Chapter 18: expansion
All the time, but especially now in our emergency departments, we need teams who are self-regulating and emotionally intelligent. Another way of describing this is to state that the people in the ED clinical team are, ideally, practitioners of mindfulness in some way, even if they do not necessarily use such wording themselves.
It is lucky indeed for an ED if a few individual nurses and doctors are consciously working on mindfulness practice – by doing yoga, for example, or meditating, or reading books that they find inspiring. Individual mindfulness is one thing, but it is much more effective if a team of clinical staff are consciously and deliberately using mindfulness principles every day, in the way that they deliver emergency clinical care
What does this mean in the real world?
Using team “time outs” before we sedate someone in the ED is an automatic habit for me now, but we all know ED clinicians who do not use time-outs.
Operating theatres have similar challenges with their clinicians, with attitudes leading to non-compliance with time-outs. Embedding permanent change in the safety culture is an ongoing challenge for all critical care areas.
So, as I called a “time out” the other day, we realised that we did not have additional IV fluid attached in case the patient dropped their blood pressure during sedation. The situation was fixed immediately, but the pre-sedation checklist was crucial in detecting this potential problem before we started the procedure.
What was mindful about this?
The staff all felt calm and listened to. The patient was included in our discussion of what we were about to do, and was advised what drugs we would be using, as an element of obtaining their informed consent. There was a deliberate calm in the room. The IV fluid error was detected as went through the checklist
When done well, these time-outs reflect a patient-centred safety culture and develop an environment of trust in staff who are empowered to report patient safety events without fear of reprisal, while acknowledging that humans are fallible and make mistakes.
During the time-out, the team comes together and develops a shared mental model of what the procedure will be like, increasing the chances that all members will have the situational awareness needed to prevent harm. It also establishes the leadership of the team and empowers all members to work on behalf of the patient. Administration of drugs, control of glycaemia, allergies, and other factors that can affect an operation’s outcome are discussed in these briefings.Pellegrini, 2017
So, what if the opposite situation had occurred?
Into the procedure room might come an aggressive and hasty senior doctor, speaking to no one in particular, just demanding that the procedure be “started”. Team members are now grappling with a sense of stress, concerned about receiving further negative comments from the senior doctor.
This might well reduce the team’s focus on the checking, and the belligerent senior clinician might then impatiently interrupt the checklist process, or try and “skip it” altogether. The lack of connected IV fluid may not have been detected, and during this hypothetical situation the BP could have then fallen to a dangerously low level.
Atul Gawande describes the links between team mindfulness and safety in his several books about safety culture in the operating room environment1, and he provides concepts that we can also apply in the ED environment.
The contrast between nurturing staff (mindful team approach, inviting input into the time out, etc.), and psychologically undermining staff, is enormous, and the implications extend beyond the safety example described above. Staff resign from full-time positions in emergency departments, because of even one such unpleasant situation, where senior clinicians did not relate mindfully and caringly to the other members of their ED Team.
This is familiar to us all – sadly – and should act as an encouragement for us to apply the mindfulness principles in our EDs and hospitals.
But it all starts at an individual level. One person decides to change something in their own life, and that begins a ripple effect. So here is another practice session that may be useful as a concept for your own mindfulness practice
Mindfulness practice session
Find a quiet place; this will take 10 minutes.
Phones off. Get comfortable in your chair.
Start breathing down from “waking” to “mindfulness” level, focussing on breathing, becoming really aware of the smooth timing and rhythm of the in-breaths, and the out-breaths.
Feel muscles loosen.
As you start to hit that feeling of calm, imagine it to be like a stop point on a “free dive”. Adjust to this level of calm, and don’t worry if distracting thoughts come. Just catch yourself, and re-focus on your breathing cycles.
And let go, and metaphorically dive down the rope again.
Now imagine that you are reaching a level of calmness that is one hundred times calmer than the first calm level you reached.
Recalibrate at this new level; you are becoming very still, very quiet.
Move on down the rope again.
Now imagine that you are reaching a level one thousand times more peaceful than the preceding stage.
How slow your breathing is now.
The mental “noise” is fading away.
Some distractions come up occasionally, but they have lost traction even as they arrive, and they fade away.
Hold this level for a while, then slowly set the intention of returning to the 3D physical world.
Slowly wake up, stretch your limbs, and return to “daily life”.
This will be my final article in this mindfulness series. I am very humbled and grateful for the positive feedback that the articles have generated. Also, I am incredibly appreciative to the editor of this publication, for the invitation to write the series of articles.
These articles have been presented in the hope that the ideas contained may be useful for you.
Mindfulness ripples outwards, as we incorporate it into our daily thinking, and our daily programme. It changes everything.
I will now be focussing on a mindfulness project of another sort. I have joined the creative and editorial team, for an upcoming film documentary about a spiritual text called A Course in Miracles.
…but that is a story for another day.
…and in closing
Our quote today comes from the French philosopher and theologian, Pierre Teilhard de Chardin (1881-1955).
Thank you for reading this, and take care of yourself
- Atul Gawande. The Checklist Manifesto. 2009
- Pellegrini CA. Time-outs and their role in improving safety and quality in surgery. Bulletin of the American College of Surgeons June 1, 2017
- Pierre Teilhard de Chardin. L’amour-énergie, In: Le phénomène humain 1955: 293-294 [Translated: Love as energy, In: The phenomenon of man. 1955: 264-265]
Waiver: These articles represent my own views and approach to mindfulness, and do not purport to be the official view of ACEM. They are not intended to replace appropriate medical or mental health care, provided by professionals in these domains