Stressed during uncertain times? If you, your staff or your colleagues are feeling particularly spent, it is probably because the level of emotional exhaustion in healthcare workers was already at an all-time-high before COVID-19, with one out of three people already meeting the criteria for burnout. In this enlightening and entertaining module, we will provide some perspective, hope and simple strategies to try during tense times.
Personal engagement video featuring local work by:
Raquel Cabral, PhD, CPH on Burnout
Karen Looper, BSN, RN, CPN on St. Louis Children’s Hospital WeCare program
Shirley Repta, PhD, RN, MBA and Cathy Powers, MSN, RN, ACNS-BC on the Barnes-Jewish Hospital You Matter Cart
Speakers share information on programs supporting personal resiliency:
Resident resources for confidential counseling and support
SLCH support program for those who have been involved in a patient safety event and need counseling and support to move forward and deal with feelings of guilt and anxiety
BJH You Matter Cart literally rolled out to the hospital providing brief moments of joy through songs, selection of personal items such as lavender sachets, journals, pizza or cafeteria coupons to say thank you and you matter.
Okay, yep. All right. Hey, you guys, uh, we're talking about the link between burnout and, and patient safety. Oh my gosh, I don't have to convince you of this at this point, but I do want to kind of give you a quick overview of some of the weird and wacky things that we've learned over the past 5 to 7 years. We've got a $3 million grant from NIH to study well being in health care workers and we ran a series of randomized controlled trials to show that you can cause burnout to go down in healthcare workers. We learned some fascinating things along the way. Something is quite surprising today. The session is going to kind of give you an overview of that and we'll also be sharing with you some practical strategies that we've learned along the way as well as pointing you towards all of the NIH funded resources that you can use as a leader that you can use on yourself, that you can share with your spouse used on your kids. Go nuts. We have some learning objectives for the continuing education credits today and I don't have any financial, uh, things to declare. But imagine if you will, that you are on a cruise ship with all of your health care worker colleagues and you're, you're all together on this cruise ship. And the problem is that there's a bad guard rail on the cruise ship and suddenly half of the people in the cruise ship, half of your colleagues fall into the water. Um, now is this really the right time to yell at your colleagues? Hey, you should really learn how to swim? No, of course it isn't. Uh, in fact, there's a false dichotomy that suggests that we should either use institutional resources to solve this problem or that we should, um, or we should provide individual resources to healthcare workers that are struggling. And I would suggest that this is not the right perspective. Indeed, the evidence that we have suggests you have to do both. You have to fix the guard rail so fewer people fall in the water. And by the way, news flash, Half of your colleagues are in the water right now. They need something right now. They can't wait 5-7 years for systems fixes to come along. So why do we even need individual or institutional resources in the first place? What I'd like to do with the presentation today is pull a threat between the things that work to help individuals and the things that work to help institutions or groups of people. And by the end of the webinar, hopefully you'll be able to use that framework to make assessments about what you want to do for your own well being and what you want to do to help promote well being in a work setting and healthcare work setting near you. But to start, let me tell you the story of the two bobs. The first is our very own baba Lefkowitz at Duke, who was awarded the Nobel Prize in 2012 on research related to stress pathways. He and his lab at Duke recently showed that prolonged exposure to our own stress hormones damages our D. N. A. Promoting aging, cancer, psychiatric disorders and miscarriages. The other Bob is Bob Sapolsky, who studied stress in primates for over 30 years. He's the one on the left, finding that stress Kenrick Havoc with your metabolism, raise your blood pressure, burst your white blood cells, make you flatulent, ruin your sex life. And if that's not enough, it even causes hippocampal atrophy. The bottom line is that stress comes from things that we can't predict and things that we can't control. And those are the only two sources from whence it came now during a global health crisis. There are a lot of things that you can't predict and things that you can't control and this creates demands and erodes your resources over time. This leads to burnout and problems with wellbeing, problems with patient safety and problems with qualities is why we're gathered here together today. There are many roads that lead to quality. But isn't it interesting to note that in times like this and I like to go to this wonderful website where you can get anti motivational posters called despair dot com, www dot despair dot com. You get posters like this quality. The race for quality has no finish line. So technically it's more like a death march. Ah yes, I see him at your targets for the quarter. Uh Now we're going to throw a global pandemic at you were gonna move in a new building. We're gonna change all of our policies and procedures. And by the way we're going to create some hostile situations between some of the patients and some of the providers and and good luck meeting your targets next quarter. Uh That is what it feels like right now and that is where this idea of how much gas do you really have in the tank to deal with all this change comes into play? No don't take my word for it. I love the work done by Ellen Galinsky who does a really interesting survey of Children of working parents in the US. and these are surveys that she sends out once every two years every 24 months and she asks Children a battery of questions. These are Children ages 8-18 years old. She has a whole bunch of different questions, but one of the questions she asks them is what are you most worried about? And wouldn't you know that two out of three of our kids are most worried about mom and dad. They wish that mom and dad were less stressed and less tired and this was before a global health crisis. So why to go back to the earlier point, why do we need individual resources and institutional resources in the first place? Let me start at the beginning with the best predictor that we have of well being. What is your well being going to look like next year? What can we measure now that will tell us where your well being is going to be next year? Well it's work life balance. And so we we ask not, Are you satisfied with your work life balance, which is technically highly related to marital satisfaction and some other things. Um, but we ask, how often, how often do you skip a meal? Eat a poorly balanced meal, not take breaks, how often do you get home late from work? I have difficulty sleeping or change your plans because of work. How often are you frustrated because of technology that didn't used to be on our list? And we went live with Epic at Duke and boom, boom. It's a frequent flyer on our list of frustrations. And then how often did you get less than five hours of sleep there? One of the nights in the past seven. So we asked behaviorally how often you you exhibit these particular behaviors and wouldn't, you know, it tells us something very interesting about work life balance and that is that work life balance behaviors cluster in work settings. So if I want to guess any one of your work life balance responses, I simply look to the people who you work with on a day to day basis, the people to your left and the people to your right, and that will give me a pretty good sense of what your work life balance is, because it's more like a group norm than we thought. There's a social contagion, the behavior of others influences your behavior. Does everybody stopped to take lunch or does nobody stopped to take lunch? Guess what that impacts whether you stop to take lunch? Uh that's a big deal. Does nobody p at work or does everybody be at work that influences whether you do these things yourself? So uh we look at this and I'm gonna show you my own dirty laundry. This is from the Duke University health system. Uh and what we found across 396 work settings is that some of our work settings do a terrible job of work life balance and others do a very good job. So there's a high degree of variation from one work setting to the next. It was actually our biggest source of variation is where you work and what are the people doing in that place where you work now? We also found variation by role. So physicians, residents, fellows and attendings have the worst work life balance of everybody. We measured. Here's nurses kind of here in the middle. Uh Dieticians, environmental services are here over here, on the right hand side, they're doing pretty well with the work life balance. Um but there was variation by role, so nurses are better at it than physicians. We find that work life balance has a lot of variation by role. You know where there's less variation. When you look at burnout, we'll come to that in a second. So there's less of this kind of roll to roll variation when we're looking at burnout per se. Um But where is the variation? Well, how long have you worked in your current specialty? And when we look at the data by years and specialty people who have been in their specialty for less than six months have pretty good work life balance. Once you've been there, though for a half a year, we kill your spirit and you begin to look like everybody else in the health system. People who work days tend to have better work life balance and people who work eight hour shifts tend to have better work life balance. But here's the first point. Well this is maybe the second bumper sticker. The first bumper sticker is stress comes from things you can't predict and things you can't control. And the second one is well being appears to have a social contagion effect. What is the well being like of your colleagues That is going to be related to your well being in some interesting and robust ways. So let's take a look not just a work life balance. Let's take a look at burnout. So here's here's a data from 31 hospitals 829 work setting 17,000 people across the state of Michigan. We collected these data with the Michigan Hospital Association and here we found the same thing for work life balance but we also look for it and found it with burnout meaning there's an I. C. C. Of burnout for 0.26 Let me explain what that means. 26% of any one person. If anyone. Healthcare workers burnout in michigan was predicted by who they work with. So how burned out of your colleagues is predicting how burned out you are. A quarter of your well being now independent of your marital satisfaction, your financial woes, your spiritual existential crisis, that freak show in your homeowners Association, put all that to the side, we can predict a quarter of your well being by looking at the well being of the people you work with. That's kind of interesting. So we haven't traditionally treated things like work life balance and burn out as a team sport but we need to be doing that. Here's another one of those despair dot com posters, burnout attitudes are contagious and mine might kill you. That's actually what we're finding is that the well being of your colleagues is a pretty good indicator of what your well being is going to look like over time. Now we've taken these big distributions of well being and we've broken them into portals and we can we can predict some pretty powerful things. We can predict disruptive behavior rates. Uh just by looking at the burnout rates that people are reporting in their work settings. Are you likely to bully other people? Yes. Are you likely to publicly humiliate others or turn your back before conversation is over? Or hang up a phone before conversations over or make comments with sexual, racist or ethnic slurs. Or even show physical aggression for every single disruptive behavior we looked at, there were very significant differences when we look at high burnout work settings versus Loberg networks, uh work settings. Now this is saying that one predicts the other, but you know, burnout can cause disruptive behaviors and disruptive behaviors can cause burnout. That causal arrow goes both ways. What's very significant to us during a pandemic is that people who are close to retirement anywhere near retirement right now are thinking pretty hard about getting the heck out of dodge when it comes to being a health care worker, because it's been a pretty rough year now. Before there was a pandemic, we already showed that this link between burnout and intentions to leave with strong, Would you like to find a better job? Are you thinking about leaving this job? They have plans to leave within the next year? Yes. So it's important for things like disruptive behavior which are difficult to manage. It's important for things like intentions to leave, which is very expensive and it's something that we're going to really start to feel the pension between kind of july and october of this year. As people really start to evaluate things as we're emerging from the worst parts of the pandemic. And then uh we we've even linked it to some important outcomes like uh here we have a burnout predicting turnover and we have burned out predicting preventable medication related sRS reports. This is pretty important because we've never actually been able to predict preventable harm, but we can use higher rates of burnout are so in units have units, those same units have higher rates of preventable harm reported in them. So that's something we're learning more and more about this all the time. And most of these studies were uh were begun well before and finished before the pandemic started. I'll show you a little bit of of post pandemic data as we keep on going. But the important thing to remember here is that burnout is contagious, but so is well being. Let me give you a bright shiny spot here. Um Did you know that having a happy spouse is associated with a lower risk of mortality? That's right for every One standard deviation increase in spousal happiness, there's a 13 point reduction in your mortality risk. It used to be happy wife, happy life, I think the more 2021 way of saying that is happy spouse long lived your house. So the social contagion we're finding with work life balance for finding with burnout funny with spousal happiness. Uh and what I'd like to do now is to kind of unpack what we mean by well being. And I want to talk about if you if you if you peel back the layers of the onion um what do we mean in terms of the psychology of burnout and well being? And I want to start with this with this first principle and that's that your focus and your reflections are what determine your reality? What do I mean by that? I mean what you're looking at is what determines what you're noticing about the world around you. Your focus determines your reality. To give you a clinical example. If you show a ct scan of along like this to a room full of radiologists and say do you notice anything unusual about the skin? Four out of five radiologists are going to say that they did not see the gorilla in the upper right quadrant. Let me go back. Now. Do you see the gorilla? Why is it that four out of five radiologists don't see that gorilla? Well the gorilla is dark and radiologists are trained to look for and find the light or white colored nodule. In a scan like this. Now that gorilla, By the way is 23 times the size of your average nodule, but they're skipping over the Gorilla because it's dark and they're focused on the light. Keep that in mind because if you're trained to look for one thing that comes at the expense for looking at other things, that's kind of what's happening with burnout. In fact, Renzo Beyonce's done this really interesting research in Germany Austria and Switzerland where they put helmets on people's heads and there's a visor on the helmet. Or they can flash images on the screen and they can do gaze tracking. They can actually follow the gaze and see what people are looking at as they put images in front of people's faces. Some of these images are positive, some of them are neutral, some of them are negative. What Renzo and his colleagues have found is that people who are burned out, we'll skip over positive images and scenes and they will skip over neutral images and scenes. But like a laser beam they focus on the negative. Uh That's very interesting because when they take off the helmet and ask people to recall what they were shown on those flashing images, they can recall with stunning accuracy, the negative images, but they cannot recall the positive or the neutral. So we just like people who are depressed people who are burned out are focused on the negative at the expense of noticing anything positive. Now from a biological perspective or from an evolutionary perspective, this kind of makes sense if you are running from a predator, if you're running for your life to escape a saber toothed tiger, what are you focused on in front of you? You're looking for other things that might try to eat you or get in your way as you're trying to escape that threat behind you, you're focused on the negative. That's a really good thing to do if your goal is to keep your genes in the gene pool. The problem is that we use that same strategy today for things like problems at work and problems at home, 30 year mortgages and things like traffic. Um Now that's not very effective because we're using a very old strategy for dealing with stressors on things that are not life threatening. They're just stressful. And what what we've seen is that the true hallmark of people who have well being under control, The true hallmark of resilience and people who are able to bounce back is not that they focus on just the negative or just the positive, but rather that people who really have grasped the the secret sauce of resilience is that they can see the good and the bad simultaneously. Yes, yesterday sucked and yes, today is a little bit better or yes, yesterday yesterday was good, but today is not as good. They can see the good and the bad stability to hold the good and the bad across situations in your perspective. And to illustrate this, let me give you kind of an analogy, have you ever noticed something about the world and then commented on that thing briefly through your mobile phone and then you get to see what other people commented on. What are we talking about here? Of course we're talking about social media and we can even make that more specific one that's been in the news an awful lot lately is the twitter Hey, if ever there was a mood ring for the world, it might very well be twitter over 6000 tweets a second. Over a billion twitter accounts worldwide. What are people noticing about the world? Are they noticing the good or are they noticing the bad? Hey, here's an idea. Wouldn't it be cool if you could follow hundreds of millions of tweets, people are tweeting about good stuff and hundreds of millions of tweets where people are tweeting about bad stuff and see, do they have different outcomes? People who focus on the good compared to people who focus on the bad? That would be a pretty cool study. Wouldn't I'd like to see that? Well, the name of that study is psychological language on twitter predicts county level heart disease mortality. Now I want to warn some of you guys, I'm about to show y'all some naughty, naughty woods and if you'll easily get the vapors, you might want to avert your gaze away from your screen. But what we found in the study is that from one county to the next in the U. S. There's a lot of variation in heart disease mortality. There's also a lot of variation and what people are tweeting about. And if you lay those sources of variation on top of each other, you see some interesting patterns. So here are the actual data from this study. Now, if you're offended, please look away from the screen for a moment. Um, hostility and aggression words. I will not be reading those out loud. Um hate and interpersonal tension words absolutely hate Mondays with the passion. Why do you need to tweet about that man? You don't need to tweet about that boredom? And fatigue were so, so, so freaking tired man. You don't need to tweet about that. Why you need to tweet about that. But people who tweet about hostility, integration, a hate and personal attention, boredom and fatigue. Those individuals have higher rates of heart disease mortality across the United States. Let's get these words kind of off the screen here for a second. What about the topics that are negatively creating more of these positive themes? You see less heart disease, mortality, skill and occupation, where it's like skills management, customer community service announcement conference meeting attend. You might tweet about me being in the webinar session here today. A positive experience is wonderful. Uh great food, friends company, fantastic weekend. Look at the size of the word weekend. Optimism words, opportunities, possibilities, achieve goals overcome. So skill and occupation words, positive experiences and optimism. Words are associated with less heart disease mortality. So but wait, there's more, If you look at the traditional demographic variables that predict heart disease mortality, you're gonna be looking at things like race and ethnicity. Are you a boy or girl? Are you obese hypertensive or diabetic? Are you smoker? Hey what your income and education. If you look at all those variables together that's the top bar they do a pretty pretty pretty good job of predicting heart disease mortality. Yes. Well here's what it looks like. If you just look at twitter it does better than all of those variables combined. So what you notice about the world says a lot about where your head is right now. So twitter already does a better job than those traditional demographic variables. In fact you can look at a. C. D. C. Reported heart disease mortality map of the United States and compared to a twitter predicted heart disease map of the United States and just see some striking similarities. In fact if you combine twitter and the traditional demographic variables, you don't see any additional predictive power. So twitter already gobbles up all the predictive, you know, utility, uh that you would find things like race and ethnicity and gender and and uh income and education, things like that. So, uh what you notice about the world is important and and keep that in mind because as we've looked at the simple things that you can do that go a long way to bolstering your well being, especially when you don't have a lot of gas in the tank. To begin with. This principle comes into play very specifically. So what's the, what's the lesson here after this little twitter tirade. Please follow us on twitter because we only post helpful things, nice things, positively phrased things we have, we put up videos, tools, publications, etcetera on our twitter. You can also get them on our website. Hsk, you do health dot org. That's where we put all of our resources and things for people inside and outside of the Duke University health system. So why is this important? Why do we need to be focusing on burnout in this way? Well, we've known for a while that burnout is highly associated with important patient outcomes. Burnout predicts lower patient engagement, health care worker burnout predicts higher infection rates, more medication errors and higher standardized mortality ratios. And the very godmother of this whole enterprise is Christina Maslakh who created the MAS LA burnout inventory and she's just a magnificent human being. I just really adore her, I've got to have an academic crush on her, she's just so good at what she does. Um uh and she's just incredibly gracious to interact with. Um and if I could channel Christina for a moment, she would say, she would say if she was explaining this to you, she came up with this instrument in 1974 and it's still the gold standard today. So she clearly knows what she's doing. Um, there are three pillars of burnout. There are three ways that you can get burned out. The first is uh, emotional exhaustion where you just don't feel like you're able to meet the demands that are placed upon you. This is what most of us are feeling right now. By the way, newsflash, if you're not feeling emotionally exhausted right now, you're not paying attention, that's kind of the way the pandemic is unfolded. Depersonalization is where you become more palace. You start to kind of view other people as objects that are kind of in your way and then in efficacy, that growing a diminished sense of personal accomplishment, you just don't feel like you're good at what you do anymore. Any one of these is sufficient to get you burned out. The most common one is emotional exhaustion. That's one that we focus on in my lab and we've collected data on over 200,000 healthcare workers and just using this one way of looking at burnout, just emotional exhaustion, we already see for people who are clinically facing, it's between 40 and 45% here's nurses, Here's physicians, pharmacists, it's about 45 of our workforce before the pandemic already reported burnout through emotional exhaustion that was necessary for being necessary and sufficient for being burned out. So that was before the pandemic. Now, when you look at this across specialties and across roles, it's between a third and about half of health care workers Before the pandemic already reported emotional exhaustion. Now that number is closer to two out of three. So technically it's worse than a coin toss as to whether or not you are burned out in health care right now. Think about that for a second. What we've learned from the COVID-19 pandemic is that the impact that this has had on the workforce is the equivalent of going live with four different M. R. S back to back in one year. There's never been anything like that. Hopefully there won't be anything like that again for quite some time to come. But of course this takes a toll. This erodes our resources and creates all kinds of new demands. It's pretty intense and it's really it's difficult to kind of um put it into perspective in terms of the impact that it's had on the where with all of our health care worker workforce. Um Now let me take a step back for a second, I'm a proud father of four. My youngest child is Tatum, now don't judge, you, don't know what you would do if you had four kids, you might put years in cages to know. She likes to crawl into the crate with our miniature dioxin willow. Now, Tatum is a fierce and avid soccer player, back when we used to go to soccer practice and she, one day I was driving her to soccer practice and I got off the phone with a medical student at Duke and she says, Daddy, you are always talking about burnout burnout burnout burnout burnout, what is burn out dad? And so I says, I says, well, honey and I started to do my whole ivory tower, academic medicine thing. Burnout is comprised of three pillars, there's emotional exhaustion, depersonalization and a diminished sense of personal accomplishment, you know, you're not following me, are you honey? And she says, no, I says, well, honey burnout is, and then it hit me if you can't explain what you do to your young Children, maybe you don't actually understand what you're doing. And this threw me for a loop. Sorry, I just paused for a minute and said, you know, Honey, look, burnout is um, I don't like the way we define burnouts not helpful. It's not helpful for senior leaders to say burnout is three past three pillars, but like that is academically accurate. It's just not useful in fixing the problem. So I said to my daughter, honey burnout is what happens when it gets really hard to notice that something is funny or that something is interesting or amazing. And she says to me, oh my gosh, daddy, that is so boring, I am not telling my friends that you work at Duke anymore. That was exactly how my daughter Tatum responded to me. But we took this little definition back and we had a lab meeting about it. We published it since. And we really like this new way of framing it burn out at its core is the imperiled ability to experience positive emotions. It's the imperative ability to get the restorative effects of positive emotions. Let me say what I mean by that there are 10 of these positive emotions and these come to us courtesy of barbara fredrickson at UNC Chapel Hill. There's joy, which is cheerfulness writ large. There's gratitude, showing appreciation for another person or another thing. There's serenity being at peace with the world around you while I'm from right here in north Carolina. If you make your way halfway through a barbecue sandwich and you realize you've got another half of that sandwich right here in front of you, that's just being at peace with the world around you. Interest, showing curiosity in the world. Hope hope springs eternal. You can be in an objectively dire situation and that one positive emotion of hope can be a thread that pulls you through to a better outcome. There's pride, I was able to achieve this. What else might I be able to accomplish? There's amusement. Did you know that you're 30 times more likely to laugh out loud in the presence of others, Then you are to laugh at the same thing when you're by yourself. It's a highly social, positive emotion. Very interesting one, uh, inspiration. It can be academic, it could be spiritual. You just witnessing that make you want to be a better person. It can be those jaw dropping moments of all. We just have to pause and take in the breadth and the scope and the scale of something like the Grand Canyon and then it's of course love which is all of the above. So you have these 10 different positive emotions and they've been studied empirically for 30 years by Barbara fredrickson. She's done randomized controlled trials where she's shown that if you have an emotional upheaval, it is positive emotions that have these restorative effects, they actually bring you back to baseline. If you have a very upsetting event with a patient or a family member or colleague at work, it's when a colleague comes and puts their hand on you on your shoulder and says, you know, let me tell you about the time that something like this happened to me. Or they or they make you laugh or see the irony of the situation or are they or they make you help you look forward to something or they make you feel inspired? Those are positive emotions that are helping to restore you back to baseline. Positive emotions have an undoing effect. A very specific and measurable undoing effect. So there's two things to keep in mind for positive emotions. One it's through positive emotions that we achieve meaning and purpose. I mean, I double dog dare you to feel like you're making a meaningful difference at work without going through one or more of these positive emotions. You can't and buy into its how we recharge our batteries as they get depleted. Okay, here's the $64,000 question, how on Earth are you supposed to make positive emotions more accessible when the negative ones are so prevalent during the global health crisis? Well, there's a simple intervention that I want to show you today called three good things. We have 18 of these interventions. We have a whole bouquet of different interventions to pick from. It's quite it's quite a buffet that you can pick whichever entrees you like. But I'm going to focus on one today. It's been very popular with healthcare workers during the pandemic and it's called Three Good Things. So how does it work now? Hold on for a second, I know your response to this is going to be similar to my response, which is, oh my God, you want me to write down three things went well today before I go to bed. Give me a break. I've got real problems. Exactly, that was my thought to. Um, but when you look at the effect sizes of this intervention, it's pretty impressive. Um Now the first randomized controlled trial to use three good things, I was in 2000 and five. And they actually showed that if you do it every day for one week, just one week and then you stop and you don't do it anymore. You fast forward six months later, you're statistically significantly happier and you're statistically significantly less depressed. Well, let's take a look at the effect size for this. What we typically see for selective serotonin reuptake inhibitors, antidepressants like PROzac isn't effects as a .3 or .32 for depression and for depression. The effect size for three good things was 30.52 is already significantly better than antidepressants. That's just doing it for one week. So we were intrigued by this and we took the intervention and we monkeyed around with it. We worked with the dose and the duration five good things. One good thing. One week, three weeks to months. We tried a bunch of different ways And we settled on 15 days. We found that health care workers, Uh, would do it for one week at the end of one week, would typically say I was just getting into the habit of noticing. The good as I go through my day. So that kind of report it out when I get my, when you ping me in the evening and I don't, I'm not ready to stop yet. Uh, and so we we we monkeyed with that a little bit. We settled on 15 days. That's why the first publication of health care workers that we did with this, It's called 45 Good Things Three Good Things for for 15 days. Um, so two weeks. And what we found was that if you do three Good things, if you write down what went well today, just briefly, just a quick phrase right before your head hits the pillow, your happiness goes up and it stays up a year later. So 15 day does, it stretches the effect from six months to a year. You get a year's worth of protection for doing this for two weeks. Your burnout goes down by one month and it stays down a year later. Your problems with work life balance, like sleep quantity and quality. This work life balance issues we were talking about before like not taking breaks and getting home late from work, They improve and they and they stay better. 12 months later, your depression is down and stays down a year later. Guess what? This is not going to interfere with anything else you're taking. So, pharmacologically speaking, if you go off of SSR is after a few weeks, the effects melt and you're right back to baseline. But we don't see that melting effect with three good things. It appears to be a skill, not a pill that is kind of changing the way you view so that you're you're focusing on the good and the bad. We don't need any help focusing on the bad, but we have a new way of deliberately focusing on the good which allows us to kind of get those restorative effects of positive emotion to help return us back to baseline. Now, we did this again, we thought this was fascinating and we wanted to kind of really dig into at what point do you see the effect? Because srs take several, they take quite a while to get the right medication and get the right dose and everything. And so how quickly does three good things work? And we actually were able to measure this. This is a whole another publication. We found that by day 15 Your burn out, your emotional exhaustion was already significantly better by day 15 and it stayed better a year later. And moreover, it's uh, well being indicators like how tall are you thriving or flourishing and how were you able to bounce back or recover from emotional upheavals? Those two were better by day 15 and stayed better 12 months later. If you want more information about these tools and these different resources, you can find out about our webinar series at B I T dot L Y ford slash Well, Duke W E L L D U K E. Um, that's on our website too. You can go to our website to get access to any of these tools or resources. Um now to channel Barbara fredrickson, who is the researcher who does this positive emotion research. She says the negative screams at you. But the positive only whispers, why is it that It's so hard to remember a good joke, but it's so easy to conjure up negative, scary images and sounds like I grew up in texas. And so uh hearing the sound of the diamondback rattlesnake on a trail is just something that still raises the hackles in the back of my neck even today. Why can I remember that sound? And that feeling so vividly, but I can't on demand produce the funniest thing that I've ever I've ever heard of. A funny thing I've ever seen. Well, it's because we're hardwired to remember the negative. We don't need help with that. Number two, we have enhanced recall of things that we review or reflect on during our last two wakeful hours. So what's the best time to do three good things? What's the best time to study for boards? It's not when you wake up in the morning, it's actually because when you're within two hours of sleep onset, because that's what populates the way your brain is metabolizing information and integrating new information into the way you understand the world around you. So you will retain it longer, you will understand it more deeply more comprehensively if you reflect on it within two hours of sleep onset. So it's the best time to study for. You know, it's it's actually right before you go to bed, even if you're tired, that's a better time to study if you want to retain that information, that's what we call it. Three good things in bed. And then lastly, with practice by day three or four or five by reflecting on positive things, you're gonna notice that it's getting easier to notice positive things as you go through your day. So we asked people at what point are they noticing that it's getting easier to notice the good and it's it's usually by day four day five sometimes by day three people saying yeah I went to my day today. I think we could put that on my list tonight. There's something about that process that it just strengthens that muscle. You can do this by email or text. You can start any time. It's on demand. We'll send you a little link and you can click the link and it says what is it says, what is uh what went well today and what was your role in making it happen? And then you get to choose a positive emotion that goes with that. So my five year old swim across the pool at the Y. M. C. Without any floats for the first time today. How to make me feel? Maybe I'll say pride, good thing number two I watched as a glorious pink and orange sunset behind the rolling hills where leaves are changing colors is beautiful. How to make me feel on wonder. Good thing number three made my wife laughed so hard at dinner tonight. Her eyes watered, so did mine. How to make me feel. Maybe I'll say amusement. Maybe also love. You just did three good things. It's not a complicated thing. It doesn't take all the time. There's no deception in our research. There's no sugar pill. We've already collected the randomized controlled trial data. If you try this out, you're gonna get the intervention immediately. Here's some samples healthy needs per ultrasound, delicious dinner out about hubby, great genes for half price as a surprise. Uh, you don't have to use our way of doing it. You can put up a piece of butcher paper in your break room and leave out some sharpies and allow people to harvest those little uplifts as they go through their day. You can put a white board outside your door and and and write your good things on the on the white board and allow people to get right on that white board as they come away to talk to you in your office, you can start a group text with people in your family members and loved ones and say here my three good things for today, what are your three good things? There are a lot of different ways that you can apply this and they all have this effect of surfacing and deliberately noticing the things that went well that day. And then there are some um positive consequences of that for your well being downstream. Here's an example of what it looks like a Duke Raleigh hospital where they put up a bulletin board and leave out sticky tabs. We can write down your good things on a flower petal and you put it on the flower patients do this. Family members do this, providers do this, staff do this. It's pretty, it's pretty straightforward. Also pause every once in a while and read through what other people have written and it's nice. Do you have to do this every day? No. Do it for one or two weeks a year. And that's it. You can spend the other 51 or 50 weeks a year doing something else for your well being, but you don't have to do this every day for it to be effective. It's just one or two weeks here. One week is the equivalent of about a half a year. Two weeks is the equivalent of about a year's worth of efficacy. The two week intervention. The 15 days actually takes you out about 14 months before it starts to wane. It's pretty simple thing to do. This is what we call them bite sized strategies. When we ask people at Duke who have done it, which is in the Green Duke University Hospital have done it versus people who have not done it, which is in the orange, we see some pretty significant differences in teamwork norms, and patient safety norms in health care worker, well being and work life balance, significant differences. When we ask people who finished the intervention That 96 said they'd like to recommend it to a friend, 86 that they've already encouraged others. Detroit. That's why it's got this kind of viral kind of, uh, you know, aura around it and then 93% of our participants, so they want to do it again next year. Hey, in 2021 when we live in as divided a country as we do, if you can get 93% of a group of people to agree on anything, that's, I'll take it, I'll take it. Um, it's on demand. You can start any time, you can choose email or text formats. All you need is a mobile phone. Does anybody, does anybody have a mobile phone? You type into your mobile phone, V I T dot L Y forward slash start the number three GT. Start three GT. It's as simple as that. And then we'll send you a text right away. B I T dot L Y. Ford slash start three G T. And there's like three good things. This is day one of 15, Day two or 15, 3, 15 and that's how you can keep track of it. Uh When we're done, we won't continue to email you but there is a one month and a six month and 12 month follow up, just like you saw in the data earlier, we still collect the follow up data and we also direct you towards other resources in those follow up, so you get something out, if you come and give us your follow up data will give you access to some more resources. Um So that's just very straightforward, very simple. We do this because the negative is like velcro, it sticks to you like static clean, get the negative off, you have to kind of peel it off one at a time because it's so sticky. The positive is like teflon and it just kind of slides off what we're trying to do with three good things that make the positive stickier so that you can get the restorative effects of positive emotions more readily for for a purpose and meaning, but also for recharging your batteries as they become depleted through so many things that have the ability to drain our batteries. Uh here lately, it's scalable. You can do this by yourself, you can do this with your spouse, you can get with your kids three good things at the dinner table, you can do when you're tucking them in. Uh you can start a group text with your older kids. Um it's relatively robust, two different applications. Uh it doesn't take long to enroll, uh 2 to 5 minutes to enroll and and get into the three good things intervention that's designed for healthcare workers, 1 to 2 minutes each evening and after two weeks or 15 days you're done. You don't have to keep on doing it. Um, if you think it's, if you like this idea and you want to share it with your colleagues, uh we made a three minute long youtube video about three good things. So you can show this at a staff meeting, you can show the grand rounds, you can put it on a ipad in the break room to let people see what this is is a resource. You can send this link, it's B I T dot L Y four slash three GT demo and it gives you the data and shows you how to do it and how it works very quickly so that you don't have to explain it. Why do we do this? Because we've been doing this for a while and people will come back to see brian, you know, I went to your grand rounds and I I did three good things myself. I'm totally convinced, totally bought in. But then when I try to explain it to my colleagues, it sounds cheesy. Like if you just write down three good things, it's gonna be good for your well, it sounds cheesy. I know. Um but we've designed this particular intervention with healthcare workers in mind, we know you're tired, we know you're distracted, we know you're just physically and emotionally and politically exhausted. We tried to make it as streamlined and as helpful as we could and we put in some bells and whistles to make it friendlier for healthcare workers. But you don't have to use our way of doing it, do it, do it in a way that makes sense for you, bringing positive emotions into interactions in ways that make it make make most sense for you in your situation now. That said, I talked to you at the beginning about pulling this thread through individual interventions and institutional interventions. and I want to kind of revisit that for a second. So how many of you are familiar with this concept of traditional patient safety leadership? Walk around. So this is a patient safety quality conference. I'm sure you guys have been playing with this in your own work settings on your own. This is when a senior leader comes into your work setting and says, so how are we going to kill the next patient around here? And what can we do to prevent it? That, by the way, was a fantastic way to start a risk related quality related conversation In 1999 in 2021. That's a really good way to piss off a bunch of your colleagues. So let's not do it that way. Instead, we've learned about positive emotions in this session today. How about you kind of take that framework and apply it to this traditional patient safety rounding concept. So instead of saying, we're going to the next patient, the positive rounding frame would be what are three things that are going well around here? And one thing that could be better. You're gonna get staff talking to you about what they're hopeful, about what, you know, what they're looking forward to, what they're inspired by, what they're grateful for, what they're interested in. And here's the pebble in my shoe about something that I wish we could make go away in the work setting by talking about both by talking about the good stuff alongside the bad stuff, you essentially create psychological safety. Now, there's more trust between that leader and the staff. We can have more meaningful conversations. You put a plank in the bridge of trust so that in the future It's easier to walk along that bridge to have those discussions about quality and safety with your colleagues. This is about using what we've learned from the wellbeing interventions to support and undergird our quality and safety efforts. We do this at Duke, we eat our own dog food. We have a 500 work settings across my health system that have tried this out. And we ask every member clinical and non clinical of every work setting, clinical and non clinical do senior leaders ask for information about what's going well. And we break it into quarters the bottom quartile there to see that we don't do a very good job very often of asking about what's going well in the top quartile. The green, We do do a good job. We asked him, hey, tell me what's going well about, you know, over 80% of the time. On average, we're asking about what's going well in that top quartile. If you just compare our top 25% of work settings for, for asking about what's going well to the bottom, 25%. You'll see some pretty interesting results when it comes to our safety culture and our workforce well being data here is our results from the Duke University health System. Are improvement readiness. Our quality improvement readiness. Our ability to take to take on new quality projects is better in work settings where we ask about what's going well. I think more highly of my nurse manager, my medical director in work settings were unmasked about what's going well. Teamwork climate. Do we resolve conflicts and ask questions to clarify ambiguities and have good physicians dynamics. Yes. Better in work settings where we ask about what's going well, safety climate. Would you feel safe being treated here as a patient? Our air is handled appropriately here. Yes. If you work in a place where we're asked about what's going well, what about my emotional exhaustion might burn out. It's actually the reverse pattern. If you work in a place where we asked about what's going well, you're less emotionally exhausted. What about how burned up my colleagues remember the social contagion of burnout. They are less burned out. If you work in a work setting where we ask about what's going well. How about work life balance? Work life balance is better and works. I think we ask about what's going well, all of this is to say that there's something very powerful about imbuing standard interactions in standard situations with little components of these positive emotions. Now, in this same data set, we ask people questions like around here, are we able to gain insights into what we do well around here to be pause and reflect on what we do, what we call this, pausing and reflecting. And you can actually capture the pause and reflect concept and control for it statistically with all the other respondents. And when you do that institutional resources like positive rounding institutional resources like second victim support, short center rounds and even traditional patient safety leadership walk grounds. They go to zero or nearly zero. We know that those institutional resources are powerful. But if you statistically control for a positive and reflecting on what's going well for those positive reflections, they lose all their emphasis, all the other kind of predictive power. So what is something simple that you can do tomorrow? If the secret sauce here remember the thread I was kind of alluding to. If the secret sauce here is pausing and reflecting on what's going well, what can you do tomorrow, regardless of what your background is, regardless of how much power or control you have? Can you, can you advocate for putting into the next meeting agenda that you're part of? One good thing so far this week? Just to have people to a quick round robin at the table. What's one good thing despite the global pandemic? Alright, what's one good thing so far this week? You'll learn interesting things about your colleagues, personally and professionally. What are they relieved about? What are they looking forward to? Its fascinating. It doesn't take much time. We have 20 people in my lab. We do this every thursday. It takes about three minutes to get 20 people to go through real quick and just talk about what they're looking forward to. You know, my um my daughter just returned from Myanmar, I'm going antique in this saturday with my spouse. You know, it's interesting and you pop pop pop popcorn and then you're done and it changes the way people are present in the rest of that interaction. It's a great way of kind of restoring a little bit, putting a little bit back in the tank before we talk about some heavy stuff and make it even more difficult to bounce back. We looked at this at Duke, we have a second victim support programme and we looked at the extent to which people felt that the mothership had their back on a particularly bad day. So here we have the percent of people who agree, yes, individuals emotionally traumatized by an unanticipated clinical event in my work setting receive appropriate support from this health system. This is this is Duke data and we break them into court trials in the same way that I've already shown you. And again, we see the same pattern of results where all the safety culture and work and well being data are impacted their powerfully predicted by the extent to which you feel supported, feeling supported by your mother ship on your worst day at work. It means everything for the safety culture and for the well being of the people who work in your work setting, it means everything. So if you think that they're reaching out and and having a conversation with a colleague after a bad day that they're having is important, if you think that somebody else is gonna do that, somebody else is bound to cheer them up, I don't want to make eye contact with them right now. Go do it. Oh my God, you don't have to be a therapist to show empathy and to show concern. Uh and that means everything for these people when they're at their most vulnerable. This is something that you can do, By the way, if you're in a leadership role. Let me show you how we measure leadership. This is a big study where we looked at leadership, as are you available at predictable times. Do you provide positive feedback about how staff are doing? You provide frequent and frequent and useful feedback? And do you communicate your expectations about things in advance when we measure leadership in this way, we actually found that for every 10 point increase in leadership There's a 20 reduction and the odds are being burned out for that respondent, wow. So that's like one step up, three steps down. One step up in leadership is three steps down for burnout. That's nice. That's so leadership matters the way you approach these situations, matters being present and even focusing on what's going well it matters. This is all about pausing and reflecting which is the secret sauce for these individual interventions. It's the secret sauce for these institutional interventions and for these effective leadership practices. Let me tell you something, my chief medical officer john bay, he'll come and say, hey man brian. Uh let me tell you about what I'm doing for my well being right now because it is crazy right now. And okay, now, what are you doing for your well being? And these conversations with my CMO allow me to be a little bit vulnerable and he's role modeling, being a little bit, you know, psychologically accessible and vulnerable with me. I can role model that with with my staff. That's really important that our leaders espouses these values and and and and there are all kinds of leaders as you well know, if you are putting yourself out there in a way that's measured and reasonable and being appropriately vulnerable during this very trying time, you can be the life preserver for the person who is in the water right now and they just need something to grab onto now. Uh let's review before we go into Q. And I'd like to tee this up for Q. And A in just in just a minute. So uh so Emily just kind of stand by and we'll we'll take a look at the chat and what people are asking to start asking your questions, put your questions into the chat now. Um uh stress we know comes from things that we can't predict. It can't control when it comes to these wellbeing nuggets that we've covered today. There's the social contagion. We saw that for well for work life balance. We saw that for burnout, we've been sought for spousal happiness. Uh, and also positive emotions are key to well being. And especially if you want your quality improvement instead of seeing the see saw, we saw two diagrams. Um, well I got better and it got worse. It got better and it got worse. You can imbue situations and your quality improvement efforts with positive emotion and have more enduring sustainable results. We also know that these individual and institutional resources the key behind three good things, pausing and reflecting on what's going well. The key behind gratitude, pausing and reflecting on what's going well. The key behind positive rounding right or second victim support, pausing and reflecting on things that are going well. So that is the threat that we wanted to pull between these individual resources and these institutional resources. As we, as we kind of look at the, at the data and the results and and our website, Hsk you Duke health dot org. We have a whole bunch of NIH funded free resources. All these tools, 18 of them here for you to check out. We, we have tools for cultivating joy For cultivating all and wonder one of the first positive emotions to leave the building when you get burned out is to feel uh, you don't feel amazed by the world around you anymore. We developed this tool specifically for physicians, but it's really popular with, with all kinds of health care workers. We have one for cultivating gratitude, which is the simplest 1. 3 good things is the most popular, but I have to tell you the simplest one. If you just give me the simple, which is the easy button. The one thing I can do. Uh, it's definitely the grad too. If you just want one simple thing you can do in seven minutes in a staff meeting, put this link in front of people, let them get out their mobile phones. It does a couple of things. It gives them feedback about their burnout relative to hundreds of thousands of other health care workers. And it gives them a simple 5-7 minute long activity where they can feel the benefit. And we have demonstrated in randomized controlled trials that that benefit is enduring a month and eight weeks later. So that's pretty cool. So five minutes today. Tell us eight weeks. Look it doesn't last eight years but for five minutes I'll take a couple of months of elevated wellbeing. We have one for cultivating humor, for cultivating work life balance, one for cultivating hope and interest. We have one for mindfulness. We have one for cultivating perspective or how to give positive feedback to others. We have one for random acts of kindness and for self compassion. One for cultivating serenity, one for using your strengths, which is particularly important during these very difficult times. We have one for improving your sleep quantity and sleep quality called the sleep tool. We have today, we talked about three good things. There's a lot of things here for you to choose from. Check it out. We explained on the website how long the tool takes is a two day tool or an eight day tool. Uh And and how much time is this gonna take for you to to do it? So you can gauge like where your interest level is and what you want to focus on and with that I want to simply state. Uh The tool we talked about today is B I T dot L Y. Ford slash Start three G T. The webinar series where you can get more information about all these tools is B I T dot L. Y forward slash well, Duke. And so with that, Emily hit me, what kinds of clarifications can we give to help people with uncertainties or anybody want to push back on anything you've heard today? Far away. So just remember if you have any questions you can put them in the Q and A at the bottom. So brian, thank you so much for that. Fabulous talk. Um I know and I started um I heard your talk this summer. I started incorporating some of these little things into just questions. I was asking my team. Um I'm I started meeting off with what was the last good deed that you did and that would get people kind of thinking of what have I done and then the clinical setting, you know, just asking some of the folks I work with, who have you helped today. Um and again getting them thinking about the good that they're doing and not just all the problems that they're seeing it. That's really impressed me with your work is how easy it is to incorporate some of these into our everyday practice. Um Thank you for saying that we're not asking anybody anybody to go with a new vendor for something. It's just like a little principle. You can use it in your marriage, you can use it as a parent, you can use it as a manager, you know, just folded in and where it seems reasonable. Yeah. So the first question is um since burnout is a team sport was their participation threshold needed to see the benefit of three good things. Um Did the whole group benefit the participation of some with three good things? That's interesting. So that's a really good question. And so we've been, we've been talking about herd immunity for all kinds of quality and well being related things for a long time before most of the, most of people were aware of this kind of public health, you know, phenomenon. Now people talk about it as if they know what it means to, but you know, two years ago, nobody really knew about herd immunity. The herd immunity level for this, if you want to confer special protection on other people in your work setting is 60% that's the level where um once you get 60% of your colleagues in a given work setting, now that's whether or not you got 40 people or 100 and 20 people in that work setting, once you get to 60% of them who have done it, it actually starts to confer additional protection on people who didn't yet do it. That's fascinating. Um another question was this is also a good practice for Children before they reach burnout. Is there a way to have this as a learned behavior to carry them into adulthood? Uh So we, I use three good things on my kids all the time. My daughter is, she just get nightmares. Uh and we would use it as a sleep aid for her and she got used to doing it just to get to get her to go back to sleep. All of my kids every once in a while, they just bring it up on their own at the dinner table. Because you haven't asked me about three good things in a while, I'm gonna tell you about three good things from today. It's a great practice to do this kind of stuff with your kids. It's also really important to role model this as parents. And so to do this in front of your staff or to do this in front of your kids is a great way for people to say, oh, this is, this is this is a good behavior to be exhibiting. Anyway, I'll give an example of gratitude has been shown if this is a little off topic and Emily, I'm sorry, but let me just go down this, this thread, this rabbit hole for a second. If you're concerned about your Children acting overly entitled, like they flip out if you take away their mobile phone, for example, if they flip out, if you tell them to go to bed a little early, you know, um then what we've actually seen is that parents who role model gratitude in front of their kids have far fewer of these kind of entitled behaviors, even with people who expressed a lot of those entitled behaviors recently. Uh, there's gratitude has a, oh, this is how we're supposed to be rolling. This is how things are supposed to be, so espousing these kinds of behaviors and values is really good for uh, it's a tonic if you will for some of the social media side effects that have led to kids not going to bed early enough kids spending too much time in front of screens. Kids being a little bit overly manipulative in there in the way they phrase things and social media. Um, we want to, we want to kind of rein that in any way because that's not going in a great direction for our youth. Yeah. And the reason I'm smelling is I'm thinking about my own Children and uh how this sounds very applicable to them. Um One of the next questions is um somebody working in the emergency med doing Q. I. And it can be hard to get the the team to buy into this um soft stuff in quotes. So what do you suggest for kind of those hardened folks that uh how do we engage them with this? Well I mean y'all are pretty quality and safety savvy. Like how would you launch a new Q. I. Intervention? You wouldn't have one person beating a drum by themselves. Like hey everybody, let's do it this way from now on. Like you have to, you have to get some select people on board who are clinically and socially and emotionally respected in that work setting. Who when you're doing a quick round robin for example. So that's one good thing so far this week. And if you're going to have 20 people stand there and do that at a shift change, make sure you get at least two or three people to do it with you the first time you do it. And then while they're doing it, it gives the fourth and the fifth and the sixth person a chance to think of what they're gonna say when it becomes their term. Uh, those are simple strategies. We've actually we trained well being ambassadors of Duke. And that has been such a powerful strategy across different types of interventions. If you just get a small number of people to talk about their experiences with it, it's not the manager saying, you know, here's what we're doing this week. It's not, you know, it's not coming from outside the unit. It's something that that that they're doing, uh, to help people inside the unit. That goes a long way across these different types of interventions. Okay. Um what do you do you get the sense? Um or kind of what would your advice be when um it feels like upper leadership is resistant to some of these principles. How can people kind of go from bottom up, you know, to to implement some of these things or try some of these things? That's a that's a great question. Uh look, my first thing I tried to do when when I encounter that kind of pushback is I try to remember that those pathologically pessimistic people, uh those people, people who are like, oh why try, It's never going to make a difference. You know, those kind of yours in the leadership world. Um they oftentimes really smart, but they're just so burned out that they don't have, they don't want to try anything. So they try to put it won't matter. Anyway, nihilism in front of any of your ideas. So the first thing I try to do is activate some compassion for them because I realized that you're being a pathological pessimist is the health equivalent of smoking two packs of cigarettes a day every day. Uh, and so my first thing is, wow, that's, that must be hard to be where you are right now. And so I don't, you don't say that out loud, You that that part you don't you don't say that part out loud, that's parts for inside your head. Um, the second thing that you do is data are fantastic Kevlar and from a quality and safety perspective, you all know that if you want to, uh, to experience that sense of being relatively bulletproof, collect some really good data before, during and after your interventions and watch what happens. This stuff does make a difference and it does matter. And we publish it in medical journals. That's it's really important to have the evidence behind it. The third thing is that, um, uh, don't wait for some curmudgeonly gray haired person in your senior leadership team to tell you that this is a good idea for you to take these little steps that make a big difference today. Um, because I got news for you if when we look at, when we, you know, if you're drawn to healthcare, uh, you are definitely high on the compassion scale, right, Pete. You're concerned about the well being in the welfare of others because you you decided to get into health care, uh, in general. So relative to the human race, you're already kind of special. If you work in health care now, that said something you should know about the human race Is that four of human beings are sociopaths. They don't have the ability to care or feel empathy or sympathize with other people. They don't feel badly about things, They don't have the ability to feel badly about things. So if you are not burned out right now, if you if you know, I'm not burned out, I'm fine, and I would argue that you're statistically more likely to be a sociopath than not because the stressors are so severe right now. So if you're if you're if you are in a leadership a role and you're hearing about all these very difficult, heavy situations from from political unrest to social injustice, to not having enough equipment and staff to do what you need to do safely and effectively the moral dilemmas that we're faced with on a day to day basis. If you're not burned out as a leader, I wonder if you have the ability to feel compassion for other people, writ large, 90 to 100% of the leaders that we measure the senior leaders, that we measure our burned out right now. That's senior leaders. So it is everywhere. And sometimes people will hide behind nihilism and say nothing you do is going to make a difference anyway, so greet that interaction with a certain amount of sympathy and recognize that you don't need their permission to make nudges and big differences in the well being and the welfare of the staff in your work setting right now. And that's kind of what this big list of interventions is about. You can pick and choose. There are things that you can do at the institutional level or at the individual level. And we have options right now. The secret sauce across them is are you pausing to reflect on what's going well? And you don't need anyone's permission to change the way you do a staff meeting or to change the way you do huddles, right? You can do that. You can make those, those changes in measured ways, um, uh, just with, just with your infrastructure within your work setting.