Error in ICU: Repurcussions and Defense Mechanisms
Error in ICU: Repurcussions and Defense Mechanisms
This qualitative study explored the psychological repercussions felt by professionals in intensive care after an error. The professionals whom we interviewed reported different psychological manifestations after her/his error, such as guilt (53.8%), shame (42.5%), anxiety states with rumination (37.5%) and fear for the patient (23%), loss of confidence (32.5%), inability to verbalize one's error (22.5%), questioning oneself at a professional level (20%), and anger toward the team (15%). These different manifestations disappeared gradually for the majority of the professionals in the months following the error. In the long term, we observed that the error remains fixed in the professional's memory. However, a feeling of guilt persisted for three subjects.
Half of the professionals questioned had a feeling of guilt after experiencing an error in ICU. From the perspective of the interviews, this guilt was expressed by a feeling of failure in the professional practice and was associated with an anxiety state characterized by rumination (37.5%) and worry about the patient (23%). However, the guilt described by the professionals did not appear to lead to chronic psychopathological symptoms as has been observed in posttraumatic stress disorder. During the interviews, the professionals made it clear that these different manifestations faded gradually in the month following the error.
The guilt described by the professionals seems to correspond more to a guilt "alarm" whose defensive function prevents emotional overflow. Considered in this way, guilt is defined as an effect which restores the subject to the place of actor "I felt guilty, because I did the procedure which led to the error": to be an actor in the event is to make the event controllable and thus assure oneself that it cannot be reproduced.
According to psychodynamics theories, being guilty signifies that one seeks to commit oneself in the area of responsibility. It indicates sufficient sensitivity and testifies to the fact that the subject has been affected and concerned by what happened. This dimension is important in a hospital service because guilt will have a healing function for the professional's peer group, that is, the ICU team " … I said it, I said it right away, I pointed it out, they saw that I was afraid, so I think a professional conscience …" and will allow the professional to maintain his/her place in the group.
However, guilt does not seem to follow the same pattern for three professionals. It is clearly differentiated from the guilt expressed by the majority of the professionals because on one hand, it persists over time (> 3 mo) and it was still present at the time of the interview, and on the other hand, it is reinforced by the death or the suffering of the patient.
Shame is defined by Tisseron as a strong fear of losing three things: the love of those close to you, self-esteem, and links with your community. Shame is influenced by the negative reaction of others to the error. In this way, shame, which is most often imposed by the group, affects the subject's self-image. It expresses fear of group judgment, of disappointing, of being incompetent and unworthy of working in the service "you're also ashamed, well you think you're lousy … you didn't do your job right." By verbalizing the feeling of shame, the professionals express their fear of being excluded from the peer group and of being stigmatized and marginalized. This shame corresponds to the decline of the caregiver's ideals; thus, it profoundly affects him/her and represents the narcissistic attack which the error provokes. The corollary being that shame will be more difficult to share than guilt, it tends to isolate and grow in silence.
Eighty percent of the 40 professionals who experienced an error more than 3 months prior to the interview stated that they perfectly remember their error, because it is fixed firmly in memory and is reactivated when the professional finds himself confronted with a similar situation. In "From the inside," Bellomo also described it: "I remember it like yesterday, but it was 25 years ago."
The imprinting of the error in memory will have a range of consequences on the professionals:
1. The imprinting of an event is part of the context of learning (76.6%). It serves as a reference, and the error is perceived as an experience which enables skills to be developed for use later in a similar situation.
The majority of the professionals with less than 1-year experience (15 of 20 subjects) explain that not forgetting allows them to be more attentive and vigilant and thus to feel more operational to avoid making the same error. After the error, the physicians (12 of 20) sought more knowledge and implemented actions to improve their professional practice.
If the error remains fixed in memory, it does not lead to persistent rumination as is found in the symptoms of posttraumatic stress. On the contrary, the error remains in memory to allow the implementation of adaptive cognitive and behavioral strategies with the aim of controlling the situation. Our results are in line with those of Reason and Amalberti et al who consider the error as a special medium for the elaboration of a skill; they emphasize the role that the error plays in the acquisition and the effectiveness of security at an individual and collective level. According to these authors, it is the inevitable price that human beings must pay in order to develop further skills. More recently, Plews-Ogan et al associated medical error with the development of professional skills as well as personal ones. Thus, Branch and Mitchell speak about "wisdom in medicine," meaning that the error will offer the possibility to know the limits of one's knowledge and the opportunity to develop the capacity for self-reflection.
2. However, for three professionals, imprinting the error in memory was experienced in a negative way, it is associated with a loss of confidence with a persistent fear of being confronted with an analogous situation "Because when you find yourself all alone … and the laryngoscope and the thingummy … and you say to yourself that that's going to begin again, they're really very very stressing situations. It's, it's the worst. It's the worst." Imprinting the error in memory is a source of anxiety here, and it seems more difficult for the professionals to transform it into a learning experience.
We observed that the majority of the psychological manifestations experienced immediately after the error do not last over time. This result corroborates other theoretical and clinical works in psychology and the psychodynamics of work which show that the constraints linked to the exercise of a profession do not have a systematic effect on the health of the personnel who are subjected to them. In essence, when confronted with a difficult situation, the subject will try to adapt by developing defense mechanisms. These defense mechanisms are defined as psychological processes allowing the subject to protect his/her psychic integrity and to continue to do his/her work in spite of the difficult events that the professional can be confronted with. Thus, the professionals of ICU will use different defense mechanisms in a more or less effective and conscious way against error, to protect themselves from this experience and make the event easier to manage emotionally. Our results show two levels of defense mechanisms:
1. Verbalization and the pursuit of knowledge and complementary skills: Engel et al listed these mechanisms in a study on error and coping among residents. According to the Diagnostic and Statistical Manual of Mental Disorders, they are among the strategies the most adaptive to difficult situations. Verbalization allows sharing one's experience. The error also reinforces motivations to learn and to develop in order to avoid being confronted with a similar situation.
We observed that the pursuit of knowledge and skills was mainly used by the physicians. The nurses did not favor this strategy to cope with error. Nurses in France do not receive specific training in intensive care during study for their diploma nor do they receive training in research. This means they are ill equipped to undertake research themselves that could enable them to better cope with the errors.
2. By contrast, minimizing (the professionals distance themselves from emotion by assessing the situation as less serious than others), rejecting responsibility, and emotional avoidance will keep the objective reality of the error, as well as the emotional load associated with it, at a distance. According to the literature, the failure to recognize the objective reality will prevent awareness of the situation experienced.
More specifically, rejecting responsibility seems to be a defense strategy accepted by the group, which becomes a dimension of group strategy and allows the professionals to not feel alone with the error and to be supported by the team. However, this defense strategy can only be implemented if the group has elaborated a common culture of work that is shared by the members of the group. This strategy is peculiar to error and will not appear in the same way when the professional was negligent, showed reckless conduct, or knowing violations.
Discussion
This qualitative study explored the psychological repercussions felt by professionals in intensive care after an error. The professionals whom we interviewed reported different psychological manifestations after her/his error, such as guilt (53.8%), shame (42.5%), anxiety states with rumination (37.5%) and fear for the patient (23%), loss of confidence (32.5%), inability to verbalize one's error (22.5%), questioning oneself at a professional level (20%), and anger toward the team (15%). These different manifestations disappeared gradually for the majority of the professionals in the months following the error. In the long term, we observed that the error remains fixed in the professional's memory. However, a feeling of guilt persisted for three subjects.
Guilt and Shame After an Error
Half of the professionals questioned had a feeling of guilt after experiencing an error in ICU. From the perspective of the interviews, this guilt was expressed by a feeling of failure in the professional practice and was associated with an anxiety state characterized by rumination (37.5%) and worry about the patient (23%). However, the guilt described by the professionals did not appear to lead to chronic psychopathological symptoms as has been observed in posttraumatic stress disorder. During the interviews, the professionals made it clear that these different manifestations faded gradually in the month following the error.
The guilt described by the professionals seems to correspond more to a guilt "alarm" whose defensive function prevents emotional overflow. Considered in this way, guilt is defined as an effect which restores the subject to the place of actor "I felt guilty, because I did the procedure which led to the error": to be an actor in the event is to make the event controllable and thus assure oneself that it cannot be reproduced.
According to psychodynamics theories, being guilty signifies that one seeks to commit oneself in the area of responsibility. It indicates sufficient sensitivity and testifies to the fact that the subject has been affected and concerned by what happened. This dimension is important in a hospital service because guilt will have a healing function for the professional's peer group, that is, the ICU team " … I said it, I said it right away, I pointed it out, they saw that I was afraid, so I think a professional conscience …" and will allow the professional to maintain his/her place in the group.
However, guilt does not seem to follow the same pattern for three professionals. It is clearly differentiated from the guilt expressed by the majority of the professionals because on one hand, it persists over time (> 3 mo) and it was still present at the time of the interview, and on the other hand, it is reinforced by the death or the suffering of the patient.
Shame is defined by Tisseron as a strong fear of losing three things: the love of those close to you, self-esteem, and links with your community. Shame is influenced by the negative reaction of others to the error. In this way, shame, which is most often imposed by the group, affects the subject's self-image. It expresses fear of group judgment, of disappointing, of being incompetent and unworthy of working in the service "you're also ashamed, well you think you're lousy … you didn't do your job right." By verbalizing the feeling of shame, the professionals express their fear of being excluded from the peer group and of being stigmatized and marginalized. This shame corresponds to the decline of the caregiver's ideals; thus, it profoundly affects him/her and represents the narcissistic attack which the error provokes. The corollary being that shame will be more difficult to share than guilt, it tends to isolate and grow in silence.
Imprinting the Error in Memory
Eighty percent of the 40 professionals who experienced an error more than 3 months prior to the interview stated that they perfectly remember their error, because it is fixed firmly in memory and is reactivated when the professional finds himself confronted with a similar situation. In "From the inside," Bellomo also described it: "I remember it like yesterday, but it was 25 years ago."
The imprinting of the error in memory will have a range of consequences on the professionals:
1. The imprinting of an event is part of the context of learning (76.6%). It serves as a reference, and the error is perceived as an experience which enables skills to be developed for use later in a similar situation.
The majority of the professionals with less than 1-year experience (15 of 20 subjects) explain that not forgetting allows them to be more attentive and vigilant and thus to feel more operational to avoid making the same error. After the error, the physicians (12 of 20) sought more knowledge and implemented actions to improve their professional practice.
If the error remains fixed in memory, it does not lead to persistent rumination as is found in the symptoms of posttraumatic stress. On the contrary, the error remains in memory to allow the implementation of adaptive cognitive and behavioral strategies with the aim of controlling the situation. Our results are in line with those of Reason and Amalberti et al who consider the error as a special medium for the elaboration of a skill; they emphasize the role that the error plays in the acquisition and the effectiveness of security at an individual and collective level. According to these authors, it is the inevitable price that human beings must pay in order to develop further skills. More recently, Plews-Ogan et al associated medical error with the development of professional skills as well as personal ones. Thus, Branch and Mitchell speak about "wisdom in medicine," meaning that the error will offer the possibility to know the limits of one's knowledge and the opportunity to develop the capacity for self-reflection.
2. However, for three professionals, imprinting the error in memory was experienced in a negative way, it is associated with a loss of confidence with a persistent fear of being confronted with an analogous situation "Because when you find yourself all alone … and the laryngoscope and the thingummy … and you say to yourself that that's going to begin again, they're really very very stressing situations. It's, it's the worst. It's the worst." Imprinting the error in memory is a source of anxiety here, and it seems more difficult for the professionals to transform it into a learning experience.
Defense Mechanisms After the Error
We observed that the majority of the psychological manifestations experienced immediately after the error do not last over time. This result corroborates other theoretical and clinical works in psychology and the psychodynamics of work which show that the constraints linked to the exercise of a profession do not have a systematic effect on the health of the personnel who are subjected to them. In essence, when confronted with a difficult situation, the subject will try to adapt by developing defense mechanisms. These defense mechanisms are defined as psychological processes allowing the subject to protect his/her psychic integrity and to continue to do his/her work in spite of the difficult events that the professional can be confronted with. Thus, the professionals of ICU will use different defense mechanisms in a more or less effective and conscious way against error, to protect themselves from this experience and make the event easier to manage emotionally. Our results show two levels of defense mechanisms:
1. Verbalization and the pursuit of knowledge and complementary skills: Engel et al listed these mechanisms in a study on error and coping among residents. According to the Diagnostic and Statistical Manual of Mental Disorders, they are among the strategies the most adaptive to difficult situations. Verbalization allows sharing one's experience. The error also reinforces motivations to learn and to develop in order to avoid being confronted with a similar situation.
We observed that the pursuit of knowledge and skills was mainly used by the physicians. The nurses did not favor this strategy to cope with error. Nurses in France do not receive specific training in intensive care during study for their diploma nor do they receive training in research. This means they are ill equipped to undertake research themselves that could enable them to better cope with the errors.
2. By contrast, minimizing (the professionals distance themselves from emotion by assessing the situation as less serious than others), rejecting responsibility, and emotional avoidance will keep the objective reality of the error, as well as the emotional load associated with it, at a distance. According to the literature, the failure to recognize the objective reality will prevent awareness of the situation experienced.
More specifically, rejecting responsibility seems to be a defense strategy accepted by the group, which becomes a dimension of group strategy and allows the professionals to not feel alone with the error and to be supported by the team. However, this defense strategy can only be implemented if the group has elaborated a common culture of work that is shared by the members of the group. This strategy is peculiar to error and will not appear in the same way when the professional was negligent, showed reckless conduct, or knowing violations.
Source...