There is a growing realization that health care organizations are not doing enough to support their health care workers.
We are in the midst of a crisis of clinician burnout, fueled by increases in workload and mandatory documentation and by reductions in autonomy and meaningful time with patients.1 These stressors are layered on top of the daily strains of patient care and interactions with families and co-workers. In this environment, clinicians sometime deal with patients harmed by care, and even with workplace violence. Burnout can have devastating personal consequences and can detract from the quality of care, leading to more medication errors and health care-associated infections, poorer perceptions of safety, and increased mortality.1-3
There is now momentum to pay more attention to the health of health care workers. In 2018, The Joint Commission emphasized the importance of creating peer support programs for health care workers, exposed to patient adverse events, which can manifest as symptoms similar to posttraumatic stress disorder after exposure to patient adverse events.4 As a program model, they recommended the Resilience in Stressful Events (RISE) service at The Johns Hopkins Hospital.
RISE was established in 2011, 10 years after a tragic death in the Johns Hopkins Children's Center. Josie King was a pediatric patient hospitalized for severe burns after a bathtub scalding accident. Although Josie was gradually recovering, a series of failures in care led to her death. Johns Hopkins quickly investigated. When Josie's death was found preventable, her story was disclosed publicly, with an apology, full acceptance of responsibility, and a pledge to improve patient safety.
Patient safety rose quickly to be a top priority for Johns Hopkins. Although the term "second victim" was coined more than a year before Josie's death, the hospital did not recognize the trauma faced by staff nor made plans to support them.5 Several staff members involved in Josie's care felt unsupported and left the unit in the year after her death.
As patient safety evolved at Johns Hopkins, leaders began to appreciate that they failed to care for the health care workers involved in Josie's care. In addition, a second root cause analysis conducted years after the first investigation identified inaccuracies in the contributing factors identified in the initial report. From that point forward, leaders in patient safety made a commitment to provide institutional support for health care workers.
A small multidisciplinary team assembled in 2011, passionate and motivated to develop a support initiative. Little financial support was available for this new program, but 18 staff members from different disciplines across the health system volunteered to serve as peer responders. They were trained to provide psychological first aid and committed to being available 24 hours/7 days a week through an on-call rotation. As hospital workers gradually began to seek support, team members devoted themselves to learning from each call.
Although initial use of RISE was low, the program is now believed to be shifting the culture at Johns Hopkins to greater acceptance of the need for staff support. The mission of RISE is "to provide timely confidential peer support to any employee who encounters a stressful patient-related event." Staff who call now freely acknowledge the feelings they experience from a range of scenarios, from tragic events to daily stresses they endure as caregivers in a hospital setting. The encounters seem to normalize talking about stressful experiences both in private and in groups.
Because the encounters are strictly confidential, follow-up data on individual calls are not collected systematically, and evaluating the impact of RISE is a challenge. However, theory suggests that talking about psychological stress can improve well-being and can help workers continue to perform their duties (Unpublished data, Cheryl Connors, DNP, RN, NEA-BC; July 9, 2019). Preliminary results demonstrate that RISE is perceived as beneficial to leadership and frontline staff of all disciplines, has contributed to improvements in culture, productivity, and turnover, and is extremely rewarding for the volunteers who serve on the team. Anecdotally, one of the nurses who cared for Josie in 2001 met with RISE to share her personal journey. After meeting with the RISE team, she reported that "the opportunity to share this painful journey with others lifted a 10,000 pound weight from my heart." She verbalized a great sense of relief and felt proud to be part of an organization that would recognize the need and value of supporting its staff.
In 2013, the Maryland Patient Safety Center sponsored RISE to develop a peer support program model for other hospitals in Maryland. The product, entitled "Caring for the Caregiver," is a 2-day curriculum to teach health care organizations how to implement similar peer support programs in their own settings.6 To date, RISE has partnered with 26 institutions across the United States and worldwide and has been implemented in large academic medical centers similar to Johns Hopkins, as well as settings differing from it in size, scope, and organization. With local adaptation, it appears that the most important elements of the program can translate into practice in a variety of contexts (Table).
There is continued progress at the national level. In May 2019, the National Academy of Medicine hosted a meeting on establishing clinician well-being as a national priority.1 We believe that health care organizations can and should do more to support their most valuable asset-their health care workers. Caring for the caregivers is necessary to provide safer care for our patients.
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