The unmeasured quality metric: Burn out and the second victim syndrome in healthcare

Moral injury: An unspoken burden of transplant surgery

Moral injury in health care is characterized as the lasting psychological, biological, and social impact on providers that occurs following an adverse patient outcome. Moral injury can contribute to second victim syndrome and lasting psychological harm. Although many surgeons face moral injury due to patient acuity and the potential for intraoperative or postoperative complications, the transplant ecosystem compounds the impact of moral injury. Institutional blame placed on the transplant surgeon following a posttransplant death or graft loss is magnified by public reporting. Centers whose outcomes fall below threshold levels are subject to regulatory citation and financial loss. Moral injury can also result in risk aversion, limiting access to transplants for higher-risk candidates and reducing acceptance of marginal organs hurting donor families. Strategies to increase resilience, reduce accusation and blame, and focus on system quality improvement are vital to mitigate the impact of moral injury on transplant professionals. The transplant community must proactively work to reduce moral injury to protect surgeons, ensure access to life-saving transplant procedures, and avoid unnecessary organ offer declines.

Interventions to support nurses as second victims of patient safety incidents: A qualitative study of nurse managers' perceptions

AIMS

To describe nurse managers' perceptions of interventions to support nurses as second victims of patient safety incidents and to describe the management of interventions and ways to improve them.

DESIGN

A qualitative study using interviews.

METHODS

A purposive sample of nurse managers (n = 16) recruited from three hospital districts in Finland was interviewed in 2021. The data were analysed using elements of inductive and deductive content analysis.

RESULTS

The study identified three main categories: (1) Management of second victim support, which contained three sub-categories related to the nurse manager's role, support received by the nurse manager and challenges of support management; (2) interventions to support second victims included existing interventions and operating models; and (3) improving second victim support, based on the sub-categories developing practices and developing an open and non-blaming patient safety culture.

CONCLUSION

Nurse managers play a crucial role in supporting nurses as second victims of patient safety incidents and coordinating additional support. Operating models for managing interventions could facilitate nurse managers' work and ensure adequate support for second victims. The support could be improved by increasing the awareness of the second victim phenomenon.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Mitigating the harmful effects of patient safety incidents can improve nurses' well-being, reduce burden and attrition risks and positively impact patient safety.

IMPACT

Increasing awareness of the second victim phenomenon and coherent operation models would provide equal support for the nurses and facilitate nurse managers' work.

REPORTING METHOD

COREQ checklist was used. What does this paper contribute to the wider global clinical community? Nurse managers' role is significant in supporting the second victims and coordinating additional support. Awareness of the second victim phenomenon and coherent operating models can secure adequate support for the nurses and facilitate nurse managers' work.

The Patient-Physician Relationship: Medical Students' Perceptions in a Novel Course

The patient-physician relationship, especially in the case of severely ill patients, is often fraught with anxiety, grief, and guilt in the physician who may come to feel that he or she has failed the patient and thereby becomes a "second victim." This notion was first explored in a 1973 publication (Artiss and Levine N Engl J Med 288(23):1210-4, 1973) that described a novel interactive seminar series for oncology fellows that had been designed to address and possibly remedy the frequent disquiet experienced by young physicians in this setting. Fifty years later, the medical student co-authors of this Perspective enrolled in an elective course that comprised a similar series of interactive seminars, now addressing the contemporary patient-physician relationship. The earlier paper was employed as a historical background, and the framework of the course then broadened such that the students considered the current environmental changes in medical practice (social, cultural, financial, legal, policy) that may be linked to the character of individual patient-physician relationships. This essay reports on the students' perception of such relationships, and on the environmental elements that may be helpful or harmful to the well-being of both patients and physicians.

Scoping review of the second victim syndrome among surgeons: Understanding the impact, responses, and support systems

BACKGROUND

It is thought that 50% of healthcare providers experience Second Victim Syndrome (SVS) in the course of their practice. The manifestations of SVS varies between individuals, with potential long-lasting emotional effects that impact both the personal lives and professional clinical practice of affected persons. Although surgeons are known to face challenging and high-stress situations in their profession, which can increase their vulnerability to SVS, majority of studies and reviews have focused squarely on nonsurgical physicians.

METHODS

This scoping review aimed to consolidate existing studies pertaining to a surgeon's experience with SVS, by broadly examining the prevalence and impact, identifying the types of responses, and evaluating factors that could influence these responses. The scoping review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Three databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception till March 19, 2023.

RESULTS

A total of 13 articles were eligible for thematic analysis based on pre-defined inclusion criteria. Effects of SVS were categorized into Psychological, Physical and Professional impacts, of which Psychological and Professional impacts were particularly significant. Factors affecting the response were categorized into complication type, surgeon factors and support systems.

CONCLUSION

SVS adds immense psychological, emotional and physical burden to the individual surgeon. There are key personal, interpersonal and environmental factors that can mitigate or exacerbate the effects of SVS, and greater emphasis needs to be placed on improving availability and access to services to help surgeons at risk of SVS.

A toolkit for individualizing interventions to mitigate second-victim syndrome in a diverse surgery community

Adverse outcomes are an inevitable consequence of surgical care. The term "second victim" was introduced by Wu to describe the emotional trauma experienced by a clinician who feels responsibility for an adverse clinical outcome. Second victims may feel shame, guilt, sadness, and a crisis of confidence. Surgeons rarely seek professional support following an adverse event but are more likely to confide in colleagues. Surgeons who represent groups traditionally underrepresented in medicine may be less likely to seek assistance following an adverse clinical outcome. There is a need for surgeons to have sufficient training to provide peer-to-peer support for wounded colleagues. The PEARLS Toolkit provides a blueprint toward this end.

Building a Culture of Support at a Pediatric Surgery Center Through Multidisciplinary Peer Support

INTRODUCTION

Surgeons and perioperative staff experience high rates of burnout manifesting as exhaustion, depersonalization, and lack of achievement. Consequences include increases in errors and adverse patient events. Little data exist regarding the effectiveness of multidisciplinary peer support systems in combatting burnout. We sought to improve staff morale through establishment of a formally trained, multidisciplinary peer support team.

METHODS

Selfselected surgeons, anesthesiologists, and nurses were formally trained as Peer Responders as part of an institutional peer support program. All perioperative staff at our pediatric surgery center (n = 120) were surveyed before initiation of the program and then 1-mo and 12-mo after initiation. Primary outcomes were unit morale, unit support, and peer approachability. Kruskal-Wallis tests and Chi-squared tests were used for comparison of primary outcomes among surveys and by position with an alpha value of 0.05 set for significance. Institutional review board approval was waived.

RESULTS

The survey response rates were 57.5%, 32.5%, and 37.5% chronologically. After 1 year, there were statistically significant increases in unit support (P < 0.01) and peer approachability (P < 0.001), and a nonstatistically significant increase in unit morale (P = 0.22). On subgroup analysis by staff role, surgeons were least likely to utilize peer support.

CONCLUSIONS

A multidisciplinary peer support team is an effective and easily reproducible means of building a culture of support and improving morale among perioperative staff. Surgeons were least likely to seek interprofessional peer support. Consequently, surgeon-specific strategies may be necessary. Further investigations are ongoing regarding secondary effects on staff burnout rates, patient safety, and quality of care.

Die Neonatologie/Pädiatrische Intensivmedizin – ein attraktiver Arbeitsplatz?

Hintergrund

Die Arbeitszufriedenheit wie auch das Wohlbefinden der ärztlichen und pflegerischen Mitarbeiter*innen sind zum einen relevant zur Mitarbeiter*innenbindung, aber auch zur Aufrechterhaltung einer qualitativ hochwertigen Patient*innenversorgung. Aufgrund des Personalmangels in der Neonatologie ist es wichtig, mehr über den aktuellen Stand der Arbeitsplatzzufriedenheit, der Work-Life Balance wie auch der Wechselabsichten zu erfahren.

Methode

Hierzu sind insgesamt 389 Ärzt*innen und Pflegekräfte befragt worden.

Ergebnisse

Insgesamt arbeiten 74 % der Ärzt*innen in Vollzeit (≥ 38 h/Woche) (Ärzte: 80 %, Ärztinnen: 69 %), wobei dies jedoch nur von 49 % der befragten Ärzt*innen (Ärzte: 57 %, Ärztinnen: 41 %) gewünscht ist. Mit 56 % an Ärzt*innen mit einem klinisch auffälligen WHO-5-Wohlbefindens Index zeigt sich auch hier Handlungsbedarf. Circa 44 % der befragten Ärzt*innen unter 60 Jahren planen, in den nächsten 5 Jahren ihren Arbeitgeber zu wechseln. Dies steht im signifikanten Zusammenhang zu Burn-out und Work-Life-Balance-Konflikten.

Diskussion

Insgesamt zeigen sich große Herausforderungen in der Vereinbarkeit von Arbeit und Familie und hierdurch der vermehrte Wunsch nach Teilzeit.

Second victim experiences and moral injury as predictors of hospitalist burnout before and during the COVID-19 pandemic

Background

The increasing number of physicians leaving practice, especially hospitalists, has been well-documented. The most commonly examined factor associated with this exodus has been burnout. The COVID-19 pandemic has put a unique and unprecedented stress on hospitalists who have been at the front lines of patient care. Therefore, the investigation of burnout and its related factors in hospitalists is essential to preventing future physician shortages.

Objective

This study examined the relationship between burnout, second victim, and moral injury experiences before and during the COVID-19 pandemic among hospitalists.

Methods

Two anonymous cross-sectional surveys of hospitalists from a community hospital in the metropolitan Washington, DC area were conducted. One was conducted pre-COVID-19 (September-November 2019) and one was conducted during COVID-19 (July-August 2020). The surveys were sent to all full-time hospitalists via an online survey platform. A variety of areas were assessed including demographic (e.g., age, gender), work information (e.g., hours per week, years of experience), burnout, second victim experiences, well-being, and moral injury.

Results

Burnout rates among providers during these two time periods were similar. Second victim experiences remained prevalent in those who experienced burnout both pre and during COVID-19, but interestingly the prevalence increased in those without burnout during COVID-19. Moral injury was predictive of burnout during COVID-19.

Conclusion

While there were some factors that predicted burnout that were similar both pre- and during-pandemic, moral injury was unique to predicting burnout during COVID-19. With burnout as a contributing factor to future physician shortages, it is imperative that predictive factors in a variety of different environments are well understood to prevent future shortages. Hospitalists may be an excellent barometer of these factors given their presence on the front line during the pandemic, and their experiences need to be further explored so that targeted interventions aimed at addressing those factors may be created.

North-African doctors as second victims of medical errors: a cross sectional survey

INTRODUCTION

Physicians involved in medical errors (MEs) can experience loss of self-esteem and negative psychological experiences. They are called "second victims" of the ME.

AIMS

To i) describe the profile, the types and the severity of MEs, and ii) explore the psychological impact on "second victims" to better understand how they cope.

METHODS

It was a cross sectional retrospective study conducted from March to August 2018. All physicians working at Farhat Hached and Sahloul University hospitals were asked to complete a questionnaire about their possible MEs. The impact of MEs was evaluated using the Impact of Event Scale-Revised (IES-R) (scoring, 0-88) (subscales ranges; intrusion, (0-32); avoidance, (0-32); hyperarousal, (0-24)). The diagnosis of post-traumatic stress disorder (PTSD) was made when the total IES-R score exceeded 33. The coping strategies were evaluated using Ways of Coping Checklist Revised (WCC-R) scale (scoring, problem-focused, (10-40); emotion focused, (9-36); seeking social support, (8-32)).

RESULTS

Among 393 responders, 268(68.2%) reported MEs. Wrong diagnosis (40.5%), faulty treatment (34.6%), preventive errors (13.5%) and faulty communication (6.4%) were the main frequent types of MEs. The most common related causes of MEs were inexperience (47.3%) and job overload (40.2%). The physicians' median (range) score of the IES-R was 19(0-69). According to the IES-R score, the most frequent psychological impacts were median (range): intrusion, 7(0-28) and avoidance symptoms, 7(0-24). PTSD symptoms affected 23.5% of physicians. Female sex and serious MEs were identified as predictors of PTSD. On the WCC-R check list, coping was balanced between the three coping strategies median (range), problem focused, 28.5(10-40); emotion-focused, 24(9-36) and seeking social support 21(8-32).

CONCLUSION

There is a relatively high impact of ME within these North-African university hospital physicians. Coping was balanced within different three strategies as reported worldwide. Physicians adopted more likely constructive changes than defensive ones.

Experience and support of Chinese healthcare professionals as second victims of patient safety incidents: A cross-sectional study

PURPOSE

To describe the experience and support of Chinese healthcare professionals as second victims of PSIs.

DESIGN AND METHODS

A cross-sectional study with anonymous online self-report questionnaires was adopted. A total of 1357 Chinese healthcare professionals participated in this study. The Chinese version of the Second Victim Experience and Support Tool (C-SVEST) was used to evaluate the experience of second victims and the quality of support resources. Descriptive and inferential statistics were employed to analyze the data.

FINDINGS

This study showed that 350 participants (25.8%) had been involved in PSIs during their careers. The majority of respondents who had experienced PSIs agreed they suffered more from psychological distress, followed by professional self-efficacy distress, and physical distress. Besides, they regarded colleague support and management support as the most desirable support. Statistically significant differences were reported in some items. First, compared with medical staff without professional titles, staff with professional titles suffered more from psychological distress but gained more support from colleagues.

PRACTICE IMPLICATIONS

The second victim phenomenon deserves further attention. The programs focusing on training qualified colleagues to provide emotional support should be developed, implemented, and evaluated. Moreover, it is necessary to build a better patient safety culture with nonpunitive responses and encourage the disclosure and reporting of PSIs.

Second-victim Experience and Support Desire Among Nurses Working at Regional Levels in China

AIM

To describe and analyse the degree of second victim syndrome and the desire for supports among nurses working in regional hospitals in China.

BACKGROUND

The evidence on the prevalence of second victim among healthcare workers remains inconsistent and have rarely focused on the regional level.

METHODS

A quantitative, descriptive, survey-based, online, cross-sectional study was conducted among 1,194 nurses in three regional hospitals.

RESULTS

A total of 918 (76.88%) nurses, who reported have had experienced patient safety incidents, were selected for the final analysis. The mean score for the Chinese version of the Second Victim Experience and Support Tool (C-SVEST) was (65.58±10.05). Psychological distress (15.91±2.99) and practice distress (15.26±4.32) had the highest score. The mean score for the desired form of support was (4.29±0.614). The option 'the opportunity to get guidance and suggestions for future work' was rated the most desired.

CONCLUSION

Nurses working at the regional level reported a similar degree of second victim experience and support desire, while the prevalence was much higher.

IMPLICATIONS FOR NURSING MANAGEMENT

The second victim phenomenon has become increasingly complex and challenging, and deserve more attention. Not only Safety-I, abut also Safety-II approaches are suggested to integrated to patient safety.

The second victim requires more than Medice Cura Te Ipsum

Burnout has attained epidemic proportions in all reaches of society. Only recently, has its impact in healthcare become a burning platform. Second victim syndrome, a consequence of an unforeseen adverse event, often precipitated by an error, can lead to a post-traumatic stress-like reaction, that is unique to healthcare workers. Often, the second victim suffers in silence, forced to rely on resilience. Peer support has been demonstrated to be beneficial in assisting healthcare workers in recovering from both burnout and second victim syndrome. Institutions and organizations must be more influential and responsive in supporting physicians and other healthcare workers in need.

The Prevalence of Second Victim Syndrome and Emotional Distress in Pediatric Intensive Care Providers

Pediatric critical care providers are at higher risk of second victim syndrome (SVS) and emotional distress after a poor patient outcome, unanticipated adverse event, medical error, or patient-related injury. We sought to determine the prevalence of SVS within our intensive care units (ICUs) and evaluate the adequacy of current institutional peer support. A validated survey tool, the second victim experience and support tool was sent electronically to all ICU providers in our pediatric health care system. Of 950 recipients, there were 266 respondents (28%). Sixty-one per cent of respondents were nurses; 19% were attending physicians, advanced practice providers, and fellows; 88% were females; 42% were aged 25 to 34 years; and 43% had worked in the ICU for 0 to 5 years. The most common emotion experienced was psychological distress (42%) and one-third of respondents questioned their self-efficacy as a provider after a second victim event. Support from colleagues, supervisors, and the institution was perceived as low. Support from a respected peer was the most desired type of support by 81% of respondents. Emotional distress and SVS are commonly found among pediatric ICU providers and the level of support is perceived as inadequate. Developing and deploying a peer support program are crucial to staff's well-being and resilience in the high-stress ICU environment.

Psychological exhaustion of nursing professionals who care for patients with neoplasms

OBJECTIVE

Identify, analyze and understand the social representations of nursing professionals about burnout syndrome.

METHOD

Qualitative study with nursing professionals who worked in the direct assistance to oncologic patients, conducted through semi-structured interview, using the technique of content analysis, anchoring the interpretations in the theory of social representations.

RESULTS

Seven professionals participated; after analysis, two categories emerged: "The stress of professionals, the naturalization of suffering and self-care strategies"; and "Ressignifications, learning in the oncologic sector and network gaps". The representations about stress and the relationship of the professionals with the daily practice were predominant.

FINAL CONSIDERATIONS

The nursing professionals represented the burnout syndrome socially as stress and made important reflections on the subject in the context of daily work. Concepts that determine the behavior of professionals were perceived as mechanisms of confrontation. In the vision of this social group, spirituality was revealed as a therapeutic strategy.

Supporting recovery after adverse events: An essential component of surgeon well-being

BACKGROUND

Failure to recover after a medical error is a major contributor to burnout. The degree to which pediatric surgeons experience errors and the barriers and facilitators to successful recovery are largely unknown.

METHODS

We conducted a survey of American Pediatric Surgical Association (APSA) members to measure frequency of personal experience with medical errors resulting in significant patient harm, describe coping mechanisms, and explore surgeon satisfaction with institutional support in the wake of an error.

RESULTS

We found that 80% of respondents have personally experienced a medical error resulting in significant patient harm or death, and that only about one-quarter were satisfied with the support provided by their institution. Only 11% of surgeons would prefer not to be contacted after an adverse event, and most would want to be contacted by their partners. Barriers to providing and receiving support included lack of knowledge, "shame and blame" culture, and lack of trust in the institution as an ally.

CONCLUSIONS

Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.

Second Victim Experience among OBGYN Trainees: What Is Their Desired Form of Support?

OBJECTIVES

Physician trainees in obstetrics and gynecology (OBGYN) experience unexpected outcomes similar to those of supervising physicians. A relative lack of experience and perspective may make them more vulnerable to second victim experience (SVE), however. The objectives of our study were to contrast the prevalence of SVE between supervising physicians and trainees and to identify their preferred methods of support.

METHODS

In 2019, the Second Victim Experience and Support Tool, a validated survey with supplemental questions, was administered to healthcare workers caring for OBGYN patients at a large academic center in the midwestern United States.

RESULTS

The survey was sent to 571 healthcare workers working in OBGYN. A total of 205 healthcare workers completed the survey, including 18 (43.9% of 41) supervising physicians and 12 (48.0% of 25) resident/fellow physicians. The mean scores for the Second Victim Experience and Support Tool dimensions and outcomes were similar between the two groups. Seven (58.3%) trainees reported feeling like a second victim after an adverse patient safety event at some point in their work experience compared with 10 (55.6%) of the supervising physicians. Five (41.7%) trainees identified as a second victim in the previous 12 months compared with 3 (16.7%) supervising physicians (P = 0.21). The most common form of desired support for both groups was conversations with their peers.

CONCLUSIONS

Trainees and supervising physicians are both at risk of SVE after an unexpected medical event and prefer conversations with peers as a desired form of support. Because trainees commonly encounter SVEs early in their careers, program directors should consider implementing a program for peer support after an unexpected event.

"I made a mistake!": A narrative analysis of experienced physicians' stories of preventable error

RATIONALE, AIMS, AND OBJECTIVES

The complexity of healthcare systems makes errors unavoidable. To strengthen the dialogue around how physicians experience and share medical errors, the objective of this study was to understand how generalist physicians make meaning of and grow from their medical errors.

METHODS

This study used a narrative inquiry approach to conduct and analyse in-depth interviews from 26 physicians from the generalist specialties of emergency, internal, and family medicine. We gathered stories via individual interview, analysed them for key components, and rewrote a "meta-story" in a chronological sequence. We conceptualized the findings into a metaphor to draw similarities, learn from, and apply new principles from other fields of practice.

RESULTS

Through analysis we interpreted the story of a physician who is required to make numerous decisions in a short period of time in different clinical environments among the patient's family and whilst abiding by existing rules and regulations. Through sharing stories of success and failure, the clinical supervisor can help optimize the physician's emotional growth and professional development. Similarly, through sharing and learning from stories, colleagues and trainees can also contribute to the growth of the protagonist's character and the development of clinic, hospital, and healthcare system.

CONCLUSION

We draw parallels between the clinical setting and a generalist physician's experiences of a medical error with the environment and practices within professional sports. Using this comparison, we discuss the potential for meaningful coaching in medical education.

Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows

Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.