What is a Second Victim?
Professor Albert Wu 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 staff and teams is now widely recognised. Figures vary but up to 50% of healthcare workers report experiencing an incident in which they considered themselves to be a second victim (Wu & Steckelberg 2012).
What is the impact on individual staff and teams?
Our systematic review (Sirriyeh et al 2010) 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 disorder (Wu & Steckelberg 2012), suicidal thoughts or even suicide (Pratt et al 2012). Differing responses to error by professional group have been explored, with doctors in training (Wu & Steckelberg 2012) and nurses (Sirriyeh et al 2010; Harrison et al 2015) identified as at potentially greater risk although such impact is not limited to clinicians (Hirschinger et al 2015). However, our most recent study (Johnson et al 2017) found not all staff experience significant emotional distress in response to failure, which points to personal resilience as a potential mitigating factor.
A six stage recovery trajectory is commonly experienced by second victims (Scott et al 2009). This includes:
- a chaos & accident response
- intrusive reflections
- restoring personal integrity
- enduring the inquisition
- obtaining emotional first aid
- moving on.
This study also found that involvement in practice change/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 and that health care leaders should introduce and evaluate strategies designed to provide supportive interventions for second victims (Seys et al 2013a, 2013b). Existing knowledge is available to guide policy makers in developing effective support programmes (Chan, Khong & Wang 2017) and the consequences of not doing so include the potential for: ‘…a vicious cycle of adverse events, burnout, poor care, and more adverse events.’(Pratt et al 2012)
How can second victims be supported?
Various interventions have been developed in response to this growing understanding of the impact on second victims. These include:
The ForYou programme – is based on The Scott Three-Tiered Interventional Model of Support” (Scott et al 2010). 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:
- basic emotional first-aid at local or department level
- peer to peer, one to one support
- access to professional counselling and guidance.
The MITSS (Medically Induced Trauma Support Services)Toolkit – launched in 2010 and freely available, this resource is designed to support organisations in developing and implementing programmes for staff suffering emotional impact from errors and adverse events (Pratt et al 2012). The toolkit comprises a range of resources and is suitable for adaptation by organisations based on local needs.
What is the role of preventative staff support?
More recently the research focus has been on identifying the factors that confer resilience to emotional distress in this context. Our recent systematic review (Johnson et al 2017) found the strongest support for:
- higher self-esteem
- more positive attributional style, and
- lower socially-prescribed perfectionism.
Such findings have been used to inform the development of preventative interventions such as online programmes like MISE (Mitigating Impact in Second Victims) (Mira et al 2015) 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 better functioning staff
- fewer staff leaving healthcare in response to a second victim experience
- a reduction in adverse events (Pratt et al 2012).
Finally, exploration of the learning and positive consequences arising from patient safety events is limited and may prove a fruitful avenue for future work.
Chan ST, Khong PCB, Wang W (2017) Psychological responses, coping and supporting needs of healthcare professionals as second victims. International Nursing Review 64(2): 242-262 DOI: 10.1111/inr.12317
Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J (2015) Emotion and Coping in the Aftermath of Medical Error: A Cross-Country Exploration. Journal of Patient Safety 11(1): 28–35
Hirschinger LE, Scott SD, Hahn-Cover MD (2015) Clinician Support: Five Years of Lessons Learned.
Johnson J, Panagioti M, Bass J, Ramsey L, Harrison R (2017) Resilience to emotional distress in response to failure, error or mistakes: A systematic review. Clinical Psychology Review 52 19–42
Mira JJ , Lorenzo S, Carrillo I, Ferrús L, Pérez-Pérez P, Iglesias P, Silvestre C, Olivera G, Zavala E, Nuño-Solinís R, Maderuelo-Fernández JA, Vitaller J, Astier P on behalf of the Research Group on Second and Third Victims (2015) BMC Health Services Research 15:341 DOI 10.1186/s12913-015-0994-x
Pratt S, Kenny L, Scott SD, Wu AW (2012) How to develop a second victim support program: a toolkit for health care organizations. Joint Commission Journal on Quality & Patient Safety, 38 (5): 235-240
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW (2009) The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care, 18 (5): 325-330
Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, Phillips EC, Hall LW (2010) Caring for our own: deploying a system wide second victim rapid response team. Joint Commission Journal on Quality & Patient Safety, 36 (5): 233-240
Seys D, Wu AW, Gerven EV, Vleugels A, Euwema M, Panella M, Scott SD, Conway J, Sermeus W, Vanhaecht K (2013a) Health Care Professionals as Second Victims after Adverse Events: A Systematic Review. Evaluation and the Health Professions, 36 (2): 135-162
Seys D, Scott SD, Wu AW, Gerven EV, Vleugels A, Euwema M, Panella M, Conway J, Sermeus W, Vanhaecht K (2013b) Supporting involved health care professionals (second victims) following an adverse health event: A literature review. International Journal of Nursing Studies, 50 (5): 678-687
Sirriyeh R, Lawton R, Gardner P, Armitage G (2010) Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care, doi:10.1136/qshc.2009.035253
Wu AW, Steckelberg RC (2012) Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Quality and Safety 21(4): 267-270