evidence and practice
Free Awareness of secondary traumatic stress in emergency nursing
Donna Barleycorn Senior lecturer/nurse practitioner, Kingston and St George’s University, London, England
This article explores secondary traumatic stress (STS) and the emotional challenges that emergency nurses face when dealing with traumatised patients. The few studies on STS have shown a higher occurrence of STS symptoms in emergency nurses but provide limited evidence on how personal experiences may contribute to STS. Risk factors identified include repeated exposure to trauma; morbidity and mortality; personal trauma; chronic stressors; workload and emergency department pressures. STS can lead to reduced job satisfaction, sick leave and burnout. Protective factors include awareness and self-care, emotional intelligence, social support and education about STS. Strategies to minimise STS include balancing personal and professional life and the support of employers to help reduce compassion fatigue and aid staff retention.
Emergency Nurse. doi: 10.7748/en.2019.e1957Peer review
This article has been subject to external double-blind peer review and has been checked for plagiarism using automated softwareCorrespondence
Barleycorn D (2019) Awareness of secondary traumatic stress in emergency nursing. Emergency Nurse. doi: 10.7748/en.2019.e1957
Published online: 20 August 2019
A personal story
A family member recently passed away after becoming suddenly unwell with sepsis and then multiple organ failure. Despite having more than 20 years of emergency department (ED), trauma and critical care experience, I felt out of control. I have worked in trauma units in South Africa, on air ambulances and in search and rescue teams. I am familiar with the ED patient journey, resuscitation and intensive care, but nothing prepared me for the lack of emotional control I would feel about the sudden ill health of a close family member.
The following weeks were spent in the intensive care unit (ICU) of the hospital where I completed my nurse training and, on qualifying, the first eight years of nursing in emergency care; the same ICU where I had spent many shifts transferring and caring for patients and their relatives, the many night shifts showing relatives to the quiet room.
Now I was the one waiting amid the all too familiar sounds and equipment, in a now haunting environment. I knew many of the senior clinicians and nurses, but this time I was the relative, not a colleague. I understood the heart-breaking journey ahead, but this time I could not detach into my professional persona.
Having cared for many critical care patients in the resuscitation room, including extubating patients at the end of life, holding their hands or supporting relatives, this was the most painful.
• Secondary traumatic stress (STS) symptoms can develop after exposure to traumatised patients and are similar to those for post-traumatic stress disorder (PTSD)
• Emergency nurses have a high exposure to major trauma and critical illness
• Exacerbation of personal trauma and unresolved trauma can be activated by exposure to similar trauma in patients
• Emergency nurses need to be aware of the symptoms and risk factors relating to STS and a balance between personal and professional life is essential
• Employers must help to prevent STS by supporting staff who are exposed to trauma, giving them time to grieve, reducing their workload and providing sympathetic leadership
Emergency nurses often care for patients who have been exposed to traumatic events; it is an occupational hazard. The author’s background in emergency nursing has led to high exposure to major trauma, critical illness and the effect it has on others, but could this have a bearing on personal trauma? Nurses are, after all, emotional human beings who experience life events and personal tragedy; being a healthcare professional does not exempt us from or make us immune to these feelings. Is there an emotional cost of caring for traumatised patients?
My observations have led me to analyse the enormity of what emergency nurses have to manage emotionally and to explore secondary traumatic stress (STS). Research on STS is limited with even less evidence on how personal experiences may trigger STS in emergency care professionals. So why do we avoid personal trauma while caring for patients experiencing life-changing situations?
Why are emergency care professionals so averse to identifying our own reactions and experiences as trauma?
A search of quantitative and qualitative studies on STS in emergency nurses was conducted using the databases Science Direct, PubMed, Google Scholar and the Cochrane Library using the following terms: ‘secondary traumatic stress’, ‘secondary post-traumatic stress’, ‘trauma’, ‘nurses’, ‘stress’ and ‘emergency’. Each database was searched using these terms or Medical Subject Headings with Boolean operators and fitting permutations. Literature was used if it was published in English between 2009 and 2019, explored emergency nurses and the emergency, trauma environment. Articles that were excluded were published before 2009 in a language other than English and focused on populations incomparable to emergency nurses.
A total of 151 articles were identified after additional hand searches and snowballing. The author independently screened the titles and abstracts and articles were removed that were irrelevant or were duplicated; 12 articles were fully read to assess suitability and narrative review.
The psychological effects of direct exposure to traumatic stressors have been documented over the past 30 years, yet the traumatic events that affect healthcare professionals indirectly have not been widely researched (Duffy et al 2015). Research on STS may have been hindered by a lack of conceptual clarity and is often used interchangeably in the literature. STS refers to the experience of symptoms similar to those found in people with post-traumatic stress disorder (PTSD) after indirect exposure to trauma and, in the case of emergency nurses, working with traumatised patients (Beck 2011).
In an older study, Figley (1999) describes the detrimental effects on healthcare workers of secondary exposure to traumatic stressors as being the same as those experienced by patients who had the primary traumatic event. Luftman et al (2017) found the more intimate the healthcare professional is with the patient or the traumatic incident, the higher risk they have for screening positive for STS symptoms. Also, as STS manifests in similar symptoms, it may lead to a diagnosis of PTSD (Figley 1995, Kintzle et al 2013).
Little is known about the long-term effects of the emergency nurse’s experience while caring for traumatised patients, especially with the additional exposure of pressures in the ED day after day. Although limited, studies on STS have reported that emergency nurses have a higher occurrence of STS symptoms (Beck 2011, Duffy et al 2015).
In a small sample of 67 ED nurses, Dominguez-Gomez and Rutledge (2009) designed a survey to examine symptoms of STS: 33% met the criteria for PTSD because of their STS symptoms.
One European cross-sectional study analysed data from a survey of 248 ED nurses from 15 hospitals. The results of the survey showed almost one in four ED nurses exceeded the sub-clinical cut-off for PTSD symptoms (Adriaenssens et al 2012). The authors highlighted high levels of anxiety, depression, somatic complaints and sleep problems from the nurses’ responses (Adriaenssens et al 2012).
A study by Morrison and Joy (2016) explored STS among 200 emergency nurses in the UK and found that 75% of them reported having at least one STS symptom in the previous week and 39% of the convenience sample met the criteria for STS.
In a recent review of the literature on the effect of STS on emergency nurses, Ratrout and Hamdan-Mansour (2017) suggested that ED nurses have higher levels of STS compared with other nurses. The data confirmed that being exposed to traumatised patients and providing healthcare when lives are at threat increases the risk of STS. They concluded that nurses in the ED are at high risk for STS and are generally under-investigated in terms of predictors and consequences compared with other vulnerable groups such as caregivers. More work is needed to examine the role of personal factors in STS to better understand the process by which it develops.
Secondary traumatic stress symptoms from exposure to secondary trauma are similar to primary PTSD, and can include intrusive recurring thoughts, sleep disturbances, fatigue, physical symptoms, hyperarousal, increased stress response, anxiety, depression and feeling emotional (Adriaenssens et al 2012).
The National Institute for Health and Care Excellence (NICE) guidance on PTSD (NICE 2018) incorporates symptoms of avoidance, negative alterations, emotional numbing, dissociation, emotional dysregulation, negative self-perception and functional impairment, but also acknowledges that a diagnosis of PTSD, including complex PTSD, may present with a range of other symptoms and requires a multifaceted approach.
Scaer (2014) highlights further symptoms of somatic sensations, depersonalisation and possibly amnesia in some people with PTSD.
Exposure to traumatic stressors and empathy are two important concepts that underlie the development of STS and are central to emergency care workers (Ratrout and Hamdan-Mansour 2017). Figley (1999) explored further reasons for healthcare professionals developing STS while caring for trauma patients, including exposure to paediatric trauma, and the healthcare professional’s own personal and unresolved trauma which can be activated by exposure to similar indirect trauma in patients. These discussion points are fundamental for increasing awareness and recognition of STS in emergency workers.
Personality traits, for example, an increased empathic response, can heighten sensitivity to STS and increase vulnerability (Ratrout and Hamdan-Mansour 2017). The evidence in the literature shows that nurses are hard-working and have high traits of empathy, and a potential to have ‘overachiever perfectionist’ personality types (Eley et al 2012), which could all be potential risk factors.
Emergency nurses often have little time to recover from traumatic stressors due to the unpredictability and the fast pace of care in the ED environment (Ratrout and Hamdan-Mansour 2017). Adriaenssens et al (2012) found repetitive exposure to trauma, mortality and morbidity is a significant risk factor in the development of STS. In an exploratory study, Garcia-Izquierdo and Rios-Risquez (2012) noted a positive correlation between the frequency of observed suffering and emotional exhaustion in the healthcare professional.
Adriaenssens et al (2012) discuss the effectiveness of coping strategies which is time related. Emergency nurses will often have a problem-solving approach in emergency situations, this is termed as an ‘avoidant emotional coping strategy’ (a distraction), so they can carry on working. However, the long-term effects of this coping strategy can delay any recovery process and lead to the worsening of STS symptoms (Adriaenssens et al 2012).
STS can have wide-ranging effects on individual healthcare professionals leading to a decline in job satisfaction, sick leave, compassion fatigue or burnout (Dominguez-Gomez and Rutledge 2009). Other considerable risk factors involve staff retention, being short-staffed, a heavy workload, a lack of emotional support, ED targets and overcrowding (Adriaenssens et al 2012, 2015).
Also, the day-to-day chronic stress experienced in Western society has a significant bearing on personal health issues, which has been explored in relation to traumatic stress and chronic diseases: ongoing exposure to stress and traumatic stressors can have a profound effect on physiology, the brain and endocrine system, and the hypothalamic-pituitary-adrenal axis (Maté 2003, Scaer 2014).
Awareness and self-care
Emergency nurses need to be aware of the symptoms and risk factors relating to STS. They require emotional intelligence, self-awareness and the ability to recognise how they are feeling and act on this. They need to develop social skills to manage emotions in relationships and be able to assess situations while interpreting and responding to the needs of others (Goleman 1998). It is essential for nurses to feel safe in opening up about any potential STS symptoms they have.
Social support can be valuable in reducing STS symptoms (Morrison and Joy 2016). Evidence shows having a supportive network with colleagues is a positive way to prevent the development of STS (Lavoie et al 2011). Poor social support and a lack of communication among ED staff signified increased levels of fatigue, STS and burnout (Adriaenssens et al 2012).
The reviewed literature suggests that strategies for minimising STS include improved education and awareness of the condition, awareness of the effects of personal trauma, which can come in many forms, and where appropriate nurses should seek support from trained professionals. They should be educated to understand stress-related disorders, particularly how these may present in physical symptoms (Morrison and Joy 2016, Luftman et al 2017). Emergency nurses should be mindful and candid about accumulated stress and subtle life stressors and act on reducing these where possible.
Balancing personal and professional life is essential. Personal strategies to maintain well-being include slowing down, getting enough sleep and rest, balanced nutrition, adequate exercise, setting boundaries, listening to your body, and learning techniques and tools to build capacity in the nervous system to manage ongoing stressors (Beck 2011). Releasing stress may incorporate somatic therapy techniques, for example, meditation, yoga and breath work (Rourke 2007).
Support from employers is equally important to prevent STS. Approaches such as screening for symptoms, allowing time to grieve, debriefing and awareness of traumatic stressors should be considered. General support from staff, reducing workload and sympathetic leadership can also reduce risk factors (Adriaenssens et al 2012, Morrison and Joy 2016).
Awareness of STS is vital not only in nursing education but also for employers to reduce the personal consequences for healthcare professionals that include burnout and compassion fatigue – and to also aid staff retention. Emergency nurses must take the necessary steps to safeguard against STS, ensuring self-care personally and professionally.
There is insufficient discussion of personal trauma and the effect of STS in nursing and medical literature and further research and tools to prevent STS are required to understand its prevalence and how it can be reduced in healthcare. Emergency care professionals need to be encouraged and supported to unlock the taboo subject of STS when caring for patients who have experienced trauma.
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