Falls Suffered by Hospitalized Adult Patients: Support to the Nursing Team as the Second Victim*

F a ll s S u ff e r e d


Introduction
The classification of incidents and adverse events related to patient safety by the World Health Organization (WHO) in the late 1990s revealed a pressing need for improvement in the quality and management of care processes and health services. Patient safety is an issue related to care practices with the objective of reducing adverse events and unsafe actions that put patients' health at risk (1). Among the identified events, which compromise patient safety, are falls in the hospital environment (2). The WHO defines 'fall' as the unintentional displacement of the body to a level below the initial position, without the possibility of timely correction, compromising stability, adding a variety of associated factors (3,4).
Falls cause injuries in almost half of the patients who are affected by this event, which may, in the most severe cases, lead to death (2). In addition, a fall can generate psychological impact by the fear of the patient falling again, which influences the risk of future falls (5), in addition to negatively interfering with the patient's functional capacity and mobility (6), which can increase the length of hospital stay and care costs, generating anxiety in the nursing team and producing repercussions on the institution's credibility, in addition to legal consequences (7,8).
Nursing teams who are directly involved in the care of a patient who has fallen experience feelings such as guilt, distress, and helplessness. These feelings stem from a self-judgment that leads to devaluation by patients, who are instructed on fall prevention care and do not adhere to the measures, and from the understanding that falls are a reflection of a work process that is solely the responsibility of the nursing team (9), when, in fact, it should be the reason for multiprofessional care, considering that it is an event that requires a multimodal approach. This happens because the implementation of collaborative practices results in better outcomes for patients and safer care, based on the promotion of trust relationships between healthcare teams (10) and, consequently, on the promotion of healthcare staff safety.
Institutions that fail to emphasize work processes related to healthcare and to promote a safety culture in the workplace lead their staff to be more susceptible to feelings of guilt due to patient falls. Moreover, this type of event can have repercussions on the institution's image (11), consisting of a challenge for nursing leaders to ensure the quality of care and patient safety (12). An organization that recognizes its susceptibility to errors is more likely to implement safety processes while supporting those that become instances of such imperfection (13).
Although an adverse event with a severe outcome and even death causes suffering to patients and their families, they are the first victims of this process, but not the only ones. The staff involved, directly or indirectly, also suffers and is considered the second potential victim; moreover, the impact caused to the caregivers involvedregardless of sex, age, and professional category-can leave permanent marks on most individuals. Therefore, any team member who is providing care to a patient who is a victim of harm resulting from care may suffer impacts from this, with repercussions on their private or professional lives, and is therefore considered a "second victim" of the event. This expression emerged in the literature for the first time in 2000, in an editorial of the British Medical Journal, concerning the impact on healthcare staff involved in an error or when they feel responsible for the adverse event and the unexpected injuries caused to the patient (14).
Second victims may experience negative feelings resulting from patient outcomes, which may vary depending on the support provided to healthcare staff. This support, although essential, is not usually widespread and frequent, but it is an effective measure to mitigate the symptoms that often affect the second victim (13,(15)(16)(17).
In light of this scenario, this study's objective was to describe the support second victims received in falls suffered by hospitalized adult patients from the nursing team's perspective.

Materials and Methods
This was an exploratory and descriptive study with a qualitative approach supported by content analysis. The study was carried out in a large general hospital in the southern region of Brazil, in a reference hospital for high complexity cases, with an installed capacity of 843 beds. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.
Data collection was carried out from March to May 2020 through semi-structured interviews with the nursing team members (nurses and nursing technicians), who were selected via random sampling (simple draw) based on the following inclusion criteria: to work as a nurse or nursing technician in one of the five inpatient units and to be working at the time of the study on a work schedule, in the respective shift where the falls occurred. The exclusion criteria considered were being a member of the nursing team with less than one year of experience in the institution, being on vacation or leave of any kind, in addition to those working under a temporary contract during the data collection period.
The five inpatient units listed for the nursing team interviews were among those where fall events had occurred, classified with moderate to severe harm, from July 2018 to July 2019, totaling 12 falls.
The participants were drawn in the presence of the unit manager for each shift where a fall had occurred; one nurse and two nursing technicians were drawn. One staff member declined the invitation to participate in the study, and another was un-able to participate due to problems in the unit. After they accepted, the informed consent form was presented, describing the study objectives, the research area of interest, the opportunities for care practice, as well as the possibility of withdrawing, if desired, and the researcher's credentials. A sample of 21 nursing team members answered the interview, which was defined by information saturation, i.e., the interviews were terminated when repeated information about the study's theme was found. The sample consisted of a total population of 153 nursing team members working in the shifts of the five inpatient units where the falls occurred.
The interview script was developed by the researchers based on the literature on which the study was based. First, a pilot test was conducted with a nursing technician belonging to a unit not included in the study, which allowed adjusting the script in order to meet the study objective.
Initially, institutional data related to the frequency and classification of safety incidents related to falls in the last year were contextualized to the nursing team. Subsequently, the participant was invited to talk about a patient fall that happened under their or a colleague's responsibility, describing the repercussions of the occurrence and how the approach was carried out with the staff member involved in that incident.
The interview was conducted in person by the main researcher, who has a master's degree, during the participants' work shifts, at a previously scheduled time, in a reserved room at the workplace of the study participant, with an average duration of 35 minutes, with audio recording and subsequent transcription. Immediately after the interviews, field notes were taken to prevent information loss. The researcher worked at the study's focus institution, was acquainted with most participants, had experience in conducting group interviews in event analysis, and periodically met with the other researchers to share information. When the researcher and the participant had not previously met, the moment of the draw and the invitation to participate in the study was the first interaction between them. It was clarified to the staff invited to answer the interview that participation was voluntary and that they could quit at any time without harm to or interference with their care attributions or work relationship. This information was also included in the informed consent form handed out to the study participants.
The data were submitted to content analysis, applying the steps of pre-analysis, material exploration, treatment of results, inference, and interpretation, without using any software (18). The codes "NUR" for nurses and "NT" for nursing technicians were used, in addition to the numbers referring to the order in which the interviews were conducted, with the objective of ensuring the participants' anonymity.
The original statements of the research participants were preserved in order to respect the internal and original vision of the thoughts and feelings of the researched group. The researcher's perspective contemplated the interpretations based on the literature and on the inferences expressed in the discussion of the data with the objective of furthering knowledge.
This study complies with Resolution 466 of 2012, issued by the National Health Council. It is a project approved by the Research Ethics Committee of the institution and complies with all ethical precepts.

Results
Seven nurses and fourteen nursing technicians participated in the study. Among the nurses, all were female, aged between 30 and 52 years. Their time working as nurses ranged from 8 to 27 years, and their time of employment at the researched institution ranged from 7 to 20 years. Regarding the nursing technicians, five were male, and nine were female, aged between 36 and 65 years, their time working as nursing technicians ranged from 7 to 34 years, and their time working at the researched institution ranged from 1 to 29 years.
The support received in the instances of involvement with a fall event was described by the nursing team based on individual aspects ("individual support" category) and institutional aspects ("institutional support" category).

Individual support
When nursing team members were asked about the support they received in a situation where a hospitalized patient suffered a fall, responses varied, ranging from receiving support from a close colleague, from the immediate manager, or from one of their family members.
[...] I receive support from colleagues first because they go through the same circumstances because of the shift nurse's point of view, but nurses already understand things in a more managerial way, while technicians are more practical. (NT1) We tell our immediate bosses, but there is no support. (NUR1) According to the interviewees, this support is provided by the proximity of previously established relationships, a possible dialogue space between the different members of the work teams, by colleagues who offer to listen and welcome the feelings arising from the experiences related to the patient's fall.
With my colleagues... just talking like this is already a relief. Whether it's over a cup of coffee or when you're sitting at the computer typing, it's already a relief; you can get it out, and it seems to give you some peace of mind. (NT9) But then you get closer to your colleague, you support them because you see that they are a little shaken, as I said [...] "but how come so-and-so fell down if they were fine just now," but then they say, "it happens," you see, there's nothing you can do. (NT10) Another aspect mentioned as desirable by the staff was to receive immediate support from their colleagues when an adverse event occurs with a patient under their care. However, they report that this is not always the case, either because the family bond is able to meet this demand in a more welcoming way or because the work environment sometimes does not allow this listening moment, given the exhausting routine and situations that may involve the denial of feelings related to the experience of the incident. The nursing team members also reported that immediate support from a colleague with whom they have an affinity bond promotes effective welcoming and reduces the feeling of judgment for being involved in an incident.

Institutional support
When questioned about the institutional support received, the nursing team members demonstrated not having found this support or that they understood that it had to be requested.
There is no support like that, I think it is very much in our heads, [...] the other day I was with the researcher [...] she even cried and felt responsible for this. But I think that there is no support. We make practical and rational referrals and I keep working because the demand is very high and we can't stop to think. Even though interviewees listed institutional support exists, they did not perceive it as efficient, requesting that it could be actively provided. They ask for structured institutional support provided by someone outside the unit who could address their feelings in the field of mental health.  The nursing team members understand that the welcoming can be structured in a better way and proposed in a continuous way. In addition, they understand that the support should be of interest to the institution in order to invest in the nursing team.
I think that in the first place the institution should give me some support within the occupational medicine service, psychology [...] they could provide this support and offer me a follow-up and I think that it's also up to the person because sometimes employees don't feel comfortable to report something within the psychology and occupational medicine environment, I see that many people seek it. ( The statements reveal that there is an identification of the need for institutional support and the consolidation of an approach for the welcoming of the staff, which possibly requires dedicated personnel for this purpose. The previous speech also displays some disbelief regarding the effectiveness of the existing service, restating the need for investment and improvement in this aspect. In turn, staff members who are involved as the second victim of adverse events recognize that the institutional approach represents a way to value and invest in their emotional safety.

Discussion
The falls suffered by patients represent not only frequent incidents in healthcare but are also the source of feelings of guilt among the nursing team members involved, amid other negative feelings typically experienced in second victim situations. These facts are evidenced in the statements when nursing team members identify the need to share with a close colleague or family members the feelings experienced by having a patient who has suffered a fall during the work schedule, which is a way of seeking support. From this perspective, it is necessary to provide greater support to the nursing team (13,19).
The psychological impact of becoming a second victim is directly related to the severity of an event. A study with healthcare staff from 93 hospitals in Belgium showed that the impact of a death is the greatest among nurses, whereas, with severe harm, it is the greatest among medical professionals. According to the researchers, the justification lies in the nature of the profession and ultimate responsibility towards the patient (20).
The second victim phenomenon occurs widely and more frequently in places with patients who require more care and with the occurrence of death. However, patients who suffered severe injuries, where the care provided had a direct impact on the outcome of these patients, led to feelings of guilt, a fact that demonstrates the importance of structuring programs that support second victims (9,20).
It is not uncommon that, in circumstances where the harm to the patient stands out, the nursing team needs to deal individually with the emotional repercussions of the event. These circumstances are validated by previous situations where the staff member needed the occupational medicine service and could not identify the organizational support.
Nursing is a profession strongly rooted in the outcome of success, disregarding the fallibility inherent in complex processes, and it holds a strong sense of responsibility, a quality that, in addition to harm reduction, influences the impact of the occurrence (20). The constant focus on outcomes intensifies the attention to adverse events and identifies opportunities for improvement, retrospectively analyzing practice scenarios, implementing improvement plans, and focusing on the continuing education of the staff who provide care.
Although all these factors are relevant, it is necessary to monitor work environments (21) and identify the repercussion of adverse events for staff in order to influence the organizational safety culture, indicating the importance of discussing when something unexpected happens, both from the perspective of the work process and of welcoming staff, aiming to create a sense of purpose.
Becoming a second victim can be equated to post-traumatic syndromes, considering the range of feelings encompassed, with about 50 % of healthcare professionals having experience feelings that caused them to doubt their ability to work and feel a profound responsibility regarding the negative repercussions on the patient's future life, which is in line with the interviewees' statements (13,16).
Among the feelings experienced by the second victim are guilt stemming from the harm done to the patient, fear for the loss of reputation, and distress over the charge of uncleared or unaddressed situations are all part of the second victim's experiences (9,20,22).
The reduction of psychological impact requires active and planned strategies well beyond any individual capacity for resilience and support-seeking, although the latter is important. The failure to clearly identify institutional support or the ineffectiveness of occupational care are important reports concerning support as a way to appreciate both the staff members and the patients. The support provided and organizational cultures with clear guidelines allow feelings like these to be at least mitigated (20).
Strategies such as avoidance are described in the literature and may become common among nurses, as the focus on tasks and emotions are also reported as second victim coping alternatives (23). Strategies such as these lead to an environment of dissatisfaction among staff members and deconstruct trusting relationships among peers (16). In this sense, institutional support, both to provide the staff with protagonism for this action and to support them, is the key to these measures (13,15).
Feelings and behaviors of avoidance and denial related to incidents, despite when they are likely to be classified as defense mechanisms, hinder the investigation of more effective possibilities for coping with situations that cause psychic suffering. These situations can occur in the absence of formal institutional support, allowing the emergence of feelings of disrespect and depreciation of staff members, in addition to the preservation of second victim feelings (24).
Appropriate coping strategies have positive repercussions when they elicit proactive actions and behaviors that are beneficial to patients, but it is necessary to identify that inappropriate strategies can weaken the provider-patient therapeutic bond, reflected by more aggressive or defensive behavior from the healthcare staff (25), representing a warning for hospital institutions and an important reason for the implementation of structured support with an early, scaled, and continuous approach.
Considering that, after an incident, the staff member feels the need to talk about it to be relieved from the work schedule and to feel supported by colleagues and the institution, it is essential to train representatives of the care and management teams who can be implemented through attentive leadership and qualified listening. For this, the level of organizational support to leaders is crucial so that they can identify programs and projects that support second victims (15,20,26).
Institutional support is paramount to mitigate the impacts of the second victim's experience, and the immediate response consti-tutes a form of welcoming. Awareness of an adverse event assists the development of individual coping strategies and support for peers going through similar situations. Therefore, avenues of support for second victims must be available, visible, and accessible; sharing the staff experiences allows restitution in the work team and enables the restoration of integrity (13,15) since the emotional disruption of participating in an adverse event can alter professional relationships and the type of support received, which influences the emotional responses (27).
The creation of a support program for second victims called Resilience in stressful events (RISE) at the Johns Hopkins University Hospital (United States) proved to be beneficial for the institution, structuring the support of the healthcare team after the occurrence of a stressful event related to patients. Other programs with a similar purpose have been created, such as the "Mitigating Impact in Second Victims" (MISE) , with a virtual support format, which aims to train frontline staff and managers to assist members of the healthcare team involved in events with repercussions for second victims. In this line, the University of Missouri (United States), with the For You program, has shown that only 10 % of second victims need specialized mental health support, which demonstrates the importance of immediate welcoming and of qualified listening to peers in the work environment (17,26,28,29).
Moreover, it is noteworthy that the support provided to the second victim by the institution can help prevent new instances of the event, as it is an investment in the staff members, not exempting them from liability, considering the repercussions of the harm. Likewise, it is important to identify the experiences of nursing team members as second victims in healthcare institutions in order to propose measures and support programs appropriate and possible to be carried out (30), immediately, in the medium and long terms for reducing the emotional stress and promoting individual and systemic resilience (25).
Finally, this is a small-scale study, where the results are sensitive to the context applied, which may characterize a study limitation, as well as the researcher's previous knowledge of the study participants. However, this methodology can be replicated, which allows for alternatives to be identified for planning support for staff members as a way of valuing and investing in workplace relationships.
As far as nursing is concerned, the identification of people who are willing and have a welcoming and empathetic profile in the healthcare units is a relevant possibility to be implemented, as a form of immediate support, based on previously built relationships and an initial step in the approach to the second victim. In addition, the discussion in academia during training constitutes another possible contribution of the present study, as there is a close relationship between attentive leadership and the promotion of a welcoming environment.

Conclusions
The present study identified the perceptions of the nursing team regarding the relevance of individual support, whether from peers in the work environment or family members in the private context or in situations that predispose second victims among nursing team members. The incipiency of institutional support and the need to talk openly about the situations experienced by second victims, even if in fear of the repercussions, is necessary to mitigate the feelings of the staff involved in care failures, to appreciate the nursing team, and to promote humanized care for the members of the healthcare teams.
The support to the nursing team enables contributing to the promotion of an institutional culture of safety that allows learning, strengthening trust relationships, and promoting the team members' well-being as a way to provide care in the search for qualification in the work environment, represented by the managerial challenge translated by the relevance of falls in the international context.
The level of investment in healthcare staff assumes that the implementation of support programs for the second victim needs to be provided early and actively, in a structured, scaled, and continuous way, identifying reference individuals with a welcoming profile that can provide this immediate and longitudinal approach, which is the main suggestion for future studies.