Aust . J.

Rural Health (2015) 23, 352–358

Face to face, person to person: Skills and attributes

deployed by rural mental health clinicians when engaging
with consumers
Nicholas Procter, PhD, MBA, GradDipAdultHealth, BA, CertAdvClinNsg, RN,1
Monika Ferguson, PhD, BPsych(Hons),1 Julia Backhouse, GradDipMentalHealth,
MHN, RN,2 Ingrid Cother, GradDipMHN, BNurs, RN,3 Adrian Jackson, PGDipHlth,
PGDipAdmin, BHlthSc, DipAppSc(Com Hlth), RPN, RN,3 Julie Murison, MMHlthN,
CertPeri-OperativeNsg, GradDipHealthCounselling, BNsg, RPN, RN,4 and
Julie-Anne Reilly, GDipCMHN BNsg, PBPsychNurs, RN5
1
School of Nursing and Midwifery, University of South Australia, 2Outer Southern Community Mental
Health, 3Eastern Community Mental Health Centre, 4Country Health SA Local Health Network, Port
Pirie Regional Health Service, Port Pirie, South Australia, Australia, 5Mental Health Directorate,
Central Adelaide Local Health Network, SA Health, Adelaide

Abstract delivery of care, a whole of community approach, being

Objective: The purpose of this study was to identify the
skills and attributes deployed by rural mental health
clinicians when engaging with consumers in the com-
munity mental health context.
Design: Reflecting the exploratory nature of this
research, a semi-structured focus group was conducted.
Setting: One community mental health service in
regional South Australia (catchment area = approxi-
mately 60 000 people).
Participants: Nine mental health clinicians.
Interventions: Not applicable.
Main outcome measures: Participants’ focus group
comments were explored qualitatively using thematic
analysis.
Results: Three major themes were identified: (i) limita-
tions to providing mental health care in the rural envi-
ronment (increased consumer vulnerability, limited
services, increased risk, and stigma); (ii) universal
engagement approaches (being consumer-focused,
appropriate communication, facilitating a connection
and normalising the experience); (iii) indicated and tar-
geted strategies for engagement (flexible and creative
Correspondence: Professor Nicholas Procter, School of
Nursing and Midwifery, University of South Australia,
Adelaide, South Australia, 5000, Australia. Email:
Nicholas.Procter@unisa.edu.au
Accepted for publication 9 April 2015.
multiskilled and technology use).
Conclusions: Although engaging with consumers
involves many skills and attributes employed universally
across mental health settings, the rural clinician’s ability
to navigate the environment and utilise this to provide
consumer care is equally important to the engagement
process. Specifically, these findings highlight the prefer-
ence of rural mental health clinicians towards a person-
centred approach, networking with others in the
community when providing care. Understanding how
best to maximise the nature of a rural environment, such
as facilitating relationships between clinicians and
others in the community, will contribute to optimised
care.
KEY WORDS: collaborative care, community mental
health care, mental health nursing, rural mental
health, therapeutic engagement.
Introduction
The experience of mental illness is common Australia-
wide,1 yet it can present particular challenges for people
living in rural and remote regions. Nurses working with
mental health consumers and carers in rural and remote
areas encounter a range of factors such as isolation,
greater stigma, economic downturn and natural disas-
ters.2 Each is known to exacerbate the experience of
mental illness, and rural Australians face difficulties in

© 2015 National Rural Health Alliance Inc. doi: 10.1111/ajr.12204

ENGAGEMENT SKILLS WITH RURAL CONSUMERS
What is already known on this subject:
• Decentralised mental health care has seen an
increasing focus on maximising care in the
community.
• A growing interest is placed on the skills and
attributes employed by mental health clini-
cians when engaging with consumers in
the community environment, yet studies
have typically focused on metropolitan
environments.
accessing mental health care.3 Suicide and suicidal
behaviours also tend to be more prevalent in rural and
remote regions.4 Understanding how to improve the
services delivered by nurses and other clinicians to indi-
viduals in these areas is pertinent and aligns with
national5 and state6 policy regarding equal access to
effective mental health services across Australia.
In particular, the shift from centralised to localised
mental health care requires an understanding of two
intersecting variables: multidisciplinary teamwork and
how to maximise available resources within existing
community mental health teams. The importance of the
latter has been highlighted by Habibis et al., who found
little differences in consumer psychosocial outcomes
after introducing a community mental health team to a
semi-rural region of Australia, compared with hospital-
based care.7 Recently, it has been found that rural South
Australians make less use of community mental health
services than metropolitan residents.8
A key aspect to improving community care is the
way in which nurses engage with consumers, yet it
appears that only one study has explored this in a
rural setting. In a qualitative UK study, nurses identi-
fied various themes related to engagement: having time
to connect with the consumer, work at their pace and
be flexible; maintaining hope; working together with
other clinicians and learning from consumers; possess-
ing a caring attitude; and doing practical things to help
the consumer.9 Despite the important insights pro-
vided, with findings that mirror those of engagement
studies in metropolitan community and in-patient
settings,10–16 this investigation is limited to one inter-
national region.
Given the paucity of present information, and the
importance of improving mental health care in rural
communities, this qualitative study aims to explore the
lived experiences of mental health clinicians (primarily,
nurses) in order to identify the skills and attributes
employed when engaging with consumers in the rural
community context.
© 2015 National Rural Health Alliance Inc.
353
What this study adds:
• The rural mental health care environment
clearly differs from the metropolitan environ-
ment, particularly in terms of increased con-
sumer vulnerability.
• Clinical engagement can be achieved through
a combination of universal skills (e.g. effective
communication) and those characteristic to
the rural setting (e.g. drawing on community
networks).
• Future research should explore engagement
in other rural settings, from clinician and
consumer perspectives. Understanding how
best to maximise the nature of a rural envi-
ronment, such as facilitating relationships
between clinicians and others in the commu-
nity, will contribute to optimised care.
Methods
Mental health clinicians employed in one rural South
Australian region (catchment area = approximately
60 000 people) were recruited via flyers distributed at
the mental health care service and an email sent from the
service’s team leader. Human research ethics approval
was granted from the University of South Australia and
the state government health service. Participation was
voluntary, and written informed consent was provided.
A focus group approach was deemed most appropri-
ate, given the exploratory nature of the study and the
aim of obtaining a detailed understanding of mental
health clinicians’ lived experience of engagement. The
focus group was conducted in the rural location in
2012, lasting approximately 90 min. Through a semi-
structured approach, the interviewers asked open-ended
questions about the experience of engagement, explor-
ing what engagement means to the clinicians and the
skills they use to engage. The questions were formulated
and refined by the research team and were designed to
allow participants to voice their opinions and describe
their experiences in depth. Probing follow-up questions
were asked to explore responses from participants, with
subsequent questions to elicit information in further
detail.
The focus group was recorded via a digital recorder,
and hard-copy notes were also taken to allow for a more
in-depth understanding of the data. Recordings were
transcribed verbatim, and identifiable information was
removed from the transcript prior to analysis to preserve
participant anonymity. Following Braun and Clarke’s
thematic analysis framework,17 the research team read
the transcript carefully and repeatedly. The content of
354 N. PROCTER ET AL.

the data was then organised into themes and sub-themes health care in the rural environment; (ii) universal
by two of the researchers, and verified by the remaining engagement approaches; and (iii) indicated and targeted
team members. Discrepancies were discussed until con- strategies for engagement.
sensus was reached.
Theme 1: Limitations to providing mental
Results health care in the rural environment
Three key sub-themes are related to the limitations of
Participants (n = 9) were predominantly female nurses,
working in the rural environment (Table 2). The first is
ranging in age from 30 to 60 years, and with an average
increased consumer vulnerability, attributed to greater
of 13 years’ experience working in rural clinical practice
visibility, greater stigma and dual relationships in the
(Table 1).
community. A second limitation is the lack of services,
Although the primary focus was to identify clinician
with participants acknowledging how the rural envi-
attributes for engagement, other factors related to rural
ronment is faced with being physically isolated from
clinical practice were also explored. Three main themes
major services, which can often result in time delays to
were identified: (i) limitations to providing mental
providing care or an absence of services altogether.
Third, a flow-on effect from service limitations is the
possibility of increased risk, for clinicians and consum-
TABLE 1: Participant demographic details
ers, when other support services (i.e. police) are
Demographic
lacking.
characteristic Number of participants
Theme 2: Universal engagement
Gender Male = 2 approaches
Female = 7
Mean age 46 years (range: 30–60 years) Despite recognising barriers to providing care, partici-
Role Nurse = 4 pants highlighted the use of various ‘universal’ engage-
Social worker = 2 ment skills (Table 3). The first sub-theme identifies the
Clinical psychologist = 1 importance of being consumer-focused, which involves
Occupational therapist = 1 being ‘on the same page’ as the consumer (i.e. under-
Paramedical aid = 1 standing what the individual wants), non-judgemental,
Mean time in rural 13 years (range: 1–30 years) guided by the consumer’s pace and needs, and armed
clinical practice with prior knowledge about the individual. Second,
appropriate communication is necessary for engage-

TABLE 2: Theme 1: Limitations to providing mental health care in the rural environment

Sub-themes Example quotes

Increased consumer vulnerability

• Visibility ‘A small community is more of a fish bowl.’
• Stigma ‘That’s because they’re scared, you know because there’s always been that stereotype, and it
will be around for a long time yet.’
• Dual relationships ‘There’s a lot of dual relationships within the country context and I know that just
personally, I come from [a town] which is 1200 people and you know I’ve lived there for
thirty years, I know lots of people, they know me. They know that I work in mental
health, so if I’m actually seeing going into someone’s house there, they know.’

Limited services ‘. . . Probably the hardest thing here is if we’ve got someone in a . . . really bad crisis and we
need to get them to the hospital. Is the amount of time they have to . . . wait to be seen
and assessed and treated. Which makes them more angry, more agitated . . .’

Increased risk ‘. . . you don’t often have [police] or other clinicians . . . so I guess the risk assessment is
really important then, to make sure that when you do engage with someone that you do
have some kind of backup or . . . you might have to leave the person just where they are,
until that support can come along . . .’

© 2015 National Rural Health Alliance Inc.

ENGAGEMENT SKILLS WITH RURAL CONSUMERS 355

TABLE 3: Theme 2: Universal engagement approaches

Sub-themes Example quotes

Consumer-focused approach
• Being on the same page
• Being non-judgemental
• Being guided by the
consumer’s pace and needs
• Having prior knowledge
‘. . . understanding what [the consumer’s] issue is and making sure that you do actually
understand what they’re saying as opposed to what you think they’re trying to tell
you.’
‘. . . not going in with preconceived ideas, or stigmas, or labels of the [consumer] but
actually meeting them where they’re at . . .’
‘Don’t overload them with too much information I think. Keep it fairly simple.’
‘. . . [finding] out as much information as you can before you have this process or you
have the interview because you already know a bit about that person then’

Appropriate communication
• Non-verbal communication
• Adapting to match the
consumer’s style
‘And don’t look at your watch, while you’re talking to somebody in an interview, because
they think that you’re going to rush them or that they’re, that you’re not interested or
you’re wanting to go somewhere else. So you’re not really paying attention.’
‘. . . but you have to have multiple skills to be able to build it with different people and
different personalities. And like you were saying before about body language and
personal space, we do get [consumers] in who are quite structured and they like to
have a structured approach with me taking notes and knowing that there’s results and
then there’s other [consumers] who like to be informal and like to just have an
informal discussion and formalise later.’

Facilitating a connection
• The importance of the first
encounter
• Demonstrating interest
• Common connections
‘. . . I think the first initial contact with somebody is how . . . they perceive you, that first
impression. So if you give the impression that you, that you’ll be there, to support
them, offer them help, uh, listen to what they have to say, and ah, advocate for them.
If that’s what they want. If they, because when somebody walks through the door, it’s
all shock, stun, what’s happening, so if you can develop a good rapport in those
opening moments and continue with that, then things tend to fall in place.’
‘I think you have to show interest. That’s the big one. You actually have to show that
person that you are interested in helping them and in what they’ve got to say.’
‘. . . you know you sort of talk about things that interest the person, and then you can
probably bring a little bit of yourself into that as well. So if they start talking about
‘oh, I’ve got this really great dog, blah, blah, blah’, you say ‘oh, we just got a new
puppy’ . . .’

Normalising the experience
‘. . . you can provide a lot of comfort to a [consumer] with a strategic provision of
information, but I always do it from the background of a common experience of
depression or what the research tells us or what other [consumers] have shared with
me. You know? Obviously generally speaking and for some [consumers] simply being
told that’s actually a very common experience in depression is enormously
empowering, because they didn’t know that that was part of it. They thought that this
was another problem that had developed.’

ment, achieved via non-verbal skills (e.g. active listening
and eye contact) and an awareness of what the clini-
cian’s non-verbal communication might say to the con-
sumer. Skilled communication also involves recognising
that it is a reciprocal process and that the clinician needs
to be guided by the consumer’s non-verbal cues. The
third sub-theme relates to the ability to facilitate a con-
nection with the consumer, in which the first encounter
can be essential for future positive rapport. Other skills
include displaying a genuine interest in the consumer/
their needs and building rapport through finding
common connections/interests. The fourth sub-theme,
normalising the consumer’s experience, can be achieved
through sharing information from research, the experi-

© 2015 National Rural Health Alliance Inc.

356 N. PROCTER ET AL.

TABLE 4: Theme 3: Indicated and targeted strategies for engagement

Sub-themes Example quotes

Flexible and creative
delivery of care
‘. . . from what I gathered from that metro community health is a lot more tightly structured
and a lot more stringent. Whereas in country allows you the flexibility to . . . be able to spend
that extra time with the [consumer], to be able to ensure that when they come home, they’ve
got the supports in place or if they are isolated out on a farm, living on a farm on their own
somewhere that they’ve got local community members or at least someone keeping an eye on
there because you can’t go out there every day.’

A whole of community ‘. . . you rely on the community to help you. Which could be the postmaster, could be the
approach shopping, it could be the person, the cleaner, all those people will suddenly become part of
what you’re doing.’
‘So you work a lot more closely with family, so that the family can be your eyes and your ears,
whereas in metro you usually use the service.’
‘. . . ringing up the local police officer that gets along with the client so if the police officer goes
out there they can have a good chance of convincing the [consumer] to come in. You know?
You know that Joe Blow the police officer gets along with this person, so you ring them
directly, you’ve got their mobile, you don’t ring the police station in [the city], because they’ll
just end up sending someone that doesn’t know him. All that internal knowledge that you’ve
got, direct numbers to say [the housing service], certain workers that if there’s a dispute, you
can ring them and get certain things done that you can’t necessarily get done through the
usual political process.’

Being multiskilled
‘We don’t often have the qualified staff . . . there’s no police officer there. On that particular
day. There’s no paramedics there. They’ve got two staff on at the hospital. The GP has gone
away for the weekend. So you become all of that.’
‘We’ve had a situation where we’ve had to detain a [consumer] and when they’ve come in
they’ve had their car full of four dogs . . . We had to play the role of taking the dogs out the
car, heading them out the back, ringing up the pound, going over to ED to make sure they’ve
got the information for the admission and all of that. So you’re multitasking all the time . . .’

Use of technology ‘. . . you might print off information and give them that hard copied information about their
illness or resources . . . So we’ll give [consumers] information, you know, if they’re interested
in following it up or websites or whatever.’

ence of other consumers, or even the clinician’s own
experience. This can empower the consumer by assisting
them to have greater insight into their experience.
Theme 3: Indicated and targeted strategies
for engagement
Participants identified four key engagement approaches
that are more targeted to the rural context (Table 4).
First, being flexible and creative in the delivery of care
was described as necessary to counter the limitations
raised in Theme 1. Second, engagement requires a whole
of community approach, whereby the clinician draws
on the assistance of the consumer’s family, friends,
neighbours and other service providers (e.g. police). The
clinician should be familiar and work productively with
others in the community. The third sub-theme identifies
how clinicians need to be multiskilled and adapt to the
needs of the consumer when other services are absent
(e.g. simultaneously taking on multiple roles). Lastly,
technology is important, particularly to compensate for
limited services. It can be used indirectly to improve
services (e.g. teleconferences for supervision and case
reviews) or directly (e.g. to provide information to con-
sumers). However, technology might have limited utility
when the rural population is ageing and consumers are
not familiar with it.
Discussion
In this study, participants have identified how, despite
increased consumer vulnerability, limited services,
increased risk and stigma, rural mental health clinicians
employ a range of skills and attributes to engage

© 2015 National Rural Health Alliance Inc.

ENGAGEMENT SKILLS WITH RURAL CONSUMERS
with consumers. Universal skills, such as adopting a
consumer-focused approach, appropriate communica-
tion, facilitating a connection and normalising the expe-
rience, broadly reflect previous research into engagement
in metropolitan community mental health settings.10–16
Building on this knowledge, participants provided
insight into skills and attributes more specific to the rural
environment (flexible and creative delivery of care, a
whole of community approach, being multiskilled and
technology use), some of which match those identified by
rural mental health nurses in the UK.9
In reflecting on their experiences, participants have
illuminated how characteristics of the rural environ-
ment – such as a greater sense of ‘community’ and
connectedness – can be drawn upon to enhance engage-
ment. By utilising their wider networks and community
support, these clinicians find creative ways to engage. In
many instances, clinicians will work with others to
provide care, which they facilitate by contacting other
service providers directly. In this way, there are fewer
layers between services, and clinicians have more
personalised awareness regarding the interactions they
have with other service providers, because they know
that these others will be directly assisting the consumer.
Members of the community also play an important role
and can be a key source of information in terms of
raising attention when a consumer requires care. This
can be seen as a positive spin-off of the greater visibility
in rural environments.
Although the majority of the participants engaged in
this study were nurses, the findings have important impli-
cations for rural mental health clinicians working as part
of the multidisciplinary team. Working collaboratively
and across disciplines requires all clinicians to maintain
well-established relationships with other service provid-
ers and the wider community and that they themselves
are respected members of the community. This might be
more easily achieved by those who have lived in the
particular rural location for longer. With rural environ-
ments often being characterised by dual relationship, the
clinician’s role is something that continues outside of
their working hours. Active reflection at work with col-
leagues can be useful in finding opportunities for collabo-
ration and tackling complex clinical issues. Specifically,
reflection on therapeutic engagement and wisdom tech-
nique through sharing and debating ideas is encouraged
to establish common ground to support recovery with
dignity.
Limitations and future directions
Given the small sample size and that the study was
conducted in one rural setting only, the generalisability
of these findings might be limited. Furthermore, insights
gained from within other regional environments, with
© 2015 National Rural Health Alliance Inc.
357
different populations (e.g. predominantly Indigenous
Australians), might differ. Notwithstanding these limi-
tations, face-to-face and person-to-person engagement
is reinforced as a central feature of practice. Future
studies should include rural consumers’ experiences of
engagement. Further, understanding how the health
system can support mental health clinicians to engage
can contribute to improved consumer care.
Conclusion
This exploratory study has highlighted how providing
mental health care in rural communities presents chal-
lenges that differ from the metropolitan environment.
Yet, for rural mental health clinicians, the intricacies
of care are characterised by creative and flexible
approaches to consumer engagement, drawing on wider
community networks to provide collaborative care. It is
important to note that participants discussed these intri-
cacies in both depth and detail. In this sense, engage-
ment is much more than a process between clinician and
consumer, but a process between clinician and the wider
community.
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