Mayo Clinic Uses SMART Approach to Enhance Caregiver Resiliency

Added on Apr 20, 2017

Mayo Clinic Uses SMART Approach to Enhance Caregiver Resiliency
By Diana Mahoney
Industry Edge April 2017

Realizing the toll that stress can take on the emotional and physical health of its workforce, Mayo Clinic has made it a priority to ensure that its care providers are trained with SMART tools for handling it.

SMART is the acronym for the Stress Management and Resiliency Training program developed by Dr. Amit Sood, professor of medicine at the Mayo Clinic College of Medicine, director of research and practice at the Mayo Clinic Complementary and Integrative Medicine Program and chair of the Mayo Mind Body Initiative. The structured program, which teaches self-care practices that build resiliency and reduce participants’ emotional and physical vulnerability to daily stress, is mandatory for all Mayo physicians, nurses and medical students enterprise-wide.

SMART is a mindfulness-based intervention focusing on the intentional act of paying attention in the present moment, without judgment. Unlike many mindfulness programs, which require protracted training and practice time—a limiting consideration for busy medical professionals—SMART can be delivered in a single 90-minute session, and daily commitment to SMART practices can be as short as five minutes, Dr. Sood explained.

The program is framed around three components: awareness, attention and attitude. To nurture awareness, participants are educated about the neuroscience and biology of stress. “It’s important to understand the connection between external reality, how we perceive that reality and how that perception influences us,” said Dr. Sood. “The truth is, there are a lot of optional stressors in life—things like spilled milk on the kitchen table, an extra patient load, and running late for an appointment. Why do these things cause so much stress in one person but not in another? Why are we not innately able to handle daily little annoyances in a more adaptive way?”

The answer, Dr. Sood explained, lies in the fact that our brains often function in a “wandering” mode. Rather than focusing on the present, we are constantly thinking about the tasks that lie ahead or the weight of a heavy workload, he said, which makes the present moment feel more burdensome than it actually is and contributes to catastrophizing, rumination, avoidance and fear—all of which lead to brain fatigue and stress.

This cycle can be deliberately interrupted by training one’s attention to focus on the present moment. The goal is to “counteract the mind’s instinctively restless and wandering nature and focus on the present moment in a relaxed, balanced way,” Dr. Sood said. Developing deep and sustained attention, or “intentional attention,” allows people to command their thoughts and shift their perspectives to detach from the negative. “When attention is deeper, your mind is less cluttered and has more bandwidth to reframe potentially stressful situations more quickly and to live more meaningfully,” he noted. On a professional level, achieving such a mindset helps providers reconnect to the meaning of their work and boosts engagement—which in turn influences patient care and organizational performance.1

One suggested SMART practice for training attention is a “morning gratitude” activity. “When you first wake up in the morning, rather than thinking about everything you have to get done, think about five people in your life who you are grateful for. Picture each of them in your mind and remind yourself of what they mean to you. In this way, you are choosing where to deploy your attention, and by doing that you are strengthening it, in the same way that you strengthen a muscle,” Dr. Sood said.

Attention training also lays the groundwork for cultivating emotional resilience, which, according to the attitude component of the SMART program, can be achieved through the active pursuit of the following five principles:

  1. Gratitude: recognizing and being thankful for all blessings, big and small
  2. Compassion: acknowledging others’ suffering and doing something to alleviate it, and acknowledging our own imperfections and loving ourselves despite them
  3. Acceptance: working to control what is controllable and accept what is out of one’s control, and being open to possibilities
  4. Higher Meaning: understanding one’s role in and contribution to the world
  5. Forgiveness: recognizing and respecting each person’s humanness and fallibility, and choosing to forgive as a gift to oneself and to others

In the SMART program, these five principles are structured as daily themes to make the practice feel more manageable. For example, Monday’s theme is gratitude, Tuesday’s is compassion, Wednesday’s is acceptance, Thursday’s is higher meaning and Friday’s is forgiveness.

So if it’s Monday and negative thoughts start creeping in, “focus on something you are grateful for, large or small. If something went wrong, focus on something that went right within what went wrong,” said Dr. Sood. “When we focus on things we are grateful for we feel full, and when we are full we are ready to give and are also better able to withstand adversity.”

The program offers various exercises that can help participants achieve moments of deep presence throughout the day, which makes them better equipped to withstand challenges and become more resilient. “The total time spent each day doing the program’s short exercises is five minutes,” Dr. Sood said, noting that the return on this time investment is a savings of one to two hours every day, thanks to better focus and less mind wandering.

Since the program’s inception, it has been evaluated in more than 20 clinical trials in various caregiver and patient populations, and the results have been overwhelmingly positive in terms of outcomes and feasibility.

In a pilot randomized clinical trial of the SMART intervention among faculty of Mayo’s Department of Radiology, for example, participation in the program resulted in statistically significant and clinically meaningful improvement in anxiety, stress, quality of life and mindful attention.2 In a separate study, researchers evaluated the feasibility of implementing SMART within a new nurse orientation program and determined that the intervention, which improved mindfulness and resilience scores in the study population and decreased levels of stress and anxiety, can be a valuable onboarding tool for new nurses.3

Similar results have been observed across the intervention trials. “In almost all of them, we were able to increase people’s resilience based on standard validating skills,” Dr. Sood said. Importantly, he added, follow-up data from faculty who have participated in the program collected by Mayo Clinic’s Office of Leadership and Organizational Development have shown that nearly all the participants consider the program to have been meaningful and helpful, and assessments of long-term outcomes have shown that the positive effects are sustained over time.

Taken together, these findings suggest that SMART is a valuable and promising tool for addressing the burnout epidemic plaguing health care providers nationally. More than half of all U.S. physicians exhibit signs of burnout, according to a recent Mayo Clinic survey.4 And multiple studies have identified stress and burnout to be major causes of distress among hospital nurses.5

Health care providers “deal with a lot of suffering and are also vulnerable to suffering,” Dr. Sood explained. “Many of us also struggle with work-life balance. These personal and professional issues lead to overtaxed brains, which in turn can limit our productivity, strain our relationships and keep us from feeling happy and fulfilled.

Because ours is an entirely different world than even a few decades ago, “we have to develop novel ways to manage the new stressors and pressure,” said Dr. Sood. “Programs like SMART are effective because they are realistic, practical and applicable to modern life.”

More information on Dr. Sood’s work in building resiliency capacity can be found on his website,

1“Achieving Excellence: The Convergence of Safety, Quality, Experience and Caregiver Engagement.” Press Ganey 2017 Strategic Insights.
Sood et al. “Stress Management and Resiliency Training (SMART) Program among Department of Radiology Faculty: A Pilot Randomized Clinical Trial.” Explore (NY). 2014 Nov–Dec; 10(6): 358–363.
Chesak, Sherry S., et al. “Enhancing Resilience among New Nurses: Feasibility and Efficacy of a Pilot Intervention.” The Ochsner Journal 15.1 (2015): 38–44. Print.
4Shanafelt, T.D., et al. “Longitudinal study evaluating the association between physician burnout and changes in professional work effort.” Mayo Clin Proc 2016; 91: 422–431.
5Holdren, P., D.P. Paul III, and A. Coustasse. “Burnout syndrome in hospital nurses” (paper presented at BHAA International 2015, Chicago, IL, March 2015).