Friday, April 25, 2008
Dear Yvonne
My evaluation
Thank you again for a thoughtful evaluation. I appreciate the effort you put into it.
My goals for the coming year
My first goal is to perform better in the areas marked ‘above average’ or ‘outstanding.’
My second goal is to continue to improve in the area of attendance. I aim to deserve an above average rating in attendance
On the final evaluation my rating for personal fitness was ‘average.’ Next year, I would like to get an ‘above average’ evaluation for personal fitness. I’ve heard that the county does not like to give above average in this category. I do not know that that is true but if it is true then that is indeed very strange. It is manifest that there are differences in most performance areas and therefore some employees must be above average. My goal is to be at least above average in personal fitness. The defining criteria for personal fitness are ‘integrity, sobriety, emotional stability, physical condition, appearance, and habits.’ I do not think it is unreasonable to suggest that I would be placed in the above average group based on these criteria. I’m assuming that my rating on the final evaluation was based on objective criteria and my goal is to rate above average on these objective and therefore measurable criteria.
I have heard some employees say that they do not care what is said on their evaluations. It is unfortunate if they sincerely mean what they say for it means that either there is an attitude issue or there is the perception that evaluations are not fair or not meaningful. I recognize that some in some workplaces evaluations are used as motivational tools and other purposes that are not strictly evaluative. However it seems to me that fairness is important in itself and that an environment in which people are appreciated and evaluated fairly provides the best general motivational environment—especially in a psychiatric setting where good performance is not merely numerical or mechanical efficiency.
An important goal is to continue to contribute to and be part of a team that provides quality care and seeks ways to see, understand and improve all aspects of care.
A full time employee spends at least fifty hours a week on work and related activities that include getting ready for work and driving to and from work. If one’s life is valuable it seems absurd that one would not want to be an excellent part of an excellent team. How can we encourage one another to have and enjoy the best attitude?
One factor that I don’t get evaluated on is ‘Ability as supervisor’ because I’m not one. However, if you look at the criteria, I do have and use the listed criteria (training employees etc.) Perhaps this could be accumulated under ‘Factors not listed’
I’ve stated some further work related goals under the heading ‘My future at Sempervirens’ below
Sempervirens rules
Some time ago I said I would think about how we deal with patients and rules. I’ve thought about this and concluded that there are some things that are done intuitively that are not easy to put in words. That’s partly because intuition is multidimensional and language is one-dimensional; intuition is implicit while words are explicit. More importantly, the best response to often depends on some thing specific to the situation that is not known and so cannot be addressed before the event. The difference might just be ‘how do we connect to this patient at this time.’ Intuition flows, an attempt at a code stops the flow. At the same time some general thoughts may be helpful.
1. The intent of rules. Some rules are meant to not be broken, e.g., safety rules or medication regimen for a diabetic. Other rules are more like guidelines to help unit flow, e.g., if we know a visit is therapeutic we may allow the visitor to stay till 7:45. In addition to the therapeutic angle, showing flexibility shows that we care for the person as much as for structure and that is important. Some things that we think are rules are not, e.g., two sugar packets and only sealed food brought in by visitors. Obviously there should be some limits but flexibility is important as well. Regarding sealed food, judgment may be used. Another thing that is not a rule is ‘no minor visitors.’ We have a definite policy that safeguards both minor and patient and we could and perhaps should follow the policy. Some people think that children on the unit are counter-therapeutic but certainly not all would agree with this.
2. Consistency. Consistency is important but sometimes it’s important to give a little. Also consistency could mean the 98 pound old lady and the 250 pound lean mean body builder get the same amount of calories and protein; or it could mean everybody according to their need. Emphasizing consistency sometimes tends to mean that everyone follows the ‘rules’ of the most OCD staff. Why should that be the case? For whatever reason, dayshift is more OCD than evenings. Perhaps, they should be consistent with us rather than us with them. I suppose that some sort of happy medium where we listen to them but don’t feel compelled to do everything they do might be good. If something to be universally followed is set up by nurses then it would be good if there were a discussion among shifts first.
3. An example over which we have little control. There’s been some discussion of diet recently. Suppose we have an over-weight 250 pound non-diabetic patient who is hospitalized for a suicide attempt. The doctor writes an 1800 ADA order. We are supposed to follow this to the letter. As you know, some nurses are willing to make exceptions and that’s because rigidly following the diet order borders on the absurd for a patient who will be here a few days and is here on a 5150 and not a serious medical condition. Of course, nursing staff is bound by the order but I wish that the medical staff would be more flexible when flexibility is indicated. I might look into the relation between diet and patient rights. Another example… ‘DL’… also an 1800 ADA diet but she’s diabetic so the situation is different. However, we get into struggles with her over that. It seems sometimes that we are ‘teaching her a lesson’ or encouraging her to seek discharge. I think there’s a better way. The idea of putting her on a diet is for health reasons. Might it not be better if the MD and the patient sat down and agreed upon some diet that the patient might be able to maintain on the outside? Might that not get the best health outcome in the long run? I imagine that we’d have some failures and some successes but, generally, better health for most. Then there’s the psychiatric concern. I think that, generally, getting into struggles is not the best way to deal with patients who we think do not belong on the unit. These kinds of decisions are not ours to make but I mention them because they reflect my thinking.
By the way—I would like to think that every patient belongs on the unit. Obviously everything has exceptions. However, as a general rule, I think that thinking that way is healthier for me; I believe that it may be healthier for the unit.
4. Flexibility, respect, patient’s rights, safety, and therapy. I believe in flexibility, respect, and patient’s rights. It’s a matter of principle. If it were automatic or given, the principle wouldn’t be needed. That obviously means that I don’t perfectly follow my own principle; but I try to follow it. And if it weren’t a good thing, it wouldn’t be a principle. How can something be a principle that does not in the long run make things better or good and has the only value that someone can think ‘I don’t know but at least I’m doing the right thing?’ I think that flexibility, respect, paying attention to rights, makes the environment safer and more therapeutic. Of course, things must be done ‘right’ and there needs to be limits—nothing should be absolute. Flexibility about flexibility is good—respecting other staff attitudes, being firm when necessary.
Summary regarding rules
The unstated assumption behind—almost all—rules is that they are there to be used when necessary. The most important reason is that while rules do attempt to capture what is important they cannot anticipate all situations. Therefore flexibility is important. The force of rules is that they are felt to be inviolable but in fact this cannot be the case.
The most human, most efficient, most therapeutic and most democratic outcome is when this ‘principle’ is followed.
Consistency is not unimportant but it can become rigidity which is less than therapeutic, not human and unsafe. We can cite examples when giving a little—being flexible—creates a problem. But it’s also true that inflexibility creates a military like atmosphere in which patients can be resentful and angry. But flexibility and humanity are important and I think that there’s a medium that we might aim at even if it's elusive. It’s a point that is most therapeutic, most human and safest. Achieving that optimal point requires that we continually seek solutions and apply our insight and intelligence…
The borderline patient on the unit
I’ve done some thinking on borderlines. I know that such people can be manipulative but I do not think that manipulative behavior is at the core of the issue. In some cases, dependency is an issue. Sometimes the problem for staff is that here is an adult who seems to be quite capable but is unable to or choosing to not take responsibility for their own emotions and behavior. Surely, though, the patient who seeks hospitalization and loses freedom over their person even though they don’t need the shelter has some kind of psychiatric issue. Our challenge is to deal with it and, ideally, turn things around. My thought it that the true borderline is normal when it comes to coping with material concerns or purely intellectual issues, in fact many are highly intelligent. Perhaps the main difference, in my observation, is that their personalities may be described as bi-stable. In the state of dyscontrol, the borderline enters a regressed and difficult to get out of state and the core feature is regression, not manipulation. ‘Normal’ people with resilient ego’s etc do not get pushed by stress into such states; borderlines do; the job of therapy is to cut that cycle (somehow.) Perhaps, there is some choice. My guess is that in some cases there is. Perhaps being dunked in a bathtub of ice water would bring him/her out of it; we don’t have that option. Dr. Walter Wilcox who was a military psychiatrist and who worked on Sempervirens in the 90’s said that one thing that ‘cured’ borderlines was joining the military, being subject to military discipline. I guess the case I might make is for firm but compassionate treatment.
My future at Sempervirens
When I think of what I want to do with my future at Sempervirens / Mental Health, it includes projects such as I described in my earlier response to evaluation. Possibilities include setting up a website (intranet) that would include such things as inservices, orientation and training manuals, policies and procedures, current news and events, useful mental health information e.g. medications information and latest thinking on treatment for various diagnoses. Another area that interests me is computer applications including documentation. I would be interested in working on projects of this sort perhaps working less on the floor, e.g. 0.8 time, and this might have the dual function of being useful and giving me something new to work on. Perhaps we could begin a dialog on this kind of possibility and see if we could interest administration in it.
An appreciation
I want to thank you again for a fair approach to evaluation. Asking for staff input makes more work for you. However, it also shows staff that you want to be fair and accurate and that makes the evaluation more meaningful and a better tool for motivation. It satisfies the dual criteria of evaluation and motivation (instead of sacrificing one of the criteria.)
When you became supervisor, I wondered what kind of leadership you might bring to the evening shift. I can see that you have put efforts into being a good supervisor. The main thing is attitude. Of course your nursing is good but we have a lot of good nurses. Because of your attitude people on our shift want to do a good job and feel supported in that endeavor. One thing that stands out for me is your high level of integrity. Even where we disagree I know the disagreement is a matter of principle. On our shift it is as though the staff have a pact to work better together to provide better care.
Sincerely
Anil Mitra