Background to the project
Albert Wu first introduced the phrase 'second victim' in 20001 to describe those who suffer emotionally when the care they provide leads to harm. In a previous issue of the MDU journal, Kevin Turner, a consultant urological surgeon, talked about the devastating impact for surgeons when things go wrong.
While the impact of patient safety incidents on patients and families remains the primary concern, the effect on individual healthcare staff and teams should not go unrecognised. Over recent years, there has been an increased awareness of the concept of second victims - and the impact is certainly not unique to surgeons.
We see junior and senior doctors from all specialties avoiding procedures in the aftermath of an incident, nurses navigating systems that routinely discipline and retrain staff, paramedics going on long term sick-leave, dentists who need counselling. The impact of making mistakes is profound, but rarely acknowledged.
In order to understand the extent to which these events impact on clinicians, in 2010 we conducted a systematic review of the academic literature on this topic2. This review found consistent evidence of an intense emotional response following an error with subsequent impact on the personal and professional lives of staff. We identified that only two small studies had been conducted in the UK and therefore we went on to conduct large scale surveys of the response of both nurses and doctors to patient safety incidents3,4 in the UK.
In our largest study of 1,755 doctors, we found that the majority had been involved in an adverse event, 76% of whom believed it had affected them personally or professionally. 1,077 (74%) reported distress, 995 (68%) anxiety, 840 (60%) sleep disturbance and 886 (63%) lower professional confidence. 81% said they were anxious about the potential for future events, but the same proportion also reported feeling determined to improve, suggesting that staff are motivated to make changes after an error.
One of the most significant findings of this study was that although nearly half of the doctors agreed that their colleagues had been empathic, 67% did not think that healthcare organisations adequately supported doctors in dealing with the stress associated with an adverse event, and few (20%) received useful feedback afterwards. In fact, second victims often report that the investigative process feels punitive, which can prohibit them from openly admitting to mistakes or discussing opportunities to reduce risk of recurrence5.
Through our research it became clear that it was not the few, but the majority of healthcare professionals who, at some point in their career, would experience these strong negative feelings, and for some (7% of our sample of doctors) this would result in long term and enduring distress associated with post-traumatic stress disorder. It also became clear that support for doctors and others experiencing these events was often not available, and resources were desperately needed to help normalise this event and to support those going through this experience.
The wider impact of second victims
When a clinician provides care that leads to harm, the impact on patient safety can be far reaching. If doctors take time off work the rest of the team is required to absorb their workload. If, as is sometimes the case, they are unable to overcome their second victim experience, they may decide to leave their role or even their profession, taking with them an enhanced skillset and years of experience. In a time of high staff vacancy rates, recruitment and retention has become a focus within NHS trusts and more widely, making the support of second victims essential within organisations wanting to retain staff.
Another effect of being a second victim is a lack of confidence. This can lead to leaning on team members for second opinions and increased risk of making further mistakes. One recent article6 suggests that the costs to healthcare of the defensive practices of those involved in harm events is significant. We therefore argue that apart from the moral imperative to support second victims, organisations who ignore the problem are likely to suffer financially and reputationally.
When a clinician provides care that leads to harm, the impact on patient safety can be far reaching.
What does Second Victim Support offer those affected by these situations?
The evidence was compelling that support for second victims was vital but lacking, so the Yorkshire and Humber Patient Safety Translational Research Centre and the Improvement Academy teams agreed to create and evaluate a website resource to address this gap, drawing on the findings from our basic research in this area.
In January 2019 we launched secondvictim.co.uk, a website that offers support both for individuals (second victims and their colleagues) and employing organisations. This website is designed to complement the support offered by employers during this time, rather than replace it.
For clinicians or their colleagues going through the second victim experience, there is information about duty of candour, guidance on sources of emotional support, a discussion on the recovery process using Scott's second victim work, and red flags to look out for in their wellbeing, to make them aware of when they may need to ask for help.
The website also has a series of short videos of clinicians telling their own experiences as a second victim. Users have found these stories helpful in connecting with their own experiences, and recognising that their experience is not isolated. For managers and organisations the website provides a section on building 'just culture', and case studies of what organisations have done to support clinicians.
In order to assess the usability and usefulness of the website resource, clinical staff and patients (n=16) were asked to spend some time looking at the website during its soft launch in late 2018 and completing a questionnaire and/or a think-aloud task7. We also requested feedback from other key organisations before launch (including the MDU and the Royal College of Physicians).
The feedback was overwhelmingly positive, with all participants agreeing that the website was easy to use and that they would recommend it to their colleagues. In particular, participants commented on the power of the videos, and that this sharing of a real-life experience would help both health professionals as second victims as well as the managers and colleagues wishing to support them. Minor changes were made to wording and ordering of sections following feedback.
What's the next stage of the project?
We know that providing web-based support for staff who have already been involved in an error is only the first step and doesn't go far enough. With funding from NIHR, the Yorkshire and Humber Patient Safety Translational Research Centre has developed a resilience training intervention to prepare healthcare professionals for adverse events and will be conducting a pilot evaluation over the next six months.
The intervention, led by Dr Judith Johnson, is based on a synergy of adverse event research, psychological research and cognitive-behavioural principles. It aims to prepare healthcare professionals and trainees for the occurrence of adverse events, and involves a half-day group workshop and subsequent one-to-one phone call with the facilitator.
Each workshop is tailored to specific professional groups, using a series of discipline-specific case studies to draw out the psychological and practical coping strategies professionals can use to deal with different challenges they are likely to face in their work. The intervention is being evaluated using questionnaires and interviews to explore participants' experiences, with results expected to be published in 2020.
The challenge now is in embedding the principles espoused in this website into practice at local and national level. We are supporting NHS organisations within our local footprint of Yorkshire and the Humber, in the expectation that the challenges they face will be similar to those nationally.
MDU perspective from Dr Michael Devlin
The focus of patient safety incidents is to understand what went wrong in order to try and prevent future harm to patients. That is obviously right, but what is striking to those of us who have spent most of our careers helping doctors and other healthcare professionals to cope with the aftermath of serious patient safety incidents is just how devastating it is for the clinicians involved.
Although we have long known about the existence of the second victim, what has been missing from our professional understanding is evidence as to what works. That is why the research described in this article, and on-going work by Kevin Turner, is so important to the profession. There is an obvious human cost to those affected by significant patient safety events and that inevitably impacts on the organisational efficiency of the healthcare body.
The MDU believes these carefully-evaluated techniques to support and prevent second victims should be embraced by organisations, as part of their commitment to developing a just and learning culture.
Iona Elborough-Whitehouse is a clinical leadership fellow at the Improvement Academy. She has joined the team in the past year and has had the opportunity to bring the Second Victim Support website to launch as one of a cluster of projects she is leading in patient safety and support for staff. She is a community dietitian by background and has experience of supporting frontline clinicians through patient safety incidents.
See more by Iona Elborough-Whitehouse
Rebecca Lawton is professor, Psychology of Healthcare, University of Leeds and director of the NIHR Yorkshire and Humber Patient Safety Translational Research Centre. Rebecca is committed to delivering research that makes healthcare safer; her work involves the application of psychological theory to address priorities for patient safety.
See more by Rebecca Lawton
Jayne Marran is a patient safety research nurse working as part of the Yorkshire Quality and Safety Research Group in the Bradford Institute for Health Research. Jayne has a long NHS nursing history and is passionate about improving the quality and safety of healthcare for patients as well as the wellbeing of those who work within healthcare.
See more by Jayne Marran
Judith Johnson is a clinical psychologist based at both the School of Psychology, University of Leeds, and the Bradford Institute for Health Research. She currently researches issues related to the healthcare workforce, and has published on topics including burnout, patient safety, communication and staff training interventions.
See more by Judith Johnson