Inadequate patient safety not only places the patient at risk of an adverse event but also has a negative effect on healthcare providers (HCPs).¹ Patient safety incident (PSI) is a sobering reality for some HCPs. It poses acute and chronic risks of psychological trauma to HCPs.^1,2 A growing emphasis on enhancing the safety of the healthcare system has resulted in several efforts in recent years to limit PSI to unanticipated causes as much as possible. Nonetheless, there has been less focus on assisting HCPs in managing distressing patient incidents.^3,4

Whenever a PSI occurs because of a failure of expected safety mechanisms or precautions, healthcare professionals (HCPs) may experience distress. This can be because of their involvement in, witnessing of, or failure to prevent the adverse event.⁵ This is what is considered to be the second victim.⁶ However, there is an emerging understanding that this term should not be used, particularly among patients and HCPs.⁷ Even Wu, who propounded the term in 2000, concurs.⁸ The current situation regarding second victims demonstrates ambiguity. There is sufficient evidence to indicate that psychological support to second victims dealing with the trauma of adverse events benefits the healthcare system. It not only improves the well-being of second victims but also benefits other staff members, enhancing retention and readiness to provide quality care.^8,9 This is in contrast with the blaming and/or punitive culture which still exists in some institutions.^10,11 Patient safety incident-related psychological and physical burdens should be addressed as they can lead to an additional PSI of future patients¹⁰ and bad practices, such as defensive medicine.^11,12

Owing to decreased job satisfaction following PSI, second victims may reconsider their perceptions of professional self-efficacy,³ or worse, consider changing professions.¹³ A range of clinical symptoms such as fatigue, frustration, guilty feelings, insomnia and anxiety were reported.^14,15,16 These can be classified as acute anxiety, acute and chronic post-traumatic stress disorder and suicide.^17,18 As a result of the severity of the problem, some second victims developed substance use disorders⁹ and relied on non-work-related support³ as a coping mechanism. Given the statistics of 10% – 30% of patients being injured by HCP during treatment or investigations, attending to the psychological needs of second victims is viewed as a priority, as more than 50% of second victims develop emotional stress post-PSI in an already precarious profession with the risk of changing careers.¹³ Attention to second victims is sadly not optimised in South Africa in general.^3,19 Additionally, there has never been a study on support to second victims in Tshwane health facilities to assess the level of assistance they receive. As a result, the current study evaluated the support of second victims in some of the health facilities in the Tshwane District Health Services.

This cross-sectional study was conducted in six primary health care facilities in the Tshwane District Health Services from April 2020 to July 2020. These facilities included three community healthcare centres (Clinic 1, Clinic 2 and Clinic 3), two district hospitals (Hospital A and Hospital B) and the family medicine ward at an Academic Hospital (Hospital C). The sample consisted of all HCPs, namely doctors, nurses and healthcare scientists (HCS), employed by the facilities mentioned earlier. The category HCS included audiologists, clinical associates, occupational therapists, pharmacists, physiotherapists, psychologists and radiographers. A convenient sample size of 319 participants was obtained. Participants registered with the Health Professional Council of South Africa and actively involved in patients’ care and safety, such as HCPs and HCS, are eligible to participate. Facility management personnel, however, are not eligible. The authors and additional nurses whom the authors had trained collected the data using a validated data collection form that had previously been utilised in other studies as a self-administrated anonymous questionnaire.²⁰ Two researchers independently piloted the questionnaire in two primary health facilities: one community health centre and one hospital. Their feedback was used to adjust the questionnaire according to the purpose of the study and the population specificity of the study. Potential participants were voluntarily invited to participate in the study after the aim of the study had been explained to them and all participants had signed an informed consent form. The researchers and research assistants recruited the participants through word of mouth by leveraging their personal and professional networks at presentations during professional meetings.

Data were captured in a spreadsheet and then imported for analysis into Instat^R. The results were presented in tables using descriptive analysis.

This study on the second victims of PSI highlighted some aspects of the phenomenon in the Tshwane District, which will be articulated in the discussion. The PSI literature has very little information on the prevalence of second victims, but the little information available shows that it ranges widely from 14.3% to 59%^1,17,21 and can even fluctuate, depending on time and place.²² We found that 19.4% of HCPs, primarily more doctors than nurses, had PSI at their current place of employment at least once. The incidence of PSI is usually patient-centred. Mgobozi¹⁹ and colleagues found 4.12 PSIs per 10 000 inpatient days. However, Gqaleni²³ and colleagues in their study classified PSI incidence into different categories. This dearth of second victim incidence reports would suggest that the current state of affairs is inadequate for handling second victims. The main focus of the literature is on how they deal with situations rather than the statistical incidence among HCPs. This is a missed opportunity because it could have been used to identify survivors who could debrief or validate feelings, provide a safe and friendly space to talk, give others a chance to process the event, reassure them that such things happen in the course of learning and practice, share similar experiences or demonstrate compassion towards others within the same institution. Considering that nearly half of HCPs would become a second victim at least once during their career,²⁴ the lack of incidence reports on second victims is astounding.

Given the fact that PSI is a daily occurrence for HCPs²⁵ and considering that it can happen in any HCP carrier,^20,25 one would anticipate that HCPs would be aware of where to resort to for help. Our results showed that 52.7% of participants were aware of the opportunity for emotional support from a well-structured organisation to assist HCPs involved in PSI at their current workplace. As PSI is evaluated by a quality assurance office in every healthcare facility, a higher percentage than that indicated earlier should have been projected. This may be understood from the findings by Mayeng,²⁶ which revealed that certain HCPs had unfavourable perceptions of all the safety dimensions. This can be a result of the inadequate way some HCPs understand PSI.²⁶ To add to the negative perceptions of patient safety culture in general by HCPs, the blaming perception around second victims, in particular, could be a part of the problem. A comprehensive quality reform initiative that considers patients, their families and HCPs is required to reduce PSI and its consequences on HCPs, and significant transformational leadership is also required to create a culture free of blame and a learning environment where PSI can be improved.¹⁹

This change ought to be thorough enough to incorporate the contentious term ‘second victim’, which is used to describe HCPs involved in PSI. Our findings revealed that 34.2% of participants were not acquainted with this term, even though it is currently becoming widely used in both scientific and political fields.^7,9 Stramez¹⁷ reported, however, that Bushc¹⁷ and Ganal found different figures at 90%. The fact that HCPs were not familiar with the term did not have any influence on their being aware of the possibility of psychological issues after PSI. This should feed the debate on the relevance of the term. Clarkson⁹ argued that the necessity to support HCPs who have been involved in PSI has never been denied, but the term ‘second victim’ was said to look like it subtly spread the idea that patient harm is random, the result of bad luck and, essentially, unpreventable. Referring to themselves as victims obscures the fact that HCPs and systems can become agents of harm, but it poses a threat to enacting the profound cultural changes required to achieve a patient-centred environment focussed on patient safety.

Our research found that 62.9% of second victims felt an emotional desire to discuss the incident, but that they did not do so at work. This should be understood in the individual’s coping mechanism and the availability of professionalism in emotional support.

In the various healthcare facilities of the Tshwane District Health Services of South Africa, where the study was carried out, participants agreed to the need to vent their emotions after PSI. However, less support was offered at the workplace, and as such, HCPs relied on friends and other structures outside of the workplace, where they typically found a source of more support than the facility management and colleagues.