Category Archives: Blog

“It’s a Fine Line” – Myth vs Reality

Every now and then somebody trots out a phrase like, “It’s a fine line between madness and sanity” (or words to that effect). It makes me cringe a little every time I hear it.

This version of “It’s a Fine Line” paints an unrealistic and unkind picture. It creates an impression that anyone who is “sane” (whatever that is) could, in a random moment, cross a line and become “insane” (whatever that is). It also creates an impression that jumping back across the line should be just as quick, just as fateful. This version of “It’s a Fine Line” is a dopey dichotomy – it divides humans into two tribes. It creates an illusion that you can only be one thing or the other, but could not be a bit of both or somewhere in-between.

Rubbish. It’s a myth.

finelinemyth

There is not a fine line to cross. There is a fine line that we all slide along – first one way, then the other.

When it comes to mental health all of us travel somewhere along a fine line that connects the extremities of “very well” to “very unwell”. We all are on the same line; we are not all on the same section of the line at the same time.

finelinereality

If we are lucky we will spend most of the time somewhere along the continuum between the middle and the “very well (thanks)” point at the end. 100% “sane” (whatever that is) is not achievable. If it is achievable, it’s not achievable 100% of the time. Even the Dalai Lama would have bad days.

Nelson Mendela seemed better put together than most of us (in a healthy-mind-kind-of-way, that is). Was Nelson Mandela 100% sane 100% of the time? Nope. None of the heroes of humanity and none of us ordinary peeps are 100% sane 100% of the time. We are not statues on Easter Island. We are human. We all change. We are all affected by what we experience. We all have good days and days.

I have worked with people who have been really unwell psychiatrically. People who have experienced “3D” in a not-so-good way. That is, these 3 Ds:
1. Dysregulated emotions
2. Disordered thoughts
3. Disturbed perception
When this combination happens people are prone to experiencing psychosis (ie: loss of contact with reality). I have not kept count of the people I’ve worked with who have experienced psychosis – certainly hundreds, probably thousands. However, I’ve never met someone who is 100% “insane” (whatever that is) 100% of the time.

People who experience mental illness are on the same line as everyone else. On occasions they spend some time closer to the difficult “very unwell at the moment” end of the mental health continuum than they would like. They are not statues on Easter Island. They are human. They all change. They are all affected by what they experience. They all have good days and days.

Of course, these things are true of us all. Don’t believe me? Try substituting “they” with “we” in the paragraph above.

The “It’s a Fine Line” Myth divides us. The “It’s a Fine Line” Reality is much different, much better.

There is a fine line. It does not separate us, it connects us.

We are all sliding along the same fine line.

finelinereality

End

Thanks for reading this far. As always, your comments are welcome below.

Short URL: http://meta4RN.com/fineline

Paul McNamara, 1st October 2014

A Blog About A Blog About Suicide

I’m going to keep this short.

On the eve of the second anniversary of the meta4RN.com blog we (guest writer Stevie Jacobs and I) have finally released her powerful, gutsy post “These words have been in my head and they needed to come out (a blog post about suicide).” I thought by opening up meta4RN.com to occasional guest posts I would save myself some time and effort. Ha! Stevie’s post has had the longest, most difficult gestation of all of the posts on this blog.

Why? It’s not because of Stevie’s writing – she writes very well – It’s because of the content.

It’s because we don’t know how to talk about suicide.

mindframe I remember as a 14  year old learning about suicidal ideation via the famous Hamlet soliloquy which starts: “To be, or not to be, that is the question…” Shakespeare didn’t seem to be as afraid as getting the tone/message wrong as Stevie Jacobs and I have been.

Luckily, we don’t have to navigate this tricky territory without a map. Mindframe – Australia’s national media initiative – have some very handy tips aimed (mostly) at media. They also have info for universities, the performing arts, police and courts. It would be silly to replicate all their information here – cut out the middle-man and visit the Mindframe website:
www.mindframe-media.info

The only thing I want to make sure is included here is that we, the health professionals, remain mindful of responsible use of language in social media, including blogs (and Facebook, Twitter, Instagram etc) . Melissa Sweet of croakey (the Crikey health blog) has used the term “citizen journalist” to refer to us non-journos who are active on social media. I have shied-away from that label because I have zero knowledge/pretensions of being a journalist. However, when it comes to talking about mental health and/or suicide, I reckon that those of using social media as health professionals should take some ownership of the “citizen journalist” tag.

Health professionals are used to being informed by evidence-based guidelines, right? That’s what the Mindframe guidelines are. They are guidelines for how language should be used by journalists. Those of us who are blogging/Tweeting/Facebooking/whatever can, if we choose to be safe and ethical, abide by the same code of good practice (here).

Let’s watch our language.

Let’s edit and re-edit.

Let’s reflect and think about our impact. Let’s do that slowly.

Let’s be safe. ethical and kind.

Let’s do no harm.

Let’s follow the Mindframe guidelines when we’re blogging about mental health and/or suicide.

End.

That’s it. Thanks for visiting.

If you haven’t done so already, visit Stevie Jacob’s guest post here: meta4RN.com/guest02 My favourite part is the middle part (the meat in the sandwich?) which is honest, powerful, raw and gutsy. I hope/think that the edits made have been in keeping with the Mindframe guidelines. If  not, that is my responsibility. Please let me know and I will fix it as soon as possible.

Paul McNamara, 23rd September 2014

Short URL: meta4RN.com/mindframe

These words have been in my head and they needed to come out (a blog post about suicide)

Trigger Alert – this blog contains info re suicide which may be unsettling for some people.

Guest Post: Stevie Jacobs has contributed this guest post to meta4RN.com

StevieJacobsStevie Jacobs is the pen name of a newly-minted Enrolled Nurse. The person behind Stevie is smart, experienced in life and has some awesome insight into the world of the student and new graduate nurse.

You can follow Stevie Jacobs on Twitter: @SJWritesHere

Stevie has contributed to other nurse blogs, including the excellent site Injectable Orange, by Jesse Spurr.

These words have been in my head and they needed to come out
(a blog post about suicide)

I am ‘Pro choice’.

I am a patient advocate.

I am a person advocate.

I support euthanasia.

I am pretty much of the opinion that if you have all the facts, figures and feelings figured out then you can go ahead and do pretty-much whatever you like. Even if it’s ‘bad’ for you. I can provide you with action plans and phone numbers and personal support, however ultimately, the choice my friend, is yours.

So when someone wants to kill themselves/suicide/take their own life (however you want to put it) what does my head feel about that? I’m not talking about obligations as a Health Care Professional, I’m talking about obligations as a human being. I can provide you with an ear to bend, a shoulder to lean on, I can find you professional help if you want, I can tell you that I don’t think you’re in a safe space and I want to get more support. For both of us. I can do all that. What I am stuck with is that if euthanasia is assisted suicide and I’m OK with that (OK meaning I won’t physically stop you nor judge you), does that mean I am ‘OK ‘ with someone’s suicide? Both have the same ending:, the removal of pain through the death of a person. I don’t know how my heart or my head feel about that.

Robin Williams was 63. That’s a long time to be living in pain. Yes, there are medications and therapies and support groups, but what if that starts to feel just all too much? That living is just all too much, a bit like ‘diabetic burnout’, where the person with diabetes basically gets fed up with ‘managing’ their diabetes and becomes unwell. That can happen with all chronic diseases. That can happen with mental health issues. Yes, some people have a depressive episode, it’s self-limiting and then they never have another one. Wonderful. For others, it just keeps on coming back, more painful than before.

To someone who is experiencing suicidal thoughts, suicide I can seem to be a rational method of pain relief. It’s the ultimate pain reliever for the person experiencing the thoughts.

For those left behind it can be devastating.

I can’t make up my mind. Do I have the ‘right’ to stop someone from suicide? I’m on the fence. The boundaries get blurred. I’ve experienced anxiety & depression, I’ve experienced suicidal thoughts & been ‘suicidally depressed’, I’ve had a family member suicide and I’ve known someone I followed on Twitter suicide. Which is a really fucking weird experience, quite frankly. Grief for someone who you ‘know’, but don’t ‘know’. 101 ‘What ifs?’. I could ‘see’ that something wasn’t right, but aside from checking in and offering an ear what else could I do? I’m at peace with those choices now, no longer haunted by ‘what ifs’. I’m sure that is not the same for their family and friends. I realised that what has stayed in my head is a photo of themselves they posted shortly before it happened. It’s their eyes. Their eyes haunt me. I can see something in their eyes I’ve seen time and time again. In my face. In the faces of others. I know those eyes so well. However good your mask is it’s in the eyes.

So, what to do? Who am I to tell anyone what to do? There isn’t really a clear answer. I think it’s really important to keep checking in on people: RU OK? I have RUOKed a few people and I will keep doing it. If it’s a ‘No’, and they express some ideas that worry you, it’s OK to ask “Do you have a plan?” If it’s a ‘Yes’, what then? Especially if you just don’t believe them. That’s trickier ground to navigate. I’m no expert on this. There are links at the end of this from people who are.

RU OK? It’s just a simple question. A simple, lifesaving question. I was on another planet from OK, and someone who barely knew me asked me that question.

It was like a thunderbolt.

It made me stop and think and choose to get help to make living less painful. Choosing to get help is hard. Getting help can be harder. What’s even harder is acknowledging that choosing to live is a conscious effort. It’s an effort. Accepting that medications and therapy and exercise and diet changes and avoiding triggers are now part of your life is an effort.

In time I hope that life will once again become effortless, but it might not.

Finally, after years of effort, I now think I am OK with that.

.

Post Script 1:

I wrote the above post a little while back. Normally when I have said all I have to say on a subject it doesn’t pop back in to my head. This post did. If I am honest, I have only scratched the surface. I have more to say. The way I write usually is like a good vomit on a night out: it all comes out in one go and it’s done and dusted and you’re up and dancing again. The other way I write is a bit more like a gastro bug: on and off with a bit of dry retching when you just can’t get it out. Then you’re done and you feel better.

Paul told me the ‘meta’ point of meta4RN is ‘talk about what you’re talking about’. So I guess that’s what I’m doing here. Rereading the above, reflecting on it and trying to work out quite what it is that I still feel I want to say.

We need to talk about mental health. We need to talk about suicide. We need to do it in a safe, appropriate and open way, but we do need to talk about it. Talking about it is hard. Talking about it can be terrifying for anyone. Talking about it when you’re a health professional is really damn hard. There are so many ‘what ifs’. What if they ‘lock me up’? What if they don’t? What if they think I’m not fit to practice? What if I lose my job? What if my colleagues find out? What if I have to be treated in the same hospital that I work in? What if…

I want to talk about how it feels to have suicidal thoughts. I want to talk about how it feels to be suicidally depressed. I’m not sure how to do that. I know that there are media guidelines for discussing suicide. As someone who is trying to describe a ‘lived experience’, I decided the best way for me to write was to let it all come out uncensored, and then give it to Paul to edit it using some of those guidelines and make it ‘safe’. I am in a safe enough space now to be brutally honest about how those suicidal thoughts feel, and far away enough from those thoughts to be able to talk about them without feeling ‘triggered’.

I can only speak for myself. For me there is a distinction between having suicidal thoughts and being ‘suicidal’ or ‘suicidally depressed’, as I have referred to it in the past. The thing about ‘suicidal thoughts’ is that the longer you have them the more rational they seem. For me suicidal thoughts are more of a hypothetical notion; it’s not something I am going to carry out. It’s an icy calm IF. IF things don’t get better, IF that was to happen, IF there isn’t another way out, IF the pain becomes unbearable, IF.

I know exactly how I would kill myself. I know exactly how I would spend the jackpot from a lottery win. I know exactly what I would get done if I had free access to plastic surgery. It’s all hypothetical.

It’s hypothetical. Until it’s not. Until I am suicidally depressed. Until I am in pain. Until the self-loathing I carry around with me every day takes over. Until I truly believe that the people in my life would be better off without me. Until I can’t see any way out aside from that way. And that place is not icy calm. It’s a messy, clinging on to something, anything to get through hour after hour, painful, emotional swamp. I feel emotionally swamped. I can’t think in a straight line. I can’t sleep. I can’t eat. The anxiety eats at my stomach. The panic attacks feel like I am dying of a heart attack. The after effects of which last for days. And nothing, nothing stops the pain. That’s how suicidal feels like for me. I know, however, that it is not what it looks like to other people. People see what they want to see. Even people who are trained to see more. I am brilliant at hiding it. I know how to put on my mask and polish up my armour. It is exhausting.

There are cracks in my armour, sometimes the mask slips. My fellow walking wounded can see though them, but for the most part the people I see every day wouldn’t know. I can make people feel so good about themselves. I can make people cry with laughter. Then, the second I am alone, the pain floods over me and I can barely breathe. I keep coming back to pain. It’s about pain. Not control, nor attention seeking, nor escape; in that moment it is about wanting that pain in my heart to stop. To. Stop.

It’s a horrendous place to live to be honest. It’s a half life. I had to choose to live better. To live for me. To get help – medications, counselling, CBT, exercise, diet. It’s a conscious choice. And what helped me make that choice was being asked ‘RU OK?’

.

Post Script 2:

So, turns out it’s not a verbal gastro bug. It’s verbal C.Diff. The words just keep coming out.

I think I need to make it clear that I am talking about a period of over 10 years. I need to make it clear that I am talking about the past. I might write ‘I know’, but I suppose really it is ‘I knew’. Deciding to share this is a decision that has been easy, but it is a decision that I have made because these words have been in my head and they needed to come out. There are more things I could say, about specific attempts, specific feelings. However, I don’t want to share them. I think that’s OK.

I need to make it clear that I support ‘RUOK’ & WHO suicide prevention strategies. I need to make it clear that if you judge me negatively based on what I have written or if it changes your opinion of me, then that’s your thing, not mine. I’m not asking for agreement or understanding, but I do ask for kindness.

I was asked recently what the best thing in my life is right now. Aside from Nursing, the answer is the people in it. I know that my people love me, and accept ‘me’, and that’s enough.

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

Black Dog Institute Healthy Living Study is a program to help those experiencing suicidal thoughts manage them: http://www.blackdoginstitute.org.au/public/research/participateinourresearch/index.cfm

End.

Short URL:  meta4RN.com/guest02

Many thanks to Stevie Jacobs for sharing this gutsy piece of writing. Your sensitive, constructive feedback is welcomed in the comments section below.

It’s also important to acknowledge that talking and thinking about suicide can be distressing. People in Australia can access support via:

Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

This guest blog post has a companion piece, which I have imaginatively called “A Blog About A Blog About Suicide” – the link is here: meta4RN.com/mindframe

Paul McNamara, 23rd September 2014

Sample Clinical Supervision Agreement

During the week I co-facilitated three days of workshops about Clinical Supervision with Paul Bailey, Clinical Supervision Program Coordinator, Queensland Centre of Mental Health Learning (QCMHL). As with other workshops I’ve had the pleasure of co-facilitating with Paul, it was an immersive learning experience that inspired, exhausted, and uplifted participants and facilitators alike.

QCMHLAmongst the many factors of the art and craft of clinical supervision discussed at the workshop was the importance of negotiating and documenting a sound Clinical Supervision Agreement. The agreement is what defines the doing of clinical supervision. It acts as an anchor to stop the supervisee, supervisor or the supervision relationship drifting aimlessly.

Examples of clinical supervision templates are available via QCMHL’s Clinical Supervision Resource Centre for Mental Health Services, the Australian College of Mental Health Nurses and elsewhere on the internet.

With the consent of the excellent Clinical Supervisor I have had the privilege and pleasure of working with over the last five years, on this webpage I am adding another version to those examples that already exist. This version is more detailed than most. For a period of time I was employed a couple of days a week as Nursing Professional Leader: Clinical Supervision (more about that on my LinkedIn page). The purpose of the role was to promote and, as much as possible, embed clinical supervision into mental health nursing practice in my local health service.

ACMHNCSAs a way to increase understanding of the process of clinical supervision I wrote an agreement that is.. umm… thorough. Actually, I think the agreement is probably over-inclusive for the needs of most people, especially if they are beginning supervises or supervisors. However, I was in a role that included the responsibility to educate, and encourage and model best practice, so tried to consider most of the factors of a “good” clinical supervision agreement.

I now offer this detailed version to the internets. Please do not consider this to be a template for what a Clinical Supervision Agreement should look like, however it may be useful as a sample for you to use and adapt as you see fit.

Anyway, with no further ado, here it is as a Microsoft Word document:

Sample Clinical Supervision Agreement in WordSampleClinicalSupervisionAgreement

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and, as PDF:

Sample Clinical Supervision Agreement as PDFSampleClinicalSupervisionAgreement

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and, for those who are paranoid careful about following the links above, here is the de-identified content of my Sample Clinical Supervision Agreement:

Clinical Supervision Agreement

  • Supervisee: [name and role/team]
  • Supervisor: [name and role/team]
  • Period of this Agreement:  [start date] to [end date]

The content/structure of this Clinical Supervision Agreement is adapted from Clinical Supervision Guidelines for Mental Health Services (Queensland Health, October 2009, p. 22) & the sample agreements made available in the Queensland Centre of Mental Health Learning (QCMHL) Supervisor’s Toolkit (2009, pp. 14-20).

Objectives

  • Supervisee
    • Restorative
      • To discuss clinical scenarios that I have faced, in a manner that is supportive and constructive.
      • To reflect on my responses to the challenges & issues I face in clinical practice.
      • To reflect on my responses to the challenges & issues I face in providing clinical supervision.
      • To identify counter-transference and prevent it from impairing my ability to work safely.
    • Formative
      • To improve skills and knowledge in delivering clinical services.
      • To improve skills and knowledge in the practice of providing education.
      • To improve skills and knowledge in the art and craft of clinical supervision.
    • Normative
      • To stay orientated to best-practice by checking adherence to Clinical Supervision Guidelines for Mental Health Services (Queensland Health, October 2009).
      • To ensure that my clinical practice & clinical supervision roles are each performed within the boundaries of best practice as determined by the Mental Health Act, Nursing & Midwifery Board of Australia and Queensland Health codes & policies.
  • Supervisor
    • To assist the Supervisee meet their objectives.

Expected Outcomes

  • Supervisee
    • Over the course of this agreement these outcomes will be met:
      • Restorative
        • To have discussed 4 or more clinical scenarios that I have faced, in a manner that is supportive and constructive.
        • To have reflected on my responses to the challenges & issues I face in 4 or more instances of clinical practice.
        • On 4 or more occasions, to have reflected on my responses to the challenges & issues I face in providing clinical supervision.
        • On 4 or more occasions explore counter-transference and the impact it has on my ability to work safely.
      • Formative
        • To have provided quality clinical practice for the majority of clients I have been referred.
        • To recognise occasions when my clinical practice has been below-par, and attempt to redress the underlying cause(s) of this.
        • To have provided quality education sessions.
        • To have provided quality clinical supervision.
      • Normative
        • That my clinical supervision be informed by the best-practice Clinical Supervision Guidelines for Mental Health Services (Queensland Health, October 2009).
        • That my clinical practice & clinical supervision role have been performed within the boundaries of best practice as determined by the Mental Health Act, Queensland Nursing Council policies and Queensland Health codes & policies.
    • Supervisor
      • By reflecting well on the goals Paul and I have agreed upon, he will have improved and consolidated his competency, his capability and his capacity in his mental health nursing role as well as making the transition with greater confidence into his role in clinical supervision. We will measure the progress through our regular reviews within supervision.

Obligations

  • Supervisee
    • Demonstrate the value placed on clinical supervision by quarantining the time set-aside for clinical supervision from other appointments & interruptions.
  • Supervisor
    • To set aside sufficient time before meeting with Supervisee to ready myself for quality reflection with him by disengaging from other commitments.

How will dual roles (eg: workshop co-facilitators, colleagues) be managed

  • Performance & planning issues regarding the work we do together will not be discussed in clinical supervision unless there is mutual consent. This will require inclusion in a pre-agreed session agenda.
  • We have had some experience in managing dual roles on occasions over the last three years; it is expected that the mutual respect we have established will continue to inform how and when boundaries are drawn and shaped.

Structure

  • Frequency
    •  Every month, with a degree of flexibility that allow for the vagaries of each other’s holidays & other work commitments.
  • Duration
    • 50-60 minutes
  • Location
    • Primarily via phone.
    • When we’re both in the same town/area we will endeavour to schedule an opportunistic face-to-face supervision session.
  • Resources
    • Quarantined time & venue, with an absence of interruptions.
    • Access to telephones.
    • Access to emails in the days leading up to sessions.
  • Cancellation
    • The nature of mental health work is such that it is common for a consumer or the workplace to be in crisis.
    • A busy day or busy week is not an adequate reason to cancel clinical supervision; in fact the more common the crisis the greater the indication for clinical supervision.
    • Consequently, for the purposes of this agreement, a crisis that warrants cancellation of a clinical supervision would be of the scale where there is a fire in the workplace requiring evacuation of staff and patients.
    • Given this definition, cancellation of clinical supervision will be a rare event.
  • Preparation
    • Phone number for Supervisee/Supervisor to dial to be confirmed by email.
    • Other preparation (eg: reading journal article, preparing sample reports and documentation) as negotiated.
  • Agenda
    • Supervisee to set a simple agenda & email this to Supervisor a day or two prior to each session.
    • The Supervisor may add to &/or adjust the agenda.
  • Availability between Sessions
    • Usually by email only.
    • Phone availability may be able to be negotiated if it is mutually convenient to do so, but this is expected to be in exceptional circumstances only.
  • Is supervisee currently receiving other supervision?
    • Yes, with a Nursing colleague [named here]
  • If yes, how will different forms of supervision be integrated?
    • The goals of this supervision agreement relate primarily, but not exclusively, to clinical practice and clinical supervision.
    • The goals of the other supervision agreement relate primarily, but not exclusively, to cross-cultural issues and pseudo-team leader tasks.
    • Consequently, it expected that each form of clinical supervision will have areas that overlap a little, but are primarily focused on different components/roles.

Evaluation

  • What is the agreed process for evaluating Clinical Supervision?
    • Each Session
      • Wrap-up discussion at the end of session to include a mutual check between Supervisor and Supervisee whether the goals of supervision are being adequately addressed.
      • If the Supervision relationship itself is causing problems, the Supervisor and/or Supervisee will ensure that this matter is included on the agenda for the next session.
    • Every 12 Months
      • Formal mutual evaluation of supervision will be conducted using this Clinical Supervision Agreement:
        • Are the objectives/outcomes being met?
        • Should the agreement/objectives be modified?
      • and the Supervisor Workbook:
        • EPSI (Evaluation Process within Supervision Inventory)
        • SWAI (Supervisory Working Alliance Inventory)

Review of Supervision Agreement

  • The agreement should be reviewed if the objectives, expected outcomes, obligations, or structure of clinical supervision change.
  • Mutual review a month prior to the end-date of this agreement to allow time for extension or conclusion of the agreement & the supervisory relationship.

Documentation/Records

  • What form will supervision records take?
    • Agendas will be simple emails (see “Structure” above).
    • As per attached “Clinical Supervision Record”, themes of the session will be recorded as numbers & brief comments will be made as required.
    • It is understood that notes regarding supervision will be more extensive and detailed if there are concerns about clinical competence/client safety. This will be done in a transparent manner where both Supervisee and Supervisor will have access to the clinical supervision record.
  • How will these supervision records be used?
    • To assist the Supervisee & Supervisor reflect on their work.
    • As an adjunct to the Clinical Supervision Evaluation process.
    • As a record of Clinical Supervision.
  • Who will have access to them and in what circumstances?
    • Under usual circumstances:
      • Supervisee
      • Supervisor
    • When there are concerns about clinical competence/client safety:
      • Line Management. This will be done in a transparent manner where both Supervisee and Supervisor are fully informed of the rationale.
  • Where will the records be stored?
    • On the Supervisee’s password protected Queensland Health drive/server (as per filepath of this document – see footer).
  • Duration of Storage.
    • 7 years
  • What records will be used/provided for performance purposes (eg. That practice supervision has occurred)?
    • The Clinical Supervision Record (copy attached).

Ethical Issues

  • How will difficulties in supervision be dealt with?
    • Difficulties in supervision initially to be discussed between supervisor and supervisee either at the time an issue arises or at the commencement of the next meeting.
  • What if the supervision relationship completely breaks down?
    • If the supervision relationship breaks down completely a third party will be invited to assist.  If relates to an operational matter should be the team leader or if of a professional matter then utilising a senior staff member.  If all other options explored and unable to resolve then utilise HRM or EAS.
  • What do your professional code and organisational policies outline as ethical conduct in and for supervision?
    • The Queensland Health ‘Clinical Guidelines for Mental Health Services’ (October 2009) serves as our reference tool regarding ethical conduct in. The guidelines describe the principles of choice, flexibility & confidentiality as being central to best practice in Clinical Supervision.
  • In general, which issues raised in supervision will be kept confidential to this relationship
    • Any matter that is personal to the Supervisee or about any patient he discusses, except if there are serious concerns about safety or competency. Pages 25 – 27 of the Queensland Health ‘Clinical Guidelines for Mental Health Services’ (October 2009) describe the circumstances & process for taking matters outside of the Clinical Supervision relationship.
  • Which aspects may be discussed and with whom?
    • It is acknowledged that the Supervisor will develop a unique insight into the Supervisee’s reflective learning and ethical practice. Consequently, the Supervisee may request that the Supervisor act a referee for future performance appraisals and/or employment opportunities. The Supervisee will discuss this with the Supervisee prior to nomination.
  • Content
    • The content of Clinical Supervision will be negotiated in confidence by The Supervisee and Supervisor. It will include a list of the knowledge and skills that the Supervisee would like to develop, and will be regularly reviewed and renegotiated.

Signatures & Date

  • Supervisee:
  • Supervisor:
  • Supervisee’s Line Manager:

That’s It

This is a long, detailed Clinical Supervision Agreement. I do not present it as a template of what everyone should be doing, but as a sample of some of the content that such an agreement could include. I hope I haven’t scared anyone off clinical supervision with the length/detail of this agreement – clinical supervision is too important.

Clinical supervision allows us clinicians safe, regular and purposeful guided reflective practice to keep us and our patients safe – I’ve spoken about this before here and here.

As always, comments/feedback are welcome.

Paul McNamara, 13th September 2014

Short URL: meta4RN.com/sample
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Sample Clinical Supervision Agreement by Paul McNamara is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Based on a work at http://meta4RN.com/sample.
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How to do Dodgy Research: A Case Study

Please let me present an excellent example of dodgy research, which in this instance is an online survey being touted as “public consultation”. I’m being a bit chicken by intentionally avoiding using an example from nursing/health, and using an example from an industry that I am not involved in*.  The example I have come across is by the Far North Queensland Ports Corporation Limited, trading as Ports North (a Queensland government-owned corporation); more info about Ports North here: www.portsnorth.com.au.

In Cairns consideration is being given to dredging the shipping channel to allow larger ships to access the port. However, because Cairns is synonymous with the Great Barrier Reef there are concerns about the impact of dredging on the living coral. This has been reported in the local newspaper (The Cairns Post), on the radio (ABC Far North Queensland) and via local university researchers (Coral CoE @ James Cook University). Ports North is preparing an Environmental Impact Statement (EIS) and are seeking community feedback as part of the EIS process. All of that sounds good, until we look at the questions.

Let’s take a step-by-step look at the online survey together (eight screenshots follow):

1. Survey Introduction

1This is pretty good: it gives an explanation of the rationale for the survey, assures confidentiality, and is friendly and inviting: “Your feedback is important to us…” It is interesting to note the choice of words “expand the shipping channel” rather than “dredging the shipping channel”. Nevertheless, the survey is inviting community feedback to inform the environment impact statement, so it would be reasonable to expect there to be questions regarding this.

2. Awareness Question2

The options in the drop-down menu are “Yes” and “No”. A simple question that again uses the word “expand” rather than “dredge”. For your consideration: what influence does choice of words/language make in surveys?

3. Support Question

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The options in the drop-down menu are “Yes”, “No” and “Don’t Know”. Again, an interesting choice of words: I wonder if there would be a difference in responses if the question was changed from “Do you support this proposed community project?” to “Do you support dredging the shipping channel?”

4. The Push-Poll Question

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Despite the previous question allowing for alternative responses, this question prompts the participant towards an affirmative response. An excellent example of push-polling.

5. The Abstract Question

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We’re more than half way through the survey inviting community feedback to inform the environment impact statement. Still no mention of the environment in the survey, but at least this question does provide an opportunity for the participant to make mention of that, I guess. However, the question is a bit abstract – a random trawl for information that seems unlikely to yield much meaningful data to inform the environment impact statement.

6. Mailing List Question Number One

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This question has nothing to do with the environment impact statement, but offers a “Yes” or “No” choice to joining the Ports North mailing list.

7. Mailing List Question Number Two

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It does not matter what the response to the previous question is, the survey asks for contact details anyway.

8. The Demographic Question (Maybe)

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I guess this question aims to capture whether the research participants are part of the Cairns community or not. It is the final in the survey.

Summary

Ports North have created an online survey that claims to seek community feedback as part of the process of preparing an environmental impact statement. However, none of the questions address environmental issues.

This is an excellent example of how to do dodgy research.

So What?

How does this relate to the meta4RN blog related to nursing/health? Well, there is an argument to be made that links health to the environment and economy, but that’s not the prompt for me. My reason for using this case study is twofold: [1] it relates to something happening in my backyard, and [2] because this survey reminded me of some of the surveys that I have been exposed to in my nursing career. There have quite a few examples of “research”, “evaluation” or “satisfaction” surveys that predetermine the answers by limiting/skewing the questions.

In a related tangent, there are plenty of examples of quackery that are passed-off as health research/interventions that can confuse us and our patients. It is fitting for nurses, midwives and other health professionals to be vigilant to signs of dodgy research, as described in the sci-ence.org comic “The Red Flags of Quackery v2.0″:

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As always, comments are welcome.

Paul McNamara, 20th July 2014

P.S.

*Explanation re choosing an example to mock that is not directly related to health/nursing: I have a mortgage and don’t feel very secure. Call me “chicken”, but that’s they way it is at the moment. Cluck! Cluck!

 

 

 

 

Lalochezia

Many nurses and midwives are so adept at swearing that they can make truckies blush. Sailors and sportsmen gather at their feet to learn the fine art of uttering profanities.

There is, however, a small rightious subset of health professionals who are absolutely determined to take offence every time a patent gets a bit sweary.  These people seem to have no tolerance for the use of vulgar, foul language to express and relieve stress or pain. There is emotional release to be had when uttering indecent or filthy words.

The phenomenon of emotional release through swearing even has a name: “lalochezia” – a word formed from the Greek lalia (speech) and chezo (to relieve oneself). Sources 1 + 2

lalochezia

 

Words only have the power that we ascribe to them. As a judge sitting on cases regarding obscene language charges said, the use of swear words in Australia is very common in music, poetry, drama and literature, by ordinary people in the street, and by those in the corridors of power. The notion that they cause offence is an individual’s decision to react, not because of the rarity or harshness of the words themselves. Source 3.

Anyway, if we are fair dinkum about being patient-focused then swearing can be very useful.

Swear words are great adjectives – think of them as something akin to the pain scale. Instead of using the ” 0 = no pain and 10 = worst pain imaginable” routine, some of our patients will use their own qualitative and quantitative pain scale. It might include descriptors like “no worries”, “a bit of an ache”, “painful”, “bloody painful”, “really bloody painful”, “bastard of an ache”, “as painful as fuck”, etc.

Maybe its those dopey “zero tolerance” signs (and the dopey attitudes they engender) that make some clinicians react to swear words as if they are weapons. As I have argued previously (see meta4RN.com/zero), we should have zero tolerance for zero tolerance and not spend so much time and effort trying to shut-down people from expressing their distress.

Swearing not only communicates emotions but, as per the definition of “lalochezia”, acts as a pressure valve for those emotions. In clinical practice we should not be too quick to try turn off that pressure valve – it may prevent an explosion.

Suggested Further Reading

Stone, T. E. and Hazelton, M. (2008), An overview of swearing and its impact on mental health nursing practice. International Journal of Mental Health Nursing, 17: 208–214. doi: 10.1111/j.1447-0349.2008.00532.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0349.2008.00532.x/abstract

Print (PDF version): LalocheziaPrint

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As always, comments are welcome.

Paul McNamara, 12th July 2014

Short URL: http://meta4RN.com/lalochezia

 

 

 

Will GP copayment increase violence in hospitals?

Guest Post: Briana Scully has contributed this (first-ever) guest post to meta4RN.com

BrianaScullyBrianna Scully is a first year journalism student at the University of Technology Sydney. As well as writing stories for university, Brianna is also a Beauty Editorial Intern at Her Fashion Box. Although she hasn’t been studying journalism for long, Brianna is sure this is the right career path for her and wishes to work in print or television production in the future. @brianna_scully

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Will GP copayment increase violence in hospitals?

Although fire extinguishers are typically thought of as potentially life-saving devices, they proved the opposite to Paul McNamara when one was “being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward.” This is the chilling account of mental health nurse Paul McNamara in his blog titled Emotional Aftershocks. Paul, who works in the medical and surgical wards of a large regional hospital, is one example of increasing violence against nurses in Australia.

A 2013 survey by Nursing Careers Allied Health revealed 39 per cent of nurses had experienced violence in the past five years. With massive cuts to health in this year’s Federal Budget, medical professionals and experts predict that violence against nurses in hospitals will rise.

A spokesperson for the Victorian Branch of the Australian Nurses and Midwifery Federation said violence has increased due to “an increase in methamphetamine abuse by the public, staffing shortages in hospitals and longer waiting periods in emergency departments.” Michael Roche, senior health lecturer and coordinator of the Glueing it Together: Nurses, their work environment and patient safety study in NSW, believes adequate staffing is key in preventing violence, and that budget cuts to health will have a detrimental outcome. “We have found that a higher proportion of registered nurses was associated with lower rates of violence, so a corresponding reduction would likely increase rates. . .if fewer staff were available then it is easy to see how patients and families could become frustrated, increasing the potential for violence. 

 Paul McNamara believes violence against nurses was not as much of an issue for previous generations. “Intoxication with alcohol and amphetamines is certainly part of the problem, but there’s more to it I think; something to do with a change in culture perhaps.”

Tara Nipe, a nurse at a tertiary metropolitan hospital, believes the proposed $7 co-payment for visits to the GP will prevent early detection of illnesses and lead to increasing numbers of patients needing emergency care. “If it’s a choice between a $7 GP fee or bread, milk, cereal and spreads for a week, some people will decide not to go in about that red, sore patch on their leg, pain in urination, or really nasty cold . . . When they present to emergency departments they’ll be sicker, needing admission and expensive intervention, putting more pressure on an already stretched system, and increasing the kinds of factors that contribute to violence.”

According to an ABC article, Health Minister Peter Dutton claimed co-payments would be beneficial to those who can’t afford healthcare in the future. However, the NSW Shadow Minister for Health Andrew McDonald believes the co-payment is a “dreadful policy” that will be “extremely damaging to the Australian health system.” Dr. McDonald believes the most effective way to prevent violence is to abandon the co-payment. “It [violence] certainly is a problem that is increasing and one that will certainly get worse if our emergency departments go into meltdown, as is highly likely with co-payments.”

Despite the fact he was not physically harmed, Paul McNamara suffered emotionally after the event, writing: “[I] get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit.” Although there are calls for a ‘Zero Tolerance Policy’ where no act of violence is tolerated by medical staff, Paul believes a caring approach is more effective. “Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job.”

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Many thanks to Briana Scully for contributing this article, initially written as an assignment for her journalism course, to be the inaugural guest post on meta4RN.com. In keeping with an university assignment Briana listed her sources, but they have not been included on the online version. To contact Briana directly go via Twitter: @brianna_scully

As always, please feel free to leave comments below. I would be pleased to hear from others interested in contributing a guest post to meta4RN.com (especially, but not limited to, students who have an assignment that it is likely to be of interest to nurses and midwives).

Paul McNamara, 25th June 2014