Investigating the status of the second victims of error and related factors in nurses: a description study

Nursing error is one factor that threatens patient safety [1]. According to the World Health Organization report, the frequency of medical errors in different countries is between 3.2% and 16.6%, and 14% of these errors lead to death and 70% lead to various disabilities [2]. The studies reported that the rate of medical mistakes in Iranian hospitals was between 42% and 60%. Nurses are responsible for patient care. The prevalence of errors among nurses is wide [3, 4]. The prevalence rate of nurse errors in Iran has also been reported to be 43.73–79% [5]. Numerous studies in Iran have linked these errors to organizational and individual factors, excessive workloads, staff shortages, and economic challenges [6‐8]. The majority of these errors were preventable [8].These errors can result in extended hospital stays, mortality, disabilities, escalated treatment expenses, diminished trust, and patient dissatisfaction with the healthcare provider system, ultimately placing substantial financial burdens on the service provider system [9].

Besides impacting patients, errors can influence nurses [2]. These effects include emotional and psychological problems such as sleep disorders, anxiety and fear, being overly cautious, loss of self-confidence, loss of social trust, and damage to reputation, which ultimately increase the likelihood of job burnout and depression [10]. The results of Ajri et al.‘s study on emergency department nurses in Iran showed that nurses suffer from depression, anxiety, and remorse after experiencing errors with patients [11]. Healthcare providers who experience an adverse event or error may show symptoms of shame and blame and, as a result, experience the second victim phenomenon [12].

The phenomenon of the second victim of error impacts healthcare personnel physically and mentally [13]. Damage caused by an adverse event leads to harmful consequences for their personal and professional lives [9]. Second, victims of the error report different symptoms and consequences. These symptoms include guilt, anger, shame, and, in some cases, concern about punishment, job loss, and litigation. The final results of these symptoms are a decrease in job confidence and job satisfaction and an increase in stress in the second victim [14, 15]. A study by Nydoo et al. (2020) showed that the effects of an adverse medical event for second victims of error are dire, and many of them experience feelings of sadness, guilt, and anxiety. Some nurses also show symptoms of post-traumatic stress [9]. Second victims of error are related to job burnout, the tendency to leave the job, and absenteeism from the workplace [16]. Ajudani et al.‘s study (2021) on a sample of medical center employees in Urmia City (Iran) showed a relationship between the dimensions of the phenomenon of second victims of error and the mental distress index [13].

A systematic review study on the second victim of error showed that 10.4–43.3% of nurses suffer from the second victim of error [17]. The prevalence of this phenomenon in the United States is estimated to be between 10 and 60% [18]. Among European countries, the prevalence of the second victim phenomenon varies from 35 to 75% [19]. In Iran, Ajri et al.‘s study shows nurses’ high involvement with the phenomenon of second victims of errors. In this study, nurses reported high stress, remorse, and avoidance behaviors after committing an error [20]. Various factors can affect the intensity of the phenomenon of the second victim of the error. Justice-oriented and support-oriented organizational culture, teamwork culture, general understanding of safety, and openness of communication channels have also been identified as effective organizational and cultural indicators in preventing the complications of the phenomenon of the second victim of error among nurses [21]. Stramets et al.‘s study showed a significant relationship between work history and the phenomenon of second victims of errors. Also, the study of Rubin et al. (2020) showed a significant relationship between the number of errors and the phenomenon of second victims of errors [22]. However, the causes affecting the severity of the phenomenon of second error victims have not been determined exactly [23].

What is seen as a research gap is investigating the second victim of the error phenomenon and related demographic and organizational factors in nurses. The available data have mainly examined the medical errors committed by the centralized nurses, the extent of their prevalence, and their relationship with various factors. Simultaneously, the nurse’s occurrence of a medical error and the emergence of the second victim phenomenon of the error happen concurrently and cannot be separated; according to the review of literature, the issue of the phenomenon of the second victim of error among nurses, who have the highest levels of contact with patients, has not been the focus of researchers’ attention, and identifying factors that influence the second victim phenomenon can reduce its prevalence and severity, enabling nurses to provide safe patient care. Hence, the present study was carried out to investigate the status of the second victim phenomenon of errors and its associated factors among nurses.

This is an analytical-descriptive cross-sectional study conducted in Iran (Ardabil city). Ardabil is a city in northwestern Iran. The study’s statistical population comprises all nurses employed in five teaching hospitals affiliated with Ardabil University of Medical Sciences, totaling 1350 individuals. Cochran’s formula was used to determine the statistical sample size. According to Cochran’s formula (first-level error of 0.5%, confidence level of 95%, population size of 1350, s = 0.48, Z = 1.96, d = 0.05, and 10% attrition.), 330 samples were obtained.

Cochran’s formula

The criteria for entering the study include having at least a bachelor’s degree in nursing, being employed in clinical training centers, not having psychological problems (self-reporting), and verbally expressing willingness to participate. The exclusion criteria in the survey included incomplete filling out of the questionnaires. A simple random sampling method was used to select nurses. Sampling lasted from September 2022 to May 2023.

In this study, three questionnaires of demographic characteristics, a questionnaire of characteristics of previous experience with nursing errors, and the second victim experience and support tool were used to collect data.

The demographic questionnaire included age, gender, work experience, education degree, number of ward beds, history of payment of dowry due to occupational mistakes, and history of going to court for patients’ complaints.

The questionnaire on characteristics of previous nursing error experience is researcher-developed (Persian). This questionnaire includes 11 questions. About awareness of the phenomenon of second victims of error, history of suffering from the phenomenon of second victims of error, history of suffering from the phenomenon of second victims of error in the last 12 months, time of conflict with the phenomenon of second victims of error, type of incident leading to the phenomenon of second victims of error, number of nursing errors in the last 12 months, the number of errors leading to death in the previous 12 months, the number of errors leading to injury in the last 12 months, how to report errors, actions taken after errors occur, and how managers deal with nurses who commit errors. Content and face validity methods were used to determine the validity of the questionnaire based on characteristics of previous nursing error experience, so the questionnaire was given to 10 faculty of nursing and midwifery faculty members. The CVR index of the tool was 0.85%. The tool’s reliability was obtained using Cronbach’s alpha method at 0.76.

The Second Victims’ Experience of Error and Support tool (SVEST) was developed by Burlison et al. in 2017 in the United States. This questionnaire includes 36 items and evaluates 10 subscales, Subscale 10 includes questions 30 to 36 about desired forms of support [24]. Questionnaire items are scored based on a 5-option Likert scale. 1 to 5 points are assigned to the options of “I strongly disagree,” “I disagree,” “I have no opinion,” “I agree,” and “I strongly agree,” respectively. This scoring is reversed for items 12, 14, 16, 17, 18, 20, 21, 22, 24, and 25. To calculate the total score of the second victim of the error phenomenon, the scores of items 1–29 are summed together. The minimum and maximum scores obtained for The Second Victims’ Experience of Error and Support tool are 29 and 145. The level of agreement has been calculated for all 29 questionnaire items about the phenomenon of second victims of error. To calculate the level of agreement, the frequency of responses of the statistical sample to the options “agree” and “completely agree” is summed together algebraically. The reliability of this tool was obtained in the study of Burlison et al. (2017) with Cronbach’s alpha method for the dimensions of the questionnaire in the range of 0.61 to 0.89 [24]. This questionnaire was translated, and psychometric properties were found in the study of Ajudani et al. in Iran. The tool’s reliability with Cronbach’s alpha method was 0.68–0.88 [13]. In this study, the scale’s reliability for all subscales was obtained in the range of 0.66–0.84 using Cronbach’s alpha. Also, the reliability of the whole tool was obtained by Cronbach’s alpha method at 0.81. For data analysis, independent t-tests, One –Way Analysis of variance, and LSD post hoc tests were used. All the studies mentioned were done in SPSS-16 software. The level of significance was considered to be 0.05.

The present study is a research project approved by the research vice chancellor of Ardabil University of Medical Sciences, with the ethics code IR.ARUMS.REC.1401.131. Verbal informed consent was obtained from the samples to participate in the study, and they were assured that their information would be confidential and anonymous. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

330 nurses participated in this study. The mean and standard deviation of the age of the nurses participating in the study were 31.97 ± 6.94 years. Most of the statistical samples studied in this research were female (71.8%). Also, most of them had a bachelor’s degree (85.2%) (Table 1).

The average score of the second victim of error phenomenon is 85.89, with a standard deviation of 10.17 (Table 2). The highest level of agreement was related to mental stress (22.24%), and the lowest was related to colleagues’ support (3.33%).

Based on the results obtained, generally, the forms of support were not highly agreed upon by the nurses participating in the research. In the meantime, the statistical sample introduced a reliable and 24-hour phone line (11.3% desired responses and 62.7% not desired responses) as the most not desired responses form of support. Also, the statistical samples accepted the possibility of leaving the department for a short period (25.5% desired responses and 44.8% not desired responses) as a desired responses form of support and, to some extent, agreed upon (Table 3).

Based on the results obtained from the data analysis, there was a significant relationship between the rate of second victims of error and the history of going to court (p < 0.05). Also, there was a negative and significant relationship between the phenomenon of second error victims and age (p > 0.01 and r = -0.179) and work experience (p > 0.01 and r = -0.156) (Table 1).

According to the results, 80% of the nurses had a history of being the second victim of the error in the past few years. Also, in the last 12 months, 82.4% of the nurses mentioned the history of the phenomenon of the second victim of the error. For 50.9% of nurses, the symptoms of the second victim phenomenon were never resolved.

Based on the results, the incidence of second victims of error has a significant relationship with the number of cases of errors in the last 12 months, having an error leading to injury in the previous 12 months, the way nursing errors are reported, and the way managers deal with nurses’ errors (p < 0.05). Also, there was no significant relationship between how nurses deal with mistakes and the phenomenon of second victims of errors (Table 4).

Based on the results obtained from Table 5 and by examining the LSD post hoc test for inter-group comparison, the rate of the second victim phenomenon was significantly higher in the group that had 10–20 errors in the last 12 months. Also, the rate of second victim phenomenon among nurses who reported their errors to department officials was significantly higher than the other two groups. Furthermore, nurses reprimanded by managers had a substantially higher rate of second-error victims than those trained by managers (Table 5).

The results of the present study were conducted to investigate the Status of the phenomenon of second victims of errors and factors related to it among nurses. They showed that the nurses participating in the study had experienced an average level of the phenomenon of second victims of errors. The study by Jeong et al. (2021) reported the average scores of the experiences of the second victim of the error as average [25].

The studies by Bullion et al. (2021) and Kim et al. (2020), which examined general and internal hospital nurses, align with the findings of the current study [24, 26]. Also, in Huang et al.‘s study (2020), almost 45.26% of nurses mentioned psychological problems after committing a mistake [27]. Also, in the study of Nydoo et al. (2020), it is estimated that half of the healthcare professionals experience the second victim phenomenon at least once in their careers [9]. About 10 to 60% of healthcare professionals experience the second victim phenomenon during their professional lives [28]. Strametz et al. (2021) stated that 35% of nurses experienced second victim phenomenon incidents during the past 12 months. In the current study, most of the damage to the phenomenon of the second victim of the error was related to the psychological dimension, and the least dimension was associated with the support of colleagues [29]. In Jonathan et al.‘s study (2017), the highest rate of the second victim phenomenon was related to psychological damage, and the lowest rate was related to the supervisor’s support [30]. The damage caused by the second victim phenomenon can lead to psychological, cognitive, and physical reactions, but it seems that the most damage is related to the psychological dimension. Nursing error rates may also increase due to the anxiety and stress of experiencing a second victim of error. Therefore, health systems should implement Coherent and regular programs to reduce the phenomenon of the second victim of error, especially in the psychological dimension. Also, in the context of the present study, the lowest score was related to the dimension of colleagues’ support. Colleagues’ support is a multifaceted phenomenon influenced by various factors [31]. Iranian nurses generally support their colleagues but may withhold assistance in situations involving errors or potential threats to their job security [32, 33]. Therefore, it should be achieved by forming close-knit groups of colleagues and enhancing the communication of impersonal relationships to better support each other when errors occur. Additionally, communication and supportive skills should also be taught to nurses.

According to the results of the present study, most of the nurses participating in the research tended to leave their jobs and be absent from work due to the phenomenon of second victims of errors. In the study by Finney et al. (2021), 14.3% intended to change jobs, and 13% experienced a decrease in professional self-efficacy due to the phenomenon of the second victim of the error [34]. Nurses in Iran are less likely to resign from their jobs due to economic problems. In the study of Ajri et al., nurses reported withdrawal reactions from their job duties [11]. Withdrawal from job duties and tended to leave their jobs can reduce the quality of nursing care. Therefore, due to the lack of human resources in the nursing profession and diminish the quality of nursing care, it is recommended that psychological interventions be performed to reduce the complications of the phenomenon of second victims of errors, especially the intention to leave the job and absenteeism.

The results of the present study showed that the symptoms of the phenomenon of the second victim of the error are forgotten too late in some cases, so in the present study, more than 50% of the statistical samples indicated that they never forgot the symptoms of the phenomenon of the second victim and the effects of their mistakes. The 2021 study by Strametz et al. on German nurses showed that the recovery time from the symptoms of the phenomenon of second victims of error is more than one year [29]. The existence of a high number of nursing errors in the last 12 months and not forgetting them causes nurses to always have the fear of repeating these errors. In turn, this way of reacting to errors causes the quality of nurses’ work to be affected by the effects of previous experiences in similar situations. The study conducted by Abbaszadeh et al. (2021) also showed that the impact of errors on nurses could affect their reactions to errors [35]. Therefore, it is recommended that people suffering from the phenomenon of second victims of error use counseling and psychotherapy to help them forget the effects of the second victim of error phenomenon, and hospital management should also try to spread the culture of learning from errors in hospitals.

The results showed that leaving the department briefly was desirable as a form of support. Also, the existence of a reliable 24-hour hotline was the most undesirable form of support. In the study of Chard (2010), it was shown that the most unfavorable support method, according to nurses, was the existence of a 24-hour hotline [34], which was in line with the results of the present study. Also, in the study of Chard (2010), the presence of a reliable colleague and talking to her or him about the incident was the best form of support [34]. In the study of Shoots-Reinhard et al. (2021), the most favorable form of support was related to crisis management, and the worst form of support was associated with leaving the department for a short period [36], which was not consistent with the results of the present study. Due to the reprimanding management atmosphere in the hospitals under study, nurses are less willing to receive support from the healthcare system. In the present study, nurses received little support from non-work-related support. Therefore, enhancing nurses’ willingness to seek support is recommended by fostering a constructive and learning-oriented management atmosphere. Nursing managers and leaders must reach a more comprehensive understanding of nurses’ attitudes toward medical errors and provide the necessary conditions to improve nurses’ attitudes toward reporting errors by supporting nurses and improving the working environment.

The results of this study showed that there is a significant negative relationship between the phenomenon of the second victim of error and the age and work experience of nurses. In the study of Strametz et al. (2021), there was a negative relationship between work experience and the phenomenon of second victims of error [29]. However, the relationship between the variables of age and work experience and the phenomenon of the second victim needs more study. It seems that nurses with a higher age and work experience are less affected by second victims of errors due to the experiences they have gained during their years of service. On the other hand, studies have shown that novice nurses have the highest rate of errors [22, 37]. Therefore, they are more exposed to the phenomenon of error victims. According to the results of the present study, novice nurses should be more closely examined in terms of the phenomenon of the second victim of error.

The results of the present study showed a significant relationship between the rate of second victims of errors and the history of going to court due to errors. In the study of Abbaszadeh et al. (2021), it was shown that referring to the court can affect the experiences of emergency nurses facing mistakes [35]. Also, in the study of Ajri et al. (2021), referring to the court can affect the phenomenon of second victims of the error [38]. In the study of Robin & Romuald (2020), one factor affecting the second victim of the error is legal encounters. In cases where a mistake occurs on the part of a nurses during work and the patient or his companions refer to the court, only the nurse must defend himself, and the hospital where he works does not support the nurse [39]. The totality of these conditions causes nurses to be condemned for their mistakes, which are part of their job, and they always have the stress of repeating these mistakes again. In the study of Teymoorzadeh et al. (2009), legal problems resulting from lawsuits following errors and a lack of legal support were important mental preoccupations of nurses [40]. Therefore, the legal authorities should understand the depth of the nurse’s fear and anxiety in these conditions and deal with the nurse’s case with empathetic answers and psychological support.

The results of this study showed that the number of error cases in the last 12 months affects the second error victim phenomenon. A higher number of errors in the past 12 months correlates with a more severe second-victim phenomenon. In the study of Robin & Romuald (2020), there was also a significant relationship between the number of errors and the rate of second victims of errors [39]. On the other hand, Krommer et al.‘s study (2023) showed that the injury caused by the second victim phenomenon could increase the nursing error rate [41]. There seems to be a two-way relationship between the phenomenon of second victims of errors and the number of errors by nurses. Therefore, it is recommended that nursing managers implement patient safety policies in their treatment systems to prevent the occurrence of errors and the phenomenon of second victims of errors.

This study’s results showed a relationship between the error leading to injury and the phenomenon of the second victim of the error. Li et al. (2019) found a direct relationship between the severity of errors and the second victim phenomenon among health system employees [42]. Also, in the study of Ozcan et al. (2019), there was a significant relationship between the severity of the injury and the phenomenon of second victims of the error [43]. The error leading to the injury is completely obvious and cannot be hidden or concealed. On the other hand, due to the clear effects of this type of error, as well as the reaction of clients, companions, colleagues, and officials toward the mistakes that lead to injury, it is expected that it will cause the largest number of symptoms of the second victim phenomenon in nurses. Therefore, it is recommended that nurses who have made mistakes that lead to injury be covered by a psychologist.

The results of this study showed that there was a significant relationship between the way nurses report errors and the phenomenon of second victims of errors, in such a way that the highest rate of the phenomenon of second victims of errors was created in nurses who had reported the error to supervisors, and the lowest rate of the phenomenon of second victims of error was related to reporting errors to doctors. Timely and correct reporting of errors is an influential factor in reducing the second victim phenomenon [44]. Fear of blame from managers, reactions from colleagues, and concerns about patient complaints and legal actions significantly contribute to nurses not reporting errors. Huang et al. (2021) reported that inappropriate feedback from managers in unsupportive work environments decreases error reporting and increases the likelihood of repeated mistakes, ultimately exacerbating the second victim phenomenon [27]. In the context of the current study, reporting errors to supervisors has increased the rate of errors, so it is recommended that workshops on how to deal with personnel when errors occur and report errors should be held for nurses, and a supportive atmosphere should prevail in the departments.

In the context of the present study, there was a significant relationship between the phenomenon of second victims of errors and the management atmosphere of the department. Quillivan et al. (2016) stated that a non-reprimanding work culture provides an environment for nurses in which the physical and professional discomfort of nurses and the phenomenon of second victims are reduced by increasing the support of managers [15]. Ajri-Khameslou et al. (2021), regarding the effect of how managers deal with nurses’ errors, point out that the presence of a punitive atmosphere in the organization, according to the majority of nurses, increases the nurse’s anxiety and tension and ultimately increases the phenomenon of second victims of errors and the possibility of more errors [38]. In the present study, there was no significant relationship between how nurses deal with errors and the phenomenon of second victims of errors. It seems that the environment, organizational culture, management actions, and the treatment of medical colleagues rather than the actions of guilty nurses towards errors more influence the phenomenon of the second victim of error. At present, the managers of medical centers focus more on the person making the errors than on the causes involved in the errors. Hospital management should move from the organizational culture of punishing errors to a positive culture of learning from errors and preventing errors.

This study, like other studies, had limitations. Because reporting errors by nurses might be associated with the fear of legal consequences, nurses might not have reported correct data despite researchers’ explanations. Another limitation of this study was the limited sample size, which reduced the ability to generalize to all nurses. Other limitations of the present study was the high workload of nurses, which may have reduced their ability to focus on the questions. Still, as much as possible, we tried to give them enough time to complete the questionnaire and explain the importance of their answers. Furthermore we used a self-administered questionnaire to collect data, which may cause bias.

The results of the present study showed that the nurses under study were affected by the phenomenon of second victims of error. The second victim of error phenomenon was more prevalent among novice nurses, who tended to make more mistakes in a reprimanding work environment. Therefore, it is recommended that hospitals use a justice-oriented policy instead of a reprimand policy against nursing errors.