Patient Safety Competence and Second Victim Experience Among Nurses

doi:10.21203/rs.3.rs-4911322/v1

Background

Nurses engage in the most direct contact with patients and face a high risk of becoming second victims.Nurses' patient safety competency is an important factor in patient safety.The relationship between second-victim patient safety competence and second-victim experience remains unclear.Hence, the objective of this study was to explore the impacts of patient safety competence on the experiences of and support provided to the second victims of adverse nursing events.

Methods

A total of 924 nurses who had experienced adverse events in four tertiary-level A hospitals in Jiangsu Province were recruited from November 03,2022 ,to April 30,2023 using the convenience sampling method; these nurses were surveyed using the SociodemographicCharacteristics Questionnaire, the Characteristics of Experiencing Adverse Events Questionnaire, the Second Victim Experience and Support Tool, and the Patient Safety Competency Self-Rating Scale.

Results

The second victim experience and support of the nurses included in this research were at moderate level, with a mean score of 2.98±0.45; psychological distress received the highestrating at 4.00±0.83 points, while coworker support received the lowest rating at 2.59±0.53 points. Nurses exhibited a higher level of patient safety competency (4.321±0.584); furthermore,patient safety competency was negatively correlated with the level of second victim distress and positively correlated with the level of second victim support, while patient safety competency was an independent factor influencing second victim experience.

Conclusion

The higher the nurse's level of patient safety competency is, the lower the level of distress and the higher the level of perceived support experienced by the second victim, thus suggesting that improving patient safety competency scan provide organizational support for the second victim and promote the second victim's recovery.

patient safety competency

second victim

cross-sectional study

analysis of influencing factors

patient safety management

As the complexity of health care increases, the likelihood of events related to patient safety such as adverse events, medical errors, attempted events, and safety hazards increases exponentially^[1]. Medical staff thus experience patient safety events more frequently. Medical staff who experience adverse patient events that result in physical and psychological trauma are considered to be "second victims"^[2]. Second victims may experience anxiety, fear, guilt, anger, irritability, self-blame and self-doubt, tachycardia, sleep disturbances, loss of appetite and social withdrawal^[3-8]. Among all health care workers, nurses engage in the most direct contact with patients and face a high risk of becoming second victims^[2,9]. Adverse second victim experience seriously affects the quality of health care and increases nurse turnover. Second victim experience is influenced by multiple factors^[10]. Patient safety competency refers to the knowledge, skills, and attitudes that health care professionals must have to reduce unnecessary health care-related harm to the lowest acceptable level of risk^[11]. Nurses' patient safety competency is an important factor in patient safety. Attention to second victims is a global trend, and hospitals are increasingly focusing on second victim experience and seeking to establish hospital environments that can protect and support second victims^[12,13]. In China, awareness of second victims among hospital administrators remains insufficient, and the relationship between second-victim patient safety competence and second-victim experience remains unclear. Therefore, this study investigated and analysed the factors influencing Chinese nurses' second victim experience, explored the impact of patient safety competence on second victim experience, and provided a basis for attempts to provide better organizational support for second victims and reduce second victim victimization in clinical practice.

1.1 Study Population

Clinical nursing staff in four tertiary hospitals in Jiangsu Province from November 2022 to March 2023 were recruited for the study using a convenience sampling method. The inclusion criteria were as follows: ① possession of a nurse practitioner certificate and registered status; ②a minimum of 3 months of experience working in clinical nursing; and ③ signed informed consent forms, which indicated participants’ voluntary participation in this study. The exclusion criteria were as follows: (1) nurse trainees from outside hospitals and (2) absences due to sick or maternity leave at the time of the investigation.

1.2 Research Tools

1.2.1 General Information Questionnaire for Nurses: This questionnaire was designed by the research team based on a literature review, group discussion, and expert consultation, and it included items pertaining to participants’ department, gender, age, marital status, education, title, professional position, form of employment, and years of experience.

1.2.2 Adverse Event Characterization Questionnaire: This questionnaire was designed by the study team based on group discussion and expert consultation, and it included the number of cases of adverse events that had occurred since the beginning of the work, the type of adverse events that had occurred recently, the grade of each adverse event, the level of harm caused to the patient, the financial penalties suffered as a result of such adverse events, the financial incentives associated with the adverse events, and the duration of the most recent adverse event.

1.2.3 Second Victim Experience and Support Tool (SVEST)

The SVEST was developed by Burlison et al.^[1⁴^]. It is used to measure the experiences of and support provided to second victims, and it includes a total of 29 items across 9 dimensions; the total Cronbach's alpha coefficient of the scale is 0.892, the content validity index is 0.950, and the items are scored on a 5-point Likert scale, with total scores ranging from 29 to 145. The higher the total score is, the greater the degree of pain, the stronger the tendency to leave the job, and the higher the absenteeism level of the second victim; in addition, the higher the total score is, the lower the level of support.

1.2.4 Patient Safety Competency Self-Rating Scale for Nurses (PSCSSN)

The PSCSSN was developed by Chinese scholars Bian Wei et al. ^[1⁵^] and is used to evaluate nursing staff's competence in the context of patient safety; this scale includes 4 factors and 29 items and is scored on a 5-point Likert scale. Total scores range from 29-145 points. Additionally, nurses evaluate and score themselves with regard to their degree of conformity, and the higher the score is, the more competence in patient safety they exhibit. The total Cronbach's alpha coefficient of the scale is 0.930, and the retest reliability is 0.945.

1.3 Methods of Data Collection

The network questionnaire method was used. After obtaining consent from the nursing departments of four tertiary hospitals in Jiangsu Province, a network questionnaire was distributed to the head of the nursing department, and the head of the nursing department assisted in the distribution of questionnaires to clinical nurses in each department for completion in accordance with the requirements. This questionnaire was based on a unified guideline, which described the purpose of the study, concepts related to the second victim, informed consent, and the anonymity of the data collection process; in addition, the completion time was required to be no less than 150 seconds, and each network address could only complete the questionnaire once. A total of 1,708 questionnaires were collected as part of the study; 68 invalid questionnaires were excluded (due to incomplete completion or logical inconsistency or for other reasons), and 1,640 valid questionnaires were ultimately collected, for an effective recovery rate of 96.02%. A total of 924 nurses reported have experienced adverse events; the final data thus included 924 questionnaires.

1.4 Statistical Methods

SPSS 20.0 statistical software was used for data processing and analysis. Normally distributed data are expressed in terms of the mean ± standard deviation. Count data are described in terms of frequency, constitutive ratio or rate. Pearson correlation analysis and multiple linear regression analysis were used to analyse the correlation between patient safety competence and second victim experience as well as the factors influencing this relationship (α in = 0.05, α out = 0.10), and differences were considered to be statistically significant at the P<0.05 level.

2.1 Sociodemographic Characteristics of the Study Population

A total of 924 nurses had experienced adverse events and were included in the analysis. The details are shown in Table 1.

Table 1

Sociodemographic Characteristics of the Study Population
Projects	Number of people	Component ratio	Projects	Number of people	Component ratio
Department			Title
General Medicine	362	39.2%	Inferior	472	51.1%
Neurosurgery	304	32.9%	Intermediate	408	44.2%
Obstetrics	40	4.3%	High grade	44	4.8%
Paediatrician	48	5.2%	Positions
Emergency department	66	7.1%	Charge nurse	622	67.3%
Intensive care unit	26	2.8%	Ward team leader	102	11.0%
Alternative	78	8.4%	Physiotherapeutic nurse	50	5.4%
Genders			Office nurse	28	3.0%
Male	18	1.9%	Head nurse	60	6.5%
Female	906	98.1%	Other	62	6.7%
Age ( in years)			Forms of employment
<25	82	8.9%	Authorized staffing	88	9.5%
25–30	248	26.8%	Employment-based	302	32.7%
31–35	232	25.1%	Contract labour	534	57.8%
36–40	188	20.4%	Years of experience (in years)
>40	174	18.8%	0–5	208	22.5%
Level of education			6–10	216	23.4%
College or below	74	8.0%	11–20	376	40.7%
Undergraduate	834	90.3%	>20	124	13.4%
Master's degree or above	16	1.7%

2.2 Characteristics of Adverse Events Experienced by Second Victims

Details regarding the types of adverse event most recently experienced by the nurses are shown in Table 2.

Table 2

Type of the Most Recent Adverse Events Experienced by Second Victims
Projects	Number of people	Component ratio	Projects	Number of people	Component ratio
Number of Adverse events experience during work			Financial Penalties for the most recently experienced adverse event (RMB)
1–3	796	86.2%	0	368	39.8%
4–6	98	10.6%	<50	68	7.4%
>6	30	3.3%	50–200	362	39.2%
Type of most recently experienced adverse event			201–1000	102	11.0%
Falls	282	30.5%	>1000	24	2.6%
Unscheduled extubation	264	28.6%	Time of most recently experienced adverse event (day)
Nosocomial pressure injuries	102	11.0%	<7	110	11.9%
Fluid infusion extravasation	42	4.6%	7–30	312	33.8%
Checking error	124	13.4%	31–90	158	17.1%
alternative	110	11.9%	91–180	156	16.9%
Grade of most recently experienced adverse event			>180	188	20.4%
Level Ⅰ	54	5.8%	Grade of the harm caused to the patient by the most recently experienced adverse event
Level Ⅱ	100	10.8%	Level A	42	4.6%
Level Ⅲ	714	77.3%	Level B	170	18.4%
Level Ⅳ	56	6.1%	Level C	666	72.1%
Financial incentives associated with the most recently experienced adverse event (RMB)			Level D	16	1.7%
0	760	82.3%	Level E	20	2.2%
<50	56	6.1%	Level F	8	0.9%
50–200	108	11.7%	Level I	2	0.2%

2.3 The Second Victim Experience and Support Level Scores for Adverse Nursing Events Are Shown in Table 3.

Table 3

Results Regarding the Second Victim Experience and Support Level Scores for Adverse Nursing Events (n = 924,\(\:\text{X}\pm\:\text{S}\), points)
Dimension	Entry parity	Total dimension Score
Psychological distress	4.00 ± 0.83	16.02 ± 3.32
Physical pain	3.51 ± 1.02	14.05 ± 4.07
Colleague Support	2.59 ± 0.53	10.35 ± 2.14
Manager Support	2.33 ± 0.63	9.35 ± 2.53
Institutional support	2.52 ± 0.56	7.56 ± 1.68
Nonwork related support	2.17 ± 0.84	4.34 ± 1.68
Occupational self-efficacy	3.09 ± 0.63	12.37 ± 2.51
Separation and absenteeism	3.07 ± 0.95	12.27 ± 3.81
Second victim experience and support	2.98 ± 0.45	86.29 ± 13.00

2.4 Patient Safety Competency and Second Victim Experience Correlations

Factors pertaining to each dimension of patient safety competence were significantly correlated with the scores for each dimension of the second victim experience, as shown in Table 4.

Table 4

Patient Safety Competence and Second Victim Experience and Support Correlations
Dimensions of patient safety competency	Score	Patient safety competency and second victim experience correlation coefficients (r-values)
Dimensions of patient safety competency	Score	Psychological distress	Physical pain	Colleague support	Manager support	Institutional support	Nonwork related support	Self-efficacy	Separation and absenteeism
Knowledge factors	4.26 ± 0.65	-0.31^a	-0.17^a	0.14^a	0.39^a	0.33^a	0.38^a	-0.04	-0.11^a
Systemic factors	4.47 ± 0.64	-0.34^a	-0.14^a	0.22^a	0.39^a	0.29^a	0.41^a	-0.07^b	-0.07^b
Attitudinal factors	4.47 ± 0.60	-0.44^a	-0.24^a	0.16^a	0.35^a	0.29^a	0.43^a	-0.16^a	-0.15^a
Skill factors	4.09 ± 0.65	-0.37^a	-0.21^a	0.16^a	0.42^a	0.37^a	0.44^a	-0.08^a	-0.15^a
Overall average score	4.32 ± 0.58	-0.39^a	-0.20^a	0.19^a	0.43^a	0.35^a	0.45^a	-0.09^a	-0.12^a

a: P < 0.01, b: P < 0.05

2.5 Results of the Multiple Linear Regression Analysis of Patient Safety Competencies on the Factors Influencing Second Victims

Multiple linear regression analyses were performed using stepwise regression, in which context the total second victim experience score was included as the dependent variable, the scores on the dimensions of patient safety competence were included as independent variables, and the sociodemographic characteristics of the second victim and the characteristics associated with experiencing an adverse event that were statistically significant according to the univariate analysis of variance were included as the independent variables. Influential factors that were statistically significant (P < 0.05) are listed, and detailed results are shown in Table 5.

Table 5

Multiple Linear Regression Analysis of Patient Safety Competence on Factors Influencing Second Victimization
Independent variable	Regression coefficient	Standard error	Standardized regression coefficient	t value	P value
Constant	2.58	0.17	—	14.78	0.000
Age	-0.05	0.03	-0.15	-1.98	0.048
Title	0.02	0.03	0.04	0.85	0.391
Position	0.01	0.01	0.05	1.44	0.122
Form of employment	0.07	0.03	0.10	2.64	0.008
Years of experience	0.05	0.03	0.12	1.63	0.104
Number of adverse events experienced during work	-2.35	0.97	-0.08	-2.43	0.015
Type of most recently experienced adverse event	0.03	0.01	0.15	3.91	0.000
Grade of most recently experienced adverse event	-0.02	0.02	-0.06	-1.25	0.208
Grade of the harm caused to the patient by most recently last experienced adverse event	-0.02	0.01	-0.06	-1.38	0.165
Financial penalties for the most recently experienced adverse event (RMB)	0.03	0.02	0.06	1.58	0.114
Time of the most recently experienced adverse event	-0.02	0.01	-0.10	2.54	0.011
Patient safety competency knowledge factors	0.59	0.11	0.86	5.62	0.000
Patient safety competency system factors	0.74	0.12	1.06	6.07	0.000
Patient safety competence attitudinal factors	0.29	0.05	0.39	5.62	0.000
Patient safety competency skill factors	0.358	0.079	0.52	4.52	0.000
Patient safety competency	1.741	0289	2.27	6.01	0.000

3.1 The Second Victim of an Adverse Nursing Event Exhibits a Higher Level of Psychological Distress and Receives Less Support. The mean score on the Nurses' Second Victim Experience and Support Survey, the mean score was 2.98 ± 0.45, and the highest score was associated with psychological distress (4.00 ± 0.83), thus indicating that nurses who have become second victims experience anxiety, depression, fear, and other emotions^[16] and even exhibit a tendency to avoid work and leave their jobs^[3]. Related support scores were low, with the lowest score (2.17 ± 0.84) pertaining to nonwork-related support, which refers to family support or friend support; furthermore, the results of other research have shown that health care workers who have become second victims are provided with more effective social support by family and friends than by managers ^[17]. Nurses believe that their family and friends cannot understand the adverse events they have experienced and usually believe that the nurses themselves are the reasons for the adverse event, thus indicating that after the occurrence of an adverse event, nurses receive a lower level of care and emotional support from their family and friends and that second-victim family support measures must be strengthened in the future. Among the items pertaining to organizational support, coworker support scores were the highest (2.59 ± 0.53), while superior support scores were the lowest (2.33 ± 0.63); furthermore, most nurses who had become second victims were willing to take the initiative to talk to their coworkers after experiencing an adverse event, especially with respect to colleagues who had experienced similar adverse events. The results of this research revealed that the provision of timely emotional support to the second victim by affable and helpful colleagues after an adverse event is crucial with respect to both the alleviation and the repair of the psychological damage experienced by the second victim ^[18] and that effective support for the second victim must be based on the establishment of a noncriticism culture, thus highlighting a problem that must be solved from the macro perspective with regard to loopholes in the operation of the health care system. The macro perspective can be used to solve this problem; however, based on the individual pursuit of blame for a particular health care worker ^[19], a fair, safe organizational culture and nonpunitive management system can help second victims repair their professional confidence while simultaneously providing them with positive emotional support and opportunities for growth ^[20].

3.2 The Level of Patient Safety Competence Exhibited by Second Victims of Adverse Nursing Events Was Moderately High, Similar to the Level of Patient Safety Competence Exhibited by Saudi Nurses ^[21] and Higher than That Exhibited by Korean Nurses ^[22]. The results of this research revealed that the higher the level of nurse patient safety competence is, the lower the likelihood of adverse events; furthermore, the higher participants’ scores regarding patient safety competence skills and attitudes are, the more willing they are to take the initiative to report adverse events ^[23]. In recent years, due to the improvement of China's health care institutional safety system, the increasing importance of various health care institutions in patient safety management has led to the standardization of the nursing workflow and system, and in the clinical work of nurses, nurses can now standardize their own nursing safety behaviours and consciously implement various safety nursing measures with the goal of enhancing the level of patient safety care they provide and thus guaranteeing patient safety. The attitude factor of the patient safety competence of the second victim of adverse nursing events received the highest score (4.478 ± 0.602), which was probably due to the experience of adverse events, thus further strengthening the importance of patient safety. Skill factors received lower scores (4.092 ± 0.655) than other factors. In this survey, patient safety competence skill factors mainly included the continuous improvement of the quality of care, measures aimed at addressing adverse events after their occurrence, and methods used to identify safety hazards with the goal of preventing adverse events. Additionally, the nursing staff exhibited less mastery of these factors, and the training of clinical nursing staff in our hospitals focused on nursing operations. The training of clinical nursing staff in our hospitals focused on nursing operations and training in specialized theoretical knowledge, and less training related to patient safety was provided; furthermore, most training targets for nursing quality management and adverse event prevention were nursing administrators, and training for clinical frontline nurses, who are the second victims who actually experience adverse events, was lacking. To improve the patient safety competence of the second victims of adverse events in the context of nursing, medical institutions must strengthen training in patient safety-related skills.

3.3 Patient Safety Competence Is an Independent Factor That Impacts the Second Victims of Adverse Nursing Events. The results of this study revealed that patient safety competence was negatively correlated with the level of second victim distress and positively correlated with the level of second victim support. All dimensions of patient safety competence were negatively correlated with the psychological distress, physical distress, occupational self-efficacy, and the tendency to leave and be absent from work exhibited by the second victim of an adverse nursing event, thus suggesting that the higher the level of patient safety competence among nursing staff is, the weaker their tendency to experience distress from an adverse event or to leave their jobs. Caregivers who exhibited high levels of patient safety competence understood that patient safety events were inevitable, furthermore, they were more aware of ways in which they could obtain support and received higher levels of support. Caregivers who exhibit high levels of patient safety competency are more willing to work and communicate as a team, which is more conducive to the provision of safe and effective care to patients ^{[24, 25]}. Therefore, improving the level of patient safety competence not only reduces the likelihood of adverse events and promotes the proactive reporting of adverse events in nursing; it also reduces the suffering of the second victims of adverse events in nursing and helps these victims obtain organizational support more effectively. In this study, other factors, such as nurses' age, form of employment, the number of adverse events experienced during work, and the time of the most recent adverse event, were also identified as independent factors that impact the experience of the second victim, in which context second victims between the ages of 31–35 years experienced the highest level of psychological distress, those whose employment type was third-party labour dispatch (i.e., nonhospital employees) received the lowest level of organizational support, the number of cases of adverse events during work increased, and occupational self-esteem increased. The more cases of adverse events that occurred during work, the lower the level of occupational self-efficacy was, and the shorter the duration of the most recent adverse event was, the higher the levels of psychological and physical distress. In response to the factors pertaining to the experience of the second victim revealed in this study, targeted interventions, such as peer support ^[26] and web-based program trauma support services ^[27], were developed to help the second victim reduce their psychological and physiological distress, recover more quickly from the injury, and provide safer care.

This study revealed that nurses in Jiangsu Province, China, exhibited higher levels of second victim psychological distress and received less support. Because Jiangsu Province is among the most economically developed regions in China and began to focus on patient safety earlier than other regions, nurses in this context exhibit higher levels of patient safety competence. Nurses' patient safety competence was negatively correlated with their level of distress as the second victim, positively correlated with the level of support provided to the second victim, and an independent factor influencing the experience of the second victim. Nurses' patient safety competency is relatively weak, and medical institutions and social families do not pay sufficient attention to second victims and provide such victims with less support. Enhancing patient safety competency skills, strengthening second victims’ attention and support, helping second victims recover more effectively, and providing better and safer nursing care to patients are recommended.

SVEST:Second Victim Experience and Support Tool

PSCSSN:Patient Safety Competency Self-Rating Scale for Nurses

SPSS:Statistical Package for Social Science

Availability of data and materials

All important data supporting the findings of the study are included in the manuscript. The necessary detailed information and raw data are available from the corresponding author.

Ethics statement

Ethics approval and consent to participate Ethics approval was obtained through Ethics Committee of Nanjing First Hospital. The hospital, afliated to Nanjing Medical University, undertakes its own ethical review. The study was carried out in accordance with relevant guidelines and regulations. Participants provided written informed consent prior to being interviewed. The participants had the right to withdraw at any time without prejudice

Consent for publication

None.

Competing interests

The authors declare no competing interests.

FUNDING:This study was funded by Nanjing Municipal Health Committee and Nanjing Medical University. The sponsors of this work had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to the data in the study and the decision to submit.The number of funding:2023ZC048;YKK23122

Acknowledgments

We would like to thank all the nurses who participated in the study. And the authors thank Yuhong Chen who assisted with coordination of components of the research study.

Author information

Authors and Affiliations

Si Sun1,MMS; Shuhua Shang2,MMS; Hongxia Sun1*,MBBS

1.Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing City, China

2.Department of Cardiology Nanjing First Hospital, Nanjing Medical University, Nanjing City, China

Author contributions

SS and HXS conceived of and designed the study. SS ,SHS and HXS collected and analyzed data, and then SS drafted the manuscript. All authors contributed to the article and approved the submitted version.

Corresponding author

Correspondence to Hongxia Sun.

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No competing interests reported.

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Patient Safety Competence and Second Victim Experience Among Nurses

Status:

Version 1

Abstract

Introduction

1. Objects & Methods

2. Results

3. Discussion

4. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1