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This is an Accepted Manuscript of an article published by Taylor & Francis in Anthrozoös on February 5, 2018, available online here: http://dx.doi.org/10.1080/08927936.2018.1406205 

Veterinarians’ Emotional Reactions and Coping Strategies for Adverse Events in Spay-Neuter Surgical Practice

Sara C. White, DVM, MSc

Spay ASAP Inc., 163 Clay Hill Road, Hartland, Vermont, 05048

sheltervet@mac.com

Conflict of Interest Statement: No potential conflict of interest is reported by the author, and no funding was received for this research.

Abstract

This study is a thematic analysis of the experiences, thoughts, and reactions of shelter and spay-neuter veterinarians as they cope with serious adverse patient events (life-threatening complications or death) related to spay-neuter. Thirty-two veterinarians responded to an electronic questionnaire containing 22 open-ended questions relating to their emotions, thoughts, experiences and actions after adverse events. Participants experienced immediate and visceral reactions to adverse events during which they described feelings of guilt, sadness, anxiety, and self-doubt and expressed empathy for their clients and for others affected by these events. Many controlled or managed their emotional response in the immediate aftermath of the event, both in order to complete the existing surgical workload and to maintain professional bearing. Participants’ initial reactions evolved over time to reflect their long-term resilience, or to be experienced as recurrent trauma. Four factors related to coping appeared to shape this long-term outcome: technical learning, perspective, support, and emotional learning. Nearly every participant emphasized the importance of technical learning in order to decrease future occurrences and improve skills. Participants used a variety of frames of reference to provide perspective, and place the adverse event in a larger context. Many veterinarians described the importance of conversations with other veterinarians following adverse events, both for technical advice and psychosocial support. Through experience, some participants attained emotional learning about how to handle and support themselves through an adverse event. Some veterinarians were able to process and move past the intrusive effects of sadness, guilt and self-doubt within a day to a week, while others were deeply affected for months or even years after a severe adverse event. Several veterinarians had considered leaving the field, and a few had stopped performing surgery.

Understanding how spay-neuter veterinarians cope with adverse events could be integral to supporting the health and welfare of these skilled workers and retaining them in the field, decreasing the shame and self-doubt experienced by many, and encouraging information-sharing practices that foster continuous improvements in the patient care that spay-neuter clinics and shelters provide.

Keywords veterinarian, spay neuter, complication, qualitative, thematic analysis, coping, adverse event

“I don’t feel the general public has any idea how deeply an ‘adverse event’ affects us.”(P-33)

Introduction

Every veterinary care provider experiences unexpected adverse events and complications, but little is known about the impact of these events on practitioners and on their work. In the past few years, there has been a growing body of research on human healthcare providers, including surgeons, and their reactions to and thoughts about adverse events in practice (Christensen, Levinson, & Dunn, 1992; Dekker, 2013; Luu, Patel, et al., 2012; Scott et al., 2009).  However, there has been no research specifically investigating veterinarians’ reactions and coping strategies for unanticipated serious, life-threatening complications or death in their patients.

Perioperative complications and deaths represent rare and serious but predictable consequences of performing surgery. Research on human healthcare practitioners has revealed that perioperative deaths can lead to feelings of guilt, responsibility, and self-blame, as well as grief and sadness (Luu, Leung, & Moulton, 2012; Ullstrom, Andreen Sachs, Hansson, Ovretveit, & Brommels, 2014) or even post-traumatic stress disorder (PTSD) (Wahlberg et al., 2016). Burnout and depression are also potential consequences of self-perceived errors (West et al., 2006), and burnout is commonly associated with poor performance, reduced quality of care, and increased error rates (Marmon & Heiss, 2015).

Several research articles on veterinarians have explored their attitudes, emotions, mental health, and coping in regards to the euthanasia of patients (Dickinson, Roof, & Roof, 2011; Fogle & Abrahamson, 1990; Morris, 2012a; Rujoiu & Rujoiu, 2014; Tran, Crane, & Phillips, 2014; Whiting & Marion, 2011). As after surgical adverse events, veterinarians performing euthanasia must manage their own emotions over the death of a patient, in addition to attending to the emotions of clients and staff (Morris, 2012b). The chief distinction is that with euthanasia, the clinician intends the patient’s death, whereas in surgical cases, they do not. The unintended patient death represents a clinical failure, leaving the clinician to cope with shock, self-doubt, and fears of their own incompetence  (Luu, Patel, et al., 2012). Thus, the reactions to and coping strategies for perioperative deaths could be expected to be different from those related to euthanasias.

Previous research has provided some predictions regarding surgeons’ coping with adverse events. In Luu, Patel, et al. (2012), accounts of surgeons in human healthcare reflected four phases in their reactions to adverse events, described as “kick,” “fall,” “recovery,” and “long-term impact.” During the kick, surgeons experienced feelings of failure along with a physiological stress response. The next phase, the fall, left the surgeons with a sense of loss of control and a desire to collect information to understand the adverse event. During the recovery phase, surgeons were able to reflect on the event and begin to move on. In the final phase, surgeons described the long-term impact of the cumulative effects of adverse events in their personal and professional lives. In an earlier paper, Scott et al. (2009) set forth three potential paths that healthcare providers may follow during this final, long-term impact phase: dropping out, surviving, or thriving. Dropping out involved leaving the field, or even the profession; surviving involved staying in the field and performing adequately but being plagued by the event; thriving described workers who had made some good come of the adverse event and had made peace with it. However, neither study sought to describe the personal, behavioral, professional, and emotional factors that determined or predicted which path the long-term impact would follow.

High-quality, high-volume spay-neuter (HQHVSN) provides an interesting and intensive context in which to study veterinarians’ reactions to adverse events. HQHVSN clinics are “efficient surgical initiatives that meet or exceed veterinary medical standards of care” while providing sterilization to large number of cats and dogs (Griffin et al., 2016). HQHVSN veterinarians most often work in animal shelters, or in clinics devoted primarily to spay-neuter. In HQHVSN, the high volume of surgeries performed means that, even in clinics with exceptionally low mortality and complication rates, some perioperative deaths and other serious adverse events will occur. The schedule of many spay-neuter and shelter clinics makes it difficult or impossible to interrupt the work schedule for debriefing and time away despite the fear, grief, or self-doubt that can occur in the wake of serious adverse events, and the limited variety of surgical procedures performed in HQHVSN means that veterinarians will often be expected to perform the same procedure in a similar patient to the one involved in the adverse event. Thus, in order to remain content and productive in this field and to provide the best patient care possible, practitioners generally must become adept at coping with adverse events.

The purpose of this research was to explore the experiences and reactions of spay-neuter veterinarians after serious adverse patient events (life-threatening complications or death) related to spay-neuter. This investigation sought to understand the ways that veterinarians react to these events, talk about them, think about them, and cope with them, both in the immediate aftermath of the event as well as in the context of their ongoing work in the field, with a particular interest in the factors, practices, activities, and patterns of coping associated with resilience and positive long-term impact. Understanding as much as possible about how veterinarians react to and process adverse events could be a vital tool for veterinarians’ self-care as well as for making continuous patient care improvements, and supporting and retaining veterinarians in the field of HQHVSN.

Methods

Questionnaire

Invitations to participate were posted on the HQHVSN Veterinarians (High-Quality, High-Volume Spay-Neuter Veterinarians) Yahoo Group on 13 April 2016, and on the Association of Shelter Veterinarians (ASV) electronic forum on 16 April 2016. The HQHVSN Veterinarians Yahoo Group is an electronic mailing list and forum with approximately 350 members as of April 2016. The ASV electronic forum is open to all 600 ASV members, but active participation on this forum is limited and the invitation to participate was viewed fewer than 26 times. Many individual veterinarians have access to both groups. Invitations contained a link to an online electronic survey, and recipients were encouraged to forward the link to others who might be interested. Responses were collected from 13 April through 31 May, 2016.

The online survey was administered using Survey Monkey, a web-based survey service. Survey responses were anonymous and IP addresses were not collected. Participants were directed to complete the survey only once. Participants were asked to confirm that they were veterinarians, and to confirm their consent to participate. This consent included permission to use quotes from participants in the write-up or presentation of this material after removal of any potentially identifying information. Participants were directed that they could withdraw from the study at any time during their completion of the questionnaire by closing the survey window to exit the survey.

The questionnaire included two sections: a brief demographic section, and a longer section containing essay-type questions. Demographic information collected included gender, veterinary school graduation year, and number of years in spay-neuter. Twenty-two essay-type questions related to the participants’ emotions, thoughts, experiences and actions after adverse events (defined as serious, life-threatening complications or death). These essay questions were based on the interview template used in Luu, Patel, et al. (2012) in their study of surgeons in human healthcare and their reactions to adverse events. Additional questions were added to this survey based on author’s experience as a HQHVSN veterinarian, prior in-person and electronic conversations with other veterinarians regarding adverse events, and general knowledge of HQHVSN practice. Topics for questions included general reactions, conversations, self-care, self-doubt, workplace support, effects on work, and social context (See Table 1).

Only respondents who reached the last page of the survey were included; those exiting prior to the last page were considered to have withdrawn from the study.

Analysis

Survey data were uploaded into Dedoose qualitative and mixed-methods software. Thematic analysis was conducted as described by Braun and Clarke (2006). The veterinarians’ responses were coded inductively for semantic themes using a realist approach without pre-existing theoretical framework. An iterative approach to analysis was followed, starting by applying codes to meaningful text units within each survey. The same unit of text could have several different codes applied. Next, similar codes were grouped together, slowly working up to more general categorizations and statements, and finally into larger themes. A reflexive approach was used throughout the study. Personal memos were recorded throughout the analysis process, as the author, a spay-neuter veterinarian herself, reflected on her own experiences with and reactions to patient deaths in spay-neuter practice. The analysis that emerged was then presented to an interprofessional conference audience containing veterinarians, managers, and psychology professionals[i] whose questions and critiques were used in verifying and refining themes and descriptions.

Results

A total of 32 completed responses were received, representing a response rate of 8.5% of those subscribed to the electronic distribution lists on which the invitation was posted. Participants had been working in spay-neuter a median of 8 years (range 6 months- 30 years), and had graduated from veterinary school a median of 17 years ago (range 1 year- 37 years). Respondents included 30 (94%) female and 2 (6%) male veterinarians. The gender distribution of veterinarians working in spay-neuter has not been reported, but in previous studies of shelter veterinarians (Haig & Spindel, 2011) and of spay-neuter veterinarians (White, 2013) respondents consisted of 89-90% females and 10-11% males.

Some participants provided detailed and specific responses, while others presented more general answers to the survey questions. Many responses revealed considerable self-awareness and introspection on the part of the veterinarians while discussing their reactions to adverse events.

Participants experienced immediate and visceral reactions to adverse events, equivalent to the “kick” and “fall” phases described by Luu, Patel, et al. (2012). These reactions evolved over time to reflect participants’ long-term resilience, or to be experienced as recurrent trauma. These long-term responses were similar to the dropping out, surviving, or thriving paradigm described by Scott et al. (2009). Four factors seemed to shape this long-term outcome: Technical Learning, Perspective and Appraisal, Support and Collegiality, and Emotional Learning (see Figure 1).

Figure 1: Thematic map of spay-neuter veterinarians’ responses to serious adverse events.

Reactions

Veterinarians’ reactions included the physiological, cognitive, and emotional aftermath of the adverse event. These reactions represent universal, normal responses, and varied little between respondents. The first reaction described by nearly all veterinarians was anxiety and stress similar to a fight or flight response, consistent with the “kick” phase described by Luu, Patel, et al. (2012).

I immediately felt guilt, remorse, nausea and, in general, like running away. Literally. (P-08)

In the moment it is horrible and I am scared for both the animal and for the owner.  Feels like hot lava coursing through my body.  Generally don’t sleep that night, wake up anxious. (P-25)

During this phase, some veterinarians noted cognitive effects:

I am often cloudy-headed for the rest of the day after a major complication. I don’t like making important decisions until at least the next day. (P-08)

It is definitely on my mind the rest of the day at work – kind of like static in my brain. (P-13)

Few veterinarians routinely cut their work day short in the wake of an adverse event. Many described being able to manage their immediate, physiological reactions and continue to perform at work. For some, this challenge was brought about by perceived necessity:

Right when the event occurs/is noted I feel like I was hit by a truck. But, being the veterinarian, I have to keep it together and move forward in a logical/productive manner. Inside, my stomach is in my throat and I want to flee the situation. I typically go home after these types of experiences and cry/talk to my husband. (P-08)

Others framed this short-term compartmentalization as beneficial and calming:

I use surgery as therapy to think. If anything, it makes me extra, extra careful and mindful the rest of the day. I tend to mentally compartmentalize the traumatic event to deal with it later. I have the mindset that other lives are waiting to be saved, the show must go on. After work is when I finish processing everything in my head. (P-17)

During the evening of the adverse event, many veterinarians described seeking distractions to get them through the intense feelings generated during the “kick” and “fall” phases. Some walked with their dog; some engaged in vigorous exercise; some played video games; some drank alcohol. The distractions utilized during this initial time period did not appear to prevent later effective coping, but instead seemed to be designed to mitigate the immediate, intense physiological and emotional reactions to the event.

Empathy

Many respondents described an immediate empathy for owners or caretakers whose animals had been affected, as well as for other staff involved in the adverse event. Some described their attunement to owners’ emotions as compounding their own emotional reactions after the event:

I would say that I feel more profound emotions when there is an owner involved who is emotionally bonded to the animal. I am sensitive to that bond as I can empathize. It makes me feel even worse because instead of feeling bad for the animal alone, I am now feeling bad for the animal’s family as well. It doesn’t change the “value” of the animal’s life to me. (P-32)

For some veterinarians, their sensitivity to owners’ sorrow made them dread interaction with owners:

Wow – the death of an owned animal makes me lose my mind. Having to tell an owner what happened is nearly impossible for me and I am sick for days. (P-33)

Other participants made a point of reaching out to bereaved owners, and used this contact as a part of their own healing routine:

There is an aching sadness the next day and I often continue to pray for the family, thinking how their pain must be so much worse than my own. I always send sympathy cards when a patient dies, and often I feel like I can mentally give myself permission to “move on” once the sympathy card is sent. (P-17)

Long-term impact: Resilience or Trauma?

Over time, participants’ immediate emotional reactions to adverse events evolved to reflect long-term resilience, or to be experienced as recurrent trauma. The four factors that appear to shape this long-term outcome include Technical Learning, Perspective and Appraisal, Support and Collegiality, and Emotional Learning.

Technical Learning

Nearly every participant mentioned that learning about the technical aspects of patient care is an important part of moving past an adverse event.

If I can learn why something happened and what to do different next time, then I think I am more confident at dealing with a similar problem the next time. (P-10)

there is always something to learn from these mistakes and that is the most important lesson I walk away with.  knowing I am now wiser and will be more cautious in these circumstances helps me deal with any feelings of guilt. (P-20)

Conversely, failing to learn from the event, or failing to know how to avoid it in the future, was an important source of anxiety for some and may have contributed to experiencing the event as traumatic:

I typically review procedures/protocols after an adverse event and make modifications if one or more areas are identified as possible sources of concern. The most frustrating thing is not knowing what went wrong to be able to make changes. (P-08)

Although hearing “yeah, I’ve had that happen to me” (by another vet e.g.) helps the emotional part it doesn’t help with what I really need i.e. what do I do wrong that causes this oozing and how can I prevent it.  No one seems to be able to help me with that….although I don’t talk about it much either. (P-25)

Perspective and Appraisal

Participants used a variety of frames of reference to put the loss in some larger context. This contextualization appeared to mitigate the traumatic effects of the adverse event on the veterinarian. In some cases, this larger frame is the perspective of the spay-neuter program itself:

I try to remember the thousands of animals who benefited from my serving as their veterinarian, even if only briefly via a spay/neuter program. (P-06)

In some cases participants found perspective through their religion or religious beliefs:

These [Christian] songs speak to the emotions I feel and give me a renewed sense of hope and peace.  They remind me that one day, it’s all going to be ok. (P-17)

And in some cases participants used the perspective of their life as a whole, noting that their life and identity is bigger than their work as a vet:

My conversations with my best [friend] from vet school are always the most helpful. We understand each other. And the most helpful thing that she offers me is perspective… we remind each other of how much more there is to us and our lives than our being veterinarians. That we are human and we have faults and imperfections like everyone else. And that when push comes to shove we are so much more than what we do for a living. We love what we do but we both remind ourselves that we want our legacies to be more than being veterinarians. Our children, our families and other causes are bigger than any single sad outcome (which usually likely would have happened regardless of our involvement). (P-30)

Each of these approaches to finding perspective served to place limits on the perceived magnitude of the adverse event, while not minimizing or making light of the event itself. This re-framing appeared to be a way of interrupting the intrusive reflections typical of the “fall” phase described by Luu, Patel, et al. (2012) and moving on with recovery.

Another aspect of perspective-finding that affected resilience and recovery from adverse events in some veterinarians was the appraisal of blame for the adverse event. For some veterinarians, the perception of being not at fault for the event mitigated or reduced the intensity and duration of their negative feelings, whereas perceived responsibility for the event intensified and prolonged their reactions.

If not my fault, I usually handle it much, much better.   Meaning after necropsy, if I find an underlying cause not a direct result of surgery but because of something physically ailing the patient prior to surgery, I do not have those doubts.  I just feel sad about the situation. (P-17)

If the adverse event was your fault, you have to deal with self-doubt, facing your peers each day at work (wondering what they think of you, or maybe worse, knowing), dealing with the possibility that you killed a healthy animal etc. If the adverse event was not your fault, you just chalk it up to the vagaries of medicine, but you don’t have to deal with feeling bad about yourself. (P-27)

Other respondents stated that their perception of responsibility did not affect their reactions to adverse events, and some found the distinction moot, stating:

I can’t think of an adverse event where I didn’t feel I was at least partially responsible. (P-15)

Support and Collegiality

The third factor that appeared important for determining the long-term impact of adverse events was talking with others and experiencing their support and collegiality. Some participants preferred to speak with family or friends, particularly about the emotional impact of the adverse event. For others, conversations with and support from colleagues was essential:

for me, i think i have to talk with another veterinarian. we are ultimately responsible for these lives; losing an animal is one thing but being the responsible trusted person and losing that animal adds another level. Unless one has that responsibility, they don’t really know how bad it is on more than just one level. (P-23)

Even when colleagues were physically distant, many respondents found satisfactory ways to communicate and experience support and collegiality:

I appreciate having the HQHV and shelter vet list serv as I learn so much from other people’s experiences and it make[s] me feel less isolated.  There are no other shelters or shelter vets close by to commiserate with so I appreciate reading other shelter vets comments.  its nice to know I am not alone and the challenges I face are not unique to me! (P-20)

Receiving support in the workplace was also important for many respondents. For some, poor support from management and colleagues stifled communication and decreased veterinarians’ ability to learn from the event:

Very little [support] from management.  Moderate from most colleagues.  One in particular is very blaming and negative, and she is really hard to be around and be vulnerable.  So when she is around, not much sharing/ discussing goes on. (P-26)

Feelings of shame and guilt affected the willingness of some participants to discuss the adverse events, or shaped which aspects of adverse events the veterinarians were willing to discuss. One described her reluctance to talk about technical matters:

Usually [I don’t talk about] the technical issues if I feel I was at fault, because then I don’t want to think about it or even bring it up – it is too painful. (P-33)

Conversely, a different veterinarian who was willing to discuss the technical aspects felt uncomfortable or inappropriate discussing emotional issues:

I only discuss the technical issues.  I always feel the emotional part is my own personal problem for me to deal with myself. (P-22)

While few respondents described such stark preferences, a hesitation to discuss adverse events was common among those experiencing more distress or less resilience in the aftermath of adverse events.

Emotional learning

Through experience, some participants described that they had learned how to handle and support themselves through an adverse event. Over time, these veterinarians have learned what to expect from themselves after adverse events, including what they typically experience and the timescale for that experience.

I remember all the adverse events i’ve ever had, but the painful feelings (repetitive thoughts about the event, visualizations, guilt, sadness) which used to take months to disappear now only last a few days where they are intense. (P-31)

Sometimes this emotional learning was a conscious, deliberate skill acquisition process:

Accepting what is (a skill I have leaned through mindfulness meditation) has helped me tremendously. I am able to keep from wishing the outcome had been different, forgive myself if I made any mistakes, and keep from ruminating on the event. In addition, having a whole set of self-care skills that keep me resilient. (P-24)

For some it took a balance of confidence and humility to face the relentless possibility of not knowing, or of doing harm while trying to do good. This veterinarian has learned to anticipate and manage her emotions in the face of uncertainty:

The harder feeling to deal with is the change to feelings of self-doubt that comes next. To me, that is the hardest thing to deal with in spay neuter, especially if doing a lot of large animals, in-heats, pregnants, debilitated etc, and it never goes away. You just learn to manage it. Because no matter how well you do your job, eventually, something unexpected will happen. And no matter how well you try to be competent, you will eventually face something you’ve never seen or dealt with before. (P-27)

However, for some veterinarians, this balance was impossible, and instead of resilience they experienced the adverse events as traumatic:

Absolutely [I doubt myself]. Almost every time. It makes me question why I became a veterinarian. It can be really debilitating. (P-08)

Trauma

For some veterinarians, the long-term effects of their experience of adverse effects made continuing to work in the field painful and difficult. These individuals represent the “dropping out” pathway described by Scott et al. (2009). Some had moved on to other areas within veterinary medicine:

Whether it’s anesthesia related or human error or surgical complication it wears on you and it’s been one component that I chose not deal with anymore and have taken myself from surgery and put myself on medical side because the pressure to do good work and fast and all is too great (P-03)

Others still in the field contemplate leaving the field, or even leaving the veterinary profession entirely:

Every day after my first patient passed away years ago I have questioned whether this job is for me and have always kept an eye open for other job opportunities….I start looking for other career opportunities because I feel I shouldn’t be a vet anymore.  I’m doing something wrong and I don’t want to have to deal with the guilt anymore….The only thing I’ve found [that helps] is an alternative means of pursuing my career where I won’t be a danger to any more animals. (P-22)

The statements of self-doubt in the above quotation represented this veterinarian’s self-perception rather than the reality of her practice: she estimated that she has just one serious complication or mortality per year.

Discussion

In the human healthcare literature, the term “second victim” has been applied to the care provider involved in an adverse event (Seys et al., 2013; Wu, 2000). These second victims experience emotional and sometimes physical distress as a result of the adverse event, and may question their own clinical skills, knowledge, and professional identity, and may experience feelings of guilt, shame, helplessness and inadequacy (Hall & Scott, 2012; O’Beirne, Sterling, Palacios-Derflingher, Hohman, & Zwicker, 2012). Perceived major medical errors have been associated with burnout, lower mental quality of life, and symptoms of depression (Shanafelt et al., 2010) and suicidal ideation (Shanafelt et al., 2011). Some second victims experience acute traumatic stress (Pinto, Faiz, Bicknell, & Vincent, 2014) or even PTSD (Wahlberg et al., 2016).

The coping strategies used by veterinarians in the current study contain some similarities to those described previously in veterinarians coping with performing euthanasia (Morris, 2012a). Both groups describe the importance of social support from colleagues, gaining perspective or distancing oneself, and emotional learning. However, the autonomic reactions, the feelings of shame and self-doubt, and the focus on technical learning appear specific to those coping with unexpected adverse events.

Veterinarian wellness and mental health have received an increasing amount of attention recently within the profession (Brannick et al., 2015). Veterinarians overall appear to be no more at risk for mental illness than those in the general population, but certain subgroups of veterinarians—young, female veterinarians, and those who work alone rather than with others—are at higher risk than other veterinarians for suicidal thoughts, mental health difficulties, and stress (Nett et al., 2015; Platt, Hawton, Simkin, & Mellanby, 2012). Further, veterinarians are about four times more likely to die by suicide than those in the general population, and twice as likely as other medical practitioners (Bartram & Baldwin, 2010). While there is no published data about mental health specifically in spay-neuter veterinarians, shelter veterinarians (many of whose  work consists primarily of spay-neuter) do appear to be at higher risk for serious psychological distress (Nett et al., 2015). Further, many shelter and spay-neuter veterinarians are young and female (Haig & Spindel, 2011; White, 2013) and work apart from other veterinarians, placing them in a higher risk demographic.

It is unknown to what extent the experience of serious adverse events in practice affects the mental health and burnout experienced by veterinarians. In one study, veterinarians ranked “demands of practice” and “making professional mistakes” among their top three stressors associated with veterinary medicine (Nett et al., 2015). Based on this information as well as studies of second victimhood in human healthcare providers, it appears likely that serious adverse events negatively impact veterinarians’ mental health. Studies like the current one could prove helpful for veterinary and human healthcare providers by supplying a language and background for insight into their responses to serious adverse events (Luu, Leung, et al., 2012). Understanding and normalizing what practitioners experience may mitigate the negative impact of these reactions, and may help shape their responses in ways that allow more effective coping.

One important difference between veterinary and human healthcare providers is the extent to which institutional or legal inquisitions occur after an adverse event. In human healthcare settings, second victims are often subject to accident investigations and legal proceedings (Scott et al., 2009; Wu & Steckelberg, 2012) that add to their distress symptoms. Such investigations are less common in veterinary practice, and were rarely mentioned by participants in the current study. Similarly, only about 10% of veterinarians in a previous study listed “fear of malpractice litigation” as a stressor in practice (Nett et al., 2015).

Medical and veterinary schools do not commonly offer any training in regards to medical errors and adverse events, their professional consequences, and the emotions they can induce (Venus, Galam, Aubert, & Nougairede, 2012). Many surgeons remain uncomfortable with candid discussion of deaths, errors, mistakes, and mishaps (Wu, 2000), and regard adverse events or errors as sources of shame. Unfortunately, not only may this avoidance negatively impact practitioners’ mental health and coping, it may also impede progress in improving patient safety. Studies of organizational safety have identified High Reliability Organizations (HROs), which are organizations in which accidents rarely occur despite the hazardous nature of the work (Reason, 2000). HROs are able to reduce adverse events in part by being preoccupied with them, using adverse events and “near misses” to gain insight into the strengths and weaknesses of their systems (Christianson, Sutcliffe, Miller, & Iwashyna, 2011). Those working in HROs do not become complacent when mishaps are rare, but continue to question and improve existing protocols, and to approach their work with a wary mindfulness of the possibility of failure, along with a belief in their ability to surmount obstacles (Vogus, Rothman, Sutcliffe, & Weick, 2014).

Thus, in order to create the safest, most reliable organizations possible, it is essential that practitioners feel comfortable and safe thinking about and discussing adverse events. Luu, Patel, et al. (2012) address this cultural shift in surgery when they write, “As a profession, is it possible to strive for perfection and accept and embrace failure transparently when it occurs?” Fortunately, this approach squares well with the current study’s findings that learning from and discussing adverse events with colleagues are positive coping methods.

In clinics and institutions, management and administration can play a role in practitioners’ experience of and recovery from adverse events. Managers should avoid blame and shame, and strive to create a supportive environment that values learning. In the current study, veterinarians with poor support from managers expressed reluctance to discuss adverse events and sometimes feared for their jobs. Managers’ and administrators’ handling of adverse events may influence whether the clinician feels safe in reporting an error or event, and thus may play a role in identifying causes for the event (Seys et al., 2013). Management and staff can work together to evaluate cases of complications and mortality and assess areas of concern to find gaps in protocols, training, staffing, or other factors. In addition, veterinarians and managers should study, learn from, and commend instances of successful recovery from or avoidance of adverse events.

Formal peer support programs for clinicians coping with emotional stressors may be possible in larger institutions (Hu et al., 2012); however, most veterinarians work in smaller institutions or in settings with few veterinarians who perform similar work. For those who work in facilities without access to peers, electronic mailing lists and online forums are a resource to allow communication with veterinarians in similar practice areas, and access to these resources should be encouraged and facilitated.

Staff education and learning and routine examination of clinic protocols is important, both in the wake of adverse events and when all is well. Supporting veterinarians’ connections with colleagues can provide both emotional and technical support for veterinarians at any stage in their career, but particularly for those new to their area of practice. As the following quotation shows, this type of support and mentorship may appear out of reach in some workplaces; however, the surgical and emotional skills and support may ultimately pay for themselves in improvements in performance, patient safety, and career longevity.

I personally would like to have more mentoring from more experienced vets, especially if an adverse event was due to inexperience. That is almost impossible with high volume, at least, given the business model of the clinic where I work. There is simply not enough time, or staff resources, given the very real need to devote time to activities that bring in dollars (i.e. surgery) versus mentoring, meeting etc. (P-27)

Individually, veterinarians may benefit from professional training in the skills needed for performance while under stress (Arora et al., 2010), early recognition of danger and error-recovery (Patel et al., 2011), and self-care and resilience (Brannick et al., 2015). In addition, individuals can work to care for their own mental and physical health in order to promote resiliency, decrease stress, and prevent burnout (Marmon & Heiss, 2015). In the current study, some participants benefitted from mindfulness training, and many described exercise as a way to handle the immediate emotional and physiologic reactions to adverse events. In addition, study participants noted that having a rich life outside of veterinary medicine enhanced their resilience after adverse events, both for the support provided and for perspective-finding.

Although the  small, self-selected group of respondents in this study limits its generalizability, their responses provide a basis for future research into effective interventions in veterinary education or in practice. Understanding how spay-neuter veterinarians react to, think about, and move on from adverse events could be a vital piece of supporting the health and welfare of these skilled workers and retaining them in the field. Increasing awareness of the complex effects of adverse events on spay-neuter veterinarians may help decrease the shame and self-doubt experienced by many, and may encourage information-sharing practices that foster continuous improvements in the care that spay-neuter clinics and shelters provide and in the health and welfare of the animals they serve.

a National Council on Pet Population & Society of Animal Welfare Administrators 2016 Research Symposium – “Solid, Stretched or Broken?: the Human-Animal Bond.” November 15, 2016, Hilton Portland & Executive Tower, Portland, OR

References

Arora, S., Sevdalis, N., Nestel, D., Woloshynowych, M., Darzi, A., & Kneebone, R. (2010). The impact of stress on surgical performance: A systematic review of the literature. Surgery, 147, 318-330, 330 e311-316. doi: 10.1016/j.surg.2009.10.007

Bartram, D.J., & Baldwin, D.S. (2010). Veterinary surgeons and suicide: A structured review of possible influences on increased risk. Veterinary Record, 166, 388-397. doi: 10.1136/vr.b4794

Brannick, E.M., DeWilde, C.A., Frey, E., Gluckman, T.L., Keen, J.L., Larsen, M.R., Mont, S.L., Rosenbaum, M.D., Stafford, J.R., & Helke, K.L. (2015). Taking stock and making strides toward wellness in the veterinary workplace. Journal of the American Veterinary Medical Association, 247, 739-742. doi: 10.2460/javma.247.7.739

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi: 10.1191/1478088706qp063oa

Christensen, J.F., Levinson, W., & Dunn, P.M. (1992). The heart of darkness. Journal of General Internal Medicine, 7, 424-431. doi: 10.1007/bf02599161

Christianson, M.K., Sutcliffe, K.M., Miller, M.A., & Iwashyna, T.J. (2011). Becoming a high reliability organization. Critical Care, 15, 314. doi: 10.1186/cc10360

Dekker, S. (2013). Second victim: Error, guilt, trauma, and resilience. Boca Raton, FL: CRC press.

Dickinson, G.E., Roof, P.D., & Roof, K.W. (2011). A survey of veterinarians in the us: Euthanasia and other end-of-life issues. Anthrozoös, 24, 167-174. doi: 10.2752/175303711X12998632257666

Fogle, B., & Abrahamson, D. (1990). Pet loss: A survey of the attitudes and feelings of practicing veterinarians. Anthrozoös, 3, 143-150. doi: 10.2752/089279390787057568

Griffin, B., Bushby, P.A., McCobb, E., White, S.C., Rigdon-Brestle, Y.K., Appel, L.D., Makolinski, K.V., Wilford, C.L., Bohling, M.W., Eddlestone, S.M., Farrell, K.A., Ferguson, N., Harrison, K., Howe, L.M., Isaza, N.M., Levy, J.K., Looney, A., Moyer, M.R., Robertson, S.A., & Tyson, K. (2016). The association of shelter veterinarians’ 2016 veterinary medical care guidelines for spay-neuter programs. Journal of the American Veterinary Medical Association, 249, 165-188. doi: 10.2460/javma.249.2.165

Haig, T., & Spindel, M. (2011). Asv veterinary wage survey 2011. https://asv.memberclicks.net/assets/docs/asv-veterinary-wage-survey-2011.pdf

Hall, L.W., & Scott, S.D. (2012). The second victim of adverse health care events. Nursing Clinics of North America, 47, 383-393.

Hu, Y.Y., Fix, M.L., Hevelone, N.D., Lipsitz, S.R., Greenberg, C.C., Weissman, J.S., & Shapiro, J. (2012). Physicians’ needs in coping with emotional stressors: The case for peer support. Archives of Surgery, 147, 212-217. doi: 10.1001/archsurg.2011.312

Luu, S., Leung, S.O., & Moulton, C.A. (2012). When bad things happen to good surgeons: Reactions to adverse events. Surgical Clinics of North America, 92, 153-161. doi: 10.1016/j.suc.2011.12.002

Luu, S., Patel, P., St-Martin, L., Leung, A.S.O., Regehr, G., Murnaghan, M.L., Gallinger, S., & Moulton, C.-a. (2012). Waking up the next morning: Surgeons’ emotional reactions to adverse events. Medical Education, 46, 1179-1188. doi: 10.1111/medu.12058

Marmon, L.M., & Heiss, K. (2015). Improving surgeon wellness: The second victim syndrome and quality of care. Seminars in Pediatric Surgery, 24, 315-318. doi: 10.1053/j.sempedsurg.2015.08.011

Morris, P. (2012a). Blue juice: Euthanasia in veterinary medicine. Philadelphia: Temple University Press.

Morris, P. (2012b). Managing pet owners’ guilt and grief in veterinary euthanasia encounters. Journal of Contemporary Ethnography, 41, 337-365.

Nett, R.J., Witte, T.K., Holzbauer, S.M., Elchos, B.L., Campagnolo, E.R., Musgrave, K.J., Carter, K.K., Kurkjian, K.M., Vanicek, C.F., O’Leary, D.R., Pride, K.R., & Funk, R.H. (2015). Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among us veterinarians. Journal of the American Veterinary Medical Association, 247, 945-955. doi: 10.2460/javma.247.8.945

O’Beirne, M., Sterling, P., Palacios-Derflingher, L., Hohman, S., & Zwicker, K. (2012). Emotional impact of patient safety incidents on family physicians and their office staff. Journal of the American Board of Family Medicine, 25, 177-183. doi: 10.3122/jabfm.2012.02.110166

Patel, V.L., Cohen, T., Murarka, T., Olsen, J., Kagita, S., Myneni, S., Buchman, T., & Ghaemmaghami, V. (2011). Recovery at the edge of error: Debunking the myth of the infallible expert. Journal of Biomedical Informatics, 44, 413-424. doi: 10.1016/j.jbi.2010.09.005

Pinto, A., Faiz, O., Bicknell, C., & Vincent, C. (2014). Acute traumatic stress among surgeons after major surgical complications. The American Journal of Surgery, 208, 642-647. doi: 10.1016/j.amjsurg.2014.06.018

Platt, B., Hawton, K., Simkin, S., & Mellanby, R.J. (2012). Suicidal behaviour and psychosocial problems in veterinary surgeons: A systematic review. Social Psychiatry and Psychiatric Epidemiology, 47, 223-240. doi: 10.1007/s00127-010-0328-6

Reason, J. (2000). Human error: Models and management. British Medical Journal, 320, 768-770.

Rujoiu, O., & Rujoiu, V. (2014). Veterinarians’ views on pet loss: Evidence from romania. Journal of Loss and Trauma, 20, 139-148. doi: 10.1080/15325024.2013.834759

Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Brandt, J., & Hall, L.W. (2009). The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care, 18, 325-330. doi: 10.1136/qshc.2009.032870

Seys, D., Scott, S., Wu, A., Van Gerven, E., Vleugels, A., Euwema, M., Panella, M., Conway, J., Sermeus, W., & Vanhaecht, K. (2013). Supporting involved health care professionals (second victims) following an adverse health event: A literature review. International Journal of Nursing Studies, 50, 678-687. doi: 10.1016/j.ijnurstu.2012.07.006

Shanafelt, T.D., Balch, C.M., Bechamps, G., Russell, T., Dyrbye, L., Satele, D., Collicott, P., Novotny, P.J., Sloan, J., & Freischlag, J. (2010). Burnout and medical errors among american surgeons. Annals of surgery, 251, 995-1000.

Shanafelt, T.D., Balch, C.M., Dyrbye, L., Bechamps, G., Russell, T., Satele, D., Rummans, T., Swartz, K., Novotny, P.J., & Sloan, J. (2011). Special report: Suicidal ideation among american surgeons. Archives of surgery, 146, 54-62.

Tran, L., Crane, M.F., & Phillips, J.K. (2014). The distinct role of performing euthanasia on depression and suicide in veterinarians. Journal of Occupational Health Psychology, 19, 123-132. doi: 10.1037/a0035837

Ullstrom, S., Andreen Sachs, M., Hansson, J., Ovretveit, J., & Brommels, M. (2014). Suffering in silence: A qualitative study of second victims of adverse events. BMJ Quality & Safety, 23, 325-331. doi: 10.1136/bmjqs-2013-002035

Venus, E., Galam, E., Aubert, J.P., & Nougairede, M. (2012). Medical errors reported by french general practitioners in training: Results of a survey and individual interviews. BMJ Quality & Safety, 21, 279-286. doi: 10.1136/bmjqs-2011-000359

Vogus, T.J., Rothman, N.B., Sutcliffe, K.M., & Weick, K.E. (2014). The affective foundations of high-reliability organizing. Journal of Organizational Behavior, 35, 592-596. doi: 10.1002/job.1922

Wahlberg, Å., Andreen Sachs, M., Johannesson, K., Hallberg, G., Jonsson, M., Skoog Svanberg, A., & Högberg, U. (2016). Post‐traumatic stress symptoms in swedish obstetricians and midwives after severe obstetric events: A cross‐sectional retrospective survey. BJOG: An International Journal of Obstetrics & Gynaecology.

West, C.P., Huschka, M.M., Novotny, P.J., Sloan, J.A., Kolars, J.C., Habermann, T.M., & Shanafelt, T.D. (2006). Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. Journal of the American Medical Association, 296, 1071-1078.

White, S. (2013). Prevalence and risk factors associated with musculoskeletal discomfort in spay and neuter veterinarians. Animals, 3, 85-108.

Whiting, T.L., & Marion, C.R. (2011). Perpetration-induced traumatic stress—a risk for veterinarians involved in the destruction of healthy animals. The Canadian Veterinary Journal, 52, 794.

Wu, A.W. (2000). Medical error: The second victim: The doctor who makes the mistake needs help too. BMJ: British Medical Journal, 320, 726.

Wu, A.W., & Steckelberg, R.C. (2012). Medical error, incident investigation and the second victim: Doing better but feeling worse? BMJ Quality & Safety, 21, 267-270.

Table 1: Contents of the questionnaire administered to survey participants regarding their experiences with adverse events in spay-neuter practice

General reactions

Recall a significant adverse event that you experienced. Describe your thought process after the event.

How do your reactions to or feelings about adverse events change over time, from right when the event occurs until the reactions disappear? How long does this process take for you?

Conversations

Do you talk with anyone about your adverse events? If so, who? (veterinary colleagues, co-workers, family, friends, therapist, clergy, etc…)

Do you use e-mail or an electronic forum or other written means to discuss your adverse events with others? If so, who? (veterinary colleagues, co-workers, family, friends, therapist, clergy, etc…)

If you talk or write to anyone, how long after the adverse event do you have these conversations?

If you talk or write to anyone, do you talk about technical issues related to the adverse event, or about emotions and coping with, thinking about, or dealing with adverse events (or both, or other topics)? If you both talked and wrote about the event, were the things you discussed the same or different?

Describe which conversations or interactions were helpful (if any). Who did you talk to? What did you talk about? What about it was helpful?

Describe what conversations or interactions were unhelpful or even made you feel worse (if any). Who did you talk to? What did you talk about? What about it was unhelpful?

Self-Care

Are there other ways (besides talking/writing to other people) in which you help yourself mentally and emotionally process adverse events? Examples could be meditation, prayer, recalling advice from mentors, listening to certain songs, reading certain books, essays, or poems, or engaging in physical activities. What was helpful to you, and why? If you have a favorite example of something that you find useful, please share it here.

Self-Doubt

Does experiencing an adverse event make you doubt yourself? If so, how? How long does this feeling continue?

Are your reactions different if you feel as though the adverse event was your fault?

Do you think your reactions to adverse events are typical of other vets in this field? In other areas of veterinary medicine?

Support

How much support do you feel at your workplace when adverse events occur?

If you have a boss or manager, is their handling of adverse events helpful to you or unhelpful? How?

If you are a boss or manager, do you do anything to help the rest of your staff handle an adverse event?

Effects on work

How do your reactions to adverse events affect your ability work, and your decision making at work? How does this vary over time (for example, on the same day as the adverse event, for the next week, and on).

How do your reactions affect your ongoing handling of the patient (if applicable), the next patient, or other similar patients? Do you often modify routines and protocols in the wake of adverse events?

Do you change work scheduling in the aftermath of an adverse event (that day, in future days)? If so, how? Why? Does it help?

Social context

How does the ownership status (e.g., owned pet, shelter animal, feral) of the animal involved in an adverse event affect your experiences and reactions to the adverse event?

Do you have a different emotional reaction if you know there are humans who are emotionally bonded to the animal involved in the adverse event?

How do you think the image of spay/neuter practice (in the public eye, or in the view of veterinary private practice) affects your experience of or communications around adverse events? Do you think you react differently in any way because you work in a high-volume spay-neuter setting?

Is there anything else that you would like to share regarding the topic of adverse events? Any additional comments?