Second victims are healthcare providers 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 provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.
(Scott et al, 2009)
The impact on the clinician can be considered in two areas:
Personal impact
For many people, being involved in a significant 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.
Professional Impact
Involvement in a patient safety incident can also affect an individual’s ongoing work in healthcare. Reduced professional confidence is common, and people may make defensive changes to their practice, such as avoiding similar patients. Becoming a second victim can increase the risk of burnout, and may result in thoughts of leaving their profession.
Prompting constructive change
A clinician 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 harder to make a mistake. It might be through highlighting or reducing risks which are "an accident waiting to happen".
Whilst nobody ever wants an incident to happen, they are much less likely to occur again if there is constructive learning and changes are implemented.
Who is affected?
A healthcare professional 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 provider who experiences personal or professional impact as a result of involvement in a patient safety incident. This means that any healthcare professional 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, therapists, technicians and administrators.
How many?
Estimates vary, but it is possible that up to 50% of healthcare workers 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.
Research summary
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:
What is a ‘second victim’?
What is the impact on individual staff and teams?
How can second victims be supported?
What is the role of preventative staff support?
What might be future second victim research priorities?
What is a Second Victim?
Professor Albert Wufirst 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.
What is the impact on individual staff and teams?