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Success in the IC Setting: Strategies for TeamBased Wellness Jennifer L. Hodgson, PhD, LMFT Professor, East Carolina University Angela L. Lamson, PhD, LMFT Professor, East Carolina University Doug Smith, MBA CEO, Greene County Health Care, Inc. Affiliate Assistant Professor, East Carolina University Collaborative Family Healthcare Association 14 th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session # D5A October 6, 2012 1:30PM-2:10PM

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Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

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Objectives At the conclusion of this workshop, participants will be able to: 1.Discuss the long term challenges of providing care for a complex patient panel in a FQHC setting. 2.Describe a theory of relational leadership and systemic dynamics. 3.Describe common workplace dynamics that can lead to a decrease in productivity and provider well-being. 4.Gain knowledge about the use of intentional relational strategies to help build sustainable integrated care teams

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Need/Practice Gap Working in an integrated care setting, while enriched by the sharing of complex patients, assumes that teams function well automatically and methodologically without relational challenges. *When teams struggle with interpersonal challenges they are vulnerable to the same loss in productivity and increase in presenteeism and absenteeism as their patients *Team members under stress are at risk for developing the same health issues as their patients *In order to reduce staff turnover and administrative time managing employee disputes, curriculum is needed to help teams maintain relational well-being between the staff and providers.

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Greene County Health Care, INC. Quick Facts 30, 822 patients Rural setting 10 sites 6% Medicaid 87% are uninsured 100% of patients are below 200% of the FPL Community Health Center (FQHC, PCMH)

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Theory of Relational Leadership Leadership is a relational and ethical process of people together attempting to accomplish positive change. Five primary components... This approach to leadership is purposeful and builds commitment, inclusive of people and diverse points of view, empowers those involved, is ethical, and Recognizes that all four of these elements are accomplished by being process-oriented. Uhl-Bien, 2003

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Process is just as important as outcome Know yourself and others; engage yourself in learning new information as you develop the competencies required in your role (knowledge) Be open to difference and value other perspectives (attitudes) Practice listening skills, coalition building, interpersonal skills, and effective civil discourse (skills) Komives, Lucas, & McMahon (2006)

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Systemic Dynamics that Impact the Workplace Environment Appreciate that each member manages anxiety differently Non-summativity-the whole is greater than the sum of its parts Boundaries are the interface between a system and its subsystems or a system and its environment Systems are goal seeking A closed system receives no inputs Systems tend toward homeostasis Synergy is when the system outputs exceed the subsystem outputs

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Sources of Power French and Raven (1959) identify five primary sources of power that individuals bring to their relationships with others expert power referent power legitimate power coercive power, and reward power. French & Raven, 1960

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The key gift that leaders can offer is power Bolman & Deal, 2003, p. 341.

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Sources of Stress 1 Insufficient Resources at My Organization Time Constraints Insufficient Referral Network Family/Responsibility Work-life Balance Staff Turnover Organizational Structure Sufficient Team Support Culturallly Appropriate Resources Insufficient Resources for my Patients Work Load 1 Hayashi, Selia, McDonnell, Stress and Provider Retention in Underserved Communities, J of Health Care for the Underserved 20(2009): 597-604.

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Workplace Dynamics Organizational Changes Staff Turnover Communication Styles/Emotional Intelligence Management Team Involvement Retention Strategies Training New Staff Healthy Workspace Training/Four Colors Stress/Frustration Technology Family/Behavioral Issues Generational Difference in Work Ethic Turf Issues Sexual Harassment Training ???????????? Access to MFTs Policies Team Meetings

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A Team-Based Relational Curriculum Individual, colleague, and group consultation services Provider and staff workshops on Anger Management Compassion Fatigue Stress Management Healthy Workplace Communication Working with the difficult patient Setting Boundaries and Finding Balance between work and family True Colors (http://www.true-colors.com/content.php?id=18)

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Can you recognize relational stress before it hits you? Anything that poses a challenge or a threat to our well- being is a stress. Stresses can be positive or negative. It is also the way that we respond to a challenge Belmonte, J. (2001-2008). Understanding stress. Retrieved from http://www.helpguide.org/mental/stress_signs.htm#what

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The situations and pressures that cause stress are known as stressors. We usually think of stressors as being negative, such as an exhausting work schedule or a rocky relationship. Anything that puts high demands on you or forces you to adjust can be stressful. Top Ten Stressful Life Events 1. Spouses death 2. Divorce 3. Marriage separation 4. Jail term 5. Death of a close relative 6. Injury or illness 7. Marriage 8. Fired from job 9. Marriage reconciliation 10. Retirement Belmonte, J. (2001-2008). Understanding stress. Retrieved from http://www.helpguide.org/mental/stress_signs.htm#what

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There is a difference between Stress and Burnout Burnout is the loss of meaning in one's work Stages include: Honeymoon Balancing Act Chronic Symptoms Crisis Enmeshment Veninga and Spradley's (1981)

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Exercises to De-Stress Creating Clear Goals for Self and Team Diaphragmatic Breathing Guided Imagery Progressive Muscle Relaxation Speaker-Listener Technique

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A Plan of Action to Reduce Stress! 1) small rather than large goals 2) be specific 3) the goal should be achievable/assignable 4) the plan should be realistic 5) understand the goal as the start of something not as the end of something 6) when reducing stress involve a new behavior rather than just stopping old behavior or habit

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Goal Setting to Minimize Stress! Urgent and Important Urgent and Not Important Not Urgent and Important Not Urgent and Not Important *Prioritize *Set yourself up for success Covey, 1990

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1.) Find a calm quiet space 2.) Visualize walking down a long hall leaving where you are fading in the distance behind you 3.) Open the door at the end of the hall to your idea of a peaceful and safe place 4.) Experience that place with all of your senses: sight, taste, smell, touch, and hearing Guided Imagery

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5.) When you feel ready turn around and walk slowly toward the door feeling refreshed and prepared to face what is on the other side 6.) Turn around once more to drink in that place knowing that you will be back again 7.) Open the door and slowly walk down the hall with the light becoming brighter and the hallway wider as you re-enter the place where you are now. 8.) Open your eyes Guided Imagery (continued)

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Speaker Listener Technique The Speaker-Listener Technique offers you an alternative way of communicating when issues are hot or sensitive, or likely to get that way. Markman, H., Stanley, S., & Blumberg, S. L. (1994). Fighting for your marriage: Positive steps for preventing a lasting love. California: Jossey-Bass Inc. Slides adopted from http://www.marriagemissions.com/the-speaker-listener- technique/

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RULES FOR THE SPEAKER: 1. Speak for yourself. Dont mind read. Try to use I statements, and talk about your own point of view. 2. Talk in small chunks. You will have plenty of opportunity to say all you need to say, so you dont have to say it all at once. It is very important to keep what you say in manageable pieces to help the Listener actively listen. A good rule is to keep your statements to just a sentence or two, especially when first learning the technique. 3. Stop and let the Listener paraphrase. After saying a bit, perhaps a sentence or two, stop and allow the Listener to paraphrase what you just said. If the paraphrase was not quite accurate, you should politely restate what was not heard in the way it was intended to be heard. Your goal is to help the Listener hear and understand your point of view. Markman et al.

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RULES FOR THE LISTENER: 1. Paraphrase what you hear. To paraphrase the Speaker, briefly repeat back what you heard the Speaker say. The key is that you show your partner that you are listening as you restate what you heard, without any interpretations. If the paraphrase is not quite right (which happens often), the Speaker should gently clarify the point being made. If you truly dont understand some phrase or example, you may ask the Speaker to clarify or repeat, but you may not ask questions on any other aspect of the issue unless you have the floor. Markman et al.

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2. Dont rebut. Focus on the Speakers message. While in the Listener role, you may not offer your opinion or thoughts. If you are upset by what your partner says, you need to edit out any response you may want to make, so you can continue to pay attention to what your partner is saying. Wait until you get the floor to state your response. As Listener, your job is to speak only in the service of understanding your partner. Your task is to understand. Good listening does not equal agreement. You can express any disagreement when you have the floor.

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RULES FOR BOTH OF YOU: 1. The speaker has the floor. Use a real object to designate the floor. When giving seminars, we hand out small cards or pieces of linoleum or carpet for couples to use. You can use anything, thoughthe TV remote, a piece of paper, a paperback book, anything at all. If you do not have the floor, you are the Listener. As Speaker and Listener you follow the rules for each role. Note that the Speaker keeps the floor while the Listener paraphrases, keeping it clear who is in which role all the time. 2. Share the floor. You share the floor over the course of a conversation. One has it to start and may say a number of things. At some point, you switch roles and continue back and forth as the floor changes hands. 3. No problem solving. When using this technique you are going to focus on having good discussions. You must consciously avoid coming to solutions prematurely. Markman et al.

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Additional Helpful Thoughts for Using this Method: When using the Speaker-Listener Technique, the Speaker is always the one who determines if the Listeners paraphrase was on target. Only the Speaker knows what the intended message was. If the paraphrase was not quite on target, it is very important that the Speaker gently clarify or restate the point and not respond angrily or critically.

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The heart of the matter At the heart of the matter, the real changes are in how you think about yourself. By discovering your limitations and then overcoming them, you learn to be your own hero. And that, for most of us, is the biggest change of all. John Bingham

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Discussion / Q & A

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References Bolman, L. G., & Deal, T. E. (2003). Reframing organizations: Artistry, choice, and leadership. San Francisco, CA: Jossey-Bass. French, J. P. R., & Raven, B. (1960). The bases of social power. In D. Cartwright and A. Zander (eds.), Group dynamics (pp. 607-623). New York: Harper and Row. Komives, S., Lucas, N., & McMahon, T. (2006). The relational leadership model. In Exploring leadership: For college students who want to make a difference (2nd ed., Chap.3, pp. 73-114). California: Jossey-Bass. Retrieved from http://www.nclp.umd.edu/include/pdfs/Exploring%20 Leadership%20II%20- %20Chapter%203.pdf. http://www.nclp.umd.edu/include/pdfs/Exploring%20 Uhl-Bien, M. (2003). Relationship development as a key ingredient for leadership development. In: S. Murphy and R. Riggio, Editors, The future of leadership development, Lawrence Erlbaum Associates, New Jersey, pp. 129147.

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Contact Information Jennifer L. Hodgson, PhD, LMFT East Carolina University hodgsonj@ecu.edu Angela L. Lamson, PhD, LMFT East Carolina University lamsona@ecu.edu Doug Smith CEO, Greene County Healthcare Inc. dsmith@greenecountyhealthcare.com

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Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!