Training Charge Nurse to Lead Second Victim Support: Fostering a Culture of Safety Through Education

Abstract

Background

In healthcare settings, staff and their leaders frequently struggle to support colleagues who are affected by adverse events, often referred to as second victims. Existing support systems have proven inadequate, leaving a gap in addressing both emotional and professional needs.

Aims

This work aims to explore the effect of educating and training charge nurses through targeted programs, while strengthening the hospital's support infrastructure.

Methods

The initiative was developed by the Patient Safety and Risk Management unit of an acute care hospital, which includes ambulatory clinics, with support from the hospital's Human Resources unit. A structured educational and training program, led by a psychologist, was designed to equip charge nurses with skills to effectively support second victims. The program included three 8-h sessions with theoretical instruction, simulations, role-playing, and reflective discussions on charge nurses’ roles. The Theory of Change approach was used to define the causal pathway from training to improved peer support, clarify key assumptions, and guide evaluation. The work adheres to SQUIRE 2.0 guidelines for nonrandomized evaluations.

Findings

The intervention received positive feedback, with charge nurses reporting increased confidence in supporting second victims. Early indicators suggest improved peer support and staff awareness. Ongoing monitoring and adaptation will ensure program effectiveness.

Conclusions

Integrating charge nurses as second victim supporters strengthens resilience and psychological safety. Future steps include continuous assessment, content refinement, and evaluation of long-term outcomes to ensure sustained impact.

Introduction

Healthcare workers involved in adverse events often experience significant emotional distress, a phenomenon known as the “second victims” (SVS) experience (Wu, 2000). These SVS frequently suffer from feelings of guilt, anxiety, and decreased job satisfaction, which can lead to burnout, reduced performance, and even decisions to leave their profession (Mota et al., 2020; Seys et al., 2013). Research indicates that between 10.4% and 43.3% of healthcare professionals encounter SVS experiences during their careers, highlighting the widespread nature of the problem (Choi et al., 2022; Naya et al., 2023; Seys et al., 2013). The literature underscores that while some support systems exist, they often remain informal, inconsistent, or insufficiently accessible to staff in need (Choi et al., 2022; Seys et al., 2013). Effective support mechanisms, particularly peer support and structured professional assistance, are crucial in mitigating the impact of adverse events on healthcare workers (Edrees et al., 2016; Scott & McCoig, 2016). Additionally, leadership roles, such as charge nurses, are uniquely positioned to provide empathetic, professional, and credible support due to their dual responsibilities in both clinical and managerial capacities. Acting as deputies to the department's nurse managers, they lead shifts, coordinate care, and ensure safe staffing and workflow. Their role requires balancing clinical competence with leadership, fostering a positive and open work environment, and promoting teamwork and communication across disciplines. As mentors and role models, charge nurses guide less experienced staff, identify professional development needs, and demonstrate integrity and professionalism. By linking frontline nurses with management, they play a pivotal role in maintaining patient safety, supporting staff well-being, and upholding the quality of care within the department (Dugan, 2024).

To develop an effective support program for SVS in the hospital, the researchers conducted an integrative literature review using the methodology outlined by Souza et al. (2010). This review served as a conceptual foundation for program development. The process consisted of six key phases: preparing the guiding question, searching the literature, extracting data, critically analyzing the studies, synthesizing the findings, and presenting the recommendations. Researchers defined a clear research question to identify best practices for supporting SVS, which shaped the study's inclusion criteria for the review. Systematic searches were performed across databases such as MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar, focusing on nursing professionals and excluding studies related to violence or disaster contexts. Only studies published in English and available in full text from 2020 to September 2025 were included. The review highlighted several key paths of support for healthcare professionals affected by adverse events and stressful clinical situations. First, peer support programs provide structured emotional assistance through trained multidisciplinary teams that respond promptly to emotional distress, reducing stigma, and fostering a culture of safety and solidarity. Examples include ForYOU, You MATTER, and Resilience In Stressful Events (RISE), which emphasize timely access, confidentiality, and psychological first aid, helping staff return to their pre-event functioning while maintaining institutional integrity (Edrees et al., 2016; Krzan et al., 2015; Merandi et al., 2017). Programs such as the Buddy Program and HELP offer early, informal, collegial support, particularly in high-stress areas such as anesthesia (Finney & Jacob, 2023; Schrøder & Assing Hvidt, 2023). Second, organizational approaches integrate emotional support into hospital systems, emphasizing just culture, emotional safety, and institutional responsibility. For example, KoHi coordinates with reporting systems, legal advice, and HR structures, ensuring sustainability and embedding support within the hospital's quality and safety culture (Krommer et al., 2023). Third, formal and informal support mechanisms include conversations with trusted colleagues or family members, professional counseling, and external specialized units mediating communication with patients and families, offering guidance on legal matters and disclosure. Online platforms such as MISE (Mitigating Impact in Second Victims) also provide guidance and raise awareness about SVS experiences (Mira et al., 2017). Fourth, individual coping strategies support emotional recovery, including mindfulness, reflective writing, self-compassion, spiritual or religious practices, and temporary leave from work to restore balance and resilience (Quadrado et al., 2021). Across most programs, key themes included fostering positive relationships (Hauk, 2018), open discussion of adverse events (Luu et al., 2012; Ullström et al., 2014), immediate peer support (Edrees et al., 2016; Scott & McCoig, 2016), access to mental health services (Joesten et al., 2015; Merandi et al., 2018; Mok et al., 2020; Sataloff, 2020), debriefings (Chung et al., 2018; Joesten et al., 2015; Kobe et al., 2019), and clinical reviews (El Hechi et al., 2020; Graham et al., 2019; Joesten et al., 2015; Rinaldi et al., 2016). By synthesizing these strategies, the charge nurse training program was designed to align with evidence-based approaches that enhance staff well-being, resilience, and patient safety.

Methods

Study Design

This non-randomized, pre–post intervention study was conducted at the Medical Center to evaluate a structured training program for charge nurses to provide support to SVS following adverse events. The study followed the SQUIRE 2.0 checklist (The Standards for Quality Improvement Reporting Excellence) (Ogrinc et al., 2016) to ensure transparency in design, implementation, and reporting. Based on the review findings of core components and organizational needs, this quality improvement project was designed to address the training needs of charge nurses. This project sought charge nurses to serve as formal peer supporters for SVS. Charge nurses’ existing leadership roles, combined with structured education and training, are hypothesized to enhance the accessibility and effectiveness of support services within the hospital setting.

The program was developed using the Theory of Change (ToC) framework, mapping causal pathways from activities to outcomes while identifying key assumptions and contextual factors (Breuer et al., 2016; De Silva et al., 2014; Vogel, 2012). This ensured that each component was aligned with the intended impact on emotional support, staff well-being, and patient safety culture. Key elements at the core of the program were formulated to ensure that no staff member is left unsupported after an adverse event. The program aims to normalize emotional responses, reduce stigma, and promote a culture of safety, peer solidarity, and system learning. Support is provided through an easily accessible approach, encouraging staff to reach out to a trained colleague (charge nurse) for immediate peer support. Figure 1 demonstrates the support program timeline based on the ToC framework.

Figure 1.

Support program timeline based on the theory of change framework.

Setting

The study took place in a tertiary care hospital with multiple clinical departments. Implementation was supported by senior leadership, and coordination was managed by a multidisciplinary project team to ensure engagement and legitimacy.

Participants

The nursing staff consists of 920 registered nurses working across more than 40 acute-care departments, 20 clinics, the emergency department (ED), the pediatric ED, the operating room (OR), the post-anesthesia care unit (PACU), the intensive care unit (ICU), and the pediatric ICU (PICU). Requests for help or support from the Second Victim Support service were not counted; however, such requests were known to occur, as the risk management unit consistently offered support and handled several situations independently. Eligible participants were charge nurses from various units with at least five years of experience in the role and a willingness to participate. Baseline data included professional role, years of experience, prior exposure to SVS support, and familiarity with SVS concepts.

Intervention

The program aimed to address the lack of structured emotional and professional support for staff involved in adverse events, which contributes to distress, burnout, and weakened patient safety culture.

The intervention consisted of three 8-h interactive sessions facilitated by a clinical psychologist experienced in supporting healthcare professionals and was implemented in June 2024. The curriculum consisted of three components: Theoretical Instruction, covering the SVS phenomenon, psychological responses to adverse events, and organizational implications; Experiential Learning, which included role-playing exercises and simulations based on real-life SVS support scenarios; and Reflective Group Discussions, designed to enhance empathy, self-awareness, professional communication, and peer support skills. In addition to the described training, participants received guidance aimed at raising awareness of the topic. The underlying idea was to prepare them to serve as leaders promoting the initiative. The training included instructions and tips on how to conduct staff meetings, ideas for awareness campaigns, ways to initiate conversations on the subject, and related activities.

The program was implemented collaboratively by the Patient Safety and Risk Management Unit (design and oversight), Human Resources (logistics), the staff's social worker (providing outreach regarding professional and clinical support as needed), and nurse managers (local support).

Implementation Procedures

Training sessions occurred during work hours with management approval and support. Feedback loops after each session allowed adjustments to curriculum content and delivery based on participant engagement and comprehension. Attendance, participation, and engagement in exercises were monitored to ensure fidelity. Participants were given a toolkit, which included presentation materials to perform a staff meeting and promote awareness, and stickers with their name tags that identify them as supporters. In addition, they receive a small pocket note, mentioning the information they learned and a summary table of do’s and don’ts (see Figure 2).

Figure 2.

Summary table of do’s and don’ts for the supporters.

Outcomes and Measures

Primary outcomes were Knowledge of SVS concepts assessed via pre- and post-training questionnaires; Perceived readiness for peer support – self-reported confidence in providing structured SVS support and satisfaction with the program – participants rated the usefulness and relevance of training content. The development process involved the multidisciplinary team, which reviewed items to ensure content validity, clarity, and relevance. Each questionnaire included a combination of knowledge-based items and self-assessment questions, with sample questions covering key SVS concepts and peer-support strategies. Reliability and validity were addressed through expert review and pilot testing with a small group of nurses before full implementation. Fidelity was monitored through observation of facilitator adherence, tracking participant attendance, and engagement in exercises. Modifications to content or logistics were documented to maintain consistency without compromising core curriculum elements.

Institutional Review Board Approval and Ethical Considerations

The project received approval from the hospital leadership and relevant institutional review committees and was deemed exempt from formal IRB review as it constituted a quality improvement initiative. Participation was voluntary, with informed consent obtained from all attendees prior to training. No personal identifying data was collected, ensuring confidentiality and adherence to ethical standards for human subjects’ rights.

Results

All 14 participants were registered nurses; most were women (10), and all of them had held the position of charge nurses for over 5 years, with a mean of 8 years. Most of them work in acute departments, one from the ER, one from the OR, and one from the ambulatory setting.

To assess how the program contributed to knowledge and awareness, pre- and post-training questionnaires were administered. Researchers compared the answers to the previous results of 28 staff members who had previously been informally responsible for SVS issues in their units but had received only minimal guidance or formal training. Before both programs, only 46% of staff members from previous guidance and 64% of charge nurses reported familiarity with the SVS concept. After training, 100% of both groups rated the workshop as effective in providing knowledge for the SVS term. Beyond knowledge acquisition, participants demonstrated increased self-efficacy and readiness to provide emotional and professional support to colleagues following adverse events. Post-training, 56% of staff members from previous guidance felt prepared to serve as SVS ambassadors, while 85.7% of charge nurses expressed confidence in fulfilling this role. This differential gain may reflect the influence of leadership positioning-charge nurses, as frontline leaders, were better situated to translate training into practice.

These outcomes suggest that the intervention not only enhanced knowledge but also strengthened participants’ confidence and preparedness to provide structured peer support within their departments. Within one year, only 7.1% (2 of 28) of staff members from previous guidance reported receiving SVS support inquiries, compared with 35% (4.9 of 14) of charge nurses who got a call within just three months. Most inquiries to charge nurses originated from their respective clinical units, indicating that the intervention effectively positioned them as accessible and credible support figures. This measurable increase in peer-support activity represents a practical translation of learning into action, corresponding to the short-term outcomes stage in the ToC model. Further analysis revealed an inverse relationship between baseline familiarity with the SVS concept and subsequent engagement. Charge nurses who initially reported limited knowledge exhibited the greatest gains in confidence and active participation after training.

In contrast, participants with higher baseline familiarity demonstrated smaller relative improvements. This finding suggests that the program was particularly effective in building capacity among those with the greatest initial need for structured knowledge and skill development. The observed progression from increased awareness and confidence to active peer-support behavior aligns with the program's intended long-term goals: strengthening psychological safety, resilience, and organizational support for healthcare workers following adverse events. As trained charge nurses began to provide peer support within their teams, a gradual shift toward a more compassionate, open, and learning-oriented safety culture was noted. These outcomes represent early indicators of systemic change, reflecting enhanced patient safety culture and a more resilient workforce capable of coping with emotionally challenging clinical experiences.

Changes Required During the Project and Outcomes of Changes

During the program implementation, feedback from initial staff participants prompted modifications to the charge nurses’ training sessions. Specifically, the charge nurses’ program was adjusted to increase interactive components and extend role-playing exercises, which better prepared them for real-world SVS support situations. Continuous monitoring allowed for ongoing refinement, contributing to the higher engagement levels observed among charge nurses compared to staff graduates.

Key Facilitators and Barriers

Key facilitators contributing to charge nurses’ success included strong leadership backing and an organizational culture focused on patient safety. The comparatively lower engagement among staff graduates highlights the need for additional strategies to sustain and increase involvement in SVS support across all trained personnel.

Discussion

Charge nurses play a pivotal role in maintaining a safety culture within the healthcare organization. Their leadership ensures patient safety, guiding teams to adhere to best practices and protocols. By promoting a culture of vigilance and continuous learning, charge nurses empower staff to prioritize safety and address potential risks. Through mentorship and clear communication, they reinforce the importance of safety, helping to identify and address potential risks before they impact patient care. This commitment not only improves clinical outcomes but also fosters a proactive organizational culture. Charge nurses help create a “no shame, no blame” environment, crucial for supporting SVS, as perceived institutional support for SVS is linked to a better safety culture (Khatri et al., 2009; Sexton et al., 2021). In addition, nurse managers are crucial in supporting nurses affected by patient safety incidents. Additionally, nurse managers provide essential emotional support, helping to mitigate the negative effects of patient safety incidents (Pohl et al., 2022). Such support is fundamental for nurses’ well-being and is directly tied to their emotional health (Cole et al., 2006; Pohl & Galletta, 2017). According to Frederickson's broaden-and-build theory, positive emotional experiences expand an individual's ability to act and recover (Garland et al., 2010).

Establishing a safety culture that emphasizes learning from errors rather than assigning blame encourages open communication and reporting of adverse events. This approach enables charge nurses to identify and support SVS effectively, addressing their emotional and professional needs. Such an environment not only aids in the recovery of affected staff but also enhances overall patient safety by promoting transparency and continuous improvement. By integrating these strategies, charge nurses can cultivate a supportive environment that addresses the needs of SVS and upholds a safety culture focused on learning and improvement.

However, several contextual factors influenced the intervention's outcomes. The hospital's strong culture of safety and continuous improvement created an environment conducive to the program's success. Leadership provided the necessary resources and ongoing monitoring. Participants’ prior knowledge of SVS, particularly among charge nurses with less experience, contributed to varying effectiveness. Additionally, the level of support within each nurse unit affected how well charge nurses were able to serve as effective ambassadors, with units focused on staff well-being more likely to engage with SVS issues.

Implications for Practice

In an effort to create an effective peer support program, one should implement the core elements-organizational initiatives, formal and informal support mechanisms, and individual coping strategies. It should be considered to offer seniors and well-trained staff members to join the peer support programs. The program's success was facilitated by the hospital's strong safety culture and leadership support, though outcomes varied according to charge nurses’ experience and unit support for staff well-being. This underscores the potential for similar programs in other organizations, where formalizing SVS support roles can improve staff morale, enhance safety, and foster a compassionate workplace.

Strengths and Limitations

This study has several strengths. The training program was grounded in evidence-based strategies and guided by a ToC framework, ensuring alignment between activities and intended outcomes. Focusing on charge nurses who are key leaders within units enhanced the potential for sustained impact on peer support and safety culture. Combining theoretical instruction, experiential learning, and reflective discussions provided participants with knowledge and practical skills, resulting in high satisfaction and increased confidence in supporting SVS.

However, several limitations should be mentioned. The hospital's well-established culture of safety and ongoing leadership support may have contributed to positive outcomes, which could differ in organizations with less-developed safety infrastructures. Differences in participants’ prior familiarity with SVS concepts and variations in unit-level support for staff well-being may have influenced the degree of improvement. The small sample size and non-randomized pre–post design limit the ability to generalize results or attribute changes solely to the intervention. Reliance on self-reported questionnaires introduces the possibility of bias, and the relatively short follow-up period did not allow evaluation of long-term sustainability. Because SVS support requests were not systematically tracked, the full impact of the program on service utilization remains unclear. Finally, the study did not include organizational or patient-level outcomes, limiting conclusions about broader system effects.

Conclusions

The positive feedback and identified areas for improvement from post-training surveys highlight the program's success and offer valuable insights for future initiatives. Integrating charge nurses into the support system for SVS can create a more supportive environment and contribute to a safer, more empathetic workplace.