The review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines,12 and specific inclusion criteria were developed to identify relevant papers13–15:

• (1)

  phenomena of interest: NMHP-DM;

• (2)

  types of participants: this review considered all studies that included NMHP, such as nurses, midwifes, physical therapists, medical laboratory personnel, nutritionists, medical technicians, etc.;

• (3)

  types of outcome measures: the aim of this review was to identify if exists a DM performed by NMHP, what are the reasons of NMHP-DM, what defensive practices are performed by NMHP and what are the effects;

• (4)

  types of studies: this review considered any qualitative and quantitative research studies that explored DM carried out by NMHP.

Identification of articles was conducted in two stages. Studies were searched in Medline, Embase, Cinhal and Cochrane Library from the start of each database to April 12, 2018. The following keywords and MeSH (Medical Subject Headings) terms were used in the search: “Defensive Medicine”, “Defensive practices”, “paramedical personnel”, “allied health occupations”, “health care personnel”, “nurses”, “midwives”, “physical therapist”, “medical laboratory personnel”, “nutritionists”, “emergency medical technicians” and “dental auxiliaries”. Boolean Operators were used to link keywords (Attachment A). No language restrictions were applied. In a second research step, a manual review of reference lists from relevant articles identified in the first step was performed. Unpublished articles were not searched. After duplicates removal, articles were screened independently by two reviewers, and if consensus was not reached, a third researcher was involved. Papers evaluated as eligible on the basis of their abstract, were read entirely by the reviewers to establish the compliance with the inclusion criteria. Every step of the research was supervised by two experts in defensive medicine, and the choice of include studies in the qualitative analysis was taken with their agreement. An ad hoc framework was built to collect data.

Every research paper was assessed for quality and risk of bias (Tables 1 and 2). Quality appraisal of qualitative studies were performed using a standardized framework outlined by the EPPI-Center.16,17 Non-intervention studies were evaluated according to six criteria: (1) an explicit account of theoretical framework and/or inclusion of a literature review that outlines the rationale for the intervention; (2) clearly stated aims and objectives; (3) a clear description of context, which includes details about important factors for interpreting results; (4) a clear description of sample; (5) a clear description of methodology, including systematic data collection methods; (6) inclusion of sufficient original data to mediate between data and interpretation. For each criterion that was met a score of one was given. Studies’ quality was evaluated “good” if all the criteria were met, “moderate” if the score was 4 or 5, “low” if the score was 3. Studies with score 1 or 2 were excluded because of their poor quality. Quality evaluation of cross-sectional studies was carried out using the seven criteria of the adapted Newcastle-Ottawa Scale (NOS)18 and studies’ quality degree was evaluated assigning a score of one for each met criteria. Quality of the studies was judged “good” if at least 5 criteria were met, “moderate” if the total score was 3 or 4, and “low” if the score was 2 or lower.

Defensive practices in health care settings are not performed only by physician, but also by non-medical health professionals.19–32 Defensive behaviors are practiced by midwives19,21–23,25,27–31 and by nurses working in nursing homes20,32 and in mental health services.26 Frequency of midwives who admitted to have changed their practice in a protective manner ranges from 34%21 to 53%.30 Data about frequency of defensive practice carried out by nurses are not available.

Weiner and Kaiser-Jones32 outlined two different typologies of defensive practices adopted by NMHP: “institution-protective strategies” (institutional strategic plans carried out to protect the structure against a damage of image or to avoid state surveyors’ admonitions) and “self-protective strategies” (practices performed by NMHP to protect themselves from litigation or from negative judgments). Midwives adopt only self-protective strategies,19,21–23,25–31 whereas nursing homes personnel tend to take both strategies.20,24,32

The main reason that induces NMHP to perform defensive practice is the fear of litigation.20–23,25,29–32 Malpractice suit are perceived as common, and health professionals believe to have to protect themselves. In some of them the fear of claim is not only abstractly based on the perception of a potential risk, but has developed following direct lawsuit experiences.21,28,31 The problem of lawsuits is enhanced by the changes occurred in liability insurance, which have increased their costs and decreased their coverage.27 It is easy to understand how fear of litigation can become widespread in this climate of ever more common claims and lower insurance coverage, especially in the obstetric field, one of the most affected by malpractice litigations.8 A further problem is the relationship between patients and professionals. The increasingly clients’ expectations, no longer able to consider the possibility of inauspicious outcomes, added to the resonance given by mass-media to malpractice events, create a climate of distrust which hinders a constructive relationship between patient and health care professionals, and contribute to generate fear of litigation among professionals.20,29 Another type of judgment feared by NMHP is that of colleagues (other NMHP and physicians).19 This shows the persistence of a blame environment where error is seen as a fault to be punished rather than a learning and improvement opportunity. An additional reason of NMHP-DM, observed especially in nursing homes personnel, is the fear of state surveyors’ admonitions.19,20,24,32 In this sense, encounters with state regulatory, advocacy and legal bodies are not perceived as an opportunity of improvement and professional development, but only as an authority tool to find structures’ weaknesses and subject them to sanctions. It is clear that this perception can lead to opportunistic behaviors, such as falsification or omission of clinical notes,32 or even inappropriate treatments such as transfer of dying patients to acute care settings or to aggressive resuscitation attempts.24

NMHP perform both positive and negative DM. The most common strategy carried out by NMHP is the excessive recording of information in the clinical documentation of patients.20,21,25,27–32 The 41.5% of midwives interviewed in a study stated to have improved documentation because of fear of litigation.30 In another study, the 8% of midwives declared to have implemented documentation as a result of the experience of lawsuit.21 NMHP feel safer recording everything and collecting consent for all procedures (7.6% of interviewed midwives), in order to avoid to be accused of negligence if an adverse outcome occurs.29,30 This is a time-consuming activity, which limits the time spent directly with patients. In some cases, internal roles to mask the truth are developed, leading NMHP to write down untrue clinical notes with the aim of not incurring in state surveyors’ admonishments. In one of the analyzed study, nursing homes’ personnel admitted to write untrue clinical notes in order to protect the institution in case of critical patient's conditions in which usual guidelines could not be applied.32 In other cases, the problem of inapplicability of general guidelines is faced by changing protocols and internal guidelines for clinical practice. This strategy is employed by the 18% of midwives who have had direct experience of lawsuit.21 Other NMHP believe that rigid adherence to guidelines and unit policies could protect themselves from litigation.20,23,28,30,31 In a study, 2% of midwives declared they had adopted this strategy.30 This is a positive factor, which allows to prevent untoward patient-care-related events,20 if it does not result in excessive inflexibility that can lead to treatments based on policies rather than on individualized care plans, losing sight of patient's centrality in the care pathway.29,31 In some cases, DM hinders the implementation of evidence-based practices.19,22 Examples of this problem are the practice of routine unnecessary episiotomy19 and the extensive use of electronic fetal monitoring (EFM) even in low-risk patients, in whom it would be discouraged.22,23,28–31 The increasing dependence on technical equipment and the growing use of diagnostic tests,25,27,29 recorded in the 36% of midwives in a study27 and in the 1.3% in another study,30 is linked to the need to have a supporting documentation if an adverse event occurs, in order to avoid the accusation of negligence.29 But the increasing use of biomedical technology in birth does not reduce maternal and newborn mortality and morbidity.33 The widespread use of EFM causes the identification of sub-normal findings that still determine concern among midwives. This leads to an increasing number of consults with collaborating physician (between the 4% and the 27% of midwives interviewed had made this change in their professional practice) and to a greater number of referrals required for probable cesarean section (9–19% of the interviewed midwives).21,23,28–30 Some consequences are the greater intervention rate in the obstetric field,22,23,29,31 with obvious effects such as increased morbidity and pain for the mother and rise of costs,31,34 and alteration of relationship between midwives and physicians.23 The increased medical role in the care of “normal” laboring women makes midwives feel deprived of their working autonomy, and this leads to job dissatisfaction and distress.23,28 Deterioration of relationship can be observed also between “established” midwives and “new comers”, that are seen not enough cautious and thus a possible danger source for the whole staff, and also between midwives and patients, when pregnant women do not want to conform to professional recommendations.23 Similar problems can be observed in nursing personnel: fear of litigation leads them to increasing impatient supervision, rate of medical consults requested by nurses, inappropriate transfer of dying patients to acute care settings and inappropriate aggressive resuscitation attempts.24,32 These practices cause a large waste of financial resources and the great number of consults required, sometimes without real needs, makes nurses seem incompetent in the eyes of doctors and contributes to a poor nurse–physician relationship.32 Midwives, having greater professional autonomy than other NMHP, practice also negative DM, decreasing number of high-risk patients cared for (12–23% of midwives performing DM) and stopping offering or attending vaginal birth after cesarean (28% of the midwives that had changed their practice based on fear of liability).21,27 An extreme defensive practice of some midwives is the avoidance of working in labor ward and small units, and their relocation to antenatal or postnatal capacity or to non-clinical areas (3% of the interviewed midwives).21,23,28,29

Some critical issues concerning the internal validity of the present study should be stated. Due to the heterogeneity of the included studies, which collected data through interviews and different ad hoc questionnaires, a comparative synthesis of results was not possible. Heterogeneity in terms of country (United Kingdom,22,28,30,31 Sweden,25 United States,20,21,24,32 Argentina,19 Australia,23 New Zealand26,29) and time period (ranging between 1985 and 2009) in which the studies have been conducted also affects the external validity of the study, because the phenomenon of litigation might vary depending on different way of claims management, coverage of insurance policies and differences in professional tasks. In addition, subjects studied were professionals working in different health settings (hospitals,19,23,25 community settings26,29–31 or both of them26,29–31), and in different health areas (maternal health,19,21–23,25,27–31 mental health,26 and elderly care20,24,32), but not all categories of NMHP were represented (for example, no studies were identified about DM practiced by general hospitals’ nurses). For all these reasons, the present study is not able to describe the true extent of the problem and the correlations between causal factors and effects. It is only possible to draw interesting reflections.