Upload
sabrina-hill
View
215
Download
0
Embed Size (px)
Citation preview
WHAT DOES ‘CARE’ MEAN IN HEALTH CARE
AND WHAT CAN WE DO TO IMPROVE IT?
Dr. Justin BrophyFRCPsych
Before we begin:
Dimensions of Care
Attentiveness
Right Intention
- Compassion
Interconnection
LET’S LOOK AT THE PROBLEMS AROUND
COMPASSION
Some Basics
Empathy is the emotional response to others
Compassion involves an authentic desire to help.
a capacity to meet pain with "kindness, empathy, equanimity and patience",
both in ourselves and in others.
5
“There is no compassion left in the NHS”
the Francis report
at Stafford Hospital identified a lack of compassion
as being amongst the major causes of negligence.
6
“Recent scandals”
At Winterbourne View,
vulnerable people were mocked
and even tortured by staff
5
7
Public & Media - “Too posh to wash.”
“university trained nurses lack compassion
The prime minister seems to agree,
“nurses should serve their time as care assistants
before they even start their training”.
saying that "nurses should be hired and promoted on the basis of having compassion as a vocation and not just academic qualification".
8
According to a new national survey,
Compassion is Missing in American Health
Care
Schwartz Center for Compassionate HealthcareBy RICK NAUERT PHD Senior News Editor
September 9, 2011
9
Competing tensions
Caring CarefulIndividualisedPerson focusedExperience focusSpontaneous /
Flexible
Satisfaction focus
StandardizedTask FocusOutcome focusStandardisedRisk - Safety focus
As the Francis report notes:
“services can be time-pressured, accounts-driven, and job-threatening,
whereas compassion grows in compassionate, supportive environment”
The Guardian, Monday 1 April 2013 15
THE CONTRARY VIEW…………
Ebola volunteers
Ryanair example
There are effective, ways of ensuring that
crucial tasks are undertaken,
without relying on compassion
“It’s dangerous to rely on compassion as the motivation” to ensure that essential tasks are carried out......says the medical ethicist Anna Smajdor, “
http://www.bbc.com/news/magazine-22773043
“Lack of compassion has also become the new stick to beat the much-beaten NHS with.”
"The effort to become more empathetic
will only increase resentment and your sense of burnout“
‘Compassionate care' has become a new healthcare buzz-phrase, Threat and fear basically inhibit compassion and negatively impact on these systems. While it is very seductive to believe that you can threaten people into becoming compassionate, all the evidence is you cannot
and that you will make things worse.The Guardian, Monday 1 April 2013 20.59 BST
19
Peter Carter, head of the Royal College of Nursing
Nurses have been scapegoats in scandals
when the main problem is understaffing,
the recommendations that tend to get implemented
are the ones . . . that don’t have resource implications
http://www.bmj.com/content/348/bmj.g126
20
And we know
Selflessness and continually giving will provide a fast-track
to
burn-out, personal health problems,
emotional anguish, and mental weariness.
21
The most compassionate are often the most
impaired
22
The ‘Kindness Paradox’
We frequently work under conditions no other workforce
would tolerate
Why?
Compassion binds us
- but also blinds us23
WHY IS CARE LIKE THIS?
Those lacking compassion
Some Frankly Uncaring
DetachedIndifferentIntentionally so
26
Physicians, trained as biomedical scientists,
have focused on the diagnosis, treatment, and prevention of disease.3 In
the process,
cure, not care,
became the primary purpose of medicine 4,5
Ann Fam Med. May 2005; 3(3): 255–262
27
Care has become Sub-contracted
Most valued
- Professional
Least valued
- Carer
BMJ 2014
Inhibitors of compassion
Personal
Fatigue
StressOver-exposure Excess Demand
DepressionInjustice
InjuryTyranny/Bullying/Abuse
Systemic Inhibitors of Compassion
Fear OppressionBlameShameSystem mistrust
“Threat and fear basically inhibit compassion and negatively impact on these systems.
While it is very seductive to believe that you can threaten people into becoming compassionate,
all the evidence is you cannot and that you will make things worse”
Larger Stage of Shame
Public hearingsPublic ReportsMedia coverageInternet diffusionPersonal ImagesLegal & Regulatory Unforgotten
Effects all grades of offenders
100 GMC suicides
Contextual inhibitors of compassion
Contextual
Pay cuts & pay differentialsAgency staff
Turnover on unitsHostile Discourse
No Right of rebuttal / challengeIngratitude
Lack of time is another major impediment to compassion
An elegant experiment from 1973 observed the behaviour of 40 theology students in a situation inspired
by the Good Samaritan parable. Students walking between two buildings, on their way to give a talk,
encountered a shabbily dressed person slumped by the side of the road. Students in a hurry to reach their destination were more likely to pass by
without stopping.
The time pressure students were under was the only factor that significantly influenced whether they helped.
Individual character traits, religious identification, and the topic of the talk they were about to give had no effect, even when the topic of the talk was the story of the Good Samaritan.
34
NHS Staff Survey Conclusion
When staff feel too much work pressure,
Experience aggression or discrimination
– either physical violence or bullying, harassment or abuse – from patients, members of the public or colleagues,
outcomes are generally worse. www.gov.uk/government/uploads/system/uploads/
attachment_data/file/215455/dh_129656.pdf
35
REASONS FOR DECLINE : INDIVIDUALS
Reasons for decline
Meta-analyses show
that clinicians' distress is a key determinant of
empathy decline those who are more sensitive, those who have difficulties regulating their negative
emotions. Or those with overly suppressed pain responses and
insufficient emotional arousalNeumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and
residents. Acad Med 2011;86:996-1009.
38
Reasons for decline
This exaggerated distress reaction
may lead to emotional exhaustion, detachment
and a low sense of accomplishment
Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents.
Acad Med 2011;86:996-1009.
39
Fear of being Compassionate
Fear of compassion,
both towards others and towards ourselves, is one of the factors identified as getting in the way of being able to be compassionate.
Fear of being overwhelmed, of becoming too upset and not able to recover… or being helpless to change anything of being too soft, too gullible Of managing hard decisions Of losing professional objectivity 40
Tricky Challenges
managing angry or dissatisfied patients,
de-escalate volatile encounters, deliver bad news,
Enlisting patients into their own treatment,
and engage de-motivated others
41
RECOGNISING THE SIGNS
Burnout-only the best!
various studies have shown that
40% to 60% of US physicians are experiencing symptoms of burnout
extra effort often increases risk for burnout, secondary trauma, and poor well-being
Patient Experience: Are We Overlooking a Crucial Element? Medscape. Oct 31, 2014.
44
Accessing mechanisms of support?
Sick note?Avenues of recovery?3 Months ‘sick’ leave
45
Being or becoming un-compassionate
Frankly UncaringBecoming uncaring Detachment
Indifference Intentionally so
Burned out Wounded Inexperienced Depressed
Compassion becomes un-learnedHouse of God
Penguins jumping off ice
47
WHY SHOULD WE BOTHER?
CAREFULNESS AND COMPASSION ARE CONNECTED AND SYNERGISTIC
“Strong evidence that
compassionate care
improves health outcomes and quality of life,
increases patient satisfaction, and lowers health care costs.”
Its not about the feeling......... its about the outcome!
50
Empathic communication is associated with
increased adherence to treatment, and fewer malpractice complaints [1].
greater agency in addressing problems such as cancer[11].
Patients' perceptions of empathy are positively related to more favourable health outcomes [2-4].
Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011;86:996-
1009.
51
“one relatively consistent finding
physicians who adopt a warm, friendly, and reassuring
manner
are more effective
than those who keep consultations formal and do not offer reassurance.
The Lancet, Volume 357, Issue 9258, Pages 757 - 762, 10 March 2001
Positive engagement
has significant associations with better patient mortality, infection rates, annual Health Check scores, staff absenteeism and turnover outcomes for that trust
NHS Staff survey ://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/
dh_129656.pdf 53
Detached concern is no longer tenable
teaching and practice of “detached concern”,
a process where physicians establish a certain emotional distance from their patients in order to maintain objectivity is not supported by the literature
negative emotions do not necessarily lead to emotional turmoil
[11].
Affective engagement improves cognitive accuracy
as well as affective understanding [12]. [14].
54
The Psycho-Biological basis for the positive effects of CompassionOxytocin
Endogenous opioids
Psychoneuroimmunolology
Epigenetic effects
+ve Pressor and cardiac effects
Mood effects
Anxiolysis – reduced fear
Recruitment of Coping strategies
Health promoting behaviour
Cognitive and meta-cognitive changes
“Compassion, both given and received, is rooted in affiliative emotion systems. It has major impacts on a range of physiological and psychological processes, including immune, cardiovascular stress and recovery processes that significantly affect outcomes”. Indeed, perceived controllability over a stressor is associated with prefrontal cortex mediated regulation of limbic (amygdala and hypothalamus) and brainstem (dorsal raphe nucleus) structures associated with neuroendocrine and autonomic nervous system reactivity[45].
This provides a direct pathway through which the perception of one's ability to control aspects of his/her disease is capable of regulating physiological processes ranging from glucose metabolism and blood pressure to immunomodulation and neurogenesis [46].
In addition to improving patient
outcomes, clinical empathy is associated with increased overall
well-being for the physician [5].
decreased burnout, personal distress, depression and anxiety,
along with increased life satisfaction and psychological well-being [6, 7].
Neumann M, Edelhäuser F, Tauschel D et al. Empathy decline and its reasons: a systematic review of studies with medical students
and residents. Acad Med 2011;86:996-1009
56
WHERE DOES THAT LEAVE US?
Fundamentally
Compassion is a one to one transactionEach time - every time
It is always required of the individual
to the individual regardless of the context
59
“PHYSICIAN HEAL THYSELF”.............
.....................BUT NOT BY THYSELF!
WHAT ABOUT COMPASSION ?
Let go of the toxic bits
63
Peter Carter, head of the Royal College of Nursing
certainly does not believe that “compassion” can be taught
—as much of the reporting of the Francis report seemed to imply.
http://www.bmj.com/content/348/bmj.g126
64
I disagree..........
It’s a competency that can be grown, developed & recovered
65
What is the minimum quantum ?
Eye contactPersonalised interactions
Framing StatementsBe less judgemental
Signpost sources
66
General Measures – Being CaringBasic Heart support
Understand your role in care of suffering Protect & Renew your ideals Refill the tanks - Take an occasional ‘care
pause’ Keep good company Avoid the angry trap
“Little by little, your frustrations mount”.
Limit commitments but commit to work Stay close to patients / mission Tend your own needs too Preserve personal and collegial relationships
67
Can we learn compassion?
Or is it something innate that we either have or don't have?Recent research by Jazaieri and colleagues
programmes based on mindfulness meditation
are associated with reduced fear of compassion
and a more compassionate attitude
This is a guest post by Dr Lucy Maddox, NHS Clinical Psychologist, lecturer and BSA media fellow. You can read more from Lucy on her blog, Psychology Magpie, and on Twitter @Lucy_Maddox.
68
A word about Mindfulness
Dissolution of narrow and isolated sense of self
Emotional awareness and stabilisation Less JudgementalSelf acceptance
Less anxiety / depressionLetting go – forgiveness
Liberates joy / bliss / love
For Compassion
69
Mental wellbeing
Yourmentalhealth.ie #littlethings
Headspace App
70
AT A SYSTEMS LEVEL……
NHS Staff survey
Conclusion
Having a safe working environment is critical
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/dh_129656.pdf
72
Compassion as Core Value
Not so lean That we carry no slack
73
Dov Seidman said that
“the last era of management was about how much performance we
could extract from people.
The next is all about how much humanity we can experience”.
74
There are an awful lot of Penguins
75
The way it will succeed.....
Small peer led teamwork informed by compassion recovery and maintenance approaches eg Bailint groups etc
76
LAST WORDS
Recovering our personal value
in kindness – it doesn’t matterin ourselves - we don’t matter
in the context - It doesn’t matter to anyone
79
Healing = care of suffering
Our workOur gift
Our professionOur reward
“The secret of the care of the patient,” Peabody noted, “is caring for the patient.”
Peabody FW. The care of the patient. JAMA. 1927;88:877–882
80
Resources Compassion
Recent research by Jazaieri and colleagues suggests that compassion cultivation programmes, based on mindfulness meditation, are associated with reduced fear of compassion and a more compassionate attitude towards oneself.
https://compassionateaction.org/global-compassion-movement http://greatergood.berkeley.edu/article/item/sustaining_compassion_in_health_care http://www.tibet.emory.edu/cbct/index.html#CBCT Look at the Cleveland clinic empathy series on youtube The Art and Science of Medicine: Guidelines for the Human Physician. Göttingen: Hogrefe
Publishing; 2011. HBR Blog Network How to Spread Empathy in Health Care Social network scientists have shown that emotions and values can spread in a community with
the same patterns as infectious diseases –”compassion cannot be taught, but it can be caught” The Center for Compassion and Altruism Research and Education (CCARE) at Stanford University http://www.psychologicalscience.org/index.php/publications/observer/2013/may-june-13/the-comp
assionate-mind.htm http://www.visimobile.com/wp-content/uploads/2014/03/Transforming-Care-at-the-Bedside.pdf Compassion and Healing in Medicine and Society: On the Nature and Use of
Attachment Solutions to Separation Challenges By Gregory L. Fricchione. Johns Hopkins University Press. 2011
Biol Res Nurs. 2012 Oct;14(4):419-30. Epub 2012 Jul 6. The biology of caring: researching the healing effects of stress response regulation through relational engagement.Zender R1, Olshansky E.
Karen Armstrong 12 steps to a compassionate life Patient Experience: Are We Overlooking a Crucial Element? Medscape. Oct 31, 2014.
81
THANK YOUComments welcome [email protected]
Synergy
Carefulness↕
Compassion
83
LET’S LOOK AT THE PROBLEM OF
ATTENTIVENESS IN THE AGE OF DISTRACTION
Personal Obstacles to Attentiveness
StressDistractionFatiguePerfectionism Carelessness
OverloadNoiseConflictHangovers etc
Time & Boundaries encroachment
87
Contextual Obstacles to Carefulness - The age of performance
CrowdingEnvironmentRegulatory
excessBureaucracy
Performance &Time pressureSectoral changeIgnored
problems
Multitasking http://enlivenwellnessworks.com/wp-content/uploads/2013/10/8036438_l.jpg
89
How Multitasking Affects Mental Health
“Inability to focus well on one activity.”
leading to
“Impatience and lack of empathy for others
who are often seen as getting in the way.”
-attention switching is difficult How Multitasking Affects Mental Health
By Rheyanne Weaver
Published January 07, 2012 EmpowHER
90
Being Too Careful is also a problem
ScrupulousRisk averse
AnxiousMistrustful
91
BECOMING MORE ATTENTIVE
Let go of the toxic bits
93
What is the minimum quantum of safe practice ?
3 ChecksTake personal responsibilityRecording
If in doubt don’t proceedConsult and confer
94
General Measures – Being CarefulBasic Head support
Beware fatigue - Protect sleep Protect health De-clutter work practices - Don’t Multitask Develop +ve rituals / habits Manage other’s access Take regular ‘attentional pauses’ Analyse and fix your weak points Don’t rely on stimulants - take Tea! Practicing mindfulness, Fun Exercise etc Supervise & review Individualise improvement & Localise the focus
95
Use Focus techniques
http://learningfundamentals.com.au/wp-content/uploads/Focus-mindmap-for-web.jpg
96
A word about Mindfulness
Clarity Calm
Energising
Short term focus → sustained clarity
Perceptual shiftDiscernment
More Intuitive
For Attentiveness
97
Resources Attention
Focus Focus Manifesto focusmanifesto.s3.amazonaws.com/FocusFree.pdf For the Mindmap go to
http://learningfundamentals.com.au/wp-content/uploads/Focus-mindmap-for-web.jpg
Mindfulness Meditation Society of Australia Mindful awareness UCLA http://marc.ucla.edu/body.cfm?id=107 Mindfulness Meditation app Lifestyle Sleep genius App also Relax and Sleep Well App Life Goals App also Get it done App IOS only Recharge App
Resilience Healthcare http://resiliencehealthcarelearningnetwork.ca/98