Key factors for effective implementation of healthcare workers support interventions after patient safety incidents in health organisations: a scoping review

Objectives This study aims to map and frame the main factors present in support interventions successfully implemented in health organisations in order to provide timely and adequate response to healthcare workers (HCWs) after patient safety incidents (PSIs). Design Scoping review guided by the six-stage approach proposed by Arksey and O’Malley and by PRISMA-ScR. Data sources CINAHL, Cochrane Library, Embase, Epistemonikos, PsycINFO, PubMed, SciELO Citation Index, Scopus, Web of Science Core Collection, reference lists of the eligible articles, websites and a consultation group. Eligibility criteria for selecting studies Empirical studies (original articles) were prioritised. We used the Mixed Methods Appraisal Tool Version 2018 to conduct a quality assessment of the eligible studies. Data extraction and synthesis A total of 9766 records were retrieved (last update in November 2022). We assessed 156 articles for eligibility in the full-text screening. Of these, 29 articles met the eligibility criteria. The articles were independently screened by two authors. In the case of disagreement, a third author was involved. The collected data were organised according to the Organisational factors, People, Environment, Recommendations from other Audies, Attributes of the support interventions. We used EndNote to import articles from the databases and Rayyan to support the screening of titles and abstracts. Results The existence of an organisational culture based on principles of trust and non-judgement, multidisciplinary action, leadership engagement and strong dissemination of the support programmes’ were crucial factors for their effective implementation. Training should be provided for peer supporters and leaders to facilitate the response to HCWs’ needs. Regular communication among the implementation team, allocation of protected time, funding and continuous monitoring are useful elements to the sustainability of the programmes. Conclusion HCWs’ well-being depends on an adequate implementation of a complex group of interrelated factors to support them after PSIs.


INTRODUCTION
It is estimated that 10.4%-50% of the professionals working in healthcare sector will experience at least once in their career the second victim phenomenon (SVP) 1 2 defined as 'any healthcare worker (HCW), directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error or patient injury, and who becomes victimised in the sense that they are also negatively impacted'. 3These types of incidents, with an unintended or unexpected nature, can harm patients (first victims of an adverse event) or pose a risk to the system (near miss). 4 5CWs play a crucial role in patient care and they can be seriously affected when a patient safety incident (PSI) happens.PSIs can impact HCWs' quality of life, 2 6 7 in

STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ The inclusion and exclusion criteria were defined in accordance with a preliminary search strategy, guided by the population, concept and context, as recommended by the Joanna Briggs Institute for scoping reviews.⇒ We did not restrict language and period of time to avoid having selection bias and compromise the validity and reliability of the findings.⇒ The data collection was limited to five interrelated dimensions (Organisational factors, People, Environment, Recommendations from other studies, Attributes of the support interventions).⇒ We used the Mixed Methods Appraisal Tool assessment tool to evaluate the quality of the included studies; however, some of the criteria could not be fully applied in some specific cases.⇒ We included five experts from different countries to complement the literature search with additional sources of information.
Open access particular their physical and psychological well-being. 8 9 study published in 2020 shows that the most prevalent symptoms in HCWs after PSIs were troubling memories, anxiety/concern and anger toward themselves. 9Work satisfaction, confidence in their abilities 2 and work performance 7 10 can also be seriously impacted by these types of incidents.It can result in turnover intentions and absenteeism 11 and in the most severe cases can lead to suicide. 12nstitutional support systems are increasingly being implemented in order to provide an immediate and empathic response to HCWs after stressful situations such as PSIs.Health organisations are recognising the importance of this type of support, due to its important impact on the organisational culture, 13 patient safety (PS) and quality of care [14][15][16] and also on the economic perspective. 17It is well-established that poor HCWs' well-being has a strong influence on the reoccurrence of PSIs. 14Therefore, prioritising interventions that effectively support HCWs after stressful situations can prevent future healthcare incidents and improve PS.
The first reported support programmes were implemented in the USA in 2006 and since then, they have been gradually multiplying all over the world. 18In recent years, there has been a growing number of publications describing the implementation of these types of programmes and practices with the overall aim of decreasing emotional and psychological distress in HCWs.A systematic review found that HCWs seek support not only after being involved in PSIs, but also when facing other distressing situations (eg, emotional distress, torpid evolution of a patient, personal crises, intraoperative mishaps). 9Based on the fact that there is still a lack of assistance to HCWs to cope in distressing situations, some support interventions are opening their scope of action. 9lthough support interventions have demonstrated their benefits and utility, there is still limited research on finding what the common elements present in the development and implementation process of successful interventions are.A toolkit was introduced in 2010 to provide guidance on the implementation of programmes to support HCWs who have been negatively impacted by PSIs. 19The development of this toolkit was an important step in assisting with the implementation of support programmes and it can be adjusted to any type of healthcare organisation. 19However, no study has been published focusing on reviewing the existing evidence to understand the main factors that contribute for an effective implementation of these types of support interventions.
Evidence shows that establishing a set of elements for implementing interventions does not ensure its effective introduction into daily usage. 20 21The success of interventions in health organisations highly depends on an adequate design, implementation and evaluation. 22One of the main aims of implementation science is to understand what are the factors that might affect the effectiveness and sustainability of the interventions and what is the necessary implementation process to produce the expected effects. 20In this sense, learning from previous experience can facilitate practical application and contribute to more effective interventions. 23

Study rationale
In this study, we set out to map and frame the main factors that underlie an effective implementation of support interventions in order to provide timely and adequate response to HCWs who are physically and/or emotionally affected by PSIs (known as second victims) or similar distressing situations.We have defined five interrelated dimensions guided by five main research questions, further described in this study, and we organised them in the Organisational factors, People, Environment, Recommendations from other studies, Attributes (OPERA) (figure 1).This framework helped to inform the planning and design of the scoping review, as well as the execution.The defined five domains were inspired on the health policy triangle (HPT) framework to guide effective implementation of health policies. 24However, HPT is a theoretical model and in order to overcome the research-to-practice gap, we have incorporated the implementation science principles and Donabedian's structure-process-outcome quality of care model, more recently adapted by Yano. 25

Objectives
We aim to understand what existing organisational factors, relevant actors, contextual factors, operational attributes are present in interventions that were successfully implemented in health organisations to support HCWs after PSIs or other similar stressful events.We also

METHODS
This scoping review is conducted using the six-stage approach proposed by Arksey and O'Malley 26 and is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews to ensure the transparency of the results obtained 27 and follows The Joanna Briggs Institute Methodology (JBI) for Scoping Reviews. 28ll the methodological steps are described in further detail in the scoping review protocol published in a previous publication. 29e applied the search strategy in nine electronic databases and the last update was done in November 2022 (CINAHL, Cochrane Library, Embase, Epistemonikos, PsycINFO, PubMed, SciELO Citation Index, Scopus, Web of Science Core Collection).The applied search strategies in the electronic databases can be consulted in online supplemental table 1.In addition to the database search, relevant websites were consulted and reference lists of the studies included in the full-text screening were screened to identify any other potential articles to include.

Stage 3: study selection
We used EndNote to import articles from the different databases and we used Rayyan as a tool to facilitate the screening of titles and abstracts.The articles were independently and manually screened by two authors between April 2022 and February 2023.In the case of disagreement on article inclusion, a third author was involved to evaluate the paper independently and contribute to making a final decision.We did not restrict the period of time or language of the included studies in order to reduce the selection bias and to undertake a comprehensive overview of the existing literature on a topic with still limited number of publications.Empirical studies (original articles) were prioritised along with systematic reviews and metaanalyses for collecting potential eligible studies.Grey literature (theses and other documents) was also considered eligible for the study.
The inclusion and exclusion criteria were defined in accordance with a preliminary search strategy, guided by the population, concept and context (PCC) framework (recommended by the JBI for scoping reviews 28 ) and are further described in the published protocol of this study. 29ased on the PCC framework, we defined the following criteria: Population: Support interventions in health organisations in which HCWs are physically and/or emotionally affected by PSIs and other distressing situations.We considered support interventions destinated to health professionals, residents and other allied health professionals (such as technicians and supply workers).
Concept: Support interventions that were fully implemented and executed in health organisations and provided measurable results that assessed the achievement of desired outcomes.
Context: Support interventions from a variety of healthcare contexts, including those in high-income, middleincome and low-income countries (eg, primary care, urgent and acute care, ambulatory services, long-term facilities).

Exclusion criteria
Editorials, letters to the editor, case series, case reports, narrative reviews and commentaries were excluded.

Stage 4: charting the data
A data extraction template was created to show the characteristics of the eligible studies (detailed information can be consulted in online supplemental table 2).

Quality assessment
We used the Mixed Methods Appraisal Tool (MMAT) Version 2018 to conduct a quality assessment of the eligible studies. 30We believe that this appraisal will be important to enhance the quality and rigour of our study, ensuring greater transparency and validity of the data.The eligible studies were evaluated by two independent reviewers.A third reviewer was involved in cases of disagreement in the quality assessment.

Open access
Stage 5: collating, summarising and reporting the results The information from the eligible studies was collected and organised into different conceptual categories, as presented in the OPERA (figure 1): Organisational factors ► Organisational structures (eg, infrastructures, resources, tools, equipment, units and staffing levels functional for managing and delivering services, leadership structure/authority and organisational culture).► Organisational processes (eg, organisational actions, procedures, recruitment criteria, training, programme implementation, communication processes, quality of interactions and coordination during programme implementation and dissemination as well as the sustainability of the practice).► Organisational outcomes (eg, implementation measures, process quality measures, utilisation measures, effectiveness measures that assess the attainment of an end state).

People
Relevant actors (individuals and organisations that actively participate in the development and implementation of the programme).

Environment
Contextual factors (type of healthcare setting and cultural context).

Recommendations described in the included studies
Recommendations to improve the implementation process of the support interventions.

Operational attributes of the interventions
Format/type of programme, accessibility, usability and confidentiality of the programme/interventio.

Stage 6: consultation exercise and stakeholder involvement
We invited a group of five experts working on SVP research from five different countries (Finland, Germany, Italy, Portugal and Spain) to complement the literature search with additional sources of information.All of them are members of The European Researchers' Network Working on Second Victims (ERNST).

Patient and public involvement and engagement
None.

RESULTS
A total of 9708 records were retrieved from 9 electronic databases, 43 articles were retrieved from the reference lists of the included articles, 11 from websites and 4 were collected from stakeholders' group inputs.
Based on the screening of titles and abstracts, 7262 articles were excluded and 13 articles could not be retrieved after trying to contact the authors.A total of 156 articles were assessed for eligibility.
A third independent author was involved in solving four conflicts in the authors' decision, leading to the inclusion of one article.In total, 127 articles were excluded after the screening, and 29 articles ultimately met the eligibility criteria.Detailed information about the data collection, screening process, duplicates removed and reasons for exclusion is exhibited in the flow chart (online supplemental figure 1), in line with the original Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. 31tudies with levels of evidence II and VI 32 met the eligibility criteria.We have included the following types of studies: mixed methods (n=15); quantitative descriptive (n=8); qualitative (n=3); randomised controlled trial (n=2) (for further details about the included studies consult online supplemental table 2).Bearing in mind that we only included empirical studies, we didn't include the first two screening questions in the MMAT evaluation (optional for MMAT). 30he characteristics of the included studies are outlined in table 1.
Most of the programmes included in this study have a multidisciplinary application and were focused on supporting HCWs after traumatic work experiences directly associated with PSIs.][35] Although one-to-one sessions were the most commonly provided support, some programmes also included group sessions.We also included interventions focused on raising awareness of SVP and creating a supportive and proactive culture to manage critical incidents and enhance HCWs' well-being.
The included interventions are described in online supplemental table 3.
In the following section, we present the results based on the organisation of the OPERA.
(Organisational factors)PERA Organisational factors: structure Resources We found four main types of useful resources used in the interventions according to different applications. 36These resources are described in table 2.

Infrastructures
The acquisition of materials and human resources was, in most cases, voluntarily.However, some studies mentioned that the intervention received specific funding for acquiring resources. 36 37he existence of a specific room for sharing information and emotions in privacy was referred to by two studies. 35 38ganisational culture We identified the following factors associated with the organisational culture that are facilitators of the implementation of HCW support programmes after PSIs: ► Openness of the health organisation to innovation. 39Implementation of previous initiatives that have contributed to the creation of a proactive organisational culture to manage PSIs 40 , to support HCWs after PSIs /other stressful situations and promote their well-being. 36 37 41 42 The existence of formalised structures directed at fostering a PS culture, based on a just culture approach, 35 36 42 and at supporting HCWs and enhancing their well-being. 35 42-44► Active involvement of leadership members in initiatives that support SVs and HCWs' wellbeing. 35 37 39 42 45-48► Existence of established policies promoting a supportive organisational culture (such as the application of paid time off after a critical incident occurs) 35 and organisational accountability for employees' support and well-being after PSIs. 49e also identified some potential organisational barriers to the implementation of programmes: ► A lack of staff and leadership awareness regarding the support programmes for HCWs. 50[53] Organisational factors: process Most of the implemented programmes had developed a needs assessment 43 45 47 49 53 54 and/or conducted a literature review 33 45 48 prior to the design and creation of the programme.The needs assessment makes it possible to adapt the interventions to the needs of the clinical teams and adjust them to the institutional context and culture in accordance with the most recent literature.
Table 2 Resources identified in the included HCWs' support programmes

Marketing and dissemination materials
Print marketing materials: posters 40 59 ; handouts such as brochures and flyers 39 45 55 identification badge of peer support for easy recognition and quick reference cards. 55igital marketing material: promotional videos 50 website 45 46 50 ; email box. 41 46 47elfcare and well-being related resources Packets with aromatherapy 36 37 ; chocolate 35 36 56 ; snacks 51 54 ; kind messages 35 36 51 ; selfcare pockets with essential support resources and guidance for coping with normal grief responses, 36 others contain a journal, a stress ball and tissues 56 ; general mental and emotional wellness advices, 49 and use existing resources. 49nctional resources for programme implementation Electronic mailbox 36 41-43 45-48 52 55 ; access to virtual zoom 41 46 and WebEx platform 46 ; dedicated mobile phone/pager/hotline/phone call system for peer supporter sessions 35 40 47 48 53 57 60 ; web-based collaborative administrative platform for sharing information and managing the programme 45 such as Sharepoint 43 55 ; checklist of responsibilities for the development team 36 ; list of peer support schedules 38 39 ; peer encounter forms 43 47 secure database of outreach attempts. 48ducational resources (most of them are related with peer support training) Online training focused on psychological first aid 33 47 PowerPoint presentations with voice narrations 33 training scenarios 44 56 57 ; videos 33 45 87 ; 'Do's' and 'Don'ts' list, self-affirmations resources 48 87 and specific facilitator's guide 46 made available to peer supporters for guidance during the encounters with SV/HCWs; tutorial for peer support facilitation. 54Posters, brochures and flyers were the most widely used marketing resources.HCW, healthcare worker; SV, second victim.

Open access
The team was recruited using three different methods: direct nomination of the team members based on their ability to provide support in an empathic way 37 40 42 47 48 ; votes from the clinical team 36 48 and voluntarily. 45 47 53n advertising campaign for raising attention of all the staff that would benefit the programme and show how to activate the service was carried out in a large number of interventions. 39 40 45 46 49 50 55e describe below some of the implemented communication strategies described in the included studies: ► Digital marketing: dissemination of the programme on computer screensavers 50 and digital communication through the institutional website. 39 46 50► Internal communication: hospital magazine, newsletters or email. 41 47 50► Networking: presentation of programme in divisional meetings 38 42 45 47 50 52 or in hospital-wide events and conferences. 38 56► Involvement of the leadership members in the dissemination process 50 51 and some programmes have included unit-level champions. 50► Previous staff training on the topic of SVP 45 50 including training for staff provides the first level of support after a PSI in the local. 57issemination was also carried out for recruiting peer supporters to join the peer support programmes. 42 43 45 48Most of the peer supporters received specific training to prepare them for providing assistance to others. 36

Sustainability of the programmes
After implementing the pilot intervention, several projects have effectively expanded the pilot intervention to other departments, 43 other healthcare facilities 45 59 or hospital wide. 49 55The full integration of the programme in the departments underlies the inclusion of the programme in the scheduled activities and in the available services of the institution. 57eadership support was an important factor for the implementation of the programme and its sustainability. 40 47 50Regular meetings were found to be important to maintain the cohesion of the team over time. 37 40 56 57Annual courses and the implementation of an interactive virtual platform were important for the expansion of the workforce working in these programmes. 40 45The high level of motivation and interest of the team 48 and retention of peer supporters were given particular consideration for programme sustainability and this was associated with work meaningfulness, staff satisfaction, commitment, a high level of resilience and a high level of confidence as a peer supporter. 50 In other cases they were integrated in major projects developed by the organisations. 42 56 60Both situations were considered potential facilitators for maintaining the programmes over time.
Funding was also an important aspect to consider for the sustainability of several programmes. 37 42 46 52 59ganisational factors: outcomes Most of the studies included in the analysis focused on collecting outcomes related with programme's utilisation and the evaluation conducted by both peer supporters and users (HCWs/second victims that attended to the programmes).
In table 3, we describe in further detail the outcomes evaluated in the included studies.

O(People)ERA: relevant actors
The establishment of a multidisciplinary team for the development and implementation of the support programmes was common to all the programmes.This team was predominantly composed by leadership members (hospital administrators and unit leaders), front-line workers, academics and experts in quality and safety. 33 34 38 43 50 52In some cases, it also included chaplains, 38 social workers 38 43 and legal department members. 52ost of the programmes' development and implementation were dependent on volunteer efforts.However, some programmes hired specific elements of the team, such as the programme directors and coordination members. 39 42 57 60Several studies highlighted the importance of these members in the programme activation process, particularly in matching the profile of peer supporters with HCWs' needs and in the contact with peer supporters and outreach people in need of support. 42 48 52 53 56Trained peer supporters are crucial for providing effective support for HCWs involved in PSIs. In some cases, there was a specialist to facilitate monthly debriefing meetings for peer supporters to process their experiences and to receive assistance. 36 37 43ost of the programmes also provided access to specialised external support that represents the third level of support in the case of programmes that follow the Scott Three-Tier Model. 34 36 45 51 57On a department level, unit leaders performed different types of essential functions by contributing to Open access the development of the programme, 37 48 participating in the recruitment of peer supporters, 33 43 50 51 providing first-level support for HCWs in need, 34 coordinating programme's components and mentoring peer support team members within the facility. 57We found that in some cases the organisational environment was beneficial to the implementation of the programme, particularly when healthcare organisations were already working towards creating a more supportive environment for their staff and strengthening the safety culture. 36 37 42 43 56 60e also found that previous occurrence of a very serious adverse event helped in recognising the need to implement a programme to support staff in supporting them to cope after PSIs. 35 50n an external level, several studies have mentioned that programme implementation was affected by the COVID-19 pandemic, such as the possibility of handling face-to-face encounters, and it also affected the data collection/monitoring process of the interventions. 6 8 9 11 22 24 27E(Recommendations)A: recommendations related with the implementation process and directly related with HCWs experience Different types of recommendations for improving the programmes were mentioned in the included studies with the ultimate goal of achieving a more effective intervention.They were identified from the user perspective (HCWs in need of support after being involved in a PSI) and also from the perspective of the implementation process (described in table 4).

OPER(Attributes): operational attributes of the programmes Accessibility
Programmes can be activated by the following people: ► Anyone who was involved in the stressful event. 34 42 47 49 56 57► Safety and risk management staff. 52 56 Peer supporters. 52 Nurse in charge. 38 Leadership members. 34 35In the case of programmes that have online resources, they could be accessed through a website. 33 39 45lthough most of the programmes were provided voluntarily, some of them have mandatory activities for Frequency of the HCWs who attended the programme 36 40 42 60 87 ; frequency of programme activation 34 37 40 42 43 45 47-49 51 52 55-57 ; average duration of the encounters 57 ; no of programme dropouts 33 ; median no of interactions per month 52 53 57 ; frequency of peer support encounters 50 53 ; no of HCWs who need external support. 57valuation of the programme by the peer supporters perspective Overall peer support satisfaction with the training 33 34 47 49 87 ; perception of acquired knowledge, meaningfulness, motivation and interest to learn more and apply the learning 44 ; satisfaction about how encounter end out 45 ; need for additional training and experience 45 ; feeling able to provide support and being comfortable with their knowledge and skills as a peer supporter. 45aluation of the programme by the user perspective (HCWs involved in PSIs/SV) Overall satisfaction with the programme 33 36-38 40 43 45 49 51 54 58 59 87 ; knowledge/skills acquisition 33 41 ; usefulness of the contents 33 ; timeliness of the programme 48 ; perceived helpfulness of the programme 46 53 ; HCWs awareness of SVP phenomenon 39 ; qualitative experience after attending the programme (how much HCWs benefit from the programme). 33-38 40

Health-related outcomes
Psychological and physical distress 47 ; emotional distress 46 ; perceived stress 44 60 anxiety and burn-out 54 58 ; assessment of quality of life 36 ; perceptions of individual coping skills such us emotion regulation, self-efficacy and resilience. 39 44 47 87ork-related outcomes Job satisfaction 36 ; turnover intention and absenteeism 47 ; return to work 35 ; confidence in coping with adverse events. 87Ws, healthcare workers; PSIs, patient safety incidents; SVP, second victim phenomenon.
Open access all staff in the departments, such as a seminar to promote a shared understanding of SVP and the need for peer support, 49 or attendance at debriefing sessions to enhance the recovery of all staff in the unit. 35rogrammes based on the Scott Three-Tier Model establish the access to the programme according to different levels of HCW needs. 34 40 57The first level of support should be available immediately after the incident has happened and team members should be prepared to provide it (local-level support).For accessing the second level of support, anyone can activate peer support with a trained peer.For the third level of support, the HCW is referred to specialised support. 57n some cases, programmes can be accessed 7 days a week. 39 43 46 47 55 57 60In a support programme implemented in New Zealand, the phone number to reach the support team was added into the staff contact list and on-call phones within the unit to facilitate the activation process. 40The dissemination of schedules, timelines and contacts was a useful strategy employed to facilitate access to the programme. 39 47ack of staff awareness about the programme 50 51 and difficulty finding time to attend the interventions were the main barriers to accessing the programmes. 59Moreover, some HCWs resisted accessing support since they did not recognise the need for it or preferred to avoid dealing with the situation again by talking about it. 35

Usability
To ensure the maximal attendance of staff, in several programmes the communication process was facilitated by peer supporters or the programme director Table 4 Main recommendations referred to in the included studies from both the user and the implementation process perspectives Recommendations related with the implementation process Recommendations directly related with users' experience (HCWs involved in PSIs/SV)

Conditions to facilitate the implementation process:
To allocate protected time for teams to implement the programme and actively participate in the tasks and training. 34 45dministrative framework should be ensured to support programme implementation. 57o develop an institutional policy to guide the management of the critical event and support the affected HCWs and patients. 35unding was an important facilitator for programme development and implementation. 37 46 55o be formally recognised as an institutional programme. 34o invest in telehealth solutions to support HCWs in the workplace. 46rocedures related with the implementation process: To invest in programme's dissemination and marketing for increasing HCWs' adherence to the programme. 34 46-49 51 55 57 60o actively involve the target group in the development of the programme and to conduct a needs assessment helps fostering interest and adapt to the specific needs of the target population. 54 58o integrate staff working in the unit in the programme's team, helps to understand the needs of the unit. 37o promote active involvement of leadership members facilitates the implementation of the programmes and contributes for staff engagement. 33 35 40 42 45 49 51 54 56 57o promote training sessions and resources to increase managers awareness about the SVP and about the existing support programmes. 51 56o create a multidisciplinary support team to facilitate a comprehensive programme's development and address different areas for support while leveraging a range of expertise. 52o set regular debriefings (in person or virtual meetings) to exchange experiences and to foster a culture of mutual support among the members of the programme's team. 40 56To develop a list of key phrases that peer supporters can use in their interactions with SVs. 50Having an electronic dashboard for sharing documentation and data collection. 55Participation in the process should be entirely voluntary and confidential. 34 40 45 52-54 57 87o invest in creating an organisational culture that addresses and acknowledges clinicians' vulnerability, while promoting a supportive environment after stressful incidents. 42 57To ensure that SV have an adequate access to the programme, feel safe and not stigmatised when accessing resources 51 ; Procedures focused on user's experience: Appropriate timing for programme's activation (ideally it should be immediately available to the HCWs after a stressful event 57 ) and adequate duration of the support. 40 87ll HCWs involved in a critical incident should be contacted to receive support. 40 52ctive surveillance in the units should be done to identify potential SV (particularly in high risk environments). 57o increase programme awareness for front-line staff and prepare them how to give first level of support. 43 47 51o train the leadership to support staff to cope with stressful situations and to direct them to support resources in case of need. 34 36 37 56 87o enhance the level of education on staff resiliency in the services. 39o establish an interdisciplinary support team to open the scope of support according to the different staff's needs and background. 43 50 55o create a safe place for sessions. 36-38 54maller groups are preferred for sharing experiences and support. 59o make resources available and close to the staff, to make them easy to reach. 38 42 51o identify barriers and facilitators for HCW to seek mental health support (eg, stigma, career concerns, protected time). 46o provide channels to reach the programme even when the HCW was not involved in a PSI. 48o provide a holistic support (eg, incorporating integrative therapy techniques; cognitive based therapy). 37 44Ws, healthcare workers; PSIs, patient safety incidents; SV, second victim.

Open access
after the activation of the programme. In several programmes, the schedule was negotiated with HCWs according to their needs, 37 40 45 48 52 53 56 and in some cases the location 37 45 and format (in person, phone call or email) of the sessions were also negotiated. 48 56n some cases, staffing relief at the workplace and protected time were provided to allow HCWs to attend the support programmes during their working time. 37 38 41 45 54 58 In other situations, such as in the Buddy Study Programme, the HCWs selected the peer supporter according to their preferences so they could contact if they needed support. 49o facilitate the HCWs' participation in the programme, some programmes prioritised the virtual format 41 45 46 52 and limited the duration of sessions to 60 min. 37 40 46 54 59 peer support intervention in Sweden defined the topics to approach in the sessions based on participants' suggestions and beliefs. 58This made it possible to attend to the needs of the participants and to promote their adherence to the interventions. 58n online programmes such as MISE (Mitigating Impact in Second Victims, we found that browsing, amount of time required to complete the activities and comprehension of the programme content were valued attributes to facilitate the usability of the programme. 33

DISCUSSION
In this study, we focused on identifying the highest number of reported programmes and other initiatives to support HCWs after PSIs.The majority of the included programmes are based on peer support.][63] We found that these types of programmes should be voluntary, with easy access and widely disseminated in healthcare organisations.This will make it possible to provide immediate psychological first aid after a distressful event and to overcome obstacles related to a lack of awareness of SVP and stigmatisation associated with HCW vulnerability. 50 55 63-65This is identified as a core condition for an open communication, and to establish positive relationships between peer supporters and HCWs, thereby enhancing programme adherence. 67 68Namely, willingness to give support with empathy, leadership skills, reliability, being communicative and not being judgemental are essential elements for effective peer support. 62Another study pointed out that the ability to understand others' feelings and experiences after a PSI can be beneficial to the support process, by improving emotional regulation and reinforcing the cooperation between HCWs and peer supporters. 69In our study we have identified that all these principles were mentioned to improve the effectiveness of the interventions and, therefore it should be taken in consideration in peer supporters training when implementing the programme.
We found that specific training for peer supporters was provided in most of the programmes to prepare them to adequately provide psychological support according to HCWs' needs.Training is believed to be one of the key components to consider when implementing a support programme. 50 55 63According to implementation research, it is essential for an effective programme implementation. 70any of the included studies also mentioned the importance of setting regular multidisciplinary meetings to share important learning and experiences and to keep the team motivated over time.Rosak-Szyrocka points out that having a motivated team is very important to ensure their commitment to and engagement in work. 71This study also points out that in hospitals, HCWs are particularly motivated by strong interpersonal relations and a positive atmosphere, as they foster cooperation and mutual support among the team members. 72Another study indicates that multidisciplinary teamwork is an essential element for improving outcomes at an organisational level. 73e found that active participation by leaders in the initiatives can influence the effectiveness of programmes implementation and their sustainability.4][75][76] Leaders' participation was not only important in the implementation process, but also in the development of the programmes.In particular, it can contribute to adjust the programmes to the healthcare context, facilitate the acquisition of resources and recruitment of peer supporters.
We also found that leadership engagement in HCWs/ SVs support initiatives is very important for strengthening the organisational culture towards a non-punitive response to error. Boguslavsky et al 74 refer the importance of having leaders with empathic and communication skills, that are able to listen, empower and encourage others, in line with non-blame culture principles.Therefore, the involvement of leaders with these types of skills will benefit the support programme's implementation.
Moreover, we also found that the success of the implementation is also dependent on how closely aligned it is with HCWs' needs.Therefore, HCWs should be consulted Open access and involved in the programme development process.Our results corroborate Søvold et al's findings, which highlight the importance of HCWs participating more in the decision-making process as well as in the development, implementation, testing and evaluation of the interventions, with the ultimate aim of improving their health, well-being and job satisfaction. 78Interventions that include the target population's perspectives from the first steps of development exhibit a higher level of adherence and adoption and are more sustainable over time. 70owever, HCWs are very often overloaded with duties that could be undertaken by other staff, and prevented from performing other necessary tasks that need their qualifications, with few opportunities to apply for training, develop their professionals skills and be available to participate in workplace initiatives. 73This contributes to less work satisfaction and more costs for the system. 73We found that working conditions are one of the main pillars for ensuring effective implementation and its sustainability.Providing protected time and staffing relief were identified as two of the main priorities for ensuring that, on the one hand, qualified HCWs could participate in the development and implementation of support interventions, and on the other, HCWs would be able to attend the support programmes if they needed support.Financial incentives play also an important role in keeping the support teams over time and to facilitate the programme implementation.Some evidence corroborates these findings, namely in what concerns to HCWs retention. 70 73inally, it is agreed that monitoring programme outcomes over time is essential for assessing programme effectiveness, and evaluating its progress and impact on HCWs/SVs and in health organisations. 79This process should be continuous and facilitates the ongoing improvement of the programmes. 22However, there are a limited number of studies that follow-up interventions over time.According to Wade et al, it is still not clear how much time would be necessary to monitor the impact of programmes on HCWs' skills and knowledge. 80Thus, we recommend that future programmes invest in monitoring their results over time and for longer periods.
In hospital settings, we have found that programmes frequently monitor before and after interventions, by collecting both qualitative and quantitative data.It is agreed that monitoring process should follow rigorous and feasible when assessing both types of measures. 79lthough hospital settings are increasingly investing in the monitoring process, the study of the impact of HCWs' support programmes it is still limited and unreported in non-hospital settings. 81This might be due to the insufficient emphasis on safety culture in non-hospital settings, 81 82 which could be improved by increasing PS initiatives and awareness campaigns in these contexts.
The experience from support programmes directly and not directly associated with supporting HCWs after PSIs was particularly useful to identify barriers and challenges in the access and adherence to the programmes and sustainability concerns.One of the main topics of discussion is focused on programmes' confidentiality. 50 83-85Wade et al highlighted the need to establish a consensus and build a body of evidence to evaluate these types of programmes in ethically and confidentially which involves protecting the privacy and confidentiality of the attendees of these types of programmes. 80We also highlight that the legal framework of each country can influence the success of the programmes' implementation.Professional liability is often not cited in articles describing interventions, despite its influence on the programmes and its impact on transitioning from a reactive safety culture to a generative safety culture. 86ltimately, we found that these types of programmes should be formalised and have defined structures to facilitate its sustainability and to overcome potential institutional barriers to the implementation of the programmes.Examples, such as RISE (Resilience in Stressful Events) programme, have demonstrated that the formal recognition of the support programme in all the large academic medical centre, the use of existing structures and involvement institutional stakeholders have not only strengthen its visibility within the institution, but also inspired other external health settings to implement their own support programmes. 50n summary, we have organised the main findings in online supplemental table 4, organised according to the OPERA.

LIMITATIONS
In this study, we have found that long-term evaluation of programmes it is still limited for the most part, and in some cases, evaluating the outcomes is not recognised as a priority for reasons of confidentiality and ethics.We recognise the need to strengthen the organisational culture towards a non-punitive response to error in order to overcome potential barriers to programme adherence and evaluation.It is very important to increase the follow-up time to understand the impact of these types of programmes and their effectiveness in the long term.
We evaluate all the included studies using the MMAT quality assessment tool since this tool is suitable for different types of methodologies, however, some of the criteria could not be applied in the descriptive studies.We suggest that this tool could be adapted in the future to these types of studies.CONCLUSION This is the first time that a study has focused on understanding the set of characteristics and elements necessary for a successful programme' implementation to respond to HCWs needs after PSIs, based on the fact that their success highly depends on an adequate implementation and evaluation process.
This study was inspired in the previous experience from other support programmes with the ultimate propose of guiding the implementation of HCWs support Open access programmes in health organisations and contributing for future evidence-based practice.
In summary, we concluded that programmes should be easily accessible and voluntary for all HCWs in health organisations.Dissemination should be prioritised in order to give higher level of visibility to these programmes.The effectiveness of programmes' implementation is highly dependent on the organisational culture, the active involvement of leadership and a multidisciplinary team.Training should be provided for both peer supporters and leadership members, to make it possible to respond to HCWs' needs in a more prepared and satisfactory way.Regular communication among support teams should be maintained over time to keep teams motivated and increase their retention.Moreover, it is recommended to allocate dedicated time and staffing resources to engage in these types of interventions.Establishing formalised structures and securing funding sources it is important for the programmes's sustainability.The use of existing resources can overcome potential institutional barriers.Finally, programmes should be monitored for their continuous improvement without compromising the confidentially of the data.

Figure 1
Figure 1 OPERA-The five key domains to guide HCWs' support interventions after stressful events such as PSIs.HCW, healthcare worker; OPERA, Organisational factors, People, Environment, Recommendations from other studies, Attributes; PSI, patient safety incident.

Stage 1 :
identifying the research question(s) In this study, we focus on the main research question: ► What are the key factors that contribute to an effective implementation of interventions to support HCWs after PSIs or other similar stressful situations in health organisations?To answer the primary research question, five secondary questions were formulated based on the specific objectives and outcomes of interest of the study : ► What are the organisational factors that contribute to an effective implementation of these interventions?► Who are the relevant actors that contribute to an effective implementation of these interventions?► What are the contextual factors that contribute to an effective implementation of these interventions?► What recommendations, as identified in previous studies, can be applied to effectively implement these interventions?► What are the operational attributes that contribute to an effective implementation of these interventions?Stage 2: search strategy A comprehensive search strategy using relevant electronic databases was developed with the support of a qualified research librarian.The search comprised Medical Subject Headings terms along with free-text keywords.

Table 1
Characteristics of the included studies 32his rating scale is based on Ackley et al.32