Second victim“The programme at NUH is going from strength to strength which is great. An additional cohort of Peer Supporters have been trained. The greatest impact of any incident is on the humans involved. Certainly the patient and their relatives foremost, but also the staff involved. Our staff are key to ensuring the organisation functions and improves; we need to support them after any incident to help normalise their feelings, support their return to practice but also to aid theirs and the organisations learning.”
Karen Whiting, Patient Safety Improvement Nurse, Nottingham University Hospitals NHS Trust

Background

An adverse clinical event, patient safety incident or medical error can have a far-reaching impact not only for the patient and their families; the first victims, but also the healthcare professionals involved. These are sometimes referred to as ‘second victims’. Often there are few opportunities for second victim healthcare professionals to discuss the details of incidents or events and share how this has affected them personally.

The East Midlands Patient Safety Collaborative (EMPSC) funded the University of Leicester (UoL) as part of their National Safety Culture workstream to develop a Second Victim Support Unit within the Children’s Hospital at University Hospitals Leicester (UHL) to test whether models of support established in the US could be successfully transferred to UK health settings.

The pilot included five key elements:

  1. Conducting semi-structured interviews with a sample of clinical and non-clinical staff who had been directly involved in a patient safety incident, adverse event or medical error in UHL and Nottingham University Hospital (NUH) to explore the impact this had on them and the type of support they would have liked to receive. These were transcribed and thematically analysed to identify core themes.
  2. Developing a three tier second victim support programme and including training peer supporters (tier 2).
  3. Piloting of the model.
  4. Evaluating the pilot by interviewing staff who had accessed the peer support.
  5. A final report which included recommendations based on findings from the scoping project.

The response from the health professionals utilising the peer support service (tier 2 support) was positive, saying the service had helped them normalise the situation, feel supported and remain in work. Specific feedback highlighted the value of the service and the benefits of having a peer support service accessible in the workplace.

Following the UHL pilot, the EMPSC published a final report outlining its findings and making recommendations to facilitate the adoption and spread of Second Victim Support Units. These were spread through an East Midlands Community of practice and the model has been embedded in Nottingham University Hospitals and spread further to the Health Service Investigation Branch (HSIB) and Lancashire Police.

Aims, objectives and scope

Second victims have been defined as: Healthcare team members involved in an unanticipated patient event, a medical error and/or a patient related injury and become victimized in the sense that they are traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.” (Scott, et al., 2009).

Second victims can exhibit a variety of physical and psychosocial symptoms, such as; anxiety, anger, guilt, fear, depression, insomnia, social withdrawal and lack of confidence in the weeks, months, or even years following an incident.

Second victims can feel devastated, singled out, hesitant in having discussions with colleagues and have concerns around job security and their own competency (Clancy, 2012, Wu, 2000). Outcomes of these experiences can vary with individuals often adopting one of three responses; survive, thrive, or drop out depending on the individual’s personal resilience, coping strategies and the support they receive following an incident (Sidney, 2013) (Scott, et al., 2009).

Healthcare professionals involved in adverse events experience emotional distress on both a personal and professional level (Mants, 2015). After an adverse event, second victims want to feel appreciated, understood and to remain a trusted member of their healthcare team as well as desiring organisational support to help them cope with the error (Scott, et al., 2009).

Given that second victimhood is estimated to affect between 10 and 43% of healthcare professionals, The University Hospitals of Leicester (UHL) recognised the opportunity to better support a significant number of their clinical and support staff following an incident.

A serious incident resulted in an avoidable child death and had resulted in far reaching consequences for both the family and staff involved.  This incident acted as the catalyst for the organisation in taking a planned and proactive approach to better understanding the experiences of their staff and knowing how best to support them.

Scoping for the pilot aimed to identify opportunities to:

  1. Provide support and wellbeing interventions to workplace second victims so they felt supported by their employer following an incident
  2. Reduce workforce sickness and absence related to struggling to deal with the outcomes of the incident
  3. Reduce the negative impact on professional and personal confidence felt by second victims following an incident
  4. Reduce the negative impact on morale felt by second victims following an incident.

Method and approach

The EMPSC worked with clinical and academic partners to explore whether approaches to supporting second victims developed in the US could be translated successfully to a UK healthcare context.

A number of US healthcare organisations had developed and implemented second victim support models which included recommendations for Psychological First Aid (PFA) as an early intervention for all survivors of potentially traumatic events (Forbes, et al., 2010) and the training of staff to offer peer support to colleagues.

The EMPSC – supported by a team of academic and clinical psychologists at the UoL and Cardiff University (CU) – funded a pilot to test if a ‘second victim support unit’ approach could provide benefits in a UK health setting.  This model has been developed by Sue Scott and a multidisciplinary research team at University of Missouri Health Care (Scott, et al., 2010) and was identified as a good fit for the UK Healthcare context.

As part of initial scoping and research, in-depth semi-structured interviews were undertaken with 21 staff across UHL and NUH who were purposefully sampled for their involvement in a historic patient safety incident.

The interview transcripts were analysed and used to support the development of a pilot second victim support unit.  Six priority themes emerged from the analysis:

Victimisation/self-blame – participants felt lack of control, vulnerable, not being heard, fear, guilt and feeling responsible for the patient and their families.

Cognitions – following the event, participants reported a lack of confidence and doubt in their own abilities and their ability to carry out their job leading to reduced professional self-efficacy, double checking, intrusive thoughts, flash backs and rumination.

Heightened emotionality – participants reported feeling very high emotions after the event, many felt very angry at the situation, the decisions made, and the response from others including the organisation. They were highly anxious, sad, upset, irritable, depressed and traumatised.

Coping behaviour – many demonstrated a physical response such as difficulty sleeping. Some demonstrated negative coping behaviours such as increased alcohol use, others used more positive coping behaviours such as exercise, seeking support from others (colleagues and family) or avoidant behaviours such as avoiding work, the ward where the incident occurred or patient and their families.

Organisational support – participants described the support they received during the incident and the support they wished they had. Many participants felt supported by their team and colleagues but wished they received more support from the management and organisation leading to a lack of faith in the organisation and a lack of commitment to the organisation.

Patient safety and culture – many reported being frustrated by response of the organisation during the investigation, they felt they were being blamed and not treated fairly with many fearing the repercussions this could bring.

The second victim support programme and associated training was developed by the team at UoL and CU and was adapted from the Scott Model (2010). This approach was piloted from October 2016 in the Children’s Hospital at UHL.

The second victim support programme comprised three tiers:

Second victim

Tier 1: Local training in the chosen clinical area, on basic supportive leadership and human factors.

Tier 2: Selection and training (1 day) of peer and self-nominated multidisciplinary healthcare professionals to provide peer support to those who are involved in a patient safety incident. Training covered having difficult conversations and recognising when to signpost to professional support and guidance.

Tier 3: Setting up of a referral network to provide further psychological and structural support for peer supporters through the internal counselling service.

An internal communication plan was put in place to disseminate information throughout the Trust on how to become a peer supporter. Information on the second victim model was circulated using the intranet, e­mail communications and information provided in the monthly CEO’s briefing to staff.   This resulted in a high volume of interest and thirty-one completed applications to the programme. Interested applicants were asked to fill in a pre-screening questionnaire detailing previous experience and their motivation to become a peer supporter.

A one-day workshop was held at the University of Leicester in October 2016. Sixteen people from UHL’s Women and Children’s department attended including play therapists, nurses, matrons and consultants.

The workshop introduced the concept of a second victim and the need to reflect on personal experiences. Organisational culture was addressed, particularly with regard to human factors and blame culture, which had been highlighted during the initial scoping interviews.

The second half of the workshop focused on outlining the role of the peer supporter including confidentiality, expectations, required skill-set, the referral process and putting into practice skills and techniques through scenarios and role play.

All attendees received certificates of competence and authorisation to act as a peer supporters within the Trust.  They were also provided with peer supporter badges and lanyards for easy identification as well as support materials including a prompt script and an evaluation sheet to fill out after each peer support interaction. Regular sessions were also scheduled with the Amica (UHL’s internal counselling service) so peer supporters could discuss their progress or any concerns about specific cases in a safe environment.

Measurement plan

As the referral process who was supported and the peer support discussions confidential in line with British Psychological Society counselling guidelines, those involved in the pilot were asked by those who provided the peer support if they wanted to take part in the evaluation. Three staff members who had been peer supported consented to taking part. The interviews explored their experience of the peer support programme and asked what had led them to access the programme. Symptoms were explored including how stressed they felt before and after using the programme.

Participants were asked for their experiences of speaking to a trained peer supporter, the value of the support offered, and whether this had helped them stay at work. Two of the three participants said receiving the peer support had significantly reduced their stress levels and all three said they had considered taking time off sick but being supported by the peer supporter helped them stay at work. One questioned whether they should leave the Trust and the profession all together, but the peer support helped them stay in the organisation.

Participant Scale of 1 to 10 before peer support Scale of 1 to 10 after peer support Help stay at work Remain in Trust
1 9 5 Yes No
2 10 3 Yes Yes
3 2 2 Yes No

NHS of staff absence represents a huge cost to the NHS and this equates to £2.4bn a year – accounting for around £1 in every £40 of the total budget (NHS Digital, 2017).  Whilst the evaluation is limited to only three participants and no formal return on investment has been conducted it is starting to demonstrate that the intervention is helping reduce staff absence.

Results and evaluation

The response from the health professionals utilising the service was positive, saying the service had helped them normalise the situation, feel supported and remain in work. Specific feedback related to the value of the service, the benefit of having access to peer support and having a service available that could be accessed in the workplace.

A qualitative approach to evaluation was taken to measure the value added by the Second Victim Support Unit model and specifically the impact of peer support. Transcripts of the follow up interviews were analysed, with outcomes categorised into themes:

Value of the peer support service

Interviewees found the opportunity to speak about their experience of a patient safety incident within a short space of time following the incident invaluable. Many stated that they were reassured by the peer supporter being aware of the incident and disclosing their own personal experiences of previous incidents.

“I found her very helpful at the time, just her being there was great.” (Nurse)

“It was very beneficial, it was very good. I was given the free space to just talk very openly. And because she was also my manager and had an understanding about the incident as well, that obviously helped I think. I felt it was managed really well, I was given the support and offered time to actually go home on that shift, which is what I needed. I was then in a much better head space to be at work. I felt much better about being in work.” (Senior Nurse)

“I did have that afternoon off after that chat, but I’ve worked better and I felt confident again, and felt happy to be in work again, without it I would have found it difficult to go back into work.” (Nurse)

Recommending the Service

All interviewees stated that not only would they use the service again, but they have promoted and recommended the service to other colleagues. This was for various reasons including to provide additional, structured support to individuals involved in a direct or indirect incident, as well as, making others aware of the programme across the ward as many did not know the service was available to them.

“I would definitely recommend the peer support to anyone, at first I didn’t even know we could have this kind of support.” (Nurse)

“I told my colleague to get some support when I saw she was struggling to manage her emotions with an incident.” (Nurse)

Using the Service

Many stated, now they were aware of the service and what it offers, they would use it again as and when they needed it. This knowledge provided somewhat of a safety net through awareness of when and where healthcare professionals can use the service during times of adversity.

“I can contact her at any point, and probably I will use a bit more.  It allowed me to put a lot of my tensions on her really, because she was here every day with me she always had time to ask me every daily, how I’m doing today.” (Nurse)

Trained Peers

Interviewees stated they felt assured that members of their own team were trained with the correct skills to support someone during times of critical incidents. Many stated the comfort in having someone already aware of the ward and the dynamics as they can provide better support than an external body. Thus, strengthening the relationship between peers.

“I think there should be more people trained into it, and maybe not only managers I would believe that you should have a mixture of people.” (Nurse)

“The fact that she came to me, the fact that she made the time. She even contacted me I remember at home, you know, asking how I’m doing. And that was really good. I really enjoyed that, and I think we should have more supporters like her.” (Nurse)

Comfort

Interviewees described the peer support meeting as a system of support they felt comfortable using. Rather than taking time off work, the health professionals felt at ease to continue working in the hospital, given a change of environment and were able to ease themselves back into the ward and their duties.

“Because that allowed me to stay in the hospital environment, instead of going off sick. It gave me a break from the labour ward. And that was the point when she contacted me and she came over to talk to me here. So, it was not in the other hospital, it was quite nice. She came over in her own time.” (Nurse)

Understanding

The peer support meetings normalised many of the reactions of the health professionals using the service. The interviewees found themselves feeling less alone with their emotions and reactions when the peer supporter disclosed that they too have had similar experiences.

“She made me realise that everyone makes mistakes, because we’re all human. And to hear from her that she’s also experienced something like this as well was really reassuring.” (Nurse)

“I actually wanted to talk about it. And, yeah, I was able to talk to her. What helped me the most was probably the fact that she said that she also has made mistakes.” (Nurse)

“I think really having that space to talk and really just let everything out was just so beneficial because, you know, she’s a trained peer supporter and she’s a manager, and could really understand.” (Nurse)

Learning points

Summary conclusions

This scoping pilot investigated healthcare professional’s experience of the concept of second victimhood.  Personal accounts of experiences of being involved in patient incidents, were explored, highlighting staff can suffer a number of negative psychical and psychological effects. These findings demonstrated that staff do need support after being involved in a patient safety incident.  If staff are supported then there can be positive development and growth from the incident both at an individual and organisational level.

The findings from initial scoping interviews helped shape the development of a Second Victim Support Programme using the established ‘Scott Model of Second Victim Support’, which involved training peer supporter to provide emotional first aid to colleagues in the immediate aftermath of an incident.

The response from the health professionals utilising the service was positive, and indicated the service had value in helping them normalise the situation, feel supported and remain in work.

The following recommendations were made following the pilot project as part of the published evaluation report.  These sought to provide other Trusts and health settings with learning for adoption and spread of the Second Victim Support Unit model.

Recommendation 1: Staff need support after a patient safety incident

The Second Victim Support Unit scoping project explored the experiences of health professionals in two clinical units in two large Acute Trusts. The findings not only supported existing literature but also illustrated the ways in which critical incidents can impact the healthcare professional over a long period of time. The implications of this are that health professionals are susceptible and vulnerable to errors and these can have detrimental consequences at both the individual and organisational levels. However if staff feel supported by their colleagues and the organisation, this can lead to positive outcomes including increased organisational and individual resilience and adaptive capacity and new ways of working developed from a supportive, learning culture to ensure those errors are not made again.

Recommendation 2: Wide dissemination and communication of Second Victim Support Programmes

Second victim support programmes need to be widely communicated and disseminated, through a structured and ongoing internal communications strategy. The team at UHL worked closely with the Trust’s communications function to ensure that the programme was communicated through a number of different channels including the staff intranet, CEO briefings, videos and posters.

The purpose of the supporting communications was to both recruit peer supporters and also raise awareness that staff were able to access the programme for support. There can be a stigma associated with seeking help so communications were carefully ‘messaged’ to normalise this, with anonymised quotes and case study examples of previous personal experiences.

Recommendation 3: Peer Supporters need structured support and on-going training

Structured support for peers was a key component of the Second Victim Support Programme. Regular meetings were set up between the trained peer supporters and Amica, UHL’s internal counselling service.  This provided peers with an opportunity to discuss, with each other or the head of the counselling service, any issues they are having or difficult cases and how to deal with these. In addition, ongoing refresher training and opportunities to reflect and practice peer support skills provides an important additional element and should be built into any peer support programmes.

Plans for spreading learning and encouraging adoption

Following on from the success of the pilot, an East Midlands Second Victim Communities of Practice was established by the EMPSC, with 120 members.

The first Communities of Practice event was held on 29 March 2018 and attended by representatives from; Nottingham University Hospitals NHS Trust (NUH), Chesterfield Royal Hospital NHS Foundation Trust, Derby Teaching Hospitals NHS Foundation Trust, and Sherwood Forest Hospitals NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust (mental health) and participation from maternity units at; Chesterfield Royal, and Derby Teaching Hospitals.

This model of Second Victim Support has been adapted and adopted by NUH who have to date trained 37 peer supporters. Kent Surrey and Sussex AHSN have set up a special interest group to develop a community of practice. Healthcare Safety Investigation Branch are currently implementing a peer support programme to support their investigators. This has been spread to Lancashire Police who are implementing a peer support programme for their senior officers.

Start date

October 2016

Contact for further information

Dr Cheryl Crocker, East Midlands Academic Health Science Network Regional Lead Patient Safety Collaborative and AHSN Network Patient Safety Lead
C Floor, Institute of Mental Health, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU
E: emahsn@nottingham.ac.uk
Twitter: @EM_AHSN