Second Victim Experiences of Nurses in Obstetrics and Gynecology: SVEST Survey

Abstract

Aim(s):

To investigate second victim experiences and supportive resources for nurses in obstetrics and gynecology.

Background:

Nurses are at risk of developing second victim experiences after exposure to work related events.

Methods:

Nurses at a single institution were invited to participate in an anonymous survey that included the validated Second Victim Experience and Support Tool to assess symptoms related to second victim experiences and current and desired supportive resources.

Results:

Of 310 nurses, 115 (37.1%) completed the survey; 74.8% had not heard of the term ‘second victim.’ Overall, 47.8% reported feeling like a second victim during their career and 19.1% over the previous 12 months. As a result of a second victim experience, 18.4% experienced psychological distress, 14.3% turnover intentions, 13.0% decreased professional self-efficacy, and 12.2% felt that institutional support was poor. Both clinical and non-clinical events were reported as possible triggers for second victim experiences. Peer support was the most desired form of support as reported by 95.5%.

Conclusion(s):

Nurses in Obstetrics and Gynecology face clinical and non-clinical situations that lead to potential second victim experiences.

Implications for Nursing Management:

The second victim experiences of nurses should be acknowledged and resources should be implemented to navigate it. Educational opportunities and peer supportive interventions specific to second victim experiences should be encouraged.

Introduction

The term “second victim” was coined by Wu (2000) when describing the need to support physicians who were deeply affected after making a clinical error. In 2009, a consensus definition emerged to include all “healthcare providers involved in an unanticipated adverse patient event, medical error and/or a patient-related injury who become victimized in the sense that the provider is traumatized by the event” (Scott et al., 2010, p. 233). Adverse events occur when medical care harms a patient in a preventable or non-preventable way. (AHRQ https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors). Clinical events can be traumatic even when the healthcare provider is not directly involved in the patient outcome (Winning, 2018) or as in near miss events, in cases where the event never reaches the patient (Wahlberg, 2017).

Involvement in adverse events can have significant psychosocial and physical impacts on health care professionals (HCPs) (Burlison et al., 2016; Pratt & Jachna, 2015; Rodriquez et al., 2018; Schwappach et al., 2009; Scott et al., 2009; Scott et al., 2010; Ullstrom et al., 2014). HCPs may experience professional self-doubt, lower professional self-efficacy, self-blame, fear of reputational loss, and an internal struggle to return to feeling like a competent provider (Burlison et al., 2016; Rodriquez et al., 2018; Scott et al., 2009; Wu, 2000). To cope with the situation, some HCPs isolate themselves, whereas others become hypervigilant (Scott et al., 2009; Ullstrom et al., 2014). Some are so traumatized by the event that they choose to change their work environment (Wahlberg, 2017), leave their chosen profession altogether or turn to suicide (Burlison, Quillivan, Scott, Johnson, & Hoffman, 2016; Cadwell & Hohenhaus, 2011; Grissinger, 2014; Rodriquez & Scott, 2018; Saavedra, 2020; Scott et al., 2009; Shanafelt et al., 2011; Ullström, Sachs, Hansson, Øvretveit, & Brommels, 2014).

The specialty of obstetrics and gynecology (OBGYN) presents unique considerations in the context of the second victim phenomenon. In the United States, approximately 700 women and more than 1 million fetuses and infants die or are seriously injured from pregnancy or delivery complications annually (Centers for Disease Control, 2019; MacDorman & Gregory, 2015). While previous studies have focused on the impact of adverse events among HCPs in various specialties (Edrees et al., 2011; Gazoni, Amato, Malik, & Durieux, 2012; Mok et al., 2019; Scott et al., 2009; Ullstrom et al., 2013), or among obstetricians or Certified Nurse Midwives (Austin, Smythe, & Jull, 2014; McDaniel & Morris, 2020; Schrøder, Larsen, Jørgensen, vB Hjelmborg, Lamont, & Hvidt, 2016; Wahlberg et al., 2017), no studies have focused on second victim experiences (SVEs) among nurses in OBGYN. The second victim experience may result from intrapartum emergencies, traumatic births, labor and delivery or surgical complications, events which limit a patient’s reproductive capacity, and maternal, fetal or infant death. The purpose of this study is to understand the SVEs of nurses caring for OBGYN patients. Specifically, this study aims to: (1) determine the prevalence and types of SVEs in nurses; (2) explore the types of support services used or most desired by nurses; and (3) identify risk factors for SVEs among nurses.

Methods

Study Design and Participants

The Second Victim Experience and Support Tool (SVEST) survey instrument [Appendix 1] was administered from July 1 to September 1 2019 to all members in the Department of Obstetrics and Gynecology at a large academic institution in the Midwest. Participants were recruited via email invitation. The email included a description of the survey, an explanation of risks and benefits of participation, and a survey link unique to each person to prevent duplicate responses. The survey was created and disseminated using Research Electronic Data Capture (REDCap, Rochester MN), a secure, web-based application used to collect and organize data. The study was reviewed and deemed exempt by Mayo Clinic’s Institutional Review Board. Respondents were informed that completing the survey implied consent to participate. Survey responses were collected anonymously. The results herein are restricted to the responses of Registered Nurses and Licensed Practical Nurses.

Survey Tool

Second Victim Experience and Support Tool

The SVEST is a validated instrument that contains 29 items/statements to which respondents indicate the extent they agree (5-point Likert scale: 1 = strongly disagree, 5 = strongly agree) with each statement as it pertains to their personal experiences with adverse patient safety events, medical errors, or unexpected outcomes. Cronbach alpha reliability scores ranged from 0.61–0.89 for the survey dimensions (Burlison et al., 2017). Seven additional items assess desired forms of support through a Likert scale (1 = strongly do not desire, 5 = strongly desire) [see Appendix]. Responses to the SVEST were scored according to published instructions (Burlison et al., 2017). Specifically, scores for seven dimensions (psychological distress, physical distress, colleague support, supervisor support, institutional support, non-work-related support, and professional self-efficacy) and two outcome variables related to employment (turnover intentions and absenteeism) were calculated from the responses to the 29 main items. For each respondent, each dimension or outcome variable was defined as the mean of 2 to 4 items specific to that variable after converting the reserve-worded item responses; mean scores were only calculated for respondents who answered more than 50% of the items specific to that variable (e.g. ≥3 of 4 items, ≥2 of 3 items, or both of 2 items). Using the mean scores for each respondent, the overall mean and standard deviation was determined for each dimension and outcome variable, as well as the number and percentage of respondents with a mean score of 4 or higher. A higher score for each specific dimension represents experiencing more psychological distress, more physical distress, decreased professional self-efficacy, and a greater degree to which support is perceived as inadequate. A higher score for each specific outcome represents more turnover intensions and more absenteeism.

Supplemental questions were added assessing demographic variables (clinical specialty, job title, and years of experience within the department). Because of the low number of male providers in the division, gender was not collected to maintain anonymity. Respondents were asked to indicate specific events that might lead to SVEs in OBGYN, assessed separately depending upon OB and GYN specialty. Finally, respondents were asked about their knowledge of the term ‘second victim’ and if they have ever felt like a second victim.

Data Analysis

Statistical analysis was performed using the SAS version 9.4 software package (SAS Institute, Inc.; Cary, NC). The data was summarized using standard descriptive statistics including counts with percentages for categorical variables and means with standard deviations for the scores from the SVEST. Comparisons between respondents who did versus did not report feeling like a second victim in the past year were evaluated using the chi-square test for specialty and years of experience and the two-sample t-test for each of the SVEST dimensions and outcomes. All calculated p-values were two-sided and p-values < 0.05 were considered statistically significant.

Results

Demographic Data

Of the 571 staff invited to participate, 205 (36%) completed the survey. The majority (310, 52.5%) of those invited were Registered or Licensed Practical Nurses, of which 115 (37.1%) completed the survey. The results herein focus on the responses from the 115 nurses, of which 76 (66.1%) work in OB, 36 (31.3%) in GYN, and 3 (2.6%) in both areas. Length of time in the OBGYN department was evenly distributed among nursing respondents: 42 (36.5%) < 5 years, 37 (32.2%) 5 to 15 years, and 36 (31.3%) for > l5 years.

Second Victim Experiences

Prior to the survey, 74.8% of the nurses had not heard of the term ‘second victim’ (Table 1). Of those 24.3% with previous knowledge of this term, 53.6% had heard it from a peer, 35.7% at an educational experience, and 21.4% at a professional conference.

Table 1.

Summary of Knowledge of Second Victim Experience

	All (N=115)†	Gynecology (N=39)	Obstetrics (N=79)
Prior to this survey, had you heard the term second victim related to adverse events
Yes	28 (24.3%)	14 (35.9%)	17 (21.5%)
No	86 (74.8%)	25 (64.1%)	61 (77.2%)
Did not respond	1 (0.9%)	0	1 (1.3%)
Where heard of the term:	% of 28	% of 14	% of 17
Peers at place of employment	15 (53.6%)	9 (64.3%)	8 (47.1%)
Supervisor or Director	2 (7.1%)	1 (7.1%)	1 (5.9%)
Professional conference	6 (21.4%)	3 (21.4%)	4 (23.5%)
Education/ school	10 (35.7%)	5 (35.7%)	7 (41.2%)
Online	0	0	0
Other	2 (7.1%)	0	2 (11.8%)
EVER felt like a second victim after an adverse patient safety event
Yes	55 (47.8%)	18 (46.2%)	38 (48.1%)
No	59 (51.3%)	21 (53.8%)	40 (50.6%)
Did not respond	1 (0.9%)	0	1 (1.3%)
Last 12 months, felt like a second victim after an adverse patient safety event
Yes	22 (19.1%)	7 (17.9%)	15 (19.0%)
No	91 (79.1%)	32 (82.1%)	62 (78.5%)
Did not respond	2 (1.7%)	0	2 (2.5%)
Type of support mechanisms or help:	% of 22	% of 7	% of 15
Conversations with peers	21 (95.5%)	6 (85.7%)	15 (100.0%)
Conversations with supervisors/managers	10 (45.5%)	5 (71.4%)	5 (33.3%)
Conversations with family	14 (63.6%)	5 (71.4%)	9 (60.0%)
Conversations with friends	11 (50.0%)	4 (57.1%)	7 (46.7%)
Conversations with chaplain	1 (4.5%)	1 (14.3%)	0 (0.0%)
Conversations with private therapist	2 (9.1%)	1 (14.3%)	1 (6.7%)
Systems review	2 (9.1%)	1 (14.3%)	1 (6.7%)
Employee Assistance Program	0	0	0
Patient safety/quality committee members	2 (9.1%)	1 (14.3%)	1 (6.7%)
Other	1 (4.5%)	0 (0.0%)	1 (6.7%)

^†Responses are from 115 nurses, of which 76 (66.1%) work in OB, 36 (31.3%) in GYN, and 3 (2.6%) in both areas

Almost half (47.8%) reported feeling like a second victim after an adverse event at some time in their career with 19.1% having this experience in the last 12 months. Support from peers (95.5%) and family members (63.6%) were most commonly relied upon as supportive resources. None of the nurses who reported feeling like a second victim over the past year sought support from the Employee Assistance Program.

Respondents were asked to indicate specialty-specific events that have the potential to make them feel like a second victim. Events with the most potential to result in an SVE (each noted by over 50%) included: fetal or neonatal loss, maternal death, intrapartum or neonatal death > 2500g, patient accusations/complaints, and coworker complaints (Table 2). Of the 44 OB nurses who reported being a part of an obstetrical adverse event during their careers, the majority (79.5%) experienced 1–5 OB adverse events in total, and a third reported that they had been part of an unanticipated death of a patient (22.7%) or unanticipated patient injury (36.4%). Of these 44 OB nurses, 11.4% seriously considered leaving their current position in the last 12 months due to an OB adverse event. (Table 2)

Table 2.

Summary of Experiences of Obstetric Nurses

	Total (N=79)
Any specific events that have the potential to make you feel traumatized and possibly feel like a second victim in obstetrics
None checked	9 (11.4%)
At least one checked YES	70 (88.6%)
Type of event:
Fetal or neonatal loss	62 (78.5%)
Maternal death	58 (73.4%)
Intrapartum or neonatal death >2500g	50 (63.3%)
Patient accusations/ complaints	47 (59.5%)
Coworker complaints	41 (51.9%)
Litigation	36 (45.6%)
Birth trauma	32 (40.5%)
Uterine rupture	20 (25.3%)
Fetal anomalies	19 (24.1%)
Admission to NICU of neonate >2500g and >37wks	16 (20.3%)
Maternal admission to ICU	14 (17.7%)
APGAR at 5 minutes < 7	11 (13.9%)
3rd and 4th degree perineal laceration	11 (13.9%)
Return to operating room or L/D	9 (11.4%)
Maternal blood transfusion	3 (3.8%)
Other	3 (3.8%)
Career: Ever been part of an obstetric adverse patient safety event
Yes	44 (55.7%)
No	35 (44.3%)
Analysis among the 44 with obstetric adverse patient safety event
Career: No. of obstetric adverse patient safety events
1–5	35 (79.5%)
5–10	6 (13.6%)
10–20	2 (4.5%)
Did not respond	1 (2.3%)
Career: Been a part of an obstetric adverse patient safety event with an unanticipated death of a patient
Yes	10 (22.7%)
No	34 (77.3%)
Career: Been part of an obstetric adverse patient safety event with an unanticipated serious injury to a patient
Yes	16 (36.4%)
No	28 (63.6%)
Past 12 months: No. of obstetric adverse patient safety events in current position
0	27 (61.4%)
1–5	17 (38.6%)
Seriously considered leaving current position in the last 12 months due to an obstetrics adverse patient safety event
Yes	5 (11.4%)
No	39 (88.6%)

For the nurses who work in GYN, patient accusations (84.6%), unexpected complications (59.0%), coworker complaints (56.4%), litigation (43.6%), missed diagnoses (33.3%) and patient death due to lack of continuity of care (33.3%) were the top events that had the potential to make them feel like a second victim (Table 3). Of the 25 GYN nurses who experienced a gynecologic adverse event during their careers, the majority (92.0%) was involved in 1–5 adverse events total and less than a third reported that they had been part of an unanticipated death of a patient (20.0%) or unanticipated patient injury (28.0%). Of these 25 GYN nurses, one (4.0%) seriously considered leaving their current position in the last 12 months due to a GYN adverse event (Table 3).

Table 3.

Summary of Experiences of Gynecology Nurses

	Total (N=39)
Any specific events that have the potential to make you feel traumatized and possibly feel like a second victim in GYN
None checked	1 (2.6%)
At least one checked YES	38 (97.4%)
Type of event:
Patient accusations/complaints	33 (84.6%)
Unexpected complications	23 (59.0%)
Coworker complaints	22 (56.4%)
Litigation	17 (43.6%)
Missed diagnoses	13 (33.3%)
Continuity of care patient death	13 (33.3%)
Return to operating room	11 (28.2%)
Intraoperative death	10 (25.6%)
Readmission to hospital	6 (15.4%)
Unexpected diagnoses	5 (12.8%)
Other	2 (5.1%)
Career: Ever been part of a GYN adverse patient safety event
Yes	25 (64.1%)
No	13 (18.8%)
Did not respond	1 (2.6%)
Analysis among the 44 with obstetric adverse patient safety event
Career: No. of GYN adverse patient safety events
1–5	23 (92.0%)
5–10	1 (4.0%)
Did not respond	1 (4.0%)
Career: Been a part of a GYN adverse patient safety event with an unanticipated death of a patient
Yes	5 (20.0%)
No	19 (76.0%)
Did not respond	1 (4.0%)
Career: Been a GYN adverse patient safety event with an unanticipated serious injury to a patient
Yes	7 (28.0%)
No	17 (68.0%)
Did not respond	1 (4.0%)
Past 12 months: No. of GYN adverse patient safety events in current position
0	13 (52.0%)
1–5	11 (44.0%)
Did not respond	1 (4.0%)
Seriously considered leaving current position in the last 12 months due to a GYN adverse patient safety event
Yes	1 (4.0%)
No	23 (92.0%)
Did not respond	1 (4.0%)

Responses to the Second Victim Experience and Support Tool Pertaining to Adverse Patient Safety Events, Medical Errors, and/or Unexpected Outcomes

The seven dimensions and two outcomes of the SVEST tool are summarized in Table 4. Higher mean scores on the SVEST represent more second victim responses. For six of the seven dimensions, the means for the overall study group were less than the neutral rating of three. In relation to an event, the percentage of respondents who experienced psychological distress (i.e. their mean rating was 4 or higher on a 5-point scale) was 18.4%. Lower professional self-efficacy was experienced by 13.0% and feeling of poor institutional support for the event was experienced by 12.2%. For the SVEST outcome variables, turnover intentions were experienced by 14.3% (Table 4).

Table 4.

SVEST Dimensions and Outcome Variables

Variable†	No. of items	No. of respondents‡	No. of respondents (%) with a mean score of 4 or higher	Overall Mean (SD)
Dimension
1. Psychological distress	4	114	18.4	2.52 (1.20)
2. Physical distress	4	115	7.8	1.90 (1.02)
3. Colleague support	4	115	0	2.08 (0.66)
4. Supervisor support	4	114	5.3	1.84 (0.87)
5. Institutional support	3	115	12.2	2.79 (0.87)
6. Non-work-related support	2	112	6.2	3.06 (0.36)
7. Professional self-efficacy	4	115	13.0	2.73 (0.94)
Outcome
8. Turnover intentions	2	112	14.3	2.12 (1.19)
9. Absenteeism	2	112	5.4	1.60 (0.94)

^†The respondents score for each dimension or outcome was defined as the mean of 2 to 4 items each rated on a 5-point scale of 1=strongly disagree and 5=strongly agree. A higher score for each specific dimension represents experiencing more psychological distress, more physical distress, decreased professional self-efficacy, and a greater degree to which support is perceived as inadequate. A higher score for each specific outcome represents more turnover intensions and more absenteeism.

^‡For each dimension or outcome, results are presented for respondents who answered more than 50% of the items (e.g. ≥3 of 4 items, ≥2 of 3 items, or both of 2 items).

Desirability of seven support options is shown in Table 5. Of the options specified in the SVEST, “a respected peer to discuss the details of what happened” was rated as the most desired form of support. The least desired form of support was “a confidential way to get in touch with someone 24 hours a day to discuss how the experience may be affecting me”, but all were rated favorably.

Table 5.

Support Options Endorsed by Respondents

Support option	No. of respondents	Desired, n (%)†	Not Desired, n (%)†	Mean (SD)
1. The ability to immediately take time away from my unit for a little while.	112	70 (62.5)	17 (15.2)	3.71 (1.20)
2. A specified peaceful location that is available to recover and recompose after one of these types of events.	112	73 (65.2)	19 (17.0)	3.70 (1.19)
3. A respected peer to discuss the details of what happened.	112	92 (82.1)	4 (3.6)	4.19 (0.84)
4. An employee assistance program that can provide free counseling to employees outside of work.	114	62 (54.4)	16 (14.0)	3.62 (1.13)
5. A discussion with my manager or supervisor about the incident.	114	77 (67.5)	10 (8.8)	3.92 (1.04)
6. The opportunity to schedule a time with a counselor at my hospital to discuss the event.	112	56 (50.0)	27 (24.1)	3.37 (1.26)
7. A confidential way to get in touch with someone 24 hours a day to discuss how my experience may be affecting me.	113	51 (45.1)	34 (30.1)	3.27 (1.25)

^†Each support option was rated on a 1 to 5 Likert scale, where a response of 4 or 5 represented the support option as being desired and 1 or 2 represented the support option as being not desired.

Factors Associated with Feeling like a Second Victim

Demographics and SVEST dimensions and outcomes of respondents who did versus did not report feelings like a second victim in the past year are presented in Table 6. No significant difference was noted between the two groups in terms of their specialty or years of experience. However, respondents who reported feeling like a second victim in the past year were significantly more likely to report experiencing more psychological distress, more physical distress, inadequate colleague support, inadequate institutional support, low professional self-efficacy, and increased turnover intentions compared to those who did not report feelings like a second victim in the past year (p<0.05). In particular, the mean (SD) score for psychological distress in the two groups were 3.4 (1.1) vs. 2.3 (1.1), where the higher mean score in the group who reported feeling like a second victim in the past year represents experiencing more psychological distress. Likewise the mean (SD) score for turnover intentions in the two groups were 2.8 (1.3) and 2.0 (1.1), where the higher mean score in the group who reported feeling like a second victim in the past year represents experiencing more turnover intentions.

Table 6.

Comparison of respondent characteristics and SVEST dimensions and outcomes between respondents who did vs did not report that they felt like a second victim after an adverse patient safety event in the past 12 months^a

Characteristic	Reported on the survey that they had felt like a second victim after an adverse patient safety event in the last 12 months		P-valueb
	No (N=91)	Yes (N=22)
Specialty			0.69
GYN/REI	29 (31.9%)	7 (31.8%)
OB and GYN/REI	3 (3.3%)	0 (0.0%)
OB only	59 (64.8%)	15 (68.2%)
Years working in the OB/ GYN department			0.89
Less than 5 years	33 (36.3%)	9 (40.9%)
5 to less than 15 years	29 (31.9%)	6 (27.3%)
15 years or more	29 (31.9%)	7 (31.8%)
SVEST dimensionc
Psychological distress			<0.001
N	90	22
Mean (SD)	2.3 (1.1)	3.4 (1.1)
Physical distress			<0.001
N	91	22
Mean (SD)	1.7 (0.9)	2.7 (1.0)
Colleague support			0.004
N	91	22
Mean (SD)	2.0 (0.7)	2.4 (0.5)
Supervisor support			0.07
N	91	21
Mean (SD)	1.8 (0.8)	2.2 (1.0)
Institutional support			0.003
N	91	22
Mean (SD)	2.7 (0.8)	3.2 (0.9)
Non-work-related support			0.55
N	88	22
Mean (SD)	3.1 (0.4)	3.0 (0.2)
Professional self-efficacy			0.004
N	91	22
Mean (SD)	2.6 (0.9)	3.2 (0.9)
SVEST outcomec
Turnover intentions			0.005
N	88	22
Mean (SD)	2.0 (1.1)	2.8 (1.3)
Absenteeism			0.71
N	88	22
Mean (SD)	1.6 (1.0)	1.7 (0.9)

^aResults based on 113 (of the 115) who answered the question about second victim experience

^bComparisons between respondents who did versus did not report feeling like a second victim in the past year were evaluated using the chi-square test for specialty and years of experience and the two-sample t-test for each of the SVEST dimensions and outcomes.

^cThe respondents score for each SVEST dimension or outcome was defined as the mean of 2 to 4 items each rated on a 5-point scale of 1=strongly disagree and 5=strongly agree. A higher score for each specific dimension represents experiencing more psychological distress, more physical distress, decreased professional self-efficacy, and a greater degree to which support is perceived as inadequate. A higher score for each specific outcome represents more turnover intensions and more absenteeism.

Discussion

Main Findings

The majority of OBGYN nurses reported SVEs during their career and many in the last year, though knowledge of the term “second victim” was limited. SVEs may be triggered by non-clinical or patient care events. Not unexpectedly the types of triggers vary between OB and GYN. Most nurses preferred peer support in the aftermath of a SVE and some identified the potential for increased institutional support. Nurses as second victims report psychological distress and low professional self-efficacy, along with turnover intentions. The SVEST survey instrument provided comprehensive assessment of SVEs in OBGYN.

Interpretation of Results

Our study is the first to examine SVEs among OBGYN nurses. About half (47.8%) of the OBGYN nurses were involved in a patient safety adverse event and experienced SVEs during their careers, similar to rates documented in other studies (Edrees et al., 2011; Seys et al., 2013; Gazonni et al., 2012; Nydoo, Pillay, Naicker, & Moodley, 2019). Involvement in adverse patient safety events can have a significant negative impact on frontline nurses. Nurses as second victims to events specific to OBGYN reported psychological distress and low professional self-efficacy as a result of SVEs, as supported by existing literature (Burlison et al., 2016; Mok et al., 2019; Rodriquez et al., 2018; Scott et al., 2009; Ullstrom et al., 2014; Wu, 2000). One in ten obstetrical nurses in the study considered leaving nursing as a result of involvement in these events; beyond the personal effects of career drop out, employee turnover poses a major financial drain on institutions (Hayes et al, 2006; Hayes et al, 2012). Turnover intentions as a result of SVEs have been previously reported (Burlison et al., 2016; Wahlberg et al., 2017). The provision of adequate support resources to help these providers navigate the post-event experience may help mitigate employee loss and promote thriving among affected nurses.

Specific events identified by nurses to have the potential to cause SVEs include patient outcomes and situations such as patient or co-worker accusations or complaints and litigation. The high percentage of respondents selecting non-clinical events as potential SVE triggers demonstrates that these events may also contribute to SVEs and should not be overlooked by nursing administrators. Types of events noted as possible triggers for SVEs varied by area of specialty. These responses are consistent with previously identified risk factors, including unexpected patient outcomes, patient demise, and litigation (Edrees et al., 2011; Manser 2011; Nydoo et al., 2019; Quillivan et al., 2016; Scott et al., 2009). The identification of patient accusations and complaints in this study as potentially traumatizing, suggests that colleagues and managers should proactively reach out to involved nurses and offer supportive interventions following these events.

While a quarter of respondents (24.3%, 28/115) reported involvement in at least one adverse event over the past year, only 39.3% of these 28 nurses reported feeling like a second victim. Therefore, not all HCPs who are involved in adverse events will experience the second victim phenomenon. Although not examined in this study, previous literature demonstrates that personality traits, personal and professional experiences, degree of self-identified personal responsibility, event outcome, and whether or not adequate support was sought or provided may influence each unique and individualized SVE (Nydoo et al., 2019; Quillivan et al., 2016; Seys et al., 2013).

Talking with peers was the most desired form of post-event support by OBGYN team members and is consistent with findings among other specialties (Burlison et al., 2017; Gazoni et al., 2012; Hu et al., 2012; Lane et al., 2018; Manser, 2011; Merandi et al., 2017; Mok, 2019; Scott et al., 2010; Seys et al., 2013; Shapiro & Galowitz, 2016; Rivera-Chiauzzi et al., 2020; van Pelt 2008; Winning et al., 2020). Establishing formal peer support programs for second victims is advocated by the Joint Commission, which encourages institutional systems to proactively reach out to affected HCPs (Joint Commission (2018), Quick safety issue 39: Supporting second victims.). Timely deployment of peer support can be a powerful tool to help colleagues involved in an adverse event work through the emotional aftermath by normalizing post-event experiences. High levels of perceived support from peers have also shown to buffer the association between involvement in adverse events and negative outcomes such as anxiety and depression (Winning et al., 2018), which may impact quality of care and work productivity (Burlison et al., 2016; Scott et al., 2009; Seys et al., 2013; Schwappach et al., 2009; Rodriquez et al., 2018; West et al., 2006).

Implications of Findings for Nurses and Nursing Management

Nurses comprise the highest proportion of hospital staff and provide the majority of direct patient care. Adverse events, medical errors and unanticipated outcomes associated with emotional implications are inevitable occurrences in the professional role of nurses. Due to the sensitive nature of nurses’ work in OBGYN, it is likely that they will be involved in clinical events that lead to SVEs, especially given the broad range of event types described as potentially traumatizing by our cohort. Nurses on the frontlines and in leadership positions must be aware of the SVE, including clinical signs and high-risk clinical situations that may lead to SVEs in order to promote post-event thriving. Possessing this knowledge allows for a proactive approach, including the early identification of affected personnel and ensuring availability of adequate resources to help nurses offload emotional labor and normalize the post-event experience. Educational opportunities and supportive interventions specific to the SVEs of nurses should be a priority for nursing leaders and nurses as frontline providers.

Directing nurses to existing organizational resources, such as employee assistance programs, may be helpful as an initial resource for affected nurses. Institutions should also consider implementing resources to specifically address SVEs, such as formalized second victim peer support programs as developed by leading health care institutions in the U.S (Dukhanin et al., 2018; Edrees et al., 2016; Krzan et al., 2015; Merandi et al., 2017; Scott et al., 2010; van Pelt 2008). Turnover intentions from SVEs may lead to nurses leaving their specialty area or profession altogether, which may justify allocation of resources for supportive interventions to prevent the financial loss associated with department or institutional loss of nursing staff. Having leadership that acknowledges SVEs of staff and ensures that supportive resources are available may foster a culture that helps affected nurses move on and thrive.

The findings of this study reinforce that the SVEST can be used to augment understanding of SVEs of nursing staff, along with their desired supportive resources. Future research could use the SVEST before and after implementation of new second victim supportive resources to measure providers’ perceptions of effectiveness. The SVEST-R was published following the completion of data collection for this study. Future research should be conducted using this instrument, which incorporates an added dimension of resilience to better assess positive outcomes and growth from SVEs (Winning et al., 2020). For some HCPs, involvement in adverse patient safety events may result in positive outcomes such as increased resilience, leading patient safety initiatives, supporting fellow nurses, or educating nurses and other disciplines on SVEs. Research focusing on personal and professional growth or thriving as a result of SVEs is an area of interest that should be further explored.

Strengths and Limitations

Strengths of this study include the use of a validated tool. From a novel angle to examine SVEs, this study also addresses the impact of adverse events on frontline providers in a clinical specialty with high potential for stressful and traumatic occurrences. Study limitations include use of a single-center and single department for the study cohort which restricted the sample size and may have decreased generalizability to nurses in other specialty areas and settings. Additionally, the survey was conducted at a single timeframe, independent of when adverse events occurred, thus potentially introducing recall bias. The data in this study is based on subjective self-reports of nurses. Non-responder bias may also have affected results given the sensitivity of the survey topic.

Conclusion

This study highlights that nurses working in the OBGYN specialty are involved in clinical situations that may lead to SVEs manifested as psychological distress, turnover intentions, and lack of professional self-efficacy. In addition to clinical triggers, nurses may also experience SVE due to patient or co-worker accusations or complaints and litigation. Since peer support is the most desired form of support following SVEs, programs to support this resource should be encouraged.