A personal reflection on staff experiences after critical incidents

The effects of adverse iatrogenic events extend beyond patients and families to health care staff and organisations

Errors are common during the delivery of complex care in the Australian health care system.1 Adverse iatrogenic events (critical incidents) resulting in patient harm or death may be the most distressing for all involved. Many of these errors are preventable, but investments in programs to prevent health care-related adverse events have had varying success.2,3

After critical incidents occur, emphasis is rightly placed primarily on the immediate, interim and long-term care of the patient and family. At the same time, health care organisations must also manage the staff involved in the incident and ensure appropriate responses to reduce the risk of future events.

This is a personal account of how individual health care workers and organisations may respond, and then recover, after a devastating critical incident. Possible ideal responses after a critical incident and preventive workplace cultures are also considered.

Personal reflection

During my intensive care medicine training, I was involved in a team failure that resulted in the injury and subsequent death of a young family man due to a medical intervention. While I was not directly responsible, I was part of the team responsible for this lethal injury. My team members and I learned many profound and lasting lessons from that terrible day. A culmination of interhospital and intrahospital system problems and failures in team planning and communication contributed to this man's death. Over subsequent years, these factors were explored and acted on at personal, departmental, hospital and coronial levels. I met the man's family on the last day of the inquest. I promised them that I would incorporate what I had learned into my practice and share it with others to try to prevent similar tragedies. This short insight into my journey through the aftermath is part of that promise.

Immediately after the critical incident, I experienced many personal, emotional and professional challenges.4 When the patient subsequently died from his treatment injuries, these feelings were exacerbated by the knowledge of the devastating financial and social outcomes for his family. I believe my team members underwent similar experiences at different times after the event, before the inquest and beyond. Due to different shifts and roster rotations, ongoing clinical workload and our varied coping strategies, I did not have many opportunities to discuss these experiences with other members of the immediately involved team.

Sharing my experiences of the event and its aftermath with others in the hospital enabled me to make sense of the situation and to identify meaningful action for my own personal and professional recovery.5 Many of my experiences matched those described by Scott and colleagues in their six-stage adverse event recovery process: 1) chaos and accident response; 2) intrusive reflections phase; 3) restoration of personal integrity; 4) enduring the “inquisition”; 5) obtaining emotional first aid; and 6) moving on.6 My recovery began with the realisation that this must be a fully grasped, lifelong, patient-centred learning and quality improvement opportunity.

I felt many of the expected emotional responses, in fluctuating intensity, including self-critical thoughts, loneliness, shame, guilt, sleep disturbance, and profound and hurtful feelings of professional insecurity. I witnessed other staff members experiencing varying levels and periods of functional impairment in the workplace. I managed to avoid serious workplace difficulties7 by using institutional, peer and family supports — by seeking company, participating in open disclosure discussions and quality review sessions, and accessing mentors. As a result, I did not require professional treatment or sick leave.

I received feedback about my personal and professional performance by discussing, listening and reflecting during and in between these opportunities — often with solemnity, sheepishness, anger, frustration, trepidation, grief and dismay. I had periods of deep and painful reflection. I also had opportunities for open and non-judgemental discussion in both private and workplace settings with my own family and friends and with colleagues from different professions and disciplines. At the same time, ongoing risk management, quality improvement and medicolegal processes enabled further clarification of “what happened”. In retrospect, I am grateful for the structured processes that supported my psychological work in understanding the incident.

Others in my team had different needs, and some appeared to experience differing levels of support from the health care organisation. Many resorted to relying on the informal support of family, friends and peers when the structured organisational support did not meet their needs.

Organisational response

The organisational response to this critical incident was multifaceted and prolonged. Initially, within the first 24 hours, the staff involved completed written statements of their personal understanding of events. This was followed by a team debriefing led by senior staff. Meetings involving the wider departmental staff, mentors and administrators took place over the ensuing days, weeks and months, with later formal departmental presentations. Further recapping with the legal team around the inquest hearing was highly valuable.

The patient's family were engaged in open disclosure processes from the time of the event. They were regularly informed of the patient's progress before his death and the ongoing hospital responses. Departmental responses included a root-cause analysis to determine all contributory factors. “Human factors” were considered predominant reasons.

The departmental nursing and medical leaders and clinical governance and medicolegal teams conducted a detailed review and improvement of equipment, policies, guidelines, processes and procedures. Case presentations and reviews at quality and safety sessions and hospital grand rounds disseminated knowledge gained and lessons learned from the incident. Reports were also prepared for the insurers and medicolegal department. Staff orientation, induction and training processes were changed to include multidisciplinary crisis resource management, to improve the staff's technical and non-technical skills.

My active and passive involvement in these processes, and associated formal and informal dialogue, assisted with my understanding of the event.

“Moving on” to future prevention

Emerging literature about the emotional and professional burdens carried by health care staff after critical incidents describes the patient and family as “first victims” and the staff involved as “second victims”.8 These terms seem pejorative, negative and unhelpful, yet I cannot find suitable alternatives. This terminology derives from the perceived gap between the support provided to staff by the employing health care organisation and the support that staff actually require, particularly when compared with the support (rightly) offered to the aggrieved patient and family.

A thematic analysis of interviews with Scandinavian multidisciplinary health care staff after adverse events explored their responses in detail.7 The range, depth and variability of emotional responses were confirmed, along with significant self-reported changes in professional performance and self-confidence. Variability in each individual's post-event personal and professional needs was also noted. The authors recommended coordinated, structured, transparent and systematic organisational responses for patient and family support, coupled with personal and professional support for staff.

After this critical incident, my personal recovery continued through the interaction of individual and organisational responses. I pursued external learning to acquire the knowledge and skills required to prevent further such incidents in my own practice. As such, I do not believe I am a second victim. Rather, I am a member of a responsible team. We have learned and helped others by conceptually placing the bereaved family at the centre of our own recovery. This long and challenging process demonstrates the power and importance of patient-centred quality and safety initiatives. After critical incidents occur, structured immediate, interim and long-term care of patients, families and staff is needed to enable enlightened improvement. Health care staff may already be carrying a disproportionate and under-recognised mental health burden and may need more attention than is often given.5,9

Developing health care organisations to be high-reliability organisations (HROs) may help to reduce second-victim scenarios.10-12 HROs are characterised by their ability to manage complex, time-pressured and demanding sociotechnical tasks while avoiding catastrophic failure. Their organisational performance is often matched by an ability to expand capacity in a crisis. This is achieved through planning for variability in human performance by accepting the possibility of failure. HROs have evolved multiple redundant preventive and adaptive systems that integrate safety, quality and workplace learning. Any error is reported and proactively examined, and prevention strategies are subsequently developed and integrated into the workplace systems. These active system responses are said to cause the “dynamic non-event” of critical incident prevention.10

However, even with the best preventive systems, critical incidents will still occur. After a critical incident, it is essential for health care staff to seek help for themselves, in addition to the support provided to the patient and family. Constructive and supportive incident responses for patients, families and staff must be activated and maintained over months to years. Lessons learned must be integrated into workplace systems. I implore readers to become proactive agents of personal and institutional change for building resilience and reliability, in honour of your patients. Remove the need for anyone to be labelled a second victim.