A recent shocking act of violence at Johns Hopkins Hospital in Baltimore quickly underscored the importance of the hospital’s state-of-the art peer responders program: Resilience In Stressful Events (RISE).
“We just had a major event at our hospital, and it affected a lot of staff members,” says Matt Norvell, MDiv, MS, BCC, NBCC, a chaplain at Hopkins and member of the RISE team. “We have probably had six or eight different individual and group meetings with folks. It was a violent event. It makes them scared about whether they are safe, and also raises the question of whether they could have done anything and [concerns] about the other patients. They just want to talk about it. We think what happened was unpreventable.”
In a case of visitor-on-visitor violence, a woman fatally stabbed her estranged husband in a closed room in a Hopkins ICU on Oct. 13, 2017, according to police and press reports. They both were visiting their son, who was a patient at Hopkins. The woman left the hospital, but was arrested and charged with the crime the next day. Some healthcare workers tried to help the victim to no avail. In the aftermath of the disturbing incident, workers on the unit turned to the RISE program to talk it out with peers.
“This was just a little sleepy inpatient unit that normally doesn’t have a lot of drama,” Norvell says. “It ended up involving a lot of staff who were present and trying to help [the victim]. Then it turned into a security question, and on and on. A lot of layers. Lots of hospitals are dealing with the issue of violence against employees and it is amazing the anxiety that it brings up, because this is supposed to be a safe place and our job is to help people get better. Everybody is dealing with some aspect of this. We are running out of safe spaces.”
While the homicide was publicly reported, the RISE team sometimes deals with healthcare workers sharing something they may not have told anyone else. Healthcare workers who come to the RISE team are termed “second victims” in clinical parlance because they often are emotionally affected by adverse outcomes in patients.
“If a nurse or physician can actually identify that they made an error, that can be traumatic,” Norvell says. “Their intention was to help someone get better. If they think they hurt them or made them worse, that causes some guilt. It also creates this really difficult swirl of self-doubt. One mistake may not be that big of a deal, but I’ve heard nurses say, ‘I had an IV that infiltrated — that’s three in two months.’ If they start to repeat something, they feel really bad. If a doctor misses a couple of diagnoses, they start to question themselves. It starts to get into these existential self-worth questions.”
Sometimes, healthcare workers are affected by an event in which they played no part — for example, a bad patient outcome that was no one’s fault, he adds.
“Sometimes, it is a surprising event,” he says. “They are not so much doubting themselves. They couldn’t have made the outcome any different, but they have to recalibrate a little and say, ‘look at the kind of things that can happen.’”
Relatively inexperienced clinicians may be particularly struck in seeing this kind of thing for the first time.
“There is always this learning curve when they see that somebody can just die,” Norvell says. “It’s a new experience. They provided all the best care they could, were safe as possible, made no mistakes — and someone can still just die.”
Peers Who Listen
People who volunteer to be part of the RISE team are trained to provide emotional support to their peers primarily by listening.
“That’s really all we do,” Norvell says. “We have taken clinical providers and have trained them to show up, listen, and not try to fix the problem. We’re kind of a bridge. It may turn out that someone needs to go talk to a licensed therapist. We are doing a version of emotional or psychological first aid.”
The current program was established after a pilot study asked workers who they would prefer to talk to in a crisis.
“Overwhelmingly, people wanted to talk to a clinician peer,” he says. “So, that’s what we created. We have nurses and doctors, respiratory therapists — I’m the token chaplain on the team. We have really worked hard to provide it as a confidential service. We don’t take notes and we don’t report to anybody. Nine times out of 10, that is the primary intervention that they need — just somebody to sit and listen.”
Of course, given the nature of the profession, healthcare workers sometimes find it difficult not to try to address the problem in providing emotional support.
“There is sort of a reassurance and normalizing,” Norvell says. “You just can’t take that away no matter how much you ask them to just sit and be present. Nurses, for example, are trained to identify problems and fix them. That’s what we pay them for and that’s why I love them. In this situation, we are asking them to not solve the problem.”
Instead, they are trained to say things like, “That sounds really hard. When you have been in difficult situations before, what did you do?”
“These are smart, capable people that have just been through something that has temporarily jarred them out of their normal thinking pattern,” Norvell says. “It’s almost like coaching them back into their right decision-making [mindset].”
Other prompts from the RISE team may include asking the troubled worker what they would tell a colleague to do in the same situation.
The approach is simple, but it can provide considerable relief. After the program started in 2010, a nurse came forward to talk about a patient death of a child that had been troubling her for a decade. The cause had nothing to do with her nursing care, but the child’s death bothered her so much she moved out of pediatric nursing to adult care two years after it happened, Norvell says. The nurse said it eased her burden to have a forum to talk about the experience.
Pay Back With Interest
The Johns Hopkins program has recently been shown in a published study to yield a good monetary return on the emotional investment.
“In a cost-benefit model showing how doing this would avert people taking off work or even quitting, it consequently saved the hospital money to the tune of approximately $20,000 per call,” says Albert W. Wu, MD, MPH, one of the RISE program founders in the Johns Hopkins Bloomberg School of Public Health.
Wu and colleagues modeled a one-year cost-benefit analysis with and without the RISE program from a hospital perspective. The cost of running the RISE program, nurse turnover, and nurse time off were modeled.
“Expected model results of the RISE program found a net monetary benefit savings of U.S. $22,576.05 per nurse who initiated a RISE call,” the researchers concluded.1 “The budget impact analysis revealed that a hospital could save $1.8 million each year because of the RISE program.”
Such findings may spur wider adoption of similar programs, which another study2 by Wu suggests are not commonly offered in hospitals. Employee assistance programs are common, but raise confidentiality concerns in some healthcare workers, he said. Wu and colleagues conducted a study to see if programs like RISE had been adopted in Maryland hospitals.
Only six of the 38 hospitals polled had second victim support programs of some sort. Another five hospitals were developing them. There is no way to extrapolate the findings nationally, but Wu offered an opinion.
“In my conversations with people around the country, I think that this is similar to — or perhaps even a little bit better than — many other parts of the U.S.,” he tells Hospital Employee Health. “I think that there are only a few well-developed programs, and then there are many programs where the hospital recognizes that this is a necessary function. There are others that are doing something, but the program may not be that developed and may not reach that many people.”
Study participants identified a need for peer support, both for the second victim and potentially for individuals who were not directly involved.
“Think about people who do disaster response,” Wu says. “You show up at an earthquake zone and you see widespread misery and destitution. Those folks themselves need counseling and support. It is completely normal that if you come into contact — whether directly or indirectly — with disturbing and tragic incidents, it is also going to have an impact on you.”
While a physician or nurse comes to mind when one thinks of a bad patient outcome, other ancillary workers also can be affected, Wu says.
“It may be a food handler who delivers a meal to a patient every day for a week and they make some connection with them,” he says. “Then, that person dies suddenly. That food service worker or, say, an environmental services worker, could be very disturbed by it. We actually have taken calls from all of these people because they are working and basically helping to take care of people, too.”
1. Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. Journal of Patient Safety April 27, 2017; doi: 10.1097/PTS.0000000000000376.
2. Edrees HH, Morlock L, Wu AW, et al. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Patient Saf 2017;43(9):471-483.