Second Victim Program Helps Health Care Workers Cope in the Aftermath of Tragedy

Author: Christina Frangou

Anesthesiology News

On Feb. 22, 2001, Cheryl Connors arrived for her shift as a pediatric nurse at Johns Hopkins Hospital in Baltimore. The next 24 hours changed Ms. Connors and her colleagues forever.

On that shift, an 18-month-old girl named Josie King, who was almost ready to go home after treatment for severe burns, died from extreme dehydration and undetected infection.

Ms. Connors, DNP, RN, who was three years into her nursing career, was precepting a new nurse that day. She still remembers the feeling of powerlessness over care decisions and the night charge nurse’s tears of anxiety over the child’s deteriorating condition.

After King’s death, the staff at Johns Hopkins, with the toddler’s family, launched a major patient safety initiative.

However, there was little attention given to the effect of the patient’s death on the health care workers who cared for her. Over the next years, Ms. Connors and her colleagues struggled with insomnia, guilt and feelings of incompetence. “A lot of people left our unit and one person even left the profession. It was pretty tragic. Morale became an all-time low.”

Ironically, one year before King’s death, Ms. Connors’ colleague, Albert Wu, MD, an associate professor of medicine at Johns Hopkins School of Medicine, was the first to describe the “second victim” phenomenon in an essay in the British Medical Journal (2000;320[7237]:726-727). He wrote that physicians and other health care workers grieve after errors and often use dysfunctional ways to respond to mistakes because there are no mechanisms in place to help them heal. “My observation is that this … includes some of our most reflective and sensitive colleagues, perhaps most susceptible to injury from their own mistakes.”

But the emotional toll of King’s death on health care workers went unaddressed in the aftermath of the tragedy. Staff members were cautioned not to talk about it because of potential legal ramifications, Ms. Connors said. The team that cared for the patient was multidisciplinary. She said the second victim concept was not considered.

Over the next eight years, Ms. Connors noticed again and again that her colleagues showed signs of lingering distress. Even daily events in the hospital—things like patient deaths unrelated to errors—dramatically affected care providers. Even people with strong support systems outside of work felt like they had no one to talk to.

So in 2010, Ms. Connors and her colleagues made the case to their hospital administration that they needed emotional support through difficult events. The administration agreed. With Dr. Wu, Ms. Connors created the Resilience in Stressful Events (RISE) program.

RISE consists of a team of peer responders who are available to help clinicians who call the service, 24 hours a day, seven days a week. Responders have been trained in peer support and include, but are not limited to, nurses, doctors, nurse practitioners, respiratory therapists, pastoral caregivers and social workers.

When a hospital employee pages RISE, the person on call responds within 30 minutes. The responder offers to meet the employee in person or talk on the phone. Most employees ask to meet in person somewhere off their unit.

“We essentially provide a safe space for them. … We spend a lot of time listening and reflecting on what they’re saying and allowing them to process the experience they’re having,” said Ms. Connors, who now directs RISE and is a patient safety specialist for the Armstrong Institute of Patient Safety and Quality for Johns Hopkins Medicine.

Responders are trained not to ask for details of the event if the health care worker doesn’t volunteer them. The conversations are confidential, with the backing of the hospital’s legal team, and do not trigger an investigation.

The RISE meeting—or multiple meetings when requested—is not an event debriefing, Ms. Connors said. “This is very much an emotional processing opportunity.”

In the first 52 months of the RISE program, the team received 119 calls involving nearly 500 health care workers. Support for the program was initially sluggish, but the rate of calls increased from one to four per month over the next four years as word of the program spread. The majority of calls came from nurses, and very few calls—4%—were related to medical errors (BMJ Open2016;6[9]:e011708). Most calls concerned situations in which staff members felt helpless to assist patients.

Matthew Morris, DNP, RN, the director of nursing for the Department of Surgery and the Department of Physical Medicine and Rehabilitation at Johns Hopkins, said RISE helps people who are struggling when they feel as if they’re not helping patients recover.

“The RISE team offers a response from people who aren’t going to ask you about the processes and the efficiencies. They’re really concerned about taking care of you versus taking care of the processes.”

In 2017, RISE experienced a bump in calls following another highly publicized tragedy on the hospital’s pediatric unit. The father of a child was fatally stabbed in a room on the ward. His wife, who was also visiting at the time, was arrested and charged with murder. “That’s rare and awful, and people relied on us heavily during that time,” Ms. Connors said.

Models indicate that RISE also resulted in cost savings for the hospital. In a study published in 2017 in the Journal of Patient Safety, an analysis of nursing staff who used RISE found a net cost savings, through retention, of $22,576 per nurse, or a potential savings of $1.81 million each year (J Patient Saf 2017 Apr 27. doi: 10.1097/PTS.0000000000000376).

In 2013, the Maryland Patient Safety Center, in Elkridge, approached RISE to develop a curriculum that could be used at other hospitals. Called the Caring for the Caregiver program, the RISE model has now been established at 24 organizations across the United States and one in Saudi Arabia. Caring for the Caregiver is a three-stage process: RISE trainers first meet in person with a hospital’s leadership; the visit is followed by teleconferencing and consultation as the hospital sets up a program unique to its needs; and finally RISE trainers return to the hospital to train peer responders.

Bonnie Di Pietro, MS, RN, the director of operations for the Maryland Patient Safety Center, recommends that all hospitals have a peer support program based on non-judgment of providers. The effects of medical errors or near errors can have permanent repercussions for health care workers, she said. The distress and guilt associated with errors can impede cognitive performance, further increasing risks to patients (BMJ 2019;365:I2167).

“We’re not robots; we’re not machines. But most people, when they make a mistake, the error stays with them,” said Ms. DiPietro.

One of the first peer support programs of this kind in the United States started at the University of Missouri in 2007, and is called the forYOU Team. Since then, peer support programs have grown steadily across the country, said Susan D. Scott, PhD, RN, a researcher and the director of nursing–professional practice at University of Missouri Health Care in Columbia. “We’re getting very close to a tipping point where, from a regulatory perspective or policy-related perspective, we’re starting to see more recognition of clinician wellness.”

Most of the studies on RISE and peer support have focused on nurses. Physicians may be more reluctant to seek support after involvement in a medical error or an adverse patient event. Studies have shown that time constraints, concerns about discovery and the stigma of mental health disease are considered impediments for physicians seeking care, and many of them are unaware of traditionally available support systems.

However, physicians may be more willing to engage in peer support than other kinds of professional support, reported researchers who conducted a study of resident and attending physicians at surgery, emergency medicine and anesthesiology departmental conferences at a large tertiary care academic hospital. “As colleagues are the most acceptable sources of support, we advocate peer support as the most effective way to address this sensitive but important issue,” the researchers concluded (Arch Surg 2012;147[3]:212-217).

Individuals who are interested in creating a program like RISE may contact Ms. Connors at Johns Hopkins, Dr. Scott with the forYOU Team (www.muhealth.org/ foryou), or the Maryland Patient Safety Center.

In addition, the Joint Commission and the National Quality Forum recommend that health care institutions recognize second victims’ needs, and establish a support structure to assist them through coping with traumatic medical events.