II. Pathophysiology
- Adverse patient outcomes (including those due to medical error)
- May result in second-victim effect, self-conscious emotions, shame and protective behaviors
- Second Victim Effect
- Health care worker experiences distress related to adverse patient outcomes
- Associated with Major Depression, anxiety decreased empathy and maladaptive coping
- Wu (2000) BMJ 320(7237):726-7 +PMID: 10720336 [PubMed]
- Seys (2013) Eval Health Prof 36(2):135-62 +PMID: 22976126 [PubMed]
- Self-Conscious Emotions
- How a person feels about themselves based on self evaluation
- Impacted by Second Victim Effect and adverse patient outcomes
- Shame
- Self-inflicted sense of decrease worth as a globally flawed person resulting in significant distress
- Broadens sense of overall worthlessness beyond a specific action, behavior or circumstance
- Self protective behaviors when experiencing shame
- Withdrawal or hiding
- Attack of self
- Avoidance
- Defensiveness
- Attack of others
III. Management: Shame Competence and Peer Support
- Shame Competence (constructive engagement by peers)
- Maintain an ongoing awareness of shame
- Shame is an unspoken taboo that is best recognized and addressed
- Recognize shame and the events that may trigger it (e.g. adverse patient outcomes)
- Peers may better understand shame by placing themselves "in their partners shoes"
- Recognize shame related behaviors (see above)
- Includes withdrawal, avoidance, defensiveness and attack of others
- Harsh reactions to these behaviors may further worsen shame
- Proactive peer support
- Peer support is based on kindness, curiosity and genuine empathy
- Provide unhurried support in a private, safe environment
- Maintain an ongoing awareness of shame
- Peer Support Strategies
- Validate emotional distress
- Listen and avoid "fixing" the distress
- Invite sharing of self-evaluation
- How does this event make you feel?
- Be aware of self-conscious emotion and shame
- Name emotions
- It sounds as if you are "down or hard on yourself","beating yourself up"
- Normalize the shame emotion
- Shame (or "beating yourself up") is a normal reaction to adverse patient events
- Share your own experiences
- "I've felt this way before, Can I share with you how I dealt with my feelings"
- Examine assumptions
- Validate the person as good (e.g. "you are a good clinician and person")
- Recognize that we are human and both fallible AND able to learn and grow from our mistakes
- Validate emotional distress
IV. Prevention: Morbidity and Mortality (M&M Conferences) and Peer Review
- M&M Conferences may exacerbate shame when focused on blame
- Instead, transition blame from self to specific actions and factors that lead to adverse outcomes
- M&M Conferences may also provide an avenue for peer growth and healing
- Focus on specific actions and system factors that lead to adverse patient outcomes
- What could you have specifically done to avert this complication in the future?
- What events or factors outside provider control impacted the outcome?
- Avoid harsh or blaming language
- Recognize provider emotional distress that results from adverse patient outcomes
- Shift focus off self and onto specific preventive actions in the future
- Encourage self-kindness (e.g. how would you medically manage others with emotional distress)
- Encourage professional help seeking
- Seek follow-up to provide longitudinal conversation, partnership and periodic check-Ins
- Focus on specific actions and system factors that lead to adverse patient outcomes