Peer Supporters’ Experience of Supporting Second Victims (KoHi-III-Study)

1. Introduction

The Second Victim Phenomenon is common among health care workers [1,2,3]. Second Victims (SVs) are health care workers also negatively impacted by unanticipated adverse events while caring for their patients [4]. The Second Victim Phenomenon (SVP) may negatively affect the involved health care workers, their organizations, and future patients. Consequences for healthcare workers can range from mainly psychological reactions, such as anxiety, loss of self-confidence [5], to physical symptoms, such as backpain, headaches, etc. [6,7,8]. Reactions detrimental for the organizations are common as well, such as absenteeism, or turnover intentions [9]. For patients SVP compromises patient safety and the received quality of care, for example by SVs practicing defensive medicine [10,11] or a heightened error rate as a result of developing post-traumatic stress disorder (PTSD) after the incident [5]. If recognized correctly, SVP is effectively treatable [12]. Scott introduced the three-tiered integrated model of interventional support for SVs [12]. The first tier is basic emotional aid at the local level and estimated as sufficient for approximately 60% of SVs. The second tier involves an escalation of support through the inclusion of specially trained peer supporters within healthcare institutions, addressing an additional 30% of SV cases. The last level of escalation involves professional counseling, support, and guidance for those unable to attain sufficient assistance in the initial two tiers. Scott estimated the third tier to be necessary for 10% of individuals affected by SVP [12]. This support model has been further conceptualized by the ERNST-consortium [13], introducing two additional levels to prevent or mitigate the effects of SVP: individual and organizational prevention, as well as self-care practices for individuals and/or their teams. Furthermore, organizational support for SVs has shown to reduce turnover intentions and absenteeism [9].

Consequently, Clinic Hietzing in Austria, Vienna (KHI) developed a peer support program tailored for employees encountering adverse events possibly leading to SVP on the basis of the three-tiered integrated model of interventional support. A preliminary descriptive study was conducted and published reporting on the prevalence, symptom load and preferred support measures for SVs within the institution (KoHi-I) [14]. This study revealed a 43% prevalence of SVP at KHI, with colleagues identified as the most important support group for those affected. These findings further justified the implementation of the peer support program KoHi (Kollegiale Hilfe/Collegial Help) at KHI. The description of the interventional program KoHi is described in detail elsewhere [15]. Following KoHi-I, members of all occupational groups were invited to participate in a five-hour training course concentrating on psychological first-aid, equipping 122 of them to become peer supporters. Participation in this training course was on a voluntary basis.

The findings of numerous studies have shown that volunteers' decision to continue helping is influenced by how satisfied they are with their experiences [16]. Volunteers can make a substantial contribution to the success of the intervention, especially when they feel valued, acknowledged, and confident in their abilities. Volunteer dropout is a critical challenge for organizations and interventions, as it directly affects their sustainability. Therefore, successful volunteer retention is crucial for an intervention's survival. To retain volunteers as crucial stakeholders in volunteer-based interventions such as peer support programs for SVs, exploration of volunteers’ views on the success and efficacy of their efforts is very important.

While the effectiveness of different peer support programs for SVs has been researched [17,18,19,20], there remains a research gap concerning the peer supporters’ experiences and psychological safety when dealing with colleagues affected by SVP. Therefore, our aim was to explore the peer supporters’ experiences and self-perceived psychological safety after supporting SVs within KHI. This study aims to provide valuable insights that can support the development and enhancement of peer support interventions for SVs tailored to the unique needs of both SVs and their supportive peers.

2. Materials and Methods

KoHi-III is a cross-sectional study conducted among the KoHis (Collegial Helpers) of KHI’s peer support program. KHI is a hospital in Vienna, Austria with approximately 3,300 employees and 1,100 beds. Approximately 250,000 outpatients and 52,000 inpatients are treated annually [21].

Eligible participants were trained KoHis that completed a KoHi-peer support session for any reason. Upon completion of a KoHi-peer support session, KoHis were advised to contact the psychological team at KHI via telephone who utilized a questionnaire in a standardized and pseudo anonymized manner to collect the data used in this study. The questionnaire used was designed for this study and consisted of 15 items. The questions regarded the information about the KoHi-session as well as the rating of helpfulness of the sessions. The participants were also asked to assess their own psychological wellbeing after having completed a KoHi-session. The complete questionnaire is provided as supplementary material in the Appendix A (Table A1). The telephone interviews were conducted between May 2020 and March 2024. All participants gave informed consent in written form. The questionnaire was externally analyzed by scientific staff at the Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP) in Germany using SPSS Statistics Version 29 (IBM, New York, NY, USA). Descriptive statistics were reported using means (M) and standard deviations (SD) for interval-scaled variables independent of normal distribution [22,23,24]. The ordinal-scale variables, each measured on a 10-point Likert scale, can be treated as interval-scaled, as demonstrated in the simulation study [25]. -Frequencies (n) and proportions (%) were calculated for nominal variables.

Before implementation of the KoHi-program, ethical approval was given by the ethical committee of the city of Vienna in September 2019 for the entire KoHi-project (EK-19-074).

3. Results

Forty-five telephone interviews were conducted after KoHi-sessions utilizing the previously described questionnaire.

Regarding initiation of the session, 53.3% (n=24) of the meetings were initiated by the KoHis themselves, 27.3% (n=12) by colleagues or supervisors of the person in need of support. Seven out of 45 KoHi sessions (15.6%) were initiated by the persons in need of support themselves. Most KoHi-sessions took place within 30 minutes after establishing first contact with the KoHis (77.8%) and 56.8% of the sessions (n=25) took place within 30 minutes after the adverse event that triggered them. The sessions’ mean duration was 40.02 minutes (Mdn=30; SD=29.28; min=1; max=180). Almost all (93.3%, n=42) KoHis found the duration of the sessions to be sufficient. Forty-two of 45 sessions took place during day-shift and most sessions were conducted within the KoHi’s own departments (n=33, 73.3%).

Most important triggers for the KoHi-session are shown in Table 1.

The events categorized as “other” were specified as (excerpt):

• - “Acute mobbing at workplace” (this was indicated three times)
• - “Sudden change in workplace”
• - “Car accident on the way to work”
• - “Suicide threat of a patient”

After 36 of the 45 reported meetings, the KoHis deemed the potential SVs as sufficiently stable and capable of acting and 18 of them continued working after the meeting. In 19 cases, KoHis established contact with further, professional support sources, (psychiatric department at KHI n=11, psychological service center (external) n=10). Seven potential SVs left work early after the session. Three potential SVs canceled their session prematurely. KoHis rated the perceived helpfulness of their sessions for the potential SVs highly (M=8.57 (SD=1.56) on a 10-point Likert-scale, 1=not helpful at all; 10= most helpful). Regarding the KoHi’s own psychological safety, KoHis reported to not feel very burdened after their sessions (M=3.42 (SD=2.41) on a 10-point Likert scale, 1=not burdened at all; 10=most burdened)

4. Discussion

To offer initial insights into the effectiveness and utilization of KoHi's peer support program for healthcare workers involved in SV incidents, we conducted our study exploring triggers, timelines, and overall helpfulness ratings evaluated by peer supporters. KHI’s KoHis reported 45 sessions in 47 months. Most sessions were initiated by the KoHis themselves and main trigger for the sessions were terrible news from the private sphere. The KoHis reported the majority of SVs to be sufficiently stable and able to continue working after the session. The meetings were rated very helpful on a scale of one to ten (M=8.5). Further, the peer supporters themselves didn’t feel very burdened after conducting KoHi-sessions (M=3.42).

Though the 45 reported number of sessions align with numbers of comparable peer support programs at other hospitals [12,26,27], it still seems to be rather low taking the baseline study into account where 43% of the participating employees stated to consider themselves as SVs [14]. One possible reason for these low numbers is underreporting. Discussions during quarterly team meetings with the psychological department indicated that, particularly during the initial year of the COVID-19 pandemic, some KoHi-sessions went unreported via telephone due to elevated workloads. In order to mitigate barriers associated with reporting, KHI should consider streamlining the reporting protocol. One proposed measure is the implementation of an additional, less time-consuming online reporting option in the future. Furthermore, the data collection could be conducted anonymously in this way. This adjustment aims to enhance the efficiency of reporting mechanisms and ensure a more comprehensive documentation of KoHi sessions. Another explanation for the low numbers of reported sessions is underutilization of the program itself. Main trigger for KoHi-sessions was terrible news from the private sphere. This contrasts with the results of the preliminary KoHi-I study, which examined the main events leading to SVP at KHI before implementation of the peer-support-program and identified them to be aggressive behavior of patients or relatives and unexpected death/suicide of a patient [14]. The observed discrepancy raises concerns about potential underutilization of the program, especially by individuals involved in adverse patient events. A possible explanation for this is self-stigmatization, which may inhibit their willingness to seek out help [28]. Another indicator for self-stigmatization is the initiation of KoHi-sessions: in over 50% of the cases, the KoHis themselves initiated the meetings and only in roughly a quarter of the cases the SVs approached the KoHis. Therefore, barriers, such as self-stigmatization, can be suspected for other SVs to seek out help. This should be addressed by the peer-support-program. Nevertheless, this emphasizes the proactive role of KoHis in providing support. Additionally, a significant proportion of sessions were initiated by colleagues or supervisors, highlighting the importance of organizational support and recognition of the need for peer support.

The promptness of the sessions is notable, with most taking place within 30 minutes after initial contact with the KoHis and over half occurring within 30 minutes after the triggering adverse event. This timely response reflects the effectiveness of the peer support program in providing immediate assistance to individuals in need. Moreover, the average session duration of around 40 minutes implies that KoHi sessions were timely efficient. The high proportion of KoHis who found the session duration adequate further supports this notion, indicating that the sessions effectively balance thoroughness with efficiency.

Most sessions happening during the day shift and within the KoHi's departments show that peer support is easily accessible and well-integrated into the healthcare workplace. Being nearby allows for quick help and makes the individuals involved in an adverse event feel comfortable, providing them with a feeling of familiarity. This could have enhanced how KoHis perceived the effectiveness and satisfaction of their sessions.

To summarize, the proactive initiation of sessions, prompt response, adequate duration, and integration into the workplace environment may have all played a role in the perceived success of the peer support program, as evaluated by KoHis, in meeting the needs of healthcare workers dealing with adverse events. The perceived success of the program by KoHis is very important as it ensures their continued involvement and support, while also providing information on its effectiveness and impact on healthcare workers' well-being.

Another notable finding of this study is that according to free text answers, three KoHi sessions were initiated in response to acute workplace mobbing. Workplace mobbing has been associated with detrimental effects on the physical and mental well-being of employees [29]. This, in combination with SVP, may increase the potential for psychological harm and occupational stress. A systematic review has suggested that there is only low-quality evidence supporting the effectiveness of organizational interventions in preventing workplace bullying [30]. Encouraging reporting empowers employees to speak up, knowing their concerns will be taken seriously. Healthcare organizations must receive input from peer supporters regarding workplace mobbing while maintaining confidentiality between peer supporters and affected colleagues, refraining from disclosing the personal data of affected individuals while still reporting the issue. Transparency ensures organizational leaders are aware of the issue while upholding privacy, allowing for appropriate measures to be taken to address mobbing while respecting the sensitivity of individual situations. Therefore, to mitigate the negative effects of workplace bullying, as well as SVP, KHI should take measures into consideration to increase healthcare workers’ resilience. This includes adapting leadership behavior, crisis communication and the continuous support of KHI’s employees [31]. Continuous support should encompass initiatives that encourage employees to practice self-care [31], which is also beneficial for preventing or mitigating the effects of SVP [13]. By fostering a resilient and supportive work environment, KHI can contribute to the well-being of its staff and potentially reduce the adverse consequences of workplace mobbing and SVP incidents.

The KoHis perceived their sessions as very helpful for the potential SVs (M=8.57), while not feeling very burdened by carrying out these sessions (M=3.42), indicating a high satisfaction of the peer supporters with their work. Another study on volunteer retention and sustainability of a SV peer support program found that volunteers found their assignments to be meaningful and personally satisfying and reported confidence in their resilience [32]. Our study’s results reflect these findings. It is advisable for the management of volunteer-based interventions to consider factors that impact volunteer’s satisfaction for a better volunteer retention [16]. Furthermore, understanding the factors that contribute to volunteers' resilience can help in optimizing training programs for both current and incoming volunteers. The previous research indicated that the primary motivation to join volunteer programs is based on mobilizing personal relationships, and issues around retention are manifested at a personal level, where the relationships in the team are very important [33]. However, the present study did not focus on examining how team and organizational factors relate to the satisfaction of peer supporters. Future research should explore how team dynamics, organizational support, and leadership impact peer supporters' experiences and overall satisfaction. Therefore, volunteers’ satisfaction should be continuously monitored and drops in satisfaction addressed immediately. However, to achieve a more in-depth understanding, the quantitative findings should be complemented by qualitative data in the future.

This study encounters several limitations. The use of a convenient sampling method and the setting of the study within one hospital restricts the generalizability of the findings. Further, social-desirability bias may play a role in the high ratings of helpfulness of the KoHi-sessions by the KoHis along with them not feeling very burdened by the sessions. While acknowledging these limitations, we still believe this study provides a first insight especially since integration and evaluation of peer support programs for SVs is a relatively unexplored area in European countries.

5. Conclusions

We identified a relevant need for the KoHi peer support program and a high effectiveness regarding stabilization after an adverse event. Main barrier of the program seemed to be underutilization of the program possibly due to self-stigmatization. KHI should address this by continuously informing their employees about the program and investigating the reasons behind this further. The peer supporters themselves do not feel psychologically burdened after offering peer support. Therefore, this peer support program is deemed safe for the voluntary peer supporters and an upscaling of this project is advisable.

6. Patents

This section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript.