Running head: SECONDARY TRAUMATIC STRESS
Secondary Traumatic Stress in Emergency Room Nurses
Jenna Ruimveld
Ferris State University
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SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES
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Abstract
Secondary traumatic stress (STS) is defined as “the emotions and behaviors that a person
experiences as a result of being exposed to another person’s traumatic experience” (Von Rueden
et al., 2012, p. 191). Many nursing staff experience STS, especially in those who work closely
with trauma victims. The symptoms associated with STS can affect the personal and professional
lives of nurses, influencing the quality and safety of patient care. This paper summarizes research
regarding secondary traumatic stress; prevalence, risks, and prevention. Theories relating to
secondary traumatic stress are described including Betty Neuman’s Systems Theory and
Maslow’s Hierarchy of Needs. The healthcare environment is assessed, including current
policies as well as consequences at a multidisciplinary level if this issue continues to occur.
Recommendations are then made, guided by research as well as the American Nurses
Association (ANA) standards of professional practice, as well as QSEN competencies;
Knowledge, Skills, and Attitudes. Secondary traumatic stress is not a well known topic among
healthcare workers and it needs to be addressed at all levels of care, in order to improve not only
patient care but to protect nurses as well.
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Secondary Traumatic Stress in Emergency Room Nurses
The issue of secondary traumatic stress and the effects it can have on healthcare is a
significant, yet understated topic. Secondary traumatic stress differs from posttraumatic stress
disorder (PTSD) in that STS is a result of being exposed to a person’s traumatic experience,
whereas posttraumatic stress disorder is caused by personally experiencing a traumatic event
(Von Rueden et al., 2012). Similar to post-traumatic stress disorder, STS is associated with a
range of physical and mental symptoms including insomnia, avoidance, anxiety, anger, inability
to concentrate, irritability, and distressing dreams (Czaja, Moss, & Mealer, 2012). These
symptoms have a direct impact on the personal and professional lives of nurses, putting not only
themselves, but patients at risk as well.
Laposa, Alden, and Fullerton (2003) identified the events that most often lead to the
development of STS in ER nurses:
(1) Providing care to a patient who is a relative or close friend and is dying or in serious
condition, (2) Threatened physical assault of self, (3) Multiple trauma with massive
bleeding or dismemberment, (4) Death of a child, (5), Providing care to a traumatized
patient who resembles yourself or family member in age or appearance, (6) caring for a
severely burned patient (p. 26, table 3).
Secondary traumatic stress affects emergency room (ER) nurses more frequently than
other areas of nursing due to the high volume of traumatized patients. However it is not limited
to ER nurses; STS can be seen in many of the different units and specialties within nursing such
as critical care, oncology, pediatrics, neonatal intensive care units, surgery, and labor and
delivery (Beck, 2011). Looking beyond just nursing, STS also has the potential to effect social
workers, doctors, managers, and nursing aides, meaning that it is a problem that occurs in all
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realms of healthcare and therefore needs to be addressed with a multidisciplinary approach. The
purpose of this paper is to analyze literature regarding secondary traumatic stress and the issues
that it poses to nursing as a profession, and to provide recommendations to reduce the impact of
STS.
Theory Base
Theories are the foundation for nursing practice driving the profession to constantly
improve. Nursing theories are not only applicable to nurses, just as psychology theories are not
just relevant to psychologists. Rather there is a sharing of information, theories, and ideas
between professions. Neuman Systems Model and Maslow’s Hierarchy of Needs both can be
applied to secondary traumatic stress. They have shared principles regarding stress and health as
well as values in self-care and understanding the important role that health plays in life.
Newman Systems Model
Newman Systems Model, a nursing theory developed by Betty Neuman, focuses on an
individual’s response to stress and stressful environments (Toto, Peters, Blackman, & Hoch,
2009). Like thumbprints, no two people are the same. A person’s stress is a constant changing
state and the responses and reactions to stress are subjective to the one experiencing them.
Stability is a term used in this theory, defined as “a state of balance of harmony requiring energy
exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal
level of health thus preserving system integrity” (Current Nursing, 2014). In order to maintain
this stability, Neuman’s Systems Model suggests that this role falls upon that of the nurse,
“…nurses can assist in preventing a stress response through primary prevention or help in
adjusting to the stress response through secondary and tertiary prevention” (Gunusen, Ustun, &
Gigliotti, 2009, p. 200).
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The threat to one’s stability or a stress response can be normal or abnormal. Emergency
room nurses who frequently work with traumatized patients work in a stressful environment;
because of this they are already at risk for deviating from stability. Nurses suffering from
secondary traumatic stress have surpassed their capacity for stress and their needs are to be
addressed with secondary and tertiary prevention methods. “The desired outcome of a primary,
secondary, and tertiary intervention is to retain, attain, and maintain balance and stability in the
client system” (Toto et al., 2009, p. 111). In summary, the Neuman Systems Model applies to
secondary traumatic stress in that it correlates environmental stress and stress response; for
example symptoms of STS. It also discusses the different levels of prevention and treatment,
primary, secondary, and tertiary, when caring for clients in whom a stress response can be
identified.
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs is a psychology-based theory created by Abraham Maslow
(Poston, 2009). Like many theories, it is applicable to more than one discipline, but most
importantly in healthcare and the assessment of a patient’s needs. There are five main aspects of
his theory that make up stages of needs in the form of a pyramid: physiological, safety, love and
belonging, self-esteem, and self-actualization (Poston, 2009). Basic human needs must be met in
order for someone to rise higher and towards self-actualization. When the stage of selfactualization has been reached, resilience to stress and stressors will also have formed.
STS is a stressor that potentially affects the needs and stage in which a person is located.
When there is a threat to safety, emotional and physical safety needs are not being met. The
ability to recognize this need internally requires reflection and self-assessment. Nurses who are
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experiencing symptoms of STS need to recognize their personal needs in order to move towards
self-actualization and constantly strive towards the top of the pyramid.
Health Care Environment Assessment
The healthcare environment is not simply the context in which a nurse works. Like any
environment, a healthcare environment is influenced by numerous factors and when assessing it,
policies (governmental and institutional), resources, and quality and safety issues, must be
considered. Secondary traumatic stress is a product of a poor healthcare environment, leading to
personal and professional mishaps in nurses.
Secondary traumatic stress is prevalent in many ER nurses;“…85% reported at least 1
STS symptom in the past week. Very concerning is the fact that 33% of the sample met the
criterion for a diagnosis of STS” (Dominguez-Gomez & Rutledge, 2009, p. 203).
Systems Framework
Government. Government support is a need for many issues in nursing; it is needed most
to protect healthcare workers. Currently, there are many policies and governmental aids for those
who have undergone a traumatic event, but no support for those who are treating them. The
Employee Assistance Program (EAP) is a federal program that provides assistance such as
counseling, legal and financial services, and more, to workers when facing troubling times (U.S.
Department of Health and Human Services, 2014). These services are limited to federal
employees only.
The Occupational Safety and Health Administration (OSHA), a governmental agency
aimed at enforcing occupational health and safety laws, does not have any enforceable regulation
or protocol for hospitals to follow after a traumatic event has occurred. Instead, they provide
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educational guides for supervisors and managers to follow after a crisis or traumatic event has
occurred (OSHA, 2014).
Healthcare Organization. The healthcare organization is responsible for its staff and
protecting their safety should be a priority. Magnet hospitals are becoming more of a trend
through the United States. Magnet hospitals are organizations that have been recognized for their
outstanding efforts towards patient and nursing care; “The Magnet Recognition Program
recognizes health care organizations for quality patient care, nurse excellence and innovations in
professional nursing practice” (American Nursing Credentialing Center [ANCC], 2014).
According to the ANCC (2014), Magnet recognized hospitals follow the Forces of Magnetism,
which are 14 characteristics the hospital has including “organizational structure and
interdisciplinary relationships”. Because of these characteristics Magnet hospitals possess, they
have a greater value of their nursing staff and are dedicated to constantly improve.
Organizations do not always have to be required by accreditation to put the needs of their
nursing staff first. Bronson hospital a local hospital in Kalamazoo, Michigan, also puts the needs
of the hospital staff following a crisis. According to Liz Colson, a Bronson Staff member,
Bronson has a crisis debriefing services for staff that is delivered by the Bronson Crisis
Debriefing Team. Staff volunteers from different areas of the hospital provide this service. The
Crisis Debriefing Team consists of 25 employees trained in Critical Incident Stress Management
and all of the services they provide are available at all times and dates to all units or departments.
The debriefings are confidential and voluntary (L. Colson, personal communication, June 12,
2014).
Quality and Safety Issues
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Secondary traumatic stress affects all aspects of life, both professionally and personally.
These affects can have significant outcomes in quality and safety of both nursing and patient
care. It is important for nurses to understand secondary traumatic stress and take action if or
when symptoms begin to arise. This is assumption can be made regarding this topic; that nurses
have an understanding of secondary traumatic stress and how to cope with traumatic events in
the ER, however this is not the case. In fact many nurses have not even heard about secondary
traumatic stress or how it can affect their lives.
Personal effects of STS. Work stress and trauma can overflow into the personal lives of
nurses, especially those suffering with STS. Secondary traumatic stress can cause a range of
symptoms all having an impact on the home lives of nurses, not just related to sleep, “... include
an altered worldview and changes in psychological and emotional needs, trust and dependence,
control, intimacy self esteem, altered beliefs and cognitions, and sense of safety that parallel
those of post traumatic stress disorder (PTSD)” (Tabor, 2011, p. 203). Strains in personal
relationships may begin to form, ultimately completing the circle and affecting job performance.
Patient care. Quality and safety is a major aspect of patient care. It is the role of the
nurse to provide each patient with the highest standard of care possible and in the safest way
possible. One of the main symptoms of secondary traumatic stress is the inability to concentrate.
In the emergency room, or a nursing setting, concentration and focus is key. Lack of
concentration can lead to medication errors, higher risk of infections, and ultimately putting the
lives of patients at risk as well as increase hospital costs.
Inferences/Implications/Consequences
Assessment of the healthcare environment initially may lead to believe there is adequate
support and knowledge regarding secondary traumatic stress in nursing. There are specific
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examples of hospitals supporting their employees through difficult times however this is not a
common trait among all organizations. The lack of legislative policy regarding the protection and
prevention of secondary traumatic stress in nursing is potentially putting many staff at risk for
this stress disorder. Healthcare is such a consumer driven product that nurses get lost in the
numbers. Magnet hospitals clearly value nursing as a profession and are dedicated to support
their staff, as well as hospitals that offer debriefing and counseling following a traumatic event.
The healthcare environment needs to be positive and uplifting, with support from peers as well as
management. All of these things can lead to a work environment of caring, which is what the
nursing profession is about.
Consequences
If there is a continuation of lack of support and education for staff following a traumatic
event, significant outcomes or complications may occur. Secondary traumatic stress can lead to
many work related issues for many nurses. Czaja et al. (2012) concluded that the presences of
PTSD and STS can lead nurses to feeling symptoms related to compassion fatigue, burnout, job
dissatisfaction, and even be the cause of nursing turnover rates in many emergency rooms.
Nursing turnover can cost the hospitals and nursing staff as a whole. A quick turnover rate can
lead to a decrease in staff, ultimately resulting in increased patient workload for many nurses
leading way to medication errors, increased risk for falls, and a decrease in patient satisfaction.
The entire system is a constant balance and shift; all of the factors are dependent upon
one another. Patient satisfaction is dependent on nursing care, nursing care is dependent on job
satisfaction, and job satisfaction is dependent on work environment and so on. It can be assumed
with an equal balance between the factors associated with secondary traumatic stress, increased
resilience and better patient outcomes can be achieved.
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Recommendations for Quality and Safety
Secondary traumatic stress directly and indirectly affects patient quality and safety. The
prevention and treatment of secondary traumatic stress does not just fall upon the nurse, but the
environment and organization as well. Strategies to implement within the healthcare environment
are discussed.
Debriefing
Critical Incident Stress Debriefing is a tool that can be utilized in all professions after a
crisis. During debriefing, which is usually voluntary, members of the group meet and share their
experiences and inform one another about the situation (Hanna & Romana, 2007). Hanna and
Romana (2007) also describe the role of the group leader as gathering facts and staff reaction as
well as the symptoms staff are experiencing or exhibiting. The leader also educates group
members about positive coping strategies and at the end of the meeting recommendations for
follow up and individual counseling are made to those who show obvious signs of secondary
traumatic stress (p. 41). Research has shown it can have a positive effect on nursing. “There were
trends for those who attended critical incident stress debriefing. They tended to report feeling
more supported by their hospital administration and to report less interpersonal conflict”
(Laposa, Alden, & Fullerton, 2003, p. 27).
Education
There is an educational gap for nurses in relation to positive coping strategies. Following
a crisis or traumatic event, resiliency is what keeps a nurse strong. Flarity, Gentry, and
Mesnikoff (2013) describe an educational program and its positive effects on secondary
traumatic stress. The educational program was implemented in a level II trauma hospital and
significant improvements were shown in the results “In the pretest, 35 participants reported
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moderate to high levels of STS but only 24 participants reported that level after the intervention,
indicating a 19% improvement (p = 0.001; see Table 4)” (Flarity, Gentry, & Mesnikoff, 2013, p.
255). By implementing an educational program for nursing staff, prevalence of secondary
traumatic stress will decline.
Support from Management
A network for support is a vital piece of resiliency in nursing. The lack of professional
support from peers and managers can cause an increase in secondary traumatic stress, “The
majority of respondents (67%) believed they had received inadequate support from hospital
administration following the traumatic event” (Laposa et al., 2003, p. 23). There needs to be a
framework of support from management, organization, peers, and personal relationships.
“…Data suggest that external support systems and relationships in the work environment may
have an important mitigating effect on the incidence of STS related to the daily exposure of
trauma nurses to seriously injured patients” (Von Rueden et al., 2012, p. 199).
Quality and Safety Standards and Competencies
American Nurses Association (ANA) Standards
Standard 12: Leadership. “The registered nurse demonstrates in the professional
practice setting and the profession” (American Nurses Association [ANA], 2010, p. 55). The
ability to be a leader in nursing does not have a direct association with power. According to
ANA (2010), nursing leaders drive the profession to improve, “provides direction to enhance the
effectiveness of the interprofessional team” (p. 56). Decrease in STS prevalence among nurses
can both be a cause and effect of more sustainable and connected interprofessional team.
Standard 14: Professional Practice Evaluation. “The registered nurse evaluates her or
his own nursing practice in relation to professional practice standards and guidelines, relevant
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statutes, rules, and regulations” (ANA, 2010, p. 59). Self-evaluation of nursing practice is
valuable to many nurses in order to identify areas of strength and needed improvement. The
foundation of nursing is compassion and caring. Nurses who are experiencing STS, burnout or
compassion fatigue, are not expressing caring qualities to each patient. Frequently performing
self-assessments allows nurses to identify areas of need and seek help guidance.
Standard 16: Environmental Health. “The registered nurse practices in an
environmentally safe and healthy manner” (ANA, 2010, p. 61). Practicing in a safe and healthy
manner does not apply to physical safety but emotional and psychological safety as well. Nurses
promote a practice environment that reduces health risks for workers as well as heath care
consumers. Nurses exhibiting symptoms of STS such as anxiety and poor concentration are at a
greater risk to produce errors. Medication errors or even back injuries are both results of poor
concentration. The nursing environment needs to be one where work can be performed
accurately and efficiently. Nurses must advocate for themselves if this environment is not being
promoted in their workplace.
Quality and Safety Education for Nurses (QSEN) Competencies
Teamwork and Collaboration. “Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making
to achieve quality patient care” (Quality and Safety Education for Nurses [QSEN], 2012, p. 4).
Functioning as an active member of a team can lead to increased quality and safety for nurses.
Teamwork provides a structure of support for its members as well as establishing trust, both of
which are involved in the prevention and treatment of STS.
Safety. “Minimizes risk of harm to patients and providers through both system
effectiveness and individual performance” (QSEN, 2012, p. 4). Safety for both patients and staff
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fall upon the responsibility of the nurses. If there is a potential risk for patient or nursing staff
harm, it needs to be resolved before incidences occur. Nurses actively participate in the safety of
the environment as well as personal safety and security. Implementing strategies to reduce the
risk of STS occurrence in the hospital is a direct example of minimizing the risk for harm.
Conclusion
The issue of secondary traumatic stress is one that cannot be over looked. STS is not only
present in emergency room nursing, but rather all aspects of nursing due to its caring nature. The
symptoms have the ability to alter personal and professional practices, putting nurses and
patients at risk. Prevention of STS needs to occur at all levels of the systems framework;
government, organization, management, and self. Nurses take care of their patients holistically,
meaning mind, body, and soul. Always putting the needs of others before themselves, there
needs to be someone to advocate for their health, “Nurses enter their profession in order to care
for others; however, that must be combined with caring for themselves and their peers” (Tabor,
2011, p. 208)
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References
American Nurses Association . (2010). Nursing: Scope and standards of practice (2nd ed.).
Silver Spring, MD: Nursesbooks.org.
American Nursing Credentialing Center. (2014). Magnet recognition program overview.
Retrieved June 20, 2014, from
http://www.nursecredentialing.org/Magnet/ProgramOverview.aspx
Beck, C. T. (2011). Secondary truamatic stress in nursing: A systematic review. Archives of
Psychiatric Nursing, 25(1), 1-10. http://dx.doi.org/10.1016/j.apnu.2010.05.005
Current Nursing. (2014). Betty Neuman’s Systems Model. Retrieved from
http://currentnursing.com/nursing_theory/Neuman.html
Czaja, A. S., Moss, M., & Mealer, M. (2012). Symptoms of posttraumatic stress disorder among
pediatric acute care nurses. Journal of Pediatric Nursing, 27(4), 357-365.
http://dx.doi.org/10.1016/j.pedn.2011.04.024
Dominguez-Gomez, E., & Rutledge, D. N. (2009). Prevalence of secondary traumatic stress
among emergency nurses. Journal of Emergency Nursing, 35(3), 199-204.
http://dx.doi.org/10.1016/j.jen.2008.05.003
Flarity, K., Gentry, E., & Mesnikoff, N. (2013). The Effectiveness of an educational program on
preventing and treating compassion fatigue in emergency nurses. Advanced Emergency
Nursing Journal, 35(3), 247-258. http://dx.doi.org/10.1097/TME.0b013e31829b726f
Gunusen, N. P., Ustun, B., & Gigliotti, E. (2009). Conceptualization of burnout from the
perspective of the Neuman systems model. Nursing Science Quarterly, 22(3), 200-204.
http://dx.doi.org/10.1177/0894318409338685
SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES
15
Hanna, D. R., & Romana, M. (2007). Debriefing after a crisis. Nursing Managment, 38(8), 3842, 44-45, 47. http://dx.doi.org/Retrieved from
Laposa, J. M., Alden, L. E., & Fullerton, L. M. (2003). Work stress and posttraumatic Stress
disorder in ED nurses/personnel. Journal of Emergency Nursing, 29(1), 23-28.
http://dx.doi.org/10.1067/men.2003.7
Magnet Recognition Program Overview. (2014).
http://www.nursecredentialing.org/Magnet/ProgramOverview.aspx
Occupational Safety and Health Administration. (2014). Managing stress during a crisis.
Retrieved from
https://www.osha.gov/SLTC/emergencypreparedness/resilience_resources/support_docu
ments/supervisorintra/intradeployment_supervisors.html
Poston, B. (2009). The Surgical Technologist, 41(8), 346-355. Retrieved from
http://www.ast.org/publications/journal%20archive/2009/8_august_2009/ce.pdf
Quality and Safety Education for Nurses. (2012). Graduate-level QSEN competencies:
Knowledge, skills, and attitudes. Retrieved June 10, 2014, from
http://www.aacn.nche.edu/faculty/qsen/competencies.pdf
Tabor, P. D. (2011). Vicarious traumatization: Concept analysis. Journal of Forensic Nursing,
7(4), 203-208. http://dx.doi.org/10.1111/j.1939-3938.2011.01115.x
Toto, D. L., Peters, A. B., Blackman, B. J., & Hoch, C. R. (2009). Bridging the gap: answering
the need for nursing faculty. Teaching & Learning in Nursing, 4(4), 109-114.
http://dx.doi.org/10.1016/j.teln.2009.02.006
U.S. Department of Health and Human Services. (2014). Employee assistance program:
Retrieved June 20, 2014, from http://foh.hhs.gov/services/EAP/EAP.asp
SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES
Von Rueden, K. T., Hinderer, K. A., McQuillan, K. A., Murray, M., Logan, T., Kramer, B., ...
Friedmann, E. (2012). Secondary traumatic stress in trauma nurses: Prevalence and
exposure, coping, and personal/environmental characteristics. Journal of Trauma
Nursing, 17(4), 191-200. http://dx.doi.org/10.1097/JTN.0b013e3181ff2607
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