The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais
Autor(a) principal: | |
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Data de Publicação: | 2022 |
Outros Autores: | |
Tipo de documento: | Artigo |
Idioma: | por eng |
Título da fonte: | Vigilância Sanitária em Debate |
Texto Completo: | https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976 |
Resumo: | Introduction: Health care can result in adverse events that directly affect patients’ health and their experience in health care, and can cause deaths, permanent and temporary sequelae, psychological distress to patients, their families and health professionals, in addition to raising costs of medical assistance services. Among the ills related to the occurrence of adverse events are the losses suffered by health professionals who are involved in an adverse event, referred to in the literature as “second victim”. These individuals experience profound psychological effects, such as anger, guilt, inadequacy, depression, and suicide, due to real or perceived flaws. Objective: to identify the manifestations, in the face of the occurrence of an adverse event, of nursing professionals in a hospital and their relationship with the phenomenon of the second victim. Method: a cross-sectional and explanatory study was carried out, using quantitative methods. The instrument used was the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC). Questions to define the population profile and to characterize adverse events based on the Notivisa adverse event notification system of Anvisa (National Health Surveillance Agency) were added. The population consisted of 203 nursing professionals involved in direct assistance to patients at a general, public hospital, of high relevance for the care of the population of the northwest region of Minas Gerais. Results: The sample was predominantly female (85%), with an average age of 40.7 years, with 74% nursing technicians, 25% nurses and 1% nursing assistants. 60% (n. 119) of the professionals reported to have been involved in at least 1 adverse event in the last 2 years. Of these, the majority were with slight damage (47%) and without damage (24%). They also reported that 75% of the events were notified to the Risk Center. Most professionals (55%) who were involved in an adverse event presented at least one type of physical and/or psychological manifestation. Anxiety was the most reported manifestation (24%). If we consider the cases in which the adverse event caused moderate, severe or death damage (n. 36), only 22% of the professionals were indifferent; other professionals showed anxiety (33%), irritation (25%), insomnia (5%), loss of appetite (5%), difficulty in returning to routine (5%) and other experiences (28%), worry, frustration, fear, indignation and greater attention at work. Three professionals (3%) reported that they needed to seek specialized emotional assistance. Conclusions: The results of this study, in accordance with what the literature on this issue presents, demonstrate how harmful and impactful for a health professional can be the experience of the phenomenon of the second victim. These effects can be aggravated if a culture of punishment and reprimand for failures prevails in the health Institution. |
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The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas GeraisAs manifestações de segunda vítima de evento adverso: uma análise dos profissionais de enfermagem de um hospital público de Minas GeraisEvento AdversoSegurança OcupacionalEnfermagemSEGURANÇA DO PACIENTESEGUNDA VÍTIMAHOSPITALEVENTO ADVERSOAdverse EventOccupational SafetyNursingIntroduction: Health care can result in adverse events that directly affect patients’ health and their experience in health care, and can cause deaths, permanent and temporary sequelae, psychological distress to patients, their families and health professionals, in addition to raising costs of medical assistance services. Among the ills related to the occurrence of adverse events are the losses suffered by health professionals who are involved in an adverse event, referred to in the literature as “second victim”. These individuals experience profound psychological effects, such as anger, guilt, inadequacy, depression, and suicide, due to real or perceived flaws. Objective: to identify the manifestations, in the face of the occurrence of an adverse event, of nursing professionals in a hospital and their relationship with the phenomenon of the second victim. Method: a cross-sectional and explanatory study was carried out, using quantitative methods. The instrument used was the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC). Questions to define the population profile and to characterize adverse events based on the Notivisa adverse event notification system of Anvisa (National Health Surveillance Agency) were added. The population consisted of 203 nursing professionals involved in direct assistance to patients at a general, public hospital, of high relevance for the care of the population of the northwest region of Minas Gerais. Results: The sample was predominantly female (85%), with an average age of 40.7 years, with 74% nursing technicians, 25% nurses and 1% nursing assistants. 60% (n. 119) of the professionals reported to have been involved in at least 1 adverse event in the last 2 years. Of these, the majority were with slight damage (47%) and without damage (24%). They also reported that 75% of the events were notified to the Risk Center. Most professionals (55%) who were involved in an adverse event presented at least one type of physical and/or psychological manifestation. Anxiety was the most reported manifestation (24%). If we consider the cases in which the adverse event caused moderate, severe or death damage (n. 36), only 22% of the professionals were indifferent; other professionals showed anxiety (33%), irritation (25%), insomnia (5%), loss of appetite (5%), difficulty in returning to routine (5%) and other experiences (28%), worry, frustration, fear, indignation and greater attention at work. Three professionals (3%) reported that they needed to seek specialized emotional assistance. Conclusions: The results of this study, in accordance with what the literature on this issue presents, demonstrate how harmful and impactful for a health professional can be the experience of the phenomenon of the second victim. These effects can be aggravated if a culture of punishment and reprimand for failures prevails in the health Institution.Introdução: A assistência à saúde pode resultar em eventos adversos (EA) que atingem diretamente a saúde do paciente e sua experiência no cuidado à saúde, podendo causar mortes, sequelas definitivas e temporárias, sofrimento psíquico aos pacientes, a seus familiares e aos profissionais de saúde, além de elevar o custo assistencial. Dentre os problemas relacionados à ocorrência dos EA estão os prejuízos sofridos pelos profissionais de saúde que se envolvem em um EA, denominados na literatura como “segunda vítima”. Estes indivíduos experimentam efeitos psicológicos profundos, como raiva, culpa, inadequação, depressão e suicídio, devido a falhas reais ou percebidas. Objetivo: Compreender as manifestações dos profissionais de enfermagem de um hospital frente a ocorrência de EA e a relação com o fenômeno da segunda vítima. Método: Foi realizado um estudo transversal e explicativo, com métodos quantitativos. O instrumento utilizado foi o questionário Hospital Survey on Patient Safety Culture (HSOPSC), acrescido por questões para definição do perfil da população e para caracterização dos EA baseados no sistema de notificação de eventos adversos (Notivisa) da Agência Nacional de Vigilância Sanitária. A população foi composta por 203 profissionais de enfermagem envolvidos na assistência direta aos pacientes de um hospital geral, público, de alta relevância para o atendimento da população da região noroeste de Minas Gerais. Resultados: A amostra foi predominante feminina (85%), com idade média de 40,7 anos, sendo 74% técnicos de enfermagem, 25% enfermeiros e 1% auxiliares de enfermagem. Relataram ter se envolvido em pelo menos um EA nos últimos dois anos, 60% dos profissionais entrevistados. Destes, a maioria foi com dano leve (47%) e sem danos (24%). Informaram também que 75% dos eventos foram notificados ao Núcleo de Risco. A maior parte dos profissionais (55%) que se envolveu em um EA apresentou pelo menos um tipo de manifestação física e/ou psicológica. Ansiedade foi a manifestação mais relatada (24%). Se consideramos os casos em que o EA causou dano moderado, grave ou óbito (n = 36), apenas 22% dos profissionais se mostraram indiferentes, os demais apresentaram ansiedade (33%), irritação (25%), insônia (5%), perda de apetite (5%), dificuldade em retornar a rotina (5%) e, dentre outras (28%), preocupação, frustração, medo, indignação e maior atenção no trabalho. Três profissionais (3%) relataram ter sido necessário buscar assistência emocional especializada. Conclusões: Os resultados deste estudo, em conformidade com o que a literatura apresenta sobre esta problemática, demonstrou o quão deletéria e impactante para um profissional de saúde pode ser a experiência do fenômeno da segunda vítima. Esses efeitos podem ser agravados se na instituição de saúde predomina uma cultura da punição e repreensão pelas falhas cometidas.Instituto Nacional de Controle de Qualidade em Saúde2022-08-31info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersion"Peer-reviewed article""Artículo revisado por pares""Artigo avaliado pelos pares"application/pdfapplication/pdfhttps://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/197610.22239/2317-269x.01976Health Surveillance under Debate: Society, Science & Technology ; Vol. 10 No. 3 (2022): August; 3-12Vigilancia en Salud en Debate: Sociedad, Ciencia y Tecnología; Vol. 10 Núm. 3 (2022): Agosto; 3-12Vigil Sanit Debate, Rio de Janeiro; v. 10 n. 3 (2022): Agosto; 3-122317-269Xreponame:Vigilância Sanitária em Debateinstname:Fundação Oswaldo Cruz (FIOCRUZ)instacron:FIOCRUZporenghttps://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976/1435https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976/1516Copyright (c) 2022 Priscila Portes Almeida, Gerusa Gonçalves Mourahttps://creativecommons.org/licenses/by/4.0info:eu-repo/semantics/openAccessAlmeida, Priscila PortesMoura, Gerusa Gonçalves2023-09-01T13:47:42Zoai:ojs.visaemdebate.incqs.fiocruz.br:article/1976Revistahttps://visaemdebate.incqs.fiocruz.br/index.php/visaemdebatePUBhttps://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/oaiincqs.visaemdebate@fiocruz.br || gisele.neves@fiocruz.br2317-269X2317-269Xopendoar:2023-09-01T13:47:42Vigilância Sanitária em Debate - Fundação Oswaldo Cruz (FIOCRUZ)false |
dc.title.none.fl_str_mv |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais As manifestações de segunda vítima de evento adverso: uma análise dos profissionais de enfermagem de um hospital público de Minas Gerais |
title |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
spellingShingle |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais Almeida, Priscila Portes Evento Adverso Segurança Ocupacional Enfermagem SEGURANÇA DO PACIENTE SEGUNDA VÍTIMA HOSPITAL EVENTO ADVERSO Adverse Event Occupational Safety Nursing |
title_short |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
title_full |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
title_fullStr |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
title_full_unstemmed |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
title_sort |
The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais |
author |
Almeida, Priscila Portes |
author_facet |
Almeida, Priscila Portes Moura, Gerusa Gonçalves |
author_role |
author |
author2 |
Moura, Gerusa Gonçalves |
author2_role |
author |
dc.contributor.author.fl_str_mv |
Almeida, Priscila Portes Moura, Gerusa Gonçalves |
dc.subject.por.fl_str_mv |
Evento Adverso Segurança Ocupacional Enfermagem SEGURANÇA DO PACIENTE SEGUNDA VÍTIMA HOSPITAL EVENTO ADVERSO Adverse Event Occupational Safety Nursing |
topic |
Evento Adverso Segurança Ocupacional Enfermagem SEGURANÇA DO PACIENTE SEGUNDA VÍTIMA HOSPITAL EVENTO ADVERSO Adverse Event Occupational Safety Nursing |
description |
Introduction: Health care can result in adverse events that directly affect patients’ health and their experience in health care, and can cause deaths, permanent and temporary sequelae, psychological distress to patients, their families and health professionals, in addition to raising costs of medical assistance services. Among the ills related to the occurrence of adverse events are the losses suffered by health professionals who are involved in an adverse event, referred to in the literature as “second victim”. These individuals experience profound psychological effects, such as anger, guilt, inadequacy, depression, and suicide, due to real or perceived flaws. Objective: to identify the manifestations, in the face of the occurrence of an adverse event, of nursing professionals in a hospital and their relationship with the phenomenon of the second victim. Method: a cross-sectional and explanatory study was carried out, using quantitative methods. The instrument used was the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC). Questions to define the population profile and to characterize adverse events based on the Notivisa adverse event notification system of Anvisa (National Health Surveillance Agency) were added. The population consisted of 203 nursing professionals involved in direct assistance to patients at a general, public hospital, of high relevance for the care of the population of the northwest region of Minas Gerais. Results: The sample was predominantly female (85%), with an average age of 40.7 years, with 74% nursing technicians, 25% nurses and 1% nursing assistants. 60% (n. 119) of the professionals reported to have been involved in at least 1 adverse event in the last 2 years. Of these, the majority were with slight damage (47%) and without damage (24%). They also reported that 75% of the events were notified to the Risk Center. Most professionals (55%) who were involved in an adverse event presented at least one type of physical and/or psychological manifestation. Anxiety was the most reported manifestation (24%). If we consider the cases in which the adverse event caused moderate, severe or death damage (n. 36), only 22% of the professionals were indifferent; other professionals showed anxiety (33%), irritation (25%), insomnia (5%), loss of appetite (5%), difficulty in returning to routine (5%) and other experiences (28%), worry, frustration, fear, indignation and greater attention at work. Three professionals (3%) reported that they needed to seek specialized emotional assistance. Conclusions: The results of this study, in accordance with what the literature on this issue presents, demonstrate how harmful and impactful for a health professional can be the experience of the phenomenon of the second victim. These effects can be aggravated if a culture of punishment and reprimand for failures prevails in the health Institution. |
publishDate |
2022 |
dc.date.none.fl_str_mv |
2022-08-31 |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion "Peer-reviewed article" "Artículo revisado por pares" "Artigo avaliado pelos pares" |
format |
article |
status_str |
publishedVersion |
dc.identifier.uri.fl_str_mv |
https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976 10.22239/2317-269x.01976 |
url |
https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976 |
identifier_str_mv |
10.22239/2317-269x.01976 |
dc.language.iso.fl_str_mv |
por eng |
language |
por eng |
dc.relation.none.fl_str_mv |
https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976/1435 https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1976/1516 |
dc.rights.driver.fl_str_mv |
Copyright (c) 2022 Priscila Portes Almeida, Gerusa Gonçalves Moura https://creativecommons.org/licenses/by/4.0 info:eu-repo/semantics/openAccess |
rights_invalid_str_mv |
Copyright (c) 2022 Priscila Portes Almeida, Gerusa Gonçalves Moura https://creativecommons.org/licenses/by/4.0 |
eu_rights_str_mv |
openAccess |
dc.format.none.fl_str_mv |
application/pdf application/pdf |
dc.publisher.none.fl_str_mv |
Instituto Nacional de Controle de Qualidade em Saúde |
publisher.none.fl_str_mv |
Instituto Nacional de Controle de Qualidade em Saúde |
dc.source.none.fl_str_mv |
Health Surveillance under Debate: Society, Science & Technology ; Vol. 10 No. 3 (2022): August; 3-12 Vigilancia en Salud en Debate: Sociedad, Ciencia y Tecnología; Vol. 10 Núm. 3 (2022): Agosto; 3-12 Vigil Sanit Debate, Rio de Janeiro; v. 10 n. 3 (2022): Agosto; 3-12 2317-269X reponame:Vigilância Sanitária em Debate instname:Fundação Oswaldo Cruz (FIOCRUZ) instacron:FIOCRUZ |
instname_str |
Fundação Oswaldo Cruz (FIOCRUZ) |
instacron_str |
FIOCRUZ |
institution |
FIOCRUZ |
reponame_str |
Vigilância Sanitária em Debate |
collection |
Vigilância Sanitária em Debate |
repository.name.fl_str_mv |
Vigilância Sanitária em Debate - Fundação Oswaldo Cruz (FIOCRUZ) |
repository.mail.fl_str_mv |
incqs.visaemdebate@fiocruz.br || gisele.neves@fiocruz.br |
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1797042046592090112 |