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The first cases of COVID-19 in Portugal were officially confirmed on 2nd March 2020. Since then, healthcare providers have worked hard in particularly demanding conditions to guarantee not only the treatment of COVID-19 patients but also the sustainability of the health system. The second victim phenomenon has been subject of research for long time but is still largely unknown to the general public.1 Although there is controversy about the appropriateness of this term,2 the current pandemic has underlined the importance of this topic. It is time for a wakeup call: it is required to support the frontline workforce.
The term second victim was introduced by Albert Wu in 2000 with a description of the impact of errors on healthcare providers.3
This concept became more comprehensive with the contributions of Scott et al in 2009, that described second victims as “healthcare providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base”.4
During the current COVID-19 pandemic, healthcare providers have been facing exceptional circumstances. Long-term stressors and risks to clinicians’ physical, mental and emotional well-being are real and represents predisposing factors for adverse outcomes for their own health as well as adverse events during patient care.5-7 Some of these risk factors have been emphasized in recent publications5,8,9: i) fear of SARSCoV-2 contagion, ii) fear of infecting family members, iii) social isolation, iv) growing number of cases with a severe and lethal course, v) caring for colleagues who got sick, vi) greatly increased workload, vii) working with new and frequently changing protocols, viii) feeling out of control and unappreciated.
For all these reasons it turns easy to understand why frontline healthcare workers can easily become second victims during this pandemic.
The natural history of the second victim phenomenon seems to occurs in 6 predictable steps: 1) chaos and accident response, 2) intrusive reflections, 3) restoring personal integrity, 4) enduring the inquisition, 5) obtaining emotional first aid and 6) moving on.4 Institutional commitment and support to address second victim needs is crucial to help them to overcome the traumatic event. Unfortunately, in most organizations, it is scarce or inexistent. In the absence of structured mechanisms that can help providers to heal, they usually find dysfunctional ways to protect themselves, that can be counterproductive for both patients1,6 and healthcare system.1
Clinician wellness must be prioritized so that high-quality of care could be provided. COVID-19-related trauma may cause symptoms of distress and burnout.8,9 We already know from the previous severe acute respiratory syndrome (SARS) outbreak in 2003 that these symptoms may even evolve into
post-traumatic stress disorder or other chronic condition.10 The knowledge on the impact of COVID-19 on healthcare providers mental health is emerging and must be worrying us. Recent data from a Portuguese study (n=2008, physicians, nurses, pharmacists, nutritionists, psychologists, other allied health professionals, and healthcare assistants) revealed high levels of personal (52.5%) and work-related burnout (53.1%).9 Other expected and important consequences that clinicians may face are sleep disorders, feelings of guilt, isolation and depression, flashbacks, medication or alcohol consumption, and even suicide.1,11,12
The integrity of healthcare systems relies on providers that are physically and mentally healthy. If the response period to the COVID-19 pandemic will be prolonged over time, additional stress for healthcare workers may accelerate the point at which the healthcare system worldwide becomes overwhelmed.
Its capacity to respond to all healthcare demands related or not with the pandemic may be frankly reduced.1,7-9
What can be done to avoid and support second victims in the present pandemic context? Albert Wu et al, recommend 3 strategic principles that may be helpful for healthcare organizations8: 1) to provide leadership focused on resilience; 2) structure crisis communications to provide information and empowerment, 3) create a continuum of staff support within the organization. Peer support programs are already implemented in some hospitals. The United States is one of the countries with more investment in this area. One good example of that is RISE (Resilience in Stressful Events), implemented at Johns Hopkins Hospital.13 RISE responds to calls 24/7 and provides in-person psychological first aid and emotional support to healthcare workers who experience stressful clinical events. For COVID-19 response, RISE also includes proactive rounds not only to problematic units but also less visible ones like laboratories, transports and pharmacy.8
Recently, an Ibero-American study of Mira et al, which includes Portuguese hospitals showed that interventions to support second victims have low level of implementation, which is worrisome and underscores the improvement need.14
In Europe, the issues related to patient safety are considered a priority. Under the Cooperation in Science and Technology (COST) there is an action (CA19113) - European Researchers’ Network Working on Second Victims (ERNST) that intends to discuss and share scientific knowledge, perspectives and best practices and implement joint cross-national efforts to support second victims. This international collaboration brings together research teams from 27 European countries, as well as experts from the US, Japan and Latin America. Portugal is represented by the NOVA National School of Public Health. We hope that the integration of our country in this initiative can bring new insights and value to the National Health System. Now that one year has passed since the beginning of this global SARS-CoV-2 epidemic, we already know that we are running a difficult marathon. If it is crucial to treat COVID-19 patients we must not forget that it is an imperative to take care of all healthcare workers that made it possible.
ORCID iD: Maria João Lobão https://orcid.org/0000-0002-3837-4476
1. Strametz R, Raspe M, Ettl B, Huf W PA. Maintaining capacity in the healthcare system during the COVID-19 pandemic by reinforcing clinicians’ resilience and supporting second victims [Internet]. 2020. [cited 1 Mar 21] . Available from: https://www.patient-safety-day.org/assets/20200618-gl-second-
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