- Email: [email protected]
Acute traumatic stress among surgeons after major surgical complications
Accepted Manuscript Acute traumatic stress among surgeons after major surgical complications Anna Pinto, Phd Omar Faiz, FRCS Colin Bicknell, FRCS Charles Vincent, PhD PII:
S0002-9610(14)00376-6
DOI:
10.1016/j.amjsurg.2014.06.018
Reference:
AJS 11242
To appear in:
The American Journal of Surgery
Received Date: 17 April 2014 Revised Date:
6 June 2014
Accepted Date: 13 June 2014
Please cite this article as: Pinto A, Faiz O, Bicknell C, Vincent C, Acute traumatic stress among surgeons after major surgical complications, The American Journal of Surgery (2014), doi: 10.1016/ j.amjsurg.2014.06.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute traumatic stress among surgeons after major surgical complications
Anna Pinto, 1 Phd
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Omar Faiz, 1 FRCS Colin Bicknell, 1 FRCS
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Charles Vincent, 2 PhD
Centre for Patient Safety and Service Quality, Department of Surgery & Cancer, Imperial College
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London, UK 2
Department of Experimental Psychology, University of Oxford, UK
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Correspondence to: Anna Pinto
Centre for Patient Safety and Service Quality Department of Surgery & Cancer
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Imperial College London, St Mary's Campus Norfolk Place, London, W2 1PG
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Email: [email protected] Tel: +44 (0)20 7594 9725 Fax: +44 (0)207594 3137
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ACCEPTED MANUSCRIPT Abstract
Background: Patient harm resulting from medical treatment may be a traumatic experience for healthcare staff. This study examined surgeons’ levels of traumatic stress in the aftermath of the
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most recent major complication that happened in their patients’ care and its relationship with surgeons’ coping strategies, causal attributions and perceived institutional culture around surgical complications.
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Methods: 47 general and vascular surgeons from three NHS Trusts in London UK completed a
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questionnaire assessing the above variables (64.4% response rate).
Results: One third of the participants reported traumatic stress of clinical concern one month after the incident. The use of self-distraction (p<.05) and being a general surgeon (p<.05) were predictive of traumatic stress of clinical concern in multiple logistic regression analysis.
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Conclusions: Some surgeons may experience acute traumatic stress after serious surgical complications. The extent to which this is of clinical concern is associated with their use of selfdistraction as well as the clinical setting. Healthcare organisations need to attend to surgeons’
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psychological needs in the aftermath of serious adverse events.
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ACCEPTED MANUSCRIPT Summary This study examined surgeons’ levels of traumatic stress in the aftermath of the most recent major complication that happened in their patients’ care. One third of the participants reported traumatic stress of clinical concern one month after the incident, while the use of self-distraction (p<.05) and
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being a general surgeon (p<.05) were predictive of scoring above the cut-off point for traumatic stress of clinical concern. Healthcare organisations need to attend to surgeons’ psychological needs
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in the aftermath of serious adverse events.
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ACCEPTED MANUSCRIPT Keywords
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Surgical complications; adverse events; traumatic stress; psychological wellbeing
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ACCEPTED MANUSCRIPT Introduction
Despite healthcare professionals’ best intentions, patients sometimes experience harm which is caused by their medical treatment. Studies around the world suggest that the rates of adverse
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events in secondary care lie between 8 and 12% of hospital admissions. 1-11 Patients may suffer both physical and psychological trauma after adverse events that result in serious harm. 12 However, the emotional toll of serious adverse events on healthcare staff may also be quite severe especially 12
Healthcare professionals
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when incidents are preventable and lead to significant patient injuries. have been called the ‘second victims’ of adverse events in healthcare.
13
A small number of early
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studies have shown profound emotional effects for doctors who are involved in serious adverse events, such as fear, guilt, anger, embarrassment, humiliation or even anxiety and depression symptoms. 14-17
One of the highest risk areas for serious medical harm is the operating room.
5, 18
A
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retrospective review of 15,000 non-psychiatric discharges from a sample of representative hospitals in Utah and Colorado, found that 66% of all adverse events were surgical and 54% amongst them were preventable. 19 Among all surgical adverse events, 5.6% resulted in death, accounting for 12.2%
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of all hospital deaths in Utah and Colorado. A survey study of surgeons found that having been involved in a preventable surgical adverse event was associated with significantly lower mental
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quality of life, higher levels of burnout and higher risk of screening positive for depression. Reported errors were also related to lower career satisfaction. 20 Another possible consequence of surgeons’ involvement in serious surgical adverse events is the experience of traumatic stress, as ‘causing death or severe harm to another’ is one of the core aspects of traumatic incidents. 21 Recently, an exploratory interview study on surgeons’ experiences of surgical complications found that many surgeons reported feelings of guilt, fear, as well as a tendency to become vigilant and risk-averse in the aftermath of surgery that went wrong.
22
Such
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ACCEPTED MANUSCRIPT reactions are commonly encountered among sufferers of post-traumatic stress disorder (PTSD), which is a syndrome associated with the experience of traumatic events involving three clusters of symptoms: (a) re-experiencing the event, (b) avoiding reminders of it and (c) experiencing increased hyperarousal.
23, 24
However, to date there is no data on healthcare professionals’ experience of
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traumatic stress as a result of their involvement in adverse events that cause patient harm. Little attention has also been paid to the mechanisms that mediate or moderate the psychological impact of adverse events on healthcare professionals.
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An exploratory interview
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study identified a number of individual, incident and institution related factors that may contribute to the severity of surgeons’ reactions to surgical adverse events. 22 One key factor of surgeons’ post-
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incident wellbeing was their ways of coping with the stress of complications.
22
Most surgeons
admitted that discussing serious complications with peers or deconstructing them in order to identify learning lessons helped them deal with incidents. Another important determinant of surgeons’ reactions to surgical adverse events was reported to be the extent to which surgeons saw 22
When surgeons felt that the incident occurred due to
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themselves as responsible for the event.
their own decisions or practices they tended to experience stronger emotional reactions. This finding is in line with earlier studies which shown that an internal locus of causality is associated with more
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PTSD symptoms, especially when the traumatic stressor is perceived as controllable. 26, 27 Lastly, the above qualitative study found that the existence of blame as opposed to a supportive institutional
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culture exacerbates the psychological impact of these incidents on surgeons.
22
A negative social
environment (e.g. indifference, criticism or blame) is often a significant predictor of the development of PTSD.
28
In this study we are interested in exploring surgeons’ levels of acute traumatic stress in the aftermath of major surgical complications and its potential predictors. We hypothesised that surgeons’ acute traumatic stress in the aftermath of serious surgical complications will be predicted by the ways in which surgeons cope with the stress of the incident, the perceived locus and
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ACCEPTED MANUSCRIPT controllability of the causes that led to the complication and their perceptions of the institutional culture around surgical complications. Methods
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Participants Participants were recruited from a series of general and vascular surgical audit meetings in three National Health Service (NHS) hospitals in London, UK. At the end of each meeting surgeons were
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provided with a hard or an electronic copy of the questionnaire. Reminder emails were sent twice. The completion of the survey was kept anonymous. In total 73 surgeons were asked to participate in
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the study; 54 completed the survey. 7 respondents did not meet the inclusion criteria of having experienced at least one major surgical complication in their practice; therefore the analysis included data from 47 surgeons (64.4% response rate). Ethical approval was obtained from the North West London REC 1 ethics committee.
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Measures
The participants were asked to complete the questionnaire in relation to their most recent major surgical complication, in order to control for biases that would operate if participants could choose
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any incident. Surgeons were asked to report the recency (1=In the last month, 2=In the last 3 months, 3=In the last 6 months, 4=In the last year) and severity of the incident (1=The patient died,
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2=The patient developed morbidity with lasting disability, 3=The patient developed morbidity but recovered fully). They were also asked whether they had been involved in legal proceedings as a result of it (Yes/No). Acute traumatic stress was assessed with the Impact of Events (IES) scale 29. IES includes 7 items on intrusive thoughts (e.g. I thought about it when I didn't mean to) and 8 items on avoidance behaviours (e.g. I tried to remove it from memory) assessed on a 4-point scale (0=Not at all, 1=Rarely, 3=Sometimes, 5=Often). A cut-off point of 19 has been suggested to indicate traumatic stress of clinical concern. 29 The participants rated the extent to which they experienced each of the
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ACCEPTED MANUSCRIPT symptoms during the first month after the incident, which is the timeframe associated with acute traumatic stress. 23, 24 The perceived locus and perceived controllability of the causes that led to the reported complication were assessed on continuous scales ranging from 1 (all to do with you/completely
30
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controllable by you) to 7 (all to do with others or external factors/completely uncontrollable by you)]. Surgeons’ ways of coping with the stress of the complication were measured with Brief-COPE (B-
COPE) which assesses the use of various coping strategies known to be relevant to effective and
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ineffective coping (e.g. self-distraction, active coping, denial, substance use, use of emotional/instrumental support) in relation to a specified event. 31 Each coping strategy is assessed
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by two items on a 4-point scale (1=I haven’t been doing this at all, 2=I have been doing this a little bit, 3=I have been doing this a medium amount, 4=I have been doing this a lot). The institutional culture around surgical complications was measured with the punitive response to error scale of the Hospital Survey on Patient Safety Culture (HSPSC).
32
This scale includes 3 items, (e.g. staff feel like
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their mistakes are held against them) which are assessed on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The items were modified in order to reflect the surgical
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context (e.g. “staff” was replaced with “surgeons”, “mistakes” was replaced with “complications”). The following participant characteristics were also assessed: age, gender, NHS organisation,
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nationality, relationship status, whether the participants had children, surgical specialty, clinical position, hours of clinical work per week and whether they held an academic position. Statistical analysis
The data were analyzed using SPSS version 20. Descriptive statistics and frequencies were used to summarise the study variables. Non-parametric tests were employed as most of the variables did not meet the assumption of normality (Mann-Whitney tests, Spearman’s rank-order correlations). Chi-square tests were used to assess the levels of one categorical variable against the levels of
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ACCEPTED MANUSCRIPT another categorical variable. Hierarchical multiple logistic regression analysis was used to assess the factors that predicted surgeons scoring above the cut-off point for traumatic stress of clinical concern (i.e. IES total score above 19). Factors that were significantly associated with traumatic stress of clinical concern in univariate analyses were entered in the regression analysis. Diagnostic
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statistics indicated that the assumption of no multi-collinearity was met. 33 Results
The majority of the respondents specialized in general surgery (60%). The majority of respondents
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were also surgical trainees (60%). The mean number of years in their clinical position was 6.2 (SD=5.9, Range=0.35-35), while the mean number of hours of clinical work per week was 50
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(SD=17.7, Range=0-72). Half of the participants (49%) held an academic position. The majority of the respondents were male (77%), British (77%) and married (68%). Their mean age was 38.5 years (SD=7.7, Range=27-64), while 55% of them had children. The majority of the participants’ most recent major surgical complication happened in the previous 3 months (54%), 17% between 3 and 6
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months ago and 17% more than 6 months ago. In most cases the patient developed morbidity but eventually recovered (41%). 28% of the complications led to patient morbidity with lasting disability, while 18% led to patient death.
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Table 1 presents descriptive information on the study variables. One third of the participants
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scored above the IES cut-off point of 19 (n=17, 36.2%), which indicates traumatic stress of clinical concern. 29
-Table 1-
There was a significant positive correlation between the use of self-distraction and acute traumatic stress (rs=.48, p=.002). Mann-Whitney tests also showed that respondents who scored above the cut-off point for acute traumatic stress of clinical concern reported significantly more frequent use of self-distraction (Median=3.5) than those who scored below the cut-off point (Median=2.0) (U=278.5, p=.006). No other coping strategies were significantly correlated with acute 9
ACCEPTED MANUSCRIPT traumatic stress scores or with scoring above the cut-off point for acute traumatic stress of clinical concern. There was also a marginally significant positive relationship between perceptions of a punitive institutional response to complications and acute traumatic stress (rs=.31, p=.047). Surgical specialty was also significantly associated with acute traumatic stress of clinical concern with 53.6%
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of the general surgeons scoring above the cut-off point for traumatic stress of clinical concern compared to only 15.4% of the vascular surgeons [χ2(2, N=41)=5.33, p=.021)]. There were no significant relationships between acute traumatic stress and perceived locus or controllability of the
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causes of the complication, the recency or severity of the incident, or the participants’ characteristics.
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The factors that were significantly associated with acute traumatic stress of clinical concern (i.e. surgical specialty, use of self-distraction and punitive institutional response) were entered in a hierarchical multiple logistic regression analysis on the occurrence of acute traumatic stress of clinical concern (total IES score above 19). Surgical specialty was entered first. Being a general
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surgeon significantly predicted the occurrence of acute traumatic stress of clinical concern (b=-2.04, SE=.87, p=.019). The addition of self-distraction use significantly improved the prediction of the occurrence of acute traumatic stress of clinical concern (b=1.08, SE=0.469, p=.021), while surgical
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specialty continued to be a significant predictor. Surgeons’ perceived institutional response to surgical complications was added in the last step but did not make any significant contribution, while
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surgical specialty and the use of self-distraction continued to significantly predict the outcome (see Table 2). In summary, practising general surgery and more frequent use of self-distraction in the aftermath of surgeons’ most recent major surgical complication significantly predicted scoring above the cut-off point for acute traumatic stress of clinical concern. -Table 2Discussion
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ACCEPTED MANUSCRIPT This is the first study to our knowledge that assessed surgeons’ (or any other healthcare professionals’) traumatic stress in the aftermath of serious adverse events. A striking finding was that one third of the participants scored above the cut-off point for traumatic stress of clinical concern during the first month after the incident. This percentage is suggestive of the high
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emotional burden that major adverse events often cause on clinical staff. This study also sought to explore if surgeons’ ways of coping, their perceptions of the locus and controllability of the causes of the incident and their perceptions of the institutional culture
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predicted their experience of acute traumatic stress in the aftermath of their most recent major complication. Self-distraction was the only coping strategy that was used significantly more
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frequently by participants who experienced acute traumatic stress of clinical concern and was also an independent predictor of traumatic stress of clinical concern in the logistic regression analysis. This is in agreement with literature which suggests that suppression of thoughts related to a traumatic incident is associated with higher PTSD symptoms. 28, 34, 35 Institutions’ punitive response
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to complications was also significantly associated with the experience of traumatic stress in the univariate analysis. The existence of blame and the lack of institutional support for staff in the aftermath of adverse events is a common finding. 25, 36 This study provides preliminary evidence on
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the existence of a negative relationship between the existence of institutional blame and surgeons’ wellbeing in the aftermath of serious complications, even though the lack of significant contribution
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of this factor in the regression analysis indicates that this relationship warrants further investigation. Lastly, contrary to our hypothesis there was not a significant relationship between surgeons’ perceptions of the locus and controllability of the causes of the reported complication and acute traumatic stress. This contradicts existing qualitative evidence which suggest that higher perceived responsibility for adverse events is associated with higher distress in healthcare professionals. 22, 37 Interestingly, being a general surgeon was predictive of higher odds of experiencing traumatic stress of clinical concern both in univariate and in multivariate analysis. A possible explanation is that
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ACCEPTED MANUSCRIPT general surgeons are less accustomed to the occurrence of stark complications such as those that often occur in vascular surgery (e.g. bleeding, limb loss). A complication arising unexpectedly in a low risk patient potentially takes a higher toll than one occurring in a high risk patient (e.g. vascular patients), as also suggested by an interview study on surgeons’ experiences of complications.22 The
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above finding highlights the importance of contextual variables such as patient risk factors and the clinical setting in explaining healthcare professionals’ reactions to adverse events and raises questions about the conditions that place healthcare professionals at higher risk for traumatic stress
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in the aftermath of major adverse events.
A few methodological limitations need to be taken into consideration. First, the study’s design
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is cross-sectional and does not allow causal inferences about the observed relationships. Secondly, the small sample size did not permit the inclusion of all relevant factors in the regression analysis. Only variables that were highly significantly associated with IES total scores were considered. Despite any limitations, this is the first study to our knowledge that investigated the experience of
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traumatic stress among surgeons (or healthcare professionals) who are involved in serious adverse events.
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In summary, the study findings suggest that a significant percentage of surgeons may experience acute traumatic stress after serious surgical complications and that the extent to which
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these symptoms will be of clinical concern may be dependent on their use of self-distraction as well as the clinical setting. Surgeons who use self-distraction as a coping strategy and surgeons who practice general as opposed to vascular surgery are at higher risk for experiencing acute traumatic stress of clinical concern in the aftermath of serious surgical complications. The implications of these findings for healthcare organisations are significant as they need to consider how best to support their staff when serious adverse events occur. For example, early training on how to cope more effectively with serious adverse events may prevent symptoms of severe traumatic distress which could lead to further suboptimal care. Lastly, there is a need for future studies with bigger samples,
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ACCEPTED MANUSCRIPT longitudinal designs and use of multivariate analyses in order to elucidate the prevalence of traumatic stress among healthcare professionals in the aftermath of serious adverse events, as well as the mediators and moderators of the traumatic impact of such incidents.
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Acknowledgements This work was supported by funding from the Health Foundation. The Imperial Centre for Patient
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Safety and Service Quality is funded by the UK National Institute for Health Research (NIHR).
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ACCEPTED MANUSCRIPT References 1.
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. Incidence of adverse events
related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Commun H 2008; 62(12): 1022-9. Baker GR. The Canadian Adverse Events Study: the incidence of adverse events among
hospital patients in Canada. Can Med Assoc J 2004; 170(11): 1678-86. 3.
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2.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in
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hospitalized patients: Results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care 2004; 13(2): 145-51.
Davis P, Lay-Yee R, Briant R, et al. Adverse Events in New Zealand Public Hospitals: Principal
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4.
Findings from a National Survey. HINZ. Brunswick East, Vic.: Health Informatics Society of Australia; Royal Australian College of General Practitioners; 2003. p. 522-43. 5.
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients.
6.
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Results of the Harvard Medical Practice Study II. NEJM 1991; 324(6): 377-84. Michel P, Quenon JL, Djihoud A, et al. French national survey of inpatient adverse events
prospectively assessed with ward staff. Qual Saf Health Care 2007; 16(5): 369-77. Schiøler T, Lipczak H, Pedersen BL, et al. Danish adverse event study. Incidence of adverse
EP
7.
5370-8. 8.
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events in hospitals: A retrospective study of medical records. Ugeskrift for Laeger 2001; 163(39):
Soop M, Fryksmark U, Köster M, Haglund B. The incidence of adverse events in Swedish
hospitals: A retrospective medical record review study. Int J Qual Health Care 2009; 21(4): 285-91. 9.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary
retrospective record review. BMJ 2001; 322(7285): 517-9. 10.
Wilson RM. The Quality in Australian Health Care Study. MJA 1995; 163(9): 458-71.
14
ACCEPTED MANUSCRIPT 11.
Zegers M, de Bruijne MC, Wagner C, et al. Adverse events and potentially preventable
deaths in Dutch hospitals: Results of a retrospective patient record review study. Qual Saf Health Care 2009; 18(4): 297-302. Vincent C. Patient safety. London: Wiley Blackwell; 2010.
13.
Wu AW. Medical error: The second victim. BMJ 2000; 320(7237): 726-7.
14.
Aasland OG, Forde R. Impact of feeling responsible for adverse events on doctors' personal
RI PT
12.
and professional lives: the importance of being open to criticism from colleagues. Qual Saf Health
15.
Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived
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mistakes on physicians. J Gen Intern Med 1992; 7(4): 424-31. 16.
SC
Care 2005; 14(1): 13-7.
White AA, Waterman AD, McCotter P, Boyle DJ, Gallagher TH. Supporting health care
workers after medical error: Considerations for health care leaders. J Clin Outcomes Manag 2008; 15(5): 240-7.
Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? The JAMA
1991; 265(16): 2089-94.
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17.
Leape LL. A systems analysis approach to medical error. J Eval Clin Pract 1997; 3(3): 213-22.
19.
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical
EP
18.
adverse events in Colorado and Utah in 1992. Surgery 1999; 126(1): 66-75. Shanafelt TD. Burnout and medical errors among American surgeons. Ann Surg 2010; 251(6):
AC C
20.
995-1000. 21.
Green BL. Defining trauma: Terminology and generic stressor dimensions. J Appl Soc Psychol
1990; 20(20): 1632-42. 22.
Pinto A, Faiz O, Bicknell C, Vincent C. Surgical complications and their implications for
surgeons' well-being. Br J Surg 2013; 100(13): 1748-55. 23.
Brewin CR, Andrews B, Rose S. Diagnostic overlap between acute stress disorder and PTSD in
victims of violent crime. Am J Psychiatry 2003; 160(4): 783-5. 15
ACCEPTED MANUSCRIPT 24.
Yehuda R. Post-Traumatic Stress Disorder. NEJM 2002; 346(2): 108-14.
25.
Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: A systematic review
of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care 2010; 19(6): 1-8. Joseph S, Yule W, Williams R. Post-traumatic stress: Attributional aspects. J Trauma Stress
RI PT
26.
1993; 6(4): 501-13. 27.
Joseph SA, Brewin CR, Yule W, Williams R. Causal attributions and psychiatric symptoms in
28.
SC
survivors of the Herald of Free Enterprise disaster. Br J Psychiatry 1991; 159(4): 542-6.
Brewin CR. Psychological theories of posttraumatic stress disorder. Clin Psychol Rev 2003;
29.
Horowitz M, Wilner N, Alvarez W. Impact of Events Scale: A measure of subjective stress.
Psychosom Med 1979; 41(3): 209-18. 30.
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23(3): 339-76.
Firth J, Brewin C. Attributions and recovery from depression: A preliminary study using cross-
31.
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lagged correlation analysis. Br J Clin Psychol 1982; 21(Pt 3): 229-30.
Carver C. You want to measure coping but your protocol’ too long: Consider the Brief Cope.
Int J Behav Med 1997; 4(1): 92-100.
Sorra J, Nieva VF. Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for
EP
32.
Healthcare Research and Quality; 2004. Field A. Discovering statistics using SPSS. 3rd ed. London: Sage; 2011.
34.
Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in
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33.
ambulance service workers. Br J Clin Psychol 1999; 38(3): 251-65. 35.
Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000;
38(4): 319-45. 36.
Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on
physicians: A call for leadership and organisational accountability. Swiss Med Wkly 2009; 139(1-2): 915. 16
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Engel KG, Rosenthal M, Sutcliffe KM, Engel KG, Rosenthal M, Sutcliffe KM. Residents'
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responses to medical error: Coping, learning, and change. Acad Med 2006; 81(1): 86-93.
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ACCEPTED MANUSCRIPT Table 1: Descriptive statistics of study variables Mean (SD)
Range
Intrusion
9.47 (7.30)
0.00-27.00
Avoidance
7.75 (6.40)
0.00-28.00
Total score (traumatic stress)
17.44 (12.17)
0.00-55.00
N (%)
Impact of Events Scale*
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Above 19 Below 19 Missing
2.93 (1.02)
2.00-5.00
Active coping
4.39 (1.76)
2.00-8.00
Denial
2.21 (0.67)
2.00-6.00
Substance use
2.36 (0.97)
2.00-6.00
Emotional support
3.30 (1.56)
2.00-8.00
4.30 (1.98)
2.00-8.00
2.39 (0.81)
2.00-5.00
3.53 (1.56)
2.00-8.00
3.52 (1.52)
2.00-8.00
4.93 (2.00)
2.00-8.00
2.60 (1.17)
2.00-7.00
5.45 (1.63)
2.00-8.00
2.30 (0.74)
2.00-5.00
4.57 (1.63)
2.00-8.00
Locus of the causes that led to the incident
3.90 (1.62)
1.00-6.00
Controllability of the causes that led to the incident
4.01 (1.80)
1.00-7.00
Institutional punitive response to surgical adverse events****
3.46 (0.92)
1.00-5.00
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Self-distraction
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Coping strategies**
Instrumental support Behavioural disengagement Venting Positing reframing Planning Humour
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Acceptance Religion Self-blame
26 (55.3) 4 (8.5)
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Causal attributions***
17 (36.2)
* This scale includes 7 items on intrusive thoughts and 8 items on avoidance behaviours assessed on a 4-point scale (0=Not at all, 1=Rarely, 3=Sometimes, 5=Often). **Each coping strategy was assessed with two items on a scale ranging from 1 to 4 (1=I haven’t been doing this at all, 2=I have been doing this a little bit, 3=I have been doing this a medium amount, 4=I have been doing this a lot) ***Causal attributions were assessed on continuous scales ranging from 1 (all to do with you/completely controllable by you) to 7 (all to do with others or external factors/completely uncontrollable by you) **** This scale includes 3 items which are assessed on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree).
1
Cut-off point for traumatic stress of clinical concern
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ACCEPTED MANUSCRIPT Table 2: Hierarchical multiple logistic regression on acute traumatic stress of clinical concern (Impact of Events Scale total score >19) 95% CI for exp b Predictors
B (SE)
Constant
-. 27 (.33)
.76
.41
Constant
-2. 37
10.78
.03
Vascular vs. General surgery
-2.04 (.87)
Exp b
Upper
a
.02
.13
Step 2b -.70 (1.63)
.50
Vascular vs. General surgery
-2.12 (.96)
.02
Self-distraction
1.08 (.47)
1.17
Step 3c
.12
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Constant
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Step 1
Lower
p
2.95
.72
.02
.67
.79
.03
7.39
.02
-1.32 (2.38)
.27
Vascular vs. General surgery
-2.03 (.99)
.02
.13
.92
.04
Self-distraction
1.06 (.47)
1.15
2.90
7.25
.02
Punitive institutional response
.16 (.43)
1.17
.50
2.72
.71
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Constant
a
.58
R2=.17 (Cox & Snell), .23 (Nagelkerke). Model χ2(1)=6.85, p=.009 R2=.31 (Cox & Snell), .42 (Nagelkerke). Model χ2(2)=13.93, p=.001 c 2 R =.31 (Cox & Snell), .43 (Nagelkerke). Model χ2(3)=14.08, p=.003
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b
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ACCEPTED MANUSCRIPT Highlights •
Patient harm resulting from medical treatment can be traumatic for healthcare staff
•
Many surgeons reported traumatic stress of clinical concern after their most recent major
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Self-distraction and being a general surgeon predicted traumatic stress of clinical concern
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•
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complication
S0002-9610(14)00376-6
DOI:
10.1016/j.amjsurg.2014.06.018
Reference:
AJS 11242
To appear in:
The American Journal of Surgery
Received Date: 17 April 2014 Revised Date:
6 June 2014
Accepted Date: 13 June 2014
Please cite this article as: Pinto A, Faiz O, Bicknell C, Vincent C, Acute traumatic stress among surgeons after major surgical complications, The American Journal of Surgery (2014), doi: 10.1016/ j.amjsurg.2014.06.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute traumatic stress among surgeons after major surgical complications
Anna Pinto, 1 Phd
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Omar Faiz, 1 FRCS Colin Bicknell, 1 FRCS
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Charles Vincent, 2 PhD
Centre for Patient Safety and Service Quality, Department of Surgery & Cancer, Imperial College
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London, UK 2
Department of Experimental Psychology, University of Oxford, UK
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Correspondence to: Anna Pinto
Centre for Patient Safety and Service Quality Department of Surgery & Cancer
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Imperial College London, St Mary's Campus Norfolk Place, London, W2 1PG
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Email: [email protected] Tel: +44 (0)20 7594 9725 Fax: +44 (0)207594 3137
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ACCEPTED MANUSCRIPT Abstract
Background: Patient harm resulting from medical treatment may be a traumatic experience for healthcare staff. This study examined surgeons’ levels of traumatic stress in the aftermath of the
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most recent major complication that happened in their patients’ care and its relationship with surgeons’ coping strategies, causal attributions and perceived institutional culture around surgical complications.
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Methods: 47 general and vascular surgeons from three NHS Trusts in London UK completed a
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questionnaire assessing the above variables (64.4% response rate).
Results: One third of the participants reported traumatic stress of clinical concern one month after the incident. The use of self-distraction (p<.05) and being a general surgeon (p<.05) were predictive of traumatic stress of clinical concern in multiple logistic regression analysis.
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Conclusions: Some surgeons may experience acute traumatic stress after serious surgical complications. The extent to which this is of clinical concern is associated with their use of selfdistraction as well as the clinical setting. Healthcare organisations need to attend to surgeons’
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psychological needs in the aftermath of serious adverse events.
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ACCEPTED MANUSCRIPT Summary This study examined surgeons’ levels of traumatic stress in the aftermath of the most recent major complication that happened in their patients’ care. One third of the participants reported traumatic stress of clinical concern one month after the incident, while the use of self-distraction (p<.05) and
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being a general surgeon (p<.05) were predictive of scoring above the cut-off point for traumatic stress of clinical concern. Healthcare organisations need to attend to surgeons’ psychological needs
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in the aftermath of serious adverse events.
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ACCEPTED MANUSCRIPT Keywords
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Surgical complications; adverse events; traumatic stress; psychological wellbeing
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ACCEPTED MANUSCRIPT Introduction
Despite healthcare professionals’ best intentions, patients sometimes experience harm which is caused by their medical treatment. Studies around the world suggest that the rates of adverse
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events in secondary care lie between 8 and 12% of hospital admissions. 1-11 Patients may suffer both physical and psychological trauma after adverse events that result in serious harm. 12 However, the emotional toll of serious adverse events on healthcare staff may also be quite severe especially 12
Healthcare professionals
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when incidents are preventable and lead to significant patient injuries. have been called the ‘second victims’ of adverse events in healthcare.
13
A small number of early
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studies have shown profound emotional effects for doctors who are involved in serious adverse events, such as fear, guilt, anger, embarrassment, humiliation or even anxiety and depression symptoms. 14-17
One of the highest risk areas for serious medical harm is the operating room.
5, 18
A
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retrospective review of 15,000 non-psychiatric discharges from a sample of representative hospitals in Utah and Colorado, found that 66% of all adverse events were surgical and 54% amongst them were preventable. 19 Among all surgical adverse events, 5.6% resulted in death, accounting for 12.2%
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of all hospital deaths in Utah and Colorado. A survey study of surgeons found that having been involved in a preventable surgical adverse event was associated with significantly lower mental
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quality of life, higher levels of burnout and higher risk of screening positive for depression. Reported errors were also related to lower career satisfaction. 20 Another possible consequence of surgeons’ involvement in serious surgical adverse events is the experience of traumatic stress, as ‘causing death or severe harm to another’ is one of the core aspects of traumatic incidents. 21 Recently, an exploratory interview study on surgeons’ experiences of surgical complications found that many surgeons reported feelings of guilt, fear, as well as a tendency to become vigilant and risk-averse in the aftermath of surgery that went wrong.
22
Such
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ACCEPTED MANUSCRIPT reactions are commonly encountered among sufferers of post-traumatic stress disorder (PTSD), which is a syndrome associated with the experience of traumatic events involving three clusters of symptoms: (a) re-experiencing the event, (b) avoiding reminders of it and (c) experiencing increased hyperarousal.
23, 24
However, to date there is no data on healthcare professionals’ experience of
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traumatic stress as a result of their involvement in adverse events that cause patient harm. Little attention has also been paid to the mechanisms that mediate or moderate the psychological impact of adverse events on healthcare professionals.
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An exploratory interview
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study identified a number of individual, incident and institution related factors that may contribute to the severity of surgeons’ reactions to surgical adverse events. 22 One key factor of surgeons’ post-
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incident wellbeing was their ways of coping with the stress of complications.
22
Most surgeons
admitted that discussing serious complications with peers or deconstructing them in order to identify learning lessons helped them deal with incidents. Another important determinant of surgeons’ reactions to surgical adverse events was reported to be the extent to which surgeons saw 22
When surgeons felt that the incident occurred due to
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themselves as responsible for the event.
their own decisions or practices they tended to experience stronger emotional reactions. This finding is in line with earlier studies which shown that an internal locus of causality is associated with more
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PTSD symptoms, especially when the traumatic stressor is perceived as controllable. 26, 27 Lastly, the above qualitative study found that the existence of blame as opposed to a supportive institutional
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culture exacerbates the psychological impact of these incidents on surgeons.
22
A negative social
environment (e.g. indifference, criticism or blame) is often a significant predictor of the development of PTSD.
28
In this study we are interested in exploring surgeons’ levels of acute traumatic stress in the aftermath of major surgical complications and its potential predictors. We hypothesised that surgeons’ acute traumatic stress in the aftermath of serious surgical complications will be predicted by the ways in which surgeons cope with the stress of the incident, the perceived locus and
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ACCEPTED MANUSCRIPT controllability of the causes that led to the complication and their perceptions of the institutional culture around surgical complications. Methods
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Participants Participants were recruited from a series of general and vascular surgical audit meetings in three National Health Service (NHS) hospitals in London, UK. At the end of each meeting surgeons were
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provided with a hard or an electronic copy of the questionnaire. Reminder emails were sent twice. The completion of the survey was kept anonymous. In total 73 surgeons were asked to participate in
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the study; 54 completed the survey. 7 respondents did not meet the inclusion criteria of having experienced at least one major surgical complication in their practice; therefore the analysis included data from 47 surgeons (64.4% response rate). Ethical approval was obtained from the North West London REC 1 ethics committee.
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Measures
The participants were asked to complete the questionnaire in relation to their most recent major surgical complication, in order to control for biases that would operate if participants could choose
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any incident. Surgeons were asked to report the recency (1=In the last month, 2=In the last 3 months, 3=In the last 6 months, 4=In the last year) and severity of the incident (1=The patient died,
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2=The patient developed morbidity with lasting disability, 3=The patient developed morbidity but recovered fully). They were also asked whether they had been involved in legal proceedings as a result of it (Yes/No). Acute traumatic stress was assessed with the Impact of Events (IES) scale 29. IES includes 7 items on intrusive thoughts (e.g. I thought about it when I didn't mean to) and 8 items on avoidance behaviours (e.g. I tried to remove it from memory) assessed on a 4-point scale (0=Not at all, 1=Rarely, 3=Sometimes, 5=Often). A cut-off point of 19 has been suggested to indicate traumatic stress of clinical concern. 29 The participants rated the extent to which they experienced each of the
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ACCEPTED MANUSCRIPT symptoms during the first month after the incident, which is the timeframe associated with acute traumatic stress. 23, 24 The perceived locus and perceived controllability of the causes that led to the reported complication were assessed on continuous scales ranging from 1 (all to do with you/completely
30
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controllable by you) to 7 (all to do with others or external factors/completely uncontrollable by you)]. Surgeons’ ways of coping with the stress of the complication were measured with Brief-COPE (B-
COPE) which assesses the use of various coping strategies known to be relevant to effective and
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ineffective coping (e.g. self-distraction, active coping, denial, substance use, use of emotional/instrumental support) in relation to a specified event. 31 Each coping strategy is assessed
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by two items on a 4-point scale (1=I haven’t been doing this at all, 2=I have been doing this a little bit, 3=I have been doing this a medium amount, 4=I have been doing this a lot). The institutional culture around surgical complications was measured with the punitive response to error scale of the Hospital Survey on Patient Safety Culture (HSPSC).
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This scale includes 3 items, (e.g. staff feel like
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their mistakes are held against them) which are assessed on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The items were modified in order to reflect the surgical
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context (e.g. “staff” was replaced with “surgeons”, “mistakes” was replaced with “complications”). The following participant characteristics were also assessed: age, gender, NHS organisation,
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nationality, relationship status, whether the participants had children, surgical specialty, clinical position, hours of clinical work per week and whether they held an academic position. Statistical analysis
The data were analyzed using SPSS version 20. Descriptive statistics and frequencies were used to summarise the study variables. Non-parametric tests were employed as most of the variables did not meet the assumption of normality (Mann-Whitney tests, Spearman’s rank-order correlations). Chi-square tests were used to assess the levels of one categorical variable against the levels of
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ACCEPTED MANUSCRIPT another categorical variable. Hierarchical multiple logistic regression analysis was used to assess the factors that predicted surgeons scoring above the cut-off point for traumatic stress of clinical concern (i.e. IES total score above 19). Factors that were significantly associated with traumatic stress of clinical concern in univariate analyses were entered in the regression analysis. Diagnostic
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statistics indicated that the assumption of no multi-collinearity was met. 33 Results
The majority of the respondents specialized in general surgery (60%). The majority of respondents
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were also surgical trainees (60%). The mean number of years in their clinical position was 6.2 (SD=5.9, Range=0.35-35), while the mean number of hours of clinical work per week was 50
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(SD=17.7, Range=0-72). Half of the participants (49%) held an academic position. The majority of the respondents were male (77%), British (77%) and married (68%). Their mean age was 38.5 years (SD=7.7, Range=27-64), while 55% of them had children. The majority of the participants’ most recent major surgical complication happened in the previous 3 months (54%), 17% between 3 and 6
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months ago and 17% more than 6 months ago. In most cases the patient developed morbidity but eventually recovered (41%). 28% of the complications led to patient morbidity with lasting disability, while 18% led to patient death.
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Table 1 presents descriptive information on the study variables. One third of the participants
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scored above the IES cut-off point of 19 (n=17, 36.2%), which indicates traumatic stress of clinical concern. 29
-Table 1-
There was a significant positive correlation between the use of self-distraction and acute traumatic stress (rs=.48, p=.002). Mann-Whitney tests also showed that respondents who scored above the cut-off point for acute traumatic stress of clinical concern reported significantly more frequent use of self-distraction (Median=3.5) than those who scored below the cut-off point (Median=2.0) (U=278.5, p=.006). No other coping strategies were significantly correlated with acute 9
ACCEPTED MANUSCRIPT traumatic stress scores or with scoring above the cut-off point for acute traumatic stress of clinical concern. There was also a marginally significant positive relationship between perceptions of a punitive institutional response to complications and acute traumatic stress (rs=.31, p=.047). Surgical specialty was also significantly associated with acute traumatic stress of clinical concern with 53.6%
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of the general surgeons scoring above the cut-off point for traumatic stress of clinical concern compared to only 15.4% of the vascular surgeons [χ2(2, N=41)=5.33, p=.021)]. There were no significant relationships between acute traumatic stress and perceived locus or controllability of the
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causes of the complication, the recency or severity of the incident, or the participants’ characteristics.
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The factors that were significantly associated with acute traumatic stress of clinical concern (i.e. surgical specialty, use of self-distraction and punitive institutional response) were entered in a hierarchical multiple logistic regression analysis on the occurrence of acute traumatic stress of clinical concern (total IES score above 19). Surgical specialty was entered first. Being a general
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surgeon significantly predicted the occurrence of acute traumatic stress of clinical concern (b=-2.04, SE=.87, p=.019). The addition of self-distraction use significantly improved the prediction of the occurrence of acute traumatic stress of clinical concern (b=1.08, SE=0.469, p=.021), while surgical
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specialty continued to be a significant predictor. Surgeons’ perceived institutional response to surgical complications was added in the last step but did not make any significant contribution, while
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surgical specialty and the use of self-distraction continued to significantly predict the outcome (see Table 2). In summary, practising general surgery and more frequent use of self-distraction in the aftermath of surgeons’ most recent major surgical complication significantly predicted scoring above the cut-off point for acute traumatic stress of clinical concern. -Table 2Discussion
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ACCEPTED MANUSCRIPT This is the first study to our knowledge that assessed surgeons’ (or any other healthcare professionals’) traumatic stress in the aftermath of serious adverse events. A striking finding was that one third of the participants scored above the cut-off point for traumatic stress of clinical concern during the first month after the incident. This percentage is suggestive of the high
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emotional burden that major adverse events often cause on clinical staff. This study also sought to explore if surgeons’ ways of coping, their perceptions of the locus and controllability of the causes of the incident and their perceptions of the institutional culture
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predicted their experience of acute traumatic stress in the aftermath of their most recent major complication. Self-distraction was the only coping strategy that was used significantly more
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frequently by participants who experienced acute traumatic stress of clinical concern and was also an independent predictor of traumatic stress of clinical concern in the logistic regression analysis. This is in agreement with literature which suggests that suppression of thoughts related to a traumatic incident is associated with higher PTSD symptoms. 28, 34, 35 Institutions’ punitive response
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to complications was also significantly associated with the experience of traumatic stress in the univariate analysis. The existence of blame and the lack of institutional support for staff in the aftermath of adverse events is a common finding. 25, 36 This study provides preliminary evidence on
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the existence of a negative relationship between the existence of institutional blame and surgeons’ wellbeing in the aftermath of serious complications, even though the lack of significant contribution
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of this factor in the regression analysis indicates that this relationship warrants further investigation. Lastly, contrary to our hypothesis there was not a significant relationship between surgeons’ perceptions of the locus and controllability of the causes of the reported complication and acute traumatic stress. This contradicts existing qualitative evidence which suggest that higher perceived responsibility for adverse events is associated with higher distress in healthcare professionals. 22, 37 Interestingly, being a general surgeon was predictive of higher odds of experiencing traumatic stress of clinical concern both in univariate and in multivariate analysis. A possible explanation is that
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ACCEPTED MANUSCRIPT general surgeons are less accustomed to the occurrence of stark complications such as those that often occur in vascular surgery (e.g. bleeding, limb loss). A complication arising unexpectedly in a low risk patient potentially takes a higher toll than one occurring in a high risk patient (e.g. vascular patients), as also suggested by an interview study on surgeons’ experiences of complications.22 The
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above finding highlights the importance of contextual variables such as patient risk factors and the clinical setting in explaining healthcare professionals’ reactions to adverse events and raises questions about the conditions that place healthcare professionals at higher risk for traumatic stress
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in the aftermath of major adverse events.
A few methodological limitations need to be taken into consideration. First, the study’s design
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is cross-sectional and does not allow causal inferences about the observed relationships. Secondly, the small sample size did not permit the inclusion of all relevant factors in the regression analysis. Only variables that were highly significantly associated with IES total scores were considered. Despite any limitations, this is the first study to our knowledge that investigated the experience of
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traumatic stress among surgeons (or healthcare professionals) who are involved in serious adverse events.
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In summary, the study findings suggest that a significant percentage of surgeons may experience acute traumatic stress after serious surgical complications and that the extent to which
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these symptoms will be of clinical concern may be dependent on their use of self-distraction as well as the clinical setting. Surgeons who use self-distraction as a coping strategy and surgeons who practice general as opposed to vascular surgery are at higher risk for experiencing acute traumatic stress of clinical concern in the aftermath of serious surgical complications. The implications of these findings for healthcare organisations are significant as they need to consider how best to support their staff when serious adverse events occur. For example, early training on how to cope more effectively with serious adverse events may prevent symptoms of severe traumatic distress which could lead to further suboptimal care. Lastly, there is a need for future studies with bigger samples,
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ACCEPTED MANUSCRIPT longitudinal designs and use of multivariate analyses in order to elucidate the prevalence of traumatic stress among healthcare professionals in the aftermath of serious adverse events, as well as the mediators and moderators of the traumatic impact of such incidents.
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Acknowledgements This work was supported by funding from the Health Foundation. The Imperial Centre for Patient
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Safety and Service Quality is funded by the UK National Institute for Health Research (NIHR).
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ACCEPTED MANUSCRIPT References 1.
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. Incidence of adverse events
related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Commun H 2008; 62(12): 1022-9. Baker GR. The Canadian Adverse Events Study: the incidence of adverse events among
hospital patients in Canada. Can Med Assoc J 2004; 170(11): 1678-86. 3.
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2.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in
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hospitalized patients: Results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care 2004; 13(2): 145-51.
Davis P, Lay-Yee R, Briant R, et al. Adverse Events in New Zealand Public Hospitals: Principal
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4.
Findings from a National Survey. HINZ. Brunswick East, Vic.: Health Informatics Society of Australia; Royal Australian College of General Practitioners; 2003. p. 522-43. 5.
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients.
6.
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Results of the Harvard Medical Practice Study II. NEJM 1991; 324(6): 377-84. Michel P, Quenon JL, Djihoud A, et al. French national survey of inpatient adverse events
prospectively assessed with ward staff. Qual Saf Health Care 2007; 16(5): 369-77. Schiøler T, Lipczak H, Pedersen BL, et al. Danish adverse event study. Incidence of adverse
EP
7.
5370-8. 8.
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events in hospitals: A retrospective study of medical records. Ugeskrift for Laeger 2001; 163(39):
Soop M, Fryksmark U, Köster M, Haglund B. The incidence of adverse events in Swedish
hospitals: A retrospective medical record review study. Int J Qual Health Care 2009; 21(4): 285-91. 9.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: Preliminary
retrospective record review. BMJ 2001; 322(7285): 517-9. 10.
Wilson RM. The Quality in Australian Health Care Study. MJA 1995; 163(9): 458-71.
14
ACCEPTED MANUSCRIPT 11.
Zegers M, de Bruijne MC, Wagner C, et al. Adverse events and potentially preventable
deaths in Dutch hospitals: Results of a retrospective patient record review study. Qual Saf Health Care 2009; 18(4): 297-302. Vincent C. Patient safety. London: Wiley Blackwell; 2010.
13.
Wu AW. Medical error: The second victim. BMJ 2000; 320(7237): 726-7.
14.
Aasland OG, Forde R. Impact of feeling responsible for adverse events on doctors' personal
RI PT
12.
and professional lives: the importance of being open to criticism from colleagues. Qual Saf Health
15.
Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived
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mistakes on physicians. J Gen Intern Med 1992; 7(4): 424-31. 16.
SC
Care 2005; 14(1): 13-7.
White AA, Waterman AD, McCotter P, Boyle DJ, Gallagher TH. Supporting health care
workers after medical error: Considerations for health care leaders. J Clin Outcomes Manag 2008; 15(5): 240-7.
Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? The JAMA
1991; 265(16): 2089-94.
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17.
Leape LL. A systems analysis approach to medical error. J Eval Clin Pract 1997; 3(3): 213-22.
19.
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical
EP
18.
adverse events in Colorado and Utah in 1992. Surgery 1999; 126(1): 66-75. Shanafelt TD. Burnout and medical errors among American surgeons. Ann Surg 2010; 251(6):
AC C
20.
995-1000. 21.
Green BL. Defining trauma: Terminology and generic stressor dimensions. J Appl Soc Psychol
1990; 20(20): 1632-42. 22.
Pinto A, Faiz O, Bicknell C, Vincent C. Surgical complications and their implications for
surgeons' well-being. Br J Surg 2013; 100(13): 1748-55. 23.
Brewin CR, Andrews B, Rose S. Diagnostic overlap between acute stress disorder and PTSD in
victims of violent crime. Am J Psychiatry 2003; 160(4): 783-5. 15
ACCEPTED MANUSCRIPT 24.
Yehuda R. Post-Traumatic Stress Disorder. NEJM 2002; 346(2): 108-14.
25.
Sirriyeh R, Lawton R, Gardner P, Armitage G. Coping with medical error: A systematic review
of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being. Qual Saf Health Care 2010; 19(6): 1-8. Joseph S, Yule W, Williams R. Post-traumatic stress: Attributional aspects. J Trauma Stress
RI PT
26.
1993; 6(4): 501-13. 27.
Joseph SA, Brewin CR, Yule W, Williams R. Causal attributions and psychiatric symptoms in
28.
SC
survivors of the Herald of Free Enterprise disaster. Br J Psychiatry 1991; 159(4): 542-6.
Brewin CR. Psychological theories of posttraumatic stress disorder. Clin Psychol Rev 2003;
29.
Horowitz M, Wilner N, Alvarez W. Impact of Events Scale: A measure of subjective stress.
Psychosom Med 1979; 41(3): 209-18. 30.
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23(3): 339-76.
Firth J, Brewin C. Attributions and recovery from depression: A preliminary study using cross-
31.
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lagged correlation analysis. Br J Clin Psychol 1982; 21(Pt 3): 229-30.
Carver C. You want to measure coping but your protocol’ too long: Consider the Brief Cope.
Int J Behav Med 1997; 4(1): 92-100.
Sorra J, Nieva VF. Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for
EP
32.
Healthcare Research and Quality; 2004. Field A. Discovering statistics using SPSS. 3rd ed. London: Sage; 2011.
34.
Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in
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33.
ambulance service workers. Br J Clin Psychol 1999; 38(3): 251-65. 35.
Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000;
38(4): 319-45. 36.
Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on
physicians: A call for leadership and organisational accountability. Swiss Med Wkly 2009; 139(1-2): 915. 16
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Engel KG, Rosenthal M, Sutcliffe KM, Engel KG, Rosenthal M, Sutcliffe KM. Residents'
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responses to medical error: Coping, learning, and change. Acad Med 2006; 81(1): 86-93.
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ACCEPTED MANUSCRIPT Table 1: Descriptive statistics of study variables Mean (SD)
Range
Intrusion
9.47 (7.30)
0.00-27.00
Avoidance
7.75 (6.40)
0.00-28.00
Total score (traumatic stress)
17.44 (12.17)
0.00-55.00
N (%)
Impact of Events Scale*
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Above 19 Below 19 Missing
2.93 (1.02)
2.00-5.00
Active coping
4.39 (1.76)
2.00-8.00
Denial
2.21 (0.67)
2.00-6.00
Substance use
2.36 (0.97)
2.00-6.00
Emotional support
3.30 (1.56)
2.00-8.00
4.30 (1.98)
2.00-8.00
2.39 (0.81)
2.00-5.00
3.53 (1.56)
2.00-8.00
3.52 (1.52)
2.00-8.00
4.93 (2.00)
2.00-8.00
2.60 (1.17)
2.00-7.00
5.45 (1.63)
2.00-8.00
2.30 (0.74)
2.00-5.00
4.57 (1.63)
2.00-8.00
Locus of the causes that led to the incident
3.90 (1.62)
1.00-6.00
Controllability of the causes that led to the incident
4.01 (1.80)
1.00-7.00
Institutional punitive response to surgical adverse events****
3.46 (0.92)
1.00-5.00
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Self-distraction
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Coping strategies**
Instrumental support Behavioural disengagement Venting Positing reframing Planning Humour
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Acceptance Religion Self-blame
26 (55.3) 4 (8.5)
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Causal attributions***
17 (36.2)
* This scale includes 7 items on intrusive thoughts and 8 items on avoidance behaviours assessed on a 4-point scale (0=Not at all, 1=Rarely, 3=Sometimes, 5=Often). **Each coping strategy was assessed with two items on a scale ranging from 1 to 4 (1=I haven’t been doing this at all, 2=I have been doing this a little bit, 3=I have been doing this a medium amount, 4=I have been doing this a lot) ***Causal attributions were assessed on continuous scales ranging from 1 (all to do with you/completely controllable by you) to 7 (all to do with others or external factors/completely uncontrollable by you) **** This scale includes 3 items which are assessed on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree).
1
Cut-off point for traumatic stress of clinical concern
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ACCEPTED MANUSCRIPT Table 2: Hierarchical multiple logistic regression on acute traumatic stress of clinical concern (Impact of Events Scale total score >19) 95% CI for exp b Predictors
B (SE)
Constant
-. 27 (.33)
.76
.41
Constant
-2. 37
10.78
.03
Vascular vs. General surgery
-2.04 (.87)
Exp b
Upper
a
.02
.13
Step 2b -.70 (1.63)
.50
Vascular vs. General surgery
-2.12 (.96)
.02
Self-distraction
1.08 (.47)
1.17
Step 3c
.12
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Constant
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Step 1
Lower
p
2.95
.72
.02
.67
.79
.03
7.39
.02
-1.32 (2.38)
.27
Vascular vs. General surgery
-2.03 (.99)
.02
.13
.92
.04
Self-distraction
1.06 (.47)
1.15
2.90
7.25
.02
Punitive institutional response
.16 (.43)
1.17
.50
2.72
.71
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Constant
a
.58
R2=.17 (Cox & Snell), .23 (Nagelkerke). Model χ2(1)=6.85, p=.009 R2=.31 (Cox & Snell), .42 (Nagelkerke). Model χ2(2)=13.93, p=.001 c 2 R =.31 (Cox & Snell), .43 (Nagelkerke). Model χ2(3)=14.08, p=.003
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b
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ACCEPTED MANUSCRIPT Highlights •
Patient harm resulting from medical treatment can be traumatic for healthcare staff
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Many surgeons reported traumatic stress of clinical concern after their most recent major
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Self-distraction and being a general surgeon predicted traumatic stress of clinical concern
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•
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complication