Critical factors shaping vicarious posttraumatic growth in nurses: a cross-sectional study

This cross-sectional survey, adhering to the STROBE guidelines for observational studies, was conducted from September to November 2023, involving a random sample of clinical nurses from 13 tertiary and secondary hospitals across Central, Northwest, and South China. Specifically, simple random sampling was used to ensure that every nurse within the participating hospitals had an equal chance of being selected. Nurses who met the inclusion criteria were randomly chosen from hospital rosters, with efforts made to represent a diverse range of departments and work experiences. This approach aimed to minimize selection bias and ensure the sample was representative of the broader population of nurses in the region.

The inclusion criteria were currently employed nurses with a valid nursing qualification, informed consent, and exposure to patients with trauma. Nurses on leave, external training, absent for over six months, or individuals on maternity leave throughout the survey period were excluded. Questionnaires were excluded if incomplete, contained errors, or showed obvious response patterns, including those with verification questions (e.g., “Please select ‘Strongly agree’ for this question”).

Following the determination of the sample size guidelines for multiple linear regression analysis, the sample size was calculated as ten to twenty times the number of variables [32]. This study included 10 general information variables for nurses and 7 variables measured by specific scales (empathy, positive and negative coping strategies, intrusive rumination, purposeful rumination, social support, and core beliefs). Thus, the initial sample size was estimated as N=(10 + 7)*20 = 340. To account for potential invalid responses, a 20% increase was applied to the sample size, yielding a final estimate of no less than 408.

Data collection was conducted by one Ph.D. student and 13 hospital research assistants. The researcher first introduced the study objectives to the directors of the nursing departments and the head nurses of each ward, obtaining approval to recruit clinical nurses. The questionnaire content and instructions were then explained to research assistants at three hospitals. Research assistants accessed the electronic questionnaire via a QR code provided by the researcher (Wenjuanxing platform: https://​www.​wjx.​cn). Nurses meeting the inclusion criteria contacted the researcher or assistants to participate by scanning the QR code. After scanning, participants viewed an electronic informed consent form and could proceed with the questionnaire only after agreeing. The Wenjuanxing platform ensures data security with no risk of breaches or third-party access.

Data analysis in this study was conducted using SPSS 27.0 software. First, continuous variables were described using mean ± standard deviation, while categorical variables were summarized with frequencies and percentages. Independent samples t-tests and one-way ANOVA were applied to compare variations in VPTG among nurses with different characteristics. One-way ANOVA was also applied to explore the associations between demographic variables and VPTG. Pearson correlation analysis was conducted to explore the relationships between VPTG and coping strategies, rumination, social support, core beliefs, and empathy. Finally, stepwise multiple regression analysis was carried out to pinpoint the critical factors impacting VPTG.

For online collection, all questions were set as mandatory, with each device limited to one submission to prevent duplicate entries. During data analysis, two researchers independently reviewed data quality, excluding responses under 180 s or those with logical inconsistencies. Data entry was conducted by two researchers and cross-checked for any discrepancies, which were resolved by comparing with the original questionnaires. A statistician provided oversight to ensure the accuracy of the statistical methods used.

A total of 1110 questionnaires were initially gathered. After excluding those that failed to meet the criteria, 1025 valid responses remained for analysis, yielding an effective response rate of 92.34%. Among the 1,025 nurses surveyed, 97.1% were female, 53.0% were aged between 31 and 40 years, and 25.4% were employed in internal medicine. A large portion of the respondents held a bachelor’s degree(78.5%) and had between 11 and 20 years of experience in the nursing field(42.6%). A significant portion were married (79.9%), and nearly half (49.9%) cared for 0–50 patients weekly. A one-way ANOVA revealed that VPTG scores varied significantly across different demographic groups. Nurses aged 41–50, those with over 30 years of experience, professors, married nurses, those caring for more than 300 patients, and those who had received trauma training exhibited higher VPTG scores. Full demographic details and VPTG scores are available in Table 1.

The mean VPTG score was 105.02 (SD = 15.75), with 17.8% of nurses classified as having low VPTG levels and 52.3% falling in the moderate range, indicating that the majority (70.1%) experienced low to moderate levels of VPTG. The mean social support score was 63.20 (SD = 12.53), with 2.9% of participants reporting low social support, 44.0% reporting moderate support, and 53.1% reporting high support. Social support subcomponents were also assessed, with family support showing a mean of 21.50 (SD = 4.60), friend support at 21.19 (SD = 4.26), and other support at 20.51 (SD = 4.69). The overall empathy score had a mean of 53.88 (SD = 9.96), with subscale scores for perspective taking (M = 13.41, SD = 3.83), fantasy (M = 13.57, SD = 3.17), empathy concern (M = 15.12, SD = 3.58), and personal distress (M = 11.78, SD = 4.76). Invasive rumination had a mean score of 14.43 (SD = 7.61), while purposive rumination scored 16.22 (SD = 7.00). Positive coping had a mean of 21.33 (SD = 5.27), while negative coping had a mean of 16.71 (SD = 5.78). The core belief score was 26.12 (SD = 9.98). Table 2 summarizes the descriptive statistics.

Pearson’s correlation analysis identified strong positive relationships between VPTG and several factors, including social support, positive coping, invasive rumination, purposive rumination, empathy, and core beliefs (P < 0.01), as outlined in Table 3.

In this study, a multiple linear regression analysis was conducted utilizing the input method to explore the factors impacting VPTG among nurses. The VPTG score was used as the dependent variable. Independent variables included positive coping, social support, core belief, age, invasive rumination, empathy, as well as training and education in courses related to psychological trauma, as these variables were statistically significant in previous analyses. The method of independent variable assignment is shown in Table 4.

The results of the regression analysis demonstrated that positive coping (β = 0.358, P < 0.001), social support (β = 0.266, P < 0.001), core belief (β = 0.186, P < 0.001), age (β = 0.083, P < 0.001), and empathy (β = 0.066, P = 0.019) positively influenced VPTG. Conversely, invasive rumination (β = -0.078, P = 0.002) had a negative impact on VPTG. Additionally, receiving training and education on psychological trauma courses (β = 0.046, P = 0.041) was a significant predictor of higher VPTG. Collectively, these factors explained 49.8% of the total variance in VPTG, as shown in Table 5.

The overall VPTG levels among the nurses were moderate to low, with 70.1% of participants reporting low to moderate levels, these findings support the conclusions of prior research. which indicate that while VPTG is present among nurses, it tends to be at moderate levels [29, 43, 44]. The moderate to low levels underscore both the potential for growth and the challenges nurses face in achieving higher levels of positive transformation. Overcoming these barriers through enhanced support systems and tailored interventions could promote more substantial personal and professional development among nurses.

This study reveals that several demographic factors significantly influence nurses’ VPTG scores. Notably, nurses aged 41–50 and those with over 30 years of experience scored higher, suggesting that age and experience enhance reflective abilities and coping mechanisms [15, 16]. Additionally, professors scored higher than other professional titles, indicating the importance of advanced training in promoting VPTG [45]. Married nurses showed greater growth, likely due to support from their spouses, which helps them cope with challenges and trauma. This emotional backing enhances their resilience and VPTG [46]. Furthermore, those caring for over 300 patients per week and those who received psychological trauma training exhibited higher VPTG scores, emphasizing the emotional challenges of heavy workloads and the value of education [29]. These results emphasize the importance of targeted approaches in nursing education and mental health interventions to promote personal growth and resilience among nurses.

Results obtained from the multiple linear regression analysis provide significant insights into the factors that influence VPTG among nurses. With an 𝑅² of 0.501, this model illustrates that a substantial portion of the variance in VPTG can be attributed to the independent variables examined. Each variable contributes uniquely to our understanding of how nurses can experience growth following exposure to trauma, emphasizing the multifaceted nature of VPTG. First, positive coping strategies were found to be the strongest positive predictor of VPTG, consistent with previous research, positive coping has been shown to help individuals reinterpret traumatic experiences in ways that promote personal development and growth [15, 26‐30]. Second, social support showed a significant positive effect on VPTG, aligning with numerous studies [47, 48]. Several studies have demonstrated that social support from colleagues, friends, and family enhances individuals’ resilience, helping them manage the emotional demands of their work and facilitating personal growth through trauma exposure [47, 48]. Rebuilding core beliefs was also found to be a significant predictor of VPTG, affirming the posttraumatic growth theory’s hypothesis that trauma often challenges fundamental beliefs, leading to a reconstruction of these beliefs and subsequent positive psychological changes [19‐21]. Nurses frequently exposed to traumatic situations may experience opportunities for psychological growth through this process. Additionally, there was a positive association between age and VPTG, suggesting that older nurses, with more experience and emotional regulation skills, may be better positioned to grow from traumatic experiences [15, 16]. On the contrary, intrusive rumination negatively impacted VPTG, consistent with prior research, indicating that excessive rumination over traumatic events hinders adaptation and increases psychological burden [49, 50]. Empathy also positively predicted VPTG, indicating that nurses’ ability to perceive and understand others’ pain may enhance emotional depth and coping capacity, fostering psychological growth [13, 51, 52]. Lastly, nurses who received psychological trauma training exhibited higher VPTG levels, highlighting that systematic trauma education and training can enhance nurses’ resilience and growth potential.

This study supports the application of Cohen and Collens’ VPTG framework, which posits that VPTG arises from indirect trauma exposure through empathetic engagement with patients. The framework suggests that empathetic interactions disrupt cognitive schemas, leading individuals to reflect on their beliefs and ultimately experience personal growth. In our findings, empathy was indeed a significant predictor of VPTG, underscoring its role in facilitating cognitive restructuring and emotional growth. These results provide empirical support for the VPTG framework and suggest that empathy, when paired with adaptive coping and social support, plays a pivotal role in fostering growth in the face of trauma. Overall, this study identified both positive and negative factors influencing VPTG, enriching the literature on VPTG in nurses. The findings provide theoretical support for promoting VPTG in clinical practice and offer guidance for designing interventions based on these influencing factors.

The results of this study hold significant implications for clinical practice. First, interventions that promote positive coping strategies, such as mindfulness and cognitive-behavioral techniques, could be integrated into nurse training programs to improve their capacity to handle trauma. Additionally, fostering a supportive work environment where social support networks are prioritized may help nurses mitigate the negative psychological effects of trauma and promote VPTG. Furthermore, providing psychological trauma training that emphasizes adaptive coping mechanisms could also be beneficial, as our results indicate that such training positively contributes to VPTG.

Although this study provides valuable insights, acknowledging its limitations is crucial. First and foremost, the cross-sectional characteristic of the research restricts our capacity to infer the causal connections between the investigated factors and VPTG. Future investigations should incorporate longitudinal approaches to assess how these variables interact over time. Secondly, the use of self-reported questionnaires may contribute to the introduction of response bias, as participants could either understate or exaggerate their experiences. Furthermore, the study’s context in China may limit the applicability about the relevance of the results to nursing populations in other cultural settings.

Given the findings and limitations, future research should explore the longitudinal impact of these key factors on VPTG to establish causality. It would also be valuable to investigate additional potential influencing factors, such as workplace culture and individual personality traits, which may play a role in promoting or hindering VPTG. Furthermore, intervention studies that assess the effectiveness of targeted strategies in fostering VPTG among nurses are needed. These interventions could focus on enhancing coping strategies, providing structured social support systems, and addressing maladaptive cognitive processes such as intrusive rumination.