CRNA Perspectives
  • Emotional Support for a Colleague after a Perioperative Critical Incident

    A critical incident is a devastating event affecting an individual’s physiological and psychological functioning. Statistically speaking, many if
    not all anesthesia professionals will experience a perioperative death or other critical incident at some point.1-2 Unfortunately, due to the nature of the career, CRNAs may experience many emotional events that can result in critical incidence stress.3 Critical incidence stress may greatly impact the ability to provide safe patient care and is defined as “any event that produces psychological and/or physiological reactions such as shock, anger, confusion, excessive fatigue, sleep disturbances, anxiety, depression and difficulty concentrating.”2

    Following a critical incident, the stress response is an expected and healthy part of coping. The reaction usually begins to subside in a week and eventually abates.4 Recognition of these symptoms in oneself and others is essential. According to Eischhorn,5 “Enhanced vigilance and sympathetic support from co-workers was the best strategy for avoiding the escalation of stress in the anesthesiologist that could result in harm to him/herself or patients.” Understanding the “normal” stress response and the appropriate interventions to provide emotional support immediately following the devastating event may lessen its impact.

    Expected Responses

    Following any critical event, especially the death of a patient, the stress response can manifest with physical and psychological symptoms. These symptoms vary in presentation between individuals, but some of the most common are listed in Table 1.

    Those who have experienced a critical incident often feel guilty regardless of whether the event was preventable, as demonstrated in a study conducted by Gazoni and colleagues. In a survey completed by 576 anesthesiologists, 52 percent of the participants stated the perioperative loss was unpreventable. However, 64 percent of the respondents still felt a personal responsibility despite the unavoidability of the event.8

    Reliving the event is also a common reaction. The event may seem so tangible, it is perceived as a premonition instead of a memory.4 Researchers have discovered common worry patterns develop in the aftermath of a critical event, including worry about the patient/patient’s family and reputation in the healthcare arena. It is common to fear the loss of respect and trust. Another pervasive concern is the fear of litigation and loss of licensure.7

    Some individuals experience delayed reactions to events. Delayed responses are not recognized early in the process and may present as increased difficulty in performing previously mundane tasks. The provider may experience changes to personal relationships, including emotional detachment.4

    Recovery Trajectory

    Although the events are traumatic, the response should resolve in a timely fashion. Even a moderate stress response should entirely dissipate in six to
    16 months without any long-term sequalae.6 Scott and colleagues9 have identified some commonalities in the recovery trajectory following critical events. The trajectory is categorized into six stages (Table 2*), which include: (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. The individual may proceed sequentially through the stages, or stages 1-3 may be experienced simultaneously.9

    When to Seek Help

    The stress response provides a process to help us cope with traumatic events. If the stress symptoms persist or if any of the following are present, then there is a need to seek support from a colleague or mentor.4

    Deterioration in mental health should prompt intervention from a mental health professional. Signs of mental deterioration include but are not limited to: severe dissociation, severe avoidance, hyperarousal, debilitating anxiety, severe depression, and substance abuse.6 Drug and or alcohol issues should involve professional assistance.6 Support in this matter is available through the American Association of Nurse Anesthetists (AANA) Helpline (800) 654-5167. See “Addressing Substance Abuse Policy Considerations” located on the AANA website (www.AANA.com/AddressingSUD).10

    Practical Steps

    If you or a colleague experience a critical incident, some practical steps include cooperating with the investigative process, avoiding isolation, and seeking support from peers and family members. In the Gazoni and colleagues8 study, 98 percent of respondents felt emotional support provided from another anesthesia professional following an event would be beneficial. Give yourself time to heal and seek help with difficult cases. Not only is this prudent advice, it also promotes safe patient care. According to Gazoni and colleagues,8 51 percent of respondents felt the ability to provide anesthesia safely was compromised for the first 24 hours after the event, and 27 percent felt this reduction continued for the entire week.

    How to Provide Emotional Support

    Van Pelt11 discussed the development of specialized peer support teams in healthcare institutions, partly due to the increased recognition of the emotional impact following a critical event. However, support can be provided without a formal support team. Do not underestimate the power of your individual support. Scott and colleagues9 found that 60 percent of providers recovered following an event if the support they received was merely another professional asking, “Are you okay?” and opening a dialogue with
    the individual about how they felt, rather than the details of what occurred. One of the most important interventions is to acknowledge the situation and the individual’s emotional response.

    Effective communication starts with allowing the individual the time to share their experience without interruption.12, 13 Remain quiet for processing of the emotional response. Successful communication involves effective listening, giving the individual your complete attention, avoiding passing judgment, and being patient for replies.13-14 Use a “mirror technique,” or paraphrasing, is often effective. Paraphrasing involves listening and summarizing critical parts of the conversation in your own words. This conveys not only a desire to understand but also ensures accurate understanding. Responses should encourage further dialogue.14

    During the interaction, focus on healthy coping strategies and
    the presence of a support system. It is perfectly acceptable to ask about his or her well-being and convey the desire to follow up with additional support. Provide a list of resources. This list may vary depending on practice location but should include information from the AANA website. If the situation is severe, or any concerns arise for the safety of the patient or provider, refer to a higher level of care such as a healthcare or mental health professional.12

    Additional Resources

    The AANA offers information for understanding second victim experiences and resources ranging from how to talk with a colleague to establishing a program in your workplace. See www.AANA.com/AdverseEvents. AANA Peer Assistance Helpline offers 24/7 confidential live support and resources at (800) 654-5167 or email wellness@aana.com.

    References:

    1. Gazoni FM, Durieux ME, Wells L. Life after death: The aftermath of perioperative catastrophes. Anesth Analg. 2008;107(2):591-600.

    2. Stone L, Tyrey S, Muckler V, Vacchiano C. Point-of-contact assessment of nurse anesthetist knowledge and perceptions of management of anesthesia-related critical incidents. AANA J. 2017. 85(1): 56-60.

    3. Prevent your staff from becoming the second victim of adverse events. Credentialing Resource Journal. 2018; 26(6). Available at: http://credentialingresoucecenter.com. Published 2018. Accessed October 20, 2018.

    4. The Association of Anaesthetists of Great Britain & Ireland. Catastrophes in anaesthetic practice—Dealing with the aftermath. 2005. Available at: http://www.aagbi.org/sites/default/files/ catastrophes05.pdf. Accessed July 12, 2017.

    5. Eischhorn J. Patient perspectives personalize patient safety. APSF Newsl. 2005-2006;20:61-4.

    6. National Center for PTSD. Effects of traumatic stress after mass violence, terror, or disaster. U.S. Department of Veterans Affairs Website. https://www.ptsd.va.gov/professional/trauma/disaster- terrorism/stress-mv-t-dhtml.asp Updated February 23, 2016. Accessed September 10, 2017.

    7. Caring for the caregiver. University of Missouri Web site. https://www.muhealth.org/about-us/quality-care-patient-safety/ office-of-clinical-effectiveness/foryou. Published 2017. Accessed July 12, 2017.

    8. Gazoni FM, Amato PE, Zahra M, Durieux ME. The impact of perioperative catastrophes on anesthesiologists: Results of a national survey. Analg & Anesth. March 2012;114(3): 596-602.

    9. Scott SD, Hirschiner LE, Cox KR. The natural history of recovery for the healthcare provider “second victim” after adverse
    events. Qual Saf health Care. 2009;18:325-330. doi:10.1136/ qshc.2009.032870.

    10.Addressing Substance Abuse Disorder. AANA Website. https:// www.aana.com/docs/default-source/practice-aana-com-web- documents-(all)/addressing-substance-use-disorder-for- anesthesia-professionals.pdf?sfvrsn=ff0049b1_4. Published 2016. Accessed August 1, 2018.

    11.Van Pelt. Peer support: healthcare professionals supporting each other after adverse medical events. Qual Saf Health Care. 2008; 17;249-252. doi: 10.1136/qsh.2007.025536

    12.Supporting a colleague. MITTS Web site. http://www.mitsstools. org/how-to-support-a-colleague.html. Published 2015. Accessed July 12, 2017

    13.Module 6: Care for the caregiver AHRQ communication and optimal resolution toolkit.Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/quality-patient-safety/ patient-safety-resources/resources/candor/module6-notes.html. [Accessed August 1, 2018].

    14.Everly GS, Mitchell Jt. Critical incident stress management
    (CISM): Individual crisis intervention and peer support. 2nd edition. Ellicot City, MD:International Critical Incident Stress Foundation, Inc, 2003

    Please see a PDF of this article here.

    *To view Table 2, please see PDF above.