Let’s talk about tattoos

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When someone mentions tattoos what is the first thing that comes into your mind?

Do you think of a heavily tattooed man or woman? Your own tattoo perhaps? As a Therapeutic radiographer the word tattoo makes me think of radiation treatment positioning. During the planning for radiotherapy, Radiation Therapists/Therapeutic Radiographers will mark a patient’s skin to indicate a reference point for positioning the patient each day underneath the linear accelerator. More often than not these reference points are made into a permanent mark, a tattoo, using sterile Indian ink and a sterile needle. These permanent tattoos act as a reference point for each radiotherapy session helping to align the patient with the treatment machine with the aim of increasing treatment accuracy.

Radiotherapy tattoos are small; they are less than 2mm in diameter. Images available to view online at CRUK website and here on this personal blog show the actual size. So what’s the fuss? They’re tiny right? So why write a blog about them?

Well here is the problem. While they are small they are permanent, and act as a permanent reminder for many patients of an experience and a time in their life they may want to forget. This quote from a blog by Andrea Hut really exemplifies what many women I’ve come across over the years as a Therapy radiographer express:

The tattoos themselves are just tiny bluish dots. They’re barely visible, but they are permanent. Nobody told me that. It’s as though they think you wont care because of all the other stuff you’re going through. I’m sorry, but I care about any permanent mark that’s being made on my body. Especially the ones I didn’t choose. Scar or tiny black dot.

The critical reason for using permanent tattoos for positioning radiotherapy is the belief they provide an accurate guide to positioning of the radiotherapy beams on a daily basis.

So how accurate are they? Set-up accuracy for breast irradiation is dependent on a range of factors including the use of immobilization devices such as breast tilt boards, how the patient’s arms are positioned (one arm up versus two arms up) and support cushions, as well as patient factors (such as breast size). Using tattoos for positioning can enable accuracy of radiotherapy field placement in the region of 2-6mm(1). Where partial breast irradiation is employed accuracy between 3-7mm(2,3) have been reported. Accuracy using semi-permanent skin marks alone have been shown to be comparable to accuracy achievable using tattoos(4) where average systematic errors were 3mm for those patients with tattoos and 3.3mm for those with semi-permanent skin marks. The disadvantage of using semi-permanent marks is the need for the patient to take care when bathing to avoid the marks disappearing; this can cause patient anxiety, and could necessitate a re-planning of the radiotherapy, potentially delaying treatment.

It’s all about choice.

Body tattoos have been a part of human culture for a long time. Initially, tattoos represented a specific aspect of culture either identifying the bearer to a religion, strength or social status. In European culture in the 20th century body tattoos have been associated with groups such as sailors, and bikers and with the advent of the punk scene they became an expression of antithesis to mainstream culture. The 21st century has seen a rapid rise in body tattooing; with tattoos no longer seen as solely representing a tie to any specific sub-culture or group. Wohlrab, Stahl, and Kappeler(5) identify 9 different motivational reasons for obtaining a body tattoo:

  1. Beauty, art or fashion,
  2. Expression of individuality
  3. Personal narrative
  4. Physical endurance
  5. Group affiliations and commitment
  6. Resistance
  7. Spirituality and cultural tradition
  8. Addiction and
  9. Sexual motivation

Except when the individual obtains a tattoo while under the influence of alcohol or drugs, the majority of these motivations above represent a personal choice, a reasoned decision to gain a permanent embellishment to their body.

Take Eve for example, here is her tattoo and her motivation for getting it.

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“My tattoo is two magpies representing the old saying ‘one for sorrow, two for joy’. The saying is based on the fact that magpies mate for life so when you see two together you know they are happy and in love. Whenever you see one magpie you are meant to salute the bird so that you respect his loss as he no longer has a mate, and I have been doing this since I was little. By having the tattoo I will see them everyday and everyday ‘hopefully’ I will have joy in my life.” Eve

Eve tells us about her decision to get a tattoo:

How long were you thinking about getting a tattoo? 

Eve: “I thought about it for a couple of years as I had to wait until I was 18 years old before I could get it done.”

What made you want something so permanent?

Eve: “I have never been worried about it being permanent, as it reflects my personality and is something I believe in.”

Were you worried about what people would think? If not why not?

Eve: “ I have heard of people talking about people with tattoos as being wayward, however, I do not believe that. Most people now a days are not as judgmental, as more and more people are getting inked.”

Do you think you will ever regret it?

Eve: “No never, it will always reflect that period in my life.”

Eve’s motivation for getting a tattoo is clear, it represents something of meaning to her, something that she see’s will bring her joy and is a part of her personality. Eve’s is just one story, but most motivations for getting a body tattoo reflect a positive connection between the individual and the permanent image they choose. Patients that are tattooed during the radiotherapy planning process have less choice. The permanent dots, although small are unlikely to add or improve their appearance, and for many simply may act as a reminder of cancer treatment. For some cancer survivors they are an unwelcome reminder of a difficult time in their lives. These quotes below from our most recent research highlight the mixed emotions patients with breast cancer experience during the planning of radiotherapy and coming to terms with the notion of having permanent tattoos. (All the names have been changed to protect the individuals’ identity). Emotions and experiences are diverse and serve to highlight the need for healthcare practitioners to understand the individual patient journey:

Gill

“I’ve written a couple of things down there that kind of go back to something that Maryanne said about choice, you know the tattoos and not feeling like you have a choice.”

Sarah

“…when they put the tattoos on so it was all in the same incident, I did feel suddenly there that there was something permanent happening because you know they say these tattoos are permanent, up to then it felt like you know we’ll cut this out, I’ll get better, it’ll go away and then they went no you’re going to be permanently tattooed, I felt like you know you’re going to make me tattooed and marked ………. I did, I felt a real sense of loss at that point and I thought no this is not something I’m going to get through this is something that I’m stuck with and it’s silly really because it’s just tattoos and I’ve got used to the tattoos and I don’t notice them.”

Miranda

“some of these points to an outsider may sound small, like the tattoos, I wasn’t happy with those either, but because you’ve lost you know your sense of self and your confidence it just, you know every little thing even though it’s small like using different cream or something is a really big issue.”

 

The picture is clearly mixed, while there are negative experiences associated with patients having tattoos like those above. The complete picture includes many positive attitudes towards radiotherapy tattoos:

“small, discreet, only a few in number, quite freckley skin anyway, don’t mind needles, nothing to worry about compared to chemo, needed to keep me alive so what’s the problem?”

Some women even choose to change their radiotherapy tattoos into works of art on completion of treatment as this Guardian article highlights. It’s clearly all about choice.

So what are the choices?

Well let’s not throw the baby out with the bath water just yet. Permanent tattoos have been used for many years to mark the placement of radiotherapy beams for a range of cancer sites. For those women that don’t mind having tattoos they remain, at the moment, possibly the best alternative and an option patients can choose. It might be worth Therapy Radiographers/Radiation Therapists considering where they position the tattoos and the number used. Where possible, if tattoos can be positioned where they are less likely to be visible when the woman is dressed in her normal clothes, it may make them more acceptable to some women. In addition, for standard whole breast radiotherapy (where only the breast or chest wall is treated and not the lymph nodes in the neck) what is the optimum number of positioning tattoos that are needed to retain accuracy? There is no research evidence for us to use, and nothing to indicate that five tattoos are better than three for example; so will three suffice to improve the cosmetic outcome?

For those women that don’t want to have a tattoo the use of semi-permanent pen marks is often used with special dressings (that act as a clear skin) to avoid the marks rubbing off onto clothes and to maintain longevity. Semi-permanent marks come with restrictions on washing but can be as accurate as permanent tattoos if application is maintained carefully(4). Some centres have access to 3D surface imaging that can complement patient alignment and enhance accuracy of set-up; unfortunately not all radiotherapy centres have such a facility.

A recent trial has tested the viability of using ultra-violet (UV) ink for permanent tattoos. This option means that the tattoos are not visible in normal daylight conditions and only visible under UV lights that are applied in the treatment room. The use of UV tattoos still requires a needle prick to get the ultra violet ink underneath the skin. However, it may offer a solution in the future, and we await the published results of this recent trial to see the full benefit in terms of accuracy for treatment and acceptability to patients. The use of UV ink for tattooing is a fairly new development and we currently don’t know if there are any long-term risks associated with using UV ink for tattoos. It does also mean that while the radiotherapy tattoos would remain invisible during normal lighting conditions under any ultra violet lighting such as those sometimes used in clubs and restaurants the tattoos maybe visible.

Another future solution that could provide patients with an alternative to permanent tattoos (either indian ink or UV tattoos) is the use of a well fitting immobilisation device where the set up marks are incorporated within the device. This approach is used for radiotherapy application to areas of the head and neck where an immobilisation mask is fitted to the patient and marks placed on the mask rather than on the patient. We are currently developing a support bra for women undergoing breast radiotherapy that may allow for marks to be incorporated within the bra, avoiding the need for skin marks or tattoos on the patient; details of the SuPPORT 4 All study can be found here.

Is there sufficient choice for patients? What’s your view?

References

  1. Probst Heidi, Bragg, Christopher; Dodwell, David; Green, David; Hart, John. A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation. Radiography. 2014;20(1):70-81.
  2. Gierga DP, Riboldi M, Turcotte JC, Sharp GC, Jiang SB, Taghian AG, et al. Comparison of Target Registration Errors for Multiple Image-Guided Techniques in Accelerated Partial Breast Irradiation. International Journal of Radiation Oncology*Biology*Physics. 2008;70(4):1239-46.
  3. Yue NJ, Goyal S, Zhou J, Khan AJ, Haffty BG. Intrafractional Target Motions and Uncertainties of Treatment Setup Reference Systems in Accelerated Partial Breast Irradiation. International Journal of Radiation Oncology*Biology*Physics. 2011;79(5):1549-56.
  4. Probst H, Dodwell, D, Gray, J.C, Holmes, M. An evaluation of the accuracy of semi-permanent skin marks for breast cancer irradiation. Radiography. 2006;12(3):186-8.
  5. Wohlrab S, Stahl J, Kappeler PM. Modifying the body: Motivations for getting tattooed and pierced. Body Image. 2007;4(1):87-95.

 

 

 

 

Mobile Learning: 7 key benefits of the MyKnowledgeMap mobile app and why you should consider using it.

It is estimated by emarketer that around 1.75 billion people worldwide are using smartphones, with the trajectory of smartphone use expected to continue to increase. Currently a quarter of the world’s population uses a smartphone at least once a month. Six in ten adults in the UK now use a smartphone according to the 2014 Ofcom report on media use. Of these smartphone users the majority are 25-34 year olds and 45-54 year olds. Even activity by those aged 65-74 has increased since 2012 when around 12% of this age category was using smart devices; activity has risen to 20% in 2014. Of those that use smartphones 48% report downloading apps and on average have 23 apps on their devices of which they use 10 on a regular basis.

So with the majority of the UK population now regular smartphone users it is not surprising that many educators are now utilising this technology for delivering information, and communicating with students. The Jisc mobile learning infokit introduces three frameworks that educators may want to consider when operationalising the use of mobile technology as a learning tool (Laurillard 2002, Park 2011, Koole 2009).

We have been trialling using mobile technology to enhance research skills in the Allied Health Professions (AHP) department. Using the MyKnowledgeMap (MKM) MyProgress app we have developed a series of 9 tasks (see table 1) for masters students to work through to take them from an initial research idea to a full research proposal that is ready for submission for governance approval processes.

Task
1 Tri-partite agreement between student, manager, and university on research topic
2 Elevator Pitch- The research idea
3 Preparing for Publication
4 The Literature in the Field
5 Method/Study Design
6 Gaining Stakeholder Input
7 The Research Journal
8 The Full Proposal
9 Feedback results to place of work- Presentation

Table 1 the Tasks used in the AHP Research app

Rather than using one of the frameworks identified by Jisc we have opted to deliver the research tasks through an intrapreneurial lens utilising an intrapreneurial pedagogy developed through a small Higher Education Funded research project(1). The pedagogy fosters learning by doing, learning by networking, learning from mentors and role models, learning from mistakes and learning from challenging tasks as a way of developing the relevant skills required to innovate within the work organisation where the student is employed; developing intrapreneurial skills through the context of their research dissertation.

So why use a smartphone app and not traditional e-learning platforms such as Blackboard and Pebblepad? Our post graduate students primarily are employed and are working mostly full time with no access to Blackboard and other e-learning platforms during working hours because of access to PCs in hospital departments. Even those that do have access to a PC can’t access traditional e-learning platforms because NHS firewalls prohibit website access to many traditional websites, and gaining the relevant access for specific users is problematic. We have found seven key benefits for using the MKM app with our PG students:

  1. Retaining contact and engagement with students that are out on placement (or at work) where the place of work has no Wi-Fi.

The MKM app works without the need for Wi-Fi. Students can download the app and all the tasks while at home or in a Wi-Fi enabled environment and work on the app tasks offline, simply synchronising the app once they are back in a Wi-Fi enabled area perhaps as they pass a Wi-Fi enabled café on their way home.

2.     Engaging students beyond the classroom.

Using the app enables learning to take place beyond the confines of the physical or virtual classroom, at any time when learning opportunities arise.

3.     Allows a student to be the orchestrator of their own learning, bringing in relevant stakeholders where appropriate.

The app and the tasks as they are designed encourage students to gain feedback from a range of stakeholders that they choose based on their own project and work situations. Stakeholders for our students can be colleagues, managers or patients/clients. For example, students are encouraged to present their research idea to a user forum (patient representative group) where direct feedback about the topic and study design can be gained from those present by handing the student’s smart device to a member of the audience and asking them to complete a short feedback form. This immediate feedback is recorded and captures important patient perspective that can inform and enhance the design of the study.

4.     Tutors can see at a glance how individual students on a cohort are progressing with tasks and activities.

Tutors either at the work site or at the University access the MKM app webpage where they can see all student activity, enabling tutors to monitor individual progression. It makes it possible to take early intervention where it is seen that a student maybe struggling and not meeting targets. Tutors can feedback directly on individual tasks providing immediate support, encouragement and advice where necessary, providing valuable links to the University. The student receives the tutor feedback each time they synchronise their app when in a Wi-Fi area.

5.     Students can monitor their own progress.

The framework of the app allows students to monitor their own progress seeing how much or how little they still need to achieve before they reach the stage where their work is ready for submission (ie all tasks are completed to a sufficient standard).

6.     Allows connections between university working and placement staff and placement learning.

The app enables better connections between University learning and real life work situations. It also provides an opportunity if required for work mentors to feed in reports on task achievements, providing a multi-faceted approach to student support.

7.     Facilitates the opportunity for stakeholder input and feedback on student work.

In the moment reflections can be recorded on the student’s smart device, simplifying the process for key stakeholders who need to provide input or feedback. The student simply hands over the smart device to the stakeholder who completes the feedback form at the point of the activity; this is invaluable for busy clinicians or staff who don’t have time to leave the clinical department to find an office and a PC in order to write and e-mail formal feedback to a student.

Why should you consider using the MKM MyProgress app?

The majority of our students now own and use a smart device and are comfortable with the technology, using it for communicating, shopping and gaming; the next natural extension for these users is to support their University learning. Accessing activities or messages from University tutors via their phone means students can feel connected to their learning in the same way they feel connected to their friends via Facebook, Instagram or Twitter. Being able to engage students beyond the classroom within a placement environment serves to authenticate and situate learning in real life scenarios enabling the learning to have greater impact.

As the majority of students are already using this technology it becomes a missed opportunity if tutors avoid engaging with smartphone technology as a platform for learning. The impact of exploiting mobile learning in the workplace via the MKM MyProgess app, particularly in relation to the 7 points above, is currently being evaluated. A future blog post will discuss the outcomes of this evaluation.

Acknowledgement to @cyclingbob1 who helped write this blog post.

Inspirational Teaching: What does it mean?

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This year I was fortunate enough to be nominated and subsequently awarded an Inspirational Research Supervisor Award by my University. What is lovely about receiving such an accolade is that your research students are the ones that nominate you. One hundred and forty six nominations were received this year from approximately 700 research degree students of which only five supervisors received the Inspirational Research Supervisors Award- and I was one of those lucky five.

After the initial shock and usual worry that they may have made a mistake and got the wrong ‘Heidi’ (there are two of us in my Faculty I often receive the other Heidi’s e-mails by mistake). I started to think:

“Well this means I’m doing something right, right?”

I know what I’m doing, but I’m not sure I know which bit of what I’m doing inspires and encourages my students.

“I’m not lost for I know where I am. But, however where I am maybe lost”
A.A. Milne Winnie-the-Poo

The thing is, being called an inspirational researcher supervisor felt somewhat alien. Mainly because most of the time after each supervisory session with a student I question:

  • Am I doing this right?
  • I’m following my instinct and my experience as a PhD student, but am I correct to do this?
  • I’m also following my instinct as a trained healthcare professional with twelve years of hard labour in the NHS, and using all my inbuilt empathy, leadership, motivational and coaching techniques, but do these work?
  • Do my students’ learn and develop from our one to one discussions?
  • Do my students feel motivated, and enthused when they leave a supervisory session? Or do they feel despondent, deflated and mentally drained?

The list of questions to self is endless.

So what does being an Inspirational teacher mean? What aspect of the relationship I have with my students is the part they find most helpful and uplifting? Or more importantly what should I be doing in the future to make sure my students always feel inspired?

Being awarded with this title comes with an invitation to attend a number of events, a faculty celebration, a University dinner for awardees and presentation at the annual graduation award ceremony, not to mention lots of photos. The best thing about attending these award ceremonies is the opportunity to listen to comments made by students about other award holders. It is a truly uplifting experience to realise the impact that tutors/teachers/educators (what ever your preference is for the title) have on the lives of their students. I felt humbled to be in the company of individuals who could inspire their students to learn, give students an opportunity to develop in their chosen professional field, and encourage them to grow as human beings. So as someone fairly new to higher degree research supervision I really started to think about the pedagogy for successful research supervision. I have completed the Institutional research supervisor’s course, I know the procedures and the regulations, but what are the successful pedagogies for research supervision? So I undertook a small search of the literature.

I was delighted when my searching led me to a report from the Department of Education, Science and Training of the Australian Government on ‘The Pedagogy of Good PhD Supervision’. Unfortunately the ‘good’ in this report relates primarily to timely PhD completions. While timely completions are advantageous to the University, as a metric they say little about the whole student experience and the knowledge development that the student has attained during their PhD journey. Surely ‘good’ supervisors want their students to complete in a timely way but to also gain positively in both knowledge and skills during the process. Nonetheless, Sinclair in this 2004 report identified a ‘hands on’ supervisory approach as a key characteristic of supervisors where students complete in a timely way. The ‘hands on’ approach (as opposed to a ‘hands off’ approach where students are left largely to their own devices) assists students to negotiate the PhD journey, by providing a structure to the PhD period. Most importantly it seems to me is that in this process of providing structure ‘hands on’ supervisors build relationships with their students. Part of this relationship building includes development of agreement of expectations between candidate and supervisor and develops trust. Where there is trust in the relationship the student feels able to approach the supervisor with confidence and the supervisor is more able to identify when it is appropriate to intervene or refer the student to others with specialist skills.

In addition, Sinclair (2004) identifies some other key strategies of the ‘hands on’ supervisor in the first year of canditure that leads to successful student progression:

• Engaging students with other students in face-to-face and online cohorts.
• Integrating the student into the supervisor’s broader research networks and research groups.
• Developing the professional development of the student via support for preparation of conference papers and publications.
• Encouraging frequent writing with rapid supervisor feedback.

These are useful strategies to employ, and I would say I employ all of these already. So in order to better understand what it means to be a good supervisor I’ve also been reading Pat Thomson’s blog ‘patter’ which I have found enormously helpful.

There are several useful posts on patter about the supervisory learning curve, particularly a guest post by Eva Bendix Petersen on ‘Learning to supervise: from training to pedagogy’. Her comments about what is generally missing from institutional supervisory courses resonate, what is missing is “conversations about pedagogy”. While Sinclair’s extensive research highlighted the importance of a ‘hands on’ approach with some specific strategies that are useful in the first year of study, the pedagogical picture presented in his report seems to be lacking a holistic element, holistic in the medical sense that is. For example, where do we consider the individual preferences and different approaches to learning of the student themselves?

In a different post in this series on supervision on ‘patter’- “supervision as an ethic of care” there is examination of care as a construct within the context of a supervisory relationship. Through theoretical examination it is proposed that supervision is seen as a caring encounter where both parties should benefit and both parties should contribute. The reciprocity is developed by 4 elements:
• Modeling- demonstrated materially.
• Dialogue- not just a statement of expectations but an explicit discussion of the care-full supervisory relationship.
• Practice- care like any other skill needs to be practiced and develops over time.
• Confirmation- supervisors like good teachers should emphasise the positive, confirming the students’ positive attributes, skills and potential.

This proposition of a caring relationship along with a framework of strategies such as those identified in the work of Sinclair (2004), feels like a more appropriate pedagogy to positively enhance the likelihood of a timely completion while maximising a student’s capabilities and fostering the opportunity for self-actualisation (Maslow 1971)

Now What?

While there is some research and some theorising about what makes a more successful or positive PhD experience for students I still felt like I needed to understand what my students want, what they like about my supervisory approach and what they feel they aren’t getting? So I asked my students to complete an anonymous survey; the results are unlikely to be generalizable, but here’s the crux of what they thought.
They agreed they had:
1. Sufficient contact to enable progression.
2. Sufficient support to allow goals to be met.
3. Enough feedback received to allow progression and
4. Rapid turnaround of feedback.
Interestingly here are some of their thoughts on what they feel helps:
5. Having a structured plan helps them keep to timescales, with regular prompts from the supervisor encouraging the student to keep to the plan.
6. Having a supervisor that is readily available.
7. Feedback given in a positive way that doesn’t overwhelm them.
8. Knowing the supervisor cares about their project.
9. Being challenged.
10. A supervisor that instils confidence.
11. Encouragement.
12. Confirmation that they may not get it right to start with but that very few students do.
13. Permission to fail and
14. Sometimes a kick up the bum!
Some of the comments made by my students in many ways replicate some of the statements made by intrapreneurs in a small study we conducted a few years ago (The 2INSPIRE project). An intrapreneur is someone who innovates within an existing organisation, developing and implementing novel solutions to organisational problems. Intrapreneurs that we interviewed also talked about failure, about confidence (or more specifically about self-efficacy) and about constantly being challenged in order to learn and grow. This makes total sense when you consider that research, specifically at PhD level is about innovating albeit at the apprenticeship level; PhD students maybe viewed as intrapreneurs/entrepreneurs in training. Hence it maybe appropriate to implement an intrapreneurial enhanced pedagogy for research supervision that I already adopt to help develop intrapreneurial behaviours in a traditional taught Masters module.

“I did then what I knew how to do. Now that I know better, I do better.”
Maya Angelou

Moving forward
Is there pedagogy for research supervision that enables the student to complete in a timely fashion but that also meets the individual student’s needs for personal growth and fulfillment? Based on the discussion above I propose the following 3-point plan as a starting point in formulating pedagogy for research supervision:

1. A structured ‘hands on’ approach specifically in the first year (with an opportunity for the student to develop writing skills early on with constructive, rapid feedback).
2. Building a care-full relationship with the student in order to nurture student potential and the opportunity for growth. A supervisor that cares about the student’s project, is encouraging and supportive, makes themself available for the students, and helps build self-efficacy.
3. If you consider doctoral research as an apprenticeship for entrepreneurialism/intrapreneurialism then the student should experience challenge, should be given permission to fail (with opportunities to learn from failure in a supportive environment), have opportunities to build resilience, opportunities to learn from mentors and role models and be exposed to collaborative research to develop key skills relevant to post-doctoral career pathways.

In another blog (Mobile Learning: 7 key benefits of the MyKnowledgeMap mobile app and why you should consider using it) a colleague and I discuss a method to provide structure for students developing a research proposal through the platform of mobile technology. This short programme maybe easily adapted for use in the first year of a research degree, providing appropriate structure and the opportunity for rapid feedback beyond the confines of the supervisory session. Building opportunities within the PhD tenure for the student to develop entrepreneurial/intrapreneurial skills will enhance the possibility of the candidate surviving within a research career beyond the completion of the PhD. Utilising opportunities for learning from mistakes, learning from role models, peers and mentors and continually setting challenging tasks to take the student outside their comfort zone, may enable entrepreneurial skill development alongside the PhD. Providing an environment where the student can model resilient behaviours needed by long-term researchers (and by successful intra/entrepreneurs) may additionally prepare the student for post-doc research and beyond.

The hardest aspect of the three-point plan above I suspect is getting the right balance of care in the PhD student-tutor relationship this quote from Gwen Boyle struck me:

“The ideal supervisor has infinite time and unparalleled knowledge. She is patient and always available; she is understanding and constantly supportive.
Unfortunately, she doesn’t exist.”
Gwen Boyle

This is true, academics have many other competing priorities (funded research, teaching, team leader responsibilities to name a few) hence as supervisors we need to balance the needs of the student with the need (and requirement) to keep abreast of our own research and teaching commitments. While we don’t have infinite time as supervisors we can provide structure for our PhD students (especially in the first year), we can enter into a care-full relationship with the student, and ensure the student is exposed to experiences that may enhance entrepreneurial/intrapreneurial skills, maybe this will allows us to be inspirational research supervisors more of the time.

HP1

The one disadvantage of being given the award of Inspirational Research Supervisor is the photographs; there are lots of them. For those of us that are camera shy this is an appreciated but painful chore. In particular, it took the poor photographer an hour to capture a decent image for this board that is displayed at the entrance to the main building of the University. I think it was a hard day at the office for him and each time I pass this board I do cringe somewhat. However, the quote beneath the image from one of my students, well that always makes me smile.

Burnout….Resilience….Balance…..Focus

 
It’s that time of year when we all reflect on the previous year and think ahead to the coming year focusing on what we might want to change in our lives to make them more satisfying or fulfilled. New Year resolutions abound with declarations about getting fitter, healthier or improving the work-life balance. At the start of 2013 I’ve been reflecting and thinking about burnout, my own susceptibility to burnout, work-life balance and building resilience. With colleagues I have studied burnout in the cancer workforce and this year I am working with a team of researchers to look at ways of building resilience in students and professionals working in the cancer field, so it makes sense for me to start this process with a little reflection on my own burnout susceptibilities and strategies for resilience.
What is Burnout?
Burnout is a phenomenon that occurs in a linear order across 3 dimensions: emotional exhaustion, depersonalisation and personal accomplishment (1). It is reported to exist where individuals have contact with the general public within roles such as nursing, the medical profession or teaching. However, it has also been studied within the sporting field. Gould and Whitley describe athlete burnout as a physical and emotional withdrawal from a sport that was previously enjoyable and characterised by:
“emotional and physical exhaustion, reduced sense of accomplishment, and sport devaluation, often occurring as a result of chronic stress and motivational changes in the athlete.” 
 
In our research we identified negative correlations between levels of work satisfaction and levels of emotional exhaustion (i.e. those that scored high for emotional exhaustion scored low for satisfaction). Emotional exhaustion was also negatively correlated with aspects of individual control. For example, those involved in role extension where there is greater opportunity for autonomy and control over the tasks and pace of work, reported lower levels of emotional exhaustion. Similarly, where participants indicated their manager’s leadership style allowed worker empowerment, staff reported lower levels of emotional exhaustion. The importance of control is supported in other research (2;3) and even considered fundamental to the prevention of burnout in athletes (4). 
 Resilience
There is much that can be done at an organisational level to reduce the risk of burnout. For example, how an organisation’s management structure influences individual workload, personal control, levels of reward, a sense of community, fairness and organisational values all of which may influence individual engagement with work (3). At an individual level what can we do?  Can we build resilience to prevent burnout? and what is the best way to achieve this? Well I wish I had the perfect answer here, but I don’t (hence our current research in this area to gain better insight). One useful conceptual model is that proposed by Dunn, Iglewicz and Moutier (5)where it is postulated that individuals have a coping reservoir. Within the internal structure of the reservoir are the individual’s personal traits, temperament, and coping style. For example, some experts talk about burnout being a greater risk to conscientious , diligent individuals or super-achievers (6). Personal traits act to top up or deplete the reservoir with some individuals naturally more able to defend against stressors. External factors act upon the reservoir including stress, time and energy demands. Positive factors influencing the reservoir include support from family and friends, social activities (which may include time out from work, study or training), mentorship, stimulation (or enthusiasm for the activities the individual is involved in). Where the individual is able to keep the reservoir replenished resilience will develop; where this doesn’t occur the consequences maybe burnout.
 Life is a great balancing act
Regaining Control or Establishing Balance
If we all indeed have a reservoir that needs to be replenished the amount that is needed to be actioned to balance the reservoir will differ from person to person based on our individual personality, traits and workloads. For some it maybe necessary to take time out to replenish energy and coping levels (5). In our qualitative work on job satisfaction with radiation therapists I interviewed a worker who narrated her experience of reaching a point of depersonalisation, she recognised this and chose to leave the profession. After a period of working elsewhere and some time out from emotional labour she realised how much she loved her job as a therapist and feeling replenished she returned to the profession; more aware of her sucsptibilities to burnout in the future. Maslach and Leiter emphasise the importance of being aware of the opportunity for burnout (3) and maybe this is the first step in gaining control, being aware, and scheduling time out  or regular breaks to prevent burnout occurring.
In an effort to establish balance and keep the coping reservoir at a healthy level is there something about the internal structure of my reservoir that I need to look at? I am a try hard perfectionist with a desire to do well, and like many I take the experience of journal article rejections and failed research funding bids as a personal failure. My karate instructor wrote an article about fear of failure in karate competitors the section I particularly like is the notion of athletes being given the freedom to fail because with that the athlete fights in a more confident, more relaxed manner; thus reducing some of the external negative pressure on the coping reservoir. For the concientious, perfectionist, super-achievers the notion of failure may be a hard pill to swallow, and maybe it starts with giving yourself permission to fail.
 
So with permission to fail how else can i regain balance? Balance is something I should be good at. I was a competitive gymnast for over eleven years in my youth, beam was my best apparatus so balance should be a doddle for me; yet I don’t appear to have got the work-life balance perfectly right so far. So maybe I need to go back to basics. Learning to balance requires practice it’s not something you achieve straight off and re-gaining your balance after some tasks is harder than others. Let’s take the example of a gymnast on a beam. Landing a back somersault on a 4 inch wide plank of wood is easier (believe it or not) than landing a forward somersault and for many gymnasts that is easier than a one foot 360 degree spin. The reason is that in a back somersault the gymnast will spot the beam well before her feet land allowing focus on landing. During a front (forward) somersault the gymnast must start to open out from the tuck position before the beam is spotted so focus on landing is delayed. For a full spin on one foot the gymnast is made vulnerable by any slight deviation from the central spinning position (i.e from a change in arm position perhaps) and focus on exit of the spin is vital if the gymnast is to avoid an early dismount from the beam. So is balancing work and the rest of one’s life actually about focus?
When I was taught to balance as a gymnast before I perfected the skill, the coaching tip was to spot something ahead of you to focus your eyes on. The process of focussing on one thing that wasn’t moving was to allow concentration on tensing the relevant muscles required to undertake the movement and retain balance.  
 
I am all too aware that sometimes my to do list is not completed because I’m distracted  sometimes by the amount of tasks I have to do, sometimes by the frustration of work processes that are beyond my control, and sometimes because I’m thinking about food (usually cake). Focussing on what the priority is for that moment as a way of balancing the demands of work and normal life seems rather obvious. However, it’s easy to forget such simple things in the complexity and speed of modern life.
 
So in order for me to retain balance in my life (and avoid burnout) I have taken control over the things that are in my power to action. I have scheduled my holidays for this year, booked at regular intervals to ensure sufficient time out. My next task for this year is to re-visit an article rejection from a high impact journal by corresponding with the journal editor on the validity of the original comments and requesting a review of an updated version; this is facing fear of second failure full on, but this time with an attitude that I have nothing to loose.
 
Finally, my New Year mantra will be focus, focus, focus. Like learning to balance it comes with practice. My five year old couldn’t do this balance two days ago, but when she learned to focus she mastered it. 
Just to disprove the saying “people that can do, people that can’t teach” this is me balancing on one leg, just need to transfer that skill to the rest of my life-then job done!
Reference List
 
(1) Maslach C, Jackson SE. Burnout in health professions: A social psychological analysis. Social psychology of health and illness .Hillsdale NJ: Erlbuam; 1982. p. 227-51.
(2) Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol 2007 Apr;109(4):949-55.
(3) Maslach C, Leiter MP. The Truth about Burnout. San Fransisco: Jossey-Bass; 1997.
(4) Coakley J. Burnout among adolescent athletes: a personal failure or social problem? 
  Sociology of Sport Journal 1992;9(3):271-85.
(5) Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry 2008 Jan;32(1):44-53.
(6) Schaufeli W, Enzmann D. The burnout companion to study and practice: a critical analysis. Taylor and Francis LTD; 1998.
 

 

 

 

 

 

 

 

 

 

 

Demons

 This is my first blog post and maybe an odd place to start but learning is chaotic so maybe it’s as good a place to start as anyA little Demon

In order to learn we often have to step outside our comfort zone. In the last two weeks I’ve been so far outside my comfort zone I almost needed a sat nav to find my way back. The problem with being out of your comfort zone is often that is the trigger for our personal demons to make an unwelcome appearance.  Those that know me are aware in my spare time I practice martial arts (karate to be specific). Only this week my instructor was telling some junior competitors about the demons that can suddenly appear when you take that long walk up to the mat for your fight.

I’ve been there myself, you look across the mat to your opponent and in an instance any personal self doubts you may have about your ability are transformed through your thought processes to create a distorted image of your opponent; depicting them as superhuman, and of gigantic proportions. All of a sudden  they’re twice your height and width, you look at the length of their arms the size of their fists and in a split second you have created  in your mind someone that is unbeatable and you’ve talked yourself out of winning before the fight has even started. You become unable to fight or use the skill you know you have, you crave to be back in your comfort zone ( in your head you’re wishing you were in your PJs watching telly at home) and as you try fighting with the equivalent of a car hand brake half engaged,  your demons win the fight. 

In life people talk about facing your demons. For a child of the seventies that spent her youth watching Dr Who from behind the sofa, having to face up to my demons seems a bit brutal and frankly scary and it also implies an element of confrontation with oneself. So I’ve decided maybe what I need to do instead is simply unmask the demons- just like in Scooby-Doo it’s bound to be the caretaker or some pesky kids- right?

So what are my demons, well someone close to me told me I’m a perfectionist (I’ve known that for some time). The point he was making was that this often means I worry a lot about whether my performance (whatever the setting) is going to be good enough. If you allow it (and I have on many occasions) this can be disabling, destructive and exhausting.

So how do you un-mask your demons and stop them from holding you back? Well there are a few strategies I’ve learned from my karate instructor and from intrapreneurs I’ve spoken to through my research.

  • Prepare well– good fighters put in hours of hard training in the dojo ( the training room), this means when they step onto the mat they know they’re not going to be faced with anything harder than they have already faced in training; giving a sense of reassurance. Similarly, research the topic or field well so that you are unlikely to be unnerved by anything that is likely to be thrown at you in a key meeting or at a presentation.
  • Rehearse – fighters practice their competition techniques over and over again until they become automatic. The purpose being that in the middle of a fight when the opponent initiates an attack they react to counter the attack instantly, without thinking and with precision. If you’re presenting on a new topic or leading a discussion forum or meeting rehearsing the content until its automatic can mean you expend less energy worrying about what you need to say next and can concentrate your efforts on other activities ( in my case trying not to fall off the lecture podium).
  • Stick with what you know works– out on the competition mat is no place to try a new move for the very first time, unless the strategy is to use this encounter as a test bed for a more important meet. If you’re presenting at a major conference or biding for a new contract or funding, using a formula or plan that’s worked before can add an element of security.
  • Teamwork – when you see an athlete win a medal what you may not see is the huge support team behind them that helped them get there; nutritionists, physiologists, technical experts oh and don’t forget the mums and dads (who hold very important team roles). Intrapreneurs I’ve spoken to in my research spoke repeatedly about the importance of bringing the team along with them. Your team holds expertise or perspectives you may not have and it’s important to recognise that and make sure they come along with you as part of the journey.

 

So now when I find myself out of my comfort zone and the demons start to appear I try to remember:

my opponent ( the audience, the company CEO) may be big and scary, but they’re human and vulnerable just like the rest of us. They may come with an impressive reputation, but it’s what happens in the here and now that matters at this moment. I remember I’ve  prepared for this, I’ve put in the training, there is nothing they can throw at me that I’ve not handled before. I’m  ready, there’s no need to panic my team are behind me all the way, and when the time is right I’ll hit them with the best of what I’ve got. Whether I win the funding bid or I get a standing ovation for a conference presentation ( that never happens by the way) is not really important (although the boss would probably say otherwise). What’s important is that the demons don’t win, because they will only grow stronger and more disabling. So here’s to unmasking demons- and let the fight begin!