Welcome to the 2009 Academic Heads' Conference "Practical Leadership"

1. Welcome to the    2009 Academic Heads' Conference "Practical Leadership"

2. Dr Craig HassedDeputy Head of DepartmentDepartment of General PracticeSchool of Primary Health Care Creating and sustaining healthy workplaces for optimal performance

3. Outline • Three dimensions of workplace stress • Functional reserve • Self-care • Mindfulness • Emotional regulation • Positive psychology • Appreciative inquiry • Strengths • Feedback • Speeding up team learning • Wood and stone

4. HIGH STRESS Low Low Control Support High High Low DemandHigh LOW STRESS KARASEK AND THORELL STRESS AT WORK

5. Control • External locus: control of events going on around us • Internal locus: given events are the way they are, do we have control over our response to or attitudes about those events? • Internal control far more important for lowering stress and effective response

6. Support • Informal: a culture of support and collegiality, availability • Formal: debriefing, methods of reporting, procedures…

7. Demands • Moderating demands • Improving capacity to meet demands • Work or study methods • Focus • Efficiency • Priorities • Examining perception vs. reality of demands

8. Functional reserve • Our bodies and all the organ systems in them have far more capacity than is required for mere survival • The extra capacity (e.g. 75%) is called functional reserve • When we have lost that functional reserve then there are measurable changes and symptoms • By the time this occurs a disease process is already well under way

9. Functional reserve 100% Normal ageing Kidney function Loss of function 50% 30% Symptoms 20% Death 20 50 60 70 years Age

10. Functional reserve in the workplace • Workplaces, operating under the constraints of scarcer resources, shorter timeframes and smaller workforces, combined with escalating expectations, generally have little or no functional reserve left • This means that it is common to be operating on a daily basis on the extremes of performance where it takes relatively small events (insults) to push the system into crisis (disease) • It also means that important but ‘non-urgent’ activities like creativity, reflection and renewal are almost constantly marginalised and neglected

11. Education Stress management Spirituality Exercise Nutrition Connectedness Environment The ESSENCE of health

12. An exercise in attention • We will watch a short piece of footage • Please remain completely quiet and do not speak throughout this task • Task is to pay attention • See if you can count how many times the team in the white shirts pass the basketball

13. Attention Deficit Trait • Newly recognized neurological phenomenon: attention deficit trait (ADT) • Response to hyperkinetic environment • Trying to deal with too much input, results in: • Black-and-white thinking; perspective and shades of grey disappear • Difficulty staying organized, setting priorities, and managing time • Feel a constant low level of panic and guilt • Hallowell EM. Overloaded circuits: why smart people underperform. Harv Bus Rev. 2005 Jan;83(1):54-62, 116.

14. Mindfulness • The faculty of voluntarily bringing back a wandering attention over and over again, is the very root of judgment, character, and will. No one is compos sui if he have it not. • William James, Principles of Psychology, 1890

15. Stress Anxiety Depression Eating disorders Panic disorder Symptom control Coping Chronic pain Neural plasticity Immune modulation Anti-inflammatory Enhancing immunity Behaviour / lifestyle change Sleep Down-regulating stress genes Longevity/survival? Clinical applications of mindfulness Results suggest that MBSR may help a broad range of individuals to cope with their clinical and non-clinical problems. Grossman P. J Psychosomatic Research. 2004;57(1):35-43.

16. Mindfulness and doctor wellbeing • An 8-week mindfulness program: improvements on all measures of wellbeing including: • Mindfulness • Burnout (emotional exhaustion; depersonalization; personal accomplishment) • Empathy and responsiveness to psychosocial aspects • Total mood disturbance • Personality (conscientiousness; emotional stability) • Improvements in mindfulness correlated with improvements on other scales • Krasner MS, Epstein RM, Beckman H, et al. JAMA. 2009 Sep 23;302(12):1338-40.

17. Mindful practice • Mindfulness is essential underpinning for self-monitoring • “Mindful practice is conscious and intentional attentiveness to the present situation – the raw sensations, thoughts, and emotions as well as the interpretations, judgments and heuristics that one applies to a particular situation.” • Avoids automatic pilot • Epstein R, Siegel D, Silberman J. Self-monitoring in clinical practice: a challenge for medical educators. J Cont Educ Health Prof 2008;28(1):5-13. • Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Fam Syst Health . 2003;21: 11-17.

18. Self-monitoring • Self-monitoring leads to: • Early recognition of cognitive biases • E.g. case of Anne Dodge • Avoidance of technical errors • E.g. drug dosage • Awareness of emotional reactions • E.g. dislike or bias against a patient • Facilitation of self-correction • Development of therapeutic relationships • Epstein R et al, 2008

19. Mindfulness and cellular ageing • Meditation may slow genetic ageing and enhance genetic repair • “...we propose that some forms of meditation may have salutary effects on telomere length by reducing cognitive stress and stress arousal and increasing positive states of mind and hormonal factors that may promote telomere maintenance. Aspects of this model are currently being tested in ongoing trials of mindfulness meditation.” • Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Ann N Y Acad Sci. 2009 Aug;1172:34-53.

20. Performance Peak performance “The zone” Restful alertness High performance Poor performance / burnout Stress Inertia Stress-performance curve

21. Emotion, decision making and the brain • Negative emotions affect the prefrontal cortex • Monopolises attention on self and emotional state: loss of focus (middle part) • Inhibits the ability to generate actions (motivation) and make decisions (outer part) • Impairs the ability to process information

22. Performance Peak performance “The zone” Restful alertness High performance Poor performance / burnout Stress Inertia Stress-performance curve

23. “Attentional blink” • Limitation in information processing: time gap in being able to identify and consolidate a stimulus in memory • Second stimulus often not detected • Person vulnerable to distractor interference • http://www.cs.kent.ac.uk/people/rpg/pc52/AB_Webscript/blink.html • 3 months of mindfulness-based attentional training reduced the attentional blink and improved the ability to select goal-relevant information from various sensory inputs • Slagter HA, Lutz A, Greischar L et al. Mental training affects distribution of limited brain resources. PLOS Biology 2007;5(6):e138. doi:10. 1371/journal.pbio.0050138

24. MRI assessed cortical thickness in long-term mindfulness meditators Brain regions associated with attention, interoception and sensory processing thicker in meditators than matched controls Including prefrontal cortex Might offset age-related cortical thinning and “evidence for … cortical plasticity” Lazar SW, Kerr CE, Wasserman RH, et al. Neuroreport. 2005;16(17):1893-1897. Mindfulness and the brain

25. Vicarious stress among healthcarers • Health workers experience work-related stress especially e.g. in cancer care • Terminologies: burnout, compassion stress, emotional contagion, ‘the cost of caring’ • Vicarious traumatisation: “a process through which the therapist's inner experience is negatively transformed through empathic engagement with client's traumatic material.” • Affects individuals who are present and those with whom they discuss experiences • Sinclair HA, Hamill C. Does vicarious traumatisation affect oncology nurses? A literature review. Eur J Oncol Nurs. 2007 Sep;11(4):348-56.

26. Mindfulness and compassion • Limbic brain regions implicated in empathic response to another's pain • Activation of brain regions associated with compassion greater in expert meditators • Embracing another’s pain with compassion and acceptance rather than stress vital to prevent carer-fatigue • Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. PLoS ONE. 2008 Mar 26;3(3):e1897.

27. Emotional Intelligence • Mindfulness related to aspects of personality and mental health • Lower neuroticism, psychological symptoms, experiential avoidance, dissociation • Higher emotional intelligence and absorption • Baer RA, et al. Assessment.2004;11(3):191-206.

28. Emotional intelligence and burnout • Burnout inversely related to EI • Lack of emotional control, emotional recognition and expression, and understanding of emotions significant predictors of burnout • Benson S, Truskett PG, Findlay B. ANZ J Surg. 2007;77 Suppl 1:A79.

29. Appreciative inquiry • Feedback tends to far more often focus on negatives rather than positives • Home, work, personal… • Focuses attention on what’s wrong rather than what’s right • Can increase anxiety, reduce motivation, slow learning and not build on strengths especially if feedback is delivered in a personally confronting way rather than objectively

30. Attending to strengths • Pay more attention to what we do well • Focus on strengths → greater engagement (flow experiences), well-being, performance and productivity. • Not saying to ignore weaknesses – do enough so that they do not get in your way or undermine your strengths • J Mitchell

31. Identifying strengths Energy: What activities give you a buzz? Ease: What activities come naturally to you? Authenticity: When do you feel most relaxed, like you are ‘being yourself’’? Motivation: What activities do you simply love to do? J Mitchell

32. Rewarding process or outcome? • Studies on the subsequent learning of children who were either praised for outcome or for effort and process • Praising outcomes not necessarily helpful • When subsequently presented with a more difficult task these children more likely to get frustrated and give up if they don’t easily get the desired outcome • These children come to prefer easier (achievable) tasks • Children who were praised for effort and process are more likely to subsequently persist with difficult tasks, enjoy learning more and learn quicker

33. Speeding up team learning • Studies performed on cardiac surgery units • Which teams: • Learned most quickly • Assimilated new technologies • Made fewest mistakes • Reduced procedure times • Enjoyed their work the most • Wasn’t the team necessarily lead by most eminent surgeon • Edmonson A. et al. Harvard Business Review 2001;Oct:5-11.

34. Speeding up team learning • Designing a team for learning • Framing the challenge • Creating an environment of psychological safety • Learning leaders

35. Speeding up team learning • Designing a team for learning • Competence • Ability to work with others • Ability to deal with ambiguity • Confidence in offering suggestions to senior members • Keeping team intact

36. Speeding up team learning • Framing the challenge • Characterise taking on new technology (learning) as an organisational challenge not a technical one • Requires new ways of working together not just learning a new skill • Acknowledge the challenge on all members • Can either feel inspired to be part of something new or resistant (ignored)

37. Speeding up team learning • Creating an environment of psychological safety • Learn through trial and error • Work on ‘real-time learning’ not just waiting for post-hoc formal review • Neutralising fear and embarrassment • Comfort with making suggestions, trying things, pointing out potential problems, admitting mistakes

38. Speeding up team learning • Learning leaders • Be accessible • Ask for input • Serve as a ‘fallibility model’

39. Wood and stone • Universities are not made up of wood and stone but rather the human natures of the people within the university • Apologies to Plato (The Republic)

40. Wood and stone • If the primary focus is on buildings, balance sheets, performance indicators and such like at the expense of the relationships, humanity, creativity and inspiration of the people working within the institution, it not only diminishes the experience of the staff, but also imperils the sustainability and quality of the performance that those things are meant to enhance.