The manifestations of the second victim of an adverse event: an analysis of nursing professionals from a public hospital in Minas Gerais

Detalhes bibliográficos
Autor(a) principal: Almeida, Priscila Portes
Data de Publicação: 2022
Outros Autores: Moura, Gerusa Gonçalves
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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spelling 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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