Aesop’s fable The Lion and the Mouse opens with a lion peacefully sleeping in the forest.1 His rest is disturbed when a mouse accidentally scurries across the lion’s nose, waking him up. The lion pins the mouse with his paw, intending to kill it. However, the mouse pleads for her life, and despite his rage, the lion decides to show the mouse grace for her innocent mistake. Later, the lion becomes trapped in a net laid out by a hunter. Unable to free himself, the lion releases a distinctive roar, inadvertently alerting the mouse to his location. The mouse arrives and chews through the net, freeing the lion and rewarding him for the benevolence he had extended earlier.1 Although the mouse’s error was unintentional, her actions disrupted the lion’s rest. Still, the lion chose a gracious approach, a gesture that was later reciprocated. It is not always the case that those who offer grace will reap direct benefits from those they forgive, but giving grace will often facilitate progress and more productive outcomes for both the giver and recipient. Because of their profound effects, medical errors are seldom met with grace from the affected patients, families, lawyers, supervisors—or even the physician who made the error.2 For example, in the first volume of Advances in Patient Safety: From Research to Implementation, Kerm Henriksen3 describes how, in a study conducted on surgical and medical intensive care unit interns, trainees in both specialties almost uniformly neglected to report mistakes or near misses if the patient did not have an adverse event. When interviewed, interns from both specialties stated that they were afraid of being perceived as incompetent by their attending physician.3 The inability of students to safely report errors without fear of harsh judgment is detrimental to both medical education and patient safety. Fostering a culture of graciousness removes focus from blame and judgment and instead emphasizes improvement in the clinical decision-making or technical skill needed to avoid errors. Recognizing that mistakes are a part of being human and offering chances to learn from those errors is the core principle behind giving grace. In this editorial, we highlight the advantages of practicing graciousness in the workplace and in everyday life, and offer strategies for doing so (Fig. 1).Fig. 1.: Framework for practicing grace and graciousness.THE IMPORTANCE OF GRACE AND GRACIOUSNESS Despite our best efforts, there is no way to eliminate mistakes. However, as Eckhart Tolle stated, “Letting go is an act of far greater power than defending or hanging on.”4 Holding on to the past prevents progress and hinders efforts to improve from past errors. Grace and graciousness are important primarily for 2 reasons: self-forgiveness mitigates the negative consequences that result from blame or shame and grace-giving results in ripple effects that create widespread benefits for parties close to the giver and recipient of grace. Grace and Graciousness as an Antidote to Blame and Shame The consequences of failing to give oneself grace are prominently displayed in the field of medicine. Physicians are more likely to condemn themselves after errors instead of practicing self-encouragement with the intention of learning from their mistakes.5 This leads to increased burnout,6 which leads to increased medical errors, poorer quality of care, patient and physician dissatisfaction, and depression-like symptoms for the physician.5 When burnout disrupts individual performance for one physician, extra responsibility and pressure fall on other physicians who must compensate for the losses. Those doctors then become more at risk for burnout with the increased workload.5 Aside from the systematic changes necessary to reduce overwhelming workloads, physicians must learn to give themselves grace to end the perpetuating cycle of burnout. When people forgive themselves, they are more likely to act constructively after errors, choosing self-improvement over self-blame.7 Essentially, self-forgiveness and forgiveness from others mitigate the depressive effects of burnout, consequently reducing individual and systemic burnout.8 The Grace and Graciousness Cascade Comparable to how individual burnout has ripple effects, individual grace-giving prompts recipient grace-giving, creating a positive cascading effect in a closed environment.9 In the workplace, individuals propagating a culture of graciousness benefit both the giver of grace and those around them.9 Previous studies found that forgiveness by a single individual was sufficient to increase the likelihood of others following suit, mitigating the ramifications of workplace conflict, improving employee well-being, and increasing gracious behavior.10 To illustrate this point, imagine an academically strong student who has been underperforming in a group setting. Because of their poor performance, additional work has fallen on the rest of the group, causing animosity and lowering the team’s effectiveness. However, when one student takes the time to ask what is wrong, chooses to forgive the underperforming individual, and helps formulate a plan for fair contribution, the team dynamic improves by encouraging a more empathetic perspective. Overall, grace and graciousness have the power to change group synergy and reduce burnout when practiced in 2 main contexts: extending grace to others and giving grace to oneself. In the following sections, we provide strategies to effectively practice both in daily life. GIVING GRACE TO OTHERS In a 2022 TED talk, Mark Guilbert, president of the Southlake Chamber of Commerce, claims “treating others with honor, dignity, and respect, regardless of whether you feel like they deserved it, was foundational.”11 Extending grace is difficult in instances where one perceives disrespect; therefore, it is crucial to interpret the actions of others with a nuanced perspective to maintain a gracious demeanor.11 The key to maintaining perspective is recalling that everyone has a story. It is easy to forget that one’s feelings toward an individual or situation could change if one knew the other side of the story. One example of context-based perspective is when Deputy Matthew Brakeman pulled over a speeding driver.12 After approaching the driver’s window, it was clear that this individual was unusually upset over the speeding allegation. Rather than responding with anger or apathy, the deputy spoke to the driver and discovered that she was going to an oncology appointment with her mother. Having lost his own mother to breast cancer, he released the family without penalty. Brakeman reasoned that the driver was not being dismissive of the law but was instead enduring challenges that resulted in an illegal act.12 The heightened emotions of the driver could have escalated the situation, highlighting the difficulty of practicing a charitable view in tense situations. Those emotions can assume control over the response, leading to a less productive reaction from the wronged party. There are 3 key steps to maintaining perspective: ground yourself before responding; assume a generous frame of mind; and choose the appropriate response (Fig. 2).Fig. 2.: Maintaining perspective to give grace to others.Regaining Composure In emotional situations, the first measure is to ground yourself before responding. In her Harvard Business Review piece, Amy Su,13 cofounder of the Mariswood Group, outlines 3 techniques to regain and maintain composure. First, Su13 recommends learning personal cues that indicate a less rational state by reflecting on past interactions or observing oneself in future encounters. According to psychologist Amy Gallo, as the body amplifies its stress response, rationality declines, and people are no longer their best selves.13 Ask the following questions: “How do I feel physically when I begin to lose composure?” “What are the signs that I am becoming angry or emotional?” Next, Su13 references Gallo’s 4-7-8 breathing pattern to momentarily shift focus from the problem and put time in between the initial reaction and the resulting action.13 The technique is inhaling for 4 seconds, holding for 7 seconds, exhaling for 8 seconds, and repeating.13 This provides both a new physical focus and time to move past immediate reaction.13 Another strategy is to focus on the immediate sensations around you: feel your feet on the ground; feel the clothes on your body; feel the object in your hand. Physical reorientation facilitates cognitive reset,13 helping maintain sound cognition in emotionally challenging situations. “What-If?” Scenarios Once calm, it becomes easier to practice “What-if” scenarios in real-life instances. “What if they are caring for a sick family member?” “What if they work even longer hours than you do?” “What if they just lost a patient?” What-if scenarios are hypothetical questions to consider before formulating conclusions about the instigator’s actions.14 For example, on the morning of March 28, 1979, the Three Mile Island Unit 2 nuclear reactor experienced a partial meltdown. Following the incident, employees at the reactor site received substantial blame, as their decision to reduce the flow of water contributed to the reactor core overheating.15 Asking, “What if I, with the same training and information, had been in the staff’s situation?” is key. The complete picture reveals that a series of unexpected systemic failures, such as a lack of instrumentation that would have revealed the issue with the water pump, explains the workers’ interpretation of events. With the information they had, plant workers reached an incorrect conclusion and made decisions that exacerbated the problem.15 When one asks, “What if I had been in their exact same situation? Would I have made the same error?” it becomes clear that the answer is unknowable.14 Practice a “We” Lens To best offer a gracious response, begin viewing interactions through a “we” lens.16 The “we” lens is a combination of the “me” lens and the “them” lens.16 Suppose a colleague has been causing delays by consistently showing up late to rounds. Through the “me” lens, this individual appears lazy, inconsiderate, or disrespectful. Through the “them” lens, that colleague might be having a challenging time with a personal situation and is fighting just to stay present. The “we” lens is a happy medium.16 Whereas it is wrong for the colleague to arrive late and impede the team’s workflow, reprimanding someone who is already struggling is not productive either. Responses are scenario-specific, but a good “we” lens response requires understanding the offending party’s perspective (“them” lens), politely communicating the recipient’s perspective (“me” lens), and helping that person implement strategies to meet the needs of both parties.16 Pull that colleague aside for a private, empathetic conversation about how they are doing and why they are presenting late instead of criticizing their tardiness. Emphasize the importance of punctuality and compassionately help them devise and implement strategies to be on time to mitigate further emotional harm and correct the counterproductive behavior.16 The best way to make this technique reflexive is to consistently practice it in as many interactions as possible.16 Even if it is difficult to employ at first, reflecting on past scenarios and rehearsing a “we” lens with hypothetical (what-if) “them” lenses will make it easier to factor the “we” lens into daily, in-person interactions. GIVING GRACE TO ONESELF Despite being its founder, Steve Jobs’ relationship with Apple was strained. In 1985, Jobs clashed with Apple CEO John Scully, blaming his leadership for the failure of the Lisa and Macintosh. In the feud’s aftermath, Jobs was ousted from Apple.17 In a later address at the 2005 Stanford University commencement ceremony, Jobs described the guilt he felt for his previous actions, claiming “I felt that I had let the previous generation of entrepreneurs down—that I had dropped the baton as it was being passed to me,” even describing how he wanted to “run away from the valley.”17 Despite these feelings, Jobs gave himself grace, and worked to rebuild his relationship with the company he founded; he was able to return as Apple’s CEO in 1997 owing to his perseverance.17 As Jobs described, shame and guilt are powerful forces that make it difficult to be gracious to oneself following mistakes. Blaming ourselves results in regret for our actions and in turn leads to shame, hindering growth, healing, and productivity.18 Without overcoming his guilt, Jobs would have never revolutionized Apple into the massive tech giant it is today. Still, even Jobs mentioned that he initially sought escape after failure, highlighting the difficulty of giving grace to oneself. To make self-forgiveness easier, use the 3 Rs: reappraisal, restitution, and reflection (Fig. 3).Fig. 3.: The 3 Rs for giving grace to oneself.Reappraisal Alison Brooks, an associate professor at the Harvard Business School, describes anxiety reappraisal—the idea that many of the same experiences can be viewed as positive or negative depending on the meaning we assign to them.19 Anxiety reappraisal directly intertwines with the views of medical anthropologist Dr. Joan Halifax. Dr. Halifax describes how embracing self-criticism must be done in healthy doses and with the intention of self-development.20 One method to effectively reappraise mistakes is to use cognitive reframing, which begins with identifying and isolating the specific mistake one made and the thoughts directly related to it.21 Following medical errors, it is easy to become overwhelmed by the long-term effects for those involved in the error. However, these feelings may not reflect reality and are likely outside the scope of the isolated mistake.21 Because feelings of extreme guilt or shame are often accompanied by cognitive distortions, it is essential to consider whether such feelings reflect reality as opposed to disastrous hypotheticals that are created by the mind. The final step is to replace the negative thoughts with realistic, productive reactions to the error.21 Following an adverse outcome, thinking “I ruined a life” or “my career is over” is less productive than “I will re-read the notes objectively, reflect on what led to the adverse outcome, review the literature, and consult mentors or colleagues to avoid similar outcomes.” In aggregate, cognitive reframing is applicable to reappraising responses to medical errors, assisting with self-grace. Sometimes, moving on is more difficult than appraisal, such as in the instance of losing a patient. Although it may feel impossible to persevere, fixating on the next steps and practical action serves as both a temporary distractor and a gateway to self-improvement.19 Restitution In instances where one’s actions inadvertently harm others, it is vital to pursue restoration of associated wrongdoings as best as possible to help rectify the situation and help the offender transition past the error. The first step to providing restitution is offering a proper apology.22 An apology done well often goes a long way in making amends.22 In medicine, a proper apology first requires a thorough understanding of the error.22 Before providing an underdeveloped explanation of the circumstances, find out as many pertinent details as possible. Ask perspectives from other members of the care team. Understand whether protocol was followed. Find out whether an error occurred at all. This information will dictate how the 5-step apology will be constructed. First, determine who should be present during the apology.22 If the error was made by a trainee, the attending should be present. If protocol was followed and an institutional failure occurred, the appropriate administrator is responsible for the apology. If no one can be identified as responsible, a health care worker the patient trusts should apologize for the circumstances.22 Ultimately, the party responsible and appropriate supervisors or trusted figures are the ones who should deliver the news. Second, find the right time and place to apologize.22 Find a quiet, welcoming, secluded space that is convenient for the affected individuals.22 Block out ample time for explanations, inquiries, and an overall meaningful conversation.22 Take time between the error and apology to understand the facts behind the error, but do not take too long, to avoid feelings of disregard from the wronged parties.22 Third, ask the affected party what they understand about the situation.22 Their perspective highlights potential misconceptions and facilitates the understanding that the party responsible is there to listen, feels remorse, and takes them seriously.22 Fourth, describe what happened.22 Without using jargon and avoiding defensive statements, describe in chronological order what happened and when and why various interventions were pursued.22 Fifth, offer the apology.22 Explain the specific error that occurred and let the recipient know that their frustration is shared by the care team and the ones who made the error.22 When apologizing, many consider it important to find meaning in their experience.22 Explain what the will for them and their situation, and how similar outcomes will be Once the apology has been offer if serves to and There is no for could extra care, a to physician, or a that is with institutional or and before the apology.22 Once these steps are one begins to the negative learn to with and for Even after reappraising the and making for the error, self-forgiveness is not a Following reappraisal and restitution, reflect on how a one would be in the same It is an of to be on ourselves than In this self-criticism more harm than hindering progress and personal Recognizing that are to in on the reality of how harsh we should be on to a one who made an error and the both your reaction and the steps you would them to and then those to they would a response than the one you gave yourself with the same response you would the strategies helps create on gracious by example is key to creating gracious Even if your is not a your actions can help change It is not but everyone has the to create widespread act at a Dr. from the of and from and has no to was received for this The president of at the of for review and
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