The study was designed as a cross-sectional questionnaire survey. In addition, three individual interviews with participants were conducted to include more elaborate answers in the evaluation.
The Buddy Study program
The objective of the Buddy Study program is to facilitate peer support after adverse or traumatic events through a formalised buddy system and a compulsory seminar about second victims and peer support. Adverse events were defined as patient events with unanticipated adverse outcomes, medical error and/or patient related injuries. Traumatic events could include situations not associated with safety incidents, such as patient death or workplace violence.
On the basis of literature searches, our previous research, and five focus groups with a total of 21 midwives and physicians , the research team defined the following five underlying principles for the peer support program. i) Recognition of exposure to adverse or traumatic events as a fundamental condition for HCPs. In modern healthcare, the prevention of adverse events is pivotal. However, the management of the aftermath of these events is also crucial, and HCPs should be acknowledged for working in complex systems with the risk of involvement in severe adverse or traumatic events. ii) Organisational responsibility towards all employees every time. Focus groups revealed inconsistency in the support offered after adverse events, even within the same department. Second-victim support resources should be reliable for all HCPs and not based on inconsistent or random assessments of when support or debriefings should be facilitated. iii) Relationships are of central importance. Second victims may feel guilt, fear, and loss of self-esteem, which are emotions one may prefer to disclose only in an already established and safe relationship. In recognition of the importance of a personal relationship, HCPs should be able to select a peer supporter of their own choice. iv) Build on existing resources in the departments. Although management may have the will to invest in the safety and health of the employees, the general soaring healthcare budget may only allow minor additional costs. HCPs are all trained to care for people in crisis, and studies have shown that colleagues are the preferred resource of support for second victims. They are a valuable resource for a support program. v) Research-based evaluation of the intervention. The program should be designed as a research intervention to contribute to the body of evidence on the effectiveness of second-victim support resources.
Grounded in these underlying principles, the Buddy Study was designed to encompass 1) a compulsory seminar, 2) a self-selection of two Buddies, and 3) a system for buddy activation and response after adverse events.
The purpose of the compulsory 2-h seminar was to provide participants with knowledge about the second victim phenomenon and stress responses that may be associated with a traumatic or adverse event. The seminars were conducted for smaller groups of 5–15 participants at the time. Through interactive exercises, participants shared their experiences and became aware of support needs after a traumatic or adverse event. Furthermore, participants were informed about the buddy system program, how to activate one’s buddy, how to respond as someone’s buddy, and when to seek further support from management or a psychologist. The seminar addressed all participants as both potential second victims and buddies. The seminar was compulsory in order to communicate that adverse events are a general risk for all (junior as well as senior staff) and promote a shared understanding of second victims and peer support.
At the end of the seminar, all participants named two colleagues whom they would want to be their buddies in case of an adverse event (on a note in a closed envelope). The selected colleagues were then asked to consent to be that person’s buddy. Eventually, a list with names of all HCPs and names of their two buddies was created, and the support program was ready for implementation.
In case of an adverse or traumatic event, the buddy system can be activated through the involved HCP, a colleague, or the manager. Although it was compulsory to participate in the seminar and to select two buddies, using a buddy after an adverse event was voluntary. If the involved HCP provided consent, the manager or charge midwife would contact their buddy. No information about the event would be passed on, nor any assessment of the emotional state of the HCP. The only information provided would state that ‘NN has been involved in an adverse event and he/she wants to activate his/her buddy’. Subsequently, it was the responsibility of the buddy to reach out and contact the HCP, preferably within the first 24 h. The time frame for a buddy contact was 2 h, which could be spent in any way the HCP and the buddy agreed on—phone calls or encounters in or out of the workplace, several shorter sessions, or fewer longer sessions—over a 4-week period. In a previous study, less than half of the respondents agreed to a great or some extent that their colleagues provided meaningful and sustained support after the event . Consequently, a four-week time period was chosen to ensure sustained support for the involved HCP balanced with the potential risk of burdening the buddy over time. After four weeks, other measures should be offered, sooner if needed. The only stipulation was that the buddy encounters would happen outside working hours to ensure a space for private, unguarded conversations. The buddy would be paid for the 2 h of work.
The Buddy Study program was implemented, and the evaluation was conducted 18 months after the last seminar.
Respondents and data collection—questionnaire survey
HCPs from two departments at Odense University Hospital in Denmark participated in the Buddy Study program: all midwives in the Department of Obstetrics and Gynaecology (OB-GYN) in Odense and Svendborg and all physicians at the Internal Medicine and Emergency Department (IME) in Svendborg. Both departments are involved in high degrees of acute patient care and decision-making.
The first questionnaire (Q1) evaluating the Buddy Study seminars was handed out to all participants at the seminars between May 2018 and April 2019. The seminar programme included time to complete and return the questionnaire. A second questionnaire (Q2) evaluating the Buddy Study program was handed out at general staff meetings in October and November 2020. Because of COVID-19 restrictions, only small groups could attend these meetings, and questionnaires were subsequently distributed via e-mail invitation with a survey link to increase the response rate. The survey was created using REDCap (Research Electronic Data Capture), and all paper versions were entered into the same database in REDCap.
Both departments have a high turnover of staff because of temporary employment during training for resident doctors, maternity leave, etc. Therefore, the study population changed during the 18 months and was not identical for Q1 and Q2.
During the study period, the use of the buddy system was registered, including the type of event that activated the need to use one’s buddy.
To assess the participants’ experiences with the Buddy Study program, 22 close-ended items were created. The first questionnaire (Q1) included nine items addressing satisfaction with the seminar, learning outcomes, sense of safety, and attitudes towards the buddy program. In the second questionnaire (Q2), five items evaluated the Buddy Study program, addressing the overall experience with the program—including the seminar and the derived change in supportive culture, awareness, and sense of security. Furthermore, eight items specifically addressed the experiences of those who had either used a buddy or been activated as a buddy.
All 22 items were specifically constructed to evaluate the Buddy Study program and were face validated by three HCPs, resulting in only minor adjustments. All items were composed of a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’.
Furthermore, the survey included two open-ended questions: 1) ‘In your own words, how did you experience using your buddy?’ and 2) ‘In your own words, how did you experience being a buddy for a colleague?’. An additional box for free-text comments was available at the end of the survey.
Finally, both questionnaires (Q1 and Q2) contained three categorical items on gender, professional background, and seniority, and Q2 included three additional items regarding the length of employment in the department, attendance at the Buddy Study seminar (yes/no), and whether two buddies were chosen (yes/no). Within a time period of 18 months, there is a turnover of staff, and items on seminar attendance and selection of buddies were included to keep track on the level of implementation of the Buddy Study program.
Respondents and data collection—interviews
Upon the completion of Q2, an e-mail invitation to participate in an individual online interview was distributed to all participants in both departments. Because of COVID-19 restrictions, interviews were conducted and recorded via Zoom. A semi-structured interview guide based on preliminary results from the survey was developed, which focused on i) experiences with having a buddy program in the department, ii) peer support in general, iii) the meaning of self-selected relations, and iv) shortcomings of the program. Interviews were conducted by the first author (KS).
Questionnaires with three or more missing responses were excluded, and the remaining missing responses were omitted from the final analyses. Respondents’ characteristics are expressed as proportions. To compare the two groups of respondents, chi-square tests were performed. The response options of the nine items assessing the participants’ experiences with the seminar, four items on using a buddy, and four items on being activated as a buddy were collapsed into three categories: ‘agree’ (agree/strongly agree), ‘neither agree nor disagree’, and ‘disagree’ (disagree/strongly disagree). The results are expressed as proportions. The five items evaluating the buddy program in general in Q2 were collapsed into’agree’ (to a large extent/ to some extent), ‘neither agree nor disagree’ (do not know), and ‘disagree’ (to a lesser extent/not at all). The results are expressed as proportions. Data analyses were performed using STATA 16.0 software (StataCorp 2019/College Station, TX, USA).
Each event leading to a Buddy contact was registered by type and number.
When performing qualitative data analysis, audio recordings of the interviews were listened to several times, and selected excerpts were transcribed, as proposed by Miles et al. . The transcribed data were pooled with the data from the open-ended questions and free-text comments in the survey. Rooted in an essentialist paradigm, and in line with the descriptive, thematic analyses of the survey data, an essentialist approach was followed for the analysis of the qualitative data assuming a simple, unidirectional relationship between meaning and experience and language, as proposed by Braun and Clarke . This entailed reporting experiences, meanings and the reality of participants, and performing a descriptive content analysis to comprehensively summarise the data by staying close to the words and events. This is an adoption of Sandelowki’s exposition of qualitative descriptive studies, representing language as a ‘vehicle of communication’, not itself an interpretive structure that must be read . The coding process departed from the pre-existing categories in the survey and the interview guide. The codes were modified by the first author (KS) during the next cycles of coding, and interviews were listened to again to select further excerpts for transcription. Descriptive themes were selected and placed in a matrix with condensed descriptions and illustrative quotes.