settings, specifically looking at mental health and substance use care in the rural context. We will also look at what can be learned from these nurses about this type of nursing care. Study Procedures: After completing this consent form on the Qualtrics website, hosted on Canadian servers, you will be contacted by email to schedule an interview. Before the interview starts, you will be asked to verify your identity by showing your ID so that the researchers can confirm you have 169 active registration on BCCNM’s nurse verification site. Then, during the interview you will be asked about the care you provide children and youth in rural community settings. Specifically, you will be asked about any mental health and substance use care that you may or may not provide. We will use UBC-hosted Zoom to conduct your interview, which may last up to 60 minutes, and potentially longer. Interviews will be recorded and saved using servers located in Canada. The interview will be audio and video recorded and transcribed, and the video portion will be deleted immediately after the interview. The student researcher will listen to the audio file and review the transcription to ensure it is accurate. All files will be saved in a password-protected location on UBC servers in Canada. Study Results: The information you provide will be used to write a thesis, at least one manuscript for publication in a peer-reviewed journal, one or more conference presentations, a plain language summary, an infographic, and a video. Results may also inform nurse training, professional development, nursing standards of practice, competency updates, and practice changes for rural community health nurses. If you have indicated that you want a copy of the results, a plain language summary and a copy of the publication(s) will be emailed to you within one month of publication. Thesis projects are publicly available on the internet via cIRcle at: https://circle.ubc.ca/ Will you be paid for participating? You will be given a $40 e-gift card as an honorarium via email. Your email will be kept separate from your study data, and we will delete your email after you receive your gift card. 170 Potential Risks and Benefits of the Study: There are no anticipated risks associated with participating in this study. If you feel emotional distress during the interview, we will talk with you about mental health resources that may be available (e.g., primary care provider, mental health clinician) and provide a crisis line number: (no area code) 310-6789. There are no direct benefits to participation in this research, although participation could be used as a way of meeting the British Columbia College of Nurses and Midwives (BCCNM) RN Professional Standard 2: Knowledge-based Practice, research competencies (British Columbia College of Nurses and Midwives, 2023). Information collected from this study will start to fill the knowledge gap about rural child and youth mental health and substance use nursing in community settings. Confidentiality: All participants' identities will be protected. You will be assigned a pseudonym and only the pseudonym will be recorded in the interview notes and used in the final report that will be written by the student researcher. We will use quotes but participant names and organizations will not be associated with the quotes. Any potentially identifying information (e.g., name of a small town) will be redacted and no identifying information will be included in any reports. Results will be shared only in aggregate form. Audio recordings and transcripts will be transferred to a password-protected UBC Okanagan secure server. All data will be kept within this secure server. Data files will only be available to the study investigator, supervisory committee members, and MSN student researcher for analysis. Once transcripts are verified, audio files will be deleted. We will only use pseudonyms in the transcripts. De-identified data will be stored securely for five years after publication in a password-protected folder on the UBC Okanagan secure server and on a secure, encrypted 171 external hard drive in a secure UBC Okanagan office. Data will be destroyed five years after the results are published. Can you say “No”? Your participation in the study is completely voluntary and you may choose to stop participating until data analysis is started, for any reason, if you so decide. In the event you withdraw from the study, all associated data collected will be destroyed wherever possible. We will not be able to remove data once data analysis has begun, but we will not use quotes from your data. Who can you contact if you have questions about the study: If you have any questions or desire further information with respect to this study, you may contact the student researcher or principal investigator. Contact information is provided above. Who can you contact if you have concerns or complaints about the study: If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Services toll-free at 1-877-822-8598 or the UBC Okanagan Research Services Office at 250-807-8832. It is also possible to contact the Research Complaint Line by email (RSIL@ors.ubc.ca ). Please reference the study number H23-00823 when calling so the Complaint Line staff can better assist you. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from this study at any time. Participation will not impact your employment. Checking the boxes below indicates that you have received a copy of this consent form for your own records via the downloadable consent form link and consent to participate in this study: being interviewed about rural child and youth mental health and substance use nursing. 172 ❑ I agree to participate in this study. I consent to my interview being recorded for the purpose of collecting data. ❑ Yes ❑ No ❑ I do not agree to participate in this study. Name:____________________________________ Date:_____________________________________ If you have consented, you will be contacted by email within 4 business days to schedule an online interview. Findings: ❑ Please send me a summary of the study findings to my email when the study is completed. ❑ I do not wish to be contacted about the study findings. Please provide us with an email address you would like to be notified about the study results. Participant email 173 Appendix G Child and Youth MHSU Resources as Described by Rural British Columbia (BC) Nurses Type & Name of Resource Description Contact Information Immediate Client, Family, or Care Provider Virtual Support 310-Mental Health Emotional support and information line. Call (no area code) 310-6789 https://helpstartshere.gov.bc.ca/resource/310-mental-health-support Kids Help Phone 2/7 e-mental health service. Text CONNECT to 686868 Call 1-800-668-6868 https://kidshelpphone.ca/ Kuu-Us Crisis Line Society 24/7 Indigenous crisis line. Child and youth line: 250-723-2040 www.kuu-uscrisisline.com Youthspace Crisis and emotional support chat service. https://youthspace.ca/ MHSU Information Anxiety Canada Self-help resources, programs and services for children, youth, adults and educators on anxiety. https://www.anxietycanada.com/ BC Association for Living Mindfully (BCalm) Non-profit society dedicated to education, research and advocacy around the benefits of mindfulness. https://www.bcalm.ca/ Canadian Mental Health Association Mental health information, education, and support. https://cmha.ca/ Drug-checking resources Free and confidential services for finding out https://helpstartshere.gov.bc.ca/substance-use/harm-reduction/drug-checking 174 Type & Name of Resource Description Contact Information what’s in someone’s substance. Mail in drug-checking service: https://getyourdrugstested.com/canada-wide-drug-checking-by-mail/ Families for Addiction Recovery Support for families who have a child with substance use challenges. 1-855-377-6677 www.farcanada.org Foundry A province-wide network of integrated health and wellness services for young people ages 12-24. https://foundrybc.ca/ Here to help MHSU information. https://www.heretohelp.bc.ca/ Kelty Mental Health MHSU systems navigation, peer support, and resources. https://keltymentalhealth.ca/ Moms stop the harm Youth and family substance use resources. https://www.momsstoptheharm.com/youth Now Matters Now Information and support for navigating suicidal ideation. Nowmattersnow.org Toward the Heart Substance use harm reduction information including online naloxone training. https://towardtheheart.com/ Trans Care BC Support for transgender people and their families. http://www.phsa.ca/transcarebc/ Nursing Practice Resources Brain Story Training Alberta Wellness Initiative. Training on the neurobiological effects of trauma. https://www.albertafamilywellness.org/ training/ Compass Mental Health Clinical consultation, support, and education for care https://www.compassbc.ca/ 1-855-702-7272 175 Type & Name of Resource Description Contact Information providers related to BC children and youth (0-25) living with MHSU concerns. compass@cw.bc.ca HEADSS Assessment Youth psychosocial assessment. http://www.bcchildrens.ca/youth-health-clinic-site/documents/headss20assessment20guide1.pdf HEARTSMAP program Psychosocial assessment and management tool for children and youth, for use in emergency department and community settings. https://openheartsmap.bcchr. ca Provincial Opioid Addiction Treatment Support Program Opioid prescribing education and training program. For NPs, RNs, RPNs, and physicians. https://www.bccsu.ca/provincial-opioid-addiction-treatment-support-program-poatsp/ UBC Substance Use education modules Addiction care and treatment online modules https://elearning.ubccpd.ca/enrol/index.php?id=164 176 Appendix H The Framework Title: Knowing the Rural Community: A Framework for Nursing Practice (The Framework) Creator: Pavloff et al. (2022) Source: Rural and Remote Health The Framework is protected under the Creative Commons license, which allows for people to use it without prior permission; see screenshot below from Rural and Remote Health. 177
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Keys, Elizabeth M.
The NURTURE study : the vital role of nurses for understanding and responding to the unique rural mental health and substance use experiences of children and youth
Text