Second Victim Syndrome and COVID-19 - Emerging Nurse Leader

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

This week, a well-respected ED doctor in New York City committed suicide. She had been on the frontline of caring for COVID-19 patients until she herself contracted the virus. Her father, also a physician, talked about the challenges she had dealing with the trauma that she had observed in her day to day work. She felt she should have done more. He added: “Make sure she’s praised as a hero because she was. She’s a casualty just as much as anyone else who has died.” His haunting statement reminded me of a phenomenon that we see in healthcare called Second Victim Syndrome.

The term was coined by Dr. Andrew Wu in 2000. Although second victim syndrome is usually applied to a specific error that a healthcare provider is involved in, the syndrome has expanded to include reactions that a healthcare provider can have about their involvement in situations of chaos and crisis where patients die. In the case of COVID-19, nurses and physicians may question themselves as to whether they did enough or perhaps even contributed to a patient’s death through well-intentioned interventions such as mechanical ventilation.

Second victim syndrome describes the suffering that the health care provider experiences as a result of the psychological trauma the event causes. In a Wall Street Journal article yesterday, Neurosurgeon Dr. Elizabeth Fontana discussed her redeployment to a COVID-19 ICU in New York. She feels very disoriented by the experience and helpless about the stark reality that few patients of her patients make it off the ventilator. She noted – “I don’t think I have done a very good job of processing it. Its been so busy and there’s a lot to juggle. When everything settles down, it’ll be a challenge to understand what happened.”

We cannot ignore the risks for Second Victim Syndrome and PTSD among frontline nurses working with COVID-19 patients. Many nurses will second guess themselves as to whether they did enough professionally for their COVID-19 patients. Some COVID-19 patients decompensated very rapidly and were in ED hallways at the time of their death. Others died alone and that last Facetime call with family never happened. These are not best professional practices, and yet they occurred in a time of crisis. In my hometown newspaper, the son of a patient who died of COVID-19 told a reporter that when talking to his father’s nurse for the last time – he overheard a discussion in the background that the hospital was out of body bags. He asked the nurse about it, and she told him she felt terrible that he heard that conversation. I am sure she will carry some of that guilt with her into the future.

Dr. Wu’s research indicates that healthcare providers go through the following second victim syndrome stages:

Chaos and Accident response – providers keep moving and caring for patients during the crisis with little time for reflection.
Intrusive Thoughts – a reflection on what has happened occurs and begins to impact aspects of life, and doubt becomes overwhelming.
Restoring Personal Integrity – the clinician looks for support from a colleague or friend.
Enduring Inquisition – further reflection leads to questioning the potential professional and legal consequences of the care that was rendered.
Obtaining Emotional First Aid – using coping mechanisms to mediate the situation and seeking help.
Moving On – drop out, survive, or thrive. The goal is to ultimately thrive again and regain zeal in all areas of life. Using reflection to understand the situation, but moving forward, recovered, stronger, and improved.

We know from the work of Dr. Martin Seligman that the stories we tell ourselves about our experiences play a key role in our ability to move on. For some clinicians, COVID-19 has shaken their confidence and led them to ask questions about whether they could have done more to prevent patient deaths. In his work, Dr. Wu noted that the most caring and reflective clinicians are also more likely to experience second victim syndrome.

As leaders, we must be aware of the risks of second victim syndrome during COVID-19 and be proactive in our response. While the world celebrates frontline nurses as heroes in this crisis, some of our nurses may be telling themselves a much different story about the care that they gave.

Editor’s Note This disturbing story that supports the ideas in this blog was published today on the front page of the Wall Street Journal title Young Doctors struggle to treat Corona Virus patients: We are horrified and scared.

Read Rose Sherman’s book – The Nurse Leader Coach: Become the Boss No One Wants to Leave