PREVALENCE OF SECONDARY TRAUMATIC

STRESS AMONG EMERGENCY NURSES

Authors: Elvira Dominguez-Gomez, RN, BSN, and Dana N. Rutledge, RN, PhD, Hemet and Fullerton, CA

Earn Up to 8 CE Hours. See page 273.

Introduction: Emergency nurses often care for persons exposedto traumatic events. In the presence of empathetic caring, nursesexposed to such stressors over time can suffer from SecondaryTraumatic Stress (STS), or Compassion Fatigue (CF). STSsymptoms (intrusion, avoidance, and arousal) may lead to jobdissatisfaction or burnout. The purpose of this study is toinvestigate the prevalence of STS in emergency nurses.

Methods: Exploratory comparative design, with 67 emergencynurses from three general community hospitals in California. Surveyinstruments included a demographic tool and the STS Survey (STSS).

Results: Nurses were most likely to have Arousal symptoms(irritability reported by 54% of nurses), followed by Avoidancesymptoms (avoidance of patients 52%), and Intrusion symptoms(intrusive thoughts about patients 46%). The majority of nurses(85%) reported at least one symptom in the past week. UtilizingBride’s algorithm to identify STS, 15% of nurses met no criteria,while 33% met all. Nurse participation in stress managementactivities was associated with less prevalence of STS symptoms.

Discussion: High prevalence of STS in our sample indicates thatpotentially large numbers of emergency nurses may be experiencingthe negative effects of STS. Symptoms may contribute to emotionalexhaustion and job separation of emergency nurses. Subsequentstudies should be done to evaluate the association of CF/STS onactual burnout and attrition among emergency nurses.

Exposure to human suffering by nurses is commonin the emergency department. On any day, emer-gency nurses care for an array of patients, varying

in age, injury, and disease process. They commonly seepatients with injuries sustained in motor vehicle crashes,

assaults, rapes, and abuse and from gunshot wounds. Emer-gency nurses may experience negative repercussions aftercaring for these types of patients with the cumulative effectof chronic exposure to patients in physical or psycho-logical distress, in conjunctionwith an empathetic response.1,2

A potential consequence of such “caring” work is anegative and profound effect on nurses’ health that is some-times referred to as compassion fatigue (CF) or secondary trau-matic stress (STS).1,3-5 CF was first described as “a uniqueform of burnout,” where people in the caregiving profes-sions are the most susceptible.6 The concept was furtherdeveloped as the emotional stress experienced (nurse) fromthe trauma of another (patient)7 and has been described asthe “emotional residual” of working with people who aresuffering or traumatized.8 Both STS and CF refer to expo-sure to a person or persons who are traumatized or suffer-ing rather than exposure to a traumatic event itself. Sabo1

posits that CF has an acute onset and results from caringfor people who are suffering rather than a toxic work envi-ronment. It may occur after multiple interactions with“traumatized and troubled” patients, resulting from thedesire to help the traumatized persons.7

STS is a term that was used previously in non-nursingdisciplines, such as social work, and reflects the emotionaldisequilibrium resulting from close contact with personswho are victims of trauma.7,9 Defined as the presence ofpost-traumatic stress disorder (PTSD) symptoms in thecaregiver, STS results from a combination of the caregivers’own previous traumatic experiences and the experiences oftheir patients.2,7 STS may occur after daily exposure totraumas in conjunction with the empathetic response.10

In this study CF and STS disorder are used inter-changeably, with persons suffering from symptoms identi-cal to those in PTSD11,12 (but only differing by exposure),based on the American Psychological Association’s defini-tion of traumatic stress disorders.

Related terms are vicarious traumatization and burn-out. Vicarious traumatization refers to an empathetic en-gagement with trauma suffered by persons cared for thatalters providers’ “inner experience”5 and implies a negativeand potentially permanent impact over time. Burnout isdefined as a “syndrome of emotional exhaustion, deperson-alization, and reduced personal accomplishment …,”13

Elvira Dominguez-Gomez, Inland Empire Chapter, is Emergency DepartmentNurse, Hemet Valley Medical Center, Hemet, CA.

Dana N. Rutledge is Associate Professor, Nursing, California State University,Fullerton, CA.

For correspondence, write: Elvira Dominguez-Gomez, 4520 Cloudywing Rd,Hemet, CA 92545; E-mail: e.dominguez-gomez@att.net.

J Emerg Nurs 2009;35:199-204.

Available online 15 July 2008.

0099-1767/$36.00

Copyright © 2009 by the EmergencyNurses Association. Published by ElsevierInc. All rights reserved.

doi: 10.1016/j.jen.2008.05.003

R E S E A R C H

May 2009 35:3 JOURNAL OF EMERGENCY NURSING 199

referring to a gradual wearing down of an individual providerbecause of imbalance between expected and actual work ex-periences.1 Nelson-Gardell and Harris imply that burnout isthe presence of symptoms such as fatigue, irritability, indif-ference, and poor work performance related to organiza-tional issues.10 All of these terms reflect a potential impacton nurses related to caregiving that comes from their em-pathetic interactions with suffering or traumatized patients.

Little is known about the effects nurses experiencewhen caring for patients and their families who are expe-riencing suffering or trauma, especially day after day. WithSTS, health care providers may experience PTSD symp-toms, a combination of caregivers’ own traumatic expe-riences and the experiences of their patients.2,7,14,15 STSis related to CF but does not have an acute onset, asdescribed by Sabo.1 High levels of STS may lead to nurseburnout and job turnover or separation from nursing.2,4

There has been no quantitative exploration of STS inemergency nurses. Therefore the purpose of this study wasto explore the prevalence of STS in a group of emergencynurses in Southern California.

Methods

An exploratory comparative study was conducted at ahealth care system (3 general community hospitals locatedin rural Southern California), after approval by health sys-tem administration and the university institutional reviewboard was obtained. According to the Office of StatewideHealth Planning and Development, emergency cases foreach of the facilities ranged from approximately 19,873to 38,164 in 2006.16 At these sites, 111 study packets weredistributed to mailboxes of registered nurses (RNs) em-ployed in emergency departments. Nurses sought wereactively employed RNs with a minimum of 6 months’experience in the emergency department. The basis forthe exclusion of inexperienced emergency RNs was thatthey may not yet have experienced enough repeated expo-sure to traumatic events that contribute to the developmentof STS. To ensure anonymity, data submission was by mailor to a designated ED mailbox.

During recruitment, posters with a description of thestudy were posted in nurses’ lounges. Reminder postcardswere placed in the emergency nurse’s mailboxes at 2 and4 weeks. Packets contained an invitation to participate, aself-addressed stamped envelope, a demographic sheet,and the Secondary Traumatic Stress Scale (STSS).

DEMOGRAPHIC SHEET

Created by the first author, this questionnaire providedbasic demographics: gender, age, ethnicity, educational

background/degree, years in nursing practice, typical workhours, and primary employment position (Table 1). Addi-tional items included whether the emergency nurse hadever sought assistance for work-related stress or participatedin stress management/self-care activities.

SECONDARY TRAUMATIC STRESS SCALE

The STSS is a self-report tool developed to measure STSin health care workers (Table 2).9 The STSS uses 17 itemsto evaluate the frequency of symptoms among 3 subscales:intrusion (5 items), avoidance (7 items), andarousal (5 items).These 3 subscales and the 17 items correspond with cri-teria B, C, and D in the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition (DSM-IV) (2000) nec-essary for PTSD diagnosis.12,17 Criterion A is identified asthe moment of “exposure” to the event, where the person“experienced, witnessed, or was confronted with an eventthat involved actual or threatened death or serious injury”and the subsequent response of the person was that of“intense fear, helplessness, or horror.”12 Criterion B isdescribed as the person “re-experiencing” the traumaticevent (intrusion), whereas criterion C is the persistentavoidance of stimuli related to the traumatic event or“numbing” of the person’s usual interests (avoidance). Cri-terion D is described as persistent symptoms of heightenedarousal or agitation (arousal). Bride et al9 used the criteriaidentified in the DSM-IV and developed 3 subscales to

TABLE 1Demographic and professional characteristics ofemergency RNs responding to STSS survey (N = 67)

n Mean SD %

Age 61 42.62 y 10.05 yExperience 57 13.96 y 10.38 yTime worked per week 61 41.03 h 7.07 hGenderFemale 52 77.6Male 14 20.9

EthnicityWhite 50 74.6Hispanic/Latino 9 13.4Asian 5 7.5Other 2 3.0

Primary positionDirect patient care/staff 55 82.1Nurse manager 3 4.5Clinical nurse specialist 2 3.0Other 1 1.5

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correspond with factors necessary for PTSD diagnosis,12

with the exception of criterion A, which entails exposure.Bride17 addresses the exposure element in the STSS by tai-loring the wording and the involvement of “stressor-specificitems” in the survey to reflect that the traumatic stressor isthe exposure to clients. Using a Likert scale ranging from 1(never) to 5 (very often), participants rate how often theyhave experienced each symptom during the past week.When a participant reported that a symptom was experi-enced “occasionally,” “often,” or “very often,” this symp-tom was interpreted as present. In earlier usage theinternal consistency of the STSS instrument, a measureof stability, was excellent (0.93) for the full STSS and goodfor the subscales: 0.80 for intrusion, 0.87 for avoidance,and 0.83 for arousal.9,18 In this sample the Cronbach αcoefficients for the sample subscales were .92 for intrusion,.92 for avoidance, and .92 for arousal, and the Cronbach αcoefficient for the total STSS was .91, indicating excellentinternal consistency.

Descriptive and inferential statistics were used for dataanalysis by use of version 15.0 of the Statistical Package forthe Social Sciences (SPSS, Chicago, Illinois).

Results

SAMPLE

Of the emergency nurses, 67 responded (response rate,63%). The sample was primarily women (78%) andof white ethnicity (75%); the mean age was 43 years(SD, 10.5 years). The majority identified themselves asAssociate-degree RNs (58%) with the primary positionof staff nurse/direct patient care (82%). The mean lengthof nursing experience was 14 years (SD, 10.39 years), andthe mean time worked per week was 41 hours (SD,7.07 hours). The majority of nurses (92%) denied any his-tory of seeking assistance for work-related stress. Over half(52%) reported regularly participating in activities thatpromote stress management and self-care.

INDIVIDUAL SYMPTOMS

Individual symptoms are reported by PTSD domain. Themost frequently reported symptom for intrusion was in-trusive thoughts about clients, with 46% of participantsreporting that they thought about their work with clientswhen they did not intend to do so. The second most com-

TABLE 2Frequency of STS symptoms reported by emergency RNs (N = 67)

Criterion (item No.)

Never

[n (%)]

Rarely

[n (%)]

Occasionally

[n (%)]

Often

[n (%)]

Very often

[n (%)] Mean SD

Criterion B: Intrusion symptomsIntrusive thoughts about clients (10) 13 (19.4) 22 (32.8) 21 (31.3) 8 (11.9) 2 (3.0) 2.45 1.04Disturbing dreams about clients (13) 33 (49.3) 16 (23.9) 14 (20.9) 2 (3.0) — 1.77 0.89Sense of reliving clients’ trauma (3) 32 (47.8) 19 (28.4) 12 (17.9) 2 (3.0) — 1.75 0.87Cued psychological distress (6) 15 (22.4) 33 (49.3) 15 (22.4) 3 (4.5) — 2.09 0.79Cued physiological reaction (2) 27 (40.3) 27 (40.3) 9 (13.4) 2 (3.0) 1 (1.5) 1.83 0.89

Criterion C: Avoidance symptomsAvoidance of clients (14) 11 (16.4) 20 (29.9) 18 (26.9) 13 (19.4) 4 (6.0) 2.68 1.15Avoidance of people, places, and things (12) 32 (47.8) 17 (25.4) 7 (10.4) 9 (13.4) 1 (1.5) 1.94 1.13Inability to recall client information (17) 30 (44.8) 23 (34.3) 9 (13.4) 3 (4.5) 1 (1.5) 1.82 0.94Diminished activity level (9) 18 (26.9) 18 (26.9) 20 (29.9) 9 (13.4) — 2.31 1.03Detachment from others (7) 25 (37.3) 23 (34.3) 13 (19.4) 4 (6.0) 1 (1.5) 1.98 0.98Emotional numbing (1) 16 (23.9) 21 (31.3) 19 (28.4) 8 (11.9) 2 (3.0) 2.38 1.08Foreshortened future (5) 19 (28.4) 24 (36.8) 14 (20.9) 7 (10.4) 2 (3.0) 2.23 1.08

Criterion D: Arousal symptomsDifficulty sleeping (4) 10 (14.9) 21 (31.3) 15 (22.4) 15 (22.4) 5 (7.5) 2.76 1.19Irritability (15) 10 (14.9) 19 (28.4) 19 (28.4) 10 (14.9) 7 (10.4) 2.77 1.21Difficulty concentrating (11) 11 (16.4) 30 (44.8) 20 (29.9) 4 (6.0) 1 (1.5) 2.30 0.88Hypervigilance (16) 19 (28.4) 26 (38.8) 15 (22.4) 5 (7.5) 1 (1.5) 2.14 0.97Easily startled (8) 32 (47.8) 19 (28.4) 7 (10.4) 5 (7.5) 3 (4.5) 1.91 1.15

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monly reported intrusion symptom was cued psychologicaldistress, with 27% reporting that reminders of work withclients upset them. The remaining intrusion symptomswere reported less frequently. Among avoidance symptoms,the most commonly reported symptom was avoidance ofclients (52%). Next was diminished activity level and emo-tional numbing, both experienced by 43% of nurses. Otheravoidance symptoms were reported less frequently. Forarousal, over half of all nurses reported that they were easilyannoyed or had difficulty sleeping.

DIAGNOSTIC CRITERIA

Diagnostic criteria for PTSD include 4 factors that cor-respond to the 17 symptoms of the STSS.12 Bride17 formu-lated an algorithm to identify cases of PTSD by mirroringSTSS items with these diagnostic criteria. Consequently,study participants who reported at least 1 intrusion symp-tom, at least 3 symptoms of avoidance, and at least 2 arousalsymptoms meet the criteria for PTSD and, thus, for STS.Criterion A (exposure) is assumed to be present based onthe population surveyed, experienced emergency nurses.This criterion is implied, both by the design of the STSS,where the care of patients is identified as the “traumaticstressor,”11 and by the nature of emergency nursing. Emer-gency nurses care for various types of patients, who differ inthe nature and severity of their injuries, which may com-prise a traumatic event to the nurse. A report released bythe Centers for Disease Control and Prevention (2005)reported that injuries sustained by falls, being struck by aperson or object, and motor vehicle accidents accountedfor 41% of injury-related visits to the emergency depart-ment.19 The repercussions of these types of patients, suchas death or severe injury, are witnessed by the emergency

nurse, who assumes the difficult task of consoling the fam-ilies and survivors of the event.

Using these diagnostic criteria, we found that only15% of participants met no criteria for STS (Table 3)whereas 32.8% of participants met all 3 criteria. Over halfof the participants (60%) reported experiencing at least 1intrusion symptom (criterion B), and 56% reported experi-encing at least 2 arousal symptoms (criterion D).

SYMPTOM SEVERITY

The potential range of scores possible on the full STSS isfrom 17, which indicates no symptoms, to 74, which is thehighest reportable score. The mean STSS score was 37.4(SD, 11.0), with a range from 17 to 74.

SUBGROUP ANALYSES

Analyses using t tests with a Bonferroni correction todecrease the chance of type I error (P = .01) found no sig-nificant differences among nurses based on demographicgroups (Table 4). However, white subjects reported higher

TABLE 3Frequency of diagnostic criteria of PTSD due to sec-ondary exposure related to practice with trauma-tized populations

Criteria meta n %

None 10 14.9Intrusion (B) 40 59.7Avoidance (C) 32 47.8Arousal (D) 36 55.7Intrusion + avoidance (B + C) 27 40.3Intrusion + arousal (B + D) 26 38.8Avoidance + arousal (C + D) 27 40.3Intrusion + avoidance + arousal (B + C + D) 22 32.8

aIn addition to the exposure criteria (criterion A).

TABLE 4Comparison of STSS scores in emergency nurses ac-cording to demographic characteristics (N = 67)

STSS score t Test P value

Gender 5.447 .023Female 39.0Male 31.3

Shift worked (12 h) 0.292 .962Days 37.7Nights 37.5

Use of counseling 1.494 .226Yes 43.2No 36.9

Use of stressmanagement strategies

2.263 .138

Yes 35.8No 40.2

Ethnicity 1.860 .146Asian 32.4Hispanic/Latino 31.8White 39.2Other 30.0

Highest level of education 0.494 .668Diploma 36.5Associate degree 37.8Baccalaureate 38.1Master’s 28.5Other 29.0

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STS scores, whereas men, nurses who participate in stressmanagement strategies, and nurses with graduate degreeshad lower scores. Correlations between STSS scores andage (r = 0.78) were significant, whereas those with yearsin nursing and hours worked per week were not.

Discussion

This study examined the prevalence of STS among emer-gency nurses. In this sample 85% reported at least 1 STSsymptom in the past week. Very concerning is the fact that33% of the sample met the criterion for a diagnosis of STS.The most frequently reported individual symptoms wereirritability, avoidance of clients, difficulty sleeping, intru-sive thoughts, diminished activity level, and emotionalnumbing. Symptoms experienced by fewer nurses werecued physiological reaction, inability to recall client infor-mation, and a sense of reliving clients’ trauma.

In describing how to interpret scores on the STSS,Bride17 recommends using a cutoff score of 38 as designat-ing the presence of STS. By use of this criterion, half of thesample would have met the criteria for STS. If the DSM-IVdiagnostic criterion is used, where the sample reported atleast 1 intrusion symptom, at least 3 symptoms of avoid-ance, and at least 2 symptoms of arousal, the prevalenceof STS is slightly higher.12

Comparing the sample of emergency nurses to the282 social workers reported on by Bride17 suggests thatnurses may be more likely to demonstrate criteria of STS(33% vs 15%) than are social workers. Whereas 70% of so-cial workers reported experiencing at least 1 symptom in theweek before being surveyed,17 85% of emergency nurses didso. This clearly indicates the need for further study. Are thefindings replicable among other groups of emergency nursesas well as among nurses in other specialties? Do nurses whoreport these symptoms risk becoming dysfunctional or suf-fering ill health because of these symptoms? Are these nurseslikely to suffer job burnout and then leave their positions?Longitudinal studies are warranted to tease out these an-swers. If nurses suffering from symptoms of STS are likelyto burn out and/or leave their jobs, effective strategies areneeded that nurse managers and organizations can use toameliorate the symptoms and prevent these sequelae.

Subgroup analyses lead to further questions. Are menand persons of ethnic diversity less at risk for STS? Are thereself-management or stress reduction strategies that emer-gency nurses can use to help ameliorate symptoms of STS?

Limitations

This study is limited in generalizability because the samplewas not randomly selected and comes from a specific geo-

graphic location. It also is limited by self-reported responsesby emergency nurses. Although the response rate isadequate, STS experiences of nonrespondents may differfrom those of respondents. Respondents may be more—or less—likely to have responded because of experiencingSTS. The STSS tool was developed for use with health careproviders, specifically social workers; it is based on the pre-mise that STS resembles PTSD and that the health careworkers being surveyed have had exposure to patients withtrauma and suffering (a component of STS). We assumedthis exposure in our sample but did not measure it.

Implications for Emergency Nurses

This is the first study to document STS in emergencynurses using a reliable and valid tool. The findings of highlevels of STS, as well as of individual symptoms, point tothe need for further research with emergency nurses. Inaddition, further examination of the potential differencesin scoring among nurses of different gender, ethnicity,and education, along with the differences in those whoused specific coping strategies and those who did not,needs to be explored. Nurses with STS may not be effec-tive with patients, because their symptoms may disableoptimal caregiving. Nurse managers should assume thata minority of emergency nurses may be suffering fromSTS and, when appropriate, urge them to seek appropri-ate counseling or to use stress management techniques.Potential strategies identified in the literature include theuse of formal and informal debriefing, providing the nursingstaff with increased education on CF/STS, burnout, anddeath education, specifically care of the dying patient andfamily.20-22 Other coping strategies identified include theuse of organizational “team-building” activities, humor,reading, and alternative therapies, such as exercise, massage,and meditation.21

Conclusions

Working at the entry point to health care for manypatients, emergency nurses play a critical role in ensuringquality care. The high prevalence of STS in this sampleindicates that large numbers of emergency nurses maybe experiencing the negative effects of STS. Increasedunderstanding of the concept of STS or CF, including itsidentifying symptoms, potential coping strategies, and orga-nizational interventions that may increase nurses’ abilitiesto manage or prevent STS, is needed. Increasing the aware-ness of this phenomenon in the workplace may preventemotional exhaustion and potential job separation of emer-gency nurses who suffer from STS.

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