Learn how a peer support program that addresses challenging experiences yields a culture of well-being.
During their career, up to 50% of health care professionals may be traumatized after an adverse event, such as a medical error or unexpected outcome, becoming what is known as “second victims.”1- 3 Despite the pervasiveness of traumatic events, health care workers often do not access formal support for these events or informal support from their peers or organization.
ChristianaCare initiated a needs assessment and found that when caregivers do seek support, they do so from a peer or supervisor (Figure 1). Most peers had no formal training in supporting their colleagues, establishing the need for a peer support program.
Figure 1. Sources of Support Used by Health Care Workers After Adverse Events
Developing the Intervention
The ChristianaCare Center for WorkLife Wellbeing (CWW) created a peer support program called Care for the Caregiver that could formally train peer supporters and then deploy them throughout the system to support colleagues. Evidence was sourced from peer-reviewed literature and obtained by consulting with other organizations that already had established peer support programs.
Preparing the program
Health care workers in clinical and nonclinical roles can request peer support themselves or be referred by colleagues or supervisors. Team members can receive individual support or support as a group. Various marketing tactics remind team members about the availability of peer support, including:
The Chief Medical Officer supported an application for a pilot program with a 1-year grant to fund the part-time work of a physician and program coordinator. Additionally, CWW formed a partnership with Quality and Safety that coincided with the launch of a Communication and Optimal Resolution (CANDOR) program, implementation of a Just Culture approach to event management, and formation of a committee on supporting psychological safety.4,5 A leadership steering committee of champions from employee health, behavioral health, an internal leadership institute, human resources, pastoral care, risk management, patient safety, and corporate communications was also formed to guide the peer support program.
CWW formalized workflows and policies into a manual which included:
Some peer support referrals eventually became hardwired into existing systemwide policies and procedures. The peer support program manager is alerted about certain workplace violence cases and attends the post-event debrief meetings to connect individuals and teams with appropriate support.
Selecting and training peer supporters
Peer supporters were selected from high risk areas in the hospital, such as the emergency department, surgery, NICU, Labor and Delivery, and the ICUs. Peer supporter backgrounds varied, from attending physicians, residents, nurses, respiratory therapists, to others in clinical roles. As the program grew over the past 5 years, nonclinical health care workers, such as constables and administrative team members were also recruited as peer supporters. Recruitment of health care workers with the skills and interest in providing peer support occurs via outreach from leadership and special events, such as Courageous Conversation™ gatherings.
Peer supporters are trained in skills that span psychological first aid, basic helping skills from counseling psychology, and in the procedures and workflows that are unique to the program at ChristianaCare.6,7 Onboarding relies on web-based training modules and in-person simulations (Figure 2). Encounters are meant to be unscripted and informal so that they remain authentic. Therefore, training does cover some unhelpful responses. The most common “watch outs” are fixing, reassuring, and discounting during an encounter (Table 1).
Peer supporters follow up with the program manager after challenging cases, coordinate referrals to long-term support (eg, employee assistance programs, therapists or counselors, pastoral care, etc.), and receive monthly newsletters with program updates and skill building tips. Quarterly meetings not only keep peer supporters engaged, they help refresh current skills and educate on new skills, offer additional training through case discussion, provide opportunities to network with peer supporters in other departments, and care for basic needs such as food and physical comfort with refreshments and chair massage. The peer support team also uses an internal social media page to share resources and connect.
Figure 2. Examples of Web-Based Training Modules
Table 1. Examples of Unhelpful Responses to Avoid During a Peer Support Encounter
Peer support encounters
Defining what peer support is, and what it is not, helps manage participant and peer supporter expectations (Figure 3). For peer supporters with training in behavioral health (eg, psychiatry, psychology, counseling, social work) it might be more important to distinguish peer support skills from therapy to prevent them from using therapy skills out of habit. Additionally, clear expectations about the duration of peer support and discussion topics should be set at the beginning of the encounter. Encounters are intended to be brief (1 or 2 15-minute to 60-minute sessions) and not longstanding relationships. The program manager and peer supporters need to be familiar with long-term support resources.
It is important for a peer supporter to redirect conversations to focus on coping with what happened rather than the details of what happened. Revealing too many of details or providing too much emphasis on the case can be risky for both parties involved in the encounter. There is evidence that detailed debriefing of potentially traumatic events may hinder natural psychological resilience and can be harmful by increasing risk for developing post-traumatic stress disorder.8 Peer supporters may also develop vicarious trauma by hearing details of multiple traumatic events in their role. In many states, peer support is not a legally protected relationship so peer supporters should minimize the details they learn about a case to limit their knowledge of any legally discoverable information.
Confidentiality is paramount in peer support encounters. It is critical that peer support programs distinguish normal distress and mental health diagnoses from impairment and that stress be considered as a continuum. Establish for both parties in the encounter that health care workers providing peer support do not have any additional reporting requirements above and beyond what they already commit to as part of their licensure and employment agreements.
The peer support program at ChristianaCare has clear guidelines and training on confidentiality of referrals. The confidentiality statement developed at ChristianaCare is, “Interactions with the Center for WorkLife Wellbeing can include discussion of sensitive topics. We value the trust caregivers place in us, and all efforts will be made to treat sensitive information with the utmost confidentiality. However, limits to confidentiality do exist. Some specific situations (e.g., reports of discrimination, harassment, retaliatory behavior, child/elder abuse, or if a caregiver is impaired or an imminent danger to themselves/others) may require breaking confidentiality to promote safety and wellbeing, and to adhere to state law and/or organizational policy. Conversations with staff members of the Center for WorkLife Wellbeing do not constitute treatment or initiate a therapeutic relationship. Additional clarity around confidentiality can be obtained by speaking to a member of our team or by emailing us.”
Figure 3. Defining Peer Support
Peer supporters complete de-identified encounter forms after each case to track the duration of the meeting, referrals provided, and other relevant information to inform the program development efforts.
Peer support programming as a springboard to an organizational culture of well-being
The overarching goal of the peer support program was to encourage culture change and support a culture of well-being across the organization through 3 mechanisms.
Table 2. Mechanisms to Encourage and Support Changes to the Culture of Well-Being
For the first 5 years of ChristianaCare's peer support program, encounters steadily increased year-after-year, from 79 encounters in year 1 to 402 encounters in year 5. Given that the number of adverse events did not increase substantially during this time period, the increase in utilization may be driven by growing knowledge of the program and an organization-wide cultural shift toward well-being and acceptance of help seeking among health care workers.
Peer support is now one of the foundational programs of CWW and continues to be the most-utilized program offered by the Center. The presence of a formal peer support program resulted in significant, notable culture change in well-being at ChristianaCare because of increasing recognition and support of second victims as well as increasing help-seeking behaviors. There is still work to be done in new areas of distress and concern for health care workers, such as global pandemics and racial injustice, and peer support will continue to adapt and grow to meet the needs of health care workers.
Headquartered in Wilmington, Delaware, ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible, and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, medical aid units, 3 hospitals (1299 beds), a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health. It also includes the pioneering Gene Editing Institute and was rated by IDG Computerworld as one of the nation's Best Places to Work in IT. ChristianaCare is a nonprofit teaching health system with more than 260 residents and fellows. We are continually ranked by U.S. News & World Report as a Best Hospital. With our unique CareVio data-powered care coordination service and a focus on population health and value-based care, ChristianaCare is shaping the future of health care. Learn how we deliver greater quality and value at https://christianacare.org.