When the job becomes a trauma

Second-victim phenomenon - old news or a perennial issue?

When a treatment incident occurs, the patient and their relatives are at the center of attention as the first victims. In 2000, Albert Wu, professor at Johns Hopkins University in Washington, coined the term second victim. This refers to the professionals involved in the incident. They too can be affected by intense emotions such as guilt, shame or self-doubt as a consequence of the incident and suffer from the resulting high level of stress. 

A look at German clinics shows that even more than 20 years after the term was introduced, there are rarely any fixed structures for dealing with such situations. Although it is pointed out in practice that there are counseling centers for those affected or internal discussion services, the implementation of these services is often unstructured.

One explanation for this could be that, according to current findings, the phenomenon is widespread but little known. These are the findings of the SeViD study series, which has been investigating this issue in individual occupational groups in Germany since 2018. The prevalence of the phenomenon seems unsurprising. Employees in the healthcare sector are already exposed to a high level of basic stress - for example due to staff shortages, critical patients, emergency situations or even hopeless fates. It is not uncommon for life and death to be at stake. It is not only young staff who are affected by serious incidents. Experienced, seasoned staff can also be exposed to serious stress.

The consequences of a traumatic event

The consequences for those affected can be manifold. Dysfunctional processing often occurs. As a result, those affected can isolate themselves, develop depression or a post-traumatic stress disorder. The stress can also manifest itself in sleep disorders and lead to the situation being relived over and over again. It can also lead to substance dependency. These and other factors not only have an impact on the health of those affected, but also on the professional context. The fear of future mistakes increases and can lead to insecurity in their own actions, so that for some, the only way out is to leave their job.

The consequences of the second-victim phenomenon can also have a negative impact on patient safety. Practitioners who are plagued by the fear of making another mistake or who doubt their own professional competence can develop defensive behavior or need constant reassurance from other team members. In addition, the health burden leads to reduced performance, which in turn increases the susceptibility to errors. This can lead to incorrect decisions and actions or delayed treatment for patients.

Ultimately, however, the entire organization also suffers the consequences. Long-term employee absences or increased staff turnover can damage the company. At the same time, the circumstances can have a negative impact on the prevailing safety culture and weaken it.

Help for those affected

Those affected often want a structured way of dealing with such situations. Managers are particularly challenged in this respect. They are not only responsible for creating any structures, but also for correctly assessing the employees and the situation in order to be able to offer and initiate appropriate measures. This can often be difficult, as they themselves may be affected by the incident. However, colleagues also have a key role to play and should be made aware of how to deal with second victims.

The three-stage model by Scott et al. is well known in the literature (Fig. 1). It describes an escalation plan for supporting second victims. In the first stage, the team members provide assistance to the victims. To do this, they must be able to correctly assess the situation and the stress and act accordingly, for example by actively offering to talk. Blame or the well-known “blame and shame” should be avoided; on the contrary, understanding for the need for help should be shown. Those affected should be encouraged to ask for help without this being interpreted as a sign of weakness. In addition, they should be offered a short break, even if this means a short-term loss of staff. 

If this support is not sufficient, a special team is activated according to the Scott et al. model. This is a team trained in dealing with the problem, which is available directly and at a low threshold for those affected. This team is then also able to recognize when stage three has been reached and professional help is needed.

Prevention and a practiced safety culture

Even though the second-victim phenomenon is widespread, dealing with it in clinics is still largely unstructured. The credo of “Just don't take it home with you!” still often prevails. However, the consequences for those affected can be serious and range from isolation and mental illness to giving up work.  These factors can have a negative impact on patient care and pose a risk to patient safety. For this reason, the aim should be to offer those affected timely and appropriate support so that, in the best case scenario, they can grow from the burden. It is advisable to address this issue preventively within the hospital in order to develop and establish structured services. The training of peers for collegial support can be a component of this. They can offer those affected competent help on an equal footing according to the motto “equals among equals”, recognize further-reaching needs and mediate accordingly. In addition, an established and practiced safety culture contributes to an open and systematic approach to dealing with errors. This enables employees to communicate without fear of blame, which also has a positive effect in the event of traumatic situations.