Keywords

Introduction

CAMHS inpatient units are well placed to provide vocational training in a range of mental health disciplines as they have an aggregation of skilled clinicians able to teach, and patients who are readily accessible. Early in his career, the editor of this e-textbook (PH) was surprised to visit a CAMHS inpatient unit that discouraged student placements, on the grounds that it disrupted patient care. In contrast, the team at the Walker Unit considers they have an obligation to support training and education to ensure there is a skilled workforce capable of delivering CAMHS inpatient care (Hazell, 2021). We aspire to make training placements available to all disciplines working within the unit, and to make placements available to people from outside of the local health district, including those who come from lower- and middle-income countries (Hazell, 2021).

Generic Training

Staff newly appointed to the local health district receive one day of generic orientation to the health service. Nurses and midwives receive a further three days of discipline specific orientation. Topics covered are summarised in Box 19.1. To be frank, this is not the most thrilling experience for most inductees, but for a large organisation such as the Sydney Local Health District, it is a means to ensure all staff have received at least minimum exposure to knowledge essential to safe work practice.

Box 19.1 Topics covered during the generic orientation to the health service

Child protection

Domestic and family violence

Acceptable workplace behaviour (including The NSW Health Code of Conduct)

In-hospital emergencies

Fire and disaster management

Security and aggression

Environmental safety

Mask Fit Testing

Hazardous chemicals and substances

Manual handling

Safe work practices

Equipment safety

Incident and Injury Management System

Orientation is supplemented by further mandatory training that must be completed during the first year of employment (see Box 19.2). Some of the topics must be renewed annually. Completion of mandatory training is considered at each staff member’s annual performance review.

Box 19.2 Generic mandatory training topics

Fire Training (Theory)*

Fire Training (Practical)*

Basic Life Support Assessment (Cardiopulmonary Resuscitation Practical)*

Basic Life Support—Adult (Online Theory)*

Hand Hygiene

Infection Prevention and Control Practices (for clinical staff)

Mental Health Clinical Handover

Working with consumers and communities

Violence Prevention and Management—Personal Safety

Child Wellbeing and Child Protection

Introduction to Safety and Quality

Detecting Deterioration, Evaluation, Treatment, Escalation and Communicating in Teams

Introduction to Work, Health, and Safety

Open Disclosure

Privacy

Care Coordination

*renewed annually

CAMHS Training (external)

Within two years of commencing in their first position in a child and adolescent mental health service, staff may also undertake a four day introductory course under the auspices of the NSW Ministry of Health (see Box 19.3). The training is informed by the NSW Child and Adolescent Mental Health Services (CAMHS) Competency Framework (NSW Ministry of Health, 2011). In addition, the NSW Ministry of Health provides scholarships for staff to undertake more intensive study in child and adolescent mental health through courses offered by the Health Education and Training Institute (Health Education and Training Institute, 2021), summarised in Box 19.4.

Box 19.3 Topics covered in the Introduction to CAMHS course

Engagement, assessment, formulation, and developmentally appropriate interventions

Working with culturally diverse communities

Common mental health presentations that affect children and young people

Evidence based interventions, including CBT, family therapy, and mindfulness.

Box 19.4 Topics covered in the HETI Graduate Certificate in Child and Youth Mental Health

Mental Health, Mental Ill Health, and Suicide

Strength-Based Assessment and Care Planning

Professional and Ethical Mental Health Care

Attachment Development and Promoting Mental Health Across the Lifespan

Sustaining your mental health practice

Core Therapeutic Skills

Child and Youth Mental Health Conditions 1

Child and Youth Mental Health Conditions 2

Diversity and Mental Health

Child and Youth Mental Health Conditions 3

Trauma-Informed Care and Practice or Recovery and Recovery-Oriented Practice

Legal and Ethical considerations for Child and Youth Mental Health

General Workplace Training

Generic training has a role, but staff working at the Walker Unit require more specific in-house training and supervision to enable them to perform their roles. All staff are invited to participate in bi-weekly sessions with an external supervisor, although in practice the session is mostly attended by allied health and medical staff. The focus may be a particular case, or it may be an issue that is of concern to the multidisciplinary team. Examples of the latter include reflection on the suicide death of a former patient, adjustment to COVID related restrictions in practice, and the right of young people under the age of 16 to exclude certain family members from their family therapy. Sessions are documented by the team and by the supervisor. We find this helpful as it enables us to identify recurring themes. Discipline specific supervision is also available for most professions. There have been challenges accessing people with sufficient relevant experience to supervise occupational therapy, speech pathology, and art therapy.

We hold ad hoc staff development sessions on topics of salience to the unit. Recent topics include the use of structured diagnostic interviews, the role of art therapy, collaborative care planning, and the manner of conducting a gown search for high risk patients returning from leave.

Discipline Specific Training

Nursing

The Walker Unit hosts nursing staff new to mental health undertaking their one year “Transition to Mental Health Nursing” course for a three month rotational placement. Allocation to a CAMHS unit can be requested by staff if preferred but is typically allocated based on staffing requirement within the service. The transition to mental health nursing course does not of itself offer any specific CAMHS training, beyond an introductory lecture that describes the health districts services for young people and their families. When assigned to the Walker Unit, transition nurses are allocated two preceptors from the established staff to support their orientation and participation into the ward activities. In addition to the one day personal safety training, all nursing staff are required to complete a three day course in violence prevention and management so that they can form part of the service duress response teams. For staff who identify CAMHS as their preferred work environment, enrolment in the Introduction to CAMHS course already mentioned is undertaken within their first two years. For more advanced clinicians, consideration to undertake CAMHS related courses is done on an individual basis, but it includes courses facilitated by the Health Education Training Institute described in Box 19.4. The unit has monthly group clinical supervision for nursing staff conducted by an external Clinical Nurse Consultant who reflects upon situations identified by the group of staff attending during the meeting. Another form of reflective practice is undertaken in monthly Incident Review Meetings, which is part of a wider mental health service initiative to learn from incidents and reflect on practice.

Nursing student placements vary in length, typically between two and four weeks in duration. Students are directly supported by a clinical facilitator from their university, and ordinarily are exposed to a range of activities common among the whole mental health service; visiting the ECT clinic, observing a mental health tribunal being conducted and participating in debriefs among their cohort to reflect upon their experiences. Nursing students are allocated a registered nurse to shadow on a shift by shift basis, whom share and supervise students conducting day to day activities. At the Walker Unit, the emphasis for nursing students is both safe engagement with young people and attendance at the weekly case review, to observe how decisions in care are made by the whole multidisciplinary team. Nursing staff supervising students have access to an array of CAMHS specific literature to provide students and assist them in their learning experience.

Psychiatry

Psychiatrists in training work in the unit. Most are completing their six month compulsory term in child and adolescent psychiatry, which is usually undertaken in Stage 2 of the RANZCP training programme. Less commonly, we have an advanced trainee in child and adolescent psychiatry (Stage 3 of RANZCP training) who will be completing a compulsory inpatient term. The term offers the psychiatrists in training exposure to severe and complex psychopathology, and intensive therapeutic work. However, we have to arrange experiences offsite to ensure the Stage 2 trainees have the necessary exposure to children under 13 years of age, and become familiar with high prevalence, mild to moderate severity conditions. We achieve this through clinic sessions in community CAMHS and consultation to community child health clinics. Because the consultant psychiatrists in the unit are ‘hands on’ with their clinical care and the allied health and nursing staff are very capable, there is a danger that psychiatrists in training are supernumerary to the programme. We try to overcome this by ensuring the psychiatrists in training have specific tasks (e.g. preparing the documentation required to present a patient to the Mental Health Tribunal) and that they are allocated therapeutic roles such as being a patient’s individual psychotherapist. In addition to the psychiatrists in training, we support observerships for psychiatry residents from other countries. To date we have hosted psychiatry residents from Asia, South America, and Southern Europe. Such observerships typically last three months. The resident participates in most ward activities, but is not authorised to treat patients.

Psychology

Provisional psychologists undertake supervised placements in the unit of up to six months, on a part-time basis. Most of these students are completing the placement as part of an APAC (Australian Psychology Accreditation Council)-accredited higher education programme (Masters or Doctorate in Clinical Psychology). The students have an opportunity to contribute to all parts of the Walker programme, including, individual therapy, group therapy, multidisciplinary team meetings and team supervision, and do so under the guidance of experienced clinical psychologists. Owing to the severe and complex nature of the presentations of patients at the Walker Unit, students are interviewed before being offered a position and the positions are typically offered to students as a final placement prior to entering the workforce, or to students who have prior experience with similar patient populations.

Social Work

The health district’s Mental Health Social Work and Psychology Educator coordinates all field placements and provides support for both the student and supervisor for the duration of the placement. To support each student’s integration into placement the Educator provides a comprehensive orientation to the service at the beginning of placement to all social work and psychology students. Ongoing learning is fostered through fortnightly education sessions in the areas of vicarious trauma, simulated learning, the National Disability Insurance Scheme, and its interface with mental health services, working with psychosis, sexual assault, family violence, alcohol and other drugs, and the justice system and mental health. The Educator also provides social work- specific fortnightly group supervision sessions to support students with any placement issues as well as to introduce key therapeutic tools utilised within general social work practice including: genograms, Eco maps, Theory circle, process recording and critical reflection. This is in addition to weekly individual clinical supervision provided by the placement supervisor.

Occupational Therapy

Occupational therapy fieldwork placement at the Walker Unit is offered to students in their third year of study or above. Students provide a brief description of their previous clinical experience and their learning goals prior to commencement. The placements are typically full time, with a duration of seven to ten weeks. Occupational therapy students are a great asset to the unit as they are expected to take on individual case loads and facilitate in the group therapy programme under supervision.

Medical Students

Students from The University of Sydney typically may spend two weeks attached to the unit during their Psychiatry and Addictions Medicine term. The placement is not mandatory, so most students who attend have specifically requested some exposure to child and adolescent psychiatry. All students, however, have access to online lectures and a case-based tutorial. For students seeking more extensive experience in child and adolescent psychiatry, we offer a personalised pathway programme which involves regular association with the Unit for up to a year. Additionally, medical students from Sydney and other universities may undertake an intensive elective placement, usually full time for four weeks.

Student Wellbeing

We stress to students attending the Unit that what they see is not representative of child and adolescent psychiatry in general. The patients we manage are severely impaired, and their problems are enduring. Intervention is delivered at a much greater intensity than one might see in a community setting, or in an acute inpatient unit. The general principles of our approach do, however, generalise to other treatment settings. We are mindful that some of the things students observe or hear about will be confronting to them. Examples include the disfigurement caused by self-mutilation, and bizarre body movements associated with neuropsychiatric disorder. As far as possible we prepare students, and are available to debrief them following exposure. Student safety is also a paramount concern. Students have not generally undertaken the extensive orientation and mandatory training required of paid staff. In addition, they do not have the clinical experience necessary to recognise when there is an escalating risk of aggression. As such, all student contacts with patients are supervised by an experienced member of staff.