When nurses become the "second" victim

Restorative Just Culture: An Exploration of the Enabling Conditions for Successful Implementation

BACKGROUND/OBJECTIVES

Restorative responses to staff involved in incidents are becoming recognized as a rigorous and constructive alternative to retributive forms of 'just culture'. However, actually achieving restoration in mostly retributive working environments can be quite difficult. The conditions for the fair and successful application of restorative practices have not yet been established. In this article, we explore possible commonalities in the conditions for success across multiple cases and industries.

METHODS

In an exploratory review we analysed published and unpublished cases to discover enabling conditions.

RESULTS

We found eight enabling conditions-leadership response, leadership expectations, perspective of leadership, 'tough on content, soft on relationships', public and media attention, regulatory or judicial attention to the incident, second victim acknowledgement, and possible full-disclosure setting-whose absence or presence either hampered or fostered a restorative response.

CONCLUSIONS

The enabling conditions seemed to coagulate around leadership qualities, media and judicial attention resulting in leadership apprehension or unease linked to their political room for maneuver in the wake of an incident, and the engagement of the 'second victim'. These three categories can possibly form a frame within which the application of restorative justice can have a sustainable effect. Follow-up research is needed to test this hypothesis.

Development and evaluation of an external second victim support program for nurses: a single-group feasibility study

BACKGROUND

Psychological support programs can help nurses who involved in patient safety incidents. However, most of these programs are operated internally by healthcare providers and utilize peer supporters, which may take a long time to implement. Therefore, there is a need to develop programs that can be used by healthcare providers in healthcare institutions that have difficulty implementing their own programs. This feasibility study aimed to develop an external support program for nurses as second victims and to examine the feasibility, acceptability, and impact of the program.

METHODS

This study was conducted using a single-group pretest-posttest design. Nurses who experienced patient safety incidents were recruited through posters at three advanced general hospitals, as well as open online recruitment and via a research agency panel from September 2020 to April 2021. The 11 participants attended a total of three one-on-one counseling sessions. Feasibility was evaluated based on participant recruitment and retention, resource availability, program procedures, and the practicability of data collection. Acceptability was assessed through program satisfaction and participant feedback. Psychological impact was measured using the Impact of Event Scale-Revised Korean version.

RESULTS

Out of 26 applicants, 11 (42.3%) completed the program, with 10 (38.5%) participants completing both pre and post-program surveys. Most participants responded that they were satisfied with the program and expressed their intention to recommend the program to others and participate in it again if similar situations arise. The participants' median total IES-R-K score decreased significantly from 30.0 to 16.0 (p = 0.028, r = 0.67).

CONCLUSION

This study demonstrates the feasibility of an external second victim support program and provides preliminary data suggesting its potential to alleviate the psychological impact of participants. To overcome the limitations of this study, it is necessary to conduct additional controlled trials with a longer follow-up period and a larger sample size.

BONE Break: A Hot Debrief Tool to Reduce Second Victim Syndrome for Nurses

The pandemic has intensified clinicians' workloads, leading to an increased incidence of adverse events and subsequent second victim syndrome, with almost half of health care clinicians experiencing its symptoms. However, following a literature review, no tools were found that addressed second victim syndrome in nurses. To address these issues and the gap in the literature, the authors developed the BONE Break hot debriefing tool. BONE Break is designed to be facilitated by charge nurses or other unit leaders as a means of offering peer support to other nurses who went through an adverse event. During its initial implementation, BONE Break was employed in 43 of 46 events adverse events (93.5%), and 41 of 43 sessions (95.3%) were deemed helpful. The research team has continued to gain stakeholder buy-in and implement BONE Break across multiple sites. Future work will determine BONE Break's efficacy in enhancing long-term nursing retention and reducing second victim symptoms.

A Qualitative Meta-Synthesis of Studies on Workplace Bullying among Nurses

This study aimed to further understand and compare the phenomenon of workplace bullying (WPB) among clinical nurses in various sociocultural contexts. The study sought to determine appropriate interventions, examining how said interventions should be delivered at individual, work-unit, and institutional levels. Qualitative meta-synthesis was chosen to achieve the study aims. Individual qualitative research findings were gathered, compared, and summarized using the thematic analysis suggested by Braun and Clark. Based on the predefined analytic points, the findings included the following themes: horizontal yet vertical violence, direct and indirect violence on victims, nurses feed on their own, accepting and condoning WPB embedded in ineffective work systems, and rippling over the entire organization. The results showed that the phenomenon of workplace bullying shares quite a few attributes across cultures in terms of the characteristics, types, perpetrators, subjects, and consequences. The findings suggest that interventions to change and improve organizational work culture must be developed and implemented.

Causes of adverse events in home mechanical ventilation: a nursing perspective

Background

Adverse events (AE) are ubiquitous in home mechanical ventilation (HMV) and can jeopardise patient safety. One particular source of error is human interaction with life-sustaining medical devices, such as the ventilator. The objective is to understand these errors and to be able to take appropriate action. With a systematic analysis of the hazards associated with HMV and their causes, measures can be taken to prevent damage to patient health.

Methods

A systematic adverse events analysis process was conducted to identify the causes of AE in intensive home care. The analysis process consisted of three steps. 1) An input phase consisting of an expert interview and a questionnaire. 2) Analysis and categorisation of the data into a root-cause diagram to help identify the causes of AE. 3) Derivation of risk mitigation measures to help avoid AE.

Results

The nursing staff reported that patient transportation, suction and tracheostomy decannulation were the main factors that cause AE. They would welcome support measures such as checklists for care activities and a reminder function, for e.g. tube changes. Risk mitigation measures are given for many of the causes listed in the root-cause diagram. These include measures such as device and care competence, as well as improvements to be made by the equipment providers and manufacturers. The first step in addressing AE is transparency and an open approach to errors and near misses. A systematic error analysis can prevent patient harm through a preventive approach.

Conclusion

Risks in HMV were identified based on a qualitative approach. The collected data was systematically mapped onto a root-cause diagram. Using the root-cause diagram, some of the causes were analysed for risk mitigation. For manufacturers, caregivers and care services requirements for intervention offers the possibility to create a checklist for particularly risky care activities.

Causes of Nurses' Second Victim Distress: An Objective Analysis

BACKGROUND

Unanticipated adverse events could harm not only patients and families but also health care professionals. These people are defined as second victims. Second victim distress (SVD) refers to physical, emotional, and professional problems of health care professionals. While positive patient safety cultures (PSCs) are associated with reducing severity of SVD, there is a dearth of research on the association between PSCs and SVD and the mediation effects in those associations.

OBJECTIVES

The purpose of this study was to explore the associations between PSCs and SVD and verify the multiple mediation effects of colleague, supervisor, and institutional supports.

METHODS

A cross-sectional study using a self-report questionnaire was conducted among 296 nurses in South Korea. The participants were selected by quota sampling in 41 departments including general wards, intensive care units, etc. Descriptive statistics, Pearson's correlation, multiple linear regression, and multiple mediation analysis were conducted using SPSS 25.0 and the PROCESS macros.

RESULTS

Nonpunitive response to errors, communication openness, and colleague, supervisor, and institutional supports had negative correlations with SVD (Ps < .05). In the multiple mediation model, a nonpunitive response to error showed a significant direct effect on SVD (direct effect β = -.26, P < .001). Colleague, supervisor, and institutional supports showed a significant indirect effect between nonpunitive response to error and SVD; colleague (indirect effect β [Boot LLCI-Boot ULCI] = -.03 [-0.06 to -0.00]), supervisor (.03[0.00 to 0.07]), and institutional support (-.04 [-0.07 to -0.01]).

CONCLUSION

The study suggests that establishing nonpunitive organizational cultures is an effective strategy to reduce SVD. The findings highlight the importance of promoting programs that strengthen PSCs in hospitals and prioritizing support resources to reduce SVD among nurses.

Profiles of second victim symptoms and desired support strategies among Korean nurses: A latent profile analysis

AIMS

To clarify second victim symptoms subgroups, explore the factors affecting profile membership and determine how desired support strategies differ between the subgroups.

DESIGN

A cross-sectional study using an online survey.

METHODS

A total of 378 Korean staff nurses directly involved in patient safety incidents were recruited between December 2019 and February 2020. Data analyses consisted of latent profile analysis, multinomial logistic regression and analysis of variance.

RESULTS

Three latent profiles were identified: 'mild symptoms', 'moderate symptoms' and 'severe symptoms'. Lower organizational support and higher non-work-related support were more likely to belong to the severe symptoms' profile. Incidents that caused temporary harm to the patient were more strongly associated with an increased likelihood of belonging to the moderate and severe symptoms profiles than no-harm events. Participants with severe symptoms agreed more with the usefulness of the support strategies than other participants; the usefulness of the psychological support strategies was rated particularly high. Participants in the mild and moderate symptoms groups agreed more strongly with the usefulness of coping strategies following patient safety incidents than psychological support. The strategy that all profiles considered the most useful was having the opportunity to take time away from clinical duties.

CONCLUSION

Tailored support should be provided to nurses with factors influencing the profile membership and subgroups of second victim symptoms.

IMPACT

This study confirmed the need to provide organizational support to nurses as second victims and provided valuable evidence for developing support programs tailored to the subgroups of second victim symptoms.

The combined effect of psychological and social capital in registered nurses experiencing second victimization: A structural equation model

PURPOSE

This study examined the combined role psychological capital and social capital play in the severity of second victim syndrome experienced by registered nurses.

DESIGN

This research study was an ex post facto, cross-sectional, non-experimental survey design. Data were collected from October to December 2018. The study sample was composed of 1167 nurses recruited through 12 professional nursing associations in the United States.

METHODS

Self-report questionnaires were administered to measure psychological capital (Psychological Capital Questionnaire), social capital (Social Capital Outcomes for Nurses) and second victim syndrome (Second Victim Experience and Support Tool). Data cleaning and analysis of 1167 cases were conducted via SPSS v25 and structural equation modeling of 999 cases was conducted with AMOS v25.

FINDINGS

The SEM analysis demonstrated that psychological capital, on its own, had no effect on the severity of the second victim experience. Social capital, on its own, had a statistically significant relationship with second victim severity. The combined impact of social capital and psychological capital had a statistically significant effect on second victim severity.

CONCLUSIONS

The results of this study have practical implications that include unit-based peer support programs and an increased focus on supportive workplace cultures. Programmatic efforts should also focus on social capital at the team level as well as the importance of building self-efficacy through increasing mastery experiences, modeling of behavior, social persuasion and monitoring one's physiological responses.

CLINICAL RELEVANCE

These findings demonstrate the importance of social capital to mitigation of second victim experiences, while also demonstrating that psychological capital has no effect on second victim severity. Building social capital and collective efficacy are critical to mitigation of second victim syndrome.

Detach Yourself: The Positive Effect of Psychological Detachment on Patient Safety in Long-Term Care

OBJECTIVES

Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, which refers to the ability to psychologically detach from work and patients in off-duty hours. The objective of this study was to examine the relationship between psychological detachment and patient safety. In addition, the ability of teams to create a safe environment to discuss errors and take personal risks, i.e., psychological safety, was explored as an underlying condition for psychological detachment.

METHODS

A total of 1219 caregivers (response rate = 44%) from 229 teams in two long-term care organizations completed a survey on psychological safety and psychological detachment at T0. Team managers rated patient safety of those teams at two points in time (T0 and T1).

RESULTS

Two-level regression analysis showed that both psychological safety (β = 0.72, P < 0.01) and psychological detachment (β = 0.54, P < 0.05) relate directly to patient safety. Psychological safety relates positively to psychological detachment (β = 0.48, P < 0.01) but was, however, not an underlying condition.

CONCLUSIONS

Perceived patient safety is enhanced by emotional competencies, at individual level by psychological detachment and at team level by psychological safety. Caregivers should be aware of the important influence emotional competencies have on patient safety and be trained to develop these competencies. Future research should focus on exploring underlying conditions for emotional competencies.

Nurses as 'second victims' to their patients' suicidal attempts: A mixed-method study

AIMS AND OBJECTIVES

To understand the effects of patients' suicidal attempts and events on nurses' second victim symptoms and to explore the association between these experiences and nurse absenteeism and turnover.

BACKGROUND

The term 'second victim' is when a healthcare professional expresses psychological symptom following adverse patient event. This has been previously shown to be associated with absenteeism and higher staff turnover.

DESIGN

A mixed-methods study with a sequential exploratory approach.

METHODS

A qualitative approach was used for nurses to relate their experiences of their patients' suicidal attempts. A cross-sectional quantitative study was conducted in 150 nurses who worked in internal departments. The Second Victim Experience and Support Tool was used to substantiate and measure second victim related distress of nurses who treated suicidal patients. The qualitative data were analysed by a constant comparative analysis method. The analytic analysis of the quantitative study included Pearson's correlations and hierarchical linear regression model to assess the explanatory variables to absenteeism and staff turnover. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies.

RESULTS

The qualitative part identified three themes and nine sub-themes, including the new variable 'sense of being alone'. The quantitative part of the study found that nurses expressed a medium level of second victim related distress. After controlling for demographic variables, second victim distress and the sense of being alone following patients' suicidal events may explain nurse absenteeism and turnover.

CONCLUSIONS

Nurses who experience suicidal attempts of their patients react as second victims. These symptoms lead to nurse absenteeism and turnover.

RELEVANCE TO CLINICAL PRACTICE

Nurses who experience suicidal attempts of their patients need treatment and support as second victims, the same as in any other medical adverse event. The nursing leadership should emotionally support these nurses and prevent consequential staff organisational problems.

Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: An exploratory cross-sectional study

BACKGROUND

A patient safety incident (PSI) is considered to have an impact on nursing students. Healthcare professionals often feel personally responsible for the unexpected patient outcome and feel as though they have failed their patient. In this way they may become second victims of the incident. Little is known about possible initiatives from hospitals or teaching institutions regarding the support of their students involved in a PSI.

AIM

The study aims to examine the prevalence, symptoms and support in the aftermath of a PSI in baccalaureate nursing students.

METHODS

A cross-sectional study in four teaching institutions for baccalaureate education across eleven campuses in Belgium. Students completed an online survey between February 2018 and March 2018.

RESULTS

About one in three (38.4%) students were involved in a PSI during their clinical experience. Of these, 84.7% experienced second victim symptoms. Most common symptoms were hypervigilance (65.7%), stress (42.5%) and doubting knowledge and skills (40.6%). Besides negative effects, the PSI also led to a more positive attitude. Students expect most support and room for open discussion from staff nurses (80.8%).

CONCLUSION

Nursing students may already become second victims during their education. PSIs have a major impact on their performance and personal life. Students have the right for a decent treatment, respect, understanding and compassion, support, transparency and the opportunity to contribute to improving procedures. Teaching institutions should therefore bear the responsibility to prepare students of the probability of the occurrence of PSIs during their clinical experience.

Strategies to support health professionals in the condition of second victim: scoping review

OBJECTIVE

To map and analyze the knowledge produced about strategies aimed at promoting support to health professionals in the condition of second victim.

METHOD

Scoping review, developed in portals, databases and academic websites, whose inclusion criteria were articles and materials indexed in the respective search sites, between January 2000 and December 2019, in Portuguese, English and Spanish. The findings were summarized and analyzed based on descriptive statistics and narrative synthesis.

RESULTS

A total of 64 studies were included, 100% international; 92.2% in English and 50% from secondary research. The support strategies were grouped into four categories and most of the studies referred to the use of the forYOU, Medically Induced Trauma Support Services and Resilience in Stressful Events programs and the interventions represented, through dialogue with peers, family, friends and managers.

CONCLUSION

Support strategies for the second victim are pointed out in international studies and mostly developed through programs/services and interventions. It is recommended to develop studies to learn about the phenomenon and to structure feasible support strategies in Brazilian health organizations.

Nurses' experiences of patient safety incidents in Korea: a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the scope and severity of the second victim problem among nurses by examining the experiences and effects of patient safety incidents (PSIs) on them.

PARTICIPANTS/SETTING

492 nurses who had experienced PSIs and provide direct care in South Korean medical institutions.

DESIGN

A cross-sectional study with anonymous online self-report questionnaires was conducted to nurses in order to examine the experiences and effects of PSIs. Scales measuring post-traumatic stress disorder (PTSD) and post-traumatic embitterment disorder (PTED) were used for a more quantitative examination of the effects of PSIs. A χ2 test was administered to find any difference in responses to difficulties due to PSIs between the direct and indirect experience of PSIs. Furthermore, linear regression analysis was conducted to investigate the factors related to scores on the PTSD and PTED scales.

RESULTS

A statistically significant difference was observed for participants who reported having experienced sleeping disorders, with those with direct experience showing 42.4% sleeping disorders and indirect experience at 21.0%. Also, there was a statistically significant difference between the 34.3% with direct experience and the 22.1% with indirect experience regarding having considered duty or job changes (resignation). Regression analysis showed total PTSD scores for indirect experience at 11.97 points (95% CI: -17.31 to -6.63), lower than direct experience. Moreover, those who thought the medical error was not involved in PSI had a total PTED score 4.39 points (95% CI: -7.23 to -1.55) lower than those who thought it was involved.

CONCLUSIONS

A considerable number of nurses experienced psychological difficulties due to PSIs at levels that could interfere with their work. The effect of PSIs on nurses with direct experience of PSIs was greater compared with those with indirect experience. There need to be psychological support programmes for nurses to alleviate the negative effects of PSIs.

Second Victim Experience and Support Tool: Persian translation and psychometric characteristics evaluation

BACKGROUND

Healthcare providers involved in an unexpected adverse patient safety event are affected by negative outcomes of the event and are called 'second victims'. The Second Victim Experience and Support Tool has been introduced as a reliable and valid measure to assess the second victim responses and to support recourses of healthcare professionals.

AIM

The core objective of this survey was to assess the psychometric attributes of the scale within Iranian nurse.

METHODS

Having translated the scale based on the WHO guidelines and assessing its face validity, a board of 8 specialists assessed the content validity of the measure. In order to assess the psychometric characteristics of the questionnaire, a survey was conducted in 5 university-affiliated hospitals of Urmia. Confirmatory factor analysis is adopted to assess the construct validity. The internal consistency and test-retest reliability of the scale were determined.

RESULTS

The Persian version of the scale consists of 29 items and 9 subscales. Confirmatory factor analysis illustrated that the scale reflects a foolproof construct validity. Cronbach α coefficients revealed the reliability of the scale (0.68-0.88).

CONCLUSIONS

The survey proves to be a reliable and valid measure to evaluate the second victim responses and conceivable support resources of Iranian nurses or other Persian-speaking healthcare professionals of the region.

IMPLICATIONS FOR HEALTH POLICY AND PRACTICE

Health policymakers ought to build up large-scale surveys to determine the degree of second victimization of healthcare professionals so as to offer suitable support systems. Taking the scale into account would improve evaluation of the benefits of second victim support initiatives in nursing practice.

Second victim phenomenon: Is 'just culture' a reality? An integrative review

BACKGROUND

Despite rigorous and multiple attempts to establish a culture of patient safety and a goal to decrease incidence of patient deaths in the health care, estimations of preventable mortality due to medical errors varied widely from 44,000 to 250,000 in hospital settings. This magnitude of medical errors establishes patient safety as being at the forefront of public concerns, healthcare practice and research. In addition to the potential negative impact on patients and the healthcare system, medical errors evoke intense psychological responses in health care providers' responses that threaten their personal and professional selves, and their ability to deliver high quality patient care. Studies show half of all hospital providers will suffer from second victim phenomena at least once in their careers. Health care institutions have begun a paradigm shift from blame to fairness, referred to as 'just culture'. 'Just culture' better ensures that a balanced, responsible approach for both providers who err and healthcare organizations in which they practice, and shifts the focus to designing improved systems in the workplace.

OBJECTIVES

The aim of this review was to identify: how medical errors affect health care professionals, as second victims; and how health care organizations can make 'just culture' a reality.

DESIGN

An integrative review was performed using a methodical three-step search on the concept of second victims' perceptions and responses, as well as 'just culture' of health care institutions.

RESULTS

A total of 42 research studies were identified involving health care professionals: 10 qualitative studies; eight mixed-method studies; and 24 quantitative studies. Second victims' perceptions of the current 'just culture' included: 1) fear of repercussions of reporting medical errors as a barrier; 2) supportive safety leadership is central to reducing fear of error reporting; 3) improved education on adverse event reporting, developing positive feedback when adverse events are reported, and the development of non-punitive error guidelines for health care professionals are needed; and 4) the need for development of standard operating procedures for health care facility peer-support teams.

CONCLUSIONS

Second victims' perceptions of organizational and peer support are a part of 'just culture'. Enhanced support for second victims may improve the quality of health care, strengthen the emotional support of the health care professionals, and build relationships between health care institutions and staff. Although some programs are in place in health care institutions to support 'just culture' and second victims, more comprehensive programs are needed.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

OBJECTIVE

The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations.

METHOD

We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases.

RESULTS

An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed.

CONCLUSIONS

The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

Supporting staff who are second victims after adverse healthcare events

Healthcare delivery is challenging and complex, At some point, most healthcare professionals, including nurses, will be directly or indirectly involved in adverse events, such as medication errors, patient safety incidents, witnessing adverse events and near misses. While the patient is considered the first and most important 'victim' of such events, the healthcare professional involved is often considered the 'second victim'. Second victims often experience negative psychological effects due to the event, may feel they have failed the patient and can doubt their clinical skills and knowledge base. This may lead to absenteeism and their leaving their profession. This article explores the concept of healthcare professionals as second victims, as well as the effects of adverse events on these individuals, their managers and healthcare organisations. It also details the investigation process, the healthcare professional's legal and professional responsibilities after an adverse event, and the resources and services available to support second victims.

Second victims and mindfulness: A systematic review

Second victims are healthcare professionals who have been involved in an unanticipated clinical event or medical error and are negatively impacted on professional and/or personal levels. One of the most prevalent symptoms second victims endure is stress, which correlates with burnout and powerlessness. These symptoms may deeply impact second victims on professional and personal levels, but can also influence healthcare organizations. Distracted and stressed clinicians can possibly create a medical error and are at an increased risk to leave their chosen profession or institution. The purpose of this systematic review is to evaluate the literature pertaining to the second victim phenomenon and the effect of mindfulness-based interventions on perceived symptoms. PubMed, CINAHL, Scopus, and Google Scholar were used to conduct this literature search. There were 23,294 articles for consideration, after the original search. The review identified n = 15 publications as meeting inclusion requirements. These studies indicated that mindfulness-based interventions positively impact stress, burnout, and self-compassion. Future research is needed to establish mindfulness-based interventions effectiveness on second victims.

Dead on the table: A theoretical expansion of the vicarious trauma that operating room clinicians experience when their patients die

The practice of operating room (OR) clinicians - nurses, surgeons, and anesthetists - is fundamentally about preserving life. Some patients, however, die in the OR. Clinicians are therefore vulnerable to moral and emotional trauma. In this paper, we discuss three forces that shape clinicians' moral and emotional experiences in OR care: biomedical values, normative death discourse, and socially (un)sanctioned grief. We suggest how each of these forces increases clinicians' vulnerability to feel traumatized when their patients die. We hope this discussion will stimulate clinicians and researchers to engage with social and cultural determinants of clinicians' experiences when patients die.

Nurses' rights of medication administration: Including authority with accountability and responsibility

Medication errors continue to occur too frequently in the United States. Although the five rights of medication administration have expanded to include several others, evidence that the number of errors has decreased is missing. This study suggests that medication rights for nurses as they administer medications are needed. The historical marginalization of the voice of nurses has been perpetuated with detrimental impacts to nurses and patients. In recent years, a focus on the creation of a just culture, with a balance of accountability and responsibility, has sought to bring a fairer and safer construct to the healthcare environment. This paper proposes that in order for a truly just culture to exist, the balance must also include nurses' authority. Only when a triumvirate of responsibility, accountability, and authority exists can an environment that supports reduced medication errors flourish. Through identification and implementation of Nurses Rights of Medication Administration, nurses' authority to control the administration process is both formalized and legitimized. Further study is needed to identify these rights and how to fully implement them.

Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review

BACKGROUND

Second victims are clinicians who have made adverse errors and feel traumatized by the experience. The current published literature on second victims is mainly representative of doctors, hence nurses' experiences are not fully depicted. This systematic review was necessary to understand the second victim experience for nurses, explore the support provided, and recommend appropriate support systems for nurses.

OBJECTIVES

To synthesize the best available evidence on nurses' experiences as second victims, and explore their experiences of the support they receive and the support they need.

INCLUSION CRITERIA PARTICIPANTS

Participants were registered nurses who made adverse errors.

PHENOMENA OF INTEREST

The review included studies that described nurses' experiences as second victims and/or the support they received after making adverse errors.

CONTEXT

All studies conducted in any health care settings worldwide.

TYPES OF STUDIES

The qualitative studies included were grounded theory, discourse analysis and phenomenology.

SEARCH STRATEGY

A structured search strategy was used to locate all unpublished and published qualitative studies, but was limited to the English language, and published between 1980 and February 2017. The references of studies selected for eligibility screening were hand-searched for additional literature.

METHODOLOGICAL QUALITY

Eligible studies 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).

DATA EXTRACTION

Themes and narrative statements were extracted from papers included in the review using the standardized data extraction tool from JBI QARI.

DATA SYNTHESIS

Data synthesis was conducted using the Joanna Briggs Institute meta-aggregation approach.

RESULTS

There were nine qualitative studies included in the review. The narratives of 284 nurses generated a total of 43 findings, which formed 15 categories based on similarity of meaning. Four synthesized findings were generated from the categories: (i) 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; (ii) 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; (iii) 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; and (iv) 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 (see "Summary of findings").

CONCLUSION

Adverse errors were distressing for nurses, but they did not always receive the support they needed from colleagues. The lack of support had a significant impact on nurses' decisions on whether to disclose the error and his/her recovery process. Therefore, a good support system is imperative in alleviating the emotional burden, promoting the disclosure process, and assisting nurses with reconciliation. This review also highlighted research gaps that encompass the characteristics of the support system preferred by nurses, and the scarcity of studies worldwide.

Distracted Practice: A Concept Analysis

PROBLEM

Distracted practice is a growing concern for all healthcare professionals working in today's complex, technology-rich, acute care hospital environment. Distractions are a threat to patient safety, frequently cited as a contributing factor when reporting an adverse event. The number of new technologies introduced to the healthcare environment has significantly increased the number of distractions. Shrinking resources and the resultant time pressure placed on all practitioners has added to the list of human factors known to be contributing to potential errors. Delivering safe, quality care in this environment has now become a daily challenge for all members of the healthcare team. Distracted practice was found to have no consistent definition in the healthcare literature.

METHOD

Walker and Avant's method of concept analysis was used to develop a preliminary definition and model of distracted practice.

FINDINGS

This analysis includes a definition, characteristics, antecedents, and consequences of distracted practice.

CONCLUSION

More research is needed to fully understand this critical human experience of distracted practice. With additional knowledge we will be able to raise awareness and create interventions to reduce its occurrence among members of the healthcare team. This will positively contribute to the team's efforts to keep all our patients safe while in the hospital. D'Esmond.

Simulation and psychology: creating, recognizing and using learning opportunities

PURPOSE OF REVIEW

Psychology is relevant for improving the use of simulation in anesthesiology, as it allows us to describe, explain and optimize the interactions of learners and instructors as well as the design of simulation scenarios and debriefings. Much psychological expertise is not used for simulation in healthcare. This article aims to help bridging the gap between professions.

RECENT FINDINGS

The evidence is building that simulation is effective for learning. Recent psychological work improves the understanding of why this is the case - or why not. Publications range from the elements to be simulated, to optimizing the presentation of scenarios and debriefings to an organizational overview of how simulation can contribute to patient safety, healthcare worker well-beings and quality of care. The psychological analysis helps in capturing the salient characteristics of the tasks to be simulated and in implementing them in a relevant learning setting.

SUMMARY

Using psychology in simulation allows us to create, recognize and use learning opportunities. The motivations of those involved can be taken into account and the simulation activity can be channeled into a goal-oriented direction.

VIDEO ABSTRACT AVAILABLE

See the Video Supplementary Digital Content 1 (http://links.lww.com/COAN/A26).

Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting: implications for curricula

Since the Institute of Medicine's landmark report on medical mistakes, To Err Is Human, was published, considerable attention has been given to training medical professionals about medical mistakes. However, little research has been conducted to explore the experiences of nursing students with mistakes made during their clinical rotations. If nurse educators are to teach nursing students how to deal with mistakes appropriately, it is necessary to have a more complete understanding of the types of mistakes nursing students make during their training, how and if they communicate about their mistakes, and students' perceptions of how prepared they were to address the mistakes. Greater knowledge in this area will help nurse educators better prepare nursing students to intercept and report mistakes. This article presents research results from three components of a larger qualitative research study that explored the socialization processes of nursing students in regard to medical mistakes.