Bad things happen in medicine. Sometimes, as doctors or nurses, the things we do, or the things we didn’t think of doing, cause harm. How we respond to those incidents determines the direction our careers follow. If the response is catastrophic, and the puncture in our confidence or self-esteem proves irreparable, we may drop out entirely. This article explores the idea of the ‘2nd victim’, that is the health care worker (HCW) involved in events that result in harm to patients. It is based on a Grand Round lecture I delivered at Frimley Park Hospital.
‘Stuff happens,’ as Donald Rumsfeld sanguinely commented after being questioned about the looting that took place in the fall of Baghdad. ‘Stuff happens, and it’s untidy.’ He certainly felt no personal responsibility for the adverse consequences of a military decision that he had been invovled in. The looting was a kind of ‘complication’.
That is not the typical response among healthcare workers. Dan Walter, in his book Collateral Damage, describes a terrible complication suffered by his wife, and the panic that he perceived in the young doctor who was involved. A novel cardiac ablation catheter was incorrectly deployed by a trainee, resulting in its spiral end becoming entwined in the cordae tendinae of the mitral valve. When the catheter was eventually removed, bits of heart valve tissue could be seen hanging off it. She developed cardiogenic shock, and had to have an emergency mitral valve repair. Dan Walter approached his wife’s cubicle;
A vivid picture there of the 2nd victim – although many would say that the author – the spouse – is the true 2nd victim here, the doctor the 3rd. For now though, I’ll stick with ‘2nd’.
The impact on HCW has been studied. Scott et al described common symptoms, both early and late, in the table below. First the physical, then the psychological. In some, there is avoidance of particular patients, and chronic uncertainty.
The authors then identified several phases in the natural history of psychological response:
At the end, the HCW ‘thrives’, that is they learn, improve, and possibly use their experiences to help other in similar situations. Others carry on, still feeling the harm and perhaps avoidng certain situations, while a third group drops out. The injury to their confidence is too deep.
As a student and trainee I saw how those around me reacted in these situations. I vividly remember the bloodless expression in the house officer whose patient became comatose after receiving a duplicated prescription of insulin; the SHO who gave Tazocin to someone who was penicillin allergic; the registrar who inserted a central line into the carotid artery accidentally. Having convinced myself that I had prescribed IV salbutamol at 10x the usual dose at three in the morning, I made up the term ‘Gut Thump’. This equates to the adrenaline-driven, panic-soaked reaction that comes minutes after the event.
Much later, after a complication, I charted my own psychological journey starting from the moment I received the CT scan report showing the damage, and I drew it on a graph. Many may recognise this line. The time it takes to reach equilibrium will vary, depending on the sense of culpability, and the outcome of the patient. In this case the patient was absolutely fine, but there was a period during which this was not guaranteed. The road to equilibrium involves communicating, receiving reassurance, and doing stuff to make it better. Also, the understanding of the patient helps.
Van Gerven et al, surveying 913 healthcare workers who had been involved in a patient safety incident, and using an Impact of Event Scale, found,
‘…higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact.’
This appears to correlate the intensity of response to the pro-activity shown by the HCW in dealing with things, which is interesting. I would have assumed the HCW who just let things be might feel less of an impact. This might indicate a link between conscientiousness, and psychological injury.
A qualitative analysis of 21 staff by Ullstrom et al, ‘Suffering in silence: a qualitative study of second victims of adverse events’, found that non-judgmental support from peers was vital. One interviewee said,
I really want to highlight how important that support is (…) without it, I don’t know where I would have been now (…), if I would have ever dared to come back and work as a nurse again. (Interviewee No 14, Profession: Nurse, Type of adverse event: Wrong medication dose)
While another spoke about reluctance of doctors to seek external help if they are not recovering,
I think there is an inner resistance towards getting external help. At least, among doctors [the idea is] “I can handle this” (…) but I think that really we should have much more general support. In difficult situations overall. Not only after adverse events. (Interviewee No 18, Profession: Doctor, Type of adverse event: Operation went wrong)
We are encouraged to be open about our mistakes, and our leaders in the profession have shown us their example. The booklet ‘Medical Error’ (published by the National Patient Safety Agency) contained vignettes from the careers of, among others, the then GMC President and the then President of the Royal College of Physicians.
Error then, happens to the best of us.
Yet, we cannot accept our role in these errors with equanimity. It takes something out of us. This is normal human behaviour surely – regret, guilt. We are now required to express these feelings to those who have been harmed, as per the Duty of Candour, which became law in March 2015. Following a series of healthcare scandals, the Francis report described a culture of obfuscation, and this was followed by A Promise to Learn… by Don Berwick which enlarged on the idea of transparency, and finally came specific recommendations from the Royal College of Surgeons which preceded Regulation 20.
So now, while handling our response as 2nd victims, we must take ourselves to the person we have harmed and apologise. This might compound the emotional challenge of the situation, or it may in fact accelerate resolution. It is amazing how a patient’s forgiveness can set an anxious doctor back on track.
It is worthwhile dwelling on how to handle Duty of Candour conversations. I have heard and used various verbal formulations, which to the outside observer might be surprising or evasive… for how hard can it be to say sorry? But… what are you sorry for. Are you sorry you did it? Are you sorry ‘we’ did it, i.e. the team, the department, the hospital? Or are you sorry it happened, in an impersonal way, the same way you felt sorry when you heard on the news that someone got run over last weekend? Which sorry? And while finding your way through the post-incident psychological reaction, do you have the emotional strength to handle the expression of sorrow, whatever form it takes? It is quite possible that a natural feeling of vulnerability and defensiveness will influence the words that are chosen, and make the conversation less candid than intended. On the other hand, perhaps, as in the figure below, those who accept a degree of personal culpability and are affected by that, are more likely to demonstrate candour than the flint-skinned individual who regards adverse outcomes as inevitable complications over which only fate can exert influence.
On the subject of defensiveness, it is impossible to discuss medical error or patient safety incidents without referring to the legal situation. We know, following the recent trials of both Dr Hadiza Bawa-Garba (which occurred after I gave this lecture) and Mr David Sellu, that doctors are not immune to prosecution following ‘omission’ harm events. These names are likely to weigh heavily in the minds of doctors who become involved safety incidents, and are likely to exaggerate the feelings of panic and ‘chaos’ that were described in the Scott paper.
This article has focussed on the healthcare workers. The response of the true 2nd victims, sons, daughters, mothers, partners, have been overlooked, but that subject would require an article of its own, and I am probably not best placed to write it. However, the Duty of Candour has, in my opinion, brought the two spheres of psychological response closer together. The (primarily physically) injured or suffering patient is now more likely to meet the (psychologically) traumatised doctor. The shared experience, and insights into the stresses experienced, may actually improve understanding. But the resources required of doctors and nurses to deal with their own regret and self-criticism, while simultaneously approaching patients or relatives, should not be underestimated.
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