Resilience and Mindfulness Training for Case Managers During COVID-19

Social workers may be at particular risk for emotional and mental health complications as they subscribe to a specific set of professional characteristics where there exists a strong desire to empower and help others; in particular those who are vulnerable and lack resources and skills to advocate for themselves. It could be argued that social workers experience empathy and awareness for their suffering clients; and a strong desire to provide resources and relief. There is much in the literature to support the great extent care professionals are at risk for compassion fatigue. This project examines efficacy and impact of resilience training on Utah's Case Managers and Department of Aging and Adult services employees, during the COVID-19 pandemic. I use the term case managers interchangeably with social workers, and case workers, as the literature often refers to social workers, but my project deals with those working in their capacity as case managers or case workers. Case managers, and social workers have been deemed non-essential workers per government guidelines during this pandemic. These guidelines limit face-to-face contact with clients, mandate the wearing of mandatory masks in public, require working from home, and cause shifts in caseloads and schedules. The impact from required mandates has left case managers feeling overwhelmed and up-ended. Ultimately this debacle creates the perfect storm, resulting in higher rates of compassion fatigue and burnout. This project presented two resilience- training videos both created by University of Utah College of Nursing faculty, during the 2020 COVID-19 pandemic, in order to provide evidence-based tools and techniques to those working with vulnerable populations. Mindfulness and breathing techniques were discusses in the videos along with methods to shift to a healthy perspective and increase well-being in order to bolster resilience. Quantitative Likert-format pre and post surveys were administered and an additional qualitative questionnaire with open-ended questions was included along with the post survey. There was a 16% participation (N=25) rate with results demonstrating a 44% increase in participant's improvement of feelings of well-being post-training. By using In-Vivo style coding- which derives codes from participants actual words and phrases, and frequency style coding, identifying multiples of similar words the qualitative findings confirmed participants felt overwhelmed and oppressed due to the pandemic mandated restrictions.

Running Head: RESILIENCE & MINDFULESS TRAINING PROGRAM Resilience and Mindfulness Training for Case Managers During COVID-19 S. Ja-Ann Wolsey College of Nursing; University of Utah Master of Science in Gerontology Dr. Nanci McLeskey, Chair Dr. Mike Caserta Dr. Kathy Supiano Nancy Madsen MS. Gerontology July 30, 2020 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 2 Abstract Social workers may be at particular risk for emotional and mental health complications as they subscribe to a specific set of professional characteristics where there exists a strong desire to empower and help others; in particular those who are vulnerable and lack resources and skills to advocate for themselves. It could be argued that social workers experience empathy and awareness for their suffering clients; and a strong desire to provide resources and relief. There is much in the literature to support the great extent care professionals are at risk for compassion fatigue. This project examines efficacy and impact of resilience training on Utah’s Case Managers and Department of Aging and Adult services employees, during the COVID-19 pandemic. I use the term case managers interchangeably with social workers, and case workers, as the literature often refers to social workers, but my project deals with those working in their capacity as case managers or case workers. Case managers, and social workers have been deemed non-essential workers per government guidelines during this pandemic. These guidelines limit face-to-face contact with clients, mandate the wearing of mandatory masks in public, require working from home, and cause shifts in caseloads and schedules. The impact from required mandates has left case managers feeling overwhelmed and up-ended. Ultimately this debacle creates the perfect storm, resulting in higher rates of compassion fatigue and burnout. This project presented two resilience- training videos both created by University of Utah College of Nursing faculty, during the 2020 COVID-19 pandemic, in order to provide evidence-based tools and techniques to those working with vulnerable populations. Mindfulness and breathing techniques were discusses in the videos along with methods to shift to a healthy perspective and increase well-being in order to bolster resilience. Quantitative Likert-format pre and post surveys were administered and an additional qualitative questionnaire with open-ended questions was RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 3 included along with the post survey. There was a 16% participation (N=25) rate with results demonstrating a 44% increase in participant’s improvement of feelings of well-being posttraining. By using In-Vivo style coding- which derives codes from participants actual words and phrases, and frequency style coding, identifying multiples of similar words the qualitative findings confirmed participants felt overwhelmed and oppressed due to the pandemic mandated restrictions. Key Words: COVID-19, Pandemic, Case Managers, Social Workers, Resilience, Wellbeing. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 4 Table of Contents Introduction ...........................................................................................................................6 Literature Review .....................................................................................................................7 Methods ...................................................................................................................................13 Recruitment and Participation ...........................................................................................13 Design...................................................................................................................................15 Results .....................................................................................................................................17 Quantitative Findings..........................................................................................................17 Qualitative Findings ............................................................................................................18 Survey Findings ...................................................................................................................19 Responses to Open Ended Questions ..................................................................................28 Future recommendations for research ...............................................................................32 Limitations...........................................................................................................................32 Conclusions ..............................................................................................................................33 References................................................................................................................................35 APPENDIX A Resilience Training Program- Invitation to Participate................................39 APPENDIX B Survey -Resilience Training Program ............................................................41 APPENDIX C Reminder for Resilience Training ..................................................................43 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 5 List of Figures Figure Page Figure 1. Pre-Survey Question 1................................................................................................19 Figure 2. Post-Survey Question 1 ..............................................................................................20 Figure 3. Pre-Survey Question 2................................................................................................20 Figure 4. Post-Survey Question 2 ..............................................................................................21 Figure 5. Pre-Survey Question 3................................................................................................22 Figure 6. Post-Survey Question 3 ..............................................................................................22 Figure 7. Pre-Survey Question 4................................................................................................23 Figure 8. Post-Survey Question 4 ..............................................................................................23 Figure 9. Pre-Survey Question 5................................................................................................24 Figure 10. Post-Survey Question 5 ............................................................................................25 Figure 11. Pre-Survey Question 6 ..............................................................................................25 Figure 12. Post-Survey Question 6 ............................................................................................26 Figure 13. Pre-Survey Question 7 ..............................................................................................27 Figure 14. Post-Survey Question 7 ............................................................................................27 Figure 15. Frequency Codes Question 1 ....................................................................................29 Figure 16. Frequency Codes Question 2 ....................................................................................30 Figure 17.Frequency Codes Question 3 .....................................................................................32 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 6 Introduction During the COVID-19 pandemic particular risk of life-threatening complications has proven disproportionally greater for older adults. In weekly reports of national provisional death counts, due to the outbreak, the Center for Disease Control and Prevention (CDC), reported that in the peak week of April 18, 2020 the number of deaths for adults over 65 years of age totaled 14,843; while the total deaths for those under 65 years of age was less than 10% of that figure at 1,111. It became evident that there was a positive correlation with higher age and a greater risk of mortality from COVID-19 (CDC, 2020). This grave reality sent a wave of swift reactive protocol changes through organizations designed to support older adults, and required them to adjust practices while at the same time maintain a high quality of care for their older adult clients (World Health Organization, 2020). Changes in workplace policy, and routines, particularly in times of crisis do not come without psychological impact to workers, and can leave healthcare and frontline workers emotionally traumatized; with anxiety resulting in a heightened risk to their wellbeing (Blake, Bermingham, Johnson, & Tabner 2020). In times of crisis, organizations are forced to shift workloads and schedules to accommodate mandated regulations, and may lack resources such as personal protective equipment to keep workers safe (Newell, & NelsonGardell, 2014; Blake, Bermingham, Johnson, & Tabner 2020). These realities permeate the workforce and can manifest negative outcomes such as emotional exhaustion, compassion fatigue, and professional burnout (Blake, Bermingham, Johnson, & Tabner 2020; Lee, Miller 2013). Dewey, et al., (2020) posit that social workers may manifest the effects of the pandemicinduced disruption by feeling upended and disoriented, and an extended term of work under these circumstances has the potential to increase workforce attrition contributing to higher RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 7 turnover rates (Dewey, Hingle, Goelz, & Linzer 2020; Graham, Shien 2010). Social workers may be at particular risk for emotional and mental health complications since social workers subscribe to a specific set of professional characteristics where there exists a strong desire to empower and help others; in particular those who are vulnerable and lack resources and skills to advocate for themselves (Forenza, and Eckert 2018). Individuals whose work requires focus on the care of vulnerable populations, where energy given is not always reciprocated and thus creates a deficit from a one-sided emotional transaction, are at greater risk of developing compassion fatigue (CF-Lee, Miller 2013). Figley (1995) first identified compassion fatigue, and explains this deficit as the inherent component in caring for others with greater emotional pain (Sansó, et al., 2015). Kapoulitsa, Corcoran, (2015) explain compassion fatigue is an empathetic emotional response to stress experienced by practitioners who help those individuals with traumatic experiences. Literature Review It could be argued that social workers experience empathy and awareness for their suffering clients; and a strong desire to provide relief (Pelon, 2017). There is much in the literature to support the great extent care professionals are at risk for compassion fatigue. Pelon, (2017) found that 80% of hospice nurses and interdisciplinary staff were at a greater risk for compassion fatigue as measured by the Professional Quality of Life (ProQOL) compassion fatigue subscale; and evidence from a national study of 503 care professionals supports the notion of a direct risk of compassion fatigue in those professionals who provide psychosocial support to families and patients (Pelon, 2017). Aside from emotional and spiritual decline, workers experiencing compassion fatigue become more apathetic towards their clients and tasks, and can become dissatisfied and often internalize their lack of efforts as incompetence (Pelon, RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 8 2017). Compassion fatigue can permeate perceptions, subsequently affecting one’s actions, interactions, and life-views (Pelon, 2017; Sabo, 2006). Social workers are innately saddled with the added strain of an empathic tendency towards clients who experience or have experienced trauma. The caseworker for the older adult is in a unique position given the added life challenges with aging. The risks here come from an unchecked empathy quota; where the caseworker begins to internalize the client’s emotions as a result of the trauma, posing a threat of compassion fatigue, or secondary trauma (Pelon, 2017). Caseworkers often struggle to prioritize their own well-being as they provide support for their clients, and are not taught how to identify symptoms of burn-out and compassion fatigue; while Lee, and Miller (2013) found that in many cases preventative self-care measures are not taught as part of their professional training despite recommendations from the National Association of Social Workers (NASW), and the Council on Social Work Education (CSWE) (Lee, & Miller 2013; Newell, & Nelson-Gardell, 2014). Blake et al., (2020) discuss how workers want, and need support from their organizations; and this need is exacerbated during a pandemic. They suggest organizations provide resources and access to concise organizational strategies to support the well-being of workers (Blake, Bermingham, Johnson, & Tabner, 2020). In a Canadian study by Graham, and Shier (2010), 700 Canadian social workers were selected to measure subjective wellbeing (SWB). Graham and Shier (2010) define SWB as one’s perception of their overall life satisfaction while taking into consideration mental and physical health. The study was largely set around organizational workplace satisfaction and proports that the common characteristics of those social workers who had the highest scores of SWB was due to their ability to set appropriate professional boundaries, and to recognize and navigate personal RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 9 limitations. Further, Graham and Shier (2010) found organizational support and realistic caseload expectations had a positive correlation with SWB (Graham, & Shier 2010). Seligman’s theory of wellbeing provides a multi-dimensional approach inclusive of five independently measurable elements: positive emotion, engagement, relationships, meaning, and accomplishment (PERMA). Seligman posited that in order for an element to be a building block in the framework of wellbeing it needs to contain three characteristics: it needs to contribute to wellbeing, it needs to be pursued for its own sake, and it needs to be measurable separately from the other elements (Seligman, 2011; Ascenso, Perkins, Williamon, 2018). Ascenso et al., 2018 provides a breakdown of each element of PERMA and explains that positive emotion pertains to feeling well across a range of personal, psychological, cognitive and social aspects. He defines engagement as it relates to a deeper connection to a particular activity or cause, and involves deep focus and concentration where one is engrossed in the activity. Seligman (2011) describes engagement as a subjective, retrospective state while positive emotion comes from awareness in the present state. It is during engagement that creativity can flow naturally and thus provides a deep sense of satisfaction. Relationships involve one’s personal perceptions of their connections and social interactions with others. The element of relationships is a subjective look at how connected, loved and supported or valued one feels from his or her interactions with others. Social support and relationships are a fundamental component of wellbeing in particular workplace interactions (Graham, & Shien 2010). Seligman (2011) describes meaning as one’s perceptions of participating in an activity that one feels has a greater purpose and is considered larger than one’s self. Accomplishment is again viewed through the individual’s own perceptions, and relates to the attainment of internal and external goals (Seligman, 2011; Ascenso, Perkins, Williamon, 2018). RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 10 Ryan et al., (2019) report that wellbeing encompasses subjective concepts that are difficult to measure since the concepts focus on individual perceptions of success in multiple realms. When we contrast personal wellbeing with professional wellbeing, the line becomes a bit blurred since professional life is often directly related to accomplishment and meaning (Lee, & Miller 2013; Graham, & Shien 2010). There is significant research that illustrates effective strategies and tools to incorporate the PERMA concepts into effective psychotherapeutic treatments for depression and community-based health and personal resiliency training programs (Ryan, Curtis, Olds, Edney, Vandelanotte, Plotnikoff, & Maher, 2019). Fostering Resilience It is widely accepted that programs designed to improve subjective wellbeing often center around a model of self-care (Sabo, et al., 2015). Self-care is, at its essence, engaging in behaviors that are conducive and supportive to one’s own well-being, and learning how to incorporate tools and techniques to gain greater compassion satisfaction; a satisfaction that develops when workers feel gratitude from caregiving (Kelly, Runge & Spenser 2015). The balance between compassion satisfaction and compassion fatigue can be a tightrope, and organizations would benefit from teaching healthcare professionals how to better cope and manage stress in order to mitigate emotional exhaustion, compassion fatigue and burnout, and to be vigilant in safeguarding those whose work entails profound emotional experiences (Sanso et al., 2015; Lee, Miller 2013). Sanso et al., (2015) identify realms of self-care that positively correlate with compassion satisfaction, and include physical, psychological, emotional, spiritual, work environment, and personal balance. They explain that working with terminally ill patients can be a rewarding experience for caregivers, but it is essential for these individuals to build emotional and psychological resilience in order to protect themselves from compassion fatigue RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 11 often felt by workers who serve vulnerable populations. In a study of healthcare professionals who work with terminal ill patients, Sanso et al., (2015) had workers participate in mindfulness and awareness self-care training programs. They found that those who participate had a positive correlation with compassion satisfaction (Sanso, et al., 2015). Resilience is not easily defined. In an article titled Making Sense of Resilience McGeary (2011), presents a definition of resilience as characteristics of preservation and recovery after exposure to a significant or traumatic event (McGeary, 2011). Some research indicates that resilience is not an inborn personality trait, or character trait, but a modifiable tool one can build to create a repertoire of personal resources to fit one’s unique personal, physical, mental and emotional needs in overcoming adversity (McGeary, 2011). Conversly, Min, Jung-Ah et al., (2012) surmised that resilience cannot be learned, and is a personality trait that can be influenced by numerous environmental factors (Min, Jung-Ah et al., 2012). The debate over definitions and origins of resilience will likely continue, but most are in agreement on the usefulness of resilience training as a measure of coping and building a stronger sense of well-being (Lee, Miller 2013; Leppin, et al., 2014). Leppin, et al., (2014) compared data from research that examined the efficacy of resilience training programs. They found resilience training programs improved care managers' overall well-being, health, and quality of life; in particular, those case managers who were working with chronically ill patients (Leppin, et al., 2014). Individuals who practice healthy self-care reap the mental and physical benefits and improve confidence in their ability to manage stressful and difficult situations when they arise, and are more productive in their work responsibilities (Lee, Miller 2013). RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 12 Organizations that support case workers would benefit from promoting resilience and self-care training in an effort to boost the overall wellbeing of their workers and limit attrition of staff while raising workers compassion satisfaction and work productivity (Sanso et al.,2015). Miller and Lee (2013) also recommend self-care and resilience training for those workers whose work focuses on death, dying, bereavements and loss. In the case of social workers supporting aging adults and caregivers much of the content of their work is related to these themes. Concerns of greater demand and stress in the workplace due to changes brought on by COVID-19 have been expressed by some of the case managers in the Utah Area Agency on Aging (AAA) throughout Utah and in the Division of Aging and Adult Services. These sentiments of greater strain and stress, are echoed in the research of social workers views surrounding organizational climate. In the United States, social workers have a 39% burnout rate and an overall lifetime burnout rate of 75% (Seibert 2005). Social workers reported a growing decline in organizational supports such as staffing opportunities, reimbursements, wait-lists for services for clients, and access to supervisor support (Lee, Miller 2013). In an industry beset with high turnover, compassion fatigue and burnout, the added pressure brought on by COVID19 creates an urgent challenge for organizations to support and improve the wellbeing of social workers. Stress has been defined as a response to pressure and not the pressure itself; in essence, stress is a subjective perception one feels from inappropriate levels of pressure or demand brought on by a worker’s organizational context (Collin, Coffey, & Morris 2010). Extended levels of stress can elicit decline in mental and physical wellbeing that can develop into compassion fatigue or burnout (Collin, Coffey, & Morris 2010). Organizations may be challenged to find ways to mitigate the collateral damage and provide solutions for supporting RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 13 social workers during COVID-19(Graham, & Shier 2010). Greater demand, and limited supply due to government mandated restrictions and requirements may alter an organization’s access to resources and limit their ability to provide healthcare professionals with adequate support. Challenges may arise such as access to and limited availability of personal protective equipment (PPE), limited staff and space, organizing coping and resilience training for social workers, and testing clients and workers for COVID-19. Methods The objective of the resilience training program was to provide support and resources to case managers and other support staff members in Utah AAA locations as well as in the Division of Aging and Adult Services during COVID-19, in an attempt to relieve, bolster, and create psychological and emotional resilience in these case managers. The program was created and presented under conditions of nationally-imposed restrictions including social distancing, isolation, working from home, mandatory masks, and limited travel, making this especially timely. The added strain on case managers who had to shift their method of interacting with clients from the customary site visits with contact and face-toface interaction, to phone conversations has generated a flip in equilibrium of the status quo; a shift creating potential drastic physical, emotional and social repercussions for the both case manager and client. Recruitment and Participation Exemption from human subject research was granted after an application was filed with the University of Utah Institutional Review Board (IRB). In order to classify these training programs as non-human research, participants had to be completely anonymous and voluntary. Participant consent was not required under the non-human subject research category. The State RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 14 of Utah Department of Human Services IRB determined that if the University IRB granted exemption, they also would grant exemption from obtaining human-subject research clearance. The Program Manager (PM) for the Utah Caregiver Support Program at the Division of Aging & Adult Services asked the states 12 AAA directors to determine if there was a level of interest among caseworkers who support family caregivers and their older adult clients, to participate in a resilience training program. Each Director gave permission to circulate the resilience training program by email to all case managers within each AAA throughout Utah. Further invitations were extended to several other applicable professionals who might also benefit from the training program. These included the Division of Aging & Adult Services directors, program managers and staff, Adult Protective Services directors and investigators, AAA directors, case managers, ombudsmen, nutrition employees, senior center employees, as well as several of Utah Department of Health colleagues. The PM emailed a letter to the program managers who in turn forwarded it to the potential participants. Approximately 200 invitations were sent (See Appendix A). Potential participants received the email that explained the program and then gave them the option to self-selected and engage in the training and subsequent surveys. Emails were sent to potential participants on two separate occasions a week apart- each corresponding to the pre-survey, and post-survey respectively. Each email contained the links to the training videos as well as the pre-and post-survey. The first email contained an explanation of the project and introduced those involved in the project. The letter included the estimated time of the program to be one hour for each video and ten minutes for each survey. It identified benefits and risks of participation and instructions. Participants were asked to click on links provided in the letter that were labeled step one through step four. The letter reiterated RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 15 participation was voluntary and anonymous, and gave a contact should participants have any questions or concerns. The second email thanked those who had already participated, and also reminded those who had not participated that they could still do so before the deadline (see Appendix C). The two links to the surveys and two links to the videos were included with instructions. The surveys were accessed through a link to Google Forms docs, which provides an anonymous response format. Data collected from the pre-and post-surveys were compared in order to determine the program achieved its intended goals. Design There were two resilience training videos, both were pre-recorded YouTube videos. The videos were approximately one hour in length each and were created by faculty in the College of Nursing at the University of Utah to address resilience building during the COVID-19 crisis. The videos were designed to aid caregivers and professionals who are susceptible to compassion fatigue. The first video titled Coping with Stress During the Health Crisis, addressed coping skills and tools to build resilience using evidence-based practices, and the second video titled Promoting Resilience through Mindfulness, discussed utilizing mindfulness techniques to build resilience. The first video was presented in a lecture style format with Dr. Katherine Supiano providing information on resilience and how to create a healthy perspective on change during times of crisis. She discussed how to create a “new normal” when equilibrium is disrupted, using current examples related to the COVID-19. She brought to the forefront how physical, emotional, spiritual, cognitive, and social well-being, are essential components one needs to maintain and create personal resilience. The second video, by Dr. Katarina Felsted involved a description of mindfulness, and provided techniques, such as an awareness of breath and how to RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 16 focus on the present moment as a means to find personal space and solace during difficult moments. Evaluation The pre-survey and post-survey were identical and consisted of 7 Likert scale questions (see Appendix B). The Likert-format questions asked participants to rate their perceptions of ability to provide quality care during the crisis on a scale of 1-5; 1 being very likely or very effective, and 5 being not likely or not effective. Specifically, the questions were: 1. How equipped do you feel you are with the emotional and physical resources needed to be effective in providing assistance to your older adult clients and their families? 2. How likely do you feel you are able to maintain high-quality care to your clients during the COVID-19 pandemic? 3. How effective do you feel resilience training is to improve your outlook on the workrelated issues brought on by COVID-19? 4. How effective do you feel mindfulness training is as a way to improve your outlook on the work-related issues brought on by COVID-19? 5. How effective do you feel resilience training is to improve your quality of care towards clients and their families? 6. How effective do you feel mindfulness training is to improve your quality of care towards clients and their families? 7. How effective do you feel mindfulness training and resilience training is to improve feelings of wellbeing? In additions to the 7 Likert questions as the pre-survey, the post survey repeated the same questions that appeared in the pre-survey- but also included a second section with three RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 17 qualitative questions prompting written feedback. These questions asked participants about changes and limitations brought on by restrictions and regulations during COVID-19: 1. What have been your greatest challenges, if any, in your ability to remain effective in your work? 2. What coping tools have you used or would consider using in order to create a new equilibrium; or new normal? 3. What suggestions or comments do you have about the efforts and/or resources provided by your organization in an attempt to facilitate the efficacy of your work? Are there specific areas for improvement such as: personal protective equipment (PPE), trainings, access to clients, testing for COVID-19? Results Quantitative Findings Descriptive Statistic were used to compare quantitative responses of both surveys in order to determine participant’s reactions towards the resilience training program (Kass, Caffo, Davidian, Meng, Yu, & Reid, 2016). In order to satisfy the State of Utah Human Subjects requirements, the surveys lacked identifiers that would allow each participant’s responses to be linked. For this reason, a global comparison of data was necessary. Survey questions were designed to gauge participant responses to each of the two videos both individually and together. Some survey questions were designated to gage reactions to the resilience training video, and some were designated to gauge reactions to the mindfulness training. Questions 1, 2, and 7 were non-designated, or global questions where participants considered both of the videos together as one training. Questions 3 and 5 were specific to resilience training while questions 4 and 6 were specific to mindfulness training. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 18 Responses to the surveys were captured in Google Forms, which were automated through Google. The Likert responses in the quantitative findings section are shown in figures 1-14, where both pre-and post-survey responses for questions 1-7 are posted. There was a total of 34 (N=34) participants who took the pre-survey and 25(N=25) participants took the post-surveys. Qualitative Findings At the end of the final survey were three open-ended questions there was a total of 24 responses to the first questions, 23 responses to the second question and 21 responses to the third question. Responses were put into an excel spreadsheet and coded using In-Vivo style coding. In-Vivo is a coding method outlined by Saldana (2012) that uses the participants actual words to establish codes. In-Vivo coding refers to “that which is alive” and codes are phrases or words extracted from participants actual responses (Saldana 2012). This coding method is useful for qualitative studies that want to capture a participant’s voice (Saldana 2012). The codes used were derived from participants words and phrases and were then grouped into categories to examine, analyze, and look for common thematic similarities. I chose to approach each of the three questions independently; thereby creating three separate sections. Each question merits an independent analysis since the questions were categorically unique. The data’s codes began to reveal trends in participants responses toward attitudes surrounding restrictions to their normal way of operating. I kept analytical margin notes as supported by the grounded theory process, where grouping and creating analytical notes helps develop further overarching categories (Saldana 2012). I noticed frequency counts of words used by the participants. LeCompte and Scensul (1999) suggest using frequency analysis of content as a secondary way to develop themes but caution that frequency count alone does not allow for a richness of context. For this reason, I used both In-Vivo and frequency count analysis to develop RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 19 themes. In the second round of coding I selected words from the data that participants often used and assigned a count next to them so that later I could tally the number of times that particular word, or derivative of the word, was used. I created a bar graph to display the number of times the word occurred over the course of all participants answers for a particular question. I did not assign psychosocial meaning to these words; however, this would be useful for a more in-depth analysis of meaning. Survey Findings Figure 1. Pre-Survey Question 1 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 20 Figure 2. Post-Survey Question 1 Of the 34 pre-survey responses to question one 22 participants felt likely and 6 felt very likely to provide assistance to clients during COVID-19. The pre-survey showed 5 participants felt undecided and one felt unlikely. After the training, more participants (n=10) felt very likely and none were undecided or unlikely. Figure 3. Pre-Survey Question 2 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 21 Figure 4. Post-Survey Question 2 Question two addresses participants feelings of being able to provide high quality care to clients during the pandemic. Prior to watching the training, most participants (n=20) felt like that they were likely to provide high quality care to clients; however, there were 11 participants who were undecided and 2 who felt unlikely. Post survey responses included none that were either undecided or unlikely to maintain high quality care, and there were 15 who felt likely and 9 participants who felt very likely to provide high quality care. There was only 1 participant who was undecided after the training compared with 11 participants who were before the training. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 22 Figure 5. Pre-Survey Question 3 Figure 6. Post-Survey Question 3 Question 3 asked participants if they felt resilience training could have an impact on improving their work-related outlook during the pandemic. Pre-training results indicated a large group of 13 participants were undecided while 14 participants felt training would be effective. A smaller number of participants (n=3) felt training would be very effective and 5 participants felt RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS it would be somewhat effective. Post-survey results showed a shift in responses where participants saw training as either effective or very effective. In contrast with the pre-survey where only 3 selected very effective, the post-survey had 10 very effective responses. Figure 7. Pre-Survey Question 4 Figure 8. Post-Survey Question 4 23 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 24 Prior to viewing the training videos participants indicated a belief that mindfulness training would be an effective way to improve one’s work related outlook during COVID-19 with 50% (n=18) of participants selecting effective on the survey: however, 25% (n=9) were undecided. There were also a few responses showing skepticism in mindfulness training as a means to improve outlook. The post-survey eliminated the skeptics albeit 2 participants who selected somewhat effective. There was a 45% increase in participants who selected very effective from pre-survey to post-survey with 11% (n=4) pre-survey responses compared to 56% (n=14) post-survey responses. Figure 9. Pre-Survey Question 5 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 25 Figure 10. Post-Survey Question 5 In the pre-survey approximately half (n=17) of participants believe resilience training was an effective way to improve quality of care while only 5% (n=2) felt it was a very effective method. Findings in the post-survey show a conversion with 44% (n= 22) of participants selecting effective and very effective equally, while 16% (n=4) were undecided. Figure 11. Pre-Survey Question 6 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 26 Figure 12. Post-Survey Question 6 The bulk of responses fell into the effective and undecided category pre-training. Sixteen participants indicated, prior to participating in the program, that mindfulness training would be effective and 10 felt undecided about the training. After participating in the program, participants shifted away from the undecided category and gravitated to the effective and very effective categories; accounting for 92% (n= 22) of responses. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 27 Figure 13. Pre-Survey Question 7 Figure 14. Post-Survey Question 7 A similar trend occurred in question 7 as in question 6. Respondents pre-survey, primarily selected the effective category (n= 19; 56%), with a small array of participants evenly distributing answers in the “very effective,” “undecided,” and “somewhat effective” categories. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 28 Post-survey participants largely agreed (n=23; 92%) that the trainings were either “very effective,” or “effective.” Responses to Open Ended Questions Question 1: What have been your greatest challenges, if any, in your ability to remain effective in your work? In the answers from question 1, there were several expressions indicating a high frequency of challenges among participants. Of the 23 responses, 8 responses include the word “able” in reference to “not able to” or “unable to.” Another similar word used was “can’t.” Participants have been restricted from preforming activities that they were used to preforming on a regular basis due to Government restrictions as case managers have been classified as nonessential workers and therefore, restricted from face-to-face interaction with clients. Frequently used words included “motivation,” in the reference to a decrease in motivation, were used directly. The concept of lack of energy, or feeling overwhelmed was another merging theme from question one. The largest theme revealed was physical distance and the debilitating effects on case managers leaving them with feelings of being distanced from clients, co-workers, and friends. Participants used phrases such as “Due to the pandemic people are experiencing more social isolation, increased depression, more negativity. It is almost impossible to hear this information non-stop all day and be able to turn it off at the end of the day. It is draining.” Another high frequency word used by participants was “overwhelmed” or “Overwhelming” in reference to the negative impact of the pandemic induced restrictions. One participant explained, “COVID-19 has affected all areas of my life in a completely overwhelming way.” RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 29 It is important to consider the language choices participants use in their responses and look for an underlying emotion or meaning (Saldana, 2012, p. 106). Emotional coding is a logical outcome that occurs when analyzing qualitative data. Since emotion is a universal common characteristic of the human experience, it can naturally flow from responses and should be curated into the process. I noticed participants use of the words “unable,” “can’t,” or “not able to” since these are oppressive words when used in the context of being prevented from engaging in usual freedoms and privileges. I grouped responses that emulated oppression into a “restricted” theme category. Figure 15 below indicates the most common words used in response to question one. I included the word “can’t” in the “unable” category. Figure 15. Frequency Codes Question 1 Question 2: What coping tools have you used or would consider using in order to create a new equilibrium; or new normal? RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 30 Using In-Vivo coding and frequency counts revealed several themes. Participants described self-care techniques; such as some form of physical activity, taking time out, and developing or working on a hobby. Forty-three percent of the responses included language that described self-care while 29% used the word “mindfulness” or “meditation.” Another theme that emerged from coding was that of connection with others, and finding ways to stay connected. One participant stated “I'm interested in any new possible tools. I think having clients have access to video calls that would be incredibly helpful. The caregiver support groups I work with are virtual and we are finding very helpful to many people feeling isolated.” Of the 24 respondents, 6 mentioned staying connected or a desire to stay connected. Thirty percent of respondents indicated use of mindfulness or breathing practice as a coping skill. Figure 16. Frequency Codes Question 2 RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 31 Question 3: What suggestions or comments do you have about the efforts and/or resources provided by your organization in an attempt to facilitate the efficacy of your work? Are there specific areas for improvement such as personal protective equipment (PPE), training, access to clients, testing for COVID-19, etc? Participants were less likely to provide an answer with suggestions for their employer. There were 11 respondents that used the word “none,” “N/A,” and “no suggestions” while a few praised the efforts of their employer- “MAG has done an exceptional job rolling with the neverending changes and following the state guidelines for safety in uncertain times.” Of the participants who left suggestions and comments, the codes showed a desire for leaders of organizations to provide more compassion, clarity, and understanding of the employee’s unique circumstances. One participant expressed, “My work place is trying to keep everyone safe. I just don't feel they have a pulse on the client population that I serve. They focus on a population that is okay with technology as a way of live. That doesn't work for 90% of my client's and upper management doesn't seem to want to address that.” Other comments were brief and to the point, “PPE and more clarity on job responsibilities moving forward.” With the number or responses being supportive of how organizations are handling the pandemic crisis, there seems to be a sense of acceptance or understanding with the changing circumstances. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 32 Figure 17.Frequency Codes Question 3 Future recommendations for research Future research could include a more comprehensive analysis of the qualitative responses including assigning In-Vivo codes to create themes with greater psychosocial meaning and a more in-depth understanding of oppression of caring populations during a pandemic. More research should be done on the impact related to the pandemic by contrasting data from similar studies conducting in a normal environment setting, or non-pandemic setting. Limitations Having to rely on managers to send the links and participation letters added a third- and fourth-party element to recruitment, thus removing the researcher’s direct involvement. There was ambiguity on the number of emails sent to potential participants requesting participation. This was inherent in the design in order to maintain anonymity and minimize the impact of solicitation attempts on supervisors. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 33 Participants pre-survey and post-survey were not compared on and individual bases, and linking respondents pre-survey to their post-survey through use of a code system in order to maintain anonymity, may have provided further unique insight. The sample was taken in Utah during COVID-19 and each state’s experience was unique in implementing policy and protective measures to reduce the spread of COVID-19. The training program and surveys were available over a two weeks period. In that two-week timeframe, Utah saw an increase in diagnosed COVID-19 cases, from 500 cases to 694 daily cases (coronavirus.utah.gov, 2020) and, as a result the Governor of Utah, Gary Herbert, mandated mask wearing in public spaces in Salt Lake County. Heightened anxieties due to changing developments may have impacted responses. Responses may have been affected by participants geographic location, as different parts of the state were impacted in unique ways based on the regional populations and the prevalence of COVID-19 in a particular region. Due to design and anonymity there was no way of knowing if participants watched any or part of the training videos. Conclusions The participant’s responses to the training program portray and overall improvement in feelings of well-being. The Likert survey findings showed a trend of overall improvement in participants attitudes towards their abilities in quality of care and, their improved feelings of well-being. Question 7 of the Likert survey directly asked participants if they felt that mindfulness and resilience training was an effective way to improve well-being, and post survey found that 92% of respondents believed the training was effective or very effective. Qualitative responses echoed the quantitative responses. When asked “what coping tools have you used or RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 34 would you consider using, respondents reported tools and skills taught in the training videos such as self-care, taking time for self, engaging with others, and positive self-talk. The resilience training program brought value to participants, and it could be surmised that the tools and techniques taught in the videos left caseworkers with added resources to access when they are feeling the effects of compassion fatigue. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 35 References Ascenso, S., Perkins, R., & Williamon, A. (2018). 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RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 38 Palliative Care Professionals' Inner Life: Exploring the Relationships Among Awareness, Self-Care, and Compassion Satisfaction and Fatigue, Burnout, and Coping with Death. Journal of Pain and Symptom Management, 50(2), 200-207. Seligman, M. (2018). PERMA and the building blocks of well-being. Journal of Positive Psychology, 13(4), 333–335. https://doi.org/10.1080/17439760.2018.1437466 Seligman, M. E. (2011). Flourish. North Sydney, N.S.W.: Random House Australia. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 39 APPENDIX A Resilience Training Program- Invitation to Participate My name is Shelly Wolsey and I am graduate student in the Gerontology Interdisciplinary program at the University of Utah College of Nursing. As part of my master’s program I have created a resilience training program and would like to invite you to participate in viewing two videos. The first video focuses on coping and personal resilience during a pandemic, and the second on mindfulness. Both presentations have been created by University of Utah faculty. It is my hope that these videos will provide you with useful tools and strategies to assist you in your important work. PARTICIPATION Participation time is estimated to be one hour for each video and 10 minutes for each survey. Your participation in this resilience-training program is completely voluntary. If you choose not to participate or withdraw from the project at any time, there will be no penalty whatsoever. You must be 18 years of age or older to participate. You are free to skip any questions that you do not wish to answer in the surveys and your answers will have no impact on your employment. BENEFITS The program may provide an opportunity for you to reflect on ways to cope and create space during COVID-19. There is a potential to enhance your interactions and experience surrounding your case management responsibilities. RISKS Risks involved are limited to what you think and feel about the videos. INSTRUCTIONS 1. Prior to watching video 1 and 2, please take a pre-survey by clicking on the pre-survey link. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 40 2. Click the video links to watch the training lectures. 3. After viewing video 1 and 2, click on the post-survey link and answer questions. Results from the pre-and post-survey will not be used in reports, presentations, or publications and no names will be used. Your answers are confidential and anonymous and will only be used to evaluate the efficacy of the program. If you have any questions concerning the training program, please contact Nanci McLeskey at [e-mail] Step 1. PRE-SURVEY- https://docs.google.com/forms/d/e/1FAIpQLSfBUBRmqM5Z5RNcgATF6Odw7aJl5cUkJM0NNkXUcCAUBrCSQ/viewform?usp=sf_link Step 2. VIDEO 1- https://www.youtube.com/watch?v=GcVSQb4CkJw&feature=youtu.be Step 3. VIDEO 2 https://utahgwep.org/files/Katarina_Felsted_Fireside_Chat_Recording.mp4 Step 4. POST-SURVEY- https://docs.google.com/forms/d/e/1FAIpQLSeIDazT5-q7xdW8zzdtPlwBaenQGv7yQn3JFL_zGB01-rOFQ/viewform?usp=sf_link Thank you for your participation. Shelly Wolsey Deadline: Please complete surveys by July 15th RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 41 APPENDIX B Survey -Resilience Training Program Thank you for your participation in the resilience-training program (RTP). Please answer the following questions 1 thru 7 to the best of your ability. Your identity will be kept anonymous and your answers will have no impact on your employment or work status. Answer questions 1 and 2 on a scale of 1-5 where 1 is very likely or effective, 2 is likely or effective, 3 undecided, 4 not likely or effective, and 5 is not likely or effective ever. 1. On a scale of 1-5, how equipped do you feel you are with the emotional and physical resources needed to be effective in providing assistance to your older adult clients and their families? 2. On a scale of 1-5, how likely do you feel you are able to maintain high-quality care to your clients during the COVID-19 pandemic? Answer questions 3-7 on a scale of 1-5 where 1 is very effective, 2 is effective, 3 undecided, 4 not effective, and 5 is never effective. 3. On a scale of 1-5, how effective do you feel resilience training is to improve your outlook on the work-related issues brought on by COVID-19? 4. On a scale of 1-5, how effective do you feel mindfulness training is as a way to improve your outlook on the work-related issues brought on by COVID-19? 5. On a scale of 1-5, how effective do you feel resilience training is to improve your quality of care towards clients and their families? 6. On a scale of 1-5, how effective do you feel mindfulness training is to improve your quality of care towards clients and their families? 7. On a scale of 1-5, how effective do you feel mindfulness training and resilience training is to improve feelings of wellbeing. RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 42 Below are some questions designed to allow interactive feedback and comments. Your input is highly encouraged and your responses will be completely anonymous, and will in no way impact your employment or relationships. With respect to changes and limitations brought on by restrictions and regulations during COVID-19: 1. What have been your greatest challenges, if any, in your ability to remain effective in your work? 2. What coping tools have you used or would consider using in order to create a new equilibrium; or new normal? 3. What suggestions or comments do you have about the efforts and/or resources provided by your organization in an attempt to facilitate the efficacy of your work? Are there specific areas for improvement such as: personal protective equipment (PPE), trainings, access to clients, testing for COVID-19, etc? RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS 43 APPENDIX C Reminder for Resilience Training “Carl Rogers may have said it best “I have always been better at caring for and looking out for others than I have for myself, but in these later years I have made progress” (Rogers, 1995). If you have not had a chance to view the videos and take the surveys there is still time as the deadline is July 15th. To participate please follow the instructions below. INSTRUCTIONS 1. Prior to watching video 1 and 2, please take a pre-survey by clicking on the pre-survey link. 2. Click the video links to watch the training lectures. 3. After viewing video 1 and 2, click on the post-survey link and answer questions. Step 1. PRE-SURVEY- https://docs.google.com/forms/d/e/1FAIpQLSfBUBRmqM5Z5RNcgATF6Odw7aJl5cUkJM0NNkXUcCAUBrCSQ/viewform?usp=sf_link Step 2. VIDEO 1- https://www.youtube.com/watch?v=GcVSQb4CkJw&feature=youtu.be Step 3. VIDEO 2 https://utahgwep.org/files/Katarina_Felsted_Fireside_Chat_Recording.mp4 Step 4. POST-SURVEY- https://docs.google.com/forms/d/e/1FAIpQLSeIDazT5-q7xdW8zzdtPlwBaenQGv7yQn3JFL_zGB01-rOFQ/viewform?usp=sf_link Results from the pre-and post-survey will not be used in reports, presentations, or publications. Names will not be used. Your answers are confidential and anonymous and will only be used to evaluate the efficacy of the program. If you have any questions concerning the training program, please contact Nanci McLeskey at [e-mail] I hope you have had the opportunity to participate in this resilience-training program. If you have, I want to personally thank you for your time. I hope that you found the information to RESILIENCE & MINDFULLNESS TRAINING PROGRAM FOR CASE MANAGERS be helpful. I encourage you to save the videos, revisit them and share them with others who might benefit from viewing them. I also wanted to thank you for supporting families and older adults in the State of Utah. Your work is profoundly important and needed. Best Regards, Shelly Wolsey 44