The importance of supporting ‘second victims’

Ms Julie Price, Consultant Clinical Risk Advisor to Medisec, outlines the toll that patient safety incidents can have on clinicians and what can be done to support them.

Involvement in patient safety incidents can significantly affect the professional and personal lives of healthcare professionals. Understanding this ‘second victim’ phenomenon and seeking appropriate support is key to achieving a healthy recovery. 

Every day healthcare professionals strive to deliver safe and effective patient care in challenging, stressful, and highly complex environments. Despite their best intentions, unexpected complications and unintentional patient safety incidents occur due to the nature of human fallibility and complex socio-technical systems, such as healthcare. Although not all errors are life-threatening, they can significantly compromise a patient’s quality-of-life. When a medical error or patient harm occurs, the patient is understandably the first victim and a key priority for clinicians is to provide them with truthful information, appropriate care, and emotional support. 

“…healthcare providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimsed in the sense that the provider is traumatised by the event.”

According to the HSE Patient Safety Strategy 2019-2024, unexpected events occur to approximately 13 per cent of patients using healthcare services. These can have traumatic effects on others, including clinicians and staff involved in the incident, ie, they become second victims. Prof Albert Wu first coined the term in 2000, to describe clinicians who were traumatised by their own errors. Scott SD et al (2009) expanded the term to describe second victims as: 

It is estimated that all clinicians, at some stage in their professional life, will become a second victim (Laue von N et al 2012). 

The pronounced psychological strain experienced by second victims, if unsupported, can pose a further threat to patient safety and can be detrimental to organisational culture; therefore, it needs to be taken seriously. 

What effect does this have on clinicians? 

In the aftermath of an incident, the clinicians involved may be left feeling unsupported and experience feelings of blame, anger, shame, failure, depression, inadequacy, and distress. 

A UK survey by Harrison R et al (2014) highlighted the professional and personal impact of adverse events on clinicians: 74 per cent reported stress, 68 per cent anxiety, 60 per cent sleep disturbance, and 63 per cent lower professional confidence. 

On a positive note, 80 per cent of respondents reported a determination to improve following an adverse event. However, 81.5 per cent were anxious about the potential for future errors, which the authors suggested may lead to clinicians exercising greater caution. 

A clinician’s response to adverse outcomes can depend on various factors, including the seriousness of the circumstance, the person’s role and perception of responsibility, the patient’s outcome, and organisational response. In some cases, clinicians might experience minor stress or anxiety that dissipates in the days and weeks following an incident. A study of anaesthesiologists, involved in difficult airway management, by Samuels JD et al (2020) illustrated that second victim symptoms persisted in 26 per cent of participants up to weeks, 8 per cent for half a year, and 5 per cent for over a year. Others may suffer from strong emotional reactions and symptoms akin to those of post-traumatic stress disorder. 

A 2016 study by Panella M et al suggested that: “Being a second victim is the strongest predictor of practising defensive medicine.” Practising defensive medicine exposes patients to the risk of unnecessary examinations and increases the costs of care. Providing effective support to second victims, together with a systematic use of evidence-based clinical guidelines, is also recognised as a key recommendation for reducing defensive medicine. 

Second victim phenomenon exacerbated by the Covid-19 pandemic 

Healthcare professionals have been facing exceptional circumstances during the current Covid-19 pandemic. A recent publication by Lobão MJ et al suggests that, “long-term stressors and risks to clinicians’ physical, mental, and emotional wellbeing are real and represents predisposing factors for adverse outcomes for their own health as well as adverse events during patient care.” These factors include: Fear of contracting Covid-19; fear of infecting family members; social isolation; growing number of cases with a severe and lethal course; caring for colleagues who got sick; increased workload; working with new and frequently changing protocols; and feeling out of control and unappreciated. There is a risk that healthcare professionals, in either primary and secondary care, could become second victims due to the impact of the pandemic. 

Strategies to support second victims 

By acknowledging and proactively addressing the patient safety incident-stress-error cycle, clinicians can work toward effectively managing the situation. The following tips may be helpful when dealing with the stress associated with an adverse patient outcome. 

1. Be open and honest with the patient/family (open disclosure) 

When things go wrong, healthcare providers have an ethical responsibility to disclose unanticipated patient outcomes, in accordance with the Civil Liability (Amendment) Act 2017. The Act provides the legal framework to support voluntary open disclosure; it applies to all patient safety incidents including near misses and no-harm events. It is essential to investigate, explain and apologise to the patient. Whilst clinicians may feel uncomfortable and anxious discussing adverse outcomes with patients and/or families, when done properly, disclosure can reduce the negative impact of adverse outcomes and support a culture of transparency and safety. 

2. Participate in peer review meetings 

An adverse patient outcome, whilst unfortunate, can present an ideal learning opportunity to reflect on personal performance and to identify potential risks within your healthcare setting. To maximise learning during this reflection, it is important to adopt a ‘systems thinking’ approach. This will provide a more meaningful analysis and understanding as to why the adverse event occurred. It does not seek to blame. 

3. Adopt an organisational safety culture 

Establish a culture of safety that encourages transparency, respect and honesty. Punitive policies and measures in relation to adverse outcomes can create barriers to disclosure of incidents and emotional coping. Consider developing written policies and procedures for second victim support and resources. Disseminate to all staff and leaders. 

4. Emphasise people skills 

If you feel anxious, fearful, or dissatisfied, you may find it challenging to relate well to patients. These feelings can impair the doctor/patient relationship, which may adversely affect mutual trust, critical to effective communication and good outcomes. Acknowledging these emotions and working to connect and engage with patients can help relieve such stress. 

5. Identify your support systems 

Your personal relationships may also suffer because of emotional distress. To address this, identify your support systems, ie, those with whom you can share your feelings and concerns without sharing specific information about the adverse patient outcome. Expressing your personal feelings and concerns to one of your support systems, such as your spouse, a trusted friend, or a colleague, can help re-establish your emotional equilibrium. 

6. Maintain a healthy work/life balance 

Most people realise the benefits of maintaining a work/ life balance. However, maintaining a “balanced” lifestyle is even more critical in this situation. At the very least, try to take care of your physical health. Consider how your eating habits, medication and alcohol intake, physical activity, sleep schedule, etc, might affect a balanced lifestyle. 

7. Stay connected with colleagues 

Working remotely, particularly due to the pandemic, may have increased the sense of clinical isolation. Consider setting up peer networks to ensure a connection with others. 

8. Seek professional help 

Managing stress on your own is not always possible. If you have been involved in an adverse event do contact your indemnifier, eg, Medisec, who provide professional support, legal guidance, and counselling. Whilst there is a widely recognised stigma amongst doctors around admitting the need for self-care and asking for help, you may need to seek help from another healthcare professional if you find you are struggling, eg, your own GP. Talking with a professional in a confidential setting can help with processing the perfectly normal reactions of being involved in an adverse/critical event. 

In summary 

Regardless of how the second victim phenomenon manifests, it can have a serious impact on healthcare providers’ personal and professional lives and, consequently, can be detrimental to patient safety and organisational culture. For these reasons, healthcare organisations should consider the systems they have in place to support staff involved in adverse outcomes. Bullying, blaming, and belittling those involved should not be tolerated. Asking for support is not a sign of weakness; it evidences a sense of responsibility towards patients. 

Second victims need to 

• Be heard and to have distress acknowledged. Asking for support is not a sign of weakness. 
• Be supported by colleagues and the organisation. 
• Make sense of what happened. 
• Have opportunities to transform experience into learning.