Why support 'second victims'?

There is now a huge amount of evidence from different countries and across different professional groups that being involved in a patient safety incident, particularly one where the patient is seriously harmed or dies can be very distressing1. The feelings of guilt, shame, incompetence, anxiety that are reported to be experienced by the healthcare staff involved in these situations are heightened when the individual perceives it was possibly something they did or did not do which caused the patient safety incident. Of the 1,463 doctors we surveyed in the UK2, 76% believed the experience of a patient safety incident affected them personally or professionally. 74% reported stress, 68% anxiety, 60% sleep disturbance and 63% lower professional confidence. Moreover, 81% became anxious that they might doing something again in the future which could lead to another patient safety incident.

It is not only doctors who experience physiological distress after involvement in an incident. In another study3we found nurses showed higher levels of distress following a patient safety incident than doctors. For many, the emotional impact of being involved in an incident is short-lived, but for other individuals the effects are long-lasting. In our sample, 8% of doctors reported symptoms associated with post-traumatic stress disorder. This impact on the healthcare employees is the reason the term ‘second victim’ was coined. The emotional impact of being involved when something goes wrong are many, but there are other impacts too which make it so very important that employers, managers and colleagues don’t disregard, ignore, or even punish further the individuals involved.

There is evidence that distress and further loss of confidence can often exacerbated by the patient safety incident investigation process – and this can lead individuals to burnout, a state of hyper-vigilance and/or the practice of defensive medicine. Some ‘second victims’ may even choose to leave the profession, especially in the absence of timely and tailored support from those around them. From a moral standpoint, supporting people in distress is essential and this includes supporting healthcare employees involved in patient safety incidents. From a healthcare organisational perspective, there is a patient safety, a staff health and well-being, and financial imperative to do so.

Patient Safety Incident Response Framework

To support the NHS to further improve patient safety, NHS England and NHS Improvement are introducing a new Patient Safety Incident Response Framework4 (PSIRF). The PSIRF describes a new approach to patient safety incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than an approach which is feeds into a “framework of accountability”.

Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic and compassionate response to patient safety incidents which is anchored in the principles of openness, fair accountability, learning and continuous improvement. The plan for the introductory version of the PSIRF is for implementation by nationally appointed early adopters during 2021.

The PSIRF outlines how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. It clearly sets out how the needs of those affected by patient safety incidents – patients, families, carers and healthcare staff – are met.

Organisations must establish procedures to identify all staff who may have been affected by a patient safety incident and provide access to the support they need.

Second victim support systems

Appendix three of the PSIRF lists national sources of support for healthcare staff affected by a patient safety incident, and also signposts to this Second Victim Support website.

A 2021 Healthcare Safety Investigation Branch national learning report5 further highlights the need for support systems for staff. Figure 2 in the report describes some of the approaches which may be offered before and/or after involvement in a patient safety incident.

Many NHS organisations already recognise the need to improve the support they offer their staff after they have been involved in a patient safety incident and are looking at ways to achieve this. The case studies below are examples of support systems for staff in NHS organisations in England.

Case study 1 – Leeds Incident Support Team (Leeds Teaching Hospitals NHS Trust) – peer support service for second victims

Who?

The risk management office at Leeds Teaching Hospitals NHS Trust (LTHT)

What?

Support for second victims provided by staff members who have themselves been involved in an incident and have made a commitment to be available to talk to other staff in a similar situation.

LIST members are identified by badges with the LIST logo, and a central list of these staff members is held by the risk management office.  They have been trained to provide advice and support relating to the investigation process

Individuals who have been involved in an incident are able to approach any member of staff with a LIST logo for support, or contact the risk management office to be put in touch with someone.

The LIST function operates in addition to the Trust’s wider staff support offer including support from line managers, the Employee Assistance Programme (access to counselling), Clinical Psychology and the Occupational Health service.  If LIST members have concerns about a colleague’s health and well-being they have information to “signpost” the member of staff to these other services for help.

Further information:

Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Hahn-Cover, K., Epperly, K.M., Phillips, E.C. and Hall, L.W., 2010. Caring for our own: deploying a systemwide second victim rapid response team. Communication of Critical Test Results.

Case study 2 – Critical Incident Stress De-Briefing Team (Bradford District NHS Foundation Trust)

Who?

Twelve members of staff have completed training to receive accrediation as stress debriefers.

What?

Bradford District Care NHS Foundation Trust (BDCT) is committed to providing a timely and supportive response in the aftermath of serious incidents. The World Health Organization et al (2011) developed guidance on psychological first aid and the structured debriefing of those affected by stress situations and symptoms in the workplace. Critical Incident Stress Debriefing (CISD) is a recommended approach for supporting teams to have space to process their experience of the impact of serious incidents (Harrison & Wu (2017) and particularly focusses on how people are coping and can support one another to cope with that impact.

Full case study here.

Case study 3 - 'Time Out’ Group Peer Support Following Patient Safety Incidents (Leeds Teaching Hospitals NHS Trust)

Background

Staff working in acute paediatric care are at risk of experiencing Acute Stress Responses (ASR), Post Traumatic Stress Disorder (PTSD), moral distress and burnout (Prentice et al 2016; Jones et al 2019). ‘Time Out’ has been developed in Leeds Teaching Hospital NHS Trust in response to Paediatric Intensive Care staff requesting more support following involvement in and exposure to patient safety incidents.

Full case study here.