The workshop participants divided into subgroups to learn about and discuss various initiatives implemented in Africa, the United Kingdom, and the United States. While the breakout group topics varied considerably—from yoga for students, to policies about bullying, to mental health counseling in rural regions of Africa, to a systems engineering approach—all had similar aims of improving the well-being of providers, learners, and communities, and to do so through systematic changes that could build or result in stronger organizational resilience. These topics were selected by the workshop planning committee (see page v) that was charged with selecting a diverse set of issues to explore in greater depth through small group discussions. Summaries from the breakout session reflect the dialogue of the group and should not be construed as consensus statements.
BREAKOUT SESSION ONE: POLICY CHANGE THROUGH EVIDENCE-BASED EMPOWERMENT
Megan Walsh, chief academic officer at Hennepin County Medical Center in Minneapolis, introduced the breakout session with two speakers who have been a part of bottom-up cultural shifts. Simon Fleming, past president of the British Orthopaedic Trainees’ Association (BOTA) told the audience about a program called Hammer It Out, while Calli Schardein, a student at Oklahoma State University Center for Health Sciences, and a member of the Council of Osteopathic Student Government Presidents, talked about her advocacy for mental health in medical students.
A Grassroots Approach to Policy Change Through Orthopedic Trainees
Simon Fleming, British Orthopaedic Trainee’s Association
Fleming led off by describing a BOTA survey performed roughly 2 years ago asking orthopedic trainees about bullying, undermining, and harassment. Because BOTA wanted a true and complete picture of the trainees’ experiences, it took several steps to ensure a high response rate: BOTA assured complete anonymity, it promised it would act on whatever it found, and it offered respondents the chance to win money to cover the cost of their exams. The survey had approximately 60 percent response rate, and the results, said Fleming, “blew us away.” The survey asked whether respondents had experienced bullying, undermining, or harassment, and if the respondents had witnessed colleagues being treated in these ways. Roughly 73 percent of trainees had witnessed a colleague being bullied, undermined, or harassed, and 23 percent had heard sexist, homophobic, or racist language used (BOTA, 2018). With these numbers in hand, BOTA created the Hammer It Out campaign in an attempt to change the culture of orthopedics. Fleming noted a fair amount of resistance among some senior people in orthopedics to this change; they had been trained in this culture, did not see it as a problem, and felt defensive about being told they were doing something “wrong.” To mitigate this resistance, BOTA presented it as a “better way of learning, a better way of training, a better way of teaching people,” rather than pointing fingers and disparaging the traditional culture in orthopedics.
Fleming compared BOTA’s model of cultural change to tectonic plates—little changes add together and “eventually you realize the world has moved underneath your feet.” BOTA started by asking people to commit to changing their own personal behavior, which is both “the simplest and the hardest thing,” said Fleming. When a person changes his or her behavior, he or she becomes a role model and creates a positive culture within the team, Fleming said. Eventually, people start to notice those happier teams, resulting in patients preferring to be treated by those teams, and residents wanting to work in the environment creating the happier teams. Such outcomes are infectious. After Hammer It Out, other departments and specialties took notice and were inspired to make their own changes—similar initiatives were implemented by emergency departments, general practitioners, and internists. These small changes eventually become large changes, said Fleming: “If you change your specialty, you start to change hospitals and if you start to change hospitals, you change health care, and if you change health care, eventually, because everyone, everyone, has to interact with health care, that’s how you change the world. And it all starts with personal change.”
A Grassroots Approach to Policy Change Through Osteopathic Student Government
Calli Schardein, Oklahoma State University Center for Health Sciences
Schardein shared her story about a similar bottom-up program that resulted in broad changes. It all started, said Schardein, when she received a call during her second year of medical school. A first-year student was distressed and suicidal, and the student called Schardein seeking help. Schardein was the student government president at the time, but did not have any knowledge or resources about how to support the student, and could only suggest that she be taken to the emergency room. After this scary situation was resolved—the student survived—Schardein knew she had to do something to improve mental health among medical students and to increase access to resources. She ran for vice-chair of the Council of Osteopathic Student Government Presidents of the American Association of Colleges of Osteopathic Medicine, and performed a survey of what resources were available on campuses, what initiatives were working, and what could be done better. The results, she said, were eye opening and revealed areas where small tweaks could result in big changes to culture. For example, at one school, the campus counseling center had glass walls; students were reluctant to seek help because everyone would know they were there. With the results of this survey, Schardein and her colleagues went to the leadership at the American Osteopathic Association Commission on Osteopathic College Accreditation. The accrediting body was receptive and supportive, said Schardein, and new standards were implemented that required schools to have certain resources in place to be accredited.
Breakout Session One Discussion
After the presentations, participants in the breakout session asked questions and discussed the lessons learned from these experiences. One participant requested both presenters elaborate further on the role policy played in effecting these changes. Fleming responded that in the case of bullying in the orthopedic profession, policies were already in place but they were being ignored. BOTA and its partners worked to rewrite and update
policies, and to get people to take the policies seriously. Fleming said, “It’s kind of embarrassing … that we should have a policy that says don’t be racist but it seems to be something that we need to have.” In addition, the association’s survey and the Hammer It Out campaign put bullying on the agendas of other organizations and accrediting bodies, such as the General Medical Council—the independent regulator of medical schools in the United Kingdom. There had been previous surveys about mistreatment in the field, but many of these surveys suffered from underreporting; BOTA pointed out the problems with these surveys and encouraged other organizations to put bullying “on their agendas.”
Schardein remarked about similar policies within the osteopathic profession, but the policies were not specific enough to be useful. For example, accredited schools were already required to have 24-hour access to mental health care. What this means in reality is that if a student has a problem in the middle of the night, they could access an online scheduling service to make an appointment for the next day. Obviously, said Schardein, if a student is in crisis at 2:00 am, the promise of a next day appointment may be too late, especially if the student is suicidal. The accreditors are currently working on a way to update and improve this policy. Another policy effort has been getting the board of deans to collaborate on a list of resources and best practices to be shared with other schools, particularly newer schools that need help getting started. Some of the policies that have been identified as best practices, said Schardein, include an on-campus psychiatrist who has no interaction with or influence over students other than counseling sessions; schools with free fitness and wellness programs; and schools with fun community-building activities such as “food truck Wednesday.”
Another participant asked Fleming about how to encourage open and honest reporting of bullying, while also not ostracizing those who are accused of bullying. Fleming said they are trying to create a “culture where accusations of bullying or harassment … are accepted with open arms.” He explained that while people are often “a bit upset” to hear they have been accused of mistreating their colleagues, it opens the door to a conversation about improving their communication style and shifting the notions of what is acceptable behavior. For example, Fleming knows of a trauma unit that wrote up a charter explaining the expectations for behavior and communication within the unit, and posted the charter on the wall. When a colleague deviates from these expectations, the charter serves as a formal way to actively address and correct the behavior and to enforce a new culture.
The breakout session participants also discussed the widespread culture within medicine that encourages practitioners—particularly students and residents—to “say yes” to everything, to work as much as possible, and to not complain or speak out. Fleming said what is needed is a cultural shift toward a system where all professionals are encouraged to ask for help,
where senior professionals actively supervise and train junior professionals, and where colleagues openly communicate about how they can support each other.
Finally, participants discussed the importance of keeping the patient at the center of care. Fleming recalled a story about a patient liaison who reminded him that the patients can hear the interactions between the health professionals who are treating them. As obvious as it might be, said Fleming, it is easy for providers to forget that when they are demeaning or bullying a colleague, patients are listening and forming opinions about their care team. Making an effort to improve communication between health professionals does not only have benefits for the professionals themselves, but also the patients they treat. Fleming emphasized that in health care, there is always a patient, and initiatives should keep these patients and their perspectives in mind at all times.
BREAKOUT SESSION TWO: CREATING A MINDFUL ENVIRONMENT
Maryanna Klatt, The Ohio State University
Klatt, professor in the Department of Medicine at The Ohio State University (OSU), focuses on creating mindful environments for health providers. Until 2011, she taught mindfulness and stress reduction for people of various professions. Although she usually worked in academic environments, Klatt found that people from all professions deal with the same issues. She told workshop participants about an experience when she was called in to help with stress reduction for trash collectors. She had assumed, based on her limited knowledge of trash collection, that the primary source of stress would be the physical difficulty of the job. She found, however, that just like the surgeons, executives, nurses whom she had worked with in the past, the refuse collectors dealt with similar stresses—favoritism among colleagues, too much to do in too little time, equipment not working, and inefficient systems.
One morning while at her office at OSU, she noticed construction workers outside doing yoga and meditation for 20 minutes before beginning their work. She talked to the workers who reported multiple benefits from the stress-reduction exercises. In particular, the manager had seen a dramatic reduction in accidents and their workers’ compensation costs had gone down “astronomically.” This experience made Klatt ask, “Why is this not happening inside the hospital? If this type of practice benefits construction workers, why not see if it can help health providers feel more focused, less stressed, and provide better care?” This flash of insight led Klatt to begin the process of instituting mindful practices and improving the work
environment for health care providers. This work always begins with a full assessment of the environment in which people work, and an understanding of the issues they face. Klatt gave an example of a project she had done for the radiological sciences department at OSU, where she surveyed the employees and shadowed people through their daily routines. What she found was that imaging techs were largely working alone in patient rooms with heavy equipment that placed physical strain on their bodies due to the awkward positioning of the machines. As a result, the techs suffered from a high prevalence of musculoskeletal discomfort, particularly lower back pain. In addition, the techs were frustrated with a lack of control over their workflow, and felt stressed from dealing with patients by themselves.
To begin the process of improving the work environment for these techs, Klatt used a design thinking approach. She wanted the techs themselves to think through the issues, brainstorm ideas, and develop solutions that would work for them. Klatt and her team talked to people at all levels of imaging to gain their perspectives and opinions about how to improve the situation. The design that was ultimately generated, said Klatt, was a process for imaging that helped the techs perform their work without damaging themselves, while at the same time offered an opportunity for the tech to connect with the patient. It involves allowing the patient to help themselves get positioned, having the tech take deep breaths, and encouraging techs to make eye contact with the patient. This process, called “mindful cueing,” is being taught to the students at OSU not just in a handout or textbook, but through a mindful process of breathing, relaxing, and visualization. In addition, students are being taught to ask for help with patients, and are being introduced to a simple daily mindful yoga practice to help them focus their attention and be present in their health care delivery. The hope, said Klatt, is that by teaching these lessons in school, the students will be prepared and will have the tools to be successful once in practice. One participant also added that students can be powerful role models; when practicing health care professionals see students taking 5 minutes to breathe, focus, and visualize their next procedure, they may be interested in trying these techniques themselves. Change is happening, one breath at a time.
BREAKOUT SESSION THREE: PROMOTING WELL-BEING IN LOW-RESOURCE ENVIRONMENTS
Javaid Sheikh, Weill Cornell Medicine–Qatar; Diana Nyirenda, United Nations Development Programme, Malawi; and Ronald Kaluya, Uganda Counseling and Support Services
Javaid Sheikh, professor of psychiatry and the dean for the Qatar campus of the Weill Cornell Medical College, oriented the breakout ses-
sion participants to the speakers and to the topic. He began with Diana Nyirenda, who is a program associate within the United Nations Development Programme in Malawi; she spoke about the mental health challenges with living and working in a developing country. Likewise, Ronald Kaluya of the Uganda Counseling and Support Service described the difficulties he and his colleagues face providing interventions in rural Uganda within villages that lack even the most basic of needs like clean water and medical care. Both Nyirenda and Kaluya collaborate with the National Board of Certified Counselors International Division, applying their train-the-trainer model for mental health counseling.
Malawi, said Nyirenda, has high rates of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), including among children and young people. In these communities that have been stricken with poverty and disease, health care workers try to balance the reality of low resources with a high demand for care, in a high-stress environment. Traditionally, people in this region sought advice and counseling from elders in their communities; however, Nyirenda said, “they have reached the point where they cannot do it anymore” because of the sheer number of young people and the increasingly global and social context in which they live. The young people in Malawi make up 60 percent of the population, and have been hard hit by the AIDS epidemic, with most having lost one or both parents, and with grandparents suffering from dementia. To fill the need for counseling and support for these communities, Nyirenda has been involved in a program to recruit and train community counselors. So far, they have trained more than 1,150 counselors, although she noted the country’s lack of standardization or ethics to govern community counseling result in slow acceptance by some communities. Because of this, she said, “we are not sure if we are doing the right thing. Much as we have been trained, there is a gap in the policies that govern the profession.” The fledgling group of community counselors gather together to discuss what they have encountered in the communities and to reflect on their experiences, in the hopes of learning from others’ successes.
Nyirenda conveyed a story about a retired health care worker, a midwife, who had returned to work in a rural setting within the Lilongwe District at age 75. Rural areas were hard hit by AIDS, and many health care workers left the profession or the country to seek other opportunities because of stress and burnout. In her career the midwife has assisted in more than 20,000 live births in remote villages. Most of these deliveries are done in the dark with no source of light or running water. She has seen young women hemorrhage to death before, during, or after delivery. She was on a monthly contract with a district health office owing to a shortage of midwives when the incident happened. She still delivered an average of 800 babies per year, but a horrific incident one night got her thinking hard
about turning her back on the profession she has cherished all her adult life. In a dark labor ward, and without any hospital attendant to assist her, she accidentally cut the forehead of a baby during a routine passage extension she had performed thousands of times before. The backlash from the baby’s mother, her family, and community in rage did not recognize her selfless service to the community at her above retirement age. According to Nyirenda, community members wondered if she came back from her retirement to kill them all. This story, said Nyirenda, demonstrates the need for support and mental health counseling for health providers in Malawi. For example, newly graduated health care workers were choosing to stay in urban areas where the working conditions were not as difficult.
Kaluya works in a region called Bulike in rural Uganda. Eight years ago, when Kaluya returned to Uganda from the United States, Bulike was hugely underresourced—there was no clean water, no schools, no medical care, and high rates of morbidity and mortality. As Kaluya put it, “People were living day by day … and had no hope for tomorrow.” Kaluya began his work by opening a mobile medical clinic that could travel to the villages in the region. He found that some of the patients who came to the clinic were not physically sick, but “emotionally sick,” and benefitted from having someone to talk to at the clinic. However, the clinic workers were being burdened by having to play the role of nurse, advocate, community mobilizer, and mental health provider, said Kaluya. In addition, the workers were largely functioning in isolation, with no colleagues or peers to share the stress of the job with; this can be “very overwhelming” and health workers were breaking down.
Kaluya’s organization, Uganda Counseling and Support Services, trains and supports mental health counselors from and for the communities of Bulike (Uganda Counseling and Support Services, 2018). By taking on the burden of mental health, these counselors free up the medical care workers to concentrate on physical health. Around 200 counselors have been trained; Kaluya said they chose to train people who were respected in the community and who could use their influence to promote acceptance of the program. While it is sometimes difficult to focus on mental health in a region that has so few resources, Kaluya said it is important to treat the entire person: “As we treat the body, we ought to treat the soul.”
Both Nyirenda and Kaluya pointed to privacy and confidentiality as major obstacles to providing mental health services in these financially poor environments. In Malawi and in Uganda, many of the counseling sessions take place in open spaces (such as gardens) because of a lack of funding to build physical structures. Everyone can see who is going to counseling. Kaluya said this is
problematic in Uganda because men, in particular, are hesitant to share their feelings with others or to cry, because of the fear of being perceived as weak.
Breakout Session Three Discussion
A breakout session participant asked Nyirenda and Kaluya how they themselves cope with the stress of working in these environments and dealing with others’ mental health issues. Nyirenda said she stays strong because she believes “a counselor is supposed to be the one standing when the whole community is falling.” This belief gives her the energy to get up every day and keep going. She is also buoyed by her strong religious faith and her passion for helping children through guidance and mental health counseling. Kaluya said he is uplifted by looking at the amazing progress they have made over the past 8 years in Bulike, and this keeps him going when times are tough.
Finally, the participants discussed the issue of providing mental health counseling in communities that lack basic needs. Nyirenda told the story of a young woman she was seeing for counseling, who told her that she did not have money for transportation to get to future counseling sessions. Nyirenda paid for transportation out of her pocket to facilitate the ongoing counseling relationship, as this would have led to premature termination of sessions. Kaluya said that in Bulike, they have relied on creativity and collaboration in order to fulfill the basic needs of the communities. The organization focuses on not just providing day-to-day care, but on establishing sustainable structures in the community (e.g., a school). As Kaluya’s organization moves on to another community, these structures can continue to be a place to get help and resources.
BREAKOUT SESSION FOUR: APPLYING SYSTEMS ENGINEERING
Pinar Keskinocak, Georgia Institute of Technology, and Sara Czaja, Weill Cornell Medicine
Keskinocak (see Chapter 1 for her introductory remarks) and Czaja, director of the Center on Aging and Behavior Research at Weill Cornell Medicine, led workshop participants in a breakout session discussion about applying systems engineering to health professionals’ well-being. First, Czaja showed a diagram that conceptualized a system—it is made of components that are independent and interact with each other (see Figure 3-1).
Systems are intended to operate as a whole, with a shared vision of objectives and goals, said Czaja. For example, an academic health center might have the goals of caring for patients, conducting research, training students, supporting the community, and raising financial support. System components are interdependent—a change in one component “reverberates and impacts other components,” she said. System relationships are maintained by defined processes, including patterns, roles, and structures within the system. Systems are not static. By their very nature, they evolve and can be influenced by external forces. Finally, said Czaja, systems are incredibly complex, particularly in the world of health care.
Keskinocak and Czaja led the breakout session participants in an exercise in which they asked participants to rotate from one station to the next discussing in small groups the following three questions from a systems perspective:
- What are the major causes of stress and burnout at your workplace?
- What are some of the effective practices for addressing some of these issues?
- If an organization tried to improve wellness or well-being, what were some of the unintended consequences of the initiative?
Breakout Session Four Discussion
After each small group rotated through the stations, the entire breakout session of participants gathered together to reflect and share their observations. One participant found listing the stress and burnout factors as the easiest thing to do noting, “none of us had a shortage of those.” Another participant concurred, and added that all of the participants could relate to the stress and burnout factors listed, even though they all came from different types of systems. When it came to listing effective practices, it became clear to one participant that even the best-intentioned intervention in a system could cause problems in other parts of the system because it is a “never-ending cycle.” She asked, “Which is the less of the evils when you are trying to fix” all of the issues in a system?
The participants concluded with a discussion about the appropriate role of systems engineers or other experts in facilitating a systems-level change in a health organization. Keskinocak expressed her perspective saying it is not always necessary for an external expert to be involved. The important piece, she said, is bringing together the perspectives of all the different stakeholders involved in a system in order to create a holistic view of the situation and to develop potential solutions. Whether or not an outside consultant is brought in, it is imperative that stakeholders from the system buy in to the process. Another participant added an observation that more and more systems engineers are working full-time in leadership positions in health care systems. This creates in-house expertise for everyone across the organization to maximize cross-sector benefits.
BOTA (British Orthopaedic Trainees’ Association). 2018. Hammer it out. http://www.bota.org.uk/hammer-it-out (accessed June 26, 2018).
Smith, M. J., and P. C. Sainfort. 1989. A balance theory of job design for stress reduction. International Journal of Industrial Ergonomics 4(1):67–79.
Uganda Counseling and Support Services. 2018. Bringing hope to Uganda—one village at a time. http://www.ugandacss.org (accessed July 17, 2018).
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