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    Sharing the load of a nurse "second victim"

    Rescuing the healer after trauma

    It was like any other Friday evening shift for "Tony," an RN with more than 17 years of critical-care nursing experience. He was assisting in a routine procedure requiring moderate sedation. Toward the end of the procedure, the patient suffered an unexpected cardiopulmonary arrest. After 60 minutes of resuscitation, the patient was pronounced dead. Unfortunately, the family declined an autopsy, so a clear understanding of the reason for the patient's death will never be known. On Monday morning, the institutional patient safety officer began investigating the unexpected death, but uncovered no preventable system or technical proficiency issues.

    Through this investigation, one of the most surprising and disturbing findings was the emotional struggle Tony had endured that weekend. He described how he relived every moment of the case countless times. The investigator remembers how Tony second-guessed his care, scrupulously reviewing in his mind the frequency and results of vital signs or other subtle clinical markers. He described an inability to concentrate on anything other than this patient experience, even while he was away from the hospital for almost three days. He had been experiencing terrible headaches, severe nausea, and insomnia for nearly 72 hours. Despite his best efforts, he couldn't shake the recurring thoughts of his final conversation with the patient. He was experiencing an internal crisis of immense proportions with one repetitive thought—he wasn't good enough to be a nurse!

    Tony's experience was a defining moment for University of Missouri Healthcare (UMHC). It became clear that we needed to understand more thoroughly the impact of unexpected patient decline on our healthcare providers.

    Measuring the problem and taking action

    The Institute of Medicine's riveting report, To Err is Human, projected that as many as 44,000 to 98,000 individuals die annually from preventable medical errors in U.S. hospitals.1 Several other authors cite similar statistics, reinforcing the epidemic of preventable harm within our healthcare systems.2,3,4 Behind these startling medical-error statistics are numerous well-meaning professionals who, like Tony, could be suffering in silence. Tony's crisis occurred despite there being no evidence of a medical error. How many other nurses are suffering in silence? How many resolve their victimization and personal conflict by leaving the profession?

    Working as patient safety experts at UMHC, an academic medical center in Columbia, MO, we began to realize that individuals directly involved at the sharp end of an unexpected patient decline demonstrated predictable patterns of behavior. The intense pain that these individuals feel is represented in emotionally poignant phrases we have heard repeatedly (see table in this article).

    Furthermore, after being involved in a medical error or with patients who unexpectedly decline, these "second victims" commonly describe a variety of physical as well as psychosocial symptoms.

    Measuring the depth of the phenomenon

    To understand the devastating impact of this phenomenon on our staff, we completed a literature review. A physician introduced the term "second victim" in the literature in 2000, writing about the suffering of a colleague who had been involved in a medical error.5 A nurse writing anonymously described the personal anguish that she experienced immediately following an adverse event and the dreaded fear of termination from the role she dearly loved.6 Others have explored the impact of medication errors on the nursing staff and associated their responses to that of post-traumatic stress disorder. Describing a loss of professional respect, emotional distress, and feelings of anger, guilt, and inadequacy, Rassin et al. encouraged additional studies to help understand the effects of an error on the mental state of employees.7 Additional studies have highlighted the impact of errors on staff, reinforcing the idea that nurses suffering from a second-victim response need support from unit leadership and professional colleagues.8,9 Wolf outlined the devastating impact of medical errors on the personal and professional psyche of the nurse, and reinforced that although the phenomenon is poorly understood, the use of critical-incident stress management techniques could help minimize personal suffering.10

    Many professionals who make errors face this career-threatening phenomenon. However, we could find no nursing-specific studies to address interventions that would mitigate this personal trauma. Therefore, we interviewed healthcare professionals whom we identified as potential second victims. Following approval of our institutional review board, second victims recalled their trauma from events between 2003 and 2007. A total of 31 professionals agreed to participate: 14 (45%) of these caregivers were RNs, 11 were staff nurses, and three were immediate nursing supervisors. Professional experience ranged from seven months to 36 years, with a median of 16.5 years. Educational experience varied from one diploma nurse (7%) to four nurses with associate degrees (29%), seven who had bachelor's degrees (50%), and two with master's degrees (14%). Nine of the nurses (64%) were female. Time since the event ranged from one to 44 months, with a median of 10.5 months.

    Testimonials from second victims

    During responses to thought-evoking questions about an error or unexpected patient outcome, it became clear that the events were defining moments in the nurses' professional careers. An overwhelming theme gleaned from every interview was the detrimental impact of the emotionally charged and intimidating experience on their professional psyches. They described second-guessing themselves, and some contemplated whether they were right for healthcare. Nurses shared their stories with uncanny and meticulous detail. One was able to recall the exact date—three years earlier.

    Following identification of a clinical problem, interviewed staff nurses had a tendency to isolate themselves in order to focus on the events and meticulously dissect them, considering what they should have done. One concern is worry for the patient and family, followed by fear of immediate termination, and concern over their professional reputation among colleagues.

    "A nurse's first thought when a death or incident happens is, it could affect our jobs. Are we going to be written up? That is why we are so apprehensive, when something happens, to report things. But when you do report something, you go into this whole panic mode, and nobody sits down with you a lot of the time."

    "I assumed I would not be a nurse anymore. I thought I was going to get fired."

    One of the interviewed nurses summarized her experience as a long-lasting personal transformation:

    "I will never forget this experience. ... This patient will always be with me—I think of her often. Because of this, I am a better nurse!"

    In response to questions asking how the institution could have provided support during their traumatic clinical event, the nurses were yearning for a sort of "emotional first aid" and were unsure where to turn. Nurses were indeed suffering in silence within our institutional walls. The majority sought comfort from close family members or significant others. However, due to privacy concerns and an overwhelming fear of litigation, many did not talk about their pain. A few confided in a close colleague on their unit, while others spoke candidly with their supervisors.

    Given a choice, participants preferred talking about the event with a peer of similar training and experience. During this time of support-seeking, staff also wanted to know from supervisors whom in the institution they could talk to for support and job security. The supervisors were unaware of specific tactics to support their staff members during these crises. As a result, the nurses frequently weren't able to express the emotional impact they were experiencing, and wondered silently about what would happen to them and their professional careers.

    We saw no difference between the experiences of nurses who had been involved in a medical error and those who had been involved in an unanticipated patient decline.

    How can we help?

    These nurses identified three key messages that they needed to hear immediately: 1) The supervisor still has confidence in their clinical skills and abilities; 2) their peers respect and support them; and 3) the nurse remains a trusted and valued member of the team.

    "I needed to be believed in. I was a new nurse at the time. I'd been a nurse less than six months when this happened. It takes a while to build up self-confidence as a new nurse anyway, and for such a traumatic event to happen in just a few months of getting started ... I had no confidence in myself and no belief in my abilities. The main thing was to know somebody was going to believe in me."

    "It is really hard with HIPAA. With my situation, there was nobody I could tell—not even my husband. All I could say is, 'I have had a really horrible day.'"

    "Just someone in a similar position [whom] you could talk to, [who] knows what you are talking about. You just have to get it off your chest because it does make a difference."

    We now believe the institution can and should develop a support process that allows an individual response for each second-victim experience. These nurses believed that a more predictable process should be planned that includes what happens next.

    "It would be nice for staff to know that when something bad happens, this is what you should expect. I know how to fill out [an incident report], but I wasn't sure how to handle this case. No errors were made, but we did have an unexpected patient outcome. So, what do I do? In case it becomes a legal case, whom can I talk to? What can I say? Whom do I turn to for advice?"

    The nurses identified numerous challenges in providing effective support, citing the fact that many healthcare professionals view reaching out as a stigma unless peers or other trusted colleagues have been pre-established to provide on-demand support. Combining lessons learned from our project with information gleaned from a presentation on second victims given at a national meeting of academic medical centers11,12, we have been developing an institutional response plan to formalize three levels of support: peers/colleagues, department leader, and other institutional resources.

    Building a second-victim support program

    Professional peers and colleagues, especially those who previously have suffered as second victims, can offer unique support and powerful healing words. After Tony's event, at the conclusion of code blues in which he has been involved, he has begun to check with clinicians who activated the code team to see how they were doing. Second victims tremendously value the simple knowledge that someone cares about them as individuals and as professionals. Tony certainly understands what they might be going through, and he can be more empathetic to their needs and offer helpful words of advice.

    Timely, effective unit support can provide much-needed guidance. Training time to learn how to provide basic support is a minimal investment. We propose training in key words at critical times to help stimulate supportive conversation and to reassure the second victim during the traumatic event. A colleague can practice key peer actions to help mitigate harm to the second victim. We estimate that 60% of second victims would need no more than this type of collegial or administrative support as an intervention.

    "I remember one of my co-workers just came up to me out of the blue and said, 'You can take care of my baby anytime.' I needed to know that I was still trusted by my peers. That was powerful. I desperately needed that vote of confidence."

    Department leaders clearly influence unit culture and should have a full understanding of the institutional investigation process for unexpected events. These leaders, as part of typical department orientation, ideally would make their staffs aware of the post-event process—specifically, the immediate requirement to focus on stabilizing the patient, the need to report the event (and how to do it), the roles and names of people who respond on behalf of the institution to investigate serious events, and the individuals in that department who are trained to provide peer/colleague support during and after these events. Developing leader actions following the event can gain or restore confidence among the staff during high-profile event investigations. The chart below provides some key recommendations for impacting staff morale during this unusually stressful time.

    "I came in and talked with all the staff. I might have felt inadequate because I never had to do that before. Trying to get the facts in a supportive way and not make them feel terrible about what happened—I don't think that I was prepared to do that. I didn't feel like I had anyone to go to after I talked to the staff to debrief myself. I felt like the buck stopped with me." (RN manager)

    An institutional response plan must establish an institutional support network that will rescue those second victims who need more than peer/colleague support. Hospitals frequently have internal resources such as chaplains, social workers, and clinical health psychologists, and some institutions have access to Employee Assistance Programs. The referral process must be clearly defined to ensure that the second victim's personal and professional needs are satisfactorily addressed. We believe an effective institutional support plan will provide emotional first aid and professional guidance that will improve nurse retention.

    Don't let wounded healers suffer

    A comprehensive event-response plan for treasured staff members who may be suffering as second victims is critical for restoring psychosocial and physical health after an event. Second victims need help in timely and predictable ways. Be sure to recognize that they are associated with medical errors as well as unexpected patient outcomes. They have unique needs that could influence future career decisions. Second-victim awareness and institutional response planning are critical steps in protecting our nurses. Every day, second victims are walking our hallways in various clinical settings. We believe no clinical area is spared from this phenomenon.

    REFERENCES

    1. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (2000). To Err is Human—Building a Safer Health System. Washington, DC: National Academy Press.

    2. Brenan, T.A., Leape, L.L., et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. The New England Journal of Medicine, 324(6): 370-376.

    3. Thomas, E.J., & Brennan, T.A. (2000). Incidence and types of preventable adverse events in elderly patients: population-based review of medical records. British Medical Journal, 320(7237): 741-744.

    4. Baker, G.R., Norton, P.G., et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11): 1678-86.

    5. Wu, A.W. (2000). Medical error: the second victim. BMJ, 320: 726-727.

    6. Anonymous. (1990). The mistake I'll never forget. Nursing 1990, 20(9); 50-51.

    7. Rassin, M., Kanti, T., and Silner, D. (2005). Chronology of medication errors by nurses: accumulation of stresses and PTSD symptoms. Issues in Mental Health Nursing, 26(8): 873-886.

    8. Meurier, C., Vincent, C.A., and Parmar, D.G. (1997). Learning from errors in nursing practice. Journal of Advanced Nursing, 26(1): 111-119.

    9. Meurier, C., Vincent, C.A., and Parmar, D.G. (1998). Nurses responses to severity dependent errors: a study of the causal attributions made by nurses following an error. Journal of Advanced Nursing, 27(2): 349-354.

    10. Wolf, Z.R. (2005). Stress management in response to practice errors: Critical events in professional practice. Patient Safety Advisory, 2(4).

    11. Barnes, J., & VanPelt, R. (2006). Helping healthcare workers heal after critical events. Presented at Continuing the Journey: Destination—Superior Performance. University HealthSystem Consortium conference. Oct. 13, 2006.

    12. MITSS Web site. (2008). Retrieved Oct. 10, 2008. www.mitss.org


    Key actions for supporting individual peer/colleagues

    "Be there"—Practice active listening skills and allow the second victim to share his or her story. Offer support as you deem appropriate.

    If you have experience with a bad patient outcome yourself, share it. "War stories" are powerful healing words.

    If you don't have experience with a bad patient outcome, be supportive and predict the victim's needs.

    Avoid condemnation without knowing the story—it could have been you!

    Let your peer know that you still have faith in his or her abilities, and that he or she is a trusted member of your unit.

    Determine a way that you can make an individual difference.


    Click here to view full-size graphic


    Key words to stimulate conversations with second victims

    "Are you OK?"

    "I'll help you work through this."

    "You are a good nurse working in a very complex environment."

    "I believe in you."

    "I'm glad that we work together."

    "Please call me if you'd like to talk about it again."

    "I can't imagine what that must have been like for you. Can we talk about it?"

    "I'm here if you want to talk."


    Key actions for department leaders in their support of second victims

    • Contact clinical staff as soon as you are aware of the incident.
    • Reaffirm your confidence in him or her as a staff member.
    • Consider calling in flex staff to cover the second victim's assignment, and to allow time to compose thoughts and prepare for discussions with event investigation team members.
    • Keep the second victim informed of likely next steps in the investigation process (i.e., who may be contacting them from the institutional patient safety or risk management team).
    • Check on the second victim regularly. Let him or her know you care both personally and professionally.
    • Be visible to all staff members. Physical presence during post-event times helps decrease anxiety related to investigations and provides an accessible resource for clarification of the investigation process.