1. Working Through a Crisis: How to Address Self-Care in a Family Medicine Department Post-Trauma
Sharon Bilsky, LCSW
Maureen Kwankam, MD
BronxCare Health System
May 8, 2018

2. There are no disclosures to report

3. Objectives
On completion of this session the participants will be able to:
Identify ways to promote individual and group self-care techniques among a medical department staff following a crisis
Understand the importance of conducting regular wellbeing activities among medical department staff
Learn how to use external resources to complement internal practices, which can reduce stress on the department’s employees so they can focus on their own wellbeing
Sharon

4. What is a Crisis? Broad/public impact Narrow/more personal impact
Natural disaster (earthquake, hurricane, wildfire, tsunami)
Terrorist attack
Violent acts
Unexpected change in health system/hospital leadership
Death of a prominent individual (ex. Community activist, local political leader)
Narrow/more personal impact
Death - in the department, a staff member’s inner circle (family, close friend, etc.)
Termination of a staff member
Assault (sexual or physical)
Mental breakdown
Resident failing board exam
Sharon
Summary: The word crisis can apply to a wide range of situations. What our department experienced is just one example of a crisis. Here are some examples of events that we consider crises. It is important to remember that crises can be both public and private, so you want to make sure you are prepared to recognize and provide support when you or someone you work with is going through something difficult.
What are some examples of emergency plans your departments have?

5. Event Details
On June 30, 2017 a gunman killed a physician and wounded six other people on an inpatient floor of BronxCare Health System (formerly Bronx-Lebanon Hospital Center). Following the shooting, staff had to work through their grief and shock while simultaneously continuing in their role as primary care and behavioral health providers, and serving as a vital community resource.
Maureen

6. Interventions Used to Manage Emotional Impact
Immediately following the shooting:
One staff member was designated to inform patients of the deceased doctor
Schedules of physicians and staff were lightened (if requested)
Grand Rounds with Psychiatry
FM Residents met with Psychiatry residents and Department Behavioralists
Over the next few weeks and months:
Department and clinics held meetings/support groups to process feelings
Received support from hospital resources and outside organizations (Department of Psychiatry, Department of Pediatrics, Office of Victim Services, Good Dog Foundation therapy dogs, massages, acupuncture)
Maureen
Summary: A lot happens in the aftermath of a crisis and while you want to make sure the immediate needs are getting met, it’s also important to remember the bigger picture. We were able to leverage existing networks, both within the hospital and with external partners, to provide a variety or services and therapies to department members.

7. Interventions Used to Manage Emotional Impact Continued
Department social workers were available at all clinics and on the inpatient unit to offer emotional support
Hospital sponsored a Vigil, Interfaith Ceremonies, Week of Wellness; staff were encouraged to attend
Schedules were adjusted for those who couldn’t return to work immediately
Department held a memorial service to honor the doctor who was killed
Wellness Clinic (where doctor had worked):
Held moments of silence
Staff checked on each other
Communicated well with each other about needs
Maureen
Summary: As you can see on this slide and the previous one, a major part of our response was addressing the emotional wellbeing of staff and employees. Although we had patients we needed to see and jobs to keep doing, we were also still processing what had happened. This was especially important for the people who had worked with the doctor who was killed. The clinic manager and staff took extra steps to check in with each other and make sure no one felt alone during the healing process. Lastly, the department held its own memorial service, which provided a space where we felt we could honor our colleague in a way that spoke to her unique role in our lives.

8. Department’s Sources of Employee Wellbeing and Unity Prior to the Crisis
Employee Wellbeing Committee
Plans events and activities to increase employee wellbeing
Sponsor an annual Department-wide retreat
Monthly support group for Residents - in addition, each resident is assigned a Behavioral Health Advisor
Monthly Team Meetings
Morning Huddles
Graduation and holiday parties
Language of Caring
Non Violent Crisis Intervention Training (Crisis Prevention Institute)
Sharon
Summary: Many of the interventions we used were successful because as a department, we were very familiar with coming together and addressing wellbeing. The department wellbeing committee plans regular events as well as retreats for residents and the entire department. Our department also emphasizes the importance of addressing employee mental health. The behavioral health team hosts a support group for our residents, and each resident has a behavioral health advisory. We’ve also used programs like Language of Caring and CPI that have helped us interact in safer and more positive ways with both each other and our patients. Having these tools and programs already in place made it easier for us to respond after the event, both in regards to having a framework we could use and peoples’ comfort with coming together to address mental and emotional health.

9. Changes Since Shooting, A Work in Progress
Logistical
Regular conversations and updates on safety and security
Safety Champions appointed at each clinic and office location
Showing Active shooter training video
Emergency Crisis Response Plan
Emotional
Increased efforts to promote positive communication
Greater emphasis on destigmatizing mental health treatment among health care professionals and sharing mental health improvement techniques
Sharon
Summary: There have been changes in both our department and the hospital since the shooting, some of which happened quickly and others that are still a work in progress. Overall, we are much more aware of our safety and feeling of security. We have also become more aware of how we work with each other and how to be aware of each other’s mental health.

10. Some Examples of Emergency Planning
Appoint safety champions - they will be the point people during a crisis
Appoint someone to inform patients of crisis if needed
Create a phone tree and update it regularly
Establish an external meeting point in the event of an evacuation
Designate “Safety Room” if evacuation is not possible
Design an evacuation route for your clinic/office space - hold drills
Create a list of internal and external resources (ex. Mental health professionals, alternative therapy providers - aromatherapy, massage therapy, pet therapy)
Designate a space that can be used for staff to take breaks/mentally decompress
Maureen
Summary: Every organization’s emergency plan will look different, because it will be designed to meet your individual needs, but here are some of our suggestions.

11. Leadership interviews
Department leaders were interviewed to get a more in-depth understanding of their role during and after the crisis
Those interviewed included: Department Chair, Department Associate Chair, members of the behavioral health team (social workers), clinic managers, and the Department Administrator

12. Changes in Roles of Leaders During and After
Department leaders found themselves in different roles than they were used to, which had both immediate and long-term effects
“To connect with vulnerable people, to help them or connect them to help if I couldn’t help.”
“To balance business needs and staffs’ emotional needs.”
“To make sure staff are able to perform their duties and help those who were struggling emotionally or struggling to perform their duties.”
“I now am more aware of the employees’ emotional states and wellness.”
“It shifted my priority to putting employee wellbeing and safety first.”
“I’ve put more thought into how my decisions and actions will impact the employees of the department.”
“I’ve made more of an effort in connecting with employees on a more personal and profound level.”

13. Caring for Others While Managing Your Own Response
“It was overwhelming. I couldn’t think of my own needs. I focused on what others need emotionally and logistically.”
“It was difficult to be strong for everyone.”
“It felt fulfilling to help others; however it was an emotional roller coaster. It was painful to see others break down.”

14. What Helped You the Most in Caring for Yourself?
Staff members reacted to the shooting in a variety of ways; many staff were able to get through the crisis with the help of their coworkers
“Having people go out of their way to check in with me.”
“Connecting with each other.”
“Keeping in contact with others to not feel alone with feelings.”
“Speaking to department social workers.”
“Group therapy offered by psychiatry department.”
“Seeking mental health treatment.”
“Support from family.”
“Working as a team to manage crisis.”

15. Changes Department Leadership Has Noticed in Employees
Observed changes are both positive and negative
“Environment among employees became kinder and gentler, there are more smiles, hugs, saying hi more”
“People were reaching out to check on each other, helping each other with workload.”
“Staff are willing to do more, complaining less.”
“Our care for one another has expanded.”
“Employees feel more fear in the workplace and express it more. Staff have firmer boundaries and are less tolerant with patients.”
“Those staff that couldn’t cope either left to another department or resigned.”

16. Interventions That Helped Employees
Department leaders and Wellbeing Committee did a self-reflection to assess the impact of their responses
“Having time together, process groups, retreat, memorial.”
“Grand Rounds with Psychiatry”
“Discussions on safety.”
“Outside counseling resources.”

17. What Could Have Improved Our Response
“Lack of sustainability in response, leadership of response, and safety planning.”
“Communication could have improved about response plan, details about the event, and safety updates.”
“It was difficult to balance business needs with staff needs, lack of time for staff to process before returning to work.”
“Increase inclusion of all clinics in processing event and interventions.”

18. Lessons Learned
It is important to have an emergency plan for crisis of any size
You can grow from a crisis as an individual and team
Don’t be afraid to reach out for help
Reinforce that it’s ok to not be ok
Impact of crisis can last for a long time, continue planning interventions
People need time to process, don’t stop checking on each other
Burnout and PTSD can accelerate in people who aren’t acknowledging it
Established wellbeing activities can provide strong basis for post-crisis healing
Connecting with outside resources before crisis occurs makes resources easier to access during crisis
New initiatives can help people feel they can use the crisis to make a difference
Sharon
Emergency plan: Helps prevent communication breakdown

19. Acknowledgments Dr. Doug Reich, Chair Department of Family Medicine
Dr. Jose Tiburcio, Associate Chair Department of Family Medicine
Jennifer Dunbar, LMSW
Maureen Healy, LCSW, MPH, LMT
Amir Levine, PhD, LCSW
Arafat Omidiran, MHA
Laura Quigley, MA
Mike Sledzinski
Alyssa Steinway, LMSW
Stephanie Taveras
Angeline Thomas
Talia Trachtman, LMSW
Jacqueline Davis, RN