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- [00:00]
A
Foreign. Welcome to the JAPA Podcast. Listeners can earn CME by listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's learning central@cme.aapa.org we know that adverse events, near misses, and medical errors contribute to burnout. While we enter this profession dedicated to promoting the health, safety and welfare of our patients, many of us have and will experience an adverse event. In the October edition of japa, a team published their work examining the impact of adverse event exposure on PA and APRN well being. Samantha Sagisi, Lead Author, is joining us today. Samantha, before we discuss your work, we'd like to learn more about you. What was your path to becoming a pa and how did you become involved with advocating for provider wellness?
- [00:59]
B
Yeah, thank you so much for having me. I'm really thrilled to be here. So I'm actually originally from Boston, Massachusetts and I went to Northeastern University for my undergraduate degree. I had been debating between a career as a chemist or in healthcare and it was there that I learned about what a PA was. Actually my cousin's husband was attending PA school at Northeastern at the same time and and then I remembered learning about the PA profession and just feeling like everything sort of clicked. This was really sort of striking the balance of what I was looking for with my career. And so I decided to focus my co op experiences around opportunities that would bring me closer to that dream. And co ops are essentially six month full time internships that are a special aspect of the educational format at Northeastern. And so the majority of my pre PA time was spent doing clinical research at various hospitals in the Boston area. As a result, I then moved to Chicago in 2017 to attend Northwestern's PA program and have been working at Northwestern Memorial Hospital since graduation in 2019 on the nephrology Inpatient Consult Service, which marries my love for chemistry and healthcare. My path to workplace well being, however, came several years later when I was invited to be a part of the first APP class in Northwestern Medicine's flagship wellbeing program called the Scholars of Wellness in 2022. This was right on the tail end of the pandemic. Scholars of Wellness is a professional development program that aims to create a critical mass of wellness experts on the front line, and it was a program that was previously open only to physicians. As you can imagine, as the pandemic was ending, the rates of burnout amongst apps in our institution were extremely high and so they saw a call to action and brought APPS into this program. And actually essentially what the program is is it's a year long program comprised of didactic lectures on workplace well being, the drivers of burnout specific to healthcare wellbeing science, and participants receive one on one coaching on leading a well being focused project. The results that you see in this article actually come directly from my own project focused within our academic medical center, along with a project that was conducted by three other APP scholars, my co authors Tina, Dorothy and Alex in our community campuses. Since Finishing Scholars of wellness in 2023, I then took on a funded leadership role in our Office of well Being as the System APP Liaison where now I get to give back and I coach APP Scholars who are doing their own Scholars of Wellness projects and I also function as the APP voice for workforce well being in our hospital system.
- [03:46]
C
Great. Thank you so much for all of that and I think it's time let's just dive right into your so as you noted in your article, PA and APRN or APP workforce is growing rapidly. As our workforce grows, so will the number of adverse events that apps are involved in. Before conducting this study, what was known about the effect of adverse events on apps?
- [04:11]
B
Yeah, thank you Joe. So data on adverse events that apps are involved in was actually really difficult for us to clearly define, which to me speaks to a lack of understanding and publication around this experience. Extremely important topic. What we do know from the literature is that about half of all physicians and nurses will experience second victim syndrome at some point in their career, and that's that heightened psychological response to an adverse event. And this means that likely the rate of adverse events is even higher than that. So as far as the impact of adverse events on apps, we did have a few studies to draw from, although the vast majority was in the APRN literature, specifically with midwives and CRNAs. Articles that included PAS specifically usually had us grouped together with other staff members like physicians or physician trainees. And this was a huge driver as to why we wanted to share the results of our study. We know intuitively that PAs and APRNs do experience ramifications of adverse event exposure. We are human after all. And finally, this was a large, diverse group that helped us to begin to understand what exactly those ramifications might be.
- [05:24]
C
So in the article you talk about second victim syndrome, can you tell our listeners a little bit more about what this syndrome is and what are signs and symptoms that those affected may experience?
- [05:36]
B
Yeah. So second victim syndrome is a phenomenon in which a healthcare worker who's exposed to an adverse patient outcome, a medical Error, patient death or injury actually experiences trauma from from said event. So the idea is that the patient is the first victim and the provider is the second victim. At nm, we like to think about adverse events as occupational hazards. They are unavoidable aspects of our jobs in medicine, even if no medical error occurs. So just like firefighters have an occupational hazard of potentially running into a burning building, we encounter the occupational hazard of taking care of complex sick patients every day. And these occupational hazards can sometimes lead to emotional, psychological and physical ramifications for the involved clinician, especially if that individual does not have adequate social support inside and outside of the workplace. So second victim syndrome is characterized by this increased feeling of anxiety, shame or self blame related to the event. Many people feel as though they should have foreseen the event, or maybe they feel personally responsible for the adverse patient outcome. This can manifest in a number of different ways. This can look like professional isolationism, so withdrawal from peers or even from patient care duties increase in defensive care tactics like the way that we order tests and imaging, or even clinical depression or suicide in extreme cases. And we know that second victim syndrome can affect any member of the healthcare team. And it may manifest in different ways depending on your level experience, for instance, or even just what might be going on in your personal life at the time of the event that can seriously impact the way that you are able to cope with some of these traumatic events.
- [07:27]
D
Thank you so much Samantha. I feel like I'm learning so much about things that I didn't even know that were a thing and that was such an interesting program. So that study is really particular. So now tell us a little bit more about it. You sent, from my understanding, you sent a 14 question survey to over 1000 apps at a large healthcare system which included an academic medical center, community hospitals and ambulatory clinics. You really touched different clinical settings, which is very comprehensive in my opinion and that was great. Which questions did you include and why for our listeners?
- [08:08]
B
Yeah, it's interesting, I think as I got more into well being work, how intuitive some of these concepts feel. But maybe we just didn't necessarily have the vocabulary for exactly what it was called. But I'm sure all of us listening, if you've been in the field for a while, you can probably relate to that feeling that I'm describing. This study was unique in that the questions were developed based on a combination of content expertise by local well being and peer support experts, as well as prior publications in this space, specifically from the Agency for Healthcare Research and Quality. Our goal with this survey was to keep it succinct but informative, especially in the well being world. We know that survey fatigue is real and so our hope was to get a large enough sample size to represent our diverse workforce while still really hitting all the high points of exploring this concept of adverse events and the impact on the well being in the app workforce. So we included demographic information on your professional title, so PA or aprn, and that was further broken down into crna, nurse practitioner, CNS and midwife, years of experience as an app and your primary work environment. So do you work in an ambulatory clinic, an inpatient setting or procedural or emergency department? This helped us a little bit with some subgroup analysis. We then wanted to characterize how many apps had just ever experienced an adverse event and we loosely defined this as a patient adverse event, medical error or near miss experienced directly by the provider. And the goal of this is just to capture any event that you feel like negatively impacted you. And this was asked about both in their lifetime experience. So have you ever experienced an event and also whether you had experienced one in the last six months. So that we're able to do some temporal analysis as it pertains to current levels of burnout in this group since we are asking them to recollect to a time in the past. And then we asked the folks who had self identified as having experienced an event in their life to think back to that period following the event and tell us how you felt after the event. And this was so that we could collect information on signs of second victim syndrome. There were the emotional symptoms such as feeling anxious, depressed or irritable, physical symptom of having trouble sleeping, patient care related symptoms related to decrease in self confidence as a provider, changing your practice of medicine to be more defensive and feeling less connected to patients. And then finally a psychological symptom of tending to isolate more personally. We then also asked clinicians whether they had considered leaving their position or clinical medicine altogether after these events. As we know, attrition is a huge issue following the experience of second victim syndrome and we felt that these questions captured the important components of published works around second victim syndrome without inundating the group with an extremely lengthy survey. And if they had more to add, we provided an open ended question where actually many apps shared anecdotes about the impact of these events on their well being. I found these results to be the most compelling personally to hear the personal stories from my workforce. And then finally we also surveyed around what types of support apps prefer to receive after experiencing an adverse event. So this could look like from a family member, a colleague, an employee assistance program, mental health professional, spiritual care, something other than that. Or some people might even say I don't really need support. And then we ask this question in particular, because the goal with conducting the survey in the first place was to build out our peer support program after we conducted the survey with the goal of helping our app workforce cope with these difficult events. And I'll talk a little bit more about that later. But finally, we surveyed around the incidence of burnout and callousness using the MASLOC Burnout Inventory 2 question short form to then correlate these responses with the incidence of burnout.
- [12:10]
D
These are all great data. 350 apps completed your SERP PAs representing 37.4% and APRNs representing 63.6%. Over half of all respondents worked in ambulatory setting followed by inpatient settings. I found it very interesting that apps with the most experience 10 years or more were more likely to respond by 37% as compared to new grads who made up 4.6% of the survey respondents. Now knowing this, it is astounding that over half of all respondents experienced an adverse event at some point in their career and 25.1% had experienced one event in six months. How does this compare the rates of adverse events experienced by healthcare providers in other professions? You did mention as an example firefighters. So I mean, it would be interesting to see how we compare to other professions.
- [13:10]
B
Yeah, no, I love that question. And we did have a great response from our more tenured apps. And I will say we do have more apps with greater years of experience, so more than 10 years of experience within our health system than we do new graduates. So that difference may in part be just a representative representative of who makes up our workforce overall. But we did see an expected trend of a higher proportion of apps having experienced at least one event in their career as they went up in years of experience. And to me this makes sense intuitively because those of us with the most cumulative experience were just simply more likely to have experienced an adverse event throughout our career. That was 60.8% of apps with 10 or more years of experience reported at least one event compared to 43.8% of apps with less than one year of experience experience. But interestingly, the rate of an event in the last six months does go down somewhat as apps gain more experience. So for example, only 14.6% of apps with 10 or more years of experience report an event in the last six months compared to about 37% of those apps with less than one year of experience and 21% of the apps in between one and nine years. And I don't think this change can be fully attributed to simply just having more experience and thus experiencing less events. As again, sometimes an adverse event occurs despite the absence of a true medical error. We might do everything we can for the young patient on a ventilator, but still they pass away from influenza and this may seriously impact our psychological well being. Similarly, we know that even a surgeon with 20 years of experience may infrequently still perform a medical error. So the change in self identification of an adverse event in the last six months could speak to experience, but also could speak to maybe we just consider different events to be impactful adverse events as we progress through our careers. So I wonder, do we build more resilience as we progress in our careers? And so I think this is an area that could use further investigation. And then as for the rates of adverse events and apps, I know the number looks really large, but actually it's roughly about the same that we're able to pull from published literature for physicians and nurses as far as experience of adverse events and second victim syndrome at some point in your careers, which I think just goes to show how sometimes adverse events, medical errors feel very. It feels like we can't talk about it in healthcare, but actually it's a shared experience for many of us. And again, that's why we think about this as simply an occupational hazard of something that can be expected to happen to all of us at some point in our careers.
- [16:00]
D
You did a deeper analysis of how apps were affected by adverse events. How was their well being impacted over time? And also how did they experience second victim syndrome, anxiety, depression or other physical responses?
- [16:15]
B
So yeah, we had found that over half. So 55.4% of apps had identified themselves of having experienced an adverse event during their career. And nearly Everybody in that group, 97.4% had reported experiencing one or more symptom of second victim syndrome following the event. So it's very common. The most common complaint was feelings of anxiety, depression or irritability following the event, which 92% of respondents reported. The emotional impact is huge and obviously can directly influence our ability to cope after such events. We can think about our personal resilience and emotional well being as a battery. When we experience these toxic stressors, our battery can become depleted suddenly. Even small inconveniences can feel like enormous hurdles to overcome. Also, about 3/4 experienced a decrease in their Self confidence as a provider following the event. You can imagine how this can have repercussions when it comes to second guessing our clinical instincts and potentially directly affecting the patient experience. And the patient experience may also be impacted by those providers who are changing their practice to be more defensive, of which more than half reported. This might mean ordering extraneous tests or studies to ensure we don't quote, unquote miss anything and the patient provider relationship suffers as about one third report feeling less connected to patients as a result. This is actually a coping mechanism that we use during periods of burnout, wherein we depersonalize from our patients to protect ourselves. It's no longer Mrs. Smith, who I've been following for years, but rather it's that dialysis patient in day seven. We do this to disconnect ourselves from that emotional toil that we take after these adverse events. Then physically more than half reported difficulty sleeping after an event, which then in turn of course can beget further errors because we know sleep deprivation impacts our cognitive abilities and when we work in such a high risk environment, these physical complaints can lead to serious concerns. And personally, I found some of the right in answers to be even more compelling. So many participants identified shame, guilt and fear as consequences of their event.
- [18:31]
C
Thanks for sharing that. So I know that in your study you did find that there was an association between adverse events and burnout. How many PAs consider leaving medicine altogether after experiencing some sort of adverse events?
- [18:45]
B
So we found that 37% of all the apps that we just happened to be serving at that time were experiencing burnout, which is about similar with published data. You'll see lots of different levels reported in publications, but we were interested to see exactly that. The rate of burnout was significantly higher by about 13% in apps who had experienced an adverse event in their entire career compared with the burnout rate of those who had never experienced an adverse event, 42% in the group that had experienced an event, compared to 30.8% in the subgroup that had never experienced an event. Burnout was even higher in those who had experienced an event in the last six months at 44%, although this difference did not reach statistical significance, perhaps due to the sample size. Then when we looked at callousness, which is a proxy for that depersonalization, again that sense of detachment that can occur sort of as a progressed stage of burnout, the rate was significantly higher in those who had experienced an event in their entire career compared to those who had not. So we found the same in the callousness subcategory and the correlation was interesting, though I would say not surprising to us because we know that errors and burnout can exist in a bidirectional relationship. More burnout means more errors and the reverse is also true. But alarmingly, one in seven apps reported that they considered leaving their role or clinical medicine altogether after the event. Many of us in health care have experienced the strain and impact of turnover, so these numbers really struck me. And of course, they actually don't capture those clinicians who have left over the years in the wake of an event. Paying attention to this and thinking, being thoughtful about how we can best support our providers as they cope through these events is extremely important when we think about the longevity of our workforce.
- [20:36]
C
Yeah, I think you bring up a really good point about that gap in our data as far as not being able to gather the data from those that have already left. Right. I mean, we don't know what that number is. So it would be really interesting to find that information out. So I have a longer kind of question that's kind of a multitude of questions that are kind of all around the same topic, but. So did the PAs and APRNs provide insight into the support they received after their adverse event? I know that many employers have like an employee assistant program and spiritual care. You know, I guess I'm wondering, are PAs likely to use these kinds of services or is it more likely that they'll reach out to a peer or colleague for support? You stated that the impact of adverse events on APP well being and the APP experience of second victim syndrome have not been very well documented. And your study has provided insight into this very important topic. But we all feel that there's more that should be done. What are the next steps you think that we should take to promote PA and APRN wellbeing after exposure to an adverse event?
- [21:47]
B
Yeah. So our study found that the majority of apps did seek out support from a peer following an exposure. Actually, 87% of those who had ever experienced an event and nearly all of them said it was helpful for them in coping with the event. This is compared to only 7% who indicated they would reach out to an employee assistance program after an event. And I would say this is traditionally what many hospital systems offer as far as supportive services following the wake of an adverse event. We know from physician literature that peer to peer support has been shown to mitigate burnout in physicians who experience adverse events. This survey, in our case, directly informed our peer support program at Northwestern Medicine. So peer to peer, or P2P is our peer support program. It began first as a program for physicians in one department, in one hospital, and has since expanded across our entire health network of hospitals and clinics. And the survey demonstrated both the desire and the need for peer support for apps, and was really the catalyst for our expansion of this amazing programs to all apps across our health system. The peer support program is voluntary and confidential. It involves pairing an affected clinician with a trained peer supporter from the same job family. Peer supporters are trained in stress first aid, and the focus of the conversation is not to perform an M and M and not to talk about what I would have done clinically, but rather to help the affected clinician identify ways that they can cope with the ramifications of an event. And since P2P was expanded to include apps, we've trained about 40 app peer supporters across our system. And we've actually replicated this survey and expanded similarly to other interdisciplinary groups across our system because we recognize that an adverse event impacts so many different members of the team. It's really not just the physician and the nurse, but it's also the social worker and the physical therapist and the pa. As far as next steps, I think this study lays a nice groundwork for discussions around the emotional, physical and psychological impacts of of adverse events on APP well being. But I do think there's a lot more to be learned. Larger studies maybe will help us further tease out that temporal relationship between events and burnout. So, for instance, is there a correlation between a recent event and current experiences of burnout? But even beyond the research world, I think this study shows us that healthcare institutions have a duty to support their clinicians through the recovery process from these occupational hazards. There's the financial incentive because we know that burnout and errors are closely related and this has implications on our workforce vitality if we have people turning over. But even just the harm of potential litigation after errors, there's the recognition incentive, where more and more institutions are seeking external recognition for their efforts and keeping their workforce healthy. This is a good place that you want to work, such as the Joy in Medicine Award, which is a recognition that Northwestern's received in recent years. And there's also a regulatory pressure to keep our workforce healthy. The Joint Commission and the National Quality Forum tell us errors need to be treated with transparency and we should provide support systems to care for the involved clinicians. Then finally, there's just the moral case for why institutions need to support their clinicians in their recovery from these events. We know that the healthcare workforce is finite, and while these events might be unavoidable hazards. The way that we treat and support our clinicians in the aftermath of these events is crucial to keeping our workforce well.
- [25:27]
A
Samantha, this has been a really interesting and powerful conversation. You know, I keep thinking about conversations I've had with my friends and colleagues if they they've experienced something really challenging and terrible at work. And what you mentioned about that peer to peer to support is really the thing that kind of brings us closer together and I think helped us come through and build some of that resilience that you're referring to. So I think it's amazing you built this program, the peer to peer to support and it's a example for the rest of us. So before we wrap up, do have to ask any final thoughts?
- [25:58]
B
Yeah. Thank you so much for giving me this platform to promote a topic that's near and dear to me. And we actually think about our peer support program as, you know, just the presence of the program sort of being the intervention. Knowing that someone cares about you to reach out to this peer support program and refer you in itself can be the intervention, not necessarily even the formal support conversation. And the more that we train people in peer support, the more you're just able to use it in your day to day interactions with your colleagues. And the ideal state is that the peer support program doesn't even need to exist. Right, because that's just how we all operate. But I would also just like to say thank you to my co authors for sharing this work with me. And my final thoughts are that research around App well being is still evolving and in many ways feels like unchartered territory. So if this feels like something that's interesting to you, I would encourage you to find ways to get involved in your local areas, whether that's within your workplace, on your team, your state organizations or national organizations. Because we need more App leaders who are leading the charge with contributing to the research pool, not only in the area of peer support and adverse events, but in many other facets of what drives app wellness and burnout. And apart from research, we need apps with a seat at the table when decisions are made that impact our workforce well being at the local level. Becoming a leader in App wellbeing was not something I had even known could be a career path for me when I was in PA school. And so I think this is an area healthcare organizations need to focus on moving forward. And I encourage all of you listening to think about how you might get involved in this really exciting area and potentially forging your own leadership path in the wellness space. So thank you guys for having me.
- [27:42]
A
Thank you Samantha and to our listeners. Don't forget, you can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you should listen to the podcast and complete the post test and evaluation in AAPA's Learning Central at cme.aapa.org until next time.