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
Creative Commons License
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

5

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)

8

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″:

End

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

End

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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End

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

 

Stay connected, stay strong… before and after baby

Copy of Stay connected, stay strong… before and after baby DVD on YouTube (33 minutes):

From the back cover of the DVD:

StayConnectedPregnancy, birth and parenting can be a very positive time, but sometimes it may not be how you expected it to be. Adjusting to life as a mother can be hard and make women feel down and distressed. In Australia, one in every six women experience depression during this time.

This DVD has been created to support Indigenous women, men and families understand the importance of good social and emotional wellbeing during pregnancy and beyond.

Going to get help might feel like the hardest part, but it is the best thing you can do for yourself, your baby and your family. Getting help early gives the best chance of a strong and healthy future.

YouTube URL: http://youtu.be/CLsjgw8pvOA

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Why is the Video Online?

The video is online so that it can easily reach the target audiences: Aboriginal and Torres Strait Islanders families, and those who support them. It is a great little video: not only does it have a very clear message that there’s no shame in asking for a bit of support, but it also looks and sounds great. My favourite thing is how the narration by Jasmin Cockatoo-Collins ties the whole thing together: even though a couple of dozen people appear on camera, Jasmin’s voice weaves the whole thing together so it kind of seems like one story. Well done to Jasmin and film-maker Jan Cattoni (Jan’s a nurse who became a film-maker).

Knowing that the video is so good that it should be shared is one thing, getting it shared is another.

Stay connected, stay strong… is available for free in Queensland and for $20 elsewhere, all you need is this PDF order form from the Queensland Centre for Perinatal and Infant Mental Health: http://www.health.qld.gov.au/qcpimh/docs/resource-order-form.pdf

youtube---the-2nd-largest-search-engine-infographicFar North Queensland residents can borrow the DVD from Cairns Libraries: link.

Queensland Health staff can access the DVD through the Queensland Health Libraries Catalogue: link

However, as accessible as all that sounds, the truth of the matter is that YouTube is the world’s largest video-sharing portal and the world’s second largest search engine. A video is not really accessible until it is online.

Now we can share the video using this link: http://youtu.be/CLsjgw8pvOA

Eek!

This is by far the riskiest thing I’ve done with my professional social media portfolio. I am not the copyright holder of this excellent short film: the Queensland Government is. Although I won’t make any money out of hosting the video, I might be subject to legal action. If there is a credible threat of legal action I will take the video down immediately. Another risk is that I might be inadvertently causing offence or distress to some person or organisation. This may mean that I will not be considered for future work in perinatal and infant mental health (perhaps funding for services will return to pre-July 2013 levels one day).

So, why take these risks?.

My agenda is simple: to demonstrate that social media can be leveraged as another channel for health promoting information. It’s something I started when working in perinatal and infant mental health in October 2011, as evidenced by this from my now-mothballed Twitter handle @PiMHnurse (now I use a less job-specific name: @meta4RN).

PIMHnurse

 

My big hope is that hosting Stay connected, stay strong… before and after baby won’t get me in too much trouble, but will serve as a spur for a more legitimate stakeholder to host the video on their YouTube or Vimeo site.

When that happens I will complete this post-script to the blog post:

Important Update DD/MM/YYYY:

Stay connected, stay strong… before and after baby is now hosted by [organisation name] at this web address: [web address]. The link and embedded video you see above are now from that site, and I have deleted the copy I posted on 7th June 2014 here: https://www.youtube.com/meta4RN

My intention in knowingly posting a video that I am not the copyright-holder of was to act as an agent of change. If I have caused harm or distress to any person or organisation I am genuinely sorry. That was not my intention.

End

That’s it. I’m feeling scared now.

Paul McNamara, 8th June 2014

A Mental Health Nurse in the General Hospital

MHCBelow is a copy of the blog post I was invited to submit at My Health Career. The website is targeted at high school and university students considering or pursuing a career in health, guidance officers, career development professionals, and others working in or with the health care sector.

To see the post where it was first published online, and/or to have a look around at the My Health Career website, please visit www.myhealthcareer.com.au/nursing/mental-health-nurse-paul-mcnamara

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A Mental Health Nurse in the General Hospital

Paul trying not to look too much like a goob.

Paul trying not to look too much like a goob.

Paul McNamara has extensive experience providing clinical and educative mental health support in general hospital and community clinical settings. He holds hospital-based, undergraduate and post-graduate qualifications, is Credentialed by the Australian College of Mental Health Nurses (ACMHN), and has been a Fellow of the ACMHN since 2007. Paul is a very active participant in health care social media, and is enthusiastic about nurses embracing “digital citizenship”. More info via his website meta4RN.com

There is an odd little sub-speciality of mental health services called “consultation liaison psychiatry”. This waffly, jargon-ridden mouthful of syllables is usually abbreviated to “CL”. What is CL? Easy – just think of it as “general hospital mental health”.

I’m a mental health nurse on a CL team. The only ward in the hospital I don’t visit is the mental health unit (the mental health unit already has heaps of mental health nurses – they don’t need me there). It’s the rest of the hospital I serve: the surgical wards, the medical wards and the maternity unit.

General hospital patients are more at risk of experiencing mental health problems than the general public – being sick is stressful. It works the other way around too: people who experience long-term mental health difficulties are more at risk of becoming physically unwell – being under lasting emotional stress can take a toll on the body.

Nurses, doctors, social workers and other allied health practitioners will phone CL when they have concerns about the mental health of a patient. Sometimes all that is required is a bit of information and clarification about medication or follow-up services available in the community – we do that over the phone. More often, we are asked to meet with the patient and determine what, if any, mental health matters can be sorted-out while they are in hospital.

The most common mental health problems experienced in the community are anxiety and depression – it’s the same in the general hospital – a lot of the people I meet with are experiencing either or both of these conditions. There are other mental health problems like eating disorders and deliberate self harm that sometimes require input from both the medical/surgical team and the mental health team concurrently. Helping-out with planning and providing support and care of these patients is a pretty big part of my job.

Sometimes it’s not the person in the pyjamas (the patient) who needs our support – sometimes it’s the communication, the systems and the clinical staff who benefit most from CL input. This can be in the form of structured education sessions or, more typically, in the form of supporting discussion, reflection and problem-solving on how best to meet the needs of the patient within the limited resources available in the hospital. In this aspect of the job, a CL nurse will try to help the clinicians involved step-back from the busyness and pressures of the hospital ward and take “a balcony view” of what is happening. By taking ourselves out of the chaos of a busy shift and calmly looking back at things with a bit of distance, sometimes we can see how we can “do business” in hospitals a little more constructively.

We also spend a lot of time “undiagnosing” (this is a “neologism” – a made-up word – I heard recently via Sydney psychiatrist Dr Anne Wand). The people we “undiagnose” the most are those who are experiencing grief. There can be a lot of grief in general hospitals, but we try to be careful not to confuse the emotions of grief (sadness, anger, temporary despair etc) with a psychiatric disorder. Grief emotions are often really uncomfortable but they are part of what makes us who we are. We don’t want to “psychiatricise” or “psychologise” the human condition. Grief is not something to be simply fixed; grief is a part of life – a difficult part of life – that is usually successfully navigated without psychiatric input. Support from loved ones and/or social workers and/or specific counselling services can help.

So, that’s an overview of what it is to be a mental health nurse in a general hospital. It’s a varied role where we spend nearly as much time with the general hospital nurses, midwives, allied health staff and doctors as we do with the hospital patients. The role involves direct clinical care, collaborating with colleagues and providing education. For more information on the speciality please visit my website or the consultation liaison nurses special interest group section of the Australian College of Mental Health Nurses website.

END

Print Version (PDF): CLnurse

Thanks to Amanda Griffiths of My Health Career for inviting me to submit this overview of consultation liaison nursing.

As always, your comments are welcome.

Paul McNamara, 2nd May 2014

 

Does the End Justify the Meanness?

Proposed changes to health funding in Australia’s 2014 Commonwealth Budget include direct costs (“co-payments”) to patients every time they see their GP or have pathology done, and an increase in the cost of prescribed medications. This extra revenue will be put towards medical research. Does the end justify the means meanness?

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine. Clozapine was initially introduced in the early 1970s but was withdrawn within a few years because some people died while taking it. Although clozapine is the only effective antipsychotic for some people with schizophrenia, about 1% of those who take clozapine will develop agranulocytosis (a dangerous drop in white blood cells, especially neutrophils – the most abundant type of white blood cells). Left unrecognised and unmanaged agranulocytosis leaves people very susceptible to serious infections and, as happened back in the 1970s, can even lead to death.

Schizophrenia is a bugger of an illness. Onset of symptoms is nearly always in teenage years or early twenties. Schizophrenia is often misrepresented as split personality – that’s wrong – it infers that a person can choose or control their symptoms. The word schizophrenia has it’s roots in the Greek language, translated it means split mind – people do not choose to have a split mind. Symptoms vary between individuals, but very often people with schizophrenia will experience thought disorder (non-sequential, disorganised, confused thinking), delusions (beliefs, often unsettling and difficult to understand, that are not shared by others) and auditory hallucinations (sounds or voices that nobody else can hear, but which sound and feel very real to the individual experiencing them). If these symptoms are intense or frequent they can really make a mess of the individual’s ability to function successfully in school, university or the workplace. Consequently people with schizophrenia are over-represented amongst the unemployed and homeless.

before

Because schizophrenia is such a bugger of an illness and clozapine can be so effective at dampening-down the symptoms, in the early 1990s clozapine was made available again with some very strict protocols in place to keep the people taking it safer from serious side effects. When starting on clozapine blood tests are taken every week to check that the neutrophils/white blood cell counts don’t drop. It is built-in to the infrastucture of clozapine management – you can’t get a prescription until you’ve had a blood test and the doctor checks it against previous blood tests. If there are any problems with the blood tests the doctor will stop prescribing clozapine – no ifs, ands or buts. For about 1% of people the risk of agranulocytosis will outweigh the benefits of staying on clozapine.

For the person with schizophrenia taking clozapine this regular regime of blood tests, visiting the GP and getting a short-term prescription (there are no repeat prescriptions for clozapine) might be the difference between being in hospital and being at home, or (sometimes) being homeless and being at home. Once initial treatment is established, safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP.

The proposed budget changes include a $7 payment to see the GP, $7 fee for out-of-hospital pathology, and an additional $5 for each prescription medication. What are the benefits of making schizophrenia treatment more expensive? Are there any foreseeable problems?

after

We are being told by our government that Australia’s universal health coverage is not under threat. $7 to visit a GP costs the same as two beers says our treasurer. What a sneering, mean thing to say.

People with schizophrenia, like people with diabetes, chronic obstructive pulmonary disease (COPD) and other enduring illnesses, are already at a social and financial disadvantage. For the individual with schizophrenia whenever there is an increased intensity or frequency of delusions, auditory hallucinations and disordered thoughts they suffer terrible distress. The people who love and care for them share in this distress. Often an expensive hospital admission for a few weeks is required to bring the symptoms back under control and sort-out the social problems that a period of being out of touch with reality can cause: unpaid bills and rent may lead to loss of accommodation; neighbours, friends and family may be feeling uncomfortable having you home again; your self care and physical health may have deteriorated; your tobacco, alcohol and drug use may have increased; you may have come to the attention of the police.

Do the benefits of co-payments really outweigh the risks?

IMG_0511

Final Notes

On Monday 19th May 2014 Joe Hockey, Australia’s Treasurer, will be appearing on Q&A. I have submitted this two-part question:

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine. 
Safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP. 
What are the benefits of making schizophrenia treatment more expensive? 
Are there any foreseeable problems?


You may have a question of your own for Mr Hockey, if so go to 
www.abc.net.au/tv/qanda

CoPayLogo2CoPayStories provides an avenue for patients and health professionals to share their perspective on the proposed GP co-payment – visit the website www.copaystories.com.au and/or follow @CoPayStories on Twitter.

For the purpose of this argument I’ve cited only one side-effect of one medication for one illness. I am aware that clozapine has more than one side-effect, and there are illnesses other than schizophrenia that require regular pathology, GP visits and prescriptions.

Thanks for visiting meta4RN: as always, you are welcome to leave feedback in the comments section below.

Paul McNamara, 17th May 2014

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