Summary of findings
The seminal report from the Institute of Medicine, To Err is Human: Building a Safer Health System, emphasized unsafe practices in health care, such as medication errors and ineffective communication processes, which often lead to adverse events and deaths that could be prevented.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 processes 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 is an error-free health care system, the strategies 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(p.4) Some errors cause adverse events, which are injuries acquired while receiving health care that cannot be attributed to the patients’ present illness or medical condition.1 These injuries can include infections, patient falls and harm from medication errors.8 Dr James Reason's Swiss Cheese Model illustrates that despite error-prevention strategies in place within a health care system, opportunities for errors (the holes in the Swiss cheese) are always present.9 Within a health care system, these opportunities can be dormant but have the capacity to cause errors when there is active involvement or trigger by individuals. Examples of these include inadequate supervision, overwhelming workload, insufficient labelling or signage, structural flaws, distractions, technological errors, and inadequate resources.7,10-12 Human fallibility is also a significant factor to errors because this proves that as humans we are not resistant to the latent conditions in which we work.9 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.13 As 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 organization.14 Patients as primary victims become the priority and the focus of interventions, however caring for the nurses as second victims is also equally important.15 Second victims are health care professionals who have made an error, and have been formally defined as “healthcare providers 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 provider is traumatized by the event”.16(p.326) 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 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.16 Unfortunately, this may be unrecognized due to the misconstrued public view that clinicians (including nurses) are perfect,17 the name and blame culture,18 and perhaps the lack of understanding of the second victim phenomenon.19
Personal descriptive accounts of second victim experiences in health care have been published since the mid-1980 s.16 Within the literature the estimated prevalence of second victims in health care varies widely and ranges from 2.5% to 43.3%.14 Despite the potentially wide prevalence there is little published evidence of the second victim phenomenon in nursing. Evidence suggests that nurses as second victims feel guilty, humiliated, embarrassed, and experience self-blame, frustration, loss of confidence and self-doubt7,10,17,20-25 that can remain even up to 10 years after the event.21,25,26 In one study, the lived experience of second victims was reported to be comparable to post-traumatic stress disorder.21 The reported symptoms include insomnia, burnout, flashbacks, emotional outbursts, distinct incessant thoughts of the event irrespective of the time elapsed, depression, fatigue and anxiety.10,17,21-24 However, distress can be moderated by the support second victims receive.27 Unfortunately only 7%23 to 35%28 of second victims receive the appropriate support from their superiors or colleagues, which at times prove to be inadequate or substandard.16,25
A search in relevant sources (CINAHL, Cochrane Library and JBI Database of Systematic Reviews and Implementation Reports) revealed three systematic reviews14,29,30 and a literature review on this topic.31 Schwappach and Boluarte30 summarized the experiences of doctors as second victims. Two reviews14,29 highlighted the experiences of all health care providers (i.e. doctors, nurses and allied health) as second victims. However the specific impact to nurses is poorly differentiated. Another limitation of the current published literature on this topic is the disproportion between doctors and nurses as the studies synthesized in the reviews were mostly representative of doctors. Having this distinction is important because it could impair how nurses as second victims are managed and supported.29 Lewis et al.31 conducted an integrative literature review that modeled the factors that affect nurses’ experiences as second victims, in particular, burnout, moral distress, intention to leave and constructive change. An important limitation of this review is that it dilutes nurses’ actual experiences as second victims and therefore leaves a risk that the depth of second victimhood in nursing may not be fully depicted.
This systematic review synthesized the available qualitative evidence on the experiences of nurses as second victims and explored the support that these second victims received. It is anticipated that 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. The methods of this review has been described and published previously.32
The review aimed to answer the following questions:
- 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 of adverse nursing errors?
- 3. How do nurses perceive or experience the support they receive as second victims of adverse nursing errors?
Types of participants
Participants were registered nurses who had unintentionally made adverse clinical errors. Nurses who witnessed an adverse error but had been emotionally or psychologically affected were excluded.
Phenomenon of interest
This review considered studies that investigated the second victim phenomenon or experience. In this review, second victims were registered nurses who had made an adverse error (i.e. medication error, fall, procedural error), and felt traumatized by the event as a result.16 In this review, adverse errors were errors that resulted in harm (i.e. temporary, permanent or death) to the patient.1 Further, studies that examined nurses’ experiences of the support they received were also included.
This review included all studies that sought to investigate the second victim phenomenon in all health care settings worldwide.
Types of studies
This review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, feminist research, discourse analysis, and mixed methods.
The search strategy aimed to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. Initial keywords used were: nurses, errors, health care errors, nursing errors, medication errors, adverse events, second victims, moral distress, emotional distress, psychological distress. A second search using all relevant keywords and subject headings was subsequently undertaken across all included databases. The final search strategy can be found in Appendix I.
In the final search, studies published in English language (due to limited funding for translators) between 1980 and February 8, 2017 were sought in PubMed, CINAHL, PsycINFO, Embase and Web of science. OpenGrey and ProQuest Dissertations and Theses were also accessed to obtain unpublished studies. The date range was chosen because 1980 was the year when publication of nurses’ descriptive accounts as a second victim commenced.33,34 Hand-searching in the references of the studies assessed for eligibility was also performed.
Assessment of eligibility and methodological quality
The final papers that were located by the search strategy were screened for relevance using the title and abstract. Full text of papers that were deemed relevant were retrieved to verify their eligibility based on the inclusion criteria.35 Subsequently eligible papers were assessed by two independent reviewers for methodological quality using a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI QARI) Any disagreements between the reviewers were resolved through discussion.
Qualitative data were extracted from papers included in the review using the standardized data extraction tool from JBI QARI (Appendix II). The data extracted included geographical location, setting, number of participants, participant demographics (e.g. age, sex, years of experience), type of error, method of data collection, study design and study findings.
Qualitative research findings were pooled using JBI QARI. This process involved aggregation or synthesis of findings to generate a set of statements that represented that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice.
Description of studies
The searches yielded 1628 citations, of which, 50 were duplicates, and 1578 were screened for relevance using the title and abstract (Figure 1). Subsequently, 49 papers were retrieved for eligibility review against the inclusion criteria. The references of these papers were also hand-searched for additional literature, wherein one paper was identified. There were 38 papers (Appendix III) that did not meet inclusion criteria, thus 12 were appraised for methodological quality.
Methodological appraisal of studies
Three papers10,19,24 were excluded because the research methodology was not sound (Appendix IV). The studies did not meet any of the following criteria that were essential to the concept of dependability in qualitative research:36
- i) Is there congruity between the research methodology and the research question or objectives?
- ii) Is there congruity between the research methodology and the methods used to collect data?
- iii) Is there congruity between the research methodology and the representation and analysis of data?
Overall, nine studies were included. The included studies fulfilled all of the quality criteria with the exception of three studies.21,22,37 Two peripheral quality criteria were not met in these studies: Criteria 6 (Is there a statement locating the researcher culturally or theoretically?) and Criteria 7 (Is the influence of the researcher on the research addressed, and vice-versa, addressed?) (see Table 1).
The findings of this review comprised narratives of 284 registered nurses in nine qualitative studies. The study design was mainly phenomenological.21,22,26,37-40 Studies were published between 1994 and 2017. Nurses were mostly women, aged between 21 and 60 years, and their post-registration experience ranged from six months to 40 years. Six studies described nurses’ second victim experiences associated with adverse medication errors,22,26,38-41 while the other three studies were combined experiences of nurses who made any nursing errors that led to adverse events.21,37,42 The studies were conducted in hospital ward settings,21,26,38,39,41,42 critical care departments (including emergency departments),22,37 and one study did not specify the settings.40 Studies were conducted in Germany and Scotland,41 Canada,38 United States of America,40,42 Israel,21 Brazil,22 Norway,26 Macau39 and Iran.37 The characteristics of the included studies are summarized in Table 2.
The review had a total of 43 study findings, which formed 15 categories based on similarity in meaning. Four synthesized findings were generated from the categories. All extracted findings are detailed in Appendix V.
Synthesized finding 1
The error brings a considerable emotional burden to the nurse that can last for a long time. In some cases, the error can alter nurses’ perspectives and disrupt workplace relations.
This synthesized finding was derived from 15 study findings and five categories. Nurses considered the error to be personally and professionally traumatizing. Several negative emotions afflicted the nurse after an adverse error; some of these were described as panic, shock, devastation, disbelief, guilt, shame and loss of confidence. Nurses affirmed that these emotions can linger for years. The distress nurses felt also came from the fear and worry of the harm they could cause to the patient, and how the error would impact their professional image and their employment.
Category 1: Emotional distress immediately afflicts the nurse after the error
All nurses reported that they felt panic, shock, disbelief, shame and anger that they made the error:
“I felt absolutely sick when I realized I gave a double dose”.40,p.1333
Category 2: The distress after the error is caused by the fear of causing harm to the patient
The error activated a sense of fear for the patient's welfare. One nurse spoke of the experience:
“My thoughts were this could be very serious incident, could jeopardize my patient's health. I felt responsible, I felt guilty, I felt devastated, and very stressed”.38,p.47
To ensure the patient's safety, nurses consulted the doctors immediately and constantly monitored their patient's status:
“I at once went to the doctor because I wanted to prevent complications from the patient. By the end of the shift I was very stressed out, and all the time I checked if he's ok”.21,p.878
Category 3: Afflicted by distress after the error: “I might get fired”
It was evident that nurses were worried how the error would have a catastrophic impact on their career:
“It was a cascade of thoughts. I replayed what happened and couldn’t sleep right. I thought how the system would treat the mistake, will they keep me or throw me out”.21,p.880
Category 4: Afflicted by distress after the error: “…it will always be on my mind”
Negative emotions such as guilt, shame, and loss of confidence were present even up to two years after the event. Despite the time that had elapsed, nurses were able to recall the event as if it only just occurred:
“Time went by and it still lingers on. For a few months I was very nervous, I had difficulties falling asleep, because most of the time my mind kept busy thinking about it. It's hard even today, it left me deeply traumatized. I can’t forgive myself. When I distribute medication I have to do it with another nurse. Every time I treat it like it's my first. It damaged my confidence a lot“.21,p.882
The experience was likened to the symptoms of post-traumatic stress disorder by some nurses.
Category 5: The error can alter nurses’ self-image and disrupt relationships in the workplace
Errors dented the nurses’ confidence. Nurses asserted that they avoided tasks that previously led to a mistake:
“I tried not to deal with urinary catheterization and if I did, I was very careful. Furthermore, if there was a case which was difficult for me to do as catheterization in bladder, I said that I was not able to do”.37,p.73
The error impacted on relationships within the department. The study described nurses as being “exhausted in the teamwork instead of getting positive energy”37,p.73 in their workplace. There was a sense of distrust and astonishingly some nurses were treated with disrespect and mocked for their errors:
“Whenever I have to work with some careless nurses who were causing problems, I tried to either change my shift or in some case that there was no other choice, I did all the tasks on my own and tried to avoid them”.37,p.73
Nurses remarked that this type of treatment was neither helpful nor constructive. This rang true to one nurse who was crippled by the ordeal, as the study described:
“For the nurse who was exposed to criticism and reproach by her management, the error was devastating to both her personal and professional life. She was no longer capable of working as a nurse, and although she did not feel disabled, she was in no position to find another job, yet felt embarrassed and ashamed of having a professional in which she could no longer participate”.26,p.321–322
Synthesized finding 2
The type of support received influences how the nurse will feel about the error. Often nurses choose to speak with colleagues who have had similar experiences. Strategies need to focus on helping them to overcome the negative emotions associated with being a second victim.
This synthesized finding was derived from nine study findings and three categories. Many nurses expressed the need to speak about their experience with a person they trusted such as their partner, friend or a close family member. As well, nurses spoke about how they were and should be treated by their colleagues and supervisors.
Category 1: The sources of support for the nurses
“I wanted someone to help me”,22,p.485 lamented the nurse at the time of the error.
Nurses looked for support and sought a person they trusted to talk to. Some chose to speak to their partner, best friend or relative, but others preferred to speak to a health care professional because they felt that their family would lack the foundation for understanding what they were experiencing. The experiences of a second victim can be isolating, therefore having someone to talk to about the error generated a feeling of assurance that they were not alone:
“Well, my closest colleagues who I work with all the time and who I trust, who I can sit down and talk to and say you know, ’this is what happened’ and, you know, they could, you know, they kind of let me know that, you know, this could happen to anybody. So having the support of your colleagues to me is very important”.38,p.59
Not all nurses who had support felt better about what transpired; to some, time was imperative to recovery:
“For most of them (nurses), time was an important factor: as time went by, the anguish lessened”.26,p.321
Category 2: Nurses’ perceptions of the support they receive from colleagues and managers
The level of support received influenced how nurses coped with the error. Unfortunately, the treatment of the nurses by their colleagues and/or manager was not always supportive. Nurses indicated that they reported their error because it was a means of getting their colleagues to support them and they also felt that having the support would lighten the burden of guilt. For some nurses, ridicule and punitive action were all that awaited them. On the other hand, some nurses indicated that their colleagues were understanding, comforting, helpful and supportive. Nurses described that this type of treatment alleviated their guilt, shame, fear and loss of confidence. As one nurse recalled:
“My senior told me that what happened was already past. I also had done the self-evaluation. She encouraged me not to be frustrated because of that event. She said not to be confused by that incident; otherwise it would be easy to make more mistakes. I would then pay more attention to everything I encountered. I was touched by hearing her words. Actually, our seniors were very helpful and appreciated our work. They would not dismiss staff because of minor events. They wanted us to learn from our mistakes, to think of improvement and ways of making our work better”.39,p.32
Category 3: Recommendations from second victims
Nurses recommended that institutions steered away from the culture of punishment:
“It helps if your facility has a non-punitive approach to med errors (as my facility does). This encourages reporting so that trends/patterns can be identified and improvement projects implemented”.40,p.1338
Synthesized finding 3
After the error, nurses are confronted with the dilemma of disclosure. Disclosure is determined by the following factors: how nurses feel about the error, harm to the patient, the support available to the nurse, and how errors are dealt with in the past.
This synthesized finding that pertains to the dilemma of disclosure was derived from three categories from five findings. Disclosure was done in two ways: informing the patient about the error and incident reporting. Although nurses were willing to report their error, the act of disclosure hinged on several factors.
Category 1: Nurses believe that disclosure is a responsibility, thus they are willing to report their errors
Several nurses asserted their willingness to report their error:
“…facing up to your responsibility, being accountable for what you do, that's what it's all about”.41,p.523
“I have to inform my manager”.41,p.523
The milieu of responsibility of disclosure originates from professional accountability and personal beliefs. Nurses believed that disclosure was an inherent responsibility of the profession. As a nurse, one was accountable for their actions and their consequences, be it therapeutic or harmful, therefore, nurses accepted disclosure as a responsibility. On the other hand, nurses also felt that disclosure was a moral responsibility to inform the patients. However, despite the nurses’ readiness to disclose their errors it was clear that this was not adhered to all the times, as described in one study:
“Several felt a moral responsibility to inform the patient about the error, its consequences, and that they were responsible. Others told the patients about the medication error, but failed to disclose the possible consequences, or that they themselves were responsible. The latter was because they were ashamed and disappointed in themselves”.26,p.320
Category 2: Disclosure is not likely to occur if there is little or no harm to the patient
Studies described that if the error was not serious but likely to be detected, it was probable that nurses would file an incident report. However, for minor errors that wereunlikely to be detected, there was a tendency that the error would be unreported. There was an indication that only errors that caused harm were reported:
“I didn’t tell the patient that he was given the wrong medication. I was afraid it would affect his illness when I told him. The medicine I gave him was vitamins and one was a coagulant. It didn’t really matter. So, I didn’t immediately tell him he was given an incorrect medication”.39,p.31
Category 3: Support is pivotal to the nurse's decision to disclose their error
The availability of support and the nurse's experience of how previous errors were handled had a significant influence in disclosure. There was an implication that if errors were handled negatively in the past, nurses were unlikely to report their errors:
“If it was in a similar situation, I would feel very reluctant to inform the nursing officer. Unless I knew the nursing officer and I knew that they were going to support me”.41,p.523
Synthesized finding 4
Reconciliation is every nurse's endeavor. Predominantly, this is achieved by accepting fallibility, followed by acts of restitution, such as making positive changes in practice and disclosure to attain closure.
This synthesized finding, which provides an insight into the key elements of reconciliation after making an error, is derived from four categories from 14 study findings.
Category 1: Reconciliation is every nurse's endeavor
There are no direct quotes for this study, however, the following was described in a study:
“Reconciling means to bring to acquiescence or to resolve an issue or situation. In reconciling, one might not be happy with the outcome but still has some degree of acceptance and acquiesces to the situation. In this instance, once participants perceived that mistakes had occurred and that they were responsible, their self-esteem plummeted, and their focus became one of regaining their self-worth through making it right”.42,p.179
Category 2: Accepting fallibility, particularly to the factors, places nurses at risk of errors
Arndt added that reconciliation was a necessity for every nurse to reverse the guilt associated with making the error.41 Reconciliation amongst nurses started with having an awareness of their weakness, “I was not the only one to do such thing”,41,p.524 as one nurse said. This insight also allowed nurses to liberate themselves from self-blame, and acknowledge their fallibility to the factors that placed them at risk. Stress, work overload, distractions, inattention and lack of concentration were frequently mentioned:
“It was two years ago. In winter there was huge and catastrophic pressure in the ward. Lots of geriatric patients. In a momentary absent mindlessness, the error occurred. Luckily for me I picked it up in a couple of minutes, so the patient's condition hadn’t worsened”.21,p.876
Category 3: The error serves as a foundation for improvements in practice
In line with the primary objective to “make it right”,42,p.179 nurses ensured that the errors were not repeated. Nurses reported that they undertook education and training, and made behavioral changes. Vigilance, cautiousness and heightened awareness were frequently described:
“I was familiar with these patients and didn’t check armbands—it was an automatic thing to go to the patient I was talking to. I tell patients now and have for years not to talk to a nurse while she is giving meds. Barcode med administration would not have helped in my error. Barcode med administration is important but the nurse must always be diligent and stay focused”.40,p.1337
“Well it's allowed me to be more careful, to check medication more carefully, or sometimes at the medication cart it can be very distracting because it's ten o’clock, everybody is trying to give their medication at the same time. I try not to do my med administered in a rush, you know. I just tell people look and find, you gotta wait and don’t rush”.38,p.61
Category 4: Disclosure brings a sense of closure to the nurse
In one study disclosure was described as an important element of reconciliation:
“The acting phase for the publicly known error included apologizing to the parties who were affected by the error and, in some instances, making restitution. Participants said they usually felt relief and a sense of closure when the mistake was disclosed and dealt with. In a very different trajectory for action after the privately known error, steps to disclose and deal with the error were not followed. Our participants never described personal instances of non-disclosed mistakes that caused harm, but such instances were described in stories of mistakes by others“.42,p.181
However, it was apparent that not every second victim had the opportunity to attain closure and there was little understanding of the course of reconciliation for these nurses who internalized their errors.
This review aimed to highlight the second victim phenomenon in nursing and determine the support provided to the nurses experiencing second victimhood. Adverse nursing errors are not only devastating for patients, but the effects also resonate among nurses. As second victims, nurses are burdened by emotionally distressing states that are expressed as panic, shock, devastation, disbelief, guilt, shame, worry and loss of confidence. Alarmingly, these can persist long-term. Nurses do not always receive the support they need. Some choose to speak about their experience to their close kin, but feel that this is insufficient as family members may be ignorant of the health care process and the extent of the emotional distress. Colleagues and managers can be sources of support, and often nurses turn to the ones they trust. The treatment of the second victim is not always pleasant as some can be made to feel worse. Despite the desire to disclose their error, the nurse's decision whether to disclose an error is ultimately determined by the degree of harm to the patient and how they are supported. Reconciliation is an important process for which every second victim strives in order to regain their self-worth. Few pivotal steps are necessary towards reconciliation, which include: nurses’ acknowledgement of their vulnerability to errors, improvements in practice, and disclosure of errors.
The review findings are echoed in other literature and systematic reviews.14,29-31 Previous reviews,14,29,30 although mostly represented by doctors, also found that second victims experience distress, self-doubt, confusion, fear, remorse, guilt, feelings of failure, depression, anger, shame and inadequacy that they have to deal with for a long time. Several factors influence the distress of nurses as second victims. First, the nurse's negative emotional response (i.e. shame. guilt, loss of confidence) can be attributed to the altruistic foundation on which the profession is built. Altruism infers that the nurse possesses expert knowledge and has the transcendent aim to heal.43 First, adverse errors can therefore be seen as a betrayal of their purpose of facilitating healing. Second, it is likely that the emotions are triggered by the harm or the possibility of fatally injuring the patient. As one nurse reported, “I was devastated. I was afraid I could kill my pt [patient]. It was horrible!”40 Third, distress can be due to the anxiety nurses feel about their jobs after the adverse error. Finally, much of the anguish felt by nurses can be caused by the detrimental treatment they received from their colleagues.
It is difficult to dismiss the possibility that had support been adequate for nurses, perhaps the emotional distress they felt could be less severe. Several nurses in this review did not feel that they were offered adequate support or that support was made available for them,21,26,39,41 but this is not uncommon. In a survey of 269 health care professionals, 65% reported that they dealt with the personal aftermath of errors by themselves.28 In another study, second victims were made to face the inquiry without being briefed of its process or being debriefed of its outcome.25 The lack of a good support system has important implications for the nurses’ well-being. Nurses seek support to lessen the emotional burden.41 Hence, in the absence of a good support system, distress is likely to worsen,30,44,45 and moving forward can become harder for the second victim.16
The absence of a supportive culture also influences the process of disclosure.41,42 Five rights of second victims have been suggested, which include: right to treatment, right to respect, right to understanding and compassion, supportive care and transparency, and opportunity to enhance practice.46 In the absence of these, organizations risk cultivating a culture of non-disclosure and underreporting.47 The danger of non-disclosure is it creates a significant discord and distrust between patients and the health care service,48 and leaves safety risks unaddressed.49
Reconciliation is crucial to enable the second victim to regain his or her self-worth. Three actions are necessary for the process of reconciliation: nurses’ acceptance of their fallibility to errors, making constructive changes in practice, and disclosure. However, Crigger and Meek asserted that these were “healthier responses”42(p.177) because other nurses kept silent about their second victim experience. Similarly, Scott et al.16 revealed that second victims could either drop out, survive or thrive. Dropping out involves leaving the profession or workplace. Surviving is being able to live with the disappointment and torment that an adverse error has been committed. Thriving is characterized by the ability to cope by turning the negative event into something beneficial. Reconciliation is an interplay between the severity of the psychological toll of the error and the nature of the support system. Inadequate support systems hamper the reconciliation process because it damages the nurse's confidence to practice and leads to anxiety, error internalization and isolation.7 Conversely, a supportive culture helps nurses unload negative emotions, accept responsibility, and make constructive changes in practice.7,50
This review establishes the importance of a supportive culture in nursing, and for nurses (second victims) to have access to a support person who is well-oriented with the processes of the health care systems (e.g. nursing colleagues, nursing managers) immediately after the error. A supportive culture can minimize the emotional burden of second victims, encourage disclosure and facilitate reconciliation. Second victims must be treated with respect, and in a manner that does not impose blame and subject them to shame.46 Seys et al.27 adds that second victims need to be reassured by their supervisors that they are valued and trusted. What is unclear from this review and would benefit from research is an exploration of how and where else nurses want to receive the support, how frequently, and for how long. In a previous study, second victims expressed the need to be given time off from work to recollect one's thoughts; receive information about the management of adverse errors, the second victim phenomenon, and information about available support networks; and have confidential access to a support system at any time.28 There can be three sources of support for second victims: i) departmental support, ii) trained peer support, and iii) external support.28 Departmental support can include a respected person from the second victim's unit that can provide one-on-one, face-to-face reassurance immediately after the error. Trained peer support can include personnel from occupational health and safety who acts as the second victim's support person through the inquiry or litigation. External support can be sought from employee assistance programs, pastoral care, social work, a psychologist or a counsellor.28 However, a respected peer is the support system most desired by the second victims.51 Recently, peer support programs have been trialed and received positively by health care professionals including nurses.52,53 The effectiveness of peer support programs has not yet been established.
The findings of this revew are not only relevant for the development of support strategies or network for second victims, but also imperative for the uptake of error prevention strategies. As Dr Caroline Clancy insinuated, “The best way to avoid second-victimhood is obviously to avoid patient harm in the first place”.54(p.4) However, it is dangerous to assume that second victims can be negated by the avoidance of mistakes altogether as risks of error are always present for nurses.55 Many of the adverse nursing errors are related to medication administration, patient monitoring (e.g. deterioration, falls), pressure injuries, and lack of equipment or resources.56 Perhaps error prevention strategies that focus on these practices can highlight that error prevention does not just safeguard patients from harm but are also vital to protect nurses from being second victims. Therefore, the management of second victims warrants a place alongside error prevention.
The views of female nurses were mostly represented in this review. In view of previous findings that women tend to worry and experience disrespect,14 our findings may not be representative of male nurses.
Although the search strategy was designed to include all relevant publications, it is still possible that the search strategy used in this review might have omitted publications that were not indexed in MeSH (Medical Subject Headings) terms. Nevertheless, the final search strategy for this review was deemed the best out of the other keyword combinations. As well, it is worth noting that this review was able to capture studies that should have been included in other reviews.14,29
Since 1980, only nine qualitative studies of sound methodological quality explored the experiences of second victims. The knowledge base of second victimhood in nursing is still in its infancy,31 but this is not to be understood that second victims in the nursing profession are scarce. Overall, there is much work to be done to highlight the prevalence of second victims and the second victim support system in nursing.
The aftermath of adverse errors proves difficult for nurses. As second victims, nurses experience emotional torment that lingers over time which may be manifested in shock, disbelief, guilt, shame, loss of confidence and worry. Unfortunately, not all nurses receive appropriate and adequate support at the time of need. It is evident that, for some, judgement, blame and disciplinary action are all they receive. For most nurses, this reception prevents nurses from reporting their errors formally to their managers, and informing patients. However, some nurses have colleagues who are understanding, comforting, helpful and supportive, which alleviate the emotional burden. After the error, nurses attempt to reconcile with the event by accepting their vulnerabilities to errors, learning from the error, and having disclosure.
Implications for practice
The review highlights the distressing experiences of nurses as second victims. The review recommends that this must be acknowledged as an expected response to adverse errors, therefore support for these nurses is paramount. Based on the studies included in this review, the following recommendations have been developed:
- (1) It is important for health care services to acknowledge the detrimental effects of adverse errors on nurses.
- (2) Nurses must have access to a support person whom they trust, is well-oriented with the health care system and understands the experiences of second victims.
- (3) The treatment of nurses must be without judgment, blame and punitive action in order to facilitate disclosure and reconciliation, and minimize the distress associated with being a second victim of adverse nursing errors.
Implications for research
Further studies are warranted to describe the experiences of nurses as second victims. In particular, the experiences of male nurses as second victims may be worth exploring as they are currently underrepresented. There are several research gaps in the desired support system of nurses that include but are not limited to: additional sources of support other than peers, delivery of support, its frequency, and the length of time the support is required. Therefore, further research is necessary to establish the desired support system of second victims.
Appendix I: Database search strategy for second victims qualitative systematic review
Appendix II: QARI data extraction instrument
Appendix III: List of studies that did not meet the eligibility criteria
Appendix IV: List of studies that did not meet quality criteria
Appendix V: Summary of extracted findings
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