How to Immediately Support a Second Victim: An Educational Program for Leaders

By

Tracy Chu
Thesis

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

in

Nursing Science and Healthcare Leadership

in the

OFFICE OF GRADUATE STUDIES

of the

UNIVERSITY OF CALIFORNIA

DAVIS

APPROVED:

______________________________________
Elena Siegel, Ph.D., R.N., Chair.

______________________________________
Susan Adams, Ph.D., R.N., N.P., C.N.S.

______________________________________
Deborah Ward, Ph.D., R.N., F.A.A.N.

Committee in Charge

2018

i




ProQuest Number: 10748074




All rights reserved

INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.






ProQuest 10748074

Published by ProQuest LLC (2018 ). Copyright of the Dissertation is held by the Author.


All rights reserved.
This work is protected against unauthorized copying under Title 17, United States Code
Microform Edition © ProQuest LLC.


ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106 - 1346
 Acknowledgements

This past year and a half has been such an incredible journey filled with typical life highs

and lows. Yet in the end, I have so much to be grateful for and so many people that helped me

succeed with my sanity still intact. I’d like to recognize a few members of my family, my

friends and coworkers, and professors who have helped contribute to my successful completion

of this program.

First, thank you to my husband and my children for supporting me. They allowed me to

study and be less present than I would have been if I had not been in school. They gave me time

to myself when I needed it and supported me throughout the program. For that I am extremely

grateful. Thank you to my mother who always was there for me and frequently helped care for

my children. Thank you to my sister and father who were always there to listen to me complain

and make me laugh.

To my friends and coworkers (Debi, Traci, Terry, Sherry, Siobhan) and countless others

who persuaded (coerced) me to get my advanced degree and mentally supported me throughout

this program, I thank you from the bottom of my heart. I know I can reach out to any single one

of you and you will talk me down from the ledge in which I am standing.

I’d like to acknowledge my professors who contributed to my successful journey. I

would like to thank Dr. Elena Siegel who served as a role model, mentor, and motherly support

when times were tough for me. You taught me how to write scholarly and continually pushed

me to be a better writer. To Dr. Bigbee, Dr. Ward, Dr. Draughon Moret, Dr. Joseph, and Dr.

Adams, I thank you for all of the support and patience that you extend to all of your students,

including myself.

ii
 I am eternally grateful to the Gordon and Betty Irene Moore Foundation. I do not take

this gift bestowed upon me lightly and hope to return the favor by serving my community in the

future.

Finally, I want to recognize my friends Jessica and Lori and my cohort who joined me on

this journey. You have served as a constant source of invaluable support and I hope to continue

the friendships that we have made for years to come.

iii
 Abstract

Purpose: The purpose of this project was to create an introductory educational PowerPoint

program to prepare nurse leaders to provide immediate emotional support for a potential nurse

second victim after an adverse event.

Background/Significance: Error prevention and patient safety are areas of critical focus in

hospitals across the world. However, adverse events still occur every day in busy hospital

environments, despite new and modern safety technology designed to prevent these events.

Most healthcare workers enter the medical field with the intention of healing and comforting the

sick, and these healers are the same people that have the potential to be traumatized when their

errors cause harm. It is important to identify and support these potential second victims

immediately after the adverse event occurs as the lasting effects from involvement can cause

emotional, psychological, physical and professional distress.

Methods: The educational offering was developed in two, sequential phases. First, all

information included in the PowerPoint slides and instructor scripts were developed based on the

results of a review and synthesis of literature related to research on the impact of adverse events

on second victims and organizations and ways to best support second victims. Second, key

stakeholders were invited to preview the slide presentation and provide input in the areas of

overall content, flow, and usefulness of the materials. Revisions were made to the PowerPoint

slides and scripts based on this input.

Results: A total of ten nurse leaders participated in sessions to provide input for this educational

offering. The final slide design incorporated participants’ suggestions on content, visual appeal,

notes, references and resources. Suggestions for revisions beyond the scope of this initial project

iv
will be considered for use in future presentations based on resources and time allocations for

sessions.

Conclusion: Nurse leaders are in a pivotal position to recognize and mitigate system issues that

contribute to adverse events and stop the blame and punishment culture that still exists today.

Educating nurse leaders on how to best support second victims is an initial step to moving from a

blame culture to a just culture.

v
 Table of Contents

Introduction……………………………………………………………………………….…….…1

Background and Literature Review and Synthesis…………………………………………….….4

Approach…………………………………………………………………………………………14

Procedures………………………………………………………………………………………..16

Results……………………………………………………………………………………………16

Discussion………………………………………………………………………………………..20

References………………………………………………………………………………………..24

Appendix A: Interview Letter……………………………………………………………………30

Appendix B: Overview…………………………………………………………………………..31

Appendix C: Interview Questions…………………………………………………….……….…32

Appendix D: Final Power Point……………………………………………………………….…33

vi
 Introduction

Error prevention and patient safety are areas of critical focus in hospitals across the

world. However, adverse events still occur every day in busy hospital environments (Conway,

Federico, Stewart, & Campbell, 2011), despite new and modern safety technology designed to

prevent these errors (Hall & Scott, 2012). The landmark report To Err is Human highlighted the

epidemic of errors and put forth the call for safer healthcare and strategies that hospitals could

utilize to prevent these errors (Institute of Medicine, 1999). The report highlighted the role of

faulty systems, not individuals, as the cause of medical errors and suggested the act of dismissing

the error-prone person would not prevent the error from occurring again in the future (Institute of

Medicine, 1999). According to Seys et al. (2013), 14% of patients are involved in an adverse

event. A study conducted by James (2013) found more than 400,000 deaths related to medical

errors occur every year, an increase from the previous estimate of 98,000 in the 1999 Institute of

Medicine’s report.

There are many victims of adverse events that occur in hospital settings, including

patients, staff members involved in the adverse event, and the organization where the event

occurred (Daniels & McCorkle, 2016). Most healthcare workers enter the medical field with the

intention of healing and comforting the sick, and these healers are the same people that have the

potential to be traumatized when their errors cause harm (Hall & Scott, 2012) or they are

involved in an adverse event.1

1
Drawing from definitions from the Agency for Healthcare Research and Quality (U.S. Department of Health and
Human Services, 2018), National Quality Forum (National Quality Forum Patient Safety Terms, 2018) and the
World Health Organization (Conceptual Framework for the International Framework of Patient Safety
Classification, 2018), this paper refers to adverse events as any unanticipated event that occurs in an inpatient
hospital setting such as a near miss (potential error that did not reach patient) or medical error that had potential to
impact or directly impacted a patient in a negative way.

1
Second Victim of Adverse Events

The term “second victim” was first described by Wu (2000). A second victim is defined

as a practicing healthcare professional that has been indirectly or directly involved in a near miss

or adverse patient event or error and subsequently suffers from a predictable trajectory of

negative emotional and psychological effects (Scott et al., 2010). The second victim

phenomenon is not widely known. In one survey of 141 healthcare workers, over half of the

respondents had never heard of the term “second victim” (Edrees, Paine, Feroli, & Wu, 2011).

However, it was found that up to 50% of healthcare workers become a second victim once in

their careers (Van Gerven, Bruyneel, et al., 2016). In a patient safety culture survey conducted

within the University of Missouri Health Care System, 15% of 1160 respondents reported

experiencing second victim symptoms within the past year after being involved in an adverse

event and 68% of these respondents reported not receiving any support from their organization

(Scott et al., 2009).

It is important to identify and support potential second victims immediately after an

adverse event occurs, as the lasting effects can be devastating for a healthcare provider, and can

include emotional, psychological, physical and professional distress. In the aftermath of a

medical error, some of the emotions felt by healthcare professionals include guilt, shame, and

feelings of helplessness (Trent et al., 2016). The experience has even been compared to a

“medical emergency” (Denham, 2007). The negative psychological impact for second victims

can be mitigated with supportive work environments that foster a non-punitive safety culture that

supports staff, reserves judgment, and explores ways to improve system issues (Quillivan,

Burlison, Browne, Scott, & Hoffman, 2016). Healthcare workers are rarely if ever taught about

the likelihood of making an error, coping with an adverse event, the emotional turmoil that they

2
might experience related to the negative outcome, and the hospital investigative processes (Scott

& McCoig, 2016). Leadership awareness of the second victim phenomena and how to support

the second victim after involvement in an adverse event could potentially mitigate/hasten the

recovery from the negative trajectory of emotions and physical symptoms experienced by a nurse

involved in an adverse event. Prevention of this sequelae can not only benefit the nurse but also

the organization in which the nurse is employed.

Online toolkits offer resources for organizations to implement comprehensive second

victim programs (Conway, Federico, Stewart, & Campbell, 2011; Communication and Optimal

Resolution, 2017; Medically Induced Trauma Support Services, 2017). However, for

organizations that do not have a second victim support program, support for second victims is

dependent on the knowledge and approach used by individual leaders. In fact, informal staff

support does not need to involve a comprehensive and organized training program. After

ensuring patient safety by focusing on immediate clinical needs after an adverse event, someone

present within the hospital environment must be ready to support the subsequent emotional

repercussions that the staff involved might suffer (Institute for Healthcare Improvement, 2011).

This immediate support is often provided by a leader (charge nurse, supervisor, manager or

director). Providing initial informal support to second victims is estimated to be sufficient for

emotional recovery 60% of the time (Scott et al., 2010). Evidence-based resources to guide

leaders’ individual support of the second victim nurse in the immediate aftermath of involvement

in an adverse event are needed.

The purpose of this project is to develop a brief educational offering in PowerPoint slide

format for organizations without a second victim program. This educational offering is intended

to serve as a guide for nurse leaders responding to an adverse event to provide immediate

3
emotional support for a potential nurse second victim. For the purpose of this project, nurse

leaders are defined as those employed in an acute care facility in a role of supervising nurses,

including charge nurses and other nurses higher on the organizational chart. The educational

offering provides leaders with foundational information in three content areas, with support from

the literature: 1) definitions and circumstances related to a second victim; 2) the support desired

by second victims; and 3) recommendations for supporting a nurse immediately after their

involvement in an adverse event.

Background Literature Review and Synthesis

Search Strategy

A comprehensive literature review was conducted utilizing Google Scholar and PubMed.

The aim of the literature review was to identify research articles that described the emotional,

physical, and psychological impact of adverse events on second victims as well as evidence-

based practice recommendations to best support second victims. Published second victim

programs were also included in the articles reviewed. Search terms included “second victim”,

“impact”, “support”, “second victim programs” and “medical errors”. Research articles that

focused solely on second victims other than nurses and articles published earlier than 2000 were

excluded from the review. Qualitative and quantitative research studies and systematic reviews

were reviewed based on the following inclusion criteria: (1) participants included nurses as the

sole category of provider or in combination with other healthcare providers as second victims;

(2) the study findings included impact of adverse events on nurses or nurses and other healthcare

professionals and/or (3) the study findings included the desired or offered support of the nurse

second victim as one of the primary outcomes. References from systematic reviews and

literature reviews were also utilized as a search strategy.

4
 The literature synthesis provides an overview of three areas of the second victim

phenomenon. The first section describes the emotional, physical, psychological and career

impact of involvement in an adverse event for healthcare professionals and their organization.

The second section focuses on research in support for second victims. The final section reviews

published comprehensive programs implemented in large hospitals to support the second victim.

The Impact of Adverse Events

The impact of adverse events on nurses is reported in both qualitative and quantitative

research studies. Twenty-four research articles were included in the review and literature

synthesis. Seven of the papers reviewed were qualitative studies, eleven used a quantitative

approach, and two used mixed methods. The review also included one case study and three

systematic reviews. Seven of the studies were conducted in countries outside of the United

States including Israel (Rassin, Kanti, & Silner, 2005), Greece (Karga, Kiekkas, Aretha, &

Lemonidou, 2011) Belgium (Van Gerven, Bruyneel, et al., 2016), Brazil (De Freitas et al.,

2011), Spain (Mira et al., 2015), Norway (Schelbred & Nord, 2007) and Sweden (Ullstrom,

Andreen Sachs, Hansson, Ovretveit, & Brommels, 2014). One study compared experiences

between the United States and the United Kingdom (Harrison et al., 2015) and the remaining

studies were conducted in a variety of settings across the United States. Participants were

recruited from a variety of settings, including, health systems (Edrees et al., 2011; Scott et al.,

2009; Scott et al., 2010), state boards of nursing (Jones & Treiber, 2010; Wolf, J. Serembus, J.

Smetzer, H. Cohen, & M. Cohen, 2000), individual hospitals (Burlison, Scott, Browne,

Thompson, & Hoffman, 2017; De Freitas et al., 2011; Joesten, Cipparrone, Okuno-Jones, &

DuBose, 2015; Quillivan et al., 2016; Rassin et al., 2005; Ullstrom et al., 2014), multiple

hospitals (Harrison et al., 2015; Karga et al., 2011; Lewis, Baernholdt, Yan, & Guterbock, 2015;

5
Mira et al., 2015; Van Gerven, Bruyneel, et al., 2016), nursing journals, and professional

organizations (Chard, 2010; Schelbred & Nord, 2007). The objective of this literature synthesis

was to determine the prevalence of psychological emotions, feelings, and fears associated with

being involved in an adverse event, physical symptoms experienced, and the impact on the nurse

related to his/her profession. Findings from this review suggest that nurses experience a variety

of psychological emotions and feelings, physical symptoms and work-related sequelae that often

impacts their lives in significant ways, both positive and negative, after a medical adverse event.

Emotional impact. Nurses experience significant emotional distress after involvement

in an adverse event (Chan, Khong, & Wang, 2017; Sirriyeh, Lawton, Gardner, & Armitage,

2010), and this experience does not appear to differ across international borders (Harrison et al.,

2015). Words used to describe the feelings and emotions associated with involvement in an

adverse event included descriptive terms such as feeling helpless (Rassin et al., 2005),

discomfort and insecurity (De Freitas et al., 2011), panic (Sirriyeh et al., 2010), remorse,

frustration, extreme sadness (Scott et al., 2009), and worried and nervous (Wolf et al., 2000).

Questioning of self-worth was also evident from descriptive terms such as self-doubt (Harrison

et al., 2015; Mira et al., 2015; Scott et al., 2009; Sirriyeh et al., 2010), self-blame, loss of self-

esteem, sense of failure (Jones & Treiber, 2010) and shame (Crigger & Meek, 2007; Rassin et

al., 2005; Schelbred & Nord, 2007; Sirriyeh et al., 2010).

Guilt. Guilt is a burdensome emotion that is defined by the Merriam-Webster dictionary

as a “feeling of deserving blame for offenses” (Merriam-Webster Dictionary, 2017). Nurses’

experiences of guilt subsequent to their involvement in an adverse event were widely reported in

the findings of the studies reviewed (Chan et al., 2017; Chard, 2010; Harrison et al., 2015; Karga

et al., 2011; Mira et al., 2015; Rassin et al., 2005; Schelbred & Nord, 2007; Seys et al., 2013;

6
Sirriyeh et al., 2010; Wolf et al., 2000). In a study by Mira et al., (2015), guilt was listed as the

most common emotion experienced by respondents, with 58.8% of 430 health professionals

(nurses and physicians) reporting guilt in the aftermath of a patient error. Guilt was also listed in

the findings of three other studies as one of the most common emotions (Harrison et al., 2015;

Karga et al., 2011; Wolf et al., 2000).

Anger. Anger also was a prevalent emotion cited throughout the literature, however, the

direction of the anger varied or was unspecified. Seven research studies mentioned the emotion

anger, two stated the anger was both self-directed and directed towards others (Chard, 2010;

Karga et al., 2011), and the other five studies were not specific in regards to whom the anger was

directed (Chan et al., 2017; Crigger & Meek, 2007; Rassin et al., 2005; Scott et al., 2009; Seys et

al., 2013).

Fear. Fear was mentioned in ten of the articles reviewed. However, the reported focus

of the fear varied. Fear about some aspect of the respondents’ career was one prominent theme

that emerged, including fear of the inquiry and repercussions (Rassin et al., 2005), reputation

damage (Scott et al., 2009), legal consequences (Mira et al., 2015; Treiber & Jones, 2010),

disciplinary action and punishment (Wolf et al., 2000), retribution (Joesten et al., 2015) and job

loss (Treiber & Jones, 2010). Fear for the patient was also mentioned (Karga et al., 2011;

Treiber & Jones, 2010; Wolf et al., 2000) and unspecified fear was found in four studies (Chan et

al., 2017; Crigger & Meek, 2007; Seys et al., 2013; Sirriyeh et al., 2010).

Physical and psychological impact. Stress-related physical symptoms associated with

the second victim experience reflect a spectrum of mild physical symptoms, ranging from

muscle tension (Scott et al., 2009) to severe psychological conditions, such as post-traumatic

stress disorder (Rassin et al., 2005; Schelbred & Nord, 2007) and thoughts of suicide (Schelbred

7
& Nord, 2007). Fatigue was described in two studies (Mira et al., 2015; Scott et al., 2009);

symptoms such as excitability and insomnia were described in others (Mira et al., 2015;

Schelbred & Nord, 2007; Scott et al., 2009; Seys et al., 2013; Ullstrom et al., 2014). Anxiety was

also described frequently as a physical symptom (Chan et al., 2017; Crigger & Meek, 2007;

Edrees et al., 2011; Mira et al., 2015; Scott et al., 2009; Sirriyeh et al., 2010)

The psychological impact of being involved in an adverse event does not always

diminish quickly and is sometimes described as long lasting (Ullstrom et al., 2014), even years

after the event (Jones & Treiber, 2010). In studies conducted by Scott et al., (2009) and Ullstrom

et al. (2014), respondents described their adverse events with amazing detail, despite the passage

of time. A frequent replaying of the event in the respondents’ mind was also described across

several studies (Joesten et al., 2015; Mira et al., 2015; Schelbred & Nord, 2007; Scott et al.,

2009; Seys et al., 2013; Ullstrom et al., 2014).

Impact on career. Several research studies report the negative aspects of personal

involvement in an adverse event on the career of a nurse. Personal consequences such as loss of

confidence (Jones & Treiber, 2010; Karga et al., 2011; Rassin et al., 2005; Seys et al., 2013;

Sirriyeh et al., 2010), decreased job satisfaction (Scott et al., 2009), and second-guessing their

career choice (Joesten et al., 2015; Scott et al., 2009; Treiber & Jones, 2010; Ullstrom et al.,

2014) were all described. Other repercussions include feelings that the respondents’ reputation

had been damaged (Ullstrom et al., 2014), strained relationships with their colleagues (Harrison

et al., 2015), fear of lawsuits (Joesten et al., 2015), disciplinary action (Ullstrom et al., 2014),

and expectation of punishment (Crigger & Meek, 2007). Study participants’ concerns about

their ability to perform their job was a theme also noted in several of the study findings (Crigger

8
& Meek, 2007; Edrees et al., 2011; Joesten et al., 2015; Jones & Treiber, 2010; Scott et al., 2009;

Ullstrom et al., 2014).

Despite the reported negative impact of nurses’ involvement in adverse events, some

studies in the literature also reported positive findings. For example, future caution and attention

to preventing errors, safety to detail and medication administration were identified (Crigger &

Meek, 2007; Harrison et al., 2015; Karga et al., 2011; Rassin et al., 2005; Treiber & Jones, 2010;

Ullstrom et al., 2014; Wolf et al., 2000).

Impact on organization. The literature reviewed included findings related to the impact

of the second victim experience on the hospital in which a nurse is employed. Two of the

quantitative research studies correlated second victim distress with absenteeism (Burlison et al.,

2017) and turn-over intentions (Burlison et al., 2017; Joesten et al., 2015). Findings from a study

of a significant adverse event in a psychiatric hospital revealed a “third victim” effect

represented by delayed discharges and increased close observation of patients (Russ, 2017).

Summary. The current literature provides a broad overview of the emotional,

psychological, physical and career impact of adverse events on healthcare professionals and

serves as a basis for further research in this area. Methodologies varied, utilizing qualitative,

quantitative and mixed method approaches. The participants represented different countries and

recruitment varied amongst the research articles. The findings from this literature review served

as a basis for the content included in this educational offering.

The literature reviewed reveals a range of emotional, psychological, physical and career

impact in the aftermath of involvement in adverse events. Emotional impact includes

experiencing guilt, anger, and fear. Physical impact includes suffering from stress responses that

can be linked to post traumatic stress disorder. Finally, the literature reflects a variety of ways

9
nurses’ careers are impacted. Supporting the second victim is essential to mitigating/hastening

second victim recovery.

Supporting the Second Victim

Evidence suggests that second victims desire some type of formal or informal support to

mitigate the emotional, physical, and psychological personal impact of their involvement in an

adverse event (Seys et al., 2013; Ullstrom et al., 2014). In one study by Edrees, Paine, Feroli &

Wu (2011), 69% of participants sought support after an incident; 15 out of 41 studies from a

systematic review included findings related to second victims seeking social support after

involvement in an adverse event (Seys et al., 2013). Findings related to the type of support

desired and received varied among the studies reviewed. Four sources of support were

commonly reported: peer, management/organizational, family and friends and professional

support.

The twelve studies reporting findings related to second victim support varied in

methodology and study design: four qualitative studies (Denham, 2007; Schelbred & Nord,

2007; Scott et al., 2009; Ullstrom et al., 2014), four quantitative (Burlison et al., 2017; Edrees et

al., 2011; Harrison et al., 2015; Van Gerven, Vander Elst, et al., 2016), a mixed methods

approach (Scott et al., 2010), one systematic review (Seys et al., 2013) and one instrument

development (Burlison et al., 2017). All research articles included nurses as participants, seven

also included physicians, three included pharmacists, and five included other disciplines. Only

three of the articles focused solely on nurses as research participants. The systematic review did

not name the professional discipline of the second victims that participated in the studies

reviewed (Seys et al., 2013).

10
 Peer support. Although different types of desired support are described in the literature,

a preference for peer support by second victims was noted in five of the research studies

reviewed (Burlison et al., 2017; Harrison et al., 2015; Schelbred & Nord, 2007; Scott et al.,

2009; Ullstrom et al., 2014). In one quantitative study with 303 healthcare provider participants,

80.5% of second victims stated their preference for support coming from peers (Burlison et al.,

2017). Turning to peers for support was reported as preferential to professional help (Harrison et

al., 2015) and was described as crucial in one study (Ullstrom et al., 2014).

Management and organizational support. Second victims are getting support from

their organizations, but the extent varies greatly and the support is often unstructured and

insufficient (Ullstrom et al., 2014). Lack of follow up, structures, and routine were all described

as barriers to support, even though formal institutional support was stated as preferential (Scott et

al., 2010). Although second victims desire support, one study found that many second victims do

not accept or utilize the offered formal support (Ullstrom et al., 2014). Findings from another

study suggest second victims are not aware of where to go for support (Scott et al., 2009);

however, for those with institutional support available, less than half of the second victims that

participated in the study reported accessing the support (Harrison et al., 2015). Important

characteristics of institutional support included management follow up (Ullstrom et al., 2014), a

just culture approach, trained peer support and internal institutional support (Scott et al., 2010)

and formal and informal support (Edrees et al., 2011).

Family and friend support. Second victims often seek support from family and friends

(Edrees et al., 2011; Scott et al., 2009). Findings from the Ullstrom et al. (2014) and Wolf et al.

(2000) studies both highlight the support elicited from friends and family. However, some

11
participants reported not knowing to whom to turn to and concerns about the non-healthcare

providers understanding their experience (Scott et al., 2009).

Summary. The findings from this literature review suggest that support for second

victims may be inconsistent. In one study by Schelbred & Nord (2007), eight out of ten

respondents were not given any support with the personal consequences of their medical error.

However, if support was given, second victim respondents generally received support from peers

or colleagues (Edrees et al., 2011; Harrison et al., 2015; Lewis et al., 2015; Wolf et al., 2000),

with managers periodically also offering support (Edrees et al., 2011; Harrison et al., 2015;

Schelbred & Nord, 2007; Scott et al., 2010; Wolf et al., 2000; Z. R. Wolf, J. F. Serembus, J.

Smetzer, H. Cohen, & M. Cohen, 2000).

This literature review represents different methodologies, participant recruitment, and

sample sizes. Support from peers, management, family and friends were identified as the most

common ways second victims receive support, with inconsistencies in institutional support.

This literature review suggests the support desired by an individual second victim is unique and

cannot be generalized across second victims. Future research is needed not only to identify best

practices for supporting a nurse involved in an adverse event, including a variety of support

options, individualized to each nurse, situation, and situational response. The findings from this

literature review served as a basis for content incorporated into the PowerPoint educational

offering.

Comprehensive Programs to Support a Second Victim

An internet search was used to identify programs to support second victims, yielding

multiple publicly-available organizational websites (e.g.: Medically Induced Trauma Support

Services, 2017; Communication and Optimal Resolution, 2017; Conway, Federico, Stewart, &

12
Campbell, 2011), as well as six research studies (Burlison et al., 2017; Daniels & McCorkle,

2016; H. Edrees et al., 2016; Mira et al., 2017; Scott et al., 2010; Trent et al., 2016), two

descriptive articles (Pratt, Kenney, Scott, & Wu, 2012; van Pelt, 2008), one website toolkit

(Clinician Support Tool Kit for Healthcare, 2017) and one white paper (Conway, Federico,

Stewart, & Campbell, 2011). The content was reviewed for information on second victim

program best practices and implementation. The recipients of the second victim programs

differed across the research studies, including: staff from a pediatric hospital (H. Edrees et al.,

2016) and two large North American hospitals (Scott et al., 2010; van Pelt, 2008), nurse

anesthetists (Daniels & McCorkle, 2016), and frontline staff at Spanish hospitals and primary

care (Mira et al., 2017). Additionally, development and program implementation varied among

the research articles. Five of the articles described institutions’ processes on assessing need and

developing a support program (Daniels & McCorkle, 2016; Edrees et al., 2016; Mira et al., 2017;

Scott et al., 2010; van Pelt, 2008). Of the five articles, two described their initial program

development as beginning with a literature review (Daniels & McCorkle, 2016; Mira et al.,

2017), one with qualitative staff interviews (Scott et al., 2010), one created a task force (van Pelt,

2008), and one surveyed staff to assess program need (H. Edrees et al., 2016). The most

comprehensive program surveyed for need, developed a peer support team, and then evaluated

the program via surveys, self-evaluations and support groups (H. Edrees et al., 2016). The focus

of who provided the second victim support differed among the articles. Of the five programs,

peers were trained in three of the programs to serve as the primary second victim support (H.

Edrees et al., 2016; Scott et al., 2010; van Pelt, 2008). Mira et al. (2017) developed an

educational website and Daniels and McCorkle (2016) designed curriculum to educate nurse

anesthetists about the second victim phenomenon.

13
 Three other web-based comprehensive organization-level second victim program

resources were identified for this review: The Institute on Healthcare Improvement’s white paper

on Respectful Management of Serious Clinical Adverse Events (Conway, Federico, Stewart, &

Campbell, 2011), Clinician Support Toolkit for Healthcare (Medically Induced Trauma Support

Services, 2017), and the Agency for Healthcare Research and Quality’s program

Communication and Optimal Resources (CANDOR) Process (Communication and Optimal

Resolution, 2017). All of these resources address second victim support as a part of their

comprehensive organizational adverse event response programs.

Summary. This review offers a broad overview of programs that specific hospitals have

implemented as well as tools available to help an organization embark on the development of a

comprehensive adverse event response plan. The programs reviewed were comprehensive and

involved different methods for developing second victim programs. Further research is needed

to develop guides or tools for organizations that do not have any second victim program or

resources to offer those that respond to second victims.

Approach

An instructor-led educational program titled “How to Immediately Support a Second

Victim: An Educational Program for Leaders” (see Appendix D) was developed using a 20-

minute PowerPoint format with instructor scripts. Nurse leaders with supervisory roles were

invited to participate in this project, as they are likely to be the first support available to second

victims after an adverse event in an acute care hospital setting.

Initially, an educational tri-fold printed brochure was developed, however, the space

limitations of this type of brochure did not support the breadth of core content identified to

provide leaders with a basic introduction to the topic. The benefits of using an instructor-led

14
PowerPoint format include the availability of a speaker notes section for each slide, limitless

space for additional content, reference and resource listing, and flexibility for an instructor to

alter the length and program content based on audience needs. In addition, an in-person format

provides a forum for engaging in a dynamic discussion of the content with the instructor and

other attendees.

The educational offering was developed in two, sequential phases. First, all information

included in the PowerPoint slides and instructor scripts was developed based on the results of an

extensive review and synthesis of literature on the impact of adverse events on second victims

and organizations and ways to support second victims (refer to the previous section “Literature

Synthesis”). Second, key stakeholders were invited to preview the slide presentation and provide

input in the areas of overall content, flow, and usefulness of the materials. Revisions were made

to the PowerPoint slides and scripts based on this input. The UC Davis Institutional Review

Board determined this project was not human subjects research.

Stakeholder Invitations

Key stakeholders include nurse leaders with supervisory responsibilities (i.e., charge

nurses through nurse executive) with current employment in an acute care facility. A sample

size of six to ten participants was determined sufficient for the scope of this project. Nurse

leaders were recruited to participate in this project through networking with colleagues and peers

in the Sacramento region. Meetings with thirteen leaders were scheduled, however, three

canceled due to scheduling conflicts. A one-page project information summary was distributed

via email or in person (refer to Appendix A for a copy). The summary included the purpose of

the project, the type of input that would be requested from participants, time involved, the

15
objectives of the PowerPoint educational offering, and voluntary nature of participation. The

summary also noted that participants’ names would not be included in the final project/report.

Procedures

The first stakeholder session was used to pilot the process for subsequent sessions.

Minor revisions, including removing duplicative points covered on some of the slides, were

made as a result of this pilot session. The subsequent nine sessions were conducted in person

over a period of two months, with revisions made to slides and scripts, as applicable, after each

session, in preparation for the next session. The sessions took place in a variety of settings based

on leader preference. The sessions lasted between thirty to forty minutes.

The sessions began with a brief overview of the process that would take place and an

opportunity for participants to ask questions. Next, each slide was presented sequentially,

utilizing an instructor script. After the presentation was complete, a one-page synopsis of the

presentation, including program objectives and descriptions of the supporting slides for each

objective (See Appendix B) was used as a reference for the second phase of the session, which

involved questions about the presentation. Each objective and corresponding slide were

reviewed and a set of questions were asked about the organization of content per objective and

overall clarity, flow, and comprehensiveness (see Appendix C). Participants’ responses to

questions and impressions made during the meeting were documented and summarized in a

spreadsheet for later review, and, as deemed appropriate, used to revise the slides and instructor

scripts.

Results

A total of ten nurse leaders participated in sessions to provide input for this educational

offering, including: four intensive care unit charge nurses from three different specialty units, a

16
manager of an obstetric department, an assistant nurse manager of a medical intensive care unit,

a director of a hospital education department, a director of three intensive care units, an

administrator and a nurse executive. The length in their current roles ranged from two to ten

years. All of these nurse leaders worked at large, urban hospitals in Sacramento, California.

These sessions were all conducted in November and December of 2017. The settings

varied and occurred in offices, a home, and restaurants around the Sacramento area. Participants

attended one session only; there were no follow-up sessions. Demographics collected on the

participants included job role title and years in the current role. The input received as well as

changes made to the questions and educational offering are summarized into session categories

to illustrate the sequential process used to revise the materials. The sequence of sessions was

based on the scheduling preference and convenience of the participants.

Sessions

Initial sessions. The first three sessions, including the pilot session described above,

were conducted with nurse leaders in positions as hospital administrator and two adult cardiac

intensive care unit charge nurses. The length in their current roles varied from two to twelve

years. Feedback was positive and minor changes to remove duplicative wording and improve

flow were suggested. As a result of these suggestions, the instructor scripts were also revised to

reflect revisions to the slides. Upon reflection on the input received from these initial three

sessions and discussions with thesis chair, questions were revised to encourage depth in

responses using a more open-ended approach to questions.

Sessions with directors. The next two sessions occurred with participants in director-

level nursing positions. These leaders had worked as directors for five and nine years

respectively. Using the revised set of open-ended questions, the feedback provided was more

17
lengthy and substantial, compared to the first three sessions. Both participants indicated they

liked the flow and the length of the presentation. They reported the content was clear but the

slides were too wordy. Neither participant indicated that any core content should be removed:

however, specific suggestions were made on ways to minimize the number of words on each of

the slides. Additional suggestions included: 1) changing the second objective to include the

wording “synthesize current knowledge of the second victim”; 2) including a story at the

beginning of the presentation; 3) rearranging slides to include “how managers can help” before

the Denham and Scott models (Denham, 2007; Scott et al., 2010); and 4) explaining where all of

this information fits in to an event investigation.

The PowerPoint slides were revised to incorporate the feedback received from these two

participants. Objective 2 was changed to better highlight that this presentation is the result of a

comprehensive literature review. A gripping second victim story that was highlighted in the

news in 2010 was added to the first slide to capture the audience’s attention. Sentences were

removed and bullet points were added to slides to decrease the number of words on each slide.

The instructor scripts were revised to include details that were removed from the slides. And the

“How can leadership help” slides were rearranged at the end of the presentation to occur before

the Denham (Denham, 2007) and Scott models (Scott et al., 2010).

Session with a Nurse Executive. The nurse executive was relatively new in her position

with two years in the role. Most of the feedback obtained focused less on the slides and more on

details of the initial story and the content of the instructor script. This participant specifically

indicated liking the length of the educational offering and the slide with content covering the

impact on career. One suggestion to improve flow/clarity included placing the slide with

definitions of a second victim and adverse events before the objectives slide, as a way to enhance

18
understanding of the objectives. Other feedback on the PowerPoint slides included: 1)

expanding the initial story with points about the just culture in the instructor script; 2) citing

theorists that support the way stressors change the environment; 3) citing websites at the bottom

of the slides for quality and safety organizations; 4) changing questions for leadership to support

staff to be more open-ended by utilizing “The Humble Inquiry” book (Schein, 2014); 5)

including a recorded personal experience about an error from a staff member and an instructor

personal experience; and 6) citing the Florence Nightingale creed.

In order to stay within the twenty-minute goal of the educational offering, not all of the

suggested changes were incorporated into the revised slides and instructor script. The changes

that were incorporated included: putting the definitions of second victim and adverse events

immediately before the objectives; expanding the details of the story to make it more personal

and meaningful to participants; including a description of personal medical errors and the

impact; citing websites and research studies on the slides; adding more notes on the

responsibility that an organization has to investigate adverse events; and changing questions

utilizing “The Humble Inquiry” book (Schein, 2014).

Final Four Sessions. The final four sessions took place with a manager of an obstetric

floor, an assistant nurse manager from a medical intensive care unit, a charge nurse from a

medical intensive care unit, and a charge nurse from a specialty cardiovascular care unit.

Experience in these leadership roles varied from three to ten years. Feedback was positive and

no suggestions for changes were received regarding the length, content, story, and flow.

Conversation flowed easily throughout these sessions. Some participants shared their personal

errors, and their feedback was offered in the context of experiences, direct or indirect

involvement in adverse events, and the time that had passed since the event. One suggestion was

19
given by a charge nurse to add more graphics to illustrate certain points. It was also pointed out

that some of the words on the slides were on top of the dark slide design and visually difficult to

decipher. Again, it was pointed out that some of the slide content was too wordy and that it

would be more powerful if the slide on words to use included citations. Other suggestions

included adding a video demonstration of support or active listening, adding a resource/reference

slide, and emphasizing that the small amount of time necessary to give support could have a

major impact on the second victim’s recovery. Again, due to the desire to keep this introductory

educational offering brief, not all of the suggestions were incorporated. Additional graphics

were added after the first of this last group of sessions, and this received positive feedback from

the remaining three leaders. Words were removed again from slides and pertinent content added

to the instructor script. The overall slide design changes incorporated participants’ suggestions,

and reference and resource pages were developed.

Discussion

The purpose of this project was to create an introductory educational PowerPoint

program to prepare nurse leaders to provide immediate emotional support for a potential nurse

second victim after an adverse event. The goal of the educational offering is to give leaders

knowledge and tools on how to support, mitigate and/or hasten recovery from the impact of

involvement in an adverse event, based on the most current literature on the emotional, physical,

and psychological impact of involvement in adverse events and second victim support. After

drafting the PowerPoint slides and scripts, the program was presented to ten different leadership

stakeholders with diverse job titles and years of experience in their current role for feedback on

overall content, flow, and usefulness of the materials. The PowerPoint slides and scripts were

revised throughout the process based on suggestions from the leaders. The variations in

20
feedback received highlight the value of obtaining feedback from a diverse stakeholder group,

with the different nurse leader positions contributing to the variety of the feedback. With

diverse stakeholder input, it became clear during the feedback sessions that the content should be

tailored to the particular audience. Nurse leaders higher up on the organizational chart placed

less significance on the aesthetics of the PowerPoint, and more emphasis on adding substance to

the content. Additionally, as the job titles changed, the knowledge on second victims changed.

Across the feedback sessions, the richness of the responses expanded as the approach

used to solicit feedback evolved. Initially, the sessions were more structured, with time for

feedback left at the end of the presentation. As the project evolved, more time was built in for

discussion during the educational presentation and questions and follow-up prompts were refined

to encourage more open-ended responses. These changes impacted the way in which the leaders

responded and allowed for more open dialogue and discussion. The increase in dialogue

contributed to the variety and diversity of the feedback.

Feedback received on the PowerPoint slide visuals reflected the literature on effective

PowerPoint presentations (Harolds, 2012; Pugsley, 2010). Similar feedback was received from

multiple leaders on the wordiness of the slides. Therefore, fewer words, more bullet points,

graphics, and notes were added to the presentation throughout the meeting process. These

strategies improved clarity, flow, and visual appeal. Suggestions received but not utilized in the

final PowerPoint will be considered for use in future presentations, considering time allocations

for the sessions and resources.

Limitations

This educational program was presented to a small group of stakeholders that only

represented one geographic area. As individual perspectives and personal experiences appear to

21
impact the diversity of the leadership feedback, the perspectives do not necessarily represent

leaders beyond the original group. However, the participants were a heterogenous group that

represented many different job titles, and their feedback was wide-ranging and diverse.

Recommendations for Further Research

Future research can include submitting the educational program to experts in the field of

second victim support to evaluate the content for accuracy, completeness, and relevance, and to

identify any additional evidence-based resources that are available to inform the program

content. After the content has been evaluated, the full program can be piloted with different

levels of healthcare leaders in a classroom environment. Feedback can be elicited on clarity,

flow, job relevance, and usefulness, and to identify potential outcomes for overall program

evaluation. In addition to piloting the educational program, steps to facilitate implementation

can be assessed and addressed. Barriers such as cost and leadership time can be identified.

Because most attempts to implement evidence-based practice are not fully recognized or

successful (Sales, Smith, Curran, & Kochevar, 2006), prior to implementing change (i.e.,

implementation of this education program for nurse leaders in a given organization), theory can

be used to help with choosing strategies, interventions, tools, and finally with the implementation

of the proposed change (Sales, Smith, Curran, & Kochevar, 2006). Creating this change within

an organization will be challenging and time consuming, therefore, an assessment of

organizational readiness and the utilization of the tenets of implementation science will be

necessary.

Implications for Nursing

Involvement in adverse events can lead to an impactful and deleterious outcome for

healthcare providers. Contributing to this, a blame and punishment culture still exists within our

22
healthcare systems (Mayer & Cronin, 2008) which contributes to poor outcomes and increased

adverse events for patients (Khatri, Brown, & Hicks, 2009). There is an increasing awareness of

system contributors to errors made by individuals (Mayer & Cronin, 2008). Nurse leaders are in

a pivotal position to practice within a just culture framework, recognize and mitigate system

issues that contribute to adverse events, and stop the blame and punishment culture that still

exists today. Educating nurse leaders on how to best support second victims is an initial step to

moving from a blame culture to a just culture.

23
 References
Baulcomb, J.S. (2003). Management of change through force field analysis. Journal of Nursing

Management, 11, 275–280.

Burlison, J. D., Scott, S. D., Browne, E. K., Thompson, S. G., & Hoffman, J. M. (2017). The

second victim experience and support tool: validation of an organizational resource for

assessing second victim effects and the quality of support resources. Journal of Patient

Safety, 13(2), 93-102. doi:10.1097/pts.0000000000000129

Chan, S. T., Khong, P. C. B., & Wang, W. (2017). Psychological responses, coping and

supporting needs of healthcare professionals as second victims. International Nursing

Review, 64(2), 242-262. doi:10.1111/inr.12317

Chard, R. (2010). How perioperative nurses define, attribute causes of, and react to

intraoperative nursing errors. Association of Perioperative Registered Nurses, 91(1), 132-

145. doi:10.1016/j.aorn.2009.06.028

Crigger, N. J., & Meek, V. L. (2007). Toward a theory of self-reconciliation following mistakes

in nursing practice. Journal of Nursing Scholarship, 39(2), 177-183. doi:10.1111/j.1547-

5069.2007.00164.x

Daniels, R. G., & McCorkle, R. (2016). Design of an Evidence-Based "Second Victim"

Curriculum for Nurse Anesthetists. Journal of the American Association of Nurse

Anesthetists, 84(2), 107-113.

De Freitas, G. F., Hoga, L. A., Fernandes Mde, F., Gonzalez, J. S., Ruiz, M. C., & Bonini, B. B.

(2011). Brazilian registered nurses' perceptions and attitudes towards adverse events in

nursing care: a phenomenological study. Journal of Nursing Management, 19(3), 331-

338. doi:10.1111/j.1365-2834.2011.01208.x

24
Denham, C. R. (2007). TRUST: The 5 rights of the second victim. Journal of Patient Safety,

3(2), 107-119. doi:10.1097/01.jps.0000236917.02321.fd

Edrees, Brock, D. M., Wu, A. W., McCotter, P. I., Hofeldt, R., Shannon, S. E., . . . White, A. A.

(2016). The experiences of risk managers in providing emotional support for health care

workers after adverse events. Journal of Healthcare Risk Management, 35(4), 14-21.

doi:10.1002/jhrm.21219

Edrees, Paine, L. A., Feroli, E. R., & Wu, A. W. (2011). Health care workers as second victims

of medical errors. Polish Archives of Internal Medicine, 121(4), 101-108.

Edrees, H., Connors, C., Paine, L., Norvell, M., Taylor, H., & Wu, A. W. (2016). Implementing

the RISE second victim support programme at the Johns Hopkins Hospital: a case study.

British Medical Journal Open, 6(9), e011708. doi:10.1136/bmjopen-2016-011708

Hall, L. W., & Scott, S. D. (2012). The second victim of adverse health care events. Nursing

Clinics of North America, 47(3), 383-393. doi:10.1016/j.cnur.2012.05.008

Harolds, J. A. (2012). Tips for giving a memorable presentation, Part IV: Using and composing

PowerPoint slides. Clinical Nuclear Medicine, 37(10), 977-980.

doi:10.1097/RLU.0b013e3182614219

Harrison, R., Lawton, R., Perlo, J., Gardner, P., Armitage, G., & Shapiro, J. (2015). Emotion and

coping in the aftermath of medical error: a cross-country exploration. Journal of Patient

Safety, 11(1), 28-35. doi:10.1097/PTS.0b013e3182979b6f

Joesten, L., Cipparrone, N., Okuno-Jones, S., & DuBose, E. R. (2015). Assessing the perceived

level of institutional support for the second victim after a patient safety event. Journal of

Patient Safety, 11(2), 73-78. doi:10.1097/pts.0000000000000060

25
Jones, J. H., & Treiber, L. (2010). When the 5 rights go wrong: medication errors from the

nursing perspective. Journal of Nursing Care Quality, 25(3), 240-247.

doi:10.1097/NCQ.0b013e3181d5b948

Karga, M., Kiekkas, P., Aretha, D., & Lemonidou, C. (2011). Changes in nursing practice:

associations with responses to and coping with errors. Journal of Clinical Nursing,

20(21-22), 3246-3255. doi:10.1111/j.1365-2702.2011.03772.x

Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture in health

care. Health Care Management Review, 34(4), 312-322.

doi:10.1097/HMR.0b013e3181a3b709

Lewis, E. J., Baernholdt, M. B., Yan, G., & Guterbock, T. G. (2015). Relationship of adverse

events and support to RN burnout. Journal of Nursing Care Quality, 30(2), 144-152.

doi:10.1097/ncq.0000000000000084

Mayer, C. M., & Cronin, D. (2008). Organizational accountability in a just culture. Urologic

Nursing, 28(6), 427.

Mira, J. J., Carrillo, I., Guilabert, M., Lorenzo, S., Perez-Perez, P., Silvestre, C., & Ferrus, L.

(2017). The Second Victim Phenomenon After a Clinical Error: The Design and

Evaluation of a Website to Reduce Caregivers' Emotional Responses After a Clinical

Error. Journal of Medical Internet Research, 19(6), e203. doi:10.2196/jmir.7840

Mira, J. J., Carrillo, I., Lorenzo, S., Ferrus, L., Silvestre, C., Perez-Perez, P., . . . Astier, P.

(2015). The aftermath of adverse events in Spanish primary care and hospital health

professionals. Boston Medical Center Health Services Research, 15, 151.

doi:10.1186/s12913-015-0790-7

26
Pratt, S., Kenney, L., Scott, S. D., & Wu, A. W. (2012). How to develop a second victim support

program: a toolkit for health care organizations. Joint Commission Journal on Quality

and Patient Safety, 38(5), 235-240, 193.

Pugsley, L. (2010). How to . . . design an effective powerpoint presentation. Education for

Primary Care, 21(1), 51-53.

Quillivan, R. R., Burlison, J. D., Browne, E. K., Scott, S. D., & Hoffman, J. M. (2016). Patient

Safety Culture and the Second Victim Phenomenon: Connecting Culture to Staff Distress

in Nurses. Joint Commission Journal on Quality and Patient Safety, 42(8), 377-386.

Rassin, M., Kanti, T., & Silner, D. (2005). Chronology of medication errors by nurses:

accumulation of stresses and PTSD symptoms. Issues in Mental Health Nursing, 26(8),

873-886. doi:10.1080/01612840500184566

Russ, M. J. (2017). Correlates of the Third Victim Phenomenon. Psychiatric Quarterly.

doi:10.1007/s11126-017-9511-1

Schelbred, A. B., & Nord, R. (2007). Nurses' experiences of drug administration errors. Journal

of Advanced Nursing, 60(3), 317-324. doi:10.1111/j.1365-2648.2007.04437.x

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 and Safety in Health Care, 18(5), 325-330.

doi:10.1136/qshc.2009.032870

Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Hahn-Cover, K., Epperly, K. M., . . .

Hall, L. W. (2010). Caring for our own: deploying a systemwide second victim rapid

response team. Joint Commission Journal on Quality and Patient Safety, 36(5), 233-240.

27
Scott, S. D., & McCoig, M. M. (2016). Care at the point of impact: Insights into the second-

victim experience. Journal of Healthcare Risk Management, 35(4), 6-13.

doi:10.1002/jhrm.21218

Seys, D., Wu, A. W., Van Gerven, E., Vleugels, A., Euwema, M., Panella, M., . . . Vanhaecht, K.

(2013). Health care professionals as second victims after adverse events: a systematic

review. Evaluation and the Health Professions, 36(2), 135-162.

doi:10.1177/0163278712458918

Sirriyeh, R., Lawton, R., Gardner, P., & Armitage, G. (2010). Coping with medical error: a

systematic review of papers to assess the effects of involvement in medical errors on

healthcare professionals' psychological well-being. Quality and Safety in Health Care,

19(6), e43. doi:10.1136/qshc.2009.035253

Treiber, L. A., & Jones, J. H. (2010). Devastatingly human: an analysis of registered nurses'

medication error accounts. Qualitative Health Research, 20(10), 1327-1342.

doi:10.1177/1049732310372228

Trent, M., Waldo, K., Wehbe-Janek, H., Williams, D., Hegefeld, W., & Havens, L. (2016).

Impact of health care adversity on providers: Lessons learned from a staff support

program. Journal of Healthcare Risk Management, 36(2), 27-34. doi:10.1002/jhrm.21239

Ullstrom, S., Andreen Sachs, M., Hansson, J., Ovretveit, J., & Brommels, M. (2014). Suffering

in silence: a qualitative study of second victims of adverse events. British Medical

Journal on Quality and Safety, 23(4), 325-331. doi:10.1136/bmjqs-2013-002035

Van Gerven, E., Bruyneel, L., Panella, M., Euwema, M., Sermeus, W., & Vanhaecht, K. (2016).

Psychological impact and recovery after involvement in a patient safety incident: a

28
 repeated measures analysis. British Medical Journal Open, 6(8), e011403.

doi:10.1136/bmjopen-2016-011403

Van Gerven, E., Vander Elst, T., Vandenbroeck, S., Dierickx, S., Euwema, M., Sermeus, W., . . .

Vanhaecht, K. (2016). Increased Risk of Burnout for Physicians and Nurses Involved in a

Patient Safety Incident. Medical Care, 54(10), 937-943.

doi:10.1097/mlr.0000000000000582

van Pelt, F. (2008). Peer support: healthcare professionals supporting each other after adverse

medical events. Quality and Safety in Health Care, 17(4), 249-252.

doi:10.1136/qshc.2007.025536

Wolf, Serembus, J., Smetzer, J., Cohen, H., & Cohen, M. (2000). Responses and concerns of

healthcare providers to medication errors. Clinical Nurse Specialist, 14(6), 278-290.

Wolf, Z. R., Serembus, J. F., Smetzer, J., Cohen, H., & Cohen, M. (2000). Responses and

concerns of healthcare providers to medication errors. Clinical Nurse Specialist, 14(6),

278-287; quiz 288-290.

29
 Appendix A

How to Immediately Support a Second Victim: An Educational Program for Leaders

Dear Healthcare Leader,

My name is Tracy Chu and I am a student at the UC Davis, Betty Irene Moore School of
Nursing. I am fulfilling requirements of a thesis project for the completion of my Master’s
Degree in Nursing Science and Healthcare Leadership.
I would like to request your review and feedback of a PowerPoint educational offering
that I have created for healthcare leaders to learn more about how to support potential second
victims. This educational PowerPoint includes three main objectives: 1) Provide leaders with
background information on who and what a second victim is and convey the importance of this
topic; 2) Synthesize the current literature on the impact of adverse events on second victims and
the healthcare organization; and 3) Review literature and expert opinion-based recommendations
on how to best support a healthcare worker immediately following involvement in an adverse
event.
As a healthcare leader of nurses, I know that you can provide valuable input and expertise
on the content of my educational program. The intent of the end product is to utilize the slides to
introduce nurse leaders to the second victim phenomena and educate nurse leaders on ways in
which to mitigate the impact that being involved in an adverse event has on a nurse.
If you agree to assist me by reviewing the educational program, we will set up a time to
meet at your location preference and time convenience. The interview will take approximately
30-40 minutes, depending on the amount of feedback that you want to share. Your name will not
be included in the final thesis project report; however, I will summarize the different roles of the
nursing leaders that provide feedback (estimating 5-10 leaders). During the meeting, I will
review each slide and each grouping with you, according to the stated objectives, and elicit your
verbal feedback.
Please know that your participation is optional we can conclude the meeting at any time.
Please contact me at your earliest possible convenience if you are willing to review the content
of my educational program. I look forward to hearing from you!

Tracy Chu, RN, CCRN

tdchu@ucdavis.edu

30
 Appendix B

Objective 1 - Provide leaders with background information on who and what a

second victim is and convey the importance of this topic
Slides
2 Background

3 Who are the victims of healthcare adverse events?

4 Second victim definition

6 Definition of Adverse Events and why they occur

7-9 Key Organizational Stakeholders-IHI, NQF, AHRQ

Objective 2 – Synthesize the current literature on the impact of adverse events on

second victims and the healthcare organization

10- Impact of adverse events:

15  Emotional impact
 Physical and psychological impact
 Impact on career
 Organizational impact

Objective 3 - Review literature and expert opinion-based recommendations on how

to best support a healthcare worker immediately following involvement in an
adverse event
16 What kind of support do second victims want?

17- What do second victims need from leaders?

19
20 What do second victims deserve? TRUST-The five rights of the second victim

21 Scott’s three tired interventional model

22 Programs and resources found in the literature

23 Conclusion

31
 Appendix C
1. What worked well? What didn’t work well? Any thoughts on improving or changing

content?

2. Do you have any thoughts on improving the clarity of the slides?

3. What content did not fit with the stated objective?

4. What questions did the content raise for you?

5. What additional content needed to be added to meet the objective?

6. Can you think of any objectives that need to be added to the presentation?

7. Was any of the content not useful in your job role?

8. What could make the presentation flow more coherently?

9. What is your feedback about the length of the presentation?

32
Appendix D

33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59