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The Best Defense May Indeed Be a Good Offense
By Caterina Spinaris & Gregory Morton
Published: 10/01/2018

Stress Reprinted with minor edits from the March 2017 issue of the Correctional Oasis.

In Desert Waters’ signature course “From Corrections Fatigue to Fulfillment™” (CF2F), we repeatedly emphasize that wellness interventions designed to bring staff from work-related fatigue to fulfillment are a two-way street in an organization. That is, to maximize the probability of successful outcomes, interventions must be BOTH top-down AND bottom-up.

By bottom-up, we mean self-care and other health-promoting activities and behaviors that individual staff can practice on their own, independently of anyone else, on and off the job.

By top-down, we mean programs, resources, and system-wide policies instituted and implemented by the organization to promote and protect employee wellness.

Bottom-up, individual-focused activities are about what employees can do themselves—and that no one else can do for them. They and only they can make these behaviors happen, and often only they know if they have disciplined themselves enough to follow through with these activities.

Individual activities—bottom-up—include a good sleep hygiene; healthy nutrition; regular physical exercise; avoidance of substance abuse; engaging in breathing, stretching and other types of relaxation and mindfulness exercises; applying anger and anxiety management techniques; practicing effective interpersonal skills; and engaging in social and/or spiritual types of activities that boost resilience, give them joy, and confer meaning to their lives.

Organizational, top-down activities are those most directly accomplished by agency leadership through a broad variety of system-wide approaches. Examples of these are strategic well-being initiatives, messaging about and recognition of Corrections Fatigue issues, specialized training courses, intentional role modeling, management performance objectives and evaluation criteria, budget and resource allocations, creation of new positions—such as wellness coordinators, staff psychologists or staff chaplains, new policies that address these issues, and as always, increased staffing levels and reduction of overtime.

In other words, organizational, top-down interventions and strategies involve bestowing on employee well-being the policy-level decision-making status equal to traditional correctional concepts, such as safety and security.

This could happen by measuring staff well-being programs in a pre-post manner to ensure return on investment; by requiring that staff training and literature on self-care and resilience-promoting behaviors be added to an agency’s employee development catalog; by offering confidential peer support, Employee Assistance Programs and other mental health and wellness services (if they do not currently exist, or improving access to them and their effectiveness, if they do ); by carefully designed programs that increase family member understanding of the challenges of the job and ways to deal with them constructively; by changes in policies and procedures, where possible, to mitigate the impact of inherent work stressors (such as creative staff-focused work scheduling emphasizing a reduction in mandatory overtime or constantly expanding caseloads); and perhaps even by advocating for the notion that staff well-being is as crucial to agency effectiveness as are successful offender programs.

And this is where a good offense becomes the best defense. In some ways, several of the bottom-up approaches can be considered “defensive” and reactive maneuvers—figuring out ways to cope, after the fact, with the negative effects of exposure to inevitable work-related stressors. (Although it is also true that some resilience-boosting and self-care behaviors may act as preventative “inoculation” strategies against future stressors, if repeated over time.)

Top-down, organizational strategies, can be both “defensive”—such as, for example, the provision of a protocol for staff support following exposure to traumatic incidents—but, very importantly, they can also be “offensive.” This happens when the organization proactively puts in place policies and procedures to lessen the occurrence or impact of anticipated work stressors. When such P&P are used effectively, staff do not have to expend (as much) energy trying to recover from the negative aftermath of workplace stressors, simply because there were supports already in place that they could recognize and count on. And perhaps because of the policies and procedures they were exposed to them to a lesser degree or not at all. That is, organizational strategies can be preventative, and as such they can be invaluable. As the folk adage goes, “an ounce of prevention is worth a pound of cure.”

We at Desert Waters maintain that both these approaches—top down and bottom up—are important and necessary. When contrasted with one another, effective top-down organizational strategies would seem to carry more weight—be even more critical than individual ones (ALTHOUGH BOTH ARE NEEDED), simply because of the energy-savings and the reduction or prevention of damaging work conditions on a large scale.

It makes sense to focus on fixing the leaky faucet, instead of just continually mopping up puddles on the floor—even if one becomes really good at mopping up water.

Interestingly, we find reinforcement for this top-down/bottom-up strategic solution approach in recent research in the medical profession. Three meta-analysis* studies of the tools used to mitigate physician burnout** address the same dynamic. The first paper [1] analyzed research results from 52 studies that included responses from 3630 physicians, and the second paper2 used results from 19 individual studies of 1550 physicians. The third, and largest, study3 drew important conclusions about professional effectiveness, thereby linking to the question: Is Fatigue/burnout mission-critical? Their answer is: definitely yes!

These studies show that burnout among physicians may be a rampant reality, frequently measured in terms of emotional exhaustion, depersonalization, and reduced sense of accomplishment. That is, there is abundant evidence that physician burnout is a commonly occurring outcome to the challenges of the medical profession—just as Corrections Fatigue is for corrections staff.

As described in these articles, physician burnout can be seen as referring to the combined outcome of what we at Desert Waters call organizational and operational stressors. (Physician burnout studies do not typically address traumatic stressors—which is the third group of stressors that we propose contributes to Corrections Fatigue.)

So what does the physician burnout meta-analysis research show?

The first paper [1] involved the review of both randomized controlled trials (15 trials, 716 physicians) and observational studies (37 studies, 2914 physicians), which met inclusion criteria. Both types of studies showed that individual-focused (bottom-up) and organizational (top-down) strategies were successful in reducing burnout—as measured by overall burnout score, and by measuring the burnout components of emotional exhaustion (14% reduction) and depersonalization (4% reduction). However, only organizational, top-down strategies lowered the overall (total) burnout score to a statistically significant degree—10%. That is, for reducing overall burnout, top-down interventions were more effective than bottom-up interventions.

For this population, individual-focused (bottom-up) interventions were similar to those presented in Desert Waters’ signature CF2F course: facilitated and non-facilitated small group curricula, stress management and self-care training, communication skills training, a "belonging" intervention to emphasize connections with others, and mindfulness-based approaches.

Top-down, organizational interventions included: shortened attending rotation length, clinical work process modifications, shortened resident shifts, changes in duty hour requirements, and changes in practice delivery.

The second paper [2] conducted a meta-analysis of randomized clinical trials and controlled pre/post studies. The effectiveness of physician-directed (bottom-up) and organization-directed (top-down) burnout interventions were again compared. Individual (bottom-up) interventions included techniques such as mindfulness-based stress reduction, exercise, and educational programs focusing on improving self-confidence and communication skills, individually or in combination. Organizational (top-down) interventions included workload interventions (such as rescheduling hourly shifts and reducing overall workloads), teamwork and leadership.

Burnout scores of most studies reviewed in this paper focused on the emotional exhaustion component of burnout. Both types of strategies (individual and organizational) led to small, but statistically significant reductions in burnout. However, treatment effects were greater with organization-directed approaches, that is, with interventions which took into consideration the effect of the work environment and tried to lessen its negative impact.

These findings provide support for the view that burnout is inherently a problem of health care organizations as a whole, rather than only being a problem of inadequate individual adaptations to work stressors.

The similarity to the challenges built into the corrections environment should be obvious, such as long working hours and high workloads. Yes, some staff adapt better than others. That’s only to be expected. But it is the overall environment and workplace culture that are most influential, so much so, that their negative influence contributes to a wide-spread condition of the profession.

The authors of this study concluded, in language that is familiar to all corrections leaders, that “[o]rganization-directed [top-down] interventions...that combined several elements such as structural changes, fostering communication between members of the health care team, and cultivating a sense of teamwork and job control tended to be the most effective in reducing burnout.”

And this is where the challenge lies for correctional leadership: what staff-focused supports can we design into our traditional corrections environment on a system-wide basis to reduce Fatigue and enhance Fulfillment? Where can we take the offensive and proactively create conditions for improved resilience in our workforce? What strategies and what resources are needed to combat what we all recognize as a long-standing condition? Which programs work? Which don’t? And for that matter, why do it?

Indeed, why pursue ways to reduce burnout (and overall Corrections Fatigue) among corrections personnel?

The reason is simple and obvious, and once again supported by physician burnout data in a recent third study [3].

Yet another systematic review and meta-analysis of physician burnout, which included 82 studies with 210,669 healthcare providers, showed that burnout was negatively correlated to a statistically significant degree with patient safety and quality of healthcare. That is, the higher the physician’s burnout score, the lower the patient safety (in terms of physician errors), and the lower the quality of care. Physician burnout—and along the same lines, corrections staff fatigue—are in fact mission-critical.

Notes:
*Meta-analysis is the research method whereby pertinent data from multiple selected studies are systematically combined and reviewed to draw conclusions of greater statistical power.
** Physician burnout is typically studied by using the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996), which measures three dimensions of burnout: emotional exhaustion, depersonalization, and a reduced sense of accomplishment.

REFERENCES

[1] West, C.P.; Dyrbye, L.N.; Erwin, P.J.; Shanafelt, T.D. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet (2016). First published online 28 September 2016. doi: http://dx.doi.org/10.1016/S0140-6736(16)31279-X

[2] Panagioti, M.; Panagopoulou, E.; Bower, P.; Lewith, G.; Kontopantelis, E.; Chew-Graham, C.; Dawson, S.; van Marwijk, H.; Geraghty, K.; Esmail, A. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA Intern Med. First published online December 5, 2016. doi:10.1001/jamainternmed.2016.7674

[3] Salyers, M.P., Bonfils, K.A., Luther, L., Firmin, R.L., White, D.A., Adams, E.L., Rollins, A.L. The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. J GEN INTERN MED (2016). First published online 26 October 2016. doi:10.1007/s11606-016-3886-9

Check back in soon for the conclusion of this article: "The Best Defense May Indeed Be a Good Offense - Part II."

This article as been reprinted with permission from the September 2018 Issue of Correctional Oasis, a monthly e-publication of "Desert Waters Correctional Outreach".

Editor's note: Caterina Spinaris is the Executive Director at Desert Waters Correctional Outreach and a Licensed Professional Counselor in the State of Colorado. She continues to contribute to the field of corrections staff well-being individually and organizationally, in particularly regarding issues of traumatic stress due to exposure to violence, injury, death on the job, and also issues of organizational climate improvement.

Gregory Morton serves as an Instructor at Desert Waters Correctional Outreach. Prior to that he worked for Oregon State Corrections nearly his entire adult life—a total of more than 34 years—after graduating from Oregon State University with a Bachelor’s degree in Psychology. He started his career at the Oregon State Penitentiary (OSP) as an academic counselor in 1975, and progressed to Staff Training / Employee Development shortly thereafter. Greg served as the department’s Leadership Program Manager and as Staff Training Administrator until 2006. He was the ORDOC’s Labor Relations Administrator until he retired in 2009. His concern for the professional and life skills of the corrections workforce has been his motivation throughout his career.

Visit the Caterina Spinaris page

Other articles by Spinaris:



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