Perspectives on the Acute Care Continuum

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A Group Approach to Fostering Resilience in Healthcare Providers

4/28/2015 11:37:48 AM | 5 comments

Recently, mindfulness expert Dawa Tarchin Phillips posted about the importance of resilience in healthcare settings. Today I'd like to share how CEP America conceptualizes resilience and how our organization equips providers to thrive in challenging environments.

A Personal Calling

Most healthcare providers choose their career out of a desire to help others. What we don't like to talk about is that in treating others, we can hurt ourselves.
This point was driven home for me when a dear friend — a gifted, empathic physician — died a few years back from an acute illness. At the time, he was feeling exhausted and overworked. He had trouble separating his patients' suffering from his own. While his emotional distress wasn't directly responsible for his death, it's probable that it weakened his defenses and exacerbated his final illness.
After my friend’s death, I set out to try to better understand what had happened. At a community lecture entitled "Spirituality in Times of Crisis," I was introduced for the first time to the concept of compassion fatigue, a combination of job burnout and secondary trauma that often affects helping professionals.
A chaplain, who worked with the local fire department, told the story of a young child who drowned in a swimming pool. He described the ordeal of the paramedics as they tried to resuscitate the boy en route to the hospital. Sadly, the child was pronounced dead in the emergency department (ED).
Based on past experience that had enlightened EMS agency policy, the first responders were given paid leave from their jobs and provided with counseling. They would not be allowed back on the job until they were determined to be at low risk for “imprinting” the trauma that they had experienced — and so would have fewer lasting effects from that experience.
As I listened, I realized that this story sounded so familiar. The same child had been brought to our ED, where we'd tried unsuccessfully to resuscitate him. We were in fact the ones who informed his parents that he had died. Afterward, while the medics were off to recover, what was expected of ED providers? Next patient!
Wow, I thought to myself. Something is wrong with this paradigm.
At the time, I was on CEP America's Credentials and Partnership Affairs Committee, which oversees wellness promotion. When I shared what I had learned with other members, it really resonated with them. So in 2011, we formed a resilience task force composed of physicians, physician assistants and nurse practitioners. Our group worked with Eric Gentry, PhD, LMHC, a psychologist and traumatologist, to create what ultimately became our practice's Professional Resiliency Program.

Defining Resilience 

Before we talk about teaching resiliency, let's take a moment to explore the concept.
Multiple studies in the past few years have shown that there is a high rate of burnout amongst ED and other hospital-based providers. Is there a way to do this kind of work and not suffer from it?
The answer is a resounding yes. Our workshops are designed to demonstrate how we can be more “resilient” to the effects of workplace stress and live more satisfying professional and personal lives.
In our workshop, we first ask everyone to write down three symptoms of work-related stress that they have experienced and to share them with the group. Common examples include difficulty sleeping, irritability and challenges with personal relationships.
"What causes these symptoms?" we then ask. Typical answers: the EHR, fear of liability, administrator demands, patient demands, conflicts with team members, long hours and so on.
But here's the rub. None of these stress factors actually cause our symptoms. They're only triggers. And truth is, we really can’t control many of these workplace factors. The ultimate cause of our “stress-related symptoms” — and the only thing that we really can really control — is our response to intense workplace factors.
Our bodies react to threats (both real and perceived) by activating our sympathetic nervous system (SNS), the component of our autonomic nervous system that mobilizes us to fight or flee. Spending too much time in this aroused state is exhausting, stressful and unhealthy. Under persistent sympathetic activation, the neocortex of the brain, which governs reason, emotion, creativity and language, is inhibited, while our more primitive brain centers are activated. This physiologic central nervous system (CNS) response to threat can adversely impact both our job performance and our personal lives.
The good news: we can prevent SNS dominance by managing our body physiology. When our bodies are relaxed, it is physiologically impossible to be stressed! And just as we can modulate our physiologic responses, we can modulate our perceptions so that we perceive fewer aspects of our work environment as threatening. These techniques have been demonstrated in evidence-based reviews to have profound beneficial effects for healthcare providers.

Teaching Resilience

The CEP America task force has developed a comprehensive resilience toolkit, including an hour-long introductory video and self-education materials that can be accessed online (for CME credit). But the foundation of our program is a workshop where participants learn and practice resilience skills.
In addition to providing background on compassion fatigue, our Professional Resilience Program emphasizes:
  • Self-regulation. This is the ability to shift immediately from SNS to PNS (parasympathetic nervous system) dominance, especially when we feel threatened. Self-regulation differs from other relaxation techniques in that it can be utilized while engaged in work-related tasks like caring for patients. No time-out is required.
  • Perceptual maturation. To a certain degree, we can lessen our tendency toward SNS activation by changing how we interpret the world. For example, we might choose to see work tasks as choices, not imperatives. And rather than trying to meet every request, we can accept that it is the nature of work systems to always demand more than we can deliver.
  • Support and connection. Hardened self-reliance will only get us so far. We all need to cultivate a trusted network of people who will both comfort us and confront us if we start to become symptomatic. The ability to connect with another and share our traumatic experiences in a controlled environment has been demonstrated to reduce the symptoms of vicarious traumatic stress.
  • Self-care. This is the core of what you hear from other “wellness programs.” Care for yourself: eat right, sleep enough, get aerobic exercise and enhance spiritual connections.

Resilience Rewards

In the words of Eric Gentry, the path to becoming resilient is simple but not easy. It takes time, diligence and persistence to hone our skills, change old attitudes and build support networks.
That being said, boosting our resilience generally improves our functioning in just about every way. Perhaps most importantly, it can rekindle that sense of mission and compassion that attracted us to healthcare in the first place.
Working on the Professional Resilience Project allows me to hone my own resilience, to continue to practice medicine and to be an effective leader. The feedback that we have gotten from resilience workshop attendees informs us that others are finding this material to be very effective.
Our committee is still working to increase awareness of these issues and engage more Partners in the program. We want to help providers understand that caring for others who are ill or injured must hurt. However, we don’t have to suffer, and we can still lead satisfying personal and professional lives.
How does your organization foster resilience? And perhaps more importantly, how do you foster resilience in yourself? Comment below and tell us about it.

[Image credit: "Desertflower" by Dsyrengelas licensed under CC BY-SA 3.0]

Anne Bruce
Dr. Dietz, I thoroughly enjoyed your article and have shared it with many others. After writing my own article for my Mindfulness in Medicine column, "What a Brain Scientist's Stroke Can Teach Us About Mindful Resiliency," here a few weeks ago, I revisited what you wrote and took notes on the professional resiliency program CEP offers. Fostering these life tools among healthcare providers is not only necessary but timely and long over due. Your article will be transformational for many. It certainly has been for me. Thank you.
8/15/2016 12:36:05 PM

Ted Muller
Excellent article Jim. I have been involved with Jim's resiliency training for the last 5 years. I have found it invaluable in my practice and in my personal life. Being able to relax onself in the context of very stressful stimuli in a matter of seconds is a wonderful skill. I have found that my overall stress level is much less and that my ability to navigate through stressful situations at work and at home is greatly enhanced. Combined with the other 3 elements of resiliency (perceptual maturation, self care, and connection and support) one has a powerful toolkit to prevent the negative effects of stress that allows one to have a long and happy career and life. I feel very fortunate to have had this opportunity to delve deeply into these skills and have come out the other end of the process a much happier and more relaxed practitioner and person. Thank you Jim! Great, great stuff here.
5/1/2015 6:03:24 PM

Cyndy Flores
Thanks Jim - so important things to remember it's too easy to just 'push on'.
4/29/2015 2:37:54 PM

David Carter
Thanks, Jim.
Such an important topic. So easy to forget ourselves in the pressure of both work environment demands and even personal life demands. Really appreciate all that you and your entire team have done to not only bring this to the forefront as an issue, but to provide practical solutions.
4/29/2015 12:08:46 PM

Jim thanks for having this resource for all of us. We are fortunate to have a group and individuals that value wellness of our providers. This allows us to be more compassionate and provide the best care to our patients and ourselves.
4/29/2015 12:45:14 AM