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The current situation and associated factors of the psychological capital of nurses’ second victims in China: a cross-sectional study

BMC Nursing volume 24, Article number: 506 (2025) Cite this article

Abstract

Background

The level of psychological capital of nurses’ second victims is critical to alleviate their negative experience after a safety incident. The purpose of this study is to understand the current status of psychological capital and associated factors of nurses after experiencing patient safety incidents.

Methods

In May 2024, an online survey was conducted on nurses from 2 tertiary hospitals and 2 secondary hospitals in Shanxi Province who had experienced patient safety incidents in the past year using the General Information Questionnaire, the Patient Safety Incident Characteristics Questionnaire, and the Nurses’ Psychological Capital Questionnaire, and finally 456 nurses filled out the questionnaire.

Results

A total of 423 valid questionnaires were collected, and the recovery rate of valid questionnaires was 92.76%. The total score of psychological capital of the nurses’ second victims was (89.13 ± 14.86), and the results of multiple linear regression showed that hospital level, department, the type of patient safety incident, the level of patient safety incident, and whether or not they were supported were independent associated factors of the psychological capital of the second victims (P < 0.05), which could explain 21.00% of the total variation.

Conclusion

The psychological capital of the nurses’ second victims was at a medium level. At the hospital level, the focus should be on nurses in tertiary hospitals. At the department level, the focus should be on the nurses in the oncology department. From the level of patient safety incidents, we should focus on the nurses with high event level and drug administration errors, and provide timely intervention support after the incident, so as to improve the psychological capital level of the second victims.

Clinical trial number

Not applicable.

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Background

Patient safety is a common concern for healthcare organizations around the world. Nearly 134 million adverse events are reported each year in low- and middle-income countries, resulting in 2.6 million deaths each year [1]. Health care providers who experience patient safety incidents are referred to as second victims [2]. The second victim will experience physical, psychological, and occupational negative experiences such as rapid breathing, increased blood pressure, muscle tension, increased heart rate, insomnia, guilt, anxiety, depression, intrusive thinking, and self-doubt [3], which persists and may develop traumatic stress disorder for the medical staff themselves [4]. For medical institutions, it may lead to an increase in absenteeism and turnover rates [5], affecting the stability of medical institutions. For patients, there is a risk of increased follow-up safety incidents due to staff burnout, resulting in potential patient harm [6]. As a result, the phenomenon of second victims is receiving increasing attention.

The concept of psychological capital was proposed in 2000 by the American psychologist Seligman et al. [7] based on positive psychology and positive organizational behavior. Subsequently, Luthans et al. [8] further refined the meaning of psychological capital, defining it as a positive psychological state exhibited by individuals in the process of growth and development, including four dimensions: self-efficacy, hope, optimism, and resilience. Self-efficacy refers to having the confidence to take on and put in the effort to accomplish challenging tasks. Nurses with high self-efficacy are often more confident in handling job responsibilities and finding long-term solutions [9]. Hope refers to perseverance towards a goal, realigning the path to a goal if necessary in order to achieve success. Resilience refers to not giving up in the face of adversity and being able to recover quickly and surpass. Optimism refers to making positive attributions to success now and in the future. One study showed that patient safety incidents had less psychological impact on healthcare workers with high levels of optimism [10].

Psychological capital is a person’s ability to actively appreciate the events of everyday life and expand their likelihood of success by entrusting perseverance and effort [11]. The improvement of nurses’ psychological capital level is also conducive to improving their work engagement and reducing professional burnout [12]. Study has shown that psychological capital can improve employees’ job adaptability, initiative, proficiency, and overall job performance [13]. Psychological capital is also seen as a viable set of resources that can promote an individual’s well-being in the face of adversity in life [14]. Psychological capital is an important predictor of nurses’ mental health. The level of psychological capital of nurses, especially self-efficacy, is particularly important for nurses’ mental health: nurses who feel they are able to cope with the demands of their new role are better able to handle the stress of their work, which can have a positive impact on their mental health [15]. Nurses with a high level of psychological capital can mobilize their own positive energy to cope with adverse emotional reactions and restore their mental health [16]. Nurses with a high level of psychological capital are able to maintain perseverance in the face of challenges and stress, which can help relieve stress and negative emotions [11]. The level of psychological capital is negatively correlated with the tendency to depression, and increasing the level of psychological capital of nurses can reduce their tendency to depression [17]. Our previous study found that the level of psychological capital of nurses’ second victims had a significant negative predictive effect on negative experience, that is, nurses with low psychological capital experienced a more severe degree of negative experience after experiencing patient safety events [18].

Current study on the psychological capital of second victims has shown that the experience of second victims weakens their psychological capital levels [19]. Positive psychological capital is a trait that can be developed and improved [20], so identifying the associated factors and giving targeted intervention strategies can help to reduce the degree of negative experience of the second victim. However, there is limited research on the associated factors of second victim psychological capital associated with patient safety incidents. Therefore, this study aims to investigate the current situation of psychological capital of nurses’ second victims in China and explore its associated factors, in order to provide a basis for formulating targeted intervention strategies to alleviate the negative experience of nurses’ second victims.

Methods

Study design

This is a cross-sectional research.

Sample size

The survey tools included 13 items of general data, 8 items of the Patient Safety Incident Characteristics Questionnaire, and 20 items of the Nurses’ Psychological Capital Questionnaire. The sample size should be 5 ~ 10 times the total number of items [21]. In this study, 5 times the total number of items and 20% of the invalid questionnaires were used, the sample size was (13 + 8 + 20)×5 ÷ 0.8, the final calculation of the sample size was not less than 257 cases, and the sample size included in this study was 423 cases.

Participants

Inclusion and exclusion criteria were developed with reference to Li’s [22] study.

Inclusion criteria:

(1) Obtained a nurse practice qualification certificate.

(2) Experienced a patient safety incident in the past year and experienced one or more negative experiences (anxiety, depression, impulsivity, embarrassment, guilt, self-blame and other psychological distress; physiological distress such as increased heart rate, sleep disturbances, nausea, exhaustion; professional burnout, self-doubt, resignation and other professional troubles).

(3) Informed consent to voluntarily participate in this study.

Exclusion criteria:

Rotation, advanced training, regular training and other personnel who were not formally employed in the investigation hospital.

Instruments

General information questionnaire

It was designed by the investigators according to the research objectives and literature review, including hospital level, department, gender, age, initial education, highest education, professional title, working years, employment form, number of night shifts per month, monthly income, marriage and number of children.

Patient safety incident characteristics questionnaire

It was designed by the investigator, including the type of most recently experienced patient safety incident, the level of most recently experienced patient safety incident, degree of responsibility, form of processing, whether he has been punished, whether he has been supported, whether the patient and his family understand, and the number of patient safety incident experienced in the past year. In this study, we used the classification criteria for medical safety events in the Standards for the Management of Medical Safety Adverse Events of the Chinese Hospital Association to classify patient safety incidents: I level (resulting in death or permanent loss of function of patients), II level (causing impairment of the patient’s body or function), III level (occurrence of errors but no adverse consequences to patients), IV level (no hidden events occurred) and non-grading.

Nurses’ psychological capital questionnaire (PCQ-R)

Translated and revised by Luo et al. [23], it included 4 dimensions of self-efficacy, hope, resilience, and optimism, with a total of 20 items, including 3 items of optimism, 5 items of resilience, 6 items of hope, and 6 items of self-efficacy. Each item adopted the Likert 6-level scoring method, from “completely disagree” to “completely agree”, respectively, 1 ~ 6 points, the higher the score, the better the psychological capital. The criteria for judging the average score of psychological capital items were as follows: the average score ≤ 2.25 was very low, and 2.26 ~ 3.50 was low, 3.51 ~ 4.75 was medium level, ≥ 4.76 was rated at the Higher level. The Cronbach α coefficient of this scale was 0.923, and the Cronbach α coefficient of the four dimensions was 0.718–0.890. In this study, the Cronbach α coefficient of the scale was 0.96, and the Cronbach α coefficient of each dimension was 0.91 ~ 0.93.

Data collection

In May 2024, nurses from 2 tertiary hospitals and 2 secondary hospitals in Shanxi Province were selected as the research subjects using convenience sampling. The WeChat questionnaire star was used to send and receive the questionnaire. The researchers explained the purpose, methods, inclusion and exclusion criteria of the study to the person in charge of the nursing department of the surveyed hospital, and after obtaining consent, the questionnaire QR code was sent to the person in charge of the nursing department of each hospital. After the person in charge trained the head nurse, the questionnaire QR code was distributed to the head nurse of each department, and then the head nurse of the department sent the questionnaire QR code to the clinical nurses, and finally, the nurses voluntarily filled in anonymously. The first page of the questionnaire was set with a frontispiece, including informed consent, contact information, etc., and the questionnaire was set up with a breakpoint answering function, all options were required questions, and each respondent could only submit one questionnairein. A total of 456 questionnaires were submitted this time, and 423 valid questionnaires were obtained, and the questionnaire response rate was 92.76%, excluding the questionnaires with a response time of < 2 min, obvious logical errors in the options, and the questionnaires concentrated on the same option.

Data analysis

Excel software was used for data entry, and SPSS27.0 software was used for statistical analysis. Normally distributed measurement data were expressed as mean ± standard deviation (X ± SD), and count data were expressed as frequency and percentage. The two-sample t-test was used for comparison between groups satisfying the normality and homogeneity of variance, and the one-way ANOVA was used to compare the normality and variance homogeneity between multiple samples, the LSD method was used for post-hoc comparison, otherwise the Kruskall Wallis test was used, all pairwise tests were used for post-hoc comparisons. Multiple linear regression was used to compare the statistically significant factors by univariate analysis, and the associated factors of psychological capital of nurses’ second victims were analyzed.

Results

Basic information about the nurse

General information

The general information of the 423 nurses was shown in Table 1.

Table 1 Comparison of psychological capital scores of nurses’ second victims with different general data (X ± SD, n = 423)
Full size table

Information related to patient safety incidents

Information on the most recent patient safety incidents experienced by 423 nurses was detailed in Table 2.

Table 2 Comparison of psychological capital scores of nurses’ second victims with different patient safety incident (X ± SD, n = 423)
Full size table

Current status of psychological capital of nurses’ second victims

The total PCQ-R score of the second victim was (89.13 ± 14.86), of which 0.95% were at very low level, 10.17% were at low level, 44.68% were at medium level, and 44.20% were high level. See Table 3 for details.

Table 3 Psychological capital of nurses’ second victims and their scores in each dimension (n = 423)
Full size table

Analysis of the associated factors of the psychological capital of the nurses’ second victims.

Univariate analysis of the associated factors of psychological capital of the nurses’ second victims.

Comparison of the psychological capital scores of nurses’ second victims with different general data

The total psychological capital scores of the second victim of nurses were statistically significant (p＜0.05) in different hospital levels (t = 9.359, p = 0.002), department (H = 43.645, p < 0.001), age (H = 19.444, p = 0.003), initial education (H = 11.376, p = 0.010), professional title (H = 7.929, p = 0.047), marital status (H = 11.216, p = 0.004), number of children (H = 14.937, p = 0.002), employment form (F = 5.042, p = 0.007), number of night shifts per month (H = 16.181, p = 0.003), and working years (H = 18.146, p < 0.001). See Table 1 for details.

Comparison of psychological capital scores of nurses’ second victims of different patient safety incidents

The results showed that the total psychological capital scores of nurses’ second victims were significantly different in terms of the type of recent patient safety incident (F = 2.015, p = 0.029), the level of recent patient safety incident (F = 13.685, p < 0.001), degree of responsibility (F = 2.854, p = 0.037), and whether they were supported (F = 0.12.554, p < 0.001), as shown in Table 2.

Multiple linear regression of the psychological capital of nurses’ second victims

Multiple linear regression was performed with the total score of psychological capital of the second victim of nurses as the dependent variable and the statistically significant variables in the univariate analysis as the independent variables, and the assignment was shown in Table 4. The results showed that hospital level, department, type of patient safety event, patient safety event level, and whether they were supported were independent associated factors affecting the psychological capital of nurses’ second victims, which could explain 21.00% of the total variation, as shown in Table 5.

Table 4 Assignment of independent variables
Full size table
Table 5 Multiple linear regression analysis of the psychological capital of nurses’ second victims (n = 423)
Full size table

Discussion

The psychological capital of the nurses’ second victims was at a medium level

The results of this study showed that the total psychological capital score of the nurses’ second victims was (89.13 ± 14.86), which was at a medium level, which was lower than the results of Gao’s [24] study on the psychological capital of 1064 nurses. It may be that due to the experience of the second victim, nurses may experience negative emotions such as self-blame, regret, and depression after experiencing a patient safety incident, or worry about the patient’s adverse outcome [25], which in turn affects the level of psychological capital. The scores of the four dimensions of psychological capital from high to low were self-efficacy (4.57 ± 0.78), hope (4.43 ± 0.81), resilience (4.40 ± 0.84), and optimism (4.36 ± 0.96). The ranking of the four dimensions is consistent with the results of Zhu’s [26] study on the psychological capital of the nurses’ second victim in the operating room. The high scores of self-efficacy and hope in this study indicate that the nurses’ second victim in this survey is confident that they can solve the problems and challenges encountered in their work, and have clear goals in the work process. The lowest score in the optimistic dimension is consistent with the results of Li [27], which may be related to the dual pressure of human resource shortage and service demand increase, and the uncertainty of future career development prospects.

Associated factors of the psychological capital of nurses’ second victims

The results of this study showed that hospital level, department, age, initial education, professional title, marital status, number of children, employment form, number of night shifts per month, working years, the type of patient safety incident, the level of patient safety incident, degree of responsibility, and whether they were supported were the associated factors of the psychological capital of the nurses’ second victims, while the hospital level, department (oncology, infectious disease), type of patient safety incident (pressure ulcer, fall/fall), level of patient safety incident, and whether they were supported were independent associated factors of the psychological capital of the nurses’ second victim.

（1）Hospital level

Hospital level was an independent associated factor on the psychological capital of nurses’ second victims (P < 0.05), and the psychological capital level of nurses’ second victims in secondary hospitals was higher than that in tertiary hospitals, which was inconsistent with the results of previous study that hospital level had no effect on nurses’ psychological capital [24]. The reason may be: first, with the development of medical technology, tertiary hospitals will take the lead in introducing advanced medical technology and equipment, which puts forward higher requirements for the professional ability of nurses, and nurses need to continue to learn new knowledge and master new skills. Second, there are many patients in tertiary hospitals, the condition is complex, and nurses have a large workload, often working overtime and training, which may lead to physical and mental exhaustion of nurses. Third, there is fierce competition for promotion in tertiary hospitals, and nurses may feel uncertain about their career prospects, which affects their optimism.

（2）Departments

The department was an independent associated factor of psychological capital (P < 0.05), and the psychological capital level of the second victim of the oncology nurse was lower than that of the second victim of the internal medicine nurse, while the psychological capital level of the second victim of the infectious disease nurse was higher. Compared with internal medicine nurses, oncology nurses are faced with a special and sensitive group - cancer patients. They are not only subjected to the increasing work pressure and workload of patients, but also are often directly exposed to the negative emotions of critically ill and dying patients and their families, which are often full of pain, helplessness, and psychological trauma [28]. Patients and their families face more life and death problems, and are prone to accumulate negative emotions and occupational grief. This is consistent with the results of Chen Wei et al. [29], and the results of negative emotions such as anxiety and depression in oncology nurses are much higher than those in general departments. On the other hand, since the outbreak of the novel coronavirus, nurses in the department of infectious diseases, as front-line prevention and control personnel in the fight against the epidemic, have grown rapidly and have mastered the management ability and occupational protection skills of infectious diseases. As the epidemic prevention and control has entered the normalization stage, the domestic epidemic has been more effectively controlled, and the number of severe new crown pneumonia patients has decreased significantly. This series of positive changes has enabled the infectious disease nurses to carry out nursing tasks more confidently, positively and optimistically in their daily work, and their psychological state is relatively better.

(3) The type of patient safety incident

The type of patient safety incident was an independent factor associated the psychological capital of nurses’ second victims (P < 0.05), and nurses’ second victims who experienced pressure ulcers and falls/beds fell had higher levels of psychological capital compared with medication errors. At present, hospitals at all levels have strengthened the monitoring of pressure ulcers and the assessment of related knowledge, and established a special nursing group for pressure ulcers [30], and the nursing staff has a good grasp of the risk assessment, prevention, and nursing knowledge of pressure ulcers. Coupled with the application of novel wound dressings [31]. At present, the incidence of pressure ulcers is decreasing, and most of them are unavoidable pressure ulcers, which has little impact on the psychological state of nurses. The mechanism of fall/fall events has the characteristics of multi-factor interaction, it may be related to the potential safety hazards of environmental facilities, the lack of safety awareness of patients and their families, etc., and the weight of nurses’ responsibility in the fall/fall event is lower than that of nurses who are directly responsible in the drug administration error event, so it has little impact on the psychological state of nurses.

(4) The level of patient safety incident

The level of patient safety incident experienced by nurses’ second victims was an independent factor associated psychological capital (P < 0.05), and the higher the level of patient safety incident, the lower the level of psychological capital of nurses’ second victims. The reason may be that the higher the level of the patient’s safety incident, the greater the harm caused to the patient, the greater the perceived stress and responsibility of the second victim, the longer the degree and duration of negative experience,[32,33,34] and the greater the impact on the psychological state of the nurse’s second victim.

(5) Whether they were supported

Whether nurses were supported after a patient safety incident was an independent associated factor of psychological capital (P < 0.05), and nurses who got support after safety events had a higher level of psychological capital. Studies have shown that effective social support is critical to improving the negative experience of nurses’ second victims, and that nurses’ second victims who receive support are more likely to make constructive changes.[35,36,37,38] After the incident, if the nurse feels the support and care from the superiors, the negative emotions such as guilt, self-blame, and anxiety can be alleviated. Talking to colleagues to gain understanding and reassurance and venting negative feelings helps to reduce psychological pressure.

Conclusion

The psychological capital of the nurse’s second victim is at a medium level. This study suggests that nursing managers should focus on the second victim of nurses in tertiary hospitals from the hospital level. At the department level, attention should be paid to the nurse’s second victim in the oncology department. From the perspective of patient safety incidents, we should focus on the nurses’ second victims with high event levels and medication errors, and provide timely intervention support after the incident, so as to improve the psychological capital level of nurses’ second victims.

Strengths and limitations

First, this study explores the current situation and associated factors of the psychological capital of nurses’ second victims, which is a topic that is rarely reported. Additionally, this study clarifies the associated factors of psychological capital and provides a reference for future psychological capital intervention. However, some limitations should be taken into account: first, this study is a cross-sectional study and focuses on correlation analysis rather than causal analysis. Second, the dependent variable only included the characteristic factors of the patient safety event. The third is that the investigation cannot reflect the law of changes in psychological capital over time. In the future, longitudinal studies are needed to clarify the changes in the psychological capital of nurses’ second victims, and provide a basis for formulating targeted intervention strategies.

Data availability

The data are available from the authors upon reasonable request.

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Acknowledgements

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Funding

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Authors and Affiliations

  1. Emergency Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, 030032, China

    Zhuoqing Deng, Hongyan Zan & Ya‘nan Zhang

  2. Department of Neurology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences,Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, NO. 99, Longcheng Street, Xiaodian District, Taiyuan, 030032, People’s Republic of China

    Qianfei Li

  3. Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, 030032, China

    Xiaohong Zhang

  4. Central Operating Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, 030032, China

    Zhiheng Gao

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Contributions

All authors conceptualized the study. Z.G and Y.Z conducted the data collection. Z.D and Q.L conducted the data analysis and interpretation, as well as drafted and revised the manuscript. H.Z and X.Z provided critical revisions for important intellectual content. All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Qianfei Li.

Ethics declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. The study has received ethical approval from the Research Ethics Committee of Shanxi Bethune Hospital: YXLL-2024-139. All participants provided informed consent. Participant involvement was voluntary. Data were carefully analysed to ensure the anonymity, privacy, and confidentiality of the participant nurses.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Deng, Z., Li, Q., Zan, H. et al. The current situation and associated factors of the psychological capital of nurses’ second victims in China: a cross-sectional study. BMC Nurs 24, 506 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03156-z

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12912-025-03156-z

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BMC Nursing

ISSN: 1472-6955

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