becoming a resilient practitioner: managing stress and avoiding
TRANSCRIPT
BECOMING A RESILIENT PRACTITIONER: MANAGING STRESS AND AVOIDING BURNOUT
Donna Costa, DHS, OTR/L, FAOTA Presented at the AOTA Student Conclave November 19, 2016
Learning Objectives:
By the end of this workshop, it is expected that participants
will be able to: ◦ Develop a plan for how you can find balance as a new
practitioner. ◦ Manage stress caused by meeting productivity standards,
learning new clinical skills, and developing professional relationships with your colleagues. ◦ Identify strategies to develop resilience as an occupational
therapy practitioner so that you live your life to the fullest!
My Background: An occupational therapist with mental health practice
experience ◦ An occupational therapy educator/researcher ◦ A mindfulness practitioner/researcher utilizing
Koru Mindfulness Program for College Students Mindfulness Based Stress Reduction (MBSR) ◦ for people with a variety of conditions ◦ for women with urinary urge incontinence
Mindfulness Based Cognitive Therapy (MBCT) ◦ for people with chronic, recurrent depression ◦ for people with co-morbid depression and substance abuse
Mindfulness Based Chronic Pain Management (MBCPM) ◦ for people with chronic pain ◦ for people with spinal cord injury
Occupational Therapy and Burnout:
The occupational therapy profession is full of rewards, but not without stress.
Concepts of compassion fatigue and burnout and the mechanisms by which they develop are important for the therapist to understand.
Helping our clients live life to the fullest requires practitioners to develop a plan for professional self-care.
What Contributes to Burnout: “Too often, we therapists neglect our personal
relationships. Our work becomes our life. At the end of our workday, having given so much of ourselves, we feel drained of desire for more relationship.” Yalom, 2002
“Many therapists, for example, grew up playing the role of caretaker, go-between, parentified child or burden-bearer within their families of origin. Having learned at an early age to attune themselves to others, therapists often have great difficulty attending to their own emotional needs.” Sussman, 1995
Burnout in Occupational Therapy: Three main components of burnout are: ◦ Emotional exhaustion ◦ Lower job productivity ◦ Depersonalization, or lack of concern for others
Professional identity plays a significant role in the experience of burnout (Edwards & Dirette, 2010)
High levels of burnout has a negative impact on the individual and also the organization in which they work (Painter et al, 2003)
Burnout is not a problem of the person, but rather of their work environment
Burnout vs Compassion Fatigue: Burnout is a gap between expectations and rewards, a
disparity of effort versus recovery. Idealistic people may burn out more often then realistic
people. Strong predictors of burnout include an intrusion of work life
into home life and feelings of being ineffective. The interruptions of technology cause stress and burnout
and decrease control and work/life balance, i.e., cell phones, email, and social media.
The degree of mismatch between the person’s skills and key aspects of the job increases the risk of stress and burnout.
Compassion fatigue is a state of exhaustion and dysfunction (biologically, psychologically and socially) as a result of prolonged exposure to secondary trauma or a single intensive event.
The coping mechanism most commonly used is to disregard the overwhelming emotions that surface repeatedly in care giving work.
http://toolkit.ahpnet.com/Dealing-with-Stress-in-the-Workplace/Introduction--Compassion-Fatigue-and-Burnout.aspx
Burnout Symptoms: Physical symptoms: fatigue, physical exhaustion, disturbed
sleep, somatic complaints
Emotional symptoms: irritability, anxiety, depression, guilt, sense of helplessness
Behavioral symptoms: aggression, callousness, pessimism, defensiveness, cynicism, substance abuse
Work-related symptoms: quitting job, absenteeism, poor work performance, lateness, avoiding work, risk-taking
Interpersonal symptoms: limited communication, social withdrawal, lack of sense of humor, poor patient interactions, dehumanization
Compassion Fatigue Symptoms:
Self-Assessment – PRO QoL: Professional Quality of Life assessment: ◦ Compassion has both positive & negative effects. ◦ This personal self-assessment may help you
examine the risk in contrast to your degree of satisfaction with helping others. ◦ Remember, it is not a diagnostic tool, just an
snapshot of how you’re feeling today.
Available at: http://www.proqol.org/ProQol_Test.html
Food for Thought… “The heart pumps blood first to itself, before
pumping it to the rest of the body. If it didn’t, it would die, and then the rest of the body would die. The art of caring for others is learning how to first care for yourself. Remember this.” Shapiro, 2009, p. 108
What is Work-Life Balance? It’s not letting work-life creep into home-life
and vice versa It means more about the feeling of being in
control so that work duties and thoughts don’t take over in the time when family, friends and leisure activities occur.
It is more about how you separate the work and home so that the pressures of work don’t influence your “time out” during the after-work hours, and so the worries and cares associated with your personal life don’t interrupt your work time.
OT Career Path and Engagment:
Graduation – high level of engagement First 5 years of practice: high work
engagement 6 – 10 years: high levels of exhaustion 11 – 15 years: low work engagement 16 – 20 years? 45 years plus – high work engagement
Poulsen, 2013
What Helps with Work Engagement?
Making a positive difference in human life is a prime motivator for entering the field.
Being successful in helping relationships can produce a profound sense of satisfaction.
The helping professions can provide many “psychic income” rewards.
When the practitioner helps a client achieve a goal, or they are discharged from therapy, there is a “joy-of-practice” reaction.
So, focus on those joys of practice!
Professional Resilience: Resilience is the ability to bounce back from
adversity or misfortune. Resilience is a capacity that develops over time as
we engage in person-environment interactions You grab at life, instead of it grabbing you. “Individuals operating in a
demanding performance environment on a daily basis would be deemed to exhibit resilience if they evaluate stressors as an opportunity for development…” Skovholt & Trotter-Mathison, 2016
What Builds Resilience? Reducing negative thinking and beliefs Manage your energy (positive energy!) Cultivate gratitude daily (5 finger gratitude
exercise) Learn good problem-solving skills Nurture and maintain strong relationships Balancing care for others with care for self Need for more self-care in crisis/high stress Create a “professional greenhouse” at work Being a “good enough” practitioner Learn to set boundaries, and create limits.
The Importance of Self-Compassion: Self-compassion involves acting the same way
towards yourself when you are having a difficult time, or you fail, or you notice something that you don’t like about yourself.
Having compassion for oneself is really no different than having compassion for others.
Self-compassion means you are kind and understanding when you become aware of your personal failings or thoughts.
Three Elements of Self-Compassion:
Self-kindness - being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than ignoring our pain or flagellating ourselves with self-criticism.
Common Humanity - recognizing that suffering and personal inadequacy is part of the shared human experience - something that we all go through rather than being something that happens to “me” alone
Mindfulness - a non-judgmental, receptive mind state in which one observes thoughts and feelings as they are, without trying to suppress or deny them…not over-identifying with thoughts and feelings, so that we are caught up and swept away by negative reactivity.
Self-Compassion Resource: Kristin Neff, PhD Book: Self-Compassion: Stop Beating Yourself
Up and Leaving Insecurity Behind Website: ◦ http://www.self-compassion.org/
Self-compassion scales: ◦ Long Version ◦ Shorter Long Version ◦ Compassion for Others Scale
Great Video Resource: “Self-care for health professionals: Building
resilience, enhancing work engagement and preventing burnout”
Dr. Anne Poulsen, PhD, B. Occ. Thy. (Hons) University of Queensland & Work-Life Balance Solutions; Retrieved from: http://webcast.gigtv.com.au/Mediasite/Play/30b0d15ddb504243ac9584694844ada11d?catalog=5ab62a2f-4400-46bc-9f6f-95f5b51209911
http://www.clinedaus.org.au/topics-category/maintaining-emotional-wellbeing-58
Strategy 1 for Well-Being & Resilience: Ability to Detach ◦ Set boundaries – shift your thoughts away from work at
the end of the day, leave notes/laptop/emails at work ◦ Try to remain in the ‘Here and Now’ – reduce thinking
about yesterday or what else needs to be done tomorrow ◦ Incorporate ‘breathing spaces’ - reflection time so that you
can catch up on what you need to do ◦ Stop to savor – pause to consider a good moment,
communicate positives with others ◦ Acknowledge three good things that happened today ◦ Use ‘Appreciative Inquiry’ – with your co-workers or other
students, actively discuss what is working well, listing achievements
Poulsen, 2013
Strategy 3 for Well-Being & Resilience: Ability to Relax: ◦ Take two deep breaths regularly ◦ Allocate 10 minutes per day to abdominal
breathing ◦ Consider the use of formal relaxation techniques
like progressive muscle relaxation 30 minutes per day. (e.g. progressive muscle relaxation, deep breathing, visualization and focus) ◦ Consider starting regular Yoga ◦ Take real breaks - sleep, naps, a vacation
Poulsen, 2013
Strategy 3 for Well-Being & Resilience: Obtain Mastery: ◦ Find a hobby ◦ Build a network. Ensure you have enough support
yourself – supervision or mentoring, as well as including an active social network outside of work ◦ Identify your strengths to energize ◦ Consider ‘Job Crafting’ – actively evaluate and
change job components to align with identified strengths ◦ Participate in lifelong learning - this can provide
access to additional opportunities and improve self-confidence and critical thinking ability Poulsen, 2013
Strategy 4 for Well-Being & Resilience: Gain Control: ◦ Become self-aware and politically adept so you
are able to identify potential stressors and manage them in a timely fashion ◦ Learn to say ‘no’ – assertive communicators are
less likely to get swamped yet still maintain professionalism ◦ Set one goal – when we have something to work
towards, we are motivated to continue and achieve ◦ Reward yourself – at the end of a fieldwork
placement, make sure you do something positive for yourself - you deserve it! Poulsen, 2013
Work Life - Home Life Separation: Is balance 8 hours at work, 8 hours lifestyle
activities, and 8 hours of sleep? It’s more about controlling your activities and
thoughts so that you are totally engaged in work during the work hours, and totally absorbed in lifestyle activities during the out of work hours.
This is where mindfulness comes in – being fully present in the present moment.
What is Mindfulness?
“Mindfulness is the awareness that emerges through paying attention, on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment.”
Jon Kabat-Zinn, 2003, p.145
Why is Mindfulness Important? Multi-tasking has become a way of life. We talk on our cell phones while commuting to
work, or scan the news while returning e-mails. In our rush to accomplish necessary tasks, we
can often lose connection with the present moment.
We stop being truly attentive to what we’re doing or feeling.
Mindfulness is the opposite of multitasking. The idea is to focus attention on what is
happening right now and accept it without judging.
Mindfulness Research: There is a growing body of research suggesting that
mindfulness has huge benefits for ◦ tired and stressed workers ◦ students who wish to focus on studying harder ◦ couples learning how to connect and re-connect ◦ individuals with health issues who wish to learn ways to
cope with intrusive, unhealthy thoughts The neuro-physiological and health benefits are well
documented and include ◦ reducing the cognitive decline associated with normal
ageing processes, ◦ decreased stress levels, ◦ improved immunity ◦ reduced chronic pain ◦ improved sleep ◦ Improved attention, self-awareness and sensory regulation.
Mindfulness for Burnout: A new study showed reduced stress levels and greater
emotional resilience in elementary school teachers trained to practice mindfulness.
“Well-being is actually a skill. It’s something that can be enhanced with training. If we can take more responsibility for our well-being, we can help to minimize burnout or decrease its severity.”
Mindfulness seems to benefit the mind just as physical exercise benefits the body. Previous research linked MBSR to structural changes in the brain. Other research linked mindfulness meditation to lower levels of cortisol, a so-called stress hormone.
18 public school teachers attended a weekly mindfulness training session, and an all-day “immersion experience”, practicing meditation for at least 15 minutes daily. After 8 weeks, the teachers showed reduced symptoms of burnout, compared to a control group of teachers who did not receive mindfulness training. ◦ Flook et al, 2013
Mindfulness Study with Physicians Krasner, Epstein & Beckman developed an
educational program for physicians in mindful communication to address burnout, empathy, and attitudes.
Results demonstrated improved personal well-being, including burnout, and improved mood.
They also experienced positive changes in empathy and psychosocial beliefs.
These behaviors are associated with improved patient trust, appropriate prescribing, reduction in health care disparities, and lower healthcare costs. Krasner, Epstein, & Beckman, 2009
Mindfulness To Reduce Job Burnout: A recent article in AJOT described a systematic
search and critical appraisal of interdisciplinary literature that was conducted
Eight articles were reviewed involving health care professionals and teachers
“There is strong evidence for the use of mindfulness practice to reduce job burnout among health care professionals and teachers. Research is needed to fill the gap on whether mindfulness is effective for treating burnout in occupational therapy practitioners.” Luken, & Sammons, 2016
Mindfulness in Clinical Education: Research is emerging in the fields of medicine,
occupational therapy, physical therapy, nursing, social work and counseling about how mindfulness practice can assist students who are learning to become skilled practitioners.
Mindfulness is a way of being in which an individual maintains attitudes such as openness, curiosity, patience, and acceptance while focusing attention on a situation as it unfolds.
“The opposite of mindfulness is mindlessness, characterized by multitasking, self-deception, covering up deficiencies, excessive reliance on facts, excessive speed, and reactivity.” Willgens, & Scarf, 2015
Mindfulness in Clinical Education: “Clinical education requires a seamless transition from
classroom to clinic. However, some students struggle to integrate affective domain skills and have difficulty applying generic abilities during real-time patient care.”
Students are often highly anxious during clinical placements and fear doing anything wrong. Under stressful conditions, self-assessment becomes inaccurate.
“Typical stress reduction techniques, such as relaxation training, do not decrease rumination, a common byproduct of worry. Mindfulness allows the student to notice their thoughts and pause to redirect the focus to the breath.” Wiggens & Scarf, 2015
Challenges in Fieldwork: “Making the transition from an academic to a
clinical setting requires an adjustment to different settings, activities and responsibilities. Literature has suggested that this transition can be stressful…Although some stress may facilitate growth and learning, high levels of stress may be related to loss of productivity and effectiveness.” Mitchel & Kamfe, 1992, p. 535
“Among students, a common anxiety-producing belief is that they must demonstrate skill and knowledge without error – certainly not the expectation of academicians or clinicians.” Mitchell & Kampfe, 1992, p. 538
Mindful Practices… Mindful eating (spend a few moments at
every mealtime without talking to enjoy tasting the food),
Mindful walking (listen to the rhythm of your foot steps),
Mindful watching (soak up the sights) Mindful listening (just paying attention to the
sounds in the environment. Savor these moments and experiences – they
provide a “time out” for yourself and your busy brain.
Becoming More Mindful: Incorporating mindfulness into daily routines is one
easy way to that can help work life separation processes.
For some people physical activity is the quickest and most effective way to enhance mood and do something that can block out intrusive work/life thoughts.
For others, going to the movies or reading a book can achieve the same aim.
But tried and true practices, such as leaving work on time to go and walk the dog, taking a regular vacation or mini-break, getting out of the office during lunchtime and smelling the roses, are not ground breaking interventions.
Do As I Do, Not As I Say: “Overall, we recommend that therapists do for
themselves the self-nurturing, self-building things they would have their clients do. Increasing our awareness of our needs and remaining connected with our bodies, our feelings, and other people will strengthen us as individuals and allow us to choose to continue to do this important work.” L.A. Pearlman, 1995
Professional Self-Understanding:
“As important as methods may be, the most practical thing we can achieve in any kind of work is insight into what is happening inside us as we are do it. The more familiar we are with our inner terrain, the more sure-footed our work – and living –becomes.” Parker Palmer, 1998, p. 5
Meditation Practice – The STOP Mnemonic: S – stop/pause
T – take a breath
O – observe
P – proceed with awareness
Siegel, 2007
Meditation Practice: The RAIN Mnemonic: R – recognize
A – accept
I – investigate
N- non-identify
Siegel, 2007
Koru Mindfulness Recordings:
Free downloads of short (10 minute) meditations
http://korumindfulness.org/guided-meditations/
Mindfulness Practice: Three Minute Breathing Space: 1. AWARENESS: being aware of the present moment,
noting your experience in thoughts, in feelings, and in bodily sensations. Acknowledge experience.
2. GATHERING: bring full attention to each in breath, and each out breath, your breath functioning as an anchor.
3. EXPANDING: expand your field of awareness to the body as a whole, your posture, and facial expression.
The breathing space provides a way to step out of automatic pilot mode and reconnect with the present moment.
Thank You for Participating Today! And now for the questions…
To contact me:
References: Skovholt, T., & Trotter-Mathison. (2016). The Resilient Practitioner: Burnout and Compassion Fatigue
Strategies and Self-Care Strategies for the Helping Professions. Third Edition. New York, NY: Routledge.
Flook, L, Goldberg, S., Pinger, L., Bonuse, K., & Davidson, R. (2013). Mindfulness for teachers: A pilot study to assess effects on stress, burnout, and teaching strategies. Mind, Brain, and Education, 7 (3), 182-195.
Elliot, M. (2011). Being mindful about mindfulness: An invitation to extend mindfulness into the growing mindfulness discourse. Journal of Occupational Science, 18(4), 366-376.
Luken, M., & Sammons, A. (2016). Systematic review of mindfulness practice for reducing job burnout. American Journal of Occupational Therapy, 70(2).
Reid, D. (2008). Exploring the relationship between occupational presence, occupational engagement, and people’s well-being. Journal of Occupational Science, 15(1), 43-47.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present and future. Clinical Psychology: Science and Practice, 10, 144-56.
Holzel, B., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S., Gard, T., & Lazar, S. (2011. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 191, 36-43.
Siegel, D. (2007). Mindfulness training and neural integration: Differentiation of distinct streams of awareness and the cultivation of well-being. Social and Cognitive Affective Neuroscience, 2(4), 313-322.
References: Poulsen, A., Henderson, J., & Castrisos, V. (2011). Sustainable occupational therapy
practice: Work-life balance, job satisfaction, and burnout. Occupational Therapy Board of Queensland.
Dobkin, P., Bernardo, N., & Bagnis, C. (2016). Enhancing clinicians’ well-being and patient-centered care through mindfulness. Journal of Continuing Education in the Health Professions, 36(1), 11-16.
Epstein, M. (1999). Mindful Practice. Journal of the American Medical Association, 282(9), 833-839.
Epstein, R., Siegel, D., & Silberman, J. (2008). Self-monitoring in clinical practice: A challenge for medical educators. Journal of Continuing Education in the Health Professions, 28(1), 5-13.
Irving, J., Dobkin, P., & Park, J. (2009). Cultivating mindfulness in health care professionals: A review of empirical studies of mindfulness-based stress reduction (MBSR). Complementary Therapies in Clinical Practice, 15, 61-66.
Reid, D. (2009). Capturing presence moments: The art of mindful practice in occupational therapy. Canadian Journal of Occupational Therapy, 76(3), 180-188.
Krasner, M., Epstein, R., Beckman, H., Suchman, A., Chapman, B., Mooney, C., & Quill, T. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association, 302(12), 1284-1293.