Second victim syndrome in nursing: what it is, how to recognize it, and when to get help

After an adverse patient event, many nurses experience something beyond normal stress – intrusive replays of the incident, clinical avoidance, hypervigilance, or a loss of confidence that persists weeks after the event. This is second victim syndrome. A systematic review of second victim studies across health care professions found prevalence estimates ranging from 10.4% to 43.3% (Seys et al., 2013). Knowing what it is, where you are in the trajectory, and what kind of support helps can make the difference between moving through it and carrying it for years.

Normal stress vs. second victim syndrome vs. requires clinical referral

What second victim syndrome is

The term “second victim” was coined by Dr. Albert Wu in a 2000 BMJ commentary arguing that the clinician who makes a mistake is harmed by its psychological aftermath and needs help too. Later work, including the AHRQ PSNet primer on the topic, widened the term to any provider involved in an unanticipated adverse event, error, or patient injury who is traumatized by it. A nurse who gave the wrong dose of a look-alike medication, a floor nurse who caught a deterioration later than they wish they had, and a postpartum nurse present at an unexpected neonatal death can all become second victims, and fault does not decide who is affected.

Second victim syndrome describes the cluster of psychological responses that follow: guilt, shame, self-doubt, anxiety, and disruption to clinical function and personal life. It is a recognized occupational hazard of clinical nursing and a predictable response to a distressing event, separate from burnout.

It is distinct from compassion fatigue (cumulative emotional cost of caring) and moral injury (distress from being required to act against one’s values). Second victim syndrome is event-specific, though it can co-occur with both.

The 6-stage trajectory (Scott et al.)

Research by Suzanne Scott and colleagues, published in Quality and Safety in Health Care, identified a six-stage trajectory that second victims commonly move through. Not every nurse passes through every stage, and the sequence is not rigid, but the framework helps locate where you are:

Stage 1 – Chaos and accident response: Immediate aftermath. The event is happening or just happened. Clinical tasks and team coordination take priority. Emotional response is suppressed by necessity.

Stage 2 – Intrusive reflections: Hours to days later. The event replays involuntarily. “What did I miss?” “What should I have done differently?” Questions cycle even when the clinical review has already found no error or no alternative course of action. Sleep disrupts. Concentration at work drops.

Stage 3 – Restoring personal integrity: The nurse begins active processing – seeking answers from medical records, talking informally with trusted colleagues, looking up literature. The goal is to understand what happened and whether they bear responsibility. This stage requires a supportive environment; an unsupportive one prolongs it or bypasses it entirely.

Stage 4 – Enduring the inquisition: Formal review processes – incident reports, root cause analysis, peer review, risk management interviews, legal inquiry. This stage is retraumatizing for many second victims regardless of the outcome. The process itself – the formal scrutiny, the institutional language of accountability – amplifies shame and anxiety.

Stage 5 – Obtaining emotional first aid: Finding the support that helps: a trusted colleague, a peer support program, EAP counseling, a mentor. Scott’s team found that the support received here shapes which Stage 6 path a clinician takes. Without it, the risk rises of leaving the profession or carrying lasting psychological effects.

Stage 6 – Moving on: Three divergent paths – dropping out (leaving nursing entirely), surviving (returning to clinical work but never fully recovering confidence), or thriving (integrating the experience and growing from it). The trajectory toward thriving requires adequate support at Stage 5 and often a shift in the nurse’s relationship with error – toward a systems-thinking view rather than individual-blame.

Who is most at risk

Research identifies several factors associated with more severe second victim responses:

• Newer nurses are commonly reported to experience stronger reactions early in their careers. The gap between expectations and clinical reality is largest here, and the identity disruption of “I made an error” hits harder when clinical competence is still being established.
• High-acuity settings – ICU, ED, NICU, OR – have higher incident rates and higher severity events, making second victim exposure more frequent and more intense.
• Nurses with a perfectionist orientation or high personal standards are more vulnerable to prolonged guilt and self-doubt.
• Nurses without peer support structures – those who are new to a unit, work nights, or are in a unit with a punitive safety culture – have fewer protective factors and longer recovery timelines.
• Repeat exposure – nurses involved in multiple adverse events over a career may show cumulative effects even when individual events are processed.

When peer support is enough vs. when to seek formal help

Peer support – talking to a trusted colleague, participating in a structured debrief, reaching out to a peer support program – is the right first step for most second victim experiences. It normalizes the response, reduces isolation, and provides a space for processing that is separate from formal review.

Peer support is sufficient when:

• The emotional response is distressing but not debilitating
• You are sleeping, eating, and functioning outside of work
• Intrusive thoughts are present but decreasing over the first 1–2 weeks
• You can return to clinical work without significant avoidance or panic

Formal support – EAP counseling, mental health referral, consultation with a psychiatrist – is appropriate when:

• Symptoms are worsening rather than improving after 2–3 weeks
• You are experiencing panic attacks at work or when thinking about work
• Sleep disruption is severe and sustained
• You are avoiding clinical situations that were previously routine
• You are having thoughts of harming yourself
• Alcohol or substance use is increasing as a coping mechanism
• You cannot function in your normal daily life outside work

If you are having thoughts of self-harm, contact the 988 Suicide and Crisis Lifeline (call or text 988) or the Crisis Text Line (text HOME to 741741). Nurses die by suicide at higher rates than the general population: in CDC National Violent Death Reporting System data for 2017–2018, the suicide rate among women nurses was 17.1 per 100,000 compared with 8.6 per 100,000 among women overall, roughly double (Davis et al., JAMA Psychiatry, 2021). Seeking help is the professional response.

Resources and how to access them

Employee Assistance Program (EAP): Most hospital systems have an EAP offering free confidential counseling sessions – typically 3–8 visits. EAP is separate from your employer’s HR function, and sessions are confidential; the usual exceptions are imminent risk of harm to yourself or others, or an employer-mandated fitness-for-duty referral, where you will be told in advance what is shared. Start here.

Peer support programs: The Joint Commission recommends that organizations build second victim support, including peer support (Quick Safety Issue 39, 2018), though it does not mandate a specific program. Programs such as Johns Hopkins’ RISE and the University of Missouri’s forYOU team are widely used models. If your facility has one, peer supporters are trained nurses who have been through the process themselves. Ask your nurse manager, nursing education department, or patient safety office whether a program exists.

Nurse attorney consultation: If the adverse event involved a patient death, a legal claim, or a potential board inquiry, consult a nurse attorney before speaking with risk management. The American Association of Nurse Attorneys (TAANA) maintains a directory of nurse attorneys. Remember that risk management represents the hospital’s interests.

Mental health referral: If EAP is exhausted or insufficient, request a referral to a therapist with experience in occupational trauma or healthcare professional stress. If symptoms meet criteria for PTSD, the 2023 VA/DoD guideline recommends trauma-focused psychotherapies, specifically cognitive processing therapy (CPT), prolonged exposure (PE), and EMDR, over medication as first-line treatment.

See nursing compassion fatigue if the distress feels more cumulative than event-specific. For burnout that predates this event, see nurse burnout. If the event involved a medication error, see nursing medication error recovery. For navigating difficult conversations with patients and families after an adverse event, see nursing difficult patient conversations.

Returning to clinical practice after a traumatic event

Most nurses return to clinical work without formal accommodations. For those who need support:

• Request a brief redeployment – even a few shifts on a less acute unit – while acute symptoms are highest. Frame it to your manager as a patient safety issue: if you are cognitively impaired by acute stress, patient care suffers.
• Ask for a phased return if symptoms are significant. This runs through your manager and HR (or occupational health), usually supported by documentation from a treating clinician; FMLA intermittent leave or an ADA accommodation may apply if you are eligible.
• Do not return to the same patient scenario immediately if avoidance is high. Systematic exposure – returning gradually to similar situations – is more effective than avoidance.
• Find one trusted colleague on your unit who knows what you’re going through. You don’t need your whole team to know. You need one person who checks in.

The aim is to carry the experience without being controlled by it. Nurses who process adverse events openly, seek support, and integrate what happened are the ones Scott’s model describes as thriving, and they often go on to become the peer supporters and safety advocates their units rely on.

References

1. Wu AW. “Medical error: the second victim. The doctor who makes the mistake needs help too.” BMJ, 2000;320(7237):726–727.
2. 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.” Quality and Safety in Health Care (BMJ Quality & Safety), 2009;18(5):325–330.
3. Agency for Healthcare Research and Quality (AHRQ), Patient Safety Network. “Second Victims: Support for Clinicians Involved in Errors and Adverse Events.” AHRQ PSNet Primer. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
4. Davidson JE, Proudfoot J, Lee K, Terterian G, Zisook S. “A Longitudinal Analysis of Nurse Suicide in the United States (2005–2016) With Recommendations for Action.” Worldviews on Evidence-Based Nursing, 2020;17(1):6–15.
5. American Nurses Association. “Preventing Nurse Suicide and Increasing Resilience” and “Well-Being Initiative.” American Nurses Association, accessed 2026.
6. Substance Abuse and Mental Health Services Administration (SAMHSA). “988 Suicide and Crisis Lifeline.” U.S. Department of Health and Human Services, accessed 2026.
7. Seys D, Wu AW, Van Gerven E, et al. “Health care professionals as second victims after adverse events: a systematic review.” Evaluation & the Health Professions, 2013;36(2):135–162.
8. 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.” BMJ Open, 2016;6(9):e011708.
9. Davis MA, Cher BAY, Friese CR, Bynum JPW. “Association of US Nurse and Physician Occupation With Risk of Suicide.” JAMA Psychiatry, 2021;78(6):651–658. doi:10.1001/jamapsychiatry.2021.0154
10. The Joint Commission. “Quick Safety Issue 39: Supporting second victims.” February 2018.
11. Schnurr PP, Hamblen JL, Wolf J, et al. “The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.” Annals of Internal Medicine, 2024;177(3):363–374. doi:10.7326/M23-2757