Usefulness of International Classification of Nursing Practice Peer Review
Int J Environ Res Public Health. 2020 Jul; 17(13): 4717.
Activeness after Adverse Events in Healthcare: An Integrative Literature Review
Mari Liukka
iDepartment of Nursing Science/Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Republic of finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (South.T.)
iiSouth Karelia Social and Health Care Commune, 53130 Lappeenranta, Finland
M Flores Vizcaya Moreno
ivFaculty of Health Sciences, University of Alicante, 03690 Alicante, Spain; se.au@ayacziv.serolf
Arja 1000 Sara-aho
fiveKinesthesia of Health Care & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland; if.bal@oha-aras.ajra
Jayden Khakurel
6Research Middle for Child Psychiatry, University of Turku, 20500 Turku, Republic of finland; if.utu@lerukahk.nedyaJ
Hannele Turunen
aneDepartment of Nursing Science/Faculty of Health Sciences, University of Eastern Finland, 70211 Kuopio, Finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (South.T.)
7Clinical Development, Education and Enquiry Unit of Nursing (CDERUN), Kuopio University Hospital, 70210 Kuopio, Finland
Susanna Tella
iDepartment of Nursing Science/Faculty of Wellness Sciences, University of Eastern Republic of finland, 70211 Kuopio, Republic of finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (S.T.)
5Faculty of Health Intendance & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland; if.bal@oha-aras.ajra
Received 2020 May vii; Accepted 2020 Jun 24.
Abstruse
Adverse events are common in healthcare. Three types of victims of patient-related adverse events can be identified. The start type includes patients and their families, the 2nd type includes healthcare professionals involved in an adverse issue and the 3rd blazon includes healthcare organisations in which an agin event occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action after adverse events, based on literature published in the last ten years (2009–2018). In the studies critically evaluated (northward = 25), central themes emerged relating to the first, 2d and third victim elements. The first victim elements contain attention to revealing an adverse event, communication subsequently an outcome, start victim support and complete amends. The second victim elements include second victim support types and services, coping strategies, professional changes after adverse events and learning about adverse event phenomena. The tertiary victim elements consist of organisational activeness after agin events, strategy, infrastructure and training and open up communication almost agin events. At that place is a lack of comprehensive models for activity subsequently agin events. This requires understanding of the miracle forth with ambition to manage adverse events as a whole. When an agin event is identified and a business expressed, systematic impairment preventing and ameliorating deportment should be immediately launched. System-broad evolution is needed.
Keywords: patient safety, adverse events, start victims, second victims, 3rd victims, management
ane. Introduction
Adverse events (AEs) are inevitable in nursing and healthcare [1,two]. Even where best professional person care exists, virtually treatments or investigations have the potential to cause harm [3]. Although the culture and arrangement of a healthcare organisation (HCO) may be well adult, AEs will happen because of homo factors and HCOs being complex adaptive systems, always irresolute and evolving. Thus, comprehensive training is important both to minimise harm to victims and to maintain the functionality of HCOs. In organisations with positive patient condom cultures professionals can speak openly nearly problems and events without fearfulness of blame or punishment. Managers promote safety and reporting of AEs is supported and organisational learning occurs [1].
An AE is defined as an unintended or unexpected incident which causes impairment to a patient and may lead to temporary or permanent disability [ane,four]. Approximately every 10th patient in infirmary suffers such events [five]. A quarter of these events in Europe are healthcare-associated infections; other AE types include medication errors, surgical errors, diagnostic errors, medical device failures or failure to human activity on test results [6]. Nurses and healthcare professionals ofttimes witness or are involved in AEs [ii,vii,viii]. In healthcare, AEs can, at worst, crusade catastrophic consequences [1]. It is clear that taking activity afterwards an AE has occurred is equally of import as prevention. Nigh one-half of physicians say that involvement in AE increases stress in their work [nine]. Many of the 2d victims seek support from family, colleagues or supervisor [10]. About 10% agree that organisations support them in coping with AEs [nine].
Three kinds of victims of AEs can be identified. The "first victims" are conceptualised every bit patients and their families. Patients can suffer from an AE in two ways: first from direct damage caused and then from the style the event is handled [1]. The "second victims", a concept originally introduced by Wu [xi], are healthcare providers, including physicians, nurses, allied clinicians, support personnel, students and volunteers [12], who have been involved in a patient related AE and subsequently feel emotional or physical distress, thus becoming a victim themselves [xiii,fourteen]. The phenomenon is quite common: the prevalence of second victim suffering is anticipated to be approximately 30%, varying from 10.4% to 43.3% [15]. Ninety per cent of healthcare professionals reported suffering at least one physical or psychosocial "second victim" symptom [16]. The "third victims" are healthcare organisations in which the AE occurs [17]. The impact on third victims can also be considerable, equally AEs may create an organisational crisis leading to long-term business organization difficulties [eighteen].
The furnishings of an AE on first, second and third victims include health-related, functional and economic consequences. These are interrelated and can cause significant costs. Both the first and second victims may endure emotional and psychological, concrete, financial and livelihood consequences [nineteen]. In improver, second victims can face professional consequences, including concerns regarding the performance of their work [12,xv,xx,21,22]. Healthcare professionals may too feel difficulties working in an environment where AEs have occurred [23,24]. Consequences for third victims relate to effectiveness [12,19,twenty], reputation [19,25], legal [twenty] and economical issues [19]. Hence, these phenomena are crucial aspects to consider later an AE.
Managing the aftermath of AEs well can be causeless to have positive consequences for first and second victims' wellness, behaviour and economical well-being. Because HCOs as third victims, but also as responsible for the get-go and second victims, it is articulate that where possible systematic prevention of commencement and second victim consequences, and advisable care subsequently an AE is crucial. Effective deportment after an event can accept a positive impact on the safe civilisation, effectiveness of services and financial situation of the HCOs. In the US, the estimated price of medical error in 2008 was USD 1 trillion, just patient prophylactic improvements are estimated to accept saved USD 28 billion [26]. Strategies to reduce the charge per unit of AEs in the European Matrimony lonely could forbid more than 750,000 harm-inflicting medical errors per year. That means over 3.2 million fewer days of hospitalisation, 260,000 fewer incidents of permanent disability and 95,000 fewer deaths per year [27]. The economic consequences of AEs, and of how the events are handled, are therefore not express to healthcare. For nations, increased absence from work, staff leaving the professions and deaths are examples of extreme consequences of AEs. Actions after AEs can exist assumed to have serious short- and long-term, direct and indirect impact on individuals, the economy and guild.
The purpose of this integrative review is to synthesise existing knowledge on actions following AEs in HCOs such as hospitals and primary intendance units. The aim is to identify the underlying elements required for damage preventing and ameliorating actions following AEs in order to provide management for evolution and future investigation. The research question is: What are the cardinal elements of action immediately subsequently AEs in HCOs?
two. Materials and Methods
2.1. Design of the Study
An integrative review approach was used post-obit Whittemore and Knafl's five stages: (1) the problem was identified; (2) the relevant literature published between 2009 and 2018 was sought; (three) the screened data were evaluated using a ten-item tool; (four) the eligible information were analysed using inductive content analysis; and (5) the findings are presented in tables [28]. In add-on, the checklist of the Preferred Reporting Items Systematic Reviews and Meta-analysis (PRISMA) Statement (2009) was used to guide the review [29].
2.2. Search Strategy
The databases Scopus, CINAHL, Cochrane and PubMed were searched for relevant manufactures. Boolean search methods were used to retrieve articles related to action after adverse events in healthcare such follows: "adverse event" AND "disclosure" OR "backwash", "agin event" AND "professional' support", "healthcare" AND "second victim", "healthcare" AND "later on fault".
The search, for example, from Scopus included search terms "agin consequence" AND "aftermath" OR "disclosure" with limits "in commodity, championship, keywords", "published 2009 to 2018", "article or review", "English language" and "in journals". Manufactures were included if they reported on action subsequently AE. Articles focusing on, for example, adverse drug reactions or AE reporting were excluded. Articles about AE reports were excluded when they were merely nigh frequency of reports, or near misses and did not present the whole process from AE to disclosure. Search methods, inclusion and exclusion criteria and search outcomes are presented in Figure 1. Twenty-5 research or review papers were found for inclusion in the data evaluation process.
Systematic literature search process regarding activeness later adverse events.
ii.3. Review and Quality Cess Process
The search process was realised independently by the authors (ML and ST). Online discussions were held with other authors to share results and make decisions on side by side steps of the process.
The "quality" of papers was evaluated using a tool developed from an amalgamation of previous piece of work [30,31,32,33] which was refined via international research group discussions. The evaluation areas included: (i) groundwork; (two) aim and inquiry questions; (iii) sample; (four) data collection; (5) data analysis; (half-dozen) results; (7) ethical problems; (eight) reliability; and (9) usefulness of the results. Afterward discussing relevant evaluation areas for a comprehensive quality assessment, the inquiry grouping added a farther area: (10) strengths and limitations. Each evaluation area was scored from 0 to two points using the following criteria: (0) does not meet the aim or lacks information; (i) inaccurate or superficial; and (two) relevant and presented systematically. With 10 evaluation areas and a maximum of 2 points for each area, the range of the scores for a study varied from 0 to 20 points. Annihilation beneath 12 points was excluded due to depression quality.
The articles retrieved were distributed evenly, and two researchers independently scored each newspaper using the tool. Total scores for each paper were compared and the content, importance, face validity and quality of each paper discussed. Where differences of iii points or more than were present, each sub-element score was discussed, and a third research team member acted as a moderator to arrive at a consensus. Cohens' Kappa was calculated to exam interrater reliability (κ = 0.83).
2.4. Information Assay
The results of the studies retrieved were analysed using anterior content analysis [34]. First, the studies were read several times and listed in a table to proceeds an understanding of the whole and the characteristics of the actions taken after an AE. The data reduction phase included extraction of the data into a manageable framework. The aims of the study, enquiry methods, findings, scores and scope of the activeness after AEs were presented. So, the data were open coded, abstracted and categorised using content-characteristic words. Sub-categories were developed and discussed in the international research group. Sub-categories were further grouped into categories describing management of activeness after AEs. Care was taken not to double count data from individual studies duplicated in literature reviews.
iii. Results
three.1. Feature for the Studies
The papers retrieved (north = 25) were published betwixt 2009 and 2018 (Table one). The largest numbers of papers were published in 2015 (north = 5) and 2018 (n = 5) and were from the Us (north = 12). Diverse methodologies were nowadays: quantitative (north = ten), qualitative (n = 8), multiple methods (n = ii) and literature reviews (north = v). The quality scores of the papers varied from 12 to twenty points, with a mean of 15.9 and standard difference 2.one. The majority (north = 21) of papers were about 2nd victim miracle and less attending was given to first (northward = half dozen) and third victim phenomena (n = 4). One paper encompassed both first and second victims, three included both second and tertiary "victims" and one paper covered all 3 "victims".
Table 1
Studies investigating action afterwards adverse event.
| Author(s) (Twelvemonth), Country | Purpose and Aims of the Report | Research Methods/ Musical instrument/Sample (north = 25) | Findings | Evaluation Scores/Scope |
|---|---|---|---|---|
| Scott et al. (2010), United states [12] | To describe a deployment of an institutional rapid response system (RRS) for second victims | Interview and 10 item spider web-based survey Interviews with 31 healthcare professionals Survey (n = 898), medical students, physicians and professional person nurses | Six distinct recovery stages were delineated. Well-nigh 40% of the respondents had previously heard the term second victim; 30% have had personal issues within the by 12 months, such as anxiety, depression or concerns about their power to perform their jobs. Thirty-5 per cent of respondents reported receiving support from colleagues and peers when it was offered and 29% received back up from supervisory personnel. Eight themes from the narratives to describe full general support infrastructure characteristics to aid 2nd victim recovery were identified. | 12.5 Second victim |
| Seys et al. (2013a), USA [15] | To identify supportive interventional strategies for 2nd victims | Literature review 21 research articles and 10 not-research articles Inclusion criteria and search strategy described PRISMA method was used for reporting | Numerous supportive actions for second victims described in the literature. Strategies included support organised at the individual, organisational, national or international levels. Second victim back up is needed to care for healthcare workers and to improve quality of care. Back up can be provided at the individual and organisational levels. Programs need to include support immediately post adverse event as well as on a heart- and long-term ground | 14 2nd victim |
| McVeety et al. (2014), Canada [19] | To analyse and synthesise best evidence on the perspectives of patients and family members who encountered adverse events | Review, xiv studies that used qualitative methodologies included Inclusion criterions and search strategy described, Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI) and Appraisal Checklist for Interpretive and Critical Inquiry | Nine themes were identified relating to patient and family perceptions and experiences of an agin event: communication, the disclosure process, amends, consequences and touch, fear of reprisal and/or interference with intendance, learned helplessness, measures of safeguarding, cocky-discovery and awareness of errors, and violations of trust. | 16 Showtime victim |
| Ullström et al. (2014), Sweden [20] | To investigate how healthcare professionals are affected by their interest in agin events, with emphasis on the organisational support they need and how well the organisation meets those needs. | Semi-structured interview guide with thirty questions. Qualitative content analysis and systematic classification was used Healthcare professionals (northward = 21) | Bear on on the healthcare professional person was related to the arrangement'south response to the outcome. | 15 Second and third victim |
| Kable et al. (2018) Australia [22] | To understand the effects of agin events on nurses in acute health-intendance settings. | A qualitative, descriptive study design; 10 nurses, semi-structural interview. | Nurses need organisational responses to adverse events, including collegial back up and provision of data after agin event occur. | 17 Second victim. |
| Rodriquez and Scott. (2018) The states [24] | To examine experiences of healthcare professionals who changed paths after an adverse event. | Web-based survey with total of 105 individual responded; 77 (73,3%) were eligible to complete the survey. | Healthcare professionals reported a pattern of inadequate social back up after adverse event. More than transparency and support to help professionals recover is needed. | xiv 2d victim |
| Mira et al. (2015a), Spain [25] | To place and analyse arrangement-level strategies adopted in both primary intendance and hospitals in Spain To address the impact of serious AE on second and third victims | A cross-exclusive survey report. The questionnaire explored five intervention areas: condom culture; health organization crisis direction plans for serious AE; measures to ensure transparency in communication with patients (and relatives) who experience an AE; care and support for 2nd victims and deportment to protect the reputation of the wellness arrangement (the third victim). Developed past consensus among the research team on the basis of reviews Managers of hospital and principal care centres (due north = 197), patient safety coordinators in hospitals or primary care (n = 209) | Scarce provision of back up for second victims was best-selling past 71% and 61% of the participants from hospitals and primary care, respectively; these respondents reported that there was no support protocol for 2nd victims in identify in their organisations. Regarding third victim initiatives, 35% of infirmary and 43% of primary care professionals indicated that no crisis management programme for serious AE existed in their organisation, and, in the case of principal intendance, there was no crunch committee in 34% of cases. The caste of implementation of second and third victim support interventions was perceived to exist greater in hospitals (mean 14.ane, SD 3.five) than in primary care (mean eleven.8, SD three.1) (p < 0.001) | 17.five Second and third victim |
| Gu and Itoh (2012), Communist china [35] | To explore Chinese patients' views on physician disclosure deportment after an adverse upshot and their acceptance of different types of apologies from the physician who acquired the event. | Questionnaire with seven sections concerning responding views of issue related to medical errors and patient prophylactic Inpatients and families (n = 934) | A large difference identified in the level of patient acceptance betwixt a physician's "full" or "partial" amends. It is suggested that Chinese hospitals should adopt an "open up" policy, which should include a "sincere" apology to the patient who experienced a medical error in order to maintain mutual trust between the staff and patients. | 17 Get-go victim |
| Mira et al. (2015b), Espana [36] | To assess the effect of adverse events that occur in primary care and hospital settings on health professionals in personal and professional terms | A cross-sectional written report Online survey, randomly selected sample; 1087 health professionals completed the questionnaires (610 from master care and 477 from hospitals) | In total, 430 health professionals had informed a patient of an error. Error reporting to patients was carried out by those with the strongest rubber culture, nether 50 years of age and primary intendance staff. Primary care (due north = 318) and hospital (northward = 346) health professionals reported having gone through the second-victim experience. The emotional responses were: feelings of guilt, anxiety, re-living the event, tiredness, insomnia and persistent feelings of insecurity. In doctors, the most mutual responses were feelings of guilt and re-living the event, while nurses showed greater solidarity in terms of supporting the second victim in both PC and infirmary settings. | 18 Second victim |
| Sorensen et al. (e-pub 2009), Commonwealth of australia [37] | To sympathise patients' and health professionals' feel of Open Disclosure and how do tin inform policy | Semi-structured open-ended interview. Grounded theory was used to analyse the data Nurses, managers, policy coordinators, patients and family members (northward = 154) | Five major elements influenced patients' and professionals' experiences of openly disclosing adverse events namely: initiating the disclosure, apologising for the agin upshot, taking the patient's perspective, communicating the agin event and existence culturally aware. | 15.v First and second victim |
| Koller and Espin (2018) Canada [38] | To capture perspectives on paediatric disclosure and identify gaps in knowledge for all-time practices and policy uptake. | Focus group interview with semi-structured questions; five parents, xiv children and adolescents and 27 healthcare providers. | Patients and families need total disclosure and correct to know near errors. Health-care professionals need more clarity in policies. Nigh agreed that a example-by-case approach was necessary for supporting variations in how medical errors are disclosed. | 19 First victim |
| Hågensen et al. (2018) Norway [39] | To present patients' perspectives of disclosure of and healthcare organisations' response to adverse events. | Qualitative study; fifteen in-depth interviews. | Three main topics regarding patients' experiences of adverse events are: (1) ignored concerns or signs of complications; (ii) lack of responsibleness and mistake correction; and (iii) lack of support, loyalty and learning opportunities. | 20 Showtime victim |
| Mira et al. (2017), Kingdom of spain [forty] | To summarise the knowledge about the aftermath of agin events and to develop a recommendation ready to reduce their negative impact in contexts where there is no previous experience and apology laws are non present. | Three information sources were used; review studies (n = 14 publications), institutional websites (xvi websites were reviewed) and experts' opinions and experience on patient prophylactic (iv focus group sessions with 27 participants). | Recommendations focused on viii areas: (ane) Prophylactic and organisational policies; (2) Patient intendance; (iii) Proactive approach to preventing reoccurrence; (4) Supporting the clinician and healthcare team; (5) Activation of resources to provide an advisable response; (vi) Informing patients and/or family members; (7) Incident analysis; and (8) Protecting the reputation of wellness professionals and of the organisation. | 19 First, Second and third victim |
| Treiber et al. (2018) USA [41] | To talk over the second victim syndrome and its impacts on nurses. | Online survey with multiple-choice and open-ended items were sent to 842 resent nursing graduates 168 responses were received. | Fifty-half-dozen per cent reported making at least one medication error. After making a medical error nurses had emotional responses, such as fear and disappointment. Nurses described frequently been supported by peers, nursing director and preceptors. | 12 2nd victim |
| Burlison et al. (2017), USA [42] | To present the evolution and psychometric evaluation of the Second Victim Experience and Support Tool (SVEST), a survey instrument that tin assist healthcare organisations to implement and track the performance of 2nd victim support resources | Quantitative report Second Victim Experience and Back up Tool (SVEST) questionnaire development, v-point Likert scale Nurses, physicians, pharmacists and medical technicians in specialised paediatric hospital (north = 305) | The SVEST (The 2d Victim Feel and Support Tool) can be used by healthcare organisations to evaluate 2nd victim experiences of the quality of existing back up resources. Means: Psychological distress 2.vi, physical distress 2.3, colleague support 2.2, supervisor support 2.8, institutional support 2.3, not-work-related support two.4, professional person efficacy 2.v, turnover intentions 2.1, absenteeism i.8 The virtually desired 2d victim option: A give-and-take with a respected peer 81% The 2nd most desired choice: A word with the manager 74% | 19.5 Second victim |
| Edrees et al. (2011), USA [43] | To emphasise the importance of back up structures for second victims in the handling of patient adverse events and in building a civilisation of safety within hospitals. | A cross-sectional survey using a 2-part 2nd Victim Questionnaire Nurses, nursing or other managers, physicians, pharmacists, therapists, clinical support, technologists (north = 140 in function ane and n = 95 in role ii) | There is a need for second victim support strategy in healthcare organisations. Breezy emotional back up and peer support are amid the most requested and almost useful strategies. Other desired support: Prompt debriefing, crisis intervention stress management (75%), an opportunity to discuss ethical concerns related to an result or process (46%), a safe opportunity to contribute to the prevention of similar events in the future (45%) | thirteen.five Second victim |
| Ferrús et al. (2016), Spain [44] | To identify what occurs among healthcare providers after an adverse upshot and what colleagues could do to help them | A qualitative study applying consensus search techniques Focus grouping and metaplan Physicians (north = 15), nurses (due north = 12) | Consensus about second victims requiring support from their colleagues and managers; many times, 2nd victims perceive rejection. They experience fright, repetitive thoughts and loneliness. Formal information channels favour implementation of improvements. HCPs perceived that information on measures for preventing another adverse consequence is inaccessible. Managers reported that a change in behaviour is necessary to improve patient prophylactic civilization. Common informal channels included cafeterias and hallways. Colleagues of second victims' reactions included surprise and pursuit to avoid involvement. | 16 2nd victim |
| Joesten et al. (2015), USA [45] | To establish a baseline of perceived availability of institutional support services or interventions and experiences following an adverse patient rubber event (PSE) | Quantitative study, The Medically Induced Trauma Support Services Staff Support Survey (MITSS) Nurses (northward = 82), physicians (n = 12) | Overall, 10–30% of respondents reported that diverse support services or interventions were actively offered. Respondents reported having experienced several distressing symptoms after PSE, such as worrying memories (56%) and concerns about lawsuits (37%). Most of them experienced more support from colleagues than from their director or department chair. Less than 32% felt that they could written report concerns without fear of castigating action or retribution. | xiv Second victim |
| Lewis et al. (2013), USA [46] | To report the event of medical errors on nurses | Integrative literature review 21 manufactures included Inclusion criteria and search strategy described Whittemore and Knafl'southward methodology used | Characteristics of units were important in nurses' experience of medical errors. Nurse characteristics were essential, for case, number of nursing practice years. Veteran nurses were more likely to make constructive changes. Two interventions were: (ane) disclosure of a medical error to the patient; and (two) support available to the nurse. Responses to the intervention outcomes were: (one) burnout, including emotional exhaustion, depersonalisation and low personal achievement; (2) moral distress; (3) intention to leave the profession; and (4) positive constructive changes after medical errors. | 15.v 2d victim |
| Davies et al. (2015), UK [47] | To explore student midwives' perceptions of what was traumatic for them and how they were supported after such events | Qualitative descriptive arroyo, using semi-structured interviews Student midwives (n = 11) | Five main themes: (ane) Students' feet about entering the profession including students beingness forced to adopt practices that devaluate their commitment; (2) Existential space between a patient and qualified midwife occupied by students, having traumatic tensions in the student part; (3) Emergency events were traumatic with students feeling unprepared and having too much responsibility; (four) Aftermath of emergency events apropos the affect of the issue on students; and (5) Learning to cope related to the fashion student coped with such incidents, equally well as other stresses in the role. | thirteen.5 Second victim |
| Harrison et al. (2015), UK/ United states [48] | To investigate: (a) the professional person or personal disruption experienced after making an error; (b) the emotional response and coping strategies used; (c) the human relationship betwixt emotions and coping strategy selections; (d) influential factors in clinicians' responses; and (e) perceptions of organisational back up | Cross-exclusive, cantankerous-land survey, The Health Professional Experience of Error Questionnaire (HPEEQ) tool Nurses (n = 145), physicians (due north = 120) | Professional and personal disruption reported as a event of making an error. Negative feelings common, but positive feelings like alertness, conclusion and attentiveness also identified. Emotional response and coping strategy option appeared to differ by professional group; nurses had stronger negative feelings subsequently an fault, but selection did not differ by perceived impairment or location. Problem-focused coping strategies were favoured. Organisational back up services perceived every bit helpful, especially peers, but in that location were fears over confidentiality. Factors that influence clinician recovery should be considered in the provision of comprehensive support programs. | 17 Second victim |
| Seys et al. (2013b), USA [49] | To determine definitions of second victim, research the prevalence and the impact of adverse effect on the 2nd victim and the coping strategies used | Literature review 32 enquiry articles and 9 non-inquiry articles were identified | 2d victims' common reactions afterwards agin events can exist emotional, cognitive and behavioural. The coping strategies used past second victims have an impact on their patients, colleagues and themselves. Defensive besides as effective changes have been reported in practice later on adverse events. It is disquisitional that support networks are in identify to protect the patient and involved healthcare providers when an adverse event occurs. | 15 Second victim |
| Edrees and Wu (2017) United states of america [50] | To assess the extent of the second victim problem in acute care hospitals, the availability of emotional support services and the need for organisational support programs. | In-depth semi-structured interviews. Patient safety representatives (n = 43). | All participants reported that they are aware of second victim bug. Almost all agreed that hospitals should accept a back up program for second victims. | 15,v Second victim |
| Delacroix (2017), United states of america [51] | To discern nurse practitioners' behaviours, perceptions and coping mechanisms in response to having made a medical error | Qualitative study, face-to-face semi-structured interviews (n = ten). | Iv themes emerged from interviews: (1) The paradox of error victimisation, two subthemes were presented (fright for the patients' welfare and fearing an uncertain professional future; (2) The primacy of responsibleness and mindfulness, three subthemes were presented (I am responsible, astute reactions and mindfulness); (3) Yearning for forgiveness and supportive other, this theme was categorised in 2 subthemes (non-supportive just civilization and seeking forgiveness and support); and (iv) Coping with a new reality is context dependent, what was split up to ii subthemes (atypical coping and constructive coping). | 15.5 2nd victim |
| Van Gerven et al. (2016), Belgium [52] | To evaluate the prevalence and content of organisations' support systems for healthcare professionals involved in an agin event. | Quantitative descriptive blueprint Dutch-speaking hospitals (n = 59) | 30 organisations had a systematic plan to back up second victims. The primary nursing officer was seen equally one of the main contact people when something went wrong. In terms of the quality of the protocols, only a minority followed office of the international resources. | 16 Second and third victim |
3.2. Key Elements of Responses and Activity after AEs Bulleted Lists Look Like This
Actions post-obit AEs were comprised of three themes, namely first victims, second victims and third victims, with empathic and ethical communication, support services, complete amends and preparation and learning every bit cross-cutting elements.
The theme of action for start victims was comprised of four elements: attention in revealing an AE, communication subsequently AEs, first victim back up and complete apology (Table ii). Patients and families [xix] and healthcare providers [35,36] akin were often afraid of speaking upwards. Empathic, upstanding and open communication played an important role overall; the quality of the communication seemed to either empower or disempower patients and their families [19,37,38,39]. In many cases, patients are not informed about AEs [40]. Support for first victims was addressed primarily as a lack or neglect of emotional support [36,39] and compensation back up [35]. Apologising was an of import element subsequently experiencing an AE [19,34,37,38]. Beginning victims perceived the apology equally an integrative procedure, where the style and the presenter of the apology, whether healthcare provider or organisation, played an of import role. Expressing empathy, giving honest information nearly the AE, taking responsibility and learning from the consequence were crucial to the apology process.
Table 2
"Action after adverse events" regarding first, 2nd and 3rd victim elements.
| FIRST VICTIM ELEMENTS | ATTENTION OF REVEALING AN Agin EVENT | HCPs listening to patients' and family members' concerns about an error Patients or family members fearing to speak upwardly HCPs fearing to speak up HCPs' empowering or disempowering patients and family unit members |
| Communication AFTER AN ADVERSE Result | Considering cultural differences in communication Providing open communication Documenting in the patient records Observing different kind of family unit dynamics | |
| Beginning VICTIM Support | Emotionally supporting patients/families afterwards agin events Bounty support | |
| COMPLETE Apology FOR FIRST VICTIMS | Apology with empathy Amends being an interactive process Presenter of apology HCPs/HCOs beingness sorry for agin event experience Patient forgiving an adverse result Amends including learning from an outcome and a change in action First victims' trust in healthcare services | |
| Second VICTIM ELEMENTS | SECOND VICTIM SUPPORT Blazon | Informal second victim support Formal second victim support Emotional second victim back up |
| SECOND VICTIMS' COPING STRATEGIES | Individuality of second victim coping strategies Seeking second victim emotional support coping strategies Trouble-solving 2d victim coping strategies | |
| SECOND VICTIM Back up SERVICES | Availability of second victim support services 2d victim legal and counselling back up Time abroad 2d victim support Open disclosure support | |
| 2nd VICTIMS' PROFESSIONAL CHANGES AFTER Adverse EVENTS | Defensive changes after adverse events Constructive changes after adverse events | |
| 2d VICTIMS' LEARNING Nearly ADVERSE Upshot Miracle | Second victim learning from an agin event Learning about second victim phenomenon Learning to communicate about agin events | |
| THIRD VICTIM ELEMENTS | ORGANISATIONAL "Activeness Subsequently Agin Event" STRATEGY | Action after adverse event plan High moral communication strategy Agile providing of support services Organisational apology policy Organisational learning from agin outcome |
| ORGANISATIONAL "Activity AFTER Adverse Event" INFRASTRUCTURE | Action after adverse event personnel Back up infrastructure Processes of "action after adverse event" | |
| OPEN DISCLOSURE Nearly ADVERSE EVENT | Process of open up communication Content of open up disclosure | |
| "Activity Subsequently ADVERSE Event" Grooming | Patient safety training Adverse events related training Communication afterward adverse events preparation |
The action for second victims theme consisted of the following elements: 2nd victim support types, coping strategies, support protocols, changes after AEs and learning about AE phenomena (Table 2). Support types consisted of informal [12,15,41,42,43,44,45], formal [15,23,25,twoscore,41,46,47] and emotional [22,42,44,45,46] support for 2d victims. Healthcare providers have indicated informal peer support equally important [20,41,42,49,50], but sensitive. The back up tin be destroyed, for example, past blaming, gossiping and silence [46]; thus, it is important to pay special attending to not-blaming, open and supportive communication. Formal support was not a certainty and was non offered in all cases [12,25,42,46,47]. The importance of emotional 2d victim support was articulate and could exist provided for all those involved, for individuals or groups [43,49,fifty]. 2nd victim coping strategies related to the individuality of strategies [12,49], emotional back up [41,47,49,51] and problem solving [47,49].
The 2nd victim back up services comprised availability [11,24,25,41,44], counselling support [36,41,44], time abroad back up [41,44,45] and open disclosure back up [37,43,44]. Changes that 2d victims make later an AE can include defensive and constructive changes [50]. It was also found that learning well-nigh AEs [47], the second victim miracle and learning to communicate near AEs are of import for staff members [12,44,48].
The action for the third victims theme consisted of organisational strategy and infrastructure [20,46,49], which was divided into activity after adverse events plan [12,25,52], personnel [36,37,42,46,52] and processes [20,36,52] subthemes (Figure two). The key elements of the subthemes were:
-
emphasising open, empathic communication (for example, open disclosure) and each staff member'south responsibleness for their empowering communication mode [25,37,42];
-
activeness after AE support services for get-go and 2d victims (for example, emotional support) [42,44,47,49]; and
-
action after AE training and learning for managers and staff members [xv,nineteen,52].
"Action afterwards adverse events" in healthcare organisations.
4. Discussion
The results of this integrative literature review demonstrate how complex and multi-layered the phenomenon "action afterwards AE" is and how this topic has gained attention in international research and healthcare development piece of work. Previous studies accept full-bodied more than on a single perspective regarding actions after AEs, while, in this integrative review, a more holistic view is presented. Key themes emerged relating to victims of AEs: first, second and third victim elements, with compassionate, constructive communication, support services, complete amends and training and learning, equally cantankerous-cutting elements.
The first victim theme comprised attention to revealing an AE, communication after an effect, first victim back up and consummate apology. The 2d victim theme included second victim support types, coping strategies, back up services, changes afterward AEs and learning about AE phenomena. The third victim theme consisted of organisational action afterwards AEs, strategy, infrastructure and training and open up communication about AEs. These iii themes interweave tightly together, and nosotros approach the themes from a healthcare arrangement's perspective to outline the needs of start and second victims and how HCOs could reply to these. In this integrative review, 2d victim support programs were under development work. For case, Scott et al. designed "A Framework of Caring: The Scott Three-Tiered Interventional Model of Back up", which features: (Tier i) unit level support; (Tier two) trained peer supporters and patient safety and risk management resources; and (Tier 3) an expedited referral network with specialist support [12]. Indeed, a similar kind of back up plan could also benefit starting time victims.
Second victim support programs can be assumed to support outset victims as well through better preparation of nurses and healthcare providers. However, it could be argued that more comprehensive first victim support programs are also needed. Attention to revealing an AE, open and emphatic communication and complete, authentic apology to, and back up of, first victims were essential afterwards AEs. For example, the apology policy of the HCOs seemed to be fragmented and ofttimes defensive. First victims highlighted the importance of an empathic, interactive procedure, where a sincere apology is expressed not but past an individual healthcare provider, but responsibility on the office of the HCO is accepted as well [53,54]. Kickoff victims implied that in some situations they might forgive, but it was unclear if forgiveness was asked for [35]. Here, an interactive back up program could exist benign for all victims, including nursing and healthcare students. For instance, first victims wanted the apology to include information nigh how the HCO would learn from the AE and make changes [xix,35]. Start victims had often lost trust in HCOs [19]. Open discussion most what went wrong, and why, can be the first step to understanding and forgiveness [55]. I reason for a loss of trust may be a lack of transparency after AE [56]. Kickoff victims should exist convinced that everything possible is being done to avoid a similar situation in the future. If the amends included a convince of systematic, organisational level learning from the AE, the professionals involved may feel supported when discussing AEs with patients, peers and managers [57]. From the literature reviewed changes appear needed at the individual, squad, unit and organisational levels. The results suggested a need for holistic approaches to managing AEs.
Safe, systematic and clear "action plan afterward AEs" required an understanding of each stakeholder'southward needs. AEs consist of complex systems of bug which ofttimes interact; thus, information technology is important to bargain with the phenomenon every bit a whole. Indeed, even those not straight involved may take impact on the consequences of AEs. The strategy and infrastructure of HCOs are crucial to managing activeness after AEs every bit part of healthcare delivery. An "action after AE" strategy needs to include a comprehensive program which attends to the interlinked complexity which often exists. Well-thought-through communication is required from everyone in HCOs: colleagues, managers and second victims equally well. AEs are very sensitive events that can accept long-term consequences [12,xv,19,20,24]. Thus, communication is cardinal to occupational and patient safety.
Organisational "activeness afterwards AEs" infrastructure needed to have appointed personnel, articulate support and learning infrastructure and clear processes. It was besides of import that the procedure and content of open disclosure are included in the direction of the events. Emphatic, support and respect by colleagues is needed subsequently AE so that healthcare professionals still feel competent to do their job [20]. With these deportment, HCOs may exist able to ameliorate the severe consequences for all victims, such as effectiveness of HCOs [12,nineteen,20], economic issues [19] and reputation [nineteen,25]. Nurses and healthcare professionals suffer when involved in AEs, may fear reporting events [48,58,59,60] and experience difficulties working in an surround where AEs have happened [23]. Being comprehensively prepared is important [58] both to minimise damage to all victims and for the functionality of healthcare systems.
Mira et al. found that many patients are not informed at all almost AE. This may exist because HCPs are afraid for their professional person future, or because they do not have competence to honestly tell a patient what has happened [38,xl,51]. A shortage of skill and resource lack of competence seems to be one barrier to developing organisational support programs afterwards AE [50]. It is important not to forget the first victims outside this back up. It is likewise skilful to recognise that outset victims accept much information about AEs to provide for organisational learning [38,39]. Crucial for this is that action after AE education is included in professional and standing healthcare program [33].
The strengths of this study include an international researcher group involved with stiff patient safety research, direction and instruction feel. For example, the data evaluation was conducted in ii groups. The quality of the research papers was evaluated with an instrument used in an integrative review. Agreement among authors was measured by Cohen's kappa (κ = 0.411), which tin can be interpreted as moderate [60]. Limitations include the method itself. Merely peer reviewed research papers were used in this review. National or international guidelines and protocols about disclosing adverse events were omitted. The search strategy may have affected the number of dissimilar victim phenomena constitute vary. Combining different methodologies such every bit qualitative, quantitative and literature reviews can be difficult due to diverse ontological and epistemological underpinnings, which some may view every bit causing bias [28]. Team discussions regarding key features of the papers were utilised to assistance in clarifying the quality of the studies and the main emergent points from each newspaper. Close attention was also given to the avoidance of double counting in club to avoid "skewing" the findings. The PRISMA statement was used to guide the writing of the review [29].
5. Conclusions
It is inevitable that AEs will occur in healthcare organisations, impacting on individual, squad, unit of measurement, system and national levels. When an AE is identified and a concern expressed, immediate and comprehensive action should exist taken. This requires trying to understand the whole miracle in its complexity, an ambition to manage AEs and a "just restorative" culture [61] that enables information technology. System-broad developments are needed regarding activity after AEs, along with the implementation of evidence-based organisational infrastructures and strategies which could ameliorate the suffering of patients, their families and healthcare providers, every bit well as assistance healthcare organisations (and ultimately nations) to utilize resource finer. For this developing, more research about patients' and their families' needs too as organisations' needs is required. Tight collaboration is needed between policy-makers, nursing and healthcare managers and educators in order to develop such systems and the necessary culture [62]. Just then will all victims receive appropriate support subsequently AEs. We as well suggest that hereafter education, research, policy and practice developments should incorporate a movement to a more balanced approach incorporating both Condom 1 (learning from failure) and Prophylactic 2 (learning from how things typically go right) perspectives [61]. At the national level, social and healthcare ministries are responsible for planning, guidance and implementation of health and social policy to safeguard people's power to piece of work and function. International collaboration between governments is needed to standardise studies concerning first, second and tertiary victim miracle. Governments should build a network of researchers and healthcare managers for developing the report protocols and shared understanding of developing first, second and tertiary victim support system in healthcare organisations. Such a movement may assist in the development of "restorative just cultures" in HCOs and more holistic approaches to actions later AEs for the do good of all "victims".
Acknowledgments
The sixth writer would similar to thank INVEST Research Flagship funded past the University of Republic of finland Flagship Programme (decision number: 320162).
Writer Contributions
M.Fifty. and S.T. conducted the literature search and evaluation of articles, and were major contributors to the manuscript. A.S., M.F.V.M., P.P., and H.T. participated in evaluation of articles and writing the manuscript. A.M.S.-a. and J.Yard. took part in manuscript writing. All authors read and approved the final manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no disharmonize of involvement.
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