Transcript Slide 1

Welcome to the
2009 Academic Heads'
Conference
"Practical Leadership"
Dr Craig Hassed
Deputy Head of Department
Department of General Practice
School of Primary Health Care
Creating and sustaining
healthy workplaces for
optimal performance
Outline
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Three dimensions of workplace stress
Functional reserve
Self-care
Mindfulness
Emotional regulation
Positive psychology
– Appreciative inquiry
– Strengths
– Feedback
• Speeding up team learning
• Wood and stone
HIGH
STRESS
Low
Low
Control
High
Support
High
Low
LOW STRESS
Demand
High
KARASEK AND THORELL
STRESS AT WORK
Control
• External locus: control of events going
on around us
• Internal locus: given events are the way
they are, do we have control over our
response to or attitudes about those
events?
• Internal control far more important for
lowering stress and effective response
Support
• Informal: a culture of support and
collegiality, availability
• Formal: debriefing, methods of
reporting, procedures…
Demands
• Moderating demands
• Improving capacity to meet demands
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Work or study methods
Focus
Efficiency
Priorities
• Examining perception vs. reality of
demands
Functional reserve
• Our bodies and all the organ systems in
them have far more capacity than is required
for mere survival
• The extra capacity (e.g. 75%) is called
functional reserve
• When we have lost that functional reserve
then there are measurable changes and
symptoms
• By the time this occurs a disease process is
already well under way
Functional reserve
100%
Normal
ageing
Kidney
function
Loss of function
50%
30%
Symptoms
20%
Death
20
50
Age
60
70 years
Functional reserve in the workplace
• Workplaces, operating under the constraints of
scarcer resources, shorter timeframes and smaller
workforces, combined with escalating expectations,
generally have little or no functional reserve left
• This means that it is common to be operating on a
daily basis on the extremes of performance where it
takes relatively small events (insults) to push the
system into crisis (disease)
• It also means that important but ‘non-urgent’
activities like creativity, reflection and renewal are
almost constantly marginalised and neglected
The ESSENCE of health
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Education
Stress management
Spirituality
Exercise
Nutrition
Connectedness
Environment
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An exercise in attention
• We will watch a short piece of footage
• Please remain completely quiet and do
not speak throughout this task
• Task is to pay attention
• See if you can count how many times the
team in the white shirts pass the
basketball
Attention Deficit Trait
• Newly recognized neurological
phenomenon: attention deficit trait (ADT)
– Response to hyperkinetic environment
• Trying to deal with too much input, results
in:
– Black-and-white thinking; perspective and shades
of grey disappear
– Difficulty staying organized, setting priorities, and
managing time
– Feel a constant low level of panic and guilt
> Hallowell EM. Overloaded circuits: why smart people
underperform. Harv Bus Rev. 2005 Jan;83(1):54-62, 116.
Mindfulness
• The faculty of
voluntarily bringing
back a wandering
attention over and over
again, is the very root of
judgment, character,
and will. No one is
compos sui if he have it
not.
– William James, Principles
of Psychology, 1890
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Clinical applications of mindfulness
Results suggest that MBSR may help a broad range of individuals to cope with their clinical
and non-clinical problems. Grossman P. J Psychosomatic Research. 2004;57(1):35-43.
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Stress
Anxiety
Depression
Eating disorders
Panic disorder
Symptom control
Coping
Chronic pain
• Neural plasticity
• Immune modulation
– Anti-inflammatory
– Enhancing immunity
• Behaviour / lifestyle
change
• Sleep
• Down-regulating stress
genes
• Longevity/survival?
Mindfulness and doctor wellbeing
• An 8-week mindfulness program: improvements on
all measures of wellbeing including:
– Mindfulness
– Burnout (emotional exhaustion; depersonalization;
personal accomplishment)
– Empathy and responsiveness to psychosocial
aspects
– Total mood disturbance
– Personality (conscientiousness; emotional stability)
• Improvements in mindfulness correlated with
improvements on other scales
> Krasner MS, Epstein RM, Beckman H, et al. JAMA. 2009 Sep
23;302(12):1338-40.
Mindful practice
• Mindfulness is essential underpinning for
self-monitoring
• “Mindful practice is conscious and intentional
attentiveness to the present situation – the
raw sensations, thoughts, and emotions as
well as the interpretations, judgments and
heuristics that one applies to a particular
situation.”
• Avoids automatic pilot
» Epstein R, Siegel D, Silberman J. Self-monitoring in clinical
practice: a challenge for medical educators. J Cont Educ
Health Prof 2008;28(1):5-13.
» Epstein RM. Mindful practice in action (II): Cultivating habits
of mind. Fam Syst Health . 2003;21: 11-17.
Self-monitoring
• Self-monitoring leads to:
1. Early recognition of cognitive biases
– E.g. case of Anne Dodge
2. Avoidance of technical errors
– E.g. drug dosage
3. Awareness of emotional reactions
– E.g. dislike or bias against a patient
4. Facilitation of self-correction
5. Development of therapeutic relationships
> Epstein R et al, 2008
Mindfulness and cellular ageing
• Meditation may slow genetic ageing
and enhance genetic repair
– “...we propose that some forms of
meditation may have salutary effects on
telomere length by reducing cognitive
stress and stress arousal and increasing
positive states of mind and hormonal
factors that may promote telomere
maintenance. Aspects of this model are
currently being tested in ongoing trials of
mindfulness meditation.”
> Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn
E. Can meditation slow rate of cellular aging? Cognitive
stress, mindfulness, and telomeres. Ann N Y Acad Sci. 2009
Aug;1172:34-53.
Performance
Peak
performance
“The zone”
Restful
alertness
High performance
Poor performance /
burnout
Stress
Inertia
Stress-performance curve
Emotion, decision making and the brain
• Negative emotions affect
the prefrontal cortex
– Monopolises attention on
self and emotional state:
loss of focus (middle part)
– Inhibits the ability to
generate actions
(motivation) and make
decisions (outer part)
– Impairs the ability to
process information
Performance
Peak
performance
“The zone”
Restful
alertness
High performance
Poor performance /
burnout
Stress
Inertia
Stress-performance curve
“Attentional blink”
• Limitation in information processing: time gap
in being able to identify and consolidate a
stimulus in memory
– Second stimulus often not detected
• Person vulnerable to distractor interference
– http://www.cs.kent.ac.uk/people/rpg/pc52/AB_Webscri
pt/blink.html
• 3 months of mindfulness-based attentional
training reduced the attentional blink and
improved the ability to select goal-relevant
information from various sensory inputs
> Slagter HA, Lutz A, Greischar L et al. Mental training affects
distribution of limited brain resources. PLOS Biology 2007;5(6):e138.
doi:10. 1371/journal.pbio.0050138
Mindfulness and the brain
• MRI assessed cortical
thickness in long-term
mindfulness meditators
– Brain regions associated with
attention, interoception and
sensory processing thicker in
meditators than matched controls
– Including prefrontal cortex
• Might offset age-related
cortical thinning and
“evidence for … cortical
plasticity”
> Lazar SW, Kerr CE, Wasserman
RH, et al. Neuroreport.
2005;16(17):1893-1897.
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Vicarious stress among healthcarers
• Health workers experience work-related
stress especially e.g. in cancer care
– Terminologies: burnout, compassion stress,
emotional contagion, ‘the cost of caring’
• Vicarious traumatisation: “a process
through which the therapist's inner
experience is negatively transformed
through empathic engagement with client's
traumatic material.”
– Affects individuals who are present and those with
whom they discuss experiences
> Sinclair HA, Hamill C. Does vicarious traumatisation affect oncology
nurses? A literature review. Eur J Oncol Nurs. 2007 Sep;11(4):348-56.
Mindfulness and compassion
• Limbic brain regions implicated in empathic
response to another's pain
• Activation of brain regions associated with
compassion greater in expert meditators
• Embracing another’s pain with compassion and
acceptance rather than stress vital to prevent carerfatigue
> Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. PLoS
ONE. 2008 Mar 26;3(3):e1897.
Emotional Intelligence
• Mindfulness related to
aspects of personality
and mental health
– Lower neuroticism,
psychological
symptoms, experiential
avoidance, dissociation
– Higher emotional
intelligence and
absorption
> Baer RA, et al. Assessment.
2004;11(3):191-206.
Definition
Selfawareness
Ability to recognise and
understand emotions, drives
and effects
Selfregulation
Can control or redirect
disruptive impulses, can think
before acting
Motivation
Passion for work that goes
beyond money or status,
energy and persistence
Empathy
Ability to understand
emotions of others, skill in
interacting with others
Social skill
Can manage relationships and
build networks, can find
common ground, rapport
Emotional intelligence and burnout
• Burnout inversely related to EI
• Lack of emotional control, emotional
recognition and expression, and
understanding of emotions significant
predictors of burnout
> Benson S, Truskett PG, Findlay B. ANZ J Surg. 2007;77 Suppl
1:A79.
Appreciative inquiry
• Feedback tends to far more often focus on
negatives rather than positives
– Home, work, personal…
• Focuses attention on what’s wrong rather
than what’s right
• Can increase anxiety, reduce motivation, slow
learning and not build on strengths especially
if feedback is delivered in a personally
confronting way rather than objectively
Attending to strengths
• Pay more attention to what we do well
• Focus on strengths → greater engagement (flow
experiences), well-being, performance and
productivity.
• Not saying to ignore weaknesses – do enough so
that they do not get in your way or undermine your
strengths
> J Mitchell
Identifying strengths
• Energy: What activities give you a
buzz?
• Ease: What activities come naturally to
you?
• Authenticity: When do you feel most
relaxed, like you are ‘being yourself’’?
• Motivation: What activities do you
simply love to do?
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J Mitchell
Rewarding process or outcome?
• Studies on the subsequent learning of children who
were either praised for outcome or for effort and
process
• Praising outcomes not necessarily helpful
– When subsequently presented with a more difficult task
these children more likely to get frustrated and give up
if they don’t easily get the desired outcome
– These children come to prefer easier (achievable) tasks
• Children who were praised for effort and process are
more likely to subsequently persist with difficult tasks,
enjoy learning more and learn quicker
Speeding up team learning
• Studies performed on cardiac surgery units
• Which teams:
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Learned most quickly
Assimilated new technologies
Made fewest mistakes
Reduced procedure times
Enjoyed their work the most
• Wasn’t the team necessarily lead by most
eminent surgeon
> Edmonson A. et al. Harvard Business Review
2001;Oct:5-11.
Speeding up team learning
• Designing a team for learning
• Framing the challenge
• Creating an environment of
psychological safety
• Learning leaders
Speeding up team learning
• Designing a team for learning
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Competence
Ability to work with others
Ability to deal with ambiguity
Confidence in offering suggestions to senior
members
– Keeping team intact
Speeding up team learning
• Framing the challenge
– Characterise taking on new technology
(learning) as an organisational challenge not
a technical one
– Requires new ways of working together not
just learning a new skill
– Acknowledge the challenge on all members
> Can either feel inspired to be part of
something new or resistant (ignored)
Speeding up team learning
• Creating an environment of
psychological safety
– Learn through trial and error
– Work on ‘real-time learning’ not just waiting
for post-hoc formal review
– Neutralising fear and embarrassment
– Comfort with making suggestions, trying
things, pointing out potential problems,
admitting mistakes
Speeding up team learning
• Learning leaders
– Be accessible
– Ask for input
– Serve as a ‘fallibility model’
Wood and stone
• Universities are not made up of wood
and stone but rather the human natures
of the people within the university
– Apologies to Plato (The Republic)
Wood and stone
• If the primary focus is on buildings, balance
sheets, performance indicators and such
like at the expense of the relationships,
humanity, creativity and inspiration of the
people working within the institution, it not
only diminishes the experience of the staff,
but also imperils the sustainability and
quality of the performance that those things
are meant to enhance.