ASHP InterSections ASHP InterSections

July 11, 2019

ASHP, Well-Being, and You

Dear colleagues,

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

There is a great deal of national attention on the issue of healthcare provider burnout, which is affecting our pharmacists, pharmacy residents, student pharmacists, and pharmacy technicians at unprecedented rates.

As many of you know, burnout is a syndrome characterized by emotional exhaustion, depersonalization, and low personal accomplishment. Moreover, there is a significant correlation between poor well-being of healthcare professionals and worsening patient safety. In May 2019, the World Health Organization clarified that burnout is an occupational phenomenon caused by chronic workplace stress that needs to be monitored and better understood. It’s also an expensive problem. Research conducted at the Mayo Clinic estimates that burnout costs the U.S. healthcare system $4.6 billion every year.

A healthy and thriving clinician workforce is essential to ensure optimal patient health outcomes and safety. That’s why ASHP has been a leader in well-being and resilience (WBR) for nearly 40 years. We first addressed this as a critical practice issue in a 1982 AJHP article that explores recognizing, reversing, and preventing hospital pharmacist burnout.

In 2017, ASHP became the pharmacy sponsoring organization of the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience. This four-year initiative is raising the visibility of clinician burnout, improving baseline understanding of challenges to clinician well-being, and advancing evidence-based solutions to improve patient care by caring for the caregiver. ASHP is a member of the NAM Action Collaborative Conceptual Model Working Group which is charged with identifying factors that affect clinician well-being and resilience. The goal is to create urgency and understanding of the issue while being careful not to oversimplify the complexity of it. In addition, we recently participated in a NAM meeting in Chicago, focused on redesigning the clinical learning environment to enhance well-being. ASHP member Kofi Andoh, a rising third-year student at Notre Dame of Maryland University School of Pharmacy in Baltimore, was one of five participants selected to share his perspective on the stressful demands placed on students.

To further assess the issue of workplace burnout, ASHP recently conducted a national survey of nearly 2,000 people with help from The Harris Poll. The results show that almost three-quarters (74%) of respondents are concerned about burnout among healthcare professionals. Furthermore, one in four Americans surveyed believes hospital pharmacists (26%) and retail pharmacists (25%) are experiencing burnout. These data show that pharmacy workforce stress is visible to our patients, which is why ASHP has made addressing pharmacy workforce well-being a top priority.

In June 2018, the ASHP House of Delegates approved a new professional policy on clinician well-being and resilience. At our Summer Meetings last month, the House of Delegates reinforced our commitment to WBR by approving a new policy on suicide awareness and prevention, the most tragic and extreme consequence of burnout. The policy recognizes the vital role of the pharmacy workforce in suicide prevention, and the importance of maintaining the health and well-being of both our patients and our colleagues.

June was National Employee Well-Being Month, and in honor of Global Wellness Day on June 8, we launched an online portal – Wellbeing & You – as a resource for pharmacists, pharmacy residents, student pharmacists, and pharmacy technicians. This website is also a place for colleagues to share their experiences with burnout and to pledge their commitment to strengthening personal and workplace resilience. I encourage you to visit the site to learn about burnout, view ASHP’s webinars on WBR, check out the ASHP State Affiliate Toolkit, and contribute to the ASHP Connect Community on Clinician Well-Being and Resilience.

Join ASHP’s movement to combat burnout by sharing your stories and taking the pledge. Keep your eye out for #WellbeingWednesday on social media, where we’ll offer even more WBR tips, member stories, and resources.

Please know that ASHP is here to support you in your career in every way we can and that we will continue to provide you with valuable WBR resources. Thank you for being a member of ASHP, and for everything you do for your patients.

Sincerely,
Paul

June 28, 2019

Advocacy in Action: Utah Pharmacists Make Contraceptive Provision a Reality

David C. Young, Pharm.D.

A NEW LAW THAT WILL CHANGE the way Utah pharmacists work began with a question that was part of a classroom assignment: “If you had one wish for a pharmacy dream bill, what would it be?” At the time, Wilson D. Pace, Pharm.D., was a University of Utah College of Pharmacy graduate student in the school’s leadership and advocacy class taught by David C. Young, Pharm.D. He immediately thought of the need for broader access to contraception and how pharmacists can fill that gap.

This issue hit home for Dr. Pace because his wife had experienced problems obtaining a prescription for a contraceptive from an obstetrician since a shortage of providers made her wait several months to get an appointment. As he further looked into the challenges women face getting contraception in a timely manner, he found that his wife’s experience was far from unique. As a result, Dr. Pace came to the conclusion that if there were a law that gave pharmacists the power to provide contraception without a new prescription, it would go a long way toward advancing women’s health in the state. This idea moved Dr. Pace to seek out other student pharmacists to form a working group. Together they started an advocacy campaign that would make this dream bill a reality.

Garnering Support from Medical Stakeholders

Wilson D. Pace, Pharm.D.

Dr. Pace and his working group began by reaching out to pharmacist mentors about their desire to take action on this idea in the hopes that the legislature would act on it. The pharmacists discussed how the advocacy process would work, and based on his prior experience, Dr. Young knew they first had to gain the support of various stakeholders in the state. Although groups such as Utah Board of Pharmacy, professional pharmacy organizations, the Utah Medical Association, and nursing organizations agreed that it was essential to address the issues women face while trying to obtain contraceptives, they had yet to agree on the exact role pharmacists should play in solving them. Specifically, whether or not pharmacists should be able to provide contraceptives without a prescription from a doctor.

As a result, Dr. Pace’s original vision of pharmacists having prescribing power was a point of contention during the discussions and ultimately something on which Drs. Pace and Young needed to compromise to get the groups’ support and move forward. In the end, the stakeholders all decided it was best for pharmacists not to have full prescribing power, but to be able to provide contraception without a prescription on a limited basis.

“We didn’t sit around the fire singing ‘Kumbaya,’” said Dr. Young. “We had very healthy, open, and honest discussions about what the idea for a new law meant, how we were going to accomplish it, and how we were going to work together.”

Hammering Out the Details

After completing discussions with all of the healthcare stakeholders and getting their support, it was time to work with the legislative research office to refine the language of the bill. This was a complicated and lengthy process because it required that every interested group sign off on each revision that was made to the draft.

“Any tiny change had to have buy-in from all of the different groups,” Dr. Pace said. “So the next big step was working out all the nuts and bolts and then coordinating to make sure everybody was on the same page.”

Legislative Support

Karen M. Gunning, Pharm.D., BCPS

Once the language of the bill was finalized, it was time to get legislative support. Finding the right sponsor was vital. Sen. Todd Weiler agreed to sponsor the bill, and Rep. Ray Ward, M.D., a family physician with a history of working on legislation related to improving public health, co-sponsored the bill. “We actually had no opposition. We were concerned that there might be different groups testifying against us or they would push back, but there was none of that,” said Dr. Pace.

The process went so smoothly that there were no opposing testimony delivered when the bill was in committee and no opposing votes in the Utah Legislature. In March, Gov. Gary Herbert signed S.B. 184.

Thanks to the efforts of Dr. Pace, the other student pharmacists involved, and guidance from their mentors, women in Utah can now get contraception from pharmacists for two years before being required to check in with a doctor for a new prescription.

“I believe this law will allow pharmacists in the state of Utah to demonstrate the value they bring to patient care, and also the team-based approach to care that pharmacists have,” said Karen M. Gunning, Pharm.D., BCPS, a Professor (Clinical) at the University of Utah College of Pharmacy, who provided expert knowledge and support to Drs. Pace and Young as they navigated the legislative process. “There is great potential for pharmacists to work with medical providers in their communities to improve access, and to ensure that patients who need contraceptive care from a non-pharmacist medical provider are referred promptly to one.”

A Future of Advocacy

With this significant advocacy win under his belt, Dr. Pace admits that he’s been bitten by the political bug and will continue working toward furthering the interests of the pharmacy profession. Drs. Pace and Young, now co-chairs in the legislative committee of the Utah ASHP state affiliate, have already begun exploring new issues to tackle in the current legislative session.

“Whatever job I end up being in, I can’t imagine not being involved in some way in the advocacy process,” Dr. Pace said.

Although at first blush many pharmacists may shy away from doing advocacy work, Dr. Young urges all pharmacy professionals to consider getting involved because of the tremendous impact it can have on the way they work in their state.

“If you’re not interested in advocating for your profession, other people may change the laws and rules on you, and you may not like it,” he said. “If you want to control your outcomes, you’ve got to get involved. The best way to control your destiny is to create it — and that’s what happened with this bill.”

 

By Kenya McCullum

 

May 20, 2019

ASHP is Committed to Ensuring that all Medications are Accessible, Safe, and Effective

Dear Colleagues,

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Many of you may have seen recent stories in the media questioning the accessibility and safety of generic drugs, including those manufactured overseas. These stories, and others like them, could lead to fear and confusion among patients, potentially leading to adherence issues and poor health outcomes. As the medication safety experts on the front lines with patients, it is critical that our members know that ASHP is committed to working with you, our partners in government, and other key stakeholders to help ensure that medications are accessible, safe, and effective, regardless of origin.

We have been in recent contact with FDA leaders to ensure that they fully appreciate the concerns that ASHP and our 50,000 members have regarding the absolute need for quality generic medications, and the need for the entire pharmaceutical industry to adhere to standards of quality. ASHP will continue to meet with FDA, Congress, industry leaders, and other stakeholders to help assure the public that the medications they take are safe and effective, and will strongly advocate for any changes that may need to be made to law or regulation to support that goal.

On Friday, the FDA’s Office of Regulatory Affairs issued a statement that reaffirms their commitment to safety and quality and outlines their risk-based approach to global inspections.

The safety and efficacy of medications is central to ASHP’s patient care and public health mission and we have championed these issues in our ongoing work in a number of areas, including sterile compounding and drug shortages. We enjoy a close partnership with officials at the Food and Drug Administration (FDA) and, as a longtime leader and Board member in the Alliance for a Stronger FDA, have been a vocal advocate for sufficient federal appropriations to the agency so that it has the resources necessary to ensure the safety and effectiveness of medical and other FDA-regulated products.

We will continue to be in close contact with the FDA and will keep you informed on steps they are taking to ensure the quality and safety of generic medications in light of recent stories in the media.

ASHP has also long been at the forefront of efforts to address escalating drug prices, including generic medications, and their impact on pharmacy practice and patient outcomes.

ASHP is a lead member of the Steering Committee for the Campaign for Sustainable Drug Pricing (CSRxP) and is actively involved in other collaborative efforts to identify bipartisan solutions to address skyrocketing drug prices and provide more affordable choices for patients. ASHP strongly supports the need for reforms to address the underlying causes of high drug prices, including increased transparency, competition, and value.

In addition to our work with CSRxP, ASHP is actively engaging Congress on critical issues related to access and affordability of medications. ASHP has submitted 11 statements related to drug pricing to congressional Committees over the past year, and in just this month alone, ASHP representatives have met with two dozen congressional offices, representing the voices of our members on the tremendous impact of escalating drug prices.

Late last week the House of Representatives passed legislation to reduce the cost of generic drugs, by prohibiting brand manufacturers from taking steps to keep generic products from the marketplace, including barring pay for delay tactics, allowing generic manufacturers access to samples of branded products, and removing regulatory barriers to the launch of multiple versions of a generic product.

ASHP is supportive of the drug pricing provisions included in H.R. 987 as they represent important steps to promote competition and ensure that generic drugs reach patients sooner. In the weeks and months ahead, we will take this message to the U.S. Senate and advocate for drug pricing legislation.

We will continue to advocate for policies and regulatory solutions that support safe, effective, and accessible medications for our patients, and will provide updates on new activities, initiatives, and outcomes from our efforts as available. If you have any questions, please feel free to contact ASHP’s Government Relations team. Further, we will plan to keep you updated on this issue and others as new developments arise.  Thank you for being a member of ASHP, and for everything you do for your patients.

Sincerely,

Paul

 

May 14, 2019

Mindfulness and Improv Help Pharmacy Students Cope with Burnout

Anne Graff LaDisa, Pharm.D., BCPS, uses improv to teach student pharmacists about effective communication skills.

IN A QUIET LOW-LIT CLASSROOM, students sit comfortably with their eyes closed and their spines straight. They bring attention to their breathing and imagine that they have a balloon in their stomachs. Every time they breathe in, the balloon inflates. Every time they breathe out, the balloon deflates. With every exhale, the students imagine their daily stresses and frustrations floating away. This isn’t a mindfulness retreat at some hideaway resort or the calming conclusion of a power yoga class. It’s a pharmacy course at the Concordia University-Wisconsin School of Pharmacy, where two professors are teaching students to use mindfulness to cope with burnout both during school and throughout their future careers.

According to Christina Martin, Pharm.D., M.S., Director of Membership Forums for ASHP, pharmacist burnout is a serious concern. A 2018 study published in AJHP reported that more than half of health-system pharmacists surveyed felt a high degree of burnout. In addition, a recent salary survey found that two-thirds of pharmacists experienced increased job stress over the previous year, and that 72 percent said workloads increased from the year before.

“When healthcare providers feel stressed, it can also have an impact on their patients,” said Dr. Martin. Burnout is associated with more medical errors and poorer patient safety outcomes, according to the Agency for Healthcare Research and Quality. “We really have to care for the caregiver and ensure that we’re providing resources and support to those who are caring for patients in very chaotic healthcare times,” she added.

Mindfulness in the Classroom

Elizabeth Buckley, Pharm.D., CDE

Elizabeth Buckley, Pharm.D., CDE, Associate Professor of Pharmacy at Concordia University-Wisconsin School of Pharmacy, often includes the balloon-in-the-stomach exercise in her classes. She first introduced it while teaching a diabetes elective for third-year pharmacy students in the spring of 2017 — and she saw immediate changes. It made a huge difference “on attitude, on calmness, on collegiality,” she said.

It worked so well that in the fall of 2018, she added it to her weekly lectures in the Applied Patient Care I course, which is for first-year pharmacy students. “The tone of the class changed in a significant way. Everyone settled down and the discussion was more robust,” she said. “The mindfulness exercise centered me, and it centered the class.”

Dr. Buckley hopes that teaching pharmacy students mindfulness now will help them avoid burnout in the future. “If you’re going to be in a career where you care for other people, you have to figure out self-care in order to be good at being a clinician,” she said.

Improv Shakes Things Up

Anne Graff LaDisa, Pharm.D., BCPS, Associate Professor of Pharmacy at Concordia University-Wisconsin School of Pharmacy, began teaching an improvisational class to first-year students to help bolster communication and teamwork skills. Improv is a theatrical technique where the characters and dialog in scene or story are made up on the spot. Communication skills learned through improv can help a student become a good pharmacist, she noted. Although she didn’t introduce improv classes for pharmacy students with combating burnout in mind, she explained that improv exercises allow students to be creative and break up a school routine.

Anne Graff LaDisa, Pharm.D., BCPS

Dr. LaDisa began taking improv classes herself in 2003. When she discovered that medical schools were using improv to teach and improve medical students’ communications skills, she became intrigued — even more so when she learned that the University of Arizona has been using improv in its pharmacy school since 2004.

She introduced improv to an existing course in 2015, then taught her first stand-alone elective course for first-, second-, and third-year students in 2017. At the beginning of every class, she reviews the rules of improv, which include always saying “yes, and …” to what your partner is trying to communicate, emphasizing the here and now, being specific, and focusing on characters and relationships.

In Dr. LaDisa’s class, a two-person scene requires the students to follow the rules of improv and may involve a scenario unrelated to healthcare. After the students complete the improv exercise, she asks them questions about how they felt about the activity – what things they found challenging and what skills they felt they had to use to be successful. Finally, the students talk about how to apply those skills to clinical pharmacy practice.

Role-playing in a healthcare or social setting can help pharmacy students improve collaboration and teamwork skills. “Improv training gives students an advantage when it comes to communication, which is a critical skill for all pharmacists,” she said.

By Jen A. Miller

 

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April 30, 2019

ASHP Joins the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic as a Sponsoring Member

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

I AM PLEASED TO SHARE WITH YOU THAT ASHP has become a sponsoring member of the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic. The other Collaborative Sponsors are:

  • Accreditation Council for Graduate Medical Education
  • Aetna
  • American Hospital Association
  • American Medical Association
  • Arnold Ventures
  • Association of American Medical Colleges
  • Centers for Disease Control and Prevention
  • CDC Foundation
  • Centers for Medicare and Medicaid Services
  • Council of Medical Specialty Societies
  • Federation of State Medical Boards
  • HCA Healthcare
  • National Institute on Drug Abuse
  • Robert Wood Johnson Foundation
  • Substance Abuse and Mental Health Services Administration

The mission of the Action Collaborative is to “convene and catalyze public, private, and non-profit stakeholders to develop, curate, and disseminate multi-sector solutions designed to reduce opioid misuse and improve outcomes for individuals, families, and communities affected by the opioid crisis.”

ASHP and our 50,000 members who serve as direct patient care providers in hospitals, health systems, rehabilitation centers and ambulatory clinics will bring a great deal of expertise to the Collaborative and play a major role to mitigate and end the opioid epidemic on behalf of our patients and communities, while ensuring that our patients receive appropriate pain management.

ASHP will serve on the Action Collaborative’s Opioid Prescribing Guidelines and Evidence Standards Working Group, and will also be providing insights and expertise to the Collaborative’s Health Professional Education and Training Working Group; Prevention, Treatment, and Recovery Services Working Group; and Research, Data, and Metrics Needs Working Group.  As part of our initial work with the Collaborative, we have made several commitments that include but are not limited to:

  • Creation and dissemination of patient and prescriber education on pain management and opioid abuse mitigation best practices.
  • Enhanced patient access to evidence-based treatment for opioid use disorder through increased utilization of pharmacists on the healthcare team.
  • Standardization of a framework for pain stewardship to coordinate pain management, opioid prescribing, and use of non-opioid therapies.
  • Coordination of care among patients, caregivers, and healthcare professionals through the use of standardized patient-specific pain management and substance use disorder treatment plans.
  • Improvement of interoperability, artificial intelligence, and clinical decision support in healthcare information systems.
  • Identification of performance and quality metrics to assess impact.
  • Stimulating research on pain and opioid use disorders and their respective pharmacologic and non-pharmacologic treatments.
  • Advancing efforts to prepare the pharmacy workforce through pharmacy education and professional development programs.

ASHP has also been actively involved in numerous public and private sector efforts to address the opioid crisis through the leadership of pharmacists and has worked diligently across a number of fronts to identify enduring solutions, including advocating for better access to medication-assisted treatment. We had the pleasure of working with the White House Office of National Drug Control Policy and attending the ceremony to commemorate the signing of H.R. 6, the “SUPPORT for Patients and Communities Act,” bipartisan legislation to combat the opioid crisis in October. ASHP will also continue to pursue policies that further support the vital roles pharmacists play as patient care providers in the treatment of acute and chronic conditions, including opioid and substance-use disorders.

You can find additional ASHP resources on our website, including:

We look forward to sharing more about our work with the National Academy of Medicine Action Collaborative on Countering the U.S. Opioid Epidemic and on ASHP’s ongoing efforts surrounding the opioid crisis, including creating various tools, education, and resources to support you in your practice.

Thank you for being a member of ASHP, and for everything that you do for your patients.

Sincerely,

Paul

April 22, 2019

Overcoming Burnout: Advice from Your Pharmacy Peers

MORE THAN 50 PERCENT OF PHARMACISTS WHO PRACTICE IN ACUTE AND AMBULATORY CARE SETTINGS EXPERIENCE BURNOUT, which is characterized by exhaustion, cynicism, and/or a low sense of personal accomplishment. While burnout is devastating on a personal level, the syndrome can also affect a pharmacist’s ability to fulfill their duties, which can negatively impact patient care.

 

Often when we have a problem, we turn to our peers for support and guidance. ASHP InterSections asked a student pharmacist, a new practitioner, and a pharmacy leader to share their thoughts on resilience and burnout. Here’s their advice.

 

ASHP InterSections: What have you found most challenging about thriving at work or school?

 

Sydney Stiener

Sydney Stiener

ASHP member since 2015

Student Pharmacist and Pharm.D. Candidate (May 2019)

University of Wisconsin-Madison School of Pharmacy

“The biggest challenge for me has been finding the right balance between meeting school-related priorities and dedicating myself to hobbies that help me recharge and be efficient and successful. As a pharmacy student pursuing a residency and facing a competitive job market, there is a constant expectation to do more. On top of rigorous course work and other demands of pharmacy school, students spend many hours a week involved in student organizations, taking on leadership positions, participating in research — and the list goes on and on. Beyond these extracurricular activities, it’s a challenge to find time to care for ourselves by doing things that make us happy outside of school. Without these things, it’s easy to lose perspective and forget the reasons you wanted to become a pharmacist in the first place.”

 

Shannon Kraus, Pharm.D., BCPS

Shannon Kraus, Pharm.D., BCPS

ASHP member since 2015

PGY1/PGY2 MS/Pharmacy Administration Resident

Riverside Methodist Hospital, Columbus, Ohio

“It’s been challenging to me as a new practitioner to balance providing quality care with the realities of needing to do so in a cost-effective way, both across the organization and within the pharmacy service line. For example, while I try to provide optimal patient care and work toward outcomes like decreased readmissions through pharmacist-led counseling at discharge, having limited resources has certainly tested my resilience.”

 

Paul Bush, Pharm.D., M.B.A., BCPS, FASHP

ASHP member since 1975

Chief Pharmacy Officer and HSPA/MS Residency Program Director

Duke University Hospital, Durham, N.C.

“I currently lead a large pharmacy program that includes 428 staff and complex pharmacy operations, so there are many moving parts that I need to be thinking about. It can be challenging to manage the many details and the demands of my job.”

 

ASHP InterSections: How do you ensure your well-being and resilience?

 

Stiener: “I can’t always control the challenges that can lead to symptoms of burnout but I can control my attitude toward those challenges. A philosophy that’s helped me bounce back from a bad exam grade, get through long hours of studying, learn from mistakes, and ultimately excel in my program is Hal Elrod’s 5-Minute Rule, which says it’s OK to be upset, angry, frustrated, or negative when something unfavorable happens to you, but you get only five minutes to feel that way. So, I allow myself five minutes to feel those emotions, but then I force myself to put it behind me, learn from it, and move on with my day with a positive attitude and a smile on my face.

 

“I also prioritize activities that make me happy and recharge my overall well-being, like running outside in the fresh air and spending time with friends and family.”

 

Dr. Kraus: “Every morning at 4 a.m., I fill up my resilience bucket by first reflecting on what I am grateful for from the previous day. After that, I go to my local fitness studio. Exercising strengthens me both physically and mentally.

 

“Throughout the day I try to spread my positive energy with my residency family. I’ve even developed Wellness Wednesday, where I send an email focused on physical, emotional, intellectual, spiritual, or financial health with the hope of providing others with an uplifting moment and helping them build resilience.”

 

Paul Bush, Pharm.D., M.B.A., BCPS, FASHP

Dr. Bush:I think the key to stepping up and leading in challenging situations is simply to stay focused. A book called The 7 Habits of Highly Effective People by Stephen Covey — and specifically the idea of putting first things first — has helped me get through the week and stay focused.

 

“I go full speed for five days a week, 10 hours a day, so recharging over the weekend with family is very important to maintaining well-being. During the week, I get on the treadmill for 20-30 minutes a day, which is both physically helpful and a good diversion. I also eat a healthy diet and try to sleep for seven hours a night. And I watch my favorite TV series and sports.”

 

ASHP InterSections: What advice would you give others in your position to help them thrive and rebound from burnout?

 

Stiener: “Surround yourself with positive and supportive friends, classmates, mentors, family members, and others who can see you through stressful times and help you maintain perspective. Also, make time for your own hobbies outside of school. It’s amazing how much easier it is to focus and stay engaged when you invest a little time in yourself.”

 

Dr. Kraus: “The triggers of burnout are often our own self-limiting beliefs. However, we can also choose to cultivate joy in our everyday life and remember that, as E.E. Cummings said, ‘The most wasted of all days is one without laughter.’”

 

Dr. Bush: “Give yourself time to recover from stressful events and reduce your workload when these things happen. Maintain a sense of hope, optimism, and self-efficacy and focus on feeling joy at work. Joyful activities such as ensuring patients have positive experiences and improving patient outcomes are healing, create connections, and add meaning and purpose. Make sure you have strategies for self-care and draw on your social safety nets and support from your organization and your peers.”

 

By David Wild

 

 

 

 

 

 

 

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