Mind Body Integration: Culture Change Kathie Nichols, BSN RN CRRN Nancy Flinn, PhD OTR/L

1. Mind Body Integration: Culture Change Kathie Nichols, BSN RN CRRN Nancy Flinn, PhD OTR/L Age and Disability Odyssey, August 18, 2009

2. Courage Center • Courage Center is an 80-year old community-based rehabilitation and resource center • 48 bed inpatient rehabilitation facility (SNF) • Outpatient rehabilitation services at 4 sites in the metro area and the community (PT, OT, SLP) • Vocational and Psychological services • Drivers assessment and treatment at 9 sites throughout the state • Health, wellness and fitness programs for individuals with disabilities • Independent Living Skills Program • Chemical dependency treatment (outpatient) • Chronic Pain Program (inpatient)

3. Issues in Health Care Today • Staff experience stress and burnout • Unacceptably high rate of turnover • Shortages of some professions made this even more challenging • Changes in health care continuum • Patients more acute throughout the system

4. Costs of losing staff • It has been estimated that training a new staff member (including recruitment) costs an organization about $40,000 • Use of Traveler or Agency staff is very expensive and can be avoided if facilities retain staff • Use of Travelers or Agency staff make it difficult to develop continuity across programs • Mission of the organization become diluted by large numbers of itinerant staff

5. Staff concerns • Nurses and therapists show higher rates of burnout and secondary stress due to their supportive care giving role • Nurses and staff who empathize with clients can share clients’ emotional reactions • Constant sharing of clients’ stress can lead to draining of emotional resources • Sleeping difficulty, emotional detachment, increased rates of job dissatisfaction. • (J. Watts, HICPRO 9 (27), www.hcpro.com, Strategies for Nurse Managers)

6. Mind Body Integration at Courage Center • Courage Center was experiencing similar issues in our organization.

7. Mind Body Integration at Courage Center • Matt Sanford is a paraplegic who has run an adapted yoga class for 10 years • He proposed training in mind body techniques for staff • Phase I started January 2008 with a 2 ½ day immersion weekend at Camp Courage • Project continued for one year

8. Mind Body Integration at Courage Center • Course was run as a research project so that data could be collected and shared more freely • The training model was a 2 ½ day immersion, 8 weekly 1 ½ hour session, • 8 monthly 1 ½ hour sessions • Data collected at beginning, 2 months, • 8 months, and 12 months

9. Mind Body Integration Research Project • The project was modeled as an initial intensive session (immersion weekend), which tapered over the year to less frequent interactions to support and maintain behavior change

10. Mind Body Integration Project at Courage Center • Weekly and monthly sessions focused on • Learning new techniques • Active problem solving about difficulties with implementation • Staff learning the process of relaxation and practicing it in their daily interactions

11. Mind Body Integration Research Project • Data was collected across a variety of areas because we weren’t sure what the results would be. • Job Stress Survey • Workplace Satisfaction Survey • Physical measures of HR, BP and flexibility • Flanagan Quality of Life Survey • Commitment to profession and employer • Measures of use of the techniques • Qualitative measures

12. Pre-Test Data Areas of Concern • Commitment to the profession and commitment to the organization were very concerning. • 62% of participants reported that they had seriously considered leaving Courage in the last year • 28% had seriously considered leaving their professions in the last year

13. Pre-Test Data Areas of Concern • Job Stress and Job Pressure levels were high • Qualitatively, staff reported burn out, compassion fatigue, and being consumed by the emotional experiences of their clients • Staff turnover high

14. Mini-Lab

15. Staff Impact of Mind Body Integration • Program was initially promoted to staff as a client-care technique • Staff soon came to realize that it was important for self care • Staff reported improvements in health and coping after using the techniques on themselves

16. Staff Impact of Mind Body Integration • Other staff noticed changes, and wanted training themselves • This built momentum for the Phase II group of staff to start the program in November 2008

17. “My treatments have changed because I am able to treat with better compassionate boundaries without giving too much of myself. Prior to this experience I feel that I gave too much of myself while trying to “fix” my clients. Now that I am able to establish the rapport and work as hard as my clients do, I can let them know that I am there for them and willing to put in 100% if they are too. I don’t feel as tired and burnt out when I finish a treatment session.”

18. Applications to therapy • Staff found that focusing on client concerns and slowing down treatment improved their outcomes • Using these techniques, staff were better able to understand what their clients were feeling without owning those client experiences • Staff reported doing fewer activities during a session, but getting better results

19. Applications to therapy • Staff also felt that they could more effectively teach clients to manage some of their own concerns • Clients recognized the benefits of these techniques and requested them • Clients reported practicing these techniques on their own

20. “A client I’ve been working with had sustained SCI, along with multiple orthopedic injuries … Consequently, he experienced significant pain in his low back, knees and feet. He initially had frequent complaints of low back pain, which limited his participation in therapy. One day we worked on having him ground his feet and elongate his spine, then added deep breathing with eyes closed and facial muscles relaxed. Almost immediately, he noticed a decrease in low back pain. He continues to use this simple technique for pain management and it has contributed to greater activity tolerance and less reliance on pain meds.”

21. Applications to Client Care • Integrated these techniques into nursing interactions with clients • Particularly helpful as integrated into a pain management project • Staff were taught to use these techniques as a part of relaxation, increasing sense of control, and focusing on self awareness.

22. How Mind Body Integration works at Courage Center • Client Centered care and Relationship Based care • While Courage Center has always been a client-centered organization, this project allowed us to integrate that concept more completely.

23. Examples of Client-Centered Care “I feel less pressured to obtain specific results using specific interventions and I’m noticing [that] the more I invite the client to make decisions regarding their treatment and their priorities, the better outcomes we have during each treatment session. When the treatment becomes more of a partnership than an intervention I provide to the client, we are both more energized and positive about the experience.”

24. Outcomes from the Project

25. Use of Techniques • At the conclusion of the Mind Body Integration Project, staff reported frequent use of these techniques • Staff reported using these techniques with an average of 61 to 80% of their client interactions. • This is a high rate of use of the techniques, and implies that it is useful with a wide range of clients

26. Workplace Satisfaction

27. Workplace Stress • While the frequency of stressful events remained the same, the severity and the effects of these stressful events decreased • This suggested that the environment had not changed, but staff’s ability to manage in that environment was improved

28. Commitment to Courage Center and to the profession

29. Significant Improvement in Quality of Life • Primarily due to • increased satisfaction with close relationships with spouses or SO • with helping and encouraging others • learning • participating in active recreation

30. Staff Perspective on the Project The desire to bring this cultural change to the larger organization was evident in the words of one participant who said, “I want as many other therapists as possible to experience this and reclaim the reason they became therapists.”

31. Qualitative Findings – Four Themes • Increased awareness of the need for self care • Compassionate boundaries • Renewed commitment to client-centered focus • The change in the culture

32. Mind Body Integration at Courage Center • Through the Phase I and into Phase II, staff report changes in expectations and interactions, both with clients and with other staff. • This change in culture is difficult to achieve, and would not have occurred without the prolonged support of the training program

33. Problems with Project • This model of training did not work for nursing staff because of the way their work is scheduled • We needed to design a model specifically for nursing staff • We also needed to design a training model for everyone else in the organization • Less intensive • Less hands-on

34. Future of Mind Body Integration at Courage Center • Phase II Project • Phase III Project

35. Phase II • Trained 27 staff, primarily therapists • This project started in November of 2008, and will complete in October of 2009 • Funding for Phase II was obtained through philanthropy, partly because we had data to demonstrate change • Although we have not completed the project, it appears that this phase will be as effective as Phase I

36. Phase III • Funding for this Phase raised through philanthropy • Will focus on nursing • Will be designed around nursing staffing requirements • Introduction, two full day sessions, and • five-six monthly two hour sessions.

37. Future of Mind Body Integration at Courage Center • We are trying to use more of our own staff, and less external staff, so that this becomes self-sustaining • We are examining the possibility of doing training for other organizations to help spread the techniques elsewhere.

38. Questions? Answers? kathie.nichols@couragecenter.org nancy.flinn@couragecenter.org