Tag Archives: clinical supervision

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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Football, Nursing and Clinical Supervision

When I started this blog in September 2012 I made a half-joke that watching Adelaide play in the AFL can inform clinical practice (see Number 8 meta4RN.com/about).

Well, as it turns out, this is absolutely true. Please let me explain. 

 

The Adelaide Crows, like all elite sporting teams, spend a lot of time preparing to play. For those unfamiliar with Australian Rules Football (AFL) it’s a fast, free-flowing, physical game that is played weekly during the winter months. Here’s a sample of play:

A game of AFL is played over four quarters, each lasting approximately 30 minutes (nominally each quarter is 20 minutes, but the clock stops when the ball is out of play). So, any player who stays on the ground for every moment of the game will play for two hours.

Guess how much time the player spends preparing for that two hours.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Think about what goes into preparation: recovery from the previous game, keeping-up and improving fitness levels, practicing individual skills, practicing team skills, discussing and developing team strategies, having coaches give feedback on what you did well and what areas could be improved, developing on-ground leadership and communication skills, nurturing confidence in yourself and your team-mates, learning about the team you’ll be playing against next week. The list goes on.

My brother, Bernie McNamara, has seen the Adelaide Crows up-close and personal over the last few years. Bern says that typically during the season a player will have about 25 contact hours each week with the club, and be expected to do about 10 hours of preparation away from the club.

So, each week, a diligent AFL player will spend  about 35 hours preparing for no more than 2 hours play.

How does that preparation:work ratio compare for clinicians?

IMG_0423

It’s not just the explicit hands-on knowledge that counts, it’s also very important that we make time for thinking-about, discussing and reflecting on our clinical roles. Clinicians, like footballers, have a desire to improve, but we may have to fight for support to do so. As noted at a recent seminar regarding clinical supervision, “in a time of austerity, high caseloads and increasing problems, the organisation is often satisfied with a ‘good enough’ (work task) rather than seeking excellence. This tends to reduce supervision to a control function rather than aspiring to best practice.” Source: Talking about supervision: conversations in Bolzano and London 

I have written about clinical supervision previously (in “Nurturing the Nurturers” meta4RN.com/nurturers), but perhaps undersold it – some have commented that it seems like a feel-good exercise for clinicians. There’s more to it than that.

Clinical supervision is a key component in providing high quality services with positive outcomes for those who use health services. Clinical supervision promotes a well trained, highly skilled and supported workforce, and adds to the development, retention and motivation of the workforce. High quality clinical supervision also contributes to meeting performance standards, meeting the expectations of consumers/carers/families and goes a long way towards developing a learning culture in a changing health care environment. Source: ClinicalSupervision

Clinical supervision guidelines are very modest compared to the preparation:work ratio of AFL footballers. Clinical supervision requires nothing like the investment of 35 hours of preparation for 2 hours of play, instead, it’s something like 1 hour of preparation for every 80 or 160 hours of work.

Are nurses, midwives and other clinicians worth the expense?

I’ve been thinking about this tweet lately:

I’m wondering whether we can tweak that sign a little – maybe something like this:

The Financial Perspective: “We can’t afford to spend money on nurses and midwives sitting around talking, thinking and reflecting.”

The Patient Safety Perspective: “We can’t afford not to.”

IMG_0449

 

As always, your feedback/comments are welcome.

Paul McNamara, 27th April 2014

Zero Tolerance for Zero Tolerance

photoA while ago I wrote about my most frightening workplace experience in a post called “Emotional Aftershocks“, which included a section titled “Zero Tolerance is Unrealistic and Unfair”.

Today, via a Tweet by Nicky Lambert I am reminded of how ridiculous the “Zero Tolerance” approach in hospitals is and (more importantly) have been introduced to an evidence-based alternative strategy that has recently been launched in the UK. To cut-out the middle-man and go straight to source of this pretty-cool strategy, click on the link: www.abetteraande.com

To subject yourself to my ideas and waffle, please read on…

What’s Wrong with Zero Tolerance?

A dumb, shouty poster.

A dumb, shouty poster.

It is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. About 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. All the shouty “Zero Tolerance” signs in the world will not make a difference to this. Why would we want to create a false expectation for staff?

As an aside, during the week I made use of Australia’s Dementia Behaviour Management Advisory Service (DBMAS) regarding strategies to use with a nursing home resident who had been aggressive. I found the service to be very user-friendly and helpful – if you provide care to people with dementia you should keep DBMAS in mind: dbmas.org.au

Huh? Of course people will get angry: it is an unavoidable, natural human emotion.

Huh? Of course people will get angry: it is an unavoidable, natural human emotion.

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things?

Our health system relies on people being tolerant. This “zero tolerance” malarkey doesn’t allow for the reality that people in hospital are often having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

A Smarter, More Sophisticated Approach

We need a smarter, more sophisticated way to manage difficult emotions in the health care setting. “Zero Tolerance” is jarringly out of step with the nurturing, caring, compassionate, altruistic qualities that most health professionals identified with when choosing their career. We need a new set of posters that are attuned to the needs of patients and the aspirations of health services and clinicians.

Of course, it’s not just posters on the wall that determine the quality and tone of the conversation. All health care workers should have an opportunity to reflect on their practice in a safe, structured way. As I’ve written about before (in “Nurturing the Nurturers“) clinical supervision (aka guided reflective practice) allows this to happen. There is an abundance of evidence that clinical supervision improves management of difficult encounters in health care settings – we should insist on it.

Nevertheless, posters and signage can play an important part in setting clear expectations. Just as they’re doing in UK accident and emergency departments, let’s take a proactive approach to preventing and managing distress. Part of that strategy should be moving way from the authoritative, uncompromising and negative campaigns of the past, to one that demonstrates and models respect.

putyourhandup

This poster is my suggestion of the how we should set the parameters. Let’s not try to shut-down people from expressing distress. Instead, let’s invite patients and relatives to articulate their concerns before the emotions become so intense that they are difficult to contain.

Here’s the script to my poster:

Put your hand up and talk to us.

We don’t want you to feel distressed.

If you are feeling upset, frustrated or unsure about what’s happening please don’t bottle-it-up: talk to us.

One of the nurses, doctors or other hospital staff will listen to your concerns and try their best to help.

pdficonPDF version of the poster here: putyourhandup

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Acknowledgement

Some of the ideas here are taken from and/or informed by a keynote presentation by Professor Eimear Muir-Cochrane at the ACMHN 39th International Mental Health Nursing Conference, held in Perth, Western Australia, 22nd-24th October 2013. Some of the Tweets from that presentation have been collated here: storify.com/meta4RN/zero

What would your poster say?

Please feel free to share your ideas in the comments section below.

Paul McNamara, 7th December 2013

Emotional Aftershocks

Warning: today I will take the risk of being ridiculed for over-sharing and being melodramatic (it’s a grand tradition amongst bloggers).

8683188_lgCrap Day at Work

Recently at work I spent a bit of time wondering whether I, one of my nursing colleagues, or one of the hospital patients or visitors was going to sustain a life-threatening brain injury at the hands of a man brandishing a fire extinguisher as if it were a weapon. Fire extinguishers are generally thought of as potentially life-saving devices. However, when a fire extinguisher is being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward they don’t look like life-savers.

Fire extinguishers weigh 9kg and are made of steel. The fire extinguisher this man was holding looked a lot like a skull-cracking device to me. It was the most frightening workplace incident I have experienced.

I have been a nurse for 25 years. Like many nurses I have been struck while at work (39% of nurses have experienced physical violence according to this recent Australian survey, 36% worldwide says this quantitative review). I am lucky: I have only been hit by frail people with delirium or dementia, so have never been hurt – just surprised and amused. To illustrate: once, an elderly lady forgot I was the nurse making her bed, and suddenly started punching me (with the strength of a wet kitten) saying, “Stop it Malcolm! Don’t take my money from under the mattress and go to the pub again! You’re such a bastard Malcolm!” It was pretty funny – always wondered whether Malcolm was a memory from her past or a distortion of the present (probably a bit of both).

Zero Tolerance is Unrealistic and Unfair

I am not a fan of being abused or hit, but think that the “Zero Tolerance” campaigns that have popped-up in health services in Australia over the last 5-10 years are unrealistic and unfair.

This shouty "ZERO TOLERANCE NO EXCUSE FOR ABUSE" poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

This shouty “ZERO TOLERANCE NO EXCUSE FOR ABUSE” poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

Unrealistic because it is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. More than half of older persons admitted to hospital will experience delirium, and about 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. We can look out for the warning signs and be proactive in protecting ourselves, but we can not expect to transfer responsibility for our safety onto someone who does not have the cognitive capacity to even keep themselves safe.

In the health system it is very common to be spending time with people who are having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things? Our health system relies on people being tolerant – this “zero tolerance” malarkey doesn’t allow for a bit of crap.

Care and Crap

"Nursing ring theory: Care goes in. Crap goes out." courtesy of http://www.impactednurse.com/?p=5755 [thank you Ian]

“Nursing ring theory: Care goes in. Crap goes out.” courtesy of http://www.impactednurse.com/?p=5755 [thank you Ian]

Instead of zero tolerance, it is more realistic to expect that patients will occasionally need to vent their emotions. Not just the pleasant emotions like love, joy, gratitude and kindness, but also the less comfortable human emotions like grief, anger, sadness, worry, despair, frustration, fear, pain and hate. For these emotions swear words are adjectives, a raised voice is empowering, tears are cathartic.

In “Nursing Ring Theory” (more info here: impactednurse.com) when someone is in a ring that is smaller than the ring you are in you offer support, compassion, care and skilful expertise. When someone is in a ring that is larger than yours you are allowed to ventilate your emotions with them. It is pure client centred care: everyone sends care going towards the direction of the patient and accepts that there will be crap coming out at times.

This acknowledgement of crap coming out is not an offer to hold out nurses and other health care workers as targets for abuse. That’s not OK. However, let’s shelf the zero tolerance crap: of course we’re tolerant of people ventilating their emotions. All we ask is that nobody is put at risk and those closest to direct patient care also have an avenue to safely ventilate their crap.

In ring theory care goes towards the patient and crap moves away from the patient. Proximity to the centre of the ring will be a fair predictor of the intensity of both care and crap.

Fire Extinguisher Guy* 

Fire extinguisher guy is admitted to a medical ward for investigation of possible neurological disorder, but it might be something mental health related. So the Consultation Liaison CNC (me) spent a lot of time talking to fire extinguisher guy before the violent outburst, and again afterwards.

Fire extinguisher guy works hard, is creative, can be warm and funny at times; sadness, anger and tears bubble-up during our conversation then settle quickly. Talking to someone is both distressing and helpful, says fire extinguisher guy. He wants to get these strong, bouncing-all-over-the-place emotions under better control. Fire extinguisher guy’s experience of terrible abuse in childhood and his recent over-the-top cannabis and alcohol use wouldn’t be helping his labile hypomanic symptoms.

Fire extinguisher guy isn’t an unlikable person – he has a job, a car, a girlfriend, workmates, footy mates, other friends and a family. Fire extinguisher guy and the people who love him are all normal people. Fire extinguisher guy is one of the 20% of Australians who will experience problems with their mental health this year.

I am really grateful that fire extinguisher guy made the choice to direct his violence at property and not people. He had the capacity to make a very bad decision to hurt somebody; he chose not to. The only person physically harmed during this violent outburst was fire extinguisher guy himself: cuts from punching glass, bruises from punching and kicking windows, doors and walls of the medical ward.

I can’t figure out how long fire extinguisher guy’s violent outburst lasted. Replaying the scene in my mind I guess it was less than 2 minutes, but it’s like time measured in dog years… even though everything happened very quickly it somehow felt like slow motion too.

The fire extinguisher had been hurled into a storeroom doorway (THUD! CRACK!), the outburst was tentatively over, and fire extinguisher guy’s mum and i were lightly holding him and talking to him quietly when security arrived. Fire extinguisher guy allowed us to lead to him to an empty room and was cooperative with all of our suggestions and interventions. He apologised first to me, then to each of the other clinicians who provided care in those first couple of hours after the event. His apologies were heartfelt. He let the nurses, the doctor and the cleaner go about their business uninterrupted: his wounds were dressed, he accepted oral medications to dampen the intensity of his emotions, the blood and broken glass were cleaned-up, the other patients and visitors were reassured, detailed file entries were made, incident reports were filled-in, and negotiations between various members of the hospital’s multidisciplinary team were underway. The request for transfer off the medical ward could not be accommodated, but the insistence on two security guards overnight for staff and patient safety was.

Those of us up-close-and-personal to the incident took a couple of moments to exchange thoughts, but we tried not to get too bogged down in feelings at the time – it’s the beginning of the shift and fire extinguisher guy is just one of many patients on this busy medical ward.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

There is a hole in the wall that fire extinguisher guy created by punching it. One of the senior nurses on the medical ward covers the hole in with an anti-violence poster. We all laugh at the delicious irony and get on with our jobs.

As with the poster covering the hole, we crudely paper-over the cracks… it’s not fixing a problem, just covering it over… that’s good enough for now.

Emotional Aftershocks

In the days that follow I find myself a bit preoccupied at times thinking about the event. Get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit… acquired brain injury anyone?

Skull-cracking thoughts are from my fear and imagination not from what actually happened.

That’s a good reminder. Keep saying that.

I’m OK: no flashbacks, no vivid dreams, no avoidance, no hyperarousal. I was back at work the next day (left a few hours early because I stayed back a few hours with fire extinguisher guy the night before). I’m seeing patients in the same medical and surgical wards, spending time with my very supportive colleagues.

I’m OK: I’m resisting the urge to quietly whisper to every fire extinguisher in the hospital, “Stay where you are my little red friend. Stay gently hooked on the wall. Do not allow yourself to be raised higher than my head. Please don’t go violently leaping about medical wards – people don’t like that THUD! CRACK! sound you make. Stay exactly where you are my little red friend.”

I’m OK: I’ve told the story a few times now – it’s losing its potency. The funny bit about the poster is good – every story needs a punchline (you’re welcome). The scary bit about the fire extinguisher is getting less vivid – it feels more like a story from the past now. It’s turning into a half-joke about fire extinguishers staying on walls exactly where they belong.

I’m OK: the only thing I’ve noticed is a bit of kummerspeck (great word, eh?). Kummerspeck is a German word that literally translates as “grief-bacon” – it refers to the weight gained through emotional over-eating. I’ve had to let my belt out a notch, and my favourite shirt feels too tight. Still going to the gym, so it must be the eating, Better keep an eye on that.

Yeah yeah yeah. If you’re so OK why are you blogging about it?

Part of the motivation is catharsis. Very self-indulgent, I know.

More importantly, senior clinicians should offer information and support that will empower and protect junior clinicians. Just a few days after the most frightening workplace incident I have experienced these two tweets popped-up on Twitter:

I do not know either of these people IRL (In Real Life), but I do feel a tremendous responsibility towards Emily, Dani and any other nearly-nurse who is as enthusiastic and passionate as these two. But what to say to Emily and Dani? How do we nurture them safely into our profession and keep their enthusiasm intact?

Nursing – mental health nursing especially – needs people like Emily and Dani.

Sharing a battle story is not enough.

Referring to a patient as “fire extinguisher guy” is not a good example to set (more about that later – look for the red asterisk*).

As a senior nurse I should be supportive and encouraging to Dani, Emily and other enthusiastic nearly-nurses, and also be providing safety-tips and useful hints. I have two:

One: Make Like a Boy Scout

Be prepared.

Be prepared for some fantastic days at work where you’ll glide home feeling like you’re doing the most important and rewarding work that any one human can do. Those will be the days where you will use your knowledge-base, your skill-set and (most importantly) yourself to make a profoundly positive difference in somebody’s life. That person might never forget you.

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. Find out about stress reactions and how to be pro-active in protecting yourself. I have an old, kind-of-dicky resource to share with you here, but you might find something better.

Two. Nurture the Nurturer

I’ve written about this before: meta4RN.com/nurturers

I am so angry that my nurse and midwife colleagues don’t have ready access to clinical supervision as a tool to reflect on practice and keep themselves (and their patients) safe. People say it would be too expensive to provide clinical supervision to every nurse who wants it, but there is huge cost already being paid. This cost (in terms of relationship stress, sleep disturbance, emotional trauma, anxiety, depression, substance use and kummerspeck) is being borne by individual nurses and the people who love them. Clinical supervision allows another way – through guided reflective practice many of these costs can be prevented.

I don’t see why looking after a nurse’s practice and emotional self through regular confidential support with a trusted colleague would be any less important than looking after a nurse’s back. Australian health facilities all have tools, time and training devoted to safe lifting, it is time to provide tools, time and training devoted to safe thinking.

Clinical supervision is available to mental health nurses, but not nurses in general hospital wards. In his epic novel Catch-22, Joseph Heller wrote:

People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital.

It is the nurses that make death and illness more neat, orderly and ladylike.

It is the nurses who paper-over the holes punched in the walls.

It is the nurses who stay on the ward to make sure that care keeps going in.

The nurses should be provided with an avenue to let crap out.

Guided reflective practice (aka clinical supervision) should be available for all nurses and midwives.

Closing Remarks

I would like to leave the story there because I have waffled-on for a long time already. However, it is necessary to address two tricky subjects raised in this blog post: [1] mental health and violence, and [2] my use of “fire extinguisher guy” when referring to a hospital patient.

Mental Health and Violence

Let’s get the facts straight:

  • the overwhelming majority of people who experience mental health problems are not violent: never have been and never will be
  • most violence is not perpetrated by people with a mental health problem
  • people who experience mental health problems are more likely to be victims of violence than perpetrators

I started specialist education in mental health nursing in 1993 and have spent most (not all) of my career working in clinical mental health nurse positions since then. I have never been physically assaulted by a person experiencing mental health problems. Never. However, earlier in the week there was a newspaper article reporting that “half of the nurses working on hospital psychiatric wards are themselves suffering from mental illnesses such as post-traumatic stress disorder, depression and anxiety.” I know that I have been more fortunate than some of my colleagues.

There are lots of myths and misunderstandings about mental health and violence. Please scroll to the bottom of the post for evidence-based resources and references.

Explanatory Note re the use of “Fire Extinguisher Guy”*

Using the term “Fire Extinguisher Guy” protects confidentiality and is, obviously, an irreverent, playful way to refer to a person. I don’t think this is wise for somebody creating a professional social media portfolio – somebody might think I’m being disrespectful.

Yet, here i am doing it anyway. Why?

Irreverence, humour and playfulness can be useful defence mechanisms: used correctly they can trivialise the other/traumatic events and empower the self. During the event I did what I could (very little) to assist this man to regain control and to keep himself and others safe from physical harm. It would not be useful to dwell on how powerless and vulnerable we all were at that time. I spent many hours talking to the man both before and after the event and treated him with kindness, respect and dignity.

Care goes in. Crap goes out.

This blog post is some crap coming out.

End

As always, your comments and feedback are welcome (scroll down).

Paul McNamara, 11th August 2013

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References and Resources re Mental Health and Violence

SANE Australia have a very readable resource, downloadable fact sheet and MP3 file here

Queensland MIND Essentials includes a resource for nurses and midwives caring for a person who is aggressive or violent here

The references below are via Australia’s Mindframe National Media Initiative:

New South Wales Health. (2003). Tracking tragedy: A systemic look at suicides and homicides amongst mental health inpatients. First report of the NSW Mental Health Sentinel Events Review Committee.

Walsh, E., Buchanan, A., & Fahy, T. (2002). Violence and schizophrenia: Examining the evidence. British Journal of Psychiatry, 180, 490-495.

Noffsinger, S. G., & Resnick, P. J. (1999). Violence and mental illness. Current Opinion in Psychiatry, 12, 683-687.

Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal violence in a Danish birth cohort. Archives of General Psychiatry, 57, 494-500.

What has social media been saying about clinical supervision this week?

At the beginning of December 2012 an “online newspaper” was created using a tool called paper.li - the weekly publication is called “The Clinical Supervision Digest“. The aim of the publication is to answer the question, “What has social media been saying about clinical supervision this week?” With that question answered, perhaps we can quickly, easily stay up to date with new information regarding clinical supervision.

The content of “The Clinical Supervision Digest” is automagically curated by bots that crawl through Twitter, Google+ and Facebook searching for the term “clinical supervision”. A little playfully, but also respectfully, I’ve also added “Brigid Proctor” as a Twitter search term as of 19/01/13. Using the paper.li technology, the search results are collated, formated, and then released every Thursday morning (Cairns, Australia time).

CSscreengrabThis style of publication certainly doesn’t have the same sort of cachet as a peer-reviewed journal or traditional paper-based publication, but it does have some advantages. Along with flushing-out newly released research articles about clinical supervision, it also uncovers opinion pieces, blogs,  online conversations, conference news and course information. In this, the information age, we don’t necessarily want to limit ourselves to academic papers alone – social media is a wonderfully effective way to share new findings quickly and broadly.

My perception is that the quality of the paper.li searches/the online newspaper has been getting better over the last six weeks. I assume (hope) that we who are using the newspaper are “teaching’ the paper.li bots (aka web crawlers) what we’re interested in. That is, I think (hope) that the bots see which articles we click the most each week, and have been modifying the search and collation functions to give us more of the same. If so, there is a delicious irony that a algorithm in a piece of software can inform and enhance the very human, very interpersonal activity of clinical supervision.

I wonder what our ancestors in clinical supervision would make of this; will robot-like web crawlers effectively become another part of the lineage of clinical supervision?

Maybe. Maybe not.

Either way, if you’re interested in staying up-to-date with information about clinical supervision, please consider subscribing to The Clinical Supervision Digest via this page. Subscription is free, and if you find the weekly updates useless or intrusive it’s quick and easy to unsubscribe.

Paul McNamara, 21st January 2013

Post Script (aka my Lance Armstrong moment)

This post is an obvious companion piece to a previous post: What is social media saying about perinatal and infant mental health this week?

Yes, self-plagiarising is alive and well in tropical FNQ.

Nurturing the Nurturers

Lately I’ve been thinking a lot about how we nurture those who nurture: nurses and midwives especially. It’s a subject that has popped-up in a couple of journal articles, on social media (including my recent blog), and in conversations at work.

Before we think about nurturing nurses, let’s think about miners.

Believe it or not, the mining industry with its big burly blokey image has some valuable lessons in nurturing for us namby-pamby health industry types.

Pit Head Baths + Pit Head Time

Back about 100 years ago Welsh coal miners said to their bosses, “We work hard in your mines all day. We get sweaty and covered head to toe with coal dust from your coal mines. Then we go home and use our time, our bath, our laundry to get cleaned up. It’s a mess of your making, shouldn’t the daily cleanup be your expense?”

Then, as now, the mining industry bosses threw their collective hands in the air and said, “No! We can’t afford to do that! Your excessive demands will send us broke!”

So the miners went on strike.

And stayed on strike until, eventually, the mining companies installed pit head baths so miners could get cleaned-up and changed in the boss’s time, using the boss’s resources. It’s called “Pit Head Time”: it’s enshrined in award conditions for miners and pit head baths are just part of the infrastructure of mines.

Todd and Brandt clocking-off.

Todd and Brandt clocking-off.

Remember the Beaconsfield miners emerging clean and shiny after a fortnight underground? They clocked-off AFTER getting cleaned and changed. The infrastructure is in place – somewhere between the working part of the mine and the clocking-on/off area is a shower and change room – the pit head baths. The miners clock-off by moving their tag from the red “underground”  section of the board to the “safe” green area of the board. That’s how pit head time works – you clock-off after you’ve cleaned-up.

"Care for the Caretaker" generously shared by Kath Evans via Twitter: https://twitter.com/KathEvans2

“Care for the Caretaker” generously shared by Kath Evans via Twitter: https://twitter.com/KathEvans2

So what?

Nurses don’t usually get covered in coal dust.

Nurses do emotional labour.

Nurses get covered head to toe in the emotional experiences of people who are, very often, having the worst, most traumatic, day(s) in their life.

Shouldn’t nurses get cleaned-up on the boss’s time too?

Clinical Supervision

Clinical Supervision is the name given to the process of cleaning-up after doing emotional labour.

Clinical Supervision is a slightly clumsy name for it, because the word “supervision” implies scrutiny. Nurses are a bit thingy about scrutiny. Nursing was born in the church and raised by the military – it has shameful history of bombastic, bullying, bellowing scrutiny. Nursing and feminism (ie: the gender equality movement) have fought hard to overcome the worst of some very bad power imbalances. That’s why it’s understandable that some nurses are cautious about volunteering for something called “Clinical Supervision” without understanding it fully.

Clinical Supervision does go by some nom de plumes: “Supported Reflective Practice” and “Guided Reflective Practice” being the most common alternatives I’ve come across. Whatever the nomenclature, they each generally attend to the same task – assisting and supporting the clinician to reflect on their work, with the intent of keeping them and their practice safe.

ProctorCSBrigid Proctor is considered one of the rock stars of Clinical Supervision, mostly because she had the capacity to simply articulate the primary functions of Clinical Supervision.

The Formative Function of Clinical Supervision (learning) attends to developing skills, abilities and understandings through reflecting on clinical practice. We don’t know what we don’t know; sometimes it is only through reflecting on our work with a trusted colleague that we get a glimpse of some of our blind spots.

The Normative Function of Clinical Supervision (accountability) is concerned with maintaining the effectiveness and safety of the clinician. Sometimes we need a trusted colleague to prompt us to revisit clinical practice guidelines, policies, procedures and legislation as a way to make sure we’re working within expected norms in everyday practice.

The Restorative Function of Clinical Supervision (support) addresses the inevitable emotional response to the privilege, the frustrations, the joys, and the stresses of working in a caring, nurturing role. Sometimes it is only through discussing our work with a trusted colleague that we recognise the emotional effects of our work, and learn how to manage our reflex responses.

It is the restorative function of clinical supervision that I value the most. By (metaphorically) cleaning-up the dust and grime I get covered in doing emotional labour, I feel that I am being nurtured, sustained. By being nurtured in the workplace not only do I avoid spending my entire wage at Dan Murphy’s bottle shop as a maladaptive coping strategy, but it also equips me with the capacity to nurture others.

http://www.psychologyboard.gov.au/documents/default.aspx?record=WD12%2F7465&dbid=AP&chksum=wn1dw%2FoJV9PLEAY7hO5kJw%3D%3DIn some workplaces (mine included) there have been attempts made to make Clinical Supervision part of the infrastructure, just like the showers and change rooms the Beaconsfield miners used. If you’re interested in an example of what the infrastructure for assisting clean-up after emotional labour looks like, take a look at the Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services [PDF].

I know that many of my Nurse and Midwife colleagues don’t have this infrastructure available to them, and I can’t understand why. If it’s good enough for miners to have pit head baths and pit head time, surely it’s good enough for Nurses and Midwives to have Clinical Supervision.

Shouldn’t we be nurturing the nurturers?

Paul McNamara, 15th January 2013

That Was Bloody Stressful! What’s Next?

It was 1998 when the decision was made to use comic sans and screen beans in this staff resource... the idea was to make a heavy subject accessible. Please don't judge me.

It was 1998 when the decision was made to use comic sans and screen beans in this staff resource… the idea was to make a heavy subject accessible. Please don’t judge me.

Gather around children, Uncle Paul has a story to tell…

No! Don’t run away! It’ll be quick, I promise!

Back in the late 1990s I was working as a Nurse Educator in Community Health – it was good to get back in touch with general nursing after a few years in mental health. One of the things that popped-up at the time was that some staff (both clinical and non-clinical) were getting pretty stressed-out at work, usually because of work-related stuff. My boss at the time was keen to tap-into my background in mental health to see if it was something we could address as an organisation.

Some of the nurses, indigenous health workers, admin officers and cleaners I chatted to at the time made it clear that they didn’t want to show their vulnerabilities to clients, colleagues or management for fear of being thought of as weak or unable to cope. Staff asked for information and support that could be accessed discretely, without it being necessary to disclose anything to anyone at work.

One nurse put it succinctly: “This place is bloody stressful. There’s no avoiding it. We know we’ll cop stress, we just don’t know what to do about it; about what comes next.”

That’s how the staff resource, That Was Bloody Stressful! What’s Next? was born. Since 1998 it has been on the workplace intranet. We told people how to find it, “Just search for ‘bloody stressful’ on QHEPS”, and asked that they pass the tip on to workmates. It has sometimes been used with general hospital patients too – feedback is that some patients find it validating to know that staff can relate, in part at least, to their experience of having a stress reaction after a traumatic event.

Over recent years information about the organisation’s employee assistance program has become much more visible and easy to access on the intranet; so much so that a dinky, amateurish, screen-bean & comic-sans laden little PDF with 10-year-old references probably isn’t really necessary anymore. Nevertheless, we made the decision a couple of months ago to keep it available because each month a dozen people or more search the organisation’s intranet using these key words: bloody stressful.

Here is what they find: BloodyStressful

Perhaps you’re wondering why, in 2013, I have decided to liberate this shabby-looking resource from the intranet to share with the internet. Well, nurses experiencing secondary traumatisation popped up as a topic in a Twitterchat last month, in a Google+ community a week ago, and again on Twitter this morning.

Nurses do emotional labour. Maybe we should pool our thoughts and resources about how best to manage the effects of this.

Paul McNamara, 4th January 2013