7. building resilience dr peter huggard...“the ability to maintain personal and professional...

Building Resilience

Dr Peter HuggardSenior Lecturer Division of Social and Community HealthUniversity of Auckland

BUILDING RESILIENCE:First Do No Self‐Harm

Peter HuggardSocial & Community HealthSchool of Population [email protected]

THERULESOFENGAGEMENT

You can’t wash the tearsfrom someone’s facewithout getting yourhands wet

Patients and clientscome second

Staff come first !!!!!

They are NOTnegotiable!!!

Sometimes, in discussions about “this stuff” we call to mind incidents, patients, families, clients, that have been significant in our lives, and we may recall the very painful memories of these events.

If these memories do re‐surface, think about why they have returned and the significance of them for you – call to mind the support that you do have in your personal and professional life.

This presentation Vicarious Trauma (compassion fatigue, secondary traumatic stress) “Hearing Voices” Current Research and Links to Resilience Resilience‐Building Strategies

Vicarious Trauma (secondary traumatic stress, compassion fatigue)

Vicarious trauma

. . . the natural consequent behavioursand emotions resulting from knowing about a traumatizing event experienced by a significant other . . (Figley, 1995)

“We view vicarious traumatization as an occupational hazard, an inescapable effect of trauma work. It is not something that clients do to us; it is a human consequence of knowing, caring, and facing the reality of trauma” (p.25)

Laurie Anne Pearlman Karen Saakvitne

Burnout emotional exhaustion depersonalisation feelings of reduced personal accomplishment

Maslach & Jackson (1981)

Compassion Satisfaction. . . an expression of the positive aspects ofcare‐giving – the joy and pleasure you receive from your work

Stamm, 2002

HEARING VOICES:

HEARING VOICES:

• Learning experiences were broad and overwhelmingly positive. They made me think especially about the empathetic side of Doctoring.

• Difficult experiences are part of everyday work

• To listen to gut feeling , it’s ok to feel sad and helpless but self preservation is key

Trainee Interns

Trainee Interns Opportunity to discuss situations to further improve my own practice and support my peers in their development

I’ve noticed at some point discussions get tense, but as soon as it ended, everything gets back to normal.

My experiences were commonly experienced by others

Trainee Interns• It is something I would wish to do again as I found the process of verbal discussion better than doing it in written form.

• Will help me reflect on my own feelings at the time of the event and later on while discussing with my peer about what they felt.

Trainee Interns• It gave me options to bring up controversial management issues with my supervisor. It was also a good refresher on moral ethical dilemmas faced in practice.

• Give me techniques for dealing with difficult situations

HEARING VOICES: Registrars

Often too busy to have time to engage in emotional issues

I find that empathy and being involved with patients is a fine goal ‐ but when you work long hours with minimal breaks, with minimal support, with patients who have high expectations, on the background of a somewhat hostile and non‐medical management, you have no time.

RegistrarsAlthough empathy for, and understanding of patients feelings and their families feelings is very important for patient well being, I feel doctors often don’t have the time to pay a lot of attention to them.

It is actually very hard to ask for help from colleagues

RegistrarsManagement and senior clinicians can be unhelpful

The medical system is not well designed to facilitate, nor support “emotional competence”

People pay “lip‐service” to support for junior doctors ‐ there really is very little

RegistrarsAfter traumatic events senior staff often ask “are you OK?” but only two or three times have they taken me away, sat me down and checked that in fact I am OK. When you get asked – knee jerk reaction is to say “I’m fine ‐ I’ll be OK” and so it’s not discussed further.

RegistrarsVery few senior staff seem to have any interest in ensuring we have a balanced life, and are coping with the stresses of the job, and generally doing OK.

HEARING VOICES: Consultants

Many of these anxieties (about death) may be compounded by the doctor’s beliefs that “things could have been done better”. The experience of repeated loss can be wearying. For some, the intimacy that develops between patient and doctor near the end of life can be a threat. Feelings of hopelessness and vulnerability may be shared by the doctor.

Palliative Care Specialist

ConsultantsTherefore, the dilemma is to find a balance between being realistic and about our complication rates . . . taking pride in those cases in which all goes well and the outcomes are excellent. The secret to coping with these issues is to form constructive collegial relationships. The ability to share narratives of the disasters and the imperfections of clinical performance is a necessary safeguard to a situation, which if persistent, will cause harm to the practitioner.

Surgeon

ConsultantsDenying feelings can be stressful. It takes a lot of work to stamp down feelings, much more than acknowledging them. It’s uncomfortable to feel patients’ pain because it can remind us of our own pain and limitations; but if you can’t access the pain, you can’t access the love, compassion, and joy in practice either.

Paediatrician

ConsultantsI have seen many colleagues who placed work before their personal lives. Some of them were my roles models and I aspired to be like them until I saw the damage they suffered. Tired, feeling unappreciated, and practicing their beloved vocation without passion, they treated their patients like objects.

Psychiatrist

ConsultantsI still witness tragedy but my response is different. I cry with my patients and offer them a hug. The tears are the beginning of healing for both of us. I walk away with compassion in my heart, not sorrow. When we open our hearts to our patients, they offer us such gifts. I thought I needed to be resilient but I learned the secret is to take off the amour, not put it on.

Anaesthetist

RESILIENCE STUDIES“There is a crack in everything.That's how the light gets in.”

Results from five resilience studies

• Resilience in resident doctor group and its relationship to vicarious trauma and burnout

• Resilience factors across a range of health professional occupations

• Resilience factors in hospice palliative care staff – nurses, doctors, family support staff

• Personal resilience as a strategy for survival• Organisational resilience

The stress of being a medical student

The stress of being a physician

Management of physician stress

Personal Reflections

OXFORD UNIVERSITY PRESS (2013)

Compassionfatigue

CompassionSatisfaction

Burnout

ProQOL

Empathy

Spirituality

Emotionality

Resilience

PARTICIPANTS

•Hospital Registrars•4 District Health Boards•n=253•Average age = 31

STUDY DESIGN

•Anonymous questionnaire•Quantitative data gathered fromvalidated instruments•Results recorded against a Likertscale

•Free‐text comments in thequestionnaire

•In‐depth interviews reviewingand discussing results, and discussing support needs

CompassionFatigue


Burnout

ProQOL

Empathy

Spirituality

Emotionality

Resilience

CompassionFatigue


Burnout

ProQOL

Empathy

Spirituality

Emotionality

Resilience

‐ sig.

Spiritual Beliefs

Relationship witha Higher Power

+ sig.

+ sig.

Strongest association with compassion fatigue?

Personal Strengths

Emotional Competence

These two subscaleswere the most strongly,

and negatively,associated with CF

Personal Strengths

• I can deal with whatever comes up• I believe that past success gives confidencefor new challenge

• I see the humour side of things• I believe that coping with stress strengthens• I tend to bounce back after illness or hardship• I believe I give my best effort no matter what• I believe I should act on a hunch

Emotional Competence

• I feel confident in my ability to care for patientsexhibiting strong emotional distress

• I am aware of my emotions as I experience them• I feel confident in my ability to understand my own

emotional responses to my patients’ distress• I feel competent in my ability to understand the

reasons for my patient’s strong emotional distress• I feel confident in my ability to care for the

emotional as well as the physical needs of my patients• I feel able to initiate access to additional support,

if required, to help me to understand and managemy emotions in relation to my patients

Nurses, social workers, counsellors,psychologists, doctors

DemographicBehavioural (personal)Behavioural (professional)Cognitive (personal)Cognitive (professional)Relational (personal)Relational (professional)

Search Criteria

Health Professionals: Nurses, social workers, psychologists, counsellors, doctors, speech‐language therapists, audiologists and optometrists.

The search was limited to English‐language peer‐reviewed journals and dissertations published in the last 12 years (2000 to 2012).

An article was included if it had a focus on coping, self‐care, well‐functioning, hardiness or resilience of health professionals; not students or patients.

Factors across the disciplinesGender (being female)Maintaining Work‐Life Balance

Laughter/humourSelf‐reflection/insightBeliefs/spiritualityProfessional identity

Women doctors more likely to have cried (doctors)

Men speaking minimally about holistic self‐care (counsellors)

Women use greater amounts of relational strategies than men (psychologists)

Females more likely than men to believe in and engage in self‐care activities (psychologists)

Females working in public settings more likely to experience emotional exhaustion thanthose who worked in private setting – no differences seen with men (psychologists)

Activities such as promoting growth in clients, helping others, professionalautonomy, intellectual stimulation, and enjoyment of work ‐ were the most highly ratedsources of satisfaction. Gender differences were observed with female respondentsendorsing more sources of satisfaction (psychologists)

Male gender a predictor of positive coping (mental health social workers – followingdeath of a client by suicide)

GENDER

Determining resilience characteristicsin hospice palliative care staff

Resilience CharacteristicsBelow is a definition of resilience.

Resilience is:“the ability to maintain personal and professional wellbeing in the face of on‐going work stress and adversity”

Based on this definition provided, please complete the following sentence with the most important characteristic you believe describes a resilient hospice worker.

I believe the most resilient characteristic of a hospice palliative care health professional is

____________________________________________________________________

Results:35 items

TOP SEVEN

Maintains a good work‐life balance Maintains clear professional boundaries at work Has a sense of humour Has, and develops, strong and trusting collegial Relationships and support at work Has a passion for their work Self‐reflective practice Spiritual beliefs

Personal resilience as a strategy for survival

Jackson, D., Firtko, A. & Edenborough, M. (2007). Personal resilience as a strategy for surviving in the face of workplace adversity: a literature review. Journal of Advanced Nursing, 60(1), 1‐9.

• Building positive nurturing professional

relationships and networks

• Maintaining positivity

• Developing emotional insight

• Achieving life balance and spirituality

• Becoming more reflective

COMMUNITY AND ORGANISATIONALRESILIENCE:

Benchmark Resilience: A study of the resilience of organisations in the Auckland region (2010)

• Resilient Organisations Research Group –Universities of Canterbury and Auckland

• Developed a measure of organisational resilience• Sampled 1009 Auckland organisations and established the validity of the instrument

• http://www.resorgs.org.nz

What is OrganisationalResilience? Resilient Organisations: University of Canterbury andUniversity of Auckland

• Leadership• Staff Engagement• Situation Awareness• Decision Making• Innovation and Creativity• Effective Partnerships• Leveraging Knowledge• Breaking Silos• Internal Resources• Unity of Purpose• Proactive Posture• Planning Strategies• Stress Testing Plans

RESILIENCE BUILDINGSTRATEGIES

Caring for Ourselvesand

Maintaining our Resilience

A, B, C’sThe

Resilience Building Strategies

Awareness:•of our needs•limits of our physical and emotionalresources

Balance:•between activities, work, play, and rest

A

B

C Connection:•to oneself, others, and something larger

Saakvitne & Pearlman (1996)

51

STEP 1

Take stock of stressors at home and at work

STEP 2

Enhance self care at home and atwork and improve work/life balance

STEP 3

Develop CF resiliency

STEP 4

Make a commitmentto implement changes

STRATEGIES

The 4 Steps

52

STEP 1

Take stock of stressors at home and at work

STRATEGIES

The 4 Steps

53

BALANCE

54

SELF CARE QUESTIONNAIREReflect on the following, and identify those areas that you need to pay more

attention to in order to have a more balanced life, both professionally and personally.

Tick

Physical Self‐Care

1 Eat regularly

2 Eat healthily

3 Exercise

4 Get medical care when needed

5 Take time off when sick

55

STEP 2

Enhance self care at home and atwork and improve work/life balance

STRATEGIES

The 4 Steps

= Homework

56

STEP 3

Develop CF resiliency

STRATEGIES

The 4 Steps

Organisational/Peer Group/Individual Processes

12 Step Plan for ‘Helpers’

Personal Debriefing Model

57

Organisational Processes

• Top‐down acknowledgement of the ‘additional’ consequences of being in a ‘carer’ role

• Commitment to providing processes that assist staff to manage these consequences

• Monitoring of staff workload and assignments

58

Peer Group Processes• “Peer monitoring”

• “Belonging” processes

– collegiality, decreased sense of isolation

• Organizational culture of fun

• Appropriate work load balance

Group SupportDelilah Smith

59

Individual Processes

Strategies fordisengagement:

Effective professional supervisionDefusing/debriefing Boundary settingPositive self‐statementsHealthy work‐life‐home balance

The Separation of Sky and WaterMichelangelo

Individual Processes

Strategies for gaining a senseof achievement:

Setting achievable goalsBeing open to feedbackFocusing on successesDeveloping a tolerance for setbacksUse of rituals

Achievement – Mark Huddleston

Personal, Professional, and Organisational Responsibilities for Health Care Professionals© Jayne Huggard 2008

THE WIDERCOMMUNITY

Develop and maintain networks:•Local•Regional•National•International

THE WIDER COMMUNITY

ORGANISATIONAL

ORGANISATIONAL•Recruitment and orientation•Accurate job descriptions•Competencies linked to

performance appraisals•HR policies and procedures•Training opportunities – support

for study•Communication channels•Critical Incident Debriefing•Regular feedback•Healthy rosters•Acknowledgement of

personal pressures•Staff support

PROFESSIONAL

PROFESSIONAL•Journal Clubs•Collegial support•Line manager support•Supervision and mentors•Personal debriefing model•Boundaries•Positive team relationships•Conflict management•Feedback•Reflective practice•Professional development•Effective communication•Maintain motivation•Prioritise workload•Manage time•Take meal breaks•Humour•Attend to grief work•Research

PERSONAL

PERSONAL•Self care questionnaire•Self care contract•Work-Life-Balance•Restorative activities•Time with family and friends•Stress management•Exercise and nutrition•“Learn to say no”•Assertiveness•Accept help and support•The inner child•Next holiday planned and booked•Nurturing, caring, and valuing self•Spiritual and religious needs


THE WIDERCOMMUNITY


THE WIDER COMMUNITY

ORGANISATIONAL





PROFESSIONAL


PERSONAL




THE WIDERCOMMUNITY


THE WIDER COMMUNITY

ORGANISATIONAL





PROFESSIONAL


PERSONAL


THE WIDERCOMMUNITY


66

Transforming Compassion Fatigue into Compassion Satisfaction: Top 12 Self‐Care Tips for Helpers

Françoise Mathieu, M.Ed

www.compassionfatigue.ca

67Take Stock

Start a Self‐Care Idea Collection

Find time for yourself every day – Rebalance your workload

Delegate ‐ learn to ask for help at home and at work

Have a transition from work to home

Learn to say no (or maybe yes) more often

Assess your Trauma Inputs

Learn more about Vicarious Trauma

Make Supervision and PeerSupport more effective

Attend Workshops/Professional Training Regularly

Can you work part time,or alter the componentsof your job?

ExerciseMount TaishanShandong Province,

China

sunrisebirth, renewal

68

PERSONALDEBRIEFINGMODEL

The Scream ‐ Edvard Munch

Giving closure to your workAnd work relationships

Acknowledging the goodwork you have done

Check that tasks are finished, anddocumentation completed

Deal with outstanding issues:• Complete if essential, OR• Delegate, OR• Write it down to do tomorrow

Acknowledge the day

• Recall what went well and whatdidn’t. Focus more on the positives andless on the negatives

• Acknowledge that you did your best withthe time and resources available to you.

• Be conscious at handover that you arenot only handing over clinically, but alsohanding over total responsibility to yourcolleagues

• Close your computer or paper fileswith intent!

Hand over responsibility for the careof your clients

• This is closure for today on yourrelationships with clients and families,and with your colleagues.

Say your goodbyes

Debrief and de‐role:

• Talk through any distressing events• Arrange for a debrief if needed• Take off your ID badge or use other

personal rituals to signify your work isfinished

• Remind yourself you are now out of role• Make your journey home a final

separation between work life and yourprivate life.

If you are on call or work from home

• Create a specific space for yourprofessional work and try to keep to thisspace only

• If you find yourself thinking about work,particularly if something about it istroubling you, write it down and placeit in your work bag.

• If it is still there the next day, do youneed to talk it through or debrief?

Still thinking about work?

It is important to remember thatwhatever work you do, and whereveryou do it, you never need to feelalone – have the names of trustedcolleagues you can call and talkthrough a situation should the needarise, or use email if your supportis out of town.

Remember . . . . .

MindfulnessSeveral important studies have shown significant improvement in the ability of physicians to:• demonstrate increased and sustained empathy and compassion to self and to others

• provide care for suffers • better regulate emotions

Reflective Writing: Accessing the Inner SupervisorA Story:

• A silent tear• The view from a hill• A talking animal• A slamming door• A pervasive emptiness• The rising sun

Reflective WritingAs the sun rises, I stand at the top of the hill overlooking my village, a village I had been born into, grew up in, and left to go to another land – to obtain my education as a doctor. I return now, many years later, feeling as though I have closed the door on my career in that other country. Yet, the pull to be here is greater than the pull to remain in that other foreign land, the land that is not the country of my birth. The emptiness I felt there is rapidly disappearing as I am greeted by my own countrymen, my family, and the old people who know the history, not only of my nation, but my village, and of my family. And yet, as I stand on the hill, looking with sadness at the hardship, I shed a silent tear, and at that moment, the Black Raven on my shoulder spoke.

Reflective WritingA Poem:

WHYWhy do you stay?Why don’t you go?Why do you let him do this?Why don’t you fight back?Why must you be a victim?Why don’t you take control?Why do you drag me into this darkness with you?

Reflective Writing

You walk through the door to my consulting roomExpensive perfume fills the airYou are stunningly beautifulYou allow me to examine youA breast falls outI want to touch it

Reflective WritingFrom the perspective ofthe Doctor

From the perspective ofthe Patient

From the perspective ofthe “wise observer in theroom”

83

STEP 4

Make a commitmentto implement changes

STRATEGIES

The 4 Steps

In Conclusion:

• Resilience could be our “fence at the topof the cliff”

• There are things we can do to managethe emotional challenges in our roles

• These are things that we MUST do• Finally, . . . . .

7. building resilience dr peter huggard...“the ability to maintain personal and professional...

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