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D. Education Tools

Helping the Peer to understand the reactions and feelings that clinicians commonly experience following an adverse event normalizes the experience and helps to mitigate the distress that the clinician may feel.

Knowing what to expect empowers the Peer to feel more in control, and the fact that educational resources have been developed validates the Peer’s feelings and needs.

Following are 4 education tools which you can share with your Peer, detailed below

The 6 Stages Clinicians Commonly Experience Following an Adverse Event
Research indicates most clinicians who are struggling with a stressful event or situation commonly experience 6 stages on their journey to recovery. If staff are unfamiliar or unaware of these stages, these stages can be distressing. Knowing what to expect can empower the Peer to feel more in control

1. Chaos and Accident Response
This stage includes realization of the event/error that promotes confusion and turmoil as individuals and teams struggle to understand what happened.

These feelings may be exacerbated by patient instability. Common clinician reactions at this time are confusion, distraction, self-blame, and disbelief.

To Do: Important actions for Peer Supporters during this time are support and assessment of the clinician for ability to continue safely caring for patients.

2. Intrusive Reflection
The affected clinician frequently relives the experience; second guessing decision making, feelings of inadequacy, and doubt are common.

Intrusive thoughts about the event increase stress and distraction. Intrusive thoughts and fears about what colleagues may think of the clinician’s skill and judgement exacerbate somatic symptoms such as insomnia, fatigue and tension. Psychosocial symptoms are also magnified, such as anger, remorse, depression, lack of concentration, and sadness.

Expect that you will have recurring thoughts, flashbacks, or dreams about the situation. Most clinicians experience these intrusive thoughts and commonly report that it amplifies the stress they already feel.

To Do: The Peer Supporter should direct the Peer to practice redirecting his/her thoughts when intrusive reflections occur. Each time they find themselves reliving the experience in their mind, they should consciously interrupt the memory and concentrate on a relaxation technique. Peers should use guided imagery, relaxation techniques, or controlled breathing to interrupt the memory and redirect their thoughts. This strategy takes practice, but can be surprisingly effective if consistently utilized. As they continue to do this, the intrusive thoughts should decrease over time. This simple strategy can be very effective in managing intrusive thoughts.

3. Restoring Personal Integrity
This period of time is when clinicians commonly seek support. Seeking support may be delayed or abandoned if the clinician does not know who they can confidentially and safely speak with about the event. If the event involves a medical error, fear of litigation may stifle efforts to seek support. Clinicians at this stage often seek 27 of 37to understand how this event has impacted their reputation and relationships with colleagues. When constructive support is absent, clinicians often have difficulty moving past this stage. Gossip about the event and a sense that others are avoiding the clinician involved make this stage particularly painful.

To Do: The Peer Supporter can listen, validate, and normalize the Peer’s feelings, while reassuring that all discussion will remain in confidence

4. Enduring the Inquisition
This stage is most commonly experienced if the event triggers a QA review or investigation. Initiation of the QA process may trigger additional fears about repercussions, job security, and licensure. It can be helpful to discuss the QA process with the Peer Supporter.

To Do: The Peer Supporter can remind the Peer that the purpose of the QA process is not to blame them personally, but to solve systemic issues and improve outcomes.

5. Obtaining Emotional First Aid
Clinicians may seek support in a variety of ways, e.g. from family/friends or colleagues, but doubts about what is allowed and safe may diminish these efforts. Clear information about what resources are available and how to access them can decrease the suffering experienced by the affected clinician.

To Do: Peer Supporters are knowledgeable about support options for clinicians and provide information to facilitate access to these resources.

6. Moving on
Peers commonly fall into one of three categories as they transition through these stages post-event:

  • Dropping Out: Clinicians leave the local clinical area, institution, or profession
  • Surviving: Peers remain in the clinical realm but suffer lingering effects of the event
  • Thriving: Clinicians move past the event in a healthy manner with increased resiliency

To Do: Peer Support increases the likelihood that a clinician will successfully recover and develop the resiliency needed to avoid burnout and job fatigue.

The Stress Continuum Model
The Stress Continuum Model is a fast and easy-to-use graphic describing 4 stages of stress reactions. Recognizing where you fall on this continuum is important to avoiding emotional fatigue and burnout.

To utilize this tool, determine where you fall on the Stress Continuum Model. See Other Stress Indicators below if you need help with this step. The more Stress Indicators you check off, the more likely you are functioning in the Injured/orange or Ill/red zone. If you fall toward the right (Injured/orange or Ill/red), take steps using coping, relaxation, and self-care mechanisms, which may include taking time off from work, to move yourself over to the left (Reacting/yellow or Ready/green).

It is unlikely that many healthcare workers are functioning in the Ready/green zone during a crisis. Realistically, most clinicians are not at optimal functioning during sustained periods of stress. The goal is to check in with yourself, be aware of your stress level, and act to move the continuum toward the left with self-care strategies. Have your Peer print out the Stress Continuum Model and check in with themselves every day.

Other Stress Indicators:

Change in eating habits
Change in weight
Loss of will power
Can’t get tasks done
Losing interest/apathy
Can’t think clearly
Conflict in relationships
Going through the motions
Sleeping more than usual
Memory problems
Don’t give yourself a break
Post-traumatic stress symptoms
Isolating self
Feeling overly busy
Feeling hurried
Can’t hold a conversation
Things excessively piling up

The Risks and Benefits of Guiding Ideals for Healthcare Professionals
Why are clinicians particularly vulnerable to burnout and the negative impact of circumstances and situations? It is important to recognize that the very ideals and strengths that draw individuals to the healthcare field in the first place make healthcare professionals more vulnerable to stresses and imperfections in the workplace.

Healthcare clinicians are dedicated professionals who often put the needs of patients before their own. This puts them at risk of becoming burned out and fatigued, especially in stressful circumstances. The graph below illustrates the pros and cons of attributes which healthcare workers commonly exhibit. Being aware of how these ideals may contribute to overwork and reluctance to accept help is key to avoiding the vulnerabilities associated with the strengths they bring to the bedside.

StrengthGuiding IdealVulnerability
Placing the wellfare of others above one’s own welfareSelflessnessNot seeking help for health problems because personalhealth is not a priority
Commitemente to accomplish missions and protecting othersLoyaltyGuilt and complicated bereavement
after loss of others
Toughness an ability to endure hardships without complaintStoicismNot aware of / acknowledging siginificant
symptoms /suffering
Following an internal moral compass to choose “right” over “wrong”Moral CodeFeeling frustated and betrayed when other fail
to follow a moral code
Becoming the best and most effectice professional possible ExcellenceFeeling ashamed / denial or minimization of imperfections

Understanding Grief
Educating the peer on the experience of grief can empower them to feel more in control.

What is Grief?
Grief is characterized by intense sadness and yearning. Intense emotions are a normal response to the loss. Over time, acute grief evolves into integrated grief: a background state that changes in quality and importance over time.

Clinicians may experience grief following an adverse event. Additionally, during the COVID-19 pandemic, people may be experiencing grief over the loss of their normal lives.

The Wave of Grief
The grieving process can be likened to a wavelike pattern, with periods of highs and lows of varying intensity and frequency.

Sometimes, clinicians can experience “trigger waves,” or heightened levels of grief intensity, when they see or experience something that reminds them of their difficult event or situation.

Faced with what may feel like erratic patterns of progress, one of the most difficult challenges for those experiencing grief is not knowing what to expect and wondering if their experience is “normal.”

Strategies that focus on increasing a sense of control can help bereaved healthcare providers successfully adjust to their loss and grief.

Part of the role of the peer supporter is to educate Peers about the wavelike nature of grief and to normalize intense emotions in order to promote realistic expectations of progress and thereby foster an increased sense of control throughout the grieving process.

Do’s and Don’ts for Supporting the Bereaved:
DON’T say “I can’t imagine” or “I don’t know how you do it.” This can make the bereaved feel isolated.

  • Instead, try to imagine and consider how they might be doing it, and reflect that back to them from a place of empathy.

DON’T ask people how they are doing. This is too general of a question, and the bereaved may feel that they are overall not doing well.

  • Consider instead asking how their day is going, or how a specific part of their experience is going. For example, ask how their shift, meal, or loved one is..

DON’T try to relate their grief to what you have seen or known. Everybody grieves differently.

  • Rather, simply connect around what you are seeing and hearing. “I can see that ___ is really hard” or “you must miss ___ so much” or “loss is so hard.”

DO help people recognize that what they are feeling emotionally is not necessarily who they are. For example, oftentimes people will say “I feel like I am unraveling” or “I feel like I am helpless” or “I feel like I am lost.”

  • When you hear this, try saying, “Just because you feel ____ doesn’t mean you are ____.”

Responding to Acute Grief
Below are some steps you can take to support your colleague who may be experiencing acute grief.

Responding to Acute Grief

Provide a safe place to grieve; give them permission to grieve

Let them tell you what they need

Let them tell their story as many times as they need

Don’t rush things

Remember you can’t take away their pain

Discuss expectations of progress, and how grief presents in a wave-like fashion

Remind them there is no single “correct” way to grieve

Increase sense of well-being: Help identify achievable rituals and ways to engage virtual supports and comfort
Identify constructive strategies that help them cope
and how to incorporate them into their daily routine (exercise, massage, relaxation techniques)

Encourage them to avoid using substances
such as alcohol or medications (unless prescribed by a mental health professional) to alleviate stress

Acknowledge that emotions might be intense, and that
they will probably continue to feel
different emotions for a while

Encourage them to maintain their normal routine as much as possible.

Expect widely varying reactions to grief

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