The Hidden Toll: Second Victim Syndrome During the COVID-19 Pandemic

COMMENTARY

The COVID-19 pandemic has significantly impacted the global healthcare system, affecting patient care as well as the emotional and psychological well-being of family members and healthcare providers. One important yet often overlooked aspect is Second Victim Syndrome (SVS), a term coined by Dr. Albert Wu in 2000 to describe the emotional trauma experienced by healthcare providers following an adverse patient event.¹ This term has since been contested, as other healthcare personnel and family members are also directly affected by the first victim, the patient.² Nearly half of healthcare providers may experience SVS at least once in their careers. A 2014 survey of 1,755 physicians outside the U.S. found that most had been involved in a serious safety event and admitted to experiencing second-victim effects.³ A recent study by surgeons revealed that 80% recalled at least one intraoperative adverse event in the past year, with substantial emotional impacts, including sadness, anxiety, and shame, sometimes requiring formal psychological counseling (32% recalled 1 event, 39% had 2 to 5 events, and 9% recalled >6 events).⁴ Despite these challenges, healthcare providers have shown immense courage in facing SVS, often not actively seeking support, suffering in silence or waiting to be approached.³

There are four common causes of stress that lead to SVS: physical-psychological, institutional-cultural, cognitive, and moral.⁵ Over the past two decades, more cases of SVS have been recognized among healthcare providers, who may experience feelings of guilt, anxiety, and inadequacy after an unexpected adverse event. These feelings have intensified during the COVID-19 pandemic, leading to burnout, depression, and even post-traumatic stress disorder. The lack of personal protective equipment, long working hours, and the emotional burden of witnessing patient suffering and death have heightened the sense of vulnerability and distress among healthcare workers. Numerous personal accounts from healthcare providers during the pandemic highlight the emotional and psychological challenges they faced, such as feelings of helplessness and guilt when unable to save patients due to overwhelming patient volumes and limited resources.^5,6 These experiences often led to self-doubt and questioning of professional competence.^7,8 Additionally, many second victims described a stigma they felt after seeking assistance, feeling that others saw their efforts to seek help as a sign of professional or personal weakness and vulnerability. Fear of litigation and the absence of a well-defined reporting system are barriers to seeking help for most healthcare providers.³

Traditionally, SVS refers to healthcare providers who experience emotional distress after being involved in an adverse clinical event. However, during the COVID-19 pandemic, this concept has expanded to include family members who have also faced significant emotional and psychological challenges.^9,10 The impact of the lockdown has had far-reaching effects in different strata of life, including changes in the accessibility and structure of education delivery to students, food insecurity as a result of unavailability and fluctuation in prices, the depression of the global economy, increase in mental health challenges, and issues of wellbeing and quality of life amongst others.¹¹ Family members of COVID-19 patients often experience intense stress, anxiety, and grief due to the illness and loss of loved ones. The pandemic’s impact on mental health was profound, with many families dealing with prolonged isolation, financial strain, and the fear of contagion. Additionally, the increase in family violence and intimate partner violence during the pandemic further exacerbated the emotional toll on families.^12–14 Due to strict quarantine measures and hospital protocols, many relatives were unable to be with their loved ones during their final moments, leading to prolonged grief and feelings of helplessness.¹⁵ Relatives may struggle with indifference, annihilation, nihilism, paranoia, sadness, fear, the contagion of virus, blaming the government, anxiety, worry about self/family/others and information dissemination due to fake news flooding social media. Self-blame can be particularly intense if people cannot visit or care for their loved ones due to COVID-19 restrictions.¹⁶ Traditional mourning practices, such as funerals and memorial services, were often restricted or modified during the pandemic, hindering the grieving process, and leaving relatives isolated.

Numerous personal accounts highlight the emotional challenges faced by relatives during the pandemic. Many families reported feeling a profound sense of loss and disconnection when they could not be with their loved ones in their final moments, often leading to complicated grief characterized by intense longing and difficulty moving forward. When parents die from COVID-19, their children may become helpless and need social structures to adopt them and provide the nurturing they need for their growth and development. When the only breadwinner of the household dies, there is an enormous financial burden on the remaining family members, leading to social disaster and complete disruption of families.¹⁷ The incidence of depression, suicidal attempts, violence, use of drugs, and addiction to other recreational substances increased among young adults during COVID-19 pandemic. Students suffered enormously due to the disruption of their studies and indulged in more screen time, affecting their brains with psychosocial problems, especially learning anxiety, sensitivity tendency, somatic anxiety, and phobia tendency, as well as risk factors for developing them.¹⁸

Furthermore, children and young people infected with SARS-CoV-2 had small but significant increases in “long COVID syndrome,” which mimicked psychological distress and manifested as persisting cognitive difficulties, headache, and loss of smell compared to controls.¹⁹ Factors associated with persisting, impairing symptoms include an increased number of symptoms at the time of testing, female sex, older age, worse self-rated physical and mental health, and feelings of loneliness pre-infection.

Addressing the emotional needs of these second victims requires a comprehensive approach. Access to mental health services, such as counseling and support groups, is crucial for helping relatives cope with their grief and emotional turmoil.²⁰ Connecting with others who have experienced similar losses can provide a sense of solidarity and understanding, with peer support groups being a valuable resource for sharing experiences and coping strategies. It’s the responsibility of society to recognize and validate the grief of relatives who have lost loved ones to COVID-19.²¹ Public acknowledgment and memorials can help provide a sense of closure and collective mourning. These individuals face significant emotional challenges, including isolation, guilt, and disrupted mourning rituals. Providing comprehensive support and acknowledging their grief is essential for helping them navigate this difficult journey, and it’s a commitment we all must uphold.²¹ The impact of social media influencers has both negative and positive impacts on health outcomes during COVID-19.²²

While the patient’s and family’s needs become the priority for the healthcare organization, the provider may be emotionally traumatized by the event, with lasting effects that persist for months or years afterward. If not treated, a second victim experience can harm the emotional and physical health of the individual and subsequently compromise patient safety.^23–25 The resources typically available to staff and leadership after an adverse event include the hospital or organization’s clergy, psychiatric department, or employee assistance program (EAP).²⁶ A qualitative study based on semi-structured interviews with patient safety officers in acute care hospitals in Maryland identified numerous barriers to staff utilizing EAPs or other supportive services, including taking time away from work to access the support services, fears or doubts about the confidentiality of services, concern that seeking psychological support would be placed in a permanent employee record, concern that accepting emotional support might affect malpractice premiums, possible negative judgments by colleagues, the stigma associated with accessing services, ineffective support, a lack of understanding of the purpose of the second victim support program, and a lack of awareness on the EAP’s part on how to support second victims.²⁷

A study by Edrees et al in the Joint Commission Journal on Quality and Patient Safety urges healthcare organizations to act to support second victims as soon as possible after an adverse event occurs.²⁸ By addressing the traumatized healthcare worker, organizations can help protect other patients from the domino effect of adverse events on healthcare worker performance. Instilling a just culture, which encourages open communication, communicating lessons learned, engaging all team members in the debriefing process, and guiding how staff can help each other during an adverse event, such as offering immediate peer-to-peer emotional support or buddy programs is crucial for supporting second victims.²⁹ The human-artificial intelligence interactions using digitally mediated empathy and communicative processes during the COVID-19 pandemic became unexpected pathways to resilience and enhanced some users’ wellbeing.³⁰ It is essential to use empathetic and communicative processes to increase individuals’ psychological resilience as a critical component of the global recovery from the pandemic and to mitigate SVS.

This manuscript was peer reviewed.

Disclaimers

The author declares that there are no undisclosed conflicts of interest regarding the publica on of this paper. The author has provided Clockwork Communica ons Inc. with non exclusive rights to publish and otherwise deal with or make use of this ar cle, and any photographs/images contained in it, in Canada and all other countries of the world.

ISSN 2819-2842