Compassion fatigue may have increased in recent years because of the demands of managed care. Because doctors and nurses have more time pressures to see more patients and complete more paperwork, they have less time to enjoy, for example, “the connection that many family physicians shared with their patients, [which] was replenishing, which helped them cope with the stressors of practicing medicine,” Indiana University School of Medicine researchers observed.
Nurses are also vulnerable to post-traumatic stress syndrome (PTSD), a psychiatric disorder experienced by 8 to 10 percent of the general public. University of Colorado researchers found that 22 percent of surveyed nurses exhibited PTSD symptoms. All of them had observed a traumatic event such as a patient death, massive bleeding, open surgical wounds, or trauma-related injuries, or they had performed futile care on critically or terminally ill patients. Other events that could lead to PTSD include helping with end-of-life care; handling postmortem care; dealing with combative patients; taking verbal abuse from patients, family members, doctors, or other staff members; performing CPR; experiencing stress because of unsafe nurse-patient ratios; and failing to save specific patients.
ICU nurses are subjected to many of these events on a daily basis. An Emory University study discovered that ICU nurses experience PTSD at a rate similar to female Vietnam veterans. Among ICU nurses, 24 to 29 percent exhibited PTSD symptoms, compared to 14 percent of general nurses. (Outpatient nurses are less likely to develop PTSD than inpatient nurses.)
A PACU nurse in Washington State said she suffered from PTSD for several months after caring for a coding post–heart attack critical care patient who died on her shift. The hospital offered no resources to help her cope. “There was nothing available to me. I still cry thinking about the situation and how I was supposed to give 150 percent to this patient who was basically already dead,” she said. This trauma came on top of the usual nurse stresses. “Often, I feel it’s an impossible job. [Some of us] go home feeling we were unable to give the care we wanted because we were so overworked by patient numbers, acuity, and needing to be everything to everyone: nurse, friend, coworker, empathetic listener, computer specialist.”
Second victim syndrome
In 2010, Kimberly Hiatt, a veteran pediatric critical care nurse at Seattle Children’s Hospital, accidentally gave an eight-month-old critically ill infant 1.4 grams of calcium chloride instead of the correct 140-milligram dose. The infant died days after the mistake. Hiatt was fired, even though it was not clear that the miscalculation directly caused the death of the infant, who had heart problems. A ten-fold overdose of calcium chloride, which is given to support circulation and prevent heart and neurological problems from low blood calcium, would not necessarily be fatal.
Hiatt, who told staff about her error as soon as she realized it, officially reported it herself. “I messed up,” she wrote on the hospital’s electronic feedback system. “I’ve been giving CaCI for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 yrs. of working here. I am simply sick about it. Will be more careful in the future.”
Hiatt reportedly was stunned that the hospital fired her for making one significant medical mistake in her entire career. Administrators had given her glowing reviews; two weeks before the incident, her evaluation awarded her a 4 out of 5 and called her a “leading performer.”
To keep her nursing license, the state nursing board required Hiatt to pay a fine and agree to a four-year probationary period during which she would be supervised when dispensing medication. But Hiatt had difficulty finding a new job, even though she aced an advanced cardiac life support certification exam, qualifying her for a flight nurse position. Seven months after her mistake, depressed and isolated, Hiatt, at age 50, committed suicide.
Hiatt apparently suffered from “second victim syndrome.” According to the Institute for Safe Medication Practices, “Second victims suffer a medical emergency equivalent to post-traumatic stress disorder. The instant patient harm occurs, the involved practitioner also becomes a patient of the organization [because he/she needs medical help]—a patient who will often be neglected.” A 2011 survey found that surgeons who thought they made a medical error were more than three times as likely to have considered suicide as those who did not.
Humans are going to make mistakes. Washington University researchers found that 92 percent of doctors surveyed had perpetrated a near miss or actual mistake and 57 percent confessed to a serious error. Retired anesthesiologist F. Norman Hamilton wrote in a Seattle Times letter to the editor following Hiatt’s death, “If we fire every person in medicine who makes an error, we will soon have no providers. We all make errors. It is only by the grace of God that most of them do not result in great harm or death.”
While second victims usually require immediate emotional support, healthcare organizations largely don’t help employees through “the deeply personal, social, spiritual, and professional crisis,” the ISMP reported. “Although the first victims of medical errors are the patients who are harmed and their families, the second victims are the caregivers and staff who sustain complex psychological harm when they have been involved in errors that harm patients while caring for them. . . . But, too often, we remain silent and abandon the second victims of errors—our wounded healers—in their time of greatest need.”
That’s what Seattle Children’s administrators did to Hiatt. Instead of easing her out of second victim syndrome, they arguably threw her under the bus, appearing to blame her for the fatality. Paradoxically, then- hospital CEO Tom Hansen wrote an internal memo in which he said, “Of course, we will also support our staff members during this difficult time.” Hansen went on to write, “It is important to me that all staff and faculty feel it is safe to report when mistakes are made, and that everyone is confident that we recognize the difference between an honest mistake and reckless behavior.”
In direct contradiction, Seattle Children’s fired the staff member who seemed to need a great deal of support, damaging the career of a nurse who apparently thought it was safe to report that she made an honest mistake. After Hiatt’s case hit the news, a Washington State Nurses Association survey found that half of nurse respondents believed “their mistakes are held against them.” Even more worrisome, a third said they would hesitate to report an error or patient safety concern because they were “afraid of retaliation or being disciplined” and more than a quarter would hesitate to report those concerns because they were afraid they would lose their job.
Following the incident, the hospital changed policies, including instating a rule that only pharmacists and anesthesiologists could prepare doses of calcium chloride in nonemergencies. Also of note: In 2003 and 2009, Seattle Children’s staff allegedly had made two other fatal medication errors. After the 2009 death, Seattle Children’s medical director Dr. David Fisher said in a statement, “This was not the fault of any one individual.” It appears the hospital’s problem was much larger than the single nurse it pushed forward as the scapegoat when her error occurred in 2010.
Instead of firing a nurse who reportedly had made a single notable error in a quarter-century of service, the hospital could have tapped her to help devise a system that would have caught her error in time, thereby both improving the hospital and allowing Hiatt to contribute to her own healing process. Firing her helped no one. As University of Missouri Health Care patient safety director Susan Scott told msnbc.com, “If my mom got an insulin overdose from a nurse in a hospital, I would want that nurse to give her that insulin tomorrow.” That nurse would probably be the least likely to make that mistake again.