When an adverse outcome occurs, support rightfully flows to the affected patients and families. However, the clinicians involved with such cases often suffer, too, and the resulting stress and anguish can lead to decreased productivity, time away from work, depression, and other serious mental health effects. In fact, in some cases, the suffering is so great that physicians and nurses will leave their professions behind.
Albert Wu, MD, MPH, director of the Center for Health Services and Outcomes Research at Johns Hopkins Bloomberg School of Public Health in Baltimore, coined the term “second victim” to describe caregivers who experience negative effects from traumatic events such as unexpected deaths, poor outcomes, or clinical errors they may have made while caring for a patient. He explains that clinicians involved with such events can experience both short-term and long-term effects.
“In the short term, people can be psychologically traumatized as they are from any great shock. They may be stunned and they can be grief-stricken,” Wu observes. “They can become very angry, and they may be unable to do the tasks that they would otherwise be doing as healthcare workers. It is really part of an acute stress reaction, which is kind of the way human beings react to great stresses.”
However, in the long term, clinicians can be injured or traumatized further by unsympathetic or critical responses from their peers, well-meaning investigations, lawsuits, or the reactions from patients or family members, which may be understandably harsh, Wu explains. “Some [clinicians] go on to develop what is essentially PTSD. People become depressed, they withdraw, and they may try to avoid any circumstance that would remind them of what happened,” he says. “They may have nightmares or flashbacks. Some turn to alcohol or drugs.”
Recognizing that this “second victim” phenomenon is hardly rare, in 2009 Wu and colleagues spearheaded the development of a peer support program that is aimed at quickly and confidentially addressing the emotional needs of caregivers whenever they reach out for help. Called the Resilience in Stressful Events (RISE) program, the approach relies on a network of volunteer peer responders who have received training in providing what is called psychological first aid to clinicians who have been involved with a difficult patient care event. This can involve an error that leads to adverse consequences, an unexpected or traumatic patient death, a mass-casualty event, or an in-hospital assault on a member of the care team.
While the impetus of the program was to provide needed care and support to healthcare workers, research has shown the approach delivers financial dividends as well. A cost-benefit analysis of the program’s effect on the nursing staff of a 1,000-bed hospital between 2015 and 2016 has found that the program saves more than $22,000 for every nurse who initiates a call to the RISE program, resulting in $1.81 million in savings each year. Researchers considered the cost of administering the RISE program, nursing turnover, and nursing time off from work.1
Prioritize Help for Caregivers
Although no single event triggered the development of the RISE program, Wu notes that a 2001 case involving the preventable death of an 18-month-old girl proved pivotal for the institution in terms of recognizing patient safety as a problem. Josie King was receiving treatment for burns at Johns Hopkins Children’s Center following a bathtub accident when a series of medical errors led to cardiac arrest and death. Investigators determined that the cause was severe dehydration, an unthinkable result, given that the little girl was receiving treatment in one of the country’s premier medical institutions.
Wu and colleagues realized that even nine years after this incident, deep-seated wounds from this case persisted. “Some of the nurses and other healthcare providers who had taken care of Josie back in 2001 felt like even though the incident had been handled in exemplary fashion, they had not been treated fairly,” he says. “They felt that they had been thrown under the bus, essentially, and scapegoated.”
Perspectives on this case, as well as other cases that have emerged over the years at multiple institutions, brought to a head the need for Hopkins to do something as an institution for caregivers who find themselves in these types of difficult situations, Wu explains. “We were about 10 years into our healthcare patient safety journey at this point, and perhaps this wasn’t the first thing that an organization would do, but having handled some of the low-hanging fruit of patient safety, we were now ready to also take care of some of our own caregivers,” he says.
With no roadmap or model to follow, Hopkins had to develop RISE from scratch, explains Cheryl Connors, MS, RN, NEA-BC, a patient safety specialist at the Armstrong Institute for Patient Safety and Quality, part of the Johns Hopkins Health System, and the administrator of the RISE program. “We found that there really wasn’t a peer responder training program for healthcare, so we relied on other training from psychological first aid, the Social Resilience Model and the GRACE Model,” she says. “They were all very good, but they weren’t specific for healthcare.”
Consequently, the Hopkins team also considered all the principles that they believed were applicable from their own encounters in the hospital as they began to build a curriculum they could use for a full day of training for peer responders, Connors explains. The reason developers focused on using peers for this work stems from a survey they conducted in which they asked healthcare workers what kind of support they would be most willing to use if a program were to be offered. “We found out that people who encounter really severe experiences really just want a peer to talk to,” Connors says.
The survey participants indicated that they didn’t want to use an employee assistance-type program because they didn’t think that was what they needed, Connors adds. “They didn’t need counseling,” she says. “They needed and wanted somebody who could understand what they were going through and could relate to the environment that they were working in, somebody who would show up and just be there with them.”
Recruit a Multidisciplinary Team
Currently, the RISE training takes place twice a year, and the program recruits a multidisciplinary group of volunteers from throughout the hospital, including physicians, nurses, social workers, and other healthcare workers. “They get a manual, they get videos, and they get a one-day workshop where we do some didactic [instruction] and then a lot of interactive scenarios so that they can feel comfortable and competent to do this work,” Connors explains.
Still, it is not unusual for new recruits to be nervous about their new role, Connors acknowledges. “I always assure them by saying that if you just show up when the person needs you, you have already done a really big part of the job,” she explains. “The other part is just to listen to them. You are providing a safe space where they can just share with you whatever they want and need. You do some reflective listening, and you empathize with them. And you might help them identify some coping strategies so that they can get through [the situation].”
Connors stresses that that peer responders never tell healthcare workers what to do, but rather help identify what resources work for them, and encourage them to incorporate those resources into their lives. “When people are feeling some distress, they often forget what those resources are,” she says. “It sounds simple, but in healthcare it goes a long way.”
A peer responder is available to respond to a call of distress from a health worker on a 24/7 basis. Typically, the peer responder will reply within 30 minutes, and then arrange to meet with the caller in a private space, ideally within that same work shift or perhaps at the end of the shift.
The encounters with a peer responder take, on average, 49 minutes, but they can range from 20 minutes to more than an hour, Connors shares. “It depends on the scenario and how many people are receiving support,” she explains.
Although the peer responders are all trained in the same way, every encounter with a healthcare worker is tailored to the circumstances and the setting involved, and what happens during this meeting is entirely confidential. “We do not report to anyone,” Wu says. “We are not in contact with risk [management], with the patient safety team, with investigators, with managers, or anyone else.”
The goal is to help make the healthcare worker feel better, Wu explains. “We try to help them to some extent reframe the incident, to understand the context better, and to provide both emotional support and some informational support,” he says.
However, if additional resources are required, the peer responders will conduct some triage as appropriate, Wu notes. “If someone is acutely or persistently in distress, we have standard operating procedures for referring someone on to a higher level of care or continued care,” he says. “We have routines, and we collect a very minimal amount of information for the purposes of debriefing with one another and doing a lot of evaluation for how we are doing.” To that end, on occasion, the peer responders will meet as a group to discuss their experiences, engage in booster training sessions, and catch up on what is going on with the program, Wu explains.
Take Note of High-stress Environments
Not surprisingly, the peer responder program is no stranger to the emergency setting. “Over the last two years, [the ED] has used us even more than they have in the past due to the nature of events that were taking place in that area,” she says. “People come through the door with a lot of drama.”
Emergency personnel see everything from gunshot wounds to children involved in abuse, and such cases can be particularly challenging and stressful, Connors notes. “Pediatrics is big, and sometimes [the difficult cases] come in waves where there will be five in a week, and that can be just too much [distress] for the staff to handle,” she says. “We have also had quite a few aggressive patients and families that have come through [the ED]. I would say that is the trend we see a lot of in the emergency area.”
In fact, Connors observes that the peer responders often conduct group sessions with ED personnel when there are times of really high stress over several days. “We may make an effort to go down [to the department] and round, and actually have peer responders tell people who they are, and just ask how they are doing,” she says. “We have a lot of individuals who open up right there on the spot.” Wu agrees that while calls of distress can come from every department in the hospital, there are a few places where there is more stress, uncertainty, bad outcomes, contentious interactions, and burnout. In addition to the ED, these include ICUs and pediatric oncology. “We get quite a lot of calls related to clinical incidents, and occasionally we get calls related to altercations,” he explains. “Healthcare workers have been assaulted by patients or bystanders, and all of these things are very disturbing when you are under a lot of stress and trying to do a good job.”
Given the tight confidentiality of the peer responder interactions, it is difficult to collect follow-up data or produce hard numbers on the program’s effect beyond the documented cost savings. However, administrators do have anecdotes they have permission to share. For instance, Connors recalls the case of an experienced critical care nurse who was responsible for double-checking to make sure an infusion was operating as ordered by the physician. She thought she had checked the infusion thoroughly, but the patient deteriorated, resulting in complications and a longer length of stay.
“The investigation found that the infusion was actually running way faster than it was supposed to,” Connors relates. “The nurse looked back at her calculations and she missed something, and so she was absolutely devastated and considered quitting.”
This was a highly experienced nurse who was very good at her job, Connors notes, but she relayed to the peer responder that she no longer thought she was good enough and didn’t want to go home feeling responsible for someone else’s life. “However, by the end of the encounter, the nurse actually seemed a bit hopeful, and she was going to take a couple days off of work,” Connors recalls.
Seven months after the incident, the nurse’s manager called RISE, and indicated that the nurse was performing at a higher level in her job than she ever had before, and actually was using the infusion incident she was involved with in teaching simulations to prevent this error from ever happening again, Connors explains. “I never heard from the nurse, but I heard from the manager, and it was very powerful,” she says.
In another case, a nurse who was still suffering from the effect of a clinical incident that had occurred several years earlier, reached out to RISE. “I thought, ‘After 10 years this is probably not going to help a whole lot,’” Connors notes. However, the nurse called back a couple of months later to report what a difference the encounter with the peer responder made. “She said that she felt like a 10,000-pound weight had been lifted from her heart,” Connors recalls.
In addition to the positive anecdotal feedback, there is clear evidence that clinicians use the resource. Program administrators report that calls into the RISE program have increased steadily since the program was first tested in 2011.
While there are costs associated with operating the RISE program, the benefits include improved healthcare worker well-being as well as a positive effect on patient safety, Wu explains. “Every time there is an incident, it represents a very stressful time for healthcare workers and a time of heightened risk that someone may either not function so well and perhaps even commit another error, or more likely that they will take some extra time off or even leave their units or the institution,” he says. “The cost of replacing a nurse is substantial, and the cost of replacing a doctor is even more.”
Wu emphasizes that although incidents involving medical errors can be terribly upsetting to the healthcare workers involved, other types of events can be similarly stressful. “There are many, many ways to be saddened or shocked by things that happen in the hospital, and our mission is to provide timely support to any healthcare worker, not just doctors and nurses, who encounters a stressful patient-related event, which could be an error, but in a large majority of cases is not,” he says.
Wu adds that program administrators see RISE as increasingly relevant to the mission of the institution. “You have to have healthy healthcare workers,” he says. “We feel as though we are doing that.”
How might other hospitals interested in caring for their healthcare workers move to establish a peer responder program? One of the essential first steps is making sure to get hospital leadership on board, Wu notes. “These incidents and RISE or RISE-like teams are involved in very sensitive issues — sometimes medical errors, some patient injuries and patient deaths, or issues related to human resources or personnel matters,” he explains. “All of those things are things that top managers at institutions care about ... so the first step is to really get buy-in from the institution.”
Interested administrators can find literature and training on peer responder programs, some of which is available through the website for the Armstrong Institute for Patient Safety and Quality (http://bit.ly/2uNoEdJ). “Once we were successful, we developed with the Maryland Patient Safety Center a curriculum and training program to help spread this [approach] — exactly what we do — to other hospitals,” Wu explains. “This is to help them short-cut the process to develop a program on their own.”
Thus far, the Armstrong Institute has helped two other hospitals in Maryland implement peer responder programs, including one academic medical center and a community hospital, according to Connors. “It was very successful in both settings. I would say this is 100% transferable,” she says. “Starting from scratch is hard, and there is a lot that we have learned that we can now share with others.”
- Moran D, Wu AW, Connors C, et al. Cost-benefit analysis of a support program for nursing staff. J Patient Saf 2017 Apr 27. doi: 10.1097/PTS.0000000000000376. [Epub ahead of print].