Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine

Abstract

Recent years have seen a shift in culture surrounding psychological wellbeing in doctors. As suicide continues to devastate medical families, friends and colleagues across the country, and significant rates of mental health issues persist, a greater focus on doctors’ psychological health has emerged. This, coupled with mounting evidence in favour of peer support, has driven the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine to implement a unique peer support programme, which has been tailored to the needs of the perioperative environment. The programme provides a peer-driven, confidential, psychological safety net for all Royal Brisbane and Women’s Hospital anaesthetic staff. It focuses on collegial support in times of stress, as well as promoting a workplace culture of understanding for staff suffering psychological strain. The benefit of a formalised programme of this kind is that while staff have the option to obtain support at any time from a responder of their choosing, they do not need to seek it out actively in the event of a critical incident when it is automatically provided to them. Consultant anaesthetists trained in psychological first aid act as responders, offering support as well as resources and psychologist referral as required. It is our hope that its success will prompt other anaesthetic departments to continue the trend towards positive health strategies for doctors and implement similar programmes.

Introduction

Anaesthesia and the perioperative setting, particularly in a tertiary institution such as the Royal Brisbane and Women’s Hospital (RBWH), presents specialists and trainees alike with challenging clinical circumstances, where exposure to patients with significant morbidity and mortality is high. This, combined with managing unpredictable adverse events and working extended hours with few breaks, results in a workforce at high risk for developing burnout, the second victim phenomenon and other mental health issues.^1–5 Burnout, as described by Wong and Olusanya in 2017, ⁴ defines a constellation of symptoms characterised by ‘depersonalisation, emotional exhaustion and loss of sense of achievement’, whereas the second victim phenomenon refers to healthcare providers who are involved in an unanticipated adverse patient event and suffer ongoing psychological trauma as a result.^4,5 Mounting evidence from research, including Beyond Blue and more recent surveys targeting the Australian and New Zealand College of Anaesthetists’ (ANZCA) trainees, have highlighted barriers to help seeking, including stigma and fear of workplace repercussions, as well as the poor usage of current employee assistance programmes.^6–8 These survey results, combined with a series of publications which detail the potential harm from engaging in group psychological debriefing after adverse events, intensify the need for investigation into other methods of staff support.^9–11 With this information and an increasing body of research demonstrating the benefits of peer support, together with the recognised need for more individualised support after critical incidents and medical error, a bespoke peer support programme has been designed and implemented within the RBWH Department of Anaesthesia and Perioperative Medicine by the authors of this article.^12–15 Ensuring individuals have access to a confidential formalised programme, with a focus on collegiate support in times of personal stress and after adverse clinical events, is imperative to ensuring staff psychological wellbeing, minimising rates of burnout-related medical error and facilitating workplace longevity.^16,17

Programme design

As defined by the online Macmillan dictionary, a peer is a person who belongs to the same social or professional group as another. ¹⁸ Defining peer support, however, tends to vary with the context but is essentially a process whereby people with similar backgrounds use their own experiences to help others. At present, peer support programmes exist for people living with cancer and other medical conditions, as well as in several schools, hospitals and emergency services, including the Queensland Ambulance Service and Fire and Emergency Services.^19–23 While these programmes all fall under the banner of peer support, each one is specific to its environment. Similarly, the programme designed for the RBWH Department of Anaesthesia and Perioperative Medicine, while based on the expert opinion of Creamer et al. in the field of peer support, has been established to address the issues which are unique to anaesthetists and the perioperative domain. ²⁴ The combination of a high-stress environment and a reluctance to seek help due to lack of time and stigma resulted in the development of four major objectives: (a) to ensure the automatic follow-up of all anaesthetic staff involved in critical incidents at the RBWH Department of Anaesthesia and Perioperative Medicine; (b) to identify staff members at risk of immediate and ongoing psychological distress and facilitate access to resources and expert assistance as required; (c) to encourage individual staff members who are experiencing difficulty for any reason to seek out and receive peer support; and (d) to promote a departmental culture of understanding for staff experiencing psychological distress.

It should be recognised that while the RBWH Department of Anaesthesia and Perioperative Medicine peer support programme is a stand-alone programme, it is complementary to the current ANZCA and hospital employee assistance programmes. It also differs substantially from both the operational and psychological group debriefing sessions which commonly occur in hospital settings after adverse clinical outcomes, where a large group of affected staff, generally guided by a psychologist or social worker, gather to discuss a specific distressing event.

Staff selection, training and commitment

The peer support group is formed by the coordinator(s) and the team of responders. All members of the peer support group are anaesthetists, with no external individuals providing direct support to staff, apart from the on-site psychologist who is available for referral as required. The coordinator is the individual responsible for the day-to-day running of the programme, whose role includes the selection and training of responders, provision of resources, organisation of staff follow-up, arrangement of the second monthly peer support group meetings and all quality assurance activities, as well as being the principal person for any questions or issues related to the programme. This role requires a welfare-orientated individual who is dedicated to maintaining the integrity of the programme and its values. The responders are a carefully selected group of well-respected, compassionate, non-judgemental consultant anaesthetists with an interest in welfare and the willingness to devote time to the programme. Responder selection is crucial to the success of the programme, and as such, each consultant was approached individually and asked to join the peer support group rather than advertising for staff to apply for the role.

A unique psychological first aid (PFA) training programme, based on the Look, Listen and Link framework and tailored to the background and expertise of anaesthetists, was attended by all responders prior to commencing in the role.^25,26 The training equips staff with the knowledge to identify behavioural warning signs, expand their active listening skills and negotiate emotionally complex conversations. It also highlights the available hospital and community supports and emphasises the triggers and pathways for psychologist referral. At the RBWH, this four-hour workshop was delivered by the on-site organisational psychologist. However, there are several online and community-based programmes available, including Lifeline, Phoenix and Mental Health First Aid Australia.^27–29 The option of a refresher course in PFA is offered annually to ensure ongoing confidence in the role.

The importance of providing purely collegiate support, rather than psychological counselling, as well as the provision of resources and referral for higher level psychological care, is emphasised to responders, as is the confidential and voluntary nature of the service. All responders sign an agreement contract on accepting the role to ensure they understand the specifics of the position and their responsibilities (see Supplemental Appendix 1), which includes attendance at the second monthly peer support group meetings, and the importance of self-care. Responder welfare is paramount to the success of the programme, and so the consultants are encouraged to contact the coordinator or psychologist to discuss any issues that have arisen during follow-up while providing support for each other.

Peer support procedure

A work-based email address was established for confidentiality purposes and utilised for all referrals within the peer support programme. In the event of a critical incident, the automatic follow-up process is triggered, as the most senior anaesthetist present for the incident emails the coordinator with the names of the anaesthetic staff present and a short description of the event (see Supplemental Appendix 2). The term ‘critical incident’ may include but is not limited to a patient death, prolonged or complicated resuscitation, medical error or difficult staff interaction. On receipt of the referral, the coordinator contacts the pool of responders and allocates follow-up of individual staff members, with a maximum of three per responder. Follow-up by the responders occurs within 48 hours of the referral and then at one week and one month after the incident, or more frequently if deemed necessary by the responder. In the absence of a critical incident, however, staff can contact the coordinator or a responder directly and request support. Staff can also anonymously refer colleagues for peer support if they have concerns about their wellbeing. Support from responders is limited to the one-month follow-up period, at which time if ongoing support is required, a psychologist referral is made. It should be emphasised that the programme is entered voluntarily by all staff, who may decline support at any stage. All topics of discussion between staff and responders are confidential, and no notes are kept on their content. In addition, at the completion of the follow-up period, or earlier if the staff member declines further follow-up, the staff member’s details are removed from the follow-up register and allocated a number. This results in a record of the number of incidents and staff referrals made with no identifying details.

Programme implementation

The programme’s implementation was a multistage process. The first stage involved distribution of an anonymous and voluntary survey to all staff in the department as a baseline prior to implementation of the programme, which aimed to canvass opinion on the adequacy of current support; knowledge of existing hospital, community and ANZCA welfare systems; barriers to help seeking; and possible interest in a peer support programme specific to the anaesthetic department. This project (ID 44886) was considered by the Prince Charles Human Research Ethics Committee and was approved as an audit/quality-assurance activity. The RBWH legal department was contacted to ensure the programme would not breach existing hospital regulations or expose staff to other potential legal issues. The legal team highlighted that as the programme is a confidential service with all staff entering or opting out of it voluntarily, in which no recorded details of staff discussions are kept, its operation would have no legal implications if current Australian Health Practitioner Regulation Agency policies on mandatory notification were upheld. The programme was then delivered in full to the anaesthetic staff at a departmental meeting and included in the weekly newsletter detailing the follow-up procedure. In the days prior to its official launch in April 2018, A3 posters advertising the process for critical incidents, as well as the contact details for the coordinator and all responders, were produced by the RBWH media team and hung in all tearooms and operating theatres. The programme continues to be highlighted at orientation sessions for new staff joining the RBWH anaesthetic department and appears frequently in the weekly departmental newsletter. Initially, after its deployment, anaesthetic medical and healthcare practitioner staff were being followed up after critical incidents. Despite not technically being ‘peers’, the decision to include the non-medical staff was made due to the close working relationships these groups had in theatre, particularly in the event of critical incidents. The intention was always to facilitate the anaesthetic healthcare practitioners launching their own peer support programme, and within 12 months of the programme launch in the Department of Anaesthesia and Perioperative Medicine, this was achieved and continues today.

Programme adaptation

As this programme is, to our knowledge, the first peer support programme in existence that is specific to an anaesthetic department, it continues to develop and improve. All staff are encouraged to provide positive and constructive feedback at any time. Since the programme’s deployment in 2018, a series of changes have taken place as a result of both responder and staff feedback. The restriction of responder follow-up to three staff per incident came about, as following up greater numbers of staff proved too onerous for the anaesthetic consultants. To facilitate this, more responders were trained six months after the programme’s commencement, giving an increased responder-to-staff ratio of approximately 1:10 from 1:12. It was also evident that due to shift work and the seemingly greater frequency of critical incidents occurring out of business hours, staff could not always be contacted within 24 hours of the event. This led to consultation with the psychologist about suitable contact time frames, and an extension of the initial follow-up period of 24 hours to 48 hours. Similarly, it was highlighted that while face-to-face contact was preferable, in the event the staff member was not at work or answering their phone, a text message was often more successful at facilitating a response than an email, and staff felt it was less invasive than repeated voicemails. Other changes have included the usage of a hospital-based file-sharing app accessible to all members of the peer-support group which contains up-to-date resources for use in staff follow-up, as well as recent articles published in the welfare literature. It was also suggested that having a business card containing the contact details for the existing ANZCA, hospital, community and online support services may be helpful for staff to take home after receiving support from a responder. This was produced and distributed to all members of the peer support group for use in their follow-up conversations with staff, while a surplus was placed in the main office, where it remains available to all staff as required. Finally, it became evident during the running of the programme that the role of coordinator should be filled by more than one individual in order to accommodate leave requirements and the time commitment required to fulfil the role effectively.

Discussion

Beyond Blue data highlight that doctors’ preference to use existing employee assistance programmes is low. ⁶ Factors such as stigma, confidentiality and having a ‘safe’ person to confide in are strong contributors to staff willingness to engage in such programmes, which is something that peer support is specifically equipped to navigate.^12,30 If we look at the Queensland Ambulance Service, which has been effective in the implementation and uptake of peer support programmes, the number of staff members utilising their programmes is 45%. ²⁰ While not directly comparable, it is not unreasonable to draw the conclusion that change is needed in the structure of our current support mechanisms, particularly when considering the possibility that the currently utilised practice of group psychological debriefing may not be beneficial to staff and may in fact be harmful.^9–11

When further reflecting on the implications of poor staff wellbeing, it is also important to consider the effect on patients and the wider hospital system. A growing body of research, including a systematic review by Hall et al. in 2016, highlights that patients may be at higher risk of adverse outcomes when managed by staff experiencing poor wellbeing or burnout symptoms.^16,17 As professionals who pride themselves on providing exceptional medical care, we feel we have a responsibility to ourselves and our patients to maintain our physical and mental health, and it should be a priority of our hospitals and departments to facilitate this. A shift to systems which deliver automatic individualised support to all staff in psychologically stressful circumstances, such as that provided by the RBWH Department of Anaesthesia and Perioperative Medicine peer support programme, would seem like an appropriate direction in which to head.

One of the key requirements for peer support success, as described by Creamer et al. in 2012, is that it is modified to fit the environment in which it is being employed. ²⁴ A major strength of the RBWH Department of Anaesthesia and Perioperative Medicine peer support programme is its customisation to the perioperative environment and the anaesthetists it supports. Through its confidential and voluntary nature, the programme engenders safe, non-judgemental support for staff at all times, with no documentation of discussions or feedback to supervisors or executives. It is these features which solidify the integrity of the programme, making it a system staff are willing to use. Moreover, in a large tertiary teaching hospital such as the RBWH, with a significant transient registrar population, the programme supports staff who have yet to form the relationships they will need to navigate the psychological difficulties that may arise during their working life. This reduces the burden on supervisors of training and facilitates choice from whom support is received. It also provides an avenue for more senior staff to access support and automatically receive it after critical incidents, overcoming the previously highlighted obstacles to help seeking commonly expressed by anaesthetists. Another significant advantage of the programme is its ability to be adapted for use in any clinical environment, and as demonstrated by the anaesthetic healthcare practitioners, by a variety of staff. Furthermore, while the programme’s initial setup requires a significant investment of time, once implemented, markedly less time is required for effective day-to-day management.

When considering the limitations of the programme, it is worthwhile noting that while a large department such as the RBWH Department of Anaesthesia and Perioperative Medicine provides greater choice for coordinator and responder selection and access to resources including PFA training and on-site psychologist referral, there can be difficulty in not only implementing, but also appraising a new programme in a department of this size. Gaining group consensus, raising awareness and delivering information to a department with more than 100 staff members takes diplomacy, time and commitment. With regard to appraisal of the programme, encouraging individuals to complete a survey in a department which already engages in a large number of research and quality assurance activities requiring staff feedback remains one of the ongoing challenges. The current evaluation plan aims to utilise annual data from informal feedback, anonymous surveys and audit in order to ensure the programme continues to evolve and adapt to the needs of the RBWH anaesthetic workforce. Utilising the theories of planned behaviour, which describe the likelihood of engaging in specific behaviours as predicted by four components—attitudes, subjective norms, control and intention to use—will make it possible to track the programme’s influence on help-seeking behaviours. ³¹ In addition, the Being Well Survey conducted by the Occupational Violence Implementation Committee tasked with implementing and analysing the success of a hospital-wide peer support programme in Mackay, will also serve as a potential template for review in the future. ¹⁹

The RBWH Department of Anaesthesia and Perioperative Medicine peer support programme was developed to fill the growing need for new and innovative strategies to support staff. As clinicians, we have not only an ethical duty to look after ourselves, but also a responsibility to facilitate good health in our colleagues. We would encourage all anaesthetists to appraise the current psychological support systems available to them and consider the potential benefits of implementing a programme of this kind in their department. As peer support programmes become a greater part of medical workplace culture, conversations surrounding mental health issues will lose their stigma, and staff will become empowered not only to accept the help which is offered, or seek it out themselves, but also to encourage others to do so. The RBWH Department of Anaesthesia and Perioperative Medicine peer support programme continues to be a work in progress, but one that is committed to improving the workplace mental health culture and welfare of anaesthetists.

Supplemental Material

AIC878450 Supplemetal Material1 - Supplemental material for Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine

Supplemental material, AIC878450 Supplemetal Material1 for Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine by Gemma Slykerman, Melissa J Wiemers and Kerstin H Wyssusek in Anaesthesia and Intensive Care

Supplemental Material

AIC878450 Supplemetal Material2 - Supplemental material for Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine

Supplemental material, AIC878450 Supplemetal Material2 for Peer support in anaesthesia: Development and implementation of a peer-support programme within the Royal Brisbane and Women’s Hospital Department of Anaesthesia and Perioperative Medicine by Gemma Slykerman, Melissa J Wiemers and Kerstin H Wyssusek in Anaesthesia and Intensive Care