The Most Important Element of Patient Safety Is Usually the Hardest to Achieve Blog Feature

By: Martie Moore, D.H.L., MAOM RN, CPHQ on September 14th, 2020

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The Most Important Element of Patient Safety Is Usually the Hardest to Achieve

Patient Safety | Peer Support

I clearly remember my phone ringing and the conversation that ensued. A sentinel event had occurred at the hospital where I was the chief nursing officer. An individual had attempted suicide by hanging in the emergency department. The nurse who found the individual was able to resuscitate, but there was potential oxygen deprivation. I initiated our processes to investigate what had happened and met with the nurse who found the individual. I asked her if she was ok, but she brushed me off and indicated that she was just fine. I offered our Employee Assistance Program (EAP) and encouraged her to reach out to them. When I looked into her eyes, I knew that she would not follow up—and that she was not ok.

We know that depression, anxiety, post-traumatic stress disorder (PTSD), and suicide are not new phenomena among healthcare providers. Research clearly indicates that providers experience and see more trauma in a shift than many people see and experience in a lifetime. When I first became a registered nurse, I recall a senior nurse telling me to get tough—that “I was going to see a lot of stuff and I needed to learn to get over it.”

I held that belief until I found one of my colleagues collapsed on the floor. I worked hard to make her breath again, to feel her heart beating, but I and others were not successful. The team that knew her and loved her could not save her. We scattered afterwards and went back to our duties. We conducted our event analysis and shared the facts of what had happened. We never talked about how we were feeling. I still see her lying on the floor to this day. We needed support beyond an offer of the program of employee assistance. We needed to be given permission to grieve and heal. We needed support. I needed support.

I was new in my role at the hospital when the individual attempted suicide, and I was just learning the culture of the organization. Culture is what you say and do on a daily basis. Culture is not what’s written on the pages of documents—although documents certainly can influence culture. It’s human behavior that brings culture to life. Unwritten messages strongly influence the actions and reactions seen when an event occurs. Unwritten messages influence culture.

After my interaction with the nurse who found the individual, I began a quest to learn how the organization supports those involved in an event. My quest led me to discover that the hospital was not unlike others. We, too, offered EAP, but the percentage of individuals involved in an incident who sought EAP services afterward was less than one percent. In talking with the team at EAP, I learned of their frustration about the lack of utilization. But they didn’t know how to address the issue. In collecting data on cultural norms, I also discovered that, like my experience as a younger nurse, the unwritten rule to just “deal with it” is well understood and still remains.

Researchers have helped healthcare leaders and organizations understand that there is a second victim when an event occurs. Second victim syndrome is defined as the healthcare provider(s) and other team members who commit or witness an event and are traumatized by the event, manifesting psychological, cognitive, and/or physical reactions that have a personal, negative impact. Second victim syndrome is not just associated with an event, but also can be accumulative. What seems to be the smallest event, therefore, can have the greatest impact.

As leaders, we must think about creating systems of support that our healthcare providers and team members can access and will use, anytime, anyplace. We must work to transform a culture from “just deal with it” to “we are going to address it every time, every day, with support and compassion.”