By Megan Headley
Second victims are getting more attention, and support options are slowly growing. It’s becoming more understood by health system administrators and safety and risk officers that doctors, nurses, and specialists directly involved in an adverse patient event or traumatic episode are likely to suffer an emotional response that might lead to difficulty sleeping, guilt, anxiety, or reduced job satisfaction. If unaddressed, these events can lead to consequences including depression, burnout, post-¬traumatic stress disorder, and suicidal ideation, according to a 2015 survey conducted by the American Society of Healthcare Risk Management.
None of these outcomes are good for healthcare professionals or the patients coming into contact with these providers, yet healthcare systems are still struggling to appropriately address the support of these second victims.
A 2013 review of healthcare professionals as second victims, published in Evaluation & The Health Professions, concluded that nearly half of healthcare providers would fit this label at least once in their career. A 2017 survey of surgeons found that 80% recalled having at least one intraoperative adverse event within the past year of their practice. Those affected reported having experienced a substantial emotional impact on their well-being, including strong feelings of sadness, anxiety, and shame.
Few seek help.
A 2017 study based on interviews with patient safety officers in acute care hospitals in Maryland highlighted numerous barriers keeping physicians, nurses, and other healthcare staff from obtaining help after an adverse event. Chief among these barriers was fear about confidentiality, negative judgment by coworkers, and the stigma of using such services.
Second victim support programs popping up in hospitals and medical centers across the country are seeking to break through these barriers and get all healthcare staff the support they need.
Support for second victim programs
Recognizing the seriousness of this problem and its impact on patient care, The Joint Commission issued an advisory in January 2018 aimed at helping healthcare organizations with recommendations and resources on how to support second victims.
“If not treated, a second victim experience can bring emotional and physical harm to our healthcare providers who work so hard to treat and care for patients,” commented Ana Pujols McKee, MD, executive vice president and chief medical officer for The Joint Commission, in a news release on the advisory.
“Unfortunately, many second victims find themselves in need of support and care that many healthcare organizations are not prepared to provide. This emphasizes the importance of establishing second victim programs which play a critical role in strengthening safety culture, as well as reducing stigma and biases.”
The safety guide offers, in brief, safety actions for healthcare organizations to consider, including developing a culture for learning from system defects and communicating lessons learned, and providing guidance on how staff can support each other during an adverse event (such as how to offer immediate peer-to-peer emotional support or buddy programs).
Jenna Merandi, PharmD, MS, CPPS, medication safety coordinator at Nationwide Children’s Hospital (NCH) in Columbus, Ohio, points out that this type of regulatory support is a major first step in encouraging more hospitals to take concrete action to support second victims.
“The more support we can continue to get from a regulatory organization such as The Joint Commission and our state boards of pharmacy, nursing, medicine, etc., to really communicate the same message, I think the more quickly we’ll be able to get more hospitals on board with having this,” Merandi predicts.
But from Merandi’s perspective, organizations that already have a culture of safety, where reporting is encouraged and supported, will be able to more quickly put a culture of peer support into place.
The culture shift
NCH began the pilot phase of its YOU Matter program in 2013, rolling out peer support training to eight members of its pharmacy department. Merandi worked on a safety team with other service nurses and physicians, and they were troubled watching the ongoing emotional struggle of individuals involved in errors, adverse events, or traumatic situations. The emotional pain was clear, even in incidents where the event did not reach a patient.
Around that same time, several of the organization’s nurses attended an Institute for Healthcare Improvement conference where they learned more about second victim programs from Susan Scott, the founder of University of Missouri Health Care’s “first of its kind” peer support network. This confluence of events sparked a grassroots effort at the hospital to create an interdisciplinary peer support program.
But Merandi emphasizes that the program might never have launched if it was not for the culture of support already in place at the institution.
“I think our culture here, from a safety standpoint, was where it needed to be,” Merandi says. “We have a very robust event reporting system at our hospital. People really feel comfortable reporting events and know that we look at things from a system’s perspective.”
In Merandi’s view, health systems do need a culture of accountability, but it must be balanced with an environment where staff feel safe in reporting problems or issues that are occurring and knowing their reports will be handled “not in a punitive environment but in an environment that really allows us to hold individuals accountable whether at the individual or system level,” as Merandi puts it.
While the NCH support program was grassroots-driven, its success was largely dependent on executive leadership’s support.
“We felt it was very important to have an executive sponsor to help advocate for the program, and work closely with our senior leadership at the hospital,” Merandi says.
It’s resistance from leadership that is among the more significant barriers to creating an effective culture around second victim support, and that often is because the value of these targeted programs is not clearly understood. “People might think if we have an employee assistance program (EAP), why do we need additional support in place for second victims?” Merandi explains.
What the development of the YOU Matter program revealed to the NCH team is that healthcare professionals often want support from their peers, managers, or supervisors—those people around them who really understand the work that they do and who may have gone through similar situations in the past. The peer support program also offers immediacy, versus setting up an appointment some weeks distant through the EAP. “That’s why we thought it was really important to build a program that encompassed that peer level support and then has more levels of support in place all the way through professional levels of support when needed,” Merandi adds.
Granting full access
Effective second victim programs also recognize that physicians and nursing staff are not the only ones impacted by adverse events.
Jaclyn Wilmarth, MS, RN, CPPS, patient safety nurse with the University of Rochester Medical Center (URMC), explains that “critical incidents” are best defined by the area that experiences them. “These are things that are outside the normal realm of your day,” Wilmarth adds.
What qualifies as “outside of normal” differs for every department. For ambulatory care offices, a critical incident could be that somebody coded. In other words, it has to be taken into account that traumatic events can happen beyond the operating room (OR) or emergency department (ED).
“The other piece we focus on beyond critical incidents are areas that have recurring or repetitive stress—ICU, OR, or ED—where every day might be high volume. In those areas, it may not be a particular incident, but just that things might be tough lately and they need a ‘debriefing,’ ” Wilmarth adds.
URMC developed its YoUR Support program around the “Demobilization, Defusing, and Debriefing” model that comes from trauma care. As described by Muriel Prince Warren in Trauma: Treatment and Transformation, demobilization involves removing the individual from the scene and provided with coping techniques. Defusing happens within 12 hours of the event and is built around group discussions designed to reduce acute stress and get staff back to their normal functioning. Debriefing should come two to 10 days later, to help give some sense of closure following the event.
Each department’s needs may be different, but every department working in healthcare has the potential to face an adverse event. It’s for this reason that an interdisciplinary approach is key in starting a second victim program.
“We did not just focus on starting a support program for second victims of clinicians but also nonclinicians as well—interpreters, security guards, and other individuals,” Merandi says. “We decided to go for an all-encompassing, peer-based program.”
URMC also recognized this wide-ranging need in setting up its critical incident response program. It’s for this reason the organization opted to partner with its existing EAP to create a complementary program.
“We already have the phone system in place where you can phone 24 hours a day if you need EAP support for yourself, and they partnered with us to triage team support needs,” explains Julie Colvin, MS, RN-BC, associate director of nursing practice at URMC’s Psychiatric Mental Health Nursing Service.
The EAP program provides individualized staff support for challenges including work-life balance and general stressors. The YoUR Support program adds a team-based emotional support element to help staff get through difficult times.
An additional benefit of partnering with EAP is that it ensures all staff members have access to the same type of support no matter when they are working. “We wanted staff members Saturday at 2 a.m. to have the same access to emotional support as if it happened on a weekday at noon when the hospital was full of leadership people,” Wilmarth says.
The YoUR Support program also provides guidance to help managers focus after an adverse event.
“We thought, ‘What if you are a new nurse manager and there’s a code on your unit? We need some sort of leadership checklist,’ ” Wilmarth says. It reminds managers to consider who to call after an event, consider safety needs, and so on. “In an event, when things get a little crazy for a minute, it helps center you and bring you back to [focus],” she adds.
A program of this magnitude isn’t rolled out overnight, and it’s not without trial and error. But at the heart of each of these peer support programs is an emphasis on collaboration and sharing successes and failures to help other hospitals succeed. These professionals offer some surprising findings that they’ve encountered along the way:
1. Timing is important. Colvin found that the excitement about the new support program meant that many staff members wanted to pull in extra support before they even needed it. As she explains it, the demobilization is meant to get staff back on track and recovering from the neurobiological effects of the stress. The defusing keeps people safe and able to go home.
“They were wanting to do a full-on debriefing a little bit too soon. You do need a little bit of time for your brain and body to filter the neurobiological sensations and effects,” Colvin says.
2. Maintain the focus on emotional, not clinical, support. The URMC team notes that it sometimes takes effort to pull clinicians into a mindset that allows them to focus purely on their emotional state.
“Everybody in healthcare is a bunch of problem solvers and want to steer the conversation to the clinical debriefing—we need to steer it right back towards truly an emotional support conversation for staff,” Wilmarth says. These conversations should not be about reviewing a timeline of what has happened and what will happen next.
“I always say we demobilize, defuse, debrief, and then we move on to problem solving,” Colvin adds. “[Problem solving is] a safe place for clinicians: ‘How do I fix this and make it better?’ What we’re trying to do is focus on the emotional stuff.”
3. Keep driving engagement. Awareness is a strong basis for success for a program like this, but all too often the attention given new programs quickly falls off. It’s for this reason that NCH built strategies into the program to keep that momentum going forward.
The organization holds an annual celebration featuring prizes, food, and continuing education opportunities for peer supporters. NCH hosts quarterly lunches with leads in different areas to help disseminate information to the peer supporters. It also created YOU Matter Awareness Week with the encouragement of senior leaders, which provides an opportunity to talk about the different support systems available to staff.
“Our senior leaders were really the ones who wanted to partner with us on that week,” Merandi shares.
“They volunteer their time to go around and deliver cookies and information and resources to share what supports we have available. The CEO of our hospital was with us this year volunteering his time to do this. It really sends a powerful message when you have that level of buy-in at all levels of the organization and they show up.”
The success of these programs is still being measured, but evidence points to the effectiveness of peer support programs in their mission to help staff cope with the challenging emotions that can follow a critical incident. NCH, for example, is in the process of publishing its research on the success of the YOU Matter program.
Merandi and her team surveyed approximately 1,000 employees at NICUs across the hospital, off-site NICUs, and other hospitals across the city that NCH operates. Some of these units had a peer support program in place, while the others received it six months later. “We utilized tools such as our Professional Quality of Life Scale, looking at compassion, satisfaction, burnout, secondary traumatic stress; as well as things such as the Hospital Anxiety and Depression Scale; and different perceived desires for support,” Merandi says.
The researchers utilized the Second Victim Experience and Support Tool to examine how supported staff felt with and without peer support programs in place, regardless of whether they’d been involved in a traumatic or adverse event of some type.
“We’ve shown statistical significance, in terms of employees who have experienced an adverse event having statistically significant higher levels of burnout and secondary traumatic stress—anxiety, depression—and showing the benefit of peer support as well,” Merandi says.
URMC is watching the data too. In the first 15 months after YoUR Support went live, URMC increased the number of debriefings done by 258% compared to the same time frame before going live. But for this type of problem, the anecdotes are a more compelling story of effectiveness.
“We do have data on how many of the formal debriefing sessions that we have, and as this becomes more engrained in the culture here, we certainly know that we’re not capturing all of those—but that’s OK,” Wilmarth says. “If people are reaching out to their natural resources and relationships that they have with their established debriefing team in real time, then they’re getting the support that they need and it’s OK that we’re not capturing every single one in data.”
Wilmarth notes that the hospital holds a leadership safety briefing every morning, and that it’s not unusual during the morning walks down the hallway for one of the leadership team members to ask, “ ‘Hey, did so and so reach out to you yet?’ because we talked about them needing support this morning for an event that happened a few days before.”
“Those are indications to us that we’re doing the right thing and getting the support to the right people,” says Wilmarth.
Taking the first step
These programs don’t come together overnight. There will be challenges along the way. And as Wilmarth points out, it’s best to be prepared for any contingency to ensure the program gains early credibility as a tool worth using.
“It was a little more than a year in planning before we were ready to go live, and the reason for this was the last five months or so was tackling all the what-ifs,” Wilmarth recalls. “We wanted to be really ready—we didn’t want to have something not go right and then have people never call us again because we weren’t able to deliver on our promises.”
Still, these professionals have some advice to offer other organizations looking to launch a peer support program:
1. Don’t reinvent the wheel. Merandi urges other organizations to collaborate with institutions that already have programs in place. “We’ve worked with a ton of other hospitals,” she recalls. The NCH program development team reached out to roughly 25 hospitals, having conversations with some and inviting others’ representatives on-site.
“I would encourage other institutions to reach out to places that have these programs so they can have some kind of a baseline to start with,” Merandi says. “We worked collaboratively with Susan Scott from the University of Missouri Health Care a lot when we got started, and having her help us initially with our program has really been a great thing. It helped us get our program up off the ground way sooner than if we had tried to do this alone.”
2. Get leadership involved. “Having executive support and identifying a champion from the executive team to help create and support the need for this type of program and help articulate that to all members of the team is important,” Merandi says.
3. Get legal involved. Balancing that line between support and accountability often poses challenges from a legal standpoint, which is why NCH involved the legal department in the earliest conversations around YOU Matter. After helping resolve these challenges, the legal team has since gone on to talk to hospitals outside of NCH to provide guidance around how they helped come to certain decisions.
4. Get everyone involved. “I think that’s really the key,” Wilmarth says. “It really must be supported and looked at from every level of the organization.”
While executive leadership’s support is pivotal, Wilmarth has found that frontline leaders most quickly grasp the need for these programs. They’re close to the events, and to the not-so-distant feelings of struggling with these emotions.
Merandi adds that, from a culture standpoint, support for peer support may take time. While not all are there yet, more organizations seem headed toward a culture of safety and support.
“I do think more hospitals are starting to create peer support programs,” Merandi says. “But I think we have a long way to go.”