Second Victims—Trauma, Treatment, and the Trouble with Tricky Terminology

Does the phrase “Second Victim” obfuscate or illuminate the trauma that health care providers experience during their careers?

Since the concept of the “second victim” was introduced nearly 20 years ago, there’s been increased awareness about the trauma that health care professionals can experience in their work, particularly during adverse patient events like medical errors. To better address how trauma impacts clinicians, a series of predictable stages of recovery have been identified, and strategies have been proposed for coping with the psychological and physical damage clinicians experience when they’re involved in an adverse patient event.

The increased transparency around this issue is a welcome development in addressing it, but the term “second victim” itself is problematic for some. Depending on where you’re standing, this wording can feel dismissive, defeatist, or disingenuous—or it can feel remarkably accurate and illuminating. It’s emotionally charged language that describes a substantively researched medical phenomenon: a provider’s experience of psychological and physical distress after involvement in a traumatic event.

A common argument in favor of the term suggests that it’s a helpful label—and a lack of alternative verbiage makes it difficult for those suffering from this kind of trauma to identify what they’re dealing with and get help for it. After all, as Dr. Albert Wu originally wrote, “Strangely, there is no place for mistakes in modern medicine.” The medical culture itself isn’t conducive to open dialog about unintended outcomes like medical errors, so putting a label on trauma makes it easier to point out.

Equally important arguments against the use of this term point out that particularly in the event of fatal medical mistakes, the phrase “second victim” falsely equates the trauma experienced by the patient and their loved ones with the distress felt by the clinician involved. Opponents of this language identify the patient who loses their life or quality of life to a medical mistake as the sole victim of the event.

The truth of the matter is that untreated trauma ultimately acts as a toxin in the mind and body of the individual who experiences is it. Patients, loved ones, and clinicians can all experience profound distress in the immediate and long-term aftermath of an adverse outcome. And all of them deserve support in recovering from their trauma.

At the Crisis Prevention Institute, we train from the perspective that the common values of a truly inclusive culture of safety can provide a foundation for recovery from traumatic events. These common values can be shared by staff, patients, and loved ones—and allow individuals in need of care to set aside semantics and focus on recovery.

Clinicians face a high likelihood of experiencing trauma after a patient-involved event—and their organizations need to support them with a robust and inclusive culture of safety.

It’s been estimated that as many as half of all health care providers will experience this type of trauma in their careers, and that most have been proximal to an adverse event that has the potential to be traumatic. This is vital to bear in mind when considering what can be done to make your organization’s existing culture of safety more robust and inclusive.

According to the University of Missouri Health System, “Frequently [clinicians] feel personally responsible for the unexpected patient outcomes.” Overwhelmed with anxiety, guilt, or depression, the past 20 years of research have identified a common pattern of recovery:

1. Chaos and Accident Response
2. Intrusive Reflections
3. Restoring Personal Integrity
4. Enduring the Inquisition
5. Obtaining Emotional First Aid
6. Moving On

It’s that final stage of recovery—Moving On—that has the most potential to positively or negatively impact organizational culture and future patient care. At that point in recovery that a clinician determines one of three paths forward:

• Thriving: restoring balance to life and career, the clinician gains insight and perspective, and draws from the experience to make a difference in the care they provide in the future.

• Surviving: continuing to work, the clinician struggles with continued intrusive thoughts and sadness, unresolved as to what can be learned from the event.

• Dropping Out: dogged by feelings of inadequacy, the clinician considers quitting or transferring, at a serious crossroads about whether they should even continue in medicine.

Knowing the well-established relationship between disruptive events and patient outcomes/staff performance, it is imperative that a culture of safety include provisions for addressing the trauma these events can cause. Everyone is at risk when a clinician is unable to address the trauma of an adverse event—but everyone can benefit when health care providers are empowered to recover and, ideally, grow, from these experiences.

How does your organization’s culture of safety empower clinicians to cope with trauma?  

In a blog post for the Joint Commission, a nurse wrote of her own traumatic experience: “Days after [an adverse patient event], the director of nursing asked me to her office to discuss the patient safety event. […] However, I was never asked how this incident may have impacted me or if I was able to continue with my duties. […] I continued working with the same team, but the event was like an elephant in the room all the time. I kept wondering, ‘What did I do wrong? How did this happen?’”

Tormented by guilt and anxiety, she found herself losing trust in her peers and her own abilities. Ultimately, she left her position—acknowledging only in retrospect that had she been able to get treatment for her distress, she might have stayed in her role.

Understanding that adverse medical events are an integrated experience in which patients, providers, and their loved ones can all experience trauma, efforts have been made to recommend constructive cultural developments to create more supportive environments that empower individuals. The thinking of these advisory organizations is that a trauma-informed environment of care empowers those who work within it to heal themselves and support the healing of others.

For example, Medically Induced Trauma Support Services (MITSS), takes a holistic view of traumatic patient events, and advocates for the support of all individuals involved. Like the Joint Commission, they advise that a robust and inclusive internal culture of safety is vital to addressing the impact of adverse outcomes for professionals and the populations that they serve.

Knowing that many of the dynamics within the medical culture are deeply rooted, consider enhancing your existing culture of safety to include a trauma-informed perspective that provides care to caregivers who are impacted by patient-related adverse events.

Take these practical steps to enrich and empower the professionals within your culture of safety.

Here are four strategies that you can immediately incorporate into your existing culture of safety to constructively address the risks of trauma:

1. Communicate in a professional, person-centered way.

• practice sincere, empathic listening
• maintain a supportive approach in collegial communication
• learn constructive strategies for facilitating difficult conversations
• make time for a complete debriefing for all involved in a crisis event

2. Provide meaningful support for the trauma that staff absorb during their duties.

• learn the signs of compassion fatigue
• encourage constructive coping methods
• value a trauma-sensitive approach that promotes healing
• sustain a work environment in which staff can safely process vicarious trauma

3. Lead with intention, knowing that even the smallest effort can reduce the likelihood of an adverse event.

• address conflict appropriately so that trust and teamwork can flourish
• own your side of the Integrated Experience—with your staff and those you serve
• replace perceived chaos with focused respect
• proactively address work environments that can be enhanced to better prevent crisis

4. Implement new practices that support true safety and collaboration.

• help your staff improve their constructive team approach
• provide the training that enhances staff skills and confidence
• practice change management that supports staff and organizational resilience  
• sustain an interdisciplinary, inclusive approach to the ongoing development of your culture of safety

In a sea of buzzwords and brand lingo, we can’t forget that we’re talking about human lives.

Particularly in evidence-based, highly regulated fields like medicine, heightened thoughtfulness and precision in the use of language are necessary. But over time, an emphasis on verbiage can deflect the focus from underlying issues that urgently need attention. There are many phrases and concepts that originated in the clinical setting that have since been co-opted by other industries, sometimes erroneously—and that can ultimately dilute, or even cheapen, the value of the words that we use to talk about lifechanging events.

Your culture of safety is not based on best practices, but people—individuals in need of care and individuals in the practice of delivering it. These individuals are linked by the potential that any of them can experience trauma. They deserve to be united by the common hope that recovery from trauma is possible.

Prevention is always the goal, but sometimes the unthinkable does occur. In those moments, there is an opportunity to set the groundwork for healing and recovery for staff who experience trauma after a patient-involved crisis. Take time to consider how inclusive your culture of safety truly is when it comes to coping with the aftermath of adverse events—when lives are at stake, don’t let the lingo trip you up.