Background To date, there has been no published work towards understanding or classifying patient safety incidents (PSIs) or their aftermath as potential morally injurious experiences (pMIEs). A morally injurious experience is one that violates deeply held moral values and beliefs, and can put an individual at risk for burnout, post‐traumatic stress disorder, and other trauma‐related problems. This can also set the stage for moral injury, which can occur when there has been a betrayal of what is right by someone in a position of legitimate authority, or by one’s self, in a high‐stakes situation. Objective The objective of this review of nurse second victim literature is to describe symptoms of moral injury empirically observed in nurses in the aftermath of a PSI. Methods A critical review using a SALSA (search, appraisal, synthesis, analysis) method commenced with a search of electronic data base–indexed original evidence between 1980 and December 2018, focusing on registered nurses involved with a PSI. Results The nurse empirical literature reviewed included qualitative (n = 10), quantitative (n = 7), and mixed‐methods (n = 4) studies (total n = 21). Core moral injury symptoms included guilt (67%), shame (71%), spiritual‐existential crisis (9%), and loss of trust (52%). Secondary symptoms of moral injury included depression (33%), anxiety (57%), anger (71%), self‐harm, (19%), and social problems (48%). Implications Moral injury better describes what historically has been called the nurse second victim phenomenon. Through identification of pMIEs and symptoms of moral injury, nurses and organizations can be empowered to advance training and intervention programs addressing pMIEs that affect nurses’ safety and retention in the aftermath of a PSI. Clinical Relevance By describing the experiences associated with a PSI as potentially morally injurious, we set the stage to describe the potential consequences associated with the aftermath of the PSI. Furthermore, this language avoids victimizing those involved by more accurately reflecting the pMIEs of the aftermath.

Bevacizumab (BEV, Avastin(®)) produces durable objective radiological responses of 20-26 %, median response durations of 16-18 weeks, and median overall survival (mOS) of 31-40 weeks. While the use of BEV is well-established, the lack of dose-response studies in glioblastoma (GBM) patients raises the question whether current dosing practice is optimal. As a result of differing approaches to BEV dosing that ranged from the FDA approved package insert dose of 10 mg/kg every 2 weeks to 7.5 mg/kg every 3-4 weeks, among physicians within Northern California Kaiser Permanente hospitals over 4+ years, we did an IRB-approved retrospective analysis of patients seen in Northern California Kaiser Permanente facilities and treated with BEV. Between September 1, 2008 and August 31, 2013, 181 patients received BEV for tumor progression/recurrence starting 2.6 weeks after completion of chemoradiation. The integrated BEV administered dose-week (AUCBEV) for all patients had a median AUCBEV of 3.6 mg·wk/kg). Maximum likelihood analysis found patients over 65 years did worse than younger patients (p = 0.004), women lived longer (p = 0.002), and patients treated below the AUCBEV did better than those treated above the median AUCBEV (p = 0.003). mOS for BEV starting 1 month after chemoradiation was 45 versus 68 weeks (p = 0.012) and BEV starting 3 months after chemoradiation was 40 versus 74 weeks (p = 0.0085). Dosing BEV at half the standard dose for progressive/recurrent GBM was at least equivalent to or, maybe better than standard dosing. Unexplained was the observation that females had longer OS with BEV than males.

Background: Nursing retention is a concern for healthcare systems, hospital administrators, and nurses who have spent considerable time and money to achieve educational goals. Nearly, 33% of nurses will drop out in the 2 years practice. Those who stay in practice face an increased risk of suicide when compared the general population.Aims: To examine the relationship between nurse sociodemographic data and unique study variables with potential morally injurious outcomes (i.e., dropping out variables: changing jobs, intention to leave the profession, or suicidal thinking).Methods: A descriptive, correlational study design was used to characterize the relationship between the sociodemographic data of 216 registered nurses (RNs) and patient safety and the suicidal behavioral questionnaire.Results: RNs involved in a patient safety incident (PSI) considered changing jobs when the degree of harm was death (p < .001) or was unknown (p < .05) when compared with no harm. RNs were more likely to consider leaving the profession when the degree of harm to the patient was permanent (p < .01) or the patient died (p < .05) when compared with having no harm. RNs future suicidal thinking (i.e., their self-reported likelihood of future suicidal behavior) was statistically significant when degree of harm to the patient was death (p < .05) as a result of a PSI (95% CI [1.11, 8.71]) when compared with no harm. The RNs who had suicidal thoughts over the past year compared with those without and the RNs with future suicidal thinking compared with those without, may respond differently in the aftermath of a PSI.Linking evidence to action: This study served as a pioneering effort to the current understanding between nurse characteristics and patient harm and "dropping out" outcomes in RNs involved in PSIs. RNs involved with PSIs that led to more harm were more likely to change jobs, consider leaving the profession, or contemplate future suicide. These findings have important implications for nurses, administrative managers in healthcare organizations, and researchers.

Objectives:The purpose of this study was to investigate the relationship between personality traits (perfectionism and neuroticism) and the traumatic outcomes of reexperiencing, avoidance, and alcohol abuse severity of registered nurses (RNs) who have been involved with a patient safety incident (PSI). We hypothesized that higher scores for perfectionism and neuroticism would predict higher reexperiencing and avoidance symptoms in RNs in the aftermath of a PSI. Also, RNs with higher perfectionism and neuroticism sum scores would be more likely to abuse alcohol. Methods: A descriptive, correlational study design was used to characterize the relationships of personality traits and potential traumatic outcomes of RNs in the aftermath of a PSI. The Almost Perfect Scale-Revised, Neuroticism Scale, Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, and Alcohol Use Disorders Identification Test-Consumption measures were administered to RNs licensed in Oregon and New York.Results: Perfectionist-discrepancy personality traits (P < 0.01) were the strongest predictors for reexperiencing symptoms and neuroticism (P < 0.05) was the strongest predictor for avoidance symptoms, when controlling for sociodemographics and experience. We found a negative linear relationship between perfectionism-order and alcohol abuse severity (β = −0.15, P < 0.01; confidence interval, −0.24 to 0.05). Conclusions:This study demonstrated a statistically significant relationship between perfectionism-discrepancy and reexperiencing as well as between neuroticism and reexperiencing and avoidance, each explaining 4% of variance of their model. The results add to the nurse second victim literature by validating 2 posttraumatic stress disorder symptoms in RNs in the aftermath of a PSI. Registered nurses with perfectionism-order were less likely to abuse alcohol.