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Good Grief RoundsUsing Storytelling Among Health Care Providers to Increase Community and Meaning in Work
Learning Objectives
Describe the scope of burnout, secondary trauma, and suicide among care providers.
Summarize the literature supporting the aims of good grief rounds
Discuss the goals, structure, and evaluation data of Good Grief Rounds.
Implement Good Grief Rounds in their own health care setting.
Katherine Morrison, MDAssistant ProfessorUniversity of ColoradoDepartment of [email protected]
Compassion Fatigue vs. Burnout
Compassion Fatigue
The emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events.
Also called “vicarious traumatization” or secondary traumatization (Figley, 1995)
Burnout
Cumulative process marked by emotional exhaustion and withdrawal associated with increased workload and institutional stress, NOT trauma-related
Compassion Fatigue and Burnout Commonalities
Exhaustion (mental, physical and emotional)
Reduced sense of personal accomplishment or meaning
Decreased interactions with others (isolation)
Depersonalization
Burnout Nurses
• Hospital nurses have 40% higher burnout rate than other healthcare workers
• Job dissatisfaction 4x greater than the average for all US workers
• 1 in 5 nurses report they intend to leave their job within a year
Aken, L. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Jama; 10/2002.Vol 288, No. 16.
Burnout Physicians
• Burnout rates range from 30-65% across specialties
• Critical Care 53%
• Emergency Medicine 52%
• Primary Care/ Surgeons 50%
Pcckham, C. Physician Burnout: It just keeps getting worse. Medscape Family Medicine, Jan 26, 15.
Consequences of Burnout for the Individual
Individual
Broken relationships
Problematic alcohol/drug use
Suicidal ideation
Shanafelt, Mayo Clinic Proc, Jan 2017
Consequences of Burnout for Patient Care
Quality of Care
Patient Safety
Patient Satisfaction
Risk of malpractice
Prescribing habits
Patient adherence
Test ordering
Shanafelt, Mayo Clinic Proc, Jan 2017
Suicide Male physicians relative risk is 1.41 x higher than general population
Female physicians 2.3 times higher26% of deaths in physicians aged 25-39 compared to 11% of same age cohort general population
American foundation for suicide prevention 2017
“The fact is that each year we lose over 400 doctors to suicide—that's like an entire medical school gone.”
Wible, Pam. Medscape Family Medicine; Nov 13, 2014
Premise Behind Good Grief Rounds
• Invite residents to share their stories about their work
• Strategy to address emotion and invite connection amidst chaos of a busy day
• Aim• Increase mindfulness• Self-reflection through storytelling• Increase sense of meaning in work• Build community at work
Storytelling”- storytellers all bearing witness to one another’s ordeals, celebrating our common heritage as listeners around the campfire, creating our
identities in the stories we tell”-Rita Charon
Storytelling• Convey information
rapidly
• Release oxytocin
• Create emotional resonance which helps us determine quickly who is
friend or foe
• Leads to empathy which helps form relationships
quickly and widelyZak, Paul. Cerebrum. 2015
Storytelling
Wang, Y. “Integrating Narrative Medicine Storytelling: Increasing Medical Care Students Sense of Meaning in Life.”
Students randomized into learning narrative medicine storytelling (45) vs control (42)
Narrative medicine group Higher meaning in life awareness Better critical thinking dispositions Greater critical thinking competence
Wang, Y.. J Med Education Vol. 18 No. 3 2014
StorytellingOther models in medical literature that
utilize storytelling include:
• Schwartz Rounds• Doctoring to Heal
• R4R• Balint Groups
• Finding Meaning in Medicine Groups
Ceremony-Leslie Marmon Silko
Meaning in Medicine
556 physicians, 465 (84%) responded
34% met criteria for burnout
Amount of time spent on working on most meaningful activity inversely related to burnout
Shanafelt et al, Career Fit and Burnout Among Academic Faculty
Arch Intern Med. 2009;169(10):990-995
Meaning in Medicine
Krasner and colleagues evaluated the effect of a mindfulness and self-awareness curriculum on primary care physicians looking at burnout, empathy and mood
Large durable improvements Mindfulness Mood Empathy Burnout
Krasner et al, Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians. JAMA, September 23/30, 2009—Vol 302, No 12
Meaning in Medicine
Primary Care Group: 32 physicians, 1 NP, 6 sites
Leadership prioritized provider well-being
3 goals were to increase autonomy, efficiency and meaning
Over 4 years emotional work related exhaustion improved significantly as well as measures of organizational health
Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007;22(11):1544-1552.
Community and Well-Being
Meta-analysis of 148 studies
308, 849 patients over 7.5 years
Mortality data shows 50% increased survival for those with stronger social relationships
“These findings indicate that the influence of social relationships on the risk of death are comparable with well-established risk factors for mortality such as smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity”
Holt-Lunstad J. 2010. Social Relationships and Mortality Risk, A Meta-analytic Review. PLOS
Gallop Poll
Trusting relationships at work key to retention
Provide emotional compensation in the workplace environment
12 dimensions that describe great work groups My superior or someone at work seems
to care about me I have a best friend at work
One of 9 strategies suggested for organizations: Improve Community at work
Improved physician loungePaid physicians to go out to lunch
Gave one hour of protected time to discuss issuesAll showed improvement in burnout and meaning in work
Shanafelt, Mayo Clinic Proceedings
Format Good Grief Rounds
Theme
Ground Rules
Mindfulness exercise
Reading/Song/Poem
Storyteller
Small Group stories
Large Group Stories/comments on materials
Themes• Importance of collegial relationships• Debriefing• Moral Distress• Making Mistakes• Talking to children about parents
death• When a young person dies• Violence against providers• Burnout and Depression• Loss of Self
Groundrules
Listen generously
If nothing to share be supportive of others
Confidentiality
Manage your technology
Mindfulness
“Mindfulness is awareness of present experience with acceptance, allowing you to see the big picture, recognize patterns, and enhance performance,
creativity, and innovation.”
-- Barbara Fredrickson
MindfulnessDecrease
BurnoutMood Disturbance Stress
Improvements AttentionEmpathy, Self-Compassion, Sleep
HeadspaceInsight Timer
Storyteller • Authentic
• Role Models Vulnerability
• NOT a lecture or didactic session
• Self-Reflection and Meaning key elements
Small Groups
• Size of small groups (2-3)
• Questions for small groups
• Emphasize listening and peer support
• 4-7 min per person person (facilitator keeps time)
Large Group
One learning from each small group
How does it feel to be listened to by a peer?
Questions/comments about extra materials
4.44.6 4.54.6
4.84.6
4.4
4.74.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Valued/Useful Relevant Liked Format
Evaluation and Assessment of Good Grief Rounds
Internal Medicine PT/OT/ST combined
Likert Scale 1-5IM evals =189
PT/OT/ST evals=107Total=296
Weighted Averages
Evaluations
Example of Comments “Excellent Conversation” “Always good to talk things out” “It’s good to debrief and talk about our experiences” “Great way to open up to each other” “Format keeps things interesting” “These are always phenomenal. Thank you” “A nice change of pace and good to take time to reflect”
Limitations
Evaluation and Assessment limited
In future link evaluations to learning objectives
Difficult to evaluate as audience constantly changing with IM residents
Good Grief Rounds Practice
Pre-reading: Not moving forward
Theme: Loss of a patient
Ground Rules
Mindfulness exercise
Reading: Airlift by Scott Wilson
Primary Storyteller
Small Group Storytelling
Large Group Learnings
Questions for Small Groups
Do you have a story of a patient who’s death touched you?
What do you remember about the patient?
What did you appreciate about the patient or situation?
What did you learn from the situation about yourself or life?
Thank You
To the IPPC team at Anschutz Medical Center
Dr. Renee Gravios, Dr. Morgan Elmore, Dr. Kate Jennings, Erin Erickson OT, William Jensen MDiv, Erin Nielsen LCSW
Dr. Jennifer Reese and Dr. Marti Shultze for their knowledge, materials and mentorship
To all of you for what you do!!!
References
Zak, Paul. Why Inspiring Stories Make Us React: The Neuroscience of Narrative. Cerebrum. 2015 Jan-Feb; 2015: 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445577/ Published online 2015 Feb 2.
Rabow. MW. Doctoring to HealFostering well-being among physicians through personal reflection. West J Med. 2001 Jan;174(1):66-9.
Kabat-Zinn. Mindfulness in Medicine. JAMA, September 17, 2008—Vol 300, No.11.
Forntey et al. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. Ann Fam Med, September/October 2013, Vol 11, No. 5.
Shapiro, S. Effiects of Mindfulness-based stress reduction on medical and premedical students. J. Behav. Med. 1998. Dec: 21(6): 581-99.
Shapiro SL, Astin JA, Bishop SR, et al. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. IntJ Stress Manag. 2005;12(2):164-176
Galantino ML, Baime M, Maguire M, et al. Association of psychological and physiological measures of stress in health-care professionals during an 8-week mindfulness meditation program: mindfulness in practice. Stress Health. 2005;21(4):255-261
References
Kemper, K. Are Mindfulness and Self-Compassion Associated with Sleep and Resilience in Health Professionals?. The Journal of Alternative and Complementary Medicine. August 2015, Vol. 21, No. 8: 496-503
Krasner et al, Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians. JAMA, September 23/30, 2009—Vol 302, No 12
Pedersen, R. Empathy development in medical education-a critical review. Med Teach. 2010;32(7):593-600.
Aken, L. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Jama; 10/2002.Vol 288, No. 16.
Peckham, C. Physician Burnout: It just keeps getting worse. Medscape Family Medicine, Jan 26, 15.
American Stress Institute. Compassion Fatigue. https://www.stress.org/military/for-practitionersleaders/compassion-fatigue/
Holt-Lunstad. Social Relationships and Mortality Risk: A Meta-analytic Review. PLOS Medicine. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000316 Published: July 27, 2010
American foundation for suicide prevention: https://afsp.org/our-work/education/physician-medical-student-depression-suicide-prevention
References
Gallup Poll. What makes a great work place? .https://thepeoplegroup.com/wp-content/uploads/2008/04/article-gallup-research-what-makes-a-great-workplace1.pdf
Shanafelt, T. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. n January 2017;92(1):129-146
Schwartz Center: https://www.theschwartzcenter.org/about-us/story-mission/
Remen, R. Finding Meaning in Medicine Groups: http://rishiprograms.org/wp-content/uploads/FindingMeaningMedicine2.pdf
Balint Groups: https://balint.co.uk/about/introduction/
Wang. Y.Integrating Narrative Medicine Storytelling into the Study of the Medical Humanities: Enhancing Medical Care Students' Sense of Meaning in Life and Critical Thinking Capacity. Airiti Magazine. Http://www.airitilibrary.com/Publication/alDetailedMesh?docid=10282424-201506-201506090021-53-64.
Wible, Pam. Physician Suicides 101: Secrets, Lies and Solutions. Medscape Family Medicine; Nov 13, 2014
Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007;22(11):1544-1552.
Shanafelt et al, Career Fit and Burnout Among Academic FacultyArch Intern Med. 2009;169(10):990-995