Review question/objective

1. What are the experiences of nurses as second victims of adverse nursing errors?

2. What type of support do nurses receive as second victims?

3. How do nurses experience the support they receive?

The objective of this systematic review is to synthesize the best available evidence to explore the meaningfulness of nurses' experiences as second victims of adverse nursing errors. The review will also explore strategies for supporting second victims, incorporating nurses' appraisal and their experience of the support.

Background

The seminal report from the Institute of Medicine in 2000, To Err is Human: Building a Safer Health System, emphasizes unsafe aspects in health care, such as medication errors and ineffective communication processes, which often lead to adverse events and deaths that could be preventable.1 As a result, many prevention strategies have been recommended and implemented to reduce health care errors. These include (but are not limited to) falls assessment and prevention strategies,2 structured communication process between clinicians,3 medication reconciliation,4 independent double-checks and checklists,5 and continuing education for clinicians.6 While the ultimate aim of these strategies would be an error-free health care system, the strategies will only mitigate errors, not eliminate them.7

Errors refer to "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim".1(p4) Some errors cause adverse events, which are incidents that result in harm and are acquired while receiving health care that cannot be attributed to the patient's present illness or medical condition.8 These include infections, patient falls, adverse medication errors and unanticipated grievances from medical devices (e.g. poor design).9 Dr James Reason's Swiss Cheese Model illustrates that despite the error-prevention strategies in place within a health care system, opportunities (the holes in the Swiss cheese) for errors are always present.10 Within a health care system, these opportunities can be dormant but have the capacity to cause errors when there is active involvement or is triggered by individuals. Examples of these include inadequate supervision, overwhelming workload, insufficient labelling or signage, structural flaws, distractions, technological errors and inadequate resources.7,11,12,13 Human fallibility is also a significant factor to errors12 because this proves that as humans we are not resistant to the latent conditions in which we work.10 In the nursing context, the nature of the work of nurses allows more patient contact and opportunities to perform procedures, hence the chances of errors are always present.14As fallible beings, nurses are susceptible to work-related fatigue, errors in judgment, memory lapses, distractions and oversights.5

When adverse events from nursing errors occur, there are three potential victims: patients, nurses, and the health care organisation.15 Patients as primary victims become the priority and the focus of interventions; however caring for the nurses as second victims is also equally important.16 Second victims are health care providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient-related injury. The term second victim was first used in an editorial by Dr Albert Wu, who highlighted the emotionally and psychologically devastating effects of adverse medical errors on doctors, and also emphasized the alienation doctors feel from the lack of support from peers and superiors.17 These second victims are generally traumatized by the event and feel that they are primarily responsible for the adverse event, which consequently induces self-doubt and feelings of failure.18 Unfortunately, this may be unrecognized due to the misconstrued public view that clinicians (including nurses) are perfect,17 the name and blame culture,19 and perhaps the lack of understanding of the second victim phenomenon.20 Since the mid-1980s healthcare professionals' personal descriptive accounts of second victim experience have been published.18 The estimated prevalence of errors resulting in second victims widely vary at 2.5% to 43.3%.15

Despite the wide prevalence there is little published evidence of the second victim phenomenon. Evidence suggests that nurses as second victims feel guilty, humiliated and embarrassed, and experience self-blame, frustration, loss of confidence and self-doubt.7,11,17,21,22,23,24,25,26 Emotional and psychological distress tends to linger, even up to 10 years after the adverse event.22,26,27 In one study, the lived experience of second victims was reported to be comparable to post-traumatic stress disorder.22 The reported symptoms include insomnia, burn-out, flashbacks, emotional outbursts, distinct incessant thoughts of the event irrespective of the time lapse, depression, fatigue and anxiety.11,17,22,23,24,25 However, negative emotions and distress are moderated by the support second victims receive,28 but unfortunately only 7%29 to 35%30 of second victims receive the appropriate support from their superiors or colleagues which at times prove to be inadequate or substandard.18,26

A search in relevant databases (CINAHL, the Cochrane Library, and the JBI Database of Systematic Reviews and Implementation Reports) revealed previous published literature15 and systematic reviews31 that summarized evidence on second victims. While the reviews are rigorous, the evidence they present might not be transferable to nurses. Both reviews combine qualitative data between all clinicians, hence specific impact to nurses is poorly differentiated. Another important limitation is the disproportion of second victim studies between doctors and nurses. Because the studies synthesized in the reviews are mostly representative of doctors, there is a risk that nurses' experiences may not be fully depicted. Having this distinction is important because it could affect how second victims are managed and supported.31

The purpose of this systematic review is to synthesize the best available evidence on the experiences of nurses as second victims and explore strategies for supporting second victim nurses. It is anticipated this review will facilitate the understanding of the depth of the second victim experience, explore support strategies, identify gaps in research, and potentially lead to appropriate care processes for second victim nurses.

Inclusion criteria

Types of participants

Participants are registered nurses who have unintentionally made adverse clinical errors. Nurses who have not been involved in the adverse error but have been emotionally or psychologically affected will be excluded.

Phenomena of interest

This review will consider studies that investigate the second victim phenomenon or experience. Second victims are nurses who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related, injury and become victimized in the sense that the nurse is traumatized by the event.32 Further, studies that examine nurses' experiences of support or management strategies for second victims will included.

Context

This review will consider all studies that seek to investigate the second victim phenomena in all clinical settings.

Types of studies

This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, feminist research, and discourse analysis.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE (PubMed) and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English language (due to limited funding for translators) between 1980 (when personal descriptive accounts of the second victim experience were first published) and 2015 will be considered for inclusion in this review.

The databases to be searched include:

PubMed, CINAHL, PsycINFO, Embase and Web of Science.

The search for unpublished studies will include:

OpenGrey and ProQuest Dissertations and Theses.

Initial keywords to be used will be: nurses, errors, health care errors, nursing errors, 'medical errors', 'medical mistake' 'patient safety' medication errors, adverse events, second victims, moral distress, emotional distress, psychological distress.

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives. Corresponding authors of primary studies will be contacted if necessary to supply data or clarify unclear data.

Data synthesis

The type of support will be analyzed deductively. Qualitative research findings of the second victim experience and the experiences of support will, where possible, be pooled separately using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

Conflicts of interest

The authors have no conflicts of interest to declare.

References