In October 2015, 55 leaders from University of Colorado Hospital gathered for a workshop aimed at finding ways to meet a growing health care challenge: managing stress and reducing burnout.

It was not an academic exercise. The attendees were inpatient nurse managers and associate nurse managers and nurse educators – people on the front lines of units faced with providing complex care to acutely and chronically ill patients in a fast-paced academic medical environment.

The pace at UCH had taken a toll on staff, said Michelle Ballou, RN, MS, nurse manager of Inpatient Pre-Op and PACU, who attended the October workshop. Her team had gone through periods of short staffing while the hospital was frequently at capacity and was handling more OR cases.

“We had gone through a lot,” Ballou said. “Staff were burned out. I wanted to find out anything I could do to get through that time.”

The answer she and the others got that day didn’t have to do with operational changes or process-improvement projects. The message was: Listen to your heart.

Get into rhythm

The group didn’t hear that from the latest author hawking a self-help bestseller. They learned it from Boulder Creek, Calif.-based HeartMath, a nonprofit research institute founded 25 years ago that today has a worldwide reach. It teaches people techniques to build emotional resilience and reduce stress by focusing on their heart rhythms, which affect key brain functions such as decision making, reaction times, and self-control, all vital elements for people working in health care.

HeartMath has built its case on a body of scientific evidence that in very simple terms shows the practical benefits of achieving “coherent,” or stable, heart rhythms. That approach helped to convince Ballou, who was one of five UCH employees (see box) to go on to attend a HeartMath Certified Trainer Course in Phoenix in February. The trainers have now rolled out two-session HeartMath workshops to employees.

The initiative isn’t a one-off stab at reducing stress. The hospital plans to send six more employees to the certification training in the fall, with the approval of Associate Chief Nursing Officer Cathy Ehrenfeucht, RN, MS. The plans illustrate hospital leadership’s growing understanding that staff need tools to care for themselves if they are to deliver the best possible patient care, said Tacy Farrington, Ehrenfeucht’s executive assistant and a certified HeartMath trainer.

“We want staff to be able to relax and find the space to focus on themselves,” Farrington said. “That can have a great positive effect on patients, kids and significant others. It starts with a single person.”

Building reserves

The organizational blessing is important, said Catherine Mickey, RN, a charge nurse in the Cardiothoracic ICU who completed the workshop in June.

Mickey said she tells staff in meetings and in person about HeartMath and the tools it has given her to manage the considerable pressure of working intensive care and being a mother to a one- and a three-year-old. She readily admits she needed help. The CTICU cares for an increasing number of highly complex patients, including heart and lung transplant and ventricular assist device recipients and individuals on ECMO (extracorporeal membrane oxygenation) machines.

“I am impressed by the organization saying, ‘We hear you, see the need for reducing stress and are reacting,’” Mickey said. She said it’s not always been easy for her to get help on her own. “I have sought balance in many other ways, yet I have a difficult time working self-care into my life, due to the busy nature of my life,” Mickey said.

The culture of health care often doesn’t encourage providers to pay attention to their own emotional well-being, she added.

“There is a feeling that during a shift, you have to leave it all out there, that if you go home totally wiped out, you did a good job,” Mickey said.

That feeling is not healthy, said Christine Griffin, RN, a professional development specialist with Children’s Hospital Colorado. Griffin, a master HeartMath trainer, helped to present the concepts to UCH leaders and staff. On the contrary, it can lead to health care providers feeling drained of the emotional reserves necessary to care for very ill patients, many of whom will have poor outcomes regardless of the quality of care they receive.

Griffin said providers often figuratively don a “superheroes cape” during their shifts on the unit, not realizing that they are depleting their emotional reserves and leaving themselves vulnerable to compassion fatigue and burnout.

“There is a limit to the amount of care we can provide to others without finding ways to care for ourselves,” Griffin said. “Getting through a 12-hour shift can be draining and it will affect the next 12-hour shift.”

She speaks from experience. Griffin was early in her career as a nurse on the Pulmonology Unit at Children’s Colorado when she began caring for an infant patient. She cared for the infant for more than a year and was emotionally shattered when the 18-month-old died while Griffin held her in the NICU. She wasn’t prepared for the shock, and thought for a time about getting out of nursing.

“Having a thick skin and good boundaries [between patients] wasn’t enough,” Griffin said. A retreat in Boulder in 2005 with Jean Watson, RN, PhD, the influential University of Colorado College of Nursing leader, taught her the importance of building the emotional resilience necessary to deliver loving, compassionate care without becoming emotionally exhausted – trying to fill the needs of others “from an empty cup,” as Griffin put it.

Scientific substance

The HeartMath message finds a receptive audience among providers because of its scientific approach, which gets into not only heart rhythms but also the release of hormones during periods of stress and emotional control, said Shannon Johnson-Bortolotto, RN, CCRN, clinical nurse specialist supervisor and one of the five UCH employees to receive the certification training.

“We knew we would have an audience of cautious skeptics,” Johnson-Bortolotto said. “Being ‘New Age’ wouldn’t get there with staff.”

One of the skeptics was Katie Winkelman, RN, clinical nurse educator with the UCH Burn Center. “I’m not one for touchy-feely,” Winkelman said. She decided to take the workshop because she “didn’t want to give push-back to something I never tried,” but admitted she “didn’t feel like it would do a lot.”

That changed when Winkelman volunteered for a demonstration of how stress affects heart rhythms. Hooked up to a heart rate variability monitor, Winkelman talked about a frustrating situation and watched lines on a screen representing her heart rhythms climb and plunge, rollercoaster-like. When she breathed deeply, banished the stressful images and thought instead about playing in the front yard with her daughter, the lines dropped and undulated more smoothly.

“I wasn’t going to believe it until I saw it,” Winkelman said. “I was shown that it does work.”

She sees the HeartMath techniques as necessary self-care that is also practical because providers can do it even in the midst of a hectic day. “You don’t have to sit down and focus for 20 minutes,” Winkelman said.

Stepping back from stress

Science aside, HeartMath pays much attention to basics like breathing, listening, and mindfulness as methods to reduce stress and interact with others productively. “I thought I was a good listener as a manager,” Ballou said. “But now I’m much more present and listen to staff instead of trying to problem-solve everything. Sometimes there isn’t a resolution to an issue. You just have to listen.”
HeartMath focuses on the central role of heart rhythms in affecting cognitive function and regulating stress.

Frank Newsome, RN, nurse manager of the Neuro ICU, who took the certification training, said HeartMath “combines the scientific and the spiritual worlds.” He said he uses breathing techniques to center himself and focus on positive feelings – a counter to negative emotions about the work environment that can consume a unit.

“HeartMath gives the tools to be more aware of how you are behaving right now and how that affects others,” Newsome said. “It’s made me more aware of my reactions to things.” Rather than contributing to the stress generated during a tough day, Newsome said he’s more likely now to focus on finding solutions to problems and moving on.

“During a stressful situation, I can say ‘HeartMath’ and take a step back. I don’t have to be ruled by emotions,” said Danielle Schloffman, RN, MS, NE-BC, director of Nursing Innovation and Outcomes at UCH. Calm and reflective thinking, she said, allows her to “create a new baseline” and a “higher threshold for stress.”

The practical aspect of HeartMath emerged quickly for David Rowley, manager of Central Supply, a department responsible for keeping units and clinics stocked with hundreds of items vital to patient care. Rowley used breathing techniques during his time as a catcher with the Creighton University baseball team.

“I learned how to get centered for the next pitch,” he said. “HeartMath took that to a different level for me by showing how the heart rate can decrease over time and stay level instead of going through peaks and valleys.”

Rowley said he plans to address the HeartMath concepts with his staff, which has more than doubled in size since the opening of Anschutz Inpatient Pavilion 2 in 2013, emphasizing that their responses to stress of various kinds can have broad-reaching effects.

“I will tell them, ‘Here is why I am taking the emotion out of situations, and here is what the emotion and stress does to you,’” Rowley said. “That’s important to interdepartmental communications. It helps to take the volatility out of communications.”

It will take time to spread the HeartMath concepts and embed them in daily practice, but that’s as it should be for people learning new life skills, Schloffman said.

“It’s good that we now have our staff doing it and we have people giving others more support,” she said. “It’s a real investment by the organization, not just a speaker coming in to give a quick fix.”

Mickey said she is committed to sharing her experience with others at staff meetings and in person. She emphasizes that self-care is essential.

“I tell them, ‘No one is going to take care of you. You have to take care of you. [HeartMath] is your organization saying that it values you,’” Mickey said.

UCH HeartMath trainers

Five UCH employees are now certified HeartMath trainers:

• Michelle Ballou, nurse manager, Inpatient Pre-Op and PACU
• Tacy Farrington, executive assistant for Associate Chief Nursing Officer Cathy Ehrenfeucht
• Hannah Harman, direct-care nurse, BMT Unit
• Shannon Johnson-Bortolotto, clinical nurse specialist supervisor
• Frank Newsome, nurse manager, Neuro Intensive Care Unit