The following blog is based around a conversation between Pernille Cedergreen (Chief Physician, Dept. for Anesthesia, Surgery and Intensive Care, Herlev & Gentofte Hospital, Copenhagen) and members of the MeSu (Mental sundhed for sundhedsprofessionelle*) project team comprising clinical, research and improvement experts. As head of the clinical leadership team, Dr Cedergreen was becoming increasingly aware of the impact that COVID-19 was having on the psychological wellbeing of her colleagues and was keen to do something that went beyond a simple ‘sticking-plaster’ approach to remedy the situation.
Set out below is the background to how and why her department is collaborating with local research and implementation experts with the aim of testing a new model which focuses on building individual and organisational resilience to support the delivering of high quality and safe care during challenging times. MeSu is a pilot project funded for 8 months to test innovative approaches and interventions in the Department for Anesthesia, Surgery, and Intensive Care, at Herlev & Gentofte Hospital, in the Capital Region of Denmark.
*Directly translated, this means ‘Mental health of healthcare professionals’, but in this context, ‘Mental sundhed’ encapsulates a state of wellbeing in which the individual can develop their skills, deal with everyday challenges and stress, and form relationships with other people. Mental health is thus not only the absence of mental illness, but also consists of psychological resources and abilities that are necessary to be able to develop and cope with the challenges that arise in the lives of all people.
Pernille Cedergreen (PC): As a leader of a multidisciplinary clinical team, I have always been aware of the psychological impact of delivering critical healthcare on the wellbeing of my team. However, the COVID-19 crisis has added significantly to this. In the last year, I have seen how staff, who already work in highly challenging circumstances, have had an extra layer of complexity added both to their work, and their private lives. Although this is deeply concerning for me as a leader, I have tried to find positives, and look for opportunities.
MeSu project team (Mpt): Internationally, the COVID-19 crisis has put the psychological health of healthcare professionals (HCP) on top of the priority list to help support patient safety and excellent health care. In addition to the everyday psychological challenges connected to work which involves patients and relatives, many of whom are in crisis, many of the decisions HCP’s make have significant consequences. Because of this, there is a high chance that at some point in their professional life, they will experience a serious event or error. All in all, this constitutes an exceptional challenge to the health and wellbeing of HCP’s.
PC: Virtually every HCP knows the sickening feeling of being involved in a serious event or making a bad mistake. These are significant, but fortunately, relatively rare events. Less rare, are the more subtle events or experiences which have an impact on the wellbeing of HCP’s. For example, we know from speaking with staff, that many are becoming increasingly frustrated that due to time and resource pressures, they feel unable to fulfill their professional role to the standard that they would like. They feel overwhelmed. These small-scale, yet more frequent events also have an accumulative impact on staff wellbeing.
Mpt: Over 20 years ago, Albert Wu coined the term ‘the second victim’ which referred to HCP’s who become involved in unanticipated adverse patient events, medical errors, or patient-related injuries. He stated that HCP’s can become victimized in the sense that they are ‘psychologically traumatized by the event’. Indeed, the literature points to the fact that up to two-thirds of HCP’s have experienced severe psychological reactions as ‘second victims’ at one or more times in their career. Although there is less literature specific to the daily challenges associated with delivering care during COVID-19, we know anecdotally, that this is also leading to increased frustration and distress amongst staff.
PC: I am seeing this more and more. And the related issues are a real concern.
Mpt: There are important consequences of HCP’s performing under psychological distress; their decision-making may be prolonged or flawed, which in turn may lead to defensive medicine and errors. Furthermore anxiety, stress, depression and associated psychological issues are the leading causes of sickness absence in healthcare. And this can lead to high job rotation, and thus, a potential decrease in patient safety and care quality. And let’s not forget, the potential financial impact. What is your perspective on this?
PC: All of these are important and concerning. So, the obvious question from my perspective was: ‘what can be done about this?’
Mpt: There is a broad body of research evidence indicating that contextual factors are critical. If we focus for example, on the issue of psychological safety in teams, which is the sense that people won’t embarrass or ridicule you for speaking up, raising a concern or asking a question, the evidence indicates that various factors influence this feeling. These factors include leadership behaviour, a supportive organisational infrastructure, and intragroup relationships. So, if leaders focus on improving these contextual factors, to support psychological safety, the outcomes will be positive. And by positive, we mean, more people speaking up, asking for help, and asking for feedback. These are the kind of actions we would associate with teams engaged in a culture of learning, and indicators of resilience against the challenges which can beset HCP’s. We believe this is important, because if HCP’s don’t feel safe to share their concerns or engage in something new, the success of any intervention is likely to be limited.
So, if we apply that ‘supportive context model’ to the issue of ‘second victim’, the evidence over the last 20 years has identified some key components that would be important in helping to reduce the impact associated with the second victim phenomenon, or indeed the ongoing distress accumulated from inevitable everyday stressors found in the clinical setting. First and foremost, HCP’s express the need to be able to talk to close peers in direct connection to the stressful episodes. Ideally HCP’s should also have access to evidence-based interventions such as debriefing and defusing, and the organisation should actively support a culture of openness and learning.
Several institutions have implemented programs trying to achieve this, for example, SVEST, For YOU, RISE, MITSS, ASSIST-ME, Byddy Study, etc., however, many of these programs have experienced difficulties in implementation and sustainability.
Our plan and intervention
Mpt: Based on the knowledge above, we realized that the work to prevent psychological distress should not be reserved to rare occurrences where HCP’s are involved in serious adverse events, but rather to all the daily clinical situations which could pose psychological distress.
PC: In that sense, the intension is to be both responsive to issues as they arise, but also to be proactive. For our department to invest in the infrastructure and culture that will lead to a reduced need for reactive interventions, whilst also making evidence-based interventions available for those that need them. As such, we’re aiming to build individual and organisational resilience.
Mpt: We assembled a group of psychologists, specialists in patient safety, cultural development and work environmental medicine, doctors, midwives, and nurses. This group put together a comprehensive program of theoretical learning in mental distress and psychological first aide, practical training in ‘supportive conversations’ among peers, and defusing. Underpinning these interventions, we are aiming to improve the psychological safety, and overall learning culture within the department, with the ultimate aim of reducing the level of emotional distress among HCP’s. Although we regard this as a pilot project, the scale is still quite large; the department has over 400 staff.
The key intervention of our model is the ‘supportive conversation’ among peers. The basic elements in this are knowledge of and training in how to initiate and perform this kind of supportive conversation among clinicians in situ. To supplement this, we will educate and train a number of identified clinicians and leaders to deliver evidence-based interventions, such as defusing. These will be relevant for more significant events or experiences. For the most severe events, access to dedicated psychological services will be available. Building the skills and knowledge within the staff team will contribute to the long-term goal of sustaining the program beyond the lifetime of the project.
PC: A crucial element of the model is the lengthy implementation period, where program managers and clinical leaders visit each team on a weekly basis, to discuss progress with HCP’s and to support learning based on the local experiences. So far, this process has helped to build interest in the project and motivation amongst the staff, especially the leaders – some of whom, it’s fair to say, had their doubts about the need to engage in this program. We believe this process will also contribute to the prolongation of the program.
Mpt: Importantly, the program includes improvement science methodology, where data are gathered frequently, from each intervention and incorporated into the collective curriculum iteratively, and thus generating the basis for the next implementation. In terms of the data, we are collecting qualitative and quantitative data in the form of interviews, questionaries, the number and types of issues covered in the supportive conservations, as well as organisational level data, such as staff sickness rates and job rotation. Some of these measures involve established, standardized tools, whilst others we have had to develop ourselves. However, if this model of interventions and implementation is successful, there is potential for it to be tested in other departments across the hospital, Denmark or indeed internationally.
We aim to share the results in a range of places, including internal papers, conferences, and peer reviewed articles. We have a page on our website (https://patientsikkerhed.dk/projekter/mentalsundhed/) which provides more detailed information about the project and will be updated over time. However, we would welcome any contact from individuals or organisations engaged in related activities who wish to share their experiences of working on similar issues such as ‘second victim’ or staff wellbeing in general and specifically during COVID-19.
We are very grateful for the support and funding from ‘Velliv Foreningen’.
The title of this blog was inspired by a quote from Dr Donald Berwick in his article ‘Choices for the “New Normal”’ (2020) in which he sets out the difference between reacting to the challenges that healthcare (society) experiences and being proactive (making active choices). We believe the MeSu project aligns with the principle of making choices and being active in the future of our most precious resource, healthcare staff. By investing in developing the infrastructure that can support the psychological health of HCP’s in their everyday work – which will inevitably include errors and distress, we will build resilience into the system and the individuals working within that system.
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Jacob Nielsen, MD and project manager, Danish Society for Patient Safety
Simon Tulloch, Psychologist and Senior Consultant, Danish Society for Patient Safety
Pernille Cedergreen, MD, Herlev-Gentofte Hospital, University of Copenhagen
Doris Østergaard, Professor, MD, Copenhagen Academy of Medical Simulation (CAMES)
Marlene Dyrløv Madsen, specialist consultant, CAMES, Herlev Hospital
Jacob Nielsen: firstname.lastname@example.org