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“After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.

The analysis identified six stages of the second victim journey. chaos and accident response intrusive reflections restoring personal integrity obtaining emotional first aid 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.

This web page is specific for manager and provides useful resources, advice and support.

In this film from the 2019 Boston Moth Grand Slam, Poorman tells her own story and argues that it's not perfection, but humanity and compassion that patients need.

On a couple of occasions when myself or other key listeners have been in the process of supporting staff in the SISOS calm zone, there has been a knock on the door. This knock speaks far louder than you or I ever could. The knock in it’s intensity says, "I disapprove". These occasions are rare but they do happen. One comment I overheard was, "if you can’t take the heat you shouldn’t be here". My answer to this attitude is onwards and upwards. 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 my other blogs on SISOS: Part one Part two Part three 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

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. In my next blog I will talk about setting up the SISOS Calm Zone, our safe space. For further information please contact me: carolmenashy@nhs.net

The Journey 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 part two and part three of my blog series where I continue the journey and talk about the challenges faced. 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.

As a second victim, on reflection, the two things I recognised that I had needed were peer support and a safe psychological space. A place where I could have been supported and my dignity protected. 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. My next blog will talk about take up. Read part one and part two of this blog series