news &views Understanding the Second Victim, continued from page 26.
A recent online survey conducted at University of Maryland Medical Center (UMMC) as part of a performance improvement project demonstrated the prevalence of second victims among UMMC healthcare professionals. Of the 410 healthcare workers who participated in the online survey, almost 40 percent indicated that they are second victims healthcare workers who have been directly or indirectly involved in an adverse patient event. Of those involved in an adverse event, 36 percent indicated that they were negatively impacted. Additionally, 38 percent of responders indicated that there was inadequate support following an adverse event and 30 percent indicated that there is a “blame culture” at UMMC. As a result of this online survey, the purpose of this study was to define the “second victim” experience among nurses practicing at UMMC, and to create effective support strategies that will enable nurses who experience an adverse patient event to engage in a healthy recovery in order to function at an optimal level. Methods and Results Following IRB approval from the University of Maryland, twelve nurses from UMMC were recruited to participate in a series of three intense one-on-one interviews to discuss their experiences as a "second victim" and how their experience can be used to create creative strategies. On average, the nurses were 34.2 years of age with 9.16 years of nursing experience. Twelve nurses completed the first interview and nine nurses completed the second and third interview. Using Streubert’s (1991) methodology for analyzing qualitative research, the following themes were identified from the interviews: A. Experienced an Adverse Event a. The Actual Moment: The nurse recognizes he/she made an error and there is a moment of overwhelming doom. b. A Few Minutes Later: The focus becomes the safety of the patient. The nurse’s response is mechanical in nature. c. After the Event: The issue is not discussed openly among the unit or organization. d. The Aftermath: The nurse questions his/her future as a nurse. B. Finding Forgiveness: Nurses, in general, do not accept or forgive those who have made mistakes. This inhibits the individual from forgiving himself/herself. C. Moving Forward: The event or error is not resolved with the individual, thus the nurse may carry the error with him/her, and as a result, the nurse begins to question his/her ability to function to his/her optimal level.
Discussion This study demonstrates the need for more discussion surrounding how UMMC handles adverse patient events with regard to the individual nurse that may be involved in the event. The focus needs to be centered on not only providing support for the individual, but providing support for the unit as a whole. The leadership team, Staff Nurse Council and the Nurse Managers Council will play an active role in creating strategies to address this important issue. References Clancy, C.M. (2012). Alleviating “Second Victim” syndrome: How we should handle patient harm. Journal of Nursing Care Quality, 27 (1), 1 – 5. National Institute of Medicine. (1999). To err is human: Building a safer healthcare system. Washington, DC: National Academy Press. Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Brandt, J., & Hall, L.W. (2009). The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Quality & Safety in Health Care, 18 (5), 325-330. Streubert, H.J. (1991). Phenomenological research as a theoretic initiative in community health nursing. Public Health Nursing, 8(2), 119-123.
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