Coping strategies in health care providers as second victims: A systematic review

INTRODUCTION

“Free from Harm” is a 2015 publication that highlights strategies for the patient's safety during healthcare (Boston, MA: National Patient Safety Foundation, 2015). Although we would like that the patient care would be risk-free, it is not, since the patient might be a victim of unexpected adverse events.

In terms of the context of the damage, adverse events may have more than one victim, which is why victims have been categorized into three groups: first victims, the patient and their family; second victims (SVs), the health professionals involved; and third victims, the organization (Seys et al., 2012).

Coined by Wu (2000) over 20 years ago, the term SV refers to health professionals who, after an adverse event, display various physical, psychological and/or behavioral responses that may even trigger suicide (Blacklock, 2012; Pratt et al., 2012).

In response to the harm that occurred to patients during care, the strategy of patient safety culture emerged. A patient safety culture can be defined as a group of initiatives that can be viewed as cogs in an overall system to enable safer care for patients (Wagner et al., 2019); and this culture has been a global concern for several decades. The publication of the report “To Err is Human” in 2000 gave figures of more than 80 000 deaths per year in the United States from adverse health events (Institute of Medicine, 2000). Twenty years later, the World Health Organization (WHO) revealed that, in high-income countries, one in 10 patients suffers an injury while receiving healthcare, and the reality is even more acute in low-income countries, where 2.6 million deaths occur per year, attributed to adverse events (World Health Organization, 2020). One publication that tracks this situation has analyzed studies carried out in 137 countries, in which 5 million people have died from deficient health services, compared to just 3.6 million deaths due to lack of access to health services (Kruk et al., 2018).

Adverse events are complex, varied, and multi-causal (Mohamadi et al., 2019). They include events related to care (pressure ulcers, patient falls, among others) related to medication, procedures, diagnosis, or infections associated with healthcare (Ministry of Health, Social Services and Equality, 2016). The WHO proposes another international classification: “The Conceptual Framework for the International Classification for Patient Safety.” In this document, the incidents are classified into clinical administration, clinical process/procedure, documentation, healthcare-associated infection, medication/intravascular fluids, blood/blood products, nutrition, oxygen/gas/vapor, medical device/equipment, behavior, patient accidents, infrastructure/building/ fixtures, and resources/organizational management (World Health Organization, 2009). Another important point is that adverse events generate great expense for public health systems as they increase the costs of hospital stays per day, procedures, and medication, among other factors (Ministry of Health, Social Services and Equality, 2016). It is estimated that 43 million adverse events occur every year, which equates to over $132 million in medical expenses (Hannawa et al., 2016). For example, a study carried out in Chile shows that the cost of each patient who has a permanent urinary catheter fitted and develops a urinary tract infection is equivalent to the cost of four patients with the same catheter who do not develop an infection (Kappes Ramirez, 2018).

So intense can SV's phenomena be that the signs and symptoms they develop have been standardized according to post-traumatic stress victims (Grissinger, 2014). The prevalence of the SV phenomenon has been documented in various ways. Some studies report that it occurs in approximately half of health professionals who have to deal with an adverse event in their professional life (Bleazard, 2019). A systematic review found that the prevalence of the SV phenomenon varies from 10.4% to 43.3% and that women are more afraid of losing their professional confidence or reputation than men (Seys et al., 2013).

The SV phenomenon involves many associated signs and symptoms, which may be physical, psychological, emotional, or behavioral in nature. They may be limited to the workplace, affect the individual in their daily life, or lead them to leave the profession (Scott et al., 2009). Of the professionals who overcome a serious adverse event, 15% seriously consider quitting their job (Pratt et al., 2012). Even links with burnout and suicidal thinking have been reported, with a higher prevalence among doctors who make mistakes than among the general population (Lane et al., 2018; Schanafelt, 2011).

Physical signs and symptoms of the SV phenomenon include extreme fatigue, tachypnoea, tachycardia, muscle tension, sleep disturbance, and headache. The signs associated with the psychological aspect also vary, including flashbacks or repeated memories of the event, grief, frustration, difficulty concentrating, fear, or remorse, with doubt about professional capacity being the most prevalent sign (Rinaldi et al., 2016). Other symptoms described include feelings of guilt and anxiety (Mira et al., 2015).

In a sample of 4369 nurses and doctors, the most common symptom experienced by SVs was found to be hypervigilance (53%), followed by doubts about knowledge and skills (27%). Furthermore, the intensity and duration of the reported signs and symptoms were greater when the adverse event caused patient death (Rinaldi et al., 2016; Vanhaecht et al., 2019), and these symptoms were more prevalent, lasting, negative, and stronger among nurses than doctors (Harrison et al., 2015; Vanhaecht et al., 2019).

As far as we know, the SV phenomenon can last for years, and non-resolution can lead the health professional to make mistakes that cause new adverse events, producing a spiral that is perpetuated in health centers (Pratt & Jachna, 2015).

In the end, to take care of the SV, we have to manage adverse events effectively. While the ethical imperative to “do no harm” is a fundamental principle, it is taken very literally. This is unrealistic when viewed from the perspective of the adverse event, causing the professional involved to experience guilt, anger, or shame, among other responses (Paparella, 2011; Steven et al., 2014). In reality, adverse events not only occur due to the complexity of medical and nursing actions but also due to the limitations of human actions (Hall & Scott, 2012; Paparella 2013).

For all these reasons, both personal and organizational strategies have been developed to deal with the SV phenomenon (Reis et al., 2018) that not only contribute toward the professionals' own well-being but also influence the well-being of the people they serve (Quillivan et al., 2016).

Thus, the patient safety culture, adverse events, and particularly the phenomenon of SV have been studied more in recent years.

METHODOLOGY

A systematic review was performed, following the recommendations set out in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al., 2019) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Liberati et al., 2009).

Search results

A total of 783 articles were identified through the initial database search. The PRISMA flowchart for this search is shown in Figure 1.

RESULTS

Of the selected 16 studies, three were carried out in the United States, three in Belgium, three in Spain, and two in Singapore. The rest were conducted in Iran, Italy, the United Kingdom, Australia, and China. Twelve were conducted after 2015. The highest frequency of publications occurred in 2016 (five of the selected studies). With respect to the research approach, 10 were quantitative (design: descriptive, correlational, systematic, or integrative review) and six were qualitative (descriptive, systematic review). Regarding the participants of the studies in qualitative studies, in three of the six studies, only nurses participated; and in the other three, doctors, nurses, and other health professionals. Of the 10 quantitative studies included, in five, only nurses participated, one had a hospital as a partner and four corresponded to reviews.

This review's main findings are detailed about personal and organizational strategies to face SVs' phenomenon and the barriers that SVs encounter to approach this phenomenon.

DISCUSSION

This review shows that the more intense the SV phenomenon, the greater the harm to the patient (Rinaldi et al., 2016; Smetzer, 2012; Tamburri, 2017). This is because professionals experience more intense feelings such as shame, anger, and guilt when they perceive the harm done to the patient and family (Seys et al., 2012). No statistically significant differences have been found between the intensity of the symptoms and the experience of the professionals, as studies of medication errors show that the SV phenomenon occurs both in recent graduates and professionals with over 40 years’ experience (Treiber & Jones, 2018).

It is also relevant that the SV phenomenon occurs to a greater extent among women than men (Van Gerven et al., 2014), and more among nurses than doctors (Harrison et al., 2015). This may be due to the fact that most nurses are women. Moreover, female SVs suffer more stress and greater fear of loss of confidence or security (Seys et al., 2012). However, women are more likely to discuss the error and attend training programs related to the issue (Seys et al., 2012).

Another important finding is that learning from errors is essential for SVs to develop effective coping strategies (Jones & Treiber, 2018). The expert consensus made by Pratt et al. (2012) shows that organizational learning is enhanced by serious mistakes. In the study by Harrison et al. (2015), coping is only perceived as useful by the SV if, by studying the error, it is possible to identify its cause and resolve it (e.g., lack of personnel). Another author concluded that learning from errors is necessary for SVs to maintain their professional identity and move forward (Chan et al., 2016). The qualitative study by Chan et al. (2017) found that nurses are helped in the healing process as SVs by sharing experiences that can prevent other errors. Similarly, Seys et al. (2012) concluded that it is essential to review the error and learn from it. In addition, Lewis et al. (2013) reported that nurses are more likely to make constructive changes in their actions after receiving support. For this reason, learning from mistakes contributes not only to the quality culture of the organization but also to the SV's professional growth and healing process. This conclusion is directly related to the results of the SV process in which the learning result would be equivalent to the sixth and final stage of “prospering” described by Scott and cited by Rinaldi et al., 2016.

In response to the research question that started this study, of the various coping strategies, peer support is widely preferred by SVs (Cabilan et al., 2018; Bleazard, 2019; Pratt et al., 2012; Quillivan et al., 2016; Seys et al., 2013). Some studies report that the fact that support is provided by strangers is a barrier to the use of support programs (Chan et al., 2017). This is because there is greater empathy in peer support, as it is understood that peers undergo the same professional experiences and are more accessible. Thus, the implementation of peer “coaches” to support SVs has been well-appreciated. These coaches must be trained and have the ability to anticipate the steps that the organization follows when investigating adverse events, which reduces the SV's anxiety (Bleazard, 2019; Vanyo et al., 2017).

With respect to organizational coping mechanisms, it can be inferred that they are necessary and should include short-, medium- and long-term actions (Seys et al., 2012). One of the main problems is that few institutions have formal SV support programs, and those that do have formal programs do not always have the services available (Harrison et al., 2015; Joesten et al., 2015; Seys et al., 2012; Van Gerven et al., 2014). Other barriers to using organizational coping systems include the mismanagement of resources, cultural and legal barriers (Mokhtari et al., 2018), mistrust in safeguarding user confidentiality (Rinaldi et al., 2016), and poor program dissemination (Tamburri, 2017). However, several studies show that when organizational coping support services are available, professionals are willing to use them (Edrees et al., 2016; Harrison et al., 2015). This fact is important if analyzed from Denham's point of view, in terms of establishing the rights that SVs would have. The process that SVs undergo should give them the opportunity to learn and contribute to learning in relation to quality care (Denham, 2007). Another important aspect is the ethical imperative to support SVs, not only in terms of helping professionals but also promoting consistency between the organizations’ stated values and practice (Monteverde & Schiess, 2017).

Of the coping strategies available to organizations, online systems are preferred, such as the support tools developed by the Spanish SV Research Group (segundasvictimas.es, 2018), the IHI (Conway et al., 2011), and the RISE programs at Johns Hopkins Hospital (Edrees et al., 2016; Tamburri 2017), implemented by the University of Missouri (Tamburri, 2017). These programs have the advantage of being accessible and developing specific emotional support actions for SVs (Pratt et al., 2012). The great challenge is that very few of these programs have been evaluated to verify what is the real contribution to the SV healing process. In this sense, one of the few programs that have been evaluated is the RISE program, which showed a positive evaluation of use and results in 52 months (Tamburri, 2017). The countries that have developed these strategies most are the United States, Spain, and other European countries. There is very little evidence from Latin America, and a study carried out in Brazil identified the knowledge gap regarding SVs in Latin American countries, stating that there are few statistics available and still a strong punitive culture against adverse events (Bohomol, 2019).

One of the essential conclusions to draw from this review is that several authors emphasize that interventions to tackle the phenomenon of SVs must be global (Bleazard, 2019; Seys et al., 2012; Tamburri et al., 2017; Zhang et al., 2019). This means that efforts should be directed at the first victim (the patient and their family) with clear policies on how to communicate errors with victim support and assistance. They should also be aimed at SVs, with an organized and formal support system that helps them overcome the symptoms caused by the phenomenon and continue their career, having learned from the mistake. The organization must also integrate these experiences into its culture of quality and safety. In this respect, it has been shown that, by finding support, SVs reduce their anguish and, as a result, their tendency to change jobs or take time off work reduces (Zhang et al., 2019). Within this context, it is essential to devise and implement mechanisms that ensure health policies that shift toward systems that generate learning from medical and nursing errors.

The aim of this systematic review was to highlight the personal and organizational coping strategies available to SVs, show the state-of-the-art in different countries, and identify the most highly valued strategies.

The limitations of this review are caused by the heterogeneity of the studies analyzed, in terms of their design, scope, and methodology. Furthermore, these studies differ with respect to the type of adverse events and their severity.

New studies should be conducted, particularly in Latin America, to improve the understanding of the phenomenon and the support given to SVs.

CONCLUSION

The SV phenomenon is complex. There is consensus that SVs need support and there are alternatives for coping at a personal and organizational level. The support most valued by SVs is peer support while the learning achieved through the support process is fundamental. This learning allows SVs to maintain their professional identity and contribute toward the quality culture of the organization. Formal evaluation of the support programs in use (mostly online) is required, as well as implementing support systems in Latin America.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Study design and manuscript writing: Maria Kappes, Marta Romero-García, and Pilar Delgado-Hito. Literature search: Maria Kappes. Article evaluation: Maria Kappes and Pilar Delgado-Hito.Study supervision: Marta Romero-García and Pilar Delgado-Hito. Critical revisions for important intellectual content: Maria Kappes and Marta Romero-García.