 Dr. Charlotte Morris has spent her career caring for poor and underserved populations. During her 30 years in clinical practice, she served as a director of temple midwifery practice, a department of temple hospital in Philadelphia. Dr. Morris has worked in a variety of clinical practice settings, including managing an out-of-hospital birth center, providing services to Philadelphia health centers, serving in a university medical practice, and a hospital-based practice. Dr. Morris is currently an assistant professor at Frontier Nursing University in Versailles, Kentucky. I'm sorry, I don't know how they pronounce that in Kentucky, but in Canada we'd say Versailles. Her other teaching experiences include Temple North Eastern Hospital School of Nursing in Philadelphia, where she coordinated and developed curriculum for maternal child's nursing and community health nursing courses. As an adjunct professor at Drexel University, she supervised students in the clinical setting and developed simulation exercises. Dr. Morris's academic preparation includes a doctorate of nursing practice, degree from the university or temple university in Philadelphia, a master of nursing degree from Temple University, a master of science and health administration from St. Joseph's University in Philadelphia. She received her midwifery training at the University of Medicine and Dentistry in New Jersey, and in 2017, Dr. Morris was inducted as a fellow of the American College of Nurse-Midwives ACNM. In May of 2021, Dr. Morris was elected as a member of the Board of Directors of the American College of Nurse-Midwives. So, if you would like to know more about Dr. Morris, I'm going to give her, there we go, there's a nice link, and I'm going to turn it over to her and first of all, let me give her presenter status. There you go, and over to you, thank you. Good day, everyone. It is truly a privilege and an honor to have the opportunity to share with you all and thank you all for taking time out of your busy day to listen to this session. I see you're from all over very different places, a few diversity in our occupations as well. So, really a great audience, and I hope you all will learn and share this information so we can really make a difference. So my topic is second victim phenomenon. And before I start my session, I want to just take the opportunity to acknowledge the land and where I'm at. So with gratitude and humility, I acknowledge the ancestral homeland of the Lenape peoples. I recognize and acknowledge that I am in buildings built on indigenous territory known as Lena Hocking, the traditional homeland of the Lenape Indians. So this is the land that we now call Pennsylvania in the United States. We pay honor and respect to Lenape ancestors, past and present, by committing to build a more inclusive and equitable space for all. And so we hope that's what we're doing, even in sharing this presentation. And so our objectives for this session is that you will walk away with really understanding and being able to define what is a second victim or who is a second victim, to be able to describe the signs and symptoms of second victim phenomenon and to identify the need to improve providers' psychological health outcomes. And so this is a general outline and overview of the information I'll be sharing, introduction to the topic, definition, symptoms, healing, intervention, organizational change. But I really want to talk about why this topic. So as healthcare providers, if we take the time to really look and share and talk to one another, we learn that this is an experience that many of us have had. We've had the opportunity to have adverse outcomes without necessarily the psychological comforting and care that we need. So some of the names that researchers who have really done a lot in this area are Dr. Rue and Dr. Scott. And over the years as they studied and worked with different providers, they learned that adverse outcomes are very common. Dr. Rue and one of his studies found that more than 41% of all providers felt that and described an adverse event. And so that's why this topic. We want to promote awareness and we want to learn it's really about the provider who's used to caring for others, learning how to care for ourselves and for one another. And so this is so important because it happens to just about all of us. So what is a second victim? So a second victim, so if we all think about, we provide care to patients and as midwives, we are known for having those greater attachments, greater support and relationships because of the type of care that we provide. So when there's an adverse outcome or something happens to that patient unexpectedly, that patient is the first victim and then us as the provider, we become the second victim. We hurt, we experience trauma in the same way as that patient. And so the second victim is a specific term that describes healthcare providers who are involved in an unanticipated adverse patient event. And we know that sometimes there are medical errors, sometimes there are anticipated things and unanticipated events, but we become just as traumatized as the patient that we were caring for. And so as a second victim, we may begin to question our skills, doubt ourself. And that first question is, how did this happen? Why didn't I anticipate that this was going to happen? And so being a second victim has a great impact on midwives. I already shared a little bit about the relationship of midwives to their patient and why the impact tends to be greater. So these are some studies where some providers looked at or specifically the impact on midwives. And the outcome and how they felt. And so I will just say here in the United States, there really has not been literature on the impact of second victim with midwives. There is a lot of literature by Dr. Wu and Dr. Scott, mostly around physician providers. So the research here are in European countries. And I think another reason for that is because they have a longer history of having midwives working as independent practitioners than we do here in the United States. So the first study was done by Schroder at L. And he looked at twelve hundred and thirty seven combination of obstetricians and midwives. And out of this group, they found that fifty nine percent of them shared that they had witnessed a traumatic birth event. And then in the second group, Wahlberg and his study, he looked at fourteen hundred and fifty nine providers, again, a combination of obstetrician and midwives. And they found that eighty four percent of the obstetrician and seventy one percent of the midwives stated that they had experienced one or more severe obstetric event, obstetric emergency with either the woman or the newborn. And then the third study, Rice and Warlock, they took a different approach. They actually studied midwives in Australia who had to transfer their patient. The patient risked out of midwifery care, yet the midwife is able to stay there and be a support person. And what this study showed that even in the role of support, again, because of that relationship of midwives with their patient, they were just as traumatized as if they had been the sole provider. So this brings up a second aspect of second victim phenomenon that it can even happen to a provider who is there as in the role of support. So it is a very real sequela and consequence and something that we need to get the word out and be able to support one another. And so there are many symptoms that define this role that that second victim may experience. And I would say, think for yourself about a time recently or in the past when you had an adverse outcome and how did you feel? So you initially very distressed, anxiety, depression, guilt. Why did this happen? I should have been able to recognize this or prevent this. And then sometimes anger. And then depending as we progress through, it affects how we continue to care for others. We lose confidence, may experience burnout, absenteeism from the job. Lacking confidence causes more errors in what we do. And then for some, they never adjust and they move on and leave the profession. And so the consequence of second victim phenomenon causes both emotional, physical and psychological impairment. And there's no order of these things, but we know that they are real and what people feel if they've been a second victim. And so Dr. Wu did some research and studied and he studied those persons who had been second victims. And he learned that there's a stage of recovery, very similar to loss and death, that there's a stage of healing or recovery. So he identified six stages and we know anything with stages. It's not that the second victim may go through all of these stages in a row, but they will experience most of them and differently. And so the first stage is that chaos and accident response. This is the immediate response when there is an unexpected adverse event. What the heck just happened? How could this have happened? What did I miss? How did this happen? And then the second stage is when we become bombarded with reflections. So it may be the next day or so, but we have flashbacks and we're thinking about, oh my God, we're reliving and rethinking about this incident and what just happened. So one of the things with second victim phenomenon is some people tend to confuse it with post traumatic stress or burnout. So what I want to say to you is these may be symptoms of second victim phenomenon, but they are not the cause. So second victim phenomenon is very specific. It is specific to providers. If I'm driving a car and have an accident and someone gets critically injured that I hit in that accident, I may suffer post traumatic stress, but a different cause. If I'm caring for my patient and during that labor or birth, she has an unexpected postpartum hemorrhage, ends up with DIC, goes to the ICU, then I'm having post traumatic stress flashbacks as a second victim from that experience. So very different. A lot of the same symptoms of other traumatic diseases or illness, but it is the cause that is different. And this syndrome is specific to providers. And so there's inquisitions for vital when they may finally meet someone they can talk to, personal integrity, and then getting help is that end stage. And finally, someone they can talk to, refer them for psychological counseling or whatever the need may be. And then that sixth stage is moving forward. And so with moving forward, it's different stages of surviving. And what we hope is that the person has gotten help and is able to move forward and thrive. And thriving is they're effectively coping and they can continue to care for others effectively. But for some, surviving means they never overcome that adverse event and they drop out or move away from the profession. And so there is evidence that shows there are things that we can do to help our second victim. So there are some interventions that can be very helpful. And that should really be our thought when something happens to our colleague. How can I help? And so the literature talks about self care and the literature shows that those persons who already have effective self care habits do much better when they are experiencing an adverse outcome because they already have habits where they've learned to effectively cope, right? So self care can be just simple thing such as good nutrition, good diet, eating healthy, having a regular exercise program, running, walking, swimming, but these are all things that we do that help to reduce our stressors, right? And so if I've already have a habit of doing these things, then I have a better possibility of having a good recovery if an adverse event happens. So other things that have been shown to be effective are meditation, mindfulness, and I want to say even at Frontier, we've implemented mindfulness sessions, so we have weekly mindfulness sessions so that the staff can move away from this computer and have a time to just to reflect, debrief, and de-stress. So very important coping habits. And then prayer, the literature also talks about persons who are established with the religious organization or a faith-based organization have better survival or self care. Prayer becomes very effective and some organizations have even incorporated spiritual help, spiritual counseling, prayer within the OR, knowing that it can make a difference in that patient's survival. And last but not least, family and friends having a supportive environment where you can go and talk about and debrief and share about the different things that happen throughout your day. So self care can also be part of what the organization does. And as I said, in my organization, we have meditation already built in as a form of self care. So a key thing is the development of a support team. And so this is an organizational, system-wide team that is put in place specifically to help the second victim. And so one of the key persons in this support team is the peer person. And so if we're talking about midwives, when something happens, you want to talk to another midwife. If we're talking about respiratory therapists, you want to talk to another respiratory therapist. So the literature clearly shows that like peer support is the most effective. So when setting up a support team, one of the things that you want to do that you need to start with is education, educating your organization and all of the staff on what is the second victim and how can we help them. And so then those persons who are designated as peer support have to go through a series of training. And part of that training is understanding second victim, understanding the appropriate conversation and how to talk supportively, and also recognizing that that interaction, those conversations are confidential. And one of the questions that people often ask is if the incident or the adverse event goes to court, is my conversation with the peer support team confidential? And so yes it is. This is a confidential organizational support and it cannot be pulled for the lawyer or for the court. So and that's another protection for the second victim. And so we learn to be non-gentimental and the team should be multidisciplinary, multidisciplinary in the sense that multiple providers, but also social workers, psychological counselors, therapists, anything that the second victim person may need to get through this successfully. And so these are a list of organizations that have peer support systems in place specifically to support the second victim. And so one of them is the University of Missouri and their program is called For You. And they worked along with the Children's National Hospital in Ohio and they helped them develop their program called You Matter. And then there's a program at John Hopkins Hospital in Baltimore, Maryland, and their program is called Rise, which stands for resilience. So I want to share a little bit about the John Hopkins program and how it came about because it is one of the signature programs and they were able to thrive and develop this program. So there was an incident where a child in the pediatric unit was being cared for and getting ready for discharge. And the mother was there and she was concerned that the child didn't look right and she didn't feel the child was ready to go home. So the mom talked to the nurse and the nurse said, oh, she looks okay. She'll be okay. And then later the nurse came back and said, I'm going to give her a narcotic for her pain and maybe that'll help her. And the mother said she doesn't get narcotic. That's not why she's here. And the nurse said, oh, there's just been a new order written. I'm going to go ahead and give the narcotic. No worries. So long story short, the patient received the narcotic, went into respiratory distress and died. So a pediatric patient on the day of discharge died from an adverse event, an error that occurred within that institution. And so the resident at the time who was the team leader felt greatly impacted. And I'm sure the rest of the staff did, the nurse did, they all became second victims, right? Feeling the impact of what happened to this child. Where did we go wrong? How could this have been prevented? So this resident suffering all the symptoms of second victim phenomenon months later, still not feeling good about this incident, went to meet with the family. And the family had opened doors and received him. And so as a result of a conversation with this family and a physician provider who took a step above his own feelings and reached out to the family, they were instrumental in developing this rise program. And so rise stands for resilience and stressful events. And now it is one of the landmark programs for second victim support. And the Johns Hopkins University also does teaching and training to other institutions who may be interested in this type of care. Or implementing this type of program. So I want to say that Dr. Scott, one of the people that was instrumental in doing research and working on an understanding second victim, developed what he calls a three tier intervention model of support for victims. So all of these programs may have their differences and how they're organized and then how they run, but they all have the foundational basis of Dr. Scott's three tier intervention. And so the first stage of the intervention says that identify persons on your unit to provide the peer support. And so an effective program is throughout the organization. So every unit should have peer support. And we talked about that peer support being multidisciplinary. And then the second tier says incorporate training for the peer group. And the training should include understanding and recognizing second victim phenomenon, learning about patient safety, risk management and of course, confidentiality. And then the third tier is developing a system that offers all the necessary and needed support. So we should so it should include spiritual counseling, psychological counseling, employee assistance program, and of course, risk management and the involvement in administration. So all of these programs have that foundation. Even though they may have more things, they carry out differently, but they all have the foundation of the Scott three tiered intervention system. And so I want to talk about organizations. So anything we do in order to be effective, it has to be a top down approach. So a lot of times what happens when someone has an adverse event or makes a mistake, we hear blame. Who is that midwife that cared for that patient? Who was that nurse that made that mistake? We're looking for someone to blame. So in order to have an effective second victim program, we need to have an organization that is created around the philosophy of just culture. So a just culture when that adverse event happens, they don't look for who did it. Who can we blame? But they come together as a group, want to support the person that may have been involved, but to look at from an organizational perspective, a systems perspective. What can we do differently to prevent this from happening again? So in order to really have an effective second victim program, it starts from the top down. The organization has to be fully engaged and supportive. And then I want to say if you work in a practice where maybe you have your practice and you just go to a hospital to do deliveries, so you're not really a full participant in that organizational structure, you can develop a second victim program right within your practice. So you have a practice, a group of six midwives and something happens to someone on call. There's an adverse event. There's a midwife that's on call as the peer support. And so you call into your practice, get the peer support and you can build in all of those other things that may be needed, right? Your psychological counseling, your spiritual counseling and they may be things that you refer to, but you have a system in place and you know where to go and how I can help my colleague. Again, this is about the care provider learning to care for one another. And so in summary, I want to say that your presence here today just goes on to help support and promote awareness of second victim syndrome or phenomenon. And I hope that you all will become advocates to get the word out and develop systems of support and know that in order to have a effective second victim support system here within one of these references. I had the opportunity to publish an article that just happened on my screen. I wanted to share with one of these references around second victim syndrome and it was published in the Journal of the Refringed Woman's Health. I put it on the materials and myself. And so at the end of my presentation, I thank you all again and I would be more than happy to enter any questions that you may have. Are there any questions? There's a few great comments here. I think that Jane Houston says, I think specifically in the U.S. we have a blaming culture. And so we are in risk, we are so risk adverse due to the health and legal systems. Yvonne says that these types of things are so needed, these types of supports. I believe to have this type of support in units and it's a great presentation. And I think many midwives are afraid of being blamed when things go on. I used to says a nice presentation. Yeah, blame culture lives in the UK too says Yvonne. And I want us to give a shout out. Hi, Jane. We have about 10 minutes for questions or comments if you prefer. Well, I'm going to just because one of my research studies I forgot to share. So I'll just take a few minutes to share that when we were talking about the self care. It was a study that was done with a group of surgeons. And so you know if you're a surgeon every time you step in that or that stress you have life and death in your hand. And so do we as midwives. But this particular study looked at a group of surgeons and one group participated in exercise and diet change and the other group did not. And they found that the group that participated in the self help events had were able to overcome their stressors more effectively and they didn't carry them long term. They cope more effectively and were much better at their job than their colleagues that didn't participate in the self care activities. So it just goes on to reinforce that any level of provider simple things just good self care and good effective coping mechanisms can make a difference in their outcome or how we handle right when an adverse event occurs. And honest maybe we should have had a poll question how many of you have can relate to this topic because you've been there and you've had an adverse event. You can type in the chat if you want to share. Yes I see Celia said yep it's a rough recovery even with support absolutely. And Lorraine is asking have I had an adverse event. Yes I have. And honestly I didn't know about second victim phenomenon at the time. So when I was involved in doing this research I said wow and I can actually say I had a lot of coping self care things that allowed me to cope effectively. So I didn't get burnout. I didn't leave the profession. It only made me better once I learned how to cope and overcome the adverse event. But he says it's a challenge to help others. You just want to make things perfect for them again instantly. Well so we feel for them right Cecilia. But if you go through the training to support a second victim you'll learn what you can and cannot say can and can and cannot do. And yes your heart feels for them right. We empathize with their situation. But I don't think there's any perfect situation. Even people who recover well have effective coping mechanism. Nothing's perfect. And we all respond differently right to adverse events even differently how we handle our stresses. And even if we're doing well or we think we're doing well my well may be very different than your well. Right. Great comments. Thank you all so much. Are there any other comments or questions please put them in the chat and we'll get to them. And I wanted I want to just say I hope that you all walk away with something that you can share when you leave this session today. So we want to be difference makers right. Let's be difference makers. Well Charlotte if there are no more questions. I think we'll move on. OK. Oh wait. Jane's typing something. Let's see here. No she just said she much love and gratitude. Jane. All right. Thank you all again. I appreciate the opportunity to share and thank you for taking the time out of your busy days. And thank you so much Charlotte this has been so informative and I've really learned a lot and even as a non midwife these are things that I can apply in my life and I'm now thinking of those events that still haunt me and I probably need to deal with them. Right. So thank you so much. Lots of nice thank yous in there and everybody let's give it the idea. Thank you to Charlotte Morris.