Translation and validation of the Second Victim Experience and Support Tool-Revised into Brazilian PortugueseSUMMARY
INTRODUCTION: The term second victim arises when a healthcare professional experiences an adverse event that has an emotional impact and/or physical suffering for the healthcare professional. The experiences of the second victim can be measured using the Second Victim Experience and Support Tool, originally developed in English, translated and validated internationally in several languages. A revised version of the tool (Second Victim Experience and Support Tool-Revised) has been published since 2020.
OBJECTIVE: The objective of this study was to translate and gather evidence of the validity of the Second Victim Experience and Support Tool-Revised Version into Brazilian Portuguese.
METHODS: This is a methodological study that involved the necessary procedures for the translation and cross-cultural adaptation of the instrument, carefully following the stages of translation, back-translation, pre-testing, evaluation by a panel of experts, and a test on a large population for validity and reliability.
RESULTS: A total of 146 health professionals took part in the study, with a greater predominance of doctors (38.4%) and physiotherapists (30.8%). Seven items were excluded, all with factor loadings of less than 0.50. The "institutional support" dimension had to be excluded due to its low factor loadings. The fit indices of the re-specified model were χ2/df=1.60, CFI=0.90, TLI=0.88, and RMSEA=0.07 (CI 0.06–0.08).
CONCLUSION: The adapted version of the instrument showed satisfactory psychometric properties when composed of 28 items distributed in eight dimensions, making it a valid and reliable instrument for assessing second victim experiences in different professions, suitable for dissemination in Brazil.
KEYWORDS: Medical error; Validation study; Occupational health; Mental health
INTRODUCTION
The World Health Organization (WHO) classifies adverse events as incidents that result in unintentional harm arising from care and not related to the natural course of the patient's underlying disease. In addition, according to the WHO, of the 421 million hospitalizations that take place every year in the world, almost 10%—42.7 million—are recorded as adverse events, ranging from mistaken administration of medication to damage that leads to the death of patients1.
In the Global Action Plan for Patient Safety 2021–2030, published by the WHO, it is estimated that around 1 in 10 patients in high-income countries experience adverse events when receiving hospital care. For low- and middle-income countries, this proportion rises to 1 in 4 patients, generating approximately 134 million adverse events per year, contributing significantly to around 2.6 million deaths2.
Adverse events also cause suffering for healthcare professionals, often exposing them to the position of being solely responsible for their occurrence, and sometimes few or no measures are implemented to address these issues in healthcare organizations, exposing professionals to a punitive culture in the institutional environment3. The term "second victim" first appeared in an editorial in the British Medical Journal, which discussed the impact of medical errors on the professionals involved4. The concept was introduced by Albert Wu, describing that health professionals also face trauma as a result of their exposure to unavoidable adverse events, unable to cope with the situation5. Despite the prevalence and consequences of this phenomenon, it is still not widely understood among health professionals6.
The Joint Commission encourages healthcare institutions to support second victims as soon as an adverse event occurs. It argues that by offering a support option to traumatized healthcare professionals, organizations can help prevent the domino effect that adverse events can have on the performance of these professionals, which in turn can have a direct impact on the care that this professional provides to other patients7. It is important to emphasize that implementing support measures for health professionals directly involved in errors does not imply exemption from their responsibility since this does not reduce the damage caused to the first victim (the patients). However, it is a welcome to the professional, aimed at preventing the error from being repeated and allowing it to continue in the work environment8.
The Second Victim Experience and Support Tool (SVEST)9, originally published in English, was developed to help assess and intervene with second victims. This same tool was later validated and translated into other languages10–16. Since 2021, a revised version of the instrument (SVEST-R) has been available in English17 and translated into German6 and Malaysia18. In Brazil, we did not identify in the literature the translation and validation of the SVEST-R. This study aims to translate and gather evidence of the validity of the SVEST-R into Brazilian Portuguese.
METHODS
This is a methodological study to translate and validate the SVEST-R into Brazilian Portuguese.
Initially, authorization was requested from the scale's developer, Dr. James M. Hoffman, with an affirmative response for translation and cross-cultural adaptation. The English version was then translated into Brazilian Portuguese. At this stage, we had two independent, bilingual translators, generating two versions of the instrument. Once the two translations were available, the research team carried out a comparative analysis, generating Synthesis I of the instrument. Synthesis I was then back-translated by two new independent translators who were native English speakers and fluent in Portuguese. These researchers/translators were not familiar with the terms used in the scale and did not have access to the original English version of the instrument. The two versions of the back-translation were analyzed again by the researchers and compared in terms of the format, wording, and grammatical structure of the sentences. Synthesis II was produced from this comparison.
Synthesis II was then pilot-tested with a sample of 10 health professionals. Each professional evaluated the items on the scale in terms of clarity, comprehension, and appropriateness. To do this, a Likert-type scale was used, with scores ranging from 1 to 5, where the closer to 5 the better the item was assessed. Next, the content validity coefficient (CVC) was calculated, and the items that obtained a CVC below 0.8 were re-analyzed and the necessary modifications were made, giving rise to the version of the instrument that supported the psychometric testing stage on a sample of the target population.
Health professionals were recruited nationwide for this stage. The inclusion criterion was being a healthcare professional involved in direct patient care, and the exclusion criterion was not having been involved in a previous adverse event. Data were collected using an online survey with snowball sampling. The analyses were carried out using confirmatory factor analysis (CFA). Bootstrapping procedures were carried out (200 re-samples) to achieve greater reliability of the results and reduce deviations from the normal distribution of the sample. The adequacy of the model tested was observed using the fit indices: estimate of χ2 divided by the degrees of freedom (χ2/df) (values less than 3 are considered adequate), root mean square error of approximation (RMSEA) (values less than 0.08 were considered satisfactory), comparative fit index (CFI), and Tucker-Lewis index (TLI) (values greater than 0.90 were considered satisfactory)19. To make adjustments to the model, the factor loadings (items with factor loadings below 0.50 were excluded) and the suggested modification indices were observed. To analyze the reliability, composite reliability indices were calculated, with values above 0.8 being considered satisfactory20.
This study was submitted to the Research Ethics Committee of the Bahiana School of Medicine and Public Health and was approved under protocol number 5,548,533.
RESULTS
A total of 146 health professionals took part in the study, with doctors (38.4%) and physiotherapists (30.8%) predominating. The median age of the professionals was 38.0 (IQR: 34.0–43.2) years, and the median length of experience was 12.0 (8.0–18.0) years.
The hypothetical measurement model for the CFA was specified according to Winning's proposal21, that is, the 35 items were distributed across the nine dimensions. The model's fit indices were: χ2/df=2.03, CFI=0.76, TLI=0.77, and RMSEA=0.08 (CI 0.08–0.09). Seven items were excluded, all with factor loadings of less than 0.50. It should be noted that the "institutional support" factor had to be excluded as a result of the exclusion of items with low factor loadings. After analyzing the modification indices, it was decided not to insert new parameters into the model. The fit indices of the re-specified model were χ2/df=1.60, CFI=0.90, TLI=0.88, and RMSEA=0.07 (CI 0.06–0.08) (Figure 1).
Re-specified Second Victim Experience and Support Tool-Revised model. Notes: D1: psychological problems; D2: physical problems; D3: support from colleagues; D4: support from supervisors; D5: professional self-efficacy; D6: intention to change; D7: absenteeism; D8: resilience.
The composite reliability indices for the eight dimensions ranged from 0.70 to 0.89, as shown in Table 1.
Composite reliability indices of the eight dimensions of the Second Victim Experience and Support Tool-Revised, n=146, Salvador/BA, Brazil.
DISCUSSION
This is the first study to translate and cross-culturally adapt the SVEST-R into Brazilian Portuguese. We identified the existence of a previous translation of the SVEST in Brazil22. However, this translation did not include the additional dimensions present in the SVEST-R. In addition, our research did not identify any studies testing the psychometric evidence of the instrument in Brazil. For these reasons, this study opted to carry out the complete process of translation and cross-cultural adaptation, carefully following all the recommended steps23.
From a psychometric point of view, the decision was made to use CFA since it is an instrument that follows an established theoretical model and has been previously tested in other countries and contexts6,18. Also for these reasons, the choice was made to keep only those items with high factor loadings (above 0.50), which led to the exclusion of seven items and, consequently, the need to exclude the "institutional support" dimension. It is possible to raise a number of hypotheses for this result in Brazil, the most accepted by the authors of this research being that institutional support for second victims in Brazil is still a subject under development, little explored, where there is a significant gap between the content produced internationally and that produced in our country8.
When evaluating the fit indices obtained in other studies, it can be seen that there was also a need to make changes to obtain a psychometrically satisfactory model. The validation study in Malaysia18, for example, presented a final model made up of seven dimensions: the psychological problems and physical problems dimensions were combined into one (called "stress"), as were the intention to change and absenteeism dimensions (which were renamed "negative consequences"). In addition, the model excluded three items, which were also excluded in the final version of this study. In the German validation6, the final instrument was made up of five factors (stress, support, change, resilience, and request for support).
To assess the internal consistency of the dimensions, composite reliability indices were calculated. Although Cronbach's alpha index is still more widely known and used as a consistency indicator, some restrictions to its use have been pointed out in the literature (especially the fact that it is strongly affected by the length of the test)24. For this reason, and especially considering the existence of dimensions with only two items in the instrument, we opted to adopt the composite reliability index, which has been presented as a more robust indicator of accuracy25. All the dimensions obtained indices were considered satisfactory (above 0.70), with the majority being excellent (above 0.80).
CONCLUSION
The adapted version of the instrument showed satisfactory psychometric properties when composed of 28 items distributed over eight dimensions, making it a valid and reliable instrument for assessing second victim experiences in different professions, suitable for dissemination in Brazil. It is important to note that the instrument tested is quite broad and complex. It is therefore advisable to consider the possibility of future research and the inclusion of a larger number of participants when testing the model.
REFERENCES
- 1 World Health Organization. Conceptual framework for the international classification for patient safety. WHO; 2009.
-
2 World Health Organization. Global patient safety action plan 2021-2030. Who.int. World Health Organization. 2021. [cited on 2023 Aug 19]. Available from: https://www.who.int/publications/i/item/9789240032705
» https://www.who.int/publications/i/item/9789240032705 -
3 Bohomol E. Beyond patient safety, the safety of professionals. Acta Paul Enferm. 2019;32(5):vi-viii. https://doi.org/10.1590/1982-0194201900066
» https://doi.org/10.1590/1982-0194201900066 -
4 Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-7. https://doi.org/10.1136/bmj.320.7237.726
» https://doi.org/10.1136/bmj.320.7237.726 -
5 Romero MP, González RB, Calvo MSR, Fachado AA. Patient safety, quality of care and ethics in health systems. Rev Bioét. 2018;26(3):333-42. https://doi.org/10.1590/1983-80422018263252
» https://doi.org/10.1590/1983-80422018263252 -
6 Strametz R, Siebold B, Heistermann P, Haller S, Bushuven S. Validation of the German version of the Second Victim Experience and Support Tool-Revised. J Patient Saf. 2022;18(3):182-92. https://doi.org/10.1097/PTS.0000000000000886
» https://doi.org/10.1097/PTS.0000000000000886 -
7 The Joint Commission, Division of Healthcare Improvement. Supporting second victims. Quick Safety: na advisory on safety & quality issues. 2018. Issue 39. Jointcommission.org. [cited on 2023 Aug 19]. 2018. Available from: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-39-supporting-second-victims/
» https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-39-supporting-second-victims/ -
8 Quadrado ERS, Tronchin DMR, Maia FOM. Strategies to support health professionals in the condition of second victim: scoping review. Rev Esc Enferm USP. 2021;55:e03669. https://doi.org/10.1590/S1980-220X2019011803669
» https://doi.org/10.1590/S1980-220X2019011803669 -
9 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. https://doi.org/10.1097/PTS.0000000000000129
» https://doi.org/10.1097/PTS.0000000000000129 -
10 Kim EM, Kim SA, Lee JR, Burlison JD, Oh EG. Psychometric properties of Korean version of the Second Victim Experience and Support Tool (K-SVEST). J Patient Saf. 2020;16(3):179-86. https://doi.org/10.1097/PTS.0000000000000466
» https://doi.org/10.1097/PTS.0000000000000466 -
11 Ajoudani F, Habibzadeh H, Baghaei R. Second Victim Experience and Support Tool: Persian translation and psychometric characteristics evaluation. Int Nurs Rev. 2021;68(1):34-40. https://doi.org/10.1111/inr.12628
» https://doi.org/10.1111/inr.12628 -
12 Scarpis E, Ruscio E, Bianchet B, Doimo A, Moretti V, Cocconi R, et al. Second Victim Experience and Support Tool: cultural adaptation and psychometric evaluation in Italy. Eur J Public Health. 2020;30(Supplement_5):ckaa166.646. https://doi.org/10.1093/eurpub/ckaa166.646
» https://doi.org/10.1093/eurpub/ckaa166.646 -
13 Brunelli MV, Estrada S, Celano C. Cross-cultural adaptation and psychometric evaluation of a Second Victim Experience and Support Tool (SVEST). J Patient Saf. 2021;17(8):e1401-5. https://doi.org/10.1097/PTS.0000000000000497
» https://doi.org/10.1097/PTS.0000000000000497 -
14 Chen J, Yang Q, Zhao Q, Zheng S, Xiao M. Psychometric validation of the Chinese version of the Second Victim Experience and Support Tool (C-SVEST). J Nurs Manag. 2019;27(7):1416-22. https://doi.org/10.1111/jonm.12824
» https://doi.org/10.1111/jonm.12824 -
15 Knudsen T, Abrahamsen C, Jørgensen JS, Schrøder K. Validation of the Danish version of the Second Victim Experience and Support Tool. Scand J Public Health. 2022;50(4):497-506. https://doi.org/10.1177/14034948211004801
» https://doi.org/10.1177/14034948211004801 -
16 Santana-Domínguez I, González-de Torre H, Martín-Martínez A. Cross-cultural adaptation to the Spanish context and evaluation of the content validity of the Second Victim Experience and Support Tool (SVEST-E) questionnaire. Enferm Clin. 2021:31(6):334-43. https://doi.org/10.1016/j.enfcli.2020.12.042
» https://doi.org/10.1016/j.enfcli.2020.12.042 -
17 Winning AM, Merandi J, Rausch JR, Liao N, Hoffman JM, Burlison JD, et al. Validation of the Second Victim Experience and Support Tool-Revised in the neonatal intensive care unit. J Patient Saf. 2021;17(8):531-40. https://doi.org/10.1097/PTS.0000000000000659
» https://doi.org/10.1097/PTS.0000000000000659 -
18 Mohd Kamaruzaman AZ, Ibrahim MI, Mokhtar AM, Mohd Zain M, Satiman SN, Yaacob NM. Translation and validation of the malay revised Second Victim Experience and Support Tool (M-SVEST-R) among healthcare workers in Kelantan, Malaysia. Int J Environ Res Public Health. 2022;19(4):2045. https://doi.org/10.3390/ijerph19042045
» https://doi.org/10.3390/ijerph19042045 -
19 Furr R. Scale construction and psychometrics for social and personality psychology. In: The SAGE Library of Methods in Social and Personality Psychology. London: SAGE Publications Ltd.; 2011. Available from: https://doi.org/10.4135/9781446287866
» https://doi.org/10.4135/9781446287866 -
20 Peterson RA, Kim Y. On the relationship between coefficient alpha and composite reliability. J Appl Psychol. 2013;98(1):194-8. https://doi.org/10.1037/a0030767
» https://doi.org/10.1037/a0030767 -
21 Winning AM, Merandi J, Rausch JR, Liao N, Hoffman JM, Burlison JD, et al. Validation of the Second Victim Experience and Support Tool-Revised in the neonatal intensive care unit. J Patient Saf. 2021;17(8):531-40. https://doi.org/10.1097/PTS.0000000000000659
» https://doi.org/10.1097/PTS.0000000000000659 -
22 Sordi LP, Lourenção DCA, Gallasch CH, Baptista PCP. The second victim experience: cross-cultural adaptation of an instrument for the Brazilian context. Rev Gaucha Enferm. 2022;43:e20210010. https://doi.org/10.1590/1983-1447.2022.20210010.en
» https://doi.org/10.1590/1983-1447.2022.20210010.en -
23 Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268-74. https://doi.org/10.1111/j.1365-2753.2010.01434.x
» https://doi.org/10.1111/j.1365-2753.2010.01434.x -
24 Busch IM, Moretti F, Purgato M, Barbui C, Wu AW, Rimondini M. Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. J Patient Saf. 2020;16(2):e61-e74. https://doi.org/10.1097/PTS.0000000000000589
» https://doi.org/10.1097/PTS.0000000000000589 -
25 Bari A, Khan RA, Rathore AW. Medical errors; causes, consequences, emotional response and resulting behavioral change. Pak J Med Sci. 2016;32(3):523-8. https://doi.org/10.12669/pjms.323.9701
» https://doi.org/10.12669/pjms.323.9701
Publication Dates
-
Publication in this collection
02 Dec 2024 -
Date of issue
2024
History
-
Received
05 Aug 2024 -
Accepted
25 Aug 2024
