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SUPPORTING RESILIENCE WHILE PREPARING FOR DISASTER-RELATED STRESS INSIGHTS FROM THE HEALTHCARE SECTOR

ROBERT MAUNDER MD FRCPC PROFESSOR, DEPARTMENT OF PSYCHIATRY UNIVERSITY OF TORONTO HEAD OF RESEARCH, DEPARTMENT OF PSYCHIATRY, SINAI HEALTH SYSTEM

@boiby

PRESENTER DISCLOSURE • RELATIONSHIPS WITH COMMERCIAL

INTERESTS: NONE • I RECEIVE PROJECT SUPPORT AND

INCOME FROM MOUNT SINAI HOSPITAL, WHOSE PROGRAMS I WILL BE DESCRIBING.

• THE PROGRAMS I AM DESCRIBING ARE NOT COMMERCIAL PRODUCTS

“We”

HISTORY

In 2003 we were caught unprepared for the SARS outbreak

In Ontario

• About 400 were infected, 43% were healthcare workers • 25,000 were quarantined • 44 died, including 2 nurses and a family physician

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“The worst day was when I came home after 12 hours of working with the sickest SARS patients to find out my son, age 5, had a high fever.”

Healthcare worker, Participant in The Impact of SARS Study

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“During SARS a nurse died and I can't believe how close it hits home. Thinking to myself, that could have been me. She only worked one floor below me… … the situation with SARS changed the way I see things now with work and with my personal life.”

Healthcare worker, Participant in The Impact of SARS Study

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IMPACT – DURING THE EVENT

High acute stress is very common • Highly studied • Typically, prevalence of high distress “cases” is ~35%

• Uncertainty • Inconsistent communication • Personal risk & family risk • Impediments to support • Unfamiliar duties and tasks • Unequal distribution of risk and burden

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IMPACT – AFTER THE EVENT

Almost no new psychiatric illness • No overall increase in PTSD, new onset depression, anxiety

disorders or substance abuse • Important exceptions are persons with prior vulnerability &

“hotspots”

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IMPACT – AFTER THE EVENT

Significant increase in markers of chronic work stress • High burnout (emotional exhaustion) scores

• 30% SARS vs 19% non-SARS hospitals • Increase in smoking, drinking, OTC drugs, behaviour that

could interfere with relationships • 21% SARS vs 8% non-SARS hospitals

• Intention to decrease patient contact, hours or change jobs • Sick days

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“This stress research is all very interesting, Bob, but who is going to pay my LCBO bill?”

Healthcare worker, Colleague in the hallway

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MORE SIGNS OF STRESS → LONGER DURATION OF PERCEIVED RISK

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FACTORS ASSOCIATED WITH BETTER LONG-TERM STRESS-RELATED OUTCOMES Strong protective factors

• Effective training and support • Years of healthcare experience

Modest protective factors • Working in intensive settings: ICU, ER • Having family at home (in spite of increase in short-term

stress) • Young children • Married or common-law

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PREPARATION = BUILDING RESILIENCE

Organizational Resilience Individual Resilience

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WEAK EVIDENCE FOR INTERVENTIONS Work- and person-directed interventions to prevent stress at work in healthcare workers 54 RCTs and four controlled before-after studies, with 7188 participants.

Individual interventions

• CBT +/- relaxation (20 studies) • No more effective than no intervention at 1 month • Better than no intervention at 1-6 months or later (↓ 13% relative risk)

• Mental and physical relaxation (20 studies) • Inconsistent. More effective than no intervention in some studies, two studies find little

difference between massage and taking extra breaks. Organizational interventions (20 studies)

• Changing schedules (2 studies) reduced stress. • Other organizational changes were not more effective than no intervention

Most studies were of low quality: small N, short follow-up, publication bias, lack of precision

Ruotsalainen et al., Cochrane Review, 2015

@boiby

ORGANIZATIONAL RESILIENCE Foster individual resilience & well-being Provide training

Skills anticipated during disaster working in new capacity, providing support etc.

Maintain reserves Material reserves - equipment Back-up & succession planning

Social support Far more effective when it occurs within existing

relationships Build “relational reserves”

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ORGANIZATIONAL RESILIENCE Develop characteristics of resilient organizations

Magnet hospitals Horizontal org chart RNs in executive Local decision-making High RN:patient ratio

Organizational justice Fair and transparent policies

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ORGANIZATIONAL CULTURE “Culture eats strategy for lunch” Leadership

• Visibility, engagement • Effectiveness • Active concern, empathy • Listening & valuing the ideas and perception

of those at the front line • Identifying natural opinion leaders, champions

of a healthy system Communication

• Effective, timely, accurate, transparent, accessible

@boiby

EVIDENCE-BASED APPROACHES TO BUILDING INDIVIDUAL RESILIENCE

Resilience is fostered by •support (vs. isolation) • feeling well-trained •reflection (vs. reaction) • tolerance of uncertainty • flexibility about approaches to coping

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CASE EXAMPLE MOUNT SINAI HOSPITAL APPROACH TO BUILDING STAFF RESILIENCE

@boiby

INDIVIDUAL RESILIENCE - INTENDED OUTCOMES

• Familiarity with normal stress response • Familiarity with an approach to coping • Reminders of previous successful coping • Information exchange • Access to supportive resources • Subjective sense of being prepared/well-trained • ↑ self-efficacy • ↑ interpersonal effectiveness

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INDIVIDUAL RESILIENCE

Minimal intensity => wide-reaching Moderately intensive => focussed Higher intensity => personalized

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MINIMAL INTENSITY, WIDE APPLICABILITY AN APPROACH TO COPING

We teach an evidence-based approach to coping using many modalities Folkman & Greer’s 3-step approach to coping

• Problem-solving: Do things to fix the problem • E.g. optimize self-care • E.g. learn about the stressor

• Emotional coping: Do things to feel better about what you can’t fix

• E.g talk to others when it feels safe and helpful • Meaning-based coping: Do things to endure suffering that you

cannot change • E.g. personal values, shared moral purpose

@boiby

7-minute video “chalkboard talk” on coping

@boiby

Photos used with permission from Mount Sinai Hospital

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MODERATE INTENSITY, FOCUSSED EXAMPLE: CLINICAL IN-SERVICE

Team-led • Often co-facilitators from psychiatry and

affected service Specific information about the stressor Enhance information Teach approach to coping

• Enhance self-efficacy Offering a conduit for communication back to

senior management • Engage in feedback, enhance collaborative

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MODRERATE INTENSITY, TAILORED TO SPECIFIC EVENTS EXAMPLE: SUPPORT HUDDLES

Critical incidents Consultation with managers Huddles with staff Availability to individuals

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HIGHER INTENSITY, PERSONALIZED EXAMPLE: THE STRESS VACCINE

@boiby

Photo used with permission from Mount Sinai Hospital

HIGHER INTENSITY, PERSONALIZED EXAMPLE: THE STRESS VACCINE Goal is to teach

• Reflective thinking • Effective interpersonal skills • Coping strategies

Personalized • Individual traits, preferences and style

Experiential • Reflective interaction around realistic workplace video

scenarios Individual

• At your own pace

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THE STRESS VACCINE 20 minute interactive online modules • Didactic learning • Assessment + feedback

• e.g. Coping style • e.g. Interpersonal problems

• Video scenarios + post video reflective exercises tailored to individual challenges

• Exercises to encourage reflecting on communication in recurrent interpersonal conflicts from both sides

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INTERACTIVE REFLECTIVE EXERCISES Watch a video scenario and imagine yourself in the scene Describe how you might respond (on a good day/on a bad day) and how someone else might respond Follow a guided sequence of personal responses and reflections on those responses

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INTERACTIVE REFLECTIVE EXERCISES

“What is going on here?!”

Photo from The Stress Vaccine, used with permission from Mount Sinai Hospital

IMPACT OF STRESS VACCINE Improved self-efficacy Improved confidence in training & support Reduced interpersonal problems Improved coping (in those who start with maladaptive coping)

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SUMMARY Disaster events can cause long-term increases in stress-related problems for healthcare workers

Evidence for effective preventive interventions is of low quality and results to date are modest.

Building resilience can be focused on individual and organizational factors. It makes sense to do both.

Many of the contributors to the harmful consequences of workplace stress are interpersonal.

• Interpersonal interventions can be pitched at different levels of resource intensity.

• Interactive technologies may complement interpersonal interventions.

@boiby