Hospitals Must Help Clinicians With 'Second Victim Distress'

More hospitals and health systems are creating second victim support programs to help clinicians cope after adverse events.

Editor's note:

COVID-19 has a grip on the nation. Since the first known case of COVID-19 hit Washington state in January, the number of cases, and subsequent deaths, continue to steadily rise. While many states have issued stay-at-home orders, as essential workers, most nurses do not have the option to stay home. In addition to being on the frontlines in the battle against COVID-19, there have been very public struggles regarding the availability of personal protective equipment.

For example, on March 27, the Association for Professionals in Infection Control and Epidemiology released data that 48% of U.S. healthcare facilities surveyed were already out of or almost out of respirators. The data was collected via a national survey of 1,140 infection preventionists in all 50 states and the District of Columbia.

Not only does lack of proper PPE put nurses' health at risk, it also jeopardizes the health of their patients, their families, and their communities.

For nurses, causing harm to patients can be devastating and a trigger for the development of second victim distress.

The article below, which appeared in the May/June 2018 issue of PSQH, offers insights on how healthcare leaders can assist nurses who may be struggling with worry and guilt of second victim syndrome during this pandemic.

Second victim distress—a phenomenon that can happen to clinicians involved in errors or adverse events—is getting more attention, and support options are slowly growing.

It's becoming more understood by health system administrators and safety and risk officers that physicians, 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 For Health Care Risk Management.

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.

But few seek help.

More hospitals and health systems are launching second-victim support programs so healthcare staff can have the support they need.

The culture shift

Nationwide Children's Hospital in Columbus, Ohio, began the pilot phase of its YOU Matter program in 2013, rolling out peer support training to eight members of its pharmacy department.

Jenna Merandi, PharmD, MS, CPPS, medication safety coordinator at NCH, worked on a safety team with other service nurses and physicians. They were troubled watching the ongoing emotional struggle of individuals involved in errors, adverse events, or traumatic situations.

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, RN, PhD, CPPS, 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.

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, 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 emergency department.

"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.

URMC also recognized the 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.

Lessons learned

Support programs aren't rolled out overnight, and it's not without trial and error. But at the heart of these peer support programs is an emphasis on collaboration and sharing successes and failures to help other hospitals succeed. These professionals offer some findings that they've encountered along the way:

• 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.

• 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.

• Keep driving engagement. All too often the attention given new programs quickly falls off. It's for this reason that NCH built strategies into its 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."

Capturing success

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," she says.

Megan Headley is a freelance writer and owner of ClearStory Publications. She has covered healthcare safety and operations for numerous publications. Headley can be reached at megan@clearstorypublications.com.

Editor's note: This story was updated on April 2, 2020.