What this article is about
In brief
In a survey of 233 Chinese nurses who had experienced adverse patient events, nearly all wanted psychological support, and active (deliberate) rumination — but not invasive (intrusive) rumination — significantly helped explain their post-traumatic growth. The cross-sectional design means these are associations, not...
For nursing students
Study summary
When a nurse is involved in or witnesses an adverse patient event — a medication error, a code that goes wrong, an unexpected death — the nurse can become what researchers call a "second victim." The patient is the first victim of the event, but the nurse can carry lasting psychological injury from it too: guilt, self-blame, anxiety, sleep problems, and doubts about their own competence. This 2022 cross-sectional study, published in Frontiers in Psychology, looked at 233 nurses from five general hospitals across Eastern, Central, and Southern China who had experienced or witnessed an adverse nursing event. The researchers wanted to know two things: how much psychological trauma these nurses were carrying, and whether the way nurses mentally replay the event — a process called rumination — helped or hurt their recovery.
The nurses completed an online survey using three validated Chinese-language tools: the Second Victim Experience and Support Scale (which measures distress and support needs), the Event-Related Rumination Inventory (which separates rumination into two types), and the Post-Traumatic Growth Inventory (which measures positive psychological change after adversity). The rumination scale is the key idea to understand here. Researchers split rumination into two kinds: active (or "deliberate") rumination, where a person consciously thinks through what happened to make sense of it and learn from it, and invasive (or "intrusive") rumination, where distressing memories of the event pop into the mind unwanted and uncontrolled.
The results showed nurses were, on average, carrying real psychological weight. Distress item scores for worry, upset, and self-blame all averaged above 4.5 on a 5-point scale, and physical symptoms such as insomnia and appetite disturbance were also elevated. Nearly all of them — 95.7% — said they needed psychological support after the event. Yet only about a quarter had ever even heard the term "second victim," showing how little this experience is named or discussed in everyday nursing practice.
The study also found that nurses showed a meaningful level of post-traumatic growth (PTG) — positive changes such as a deeper appreciation of life or stronger relationships that can emerge after struggling with hardship. Statistically, psychological trauma was positively correlated with rumination and negatively correlated with PTG, meaning more distress was generally linked to less growth overall. But the real story was in the mediation analysis: active rumination significantly helped explain the path from trauma to growth, while invasive rumination did not have a significant effect on that path. In plain terms, nurses who deliberately, constructively processed what happened to them were more likely to grow from the experience, while nurses whose minds were simply replaying disturbing images did not show the same benefit — but that intrusive replaying also didn't clearly block growth in this sample, which surprised the researchers somewhat, since prior trauma research on more severe events often finds intrusive rumination actively harmful.
For nursing students and working nurses, this study offers a concrete, evidence-based way to think about recovering from a bad clinical event. It suggests that simply avoiding thinking about a difficult incident, or only experiencing unwanted flashbacks, is not enough for growth — nurses may benefit more from structured, reflective processing (debriefing, mentorship conversations, guided reflection, journaling) that helps them actively make sense of what happened rather than just relive it. It also highlights an organizational gap: the vast majority of these nurses wanted psychological support, but the concept of "second victim" itself was unfamiliar to most, suggesting hospitals may not be naming or addressing this need directly. As always with a single cross-sectional study from one country's hospital system, these findings describe an association at one point in time, not a guaranteed cause-and-effect relationship, and should be read as one piece of a larger conversation about supporting nurses after traumatic clinical events.
Original publication
Source abstract and study details
Read the source abstract
Background: Nurses can experience psychological trauma after adverse nursing events, making it likely for them to become second victims (SVs). This negatively impacts patient safety and nurses’ development. This study aims to understand the status of psychological trauma and recovery of nurses as SVs in domestic China and examine the influencing mechanism of cognitive rumination during their recovery from psychological damage.Methods: This was a cross-sectional survey. An online questionnaire was completed by 233 nurses from across China. Data were collected using Chinese versions of the Second Victim Experience and Support Evaluation Scale, the Incident-related Rumination Meditation Questionnaire, and the post-traumatic growth (PTG) Rating Scale. Descriptive statistics, correlation, and regression, as well as mediation analysis, were used for different analyses in this study.Results: Participants experienced apparent psychological traumas (4.65 ± 0.5583) with a certain degree of PTG (76.18 ± 16.0040); they reported a strong need for psychological support (95.7%). Psychological trauma was positively and negatively correlated with rumination and PTG (r = 0.465, p < 0.001; r = −0.155, p < 0.05) respectively. Both psychologically impaired experience and rumination had significant predictive effects on participants’ PTG (both, p < 0.001). Nurses’ active rumination significantly mediated their psychological recovery from trauma to PTG (p < 0.05), but the effect of invasive rumination was not significant (p > 0.05).Limitation: The specific manifestations of the mechanism of invasive rumination are not clarified in this study.Conclusion: The present study investigated the psychological trauma of SV nurses as well as their support needs, and explored the role of cognitive rumination in the psychological repair and PTG of SV nurses. Results showed that SV nurses’ active rumination on adverse nursing events could promote their recovery from psychological trauma, but invasive rumination could not. This study provides a trauma-informed approach to care at the clinical level for nurses who experience psychological trauma caused by adverse events.
Reviewed findings
Main findings
- Among 233 Chinese nurses who had experienced or witnessed an adverse nursing event, average psychological distress scored 4.65 ± 0.5583, with worry, upset, and self-blame each exceeding 4.5 on a 5-point scale.
- 95.7% of nurses reported needing psychological support after the event, yet only 26.6% had ever heard of the 'second victim' concept.
- Psychological trauma was positively correlated with rumination (r = 0.465, p < 0.001) and negatively correlated with post-traumatic growth (r = −0.155, p < 0.05).
- Both psychological trauma and rumination significantly predicted post-traumatic growth (both p < 0.001).
- Active rumination significantly mediated the pathway from psychological trauma to post-traumatic growth (the mediated path accounted for roughly 35% of the total effect, |a2b2/c'| = 0.3469, p < 0.05), while invasive rumination's mediating effect was not statistically significant (p > 0.05).
Using the findings
Practice considerations
- Structured, active reflection on an adverse event — such as guided debriefing or reflective journaling — may support nurses' psychological recovery more than passive replaying of the event alone, based on this study's mediation findings.
- Given that 95.7% of surveyed nurses wanted psychological support after an adverse event, healthcare organizations should consider building accessible, proactive support pathways rather than assuming nurses will self-identify their needs.
- Because only 26.6% of nurses recognized the term 'second victim,' educating clinical staff and leadership about this concept may help normalize seeking support and reduce stigma around post-event distress.
- Nurse managers and educators could use these findings to design post-incident debriefing protocols that intentionally promote active, sense-making reflection rather than open-ended discussion alone.
- Since invasive rumination did not significantly aid recovery in this sample, interventions that specifically help nurses shift from intrusive, unwanted replaying toward deliberate processing may be a useful clinical target, though this remains an area needing further study.
For educators
Teaching and appraisal notes
This cross-sectional survey study (Sun, Deng, Xu, & Ye; Frontiers in Psychology, 2022) examined the second victim phenomenon among 233 nurses from five general hospitals in Eastern, Central, and Southern China, focusing on the mediating role of cognitive rumination between psychological trauma and post-traumatic growth (PTG). The sample was predominantly female (approximately 96.6%), with a mean age of 41.53 ± 6.37 years. Nurses were recruited via an online questionnaire distributed institutionally over roughly two weeks in July 2020, and all had personally experienced or witnessed an adverse nursing event.
Three validated Chinese-language instruments anchored the design: the Chinese Second Victim Experience and Support Assessment Scale (C-SVEST, 24 items measuring psychological/physical distress and occupational difficulties), the Chinese Event-Related Rumination Inventory (C-ERRI, 20 items distinguishing active/deliberate from invasive/intrusive rumination), and the Chinese Post-Traumatic Growth Inventory (C-PTGI, 21 items across five growth dimensions). Analyses included descriptive statistics, correlation, regression, and formal mediation analysis — a methodologically appropriate progression for testing whether rumination type mediates the trauma-to-growth pathway.
Key quantitative results worth foregrounding in class discussion: mean distress score 4.65 ± 0.5583 (the highest-scoring items — worry, upset, and self-blame — each exceeding 4.5 of 5, with physical-distress items such as insomnia and appetite disturbance also elevated); mean PTG score 76.18 ± 16.0040; and a striking 95.7% reporting a need for psychological support, against only 26.6% who had even heard the term "second victim" — a gap worth highlighting as an institutional awareness failure independent of the mediation findings. Psychological trauma correlated positively with rumination (r = 0.465, p < 0.001) and negatively with PTG (r = −0.155, p < 0.05). Both trauma experience and rumination significantly predicted PTG (p < 0.001 for both). Critically, the mediation model showed active rumination significantly mediated the trauma-to-PTG pathway (the mediated path accounted for approximately 34.7% of the total effect, |a2b2/c'| = 0.3469, p < 0.05), while invasive rumination's mediating effect was not significant (p > 0.05).
This asymmetry is the paper's central teaching point and diverges somewhat from prior trauma literature on more severe traumatic events, where invasive rumination is typically found to actively impede growth rather than simply show a null mediating effect. Instructors can use this as a prompt for discussing boundary conditions of rumination theory — whether occupational/adverse-event trauma among nurses behaves differently from trauma following major life-threatening events, and what contextual or cultural factors (workplace culture, event severity, time since event, single time-point measurement) might explain the divergence.
Methodologically, the cross-sectional design limits causal inference: mediation analysis in cross-sectional data assumes but cannot confirm temporal precedence, so "rumination causes growth" claims should be presented to students as plausible, not proven. The sample is geographically and culturally specific (three regions of China, single time point, July 2020, self-report online survey), constraining generalizability to other health systems, including Canadian settings. The authors themselves note that the specific mechanisms underlying invasive rumination's non-significant effect remain unclarified and call for longitudinal or experimental designs. For appraisal exercises, this is a strong case study in distinguishing statistically significant correlation/mediation findings from clinically actionable causal claims, and in identifying when a null result (invasive rumination not significantly mediating) is itself a noteworthy finding rather than an absence of one. It also offers a natural bridge to discussing trauma-informed organizational support structures, since the support-need/awareness gap (95.7% vs. 26.6%) speaks directly to practice and policy even independent of the mediation statistics.
Critical appraisal
Limitations
- The cross-sectional, single-time-point design means the mediation analysis cannot establish causal direction between rumination and post-traumatic growth.
- The sample of 233 nurses was drawn from five hospitals in Eastern, Central, and Southern China, limiting generalizability to nurses in other countries, including Canada, with different healthcare systems and cultures.
- Data were collected via self-report online questionnaire during a two-week window in July 2020, which may introduce recall bias and does not capture how distress or rumination evolves over time.
Classroom use
Discussion Questions
- How does the concept of the 'second victim' apply to adverse events you have witnessed or heard about in clinical placements, and had you encountered this term before reading this study?
- Why might active rumination help post-traumatic growth while invasive rumination shows no significant effect, and how might you explain this difference to a colleague?
- What does the gap between 95.7% of nurses wanting psychological support and only 26.6% recognizing the term 'second victim' suggest about how healthcare organizations currently address this issue?
- Given the cross-sectional design, what would need to change about this study's methodology to test whether active rumination actually causes post-traumatic growth, rather than simply correlating with it?
- How might a nurse manager design a debriefing process after an adverse event that intentionally encourages active rather than invasive rumination?
- What cultural, organizational, or health-system factors might make these findings from Chinese hospitals apply differently, or not at all, to Canadian nursing settings?
Source-based questions
Frequently asked questions
What does 'second victim' mean in nursing?
It refers to a nurse or other healthcare worker who experiences psychological distress, such as guilt, anxiety, or self-blame, after being involved in or witnessing an adverse patient event, since the patient is considered the 'first victim' of the event.
Does rumination help or hurt a nurse's recovery from a traumatic clinical event?
According to this study, it depends on the type: active, deliberate rumination significantly helped explain nurses' movement toward post-traumatic growth, while invasive, intrusive rumination did not show a significant effect on recovery.
How many nurses were surveyed in this study on second victim recovery?
The study surveyed 233 nurses from hospitals across China using an online questionnaire.
What is post-traumatic growth in the context of nursing?
Post-traumatic growth (PTG) refers to positive psychological changes, such as a deeper appreciation of life or improved relationships, that some individuals experience after struggling with a difficult or traumatic event, including adverse events at work.
Can this study prove that active rumination causes post-traumatic growth in nurses?
Not definitively. Because the study used a cross-sectional design, measuring everything at one point in time, it can show a significant statistical mediation relationship but cannot confirm cause and effect.