Understanding resident wellness: A path analysis of the clinical learning environment at three institutions.

PURPOSE: The clinical learning environment (CLE) affects resident physician well-being. This study assessed how aspects of the learning environment affected the level of resident job stress and burnout. MATERIALS AND METHODS: Three institutions surveyed residents assessing aspects of the CLE and well-being via anonymous survey in fall of 2020 during COVID. Psychological safety (PS) and perceived organizational support (POS) were used to capture the CLE, and the Mini-Z Scale was used to assess resident job stress and burnout. A total of 2,196 residents received a survey link; 889 responded (40% response rate). Path analysis explored both direct and indirect relationships between PS, POS, resident stress, and resident burnout. RESULTS: Both POS and PS had significant negative relationships with experiencing a great deal of job stress; the relationship between PS and stress was noticeably stronger than POS and stress (POS: B= -0.12, p=.025; PS: B= -0.37, p<.001). The relationship between stress and residents' level of burnout was also significant (B = 0.38, p<.001). The overall model explained 25% of the variance in resident burnout. CONCLUSIONS: Organizational support and psychological safety of the learning environment is associated with resident burnout. It is important for educational leaders to recognize and mitigate these factors.

Patient and Family Mistreatment of Residents in the Surgical Learning Environment.

OBJECTIVE: Identify the frequency and types of mistreatment experienced by residents from patients and their families (P&F) and determine whether the types and frequency varied based on resident gender. DESIGN: An anonymous survey was distributed to residents to assess the types of P&F mistreatment toward residents and the association with resident gender. SETTING: The survey was distributed to the general surgery and urology programs at a large academic medical center in the mid-Atlantic. Participants: 23 of 53 residents (43% response rate) participated in the anonymous survey. Residents: 15 male residents (65%), 8 female residents (35%). Results: 12 of 23 responding residents (52%) indicated they experienced at least one form of mistreatment from P&F. Women were more likely to experience mistreatment (88% vs. 33%), with verbal assault was the most frequent (50% for female residents, 33% for male residents). Patients were more often the source than families (52% vs. 41%); verbal assault or threats of physical harm were the most common (50% for female residents, 33% for male residents). CONCLUSIONS: Residents experience mistreatment from multiple sources. This paper provides insight into the experiences of surgical residents with mistreatment from their P&F, with differences in frequency of behaviors dependent upon the perpetrator group and resident gender. Patients and their family mistreatments are likely underreported and may be more difficult to prevent. It is important to identify mitigation strategies and ensure resources are available for those residents experiencing mistreatment. A strong culture against mistreatment and providing specific resources may minimize the experience and negative effects of mistreatment.

Influence of Psychological Safety and Organizational Support on the Impact of Humiliation on Trainee Well-Being.

OBJECTIVES: To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator). METHODS: Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists. RESULTS: Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety. CONCLUSIONS: The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Suicide and Suicide Attempts on Hospital Grounds and Clinic Areas.

OBJECTIVES: The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States. METHOD: This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014. Each RCA report was coded for the location of the event, method of self-harm, if the event resulted in a death by suicide, and root causes. RESULTS: We found 47 RCA reports of suicide and suicide attempts occurring on hospital grounds, common spaces, or clinic areas. The most common methods were gunshot, overdose, cutting, and jumping, and we have seen an increase in these events since 2011. The primary root causes were breakdowns in communication, the need for improved psychiatric and medical treatment of suicidal patients, and problems with the physical environment. CONCLUSIONS: Hospital staff should evaluate the environment for suicide hazards, consider prohibiting firearms, assist patients with no appointments, and promote good communication about high-risk patients.

When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"

STUDY OBJECTIVE: Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs. METHODS: Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described. RESULTS: A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%). CONCLUSION: Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

Incidence of resident mistreatment in the learning environment across three institutions.

INTRODUCTION: Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment. METHODS: Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences. RESULTS: Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior. CONCLUSION: Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

Review of the Basics of Cognitive Error in Emergency Medicine: Still No Easy Answers.

Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.

Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education.

INTRODUCTION: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. METHODS: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. RESULTS: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and <1% requiring simulation. CONCLUSION: Twenty years after the publication of To Err is Human, gains have been made integrating quality assurance and patient safety within medical education and hospital systems, but there remains extensive work to be done. Through a review and analysis of our patient safety event reporting system, we were able to gain a better understanding of the events that are submitted, including the types of events and their severity, and how these relate to the types of educational interventions provided (eg, feedback, simulation). We also determined that these events can help inform resident education and learning using various types of education. Additionally, incorporating residents in the review process, such as through root cause analyses, can provide residents with high-quality, engaging learning opportunities and useful, lifelong skills, which is invaluable to our learners and future physicians.

Physician mistreatment in the clinical learning environment.

BACKGROUND: Mistreatment has been correlated with burnout and poor well-being in medical students, but data regarding residents and faculty are limited. The objective was to investigate the prevalence of mistreatment towards surgical housestaff and faculty and characterize such experiences. METHODS: In 2018, the Department of Surgery surveyed housestaff and faculty on incidents of mistreatment. RESULTS: Clinical faculty (63%) and residents (72%) completed the mistreatment survey. Excluding public embarrassment, 48% of residents and 29% of clinical faculty experienced mistreatment. Residents experienced public embarrassment and public humiliation more frequently than faculty, however faculty were subjected to racially or ethnically offensive remarks/names more frequently than residents (p < .05). Faculty within and external to their department were most cited as instigators of mistreatment. Residents experienced mistreatment most often by faculty, co-residents, and nurses. Reporting of the behaviors was low. CONCLUSIONS: Incidents of mistreatment are frequently occurring for surgical residents and faculty.

Nurse survey, knowledge gaps and the creation of an environmental hygiene protocol for patient transport and removing linen from patient rooms.

General guidance for personal protective equipment (PPE) is provided by the Occupational Safety and Health Administration and the United States Centers for Disease Control and Prevention. Previous research of PPE demonstrates the ability of gloves to harbor infectious pathogens. We surveyed health care workers to investigate current PPE practices during linen removal from patient rooms and during patient transport. The results suggest a possible risk for cross-contamination of the environment from overuse of gloves.

Clostridioides difficile nurse driven protocol: A cautionary tale.

In a 12-month study, a nurse driven protocol was implemented at a tertiary academic medical center. The purpose of the nurse driven protocol was to identify community-onset Clostridioides difficile infections, expeditiously isolate patients with presumed C difficile diarrheal illness, and prevent transmission while simultaneously decreasing the incidence of hospital-onset C difficile. The overall adherence to fidelity of the protocol was poor and failed to have a significant impact on infection rates.

Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome.

OBJECTIVES: Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS: A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS: Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS: Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.

Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association.

OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database. Adverse event type, procedure, location, severity, and frequency were extracted. Spearman ρ was used to determine associations between types of adverse events and harm levels. RESULTS: We reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the adverse events for which we could determine location (n = 25), 10 (40%) were in the operating room and 15 (60%) occurred in a nonoperating room. Endoscopies were associated with the least amount of harm. The most frequently reported adverse event types were human factors (22.22%, n = 6) and retained items (18.52%, n = 5). Retained item events were associated with the most harm. The most common root causes were lack of standardization in the process of care and suboptimal communication. CONCLUSIONS: Retained items after invasive procedures and human factors errors were the most common and harmful type of adverse event in this study. Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures.

The learning hospital: From theory to practice in a hospital infection prevention program.

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.