Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty-Fowler: And I'm Carolyn Cumpsty-Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Lee Daugherty Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning.

Carolyn Cumpsty-Fowler: Thank you for joining us.

Lee Daugherty Biddison: Hello and welcome to this episode of the Vital Conversations Podcast. I'm your host today, Lee Daugherty Biddison, Chief Wellness Officer for Johns Hopkins Medicine. And I am delighted to welcome my friend and colleague, Dr. Carolyn Cumpsty-Fowler Executive Director for Nursing Well-being for Johns Hopkins Medicine. Carolyn, I'm so excited to have this conversation.

Carolyn Cumpsty-Fowler: Hello, Lee. I'm so excited too, because you and I have spent many hours talking about belonging and its connection to well-being. So thank you for thinking of doing this one.

Lee Daugherty Biddison: Well, as we plunge into this conversation, Carolyn, can we just start with the basics? What does it mean to belong? What is belonging? What are we talking about?

Carolyn Cumpsty-Fowler: Could I just contrast it with what it is on an engagement survey and what it is physically? We ask questions about belonging on engagement surveys because when people feel that they belong in an organization, when they express that they belong in an organization, they're much more likely to be engaged, much more likely to be satisfied, and much more likely to be positive and connected members of teams.

And as we've talked about before, all of those things are really great markers for all the things we care about, like quality, safety, compassionate care, learning, growth, development, etc. What belonging means when I think about it simply from a perspective about of how do we influence it, is it is a felt sense of safety and connection and a sense of being part of a team. The safety is both physical safety and psychological safety. I feel that I am valued so that you see me as Carolyn, not as my job description or the list of tasks you need me to do. You see me and I am valued unconditionally for who I am in this relationship with you, whether that's professional or personal.

And we can think about whether we belong by thinking about it. But the way that I often like to check in with it is through sensation and through feeling. So Lee, if I were to say to you, bring to mind a time or a situation in which you feel you truly, deeply belong, what are you noticing in your body as you tap into that sense of belonging?

Lee Daugherty Biddison: I feel like a sense of things slowing down a little bit. And I think more of a sense of peace and certainly a desire to get there as quickly as I can.

Carolyn Cumpsty-Fowler: Right. Yeah. And one of the reasons that well-being is felt so strongly viscerally whether we have belonging and we feel that peacefulness and safety and calm and openness, or whether we don't, in which case we feel or we notice in our bodies all the things we would associate with fear and stress. So we might feel tight, we might feel tense, we might notice changes in our breathing or in our dry mouths, any of those things, any of those things, depending on how isolated we feel can be true.

Because belonging is a biological need. It's an evolutionary need. If we think back to the ancient times when we lived in communities surrounded by saber-toothed tigers, right? We were dependent for our survival on our connection to our tribe, our connection to our people. And if we were excluded from that community we were vulnerable, we wouldn't survive. And so we recognize a sense of belonging.

When I feel that I'm connected in community to people, I read that as safety. And when I feel that I'm not connected and I don't belong, then I read that as a lack of safety. And so that is why belonging-- yes.

Lee Daugherty Biddison: Yeah.

Carolyn Cumpsty-Fowler: Right.

Lee Daugherty Biddison: I'm at risk. Sure.

Carolyn Cumpsty-Fowler: And that is why it's so bad for a lack of belonging is not only bad for engagement and satisfaction and all the professional markers we're looking for. It's just bad for us in terms of our well-being. Because on the flip side of that, you and I have talked about the fact that the single biggest predictor of human resiliency is whether or not a human being feels connected in a safe relationship with somebody who will support them. And so belonging drives every aspect of well-being, and it also drives our connection to our team and our sense of community in the workplace.

Lee Daugherty Biddison: I can't count the number of times I've thought about how important it is, especially in the workplace, but certainly everywhere, to feel like someone has your back. You know, you feel that in healthcare, that what we do is hard, that we step into the lives of our patients and their families at vulnerable times. And it's challenging.

And many times, most of the time things go smoothly, but if they don't, are you, whether you're in that place feeling like your team, the people that you report to have your back, knowing that you're doing the very best you can or not makes a huge difference in how you perform.

Carolyn Cumpsty-Fowler: Right, absolutely. And I think an important distinction about people having your back is that when you truly belong, you feel that people have your back unconditionally.

So they don't just have your back on the days when you can be helpful or the days when you're functioning at your best. Those days which are just the really challenging days or the days where you have something going on at home that unfortunately is compromising your bandwidth to put up with stress at work, that unconditional valuing and that unconditional sense of support is what's really important in belonging.

Lee Daugherty Biddison: So can we say a little bit more about sort of what we know about the science, the data around why belonging matters? What impact does this really have?

Carolyn Cumpsty-Fowler: Perhaps we can talk about the opposite. So when I don't feel that I belong, the opposite of belonging is loneliness. And the important thing for us to know about loneliness is I can be lonely in a crowd. I can be in a very busy unit surrounded by my colleagues, surrounded by patients, and I can feel lonely. And one of the things that I think really woke us up to it, because we've spent some time talking about it, is when we read Dr. Vivek Murthy's report that came out in 2023, I think it was. That was called Epidemic of Loneliness and Isolation. And he talked about how pervasive loneliness and isolation is. And he also then talked about the power of social connection and support, and he was really challenging us. In workplaces, and especially we've thought about it in healthcare, how do we create workplaces where people feel connected and supported and seen?

Lee Daugherty Biddison: Yeah. So how do we? Well, it starts with a seeing and it starts with a presence.

Carolyn Cumpsty-Fowler: And I think that is often the challenge for us when we're working in healthcare because we never have a day when we're not crazy busy. Our to-do lists and our responsibilities are always longer than we feel that we can comfortably do.

And that's just the reality of working in healthcare. And then just when we think we've got it together, the unexpected happens and we have to rearrange everything. So I think that when we're in that kind of place, it's so easy just to look at somebody else who is the action partner, the person who has to do things with you. And so it can become quite easy to slip into what I call transactional relationships, where, “Lee, I need you to do this for me. I'm going to do this for you. Who's going to bring this in for our patient?” And so our recognition of the other person is purely a recognition in terms of what they have to do or what they've been assigned.

Lee Daugherty Biddison: Very task oriented. Yeah.

Carolyn Cumpsty-Fowler: Very task oriented, which also makes it very conditional, right? Like I'm recognizing you because you have to do something for me or with me or you're part of this team that we're working with. And that's important. And I think that we have to be able to have those relationships, especially in a crisis situation, where we're very comfortable with each other. And we know that I can count on you to do certain things while I will do other things.

So I'm not saying those aren't important relationships. They are, but they're not the ones that are fundamental to belonging. The one that is fundamental to belonging is when I feel that I can be truly present with you and you can be truly present with me and that we are present in relationships. So this is the thing about belonging. Belonging by definition is deeply relational. And so we can't be relational when we're flying by each other in our crazy busyness.

So that moment you take to say, “hello, how are you? Thank you. I'm so grateful to know that I'm working with you in this shift. This is wonderful to know that you're here.” Perhaps if they have a child who's sick, you might ask, “how's Jamie doing?” If they had a paper due for grad school, you might say, “were you able to get your paper in? And what we're doing is we're connecting with curiosity.” So we're present, we're curious, we're connecting.

And in fact, in nursing, we've been encouraging a practice called connect with curiosity to intentionally throughout a shift, try to find those moments where we can do that human to human connection that is not about the tasks of the shift.

Lee Daugherty Biddison: You know, it's so interesting as you're talking, what occurs to me is sort of going back to this concept of going slow to go fast, right? If we are deeply connected and our team has a sense of belonging, I know how you're going to respond and I'm more likely to know how you're going to respond in a situation. I know I can rely on you for something. I know all of those things and that means the task can go much more quickly, more efficiently, right?

When we're in the ICU and someone starts to bleed out, we've spent the time we've taken in those other moments that don't require the instant transactions to build that trust and sense of belonging. So when we enter into that high stress moment where better primed to function together efficiently. So it's interesting to see how the thing we don't have time for, it makes us better at the thing we are sure we've got to do right now.

Carolyn Cumpsty-Fowler: Right. And you and I have had so many conversations where we've looked at something that's important in healthcare related to well-being, whether it's gratitude or listening, silence, in this case, supporting belonging through presence.

And we've found it ironic that people will say, we don't have time for that. And I think the reality is this is the same. If this is truly as important as it is, then we don't have time to not be doing it. Because in the absence of a sense of belonging, people are not willing to admit mistakes. They're not willing to admit vulnerability. They're not willing to ask for help. All of those things, they're not willing to speak up. They're not willing to offer an opinion that may not be the consensus opinion, but it's a very valuable and important perspective to be shared. None of those things is going to happen without belonging.

Lee Daugherty Biddison: Gosh, these are such important lessons, such important lessons. Carolyn, tell me about a little bit about your reflections on what stands in the way or gets in the way of or is a threat to building a sense of belonging amongst your team.

Carolyn Cumpsty-Fowler: Yeah. Unfortunately, there are a lot of them, but me, I am a glass half full person.

Lee Daugherty Biddison: So let me start this list.

Carolyn Cumpsty-Fowler: Yeah, let me no, let me start this list of terrible things by saying this. What's important about knowing what threatens belonging is the fact that if it, we can do something about changing it. And so the invisible things that get in the way of belonging are some things that now once we've seen them, we can change them. But I'm going to say hands down, I think the thing that destroys belonging faster than anything else is gossip. Negative gossip. Because gossip is exclusionary. Even if they are gossiping to me, so I'm part of the group that's being included in the gossip.

I subconsciously-- or maybe not subconsciously, maybe consciously -- I realize that if they can talk about someone in front of me, they can talk about me in front of someone else. Gossip is something that is a huge trust breaker and a huge community destroyer. And I actually have one of our 10-minute leadership tip series that I recorded on creating a gossip-free zone in your workplace. And I can't emphasize that enough.

Lee Daugherty Biddison: Fantastic.

Carolyn Cumpsty-Fowler: Gossip.

Lee Daugherty Biddison: You know, it occurs to me as you're talking too that, you know, while the biggest threat is, you know, negative gossip, that any gossip can be trustbreaking, even if it's not explicitly sort of critical or if it's just sort of--

Carolyn Cumpsty-Fowler: Yeah, the challenge is that gossip is fundamentally untrue or at best partially true. And just because six people think that it's partially true, will never make it true. Right. And so we can vent to each other as long as we're careful about the content and the intent with which we're having these conversations. That's okay.

I can let you talk about things that are bothering you personally, but what I can't do is allow you to come and talk to me about other people in a way that is dismissing the other person or expressing opinions that they cannot defend or cannot justify. So I know some people say that gossip is pro-social, but it's only pro-social if it has no potential to damage. And in our kind of environment, it absolutely has the potential to damage.

In fact, I was talking to somebody the other day who reinforced for me something another patient told me years ago. But let me tell you what my colleague said. As somebody who has been in the hospital recently, healthcare provider has been in the hospital recently as a patient, said, when I hear gossip outside my door as a patient, I feel unsafe.

Because if people are gossiping about each other outside of my room, that teamwork is not where it needs to be. They can't trust each other. They're not going to do what they need to do. And therefore, it makes me, knowing what I know about the importance of teamwork, feel unsafe as a patient. That's a big aha.

Lee Daugherty Biddison: Right. And such an important thing for us to remember.

Carolyn Cumpsty-Fowler: Yeah, absolutely. So let's talk about some other ones, right? Because gossip is, I mean, gossip is #1, but there's lots of others. Another one that you and I have talked about before in another podcast is listening.

You know, if we are in a situation where I feel that my voice is never heard, either people are talking over me or not giving me an opportunity to speak or immediately discounting or invalidating what I'm saying. If my voice is not heard, it challenges belonging. So it's not just that we want to avoid the harm of listening, but we need to intentionally be creating environments in our working place where we listen, where we listen to each other, where we allow for listening to understand and where we allow for silence. That's very important.

And sometimes one of the things I think we do is we overpack our agendas. So we're so busy flying through the meeting agenda that there is no time to connect, to just really be with each other and to leave enough space for those voices in the room to be fully heard. That's not only a bad thing for belonging, it's also a bad thing for creating the conditions in which we really are able to harvest the richness of perspectives that are sitting around that table or on the Zoom call, as is usually the case these days.

Lee Daugherty Biddison: Something's jumping to mind that we haven't talked about, but I think is germane. So I'm actually reading a book on digital minimalism by Calvin Port. It was recommended to me by Chris Sinsky, who's sort of just such an amazing leader in the well-being space. But one of the things he talks about is how we substitute these relatively unsophisticated ways of communicating with each other, meaning text messages or a comment on social media for the rich conversation that actually feeds connection and relationship. And I think that this is really, this is applicable to within our work teams.

You know, if I have, you know, gone back and forth with you, rapid fire text messages or emails or teams or take your, choose your way of thinking about communicating without actually engaging in the give and take and the deep listening that I've missed something and I've tricked myself into thinking that we're connected when perhaps we really aren't.

Carolyn Cumpsty-Fowler: Well, and these digital forms of communication, we love them because they're efficient doesn't mean they're effective. And it doesn't mean that they do no harm.

Lee Daugherty Biddison: That's right. We just have to figure out where they belong. Yep.

Carolyn Cumpsty-Fowler: Exactly. And so if you think about some of the other challenges to belonging. Hierarchical structures, silos, obviously challenge belonging, any sort of implicit bias, microaggression, anything that challenges a sense of inclusion is going to be a problem for belonging. Poor communication, unclear expectations of people, challenge belonging.

And I think what's really important in belonging also is that if I work in this environment or in this team, I need to feel that I share the values of this team, the values of this organization, or at very least I feel like I can align with them, that I don't feel that they're foreign to me or what would be terrible would be they're absolutely opposed to the opposite of what I believe. And having shared goals is also a way of creating, but not goals that have been created for me and imposed on me, but really goals where I feel, yeah, I can I can get my head around this goal. This is something that is meaningful to me. This is something where I feel I can contribute. And it's something that I feel sort of plays to my strengths. So those are all challenges to belonging. But of course, the opposite is true.

So if we can be more inclusive in our goal setting and if we can really think about how the work we do aligns with the values and the very reason we came into healthcare in the 1st place, that's when we're now creating belonging, but also we're supporting that sense of meaning and purpose, which is important in well-being, and we're supporting professional fulfillment.

Lee Daugherty Biddison: I love all of that, as you mentioned, unclear expectations, and I so resonates when you're, you know, the number of times when I've personally been in a situation or heard people talk about being in a situation where they feel stuck because they're just unclear about what's expected and it feels unsafe. “How can I perform? How can I deliver if I'm not clear about that?” It makes me think of a Brene Brown sort of mantra about clear is kind.

Carolyn Cumpsty-Fowler: Clear is kind. And also she always does that wonderful thing, which is about paint done. Paint done for what I want it to look like so that I can check in with the expectations. “Can you do this? Do you have what you need? What are you unsure about?” Yeah, all those wonderful tips she's given so many of us over the years.

Lee Daugherty Biddison: Absolutely. Absolutely. Carolyn, if you were to give our listeners 3 tips for cultivating belonging in their teams. What's the sort of micro learning, as it were? Like, here's the thing you can go do today that would really get you started. And maybe it's not three, maybe it's one or two. But somebody said, “Oh, what you just said resonates with me, Carolyn. Tell me what to do right now.”

Carolyn Cumpsty-Fowler: All right, well, I'll give you a couple. The first I think I'm going to offer is do your very best to connect in person. This may be challenging if you're working remotely, but even if you're talking to somebody so that they can hear your voice as opposed to reading a text message, prioritize the connection, the in-person connection, because connection is at the heart of all of this. I'd like to reinforce this connect with curiosity thing that I mentioned earlier. Because when I connect, I can also connect in a way that has you feel that I see you and I want to know more about you.

And so taking the moment to say, “How are you today? What support might you need? What's the point of pride for you? What feels most meaningful to you about this? Or what did you feel the most concerned about?” Or if you were feeling stressed out, but suddenly everything fell together, you say, “Well, that's great. When did you know that was going to come together? I'm so glad to see that happen for you.”

So what you're doing is you're connecting with a human. You're connecting with a person. And you're there to say, I see you and I care about you. So that would definitely be something I would recommend. Connected to that as a leadership behavior is what I call relationship rounding or genderless rounding. And that's where we take the time to get out of our offices or out of wherever it is that we work and to just be there, to walk around. I'm not doing safety rounds or quality rounds or line rounds or whatever else it is I'm doing.

I'm there simply to walk around and be present and to see, to bear witness to what you're doing. To be able to say, you matter enough to me that I'm taking time to be here with you. That would be such an important message. Yeah, absolutely. And then I also think that other things we can do about the room belonging that may not feel as obvious but I'm going to mention them anyway. And I think this is very important to us because we are Johns Hopkins Medicine.

And so there's a lot of focus on excellence, on continued development and growth and learning and all of those things. Creating conditions in our teams where people feel that we are invested in their success, we're invested in their ongoing growth, their ongoing learning, their ongoing development, and we are there to support them. and in reaching those goals and doing things that are more meaningful for them, that is something we can do that supports belonging and it also supports other things that we're committed to.

And maybe I'll wrap up. There are so many things we could do, like inclusive language, but I'm going to wrap up with the one that we just recorded a podcast on Lee, and that is authentic gratitude.

Lee Daugherty Biddison: Yep.

Carolyn Cumpsty-Fowler: When I express gratitude authentically to you, I'm able to have you know that I saw you, I appreciated what you did, and I'm taking the time to express that to you. So express authentic gratitude will be another big belonging builder.

Lee Daugherty Biddison: Okay. So let's review those. So the first was.

Carolyn Cumpsty-Fowler: No gossip. No, I mean, I think the--

Lee Daugherty Biddison: First thing we talked about at the beginning.

Carolyn Cumpsty-Fowler: No, the first was presence. The first was presence. Presence and connection. That was the first one. I can't remember because we've talked so much. So presence and connection.

Lee Daugherty Biddison: Investment in development.

Carolyn Cumpsty-Fowler: The investment in development, the connecting with curiosity, that general, not just the physical connection, but the connecting with curiosity to truly learn them, see them, value them, and so on. The inclusive language. And then of course, the gratitude. Gratitude.

Lee Daugherty Biddison: I love it. Those are all very actionable things, as we like to say. Carolyn, what didn't I ask you about related to belonging? That we should cover before we sign off.

Carolyn Cumpsty-Fowler: Maybe I could just offer a last thought for our leaders, especially our more senior leaders. And that is the importance of being able to lead with vulnerability. If I come across as super confident, competent, super confident, super together, super certain, then I can actually be intimidating. People feel that there's no space for them to feel unsure or to feel that they have a place to grow. And so there are many people who write about leadership who consider the ability to lean into our own vulnerability and express our vulnerability a leadership superpower.

Lee Daugherty Biddison: Absolutely.

Carolyn Cumpsty-Fowler: Maybe that's what I would leave because it's when we are able to lean into vulnerability, that also has a big impact on creating psychological safety at work.

Lee Daugherty Biddison: I love that. I love that. Well, I would like to end by saying that I am grateful to you, Carolyn, for creating a space for me and for our team to feel like we belong. It's so important.

Carolyn Cumpsty-Fowler: Thank you, Lee. Yeah, we have certainly, we have certainly built a safe and wonderful place to work.

Lee Daugherty Biddison: Very thankful for that. Well, for our listeners, thank you for joining us today. It has been a pleasure to have you with us. Please reach out with ideas or questions, and we would love to hear from you can reach us by e-mail at [email protected]. Take care.

Carolyn Cumpsty-Fowler: Thank you. Bye. So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being 
Johns Hopkins Health System 

1. Belonging is a biological necessity, not a luxury.
   Humans are wired for connection and a strong sense of belonging directly influences wellbeing, resilience, engagement and performance.
2. Psychological safety is the foundation of belonging.
   People thrive when they feel physically and emotionally safe, supported and accepted, especially during difficult moments or periods of struggle.
3. Connection requires intentionality.
   Practices such as connecting with curiosity, deep listening and expressing gratitude can transform transactional relationships into meaningful connections.
4. Trust-building improves team performance.
   Teams that invest in relationships and cultivating belonging are more effective during high-stress situations because they communicate better and can rely on established trust.
5. Belonging is undermined when trust and connection break down.
   Gossip, poor listening, ineffective communication and unclear expectations can make individuals feel excluded, while fostering open communication strengthens trust and a culture of belonging.
6. Leadership plays a critical role in creating belonging.
   Vulnerable leadership, authentic presence, and commitment to inclusion help build cultures where people feel valued and empowered.

Suggested Practices:

• Connect with curiosity during daily interactions at work.
• Prioritize in-person conversations whenever possible.
• Express authentic gratitude regularly (listen to podcast episode 24)
• Conduct relationship-focused leadership rounding.
• Create and maintain gossip-free environments.
• Invest in team members' growth and development.
• Practice vulnerable leadership to strengthen psychological safety.

• Dr. Vivek Murthy, Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General's Advisory on the Healing Effects of Social Connection and Community (2023)
• Johns Hopkins Medicine Office of Well-Being’s 10-minute Well-Being Tips for Managers, including "Creating Gossip-Free Zones"

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Lee Daugherty Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning.

Carolyn Cumpsty Fowler: Thank you for joining us.

Lee Daugherty Biddison: Hello, and welcome to this episode of our Vital Conversations podcast. I'm your host today, Lee Daugherty Biddison. I'm Chief Wellness Officer for Johns Hopkins Medicine, and I have the privilege of welcoming my friend and colleague, Dr. Carolyn Cumpsty Fowler, Executive Director for Nursing Wellbeing for Johns Hopkins Medicine. Carolyn, so excited to do this today.

Carolyn Cumpsty Fowler: Oh, Lee, I'm always happy to do podcasts with you, my friend. And I'm grateful that we are going to be talking about gratefulness today. It's one of my favorite topics, and I think it's sometimes under-recognized by many of us for the potential for its impact on well-being. It's really significant.

Lee Daugherty Biddison: So important. So gratitude. What do we mean, Carolyn, when we're talking about gratitude? I know what I mean when I'm encouraging my 6 and 10-year-old to express gratitude and say thank you for things that have been done or given to them, but I think we're trying to go deeper than that. So say a little bit more about what we mean.

Carolyn Cumpsty Fowler: Right, so we are kindred brainwashers when it comes to saying please and thank you, although mine are 33 and 31. Let me just refer immediately to Dr. Robert Emmons. He's somebody who's written and researched extensively in the field of gratitude. And I think that certainly the way that I think about the importance of gratitude is influenced by him in no small measure. What Dr. Emmons says is that when we live gratefully, so we're moving beyond just saying thank you, we're moving into this realm of grateful living. And when we are living gratefully, we're able to recognize that there are so many sources of goodness that are outside of ourselves. And whether that source of goodness is a person, or perhaps it's just an opportunity, something that we may take for granted, the fact that we have clean water to drink, or we have a safe home to live in, or we had the opportunity for higher education, whatever that is, often we take those for granted, and so therefore we're not reaping the benefits. And so the process of gratefulness really is almost like a two-step process. We are affirming, first of all, that there are things that we're grateful for. And then we're recognizing the gifts that we've been given and the contributions of other people to the fact that things have been going well. So in a clinical setting, for example, if we've had a relatively peaceful, uneventful shift.

Lee Daugherty Biddison: Those rare occasions.

Carolyn Cumpsty Fowler: Those rare occasions. Or even if we've had a stressful shift, but because of the way our team worked together, we were able to avoid harm to a patient and we were able to support each other during the stressful moments of our shift. That's happened because of the contribution of so many of us into this situation. And we have received so much from each other and we absolutely know and talk a lot about situations in which people were not there for us. And yet when we are surrounded by resources and by support and by these gifts, whether they're human or otherwise, we often don't see them. We don't necessarily see them as we sort of are rushed along in that rapid pace of our lives.

Lee Daugherty Biddison: It's so true. The rush changes everything, doesn't it? We just miss things that really matter. Well, okay, so we have this a little bit more full understanding of what we mean by gratitude, but this is a well-being podcast. Our, we've built our work around well-being. What is the impact of engaging in gratitude and this grateful living for our overall well-being?

Carolyn Cumpsty Fowler: Well, frankly, they're far-reaching and very impactful. There are some people who have called gratitude the wonder drug, others who've called it vitamin G. But essentially, let's just break it out into three or four categories. So the first big category is the ability of grateful living to enhance our well-being and our life satisfaction. We just feel better about our life and the circumstances of our life. The second big category is that grateful living supports a higher quality of relationship and connection. If I am appreciating what you bring to my life or how we can make a difference together, then I'm connecting to you. And as you and I have talked about often, that sense of connection and mutual support is a powerful driver of resiliency. Huge. It's also a fundamental human need to feel connected and supported.

Lee Daugherty Biddison: Absolutely.

Carolyn Cumpsty Fowler: And also lead to better physical health. And the interesting thing about the impact on physical health is not only can it help with physical health gaps as our stress is reduced or we feel less isolated or less alone, but it's also been shown to increase our self-efficacy around the management of health conditions. And yeah, isn't it? Isn't it? And as somebody who lives with those, I think it's true it can be quite frightening to get a diagnosis or realize that perhaps we have to deal with something health-related. And yet our appreciation of the resources that are available to us and our appreciation for the care that we can receive, the support we can receive, can go a long way to having us feel less, sort of almost less victimized by whatever it is that we're living with. And then, of course, gratefulness is very supportive for our mental health. And part of that is because of the way that gratitude actually acts on our brain. And that I find absolutely fascinating.

Lee Daugherty Biddison: Say a little bit more about that.

Carolyn Cumpsty Fowler: Well, I mean, you've probably heard, right? So the same way that carbs and sugar can do good things for our brain and not good things for our health and our body, gratefulness can do the same thing. So the grateful living, the more we think about, the more we think about what we're grateful for and the more we express grateful thoughts, the more we're going to see sort of the neurochemical responses to that. So gratefulness can boost the levels of our neurotransmitter serotonin. And it can also activate our brain to produce dopamine. And we all know the power of dopamine.

Lee Daugherty Biddison: Absolutely.

Carolyn Cumpsty Fowler: So it can do that. It can also, and not disconnected from that, gratitude can help reduce pain. It can help reduce our experience of pain. It can improve our sleep quality, which in itself has then consequences. Absolutely. It can aid us in our stress regulation as we become aware of stress, we're able to sort of call on our resources and call on our supports, which are an important way of actually managing stress. It can then, it can also help us reduce symptoms of anxiety and depression. So whether we do that in the acute sense of anxiety and depression, where we're calling on a resource to help bring our parasympathetic nervous system online, or whether we're doing it more generally, that we can use it that way. And it also helps us in some ways release the toxic or the negative emotions that we're experiencing and specifically their grip on us because we can get pretty enmeshed in negative emotions, stressful experiences, those ruminating, recurring thoughts that we may have, especially if we think that something's been going wrong. And gratefulness can help us release that. Just to give you a quick example of that. It's so easy, for example, when we've had, let's get back to this difficult shift. We've had this difficult shift. So many things were challenging. So many things could have gone wrong or did go wrong. And it's so easy for us, because of our tendency to focus on the negative, to get stuck in that rabbit hole of all the things that almost were a problem or that were a problem, the things I didn't think about, the things I didn't do. Being less than, that whole scarcity mindset. And at the same time, if I'm able to pause, I can say, this is only one side of this story. Now, I'm not suggesting we go to toxic positivity and deny that anything bad happened at work today. That is not what we're talking about. What I can acknowledge, though, is that despite the stresses and despite everything that was going on, there were also things that went well. There were people there who supported me. There were pieces of equipment that worked, or there were perhaps family members of a patient who were willing to just stand next to us while we did what we had to do and didn't complicate the situation any more than it could have been complicated and all of those things as we think about them can help us. And then if we aren't able to think of them real time, a practice that I recommend a lot to people in a clinical environment is as you leave your shift, before you're leaving to transition back to your home, it's so natural for us to obsess about everything we didn't get done that day or every mistake we almost made that day or did make that day. And transitioning that to a process of thinking about what actually went well and what are you grateful for? And what would you like to acknowledge about what made this day manageable or even joyful? Is it practice which can help you transition very differently from work to home?

Lee Daugherty Biddison: Just to dive a little deeper on that, how much difference does it make whether I just acknowledge that to myself I think of something, oh yeah, this other thing, or versus writing it down or telling someone else. Is there any data around that?

Carolyn Cumpsty Fowler: Well, I think, as you know, I'm a great fan of expressing gratefulness. I call it the buy one, get two free strategy. When I feel, when I become aware of the things that I'm grateful for, I acknowledge them, I affirm them, I will get that gratitude benefit. When I, in an act of sort of connection to other people, take the time to express my gratefulness to somebody else, I get another benefit. And the person to whom I express my gratefulness also gets a benefit. And so the power of expressed gratitude is that we are actually taking the time to surface it from just that fleeting awareness of gratitude to a very intentional act of giving my gratefulness or acknowledging my gratefulness to other people.

Lee Daugherty Biddison: So interesting. I know I think you know one of the things that we sometimes hear people say when we're talking about well-being or lack thereof is I just feel so unappreciated. Nobody appreciates what I do. I work so hard, et cetera, et cetera, which is a real felt loss or felt need for many of us. I could be feeling unappreciated. But I love what we're saying here about that there is, we don't have to sit in that scarcity space, that gratitude can be operative and impactful for us, even when we feel unappreciated. Not failing to, not the toxic positivity, I'll just do this all myself aspect of this, but in a space of feeling unappreciated, we can activate the energy of gratitude, as it were, in that expressive space.

Carolyn Cumpsty Fowler: Right. Well, I think I have mentioned to you once before, I think, something that I also learned from Dr. Robert Emmons, which was this ARC model of gratitude and how that supports us. Yeah. And I hadn't really thought about it, but I think it's sort of simple and elegant. So if you think about it, when I'm feeling stressed or feeling overwhelmed or feeling underappreciated, any of those scarcity places that it's so human for us to be in at any time, gratefulness it helps us amplify the good. So that's the A. It helps us amplify the good. And that good could be things that we see in ourselves, things we see in other people, things we see in the world, things we see in our workplace. And so then when we acknowledge them and amplify them, we're kind of locking them in. The second thing it does, the R, is rescue. And we've already talked about this briefly. We, in stressful situations, can get so trapped in this spiral. You know, it just, it's just the volume, it's almost like the volume of the negativity goes up. We're just locked in this sense of, I don't feel appreciated, or I don't like the ungratefulness. I think people are entitled, or I'm distracted, or I'm forgetful, whatever that is. Gratefulness helps us stay, get back into the present moment, and it helps rescue us from that sort of spiraling place that we're in. Makes sense. And then an very important, a very important piece of it, the C, is that it connects us. It connects us to each other. It connects us to that sense that we have a supportive community. It connects us to that sense of a greater good. And so at all levels, gratitude is very powerful influence on us when we're feeling less than.

Lee Daugherty Biddison: I love that. I love the sort of completeness of that model, taking in all those aspects. All right, so let's say I'm sold on express gratitude. That expressing gratitude, even if I feel unappreciated, I want to lean into that. What are the things I need to be thinking about in terms of how I express my gratitude? Are there specific skills or approaches to that are important.

Carolyn Cumpsty Fowler: Well, the first thing is I don't want to give anybody performance anxiety to the extent that they never say thank you. All right. So a thank you is a great thing. It's a great place to start as we have brainwashed our children to understand.

Lee Daugherty Biddison: Absolutely.

Carolyn Cumpsty Fowler: But let's get precise about it. So the first thing I would say is that gratitude is most impactful when it's authentic when I'm expressing it completely authentically in a way that just feels natural for me and doesn't feel that it's being done for impact or for anybody else. It's just, I'm just my natural expression of gratitude to you or to other people. I'm also a great believer in specific gratitude. So it's very easy to say, hey, gee, thanks, great job. You know, maybe even when I've been doing something with you as part of a team in the hospital, I'll say, oh, Lee, it was great to work with you today. Thanks. I always appreciate it when you work with me. And that's great. And that's better than nothing. And yet what I could say would be, for example, you know, Lee, that situation we had that was so stressful, what I really appreciated is how you were able to stay so present and so calm and so open. And I was just really impressed by just the impact that had on all of us in that moment. That's a very different level of gratitude.

Lee Daugherty Biddison: Well, and I love the way that impacts the receiver too, right? So when you are specific, about what it was that I did or said or whatever that was helpful, it's much harder for me to get to stay in that space, that stock space too. If, oh, she's just being nice, she says that to everyone. Well, if you tell me something specifically, if it's a specific appreciation that you observed, it couldn't have been just anyone. It was actually me. And I just, it sort of subverts our desire to or are maybe reflexed to dismiss positivity and just latch on to negativity as it were. Does that make sense?

Carolyn Cumpsty Fowler: Oh, absolutely. And it can be really influential when we express gratefulness like this. I'll give you another example. You and I have lived in far, far, far too many meetings where people do not listen to each other. They do not give other people the space to think or to express opinions. It's just this constantly like jumping on top of each, talking on top of each other or immediately discounting somebody else's opinion. And I've actually done this publicly and I've done it privately depending on what I know about the person. But I have publicly in a meeting when somebody has said something and somebody has actively held space for somebody to finish their thought and then taken a moment before they respond, I will actually say, Lee, I'm really grateful for the space you held for us all to really think about what, you know, Susan was saying and not just to jump on top of that. Yeah. And because what I'm saying is, firstly, I'm saying I saw you. I saw you do it. And I'm grateful for what you did. And I'm also grateful for the impact of what you did. And it can also, now you have to be careful because some people don't like to be outed, but you can do it generically. You could say, I would be very, I'll be very, I'd be very, or I was grateful today in our meeting just how much space we left for each other and how much silence we left for each other to do the thinking we had to do. We can say that more generally, but we're being very precise either about the person, in that case I'm saying I see you, I see you and I see your strength and I see your gift and I see the impact of what you did. Or I can also be very precise about what I'm grateful for. I'm grateful when we leave space and silence for each other because that's very tangible. Right. And it's also then almost a way of saying, space and silence is something that's really valuable if we're trying to think about things.

Lee Daugherty Biddison: It sort of marks the importance of that.

Carolyn Cumpsty Fowler: Right. Okay. So then, I mean, unexpected is another one.

Lee Daugherty Biddison: Oh, yeah.

Carolyn Cumpsty Fowler: You know, if I give you something or do something for you, I kind of expect you to say thank you. And if you don't, I'm like, didn't your mother teach you to say thank you? Exactly. Excuse me. But almost, when I don't expect it, I'm just doing my job and somebody says something about really acknowledging what it is that I've just done. Like working with a new grad, a new clinician who maybe is a little anxious, is not feeling very confident, but this new grad that we're working with says, you know, I don't feel comfortable about this. I'm concerned that I don't know what I need to know here. The fact that I can say to them, well, I appreciate, firstly, that you spoke up, and I appreciate your courage in admitting what you don't know, because that's the gateway to learning.

Lee Daugherty Biddison: Right.

Carolyn Cumpsty Fowler: Then I've also, I've immediately sort of normal, not just normalized, but I've actively appreciated the fact that somebody says, I don't know. Let me think about it. What else? So we did, we did authentic, specific, timely, unexpected, personalized. So I think I mentioned this before. I wanted to think about how people like to be acknowledged. Some people love public recognition. They thrive on it. You know, and kudos boards and people giving them shout outs and winning little recognitions and so on. And other people do not. And expressing gratefulness to somebody in a way that makes them cringe is not helpful. Right. I also, I'm vehemently opposed, but this is a personal bias. I want to own that it's purely a personal bias. I'm vehemently opposed to things like star of the week or star of the month, where in a teamwork environment, we say, you're the superstar. We want to acknowledge you this month. Because I think when we do that, we're acknowledging one person almost at the cost of saying, well, you did this all by yourself, not the fact that we as a team created the conditions in which you were able to excel. So I always get worried about that. That's why I actually really like team acknowledgement and team awards, because it's speaking more to the interdependency that we have with each other.

Lee Daugherty Biddison: The other thing that occurs to me in that context Carolyn, is that it also, it's going back to that concept of being able to discount it. Oh, I'm the person who's the star of the week because they just needed somebody this week. Right. So it feels less about me and more about the fact that we do this. So it had to be someone.

Carolyn Cumpsty Fowler: Right. Or it was luck, you know, we've got so many nominations and we put all of you into a, in a jar and then we pull one of you out. Well, and that is, at that point, it is just luck that your name got pulled.

Lee Daugherty Biddison: Yeah.

Carolyn Cumpsty Fowler: And I think we also need to think about how we express gratefulness. You and I have talked about, the idea of muffin rage or pizza rage, right? Where people have gone... Yes, Gillian Horton's muffin rage, yes. So, you know, people have gone above and beyond and above and beyond and above and beyond and above and beyond and we send them muffins or pizzas. And we're not really acknowledging what it's taken for them to perform at this level. And sometimes, I mean, I'm not saying we shouldn't acknowledge people with something that's meaningful to them. If having a meal sent to them is important, absolutely we should, if we know that and we can manage it. But I think the simple act of acknowledging what we know people had to do to make it happen or what people have committed to doing, I think that's really, I think that's really important. And I think it gets lost when we just say, okay, well, let's send them a pizza or send them a box of donuts. It's just, it devalues the extent of what it is that they have truly had to contribute.

Lee Daugherty Biddison: It's so important because the sort of halfway gratitude or sort of token gratitude, I think, can really backfire.

Carolyn Cumpsty Fowler: Right.

Lee Daugherty Biddison; Let me ask you this, Carolyn. I, we've talked about this a little bit before, but this notion of sort of the difference between thanks for your help with that. I appreciate it. And thanks for your help with that. I appreciate you. And how those things land very differently and both for the speaker and for the hearer. Can you comment on that?

Carolyn Cumpsty Fowler: I think I appreciate it is saying I appreciate what I received. And when I say I appreciate you, it's obvious that I appreciate what it is I received. I'm appreciating you as the person who contributed to that or directly influenced that. And so that's a very different message. I don't just conditionally appreciate you for what you gave to me, but I appreciate you.

Lee Daugherty Biddison: Great. I think the other piece of that I've reflected on sometimes is that there is an almost an inherent vulnerability in shifting from the I appreciate it to I appreciate you because I'm acknowledging in some capacity my need for not just a task to be done, but for you as my fellow human being to do that and to engage with me in that way in a place of need or lack in my life.

Carolyn Cumpsty Fowler: Right. Which is what then makes it such a powerful human connector when you lean into the vulnerability and express it.

Lee Daugherty Biddison: Absolutely. Okay. We know I've we've all come across various tools to support us in our gratitude efforts or journey, whether it's a thank you card or some other modality. But I know that there are some resources that you have really found to be helpful and recommended in the past. I'm wondering if you could summarize some of those for our listeners today. All.

Carolyn Cumpsty Fowler: Right, well, maybe we can move from individual to team, if that would be a logical sequence. Obviously, I think whatever reflection practice you can develop, that will be the first I would recommend. And that would be a gratitude reflection or a gratefulness reflection. And there are all sorts of ways to do that. I mean, there are obviously apps that, you know, the Three Good Things apps and all sorts of apps where we can actually go in and note gratefulness. Of course, I love Brian Sexton's Three Good Things strategy because what it, I mean, three good things was predated, Brian, right? But what I love about his strategy is that the process of documenting it, you're also then attaching it to a positive emotion, one of Barbara Fredrickson's positive emotions. And so I'm not only cognitively recognizing what the thing is that I'm grateful for, but I'm really leaning into connecting it to the emotional experience of feeling grateful for it. So that's one way. I've actually found having practiced that, having learned that from Brian and practiced that, I have actually leaned very heavily into the positive emotion space. I find, and I, Barbara describes, 10 powerful emotions. But for example, I find that awe, A-W-E, I look at something and there's what a spectacular sunrise, or I'm looking out of my window and I see birds sitting on the bird feeder or whatever it is, or it's been so crazy and so noisy and my patient has been struggling and now suddenly they're quiet and they're peaceful. And everything just settle and I can just, I can just, I can just appreciate that moment. So leaning into those positive emotions is something that I find very, very helpful and especially real time to do that. So yes, journaling is another one. And we, can buy gratitude journals and a lot of people talk about journaling every single day. If that's something that works for you and you want to journal every day, absolutely. This is another thing that Robert Emmons has talked about, though, where he says that sometimes there can be a law of diminishing returns where perhaps three times a week may be perfectly fine for you in terms of expressing gratefulness. So that's another option. But actually writing gratitude is not a bad thing at all. I will actually, I have actually used gratitude writing in two distinct camps also. So gratitude, I mean, I can send, let me not get too complicated here. Let me just separate them out. So the first is I can send a note. I can actually write down what I'm grateful for. But as a leader, I can actually send a letter of acknowledgement or an appreciation note, an applause, recognition, whatever it is. I can actually take the moment to surface it and then write it. So I can send it to my colleague, I can send it to somebody who reports to me, and I've actually taken the time to send a note or to actually go in and put into words the appreciation that I feel for somebody. There's another practice that is the sort of the gratitude letter writing. That's different than writing a note just to somebody who's done something for you in the short term. But this is sort of the practice of thinking about, as you think about your life or as an experience you're having, is there somebody who's really been so influential or so important in your life that you feel that maybe you haven't expressed the gratefulness to that you would like to? You know, maybe a mentor or somebody who was there for you in a challenging time, somebody who encouraged you to lean into a stretch goal, whatever that is, right? And we're reflecting on, gosh, you know, that person really made a difference at that point. And to actually sit down and write them a letter, and say, I've been reflecting and I'm thinking about this. And well, firstly, that's going to be unexpected when it arrives. So when it arrives, what a lovely gift that you've given them. So, you know, there are all those practices. Now, I have actually used great gratitude letters personally and also working with people who have had difficult experiences stressful experiences, difficult experiences, maybe a difficult person in their lives, or perhaps they've had a failure of some sort that feels that it's a hurdle. And we can actually almost write letters to the person or to the experience. Now, these are not letters we send. But for example, I have somebody that I've worked with who always allows me to tell this story, not that you'll ever know who this is, which is there was a, they've always said that they had a voice in their head and that was a certain person's voice that always doubted them. So when they would find themselves in tricky situations, they would get this imposter, a sense of imposter syndrome because their relative's voice in their head was saying, well, you really shouldn't take this risk. They're not going to take you seriously. I mean, after all, you don't have enough power and you don't have enough this and you don't have that. And, you know, my colleague recognized that this was this voice and in some ways was well-intentioned as trying to save you from yourself and protect you, but it was no longer relevant or helpful. Right. And so she wrote a letter to this person. She knew who this person was saying, I really appreciate that you want to keep showing up to protect me. And you did that when I was younger. And I really don't need you to protect me in this situation, but thank you for caring about me. Wrote the letter and then actually ended up shredding it. But it was a way of actually acknowledging that this thing that was so unhelpful now to her as an older adult was something that had echoes of the past, and she was able to acknowledge it for what was well-intentioned, where it was well-intentioned, and then let it go.

Lee Daugherty Biddison: Let it go.

Carolyn Cumpsty Fowler: Let it go.

Lee Daugherty Biddison: Love that. That's fantastic. Any other resources we should share with our listeners?

Carolyn Cumpsty Fowler: The gratefulness.org is a lovely resource. We can link that in the show notes. That has all sorts of resources about the practice of gratefulness. It has videos. It has a wonderful video by Brother David Standall Rast called A Good Day. That is something that if you want to just feel generally good, it's something that is worth watching. There's also a version of it that was made with Dr., with Brother David Standall Rast's meditation and then just wonderful videography by the filmmaker Louis Schwartzberg. So that's also, we can link that. That's also just a beautiful experience. But on gratefulness.org, you can actually request a daily gratitude reflection prompt. So that could be sent to you. And if that's something that, if you're one of these people, if it pops up in your inbox in the morning, you're more likely to remember it, that's something. And then I would very much recommend some of Dr. Emmons' books. Dr. Robert Emmons books. He's got a really tiny little one that if you don't want to be reading a great big book, he's got one that's literally called The Little Book of Gratitude. Nice. But the one that I really like a lot is Gratitude Works. And then of course, he's also got endless peer-reviewed publications about his research in this space. But I find his work very accessible. But then there's all sorts of resources, you know, as I say, at gratefulness.org. Fantastic. There are also, you can also do things like look at the best gratitude TED Talks. I mean, it's all over the place. But the reason I'm recommending gratefulness.org is because gratitude.org is, no, it's actually grateful. It's gratefulness.org. And the reason I'm recommending gratefulness.org is because what we've been talking about today is actually gratefulness. It's not that just quick, more hokey gratitude. It's the act of grateful living and grateful awareness that is what is really the thing that influences well-being.

Lee Daugherty Biddison: We're just looking for our listeners, it's grateful.org, G-R-A-T-E-F-U-L.org, and we'll link it in the show notes too.

Carolyn Cumpsty Fowler: So it's changed. Even since I looked at it last time, it's changed to grateful.org.

Lee Daugherty Biddison: Just grateful.org. But Brother David Stendel Rast is right there, so I'm sure it's the right one. Carolyn, I am grateful to you for this conversation. And I know our listeners are too. What a joy to talk about this critical practice in appreciating each other and the world around us and maintaining our well-being. Thank you so much. To our listeners, thank you for joining us. As always, please feel free to reach out with comments or questions or ideas for future podcasts. We hope to see you soon.

Carolyn Cumpsty Fowler: Right. And Lee, I'm so grateful for you, as you know. And I'm also grateful to everybody who just takes a moment to listen to this and then pass on the gift of gratitude to the people in your lives.

Lee Daugherty Biddison: Absolutely. Take care, everybody.

Carolyn Cumpsty Fowler: So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague.

Lee Daugherty Biddison: And as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being 
Johns Hopkins Health System 

1. Gratitude is more than a polite “thanks”—it is a way of living.
   Fowler differentiates “thank you” manners from a practice of grateful living: In healthcare, this can look like recognizing teamwork that prevents harm, or appreciating the often invisible supports that make safe care possible.
2. Gratitude measurably strengthens well-being across several domains.
   A consistent gratitude practice supports:
   1. Greater life satisfaction and overall well-being
   2. Stronger relationships and a deeper sense of connection
   3. Better physical health, including confidence in managing health conditions
   4. Improved mental health, and ability to regulate the stress response
3. The ARC model offers a practical framework for why gratitude works—especially in high-stress environments.
   Gratitude can: Amplify positive experiences, Rescue people from negative spirals, and Connect them to community and support. It helps explain how gratitude interrupts the negative thought cycle commonly experienced by healthcare workers.
4. Expressed gratitude is most impactful when it is:
   1. Authentic and Natural (felt, not performative)
   2. Specific (what exactly helped and why it mattered)
   3. Timely (close to the moment)
   4. Unexpected (not just routine)
   5. Personalized (aligned to the recipient’s preferences—public vs. private, written vs. verbal)
5. Token gestures can backfire when they substitute for meaningful recognition.
   When food or perks take the place of effective gratitude, it can feel dismissive. There is a powerful difference between “I appreciate it” (the task) and “I appreciate you” (the person’s inherent value).
6. Small, repeatable practices build sustainable gratitude habits.
   Fowler shares tools that make gratitude actionable, including:
   1. Brief reflection practices such as a “three good things” practice to link gratitude with positive emotions and perspective
   2. Expressing gratitude in a note to a colleague, maybe on an employer-based gratitude platform
   3. Gratitude letters to people who shaped your life, or in a personal letter to difficult experiences or to negative inner voices, acknowledging their protective intent while releasing their unhelpful influence now

• Learn about the work of Robert Emmons ‎around practicing grateful living and the ARC model
• Learn about the work of Martin Seligman and the "Three Good Things" exercise, a positive psychology practice to write down three things that went well each day and why. The Three Good Things app is a research-based, free, and ad-free gratitude journal developed from studies by Dr. Bryan Sexton and the Duke University Center for Healthcare Safety and Quality.
• Learn about the work of David Steindl-Rast and access daily gratitude reflection prompts, programs and resources on Grateful.org
• Learn about the work of Barbara Fredrickson and the 10 positive emotions
• Muffin Rage op-ed by Dr. Jillian Horton

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Lee Daugherty Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning.

Carolyn Cumpsty Fowler: Thank you for joining us.

Lee Daugherty Biddison: Hello and welcome to the Vital Conversations Podcast. I'm Lee Biddeson, Chief Wellness Officer for Johns Hopkins Medicine and your host for today's episode, along with my awesome co-host, Dr. Carolyn Cumpsty Fowler, who is Executive Director for Nursing Well-Being here at Johns Hopkins. And it is such a pleasure to be here together.

Carolyn, we haven't done this in a little while.

Carolyn Cumpsty Fowler: You haven't. Hello, my friend. And I know how much we love getting together to talk about how we impact well-being. So I'm delighted to be with you today.

Lee Daugherty Biddison: Delighted to be able to share this conversation with our listeners. So hot topic for us, well, really a big hot topic for the last year has been just a lot of change and a lot of transitions, been changes.

We're in academic medicine, changes in academic medicine with funding policies and priorities, changes in thinking about how healthcare, things like Medicare and Medicaid are funded and those approaches, especially here in Maryland. And there's just a lot to be said about that.

And I would love sort of, you know, you've taught in the past on change and transition. I would love to hear some of your reflections on the principles that apply in this space and how we can use those moving forward to effectively embrace the new year.

Carolyn Cumpsty Fowler: Wonderful. Well, let's just for a moment separate the fact that there are two big components of this.

So the one big component is that when we have rapid change, there are tactical and logistical things that we need to pay attention to, which is a whole different conversation. And then there's the human response to change and transition.

And I think that's really what we're talking about, because it's that human response that can feel so hard for us and can lead to challenges to our well-being. So I'm not going to share with you anything sort of earth-shatteringly new, but rather some work from William Bridges.

Now, William Bridges wrote a sentinel book on change and transition over 35 years ago. And the reason I like his work is because he's very clear to distinguish between what change is and what transition is. And we talk a lot about managing change or living through change, but actually it's not the change we're living through. So a change is a moment in time, something happens or it stops happening.

For example, when we're bereaved or we finish grad school or we get married or have children, there's a date on which those things happen. And that's a very clear change from before.

Lee Daugherty Biddison: Specific time point.

Carolyn Cumpsty Fowler: To after the change, right. It's a very clear before and after. What Bridges described is that there is a physical change, which is before and after, but there is also a period of psychological adjustment, where what we're being asked to do is to transition from a place of where we understood ourselves in relationship to one state of being or one set of conditions, and we're now being asked to transition to the reality of living in a different set of conditions.

And what's important about this, firstly, is that it's frightening and it's stressful, and we have to acknowledge that and not downplay it. I think a lot of us want to get busy and fix things and do things and say, well, the other stuff will take care of itself. No, it won't.

Lee Daugherty Biddison: We like to distract ourselves.

Carolyn Cumpsty Fowler: We do, indeed. We love to distract ourselves. And also, I think sometimes the temptation for leaders is to get busy with the logistical things because firstly, they're important to take care of. Secondly, they're kind of, they're clear. Like, I know what I have to do. Whereas dealing with the psychological response to transition, it's messy.

It's more of that emotional response stuff that we heard when we were teaching crisis leadership, how people say that's the piece that feels stressful because it's something we're not used to dealing with.

So in this period of transition that Bridges calls the neutral zone, we see several things happening. We see people's motivation dropping off. We see people's engagement dropping off. We see people's collaboration and energy dropping off.

And it's so easy for us to try and manage that tactically, like we just need you to produce more or do more or be here more. But what we're being invited to do is to say, What is the lived experience of our colleagues when they are living through this transition? And what do they need to help them firstly come to terms with where we're journeying to?

And also, what do we need to do to help acknowledge their experience so that we can support them in moving through the transition more smoothly?

Lee Daugherty Biddison: That's so rich. And I love the clarity that brings, I think, in separating the change from the transition and thinking about the transition as being much more fluid and also much harder to manage.

You mentioned the, we could say you did some teaching in crisis leadership and other members of the team were involved in that during COVID. But there were some big pieces of that I think resonate very much with, the more recent changes that people have been navigating. A big piece of that is the communication piece.

And I was just curious about your thoughts on, you know, as you look back to what we learned from that other big, the pre-post COVID transition, but some of those key learnings were that are really important for us to remember now.

Carolyn Cumpsty Fowler: Well, before I actually discuss the key learnings, I'd like to give gratitude to two groups of people, one person and a group of people. Firstly, Dr. George Everly, who was the person who brought his expertise about crisis leadership to us and helped shape on the GFL.

So George, if you're listening, shout out to you. And the other group of people I want to say thank you to before I tell you what I learned was the 1,700 plus leaders that I worked with in facilitating that training, because we learned so much about what it's like to be in the trenches, leading through change, leading through disruption, leading through ambiguity from them. And so part of the wisdom we're sharing is what we learn from them.

Lee Daugherty Biddison: And so much of that wisdom really doesn't show up in a textbook, does it? It's the lived experience and it's very...

Carolyn Cumpsty Fowler: The first thing that I would share, and as my friend and my colleague that this has become a professional obsession for me, is the importance of listening. But where I really heard that was when I was talking with the leaders about what is the hardest thing that you are having to do to lead through this change during COVID?

What people said to me is, managing the people, listening to the people, this feels like a full-time job, and I don't feel fully equipped to do it. And so we began to think more and more, well, firstly, I was grateful that they were self-aware enough and compassionate enough to want to be doing it better.

Lee Daugherty Biddison: Absolutely.

Carolyn Cumpsty Fowler: We were aware that it was exhausting to them. And so I think that one of the key principles that we learned and that we facilitated understanding of was the fact that we're invited to listen before we speak and to listen much more than we speak.

Lee Daugherty Biddison: Our colleague, another colleague who was involved in some of this early work, Paula Teague, I remember she would talk about the ratio of listen, listen, talk, listen. So about one part talking to three parts listening.

But it's hard. It's hard to be a good listener. We've had lots of conversations. You've done lots of training. We've done some training together on what it means to build a listening culture and to listen well. But it takes work. It takes work. And it's a skill.

I've reflected many times, Carolyn, on how in the spaces we've talked about, the fact that we get lots and lots of training in our professional lives on how to give a good talk, on how to present well, on how to speak clearly, all of which are important skills.

But it's just one part of the equation, the communication equation. And it's perhaps the less important part, especially in times of transition and change, et cetera. So interesting.

Carolyn Cumpsty Fowler: I couldn't agree with you more. And I think one of the challenges to becoming a good listener and becoming an effective listener is that we are so busy. We have so much going on in our brain. That while we are allegedly listening to what people are talking to us about, we're processing it. We're processing it to either disagree with it or to try and fix it or to respond to it. What we're seldom doing is listening to understand.

And even when people will say things to us that we might not understand, it's so easy for us to sort of fill in the gap with an assumption. I think that's what they're doing. As opposed to saying, “What is it that you mean by that?”

Now, I did a podcast with Dr. Deb Baker, our chief nursing executive, and she was talking about the impact of a question that I shared with her during the pandemic, and that is sort of the and what else question.

Lee Daugherty Biddison: I was just going to ask you about that. Tell us about that.

Carolyn Cumpsty Fowler: Tell us about that. Well, this is the work of Michael Bunge Stanier. His question again, this question comes from him. But essentially, one of the things I realized is that we have come into a helping profession.

Every one of us who works in healthcare came into this profession to help people. And so we want to help, we want to fix, we want to solve, we want to reduce people's suffering. And that sets us up for trouble when it comes to being a great listener.

Because if I am listening with the intent to fix something or to help you, or to provide an answer to you or help you find some certainty, then what I am doing is I am not actually unpacking what it is you're wanting to say to me.

And so what Michael Bunge Stanier recommends is this question called the or question or the and what else. So when somebody is saying like, this is what's troubling me, you might say, well, and what else? And gradually you're going to repeat that and what else several times. Now, not to be repetitive, there are different ways of doing it, but essentially, what we're inviting people to do is to just keep talking and reflecting on what's going on with them. And at some point, it's almost like you're taking the pressure out of a pressure cooker.

Lee Daugherty Biddison: You're offloading the tension. Yeah.

Carolyn Cumpsty Fowler: Right. That's kind of, it's coming off because I've always said the time to ask what's going on is not when you try and take, like we're not going to take the lid off a pressure cooker when it's blowing steam.

That's just a disaster waiting to happen. So we want the pressure to come down, then we can take the lid off and look inside and see what's going on. And the same is true when people are in this position.

Lee Daugherty Biddison: I love that analogy.

Carolyn Cumpsty Fowler: Right? That we want to be able to give them enough space that they can get some of this steam, the anxiety, whatever the frustration is, off. And then once they've settled, we can ask them what they want to talk about.

And so a question that I will often, when people are talking to me and they've given me a lot of different things, I might just firstly acknowledge and say, that's a lot. That feels like a lot to be dealing with.

Lee Daugherty Biddison: I feel like you've said that to me before, Carolyn.

Carolyn Cumpsty Fowler: Oh, I have. I've even said it to myself before. Because the piece that I follow up with is, and what piece of this feels like the place we need to start, or what piece of this feels the most important to you right now, or the most pressing to you right now, depending on the context of what's being shared, I will always ask this question, and what part of this is the piece that we need to be talking about?

So one of two things will happen. People either have enough clarity that they'll say, well, actually, this is the priority. I want to talk about this first. Or more often, which always makes me smile internally, they'll say, “Oh, no, none of that. That's not the issue at all.”

This is the issue. Because what we've done when we've listened to them is we've given them the space to unpack it. And in unpacking it and getting some distance from it, they're able to get increased perspective on it. And identify the thing underneath all of that. Yeah.

Lee Daugherty Biddison: So good. So, good. What do you say to the person who says, “I agree with you, Carolyn. I think listening is so important. I just don't have the time. I'm, you know, I'm with my, working with my team. We've got a ton going on. I'm managing so much. And I don't know how to find the time to do that.”

Carolyn Cumpsty Fowler: I think the thing we have to remember is listening is part of communication. And if the goal is effective communication, so that I hear what somebody is trying to say to me, they are able to hear and process what I am trying to say to them. The metric we should be looking at is not necessarily just time, it's what is the effectiveness of the communication that we're trying to.

Lee Daugherty Biddison: That's good. Yeah, say more about that.

Carolyn Cumpsty Fowler: Because if we are in a conversation where we're trying to exchange ideas or understand what's going on, and one or both of us is not listening properly. Especially, let's just say one person's not listening.

And I'm trying to share with you things that are concerning me, and you're just not listening to me. Because it's so important historically, it's been so important in our evolution that we feel that we're accepted and heard because that gave us the message that we were safe within our community, within our tribe. We are very, very good at knowing when we're not being heard.

The minute that I, and this doesn't even have to be a conscious recognition, the minute my body or my brain recognizes that I'm not being listened to, it interprets that as risk. And so we begin to go into a more defensive position where we're trying to understand what we need to do to make ourselves be heard.

Now, whether that's talking louder or performing the way a child might cry louder if they haven't been fed, or whether it's, trying to find somebody else to talk to or just keep talking so somebody is forced to listen to us, we begin with patterns in communication which are completely not effective.

So even though we may only take, you know, 4 minutes or 5 minutes, essentially we've wasted 5 minutes because nobody has communicated effectively. And when I'm stressed and I'm afraid, my ability to process, to reason clinically is less clear. And so therefore, the arguments I'm making are less articulate. They may be more long-winded, or I may just not even be able to put it into words at all. So essentially, we've put some time in, but we've got no effective communication. When we have a situation where two people are able to listen to each other deeply, and it doesn't actually need to take a lot longer, it can be the same or shorter.

When we are able to listen to each other deeply, the person who is talking is under less pressure to talk quickly. They have time to get their thoughts organized and to explain what it is they're trying to say. And the person who's listening has time to really receive it, hopefully with curiosity and be able to clarify. And so what we have is time that's been then invested in effective communication. So when people say to me, I don't have time to listen, what I offer them is, given how busy and critical some of the work is that's going on, we don't have time to not listen. Because every minute we spend not listening to other people is a minute wasted and then potential risk introduced.

Lee Daugherty Biddison: So important.

Carolyn Cumpsty Fowler: But I actually got sidetracked from the all question.

Lee Daugherty Biddison: You did, sorry.

Carolyn Cumpsty Fowler: And so we talked all about that, but the thing that Deb Baker taught me was that she said she felt that when she was able to avoid jumping straight in to fix the first thing people said was the issue. She was more able to be fully present with people and to be a better witness to what their experience was of this disruption that was happening in their lives. And so therefore developed greater insight into what it was that were really the issues that people were facing.

Lee Daugherty Biddison: Insight and I imagine empathy.

Carolyn Cumpsty Fowler: Yeah.

Lee Daugherty Biddison: Well, so let's say that we all agree that we can't afford not to listen. But now we're in the space of, but things are changing so fast. I just need to wait till things settle out enough that I know what to say when I'm responding. Like, you know, there's a lot of change, there's a lot of transition, there's a lot happening, but there's going to be an update and another 24 hours or an update thinking back to COVID times, right? There was a change, there was an update every 20 minutes.

It's felt like, but I'm just gonna wait. I'm just gonna wait. You know, that leader says in terms of communicating. What, we have talked a lot about some of the risks associated with that, but I'd love to sort of hear your thoughts and lived experience as you talk to leaders in that space and how it might apply now.

Carolyn Cumpsty Fowler: I think there are two related principles here. The first is that moment of absolute certainty is never going to arrive. And so if we keep waiting to say, you know, when am I going to be certain? When am I going to be certain? When am I going to be certain? When am I going to feel that this is correct enough or close enough to communicate?

We're never going to get there. Time will just keep passing and we'll never get there. Now, I'm not suggesting that there aren't situations where certainty is essential, like medication dosing and safety time and so on, which is another situation in which we've understood the importance of listening, right? We've got to listen during those.

But the other principle that is the one that we really need to remember is there's no such thing as an information vacuum. So that if you are not communicating with me, if you are not giving me information about what's going on, it's not that I'm sitting there waiting for you to tell me and I'm not thinking of any other options.

I will fill that vacuum with available information. Sometimes it will be my assumptions or my fears. Other times it will be misinformation that I'm getting from the internet or misinformation that we're getting via the gossip chain that's happening in our organization. And the more that people don't get the information they need, the more and the more they feel that people are not sharing information, the more they become suspicious of the motivation of leaders, they stop being trusting of the leaders, they think that leaders are withholding information, they're not being transparent.

Typically, people assume the worst, so that they assume that it has to be bad news, because if it weren't bad news, they wouldn't be, they'd be telling them something. And so there is no, there is no situation in which we can win this.

We have, even if what we're saying is we hear your concern and we are working on it and we want to be clear about what it is that we don't want to be chopping and changing. We want to be able to give you a clear response and we're going to check in with you daily until we've got it.

Even if it's just that, like we hear you, we're working on it and we are going to continue to check in, that's important. And or to do what I think a lot of our leaders did quite effectively during COVID, which was to say, given how quickly everything's changing, what I tell you today may need to be updated and changed two days from now.

Lee Daugherty Biddison: And so we're letting people know that up front. Yeah.

Carolyn Cumpsty Fowler: Right. Completely transparent. I'm going to we're going to give you our best decisions. Given the information we have, we're going to give you our best decisions, our best judgment today.

And we're going to be vigilant about things that may require that to change. And if we have to change, we are going to let you know as soon as we know that. Because that has people feel respected. It has people feel included. And we just feel safer when we feel that everybody's watching out for everybody else.

Lee Daugherty Biddison: You know, this is reminding me of that first round of data we looked at on our interprofessional well-being survey in the summer of 21, so not long after COVID, are really kind of still coming out of it, and how strong the association was between that question, that leadership question we asked around whether your supervisor kept you informed of information that impacted your work.

If people answered that positively, they were much less likely to be burned out and more likely to feel fulfilled. And that was such an impactful lesson to me to see that data, that it's people that, knowledge, and that sort of form of knowledge is power. It's that it's as much as you can know, knowing that and feeling like you're being offered that as often as possible, really does impact people's overall experience of transition.

Carolyn Cumpsty Fowler: It does. And people are afraid of the unknown. And there's a reason for that, right? We don't know what we're walking into. It's like trying to walk into, you know, walk down a street in the dark. You don't know what you're going to trip over or who's around a corner.

It's frightening to us. We know that it is. And so I think that's another principle that the Bridges talks about a lot, which is the importance of regular communication and not just generic communication, but communicating in different ways with different messengers at different times.

And he talks actually about four Ps that need to be part of communication and change which I find interesting. I mean, I think there are a lot of people who write about change communication, but let me just offer this because it's a good framework just to think about. So when he talks about the four Ps, he says, so when we're communicating about a big change or something that has to happen, we first need to be very clear about what the problem is.

What is it that we're dealing with that is requiring us to initiate a process of change and transition in the 1st place? Why is this necessary? And as much as possible, when we can have conversations where we're able to tap into, are we clear about how this why would land for other people, that's also helpful. Because this may be our why as leaders, or this may be the executive team's why, because they are privy to all sorts of important information that helps them be clear about that why.

Without that context, without that background, without that expertise, we might not come to the same conclusions.

Lee Daugherty Biddison: And so- We may not even recognize there is a problem.

Carolyn Cumpsty Fowler: Right. And we don't know what we don't know. And so being able to sort of tap into how does this resonate with people? Do people believe us when we say that this is something that we are going to have to do?

It’s clear we need to check for real understanding of that in people. The second is the picture. We have to paint a picture for what change will look like or what things will look like after this change. Remember, that's just a time.

So when we had funding challenges or reimbursement challenges or staffing changes or when we're introducing technology, virtual nursing, scribing, all sorts of ideas that may help us but have not been what we've been using.

Lee Daugherty Biddison: They're new, they're different. Yep.

Carolyn Cumpsty Fowler: They're new, they're different. And so we have to paint this picture of what will that look like and what will be possible for us when we've made this transition? What will we be able to do together, et cetera, right? So that picture has to be painted because people can't imagine it.

Lee Daugherty Biddison: I'd love this point, Carolyn, because I do, I think it's analogous to the information vacuum, which if there's a picture vacuum, we're going to paint a picture that maybe sort of manifests all our concerns or anxieties or fears rather than the true end goal. So important.

Carolyn Cumpsty Fowler: And when we think about, I know, but if you think about it, when we then, you know, when we talk to clinicians, and leaders, even a year into the pandemic or even 18 months.

And we invited them to look back and look at what they've learned, the skills they've developed, how they'd reimagine their practice, how they'd reimagine care delivery. I mean, the just incredible level of adaptability and development and learning that happened is really quite extraordinary.

And yet if in March of 2020, we'd said to people, 18 months from now, you will have done all of this. They'd be like, oh no, but we could never do that. And yet, yet we all did. We all did. It wasn't, it was not without stress. It was not without pressure. It wasn't without cost. Of course it wasn't.

But we have an incredible capacity to flex. And I think that's one of the challenges right now in healthcare. We're being, we're being challenged to change a lot of things really quickly. And so there's a lot of change going on. And that, I think, is what's making it feel so anxiety provoking because it's not just one change we can wrap our heads around. There are all sorts of things in the air at the same time. And that's the challenge. The third P, though, let's get back to that, is the plan.

We need to be transparent about as we're moving forward in addressing this or as we're moving forward in rolling out this change, What's the plan for it? What can we expect? What sort of timeline are we on? Importantly, and I have an evaluation background, so I'm always going to advocate for this piece, are we allowing a period in which we roll something out and we are very open to the fact that there could be mistakes, there could be things that are not working, there could be things that need to be adjusted.

So we're not thinking it's finished and we're just going to roll it out, but we're very much in that design thinking place of there are going to be several iterations. We need to keep getting feedback, adjusting, tweaking until this fits with our practice environment. But that plan is something that's important because when people are going on a journey, which is what transition is, right?

It's a journey from where you were to where you're going to be. It's like saying to somebody, well, we want you to navigate across the country without any kind of navigation help, right? You just need to be there by a certain date. Go west. Go west and you can find yourself, even if you were going northwest, you're off track, right?

So that idea that the plan has to involve some monitoring of it, which allows us to say, are we on track? What do we need? What skills do people need in terms of being upskilled, supported, et cetera? So that's the plan. And then the 4th P is what is my part?

What part do I have to play in this? Because if our executives are talking to us, our senior leaders are talking to us, it's clear we may be, they may be clear or we may be clear what it is we're being asked to do in our roles. And for many of our colleagues, that may not be clear at all.

It's like, well, what do you want me to do? What do you want me to do? What do you want me to stop doing? What do you want me to do? And so I think getting, helping people to get very clear about what is my role in this? What am I being asked to do? What am I not being asked to do? How much am I being asked to lift of this burden? How much am I absolutely not being asked to lift? That's really important. It helps us with ownership and it helps us sort of get a sense of whether or not I feel equipped for what it is that my part in this process is.

Adds a little bit of ownership, you know, as we engage everybody.

Lee Daugherty Biddison: Actually, everybody has a part and here is yours and clearly defining that. I love that. I love that.

Carolyn Cumpsty Fowler: But a part of holding people accountable is being clear that when things are being delegated, they're being delegated fairly, equitably, that people have the skills and the resources necessary to do what it is we're delegating to that.

So it's not fair for us to hold people accountable for practicing differently or doing things differently if we have not asked the question, what do they need to be successful to do this?

Lee Daugherty Biddison: So true. So true. So are we ready to navigate all the change? If we get this, if I get an A on this quiz, Carolyn, can I get there?

Carolyn Cumpsty Fowler: And I always feel a little bit like an imposter when we have these conversations, because I have change and transition anxiety as well. And so I think, in our space, so I mean, no one's going to get an A on it, right? It's like we're aiming for progress, not perfection. But I think what is important is that we are authentic, that we're transparent, that we tell the truth. And that may seem like one.

Lee Daugherty Biddison: This is one of those crisis leadership communications principles too. That's what makes you credible.

Carolyn Cumpsty Fowler: Right. Well, and people say, but of course I'm telling the truth. And yet I would challenge each one of us to think of a time when we have avoided telling the truth or the whole truth or the difficult truth because we just didn't want to deal with the emotional fallout of it or the pushback of it.

And so we're actually not telling the truth by omission. We're not having those important conversations. So I think it's important because I think in order to be able to feel safe with each other during times of change, we need to feel that people are being honest with us.

And some of that requires us as leaders, and I'm not I'm not in a position of leading this kind of change. I just want to be clear about this. But I think part of it also invites us to say, how much of this are we going to trust our colleagues with? Because sometimes when we, with all good intention, decide that some of this is just too much for our people to handle, we do something that is violating another principle of this leadership, which is we get in the way of their autonomy, we get in the way of their agency, and therefore we're compromising their sense of empowerment and motivation.

Lee Daugherty Biddison: And so that's a whole other podcast.

Carolyn Cumpsty Fowler: That's another whole podcast. So I think the thing that's really important about this is for all of our leaders who are in this space, thank you for being honest and transparent and authentic about how stressful it is. I mean, we've had leaders in our health system say, this is hard, it's stressful, and I'm stressed, and I'm waking up at night about this.

You know, this is, we want people to actually tell us the truth, and we want people to communicate with us and work with us so that we feel that we have some capacity to actually be an active part of this process.

Lee Daugherty Biddison: So true. So true. Thank you, Carolyn, for chimping on and doing this conversation. We need to do this more often. We said it's been a while, and it absolutely has been a while. Any final words for our listeners?

Carolyn Cumpsty Fowler: I would just invite our listeners, when they find themselves in these situations, to challenge themselves to stay fully present.

Lee Daugherty Biddison: Wow.

Carolyn Cumpsty Fowler: And curious, and to give yourself permission not to feel that you are responsible for every piece of the solution. Allowing our humanity to be visible, I think, is a good thing.

Lee Daugherty Biddison: Well said. Well, thank you again for this really fun conversation. I'm Lee Daugherty Biddison, and this is...

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we always love hearing from you. So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback.

Lee Daugherty Biddison: If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Carolyn Cumpsty Fowler, Ph.D., M.P.H., N.B.C.-H.W.C., P.C.C.
Executive Director for Nursing Well-Being 
Johns Hopkins Health System 

• Change and transition are not the same - Change happens in a moment; transition is a psychological journey that occurs over time and benefits from active leadership support

• Listening is an essential and often underdeveloped leadership skill - Effective listening saves time and reduces risk. Using the simple “And what else?” question from Michael Bungy Stanier allows team members to fully express concerns, decreases emotional pressure, and leads to clearer, more productive conversations

• Communication must be transparent even when certainty isn’t possible - Information vacuums don’t exist; if leaders don’t communicate early and consistently, people will naturally fill gaps with assumptions, introducing misinformation and eroding trust

• The Four P’s guide effective communication in times of change - Dr. Fowler outlined William Bridges' Four P's framework. Each component is important for maintaining engagement throughout transitions:
  • Problem (why change is necessary)
  • Picture (vision of post-change state)
  • Plan (timeline and implementation strategy with feedback loops)
  • Part (individual roles and responsibilities)

• Authenticity builds trust during transition - Leaders who acknowledge their own stress and humanity strengthen connection, agency, and resilience within their teams

Researchers referenced in podcast:

• George Everly
• William Bridges
• Michael Bungay Stanier 

Effective Crisis Leadership (Quick Tips), an International Critical Incident Stress Foundation (ICISF) Podcast

COVID-19 Crisis Leadership at the Frontline, video training series developed by the Johns Hopkins Medicine Office of Well-Being

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Lee Daugherty Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning.

Carolyn Cumpsty Fowler: Thank you for joining us.

Lee Daugherty Biddison: Hello and welcome to the Vital Conversations podcast.

Lee Daugherty Biddison: I'm Lee Biddison, Chief Wellness Officer for Johns Hopkins Medicine, and your host for this episode.

Lee Daugherty Biddison: Today, I'm delighted to welcome my colleague, Dr. Jose Suarez, for a conversation about culture transformation. Dr. Suarez is Professor of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery at Johns Hopkins. Jose also serves as the Director of Neurosciences Critical Care and the Director of the Johns Hopkins Precision Medicine Center of Excellence for Neurocritical Care. In addition to these leadership roles, Jose maintains active engagement in all parts of our tripartite mission in clinical care and research and education. He's a PI on numerous NIH-funded grants and has served as mentor for scores of trainees. I'm thrilled to welcome Jose here today to talk about this really essential well-being topic of culture transformation.

Jose, thank you for being here.

Jose Saurez: No, thank you, Lee, for inviting me. I'm really honored and excited to share our experience.

Lee Daugherty Biddison: Well, Jose, you know, it just, it's been just a couple months ago now that you and I sat down on a, you know, Zoom call to catch up and you shared the work that had been happening in the neurocritical care unit here at Johns Hopkins.

And I was just delighted to hear the amazing work that's been going on, and I'm grateful that you're willing to talk about it with our audience. So maybe just to go all the way back to the basics, sort of to the starting point, tell us what was happening in the NCCU that motivated you to really start to think about this whole culture transformation concept.

What was happening?

Jose Saurez: Yeah, and I think I will probably start by saying that obviously the neurocritical care unit, like most ICUs or all ICUs, you know, they're high acuity environments, you know, where you're required to work with multidisciplinary teams.

Jose Saurez: And there is often the experience of emotional and cognitive strain due to workload and unpredictable patient outcomes that may all lead to obviously provider burnout, impaired team dynamics, and compromised patient care sometimes because of that.

And obviously that's also compounded more recently by our experience with the COVID-19 pandemic. That further amplified and left the lingering effect and ICU burnout by increasing our workload from higher acuity and also staffing shortages. So I think that was the perfect storm that I think led us to find out that our team was really not working as a team.

We were working as pseudo-teams. And this was all based on informal information that we were receiving from nursing staff, from our APPs, and also from our faculty and trainees. And also that, so that led us to actually create formal surveys to ask people opinions.

And so we wanted to create a safe environment for people to voice their concerns. And that's what we did.

And what we found is that there was significant disruption in the interaction and the workflow in our NCCU. Particularly, I think the point that was more concerning for me was that there was this perceived long-standing unprofessional behavior that somehow was tolerated. And so obviously we were all responsible for that culture, because obviously either by omission or commission, either some of us were actually the perpetrators and some of us were actually being silent or not doing enough time to resolve that problem.

So clearly something needed to be done, and that was the urgency that we decided to implement these changes. And this was all back in the fall of 2023.

Lee Daugherty Biddison: So a really intense environment with, sort of some of the challenges that, are at baseline in any ICU, compounded by challenges about the crisis of COVID-19, sort of a real perfect storm. But how did you decide what to do?

Jose Saurez: Yeah, this is interesting. I really didn't know how to do this and where to begin, right? So the first thing that I did was to set up a multidisciplinary team to sort of gather input from everyone.

And so the team was made-up of senior and junior faculty and mid-level faculty, also mid-career faculty, I'm sorry, and also APPs, trainees, a pharmacist and also nursing staff. So we really wanted to get all stakeholders or at least representative from all groups together to try to decide how to do it.

So the first thing I did, I took a deep dive into the literature and see maybe somebody else has probably done this before and maybe we can get some guidance, right, some sort of roadmap. That's what I was trying to look for. But it was really overwhelming because when I went and looked at the literature for the past decade, I found a lot of information on different topics, but they were isolated topics.

For example, people working on how to make people happier at work, or how to improve well-being, or how to work on perfectionism, you know, things like that.

So there were a lot of these buzzwords that were available out there in the literature, but there wasn't really one all-encompassing work that was actually tend to put all those things together. Until actually, by chance, I discovered this other paper that initially I had dismissed, because the title was a little misleading.

But actually, when I actually looked at the paper, the paper actually showed a model that I thought it was perfect, because what they proposed, and again, it was a hypothesis, also probably based on all what was available in the literature was that if you improved resilience in the team, but not just individual, not working on just individual resilience, but also institutional resilience.

And if you created bonds between those two and worked on them, improving the bonds, then you would lead to a better performing team. And with improved resilience, decreased burnout and improved dynamics and also improved well-being. So I found this paper that actually described the model that I was probably hoping to find, which it was great. So what the authors proposed, and this was a hypothesis, of course, because it hadn't been tested, was that if you strengthen the four bonds between the individual and the organizational resilience, and those that you will lead, that will result in an improved team dynamics, decreased burnout, and more efficient teamwork.

And those bonds are a shared vision, improved communication, recognition of gifts, and creating a sense of belonging. So of course, we also needed to look at how we would build such structure, right? So also we probably needed to do some educational reform and educate our team actually how to get there.

And so to me, the finding of that paper, that was sort of the, enlightening moment for me. So I brought that proposal to the team, and along with all the literature that we have found, and everybody else also brought their own literature, for example, perhaps literature from the nursing literature that I had obviously overlooked, or from the pharmacy literature or the APP literature.

So everybody sort of provided also their own input. And we all agreed that creating or testing such a model would be desirable, and that was the way to move forward, because we thought that did encompass what we were hearing from people that we were missing.

So that was a great moment and that was our first meeting. The last two, three hours, but at least we came to the consensus that we needed to work on those four bonds. So then we, what we did at that time, then we created subgroups of individuals that volunteered to work on every single one of those four bonds to hash that out a little more and come up with specific recommendations to be presented to the bigger group and then so that we would all vote on them and then agree that those were issues or things that we wanted to move forward with.

Lee Daugherty Biddison: Okay, Jose, this is amazing. So many questions. First of all, I need to take some lessons in leading meetings. If you can keep a group engaged for three hours, there definitely, you definitely have got some skills to share.

But in all seriousness, so number one, I'd love to, we'll want to reference the article that you're chatting about for our readers. And so we can if you want to share that now, that's fine. Or we can attach it to the--

Jose Saurez: Yeah, sure. I can share it now. It's by Versio et al. Versio is V-E-R-C-I-O. And it was published in Teaching and Learning in Medicine in 2021. And so, and I could probably share it with you so that you could probably share the actual citation.

Lee Daugherty Biddison: We'll put that in, we'll put that definitely want to put that in the podcast notes. That's great.

The other question that I, or just sort of comment, I guess, in question is all rolled into one is, I'm loving how you're describing bringing all the stakeholders together, that really the function, the transformation of the culture and the function of the team needed to have everybody at the table.

I have a, we have a colleague in the well-being space who likes to talk about nothing about me without me. And I love the idea that that's exactly what you did. You brought all the different people who were going to be involved in any change in culture together in the same space to sort of weigh in.

So that's a really, it's exciting to see that right at the outset. I think sometimes when we're thinking about work that needs to be done, we get sort of halfway through a project and think, oh, I should have asked X and we invite them in which isn't bad, but what a gift to have all the right stakeholders at the very outset.

Jose Saurez: Yeah, and it was also interesting because I didn't know how to begin the meeting. And it just occurred to me because when I was hearing what people were telling me and several of the people that I met with in the safe space that we provided them, they did bring this up about people being responsible for the culture by omission or commission, right?

So then what I told everybody from the beginning is that, well, I welcome you all and I'm glad that you're all here, but the first reflection that we need to make is that we all need to acknowledge that we are responsible for this.

And I told him, and if you cannot acknowledge that at the outset, then I'm going to ask you to excuse yourself from the group. And then we can bring somebody else in your place, somebody who we're willing to acknowledge that.

Because I think we all need to, for that's without acknowledging this, I don't think we'll be able to move forward.

Jose Saurez: And I'm glad that everyone in the group acknowledged that very quickly. And I said, you know, yes, we know we're all responsible, but we want to build something better.

We want to build a community that we all feel proud of and that we all want to belong to. So then we moved on to ask the three questions. One of them was, why are we here? How do we get here? And what is your contribution to the very thing you complain about? And finally, we said, well, maybe we can sneak in a fourth one in there. What do we want to create together that would make the difference? Right?

So then obviously, everybody acknowledged, yes, we have a great opportunity here, and yes, we want to move forward. And everybody, I was really amazed and pleasantly surprised by how engaged everybody was, because they were really invested in making sure that we ended up with the culture change, knowing the risks, right, because we also acknowledged the risks, you know, because it could have gone the other way it could have just completely destroyed the team rather than come up at the end with a stronger team. Because that was the risk that we all thought that we needed to take.

Lee Daugherty Biddison: I think that point that you're making is so important that this, you know, embarking on this journey of culture transformation is a risk. Because, you know, if we're operating in that space of transparency and full engagement, it may be that we don't like, they're part of the team, members of the team don't like where it goes and can be, and can be really problematic.

But what a beautiful thing if it, everybody's able to lean into the process as you all experienced. So you said you made the, you created subgroups and sort of how did their work progress and what did that look like?

Jose Saurez: Yeah, so the, so the. The group, we started with having the shared mission group, subgroup present first. And I think the recommendation was that the first thing we had to do is to come up with a position statement or a shared vision that we can all, own up to and decide that we want to move forward with.

So that they all thought that it was that urgency that we needed to do that as the first step. So, and it was interesting, so we proposed people to volunteer and come up with statements or whatever, what they wanted.

And it was interesting, the one that the winner was actually proposed by the APP that was participating in the walk, which is interesting. And that's when we looked the statement, we tweaked it a little bit, but really encompassed all the values of Johns Hopkins Medicine.

So we thought that, yes, that's perfect, that aligns our values with those to Johns Hopkins Medicine. So it's perfect. And that's the one that we picked as the winner. And that's how we moved, that's how we moved forward.

And so once that was available, then they also proposed that we should set up a banner in both units, because we have two units. We have one at Bayview, and we have another one at Johns Hopkins Hospital, and to print two banners with that position statement and ask everyone working in the NCCU to sign it.

But we also thought that it would be important that the first people, the first signatories of the banners had to come from the top.

So we asked the department directors from neurology, neurosurgery, and anesthesiology and critical care medicine to be the first. The nursing directors also from the hospital also to come in and sign it. And they were the first ones to sign it.

And we took pictures, distributed pictures, everybody knew, yes, they were here. They were the first ones to sign it. They are supportive of what we're doing here. Now, please, everyone come in and sign it.

And you saw after that, there was all these, there was even one day I remember I was so impressed because there was a line. There was a line in the two people lining up to sign it. And so that, to us, that meant that we were probably up to something good here that people are willing to participate in.

And it was in both units. It wasn't just a downtown or maybe both units. Everyone came up to sign it. So that was extremely encouraging for us. So we thought that was a great first step to move forward. Now, the other thing that was also recommended by the group of the shared vision and also the group of the sense of belonging is that we also needed to relearn how to provide feedback, how to take feedback, and how to act upon the feedback, right?So then, so what we did with the faculty, and it was amazing, because the other point that I think is important for our listeners to know is that we have an amazing institution.

Okay, so Johns Hopkins is an amazing place to work because we have so many resources available. Sometimes people just don't know that we have them available, but we do. We have, so when I reached out to many people, you know, across the university, it wasn't just the School of Medicine, but beyond the School of Medicine, School of Nursing, the School of Business, you know, the Office of the Provost, you know, at everyone was so willing to help. And they pointed me also on the right direction every time I had a question about something. For example, the best example is this, how to give feedback, right? So they pointed me to two great resources that we have.

One is the teaching academy, you know, for faculty. And quite honestly, up until that point, I wasn't too familiar. I sort of, I had heard about the academy, but I hadn't really delved deeply into what they actually, what they had. And they do provide, best teaching practices in university teaching, right? So then we learned about that. So we sent all the, all of us went there, the entire faculty joined that. And it was an amazing experience, right?

Because it was like, we relearn how to teach, relearn how to provide feedback. And we also heard from Rachel Levine, from the, that she was an amazing, amazing resource. She was so eager to come and spend three days with us, you know, three days with us, three afternoons. usually on Fridays, that people were willing to come. And we opened it up to not only to faculty, but also to APPs and also to the nurses that wanted to come and work with us. So what we did, she asked us to provide specific case examples, right? So specific examples as to where we thought that perhaps the feedback wasn't provided in an adequate manner. So we asked people to give us specific examples, and we gave it to her. And then we worked with those examples so that people could see where the feedback was not properly delivered or perhaps when was not properly accepted by the person that was getting the feedback so that we could all learn from that exercise.

And then we also, obviously, she also shared with us some manuscripts that were available in the literature as to how to do that best. And I think that one of the points that really stood out for me was, making sure that when we were rounding or when we were working with the multidisciplinary team, always ask ourselves the question, was anybody left out? And to me, that was sort of an eye-opening for me too. And then now I have incorporated that into my daily work in the ICU.

Every time I'm rounding or I'm in a meeting or I'm delivering a lecture, I want to make sure that I'm looking at everybody and make sure I'm making the point that everybody should ask the question. Did you ask the question? Do you have feel free to interject and recommend whatever you think we need to implement here. I want to make sure that your voices are heard. So that was, and I think everybody else has sort of more or less followed that example because people feel more included now.

Lee Daugherty Biddison: Great. For our audience, Dr. Rachel Levine is a part of the leadership team in the Office of Faculty here at Johns Hopkins. She's one of our associate deans and a really magnificent clinician educator and a teacher in the space of education. So just as a side note for the reference or the support resources that Jose is sharing. Yes, I completely agree with you, Jose. We have just a wealth of resources and sometimes it's hard to know exactly where they all are, but wonderful to highlight these here and think about how they could be applied elsewhere across the institution or serve as an external resource as well.

Jose Saurez: Yes, And then the other point that was made by the group that worked on communication was obviously improving, the communication not only among ourselves, but also from the top down. So from the leaders in the NCCU.

And so that led to obviously sending more frequent messaging, weekly messaging, making sure that people are up to date. we also developed some monthly small group and division-wide meetings to make sure that also all of them multidisciplinary in addition to the individual meetings that say the providers had their own meeting.

Physicians and APPs, the nursing staff at their own meeting, pharmacy had their own meetings. But then we would also have this monthly meeting where we would bring everyone together and emphasizing that we were obviously creating a safe space so that people could provide feedback. And if they didn't feel comfortable sharing it, you know, in front of the bigger group that they should feel free to reach out to the leadership and share what they thought that perhaps they were bothered by or something that they thought needed improvement. And so that actually also helped because then we told them, if we don't hear from you what the issues are, there's no way that we can actually try to fix that because we don't know what they are. So, and so people felt comfortable about bringing that up as well. And that was wonderful to see because we heard it from everyone, even the EDS staff, even they also brought up their own issues, that they were also having. So that was amazing. So the other thing that we also thought that it was important was to create this zero tolerance policy for unprofessional behavior. Okay, so because what we what we defined as this unprofessional behavior was a behavior or a personal conduct that harms patient care, teamwork, organizational trust, patient safety, and of course, the clinical learning environment. So by defining it that way, we also said, look, we all need to be committed to being good citizens, right? So the good citizenship also was defined as accountability to the whole without any barter. Okay, this is not quid pro quo here. This is something that we want to be good citizens because this is good for everyone. And we should not expect anything in return except great teamwork. That should be our reward by being good citizens. And so then we told people, you know, we also created a document. That was the other recommendation to draft the document.

That is that kind of acknowledgement from all team members that they were going to share this vision that we had created, they're aligning our values with those at Johns Hopkins Medicine, and that we were also going to go along with the 0 tolerance policy for unprofessional behavior. And so we gave it to everybody and I said, look, we know this is obviously, this is not legally binding.

But this is a document that is actually telling us that you are willing to be part of our team, right? So, and I think the, and it's also important to share that most people actually signed it. There were some people that did not sign the document. And so we obviously had to have a conversation with those individuals and said, look, we were here tend to build a better team, but in the fact that you're not signing the document, perhaps that indicates that it may be time for you perhaps to look for another team, right? Maybe this may not be the perfect team. So reflect upon that and let us know whether you still want to be part of our team, because we want everybody to work together. And we cannot continue with business as usual the way it was before, because clearly that was not good. And that was hard. That was obviously a hard conversation to have, but we needed to be honest and transparent with everyone that was the expectation.

Lee Daugherty Biddison: And so you said that not everyone signed. So do I remember correctly from our previous conversation that there were a few people who left the team ultimately?

Jose Saurez: Yes, there were some individuals that left the team that they decided perhaps that they wanted to go and work elsewhere or that they were not sharing, what these multidisciplinary team had come up, the recommendations that we had come up with. Yes, so that was that, and it was hard, and it was, because obviously all every time you implement changes, that creates that brings, emotional an emotional component to it, because obviously, you have to have honest conversations, and transparent conversations, but I think we were, we, were very empathetic as well. I think we tried to be very empathetic and very understanding and trying to understand where these minority individuals were coming from as well, so that we could also help them and provide them with support, because I think that's also important, to try to help them and also move and also move forward, right? So, and that was also important. And I think there was another conversation that I'm bringing her name here because she told me that it was okay to quote her. Charlene Gamaldo, who is at the Office of the Provost now, she's also faculty in the Department of Neurology. She was also super helpful. And, you know, she's an expert in this Strength-based coaching, yeah. So she, I did the exercise with her and several of our faculty also did with her so that people could identify their strengths and how you could work your strength, maybe somebody else's weakness and your weakness, maybe somebody else's strength. So I think it's a great concept. And so we also brought that up, but she also told me, you know, that yes, but you're also going to have

Some individuals in the team that may be, quote unquote, more toxic than others, right? So, and then what she said is that, yes, you could provide coaching, but some of that coaching may not work for some of those individuals. And she said, you will have to do the way we treat cancer. So if you find a cancerous cell, then the cancerous cell has to be excised somehow. So then you also have to provide an ave for those individuals to move on. So essentially, perhaps leave your team because otherwise the dynamics will never improve. And that was very helpful to me to hear that because that also provided me with, gave me some empowerment to also to make some decisions and discuss with other leaders, how we're going to do this so that we make sure that we provide the adequate pathway for those individuals that perhaps didn't need to be in our team, but we can find them other positions in other areas based on their strengths so they can move on and perhaps use their strengths in other teams, but not in ours.

Lee Daugherty Biddison: So I'm anxious to, I'm loving all of these details, but I'm also anxious to get to the good stuff. So you've done all this work and bringing everybody together, meeting, agreeing on principles and purpose and all these things. And this unfolded over the course of how long?

Jose Saurez: So we began, everything began, in January of 2024. Okay, so then, and we've been doing all this since that time. So obviously we implemented very quick measures, the most urgent ones, like re-education, learning how to give feedback, how to take it, changing the team dynamics, interactions, all that had to be done fairly quickly.

And so then, but we also, and I think it was good that we also had the forethought of measuring it, because I said, how are we going to measure this? Because if you only go by qualitative assessments and asking people informally, you may not get the true picture of what's actually happening.

So we decided to send out a survey, a baseline, and then we said we should measure it every six months and see how we're doing. So we have data all the way through a year into this process. So we began, the survey that we used, we used the mass lag burnout inventory, not because it's the best out there, but is the best validated. I mean, it's obviously, there's really nothing, I wouldn't say that none of those measures out there are probably the best that we want, but that's the one that is the most widely validated. So we wanted to use it.

So and we wanted to use the three domains from the Mass Lack Burnout Inventory, this personalization, personal accomplishments, you know, so as a group and to group all the questions into the three domains. And we also used to modify some of the well-being index questions, specifically those that pertain to team leadership, as to how well they feel supported by the leaders of the team and also how well they feel that we're working together as a team and whether the well-being measures that we were implementing were actually meaningful to them.

So we started a baseline and time zero, and then send out the survey. It was really a seven months. That's how we worked out. And then 13 months later, we didn't look at the data until after 13 months, but we did agree to have, informal during the meetings and also informal conversations with people, hallway conversations, if you will, like nursing leadership with the nurses, I with the faculty and the APPs and the fellowship director with the learners. And so we immediately, very quickly, within the first three months, we started noticing that people were changing their responses. So they were saying, well, yes, we feel better. Yes, there is a positive attitude in the team. We feel like everybody seems happier. There is more collaboration between the different disciplines. So we knew that something was happening. And then finally, after 13 months when we, looked at the data, the first thing that we noticed is that there was a high degree of participation. So the overall... Yes, yeah, we found that the overall response was the average was 65%. So we send it to 124 individuals, between nurses, pharmacists, learners, and faculty, and 65.4%. The literature out there says that 50% or above is excellent. So we were really encouraged by that high degree of participation. And it was sort of maintained throughout the three time periods that we were looking at.

And the other thing that we were highly encouraged, really, that filled our cup when we realized that we started at a baseline respondent of high emotional exhaustion of 40, or 20, sorry, increased by 43.4% from baseline. So we began by having 50% of our team members saying that they were spent, that they felt exhausted pretty much every day or most days when they were coming to work. And that improved by 43%. It's amazing.

So we really felt like, okay, maybe what we did was great. It's hard to tell which one of those components. were responsible for this, but with that, we decided, okay, maybe everything that we were doing was actually improving. And we saw a positive trend also on the high degree of this personalization and also in high personal accomplishment. And then when we looked at the team dynamics, we also saw similar trends, that it was like a 38% improvement in good team trust and collaboration and also a 39% improvement in the perception that the welding measures were being well prioritized, that they felt that they were meaningful to them. And also there was an improvement in the perception that the leaders of the teams in the NCCU were actually being very responsive. So there was a improvement in managerial support up to 86.5%. So this was, it was significant. And so we have continued measuring it.

So we had to have a follow-up to see whether we could actually sustain that for more than a year. So our goal is to continue because that's the only way that we can actually check and see whether the measurements are still having an impact, whether we are regressing, and in which case we may have to look exactly as to which areas we're failing out. But so far, everything has been very positive.

Lee Daugherty Biddison: I'll say I just love this story. It's such an encouragement to see just the investment in the culture transformation because of all the wonderful things that are happening, people are happier coming to work, the patients are, shifting back to the center of focus, and we are, getting away from the fractured teams and more towards the optimal care that we want to deliver, which is really what we're, what the mission is all about. And it's so, fantastic.

I could keep talking to you about this for hours, but we should probably wrap up. But before I do, I just wanted to ask if there's anything about your journey and the NCCU that I haven't asked about that you would like for our listeners to know.

Jose Saurez: No, I think you asked the right questions, but I think I wanted to sum it up by telling people that, you know, culture change is difficult, and it's a risk, as I mentioned before, but it is a risk worth taking. And I think the only way to do it is through hard work and providing people a safe space. Just because you are not hearing feedback from people about how your team dynamics is, does not mean that everything is perfect. It may mean that they're afraid to tell you, oh, there is something going on with the team that they don't want to be transparent and don't want to come forward. So it's important to provide a safe space. Once you provide a safe space and talk to people, then you'll realize that perhaps your team is not as perfect as you thought it was.

Lee Daugherty Biddison: Jose, such an important reminder. And once again, thank you so much for this thought-provoking, insightful, inspiring conversation. And for our listeners, as always, we love to hear from you. So we are signing off now for the Vital Conversations podcast. Take care.

Jose Saurez: Thank you. Thank you.

Lee Daugherty Biddison: So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback. If there are any topics you'd like to hear about, please e-mail us at [email protected].

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Jose Suaez, M.D.
Professor and Chief Neurosciences Critical Care
Director Precision Medicine Center of Excellence for Neurocritical Care
Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery

1. The team followed a culture change model to strengthen four bonds between individual and organizational resilience leading to better team performance: shared vision, improved communication, recognition of gifts, and sense of belonging. (citation below)
2. A multi-disciplinary team created a departmental vision statement that aligned with organizational values. All team members were invited to sign the statement banner, and a significant moment was when lines formed with people waiting to sign.
3. Suarez suggests that leaders incorporate the question, "is anybody left out?" as a regular practice during rounds and meetings to maintain inclusive participation.
4. The leadership learned that absence of feedback doesn't indicate perfection but instead may reflect fear or lack of transparency, making safe spaces essential for honest assessment and improvement.
5. As part of the culture transformation, the NCCU has a zero-tolerance policy for unprofessional behavior, recognizing it harms teamwork, organizational trust, patient safety, and the clinical learning environment.

Citation: Chad Vercio, Lawrence K. Loo, Morgan Green, Daniel I. Kim & Gary L. Beck Dallaghan (2021) Shifting Focus from Burnout and Wellness toward Individual and Organizational Resilience, Teaching and Learning in Medicine, 33:5, 568-576. https://doi.org/10.1080/10401334.2021.1879651

Lee Daugherty Biddison: I'm Lee Daugherty Biddison.

Carolyn Cumpsty Fowler: And I'm Carolyn Cumpsty Fowler, and we're your co-hosts for the Johns Hopkins Office of Well-Being's podcast, Vital Conversations, Influencing Workplace Well-Being in Healthcare.

Lee Daugherty Biddison: We spend a lot of time thinking about how to influence workplace well-being in healthcare, and we're excited to share what we're learning.

Carolyn Cumpsty Fowler: Thank you for joining us.

Lee Daugherty Biddison: Hello and welcome to the Vital Conversations Podcast. I'm Lee Biddison, Chief Wellness Officer for Johns Hopkins Medicine and your host for this episode.

Today, I am excited to welcome my colleague and friend, Bryan Sexton, for a conversation about his journey to Chief Wellness Officer at Duke, as well as some highlights from things he's thinking about over his many years thinking about and studying well-being.

So to tell you a little bit more about Bryan, Bryan is currently the Chief Wellness Officer for Duke Health Integrated Practice, as well as Director of the Duke Center for the Advancement of Well-being Science.

He's A psychologist by training and has been a psychometrician and well-being and patient safety researcher for more than 30 years, both at Duke, Marie's faculty in the Department of Psychiatry and Behavioral Sciences.

Before that, at Johns Hopkins, where we first met, had a chance to work together, and became friends. In addition to all of that, he is a father of four and an aspiring. He told me to tell you aspiring, not avid, woodworker. Aspiring woodworker. And hopefully we'll get to a little bit of that.

So, Bryan, thank you so much for being here today.

Bryan Sexton: Thank you, Lee. And I would say perpetually recovering father of four.

Lee Daugherty Biddison: I'll add some more adjectives next time. Very fair. I'm just thrilled to have this chance to talk and hear a little bit more about your journey.

So, we met 20 years ago now, what, I was 6, and started talking about, at the time we were talking about patient safety and some spaces, some things going on in that space here at Hopkins and in your previous research work. And that journey has really taking you into the space of well-being and its connections to patient safety and overall outcomes.

But I would love it if you would just sort of describe for our audience sort of that journey, because it's such a fascinating one.

Bryan Sexton: Yeah, there's some interesting parallels between like the patient safety movement and the well-being movement in healthcare.

I started off doing similar work in flight safety for commercial aviation, using funding from the FAA, looking at things like safety culture in the cockpit and how to inform training programs and how to kind of monitor and surveil safety incidents. And a lot of that methodology was being brought over to do patient safety stuff early on.

And so I had a kind of a front row seat as a very young researcher, like while I was still in graduate school to the first IOM report being released and, two errors human and a lot of kind of concerning statistics coming out about, just how safe, healthcare really was.

And at the same time, had to make a decision for, literally from my PhD, did I want to hang around and wait 75 years to see whether or not we could create an increase in flight safety? Or did I want to kind of hang out in a parking lot of an ED for two days to see if we could, increase safety?

And it was just the prevalence and severity of safety issues was just so much richer in healthcare as a target-rich environment. So that was a lot of fun to kind of come over and be young and figure that out.

But then along the way, we kind of learned from a lot of really people who I admire greatly from Johns Hopkins taught me a lot about how to think about, is this group ready to do quality improvement stuff?

Because they seem to be struggling just in general. And I had some really potent and kind of career-altering conversations with people like Lori Payne at the time there at Hopkins. And that really set me into, well, we should be measuring people's ability to do stuff.

And it turns out when you're measuring well-being well, what you're really looking at is people's ability to do stuff.

And lo and behold, we have a bunch of metrics and stuff. You said I was a psychometrician, just for your listeners, like, a psychometrician is someone who creates metrics and then makes sure that they measure what you think that they're measuring. So we create a well-being metrics and well-being interventions for busy, tired, cranky healthcare workers.

Lee Daugherty Biddison: This is so important though, Bryan, because I think, and it's one of the things that I learned from you when we were working together, is that it's how important it is to be sure that you're measuring what you think you're measuring.

Just like a random question that seems okay in a conversation in which we can go back and forth and clarify what we really mean is a very different thing from a question someone takes on a survey or something like that. And you've got one chance to be sure they understand what you're asking of them and that, you know, all but the components that go with that.

Bryan Sexton: Yeah, I mean, I've had a really amazing series of HR colleagues that it's been a journey to get to where we kind of say and mean the same thing when we say something like engagement.

I think it's common in the HR world when you say like engagement, like employee engagement, a lot of people in HR think that means engagement. But when you look at the data behind what's being collected by a lot of these vendors, they say it's engagement, but there's no evidence that it actually predicts turnover or predicts kind of... this is really geeky, but what we talk about is what's called organizational citizenship behaviors, like do you steal from work and do you kind of like do your best for every patient in every situation, every day kinds of things.

So organizational, like does engagement actually predict that stuff? And for the most part, the stuff that's really expensive that people pay a lot of money for, no, it's what they're paying for is a bright and shiny dashboard.

But the measures behind that dashboard aren't really, there's not Bryan Sexton much there. So we're very careful and you've done this too, like your work, you've shown that like if you're measuring patient safety, how do we know this is patient safety?

Well, it's because it actually predicts whether or not you wash your freaking hands, you know, so that's a behavioral kind of, you know, thing that is predicted by what people report on a survey.

And if you're going to measure things like if you're going to take the time, this is something that this person will go nameless, but it was a very, interesting entrance for me into the Hopkins world fresh out of my training was a surgeon pulled me aside and he said, you're about to go give grand rounds at Johns Hopkins.

You're going to stand right there at that podium and you're going to waste the time of all these really important busy people.

So whatever you do, you be useful. And every, literally, I can't make any GME slides or I can't make a PowerPoint deck now without having that echo in my head, like, is this useful? Is this really useful?

And so that has really shaped this idea of when you're doing the research or you're creating the measure or you're going to kind of, you're going to put something on a questionnaire and take the time of busy distracted healthcare workers, make sure it's useful.

Make sure that it's important. Make sure that it's relevant.

Bryan Sexton: Make sure that it's an actual outcome, like not engagement in quotation marks, but engagement because it predicts lower disruptive behavior rates, fewer communication breakdowns, lower turnover, right?

You know, things that you can measure independently and link it back. But I could never in the patient safety world, in the well-being world, just say, this is well-being, trust me. I, because I say it's well-being, it's well-being. So when we say psychometrician, it's, we want to make sure that we measure what we think we're measuring.

Lee Daugherty Biddison: I love that. Thank you for expounding on that, because I think it's really important. But we got you off track.

Bryan Sexton: Yes.

Lee Daugherty Biddison: So you were, you had made it from flight safety to patient safety. And then what happened? Conversation with Lori Payne.

Bryan Sexton: So the, this is, this was a pivotal moment in my career where I was sitting in her office and we were looking at the data. At the time, this was about putting bloodstream infection protocols in every ICU in the known universe. It was like, that was the goal. We will put these protocols in every ICU. And we were looking at the kind of, about a third, I think it was like 35% of the ICUs, they either stayed the same or they got worse, despite putting this protocol in.

And in every single one of those kind of failures to launch, in every single one, there were moderate to high levels of burnout amongst the staff. And the question then became, well, why are we wasting time in one out of every three of these kind of, you know, interventions, one out of every three of these applications of this protocol, why don't we do some pre-work?

Why don't we make sure that we're putting gas back in the tank before we get the new stuff to do? And that kind of became its own thing. So I started my role at Duke as the director of the Patient Safety Center. And very quickly, over 90% of my time was spent getting teams ready to do quality, which meant well-being. And so that kind of evolved into well-being that way.

Lee Daugherty Biddison: You know, it seems, as we talk about it, like such a no-brainer, but it's been a real barrier, I think, in the patient safety space, that readiness for change concept. I was talking a lot to another colleague that we work with very closely here, Michelle Eakin, who does a lot of work in implementation science.

And the real challenges, especially like if we think about, I mean, this has been true over the arc of the time we've been talking about, but especially like post-COVID, trying to get anybody to engage in implementing anything new, changing something, doing a new procedure.

People were so exhausted, they absolutely did not have the capacity to engage in whatever that was. And no amount of hand-wringing and shouting and jumping up and down is going to motivate people to do that if they're not in a place where they're ready to engage.

Bryan Sexton: Yeah, I would go one further and say that 2025 was a year that did a whole nother number on the well-being of, in particular, academic medicine. But it was so much harder in so many ways than COVID for so many people in this field.

This is kind of fun, and if you don't mind me geeking out for a second, there's a really brilliant social psychologist. Her name is Susan Fisk. And she famously had this line of research that says kind of attention follows power. So secretaries know more about bosses than bosses know about secretaries. Nurses know more about physicians than physicians know about nurses. Attention follows power.

And basically the idea behind that is that kind of primates generally pay attention to other primates that might control their outcomes. So it makes sense that attention follows power. What happened in, I think, 2025 was academic medicine, science and healthcare, and in particular, academic medicine just lost a lot of momentum, lost status, basically.

And when you lose status, you have to then scan your environment for other things that might possibly go wrong. So it was a very specific kind of exhaustion that people experienced in 2025.

And I don't think they were aware of why they were just so, I'm not going to say frightened, but there is a nervous energy that's behind what else might go wrong, what else might go wrong. And that's on top of your day job. So that manifests in things like emotional exhaustion.

And for other people, things like, moral injury and moral distress. And it's like, why am I doing this? If AI is going to take over my job anyway, oh my gosh, what's the point? Like it can become very overwhelming very quickly.

Lee Daugherty Biddison: Like, okay, so we have unpacked that mess a little bit.

Bryan Sexton: Yes, that's why we need well-being, because there's so many things.

Lee Daugherty Biddison: The chief wellness officer role now for six months. Most people might think who've like, read your work that you've been doing it for a long time, but the specific chief wellness officer role.

Tell us a little bit about that transition and then maybe we'll talk a little bit about what you've been thinking about is most important in terms of what you're doing in that space.

Bryan Sexton: Sure, So for, we've done a lot of research with like large data sets looking at the prevalence and severity of different types of well-being or work-life balance, the things and healthcare workers.

We've also done a lot of work with randomized controlled trials showing that we can cause well-being to improve, using something we'll talk about here in a bit, kind of micro interventions or kind of bite-sized kind of interventions.

So we were doing that for a long time. It was interestingly, it was going live with Epic at Duke and being ready for that kind of assault on well-being, if you will. Like how cute to think of it. Like, oh, we have to get ready for all of these really, really hard things, given what has happened since then but we wanted to be able to package well-being interventions in a way that would not be very burdensome for busy healthcare workers, but had good data behind them.

And in so doing, it took a lot of time to, cultivate and curate these interventions so that we were, it's a 10-minute intervention that you do twice, or it's a four-minute intervention that you do kind of four times. So not 45 to 60 minutes a day for the rest of your life so that you can kind of clear your head of all your woes.

And that there's nothing wrong with meditation and yoga and diet and exercise. Those are, there's great data behind all of those things. And it's a heavy lift if you're miserable. If you're just not feeling it, like taking on a new life skill is really hard.

So we did a lot of that data, a lot of that research to kind of make it as easy as possible for the healthcare workforce and then to kind of do those grants. And this is, Robert Wood Johnson and HRQ and NIH and HRSA. These are all places that, you know, we would get funding from to do this research.

And then in 2025, things just got so crazy with well-being that instead of taking these interventions and making them available for the for the masses outside of Duke, the idea was we need to do more focused work internally and make sure that these things that are so popular outside of Duke are brought in a deliberate way.

And that's my current role, which I'm not even six months in yet. That's what we're trying to do at Duke Health Integrated Practice.

Lee Daugherty Biddison: That's awesome. Okay, let me ask you, as we talk, you know, more questions pop into my head. So I'm gonna just run down this rabbit trail for just a second.

And as you're describing these micro interventions, and many of them are, well, I'm happy for you to tell us about a few of them, but my understanding, and you correct me if I'm wrong, is that they're really about sort of how managing ourselves in some way and how we interact with a system. Right.

Bryan Sexton: Kind of, yes, kind of. I mean, I want to be careful about saying like. It's your responsibility to manage your own well-being. I think that... Yeah, that's what I want to get at.

Lee Daugherty Biddison: So the Lancro intervention, talk to me about the interface between the micro intervention that you're describing and the systems change that people have talked about.

It's a big, big push of the National Academy of Medicine and other groups. So say a little bit more about how those pieces put together.

Bryan Sexton: Sure, yes. No, I think that a lot of very well-intentioned people that had their favorite thing, which whether it was like fitness or yoga or meditation or you name it, they came forward and they said, hey, you should do this because this works for me.

And what it kind of began to do is point the finger at the healthcare worker to say, you need to go be more resilient. And even the word resilience is considered kind of like, why would you put that in your title of your presentation?

You're going to just, you're going to draw the ire of like 35% of your audience. So we use the word well-being, you know, instead of resilience in all those cases, I'm sure you all do too.

And the idea now is we have to do two things. We have to walk and chew bubble gum. The system's broken. The system has to be fixed. And it hurts so many people that it's ridiculous. Like your colleagues, my colleagues, it's now close to two out of three of them are really suffering in their roles. So to say that we got to fix the system is ignoring the fact that the majority of our colleagues they need some gas back in their tank. They need a recharge.

And so the question is, what are the evidence-based things that you can do to put gas back in your tank? And can it be more than just meditation, please? Can there be other things that we can do?

And so there are lots of diverse things that you can lean into in kind of bite-sized ways. One of them is spending time in nature or awe and wonder. Like what are some things that you can do to kind of, it's spending time in nature and noticing nature is a remarkably restorative thing, especially for physicians. It's a big, it's a real popular one in our physicians and our APPs.

But then there's, you've probably heard of like gratitude and random acts of kindness, but there are other things that you can do, like there's some really cool sleep hygiene hacks that I'm kind of smitten with.

As someone who's struggled with, you know, good sleep for a long time, I was really fascinated by things like the, I don't know if you've heard of the 3-2-1 rule, but like 3 hours before bed, no more food, two hours before you want to fall asleep, no more liquid, or one hour before bed, just in the lights. And if you just do those three things, it's so much easier to fall asleep and stay asleep.

And these are simple things that it's just not known. And there's really good data behind it, but it's just not known. So part of our job in well-being is to put, to embed this these interventions, these micro interventions into, CMEs and CEUs so that when you're going to gather some of the stuff just to stay current, you get the best available evidence and things that you can choose to do for yourself.

So that's, those are examples of like, of like bite-sized things that you can do. Like the time and nature, the awe and wonder intervention that we have is super popular and it takes 10 minutes one time.

And we can measure differences in your well-being two months and four months and six months later. So that it's things like that when we say bite size that are so powerful. Now put that against the backdrop of the system's broken.

So what are you doing to fix the system? What you're you don't just fix me, fix the system 100%. You know, we have to do both. It's not one or the other. And let me just pause and say, can anybody tell me what is the one thing you can do to fix the system that helps everybody? What is the one thing you can do that helps everyone?

I haven't found it yet. That's right. That's right. It's a lot. It's and so where I think that there's a happy medium between just obsessing about individual well-being and just obsessing about fixing the system is how do we make sure that every clinic, every department, every division has a, not one, but a number of people that are well-being informed.

The science of well-being has a concentration in that group where a leader in that area can lean into that expertise where they know what the metrics are.

They know what the interventions are because what you're going to do in your cath lab is going to look very different than what's going to work in peri-op.

And what's going to work in surgery is going to look different than what's going to work in peds. And what's going to work in my pod may look different than what's going to work in your pod, even though we share a bathroom and a break room.

And so recognizing that diversity of need and that you need different things in different situations,

The best person to do that is a local kind of well-being dignitary or a fellow or an ambassador. We call them fellows.

Lee Daugherty Biddison: Dignitary, I like that one.

Bryan Sexton: Yeah. I think you, I think you actually, you were using the word fellow. Did I get that from you?

Lee Daugherty Biddison: I thought, I thought I wrote down something you said. Anyway, yeah, it's a great idea.

We had something not fellows, but something similar sort of folks who are sort of leading the charge within their own departments who can contextualize the things that are offered and think about, hey, these are, different resources.

And I love this concept. It's something we've spent a lot of time about, but how do we, you know, it sort of goes back to your comment about do something useful. How do we in leading well-being approach departments and leaders and even, even down to the unit level and say, we're here to support your journey, not here's one more thing you need to do, right?

Be sure your people aren't miserable. As if those leaders, wanted them to be miserable, right?

Bryan Sexton: Yeah, well, and by the way, if you're a leader and you're not miserable right now, you're not paying attention. I mean, there's a lot of, we've, so many leaders have lost so much autonomy that it's been, it's been really, it's been a hard time for people in leadership positions.

But can I go back to something you were saying before? You were talking about how it just became so difficult to get people to engage in quality and safety when they were so overwhelmed by kind of what was happening in society and what's happening in life.

And we were doing some of the coolest randomized controlled trials I've ever been involved with, and I was so excited to be doing it right in the middle of Delta and Omicron, which is the worst time ever to recruit busy healthcare workers for well-being.

What are you talking about? You know, this is a crisis. I can't go do your well-being intervention right now. And we learned something really profound during that time. And I'm really grateful for this. We were experimenting with different ways of incentivizing participation and well-being.

And what we learned was that, there isn't really a gift card amount that's going to work to get a busy physician to do something for their own well-being. Right. It's not like, well, should we double that amount? Should we double that? What we found is that if you can make it minimally, if you can really say, give me two minutes, and I'll give you a brief assessment of your well-being and I'll feed it back to you. And I'll even benchmark you and show you how you compare to your peers. Give me two minutes. They'll say, you know what? Okay, I'll give you 2 minutes.

And then once you've done that, you say, okay, if you would like to do something about your well-being, now that you see your well-being relative to like a quarter million of your peers, because we have these really big data sets.

If you want to do something about that, here are the best available interventions that match your well-being need right now. And if you do one of these interventions, we'll measure again in a week, and you can see if it changed.

You can look at your feedback. And so it was actually giving busy healthcare workers feedback that was the best incentive for retaining their participation in these well-being interventions.

And we went hog wild. We turned everything that we do into an opportunity to give people feedback about their well-being. And so it gets them hooked, initially, and it gives them a reason to come back and check to see if it improved.

And that, and it cost us nothing, right? So we were thinking about all these elaborate ways of incentivizing, but it turns out, healthcare workers are pretty competitive with themselves. They want to see that they're getting better.

Lee Daugherty Biddison: Yeah, absolutely. I love that. So interesting about how we're motivating our desire for information about ourselves and how we're doing.

Bryan Sexton: And make sure it's evidence-based the way you're going to use that Google and make sure that it's there's some legitimacy behind it. But let me go one further.

We can ask you 5 questions like Christina Maslach's like emotional exhaustion questions. These are questions like, I feel burned out from my work. I feel exhausted by my job. I feel I'm working too hard, you know, at my job, things like that.

And we ask you if I can ask you 5 questions and then based on your responses, I can give you an emotional exhaustion profile. And we've already identified out of our 21, I guess we have 22 interventions now, out of all of our interventions, here are the three that are most suited for your well-being profile right now.

So we can target, that's, it makes it very, it's not just personal feedback, but it's personal recommendations or strategies for what to do with that feedback. And that marrying the feedback and the assessment to the bite-sized next step is what makes it kind of a personalized, you know, tailored journey. Kind of like, kind of like, you know, personalized medicine. This is personalized well-being. It's tailored to the individual.

Lee Daugherty Biddison: I love it. I love it. Can't wait to check in another 6 to 12 months and see how it all went.

And I think to that, are there, you know, as we sort of wrap things up for this conversation, and you well know I could keep it going for a long, time, but as we wrap things up for this conversation, and we talked a little bit about the personalized medicine, excuse me, personalized well-being and micro-interventions, are there other things that are sort of top of mind for you in this sort of front end of this, your time in this role that you're really hoping to prioritize and kind of excited to see how they unfold.

Bryan Sexton: Yeah, I think it's a really good question and I don't know how this is going to go to be honest, but I think in the kind of Maslow's hierarchy of needs, there's like well-being needs to be elevated more than it is now.

And so I think if we can continue to promote healthcare worker well-being first, and then quality improvement and system change and change management kind of after that, everyone's going to be better off. Because if we continue just to kind of blindly plow forward and say, we have to fix all these problems in healthcare, without giving people a chance to kind of pause.

It's going to, I really do believe it's going to backfire.

Lee Daugherty Biddison: I agree wholeheartedly.

Bryan Sexton: Yeah. The phrase that people say to me is, I'm actively drowning and you're asking me to envision a better future. I need a life preserver, not an exercise in visioning. Yeah.

Lee Daugherty Biddison: When you're bobbing, to just barely coming up for air every couple of minutes. Yes, absolutely.

Bryan Sexton: Right.

Lee Daugherty Biddison: Absolutely.

Bryan Sexton: So let's watch this space together.

Lee Daugherty Biddison: Absolutely. So important. So important.

Well, Bryan, thank you so much for this really thought-provoking, insightful, and fun conversation. I hope we can do this again sometime. For our listeners, we always love to hear from you.

So please reach out. You can reach us on our website, OWB@ jhmi.edu is our e-mail and our website as well. So please reach out and let us know if you've got ideas for upcoming podcasts.

It'll be hard to top this one, but we really appreciate your time today. Thank you.

Bryan Sexton: Thank you.

Lee Daugherty Biddison: So that's it for today. If you enjoyed what you heard, please share this podcast with a colleague. And as always, we welcome your feedback.

If there are any topics you'd like to hear about, please e-mail us at [email protected].

 

Lee Daugherty Biddison, M.D., M.P.H.
Chief Wellness Officer
Johns Hopkins Medicine

Bryan Sexton, Ph.D.
Chief Wellness Officer for Duke Health Integrated Practice 
Director of the Duke Center for the Advancement of Well-being Science

1. Healthcare worker well-being is foundational to quality improvement. A lesson from early patient safety work, reinforced during COVID-19, is that exhaustion can undermine well-meaning initiatives. You have to be well to do hard things.
2. Organizations looking to improve engagement should measure specific predictive outcomes. This requires good measurement science, not just good will.
3. Advancing well-being requires both systemic change and individual approaches. Organizations need those leading the change, at all levels, to understand the science of well-being and the need for both types of approaches.
4. It’s hard to tackle lifestyle change when you are struggling. Organizations can package short, research-backed interventions for busy healthcare workers.