Promising Results, Lessons in New Primary Care Stress Reduction Project

people practice qi gong in nature
Qi Gong practice led by long-time Nova Institute friend Mary Pinkard in the “Joy and Work” retreat with Professor and Chair of the Department of Family Medicine Dr. David Stewart (red shirt), Professor and Vice Chair of the Department of Family Medicine Dr. Rich Colgan (blue and green shirt), and several primary care clinicians.

Recognizing the unsustainable physical and psychological strain that COVID-19 had on their patients and staff, the University of Maryland School of Medicine Department of Family and Community Medicine contacted the Nova Institute for help. In response, Nova Fellow Chris D’Adamo and President Brian Berman developed a new demonstration project, Primary Care: A Bridge from Fear to Flourishing, which aims to to help primary care practitioners identify and support patients suffering from high levels of stress or trauma. The program introduces stress reduction tools and techniques to clinicians for their own self-care and so they can recommend appropriate stress reduction tools for patients. 

One year later, the project is showing signs of success, with lessons along the way. The multidisciplinary project team comprises board-certified Family and Community Medicine physicians and licensed social workers, clinical researchers at several academic institutions, leadership from the National Institutes of Health, and Nova Visiting Visionaries Rebecca Etz and Valentina Morani

The team first shared the project concept at a faculty meeting that included metrics evaluating current stress levels among clinicians and guided practices in stress management tools. When follow-up baseline questionnaires and stakeholder conversations revealed that sleep was the main area of concern, the team developed the “Better Sleep for Stress Management” video series. The first video includes practical sleep hygiene tips that physicians could start implementing for better sleep and the next two videos explain how essential oils can enhance sleep and relaxation through topical use and inhalation. The videos were shared with and well-received by more than 75 medical faculty and staff.   

At a Grand Rounds presentation, the team shared evidence of stress management in clinical settings and helped clinicians better recognize stress and anxiety “red flags” in themselves and patients. Participants were also guided through  healthy coping exercises such as a body scan, breathing meditation, and chair yoga. 

Later the team led three stress management activities for the Department of Family and Community Medicine physicians’ “Joy and Work” retreat: nature immersion, a mindful walk, and guided breathing meditation. Each was followed by a reflection and discussion around stress, the physicians’ current needs, and what actions they were already taking.    

Moving forward, the team is engaging patients by working with a Patient Advisory Council and developing a Patient Stress Screening Assessment with patient feedback. This screener aims to address the major gap of a brief, clinically practical tool for assessing stress in clinical care, and it is currently being deployed to 500 patients.  

"The stress assessment and management being offered to our busy practice of over 30,000 visits per year has been spectacular! The training we are receiving and the benefits it will afford our clinicians and patients could not have come at a more appropriate time. Primary care physicians and Advanced Level Practitioners are experiencing a great deal of stress because of this pandemic, as are our patients. Being cognizant of these extraordinary factors and offered some tools on how to deal with them has been very helpful to our faculty and residents. We expect the benefits will be enjoyed even more so by our patients.”

Dr. Richard Colgan, Professor and vice-chair, Department of Family and Community Medicine

Lessons Learned 

By listening to the clinicians, we were able to hear directly about their concerns and adapt the project to overcome them. Some concerns were about getting “buy-in” and engagement around the idea of stress management, a lack of time for adding stress assessment and intervention into both patient care and their own lives, and uncertainty about patient receptivity. 

Additional lessons learned have included:    

  • Engagement with a diverse set of stakeholders is essential to successful program implementation. Such engagement revealed factors precluding communication of stressors by patients to clinicians, including feelings of hopelessness that nothing could change their stress, lack of comfort in sharing their stressors, limited understanding of the ways stress may manifest in their lives, and what they perceived to be more pressing clinical needs or life challenges. This feedback has been incorporated into our Stress Screener and the ongoing development of the stress management tools for patients.
  • Co-creation and co-ownership with clinicians is essential for the feasibility of implementing a novel program into primary care. Including clinicians in the planning and encouraging them to share with their peers created a rapport that secured interest, engagement, and openness with each other and to the project. This also provided valuable feedback that was incorporated into meetings, presentations, and videos. 

To make it easy for both physicians and patients to understand and share evidence-based methods, the team is compiling a Clinical Stress Management Resource Compendium with dozens of practical and proven stress management tools.

The team is looking forward to working closer with patients and physicians to better help them assess and manage stress. Because of the project’s success, it is being expanded to the University of Maryland Medical Center Shock Trauma Center (STC), which is widely considered to be the leading critical care institution in the world. Stay tuned for more updates!

Developing safety, persistence, trust

Healing is facilitated through safety, persistence, and trust.

  • Persistence: “People did not simply progress through this sequence and experience healing. The healing journey was a recursive, back and forth process. They found helpers, used the skills/resources that those helpers provided, found other helpers that provided more resources and used those skills and resources. As this process continued, people experienced a gradual amelioration of their suffering. Although many despaired at times, all demonstrated the quality of persistence—they refused to give up.”
  • Safety & Trust: “To connect to helpers, it was essential for people to feel safe in those relationships and able to trust that the person would be a helper and not a barrier to healing. Persons whose wounds included a violation of trust were especially careful about testing the safety of new relationships.”

Acquiring Resources

Resources support us as we heal. They include reframing, responsibility, and positivity. “Making connections enabled participants to acquire and refine resources and skills that were essential in their healing journey. People also brought their own personal strengths to the journey.”

  • Reframing: “A particularly important skill was the ability to reframe—that is to look at suffering through a different lens.” This does NOT mean minimizing trauma or pain, but rather it often means the opposite: understanding what happened was wrong, unfair, or uncontrollable and that we are not to blame for it.
    • “I think I kept trying to convince him I was crazy. And he kept saying, ‘No, you’re not crazy.’ […] You wouldn’t necessarily say a Vietnam Vet was crazy. You’d say they are responding like you’d expect to extraordinary circumstances.”
    • “I’m not the only one who have [sic] this problem. A lots, millions of people, you know. […] They don’t have nothing to do with that. I guess I have to live.”
  • Responsibility: While we don’t have control over what happened to us, we are the only ones who can help ourselves heal. “A third essential resource that people acquired or refined was the ability to take an appropriate amount of responsibility for their healing journeys. They participated actively in the process of healing. Once again, some participants already had developed this skill, and some acquired or refined it from their helpers.”
    “You need a lot of energy and a lot of work … it takes a lot of work. It doesn’t just happen. It’s not like a magic wand.” This patient understood that they had to actively participate in the healing process.
  • Positivity: “Another resource that people acquired or refined during their healing journey was choose to be positive—that is to have some optimism about their situation.” People have varying predispositions to positivity. In the study, positivity was important in helping people heal. This doesn’t mean a toxic positivity, but rather simply finding some good in life and feeling hopeful about our situations.

Helping Relationships

“Connection to others was an essential part of all the healing journeys.” Humans are social creatures, and even the most introverted of us need close relationships. Friends and family add meaning and value to life and help support us, in good times and bad. When we experience relational trauma, relationships can feel scary, but reestablishing safety and trust in relationships is where the healing happens. (To be clear, we do not mean reestablishing safety and trust with abusers, but rather finding other healing relationships.) “When safety and trust had been established, people were able to connect with helpers. The nature of the behaviours of helpers that fostered healing ranged from small acts of kindness to unconditional love.”

  • “Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.”
  • “Relationships with health professionals were among these but were not necessarily any more important to the healing journey than other kinds of helpers, which included family members, friends, spirituality and their God, pets, support groups, administrators, case workers and supervisors.”

Healing

Healing probably means different things to different people, but one definition that emerged from the study is: “The re-establishment of a sense of integrity and wholeness.” Healing was an emergent property that resulted from each individuals’ complex healing journey, a result of bridged connections between resources and relationships. Healing, in this sense, does not mean cured—none of the study participants were cured of their ailments—”but all developed a sense of integrity and wholeness despite ongoing pain or other symptoms.” In varying degrees, “they were able to transcend their suffering and in some sense to flourish.” When we begin to heal, we find increased capacity for hope, renewed motivation to help others, and are more able to accept ourselves as we are.

Suffering

Suffering is the ongoing pain from wounding. There is debate about whether or not one actually needs to experience suffering on the path to healing.

Wounding

Wounding happens when we experience physical or emotional harm. It can stem from chronic illness or by physical or psychological trauma for which we do not have the tools to cope, or a combination of those factors. “The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.”