Strid et al.

BMC Health Services Research (2021) 21:511

https://doi.org/10.1186/s12913-021-06517-x

RESEARCH ARTICLE Open Access

Health care workers’ experiences of

workplace incidents that posed a risk of
patient and worker injury: a critical incident
technique analysis
Emma Nilsing Strid1* , Charlotte Wåhlin2,3, Axel Ros4 and Susanne Kvarnström5

Abstract
Background: Health care workers (HCWs) are at high risk of occupational injuries and approximately 10–15% of
patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how
HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for
patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk
of patient and worker injury, with focus on HCWs’ emotions and actions.
Methods: This study employed a qualitative design using the critical incident technique. Semi-structured individual
interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category
development.
Results: Altogether 71 workplace incidents were reported. The analysis of two dimensions – the emotions HCWs
feel and the actions team members and managers take when a workplace incident occurs – yielded two categories
each: Anxiety during the incident, Persistent distress after the incident, Team interplay for safety actions and
Support and ratification from managers and colleagues. Health care workers risked their own safety and health to
provide patient safety. Teamwork and trustful relationships were critical for patient and worker safety. Support and
validation from colleagues and managers were important for closure; unsatisfactory manager response and
insufficient opportunities to debrief the incident could lead to persistent negative emotions. Participants described
insecurity and fear, sadness over being injured at work, and shame and self-regret when the patient or themselves
were injured. When the workplace had not taken the expected action, they felt anger and resignation, often
turning into long-term distress.
Conclusions: Work situations leading to injury or risk of patient and worker injury are emotionally distressing for
HCWs. Team interplay may facilitate safe and dynamic practices and help HCWs overcome negative emotions.
Organizational support is imperative for individual closure. For safety in health care, employers need to develop
strategies for active management of risks, avoiding injuries and providing support after an injury.
Keywords: Patient safety, Occupational health, Safety management, Musculoskeletal pain, Psychological distress

* Correspondence: emma.nilsing-strid@regionorebrolan.se
1
University Health Care Research Center, Faculty of Medicine and Health,
Örebro University, Örebro, Sweden
Full list of author information is available at the end of the article

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Strid et al. BMC Health Services Research (2021) 21:511 Page 2 of 12

Background better job of actively managing risk [25]. This active

In Western countries, injury rates are higher among management of risk requires engagement and actions at
health care workers (HCWs) than among workers in any all managerial levels as well as coordinated actions be-
other field [1]. Being in patient care, HCWs are exposed tween managers and frontline staff [25]. As suggested in
to several occupational health hazards, such as viruses “resilient health care” studies, safety can be described as
[2], ergonomic or physical hazards [3, 4] and physical the capacity of a system (its individuals, teams and
violence [5]. Threats and violence are in fact more fre- organization) to adapt to varying conditions such as
quently reported in Swedish health care than in other threats, hazards, possibilities and a changing work envir-
Swedish workplaces, and the percentage of those ex- onment, so that the system succeeds in its activities and
posed has increased in the last years [6]. All of these ex- tasks [26]. In order to develop dynamic, practical strat-
posures may lead to a variety of injuries such as egies, we need descriptive studies that will help to iden-
musculoskeletal injury, wounds, infections or psycho- tify degraded conditions and the risks they pose to
logical symptoms [7, 8]. The risk factors for occupational patients and HCWs [25]. There is scarce scientific litera-
injury can be attributed to an interaction between char- ture about how HCWs manage these workplace risks in
acteristics of the worker and the patient, and the work- practice and what support they need. This knowledge is
place [9, 10]. Adverse events may affect not only HCWs needed to further improve the safety of patients as well
but also patients, and in addition may have a negative as occupational safety and health for HCWs.
impact on relatives and health care organizations, all
considered as a significant problem [11, 12]. Approxi-
mately 10–15% of patients are affected by an adverse Aim
event during their hospital stay, and a substantial part of The aim of this study was to explore HCWs’ experiences
these events are considered preventable [13, 14]. of workplace incidents that led to injury or posed risk
A few studies have explored the relationship between for patient and worker injury, with a special focus on
working conditions and both patient and HCW injuries. their emotions and actions.
The findings show that a high safety climate supports
safe patient care and also ensures HCW safety [15–18].
Pousette and co-authors (2017) concluded that safety Materials and methods
improvement interventions should be planned so that Design
both patient safety and occupational safety and health This study employed a qualitative design using the crit-
are considered concomitantly, and not separately in dif- ical incident technique (CIT) [27] to explore HCWs’ ex-
ferent processes as has been previously done in practice periences of workplace incidents. “Health care workers”
and research [15]. is used as an umbrella term referring to people involved
Qualitative study designs are used to explore the expe- in promoting, protecting, caring for or improving the
riences of individuals, information that is difficult to ob- health of the population [28].
tain with quantitative methods [19]. Recent literature Individual interviews were used for data collection.
has highlighted that adverse events affecting the patient, The technique in CIT consists of a set of procedures for
the first victim, are also stressful for the HCWs involved, gathering observations of human behaviour in defined
who are therefore commonly considered as secondary situations [27]. Incidents may be events, activities or role
victims [20]. In a recent systematic review and meta- behaviours that affect an outcome and are memorable to
analysis, more than two-thirds of the affected HCWs re- those involved [29]. To be critical, an incident must
ported troubling memories, anxiety, anger, remorse and occur in a situation where the purpose or intent of the
distress [21], and elsewhere it was shown that the sup- act seems fairly clear to the observer and where its con-
port received influences how the worker will feel about sequences are sufficiently definitive to leave little doubt
the error as well as the recovery process [21–23]. Des- as to its effects [27]. The method implies that distinct
pite the amount of literature about occupational hazards questions are asked, which enables participants to de-
in health care, there are few studies on how HCWs ex- scribe their experiences of critical incidents at work, as
perience work situations where they have been injured well as their thoughts, actions and processes during the
[24]. To the authors’ knowledge, there are no previous situation [29]. CIT originates from the 1950s, but the ap-
studies exploring HCWs’ experiences of situations at proach is still applied in contemporary qualitative stud-
work putting them and patients at risk of injury. ies in health care contexts [30, 31]. Compared with
To improve safety at work and reduce harm for both other inductive approaches, the CIT approach was
patients and HCWs, it has been suggested that we chosen due to the potentials to explore HCWs experi-
should shift our focus from creating absolute safety, i.e. ences of specific workplace incidents as the unit of ana-
from the unattainable goal of zero harm, to doing a lysis [30], in line with the research aim.
Strid et al. BMC Health Services Research (2021) 21:511 Page 3 of 12

Setting and participants departments including emergency care, geriatric care, in-
This study was conducted in three health care regions in tensive care, internal medicine, primary health, psychi-
central Sweden with a total of nine hospitals and about atric care, radiology, audiology, rehabilitation medicine
120 health care centres. Information about the study was and surgery.
sent to the regions’ human resources departments,
health care departments and trade union departments, Data collection
which further distributed the information to health pro- Semi-structured interviews were performed based on an
fessionals. Information about the study was also distrib- interview guide. The interview guide was based on a
uted through social media channels, the unions and the guide for researchers using the CIT [29], but developed
regions’ internal websites. Interested HCWs and heads by the research team for this study and is provided as
of health care departments contacted the project man- Additional file 1. A pilot interview was conducted to
ager (C.W.) for more information about the study. The evaluate the questions and to refine and coordinate the
information stated that participation was voluntary and researchers’ interview technique and the procedures,
could be discontinued at any time without explanation, since two researchers (E.N.S. and S.K.) would be holding
and that all data would be handled confidentially. One the interviews. Only minor revisions were made to the
of the main researchers (E.N.S. or S.K.) contacted the interview guide and the pilot interview was therefore in-
HCWs who had agreed to participate. Inclusion criteria cluded in the final sample. The interview started with
were: HCWs who had experience of at least one work- the main question: “Describe a work situation (a critical
place incident with risk of injury for both the patient incident) when you experienced injury risk for both you
and themselves and ability to understand Swedish. We and your patient.” This question was followed by more
aimed for a range of experience and purposeful sampling specific questions regarding the context, the participat-
in terms of age, gender and profession was applied. ing HCWs’ own actions, thoughts and feelings, actions
Thirty-seven individual interviews were held between of others, how the situation was resolved, and how the
April 2016 and February 2018. Two interviews were ex- participant and the patient were affected by the situ-
cluded because of technical problems during recording ation. Probing questions were used to develop and
and one because the incident reported had occurred too deepen the answers. The role of the interviewer was to
long ago. enable the participants to be as specific as possible in
In total, 34 interviews were included in the analysis. their description of the critical incident [29].
Mean age of the HCWs was 46 years and the majority A time and place for the interview was set in agree-
were registered nurses (Table 1). The settings where the ment with each participant. Written informed consent
incidents occurred were health care centres and hospital was obtained before every interview. The interviews were
held in a private room at the participant’s workplace or
Table 1 Characteristics of the participants the researcher’s office. All 34 interviews were face-to-
Sex face interviews except three, which for reasons of illness
Female 23
or convenience had to be performed as telephone inter-
views. Each interview lasted between 25 and 66 min,
Male 11
mean 49 min. The interviews were digitally recorded and
Total 34 transcribed verbatim by a professional transcriber. To
Mean age (range), yrsa 46.5 (21–64) preserve confidentiality, participants were pseudony-
Profession mised and each assigned a code name.
Registered nurse 13
Data analysis
Certified nurse assistant 7
An inductive category development was used as de-
Nurses’ aide 6
scribed by Flanagan [27]. NVivo 11 and 12 was used to
Registered physiotherapist 4 manage and code the data (QSR International, Mel-
Physician, psychologist, or other 4 bourne, Australia). All the transcripts were read to get a
Number of years in the professiona sense of the whole and to discover similarities and differ-
Mean 19 ences. Two transcribed interviews were jointly analysed
1–5 5
by three researchers (E.N.S., S.K. and C.W.) to develop a
tentative coding scheme. Two of the researchers (E.N.S.
6–10 5
and S.K.) coded all the transcripts and continuing dis-
11–20 7 cussions were held throughout all analytical steps. First,
> 21 16 incidents related to the aim were identified and sub-
a
information missing on one informant jected to structural analysis aiming to describe the type
Strid et al. BMC Health Services Research (2021) 21:511 Page 4 of 12

of incident (Table 3). In the second step, meaningful informed consent after receiving both written and oral
units of the experiences of incidents were derived, coded information about the study, including the voluntary na-
and divided into actions and emotions. In a third step, ture of participation, the possibility to withdraw at any
these codes were compared to find similarities and dif- time without explanation, and assurance that all col-
ferences and with the aim of grouping them together lected data would be handled confidentially and no indi-
into sub-categories, and thereafter into categories and, vidual would be identifiable in the quotes or the results.
finally, main areas. The purpose of a category is to de- Only the research team had access to the original inter-
scribe the general character of the sub-categories, while view files, transcripts and informed consents. The partic-
that of a main area is to describe the overall theme con- ipants were also informed of the interviewer’s
tained in the data. Examples of the coding strategy is professional background, reasons for interest in the topic
provided in Table 2. This analytical process is similar to and that the interview data would be analysed and pub-
that described in previous studies of HCWs’ experiences, lished in a research journal. The study followed the Con-
emotions and actions using CIT [30, 32–34]. There is no solidated Criteria for Reporting Qualitative Research
consensus on a definition of the term “emotion”, and the (COREQ) checklist [36].
scientific use of the term reflects several different mean-
ings of “emotions”. In this study, we acknowledge that Results
“emotion” consists of neural circuits, response systems, In total, 71 workplace incidents were identified in the 34
and a feeling state/process that motivates and organizes interviews (Table 3). Every participant described at least
cognition and action, as previously described [35]. one incident (range 1–5). HCWs’ experiences of work-
During the analytical process, tentative categories were place incidents that led to injury or posed risk for injury
modified and redefined, and new categories were devel- that emerged from the analysis comprised two main
oped where needed. The categories were aimed to be in- areas with two categories and four to five sub-categories
ternally homogeneous and externally heterogeneous but each. The first main area Emotions evoked by an inci-
when a behaviour fitted into more than one sub- dent comprised the categories: Anxiety during the inci-
category, the category that best fit the described behav- dent and Persistent distress after the incident. The
iour was chosen. To strengthen the confirmability, the second main area Actions by team members and man-
two authors who were responsible for the data analysis agers covered the categories: Team interplay for safety
(E.N.S. and S.K.) held continuous consensus discussions actions and Support and ratification from managers and
throughout the analysis until agreement upon final sub- colleagues (Table 4).
categories, categories and main areas was reached. A
third author (C.W.) reviewed the adequacy of the cat- Emotions evoked by an incident
egories and areas derived from the data analysis. Finally, The main area describing the emotions HCWs experi-
all authors discussed the categorization and agreed upon ence when handling a work situation that led to injury
the final version. Quotes capturing the essence of what or posed risk for worker and patient injury resulted in
was said were selected to illustrate the different categor- two categories: Anxiety during the incident; and Persist-
ies. The selected quotes from the transcripts were trans- ent distress after the incident.
lated into English and then retranslated into Swedish, to
ensure that their meaning was retained. Anxiety during the incident
Permission to conduct the study was obtained from This first category is supported by two sub-categories,
the regional ethical board in Linköping (dnr 2015/330– To feel safe within the team; and Feelings of insecurity,
31 and 2016/197–32). The participants provided written and elucidates the emotions HCWs expressed when
Table 2 Examples of coding strategy
Quotation Code Sub-category Category Main area
Disgusting and you feel all the time this, why didn’t I do It was disgusting. Why Shame and self-regret when a Persistent Emotions
anything, why didn’t I do more (Fia) didn’t I do more. patient had been exposed to distress after evoked by an
risk of injury the incident incident
I thought it was I who caused it, as I didn’t walk in to I caused it or I could
his room when he was at the toilet, could I have avoid have avoid it
it (Vera)
Permanent, actually. It (the pain) has impacted on my Pain impacts on the Sadness over being injured at
whole life (Greta) whole life work
I can’t say it’s a success story because I would rather be Incident no success
without it, so to speak. It still hurts when I do something story. Still suffering
stupid (Frida) from pain.
Strid et al. BMC Health Services Research (2021) 21:511 Page 5 of 12

Table 3 Description of the reported critical workplace incidents Feelings of insecurity in unsafe situations, especially in
posing a risk for the patient and the health care worker (HCW), sudden, unexpected situations, were described by the
categorized by type of situation HCWs. These could involve anxiety and fear of making
Type of critical incident (71) mistakes or acting wrong – also, fear of what others,
Violence or threat (37) such as the relatives of an injured patient, might think.
- Patient threatening or violent (27) Not knowing how to handle a threatening situation was
- Close relative threatening or violent (5)
connected to feelings of stress and even panic; some-
times, it damaged the self-image. Most prominent were
- Other threatening situation (5)
descriptions of fear of what a threatening or violent pa-
Moving and manual handling of patients (30) tient was capable of, fear of being hurt during the inci-
- Patient falls or nearly falls (20) dent and of what the consequences might be.
- Equipment and external environment (6)
- Other situation (4) Oh yeah, there was one small, horrible thing, be-
cause I was really afraid that I would wreck my back
when I was to turn 65 and retire, that wrecking my
back would be the last thing I did. So my thought
recalling a workplace incident posing risk of injury to was this must not happen, and it was not a big deal,
themselves and a patient. The HCWs often described so everything’s okay, but of course you don’t know
satisfaction with team actions during an incident and that then when it happens… (Vera)
expressed pride when no one had been injured. They
highly valued working with experienced and trusted col- According to the HCWs, when they felt focused dur-
leagues as it made them feel safe and as it contributed to ing the actions, they were able to regulate their emo-
a safer workplace. Previous experiences of incidents and tions, and could act as required and feel competent,
risks at work made the HCWs feel prepared for inci- even though they might feel afraid and though they wor-
dents to happen. Working in critical settings such as ried initially. They unloaded their feelings and emotions
psychiatric care or at emergency departments was de- afterwards.
scribed as a challenge but could also make HCWs feel
blunted. Safeness was characterized by trust in the team Persistent distress after the incident
and having an open and friendly atmosphere without The second category conveys emotions of distress that
judgements. the HCWs still felt a long time after an incident had
happened. The category consists of three sub-categories:
Of course you have to be able to say, “Yeah but, I … Shame and self-regret when a patient had been exposed
I can do this. I’m not afraid,” or “Whoa, I don’t want to risk of injury; Sadness over being injured at work; and
to go in to see him alone.” You have to decide for Anger and resignation when managers had not taken ne-
yourself what does and what doesn’t feel okay, and cessary action. Feelings of blame and self-regret were re-
not just pretend something is okay. (Klas) current throughout the data regardless of setting or type

Table 4 Summary of main areas, categories and sub-categories regarding health care workers’ (HCWs) experiences of workplace
incidents that led to injury or posed risk for patient and worker injury
Main area Category Sub-category
Emotions evoked by an incident Anxiety during the incident To feel safe within the team
Feelings of insecurity
Persistent distress after the incident Shame and self-regret when a patient had been ex-
posed to risk of injury
Sadness over being injured at work
Anger and resignation when managers had not taken
necessary action
Actions by the team and managers when Team interplay for safety actions Act adequately and supportively
handling an incident
Take responsibility and team leadership
Support and ratification from managers Informal debriefings with colleagues to release
and colleagues emotions
A validating approach and follow-ups by the manager
Strid et al. BMC Health Services Research (2021) 21:511 Page 6 of 12

of incident. The HCWs wondered whether they had the emotions HCWs expressed when describing how the
acted correctly, what they should have done instead, and incident had been handled at the workplace by the man-
how the incident could have been avoided. They de- ager. The sub-category also includes feelings of anger
scribed ambivalence about what would have been the evoked by being hit by a patient they were treating.
correct way to act. An incident such as a patient fall, de- Some of the HCWs related that their manager had made
scribed as difficult to predict, was acknowledged as a some adjustments at work or helped them to change to
failure even when all necessary actions had been taken another department after an incident. The perceived
to prevent it. Some participants described these inci- support from the managers and the emotions this
dents as “just bad luck”. Resignation over workplace ac- evoked varied substantially. The HCWs expressed anger
tions such as use of different work equipment for when, previous to the incident, they had informed their
handling patients, which sometimes turned out to con- manager of risks at work, but the manager had not taken
stitute a risk for both patient and HCW, was described. any action or had not responded sufficiently, and the an-
It was evident that some participants felt ashamed and ticipated incident had then happened. Such risks for pa-
guilty about having caused an incident. The HCWs tient injury included lack of a care plan, lack of overall
expressed recurrent thoughts of self-regret, sometimes medical responsibility, lack of routines or poor quality of
several years after an incident, as illustrated in the equipment. Risks related to the psychosocial work envir-
quotation below. onment, such as high workload, were described as risks
for both patient and HCW injury. Incident reports were
Did that cause me to be more vulnerable after- written, but when actions and feedback from the man-
wards? Would it have been worth it, then, not to agers were perceived as deficient, the HCWs stopped
have done that? And that it would have been better writing reports. Often, they felt not listened to, and they
for me in the long term... and that my life, you know, felt sad, angry and dejected when they perceived negli-
if I had chosen not to do that ... – that thought has gence from the managers. In the quotation below, a
occurred to me … (David) physician expresses anger at having previously com-
plained about poor quality of material and not having
The HCWs provided a substantial number and variety obtained the desired response. When she was injured as
of descriptions of pain located in the neck, back, shoul- a result of the problem that she had identified, she did
der, arm, hand, hip, and foot after being injured at work. not get an appropriate response either.
Mostly, they had returned to work immediately or after
a few days off, but in some cases, the acute pain devel- I can still feel it was a real bummer to have to pay
oped into disability and long-term sickness absence. The for that sick day out of my own pocket. I’d say that’s
HCWs were emotionally affected when talking about an almost a slap in the face! Now, I’m not going to go
incident that had happened and especially about the bankrupt just because I lost a day of work, but that’s
consequences the incident had had, and continued to not the thing that really bothers me; it’s the attitude!
have, for their working and private life. They kept strug- Here we’ve identified a problem, and then an inci-
gling with memories, emotions of worry and stress reac- dent occurs as a result of the problem – it was not
tions that were often evoked when they were exposed to unknown. (Cia)
noise, places or persons reminding them of the incident.
Some HCWs described having sacrificed their own Actions by the team and managers when handling an
health for the sake of a patient, and in some cases they incident
related that the patient had not noticed this or had died The main area describing HCWs’ actions when experi-
anyway. This created feelings of emptiness. Overall, sad- encing a situation at work that led to injury or posed a
ness was the overarching emotion. risk for worker and patient injury includes the two cat-
egories: Team interplay for safety actions; and Support
I felt it was a pity; it was a failed mobilization that and ratification from managers and colleagues. This
frightened the patient, which reduces the outlook for main area incorporates actions taken by the team during
future mobilization and, well, ultimately puts my an incident as well as the actions taken by colleagues
health at risk, too. (Albert) and managers after such an incident has happened.

Lasting, actually. That [injury] has affected my en- Team interplay for safety actions
tire life situation, you know? (Greta) This category includes two sub-categories: Act ad-
equately and supportively; and Take responsibility and
The third and last sub-category, Anger or resignation team leadership. Under the first sub-category, Act ad-
when managers had not taken necessary action, conveys equately and supportively, the HCWs described
Strid et al. BMC Health Services Research (2021) 21:511 Page 7 of 12

themselves as being well coordinated and assisting each … the problem was the allocation of responsibility,
other. Clinical decisions, for example regarding patient since this CNA [certified nursing assistant], who was
manual handling, were based on updated information on experienced, was in the room, and I was put in as
patient health and functioning, and were made in mutual an extra resource [...] and she had prepared every-
agreement with colleagues, including decisions to dis- thing and kind of wanted to be in charge. So the
continue a mobilization effort. The HCWs described be- roles were mixed up from the start, so I somehow
ing aware of their own work postures and safety. They didn’t have it in me to stand my ground and de-
said that colleagues acted quickly when needed, and gave mand an additional resource before we started, and
examples such as colleagues coming running to assist in during the mobilization she took over more than
a near fall situation or taking physical control over a vio- what I had intended. (Albert)
lent or confused patient. Violence and threats were
present in all clinical settings. These situations were de- Support and ratification from managers and colleagues
scribed as often unpredictable and when organizations The second category, Support and ratification from
and HCWs were not prepared, individual initiatives were managers and colleagues, includes two sub-categories:
taken to avert the threat. The HCWs put trust in their Informal debriefings with colleagues to release emotions;
colleagues’ competence. Team interplay and trustful re- and A validating approach and follow-ups by the man-
lationships within the team were highlighted as import- ager. To discuss an incident with a colleague directly
ant for safe actions and good outcomes for both the after the incident was described as important. Experi-
HCW and the patient. The participants described that, ences were shared and discussed in a friendly atmos-
before acting in an emergency situation, they made an phere where support and encouragement were given and
assessment based on clinical reasoning, not only of the the HCWs were able to somehow lessen the gravity of
situation itself, but also of the patient and the colleague the situation and laugh together. These discussions rep-
they were working with. The quotation below illustrates resented informal debriefings in the team and released
how an assistant nurse shaped his perception of the situ- negative emotions.
ation and the actors involved, before acting.
… so it was my co-worker, another nurses’ aide, and
What happened? Who’s that lying there? Who – I who talked about it, since we’d both seen what
what patient is that? [...] And who’s holding the pa- happened and we’d had the same reaction, you
tient? Who am I supposed to be working with? (Klas) know. But we talked about it a lot afterwards and
that was helpful ... also with other staff, and so on.
There were also situations when team interplay failed, such So that was a way to put it all behind me. (Lena)
as performing patient manual handling alone, instead of
waiting for other team members and despite acknowledging However, there were also descriptions of unwillingness
the risks. The HCWs described a focus on the patient with at the workplace to discuss difficulties. Reasons for not
little thought for their own ergonomics or injury risk, espe- bringing incidents up in discussions were respect to a
cially in falls or near falls, but also in other situations such patient, heavy workload, and stress; but sometimes there
as when performing cardiopulmonary resuscitation: was also a reluctance to uncover and deal with
problems.
You just had to get on with it. It was like ... I didn’t The second sub-category, A validating approach and
think about myself at all, that anything could go follow-ups by the manager, deals with how managers’ at-
wrong. I was focusing only on the patient. (Wilma) titudes and actions affect how HCWs experience an inci-
dent and its consequences. A listening and emphatic
The second sub-category, Take responsibility and team manager, who follows up the incident, encourages writ-
leadership, includes the importance of someone taking ing an incident report and modifies work tasks when
the main responsibility, making decisions and guiding needed, was described as supportive. This approach was
colleagues. Giving positive feedback and praising each perceived as a validation of the HCW’s experience as it
other was also important for team interplay. According creates feelings of trust and conveys a sense of ratifica-
to the participants, the team leader was normally the tion, which may be important for how an HCW may feel
person who was the most skilled and experienced, and about and cope with an incident and its consequences.
who was highly trusted by the team. Planning was cru-
cial for safe actions and the team should clarify the re- I stuck to my guns and the boss listened to me. Then
sponsibility before actions took place; if they did not do we sat down and had a good chat with the medical
this, safety could be jeopardized, as illustrated in the supervisor and with everyone who had been involved
quotation below where a patient had a near fall. and the boss. And also, for a long time I’ve been
Strid et al. BMC Health Services Research (2021) 21:511 Page 8 of 12

pushing the idea that we have to have a routine [...], important for the HCW to cope with the incident. These
so I can feel safe at work. (Erika) are findings that can be seen as part of the
organizational culture of HCWs’ workplaces, which can
There were also descriptions of unsupportive manage- be related to safety for patients and HCWs [40]. The
ment, for example involving managers being hard, not findings also emphasize the importance of good team-
listening, not showing understanding for the HCW’s ex- work for active risk assessment and management of
perience, or not giving feedback as expected. Some risks. Such teamwork requires engagement, mutual un-
HCWs were told that, as an HCW in a certain work derstanding and coordinated actions between managers
context, “one should expect risks” for occupational in- and HCWs as well as within the team, both during and
jury and then go on: business as usual. Absent managers, after an incident, as suggested for resilient health care
that is, managers who were not present and did not [25]. Resilience has been suggested to depend on four
regularly meet with their HCWs, were described as capacities in a system, which are: to be able to react
problematic as they showed a lack of understanding of when something happens; to monitor what is happening;
the work situation. An unsatisfactory response from the to anticipate what might happen; and to learn from
manager and insufficient opportunities to debrief an in- everything that happens [41]. To achieve better safety in
cident and the emotions it evoked could shape negative a system, efforts should be taken to increase these cap-
emotions. acities. In this study the HCWs gave examples of these
capacities, such as being able to react as an individual
You might not always have the supervisors’ under- and a team when something happens; to monitor what
standing that it does involve such a risk factor, in- has happened and write incident reports (as well as ex-
stead, well, you’ll have to make sure they [the pect feedback and reactions); and to anticipate what
patients] sit still then, but that’s not always easy. might happen by planning work tasks, following routines
(Fia) and being part of a trustful and competent team. Finally,
managers capable of giving feedback, reacting and pro-
Discussion viding support are needed to enable organizational
The aim of this study was to explore HCWs’ experiences learning and individual closure. The findings of this
of workplace incidents that led to injury or posed risk study point to possibilities for further strengthening of
for patient and worker injury, with a special focus on both patient safety and occupational safety and health.
their emotions and actions. The novelty revealed in this One of the core strategies for patient and HCW safety
analysis is that work situations leading to injury or pos- may be to develop and maintain good teams with suffi-
ing risk for patient and HCW injury are emotionally dis- cient resources, as well as to provide opportunities for
tressing for HCWs. Team interplay may facilitate safe the teams to reflect on risks. Our study identified the
and dynamic practice and help HCWs to overcome importance of good teamwork for safety and in this re-
negative emotions, but organizational work support is spect our findings share some similarities with the find-
imperative for individual closure. Our analysis under- ings from previous qualitative studies describing what
scores the need for employers to develop strategies to- HCWs perceive as important for patient and worker
gether with HCWs and teams for active risk safety [42–44]. In a focus group study with nurses and
management at work, to avoid injuries and provide sup- physicians, patient and worker safety was found to be
port after an injury, regardless of whether it was the pa- determined by interpersonal communication with col-
tient or the worker who was at risk or injured. That leagues, trust and worker readiness to take responsibility,
organizational support provided by colleagues and man- as well as emotional and practical support [42]. The
agers was perceived as important is in line with the the- HCWs in our study prioritized protecting the patient,
ory of perceived organizational support, which concerns sometimes at the expense of their own safety, as also de-
employees’ general belief that their work organization scribed elsewhere [43]. Our analysis revealed conflicting
values their contribution and cares about their wellbeing actions and attitudes, for example when HCWs caught a
[37–39]. Perceived organizational support is suggested falling patient and performed patient handling alone or
to be especially helpful in reducing traumatic conse- with too few personnel, despite the inherent risk. This
quences of stressors at work [37]. Feeling safe within the could be interpreted as risk acceptance. When team
team, which incorporates trustful relationships, team members do not respect or agree to a request for an
leadership, confidence in each other’s competence, and extra person in patient handling, this could be devastat-
openness to share emotions, was described as important ing for both teamwork and the safety of the patient and
for safe and dynamic practice. To share emotions means worker; also, it can create feelings of powerlessness and
also that somebody is listening, which is an example of self-regret of the injured worker. Respect for its individ-
empathic support provided by colleagues that may be ual members is important for a team in order for it to
Strid et al. BMC Health Services Research (2021) 21:511 Page 9 of 12

be effective, as previously demonstrated [44], and our Methodological considerations

findings underscore the need to disclose teams’ values The limitations and strengths of this study are discussed
and norms as risk acceptance may be negative for both in terms of the components of trustworthiness: credibil-
patient and worker safety. ity, dependability, confirmability and transferability [30,
In some situations, HCWs may have to physically con- 48]. The CIT [27] was employed to explore HCWs’ ex-
trol the patient, using different physical restraint periences of workplace incidents. CIT is widely used in
methods and devices. These devices, in turn, may in- contemporary qualitative research to explore the per-
crease the risk of patient injury and extend the duration spective of patients or healthcare providers [29–34]. As
of the hospital stay [45]. These complicated events cre- previously described when using CIT in qualitative re-
ate persistent emotions of distress and present HCWs search [30], the data collection was based on the individ-
with ethical dilemmas, which the present study contrib- ual perspective and the interviewees were encouraged to
utes to explore. In one study, perceived high team effi- recall real incidents with a clear beginning, clear end
cacy in dealing with patient and visitor aggression was and generating actions that had an impact (positive or
shown to be predicted by physical environment, a shared negative results). This detailed description of the inci-
positive organizational attitude and psychiatric setting dents provided by the participants is considered a
[46]. The authors conclude that general hospitals could strength of CIT and this study, as it can be assumed that
benefit from approaches in psychiatry focusing on staff this information is accurate, strengthening credibility.
efficacy in the management of patient and visitor aggres- The participants in this study reported 71 unique critical
sion. Managers may need support or training for this incidents, which is within the recommendations of 50–
task by their organizations. 100 critical incidents required to describe a problem
Our results emphasize that workplace incidents posing [27]. The purposeful sampling strategy strived for a wide
risk for patient and worker injury are emotionally dis- range of experiences and resulted in a diverse variation
tressing for HCWs and that self-regret and distress can of descriptions of workplace incidents that occurred in
last for a long time if not properly addressed. Perceived different parts of the health care system. This can be
organizational support may influence how HCWs feel interpreted as a strength, but may also restrict the trans-
about the recovery process. In this study, we show that ferability. The authors responsible for data collection
the absence of a safety culture to reflect on risks and in- and analysis (E.N.S. and S.K.) had previous experience in
cidents and insufficient manager support could create conducting qualitative studies. These two authors held
emotions of anger and resignation that could last for the interviews and individual differences may have influ-
many years. The experiences of HCWs as second victims enced the data, but dependability was strengthened
of error when a patient has been injured have been through efforts to fine-tune and coordinate the re-
explored and synthesized in a few recently published searchers’ interview techniques and procedures. There
systematic reviews [21, 23]. The findings indicate that are both advantages and disadvantages to interviewing
an error brings a considerable and longstanding emo- one’s peers. To promote transparency, the participants
tional burden to the HCW [21, 23]. Second victims were informed of the interviewer’s professional back-
have been shown to experience negative emotions ground. As a fellow practitioner, the participants’ confi-
after an adverse event such as anxiety or anger di- dence may be gained more readily than if the
rected towards themselves, towards others or to the interviewer were a non-practitioner, and the shared
work environment [21, 22] and it has been reported knowledge and interest between the participants may in-
that an error can have a negative impact on self- crease the interviewer’s credibility. Although the partici-
image and interpersonal relationships at the work- pants were encouraged to openly convey their
place [23]. The findings from our study emphasize experiences, there may always be a professional vulner-
that active support is required to reduce negative ability and risk of feeling judged [49]. There was no rela-
emotional responses and to facilitate coping after an tionship prior to the interviews. All of the authors were
incident and create a just culture free from blame or researchers with several years of health care experience,
judgment. This active support should include direct working as a nurse, physician, and physiotherapist, as
and emphatic collegial and managerial support, well as a human resources manager and consultant in
follow-ups and provision of psychological support patient safety. The authors had good knowledge of CIT,
when needed. To regularly reflect on incidents and occupational safety and health, and patient safety. These
risks within the team is another important strategy different theoretical and practical perspectives may have
that may be facilitated by local managers. It has been enhanced the understanding of the phenomenon of
suggested that supporting all victims of patient harm workplace incidents. We have been aware of our per-
(i.e. patients, their relatives, and HCWs is one im- spectives during the data collection and analysis, and
portant strategy in patient safety management [47]. have strived to correctly convey the participants’
Strid et al. BMC Health Services Research (2021) 21:511 Page 10 of 12

perspectives in the results. The data were analysed sys- her knowledge of patient safety issues. This study was a collaboration
tematically and independently using inductive category between three regions in central Sweden, and the authors would like to
thank the organizations involved for the possibility to conduct this study.
development as previously described [27, 30]. To
strengthen confirmability, the entire research team held Authors’ contributions
consensus discussions throughout the analysis and the All authors contributed equally in applying for research funding, creation of
the research questions and study design and participated in data analysis as
findings were finally approved by the research team and well as writing the manuscript. C.W. contributed substantial to creation of
discussed with other researchers and HCWs. Confirm- research questions and analysis of data. E.N.S. and S.K. conducted the
ability and transferability were reached by providing a interviews and were main responsible for analyzing the data. E.N.S. was
responsible for drafting the manuscript. A.R. contributed substantial to
description of the participants and setting, enabling the interpretation of data and revising the manuscript. All authors have read and
reader to decide whether these findings can be trans- approved the final manuscript.
ferred to other, similar contexts. It was not within scope
Authors’ information
of this study, but to collect and analyze multiple per- E.N.S: PhD, RPT.
spective, using triangulation of diverse data sources such C.W: PhD, RPT.
as to combine incident reports with interviews with A.R.: PhD, MD.
S.K.: PhD, RN.
HCWs, managers and patients could have given more
information about the context and enriched the data. Funding
The findings from this study may shed light on HWS’ This work was also supported by the Medical Research Council of Southeast
journey after their experience of a workplace incident, Sweden (FORSS-857091) and by grants from Region Östergötland (LIO-
630281). The funding body had no involvement the design of the study, in
which can be long and distressful. These findings may the collection, analysis, and interpretation of data, or in writing the
serve as a starting point for further research on how to de- manuscript. Open Access funding provided by Örebro University.
velop strong health care teams that can perform active risk
Availability of data and materials
assessment and manage risks built on trustful relation- The data that support the findings of this study are available on request
ships and support by managers. The clinical implications from the corresponding author [E.N.S.]. The data are not publicly available
of these results indicate a need for increased focus, among due to them containing information that could compromise research
participant privacy/consent.
managers, on occupational safety and health at the work-
place and highlight the importance of manager strategies Declarations
to validate the HCW’s experiences, take actions to prevent
Ethics approval and consent to participate
recurrence of safety breach incidents, strengthen team- The study followed the ethical principles of the Helsinki Declaration.
work and provide tools for collegial support and feedback. Permission to conduct the study was obtained from the regional ethical
board in Linköping, Sweden (dnr 2015/330–31 and 2016/197–32). The
participants provided written informed consent. There was no relationship
Conclusions with the participants before the study.
The key finding in this explorative study is that work sit-
uations leading to injury or posing risk for patient and Consent for publication
Not applicable.
HCW injury are emotionally distressing for HCWs.
Team interplay is critical and may facilitate safe and dy- Competing interests
namic practices and help HCWs to overcome negative The authors declare that they have no competing interests to declare.
emotions, but organizational support is also imperative Author details
for individual closure. For safer health care for both pa- 1
University Health Care Research Center, Faculty of Medicine and Health,
tients and workers, there is a need for employers, to- Örebro University, Örebro, Sweden. 2Division of Prevention, Rehabilitation
and Community Medicine, Occupational and Environmental Medicine
gether with employees, to develop strategies for active Centre, and Department of Health, Medicine and Caring Sciences, Linköping
management of risks, avoiding injuries and providing University, Linköping, Sweden. 3Unit of Intervention and Implementation
support after an injury. Research for Worker Health, Institute for Environmental Medicine, Karolinska
Institute, Stockholm, Sweden. 4Region Jönköping County and The Jönköping
Abbreviations Academy for Improvement of Health and Welfare, School of Health and
CIT: Critical incident technique; HCWs: Health care workers Welfare, Jönköping University, Jönköping, Sweden. 5Region Östergötland,
Department of Health, Medicine and Caring Sciences, Linköping University,
Linköping, Sweden.
Supplementary Information
The online version contains supplementary material available at https://doi. Received: 3 September 2020 Accepted: 12 May 2021
org/10.1186/s12913-021-06517-x.

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