Human Factors in Patient Safety - Fellowship Update 2

Outside the Emergency Department at The Johns Hopkins Hospital

Outside the Emergency Department at The Johns Hopkins Hospital


I am sure we can all agree that working in an emergency department can at time be stressful, busy, emotionally charged and requires us to move from one case to the next often without thought or hesitation. There is also a well recognised issue with recruitment and retention of all staff in the specialty of emergency medicine. Our department attracts some of the most compassionate, hard working and kind staff you will find anywhere in the hospital and I was interested to find out what steps other organisations take to support their staff and encourage resiliency. In addition, how do they support them when they feel overwhelmed, things have not gone well or there has been an adverse event. 

Since we last spoke I have been spending time with some pretty cool people at The Johns Hopkins Hospital learning about RISE (Resilience in Stressful Events). This is a peer-led support programme that is offered to all staff throughout the hospital. I have been intrigued and interested to find out why this was implemented, how it works, what the culture of their organisation is like and has it worked. 

The literature states that organisations often fail to recognise the impact of adverse events on healthcare providers who can suffer emotional distress after the same incidents that harm patients. The concept of the healthcare worker as a “second victim” and the hospital often as a “third victim” is frequently mentioned. Those who become a “second victim” can experience a wide range of adverse effects including sleep disturbance, anxiety and even depression. This in turn leads to healthcare workers who are distressed and at risk of making further mistakes. There may be an increased rate of sick leave and subsequent turnover of staff which can be costly to an organisation. 

The Johns Hopkins Hospital is only one of a few hospital in the United States to adopt a peer-led support programme. It was implemented initially on the paediatric ward in 2011 when several second victims were identified after a tragic and highly publicised death of child on the ward as a result of an adverse event. The programme was subsequently rolled out hospital wide in 2012. There are currently 35 trained peer providers who take it in turn to be “on-call” for the week.

The mission of RISE is “to provide timely support to employees who encounter stressful patient-related events - defined as including adverse events, medical errors, deaths, unexpected outcomes, non-accidental trauma, and difficult or violent interactions. Support is offered 24 hours per day and seven days per week in a peer-to-peer or group format depending on the request. The support is provided by peers: colleagues who work in the hospital environment and who have been trained to provide appropriate support.” It is confidential and completely separate from any investigation into how an adverse event occurred. 

The programme is led by Professor Albert Wu. He is a Professor of Health Policy and Management and Medicine at Johns Hopkins. He leads the Armstrong Institute centre for measures of quality of care and patient safety and is a leading expert on disclosure and the psychological impact of medical errors on both patients and caregivers. He is so approachable and an all round good guy who is both interested and interesting. Since our first meeting he has set me to work reading many papers about the RISE programme/second victim/psychological first aid, peer reviewing for a journal and encouraging me to write more. I have been writing  about my experiences and also an outline plan for a future project. We have been meeting regularly to discuss my progress. 

Through Albert I have been lucky enough to also meet and spend time with several members of the RISE team. This allowed me an opportunity to pick their brains and find out first hand what it is like being a RISE provider. They were also able to give me some insight into the culture of their organisation and how it has changed over the years. I spent time with Matt Norvell the paediatric hospital chaplain, his main role is to provide emotional support to patients and families so it seemed a great fit that he was involved in RISE. I met up with Cheryl Connors who is a paediatric nurse and patient safety specialist with the Armstrong Institute for Patient Safety and Quality. Cheryl co-led the development of the RISE programme. Lastly, I met Laurie Rome a paediatric oncology nurse. I attended a monthly event that she facilitates held on the paediatric oncology ward called “Processing and Resilience Sessions.” This event was open to all staff on the ward. The goals of the session were to promote resilience, help with processing distressing events, learning strategies to manage stress, a forum to support each other and share stories and allow staff to get to know each other off the “shop floor.” Snacks were included (I think this helped) and interestingly it was all nursing staff apart from one doctor who turned up late. Many of the nurses were relatively junior and you could see that they benefited from speaking about what had been bothering them particularly having to work in an environment such as paediatric oncology. Senior nurses provided reassurance and solutions to junior nurses and people were really open and comfortable to chat. It was awesome to see an example of a department taking matters into their own hands. The staff enjoyed it and found it useful, with one nurse telling me “its like therapy for me.” 

Next week I am due to attend the RISE team meeting to discuss how things are going and recent calls that have been received. While I have been spending time with the RISE team I have been part of the on-call team. Although I obviously don’t want there to be an adverse event, I am really hoping they get a call so that I can see the RISE team in action. There has not been any calls yet but fingers crossed!!

Everyone I have spoken to is incredibly positive about RISE and its importance, not just those directly involved in the programme. Everyone is aware of the programme and support its existence. They report a big drive throughout the hospital to improve staff resilience and note that in a very competitive and academic institution there has been a definite culture change and that people are more open and supportive. The programme has been fully supported and embraced by senior clinicians and hospital management. I have loved the opportunity to learn about a novel programme of peer support and I am interested to explore some specific aspects of this going forward and hope that we could take even some baby steps towards improving how we look after and support our own staff. I appreciate we may not experience adverse events every day but we do experience suffering and some traumatic situations on a daily basis and this in addition to the pressures of the environment we find ourselves working in means we are more susceptible to feeling stressed and are subsequently at risk of burnout. 

Carlyn Davie

RISE recognised on the cover of the hospital magazine.

RISE recognised on the cover of the hospital magazine.