Critical Incidents’ Impact on Nurses and Midwives Essay

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Abstract

Objective: Knowledge of how critical occurrences affect nurses and midwives and how they cope with the support they get in the current healthcare context is the focus of this study, which aims to summarize that research.
Introduction: An extensive search of electronic databases such as CINAHL and MEDLINE was conducted from 2013 to 2018, as was a manual review of relevant articles in journals such as Nursing and Allied Health (ProQuest), PsycINFO, PsycMed, PubMed, and Embase.
Inclusion criteria: Qualitative studies of all kinds of study designs published in English met the PRISMA reporting standards (1). It was decided to apply the JBI Critical Appraisal Checklist for Qualitative Research to evaluate the research methods employed. There were 7,520 different publications that were considered.
Methods: Eleven excellent primary research papers proceeded to meta-aggregation via duplicate citation removal, studies chosen, and evaluations done to the meta-synthesis. (2).
Results: From the included studies, 179 conclusions and sub-findings have been combined into three components that address three unique aspects of critical incidents: the perceptions of consequences, the perceptions of aid, and the ability to move forward. When it came down to it, it was discovered that nurses and midwives had a tough and laborious time moving on from traumatic experiences (3).
Conclusions: Nursing and midwifery subsequent victims should be given greater attention in order to increase their capacity to handle the aftermath of catastrophic events and restore their professional confidence.

Introduction

Following up midwives after harmful incidents and how front-line management approaches aid second victims to focus on this assessment. Nurses and midwives, in particular, have regarded their participation in critical incidents as the ‘darkest hour’ of their professional lives (4). As a result, healthcare workers have been referred to as the second victims of catastrophic occurrences because of their emotional distress. The concept of second victims has drawn worldwide attention and sparked investigations into this phenomenon.

Any incident that comes out of nowhere and has far-reaching emotional consequences that go beyond a person’s normal ability to cope and cause them significant psychological stress is included in the category of “critical occasions.” In such a case, the effect on those involved may arise as a consequence of any alarming occurrence, clinical mistake, or patient incident, regardless of how tragic the circumstances may be (5). Many healthcare professionals might endure mental distress and distressing impressions of their personal and professional self-image due to their participation in these situations, commonly linked to long-term emotional sequelae and professional isolation.

Professional self-esteem, clinical competence, the quality of patient treatment, and the ability to perform within the profession are all negatively impacted by key events. Workers’ emotional, social, and professional health may suffer as a result of the stress they experience at work, but healthcare organizations are not doing enough to address this risk of workforce turnover (6). Events that needed life-saving treatment and those that resulted in prolonged hospitalizations, permanent damage, or death are all included in this category, and rashes are an example of bodily events. Healthcare providers are required by law to report incidents that may have resulted in injury to patients or customers without their knowledge or consent.

Pregnant women who use them have had no issues whatsoever. Nursing cares for people of all ages, families, groups, and communities, whether they are ill or well and, in any situation, (8). Health promotion, disease prevention, and patient care are all aspects of nursing (9). A nurse’s primary responsibility is to advocate for and provide care for patients and assist them with their health care needs.

There are 28 million nurses and midwives in the world, accounting for 59% of the global health workforce, according to the World Health Organization, 2020. 5.7 million nurses and midwives are expected to be short by the year 203, according to a World Health Organization (WHO) estimate released in 2020. (10). According to the World Health Organization (WHO), there will be an increase in the percentage of people aged 60 and above from 12 percent to 22 percent by 2050, according to the World Health Organization (WHO). This trend, along with the expected worldwide shortage of nurses and midwives, makes the retention of nurses and midwives in the workforce even more important (11). According to this study, second victims’ experiences and the assistance they need to maintain their clinical duties might counteract the work-stress-related attrition in nursing and midwifery. In addition, it has the potential to improve retention and help solve the predicted national and international nursing and midwifery workforce shortages.

Review question

How do critical occurrences affect nurses and midwives and how do they cope with the support they get in the current healthcare context?

Keywords: Adverse events, clinical incident, critical incident, midwives, nurses.

Inclusion criteria

Participants

The EndNote bibliographic management application was used to remove duplicate citations and begin the research selection process with a total of 7,520 prospective publications. A total of 4,408 titles and 174 abstracts were scrutinized for relevance to the Pico’s after 3,112 duplicates were removed. There were 54 articles reviewed in their entirety, and the number of publications that did not meet the inclusion criteria or reported on issues related to the exclusion criteria (no evaluation of the impact on a nurse or a midwife involved; not concentrated on nurses or midwives) was further reduced. A rigorous evaluation of twenty studies was conducted (12). There were 15 midwives who had been traumatized by difficult labor (shoulder dystocia, occiput posterior presentation, induced labor, extended labor, third/fourth-degree perineal tear, and vaginal variceal hemorrhage) when their traumatic circumstances were evaluated.

In ten instances, the trauma led to the infant’s death, and in four cases, the mother died as a result of the trauma (13). A traumatic delivery experience was reported by all of the midwives who took part in the study. In-depth interviews with midwives revealed that they had little time to reflect on the upsetting circumstances they had encountered since they had to continue working after the incident owing to the workload. As a result, the local midwives had to put in long hours and assist with a large number of babies. They may have been compelled to accept the terrible events as part of their daily routine as a result of this predicament.

Intervention/Phenomena of interest

In the research, it was found that the MWM uses either a proactive or a reactive approach. It is clear that the MWM takes a proactive approach once adversity strikes, and she encourages others to do the same by holding team meetings, setting up peer support groups, seeking professional counseling, or just talking to one another. Because of her tight relations with the midwife that is in charge of the night shift, she is able to recognize when a woman needs extra help following a miscarriage.

According to midwives, peer support is an emotional first aid in which people may freely express their thoughts and feelings in a non-judgmental and private environment. There has to be an abundance of mental health experts, including psychiatric nurses, psychologists, and psychiatrists. Preventative measures are necessary for a peer support program to be successful (14). Not many midwives are willing to seek treatment because of the shame associated with doing so.

As a result of this trust, the MWM’s practical approach to peer help is founded on Entrusting one’s well-being to another midwife and trusting the other midwife to give support and understanding in order to expose oneself (15). During team meetings, the MWM may build trust and lower the bar for assistance by highlighting how one of nurse’s colleagues’ aid, allowed the an-another midwife to make a distinctive contribution.

Table 1: Report Findings

Study	Main Themes (finding)	Finding illustration	Synthesis finding
To describe nurses’ needs and how they are being met after caring for a patient who died after a failure to rescue.	There is no one-size-fits-all approach to coping in different populations. Subtheme 1 Criteria for dividing the population into groups Subtheme 2 Differentiated approach to work Subtheme 3 Complex stratification structure	Their nurse leaders failed to provide the feedback and support that many nurses lacked.	Immediate nurse leader support and follow-up debriefing should be mandatory.
To describe an adverse event’s physical and psychosocial impact on second victims, specify the recovery course and describe the actual assistance provided.	Adverse events were well-remembered by participants, who expressed their physical and psychological effects. Subtheme 1 Psychological consequences of unpleasant situations Subtheme 2 Overcoming the consequences of psychological trauma Subtheme 3 Psychological effects caused by traumatic events	The support obtained was poor and inefficient.	It is crucial to implement actual interventional programs that would support and train the HCPs.
To get insight into ICU nurses’ most critical work-related incidents, their coping mechanisms, and perceived support.	Both adequate and inadequate response strategies with problems persisting after severe incidents were reported. Subtheme 1 Incident response process Subtheme 2 Launching the major incident management process Subtheme 3 Lack of adequate process	Feelings of powerlessness, anger, and shame hindered the recovery process.	Talking to colleagues was found helpful, but their support was still not satisfying enough.
To explore the impact of maternal death on maternity professionals and their related professionals and personal needs.	Maternal death has a significant impact on HCPs’ feelings of grief, guilt, and shame, about which they were reluctant to talk. Subtheme 1 Clinical and social burden of relatives of suicide victims Subtheme 2 Intergenerational transmission of trauma Subtheme 3 Symptoms of stress disorders after the death of loved ones	HCPs expressed their desire for training to prepare themselves to respond effectively in the event.	There was ambiguity about debriefing with a changing institutional culture.
Examine how healthcare professionals are impacted when they are involved in adverse events, focusing on the organizational support they need and how well those needs are met by organizational support.	The impact on healthcare professionals is related to organizational response. Subtheme 1 Assessment and control of the risk of exposure to medical workers Subtheme 2 Types of responsibility of medical workers Subtheme 3 Rights and obligations of medical workers	Most lacked organizational response or received unstructured and unsystematic.	Inadequate support and lack of response turned event handling and conclusions more difficult.
To explore grief and coping among nurses working in a medical ICU.	Nurses had unique grief experiences, and their coping was individualized. Subtheme 1 Psychotherapy in working with patients experiencing grief Subtheme 2 Dealing with grief and loss Subtheme 3 Nursing intervention at various stages of grief	They were aware of the effects grief had on their personal and professional lives.	All developed effective coping habits to manage their grief based on the support and camaraderie of their colleagues.

Outcomes

Initially, the main author analyzed the themes and sub-themes retrieved from the review to find thematically or conceptually relevant similarities. There is a wide range of factors that contribute to a person’s mental, physical, and professional well-being and their ability to cope with the aftermath of an occurrence. Information F outlines how the consolidation of these nine categories confirmed the results of this systematic review into representative statements.

Nurses and midwives described a variety of experiences after their involvement in critical events. They said that they and others may have overestimated the impact on their emotional, physical, and professional well-being. A total of 50 results and sub-findings were collected in three categories to produce this synthesized statement. According to my findings, 2—Perceptions of support: The degree of support nurses and midwives received from family and friends, work colleagues, and supervisors via workplace practices and debriefing opportunities varied from adequate to entirely missing. The 53 outcomes and sub-findings in categories four, five, and six were merged to form this synthesis. The consequences of critical events and the effort it needed to overcome them were seen too lightly by most people (25). A nurse’s or a midwife’s capacity to move on from a tough situation depends on her or his ability to learn from the experience, grow from the experience, and deal constructively (27). The 76 aggregated results and sub-findings in this final synthesis came from categories seven, eight, and nine.

They referred to a newfound sense of hope and a desire to make a difference in the lives of my dying patients that made me appreciate life even more (26). Nurses’ and midwives’ perceptions of what would help them cope with the disaster were not always encouraged and welcomed. Access to counseling is made easier by establishing a base in the hospital that is as close to the actual occurrence of the incident as possible.

Types of studies

In this study, a meta-aggregation of four sources raised the posttraumatic syndrome problem in nursing practice. This approach highlights the central values of qualitative research. This is used to determine the research information in a category, which is then fed to a particular synthesis. Thus, the main category is to analyze the stress arising from the activities of midwives (Table 2). The keywords were nurses, post-traumatic experience, help, adverse incidents, and stress. Therefore, one of the subcategories can be the reason for such a condition. The second subcategory that must be mentioned is the influence and outcomes of the experienced stress. The third is how post-traumatic conditions can be treated and who can provide assistance to improve the emotional state of nurses and midwives.

Main Category

To analyze the stress arising in the activities of midwives.

Subcategory 1

The reasons for stressful conditions.

Subcategory 2

The influence and outcomes of the experienced stress.

Subcategory 3

How post-traumatic conditions can be treated and who can provide assistance to improve the emotional state of nurses and midwives.

Table 2. Categories of the Research.

Methods

Search strategy

This study’s research strategy uses a content analytic method and the Critical Incident Technique. The method focuses on events that major impact future behavior and actions, such as important or revealing activities and events. For management studies, the most important benefit is its ability to understand complicated circumstances and processes that arise in and across different groups. Following a terrible scenario, front-line supervisors are categorized according to their follow-up methods.

Information sources

Following an unfortunate incident, midwives are the primary sources of information for this study (17). There are two types of managers: those on the front line and those in the middle. They may be referred to by several titles, such as head or chief midwife in charge of the labor ward, maternity ward manager, or coordinator. Here is the reference to the person in charge of a maternity ward as the “maternity ward manager” (MWM). It was a group of midwives. The critical Incident Technique uses the number of essential incidents recorded to determine the scope of research. Critical incidents may refer to the overall plot or a single instance of isolated behavior inside it. Discrete actions are usually referred to as incidents when discussing discrete behavior (17). What constitutes a crucial incident depends on the definition. The birth is similar to a regular midwife-led birth in a maternity ward, except for the fact that the labor is induced.

Study selection

For example, the delivery results in the death or injury of the mother and/or baby, a third-degree tear, shoulder dystocia, or infant resuscitation/asphyxia. After the event, the midwife may need further emotional and/or clinical support. Interviews spanning from 90 minutes to almost three hours were conducted with 33 midwives, who remembered 57 specific events and described them in their own words from first-hand experience. A non-disruptive place was used for all interviews. A professor and a midwife, both of whom have extensive clinical expertise, performed all of the interviews in tandem. Audiotapes of the interviews were made, and then verbatim transcripts were created. Neither of the interviewers knew any of the subjects. Mistakes such as blunders, near misses, active mistakes, and patient damage, including medical injury and iatrogenic harm, are all included in the term “unfavorable occurrences.” In this research, the results of patients fell into the following categories of severity of injury (20). The number of crucial incidents observed does not limit the study’s scope when conducting CIT research.

Assessment of methodological quality

A significant event may be linked to the overall plot, or it may be a single instance of a certain kind of behavior inside the story. For this study, the unit of analysis is the perceived follow-up practice that is conducted after a critical occurrence, which is best represented by discrete behaviors. Content analysis is used in this investigation. In this study, inductive analysis was used (Polit and Beck, 2004) to uncover recurrent themes and subthemes in the research transcripts and horizontal reading to classify sections of the text. To begin the investigation process, read the whole transcripts of each key occurrence that occurred. A reactive and proactive attitude to following up with midwives after major events were seen at the beginning of the study.

Data extraction

For those two themes, further reading revealed the meaning units that describe a certain content or environment (21). After reducing the meaning units, they were given a unique code to identify them. One meaning unit is represented by each code. For comparative purposes, the second step of analysis involves reading the transcripts horizontally. Recoding and clustering of the first level of analytical codes allowed for the creation of new categories, subcategories, and subgroups. Following an unfavorable incidence, two themes were identified: individual assistance and case investigation following critical incidents, coinciding with the overarching topic of following maternity ward management practices.

Data synthesis

According to the Norwegian Centre for Research Data, the research has been approved (22). According to the principles of the World Medical Association’s Declaration of Helsinki for Medical Research in Human Subjects, the research was carried out ethically. All people were given the opportunity to provide their informed permission. It was made clear to all participants that participation in the study was optional and may be withdrawn at any time, with no explanation required, and that anonymity would be maintained throughout the whole procedure (23). In the interview, they were allowed to talk freely about traumatic events, and they may phone the Norwegian Midwives and Nurses Association if they needed more support. In order to properly document the qualitative study, a 32-point checklist was used.

Psychological Impact

According to a number of studies, stressful delivery experiences may lead midwives to develop PTSD and emotional stress. As a result, the “psychological effect” is the study’s most prominent topic. According to the interviews, 19 midwives who were severely affected by the tragedy and needed professional assistance were present. The researchers believe that the 19 midwives who received counseling from them will be able to understand the psychological repercussions better. Moreover, half of the midwives in the research were mentally disturbed, yet they did not seek professional care for this issue.

The difficulties that midwives face were discovered via the research. Midwives should be advised to develop professional assistance based on these results (28). Some of the midwives who participated in the research reported experiencing flashbacks to the day they gave birth to a child, which was distressing. Qualitative research has shown that following a stressful delivery experience, intrapartum nurses show signs of flashbacks. The findings of this study are based on the assumption that midwives who have had a traumatic delivery experience themselves are more likely to acquire post-traumatic stress disorder (PTSD) as a consequence of their exposure to trauma in the workplace.

According to the current research, when a woman and/or fetus were in significant danger of harm or death, midwives who watched or intervened in the situation experienced panic. Research shows that midwives who experience severe anxiety during traumatic deliveries are more likely to develop post-traumatic stress disorder (PTSD) (29). Consequently, this supports the findings of epidemiological research that show that peritraumatic panic, horror, or helplessness increases the likelihood of and propensity to post-traumatic stress disorder. After their horrible delivery experience, midwives said they had to keep working, could not think about it because of the intense workload, could not recall how they were able to deliver the next labor, and felt like robots. A similar finding was discovered in another research when midwives hesitated to continue their work after having a difficult delivery (30). Hence, it is reasonable to anticipate that midwives who continue to practice while seeing awful deliveries would suffer from psychological effects.

Expectations in Terms of Support from Hospitals

Midwives reported feeling emotionally and socially supported by their co-workers and family. This sad event left a midwife so shaken that she refused to speak about it or accept any help, suggesting that their social and emotional care was not genuine and not tailored to their needs (31). As a result, midwives who experience a traumatic prenatal event should be provided with appropriate mental testing and support (32). Despite hospital administrators’ expectations for uninterrupted support from midwives to pregnant women, it was found that they were unable to offer it, revealing a significant gap between them. While midwives were supposed to care for pregnant mothers throughout the delivery process, it was found that their own professional and personal support needs were mostly ignored.

Limitations

The interviews were done face-to-face. When several midwives were known to shed tears while explaining the incident to researchers, this study component was regarded as extremely powerful and fulfilling. Accordingly, the outcomes of this research cannot be extended to all midwives. In this respect, it is expected that this research might make a major addition to both national and international literature since this is the first qualitative study to assess the level of trauma experienced by Turkish midwives.

Unindexed or gray literature may have been accidentally missed from this systematic review’s search approach, notwithstanding the completeness of the search. Because the PICoS only included nurses and midwives, it did not include other professional groups such as doctors, surgeons, paramedics, or respiratory technicians in the search phrase second victims. Additionally, the removal of quantitative research and non-English publications from this systematic review may have restricted its breadth. Accordingly, a five-year search limit was devised to verify that relevant past articles were not ignored.

The meta-synthesis through meta-aggregation underwent considerable debate with all authors until an agreement was achieved to limit the risk for single-reviewer bias. It is probable that results from the included studies may not be relevant to other clinical areas since they were done in specialized healthcare settings, such as an ICU, an ED, or a specific hospital ward, with just a limited number of individuals.

Recommendations

Information brochures, peer assistance, and training and support resource packages incorporating trauma-oriented psychological counseling may be used to help the midwives cope with the terrible experiences they have encountered. Because of this, it is critical to educate and assist the midwives in their care by providing them with appropriate psychological inputs in order to protect them from traumatic delivery experiences. Midwives should be given more autonomy, and their profession should be developed in order to avoid future disputes within the field. It is also important for midwives to realize that they are not alone and build safe and confidential support platforms to share their experiences and problems. Midwives in the delivery room are likely to be exposed to upsetting events, thus a support system should be created in advance.

In the three years from 2013 to 2018, there were only 11 robust qualitative studies on the experiences of nurses and midwives after catastrophic events. Even while this research emphasized the need for support, it did not particularly address the adaptive coping mechanisms that are thought to be effective in dealing with the long-term effects of an event. Nurses and midwives outside of critical or emergency care face a notable lack of evidence in the literature that demonstrates a relationship between adaptive coping abilities and their ability to cope with the demanding work environment seen mostly in ICU or ED.

Additional research on the requirements of second victims is needed to improve the provision and access to support services for employees in the workplace. Moreover, the leadership of the organization can also be improved when it comes to managing employees who are engaged in critical situations. As a result of this study, nurses and midwives, and other healthcare workers will be better equipped to deal with the aftermath of catastrophic situations and regain their professional confidence, which is essential for them to continue in the workforce. An audit trail of the coding is given to strengthen the study’s validity. The content analysis technique utilizes an objective classification system that perceives full objectivity as impossible as an inductive method. A cause-and-effect analysis operates the data collection, and a frame of reference guides data analysis.

Conclusion

In addition to previous research on midwifery leadership, the results support previous findings stressing the advantages of relational nursing leadership. To better understand how managers might utilize their position to enhance employee outcomes after terrible events, the results describe how they prepare and offer supportive leadership. Second-victim mental health issues are extensively established in studies, and the necessity for help programs is well shown. Second, victims’ needs have been overlooked in practice, education, and policy, according to this research. The quality of care provided by midwives may be significantly improved if support programs tailored to their unique requirements can be easily accessible. It is recommended to take a proactive approach to key circumstances in education and practice based on obtained results. Access to programs tailored to the unique needs of MWMs’ staff would help them better serve their employees. This makes it more difficult to give the necessary assistance if just reactive reactions are used. In addition, it is advised to adopt proactive methods for briefings and debriefs. As a result of these procedures, MWMs are better equipped to provide cross-functional leadership and support to their staff, demonstrating that good processes may assist managers in providing important supportive leadership to second victims after a traumatic event.

This is the first qualitative research in Turkey on the subject of traumatic delivery experiences for midwives caring for pregnant mothers. Hospitals with a high volume of deliveries and long workdays are where the midwives questioned for this research are found to work. Midwives who watched or intervened in traumatic deliveries on a regular basis were found to be emotionally exhausted. It was also shown that midwives’ ability to provide compassionate care to their patients suffered greatly after a traumatic delivery experience caused them to practice more defensively in order to be cautious and protective. To help midwives cope with traumatizing deliveries, in-service training should be encouraged to limit defensive interventions.

Giving midwives the right professional guidance and clinical monitoring, reforming maternity care models helps decrease defensive behaviors. Welfare programs, providing effective leadership, and addressing the issues within the midwifery workforce are also essential. Professional organizations and hospitals should be aware that midwives may be traumatized after watching certain births and that special professional and physiological assistance should be offered to them to cope with such unfortunate and unpleasant experiences.

Nurses’ and midwives’ perceptions of the availability of support services and their capacity to understand the events that led to those perceptions were all highlighted by the results of this systematic study. Future research might fill a particular hole in the present body of knowledge, as discussed in the review. Nurses, midwives, and other healthcare professionals who worked in ICUs and EDs accumulated the majority of the extant information. To learn more about how nurses and midwives in various non-critical clinical settings have been able to move on after experiencing the effects of critical events and how their future professional careers have been affected by it, further study is needed. Adaptive approaches that persons impacted by critical occurrences have effectively used should be explored and disseminated in order to enable second victims of critical incidents to thrive in their profession and stay devoted to good quality care.

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