Second victims are healthcare employees who are involved in an unanticipated adverse patient event, a medical error and/or a patient-related injury and become victimized in the sense that the employee is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have let the patient down, second-guessing their clinical skills and knowledge base1.
The impact on the employee can be considered in two areas:
For many healthcare employees, being involved in a significant patient safety incident is an intensely emotional time. Feelings of distress, self-doubt and fear are common and may persist long after the original incident. These may be accompanied by physical symptoms, such as sleep disturbance, or difficulty concentrating.
For some individuals, involvement in a patient safety incident contributes to the development of mental health issues, including depression, anxiety and post-traumatic stress disorder.
Involvement in a patient safety incident can also affect an individual’s ongoing work in healthcare. Reduced professional confidence is common, and those involved may make defensive changes to their practice, such as avoiding similar situations or patients with similar presentations. Becoming a second victim can increase the risk of burnout, and may result in individual's having thoughts of leaving their profession.
A healthcare employee who has experienced a patient safety incident or a near miss may wish to take constructive action to prevent further similar incidents from occurring. This might be through improving safety measures or changing a process to make it less likely that the same incident could happen again. It might be through highlighting or reducing risks as they present or through putting in place steps to mitigate the risks identified.
Patient safety incidents are much less likely to occur again if there is constructive learning and changes are implemented.
A healthcare employee involved in a patient safety incident can experience significant impact, both personally and professionally. It is therefore important that we understand both Who can become a second victim and How many are affected?
Who can become a second victim?
A second victim is a healthcare employee who experiences personal or professional impact as a result of involvement in a patient safety incident. This means that any employee who may be involved in a patient safety incident could become a second victim. The majority of research to date has focussed on the experiences of doctors, and more recently nursing staff, as second victims. However, where support for second victims has been put in place, it has been accessed by a wide range of professionals, including pharmacists, social workers, allied health care professionals, non-professional body registered staff including healthcare support workers, technicians and administrators.
How many?
Estimates vary, but it is possible that up to 50% of healthcare employees have experience of being a second victim. Given that the NHS is one of the world’s largest employers, this means that potentially hundreds of thousands of people across the UK are affected, yet at present there are very few specific support services available.
Over the last two decades, much research has been done to understand the issues second victims face, and how the impact on second victims can be alleviated. This research can broadly be considered under the following questions:
Professor Albert Wu2 first coined the phrase ‘second victim’ in the 1980s to describe those who suffer emotionally when the care they provide leads to harm. The impact of patient safety incidents on patients and families remains the primary concern, but the effect on individual healthcare employees and teams is now widely recognised. Figures vary but up to 50% of healthcare staff report experiencing an incident in which they considered themselves to be a second victim2.
Our systematic review3 found consistent evidence of an intense emotional response following an error with subsequent impact on the personal and professional lives of staff. This includes acute stress disorder2, suicidal thoughts or even suicide4. Differing responses to error by professional groups have been explored, with doctors in training2 and nurses3; 5 identified as at potentially greater risk although such impact is not limited to clinicians6. However, our most recent study7 found not all staff experience significant emotional distress in response to being involved in a patient safety incident, which points to personal resilience as a potential mitigating factor.
A six stage recovery trajectory is commonly experienced by second victims1. This includes:
This study also found that involvement in the planning and implementation of practice change or improvement as a result of the patient safety incident experience was associated with a positive response and recovery.
Systematic reviews have concluded more awareness is needed on the ‘second victim phenomenon’ health care leaders should introduce and evaluate strategies designed to provide supportive interventions for second victims 8,9. Existing knowledge is available to guide policy makers in developing effective support programmes10 and the consequences of not doing so include the potential for: ‘…a vicious cycle of adverse events, burnout, poor care, and more adverse events’4.
Various interventions have been developed in response to this growing understanding of the impact of patient safety incidents on second victims. These include:
The ForYou programme – based on The Scott Three-Tiered Interventional Model of Support”11. This is a system-wide, escalating approach to addressing the support needs of second victims using an on-demand emotional support rapid response team. The three tiers cover:
More recently the research focus has been on identifying the factors that confer resilience to emotional distress in this context. Our recent systematic review7 found the strongest support for:
Such findings have been used to inform the development of preventative interventions such as online programmes like MISE (Mitigating Impact in Second Victims)12 that are designed to raise staff awareness, and psycho-education programmes designed to help staff develop the positive psychological characteristics associated with resilience which can moderate the degree of distress when faced with a patient safety event.
What might be the future second victim research priorities?
Evaluation of the impact of second victim support interventions is ongoing along with the need for further research to determine if the provision of effective emotional support for second victims actually does lead to:
Finally, exploration of the learning and positive consequences arising from patient safety events is limited and may prove a fruitful avenue for future work.
