Introduction
A patient safety event can be defined as any process, act of omission, or commission that results in hazardous healthcare conditions and/or unintended harm to patients.1,2 These events include incidents related to medication, treatment, surgery, anesthesia, and diagnosis and exclude unpreventable complications that are generally accepted risks of medical or surgical treatment.1,3–5 Patient safety events typically involve several elements and a multitude of factors.6 The impact of these events is significant; they are a leading cause of human death in the US,7,8 with studies7–9 estimating that approximately 400,000 US hospitalized patients experience some preventable harm each year and more than 200,000 patient deaths annually are caused by preventable medical errors. As a result, patient safety events have been extensively studied in human medicine, yet they have only recently garnered warranted attention in veterinary medicine.3–6,10–15 Yet similar to human medicine, they appear to be common; in a study by Kogan et al,10 for example, 74% of veterinarians reported being involved in an adverse event (patient safety event) in the past 12 months.
In addition to the negative impact on patients, several studies and reviews16–22 suggest that healthcare providers involved in patient safety events can become second victims. Secondary victims may experience feelings of guilt, shame, anger, self-doubt, fear, anxiety, depression, grief, impaired concentration, poor memory, sleep disturbances, and intrusive memories about the event.16,18 These negative impacts can be long- or short-term and can result in significant functional difficulties.18 In addition, patient safety events have been found to be ethically challenging for veterinary professionals as they wrestle with balancing personal needs with external demands, as well as navigating the appropriate level of honesty with clients.13,23 Although not yet studied in veterinary medicine, human physicians who experience negative impacts after a patient safety event are at an increased risk of making future mistakes.24
Findings from previous studies10 suggest that veterinary professionals are similarly affected by patient safety events. Veterinary professionals report finding these events ethically challenging, one of the most negative aspects of the job, and a cause to consider leaving the profession.10,25 Given the prevalence and importance of patient safety events, this study was designed to better understand the experiences and consequences of patient safety events on veterinary professionals. It was hypothesized that patient safety events are common and have negative effects on those involved. This study examined the impact of patient safety events on psychological and physical distress; perceptions of colleague, supervisor, institutional, and noninstitutional support; self-efficacy (a person’s belief in their ability to perform tasks and achieve goals); turnover; and absenteeism. It also assessed the potential predictive values of resilience, supervisor response, and a psychologically safe culture on the negative aspects of patient safety events.
Methods
An online, anonymous, cross-sectional survey was developed with Qualtrics (Supplementary Material S1). The study was approved by the Colorado State University Institutional Review Board (No. 5398). Survey respondents were 18 years or older, resided in the US, and were veterinary professionals working in a Mars Veterinary Health hospital (ie, Banfield, VCA, BluePearl) or members of the American Animal Hospital Association or American College of Veterinary Internal Medicine. Participants, representative of the varied positions in a veterinary hospital, were recruited through Mars Veterinary Health’s internal email system and American Animal Hospital Association and American College of Veterinary Internal Medicine listservs from March 13 through May 17, 2024. An initial email was sent, along with 2 follow-up reminder emails.
Survey
The survey began with an introduction that explained the study’s purpose, followed by a series of demographic questions. Prior to questions about patient safety events, participants were given the following definition: “A patient safety event is something that results in harm—or could have resulted in harm—to a patient, whether human error was involved or not (eg, wrong surgery site, drug overdose, anesthetic complication, reaction to a vaccine or antibiotic)”. They were asked how many patient safety events they had been involved with (directly or proximally) in the last 12 months. Those who reported being involved in any patient safety event within the last 12 months were asked to report the number of events they had been involved in that caused serious patient harm and number of events that caused minor patient harm. They were also asked whether they talked to a supervisor and, if so, to rate their satisfaction with their supervisor’s response to their most recent disclosure of a patient safety event.
The Second Victim Experience and Support Tool
The Second Victim Experience and Support Tool (SVEST) has been cross-culturally adapted from English into other languages and used in general hospitals, pediatric and maternity hospitals, and emergency departments with numerous healthcare professionals, including doctors, nurses, midwives, and pharmacists.26 It includes 29 statements pertaining to participants’ personal experiences with adverse patient safety. Participants are asked to indicate their agreement to each item with a 5-point Likert scale (1, strongly disagree; 5, strongly agree). These items reflect 7 dimensions and 2 outcomes, including psychological distress, physical distress, colleague support, supervisor support, institutional support, non–work-related support, professional self-efficacy, intention to resign, and absenteeism.27 Each dimension or outcome variable was defined as the mean of 2 to 4 items specific to that variable after converting the reverse-worded item responses. Using the mean scores for each respondent, we determined the overall mean and SD for each dimension and outcome variable and the number and percentage of respondents with a mean score of 4 or higher, which reflected more psychological distress, more physical distress, decreased professional self-efficacy, a greater degree to which support (ie, colleague, supervisor, institutional, and non–work-related support) was perceived as inadequate, increased intention to resign, and more absenteeism.28 In addition, 9 items assessing desired forms of support were included and participants were asked to rate each form with a 5-point Likert scale (1, strongly do not desire; 5, strongly desire).
The Brief Resilience Scale
The Brief Resilience Scale (BRS) was developed to assess the ability to bounce back or recover from stress.29 It has been used extensively with a variety of populations and translated into numerous languages.30 The BRS consists of 6 items (3 positively worded and 3 negatively worded). Participants are asked to indicate the extent to which they agree with each statement using a 5-point Likert scale (1, strongly disagree; 5, strongly agree).
The Team Psychological Safety Scale
The Team Psychological Safety Scale (TPSS) is a widely used instrument containing 7 items developed to assess perceptions of psychological safety at work (namely, that the team is safe for interpersonal risk-taking).31 It has been used in numerous countries with various populations.32 The scale uses a 7-point Likert scale (1, very inaccurate; 7, very accurate). Higher numbers reflect higher team psychological safety.
Statistical analysis
Descriptive statistics, χ2, Pearson correlation, and multiple regression were conducted with SPSS Statistics (version 26, IBM). Descriptive statistics were calculated to characterize participant demographics and means for each assessment tool (ie, SVEST, BRS, TPSS). Participants could choose to skip a question; incomplete responses were included in analysis. Denominators were included in results of less than the total sample. Multinomial logistic regression models were created to determine predictors of BRS scores, TPSS scores, and the scores for each dimension of the SVEST. The χ2 test was used to assess relationships between responses and role.
Results
The sample consisted of 2,182 participants, predominantly White female small animal professionals working in either primary care or a specialty hospital for 6 years or longer (Tables 1 and 2). For further analysis, the demographic variables were categorized. Hospital type was categorized into primary care (1,474 of 2,180 [67.6%]), specialty (383 of 2,180 [17.6%]), and other (325 of 2,180 [14.9%]). Due to the small number of participants who identified as nonbinary (n = 37), gender categories were limited to male (203 of 1,789 [11.3%]) and female (1,586 of 1,789 [88.7%]). Age was categorized into 30 years and younger (414 of 1,818 [22.8%]), 31 to 40 years of age (646 of 1,818 [35.5%]), 41 to 50 years of age (437 of 1,818 [24.0%]), and 51 years of age and older (321 of 1,818 [17.7%]). Created role categories included veterinarian (628 of 2,150 [29.2%]), veterinary technician (558 of 2,150 [26.0%]), veterinary assistant (322 of 2,150 [15.0%]), client service provider (302 of 2,150 [14.0%]), and manager/director (340 of 2,150 [15.8%]). Only participants who reported having been involved in at least 1 patient safety event (either directly or proximally) in the last 12 months were included in further analysis.
Role, hospital type, and length in current position of participants.
| Demographic | n (%) |
|---|---|
| Role (n = 2,182) | |
| Veterinarian | 628 (29) |
| Intern | 7 (< 1) |
| Resident | 2 (< 1) |
| Veterinary technician/nurse | 558 (26) |
| Veterinary assistant | 322 (15) |
| Client service provider | 302 (14) |
| Patient care attendant | 19 (1) |
| Hospital manager/director | 340 (16) |
| Other | 4 (< 1) |
| Hospital type (n = 2,180) | |
| PC | 1,474 (68) |
| Urgent care | 38 (2) |
| ER | 192 (9) |
| Specialty | 383 (18) |
| Academia | 12 (1) |
| Combination of PC, urgent care, ER, and specialty | 77 (4) |
| Other | 4 (< 1) |
| Length in current position (y; n = 2,182) | |
| < 1 | 256 (12) |
| 1–3 | 566 (26) |
| 4–5 | 272 (13) |
| 6–10 | 393 (18) |
| > 10 | 695 (32) |
ER = Emergency. PC = Primary care.
Gender, race, ethnicity, and age of participants.
| Demographic | n (%) |
|---|---|
| Gender (n = 1,874) | |
| Female | 1,586 (85) |
| Male | 203 (11) |
| Nonbinary | 37 (2) |
| Other | 5 (< 1) |
| Prefer to not answer | 43 (2) |
| Race (n = 1,874) | |
| African American/Black | 37 (2) |
| Asian | 40 (2) |
| Biracial/Multiracial | 67 (4) |
| Middle Eastern | 11 (1) |
| Native Hawaiian/Pacific Islander | 6 (< 1) |
| White/Caucasian | 1,545 (82) |
| Other/prefer to self-describe | 51 (3) |
| Prefer to not answer | 117 (6) |
| Ethnicity (n = 1,867) | |
| Hispanic/Latinx | 192 (10) |
| Not Hispanic/Latinx | 1,524 (82) |
| Prefer to not answer | 151 (8) |
| Age (y; n = 1,818) | |
| 30 and younger | 414 (23) |
| 31–40 | 646 (36) |
| 41–50 | 437 (24) |
| 51 and older | 321 (18) |
| Prefer to not answer | — |
Patient safety events
A total of 1,422 of 2,182 (65.2%) of respondents indicated they had been involved (either directly or proximally) in at least 1 patient safety event in the last 12 months. There was a significant difference in responses based on role (P < .001), with 497 of 628 veterinarians (79.1%) reporting having been involved in at least 1 patient safety event, followed by managers/directors (252 of 340 [74.1%]), veterinary technicians (373 of 558 [67%]), and veterinary assistants (182 of 322 [57%]). In contrast, only 103 of 302 client service providers (34.1%) reported being involved in at least 1 patient safety event.
When asked for the number of events they had been involved with that led to serious patient harm, most reported none (987 of 1,422 [69.4%]), while 287 of 1,422 (20.2%) reported 1 event and 91 of 1,422 (6.4%) reported 2 events. Only 28 of 1,422 (2%) reported 4 events or more.
For events that led to minor harm, the largest percentages reported 1 event (357 of 1,422 [25.1%]) or 2 events (301 of 1,422 [21.2%]). A total of 356 of 1,422 (24.9%) reported 4 or more events, including 104 of 1,422 (7.3%) who reported 10 or more events.
Participants were asked whether they talked to their supervisor, to which 1,120 of 1,422 (78.8%) responded yes, 247 of 1,422 (17.4%) responded no, and 55 of 1,422 (3.9%) reported having no supervisor. When asked how satisfied they were with their supervisor’s response, most reported being somewhat (238 of 1,120 [21.3%]) or very satisfied (504 of 1,120 [45.0%]), while a minority reported feeling somewhat (95 of 1,120 [8.5%]) or very dissatisfied (114 of 1,120 [10.2%]).
The SVEST
Cronbach α (the internal consistency of a set of survey items or test questions) reliability scores for the SVEST have been reported27 to range from 0.61 to 0.89. Reliability scores (Cronbach α and coefficient ω), means, and SDs for each dimension and outcome variable, as well as categorization by role, are presented in Supplementary Table S1.
The mean scores for each dimension and outcome variable were next divided into 2 previously established28 categories to indicate less distress/negative impact (≤ 4) and more distress/negative impact (> 4). With these binary categories, significant differences based on role were found for psychological distress (P ≤ .001), supervisor support (P = .018), institutional support (P = .005), self-efficacy (P < .001), intention to resign (P = .012), and absenteeism (P = .005). For psychological distress, client service providers and managers/directors reported significantly less distress compared to veterinarians, veterinary technicians or veterinary assistants, and managers/directors reported even less distress than client service providers (P ≤ .001). When assessing supervisor support, veterinary assistants reported significantly less support than all other roles and managers/directors reported more support than all other roles (P = .018). In terms of institutional support, client service providers and managers/directors reported significantly more support than all other roles (P = .005). For self-efficacy, veterinarians reported significantly lower levels of self-efficacy than any other group. There were no differences between veterinary technicians and veterinary assistants, but both groups reported less self-efficacy than client service providers and managers/directors. Managers/directors reported significantly higher highest self-efficacy than any other group (P < .001). In terms of intention to resign, managers/directors scored significantly lower than all other groups; no other differences were found (P = .012). For absenteeism, veterinarians and veterinary assistants reported less than all other roles (P = .005; Supplementary Table S1).
Desired forms of support
Participants indicated their opinions regarding 9 forms of support. The types of support most desired included “a respected peer to discuss the details of what happened” (desired by 837 of 1,174 [71.3%]), “a specified peaceful location that is available to recover and recompose after one of these types of events” (desired by 751 of 1,175 [63.9%]), and “an employee assistance program that can provide free counseling to employees outside of work” (desired by 721 of 1,175 [61.4%]; Figure 1).
Stated desire for patient safety interventions.
Citation: Journal of the American Veterinary Medical Association 263, 3; 10.2460/javma.24.09.0620
The TPSS
The Cronbach α of the TPSS in the current study was 0.921 (Ω = 0.921), and the mean score was 5.11 (SD, 1.32), similar to figures reported by Edmondson31 (mean, 5.25; SD, 1.03; α = 0.82). There was a significant difference in mean score based on role (P < .001). Veterinarians (mean, 5.35; SD, 1.26) and managers/directors (mean, 5.63; SD, 1.07) reported a higher perception of team psychological safety than veterinary technicians (mean, 4.80; SD, 1.30), veterinary assistants (mean, 4.66; SD, 1.42), or client service providers (mean, 4.61; SD, 1.42).
The BRS
Reported mean scores for young (approx 20 years old), primarily female responders are between 3.53 and 3.57. The mean score29 for older females (mean age, 47 years) is 3.61. The reported29 Cronbach α ranges from 0.80 to 0.91. The Cronbach α of the BRS in the current study was 0.901 (Ω = 0.901). The mean score for the BRS in this study was 3.41 (SD, 0.86). There was a significant difference in mean score based on role (P < .001). Managers/directors had the highest resilience score (mean, 3.77; SD, 0.78), followed by veterinarians (mean, 3.41; SD, 0.89) and veterinary technicians (mean, 3.40; SD, 0.84). Veterinary assistants (mean, 3.18; SD, 0.82) and client service providers (mean, 3.11; SD, 0.78) reported the lowest resilience. Mean resilience scores were divided into 3 categories based on previously established cut-off points33 of low (1.00 to 2.99), normal (3.00 to 4.30), and high (4.31 to 5.00). Of 1,144, a total of 313 (27.4%) scored low, 664 (58.0%) scored normal, and 167 (14.6%) scored high. Numbers and percentages of low, normal, and high resilience, based on role, are presented in Table 3.
Resilience by role.
| Role | Low resilience | Normal resilience | High resilience |
|---|---|---|---|
| Veterinarian (n = 424) | 122 (29) | 243 (57) | 59 (14) |
| Veterinary technician (n = 301) | 74 (25) | 187 (62) | 40 (13) |
| Veterinary assistant (n = 144) | 56 (39) | 73 (51) | 15 (10) |
| Client service provider (n = 77) | 27 (35) | 47 (61) | 3 (4) |
| Manager/director (n = 186) | 28 (15) | 108 (58) | 50 (27) |
Data are presented as number (percent within role) of respondents.
Predictors of SVEST dimensions
Multinomial logistic regressions were conducted to determine predictors of each of the SVEST dimensions and outcome variables. The potential predictors included in the models included role (veterinarian, veterinary technician, veterinary assistant, client service provider, manager/director), hospital type (general practice, specialty, other), gender (male, female), age (30 years and younger, 31 to 40 years, 41 to 50 years, 51 years and older), resilience (BRS score), team psychological safety (TPSS score), and satisfaction with supervisor’s response (very dissatisfied to very satisfied).
Psychological distress
The model was significant (F [16] = 12.08; P < .001; R2 = 0.192). Significant predictors included role (managers/directors reported less distress than other positions; B = 0.434; 95% CI, 0.231 to 0.637; P < .001), resilience (higher resilience predicted less psychological distress; B = –0.399; 95% CI, –0.477 to –0.321; P < .001), age (younger participants reported higher distress; B = 0.263; 95% CI, 0.019 to 0.508; P = .024), and supervisor response (those more satisfied reported lower distress; B = 0.359; 95% CI, 0.130 to 0.588; P = .011).
Physical distress
The model was significant (F [16] = 14.48; P < 0.001; R2 = 0.221). Significant predictors included resilience (higher resilience predicted less physical distress; B = –0.493; 95% CI, –0.572 to –0.413; P < .001), team psychological safety (higher psychological safety predicted less physical distress; B = –0.238; 95% CI, –0.410 to –0.065; P < .001), and supervisor response (those more satisfied reported lower physical distress; B = 0.453; 95% CI, 0.220 to 0.686; P < .001).
Colleague support
The model was significant (F [16] = 16.40; P < 0.001; R2 = 0.243). Significant predictors included resilience (higher resilience predicted greater perceived support; B = –0.138; 95% CI, –0.186 to –0.089; P < .001), team psychological safety (higher psychological safety predicted less physical distress; B = –0.425; 95% CI, –0.529 to –0.320; P < .001), and supervisor response (those more satisfied reported greater perceived support; B = 0.395; 95% CI, 0.254 to 0.537; P < .001).
Supervisor support
The model was significant (F [16] = 26.12; P < 0.001; R2 = 0.339). Significant predictors included resilience (higher resilience predicted greater perceived support; B = –0.069; 95% CI, –0.127 to –0.010; P = .021), team psychological safety (higher psychological safety predicted less physical distress; B = –0.529; 95% CI, –0.656 to –0.403; P < .001), gender (female respondents reported greater perceived support than male respondents; B = –0.208; 95% CI, –0.366 to –0.051; P = .009), and supervisor response (those more satisfied reported greater perceived support; B = 0.767; 95% CI, 0.596 to 0.938; P < .001).
Institutional support
The model was significant (F [16] = 12.81; P < 0.001; R2 = 0.201). Significant predictors included role (managers/directors reported less distress than other positions; B = 0.177; 95% CI, –0.001 to 0.355; P = .007), resilience (higher resilience predicted greater perceived support; B = –0.140; 95% CI, –0.209 to –0.071; P < .001), team psychological safety (higher psychological safety predicted less physical distress; B = –0.432; 95% CI, –0.581 to –0.283; P < .001), hospital type (those in primary care reported more perceived support than specialty or other; B = –0.105; 95% CI, –0.279 to –0.069; P = .039), and supervisor response (those more satisfied predicted greater perceived support; B = 0.443; 95% CI, 0.242 to 0.644; P < .001).
Noninstitutional support
The model was significant (F [16] = 2.40; P = 0.002; R2 = 0.045). Significant predictors included hospital type (those in primary care reported more perceived support than specialty or other; B = –0.233; 95% CI, –0.439 to –0.027; P = .014), and supervisor response (those more satisfied reported more perceived support; B = 0.035; 95% CI, –0.203 to 0.274; P = .009).
Self-efficacy
The model was significant (F [16] = 21.79; P < 0.001; R2 = 0.299). Significant predictors included role (managers/directors reported higher self-efficacy than other positions; B = 0.440; 95% CI, 0.257 to 0.623; P < .001), hospital type (those in primary care had higher self-efficacy scores than those in specialty or other; B = –0.253; 95% CI, –0.432 to –0.074; P = .021), age (older participants reported higher self-efficacy than younger participants; B = –0.388; 95% CI, 0.167 to 0.608; P < .001), and resilience (higher resilience predicted higher self-efficacy scores; B = –0.565; 95% CI, –0.636 to –0.495; P < .001).
Intention to resign
The model was significant (F [16] = 14.75; P < 0.001; R2 = 0.224). Significant predictors included resilience (higher resilience predicted lower intention to resign; B = –0.525; 95% CI, –0.612 to –0.439; P < .001), age (participants 50 years and older and those 30 years and younger reported lower intention to resign than participants between 31 and 50 years of age; B = 0.247; 95% CI, –0.024 to 0.518; P = .046), team psychological safety (higher psychological safety predicted lower intention to resign; B = –0.389; 95% CI, –0.577 to –0.200; P < .001), and supervisor response (those more satisfied reported lower intention to resign; B = 0.365; 95% CI, 0.114 to 0.617; P < .001).
Absenteeism
The model was significant (F [16] = 4.31; P < 0.001; R2 = 0.078). The only significant predictor was resilience (higher resilience predicted lower absenteeism; B = –0.269; 95% CI, –0.352 to –0.186; P < .001).
Predictors of team psychological safety
Multinomial logistic regression was conducted to determine predictors of team psychological safety. The potential predictors included in the model included role, hospital type, gender, age, resilience, and satisfaction with supervisor response.
The model was significant (F [15] = 12.96; P < 0.001; R2 = 0.192). Significant predictors included hospital type (those in primary care had higher perceived team psychological safety than those in specialty or other; B = –0.257; 95% CI, 0.008 to 0.506; P = .017), resilience (higher resilience predicted higher perception of team psychological safety; B = 0.234; 95% CI, 0.136 to 0.332; P < .001), and supervisor response (those more satisfied reported higher perception of team psychological safety; B = –1.012; 95% CI, –1.294 to –0.729; P < .001).
Discussion
Patient safety events, often referred to as adverse events, are common, yet there is little research pertaining to their effects on veterinary professionals.13 This study explored the experiences and consequences of patient safety events on veterinarians, veterinary technicians, veterinary assistants, client service providers, and managers/directors. Attention to this area is paramount in helping support veterinary professionals’ well-being and mental health. Recent research34–36 suggests that there are unique factors that can impact the mental health of veterinary professionals, so careful attention needs to be paid to ensure they have the internal and external support they need to thrive and grow within the profession.
The majority of participants in this study, with the exception of client service personnel, reported having experienced at least 1 patient safety event within the last 12 months. This number was highest for veterinarians (79%), followed by managers/directors (74%) and veterinary technicians (67%), and similar to those previously reported for veterinarians and physicians.10,18 Involvement with patient safety events has been found to be among the top stressors for veterinarians.37 Many veterinarians’ and physicians’ responses to adverse events include initial anxiety and stress, followed by a desire to learn about the technical aspects of the case. While some veterinarians are able to put the event in perspective and minimize the negative effect, others are left traumatized and find it difficult to continue in veterinary medicine.12,20 While veterinary schools do not yet routinely include training in regards to adverse events, the prevalence of patient safety events has led to the call for increased educational focus within veterinary curricula on patient safety and appropriate support after an adverse event.12,14,38
In our study, we found that approximately 50% of veterinarians, veterinary technicians, and veterinary assistants who reported being involved in a patient safety event indicated at least 1 of these events caused serious harm. These numbers approximate an earlier study10 that found that 63% of veterinarians who reported personal involvement in at least 1 patient safety indicated that it caused serious patient harm. Because of these high numbers, the veterinary field is working towards creating reporting mechanisms and safety procedures that can reduce errors. For example, recent research39 identifies specific types of medication errors that can be targeted to increase patient safety.
When asked what types of support participants wanted after a patient safety event, the most desired included access to a respected peer to discuss the details of what happened, a specified peaceful location available to recover and recompose, and an employee assistance program that provides free counseling. The majority of those involved in a patient safety event reported that they talked to their supervisor about the incident, yet approximately 15% of veterinary professionals who had a supervisor chose to not talk with them. Furthermore, while two-thirds of clinical veterinary professionals reported feeling satisfied with how their supervisor responded (68% of veterinarians, 65% of veterinary technicians, and 60% of veterinary assistants), a minority of people in our study (18% of veterinarians, 22% of veterinary technicians, and 20% of veterinary assistants) who experienced a patient safety event felt unsupported by their supervisor.
There are many ways that patient safety events can negatively affect veterinary professionals, including causing psychological and physical distress. In our study, we found that approximately 20% of veterinary professionals working in a clinical setting (veterinarians, veterinary technicians, veterinary assistants) reported high levels of psychological distress and approximately 10% reported high levels of physical distress. These results mirror previous research10,17,40 that suggests some medical professionals involved in patient safety events become secondary victims and experience both personal and professional distress that can cause long-term or even permanent effects. A secondary victim, someone involved in an unanticipated adverse patient event, medical error, and/or a patient related-injury, is left with feelings of shame and judgement—in essence, traumatized by the event.17,20,41
In terms of support, we found that nearly all participants reported feeling highly supported by colleagues (approx 99%), friends and family (approx 86%), and their hospital and team (approx 89%). Despite this, 20% of veterinarians, 17% of veterinary technicians, and 16% of veterinary assistants reported a strong negative impact on their feelings of professional self-efficacy, which includes feelings of inadequacy, fear of attempting difficult or high-risk procedures, and questioning one’s professional abilities. In terms of negative work outcomes, we found that 20% of veterinarians, 17% of veterinary technicians and veterinary assistants, and 21% of client service providers reported a heightened likelihood of resigning. In addition, 12% of veterinary technicians, 13% of client service providers, and 10% of managers/directors reported higher levels of absenteeism as a result of the patient safety event (these numbers were lower for veterinarians [5%] and veterinary assistants [6%]).
These negative psychological and behavioral impacts carry serious ramifications for not only the individuals involved but also clients, patients, and the hospital. Yet our results suggested that not everyone who experiences a patient safety event suffers negative psychological and physical effects. We found that personal resiliency, perceived supervisor support, and the perception of a psychologically safe team culture often predicted several important aspects of work: participants’ level of distress, perceived lack of adequate support, diminished self-efficacy, and increased absenteeism and intention to resign after a patient safety event. This knowledge offers insights into how, combined with a patient safety culture, veterinary hospitals can both help minimize the chances of patient safety events and best support involved individuals when they happen.
Resilience is the ability to successfully adapt to stress and adversity.42 It can be defined as returning to a previous level of functioning after an adverse event; it is a collection of personal qualities that enable a person to adapt well and even thrive in the face of adversity.43 Resilience includes both personal attributes and environmental resources44 and develops and changes over time through experiences and the attainment of practical skills and implicit knowledge.45 Building resilience is a common feature in many psychological interventions and commonly used with people experiencing psychological distress, and it is also a tool to help people cope with future challenges.46 In our study, we found that only 15% of participants had high resilience and 27% indicated low resilience, scores similar to previous studies44,47–49 assessing veterinarians, veterinary students, and zoo professionals. The percentage of those with low resilience was even higher for veterinary assistants (39%) and client service providers (35%). These figures support earlier research50 of veterinarians in both Canada and Australia. Matthew et al,50 for example, found that 34% of Australian veterinarians reported low general resilience.
We found that resilience plays a critical role in predicting how someone responds to a patient safety event; it was a significant predictor (with the exception of perceived support from friends and family) of every dimension and outcome variable. These results support earlier research51 that found a positive association between increased resilience and decreased burnout among veterinary technicians.
Strategies for enhancing resilience include teaching and implementing coping strategies, fostering work-life balance, and accessing counseling services.44,52 These same elements have been recognized as important in preventing burnout and increasing retention.53
A previous study54 suggests that resilience can have a positive effect on professional engagement, job satisfaction, and increased positive mental health states and well-being. Recent research, including the creation of the Veterinary Resilience Scale–Personal Resources55 to assess personal resources for resilience in veterinary medicine, as well as resiliency training within the veterinary curricula,52 suggests growing recognition of the importance of resilience in veterinary professionals’ mental health and well-being.
In addition to personal resilience, 2 external factors were found to play a key role in predicting how individuals respond to patient safety events: supervisor response and the perception of team psychological safety. These elements often go hand in hand, whereby an exemplary leader can instill a culture of psychological safety that positively impacts patient safety.56 Top leaders are adept in identifying potential threats to a team, encourage innovation, and are willing take on personal risk.57 A patient safety culture is the extent to which an organization’s culture supports and promotes patient safety and the people involved in these events. It applies safety methods designed to reduce the occurrence of avoidable harm, make errors less likely, and minimize their impact when they do occur.58 A culture that prioritizes safety is one where safety values, beliefs, and norms are shared by all and can be measured by determining the extent to which these factors are supported, expected, and rewarded.59–61 This culture is a multidimensional construct that includes organizational learning, error feedback, and a nonpunitive environment, key factors to making improvements in patient safety.15,62 In this type of culture, the focus is on the system rather than the individual.15 A safe culture requires engagement and buy-in from all levels of an organization, whereby the tone is set by administration and obtains buy-in from employees at every level.60 When successful, a patient safety culture can not only reduce human errors associated with ambiguous rules or guidelines, fatigue, and poor communication but can also improve safety-related performance, reduce accident and injury rates, and increase both engagement and retention.63 There are several instruments designed to measure safety culture that can be used to identify challenges within a culture before negative results.64,65
Because safety behaviors are primarily voluntary in nature, it is imperative that employees feel safe in disclosing their involvement with patient safety events.66 Fear of punishment and retaliation are 2 of the most common reasons for underreporting patient safety events.67 Employees must feel safe to report patient safety events. When they are empowered and feel safe to report, not only do patient outcomes and experiences improve, but employees’ well-being and engagement improve as well.68 Part of creating a psychologically safe culture entails establishing a “safe container,” demonstrating a commitment to respect all those involved and normalizing adverse events through both verbal (clear, overt) and nonverbal (subtle, attitudinal) ways.69–71 Hospitals can help create safe environments by prioritizing confidentiality, transparency, inclusive language, and a commitment to respect.69,72 When team members feel psychologically safe, they feel they can take interpersonal risks, speak up, ask questions, and freely share ideas and, as a result, enjoy improved team learning, creativity, and performance.31 Four elements of psychological safety have been identified.73 These include creating a culture of inclusion safety (where all individuals are treated with respect and unconditional positive regard), providing learner safety (where all employees can be vulnerable, try alternative approaches, and make mistakes), providing contributor safety (creating opportunities for all employees to have autonomy and practice what they have learned), and fostering challenger safety (creating a culture where team members can voice constructive criticism and challenge the status quo).73
Despite the importance of psychological safety in healthcare teams, it is unfortunately too often lacking. A previous study11 suggests that many healthcare professionals are reluctant to speak up because of retribution concerns, feel they are unheard, or do not want to appear to be troublemakers. Leaders’ behaviors can have a significant impact on these concerns.74 A psychologically safe team culture, critical to the development of a patient safety culture, is largely contingent on effective leadership.75 This makes psychological safety particularly vital within healthcare settings, with a previous study76 suggesting a synergistic relationship between a patient safety culture and psychological safety culture. In particular, transformational leadership has been advocated for healthcare settings, including veterinary medicine.77,78 The term transformational implies being visionary, having ideas and aspirations on how things could be different and better, and then implementing these visions. Transformational leaders are self-aware, confident, and charismatic leaders who help their employees reach and exceed their potential.79 A transformational leader builds trust and acts with integrity and values others as individuals.78 In these ways, transformational leaders help create strong, safe teams, impacting both team and self-efficacy, as well as job satisfaction, job effectiveness, and, as a result, patient and client care.80
Transformational leadership has been associated with better team performance as well as improved patient care and safety.56,63,79 Psychologically safe teams positively impact a patient safety culture because they facilitate learning, in part because they minimize concern about others’ reactions to actions that have the potential for embarrassment or threat.31
This study had several limitations inherent in cross-sectional research, including the potential biases of self-reports. It is possible that participants interested in completing this study had more experience or interest in patient safety events than other veterinary professionals. In addition, the sample consisted of participants within the US with limited gender, race, and ethnic diversity. We also collected limited information regarding the type of practice and did not ask about years working in the veterinary field. It is important to note that this lack of diversity limited our ability to generalize these findings to other populations.
In conclusion, while the traditional approach to patient safety events has been to focus on the individual involved,60 more recent thought has shifted to focusing on correcting systemic issues and improving institutional outcomes.10,11 Central to this approach is the idea that patient safety events occur within an organizational context that often includes systemic weaknesses, setting the veterinary professional up for failure.60 Even with a patient safety culture, patient safety events are unavoidable and can lead to significant negative effects for those involved. Yet much can be done to not only minimize the risk of these events but protect those involved from secondary victimhood. Creating and prioritizing educational opportunities pertaining to resilience, transformational leadership, and cultivating psychologically safe team cultures can help minimize the risks of patient safety events and best support those involved when these events do occur.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
ORCID
L. R. Kogan https://orcid.org/0000-0002-5816-9672
References
- 1.↑
Gong Y, Kang H, Wu X, Hua L. Enhancing patient safety event reporting: a systematic review of system design features. Appl Clin Inform. 2017;8(3):893-909. doi:10.4338/ACI-2016-02-R-0023
- 2.↑
Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform. 2003;36(1-2):131-143. doi:10.1016/j.jbi.2003.08.003
- 3.↑
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. doi:10.1056/NEJM199102073240604
- 4.
Pinho RH, Tscheng D, Cheema JS, Pang DSJ. Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada. Am J Vet Res. 85(9):1-8. doi:10.2460/ajvr.24.04.0119
- 5.↑
Schortz L, Mossop L, Bergström A, Oxtoby C. Type and impact of clinical incidents identified by a voluntary reporting system covering 130 small animal practices in mainland Europe. Vet Rec. 2022;191(2):e1629. doi:10.1002/vetr.1629
- 6.↑
Love L, Patten T, Hofmeister EH, Schoenfeld-Tacher RM, McLaughlin AC. The Veterinary Student Survey on Patient Safety Culture (VSSPSC): a quantitative and qualitative exploration of American veterinary students’ perceptions of patient safety culture. J Vet Med Educ. Published online August 21, 2024. doi:10.3138/jvme-2024-0038
- 7.↑
Rodziewicz TL, Houseman B, Vaqar S, Hipskind JE. Medical error reduction and prevention. In: Ackley WB, Adolphe TS, Aeby TC, et al., eds. StatPearls. StatPearls Publishing; 2024.
- 8.↑
Sameera V, Bindra A, Rath GP. Human errors and their prevention in healthcare. J Anaesthesiol Clin Pharmacol. 2021;37(3):328-335. doi:10.4103/joacp.JOACP_364_19
- 9.↑
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews. Front Med (Lausanne). 2022;9:875426. doi:10.3389/fmed.2022.875426
- 10.↑
Kogan LR, Rishniw M, Hellyer PW, Schoenfeld-Tacher RM. Veterinarians’ experiences with near misses and adverse events. J Am Vet Med Assoc. 2018;252(5):586-595. doi:10.2460/javma.252.5.586
- 11.↑
Wallis J, Fletcher D, Bentley A, Ludders J. Medical errors cause harm in veterinary hospitals. Front Vet Sci. 2019;6:12. doi:10.3389/fvets.2019.00012
- 12.↑
White SC. Veterinarians’ emotional reactions and coping strategies for adverse events in spay-neuter surgical practice. Anthrozoos. 2018;31(1):117-131. doi:10.1080/08927936.2018.1406205
- 13.↑
Gibson J, Brennan ML, Oxtoby C, Mossop L, White K. Ethical challenges experienced by veterinary practitioners in relation to adverse events: insights from a qualitative study. Vet Rec. 2023;193(12):e3601. doi:10.1002/vetr.3601
- 14.↑
Love LC, Hedgpeth MW, Robertson JB, Marks SL, Schoenfeld-Tacher RM. Assessment of safety culture at a veterinary teaching hospital in the United States. Front Vet Sci. 2021;8:638764. doi:10.3389/fvets.2021.638764
- 15.↑
Tivers M, Adamantos S. Significant event reporting in veterinary practice. Vet Rec. 2019;184(16):498-499. doi:10.1136/vr.l1212
- 16.↑
Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7(4):424-431. doi:10.1007/BF02599161
- 17.↑
Nydoo P, Pillay BJ, Naicker T, Moodley J. The second victim phenomenon in health care: a literature review. Scand J Public Health. 2020;48(6):629-637. doi:10.1177/1403494819855506
- 18.↑
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33(8):467-476. doi:10.1016/S1553-7250(07)33050-X
- 19.
Wu AW. Medical error: the second victim—the doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. doi:10.1136/bmj.320.7237.726
- 20.↑
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330. doi:10.1136/qshc.2009.032870
- 21.
Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013;36(2):135-162. doi:10.1177/0163278712458918
- 22.↑
Vanhaecht K, Seys D, Schouten L, et al.; Dutch Peer Support Collaborative Research Group. Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. BMJ Open. 2019;9(7):e029923. doi:10.1136/bmjopen-2019-029923
- 23.↑
Gibson J, White K, Mossop L, Oxtoby C, Brennan M. ‘We’re gonna end up scared to do anything’: a qualitative exploration of how client complaints are experienced by UK veterinary practitioners. Vet Rec. 2022;191(4):e1737. doi:10.1002/vetr.1737
- 24.↑
Landrigan CP, Rothschild JM, Cronin JW, et al.; Harvard Work Hours, Health and Safety Group. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-1848. doi:10.1056/NEJMoa041406
- 25.↑
Spendelow J, Cripwell C, Stott R, et al. Workplace stressor factors, profiles and the relationship to career stage in UK veterinarians, veterinary nurses and students. Vet Med Sci. 2024;10(4):e1547. doi:10.1002/vms3.1547
- 26.↑
Dato Md Yusof YJ, Ng QX, Teoh SE, Loh CYL, Xin X, Thumboo J. Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review. Public Health. 2023;223:183-192. doi:10.1016/j.puhe.2023.08.003
- 27.↑
Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources. J Patient Saf. 2017;13(2):93-102. doi:10.1097/PTS.0000000000000129
- 28.↑
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology. J Patient Saf. 2022;18(2):e463-e469. doi:10.1097/PTS.0000000000000850
- 29.↑
Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194-200. doi:10.1080/10705500802222972
- 30.↑
Kyriazos TA, Stalikas A, Prassa K, Galanakis M, Yotsidi V, Lakioti A. Psychometric evidence of the Brief Resilience Scale (BRS) and modeling distinctiveness of resilience from depression and stress. Psychology (Irvine). 2018;9(7):1828-1857. doi:10.4236/psych.2018.97107
- 31.↑
Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
- 32.↑
Ramalho MCK, Porto JB. Validity evidence of the Team Psychological Safety Survey. Psico-USF. 2021;26(1):165-176. doi:10.1590/1413-82712021260114
- 33.↑
Smith BW, Epstein EM, Ortiz JA, Christopher PJ, Tooley EM. The foundations of resilience: what are the critical resources for bouncing back from stress? In: Prince-Embury S, Saklofske DH, eds. Resilience in Children, Adolescents, and Adults: Translating Research Into Practice. Springer; 2013. Saklofske DH, Zeidner M, eds. The Springer Series on Human Exceptionality; vol 12.
- 34.↑
Kogan LR, Wallace JE, Schoenfeld-Tacher R, Hellyer PW, Richards M. Veterinary technicians and occupational burnout. Front Vet Sci. 2020;7:328. doi:10.3389/fvets.2020.00328
- 35.
da Silva CR, Gomes AAD, Dos Santos-Doni TR, Antonelli AC, Vieira RFDC, da Silva ARS. Suicide in veterinary medicine: a literature review. Vet World. 2023;16(6):1266-1276. doi:10.14202/vetworld.2023.1266-1276
- 36.↑
Volk J. Veterinarian wellbeing and mental health. In: Loue S, Linden P, eds. The Comprehensive Guide to Interdisciplinary Veterinary Social Work. Springer Nature; 2022:229-245.
- 37.↑
Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc. 2015;247(8):945-955. doi:10.2460/javma.247.8.945
- 38.↑
Cathcart EJ, Russell E, Schortz L, Mossop LH. A human factors and systems-thinking approach to veterinary patient safety education: why, what, and how? J Vet Med Educ. Preprint posted online May 24, 2024. doi:10.3138/jvme-2024-0009
- 39.↑
Hepworth-Warren KL, Maynard-Swift E, Prange T, et al. Error reporting in a large animal veterinary teaching hospital identifies medication errors occur most often in the prescribing phase of therapy. J Am Vet Med Assoc. 2023;262(3):1-7. doi:10.2460/javma.23.10.0556
- 40.↑
Ullström S, Andreen Sachs M, Hansson J, Ovretveit J, Brommels M. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014;23(4):325-331. doi:10.1136/bmjqs-2013-002035
- 41.↑
Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-240. doi:10.1016/S1553-7250(10)36038-7
- 42.↑
Wu G, Feder A, Cohen H, et al. Understanding resilience. Front Behav Neurosci. 2013;7:10. doi:10.3389/fnbeh.2013.00010
- 43.↑
West CP, Dyrbye LN, Sinsky C, et al. Resilience and burnout among physicians and the general US working population. JAMA Netw Open. 2020;3(7):e209385. doi:10.1001/jamanetworkopen.2020.9385
- 44.↑
McArthur ML, Learey TJ, Jarden A, et al. Resilience of veterinarians at different career stages: the role of self-efficacy, coping strategies and personal resources for resilience in veterinary practice. Vet Rec. 2021;189(12):e771. doi:10.1002/vetr.771
- 45.↑
Resnick B. Resilience in older adults. Top Geriatr Rehabil. 2014;30(3):155-163. doi:10.1097/TGR.0000000000000024
- 46.↑
Johnson J, Panagioti M, Bass J, Ramsey L, Harrison R. Resilience to emotional distress in response to failure, error or mistakes: a systematic review. Clin Psychol Rev. 2017;52:19-42. doi:10.1016/j.cpr.2016.11.007
- 47.↑
McDonald SE, Kogan LR, Nageotte NL, Currin-McCulloch J, Dickler-Mann R. Zoo professionals and volunteers in the US: experiences and prevalence of burnout, mental health, and animal loss. Front Psychiatry. 2024;15:1373525. doi:10.3389/fpsyt.2024.1373525
- 48.
Best CO, Perret JL, Hewson J, Khosa DK, Conlon PD, Jones-Bitton A. A survey of veterinarian mental health and resilience in Ontario, Canada. Can Vet J. 2020;61(2):166-172.
- 49.↑
McArthur M, Mansfield C, Matthew S, et al. Resilience in veterinary students and the predictive role of mindfulness and self-compassion. J Vet Med Educ. 2017;44(1):106-115. doi:10.3138/jvme.0116-027R1
- 50.↑
Matthew SM, Carbonneau KJ, Mansfield CF, Zaki S, Cake MA, McArthur ML. Development and validation of a contextualised measure of resilience in veterinary practice: the Veterinary Resilience Scale-Personal Resources (VRS-PR). Vet Rec. 2020;186(15):489. doi:10.1136/vr.105575
- 51.↑
Hayes GM, LaLonde-Paul DF, Perret JL, et al. Investigation of burnout syndrome and job-related risk factors in veterinary technicians in specialty teaching hospitals: a multicenter cross-sectional study. J Vet Emerg Crit Care (San Antonio). 2020;30(1):18-27. doi:10.1111/vec.12916
- 52.↑
Moffett JE, Bartram DJ. Veterinary students’ perspectives on resilience and resilience-building strategies. J Vet Med Educ. 2017;44(1):116-124. doi:10.3138/jvme.0216-046R1
- 53.↑
Volk JO, Schimmack U, Strand EB, et al. Executive summary of the Merck Animal Health Veterinarian Wellbeing Study III and Veterinary Support Staff Study. J Am Vet Med Assoc. 2022;260(12):1547-1553. doi:10.2460/javma.22.03.0134
- 54.↑
Wang L, Tao H, Bowers BJ, Brown R, Zhang Y. Influence of social support and self-efficacy on resilience of early career registered nurses. West J Nurs Res. 2018;40(5):648-664. doi:10.1177/0193945916685712
- 55.↑
Taylor DB, Johns KM, Reilly ML, Hedlefs RM. A career development program: building resilience in veterinary undergraduates. Aust J Career Dev. 2022;31(1):26-41. doi:10.1177/10384162211066372
- 56.↑
Ree E, Wiig S. Linking transformational leadership, patient safety culture and work engagement in home care services. Nurs Open. 2019;7(1):256-264. doi:10.1002/nop2.386
- 57.↑
Remtulla R, Hagana A, Houbby N, et al. Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study. BMC Health Serv Res. 2021;21(1):269. doi:10.1186/s12913-021-06232-7
- 58.↑
Emanuel L, Berwick D, Conway J, et al. What exactly is patient safety? J Med Regul. 2009;95(1):13-24. doi:10.30770/2572-1852-95.1.13
- 59.↑
What is patient safety culture? Agency for Healthcare Research and Quality. March 2022. Updated June 2024. Accessed August 17, 2024. https://www.ahrq.gov/sops/about/patient-safety-culture.html
- 60.↑
Hofmeister EH, Love L. Patient safety culture is needed in veterinary medicine. J Am Vet Med Assoc. 261(12):1908-1912. doi:10.2460/javma.23.07.0370
- 61.↑
WHO. Patient Safety Incident Reporting and Learning Systems: Technical Report and Guidance. WHO; 2020. Accessed August 21, 2024. https://iris.who.int/bitstream/handle/10665/334323/9789240010338-eng.pdf
- 62.↑
Farag A, Lose D, Gedney-Lose A. Nurses’ safety motivation: examining predictors of nurses’ willingness to report medication errors. West J Nurs Res. 2019;41(7):954-972. doi:10.1177/0193945918815462
- 63.↑
Zohar D. The effects of leadership dimensions, safety climate, and assigned priorities on minor injuries in work groups. J Organ Behav. 2002;23(1):75-92. doi:10.1002/job.130
- 64.↑
Flin R, Mearns K, O’Connor P, Bryden R. Measuring safety climate: identifying the common features. Saf Sci. 2000;34(1-3):177-192. doi:10.1016/S0925-7535(00)00012-6
- 65.↑
Oxtoby C, Mossop L, White K, Ferguson E. Safety culture: the Nottingham Veterinary Safety Culture Survey (NVSCS). Vet Rec. 2017;180(19):472-472. doi:10.1136/vr.104215
- 66.↑
Neal A, Griffin MA. A study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels. J Appl Psychol. 2006;91(4):946-953. doi:10.1037/0021-9010.91.4.946
- 67.↑
Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. Nurses’ perceptions of error communication and reporting in the intensive care unit. J Patient Saf. 2008;4(3):162-168. doi:10.1097/PTS.0b013e3181839b48
- 68.↑
Scott G, Hogden A, Taylor R, Mauldon E. Exploring the impact of employee engagement and patient safety. Int J Qual Health Care. 2022;34(3):mzac059. doi:10.1093/intqhc/mzac059
- 69.↑
Kolbe M, Eppich W, Rudolph J, et al. Managing psychological safety in debriefings: a dynamic balancing act. BMJ Simul Technol Enhanc Learn. 2020;6(3):164-171. doi:10.1136/bmjstel-2019-000470
- 70.
Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014;9(6):339-349. doi:10.1097/SIH.0000000000000047
- 71.↑
Rudolph JW, Foldy EG, Robinson T, Kendall S, Taylor SS, Simon R. Helping without harming: the instructor’s feedback dilemma in debriefing—a case study. Simul Healthc. 2013;8(5):304-316. doi:10.1097/SIH.0b013e318294854e
- 72.↑
Weiss M, Kolbe M, Grote G, Spahn DR, Grande B. We can do it! Inclusive leader language promotes voice behavior in multi-professional teams. Leadersh Q. 2018;29(3):389-402. doi:10.1016/j.leaqua.2017.09.002
- 73.↑
Clark TR. The 4 Stages of Psychological Safety: Defining the Path to Inclusion and Innovation. Illustrated ed. Berrett-Koehler Publishers; 2020.
- 74.↑
Aranzamendez G, James D, Toms R. Finding antecedents of psychological safety: a step toward quality improvement. Nurs Forum. 2015;50(3):171-178. doi:10.1111/nuf.12084
- 75.↑
Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156-165. doi:10.1111/j.1547-5069.2009.01330.x
- 76.↑
O’Donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020;32(4):240-250. doi:10.1093/intqhc/mzaa025
- 77.↑
Fischer H, Heidler P, Coco L, Albanese V. Leadership theories and the veterinary health care system. Vet Sci. 2022;9(10):538. doi:10.3390/vetsci9100538
- 78.↑
Moon SE, Van Dam PJ, Kitsos A. Measuring transformational leadership in establishing nursing care excellence. Healthcare (Basel). 2019;7(4):132. doi:10.3390/healthcare7040132
- 79.↑
Schwartz DB, Spencer T, Wilson B, Wood K. Transformational leadership: implications for nursing leaders in facilities seeking magnet designation. AORN J. 2011;93(6):737-748. doi:10.1016/j.aorn.2010.09.032
