What is Second Victim Syndrome?

Health care workers, such as doctors and nurses, often put a lot of pressure on themselves to be perfect due, in part, to the high expectations of society. However, being perfect all the time is impossible, even for these dedicated and caring individuals. The medical system has a history of dismissing the fact that healthcare workers are human too and can make mistakes.

For many years, the blame for medical errors fell on the physicians, labeling them as “bad” or flawed. But significant change happened in the 21st century when an important report titled ‘To Err is Human: Building a Safer Health System’ was published by the Institute of Medicine. This report acknowledged an important truth: it’s not that there are bad people in healthcare, but rather good people working in flawed systems that need improvement.

Despite this important recognition, many healthcare workers still expect perfection from themselves. Often, they are not given ample time and resources to handle their emotions and grieve when a patient’s treatment doesn’t go as planned. This can lead to intense feelings of anxiety, depression, and shame. This emotional burden, referred to as “second victim syndrome,” was first identified by Dr. Albert Wu in 2000.

In this context, the first victim is the patient affected by an unexpected outcome or event. The second victim is the healthcare provider who is emotionally impacted by the situation. Although Dr. Wu originally used “second victim” to describe physicians who made errors, it has since been broadened to include any healthcare worker who experiences feelings of anxiety, depression, and shame after any traumatic or unexpected event in patient care.

What Causes Second Victim Syndrome?

Second victim symptoms refer to the emotional distress a healthcare provider may experience following a traumatic incident in their line of work. Such incidents could involve close calls, patient complications or deaths, or mistakes made by the healthcare provider themselves. Effectively, any situation that significantly stresses the mental wellbeing of the healthcare provider is considered.

The term “second victim” comes from the recognition that healthcare providers, like the patients under their care, can also be deeply affected by adverse events in the healthcare setting. Every “second victim” will experience the situation in their own unique way, with different feelings, needs, and responses tied to the incident. These symptoms can crop up at various times following the incident.

Risk Factors and Frequency for Second Victim Syndrome

Most medical professionals feel some degree of second victim syndrome symptoms during their careers. Rather than a clear-cut condition, these symptoms exist on a scale and can vary in intensity. We call this the second victim symptom (SVS) pattern, which can extend to a full-blown second victim syndrome in severe cases. Although not fully meeting the syndrome definition, these symptoms can still occur among medical professionals.

SVS is a common issue in the medical field as the emotional impact of serious patient incidents or near-miss accidents can affect those involved. Medical professionals working in high-stress areas like emergency medicine, surgery, and intensive care, where unexpected and sometimes disastrous patient incidents are common, are at an increased risk. For instance, around 25% of emergency doctors, 27% of emergency nurses, 22% of ICU nurses, 22% of surgical trainees, 15% of trauma surgeons, and 17% of anesthesiologists report severe and continuing distress. If not addressed, these severe SVS can escalate into actual second victim syndrome and potentially lead to post-traumatic stress disorder (PTSD).

The severity of SVS depends on the specifics of the incident and other surrounding factors. Certain factors, like the death or near-death of a patient, incidents affecting someone the provider knows, or harmful outcomes due to uncontrollable system issues, are more likely to trigger severe SVS. Research shows that SVS tends to last longer following incidents involving significant harm or death due to medical mistakes. Providers were found 8 times more likely to show symptoms for over a month and 9 times more likely to show symptoms for over 6 months in cases involving permanent harm or death, compared to incidents where the patient was not harmed.

The sudden, unexpected death of a patient universally induces strong emotion among doctors. However, traditionally doctors are expected to suppress these feelings, a phenomenon called disenfranchised grief. It happens when people experience a loss that isn’t publicly acknowledged, accepted, or mourned. However, in reality, expressing and dealing with such grief is not only natural but also necessary for emotional progress and maintaining healthy empathy.

Signs and Symptoms of Second Victim Syndrome

In a study conducted by Scott et al., 31 providers were asked about their experiences following a second victim event. The results showed that the experience could be divided into six stages.

Chaos and accident response: The provider notices the adverse event and carries out emergency care to stabilize the patient.
Intrusive reflections: After the patient is stable, the provider often keeps reflecting on the incident, which can interfere with their personal and professional life.
Fear of rejection versus seeking confirmation: The provider worries about what others think of the event and often seeks affirmation from trusted peers.
Enduring the inquisition: The incident may be investigated by administrative or legal parties, such as peer review or licensing boards, which can be stressful for the provider.
Emotional first aid: The provider seeks help from a colleague, mentor or mental health professional to cope with the aftermath.
Final disposition: Over time, the provider may continue as usual, quit their practice or prosper regardless of the incident.

The researchers noted that these stages can vary in severity and duration. Not all providers experience these stages in the same order or even go through all of them. Also, some providers may spend more time in a particular phase than others.

In a separate study involving 11,649 healthcare providers, the following symptoms were commonly reported among those who had experienced a second victim event:

Troubling memories (81%)
Anxiety (76%)
Anger towards themselves (75%)
Regret or remorse (72%)
Distress (70%)
Fear of making future mistakes (56%)
Embarrassment (52%)
Guilt (51%)
Difficulty sleeping (35%)

Testing for Second Victim Syndrome

As there isn’t a certified method to recognize symptoms of distress in medical providers, it can sometimes take these professionals time to figure out why they feel stressed or upset. Therefore, it’s incredibly important that health systems are able to identify high-risk situations and provide individual support to these providers as they process these events. These one-on-one interactions can then help the health system to find those providers who are facing more serious or long-lasting stress. Once identified, these providers can be offered the appropriate support, whether that comes in the form of counseling from their peers or professional mental health services.

Treatment Options for Second Victim Syndrome

Workplace stress in healthcare can have serious consequences and lead to something known as Second Victim Syndrome (SVS). This is when healthcare providers suffer emotionally after an adverse event involving their patients. It’s crucial that healthcare organizations identify these high-risk events and provide resources to help their employees cope with the emotional aftermath.

The best support systems typically involve three stages:

1. Emotional first aid from a trusted colleague or mentor: Here’s where a healthcare provider’s colleague or mentor steps in after an adverse event. They’ll help their friend by listening and providing support but not trying to solve the problem immediately. They’ll reassure their colleague that it’s normal to feel bad and that everyone responds differently after adverse events. If possible, they’ll share their own experiences of past mistakes.

Ideally, the conversation should take place privately and at the affected provider’s pace. It might mean having a brief chat or discussing the issue multiple times. The supporting colleague should also check in later to see how they’re doing and particularly if professional help might be needed. By the way, they should avoid saying things like “Tell me what happened,” “Everything will be okay,” or “Don’t worry about it.”

2. Support from trained peers: After the initial incident, specially trained colleagues should follow up to make sure that the affected healthcare provider is coping well. This could be a simple check-in or perhaps organizing further support if needed.

3. Support from mental health professionals: If the symptoms of SVS start to interfere with a healthcare provider’s personal or professional life, or if their symptoms get worse over time, mental health professionals should be engaged.

Experiencing a patient’s death can be particularly challenging and may lead to severe or prolonged SVS. In such cases, immediate support and shared moments of respect and remembrance can be helpful. Organizing regular group meetings to process such events can also be beneficial.

When trying to identify SVS (Second Victim Syndrome), it might be difficult because the symptoms can look very similar to other conditions that affect a person’s well-being. However, having support from colleagues, timely professional referrals, and adjusting the work environment can also be beneficial for dealing with these other conditions. The following conditions should be considered when diagnosing SVS:

Burnout
Depression
Prolonged grief disorder
Job stress reaction and fatigue
Issues with alcohol, medications, or substance use
Physical health and illness concerns

What to expect with Second Victim Syndrome

The final phase of dealing with Second Victim Syndrome (SVS), a condition where healthcare providers feel intense emotional distress after a negative patient outcome, as explained by Scott et al., is important since it can greatly influence the healthcare provider’s career and the institution they work for.

There are three main responses:

“Drop out”: Healthcare providers decide to leave their current job, their specialty, or quit clinical care altogether. This can be quite costly for institutions, with the cost of replacing a physician estimated to be over $500,000.

“Survive”: Providers remain in their current job, but the effects of the negative event and the outcome impact them mentally and continue to experience symptoms of SVS.

“Thrive”: Providers adopt a growth mindset where they transform their experience into a lesson that can be used to improve patient care and medical practices. This could involve improving quality control or developing better support systems for physicians after a negative event.

Although these categories provide a good starting point for discussing the impact of SVS, not all healthcare providers will fall neatly into each category. Also, these categories are not strictly separated – a healthcare provider might go through different stages by quitting practice and later returning and thriving. Additionally, a provider who seems to be thriving may still experience moments of doubt and recall the negative outcome.

Possible Complications When Diagnosed with Second Victim Syndrome

Studies indicate that experiencing Second Victim Syndrome (SVS), which can occur in medical providers following adverse patient events, can negatively impact a provider’s ability to concentrate. In fact, nearly 79% of providers with SVS report facing such difficulty. Moreover, those with this syndrome are twice as likely to feel burnout at work and even contemplate leaving their jobs.

A specific study on nurses dealing with SVS revealed that they have a higher likelihood of wanting to quit their current jobs and show increased levels of absenteeism. Yet, it’s worth noting that these risks can be lessened if the nurses feel their workplaces support them amid such adversities.

What’s particularly worrying is how severe or lasting symptoms of SVS can lead to mental health problems like depression and even suicide. For example, surgeons who’ve faced lawsuits due to negative patient outcomes in the past two years are around 1.64 times more likely to think about suicide in the following year. Furthermore, healthcare providers who contemplate suicide are around 3.4 times more likely to think they’ve made a medical error in the preceding three months.

Summary:

Second Victim Syndrome (SVS) affects cognitive function and concentration
SVS can lead to job burnout and thoughts of leaving one’s job
Nurses with SVS are likely to consider quitting their job and may take more sick days
Workplace support can help decrease these risks
SVS can lead to major mental health concerns such as depression
It can also significantly increase the likelihood of suicidal thoughts, particularly in practitioners facing lawsuits or believing they’ve made a medical mistake

Preventing Second Victim Syndrome

Healthcare organizations need to prioritize creating programs designed to give students, trainees, and healthcare providers understanding about the impact of situations that negatively impact patient outcomes. These educational initiatives should give all caregivers information about what happens after such cases, and make sure that help is easily available and free of charge.

Moreover, the systems need to pinpoint events with high risk and give individual support to healthcare providers to ensure necessary follow-up and assistance. Whenever a healthcare provider faces a lawsuit related to medical malpractice, encounters an unexpected patient death, or a case is submitted for review of care quality, it’s suggested that automatic referrals be made. Likewise, contact with peer supporters who have been trained on these matters should also be arranged.