Thriving vs. Surviving during Times of Change: The Science of Enhancing Resilience

Thriving vs. Surviving during Times of Change: The Science of Enhancing Resilience J. Bryan Sexton, PhD Director, Patient Safety Center Duke University Health System

Thriving vs. Surviving during Times of Change: The Science of Enhancing Resilience J. Bryan Sexton, PhD Director, Patient Safety Center Duke University Health System While you are waiting for us to start, perhaps you could send a quick text to someone important to you, to send a kind thought their way.

Ask the kids

National Study of the Changing Workforce Ask the kids

Ask the kids 65% of children (age 8 18) of working parents: National Study of the Changing Workforce

Ask the kids 65% of children (age 8 18) of working parents: worried about parents National Study of the Changing Workforce

Ask the kids 65% of children (age 8 18) of working parents: worried about parents wish parents were less stressed and less tired National Study of the Changing Workforce

In the past week, how many of you

In the past week, how many of you Skipped a meal?

In the past week, how many of you Skipped a meal? Ate a poorly balanced meal?

In the past week, how many of you Skipped a meal? Ate a poorly balanced meal? Worked an entire shift without any breaks?

In the past week, how many of you Skipped a meal? Ate a poorly balanced meal? Worked an entire shift without any breaks? Changed personal/family plans because of work?

In the past week, how many of you Skipped a meal? Ate a poorly balanced meal? Worked an entire shift without any breaks? Changed personal/family plans because of work? Arrived home late from work?

In the past week, how many of you Skipped a meal? Ate a poorly balanced meal? Worked an entire shift without any breaks? Changed personal/family plans because of work? Arrived home late from work? Felt frustrated by technology? Drank too much coffee? Slept less than 5 hours in a night? Over 40% of Americans regularly sleep less than 5 hours a night 2X as likely to die of heart disease 1.7x as likely to die of all causes (Cappuccio, 2007)

% of respondents reporting 3 or more days in past week 100 90 80 70 60 50 40 30 20 10 0 Sleepy at Work: Slept less than 5 hours in a night: 3 or more nights in the past week. Each bar = 1 DUHS Clinical Area 18

% of respondents reporting 3 or more days in past week 100 90 80 70 60 50 40 30 20 10 0 Sleepy at Work: Slept less than 5 hours in a night: 3 or more nights in the past week. Teamwork Safety % Resilient Climate = 51.6 = 76.3 77.8 Teamwork Safety % Resilient Climate = 45.8 = 66.7 70.6 Each bar = 1 DUHS Clinical Area (n=258) Teamwork Safety % Resilient Climate = 36.3 = 65.2 67.3 Teamwork Safety % Resilient Climate = 32.9 = 61.2 60.8 19

After controlling for pt severity and nurse and hospital characteristics, only nurse burnout was associated with the clinical outcomes

Impact on critical care nurses Half are emotionally exhausted (burned out) Sexton, et al. (2009). Palliative Care.

Impact on critical care nurses Half are emotionally exhausted (burned out) 2 out of 3 have difficulty sleeping Sexton, et al. (2009). Palliative Care.

Impact on critical care nurses Half are emotionally exhausted (burned out) 2 out of 3 have difficulty sleeping 1 out of 4 are clinically depressed Sexton, et al. (2009). Palliative Care.

Am I burned out? You try to be everything to everyone You get to the end of a hard day at work, and feel like you have not made a meaningful difference You feel like the work you are doing is not recognized You identify so strongly with work that you lack a reasonable balance between work and your personal life Your job varies between monotony and chaos You feel you have little or no control over your work You work in healthcare

Are they burned out? A brief tour of prevalence Page 11

Burnout is common among physicians in the United States, with an estimated 30% to 40% experiencing burnout.

Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout. Active surveillance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors per resident month as residents who were not depressed: 1.55 (95% confidence interval 0.57 to 4.22) compared with 0.25 (0.14 to 0.46, P<0.001)

a person s future level of cognitive vulnerability was significantly affected by his or her roommate s baseline level of cognitive vulnerability (and vice versa)

Burnout by Specialty Emergency medicine General internal medicine Neurology Family medicine Otolaryngology Orthopedic surgery Anesthesiology Obstetrics and gynecology Radiology Physical medicine and rehabilitation Mean burnout Mean burnout among among all all physicians participating General surgery Internal medicine subspecialty Ophthalmology General surgery subspecialty Urology Psychiatry Neurosurgery Pediatric subspecialty Other Radiation oncology Pathology General pediatrics Dermatology Preventive medicine, occupational medicine, or environmental medicine % Reporting Burnout 0 10 20 30 40 50 60 70 Arch Intern Med. Published online August 20, 2012. doi:10.1001/archinternmed.2012.3199

Burnout by Specialty Mean burnout among all physicians participating 0 10 20 30 40 50 60 70 % Reporting Burnout Arch Intern Med. Published online August 20, 2012. doi:10.1001/archinternmed.2012.3199

Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado 80045, USA. Meredith.Mealer@UCDenver.edu

18% (61/332) Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado 80045, USA. Meredith.Mealer@UCDenver.edu met diagnostic criteria for PTSD

Burnout and Suicidal Ideation among U.S. Medical Students Dyrbye et al., 2010 50% of medical students burned out 10% have suicidal ideation

Burnout is associated with: Infections Cimiotti, Aiken, Sloane and Wu. Am J Infect Control. 2012 Aug;40(6):486 90. Lower Patient Satisfaction Aiken et al. BMJ 2012;344: e1717 Vahey, Aiken et al. Med Care. 2004 February; 42(2 Suppl): II57 II66. Medication Errors Fahrenkopf et al. BMJ. 2008 Mar 1;336(7642):488 91. Higher Standardized Mortality Ratios Welp, Meier & Manser. Front Psychol. 2015 Jan 22;5:1573.

Burnout is associated with:

Burnout is associated with: Shorter lifespan

Burnout is associated with: Lower quality of relationships/ marital satisfaction Shorter lifespan

Burnout is associated with: Lower quality of relationships/ marital satisfaction Shorter lifespan Decreased immune system function

Burnout is associated with: Lower quality of relationships/ marital satisfaction Shorter lifespan Decreased immune system function Personal injury

Burnout is associated with: Lower quality of relationships/ marital satisfaction Traffic violations and accidents Shorter lifespan Decreased immune system function Personal injury

Burnout is associated with: Lower quality of relationships/ marital satisfaction Traffic violations and accidents Shorter lifespan Decreased immune system function WLB / depression / PTSD / suicide Personal injury

From First to Worst Those with tenacity, dedication and a strong sense of responsibility are vulnerable to burnout Burnout Lead Weights: work hours, night shift, conflicts with colleagues, fiscal debt, poor boundaries between work/home life Burnout Band-aides: spending time with spouse, social support, positive learning environment, having a clinician as a parent, being a parent, and getting satisfaction from conversations with others, control over days off, quality of working relationships

Psychology of Burnout Your focus determines your reality & Perceptions are influenced by how you feel

Psychology of Burnout Your determines your reality

Notice anything unusual about this lung scan?

Notice anything unusual about this lung scan? Harvard researchers found that 83% of radiologists didn't notice the gorilla in the top right portion of this image.

What the burned out eyes are able to see is limited: Eye-tracking of attention of burned out and depressed participants was the same: more focus on dysphoric stimuli / less focus on positive stimuli

Psychology of Burnout

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Burnout, at its core, is the impaired ability to experience positive emotion Page 42

Joy Gratitude Serenity Interest Hope Pride Amusement Inspiration Awe Love

Social Connection: Positivity in Stereo

Having High-quality Social Connections Is Associated with:

Having High-quality Social Connections Is Associated with: Positive Emotions and Well-being Kok BE, Fredrickson BL. Biological Psychology 2016; 117:240.

Having High-quality Social Connections Is Associated with: Lower Rates of Anxiety and Depression Cohen S, Wills TA. Psychological Bulletin 1985; 98 (2):310 357. Positive Emotions and Well-being Kok BE, Fredrickson BL. Biological Psychology 2016; 117:240.

Having High-quality Social Connections Is Associated with: Lower Rates of Anxiety and Depression Cohen S, Wills TA. Psychological Bulletin 1985; 98 (2):310 357. Better Immune Function Kiecolt-Glaser et al. Annual Review of Psychology 2002; 53:83 107. Cole S. Current Directions in Psychological Science 2009; 18(3):132 13. Positive Emotions and Well-being Kok BE, Fredrickson BL. Biological Psychology 2016; 117:240. Lower rates of Cardiovascular Disease Knox SS, Uvnas-Moberg K. Psychoneuroendocrinology 1998; 23:877 890.

50% increased chance of longevity for those with stronger relationships

Meaningful Connections Are a Health Behavior

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Friend Page 50

Best Friend Page 50

4 a.m. Friend: Is there someone in your life whom you would feel comfortable phoning at four in the morning to tell your troubles to? If so, you are likely to live longer than those who say no. Discovered by George Vaillant (Harvard psychiatrist) and called the capacity to be loved. Conversely, loneliness is such a disabling condition that it suggests the pursuit of relationships is a fundamental to well-being. -- Marti Seligmann, 2011 Page 51

Buddy Up

Buddy Up optimizing oxytocin and serotonin - which boost mood and promote bonding - hold a handshake for at least six seconds.

Active Destructive Responding Finding the bad in the good: where you find the cloud in the silver lining

Active Destructive Responding Passive Destructive Responding Finding the bad in the good: where you find the cloud in the silver lining Not caring at all about their news

Active Destructive Responding Passive Destructive Responding Passive Constructive Responding Finding the bad in the good: where you find the cloud in the silver lining Not caring at all about their news Not making a big deal out of it

Active Destructive Responding Passive Destructive Responding Passive Constructive Responding Active Constructive Responding Finding the bad in the good: where you find the cloud in the silver lining Not caring at all about their news Not making a big deal out of it Reacting positively, being interested and caring about their news.

Active Constructive Responding Maintain eye contact / smile / touch / laugh Don t overdo the praise and positive feedback (it can make people feel uncomfortable/patronized) Concentrate on asking questions which encourage the person to talk about their good news/ savor their positive emotions. If this type of active and constructive response does not come easily to you try to ask at least three questions.

Three Good Things

Three Good Things 65 Placebo control (n = 70) Three good things (n = 59) Happiness 60 55 Pre- Post- One One Three months Six months Seligman, Steen, Park & Peterson, 2005

Three Good Things Depressive Symptoms 14 12 10 Placebo control (n = 70) Three good things (n = 59) 8 Pre- Post- One One Three months Six months Seligman, Steen, Park & Peterson, 2005

The negative screams at you, but the positive only whispers -- Barbara Fredrickson #1) We are hard-wired to remember the negative.

#1) We are hard-wired to remembe the negative. #2) Enhanced recall of material reviewed during last 2 wakeful hours.

#1) We are hard-wired to remember the negative. #2) Enhanced recall of material reviewed during last 2 wakeful hours. #3) With practice (by day 4 or 5) reflecting on the positive leads to noticing more positive.

#1) We are hard-wired to remembe the negative. #2) Enhanced recall of material reviewed during last 2 w #3) With practice (by day 4 or 5) reflecting on the positive leads to noticing more positive.

Duke Internal Medicine Resident Results Thanks to the efforts of Drs. Jon Bae and Amy Zaas, as well as our Medical Student researcher Whitney Chadwick. Main Findings: Lower burnout, lower depression in the post Fewer delays Less conflict Better work-life balance Residents enjoyed participating in the research

100 Resilience across DUHS (for pace and intensity of innovation) % of respondents reporting no burnout 90 80 70 60 50 40 30 20 10 0

% of respondents reporting no burnout 100 90 80 70 60 50 40 30 20 Resilience across DUHS (for pace and intensity of innovation) --IM Residents Pre 35% --IM Residents Post 50% 10 0

% of respondents reporting no burnout 100 90 80 70 60 50 40 30 20 10 Resilience across DUHS (for pace and intensity of innovation) --PS Conference Pre 43% --PS Conference Post 62% 0

% of respondents reporting no burnout 100 90 80 70 60 50 40 30 20 10 0 Resilience across DUHS (for pace and intensity of innovation) --PS Conference Pre 43% --PS Conference Post 62% 95% would recommend 3 Good Things to a Friend / Supervisor

% of respondents reporting no burnout 100 90 80 70 60 50 40 30 20 Resilience across DUHS (for pace and intensity of innovation) --Stanford NICU Pre 36% --Stanford NICU Post 47.3% 10 0

% of respondents reporting no burnout 100 90 80 70 60 50 40 30 20 Resilience across DUHS (for pace and intensity of innovation) --Stanford NICU Pre 36% --Stanford NICU Post 47.3% 10 0 93% would recommend 3 Good Things to a Friend / 91% Supervisor

Mean of the clinical area scores 100 90 80 70 60 50 40 30 20 10 0 Teamwork Climate, 68 Teamwork Climate, 77 DUHS Safety Culture & Teamwork Climate, 64 Safety Climate, 71 Resilience Safety Climate, 80 Safety Climate, 67 Resilience, 40 Resilience, 45 DUHS 3GT Yes 3GT No Resilience, 37 Work Life Balance, 49 Work Life Balance, 51 Teamwork Climate Safety Climate Resilience Work Life Balance Work Life Balance, 47

Meeting Agenda Item -One good thing so far this week

Positive Leader Rounds Did leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?: Yes / No / Not Sure

Mean of the clinical area scores 100 90 80 70 60 50 40 30 20 10 0 t=40.33, p<.001 Learning Env, 76 Safety Culture Domains by Learning Env, 40 Positive Rounds t=37.24, p<.001 Local Leadership, 66 Local Leadership, 31 t=34.10, p<.001 Teamwork Climate, 71 Teamwork Climate, 39 t=41.17, p<.001 Safety Climate, 75 Learning Env Local Leadership Teamwork Climate Safety Climate Burnout (My Burnout) Burnout Climate Work Life Balance Safety Climate, 38 t=-25.09, p<.001 Burnout (My Burnout), 36 Burnout (My Burnout), 61 PosRd Yes (n=6585) PosRd No (n=2212) t=-24.15, p<.001 Burnout Climate, 53 Burnout Climate, 76 t=18.76, p<.001 Work Life Balance, 67 Work Life Balance, 50

Get out your mobile phone.

73940 Click the link to sign up for our Resilience Intervention: WISER. http://bit.ly/3wiser @3wiser

Want to try WISER? enroll: bit.ly/3wiser enrollment video: bit.ly/3wiservideo

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Humans are capable of being physically, emotionally, cognitively, socially, financially and spiritually overwhelmed from time to time. When we are particularly challenged, we need a combination of resilience role models, tools, strategies, and protected time, so that we don t just bounce back we bounce higher

Take Home Burnout/Resilience predicts quality 1 out of 3 are burned out in healthcare Over half of USA docs are burned out Burnout linked to: clinical quality; patient mortality; patient satisfaction; depression and suicide WISER: bit.ly/3wiser Positive Emotion & calibrating to situation are keys to resilience Frequency not magnitude of positive emotion www.dukepatientsafetycenter.com

The Story of the Two Monks

Analogy: Noticing something about the world Commenting on it briefly through your mobile phone Seeing what other people commented on

Specific Tools 3 Good Things: bit.ly/3gtapril17 Gratitude Letters: bit.ly/grattool Signature Strengths: bit.ly/sstrengths Daily Acts of Kindness: bit.ly/kindtext Cultivate Confidants 2 day Resilience Retreat in Jan May & Nov 1 day Resilience Essentials Jan/April/Sept bit.ly/wiserstudy Courses in Durham www.dukepatientsafetycenter.com

led to increases in positive affect, as well as reductions in negative affect, mediational analyses showed that gratitude was uniquely responsible for the effect of the intervention on positive affect. In addition, the gratitude intervention improved people s amount of sleep and the quality of that sleep. Furthermore, the effects on well-being were apparent to the participants spouse or significant other.