Hello, I'm Lori Shirley, Chair Elect of the AANA Foundation. Thank you for joining us today. On behalf of the AANA Foundation, we are pleased to support the 2024 Jan Stewart Memorial Lecture. Like other research the Foundation sponsors, this well-being message at our annual Congress benefits all CRNAs and RRNAs. I'd like to thank the AANA and the AANA Foundation for addressing the importance of holistic well-being, how to navigate being impacted by an adverse event, and the importance of clinician peer support programs. All of us, from nurse anesthesia residents to educators to clinical CRNAs, have a role in promoting wellness and self-care. Visit aana.com for resources on adverse events, stress management, suicide prevention, peer assistance support, and other topics. The AANA helpline is also available 24-7 for live confidential support for drug or alcohol concerns. My hope is that by utilizing these resources, we will all be better equipped to be the voice that makes a difference for anyone who might be struggling to stay well. Now I would like to introduce Donna Keeney, the Chair of the AANA Health and Wellness Committee, who will introduce today's speakers. Welcome, Donna. MS. DONNA KEENEY, CHAIR, AANA HEALTH AND WELLNESS COMMITTEE Thank you, Lori. Good morning, everyone. It's my pleasure to welcome you to our 2024 Hybrid Annual Congress. We're excited to have you join us both in person and virtually. Before we begin, we've got just a few announcements, a few housekeeping items for everyone in the room. Please be sure to download the AANA Meetings app from the Apple Store or Google Play. Once downloaded, select AANA 2024 and remember to log on using your AANA credentials, aana.com member credentials. From there, you'll be able to see the individual session pages, any speaker bios or handouts that are available, and that button I know we're all looking for to claim those Class A Continuing Education credits. We recommend that you complete those as soon as each session is finished and that you attend. For those joining us virtually, you can find that same information on the schedule page of the website within each separate live streamed session. Evaluations will open 15 minutes before the end of each session, and then you will have until Monday, September 9th, 2024 at 12 noon, that's 12 noon Pacific time, to complete and submit all individual session evaluations and then the overall conference evaluation. During this date, however, you will no longer be able to claim those credits for the workshop meeting. And additionally, everyone can send questions to our speakers via the live question and answer chat box, both in the mobile app for our in-person attendees or from the live stream broadcast for the virtual attendees. For any of the in-person attendees who don't want to do it on the app, we ask that you just please come to the microphone in the aisle and ask it through that way so that our virtual attendees can hear your questions as well. We'll monitor the questions throughout this presentation, and if time permits, then your questions can be asked and answered live by our speakers. We'll alternate between the live questions and the virtual questions, so just look for us to direct you when it's your turn to ask those questions. This morning we are celebrating our 20th anniversary of the AANA Wellness Program. And we'll recognize this milestone in just a moment in a video that will follow. After the video concludes, I am honored to introduce our esteemed panel, Dr. Maria Van Pelt and Dr. Susan D. Scott. Dr. Maria Van Pelt is a clinical professor at Northwestern, sorry, Northeastern University at Westboro, Massachusetts, while Dr. Scott is a nurse scientist at the University of Missouri Health System, healthcare system in Columbia, Missouri. Please join me in welcoming our panel as they present the Jan Stewart Memorial Wellness Lecture on Lessons Learned from the Sharpened of Care, 40 Years of Collective Experience Supporting our Caregiver. And now, the AANA Wellness 20th Anniversary Video. In 2024, we are honored to recognize the 20th anniversary of the AANA Wellness Program and all the crucial member contributions that paved the way. In 1983, the AANA Board established the Ad Hoc Committee on Chemical Dependency to raise awareness of substance use disorder. By 1984, the State Peer Advisor Network united over 200 CRNAs and the first Anesthetists in Recovery meeting was held. These efforts helped struggling CRNAs until a tragic loss showed AANA members how much more we needed to do. In 2002, the accidental overdose death of former AANA President Jan Stewart underscored the need for more support, leading to the creation of the AANA Helpline and the Anesthetists in Recovery Virtual Network that same year. In 2004, the formal AANA Wellness Program began, introducing resources like the Jan Stewart Memorial Wellness Lecture, Wellness Exhibit, and Wellness Walk. In 2014, Nurse Anesthesiology experienced another loss with the passing of Art Zwirling, a dedicated advocate for AANA Wellness and Peer Assistance Education. Today, the Art Zwirling Wellness Modules have been viewed online by countless professionals. In 2018, AANA partnered with the Parkdale Center for Professionals to launch the 24-7 confidential AANA Helpline for guidance on substance use disorder. All these wellness tools faced their biggest test during the COVID pandemic. When COVID-19 rocked the world in 2020, CRNAs were overloaded with stress, depression, and burnout. AANA responded with public calls for proper PPE, mental health advocacy, and virtual support groups like Support the Front and the Resident Roundtable. Though the height of COVID has passed, AANA continues to prioritize CRNA and resident well-being. State peer advisors, Health and Wellness Committee members, and the Peer Assistance Panel have led initiatives like Suicide Prevention Resources and Wellness Education. The future of AANA Wellness is bright. AANA's Revitalized Wellness Committee promotes holistic well-being, and the Wellness Ambassador Network will provide education, resources, and engagement for all CRNAs and RRNAs. Today, we celebrate AANA Wellness as both a program and a transformation. It has been a 20-year journey of resilience, recovery, and renewal, inspired and led by our AANA members. We welcome Dr. Van Pelt and Dr. Scott. Thank you. Morning, everyone. Can you hear me okay? Awesome. All right. Well, first off, I'd like to say good morning to everyone and happy anniversary to the AANA, and thank you for your unwavering commitment to health and wellness over the past two decades. On behalf of Dr. Scott and I, we would like to say we were truly honored and privileged to have been selected to do this JAN Memorial Lecture today. I always say that we stand on the shoulders of those giants who came before us, and Jan Stewart was one of those giants. We thank her for her legacy that she has left and are forever grateful for her leadership. A couple of housekeeping things before I get started. See if I can make this work here. Perfect. For disclosures, I have no relevant financial relationship with commercial interests. Some of the research that I will cite today has been made possible through the funding of the AANA Foundation, as well as the Pennsylvania Association of Nurse Anesthetists. Dr. Scott serves as an educator consultant for the Center for Patient Safety and for TierraHealth. Some of the CRNAs and resident student nurse anesthetists that you'll see in the pictures here are not the real individuals. They're actually actors that I've hired from Vanderbilt University's School of Medicine Program in Human Simulation to enact those individuals. Last but not least, today's information contains sensitive material. Dr. Scott and I are not here to tug on your heartstrings by any means. We are really here to increase the awareness that it's okay not to be okay, and that there are resources after adverse events. If for some reason you feel like you need support after today's lecture, these resources are available here, and we will leave them up as our last slide as well. The learned outcomes, excuse me, for today are that I plan to discuss, I know I should have brought water. It's right there. Let me grab it. Sorry. Okay. Reset. Okay. Reset. Is that I plan to discuss the 20-year history of the second victim phenomenon and the impact of adverse medical events and what adverse medical events have had on healthcare providers, namely CRNAs. I plan to describe, introduce Sue Scott, where she will describe the advances of the Scott three-tier interventional support model since its inception from the lived experience. The two of us together as we give our talk today will integrate a synergistic approach to clinician peer support programs that enhance the well-being and healthcare professionals and promote patient safety and a culture of safety within our healthcare organizations. The National Academy of Medicine, formerly known as the Institute of Medicine, serves as an advisor to improve healthcare. On November 1st, 1999, the IOM broke the silence that surrounded medical errors and their consequences. They stated that healthcare is not as safe as it should be or can be. And they also cited what is now considered the most cited publication in the field of quality and safety when they stated that at least 44,000 people to at least 100,000 people die in hospitals each year as a result of preventable medical error. What we learned from the IOM report is that errors are caused by faulty systems, by processes, and by conditions that lead people to make mistakes or fail to prevent them. What it did is it set forth processes for developing and adopting practice standards and really the belief was that it would help form expectations for safety among healthcare providers and consumers. What we've learned from the IOM report is phenomenal. We learned that improving safety, that the groundwork has been laid. However, I have to say that the progress has been frustratingly slow. Developing this culture of safety has been an immense task and the fact remains that we are human and to err is human. What we know about medical errors is that they're sorely underestimated. They are underestimated in 1999 and they're currently underestimated in this article that I have here. It's an article from Dr. Professor McCary and Dr. Daniel from Johns Hopkins where they cited that medical errors are the third leading cause of death in the U.S. They increased the number from almost 100,000 to 251,000 annual deaths as a result of medical errors. What is important to note is that behind every one of those 251 medical errors are healthcare professionals that have been impacted. To capture the hidden toll of healthcare professionals, Dr. Albert Wu back in 1999, then a medical resident, coined the term second victim. Dr. Wu witnessed one of his resident colleagues misdiagnosed a pericardial tamponade. This would rush the patient emergently to the operating room. The news spread quickly and Dr. Wu witnessed his colleagues judge his colleague who made this medical error. He said that they were being judged. He was being judged by this incredulous jury of peers who deemed his colleague as incompetent. He was dismayed at the lack of sympathy that was showed and he went on to describe the second victim phenomenon as one where surely the patient is the first victim of a medical error. However, the second victim is the physician. It was around the same very time in 1999, actually on November 18th, that Dr. Rick Van Pelt was caring for a patient by the name of Linda Kenny. Linda presented to the Brigham and Women's Hospital in Boston for a total ankle arthroplasty. Dr. Van Pelt placed a palpiteal fossil block utilizing a peripheral nerve stimulator which was standard of care back then. He incrementally dosed the bupivacaine in 5cc increments with negative blood aspiration. In spite of that, Linda received an intravenous injection of bupivacaine. Everyone in this room knows what the consequence of that is going to be. Linda rapidly deteriorated into V-fib arrest. They recognized the pharmacological profile of bupivacaine and they rushed her into cardiopulmonary surgery and she was placed on cardiopulmonary bypass for cardiotoxicity. What you can see in this case report when you read it is the case that I just described to you. What the case doesn't talk about is the fact that Linda, when she was discharged 10 days later, physiologically 100% intact, that she was told she had an allergic reaction to anesthesia. What the case report doesn't discuss is that Dr. Rick Van Pelt was forbidden to see the patient during her hospital stay. In fact, legal counsel told him he was forbidden to ever have contact with the patient for fear of litigation. Dr. Van Pelt wrote a letter of apology and mailed it to Linda's home. What happened from there is that Linda appreciated the fact that she was going through a lot of psychological distress, that she had survivor guilt, and again what the case report doesn't talk about is that Dr. Van Pelt had a lot of post-traumatic stress. So after receiving the letter, the two of them met over a cup of coffee and they decided that they were going to go public with the story and that they were going to take action, that they were going to increase awareness of what it feels like to be a second victim and on the patient side what it feels like to be the recipient of being told that they had an allergic reaction to anesthesia and when really it was quite different. So it was featured on the front page of the Wall Street Journal and shortly thereafter in 2002, the Medically Induced Trauma Support System was founded to support patients, families, and care providers. And Dr. Van Pelt opened one of the first peer support programs at the Brigham in Boston. Additionally, around the same time, Dr. Sue Scott was studying this phenomenon at the University of Missouri. She took the original term of second victim by Dr. Wu and she defined it and she expanded the scope and stated that it's not just physicians, it's not just medical errors, but it's any health care provider, any team member involved in an unanticipated patient event, a medical error and or patient-related injury who becomes victimized in the sense that they are traumatized by the event. So around the next, around the same time, it's 20 years ago, I was the program director and many of you in the room have probably heard this video. It's too long for me to share during this presentation. But what I will share with you who don't know the story behind this case of the red hat is that this is a student of mine at that time 20 years ago who had not one catastrophic event but two in the short span of just a few months. After the first event, which was a young healthy patient coming in for a total abdominal hysterectomy for dysmenorrhea where they inadvertently hit the aorta and she exsanguinated and died, she was sent on a break. When she returned from her break, She was very emotional about the event. She shared that with her preceptor. Her preceptor said to her, if you can't handle this, then maybe you should consider a different career. You need to be able to pull up your bootstraps and get back up on that horse. She was still upset, so she left, took another break, and called me. And of course, she didn't go back to that case. A couple short months later, she was doing her neurosurgical rotation for a tumor, the bulking. After they made the thorough incision, the patient's end-tidal CO2 precipitously dropped. It was followed by a PEA arrest, and they again were unable to successfully resuscitate that patient. The difference is that preceptor afterwards appreciated and recognized how visibly upset this student was, and she sent her to my office and said, you need to go see Dr. Van Pelt and talk about this. She came to my office in her scrubs. She sat down with me. She recounted the resuscitative efforts of both those patients, and I sat there and listened to her. At the end of the conversation, she took her red hat off, and she held it in her hand, and she looked at me, and she said, I know exactly why those two patients died. It's because I was wearing my red hat in both cases. It was at that point in time, as an educator, I felt an overwhelming sense of responsibility to know the right thing to say, and the only thing at that point in time I knew to say was, I'm so sorry, and we'll get through this together. So really, that case of the red hat is where my quest for knowledge began. So over the next span of the four years, I began to just learn and grow, and learn from experts that I've mentioned who've come before me in this PowerPoint presentation. I was funded by Penn for Educational Initiative Grant. I went to Critical Instance Trusted Briefing to learn how to provide peer support, but ultimately, it really was a couple years into my journey that I decided that this was going to be my life's work. And I had an incredible opportunity in 2009 to present nationally for the first time, and I was able to go to the Assembly School Faculty Meeting, which is now our ACDE Educator Conference, and talk about this. And so I feel so honored and privileged to be here 15 years later to share the same message, that it's okay not to be okay. And so really, when we think about learning to look and increasing awareness, this is actually from MEDLINE. It's a MEDLINE search that I did prior to this conference, and I put in the keywords, second victim. So as you can see, 20 years ago, there was Dr. Wu's story, there was Dr. Van Pelt's story, there was Susan Scott's story. And really, we were just learning about the phenomenon. We were looking to, learning to look to increase awareness. I was on the National Circuit saying, it's okay not to be okay. And it really wasn't until close to that five, ten year mark, we started to see some research. So we were starting to look to understand it, and understand the phenomenon from a research perspective. And so I embarked upon my first research endeavor back in 2012, when I conducted a psychometric evaluation of the tool that Dr. Cozzone had utilized when she had done a national survey of physician anesthesiologists to look at the phenomenon. And so I adapted her survey to look at CRNA's reactions. And what we found in that study in 2012, is that it was clear that all types of anesthesiology professionals had similar emotions after a catastrophic event. But more importantly, what you can see here is four different studies, three of which I conducted. One at a hospital-based regional level, one at a state level, and one at a national level, compared to Dr. Cozzone's national data, is that four studies had similar top three impact responses across progressive scope. Our CRNAs and our physician anesthesiologists were reliving the event. They had anxiety, and they had a lot of guilt of what happened. More importantly here, as you can see, that the emotional recovery after the event can last for extended period of time. All four of those studies, 20% of the participants stated that they had never fully recovered. So we started to see patterns emerging, and here are some quotes. I'll never be the same. This shook me to the core. And I want to share some very specific quotes from our CRNA colleagues nationally back in 2015, when I wanted to learn what the memorable characteristics were of these perioperative catastrophes. And so thematic analysis showed that it was the young, it was the elective, it was those rare never events, it was complications, it was lawsuits, it was lack of support. And it just was. Some of these quotes here are just bone chilling. I will never forget their face. I had a difficult airway and left them brain dead. I'll never work again. Told the patient that they would be okay, and he wasn't. So since 2015, I have to applaud our organization, the AANA, as well as many of our CRNA colleagues who are here in this audience. The research has taken off, and we have so many incredible CRNA contributors to the second victim phenomenon. And I'd just like to take one small minute to ask everyone whose name is listed there, if you're here, please stand. If your name is not listed there, please forgive me and please stand, so that everyone around the room can see all the CRNA contributors to this phenomenon. And we'll give them a round of applause. I know you're here. Don't be shy. Oh. Thanks. Thank you, Sue. Awesome. Thank you, Sue. Thank you, Sue. Thank you, Sue. Awesome. So what I have to say is that we really have learned a lot, and we know that second victims usually feel personally responsible for the outcome. They feel as though they failed the patient. They second guess their clinical judgment, and they feel as though they could and should have done more. So what do second victims desire? They desire help. They desire someone to talk to. They want someone to listen to their concerns. They want guidance. And sometimes they want immediate help. And so we've developed what's called peer support. And the definition of peer support clearly is just emotional first aid from a peer. And this is just some data back from the early 2012 study that I conducted that states that CRNA has really wanted to brief with other CRNA colleagues, other anesthesiology professionals. And not only that, but they want and they believe that it should be standard operating procedure to have clinician peer support. So I say if you build it, they will come. We have done an incredible job over the past decade with looking and developing clinician peer support programs. And so those of you who are in the audience have certainly published on this and you've shared your experiences. And when you read those articles and you talk to individuals like myself and Dr. Scott, you will learn that it's not without challenges. So back in 2013 when I was a patient safety fellow and I had just moved to Boston and I was working at MGH, as part of the patient safety fellowship, I was asked to develop an action learning project. So I myself and Dr. Terry Morris co-developed the clinician peer support program at the MGH. And when I say it wasn't without challenges, I just want to share with you that we had 100% leadership buy-in. They were very supportive. We were using data within our healthcare organization to support the need. In 2013 on this very day here you can see, I gave grand rounds and we wanted to understand what the climate was and how accepting our CRNA and physician anesthesiologists would be. We are not asking for help. We are average people and cannot be treated like anybody. Some need to make mistakes. Most thrive on mistakes. We are pilots, mountaineers, and horsemen. Fall off once, get back right away. If you need mommy to wipe your tears, go bake cookies and sell insurance. You are in the wrong job. We despise people who are really like you who think anesthesia is a bad job. Don't bring the nannies in. It will not make us better. So you can clearly see that we were challenged with individuals who didn't see the need for peer support. I will share with you that ten years later, we are ten years strong. We are no longer an anesthesia department peer support program, but we are MGB-wide. And so the synergistic approach to clinician peer support programs really involves developing a team of champions that includes all key stakeholders, most importantly the leadership. Because it really was the leadership that backed me after those comments came in. Because we had staff administrators that absolutely were not interested in supporting clinicians after an adverse event. It's a business. We have a business to run. How are we going to give them time off? And it was pretty much stated that if you didn't want to be part of the peer support program, then you didn't have to be a staff administrator. So we really had the support. Honestly, really having the data to support the need is going to be super important. Understanding the internal culture of safety and having an operational plan that is dynamic and always looking to learn and improve based on your current outcomes is critical. So as you saw with some of those comments, it wasn't easy, but we did it. And I'm here to tell every single one of you in this room that if you are interested in doing this, you absolutely can do it and be the change agent. Clinician peer support programs are needed now more than ever. And that's really because of all we have gone through, right, since the pandemic. So enter the pandemic. And as you know, on March 15th, 2020, states began to implement shutdowns in order to prevent the spread of COVID-19. And like many of you on 318, I began to watch the CDC worldometer. And I'm sure that many of you were glued to that just like I was. We watched COVID go from the cause of death was number 16 all the way up to number one in a short four weeks. So for many of you who are in the peer support space, the landscape for clinician peer support changed. There was a national need to support clinicians in face of COVID. And really what we found is that we didn't have the opportunity because we couldn't be in person any longer. So again, those of you who had these peer support programs, I'm sure you pivoted like we did. We went remotely online and we transitioned. And we were then really providing support and collaboratives for hospitals across the globe who said we need to deepen our bench here because we're in trouble. Our clinicians are in trouble. And we were hearing this. So it was super, super important for us to say, well, what are they experiencing and how can we help? So myself and Dr. Pavone and colleagues at the height of the pandemic in June decided to conduct a observational cross-sectional online survey. And we collected data from almost 500 health care professionals to assess the psychological distress and understand what protective factors were going to help our clinicians during that time. Also to understand what the psychological burden was. So the data here, as you can see, reinforced the fact that in the United States, our health care professionals were clearly distressed, specifically those who were deployed from their normal working environment. And they reported an increased psychological burden. I think everyone in the room knew that that hypothesis was going to be true. But what we found was that increased levels of resilience and support were found to be protective factors. So this data reinforced the need for clinician peer support programs. And remember that resilience is not a fixed state. You may be more resilient at one time versus another. But more importantly, resilience can be learned. It can be practiced. It can be developed. And it can be strengthened. And this became a standard then as part of our peer support clinician training. So in this next slide, I don't think I need to say anything because a picture is worth 1,000 words. In spite of us doing our best to deploy peers for clinician peer support, with the pandemic, we saw an increased incidence of death by suicide. 20 years ago, when we were talking about the peer support programs and developing them, suicide was, by short, part of our prevention methodology. However, today, it's become more important than ever. Suicide in the U.S. is a societal epidemic and a staggering public health crisis. And so we certainly need to pay attention to this. Suicide was responsible for close to 50,000 deaths in 2021. And it increased by approximately 36% in a span of 11 years. So back to 2021, that's the year after the pandemic, we were seeing about one death every 11 minutes. Lastly, suicide affects people of all ages. It's the second leading cause of death for people ages 10 to 14 and 20 to 34. And if you look at that age group, 20 to 34, that's the exact age group of our RNAs, our student nurse anesthetists. I'd like to just highlight this study that Dr. Griffiths and colleagues did. It was a pilot study of wellness and suicide prevention for student registered nurse anesthetists. Staggering statistics from this pilot indicated that 35% of the students reported suicidal thoughts during their training. So I bring you to the next picture. First off, I'd like to say we're always looking to learn by increasing awareness, always looking to learn and to understand by conducting research. But in 2024, we are and we always should be understanding to act to change the current state. So I share with you this picture of the Chalocheca-Honduras Bridge. And as you may or may not know, Honduras is considered the hurricane city because it sits in the hurricane belt. And what this picture is, is it's a picture of a bridge in Honduras that actually allows their villagers to get to safety during the rising water season of hurricane season. And as you can see, it's broke. So back in the 1930s, they asked the United States Army Corps of Engineers to build them a bridge, a bridge for safety for their villagers. And that they did. That was built in 1937. What they didn't expect was that in 1998, Hurricane Mitch would hit and that everything would change. So this is called the Bridge to Nowhere. I like to use the Bridge to Nowhere as an analogy to healthcare. Just as the Chalocheca-Honduras Bridge stood resilient during Hurricane Mitch in 1998, our healthcare systems have weathered many storms. And as you can see, the bridge remained intact while the landscape around it was altered by the hurricane. The river beneath changed course, leaving the bridge spanning dry land. And that's why it's called the Bridge to Nowhere. Similarly, our healthcare systems are designed to care for patients and has remained structurally intact during various crises, namely COVID. However, the landscape of healthcare needs have shifted dramatically, particularly regarding the mental health and well-being of our providers. I say it's time for us to be the engineers to build that new bridge, to build the swing bridge, so that our providers feel safe in the most vulnerable time of need. So although peer support programs have traditionally been established to support caregivers involved in adverse medical events, you can see that the relevance and applicability of these programs has found substantial traction across broader crisis domains, two of which, one of which I've just described extensively, and that's post-COVID, post-traumatic stress disorder. And then other ones, to name a few, are workplace violence and things of that nature. So now I hand you over to Dr. Susan Scott, who will share with you yet another revised definition of the second victim in 2024. Thank you, Dr. van Pelt. I'd like to talk a little bit about what went into our decision-making on changing the definition, because it's very different from our original definition. As we prepared for our 15-year anniversary of being a peer support process, we decided to change the definition of the second victim in 2024. As we prepared for our 15-year anniversary of being a peer support process, we evaluated those individuals that we were offering support to, and we found three main buckets. The primary bucket was unexpected patient outcomes without patient error, without medical error. Cases like the motor vehicle accident where the mother and father are both killed, but the small children in the backseat are perfectly fine. Or the patient that gets his final treatment of chemotherapy that rings a bell in a celebratory manner and is walking out in the hospital lobby collapses with a massive MI. Those types of unexpected events have happened about 54% of our encounters. And we realized that probably myopically, we were focused on medical errors. But the trauma that clinicians experience in health care is much broader than medical errors. In fact, medical errors only account to about 10% to 12% of our peer encounters to this day. The other, the third category, is tragic clinician events. Initially started with death by suicide of a young ICU nurse that later transitioned to in the 2018 range where we saw widespread exposure to workplace violence. And 98% of our staff not documenting emotional distress as a result of that. So because of those complexities, because of the maturity of our team, we realized that we needed to shift the definition. So the definition is now much more holistic. It looks at the entire environment and includes not only clinicians but non-clinicians who are trying to offer supportive presence within our health care environments. We've learned a lot about the importance of support. And initially, we interviewed 31 clinicians, physicians, nurses, respiratory therapists, and allied health professionals. And we learned from them that the perceived support was critically important. From this quote, this is a quote from one of the 31. She said, I will never forget this experience. This patient will always be with me. I think about her often because of this. I'm a better clinician. So she was exhibiting signs of post-traumatic growth from her experience. But others weren't quite so lucky. In fact, 26 of 31 had more of a negative remembrance of that day. So a little bit of audience participation for this next slide. I'd like for you to envision a ghost-like image on the back of this paramedic. All 31 individuals talked about how their patients stayed with them throughout their careers. And many of them had stories that were greater than 15 years old that they were willing to share with us. What we learned was when we split up those 31, only five had a perceived supportive presence. The other 26 did not. And the five with support seemed to have this positive growth experience because of that experience. The other 26 had a very negative, haunted, chronic, almost PTSD type of remembrance. Many of you will recognize there's six stages of recovery to the second victim as they heal. The focus that I have right now is on the sixth stage, which is really the outcome stage with three possible trajectories that the individual can transpire. They can thrive in the form of post-traumatic growth. They can survive. They can just be OK and kind of practice presenteeism in the workforce, where they don't want to put their heart on the line, but they just are given what they have to and still protect themselves. The ones that I worry about the most are the dropouts. Dropouts are defined as those individuals that, because of one particular clinical challenging event, they'll transition their career trajectory. So examples would be a surgeon who just changes his career altogether and becomes a researcher or a pharmacist who turns to pharmaceutical sales. Those individuals are known as dropouts. And they're really hard to find their story, to understand their lived experiences. So we did a social media campaign and had 105 respondents from around the world that talked about their lived experience as a dropout and found some really insightful information. About a third of them reported a significant drop in joy and meaning at work. In fact, many of them talked about it as it's just a paycheck. It doesn't bring me excitement anymore. 50% were direct care providers, which I think was a little shocking. I was expecting a lot more. When you peel the onion back, the other 50% were educators supervising student learners, or they were supervisors supervising personnel under their domain. And almost 60% of them all sought roles that would protect them from future harm so they would have less risk to that type of similar exposure. But when asked, what was a major influencer to support your role change? Unanimously, all of them said, inadequate social support from my professional social network within the health care environment. So it reinforces the importance of support. And so what are our support objectives? There's three primary objectives that pretty much keep in focus year after year after year as we evaluate these objectives. We want to try to figure out ways to minimize the human toll when this event does happen. We want to get rid of the veil of secrecy and the inner turmoil that clinicians are experiencing when they go through a second victim phenomenon. We want to provide that safe zone where they feel comfortable sharing their insights and their vulnerabilities into what is probably one of the darkest hours of their professional lives. Last but not least, we want to provide an emotional first aid to these individuals. And what we've learned is the best way to do that is through the form of peers. About 84% of individuals would like to have an individual offer support that is a peer that knows what it's like to be a CRNA in a busy trauma center, that knows what it's like to work as a CRNA in a busy obstetrical unit. We learned that individuals that are second victims have five deep desires. They want to be appreciated, respected, valued, understood, but most of all, trusted. And you might look at this list of attributes and say, well, doesn't every human have this attribute? But I push back and say that individual suffering and recovering as second victims have these needs on steroids. They need to hear it from their co-workers, from their leaders, from their colleagues. And their best source of that reinforcement is through their work environment. So what should support look like? We ask about a little over 800 individuals, what would support look like if we could dream the perfect team? And they wanted the local confidence. They wanted their peers to be that primary resource. They wanted to be voluntary, and we're starting to learn that there's some individuals that don't want support from their professional social network. About 25% of individuals are like that, and that's OK. It needs to be voluntary. It needs to be available when the event happens. So at 2 in the morning on Saturday morning, who can we turn to for support? And they also thought that two types of support were critically important, the one-on-one support that peers can offer, and then the second is when the whole team is impacted by a challenging clinical event, what a group debriefing could be like so they could share that common lived experience and talk a little bit about the mutual healing. And then they all realized that they needed fast tracks to internal mental health wellness experts, as opposed to making an appointment, per se, with a professional counselor in two or three weeks. We needed something more instantaneous than that. Peer support can be formed by anybody. Anybody in this room is capable of offering peer support. There's four basic steps to a peer support process. Acknowledge the challenging clinical event. Acknowledge that it happened to them. Validate what they're going through. Understand their feelings, their emotions. Many times, these individuals, once they hear what you're going through is a perfectly predictable response to this very abnormal clinical event. You can just see their shoulders relax and realize, maybe I'm not having a psychological crisis like I fear. Maybe this is a human response to this calling that I've pursued. And then guidance. Talk about strategies for self-care and stress management. Talk about resources, both within your department, your institution, perhaps, and your profession. You have some amazing resources in your profession that could help support the recovery process. We've learned there's barriers to receiving support. There's still a stigma for reaching out for support. And my hat's off to Simone Biles, who took a pause. It was OK not to be OK. Look at her today. High acuity areas, like the areas that you practice in every single day, you have little time to really process what's happened to you. And it's on to the next case. Access and trust. Who can I talk to? Who's a safe spot for me? Fear of the unknown is incredible for these individuals. They fear the litigation process. They fear the unknown. They fear completing the proper documentation. The fear is profound. Probably the biggest barrier, I think, is this own personal and societal expectation we put on ourselves. I call it a Vyokha perfection. As humans, we're fallible. Dr. Van Pelt clearly described that in our two-year human summary. And those restraints that we put on ourselves, sometimes they are our most self-limiting. I'd like to talk a little bit about the interventional design that we chose at MU Health Care to start addressing the problem. It's a three-tier model. It's actually designed. It looks similar to Maslow's hierarchy of needs with basic needs at the base. It really emulates our emergency medical response system. It's kind of what I took it from. So base one is tier one, where about 60% of individuals who are suffering can be taken care of by their local leadership and their local co-worker. Tier two is where we have trained peer supporters that have a little additional insights. They have this incredible empathic presence and qualities that make them a great peer supporter. And we give them the knowledge and insights into the second victim phenomenon so that they can offer that supportive guidance and healing. But we realize there's going to be a certain population of staff who need trained mental health professional experts. In fact, it's bearing out to be about 12% of our individuals that we support have needs exceeding capabilities of our trained peers. So that's where we harness our trauma rooms, our tier three, our licensed professional counselors. Just a little bit about each of the tiers. Tier one, these are important aspects if you're a department leader or supervisor. There's four basic things that individuals who are suffering want. They want to connect with that leader. They want them to have a supportive presence almost instantaneously after they hear about that event. They want the leader to keep them informed of next steps. That helps really diminish that fear of the unknown that we talked about. Consider calling in flex staffing, and that's usually where I hear a heavy sigh from the audience, because staffing is hard everywhere. But what I've found is even an extra 30 minute break can make a difference for these people. And what I've found is if I offer, do you need to take tomorrow off? Do you need to be off so you can kind of get better? 99% of the times they say, I want to be with the people that know what I'm going through. Many don't take you up on that, but the fact that they have that choice makes a difference. And then they want to check on them regularly. They say the day of the event, they have help like everywhere they look. And the next day, it's like water under the bridge. But what if you have another three-year-old in OR2, and that's where you're assigned? In my case yesterday, involved a three-year-old. Can that supervisor maybe predict and talk a little bit to them? Can they check on them and see how they're doing regularly? If there's a similar case that transpires in the future, that's what they desperately want. There's also things that you as colleagues in the audience could participate in. You want to befriend that individual. Remember what they want to hear? Things like some of the individuals, we've described them as lifelines. They talked about, I'm so glad you're here today. I love when you're on our shift together. That's a vote of confidence. That's a trust that you have in your coworker. It's these little things that can make such a huge difference. Know that silence is OK. That's one of the hardest things for me. I tend to like to fill the air with my voice when I'm nervous and when it's quiet. But sometimes it's those silent, reflective pauses that make all the difference in the world. And then just be there. Predict what you could do to help make a difference for that individual. You know that peer better than anybody else in the room. Tier 2 is where we do our peer one-on-one support and our team debriefings. Like I said, Tier 3 is our expedited referral network to mental health experts. These individuals, besides being on call for our second victims, also are mentors to our youth support team. They attend our meetings. They provide our continuing education. And they get to know these people really well. And that makes it an effective transition when there is a referral for a peer to one of our Tier 3 individuals. So for those of you interested in conceptual models, we've historically had these unanticipated clinical events with these psychological, social interactions, responses from our participants. We've had some support. And then the clinician recovers in one of three paths. We realized to change our culture, our veil of secrecy, our culture, that we had to introduce a habit, an intervention. So that intervention was our three-tier model of support in the form of the 4U team, with our ultimate goal of improving the thriving and surviving of our team members. The military's developed an incredible stress model that I like to use whenever I'm teaching individuals about the peer support process. It's really a basic four color zones. They're reddy is green, and red is ill. And it has them clearly defined. I'd like to take it just a little step further. If you see a colleague, and you can classify them, or even yourself, look in the mirror and do a self-check after these events. They go everywhere from just monitoring how I'm doing after the event, all the way up to getting professional support, and knowing that that's OK. I'd like to just share. So is support really important? And this starts to build our business case for executive administration on why is it important. So the results I'm going to show you are from an unpublished, a non-peer-reviewed manuscript that I'm working on right now with a company that provides survey perceptions to staff. And what they've done is they've combined the hospital survey on patient safety with staff perceptions of safety, joy in work, and net promoter scores. There are about 118 facilities that participated in the study between 2018 and 2020 with almost a little over 73,000 individuals. So the first question they ask is, how many of you have been involved in an emotionally challenging event? This, by the way, has been changed to the more recent definition wording. About 14% of those individuals responding said yes in the past year. One in seven to eight of us in the past year. That's a lot. Did they receive support? 50% said they received support. So that's promising. We're showing a difference. Our target goal is probably 75 to 80, keeping in mind that some don't want support. Looking at the 10 dimensions on the XSS with 100% being the highest, looking at those individuals that declared themselves as not having experience with second victim is black. The gray is those that said second victims. And all 10, they're statistically significantly lower than their colleagues that did not have exposure. Similar to the joy in work, IHI, Institute for Health Care Improvement, has five joy in meaning questions. I'm not going to review those questions because we're running out of time. But you can see the gray, the dark line at the top are all those individuals not exposed to second victim, all the way down to second victims with support or getting close. And the second victims without support are dragging down on all the categories. Again, statistically relevant. Net promoter scores, how well are you going to promote your organization as a place to work or to receive care? You can see that the ranges are really low. In fact, the second victims without support are dangerously low and almost distractors, where they're actively not sabotaging, but covertly maybe being very negative about your work environment. So as we pursue high reliability organizations, patient safety has been the important infrastructure we've used for that. Each step of the way is critically important. What might seem like a theme of the year with disclosure or with teamwork, communications, all are important steps to providing that highly reliable, predictable, excellent care to each patient in each environment. I'll turn it over to Dr. Van Pelt to bring us home. Thank you, Dr. Scott. So as we conclude our lecture, we'd just like to say that we have 40 words with 40 years of collective experience that we'd like to share with you. Looking to learn increases awareness. So it really is your first intervention. It paves the way for targeted solutions. Never stop looking to understand and continue to conduct the research. Rigorous research provides the foundation for informed decision and effective advocacy. Last but not least, understand to act and be the change agents. You are the future engineers, and so we ask you to go build those swing bridges for tomorrow's solutions. And our hope for all of our healthcare professionals across the globe is that they feel safe when they're most vulnerable. Thank you.

Lori Shirley

AANA Foundation

Jan Stewart Memorial Lecture

holistic well-being

clinician peer support

stress management

suicide prevention

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