Maintaining Relationships While Having Difficult and Awkward Conversations

Transcription

1 Medical Education Day Island Medical Program Maintaining Relationships While Having Difficult and Awkward Conversations November 19, 2016 Douglas Cave, MSW, RSW, PhD, RPsych, MA, AMP, MCFP Centre for Practitioner Renewal Providence Health Care/University of British Columbia

2 Financial Disclosure No relevant disclosures

3 3 Outline Group Agreements (Guidelines) Check-in Review models pertinent to conversations and relationship maintenance Self-Reflective timeline exercise ABCD Communication template: Practice/debrief Check-out

4 4 Objectives Discuss and define explicit guidelines designed to create safety, inclusion and trust Talk about successes and struggles conversations ABCD communication template Practice using template Experience the template as a listener Witness template being used by others

5 Communication Template A ttend Self: What am I experiencing? What am I aware of? Other: What is the other person experiencing? B ridge Introduce topic (broadly) Introduce subject (specifically) Relationship awareness (dr/pt, colleagues, etc.) C omment: Say message Ask for what you need Check for understanding D evelop Contract: Acknowledge impact on patient (includes feelings, experiences and behaviours) Establish timeline/follow-up Immediate Plans (safety) 5 Centre for Practitioner Renewal 5

6 Centre for Practitioner Renewal How do we sustain health care providers in the work place? What is the effect of being in the presence of suffering? Efficiency through relationship What would be reparative, healing or restore resilience for health care providers?

7 Core Messages 1. Relationships can sustain if they are maintained (self, others and Other) 3. Self awareness is a key tool 2. The past is always present

8 psychologists Drs. Joseph Luft and Harrington Ingham Designed as a feedback and self awareness tool Johari Window: Expanding Self Knowledge

9 Trauma awareness Trauma-Informed Care Centre for Practition er Renewal Emphasis on safety and trustworthiness Opportunity for choice, collaboration and connection Strengths-based and skill building Trauma-informed Practice Guide 9

10 Guidelines for Safer Self Exploration and Expression Creating safety makes experience predictable Safety comes from predictability If we don t establish predictability explicitly, then it will happen implicitly Without guidelines, we are more likely to apply rules set by family/culture

11 11 Group Agreements C onfidentiality (with standard limits) E qual airtime N on-judgemental listening T imeliness R ight to pass E ngaged

12 Check-in: Self FIFE Regarding difficult or awkward conversations: Feelings What do you feel about these conversations? Impression What are your ideas about these conversations? Function What effect do these conversations have on you? Expectations What expectations do you have about these conversations?

13 Group Check-in My name is... I am from... My experience with difficult conversations is... My hope for today is...

14 Centre for Practition er Renewal Relationships OTHER Reciprocal effect Others The relationship to an experience is more important than the experience itself Briere Self

15 Participant, Observer, Meta-Observer Freeman, T.R. (2016). McWhinney Textbook of Family Medicine 4 th ed. P136. Oxford. To know a patient, we have to know ourselves and the relationship between ourselves and patients.

16 16 Effect on Relationships Self -Ego integrity is at risk Others - Perceived as nice and likeable are at risk - Hard to express hard emotions Other Loss of meaning

17 17 Iatrogenic Suffering Suffering resulting from actions or inactions by healthcare providers that increase distress, anxiety, and mistrust felt by patients and families

18 Iatrogenic Suffering and Burnout Iatrogenic Suffering seen relationship with burnout Sx: Emotional exhaustion Depersonalization Centre for Practition er Renewal A negative attitude towards patients/clients Personal detachment Loss of ideals Reduced sense of personal accomplishment and commitment to the profession. Maslach,

19 Satir Iceberg BEHAVIOUR (action, storyline) COPING (stances) FEELINGS (joy, excitement, anger hurt, fear, sadness) FEELINGS ABOUT FEELINGS (decisions about feelings) PERCEPTIONS (beliefs, assumptions, mind-set, subjective reality) EXPECTATIONS (of self, of others, from others) YEARNINGS (loved, lovable, accepted, validated, purposeful, meaning, freedom) SELF: I AM (life force, spirit, soul, essence) Centre for 19See: Satir, V, Banmen J., Gerber, J., and Gamori, M. (1991). The Satir Model Practitioner of Family Therapy and Beyond. Palo Alto, CA: Science and Behaviour Books, Inc. Renewal

20 20

21 Shadow Exercise

22 Mindfulness Dr. Jon Kabat-Zinn (1979) developed Mindfulness Based Stress Reduction program at the University of Massachusetts Medical Center. Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. (Epstein, 1999)

23 Mindfulness Mindfulness is ability to pay attention on purpose in the present moment and without judgement (Krazner, 2009) Being completely in touch with and aware of the present moment, as well as taking a non-evaluative and nonjudgmental approach to your inner experience Mindfulness informs all types of professionally relevant knowledge including: facts, personal experiences, processes, and know-how, each of which may be tacit or explicit

24 Elements of Mindfulness Practicing mindfully is a choice Integral to the professional competence of physicians Exemplary physicians have the capacity for self-reflection that pervades all aspects of practice including being present with the patient (Epstien, 1999)

25 Mindfulness Explicit knowledge: Readily taught Accessible to awareness Quantifiable Easily translated into evidence-based guidelines Tacit knowledge: Learned during observation and practice Includes prior experiences theories-inaction, and deeply held values Usually applied more inductively

26 Your Timeline Birth X Your Name Death As I complete this time line I feel 26 Centre for Practitioner Renewal

27 Life Altering Event Birth X Your Name Death As I complete this time line I feel 27 Centre for Practitioner Renewal

28 Window of Tolerance Centre for Practition er Renewal Empathic Over Arousal 28 E M P A T H Y Identification vs. Empathy Extreme sense of personal responsibility Loss of boundary between self and others Zone of Effective Empathy Empathic Silencing Blocked Compassion Cynicism, Doubt, Mistrust, Disbelief Avoidance of self and others suffering 28

29 Window of Empathic Engagement Centre for Practition er Renewal E M P A T H Y Empathic Over Arousal Identification vs. Empathy Extreme sense of personal responsibility Loss of boundary between self and others Zone of Effective Empathy Empathic Silencing Blocked Compassion Cynicism, Doubt, Mistrust, Disbelief Avoidance of self and others suffering Over-Arousal Activation of personal trauma history Transfer of intensity/anxiety from self to other Silencing Response Minimizing others distress Avoiding the topic/fearing what the other person has to say Blaming others for their experiences Feeling numb 29

30 Window of Effective Empathic Engagement: Mediating Factors 30 Self Work Life stage Current personal stressors Stress Hardiness Spiritual Connection Resolution of personal trauma history Supervision: Skill based/support based Role: Degree of isolation/agency Experience: History Training Skill Level Quality of working relationships Ecological context

31 Physicians Dealing with Patient Death Action versus Presence Action Mode Acute situations Life or Death Focus on pre-established protocols or pathways Reduced personal/emotional experience Presence Mode Calmer situations No immediate intervention needed Focus on mindful awareness of self and other Greater receptivity to new information/connection (Whitehead, 2012)

32 Functional Disconnect There is a separation between your professional and your private life that has to be there a disconnect that has to be there for you to disconnect that has to be there for you to function (Dr. H.)

33 Functional Disconnect Emotional Disconnect a part of Burnout Compassion Fatigue Vicarious / Secondary traumatic stress Functional because of a balancing emotional re-connect Allows emotional distance as a tool to remain functional Disconnect can be generated by focusing on protocols Reconnect can be generated by focusing on mindfulness

34 Debriefing Centre for Practition er Renewal Prior to event create agreement about how to debrief Focus is impact rather than content 34

35 Intentional Connection and Disconnection Centre for Practition er Renewal Intentional disconnect for safety from harmful effects of difficult event. 1. Understand (empathy) experience of listener 2. Understand (self compassion) own triggers 3. Disconnect from the personal emotional relationship 4. Reconnect with your compassionate and empathetic self 35 35

36 End of Day Ritual Centre for Practition er Renewal Leaving work and reconnecting to yourself 36

37 Communication Template Centre for Practition er Renewal A ttend B ridge C omment D evelop Agreements 37

38 Communication Template A ttend Self: What am I experiencing? What am I aware of? Other: What is the other person experiencing? B ridge Introduce topic (broadly) Introduce subject (specifically) Relationship awareness (dr/pt, colleagues, etc.) C omment: Say message Ask for what you need Check for understanding D evelop Contract: Acknowledge impact on patient (includes feelings, experiences and behaviours) Establish timeline/follow-up Immediate Plans (safety) 38 Centre for Practitioner Renewal 38

39 ABCD template Highly Transferable Centre for Practition er Renewal Smoking cessation Sex and sexuality Obesity Collegial conversations Resident conversations Out-of-work conversations Others? 39

40 Difficult and Awkward Conversations Centre for Practition er Renewal What are the most challenging to have? (patients, their families, colleagues in same profession, different, within your own family) What makes it challenging? 40

41 Role Rehearsal Centre for Practition er Renewal What did you see? What did you hear? 41

42 Practice in Pairs Centre for Practition er Renewal What did you do well? (how do you know?) What would you do differently next time? 42

43 Closing What I take from today s session is 43 Centre for Practitioner Renewal 43

44 Centre for Practitioner Renewal Centre for Practition er Renewal 44

45 Draft Group Agreements C onfidentiality (with standard limits) E qual airtime N on-judgemental listening T imeliness R ight to pass E ngaged 45

46 Check-in My name is I am from My experience with mindfulness is My hope for today is

47 Centre for Practitioner Renewal How do we sustain health care providers in the work place? What is the effect of being in the presence of suffering? Efficiency through relationship What would be reparative, healing or restore resilience for health care providers?

48 Core Messages 1. A intentional relationship with yourself can sustain if it is maintained 4. The tools can be embedded into your daily routine 2. Mindfulness is manageable with a busy schedule 3. Mindfulness can be taught to patients for a range of chief complaints

49 Objectives By the end of this workshop, participants will: 1. Have an awareness of what mindfulness is 2. Know how it can be incorporated into a busy day 3. Have practiced a few techniques 4. Know some techniques for practice 5. Know some techniques to teach patients

50 Centre for Practition er Renewal Participant, Observer, Meta- Observer Freeman, T.R. (2016). McWhinney Textbook of Family Medicine 4 th ed. P136. Oxford. To know a patient, we have to know ourselves and the relationship between ourselves and patients.

51 Exercise 1: 3 Minutes of Mindfulness Bio-dots

52 Centre for Practition er Renewal Relationships OTHER Reciprocal effect Others The relationship to an experience is more important than the experience itself Briere Self

53 Basic Human Needs and Connection Exist Relate Grow Functional Disconnect Emotional Reconnect (Alderfer,1969) (Whitehead, 2005)

54 Retrospective Chart Review Referral Reasons Frequencies Examples L M S Total Emotional reactions about work Overwhelmed by work after learning of colleague s severe criticisms Family/ relationship issues Relationship issues related to 20- year marriage Misc Feeling apologetic for living Stress/ cumulative stress Stress at work from relationship with colleague

55 Retrospective Chart Review cont d. Underlying Concerns Intrapersonal Frequencies Examples L M S Total Work-related incidents Personal betrayal when told to remove praying people Stress/cumulative stress Stress from relationship with colleague Disengagement/estrangeme nt Isolation at work and home Self-esteem/worth Feeling less than others Family of origin Fear of letting anyone close and want to prevent same hurt from family of origin

56 Retrospective Chart Review cont d. Underlying Concerns Interpersonal Frequencies Examples L M S Totals Romantic relationship Frustration with spouse & work situation Collegial challenges Dual relationship Family/personal Family of origin issues Communication Ineffective skills Family of origin Isolated to prevent hurt from others like from family of origin Stress/cumulative Collegial relationship stress

57 Boundaries Professional Boundaries are: The limits that protect the space between the professionals power and the client s vulnerability that may overlap into personal spheres.

58 Centre for Practition er Renewal Boundary Types 1. Soft 2. Spongy 3. Rigid 4. Flexible What circumstances or people cause this for you? How do you recognise it? How might you change your response? Brown,(2006). Coping With Infuriating, Mean, Critical People

59 Soft Their Space Your Space Centre for Practitione r Renewal May struggle with sense of self May agree to more activity than energy allows May feel like a victim Can feel scattered, anxious, overwhelmed, insecure, afraid. Can hurt others without realizing or caring May experience the needs of others more readily then their own

60 Their Space Your Space Spongy Centre for Practitione r Renewal Variable ability to say No Inner experiences may interfere in limit setting ability (tired or scared) Feel responsible for other people s feelings, behaviour Passive control or may be manipulated May forego own principles to be nice and liked Unsure what to let in and what to keep out.

61 Their Space Your Space Rigid Centre for Practitione r Renewal Unwavering boundaries that are declared either actively or passively Have a wall up between self and others Intimacy on that person s terms Doubts, rejects, blames, criticizes others Believes only own truth Sees own perspective more easily than others

62 Flexible Centre for Practitione r Renewal Their Space Your Space Clear sense of self and limits Recognises when risk of hard to others and self Clear sense of when to say yes or no Agentic capacity to make choices in the world Empathic to others and compassionate to self

63 Soft Their Space Centre for Practition er Renewal Your Space May struggle with sense of self May agree to more activity than energy allows May feel like a victim Can feel scattered, anxious, overwhelmed, insecure, afraid. Can hurt others without realizing or caring May experience the needs of others more readily then their own

64 Centre for Practition er Renewal Spongy Their Space Your Space Variable ability to say No Inner experiences may interfere in limit setting ability (tired or scared) Feel responsible for other people s feelings, behaviour Passive control or may be manipulated May forego own principles to be nice and liked Unsure what to let in and what to keep out.

65 Centre for Practition er Renewal Flexible Their Space Your Space Clear sense of self and limits Recognises when risk of hard to others and self Clear sense of when to say yes or no Agentic capacity to make choices in the world Empathic to others and compassionate to self

66 Centre for Practition er Renewal Rigid Their Space Your Space Unwavering boundaries that are declared either actively or passively Have a wall up between self and others Intimacy on that person s terms Doubts, rejects, blames, criticizes others Believes only own truth Sees own perspective more easily than others

67 Mindfulness Dr. Jon Kabat-Zinn (1979) developed Mindfulness Based Stress Reduction program at the University of Massachusetts Medical Center. Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. (Epstein, 1999)

68 Mindfulness Mindfulness is ability to pay attention on purpose in the present moment and without judgement (Krazner, 2009) Being completely in touch with and aware of the present moment, as well as taking a non-evaluative and nonjudgmental approach to your inner experience Mindfulness informs all types of professionally relevant knowledge including: facts, personal experiences, processes, and know-how, each of which may be tacit or explicit

69 Elements of Mindfulness Practicing mindfully is a choice Integral to the professional competence of physicians Exemplary physicians have the capacity for self-reflection that pervades all aspects of practice including being present with the patient (Epstien, 1999)

70 Mindfulness Explicit knowledge: readily taught accessible to awareness quantifiable easily translated into evidence-based guidelines Tacit knowledge: learned during observation and practice includes prior experiences theories-inaction, and deeply held values usually applied more inductively

71 Ex 2: Raisin Exercise

72 What Does the Research Say? Improves resilience Reduces BP Increases satisfaction Reduces depression/anxiety Helpful for pain management Stress management Disordered eating Addiction Improved immune response Burnout Physician empathy Psychosocial orientation to patient care Traditional mindfulnessbased techniques take time and commitment

73 Exercise 3: Breathing Exercise

74 Characteristics of a Mindful Practitioner Active observation (self, patient, problem) Peripheral vision Pre-attentive processing (intuition) Critical curiosity Courage Willingness Beginner Humility Connection knowerknown Compassion Presence

75 Barriers Intrusions Adding 1 more thing to a busy schedule feels impossible Fatigue/Time pressures Dogmatism Emphasis on short-term goals rather than context of patient/doctor relationship Unexamined negative/positive emotions Failure of imagination/literal mindedness

76 Most Common Signs of Distress Increased rates of illness Withdrawal - Isolation Cynicism - Sadness - Depression Exhaustion - Presenteeism Addictive responses Loss of efficiency - Judgment errors Challenging team dynamics Impaired boundaries - Identification vs. Empathy

77 Exercise 4: Body Scan

78 Mindfulness Necessary component of: Psychological wellbeing Maintaining resilience at work Component of effective patient care Requires 3 mechanisms: Motivation to selfreflect and develop insight Memory cues as a reminder to emerge from daily routines A tool to help selfreflection/selfawareness

79 Performance = f(ability + Motivation + Environment)

80 Memory Cues Hand washing Going to the toilet Closing the office door at the end of the day Sitting in a particular chair Pulling a chart out of the door holder Checking off a patient s name on the day sheet Logging into or out of the EMR program Placing a chart into the folder for filing

81 Self FIFE Feelings Impression Function Expectations (McWhinney, 1989) Feelings What do you feel about yourself/patient/colleague? Impression What is your impression (judgment) of yourself regarding your patient/work/colleague? Function What effect does this patient/work colleague have on you? Expectations What expectations are you expressing in how you are communicating?

82 Self FIFE as Mindfulness Tool

83 Self FIFE as Mindfulness Tool

84 Self FIFE as Mindfulness Tool

85 Conclusion Even a few minutes of regular mindful reflection has a positive effect A pre-selected memory cue is useful as a reminder to self reflect A pre-established set of questions was very useful Even a few minutes of mindful reflection has a positive effect on depression, hopelessness satisfaction with life and a sense of personal achievement.

86 Exercise 5: FIFE Self Feelings What do you feel about yourself/patient/colleague? Impression What is your impression (judgment) of yourself regarding your patient/work/colleague? Function What effect does this patient/work colleague have on you? Expectations What expectations are you expressing in how you are communicating?

87 Teaching Mindfulness to Patients

88 End of Day Ritual

89 Centre for Practitioner Renewal

90 References Alderfer, Clayton P., An Empirical Test of a New Theory of Human Needs. Organizational Behaviour and Human Performance, 4(2), Cave, D.G. (2009). Fife yourself. Dobie, S., (2007). Reflections on a Well-Traveled Path: Self-Awareness, Mindful Practice, and Relationship-Centered Care as Foundations for Medical Education. Academic Medicine, 82: Epstein, R. (1999). Mindful Practice. JAMA., 282(9), Herzberg, F. (1968), One more time: how do you motivate employees? Harvard Business Review, 46(1), Michael S. Krasner; Ronald M. Epstein; Howard Beckman; et al. (2009). Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians, JAMA., 302(12), Shanafelt, T.D., (2009). Enhancing Meaning in Work A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care. JAMA 302(12), , Weiner, E.L., Swain, G.R., Wolf, B., Gottlieb, M. (2001). A qualitative study of physicians own wellness- promotion practices. Western Journal of Medicine, 1(174), Whitehead, P.R. (2005). Exploration of Physicians who deal with Patient Death. Unpublished PhD dissertation, UBC.