# Introduction

Mental disorders are among the most prevalent and disabling diseases, and it is estimated that one person in eight currently lives with this condition worldwide (World Health Organization [WHO], 2022). Mental disorders are defined by the World Health Organization as “clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour” (WHO). People living with mental disorders in the community have varied health needs relating to their immediate safety, relief of symptoms, daily functioning, and extending to recovery needs. Recovery refers to the possibility of living a satisfying life and contributing to one’s community based on goals centered around one’s strengths, interests, and desires (Commission de la santé mentale du Canada, 2021).

Primary care and community teams play an essential role in identifying people with mental health issues and assessing their health needs (WHO, 2022). Nurses in Quebec (Canada), as in many parts of the world, are key members of interdisciplinary primary care teams (Katon et al., 2010). Furthermore, assessing health conditions centered on people’s mental health needs and recovery is both a standard and a norm of nursing practice in Quebec (Ordre des infirmières et des infirmiers du Québec, 2016) as well as in other countries, such as Australia (Australian College of Mental Health Nurses, 2018). Thus, people living with mental health issues can expect to receive care that aligns with best practices and assessment standards when they interact with a primary care nurse (PCN).

Assessing people’s mental health issues and health needs is essential for accessing evidence-based treatments (Ministère de la Santé et des Services sociaux [MSSS], 2020; National Institute for Health and Care Excellence, 2011). Previous studies have reported the complexity and challenges associated with adopting a comprehensive mental health assessment grounded in recovery principles, which focus on the patient’s mental health self-management (Beaudin et al., 2024; Coombs et al., 2011; Davies, 2023; Girard et al., 2017; Wand et al., 2020). In addition to conducting mental health assessments, PCNs can provide a range of interventions for individuals with mental health issues, such as psychological education, emotional and social support, and treatment management (Aurizki et Wilson, 2022; Halcomb et al., 2019). However, PCNs often feel they do not have the best conditions to adopt evidence-based practices for people living with mental health issues (Ekers et al., 2013; Girard et al., 2017, 2019; Girard, Ellefsen, et al., 2021; Halcomb et al., 2022).

Several conditions are known to improve the adoption of best nursing practices for individuals living with mental health issues in primary care. In general, healthcare workers need the ability, motivation, and opportunities to take up a specific behaviour (Bos-Nehles et al., 2023). The favourable conditions for nurses to adopt best practices are: 1) a sense of competence (e.g., attitudes and beliefs about one’s knowledge and skills); 2) opportunities to reflect on one’s practice and access specialized mental health knowledge (e.g., support from a specialist or a team specialized in mental health, the opportunity to discuss with colleagues about the more complex cases); 3) the ability to identify real-world assessment opportunities (e.g., clear roles and responsibilities, clear referral procedures, space conducive to effective communication among patients and teams); and 4) motivation and interest in working with people with mental health issues (Girard et al., 2019; Girard, Ellefsen, et al., 2021). However, due to the complexity of people’s mental health needs and the unique characteristics of the local contexts, strategies to improve conditions favourable to the adoption of best practices (including mental health clinical assessment) may vary across clinical settings and among nurses (Girard, Roberge, et al., 2021).

As healthcare professionals, nurses must continuously update their practice through a reflective process based on comparing their current practice with best practices. Reflective practice requires professionals to critically examine their actions, behaviours, and attitudes they must adopt in relation to their environment (Patel et Metersky, 2022). In a real-life context, professionals operationalize reflective practice through a process of change that can be described in terms of the following stages: 1) preparation, 2) critical analysis and action plan, 3) action, 4) reflection and maintenance (Wensing et al., 2020). This process of changes and thoughts requires facilitation mechanisms, such as support from a clinical supervisor, through various activities like goal planning and self-assessment, problem-solving, and monitoring (Patel et Metersky). Clinical supervision aims to promote the well-being of professionals and enhance the adoption of best clinical practices (Centre intégré universitaire de santé et de services sociaux de l’Estrie & Centre hospitalier universitaire de Sherbrooke, 2019). Professionals providing clinical supervision to nurses can use facilitation strategies to reinforce the conditions (ability, motivation, and opportunity) that support the adoption of evidence-based practices, considering each professional’s local context and individual needs. Thus, training and clinical supervision emerge as essential strategies to increase PCNs responsibilities towards mental health care (Aurizki et Wilson, 2022) and to improve the adoption of evidence-based practices (Choy-Brown et al., 2023).

However, to our knowledge, no previous training program has simultaneously targeted reflective practices and clinical support processes to improve mental health assessment practices of PCNs. Consequently, there is little scientific literature to guide the structuring adaptation of such a program’s process and activities in the local context to achieve the desired results.
# Objectives

The proposed study protocol aims to evaluate the acceptability and the perceived effects of a training program prototype designed to enhance the adoption of best mental health assessment practices by PCNs, while also exploring the feasibility of integrating clinical supervisors into the program. Specifically, the objectives are to:

1. Assess the acceptability of the program from the perspective of PCNs during and after the training, including their reactions, engagement and overall satisfaction.
2. Explore and analyze the perception of PCNs of the program’s impact on their ability, motivation, and opportunities to adopt best mental health assessment practices.
3. Evaluate the feasibility of integrating clinical supervisors into the program’s activities, including their perceptions of the acceptability and potential challenges of their involvement.

## Ethical Considerations

The ethics committee of the *Centre intégré universitaire de santé et de services sociaux de l’Estrie-Centre hospitalier universitaire de Sherbrooke*has approved the study (MP-31-2024-5109).
# Discussion and Research
				Spin-offs

To our knowledge, this is one of the first studies investigating the perceived effects of a reflective training program and how to structure the clinical supervision or support process to help general practice nurses, such as PCNs, adopt best mental health assessment practices. Co-creating the training program with end users at the centre of the process is also crucial for developing a program tailored to the context and ensuring its sustainability. This prototyping phase, based on a living lab approach, will identify areas for improvement in the training program, leading to the final development phase. This will help us understand how to guide clinical supervisors and clarify the governance management structure necessary for its sustainability. It is expected that the improved PCN training program will enhance mental health assessment, facilitating the identification of mental health issues and, therefore, improve access to effective care for this population in the specific context of primary care nursing practice, as suggested by some authors (Lau et al., 2016; McKinlay et al., 2011). Our study will contribute to a better understanding of how to best train and supervise PCNs concerning mental health clinical assessment in their clinics, where task-sharing is recommended to answer the patient’s needs (Aurizki & Wilson, 2022).

## Références

G. E., & Wilson, I. (2022). Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review. *International journal of nursing practice*, *28*(5), e13046. https://doi.org/10.1111/ijn.13046

Australian College of Mental Health Nurses. (2018). *Mental Health Practice Standards for Nurses in Australian General Practice 2018.* https://acmhn.org/common/Uploaded%20files/PDFs/Best%20practice/ACMHN-Publications-GeneralPracticeStandards.pdf

J., Chouinard, M. C., Hudon, É., & Hudon, C. (2024). Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a qualitative study. *BMC primary care*, *25*(1), 212. https://doi.org/10.1186/s12875-024-02464-8

M., & Pringle, C. D. (1982). The Missing Opportunity in Organizational Research: Some Implications for a Theory of Work Performance. *The Academy of Management Review*, *7*(4), 560–569. https://doi.org/10.2307/257222

G. (2022). Action learning and healthcare 2011–2022. *Action Learning: Research and Practice, 19*(3), 251–268. https://doi.org/10.1080/14767333.2022.2133376

A., Townsend, K., Cafferkey, K., & Trullen, J. (2023). Examining the Ability, Motivation and Opportunity (AMO) framework in HRM research: Conceptualization, measurement and interactions. *International Journal of Management Reviews*, *25*(4), 725–739. https://doi.org/10.1111/ijmr.12332

Boxall, P. F., & Purcell, J. (2003). *Strategy and Human Resource Management*. Palgrave Macmillan.

V., & Clarke, V. (2022). *Thematic Analysis: A Practical Guide.* SAGE Publications Ltd.

Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke. (2019, October 22). *Cadre de référence encadrement et soutien clinique*. https://numerique.banq.qc.ca/patrimoine/details/52327/4035166

M., Williams, N. J., Ramirez, N., & Esp, S. (2023). Psychometric evaluation of a pragmatic measure of clinical supervision as an implementation strategy. *Implementation Science Communications*, *4*(39), 1–14. https://doi.org/10.1186/s43058-023-00419-1

Commission de la santé mentale du Canada. (2021). *Mettre le rétablissement en pratique. Une introduction au Guide de référence pour des pratiques axées sur le rétablissement.*https://commissionsantementale.ca/wp-content/uploads/2021/09/Mettre-le-retablissement-en-pratique-Une-introduction-au-Guide-de-reference-pour-des-pratiques-axees-sur-le-retablissement.pdf

T., Curtis, J., & Crookes, P. (2011). What is a comprehensive mental health nursing assessment? A review of the literature. *International journal of mental health nursing*, *20*(5), 364–370. https://doi.org/10.1111/j.1447-0349.2011.00742.x

Creswell, J. W., & Plano Clark, V. L. (2011). *Designing and Conducting Mixed Methods Research* (2nd ed.). SAGE Publications.

T. L. (2023). Tailoring the mental health assessment to older adults. *The Nurse practitioner*, *48*(1), 10–18. https://doi.org/10.1097/01.NPR.0000902992.34389.1f

Desjarlais, M., & Smith, P. (2011). *A Comparative Analysis of Reflection and Self-Assessment*.

Dubé, P., Sarrailh, J., Billebaud, C., Grillet, C., Zingraff, V., & Kostecki, I. (2014, March). *Le livre blanc des living labs*. Umvelt. https://www.montreal-invivo.com/wp-content/uploads/2019/12/livre-blanc-ll-umvelt-final-mai-2014.pdf

D., Murphy, R., Archer, J., Ebenezer, C., Kemp, D., & Gilbody, S. (2013). Nurse-delivered collaborative care for depression and long-term physical conditions: a systematic review and meta-analysis. *Journal of affective disorders*, *149*(1-3), 14–22. https://doi.org/10.1016/j.jad.2013.02.032

T., Robinson, K., Elliott, S. J., & Eyles, J. (2006). Developing and implementing a triangulation protocol for qualitative health research. *Qualitative health research*, *16*(3), 377–394. https://doi.org/10.1177/1049732305285708

Friedrich-Nel, H. (2019). Reflection, self-assessment and continuous professional development : An opinion paper. *South African Radiographer*, *57*(1), 27–30.

Girard, A. (2016). *Description de la pratique des infirmières en groupe de médecine de famille oeuvrant auprès des personnes atteintes de maladies chroniques physiques et présentant des troubles mentaux courants* [Mémoire de maîtrise, Université du Québec à Chicoutimi]. Constellation. https://constellation.uqac.ca/id/eprint/4070/1/Girard_uqac_0862N_10253.pdf.

A., Ellefsen, É., Roberge, P., Bernard-Hamel, J., & Hudon, C. (2021). Adoption of care management activities by primary care nurses for people with common mental disorders and physical conditions: A multiple case study. *Journal of psychiatric and mental health nursing*, *28*(5), 838–855. https://doi.org/10.1111/jpm.12788

A., Ellefsen, É., Roberge, P., Carrier, J. D., & Hudon, C. (2019). Challenges of adopting the role of care manager when implementing the collaborative care model for people with common mental illnesses: A scoping review. *International journal of mental health nursing*, *28*(2), 369–389. https://doi.org/10.1111/inm.12584

A., Hudon, C., Poitras, M. E., Roberge, P., & Chouinard, M. C. (2017). Primary care nursing activities with patients affected by physical chronic disease and common mental disorders: a qualitative descriptive study. *Journal of clinical nursing, 26*(9-10), 1385–1394. https://doi.org/10.1111/jocn.13695

Girard, A., Lafontaine, S., Beaudin, J., Carrier, J.-D., & Lemée, M.-H. (2024). *Guide d’orientation : l’évaluation clinique orientée vers les besoins de santé mentale et le rétablissement*. https://savoirs.usherbrooke.ca/bitstream/handle/11143/21451/guide_orientation_version%201.1.pdf?sequence=5&isAllowed=y

A., Roberge, P., Ellefsen, D., Bernard-Hamel, J., Carrier, J. D., & Hudon, C. (2021). The Influence of Contextual Factors on the Process of Formulating Strategies to Improve the Adoption of Care Manager Activities by Primary Care Nurses. *International journal of integrated care*, *21*(2), 20. https://doi.org/10.5334/ijic.5556

K. J., & Widaman, K. F. (2012). Construct validity. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), *APA handbook of research methods in psychology, Vol 1: Foundations, planning, measures, and psychometrics* (pp. 621–642). American Psychological Association. https://doi.org/10.1037/13619-000

E. J., McInnes, S., Patterson, C., & Moxham, L. (2019). Nurse-delivered interventions for mental health in primary care: a systematic review of randomized controlled trials. *Family practice*, *36*(1), 64–71. https://doi.org/10.1093/fampra/cmy101

E., McInnes, S., Patterson, C., Moxham, L., & Bird, S. (2022). Australian general practice nurse involvement in mental health: A descriptive survey. *Collegian*, *29*(4), 448–455. https://doi.org/10.1016/j.colegn.2021.10.011

W. J., Lin, E. H., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., Peterson, D., Rutter, C. M., McGregor, M., & McCulloch, D. (2010). Collaborative care for patients with depression and chronic illnesses. *The New England journal of medicine*, *363*(27), 2611–2620. https://doi.org/10.1056/NEJMoa1003955

Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). *Kirkpatrick’s four levels of training evaluation*. ATD Press.

R., Stevenson, F., Ong, B. N., Dziedzic, K., Treweek, S., Eldridge, S., Everitt, H., Kennedy, A., Qureshi, N., Rogers, A., Peacock, R., & Murray, E. (2016). Achieving change in primary care—causes of the evidence to practice gap: Systematic reviews of reviews. *Implementation Science*, *11*, 40. https://doi.org/10.1186/s13012-016-0396-4

K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: a systematic review. *Advances in health sciences education: theory and practice*, *14*(4), 595–621. https://doi.org/10.1007/s10459-007-9090-2

E., Garrett, S., McBain, L., Dowell, T., Collings, S., & Stanley, J. (2011). New Zealand general practice nurses' roles in mental health care. *International nursing review*, *58*(2), 225–233. https://doi.org/10.1111/j.1466-7657.2010.00859.x

Miles, M. B., Huberman, A. M., & Saldaña, J. (2020). *Qualitative data analysis: A methods sourcebook* (4th, ed.). SAGE Publications Ltd.

Ministère de la Santé et des Services Sociaux. (2019, September 24). *Guide pratique à l’intention des infirmières cliniciennes qui travaillent dans un groupe de médecine de famille ou un groupe de médecine de famille universitaire* (publication no : 19-924-11W). Gouvernement du Québec.https://publications.msss.gouv.qc.ca/msss/fichiers/2019/19-924-11W.pdf

Ministère de la Santé et des Services sociaux. (2020, February 10). *Cadre de gestion des groupes de médecine de famille universitaires (GMF-U)*(publication no : 19-920-01W). Gouvernement du Québec. https://publications.msss.gouv.qc.ca/msss/fichiers/2019/19-920-01W.pdf

National Institute for Health and Care Excellence. (2011, May 25). *Common mental health problems: Identification and pathways to care*. https://www.nice.org.uk/guidance/cg123/resources/common-mental-health-problems-identification-and-pathways-to-care-pdf-35109448223173

Ordre des infirmières et des infirmiers du Québec. (2016). *Standards de pratique de l’infirmière dans le domaine de la santé mentale*. https://www.oiiq.org/documents/20147/237836/4462_doc.pdf

J. (2009). HRM and Performance: Achievements, Methodological Issues and Prospects. *Journal of Management Studies*, *46*(1), 129–142. https://doi.org/10.1111/j.1467-6486.2008.00809.x

K. M., & Metersky, K. (2022). Reflective practice in nursing: A concept analysis. *International journal of nursing knowledge*, *33*(3), 180–187. https://doi.org/10.1111/2047-3095.12350

Patton, M. Q. (2015). *Qualitative Research & Evaluation Methods: Integrating Theory and Practice* (4th, ed.). SAGE Publications, Inc.

Payette, A., & Champagne, C. (2011). *Le groupe de codéveloppement professionnel*. Presses de l’Université du Québec.

M. E., Chouinard, M. C., Gallagher, F., & Fortin, M. (2018). Nursing Activities for Patients With Chronic Disease in Primary Care Settings: A Practice Analysis. *Nursing research*, *67*(1), 35–42. https://doi.org/10.1097/NNR.0000000000000253

Hecke, A., Duprez, V., Pype, P., Beeckman, D., & Verhaeghe, S. (2020). Criteria for describing and evaluating training interventions in healthcare professions - CRe-DEPTH. *Nurse education today*, *84*, 104254. https://doi.org/10.1016/j.nedt.2019.104254

T., Buchanan-Hagen, S., Derrick, K., & Harris, M. (2020). Are current mental health assessment formats consistent with contemporary thinking and practice?. *International journal of mental health nursing*, *29*(2), 171–176. https://doi.org/10.1111/inm.12656

M., Grol, R., & Grimshaw, J. M. (2020). *Improving Patient Care: The Implementation of Change in Health Care* (3rd, ed.). John Wiley & Sons Ltd.

World Health Organization. (2022, June 8). *Mental disorders*. https://www.who.int/news-room/fact-sheets/detail/mental-disorders⁠⁠⁠⁠⁠⁠⁠