Looking After Yourself, Looking After Others Jo Soldan Doc.Clin.Psy Clinical Psychologist in Critical Care & Ko Awatea Counties Manukau DHB. Sue Dykes MSc Dip Clin Psych Clinical Psychologist in Private Practice Mindfulness Auckland Date: Created by:

Coming onto room practice Acknowledge all things of the morning, getting here, seeing people or not, head buzzing, maybe even next session! Deliberately letting them go – nothing need to do in next 75 mins than be here – check in with self – not to change it but to just be aware – how am I feeling right now? Body emotion mind Gather Awareness to breath in out flow – not control Expand to body - scan through body Notice feet on floor, contact, posture Silence 1 min? every time mind wanders bring it back – not judging – just noticing Back to room Turn to neighbour – say what you noticed – doing that (busy mind, slow down etc)

Illustration from ‘Quiet the Mind’ – Matthew Johnstone You know about mindfulness – best way often t introduce is the opposite e- people recognise that - mindlessness Illustration from ‘Quiet the Mind’ – Matthew Johnstone

Illustration from ‘Quiet the Mind’ – Matthew Johnstone

What is Mindfulness? Jon Kabat Zinn: Paying attention ‘on purpose’ Rooted in the present moment Non judgmental Story of John moving form eastern traditions ot medicine Not – clearing your mind Mindlessness – drive to work – not aware how you got there – frazzled – hard to focus Automatic pilot Preoccupied with past or future Average time we conc in work before interruption – 3 mins

Mindfulness Based Stress Reduction Jon Kabat-Zinn and Saki Santorelli University of Massachusetts 8 week group programme, with one day silent retreat Various mindfulness practices Strong research base Modified programmes used in many areas Started in 1979 Working with peoplewith serious healht issues Mindfulness is not relaxation – achieveing out of body experience Working with patitns with pain not going away – enabling them to sit with different relationship with the pain etc Sit with unpleasant

Efficacy of Mindfulness Based Stress Reduction Depression Anxiety Psoriasis Chronic Pain Cancer Mindful Eating. Evaluated on various patient groups Indeed starting to be added to Nice guidelines

A Beginners Mind Raisin exercise Focus Clarity Calm Openness Equanimity

Following the breath

Why the breath? Accessible Regular Away from thinking Only ever in the present moment At the intersection of body and mind Innate capacities for calming

Mindfulness restores the balance Too much sympathetic nervous system (fight or flight) leads to problems remembering, fatigue, lack of energy and frequent illness. Parasympathetic system (rest and digest) counteracts this Huge amount of neuro research at the moment – v exciting When frazzled thought control shifts from the prefrontal area to the more primitive emotional circuitry of the mid brain/limbic system. This gives priority to speed and knee-jerk reactions over thoughtfulness and creativity. Left activated by meditiationWandering mind Fragmented attention Clinging/Ruminating Avoidance

The nature of the mind Wandering attention “monkey mind” Fragmented attention, leads to mistakes Clinging/chasing after/ruminating Experiential avoidance – what we resist persists

Illustration from ‘Quiet the Mind’ – Matthew Johnstone

Facing the unpleasant When we bring full awareness....to the whole of our experience....our relationship to the difficult emotions can shift dramatically Williams et al. In The Mindful Way Through Depression( 2007)

Illustration from ‘Quiet the Mind’ – Matthew Johnstone Not fighting with mind to insist on calm – but understanding the mind Illustration from ‘Quiet the Mind’ – Matthew Johnstone

Outcomes of Mindfulness Practice Focus, clarity and wisdom Interruption of autopilot (ruminating,etc) Metacognitive awareness Approaching rather than avoiding Responding rather then reacting Compassion

Matthieu Ricard

Effects of meditation on the brain (Lazar, 2013) Increased gray matter in long-term meditators, and after 8 weeks of MBSR, in regions involved in: Learning and memory Emotion regulation Empathy Self-referential processing Decreased gray matter density in Amygdala, correlated with perceived decreases in stress levels “meditation may result in enduring, beneficial changes in brain function,”Frontiers in Human Neurosciences, November 2012 1)Insula (anterior)- interoception, self-awareness ,empathy for emotions (Holzel et al. 2008, Lazar et al. 2005) 2) Hippocampus – visual-spatial memory, establishing context, emotion regulation, inhibiting amygdala and cortisol (Holzel et al. 2008, Luders et al.2009) 3)Prefrontal cortex -executive functions,(cognitive processing) attention control , decision-making, And sensory cortex....observing internal and external physical sensations(Lazar et al. 2005, Luders et al. 2009) Reduced cortical thinning with aging in 1) and 3),(Lazar et al. 2005) Also, studies showing changes after only 8 weeks of MBSR training, ie in novices....(in 4 regions, hippocampus, posterior cingulate cortex (contect and self-reference), temporal-parietal junction (empathy and compassion, and monitoring of internal bodily states...ie embodiment)and part of the cerebellum, NB Insula changes were not stat. Signif after 8 weeks))

Why - Mindfulness at Work? Association with Emotional Intelligence More engaged in work, energised and less anxious. Reduced Cortisol, increase immunological response to flu jab (Davidson et al 2004) 70% reduction in sick leave American Army safeguards against distraction and emotional reactivity (reduced Depression and PTSD, clearer thinking in stressful situations) "It's like doing push ups for the brain." Emotional Intelligence(85% of the difference between good and average senior lead Davidson rct in lab workers Outcomes demonstrate Mind body interaction Transport worker s- 70% reduction in sick leave for anx and depression – cited in mental health foundation mindfulness report 2010

Mindfulness at work – moved fr0m patient groups into resilience and workplace Not surprisingly corporates there first Average conc is 3 mins before ibterrupted at work Mindful e mailing etc Write ..breathe Read form others perspective

Why Relevant in Health Care Burn Out and Depression are known to be high in staff. Increase Resilience to Nature of our Work. Mirroring Neurons - A way of balancing brain activity. Clearer Thinking – Patient Safety. Self Compassion PAFCC Average time we concentrate for in work before interruption – 3 mins Burn out/peak performance works for a sprint, but does not provide the resilience needed for a marathon Mirroring – we either learn to block it out – or deal with this brain activity – need to over develop our parasympathetic system (balance sympathetic/parasympathetic) Clearer thinking – decreased amygdala activity - Meditation training has been shown to affect emotional processing in the brain outside of the meditative state Study group (MBSR _ showed decreased activity in the right amygdala in response to emotional images Overall these results are consistent with the overarching hypothesis that meditation may result in enduring, beneficial changes in brain function, especially in the area of emotional processing Research at Mass General Hospital reported in Frontiers in Human Neurosciences November 2012 Self compassion - (recent paper of self esteem/self compassion following critical incidents) PAFCC stidies reporting staff feel better able to be present with patient/family sand listen to them

Efficacy of Mindfulness Training in Health Care Reductions in stress, depression, anxiety, burn out. (Krasner et al (2009) Shapiro et al 2005,Corey et al 2006,Britt et al 2009 ) Increased Empathy (Krasner 2009, Shapiro et al 2009) Staff report increased ability to listen and be patient-centered (Krasner 2009) (Krasner et al (2009) - Drs, Shapiro 2005 study of HCP ,Corey et al 2006 –nurses, Britt et al stress in nurse leaders )groups studied - Nurses, doctors, mixed groups and nursing leaders Empathy – demo’d to drop off as students meet patients! Britt et al 2009 – 4 week Mindfulness course – reduced self reported measures of stress journal of nursing administration Shapiro 2006 int jnl stress management vol 12 no 2– 8 week mbsr reduced stress, increase self compassion and qoL (8/18 dropped out of intervention) Corey et al 2006 applied nursing research Waiting list control – sig improvements in burn out, relaxation and life satisfaction. Coehn Katz et al -(12/14 nurses completed the prog)nurses sig reduction in burn out over waiting list controls – 8 week mbsr

Not Just Self Care - Compassion Nurses told to focus on compassionate care Three-year strategy unveiled to tackle 'crisis in standards of care' amid concerns over treatment in NHS hospitals and care homes Trainee nurses should be selected on compassion to avoid repeat of Mid-Staffs scandal: As can see form these headlines - Concern in current health care system about how we maintain compassion in health care staff How do we put the compassion back into healthcare?: Full round table discussion In the wake of the Francis report, the BMJ gathered experts to discuss compassion in the health service.

With help of learning and development – Carole Stiles our course organiser..,.,.

Mindfulness at Work in Counties Manukau Abbreviated Courses 4 x 2 hours Intensive – 8 hour day followed by follow up at 4 weeks Lunchtime sits Integrated into work day Tell oyu a bit about the course – doing with Dianne May form Mindfulness Auckland Groups are Educational and Experiential – Practice is key Exercises such as raisin, mindful communnication Formal Practice – Body Scan, Sitting Medication, Walking Meditation, Mountain meditation. Short Practices – Three minute breathing Space, STOP whilst washing your hands, Mindful movement -Cued by everyday events. Raisin Exercise, Pleasant and Unpleasant Events, Mindful communication - listening and e mails. Attitudes of Mindfulness, Stress and Mindfulness, Accepting and Allowing, Thoughts, Stress Reactivity.

Mindful Minute Short in work practices eg As when came in – sot comfortable if comfortable clos eyes Become aware of breath – not control it – focus on physical sensations of breathing – count them – 1 min Now you know how to readily take 1 min breathing space Can do anywhere any time – groups choose a cue – computer loading, phone ringing, climbing stairs ec

S stop what you’re doing T take a breath O observe your environment (int and ext) P proceed Another great one in clinical area STOP whilst WASHING HANDS www.impactednurse.com

Mindful communication – participants get excited – what would it be like if in work we really listened to one another

Mindfulness Based Resilience in the Workplace at Counties. Quantitative outcomes p value paired sample test Brief Resilience Scale 0.02 Maslach Burn Out Inventory : Emotional Exhaustion 0.02 Depersonalisation 0.05 Perceived Stress Score 0.0003 MBI D and PI and PSS t test others signed rank test Personal Accomplishment 0.08 Irene Zeng Research Office Ko Awatea

Mindfulness Based Resilience in the Workplace CMDHB/Ko Awatea Has the course impacted on you professionally? 100% Have you noticed any positive change in your reactivity at work? 95% Have you noticed and positive change in your ability to handle stressful situations 97% Would you recommend the course to colleagues? 100% 

Mindfulness Based Resilience in the Workplace CMDHB/Ko Awatea “I believe the course is a real gift from the organisation in terms of the cost and time commitment. However I do think this is more than outweighed by the positive benefits that follow that can be taken into the participants personal and professional life” “it has huge benefits for reducing stress levels and produce a more positive attitude which is noticed by others”  

Mindfulness Based Resilience in the Workplace CMDHB/Ko Awatea Changes noticed in themselves “more able to focus on the moment – I can do the work faster” “Singing again” “able to handle things differently, confident, better at making decisions, cope with stress better” “I am much more relaxed and alert in dealing with stressful issues and concerns and people” Remember their jobs havent changed – they are being more present – their capacity to sit with it - different attitude to it

Mindfulness Based Resilience in the Workplace CMDHB/Ko Awatea Many reported colleagues noting changes in them over the 4 weeks: “Not taking negative feedback so personally” “Seems calmer” “More even tempered” “Not getting overwhelmed by stressful situations” “Much more present and confident” “Less anxious and more positive about things” “My manager attended the course last year and speaks very highly of it. There is also a noticeable change in his demeanour and stress response. I would like to see if I can obtain the same benefits from the programme” Next quote speaks directly to the patient safety potentials - doctor talking about impact of doing short workplace pratcises

Mindfulness Based Resilience in the Workplace CMDHB/Ko Awatea “I have noticed that I am as present with the last patient on my list as the first If I tell you this was an Anaesthetist even more powerful This quote supports my vision – bear with me…..

Not just Self Care – Patient Safety Mid Staffordshire NHS Trust 'should be dissolved' Another pressing issue in health care is patient safety and compassionate care mid staffs Recent report about this by Don Berwock Obama IHI

‘A promise to learn - a commitment to act’ “Leaders and managers should actively support staff by excellent human resource practices, promoting staff health and well-being” (Berwick Report 2013). Amongst other things they call for attention to staff well being Sets staff well being as central to achieving safety

Escape Fire – Don Berwick There are a number of things we need to do in health care “The first is the toughest: we need to face reality. This is very very hard….Our challenge is to have the courage to name clearly and boldly the problems…we must find ways to do this without either marginalizing the truth teller or demoralizing the good people working in these bad systems” Quote form Dons early work on patient safety and health care system Mindfulness – sitting with unpleasant, non judging, acceptance etc…….. RCA……

Mindfulness in Healthcare Staff Resilience – reducing Burn out, Depression, Anxiety. Increasing Joy at Work Supporting Compassion, Patient Centered Care Patient Safety – being present – ability to sit with difficulty Summary of potential benefits- some proven now others need more research Continue to measure Find ways of tapping into any change in patient safety – compassion etc Find ways tp evaluate and research impact on patient safety

Resources ‘The Mindful Workplace: Developing Resilient Individuals and Resonant Organizations with MBSR’ Michael Chaskalson ‘Search Inside Yourself: The Unexpected Path to Achieving Success, Happiness (and World Peace)’ Chade-Meng Tan CALM.ac.nz www.smilingmind.au.com www.mentalhealth.org.nz - 5 ways to well being - take notice www.bemindful.co.uk - online courses www.compassionatemind.co.uk (Paul Gilbert) www.selfcompassion.org (Krisitin Neff) www.mindfulnessauckland.co.nz www.openground.com.au Best resource - having a go! / developing a practice ……. Jo.Soldan@middlemore.co.nz