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Voices for Safer Care Home Organizational and Cultural Change Supporting ‘Second Victims’ with Emotional First Aid

Supporting ‘Second Victims’ with Emotional First Aid

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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Cheryl Connors

Cheryl Connors is a patient safety specialist with the Armstrong Institute for Patient Safety and Quality. A pediatric nurse by training, Connors co-led development of the Resilience in Stressful Events program, which provides trained peer support to caregivers who encounter stressful, patient-related events.

2 thoughts on “Supporting ‘Second Victims’ with Emotional First Aid”

  1. When my mother had a massive stroke 11 months ago I was completely submersed in the day to day operations of her care. As her daughter and her caregiver I was dealing with ER Doctors, Nurses, Specialists, Physical Therapists and case workers. I saw first hand the stress and strain on these professionals as they try to give the best care possible to their patients. One of the biggest challenges that they face is dealing with the stress and strain of the family of the patient who is under stress and strain from an event that they were not prepared to handle. I see the need to provide support to those healthcare professionals who are on the receiving end of so much stress. They are human beings too! My heart goes out to them.

    I think that in order to alleviate their stress levels, hospitals may want to consider putting programs into place for the families and the caregiver to manage their stress, understand the processes and the needed care that is being thrown like a hand grenade into their lives. This training could include sessions on how to effectively interact with Nurses, Doctors and others and give them an understanding of the "Behind the Scenes" work that they do and the pressure and stress that they are under. Too many times, family members of patients are tired and worn out, uneducated, untrained and feel it is their right to take their frustration out on the Professionals. Consider writing a piece on this Cheryl. I firmly believe it is greatly needed for everyone!


    Donna Williams

    1. Hi Donna,
      I am so sorry to hear about your mom. As someone who has had a family member in the hospital, I can certainly relate to your experience. You raise a good point regarding the stress and strain on both sides. You also make a great recommendation for managing that stress and strain for families and clinicians. I will bring this to our Patient and Family Advisory Council to get their input.

      We are hopeful that RISE can help reduce the stress on the clinician side, which will enable them to provide better support to patients and families. We have been asked if similar programs exist for families, but thus far, I am unaware of any. It could be a much-needed resource that improves the hospital experience for our patients and families, as we recognize all hospitalizations are stressful.

      Thank you for sharing your experience and your thoughts.


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