At a recent development session for board safety champions in maternity and neonatal care at national level, where the focus of many of our conversations centres on safety culture, we touched on the subject of ‘second victims’. This resonated with me, not solely from a maternity perspective, but from the broader area of staff psychological safety and if, indeed, enough focus is being placed on this to support staff?
The term ‘second victim’ was coined by Professor Albert Wu in the 1980s to describe those who suffer emotionally when the care they provide leads to harm, as cited by Second Victim Support, a website supporting health professionals who have been involved in a patient safety incident. What shocked me most from the statistics was that, although figures vary, up to 50% of healthcare staff may experience an incident in which they will consider themselves to have been a second victim (Second Victim Support, 2021).
A study into the concept of the second victim (Jones et al, 2019) undertaken to inform two large NHS trusts looking to develop a pilot to support staff found that the opportunity for health professionals to discuss the details of an event and share how it affected them personally is often lacking.
Jones et al (2019) explored the theory that second victims see themselves as ‘victimised’—in the sense that they are traumatised by the event—and that, frequently, these individuals feel personally responsible for the adverse patient outcome. In addition, many feel that they have failed the patient, questioning their own clinical skills.
All my reading in this area identifies that there is an impact on the employee, both personally and professionally.
The personal impact is that, for any health professional who has been involved in a patient safety incident or adverse event, the immediate aftermath of the event is an intensely emotional time, which will have physical and emotional manifestations.
Examples shared with Second Victim Support by those who have been involved in an incident include feelings of distress, self-doubt and fear; these are common and may persist long after the original incident. These emotions are often accompanied by physical symptoms, such as sleep disturbance or difficulty concentrating. Sadly, for some individuals, involvement in a patient safety incident can contribute to the development of mental health issues, including depression, anxiety and post-traumatic stress disorder.
The professional repercussions of being involved in a patient safety incident, according to Second Victim Support, can have an ongoing effect on an individual's work in health care. This may commonly present as reduced professional confidence, and in addition increase the possibility that the individual(s) may make defensive changes to their practice, such as avoiding similar situations or patients with similar presentations. Second Victim Support also suggests that being a second victim can increase the risk of burnout and may result in individual having thoughts of leaving their profession.
Systematic response
On reflecting on what can be done, one can't help but feel that the way in which the NHS has traditionally managed patient safety incidents has not systematically supported the staff involved.
On a more positive note, however, NHS England (NHS England/NHS Improvement, 2020) has launched an introductory Patient Safety Incident Response Framework 2020. This is a new approach to incident management that is underpinned by the conviction that the NHS can go much further in learning from incidents. The framework aims to facilitate ‘inquisitive examination of a wider range of patient safety incidents’ in the spirit of reflection and learning rather than as part of a framework of accountability.
The framework, whose early adopter sites are live (with other trusts having until 2022 to implement it), draws on good practice from the healthcare sector, as well as other fields, and supports a systematic, compassionate and proficient response to patient safety incidents, which should be anchored in the principles of openness, fair accountability, learning and continuous improvement.
According to NHS England, staff should never be left feeling isolated and uninformed about what will happen following a patient safety incident. Organisations must also establish procedures to identify all staff who may have been affected by a patient safety incident and to provide access to the support they need.
In summary, although the impact of patient safety incidents on patients and families undoubtedly remains our primary concern, the effect on individual healthcare employees and teams is now widely recognised.
The new framework shows that NHS England is committed to learning from the early adopter sites and expanding the initiative. In the meantime, there is a range of support programmes to consider in preparation for this welcome change in patient safety culture.