Mindfulness: A path to reciprocal relationshiprelationship...

Mindfulness: A path to Mindfulness: A path to

reciprocal reciprocal relationshiprelationship--basedbased carecare

St. Paul’s CME ConferenceSt. Paul’s CME Conference

© Centre for Practitioner Renewal

NovemberNovember, , 20162016

Douglas Cave, Douglas Cave, MSW, RSW, PhD, MSW, RSW, PhD, RPsychRPsych, MA, AMP, MCFP, MA, AMP, MCFP

Centre for Practitioner RenewalCentre for Practitioner Renewal

Providence Health Care/University of British ColumbiaProvidence Health Care/University of British Columbia

Financial Disclosure

� Self-FIFE study was funded by the Department of Community and Family Medicine, SPH for approximately 750$ to purchase participant


approximately 750$ to purchase participant compensatory bookstore gift cards

� I am neither a member nor receive regular financial support from the Department

� The department hosts this conference

Draft Group Agreements

C onfidentiality (with standard limits)

E qual airtime

N on-judgemental listening

3

N

T imeliness

R ight to pass

E ngaged

Check-in

� My name is

� I am from


� My experience with mindfulness is

� My hope for today is

Centre for Practitioner

Renewal

� How do we sustain health care providers in the work place?

Efficiency

throughrelationship

� What is the effect of being in the presence of suffering?

� What would be reparative, healing or restore resilience for health care providers?


Core Messages

1. A intentional relationship with yourself can sustain if it is maintained

2. Mindfulness is

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

Objectives

By the end

of this

workshop,

participants

1. Have an awareness of what mindfulness is

2. Know how it can be incorporated into a busy day

participants

will:3. Have practiced a few techniques

4. Know some techniques for practice

5. Know some techniques to teach patients


© Centre for

Practitioner

Renewal

Participant,

Observer,

Meta-

To know a patient, we have to know

ourselves and the relationship between

ourselves and patients.

Meta-

Observer

Freeman, T.R. (2016).

McWhinney Textbook of

Family Medicine 4th ed.

P136. Oxford.

Exercise 1:

3 Minutes

Bio-dots

3 Minutes

of Mindfulness


Relationships

Reciprocal effect

Others

OTHER

© Centre for

Practitioner

Renewal

Self

Others

“The relationship to an experience is more important than the experience itself”

Briere

Basic

Human

Needs and

Connection

� FunctionalDisconnect

� Emotional Reconnect

� Exist

� RelateConnectionReconnect

(Whitehead, 2005)

� Grow

(Alderfer,1969)


Retrospective Chart Review

Referral Reasons Frequencies Examples

L M S Total

Emotional reactions about work 1 7 13 21 Overwhelmed by work after

learning of colleague’s severe

criticisms


criticisms

Family/ relationship issues 6 1 10 17 Relationship issues related to 20-

year marriage

Misc. 5 4 8 17 Feeling apologetic for living

Stress/ cumulative stress 5 1 9 15 Stress at work from relationship

with colleague

Retrospective Chart Review cont’d.

Underlying Concerns

Intrapersonal Frequencies Examples

L M S Total

Work-related incidents 20 8 70 98 Personal betrayal when told to

remove praying people

Stress/cumulative stress 5 1 9 15 Stress from relationship with


Stress/cumulative stress 5 1 9 15 Stress from relationship with

colleague

Disengagement/estrangeme

nt

8 9 12 29 Isolation at work and home

Self-esteem/worth 8 8 7 23 Feeling “less than” others

Family of origin 13 12 16 41 Fear of letting anyone close and

want to prevent same hurt from

family of origin

Retrospective Chart Review cont’d.

Underlying Concerns

Interpersonal Frequencies Examples

L M S Totals

Romantic relationship 13 9 23 45 Frustration with spouse & work

situation


Collegial challenges 10 2 19 31 Dual relationship

Family/personal 4 10 13 27 Family of origin issues

Communication 13 9 7 29 Ineffective skills

Family of origin 13 12 16 41 Isolated to prevent hurt from

others like from family of origin

Stress/cumulative 5 1 9 15 Collegial relationship stress

Boundaries

Professional Boundaries

are:

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

www.genderandhealth.ca/en/modules/meded/meded-

boundaries


Boundary

Types� What circumstances or people cause this for you?

� How do you recognise it?

� How might you change your response?

1. Soft

© Centre for

Practitioner

Renewal

response?2. Spongy

3. Rigid

4. Flexible

Brown,(2006).

Coping With Infuriating, Mean, Critical People

Soft� 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

© Centre for

Practitioner

Renewal

� Can hurt others without realizing or

caring

� May experience the needs of others more

readily then their ownYour Space

TheirSpace Your SpaceTheirSpace

Spongy� 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

© Centre for

Practitioner

Renewal

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.

TheirSpace

Your Space

TheirSpace

Your Space

Flexible� Clear sense of self and limits

� Recognises when risk of hard to others and self

� Clear sense of when to say “yes” or “no”

© Centre for

Practitioner

Renewal

� Agentic – capacity to make choices in the world

� Empathic to others and compassionate to selfYour

Space

Their Space

Rigid� Unwavering boundaries that are declared either actively or passively

� Have a wall up between self and others

� Intimacy on that person’s terms

© Centre for

Practitioner

Renewal

� Intimacy on that person’s terms

� Doubts, rejects, blames, criticizes others

� Believes only own truth

� Sees own perspective more easily than others’

Your Space

Their Space

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)

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 non-


moment, as well as taking a non-evaluative and non-judgmental 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

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)


Explicit knowledge:Explicit knowledge: Tacit knowledge:Tacit knowledge:

� learned during

observation and practice

Mindfulness

� readily taught

� accessible to awareness


� includes prior

experiences theories-in-

action, and deeply held

values

� usually applied more

inductively

� accessible to awareness

� quantifiable

� easily translated into evidence-based guidelines

Ex 2: Raisin Exercise


What Does the Research Say?

� Improves resilience

� Reduces BP

� Increases satisfaction

� Reduces depression/anxiety

� Helpful for pain

� Addiction

� Improved immune response

� Burnout

� Physician empathy

� Psychosocial orientation to


� Helpful for pain

management

� Stress management

� Disordered eating

� Psychosocial orientation to

patient care

� Traditional mindfulness-

based techniques take time

and commitment

Action ModeAction Mode Presence ModePresence Mode

� Acute situations – Life or Death

� Calmer situations – No immediate intervention needed

Physicians Dealing with Patient Death Action versus Presence

� Focus on pre-established protocols or pathways

� Reduced personal/emotional experience

needed

� Focus on mindful awareness of self and other

� Greater receptivity to new information/connection

(Whitehead, 2012)

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.)

Functional Disconnect

Emotional Disconnect – a part of

� Burnout

� Functional because of a balancing

“emotional re-connect”

� Allows emotional distance as a tool to

remain functional

Disconnect can be generated by focusing � Compassion Fatigue

� Vicarious / Secondary traumatic stress

� Disconnect can be generated by focusing

on protocols

� Reconnect can be generated by focusing

on mindfulness

Exercise

3:

Breathing

Exercise


Characteristics of a Mindful Practitioner

� Active observation (self, patient, problem)

� Peripheral visionPre-attentive

� Willingness� Beginner� Humility


� Pre-attentive processing (intuition)

� Critical curiosity� Courage

Humility� Connection knower-known

� Compassion� Presence

Barriers

Intrusions

Adding 1

� Fatigue/Time pressures

� Dogmatism

� Emphasis on short-term goals rather than context of patient/doctor relationshipAdding 1

more thing to a busy schedule feels impossible

rather than context of patient/doctor relationship

� Unexamined negative/positive emotions

� Failure of imagination/literal mindedness


Most Common Signs of Distress

� Increased rates of illness

� Withdrawal - Isolation

� Cynicism - Sadness - Depression

� Exhaustion - Presenteeism


� Exhaustion - Presenteeism

� Addictive responses

� Loss of efficiency - Judgment errors

� Challenging team dynamics

� Impaired boundaries - Identification vs. Empathy

Exercise

4:

Body Body

Scan


Necessary component of:

Necessary component of:

Requires 3 mechanisms: Requires 3 mechanisms:

� Psychological well-being

Maintaining resilience at

� Motivation to self-reflect and develop insight

Mindfulness


� Maintaining resilience at work

� Component of effective patient care

insight

� Memory cues as a reminder to emerge from daily routines

� A tool to help self-reflection/self-awareness

Performance = f(Ability + Motivation + Environment)


Memory Cues

� Hand washing

� Going to the toilet

� Closing the office door at the end of the day

� Sitting in a particular chair


� 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

Self

FIFE

Feelings

Feelings

What do you feel about

yourself/patient/colleague?

Impression

What is your impression (judgment) of

yourself regarding your

patient/work/colleague?Impression

Function

Expectations

(McWhinney, 1989)


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?

Self FIFE as Mindfulness Tool

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.

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?


Teaching Mindfulness to Patients


End of Day Ritual


Centre for Practitioner Renewal

www.practitionerrenewal.cawww.practitionerrenewal.ca


[email protected]@providencehealth.bc.ca

References

AlderferAlderfer, Clayton P., An Empirical Test of a New Theory of Human Needs. , Clayton P., An Empirical Test of a New Theory of Human Needs. Organizational Behaviour Organizational Behaviour and Human Performanceand Human Performance, 4(2),142, 4(2),142––175.175.

Cave, D.G. (2009). Fife yourself. Cave, D.G. (2009). Fife yourself. http://www.ephysicianhealth.com/http://www.ephysicianhealth.com/

Dobie, S., (2007). Reflections on a WellDobie, S., (2007). Reflections on a Well--Traveled Path: SelfTraveled Path: Self--Awareness, Mindful Practice, and Awareness, Mindful Practice, and RelationshipRelationship--Centered Care as Foundations for Medical Education. Centered Care as Foundations for Medical Education. Academic MedicineAcademic Medicine, 82:422, 82:422––427. 427.

Epstein, R. (1999). Mindful Practice. Epstein, R. (1999). Mindful Practice. JAMAJAMA., 282(9),833., 282(9),833--839. 839.

Herzberg, F. (1968), One more time: how do you motivate employees? Harvard Business Review, 46(1), 53–62.


53–62.

Michael S. Krasner; Ronald M. Epstein; Howard Beckman; et al. (2009). Association of an Educational 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 Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians, Physicians, JAMA., 302(12),1284-1293.

ShanafeltShanafelt, T.D., (2009). Enhancing Meaning in Work A Prescription for Preventing Physician Burnout and , T.D., (2009). Enhancing Meaning in Work A Prescription for Preventing Physician Burnout and Promoting PatientPromoting Patient--Centered Care. Centered Care. JAMAJAMA 302(12), 133801340,302(12), 133801340,

Weiner, E.L., Swain, G.R., Wolf, B., Gottlieb, M. (2001). A qualitative study of physicians’ own wellnessWeiner, E.L., Swain, G.R., Wolf, B., Gottlieb, M. (2001). A qualitative study of physicians’ own wellness--promotion practices. promotion practices. Western Journal of MedicineWestern Journal of Medicine, 1(174), 19, 1(174), 19--23.23.

Whitehead, P.R. (2005). Whitehead, P.R. (2005). Exploration of Physicians who deal with Patient DeathExploration of Physicians who deal with Patient Death. Unpublished PhD . Unpublished PhD dissertation, UBC.dissertation, UBC.

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