Which of the Following Is a Researcher Least Likely to Do When Conducting a Literature Review?
Int J Environ Res Public Health. 2020 Jul; 17(13): 4717.
Action later on Adverse Events in Healthcare: An Integrative Literature Review
Mari Liukka
1Department of Nursing Science/Kinesthesia of Wellness Sciences, University of Eastern Finland, 70211 Kuopio, Finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (Due south.T.)
2Due south Karelia Social and Health Care District, 53130 Lappeenranta, Finland
M Flores Vizcaya Moreno
4Kinesthesia of Health Sciences, University of Alicante, 03690 Alicante, Spain; se.au@ayacziv.serolf
Arja M Sara-aho
fiveKinesthesia of Health Intendance & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland; if.bal@oha-aras.ajra
Jayden Khakurel
6Enquiry Center for Child Psychiatry, University of Turku, 20500 Turku, Finland; if.utu@lerukahk.nedyaJ
Hannele Turunen
1Section of Nursing Science/Faculty of Health Sciences, Academy of Eastern Finland, 70211 Kuopio, Republic of finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (Southward.T.)
7Clinical Evolution, Education and Research Unit of Nursing (CDERUN), Kuopio Academy Hospital, 70210 Kuopio, Finland
Susanna Tella
aneDepartment of Nursing Scientific discipline/Kinesthesia of Health Sciences, University of Eastern Finland, 70211 Kuopio, Republic of finland; if.feu@nenurut.elennah (H.T.); if.bal@allet.annasus (Due south.T.)
5Faculty of Health Intendance & Social Services, LAB University of Applied Sciences, 53850 Lappeenranta, Finland; if.bal@oha-aras.ajra
Received 2020 May seven; Accepted 2020 Jun 24.
Abstract
Adverse events are common in healthcare. 3 types of victims of patient-related adverse events can be identified. The first blazon includes patients and their families, the second type includes healthcare professionals involved in an adverse consequence and the third blazon includes healthcare organisations in which an adverse issue occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action afterwards adverse events, based on literature published in the concluding ten years (2009–2018). In the studies critically evaluated (n = 25), key themes emerged relating to the offset, second and third victim elements. The beginning victim elements comprise attention to revealing an adverse effect, communication afterwards an event, offset victim back up and complete apology. The second victim elements include second victim support types and services, coping strategies, professional person changes after adverse events and learning virtually agin outcome phenomena. The third victim elements consist of organisational action after adverse events, strategy, infrastructure and preparation and open advice about adverse events. There is a lack of comprehensive models for activeness afterwards adverse events. This requires understanding of the phenomenon along with ambition to manage adverse events every bit a whole. When an adverse event is identified and a concern expressed, systematic damage preventing and ameliorating actions should exist immediately launched. System-wide development is needed.
Keywords: patient condom, adverse events, starting time victims, 2d victims, tertiary victims, management
ane. Introduction
Adverse events (AEs) are inevitable in nursing and healthcare [i,2]. Even where best professional care exists, about treatments or investigations have the potential to cause harm [three]. Although the culture and system of a healthcare organisation (HCO) may exist well developed, AEs will happen considering of human factors and HCOs being complex adaptive systems, always changing and evolving. Thus, comprehensive preparation is important both to minimise harm to victims and to maintain the functionality of HCOs. In organisations with positive patient rubber cultures professionals tin speak openly about issues and events without fear of blame or punishment. Managers promote safe and reporting of AEs is supported and organisational learning occurs [1].
An AE is defined as an unintended or unexpected incident which causes impairment to a patient and may pb to temporary or permanent disability [1,4]. Approximately every tenth patient in infirmary suffers such events [v]. A quarter of these events in Europe are healthcare-associated infections; other AE types include medication errors, surgical errors, diagnostic errors, medical device failures or failure to act on test results [6]. Nurses and healthcare professionals frequently witness or are involved in AEs [two,seven,eight]. In healthcare, AEs can, at worst, cause catastrophic consequences [1]. It is clear that taking action after an AE has occurred is as important equally prevention. About half of physicians say that interest in AE increases stress in their piece of work [9]. Many of the 2nd victims seek back up from family unit, colleagues or supervisor [10]. Nigh 10% concord that organisations back up them in coping with AEs [9].
Iii kinds of victims of AEs can be identified. The "first victims" are conceptualised as patients and their families. Patients can endure from an AE in two ways: offset from direct damage caused and so from the mode the event is handled [1]. The "2d victims", a concept originally introduced past Wu [11], are healthcare providers, including physicians, nurses, allied clinicians, support personnel, students and volunteers [12], who have been involved in a patient related AE and subsequently experience emotional or concrete distress, thus becoming a victim themselves [13,14]. The miracle is quite common: the prevalence of second victim suffering is predictable to be approximately 30%, varying from x.four% to 43.iii% [15]. Ninety per cent of healthcare professionals reported suffering at least one physical or psychosocial "second victim" symptom [16]. The "third victims" are healthcare organisations in which the AE occurs [17]. The impact on tertiary victims tin likewise be considerable, as AEs may create an organisational crisis leading to long-term business difficulties [18].
The effects of an AE on first, second and third victims include health-related, functional and economical consequences. These are interrelated and can cause pregnant costs. Both the first and second victims may suffer emotional and psychological, concrete, financial and livelihood consequences [nineteen]. In add-on, second victims tin confront professional person consequences, including concerns regarding the performance of their work [12,xv,20,21,22]. Healthcare professionals may also experience difficulties working in an environment where AEs have occurred [23,24]. Consequences for 3rd victims chronicle to effectiveness [12,nineteen,20], reputation [19,25], legal [20] and economical issues [19]. Hence, these phenomena are crucial aspects to consider after an AE.
Managing the aftermath of AEs well can exist assumed to have positive consequences for beginning and second victims' wellness, behaviour and economic well-being. Because HCOs every bit tertiary victims, only as well equally responsible for the starting time and second victims, it is clear that where possible systematic prevention of first and second victim consequences, and appropriate care after an AE is crucial. Constructive deportment after an event tin take a positive impact on the safe civilization, effectiveness of services and fiscal situation of the HCOs. In the US, the estimated toll of medical error in 2008 was USD 1 trillion, but patient safety improvements are estimated to have saved USD 28 billion [26]. Strategies to reduce the rate of AEs in the European Matrimony alone could prevent more than than 750,000 harm-inflicting medical errors per year. That means over 3.2 million fewer days of hospitalisation, 260,000 fewer incidents of permanent disability and 95,000 fewer deaths per yr [27]. The economic consequences of AEs, and of how the events are handled, are therefore not limited to healthcare. For nations, increased absenteeism from work, staff leaving the professions and deaths are examples of extreme consequences of AEs. Actions after AEs can be causeless to have serious short- and long-term, direct and indirect bear upon on individuals, the economic system and society.
The purpose of this integrative review is to synthesise existing cognition on deportment post-obit AEs in HCOs such equally hospitals and primary care units. The aim is to place the underlying elements required for harm preventing and ameliorating deportment post-obit AEs in guild to provide direction for development and futurity investigation. The enquiry question is: What are the cardinal elements of action immediately after AEs in HCOs?
2. Materials and Methods
2.1. Design of the Study
An integrative review approach was used following Whittemore and Knafl's five stages: (1) the problem was identified; (ii) the relevant literature published between 2009 and 2018 was sought; (three) the screened information were evaluated using a 10-item tool; (4) the eligible data were analysed using anterior content assay; and (v) the findings are presented in tables [28]. In addition, the checklist of the Preferred Reporting Items Systematic Reviews and Meta-analysis (PRISMA) Statement (2009) was used to guide the review [29].
ii.2. Search Strategy
The databases Scopus, CINAHL, Cochrane and PubMed were searched for relevant manufactures. Boolean search methods were used to call up articles related to action later on adverse events in healthcare such follows: "agin event" AND "disclosure" OR "aftermath", "adverse event" AND "professional' back up", "healthcare" AND "second victim", "healthcare" AND "after error".
The search, for example, from Scopus included search terms "adverse upshot" AND "aftermath" OR "disclosure" with limits "in article, championship, keywords", "published 2009 to 2018", "article or review", "English" and "in journals". Articles were included if they reported on action after AE. Manufactures focusing on, for example, adverse drug reactions or AE reporting were excluded. Articles about AE reports were excluded when they were only well-nigh frequency of reports, or virtually misses and did not present the whole process from AE to disclosure. Search methods, inclusion and exclusion criteria and search outcomes are presented in Figure 1. Twenty-v research or review papers were institute for inclusion in the data evaluation process.
Systematic literature search process regarding action after adverse events.
2.three. Review and Quality Assessment Process
The search process was realised independently by the authors (ML and ST). Online discussions were held with other authors to share results and make decisions on side by side steps of the process.
The "quality" of papers was evaluated using a tool developed from an amalgamation of previous work [30,31,32,33] which was refined via international research group discussions. The evaluation areas included: (1) background; (2) aim and research questions; (3) sample; (4) data collection; (5) data analysis; (6) results; (seven) ethical issues; (viii) reliability; and (9) usefulness of the results. Afterward discussing relevant evaluation areas for a comprehensive quality assessment, the inquiry group added a further surface area: (x) strengths and limitations. Each evaluation area was scored from 0 to 2 points using the following criteria: (0) does not see the aim or lacks information; (ane) inaccurate or superficial; and (2) relevant and presented systematically. With 10 evaluation areas and a maximum of 2 points for each surface area, the range of the scores for a study varied from 0 to 20 points. Annihilation below 12 points was excluded due to low quality.
The articles retrieved were distributed evenly, and 2 researchers independently scored each newspaper using the tool. Full scores for each paper were compared and the content, importance, confront validity and quality of each paper discussed. Where differences of iii points or more were present, each sub-element score was discussed, and a third research team member acted every bit a moderator to get in at a consensus. Cohens' Kappa was calculated to exam interrater reliability (κ = 0.83).
two.4. Data Analysis
The results of the studies retrieved were analysed using inductive content analysis [34]. Showtime, the studies were read several times and listed in a tabular array to gain an understanding of the whole and the characteristics of the actions taken after an AE. The data reduction phase included extraction of the information into a manageable framework. The aims of the study, research methods, findings, scores and scope of the action after AEs were presented. So, the data were open up coded, bathetic and categorised using content-feature words. Sub-categories were developed and discussed in the international inquiry group. Sub-categories were farther grouped into categories describing management of activity after AEs. Intendance was taken not to double count information from individual studies duplicated in literature reviews.
three. Results
iii.1. Characteristic for the Studies
The papers retrieved (northward = 25) were published between 2009 and 2018 (Table 1). The largest numbers of papers were published in 2015 (n = 5) and 2018 (n = 5) and were from the U.s. (northward = 12). Various methodologies were nowadays: quantitative (n = 10), qualitative (northward = 8), multiple methods (n = 2) and literature reviews (northward = 5). The quality scores of the papers varied from 12 to xx points, with a hateful of fifteen.9 and standard difference 2.1. The majority (n = 21) of papers were well-nigh second victim phenomenon and less attention was given to first (n = 6) and tertiary victim phenomena (due north = 4). One paper encompassed both start and 2d victims, three included both second and third "victims" and i paper covered all three "victims".
Tabular array 1
Studies investigating activeness after adverse outcome.
| Author(s) (Year), Land | Purpose and Aims of the Study | Research Methods/ Musical instrument/Sample (n = 25) | Findings | Evaluation Scores/Scope |
|---|---|---|---|---|
| Scott et al. (2010), USA [12] | To describe a deployment of an institutional rapid response arrangement (RRS) for 2d victims | Interview and 10 item spider web-based survey Interviews with 31 healthcare professionals Survey (due north = 898), medical students, physicians and professional person nurses | Six distinct recovery stages were delineated. Almost 40% of the respondents had previously heard the term second victim; 30% accept had personal problems within the past 12 months, such equally anxiety, low or concerns nigh their power to perform their jobs. 30-five per cent of respondents reported receiving back up from colleagues and peers when it was offered and 29% received support from supervisory personnel. Viii themes from the narratives to draw full general back up infrastructure characteristics to assistance 2nd victim recovery were identified. | 12.5 Second victim |
| Seys et al. (2013a), U.s.a. [15] | To identify supportive interventional strategies for second victims | Literature review 21 research articles and x non-enquiry articles Inclusion criteria and search strategy described PRISMA method was used for reporting | Numerous supportive deportment for second victims described in the literature. Strategies included support organised at the individual, organisational, national or international levels. Second victim support is needed to care for healthcare workers and to improve quality of care. Support can exist provided at the individual and organisational levels. Programs need to include support immediately postal service adverse event equally well as on a eye- and long-term basis | 14 Second victim |
| McVeety et al. (2014), Canada [xix] | To analyse and synthesise best evidence on the perspectives of patients and family unit members who encountered adverse events | Review, 14 studies that used qualitative methodologies included Inclusion criterions and search strategy described, Joanna Briggs Institute Qualitative Appraisal and Review Instrument (JBI-QARI) and Appraisement Checklist for Interpretive and Critical Research | Nine themes were identified relating to patient and family perceptions and experiences of an adverse event: communication, the disclosure process, apology, consequences and affect, fear of reprisal and/or interference with care, learned helplessness, measures of safeguarding, cocky-discovery and awareness of errors, and violations of trust. | 16 First victim |
| Ullström et al. (2014), Sweden [20] | To investigate how healthcare professionals are affected by their involvement in agin events, with accent on the organisational support they need and how well the organisation meets those needs. | Semi-structured interview guide with xxx questions. Qualitative content assay and systematic classification was used Healthcare professionals (northward = 21) | Bear on on the healthcare professional was related to the organisation's response to the event. | 15 Second and third victim |
| Kable et al. (2018) Australia [22] | To sympathise the effects of adverse events on nurses in acute wellness-care settings. | A qualitative, descriptive written report design; 10 nurses, semi-structural interview. | Nurses need organisational responses to adverse events, including collegial support and provision of information after adverse event occur. | 17 Second victim. |
| Rodriquez and Scott. (2018) USA [24] | To examine experiences of healthcare professionals who changed paths after an adverse consequence. | Web-based survey with total of 105 individual responded; 77 (73,three%) were eligible to complete the survey. | Healthcare professionals reported a pattern of inadequate social support subsequently adverse event. More transparency and support to aid professionals recover is needed. | 14 Second victim |
| Mira et al. (2015a), Espana [25] | To identify and analyse organisation-level strategies adopted in both primary care and hospitals in Spain To address the impact of serious AE on second and third victims | A cross-sectional survey study. The questionnaire explored five intervention areas: rubber civilization; health system crisis management plans for serious AE; measures to ensure transparency in communication with patients (and relatives) who feel an AE; care and support for 2nd victims and actions to protect the reputation of the wellness organisation (the tertiary victim). Adult past consensus among the inquiry team on the basis of reviews Managers of infirmary and primary intendance centres (n = 197), patient safety coordinators in hospitals or primary care (north = 209) | Deficient provision of back up for second victims was acknowledged by 71% and 61% of the participants from hospitals and primary care, respectively; these respondents reported that at that place was no support protocol for 2nd victims in place in their organisations. Regarding tertiary victim initiatives, 35% of infirmary and 43% of primary care professionals indicated that no crisis management programme for serious AE existed in their system, and, in the example of primary care, there was no crunch committee in 34% of cases. The degree of implementation of second and third victim support interventions was perceived to be greater in hospitals (hateful fourteen.1, SD 3.five) than in main intendance (mean 11.viii, SD 3.1) (p < 0.001) | 17.v Second and third victim |
| Gu and Itoh (2012), China [35] | To explore Chinese patients' views on physician disclosure actions after an agin event and their acceptance of unlike types of apologies from the medico who acquired the effect. | Questionnaire with seven sections concerning responding views of issue related to medical errors and patient rubber Inpatients and families (n = 934) | A big difference identified in the level of patient credence between a physician's "total" or "fractional" apology. It is suggested that Chinese hospitals should prefer an "open" policy, which should include a "sincere" apology to the patient who experienced a medical error in order to maintain mutual trust between the staff and patients. | 17 First victim |
| Mira et al. (2015b), Espana [36] | To assess the effect of agin events that occur in primary care and hospital settings on health professionals in personal and professional terms | A cantankerous-sectional report Online survey, randomly selected sample; 1087 wellness professionals completed the questionnaires (610 from master care and 477 from hospitals) | In total, 430 health professionals had informed a patient of an error. Error reporting to patients was carried out by those with the strongest safety culture, under 50 years of age and primary care staff. Main care (n = 318) and hospital (due north = 346) health professionals reported having gone through the second-victim feel. The emotional responses were: feelings of guilt, anxiety, re-living the upshot, tiredness, insomnia and persistent feelings of insecurity. In doctors, the nigh mutual responses were feelings of guilt and re-living the issue, while nurses showed greater solidarity in terms of supporting the 2d victim in both PC and hospital settings. | xviii Second victim |
| Sorensen et al. (e-pub 2009), Australia [37] | To sympathize patients' and health professionals' experience of Open Disclosure and how practice tin inform policy | Semi-structured open-ended interview. Grounded theory was used to analyse the data Nurses, managers, policy coordinators, patients and family members (northward = 154) | Five major elements influenced patients' and professionals' experiences of openly disclosing adverse events namely: initiating the disclosure, apologising for the adverse event, taking the patient's perspective, communicating the adverse outcome and beingness culturally aware. | 15.5 First and 2nd victim |
| Koller and Espin (2018) Canada [38] | To capture perspectives on paediatric disclosure and place gaps in knowledge for all-time practices and policy uptake. | Focus group interview with semi-structured questions; 5 parents, fourteen children and adolescents and 27 healthcare providers. | Patients and families need full disclosure and right to know about errors. Health-care professionals demand more than clarity in policies. Well-nigh agreed that a instance-by-case approach was necessary for supporting variations in how medical errors are disclosed. | 19 First victim |
| Hågensen et al. (2018) Kingdom of norway [39] | To present patients' perspectives of disclosure of and healthcare organisations' response to adverse events. | Qualitative study; 15 in-depth interviews. | 3 main topics regarding patients' experiences of adverse events are: (one) ignored concerns or signs of complications; (2) lack of responsibility and fault correction; and (three) lack of support, loyalty and learning opportunities. | twenty First victim |
| Mira et al. (2017), Spain [40] | To summarise the noesis most the aftermath of adverse events and to develop a recommendation set to reduce their negative touch on in contexts where there is no previous experience and apology laws are not nowadays. | 3 information sources were used; review studies (n = 14 publications), institutional websites (16 websites were reviewed) and experts' opinions and experience on patient safe (four focus grouping sessions with 27 participants). | Recommendations focused on eight areas: (one) Safety and organisational policies; (ii) Patient intendance; (3) Proactive arroyo to preventing reoccurrence; (4) Supporting the clinician and healthcare team; (5) Activation of resource to provide an advisable response; (6) Informing patients and/or family unit members; (7) Incident analysis; and (8) Protecting the reputation of health professionals and of the organisation. | nineteen First, Second and third victim |
| Treiber et al. (2018) USA [41] | To talk over the 2d victim syndrome and its impacts on nurses. | Online survey with multiple-pick and open up-ended items were sent to 842 resent nursing graduates 168 responses were received. | Fifty-half dozen per cent reported making at least one medication error. After making a medical mistake nurses had emotional responses, such as fear and thwarting. Nurses described often been supported past peers, nursing manager and preceptors. | 12 Second victim |
| Burlison et al. (2017), USA [42] | To present the evolution and psychometric evaluation of the Second Victim Feel and Support Tool (SVEST), a survey instrument that can help healthcare organisations to implement and rails the performance of second victim support resources | Quantitative report Second Victim Experience and Support Tool (SVEST) questionnaire development, 5-point Likert scale Nurses, physicians, pharmacists and medical technicians in specialised paediatric infirmary (n = 305) | The SVEST (The Second Victim Feel and Support Tool) tin be used by healthcare organisations to evaluate second victim experiences of the quality of existing support resource. Ways: Psychological distress 2.6, physical distress 2.3, colleague support 2.2, supervisor support 2.8, institutional support ii.3, non-work-related support 2.four, professional efficacy 2.5, turnover intentions 2.1, absence ane.8 The most desired second victim option: A give-and-take with a respected peer 81% The 2d most desired option: A discussion with the manager 74% | nineteen.5 Second victim |
| Edrees et al. (2011), U.s.a. [43] | To emphasise the importance of back up structures for 2nd victims in the treatment of patient adverse events and in edifice a civilisation of condom inside hospitals. | A cantankerous-sectional survey using a two-part Second Victim Questionnaire Nurses, nursing or other managers, physicians, pharmacists, therapists, clinical back up, technologists (n = 140 in part ane and northward = 95 in function two) | There is a need for second victim back up strategy in healthcare organisations. Informal emotional support and peer back up are among the most requested and most useful strategies. Other desired support: Prompt debriefing, crisis intervention stress direction (75%), an opportunity to discuss ethical concerns related to an outcome or process (46%), a safe opportunity to contribute to the prevention of similar events in the future (45%) | 13.v Second victim |
| Ferrús et al. (2016), Spain [44] | To place what occurs among healthcare providers after an adverse result and what colleagues could do to aid them | A qualitative report applying consensus search techniques Focus grouping and metaplan Physicians (n = 15), nurses (n = 12) | Consensus about second victims requiring support from their colleagues and managers; many times, 2nd victims perceive rejection. They experience fear, repetitive thoughts and loneliness. Formal information channels favour implementation of improvements. HCPs perceived that data on measures for preventing some other adverse event is inaccessible. Managers reported that a change in behaviour is necessary to amend patient condom civilization. Common informal channels included cafeterias and hallways. Colleagues of second victims' reactions included surprise and pursuit to avoid interest. | 16 Second victim |
| Joesten et al. (2015), U.s.a. [45] | To establish a baseline of perceived availability of institutional back up services or interventions and experiences following an agin patient condom event (PSE) | Quantitative written report, The Medically Induced Trauma Support Services Staff Back up Survey (MITSS) Nurses (n = 82), physicians (n = 12) | Overall, 10–30% of respondents reported that diverse support services or interventions were actively offered. Respondents reported having experienced several pitiful symptoms afterwards PSE, such as worrying memories (56%) and concerns about lawsuits (37%). Most of them experienced more than support from colleagues than from their manager or department chair. Less than 32% felt that they could report concerns without fear of punitive action or retribution. | xiv Second victim |
| Lewis et al. (2013), Us [46] | To report the event of medical errors on nurses | Integrative literature review 21 articles included Inclusion criteria and search strategy described Whittemore and Knafl's methodology used | Characteristics of units were important in nurses' experience of medical errors. Nurse characteristics were essential, for instance, number of nursing exercise years. Veteran nurses were more than likely to make constructive changes. 2 interventions were: (1) disclosure of a medical fault to the patient; and (2) support available to the nurse. Responses to the intervention outcomes were: (i) burnout, including emotional exhaustion, depersonalisation and low personal accomplishment; (two) moral distress; (3) intention to exit the profession; and (4) positive constructive changes afterwards medical errors. | xv.v Second victim |
| Davies et al. (2015), UK [47] | To explore student midwives' perceptions of what was traumatic for them and how they were supported after such events | Qualitative descriptive arroyo, using semi-structured interviews Pupil midwives (n = 11) | 5 principal themes: (1) Students' anxiety about inbound the profession including students beingness forced to adopt practices that devaluate their delivery; (2) Existential space between a patient and qualified midwife occupied by students, having traumatic tensions in the student function; (3) Emergency events were traumatic with students feeling unprepared and having also much responsibility; (iv) Backwash of emergency events concerning the bear on of the event on students; and (5) Learning to cope related to the way student coped with such incidents, every bit well as other stresses in the part. | xiii.5 Second victim |
| Harrison et al. (2015), UK/ USA [48] | To investigate: (a) the professional person or personal disruption experienced after making an error; (b) the emotional response and coping strategies used; (c) the relationship between emotions and coping strategy selections; (d) influential factors in clinicians' responses; and (e) perceptions of organisational support | Cross-sectional, cross-country survey, The Wellness Professional Experience of Error Questionnaire (HPEEQ) tool Nurses (due north = 145), physicians (n = 120) | Professional and personal disruption reported equally a event of making an error. Negative feelings common, but positive feelings like alertness, determination and considerateness likewise identified. Emotional response and coping strategy selection appeared to differ past professional group; nurses had stronger negative feelings after an mistake, only selection did not differ by perceived harm or location. Problem-focused coping strategies were favoured. Organisational support services perceived as helpful, peculiarly peers, only there were fears over confidentiality. Factors that influence clinician recovery should be considered in the provision of comprehensive back up programs. | 17 2d victim |
| Seys et al. (2013b), U.s.a. [49] | To determine definitions of second victim, research the prevalence and the impact of adverse event on the second victim and the coping strategies used | Literature review 32 research articles and ix non-research manufactures were identified | Second victims' common reactions afterwards adverse events can be emotional, cognitive and behavioural. The coping strategies used past second victims take an impact on their patients, colleagues and themselves. Defensive as well as constructive changes take been reported in practice after adverse events. Information technology is disquisitional that support networks are in place to protect the patient and involved healthcare providers when an adverse issue occurs. | xv Second victim |
| Edrees and Wu (2017) Usa [50] | To assess the extent of the second victim problem in astute care hospitals, the availability of emotional back up services and the need for organisational support programs. | In-depth semi-structured interviews. Patient safety representatives (n = 43). | All participants reported that they are aware of second victim problems. Nigh all agreed that hospitals should take a support plan for second victims. | 15,5 2nd victim |
| Delacroix (2017), USA [51] | To discern nurse practitioners' behaviours, perceptions and coping mechanisms in response to having fabricated a medical mistake | Qualitative written report, face-to-face up semi-structured interviews (north = 10). | Four themes emerged from interviews: (i) The paradox of error victimisation, ii subthemes were presented (fear for the patients' welfare and fearing an uncertain professional hereafter; (2) The primacy of responsibility and mindfulness, iii subthemes were presented (I am responsible, acute reactions and mindfulness); (three) Yearning for forgiveness and supportive other, this theme was categorised in 2 subthemes (not-supportive simply civilisation and seeking forgiveness and support); and (4) Coping with a new reality is context dependent, what was split to two subthemes (atypical coping and constructive coping). | 15.five 2d victim |
| Van Gerven et al. (2016), Belgium [52] | To evaluate the prevalence and content of organisations' support systems for healthcare professionals involved in an adverse event. | Quantitative descriptive design Dutch-speaking hospitals (n = 59) | Thirty organisations had a systematic plan to support second victims. The main nursing officer was seen as one of the primary contact people when something went wrong. In terms of the quality of the protocols, only a minority followed role of the international resources. | sixteen Second and third victim |
3.2. Key Elements of Responses and Action after AEs Bulleted Lists Expect Similar This
Deportment following AEs were comprised of 3 themes, namely first victims, second victims and third victims, with empathic and ethical advice, back up services, consummate apology and training and learning every bit cross-cut elements.
The theme of activity for first victims was comprised of four elements: attention in revealing an AE, communication after AEs, starting time victim support and consummate apology (Table two). Patients and families [19] and healthcare providers [35,36] alike were often afraid of speaking upward. Empathic, upstanding and open communication played an important role overall; the quality of the communication seemed to either empower or disempower patients and their families [19,37,38,39]. In many cases, patients are not informed about AEs [40]. Support for first victims was addressed primarily as a lack or fail of emotional support [36,39] and bounty support [35]. Apologising was an important element afterward experiencing an AE [xix,34,37,38]. First victims perceived the apology equally an integrative process, where the style and the presenter of the apology, whether healthcare provider or organization, played an important role. Expressing empathy, giving honest information about the AE, taking responsibleness and learning from the event were crucial to the apology procedure.
Table ii
"Action after adverse events" regarding first, second and third victim elements.
| FIRST VICTIM ELEMENTS | ATTENTION OF REVEALING AN ADVERSE Event | HCPs listening to patients' and family unit members' concerns about an error Patients or family unit members fearing to speak upward HCPs fearing to speak up HCPs' empowering or disempowering patients and family members |
| Advice Later AN Adverse EVENT | Because cultural differences in advice Providing open up communication Documenting in the patient records Observing different kind of family dynamics | |
| FIRST VICTIM SUPPORT | Emotionally supporting patients/families after adverse events Compensation back up | |
| COMPLETE Apology FOR FIRST VICTIMS | Apology with empathy Apology being an interactive process Presenter of apology HCPs/HCOs existence sorry for agin result experience Patient forgiving an agin event Apology including learning from an consequence and a change in activeness First victims' trust in healthcare services | |
| 2d VICTIM ELEMENTS | SECOND VICTIM SUPPORT Blazon | Informal 2d victim support Formal 2d victim support Emotional 2d victim support |
| SECOND VICTIMS' COPING STRATEGIES | Individuality of 2d victim coping strategies Seeking second victim emotional support coping strategies Problem-solving second victim coping strategies | |
| 2d VICTIM Support SERVICES | Availability of second victim support services Second victim legal and counselling support Time away second victim support Open disclosure support | |
| SECOND VICTIMS' PROFESSIONAL CHANGES Later on ADVERSE EVENTS | Defensive changes after adverse events Effective changes subsequently agin events | |
| 2d VICTIMS' LEARNING ABOUT Adverse Issue Miracle | 2d victim learning from an adverse event Learning virtually second victim phenomenon Learning to communicate about adverse events | |
| Tertiary VICTIM ELEMENTS | ORGANISATIONAL "Activeness After Agin EVENT" STRATEGY | Action subsequently adverse upshot plan Loftier moral communication strategy Active providing of support services Organisational apology policy Organisational learning from agin event |
| ORGANISATIONAL "ACTION AFTER Agin EVENT" INFRASTRUCTURE | Action afterward adverse effect personnel Support infrastructure Processes of "activeness later on adverse event" | |
| OPEN DISCLOSURE About Adverse Effect | Process of open communication Content of open disclosure | |
| "ACTION Afterward ADVERSE EVENT" TRAINING | Patient prophylactic training Agin events related grooming Advice after adverse events preparation |
The action for second victims theme consisted of the following elements: 2d victim support types, coping strategies, support protocols, changes later on AEs and learning about AE phenomena (Tabular array two). Support types consisted of breezy [12,fifteen,41,42,43,44,45], formal [15,23,25,forty,41,46,47] and emotional [22,42,44,45,46] back up for 2d victims. Healthcare providers accept indicated informal peer support as of import [20,41,42,49,50], but sensitive. The support can be destroyed, for case, by blaming, gossiping and silence [46]; thus, information technology is important to pay special attention to non-blaming, open and supportive communication. Formal support was not a certainty and was non offered in all cases [12,25,42,46,47]. The importance of emotional 2d victim support was clear and could be provided for all those involved, for individuals or groups [43,49,50]. 2nd victim coping strategies related to the individuality of strategies [12,49], emotional support [41,47,49,51] and trouble solving [47,49].
The 2d victim back up services comprised availability [11,24,25,41,44], counselling support [36,41,44], time away support [41,44,45] and open disclosure support [37,43,44]. Changes that second victims make afterwards an AE can include defensive and effective changes [fifty]. It was also found that learning near AEs [47], the second victim miracle and learning to communicate about AEs are of import for staff members [12,44,48].
The activeness for the tertiary victims theme consisted of organisational strategy and infrastructure [20,46,49], which was divided into activeness after agin events program [12,25,52], personnel [36,37,42,46,52] and processes [xx,36,52] subthemes (Figure ii). The key elements of the subthemes were:
-
emphasising open up, empathic communication (for example, open disclosure) and each staff fellow member'due south responsibleness for their empowering communication way [25,37,42];
-
action subsequently AE support services for first and second victims (for case, emotional support) [42,44,47,49]; and
-
action after AE training and learning for managers and staff members [15,19,52].
"Activity after adverse events" in healthcare organisations.
iv. Discussion
The results of this integrative literature review demonstrate how complex and multi-layered the phenomenon "action after AE" is and how this topic has gained attention in international research and healthcare development piece of work. Previous studies have concentrated more than on a unmarried perspective regarding actions afterward AEs, while, in this integrative review, a more holistic view is presented. Key themes emerged relating to victims of AEs: first, second and third victim elements, with empathetic, effective communication, support services, complete apology and training and learning, every bit cross-cutting elements.
The first victim theme comprised attending to revealing an AE, communication after an event, first victim back up and consummate apology. The second victim theme included second victim support types, coping strategies, support services, changes after AEs and learning about AE phenomena. The third victim theme consisted of organisational action later on AEs, strategy, infrastructure and grooming and open communication about AEs. These three themes interweave tightly together, and we arroyo the themes from a healthcare arrangement's perspective to outline the needs of first and second victims and how HCOs could respond to these. In this integrative review, 2nd victim back up programs were under evolution work. For example, Scott et al. designed "A Framework of Caring: The Scott 3-Tiered Interventional Model of Support", which features: (Tier i) unit level support; (Tier 2) trained peer supporters and patient safety and risk management resources; and (Tier 3) an expedited referral network with specialist support [12]. Indeed, a similar kind of support program could also benefit first victims.
2nd victim support programs can be assumed to support commencement victims as well through improve grooming of nurses and healthcare providers. Still, it could exist argued that more comprehensive beginning victim support programs are too needed. Attention to revealing an AE, open up and emphatic advice and complete, authentic apology to, and back up of, first victims were essential later on AEs. For example, the apology policy of the HCOs seemed to exist fragmented and oftentimes defensive. First victims highlighted the importance of an empathic, interactive process, where a sincere apology is expressed not only by an individual healthcare provider, but responsibility on the part of the HCO is accepted also [53,54]. First victims unsaid that in some situations they might forgive, but it was unclear if forgiveness was asked for [35]. Here, an interactive support program could be benign for all victims, including nursing and healthcare students. For instance, first victims wanted the apology to include information about how the HCO would acquire from the AE and make changes [19,35]. First victims had often lost trust in HCOs [19]. Open give-and-take about what went wrong, and why, can be the first step to agreement and forgiveness [55]. One reason for a loss of trust may be a lack of transparency after AE [56]. First victims should be convinced that everything possible is being done to avoid a similar situation in the future. If the apology included a convince of systematic, organisational level learning from the AE, the professionals involved may feel supported when discussing AEs with patients, peers and managers [57]. From the literature reviewed changes appear needed at the private, squad, unit and organisational levels. The results suggested a need for holistic approaches to managing AEs.
Rubber, systematic and articulate "action plan after AEs" required an understanding of each stakeholder'south needs. AEs consist of complex systems of problems which frequently interact; thus, it is of import to deal with the phenomenon as a whole. Indeed, even those not direct involved may have impact on the consequences of AEs. The strategy and infrastructure of HCOs are crucial to managing action afterwards AEs every bit part of healthcare delivery. An "action after AE" strategy needs to include a comprehensive programme which attends to the interlinked complexity which ofttimes exists. Well-thought-through communication is required from anybody in HCOs: colleagues, managers and second victims as well. AEs are very sensitive events that tin have long-term consequences [12,15,xix,20,24]. Thus, communication is fundamental to occupational and patient safe.
Organisational "action later on AEs" infrastructure needed to have appointed personnel, clear support and learning infrastructure and clear processes. It was also important that the procedure and content of open disclosure are included in the management of the events. Emphatic, support and respect past colleagues is needed after AE so that healthcare professionals notwithstanding feel competent to do their job [20]. With these actions, HCOs may exist able to ameliorate the severe consequences for all victims, such as effectiveness of HCOs [12,19,20], economical issues [19] and reputation [nineteen,25]. Nurses and healthcare professionals endure when involved in AEs, may fear reporting events [48,58,59,60] and experience difficulties working in an environs where AEs have happened [23]. Beingness comprehensively prepared is of import [58] both to minimise harm to all victims and for the functionality of healthcare systems.
Mira et al. found that many patients are not informed at all most AE. This may exist considering HCPs are agape for their professional future, or because they do not accept competence to honestly tell a patient what has happened [38,40,51]. A shortage of skill and resource lack of competence seems to be i barrier to developing organisational support programs subsequently AE [50]. It is of import not to forget the first victims outside this back up. It is also good to recognise that first victims have much information about AEs to provide for organisational learning [38,39]. Crucial for this is that activity after AE education is included in professional and continuing healthcare program [33].
The strengths of this study include an international researcher group involved with strong patient safety research, direction and education experience. For case, the data evaluation was conducted in two groups. The quality of the research papers was evaluated with an musical instrument used in an integrative review. Agreement among authors was measured by Cohen's kappa (κ = 0.411), which can be interpreted as moderate [60]. Limitations include the method itself. Merely peer reviewed inquiry papers were used in this review. National or international guidelines and protocols about disclosing adverse events were omitted. The search strategy may have affected the number of unlike victim phenomena found vary. Combining different methodologies such equally qualitative, quantitative and literature reviews tin be difficult due to diverse ontological and epistemological underpinnings, which some may view equally causing bias [28]. Team discussions regarding key features of the papers were utilised to assist in clarifying the quality of the studies and the main emergent points from each paper. Close attending was also given to the abstention of double counting in society to avert "skewing" the findings. The PRISMA argument was used to guide the writing of the review [29].
5. Conclusions
It is inevitable that AEs will occur in healthcare organisations, impacting on individual, team, unit of measurement, organization and national levels. When an AE is identified and a concern expressed, immediate and comprehensive action should be taken. This requires trying to sympathise the whole miracle in its complication, an ambition to manage AEs and a "just restorative" culture [61] that enables it. System-wide developments are needed regarding activity later AEs, along with the implementation of evidence-based organisational infrastructures and strategies which could ameliorate the suffering of patients, their families and healthcare providers, likewise as help healthcare organisations (and ultimately nations) to use resources effectively. For this developing, more enquiry about patients' and their families' needs besides as organisations' needs is required. Tight collaboration is needed between policy-makers, nursing and healthcare managers and educators in social club to develop such systems and the necessary civilisation [62]. Just and so will all victims receive appropriate support after AEs. We also suggest that future education, research, policy and practice developments should incorporate a motion to a more than counterbalanced arroyo incorporating both Safety 1 (learning from failure) and Prophylactic 2 (learning from how things typically become correct) perspectives [61]. At the national level, social and healthcare ministries are responsible for planning, guidance and implementation of health and social policy to safeguard people's ability to work and function. International collaboration between governments is needed to standardise studies concerning first, 2d and third victim phenomenon. Governments should build a network of researchers and healthcare managers for developing the written report protocols and shared understanding of developing offset, 2d and 3rd victim back up organisation in healthcare organisations. Such a movement may assist in the development of "restorative merely cultures" in HCOs and more than holistic approaches to deportment later on AEs for the benefit of all "victims".
Acknowledgments
The sixth author would like to thank INVEST Research Flagship funded by the Academy of Finland Flagship Programme (conclusion number: 320162).
Author Contributions
M.L. and S.T. conducted the literature search and evaluation of articles, and were major contributors to the manuscript. A.S., M.F.5.M., P.P., and H.T. participated in evaluation of articles and writing the manuscript. A.M.Due south.-a. and J.K. took office in manuscript writing. All authors read and approved the final manuscript.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no disharmonize of interest.
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