Taking Care of Our Caregivers

The Role for Structured Debriefing After Adverse Patient Outcomes

Clinical work can take an emotional toll on health care providers. Especially, when despite our best intentions; one of our patients gets sicker unexpectedly or as a result of the care that we have provided. This can be difficult and, at times, traumatic not just for the family and friends of the patient, but for those involved in his/her care.  While the priority is our patients and their families during these stressful and potentially life-altering events, it is important to recognize that adverse outcomes in hospitalized patients also affect health care providers.

Nearly one-half of all health care providers report having been involved in an adverse patient outcome which affected their personal or professional lives. Research shows that medical students, nurses, residents and attending physicians all may experience feelings of guilt, frustration or sadness related to adverse events. Such reactions are often intense and may result in significant personal suffering, especially when patient outcomes are worse, and personal responsibility is perceived to be greater. Regardless of whether a medical error has occurred, health care providers may experience a range of emotions from acute grief to the development of post-traumatic stress disorder. Many suffer silently and may experience long-term consequences including depression and burnout. In extreme cases, providers may even choose to change professions.

Every provider has a different strategy for dealing with poor patient outcomes. Some are constructive – seeking social support and proactive changes in practice. Others choose to avoid coping with it all together. Avoidance as a strategy may ultimately hurt the patient more, damage the relationship between patient and provider and damage the provider’s relationship with future patients.

Hospitals and training programs review and evaluate adverse patient outcomes using team debriefings and morbidity and mortality conferences.There are also formal institutional review processes. The goal of these reviews is to use the information gathered to make meaningful organizational change in an effort to prevent similar adverse outcomes in the future. While certainly an important undertaking, these investigations may lack adequate emotional and/or structured support for the involved healthcare professionals.

On the other hand, informal team debriefings may focus on systems analysis as well as the psychological and emotional aspects of the case.Studies have shown that involvement of senior staff members who share their own past experience may be particularly valuable. Fostering empathy and support within the institutional review process is likely to lead to enhanced reporting of adverse events, more effective evaluation and growth for both the provider and healthcare institution.

The aviation industry, as well as firefighters and other first responders have long utilized Critical Incident Stress Debriefings (CISD) to help them manage work related stress and trauma. CISD has been shown to reduce the incidence of PTSD, suicide and substance abuse following traumatic incidents in these professions. Several prominent health care organizations, such as the University of Missouri and Johns Hopkins University, have adapted this model to create their ‘forYOU’ and Resilience in Stressful Events (RISE) programs. These teams consist of clinicians trained in crisis support and stress management that provide “psychological first aid” for individuals involved in unanticipated or stressful events. 

Creating a culture of openness and support for patients and providers through widespread adoption of structured debriefing models is likely to enhance patient safety, while improving the well-being of care providers. It will also decrease staff turnover. Future efforts to improve structured support for healthcare providers involved in adverse patient outcomes are critical to reduce the negative impact of adverse events and their aftermath on health care providers, their patients and health care organizations as a whole.

For more information on peer support programs in health care visit: John Hopkins University's RISE: Resilience in Stressful Events page, the University of Missouri's forYou Team page and Brigham and Women's Hospital's Peer Support Programs page.