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Illuminating the shadows: Supporting healthcare’s ‘second victims’

How the healthcare industry can transform support for providers affected by adverse events, from silence to wellness advocacy.

This article is Part 2 in a 2-part series on Second Victims. View Part 1.

After two decades of researching and writing about "second victims" in healthcare, Dr. Susan D. Scott — a nurse by training — has come to what seems like the grimmest of conclusions. As she writes in Care at the Point of Impact — Insights Into the Second-victim Experience.

“A vast majority of the healthcare workforce has been suffering in silence from career-related anxiety and stress associated with adverse events within the clinical setting. Feelings of shame, guilt, anger, loss of confidence and depression are all possible reactions experienced by the suffering healthcare provider. Signs and symptoms of this emotional aftershock may last days, a few weeks, a few months or even longer. Most second victims feel defenseless to the wide-ranging symptoms and frequently express that they have never experienced such an extreme emotional response in their lives. Some clinicians will isolate themselves and may avoid returning to work.”

And yet, Scott is buoyed rather than depressed by her work because it — along with recent research by practitioners and academics around the world — is shedding new light on a topic that was for years a taboo.

In the pre-pandemic era, she and her co-authors found that nearly two-thirds of clinicians affected by an unexpected adverse outcome "indicated that they did not receive support from anyone within the healthcare community after the adverse clinical event. Furthermore, those who did typically received support in ways that did not satisfactorily address all their needs." Instead of support, they reported widespread institutional and professional expectations to suppress their emotions, keep quiet and return to work.

More than one in three clinicians reported being told, explicitly, to avoid discussing the event.

"But today those attitudes have truly shifted," Scott said. COVID-19 shined a bright light on wellness and wellness among healthcare workers. "It actually helped us by showing that the mental and emotional well-being of our workforce must be a priority to ensuring a healthy work environment."

As an example, Scott points to the forYOU team she helped create at the University of Missouri Health Care (MUHC) system. First started in 2007, the forYou team is an evidence-based, second-victim intervention offering three-tiered, immediate support to clinicians experiencing an emotionally challenging clinical event.

"The structure of the forYOU Team allows for interventional support from basic emotional first aid at the unit/department level to comprehensive, professional counseling services based on the individual needs of each clinician," Scott has written. "Each tier provides increasing institutional resources to help ensure that the emotional needs of the clinician are met. While some clinicians may need the resources available from only one tier of support, others might need resources from all three tiers to support professional and personal recovery from the event."

Scott and her co-writers first described the tiered approach in a paper, Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team.

Tier 1. Similar to a first-responder concept, Tier 1 promotes basic emotional first aid at the “local” or departmental level. We estimate that as many as 60 percent of second victims will receive sufficient support at this level. This tier involves preemptively addressing potential second victims to ensure they are “OK” immediately following a critical clinical event that could potentially evoke a second victim response.

Tier 2. This middle tier provides guidance and nurturing of previously identified second victims. It is projected that this type of support and guidance will meet the needs of an additional 30 percent of second victims. Specially trained peer supporters are fundamental at this level as a vital component of a rapid response team. Team briefings are also offered to assist when an entire team is involved in an emotionally challenging clinical event.

Tier 3. This tier must ensure prompt availability and access to professional counseling support and guidance when a second victim’s emotional stress exceeds the expertise of the peer rapid response team members. We estimate that 10 percent of second victims will require this level of support and guidance at some point after emotional trauma. Examples of Tier 3 professionals include chaplains, EAP personnel, social workers, holistic nurses and clinical health psychologists. As a result, we believe a large portion of the healthcare workforce has been suffering in relative silence, unsupported during career-related anxiety, stress and sometimes even shame or guilt. We now believe that it is our moral imperative to design and deploy a readily accessible and effective support infrastructure for all healthcare providers beginning when events causing anxiety and stress are discovered and extending through years of protracted litigation as necessary.

Now, Scott says, the forYOU team and its approach have become a model for hundreds of other similar programs around the globe. She suggests two reasons for its widespread adoption. The first is financial — a significant number of clinicians who experience the second-victim phenomenon may leave their work or transfer to non-clinical roles. The cost of replacing even a single nurse is estimated to be at least $80,000.

"Prior to 2020 and the COVID pandemic, the major focus of hospital administrators considering clinician support was to learn more about financial considerations for deploying a support team – specifically, the ROI," Scott said.

But, she added, the COVID experience taught the industry that the well-being of healthcare workers is the foundation of healthcare generally. Instead of leaving second victims to deal with the physical, intellectual and emotional labor of recovery alone, administrators learned that providing them with a support team to work through the complex feelings and emotions they experienced could lead to improved patient outcomes, more reflective practitioners, and a healthier workforce.

"It's finally become apparent in healthcare that not being ‘okay’ after emotionally challenging clinical events is an expected and normal human response that a nurturing and supportive work environment can easily address," Scott said.

This article was previously published by ICD on May 4, 2023.

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