Enhancing Health Equity: The Potential of Peer Health Ambassadors
ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER …ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER SUPPORT...
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ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER SUPPORT TO IMPROVE HEALTH & WELLBEING OF NURSES Joanne Chapman, MSN, M.Ed., RN, NE-BC Director of Professional Practice/ Magnet Program Leslie Knight, BSN, RN, CMSRN Ambulatory Surgery Unit Maine Medical Center, Portland, Maine Maine Nursing Summit – March 22, 2017
Transcript of ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER …ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER SUPPORT...
ENHANCING A CULUTRE OF SAFETY: PEER-TO-PEER SUPPORT TO IMPROVE HEALTH & WELLBEING OF NURSES
Joanne Chapman, MSN, M.Ed., RN, NE-BC Director of Professional Practice/ Magnet Program
Leslie Knight, BSN, RN, CMSRN Ambulatory Surgery Unit
Maine Medical Center, Portland, Maine Maine Nursing Summit – March 22, 2017
About MMC
• 637 Bed Tertiary Care Teaching Hospital
• Level 1 Trauma Program
• U.S. News & World Report “One of America’s Best Hospitals” #1 Hospital in Maine
• Awaiting 3rd Magnet® Designation
Objectives • Describe second victim syndrome and effects on patient safety
and caregiver stress
• Describe how to develop and implement a peer support program
• Identify the benefits of a peer support program
• Work overload
• Time pressure
• Lack of social support
• Exposure to infectious disease
• Needle stick injures
• Exposure to work related violence or threats
• Role ambiguity
• Dealing with difficult or seriously ill patients
NIOSH Exposure to Stress
Why?
…and then something happens
Second Victim Syndrome “Virtually every practitioner knows the sickening realization of making a bad
mistake. You feel singled out and exposed—seized by the instinct to see if
anyone has noticed. You agonize about what to do, whether to tell anyone,
what to say. Later, the event replays itself over and over in your mind. You
question your competence but fear being discovered. You know you should
confess, but dread the prospect of potential punishment and of the patient's
anger. You may become overly attentive to the patient or family, lamenting
the failure to do so earlier and, if you haven't told them, wondering if they
know” Albert Wu
Presenter
Presentation Notes
What all of us are really talking about has been labeled as the second victim syndrome There is a term for this…..Second victim syndrome Albert Wu, Johns Hopkins University
Second Victim
“ a health care provider involved in an unanticipated
adverse patient event, medical error, and/or patient
related injury who becomes victimized in the sense that
the provider is traumatized by the event”
Susan Scott
Presenter
Presentation Notes
Commonly associated with medication errors, but various situations that can have an emotional impact on healthcare professionals. For example an individual might become a second victim after being involved with multiple trauma cases that result in a negative outcome, after being assigned to care for a violent patient or family or caring for a patient who was a victim of abuse. In a study by Susan Scott found that 30% of people surveyed n 898 reported personal problems as a result of a clinical patient safety even in the past year. 15% saying the contemplated leaving the profession.
Common Symptoms: Physical • Uncontrolled crying or shaking
• Increased blood pressure
• Extreme fatigue/exhaustion
• Abdominal discomfort
• Sleep disturbances
• Nausea, vomiting & diarrhea
• Muscle tension
• Headaches
Common Symptoms: Psychosocial • Extreme guilt, grief
• Repetitive, intrusive memories
• Difficulty concentrating
• Loss of confident, self doubt
• Return to work anxiety
• Excessive excitability
• Frustration, anger, depression
• Second guessing career
• Fear of damage to the professional life
• Avoidance of patient care areas
• Human errors, deaths, complications, and complaints will occur with some regularity
• May have a devastating effect
• Our training does not typically prepare us for this
• Compounded by lack of time to process events
• Complex system may contribute to increased frequency of events
Suffering in Silence
Presenter
Presentation Notes
Do we really need peer support? We process differently: Female second victims report more distress than men, more concerned about losing their job, more concerned about loss of confidence, damage to reputation and are more likely to discuss it, as well as attend training programs
Develop successful
Peer-to-Peer support system
How Can We Increase Workplace Wellness & Resilience?
Why Formal Support is Needed: Barriers for Individuals to Reach Out on Own
Stigma
Culture of endurance
Licensing fears
Inadequate workplace
support
Formal Programs • Employee Assistance Program (not utilized if the individual needs to seek this
out)
• Pastoral Care – Great for group debriefing
• Trauma intervention program (volunteer)
• ANA Healthy Nurse Healthy Nation – Self Care
• Peer-to-Peer Support & Conversation
Presenter
Presentation Notes
Underutilization of these programs one study found 1% of responsdants sought these out. 83% desired support from peers. Individuals want peer support.
Definition & Purpose of Peer Support Confidential program of Peers supporting other Peers who experience distress caused by workplace events:
To reduce isolation and shame
To provide a confidential outlet to discuss the event/circumstance and their reaction with someone who “has been there” or who can support them
Reinforce action steps for improved coping mechanisms, health and resiliency
Toolkit for additional resources
Presenter
Presentation Notes
A way to alleviate the impact on the second victim
Peer Support - Valuable • Standard practice: call to everyone
• Peer Support combats:
Culture of invulnerability: human factors
Shame and blame
Expectation of emotional denial: normalizes wide variety of reactions
Solely personal responsibility: systems issues
Isolation: community/solidarity
“Self care is selfish” – ANA Healthy Nurse/Healthy Nation
Presenter
Presentation Notes
Self care is not selfish, it’s important so that you can get back to doing what you do well
Setting Up a Program • Determine Point Person
• Partner with Risk/Patient Safety and take referrals from others
Need a consistent mechanism for referrals to identify those who need peer support
Cannot rely on individuals to seek out peer support or management team
Mechanisms for communication with peer supporters to make calls
• Recruit and train those who are interested and have a passion
• Peer Supports are just that: Peer supports, not psychotherapists
Presenter
Presentation Notes
Your compassionate listening is a gift to your. Colleague.
Situations Peer Support Offered
• Peer who was a patient had complications during her labor
• Medication Errors
• Assaulted by a patient
• Upset family member reported nurse to “state” facing apprehension and stress
• Peer found by colleagues and started CPR, coworker deceased
• Patient’s condition changed and nurse did not recognized
Outreach - Peer Support Call
• Contact (normalize the call, explain peer support)
• Invite individual to talk about what happened, how they are feeling
• Listen
• Reflect – honor emotions, validate, normalize
• Coping strategies
• Closing
• Resources/Referrals
Presenter
Presentation Notes
The outreach call- 7 points to hit Thoughts re Peer to Peer calls What is said when making first call Hi ____ I’m Leslie Knight from MMC, I’m a nurse in ASU and I’m calling as part of the Peer to Peer Support team. We’re a group of about a dozen nurses trained to support our peers when they’ve gone thru a difficult situation. Is this a good time to chat, or would you prefer to talk another time? If good time to talk I’m basically checking in to see how you’re doing. I understand you recently went thru a difficult situation at work, so I’m calling to offer my support… check in and make sure you’re doing okay… sleeping, eating, have the support you need at home and at work. And to see if you want to talk about what happened. Sometimes it really helps to share your experience with another nurse, someone who can relate as a nurse wasn’t involved. What we talk about, what you share with me, is strictly confidential. I don’t keep any notes and this is truly non-judgmental. Then I share what I know I was given your contact info thru our confidential email but nothing about the difficult situation you recently went thru… would you like to fill me in and talk about it? I understand there was a difficult situation you went thru with (an infant, a discharged patient, a medication issue, a very sick patient, etc.), but I don’t know more than that… would you like to share it with me? If not a good time I’ll make this quick… but I’m (introduce self and program) and basically checking in to see how you’re doing, offer you support, give you the opportunity to share confidentially with a peer. So please give me a call when you get the chance. Here’s my number and (when available). We can chat over the phone or perhaps meet somewhere at work. Whatever is best for you. If I don’t hear back from you in a few days, I’ll call you again to check in. Don’t hesitate to call or text anytime… if I don’t answer I’ll get back to you asap. Even if it’s in a month or so, it’s okay to call. If no answer, I leave a message A brief introduction and much of #4. Please give me a call when you get the chance, even if it’s just to say you’re doing fine and don’t feel the need to talk. If I don’t hear from you in a few days, I’ll give you another call. Hope you’re doing well… I look forward to hearing from you. During the conversation Important to speak in a calm, gentle, supportive voice… be mindful of the emotional trauma. The peer deserves kindness and respect and compassion. Be honest and open. Be selective in when to interject or interrupt. Actively listen. Allow the person to process, jump all over the place in conversation. Be non-judgmental, let peer share with free flowing thoughts. Use validating/supportive comments: “I hear what you’re sharing with me.” “I respect how that must make you feel.” “I’ve been thru a similar situation, so I can relate to how you must feel.” “It sounds like you did everything you thought was best.” “It sounds like it really was out of your hands.” “You are human, we all make mistakes, but there is good that can come out of a bad situation. And you can be part of that good.” “Your emotions tell me you’re HUMAN! Many of the emotions you’re feeling are to be expected, you need to honor those emotions and allow yourself the chance to process and work this through. Be patient with yourself and give yourself the time you need.” “From everything you’ve shared with me, it’s sounds like you’re a really good nurse and a really good person” (sounds judgmental, but I use that when I know it’s appropriate, response is often: “thank you, I really needed to hear that”). If peer expresses frustration that family and friends don’t understand: “It’s often difficult to share the details with family and friends. They don’t always understand what we do as nurses, that’s why sharing it with a peer can be helpful. But it’s important that they are there for you in whatever way they can be.” Be supportive of the stages peer is going thru… acceptance, sadness, self-doubt, questioning if the nursing profession is the right one, etc. Actively listen! Encourage peer to give her/himself time. Offer to follow up in a week or so, allows you to check in to see if they’re moving thru the process, if still obsessing and “time doesn’t seem to be healing”. If “stuck” or “red flags”, referral may be needed. Some conversations last for only 10 mins, but most up to an hour. Be selective in when you call. Find a quiet time, when you expect no interruptions and are able to be focused and attentive. The peer nurse on the other end is feeling vigilant, emotions are heightened, so may be more aware than normal if not receiving full attention. End of the conversation… “do you want to talk again?” or “sounds like it would be good to chat in a about a week”, if so when and who will initiate the call. Remind peer that you’re available, even if it’s a month or so down the road. If it is agreed no additional call needed, but IRB meeting is pending, offer to be available before and/or after the IRB meeting. Encourage peer to be honest and open, trust her/himself, that the IRB meeting may provide the opportunity for much good to come out of a very difficult situation, that it may ultimately benefit other patients or families or care providers. Support the individual in self-care! Allow emotions to run their course, allow for sadness, anger, confusion, etc. Similar to a grieving process, it is different for each person. Encourage self care: honor yourself and your emotions, try to stay rested, eat well, get some exercise, meditation/yoga… truly listen to your body and your mind and your heart… and take care of yourself. If you need additional support, then reach out for it… whether it’s a support group, a counselor, primary care physician. That isn’t a sign of weakness, you are human. You deserve to heal with support and guidance. Ending the conversation, I always reiterate that I am available, for peer to reach out whenever support is needed, even months down the road. And I always say how grateful I was that she/he was willing to share with me. * I truly feel it is an honor to be allowed into someone’s life during such a vulnerable time…! Comments shared with me It is so great that we have this program. Thank you so much for calling me. I’m really doing fine, but it’s great to know you’re there. Very grateful for the support and calls, reinforced that MMC really cares. Grateful for the peer support program and the connection made by someone from “outside of work” environment. Very grateful for the Peer to Peer Support Program. Felt discussing with the situation and sharing with another RN who isn’t involved, in a non-judgmental and confidential way, helped her move forward. Would definitely recommend it to others. Expressed appreciation for the Peer to Peer Support Program. Thought she had been coping well, until given the opportunity to share with another RN and later said “I guess I really needed that!” Thank you so much for calling. I can’t talk right now, but I’ll call you when I can. Just knowing you’re there is great. I’m getting lots of support from my manager and peers, so I think I’m all set. But I’ll call you if I need to. It’s so great we have this program. Examples of Situations RN - Patient from several floors above fell out of window and landed on roof outside patient room window; nurse in room with her patients when this occurred. RN - Patient discharged without respiratory equipment, RN didn’t feel it was safe for patient to be discharge, resident insisted patient leave, was found dead by young son next day. RN - Patient died soon after placement of NG tube, comorbidities, CXR to verify placement not done per protocol. Cause of death questioned, ? NG tube placement, found to not be the cause. Certified nurse aide - Wrong patient brought into patient care room, not ID’d by physician, wrong treatment discussed and started. Certified nurse aide, RN - Assaulted by patient. Bitten by a patient. Sleep Study staff - Peer found dead, CPR without success… 3 employees involved. RN - Patient became very ill during nite shift, new nurse did one on one, did not feel supported by physician but peers supportive. Lots of doubt re how she communicated to physician, what more she could’ve done. RN - Peer developed life threatening situation while in labor and her peers were her nurses. RN - Urine pregnancy test performed by certified nurse aide, positive but read as negative. Nurse was under pressure to get patient ready for surgery, did not read test. Fetus found too late during hysterectomy. RN - Med errors. One peer commented: It was the absolute worst thing that has happened to me in my life. Security guard – Assaulted by patient. RN - She and peers reported to State by patient and family. Believes they did nothing clinically incorrect. Great deal of apprehension and stress related to impact of future findings, feeling of incompetence and having to prove/defend self to peers. 1. Context- normalizes the call, explain the peer support program Hi. I am one of the peer supporters here. I'm just calling to check on how you're doing. We actually reach out to any clinician involved in an adverse event- only because it can often be really stressful. Every clinician I know has been in this position at some point in their career, and I have too. We’ve found that most of us appreciate talking to a peer because it's hard for other people to really get how bad this can fee/, 2. Invitation Would it help you to talk about what happened and how you're feeling? 3. Listen -to the story, how they are feeling, how they are coping 4. ·Reflect- honor their emotions, validate, normalize These events can be really traumatic. As you know, as with most traumatic events, the difficult feelings usually slowly lessen over time, The fact that you are upset shows that you are a caring, committed physician. Everyone reacts differently to these events, so I am in no way saying that I know exactly what you are going through. But we do know that most of us have some common reactions. 5. Coping- rephrase, normalize/put in perspective, elicit their personal coping strategies, discuss their support system, and stress importance of self-care and of mindfulness I'm going to tell you some things that you already know on an intellectual level, because sometimes it's important to hear from a peer: Humans make errors at predictable rates; it's our job as an institution to create systems that prevent errors from reaching the patient. You are not a bad physician and you have done so much good for people. You are not your error. Are you sleeping OK? It's so important to do what you can to take care of yourself at stressful times like this.'· I don’t know if you've found this, but it's really common to keep going over this event in your mind. I know I found myself doing this whenever I wasn't distracted, and it can really be frustrating, Is that happening to you? A lot of us ore a bit perfectionistic and slightly obsessive which is a great quality most of the time. It's -. important that you are taking personal responsibility and that you have /: I am thinking about what you have learned. But at some point obsessing just isn't helpful. Techniques to interrupt the feedback loop: notice when you are doing! it, and then gently bring your thoughts back to breathing or to the present. Sometimes exercise .or other distractions ore helpful as well. What have you done in the past that has helped you through difficult times? What are your usual supports or strategies for dealing with emotionally stressful events? 6. Closing- repeats putting in perspective, offer sense-making Remember how much good you have done. This happened because you are human, not because you are a bad doc. if you can work with your program on looking at systems issues, then you can help prevent your colleague [rain making a similar error in the future, which is bound to happen. 7. Resources/referrals-offer to all As I mentioned, you may slowly start to feel better. But if you find that this gets under your skin in some way that is Impairing your coping, please let us know. We don't want you to suffer. You are not alone. if you have any questions or concerns, let me know, and I'll make sure you get help from whomever you need [provide your peer support contact information] _ Have on hand other resources within your organization- mental health professionals, risk management
Peer Response – Examples • It is so great that we have this program. Thank you so much for calling
me. I’m really doing fine, but it’s great to know you’re there.
• Very grateful for the support and calls, reinforced that MMC really cares.
• Grateful for the peer support program and the connection made by someone from “outside of work” environment.
• Very grateful for the Peer-to-Peer Support Program. Felt discussing the situation and sharing with another RN who isn’t involved, in a non-judgmental and confidential way, helped her move forward. Would definitely recommend it to others.
Peer Response – Examples • Expressed appreciation for Program. Thought she had been coping well,
until given the opportunity to share with another RN and later said “I guess I really needed that!”
• Thank you so much for calling. I can’t talk right now, but I’ll call you when I can. Just knowing you’re there is great.
• I’m getting lots of support from my manager and peers, so I think I’m all set. But I’ll call you if I need to. It’s so great we have this program.
Pitfalls of Confidential Program • Avoid getting drawn into commenting on the case
• How much you share about your own experience will depend on your judgment in any given situation
• It's important to set a high bar for breaking confidentiality. Your role is not to judge the person's competence. However, if you think the person is behaving recklessly (i.e., is at risk of harming himself or others) you do have a duty to report.
Pitfalls of Confidential Program Remember:
• Denial can be a healthy coping mechanism for many people
• No one should be made to talk about an event. Let them know that you understand and that you’re available if they change their mind.
Summary • Offered to everyone – automatic referral but referrals from peers/
managers/directors accepted as well
• Need trained staff who can actively listen
• Expanded outside nursing
Physicians have program
But others need peer support
• Confidential
Would love evaluation but since confidential, no evaluation.
• Program is contributing to resilience in employee wellness and KEEPS NURSES WORKING in field!
