The role and activities of the Traveller mental health liaison nurse: Findings from a multi‐stakeholder evaluation

Irish Travellers are a minority ethnic group within the Irish state with a distinct culture and set of traditions. Travellers experience mental health inequalities, high rates of mental ill health, and structural and individual barriers to mental health supports. A Traveller Mental Health Liaison Nurse (TMHLN) was introduced in a healthcare region in Ireland to provide greater mental health-related support to Travellers. This paper presents a description of the TMHLN role following a multi-stakeholder evaluation. The research design was descriptive qualitative and the findings are reported using COREQ criteria. Thirty-four key stakeholders were interviewed individually or as part of focus groups. Thematic analysis generated two broad themes: the role context, and the specific activities of the role. Mental health nursing experience and understanding of local issues and services were key, as was use of language, building trusting relations, creating the metaphorical, and having the physical, space for working. Specific activities involved in-reach and outreach work, including one-to-one mental health support provision, delivery of education/training sessions to Travellers and service providers, (re)establishing links to specialist services, integrated and interagency working, and promoting cultural competency. The findings set out a role with a greater emphasis on the use of recovery technologies, having an emphasis on psychosocial interventions and self-care, and less focus on biomedical technologies, signs and symptoms, and clinical outcomes. This study contributes to knowledge on the role of a MHLN as this relates to working with marginalized minority groups.


INTRODUCTION
Irish Travellers were formally recognized in 2017 as a distinct ethnic group within the State, but have, for centuries, been an indigenous minority group in Irish society with a distinct language, value system, and customs and traditions (Abdalla et al. 2010;Daly 2017). The 2016 Irish census recorded 30 987 Irish Travellers, representing 0.7% of the general population, and 8717 Traveller households (Central Statistics Office 2017). Poor mental health has long been an issue for the Traveller Community, an issue reported by Travellers to have worsened during the recent years of austerity (O'Mahony 2017).
Despite a lack of recent Irish prevalence data on mental health issues among the Traveller Community, studies on Traveller/Gypsy 1 [mental] health, not only in Ireland, but also in the UK, found up to two and a half times higher rates of reported poor mental health among samples of the Traveller/Gypsy population compared to samples of the general population (Abdalla et al. 2010;Goward et al. 2006;McGorrian et al. 2013;Parry et al. 2004;Van Cleemput & Parry 2001). Suicide accounts for 11% of all deaths within the Irish Traveller Community, which is six times the national average (Abdalla et al. 2010). Inequalities in income, health, educational attainment, and employment between Travellers and the general population are stark (Brady & Keogh 2016; Central Statistics Office 2017; Watson et al. 2016). Travellers can experience poor living conditions, often living in overcrowded, sub-standard accommodation, and/or sites, that lack basic facilities and amenities (Watson et al. 2016). Extremely negative attitudes towards Travellers have been found in the general public in Ireland (Watson et al. 2016), and Travellers have been subjected to discrimination in the areas of education, employment, housing, healthcare provision, media reporting, and decision making (Hammarberg 2008). Issues more local to Travellers lives that impact on mental health include changes in family structure and rituals (Watson et al. 2016), gender roles and responsibilities (Abdalla et al. 2010;Hodgins et al. 2006), and age (Pavee Point 2015).
Engagement with mental health services by Travellers tends to occur in times of emergency or crisis rather than as a part of routine care (Abdalla et al. 2010;Bergin, Wells & Owen, 2017;Hodgins et al. 2006). Barriers to accessing mental health services are both structural and individual. Barriers at a service level include a lack of cultural competency among staff (Carew et al. 2013) and institutional racism (Van Hout 2010). Travellers have reported negative experiences of mental health service use including being treated unfairly, not being understood by health professionals (Abdalla et al. 2010;Watson et al. 2016), dissatisfaction with the quality of care received (Watson et al. 2016), and a general distrust of services (McFadden et al. 2016;Ireland's Health Service Executive 2015). Service gaps have been identified, particularly in relation to a lack of Traveller specific mental health services for young Travellers in Ireland (Pavee Point 2015). A lack of knowledge of existing services among Travellers (Pavee Point 2015) and the stigma attached to mental distress within the Traveller Community are also significant barriers to seeking service support (Van Hout 2010; O'Mahony 2017).
Existing community Traveller health and well-being services in the study healthcare region of Ireland collectively recognized the need for targeted mental health interventions, a more accessible route to mental health services, and wider services and supports for Travellers. To that end, a Traveller Mental Health Liaison Nurse (TMHLN) role was conceptualized, funded, and actioned. The remit of the TMHLN aligned with the local area health strategic plan (Ireland's Health Service Executive 2015) where its goals relating to Travellers were to, increase access to mental health services through referral and signposting; help alleviate fears and anxieties that Travellers may have about accessing mental health services through information and knowledge exchange; build the Traveller-related cultural competency of service staff, and; reduce the stigma and shame Travellers experience about using mental health services (Ireland's Health Service Executive 2015;Keogh et al. 2020). There is a dearth of literature on the Mental Health Liaison Nurse role for marginalized minority groups. Research was commissioned to evaluate the role of the TMHLN and make recommendations for future role sustainability, development, extension, and expansion. The aim of this paper was to discuss the findings from the evaluation of the role and activities of the TMHLN as found in this multi-stakeholder context. Service user perspectives of the role of the TMHLN from the same evaluation are published elsewhere (Keogh et al. 2020).

METHODOLOGY
A qualitative descriptive approach was used in this research. Doyle et al. (2019, p. 1) state that these designs have an 'inherent simplicity, flexibility, and utility in diverse healthcare contexts'. Constructivist in orientation, the aim is to generate data on the 'who, what and where of events and experiences' from a subjective perspective (Kim et al. 2017, in Doyle et al. 2019 3), providing a broad insight into little known about phenomena (Doyle et al. 2019).
In recognition of the ethical considerations necessary for undertaking research with a marginalized minority group, a participatory approach to inquiry was chosen (Brady & Keogh 2016;Brown & Scullion, 2009;Wallerstein & Duran 2010). A research steering committee was established, which contributed to the cultural congruency of the research design. A peer researcher from the Traveller Community was also engaged for congruency purposes, and to assist with participant recruitment and data collection. Reporting here adheres to the COREQ criteria (Tong et al. 2007).

Data collection
The participants were recruited by the researchers through purposive sampling, using individual interviews and focus groups for data collection. An initial interview with the TMHLN took place to gain insight into the role and from that a list of key stakeholders who were familiar with the role was identified (n = 34). An email was sent to (TMHLN and evaluation steering committee identified) key stakeholders by a gatekeeper informing them of the evaluation and inviting them to take part. Stakeholders were advised to contact the researchers directly if they were interested in taking part. The data collected focused on identifying the role of the TMHLN and the perceptions of that role from these key stakeholders (Table 1). Topic guides were designed in collaboration with the steering committee. Data were collected by telephone or face-to-face in participants' workplaces. Interviews and focus groups were 30 min to an hour long and were audio-recorded. The interviews focused on the role and activities of the TMHLN as experienced by the key stakeholder including specific examples of how the TMHLN supported Travellers within that specific context. The TMHLN was also a key informant and several follow-up interviews and phone calls were undertaken to understand the evolving role. The interviews with the TMHLN focused on gaining a deep understanding of her role and activities with a specific emphasis on the strategies she used when working with Travellers and their theoretical underpinning. Interviews were conducted over a 3-month period, from January to March 2018.

Data analysis
Qualitative data were analysed using thematic analysis guided by Braun and Clarke's (2006) analytical framework. Interviews and focus groups were transcribed verbatim, anonymized and given a key code. The data were coded, and themes and relationships were identified. The computer software package NVivo 12.0 was used to assist in the management of the analysis process.

Ethical considerations
The study received ethical approval from the local Health Services Executive ethics committee dated, 6 November, 2017. The researchers adhered to national and international good practice guidelines, including the Code of Professional Conduct and Ethics for Nurses and Midwives (Nursing & Midwifery Board of Ireland 2014). Both written and verbal consent was obtained before interviews. The voluntary nature of participation was emphasized throughout the data collection process and participants were informed that they were free to withdraw from the study at any time without fear of penalty.

RESULTS
The results are presented under two broad themes (i) the wider context of/for the role, and (ii) Traveller Mental Health Liaison Nurse Activities.
Wider context of/for the role While a job description for the TMHLN was drawn up at the outset, the person was given considerable scope to develop the role in a responsive way. This allowed for flexibility in role development informed in the process of relationship building with the Traveller Community and healthcare area agencies and services. The TMHLN had extensive experience both as a Mental Health Nurse employed in acute mental health and of working in the community, specifically with families and disadvantaged groups, including Travellers, and of interagency working. The title of 'Wellbeing Nurse' emerged for the MHLN role, because of the negative connotations that use of the title of mental health nurse might have for Travellers, and to better reflect the broad and preventative nature of the role. In addition, the title was felt to be important for distinguishing the MHLN from the existing Traveller Community nursing service. It was decided that the TMHLN would not wear a uniform, again with a view to disconnecting the role from signifiers associated with mental health services, and the barrier that this might create.
Travellers know me as the Wellbeing Nurse, and it is important that they are not confused between my role and the PHN, which can happen at times. [TMHLN] Building trust and creating relationships with the traveller community In recognition of the historically fragile relations between Travellers and mainstream services the TMHLN invested considerable time in building relationships and establishing trust. The TMHLN described this as a learning process which was fundamental to successful engagement with Travellers. It was noted that developing trust was greatly assisted through introductions made by established service providers such as Traveller Community Health Workers (TCHW) 2 and the Men's Health Workers 3 . Some of these service providers were also members of the Traveller Community, a factor that played a crucial part in fostering trust. This was evident in that Travellers taking part in the study linked their trust in the TMHLN to the trust they had in the wider Traveller support infrastructure.
In the area of mental health, Travellers are on a journey, and I am on this journey with them. I am pioneering something completely new to the Traveller Community. I am learning as I go and have learned so much. I am doing clinical work and also education and mental health promotion. [TMHLN] The importance of metaphorical and physical space for working The TMHLN highlighted how trust building between Travellers and the TMHLN was an ongoing process, rather than 'a quality achieved'. This was reported as being at the core of the creation of a metaphorical space for working between the TMHLN and Travellers. The prior work experience of the TMHLN was crucial as having knowledge of the complex issues that can impact on Traveller mental health equipped the TMHLN with an awareness for framing and informing her approach to working.
Travellers often present in crisis and need practical help and support, e.g. suggesting that they go to the doctor. That can be simple enough for me or you, but sometimes it can be a challenge for Travellers. Travellers may not have a medical card or a GP. They may not feel comfortable to arrange an appointment or know what to tell the GP when they get there. [TMHLN] Physical space for working with Travellers was also highlighted as crucial. Engaging Travellers was found to be easier in one of the two study regions, where many already utilized a community centre, and its services, and therefore Travellers were more likely to access the TMHLN at this site. Also, access through a busy community centre appealed to Travellers' wish for privacy. Attending the centre could be attributed to a wide range of reasons, thus providing a degree of confidentiality for people attending the mental health service.

Traveller mental health liaison nurse activities
In-reach and outreach activities The activities of the TMHLN involved both in-reach and outreach work. In-reach activities comprised creating links with Travellers already attending or involved with the Traveller Health Projects in the region. Outreach work involved establishing links with Travellers not connected to these health projects. Encouraging and supporting links to mainstream primary care or mental health services were primary objectives. Prevention work was central, offering advice and support to individuals for managing current stressors, and in making referrals, re-establishing or maintaining links made to mental health services.

Mental health promotion sessions -Traveller wellbeing groups
The TMHLN worked with Travellers through already established Traveller Wellbeing Groups in the regions. A themed and flexible approach was taken here, informed by the changing needs of attendees, sometimes influenced by upcoming stressful events; Christmas being one example. In recognition of the fact that Travellers attending the groups might be dealing with multiple stressors, the workshops were used as a space to relax by practicing mindfulness, engaging in craft making, relaxation techniques, and other shoulder to shoulder interventions. Facilitated this way, the groups provided a space for the delivery of well-being messages inspired by an Ireland Health Services Executive campaign entitled 'Little Things'. 4 Mental health education was offered, through examination of the topic of mental health and how this linked to a more holistic understanding of well-being incorporating physical and mental health. Methods/tools used in the delivery of sessions included; repetition, particularly for meeting concentration or literacy needs; the use of visual images to overcome literacy issues; and short sessions, all with a view to creating accessible and inclusive spaces.
I run wellbeing themed workshops at the project and on the [caravan] sites. I try to pick a relevant topic, e.g. 'surviving the Christmas season' or 'managing stress over the school holidays'. It is focused on a few simple messages and practising a little bit of mindfulness during the workshop. [TMHLN] One-to-one sessions The TMHLN role involved the provision of one-to-one sessions. Travellers both self-referred and were referred from sources including supports/services and family members. One-to-one sessions occurred in community centre settings and/or at the Travellers home. Sessions began by setting out the parameters of the TMHLN remit, a discussion about confidentiality and the legal limitations of same, the rights of the person in terms of the records being generated, and verbal or written consent agreed on that basis. Having time for engaging in these discussions was reported by the TMHLN as being crucial in the work of trust building between parties and a necessary precursor to offering interventions and/or onward referrals. One-to-one sessions involved undertaking a needs assessment, using an informal approach, underpinned by the use of active listening. The TMHLN role required a capacity to respond to individuals presenting in crisis, often with multiple co-existing issues. Depending on the context and presenting needs, the sessions remained as discussions between the TMHLN and Traveller, or the suggestion of, and support for, onward referral would be offered. When a woman comes to meet me, I will listen to her worries and provide support. Sometimes I am limited as to what I can do. I aim to help this woman to problem-solve and identify what she needs at that moment in time. I can signpost on when that is required also.
[TMHLN] A brief intervention can work well for some and can de-escalate issues and help to problem-solve, which can often be sufficient. [TMHLN] A range of interventions were offered in these sessions including listening and support, Wellness Recovery Action Plan (WRAP), self-care support, brief intervention, support for (re)linking to mental health services, referrals to GP and community support, and advocacy. Responses were informed by the issues of individuals presenting, including housing, relationships, addiction, bereavement and loss, and mental health issues. A 'wrap-around-approach' was the overarching style used by the TMHLN. This approach draws inspiration from solution-focused interventions, family work, and recovery-oriented approaches with an emphasis on Wellness Recovery Action Planning (WRAP) (Copeland 1997). Support strategies use was eclectic, not only in terms of drawing from the mix of different approaches but also in terms of choosing strategies from within any single approach, decided upon based on presenting individuals' needs. Notably, this work came with challenges in terms of service capacity, and Traveller willingness to engage. The work of the TMHLN extended beyond the individual to include work with families, drawing on some of the skills of family therapy (without being 'family therapy' per se). Support provided ranged from once-off sessions, up to, at the time of the study, two years.

Integrated working
The TMHLN role included integrated working with existing Traveller Health Projects (THP) in the area, often around the filling of a gap in mental health service provision and service access they felt existed. This was not only a 'future appointment' referral option for the Traveller Health Project, but also, on the spot over the phone support and advice in the event of Travellers presenting in crisis. In addition to this, the knowledge of the wider range of services provision in the region that the TMHLN brought to the role was identified as being particularly helpful for existing service providers that had struggled to make sense of this landscape. Mental health education/training for service provider use The TMHLN role had a knowledge sharing component. For example, workers in the THP reported gaining skills in the delivery of preventative health messaging, from the TMHLN, which they used in their own provision of services. In addition, the TMHLN role provided service providers with WRAP training, as well as support to service providers through the facilitation of mindfulness workshops.
The keeping yourself well, working on . . . all the things that keep yourself well, the food, sleep, linking to people, relaxation, walks. . . . . . all the different ways of maintaining your health. So, I've learnt an awful lot of that [from the TMHLN]. So,. . . I could give some of those messages now myself.

Links to specialist mental health services
Key also for the TMHLN role was supporting the creation, (re-)establishment, and maintenance of links to specialist mental health services. This involved supporting referrals for Travellers who required more specialist medical intervention, usually done through the persons' general practitioner.
Her key role is about signalling and signposting people who are not currently in the mental health services. . . and who require inputs from GP's from primary care and from the [TMHLN] herself. For those people who need more and who need a secondary specialist, mental health services, it's about signposting and directing those service users into the sector of mental health services, which is us. [Key Stakeholder 22] Much of this work, for the TMHLN, involved support around appointment making and attendance at an individual level, which was a point in the interface between specialist services and Travellers where links were often found to break down. In addition, the TMHLN provided support for following up on mental health service consultation recommendations. This occurred at an individual level, and through referral to the Traveller Wellbeing Groups in the regions. Feedback from specialist mental health services stakeholders suggested that this was working well where referrals through the TMHLN were reported as being appropriate and there was a general sense that service access and provision was operating more smoothly.

Widening services provision framing
Another aspect of addressing the barriers that existed between Travellers and mainstream/specialist mental health services involved the championing of Travellers by the TMHLN in ways that helped services to better understand Traveller culture, and service barriers. One vehicle for this work was contributions by the TMHLN on diversity and Traveller culture to multi-disciplinary team meetings, inclusive of specialist mental health services. The belief was that greater knowledge of Traveller culture within the services can inform how mental health services can be made more accessible to the Traveller Community.

Interagency working
The TMHLN role also involved interagency working with wider services in the region, informed by Travellers' identified needs and in recognition of the impact of wider issues on mental health. Key here was work with housing support services, substance misuse services, family resource centres, and youth services, where a reciprocal arrangement was developing around Traveller support provision.
It's a two-way process, very often people who I would be dealing with have health concerns, or mental health concerns, or substance misuse, or domestic violence concerns. In incidences where I think there's a relevance to the [TMHLN], I will contact [her] and let her know. Reciprocally, if there are issues in which accommodation is brought up as a central kind of problem, then the [TMHLN] will say, 'look we have to sort this out. . .. I can help you with your mental health problem, but I'll refer you straight onto [stakeholder] here to deal with the accommodation problem. [Key Stakeholder 9] In terms of the TMHLN role, work at this interagency level included two-way referrals, support for accessing and maintaining links with services, facilitation of Traveller Cultural Awareness Programmes to service providers, facilitation of Traveller Wellbeing Groups in Family Resource Centres, and while the TMHLN was an adult service, support for Traveller families around accessing youth services on their and their children's behalf. Having the TMHLN role was reported by stakeholder interviewees as greatly benefiting interagency working in the region.

DISCUSSION
The inquiry into the evolving role of the TMHLN demonstrates a broad brief inclusive of in-reach, outreach, liaison, and education work. In summary, the core aspects of the TMHLN role were mental health case management and referrals and development of links to Primary Care services in/ for the healthcare area. The TMHLN worked with existing Traveller Health Projects raising awareness around mental health issues and support services. In addition, the TMHLN assisted the professional development of agencies/organizations to be in a position to refer/signpost to primary and mental health services as needed and supported Traveller skills development in the area of mental health with a view to Travellers being a resource in their own community.
Activities and skills that this encompassed in work with Travellers and support providers ranged across the provision of psychosocial interventions, crisis intervention, active listening, provision of health and well-being education, support for accessing services/appointments, and advocacy more generally for and with Travellers. The role involved the provision of cultural awareness education to health and social care agencies with a view to developing cultural congruency, also working with agencies for the provision of integrated service responses. The activities of the TMHLN speak to targeted mental health interventions for Travellers, with emphasis on the use of existing services within the community, and referral to primary care or re-establishing links with mental health services when necessary. This approach appears to align with the consultation-liaison approach to the interface between primary and specialist mental healthcare as described by Gask and Khanna (2011).
Nursing within primary care is an evolving speciality and the role of the nurse in this context varies considerably internationally (Halcomb et al. 2019). Our findings help to clarify the contribution that mental health nurses can make in an area that has previously been described as poorly understood (McLeod & Simpson 2017). As there have been calls for greater integration of mental health into primary care (World Health Organisation 2008) learning can be drawn from our evaluation that can support initiatives to develop this aspect of mental health support. Knowledge of community resources, emphasis on the social determinants of health and their impact on mental health, and utilizing social prescribing approaches as advocated by mental health policy (Ireland's Department of Health 2020) and use of existent services, has the potential to reduce GP and secondary mental health service referral. This 'wrap around' approach speaks to the holistic nature of the nursing interventions utilized. The use of recovery technologies (Smith-Merry et al. 2011) which underpinned the overall approach allowed the TMHLN to focus on service user narratives, incorporate peer support, use strengths-based interventions and foster social inclusion, all of which demonstrated the overall recovery orientation of the role. This permitted an emphasis on psychosocial interventions and self-care with less focus on biomedical technologies, signs and symptoms and clinical outcomes.
The establishment of the TMHLN within services already embedded within the community facilitated greater access to, and for, service users especially in the context of historically complex service relations, such as those between Travellers and mental health services. However, there is a lack of evidence to support the MHLN role in the context of working with minority groups such as Travellers. The MHLN role is well-established within the acute services, especially the emergency department although no standard model of care is used (Wand et al. 2015). However, only one study could be located which describes the role of liaison nursing within a similar context (McBride et al. 2016). In that evaluation, the authors emphasized how nurses can support patients who struggle with access to health services through the development of therapeutic relationships set within a social determinants framework (McBride et al. 2016). These approaches underpin the work of the TMHLN being evaluated here. In addition, the lack of standardized approaches worked in the TMHLN's favour, allowing her role to emerge and adapt in response to Traveller need. The potential for this approach to MHL nursing within primary care especially among minority ethnic groups is recognized.

Limitations
As with any qualitative research, it is not possible to generalize the findings from this evaluation. The use of standardized pre and post interventions measurements would have enhanced the findings of this research but were not possible as part of this evaluation. Furthermore, longitudinal data collection might demonstrate the effectiveness of the intervention over time.

CONCLUSION
A recent report from the UK Mental Health Foundation points to the fact that those who face the greatest disadvantages in life also face the greatest risks to their mental health (McDaid & Kousoulis 2020). This paper discussed the role and activities of a Traveller Mental Health Liaison Nurse, a recovery-orientated innovation introduced to address the needs of a socially disadvantaged and marginalized group in Ireland. The introduction of the TMHLN within an existing framework of committed support for Travellers was instrumental to its success and reach. However, the risks associated with a single-post holder such as the TMHLN must be recognized. For example periods of absence (e.g. annual leave), and/or an increasing volume of work that is likely to occur as the role becomes more embedded, are likely to pose challenges to service implementation and sustainability.

RELEVANCE FOR CLINICAL PRACTICE
The TMHLN role described here, underpinned by a recovery approach, can act as a bridge between the community and established mental health services. The nature of integrated working identified facilitates the aim of working towards better access to mental health supports for minority groups, not only by supporting marginalized individuals and groups but also by working to make services more accessible for them. As such, this kind of role can be of benefit to mental health nursing within primary care.