Wellness Newsletter Announcements - Wellness Section Newsletter, September 2013
Please make plans to attend the ACEP Wellness Section meeting at ACEP13 (Scientific Assembly) in Seattle.
Sheraton Seattle Hotel, Jefferson A
Tuesday, October 15
4:00 pm – 5:00pm
Sheraton Seattle Hotel, Ravenna A-C
Monday, October 14
4:00 pm – 5:30 pm
Convention Center, TCC, LL1
Monday, Tuesday, Wednesday
7:00 am – 5:00 pm
Parents with Infants Lounge
Convention Center, Room 302
Monday, Tuesday and Wednesday
8:00 am – 5:00 pm
Alcoholics Anonymous and Narcotics Anonymous meetings will be held at the Convention Center on Monday and Tuesday morning. Please check the on-site schedule for meeting locations.
Starting this year, the ACEP Wellness Center will be part of the Resource Center adjacent to the ACEP Bookstore in the exhibit hall.
ACEP Wellness Center
Monday | 9:30 a.m.–3:30 p.m.
Tuesday | 9:30 a.m.–3:30 p.m.
Wednesday | 9:30 a.m.–3:30 p.m.
Booth 1701, Exhibit Hall, Washington State Convention Center
ACEP members — visit the ACEP Wellness Center and assess your level of well-being.
The Wellness Center offers services to ACEP members including blood pressure checks, blood chemistry, body composition screening, flu vaccine, wellness-related resource materials and a burnout questionnaire with personalized feedback. This is a $160 value but only $40 for ACEP members. Admission tickets to the Wellness Center may be obtained at the ACEP13 registration area or at the nearby ACEP Bookstore.
From the Chair - Wellness Section Newsletter, September 2013
Sarah McCullough, MD, FACEP
By the time this newsletter is out we will be looking at Fall and I hope all of you are still savoring memories of a great summer. Now we have the upcoming section meeting at ACEP13 (Scientific Assembly) in Seattle to look forward to. I always think of this as a great time to catch up with friends and also reassess my career and life plans. This includes wellness, which is an ever growing topic for research and analysis. Unfortunately, our profession, and particular emergency medicine has been ranking high on the charts for burnout.
Studies have implicated shift work hours, challenging and high stress patients, bureaucratic tasks, increasing patient load, loss of autonomy and a host of other factors. Though we may be coming up with reasons, for burnout, it is most important that we develop ideas on how to prevent it. Studies on resilience will hopefully point to those factors that keep us working in our chosen profession. An ACEP Wellness Section Grant has provided support for the “Resilience Survey for Emergency Physicians” as developed by researchers Vicken Totten MD and 'Alim Beveridge. I recently took this survey and look forward to the results. In the meantime, I would like to see the Wellness Section help its members and all physicians develop their own wellness.
I think that developing wellness is a dynamic process and is different for every person. We need to get to know ourselves, our strengths and weakness, so that we can learn to cope with whatever comes our way. It is easy to lose sight of who we really are with the process of college, medical school and residency. We are in a system that teaches us to be doctors and though we learn how to take care of patient's physical problems, there is not much time to explore our personal reaction to what we are doing. I am hoping that discussions of wellness during residency will better prepare our future emergency physicians and there will be less burnout.
For those of you who are currently practicing, I would like to offer ideas to help you develop wellness. I am hoping that our newsletter can offer insight in to how you can determine your strengths and how to connect with yourself. I am interested in hearing from others about the ways that they maintain their wellness and I am also interested in finding out what makes you feel “not well” and how you cope with it. It would be awesome if we could set up some type of resource where physicians could connect-tweet, email, call etc. when they needed a boost, had a bad day, or are feeling like their wellness is slipping away. We have all had a shift that was difficult for one reason or another and it keeps playing through our mind. Wouldn't it be great to have a “Wellness Hotline” to connect with? I know, there would be multiple concerns including legal implications, HIPAA, etc, but I like the concept. It is important to share our experiences so that others can get ideas about “what went wrong” and “what went right.”
There have been a number of disasters in our country over the past few years and we would like to hear from some of the emergency physicians that cared for the injured, for example, at the Boston Marathon bombing. I was there as a runner and watched the amazing process unfold. It would be great to have an article on providing the medical care and then the after effects of being involved. I know that at least one of you reading this was there, and the same is true for the explosions and shootings in our country over the past few years which have required emergency services.
I hope that many of you are able to attend ACEP13 in Seattle. Enjoy the city, connect with friends and take time to assess your career, family, and your wellness. Please let us know if you have any stories to share regarding your experiences.
A Wake-Up Call - Wellness Section Newsletter - September 2013
Jay Kaplan, MD, FACEP
35 years old you look at me
terror pouring out of your blue eyes
as red life blood pours out elsewhere
your bold query
am I going to die
yet I hear it and respond
no I say now is not your time
I watch you wonder
who will be the mother to my child
who will be the lover to my husband
am I replaceable
can you help me
I cannot answer you for I am called elsewhere
to meet the questions of others
does my child have a broken neck
can you fix my lip so I will look as handsome as I have before
why does my hip hurt
can you ease my pain
is the child within me going to have the hope of life
I do my best to reply
and then circle back to you
meet your eyes
listen to your heart
hold your hands
assure you that you are
we will walk with you
we will find the way
we have journeyed here before
now is not your time
a wake-up call
for you and for me
This time is short
feel your life while you have it
be astonished by its challenges
and its colors
breathe in its expansiveness
be nourished by its moments
there are no guarantees
for any of us
this life is not the dress rehearsal
Positive Psychology: Part 2: Creating a Positive Healthcare Environment - Wellness Section Newsletter, September 2013
Neil Elliott Farber, MD, PhD
Assoc. Prof, Anesthesiology, Pediatrics, and Pharmacology & Toxicology
Medical College of Wisconsin,
Children’s Hospital of Wisconsin
9000 W. Wisconsin Ave, P.O. Box 1997
Milwaukee, Wisconsin 53201-1997
Email Dr. Farber
Creating a Positive Healthcare Environment
The healthcare environment is stressful; not just for patients but also for physicians.1-3 Workplace negativity is associated with diminished communication, increased stress, decreased productivity; physical, emotional and psychological illnesses, and compromised patient care. Happiness raises nearly every business and educational outcome: raising sales by 37%, productivity by 31%, and accuracy on tasks by 19%, as well as a myriad of health and quality of life improvements. The question is not does happiness help, the question is how to get there. This article will focus on how emergency physicians may incorporate and utilize the concepts presented in the Positive Psychology Primer (ACEP newsletter, May 2013) into the health care setting to achieve positive benefits for themselves and their patients.
What is a Positive Healthcare Environment?
A Positive Healthcare Environment (PHE) is patient-focused care emphasizing positive emotions, positive language, and positive actions. It involves working productively as a team, thinking and acting with optimism and using a mindful approach to create an atmosphere conducive to healing, safety, and satisfaction for both patients and healthcare workers.4 As discussed in the Part 1 Primer, one important predictor of happiness and satisfaction is the ratio of positive to negative interactions.5 A neutral ratio of 1:1 is associated with failing companies, organizations, and relationships. Achieving a ratio of greater than 3:1 is difficult to accomplish by simply reducing negative interactions. Thus, the goal is not simply to negate negatives, but to potentiate positives. In all areas of the hospital and for all physicians, there are commonalities in both negatives/stressors which can be reduced and positives/benefits which can be enhanced. However, it is also true that with each specialty comes specialized stressors unique to that field. Emergency care is no exception. Thus, to create a PHE we must also promote and focus on a Positive Peri-Emergency Department (PPED). The word “Peri” in this context refers to the fact that while the main locus of practice for emergency physicians resides in the emergency department (ED), the effects of the practice and daily interactions occur throughout the hospital and even beyond the hospital setting.
Sources of Emergency Department Negativity
For Patients: Fears and anxieties related to coming to the hospital, fear of the unknown, embarrassment regarding their injury or illness, potential procedures, financing an illness and financing the ED visit, putting their faith in a physician whom they don’t know, nausea, vomiting, pain, a lack of control, and negative language, emoting, behavior and conflicts. Being treated by and putting your trust in medical staff with whom you have no bond or previous relationship. By necessity, patients will be required to tell their story several times. This is often interpreted as “No one is listening to me” or “Why doesn’t anyone here communicate this information or write this down.” Patients are often unnecessarily exposed to our internal struggles, conflicts, and discontent; creating a cycle of negativity as their stress levels increase, which makes our jobs harder and lessens our desire to be around negative people. We often believe that we are good at hiding this from our patients however patients already have a high level of suspicion about physicians whom they don’t have a previous relationship making them more sensitive to negative emotions and interactions.
For Emergency Physicians: Conflict is the result of differing expectations, agendas, personal needs, and communication styles. Conflict in the ED can occur with patients, family members, nurses, consultants, technicians, residents, students, staff, and consultants. The ED has a unique set of reasons that increase the chance of conflicts.2,3 Complaining, blaming, conflicts, stress, lack of control, sick patients, pessimism, long hours, night shifts, “life in a fishbowl”, excessive workloads, economic difficulties, death and dying, depression, threat of litigation, job insecurity, production pressure, and unrealized patient expectations. Dealing with patients, physicians, and ancillary services with whom you often have no previous relationships. Dealing with the widest range of illnesses, accidents, and diseases of any medical specialty. Emergency physicians also have to deal with patients who argue about the diagnosis or recommended treatment, patients who don’t come in until diseases have progressed too far or patients who come in for unnecessary issues. Many patients feel that because of their income or job, they may be entitled to special care, which is essentially impossible to accomplish for the unbiased emergency physician. ED physicians deal with all members of healthcare and do it at all hours of the day and night under high stress conditions. They are blamed for doing their job well and admitting patients who need to be admitted or sending patients home who should have been admitted. There is often a feeling of “I just can’t win…” Stress due to high pressure/high risk work environments and pressure to perform expedient and complete history and physical exams in sometimes non-compliant patients. Consequently emergency physician residents have a higher prevalence of substance abuse compared to other specialties.6 These stressors do not confine themselves to the job; rather the stress spills over to personal lives to create further conflicts and relationship issues with families and friends.
Benefits of a PHE
For Patients: Enhanced safety, satisfaction, confidence, doctor-patient relationships, communication, and perceived control, while potentially reducing pain, nausea and vomiting, learned helplessness and stress.7
For Emergency Physicians: Better mental, emotional, and physical health, greater job productivity, creativity, innovation, and engagement (working with passion/commitment). Positive workers are more motivated, optimistic, resilient, and have better coping skills.5 Reducing negativity decreases conflicts, exhaustion, depression (which costs companies $30-44 billion per year), medical errors, suicide, chemical dependency, adverse patient outcomes, job turnover, burnout and sick leave. Physicians who have a more positive attitude about their hospital work environment less often complain and blame others, have fewer conflicts, are more satisfied with their work environment, and are more fulfilled and committed to their jobs.4,7 Fortune 500 companies screen potential employees for positivity characteristics such as hope and optimism (to derive a PsyCap – psychological capital score) as individual positivity and engagement are important components for corporate success.
Enhancing Peri-Emergency Department Positivity (PEDP)
For Patients: Focus on positive attitudes, emotions, language, and actions.
Pre-ED: Unlike most medical specialties, emergency care does not allow for patients to become psychologically prepared for their visit. In fact, this is one of the major sources of stress. Therefore, the initial meeting – at triage and registration, should be, as much as reasonable, a welcoming and friendly environment.
In the ED: Interactions with patients and families should, if possible, avoid tense and hurried discussions. This is especially difficult given the demands for efficient flow-through. The diversity of cultures and languages requires greater patience with our patients. We can view this as a problem that we will need to “put up with” or we can view this as a challenge and “try to rise to the occasion” or we can view this as an opportunity to care for such a wide variety of peoples.
Consents and assents should be acquired honestly but without scaring. The use age-appropriate language, jokes, and stories is also important and often overlooked. The use of positive forms of communication to patients and coworkers is critical to promote a positive environment. While it may be difficult to make this transition, try to utilize compliments and encouragement when possible and if appropriate. Quickly resolve or postpone conflicts with coworkers and other team members that don’t directly involve patient care. When performing procedures whether utilizing sedation or simply under local anesthesia, employing guided imagery, distraction, or hypnosis assists in reducing patient stress levels. Try to limit conversations to patient-centered topics. Utilizing a team approach reduces miscommunication and poor communication, enhances smooth transitions between patient care areas, and lowers risk of medical errors.
For Emergency Physicians:
Nurture optimism: Approximately 50% of happiness and 75% of optimism is due to nurture, not nature; therefore they are up to you. Just as there is learned helplessness, there is also learned optimism.8 Optimistic physicians have a more positive personal self-assessment, feel more valued at work and feel more personal control at work. They are also more committed to and satisfied with their jobs.7
Respect and Value: Realize the necessity of all team members: from housekeeping to secretaries to technicians, nurses, and coworkers. Appreciate that everyone has an important role in promoting a healthy environment and taking care of the patient. Everyone also has a role in making your life easier. You may view your role as a physician as being more important than that of the triage nurse. However, we have all experienced the result of poorly trained or disengaged nurses and how crucial their role is in expediting proper patient care and directing patients to their appropriate destinations. It should go without saying that without housekeeping, we would not last more than two hours without garbage overflowing or human waste not being cleaned up. Poorly trained secretaries would result in billing deficiencies that would threaten your own job security. These are all common knowledge, yet we need to continually remind ourselves that we are not the “rulers of the ED,” we are “valued members of a team.” Being both humble and respectful will go a long way to help build camaraderie.
Practice Gratitude - Appreciate that Patients Have Choices: It’s late at night, you’re tired, you haven’t slept and you missed dinner. There’s a lull in the action and it looks like this will be your opportunity to get some food and maybe take a nap. You head for the cafeteria and two minutes later you get a page that another patient is waiting to see you. First thoughts? Are you thinking, “damn them!” “Why are they doing this to me?” “Why now?” Why couldn’t they have gone somewhere else?” These are common reflections. However, the result of this way of thinking is that I regret going into this profession, I don’t like my job, and I resent this patient coming to the hospital. This form of reflection will most assuredly lead to poorer patient care, and active disengagement and dissatisfaction regarding your job. Instead, appreciate that while we don’t hope for people to get sick or have devastating accidents, if we got our wish and no one had a need for emergency care, we would be out of a job, waste a lot of training, and not be able to support our families.
Most patients have choices regarding their medical care. Try to maintain an attitude of gratitude that they chose to trust you with their health. Be grateful for the opportunity to use your knowledge and skills; be grateful that everyone patient treated is a learning and growing experience, every patient is unique and even a simple laceration or diagnosis of appendicitis is slightly different for every patient; be grateful to God or the Universe that you have the combination of opportunity and ability to help someone; be grateful that every patient brings you closer to your goal of paying off your mortgage, or your children’s college education, or your next vacation! The recognition that we are benefiting in many ways from every single patient visiting the emergency department will enhance your ability to effectively treat your patients. You will listen, not just with your ears but with your heart. Your days will fly by faster and you will have a greater chance of being in flow (see below). Gratitude practice enhances optimism, altruism, and life satisfaction while reducing stress levels.9
Promoting positive, productive communication: The goal of conflict resolution is to decrease risk of medical errors and reduce stress among patients and healthcare workers. Positive communication is not just “nice” but is critical to creating a healthy positive and cooperative environment – both for patients and workers.10 Various interactions and conflicts in the ED may include emergency physician with emergency nurses, physician assistants, secretaries, ED technicians, residents, students, and other staff.
The goal of positive communication moves beyond conflict resolution to optimize patient care as well as improving ED worker (including physicians) engagement and fulfillment. Avoid “win or lose” thinking. When conflict exists that involve patients, everyone loses. Effective communication requires mutual respect among all team members as well as between you and your patients. Physicians are not always the best listeners, often interrupt patients, make assumptions, and have an agenda. Effective communication styles include not interrupting, active listening, paraphrasing and expressing a willingness to find and explore common ground. A 3-part series of articles has delineated various aspects of physician-patient communication in Emergency Medicine. 11-13
No-complaining rule14: No mindless, toxic complaining – this negatively and directly effects all coworkers and spreads like a virus. Rather than non-directed complaining, one should direct substantial concerns to someone who can affect change (director/chief) with the caveat that you have to bring one or two potential solutions.
Reduce Blaming/Practice Forgiveness: Decrease blaming by taking responsibility for all of your actions as well as your responses and reactions.15 Physicians who less often blame others, have fewer conflicts and a more positive attitude about the healthcare environment.4,7 If you blame, then practicing forgiveness results in significant physical and mental health benefits; more life satisfaction, positive mood, and fewer physical symptoms.
Decrease Stress: Work-directed strategies like decreasing workload may have little long-term benefit. Person-directed strategies such as cognitive-behavioral modeling or learning effective coping strategies have better long-term efficacy. Viewing potential problems as challenges, issues or situations, or perhaps even opportunities rather than threats reduces the assessment of stressors. One may change detrimental stress to beneficial “eustress”.
Find Flow: Like being “in the zone;” completely involved and motivated in an activity. You are well-trained and possess the ability to succeed at these challenges.16 Flow is associated with happiness and mindfulness.
Strengths: Rather than improving your weaknesses and spending your time and energy on techniques or skills in which you are not particularly fond; identifying and using your top 5 (signature) strengths in new ways has been shown to lead to long term happiness.17 For example: you find yourself managing the majority of difficult airway cases, one of your signature strengths is bravery. Rather than complain about how hard your cases are, realize that this assignment provides you with the opportunity to utilize one of your best assets. www.viastrengths.com provides a free strength assessment.
Meditate: Meditation has many health and wellness benefits. Meditators have increased neuronal firing in the left frontal cortex,18 decreased loss of gray matter that normally occurs with aging, 19 and thicker cerebral cortices of the anterior insula, sensory cortex and prefrontal cortex – areas associated with attention and awareness.20 The benefits of meditation extend well beyond your head. Meditation reduces stress and anxiety, improves mood, allows you to think more clearly, while boosting your energy level.21 Even for 2 minutes per day will help alleviate some workplace stress.
Be Mindful: Mindfulness is the process of being aware and living in the present moment, on purpose, non-judgmentally as if your life depended on it.22 Being mindful helps us remain patient focused and not day-dream about being somewhere outside of work. In addition, mindfulness is beneficial in terms of stress relief, improved immunity, enhanced safety for both patients and healthcare workers, and greater satisfaction with career and life. Mindfulness practice has been shown to reduce chronic pain, improve mood, and enhance empathy. 23
Reduce Fundamental Attribution Errors: Automatically attributing negative actions and bad behavior by others to their personality – not the situation is making a fundamental attribution error. By reducing or eliminating fundamental attribution errors we can reduce the incidence of blaming and negativity. Begin by giving people the benefit of the doubt and assume that people are inherently good. When someone does or says something that you consider bad, try to put yourself in their shoes and give them the same excuse that you would give yourself had you done that same thing. This will immediately reduce your stress level and replace frustration with empathy.
Practice empathy: Try to replace sympathy with empathy. The more you can relate to what others’ are experiencing the easier it will be to reach out and help them. This applies not just to patients but also to coworkers, colleagues, and other team members. Empathy is a great way to enhance your satisfaction and engagement at work.
3 good things17: For long term increases in happiness, every night recall 3 good things from the day. Try to make them different things every day and reflect on what role you played in making it happen.
Spirituality: This is different from a religious belief; it is faith in something greater than yourself. You can find spirituality in listening to inspirational music, reading a motivational book, taking a brief nature walk, etc. Bringing spirituality into your life will aid in coping, stress reduction, and mental and emotional health.
Exercise regularly: Exercise improves mood, reduces risk of several diseases, and enhances immunity. Exercise is more effective than some prescription medications for treating depression.24
Other Positivity Strategies:
• Healthy eating habits: decreases illness and enhances energy.
• Healthy sleep habits: reduces stress, repairs your body, and strengthens immunity.
• Happiness comes more from doing than having: Don’t rely on external things to make you happy.
• Making Lemonade: Continually look for ways to convert apparent negatives into positives. Changing problems into situations, then challenges, then opportunities. Look for blessings in disguise. 25
• Developing Resilience: Underlying many of the techniques, skills, and behaviors discussed above is the concept of resilience. The ability to withstand stressors, bounce back from set backs and view problems as opportunities.
Engagement: In addition to the role that we as physicians can play in creating a positive healthcare environment, hospitals and organizations can also play an active role in promoting positive organizational behavior.26 To encourage engagement and a feeling that this is not a job or even a career but rather a calling that you were meant to do, businesses (including healthcare businesses) should encourage friendships at work, increase responsibilities and opportunities; utilize individual skills and strengths, autonomy, and shared values with the organization. Developing personal initiative improves success and satisfaction. This is both our responsibility and that of our healthcare organization and/or management. Among physicians, positive feelings about management correlate with both positive attitude toward patient care and work engagement.4,7
Negativity is prevalent in the ED, as in most stressful work environments. Physicians who feel more engaged in work, have a more positive view of their life outside of work. A positive healthcare environment and PEDP will enhance safety and satisfaction for both the patient and the Emergency Physician, allowing us to truly focus on health and wellness for our patients and ourselves.
- McCue JD. The effects of stress on physicians and their medical practice. N Engl J Med. 1982:306;458-463.
- Doan-Wiggins L, Zun L, Cooper MA, et al. Practice satisfaction, occupational stress, and attrition of emergency physicians. Wellness Task Force, Ill Coll Em Physicians. Acad Emerg Med. 1995:2(6):556-63.
- Lee YK, Lee CC, Chen CC, et al. High risk of ‘failure’ among emergency physicians compared with other specialists: a nationwide cohort study. Emerg Med J. 2013:30(8):620-2.
- Farber NE, Farber SL, Staudt SS, et al. Creating a Positive Perioperative Environment: A Patient-Focused Approach. Scientific Exhibit, American Society of Anesthesiologists meeting, New Orleans, 0ct, 2009.
- Fredrickson B. Positivity. New York, NY: Crown Publishers; 2009.
- Hughes PH, Baldwin DC, Sheehan DV, et al. Resident physician substance abuse by specialty. Am J Psychiatry. 1992:129:1348-54.
- Farber, NE, Farber SL, Hoffman G, et al. Anesthesiologists’ assessment of the perioperative environment. American Society of Anesthesiologists. 2010.
- Seligman ME. Learned Optimism: How to Change Your Mind and Your Life. New York, NY: Vintage Books; 2006:205-281.
- Emmons RA. Gratitude, subjective well-being, and the brain. In RJ Larsen and M Eid (Eds) The Science of Subjective Well-Being (pp 469-489). New York. The Guilford Press.
- Katz JD. Conflict and its resolution in the operating room. J Clin Anesthesia. 2007;19:152-158.
- Knopp R, Rosenzweig S, Bernstein E, et al. Physician-patient communication in the emergency department. Part 1. Acad Emerg Med. 1996;3:1065-1069.
- Totten V, Knopp R, Rosenzweig S, et al. Physician-patient communication in the emergency department. Part 2: Communication strategies for specific situations. Acad Emerg Med. 1996;3:1146-1153.
- Rosenzweig S, Knopp R, Freas G, et al. Physician-patient communication in the emergency department. Part 3: Clinical and educational issues. Acad Emerg Med. 1997;4:72-77.
- Gordon J. The No Complaining Rule: Positive Ways to Deal with Negativity at Work. Hoboken, NJ: John Wiley & Sons, Inc; 2008:96-102.
- Farber NE. The Blame Game: The Complete Guide to Blaming. Minneapolis, MN: Bascom Hill Press; 2010:116-149.
- Csikszentmihalyi M, Abuhamdeh S, Nakamura J. Flow. In: Elliot AJ, Dweck CS. ed. Handbook of Competence and Motivation. New York, NY: The Guilford Press; 2005:598–609.
- Seligman MEP, Steen TA, Park N, et al. Positive Psychology Progress: empirical validation of interventions. Am Psychol. 2005;60:410-421.
- Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003:65:564-70.
- Pagnoni G, Cekic M. Age effects on gray matter volume and attentional performance in Zen meditation. Neurobiol Aging. 2007:28(10):1623-7.
- Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005:16(17):1893-7.
- Greeson JM. Mindfulness Research Update 2008. J Evid Based Complementary Altern Med. 2009:14:10-18.
- Kabat-Zinn J. Wherever you go, there you are. 1994: New York: Hyperion.
- Grossman P, Niemann L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res. 2004:57(1):35-43.
- Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: Benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the committee on exercise and cardiac rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation. 1996;94:857–62
- Farber NE. Making Lemonade: 101 Recipes to Convert Negatives into Positives. 2012, Mequon, WI. Dynamic Publishing Group.
- Luthans F. The need for and meaning of positive organizational behavior. J Org Behavior. 2002:23(6): 695-706.