Second Victim Syndrome Among Healthcare Professionals: A Systematic Review of Interventions and Outcomes

Introduction

Healthcare professionals (HCPs) work in high-stakes environments where adverse events and medical errors are an unfortunate reality.¹ While the immediate focus is often on patients and institutional accountability, the emotional and psychological toll on healthcare providers involved in such incidents is increasingly recognized as a critical issue.^1,2 This phenomenon, termed Second Victim Syndrome (SVS) by Wu in 2000, refers to the emotional distress, self-doubt, and psychological sequelae experienced by HCPs following adverse patient outcomes, unanticipated events, or clinical errors.² ‘Second Victims’ may be directly or indirectly involved in the unanticipated adverse patient event, and SVS can manifest as guilt, anxiety, sleep disturbances, and diminished professional confidence, with potential long-term repercussions on well-being and career trajectory.^3–5SVS is highly prevalent. Global estimates suggest that almost 50% of healthcare providers experience SVS at least once in their career, and the prevalence ranges from 10.4% to 43.3%.³ The consequences extend beyond individual suffering, with exacerbated risks of increased burnout, absenteeism, staff turnover, and even compromised patient safety and quality of care.^1,5

Recognizing the detrimental impact of Second Victim Syndrome (SVS), healthcare institutions have developed various interventions to support affected professionals. Notable programs such as the Resilience in Stressful Events (RISE) initiative at Johns Hopkins Hospital⁶ and the ForYOU program at the University of Missouri Health Care⁷ emphasize peer support, individual counseling, and structured debriefing. Scott’s Three-Tiered Model of Support, which includes immediate emotional first aid, peer support, and access to professional counseling services, has emerged as a widely adopted framework.⁸ However, the effectiveness of such interventions remains poorly understood, as most studies focus on subjective experiences rather than standardized outcome measures.

There is limited consensus on which interventions are most effective, especially in the long term. Prior reviews, including those by Coughlan et al (2017) and Nydoo et al (2020), have synthesized available programs but primarily focused on describing the types of support offered rather than evaluating outcomes.^9,10 More recent reviews often emphasize the availability of resources or theoretical models without critically appraising the effectiveness of interventions or using standardized outcome measures.^1,9 Besides many studies relying on anecdotal feedback or non-validated tools, significant variability exists in intervention outcome measurement, including differences in tools used, study design, targeted populations, and types of interventions,^11–13 which inevitably hinders cross-study comparison, comparability and generalizability. Only recently has an international consensus been reached on key indicators for evaluating SVS programs;¹⁴ inadequate evaluation of such programs limits understanding of program effectiveness, which, in turn, impedes institutional adoption.

This systematic review therefore aims to identify the interventions supporting Second Victims in literature and examine their effectiveness, so as to inform healthcare institutions on best practices for mitigating SVS and inspire further investigation in this important area of research. These findings aim to bridge the methodological limitations of past reviews, as well as the gap between research on SVS and their practical applications in healthcare institutions.

Methods

Study Design

This current systematic review adhered to the latest Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) statement,¹⁵ with search terms including but not limited to: “Intervention”, “Second Victim Syndrome”, “Medical Errors” and “Healthcare Personnel”. We searched MEDLINE, Embase and Cochrane library databases, covering all records up to July 7, 2024. The full search strategy is available in Table S1. The study protocol was prospectively registered in PROSPERO (registration number CRD42024562333). In addition to peer-reviewed databases, we reviewed reference lists of included studies and relevant grey literature sources (eg, institutional reports and program evaluations) to ensure a comprehensive search. However, we did not include unpublished conference proceedings.

Eligibility and Selection Criteria

All search results were imported into Covidence (Melbourne, Victoria, Australia), a systematic review management software platform, used to facilitate duplicate removal and study screening. Each title and abstract were independently screened by two pre-assigned reviewers (TOSK, CNG, EKYET or KAS) working separately to ensure unbiased assessment. Reviewers were assigned in rotating pairs to evenly distribute the workload across the team. Any discrepancies were resolved through discussion, and, if necessary, with input from a third reviewer (ASPT, HKT or QXN). The term “independent” refers to the independent conduct of initial screening by reviewers within the study team, not to external or unaffiliated reviewers. Full-text articles were similarly assessed in duplicate using the same process. We did not formally calculate inter-rater reliability (eg, kappa), but discrepancies were minimal and resolved through consensus with a senior author (ASPT, HKT or QXN).

Studies selected for inclusion had to: (1) be original randomized controlled trials, observational studies, pilot studies and quasi-experimental studies; (2) investigate the Second Victim phenomenon and interventions, programs, or strategies to improve outcomes of Second Victims; (3) report the efficacy of these interventions regarding personal, physical, mental health or workplace outcomes; (4) be available in English or have a professionally translated English manuscript. Second Victims were defined as HCPs involved in an unanticipated adverse patient event, in a medical error and/or a patient-related injury and become victimized in the sense that they are traumatized by the event. Second Victim syndrome was defined as the continuum of symptoms and emotions experienced by Second Victims. Systematic reviews, editorials, opinion pieces, case reports and conference abstracts; studies investigating non-healthcare worker populations; and studies not available in the English language were excluded.

Data Extraction and Outcomes

We developed and piloted a standardized data extraction form on a small subset of studies to ensure clarity and consistency. Two pairs of authors (TSKO, CNG, EKYET or KAS) independently extracted data including: (1) study characteristics (author, publication year), (2) patient demographics (number, age, gender), (3) baseline status, (4) treatment characteristics and (5) treatment outcomes. Any discrepancies were resolved in consultation with a senior author (ASPT or QXN). Given the anticipated heterogeneity of outcomes, narrative synthesis was utilized to examine the impact of different methods employed for SVS in literature. The primary outcomes of interest were the improvements in psychological and physical well-being of Second Victims. For the purposes of this review, immediate outcomes were defined as those pertaining to emotional and psychological well-being shortly after implementation of the intervention, for example, individual emotions and satisfaction. Long term outcomes were defined twofold. Firstly, as those pertaining to helping individuals deal with future adverse events, such as department culture, resilience and perceived institutional support and secondly, as longer-term impacts on individual well-being, such as burnout and depression.

Quality Assessment

The Joanna Briggs Institute (JBI) critical appraisal tool¹⁶ was used for quality assessment for the studies included in this review. We chose this tool as all the studies included in this review were quasi-experimental in nature. The JBI checklist for quasi-experimental studies contains 9 items that evaluate the internal validity and risk of bias across various domains such as the bias related to temporal precedence, selection and allocation, confounding factors, administration of intervention and measurement of outcomes. An overall appraisal rating is synthesized to determine the quality of the paper. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was also used to evaluate the certainty of evidence for outcomes.¹⁷ The GRADE framework assesses five domains including: Risk of bias, inconsistency, indirectness, imprecision and publication bias. The GRADE assessments were conducted with input from the senior authors (ASPT and QXN) and presented in a structured and transparent approach to guide the interpretation of the findings.

Results

Study Selection and Characteristics

A comprehensive search across Embase, MEDLINE, and Cochrane Library databases identified 10,322 studies. After removing 2615 duplicates, 7647 studies were excluded during title and abstract screening for not meeting inclusion criteria. Following full-text review of 58 studies and additional grey literature search, 15 studies published between 2015 and 2024 were included.^{6,12,13,18–29} The selection process was summarized and is available in Figure 1 (further details of excluded studies are available in Table S2). Characteristics of the included studies are summarized in Table 1.

Table 1 Summary of Included Studies

Figure 1 PRISMA flowchart showing study selection process.

As shown in Table 1, a total of 11 studies were conducted in the United States (US),^{6,12,13,19–22,24,25,27,28} with the remaining 4 studies conducted in Spain,¹⁸ China,²³ Denmark²⁶ and the United Kingdom (UK),²⁹ respectively. Participants were predominantly female and included HCPs across roles such as medical doctors, nurses, pharmacists, and administrative personnel. Three studies focused on paediatric departments. Definitions of SVS were roughly consistent across most studies, typically describing HCPs who after being involved in unanticipated adverse patient events, medical errors, or patient-related injuries, suffer physical or psychological sequelae. The programs differed slightly in terms of the adverse events studied, ranging from stressful circumstances,²⁷ new or ethically challenging cases and unfamiliar work environments,²⁴ to incidents in patient care such as medication errors, patient harm, decline or death^{6,18–20,22–27} and even patient suicide.^15,23 Notably, four studies did not explicitly define the nature of adverse events studied.^13,21,28,29

Across the included studies, several demographic trends were observed. Participants were predominantly female HCPs, reflecting broader workforce demographics in nursing and certain medical specialties. Many studies focused on staff from anesthesia and pediatric departments, which may be due to the high acuity and emotional demands associated with these specialties. A wide range of professional roles were represented, including nurses, physicians, residents, pharmacists, and allied health staff, indicating the cross-cutting occurrence of SVS across clinical hierarchies and disciplines. However, few studies disaggregated findings by profession or gender, limiting more nuanced analysis.

Quality Assessment

Quality of the included studies was assessed using the JBI checklist for quasi-experimental studies. Of the included studies, one (6.7%) was rated high quality,²³ 14 (93.3%) moderate quality,^{6,12,13,18–22,24–29} and none of low quality. Most studies defined their study variables, defined the outcome measurement, and employed appropriate statistical analyses. Common flaws included lack of control groups, insufficient justification for exclusions, and incomplete follow-up descriptions. Table S3 provides the detailed quality assessment findings.

Types of Interventions

Details of Second Victim Interventions and their key intervention characteristics and outcomes are summarised in Table 2. Majority of the studies involved peer support programs.^{6,12,13,18–22,24–29} Implemented in 13 studies, peer support programs were largely modelled after early initiatives such as forYOU, RISE, and HELP. These programs provided emotional and psychological first aid to Second Victims, either individually or in groups, with timing ranging from immediate outreach to multi-week follow-ups. Two studies used online formats,^13,29 while others were in-person.^6,12,18–28 Programs emphasized non-judgmental support, often employing Scott’s Three-Tiered Model of intervention.⁸

Table 2 Summary of SVS Intervention Details and Outcomes

Additionally, two studies evaluated specific psychological therapies; Vogt et al studied cognitive behavioural therapy (CBT) in individual and group settings,²⁹ while Li et al implemented mindfulness and meditation techniques.²³

Effectiveness of Interventions

To further elaborate on the outcomes achieved, for peer support programs, most studies reported positive short-term outcomes, including reduced loneliness, isolation, and emotional fatigue. For example, Simpson et al found significant reductions in perceived judgment and disengagement (p<0.01).²⁷ However, in terms of long-term outcomes, these programs generally increased awareness of available resources and willingness to seek support,^13,19,25 but there were mixed results for sustained improvements in professional efficacy and reduced turnover intentions.^12,18

With regard to psychological therapies, Vogt et al reported significant reductions in burnout and depression (p<0.001) and improved resilience (p<0.001).²⁹ Li et al demonstrated increased mindfulness and physical/mental coping skills (p<0.01).²³

Few studies used standardized tools to evaluate interventions. Four studies assessed intervention effectiveness using the Second Victim Experience and Support Tool (SVEST),^21,23,24,28 which reported mixed results across various dimensions. Psychological distress showed slight reductions post-intervention in some studies, but the improvements were statistically insignificant in most cases (p-values ranging from 0.04 to 0.61).^21,24,28 Physical distress demonstrated minor declines post-intervention, though these changes were also not statistically significant (p-values ranging from 0.24 to 0.28).^21,24,28 Colleague and supervisor support showed inconsistent trends. While one study (Li et al) reported a significant decline in perceived colleague and supervisor support following intervention (p<0.01),²³ other studies found no meaningful changes (p-values ranging from 0.06 to 0.95).^21,24,28 Institutional support, however, consistently improved across studies (p-values ranging from <0.01 to <0.001),^21,23,24,28 indicating that interventions, particularly structured peer support programs, contributed to greater awareness and perceived organizational backing. Conversely, non-work-related support and professional self-efficacy did not show meaningful changes, with all studies reporting non-significant p-values (p = 0.13 to 0.78).^21,23,24,28 Turnover intentions and absenteeism remained largely unchanged post-intervention, with negligible effect sizes (p-values ranging from 0.09 to 0.99).^21,24,28 Overall, while peer support interventions and institutional support programs were associated with short-term improvements in perceived institutional backing, their impact on long-term psychological well-being, professional self-efficacy, and retention outcomes remain unclear.

GRADE Assessment of Certainty of Evidence

Using the GRADE framework, the overall certainty of evidence for short-term improvements in emotional well-being after peer support was rated as ‘Low’, primarily due to serious risk of bias (lack of control groups, small sample sizes) and imprecision. Evidence for long-term mental health outcomes (eg, reductions in burnout or depression) was ‘Very Low’, reflecting inconsistency among studies, lack of standardized measures, limited follow-up and the overall sparse number of studies. While individual studies of formal counseling or mindfulness reported promising results, the confidence in these findings remains ‘Low’. These data are likewise limited by small sample sizes and lack of control groups, resulting in an overall ‘Low’ certainty. The results for the GRADE methodology can be found in Table 3.

Table 3 GRADE Appraisal for Certainty of Intervention Outcomes

Discussion

Based on the findings of our review, there are a number of interventions studied for tackling the issue of SVS. Peer support is the most widely studied intervention likely due to its simplicity, accessibility and adaptability to various healthcare settings.³⁰ The immediate benefits of peer support include reduced feelings of loneliness, isolation, and emotional distress, with many participants reporting positive subjective experiences. However, peer support programs, albeit widely implemented and generally perceived as beneficial for immediate emotional support, may lack long-term efficacy for improving mental health and professional outcomes based on the overall body of evidence.^{6,12,13,18–22,24–29} Programs such as HELP,²¹ RISE,⁶ and forYOU⁷ aim to provide structured, tiered support, fostering a culture of institutional backing. However, the effectiveness of these interventions in terms of long-term psychological well-being and professional resilience remains unknown. To be effective, these programs also require some degree of customisation, co-production and tailoring to setting-specific implementation.³⁰ The inherently transient nature of peer support encounters may limit their ability to address deeper psychological and emotional impacts.

Moreover, despite the availability of these programs and that participants generally reported satisfaction with peer support, only a subset of Second Victims engaged with the programs, with reported refusal rates of 40% to 65%. Several key barriers have been often cited. In one study, among 234 second Victims offered peer support, 58.1% declined, citing self-sufficiency, unfamiliarity with the program, or discomfort with peer supporters as primary reasons.²⁷ Fear of judgment and lack of anonymity were minor concerns.²⁷ Affected individuals may not recognize their own suffering as well as the importance of addressing the psychological impacts of adverse events.^1,10,11 Although engagement and perceived acceptability of interventions in the studies reviewed appears high, this is likely skewed by those already willing to partake in these programs. There is a need for greater research into targeted strategies to increase the uptake by other Second Victims. Alternative programs should also be explored amongst those who find peer support less desirable.

While peer support can serve as a stepping stone, it is insufficient as a standalone solution, as highlighted by prior reviews.^1,10,11 To enhance the effectiveness of peer support programs, structured training for peer supporters and tiered support models that provide escalation pathways are recommended. Trusted peer supporters—rather than anonymous individuals—may also enhance program acceptance and confidentiality. A multi-faceted strategy to support Second Victims, blending peer-based and professional interventions should be the focus of future research. Moreover, compared to peer support, structured psychological interventions, including mindfulness and CBT-based programs, demonstrated promising results, albeit only two studies assessed psychological interventions, making it difficult to draw firm conclusions.^23,29 Vogt et al showed significant reductions in burnout and depression scores (p<0.001) following structured CBT sessions.²⁹ Li et al reported increased mindfulness and improved emotional regulation (p<0.01) following a guided meditation and mindfulness-based intervention.²³ These findings mirror broader literature on stress reduction interventions in HCPs, which suggests that counselling and mindfulness-based strategies may be more effective in fostering long-term resilience.³¹

In a recent meta-analysis, Ong et al reported that mindfulness-based interventions such as stress reduction programmes and meditation had significant emotional and psychological benefits to HCPs in general, although long-term outcomes were variable and not consistently sustained.³¹ The structured nature of these programs ensures that participants receive targeted coping strategies, unlike peer support models, which generally rely more on informal emotional validation. Hence, peer support programs should be viewed as an entry point for comprehensive SVS care, with mechanisms to escalate to other support and professional interventions as required. Integrating mindfulness and counselling into institutional frameworks may provide a more holistic approach, and a multi-faceted strategy blending peer-based and professional interventions should be the focus of future research.

Theoretical Implications

The findings of this review highlight important theoretical considerations for understanding SVS interventions. Peer support programs, while valuable for immediate relief, may not sufficiently address the extant psychological impact of adverse events. This aligns with stress-coping models and theories of trauma recovery, which emphasize the need for structured, guided processing to achieve long-term resilience.³² The review also underscores the importance of institutional culture as a mediating factor—HCPs’ perception of organizational support may influence not only engagement with interventions but also the trajectory of recovery. Furthermore, SVS can be framed within occupational stress and burnout frameworks, reinforcing the idea that post-event distress is not an isolated psychological issue but part of a broader ecosystem involving workload, team dynamics, and leadership behaviors. The paucity of reports of peer support improving long-term outcomes may point to the need for more integrated, system-level interventions that go beyond interpersonal coping to address structural contributors to distress.

Practical Implications

Although interventions to tackle SVS have been increasingly documented over recent years, to the best of our knowledge, this is the first paper attempting to systematically review the outcomes arising from such interventions. Existing reviews are sparse and focus mainly on reporting the availability of Second Victim support resources. A 2021 systematic review primarily investigated peer support interventions, with outcomes mainly related to descriptive statistics and self-reported benefits of the intervention itself.³³ Similarly, a 2020 literature review by Stone provided a brief summary of SVS programs implemented,³⁴ and a more recent scoping review by Wade et al focused only on mapping the available support at an institutional level.¹¹ The aforementioned studies were also conducted some years ago between 2020 and 2021. Our review thus represents a significant advancement by synthesizing newer evidence on intervention outcomes, identifying key limitations, and providing direction for future research.

In terms of the areas for future research, there is a need for greater research into targeted strategies to increase coverage and engagement of potential Second Victims. It is well documented that stigma is a significant barrier to healthcare workers receiving mental health support in any form.^35,36 It is therefore imperative that institutions and healthcare leaders continue raising awareness of support available while normalizing responses to adverse events, without stigmatising Second Victims who require support. Similar to the findings of a focus group conducted by the European Researchers’ Network Working on Second Victims (ERNST),³⁷ the importance of a comprehensive occupational health approach, strong organisational safety culture, allocating adequate resources for ongoing support, securing leadership commitment, and tailoring interventions to the unique sociocultural and legal contexts of each institution and country cannot be overemphasized. Programs are more likely to be accepted and sustained when leadership visibly endorses them, when psychological safety is prioritized, and when organizational norms encourage open discussions about emotional well-being. Leadership training, trauma-informed supervision, and policies that normalize help-seeking behavior are thus crucial. Finally, the metric of outcome measurement was poorly standardized across papers. Given the equivocal nature of many of the subjective results from various studies, formal indicators of Second Victim outcomes and tools such as the SVEST³⁸ to assess Second Victim interventions need to be used by future studies. Assessment of psychological symptoms should ideally use established questionnaires, for example, the Patient Health Questionnaire-9 (PHQ-9) for depression. We urge future studies to adopt appropriate survey and statistical techniques to assess significance and provide numerical outcomes where necessary, rather than generic survey questionnaires.

To situate SVS interventions within the broader healthcare resilience landscape, it is helpful to compare them to other established programs. For instance, Schwartz Rounds foster emotional reflection and team cohesion through narrative exchange,³⁹ while Mindfulness-Based Stress Reduction (MBSR) and resilience training programs have shown sustained benefits on stress, empathy, and well-being in healthcare settings.³¹ Unlike SVS interventions, which often focus on reactive support after adverse events, these broader approaches tend to emphasize preventive resilience and are often more embedded into institutional routines. This suggests that combining the strengths of both models—reactive and preventive—could provide a more comprehensive support system for HCPs.

Limitations and Future Research

Nevertheless, several limitations of the review should be acknowledged. First, a major limitation in the current literature is the lack of standardized outcome metrics, as aforementioned. Many studies rely on subjective evaluations or non-validated tools, leading to equivocal findings. As previously mentioned, validated instruments such as the SVEST should be more widely adopted to enable robust comparisons across studies. Second, most of the included studies were short-term and most interventional studies to date focus more on process measures related to the delivery and perceived utility of the intervention, instead of analyzing outcomes related to the actual benefit to Second Victims, attrition data and follow-up on their status. Finally, the heterogeneous nature of the studies reviewed and their varied outcome measures precluded the possibility of conducting a meta-analysis.

Conclusion

In summary, this systematic review identified 15 studies analyzing Second Victim interventions and their outcomes. Peer support interventions were the most studied intervention and appeared feasible and appropriate as initial support methods, but their overall benefit tended to be equivocal. Structured psychological interventions, such as CBT and mindfulness programs, show promise but remain underexplored. Given the high prevalence of SVS and its implications for both HCPs and patient safety, future strategies should focus on integrated, multi-tiered models that combine peer support with access to professional mental health services. To advance the field, there is a pressing need for standardized outcome measures and longitudinal research to assess lasting impact and implementation effectiveness. More broadly, addressing SVS demands a shift from reactive, optional support to a proactive, institutionalized culture of psychological safety. Professional bodies such as the World Health Organisation (WHO), the American Medical Association (AMA), and their national counterparts should develop formal SVS response frameworks that provide institutions with guidance on best practices, implementation strategies, and evaluation metrics. Furthermore, we advocate for the integration of SVS awareness and support training into healthcare professional education, as well as continuing professional development, to ensure that HCPs are equipped to recognize and respond to emotional and psychological distress resulting from adverse events.