The location of the room is in it’s favour because it isn’t isolated and is easily accessible without the need to change into or out of scrubs. This makes it available to other departments and also to the support staff, such as chaplaincy who visit us fairly frequently when we request. This clearly has had a positive effect on take-up.

The room itself is simply furnished and is in sharp contrast to the clinical environment. A small windowless store room, triangular in shape, has been transformed into a sanctuary of calm and psychological safety. The makeover consisted of a woodland scene wall mural, a Himalayan salt lamp, a reclining chair, a small side table, a coffee table and two regular chairs. 

I’m frequently asked, "Can we use the  calm zone as a prayer room?" The answer is yes, because we must aim to support staff in their working environment and, provided one group or another doesn’t claim the room as their own, then why not? None of us can know what someone else’s journey has been like. When we put on our shoes and leave our homes to come to work we also put on our professional fronts often masking our private lives. This became very apparent to me in the first week and is shaping how the framework for SISOS is evolving and the breadth of support we are now providing.

Originally set up to provide emotional support for staff centrally or peripherally involved in safety incidents, we recognised that these incidents are fortunately rare. However, you don’t need to be involved in an incident to be affected emotionally and most of our take-up is supporting staff for none-incident related events.

We had one such event recently that affected a large number of our staff because of the circumstances and the age of the patient. Following this event, myself and another 'key listener' were relieved of our clinical duties and we were able to provide emotional support over a couple of days. This put our model to the test and I'm pleased to say it passed. 

These are work-related events. The other side to take-up involves staff who are distressed because of none-work related issues. We deal with this by signposting staff to other support structures, such as our Employees Assistance programme and our mental health First Aiders Hub. What we discovered was staff were not prepared to accept SISOS simply as a support for ‘second victims’. They demonstrated a need for other kinds of support, such as domestic abuse, money worries, bullying, and they wanted support for these issues. They weren’t prepared to differentiate. 

We have developed other pathways to support staff holistically. Staff come to us at a rate of approximately three per week (theatre department) requesting a ‘SISOS’ – meaning, I need to talk, and that can be on any topic. The anonymity SISOS provides, because of the confidentiality and trust, is impacting favourably and staff are opening up. 

Patients too. Our badge wearing listeners have attracted the attention of several patients who have felt safe enough to open up about domestic abuse. The SISOS team have supported three such patients and have taken advantage of that small window of opportunity to hopefully help them to change their lives for the better.

SISOS is now part of a broader staff support model at Chase Farm Hospital and we are working on various new arms for it, including a student nurse support arm. This happened directly as a result of a student nurse needing support out of university hours after witnessing a distressing event.

Read the other blogs in my series

• Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space
• Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration

If you are thinking about setting up a similar initiative in your trust, I would be happy to discuss SISOS further with you. Contact: carolmenashy@nhs.net 

• Bullying and scapegoating ride on the back of fear: When things go wrong or have an outcome that we were not anticipating different aspects of second victim phenomenon kick in, such as shame, guilt and fear. It is terrifying to fear for the loss of one’s professional registration or to be recognised as the care worker who damaged the reputation of your organisation. Quite apart from the pain and accompanying worry of knowing that you may have brought harm to your patient. Encouraging openness and honesty, permits emotional healing, supports staff retention and reduces the number of safety incidents.

• Emotional healing rides on the back of openness and honesty: In order to move on from a safety incident, it is essential to be truthful. Recognise that peoples’ perceptions of an incident are subjective and may differ from your own. Perceptions often germinate during a time of chaos. Refrain from judging, instead focus on your own personal recovery. Draw strength and comfort from your courage to speak the truth as you perceive it. 

• No such thing as a Never Event: The use of the term ‘Never Event’, increases feelings of guilt and shame for those of us unfortunate enough to be associated with a safety incident. We are, at the end of the day, human beings working within a system of systems. There can never be such a thing as a Never Event.

• The term second victim is out dated: It degrades the trust that patients and families place in us as care givers. I suggest the term PIAE as an alternative. People In Adverse Events. Not all PIAEs will be involved in a review process. The majority won’t. Sometimes simply seeing something is sufficient to cause psychological trauma for a care worker. All PIAEs should have access to tiered emotional support. This is my challenge to the NHS.

Finally the biggest challenge I faced on my amazing  journey, was helping people to understand that PIAE support is not competing with other support initiatives. It is a specialised area, providing  timely, empathetic, non-judgmental support by trained Listeners, for a specific group of people, namely PIAEs.

Read the other blogs in my series

• Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up

1. chaos and accident response
2. intrusive reflections
3. restoring personal integrity
4. obtaining emotional first aid
5. moving on.

The authors defined the characteristics and typical questions second victims are desperate to have answered during these stages. Several reported that involvement in improvement work or patient safety advocacy helped them to once again enjoy their work.

The authors conclude that institutional programmes could be developed to successfully screen at-risk professionals immediately after an event, and appropriate support could be deployed to expedite recovery and mitigate adverse career outcomes.

Over the years I’ve seen too many of my colleagues breaking down in the tea room, hiding in the sluice, or crying in the toilets. This is not acceptable. The NHS Constitution Key principal three states:

"Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported".

Health Education England are now talking about safe spaces and psychological support. Our SISOS Calm Zone has been the most amazing achievement. Since the provision of our safe space, our staff talk about feeling valued. A member of staff who might have previously gone home because they had a headache, rest in this safe space and often are able to return to work safely within the shift.

I talked about setting up a safe space where staff could go and rest and be support if needed and was promised that when we moved to our new hospital building a room would be provided. For the first six months SISOS functioned without a dedicated safe space in our old building and I faced the same old challenges that I’d faced as a member of the bullying and harassment support team many years ago.

One of my roles then was to support staff who alleged bullying and the biggest challenge I always faced when I received a call was finding a suitable place to provide support. So often the support I gave was negatively impacted by an inadequate space. So I was very disappointed to find every door in our new department had a label on it and not one said SISOS Calm Zone.

This was a challenge and I approached my manager and asked nicely but directly: "Where is the room I was promised?" "You’ll need to speak to orthopaedics," came the reply and so I did.

"We have a lot of equipment", said the orthopaedic sister.

"What’s more important, your crates or our staff?" I said.

My words didn’t fall on deaf ears and our fabulous staff helped to clear the storeroom, relocate stock and also get rid of stuff we hadn’t used for years. The room is small, triangular in shape and windowless but the location is perfect.

Safety is paramount and the room is located next to the tea room and so isn’t isolated and is easily accessible without the need to wear scrubs. This is important for staff who need support but also for anyone coming in to support staff such as chaplaincy, who frequently come up to support our staff when requested.

Once we had the room I panicked a little realising that we would need to furnish it. I wrote to several charities, one of which was the Louise Tebboth Organisation. I was seeking confirmation that I was on the right track. This wonderful organisation not only supported our initiative but donated generously towards the purchase of a reclining chair. Realising that I wasn’t able to personally receive funds, I contacted our Royal Free Charity who took up the reins. They guided us and provided further funding for a woodland scene wall mural, a side table and a Himalayan Salt lamp. These simple furnishings have transformed the store room into a sanctuary of peace.

My next fear was, "What if no one uses the room?" So I put in a wooden money box with bingo counters and a short note asking people to place a counter into the box if they had used the room and felt that they had benefited from it. I wanted to maintain confidentiality but needed to know numbers. We have eight theatres in our department and in the first week I counted 52 counters, the second week 56 counters. I carried on counting for a couple of months and the lowest count was 38. We knew for certain that the room was being used and it was being used appropriately and with respect. One consultant I work with classes himself as a SISOS frequent flier. He has a ten minute power nap during his shift. So the room isn’t only used to support second victims, fortunately that isn’t needed very often, but on a daily basis staff can zone out when they need to with or without support.

We would highly recommend a safe space but if your department cannot provide any such space then look to see where a room might be found in another area that you can use to support staff. It is about planning and even if no room is available anywhere think about how you could set up a temporary safe space if needed.

Read the other blogs in my series

• Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up
• Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration

A flower does not think of competing with the flower next to it. It just blooms. (Zenkei Shibayama)

My original presentation of SISOS to the department where I work (theatres) had a huge impact and colleagues recognised the need for it and wanted it.

Strong leadership and commitment is essential. I have faced challenges along the way and so far have managed to keep going, but it hasn’t always been easy. I will talk about those challenges as I go. There have been times when I have questioned why I’ve kept going and every so often that question is answered.

At a recent conference where I presented a  poster, a beautiful human being, kind, intelligent, dedicated to saving lives, looked me in the eyes and said, "How do you support second victims?" and then proceeded to weep uncontrollably.

Needless to say I took their willing hand and we shared tea together in a quiet spot. Their incident happened 4 years ago and no blame was attached. This beautiful human being was not an F1 but a consultant. 

Ironically two days later at work, a consultant suggested that consultants as a group don’t need support because "We have years of experience, we can manage".  It’s fair to say that as a group, experienced consultants have challenged the need for this initiative more than other groups and some have been very cynical. However on the whole they have been supportive and welcoming of it.

Following my original presentation and the positive feedback from my colleagues, the first thing I did was to form a working group of very senior staff. Nothing would have been possible without their belief and their buy-in. We examined our Trust policy and looked at existing resources; for example, we have an Employee Assistance Programme, which provides professional counselling free of charge to our staff. It was important to see what we as an organisation could provide without incurring additional cost.

My experience has been that although support is there in theory, in reality staff were not necessarily accessing it and so one of our roles as Listeners is to improve accessibility.

As a group we looked at safety, including the safety of our Listeners and how we support them. Guidelines were produced and training provided. We recognise that we are not experts and that this is still a relatively new initiative for us and one which is evolving. 

Read the other blogs in my series

• Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up
• Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration

For further information please contact me: carolmenashy@nhs.net 

In the changing rooms where I worked as a scrub nurse, I overheard a group of nurses discussing the distressed state of a young doctor. There had been a never event in their theatre that day and the young doctor was the operating surgeon.

Moved to tears I wanted to go and put my arms around that doctor but I didn’t feel that I had ‘permission’. ‘It was none of my business, what if I made things worse?’  So I dumped my scrub suit into the laundry bin, put my theatre shoes away and went home.

I’m a theatre nurse but more importantly I’m a mother, the mother of a young doctor and that night fearful for the surgeon’s safety I was unable to rest. If it was my daughter I would have wanted someone to be there for her.

Galvanised by a mother’s strength, I vowed that nothing could or would hold me back and so the next morning I wasted no time in knocking on my matron’s door. "I was worried about that young doctor last night", I said. "So was I", said my matron. "I rang her and she’s coping’". I was relieved to hear this but as I turned away I realised that there was an urgent need for timely, accessible structured support for when things go wrong.

I reflected on an incident that had  happened to me and I asked myself this question: What would have helped me, at one o’clock in the morning, all those years ago, when I sat alone in a hospital tea room: devastated, anxious, ashamed, guilty, having flashbacks and feeling like the worst nurse on the planet? I had let my patient down.

Two things came out of those reflections. Firstly, I had craved the companionship and compassion of my colleagues because I knew that they above all people would get it. They would understand how this situation could possibly have arisen without attaching blame. Secondly I recognised the need for a safe space, a place where my dignity could have been protected and I could have shared this experience in privacy. As far as I was concerned, my name was in neon lights, I was the failed nurse, there to be gawped at.

These two experiences, the young doctor’s and my own were the catalyst for SISOS. Safety Incident Supporting Our Staff.

Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model which I’ve developed is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. 

The care which we can now give our second victims is compassionate, non- judgmental and happens in a dedicated safe space, where experiences are shared in confidence.  Empathy, respect and compassion assist in emotional healing. 

Following a successful audit I’m delighted to say that this model is now being rolled out Trust wide. My passion is that all of our colleagues deserve access to this kind of care. I recognise that it won’t be easy but I will not be deterred, will you?  

Read the other blogs in my series

• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space
• Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up
• Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration

For further information please contact me: carolmenashy@nhs.net 

Further reading:

• Hirschinge, LE et al. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare. March/April 2015.
• Willis D, et al. Lessons for leadership and culture when doctors become second victims: a systematic literature review. BMJ Leader 2019;1–11.

The review concludes that a prevailing silence, exacerbated by poor organisational culture, inhibits proper disclosure to the first victim, the patient and family. It also impedes a healthy recovery trajectory for the doctor, the second victim. Leaders of organisations have a vital strategic and operational role in creating open, transparent and compassionate cultures where dialogue and understanding takes place for those affected by second victim phenomenon.

• Conducting semi-structured interviews with a sample of clinical and non-clinical staff who had been directly involved in a patient safety incident, adverse event or medical error in University Hospitals Leicester and Nottingham University Hospital to explore the impact this had on them and the type of support they would have liked to receive. These were transcribed and thematically analysed to identify core themes.
• Developing a three-tier second victim support programme and including training peer supporters (tier 2).
• Piloting of the model.
• Evaluating the pilot by interviewing staff who had accessed the peer support.
• A final report which included recommendations based on findings from the scoping project.

PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm.