The RISE (Resilience in Stressful Events) Peer Support Program: Creating a Virtuous Cycle of Healthcare Leadership Support for Staff Resilience and Well-Being

Abstract

Healthcare leaders are responsible for creating an environment where their staff can maintain their resilience and well-being. However, there is a crisis of burnout among healthcare workers. The resulting increased turnover, diminished morale and performance, safety risks, and decreased worker engagement produces a vicious cycle of burnout. A strategic intervention is needed that focuses on worker wellbeing. This paper describes how the Johns Hopkins Resilience In Stressful Events (RISE) peer support program has helped healthcare leaders support their workers and strengthen the resilience of their organization. It explains the crucial role that leaders play in the success of the program. RISE peer was established at Johns Hopkins Hospital in 2011 to provide timely peer support for stressful patient and work-related situations. RISE helps break the cycle of healthcare worker burnout by providing peer support for stresses at work 24 hours a day, 7 days a week. This program structure also supports leaders by sharing the responsibility of emotional support and by providing them with new skills to do their job in a way that generates personal and professional satisfaction. The program has been implemented globally in over 140 healthcare organizations. Leaders are essential to integrate support and serve as role models. Institutions that successfully launch peer support programs engage leaders to participate in program design, participate in the program themselves, and adapt the program to meet the needs of their staff and organization. Peer support programs broaden the base of support for all healthcare workers by providing an employee-focused resource. Implementation of a RISE support model demonstrates an institution’s commitment to the overall health of the people it employs. Operational integration of the model conveys a positive impact on resilience at all levels of the organization, especially in institutions that broadly engage organizational leaders.

Plain Language Summary

Before the COVID-19 pandemic, burnout was a major concern for healthcare workers globally. Unfortunately, in the worst of the pandemic, the impact of burnout was greatly magnified.

In an attempt to mitigate the impact of healthcare worker burnout, in 2011 Johns Hopkins Hospital was among the first to implement an institutional peer support program, which was called RISE (Resilience In Stressful Events). Because of its pre-established presence, during the pandemic RISE was a primary source of mental, psychological, and emotional support, allowing healthcare workers to process their stressful experiences with a trained responder in a confidential, non-judgmental encounter. Leadership heavily relied on RISE to support them and their staff during these times of extreme duress.

Leadership advocacy for the creation and adoption of the RISE peer support program yielded a substantial return on investment in terms of the resilience of both individual workers and the organization. With active leadership support, the RISE program established a formal curriculum that trains hundreds of Johns Hopkins employees per year, and expanded into a standardized employee support program which has spread globally.

Peer support, as exemplified by RISE, helps health workers recover through difficult situations, and also serves as a resource for leaders. Leader engagement and buy-in are crucial for establishing an organizational peer support structure, and implementation and integration of a program into operations. Ultimately, leader engagement in peer support programs can result in culture change and strengthened resilience which benefit the individual, the team, and the organization.

Introduction

Healthcare worker burnout has been a topic of concern for more than a decade.¹ Occupational burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.² Research has also emphasized the potential risks of burnout for patient safety, with increased chances of error and liability for healthcare organizations.³ The COVID-19 pandemic exacerbated burnout and contributed to persistently high rates of turnover beyond the worst of the pandemic. The resulting global healthcare workforce crisis, which has been termed “The Great Resignation” represents a deficit in professionals that includes physicians, nurses, and other allied health workers. Healthcare leaders are now faced with the task of managing a healthcare workforce with diminished resources, fewer workers, and decreased morale.

Healthcare staff are accustomed to working under stressful conditions. In general, operating margins for healthcare organizations are slim, and available resources never seem sufficient to meet the need. Nursing units often operate with the minimum number of staff needed to manage the patient load. Medical trainees and providers work long hours to care for the inpatient and outpatient demands. This occurs within a complex healthcare ecosystem that was not intentionally designed with the emotional and physical well-being of healthcare workers in mind. Although everyone is working as hard as they can to care for patients while also sustaining themselves, the overall system was not designed to do both.

Many dedicated leaders, managers, and supervisors work diligently within this challenging context to simultaneously satisfy the needs of their patients and workers. Leaders from mid-level managers to the corporate leaders serve in many capacities: they are change-catalysts for culture, strategists for organizational goals and priorities, innovators, problem solvers, and coaches and are responsible for effective communication to and from the top and the bottom. Through their attitudes and actions, and the culture they convey, they can contribute to or reduce the wellbeing and resilience of their workers. With all of these variables in constant flux the potential always exists for the system to fall into a vicious cycle of health worker burnout, increased turnover, diminished performance, safety risks, worsened patient experience, and shrinking worker engagement.

This vicious cycle was managed with variable success before the COVID-19 pandemic. The increased stresses associated with the pandemic exposed the emotional, psychological, and physical impact on workers. Even in the absence of a crisis, leaders had struggled for more than a decade to reduce burnout and promote the well-being of their workforce.¹ The pandemic highlighted the urgent need to break the cycle and strengthen the resilience of individuals and systems, improve the health and well-being of workers, and deliver high-quality patient care.

The ongoing workforce crisis is multifactorial, and no single intervention can prevent, much less eliminate the phenomenon of burnout.¹ Many problems need to be addressed on individual, departmental, institutional, systemic, and societal levels. However, there is evidence that workforce perception of institutional support for health workers who experience unanticipated clinical events is associated with less emotional exhaustion, better safety climate, and improved assessments of local leadership.⁴ As safety climate is associated with patient outcomes, this could also reduce stress on healthcare leaders and improve the quality of care.

Peer support can be considered to be an evidence-based intervention to support the emotional wellbeing of workers. Despite this, there are barriers to providing workers with peer support in a health care institution. These include the stigma that surrounds the seeking of help in general, and counseling in particular; the lack of organized, confidential, accessible, and timely peer support; and the lack of trained peer supporters who can provide emotional first aid with the contextual knowledge of the unique experiences associated with the specialized setting of healthcare.

This paper describes work done over the last decade with the RISE (Resilience in Stressful Events) peer support program at Johns Hopkins Hospital. It highlights two key success factors for the implementation of RISE: the initial support for the concept provided by top leaders and managers, and the subsequent incorporation of leadership training and engagement into the broader implementation of RISE. The paper aims to encourage healthcare leaders to adopt person-centric modalities such as peer support that can enhance the resilience and well-being of their healthcare workforce, including the well-being of institutional leaders. The results of leadership buy-in and support for worker well-being could help to break the vicious cycle of workforce demoralization, and ultimately contribute to a positive culture where staff can cope effectively and thrive.

A Peer Support Team for Health Workers

Healthcare leaders cannot eliminate all of the stressors inherent in the process of delivering healthcare, but they can influence how institutions respond when unanticipated events inevitably occur. Leaders are well situated to integrate supportive structures and modalities into the healthcare setting. One attainable intervention for organizations, from clinic sites to multi-institution systems, is to incorporate intentional, resourced, thoughtfully organized peer support programs.

A growing body of literature indicates that organizational support structures can prevent, minimize, or relieve distress among healthcare workers.⁵ In 2016, Quillivan et al demonstrated a significant positive association of peer support with the successful attainment of safety culture in units that encounter high levels of stress.⁶ Peer support can be considered to be an evidence-based intervention to support the emotional wellbeing of workers. Despite this, there are barriers to providing workers with peer support in a health care institution. These include the stigma that surrounds the seeking of help in general, and counseling in particular; the lack of organized, confidential, accessible, and timely peer support; and the lack of trained peer supporters who can provide emotional first aid with the contextual knowledge of the unique experiences associated with the specialized setting of healthcare.

The Resilience In Stressful Events (RISE) program was established at Johns Hopkins Hospital in 2011 to support healthcare workers. At the time, aftershocks from the Josie King tragedy continued to reverberate throughout the institution.⁷ Top leaders were strongly committed to patient safety and convinced of the need to provide emotional support to healthcare workers. RISE was designed to provide timely peer support to healthcare workers who encounter work-related stressors including medical errors and adverse events, as well as day-to-day and unexpected stresses associated with providing care.⁸ After an initial pilot the RISE peer responder team and utilization of the program by health workers grew steadily. Hospital survey data from 2018 indicated that most nursing leaders were aware of the program, found it helpful, and had used the program for themselves and/or their staff.⁹ At the time, the RISE service routinely received approximately 10 requests per month and supported 20–40 workers per month.¹⁰ It was also shown that there was a financial benefit toward supporting and thereby retaining hospital workers.¹¹

The COVID-19 Pandemic: A Silver-Lining for Peer Support

RISE had been established as a model of peer support for nearly a decade when the COVID-19 pandemic struck the US in 2020.¹² As was true in most healthcare settings, the pandemic was accompanied by universal and unprecedented levels of distress in the Johns Hopkins community. RISE was well situated to provide timely support to thousands of first-line workers.¹³

A crucial element for the extraordinary increase in RISE volume was the full-throated endorsement of the program by those leading the COVID-19 Unified Incident Command Center, and top leaders across the Hopkins system.^14,15 Leaders took every opportunity to advocate for the use of peer support and encourage calls to RISE, going so far as to cite their personal use of the services. This played a critical role in normalizing the act of seeking help and accepting peer support.¹⁶

Additionally, members of the RISE team, together with members of the Office of Well-being, designed and provided an in-person and online tutorial focused on key elements of successful crisis communication. This tutorial, adapted from prior work in disaster areas, specifically targeted health system leaders and managers with helpful guidance about effective communication in the context of constantly evolving circumstances.^17,18 These sessions on structured communication ultimately reached over a thousand leaders and managers.

Benefits of RISE to Leaders and Managers

RISE has potential personal benefits for leaders and managers. Leaders use RISE training to enhance their ability to better support their employees. Given their broad scope of service and expectations, leaders contribute to the success of RISE across entire institutions. These same people who keep organizations running are also are key recipients of RISE support services because of the stressful, impactful, and often traumatic situations they face for themselves and the teams for which they have responsibility. Those who are trained in peer support can use these skills in their daily work, which helps them feel better equipped and more effective. Their use of skills and activation of support calls can bring presence, active listening, and empathy into daily interactions.¹⁹ Additionally, some leaders apply their knowledge and skills from the RISE training to advocate for the service and refer colleagues for appropriate emotional support.

Unit managers and other supervisors can also rely on RISE peer supporters from outside of their work area to provide appropriate emotional support to their workers, thus relieving them of the overwhelming responsibility of providing for every need of every employee. This can provide a measure of relief from demanding leadership expectations. An evaluation of RISE six years after its initial launch at Johns Hopkins found that nurse leaders who activated RISE were significantly more resilient than those who had not.¹⁰

RISE Implementation: Training of External Organizations

Leadership buy-in and engagement were critical to the development and utilization of the RISE program at Johns Hopkins. Experiences during the COVID-19 pandemic reinforced the observation that to lead from the podium and actively promote the use of RISE, leaders need a thorough understanding of the factors that influence resilience and well-being, and the tools that can be used for support. They must act as “influencers” on the institutional level demonstrating commitment to staff support programs, and their important role in the work setting.

Since 2015, the Johns Hopkins RISE team has partnered with the Maryland Patient Safety Center to help other healthcare organizations implement RISE for their workers. Since leader influence is essential, the RISE implementation curriculum is divided into two parts. The first part focuses on leadership training to help top leaders and managers grasp the fundamentals of a peer support program, establish a shared mental model among leaders in the organization, and begin to make decisions around program features and operations.

The leadership training was initially piloted in a large academic medical center and a small community hospital. Both types of organizations demonstrated the transferability of the leadership curriculum which has since been implemented in over 140 other healthcare organizations as diverse as veterinary associations, schools of nursing, and a state hospital association. Organizations are primarily based in North America but include Northern Europe and the Middle East. In some organizations, leaders also serve as RISE peer supporters. In others, leaders and managers are readied with a detailed knowledge of what to expect from a RISE encounter and use their knowledge and skills to advocate for the use of RISE.

Leadership engagement in the planning phase of a new RISE program allows leaders to discuss the cultural facilitators and barriers that impact the credibility of a peer support program as perceived by the healthcare workforce unique to their organization. Leaders begin to anticipate how to overcome the challenges and leverage the strengths of the organization. Participation by representatives from human resources and risk management promotes discussions about confidentiality and compensation of peer responders. Processes are discussed for identifying qualified candidates to serve as peer responders and strategies for recruitment. Typically, by the end of the implementation training day, leaders demonstrate motivation to invite staff or to serve personally on the new teams to support workers. Action items that advance program creation begin immediately after the initial leadership training. These are followed within weeks to months by the RISE peer responder training day.

Organizations with more engaged leader participants and diverse representation of staff in peer support implementation and peer responder training have demonstrated greater utilization and sustainment of the RISE peer support program in their institutions.

An Increased Culture of Wellbeing

Despite the officially declared end of the COVID-19 pandemic and reduction in levels of related acute distress, the crisis of healthcare worker burnout has continued. The embers of the pandemic have been fanned by what has been termed “The Great Resignation” which has resulted in pervasive under-staffing, reduced team functioning, and increased workloads. But there has been a sea change towards greater acceptance of support.¹⁶ Leaders have continued their increased focus on worker wellness, well-being, and resilience.

At Johns Hopkins Medicine, the RISE program that was once lightly utilized in the initial hospital has spread throughout the health system and today offers support to over 40,000 employees. Beginning in 2023, it has been extended beyond the inpatient hospital setting to the institution’s network of primary care ambulatory practices.

RISE peer support has had additional positive impacts on the institutional culture of well-being. For example, Johns Hopkins leaders, now aware of the effectiveness of the program, have integrated peer support into standard operating procedures for crisis response, such as the handling of an unexpected employee death. The integration of a RISE support model into operating procedures confirms a positive impact on resilience at all levels of the organization, specifically when there is broad engagement by organizational leaders.

Nurse leaders also advocated for physical space within the hospital to accommodate peer support encounters away from work areas. At the same time, there were requests from health workers for a space to uncouple from work, to seek respite, relax, and recharge. In academic health centers, physical space is often hotly contested and is generally difficult to secure. Nonetheless, top leaders in the hospital were willing to designate protected space where staff could recover before, during, and after work. The designated space is intended for individual use, as well as providing a place to connect with others. Staff can drop in or make a reservation and is available 24/7. The space includes a sensory room, a Tune Room, an art activity area, and a gathering space to promote social connection.²⁰ In the first 6 months, the space had over 7,000 uses, and the hospital is actively making plans to develop other similar spaces on campus.

Conclusion

Peer support has been demonstrated to be an effective strategy to reduce the impact of stress on healthcare workers. The RISE peer support program developed at Johns Hopkins has been embraced by leaders and managers, and has been integrated with other elements of healthcare operations, providing support to well over a 1000 workers per year. It has also been adopted by over 140 external organizations in the US and globally. In all of these cases, leadership engagement and buy-in have been crucial for the successful implementation of RISE. By active endorsement of the service, encouraging its use, approving enabling policies, and integrating it into standard operations, leaders have helped shift institutional culture towards greater emphasis on the wellbeing of workers.

Healthcare organizations should implement peer support programs as a way to interrupt factors that induce burnout and enhance the recovery and resilience of workers after stressful events. Leaders can be the main drivers for these strategies. Once a program has been established, broad engagement by organizational leaders and managers is critical to the integration and acceptance of those resources. Sincere endorsement of institutional support structures, conveying the expectation that workers should use them when they are needed, and personally modeling their use can acknowledge the impact of workplace stress and motivate the use of support. Leaders should also take steps to make it easy for workers to use those services by providing the necessary time and space. A fringe benefit for leaders is that RISE also serves as resource for them, by equipping them with skills and tools to support themselves and their staff, and helping them secure the trust of their workforce.

There is the potential for greater benefits for entire healthcare organizations. Effective leadership and peer support can lead to a healthier work environment, and happier and healthier workers. This could help reduce turnover rates and the stresses of overwork, and improve the functioning of care teams, creating a new virtuous circle that enhances safety and patient outcomes.

Future research should include the perceptions of leadership influence and support as it relates to support programs. It would be important to evaluate the direct impact on the staff who receive support through such programs. Research should also capture the perceptions of staff who are aware that they work for an organization with such support structures, even if they have not utilized the support.

Implementation of a peer support program like RISE will not eliminate burnout among individual workers. It will not relieve all the challenges of leadership in the healthcare setting. But it can broaden the base of support for all healthcare workers by providing another trusted and dependable employee-focused resource. Implemented well, peer support programs demonstrate an institution’s commitment to the overall health of the people it employs. Establishing a support structure like RISE can help to interrupt the vicious cycle of worker burnout that plagues healthcare.

Disclosure

The authors report no conflicts of interest in this work.