The urgent case to support staff after adverse events

Bad outcomes can weigh heavily on a doctor’s mind. The failed resuscitation attempt on an after-hours shift. A missed investigation and subsequent clinical deterioration. Worse still, the wrong diagnosis, a serious complication, or patient suicide or unexpected death; and the way it changes our clinical practice, are forever a reminder of the patient we couldn’t save. 

Often not given voice or name, doctors can be deeply affected by the adverse events in their career, including where there is no malpractice or negligence. We are by nature perfectionists and overly conscientious, driven by service and a desire to help others. When things go wrong it can affront not only our work lives, but our core sense of self. Investigations, legal proceedings or coroner’s court processes may be necessary, but often prolong and worsen the suffering. Feelings of guilt, anger, frustration, distress and fear are common. Many consider or make a change in career. Some burn out or leave the profession. Sadly, depression and even suicide can occur.

Doctors as second victims

Fortunately, this concept of ‘second victims’ as 'healthcare providers involved in an unanticipated adverse patient event, medical error or patient related injury...[who become]...traumatized by the event’ is now fairly well-researched and understood. Such research does not detract from the primary victims — the patients and their families — but bolsters the health system and the care we provide. Distressed and unwell doctors are not functioning at their best; and their suffering alone is enough justification for action. 

Staff peer support programs offer a systemic solution, having their origins in vanguard organisations in the US. These early programs now have evidence of improved emotional state and return-to-work outcomes. Such programs have spread globally, and increasingly we are seeing them here in Australia and New Zealand. Based on early research, staff peer support provides an extra intervention between the informal support we provide each other, and the professional support provided by trained mental health clinicians. Embedded within Restorative and Just Culture principles, operationalised staff peer support reminds us that many people are harmed in adverse events, and aims to heal those harms without blame or retribution.

Colleague care

Colleague Care is our Sydney Local Health District all-staff peer support program, open to all thirteen thousand staff in our District in recognition that it is not just doctors or even just clinicians who are impacted by adverse events. This program, piloted briefly before COVID-19 but now running sustainably since 2022, is only possible due to the dedicated funding of a doctor wellbeing team, MDOK (Medical Doctor OK). Resourcing such a team ensures that wellbeing initiatives, often driven by enthusiastic and committed staff, remain sustainable in the long-term, rather than faltering when individual clinicians move on.

Colleague Care models itself on common principles found across staff peer support programs nationally and internationally. Our scope is to support staff after adverse events, which can range from near misses, medication errors and difficult CERS responses, to sentinal events, unexpected deaths, staff injury and legal matters. We train trusted and experienced staff to become ‘peer responders’. Any staff member can access the program without a referral, finding details on the intranet and reaching out to peer responders directly. The interaction is non-clinical — it is two colleagues spending time together, a 'friendly ear', sharing of lived experiences of adverse events, and what might be helpful to move on, including linking to other services. 

Confidentiality and trust in the program has been essential, and the program sits within the wellbeing team, separate from clinical governance, line management and human resources. Whilst de-identified data is collected, no notes or records are kept of people accessing the program. Running on fractional staffing, we are fortunate to have a coalition of exceptional humans supporting the program in addition to their usual roles — medical educators providing the training, psychologists supervising our peers, and of course, our generous peer responders, many of whom have had a negative experience themselves in an adverse event, and wish only to prevent this for others.

A growing uptake in Colleague Care

Programs like this take time to build trust and awareness, and we have seen over the past three years a slow but growing uptake. We know that approximately 31% of our program use comes from doctors — a close match to their workforce proportion, and a sign of the program’s acceptability. Current data shows the most common reason for doctors to use the program is legal reasons (52%), followed by other serious events (‘Harm-score 1 or 2’) (18%) and patient complaints (9%). The number of catch-ups can vary, but with a median of two, for just over an hour total, one can imagine two cups of coffee; the first to debrief the shock of the incident, and the second to prepare or debrief for the investigation process. Hearteningly, over 70% of staff who utilise the program go on to access other supports, with unions, defence organisations, legal teams, and private mental health clinicians or GPs being the most common. Unsurprisingly, doctors are less likely to access other supports compared to peers.

Staff peer support programs function as more than just a formalised buddy system. They complement rather than replace other supports. They allow a conversation about what can go wrong in healthcare, reminding colleagues they are not alone when it does happen. As much as we should try to avoid adverse events, we need to normalise that these things will happen. Such programs skill us to check in with our impacted colleagues, rather than being complicit in their isolation through silence. 

As hospitals have rightly allocated resources and time to investigating and avoiding adverse events, hopefully a new paradigm further brings systemic support for the doctors and other clinicians impacted as well.

Dr Sarah Michael is the Director of Psychological Wellbeing with the MDOK Program