Continuing Education Activity

Health care workers often expect perfection from themselves, and societal opinions reinforce this expectation. However, perfection will always be an elusive goal, even for this group of hard-working, self-sacrificing, and altruistic humans. This activity outlines the risk factors, symptoms, evaluation, and management of second victim syndrome. It also explains the role of the interprofessional team and medical institutions in improving support and care for providers suffering from second victim symptoms.

Objectives:

• Describe the patient care events that commonly lead to second victim symptoms and syndrome.
• Review provider and patient event risk factors associated with developing second victim syndrome.
• Identify the most common symptoms experienced by providers suffering from second victim syndrome.
• Explain the importance of a peer response program as well as the role of interprofessional team in attenuating the impact of second victim syndrome.

Introduction

Health care workers often expect perfection from themselves, and societal opinions reinforce this expectation. However, perfection will always be an elusive goal, even for this group of hard-working, self-sacrificing, and altruistic humans. For decades, the system that trains and accredits medical providers, especially physicians, denied providers their own human imperfections and concomitant vulnerabilities. Mistakes in medicine were blamed on “bad” and/or imperfect physicians. Finally, in the 21 century, the Institute of Medicine admitted an undeniable truth in the oft quote publication, To Err is Human: Building a Safer Health System, when they asserted that “the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer.”[1] 

Despite this acknowledgment, those indoctrinated by the medical system continue to expect perfection from themselves and are more often than not denied the time and resources necessary to process feelings and grieve losses when an adverse patient event or mistake occurs. As a consequence, health care workers often suffer life-altering burdens of anxiety, depression, and shame after an adverse patient outcome. Dr. Albert Wu named this burden “second victim syndrome” in his pivotal publication in 2000.[2] 

In this framework, the first victim is the patient and the second victim is the health care provider(s). Though Wu initially discussed the second victim in relation to patient harm after a physician error, the term has since been expanded to include the burdens of anxiety, depression, and shame that any healthcare provider feels after any traumatic adverse and/or unexpected patient care experience.[3]

Etiology

Second Victim Symptoms are the result of a traumatic patient care event in the healthcare setting. These events can include near misses, patient adverse events, deaths, or provider mistakes but really encompass any event that leads to significant mental stress on the part of the provider (otherwise known as the "second victim"). Each second victim will have unique perspectives, needs, and emotions related to the event, and symptoms can occur in various timelines after the event.

Epidemiology

Almost all providers experience some symptoms of second victim syndrome over the course of their careers. These symptoms can be imagined as a continuum of emotions and symptoms rather than the binary presence or absence of a defined syndrome. This more nuanced understanding of a collection of symptoms leads some to use the term second victim phenomena rather than the term syndrome, which connotes a binary pathology. In this article, we use the term second victim symptoms (SVS) to denote symptoms that can comprise a true "second victim syndrome" in their extreme form but are experienced in a more mild range by almost all medical providers throughout their career. These symptoms can be present even if they don’t meet the full definition of a syndrome.

Prevalence of SVS in General and by Medical Specialties

The majority of providers experience SVS at some point in their career as the trauma of witnessing a serious patient adverse event (or even a near-miss event) carries emotional ramifications for the witnesses.  

As expected, fields with higher burdens of unexpected and sometimes catastrophic patient events such as emergency medicine, surgery, and intensive care have increased provider SVS and their attendant psychological ramifications. Approximately 25% of emergency physicians, 27% of emergency nurses, 22% of ICU nurses, 22% of surgery residents, 15% of trauma surgeons, and 17% of anesthesiologists report extreme and pervasive distress. These severe SVS can lead to true "second victim syndrome," which, if unchecked, can lead to the diagnosis of true posttraumatic stress disorder (PTSD).[4][5][6][7]

Event Characteristics

Not all SVS triggering experiences carry equal psychological weight, and providers may suffer more or less depending on both event characteristics as well as other surrounding factors. Though any event can lead to SVS, certain event characteristics are more likely to trigger severe or pervasive SVS. These events include the death or near-death of a patient, an event affecting a patient known to the provider (i.e., coworker, relative, friend), or untoward morbidity and mortality secondary to systems issues out of the control of the provider (i.e., a pandemic, a local crisis such as an earthquake or adverse events due to system overcrowding such as emergency department inpatient boarding).

The literature also suggests that SVS last much longer after events involving significant harm or death from a medical error. In the presence of permanent harm or death, providers were 8 times more likely to be symptomatic for more than 1 month and 9 times more likely to have symptoms lasting longer than 6 months compared to events in which the patient was not harmed (i.e., a "near miss" event).[8] 

A sudden unexpected patient death universally triggers intense emotion, and doctors, in particular, have been taught to essentially “stuff these feelings." Until recently, permitting oneself time to outwardly express the loss contradicted the required stoic exterior of a "good" doctor. Ken Doka labeled this phenomenon disenfranchised grief and defined it as “Grief that individuals experience when they incur a loss that is not or cannot be openly acknowledged, socially sanctioned, or publicly mourned.”[9]

In reality, expressing and processing such grief is not only human but it is required to move on emotionally and maintain healthy compassion.[10]

History and Physical

Second Victim Symptoms

Scott et al. performed a qualitative study of 31 providers after a second victim event describing the provider’s experience during the aftermath.  She divided the progression into the six stages below:[11]

1. Chaos and accident response – The adverse event is noted, and the provider performs required emergent patient care tasks to stabilize the condition.
2. Intrusive reflections – After the patient has stabilized, the provider worries, ruminates, and mentally “replays” the incident for days, weeks, months, or even sometimes years.  This often interferes with providers’ personal and professional lives. 
3. Fear of rejection versus seeking confirmation – The provider worries about others’ perceptions of what happened and that others may doubt their competence.  They may confide in trusted peers, seeking affirmation that the poor outcome was not entirely their fault, and may try to identify other factors that contributed to the adverse outcome.
4. Enduring the inquisition – Administrative or legal parties may investigate the incident, such as peer review, quality improvement review, licensing boards investigations, or lawsuits. Providers perceive these reviews as inquisitions of their competence.
5. Emotional first aid - The provider connects with a colleague, mentor, and/or mental health professional to assist in processing the event.
6. Final disposition -In the long term, a provider may “drop out,” “survive,” or “thrive” after the event. This is discussed in more detail later.

As mentioned earlier, these post-event symptoms fall on a spectrum of severity and length of time to resolution. Subsequent qualitative studies demonstrate that many providers fail to progress in this order or even experience all the stages consistently. Additionally, there is a broad variation in the length of time providers spend in each phase.[12]

A recent systematic review of 18 studies involving 11,649 healthcare providers suffering from SVS found the following symptom prevalence:[13]

• Troubling memories (81%, 95% confidence interval [CI] = 46–95)
• Anxiety/concern (76%, 95% CI = 33–95)
• Anger toward themselves (75%, 95% CI = 59–86)
• Regret/remorse (72%, 95% CI = 62–81)
• Distress (70%, 95% CI = 60–79)
• Fear of future errors (56%, 95% CI = 34–75)
• Embarrassment (52%, 95% CI = 31–72)
• Guilt (51%, 95% CI = 41–62)
• Sleeping difficulties (35%, 95% CI = 22–51)

Evaluation

As there is no validated tool to identify second victim symptoms, and it sometimes takes providers time to identify the cause of distressing symptoms, it is imperative that systems identify high-risk events and support providers in recovering and processing the event individually. In addition, these 1 on 1 interactions will help systems identify those providers suffering from more severe or longer-lasting SVS and support them appropriately with either directed peer counseling or even professional mental health support (see below).

Treatment / Management

Since SV phenomena are a direct result of work demands, healthcare organizations have a duty to offer effective resources and implement programs to identify high-risk events and attenuate the consequences of second victim experiences. Given the heterogeneous nature of each medical specialty and institution, these programs should be tailored to the unique needs of the providers they serve. The discussion below provides a general overview of current processes that demonstrate preliminary efficacy in addressing and attenuating second victim distress.

The literature from early adopter institutions suggests the following 3-tiered support system:[14][15]

Stage 1. Emotional first aid provided by a trusted colleague or mentor:

This stage covers the majority of adverse events and involves a post-incident immediate discussion to allow those involved (if desired) to debrief in time following the incident before returning to work tasks. The most important thing for colleagues at risk for SVS is to listen and not jump in to provide solutions. Trusted colleagues should strive to normalize the provider's feelings by acknowledging that all providers are human, feel bad about mistakes and/or adverse patient outcomes, and suffer when these events occur. It is also important to help the individual understand that each provider will respond to a particular event with different symptoms and severity, even for an event that appears similar. If relevant, trusted colleagues can also share their own prior mistakes.

Below are some specific suggestions to engage affected providers in emotional first aid:

• Take the provider to a private place away from the scene of the clinical event as soon as safely possible.  
• Use open-ended questions, such as “How are you feeling?”  “Do you want to talk about it?” 
• Listen and allow them to control the conversation. For example, providers may wish to keep the conversation brief or may want to discuss it many times.
• Ask if you can call the provider later that day or tomorrow to ensure they are doing ok and/or if you can arrange contact with a peer supporter or professional.  
• Give the provider time alone to collect their thoughts before returning to clinical duties.
• Some providers may need to leave the worksite, and the person providing emotional first aid may need to help facilitate this coverage if possible.[16][17]

Before ending the contact, make sure the provider has referrals for the emotional, psychological, and/or professional help they may need.

It is NOT helpful to say: “Tell me what happened.” “Everything will be OK.” And or “Don’t worry about it.”

Stage 2.  Support by trained peers:

This is administered by specific coworkers trained in mentoring and supporting peers after an adverse or traumatic encounter. These trained peers follow up in the days and weeks following the incident to ensure the provider’s wellbeing and referral for further support as needed.

Stage 3.  Support by mental health professionals.

This should be available to all clinical employees and is encouraged if the provider’s second victim symptoms interfere with their professional or personal lives or if symptoms fail to improve or worsen over time.

Emotionally Processing Patient Death

As patient deaths are particularly high risk for leading to severe or longer-lasting SVS, these events deserve special discussion. Immediately after a patient's death, team leaders and attendant providers find value and meaning in honoring that patient's life and sharing a moment of common humanity.[18]  Additionally, a scheduled regular forum to collectively process patient deaths through group reflection has also demonstrated valuable emotional support to providers.[10]

Differential Diagnosis

SVS symptoms may overlap and be hard to differentiate from other conditions that impair providers’ wellbeing.  Supportive colleagues and timely professional referral and workplace modifications can still be used to address other similar conditions. Consider these conditions in the differential diagnosis for SVS:

• Burnout[19]
• Depression[20]
• Prolonged grief disorder[9]
• Job stress reaction and fatigue[21][22]
• Issues with alcohol, medications, or substance use[23]
• Issues with physical health and illness

Prognosis

The last stage of SVS described by Scott et al. involves the ultimate career disposition and has important life-altering provider consequences and institutional impact.

• “Drop out”:  Providers leave their current job, specialty, or clinical care altogether.  This may cost institutions upwards of $500,000 per physician to replace.[24] 
• “Survive”: Providers stay in current employment but are haunted by the event and adverse outcome and continue to have long-lasting SVS symptoms.
• “Thrive”: Providers adopt a growth mindset, choosing to turn the experience into one that improves systems processes to benefit future patients and providers, such as quality improvement initiatives or improved support systems for providers after an adverse event.

Though these career disposition categories provide a convenient frame of discussion, not all affected providers fall within a discrete category, nor are the categories mutually exclusive. For instance, a provider may leave clinical practice for a period of time (dropout) but later return and thrive. Or a provider who appears to thrive and learn from the experience may still have moments of self-doubt and intrusive reflections of the adverse outcome.

Complications

Research has shown that SVS after adverse events impairs provider cognitive functioning, with approximately 79% reporting difficulty concentrating.[25]  Providers with SVS were twice as likely to report burnout and a desire to leave their jobs.[26] 

One study of nurses suffering from second victim symptoms found an increased intention to leave their current job and increased absenteeism in this population. However, it is important to note that these risks were decreased if the nurses perceived that their organizations supported them through the response.[27]

Most concerning of all, severe or long-lasting symptoms of SVS are associated with subsequent depression and suicide. Surgeons with lawsuits due to an adverse outcome in the prior two years are 1.64 times more likely to consider suicide in the subsequent year.[28] In addition, those who consider suicide are 3.4 times more likely to report a self-perceived medical error in the prior 3 months.[29]

Deterrence and Patient Education

Organizations must develop proactive programs to educate students, trainees, and providers about the impact of adverse patient events. These educational programs should make all providers aware of the post-event process and provide several free and easily accessible routes for help. Additionally, systems must work to identify high-risk events and individually support providers in order to ensure appropriate follow-up and support. Automatic referrals and trained peer support contact are recommended in all cases where the provider is challenged with a legal malpractice action, and there is an unexpected patient death and cases that are referred for quality review.[30]

Enhancing Healthcare Team Outcomes

Identifying high-risk events and creating a three-tiered response system are important first steps in the institutional response to supporting provider well-being after second victim events. However, the mere presence of a reported response team does not automatically translate into effective psychological improvement for workers. It appears employee perception of support and individual respect by the organization is the most important factor in ameliorating symptoms of SVS.[30] Organizations must continue to abandon the “shame and blame” culture of the past that focused on the individual provider and embrace a just culture that views adverse unintentional events as learning opportunities to improve the system's safety as a whole.