Tag Archives: nursing

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

3

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

4

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

6

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

7

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″:

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As always, comments are welcome.

Paul McNamara, 20th July 2014

P.S.

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

 

 

 

 

Lalochezia

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

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

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

lalochezia

 

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

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

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

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

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

Suggested Further Reading

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

Print (PDF version): LalocheziaPrint

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As always, comments are welcome.

Paul McNamara, 12th July 2014

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

 

 

 

Will GP copayment increase violence in hospitals?

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

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

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Will GP copayment increase violence in hospitals?

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

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

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

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

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

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

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

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

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

Paul McNamara, 25th June 2014

 

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.

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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

List of Australian Nurse Colleges

Australia-map-wall-art-sticker-62Professional associations in health often (not always) define themselves as colleges. That is, a formal group of colleagues who abide by the same set of standards or laws.

I could not find a single list of Australian colleges of nursing and midwifery, so have created one here, and have added a couple of college-like speciality nursing associations. Inclusive, not exclusive.

To keep this alphabetical list simple but useful, links to each college’s website, Twitter and Facebook page have been added.

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Australasian Cardiovascular Nursing College Web Twitter Facebook

Australasian Neuroscience Nurse’ Association Web Twitter Facebook

Australian Association of Stomal Therapy Nurses Web Twitter Facebook

Australian College of Children & Young People’s Nurses Web Twitter Facebook

Australian College of Critical Care Nurses Web Twitter Facebook

Australian College of Mental Health Nurses Web Twitter Facebook 

Australian College of Midwives Web Twitter Facebook

Australian College of Neonatal Nurses Web Twitter Facebook

Australian College of Nurse Practitioners Web Twitter Facebook

Australian College of Nursing Web Twitter Facebook

Australian College of Operating Room Nurses Web Twitter Facebook

Australian Nurse Teachers’ Society Web Twitter Facebook

Australian Primary Health Care Nurses Association Web Twitter Facebook

Australian Society of Post Anaesthesia and Anaesthesia Nurses Web Twitter Facebook

College of Emergency Nursing Australasia Web Twitter Facebook

College of Remote Area Nurses of Australia (CRANA is now a multidisciplinary organisation for all remote health professionals; to reflect this they have re-badged as CRANAplus) Web Twitter Facebook

Drug and Alcohol Nurses of Australasia Web Twitter Facebook

Renal Society of Australasia (mostly, not exclusively, nurses) Web Twitter Facebook

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Thanks to RoxaneStefan CampbellCaleb Ferguson, Jess and  Clinical Educators for their suggested additions to the list. Part of the Twitter consultation process revealed that there are existing lists here: www.nurseinfo.com.au/links.html (thanks Roxane) and here http://www.conno.org.au/members (thanks Colleen). Nevertheless, please let me know of the colleges/links I’ve missed in the comments section below.

Paul McNamara, 11th May 2014

You are welcome to link to/share this page. Short URL: http://meta4RN.com/colleges

 

 

Luddites I Have Known

In the never-ending quest to enthuse midwives and nurses about professional use of social media I’ve talked to people about it, given inservice education sessions, demonstrated is use as an adjunct to education, facilitated workshops, submitted conference posters, contributed to journal articles and have been invited to speak at conferences. To spread the word I’ve taken the risk of being called geek wanker narcissist, and even had cards printed:

BusinessCard4

When I talk to people about health care social media, I always mention how it lets information be shared quickly and easily,  and network with people from a range of professions/walks-of-life from all around the world. However, the thing I value the most and try to emphasise the most, is the participative, interactive nature of social media. Social media is where the debates are held; those of us who want to influence and participate in decisions gather and test our ideas on social media. Twitter is especially good for this: it lets anyone join in and contribute to- and be enlightened by- the contest of ideas.

To see how Twitter works to share information and the contest of ideas, see these two recent examples (click on the pics to see the complete conversations unfurl):

In health and education roles I encounter many people who give dumb blanket statements like, “I will never use Twitter – I don’t care what Justin Bieber had for breakfast”. Much to my embarrassment, this is the sort of thing I hear nurses (especially those in positions of influence and power) say all the time. These people are so stubborn that they won’t even look, listen or learn about professional use of social media.

A few months ago two Australian nurse lecturers forthrightly and very confidently told me that Twitter and facts are (somehow) mutually exclusive, and they do not and never will use it. I tried being zen about the whole thing (water flows around resistance, rocks in the stream shift or erode), and celebrated some of the nurse academics who are more enlightned about health care social media (see storify.com/meta4RN/lecturers).

However, the same thing keeps happening: people in positions of power and influence in the health care and higher education systems are still using silly, uninformed, blanket statements to decry the use of social media and warn people off from using it.

No more Mr Nice Guy – I’m calling these people what they are: Luddites.

People being resistive to new technologies and innovations is not new, and in my lifetime I have seen that change is inevitable – the luddites and laggards will catch-up eventually.

In the 1970s I knew people who refused to play video-games like Space Invaders – “No it’s too confusing, I’m sticking with the pinball machine” said my friend when we went into the pinball parlour.

In the 1980s I knew people who refused to use ATMs (automatic teller machines) – “No, you can’t trust a little card and machine. I’ll wait until the bank opens on Monday.” said my relative.

In the 1990s I knew people who refused to use computers. Every now and then I still hear people say, “I don’t believe in computers” as if computers are akin to the tooth fairy or religion.

In the 2000s I knew people who refused to use a mobile phone, “Why would I ever need one?”, people would say. Now, in Australia, there are more mobile phones than people (for more info: meta4RN.com/mobile).

In the 2010s I know people who refuse to use social media. As evidenced by the “I don’t need to know what Justin Bieber had for breakfast” type of statements, the reason they don’t use it is twofold: [1] they do not understand it, and [2] they decline the opportunities to learn.

I guess I should be patient with my resistive colleagues – history shows that they’ll come around eventually. However, for those nurses and midwives in positions of power and influence, I’m hoping people will print and fax you a copy of this picture below. If  you can’t summon the willingness to learn about professional health care social media, please summon the dignity and sense to stop critiquing something you do not understand.

luddites

PDF version (suitable to print and fax to a social media denier of your choosing): Luddites

As always, your comments/feedback is welcome.

Paul McNamara, 3rd May 2014

 

 

 

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

Trying to Stay Focused

PatientFocused Some days it feels like a cruel conspiracy.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. SystemsFocused So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes - can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system –  this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

Why? Because we are trying to stay focused - patient focused.

*Clarification re using the word “Patient”

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.

End

As always, your thoughts/feedback is welcome in the comments section below.

Paul McNamara, 6th April 2014

Nursing’s Peculiar Privilege

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

Suicide rates per year. Chart courtesy of www.mindframe-media.info

Suicide rates per year. Chart courtesy of http://www.mindframe-media.info

Parallel Processes

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Suicide rates per age group (2010). Chart courtesy of www.mindframe-media.info

Suicide rates per age group (2010). Chart courtesy of http://www.mindframe-media.info

Profound Moments

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff:  delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So,  I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

 Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

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

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

Paul McNamara, 19th January 2014