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      Moving on after critical incidents in health care: A qualitative study of the perspectives and experiences of second victims

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          Abstract

          Aims

          To gain a deeper understanding of nurses and midwives' experiences following involvement in a critical incident in a non‐critical care area and to explore how they have 'moved‐on' from the event.

          Design

          An interpretive descriptive design guided inductive inquiry to interpret the meaning of moving‐on.

          Methods

          Purposive sampling recruited 10 nurses and midwives. Data collection comprised semi‐structured interviews, memos and field notes. Data were concurrently collected and analysed during 2016–2017 with NVivo 11. The thematic analysis enabled a coherent analytical framework evolving emerging themes and transformation of the data into credible interpretive description findings, adhering to the COREQ reporting guidelines.

          Results

          The findings revealed five main themes: Initial emotional and physical response, the aftermath, long‐lasting repercussions, workplace support and moving‐on.

          Conclusion

          This study shed light on the perceptions of nurses and midwives who lived through the impact of critical incidents. Through their lens, the strategies engaged in to move‐on were identified and their call for organizational and collegial support received a voice.

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          Most cited references60

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          Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.

          Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design. To develop a checklist for explicit and comprehensive reporting of qualitative studies (in depth interviews and focus groups). We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.
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            Special report: suicidal ideation among American surgeons.

            Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown. Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life. Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI. Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.
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              COVID-19: a heavy toll on health-care workers

              The COVID-19 pandemic has challenged and, in many cases, exceeded the capacity of hospitals and intensive care units (ICUs) worldwide. Health-care workers have continued to provide care for patients despite exhaustion, personal risk of infection, fear of transmission to family members, illness or death of friends and colleagues, and the loss of many patients. Sadly, health-care workers have also faced many additional—often avoidable—sources of stress and anxiety, and long shifts combined with unprecedented population restrictions, including personal isolation, have affected individuals' ability to cope. As the pandemic unfolded, many health-care workers travelled to new places of work to provide patient care in overwhelmed facilities; those who volunteered in unfamiliar clinical areas were often launched into the pandemic ICU setting with insufficient skills and training. The burden of training and supervising these volunteers fell on already stressed clinicians. Hospital-based health professionals worked long hours wearing cumbersome and uncomfortable personal protective equipment (PPE), after initial shortages of PPE had been addressed. They strived to keep up with emerging knowledge, institutional and regional procedures, and changing PPE recommendations, while trying to distinguish accurate information from misinformation. Health-care workers had to adopt new technologies to fulfil patient care and educational responsibilities, including the provision of telemedicine. Insufficient resources and the absence of specific treatments for COVID-19 added to the challenges of managing severely ill patients. Health-care workers had to care for colleagues who were ill, offer comfort to dying patients who were isolated from their loved ones, and inform and console patients' family members remotely. Some health-care workers were burdened with emotionally and ethically fraught decisions about resource rationing and withholding resuscitation or ICU admission. They shared the pain of patients without COVID-19 who had their surgery or other essential treatments cancelled or postponed. The fear of transmitting COVID-19 led many health professionals to isolate from their families for months. Working remotely and being shunned by community members further contributed to loneliness. Many health-care workers experienced lost earnings because of cancellations in outpatient visits and elective procedures. The training of health-care workers (eg, medical students, residents, and allied health learners) was also interrupted, leading to loss of tuition fees, missed learning opportunities, missed exams, and potentially delayed certification. Home health-care workers experienced additional challenges that exacerbated the inequities they face as a marginalised workforce, including limited or no PPE, varying levels of employer support, and the difficult choice of working with its attendant risk or losing wages and benefits. 1 The burden of COVID-19 on health systems and health-care workers was substantial in low-income and middle-income countries (LMICs), where difficult daily triage decisions had to be made in the context of grave shortages of basic equipment and consumables. LMICs saw an internal drain on human resources as health-care workers were pulled from clinical practice to join COVID-19 committees and task forces. In the already stretched areas of anaesthesia and intensive care, a high clinician burnout rate might have contributed to worse outcomes for patients with COVID-19. An increase in non-COVID-related health problems and deaths (eg, those caused by disruptions to vaccination or screening programmes for other infectious diseases), including personal health challenges for health-care workers (eg, worsening of diabetes control), further strained poorly resourced health systems. LMICs experienced high rates of health care-associated COVID-19, due in part to a shortage of PPE, increased workload, inadequate training and infection control practices, and pandemic fatigue. Guilt and stigma associated with COVID-19 were common. Cases of health-care workers abandoning their posts or refusing to attend to patients suspected of having COVID-19 were not uncommon. Health-care workers have been subjected to denigration from various sources during the pandemic, including political leaders and hospital administrators. In some LMICs, such as Uganda, health professionals were targeted by the public because of their roles on scientific advisory committees, and their policy decisions were met with mistrust and hostility. Health-care workers are known to be at risk for anxiety, depression, burnout, insomnia, moral distress, and post-traumatic stress disorder.2, 3 Under usual working conditions, severe burnout syndrome affects as many as 33% of critical care nurses and up to 45% of critical care physicians.2, 3 Extrinsic organisational risk factors—including increased work demands and little control over the work environment—and the trauma of caring for patients who are critically ill have been heightened by the COVID-19 pandemic and represent important exacerbating factors for poor mental health among health-care workers. Following the outbreak of severe acute respiratory syndrome in 2003, health-care workers reported chronic stress effects for months to years. 4 Among health-care workers treating patients with COVID-19, a Chinese study reported high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%). 5 These findings were supported by a systematic review of 13 studies including more than 33 000 participants. 6 Studies from Italy and France reported a high prevalence of depressive symptoms, post-traumatic stress disorder, and burnout; risk factors for adverse psychological outcomes included younger age, female sex, being a nurse, and working directly with patients with COVID-19.7, 8, 9 The long-term effect on the health of those working in health care remains to be seen. The COVID-19 pandemic is a stark reminder of racial and socioeconomic disparities, with disproportionate infection and death rates among migrants, the poor, and racialised groups. COVID-19 has also had a disproportionate effect on women health-care workers. Women comprise 70% of the global health and social care workforce, putting them at risk of infection and the range of physical and mental health problems associated with their role as health professionals and carers in the context of a pandemic. The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence. While trying to fulfil their professional responsibilities, women had to meet their families' needs, including childcare, home schooling, care for older people, and home care. Burdened by these obligations, women had reduced academic productivity relative to men, as evidenced by fewer women being part of the cohort producing new knowledge about the pandemic. 10 There was a disconnect between the demands of parenting and the expectations of the scientific community, as shown by ultra-short timelines for COVID-19-related grant proposals, which further deepened the divide between women and men. During the pandemic, there have been glimmers of hope and solace. We were buoyed by support from institutional and government leadership, the spirit of teamwork, the celebration of lives saved, and the acknowledgement of our value by the public. Social media was a venue for health-care workers to share their anxiety, insomnia, and fatigue, which reduced the sense of isolation and normalised conversations about mental health. To effectively support health-care workers—the greatest assets of our health-care systems—we must understand their challenges and needs. Burnout and other forms of work-related psychological distress are unavoidable occupational health issues. By acknowledging the commonality of psychological distress related to caring for patients with COVID-19, we can destigmatise work-related mental health issues and appropriately attend to the mental health needs of all health-care workers affected by the pandemic. Finally, we hope that the COVID-19 pandemic will prompt a redefinition of essential support workers, with recognition of the contribution of all health-care workers and appropriate education, protection, and compensation. © 2021 Adam Gault/Science Photo Library 2021 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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                Author and article information

                Contributors
                m.buhlmann@ecu.edu.au
                Journal
                J Adv Nurs
                J Adv Nurs
                10.1111/(ISSN)1365-2648
                JAN
                Journal of Advanced Nursing
                John Wiley and Sons Inc. (Hoboken )
                0309-2402
                1365-2648
                22 April 2022
                September 2022
                : 78
                : 9 ( doiID: 10.1111/jan.v78.9 )
                : 2960-2972
                Affiliations
                [ 1 ] School of Nursing & Midwifery Edith Cowan University Bunbury Western Australia Australia
                [ 2 ] School of Nursing & Midwifery Edith Cowan University Joondalup Western Australia Australia
                Author notes
                [*] [* ] Correspondence

                Melanie Buhlmann, School of Nursing & Midwifery, Edith Cowan University, 585 Robertson Drive, Bunbury WA 6230, Western Australia.

                Email: m.buhlmann@ 123456ecu.edu.au

                Article
                JAN15274 JAN-2021-2086.R1
                10.1111/jan.15274
                9543713
                35451525
                f3c299e3-8e8e-4674-8f52-5fc126451ad3
                © 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                Page count
                Figures: 0, Tables: 3, Pages: 13, Words: 10495
                Product
                Categories
                Original Research: Empirical Research ‐ Qualitative
                Research Papers
                Original Research: Empirical Research–Qualitative
                Custom metadata
                2.0
                September 2022
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.0 mode:remove_FC converted:07.10.2022

                Nursing
                adverse event,clinical incident,coping,critical incident,midwifery,midwives,nurses,nursing,trauma
                Nursing
                adverse event, clinical incident, coping, critical incident, midwifery, midwives, nurses, nursing, trauma

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