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Feature: Self-Care for Nurses

Second victim support programs for healthcare organizations

Stone, Misty PhD, RN

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Nursing Management (Springhouse): June 2020 - Volume 51 - Issue 6 - p 38-45
doi: 10.1097/01.NUMA.0000662664.90688.1d
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In Brief


Although it was undefined and unnamed, the second victim concept was first introduced in 1954 when two surgeons shared their unexpected OR catastrophes, along with the emotional impacts that followed their experiences.1 For unclear reasons, the second victim phenomenon isn't commonly recognized in today's healthcare organizations.2 The second victim can be any healthcare worker who's been involved in an adverse patient event. Specifically, second victims have been defined as “healthcare providers who are involved in an unanticipated adverse patient event, medical error, and/or a patient-related injury and become victimized in the sense that the provider is traumatized by the event.”3

One study found the occurrence of the second victim phenomenon to be as high as 43.3%, in which 40.8% of clinicians indicated a “moderately severe harmful impact” and 2.5% reported a “severe impact” on their lives.4 Sixty percent of these clinicians noted being involved in an adverse event, with 66% experiencing anxiety, depression, or questioning their ability to perform their job duties.4 The second victim phenomenon can cause healthcare workers to lose their professional confidence, with some individuals leaving the profession altogether.5 Second victims have reported reliving and fixating on the adverse patient event for years or even decades later. Once a staff member experiences the second victim phenomenon, his or her chances of making another error increase, consequently putting patient safety at risk.5

Second victims are left feeling personally responsible for the patient outcome and most experience feelings of failure and second-guessing their nursing skills and knowledge.3 Research studies and The Joint Commission indicate the need for organizations to develop support programs for clinicians following an adverse patient event because it's critical for their psychosocial and physical recovery.3,6-11 The Joint Commission issued an advisory in January 2018 providing healthcare organizations with recommendations and resources for supporting second victims. It isn't known if support for second victims is a one-size-fits-all approach or if nurses require a different type of support than other healthcare workers. What is known is that support is needed for second victims, and healthcare leaders should mitigate the impact of adverse patient events on their staff members.5

The purpose of this integrative literature review is to describe the types of second victim support programs being offered by healthcare organizations to understand how best to assist second victims and highlight effective evidence-based strategies.


A comprehensive literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature, PubMed, Google Scholar, MEDLINE, ProQuest, and E-Journals Database, as well as reference lists from studies. The search was limited to research and/or evidence-based studies conducted in the US, focused on types of support for second victims in healthcare, and published in English between 2009 and 2019. The year 2009 was chosen as the starting point because this was when the second victim phenomenon was first defined.

Eleven studies were identified for review in two areas: types of second victim support suggested and the development and implementation of support services/programs in hospital settings. (See Summary of reviewed studies.) Two studies were qualitative, one was quantitative, six studies used mixed methods, and two were intervention studies. Sample sizes ranged from 4 to 575 healthcare workers (such as physicians, nurses, midlevel providers, risk managers, and others), with three studies not reporting a sample size and one study approximating a sample size. Four of the studies developed a second victim support program; three only described support needed; two studies evaluated support programs, with one using a longitudinal design; one study implemented a support program; and one made an effort to implement. Of the 11 studies, 2 were specific to nurses only.

Proposed support for second victims

Three studies offered suggestions for support needed for healthcare workers following an adverse patient event.3,12,13 Using a qualitative approach, Scott and colleagues developed a six-stage recovery trajectory for second victims.3 Participants noted they wanted a trusted person to confide in and suggested that organizations have a formal support program in place, along with clear procedures for how to access such support. Overall, the authors suggested that organizations train supervisors and peers in providing immediate support to those needing it, with the first step being the launch of an awareness campaign to educate all staff on the second victim phenomenon.3

In another study, the author explored types of support offered to second victims in 38 Maryland hospitals.12 Of the 43 participants, all but 1 reported that their hospital offered Employee Assistance Program (EAP) services to staff. In open-ended interviews, most participants reported wanting 24/7 peer support availability, the opportunity for time to reflect on the adverse event, the option of time off following the event, and support from executive leadership or their direct supervisor. Nearly 70% of the hospitals surveyed didn't offer a support program, whereas 13.2% were developing one. Six of the 38 hospitals (15.8%) had individual and multidisciplinary group support programs in place.12

Summary of reviewed studies
Summary of reviewed studies (Continued)

To understand risk manager perceptions of support program characteristics, White and colleagues conducted a qualitative study with 575 American Society for Healthcare Risk Management members, representing 423 healthcare organizations.13 Of the respondents, 73.6% reported that their organization had some type of emotional support program, with 7.3% reporting their organization planned to initiate a support program. Four participants noted that their organization previously had a support program, although it had been discontinued. In the 42 healthcare organizations planning to develop support programs, 76.2% noted that they would likely train individuals and base the program's design on an already developed model, citing the Medically Induced Trauma Support Services program and the forYOU program. Healthcare organizations planning to provide support services were more likely to utilize peers than those with an existing support program. The authors suggested specific processes for leaders to improve existing support programs, including assessing the structure, utilization, and efficacy of current support programs; raising awareness; developing a plan to close gaps; and creating additional tiers of service similar to the forYOU program.13

Support programs provided by healthcare organizations

Developed at the University of Missouri Health System, the forYou program uses a three-tiered model that provides confidential peer-to-peer support for clinicians following a stressful event to address their unique needs.14,15 Tier 1 consists of “local” unit/department support; tier 2, trained peer supporters and patient safety and risk management resources; and tier 3, expedited referral to additional support, such as the EAP or a chaplain, social worker, or clinical psychologist.14 Eighty peer supporters were originally trained to support individuals in the acute stages of emotional trauma; the program was then expanded to include 137 peer supporters.14,15 Following involvement in an adverse event, a second victim rapid response team is immediately activated. The overall goal of the forYOU program is to ensure that healthcare workers don't go home to suffer alone, assisting them to move past the event, return to their preevent performance and, ultimately, thrive in their profession.14,15

After 5 years of the forYOU program being implemented throughout the University of Missouri Health System, a longitudinal study was conducted to evaluate the program.15 During the first 5 years of the program, 1,075 clinicians were documented as receiving either group debriefings or one-on-one peer support. Most of these clinicians received tier 1 and tier 2 support, including mentoring, group debriefings, and one-on-one caring moments. However, 9.7% required professional referrals as part of tier 3 criteria. Due to the success of the forYOU program, employees began using the program for incidents not related to adverse patient events, causing the program to limit its scope to keep the focus on second victims.15

A freestanding pediatric academic healthcare organization in Columbus, Ohio, replicated the forYOU program in collaboration with the University of Missouri Health System.16 A multidisciplinary steering committee was developed to implement the YOU Matter second victim program throughout the organization. Piloting with the hospital's pharmacy staff was successful and the program was then implemented in the ED, with various departments following until the program was available to all urgent care, outpatient primary care, and ambulatory specialty clinics. The authors noted that training and implementation followed the forYOU program, including the three-tier model, which enabled the YOU Matter program to be operational within 6 months. What's different about the YOU Matter program is the use of electronic documentation to quantify the frequency and types of encounters with second victims. From its implementation in 2013 to 2017, the YOU Matter program had over 300 trained peer supporters, with the majority being nurses. Nurses were also the most documented users of the program.16

The Resilience in Stressful Events (RISE) peer support program was developed at Johns Hopkins Hospital by patient safety, risk management, and clinical department leaders.8 The RISE program provides timely psychological first aid and emotional support within 12 hours of a clinician experiencing an adverse patient event. It offers 24/7 support in a peer-to-peer or group format, depending on the healthcare worker's request. The support groups are made up of trained peer responders, including nurses. Implementation of the RISE program consisted of four phases, including an awareness campaign using website advertisements, promotional videos, and screensavers on work computer screens; presentations given to clinic unit staff; recruitment of unit-level champions; and hospital-wide expansion.

The first phase included the development of the RISE leadership team and the program's mission. A six-member multidisciplinary team designed a work plan and procedures for providing support, identified team members, and determined training and additional resources needed. The second phase involved recruitment and training of the RISE peer responders. In the original peer responder group, nurses were the majority at 63%. During this phase, it was mandated that peer responders attend 6 hours of psychological first-aid training sessions to properly address emotional distress, including lectures, storytelling, role playing, and group discussions. Phase three launched and piloted the RISE program in the 205-bed pediatrics department at Johns Hopkins Children's Center. Phase four was the hospital-wide expansion of the RISE program, which occurred 7 months after the pilot. During this phase, a two-tiered anonymous call system was designed in which two peer responders are on-call at all times, allowing one to assist the other if needed. Additionally, should the first peer responder be a coworker on the same unit as the caller, the call is passed off to the second responder. A limitation of the RISE program was that employees weren't made fully aware of the program despite the awareness efforts before implementation; therefore, the program wasn't frequently utilized.8

Since the implementation of the RISE program at Johns Hopkins Hospital, a study was conducted to evaluate the program's implementation and effectiveness.17 Nine-hundred individuals were sent a 4-year follow-up survey; however, the response rate was low and estimated at 23.3%, with the majority of responses coming from nurses. Respondents were 93% likely to recommend the RISE program and most characterized the program as being useful and worthwhile, with only a few expressing doubts about the program. Content analysis identified barriers to utilizing the program, such as overcoming blame culture and the need to promote the initiative. Respondents also reported wanting more staff time to handle adverse events, echoing recommendations from respondents in the White and colleagues' study.13 The most desired aspects of the RISE program were its nonjudgmental approach, 24/7 access, and the commitment to follow-up.17

One study developed a curriculum for certified registered nurse anesthetists (CRNAs) through a literature review and utilization of a five-expert panel, consisting of a doctorally prepared RN, two physicians, a doctorally prepared CRNA, and a doctorally prepared psychologist, with second victim experience.2 The authors recommended adding educational content to CRNA programs to help with understanding the second victim phenomenon, as well as how to support second victims.

Another study developed a clinician peer support program at two large teaching hospitals affiliated with Washington University School of Medicine in St. Louis, Mo.18 The program provides support to only physicians, residents, fellows, physician assistants, NPs, and CRNAs following an adverse patient event. Peer supporters received training on the emotional and functional impact of adverse patient events on clinicians and education about warning signs and known risk factors signifying that clinicians may need additional support from internal and/or external resources. Simulations were used in which peer supporters had the opportunity to act in both the peer supporter role and the supported clinician role. Additionally, a 1-hour presentation focusing on the second victim phenomenon was presented during grand rounds, faculty and staff meetings, and other departmental meetings. Peer supporters aren't assigned to peers in the same field or who hold a supervisory position to the peer supporter. Changes were later made to the program in that peer supporters began proactively contacting all physicians and midlevel providers after being involved in a serious error or adverse event.

As a Capstone project, one study attempted to implement a support program called Helping Others Process the Event (HOPE) at a 247-bed community hospital in rural North Carolina.19 Implementation began with establishing a multidisciplinary advisory group to assess the organization's safety culture and internal and external support resources, staff members' awareness of adverse events, and clinician and staff responses. It was discovered that the organization didn't offer formal support to employees. With a focus on staff members who had been involved in an adverse event in the last 12 months, 68 nurses were surveyed to assess resources for formal and informal emotional support. Due to a low response rate of four nurses, the organization suggested postponing the HOPE program until revisions were made to the survey and it was distributed to all hospital employees. Unfortunately, there was no ongoing communication with the hospital due to a “lack of trust, poor attitudes, and low morale,” causing implementation of the HOPE program to be unsuccessful.19

Management implications

This integrative literature review allows for the exploration of two distinct areas: the types of support researchers propose for second victims versus how organizations are truly supporting these individuals. For organizations considering starting a second victim support program, this review provides insight into what clinicians would like in a support program and examples of programs that already exist, which can be used as a starting point during the development phase. Although it's unclear if a one-size-fits-all approach is effective or which programs have performed better than others, what does remain evident is that some type of support should be provided to second victims. In the studies surveyed, it was found that nurses used the support programs the most; however, the extent of support programs in hospitals is limited.

Organizational support is of the utmost importance for second victims to assist them with coping effectively and increasing the likelihood of being able to return to their normal clinical duties while contributing to preventive strategies for adverse patient events.20 Effective and sustainable organizational support can help ensure that nurses and other healthcare workers never have to experience the second victim phenomenon alone. The Joint Commission provides recommendations for designing second victim support strategies, such as instilling a just culture, offering immediate peer-to-peer support, and engaging all team members in the debriefing process.6

Research has amplified our understanding of the second victim phenomenon, yet additional studies are needed to better understand nurses' emotional and psychological needs following an adverse patient event. More research is warranted to determine what types of support specifically benefit nurses to strategically develop effective second victim support programs.

Bonus content

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