Abstract
Background:
Second victim syndrome (SVS) is an entity known to corrode healthcare providers from within. To analyze the interaction of different factors of SVS, an online questionnaire (based on the Second Victim Experience and Support Tool – Revised) was used for a cross-sectional survey.
Aim:
To know the prevalence and the psychological impact of SVS among Indian surgeons.
Materials and Methods:
This cross-sectional online questionnaire survey-based analytical study collected responses of 200 Indian Surgeons of different types and levels of speciality. Inputs on all dimensions of SVS, namely, psychological distress, physical distress, colleague support, supervisor support, institutional support and professional self-efficacy, and outcome parameters, that is, turnover intentions and absenteeism, were collected and analyzed.
Results:
The SVS prevalence in the sample was 18.5%, the highest among specialists at 24.3%. Affected surgeons experienced significant psychological and physical distress and reported less peer and institutional support, lower self-efficacy, more intent to leave, higher absenteeism, and reduced resilience. Regression analyses identified distress as a predictor for turnover intentions and absenteeism, with SVS severity similar across all specialities and levels.
Conclusions:
SVS can have significant psychological effects, with its aftermath potentially manifesting as somatic symptoms, self-doubt, insecurity, and both mental and physical disengagement from the workplace. This may contribute to considerations of leaving the profession. There is a clear need for comprehensive institutional support systems to address these challenges and enhance professional outcomes.
Keywords: Resilience, second victim syndrome, surgeons, SVEST-R tool
Like Atlas in Greek mythology, surgeons often bear the enormous weight of responsibility for patient outcomes and adverse events, which can have profound psychological, emotional, and professional consequences. The “second victim” concept describes healthcare workers who experience distress after adverse events or errors, becoming “second victim” themselves.[1] Healthcare providers experience after a medical error is described in six stages: initial confusion during ongoing patient care, reflection on the event, concern about others’ perceptions, anxiety over professional impact, seeking support, and ultimately either leaving or continuing their role with lasting effects.[2] Although surgical errors are prevalent and surgeons often work under high-stress conditions, there is limited research in India on the impact of these errors on surgeons. This study aims to assess the prevalence and the psychological impact of second victim syndrome (SVS) among Indian surgeons and address this gap in knowledge by providing insights gathered during its conduct.
MATERIALS AND METHODS
This cross-sectional study was conducted at a tertiary care center in Western Maharashtra, India, from September to December 2024, following Institutional Ethics Committee approval. The sample size of 119 was calculated with a 5% type 1 error (SD = 1.167, d = 0.21). Participants included all practicing surgeons across specialities and subspecialities as well as junior residents (JRs) (with at least 1 year’s experience).
The Second Victim Experience and Support Tool – Revised (SVEST-R) is a validated instrument that evaluates multiple psychosocial domains of SVS. Validation studies have demonstrated good construct validity and internal consistency, with Cronbach’s alpha ranging from 0.66 to 0.86 across its domains. Factor analysis supported its multidimensional structure, confirming its suitability for examining second victim experiences in healthcare settings.[3,4]
A multiple-choice questionnaire (37 questions, hosted on Google Forms™, (supplement to this article) based on the SVEST-R was created to assess SVS domains. SVS is diagnosed if mean psychological scores are more than or equal to 4 in each subset of question in psychological distress. Scores are given on a 5-point Likert scale ranging from “Strongly disagree = 1 to Strongly agree = 5.
It was distributed via social media and email to surgeons and residents across India through snowball sampling. Participation was voluntary and anonymous, with consent incorporated into the questionnaire.
Statistical analysis
Statistical analysis was performed in JASP™ version 0.19.3 using nonparametric tests like Wilcoxon signed rank test, Kruskal–Wallis test, one-way ANOVA, and Spearman correlation test.
RESULTS
The study included responses from practicing surgeons. Descriptive data of study participants are tabulated in Table 1. Specialists (n = 115), subspecialists (n = 57), and SRs in subspecialties (n = 5) attributed case complexity as the predominant factor (reported by General Surgeons at 49%, ENT and Orthopaedic Surgeons at 47%, and other specialities ranging from 50% to 53%), with surgeon inexperience as the next most common reason. Notably, JRs (n = 24) were more inclined to attribute poor outcomes primarily to inexperience, followed by case complexity [Figure 1].
Table 1.
Descriptive parameters of participants of the study
| Descriptive parameters | Number of participants (n=200) |
|---|---|
| Age (years) | Mean=41, Median=39, Range=25–71 |
| Years of work experience | Mean=10.7, Median=9, Range=1–40 |
| Male | 171 (85.5%) |
| Female | 29 (14.5%) |
| Level of Specialities | |
| Specialist | 114 (57%) |
| Subspecialist | 57 (28.5%) |
| Junior Resident | 24 (12%) |
| Senior Resident in Subspeciality | 5 (2.5%) |
| Type of Surgical Specialities | |
| General Surgery | 87 (43.5%) |
| Orthopaedics | 22 (11%) |
| ENT | 23 (11.5%) |
| Obstetrics and Gynaecology | 11 (5.5%) |
| GI Surgeon | 10 (5%) |
| Urology | 8 (4%) |
| Plastic and Reconstructive Surgery | 8 (4%) |
| Ophthalmology | 8 (4%) |
| Vascular surgery | 5 (2.5%) |
| Neurosurgery | 5 (2.5%) |
| Oncosurgery | 3 (1.5%) |
| Paediatric surgery | 2 (1%) |
| Oromaxillofacial surgery | 2 (1%) |
| Trauma Surgery | 1 (0.5%) |
| Gynae Oncology | 1 (0.5%) |
| Oncosurgery | 1 (0.5%) |
| Obstetrics and gynaecology | 1 (0.5%) |
| Prosthetic Surgeon | 1 (0.5%) |
| CTVS | 1 (0.5%) |
Figure 1.
Responses regarding most common causes of poor surgical outcome and frequency of encountering adverse events in surgeries
For the second question about the frequency of encountering adverse medical events, specialists (64, 55.7%) and subspecialists (39, 68.4%) reported occasional occurrences. JRs and SRs in subspecialties primarily reported occasional or rare exposure, with only one junior resident reporting frequent adverse events [Figure 1].
The overall prevalence of SVS was calculated to be 18.5%. Mean scores of all 9 domains are given in Table 2. SVS was most common among specialists (24.3%) and subspecialists (14%), but rare in JRs (4.3%) and absent in SRs, likely due to a very small sample size (n = 5). The association between SVS presence and surgical specialty level was not statistically significant (Chi-square test, P = 0.057), though it was borderline. Among specific specialties, all Trauma Surgeons, 50% of Pediatric Surgeons, 31.8% Orthopedic Surgeons, 27% Obstetrics and Gynecology Surgeons, 25% Ophthalmologists, 20% General Surgeons and Neurosurgeons, 13% ENT Surgeons, and 10% of Gastrointestinal Surgeons were affected by SVS, but these differences were also not statistically significant (Chi-square test, P = 0.559).
Table 2.
Mean scores of all factors covered in the questionnaire based on SVEST-R tool
| Descriptive statistics | Total Psychological distress | Total Physical distress | Total Colleague support | Total Supervisor support | Total Institutional support | Total Professional Self efficacy | Total Turnover intentions | Total Absenteeism | Total Resilience |
|---|---|---|---|---|---|---|---|---|---|
| Median | 12.000 | 12.000 | 9.000 | 9.000 | 9.000 | 9.000 | 8.000 | 8.000 | 8.000 |
| Mean | 11.965 | 12.110 | 9.005 | 8.875 | 9.280 | 9.510 | 7.850 | 7.970 | 7.635 |
| Std. Deviation | 3.521 | 4.475 | 2.584 | 2.749 | 2.945 | 3.683 | 3.338 | 2.782 | 2.231 |
| Minimum | 4.000 | 5.000 | 4.000 | 4.000 | 3.000 | 4.000 | 4.000 | 3.000 | 4.000 |
| Maximum | 20.000 | 25.000 | 20.000 | 20.000 | 15.000 | 20.000 | 20.000 | 15.000 | 16.000 |
Evaluation of the impact of SVS using various dimensions of the SVEST-R tool showed that surgeons with SVS had higher psychological (mean 4.216, SD ± 0.344) and physical distress scores (mean 3.108, SD ± 0.904) than those without SVS (psychological: mean 2.713, SD ± 0.710; physical: mean 2.266, SD ± 0.819), with statistically significant differences (P < 0.001) and a large effect size [Figure 2].
Figure 2.
Impact of second victim syndrome among the study participants
Participants with SVS experienced more physical distress, less workplace support, lower self-efficacy, and higher intentions to leave or be absent from work (all statistically significant with P < 0.01 and moderate to large effect sizes). MANOVA identified a strong multivariate impact of SVS on distress, support, and confidence (Pillai’s Trace = 0.468, P < 0.001).
Spearman’s rank correlation analysis revealed significant positive correlations between psychological distress and turnover intentions (Spearman’s rho (ρ) = 0.42, P < 0.001) and absenteeism (ρ = 0.39, P < 0.001). Physical distress demonstrated stronger positive associations with turnover intentions (ρ = 0.56, P < 0.001) and absenteeism (ρ = 0.58, P < 0.001), indicating that increased distress levels are linked to adverse professional outcomes among Indian surgeons.
Multiple linear regression analysis was conducted to determine the predictors of turnover intentions. The model was statistically significant (F (2, 197) = 48.16, P < 0.001), accounting for approximately 32.8% of the variance in turnover intentions (R² = 0.328, Adjusted R² =0.322) and 35.0% of the variance in absenteeism (F (2, 197) = 53.12, P < 0.001, R² = 0.350, Adjusted R² = 0.344). These results indicate that combined levels of psychological and physical distress significantly predict turnover intentions and absenteeism. However, a specific threshold of distress scores predictive of departure from the workplace could not be identified.
Kruskal–Wallis test was performed to compare the severity of SVS—assessed via distress, support, and self-efficacy scores—across participants grouped by training level (resident vs. consultant), specialty type, and years of clinical experience, and it showed no statistically significant differences by level of training or surgical specialty. However, institutional support scores differed significantly across years of experience (H = 6.26, P = 0.044), suggesting variations in perceived institutional support with increasing clinical experience.
Spearman correlation analysis revealed that resilience among Indian surgeons was significantly and positively associated with psychological distress (ρ = 0.19, P = 0.008), physical distress (ρ =0.23, P = 0.001), colleague support (ρ = 0.30, P < 0.001), supervisor support (ρ = 0.30, P < 0.001), and professional self-efficacy (ρ = 0.32, P < 0.001). Institutional support was not significantly correlated with resilience (ρ =0.08, P = 0.29). Additionally, resilience showed positive correlations with turnover intentions (ρ = 0.39, P < 0.001) and absenteeism (ρ =0.22, P = 0.001). In the SVEST-R tool, resilience is a reverse-scored item—higher scores indicate lower resilience. In this sample, resilience scores positively correlated with psychological and physical distress, turnover intentions, and absenteeism, aligning with findings that surgeons with greater distress and higher turnover or absenteeism had lower resilience.
A multiple regression analysis found that professional self-efficacy was the strongest predictor of turnover intentions in individuals with SVS (β = 0.305, P < 0.001). Physical distress (β = 0.151, P = 0.049), absenteeism (β = 0.2, P < 0.01), and resilience (β =0.115, P < 0.028) were also significant predictors, while psychological distress and environmental support were not statistically significant.
Analysis of SVEST-R support subscales showed surgeons reported moderate mean support scores after adverse events—9.01 (colleague), 8.88 (supervisor), and 9.28 (institutional). Although most indicated support was available, some surgeons had much lower scores (minimums of 3–4), suggesting gaps exist in peer and institutional support for a minority.
DISCUSSION
The present study reveals how surgeons struggle under this burden, experiencing second victim phenomena that erode their wellbeing and professional confidence. Understanding these challenges is crucial as no clinician should be left alone to carry the world’s weight after an adverse clinical event.[5] A few studies have systematically examined this phenomenon using validated protocols. Using the SVEST-R tool, our study provided nuanced insights into SVS.
Higher prevalence of SVS among surgeons is not an alien concept and has been noted in a number of studies conducted worldwide.[6,7] Ambiguity in measuring the prevalence of SVS has led to unclear study results. SVS, as defined by its origins and the SVEST-R tool, primarily involves the emotional trauma and psychological distress healthcare providers experience after adverse clinical events, rather than just a lack of support or professional uncertainty.[2] Therefore, mean psychological scores were used in this study to measure prevalence of SVS. The role of other measurements is for measuring the impact of SVS, not to define the presence of it.[3] This study found that one in five surgeons struggles with SVS. While age, gender, and specialty type showed no significant correlation with SVS prevalence, specialists experienced more SVS than JRs, SRs, or subspecialists, with borderline statistical significance. This may be due to heavy workloads, limited resources, high expectations, and low patient awareness.[6,8]
The psychological impact refers to the level of emotional distress and psychosomatic symptoms that surgeons may experience after an adverse clinical event. This impact can be evaluated using the SVEST-R’s psychological and physical distress subscales. The psychological distress scale measures emotions including guilt, fear, and shame, while the physical distress scale examines psychological trauma by assessing somatic symptoms such as insomnia and exhaustion.[3]
This study identified a significant difference in psychological distress between surgeons who experience SVS and those who do not, with a Cohen’s d of –2.28 indicating a strong effect size. Surgeons experiencing SVS reported higher levels of emotional and physical distress. These results align with previous research.[9,10]
The impact of SVS is not limited just to psychological and physical distress, but it spans across other dimensions like colleague support, supervisor support, institutional support, and professional self-efficacy. Colleague, supervisor, and institutional support measure the role of the environment which is a contextual moderator of effects of SVS and can affect the outcomes like professional self-efficacy, which reflects the self-confidence remaining in a person suffering from SVS. Surgeons affected with SVS reported experiencing insufficient support from colleagues, senior staff, and institutional administrators. This lack of support adversely impacted their self-confidence and contributed to doubts about their professional competence.[11,12]
An interdimensional correlation analysis was performed to assess the effects surgeons experience following an adverse medical event. The study compared psychological and physical distress, as well as environmental support, to evaluate their impact on key outcomes. These outcomes include absenteeism associated with physical or mental disengagement from work, and increased intention to leave the workplace or seek alternative employment. Findings are consistent with prior research, showing that surgeons affected by these factors report more somatic symptoms, are more likely to request time off, and exhibit higher turnover intentions.[2,13]
It was observed indicating that specialists, compared to subspecialists experiencing SVS, reported higher intentions to leave their positions while maintaining lower absenteeism rates. This trend was limited and appeared to be associated with somewhat greater support from peers, rather than supervisors or institutions. One possible reason for this pattern is that subspecialists may encounter increased expectations concerning outcomes from patients, colleagues, senior staff, and administrators.[8,14] As a result, they may perceive less environmental support following adverse medical events vis-à-vis specialists who seem to support each other regardless of what rest of the world thinks. This finding being statistically nonsignificant requires further research.
Generally, higher resilience is associated with lower levels of distress and negative outcomes, whereas lower resilience is linked to increased distress. Healthcare physicians experiencing SVS typically exhibit reduced resilience, reflecting this negative correlation.[8,13,15] In sample of this study, a significantly lower level of resilience was found associating with higher distress, stronger desire to leave work or workplace, and higher absenteeism rates.
Predicting turnover intentions among healthcare professionals is crucial for medical administrators for better workforce planning and patient safety as high turnover is linked to burnout, reduced patient care quality, and, thus, increased institutional costs; current literature identifies factors such as low self-efficacy, absenteeism, and inadequate support as key predictors,[16,17] with professional self-efficacy emerging as a consistent protective factor against disengagement[18]; however, a few studies have specifically examined these predictors in the context of SVS among surgeons, a gap this study addresses by demonstrating that diminished professional self-efficacy, along with physical distress, absenteeism, and resilience are significant predictors of turnover intentions in surgical practice.
Medical errors are inadvertent and so is the damage its aftermath does to a healthcare worker.[19] But the comprehensive analysis of all dimensions of SVS suggests that the most effective moderator, that could potentially change the long-term outcomes, is the environmental support, from peer groups, team leaders/seniors, and institutional administrators.[2] It can range from a nonjudgemental look and hand holding from peers, a dialog with an empathetic senior surgeon delving in critical step-by-step analysis of the situation and institutional approach of finding “what went wrong?” instead of “who went wrong”. Despite these being flagged by multiple studies as potential gaps, concrete efforts of devising a nonbiased institutional support system is still a far cry.[6]
The sample indicated receiving lower levels of environmental support, though there was significant variability, suggesting differences in the level of support received among surgeons, specialists, versus subspecialists.[20]
The range of potential solutions includes the development of institutional-level support programs and training for healthcare providers. An institutional support program should maintain confidentiality, adopt a nonjudgmental approach, offer healthcare providers opportunities to discuss complications, and provide both emotional and legal assistance as needed. Training modules on the subject should be introduced early in healthcare careers to raise awareness about SVS and strategies for addressing it.[6]
Limitations
While this analysis offers valuable insights, it is limited by its sample size and design, calling for larger, multicentric studies to validate nuanced findings regarding junior and senior resident, specialist, and subspecialist experiences.
CONCLUSIONS
This study illuminates the profound psychological and professional impact of SVS among surgeons, highlighting the crucial role of environmental support systems in mitigating its adverse effects. The data underscore that surgeons experiencing SVS endure significantly greater psychological distress, often compounded by inadequate support from peers, supervisors, and institutions. This not only undermines their professional self-efficacy but also elevates absenteeism and intentions to leave the workforce or workplace.
The importance of institutional responsibility is clear: Confidential, judgment-free support programs, early education on SVS, and the cultivation of open dialogs about adverse events are essential for fostering recovery and resilience.
Authors’ contributions
Concept, Design, Definition of intellectual content, Literature search: MJ, SKG, RR, NJ, SS. Data acquisition: MJ, SKG, RR, SS. Statistical analysis: SKG. Manuscript preparation: SKG, MJ. Manuscript editing and Manuscript review: SKG, MJ. All authors have read and approved the final manuscript.
Data availability
Data can be made available on reasonable request.
Ethics statement
Ethical approval was obtained from the Institutional Ethics Committee (IEC ref. No: IEC/2025/893 dated 28th July 2025) of the Armed forces Medical College, Pune, India.
Conflicts of interest
There are no conflicts of interest.
Participants consent
All participants were informed that their participation was voluntary and their identities would be kept strictly confidential.: Informed consent was integrated into the questionnaire given to all individual participants included in the study.
SUPPLEMENT
37 point Questionnaire based on SVEST-R tool
| Question | Response | ||||
|---|---|---|---|---|---|
| As per you, what is the most common cause of poor surgical outcome? | Inexperience of Surgeon | Complexity of case | Job overload | Faulty communication | Other |
| How often do you encounter adverse events in surgeries/procedures | Rare | Occasionally | Frequently | Very frequently | |
| I have experienced embarrassment from these instances | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My involvement in these types of instances has made me fearful of future Occurrences | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My experiences have made me feel miserable | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I feel remorseful for my past involvement in these types of events | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| Mental weight of my experience is exhausting | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My experience with these occurrences can make it hard to sleep regularly | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My stress from these situations has made me feel nauseous | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| Thinking about these situations can make it difficult to have an appetite | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I have had bad dreams as a result of these situations | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My colleagues can be indifferent to the impact of these situations have had on me | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My colleagues help me feel that I am still a good surgeon despite any mistakes I have made * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My colleagues no longer trust me due to these surgical complications | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My professional reputation has been damaged because of these situations | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I feel that my senior treats me appropriately after these occurrences * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My senior’s responses are fair after these occurrences * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My seniors blame me after these occurrences | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I feel that my supervisor evaluates these situations in a manner that considers the complexity of patient care practices * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My organization understands that those involved may need help to process and resolve any effects they may have on healthcare providers * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My organization offers a variety of resources to help me get over the effects of involvement with these instances * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| Concern of wellbeing of those involved in these situations is not strong at my organization | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| Following these incidents, I feel a sense of inadequacy in my patient care Abilities | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My experience makes me wonder if I am not really a good health care provider | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| After my experience i became afraid to attempt difficult or high-risk situations | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| These situations have negatively affected my performance at work | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My experience with these events has led to a desire to take up a position outside patient care | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| Sometimes stress from being involved in these situations make me want to quit my job | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I have started to ask around for other job opportunities | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I plan to leave my job in another 6 months because of my experience with these events | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| My experience with these events has led me to take a day out for my mental health | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| I have taken time off when such incident occurs | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| When I am at work, I feel distracted after these events | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
| Because of these situations, I have become more attentive at work* | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| The situations have caused me to improve quality of my work * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| My experience with an adverse patient event has resulted in positive changes in procedures or care in unit * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
| I have grown as a professional as a result of these events * | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data can be made available on reasonable request.