Resilience: Helping Clinicians. Orla Smith, RN PhD Associate Scientist, Li Ka Shing Knowledge Institute St. Michael s Hospital

Transcription

1 Resilience: Helping Clinicians Orla Smith, RN PhD Associate Scientist, Li Ka Shing Knowledge Institute St. Michael s Hospital

2 Disclosures Principal investigator of ARISE Study (Achieving Resilience in Acute Care Nurses; NCT ) funded by grants from the Canadian Association of Critical Care Nurses (CACCN) and the Canadian Critical Care Trials Group (CCCTG)

3

4 Dyrbye L et al. NAM Perspectives 2017

5

6

7 Objectives To explore the need for resilience amongst health care professionals To describe the role of resilience in mediating negative outcomes for health care professionals To share practical strategies for building personal resilience Gratitude Mindfulness Self-compassion Three Wishes

8 Disclaimer Focus on individual strategies does not obviate responsibilities of systems/organizations to create and sustain practice environments that foster individual and collective resilience Shanafelt TD & Noseworthy JH. Mayo Clin Proc 2017;92:

9 Burnout syndrome (BOS) occurs in all types of health care providers, in particular those who care for the critically ill Interventions to prevent or minimize BOS can be categorized as follows: Environmental Team-based Practitioner-focused Individual focused interventions can be effective HCPs should be engaged in: Promoting self-wellness Recognizing and responding to symptoms Supporting colleagues Panagioti M et al. JAMA Int Med 2016; doi: West CP et al. Lancet 2016;388;

10 The Quadruple Aim An environment that is deficient in joy and meaning. is an environment where both the workforce and patients suffer. Report of the roundtable on Joy and Meaning in Work and Workforce Safety, Lucien Leape Institute, 2015 Bodenheimer T & Sinsky C. Ann Fam Med 2014;12: Sikka R et al. BMJ Qual Saf 2015;24:

11 Second Opinion by Rob Rogers, Rogers R. Chest

12 What is resilience? Rooted in the Latin term resilire, which means to recoil Ability to bounce back from adversity Capacities for persistence, creativity, emotional intelligence, grit, cognitive flexibility, risk-taking, agency, adapting to change, delaying gratification, learning from failure, and questioning success Resilience is present in actions, behaviours, and thoughts Resilience is built within supportive communities System factors contribute to the development and destruction of resilience Resilience requires: Self-awareness and self-monitoring Self-care Self-regulation Epstein RM & Krasner MS. Acad Med 88: McDonald G et al.. J Nurs Mgmt 2016;24: Shanafelt TD & Noseworthy JH. Mayo Clin Proc 2017;92: Zwack J & Schweitzer J. Acad Med 2013;88:

13 Charney s Model of Resilience Resilience is a multi-dimensional construct Proposes ten characteristics of resilience that can be learned These interact with biologic, genetic, epigentic, developmental, neurochemical, and neurocircuitry to enhance adaptation and confer resilience Similar characteristics identified in sample of highly resilient ICU nurses Charney DS. Am J Psych 2004;161: Mealer M. Int Care Med 2012;38: Wu G et al. Front Behav Neurosci 2013;7:10

14 Are you resilient? How resilient are you today?

15 Physician Well-Being Index Includes domains of burnout, depression, stress, fatigue, and mental and physical quality of life Brief, 7-item screening tool to identify distress, based on feelings in the last week Threshold score is 4 Can be used by individuals and by organizations Have you felt burned out from your work? Have you worried that your work is hardening you emotionally? Have you often been burdened by feeling down, depressed, or helpless? Have you fallen asleep while stopped in traffic or driving? Have you felt that all things you had to do were piling up so high that you could not overcome them? Have you been bothered by emotional problems? Has your physical health interfered with your ability to do your daily work at home and/or away from home? Dyrbye L et al. J Gen Int Med 2012;28:421-7

16 Why resilience? Resilience is skill-based and can be learned proactively Undergraduate health professions education poses important opportunity Resilience is both a personal and a cultural strategy Clinicians are interested in participating in resilience-based interventions For clinicians, resilience is associated with: Decreased Burnout Post-traumatic stress Stress Increased Hope Mindfulness Sleep quality Self-compassion Back AL et al. J Pall Symp Mgmt 2016;52: Hart PL et al. J Nurs Mgmt 2014;22: Hylton-Rushton C et al. Am J Crit Care 2015;24: Jennings T et al. Nurs Times 2017;113:22-26 Kemper K et al. J Alt Compl Med 2015;8: McAllister M & McKinnon J. Nurse Educ Today 2009;29: Mealer M et al. Int J Nurs Stud 2012;49: Mealer M et al. Am J Crit Care 2014;23:e97-e105

17 The Resilient Clinician Sensing the dangers: Chronic and acute secondary stress Enhancing resiliency: Strengthening one s own self-care protocol Replenishing the self: Solitude, silence and mindfulness Daily debriefing: Mindfulness and positive psychology What s your self-care protocol?

18 What does your day look like? Siegel and Rock describe a healthy diet for the mind using the Healthy Mind Platter Focus Time Spent on tasks in a goal-oriented way One day: Connecting Time 86,400 seconds Spent connecting with others Play Time 1440 minutes Spent being spontaneous or creative 24 hours Physical Time Spent moving or exercising Time In Spent on reflection Down Time Spent relaxing, without any specific focus or goal Sleep Time

19 Origins of Mindfulness Rooted in centuries old Buddhist traditions Scientific beginnings with Dr. Jon Kabat-Zinn, 1979 Centre for Mindfulness, University of Massachusetts Initial focus was on patients with chronic pain Classic training is Mindfulness Based Stress Reduction (MSBR) 8 week process Weekly instructor-led sessions Daily audio-guided practice One day retreat Various forms currently in use and under study in multiple populations and settings: Clinics and hospitals Patients and clinicians Military Prisons Schools (all levels) Sport Cresswell DJ. Ann Rev Psych 2017;68:

20 Cresswell DJ. Ann Rev Psych 2017;68:

21 What is mindfulness? Intentionally paying attention to the present, without judgement (of self or others) Can be learned and practiced in structured or unstructured form Individual versus group Short versus long sessions In-person versus online/apps Ways to practice: Body scanning Forest bathing Hatha yoga Mindful eating Sitting meditation Walking meditation Have you tried it? Boettcher J et al. Behav Ther 2014;45: Craigie M et al. Mindfulness 2016;7: Fang R and Li X. J Clin Nurs 2015;24: Gauthier T et al. J Ped Nurs 2015; 30: Kemper KJ et al. J Evidence-Based Compl & Alt Med 2015;20: Kemper KJ and Khirallah M. J Evidence-based Compl & Alt Med 2015;20: Klatt M et al. Compl Alt Med 2012;12Suppl:016 Krasner K et al. JAMA 2009;302: Lim D et al. PLoS One 2015;10:e Mahon MA et al. J Res Nurs 2017;1-12

22 Mindfulness for Clinicians Clinicians are interested in participating in mindfulness-based interventions In health care professionals and in trainees, associated with: Decreased Anxiety Burnout Depression Stress Increased: Attention Compassion satisfaction Confidence Empathy Resilience Self-compassion Sleep quality Work engagement Working memory Craigie M et al. Mindfulness 2016;7: Fang R and Li X. J Clin Nurs 2015;24: Fortney L et al. Ann Fam Med 2013;11: Gauthier T et al. J Ped Nurs 2015; 30: Kemper KJ et al. J Evidence-Based Compl & Alt Med 2015;20: Kemper KJ and Khirallah M. J Evidence-based Compl & Alt Med 2015;20: Klatt M et al. J Vis Exp 2015;101:1-11 Klatt M et al. Compl Alt Med 2012;12Suppl:016 Krasner M et al. JAMA 2009;302: Mahon MA et al. J Res Nurs 2017;1-12 Steinberg B et al. Am J Crit Care 2017;26:10-18

23 Self-Compassion First defined and measured Dr. Kristen Neff in 2003: Self-kindness versus self-judgement Common humanity versus isolation Failure and feelings of inadequacy are part of the shared human experience Mindfulness versus over-identification Self-compassion is associated with: Increased: Happiness Life Satisfaction Resilience Sleep Decreased: Anxiety Burnout Depression Stress Have you tried it? Gracia-Gracia P & Olivan-Blazquez B. Hol Nurs Prac Kemper KJ et al. J Alt and Compl Med 2015;8:1-8 Mahon MA et al. J Res Nurs 2017;1-12 Neff KD & Germer CK. J Clin Psych 2012;1-17 Neff KD. Self and Identity 2003;2: Neff KD. Self and Identity 2003;2:

24 Self-Compassion Practice Many simple exercises can help develop self-compassion Write down your self-talk then ask yourself if you would ever say those things to a friend Write yourself a letter from the perspective of a compassionate friend Take a self-compassion break This is stress. I m not alone. We all struggle in our lives. Put your hands over your heart, or whatever feels best for you, and say: May I be kind to myself.

25

26 Power of Gratitude Undergraduate students in health psychology were randomized to daily written reflections on one of the following conditions for a 2 week period: Gratitude (n=52) What 3 things went well today? What was your role in bringing them about? Hassles (n=49) Downward social comparison (n=56) Students in the gratitude group: Reported significantly more positive affect Were more likely to have offered emotional support to others Emmons RA & McCullough ME. J Personality and Soc Psych 2003;84: Seligman MEP et al. Amer Psychologist 2005;60:

27 2014 MidMichigan Health 27

28 Three Good Things NICU clinicians (n=89) participated in a study of Three Good Things reminders prompted participants to document the good things and their role in each Three themes emerged in a qualitative analysis of their responses: Having a good day at work Successful patient outcomes Effective teamwork Manageable workload Out on time Having supportive relationships Making meaningful use of self-determined time Rippstein-Leuenberger K et al. BMJ Open 2017;e015826

29 Three Wishes Spearheaded by Dr. Cook and colleagues at St. Joseph s Healthcare, Hamilton, ON Designed to bring peace to the final days of an ICU patient s life and to ease grieving A set of three wishes, identified by any of patients, families, clinicians, or project team, is elicited and implemented Three wishes: Encourages individualized end of life care, guiding us to honour dignity in dying persons Helps create enduring positive memories for families Fosters humanism and meaning in practice for clinicians It takes us from being detached to being engaged. It is often a means of reaffirming why it is we do the work we do. It's transformative.... I never would have thought to do these things as a physician... The 3 Wishes Project reengages the human aspect of medicine. Centofanti et al. BMJ Open 2016;6:e Cook DJ et al. Ann Intern Med. 2015;163: Swinton M et al. Am J Resp Crit Care Med 2016;195:198- Vanstone M et al. BMJ Supp Pall Care 2016;1-8

30 Our Three Wishes Experience 51 patients, 194 wishes Top three categories of wishes: Rituals and spiritual support (n=47; 24%) Connections (n=33; 17%) Preparations and final arrangements (n=19; 10%) Mean (SD) cost per wish = $2.00 ($11.51) Majority of wishes (n=171; 92%) cost $0

31 Summary: Conditions for Resilience Build positive professional relationships through networks and mentoring Develop emotional insight to understand one s own risk and protective factors Become more reflective to help in finding emotional strength and assist in meaning-making Maintain positivity through laughter, optimism, and positive emotions Use life balance and spirituality to give one s life meaning and coherence Charney DS. Am J Psych 2004;161: Jackson et al. J Adv Nurs 2007;60:1-9 Mealer M. Int Care Med 2012;38: Wu G et al. Front Behav Neurosci 2013;7:10

32 Be present in all things and thankful for all things. My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humour, and some style. Maya Angelou

33 Gratitude can transform common days into thanksgivings, turn routine jobs into joy, and change ordinary opportunities into blessings. William Arthur Ward "Silent gratitude isn't very much use to anyone." Gertrude Stein Courtesies of a small and trivial character are the ones which strike deepest in the grateful and appreciating heart. Henry Clay Thank You Showing gratitude is one of the simplest yet most powerful things humans can do for each other. Randy Pausch "This a wonderful day. I've never seen this one before." Maya Angelou Feeling gratitude and not expressing it is like wrapping a present and not giving it. William Arthur Ward