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Cultivating resilience for culture change

How teamwork-building training helped a hospital curb staff stress and improve its culture of safety


A North Carolina hospital is using the power of positive thinking to help its clinical staff build resilience to counter burnout and to improve safety culture and teamwork within high-risk health care settings.

Duke Raleigh Hospital, a community hospital that is part of Duke Health, employed regular exercises in gratitude and a focus on the positive in addition to its Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) teamwork-building program, and saw improvements in resilience and safety culture survey ratings.

While positivity and gratitude may seem like simple concepts to counter the serious, life-and-death issues that physicians, nurses and other health care professionals face every day, they are remarkably powerful in protecting people from depression and emotional fatigue, explains Melissa Sullivan, MHA, BSN, RN, the hospital's patient safety manager. "Positive emotions can help build resilience, which allows you to respond to stress in a healthy way," Sullivan says. “The more resilient you are, the more likely you are to bounce back when times get tough."

Melissa Sullivan, MHA, BSN, RN
Patient Safety Manager
Duke Raleigh Hospital

Sullivan and colleagues pursued the project based on resilience research by social scientists such as Barbara Frederickson, PhD, who studies the effects of positive emotions such as joy, inspiration and pride; and Martin Seligman, PhD, director of the Penn Positive Psychology Center. They were also fortunate to have an in-house expert on the culture of safety, Bryan J. Sexton, PhD, who focuses on the relationship between culture and patient safety and serves as director of the Patient Safety Center at Duke University Health System.

As part of the intervention, Sexton provided 50-minute educational sessions with participating hospital units, who also were given training on regularly calling out positive things going on in their lives, cultivating gratitude by writing a letter to someone who made a difference in their lives, engaging in meaningful conversations with colleagues, practicing random acts of kindness, and reflecting on awe-inspiring experiences.

First, though, the project's organizers began with an initial assessment of burnout in various hospital departments. Duke Raleigh’s 2014 work culture survey and safety attitudes questionnaire demonstrated opportunities for improvement, with some units reporting high feelings of burnout and low resilience, many units needing improvement in a climate of teamwork, and most needing an increased culture of safety.

Project leaders naturally chose units that had the greatest opportunities for improvement as their first units to approach. But after checking in with Sexton, they changed course. He advised them to leave the most stressed units for later. “Right now they are struggling to keep the boat afloat," explains Tammi Hicks, DNP, RN, administrative director for clinical education and professional development for Duke University Health System. “They are angry, disengaged and emotionally exhausted. They don’t have the capacity, the energy, or the desire to take on even more stuff."

Tammi Hicks, DNP, RN
Administrative Director, Clinical Education and Professional Development
Duke University Health System

So they rethought and instead chose to start with units with higher resilience scores. The units with greater rates of burnout, meanwhile, were provided targeted resilience-enhancing efforts for several months before being approached to participate in TeamSTEPPS.

To get administration buy-in, the project leaders put together a cost-benefit analysis of how much it would cost to train staff by calculating how much a medical error would cost and how much training that dollar amount would buy. “For our ambulatory oncology centers, the cost of materials, training, and even food that we used to entice them to get there, if we reduced one safety event, it more than covered the cost of training," Hicks says. "We estimated the cost of a medical error at $11,366, which would cover training for 155 oncology providers."

The intervention used the TeamSTEPPS model to provide training to staff in the program’s trademark flexible fashion, incorporating it into staff workflows in small bites to improve the chance of adoption. The project leaders recruited individuals throughout the hospital to become master trainers, and currently have 32 people with the designation. The master trainers were assigned to units, working with unit leaders to assess their readiness to start the training, making sure it wasn’t bumping into other project implementations.

Participants in Duke Raleigh’s resilience training

They focused on gratitude and positive thinking to specifically address burnout and resilience. One of the main tools is called Three Good Things, a simple, research-based technique that has the individual write down three things that went well that day and why they went well before bed every night for a week. "The best part is that it’s extremely low-cost, it can be done anywhere and can easily be shared with anyone to help build resilience with all of those around you," explains Sullivan. The "three things" can be as small as making a new recipe for dinner, noticing a beautiful sunset, or taking the dog on a longer walk to enjoy a beautiful day.

Some hospital units shared their "three things" on a bulletin board. They may post a prompt on the board such as "share something you’re proud of."

"What we have found is that [the boards] become a central location for people to go to read what other people are putting up there, and that breeds positivity and keeps good feelings going," Hicks says.

Another effective resilience tool is to send colleagues thank you notes, which can become contagious, Sullivan says. Recipients of the notes then think to thank others and expressing gratitude cultivates that positive emotion and helps improve your own personal resilience.

They also post humorous items on the board, which is effective in drawing in disengaged staff members. Hicks notes that reaching disengaged staff members takes some extra time and effort, but there are tools in the TeamSTEPPS toolkit to address them, Hicks says. "You ask them to share some of their experience and then suggest a tool to use, or share a personal example … so they can see the benefit of using the tools," she explains.

The positivity training includes leaders, Hicks and Sullivan say, who also face burnout risks.

They found the process works best by being flexible with it and having fun.

"You may get derailed, but it's important that you keep on going and celebrate each other and where you are," says Hicks. "You want to create milestones and celebrate those, because it takes a long time to change culture. Celebrating the team, just creating excitement, and having fun with it. If you don't have fun with it, it will just fade into the wallpaper."

After about two years of spreading the positivity tools throughout the hospital, follow-up surveys found significant improvements in questions around burnout. Two-thirds of departments had improved, and at least half had statistically significant improvement on at least one of three questions related to feeling burned out, being emotionally exhausted, or events at work having an unhealthy impact. There were also improvements in both safety climate and resilience.

The Three Good Things tool continues to be used regularly, incorporated into the daily safety briefing, staff meetings, and leadership meetings "to help us all focus on the positives throughout our day," Sullivan says. During the safety briefing on Tuesday, coined as TeamSTEPPS Tuesdays, someone is invited to share a brief story about teamwork in their unit improving safety or communication. "We're always working to keep it interesting and exciting," says Sullivan.

Ten positive emotions that build resilience

  • Joy
  • Inspiration
  • Amusement
  • Love
  • Interest
  • Pride
  • Gratitude
  • Serenity
  • Hope
  • Awe

Wellspan Health building a just culture

Wellspan Health, an integrated health system serving central Pennsylvania and northern Maryland, is using risk management software to promote system-wide "just culture" — a supportive system of shared accountability. The software supports a system-wide initiative to promote patient safety. It documents just culture interventions to ensure that safety problems were being identified and fixed. The software, from RL Solutions, was modified by Wellspan to allow a manager to add information in an incident report about the contributions of system design and staff behavior and follow-up actions. The information supports mid-level management in identifying systems, processes and working conditions that contribute to errors. More information about Wellspan’s use of the software is available on AHA Health Forum.

"We need to demonstrate to our staff that when they do report, things will happen — moreover, the right things will happen," says Gary Merica, a patient safety officer at WellSpan Health. The addition of just culture documentation demonstrates that these reports are intended to improve systems, behavior and safety — not to punish people for human error or badly designed systems. RL Solutions' Incident Reporting & Management solution has earned the exclusive endorsement of the American Hospital Association.

Taking Stepps to sustain a just culture

"Just culture" in health care provides an environment for reducing safety risks while being fair to staff who make errors. TeamSTEPPS is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals. An AHA Team Training webinar addressed the question of helping hospital staff understand "just culture" and a non-punitive environment. The webinar provided a brief overview of the key components of just culture and the use of TeamSTEPPS to further it.

For more insights from the field, visit our Critical Topics Driving the Field directory.

About American Hospital Association (AHA) Team Training Including TeamSTEPPS

AHA Team Training strives to make teams of experts into expert teams using TeamSTEPPS as well as other strategies, like improving resiliency and connecting teams to high-reliability organization (HRO) principles. Teams working with AHA faculty have dramatically improved communication and teamwork within their organizations to provide safer team-based care. AHA Team Training provides courses, onsite consulting and coaching, free webinars, community support and engagement. Learn more about AHA Team Training. And mark your calendar for the 2019 AHA Team Training National Conference, June 12-14 in San Antonio. The conference is open to all — from clinical to non-clinical, and from novices to experts in TeamSTEPPS and patient safety.