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

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Interventions to support nurses as second victims of patient safety incidents : A qualitative study of nurse managers' perceptions © 2023 the Authors Published version Järvisalo, Paula; Haatainen, Kaisa; Von Bonsdorff, Monika; Turunen, Hannele; Härkänen, Marja Järvisalo, P., Haatainen, K., Von Bonsdorff, M., Turunen, H., & Härkänen, M. (2023). Interventions to support nurses as second victims of patient safety incidents : A qualitative study of nurse managers' perceptions. Journal of Advanced Nursing, Early View. https://doi.org/10.1111/jan.16013 2023 J Adv Nurs. 2023;00:1–14. | 1wileyonlinelibrary.com/journal/jan Received: 15 May 2023 | Revised: 20 November 2023 | Accepted: 26 November 2023 DOI: 10.1111/jan.16013 EMPIRICAL RESEARCH QUALITATIVE Interventions to support nurses as second victims of patient safety incidents: A qualitative study of nurse managers' perceptions Paula Järvisalo1 | Kaisa Haatainen1 | Monika Von Bonsdorff2 | Hannele Turunen1,3 | Marja Härkänen1 1Department of Nursing Science, University of Eastern Finland, Kuopio, Finland 2Jyväskylä University School of Business and Economics, University of Jyväskylä, Jyväskylä, Finland 3Kuopio University Hospital, Kuopio, Finland Correspondence Paula Järvisalo, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland. Email: [email protected] Abstract Aims: To describe nurse managers' perceptions of interventions to support nurses as second victims of patient safety incidents and to describe the management of interventions and ways to improve them. Design: A qualitative study using interviews. Methods: A purposive sample of nurse managers (n = 16) recruited from three hospital districts in Finland was interviewed in 2021. The data were analysed using elements of inductive and deductive content analysis. Results: The study identified three main categories: (1) Management of second victim support, which contained three subcategories related to the nurse manager's role, support received by the nurse manager and challenges of support management; (2) interventions to support second victims included existing interventions and operating models; and (3) improving second victim support, based on the subcategories developing practices and developing an open and nonblaming patient safety culture. Conclusion: Nurse managers play a crucial role in supporting nurses as second victims of patient safety incidents and coordinating additional support. Operating models for managing interventions could facilitate nurse managers' work and ensure adequate support for second victims. The support could be improved by increasing the awareness of the second victim phenomenon. Implications for the Profession and Patient Care: Mitigating the harmful effects of patient safety incidents can improve nurses' wellbeing, reduce burden and attrition risks and positively impact patient safety. Impact: Increasing awareness of the second victim phenomenon and coherent operation models would provide equal support for the nurses and facilitate nurse managers' work. Reporting Method: COREQ checklist was used. What does this paper contribute to the wider global clinical community? • Nurse managers' role is significant in supporting the second victims and coordinating additional support. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2 | JÄRVISALO et al. 1 | INTRODUCTION Healthcare professionals are expected to maintain a high standard of patient safety, which leaves little room for human errors. However, errors may still occur since healthcare is inherently linked to human performance. It is estimated that nearly 70% of healthcare professionals are involved in patient safety incidents at some point in their careers (Vanhaecht et al., 2019). A patient safety incident refers to an event that has resulted in or could have resulted in unnecessary or unanticipated harm to a patient (WHO, 2010). When healthcare professionals are involved in such incidents, they may become second victims. The term ‘second victim’ refers to healthcare professionals who are psychologically affected by patient safety incidents under their care (Scott et al., 2009; Wu, 2000; Wu et al., 2020). Doctor Albert Wu first coined the term for doctors in 2000, which has been expanded to include other healthcare professionals by Scott et al. (2009). Although the term ‘second victim’ has been criticized for minimizing the suffering of the patients and their relatives (Clarkson et al., 2019), the concept has highlighted the pressing need for support for healthcare professionals (Wu et al., 2020). The harmful effects of patient safety incidents are currently estimated to be more significant than previously understood (Vogus et al., 2020). The symptoms of second victims can be psychological and physical (Wu, 2000). Second victims may experience guilt, selfdoubt, shame and depression (Scott et al., 2009; Wu, 2000). The distress can negatively impact their professional selfesteem and job satisfaction, leading to absenteeism (Burlison et al., 2021), burnout and even leaving their profession early without adequate support (Van Gerven, Vender, et al., 2016). Healthcare organizations are responsible for supporting professionals in their recovery (Van Gerven, Vender, et al., 2016). However, Ullström et al. (2014) noted a gap between second victims' needs and available organizational support. Nurse managers play a crucial role in both preventing patient safety incidents (Christoffersen et al., 2020) and coordinating support for second victims (Liukka et al., 2018). However, we do not know nurse managers' perceptions of the support or whether these perceptions can be used to develop the current support further. 2 | BACKGROUND The effects of patient safety incidents on professionals have been associated with the patient safety culture within the organization (Ullström et al., 2014). A safe environment promotes the identification of patient safety threats (Levine et al., 2020) and encourages more frequent incident reporting compared to an unsafe environment (Joesten et al., 2015). An open and nonblaming patient safety culture, coupled with a focus on analysing systemic factors after patient safety incidents, supports professionals in preventing the occurrence of the incidents (Van Gerven, Vender, et al., 2016). Additionally, it aids in reducing the adverse impact of these incidents by transforming them into valuable learning opportunities, benefiting both the organization and the involved individuals (Levine et al., 2020). Awareness of the second victim phenomenon can reduce the harmful effects of incidents (Kobe et al., 2019), while awareness of existing interventions can improve usability (Joesten et al., 2015). Peer support is often considered the most important intervention following patient safety incidents (Kobe et al., 2019), and many second victim programmes have been developed around it (Edrees et al., 2017). Unlike support from nurse managers, peer support can help avoid the negative feelings of being evaluated professionally (Joesten et al., 2015). Peer support can be provided in official or unofficial capacities (Ullström et al., 2014) using formal methods such as debriefing. Positive patient safety culture and peer support may not suffice for second victim support; official operating models are also needed (Schrøder et al., 2018). Operating models, such as second victim programmes, support employees' coping mechanisms after patient safety incidents (Habibzadeh et al., 2020). These programmes typically involve rapid and confident discussion support with a trained peer (Burlison et al., 2021). Integrated and structured practices benefit organizations and individuals (Ullström et al., 2014). With explicit operating models, nurse managers and employees can act purposefully after incidents (Burlison et al., 2021). These programmes are necessary for modern healthcare environments (Christoffersen et al., 2020), and several have been developed in the USA, including for YOU Team (2007) and Resilience in Stressful Events 2011, which rely on multiplestage peer support (Wu et al., 2020). However, a lack of awareness (Kobe et al., 2019), interest, trust and fear of stigma can prevent participation in these programmes (Edrees & Wu, 2017). Management is pivotal in influencing outcomes for professionals and the work environment, and managers must actively strive to enhance staff satisfaction (Specchia et al., 2021). This study aimed to describe nurse managers' perceptions of existing interventions to support nurses as second victims of patient safety incidents. Additionally, it aimed to describe the management of interventions and ways to improve them. Based on our understanding, previous information on the topic from nurse managers' perspective is limited. However, studies on nurse managers' actions after incidents are available. For instance, Christoffersen et al. (2020) examined midwives' experiences of support received from nurse managers. According to • Awareness of the second victim phenomenon and coherent operating models can secure adequate support for the nurses and facilitate nurse managers' work. KEYWORDS interventions, nurse, nurse manager, patient safety incidents, second victim, support 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 3 JÄRVISALO et al. them, nurse managers play a crucial role in supporting the recovery of second victims by preventing incidents and responding to them. Nurse managers' visible role as support coordinators has been shown to promote recovery. Second victims prefer leadership styles such as distributed and transformational leadership. This helps create a supportive and empathetic workplace culture that promotes healthcare providers' psychological wellbeing following patient safety incidents. Through the actions of nurse managers, harmful experiences associated with patient safety incidents can be reduced, and the employee's recovery from the incident can be supported (Van Gerven, Bruyneel, et al., 2016). Nurse managers ensure that their employees are adequately aware of the second victim phenomenon and how to respond to incidents (Van Gerven, Vender, et al., 2016). Additionally, the task of nurse managers is to promote a positive patient safety culture (Van Gerven, Bruyneel, et al., 2016). According to Vogus et al. (2020), negative experiences of patient safety incidents decrease when managers foster a positive organizational atmosphere. By acting this way, nurse managers enable employees to feel comfortable speaking up and reporting adverse events (Liukka et al., 2018) and seeking the necessary support (Edrees & Wu, 2017). To fulfil their responsibilities, nurse managers require knowledge and continuous education about existing interventions for second victims (Zaheer et al., 2015). To our knowledge, the present study is the first in this area, indicating limited knowledge on this topic. This highlights the importance of exploring this area since improving the support available to second victims can significantly impact staff wellbeing. The present study expands the existing knowledge of the interventions for second victims by describing nurse managers' perceptions. Additionally, the management and possible improvements in these interventions have been described. 3 | THE STUDY The present study aimed to describe nurse managers' perceptions of existing interventions to support nurses as second victims of patient safety incidents. Additionally, it aimed to describe the management of interventions and ways to improve them. The research questions were as follows: 1. How is the second victim support managed? 2. What kind of interventions exist for second victim support? 3. How could the support for second victims be improved? 4 | METHODS 4.1 | Design and setting This qualitative descriptive study was conducted in three hospital districts in Finland, using remote interviews of nurse managers from diverse specialty areas. Data analysis included elements of both inductive and deductive content analysis. 4.2 | Sample Data for this study came from interviews of 16 nurse managers. The participants were recruited via email from three university hospital districts in Finland with the assistance of contact persons. The study aimed to obtain data from diverse healthcare environments to enhance the richness of the findings. The contact persons were expected to present diverse nursing services comprehensively and where patient safety incidents are familiar. Eligible participants were expected to have knowledge of the interventions related to patient safety incidents, which made the sample purposive. The contact persons were informed of the criteria via email. The recruitment of the participants followed the research permissions admitted in February and March 2021. The contact persons evaluated suitable participants and requested their consent to participate. Before the study, participants were informed of the interview topics via email by the first author after the contact person had identified potential participants and informed the first author of the candidates. One contacted nurse manager declined to participate due to a lack of awareness. No one dropped out of the research. 4.3 | Data collection An interview guide (Table 1) was developed based on the literature review conducted in October 2020 using CINAHL, Medline, PsycINFO, PubMed and Cochrane databases. The search of studies published between 2015 and 2020 revealed twentysix original studies. Based on these studies, eight interview topics were identified: (1) participant characteristics, (2) the need for interventions after patient safety incidents, (3) the need for further development of these interventions, the roles of (4) employees, (5) peer support, (6) nurse managers, (7) the organization and (8) safety atmosphere within the organization. The topics were displayed on the screen during the online interviews to guide the discussion, while maintaining flexibility. One volunteer nurse manager from a different hospital district was interviewed as a pilot; this interview did not lead to changes in the interview guide. The pilot interview was not included in the final data. The first author remotely conducted individual interviews with participants between March and April 2021 using Microsoft Teams, considering the COVID- 19 pandemic. Participants joined the online interview from their work offices, while the interviewer joined from her home office. No one else was present besides the participant and researcher. Before the interviews, participants were informed about the study's aim and background and participation's voluntary and confidential nature. The researcher's professional background and interest in the phenomenon were also presented. Of the 16 participants, ten (n = 10) chose to turn on their cameras while the interviewer kept her camera on throughout the interviews. On average, the interviews lasted 39 min (between 25 and 62 min). In total, data worth 10.5 h were 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 | JÄRVISALO et al. collected. All interviews were digitally audiorecorded using Microsoft Teams and transcribed verbatim by the first author immediately after each interview. The written data consisted of 108 pages written with 12- point Times New Roman font and 1.5 line spacing. 4.4 | Data analysis After finishing and transcribing all interviews, data were analysed by the first author. The analysis was conducted using elements of TABLE 1 The interview guide. Interview theme Interview question Characteristics Age (years) Gender Education Healthcare experience (years) Nursing management experience (years) Healthcare environment The need for interventions after patient safety incidents as a phenomenon What kind of experiences do you have with interventions after patient safety incidents? The role of the employee after a patient safety incident What kind of patient safety incidents require support for employees? How is the employee guided to the resources of support? • by themselves • by colleague • by following an operating model The role of the organization after a patient safety incident Does the healthcare organization have an operating model for interventions after patient safety incidents? Describe the content of the available operation model. If not, describe the desired content. What kind of supportive interventions can be offered? What sources are available for support? • peer support • nurse manager • patient safety advisor • occupational health care • psychologist and so on. In what kind of situation is the employee supervised to have external support? How is the work wellbeing ensured? Are there possibilities to make work adjustments? The role of peer support What is the significance of peer support after patient safety incidents? How could the quality and efficiency of peer support be improved? The role of the nurse manager How can the nurse manager recognize the physical or psychological symptoms of the employee's involvement in a patient safety incident? What kind of competence is needed to be able to support the involved employees? From whom can the nurse manager receive support related to patient safety incidents and interventions after the patient safety incidents? Does the nurse manager or patient safety advisor contribute to the employees' conversations with the patients and their relatives after patient safety incidents? The safety atmosphere of the organization How is the safety atmosphere of the organization experienced? What is the attitude toward incident reporting? How are the reports managed? How can the organization learn from the events? How can the nurse manager promote a positive patient safety culture and atmosphere? The development of interventions after patient safety incidents How would you improve the interventions after patient safety incidents? Is there something else you would like to tell me? 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 5 JÄRVISALO et al. inductive and deductive content analysis. A deductive content analysis approach was employed in the data collection, which was based on the interview topics and drew upon insights from previous studies. Subsequently, an inductive content analysis method was applied to analyse the data collected within the framework of these predetermined topics. The transcripts were read several times to get a sense of the whole. After multiple readings, units of meaning were identified, and meaningful impressions were underlined and then coded manually using prints of transcripts and pen. The coded original impressions were then simplified to describe them (Lindgren et al., 2020) and then clustered into seven subcategories based on the content after comparing the differences and similarities of the impressions. The categories evolved through interpretation and abstraction. The subcategories were written into new pages of Microsoft Word documents and named to describe the content. Then, the subcategories were combined into three main categories: Management of second victim support, interventions to support second victims and improving second victim support. The categories were transferred into abstract text and illustrated with selected quotations. Repeated reading and analysis led to an understanding of participants' perceptions of the topic. Finally, the first author relistened all the interviews, ensuring the authentic representation of participants' perceptions within the interpreted findings. Table 2 presents an example of the process of content analysis. 4.5 | Ethical considerations Ethical principles, such as honesty, precision and punctiliousness, were considered throughout the research process. Based on the research organization's statement of the Research Ethics Committee, an ethical review was not required for this research following Finnish ethical regulations. The participating organizations granted the research permits in February 2021. Written informed consent was obtained from the participants after their independent decision to contribute to the study. Before the interviews, participants were informed about the study's aim and background and participation's voluntary and confidential nature. Furthermore, they were informed about their right to discontinue their participation in the study at any time. The researchers did not find any way the study could harm the participants. On the contrary, participants indicated that increased knowledge of the subject matter would benefit them as nurse managers. Data were managed and preserved following the requirements of the General Data Protection Regulation (European Union, 2016). Personal details were redacted to protect participants' confidentiality and privacy (Finnish national board on research integrity TENK, 2019). 4.6 | Rigour To mitigate the research bias, the first author recognized preexisting assumptions of the phenomenon. The first author has experience as a nurse and a nurse manager with second victims. Engaging reflection at each phase of the study and continuously questioning these assumptions were ways to diminish bias within the research process. Each study phase was carried out collaboratively, involving discussions in the research group. The discussions generated by the authors were necessary for the process as being critical voices, strengthening this study's trustworthiness. All study phases were conducted based on discipline, transparency and conscientiousness to enhance its credibility. Transferability and credibility were maintained by clearly describing the research process (Malterud, 2022). The reliability of the results was strengthened by the participants' experience in healthcare and nursing management. This qualitative study did not aim to generalize the results (Malterud, 2022). Instead, data were collected from participants who had relevant experiences on the topic. Having participants from various healthcare environments increases the possibility of describing the phenomenon from different perceptions, even if the study sample is limited. Participant characteristics are described, and the findings are presented with appropriate original impressions of the participants to indicate the TABLE 2 An example of the process of content analysis. Original impression Simplified impression Code Subcategory Main category ‘the role of the nurse manager is that you have to go through the process and then you need to manage it with the employee’ (P8) Reviewing the patient safety incident from the perspective of the process and the employee Solving the patient safety incident Nurse manager's role Management of second victim support ‘you should be able to have a discussion with people at the same level’ (P1) The nurse manager needs peer support concerning questions after patient safety incidents The professionals supporting the nurse managers Support received by the nurse manager ‘especially as this area is large, the farthest employees are 100 kilometres away and I cannot see them. I hear their voices, but I do not necessarily see their faces’ (P1) The physical distance between the nurse manager and employees restrains the assessment of the intervention needs after patient safety incidents Factors challenging the intervention coordination Challenges of support management 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 6 | JÄRVISALO et al. author's deductions and allow readers to conclude on the degree of transferability. Saturation was observed in the latest interviews, indicating the comprehensiveness of the collected data. All interviews were conducted by the first author, ensuring the data's dependability. The interview guide ensured that participants were asked the same questions, even if the followup questions varied. The original impressions in the Findings section represent the participants' authentic views and substantiate the analytic findings. Finally, The COREQ guidelines were followed in reporting the study process (Tong et al., 2007). 5 | FINDINGS The research results are based on interviews with 16 nurse managers. The participants represented a diverse range of healthcare environments: emergency department (n = 1), intensive care unit (n = 2), obstetrics (n = 1), operating department (n = 1), paediatrics (n = 3), paramedics (n = 2) and psychiatry (n = 6). Among the participants, two were men (n = 2) and 14 were women (n = 14). The average age was 52 years. All participants had a background as registered nurses and had received management training. The participants had an average of 27.5 years of work experience in healthcare, and they had an average of 10 years of nursing management experience. Depending on the operational unit and organizational structure, the participants had approximately 20–200 employees. Table 3 presents the participants' characteristics. Three main categories and seven subcategories describe the results of the study. 5.1 | Management of second victim support 5.1.1 | Nurse manager's role The role of a nurse manager in second victim support was evident at both unit and individual levels. Support was provided proactively by fostering an open patient safety culture, ensuring employee competence and promoting wellbeing. Nurse managers played a crucial role in providing individual interventions. If a positive patient safety culture and the nurse manager's support after a patient safety incident were insufficient for recovery, the nurse manager coordinated additional support for the employee. After a patient safety incident, the nurse manager promptly gathered information related to the incident and initiated the intervention process to support the involved employee. Time since the incident did not diminish the need for action. Information was typically obtained from the second victim directly or through the incident reporting system. Some employees sought support independently, while others required the nurse manager's assistance. Private conversations were preferred when only one employee was involved. Incidents resulting from apparent process deviations were managed within the workplace community. The role of the nurse manager is that you have to explore the process and manage it together with the employee. (P8) The nurse manager needed knowledge of the second victim phenomenon to determine the necessary action. Building close relationships with employees helped identify intervention needs. However, TABLE 3 Participants' characteristics. Demographic variables Total (N = 16) Demographic variables Total (N = 16) Gender Healthcare experience Male 2 (12%) 5–9 years 0 (0%) Female 14 (88%) 10–14 years 1 (6%) Age ≥15 years 15 (94%) 30–39 years 3 (19%) Management experience 40–49 years 2 (12%) 1–4 years 3 (19%) ≥50 years 11 (69%) 5–9 years 5 (31%) Education 10–14 years 3 (19%) Management training (no degree) 4 (25%) ≥15 years 5 (31%) Master's degree (university of applied sciences) 8 (50%) Environment Master's degree (university) 4 (25%) Emergency department 1 (6%) Intensive care unit 2 (12%) Obstetrics 1 (6%) Operating department 1 (6%) Paediatrics 3 (19%) Paramedics 2 (12%) Psychiatry 6 (39%) 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License | 7 JÄRVISALO et al. recognizing these needs became challenging when second victims concealed their symptoms. It was advisable not to pressure employees but rather to encourage them to express their needs when ready. I am sure I do not recognise them all. Some can cover up if they have been there. But when you call or see them, it can suddenly be when they talk about all these things. Then it will be revealed that this happened, and then we will talk about the required help. (P7) When action was required, the nurse manager offered support and coordinated interventions to aid in the employee's recovery. The conversations between the nurse manager and employee focused on alleviating burdens and reducing blame. Providing support to second victims was considered one of the primary responsibilities of the nurse manager. I assess and ask if the employee needs more support. And then, I arrange time for the conversation and management. (P8) The nurse manager's compassionate and nonjudgemental approach facilitated open and honest communication, reducing feelings of burden and blame. Normalizing the situation and creating an atmosphere free of fear or shame were additional benefits of the nurse managers' behaviour. However, it was acknowledged that the incident itself could not be minimized. The nurse manager encouraged the second victim to view the incident as a learning opportunity for the community and promoted a compassionate and secure atmosphere among colleagues. You need to be open and able to create a safe atmosphere. And that you can always come and talk to me. (P14) In cases where support from the nurse manager and colleagues fell short, the nurse manager coordinated additional interventions. Awareness of available intervention options within the organization was essential. Understanding the specific nursing environment and existing patient safety risks was equally important. The nurse manager's comprehension of the significance of second victim support was crucial, gained through work experience, organizational support and further education in leadership and management. A university degree alone was insufficient, prompting a need for education in managing patient safety incidents, including courses in human resources management, crisis management and debriefing techniques. General knowledge of the healthcare system, workplace safety and relevant legislation was also essential for effective intervention coordination. Situational awareness and understanding of the work and the tasks are required, that you know how the situations are. (P15) 5.1.2 | Support received by the nurse manager Nurse managers received support from various sources in managing support for nurses as second victims of patient safety incidents. Peers and the nurse director provided practical and emotional support through teamwork and regular meetings. Ward doctors, human resource specialists, security and patient safety specialists, and occupational healthcare services were available for guidance and counselling during patient safety incidents. The adequacy of the support was acknowledged, and nurse managers did not feel isolated. Occupational healthcare and occupational health and safety advisers help us, and the nursing director and even the consultant can come and try to help solve things. (P10) 5.1.3 | Challenges of support management Nurse managers often found managing second victim support challenging, primarily due to the sensitive nature of the situation, including concerns about employee competence and potential career impact. Because it is a massive thing for me as well. And very scary. And things like this … Am I right, do I blame, and am I going to destroy someone's career? Have I done everything right? (P6) Detecting potential second victim symptoms after patient safety incidents could be challenging due to daily workloads, physical distance and the number of employees. In cases like paramedics, remote work added to the challenge. We have such a large field here. The farthest employees are 100 kilometres away, which means I cannot see them. I can hear their voices, but I cannot see their faces. (P1) Furthermore, coordinating interventions could be challenging due to shift work and a lack of incident awareness. Nurse managers often struggled to prioritize tasks, hindering their ability to provide expected interventions related to patient safety incidents. The volume of information could complicate communication about patient safety incidents. Nurse managers wanted information about intervention needs, even when not recognized. Additionally, nurse managers feel inadequate when trying to find solutions for all involved employees. 5.2 | Interventions to support second victims 5.2.1 | Existing interventions The study identified various interventions to support nurses as second victims. These interventions are presented as a process, with 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 8 | JÄRVISALO et al. the elements depicted in Figure 1. The process began with the occurrence of the incident and ended with employee recovery. The order of implementation varied, tailored to each situation, and not all interventions were used in every incident. Assessment of support needs Recognizing the second victim's need for support was key to initiating the intervention process. The responsibility for this assessment fell to the charge nurse, and the initiative for support could come from the involved employee, colleague, or the nurse manager. Information about the need for support typically reached the nurse manager during working hours, with their active involvement in the work community aiding the identification of intervention needs. However, in the absence of the nurse manager, mutual trust was necessary to replace their continuous physical presence. In this context, trust implied that the employee possessed the autonomy to work independently while also maintaining an awareness that the manager remains accessible for assistance when required. It is mostly the employee who is panicking and expresses the need for support. Then, some colleagues may come and say: have you noticed that? So yes, they are taken care of by others. (P2) Unofficial peer support Peer support was considered the most critical intervention method following patient safety incidents. and it was widely recognized among healthcare professionals. They showed genuine concern for their colleagues' work wellbeing, and the need for support after challenging events was evident. Most participants believed that work communities could provide peer support independently of the nurse manager. Peer support and compassion effectively reduced the second victim's feelings of blame and it was considered feasible as it did not require special arrangements. It is probably the most important way to recover. The manager can offer some support, but the manager and employee are on the kind of different levels there anyway. (P8) Incident investigation Identifying the process leading to patient safety incidents played a crucial role in the intervention process. To determine the contributing factors, involved employees were interviewed by either the nurse manager or patient safety manager. The primary objective was to investigate process deviations to prevent incidents' recurrence and promote a comprehensive understanding of the incident while facilitating employee recovery. Documenting these details was essential to help nurses accurately recall the sequence of events, prevent misunderstandings and avoid escalating incidents into more significant issues. Implementing an anonymous incident reporting system was identified as an effective means to enhance documentation, promote patient safety and prevent the practice of individual blaming. Some come and say: yes, now I made a mistake, I will make an incident report. (P5) Informing the patient or relatives Participants highly valued the culture of openness in healthcare, considering it essential to disclose incidents to patients or their relatives. Conversations between the employee and the patient's family were seen as crucial for recovery, but emotionally intense. Therefore, participants recommended the presence of a nurse manager or ward doctor during these discussions. FIGURE 1 The process of supporting the second victim after a patient safety incident. A patient safety incident Assessment of support needs Unofficial peer support Incident investigation Informing the patient or the relatives Debriefing sessions Adjustments for work-wellbeing Individual support of occupational healthcare Recovery 13652648, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.16013 by University Of Jyväskylä Library, Wiley Online Library on [10/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License