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Just Culture – Who is the Second Victim?

By: Suzanne Crouch, Director of Training on 05/04/2017

I recently wrote about the concept of Just Culture. As I was researching for the blog I not only read Sydney Dekker’s book – ‘Just Culture’ but also came across his video ‘The Second Victim’. Dekker is one they key thinkers behind the concept of Just Culture.

His premise about victims after an event is that when an event happens within your organisation there will be more than one type of victim. In this short film he introduces the idea of First and Second victims.

First victims – can be patients, passengers, colleagues, the surrounding community who suffer consequences of an incident or event, in essence any one who is proximal and affected by the event.

Second victims – he suggests are the practitioners/operators involved in the event who feel personally responsible for the happening of the event and suffer as a result. These practitioners are not necessarily the cause of the incident but they feel the responsibility. It could be argued that in some cases they are on the receiving end of issues that lie deeper within your organisation and this is what, therefore, makes them victims.

In a Just Culture, a restorative culture, the organisation will take care of Second Victims as much as they care for the first. After the incident or event Second Victims may need anything from empathy to counselling to trauma care.

However they may also need the opportunity to be empowered.

Typically Second Victims need an opportunity to tell their story.

The incident may well have disrupted their trust in the system or its practitioners. Telling their story in a participative and visual way and involving them in the investigation and RCA process can help them to reconcile themselves with the incident.  Second victims need to regain trust in their own competencies, and rebuild relationships with others who rely on them. They want reassurance that they, and their organisation, have done everything to prevent recurrence. This involvement in the investigation process and the RCA can often assist in transforming any guilt and shame that they may be feeling and actions that help them, the first victims and also the organisation.

But let’s not forget the First Victims – one thing that First Victims typically crave after an untoward event is information.

The want to know:

“What happened, and why?”

This makes consideration of how we work with and empower our second victims even more crucial. To get the real story, the “what happened and why”, we need to genuinely hear the Second Victim.

In addition to the First and the Second Victims, your organisation will also have needs and requirements. These will doubtlessly include a need for information about what happened and the response. This requirement will be much better served by the restorative Just Culture approach. But it must be remembered that there also other opportunities that come with this approach and these are:

• to help First and Second Victims to heal

• to understand the deeper issues that lie within your organisation

• to identify opportunities for improvement and increased productivity

• to restore relationships and trust

• to develop a sense of joint problem ownership and community within the organisation.

  1. About Suzanne Crouch

    Director of Training

    Suzanne is a Master RCA Practitioner. Her background is in project management and organisational research, delivering numerous projects for national and global corporations both in the private and the public sector. These include the development of the reliability competence framework for Shell EPE, developing and editing the National Leadership Development Programme for UK College Principals and authoring and rolling out the National Training Manual for Multi Agency Public Protection Arrangements (MAPPA - UK Ministry of Justice). Suzanne is a qualified trainer with a Masters Degree in Education and Training and a Post Graduate Certificate in Post Compulsory Education (PGCE). She has a special interest in professional development,  coaching individuals on a one to one basis, and as well as delivering Root Cause Analysis training has extensive experience of delivering and implementing leadership and management programmes.

    Suzanne is a highly skilled RCA trainer and facilitator. She is known for her abilities to motivate and energise RCA teams and classes, working with and challenging participants, provoking enquiry and creating structure and providing insight to the problems encountered in organisations. Through her inspirational training and leadership Suzanne encourages the participants that she works with to make meaningful changes to their work, processes and behaviours. She has been facilitating and training RCA teams nationally and internationally across a spectrum of global organisations since 1995.

    Suzanne holds a Diploma in Coaching and is a Fellow of the Institute for Learning.

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