One Million+ Nurses Become Second Victims Annually: Nursing Education's Role in Prevention?
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Nurses function in fast-paced, stressful, complex, unpredictable environments. In these environments, errors are made. They are made by well-intentioned, conscientous nurses. The impact of that error-making has been likened to post-traumatic stress syndrome. There are feelings of guilt, shame, and remorse. There is loss of professional and personal self-esteem. Nurses have quit their jobs, been criminally charged, sued, deemed incompetent, been fired, committed suicide and have left their professions.
They have also become the “second victims,” of the error, a term originally coined by Dr. Albert Wu (2000). Although he applied the concept to medical residents, the term has evolved and expanded to include any “healthcare provider who is involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and becomes victimized in the sense that the provider is traumatized by the event” (Scott et al., 2009).
The number of nurses that become second victims annually is unknown. Attempts to quantify are problematic. Second victimhood occurs as a result of error. We know that the IOM (2007) estimated that 1.5 million people are harmed each year by medication errors in hospitals. We know that preventable medical errors are now the third leading cause of death in the United States, with up to 440,000 Americans dying each year (Makary & Daniel, 2016). Every one of these error represents a potential second victim. However, because nurses who have made errors can suffer even in the absence of harm to their patients, these numbers cannot come close to representing the true number of nurses who suffer as second victims.
The literature is replete with information about the need to support healthcare professionals who become second victims. Denham (2007) developed the 5 rights of second victims. There are second victim rapid response teams, there are caring for the caregiver programs. There are peer support programs such as R.I.S.E. (Resilience in Stressful Events) (Trossman, 2016). There are recommendations, tools, programs, initiatives, white papers, and calls for a just culture. The overwhelming preponderance of these efforts have been developed and implemented at an organizational level.
The role that nursing education plays in preventing this phenomenon, or even if it has a role, is less well understood and there is an almost complete lack of information about it in the literature. These authors have researched medication errors and the second victim phenomenon for several years. This paper will present a study designed to investigate recent graduate students’ opinions about medication error.
A survey was conducted in February of 2015 which surveyed graduates from the preceding 5 years from a prominent undergraduate nursing program in the southeast. The survey sought to determine the graduates’ perceptions of how well the nursing program had prepared them for administering medications in the clinical environment. It also asked questions about whether they had made a medication error since becoming a nurse and, if so, to describe the circumstances and their feelings associated with the error-making. In addition to asking whether the program had prepared them for medication administration, it also asked their perceptions of how well the program taught them to advocate for patients and for themselves. Both quantitative and qualitative data were collected and analyzed.
168 graduate nurses participated in the study. Of those, 166 respondents indicated that the nursing program had prepared them adequately, well, or very well to administer medications. When asked whether they had made a medication error since becoming a nurse, 89 (56%) stated yes. Details regarding the event, the organizational follow up, and their own feelings were elicited. There was a significant difference in the number of respondents who felt that they had been prepared to advocate for patients and advocate for self.
The comments provided indicate that both the errorless imperative and the second victim phenomenon were experienced by our graduates. It is also clear that these students were taught patient advocacy but much less about self-advocacy.
Ultimately, this study raised as many questions as it answered. What role does nursing education play in preventing the second victim experience? Most, if not all, nursing programs have incorporated teaching their students all the recognized safety and quality competencies. They strive to teach their students how to do it all perfectly and without error. However, have we failed to teach them how to survive in an environment that is demanding and rife with opportunity for error? What are the best practices for nursing education to prevent their graduates from becoming second victims?