SYNCOPE 2007: Some Principles and Some Cases Mark Linzer, M.D. General Internal Medicine UW-Madison.
Self Care & Well-being : 12 Rules · Linzer M et al. 10 Bold Steps to Prevent Burnout in General...
Transcript of Self Care & Well-being : 12 Rules · Linzer M et al. 10 Bold Steps to Prevent Burnout in General...
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Self Care & Well-being :
12 RulesDr Mick O’Keeffe
Developmental-Behavioural Paediatrician
Child Development Service CHQ
&
Child Development Network
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Today’s talk
• Burnout risks & symptoms
• Framework for Self care &
Wellbeing
• Strategies for Individuals
* highlighting some personal
experiences
• Fostering a resilient workforce :
organisations
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RULE 1
YOUR WELL-BEING
MATTERS
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The Physician’s Pledge
World Medical Association
Amended in 2017
https://www.wma.net/policies-
post/wma-declaration-of-geneva/
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I promise to put the patients first when I am practicing my
craft as a physician
I promise to attend to my own needs and the needs of my
family when I am not practising medicine.
My health, wellbeing and energy levels are the single most
important determinants of the quality of care I provide to my
patients.
This balance is crucial to the wellbeing of patients, my family
and myself
Dr Dike Drummond
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RULE 2
UNDERSTAND
YOUR
PROGRAMMING
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The Saint
The Superhero
House MD
The Weak Link
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RULE 3
NAME THE
STRESSORS
AND THE
STRENGTHS
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The worker
The work
The workplace
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The Happy MD
http://www.thehappymd.com
Dr Dike Drummond
physician wellness guru
lots of relevant blog posts
downloadable resources including Burnout Prevention
Matrix
RACP : Physician Health and Wellbeing
https://www.racp.edu.au/fellows/resources/physician-
health-and-wellbeing
includes;
**RACP eLearning module ; Physician Self-Care and
Wellbeing
policy statements
resource links
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Skovholt T, Trotter-Mathison M.
The Resilient Practitioner: Burnout Prevention and Self-
care strategies for counselors, therapists, teachers and
health professionals.
2011, Routledge , Taylor & Francis Group.
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RULE 4
MAKE A PLAN
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Framework for ActionDr Dike Drummond
INDIVIDUAL WORKPLACE
REDUCE
STRESSORS
ENHANCE
RESILIENCE
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INCREASE RESILIENCE
Attention to
- physical health
- mental health
- key relationships
Access to R & R time (recreation, relaxation)
Training in Stress Reduction Techniques
- Mindfulness
- Acceptance and Commitment Therapy
- Positive Psychology Approaches
- Meditation
Professional supports (away from work)
- Supervision/ Mentoring/ Coaching
- Peer group supports/ activities
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RULE 5
SOMETHING OLD,
SOMETHING NEW
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The Happy MD
http://www.thehappymd.com
Dr Dike Drummond
physician wellness guru
lots of relevant blog posts
downloadable resources including Burnout Prevention
Matrix
RACP : Physician Health and Wellbeing
https://www.racp.edu.au/fellows/resources/physician-
health-and-wellbeing
includes;
**RACP eLearning module ; Physician Self-Care and
Wellbeing
policy statements
resource links
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RULE 6
SEEK THE
COMPANY OF
PEERS
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Peer Group Support – Formats
Informal meetings
eg dinners
practice/ workgroup meetings
Formal peer group meetings
eg Balint Groups
Group Supervision
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Group Supervision Child Development Service :
BENEFITS
Sharing of perspectives
Normalising of responses
Reining in of excessive self-criticism
Restorative - an injection of clinical energy
Reduction in professional isolation
Strengthening of professional bonds
Growth mindset – exposure to new ideas
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O'Keeffe M, James F.
Facilitated Group Supervision -
harnessing the power of peers.
Journal of Paediatrics and Child Health
2014 ; 50 : 944-948
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QUOTES 2011 – end of pilot (12 months)
“It was reassuring that some feelings were commonly
held within the group”
“I have recognised the value of sharing and peer
support”
“I have developed a framework for understanding
interactions with families”
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QUOTES 2016 – 6 years in !! (Louise Butler thanks)
“ My main message to other professional colleagues would be that
our supervision group has provided the most enriching and thought
provoking professional development that I have ever received”
“ It has greatly influenced and improved my practice and has
contributed to a greater sense of wellbeing”
“The supervision group has made me aware of the aspects of
consultation and practice that are beyond the technical content”
“ It has given me the confidence to be aware of the emotional level of
the interaction, understand the process, and to use this awareness in
my clinical care”
“ It has improved my resilience professionally”
“The supervision group has enabled me to learn about reading my
own behaviour and that of others. This insight is powerful and enables
care of others and care of self”
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Other examples – “COMPASS” (MAYO CLINIC)
“COlleagues Meeting to Promote and Sustain
Satisfaction”
Groups of 6-7
Fortnightly dinners
20 mins on “an issue”
Mayo clinic pays
2015 rolled out – available to 3755 Drs 7 scientists at the
Mayo clinic
1100 signed up within 1st 10 months
RCT – showed improvement (increased sense of meaning in
work, less burnout Sx)
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Johnson, K.
Peer support trumps time off in
preventing MD burnout.
Medscape Nov 6, 2012
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RULE 7
INVITE YOUR
ORGANISATION TO
THE PARTY
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Blind Spot ?
INDIVIDUAL WORKPLACE
REDUCE
STRESSORS
ENHANCE
RESILIENCE
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Tackling Workplace Stressors
• Physical work environment
• Workload
– total
– “productivity” expectations
– “dosage” of most stressful components
• Incident Debriefing
• Role & skill match/ mismatch
• Variety
• Control over calendars
• Team dynamics
• Non-clinical (eg EMR, IT systems)
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Tackling Workplace Stressors
Use a framework
Identify the biggest challenges…
…then things within the organisation/ work
unit’s locus of control regarding these
problems
Brainstorm possible improvements
Decide on a strategy and
Pilot it
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“ I’m always amazed at how much
low hanging fruit there is”
Dr Tait Shanafelt in Schapira L.
Isolation and burnout in physician
culture : innovative solutions.
Medscape May 29 2018
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What Frameworks?
Eg
Seven Drivers of Burnout and Engagement in
Physicians
in
Shanafelt T, Noseworthy J. Executive Leadership and
Physician Wellbeing : Nine Organizational Strategies to
promote Engagement and Reduce Burnout. Mayo Clinic
Proceedings ; 2017 : Vol 92 (1) P129-146
& also featured in American Medical association’s STEPS
Forward Program
https://www.stepsforward.org
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What Frameworks?
LCCH Oncology group
https://clincialexcellence.qld.gov.a
u/improvements-exchange/chq-
oncology-wellbeing
Used PERMA model
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LCCH Oncology group
https://clinicalexcellence.qld.gov.au/improvement-
exchange/chq-oncology-wellbeing
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Preventing burnout – role of
organisations
some key papers
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Linzer M et al. 10 Bold Steps to Prevent Burnout in General Internal Medicine. J Gen Intern Med 2013; 29(1):18–20
Swensen S, Kacenell A, Shanafelt T. Physician-organization collaboration reduces physician burnout and promotes engagement ; The Mayo Clinic Experience. Journal of Healthcare Management 2016; 61 (2) March/April
West C et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016; 388: 2272-81
Suchman A. The influence of health care organizations on well-being. West J Med 2001;174:43-47
Brown S, Gunderman R. Enhancing the professional fulfilment of physicians. Acad Med. 2006; 81:577–582.
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Ward S & Outram S. Medicine in need of culture change. Internal Medicine Journal2016; p112-116
Shanafelt T, Noseworthy J. Executive Leadership and Physician Wellbeing : Nine Organizational Strategies to promote Engagement and Reduce Burnout. Mayo Clinic Proceedings 2017 ; Vol 92 (1) P129-146
American Medical association’s STEPS Forward Programhttps://www.stepsforward.orgSeven Drivers of Burnout and Engagement in PhysiciansTalking points for leaders
Shapiro J. Peer support for clinicians: a programmatic approach. Academic Medicine2016; Vol. 91, No. 9 / September
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July/August
Nedrow A, Steckler N, Hardman J. Physican resilience and burnout: can you make the switch? Family Practice Management 2013 Jan/Feb
Wallace J, Lemaire J, Ghali W. Physician Wellness: a missing quality indicator. Lancet 2009; 374: 1714–21
Wei J, Rosen P, Greenspan J. Physician burnout: what can chairs, chiefs, and institutions do? Notes from the Association of Medical School Pediatric Department Chairs. Journal of Pediatrics Vol 175; p5-6
McCrory K. Tackling burnout in employed physicians. Family Practice Management 2016 July/August
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RULE 8
STOP THINKING IT
WON’T HAPPEN TO
YOU
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RULE 9
LOOK TOWARDS
THE LIGHT
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Strength-based Positive
Interventions
eg Three Good Things
Rabiya S. Tuma.
Simple Tool Shows Lasting Reduction in
Burnout.
Medscape - Oct 23, 2017.
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Joy
Gratitude
Serenity
Interest
Hope
Pride
Amusement
Inspiration
Awe, and
Love
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Other Strength-based Positive
InterventionsGRATITUDE exercises (eg ; letter, visit)
PERSONAL STRENGTHS EXPLORATION
VALUES CLARIFICATION
THREE FUNNY THINGS
COUNTING KINDNESS
GIFT OF TIME
ANOTHER DOOR OPENS
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RULE 10
WORK OUT WHAT
YOU STAND FOR
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Clarification of Values : Resources
The Happiness Trap ; Dr Russ Harris
principles of ACT (Acceptance and
Commitment Therapy)
+ couple chapters on values
Values In Action website
https://www.viacharacter.org/www/
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RULE 11
APPRECIATE YOUR
ADVENTURE
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RULE 12
STAND UP
STRAIGHT, YOU’RE
A DOCTOR !
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PARKING LOT
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What is Burnout ?
• multidimensional, work-related
syndrome
• “a state of exhaustion in which one
is cynical about the value of one’s
occupation and doubtful of one’s
capacity to perform”
Maslach et al 1996
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Burnout – warning signs
Can include any/ all of
- feeling of being overwhelmed by work
- increased pessimism about patients
- doubting whether work contributes anything meaningful
- sense of “depersonalisation” (disconnection) in relationships with patients, co-workers or both
- deterioration in mental health (eg anxiety, depression and loss of self-esteem)
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Causes of Burnout -
Mythbusting
psychological distress and burnout is
NOT limited to an "inherently weak"
subset of clinicians
........we are all at risk !
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Burnout - causes
• multi-factorial
• related to
1. the work (provision of healthcare)
2. the worker (personal characteristics and situational factors)
3. the workplace (organisational stressors)
• some obvious, others hidden
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Workplace Culture
Prevailing culture often demands an
unhealthy neglect of self-care…
….& when burnout occurs,
responsibility is slated home to the
individual
“if you’re feeling burned out, then it is
you who has a problem, not our
workplace”
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Consequences of Burnout
(and why health care
organisations should care)
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Clinician burnout & psychological
distress : consequences
• Bad for clinician
• Bad for the clinician’s family
• *** Bad for patient care !!
– reduced job performance (less
productive & effective)
– increased errors
– decreased patient satisfaction
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Self Care & Wellbeing Plan :
A Framework
- Strategies for Individuals
* highlighting some personal adventures in self
care
- Fostering a resilient workforce :
Organisations
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Take the Pledge - Individuals
• Be proactive about your own
wellbeing
- for yourself
- for those close to you
• Self-care = a mandatory element of
professionalism
- for your patients
- for your colleagues
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Take the Pledge - Organisations
- Staff wellbeing is a big factor in patient
outcomes
- Health care organisations must approach
staff wellbeing in a meaningful, multi-level
way, not just leave it up to individuals
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Awareness
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Burnout – know the enemy
• Risks
• Symptoms
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Resilience & Wellbeing
• what does this look & feel like ?
• what are the good bits of medical
life ?
• what is going well ?
• strengths/ positives (work, worker,
workplace)
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Develop a Self Care &
Wellbeing Plan
• Multimodal
• Goals
• Actions
• Monitoring
• Review
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Framework for ActionDr Dike Drummond
INDIVIDUAL WORKPLACE
REDUCE
STRESSORS
ENHANCE
RESILIENCE
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Health & Home Basics
• Physical health
- nutrition
- exercise
- sleep
- dental care
- medical care
do you have your own GP?
do you have a regular check up?
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Health & Home Basics
• Mental Health
- Recognise the symptoms
- Recognise personal barriers to
seeking help
eg I can deal with this all by myself
- Seek appropriate help
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Mental Health
- Look out for your mates
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Health & Home Basics
• Attention to key relationships
- Seeing enough of me ?
- Am I present when I’m there ?
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Health & Home Basics
• R & R time (recreation, relaxation) →
time actively scheduled
- sport, art, literature, hobbies
- a regular dose of nature
- holidays
- unlocking your creative side
- novelty
- play & humour
- personal identity (outside work)
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Health & Home Basics
• Solitude / Down Time (doing
nothing at all, being still)
Solitude = an “antidote to people
intensity”
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Health & Home Basics
• Consolidating a Personal Philosophy
- Allocating time to clarify your guiding values
- answers to the big questions
- how you want to live your live (from here on !)
Eg; organised religion
Eg; secular framework - Humanism
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CPD – Skill Development
• Not just to rack up credit
points.....but to strategically extend
yourself
• “Focus Time” (Dan Siegel)
• Fully embrace
“the inexhaustible curriculum of
self-improvement from which we
never graduate"
Irvin Yalom : Love's Executioner
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Building a Resilient Clinician –
Next Level
• “We should stop expecting health
practitioners to pull themselves up by
their bootstraps by “standard” individual
coping strategies of leisure time and
CPD…….and re-calibrate the way we
think of self care”
Killian K. Helping til it hurts ? A multimethod study of compassion
fatigue, burnout and self-care in clinicians working with trauma
survivors Traumatology published on line May 29 2008
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Building a Resilient Clinician –
Next Level
• Activities, Interventions & Tools
• Organisational Responses
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Regular, conscious personal
reflection
use patient encounters as an
opportunity for reflection (self/ with
others)
• Difficult encounters & challenging
stuff
**caveats
– positive/ constructive take aways
“ this bit was done well”
“how to approach differently next time”
– practice being kind to yourself
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Regular, conscious personal reflection…
…on the good bits
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Positive Reflections – The
Joys of Practice
• Smaller “I made a difference” moments
– Daily Treasure Hunt
– Journaling
• Greatest Hits
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External 1:1 support
• Supervision/ Mentoring/
Coaching
- senior colleague / junior colleague
(mentor to mentee)
**especially in the post training
phase**
- peer to peer
- with professional from different field
(psychologist, psychiatrist, family
therapist)
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Possible content of
supervision / mentoring
• clinical case discussions
……but arguably more importantly
• managing difficult consultations
(transference etc)
• workplace & collegiate relations
• career development & planning
• work-life balance
• managing own emotional well-being
• joys of practice !
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1:1 Supervision - personal
experience
• Senior colleague – junior colleague
model
• 2004 – 2010
• 2 monthly
• 60 - 90 mins
• Agenda set by myself
• Documented – summary, outcome
measures
• Fee for service
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MJ O’Keeffe, DC Shelton.
Personal Supervision for
Paediatricians
Journal of Paediatrics and Child
Health: 2007 43: 103 – 6
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Peer Group Support
well-orchestrated peer group support
= very valuable resilience practice
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Peer Group Support - Formats
• Informal meetings
eg dinners
practice/ workgroup meetings
• Formal peer group meetings
• Within workgroup
• Broader peer group
Eg Balint Groups
Group Supervision
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Facilitated Group
Supervision :
Child Development Service
Personal experience
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Group Supervision CDS : Aims
• maintain and enhance personal
wellbeing and professional function
• reduce risk of burnout
• mechanism for ongoing skill
development in developmental-
behavioural paediatrics
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Group Supervision CDS : Rationale
• forum for sharing of the experience of
practice in developmental-behavioural
paediatrics
• a safe environment to air previously
unacknowledged emotions and beliefs
about clinical encounters
• introduction of novel frameworks for
considering doctor-patient interactions
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Group Supervision CDS : key
ingredients
• skilled external supervisor
• clinician resistance, group dynamics
• atmosphere of trust
• energetic drivers
• commitment to attend and participate
from all (100% in or not at all)
• supervision ground rules & signed
agreement
• support from leadership
• advance bookings/ protected time
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Group Supervision CDS : Process
• Began with a 12 month pilot
• 6 sessions/ year
• 90 minute sessions
• Financed initially by service, then by us
• Focus is on understanding the
interpersonal bits
• NOT group therapy
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Group Supervision CDS :
Experience
• Very stable membership
• Near 100% attendance
• Running for 7 years (& counting)
• Focus and process has evolved
• Second group within our service
now also meeting
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Group Supervision : Benefits
• sharing of perspectives
• normalising of responses
• reining in of excessive self-criticism
• restorative - an injection of clinical
energy
• reduction in professional isolation
• strengthening of professional bonds
• growth mindset – exposure to new ideas
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Group Supervision : Benefits
QUOTES 2011 at end of pilot
(12 months)
QUOTES 2016 ( 6 years in )
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O'Keeffe M, James F.
Facilitated Group Supervision -
harnessing the power of peers.
Journal of Paediatrics and Child
Health 2014 ; 50 : 944-948
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Peer Group support
- another example
COMPASS; MAYO CLINIC
COlleagues Meeting to Promote and
Sustain Satisfaction
2015 rolled out
1100 signed up within 1st 10 months
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Training in Stress
Reduction
• Mindfulness
• CBT based stress prevention
• Acceptance and Commitment
Therapy
• Positive Psychology Approaches
• Meditation
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Healthcare
Organisations……
…..The Workplace
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Fostering Clinician
Resilience -
what can organisations do ?
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“Does clinician wellbeing
feature in the organisation’s
mission statement ?”
TheHappyMD
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CHQ Strategic Plan 2016-2020
• Strategic Direction 3.
“People – Working, Learning,
Growing”
..including – “implement a
progressive CHQ People Plan
focused on workforce wellbeing,
leadership, culture and capability”
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OK good start – where to
from there ?
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CHQ Wellbeing &
Resilience Working Group
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Self-care – Interventions in the
Workplace
• Teaching about burnout & resilience
• Wellness rounds
• Formal training in self-care strategies (eg Mindfulness)
• Helping engineer peer support groups
***protected time for these***
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Self-care – Interventions in the
Workplace
• Wellness champions
- Leadership
- Clinical coalface
FTE allocation + budget !
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Tackling workplace
stressors
• Physical work environment
• Workload (total, “dosage” of most
stressful components)
• Role & skill match/ mismatch
• Variety
• Control
• Team dynamics
• Non-clinical (eg EMR, IT systems)
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Tackling workplace stressors
• Reduced stressors to some degree
→ less clinician burnout /
psychological distress
→ better quality patient care
NB – wellbeing not just an individual’s
responsibility
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Tackling workplace stressors
1. Not modifiable
→ Focus may instead be on reducing
exposure, impact etc
2. Potentially Modifiable
3. Zero Tolerance
→ Eg workplace bullying, occupational
violence
•
•
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Clinician wellbeing as an
Organisational KPI
• Wallace J, Lemaire J, Ghali W.
Physician wellness : a missing
quality indicator. The Lancet
2009; 374: 1714-21
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Surveys to Action
• comprehensive survey of wellbeing
and workplace conditions
• meaningful metrics and tools
• close the feedback loop (ie
aggregated at work unit level and
used to change practice)
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Training Organisations
• RACP Self Care & Wellbeing
Module
- trainees AND consultants
- Joint conversations
• CPD requirements
– visibility of self care & wellbeing
initiatives
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Resources
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Wrapping Up - Recommendations
• become familiar with the signs of
burnout, and the things that contribute to
it
• banish the idea that it arises from
personal failings
• understand the menu of options to
enhance our wellbeing
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Take action NOW
• draw up your own Self Care & Wellbeing
Plan
• ensure health & home basics are
covered
• tackle more serious mental health
concerns head on
• pick one or two new actions that makes
the most sense, & start implementing
immediately
• drive clinician wellness initiatives in your
service
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Gaudeamus igitur
(Therefore, let us rejoice)
John Stone
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mick.o’[email protected]