Washington, DC—In the US healthcare system, between 210,000 and 400,000 patients die every year because of preventable adverse events. That is equivalent to 1 jumbo jet crashing every 4 hours. Estimating 4 clinicians per patient, that translates to between 840,000 and 1.6 million clinicians that are impacted—and potentially traumatized—by these preventable deaths every year. According to Susan D. Scott, PhD, RN, Manager, Patient Safety and Risk Management, University of Missouri Health Care, Columbia, this could represent the next healthcare crisis in the United States.
Sir Cyril Chantler, GBE, FRCP, FMedSci, FRCPCH, a renowned British physician, said, “Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”
According to Dr Scott, that danger applies not only to patients, but also to the clinicians caring for them, particularly in oncology settings. When a patient dies because of an unexpected medical event, the guilt, shame, and trauma that providers endure can be overwhelming.
Secondary Trauma More Common Than Expected
In conducting research on the secondary trauma endured by clinicians, Dr Scott said she heard similar “gut-wrenching” comments from staff members.
“These people came to work to help, and their healing hurt someone. It is a deep, visceral response that they say will change their careers forever,” she said at the Oncology Nursing Society 2018 Congress.
Dr Scott found that these experiences were ubiquitous among healthcare providers. “Everyone I talked to was a second victim, yet there was really nothing in the literature about it, so no one knew what we were dealing with,” she noted.
In 2007, Dr Scott and colleagues were preparing to launch a safety culture survey. Realizing the potential reach of secondary victimization, they added 2 basic questions to assess its incidence among providers. Of approximately 1200 clinician respondents, 1 in 6 said they had experienced secondary victimization in the past year alone.
“But what really was disturbing was, 62% had to get help on their own. This was enough for our administration to decide to do something,” she noted.
They formed a steering team and devised a definition that is still used to guide research internationally on individuals who experience negative effects after these unanticipated medical events. Second victims were 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.”
Next, Dr Scott and colleagues conducted a qualitative research study of 31 nurses, physicians, and allied health professionals. Participants were 58% women, with an average of 14 months since the last unanticipated patient event. The oldest and youngest were nurses with 36 years and 8 weeks of nursing experience, respectively.
“We learned that staff worry, and in a very predictable manner,” she reported.
First, they worry about the patient, then about themselves as professionals. All of the nurses worried about being fired, whereas physicians worried about lawsuits. Next, they worried about their peers.
Support from Colleagues Critical for Recovery
“Our hospital grapevines are healthy in a very negative way. Peers know what happened to their colleagues, but they frequently do not say anything,” Dr Scott observed. This leads to clinicians feeling ostracized or worried that their colleagues consider them a weak and untrusted member of the team.
“If you have a colleague in this state, reach out to them. They do not want to be ostracized. They do not want to have a black cloud hanging over their heads,” she urged.
Finally, providers fear what will happen next.
“Fear of the unknown and not knowing who they can reach out to safely is really debilitating for these clinicians as they suffer in the aftermath of an adverse patient event,” she added.
When clinicians respond to adverse clinical events, they typically exhibit 4 different domains of behavior—physical (eg, sleep disturbances, extreme fatigue), emotional (eg, anger, shame, guilt, anxiety), cognitive (eg, difficulty concentrating, invasive rumination), and behavioral (eg, isolation, decreased interactions). Certain high-risk scenarios can evoke a second victim response, including pediatric cases, medical errors, failure-to-rescue cases, and first death experiences. In oncology, however, it is typically tied to how much time providers and their patients spend together. Providers get to know their patients and family members, and they feel connected to them. Losing those patients can be devastating.
All 31 patients in the study by Dr Scott and colleagues reported similar accounts of the event having “stuck with them” in some way, but whether they perceived the event as positive (ie, learning experience) or negative (ie, haunted by the experience) was directly related to the support or lack of support they received within their institution, she said.
The researchers observed 6 predictable stages of recovery that clinicians go through after these events—chaos and accident response, intrusive reflections, restoring personal integrity, enduring the inquisition, obtaining emotional first aid, and moving on—by either thriving, surviving, or dropping out.
“It is not important to memorize the stages. What is important to remember is, if you are going through an event or you have a colleague going through an event, you can almost sit in an anticipatory manner and guide them to recovery. Stage 6 is unique in that it actually describes the outcomes on that clinical event. It does not predict future success or failure as a clinician, but rather how they have healed from the event,” Dr Scott said.
Finally, clinicians in the study were asked, “If your best friend were to go through a similar event, what would you dream of for them?” Above all else, they desired immediate support and guidance.
“They really want a lifeline. They want somebody to reach out to them, check on them, and actively listen to them,” she reported. Second victims want to be appreciated, respected, valued, and understood. But most of all, they want to remain a trusted member of their team. This takes the support of the whole team, not just one peer, she added.
Whereas the benefits of a clinician support network can be far-reaching, actually establishing one can be fraught with challenges.
The forYOU Team
Dr Scott and her colleagues at University of Missouri Health Care formed the forYOU Team, a peer-to-peer support model based on evidence-based research. The team employs local (unit or department) support, trained peer supporters, and patient safety and risk management resources. It offers 2 specific kinds of interventions after an adverse clinical event—one-on-one support and group debriefings when a whole team is impacted—and is coordinated to facilitate prompt referrals when clinicians’ needs exceed the capabilities of its team members.
“We had to break that habit, that veil of secrecy we have in healthcare. When something bad happened, we really did not talk about it. We designed the forYOU Team to promote healing from the perspective of clinicians, so they do not have to suffer in silence,” she said.
The team aims to minimize the human toll when unanticipated adverse events occur, provide a “safe zone” for faculty and staff to receive support and mitigate the impact of an adverse event, and develop an internal rapid response infrastructure of “emotional first aid” for clinicians and personnel following an adverse clinical event.
According to Dr Scott, implementing this interventional strategy has led to certain realizations.
“We realized that no 2 clinicians have the same support needs; awareness of the second victim phenomenon is the first intervention, and fear of the unknown is profound. We are learning that the aftermath of no support has a devastating impact, not only on the clinicians themselves, but on the units in which they work. It erodes teamwork and communication, and patients are actually less safe in this environment. So it starts to build a business case that this is really important work,” she concluded.