Supporting Second Victims

Gwen, a registered nurse for 28 years, knew her maternity patient’s condition was changing for the worse – and fast.

As the 3-hour clinical event played out, her adrenaline took over.

“It kind of feels like time stands still, like you are walking through maple syrup. But your thoughts, they are accelerated,” she recalled of the confidence-crushing medical error. “Once the event is taken care of, your body catches up.”

For Gwen, the catching-up process lasted days. Though it happened years ago, her memories remain fresh.

“It feels like electricity coursing through your limbs, a quaking feeling all through your body,” she shared. Her identity is being withheld to protect the privacy of the patient, as are details of the event. “For the first time in my life I felt like I shouldn’t go outside my house.”

After the event, which Gwen still considers as “the most intense experience” of her life, she wanted to know other people’s stories, how they coped.

“I’d been around long enough to know that other people had gone through this kind of stuff and came out on the other side,” she recently told ADVANCE.

Today, Gwen is a member of University of Missouri Healthcare, and a “second victim” survivor who wants to give back to others as a trained member of MU Healthcare’s forYOU Team.

Since they began collecting data in 2009, the forYOU Team has assisted 640 employees, either in one-on-one encounters, 48 group briefings or 26 leadership-mentoring sessions.

Drama vs. Trauma

Operational since 2007, the forYOU Team provides what Patient Safety Coordinator, Susan Scott, MSN, RN, and Clinical Improvement Specialist, Laura Hirschinger, MSN, RN, equate to a form of “emotional first aid.”

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Currently, about 130 employees are trained to provide one-on-one support and stress management interventions for stressful events including unexpected patient outcomes and medical errors.

There are approximately 6,000 employees throughout MU Healthcare’s seven hospitals and multiple clinics, including more than 1,400 nurses.

“Really, it can be any event that is emotionally challenging and stressful,” said Scott. “There is so much drama in a hospital hallway sometimes that drama turns to trauma.”

Offered Hirschinger: “You can handle it all, day in and day out, until one day, for some reason, you can’t.”

It’s called “second victim” phenomenon.

Second victims are healthcare providers who are involved in particularly stressful or traumatic clinical events, Scott said, such as:

  • failure-to-rescue efforts following prolonged intervention,
  • an adverse patient outcome,
  • an event related to a medical error,
  • the death of a child, or
  • any other event that is unusual and emotionally challenging.

“Involvement in any of these scenarios could lead a healthcare provider to become victimized by the trauma they experienced [and begin] second-guessing their own clinical skills and knowledge base,” Scott said, adding “these stressful events can occur in the healthcare environment or even outside work in our personal lives.”

When that day comes, Scott and Hirschinger want their colleagues to know they are not alone.

The forYOU Team moniker was the winning entry in a contest among members of the team’s steering committee, noted Scott.

“The name was chosen to be one continuous long name to represent that we are all in this together, and that you are the center of our care at this point,” she said. “Our mantra is” ‘You’ve cared for our patients, now let us care for YOU!’ “

Silently Suffering

Scott, a nurse since 1977 whose background is in neonatal critical care, and Hirschinger, a nurse since 1996 whose master’s is in holistic care, were instrumental in the creation of the forYOU Team.

The team works within the Departments of Patient Safety and Risk Management, under the direction of the health system’s Office of Clinical Effectiveness (OCE).

The knowledgeable pair both acknowledge that awareness of the phenomenon, as well as proactive institutional response, is critical.

In fact, they both feel that awareness of the second victim phenomenon is the first intervention that a facility can deploy.

“We are so focused on caring for others, we need to nurture each other to keep our healing environment positive,” Hirschinger said. “Laura’s and my mission is to get the word out about the second victim experience,” Scott reinforced.

When Scott assumed coordination of MU Healthcare patient safety efforts in 2006, one of her roles was working with clinicians following an unexpected clinical event.

Those encounters convinced her that far too many clinicians “were experiencing a tremendous amount of professional and personal suffering following these unanticipated events.

“I just knew it was a very miserable experience for the clinician,” Scott said.

Scott was reminded of Tony, another employee survivor whose story became a critical milestone in the OCE’s early journey to help understand the phenomenon.

Three days after losing a patient to an unexpected cardiopulmonary arrest, Tony met with Scott as the investigation into the patient’s death got under way.

“Tony’s Story,” published on MU Healthcare forYOU Team website, describes his inability to concentrate on anything other than this patient experience, even while away from the hospital, for almost 3 days, which were filled with headaches, severe nausea and insomnia.

“Despite his best efforts, he couldn’t shake the recurring thoughts of his final conversation with the patient,” Tony’s story continues. “He was experiencing an internal crisis of huge proportions with one repetitive thought – he wasn’t good enough to be a nurse and should leave the profession.”

Scott said the MU Healthcare forYOU Team is dedicated to “Tony” and his many colleagues who choose to face stressful events daily in order to help improve the lives of those under their care.

Naturally Supportive

As a way to quantify the prevalence of the second victim phenomenon at MU Healthcare, in 2007, they added two questions to their routine patient safety culture survey.

Scott said they found almost one in seven employees experienced an event within that past year that resulted in feelings of anxiety, depression or concerns about their ability to do their job.

Additionally, 68 percent of the respondents reported they didn’t receive workplace support.

From there, Scott said she began to assemble a task force to address staff support in the aftermath of an unanticipated clinical event.

She sought out what she described as all the “natural supporters in the hospital environment,” including social workers, the director of employee assistance, respiratory therapists, a few staff nurses, nurse managers and physicians.

For 18 months, a 14-member steering committee met a least twice a month to design a plan for addressing the needs of second victims at MU Healthcare.

Over that time span, a research subcommittee completed 31 qualitative interviews, promising total anonymity. Participants included 10 physicians, 10 health professionals and 11 RNs.

For many, it was the first time they were encouraged to talk about their feelings, according to Scott.

Scott was amazed when many participants provided meticulously detailed accounts of their respective events, down the color of scrubs worn when the event occurred. She was also surprised to find a fairly predictable recovery trajectory.

6-Stage Process

According to Scott, the researchers found that while second victims develop their own coping mechanisms, they all went through a similar 6-stage process:

  • chaos and accident response;
  • intrusive reflections;
  • restoring personal integrity;
  • enduring the inquisition;
  • obtaining emotional first aid; and
  • moving on.

The sixth stage was unique in that it led to one of three potential outcomes – dropping out, surviving or thriving.

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Scott knows about thriving.

Looking back, she was barely out of nursing school when she experienced her first second victim event. An accidental shooting had claimed the life of an early adolescent.

“I truly thought if every day was going to hurt as bad as that day, I couldn’t do it,” she said. She credits her husband, Gary, for making it through.

“I think I thrived as a result of it.”

But she’s never forgotten the response of her senior nursing mentor that day: “Welcome to nursing honey, buck it up.”

There are countless stories like hers, Scott said.

Other second victims were not as resilient.

Scott often uses the story of Kimberly Hiatt, the nurse at Seattle Children’s Hospital who committed suicide seven months after she administered 10 times the prescribed dose of calcium chloride to an eight-month baby, as an example of “the ultimate drop-out.”

“I think Kimberly has a powerful message for all us in healthcare.”

According to Scott, healthcare facilities can help clinicians who are experiencing the second victim phenomenon in a number of ways, including:

  • recognizing the impact errors have on employees;
  • implementing formal assistance programs;
  • responding swiftly when an adverse event occurs; and
  • advocating an environment of support and trust instead of blame.

Culture Change

Scott and Hirschinger believe that sometimes, all it takes is for someone else to share a story for the floodgates to open.

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Recently, Hirschinger spent part of her day lecturing on the Second Victim experience to 12 nurses during nursing grand rounds at Ellis Fischer Cancer Center in Columbia, MO.

Her audience was receptive and interested. And typically, after her hour-long Power Point presentation, they started to talk about their own experiences. Some tears were shed. “Everyone in healthcare for even a brief period of time has their own personal story,” declared Scott.

“A lot of times, they will hear about an incident and then reflect on their own careers. Memories you thought were long buried rise to the surface. It’s like taking a scab off, in a way,” Scott said. “Afterwards, when they have a better understanding of their own personal second victim experience, it empowers them to help others.”

Scott said the forYOU Team is probably called into action at least once a week.

One recent event involved a coworker whose significant other died unexpectedly on the floor where she worked.

The forYOU Team goal was to offer encouragement to the grieving team who felt that they had let their co-worker down and to provide guidance on ways to support the co-worker upon her return to work.

Hirschinger looks forward to the day when a formal team is no longer necessary, when the collective ideals of forYOU Team become “embedded in all us.”

Rose Quinn is a frequent contributor to ADVANCE.

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