Thank you, Gretchen. There is a slight change of order for the presentations if you're following the app, but I promise you these themes will all come together. So, again, I am Asha Shannoy. I am gonna be talking about practical strategies to improve resilience and work-life integration and focus on mindfulness and building resilience. You know when you travel, you get some strange questions from folks, right? So my experience goes like this. Usually they ask, what do I do for a living? If I say pediatric critical care, they say, how do you do it? And then the next question, especially if I'm in the South, they say, bless your heart. I am not a fan of this question because it forces me to, one, defend my career choice. Second, also explain to them the meaning and the purpose I derive from my profession, and it can be sometimes exhausting. So most of the time, unless I'm in the right mood, I just tell them I'm a pediatrician. But this question does force me to ponder how do critical care providers, whether you're a physician, nurse, respiratory therapist, pharmacist, nurse practitioner, physical therapist, occupational therapist, how do ICU providers navigate the cumulative and sometimes toxic stress on a day-to-day basis and also integrate work and life? I don't think there's an easy answer to this, but studies, mainly from the field of organizational psychology, tells us that building resilience may be a key skill that we need to develop, not only personal resilience, but also professional resilience. I have no financial disclosures. And today, I'm gonna discuss specifically the role of resilience in work and life and specific strategies to build resilience and mindfulness. I do have a disclaimer. We have been to several talks already on burnout. I completely agree that the interventions to address burnout should be focused at the organizational level. So I am not proposing psychological solutions to organizational problems related to burnout and wellness. Literally, I'm not trying to catch a lion with a mousetrap. But I do think that the personal strategies that we use will help us get through our day-to-day life and have a successful and resilient career and also personal life. The honors should be on the organization to promote these personal strategies too. So for those of you who are leaders and educators, we have a lot of opportunities to weave these resilience skills into the curriculum as well as into the policies and the overall structure. I'll talk more about it. And there are sessions coming up, especially Heather is talking about a resiliency program that she built. For that, we also need organizational support. So we need to do both because regardless of how much support you have and several processes in place to improve our workflow, especially in critical care, we are going to deal with death, uncertainty, and a lot of setback. So we really need to build in and hone in our resilience skills too. So talking about what exactly is resilience. So resilience, simply put, is psychological fitness. Traditionally, we associate resilience with bouncing back. That is recovery resilience from an adverse event or a traumatic experience that we don't want. But not all of us will go through a very severe traumatic experience. This is only one domain of resilience. All of us can identify with this. In our day-to-day life in ICU, we have multiple micro and macro setbacks. We also have a lot of uncertainty, a lot of adverse outcomes that we don't want. So those micro insults, how do we bounce with those micro and macro insults and setbacks? That is where we need to build our adaptive resilience, and this is from the book called Seven Ways to Build Resilience by Chris Johnson. The third is bouncing forward. This is a concept very similar to anti-fragility. So you have adverse event, you bounce back to your baseline, but also use this as an opportunity to grow and be transformative. So that is transformative resilience. Last but not the least, bouncing outwards. How can we spread resilience? This is mainly important for organizational leaders and educators, right? So four domains, so the theme today is bounce. You bounce back, you bounce with, you bounce forward, and you bounce outwards. Before I go on to the concept of bounce, I do wanna spend a little bit of time on this longitudinal development model. So Dr. Cordova and colleagues published this in 2020 in Mayo Clinical Proceedings, where they talk about a longitudinal, intentional, and developmental approach to resilience building. This is physician-centric, but I bet this is applicable to pharmacy training, nursing training, any training. So where they talk about is integrating this resilience model very early in training, starting with undergrad, graduate medical education, and fellowship, and even after early career and ongoing career. So if you look at this model, so the resilience training is just not bouncing back. It's just not recovery resilience. There are several elements to it. They specifically talk about the interpersonal systems and sustainability approach. So as you can see, DEI is woven into all three approaches, right? So it includes attentional practices, changing the culture of medicine, learning emotional skills and integrating into our curriculum, or even day-to-day teaching rounds, navigating interpersonal dynamic conflict, dealing with difficult teams, leading teams, leading with workload, workload attrition issues, all of that building up to career and professional resilience, and also some specific trainings depending upon the fellowship. We are going to unpack that a little bit. So looking at that previous developmental model and keeping up with the theme BOUNCE, I've come up with this acronym, how can we build our BOUNCE mindfully? So it starts with the fundamentals, building resilience skills, building our organizational resilience, undertaking the long path to resilience, understanding this as a lifelong skill to learn, navigating challenging dynamics, community building and culture change, and engagement and professional fulfillment. We will be talking about some of these themes in details, especially the community building and building of organizational resilience. So let's start with building resilience skill. This is not only for us as a person, this is important for us as educators and leaders to support resilience building skills in our organization. The first one is emotional regulation skills, active coping. So if you have read the study by Dr. Burns et al that was published in Critical Care in 2022, it's an excellent study, she found that one in five, so almost 20% critical care physicians use maladaptive coping skills to deal with stress. So they either drink, substance abuse, excessive and emotional eating, binging, you name it, that was the skill that they used. The problem with that is avoidant coping is associated with increased burnout and increased psychological distress, whereas active coping, which is dealing with the stressor or how the stressor is perceived, for example, yesterday we had a wonderful plenary looking at how they used humor as an active coping mechanism to deal with multiple setbacks. So yesterday I was looking at both of them and see, oh, there is recovery resilience. Every single day they bounce with several things, every single day that is adaptive resilience and they have transformed and they've grown from the experience and yesterday they were spreading resilience. So this was beautiful for me yesterday to watch, all domains of resilience coming together in like one hour. Active coping mechanisms are what we encourage, either through humor, building up habits, new healthy habits or journaling, there are several. Second one is boundaries. So setting good boundaries, both in personal and professional life, builds resilience. I'm not here to tell you how to set your own boundaries, but for those leaders among you and for all of us, we should advocate for healthy boundaries between home and work. We should have policies and practices in place and the support needed to build those boundaries that facilitate work-life integration. There are tons of studies out there that boundaries build resilience. Resilience building activities, I'm not going to spend a lot of time on it because the bedrock of resilience building is good habits, good sleep, good exercise and nutrition. There is a session coming up, but again, from an organizational standpoint, we need to make sure that our learners and our employees have access to this, easy access to this resilience building activities, especially I am in the GME, like access to gym, access to nutritional snacks when you're on a 30-hour call and all of that. So that is the onus on the organization to promote resilience building activities rather than just holding us accountable for all building our own resilience by ourselves. We need help. The last one is attentional practices. These practices help us maintain our calm amidst the chaotic environment of our daily life. So the first one is reflections. So there was a study, it was an eight-month study done, and again, a lot of the studies were in physicians. They did reflective sessions, which is guided reflective session biweekly over a period of eight months, and they looked at burnout and fulfillment and in general satisfaction. They showed that guided reflection, and I mean guided, it is avoiding this negative self-talk. The guiding principles are specificity, self-compassion, and specificity and self-compassion. So some of the phrases that people use is what I'm assuming that may or might not be true of the situation, and spending three to five minutes every day to actually specifically analyze in a kind and compassionate way. So those physicians had decreased rate of burnout and increased rate of professional satisfaction. Second one is mindfulness. I'm gonna talk about it in the next slide. Mindfulness sometimes get a lot of negative buzz from a cultural or religious standpoint. What I'm here to talk about mindfulness as really a way to focus ourselves, right? A way to get out of a robotic thinking and doing mode. That essentially is mindfulness to me. Last year, in 2022, there were 6,000 articles published on looking at mindfulness and various domains of psychological distress, burnout, moral distress, and resilience, and all shows that mindfulness, whether you pick up a formal mindfulness practice, like meditation guided through an app, or a meditation guru, or you partake in mindfulness-based stress reduction courses, or in some programs, there is enhanced stress resiliency training which is based on mindfulness. It helps. It helps to decrease burnout. It helps to decrease psychological distress. It helps communication with the patients. In general, a surgery training program implemented this two years ago, and the study shows that in surgical residents, it improved patient communication. So that's huge. For a lot of us, including myself, I do not practice formal mindfulness, but there are ways to integrate this into our day-to-day life. I call it micro-mindfulness. It takes anything that takes 30 seconds, one minute. A lot of primary care physicians that I know have this practice of stopping for a moment before they go into the room, because you're seeing 40 patients and go, go, go. The same for us in pediatric ICU. I may have a code, and then I'll have to go head back to another room within a minute or so. So there's some of the techniques I use, and I'm gonna share it with you. It came out in Critical Care Connections, I think it was in 2017. It's called the STOP technique. It literally says S-T-O-P. S stands for literally stopping. It takes 30 seconds to do the whole thing. T stands for taking a deep breath. O stands for observing your thoughts, good or bad, whatever it is, observing for whatever they are without judgment. And P, proceeding with greater awareness. So I do the STOP technique every time I am doing my hand wash, in and out. It kind of helps me anchor and be fully present for the next patient and the family. And again, mindfulness on the go. I do get a lot of questions about, is it possible to implement a program like this in our institution? The answer is yes. There was a study done on nurses where they actually trialed out, which is called mindfulness on the go, looking at the feasibility of implementation programs, where they taught nurses to do micro-mindfulness. Micro-mindfulness, traditionally, anything that less than 10 seconds, 10, sorry, I said 10 minutes, is defined as micro-mindfulness. It does help with burnout and decreasing psychological distress. And then different anchoring techniques. The most common ones are the breathing techniques, whatever method you use. So I think I only have one, yeah, this slide on mindfulness, but again, formal versus informal. I do encourage you today, at least to try informal mindfulness. It has helped me get through pediatric ICU, especially in 2022. Any pediatric ICU folks here? I needed a lot of this last year. It was a hard year. Before I finish on this topic, I do want to put a plug in here for career intentionality. This research was done in women. But the reason I want it up here, for those of you who are leaders among this, when you're supporting a mentee, or you're guiding them through different phases in their life, you're supporting a junior faculty, especially women, but this is applicable to men too, because this is a little bit old research, 2014, so I don't have the latest one. It's like a kaleidoscope. Depending upon your stage in life and in your career, there are three guiding principles that helps you navigate work and life. So what should I do? The three guiding principles are challenge, balance, and authenticity. Like a kaleidoscope, mostly one is a prominent guiding principle. The rest are there. But for example, those of you who are trainees here, we focus a lot more on challenge, right? Challenge, because you are building up your competence. You may not need that much, you may not strive for that much balance, but again, as you advance in your life and career, many may shift gears, and they want more balance, more work-life integration. And later on, mid-career, I was told that I'm technically mid-career, I'm 10 years out, and late career, you may want more authenticity. So just keep that in mind, and be flexible and adaptable to the needs of our employees, and our mentees, and our learners. So that's why I put that slide in there. Next, O stands for organizational resilience. Pandemic really tested the resilience of our organization, right? So a resilient organization shared the three Cs. Those who survived pandemic well, and grew, and had that transformative resilience that I was alluding to, they had good institutional development, and they vested in institutional leadership and development. Their culture was very inclusive and diverse. They had high-quality, timely, effective communications, and they spent a lot of their focus and energy on intentional community building. I can't tackle all of this in one slide, but I do want you to take home and advocate for a culture that is inclusive, focused on communications that are effective, and also building an intentional community. U stands for undertaking the long path to resilience, understanding this as a lifelong skill to build, and also advocate for resilience training during your life, whether you are a learner, or whether you're an employee, or whether you're early, late, mid-career, and a lifelong commitment. And changes are incremental. And my grandmother used to say, T-T-T, so things take time, one step at a time. I do encourage you to actually consider building up your, not only personal resilience, but professional resilience, and take that first step today as you go back tomorrow, or whenever you're traveling back. Just make that commitment to yourself to build resilience, not only personal, but professional too. So I do want to put a plug in here. For professional resilience, right? So navigating challenging dynamics at work builds up our professional resilience, and that involves good negotiation skills, good conflict resolution, and using the shift and persist model of resilience where you use adversity as an opportunity to grow, and persisting as a negotiator. This is very specific to career resilience. So these are the skills that you may want to consider taking up on as you are advancing in your career. And this may also be the skills that you might want to weave in if you are an educator or a leader, if you're supporting your mentee or your early career faculty, even mid to late career faculty. Community building. So we are all here together, right? So keeping up with the theme of 2023, we are always better together. Please spend time to build that social capital and be intentional about your professional and personal community. So keep networking, keep building the community because they're gonna get you through hard times. Last but not the least, engagement and professional fulfillment. I do want to share this. This was a note that was left to me last Christmas, along with flowers. It says, it has been more than five years, but what you have done to my boy is unforgettable. I was having an extremely hard day, extremely hard day, and I found this note with flowers. And the thing is, I don't actually remember that family. But the thing is, I know that I've made such a difference in that boy's life and the entire family. So this is our saving grace in critical care community. This helps me defend my career choice because we are entrenched in advocacy every single day, all of us, advocate of patients. We do it every day, multiple times a day. We have an active engagement with the profession, right? We are very vocal with both the upside and the downside. And we do have strong meaning and purpose in our life. So together that, I think, helps us get through and build some resilience. So as you're leaving this, I do want you to think about the theme bounce and bounce mindfully. I do want to leave some resources. So there are several resources for SCCM. There's a burnout keg. I'm one of the members and co-chairs. The next meeting is on January 3rd, 5 p.m. Please try to join. And there is also an SCCM wellness task force if you're interested. Thank you. I'll take questions at the end. I do have to leave a little bit early. So if you have questions, please reach out to me. This is my email. And thank you. Thank you for your time. And let's keep bouncing forward.

resilience

work-life integration

mindfulness

pediatric critical care

psychological fitness

emotional regulation skills