With continued rise of overhead costs on an upward spiral, the nurse finds herself or himself caught in the midst of administrative decisions that involve staffing and direct care delivery decisions all the while providing quality of care to the patient. Additionally, the demands of technological advancement will directly affect the future delivery of care and how that care is delivered to those in need. So, where does nursing theory fit in the future of nursing and what theory is most applicable to usage by the professional nurse in this changing health care market?
Print Perspective The Institute of Medicine's report on medical mistakes, To Err is Human, described surprising numbers of projected deaths as a result of preventable medical errors within health care systems. Frequently, clinicians review medical errors and understand what has unfolded, reacting with appropriate sadness and concern.
Such errors occasionally result in an intense period of professional and personal anguish, even among the "strongest" caregivers. Publications describing these experiences initially appeared in the literature as personal anecdotes describing powerful feelings of guilt, incompetence, or inadequacy following a medical error.
Soon authorities began highlighting the importance of various forms of support Clinical nursing phenomenon assist with healthy recovery for suffering clinicians. To quantify the prevalence of the second victim phenomenon at MUHC, in we added two questions to an internal patient safety culture survey.
As a result of these disturbing findings, we assembled a research team to gain a deeper understanding of the experience that one seasoned MUHC clinician described as "the darkest hour of his professional career.
The research team used the following definition to identify potential second victims for the project: Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.
Research participants included 10 physicians, 10 health professionals, and 11 registered nurses. Incredibly, many of the research participants provided meticulously detailed accounts of their respective events.
Some were able to cite the exact date of the event while others provided event-specific details such as the color of scrubs worn when the event occurred.
One of the most striking findings was that every second victim participating in the project described their respective unanticipated clinical event as a life-altering experience that left a lasting impression on them.
One clinician described his second victim experience as an "emotional tsunami," unlike anything he had ever experienced before in his professional career.
Numerous variables contributed to the severity of the second victim response. Although research participants developed individualized coping skills, they described a fairly predictable recovery trajectory.
During iterative analyses, we identified six stages that described the second victim recovery process: The Table illustrates the six-stage recovery trajectory as well as stage characteristics and recommended institutional interventional coping strategies. To validate these findings, we conducted focus groups with original research participants.
Participants reviewed the proposed recovery trajectory and validated that they had indeed experienced the identified stages. The participants then offered their recommendations regarding desired or ideal institutional support for each stage.
Research participants provided many insights into the complex second victim phenomenon. Although each clinician's experience is unique, their evoked response story is somewhat predictable, which might lead one to believe that a stereotypical program of support would be effective.
Yet individual clinicians have unique support needs, and our experience has taught us that no one intervention will meet everyone's support needs. It is important to design an infrastructure with numerous support options to address these needs such as employee assistance programs [EAPs], clergy, social workers, clinical psychologists, or counselors.
How does this actually work in practice? Let's say a nurse on the evening shift harms a patient by administering the wrong medication. In a traditional health care setting, the department manager would be notified of the event and a report entered into the hospital's incident reporting system for review by risk management.
The staff member is interviewed and investigation findings are considered. A root cause analysis if indicated is planned. However, in a health care system that focuses on addressing both patient incident investigations and the distinct needs of a second victim, real-time surveillance of all caregivers by individuals specifically educated on the second victim phenomenon occurs as the unanticipated clinical event unfolds.
An emotional first aid rapid response team for the clinician is instantaneously deployed to address the needs of the second victim with immediate support and guidance. Members of University of Missouri Health Care System's second victim support team are purposefully embedded on every shift in high-risk clinical areas such as intensive care units or operating rooms as well as on high-risk clinical teams such as rapid response teams, code blue teams, and palliative care teams.
Our team's ultimate goal is to ensure that the clinician does not go home after an unanticipated clinical event to suffer alone. Clinicians who are severely traumatized and require the services of a professional counselor also benefit from a fast-track referral process to clinical health psychologists, counselors, clergy, social workers, or the EAP.
It is important to recognize that clinician support is a completely separate function from that of the event investigation. One person provides peer support while a different individual either patient safety expert or risk manager serves as the investigative lead for the investigation and review of the clinical event.
We have found that initial support of the second victim—followed by the traditional event investigation—yields more efficient case exploration by the designated case investigator. If an RCA is indicated, our institution has opted to invite the second victim to participate in the case review to help address identified system issues and build action plans to prevent future incidents.
In our experience, inclusion in these blame-free discussions helps promote clinician healing and recovery from the second victim experience. Participation in both the RCA meeting and second victim support is a voluntary process.
Awareness of the second victim phenomenon and proactive institutional response planning are critical steps in protecting and supporting future clinicians from the emotional trauma so often experienced by clinicians after unanticipated clinical events or medical errors.In this regard, Watson stated that the Theory of Human Caring could serve to guide clinical nursing practice by enabling it to transcend the physical dimensions of the care recipient in order to grasp the whole of the care situation as experienced by the person.
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