Healthcare is experiencing a dramatic shift on so many levels: patients are frightened and hesitant to seek care unless they think it is an urgent issue, the world is dealing with a pandemic that has many unanswered questions, and healthcare providers are growing increasingly anxious about their own risk of exposure. To name just a few of the challenges! Of course, while the pandemic represents a crisis of unequal proportions, not all urgent situations are pandemic-related. It just adds to the stress of dealing with non-COVID-19 emergencies. Needless to say, the time is ripe for significant psychological impacts on healthcare providers. Just being aware of this increased risk of the deleterious impact of stress is the first step to improving one’s ability to cope. It is important to be aware that you, your staff and your patients are probably all experiencing heightened levels of stress.

Ironically, it is during emergency and other high-stress situations where we need to be on top of our game in terms of cognitive functioning, decision making and attention, that we are at greatest risk of having our amygdala’s grab more of our focus, and can significantly affect emotional and mental well-being, both in the short-term and over time 1.  Not only do emergency situations call for thinking quickly on one’s feet and making timely (and often life or death) decisions, but the ability to be aware of how one is relating to self and to others, is also critical. That requires a degree of self-reflection, a willingness to engage in self-care, an ability to stay focused on the task at hand, and being capable of adapting to quickly changing circumstances–all this while staying tuned in to how one is relating to others so that they can stay focused and engage in effective decision-making and cognitive processing. As physicians, you are often required to step into a leadership role–making your ability to self-regulate, to communicate and to interact with others vital to successful healthcare outcomes.

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There are strategies for developing your ability in all these areas–practicing mindfulness would be at the top of that list. As scientists and healthcare providers dedicated to evidence-based practices, mindfulness deserves a place in your toolkit–but not just for your patients–for you too! Recent meta-analyses point to the many psychological and physical benefits of mindfulness practices for healthcare providers 2,3. 

So, what exactly do we mean by mindfulness? Perhaps the most widely cited practitioner of science-based mindfulness, Dr. John Kabat-Zinn, gives us this definition: “Mindfulness means paying attention in a particular way, on purpose, in the present moment and nonjudgmentally) 4.  What does this mean in practice? It means that we are intentional about where we focus our attention; that we observe what is going on internally and externally) without making an evaluation or judgment (especially about ourselves); and that we stay committed to repeatedly bringing our attention back to the present moment. Why is this a useful practice? Because it has been shown to improve one’s ability to cope when experiencing distress (such as fear, anger, and anxiety), to sharpen one’s focus, and to intentionally direct attention where it is most needed 5. The key to success is simple–practice mindfulness. Like any other skill, the more you practice, the better you get. And if you think you can’t afford the time, think again. Mindfulness can be practiced anywhere and for any period of time. All it requires is an intentional, nonjudgmental focus on the present moment, regardless of what’s going on in that moment. Having an anchor (the most common one being the breath) helps to bring your attention back to the present, over and over again. The more you do this, the better you will get at staying focused and present during any situation. Think of it as a form of stress-training–preparing your mind to focus awareness during a time when it is likely to be most distracted (think crisis or emergency). And like any form of training (be it for a sport, learning a language, or engaging in some form music/art), first you learn the skill and then you practice over and over. There are many resources available for learn mindfulness–such as Kabat-Zinn’s website or any of a number of phone apps. And practicing just 15 minutes throughout the day is enough to make a difference. So, give it a try. You might just find that not only does your mindset and ability to cope at work improving, but other aspects of your life as well. And there is an added benefit–research finds that people who spend more time focused on the present, rather than engaging in mind wandering, are happier. 

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Ready to practice? Take a quiet moment (the more the better) and focus on your breath, where-ever you notice it in your body. When you find your mind wandering, gently bring it back to the breath. Whenever you find yourself experiencing negative emotions, observe what you are experiencing without judgment, and bring your focus into the here-and-now. It’s that easy. 

Catherine Hambley, PhD, is CEO of Brain-Based Strategies Consulting, where she specializes in executive coaching, leadership and team development and organizational transformation. Catherine has an extensive background in healthcare, where she works with physicians, nurses and hospital executives to create cultures of learning, collaboration and engagement. Check out her website at www.brainbasedstrategies.com
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References:1. Harvey, S., Milligan-Saville, J., Paterson, H., Harkness, E., Marsh, A, Dobson, M. & Bryant, R. (2016). The mental health of fire-fighters: An examination of the impact of repeated trauma exposure. The Australian and New Zealand Journal of Psychiatry, 50(7), 649-58.
2. Gilmartin, H., Goyal, A., Hamati, M., Mann, J., Saint, S., & Chopra, V. (2017). Brief mindfulness practices for healthcare providers–A systemic literature review. The American Journal of Medicine, Vol. 130(10), 1219.e1-1219.e17.
3. Westphal, M., Bingisser, M., Feng, T., Wall, M., Blakley, E., Bingisser, R., & Kleim, B. (2015). Protective benefits of mindfulness in emergency room personnel.  Journal of Affective Disorders, Vol. 175, 1: pp. 79-85.
4. Kabat-Zinn, J. (1994), Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.
5. Zanesco, A., Denkova, E., Rogders, S., MacNulty, W. & Jha, A. (2019). Mindfulness training as cognitive training in high-demand cohorts: An initial study in elite military servicemembers. Progress in Brain Research, 244, 323-354.

Medicine is a team sport-the collective is often much greater than the individual when it comes to patient care, innovative ideas, productivity, and efficiencies. Even more important is that effective teamwork leads to fewer medical errors.1
It’s helpful to think about team tasks rather than individual ones because within a team there exists a diversity of skills, experience, talent, and perspective, allowing members to take on more complex and involved work than individuals. The science of teamwork has made significant advances, such that we can now draw upon evidence-based practices to guide us in forming and maintaining higher function teams.2
Teams come together for a variety of purposes, for different time spans, and with differing skills sets and background. Some teams are highly interdependent (they need each other to accomplish tasks), while others work together more independently, seeking advice or guidance from team members when needed. For example, in physician practices, you are likely to have highly interdependent teams-such as the team focused on direct patient care and one that is focused on administrative responsibilities. Depending on the size and complexity of the practice, one team may be focused on both “front” and “back” office responsibilities. 
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Despite the differences in team purpose, composition, structure, and inter-relatedness, there are several factors common to all teams. The most important one being a concept of “psychological safety”- where team members believe that it is “safe” to share their thoughts, ideas, and experiences (even mistakes) without fear of judgment or retribution.3 Bearing in mind that not all teams are created equal, below are some strategies worth considering to get the most from your team.
1. Develop a team mission – your purpose for being. When people all agree on a common purpose and feel that they are all working towards that purpose, there is a greater sense of camaraderie and teamwork. Reminding people of that common purpose (i.e. patient care and comfort) helps them feel a sense of meaning and significance and helps break down and/or avoid silos. It is critical for teams to understand that success is best defined by achieving your purpose In other words, it is more about team success than individual success.

2. Develop team agreements. One of the most common traits of successful teams, is that they have established norms by which they agree to operate under.4 Here are some questions I typically use when helping teams develop their agreements:
a. What are the behaviors we need from each other to develop greater trust?
b. How do we want to make team decisions?
c. How do we ensure that everyone’s voice is heard?
d. When we have an issue to address with one of our team members, are we willing to go directly to the person (and not talk behind their backs). This last one is critical. I often help teams learn how to have difficult conversations in an effective and productive way. Team members need to not participate in talking about others and instead, encourage their colleagues to go directly to each other.

3.Clarify team roles (what is expected of each other individually and of the team collectively) and create team goals. When team members clearly understand each other’s roles and responsibilities, they can then find opportunities to help each other out. I often ask healthcare teams how they define success at the end of their day. My objective is for them to see that their work is all about the best interest of patient care, and that includes helping out our colleagues when needed. Establishing a common set of metrics helps to define success and ensure that the team is able to measure their progress. The ability to achieve goals not only boosts team morale and reinforces the team mission, it also helps the team to identify factors that contributed to their success. When goals are not achieved, it allows the team to discuss strategies that might be more effective.
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4. Learn from mistakes and failures. Teams that learn together, bond together. It is critical, especially in a health-care setting, that mistakes are seen as an opportunity to learn and improve, versus an opportunity to shame and blame. The team agreements should address this issue. You want people to openly discuss errors and near misses so that they can continually improve patient care and safety. A culture of continuous improvement among a team means that everyone knows that mistakes are bound to happen and that the best thing that can come from them is learning. 

5. Provide opportunities for the team to get to know each other on a more personal level. One great way to do this is through a personality workshop (see my previous article on the NeuroColor personality assessment). It is a perfect opportunity to learn about people’s different styles, preferences, communication behaviors, and ways they might be misunderstood. It can lay the foundation for ongoing sharing, a key element for teams to develop psychological safety.

Catherine Hambley, PhD, is CEO of Brain-Based Strategies Consulting, where she specializes in executive coaching, leadership and team development and organizational transformation. Catherine has an extensive background in healthcare, where she works with physicians, nurses and hospital executives to create cultures of learning, collaboration and engagement. Check out her website at www.brainbasedstrategies.com
References:Edmondson, A. The kinds of teams health care needs. Harvard Business Review, December 16, 2015.
Salas, E., Reyes, D. and McDaniel, S. The science of teamwork: progress, reflections, and the road ahead., The American Psychologist, 2018, Vol. 73, No. 4, 593-600.
Edmondson, A and Zhike, L.. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior. 2014, Vol. 1: 23-43
Duhigg, Charles. What Google learned from its quest to build the perfect team. The New York Times Magazine, Feb. 25, 2016.

Here are 3 main reasons:

1. Work requires people to think, to innovate, to problem-solve and to focus (among other important cognitive activities).
2. When asked where they do their best thinking, most people do not say “at work”. Rather, they indicate their best thinking happens in places like the shower, while driving, during exercise, and outdoors.
3. Everyone brings their brain to work. ​

Understanding some basic brain dynamics will allow you to optimize thinking while AT work and leverage the thinking of your people. Tap into what is likely to be your organization’s greatest asset - the brain power of your people!

Here is what you need to know to start translating neuroscience into practical skills and behaviors.

1. The brain’s number one job is to keep you alive - therefore, it is highly oriented towards detecting threat and keeping you safe. The brain typically responds before it thinks - emotions grab our attention. Our “threat detector” lies in the amygdala, a structure in the brain that is located in the limbic system - a relatively primitive part of our brains. The more threat we perceive, the more our amygdala is activated, which impacts another part of our brains - the prefrontal cortex (affectionately known as the PFC). The PFC is the newest part of our brains, evolutionary speaking - and is responsible for more complex cognitive processes such as planning, organizing, innovating, focusing, solving problems, and setting goals. Located in the PFC is a structure that helps avoid committing CLM’s (career limiting moves)! In other words, it is a structure that puts the brakes on our emotional responses so that we avoid saying and doing things that we regret. But here is the problem: The more our limbic system is activated (i.e., the more threat we experience), the more our PFC gets compromised. It can get so compromised that the breaking system stops working for us and we experience an “amygdala highjack”. Examples of this might be yelling at people, throwing an inanimate object, storming out of a room….you get the picture and it’s not pretty. Because of this inverse relationships between the amygdala and the prefrontal cortex, finding ways to mitigate threat at work becomes paramount if we want people to do their best thinking at work.
2. Social “pain” is real. There are many many structures in the brain that are geared towards social connections. Indeed, infants cannot survive unless they are able to bond with their caregivers. Recent research has discovered that when we experience social “pain”, such as not being included in an important meeting, or feeling that our boss is not being fair with us, our amygdala gets triggered. And so does the neural pathway that registers physical pain. Social pain is very real - at least it is in our brains - and we will react to it in a very similar way to physical pain. This means we will try to avoid situations and people that cause us pain and when we get triggered, our PFC starts to get compromised. Understanding some of the basic social needs that are common to all people is very useful when developing strategies to promote a more “brain-friendly” work culture. These needs, when met, create a reward state in the brain and when not met, trigger a threat response. I have created the CONNECT™ model as a convenient way to remember those basics. (See my CONNECT blog). Remember, work is a highly social environment, which means it has the potential to cause threat (think a compromising of our higher cognitive functions) and to create reward (think drive, motivation and engagement). There are strategies to mitigate threat (lessen the avoid response) and create a toward state where people feel engaged and motivated to be at work.
3. An interesting factoid about the PFC - it is an energy hog. Relative to its size, it requires more glucose (more fuel) than any other part of our body! And it gets tired pretty quickly. Ever notice that after a certain period of time of heavy concentration (somewhere in the neighborhood of 20 to 30 minutes), you start feeling mental fatigue and/or you get hungry. Well that’s your PFC telling you that it is working hard and needs a break. So in order to preserve energy, our brains like to be in auto-pilot mode as much as possible, so it does not have to use up the limited energy resources of the pre-frontal cortex. ​It might surprise you to learn that much of the brain’s functioning occurs automatically and unconsciously. And that is actually often a good thing. Imagine if you had to think about which muscles to fire and which ones to relax just to take one step! We like think that we are in control and the master of our thinking and decision-making, but it is an illusion. The fact is that the brain uses lots of cognitive short-cuts or thinking errors…and most of the time we don’t even know it’s happening. There are numerous cognitive biases (mental heuristics) such as the confirmation bias (the tendency to seek and pay attention to information that confirms our believes and to discount or negate information that is contrary to what we believe). There are over 175 identified biases that the human brain uses to be efficient - this can cause us to make decisions without considering enough of the relevant facts and information. The implications of these biases is that, unless we employ strategies to minimize their impact, our decision-making may not be the most effective. Fortunately, there are some tactics that facilitate this, such as slowing down the decision-making process, including a diversity of people (and opinions) in the room, challenging assumptions, and asking questions to uncover potential thinking errors. (See my blog on cognitive biases). ​
4. The final brain dynamic, and perhaps the most exciting one, is that our brains continue to learn and grow throughout our lives, There is this concept, “neural plasticity”, that basically means that if we practice new behaviors or patterns of thinking and responding, the neurons in our brains can form new connections. We literally create new wiring! Rather than stopping a habit, it is much more efficient to change or form new habits to facilitate this process of developing new wiring. So, you can teach an old dog new tricks - all it takes is repetition, or as neuroscientists like to say, “neurons that fire together wire together”. Not only do we form new neural connections, but we can also practice behaviors that enhance our brain’s resiliency, making us less prone to the ill effects of stress. But that’s for another blog - stay tuned.​

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