The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement.
Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts.
- 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 Carol Menashy's other blogs on SISOS:
About the Author
Carol is a retired theatre nurse.