Despite major improvements in patient safety in the last decades,1 adverse events remain a threat to the quality of care and an urgent global problem.2,3 Adverse events harm first and foremost patients and caregivers4,5 and include severe physical harm,6 psychological distress,7,8 and even death.9 Moreover, patient safety incidents inflict a heavy financial burden on the healthcare system; for example, medication errors cost an estimated U.S. $42 billion per year.10 Patients and caregivers are described as the first victims of these incidents, whereas the involved healthcare providers who can be emotionally affected as well11 are frequently called second victims, a term coined by Wu in 20004 and controversially discussed in recent years.5,12–14 Indeed, although it has generated discomfort among many patients and healthcare providers who argue that the term victim implies that healthcare providers who were involved in an adverse event are not responsible and cannot be held accountable and that it may downplay the experience of the patients,5,12,14 others, for instance Petersen,13 a first victim himself, consider the term appropriate. However, a more suitable term has not successfully established itself until now.12,14
A recent meta-analysis by Busch et al11 demonstrated that second victims strongly experience various psychological and psychosomatic symptoms in the aftermath of adverse events, such as anxiety, sleeping difficulties, and troubling memories. Furthermore, the involved health care workers, in response to these stressful events,15,16 apply coping strategies, which as defined by Folkman and Lazarus17 represent “cognitive and behavioral efforts to manage (master, reduce, or tolerate) a troubled person-environment relationship.p.152” Coping mechanisms vary and can be more or less adaptive.18 For instance, second victims may consider career changes, try to distance themselves from the incident, seek social support, change their attitude to work, or practice defensive medicine.19–21 Coping, a shifting, nonstatic process,15,22–24 is influenced by individual aspects (e.g., personality traits, regulatory control processes) and situational factors (e.g., severity and duration of the stressor, stressor perceived as controllable or uncontrollable, organizational culture of the healthcare institution).17,25–27 There is a large body of research on the different types of coping mechanisms.15,17,22–24,28,29 For instance, although Folkman and Lazarus17,22 differentiated only between problem-focused (actively approaching a problem) and emotion-focused coping (trying to regulate one’s own emotions accompanying the perceived stressor), Endler and Parker15,23,24 suggested a third type, avoidance oriented (trying to avoid the factors causing the psychological distress). A distinction between adaptive/functional and maladaptive/dysfunctional coping strategies is often discussed as well.25,30–32
As highlighted by Waterman et al,33 a deep understanding of second victims’ diverse responses to adverse events is vital for developing adequate psychological support programs and to help guarantee patient safety and well-being and a high quality of care. Although some literature reviews18,19,34–37 have described the coping of healthcare providers involved in an adverse event, to date, there has not been a meta-analysis focusing on the type and frequency of coping strategies. In this study, we aimed to quantify and critically analyze the coping strategies applied by healthcare providers in the aftermath of adverse events.
METHODS
The protocol of this study is registered in the International Prospective Register of Systematic Reviews (Registration Number CRD42016053239). Here follows the description of the main methodological steps. For further explanation, we refer to Busch et al.11
Search and Selection Process
We performed a systematic search of nine electronic databases (e.g., PubMed, Cochrane Library, Web of Science) up to October 2018, without restrictions to publication date and language, using the same search strategy as in our previous study.11 We examined also additional sources (e.g., databases of gray literature, reference lists of systematic reviews). Supplemental data file 1 and 2 (https://links.lww.com/JPS/A262), respectively, provide a precise record of the applied search strategies for each database and of the additional searches.
Studies were eligible for inclusion if (a) the participants were healthcare providers involved in adverse events/patient safety incidents (i.e., harmful incidents, near misses, and no-harm incidents)38 and (b) the frequency of coping strategies in this population in the aftermath of an adverse event was reported. We did not set any restriction on age, sex, healthcare profession, and setting.
We excluded systematic reviews, single case studies, case series, qualitative studies, general discussion papers, book chapters, editorials, letters, and comments because we assumed that original, quantitative data (i.e., frequency rates of coping strategies used by healthcare providers involved in an adverse event) would not be presented in such papers.
Two reviewers (I.B. and F.M.) screened study titles and abstracts independently using Rayyan, a systematic reviews web application,39 and retrieved full texts of the records considered as eligible. In case of dissent, a third reviewer (M.R.) was involved to reach a consensus. We recorded all excluded studies and the reasons for exclusion as recommended in the Cochrane Handbook.40
Two appraisers (I.B. and F.M.) rigorously assessed, first independently, and then by consensus, the quality of the included studies, applying the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data41 composed of nine quality criteria (e.g., appropriate method of recruitment, use of valid methods to identify the condition). Any potential dissent was discussed and resolved, involving a third appraiser (M.R.) when consensus was not reached.
Data Analysis
We considered the frequency of coping strategies applied by healthcare providers who had been involved in an adverse event as the primary outcome measure. We categorized the identified coping strategies according to the framework by Endler and Parker15,23,24 as either task oriented, emotion oriented, or avoidance oriented. All attempts to actively tackle a problem, to solve it, or reduce its impact were categorized as task-oriented coping strategies. All endeavors to deal with emotions, including self-absorption and imagining reactions, were labeled as emotion-oriented coping strategies. All efforts to avoid stressors, such as getting distracted or avoiding certain situations, were defined as avoidance-oriented coping strategies. The methodological steps of data extraction and synthesis are shown in Supplemental Data File 3 (https://links.lww.com/JPS/A262).
Taking into account potential heterogeneity across studies, we used random effects modeling to perform the meta-analyses. We calculated the overall frequency of coping strategies with 95% confidence interval (CI) by pooling the individual frequencies of at least two primary studies. To assess statistical heterogeneity, we visually examined forest plots and calculated the I2 statistic (0%–40%, not important; 30%–60%, moderate heterogeneity; 50%–90%, substantial heterogeneity; 75%–100%, considerable heterogeneity).42 We used Comprehensive Meta-Analysis V3 (Biostat Inc, Englewood, NJ) to conduct the meta-analyses.
RESULTS
Selection and Inclusion of Studies
The search of the electronic databases (see Supplemental Data File 1, https://links.lww.com/JPS/A262) and additional sources (e.g., databases of gray literature, volumes of journals) (see Supplemental Data File 2, https://links.lww.com/JPS/A262) yielded a total of 10,721 records, of which 111 full-text articles were assessed for eligibility (see Supplemental Data File 4, https://links.lww.com/JPS/A262). In seven cases, the authors of the selected studies were contacted to request further data. After the exclusion of 97 articles due to various reasons (e.g., mixed population, lack of sufficient information) (see Supplemental Data File 5, https://links.lww.com/JPS/A262), we included 14 studies,20,43–55 all meeting the inclusion criteria, in the systematic review and meta-analysis.
All included studies met more than half of the criteria listed in the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies41 (see Supplemental Data File 6, https://links.lww.com/JPS/A262). All studies used an appropriate sample frame and performed satisfactorily the data analysis and the measurement of the condition. Some studies, however, showed limitations or lacked clarity regarding the method of sampling, sample size, descriptions of study subjects and settings, use of valid methods, the analysis (e.g., frequency rates expressed only by percentages), and the response rate.
Characteristics of Included Studies
The 14 included studies20,43–55 (Supplemental Data File 7, https://links.lww.com/JPS/A262) were published between 1991 and 2016 and conducted in several countries (i.e., Belgium, Denmark, Finland, Germany, Greece, Iran, United Kingdom, United States). All studies had a cross-sectional study design and applied descriptive and, in some cases, inferential statistics. Aside from Schrøder et al52 who not only administered a questionnaire with closed-ended questions but also conducted semistructured interviews, all other authors applied only self-report questionnaires with predominantly closed-ended questions. Only the quantitative findings by Schrøder et al52 were used for our analyses. Sample sizes ranged from 40 to 1463 (a total of 6351 participants). Participants worked in different professions (e.g., nurses, midwives, physicians, residents) and settings (e.g., intensive medicine, general medicine, emergency department).
Regarding the adverse event itself, several studies assessed the point in time that it occurred (e.g., in the previous 6 months, more than 4 y before the study), its type (e.g., medication error, diagnostic error, procedural error), categorized its severity (e.g., high, medium, low, no perceived error severity), and patient outcomes (e.g., need for additional therapy, clinical deterioration, serious injury, death).
Meta-analyses
After categorizing the coping strategies according to the criteria listed previously, we identified 26 coping strategies adopted by healthcare providers who had been involved in an adverse event (Supplemental Data File 8, https://links.lww.com/JPS/A262). We calculated the overall frequencies for these coping strategies (C.B. and M.P.) (Table 1 and Supplemental Data File 9, https://links.lww.com/JPS/A262) and categorized them as task oriented, emotion oriented, or avoidance oriented (I.B., F.M., M.R.). Three coping strategies (i.e., Disclosing the error/talking to/support from staff, Apologizing or doing something to make up, Disclosing the error and talking to the patient and the family) were categorized as both task oriented and emotion oriented.
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TABLE 1: Overall Frequency Rates of Second Victims’ Coping Strategies
The use of the specific coping strategies varied, ranging from 8% to 89%. The four most frequently used strategies were task oriented, and the four strategies least frequently used were avoidance oriented.
Task-Oriented Coping Strategies
Task-oriented strategies were reported by 89% of second victims. The most frequent coping strategies were Changing work attitude (89%, 95% CI = 80–94), Following policies and guidelines more accurately and closely (89%, 95% CI = 54–98), and Paying more attention to detail (89%, 95% CI = 78–94), and Ordering more tests (20%, 95% CI = 10–36) was used the least.
Emotion-Oriented Coping Strategies
Criticizing or lecturing oneself (74%, 95% CI = 47–90) was the most frequently adopted emotion-oriented coping strategy. Positive reappraisal (21%, 95% CI = 8–43) was used the least.
Avoidance-Oriented Coping Strategies
Although the avoidance-oriented coping strategy Wishing the situation away was used by 55% of the second victims (95% CI = 29–78), only 8% reported Use of alcohol/drugs/medication (95% CI = 3–23).
I2 estimates, ranging between 0% and 69.8%, showed negligible to moderate heterogeneity across studies, with one exception (I2 = 69.8% for Better monitoring of the patient/paying better attention to the patient). There were insufficient data to perform subgroup analyses (e.g., according to different types of healthcare profession or adverse event).
DISCUSSION
This study adds to a growing body of literature on second victims’ responses after patient safety incidents. As far as we know, this is the first systematic review and meta-analysis providing a precise overview of second victims’ coping in the aftermath of adverse events that quantifies the frequencies of the applied coping strategies. Our findings demonstrate that a large proportion of second victims uses different types of coping strategies to deal with the emotional impact of medical errors. This evidence has a relevance not only for healthcare providers’ well-being and prevention of burnout but also regarding the quality of the patient-provider relationship and risk management in general.
In particular, we found that the most frequently reported coping strategies were task oriented, suggesting that second victims are strongly committed to managing the consequences of the event (e.g., Problem-solving) and improving their own work performance (e.g., Following policies and guidelines more accurately and closely). Interestingly, on the contrary, the least applied coping strategies were avoidance oriented (e.g., Trying to hide error/refusing to talk about it, Avoidance of patients, procedures, situations, Turnover intentions, Use of alcohol/drugs/medication). Although it is possible that these strategies were underreported, it seems that second victims tend to accept the responsibilities related to their role in the adverse event (e.g., Trying to hide error). Moreover, the emotional impact of the adverse event, which previous studies have indicated as highly present and characterized by a wide range of psychological symptoms,19,34,37 is managed mainly by admitting personal responsibility and showing awareness of the implication of this event for patients and their families. Indeed, the most frequent emotion-oriented coping strategies resulted to be Criticizing or lecturing oneself, Disclosing the error/talking to/support from medical staff, and Apologizing or doing something to make up. This attitude is supported by our recent meta-analysis11 that identified anger toward oneself, regret/remorse, embarrassment, and guilt as common psychological reactions of second victims. The fact that many healthcare professionals aim to improve their performance to prevent future errors, take responsibility for their doing, and attempt to make amends is an encouraging indication that the majority of these people respond to adverse events in an overall constructive, proactive way. Thus, our results do not seem to suggest that these healthcare providers show the traits the term second victim may imply, namely, passivity, powerlessness, lack of responsibility, and accountability.5,12 Considering also the recent controversy over the use of this term5,12–14 as pointed out earlier, it would be of great interest to quantitatively explore, using a large sample of healthcare providers from different disciplines, if they see themselves as “victims” or feel uncomfortable being referred to as such, as a qualitative study by Tumelty12 indicates.
In a systemic approach to risk management, the healthcare provider is considered only as the sharp end of a chain of events eventually leading to an incident.56–58 Indeed, even if adverse events are directly caused by healthcare providers’ active, unintentional failures, usually, medical errors are triggered by latent conditions of the healthcare institution including decisions taken by the top-level management.56 Following such a systemic approach, second victims’ actions and decisions in response to stress and professional requirements in the aftermath of adverse events should not only be seen in relation to their personal and professional life including the relationship with patients but also be seen in relation to the overall healthcare system. Figure 1 shows that coping strategies can influence healthcare providers, patients, and the healthcare system in a positive or negative way (adaptive versus maladaptive for healthcare providers; appropriate versus inappropriate for patients, and functional versus dysfunctional for the healthcare system).
FIGURE 1: Second victims’ coping after adverse events and its overall effects on patients, healthcare providers, and the healthcare system.
For healthcare providers, coping strategies can be considered adaptive if they lead to a better psychological adjustment and reduce the stress caused by the medical error, preventing the loss of emotional, cognitive, and behavioral functioning. On the contrary, maladaptive coping may cause feelings, beliefs, and behaviors that negatively influence functioning.30,59,60
For the welfare of patients, coping strategies can be considered appropriate if they evoke proactive professional skills, attitudes, and behaviors, which are beneficial for the well-being of the patients and for the therapeutic alliance. Inappropriate strategies may lead to more defensive, aggressive, and emotionally detached interactions with patients, weakening the therapeutic alliance and reducing patient satisfaction.
For the healthcare system, coping strategies can be defined as functional if they facilitate a reliable and effective performance. Hollnagel et al57 argue that promoting system resilience is a key element for ensuring safety. Indeed, the ability of a healthcare organization to provide high reliability under varying conditions is a critical achievement only possible through actively fostering the adaptability and creativity of human performance—a Safety II approach. Accordingly, a coping strategy can also be seen as functional for the system if it strengthens professionals’ resilience. Coping strategies that compromise achievement of quality and safety standards and reduce resilience can be considered dysfunctional for the healthcare system.
Although some of the coping strategies identified in our study are classifiable to specific and stable categories (e.g., Use of alcohol/drugs/medication can be defined as maladaptive/inappropriate/dysfunctional independently from the context), most cannot be categorized without also considering contextual and temporal variables. For example, a coping strategy that in the short term might be adaptive for the second victim can become maladaptive if applied in the long term (e.g., Distancing). Similarly, strategies that are functional for the system if flexibly applied may become dysfunctional and negatively affect the efficiency of the healthcare system if adopted in a rigid and decontextualized way (e.g., Paying more attention to details). Table 2 illustrates a critical approach in the assessment of second victims’ coping strategies, highlighting the positive and/or negative aspects of the most and least frequent coping strategies from the perspectives of the involved provider, the patient, and the healthcare system.
TABLE 2: Potential Effects of Second Victims’ Coping With Adverse Events
Implications for Clinical Practice and Policy
Our results suggest that the coping strategies used by second victims in the aftermath of an adverse event are part of a complex, multifaceted process that directly affects healthcare providers and indirectly influences patients and healthcare services.
Regarding the role of healthcare organizations, it may be assumed that investing in a systemic approach to risk management,56–58 strengthening resilience,57 promoting a “Just Culture,”72 offering training courses that foster the adoption of proactive reactions to work-related stress, and establishing psychological support programs that increase the well-being of second victims and other frontline healthcare personnel could probably encourage the use of adaptive, appropriate, and functional coping strategies.19 Such support programs should not only focus on second victims’ psychological and psychosomatic symptoms but also explicitly address the type of the used coping strategies and their effects on all involved stakeholders. Nevertheless, more evidence is needed to fully address these aspects.
Limitations and Directions for Future Research
Our results should be interpreted in light of some limitations. Although the quality of the primary studies was satisfactory, our calculations are based only on the self-reported, cross-sectional data extracted from the included studies and are thus likely to be affected by certain biases. For example, participants might have had problems to correctly remember what kind of coping strategies they had used (i.e., recall bias)78 or might have had difficulties in recognizing certain behaviors, in particular avoidance behaviors due to low self-awareness and a lack of introspective skills, thus resulting in underreporting. Furthermore, because of the social desirability bias,79 participants may have avoided reporting strategies commonly seen as inappropriate (e.g., Use of alcohols/drugs/medication, Trying to hide error/refusing to talk about it) and reported those that are generally considered socially desirable (e.g., Apologizing or doing something to make up). It might be also argued that some coping strategies reported in the primary studies were not the expression of a “real choice” of the healthcare provider but rather mandatory actions. For instance, in some cases, Disclosing the error with patients might have been required by the healthcare institution, thus not representing a personal coping strategy.
Moreover, the included studies differed in terms of medical setting, professions, type of adverse events, and cultural background. We also found for some coping strategies a wide variability in the reported frequency rates of the primary studies. Although we cannot rule out that this variability may have somewhat confounded our analyses, we did not further analyze these differences because most of the I2 estimates indicated negligible or only moderate statistical heterogeneity across the studies with none suggesting considerable heterogeneity.
Nevertheless, to increase the depth of understanding, future research on these issues is recommended. For instance, regarding the coping strategy Apologizing or doing something to make up, a strong increase in the frequency rates of the primary studies (i.e., from 20%55 to 86%53) could be observed. Although this finding may be only coincidental, it could also indicate a change in healthcare providers’ attitudes toward apologizing and making amends, reflecting the growing efforts in healthcare to be transparent and open with patients and to deal with adverse events promptly and proactively.69,80,81 It would be interesting to investigate this apparent trend over time and to correlate it with other trends. Similarly, the underlying reasons for certain outliers in the data, such as the exceptionally high frequency rate of Better monitoring of the patient/paying better attention to the patient (i.e., 95%, 95% CI = 91–98) reported by Taifoori and Valiee,53 might be further explored.
In addition, many of the included studies did not record the severity of the adverse events and did not address the potential relationship between the type and outcome of the event (e.g., near miss versus sentinel event). Thus, overall, future studies should examine the significant differences in coping strategies across time, cultures, types, and outcomes of the incident, professions, and settings of care.
CONCLUSIONS
Our meta-analysis adds insight into the coping strategies adopted by healthcare providers involved in adverse events. The results suggest that second victims’ coping is primarily task, emotion, and, to a lesser extent, avoidance oriented. These coping strategies should be further evaluated considering their positive and negative effects on second victims’ personal and professional well-being, the impact on the relationship with patients and their families and, last but not least, taking into account the overall quality and safety of care delivered by the system.
ACKNOWLEDGMENT
The authors thank Prof. Susan D. Scott, Prof. José Mira, and Prof. Reema Harrison for providing useful information for this study.
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