This mixed methods research study explored the incidence and symptoms associated with the second victim (SV) phenomena in hospital employees from a large 5-hospital healthcare system in southern California. Using the validated Second Victim Experience and Support Tool (SVEST), this study examined 8 domains including correlations with SV experiences and physical/psychological distress, self-reported absenteeism, and intent to turnover (Burlison, Scott, Browne, Thompson, & Hoffman, 2017). Two open-ended qualitative questions examined desired forms of support following an event.
The term SV is related to the caregiver’s response to a serious safety event (Wu, 2000). With the patient as the first victim, health care providers involved in an unanticipated adverse patient event, medical error and/or a patient related injury may be traumatized by the event and become second victims. SVs often experience various psychological and physical symptoms (Harrison, et al., 2015). Less than 10% of healthcare providers will reach out for help following a serious safety event (ASHRM, 2014).
In 2009, Dr. Scott outlined the Six Stages of Impact Realization that can result from being a second victim. Several studies indicate symptoms include insomnia, nightmares, reliving the incident repeatedly, loss of trust by their colleagues, lack of self-confidence, and fear of making another error.
This research study was conducted within the culture of being a High Reliability Organization (HRO). HROs create structures and processes to decrease shame and blame while increasing transparency, learning, and resiliency (AHRQ, 2017). HROs are to reluctant to simplify solutions (i.e. fully explore complex situations) along with being preoccupied with failure (i.e. focus on predicting and eliminating failures rather than reacting to them) (AHRQ, 2017). With enhanced sensitivity and insights to the complexities of the work environment, organizations will benefit from exploring the SV incidence and effects with their employees.
Methods:
After obtaining Institutional Review Board (IRB) approval, the survey was emailed to, Registered Nurses, Pharmacists, Physicians, Social Workers and Therapists with a cover letter indicating implied informed consent by completing the 6-minute survey. Employees were told the confidential self-reported information would assist with the development of a program to provide support to clinical staff following an event.
Results:
890 employees completed the survey (10% response rate) with 72% self-identifying as a SVs from an event occurring within the past 5 years (range 1 year – 15+ years ago). Respondents were Registered Nurses (73%); Therapists (PT, OT, ST, RT) (4%); Social Workers (4%); Physicians (4%) and Pharmacists (3.5%). Areas of employment included Critical Care (ICU/PCU) 25%; Acute Care (11%); ED (7%); Surgical Services (6%); Labor & Delivery (4%); Neonatal ICU (4%); and Acute Rehabilitation (3%). The mean age working in the profession was 17 years with 12 years in their current role. After the event, most (73%) had either physical and/or psychological distress and 66% sought consultation from a co-worker followed by manager (29%) and employee assistance program (13%). Social Workers had lower psychological distress as did the employees working at the acute psychiatric hospital (p=.007) when compared to other disciplines and hospitals. Physical distress had the greatest prediction of intent to turnover (B=.33, p=.000). Colleague support was also predictive of reduced turnover intention (B=-.123, p=.05). Qualitative themes for additional forms of support included improved management training in responding and supporting the employee; more 1:1 peer support; increased debriefings (individuals and group); immediate time away from department following the event to allow for emotional decompression; and additional counseling with internal and external professionals as well as remote support.
Conclusion:
Approximately 440,000 patients encounter a serious safety event each year (Leapfrog, 2018). This estimate places medical errors as the third leading cause of death in the United States. After an event, SVs will likely experience a wide range of career impacting responses ranging from learning and thriving, to dropping out of the profession and potential self-harm (Harrison, et al., 2015; Joesten, Cipparone, Okuno-Jones, & DuBose 2015; Scott et al., 2009).
Within the quality department, the study site uses a Cause Analysis, Response and Evaluation (CARE) framework. Within this framework a new interdisciplinary CARE for You collaborative has been created. Modeled after the University of Missouri’s program, the study site is developing a 3-tired Second Victim’s Support Program. Colleague support, consistency with debriefing, and the use of same-day employee assistance program appointments are being emphasized. After ethical dilemmas, interdisciplinary groups are conducting emotional debriefs to assist staff with “safe-zone” coping. Additionally, new graduate nursing residents now receive two-hours of training on the topic of SVs with a focus on awareness, self-efficacy, and resources.
Executive sponsorship from both departmental and administrative leadership has been successful and our SV program is growing and evolving. The National Quality Forum has called for organizations to assess and establish support structures for clinicians. Results from this study are shaping our customized support program. We strive to reduce errors, support our employees to minimize the SV phenomenon, facilitate learning from safety events, and promote a culture of high reliability.