Assessing safety culture and second victim experience following adverse events among Romanian nurses: a cross-sectional study
The definition of adverse events (AEs) in healthcare can differ significantly across institutions and studies. For instance, the National Health System (NHS) in the United Kingdom defines it as “any unintended or unexpected occurrence that could potentially harm or has harmed one or more patients receiving NHS-funded healthcare,” thus encompassing incidents that cause no harm or near misses . In contrast, the Harvard Medical Practice Study defines it as an injury resulting in prolonged hospitalization, disability, or death caused by healthcare management rather than the underlying disease . For the purpose of this study, we utilized the definition provided by the World Health Organization, which states that an AE is defined as an incident that causes harm to a patient and is an unexpected and unintentional clinical outcome of healthcare. This outcome may or may not be related to a clinical error . For serious AEs, we employed the classification proposed by Field et al. . The emphasis in healthcare management is placed on fostering a safety culture that learns from AEs, alongside the significance of systematic methods for identifying and measuring these occurrences . AEs encompass a range of occurrences, including medication errors, surgical complications, and healthcare-associated infections . Medication-related AEs, also known as adverse drug reactions, are particularly prevalent and can affect various body systems, including the central nervous, gastrointestinal, and cardiovascular systems . The occurrence of AEs has a significant impact on patient safety and the overall quality of care . AEs have significant implications, as well, at the macro level, impacting the effectiveness of medical care safety management systems. These events can lead to prolonged hospitalization, disability, and increased healthcare costs. Addressing adverse events at the community care level requires policy changes and improved collaboration and communication among providers . Safety culture in healthcare is defined as the shared values, attitudes, perceptions, and behaviors of individuals and groups within an organization that determine their commitment to health and safety management . It encompasses the collective commitment to safety at all levels of an organization, influencing how safety is prioritized and managed [ , , ]. Key components of a robust safety culture include leadership and accountability, where leaders actively promote safety as a core value; teamwork and communication, which are essential for identifying and addressing safety issues promptly; learning and improvement, which involves learning from past incidents and implementing changes to prevent future occurrences; a just culture that balances accountability with a non-punitive approach to error reporting; and patient-centered care, ensuring that patient safety is at the forefront of care delivery . Various factors, such as working hours, night shifts, and days off, can impact safety culture by affecting staff perceptions and behaviors toward safety . The current literature  underscores the importance of nontechnical skills such as effective communication and teamwork in improving patient safety. These skills are essential for creating a safety culture and improving patient outcomes. Tools like the Hospital Survey on Patient Safety Culture and the Safety Attitudes Questionnaire (HSPSC) are commonly used to assess safety culture, helping organizations identify areas for improvement . Existing literature consistently shows that AEs can exact a substantial emotional toll on healthcare professionals , particularly in environments lacking feedback mechanisms or adequate organizational support . Following an AE, apart from the primary victim—the patient (referred to as the first victim)—a second victim emerges, namely, the healthcare professional affected by the incident . There are several definitions of the term “second victim” . The ERNST consortium recently finalized a revised definition, characterizing a second victim as “Many healthcare workers, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error, or patient injury, and becomes victimized in the sense that also the worker is negatively impacted” . These individuals, often directly involved in the event or its aftermath, can suffer from a range of psychological and physical symptoms . Such symptoms can significantly impact their professional performance and personal well-being . Robertson et al.  and Sirriyeh et al.  have highlighted negative emotions such as guilt and shame, anxiety, and self-doubt that can lead to burnout and deficient performance. Other studies  also emphasize feelings of helplessness, sadness, fear, and blockage that can lead to post-traumatic disorder. The psychological impact of adverse events may lead to attrition and absenteeism, highlighting the importance of meeting the needs of the second victim . Various factors can influence the risk that healthcare professionals, including nurses, become second victims. These include their proximity to the patients, direct patient-care responsibilities, communication roles, and team dynamics . Adverse events in healthcare settings significantly impact nurses, often leading to the “second victim” phenomenon, characterized by emotional distress following an adverse event . Nurses report psychological distress, including anxiety, depression, and post-traumatic stress symptoms . These events contribute to burnout, impacting patient care and potentially increasing future adverse events . Professionally, adverse events are linked to increased stress, reduced job satisfaction, and higher turnover intentions . As second victims, nurses also experience the consequences of these events, including psychological trauma, emotional reactions, self-confidence issues, and professional performance. All these highlight the necessity for organizational support . Furthermore, fostering a nonpunitive safety culture is crucial in reducing the distress experienced by second victims . To avoid a narrow focus on individual blame, it is important to understand the role that cognitive biases play in adverse events . A structured and blame-free approach is needed to respond to errors, focusing on preventing future occurrences . The importance of nurses reporting adverse events is acknowledged; however, there is a fear of retaliation and the need to review the patient safety culture . Healthcare organizations increasingly need support structures, including peer support programs, to address this issue . Recognizing the impact on healthcare providers, there is a growing emphasis on the need for structured support programs . These programs aim to help second victims cope with the aftermath of adverse events by fostering coping strategies and promoting resilience among affected staff . Organizational strategies highly valued by nurses include peer support and second-victim support programs, which are crucial for coping and recovery . Implementing effective psychosocial peer support programs and linking patient safety measures to second-victim support are recommended . Many healthcare organizations have implemented peer support programs, such as the RISE program at Johns Hopkins Hospital, which provides emotional support through trained peer responders . The “forYOU” model, used in a University Hospital in Spain, offers a tiered support system based on the severity of emotional distress. This model has been effective in increasing the visibility of support actions and fostering a culture of patient safety . To prevent healthcare professionals from becoming second victims, providing immediate support and implementing institutional programs to facilitate recovery and minimize career consequences is important . Creating a supportive environment and reporting culture can also help this prevention effort . International studies have examined patient safety culture in healthcare settings across Europe, including a specific focus on Eastern Europe and Romania. A systematic review of 62 international studies using the HSPSC revealed a growing trend in assessing patient safety culture across Europe. However, it emphasized the need to carefully adapt the HSPSC to local contexts . A study of hospitals in Croatia, Hungary, Spain, and Sweden found that teamwork was generally positive, but staffing and workload needed improvement. Sweden reported the best perceptions of safety culture, while Croatia, Hungary, and Spain ranged from adequate to poor. It highlighted inconsistencies between perceived and actual safety practices, suggesting that national culture, organizational practices, and health system structures affect safety culture perceptions . Research on the second victim phenomenon (SVP) among nurses in the European Union highlights the prevalence, causes, and coping strategies associated with this experience. In Germany, 60% of nurses reported experiencing the SVP at least once in their careers, with aggressive behavior by patients being a significant cause . In Austria, intensive care nurses frequently reported feelings of guilt and sleep disturbances as symptoms of SVP . In obstetrics and gynecology, 47.8% of nurses reported feeling like a second victim during their careers, with clinical and non-clinical events triggering these experiences . In Romania, the COVID-19 pandemic exacerbated these challenges, with nurses facing significant moral injuries, burnout, and increased turnover intentions . Romanian healthcare workers experienced high levels of burnout and depression  and lower resilience and quality of life . A study in Romania evaluated the culture of patient safety within anesthesia and intensive care departments. While the overall perspective was positive, notable differences were observed between tertiary and secondary hospitals. The study used a Romanian version of the HSPSC . Another Romanian study explored the psychometric properties of the HSPSC, suggesting that while the survey was generally reliable, some composites needed adjustment to better fit the Romanian context . In the Republic of Moldova, a study using the Romanian translation of the HSPSC identified teamwork and management support as strengths, while staffing and communication openness needed improvement . In Romania, research on adverse events and second victims, as well as patient safety, is very limited. Pan-European research identified these gaps, emphasizing the well-being and impact of healthcare professionals on patient safety . Literature shows that there is scarce research about patient safety in Romania . This highlights the need for research initiatives to generate evidence, raise awareness, propose appropriate policies, and facilitate international collaboration to develop and implement initiatives on patient safety. On September 15, 2015, Romania advanced its PSC by establishing the National Authority for Quality Management in Health (ANMCS), which aims to implement quality assurance mechanisms, accredit healthcare providers, enhance patient safety, and improve medical quality . The National Patient Safety Council was established on February 23, 2021, to promote quality and patient safety in healthcare, research service delivery quality, and provide training programs on PSC . Comprehending the impact of adverse incidents on team dynamics and exploring resilience and coping techniques employed by healthcare professionals is crucial for developing targeted intervention and support systems . This study aimed to assess the PSC among Romanian nurses using a cross-sectional survey, focusing on their experiences with AEs and the second victim phenomenon. Specifically, we sought to (1) evaluate nurses’ perceptions of safety culture, (2) quantify experiences with AEs as reported in the survey, (3) characterize the impact of the second victim phenomenon, and (4) identify associations between safety culture dimensions and the likelihood of AEs or second victimhood. By integrating international evidence on AEs and healthcare providers, this research situates Romania in the global patient safety discourse and provides insights for targeted interventions. 

Study design and population This cross-sectional study examined adverse events (AEs) and second-victim experiences among nurses in Romanian healthcare. The target population included nurses from all 8 development regions in Romania (North-West, Center, North-East, South-East, South, Bucharest, South-West, and West), allowing a broad assessment of PSC and its emotional and professional ramifications for healthcare providers. Sampling and data collection A convenience sample was employed, leveraging the network of the Order of Nurses, Midwives, and Medical Assistants in Romania (OAMGMAMR), the primary regulatory and representative body for the nursing profession in Romania . The OAMGMAMR facilitated the dissemination of the online and onsite survey, reaching a broad spectrum of respondents nationwide. A total of 1,085 responses were collected. For this analysis, we focused specifically on nurses ( N = 995), thus excluding 90 respondents whose professional roles were physician ( N = 26), nursing assistant ( N = 21), porter ( N = 4), or other categories ( N = 28), and 11 responses marked as missing. Data collection took place from April to June 2022. The survey was previously used in a study measuring adverse events in Spanish healthcare professionals , ensuring consistency in assessing AEs and related experiences. Ethical considerations Researchers dispatched detailed study information, consent forms, and questionnaires to participants. Before data collection, informed consent was obtained from all participants. The study’s protocol was reviewed and approved by The Scientific Council of the Babeș-Bolyai University of Cluj-Napoca, Research Ethics Approval no. 1075/04.02.2022, ensuring adherence to ethical standards in research. Questionnaire structure For the purposes of our study, we employed a questionnaire that was originally developed and has been previously published by Mira et al. . It was developed through a rigorous consensus-building process, drawing on insights from various sources to ensure its validity and relevance. The methodology was guided by published reviews and studies  and questions employed in studies conducted in North America  and Norway . A systematic procedure was employed to back-translate the instrument for the current study, adhering to the guidelines established by the World Health Organization . This methodical process comprised five key steps: forward translation, expert panel discussions, backward translation, a pre-test, cognitive briefing, and consensus on the final version. Two translators, native speakers of Romanian, were engaged to translate the questionnaire items into Romanian. These translations were combined into a Romanian version, which underwent thorough examination by an expert panel possessing expertise in public health. Back-translation was carried out by a researcher unaware of the survey content. A comparison between the translated version and the original instrument identified minor discrepancies resolved through consensus within the expert panel. The questionnaire comprised three sections, assessing the impact of safety culture on AEs, professionals’ experiences in informing patients about AEs, and the frequency and intensity of common personal- and work-related problems among second victims. Items regarding safety culture were sourced from validated questionnaires used in previous studies, ensuring cross-cultural applicability and comparability of results . The safety culture section comprises 11 items. A composite score for the brief safety culture scale (comprising five items) was determined by summing the scores across all items, with a maximum score of 25 points. Study participants were nurses from diverse healthcare settings across Romania, categorized into three groups based on their primary department type: medical, surgical, or other, in accordance with the Romanian Ministry of Health’s Order No. 1509/2008 . Medical departments included specialties such as Anesthesia and Intensive Care, Cardiology, and Internal Medicine, focusing on non-surgical treatments. Surgical departments encompassed specialties, including General Surgery, Obstetrics and Gynecology, and Orthopedics, focusing on surgical interventions and post-operative care. Other departments include specialties such as Anatomic Pathology, Epidemiology, Dental Medicine, Hygiene, Laboratory Medicine, Forensic Medicine, Nuclear Medicine, Radiology-Medical Imaging, and Community Healthcare. Data analysis Our study employed a combination of statistical tests to examine the relationships between various categorical and continuous variables. Data were presented as frequency and percentage for categorical variables and as the mean and standard deviation for continuous variables. Chi-square tests were used to explore associations between categorical variables, such as department type (medical, surgical, and other), gender, and the occurrence of AEs. For continuous variables, such as age and safety culture scores, we utilized Student’s t-tests and one-way ANOVA. These were applied to compare mean responses across different groups, focusing on age (below or above 50 years), sex, and department type. Furthermore, logistic regression was employed to assess the likelihood of certain outcomes, specifically the probability of patients being informed of an AE and the frequency of emotional problems experienced by second victims. The logistic regression method was employed to assess the predictive capacity of the variables age, gender, professional experience in years, and safety culture scores. Differences or associations were considered statistically significant at a p- value under 0.05. The SPSS version 29.0 for MacOS (IBM SPSS, Inc., Chicago, IL, USA) was used for this analysis. 

This cross-sectional study examined adverse events (AEs) and second-victim experiences among nurses in Romanian healthcare. The target population included nurses from all 8 development regions in Romania (North-West, Center, North-East, South-East, South, Bucharest, South-West, and West), allowing a broad assessment of PSC and its emotional and professional ramifications for healthcare providers. 

A convenience sample was employed, leveraging the network of the Order of Nurses, Midwives, and Medical Assistants in Romania (OAMGMAMR), the primary regulatory and representative body for the nursing profession in Romania . The OAMGMAMR facilitated the dissemination of the online and onsite survey, reaching a broad spectrum of respondents nationwide. A total of 1,085 responses were collected. For this analysis, we focused specifically on nurses ( N = 995), thus excluding 90 respondents whose professional roles were physician ( N = 26), nursing assistant ( N = 21), porter ( N = 4), or other categories ( N = 28), and 11 responses marked as missing. Data collection took place from April to June 2022. The survey was previously used in a study measuring adverse events in Spanish healthcare professionals , ensuring consistency in assessing AEs and related experiences. 

Researchers dispatched detailed study information, consent forms, and questionnaires to participants. Before data collection, informed consent was obtained from all participants. The study’s protocol was reviewed and approved by The Scientific Council of the Babeș-Bolyai University of Cluj-Napoca, Research Ethics Approval no. 1075/04.02.2022, ensuring adherence to ethical standards in research. 

For the purposes of our study, we employed a questionnaire that was originally developed and has been previously published by Mira et al. . It was developed through a rigorous consensus-building process, drawing on insights from various sources to ensure its validity and relevance. The methodology was guided by published reviews and studies  and questions employed in studies conducted in North America  and Norway . A systematic procedure was employed to back-translate the instrument for the current study, adhering to the guidelines established by the World Health Organization . This methodical process comprised five key steps: forward translation, expert panel discussions, backward translation, a pre-test, cognitive briefing, and consensus on the final version. Two translators, native speakers of Romanian, were engaged to translate the questionnaire items into Romanian. These translations were combined into a Romanian version, which underwent thorough examination by an expert panel possessing expertise in public health. Back-translation was carried out by a researcher unaware of the survey content. A comparison between the translated version and the original instrument identified minor discrepancies resolved through consensus within the expert panel. The questionnaire comprised three sections, assessing the impact of safety culture on AEs, professionals’ experiences in informing patients about AEs, and the frequency and intensity of common personal- and work-related problems among second victims. Items regarding safety culture were sourced from validated questionnaires used in previous studies, ensuring cross-cultural applicability and comparability of results . The safety culture section comprises 11 items. A composite score for the brief safety culture scale (comprising five items) was determined by summing the scores across all items, with a maximum score of 25 points. Study participants were nurses from diverse healthcare settings across Romania, categorized into three groups based on their primary department type: medical, surgical, or other, in accordance with the Romanian Ministry of Health’s Order No. 1509/2008 . Medical departments included specialties such as Anesthesia and Intensive Care, Cardiology, and Internal Medicine, focusing on non-surgical treatments. Surgical departments encompassed specialties, including General Surgery, Obstetrics and Gynecology, and Orthopedics, focusing on surgical interventions and post-operative care. Other departments include specialties such as Anatomic Pathology, Epidemiology, Dental Medicine, Hygiene, Laboratory Medicine, Forensic Medicine, Nuclear Medicine, Radiology-Medical Imaging, and Community Healthcare. 

Our study employed a combination of statistical tests to examine the relationships between various categorical and continuous variables. Data were presented as frequency and percentage for categorical variables and as the mean and standard deviation for continuous variables. Chi-square tests were used to explore associations between categorical variables, such as department type (medical, surgical, and other), gender, and the occurrence of AEs. For continuous variables, such as age and safety culture scores, we utilized Student’s t-tests and one-way ANOVA. These were applied to compare mean responses across different groups, focusing on age (below or above 50 years), sex, and department type. Furthermore, logistic regression was employed to assess the likelihood of certain outcomes, specifically the probability of patients being informed of an AE and the frequency of emotional problems experienced by second victims. The logistic regression method was employed to assess the predictive capacity of the variables age, gender, professional experience in years, and safety culture scores. Differences or associations were considered statistically significant at a p- value under 0.05. The SPSS version 29.0 for MacOS (IBM SPSS, Inc., Chicago, IL, USA) was used for this analysis. 

Demographic profile The demographic profile of the sample is presented in Table . A total of 995 nurses participated in the survey, most aged between 31 and 50 years, making up 67.8% (N = 675) of the total sample. The second largest age group was between 51 and 70 years, comprising 24.7% (N = 246), while those aged 30 or younger were the least represented, with only 7.0% (N = 70). Most respondents were female (89.2%, N = 888), while males accounted for 10.5% (N = 104) of the sample. Professional experience was skewed towards those over three years in their field, who constituted an overwhelming 92.6% (N = 921) of the sample. Respondents with 1–3 years and less than one year of experience represented only 4.8% (N = 48) and 2.4% (N = 24), respectively, with a 0.2% (N = 2) non-response rate. Regarding departmental distribution, the ‘Other’ category was the most represented, with 47.4% ( N = 472) of the sample. The medical and surgical departments constituted 29.7% ( N = 296) and 21.5% ( N = 214) of the sample. Missing departmental data was reported at 1.3% ( N = 13). Over half of the participants (57.9%, N = 576) reported having observed or heard of near-miss incidents corrected in time. In comparison, 30.8% ( N = 306) reported being aware of serious adverse events affecting one or more patients. Patient safety culture The mean score on the safety culture subscale was 20.59 (SD = 2.64, 95% CI = 20.39–20.80). “Higher safety culture scores were obtained by nurses over 50 years old (M = 20.98, SD = 2.65) compared to those younger than 50 years old (M = 20.45, SD = 2.64), with this difference being statistically significant ( p =.024, Student’s t-test). There was no significant difference in the score between types of departments, genders, or levels of work experience. Table presents the responses to the safety culture subscale across different hospital departments, including Medical, Surgical, and Other Departments. The table reports the mean and standard deviation (SD) for each statement regarding safety practices and perceptions within the departments, along with the p -value to assess the statistical significance of differences between departments ( p -values are from one-way ANOVA). Surgical departments scored higher (M = 4.33, SD = 0.819) than other departments (M = 4.13, SD = 0.891) on having an anonymous incident reporting system. This difference was statistically significant ( p =.021). Additionally, nurses from medical departments had a higher mean score (M = 4.42, SD = 0.703) in undertaking systematic analysis after a serious adverse event than nurses from the other departments category (M = 4.29, SD = 0.740), which was also statistically significant ( p =.035). The probability of serious AE occurring in the healthcare setting where the nurses worked within the 12 months following survey completion was estimated to be low or very low by 66.5% of nurses ( N = 662). The percentage rating this risk as low or very low did not change with increasing scores on the safety culture scale or the department type. Furthermore, 72.7% of nurses ( N = 723) perceived the likelihood of an AE occurring in their department/unit over the next 12 months as low or very low. No significant variations were observed between department types, age groups, gender, or years of experience of the nurses. Open disclosure experience The analysis of experiences of adverse effects from Table reveals that the nurses from the surgical department reported the highest frequency of near misses, adverse events with serious consequences, and emotional impact on professionals due to adverse events, compared to the medical and other departments. However, the only statistically significant difference was found in the incidence of work-related problems due to an adverse event, where the nurses from the surgical department reported a notably higher percentage (31.3%), χ² (2, N = 979) = 5.98, p = .050. The strength of the safety culture was inversely associated with the probability of seeing or hearing cases considered near misses. The odds ratio was 0.90, 95% CI [0.85, 0.96], p < .001 (logistic regression), indicating a statistically significant lower likelihood of reporting near misses among those with a higher safety culture score. In the situation of adverse events with serious consequences, the probability was lower among those with higher safety culture scores (OR = 0.91, 95% CI [0.86, 0.97]). Furthermore, nurses with more than three years of professional experience were significantly more likely to report adverse events with serious consequences, with an odds ratio of 2.16 (95% CI [1.29, 3.63]). Around 12.5% of nurses reported informing a patient about an adverse event (Table ). The probability of having this experience was lower among those with the higher safety culture score (OR = 1.1, 95% CI [1.0, 1.2]), p <.001 (logistic regression), Additionally, the likelihood of formal complaints being filed by patients was significantly higher in other departments (17.7%), χ² (2, N = 965) = 6.39, p = .041. Other measured outcomes, such as the acceptance of explanations by patients and the worsening of patient-provider relationships, did not show statistically significant differences across departments; however, between one-quarter to one-third of nurses from all types of departments indicated that patients may respond negatively to being informed about an adverse event and that this can affect their future relationship with healthcare providers. A total of 88.9% ( N = 866) of nurses would be interested in receiving specific training on how to cope better with the consequences of AEs, and a total of 89.3% ( N = 867) would be interested in specific training on how to tell patients about AEs. These types of training were of similar interest to nurses working in all three categories of departments, p =.094 and p =.158, respectively (one-way ANOVA). Second victim experience A total of 61 (20.6%) nurses in medical departments, 45 (21.0%) in surgical departments, and 131 (23.8%) in other departments reported having suffered at least one second-victim experience (themselves or through colleagues) in the previous five years (Table ). Statistically significant differences were observed in the rates of second victim experiences across medical, surgical, and other departments (χ²(2, N = 979) = 6.62, p =.038). The rates of second victims among nurses from different socio-demographic groups (age, gender, or professional experience) were similar, with no statistically significant differences between the categories. Table shows that almost one-fifth of nurses reported that second victims could not continue working after an AE and required time off. In contrast, 2.3% reported that second victims left the profession. The reported work-related consequences for second victims were significantly different in the three categories of departments. For instance, nurses in other departments reported a higher rate of second victims taking time off work, χ² (2, N = 979) = 6.38, p =.041, and requesting transfers, χ² (2, N = 979) = 6.29, p =.043. Following adverse events, nurses most frequently experienced the following emotional responses (Table ): tiredness (68.5%, 682 individuals), feelings of guilt (59.2%, 589 individuals), anxiety (53.3%, 530 individuals), insomnia or difficulties in getting proper sleep (53.0%, 527 individuals), bewilderment and confusion with difficulties in concentrating on their job (52.1%, 506 individuals), and pessimism about life coupled with sadness (45.7%, 455 individuals). The proportion of emotional responses was not significantly different between genders, years of professional experience, and age categories. Table presents a detailed analysis of the emotional responses commonly observed in nurses following serious adverse events. Feelings of guilt showed a significantly higher mean in the Medical Department (M = 2.02) compared to the Surgical (M = 1.99) and Other Departments (M = 1.85), with a statistically significant difference ( p = .032). In contrast, insomnia and difficulties in getting proper sleep were significantly more prevalent in the Surgical Department (M = 1.83) compared to the Medical (M = 1.77) and Other Departments (M = 1.65), p = .015. Other emotional responses, such as confusion, pessimism, tiredness, anxiety, reliving the event, anger and mood swings (both at work and home), constant doubts about clinical decisions, and concerns about professional reputation, do not show statistically significant differences across departments. In the analysis of the predictive value of safety culture on the most frequent emotional responses among nurses post-adverse events, the logistic regression results show that higher safety culture scores were associated with reduced bewilderment and difficulty concentrating (OR = 0.93, 95% CI [0.88, 0.99], p =.020), lower likelihood of insomnia (OR = 0.88, 95% CI [0.82, 0.93], p <.001), decreased anxiety (OR = 0.90, 95% CI [0.84, 0.96], p =.001), and lesser feelings of guilt (OR = 0.90, 95% CI [0.84, 0.96], p =.001). The strongest negative association was observed with tiredness (OR = 0.87, 95% CI [0.81, 0.94], p <.001). No significant association was found between these emotional responses and the age categories, gender, or professional experience of nurses. The second victim’s most common professional consequences were apologizing to the patient or relatives, informing the patient or the relatives, and being afraid of losing their professional reputation (Table ). The fear of facing legal consequences of an AE shows a significant difference across departments ( p <.001, one-way ANOVA), with the highest mean in the Medical Department (M = 6.51) compared to the Surgical (M = 6.29) and Other Departments (M = 5.65). Another significant finding is the fear of losing professional reputation, which varies significantly across departments, p =.018, where the Surgical Department reported a slightly higher mean (M = 6.67) compared to the Medical (M = 6.56) and Other Departments (M = 6.06). Positive safety culture was notably associated with a decrease in conflicts with other professionals (OR = 0.90, 95% CI [0.85, 0.96], p =.002) and reduced uncertainty about informing clinical management (OR = 0.87, 95% CI [0.82, 0.93], p <.001). Furthermore, it was linked to a lower fear of losing professional prestige (OR = 0.91, 95% CI [0.84, 0.98], p =.014) and diminished fear of legal consequences (OR = 0.85, 95% CI [0.79, 0.92], p <.001). Contrasting these, a positive safety culture increased the likelihood of apologizing to patients or their families (OR = 1.23, 95% CI [1.14, 1.33], p <.001). No significant associations were found between relational difficulties and gender, age category, or years of professional experience of nurses. 

The demographic profile of the sample is presented in Table . A total of 995 nurses participated in the survey, most aged between 31 and 50 years, making up 67.8% (N = 675) of the total sample. The second largest age group was between 51 and 70 years, comprising 24.7% (N = 246), while those aged 30 or younger were the least represented, with only 7.0% (N = 70). Most respondents were female (89.2%, N = 888), while males accounted for 10.5% (N = 104) of the sample. Professional experience was skewed towards those over three years in their field, who constituted an overwhelming 92.6% (N = 921) of the sample. Respondents with 1–3 years and less than one year of experience represented only 4.8% (N = 48) and 2.4% (N = 24), respectively, with a 0.2% (N = 2) non-response rate. Regarding departmental distribution, the ‘Other’ category was the most represented, with 47.4% ( N = 472) of the sample. The medical and surgical departments constituted 29.7% ( N = 296) and 21.5% ( N = 214) of the sample. Missing departmental data was reported at 1.3% ( N = 13). Over half of the participants (57.9%, N = 576) reported having observed or heard of near-miss incidents corrected in time. In comparison, 30.8% ( N = 306) reported being aware of serious adverse events affecting one or more patients. 

The mean score on the safety culture subscale was 20.59 (SD = 2.64, 95% CI = 20.39–20.80). “Higher safety culture scores were obtained by nurses over 50 years old (M = 20.98, SD = 2.65) compared to those younger than 50 years old (M = 20.45, SD = 2.64), with this difference being statistically significant ( p =.024, Student’s t-test). There was no significant difference in the score between types of departments, genders, or levels of work experience. Table presents the responses to the safety culture subscale across different hospital departments, including Medical, Surgical, and Other Departments. The table reports the mean and standard deviation (SD) for each statement regarding safety practices and perceptions within the departments, along with the p -value to assess the statistical significance of differences between departments ( p -values are from one-way ANOVA). Surgical departments scored higher (M = 4.33, SD = 0.819) than other departments (M = 4.13, SD = 0.891) on having an anonymous incident reporting system. This difference was statistically significant ( p =.021). Additionally, nurses from medical departments had a higher mean score (M = 4.42, SD = 0.703) in undertaking systematic analysis after a serious adverse event than nurses from the other departments category (M = 4.29, SD = 0.740), which was also statistically significant ( p =.035). The probability of serious AE occurring in the healthcare setting where the nurses worked within the 12 months following survey completion was estimated to be low or very low by 66.5% of nurses ( N = 662). The percentage rating this risk as low or very low did not change with increasing scores on the safety culture scale or the department type. Furthermore, 72.7% of nurses ( N = 723) perceived the likelihood of an AE occurring in their department/unit over the next 12 months as low or very low. No significant variations were observed between department types, age groups, gender, or years of experience of the nurses. 

The analysis of experiences of adverse effects from Table reveals that the nurses from the surgical department reported the highest frequency of near misses, adverse events with serious consequences, and emotional impact on professionals due to adverse events, compared to the medical and other departments. However, the only statistically significant difference was found in the incidence of work-related problems due to an adverse event, where the nurses from the surgical department reported a notably higher percentage (31.3%), χ² (2, N = 979) = 5.98, p = .050. The strength of the safety culture was inversely associated with the probability of seeing or hearing cases considered near misses. The odds ratio was 0.90, 95% CI [0.85, 0.96], p < .001 (logistic regression), indicating a statistically significant lower likelihood of reporting near misses among those with a higher safety culture score. In the situation of adverse events with serious consequences, the probability was lower among those with higher safety culture scores (OR = 0.91, 95% CI [0.86, 0.97]). Furthermore, nurses with more than three years of professional experience were significantly more likely to report adverse events with serious consequences, with an odds ratio of 2.16 (95% CI [1.29, 3.63]). Around 12.5% of nurses reported informing a patient about an adverse event (Table ). The probability of having this experience was lower among those with the higher safety culture score (OR = 1.1, 95% CI [1.0, 1.2]), p <.001 (logistic regression), Additionally, the likelihood of formal complaints being filed by patients was significantly higher in other departments (17.7%), χ² (2, N = 965) = 6.39, p = .041. Other measured outcomes, such as the acceptance of explanations by patients and the worsening of patient-provider relationships, did not show statistically significant differences across departments; however, between one-quarter to one-third of nurses from all types of departments indicated that patients may respond negatively to being informed about an adverse event and that this can affect their future relationship with healthcare providers. A total of 88.9% ( N = 866) of nurses would be interested in receiving specific training on how to cope better with the consequences of AEs, and a total of 89.3% ( N = 867) would be interested in specific training on how to tell patients about AEs. These types of training were of similar interest to nurses working in all three categories of departments, p =.094 and p =.158, respectively (one-way ANOVA). 

A total of 61 (20.6%) nurses in medical departments, 45 (21.0%) in surgical departments, and 131 (23.8%) in other departments reported having suffered at least one second-victim experience (themselves or through colleagues) in the previous five years (Table ). Statistically significant differences were observed in the rates of second victim experiences across medical, surgical, and other departments (χ²(2, N = 979) = 6.62, p =.038). The rates of second victims among nurses from different socio-demographic groups (age, gender, or professional experience) were similar, with no statistically significant differences between the categories. Table shows that almost one-fifth of nurses reported that second victims could not continue working after an AE and required time off. In contrast, 2.3% reported that second victims left the profession. The reported work-related consequences for second victims were significantly different in the three categories of departments. For instance, nurses in other departments reported a higher rate of second victims taking time off work, χ² (2, N = 979) = 6.38, p =.041, and requesting transfers, χ² (2, N = 979) = 6.29, p =.043. Following adverse events, nurses most frequently experienced the following emotional responses (Table ): tiredness (68.5%, 682 individuals), feelings of guilt (59.2%, 589 individuals), anxiety (53.3%, 530 individuals), insomnia or difficulties in getting proper sleep (53.0%, 527 individuals), bewilderment and confusion with difficulties in concentrating on their job (52.1%, 506 individuals), and pessimism about life coupled with sadness (45.7%, 455 individuals). The proportion of emotional responses was not significantly different between genders, years of professional experience, and age categories. Table presents a detailed analysis of the emotional responses commonly observed in nurses following serious adverse events. Feelings of guilt showed a significantly higher mean in the Medical Department (M = 2.02) compared to the Surgical (M = 1.99) and Other Departments (M = 1.85), with a statistically significant difference ( p = .032). In contrast, insomnia and difficulties in getting proper sleep were significantly more prevalent in the Surgical Department (M = 1.83) compared to the Medical (M = 1.77) and Other Departments (M = 1.65), p = .015. Other emotional responses, such as confusion, pessimism, tiredness, anxiety, reliving the event, anger and mood swings (both at work and home), constant doubts about clinical decisions, and concerns about professional reputation, do not show statistically significant differences across departments. In the analysis of the predictive value of safety culture on the most frequent emotional responses among nurses post-adverse events, the logistic regression results show that higher safety culture scores were associated with reduced bewilderment and difficulty concentrating (OR = 0.93, 95% CI [0.88, 0.99], p =.020), lower likelihood of insomnia (OR = 0.88, 95% CI [0.82, 0.93], p <.001), decreased anxiety (OR = 0.90, 95% CI [0.84, 0.96], p =.001), and lesser feelings of guilt (OR = 0.90, 95% CI [0.84, 0.96], p =.001). The strongest negative association was observed with tiredness (OR = 0.87, 95% CI [0.81, 0.94], p <.001). No significant association was found between these emotional responses and the age categories, gender, or professional experience of nurses. The second victim’s most common professional consequences were apologizing to the patient or relatives, informing the patient or the relatives, and being afraid of losing their professional reputation (Table ). The fear of facing legal consequences of an AE shows a significant difference across departments ( p <.001, one-way ANOVA), with the highest mean in the Medical Department (M = 6.51) compared to the Surgical (M = 6.29) and Other Departments (M = 5.65). Another significant finding is the fear of losing professional reputation, which varies significantly across departments, p =.018, where the Surgical Department reported a slightly higher mean (M = 6.67) compared to the Medical (M = 6.56) and Other Departments (M = 6.06). Positive safety culture was notably associated with a decrease in conflicts with other professionals (OR = 0.90, 95% CI [0.85, 0.96], p =.002) and reduced uncertainty about informing clinical management (OR = 0.87, 95% CI [0.82, 0.93], p <.001). Furthermore, it was linked to a lower fear of losing professional prestige (OR = 0.91, 95% CI [0.84, 0.98], p =.014) and diminished fear of legal consequences (OR = 0.85, 95% CI [0.79, 0.92], p <.001). Contrasting these, a positive safety culture increased the likelihood of apologizing to patients or their families (OR = 1.23, 95% CI [1.14, 1.33], p <.001). No significant associations were found between relational difficulties and gender, age category, or years of professional experience of nurses. 

Adverse events in healthcare can have a devastating impact on nurses, leaving them reeling with feelings such as guilt, shame, and anxiety . Furthermore, adverse events can damage confidence, job satisfaction, and well-being while straining organizational relationships . Frequent exposure to traumatizing events among emergency nurses may lead to posttraumatic stress symptoms that impact both their well-being and the quality of care provided, potentially leading to an increased need for defensive practices and the heightened risk for certain patients ; fear of legal consequences could prevent nurses from reporting adverse incidents, highlighting the need for legal regulations to address this issue . The findings of this study highlight the significant impact of patient safety incidents on nurses in Romania and the need for comprehensive support and regulatory measures in healthcare settings. Figure illustrates the primary findings of the study. This research began as an effort to assess the impact of adverse events on healthcare professionals in Romania. However, since nurses dominated participation, responses from other categories were ultimately excluded, and the primary focus of the research shifted to exploring nurses’ perceptions regarding such events and their relationship with PSC. This indicates a potential need to address and improve the overall safety culture within healthcare settings to ensure the well-being of both healthcare professionals and patients. Our findings align with the ERNST Policy Statement, supporting its call for systemic changes to address the second victim phenomenon . The correlation between a positive safety culture and reduced emotional distress among Romanian nurses provides empirical evidence for ERNST’s recommendations. The identified need for specific training emphasizes the global movement towards open disclosure and robust support systems. Our study identified notable variations in safety culture and second-victim experiences across medical, surgical, and other departments. These variations likely stem from a confluence of factors, including the nature of work, team dynamics, communication patterns, types of adverse events, and existing safety protocols, each of which can differ substantially between departments. In surgical settings, diverse communication styles are observed, ranging from proactive to ambiguous, influenced by procedural complexity . Strong relational coordination, characterized by mutual respect and effective communication, enhances psychological safety and learning from mistakes, contributing to a robust safety culture . Surgical departments face unique challenges from adverse events like surgical site infections and technical failures . Crew Resource Management (CRM) has shown promise in these settings by improving communication and reducing patient morbidity . Medical departments exhibit close links between team dynamics, care coordination, and perceptions of safety culture . Adverse drug events and healthcare-associated infections are prevalent in these settings . For example, emergency departments benefit from structured communication training like TeamSTEPPS and CRM, which improves teamwork and communication . The emotional toll of adverse events is significant across all departments, with healthcare professionals often experiencing anger, guilt, and anxiety . Implementing tailored safety training programs that incorporate simulation interdepartmental collaboration and address the specific needs of each department is crucial . For example, programs that improve relational coordination and psychological safety might be most effective in surgical settings . In contrast, those focusing on team dynamics and care coordination are essential in medical departments . These insights highlight that healthcare organizations should prioritize department-specific safety protocols and training. Surgical departments could benefit from expanded CRM training, while medical departments should enhance team dynamics and care coordination. All departments must foster psychological safety, allowing professionals to address the emotional toll of adverse events and learn from mistakes. Patient safety incidents were widespread among participants; over half reported witnessing or hearing of near-miss incidents that highlighted ongoing challenges within healthcare environments. A significant presence can also be found within “Other” departments (besides the Medical and Surgical departments), illustrating their wide diversity within this sample population. The symptoms observed in this study are consistent with findings from other European studies , including the need for time off work. This similarity in symptoms and outcomes underscores the universality of the impact of adverse events on healthcare professionals across different regions and healthcare systems. It also emphasizes the importance of developing standardized support systems and interventions to address these challenges effectively and promote the well-being of healthcare workers worldwide. Our study highlights a discrepancy between the low reported rate of adverse events (30% among nurses in five years) and high patient safety culture scores, contrasting with higher international estimates [ , , ]. This suggests significant underreporting, potentially due to a positive safety culture paradoxically hindering reporting because of fear of negative impacts or unclear definitions of reportable events. This is supported by the Romanian Health Observatory’s finding that 42% of Romanian healthcare facilities reported zero adverse events in a year, indicating systemic underreporting . Their data also highlighted issues like inadequate infection prevention compliance, mirroring our findings in surgical departments. The Observatory’s data showed over 5,800 cases of healthcare-associated infections in 2019 and 2020, over 1,300 medical errors resulting in patient injury, and 128 deaths due to medical errors, indicating a significant underreporting of adverse events compared to our findings . Thus, while crucial, a high safety culture score alone does not guarantee accurate reporting or a safer environment in the Romanian context. Assessments of PSC revealed a positive perception among the surveyed nurses. While age differences exist, nurses over 50 scored higher, and an overall high mean score indicates positive perceptions about safety culture among all nurses surveyed. Surgical departments showed statistically significant strengths, such as having anonymous incident reporting systems or conducting systematic analyses after serious adverse events that can be leveraged further for improvement. These findings indicate areas of strength within the safety culture but also offer opportunities for improvement. They underscore the positive perception of safety culture among nurses surveyed, identify specific strengths in surgical departments, and point to areas where enhancements can be made to strengthen patient safety practices and the culture of healthcare organizations. Regarding their perceptions of adverse events within 12 months following survey completion, most nurses reported an extremely low or very low likelihood. Their perspectives did not vary significantly according to safety culture scores or department types; instead, they demonstrated awareness of potential adverse events within their departments that were consistent across medical and surgical staff. The quality of care provided by these personnel could be impacted by the stress caused by safety incidents among the professionals and their vigilance in anticipating new occurrences. Addressing these incidents during briefings at the start of shifts can promote the normalization of such situations and enhance patient safety. Numerous ongoing studies have investigated PSC in hospitals from the perspectives of nursing professionals. Yavuz  found that surgical nurses surveyed perceived the PSC as a medium, with highly positive responses in “Teamwork within Units.” However, positive responses were lower on the “non-punitive response to errors” subdimension, indicating a need for improvements in error reporting and management practices. Other researchers also highlighted the significance of professional satisfaction, dialogue, and support from management in maintaining patient safety . Areas for improving PSC were identified , including staffing levels, response to errors without punitive actions being taken, as perceptions of management support and perceptions of teamwork in hospitals. These findings confirm the necessity of ongoing efforts to strengthen safety cultures and emphasize teamwork, error reporting, psychological safety, and management support. The open disclosure experience analysis demonstrates the devastating impact of adverse events on healthcare professionals, with surgical departments reporting higher frequencies of near misses and adverse events with potentially serious outcomes than others. Notably, nurses working in surgical departments reported significantly higher incidences of work-related problems caused by adverse events. The legal framework in some European countries can present challenges that limit healthcare professionals’ decisions to inform patients about adverse events. For example, in Denmark, there may be legal barriers or uncertainties regarding disclosing adverse events to patients, leading to hesitation or reluctance among healthcare providers to communicate openly with patients about such incidents . Furthermore, the strength of safety culture inversely correlated with reporting near misses, suggesting its potential protective role. Studies have illustrated the severity of adverse events on healthcare professionals, mainly within surgical departments . Recent studies from 2021  reported that an ideal safety culture could predict higher intentions to report near misses; its components, such as communication openness and teamwork, proved significant predictors. Kim  highlighted the significance of ethical awareness and PSC as key enablers for encouraging open disclosure of patient safety incidents. Other studies  identified several barriers to reporting near misses in laparoscopic surgeries, such as heavy workload, privacy concerns, lack of support, and fear of disciplinary actions as barriers for reporting near misses. These findings highlighted the necessity of creating a supportive safety culture and developing effective strategies that address these obstacles to improve patient safety. Ample evidence exists for targeted nursing support and education regarding adverse events and communicating these incidents to patients, demonstrating their high interest. This interest was consistent across medical, surgical, and other departments. Umpierrez  and Goniewicz  highlight the value of training programs in improving nurses’ communication skills and self-efficacy, specifically noting the need to empower human resources and strengthen recruitment systems, with Goniewicz  emphasizing work experience, workplace preparation, and disaster response training as essential components of improving nurses’ competencies. Their findings reinforce the need for targeted support and education in these vital areas. Limitations and future research The study’s limited scope may impede its applicability to other healthcare professionals and thereby limit the generalizability of findings. Age, experience, and gender biases within the sample limit generalizability further by hindering insights into younger professionals and diverse gender dynamics. Furthermore, the overrepresentation of “Other” departments dilutes department-specific insights. Self-reporting introduces recall and social desirability biases, limited longitudinal perspectives and non-response considerations add further complexities, and safety culture differences across departments are explored while causation inference remains difficult; acknowledging these limitations is crucial for nuanced interpretation while emphasizing the need for further research to fill any gaps that exist, increasing result robustness and applicability. It is important to acknowledge that this study utilized a convenience sampling method, which inherently introduces limitations to the generalizability of the findings. While our sample’s demographic and geographic distribution exhibits similarities to the 2022 National Institute of Statistics data  – notably, an 88.0% female representation mirroring the national 90.4% and a close alignment in participant distribution across counties despite minor county-level variations – the non-random nature of participant selection may introduce biases. While the sample aligns with national data, caution is necessary when generalizing findings beyond the population. Building on this study’s findings about safety culture and second victim experiences among Romanian nurses, several important research avenues emerge. Limited national data on adverse event incidence in Romania restricts this study. The Romanian Health Observatory’s report highlights systemic underreporting . Future research should address barriers to reporting, including cultural and systemic factors. Studies could investigate reporting systems, training programs, and the link between safety culture and reporting behaviors. Qualitative research could illuminate nurses’ reporting experiences and healthcare providers’ experiences as second victims. Such insights are critical for tailoring interventions to the cultural and organizational context of Romania’s healthcare. The Observatory’s recommendations, such as improving reporting methodology, data transparency, reporting incentives, and fostering a non-punitive culture, offer valuable guidance. Addressing these limitations, informed by the Romanian context, will enhance understanding of patient safety and help develop strategies to mitigate risks and improve care quality. Longitudinal studies are essential to determine the lasting psychological effects of adverse events in this population. While our data offers a snapshot, prospective studies can clarify the distress dynamics, including the ongoing guilt, anxiety, and decreased professional confidence noted elsewhere [ , , ]. These studies should explore recovery pathways, identifying factors that aid or hinder resolution. Since there is a clear need for better support within our sample, future research must also thoroughly assess the efficacy of interventions, many of which have shown limited success in other environments [ , , ]. Intervention research should develop and test support programs for Romanian healthcare professionals, for example, by addressing emotional distress with peer support and structured psychological interventions. These initiatives must tackle systemic issues like low awareness and blame-oriented cultures in healthcare institutions [ , , , , ]. 

The study’s limited scope may impede its applicability to other healthcare professionals and thereby limit the generalizability of findings. Age, experience, and gender biases within the sample limit generalizability further by hindering insights into younger professionals and diverse gender dynamics. Furthermore, the overrepresentation of “Other” departments dilutes department-specific insights. Self-reporting introduces recall and social desirability biases, limited longitudinal perspectives and non-response considerations add further complexities, and safety culture differences across departments are explored while causation inference remains difficult; acknowledging these limitations is crucial for nuanced interpretation while emphasizing the need for further research to fill any gaps that exist, increasing result robustness and applicability. It is important to acknowledge that this study utilized a convenience sampling method, which inherently introduces limitations to the generalizability of the findings. While our sample’s demographic and geographic distribution exhibits similarities to the 2022 National Institute of Statistics data  – notably, an 88.0% female representation mirroring the national 90.4% and a close alignment in participant distribution across counties despite minor county-level variations – the non-random nature of participant selection may introduce biases. While the sample aligns with national data, caution is necessary when generalizing findings beyond the population. Building on this study’s findings about safety culture and second victim experiences among Romanian nurses, several important research avenues emerge. Limited national data on adverse event incidence in Romania restricts this study. The Romanian Health Observatory’s report highlights systemic underreporting . Future research should address barriers to reporting, including cultural and systemic factors. Studies could investigate reporting systems, training programs, and the link between safety culture and reporting behaviors. Qualitative research could illuminate nurses’ reporting experiences and healthcare providers’ experiences as second victims. Such insights are critical for tailoring interventions to the cultural and organizational context of Romania’s healthcare. The Observatory’s recommendations, such as improving reporting methodology, data transparency, reporting incentives, and fostering a non-punitive culture, offer valuable guidance. Addressing these limitations, informed by the Romanian context, will enhance understanding of patient safety and help develop strategies to mitigate risks and improve care quality. Longitudinal studies are essential to determine the lasting psychological effects of adverse events in this population. While our data offers a snapshot, prospective studies can clarify the distress dynamics, including the ongoing guilt, anxiety, and decreased professional confidence noted elsewhere [ , , ]. These studies should explore recovery pathways, identifying factors that aid or hinder resolution. Since there is a clear need for better support within our sample, future research must also thoroughly assess the efficacy of interventions, many of which have shown limited success in other environments [ , , ]. Intervention research should develop and test support programs for Romanian healthcare professionals, for example, by addressing emotional distress with peer support and structured psychological interventions. These initiatives must tackle systemic issues like low awareness and blame-oriented cultures in healthcare institutions [ , , , , ]. 

Overall, this study offers valuable insights into the demographic profile, patient safety incidents, safety culture perceptions, and open-disclosure experiences of nurses in Romania. The results highlight the necessity of ongoing efforts to strengthen safety cultures by taking account of age-related variations and specific departmental needs. Data in the present study suggest that these efforts can be directed along three main pathways. Firstly, training opportunities, both initial education and ongoing professional development, should be enhanced. Institutions can better prepare their staff to respond to and manage complex situations or unexpected challenges by offering initial training and continuous educational programs. Moreover, these initiatives enhance a culture of open dialogue with patients, highlighting the importance of transparent communication and mutual understanding in delivering high-quality care. Through ongoing training, professionals can continuously refine their skills, be up to date with the latest practices in the field, and cultivate a patient-centered approach to healthcare delivery. Secondly, developing and implementing policies that uphold the standards and quality of the medical act and ensure patient safety. Development or improvement of such policies could include clinical practice guidelines to provide evidence-based recommendations, medication safety policies to avoid errors in prescribing and administration, infection control protocols, and incident reporting policies. Lastly, a legal framework regarding adverse events and second victims in healthcare should be developed to clarify and guide legal responsibilities and liabilities, offer protection for healthcare professionals and patients, and foster a blame-free culture. It would also be beneficial to standardize procedures on reporting, investigating, and addressing adverse events, promoting transparency and accountability within healthcare settings, and ensuring that second victims receive appropriate support to cope with the psychological and professional impact of AEs. Moreover, it contributes to a more robust and resilient healthcare system by fostering a culture of learning and improvement, facilitating the analysis of root causes, and implementing preventive measures to ensure patient safety, which is also emphasized in the ERNST Policy Statement . 

