Fact-File 32: Cultivating – the role it plays in self-care and stress-relief... Extracts from a presentation for

Healthcare is rewarding. We’re uplifted by stories Our Putting Patients First Clinics centre on 5 of recovery, renewal, and . Yet it’s principles to cultivate what we call the 3-C’s: also occupationally highly prone to stress and burn- Caring, Connecting and Compassion’. out. Daily heavy-duty demands, over-loaded schedules and a sheer sense of -and-hurry can Some clinicians remain convinced there’s no time leave us exhausted and drain our reserves of for compassion. Yet that’s what great carers do resilience, caring and compassion. We’re in make time for. Others see compassion as a kind- healthcare because we care. But how do we care hearted, soft-headed response that gets in the for ourselves? We can feel unsupported and way of good clinical practice and has little impact isolated ourselves as stress and toxicity take their toll on our emotional and physical well-being. We on patient outcomes. Emerging research says the all need to find ways to re-energise and renew opposite: the compassion that comes with the ourselves in body, mind and spirit. That’s what this mindful act of putting patients first, not only has LC4HC Forum is about – and in this factfile we look direct impacts on clinical and patient outcomes at how cultivating compassion can help... but also contributes to more emotional balance and less stress amongst healthcarers. Compassion – the caring core Compassion is a conscious choice to understand, Compassion seems to be an and emotionally identify with, someone’s plight – enduring value in healthcare. patient, workmate, friend, foe or stranger and Patients expect it by virtue of want to do something about it. It’s benevolence - the fact we work in health. Yet doing small acts of for others, regardless there’s growing concern that of how they treat you. It’s a warm face, human touch, a small piece of comfort or simply being despite healthcare’s bio- there supportively. It’s selfless: putting other’s technical sophistication, it’s faltering, as Robin needs first, without ‘favour-trading’ or expecting a Youngson says, at the basic level of caring and return and it’s being unconditional. You act this compassion. While it’s wrong to say a majority of way to all. Finally, it’s committed action: being clinicians don’t display compassion, do we pay generous and willing to act to alleviate and less heed to it these days? Compassion should where you can. be core to caring, but it’s often absent. Many in healthcare have not embraced the value Will compassion make a come-back or will it be of compassion for their patients and certainly not swamped in a tidal-wave of medical technological for themselves. Here’s some of the many reasons detachment? A prime focus for the overhaul of the for compassion aversion: UK Health System is to create a culture of compassion. The reaction of many in healthcare  A belief that staying clinical is what good to pleas to be more compassionate is dismay. In professionals do. They don’t deal with or our minds, this is what we do day-in and day-out. display and compassion is seen as giving into or being overly sympathetic We all like to think we’re compassionate, but we all know there can be a big gap between what we  Healthcare people are naturally gifted with say we value and how people behave. Some high levels of compassion. Patently not true. cultures militate against compassion. Clinicians  Many overly-empathetic clinicians are at who openly display compassionate values may be risk of burnout – that it’s safer to maintain ridiculed by compassion-hardened comrades. . Others notice the adverse influence of medical regimes where speed or through-put is rewarded. Compassion-Fatigue Myth Compassion Aversion It’s a mistaken belief too much causes There’s a widespread belief ‘compassion-fatigue’ and clinicians must stay stoic and clinical detachment is the keep at bay. Hospital way to defend against the cultures tell staff to “harden up, stress of caring too much. leave emotions at home or put a This reflects a basic misapprehension of what teaspoon of cement in it!” It’s confusing how these compassion fatigue is that has grown into a emotionally-hardened cultures seem to put up damaging myth. more easily with dysfunctional emotions like irritation, or abruptness than with empathy  Compassion fatigue isn’t a myth. What is a and compassion? myth is that compassion causes it. It is really

Copyright  Bill Cropper 2013------ 1 Please respect our copyright. You may reproduce small quantities of this document within your own work unit for learning exchange, provided due acknowledgement appears on all copies and any materials derived from it. Fact-File 32: Cultivating Compassion – the role it plays in self-care and stress-relief... Extracts from a presentation for

traceable to stress overload, overwork, poor detect a degree of resigned of bad self-care and inability to insulate ourselves behaviour (“that’s just the way they are”) – to put it from the effects of toxic emotions down to stress and strain of the job, shift or patient overload, lack of sleep, or other  Compassion fatigue isn’t caused by having justifications that don’t change the bottom line for too much compassion. It’s having too little. colleagues or patients finding themselves on the Experiences of those who are compassionate wrong end of unfettered . is that they increase their resilience. Toxic emotions you generate or pick up from  Combating compassion fatigue means not others, leave a residual that can slowly penetrate cutting compassion, but working on emotional our defences. Repeated bursts of adrenaline and self-management (and other stress-relieving) cortisol begin to wear down our immune system strategies to help process toxic emotional leading to physical and mental ill-health. encounters, retain emotional balance and build resilience. “Strong negative emotions such as anger, , When compassion, an that buoys, uplifts , or despair can be particularly toxic to and restores, is stifled, and we feel forced to cut the human body and the immune system’s or curtail it, it leaves us more vulnerable to the ability to protect it...contagion can be negative or stress effects of toxic emotions. positive and emotions experienced by one person can be absorbed by the person who attempts to help. Trying to ease another’s pain might prove a “Compassion fatigue or, 2ndary traumatic stress psychological and even physiological threat to the disorder, is characterised by a gradual lessening of handler, who might become vulnerable to the same compassion over time. Compassionate patient emotional pain.” Peter Frost Toxic Emotions at Work relationships can protect clinicians against stress, HBR 2003 pp. 3-6 burnout, substance abuse, and even suicide attempts” Shanafelt, TD. "Enhancing the Meaning of Work: A Prescription for Preventing Physician Burnout and From Stress to Distress Promoting Patient-Centered Care." Journal of the American Medical Association, 302, 2009:1338-1340) Healthcarers deal with dramas every day: death and dying, conflict with colleagues, heavy Toxic Emotions workloads, pressures to get results. Stress is a natural bodily response to tense situations. It’s an Brain-wise, our immune system is emotional reaction first and EI plays a big role in wired to our emotions, which is how we cope with it. germane to understanding why  Short term stress is good. Measure this over compassion’s a key practice for minutes. Long term stress is bad. Measure patients and health-carers alike. over months. over prolonged  When emotions are up we’re resilient and periods drains energy, liveliness and makes resistant. If we’re down, our immune system you feel exhausted, distracted, irritable or gets depressed and more vulnerable. If we forgetful and lead to feelings of hopelessness. manage moods well, we’re buoyant, positive,  When stress levels go into the red, chemicals supportive and connective. Patients feel that energised and made us alert, like cortisol supported and we feel better too. and adrenaline, work in reverse. They build  It helps us handle stress and stay balanced up in our system – drain us, fatigue sets in, too. But bad moods are equally infectious. If we can’t focus, increases, we feel out you’re abrupt, people may be rude back. If of control. you’re cranky, you infect others and they treat you the same. Toxic emotions festering in your facility can often go unchecked. People coming to work constantly cranky can create a toxic climate if this continues over the long term. It’s far too common to hear people in health talk of toxic workplaces and tell stories of emotional outbursts, caustic comments, disruptive emotions or counter-productive behaviours. It’s even more uncomfortable to

Copyright  Bill Cropper 2013------ 2 Please respect our copyright. You may reproduce small quantities of this document within your own work unit for learning exchange, provided due acknowledgement appears on all copies and any materials derived from it. Fact-File 32: Cultivating Compassion – the role it plays in self-care and stress-relief... Extracts from a presentation for

 These feelings affect behaviour. We start Emotional strategies don’t stop us from relating in scratchy ways – snapping at people having emotional reactions to distressing events as we start snapping on the inside. We feel or daily pressures – our emotional circuitry still the job or those around us are demanding too registers them as bodily sensations. The reverse much, which eats into our relax-time and is actually true. Closing down can leave us more physical or other pursuits that kept us open to catching them. balanced – and we go into meltdown. Human Moments are Connective  To combat our distress, we work harder, schedules begin to drive us – or we withdraw We’re born to connect. It’s a basic, into our shell, distance ourselves and stop primal urge hard-wired into every connecting – the one way we derive support single synapse. It’s a badge of our in stressful moments. basic humanity, and it’s vital for emotional and physical well-being. None of this is sudden. It’s insidious and slow. We ignore wake-up signals and rationalise our Connective moments are times our dissonant behaviour. We make excuses, blame or limbic system tunes into another find fault with others for our feelings and person’s. It may only be a moment but tension behaviour. The stress and pressure medical staff leaves their bodies as they incline toward each work under, leads to more caustic behaviour and other and an aura of relaxed attentiveness toxic work climates, as others catch our distress. pervades. Connective moments too easily slip past our notice amidst daily pressures, “Physicians report alarming levels of professional distractions and busy-ness but when it comes to and personal distress. Up to 60% report symptoms caring both for our patients and ourselves, of burnout, defined as , connecting, caring, and compassion serve us well depersonalisation (treating patients as objects), in many practical ways. and low sense of accomplishment. Physician burn- out has been linked to poorer quality of care, including patient dissatisfaction, increased medical “A human moment doesn’t have to be emotionally errors, lawsuits and decreased ability to express draining or personally revealing. A 5-minute empathy.” Michael Krasner et al American Medical conversation can be a perfectly meaningful human Association Sept 29-30 2009 vol 302 No 12 moment. To make the human moment work, you have to set aside what you’re doing and focus on the person you’re with. Usually when you do that, The Cure of Compassion the other person will feel the energy and respond Not everyone reacts to stress the in kind.” Edward M. Hallowell “The Human Moment at Work” in Harvard Business Review Jan–Feb 1999 same way. Some control the stress response better than others and often seem more Research shows connective moments can calm, robust, calm and controlled. restore and heal. Their underlying chemistry is Research shows compassionate compelling evidence for why they’re such a great clinicians have the least risk of burnout. It seems stress reliever. Being connective can head-off to shield us from toxic emotions, helps us stay emotional outbursts, cool-down situations and less stressed and builds resilience. keep us emotionally balanced in the face of . Clinicians lacking in connectivity and “Positive emotions such as compassion have a compassion often act in ways that antagonise decidedly constructive effect on neurological colleagues and patients alike, generating negative functioning, psychological well-being, physical emotions that boomerang to infect them and health and personal relationships Consciously create contagious stress-creating circles. engaging emotions such as hope and compassion, counters the physiological and psychological harm done by stress.” McKee, Boyatzis & Johnston Becoming a Cultivating Compassion Resonant Leader p.38 Everyone knows about  We call this emotional insulation. It’s a way to neuro-plasticity by now, avoid catching bad feelings from patients, how our brain changes colleagues or traumatic events. according to what we do with it and what we expose it to. It attracts new  By contrast, if we detach, distance or neurons to whatever brain-part is being used for a depersonalise we make matters worse. We certain thing to strengthen it – a bit like going to call this ‘emotional isolation’.

Copyright  Bill Cropper 2013------ 3 Please respect our copyright. You may reproduce small quantities of this document within your own work unit for learning exchange, provided due acknowledgement appears on all copies and any materials derived from it. Fact-File 32: Cultivating Compassion – the role it plays in self-care and stress-relief... Extracts from a presentation for the gym to develop muscles. This in turn affects  If compassion is a long-reach, try equanimity our thinking, behaviour and emotional habits. or even-mindedness (this is not the same as neutrality, indifference or detachment) where “The experience of all who empathise deeply and you keep your judgement filters switched off bring open-hearted compassion to their work is and just be curious, concerned and helpful. that they increase their store of . Empathy, compassion and loving kindness have a biological  Emotional regulation can curb destructive basis. The daily practice of compassion may emotions like anger, irritation, indifference, or immunise the practitioner from negative emotions busyness which are blocks to compassion. and diminish the risk of burnout.” Youngson Compassion in Healthcare NHS Paper #2 May, 2008  Compassion can be deepened by reflection. At the end of each day, reflect on significant While we have a natural capacity for compassion, interactions and diary-note events. Notice cultivating it doesn’t just come naturally. Like most what happens in mind and body as you do things, we have to work on it and integrate it into But the most simple way to show compassion is in our practice. You can train your brain to tune in to conversations we take time to have. Bringing compassion and get better at being in this space. others into your space of kindness, tolerance and Richard Davidson’s FMRI studies at Madison- understanding may make momentous differences Wisconsin confirm that regular practice, can alter to a patient, colleague or for you. The most real brain function, improve temperament, adjust our manifestation of compassion is being willing to emotional style and make ourselves more act in terms of benevolent attitude and resolved compassionate. determination to help others. Ultimately, compassion is seeing everyone as essentially human – like you, despite their foibles. It’s a sincere wish for everyone to be well, happy or free from pain and suffering, without exception. The Buddhists say the only mental state in which you can make clear, accurate perceptions is compassion – fully engaging the heart as well as the mind. So we’d better get more skilled in using our in our roles as health professionals, rather than think we can leave emotions in a corner. But how do clinicians cultivate compassion? If we want to increase it, we need to practise acts that And since emotions are contagious, the stimulate those neuronal pathways that enable that comes with compassion spread to others compassion. For example: around you. Your stress will be less, your focus will be clearer, your interactions will be more  Mindfulness meditation (focussed attention caring and respectful and your compassion may exercises if you like) can nudge you to the well be recalled by patients as the moment their positive end of the spectrum on the resilience real healing began. scales and activate the insula that links to compassion. Sydney Uni Medical Faculty recommends it for stress-relief and Harvard Medical School runs a meditation course for The Change Forum runs awareness programs on clinicians on cultivating compassion. Putting Patients First: Caring, Connecting &  If meditation is too menacing, try training your Compassion in Healthcare. Our suite of programs brain for a daily act of spontaneous kindness. also includes emotional intelligence, dealing with difficult discussions, compassionate leadership, As you fall into this habit you begin to notice building respect and resilience. Visit on-line or others may respond to you more generously. contact Bill Cropper:  Go out of your way to connect with patients : 07-4068 7591 or 0429-687513 and colleagues. It isn’t compassion but it’s a : http://www.thechangeforum.com step toward it and those connective moments : [email protected] certainly have a calming effect as we’ve seen.

Copyright  Bill Cropper 2013------ 4 Please respect our copyright. You may reproduce small quantities of this document within your own work unit for learning exchange, provided due acknowledgement appears on all copies and any materials derived from it.