Providing medical and health professions students with academic and pastoral support is increasingly of interest around the world. The impact of student stress on their wellbeing, mental health and performance is well known, but staff are often not trained to assist students.  This interactive workshop aims to provide participants with opportunities to: 1.      Reflect on their experiences in supporting students and/or in supporting the staff who support students. 2.      Discuss with peers the personal and procedural issues which can arise when dealing with student concerns, and 3.      Identify appropriate staff responses, such as response flowcharts. Workshop activities will be tailored to the practical strategies for the participants’ work settings.

Supporting Staff who Support Students 00:00 Welcome Personal introductions – who we are, what led us to develop this workshop Providing medical and health professions students with academic and pastoral support is increasingly of interest around the world. The impact of student stress on their wellbeing, mental health and performance is well known, but staff are often not trained to assist students.  This interactive workshop aims to build on your experiences as professional, academic and clinical staff who support health professions students, and especially for newer staff members to hear from the experiences of more experienced staff. Wendy Hu1, Eleanor Flynn2, Robyn Woodward-Kron2 1School of Medicine, Western Sydney University 2Melbourne Medical School, University of Melbourne Acknowledgements: ANZAHPE & ACEN Research Grants

Aims To provide opportunities to: Reflect on experiences in supporting students and/or in supporting the staff who support students, Discuss the personal and procedural issues which can arise when dealing with student concerns, and Identify appropriate staff responses.

Overview Background Workshop activities tailored to practical strategies for your setting Video discussion triggers A critical incident response flowchart Please Note Scenarios based on many real life stories Feel free to share experiences, but keep discussions private within this group We will report briefly on research conducted at UWS and UoM that provided the impetus to develop this evidence based training resource. The workshop is designed to be practical and feasibly be delivered in busy teaching and clinical environments to all staff who deal with student concerns. Recognise that each training site and clinical school will have different processes, staffing, students and support service networks In particular, to test whether the training and issues raised are applicable in your setting (Malaysia, Sri Lanka) The aim is for you to reflect on and share experiences to date, take away a framework to further develop with the details appropriate to your setting Although resource has been designed from a study which focused on med students, previous workshops have shown it is relevant to supporting health professional students The workshop evolves with each group, so your feedback is particularly valued for further developing and releasing the training resource PLEASE NOTE: although the scenarios may seem familiar and bear resemblance to actual events, they are NOT based on any particular events, but are an amalgam of different staff experiences and stories that we have heard. Please note that while everyone should feel free to talk about their own experiences where relevant to the discussion, we should respect the privacy of the individuals concerned. So do not pass on anything that is discussed today in a way that identifies individuals. “Chatham House rules” Depending on size of group and how well they know each other: Small group, not known to each other: each person introduces themselves and describes their support role Larger group, known to each other: Ask for show of hands. Who is: Professional or administrative staff member? Academic staff member? In the front line for students seeking help? Other?

Why is supporting students important? JAMA Special Issue in Medical Education, 6th December 2016 Health professions students have unique stressors1-2 While all university students require support, health professional students will meet unique stressors (sickness, death, cadavers, challenging learning environment, ambiguity, dealing with distressed patients and families) Importance of student health and wellbeing Effects on patient safety and quality of care

Why is supporting staff important? Expectations to provide academic & pastoral support Professional staff are often the first point of contact On-campus services may not be accessible Little research on training and support needs of staff Providing academic and pastoral support to health professional students is expected by both the community and accreditation bodies Typically medical students (and significant proportion of health professional students) spend more than half their training off campus on clinical and community placements and at clinical schools, which are remote from on-campus student support and services We know that professional staff provide a lot of the support at the coal face and have to balance this with other administrative work that they do There is little work on the experiences and training needs of staff who support students, in particular professional staff REFERENCES – see Participant handout and Facilitator guides WFME STANDARDS for BASIC MEDICAL EDUCATION 4.3 STUDENT COUNSELLING AND SUPPORT Basic standards: The medical school and/or the university must • have a system for academic counselling of its student population. (B 4.3.1) • offer a programme of student support, addressing social, financial and personal needs. (B 4.3.2) • allocate resources for student support. (B 4.3.3) • ensure confidentiality in relation to counselling and support. (B 4.3.4) Quality development standards: The medical school should • provide academic counselling that § is based on monitoring of student progress. (Q 4.3.1) § includes career guidance and planning. (Q 4.3.2) Annotations: § Academic counselling would include questions related to choice of electives, residence preparation and career guidance. Organisation of the counselling would include appointing academic mentors for individual students or small groups of students. § Addressing social, financial and personal needs would mean professional support in relation to social and personal problems and events, health problems and financial matters, and would include access to health clinics, immunisation programmes and health/disability insurance as well as financial aid services in forms of bursaries, scholarships and loans.

What is the impact on staff from supporting students? Background Review of student support showed significant impact on staff Aims To investigate the student support experiences of professional and academic staff To develop evidence based training resources Method 11 sites (urban + rural) Participatory action research Interviews and workshops So we undertook to conduct a research study focusing on the effect on staff of providing support to medical students at our two medical schools It aimed to…. Flynn EF, Woodward-Kron R, Hu W. Training for staff who support students. Clin Teach, 2015. 12:1-6 Hu W, Mann R, Flynn E, Woodward-Kron R. From Paperwork to Parenting: Experiences of professional staff in student support. Med Educ, Published online: 5 DEC 2016 | DOI: 10.1111/medu.13143

Participants Interviews (n=40) No. of Participants 23 17 PROFESSIONAL ACADEMIC/CLINICAL No. of Participants 23 17 No. Years in Role 1 to 17 years 1 to 10 years Female 95% 29% Clinical Background 13% Clinical > 80% Clinical Previous Experience > 75% HP Students > 50% HP Students Formal training Mental Health Counselling Workshops (n=102) URBAN RURAL 75 27 Sites sampled: 5 UWS, 6 UoM Less than 50% had done MHFA, but that was the most common formal training taken up

Range of Student Concerns Scheduling, procedures, paperwork Study: progress and assessments Clerkships: learning issues, isolation Relationships: peers, staff and family Financial and employment pressures Physical illness and impairments Mental health and substance abuse Acute life-threatening events, deaths From Routine to Emergency From Rare to Frequent

Discussion Activity 7 minutes – Think-Pair-Share What student concerns do you see? What is the impact on you, and on staff, from managing student concerns? Discussion Activity 7 minutes – Think-Pair-Share 00:07 EXERCISE 1 So do you or your staff have students come to you with similar concerns? What issues do these student presentations raise for you as a staff member, work colleague or staff supervisor? Talk to your neighbour for a few minutes, then we’ll share some experiences and relate what our study found [if available, whiteboard these to refer to later on]

Findings – Impact on Staff Formal work Position description Informal work Personal orientation Boundaries Professional approach Accessibility Emotional labour Reporting & documentation VS Privacy & confidentiality Feeling responsible Doctors of the future Career advice (A) Feeling ineffectual Professionalism (A) 15:00 For the staff in our study we found a series of tensions and uncertainties relating to their role in providing student support. Do these resonate for you? Emotional Labour seems to be very applicable to the experiences of staff and its impact on their work, as well as more personally. Emotional Labour is….. yet crucial for student well-being Emotion work refers to …..management of emotion in personal interactions (e.g., with family and friends). It emphasises the time and effort involved in the monitoring and managing emotion (Daniels 1987; Erickson 2005). The term emotional labor refers to emotion work in occupational contexts where one is managing emotions because it is part of what the job requires (Hochschild 1983). When performing emotional labor, individuals generally must conform to the expectations outlined by the employer (Fineman 1993; Hochschild 1983; Van Maanen and Kunda 1989). However, a key finding was that the majority had received no formal training, were unaware of resources and services and wanted more support themselves.

Training & Support Recommendations PROCESSES RESOURCES Orientation to and clarification of role Management of workload, formal recognition Clearer communication: when to refer and to whom, what to document Peer support: informal debriefings Self care, boundary setting Skills training e.g. Mental Health Information about local referral and support services Information about policies and procedures Critical incident flowchart and checklist Training resource with video simulations From the research recommendations for support and training needed by staff: In terms of processes, our findings suggest that a training and support program for staff should include: Role clarification, including orientation briefing Formal recognition and acknowledgment of the role of staff in supporting students in workload policies and performance review Opportunities to network and build a community of practice and support (in addition to formal training), and particularly Opportunities to informally debrief after distressing or disturbing encounters. While formal training is important, they didn’t feel you could cover all contingencies in a formal training session. So the opportunity to talk through student issues and seek advice with colleagues was highly valued (e.g. Wendy’s weekly meetings with Dean’s Exec) Self care, boundary setting, training in emotional intelligence The resources that a training and support program for staff should include: Training to develop skills in talking to disturbed students and supporting colleagues Knowledge about common (mental health) presentations and referral services. Provision of readily accessible (“just in time”) and up to date information about support services and about… policies and procedures, especially assessment, progression, obligations to provide support such as disability, report and documentation requirements An emergency flowchart to follow in crisis situations. Several of the staff related crisis life-threatening situations for which a chart of list of steps to refer to during the chaos of the event would have been very helpful, rather than “making it up” on the run Later in the workshop we’ll have a chance to work on such a checklist. But going back to the desire of many staff to have the opportunity to debrief and talk through student issues with colleagues, we would like to spend the next 30 minutes on an exercise to foster this discussion

When students disclose: How should I respond? Discussion Activity 15 minutes each– Video scenarios 00:20 (40 mins) EXERCISE 2 Aim of this exercise is to use a “true to life” incident which is an amalgam of narratives from the study to trigger discussion and exchange experiences and advice between you, as staff working in the same setting, about a student concern. We have two but will see how we go for time…..[depending on size of the group, can watch both and discuss sequentially or divide into 2 groups and ask each to discuss one and report back]

A student comes to your office for help… A Scenario A student comes to your office for help… Questions to consider: What happens in the video scenario? What issues does the scenario raise about staff roles and responsibilities? How should the staff member respond? Briefing: in this video you will see…….a student approach a professional staff member in a reception area with an apparently routine request… While you are watching the video, we’d like you to consider the following questions [refer to handout and facilitator notes] Brainstorming [in groups] Does this happen in your clinical school/program? Has this happened to you or one of your staff? What should the staff member do? If you were the staff members colleague or supervisor, how would you advise and support her? Do you have any training or protocols in your school to cover these situations? For example privacy, documentation? What if the student had approached an academic? What if the student was in another health professional training program? Does this ring true for you? How is it same or different? Issues: boundaries; the “mother hen”, who and when to refer, confidentiality and privacy, distress/ safety, emotional labour, accessibility; “customer service”, staff training/ part of role? boundary setting, privacy and confidentiality, emotional labour, notions of “customer service”, differences between academics and professionals, clarity of processes….

James Insert links to appropriate videos

Preeti

The Missing

Sarah

Summing up… To recap: The aim was to explore some of the issues for staff when they are approached by a student with a concern From the discussion, these included…………[refer to whiteboard] We have found that the process of staff such as yourselves sharing and exchange experiences provides invaluable peer support to staff members. If you found it useful – even just for finding out what each of you do to support students – you might consider providing or identifying opportunities for informal debriefing sessions. Do you see a need for such opportunities at XXX? Where and how might they occur? [communities of practice] Then there are the system, or organisational issues. Let’s move onto……

When the unexpected happens: Developing a response flowchart Discussion Activity 20 minutes 00:60 When disaster strikes…… One of the resources most commonly requested by staff in the study was a readily available flowchart or checklist to refer to when “disaster strikes” We will go into what constitutes this, but it might be something that demands an immediate or urgent response, that is outside the “ordinary” student concern [We can be flexible here: if the participants say they have more need to clarify a standard pathway as a result of discussing the videos, do that instead]

Types of student concerns Usual Staff-Student interactions Student request Staff response (check policy) Referral  Documentation  Follow-up Critical incident – a definition5,6 Traumatic and serious event Extreme physical and/or emotional distress Outside normal range of experience  Imbalance between usual staff capacity and resources, and the needs of affected person(s) So responding to an ‘ordinary’ or ‘usual’ student concern might look like this…. Definitions of disasters “A serious disruption to the functioning of society, causing widespread human, material and environmental losses which exceed the ability of the affected society to cope using only its own resources, the result of a vast ecological breakdown in relation between man and his environment, a serious and sudden event (or slow in a drought) on such a scale that the stricken community needs extraordinary efforts to cope with it, often with outside help or international aid.” WADEM “ An event characterised by acute and unforeseen imbalance between the capacity and resources of the medical profession and the needs of survivors who are injured, whose health is threatened, over a given period of time” WMA Definitions of critical incident A critical incident is as a traumatic event which does or is likely to cause extreme physical and/or emotional distress to staff and/or students and may be regarded as outside the normal range of experience of the people affected. A critical incident may take place either on or off campus. (CSU) Examples: Any fatality, near fatality or incident likely to affect seriously a number of staff and/or students; • Serious traffic accidents; • Murder or suicide involving students/staff and their family members; • Physical or sexual assault; • Injury or death of a colleague; • Fire, explosion, bomb threat; • Hold-up or attempted robbery; • Threats of violence to staff/students; • Major theft or vandalism; • Threat of HIV infection; • Incidents involving pain or abuse of children; • Incidents in which sights, sounds, or smells are distressing; • Storms/natural disasters.

A NOWRA medical student killed last week in a motorcycle crash near Goulburn has been described as an exceptional young man who had an insatiable thirst for life. Chris Zweerman, 26, was killed on November 14 when he crashed his motorcycle on the Hume Highway about 5pm. He was riding his motorcycle north on the highway when it left the road and travelled along the unsealed surface of a break down lane before he hit the ground. Police said Mr Zweerman suffered severe internal injuries, which ended his life after he was taken to Goulburn Base Hospital. At the time Mr Zweerman was returning to Nowra after visiting his brother in Canberra. An example of a real critical incident – imagine if you were the staff member in the office who first hears – via a panicked student phone call or SMS - that a student has been seriously injured in a road accident, but nothing has been confirmed. http://www.southcoastregister.com.au/story/1010369/medical-student-killed-near-goulburn/ http://www.southcoastregister.com.au/story/1010369/medical-student-killed-near-goulburn/

http://www.conversationsmatter.com.au/

Developing a flowchart STUDENT CONCERN Critical, Urgent or Non-Urgent? What follow-up is needed? What resources are available? What to document, and how? What are the relevant policies? Who needs to know? When? When to refer on? To whom? So the aim is to build on the previous discussions to develop a flowchart that is relevant to your setting….for responding to a critical incident type of student concern [refer to handout] Refer to the definition of a critical incident and think of an example you can work through to develop the flowchart. Depending on the groups’ needs, use Exercise 3 (no established policies, uncertainty about what everyone does), 4 (developing a new pathway, implementing an existing pathway) or 5 (improving to existing pathways). Discuss for 15 mins in your groups and report back [can use butcher paper or the write on the handout] [handout examples of pathways if participants get stuck, or if a large group, can split and do ‘standard’ and CI pathway each]

Summing up… To recap: The aim was to develop a quick reference flowchart for events which are out of the ordinary and stretch the available resources and staff capacity to respond From the discussion and flowcharts, the key decision and response points were…… A secondary aim of the exercise was to clarify the roles and responsibilities of staff in your setting and the university/health service/regulatory and legal policies and procedures which need to be applied What questions or issues remain to be resolved?

Develop a “standard” referral pathway Circulate information about support services Where to from here? Disseminate an incident response pathway Develop a “standard” referral pathway 00:80 [Go round room] What is one thing that you have taken away from this workshop? So what issues and unanswered questions remain? [Ensure that staff “take home” the pathways they have worked on for further development and possible implementation] What suggestions do you have for the best mode of staff training that will be effective and feasible? Some follow up activities to consider…… Developing a “standard” referral pathway Creating and disseminating a list of local student services and resources Developing and implementing staff orientation and training THE RESOURCE How could the video resources be used in your program? For example orientation or induction of staff – or even selection interviews (eg Flinders) EVALUATION and CONSENTS Please complete the evaluation for continuous improvement Further staff orientation and training

Further information Eleanor Flynn e.flynn@unimelb.edu.au Wendy Hu w.hu@westernsydney.edu.au Robyn Woodward-Kron robynwk@unimelb.edu.au 85:00 Thank you and evaluation please