Assessing safety culture and second victim experience following adverse events among Romanian nurses: a cross-sectional study

The definition of adverse events (AEs) in healthcare can differ significantly across institutions and studies. For instance, the National Health System (NHS) in the United Kingdom defines it as “any unintended or unexpected occurrence that could potentially harm or has harmed one or more patients receiving NHS-funded healthcare,” thus encompassing incidents that cause no harm or near misses [1]. In contrast, the Harvard Medical Practice Study defines it as an injury resulting in prolonged hospitalization, disability, or death caused by healthcare management rather than the underlying disease [2]. For the purpose of this study, we utilized the definition provided by the World Health Organization, which states that an AE is defined as an incident that causes harm to a patient and is an unexpected and unintentional clinical outcome of healthcare. This outcome may or may not be related to a clinical error [3]. For serious AEs, we employed the classification proposed by Field et al. [4].

The emphasis in healthcare management is placed on fostering a safety culture that learns from AEs, alongside the significance of systematic methods for identifying and measuring these occurrences [2]. AEs encompass a range of occurrences, including medication errors, surgical complications, and healthcare-associated infections [5]. Medication-related AEs, also known as adverse drug reactions, are particularly prevalent and can affect various body systems, including the central nervous, gastrointestinal, and cardiovascular systems [6]. The occurrence of AEs has a significant impact on patient safety and the overall quality of care [7]. AEs have significant implications, as well, at the macro level, impacting the effectiveness of medical care safety management systems. These events can lead to prolonged hospitalization, disability, and increased healthcare costs. Addressing adverse events at the community care level requires policy changes and improved collaboration and communication among providers [8].

Safety culture in healthcare is defined as the shared values, attitudes, perceptions, and behaviors of individuals and groups within an organization that determine their commitment to health and safety management [9]. It encompasses the collective commitment to safety at all levels of an organization, influencing how safety is prioritized and managed [9, 10, 11]. Key components of a robust safety culture include leadership and accountability, where leaders actively promote safety as a core value; teamwork and communication, which are essential for identifying and addressing safety issues promptly; learning and improvement, which involves learning from past incidents and implementing changes to prevent future occurrences; a just culture that balances accountability with a non-punitive approach to error reporting; and patient-centered care, ensuring that patient safety is at the forefront of care delivery [9, 12]. Various factors, such as working hours, night shifts, and days off, can impact safety culture by affecting staff perceptions and behaviors toward safety [11]. The current literature [13] underscores the importance of nontechnical skills such as effective communication and teamwork in improving patient safety. These skills are essential for creating a safety culture and improving patient outcomes. Tools like the Hospital Survey on Patient Safety Culture and the Safety Attitudes Questionnaire (HSPSC) are commonly used to assess safety culture, helping organizations identify areas for improvement [14, 15].

Existing literature consistently shows that AEs can exact a substantial emotional toll on healthcare professionals [16], particularly in environments lacking feedback mechanisms or adequate organizational support [17]. Following an AE, apart from the primary victim—the patient (referred to as the first victim)—a second victim emerges, namely, the healthcare professional affected by the incident [18]. There are several definitions of the term “second victim” [19]. The ERNST consortium recently finalized a revised definition, characterizing a second victim as “Many healthcare workers, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error, or patient injury, and becomes victimized in the sense that also the worker is negatively impacted” [20]. These individuals, often directly involved in the event or its aftermath, can suffer from a range of psychological and physical symptoms [21]. Such symptoms can significantly impact their professional performance and personal well-being [22, 23]. Robertson et al. [24] and Sirriyeh et al. [25] have highlighted negative emotions such as guilt and shame, anxiety, and self-doubt that can lead to burnout and deficient performance. Other studies [26] also emphasize feelings of helplessness, sadness, fear, and blockage that can lead to post-traumatic disorder. The psychological impact of adverse events may lead to attrition and absenteeism, highlighting the importance of meeting the needs of the second victim [27]. Various factors can influence the risk that healthcare professionals, including nurses, become second victims. These include their proximity to the patients, direct patient-care responsibilities, communication roles, and team dynamics [28].

Adverse events in healthcare settings significantly impact nurses, often leading to the “second victim” phenomenon, characterized by emotional distress following an adverse event [29, 30]. Nurses report psychological distress, including anxiety, depression, and post-traumatic stress symptoms [29, 31]. These events contribute to burnout, impacting patient care and potentially increasing future adverse events [32]. Professionally, adverse events are linked to increased stress, reduced job satisfaction, and higher turnover intentions [33, 34]. As second victims, nurses also experience the consequences of these events, including psychological trauma, emotional reactions, self-confidence issues, and professional performance. All these highlight the necessity for organizational support [35].

Furthermore, fostering a nonpunitive safety culture is crucial in reducing the distress experienced by second victims [23]. To avoid a narrow focus on individual blame, it is important to understand the role that cognitive biases play in adverse events [36]. A structured and blame-free approach is needed to respond to errors, focusing on preventing future occurrences [37]. The importance of nurses reporting adverse events is acknowledged; however, there is a fear of retaliation and the need to review the patient safety culture [38]. Healthcare organizations increasingly need support structures, including peer support programs, to address this issue [39]. Recognizing the impact on healthcare providers, there is a growing emphasis on the need for structured support programs [40]. These programs aim to help second victims cope with the aftermath of adverse events by fostering coping strategies and promoting resilience among affected staff [41]. Organizational strategies highly valued by nurses include peer support and second-victim support programs, which are crucial for coping and recovery [31, 42]. Implementing effective psychosocial peer support programs and linking patient safety measures to second-victim support are recommended [42]. Many healthcare organizations have implemented peer support programs, such as the RISE program at Johns Hopkins Hospital, which provides emotional support through trained peer responders [40, 43]. The “forYOU” model, used in a University Hospital in Spain, offers a tiered support system based on the severity of emotional distress. This model has been effective in increasing the visibility of support actions and fostering a culture of patient safety [44]. To prevent healthcare professionals from becoming second victims, providing immediate support and implementing institutional programs to facilitate recovery and minimize career consequences is important [45]. Creating a supportive environment and reporting culture can also help this prevention effort [46].

International studies have examined patient safety culture in healthcare settings across Europe, including a specific focus on Eastern Europe and Romania. A systematic review of 62 international studies using the HSPSC revealed a growing trend in assessing patient safety culture across Europe. However, it emphasized the need to carefully adapt the HSPSC to local contexts [47]. A study of hospitals in Croatia, Hungary, Spain, and Sweden found that teamwork was generally positive, but staffing and workload needed improvement. Sweden reported the best perceptions of safety culture, while Croatia, Hungary, and Spain ranged from adequate to poor. It highlighted inconsistencies between perceived and actual safety practices, suggesting that national culture, organizational practices, and health system structures affect safety culture perceptions [48].

Research on the second victim phenomenon (SVP) among nurses in the European Union highlights the prevalence, causes, and coping strategies associated with this experience. In Germany, 60% of nurses reported experiencing the SVP at least once in their careers, with aggressive behavior by patients being a significant cause [49]. In Austria, intensive care nurses frequently reported feelings of guilt and sleep disturbances as symptoms of SVP [42]. In obstetrics and gynecology, 47.8% of nurses reported feeling like a second victim during their careers, with clinical and non-clinical events triggering these experiences [50].

In Romania, the COVID-19 pandemic exacerbated these challenges, with nurses facing significant moral injuries, burnout, and increased turnover intentions [51]. Romanian healthcare workers experienced high levels of burnout and depression [52] and lower resilience and quality of life [53].

A study in Romania evaluated the culture of patient safety within anesthesia and intensive care departments. While the overall perspective was positive, notable differences were observed between tertiary and secondary hospitals. The study used a Romanian version of the HSPSC [54]. Another Romanian study explored the psychometric properties of the HSPSC, suggesting that while the survey was generally reliable, some composites needed adjustment to better fit the Romanian context [55]. In the Republic of Moldova, a study using the Romanian translation of the HSPSC identified teamwork and management support as strengths, while staffing and communication openness needed improvement [56].

In Romania, research on adverse events and second victims, as well as patient safety, is very limited. Pan-European research identified these gaps, emphasizing the well-being and impact of healthcare professionals on patient safety [57]. Literature shows that there is scarce research about patient safety in Romania [58]. This highlights the need for research initiatives to generate evidence, raise awareness, propose appropriate policies, and facilitate international collaboration to develop and implement initiatives on patient safety. On September 15, 2015, Romania advanced its PSC by establishing the National Authority for Quality Management in Health (ANMCS), which aims to implement quality assurance mechanisms, accredit healthcare providers, enhance patient safety, and improve medical quality [59]. The National Patient Safety Council was established on February 23, 2021, to promote quality and patient safety in healthcare, research service delivery quality, and provide training programs on PSC [60]. Comprehending the impact of adverse incidents on team dynamics and exploring resilience and coping techniques employed by healthcare professionals is crucial for developing targeted intervention and support systems [27].

This study aimed to assess the PSC among Romanian nurses using a cross-sectional survey, focusing on their experiences with AEs and the second victim phenomenon. Specifically, we sought to (1) evaluate nurses’ perceptions of safety culture, (2) quantify experiences with AEs as reported in the survey, (3) characterize the impact of the second victim phenomenon, and (4) identify associations between safety culture dimensions and the likelihood of AEs or second victimhood. By integrating international evidence on AEs and healthcare providers, this research situates Romania in the global patient safety discourse and provides insights for targeted interventions.

Adverse events in healthcare can have a devastating impact on nurses, leaving them reeling with feelings such as guilt, shame, and anxiety [35]. Furthermore, adverse events can damage confidence, job satisfaction, and well-being while straining organizational relationships [68]. Frequent exposure to traumatizing events among emergency nurses may lead to posttraumatic stress symptoms that impact both their well-being and the quality of care provided, potentially leading to an increased need for defensive practices and the heightened risk for certain patients [69]; fear of legal consequences could prevent nurses from reporting adverse incidents, highlighting the need for legal regulations to address this issue [70]. The findings of this study highlight the significant impact of patient safety incidents on nurses in Romania and the need for comprehensive support and regulatory measures in healthcare settings. Figure 1 illustrates the primary findings of the study.

This research began as an effort to assess the impact of adverse events on healthcare professionals in Romania. However, since nurses dominated participation, responses from other categories were ultimately excluded, and the primary focus of the research shifted to exploring nurses’ perceptions regarding such events and their relationship with PSC. This indicates a potential need to address and improve the overall safety culture within healthcare settings to ensure the well-being of both healthcare professionals and patients. Our findings align with the ERNST Policy Statement, supporting its call for systemic changes to address the second victim phenomenon [71]. The correlation between a positive safety culture and reduced emotional distress among Romanian nurses provides empirical evidence for ERNST’s recommendations. The identified need for specific training emphasizes the global movement towards open disclosure and robust support systems.

Our study identified notable variations in safety culture and second-victim experiences across medical, surgical, and other departments. These variations likely stem from a confluence of factors, including the nature of work, team dynamics, communication patterns, types of adverse events, and existing safety protocols, each of which can differ substantially between departments. In surgical settings, diverse communication styles are observed, ranging from proactive to ambiguous, influenced by procedural complexity [72, 73]. Strong relational coordination, characterized by mutual respect and effective communication, enhances psychological safety and learning from mistakes, contributing to a robust safety culture [73, 74]. Surgical departments face unique challenges from adverse events like surgical site infections and technical failures [75]. Crew Resource Management (CRM) has shown promise in these settings by improving communication and reducing patient morbidity [74].

Medical departments exhibit close links between team dynamics, care coordination, and perceptions of safety culture [76]. Adverse drug events and healthcare-associated infections are prevalent in these settings [77, 78]. For example, emergency departments benefit from structured communication training like TeamSTEPPS and CRM, which improves teamwork and communication [72]. The emotional toll of adverse events is significant across all departments, with healthcare professionals often experiencing anger, guilt, and anxiety [79]. Implementing tailored safety training programs that incorporate simulation interdepartmental collaboration and address the specific needs of each department is crucial [72, 80]. For example, programs that improve relational coordination and psychological safety might be most effective in surgical settings [73, 74]. In contrast, those focusing on team dynamics and care coordination are essential in medical departments [76]. These insights highlight that healthcare organizations should prioritize department-specific safety protocols and training. Surgical departments could benefit from expanded CRM training, while medical departments should enhance team dynamics and care coordination. All departments must foster psychological safety, allowing professionals to address the emotional toll of adverse events and learn from mistakes.

Patient safety incidents were widespread among participants; over half reported witnessing or hearing of near-miss incidents that highlighted ongoing challenges within healthcare environments. A significant presence can also be found within “Other” departments (besides the Medical and Surgical departments), illustrating their wide diversity within this sample population. The symptoms observed in this study are consistent with findings from other European studies [17], including the need for time off work. This similarity in symptoms and outcomes underscores the universality of the impact of adverse events on healthcare professionals across different regions and healthcare systems. It also emphasizes the importance of developing standardized support systems and interventions to address these challenges effectively and promote the well-being of healthcare workers worldwide.

Our study highlights a discrepancy between the low reported rate of adverse events (30% among nurses in five years) and high patient safety culture scores, contrasting with higher international estimates [77, 81, 82]. This suggests significant underreporting, potentially due to a positive safety culture paradoxically hindering reporting because of fear of negative impacts or unclear definitions of reportable events. This is supported by the Romanian Health Observatory’s finding that 42% of Romanian healthcare facilities reported zero adverse events in a year, indicating systemic underreporting [83]. Their data also highlighted issues like inadequate infection prevention compliance, mirroring our findings in surgical departments. The Observatory’s data showed over 5,800 cases of healthcare-associated infections in 2019 and 2020, over 1,300 medical errors resulting in patient injury, and 128 deaths due to medical errors, indicating a significant underreporting of adverse events compared to our findings [83]. Thus, while crucial, a high safety culture score alone does not guarantee accurate reporting or a safer environment in the Romanian context.

Assessments of PSC revealed a positive perception among the surveyed nurses. While age differences exist, nurses over 50 scored higher, and an overall high mean score indicates positive perceptions about safety culture among all nurses surveyed. Surgical departments showed statistically significant strengths, such as having anonymous incident reporting systems or conducting systematic analyses after serious adverse events that can be leveraged further for improvement. These findings indicate areas of strength within the safety culture but also offer opportunities for improvement. They underscore the positive perception of safety culture among nurses surveyed, identify specific strengths in surgical departments, and point to areas where enhancements can be made to strengthen patient safety practices and the culture of healthcare organizations.

Regarding their perceptions of adverse events within 12 months following survey completion, most nurses reported an extremely low or very low likelihood. Their perspectives did not vary significantly according to safety culture scores or department types; instead, they demonstrated awareness of potential adverse events within their departments that were consistent across medical and surgical staff. The quality of care provided by these personnel could be impacted by the stress caused by safety incidents among the professionals and their vigilance in anticipating new occurrences. Addressing these incidents during briefings at the start of shifts can promote the normalization of such situations and enhance patient safety. Numerous ongoing studies have investigated PSC in hospitals from the perspectives of nursing professionals. Yavuz [84] found that surgical nurses surveyed perceived the PSC as a medium, with highly positive responses in “Teamwork within Units.” However, positive responses were lower on the “non-punitive response to errors” subdimension, indicating a need for improvements in error reporting and management practices. Other researchers also highlighted the significance of professional satisfaction, dialogue, and support from management in maintaining patient safety [85]. Areas for improving PSC were identified [86], including staffing levels, response to errors without punitive actions being taken, as perceptions of management support and perceptions of teamwork in hospitals. These findings confirm the necessity of ongoing efforts to strengthen safety cultures and emphasize teamwork, error reporting, psychological safety, and management support.

The open disclosure experience analysis demonstrates the devastating impact of adverse events on healthcare professionals, with surgical departments reporting higher frequencies of near misses and adverse events with potentially serious outcomes than others. Notably, nurses working in surgical departments reported significantly higher incidences of work-related problems caused by adverse events. The legal framework in some European countries can present challenges that limit healthcare professionals’ decisions to inform patients about adverse events. For example, in Denmark, there may be legal barriers or uncertainties regarding disclosing adverse events to patients, leading to hesitation or reluctance among healthcare providers to communicate openly with patients about such incidents [87].

Furthermore, the strength of safety culture inversely correlated with reporting near misses, suggesting its potential protective role. Studies have illustrated the severity of adverse events on healthcare professionals, mainly within surgical departments [88]. Recent studies from 2021 [89] reported that an ideal safety culture could predict higher intentions to report near misses; its components, such as communication openness and teamwork, proved significant predictors. Kim [90] highlighted the significance of ethical awareness and PSC as key enablers for encouraging open disclosure of patient safety incidents. Other studies [89] identified several barriers to reporting near misses in laparoscopic surgeries, such as heavy workload, privacy concerns, lack of support, and fear of disciplinary actions as barriers for reporting near misses. These findings highlighted the necessity of creating a supportive safety culture and developing effective strategies that address these obstacles to improve patient safety.

Ample evidence exists for targeted nursing support and education regarding adverse events and communicating these incidents to patients, demonstrating their high interest. This interest was consistent across medical, surgical, and other departments. Umpierrez [91] and Goniewicz [92] highlight the value of training programs in improving nurses’ communication skills and self-efficacy, specifically noting the need to empower human resources and strengthen recruitment systems, with Goniewicz [92] emphasizing work experience, workplace preparation, and disaster response training as essential components of improving nurses’ competencies. Their findings reinforce the need for targeted support and education in these vital areas.

Overall, this study offers valuable insights into the demographic profile, patient safety incidents, safety culture perceptions, and open-disclosure experiences of nurses in Romania. The results highlight the necessity of ongoing efforts to strengthen safety cultures by taking account of age-related variations and specific departmental needs.

Data in the present study suggest that these efforts can be directed along three main pathways. Firstly, training opportunities, both initial education and ongoing professional development, should be enhanced. Institutions can better prepare their staff to respond to and manage complex situations or unexpected challenges by offering initial training and continuous educational programs. Moreover, these initiatives enhance a culture of open dialogue with patients, highlighting the importance of transparent communication and mutual understanding in delivering high-quality care. Through ongoing training, professionals can continuously refine their skills, be up to date with the latest practices in the field, and cultivate a patient-centered approach to healthcare delivery.

Secondly, developing and implementing policies that uphold the standards and quality of the medical act and ensure patient safety. Development or improvement of such policies could include clinical practice guidelines to provide evidence-based recommendations, medication safety policies to avoid errors in prescribing and administration, infection control protocols, and incident reporting policies.

Lastly, a legal framework regarding adverse events and second victims in healthcare should be developed to clarify and guide legal responsibilities and liabilities, offer protection for healthcare professionals and patients, and foster a blame-free culture. It would also be beneficial to standardize procedures on reporting, investigating, and addressing adverse events, promoting transparency and accountability within healthcare settings, and ensuring that second victims receive appropriate support to cope with the psychological and professional impact of AEs. Moreover, it contributes to a more robust and resilient healthcare system by fostering a culture of learning and improvement, facilitating the analysis of root causes, and implementing preventive measures to ensure patient safety, which is also emphasized in the ERNST Policy Statement [71].