Chapter 5
Authentic Integrity
A Premier Character Strength
Abstract
Learned Mindfulness is the process of achieving Authentic Integrity, a tool helping prevent physician burnout. “Authentic Integrity” is psychological wholeness and personal freedom from self-deceit. Mindfulness brings hitherto hidden mental capacities to the light of mindful awareness. Integrity creates the entirety and transparency making possible a sense of being undiminished. Character strengths are positive psychological characteristics based on consciously chosen values. These preferred beliefs guide life goals, choice of personal and social affiliations, occupation, and living in these pursuits. Inner character strengths pivot on “Integral Empathy”: cognitive perspective-taking and emotionally grasping and outwardly responding to another's sentient experience. Empathy includes attunement to nonverbal communications such as facial expressions and body language. This resonant social conduit adds meaning to the biomental perspective of Learned Mindfulness of body-mind synchrony. Transparency implies authenticity and honesty reflecting the level of perceived understandability, completeness, and correctness in communication. A high-reliability person sustainably identifies problems, assigns ownership, sets goals, outlines targets, and timelines for tracking progress and resolving problems.
Keywords
Authentic integrity; Character strengths; High-reliability personality; Integral empathy; Transparency
5.1. An “Integrity Mindfulness” Model
The awakening of Learned Mindfulness uses emotional intelligence as its scaffolding. To this, it integrates core values of the Hippocratic Oath regarding integrity, character strengths, integral empathy, transparency, and a high-reliability personality. These are consistent with what classical Satipatthana has described as establishing mindfulness. The fourth dimension or platform for Satipatthana was the array of cultural teachings. Now, for physicians, this decisive foundation is emotional literacy, the context of medicine, and 21st century work-life integrity.
Authentic Integrity is integrating emotion with thought resulting in integral, less divided mental functioning. This assimilation is the core process of bringing into greater awareness previously unrecognized aspects of one's inclinations, aspirations, attitudes, and what had been less mindful behaviors. Learned Mindfulness is the process of achieving authentic integrity. Understanding this activity is an “Integrity Mindfulness” model. Using it as a tool in practice helps to prevent physician burnout. Thus, mindfulness, authenticity, and integrity broaden one's quality of life (QoL) and promote well-being. Entrainment to the natural cycle of emotion restores reason to thought.
Authentic integrity is psychological wholeness and personal freedom from self-deceit. Mindfulness brings hitherto hidden mental parts to the light of mindful awareness. Integrity creates the entirety, soundness, and transparency making real a sense of being undiminished. Mindfully recognizing the nuances of sensation, breathing, and how they configure perceptions of conscious feelings adds greater intactness to cognitive-emotional life. Significant consistency in grasping experience ensues when being in the moment of waking experiences makes them vivid yet tranquil with fresh meaning. This ever-new grasp on everyday experience is the essence of immediacy—being in integrity mindfulness. It is even-minded equipoise and the equanimity of emotional composure.
Integrity often correlates with honesty. While the two notions relate and overlap, they have differences. Honesty emphasizes freedom from deceit and fraud, states of uprightness, the absence of corruption, and a tendency to plan evaluations with definitions having clear-cut labels, not gray areas. Integrity is a concept emphasizing soundness, entirety, and communicative transparency (Erhard, Jensen, & Zaffron, 2013). Transparency and openness, therefore, make potential errors and mistake-making more visible. The honesty and integrity dimension of transparency strengthens the physician's ability to avoid drifting into “normalized deviance.” Minimizing the significance of errors and incorrect performance making them routine and left unattended is counter to mindfulness.
Authentic integrity connects with the core personality strength of high reliability. Essential dimensions of the high-reliability person are accountability and responsibility. Accountability often means individual answerability for actions already done. This product includes the consequences and outcomes of one's efforts and projects. In addition, accountability means one will do what they are expected to do. Personal accountability establishes and reinforces the link between behavior and consequences or cause and effect. One cannot delegate accountability. It is a habit of building intrinsic motivation to meet performance expectations. Leaders take part in vertical accountability. Peers and collaborative teams engage in horizontal accountability.
Responsibility is both individual and shared ownership of actions and projects to be accomplished. Responsibility, unlike accountability, is a more social endeavor. Both accountability and responsibility are core to the high-reliability person. They imply honest and effortful advancement toward choice and intention.
This completeness is key to maintaining enthusiasm for the engaged physician. Successful physicians engage in organizations transparently aligned toward efficiency and reliability for safety and quality.
5.2. Learned Mindfulness
Learned Mindfulness is the emotional hygiene technique in an emotional intelligence model. This intention promotes significant emotional knowing to reclaim a mind of emotional insufficiency toward one of wholeness and integrity. The underlying anxieties generated by feelings of inadequacy diminish. As emotions materialize into graspable knowledge, motivation invigorates thinking toward executive action in real life. Attuning keen attention to embrace emotion restores the natural cycle launched by the primacy of emotion.
Mindfulness defines awareness as knowing one's experiencing. Intentionally inducing this mental frame creates an active, paused space—neutral yet dynamically complete. Included are the bodily sensation, breath, perception, emotion, and the burgeoning retrospective narratives. This pause-generating expanded awareness is a biomental state accompanied by degrees of equipoised tranquility. In such active relaxation, mental processing opens itself to a more transparent awareness of emotion engaged with thought generating insights. Inherent abilities of intuition unleash themselves. Engagement is mental integrity—emotion and thought assimilated with one another.
Authentic emotional intelligence develops in degrees over a lifetime. The Integrity Mindfulness model discussed, Learned Mindfulness, is both a theoretical construct and a tool to describe the facets of sound emotional intelligence. The practices and techniques are only broadly suggested.
Two types of Learned Mindfulness practice are
- 1. Formal, structured intensive application and
- 2. Informal “mindful awareness:” an orientation characterized by everyday alert noticing interspersed throughout the day. Informal practices may be very effective change agents if used daily. For example, doing many brief practices many times during the day.
Both methods of practicing pause require instruction because paying attention means mindful attention. Reading about these and how to use them is practical, useful, and beneficial. It may be a beginning effort prompting further exploration. This extension may require more in-depth understanding within a person-centered context with face-to-face real-time feedback (Schulte-Rüther, Markowitsch, Fink, & Piefke, 2007; Stephens, Heaphy, & Dutton, 2012). A variety of mindfulness programs, informal and formal, are now available both as in-person training and as self-learning. All have value depending on preference. These may complement Learned Mindfulness just as this emotional intelligence mindfulness approach may augment other programs. Whether Learned Mindfulness or other practices are used, mindfulness capacities are sure to expand. A foundation establishing mindfulness is familiarity with multidimensional integrity.
5.3. Learned Mindfulness: Achieving Authentic Integrity
Integrity is a sense of wholeness, being integrated into an awareness of one's sensations, emotions, thoughts, and intuitions. This wholeness is freedom from self-deceit made possible by transparency. This assimilated configuration is not a fixed, immutable condition but instead, one dynamically growing, learning, and developing. Integrity is not a static reaction to events. It is sensitive, attentive responsiveness nuancing itself by its subfacets to the adaptive realities relevant at each changing moment.
Authentic integrity means empathetic listening, shifting gears, and releasing oneself from outmoded past expectations now unneeded. Therefore, being alert, consciously aware, and mindfully choosing shows integrity. Those having cores of integrity reflect routinely on their values and current challenges, how they fit and influence the broader vista. This strategy helps self-correction. It is needed for the continuous process of high-value character development. This continuity is essential to maintaining and supporting a more extensive range of integrity. A physician with integrity leads by living example, thus expanding the integrity of the entire medical workforce.
Integrity is a broad term, sometimes nebulous in everyday parlance. In real-time action, authentic integrity is leadership. Leadership means self-determined leadership, self-direction, and adherence to clear-cut values (Gardner, Cogliser, Davis, & Dickens, 2011). From this intrinsic sense of accountability, leadership skills emerge orienting themselves to guiding others in effective ways (Wang & Hsieh, 2013; Zenger & Folkman, 2009, 2016). The terms integrity and leadership are interdependent (Table 5.1).
The undivided condition of integrity, a human birthright, aims toward breaking through a zero point of merely surviving toward reaching the innate potential of wholeness core to human nature. This genuine depth of character strengths pivots on integral empathy. Cognitive
perspective-taking and emotional engagement with another's experience enriches broad self-development with increased awareness and understanding. Self-activism enhances meaningful social communication and reciprocity.
Table 5.1
Learned Mindfulness goes beyond being a strategy for breaking the cycle of burnout prevalent today. Learned Mindfulness and achieving authentic integrity aims toward the gold standard of health and well-being. This vision comprises physical wellness, experiencing a balance of emotions toward positivity, and the belonging felt with satisfying social engagement. Progress in this not only prevents problems but enables one to thrive, even flourish. Thriving in QoL is expanding one's real-time here and now. The expansion flows in each moment. Seeing this unfolding world can be appreciated with a sense of gratitude both alone and shared with others is a bonus.
Having an active sense of integrity is relevant in the face of the inevitable transitions physicians face daily. Transitions can be changes on a micro- or macrolevel with varying degrees of priority and consequence needing negotiation multiple times. How one encounters and manages change reflects the integrity or wholeness of one's state of mind. This presence of mind is mindfulness of integral emotion and thought resulting in rational decision-making. It is performance utilization, real-life behavior, reliable and effective in changing contexts.
Transitions entail both inanimate and animate alterations. These shifts are neither mere material changes nor rearrangements of people. They are mindset revisions. While it may be easier to negotiate physical alterations in decision-making about a career change, job relocation, and even interpersonal and social relations, the essential dimension in transitions is the way our minds—intellect together with emotions—grasps, interprets, and adapts to these. This integrity of self assumes one is whole and assimilated in the way thoughts and feelings interface and work together. This character quality of authentic integrity arises from the emotional literacy resulting from how emotional intelligence refines itself.
Work-life balance is crucial, but life management is more than avoiding unhappiness, it is enhancing the elusive emotion of joy, equanimity, and peace of mind. Learned Mindfulness and authentic integrity value the spectrum of nuanced human strengths, weaknesses, and potentials, notably reclaiming forgotten emotions, including joy. Joy is the enjoyment including but going beyond pleasurable happiness. Joy, the core of subjective well-being, is esthetic self-wonder and appreciating being with others in an environment felt full of engagement energized by meaning and purpose.
This book all too well declares emotion is uniquely experienced by the one who feels it. Therefore, when the feeling termed “joy” is proposed, as will be the emotion of happiness, its meaning approximates a positive state of health and well-being nuanced differently by the person experiencing it. For example, some might sense exhilaration, others a quietly poised state of wonder, gratitude, and meaning. Others may sense the “joy” of being alive and being able to continue being with family, friends, work activities, and a variety of pursuits felt “enjoyable.” Some sense joy when alone. These contexts are legitimate attributes conducive to joy (Wright & Katz, 2018). These “lived feelings” approximate emotional equanimity on a platform of mindful equipoise.
Learned Mindfulness creates a framed space giving each the opportunity to unbiasedly explore mental contents freely as individuals, step back, and alertly choose “emotion-full” ideas appealing enough to be pursued.
5.4. Authentic Integrity Is a Peakless Mountain
Authentic integrity—as wholeness—is freedom from self-deceit because hitherto hidden parts can now be accessed and brought to the light of mindful awareness. Integrity brings entirety, soundness, greater self-transparency, and a sense of being undiminished. The wholeness of authentic integrity involves being true to oneself. This realization entails honestly detecting what one genuinely senses and knows to be part of inner being, even if previously underdeveloped or out of synchrony with what had been experienced. Integrity is a QoL virtually unimpaired. QoL and dynamic value-creation expand. This summary is the essence of the Making Sense of Emotion model.
Integrity in this emotional intelligence model also suggests a real biomental integration. The neurocircuitry of emotion, feeling, and thought is delineated in the model's perspective. Practices such as Learned Mindfulness may foster stronger connections among these neural pathways. The concept and reality of neuroplasticity and neurogenesis are proven facts. The brain is capable of new growth and positive change (Eriksson et al., 1998). Specifically, episodic memory builds records of sensory-perceptual-conceptual-affective processing. Episodic memory is the memory of autobiographical events (i.e., times, places, associated emotions, and other contextual “who, what, when, where, and why” knowledge). These events can be explicitly stated or accessed, mainly by visual images. It is the collection of past experiences occurring at an exact time and place. Episodic memory supports orientation in space and time. Chapter 3 mentions decisive neuroscience foundations of this relating to emotional intelligence and decision-making.
This strengthening of episodic memory by mindful awareness is an expansion of integral self-awareness. For example, the two top-rated subdomains of highest value in the United States “National Institute of Health Toolbox for the Assessment of Neurological and Behavioral Function” are Executive Function and Episodic Memory (Weintraub et al., 2013).
Growth and change in the hippocampus' dentate gyrus (e.g., learning, memory, and spatial navigation) occur (Eriksson et al., 1998). This expansion may compensate for age-related declines. This improvement happens when a biomentally positive strength building lifestyle is part of one's routine (Gage, 2002). This generative protocol includes nutrition, exercise, and active cognitive and social engagement.
5.4.1. Learned Mindfulness: Entering the “into Integrity Zone”
Authentic integrity is an achievement of self-determination, self-activism, and consciously prudent self-agency. This integration brings consistency to one's temperament, personality, and character. By using the tool of Learned Mindfulness, emotion engages with thought. Together, these generate “emotion performance utilization,” successful and effective performance in real life. Personal development, self-integration, and emotional intelligence advance together. All these strengths stabilize the self-constancy of implicit emotional modulation and explicit emotional expression: general self-regulation. They are actionable pathways to becoming whole and complete with oneself, an integrated person.
Learned Mindfulness is the active tool using intentional self-dialogue to enter an “into integrity” zone. Personal accountability and shared responsibility become buzzwords, rising to the level of axioms, for personal initiatives and a sense of belonging to teams that collaborate. Negative states of mind thwarting such positive initiatives are “out of integrity” attitudes. They are untrustworthy. Low reliability characterizes them. Prime examples of such negativity are attitudes of envy and ruthless competitiveness. In these situations, one sees others becoming better off; misperceived as being superior and getting ahead at one's expense, then feeling bitter and confused. This adverse reaction spoils going forward constructively and feeling pleased.
“Into Integrity” attitudes see a world of fresh opportunity and adventure. Integrity supports increased performance and value creation. Appreciating this vision inevitably evokes responses of gratitude building cumulatively and resonating with others.
5.5. Learned Mindfulness: Character Strengths and Positive Psychosocial Characteristics
Character comprises a literacy of the nuanced super-refinements of one's personality. On basic temperamental predispositions, a unique character develops from the consciously chosen values actively espoused. The simple formulation of a “hedonic set point” or fixed reference of well-being inducing strengths and predispositions made from both (1) genetic constraints and (2) learned habits from social and environmental experience may have merit. Other yet undetermined factors are involved in orienting values and behaviors toward
these broad set points. Motivation, learning from the environment, and random occurrences can change “fixedness” to other set points in remarkable ways, especially if determined to change.
Striving to achieve greater self-direction is needed to induce self-change. This upsurge in efficacy consists in becoming a self-activist. A self-activist is self-directed, has self-initiative, and is intrinsically motivated. Self-activists thrive in collaborative settings where belonging and resonating with others both supports and challenges values and styles that may differ. Valuing one's life together with the lives of all humankind exemplifies reality-based perspectives on genuine empathy. Authentic integrity magnanimously respects the worthwhile commonality shared by humankind.
Character strengths are positive psychological characteristics based on consciously chosen values. These preferred beliefs guide life goals, choice of personal and social affiliations, occupation, and the conduct of life. Character strengths have been called “values in action.” They are carried out as part of routine daily living. These strengths are values showing up in actions and behaviors. Other less pronounced character strengths can be significant yet underdeveloped. Of note: physicians who experience burnout sense their values are compromised by the unempowering workplace devaluing their autonomy on a variety of levels. This undervaluing deflates the soundness of a doctor's character strengths. Chapter 6 discusses this sense of diminished meaning.
Character includes one's moral sense of right and wrong and a code of ethical standards of behavior held to be correct, honest, and interpersonally sincere. “Good” in the authentic integrity model suggests healthy, life-promoting, -supporting, and -engendering feelings, ideas, and behaviors. The most abstract, ideal, humanistic level of values aims to approach degrees of excellence. At this level, multiple values merge under broader frames of reference called “virtue.”
Positive Psychiatry captures such an extensive array of ideas by the phrase “positive psychosocial characteristics.” This clustering encompasses one's individual character strengths and traits and their social/environmental components. Active social engagement is vital to one's characterological well-being. Authentic integrity correlates with high-value character strengths. Such positive psychosocial characteristics have empathy and communicative transparency as top values. Authentic integrity is exemplified by “keeping your word” both verbally and in performance. Terms characterizing such behavior include “trustworthy” and “high reliability.”
This sentient, emotional fluency also results in an expansion of integral empathy: cognitive perspective-taking of beliefs and intentions integrated with emotional grasping of and responding to another's feelings, hopes, wishes, needs, and anticipations. Empathy includes social attunement to nonverbal communication such as facial expressions and body language. These are relevant signals warranting attention. Feeling states of compassion impel one to act on the perceived needs of others to help. This requisite knowledge adds meaning to the biomental perspective of Learned Mindfulness as body-mind synchrony.
5.5.1. Top Character Strengths: Resilience, Optimism, and Active Social Engagement
Distinguished researchers in the fields of positive psychology and psychiatry (Gengoux & Weiss Roberts, 2018) have described the essential qualities exemplifying people who show the underlying resilience pervading all character strengths, not only in the face of stress and trauma but also in successful everyday living. Outstanding features include several character qualities:
- 1. Self-directed: a meaningful, value-laden life with purpose despite mistakes and errors, persistence, achievement, and resourcefulness.
- 2. Positive emotions balanced with negative emotions, e.g., optimism.
- 3. Relationships with others: empathy (cognitive and emotional) and leadership.
- 4. Personal growth and engagement and self-development aspirations.
- 5. To the above, Learned Mindfulness proposes one's character, resilient, optimistic, and socially engaged, is also reliable, accountable, can forgive, is profoundly empathetic, holds gratitude in high esteem, and embodies the wholeness of genuine authentic integrity.
5.6. Integral Empathy
Inner character strengths pivot on “Integral Empathy”: cognitive perspective-taking and emotionally grasping and outwardly responding to another's sentient experience. Performing this communicative skill enhances empathetic interpersonal relations. Empathy includes attunement to nonverbal communications such as facial expressions and body language. This resonant conduit adds meaning to the biomental perspective of Learned Mindfulness of body-mind synchrony. Although
empathy is multidimensional, its emotional sense often dominates its ordinary meaning.
Integral empathy is never unidirectional. Empathy's grasp elicits joint attention and fosters a shared agenda between people. Empathy encompasses cognitive, emotional, and behavioral processes whose interrelationships make possible responding authentically in helpful ways to another. Grasping what the other is inferred to be sensing, feeling, thinking, and needing elicits a compassionate response to help. Empathy is both a nonconscious and conscious understanding of another person's experiential frame of reference.
The term “empathy” comes from ancient Greek ideas, whose meaning suggests physical affection and passion, and the modern German word “Einfuhlung” translating as “feeling into.” Empathy shows attentive caring. Empathy as an emotional, cognitive, and somatic resonance with another is different in meaning from the term “sympathy.” Sympathy is an involved sharing of concern for another's feelings of sorrow or distress. Sympathy also connotes one's endorsement and support of another's opinion or point of view.
Empathy is a sophisticated, multidimensional attitude. It is an attunement, resonance, and synchrony with another's ideas, feelings, and potential needs. There are two primary aspects of empathy:
Affective empathy, sometimes called “simulation empathy,” is an almost automatic, shared, emotional feeling motivating social concern and the impulse to help. This effortless, emotional component correlates with the ventromedial prefrontal cortex, Brodmann area 44, and mirror neurons in the premotor cortex, the supplementary motor area, the primary somatosensory cortex, and the inferior parietal cortex.
Cognitive or intellectual empathy includes a more controlled emotion perception and perspective-taking. This cognitive component comprises executive inhibition, the distinction between self and others, prediction under uncertainty, and the perception of another's intentions. These features, mainly perceiving other's intentions, involve the capacity for understanding other's behavior.
Scientific research links cognitive empathy to mentalizing, perspective-taking, and theory of mind (Lamm, Bateson, and Decety, 2007). Such perspective centers in the dorsomedial prefrontal cortex (dmPFC). These effortful and controlled abilities entail conscious choice associated with the right dorsolateral prefrontal cortex and dmPFC and Brodmann areas 10 and 11 in the brain. Brodmann areas 6, 8, and 9 are also mentioned. The neuroscience of this social cognitive ability processing has been discussed in Chapter 3.
Researchers emphasize that while aspects of empathy are dissociable, they interact. Recent studies investigating the neural underpinnings of empathy and shared metaphoric interpersonal space models (e.g., visuospatial) highlight the role of the right temporoparietal junction (Scholz, Triantafyllou, Whitfield-Gabrieli, Brown, & Saxe, 2009). Functionally, this area associates with the ability to distinguish one's perspective from another's view (e.g., perspective-taking, Theory of Mind, and false-belief understanding). This capacity also plays a significant role in one's sense of agency, e.g., being the primary cause of one's behavior discussed in Chapter 1.
Profound empathy goes beyond conscious understanding and shared feelings. It expects what the other person's experiences are, what they are becoming, and how they might be emerging. These processes, having both nonconscious and conscious components, mitigate the perceiver's sense of sharp demarcation from the other and show him or her as beneficent by establishing a transitory identification. Thus, empathy is crucial for social competence and an engagement of cooperativeness to help. Empathy as an understanding of the mental states of others draws on profound intuitive capacities enabling the richness of experience grasped. Intuitive “seeing” beyond words is fundamental. Empathy is the ultimate development of refined emotional grasping—the epitome of emotional knowing, intelligence, and literacy. Integral empathy comprises the optimal refinement of emotions for the effective comprehension of self-experience and that of others.
5.7. Transparency
Transparency implies authenticity and honesty. It reflects the level of perceived understandability, completeness, and correctness in communicational discourse. Transparency is an essential value and strength for physicians and the healthcare organizations in which they work. Transparency first centers on personal transparency—a self-awareness of one's emotions, thoughts, motives, and intentions. This core understanding more easily facilitates interpersonal transparency. A thorough discussion of transparency is essential for physicians, leadership, and the burnout syndrome. Dilemmas reaching impasse proportions have a core of opaqueness that intervening with transparency could attenuate.
Transparency is both a communication and an information transfer activity. Transparency as a frank exchange is interpersonal interfacing within
organizations, notably relevant in healthcare. Frank discussions presume belief in the reliability, truth, ability, or strength of someone or something. Transparent communications are revealed disclosures of valuable information aiming for open access and accessibility toward decision-making. They minimize opaque transfers. Transparency reflects leadership. It is the organization's consistency with its values. This openness promotes a working culture supporting accountability and a mutually shared, responsible exchange of ideas.
Communicational transparency associates itself with organizational trust, company buy-in, and information usefulness. This lucid directness is especially relevant regarding employee-employer trust. Two chief determinants of the trustworthiness of communication, mainly from organizations, are understandability and completeness. Data integrity accounts for company buy-in and information usefulness based on perceptions of organizational trust.
The Latin etymology of transparency is twofold: trāns meaning “across” or “through” and pāreō meaning “be seen.” Definitions of transparent also range from a transparent object having the property of transmitting light without appreciable scattering to understanding the intentions of the sender. The latter definition is reminiscent of the meaning of the cognitive dimension of empathy, perspective-taking.
Authentic integrity as wholeness embraces transparency in the psychological sense of having a sound ability to engage in a variety of differing perspectives. Doing this assumes mindfulness of inclusive emotionality and acceptance of a view that may be contrary or opposing. This openness prevents triggering avoidance or rejection. Maintaining a mindful approach works with other professional values such as collaboration and respect. Autonomy in the service of achieving rational conclusions, excellence, and service to safe and high-quality treatment in patient healthcare must embrace respectful collaboration.
Transparency entails relevant quality information in institutional communications and organizational behavior. Transparency in hospitals and universities reflects the degree to which data are disclosed timely, their level of clarity and understandability, and their consistent accuracy. Its ease of being perceived determines the level of transparency in systems.
Transparency is the level of perceived completeness (i.e., disclosure), correctness (i.e., accuracy), and understandability (i.e., clarity) in messages, documents, and other institutional communications. Completeness is the perceived quantity of information in messages or other contacts and the availability of that information to interested parties. Correctness is the degree to which material claims truthfully reflect qualifications about their perceived validity. Understandability is the extent to which representations are designed in ways clear to pivotal audiences.
Organizations and employment services often comment that employees do not quit their jobs, they “quit their bosses.” Therefore, in building stable workplace relationships secure and enduring, trust takes center stage. Keeping employees involved and up to date with continuing, transparent communications about organizational happenings are crucial because this enhances trust.
Transparency creates better engagement of employees with organizational priorities. Employee engagement, with transparency, means looking at and comprehending the big picture and understanding individual roles within it. This comprehensive perspective is done without difficulty when employers align themselves with their workforce and practice transparency in the workplace. Transparent leadership results in employees who understand the company vision and how efforts help to achieve company-wide goals. When leaders are transparent, problems are more quickly resolved. Being open and honest about system problems maintains an attitude of authenticity. Therefore, employees can share in helping to find solutions.
An organizational culture such as healthcare that values transparency in the workplace generates engaged physicians. It does not confine vital information (e.g., organizational goals, performance metrics, and resource utilization plans) to a small circle of executives. Democratic information sharing characterizes high-value transparent enterprises. These organizations drive participation and engagement at all levels, leveraging 100% of their knowledge capital to make better decisions.
Transparent enterprises encourage employees to see how their contributions fit the bigger picture. Aligning input with impact is the smartest way to drive employee investment. Real-time applicability is not just the basis for growth. Maintaining and supporting valued, talented professionals, notably physicians, are more valuable “capital” (Clapp-Smith, Vogelgesang, & Avery, 2009). This profound sense of respect is critical for survival and improving quality healthcare. Evolving a transparent enterprise is a central concern for organizational leaders because they determine how their culture develops. Thus, it is advisable for professional leaders of physicians to commit to changing their organizational structure. Hierarchical and centralized to flatter and more democratic is optimal. This equality leveling helps build trust in the workplace.
Organizational alignment with physicians means engaging physicians in decision-making directly affecting them. Paying careful attention to professional working relationships enhances staff morale. When an employee quits, it is often due to difficulties with their direct leadership. This phenomenon gives credence to the sensitive role a physician has with physician leaders, mentors, directors, and department heads. Good to excellent working relationships based on transparency are decisive to high reliability in safe and efficient healthcare on all levels.
Building trust involves affording staffers regular opportunities to give feedback and share decisions. If physicians are invited to contribute ideas, they are more likely to trust their leaders. Providing constructive feedback from leadership to other members of the team is also significant. It enormously helps to improve working relationships and healthcare quality. Employees perform better when managers give constructive feedback. Punishing physicians for failures is now outmoded. It seldom works. What improves performance is corrective guidance including clear-cut positive discussions about errors and delivering the feedback needed to improve. For example, if an employee misses a deadline, exacting an immediate penalty may not be effective. Instead, discussing the details of the steps leading to went wrong avoids future errors. Teaching time management is crucial to error prevention and is a part of alert mindfulness.
Transparency in an organizational culture promotes consistency. This reliability is a feature of everyday mindfulness in action. Vague expectations are not mindful. Leaders and organizations need a thoughtful and well-prepared manifesto of stated values and professional guidelines including professional and ethical expectations. Learned Mindfulness contributes to this need. Allied with this is providing needed resources and readily available guidance and mentoring. An adequate reward system for accomplishments complements this. Adhering to them promotes transparency. Physicians who experience burnout raise these issues and strive to collaborate with leadership for workable solutions.
Transparency is specially reinforced when leaders plainly communicate during the decision-making processes and admit mistakes made. Maintaining transparency by encouraging managers and employees to generate accurate presentations works well in optimally functioning work cultures. Making information, data, and assessments about decisions readily available supports optimal cultures. These mindful guidelines reflect transparency and support values engaging physicians and aligning leadership.
Last, creating a culture of a community of professionals who value mindfulness, authenticity, integrity, empathy, and teamwork is crucial. This mindset promotes a collaborative atmosphere accomplishing more than an organization with a competitive environment. Instead of focusing on organizational hierarchies, encouraging leaders to align and work together with doctors to support physician engagement is the best. This partnership fosters closer bonds between those at the sharp end of clinical care and a mindful managerial alignment.
5.8. Personality
Understanding personality is crucial to understanding how to enhance integrity in mindful awareness. For physicians, in-depth working knowledge of oneself is core to adequate self-esteem, self-confidence, and sense of effective performance. These assets are character strength values countering proneness to burnout.
Human personality is complex. It is an organization of inherent traits, infantile temperament, early childhood attachment patterns, developing coping skills, and emotional defense mechanisms. Motivation and mental adaptation are central drivers organizing and reconfiguring the personality. Self-aware learning and proactive planning characterize, to varying degrees, adaptive progress.
Personality has an innate dispositional and social learning base. This complexity makes it difficult to categorize a person into “types” because the variety is immense. When so-called types are described, the primary, dispositional temperamental underpinnings of personality are being recognized, for example, avoidant, fearful, novelty seeking, affectionate, or persistent. The emotional cores driving these are their prominent markers. One's temperament, therefore, is a primary predisposition characterizing an individual's attitude and behavior throughout life. Personality, thus, is enormously fluid and flexible. This essential feature cannot be underestimated because it affords directions for change. In childhood, emerging personality patterns are discernible about age four and gradually merge across time. However, a porosity remains that makes changing on nonconscious and conscious levels real.
Another way of describing human personality is by using the classical “Big Five” model. The adult personality, rooted in early infantile temperamental proclivities, has been the subject of scientific investigation for many decades. The prevailing theory or model is the “Big Five,” a descriptive system of five factors or domains. Personality has a share of each of these five
components. Only one or two dominate. Personality refers to the relatively stable pattern of functionally interrelated processes including cognition, emotion, interpersonal relatedness, behavior, coping strategies, and emotional defenses (McCrae & Oliver, 1992). All people share the fundamental qualities forming personality.
The Big Five personality domains are (1) Openness to New Experiences, (2) Conscientiousness, (3) Extroversion or Positive Emotions, (4) Agreeableness, and (5) Neuroticism or Negative Emotions.
Child development textbooks (Ninivaggi, 2013) discuss and explain both temperament and the Big Five personality domains, their meaning, and significance. Their origins in childhood and emergence in adulthood review their relevance to mindfulness, integrity, and the life span.
Research has shown agreeableness and conscientiousness are the leading factors associated with mental health and well-being. Agreeableness includes features of personalities that are sympathetic, kind, affectionate, helpful, empathetic, cooperative, able and eager to share, friendly, and forgive others with compassion. Positive emotionality recognizes, works through, and diffuses envy, jealousy, vengeance, staunchly holding a grudge, and negative competitiveness (all under “neuroticism”). Conscientiousness denotes awareness of details, and their follow through. It includes being organized, responsible, reliable, watchful, and efficient. Tendencies to show self-discipline, act dutifully, exhibit ethical behaviors, aim for achievement, and show preplanned behavior without inordinate impulsivity are outstanding. Underlying themes include being self-directed, motivated, and cooperative. Successful physicians who engage in collaborative teamwork enhance agreeable and conscientious features in others.
Personality is one's personal “culture”—a performance style that is skill-based (i.e., built up through subliminal, implicit, automatic learning and memory), rule-based (i.e., built up through conscious trial-and-error experience), and knowledge-based (i.e., built up through conscious and intentional critical thinking). Emotions give an affective tone to the cognitive and physical gestures making up personality.
A critical dimension of personality is “mind.” This center of self is the nidus of communication both to self and others. In Chapter 1, various theories of mind and thinking were discussed to show how modern psychiatry understands the brain's transformation of its processes into meaningful experiences. Chapter 3 added a model of emotional intelligence. These theories approximate what evidence-based and evidence-informed data have contributed to this ever-evolving wealth of making sense of the human mind. Knowing human mentation more significantly is still unfolding.
When using our minds to engage with one another, this communication reflects the capacity for interpersonal and social perspective-taking and empathy. This social communication is a core faculty. It humanizes individuals and civilizes larger groups to behave with one another and with others in understanding, cooperative, and nondestructive ways. The center of the biomental self is the brain-mind. Chapter 1 discussed the biomental conceptualization. “Biomental” is the shorthand term for the self as an integrating mindful person. It functions as the executive “problem identifier-solver.” In healthy people, emphasis in thinking about problem situations shifts raw guilt and blame toward more constructive frameworks asking: “Why did I act this way and how can I refine my thinking and feeling to perform in more ethical, just, and beneficent ways?”
A healthy personality is stable—cause and effect are dependable and consistent. This stability becomes increasingly reliable. Reliability denotes consistency, resilience, dynamic stability, and minimizing and eliminating errors and adverse events. Its default homeostasis entails pause, think, then act, review, and refine. These capacities reflect developing a sense of integrity (West et al., 2006).
Reliability is the probability of a system, structure, component, process, or person successfully and consistently providing the intended function. Reliability emanates from trust in oneself as being good, worthwhile, sound, and having value. A practical feature of reliability is the capacity for mood maintenance when faced with ambiguous and stressful events. Safe values and resultant behaviors expect the “unexpected.” Mindfulness emphasizes this “situational awareness” with its core of remembering how the present may differ from expectations of what should be. Mindfulness enhances emotional equanimity and mental equipoise in the face of change.
Situational awareness and detecting subtle “errors-in-the-making” is high reliability. Seemingly “negligible” near misses, amplifying them, and correcting them before they become accidents or disasters is mindful, high-reliable performance. The situational context involves influences from social and physical environments. Maintaining a safe environment is the uppermost priority. People with a significant concern for improvement hold this dear. Personal values offer a compass for an orientation toward concerns that count.
5.8.1. Values
Values denote chosen beliefs and their practice. One strives to attain values as they are perceived to have intrinsic worth, relevant purpose, and meaning. They are life-relevant orientations. Along the course of personality development, values emerge, sometimes consciously, often unwittingly. Values as beliefs and mindsets have many implicit nonconscious origins. Nonconscious changing both emotional and cognitive contribute to forming values across life. They then incorporate into the framework of one's personality, structure its form, and direct its functions. Values act as reference points. Values hold meaning ranging from abstract to more concrete with overlaps. An organization's values drive vision and mission statements.
As physicians, values are crucial. They become integrated into belief systems. As part of professional healthcare, values are guiding principles going forward. As the foundation for a healthcare's culture, values translate to value statements. These potently set the direction and tone for the collaborative healthcare team from clinicians to leaders. They affect the character of patient safety and quality care.
Values, value statements, and transparency demand alignment. This confluence empowers providers to know, understand, and engage in meaningful ways. Because transparency assumes honesty, openness, completeness, clarity, and timely involvement, transparency reinforces integrity. Both physicians and leadership must take part in this transactional integrity building. Physicians hold in high esteem a medical workplace behaving as a willing “change partner.” Core values include safety, avoiding harm, seeking pleasure while considering consequences, pausing before acting, treating others fairly and justly, nonviolent conflict resolution, attitudes showing compassion, rational mercy, helping, and justly forgiving a wrong. Core values are more than priorities. These mindsets must endure as mindful orientations.
Biases, prejudices, and preferences can also contain values. Thus, values may be constructive or toward destructive aims. Their content derives from multiple sources: genetics, upbringing, learning, society, culture, habit, and choice. As greater judicious self-efficacy unfolds, values may become more consciously considered, updated, decided on, refined, nuanced, and commensurate with one's current life situation, needs, and social culture. Values have the ability to change and update based on learning from experience and mindful emotion comprehension.
5.8.2. 24 Character Strengths
The field of Positive Psychology with its contributions from distinguished psychologists, Christopher Peterson and Martin Seligman (2004) and Ryan Niemiec (2012, 2013), has done much to classify character strengths and virtues to improve well-being. The approach is laudatory and useful, providing an educational framework for use by itself and as part of other wellness curriculums.
Character strengths have been proposed to deal with the ever-occurring obstacles challenging maintaining any mindfulness or meditation practice. Naturally encountered barriers include mind wandering, boredom, physical discomfort, distraction by external events such as noise or sound, and even difficulty with an adequate commitment to a practice schedule. Helpful character strengths evoke perseverance followed by an openness to fresh experiences and maintaining feelings of zest while seeing the broader perspective of endeavors. Character strength enthusiasts ally with this. They “decenter” and avoid rigidly identifying with events that at first present challenges eliciting avoidance.
Character strengths are values supplying purpose and meaning guiding behavior. These strengths are foundations for mindfulness, emotional literacy, and character resilience to face and recover from stress in health-promoting ways. Character strengths derive from six classes of virtues defined as abstract, ideal, humanistic pursuits aiming toward excellence.
A list of the six classes of virtues with their respective 24 character strengths, values, and psychological subtraits follows. They are authentic integrity principles:
Other features of these integrity traits include several qualities. Each of these character strengths has dimensional subtraits believed to be stable across time and varying situations. Each influences one another. They are valued both alone and recognized and appreciated in most cultures. The strengths appear as noncontroversial and apolitical. Their proponents state these human strengths can act as buffers against mental disorders. One may identify their unique character strengths by consulting www.viasurvey.org.
5.9. The High-Reliability Personality
This section focuses on the source from which an array of diverse emotions and fundamental attitudes such as love, affection, empathy, gratitude, poise, admiration, cooperation, agreeableness, and effective teamwork arises—authentic integrity. The collaborative framework from which these emerge is “personality.” This analysis emphasizes reliability and values. A downstream goal is behavior change.
Behavior change must always begin with self-change; the first step is mindful self-reflection. Self-reflection entails introspection and retrospective review of attitudes and behaviors needing improvement. If this stirs the motivation for self-improvement, the process of behavior change has been launched—but only begun. It cannot sustain itself on autopilot for long but requires a persistence calling for curiosity, exploration, and refinement. It may be OK not to know; not to find out is not. Using critical thinking launches a conscious, effortful process of change. Nonconscious changing parallels this in subliminal ways. Changing behaviors entails setting expectations, educating oneself, building implementation skills, and reinforcing accountability. Among the many benefits of mindful living, personality refinement toward more in-depth high reliability can expand.
High reliability comprises psychological and behavioral facets contributing to correct performance in consistent, stable, sustainable, and dependable ways to minimize serious safety errors thus maximizing overall safety. Correct, intended, successful performance of one's work function and role expectations result. Errors and near miss errors become less likely; thus, the physician and the workforce guard against being disabled.
High-reliability personalities are mindful of nonobvious, latent errors waiting to happen. These layers of risk contribute to near miss accidents in healthcare. Actionable correction follows. Individual work helps the self—at first—and then has a halo effect in engaging others. This resilience occurs if teamwork—active teaming—becomes a dedicated value along the line of collaborative self-improvement.
5.9.1. Becoming a High-Reliability Person: Action Plan
An action plan is the scaffolding for problem-solving. On a foundation of mindfulness, critical thinking and focused executive attention engage motivation and abilities toward action. These steps comprise identifying problems, assigning ownership to a problem solver, setting goals, outlining steps toward goal accomplishment, and charting timelines for tracking progress and resolution. Becoming a high-reliability person comprises these steps. As mentioned, the wish to improve must first involve becoming one's personal leader. This mindful self-agency entails taking conscious ownership and purposeful accountability thus becoming the identified problem solver.
Next, mindful self-reflection on one's core values is essential (Ninivaggi, 2017, pp. 289–297). Seeing in what ways these facilitate or impede one from attaining a higher QoL for both self and others is a useful metric reflecting progress. Looking outside the self for guidance, direction, and mentoring from others deemed to have more significant expertise is always useful, if not essential, to promote further advancement.
Authentically inspired motivation drives action. Reasoned belief (i.e., judiciously regarding one's set of values) is the background for effective performance. True belief drives motivation, then intention, then action. Transformational motivation is both personal and social—maximizing safety for self and one's team. Motivation is essential. It requires an authentic belief in the values described in this discussion. Without genuine, heartfelt motivation, traction and progress are difficult. With intrinsic motivation and enthusiasm, advancement and success become adventurous and risk-avoidant.
In these endeavors, good to excellent communication skills is a needed asset. One must pause, think
before speaking, speak slowly and meaningfully, pause again, listen carefully to the meaning others are trying to convey, foster informative, cooperative dialogues, ask for clarification when necessary, and give constructive, positive feedback. The ratio of positive to negative feedback should be five positive statements to one correctively reframing comment, and always in a tempered, helpful tone. “Negative” feedback should be a constructive, corrective, educational redirection toward improving performance.
Last, human error in any endeavor is typical. Honest mistakes are inadvertent slips. Identifying these and applying self-correction—emphasizing what is better, reasonable, and low-risk is fair and just self-improvement. In striving for behavior change, realizing that one's values are guidelines means goals to strive toward, but goals normatively and often forgotten.
An excellent example is hand washing. No one can deny conscientious hand washing, and using hand sanitizers is universally beneficial. Routinely doing this is a safety requisite. Implementing safe behaviors integrate themselves best when titrated upward slowly and gradually.
Significant tools to safeguard a trajectory toward high reliability and core value success entail an action plan based on (1) maintaining a sense of conscientiousness active through time: self-observation, reasonable self-reflection, self-assessment, and self-realignment toward self-improvement and (2) maintaining perspective-taking and agreeable cooperativeness whose aim is team improvement, an embedded social engagement.
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