Introduction
Patient safety incidents are defined as situations in which a patient is or has been subjected to unwanted or unnecessary physical harm, which could lead to extended hospital stays, disability, or even death in certain cases [1]. Nevertheless, patients are not the only victims of such patient safety incidents. Medical personnel involved in the course of events related to such incidents often become as they are the ones who have the accountability of handling the incident [2]. Nurses are particularly vulnerable to such incidents and at a higher risk of becoming secondary victims compared to the other members of the healthcare community [3, 4]. According to a survey [5], there is a 10.0–72.6% prevalence of second victims. Healthcare workers who experience patient safety incidents can be characterised by varying degrees of symptomatology, manifesting as varying degrees of psychological distress, including guilt, anger and fear, which may be related to the degree to which the individual has come to terms with the incident, as well as differences in the safety culture of blame and punishment [6, 7]. It has been demonstrated that nurses experience significant stress and injury, which negatively impacts their physical and emotional well-being and their ability to perform well at work and might as well increase the probability of them quitting their job [8].
The concept of a culture of safety was first introduced into the field of healthcare management in 2003 by Singer et al. [9], who stated it as “a safety culture with shared attitudes, values, and experiences that healthcare organisations develop on the basis of their respective healthcare systems to ensure the safety of patient care”. Patient safety culture is an important concern for every hospital administrator and leader [10]. A good patient safety culture at a hospital reduces the number of patient safety incidents and employee burnout [11]. A non-punitive patient safety culture is reported to greatly improve the suffering of second victims [12]. In China, the concept of patient safety culture was adopted late. After the introduction of the non-punitive concept to the nation, healthcare organizations established non-punitive adverse event reporting systems, intended to encourage proactive reporting of all incidents by nurses. Nurses in China are expected to report patient safety incidents to the Nursing Quality and Safety Committee or the nursing department within 24 h of the incident, along with a summary of the cause leading to the incident and any necessary corrective action. This activity allows for a smoother oversight, correction, and tracking of an incident. True reflection and prompt reporting of an incident are crucial to ensure that solid and trustworthy data are available for improvement initiatives [8]. Studies have, however, demonstrated that recollection during the reconstruction of the course of events leads to secondary victimization of nurses, although a well-executed reconstruction process might be beneficial to the second victim as well, as it would reduce the risk of repeat errors on their part in future [11, 13, 14]. However, the actual psychological experiences of second victims during the reconstruction process remain to be understood to date.
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In this context, the present study utilized an exploratory mixed-methods research approach to gain a comprehensive understanding of the psychological experiences of secondary victims during the process of reconstruction of the course of events related to an incident. The main objective was to establish a foundation for promoting a positive safety culture in medical institutions in the future.
Methods
Design
A sequential, exploratory, mixed-methods research design was adopted for the study, which included a qualitative phase comprising one-on-one semi-structured interviews and a quantitative phase comprising a survey [15]. The qualitative study was conducted between February 2022 and May 2022. The quantitative study was conducted between May 2022 and December 2022. The data from the qualitative phase served as the foundation for the second phase of the quantitative investigation of the same phenomenon among a wider range of people.
Sampling method and recruitment
Qualitative research
Purposive sampling was adopted, and the nurses who had encountered patient safety incidents in a tertiary hospital in Shanxi Province, China, where the interviews were conducted, were selected as study subjects according to the maximum difference sampling strategy. The inclusion criteria were as follows: registered nurses; having encountered patient safety incidents; willingness to cooperate with the interview process. The exclusion criteria were: nurses promoted to the position of head nurse.The sample size was determined based on the criterion that the collected had reached saturation. The study methodology was approved by the Hospital Ethics Committee.
Quantitative research
Convenience sampling method was adopted to select hospitals in 11 cities and districts of Shanxi Province, China for sites to conduct the questionnaire surveys. The study population was the parallel sample population in the qualitative study.
Data collection
Qualitative research
The descriptive qualitative research methodology was adopted for the qualitative research phase. This was based on the theory of natural inquiry research. The data were collected via semi-structured face-to-face interviews. The interview duration was agreed upon in advance between the researcher and the interviewee. Prior to conducting the formal interview, the researcher introduced the content and significance of the interview to the respondents and obtained their informed consent from each one of them. The interviews were conducted in a separate room to ensure the privacy of each interviewee. Each interview was audio-recorded and transcribed by two researchers, who managed the confidentiality of all audio and transcripts. During the interview, respondents could stop at any time if they had any psychological or physical discomfort. The interview outline was initially developed according to the purpose of the study, and two nurses who had also experienced patient safety incidents were selected for conducting the pre-interviews (the results of which are not presented here). The formal interview outline was finally adjusted according to the information gathered in the pre-interviews. The researcher began the interview with the question, “What is the most significant patient safety incident you have experienced?” to establish a relationship with the interviewee. The interviews lasted for 30–50 min. All interviews were completed by the researcher.
Quantitative research
The themes derived from the qualitative research phase were utilized to guide the specific research questions in the quantitative phase. Accordingly, a quantitative survey was designed to determine the psychological experiences and support requirements of second victims during the reconstruction of the course of events following the patient safety incident. The questionnaire included items on the hospital location, city, gender, working age, the number of patient safety events encountered, negative psychological experiences, etc. of the nurses. According to the themes derived in the qualitative research, the second victim presented various requirements, such as personal growth, trust from their leaders, etc. Meanwhile, using the data collected using the Second Victim Experience and Support (SVEST) scale compiled by American scholars Burlison et al., together with the opinions of experts, 9 specific entries of the support requirements of nurses during the reconstruction of the course of events of the incident were revealed using the 5-level Likert scale, evaluating the entries in the range of 1 (very less requirements) to 5 (very high requirements). The total attainable score ranged from 9 to 45 points, with a higher score indicating that more nurses required various kinds of support. The total content validity index of the questionnaire was 0.94, and the content validity index of each entry level was > 0.83. The total Cronbach′s alpha coefficient of the questionnaire was 0.895, which indicated good reliability and validity [16], and could represent the nurses’ requirement for support after the reconstruction of the course of events of the incident.
Data analysis
Qualitative data analysis
At the end of each interview, 2 researchers listened to the audio recording repeatedly and transcribed it within 24 h of the interview. Data synchronization and analysis were conducted. The data were analyzed using the conventional content analysis method for qualitative research. The researcher read the data repeatedly with an open attitude and “low inference description” to analyze the explicit content and the implicit relationship of the interview data. The specific steps were as follows. Reading and organizing the original data: transcribing verbatim all the content of the interviewee’s statements and the interviewee’s non-vocal expressions, such as verbal pauses, sighs and sobs, body language, etc., in order to interpret the data from the interviewee’s perspective. Finding units of meaning: disintegrating the materials, followed by reassembling and condensing them, assigning concepts and meanings, and attempting to use local concepts as code numbers to express the interviewees’ meaning construction. Establishing a coding and filing system: open coding (including the steps of condensing units of meaning, conceptualizing, and categorizing), creating categories, and establishing themes.
Quantitative data analysis
The questionnaire was completed by the nurses, and the informed consent part of the questionnaire required that all respondents had experienced one or more patient safety events. The questionnaire considered “the number of patient safety events” as a logical question, and “0” was considered invalid. A total of 3394 valid questionnaires were collected finally, with a valid recovery rate of 88.39%.
SPSS 24.0 was used for statistical analysis. Numerical data were expressed as frequencies and percentages. The measurement data were expressed as mean ± standard deviation.
Results
Qualitative findings
When the number of interviewees reached 12, no new themes emerged during the analysis of the interview data., Another 2 more cases were added ubsequently, which also did not lead to any new information appearing, Therefore, it was understood that data saturation had been reached. Data collection was then halted with a total of 14 interviewees selected as the study sample finally. The sociodemographic characteristics of these 14 interviewees are presented in Table 1. Through data analysis, we identified the following three themes: (1) Negative views as initial psychological impact, (2) Avoidance as part of psychological Impact, and (3) Expectations and growth in overcoming negative psychological impact. Each of the three themes is described below with supporting quotes from the participants.
Table 1
Sociodemographic of interview participants (total n = 14)
Age, n (%) | < 30 | 4(28.57%) |
30–40 | 8(57.14%) | |
> 40 | 2(14.29%) | |
Gender, n (%) | Male | 2(14.29%) |
Female | 12(85.71%) | |
The number of patient safety incidents reported, n (%) | 0–1 | 3(21.43%) |
2–3 | 6(42.86%) | |
> 3 | 5(35.71%) |
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Theme 1: Negative views as initial psychological impact
When recalling a patient safety incident, the individual expressed feelings of self-blame and nervousness. In addition, feelings of shame were expressed as the words and actions of the people who were present at the scene caused the person to feel embarrassed. Most of the interviewees indicated that they were permanently overshadowed by negative emotions such as self-blame, guilt, tension and fear. These emotions became further intense during the recreation of the course of events, and new negative emotions also emerged.
“I feel so ashamed, the head nurse emphasized it so many times, I know how to do it, but it still happened” (N11).“I was afraid of the impact on the patient, the criticism from the leadership, and the fact that I would always be so tense in my future work” (N12).“It was quite painful after the incident had happened, and I had to continue to visit work and rapidly adjust my emotions. I wish to forget the pain it caused and move on; however, the head nurse keeps making me revisit the pain again and again” (N1).“I had a breakdown during the recreation process, I couldn’t control my emotions” (N7).
Theme 2: Avoidance as part of psychological impact
In the process of reconstructing the course of events, the person felt a sense of conflict. While the person wanted to be completely truthful to learn from the incident and improve, in reality, they just embellished or simplified the event for a variety of reasons.
“I felt like I should not provide much details as it is anyway not easy to find the root cause and providing details would only cause the nurse manager to scold me as to how such an error is possible at such a small place” (N2).“There are links I do not dare to say. In fact, the scheduling is not appropriate, and I would like to talk about it so that it is paid attention to in the future. However, I am worried that it will make the head nurse unhappy” (N9).
Theme 3: Expectations and growth in overcoming negative psychological impact
Most of the respondents had a positive attitude toward their experience of recreating the course of events related to the incident as they aimed to understand the causes and undertake preventive measures in the future, which would contribute to their personal growth. A few respondents were particularly keen to gain the understanding and trust of their leaders when recalling the incident and hoped that their respective responsibilities would be clarified based on that understanding and trust.
“My own habits and processes may be different from others, and I would like people to help me point out the problems when I restore” (N5).“I wish the head nurse would consider thinking from the nurses’ perspective as wells” (N2).
Quantitative findings
A total of 3394 participants completed the survey. The sociodemographic characteristics of these participants are presented in Table 2. The second victim support needs score was 39.58 ± 5.45, presenting a high support need. The findings of this study indicate that the second victim’s top support needs in resolving the incident were for determining the incident’s cause, developing abilities, and increasing knowledge (Table 3).
Table 2
Sociodemographic of respondents (total n = 3394)
Gender, n (%) | Male | 129(3.80%) |
Female | 3265(96.20%) | |
Working experience, n (%) | < 5 years | 704(20.74%) |
5–10 years | 864(25.46%) | |
> 10 years | 1826(53.80%) | |
The number of patient safety incidents reported | 2.26 ± 2.62 | |
Table 3
Negative psychology and support needs of the second victim
Project | Content | Number | Percentage (%) |
|---|---|---|---|
Original negativity | Guilt | 2471 | 72.80 |
Blame oneself | 2680 | 78.96 | |
Fear | 1680 | 49.50 | |
Stressful | 2367 | 69.74 | |
Others | 268 | 7.90 | |
Added negativity | Shameful | 2562 | 75.49 |
Others | 1105 | 32.56 | |
Changes in negative emotions | Make more serious | 2145 | 63.20 |
Remain unchanged | 1249 | 36.80 | |
Support requirementa | Quiet and secluded environment | 2922 | 86.09 |
Company of family/friends/colleagues | 2436 | 71.77 | |
Understanding and support from leadership | 3231 | 95.20 | |
Understanding from patients and families | 3220 | 94.87 | |
Acceptance and trust from coworkers | 3245 | 95.61 | |
Enhancement of knowledge | 3272 | 96.41 | |
Upgrading skills | 3274 | 96.46 | |
Identifying the causes | 3275 | 96.49 |
Mixed-methods findings
Certain findings of the quantitative phase of the present study confirmed the results of the qualitative study and explained the qualitative results in further detail. In regard to the first domain(status of psychological experience), the qualitative research revealed that after a patient safety incident, the concerned person experienced several negative emotions, such as, guilt, self-blame, fear, and nervousness. Moreover, the restitution of the incident led to the addition of new negative emotions. The new negative emotions came from two sources: firstly, the existing negative emotions were aggravated, which made the person feel worse; secondly, the restoration of the scene made the person feel very ashamed. This was confirmed by the results of the quantitative phase of the studies. In regard to the second domain (status of support requirements), the results of the qualitative study indicated that the second victim was eager to receive support in various areas and wanted to gain experience from the incident to improve his or her skills. The support requirements questionnaire developed based on the results of the qualitative study was tested to have good reliability and validity, and was representative in investigating the second victim’s support needs at the time of reversion. Meanwhile, the quantitative study refined the content of support requirements, and the results showed that the support requirements of the second victim were higher when recalling the incident. The results of both the quantitative and qualitative phases of the study are presented in Table 4.
Table 4
Integration of quantitative and qualitative results
Domain | Qualitative findings | Quantitative findings | Integrating resultsfindings |
|---|---|---|---|
Status of psychological experience | Negative views as initial psychological impact | Original negativity: guilt[2471(72.80%)], blame oneself[2680(78.96%)], stressful[2367(69.74%)] | Quantitative studies confirm negative emotions, while reductive events exacerbate negative emotions. Qualitative results show that avoidance occurs with negative emotions |
Added negativity: shameful[2562(75.49%)] | |||
Avoidance as part of psychological Impact | Changes in negative emotions-make more serious[2145(63.20%)] | ||
Status of support requirements | Expectations and growth in overcoming negative psychological impact | Support requirements: quiet and secluded environment, company of family/friends/colleagues, understanding and support from leadership, understanding from patients and families, acceptance and trust from coworkers, enhancement of knowledge, upgrading skills, identifying the causes | The quantitative study has refined the content of support needs and the questionnaire entries are well represented |
Discussion
The outcomes from both the qualitative and quantitative phases were consistent with the principles of study design, analysis, and data interpretation. There were numerous agreements between the two phases, rather than disagreements. As our findings indicate, negative views as initial psychological impact. After a patient safety incident, nurses experienced distress, anguish, including worry, despair, and guilt. This distress was compounded by the requirement to reconstruct the course of events related to the incident precisely. According to 63.20% of the second victims, this reconstruction process left them further anxious and with greater guilt and self-blame. In addition, it led to the emergence of new unpleasant feelings, such as those of embarrassment and tiredness, both physical and emotional. These results are consistent with those reported by Scott [17], who observed that after the patient’s stabilization and introspection, the second victim began thinking about how the incident would influence future lawsuits, job security, and licensing. The incident’s unpleasant feelings incited by the incident may affect the emotional health and future practice of nurses for a considerable period, if not forever [18]. “Avoidance as part of psychological impact” emerged as a theme in the findings of the qualitative phase of the study, and such elevated negative emotions could impact the authenticity of event reports and the willingness to commence reporting, both of which are critical for ongoing nursing care improvement [19]. This could be caused by numerous factors, which include feeling burdened by the reporting process and a lack of a safety culture [19, 20]. Therefore, it’s critical to create a culture of safety in which the nurses are free from any fear, guilt, and punishment from the authorities of the units and organizations [10].
Reconstruction of the course of events of an incident is the crucial first step in the reporting process. Additionally, incident reporting is crucial for the ongoing advancement of the nursing profession [20]. Nurses, nursing managers, or healthcare organizations can learn ideas and techniques to enhance their workflow and expertise from their experience of this reconstruction process, which is a thorough examination and analysis of the incident. When nurses perform incident reduction, it is advised that nursing managers or healthcare organizations provide comprehensive positive feedback rather than critical criticism [21]. It is advised that nursing administrators and healthcare organizations create policies to reduce false reporting and withholding information, and to encourage nurses to cultivate a genuine culture of learning and see experience restoration and truthful reporting as a privilege rather than a burden [22]. An After Action Review (AAR) is a guided, organized conversation about an event that allows teams to develop a common understanding of what occurred, the reasons behind it, and to pinpoint lessons learned and areas for improvement [23]. AAR creates an organized setting that focuses on examining issues from a systemic perspective instead of assigning blame to individuals, which helps alleviate guilt and shame among healthcare professionals [24]. By participating in AAR, healthcare workers can enhance their ability to manage similar situations and develop their professional skills and coping mechanisms [11]. To improve the culture of patient safety and reduce the impact of the second victim phenomenon, it is advisable to implement AAR extensively in patient safety management.
Nurse leaders may be the first person to whom a nurse reports an error. These leaders should support nurses throughout the investigation process and subsequent recovery [25]. The nurse manager’s need for comprehension and support was as high as 95.20% in the support needs survey, which was essential in lowering the second victim’s negative feelings. In order to give early intervention for the second victim to lessen his or her negative emotions, nurse leaders should offer emotional support through encouraging words and soft physical gestures like shaking hands, giving each other a gentle glance, and inviting the person to sit down when recreating the course of events. Nursing leaders should possess immense knowledge and prepare well prior to the incident reconstruction process to facilitate the process being considered an opportunity by the second victim to improve their knowledge and skills. In addition, the leaders must pay attention to the way the coworkers of the concerned person communicate with them and then correctly guide these coworkers to have empathy for their colleagues. In the present study, the requirement for acceptance and trust from coworkers was revealed to be 95.61%, and due to similar work experiences, peer support was considered the first choice for second victims to obtain support, although only 35% of them reported having received peer support [26‐28]. FOR YOU [28], You matter [29], RISE [30], and Buddy Study [31] are the commonly used peer support strategies, although a structured peer support approach for second victims is currently unavailable in China. It is, therefore, recommended that a peer support plan for second victims in the Chinese context be developed, which would be based on the traits of second victims and the real scenarios existing in the nation. A study [32] indicated that the EAERI support strategy can enhance the ability of nursing managers to assist second victims in objectively addressing adverse events and minimizing the secondary harm they experience. This strategy serves as a valuable reference for nursing managers when analyzing adverse events to effectively and objectively restore the situation [33]. It includes providing environmental, companionship, emotional, respect, and informational support to the nurse who is a second victim, thereby aiding in the recovery process related to the safety event. Therefore, it is recommended that relevant support strategies be integrated into patient safety management and explored the long-term effects experienced by the second victims after they return to work.
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Conclusion
The present study adopted a mixed-methods research approach and contributed to the existing understanding of the true emotional experiences and support requirements for nurses as second victims of an incident during the process of reconstructing the course of events of the incident. It was confirmed that the second victims experience a range of physical and psychological injuries during the reconstruction of the course of event. In addition, the reconstruction process exacerbates the victim’s negative emotions. The study highlights the importance for nursing managers and healthcare organizations to recognize the adverse psychological effects experienced by second victims when reviewing incidents. This awareness is essential for promoting a positive safety culture and minimizing the risk of secondary trauma resulting from improper handling. Additionally, it emphasizes the urgent need for a supportive and non-punitive environment in healthcare settings, as well as the importance of ensuring a safe atmosphere for all staff members.
Limitations and future steps
Some limitations of our study should be acknowledged and considered. First, the representativeness of our study is restricted, and it is only investigated provinces in central China and failed to examine the impact of geographic differences on the psychological experience of second victims. Besides, we only combed through the negative psychology and support needs of the second victim without providing detailed guidance. However, we made some suggestions for nursing managers and healthcare organizations in the areas of environmental support and language skills. Thus, future research can explore the barriers faced by managers on the development of support programmes for second victims.
Acknowledgements
The authors would like to thank all nurses and patients who participated in this survey.
Declarations
Ethics approval and consent to participate
This study was approved by the Medical Ethical Committee of Shanxi Bethune Hospital (YXLL-2023-047) and informed consent was obtained from the participants.
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Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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