TERMINOLOGY Second Victim - health care providers who are involved - - PDF document

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SECONDARY TRAUMATIC STRESS in OB-GYN

Amy Domeyer-Klenske, MD; Abbey Kruper, PsyD; Kristina Kaljo, PhD

2019 Women’s Health Conference: April 12, 2019

TERMINOLOGY

• Second Victim - “health care providers who are involved in an

unanticipated adverse patient event, in a medical error and/or patient-related injury and become victimized in the sense that the provider is traumatized by the event” (Scott SD et al, 2009)

• Secondary Traumatic Stress - “natural, consequent behavior and

emotions resulting from knowledge about a traumatizing event experienced by another individual.”

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THE PATIENT PROBLEM

• 44,000-98,000 deaths/year in the US due to preventable adverse events (Kohn et al,

2000)

• Revised estimates suggest at least 210,000-400,000/year (James, 2013)
• Presuming at least 4 clinicians/impacted patient, 840,000-1.6 million clinicians

impacted (Scott, 2019)

• Maternal mortality increased 26.6% from 2000-2014 (MacDorman et al, 2016)
• Over the past decade, severe maternal morbidity in the US has increased by 75% for

complications associated with delivery (Committee on Patient Safety and Quality Improvement, 2014)

THE SECOND VICTIMS

• Medical errors, non-error patient safety events, near misses are common

and can impact the well-being of the provider

• Can lead to secondary traumatic stress
• Emotional distress, sleep difficulties, anxiety, distress, PTSD,

guilt/shame, fear, suicidality, negative effect on work performance such as absenteeism, reduced confidence, potential secondary medical errors (Nimmo et al, 2013; Burlison et al, 2016; Robertson et al, 2018)

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WORD IS OUT…

…but where are the OB/Gyns?

Secondary Traumatic Stress in Ob-Gyn: Provider Experience & Program Needs

Abbey Kruper, Psy.D. Kristina Kaljo, Ph.D. Kristina Parthum, Third-Year Medical Student Robert Treat, Ph.D. Amy Domeyer-Klenske, MD

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Exploratory Mixed-Methods Study** IRB Approved

Quantitative

• Anonymous online survey distributed to all Ob/Gyn residents, fellows, and

faculty

• ANOVA – mean and median differences
• Cohen’s d calculated effect sizes of mean differences

Qualitative

• Listening sessions (1-1 interviews or focus groups)
• Transcribed using Transcribe Me
• General inductive approach – coded data line-by-line
• Interpretive analysis with member checks to determine coder reliability
• Contextualized findings to broad themes

OUR EXPERIENCE: Sample

Online Survey

Residents Faculty Unidentified

Focus Groups/Interviews

Generalist Sub-Specialists

>50% generalists

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OUR EXPERIENCE: Basics

5 10 15 20 25 30 35 40 45 Very Familiar Somewhat Familiar Not Familiar

KNOWLEDGE OF TERMS

Second Victim Secondary Trauma

OUR EXPERIENCE: Basics

• 89% providers reported involvement in adverse medical event (medical

error, non-error patient safety event or near miss)

• 69% indicated experiencing STS, 15% unsure and 8% had not experienced

STS

• 58% experienced STS 2-5x in their career
• 15% experienced STS 6+ times in their career

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OUR EXPERIENCE: Symptoms

• Symptoms -
• Anxiety (81%), guilt (62%), disrupted sleep (58%) (mean number of symptoms = 3.4)
• Fear of litigation/disciplinary action (50%)
• Concerns with professional relationships (27%), personal relationships (27%), depression

(19%) and/or work interference (15%)

• Duration - weeks (31%) to months (35%)
• Faculty reported more symptoms (4.1 +/- 1.6) than residents (3.3 +/- 2.1)

OUR EXPERIENCE: Symptoms

• Anxiety & Rumination

“You replay events in your mind…what could I have done differently?” “There are things I go back to hours or days later, weeks later and I’ll go back and forth

• n it.”

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OUR EXPERIENCE: Symptoms

• Sleep Disturbance

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thoughts.” “It kind of preoccupies your mind a lot, can awaken you from sleep…it occupies a lot, a lot of time…waste a lot

• f time on continuous

thoughts.” “I wasn’t sleeping. I kept going back and forth about all the things that we did. I was very anxious about it.” “Difficulties falling asleep…just thinking about

• it. Just kind of heart racing,

laying in bed, unable to calm down.”

OUR EXPERIENCE: Symptoms

• Guilt

“Sometimes it’s hard to tease out the second victim versus the secondary trauma because a lot

• f times I make myself into a

victim whether I actually committed an error or not.” “[There’s a] fine line between doing something wrong that leads to a bad outcome and not doing enough right to prevent the bad outcome…I mean, my job is to prevent the bad stuff from happening and sometimes I don’t, or I can’t.” “I think if you do something unintentionally, you still did something that could have caused it [the bad outcome].” “I feel like I should have less tolerance for my own mistakes because I have so much more experience. I consider myself more responsible if I’m the senior person in the room.”

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OUR EXPERIENCE: Symptoms

• Shame
• "I had a lot of shame…for my partners to see

that [bad outcome] Incredibly ashamed for the residents to see that. And then what really sort of hurt in retrospect is that I think the patient took a second-place role to my personal shame and anxiety and distress."

OUR EXPERIENCE: Symptoms

• Self-doubt
• “Personal doubt, will I ever be good

enough rather than am I smart enough.”

• “I shouldn’t be doing this, I don’t belong.”
• “Significantly impacted my approach to

surgical training going forward. I was much more cautious. There were even times when I was prolonging that step of a procedure that is otherwise relatively straight-forward…that step for me always took longer than my cohort.”

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OUR EXPERIENCE: Behavioral Impact

Task Avoidance Task Avoidance Hypervigilance Hypervigilance

OUR EXPERIENCE: Behavioral Impact

• Task avoidance
• Avoiding colleagues
• [I would] try to hide from everyone

else

• [I was] less willing to help people that

asked me for help…I didn’t want to not be a good assistant for them

• Avoiding patients
• [I felt] more cautious and avoided certain

cases or being alone.

• That patient would come back for some
• ther reason…and part of me just didn’t

want to see her…as much as you’re interested in what happened to them, it sort of bubbles up again if they come back to you for something else.

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OUR EXPERIENCE: Behavioral Impact Hypervigilance

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“I kept checking in with the NICU staff. That was really, I would say, the most prolonged, very severe symptom that I had with this.” “I’ve never once in any of these kind of instances felt like I didn’t want to go back to work the next day…to an extent sometimes even the people around me would say almost too immersive. And say, never wanting to leave the bedside because not knowing what’s going to happen kind of thing.”

OUR EXPERIENCE: Coping Responses

• 69% sought support from colleagues in their division
• 58% sought support from significant other, 27% from family and

42% from friends

• 19% coped without assistance

 Those with disrupted sleep more commonly reported seeking mental health services.

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OUR EXPERIENCE: Protective Factors

• Compartmentalizing Personal & Professional

“I think just separating yourself and realizing you have a separate life outside of work has been my most helpful way that I manage that…just putting it in a box somewhere on a shelf and just kind of moving on and enjoying the positive parts of life has helped me.” “One of my things is trying to find balance because this job could completely consume you and it could take up every hour of every day. And I know to find that balance I’m probably not getting as much done professionally as I could, but I think that’s a commitment that I’m OK with because I have to enjoy life too.”

OUR EXPERIENCE: Protective Factors Faith/Introspection

“I’d say a lot of coping…comes from my faith. I use that as some of my basis to feel confident and at least reassured in the greater picture of things.” “In general having faith, just being able to pray about it and say, ‘I’m not perfect and can’t prevent these things from happening’.”

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OUR EXPERIENCE: Protective Factors

• Peer/Colleague Support
• [I find] comfort in talking to people that

go through the same thing I go through.

• Often we kind of seek help from people

who are more mature, older with more experience, life experience. And so you feel they have more to teach you.

• I seek out someone who has expertise

in the field that knows me on a personal level too. And those people are hard to find, especially if you are in a new space.

PROVIDER PREFERENCES

• Faculty surveyed felt more supported than residents. (p<0.023)
• Majority of survey respondents in favor of formalized support at

department/institutional level

Peer-to-Peer Mental Health Support Debriefing

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WHERE DO WE GO FROM HERE? WHAT’S OUT THERE?

Peer Support Programs -

• forYOU team (University of

Missouri)

• RISE Program (Johns Hopkins)
• WeCare Team (Barnes Jewish

Hospital)

• Center for Professionalism

and Peer Support (Brigham and Womens)

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BENEFITS OF A PEER SUPPORT NETWORK

• Helps to normalize the situation
• Allows the provider to address emotions and engage in

health stress management behaviors

• Studies show that second victims prefer the support of a

colleague within their same specialty

• Able to relate and to have shared experiences

WHAT’S NEXT?

• FMLH&MCW Peer Support Program
• Peer supporters trained in every department by Dr. Sue Scott - creator of the

forYOU team at University of Missouri

• Ob-Gyn Supporters: Dr. Klatt, Dr. Domeyer, Dr. Kurtz PGY-2, Jody Harris, RN
• Plans to train additional supporters in the future
• “Tier System” similar to the forYOU model
• Peer supporter reaches out to affected individual
• Additional assistance/support triaged to higher tiers as needed

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FMLH & MCP Peer Support Structure

Tier 3

Expedited Referral Network

Tier 2

• Trained Peer Supporters
• Patient Safety and Risk
• Management Resources

Tier 1

Local Support (Unit/Departmental)

Employee Assistance Program Mental Health Services Spiritual Services Alicia Pilarski, DO Jonathan Wertz, JD, RN Timothy Klatt, MD As of 1/30: Each Department’s Trained Peer Supporter Dyad Peer-to-Peer Support: Very Near Future: Additional Trained Physicians, Advanced Practice Providers, Residents, Nurses and Staff

Innovative Approach

• Tier 1 includes the entire care team
• Like optimal patient care, optimal support &

recovery requires a team.

• Intention is for providers and personnel to

reach out to each other.

• Helps erode unnecessary barriers between

personnel and providers.

• Promotes team recovery.
• Promotes future team functioning & culture
• f safety

WE CAN PROVIDE EMOTIONAL FIRST AID

Reach out to our colleagues as Tier 1 support

• Ask how they’re doing: “Are you OK?”
• Listen
• Seek to understand
• Avoid criticizing anyone involved in the event
• Share your personal experiences and emotions
• Be there for each other!
• Involve your Department’s Peer Support

Leaders when you become concerned about someone

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GOALS OF THE PROGRAM

• To have trained peers supporters in each department/unit from multiple

healthcare backgrounds (i.e. nursing, physicians, APPs, residents, pharmacists, etc)

• To foster a supportive culture around patient safety
• To improve provider well-being by addressing the emotional distress

following an adverse event through local peer support and streamlined Tier 3 support

WHAT’S NEXT

• Identify symptoms of second victim syndrome/secondary traumatic stress

in yourself or others

• Reach out to peer support team if you are interested in the program or

aware of an individual who may need support

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Acknowledgements

• Study Participants
• Dr. Treat – statistical analysis
• Kristina Parthum, MS3
• Drs. Pilarski and Klatt – leading peer

support program at FMLH

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REFERENCES

• Scott SD, Hirschinger LE, Cox KR et al (2009). The natural history of recovery for the healthcare provider second victim after adverse patient safety events. Journal of Quality

and Safety in Health Care; 18: 325-330

• Scott SD. Clinician peer support: caring for our own. Presented 1/30/2019 at Medical College of Wisconsin.
• Kohn LT, Corrigen JM, Donaldson MS (2000). To err is human: building a safer health system. Washington, DC: National Academy of Sciences Press.
• James JT (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety; 9(3) 122-128.
• MacDorman MF, Declercq E, Cabral H et al (2016). Is the United States maternal mortality rate increasing? Disentangling trends from measurement issues. Obstetrics and

Gynecology; 128(3): 447-455.

• Committee on Patient Safety and Quality Improvement. “Preparing for Clinical Emergencies in Obstetrics and Gynecology.” American College of Obstetrics and Gynecology

Committee Opinion Number 590. March, 2014.

• Nimmo A, Huggard P (2013). A systematic review of the measurement of compassion fatigue, vicarious trauma and secondary traumatic stress in physicians. Australasian

Journal of Disaster and Trauma Studies; 2013-1.

• Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM (2016). The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver

distress to turnover intentions and absenteeism. Journal of Patient Safety, 00-00.

• Robertson JJ, Long B (2018). Suffering in silence: medical error and its impact on health care providers. Journal of Emergency Medicine; 54(4): 402-409.
• Marmon LM, Heiss K (2015). Improving surgeon wellness: the second victim syndrome and quality of care. Seminars in Pediatric Surgery; 24(6) 315-318.
• Tawfik DS, Profit J, Morgenthaler TI et al (2018). Physician burnout, well-being and work unit safety grades in relationship to reported medical errors (2018). Mayo Clinic

Proceedings; 93(11): 1571-1580.