Resilience Training, Mindfulness Can Ease Emergency Department Stress

According to Bonnano, “Resilience is the process of experiencing an adversity and managing to maintain a relatively stable trajectory of healthy functioning and adaption.”¹ Deveson describes resilience as “a life force that promotes regeneration and renewal” and “the ability to confront adversity and still find hope and meaning in life.”² Resilient providers experience stress and distress, but the resulting symptoms remain mild and transient and do not interfere with long-term functioning. Resilient providers recover quickly in response to challenging situations, and they also grow stronger.

Clearly, the emergency department is a work environment full of stressors. These include high-acuity patients, large volumes of patients, frequent interruptions, high expectations of family and friends, long wait times, boarders, consultants’ demands, inability to reach required performance indicators, and many others. As such, stress-induced activation of the sympathetic nervous system, when chronic, has deleterious health effects, resulting in depersonalization, emotional exhaustion, loss of enthusiasm, compassion fatigue, cynicism, and a low sense of accomplishment. Beyond individual health effects, being constantly stressed can affect one’s capacity to make medical judgments, which may impair ED teamwork and ultimately compromise patient care.

The profession of medicine is held in high esteem, but there is also widespread agreement that strategies and education are needed to improve resilience and well-being in physicians’ professional and personal lives. Such improvement correlates with work engagement. Crowe mentions the importance of resilience training as a method of controlling one’s range of emotional responses to adversity by building compassion satisfaction and lowering compassion fatigue.³ Self-compassion is a first step and can be protective. Also, building a repertoire of empathic responses to stressful situations may condition providers, allowing them to externalize adversity as part of a larger experience rather than learning to internalize the negativity as an individual failing. Thus, managing situational stress by applying strategy to it eventually makes the focus, practice, and exercise become teachable moments. By using these events to teach that experiencing a range of emotions is normal and then offering support, team cohesion can be encouraged. Leading and teaching in this manner can be effective role modeling, facilitate connecting with team members, and promote the recognition and use of empathy.

Various mindfulness training methods, such as mindfulness-based interventions (MBI) and mindfulness-based stress reduction (MBSR), emphasize using one’s sensory awareness and self-reflection to promote well-being and resilience.^4,5 Klatt characterized mindfulness as “nonjudgmental, sustained moment-to-moment awareness of physical sensations, perceptions, affective states, thoughts, and imagery.” Many studies have noted positive effects of mindfulness training techniques when done on-site during the stressful workday.

Educators like Beckman realize that a culture change to improve resilience must become a necessary part of medical education.⁶ Some of his recommendations include making wellness a metric for training; using reflection and talking about stressors, the fear of mistakes, and the positives of medical education; using interdisciplinary mindfulness training; promoting the use of guilt-free time for self-care; developing and discovering resilient role models and mentors; and including at least short times for movement, relaxation, yoga, meditation, or spirituality. Wellness among emergency physicians has been associated with exercise and leisure activities.⁷

In summary, the resources brought by organizations to address the problem of physician burnout primarily focus on improving wellness and entraining resilience. Clearly this focus, while beneficial, does not begin to address the increasing need for operational solutions at the organizational level to address the problem.⁸

The recently announced National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience is an example of the unified approach necessary to address the issues involved in professional burnout.⁹ Solving this problem will require cooperation at every level of the health care system.

Dr. Goett is assistant professor of emergency medicine and assistant director for advanced illness and bioethics at Rutgers New Jersey Medical School in Newark