Distress, Support, and Occupational Functioning: Predictors of Turnover Intentions and Absenteeism Among Israeli Nurses Following Adverse Events

Distress, Support, and Occupational Functioning: Predictors of Turnover Intentions and Absenteeism Among Israeli Nurses Following Adverse Events | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Distress, Support, and Occupational Functioning: Predictors of Turnover Intentions and Absenteeism Among Israeli Nurses Following Adverse Events Rinat Cohen, Yael Sela, Or Catz, Rachel Nissanholtz-Gannot This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7878713/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: The global healthcare system is grappling with a severe shortage of nursing staff, a deficit exacerbated by the prevalent Second Victim Phenomenon (SVP), where nurses experience significant emotional, physical, and professional distress after involvement in adverse events (AEs). Research consistently links SVP to nurse absenteeism and turnover, underscoring the critical need for effective support systems. Unlike many countries with established SVP support, Israel lacks systemic national and organizational level strategies, leading to potential underreporting of AEs and a hidden burden of distress among caregivers. This study examined the association between SVP and absenteeism and turnover intentions among Israeli nurses, specifically investigating the roles of direct managers and the organization. Methods: A culturally diverse sample of 174 postgraduate nurses who reported experiencing an adverse event the Hebrew-validated Second Victim Experience and Support Tool (H-SVEST), assessing psychosocial factors and employment outcomes (turnover intentions, absenteeism). Results: Over 90% of nurses reported psychological and physical distress following AEs. Physical distress emerged as a primary driver for both turnover intentions and absenteeism. In contrast, professional self-efficacy and various forms of organizational support (from colleagues, supervisors, and the institution) acted as critical protective factors, significantly reducing these negative outcomes. The path analysis model explained 52.7% of the variance in turnover intentions and 39.2% in absenteeism. Notably, supervisor support significantly and negatively predicted absenteeism (B = -0.243, p < .01). Conclusions: This study provides the first quantitative examination of SVP among Israeli nurses, affirming its profound impact on workforce stability. Our findings highlight the significant role of physical distress in predicting turnover and absenteeism in the Israeli context. The crucial role of various forms of organizational support and professional self-efficacy as mitigating factors underscores the urgent need for structured, systematic support systems within Israeli healthcare Figures Figure 1 Background The global healthcare system is grappling with a severe shortage of nursing staff, with the worldwide deficit standing at approximately 5.8 million nurses, despite an increase in personnel from 27.9 million in 2018 to 29.8 million in 2023 [ 1 ]. In the United States, of approximately 4.5 million registered nurses, over a quarter have planned to leave the profession by 2027, and about 100,000 have already departed [ 2 ]. Within this context, Israel stands out as a particularly complex case, facing several structural and demographic workforce challenges that exacerbate the crisis [ 3 ]. Israel is currently facing a severe nursing shortage, consistently ranking at the bottom among OECD countries in nurse per resident ratio. In 2022, there were only 5.57 nurses per 1,000 residents, a significant 39.5% below the OECD average of 9.2/1000 residents [ 4 ] [ 5 ]. Despite a moderate increase in the number of actively employed nurses, the deficit remains substantial and is particularly acute in peripheral regions. The Israeli Ministry of Health (MOH) has set a target to reach 7 nurses per 1,000 residents by 2027 [ 6 ]. However, achieving this goal is challenging, as approximately 1,500 additional nurses would be needed to fill this void. This persistent gap underscores ongoing challenges in the recruitment, retention, and effective utilization of Israel's nursing workforce. The Second Victim Phenomenon (SVP) is pervasive issue among nurses, with 60% to 92% reporting this experience [ 7 ]. Nurses universally face the Second Victim Phenomenon (SVP) after adverse events (AEs), with severity influenced by factors like high-intensity work environments, gender, age, seniority, and a lack of organizational support [ 8 ] [ 9 ] [ 10 ] [ 11 ]. The phenomenon (SVP) specifically describes the emotional, physical, and professional distress nurses endure, especially after being involved in or exposed to an AE [ 12 ] [ 13 ] [ 14 ]. Traditionally, the primary focus has been on the patient, or "first victim", yet there is an increasing international recognition of the profound and lasting impact on caregivers, alongside the organization itself also being acknowledged as a "third victim" [ 15 ] [ 8 ] [ 16 ]. Research has found significant associations between occurrence of the Second Victim Phenomenon (SVP) and nurse absenteeism and turnover [ 17 ]. Most nurses experience distress shortly after an AE, and about half still report distress and turnover intentions three months later [ 8 ]. SVP's multifaceted presentation, encompassing emotional, psychological, and physical symptoms [ 18 ], can lead to chronic stress, burnout, post-traumatic stress disorder (PTSD), and significant professional consequences, notably increased turnover [ 9 ] [ 19 ] [ 17 ]. This phenomenon not only compromises nurse well-being but also jeopardizes patient safety and care quality by fostering errors and defensive practices. The resulting psychological distress frequently contributes to burnout and a subsequent desire to leave the profession [ 20 ]. Organizational cultures that are punitive may exacerbate SVP distress, while supportive environments can mitigate the associated trauma. Importantly, several studies have found that organizational support seems to completely mediate the relationship between SVP distress and turnover intentions,[ 17 ] [ 21 ] indicating its crucial role. However, structured support systems for second victims are rare in most healthcare organizations, including Israel [ 22 ] [ 23 ]. Key barriers include lack of awareness, stigma, absent protocols, and over-reliance on individual initiative[ 24 ] [ 9 ] [ 16 ]. A recent study found that Israeli nurses experienced significant distress after adverse events but rarely sought help, and their organizations typically didn't offer active support [ 9 ] [ 23 ]. Despite existing guidelines, there is no uniform national policy for SVP in Israel [ 23 ], with support often limited to local initiatives rather than integrated into a broader organizational culture. Given the scale, impact, and severity of the SVP for nurses, patients, and the healthcare system, it is essential to understand this phenomenon among healthcare teams. Therefore, the aim of this study was to determine the association between the second victim phenomenon and absenteeism and turnover intentions among Israeli nurses, examining the role of the direct manager and the organization. Methods Study population Postgraduate nurses from diverse medical organizations and disciplines, encompassing hospitals, geriatric home care, and community settings, were recruited using a written invitation accompanied by an information letter. This broad recruitment strategy aimed to minimize selection bias and enhance response rates. The recruitment process involved three rounds within these professional networks. Research tools and variables The H-SVEST [25], is a culturally and linguistically validated version of the SVEST was used to assess the second victim experience of providers as well as their desired forms of support. The full process of its translation and psychometric validation has been reported in a prior publication. The final validated version includes 26 items and 9 factors with Cronbach α values ranging from 0.66 to 0.94. Data Collection Upon receipt of the ethics committee approval of the participating academic institution (AU-20220409). The study was administered through Qualtrics (Provo, UT) from January to May, 2023. Participants were recruited via social media, online forums, and local and regional connections. All participants provided their consent. Each participant completed the adapted instrument in a single session. Sample size A priori analysis was conducted using G-Power version 3.1.9.7 [26] to determine the required sample size for testing the research hypotheses. Statistical power at 80% with a medium effect size, at a significant level of α=.05 for a two-tailed hypothesis, required 84 participants. To determine the sample size for the path analysis, the Monte Carlo method [27] [28] was applied. This method revealed a minimum sample size of 150 participants. The total sample was N=174. Data analysis Data analysis was conducted using SPSS software (SPSS Inc., Chicago, IL, USA, v. 29.0.1.0) and R (R software 4.3.3) via “Iavaan”. To examine whether there were correlations between the research variables, Pearson correlations using SPSS software were used, and to test whether H-SVEST measures predict turnover intentions and absenteeism, path analysis using R was used. Results The study included 174 nurse participants who reported experiencing an adverse event sometime during their healthcare careers. The majority of the sample were women, married, and held academic degrees (Table 1). The average age was 42.6 (24-67 SD 9.47). Most participants had completed post-basic training, primarily in hospital-related fields, like emergency medicine or ICU. The average professional experience was approximately 17 years, with an average of 10 years at the current workplace (Table 2). Approximately 60% (61.5%) of respondent's report experiencing an adverse event in the past year (Table 3). The majority reported near misses without patient harm or errors without patient harm, but included were incidents involving violence, abuse, patient death, or patient falls. All participants had reported experience with adverse events, but only 85.1% had completed an adverse event report, and 45.7% reported that they had avoided filing an adverse event report at least once for various reasons. Finally, 96.5% witnessed adverse events involving other staff members, and in approximately 70% of cases (70.1%), they participated in writing the reports with other staff members. Response Measures to the Event To examine whether there is a relationship between turnover and absenteeism to the other H-SVEST measures, Pearson correlations were administered (Table 4). Statistically significant positive correlations were found between turnover and absenteeism, and statistically significant positive correlations were found between both of them and with measures of psychological distress and physical distress, and statistically significant negative correlations between turnover and absenteeism with supervisor support, organizational support, and professional self-efficacy. Additionally, a statistically significant negative correlation was found between turnover and peer support, and a statistically significant positive correlation between absenteeism and support from significant others. In other words, the higher the psychological and physical distress, and the lower the support from colleagues, direct supervisor, and organization, and the lower the professional self-efficacy, the greater the thoughts of leaving. Furthermore, the higher the psychological and physical distress, the lower the support from the direct supervisor and organization, the lower the professional self-efficacy, and the greater the support from close significant others, the higher the absenteeism from work. Relatively similar correlations were found when we split the sample into participants who experienced an adverse event in the past year and participants who experienced an adverse event but not in the past year. The few differences found between the correlations stem from a significant decrease in sample size from the general sample to two separate samples. Path analysis linking H-SVEST measures to turnover intentions and absenteeism To test the paths from H-SVEST measures to turnover intentions and absenteeism, we used path analysis using R (lavaan package). The model provided was saturated, TLI=1.000, CFI=1.000, RMSEA[90% C.I.]=0.000 [0.000, 0.000], SRMR=.000) (Table 5). Results indicate that physical distress positively predicted turnover intentions (B=0.361), and colleague (B=-0.248) and institutional (B=-0.228 ) support, and professional self-efficacy (B=-0.540) negatively predicted turnover intentions. Physical distress (B=0.532) and non-work-related support (B=0.116) positively predicted absenteeism, and supervisor support (B=-0.243) negatively predicted absenteeism. Thus, increased physical distress and lower colleague support, institutional support, and professional self-efficacy, the higher the turnover intentions. The higher the physical distress and non-work-related support, and the lower the supervisor support, then the higher the absenteeism (Figure 1). Discussion This study offers the first quantitative examination of the occurrence of Second Victim Phenomenon (SVP) among Israeli nurses and its relationship to critical workforce outcomes: turnover intentions and absenteeism. Consistent with prior studies [23] [10], all 174 participants in our research reported experiencing an AE at some point in their clinical careers, with 61.5% reporting SVP due to an AE in the past year. This underscores the pervasive nature of AEs in clinical practice and, aligning with other research, emphasizes the critical importance of understanding their profound impact on healthcare professionals and healthcare in general [29] [30]. Psychological distress following an adverse event (AE) significantly correlated with both turnover intentions and absenteeism among Israeli nurses in our study, which mirrors findings from the United States [17] and Europe [31] and other Middle Eastern countries [32], indicating the universality of this phenomenon despite cultural and organizational differences. Our research brings to light the significant contribution of the physical manifestations of distress in predicting these negative workforce impacts. The findings also highlight that the recency of an adverse event (AE) has a significant impact on distress levels and negative outcomes, positioning recent AEs as an immediate concern for workforce stability. Conversely, professional self-efficacy and various forms of organizational support, including aid from colleagues, supervisors, and the institution emerged as vital protective factors. These elements significantly reduced both turnover intentions and, to some extent, absenteeism, aligning with existing literature that acknowledges the profound impact of the Second Victim Phenomenon (SVP) on healthcare professionals [17]. Specifically, our findings indicate that institutional support and supervisor support are strong negative predictors of turnover intentions and absenteeism, respectively, underscoring the crucial role of a supportive organizational climate and structured support systems. Our model provided robust empirical support for theoretical linkages proposed in the literature, [33] [34] while uniquely shedding light on the Israeli healthcare context. As our model also demonstrated that supervisor support significantly and negatively predicted absenteeism (B=−0.243, p<.01), emphasizing the direct manager's crucial role in fostering a work environment that reduces absenteeism post-AE [17] [35]. Finally, while the high rate of nurses witnessing adverse events (AEs) involving other staff members and their frequent engagement in co-authoring related reports strongly underscore the inherent collective nature of AE exposure within clinical nursing practice, a notable discrepancy emerges when examining individual reporting behaviors. Despite that a substantial majority of nurses did complete an AE report, a significant proportion admitted to having avoided filing a report on at least one occasion. These barriers prevent professionals from transparently reporting errors they were personally involved in, which significantly contributes to underreporting. Consequently, this leads to the under-identification of Second Victims (SVP), leaving a substantial portion of affected healthcare professionals without the necessary institutional support and resources [36]. This situation creates a hidden burden of psychological distress among caregivers, ultimately undermining efforts to foster a resilient and safety-oriented healthcare culture, and potentially influencing nurse absenteeism and turnover. Thus, there is a critical need to further investigate the underlying barriers to transparent reporting within the specific context of Israeli healthcare. The concerning finding that 45% of nurses avoided reporting adverse events at least once further points to a punitive safety culture or a lack of supportive reporting mechanisms, which likely exacerbates distress [37]. Given the reported lack of systematic support for SVP in Israel, our results offer a compelling quantitative basis for advocating for the implementation of formal, accessible support programs at both organizational and national levels. Such initiatives are not a luxury but a necessary condition for system sustainability, providing strong empirical evidence for the relationship between SVP and turnover intentions and absenteeism among Israeli nurses. Limitations The cross-sectional design and reliance on self-reported data introduce potential biases, including recall bias, social desirability bias, and underreporting of sensitive events. This methodological approach inherently limits the ability to establish causal relationships between variables, allowing only for the identification of associations. Furthermore, the convenience sample, recruited through online professional networks, may not fully represent the broader nursing population and could be subject to selection bias, particularly given the sub-group analyses which further reduced sample sizes. The lack of objective measures for absenteeism and turnover, relying instead on self-reported intentions, represents another limitation, as stated intentions may not always translate into actual behaviors. Finally, the findings are situated within the unique context of the Israeli healthcare system, characterized by a critical nursing shortage and a notable absence of systematic SVP support, which may limit the generalizability of these results to other national healthcare systems with different cultural, organizational, and structural characteristics. Addressing these limitations, future research should consider several key directions. Longitudinal studies are crucial to establish causal inferences, allowing researchers to track the progression of distress, turnover intentions, and absenteeism over time following adverse events. In addition, a cross-cultural comparative study involving nurses from Israel and countries with established SVP support programs could highlight the unique impacts of the Israeli context on the SVP experience and its outcomes. Conclusions This study provides the first quantitative examination of the Second Victim Phenomenon (SVP) among Israeli nurses, confirming its significant impact on workforce stability. Our findings highlight that physical distress following adverse events is a major predictor of both turnover intentions and absenteeism among nurses, a crucial insight that expands on the literature's traditional focus on psychological distress. Conversely, professional self-efficacy and various forms of organizational support (from colleagues, supervisors, and the institution) emerge as critical protective factors, substantially reducing these negative occupational outcomes. Our data underscore the high prevalence of adverse events and the urgent need for structured support systems. The Israeli context, marked by a severe nursing shortage and a notable absence of systematic SVP support, exacerbates the impact of distress on workforce retention. The study's findings emphasize the pivotal role of direct managers in reducing absenteeism after adverse events, indicating that targeted support at the managerial level can serve as a strategic cornerstone. A comprehensive understanding of the Second Victim Phenomenon and its effects on nurse retention in Israel is paramount. Implementing comprehensive organizational support mechanisms is not merely a matter of individual well-being but rather a strategic imperative for maintaining a stable and capable healthcare workforce in a system facing severe challenges. By effectively addressing nurses' distress and providing adequate support, it may be possible to significantly improve nurse retention, reduce absenteeism, and ultimately contribute to patient safety and quality of care at a national level. Abbreviations AEs- Adverse Events SVP- Second Victim Phenomenon H-SVEST- Hebrew-validated Second Victim Experience and Support Tool MOH- Ministry of Health PTSD- Post-Traumatic Stress Disorder RN- Registered Nurse ICU- Intensive Care Unit ED- Emergency Department TLI- Tucker-Lewis Index CFI- Comparative Fit Index RMSEA- Root Mean Square Error of Approximation SRMR- Standardized Root Mean Square Residual SE- Standard Error LLCI- Lower Limit Confidence Interval ULCI- Upper Limit Confidence Interval Declarations Ethics approval and consent to participate- This study received ethical approval from the Institutional Review Board/Ethics Committee of Ariel University (Approval ID: AU-20220409), with all methods performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki, and all human participants providing written informed consent prior to their participation. Consent for publication- Informed consent was obtained from all subjects involved in the study. Availability of data and materials- The data presented in this study are available on request from the corresponding author. Competing Interests / Conflicts of interest – The authors report no conflicts of interest Funding- No funding was received to support this study. Authors' contributions- Conceptualization, R.C., Y.S., R.N.-G.; methodology, R.C., Y.S., R.N.-G., O.C.; software, O.C.; validation, R.C., Y.S., R.N.-G.; formal analysis, O.C.; investigation, R.C., O.C.; resources, R.C.; data curation, R.C., O.C.; writing—original draft preparation, R.C., Y.S., O.C.; writing— review and editing, R.C., Y.S., R.N.-G., O.C.; visualization, R.C., Y.S., R.N.-G., O.C.; supervision, Y.S., R.N.-G. All authors have read and agreed to the published version of the manuscript. Acknowledgements- The authors wish to thank Aviva Yoselis for her editorial support. References World Health Organization (WHO). 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International Journal of Nursing Sciences, 8( 4), 453–469. https://doi.org/10.1016/j.ijnss.2021.07.004 Tables Tables 1 to 7 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Cohen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYFACHiA2AJOMD0BcPuK0FIBIZmYDEJeNOC0fQAxmNgkQRVALf3vvwccFBvdkzNnPH6v8mmMnw8bA/PDRDTxaJM6cSzaeYVDMY9mTzHZbdlsy0GFsxsY5eLQYSOSYSfMYJPAYHABqkdzGDNTCwyZNQIv5b7CW84/ZiiW31ROlxYwZrOVGMhvjx22HCWuROHPGGOKwG4+NpRm3HedhYybgF/72HsPPPH8S7A3OJz78+HNbtT0/e/PDx/i0oABmHjBJrHIQYPxBiupRMApGwSgYMQAAH/s8/YizoxYAAAAASUVORK5CYII=","orcid":"","institution":"Tel Aviv Yaffo Academic College, Tel Aviv Yaffo","correspondingAuthor":true,"prefix":"","firstName":"Rinat","middleName":"","lastName":"Cohen","suffix":""},{"id":541528212,"identity":"334924e7-8448-4b19-921b-c63a95c67817","order_by":1,"name":"Yael Sela","email":"","orcid":"","institution":"Ruppin Academic College, Emek -Hefer","correspondingAuthor":false,"prefix":"","firstName":"Yael","middleName":"","lastName":"Sela","suffix":""},{"id":541528217,"identity":"df080c9e-66b8-4d6a-a922-4bf5e37ba382","order_by":2,"name":"Or Catz","email":"","orcid":"","institution":"Ashkelon Academic College","correspondingAuthor":false,"prefix":"","firstName":"Or","middleName":"","lastName":"Catz","suffix":""},{"id":541528218,"identity":"764ad682-617c-4918-862b-d2a8309ce35f","order_by":3,"name":"Rachel Nissanholtz-Gannot","email":"","orcid":"","institution":"Ariel University","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Nissanholtz-Gannot","suffix":""}],"badges":[],"createdAt":"2025-10-16 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1","display":"","copyAsset":false,"role":"figure","size":131640,"visible":true,"origin":"","legend":"\u003cp\u003ePath model linking H-SVEST measures to turnover intentions and absenteeism.\u003c/p\u003e\n\u003cp\u003e* \u0026lt;.05 ** \u0026lt;.01 *** \u0026lt;.001\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7878713/v1/c1aafb21dfc91b677b4a11bb.png"},{"id":96362921,"identity":"a9b11b23-38d2-4427-9a81-008366ada44f","added_by":"auto","created_at":"2025-11-20 10:02:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":535278,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7878713/v1/dee352fd-5664-44d7-a234-e2546c9d95a4.pdf"},{"id":96244312,"identity":"8ca4e79e-ef5f-4c74-b71a-03b7bdca6c48","added_by":"auto","created_at":"2025-11-19 07:18:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28785,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7878713/v1/2783bf3f629abb590a1704f0.docx"},{"id":96115307,"identity":"b11169b3-a28b-4876-85c0-604a65932b6c","added_by":"auto","created_at":"2025-11-17 18:27:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28785,"visible":true,"origin":"","legend":"","description":"","filename":"Tables20.docx","url":"https://assets-eu.researchsquare.com/files/rs-7878713/v1/c64b8f29a65ffbcb0302342c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Distress, Support, and Occupational Functioning: Predictors of Turnover Intentions and Absenteeism Among Israeli Nurses Following Adverse Events","fulltext":[{"header":"Background","content":"\u003cp\u003eThe global healthcare system is grappling with a severe shortage of nursing staff, with the worldwide deficit standing at approximately 5.8\u0026nbsp;million nurses, despite an increase in personnel from 27.9\u0026nbsp;million in 2018 to 29.8\u0026nbsp;million in 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the United States, of approximately 4.5\u0026nbsp;million registered nurses, over a quarter have planned to leave the profession by 2027, and about 100,000 have already departed [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Within this context, Israel stands out as a particularly complex case, facing several structural and demographic workforce challenges that exacerbate the crisis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIsrael is currently facing a severe nursing shortage, consistently ranking at the bottom among OECD countries in nurse per resident ratio. In 2022, there were only 5.57 nurses per 1,000 residents, a significant 39.5% below the OECD average of 9.2/1000 residents [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite a moderate increase in the number of actively employed nurses, the deficit remains substantial and is particularly acute in peripheral regions. The Israeli Ministry of Health (MOH) has set a target to reach 7 nurses per 1,000 residents by 2027 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, achieving this goal is challenging, as approximately 1,500 additional nurses would be needed to fill this void. This persistent gap underscores ongoing challenges in the recruitment, retention, and effective utilization of Israel's nursing workforce.\u003c/p\u003e\u003cp\u003eThe Second Victim Phenomenon (SVP) is pervasive issue among nurses, with 60% to 92% reporting this experience [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Nurses universally face the Second Victim Phenomenon (SVP) after adverse events (AEs), with severity influenced by factors like high-intensity work environments, gender, age, seniority, and a lack of organizational support [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The phenomenon (SVP) specifically describes the emotional, physical, and professional distress nurses endure, especially after being involved in or exposed to an AE [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Traditionally, the primary focus has been on the patient, or \"first victim\", yet there is an increasing international recognition of the profound and lasting impact on caregivers, alongside the organization itself also being acknowledged as a \"third victim\" [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResearch has found significant associations between occurrence of the Second Victim Phenomenon (SVP) and nurse absenteeism and turnover [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Most nurses experience distress shortly after an AE, and about half still report distress and turnover intentions three months later [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. SVP's multifaceted presentation, encompassing emotional, psychological, and physical symptoms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], can lead to chronic stress, burnout, post-traumatic stress disorder (PTSD), and significant professional consequences, notably increased turnover [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This phenomenon not only compromises nurse well-being but also jeopardizes patient safety and care quality by fostering errors and defensive practices.\u003c/p\u003e\u003cp\u003eThe resulting psychological distress frequently contributes to burnout and a subsequent desire to leave the profession [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Organizational cultures that are punitive may exacerbate SVP distress, while supportive environments can mitigate the associated trauma. Importantly, several studies have found that organizational support seems to completely mediate the relationship between SVP distress and turnover intentions,[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] indicating its crucial role. However, structured support systems for second victims are rare in most healthcare organizations, including Israel [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Key barriers include lack of awareness, stigma, absent protocols, and over-reliance on individual initiative[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A recent study found that Israeli nurses experienced significant distress after adverse events but rarely sought help, and their organizations typically didn't offer active support [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite existing guidelines, there is no uniform national policy for SVP in Israel [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], with support often limited to local initiatives rather than integrated into a broader organizational culture.\u003c/p\u003e\u003cp\u003eGiven the scale, impact, and severity of the SVP for nurses, patients, and the healthcare system, it is essential to understand this phenomenon among healthcare teams. Therefore, the aim of this study was to determine the association between the second victim phenomenon and absenteeism and turnover intentions among Israeli nurses, examining the role of the direct manager and the organization.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostgraduate nurses from diverse medical organizations and disciplines, encompassing hospitals, geriatric home care, and community settings, were recruited using a written invitation accompanied by an information letter. This broad recruitment strategy aimed to minimize selection bias and enhance response rates. The recruitment process involved three rounds within these professional networks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch tools and variables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe H-SVEST [25], is a culturally and linguistically validated version of the SVEST was used to assess the second victim experience of providers as well as their desired forms of support. The full process of its translation and psychometric validation has been reported in a prior publication. The final validated version includes 26 items and 9 factors with Cronbach α values ranging from 0.66 to 0.94.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUpon receipt of the ethics committee approval of the participating academic institution (AU-20220409). The study was administered through Qualtrics (Provo, UT) from January to May, 2023. Participants were recruited via social media, online forums, and local and regional connections.\u0026nbsp;All participants provided their consent. \u0026nbsp;Each participant completed the adapted instrument in a single session.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample size\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA priori analysis was conducted using G-Power version 3.1.9.7\u0026nbsp;[26]\u0026nbsp; to determine the required sample size for testing the research hypotheses. Statistical power at 80% with a medium effect size, at a significant level of α=.05 for a two-tailed hypothesis, required 84 participants. To determine the sample size for the path analysis, the Monte Carlo method\u0026nbsp;[27] [28]\u0026nbsp; was applied. This method revealed a minimum sample size of 150 participants. The total sample was N=174.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was conducted using SPSS software (SPSS Inc., Chicago, IL, USA, v. 29.0.1.0) and R (R software 4.3.3) via “Iavaan”. To examine whether there were correlations between the research variables, Pearson correlations using SPSS software were used, and to test whether H-SVEST measures predict turnover intentions and absenteeism, path analysis using R was used.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 174 nurse participants who reported experiencing an adverse event sometime during their healthcare careers. The majority of the sample were women, married, and held academic degrees (Table 1). The average age was 42.6 (24-67 SD 9.47). Most participants had completed post-basic training, primarily in hospital-related fields, like emergency medicine or ICU. The average professional experience was approximately 17 years, with an average of 10 years at the current workplace (Table 2).\u003c/p\u003e\n\u003cp\u003eApproximately 60% (61.5%) of respondent\u0026apos;s report experiencing an adverse event in the past year (Table 3). The majority reported near misses without patient harm or errors without patient harm, but included were incidents involving violence, abuse, patient death, or patient falls. All participants had reported experience with adverse events, but only 85.1% had completed an adverse event report, and 45.7% reported that they had avoided filing an adverse event report at least once for various reasons. Finally, 96.5% witnessed adverse events involving other staff members, and in approximately 70% \u0026nbsp; of cases (70.1%), they participated in writing the reports with other staff members.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResponse Measures to the Event\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo examine whether there is a relationship between turnover and absenteeism to the other H-SVEST measures, Pearson correlations were administered (Table 4). Statistically significant positive correlations were found between turnover and absenteeism, and statistically significant positive correlations were found between both of them and with measures of psychological distress and physical distress, and statistically significant negative correlations between turnover and absenteeism with supervisor support, organizational support, and professional self-efficacy. Additionally, a statistically significant negative correlation was found between turnover and peer support, and a statistically significant positive correlation between absenteeism and support from significant others. In other words, the higher the psychological and physical distress, and the lower the support from colleagues, direct supervisor, and organization, and the lower the professional self-efficacy, the greater the thoughts of leaving. Furthermore, the higher the psychological and physical distress, the lower the support from the direct supervisor and organization, the lower the professional self-efficacy, and the greater the support from close significant others, the higher the absenteeism from work.\u003c/p\u003e\n\u003cp\u003eRelatively similar correlations were found when we split the sample into participants who experienced an adverse event in the past year and participants who experienced an adverse event but not in the past year. The few differences found between the correlations stem from a significant decrease in sample size from the general sample to two separate samples.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePath analysis linking H-SVEST measures to turnover intentions and absenteeism\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo test the paths from H-SVEST measures to turnover intentions and absenteeism, we used path analysis using R (lavaan package). The model provided was saturated, TLI=1.000, CFI=1.000, RMSEA[90% C.I.]=0.000 [0.000, 0.000], SRMR=.000) (Table 5). Results indicate that physical distress positively predicted turnover intentions (B=0.361), and colleague (B=-0.248) and institutional (B=-0.228\u003cstrong\u003e)\u003c/strong\u003e support, and professional self-efficacy (B=-0.540) negatively predicted turnover intentions. Physical distress (B=0.532) and non-work-related support (B=0.116) positively predicted absenteeism, and supervisor support (B=-0.243) negatively predicted absenteeism. Thus, increased physical distress and lower colleague support, institutional support, and professional self-efficacy, the higher the turnover intentions. The higher the physical distress and non-work-related support, and the lower the supervisor support, then the higher the absenteeism (Figure 1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers the first quantitative examination of the occurrence of Second Victim Phenomenon (SVP) among Israeli nurses and its relationship to critical workforce outcomes: turnover intentions and absenteeism. Consistent with prior studies [23]\u0026nbsp;[10], all 174 participants in our research reported experiencing an AE at some point in their clinical careers, with 61.5% reporting SVP due to an AE in the past year. \u0026nbsp;This underscores the pervasive nature of AEs in clinical practice and, aligning with other research, emphasizes the critical importance of understanding their profound impact on healthcare professionals\u0026nbsp;and healthcare in general [29] [30].\u003c/p\u003e\n\u003cp\u003ePsychological distress following an adverse event (AE) significantly correlated with both turnover intentions and absenteeism among Israeli nurses in our study, which mirrors findings from the United States [17] and Europe [31] and other Middle Eastern countries [32], indicating the universality of this phenomenon despite cultural and organizational differences. \u0026nbsp;Our research brings to light the significant contribution of the physical manifestations of distress in predicting these negative workforce impacts.\u003c/p\u003e\n\u003cp\u003eThe findings also highlight that the recency of an adverse event (AE) has a significant impact on distress levels and negative outcomes, positioning recent AEs as an immediate concern for workforce stability. Conversely, professional self-efficacy and various forms of organizational support, including aid from colleagues, supervisors, and the institution emerged as vital protective factors. These elements significantly reduced both turnover intentions and, to some extent, absenteeism, aligning with existing literature that acknowledges the profound impact of the Second Victim Phenomenon (SVP) on healthcare professionals [17]. Specifically, our findings indicate that institutional support and supervisor support are strong negative predictors of turnover intentions and absenteeism, respectively, underscoring the crucial role of a supportive organizational climate and structured support systems.\u003c/p\u003e\n\u003cp\u003eOur model provided robust empirical support for theoretical linkages proposed in the literature, [33] [34] while uniquely shedding light on the Israeli healthcare context. As our model also demonstrated that supervisor support significantly and negatively predicted absenteeism (B=\u0026minus;0.243, p\u0026lt;.01), emphasizing the direct manager\u0026apos;s crucial role in fostering a work environment that reduces absenteeism post-AE\u0026nbsp;[17] [35].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Finally, while the high rate of nurses witnessing adverse events (AEs) involving other staff members and their frequent engagement in co-authoring related reports strongly underscore the inherent collective nature of AE exposure within clinical nursing practice, a notable discrepancy emerges when examining individual reporting behaviors. Despite that a substantial majority of nurses did complete an AE report, a significant proportion admitted to having avoided filing a report on at least one occasion. These barriers prevent professionals from transparently reporting errors they were personally involved in, which significantly contributes to underreporting. Consequently, this leads to the under-identification of Second Victims (SVP), leaving a substantial portion of affected healthcare professionals without the necessary institutional support and resources\u0026nbsp;[36]. This situation creates a hidden burden of psychological distress among caregivers, ultimately undermining efforts to foster a resilient and safety-oriented healthcare culture, and potentially influencing nurse absenteeism and turnover. Thus, there is a critical need to further investigate the underlying barriers to transparent reporting within the specific context of Israeli healthcare.\u003c/p\u003e\n\u003cp\u003eThe concerning finding that 45% of nurses avoided reporting adverse events at least once further points to a punitive safety culture or a lack of supportive reporting mechanisms, which likely exacerbates distress\u0026nbsp;[37]. Given the reported lack of systematic support for SVP in Israel, our results offer a compelling quantitative basis for advocating for the implementation of formal, accessible support programs at both organizational and national levels. Such initiatives are not a luxury but a necessary condition for system sustainability, providing strong empirical evidence for the relationship between SVP and turnover intentions and absenteeism among Israeli nurses.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe cross-sectional design and reliance on self-reported data introduce potential biases, including recall bias, social desirability bias, and underreporting of sensitive events. This methodological approach inherently limits the ability to establish causal relationships between variables, allowing only for the identification of associations. Furthermore, the convenience sample, recruited through online professional networks, may not fully represent the broader nursing population and could be subject to selection bias, particularly given the sub-group analyses which further reduced sample sizes. The lack of objective measures for absenteeism and turnover, relying instead on self-reported intentions, represents another limitation, as stated intentions may not always translate into actual behaviors. Finally, the findings are situated within the unique context of the Israeli healthcare system, characterized by a critical nursing shortage and a notable absence of systematic SVP support, which may limit the generalizability of these results to other national healthcare systems with different cultural, organizational, and structural characteristics.\u003c/p\u003e\n\u003cp\u003eAddressing these limitations, future research should consider several key directions. Longitudinal studies are crucial to establish causal inferences, allowing researchers to track the progression of distress, turnover intentions, and absenteeism over time following adverse events. \u0026nbsp;In addition, a cross-cultural comparative study involving nurses from Israel and countries with established SVP support programs could highlight the unique impacts of the Israeli context on the SVP experience and its outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides the first quantitative examination of the Second Victim Phenomenon (SVP) among Israeli nurses, confirming its significant impact on workforce stability. Our findings highlight that physical distress following adverse events is a major predictor of both turnover intentions and absenteeism among nurses, a crucial insight that expands on the literature's traditional focus on psychological distress. Conversely, professional self-efficacy and various forms of organizational support (from colleagues, supervisors, and the institution) emerge as critical protective factors, substantially reducing these negative occupational outcomes.\u003c/p\u003e\u003cp\u003eOur data underscore the high prevalence of adverse events and the urgent need for structured support systems. The Israeli context, marked by a severe nursing shortage and a notable absence of systematic SVP support, exacerbates the impact of distress on workforce retention. The study's findings emphasize the pivotal role of direct managers in reducing absenteeism after adverse events, indicating that targeted support at the managerial level can serve as a strategic cornerstone.\u003c/p\u003e\u003cp\u003eA comprehensive understanding of the Second Victim Phenomenon and its effects on nurse retention in Israel is paramount. Implementing comprehensive organizational support mechanisms is not merely a matter of individual well-being but rather a strategic imperative for maintaining a stable and capable healthcare workforce in a system facing severe challenges. By effectively addressing nurses' distress and providing adequate support, it may be possible to significantly improve nurse retention, reduce absenteeism, and ultimately contribute to patient safety and quality of care at a national level.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cem\u003eAEs-\u003c/em\u003e\u003cem\u003eAdverse Events\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eSVP-\u003c/em\u003e\u003cem\u003eSecond Victim Phenomenon\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eH-SVEST- Hebrew-validated Second Victim Experience and Support Tool\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eMOH- Ministry of Health\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003ePTSD- Post-Traumatic Stress Disorder\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eRN-\u003c/em\u003e\u003cem\u003eRegistered Nurse\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eICU-\u003c/em\u003e\u003cem\u003eIntensive Care Unit\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eED-\u003c/em\u003e\u003cem\u003eEmergency Department\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTLI- Tucker-Lewis Index\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCFI- Comparative Fit Index\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eRMSEA- Root Mean Square Error of Approximation\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eSRMR- Standardized Root Mean Square Residual\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eSE- Standard Error\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eLLCI- Lower Limit Confidence Interval\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eULCI-\u003c/em\u003e\u003cem\u003eUpper Limit Confidence Interval\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate- This study received ethical approval from the Institutional Review Board/Ethics Committee of Ariel University (Approval ID: AU-20220409), with all methods performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki, and all human participants providing written informed consent prior to their participation.\u003c/p\u003e\n\u003cp\u003eConsent for publication- \u003cem\u003eInformed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials- The data presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests / Conflicts of interest – The authors report no conflicts of interest\u003c/p\u003e\n\u003cp\u003eFunding- No funding was received to support this study.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions- Conceptualization, R.C., Y.S., R.N.-G.; methodology, R.C., Y.S., R.N.-G., O.C.; software, O.C.; validation, R.C., Y.S., R.N.-G.; formal analysis, O.C.; investigation, R.C., O.C.; resources, R.C.; data curation, R.C., O.C.; writing—original draft preparation, R.C., Y.S., O.C.; writing— review and editing, R.C., Y.S., R.N.-G., O.C.; visualization, R.C., Y.S., R.N.-G., O.C.; supervision, Y.S., R.N.-G. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements- The authors wish to thank Aviva Yoselis for her editorial support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO). (2025). State of the World\u0026apos;s Nursing Report 2025. https://www.who.int/publications/i/item/9789240110236\u003c/li\u003e\n\u003cli\u003eSuran, M. (2023). Overworked and understaffed, more than 1 in 4 U.S. nurses say they plan to leave the profession. \u003cem\u003eJAMA 330\u003c/em\u003e(16):1512\u0026ndash;1514. doi:10.1001/jama.2023.10055\u003c/li\u003e\n\u003cli\u003eDavidovitch, N., \u0026amp; Lev, N. (2024). The Healthcare system in Israel, 2024: Between resilience and continued challenges. \u003cem\u003eTaub Center for Social Policy Studies in Israel.\u003c/em\u003ehttps://doi.org/10.5281/zenodo.14568456\u003c/li\u003e\n\u003cli\u003eOECD. 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M., Vehvil\u0026auml;inen-Julkunen, K., Mikkonen, S., \u0026amp; H\u0026auml;rk\u0026auml;nen, M. (2025). Impact of second victim distress on healthcare professionals\u0026apos; intent to leave, absenteeism and resilience: A mediation model of organizational support. \u003cem\u003eJournal of Advanced Nursing, 81\u003c/em\u003e(9), 5376-5388. https://doi.org/10.1111/jan.16291\u003c/li\u003e\n\u003cli\u003eBurlison, J. D., Quillivan, R. R., Scott, S. D., Johnson, S., \u0026amp; Hoffman, J. M. (2021). The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-Reported Caregiver Distress to Turnover Intentions and Absenteeism. \u003cem\u003eJournal of Patient Safety, 17\u003c/em\u003e(3), 195\u0026ndash;199. https://doi.org/10.1097/PTS.0000000000000301\u003c/li\u003e\n\u003cli\u003eKohanov\u0026aacute;, D., \u0026amp; Barton\u0026iacute;čkov\u0026aacute;, D. (2024). Barriers to reporting adverse events from the perspective of ICU nurses: A mixed-method study. \u003cem\u003eEnfermeria Intensiva, 35\u003c/em\u003e(4), 287\u0026ndash;298. https://doi.org/10.1016/j.enfie.2023.12.005\u003c/li\u003e\n\u003cli\u003eWoo, M. W. J., \u0026amp; Avery, M. J. (2021). Nurses\u0026apos; experiences in voluntary error reporting: An integrative literature review. \u003cem\u003eInternational Journal of Nursing Sciences, 8(\u003c/em\u003e4), 453\u0026ndash;469. https://doi.org/10.1016/j.ijnss.2021.07.004\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7878713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7878713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The global healthcare system is grappling with a severe shortage of nursing staff, a deficit exacerbated by the prevalent Second Victim Phenomenon (SVP), where nurses experience significant emotional, physical, and professional distress after involvement in adverse events (AEs). Research consistently links SVP to nurse absenteeism and turnover, underscoring the critical need for effective support systems. Unlike many countries with established SVP support, Israel lacks systemic national and organizational level strategies, leading to potential underreporting of AEs and a hidden burden of distress among caregivers. This study examined the association between SVP and absenteeism and turnover intentions among Israeli nurses, specifically investigating the roles of direct managers and the organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A culturally diverse sample of 174 postgraduate nurses who reported experiencing an adverse event the Hebrew-validated Second Victim Experience and Support Tool (H-SVEST), assessing psychosocial factors and employment outcomes (turnover intentions, absenteeism).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Over 90% of nurses reported psychological and physical distress following AEs. Physical distress emerged as a primary driver for both turnover intentions and absenteeism. In contrast, professional self-efficacy and various forms of organizational support (from colleagues, supervisors, and the institution) acted as critical protective factors, significantly reducing these negative outcomes. The path analysis model explained 52.7% of the variance in turnover intentions and 39.2% in absenteeism. Notably, supervisor support significantly and negatively predicted absenteeism (B = -0.243, p \u0026lt; .01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study provides the first quantitative examination of SVP among Israeli nurses, affirming its profound impact on workforce stability. Our findings highlight the significant role of physical distress in predicting turnover and absenteeism in the Israeli context. The crucial role of various forms of organizational support and professional self-efficacy as mitigating factors underscores the urgent need for structured, systematic support systems within Israeli healthcare\u003c/p\u003e","manuscriptTitle":"Distress, Support, and Occupational Functioning: Predictors of Turnover Intentions and Absenteeism Among Israeli Nurses Following Adverse Events","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-14 10:37:52","doi":"10.21203/rs.3.rs-7878713/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-22T20:32:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296136681117158760379329746476548724229","date":"2025-12-12T12:22:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60368809520988366076817761929171151114","date":"2025-12-08T05:18:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-06T04:50:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86511294626650947051761847890470448796","date":"2025-12-06T04:26:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-18T12:05:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228171754482131307145540879614199203134","date":"2025-11-07T11:50:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-04T19:20:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-03T21:05:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-24T06:48:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-22T10:00:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-10-21T18:39:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ff66dcf3-ee9f-45d1-8d22-169e5f76dc90","owner":[],"postedDate":"November 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-14T10:37:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-14 10:37:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7878713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7878713","identity":"rs-7878713","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}