Peer support after stressful events

A program at Johns Hopkins provides a team of 39 peer responders who take turns volunteering to support clinicians affected by stressful cases.


Background

In 2001, a series of medical errors at Johns Hopkins Hospital led to the dehydration and death of Josie King, an 18-month-old burn victim. “It happened on my unit,” said pediatric nurse Cheryl Connors, RN, MS. “As a result, we lost a lot of good people by choice” over the following year, when some clinicians quit working on the unit or at Johns Hopkins.

Administrators eventually concluded that the hospital had harmed clinicians by not providing a therapeutic outlet after the horrible event, she said. This finding led them to support the creation of a peer program to provide immediate support for clinicians affected by stressful cases.

In 2010, Ms. Connors developed the Resilience in Stressful Events (RISE) program with a pediatric chaplain, a patient safety director, a doctoral student, and general internist Albert Wu, MD, FACP. “He actually coined the term the ‘second victim,’” referring to caregivers who become distressed after involvement in stressful medical events, Ms. Connors said.

Although a sentinel event sparked the program idea, calls come from employees involved in a range of situations, from severe, tragic events to care issues that result in minor or no harm, such as an IV infiltrate.

How it works

The RISE program, which launched in November 2011, provides a team of 39 peer responders who take turns volunteering their time to support clinicians who call the service. RISE team members include nurses, doctors, nurse practitioners, respiratory therapists, pastoral caregivers, and social workers. They undergo didactic, video-based, and role-playing training.

So far, more than 700 Johns Hopkins employees have called the team, Ms. Connors said. When employees request RISE, an on-call team member can immediately respond to a page. “We always offer to meet them in person, and most people want that, but some people prefer to talk on the phone,” Ms. Connors said.

Results

The RISE team was able to provide support to an experienced nurse who was devastated after a mistake contributed to a patient's adverse outcome. “The first words out of her mouth were, ‘I think it's time for me to throw in the towel,’” Ms. Connors said.

After an hour-long conversation focused on how the nurse was feeling, she stopped crying and became somewhat hopeful. “There was a visible change in her as we continued talking. This nurse is still working at Hopkins,” Ms. Connors said, noting that the nurse's manager called seven months after the meeting to say that she was doing better than ever at her job and even teaching new staff about how mistakes happen and how to prevent them.

The program also appears to be cost-saving for the hospital, according to a study published online in April by the Journal of Patient Safety. The analysis of nursing staff who used the RISE program between 2015 and 2016 found a net cost savings (through retention) of $22,576 per nurse and projected that it could save the hospital more than $1.8 million each year.

Although the study focused on nurses, doctors also use the confidential program. “In fact, it seems like doctors may need the program more because it seems like there's less informal support among the medical staff. . . . When I talk to doctors, there's often a lot of fear about admitting mistakes and feelings of stress or reconsidering their career choice,” Ms. Connors said.

The cost savings could be even greater if physicians were included in the analysis. “The impact would be huge because the cost of losing a physician is at least three times the cost of losing a nurse,” she said.

Challenges and next steps

In the beginning, the challenge for the RISE team was a very low volume of calls. Now it's the opposite. Sometimes the team receives several calls within 24 hours, Ms. Connors said. “We always connect with the caller, but to get a person physically there when the call volume is high in short periods of time is sometimes a challenge,” she said.

The hospital is now piloting a couple of related initiatives, including training a small cohort of residents in peer responder skills. “They actually won't be RISE responders, but the training will equip them with the skills to be able to take care of themselves and to be able to support their colleagues when things happen,” Ms. Connors said.

Because clinicians in some units, such as the ED and the ICU, encounter stressful events more often, the RISE team is piloting a more proactive approach in the ED, scheduling RISE visits on a regular basis and facilitating group sessions, Ms. Connors said. In addition, through an initiative called Caring for the Caregiver, Johns Hopkins partners with the Maryland Patient Safety Center to help other health care systems implement the RISE model.

Words of wisdom

The hospital already had a free program that enabled clinicians to make appointments with licensed mental health clinicians, but a survey of Johns Hopkins staff members indicated that most had experienced stressful events but did not use or want professional counseling, Ms. Connors noted. “They actually prefer somebody who knows what they're going through—another health caregiver who can relate—and when they need it, not a week later,” she said.