She was a newly minted Johns Hopkins Hospital pediatric nurse — let's call her Mary — but she was already unsure if she had chosen the right career path. She had inserted an intravenous line into a young patient's arm, and there had been an infiltrate, a pooling of IV fluid under the child's skin that indicated it was not flowing into the vein. It was not a serious complication; it's actually quite common in young patients, with their tiny blood vessels and difficulty keeping their arms still. But the event had shaken Mary's self-confidence. Maybe the next slip-up would do real harm.
Mary felt embarrassed, scared to talk about her feelings to her new colleagues and unsure whom to trust. But she had heard about a confidential peer support program that the hospital had launched for its staff following stressful, patient-related events. Called RISE — Resilience in Stressful Events — it provides trained peer responders who are on call 24 hours a day to provide help. She arranged a meeting with a responder, who happened to be a nurse as well. Mary shared her doubts, heard that she wasn't alone, and came to understand how her experiences and fears were common for nurses.
Today, Mary is still a practicing nurse here. She credits that peer support session for keeping her in the profession.
As the patient safety movement has gained momentum, a parallel campaign has grown in its shadow. We've increasingly recognized the importance of providing emotional support for "second victims" — caregivers who are traumatized by events such as an unexpected death, a medical error or an unplanned transfer to the ICU. Albert Wu, a physician who has been a driving force to create RISE, found through a survey of more than 200 caregivers that 85 percent had been involved in an event involving serious patient harm at least once in their careers. But caregivers can also be distressed after seemingly minor complications or even when they deliver excellent care in the face of tragic circumstances, such as a long-standing patient who finally succumbs to illness.
In an insightful commentary this year in JAMA, physician Marjorie Podraza Stiegler shared how even heroic successes can leave us traumatized. Many of us remember the January 2009 "miracle on the Hudson," in which airline pilot Chesley Sullenberger and crew safely landed a disabled US Airways plane on the frigid river without any loss of lives. While this outcome resulted from amazing skill and teamwork, Stiegler writes that Sullenberger had trouble sleeping and concentrating for the first three months after the water landing, and he did not return to the cockpit for nearly six months. Even the air traffic controller involved in the event could not return to work for about a month and took nearly a year to begin to feel good about the event again.
Captain Sully, as he's known, said that a supportive debriefing was arranged within 24 hours for the flight team and family members to prepare them "for the emotions and physical responses they might have, and normalizing the post-event experience and timeline for emotional recovery," according to the commentary.
When we created the RISE program, we wanted to take a similar approach: Regardless of patient harm, if a patient event causes stress to caregivers, we want to be there to support them. With a grant from the Josie King Foundation, RISE leaders evaluated advanced training curricula for peer support and stress management, applying them to the second victim model. To date, we have delivered peer support in more than 85 cases to both individuals and groups, touching hundreds of people. Through a collaboration with the Maryland Patient Safety Center, we now help other organizations implement programs based on the RISE model.
This issue isn't solely about caring for the caregivers themselves. If we don’t come to second victims' aid in times of need, they may have sleepless nights, or suffer burnout or other impacts that could harm their ability to provide care that is compassionate, high-quality and safe. And yet most of the time, caregivers are pressed back into service shortly after a traumatic event. There are more patients needing their help, a busy operating room schedule and colleagues who depend on them to get through the day.
After adverse events, time is usually set aside for a debriefing session, led by a physician or nurse manager, seeking to understand what happened in an adverse event and prevent future harm. Even though these groups may try to understand an event as the output of a faulty system rather than a flawed individual, they don't typically seek to provide support for the caregivers involved. We need separate debriefings to help with those issues and provide emotional first aid.
Maybe health care can't afford to give caregivers months or weeks to deal with their emotions following a stressful event — although it might be wise in particularly traumatic cases. However, quickly linking them with peer support could be the first step in processing their feelings and identifying additional resources to help them heal, such as an employee assistance program. And it would make sense for hospitals to put protocols in place, making it understood that in certain circumstances clinicians need to step away from the bedside, for their benefit and for patients' health.
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Resources for Hospitals and Caregivers
- Johns Hopkins Hospital RISE Program (for JHH employees seeking peer support)
- Caring for the Caregiver: The RISE Program (training program for hospitals implementing RISE)
- Medically Induced Trauma Support Services (confidential second victim support)
- Support for Clinicians Involved in Errors and Adverse Events (AHRQ patient safety primer)