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

4/3/2019 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.” 1

4/3/2019 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) 2

4/3/2019 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 3

4/3/2019 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 Focus Groups/Interviews >50% generalists Generalist Sub-Specialists Residents Faculty Unidentified 4

4/3/2019 OUR EXPERIENCE: Basics KNOWLEDGE OF TERMS 45 40 35 30 25 20 15 10 5 0 Very Familiar Somewhat Not Familiar Familiar 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 • 5

4/3/2019 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 “There are things I go mind…what could back to hours or days I have done later, weeks later and differently?” I’ll go back and forth on it.” 6

4/3/2019 OUR EXPERIENCE: Symptoms • Sleep Disturbance “I wasn’t sleeping. I kept going back and forth about all the “It kind of preoccupies your things that we did. I mind a lot, can awaken you from sleep…it occupies a was very anxious lot, a lot of time…waste a lot about it.” of time on continuous “Difficulties falling thoughts.” thoughts.” asleep…just thinking about it. Just kind of heart racing, laying in bed, unable to calm down.” 13 OUR EXPERIENCE: Symptoms • Guilt “[There’s a] fine line between doing something wrong that “Sometimes it’s hard to tease out leads to a bad outcome and the second victim versus the not doing enough right to secondary trauma because a lot prevent the bad outcome…I of times I make myself into a mean, my job is to prevent the victim whether I actually bad stuff from happening and committed an error or not.” sometimes I don’t, or I can’t.” “I feel like I should have less tolerance for “I think if you do something my own mistakes because I have so unintentionally, you still did much more experience. I consider something that could have myself more responsible if I’m the caused it [the bad outcome].” senior person in the room.” 7

4/3/2019 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.” 16 8

4/3/2019 OUR EXPERIENCE: Behavioral Impact Task Task Avoidance Avoidance Hypervigilance Hypervigilance OUR EXPERIENCE: Behavioral Impact • Task avoidance • Avoiding patients • Avoiding colleagues • [I felt] more cautious and avoided certain  [I would] try to hide from everyone cases or being alone. else • That patient would come back for some  [I was] less willing to help people that other reason…and part of me just didn’t asked me for help…I didn’t want to want to see her…as much as you’re not be a good assistant for them interested in what happened to them, it sort of bubbles up again if they come back to you for something else. 18 9

4/3/2019 OUR EXPERIENCE: Behavioral Impact “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.” Hypervigilance “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.” 19 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. 10

4/3/2019 OUR EXPERIENCE: Protective Factors • Compartmentalizing Personal & Professional “One of my things is trying to find balance “I think just separating yourself and because this job could completely consume you realizing you have a separate life outside of and it could take up every hour of every day. work has been my most helpful way that I And I know to find that balance I’m probably not manage that…just putting it in a box getting as much done professionally as I could, somewhere on a shelf and just kind of but I think that’s a commitment that I’m OK with moving on and enjoying the positive parts of because I have to enjoy life too.” life has helped me.” OUR EXPERIENCE: Protective Factors “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’.” 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.” 11

4/3/2019 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 12

4/3/2019 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) 13