Burnout is a well-known syndrome characterized by poor self-care, dehumanization, exhaustion, and reduced effectiveness. The study of wellness and resilience among emergency medicine (EM) providers and trainees has recently blossomed, largely as a consequence of recent tragedies of physician suicide, provider distress, and an increased awareness the impact burnout has on both personal and professional domains. While there are ongoing discussions on practices to best address burnout, methods have focused on promoting resilience, mindfulness, and provider engagement.1
Due to competing curricular demands, time for reflection and discourse on provider personal wellness is infrequently integrated into formal programming. The authors sought to develop a meaningful workshop that would allow EM residents the opportunity to reflect on their resilience and create a ‘space’ that would allow them to share outlets that serve to recharge them amidst their training.
Several instruments have been developed to help describe wellness patterns, engagement, as well as resilience. The Connor-Davidson Resilience Scale (CD-RISC) is a psychometrically valid and reliable scale that was originally developed to objectively measure and monitor resilience in patients diagnosed with post-traumatic stress disorder (PTSD). The CD-RISC also offers normative scores for the U.S. general population. For the purpose of our workshop, the CD-RISC was purchased and used as the instrument for residents to reflect on their quantitative resilience scores.
To support a follow-up peer-to-peer discussion on resilience among EM residents after the CD-RISC self-assessment, the Visual Explorer (VE) exercise was used. VE is a set of over 200 evocative images created and sold by the Center for Creative Leadership. VE has been successfully used in organizations to promote reflection, collaboration, and creative conversations among participants. Facilitators of the VE exercise typically provide participants with a framing question that helps guide their selection of an image that best captures their personal reflections.
The workshop was designed for all post-graduate year (PGY) levels in EM at Thomas Jefferson University, a 3-year EM training program. The workshop can easily be integrated into the training curricula of other disciplines, and can be generalized to non-resident participants, including medical student and faculty.
25 residents participated in the exercise with 1 primary facilitator and 2 additional faculty members to help facilitate small group discussions.
While the CD-RISC was the instrument of choice for residents to self-assess their resilience for the workshop, any survey can be used to prompt residents to think about their wellness and/or resilience. The CD-RISC can be requested directly from the developers.
The Visual Explorer Facilitator’s Set ($320-380) is available directly through the Center for Creative Leadership. It consists of 216 postcard-sized images, as well as a Facilitator’s Guide. Images are also available in playing-card or letter-size sets.
Description of the Innovation
The workshop was scheduled for 90 minutes during our regularly scheduled, weekly EM resident conference. Residents were divided into groups of 5. A 10-minute opening presentation was given by the facilitator that introduced the workshop, described the importance of resilience, and discussed the CD-RISC tool.
Residents were then given 10 minutes to complete the 25-item CD-RISC instrument. Normative scores for the general population were provided, which allowed them to see how they numerically compared with the general public. Residents were given the optional opportunity to share their reactions to their scores within their small group peer groups.
Visual Explorer Exercise
Following CD-RISC self-assessment, the facilitator introduced the VE exercise and its instructions. Prior to the beginning of the workshop, >200 VE images were placed on tables in a separate room that adjoined the conference room. They were instructed to first reflect on the framing question, “What makes you resilient?” After reflecting on this question for 5 minutes, residents were asked to move to the next room, to browse through all the images, and to choose the single image that best resonated with their respective reflections. Residents were given 10-12 minutes to complete this task, without discussion, while music played in the background.
After all residents chose their images, they were asked to sit down and reflect on their image of choice. Specifically, they were asked to answer 5 reflective questions.2 Questions included:
- What is the image that you chose?
- What is happening in the image?
- What is the context of the image?
- Is there anything surprising about the image you chose?
- How does the image connect with the framing question about what makes you resilient?
Residents were given 10 minutes to answer these questions. If they chose, residents had the opportunity to capture their thoughts on paper.
Within their small groups, residents were asked to take turns to present their images and share how their selected images tied to the framing question on what makes them resilient. Residents who listened to the presenter were then asked to share their observations of the image, and share subtle findings that may not have been described by the presenter. Each resident in the group was given the opportunity to present her/his image. The remainder of the workshop was allocated for this segment (30 minutes).
Workshop Reflection and Survey
Prior to closing the workshop, participant volunteers were asked to share any surprises and/or insights gained through the dialogue with their peers. The facilitator then closed the workshop, and asked residents to complete a brief survey.
Participants completed a brief 5-item survey based off of Stephen Brookfield’s Critical Incident Questionnaire (CIQ).3 The following open-ended questions were asked:
- At what moment during the workshop did you feel most engaged with what was happening?
- At what moment during the workshop did you feel most distanced from what was happening?
- What actions did anyone take (facilitator or peer) that you found most supportive or helpful?
- At what point in the workshop did you feel most confused?
- What surprised you the most during the workshop?
Overall, the residents enjoyed the activity. By and large, they felt most engaged when choosing and reflecting on their own personal images, as well as listening to their colleagues share their perspectives on what makes them resilient. When asked what they found to be the most supportive or helpful part of the workshop, several residents commented on the supportive feedback provided to them by their peers. Some residents were surprised by some of the subtleties that were unnoticed to them, but observed by their peers. Residents expressed an interest to use VE for other applications during conference.
Theory Behind the Innovation
The workshop is informed by the work of Heron and Reason,4 and is based on presentational knowing. Heron and Reason introduce 4 ‘ways of knowing’ that are defined both in terms of process and outcome. Presentational knowing refers to knowledge that an individual creates and communicates through expressive imagery in lieu of language, which may often constrain discovery and knowledge. This may include movement, dance, sound, music, drawing, painting, sculpture, story, and images. By having residents answer the framing question (i.e., “What makes you resilient?”) through imagery (i.e., selecting a single image from a series of random images), they had the opportunity to tap into a deeper understanding of what makes them resilient, and, in the process, potentially reveal unconscious assumptions they never previously critically thought about.
1.Shanafelt T, Noseworthy J. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146. https://www.ncbi.nlm.nih.gov/pubmed/27871627.
2.Visual ExplorerTM | Leadership Explorer Tools. Center for Creative Leadership. http://www.ccl-explorer.org/category/visualexplorer/. Accessed February 10, 2019.
3.D. Brookfield S. Becoming a Critically Reflective Teacher. 2nd ed. John Wiley & Sons; 2017. https://amzn.to/2SM1CAK.
4.Heron J, Reason P. The Practice of Co-Operative Inquiry. In: Reason P, Bradbury H, eds. The SAGE Handbook of Action Research. Vol 2. SAGE; 2013:. https://amzn.to/2UTtGQl.