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The serpentine wall was built by Thomas Jefferson at the University
of Virginia nearly two hundred years ago. Only one brick thick, it
takes its resilience from the curvature of the wall, needing only one
brick sitting beside and supporting one another. Resilience is essential
for health care providers as well.
I was attracted to a career in nursing because of a love of science
and people. I admit it was also a plus that several good friends
were also making the same career commitment. Beyond graduation,
nursing became a passion and a way of life. It has inspired
me to reach inside and outside of myself to make a meaningful
difference in the world. In the beginning, I was a follower. Now I
am a leader. Here is the story about how all that came about.
I began working at a small community hospital in the early 70’s
as a new nurse in the intensive care unit, back when these units
were in their infancy. A 60-year old woman’s cardiac resuscitation
had gone badly on the night shift and I believed the patient could
have been saved. I spoke to the physician in charge and begged
him to give more and appropriate drugs. He just shrugged. In
protest, I went to the Director of Nursing after my shift who
looked at me with a sigh and said, “Those codes never work. Go
home and go to bed.” I have never forgotten how those words
pierced through me. From them I developed a passion for standing
in my own power. I said to myself, “I will show her. We can
improve care and be excellent! We can save lives and prevent
suffering.” I have watched too many patients suffer and die in the
intensive care unit when we didn’t allow families in, worrying
more about ourselves than the anxiety of loved ones.
Saying ‘no’ to injustice and suffering has inspired and sustained
me over a 40-year career. Now I am an academic leader in charge
of educating 700 nurses, working with over 130 faculty and staff
at the University of Virginia (UVA) School of Nursing. As a newly
appointed Dean in 2008, I had three goals:
My commitment was to excellent patient care and quality education.
I realized that passionate nurses often become heartbroken
over the challenges they face on the job and need support to continue.
I initiated the Compassionate Care and Empathic Leadership
project to inspire health care providers to share kindness, to
deeply engage with others and to continue with patience and optimism
in the face of obstacles. These values were solidified and
honed even further when I attended the Upaya Zen Buddhist
Retreat Center and later met Dr. Monica Sharma.
Building Resilience in the Workplace
In the Spring of 2009, I attended an Upaya course called ‘Being
with Dying’ (www.upaya.org/bwd/). The course focuses on improving
care for the dying by cultivating prosocial mental capacities
combined with practical skills that allow caregivers to truly
accompany dying people and their families. A dear nursing
friend, Dr. Cynda Rushton, who teaches at Upaya, convinced me
that I would gain new insights that could dramatically change
how I was leading the nursing school. Those eight days of silent meditation
and mindfulness changed not only my work, but also my life.
Today, 45 interdisciplinary UVA colleagues—chaplains, social
workers, physicians and nurses—have attended the Upaya program,
building a foundation for our work of fostering compassionate
care and building resilient caregivers. When health care
providers can stand in power and resilience—‘fierce compassion’
as my emergency department nurse colleague, Jonathan Bartels,
refers to it—patient and family care is improved. ‘Fierce compassion’
is what fuels my passion for fostering diversity of ideas and
pushing for interprofessional engagement.
Funded by a generous donor, the School of Nursing has built a
Resilience Room out of an old classroom where we meditate and
practice quiet reflective thinking and yoga. This space represents
our nurturing and respect for handling patient care with compassion
and resilience. Several faculty members championed the
project, but a few others thought we were ‘pushing religion.’ Time
and patience helped us navigate the issues respectfully as we
demonstrated that this initiative is beyond religion.
The resilient caregiver is one who can withstand the routine joys
and sorrows within the chaos of the clinical setting and stay balanced,
calm and able to make good choices for self and others.
More than just dedicating a room, creating a resilient workplace
has a deep core meaning for each of us.
Compassionate Care and Empathic Leadership Initiative:
A Journey on the Serpentine Wall
In 2010, our two consultants, Drs. Monica Sharma and Cynda
Rushton, aligned their efforts to lead an emerging Compassionate
Care Initiative at the UVA School of Nursing and the broader
health system at the University. Dr. Sharma is a physician and former
director of the United Nations for Leadership and Capacity
Development. Dr. Rushton is a pediatric nurse, professor of nursing
and ethics and director of the program in palliative care for
children at the Johns Hopkins Hospital. Dr. Sharma’s model has
inspired UVA clinicians, faculty and the community to create and
sustain change. The challenge we chose was to improve end-oflife
care in the Charlottesville community by focusing on resilience,
interprofessional collaboration and what we had learned
from the Upaya program.
Our model begins with identifying one’s values and contribution
to the world. More than 60 UVA Medical Center
professionals have now embraced this approach. Perhaps fearful
at first, they quickly caught the magic of ‘standing in your own
power’ to shift system barriers and solve problems for lasting
results. We named our resilience initiative Compassionate Care
and Empathic Leadership (CCELI) and called this our ‘journey
on the serpentine wall.’
The purpose is to reduce human suffering by cultivating compassionate
people and systems. Our vision is to promote health and
well-being through the creation of innovative, scalable, adaptable
models of health care that incorporate practices that invite stillness,
inquiry and insight, and are grounded in compassionate
action and empathic leadership. We are also developing clinical,
educational and research initiatives to optimize the quality of life
for patients and their families.
Designed for transformation and results, our program is shifting
people from scarcity to abundance, from fragmentation to wholeness,
from isolation to connectedness, and from fear to courage.
We have trained leaders in several departments, including the
emergency department, education, palliative care and pediatrics.
The Emergency Department: The outcomes are truly changing
lives and spirits while creating an army of empathic leaders. One
nurse in the Emergency Department (ED), Jonathan Bartels, instituted
the ‘Pause’ as a compassionate intervention.
“ I noted that when people die after a traumatic incident I would
often see surgeons, docs and nurses walk away with frustration,
throwing their gloves off in a defeatist attitude, not recognizing that
the patient was a human being we had just worked on saving. So after
these deaths I decided it would be a good thing to pause in a moment
of silence. Just stop. Honor them in your own way, in silence.”
Note the shifts here toward integration, inclusion and connectedness.
In the words of Pamela Ross, ED physician, “To operate
compassionately, minister from the heart, see the person before the
disease… To take the time to humbly acknowledge the human life
that has entered your presence that day… To be fully accepting of
whatever comes… To hesitate and wonder if you have what you need to give to that person in that moment. And to worry if, in any
given moment, you will be swallowed whole by the process or overwhelmed
by the condition of the masses… Sometimes it’s enough to
knock you over and render you motionless from frustration and
But then you breathe in and breathe out. Suddenly, it’s like a brand
new day has just begun, with brand new mercy. Look up and take
courage. Angels are nearer than you think. That is the strength of
CCELI for me.”
Palliative Care: Nurse and physician colleagues in Palliative Care
are creatively teaching an interactive
course called ‘Difficult Discussions’
about end-of-life care to medical and
nursing students. Knowing how challenging
it is to give bad news to patients,
this course gives students
practice with standardized patients.
Renewed awareness of what the patient
and family experience and their
own values about the meaning of life
are encountered. CCELI colleagues
Jeanne Erickson RN and physician
Dr. Leslie Blackhall serve as empathic
role models for these traits and skills
in the next generation. The work has garnered several grants,
including a prestigious Josiah Macy Jr. Grant, to extend this work.
Here is what Dr. Blackhall had to say about the initiative:
“One of the problems when you work in a big institution is people
work in silos and do not have a sense of shared vision. People can
get lonely and burnt out. Having a sense of shared community
makes everyone feel more energized and inspired. …CCELI helps
to take things that seem like intractable problems and reframe them.
Instead of being debilitated or hopeless, it gives a sense of energy…
The project has grown way beyond its small beginnings to teach residents,
nurses and others how to work together and communicate
better with their patients.”
Interdisciplinary teams in the Palliative Care group have also
worked with the Coronary Care Unit and other units to develop
an engagement tool, ‘All About ME,’ based on literature that shows
how helpful it is to encourage patients and families to provide
personal information about themselves. Team members include
social workers, chaplains, as well as nurse clinicians and physicians
from the community.
Education: Creating Resilient Practitioners by Starting with
Students and Mindfulness: We needed to find champions among
the faculty who valued our experience that students with a
reflective practice are more likely to better care for themselves
and in turn generously care for others. Faculty leaders for the
initiative continue to emerge and the culture is becoming more
open and transparent. All third-year nursing students participate
in a mindfulness day at a local farm. It consists of gentle yoga,
relaxation using body scan techniques and mindfulness meditation
opportunities modeled after Jon Kabat-Zinn’s Mindfulness
Based Stress Reduction program. Much of the day is spent
In addition to personal practice, there are multiple competencies
to learn and practice. Self-awareness is necessary but not sufficient.
I needed to increase my own skills as a dean and leader
while also cultivating and supporting the leadership of others.
Moving flexibly between my personal and professional profiles
helped. It is important to articulate with the greatest clarity who
you are at the deepest level, what you stand for and what people
can count on you for. Fostering leadership, building partnerships,
speaking up and speaking out and creating platforms for transformation
are key to making resilience and compassionate care
come alive for others. We turned reluctant faculty and clinical staff
into believers by enrolling them in an initiative where they could
rediscover their own passion, see
their own transformation and feel the
power of standing up. New pattern
makers emerged and people began
to follow. Followers became leaders.
One nursing faculty put it this way:
“As an oncology nurse I always strive
to give compassionate care to patients.
In an environment that is distressing,
we can lose sight of this.
CCELI helps me to keep this in focus
and to see colleagues who also have
this as a priority… I try to be supportive,
encouraging and nurturing to everyone I interact with.
What energizes me is to remember strategies I have learned in the
workshops here that keep compassionate care a priority.”
Pediatrics: Nurses, physicians, chaplains, and social workers in
Pediatrics help young children die at home rather than in the hospital.
They garnered financial support for an enhanced care
model using both a nurse practitioner and a physician for home
visits. Focused on results and a new fire in the belly to remove
barriers and shift systems, this group successfully lobbied to improve
the care of vulnerable children dying in our community
and to better support family members. Making the shift from fear
to courage and from scarcity to abundance is happening. A community
pediatrician devoted to making home visits for dying children
shared his lessons:
“CCELI helps me lead from strengths and core values. It gives me
an opportunity to think about who I am and who I can be as a
leader. It helps me to see the effects of engaging people’s commitments
to a project and to their core values. It also creates synergy
in a group. We have been able to extend the palliative care with
children and improve the services in the hospital and the community
through partnerships. What keeps me coming back to the meetings
is sharing the energy and having a place to think about and
explore my own passion for what I do, but also to sustain and draw
on the passion of other people.”
Strategies to Establish a Resilient Workplace
Create a healthy work environment with a generosity of spirit. Being a generous leader means not caring about who receives credit,
putting others’ needs first and leading with love. This does not
mean tolerating poor performance or unacceptable behavior. Recall
that the first step is to have individuals know and acknowledge their inner capacities, what they stand for, and recognize and live
their unique contribution. With a generous spirit then, the leader
captures the passion of the group and helps to inspire a new vision.
Create connectedness with conversation about contribution. In
a resilient workplace everyone’s contribution is valued and respected.
When we can call upon the best within each of us, the
organization achieves results. It is critical to make time for conversations
that lead to improvements and even new connections
among people in the organization.
Celebrate a new narrative of optimism with results. No one follows
a depressed, cynical, glass-half-full leader. Change your narrative
to be one of constant optimism and the world changes
around you. Having the courage to remain positive and try new
things is a hallmark of a resilient leader. For decades, it was
thought that the lock-step schedules of the nursing and medical
schools prohibited active learning together. I found that those
who were passionate about training students together circumvented
enormous barriers because they believed in the benefits.
I relentlessly pushed this initiative from my earliest days as a dean
because I too believed in the benefits and stayed optimistic despite
the cynics worn down by decades of negativity and hierarchy.
Cultivate competencies and inner capacities to unleash creativity.
Mindfulness practices of being present, paying attention and not
being attached to outcomes has enabled many of us to step back
in order to move forward. Creative ideas can emerge with new
freedom when we let go of who takes the credit. Who would have
thought we could ever have a new way to deliver pediatric palliative
care when the answer had been a resounding ‘no’ for a
decade? Asking colleagues to turn off electronic devices during
meetings, take a moment to focus on the breath, and then deeply
listen to each other can truly transform our challenges.
Apply breakthrough technologies to move past breakdowns.
Too many times events happen and fester without the skills to intervene,
causing lasting damage to relationships and letting projects
languish. We learned how to move from breakdown to
breakthrough. At each group meeting, we focus on the following
questions: How do we show up differently? How do we notice
when we are acting with integrity and when not? A leader who
learns to turn breakdowns into breakthroughs can achieve amazing
results. One colleague stated, “Instead of seeing only failures
and problems in the institution, in this group I see for the first
time promise and genuine possibilities for embodied compassion.”
Become more of yourself to set yourself free. The transformational
model allowed me to analyze my values and stand up as an
authentic leader. In moving from fear to courage, our group and
I often found ourselves asking, “What is the worst thing that can
happen?” And having Dr. Sharma’s and Josselyne Herman-Saccio’s
concepts of ‘bozo-ability’ and ‘un-messablewith-ness’ were key.
Bolster self-esteem in others and use humor. I try to always leave
fellow faculty, staff and students with encouragement and stories
they will remember and laugh about. Stories of how I have made
mistakes and misjudged a situation and how to then make things
right. Dr. Sharma’s work on transforming breakdowns to breakthroughs
has also helped here.
Get the right colleagues on the bus. Engage and enroll others to
be champions of the work. Hone inspirational messages to provide
a compelling story of why others should care about and contribute
resources for the work. I have the responsibility to bring
people into the organization that are not just aware of the work
but also encourage it and stand up for compassionate care. Our
work enabled a generous donor to provide a $15 million gift in
2011 to open a Contemplative Sciences Center to pull together
the Schools of Arts and Sciences, Medicine, Nursing and Education,
as well as the Tibet Center, to offer innovative education and
begin research into contemplative practices such as yoga, mindfulness
and healing and resiliency outcomes.
Kindness feels better and opens more doors. Practicing mindfulness
invites reflection on what matters most in the moment.
Acknowledging and respecting everyone on the organizational
chart from housekeeping personnel to the most seasoned leader
is watched and appreciated. This cannot be accomplished if your
nose is in your electronic device.
Standing in My Power: Becoming the Fearless Dean
In June 2012, the abrupt and unjust firing of the President of UVA
brought 17 days of emotional trauma to campus. Faculty, administrators,
students, alumni and local citizens were outraged and
media attention was unrelenting. I brought all my faculty and staff
together for a dialogue to support each other. Anger and sadness
remained palpable for weeks and finally triggered action. The
Faculty Senate energized the community to support the return of
our President. In a Rally for Honor led by student leaders, I was
asked to speak, along with other faculty and students, on the steps
of the Rotunda in front of thousands. My rally speech was well
received. I was the only dean to speak up that day. Many of the
nurse and physician leaders from our compassionate care initiative
were there. One said, “Don’t you think Monica Sharma would
be proud of all she taught us?” We were standing in our power.
The President was reinstated. I was called the ‘fearless dean’ by
many and it made me smile. Now the work continues and there
is no limit to where we can go.
This paper describes my journey from intensive care staff nurse
to standing in my power as dean of a major nursing school. The
model of transformational leadership to shift systems, source wisdom
and obtain lasting results has changed my life and those
The serpentine wall was built for resilience and so am I.
So are we!
A passion for critical care nursing underlies the distinguished career of Dorrie K. Fontaine, RN, PhD, FAAN, as clinician, scholar, researcher, educator and professional leader.