GUIDE to MENTORSHIP in the CMHCN
ORIGINS OF THE CMHCN
The Collaborative Mental Health Care Network was initiated in 2001 as a collaborative shared care network utilizing a medical mentorship model for family doctors throughout the province of Ontario. It originated as a collaborative effort between the Ministry of Health and Long Term Care of the Government of Ontario as funder and the Ontario College of Family Physicians as program developer. It was developed to deal with mental health issues in primary care practice since such issues are central to primary care. It is one of the largest and most successful programs of its kind and from the beginning has involved both principles of collaboration and principles germane to medical mentorship.
WHY MENTOR FOR THE CMHCN?
• You will be remunerated for your efforts and involvement on behalf of the CMHCN.
• You will assist mentees to provide best-practice care for mental health issues to those patients most in need.
• You will undergo valuable professional development by exposure to new ideas and skills in mentoring and leadership.
• You will have access to a province wide system of peer support. The CMHN has a roster of Adjunct Mentors with a diversity of specialized interests. Their Mentoring is available to other Mentors as well as the Mentees in the program.
• The CMHN provides both mentors and mentees with best practice, interactive CME events.
OVERVIEW OF MENTORING
DEFINITION
The Oxford Dictionary defines ‘Mentor' as a “trusted adviser,” and finds its origin in Greek mythology. In Homer’s Odyssey, Ulysses’ trusted friend, Mentor, protects, nurtures, educates and guides Ulysses’ son Telemakhos into adulthood in Ulysses’ absence.[i] The modern equivalent might be construed as a kindly, aunt or uncle, acting as an advisor or guide during a stressful circumstance.
Mentoring presumes the willingness of the mentor to develop a relationship with the mentee that acknowledges the level of professional development of the mentee and fosters that development congruent with the particular needs of that mentee. CMHN mentoring includes a clinically focused, ‘just-in-time’ intervention to assist with a short-term situation engendering high anxiety in the treating doctor.
CONTEXT of MENTORING WITHIN THE CMHCN
The CMHCN has the specific focus of providing mentoring for Ontario family doctors in the management of mental health issues. While the focus is specific in intent, it is not narrow in expression. Managing patients with mental health issues makes significant personal and professional demands on the primary care practitioner. Often such patients elicit strong emotional reactions from doctors which threaten to compromise patient care and may pose a medico-legal risk. For these, the CMHCN Mentor should be prepared to build a supportive relationship with their mentees and to provide personal support when required, as well as offering support for professional development issues.
QUALIFYING AS MENTOR
The CMHCN will choose Mentors for their interpersonal skills and availability, as well as their professional standing. Qualities germane to mentoring include :
• ‘humane, relates well to colleagues, acquainted with a diversity of practice settings, good communicator’, etc.
CMHCN mentors should be willing and able to provide a minimum time commitment and be available consistently.
• considerable clinical experience and a willingness to share this experience
• a defined professional identity
• a willingness to interact with mentees around questions of professional identity, doubt and anxiety, the logistics of managing mental health issues etc
• willingness to attend a mentors’ training group to help de-brief current interactions with mentees and acquire familiarity with mentoring approaches
To successfully provide personal support considerable skill in managing collegial relationships is important for mentoring function. This requires not only empathic capacity but willingness to challenge and constructively confront, when necessary.
CORE VALUES IN CMHCN MENTORSHIP
It is presumed that mentors will espouse the value system implicit in shared care mentoring approaches in medical care.
Core values are described as follows:
COLLABORATIVE VALUES
The intent of collaboration is for participant to foster the goals and needs of their collaborative partner, in a reciprocal fashion. This presumes that each person will understand and use the clinical ‘language’ most accustomed in their partner’s experience, and familiarize themselves with the clinical culture of their partner, constituting ‘cultural competency’. In this way asymmetry of power in the mentor-mentee relationship can be diffused. This management of the power relationship will make it easier to form a collaborative working relationship.
RELATIONAL VALUES
Face-to-face
Ongoing
Collegial/social
Inclusive
Inclusivity is the key aspect of the relational value of collaborative mentoring. It is collegial as well as social. The goal of this value is to develop trust between participants. Mentors will be encouraged to have face-to-face collegial and social contact with mentees on a regular basis as a way to develop and maintain trust in the mentoring relationship.
CONTRACTUAL VALUE
Permission to be active
Clear expectations
Conflict management
Developing a contractual understanding between mentor and mentee or mentee group involves defining the logistics of the collaborative working relationship. The intent is to clarify the mutual expectations between mentor and mentee or mentee group as well as the program expectations. This allows participants to feel they understand the circumstances in which they may contact their mentor and how to proceed. It also provides implicit permission to be active in initiating such contact.
EDUCATIONAL VALUE
Feedback
Reflective
Evaluative
Mentors will be trained in the appropriate way to give feedback to mentees as well as developing the mentees’ reflective capacities. Mentors will exposed to learning situations which allow them to develop a sense of assessing adult learner needs as well as problems with learning in adults. Mentors will be encouraged to model reflective behaviour by offering examples from their own clinical experience. In mentor training days they will gain experience in evaluating their mentee’s stage of clinical experience to discern the need for specific on-demand didactic intervention from the mentee’s need for decision support, and being allowed to develop their own approach to the clinical predicament.
EVALUATIVE VALUE
The CMHCN tracks the mentorship experience with focus groups, pre and post program assessments of clinical confidence and ability in mental health services as well as mentee learning needs. The program tracks quality and quantity of mentor-mentee contact. This information is statistically analysed where appropriate and provides feedback for ongoing development of CME and educational module development.
Mentors will be required to use an eMentor log of their contact with mentees to serve research purposes and provide the basis for their remuneration. As well they will help mentees to understand the reporting needs of the program specifically the pre and post mentees’ assessment forms.
EXAMPLES OF SOME USEFUL SELF-ASSESSMENT QUESTIONS FOR NEWMENTORS;
• What tangible and intangible rewards do you expect from entering into a mentoring relationship?
• What goals do you have for your personal and professional development that can be addressed by a mentoring relationship?
• What time do you anticipate dedicating to the mentoring relationship?
• How long do you think you need to be involved to reach your desired outcome? [ibid]
• What is the most important question you have about mentoring?
• What is most important clinical idea you might draw upon in mentoring
• Am I ready and willing to be a mentor/protégé?
• Do I have the time, resources, knowledge, skills, and behaviors to serve as a mentor/protégé?
• What are my areas of strength and weaknesses as a mentor/protégé?
• For what role(s) do I feel most/least comfortable in providing mentoring? (eg. practitioner, educator, researcher, manager)
• What characteristics do I bring to the mentoring relationship?
• Are my personal and professional goals such that I need a mentor?
• What do I expect of the mentoring relationship?
• What are the benefits and costs in becoming a mentor/protégé at this time?[ii]
CMHCN EXPECTATIONS OF MENTORS
GENERAL
• It is hoped Mentors will try to establish a supportive, collegial relationship with their mentees. This necessitates their availability above and beyond answering clinical questions put to them by mentees. Mentors should have had experience as mentees, and demonstrate their skills in working supportively with colleagues.
• The Three Times Three Plan: in order to encourage the development of a working, mentoring interaction, each mentor should attempt to identify a subset of mentees that show interest in more intensive mentoring. Mentors may then to negotiate meeting regularly with such mentees eg., agree to meet three times in one year by pre-scheduling, for about three hours.
LOGISTICAL EXPECTATIONS
The responsibilities listed below, for both the mentors and mentees, are considered to be minimum requirements for continuing involvement in the CMHCN. Please bear in mind that if it comes to the attention of the CMHCN administration that these expectations are not being met, it will be brought to the CMHCN Steering Committee, and involvement of the mentor in question will be reconsidered, and may result in the mentor being requested to leave the program. Years of experience in the CMHCN have shown this requirement to be a rare event.
• 24-48 hour response time to administration and mentees to optimise accessibility of mentors
• Mandatory attendance at the annual large group CME event since the annual conference day sets the tone for the next year and fosters small group dynamics. (unless there are mitigating circumstances beyond one’s control i.e. on call, holidays booked prior to notice). CMHCN administration will provide at least three months notice for events.
• Provide input on organizational matters when requested, although the CMHCN administration encourages more active participation; attendance at planning meetings, and contributing to CME events. The ultimate success of the program depends on active involvement by a majority of mentors.
• Initiating contact with individual mentees on a regular basis in a manner which best suits the mentee (i.e. weekly, monthly, etc.), in the preferred method of the mentee (phone, email, and/or fax). It is this regular contact which fosters the development of the mentor-mentee interaction.
• Keeping and reporting of mentee contact log (supplied), throughout the year.
This will help clarify billing and program evaluation.
• Initiating contact with mentee group to develop/organize small group learning sessions on a regular basis, (ie 3x/year), in person, by video, telephone or face to face.
MENU OF MENTORING CONTACT POSSIBILITIES
• Email, telephone, fax - informal/formal consult requests for advice/information.
• Face-to-face consultation between mentor/mentee with/without patient - case based
• Small group activities - dinner, teleconference, videoconference - case based
• Overnight retreats - case based or more extensive relevant mental health CME
The CMHCN committee/administration is open to new and innovative ideas and are willing to assist in coordinating these sessions.
FOR MENTORS’ INFORMATION: MENTEE PERFORMANCE EXPECTATIONS
• Mandatory completion of surveys: needs assessments, pre/post patient profiles, reflective learning activity, post CME evaluations, response/feedback surveys. This paperwork is an unavoidable burden to clarify program evaluation and ensure ongoing Ministry funding.
• Mandatory attendance at annual large group CME session
• Attendance at majority of organized small group events - in person by video, telephone or face to face
• Required contact of mentors - 6x per year
CUSTOMARY CMHCN MENTORING ROLES
The CMHCN Mentor is expected to provide the level of collegial support deemed most useful for their Mentee taking into account level of professional development and mentee’s preferred clinical ‘language’. The objective is to achieve some sense of mutuality with the mentee, to foster a supportive mentor-mentee relationship. The Mentor does not have to be the ultimate expert in their field to be helpful, since the mentoring role is much broader than mere information transfer. Although the Mentor should be ‘senior’ in some sense, verticality of hierarchy should be de-emphasized in the relationship.
There is a diversity of customary tasks or roles to consider in providing a mentoring function. The mentor will draw upon different roles at different times taking into account the context of mentee exigencies. Not all roles/tasks will be activated. Available roles include:
• initial assessment of mentee level of experience and capability,
• negotiation of a common clinical language and
• negotiation of a clinical focus ie the most urgent concern of mentee regarding their patient
• negotiation of a contract with the mentee, involving a discussion of factors such as: scheduling of contact, mode of contact, desired response time, emergency protocol, and dispute resolution. An outline of such a contract is provided in the binder that mentors receive.
• processing the clinical information provided by the mentee which may involve; monitoring, assisting, confronting, clarifying, re-directing, modeling, teaching, questioning, encouraging,
• providing role modeling such as; enhancing clinical competency, being accessible, providing a sounding board, advising, facilitating clinical reflection, identifying factors inhibiting development, fostering positive approaches, discussing boundary issues and ethical predicaments, providing support and challenge, providing guidance on medico-legal issues, and giving clear feedback about unacceptable clinical behaviours
As the mentee develops in confidence the more relevant roles of mentor may involve:
• encouraging the development of self-supervision,
• the use of parallel process to show the mentee how their own reactions may contribute to difficulties, and
• the shift from clinical observation to conceptualization, and
• application of current literature.
As the Mentor develops their relationship with their Mentees, they may find their accustomed roles shifting. Initially the Mentor may be required to provide a very active and interventionist stance with ‘on demand’, ‘just-in-time’ feedback. Over time, the mentee can be expected to feel more confident, to carry more responsibility in treating mental health issues in their practice. They may be better able to shift from symptom description to overview and conceptualization of patient’s mental health, and therefore less reliant on the CMHN. At this phase the Mentor is providing a form of Decision Support, facilitating consideration of therapeutic options to determine which approach feels most acceptable to Mentee.
Some examples of the more developed mentoring tasks might be:
• mentors assisting mentees to improve their understanding of somatization disorders by distinguishing the mental health implications of somatic symptoms.
• The mentee may need help in looking at qualities of their interpersonal relationship with their patient and its impact on care.
• Helping mentees to develop their own nosology of mental health patients using DSM and narrative formulation criteria may be useful.
• helping to organize clinical material so as to prioritize the patient’s need and choose a focus of concentration to prioritise with the mentee
MODELS of MENTORING
There are many models of mentoring that have been drawn upon for application within health care that derive from related disciplines, business, academe, pastoral relationships, training and apprenticeship, Big Sister/Brother, models etc.
The CMHCN is hoping that mentors will not see themselves as simply providing instruction but rather will seek to develop a connection with mentees that seeks an ideal perhaps resembling the relationship with a well-meaning aunt or uncle.
Of prime import for the purpose of the CMHN is the ‘Holistic’ model of mentoring[iii] A Holistic model will give equivalent weight to the balance between a system and its parts. It will also focus on the necessary interdependence of parts. Equal weight is assigned to three overlapping components:
•Didactic education,
• Professional Development emphasizing Role Modeling
• Personal Support.
Didactic Education:
A didactic approach of the mentor is of greatest value for the less experienced mentee, but may be necessary at any stage of professional development depending on the urgency of the clinical context. As the mentoring relationship develops it is hoped the mentee will develop a degree of self-supervision to bolster confidence in clinical management of mental health issues, and be less in need of ‘being taught’.
Professional Development:
The goal of Professonal Development involves a more defined sense of professional identity for the mentee, with a presumed increase in confidence as desired outcome.
PD also involves providing the mentee with appropriate links to literature or CME events. The CMHCN seeks to foster this aspect of mentoring with regular small group meetings as well as conference calls and an Annual Conference.
Role Modeling:
Role modeling presumes the Mentor models best practice behaviours with respect to skill acquisition, boundary maintenance, modeling of ethical approaches in complex clinical situations, and issues of clinical management. Role modeling implies an intent to foster the mentee’s professional goals, through interpersonal connection with their mentor. It may require the Mentor to assist in career path management.
Personal Support:
A relationship which provides personal support for the mentee implies a willingness for both parties to deal with questions of professional identity, self-doubt and learning curve anxiety. Etymology of the word ‘relationship’ implies an efficacy, as in ‘lordship’ or ‘friendship’, to connect and re-connect.
Both Professional Development and Personal Support functions of Mentors are dependent for their success upon the interpersonal interaction between mentor and mentee. The CMHN is concerned to provide the best working relationship environment possible for its participants.
OTHER MENTORING CONCEPTS:
Stages of Mentoring Relationship
In the initial stages the mentor may feel they are carrying most of the responsibility for initiating contact with the mentee. The mentee may attend a teleconference but not initiate contact otherwise. Eventually there may be a ‘testing of the waters’ with brief and infrequent contact through email. Later the mentee may feel emboldened as they develop trust in the mentor, and offer a test clinical predicament (filtered from many that have been considered for this purpose) for the mentor’s consideration. If the mentor-mentee relationship survives this the mentor may get ‘buy-in’ which involves commitment from the mentee in participating. The mentee may then take increasing responsibility in the relationship as their confidence and identification with the program increases.