No one left behind: Expanded peer support and second victim syndrome


AMA STEPS Forward® podcast

No One Left Behind: Expanded Peer Support and Second Victim Syndrome

Dec 4, 2023

Alicia Pilarski, DO, associate professor of emergency medicine, associate chief medical officer, and medical director of the Supporting Our Staff (SOS) Peer Support Program for Froedtert Hospital & Medical College of Wisconsin, shares her experience building an expanded peer support program for the entire health care team. 

  • Alicia Pilarski, DO, associate chief medical officer, medical director of the Supporting Our Staff peer support program and associate professor of emergency medicine for Froedtert and the Medical College of Wisconsin
  • Jillian DeGroot, practice transformation and sustainability, AMA  

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DeGroot: Hi, everyone, welcome back to the AMA STEPS Forward® podcast. We are joined by Dr. Alicia Pilarski, associate chief medical officer for Froedtert Hospital, medical director of the Supporting Our Staff peer support program and associate professor of emergency medicine for Froedtert and the Medical College of Wisconsin. We are going to discuss how she implemented a successful peer support program for health care professionals who have experienced second victim syndrome and other distressing events in medicine. Dr. Pilarski, thank you so much for being here today.

Dr. Pilarski: Thank you, Jill. I'm looking forward to being here.

DeGroot: So to start, can you tell our listeners a little bit about yourself and how you became interested in this particular kind of work?

Dr. Pilarski: Sure. So as you mentioned in the intro, I'm an emergency medicine physician and I've been doing that for over 12 years now here at Froedtert and MCW. And even prior to that, in my residency I was really passionate about health care team well-being, and recognized that supporting one another during our medical day-to-day lives here in the hospital as well as just in general in health care is something that's really critical to the well-being of our entire health care team. Really, I kind of started off when I went to a conference in 2017. I was involved in residency leadership, so I went to a conference and learned a little bit about second victim syndrome and peer support.

And it was a presentation that was done by the team over at University of Missouri and their forYOU peer support team. I recognized at that point that I had not even really known what the term "second victim" was when I first heard it. But I definitely identified with it because I realized I had been one at a couple points in my career. I thought to myself that we needed to have a program that supported our care team following distressing events or medical errors. And so really first learning about that drew me to creating a peer support program for our organization.

DeGroot: From what I understand, the literature describing the development of effective peer support programs for second victim syndrome is limited. So before we get into this expanded peer support program, can you tell us a little bit more about second victim syndrome, what you've learned about it, what it is, that sort of thing?

Dr. Pilarski: Absolutely. I think the term second victim was coined back in 2000 by Dr. Albert Wu. In any medical error or adverse event, the first victim is the patient. And it was recognized very quickly that those who are involved in the care of that patient, whether it's the physician, the nurses, the residents, the techs, also are impacted when there is an adverse outcome. And so the term was the second victim was the rest of the care team that may have potentially been traumatized by the event that occurred that was related to that patient care. That term, again, as it was coined then, I think that we all recognize this is not something that is in isolation, in terms of a lot of health care team members have been second victims.

And again, it doesn't necessarily have to be just a physician. It can be our nurses, our pharmacists, our EMS providers, that many people can identify with being a second victim at some point in their career. And I think that was one of those turning points for me as well is when I first heard about that term, I identified myself as one. I was a resident, and recognized that importance of having some supportive network that can get you through those times to recognize that you're not alone, and going through the emotional distress that follows that is really important and very critical to the health and well-being of our entire health care team.

DeGroot: Tell me a little about this expanded peer support program. Where do you even start?

Dr. Pilarski: So there's a lot of different models out there, which I had an opportunity to kind of research. So after that conference, I shared the three-tiered system that the University of Missouri did, which I found to be really a unique program and really neat model to mirror our program after. It was interesting because when we first started talking about peer support, some models were ... there's maybe a handful of people who are trained, maybe like five to 10 people, and they sit by a phone and wait for those calls to come in for peer support. And many of those programs, that phone didn't ring often because not a lot of people really want to reach out after they've been involved in a medical error. They're afraid to talk about things, they don't know if they can talk about things.

So one of the most important pieces to our model is that we wanted to be very proactive. I said, let's try this in the emergency department first. This is a high-stress environment. There's a lot of distressing cases that can come through. So I basically went on a little bit of a roadshow and talked with my faculty, our APPs, our learners, our residents. I went to nursing and staff meetings and talked about what does it mean to be a second victim, and why is it important to have peer support?

And a lot of people that instantly gravitated to the talk and the work that I was proposing to have done in the emergency department, because many others also self-identified as a second victim and they said that this was important and this was meaningful work for them. So we started a grassroots effort, if you will. Did some mostly awareness building and created a small cohort of nurses, physicians, APPs that would be called upon as needed if a situation occurred in the emergency department that may require peer support.

We started that in the fall of 2017 and continued to develop that program, spoke about it and was invited to other departments to talk about it as well. And actually it started to really gain traction and we started to see an uptick in when a case was identified in the clinical environment that was potentially distressing, we would send out a peer supporter to reach out to the individual, or individuals most often, who were involved in that case. And soon enough, after about almost a year, the hospital started to get wind of what was going on in the emergency department. And they said, we need to have a little bit more understanding of how do we create the same model for the rest of our care team throughout the entire organization.

I partnered with our medical director of patient safety at the time, and currently is still, Dr. Tim Klatt, who's also an ob-gyn physician and colleague. And we came together to best structure this peer support program in partnership, and using best practices that were already out in the literature to say how do we take this model and adapt it to what our organization needs? Part of that work was also partnering with our risk management team from Medical College of Wisconsin, who recognized that this was going to be a valuable add to our organization because they had also seen the effects of medical error and what it does to the care team involved. We essentially reached out to Susan Scott and the forYOU team and said, "We'd like to start this program, we want to base it off of your model." And so they came and actually did a training with us in January of 2019. And their model, it's a three-tiered system, so that first tier of peer support is really open to everyone and anyone in the entire clinical environment.

And part of that first tier is just building awareness about high-risk situations or cases, bringing awareness to the importance and value of peer support, and then also how to reach out to peer support when you identify that this might be someone who might be struggling. So that's the first base. And the importance there is to really try and build that awareness piece, whether it's through ... for me, I did a lot of presentations and going to staff meetings and everywhere else to just talk about this.

The second tier is our trained peer supporters. So these are the individuals from various professional types and backgrounds, all from different departments and units all throughout the hospital who volunteer their time to be a peer supporter for their local environment as well as for the entire organization as needed. At our first training, we started with 55 people that we invited that we tried to identify as people who were trustworthy and already had that kind of lens of peer support that they may have already been doing without a formal title and invited them to the training.

We had about 50 people that came, and actually it was a funny story. The training took place on a very cold day in Wisconsin called the polar vortex. We were afraid that of the 55 people that we invited, no one would show up. And 50 out of the 55 did for a four and a half hour voluntary training session. So I found that to be really inspiring to see my colleagues and staff from across the organizations still come for this because it was that important to them. And so that tier two group is a group that we continue to expand and train throughout the organization. And then tier three is a group of, again, peers but who have more advanced training, like our psychologists, psychiatrists, our employee assistance program team, spiritual services, some of our social workers, so individuals who just have a little bit more background in providing advanced support.

So we have kind of an expedited referral if one of our trained peer supporters from tier two is finding that one of their colleagues is struggling more than what's in their scope. So we have that as well. Teams are so different, so what happens in the operating room versus what happens in the ICUs versus the floors, we want to make sure that peer supporters would be able to adapt to our local environment and bring whatever peer support, the way of providing peer support would be the most effective in those local environments.

DeGroot: That sounds really great. I'm curious if you have any insight as to what it was like for both the recipient of the support and also the giver of support, what that was like. I know you said you might identify an adverse event that happened within the emergency room, and instead of waiting for the phone to ring, so to speak, you sent out someone to make contact. And I'm wondering if you have any sort of insight as to what that was like for those two people?

Dr. Pilarski: So I think one of the biggest things too is for a long time, and it still is and we're trying to break down that stigma, is really no one likes to talk about these things. Feelings and emotions in health care and medicine tended to be stuffed real deep downside. I mean, you got to move on and see the next patient, and sometimes it's hard to process these things. And so I think it offered people who were involved in these situations, when someone came to them and was genuinely concerned and wanted to check in on how they were doing, it really had a culture-changing effect. Because someone was reaching out to them and wanted to have a conversation about them and how they're processing or going through these emotions that are just normal reactions to an abnormal event. And I think, so, it kind of opened up that dialogue.

And I think that, again, you can support one another. It doesn't have to be a physician supporting a physician, it can be a nurse supporting a physician and vice versa or any member of the care team. And I think it also helped to bridge that gap amongst all the professional types in our organization of that, we're all in this together no matter what your role is. And then for the person who's providing support, recognizing that; for me, personally, I've been able to step back sometimes too when I see potentially, let's say, a loss of a patient. If they came in, maybe were undergoing CPR, it was a really unfortunate situation.

Whereas potentially with my experience sometimes I know that that might be the outcome, but then I now pause and I look around and I see the medical student at the bedside who maybe this is their first patient loss and I need to think about how to support them going through that process. Or maybe one of our newer nurses who is just trained to be in the critical care area of our emergency department that maybe that's a situation that they're not used to as well. And so it helps bring awareness for me that we need to really take a look at the rest of our care team when undergoing these distressing events that happen.

DeGroot: That makes sense. What were some of the biggest challenges or obstacles that you faced as you were either developing this model or trying to deploy it and enact it?

Dr. Pilarski: Great question. So I mean, one of the things that came up is obviously I identified with the program very quickly, knowing we need this in our department, we need this in our organization, and I knew that this was a big deal. And I would talk about it at various meetings and things like that. I think everyone agreed, yes, this seems very important, but it was very hard to figure out where it's going to live. Who's going to run this program? How many people do we need? I think it seemed like an overwhelming task, and so for at least about a year and a half, it was just a hard place to figure out how do you get this started? And there wasn't a lot of research out there, there was a few programs that existed. A lot of that just uncertainty of what the value would bring and how to structure that.

One of the best things about our program is because we cross both or all of the organizations and we're wanting to have everyone a part of the team, we do at our institution ... we're two separate organizations. So we're Froedtert and then the medical college but we're a partner. But having the employees from one platform versus another, just logistic things like having different emails and trying to communicate appropriately where everyone hears the same message. But I do think it was really unique that we had this program that really crossed over the organizations that really helped make it successful. Those were definitely some challenges, just like I have two websites to put the program information on and you have to make sure that one side of the organization hears the same information as the other.

And then I think now as we're growing with this program and we have greater than 380 trained tier two peer supporters, which is wonderful. But as we've grown, the administrative support around that to make sure people want to sign up to become a peer supporter, that we're getting them going through the training process as well as making sure they're added to the list and that's communicated to their own local environment that they have a new peer supporter, those kind of administrative tasks are definitely a challenge. So those are the things that we're working on right now.

DeGroot: It seems like it's always the logistical things that seem to be the biggest hurdles. Seems like just bringing it up in meetings was the first step to get people to be like, we need this.

Dr. Pilarski: And to that point, I think one of the things that was important is not even just talking about second victim, but sharing a vulnerable story. So one of the things that I did with a lot of our learners and our trainees was presenting at their grand rounds or their lectures and sharing my own personal story of a medical miss that had a bad outcome for a patient and what I went through personally, and then my road to recovery during that process and how peer support was so instrumental in ensuring that I was recovering in an appropriate way. Actually, that's one of those things that during our training process, we have three of our colleagues who also share their own experience as a second victim and their patient case, as well as other distressing situations and what those individuals felt going through that and whether or not they had peer support or not, and how that looked for their recovery.

And so even during our training, I think that's one of the most powerful pieces, is that's where people really can relate and then have that connection to why this is meaningful work. Because many people can identify, they've had their own personal story and see that others are willing to share that story with one another. And then that really helps pull in the peer supporters that I know we have on our team right now.

DeGroot: It seems like all it takes is one person to be vulnerable and to set an example of not stuffing it deep down to really help move towards a broader cultural shift. How did you measure success in this scenario?

Dr. Pilarski: A couple different ways. So number one, when we obviously had our first cohort of trained peer supporters, we had them for the first few months and we met with the team monthly to say, what do we need to do to grow this program? And so we used feedback from our team that we had just trained, they actually helped us create the name of the program. They helped us create what their expectations would be as peer supporters and their scope.

And then one of the things that we talked about is we need to be able to track some of these encounters, but how do you do this in a way that's confidential, that we're using the data in a meaningful way. So we're using the data to make sure that we have enough peer supporters in certain areas, that we have enough skillset to provide support depending on the reasoning for the peer support request, and then making sure we have the right resources in place to refer forward as needed if a colleague needs advanced support.

So one of the things we created, we have a weekly Qualtrics survey that goes out to the entire peer support team that asks them to confidentially say if they've been involved in an encounter that week or a follow-up encounter to just track it. What was the general theme, the reason for the support? And we have some categories that they can fill out that are not identifiable or anything like that. And then just trying to make sure who was supported, so some overall professional titles. Was it a physician? Was it a resident? Was it a paramedic? Was it a pharmacist? You name it.

And then we have been tracking that. Initially, it was a pen and paper kind of thing, but then we transitioned to the Qualtrics. And we send it out every Monday so that people know it's coming, so that if you've had a peer support encounter, you can quickly fill it out. It takes less than 30 seconds to a minute to fill out. And we've been able to monitor that data since June of 2019. For a long time we were averaging about maybe three to five peer support encounters when we first started. And then through the first year of our program, we went up to about five or six encounters per week. As of our last data and with our peer supporters, we're closer now to about 10 to 12 peer support encounters per week. And those are of the documented ones.

I know that there's so much other peer support that happens that doesn't get captured by that data, but we've been at least able to see a trend going up. And then we also monitor too from that is how was support enacted. So was it peer supporter initiated? Was it someone requested peer support on behalf of someone else, or did someone come to you and say, "I need peer support for myself"?

And we actually have seen an uptick in that self-referral of individuals coming to our peer support team following events. So it's very encouraging to see that since we know that, again, back to that stigma for reaching out for help that we're starting to see that trust in our program as well as that kind of self-referral and we know that's happening. And we've also, with our taking it back, as I mentioned, when we've trained these peer supporters, they go back to their local environments and then they're able to create what would be successful for their own unit.

Now we have our medical intensive care unit team that is doing emotional debriefs following every patient death that are led by our peer supporters in that unit. We have a whole offshoot of a residents supporting residents program that meets quarterly to talk through distressing cases with residents across all specialties, and they're peer supporter led as well. So we're seeing a lot of local ownership and individuals taking the peer support team and doing really great things with it to help expand the support that's available.

DeGroot: That's incredible. It's really cool to see the cultural shift happening in real time. And you're seeing people kind of take local ownership, like you said, in making it something instilled within their own departments and specialties. That's really cool. I'd also like to ask if there's anything that surprised you during either the building of this program or the running of it?

Dr. Pilarski: So, I think I knew right off the bat that I wanted this program to be all-inclusive, that as we developed it, it wasn't going to be peer support only for our physicians and APPs or only for our nurses. I think that was something that myself and Dr. Klatt really were like, we need to have the entire care team involved in this program for the success of it. And I think that, even though I knew I wanted that, I didn't realize how much that would make such a key difference in the success of this program is really having all members of the care team being able to not only be a peer supporter, but recognize that we can reach across our professional titles and support one another following these events.

And I think it really helped to, in some areas, break down a hierarchy too of just because someone is an expert surgeon in their field and they've done this, that they also can sometimes struggle. And seeing that vulnerability with others within the organization and willing to share those stories, I think was really inspiring to see. I think then it shows that reflection too of that the care team really understands each other a little bit better. And I think that piece has been the most exciting for me to see what that means to the teams taking care of our patients, that they're taking care of one another as well.

DeGroot: That's lovely. Any final pearls of wisdom or final thoughts?

Dr. Pilarski: Sure. I mean, think back to just again that as someone's creating a peer support program, it's a lot. It took us about four years to really get to this point. It took a lot of perseverance and speaking about it multiple times. I think I've talked on second victim syndrome and shared my own personal story at least, I don't know, 30, 40 times. I can't even remember. But I think that's really important to just keep at it. And you'd be surprised at how many people can relate to this. And it's so meaningful to people when you also can share your own story so that it can help create that connection with other individuals who will be a good part of that team as you develop it. And realize that you don't have to do it on your own too, there's a lot of resources out there.

I know we've actually been recently asked to help train other organizations across the country. And that's something that we're willing to help with because I think it's important to not necessarily recreate the wheel here. I give credit to Susan Scott and her team from the University of Missouri's forYOU team for helping us start the framework. And then we adapted it based on what our organization needed, and we continue to grow it based on that feedback. But I think that's the other key is really don't reinvent the wheel. Find a model that might work for you and adapt it as you see fit. And lean on colleagues and other parts of a different organizations to help with that, because we're all willing to help. We all have a passion for this and realize it's really important.

DeGroot: Well, thank you so much for joining us today, Dr. Pilarski. For our listeners who are interested in learning more about different types of peer support programs, there will be links to further resources in the show notes.

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