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  1. Whittle, Shanda N. MSN, RN-BC, CNL
  2. Horton-Deutsch, Sara PhD, RN, FAAN, ANEF


The second victim phenomenon is one in which nurses and other health care providers use dysfunctional mechanisms, such as anger, projection of blame, or drugs and/or alcohol, to cope with serious mistakes in the absence of a healthier means for healing. The main purpose of this article is to provide evidence and practices that support the need for caring organizational support systems following serious adverse clinical events. Recommendations are provided on key elements of programs to prevent the prevalence, symptoms, and impact of the second victim phenomenon on our health care professionals, our patients, and our health care system.


Article Content

There is a silent epidemic growing in our health care organizations. Nursing, health care, and medical technology have evolved, making our health care system more complex than it has ever been. As this shift occurs, Watson1 points out that there is a call by more than 20 million nurses and midwives, uniting with more than 7 billion people, crying out for healing and human caring connections worldwide. Work by the National Academy of Medicine's (NAM's) Action Collaborative on Clinician Well-Being and Resilience has shown that this call is only growing, and the time for action is now.2


The data NAM2 gathered revealed alarming statistics about rates of depression, posttraumatic stress, and emotional exhaustion among health care providers. Findings revealed 400 physician deaths by suicide each year and 39% of physicians experiencing depression. The NAM's2 campaign also provided statistics demonstrating that nurses are similarly affected. Their report noted that 24% of intensive care unit nurses tested positive for symptoms of posttraumatic stress disorder, and the prevalence of emotional exhaustion among primary care nurses was 23% to 31%.2 Included in the report by the NAM2 was the financial cost of health care professional burnout. This includes the cost of nurse turnover being $82 000 to $88 000 per nurse and the cost of replacing 1 physician is roughly $1 million. Given these staggering effects the second victim phenomenon can have on our health care system, we can no longer ignore this phenomenon. Cabilan and Kynoch3 point out that there is minimal published evidence on the second victim phenomenon in nursing. This lack of knowledge and understanding is of grave concern, given the impact the second victim phenomenon can have on the nursing professional.


This article provides an overview of how Watson's transpersonal caring theory can answer this call and presents a theoretical framework encompassing transpersonal caring strategies for nurses and health care professionals to use to address the second victim phenomenon.



The second victim phenomenon consists of a group of symptoms experienced by health care professionals following an adverse traumatic clinical event. These events can cause physical and psychological symptoms including the impairment of medical judgment, flashbacks of the event, insomnia, fatigue, emotional outbursts, guilt, anxiety, depression, and thoughts of suicide.3,4 Many health care researchers and organizations have implemented programs to care for these professionals following an adverse traumatic clinical event, and many medical and nursing researchers have begun studying this phenomenon that impacts the human capital, along with the patient and financial outcomes of our care delivery systems.


There have been several definitions of the "second victim" in the literature. Each of the articles reviewed gave 1 or more definitions with an in-depth description. The most widely used definition of "second victim," was developed by Scott et al. and is as follows:


Second victims are health care 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.5


Prevalence, symptoms, and impact of the second victim phenomenon


The prevalence of the second victim phenomenon is a growing problem in our increasingly complex health care system. Prevalence from this review of evidence ranges from 2.5% to 43.3% and "high."3,6,7



The symptoms found in health care professionals who are second victims include guilt, incompetence, self-doubt, humiliation, embarrassment, self-blame, frustration, loss of confidence, detachment, burnout, symptoms of depersonalization, anger, psychological distress, and fear.3,6-8 These symptoms are similar to ones found in burnout syndrome. However, there is currently no internationally agreed-upon definition of burnout.9



Errors that occur within health care systems that are not followed up with organizational support can lead to the second victim phenomenon and over time can lead to increased absenteeism, decisions to leave the organization, or even more severe decisions such as leaving the profession.10 The NAM2 recognizes health care professional burnout as a threat to safe, high-quality care. Given that the symptoms of burnout are becoming more defined through research and an agreed-upon definition of the second victim phenomenon, these 2 findings highlight the importance of supporting health care professionals in their times of need.


Strategies to improve the impact of the second victim phenomenon

Cabilan and Kynoch3 stress the importance of support for the RN following an event and the use of the error as a foundation to make improvements in the practice setting. The disclosure standards following an adverse event, such as providing facts about the event to patients, were found by Cabilan and Kynoch3 to be a means to bring closure to the nurse following an adverse event.


Edrees et al11 conducted a comprehensive study at Johns Hopkins Hospital. They used the RISE (Resilience in Stressful Events) peer support program, which was developed to provide support to employees following adverse events. Edrees et al11 reported the importance of support systems within health care organizations to help health care professionals handle and deal with traumatic medical and nursing events. They also reported that most second victims prefer individual peer support a couple of days after the event occurred rather than immediately after the event, hours after the event, or a week after the event.


Findings by Edrees et al11 were similar to those reported by Seys et al.7 Both studies stressed the importance of supportive interventions for health care professionals following an adverse event and the need for national and local quality improvement initiatives regarding the second victim phenomenon. In the absence of organizations developing support systems for health care professionals following adverse events, the health care organization can become the third victim through the financial costs of the error, losing staff who become second victims, and an increase in future errors in health care.7


The link between peer support programs to reduce the second victim phenomenon and transpersonal caring is evident in the literature. Van Wijlen12 points out that using a Caring Science framework to counter moral distress in new graduate nurses allows these clinicians to replenish what has been drained to aid them in returning to a place of authenticity. This approach involves practices that cultivate mindfulness, reflection, personal growth, and self-development.12


Lowe13 notes that Watson's theory fosters nurse well-being through the use of her Caritas Processes. While Watson's human caring theory and Caritas Processes were initially developed to facilitate a healing relationship between nurse and patient, Lowe13 points out that the theory and its concepts provide an important foundation to build and develop a caring, healing environment for nurses and the health care team.


McElligott14 highlights that the transpersonal caring process is not just a journey between the patient and the nurse. She notes its importance for nurse self-care and self-awareness as a means of healing.14 These 3 articles offer essential knowledge about how transpersonal caring and Caritas can heal nurses and our other health care professionals.


Relationship between Caring Science and healing from the second victim phenomenon

The relationship between Caring Science and healing can be found in the work of Watson15 in that everything is connected energetically and even small acts of caring can change an environment from a biocidic or life-destroying field to a biogenic or life-giving/life-receiving field. This manifestation of the Caritas field is a source of healing for self and others. Watson's16 recent work in unitary Caring Science calls for and guides nursing practitioners to awaken, promote, and sustain caring-healing values and authentic acts of caring for self and others. This call is more important today than it has ever been.



Errors made by nurses and other health care professionals can lead them to lose the sense of connectedness they once deeply and meaningfully desired. Errors can lead to clinicians feeling as though they have failed their patients and their team, leading them to second-guess their knowledge and skills.5


One solution is to use the work of Watson to help the second victim and prevent the second victim phenomenon. Dr Watson18 proposes that human-to-human acts of caring within a caring moment unite us and the cosmic energy of love as one. She also notes the act of turning away from facing our own humanity or turning away from our colleagues in crisis can be an act of cruelty.18 She emphasizes the importance of supporting, instead of turning away from, our colleagues and other health care professionals in their time of need.


Consider the possibility that when a health care professional is involved in a serious adverse clinical event, he or she be given freedom and the opportunity to reflect upon the deeper meaning of being a clinician. Given time to be present and process their mistake encourages health care professionals to embrace their emotions of fear and guilt and to use the mistake to venture home to the roots of connectedness to their profession of caring, helping, and healing.17,18


The Caritas Coach

Caritas coaching is a form of advanced education developed by Jean Watson and colleagues.19 It is transpersonal in nature and brings the coach into the personal frame of reference of the person being coached. This type of coaching helps others face and work through their negative habits and ways of thinking to find their inner strength and gifts.19 It is a holistic form of coaching that promotes transformative alignment of thoughts, feelings, actions, and intentions, which are the foundation for expanded consciousness, health, and well-being.20 The Watson Caring Science Institute21 defines the Caritas Coach as follows:


A knowledgeable, experienced, reflective health care professional, who is prepared and committed to personally and professionally practice and model intelligent heart-centered approaches to health care by translating and sustaining the ethic, philosophy, theory, and practice of the Science of Human Caring into our systems and society.21(p1)


The Caritas Coach embraces the healing, transformative evolution of the spirit and soul of each person.20 The Caritas philosophy and the transformative journey leads one to deeper questions many may ask themselves as second victims. These include the following: (a) Who am I? (b) Why am I here? (c) What is my purpose? (d) How can I make a difference? (e) What are health and healing? (f) How do I affect care and healing for those in my care? and (g) How can I change this experience?20 However, the guilt and fear a clinician experiences following a serious adverse event may lead him or her, as a second victim, to ask these questions critically instead of with positive healing energies. This is where the skills and knowledge of a Caritas Coach are necessary.


Many clinicians who become Caritas Coaches do so because they recognize the need in their own lives.22 Many enter the Caritas Coach Education Program after experiencing some of the same feelings many second victims encounter. These may include contemplating leaving their profession or feeling depleted of the ability to care or give.22 These similarities between the second victim phenomenon and the transpersonal caring skills of Caritas Coaches bring a new outlook for the care and healing of second victims.


The Caritas Coach can become the healing catalyst for change in our complex health care systems. Through their advanced skills in loving, caring, and compassionate coaching, they become advocates for patients, clinicians, colleagues, themselves, and the health care system.22 These simple acts of loving, caring, and compassionate coaching of clinicians following a serious adverse event, leading to transpersonal biogenic relationships proposed by Watson23 as the "transpersonal caring moment" or the evolution toward Caritas Consciousness and Processes, are the foundation for an authentic caring-healing relationship. These authentic caring-healing relationships are something clinicians, patients, and our complex health care systems need now more than ever.


We often hear about the 5 rights of safe medication administration, but we rarely, if ever, hear about the 5 rights of the second victim. These rights were first proposed by Denham24 using the TRUST acronym and were later proposed by Cabilan and Kynoch,3 who note that in the absence of these rights, organizations risk cultivating a culture of nondisclosure and underreporting, putting patient safety at risk. These 5 rights include the following:


* Treatment that is just: Denham24 proposed that the presumption of guilt cannot be assigned solely to the clinician involved in the error. Instead, a "Just Culture" must be adopted with nonpunitive approaches that can lead to improving the system to prevent similar future errors.24 Watson15 supports this through her Caritas Process of engaging in genuine teaching-learning experiences that attend to unity of being and meaning while attempting to stay within the second victim's frame of reference. Through this process, the Caritas Coach promotes knowledge, growth, empowerment, and healing in the second victim.15


* Respect: Denham24 proposed that nurses, pharmacists, and all members within the health care system are susceptible to error and the fallout, which can include blaming and withholding respect for the clinician involved in the error. Leaders must encourage respect for the clinician involved in the error and encourage the use of "the golden rule" by treating the clinician with the same respect we would expect if in their shoes.24 Watson15 supports this through her Caritas Process of practicing loving-kindness and equanimity within the context of caring consciousness. Through this process, respect for the second victim is embraced by the Caritas Coach, which honors the human dignity of the second victim.15


* Understanding and compassion: Denham24 proposed that when an unanticipated error occurs, the clinician involved becomes akin to a patient and needs time to grieve following the serious adverse event, using the strategies first proposed by Kubler-Ross: denial, anger, bargaining, depression, and acceptance. Leaders must reach out to clinicians involved in the error and offer them the same compassion and understanding they would offer their patients.24 Watson15 supports this through her Caritas Process of allowing for expression of positive and negative feelings and listening authentically to the second victim's story. Through this process, a caring relationship is cocreated between the Caritas Coach and the second victim, which opens and awakens the second victim to the possibilities of spiritual growth.15


* Supportive care: Denham24 proposed that clinicians are entitled to psychological and supportive services due to their day-to-day encounters with trauma, loss, and unintentional errors, which can make them the second victim of these events. Health care systems must deliver supportive care to its clinicians in the same way it would give this care to patients.24 Watson15 supports this through her Caritas Process of creating a healing environment at all levels; a subtle environment for energetic, authentic caring practices to assist in healing the second victim. Through this process, the Caritas Coach is able to create space for the second victim to participate in the caring-healing process.15


* Transparency and the opportunity to contribute: Denham24 proposed that patient safety depends on health care clinicians' and leaders' ability to be more transparent about unintentional mistakes to patients, colleagues, and themselves. Denham24 points out that the current system of writing an error report, saving the information in silos, and suppressing discussions about the error out of fear of lawsuits does no justice to the patient, the clinician involved in the error, or the system. Instead, health care leaders must use the error to learn and make changes within the system. This provides an opportunity for those involved in the error, including the clinician, to heal.24 Watson15 supports this through her Caritas Process of developing and sustaining a loving, trusting, and caring relationship with the second victim. Through this process, the Caritas Coach is able to develop a helping-trusting and caring relationship with the second victim that promotes healing.15



This process of bringing Caring Science together with the 5 rights of second victims creates a biogenic, or life-giving/life-receiving, environment wherein the second victim is given the same values of care and love we, as nurses, give our patients and families every day.



Dr Watson's15 theory of transpersonal caring and the Scott et al25 3-tier interventional model of second victim support provide a theoretical framework to support clinicians following a serious adverse clinical event.


Transpersonal Caring Science

Jean Watson's theory of transpersonal Caring Science and her work in Caritas is a model that continues to evolve as she builds upon her original work of understanding what it means to be human, to be a nurse, to be ill, to be healed, and to give and receive human care.18 The meaning of Caritas comes from the Latin word meaning "to cherish, to appreciate, to give special, if not loving, attention to."26 Five core aspects of Dr Watson's original theory provide a framework for healing our health care professionals. These included the following: (a) relational caring for self and others as an ethical-moral-philosophical values-guided foundation; (b) use of the caring core or the 10 carative factors/Caritas Processes to guide the process of putting the theory into action; (c) the transpersonal caring moment-caring field, which is guided by an evolving Caritas Consciousness or one's moral, ethical commitment, and intentionality with each person; (d) caring as consciousness-energy-intentionality-human presence; and (e) caring-healing modalities.23,27


The Scott et al 3-tier interventional model of second victim support

The Scott et al25 3-tier interventional model of second victim support guides how to support second victims within 3 different tiers, each of which identifies the type of support and who will receive it. Tier 1 support is offered immediately following an adverse clinical event by unit leaders and peers to reduce possible second victim responses. Tier 2 support is provided by trained peer supporters who provide one-on-one crisis intervention, peer support mentoring, team debriefings, and support for clinicians who are showing signs and symptoms of the second victim response. Tier 3 support is provided within an organizational established referral network, which can include an employee assistance program, chaplain, social worker, or clinical psychologist, to support second victims when their emotional stress response escalates to a point outside the expertise of the peer support team.25


Together, Watson's theory and the Scott et al model create a theoretical framework to support the second victim by providing caring strategies to reduce and even prevent the potential signs and symptoms of this phenomenon and ensure that health care professionals do not suffer in silence.



Jean Watson's work on Caritas and Caritas Coaching was something the first author was not aware of until she began researching the second victim phenomenon and was introduced to a fellow student who is a Caritas Coach. The result of this connection led the first author down the path to become a Caritas Coach as part of a passion to help and support other health care professionals. Since becoming certified as a Caritas Coach, the first author has come to find that many working on the front line of health care are unaware of the second victim phenomenon or the need to support their colleagues in times of crisis. Health care professionals and systems must have an awareness through research and education of the devastating effects the second victim phenomenon can have on our health care professionals and the health care system. It is evident that they must unify in identifying and implementing transpersonal caring practices to support second victims.


Caritas Coaching and the advanced education provided in becoming a Caritas Coach give the Caritas Coach a skill set needed to form authentic caring relationships with others and to aid them in finding healthy solutions and strategies to overcome their self-identified issues and needs.19 Consider the possibility of having a Caritas Coach to assist clinicians following a serious adverse event. Is it possible that the Caritas Coach could fill the need in our health care organizations to assist our clinicians following a serious adverse event, leading to healthier clinicians, safer care for our patients and their families, and a reduction in the prevalence of the second victim phenomenon? More research and evidence-based projects need to be done to evaluate this promising intervention.




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2. National Academy of Medicine. Action collaborative on clinician well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being. Updated 2019. Accessed February 18, 2019. [Context Link]


3. Cabilan CJ, Kynoch K. Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review. JBI Database System Rev Implement Rep. 2017;15(9):2333-2364. [Context Link]


4. The Joint Commission. Quick safety. Supporting the second victim. Supporting second victims. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_39_2017_Second_vi. Published January 2018. Accessed April 24, 2019. [Context Link]


5. 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. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edsbas&AN=eds. Published 2009. Accessed January 3, 2019. [Context Link]


6. Lewis EJ, Baernholdt MB, Yan G, Guterbock TG. Relationship of adverse events and support to RN burnout. J Nurs Care Qual. 2015;30(2):144-152. [Context Link]


7. Seys D, Scott S, Wu A, et al Supporting involved health care professionals (second victims) following an adverse health event: a literature review. Int J Nurs Stud. 2013;50(5):678-687. [Context Link]


8. Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The Second Victim Experience and Support Tool (SVEST): validation of an organizational resource for assessing second victim effects and the quality of support resources. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edsbas&AN=eds. Published 2017. Accessed March 20, 2019. [Context Link]


9. Breitenburger W, Baschek V, Steinert W, et al Burnout: a fashionable diagnosis. Dtsch Arztebl Int. 2012;109(18):338. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edb&AN=775550. Accessed August 27, 2019. [Context Link]


10. Burlison JD, Quillivan RR, Scott SD, Johnson S, Hoffman JM. The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Saf. doi:10.1097/PTS.0000000000000301. [Context Link]


11. Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edsbas&AN=eds. Published 2016. Accessed March 14, 2019. [Context Link]


12. Van Wijlen J. Healing the healer: a Caring Science approach to moral distress in new graduate nurses. Int J Hum Caring. 2017;21(1):15-19. doi:10.20467/1091-5710-21.1.15. [Context Link]


13. Lowe LD. Creating a caring work environment and fostering nurse resilience. Int J Hum Caring. 2013;17(4):52-59. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=ccm&AN=103869. Accessed May 19, 2019. [Context Link]


14. McElligott D. Healing: the journey from concept to nursing practice. J Holist Nurs. 2010;28(4):251-259. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edsbl&AN=RN28. Accessed April 17, 2019. [Context Link]


15. Watson J. Background: Caritas and theory of transpersonal caring. In: Watson J, ed. Unitary Caring Science: The Philosophy and Praxis of Nursing. Louisville, CO: University Press of Colorado; 2018:44-56. [Context Link]


16. Watson J. The philosophy of science. In: Watson J, ed. Unitary Caring Science: The Philosophy and Praxis of Nursing. Louisville, CO: University Press of Colorado; 2018:22. [Context Link]


17. Watson J. Love and caring: ethics of face and hand-an invitation to return to the heart and soul of nursing and our deep humanity. Nurs Adm Q. 2003;3:197. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=edsghw&AN=eds. Accessed April 12, 2019. [Context Link]


18. Watson J. From caring science to unitary science: the maturing of the discipline of nursing. In: Watson J, ed. Unitary Caring Science: The Philosophy and Praxis of Nursing. Louisville, CO: University Press of Colorado; 2018:44-46. [Context Link]


19. Watson J. From Caritas factor 7 to Caritas process 7. In: Watson J, ed. The Philosophy and Science of Caring. Rev ed. Boulder, CO: University Press of Colorado; 2008:127. [Context Link]


20. Anderson J. Caritas Coaching: an overview. In: Horton-Deutsch S, Anderson J, eds. Caritas Coaching: A Journey Toward Transpersonal Caring for Informed Moral Action in Healthcare. Indianapolis, IN: Sigma Theta Tau International; 2018:11, 12, 24. [Context Link]


21. Watson Caring Science Institute. Overview of WCSI Caritas Coach Education Program (C) &application process. https://www.watsoncaringscience.org/files/PDF/CCEP_APPLICATION_Instructions.pdf. Published 2019. Accessed March 2, 2019. [Context Link]


22. Horton-Deutsch S, Anderson J. The ever-evolving, introspective, and morally active life of a Caritas Coach. In: Horton-Deutsch S, Anderson J, eds. Caritas Coaching: A Journey Toward Transpersonal Caring for Informed Moral Action in Healthcare. Indianapolis, IN: Sigma Theta Tau International; 2018:292, 296, 300-301. [Context Link]


23. Watson J. Theoretical framework for Caritas/caring relationship. In: Watson J, ed. The Philosophy and Science of Caring. Rev ed. Boulder, CO: University Press of Colorado; 2008:79-86. [Context Link]


24. Denham CR. TRUST: the 5 rights of the second victim. J Patient Saf. 2007;3(2):107-119. [Context Link]


25. Scott SD, Hirschinger LE, Cox KR, et al Caring for our own: deploying a systemwide second victim rapid response team. Joint Comm J Qual Patient Saf. 2010;36(5):233-240. [Context Link]


26. Watson J. Caritas processes: extension of carative factors. In: Watson J, ed. The Philosophy and Science of Caring. Rev ed. Boulder, CO: University Press of Colorado; 2008:39. [Context Link]


27. Watson J. Caritas factors/Caritas processes. In: Watson J, ed. The Philosophy and Science of Caring. Rev ed. Boulder, CO: University Press of Colorado; 2008:29-30. [Context Link]


Caritas; second victim phenomenon; secondary traumatic stress; transpersonal caring