When informal caregivers become double victims: Development of a multilevel conceptual framework for safer home care.

Background: As healthcare increasingly shifts toward the home, the burden of care often falls on informal caregivers-family members, friends, or acquaintances-who frequently lack formal training and systemic support. This transition has intensified the risk of safety incidents in home care settings, including medication errors, falls, and other preventable harms. While patient safety researchers have traditionally focused on clinical environments, far less attention has been given to safety incidents in home care and to their cascading consequences for both care recipients and informal caregivers, who can become double victims (i.e., experiencing both the emotional impact of harm to a loved one and distress associated with their own involvement in the event). Purpose: To develop and internationally appraise a safety-oriented, multilevel explanatory framework for safer home care provided by informal caregivers, specifying how conditions across ecological levels shape everyday caregiving processes, safety incidents, and interdependent consequences for care recipients and informal caregivers. Methods: In this discursive paper, we have described the development of a conceptual framework and its international expert appraisal using a modified Delphi approach. The framework was co-developed within the BetterCare European Cooperation in Science and Technology Action CA22152 through interdisciplinary expert deliberations and a relationship-oriented narrative synthesis of literature identified in PubMed and CINAHL in September 2024. The modified Delphi process appraised the content relevance and cross-contextual interpretability of the principal framework components. Results: Thirty-six experts from 19 countries participated in the Delphi appraisal. Consensus was achieved across all framework components in the first round. The final conceptual synthesis, termed the Double Victim Ecosystem Framework for Home Care Safety (DOVE Model), integrates Donabedian's structure-process-outcome logic with a social ecological perspective. At the micro-level, care-recipient needs, informal caregiver capacities and vulnerabilities, dyadic-relational conditions, and the home environment form an interdependent structural configuration that shapes everyday caregiving and care-coordination processes. Meso-level system capacity and professional support processes, together with macro-level policy, legal, sociocultural, and socioeconomic structures, may buffer or amplify these pathways. Safety incidents represent proximal safety outcomes that may generate cascading clinical, psychological, physical, and relational consequences, including the Double Victim Phenomenon. Conclusion: Safety in informal home care is a dynamic, multilevel capacity to anticipate and reduce avoidable harm, respond effectively when harm emerges, and support recovery and learning. The DOVE Model highlights the need for coordinated multilevel strategies to prevent safety incidents, strengthen caregiver preparedness, and provide structured support following safety incidents.