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EXAMINING THE LIVED EXPERIENCE OF

SECONDARY TRAUMATIC STRESS

IN EMERGENCY ROOM NURSES:

A MIXED METHODS STUDY

Mary C. Frazier, M.S.N., R.N.

A Dissertation Presented to the Graduate Faculty of Saint Louis University in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

2023

Mary Christina Frazier

2023

COMMITTEE IN CHARGE OF CANDIDACY:

Professor Joanne Langan

Chairperson and Advisor

Professor Helen Lach

Associate Professor John M. Taylor

iii

Dedication

This is dedicated to all the emergency room nurses who are all working so hard to help

those who are in crisis, sometimes at the risk to their own mental, physical, and social health.

You are all such an inspiration, as you care for those in need, regardless of what that day brings.

You are all heroes in your own right, even if society has slowly forgotten about you. May you all

continue to help those who seek your care, and may we begin to start learning how to take care

of you.

Acknowledgements

Thank you to my biggest supporters – my family. My husband has been my biggest

supporter throughout this whole journey. He was quick to assume additional responsibilities at

home so that I had more time to dedicate to my homework, research, and writing. He listened to

me cry, scream, and nearly reach my breaking point. He picked me up, told me I was stronger,

and encouraged me to continue on. He has also shared in my joy and happiness in my successes

throughout this journey. To my two beautiful daughters, you have watched me go to school

throughout your entire lives, from my BSN to my MSN and now my PhD. You understood when

I had to stay home from the pool, missed out on adventures, and had to make bedtime shorter.

Your unconditional love kept me motivated to finish. To my parents, who were always quick to

offer support in the form of babysitting, financial help, academic support, and words of

encouragement, thank you for being amazing role models and pillars of support. To my

classmate and now forever friend Amber, thank you for the late-night freak-out sessions and

continuous encouragement when I didn’t want to continue writing. You have been one of my

biggest pillars of support and my strongest sounding board. To the Epsilon Eta chapter of

SIGMA Theta Tau, thank you for the funding you provided. To my dissertation chair, Dr. Joanne

Langan, thank you for helping me along this journey. Your constant feedback, encouraging

words, and being around when I needed a moment to cry; I could not have made it to this point

without you. And to the rest of my committee, Dr. Lach and Dr. Taylor, you have both supported

me throughout my program and throughout my research. I appreciate your advice and your help.

Table of Contents

List of Tables ................................................................................................................................. viii

List of Figures .................................................................................................................................. ix

Chapter I: Background of the Problem.............................................................................................1 Significance of the Study ...............................................................................................................3 Conceptual Definitions ..................................................................................................................3 Theoretical Framework ................................................................................................................6 Philosophical Underpinnings.........................................................................................................7 Purpose of Study ...........................................................................................................................9

Chapter II: Literature Review ........................................................................................................ 10 Method........................................................................................................................................ 10 Study Characteristics .................................................................................................................. 10 Demographics of Study Participants ........................................................................................... 11 Measurements Used .................................................................................................................... 12 Prevalence of Secondary Traumatic Stress ................................................................................. 14 Identification of Causes of STS ................................................................................................... 16 Risk Factors ................................................................................................................................ 17

Nursing Experience ............................................................................................................. 17 Workplace Factors............................................................................................................... 17

Personal Characteristics ..................................................................................................... 18 Personal History................................................................................................................... 18

Consequences of Secondary Traumatic Stress............................................................................. 19

Workplace Factors ................................................................................................................ 19

Psychological Effects ............................................................................................................ 20 Physical Effects ..................................................................................................................... 20

Substance Use ....................................................................................................................... 21 Protective Factors ....................................................................................................................... 21

Positive Self-Care Strategies ................................................................................................ 22 Informal Support .................................................................................................................. 23

Formal Debriefing ................................................................................................................ 23 Recommendations for Future Research/Practice ........................................................................ 24 Gap of Research .......................................................................................................................... 24

Chapter III: Methodology............................................................................................................... 26 Purpose ....................................................................................................................................... 26 Design ......................................................................................................................................... 26

Phenomenological Design .................................................................................................... 27 Mixed Methodology..................................................................................................................... 30 Sample and Setting ...................................................................................................................... 31 Recruitment ................................................................................................................................ 32 Ethical Considerations ................................................................................................................ 33 Data Collection............................................................................................................................ 34

Demographics ....................................................................................................................... 34 Secondary Traumatic Stress Scale ....................................................................................... 34

Brief-COPE Inventory .......................................................................................................... 36 Visual Analog Scale for Perceived Stress ............................................................................ 37

Interview ................................................................................................................................ 37 Data Analysis .............................................................................................................................. 39

Quantitative Analysis ............................................................................................................ 39 Qualitative Analysis .............................................................................................................. 40

Mixed Methods Analysis....................................................................................................... 41 Validity .................................................................................................................................. 42

Trustworthiness and Rigor ................................................................................................... 42

Chapter IV: Results ........................................................................................................................ 44 Research Aim 1 ........................................................................................................................... 46 Research Aim 2 ........................................................................................................................... 51

Patient Care Suffers.............................................................................................................. 52 Relationships at Work are Impacted ................................................................................. 60

Life Continues Outside the Hospital .................................................................................. 64 Impacting Me on a Personal Level ..................................................................................... 72

Residual Stress Despite Coping Attempts ......................................................................... 77 Research Aim 3 ........................................................................................................................... 83

Positive Coping Strategies................................................................................................... 84 Dysfunctional Coping Strategies ........................................................................................ 86

Debriefing as Coping ........................................................................................................... 87 Research Aim 4 ........................................................................................................................... 95

Convergence ......................................................................................................................... 95

Divergence ............................................................................................................................ 96

Chapter V: Discussion .................................................................................................................. 100 Summary of the Study............................................................................................................... 100 Research Aim 1: Summary and Discussion ............................................................................... 101 Research Aim 2: Summary and Discussion ............................................................................... 103

Arousal ................................................................................................................................ 104 Avoidance ............................................................................................................................ 105

Intrusion .............................................................................................................................. 106 Revised Transactional Model of Occupational Stress and Coping ................................... 108

Research Aim 3: Summary and Discussion ............................................................................... 110

Positive Coping ................................................................................................................... 110

Dysfunctional Coping ......................................................................................................... 112 Debriefing as Coping .......................................................................................................... 113

Research Aim 4: Summary and Discussion ............................................................................... 115 Recommendations for Future Research .................................................................................... 117 Recommendations for Future Practice and Policy..................................................................... 118 Limitations................................................................................................................................ 119 Conclusion ................................................................................................................................ 121

Appendix A: Permission for Revised Transactional Model of Occupational Stress and Coping.... 122

vii

Appendix B: PRISMA Diagram.................................................................................................... 124

Appendix C: Community Resources for Mental Health Concerns ................................................ 125

Appendix D: Demographic Survey................................................................................................ 126

Appendix E: Secondary Traumatic Stress Scale ........................................................................... 127

Appendix F: Brief-COPE Inventory ............................................................................................. 128

Appendix G: Interview Guide ....................................................................................................... 129

Appendix H: Mixed Methods Table .............................................................................................. 131

References..................................................................................................................................... 132

Vita Auctoris................................................................................................................................. 140

viii

List of Tables

Table 1: Demographics of the Sample .......................................................................................... 45

Table 2: Secondary Traumatic Stress, Brief-COPE, Change in Perceived Stress ........................ 46

Table 3: Analysis of Factors Associated with Secondary Traumatic Stress ................................. 51

Table 4: Breakdown of Theme Responses by Participant ............................................................ 83

Table 5: Coping Strategies ............................................................................................................ 94

Table 6: Convergence and Divergence of Participants’ Responses .............................................. 98

Table 7: Secondary Traumatic Stress Scale ................................................................................ 127

Table 8: Brief-COPE Inventory .................................................................................................. 128

Table 9: Mixed Methods Table ................................................................................................... 131

List of Figures

Figure 1: Revised Transactional Model of Occupational Stress and Coping ................................. 7

Figure 2: PRISMA Diagram ....................................................................................................... 124

Chapter I: Background of the Problem

Nurses who work in the Emergency Room (ER) are routinely exposed to illness,

pathogens, trauma, and death throughout each shift. ER nurses care for patients and family

members during some of the worst times in their lives: motor vehicle accidents, myocardial

infarctions, cerebral vascular accidents, violence, rape, trauma, and death. Although nurses are

not directly experiencing the traumatic event(s) themselves, the continuous exposure puts them

at risk for secondary traumatic stress (STS). STS is an acute phenomenon, resulting from an

indirect exposure to a traumatic event (Beck, 2011). Repeated exposure to trauma has long been

recognized to impair a nurse’s ability to cope, which can manifest in STS symptoms (Badger,

2001). Symptoms of STS are similar to those of post-traumatic stress disorder (PTSD):

nightmares, avoidance of people/places that remind the individual of the trauma, hypervigilance,

paranoia, and intrusive thoughts (Wolf et al., 2020). Increased empathy, which is a common trait

in ER nurses, can lead to feelings of guilt over not saving the patient, or feelings of extreme

responsibility, which can exacerbate STS symptoms (Erkin et al., 2021).

STS symptoms are organized in three categories: intrusion, avoidance, and arousal

(Beck, 2011). Intrusion symptoms include feelings of re-experiencing the event, including

disturbing dreams/nightmares; thinking about patients outside of work; physical symptoms such

as an increased heart rate when thinking about patients; and/or psychological symptoms, such as

flashbacks and frustration when thinking about patients (Bride et al., 2004). Avoidance

symptoms include avoiding working with or being around people or places that are reminders of

the traumatic experience, losing interest in prior activities or the future, memory disruptions

about patient situations, and feelings of emotional numbness (Bride et al., 2004). Arousal

symptoms include feelings of irritability, difficulty concentrating, difficulty sleeping,

hypervigilance, and feeling jittery and jumpy (Bride et al., 2004).

According to the Centers for Disease Control and Prevention (CDC), ER visits have

steadily increased from 1997-2018 (Centers for Disease Control and Prevention, 2021).

Increased visits put a heavier strain on ER nurses, requiring them to care for more patients per

shift. Nurses are exposed to more stressful and traumatic events during periods of increased

patient load. The fast-paced nature of the ER does not allow nurses to take time during their shift

to rest and mentally process traumatic events (Badger, 2001). They are expected to suppress their

feelings and emotions following a traumatic incident and continue caring for the other patients in

the department (Rozo et al., 2017).

Nurses who experience high levels of STS demonstrate an increased level of anxiety and

depression (İlhan & Küpeli, 2022; Măirean et al., 2014). Anxiety has been shown to cause

concentration and attention impairment, which can lead to patient safety concerns, such as

medication errors (Stathopoulou et al., 2011). Sleep alterations have been seen in nurses who

experience depression, which can have an impact on blood pressure and heart rate (Shechter et

al., 2020).

Nurses experiencing STS have also reported intention to leave their position in the

hospital or leave the profession completely (Măirean et al., 2014). Increased attrition rates can

place a significant burden on remaining nurses, requiring them to work additional hours to cover

the absence. Institutions will also have to invest financially to recruit, prepare, and educate new

nurses to fill the need. This will put an additional strain on the working nurses, as they will be

required to spend time and effort orienting replacement nurses.

Significance of the Study

Understanding how nurses experience and cope with STS will help nurses, managers,

educators, policy makers, and future researchers develop and implement strategies to help

mitigate the negative effects manifested with STS. Researchers have focused on the prevalence

of STS in ER nurses; however, very few researchers have examined the impact that STS has in

the lives of ER nurses. The effect of the emotional, psychological, and/or physical reactions on

the relationships with family, friends, and co-workers has not been thoroughly researched in ER

nurses. Although STS may not be able to be prevented completely, by understanding how it

impacts nurses, we can help teach them positive coping strategies to hopefully mitigate negative

complications, such as anxiety, depression, or the intent to leave the profession. These negative

complications can have a significant impact on the nurse, the facility, and the community.

The proposed study will be conducted using a mixed methods research design. The

Secondary Traumatic Stress Scale (STSS) will be used to quantitatively measure the levels of

STS in ER nurses. In-depth interviews will be conducted to qualitatively examine the lived

impact of STS in ER nurses, as well as coping strategies and their effectiveness at mitigating the

negative effects of STS. A mixed methods approach will allow the researcher to utilize the

strengths of both qualitative and quantitative research designs (Gray & Grove, 2021).

Conceptual Definitions

Throughout the literature, researchers have used multiple terms to describe the emotional,

physical, and/or psychological effects experienced by those in helping professions: secondary

traumatic stress, burnout, compassion fatigue, and vicarious traumatization. All four terms are

classified as empathy-based stress, meaning that they occur when a stressor, such as a traumatic

exposure, combines with the experience of empathy, seen in ER nurses (Rauvola et al., 2019).

These terms have been used interchangeably related to exposure to a traumatic experience;

however, each term has its own unique definition (Rauvola et al., 2019). For the purposes of this

dissertation, the concept of STS will be the focus of all interviews and analyses. However, it is

important to understand the differences and unique characteristics of each of the four concepts.

Each term is defined below to clarify any confusion and identify the differences between such

similar terms.

Secondary Traumatic Stress

STS is defined as the negative emotional, psychological, and/or physical reaction

experienced by someone who had an indirect exposure to trauma, typically resulting from caring

for trauma victims (Beck, 2011; Erkin et al., 2021; İlhan & Küpeli, 2022; Jobe et al., 2021;

Măirean et al., 2014; Rauvola et al., 2019). Symptoms of STS mirror those of post-traumatic

stress disorder (PTSD): avoidance of places/individuals that remind persons of the trauma,

arousal, intrusive thoughts of the trauma, and re-experiencing of the event (Măirean et al., 2014;

Wolf et al., 2020). The difference between STS and PTSD is the proximity of the care provider

to the traumatic event: individuals with STS are exposed to the trauma through contact with the

patient (Badger, 2001). STS can occur immediately following exposure to a traumatic event, or it

can be delayed (Von Rueden et al., 2010).

Burnout

Burnout is defined as feelings of frustration and exhaustion related to work-place factors

that occur over an extended period (Beck, 2011; O'Callaghan et al., 2020). Burnout is influenced

by an individual’s work environment, not the act of caring for a person in need, which is what

distinguishes burnout from STS (Beck, 2011). Workplace factors that contribute to burnout

include lack of adequate staff, working long hours, working extra shifts, difficult relationships

with co-workers, and perceived lack of support from management (Ivanić et al., 2017).

Symptoms of burnout include irritability, decreased work performance, fatigue, and strained

relationships with co-workers (Dominguez-Gomez & Rutledge, 2009).

Compassion Fatigue

Compassion fatigue (CF) is defined as emotional, physical, and mental exhaustion

resulting from long term stress (O'Callaghan et al., 2020; Tabor, 2011). In early literature, CF

and STS have been used synonymously (Beck, 2011; Dominguez-Gomez & Rutledge, 2009).

Recently, compassion fatigue is thought to be comprised of two elements: burnout and STS

(Nilan et al., 2019). The cumulative effects of repetitive exposure to the stress of others through

trauma and illness (STS) paired with repetitive stress from workplace factors (burnout) puts

individuals who work in caring professions (nurses, social workers, mental health professionals)

at an increased risk for developing CF (Flarity et al., 2013).

Vicarious Traumatization

Vicarious traumatization (VT) is a term that has been used in literature to refer to the

alteration in personal feelings, values, and perspective on life because of secondary exposure to

trauma (Rauvola et al., 2019; Tabor, 2011). While similar to STS with regards to an individual’s

negative response to a secondary traumatic exposure, VT does not manifest with physical or

emotional symptoms. Individuals suffering from VT may look on the world, environment, or

other individuals in a different manner as the result of the repetitive exposure to a traumatic

situation (Beck, 2011; Rauvola et al., 2019). VT is thought to have a slower, more gradual onset

and have a longer lasting influence than STS (Rauvola et al., 2019).

Theoretical Framework

The Transactional Model of Stress and Coping theorizes that when presented with an

event, an individual will undergo a primary appraisal to determine if the event is perceived as

challenging/threatening or benign (Lazarus & Folkman, 1984). If the event is determined to be

challenging or threatening, the individual undergoes a secondary appraisal to determine what can

be done to manage or cope with the event. Then, coping strategies are used , and the effectiveness

of the coping strategies determine the psycho-physiological reactions experienced by the

individual. This model lacks the presentation of adaptive coping strategies that lead to a positive

response to the stressful experience or maladaptive coping strategies that result in a lack of

resolution or residual stress.

A Revised Transactional Model of Stress and Coping Model, adapted from Goh, Sawang,

and Oei (2010), is used to guide this study (Figure 1). This model, adapted from Lazarus and

Folkman’s Stress and Coping Model, has incorporated a negative stress response following the

appraisal stage and prior to the implementation of coping strategies (Goh et al., 2010). According

to Goh et al. (2010), the determination and use of specific coping strategies is dependent on the

individual’s response to the stressful situation. This model has been used in the context of trauma

nurses by Jobe et al. (2021), who stated that even though coping strategies can be effective to

mitigate the effects of STS, residual stress can remain, especially if the individual has repeated

exposures to threatening situations. This is commonly seen in ER nurses, who are exposed to

repeated stressful situations by the nature of their job. Permission to use this model was granted

by the publishing journal (Appendix A).

Figure 1: Revised Transactional Model of Occupational Stress and Coping

Philosophical Underpinnings

Phenomenology is a method used by researchers who seek to describe a phenomenon as a

lived experience, rather than as a set of defined constructs (Smith et al, 2022; Streubert, 2011).

Phenomenology is an important methodology to help understand how an individual experiences

something and how the phenomenon affects their life, thoughts, and relationships with the world

(Streubert, 2011). Phenomenology allows for the researcher to understand the phenomenon; in

this study it is STS, as a unique experience for each individual, based on how it impacts their

lives.

One primary data source is in-depth interviews with ER nurses. Through these

interviews, the researcher’s goal is to hear the lived experiences of the participants: how they

experience, process, and cope with stress in the ER and how that stress impacts themselves and

others in their lives. The researcher will gather information and attempt to experience the

phenomenon through listening and observing each participant and reflecting on their stories as

well as reflecting on my own experiences and expectations. The interviewees will likely share

vivid reports to help the researcher and others understand the experiences of the ER nurses (Polit

& Beck, 2012).

Martin Heidegger, believed to be one of the fathers of interpretive phenomenology, stated

that knowledge is an interpretation of an event or thing (Burns et al., 2019; Horrigan-Kelly et al.,

2016; Smith et al., 2022). Heidegger approached phenomenology differently than his mentor,

Edmund Husserl, by viewing phenomenology from an ontological approach (the science of

being) instead of the previously used epistemological approach (theory of knowledge) used by

Husserl (Rodriguez and Smith, 2018). By using an ontological approach, the primary goal of

interpretive phenomenology is to describe the meaning of the lived experience of the

phenomenon being examined (Miller and Minton, 2016). Their reality is their perception;

therefore, individuals can go through the same event, but have different experiences based on

many factors including personal factors and previous experiences.

Interpretive phenomenology, or hermeneutics, will be used to gain an understanding of

the experiences of the ER nurse participants. Hermeneutics acknowledges the prior

understanding of the researcher; the researcher is an experienced ER nurse. The researcher will

examine information and data through their own lens of experience and assumptions but will be

open to hearing what the transcribed words of each nurse mean (Smith et al., 2022). Essentially,

the researcher will attempt to gain a better understanding of the lived experiences of these nurse

participants by being immersed in their worlds during data collection and analysis (Polit & Beck,

2012). By using this approach, researchers are able to reveal the experiences and ways of

thinking, being, and behaving to help bring to light what is known – nurses have STS – but what

is frequently covered up – how does that experience affect nurses’ lives (Crowther et al., 2017)?

Purpose of Study

The purpose of this mixed methods study (quantitative and qualitative) is to answer the

research question ‘What is the lived experience of secondary traumatic stress in ER nurses, and

what coping strategies are being used in response to the secondary traumatic stress?’ The

Secondary Traumatic Stress Scale (STSS) will be used to gather quantitative data of the

prevalence and severity of STS experienced by the participants, the BRIEF-coping scale will be

used to examine various coping methods, a Visual Analog Scale will be used to examine changes

in perceived stress at the beginning and end of the shift, and qualitative interviews will give an

insight into the unique impact of STS on the lives of each participant. There are four specific

aims of this study:

1. to examine the relationship between experience levels, education levels, employment

status, shift worked, hospital trauma levels, change in reported stress, and reported coping

level with reported STS levels in ER nurses

2. to describe STS experiences in ER nurses from the nurses’ perspectives

3. to examine coping strategies, described by ER nurses, in response to STS

4. to compare individual participant interview responses with corresponding survey

responses to identify similarities and differences in reported stress level and coping

techniques.

Chapter II: Literature Review

Method

Following the recommended guidelines for an integrative literature search (Whittemore

& Knafl, 2005), six databases were thoroughly searched, including the Cumulative Index of

Nursing and Allied Health Literature (CINAHL), PubMed, SCOPUS, APAPsycArticles

(formerly PsychInfo), OVID, and Health Source: Nursing/Academic Edition. These databases

provide an extensive compilation of nursing literature as well as the phenomena of secondary

traumatic stress (STS). Search terms included ‘secondary traumatic stress’, OR ‘compassion

fatigue’, OR ‘vicarious trauma’, AND ‘emergency department’, OR ‘emergency room’, AND

‘nurs*’, OR ‘emergency nursing’. There were no time parameters set for this study.

The initial search identified 188 articles, and an additional 37 articles were retrieved

using ancestral searching. After removing duplicates, 119 article titles and abstracts were

reviewed. Inclusion criteria included articles that were published in English, included a study

population of emergency room (ER) nurses, examined secondary traumatic stress, and were

primary articles. Nineteen articles met all inclusion criteria for review (see Appendix B).

Study Characteristics

STS has been studied in ERs across the globe: United States of America (Cantu &

Thomas, 2020; Dominguez-Gomez & Rutledge, 2009; Flarity et al., 2013; Jobe et al., 2021;

Nilan et al., 2019; Wijdenes et al., 2019), Ireland (Aisling et al., 2016; Duffy et al., 2015),

Turkey (Erkin et al., 2021; İlhan & Küpeli, 2022), Australia (O'Callaghan et al., 2020), China

(Wang et al., 2020), Israel (Yaakubov et al., 2020), Jordan (Ratrout & Hamdan-Mansour, 2020),

Korea (Woo & Kim, 2021), Romania (Măirean et al., 2014), Scotland (Morrison & Joy, 2016),

and South Africa (van der Wath et al., 2013). Wolf et al. (2020) conducted their study during an

international conference and sampled nurses from the USA, Canada, and Norway. All studies

reviewed were cross-sectional in design: 18 were descriptive and one was interventional. Of the

19 studies, 14 used quantitative measurements (Cantu & Thomas, 2020; Dominguez-Gomez &

Rutledge, 2009; Duffy et al., 2015; Erkin et al., 2021; Flarity et al., 2013; İlhan & Küpeli, 2022;

Jobe et al., 2021; Măirean et al., 2014; Nilan et al., 2019; Ratrout & Hamdan-Mansour, 2020;

Wang et al., 2020; Wijdenes et al., 2019; Woo & Kim, 2021; Yaakubov et al., 2020), one used

qualitative measurements with interviews (van der Wath et al., 2013), and four were mixed

methods and incorporated both quantitative methods and qualitative approaches via focus groups

(Morrison & Joy, 2016; Wolf et al., 2020) and open-ended questions at the end of the

quantitative instrument (Aisling et al., 2016; O'Callaghan et al., 2020).

Demographics of Study Participants

While many studies included a sample exclusively of ER nurses (Dominguez-Gomez &

Rutledge, 2009; Duffy et al., 2015; Erkin et al., 2021; Flarity et al., 2013; Jobe et al., 2021;

Morrison & Joy, 2016; O'Callaghan et al., 2020; Ratrout & Hamdan-Mansour, 2020; van der

Wath et al., 2013; Wang et al., 2020; Wijdenes et al., 2019; Wolf et al., 2020; Woo & Kim,

2021), some of the studies included participants from other emergency medical professions in

addition to nurses: physicians, ambulance workers, and ER support staff (Aisling et al., 2016);

physician assistants, physicians, residents, and technicians (Cantu & Thomas, 2020; Măirean et

al., 2014; Nilan et al., 2019); auxiliary staff (İlhan & Küpeli, 2022); and physicians (Yaakubov et

al., 2020). One study was conducted in pediatric ER (Nilan et al., 2019), one study was

conducted at a Level 1 trauma center (Wijdenes et al., 2019), and the remaining studies were

conducted in regional ERs that treat both adults and children (Aisling et al., 2016; Cantu &

Thomas, 2020; Dominguez-Gomez & Rutledge, 2009; Duffy et al., 2015; Erkin et al., 2021;

Flarity et al., 2013; İlhan & Küpeli, 2022; Jobe et al., 2021; Măirean et al., 2014; Morrison &

Joy, 2016; O'Callaghan et al., 2020; Ratrout & Hamdan-Mansour, 2020; van der Wath et al.,

2013; Wang et al., 2020; Wolf et al., 2020; Woo & Kim, 2021; Yaakubov et al., 2020). Sample

sizes in the quantitative studies ranged between 39 (Cantu & Thomas, 2020) and 1044 (Wang et

al., 2020), while sample sizes in qualitative studies ranged between 10 (Morrison & Joy, 2016)

and 53 (Wolf et al., 2020).

In each study, the majority of participants were female, ranging between 59.8% (İlhan &

Küpeli, 2022) – 95.2% (Duffy et al., 2015). This is an expected finding, as this corresponds with

the field of nursing being primarily comprised of females (World Health Organization, 2020).

Ages of the participants ranged from 18 (O'Callaghan et al., 2020) – 84 (Wolf et al., 2020).

However, age and gender were not identified to be a significant factor in the development of STS

in any of the reviewed studies. In the studies that reported nursing experience, ranges varied

between less than 3 years to greater than 25 years.

Measurements Used

Examining STS quantitatively was achieved using three different instruments: Secondary

Traumatic Stress Scale (Aisling et al., 2016; Dominguez-Gomez & Rutledge, 2009; Duffy et al.,

2015; Erkin et al., 2021; İlhan & Küpeli, 2022; Măirean et al., 2014; Morrison & Joy, 2016;

Ratrout & Hamdan-Mansour, 2020; Wolf et al., 2020; Woo & Kim, 2021; Yaakubov et al.,

2020), Professional Quality of Life Scale (Cantu & Thomas, 2020; Flarity et al., 2013; Nilan et

al., 2019; O'Callaghan et al., 2020; Wang et al., 2020; Wijdenes et al., 2019), and the Impact of

Events Scale-Revised (Jobe et al., 2021).

The Secondary Traumatic Stress Scale (STSS) is a 17-item self-report instrument that has

produced scores with strong psychometrics in their ability to identify individuals experiencing

STS (Bride et al., 2004). Scores on the full STSS showed a Cronbach alpha of .93 in a study

conducted with 287 social workers (Bride et al., 2004). Cronbach’s alpha is used to measure the

internal consistency reliability for an instrument and can range from .00 – 1.00, with higher

numbers indicating higher internal consistency (Polit & Beck, 2012; Warner, 2013). STSS scores

have also demonstrated evidence of strong convergent and discriminant validity (Bride et al.,

2004). This instrument has been the most widely used to measure STS in the population of

emergency nurses, however it has also been used to examine STS in other populations, such as

social workers (Bride, 2007). Items in the STSS examine the three subscales associated with

STS: intrusion, avoidance, and arousal. Possible scores for the STSS range from 17 – 85. Cutoffs

for the STSS have been identified as the following: scores lower than 28 are interpreted as little

to no STS, scores between 28-37 are interpreted as mild STS, scores between 38-43 are

interpreted as moderate STS, scores between 44-48 are interpreted as high STS, and scores

higher than 49 or higher are interpreted as severe STS (Bride, 2007).

The Professional Quality of Life Scale (ProQOL 5) is a 30-item self-reporting instrument

that measures the three subscales of compassion fatigue: compassion satisfaction, STS, and

burnout. The scale has 10 items addressing each subscale (total of 30 items) and instructs the

participant to respond based on their experiences in the past 30 days. Scores are summed for a

total score ranging between 10-50, with higher scores indicating higher levels of compassion

satisfaction, STS, and burnout (Cantu & Thomas, 2020; O'Callaghan et al., 2020). This

instrument has demonstrated strong psychometrics in the use of examining compassion fatigue in

various populations, such as nurses, with reports of Cronbach’s alpha ranging from 0.84 to 0.90

(Flarity et al., 2013; Nilan et al., 2019; O'Callaghan et al., 2020).

The Impact of Events Scale-Revised (IES-R) is a 22-item self-reporting instrument that

measures three clusters of symptoms: avoidance, intrusion, and hyperarousal. These are the same

subconstructs of STS, although the IES-R uses the word hyperarousal instead of arousal. This

scale uses a Likert scale 0 (not at all) to 4 (extremely), for a possible score of 0-88. Cutoffs for

the scale are set to 0-9 as low STS, 10-19 as moderate STS, and scores greater than 20 as high

STS (Jobe et al., 2021). This scale has demonstrated a Cronbach’s alpha between 0.79 to 0.91

(Jobe et al., 2021).

Prevalence of Secondary Traumatic Stress

In studies that reported the mean STS scores, the lowest mean score was 37.4, which is

classified as mild STS (Dominguez-Gomez & Rutledge, 2009), three studies reported the

participants scored in the moderate STS category (Aisling et al., 2016; Morrison & Joy, 2016;

Yaakubov et al., 2020), three studies reported the participants scored in the high STS category

(Duffy et al., 2015; Ratrout & Hamdan-Mansour, 2020) and three studies reported the

participants scored in the severe STS category (Erkin et al., 2021; Wolf et al., 2020; Woo &

Kim, 2021). Mild STS was also seen in a study that utilized the IES-R, with a mean score of 19.1

(Jobe et al., 2021).

Four studies compared participant scores to the cutoff scores in the STSS: 3.4% - 13.6%

of participants scored in the little/no STS category, 10.4% - 18.8% scored in the mild STS

category, 12.6% - 22.3% scored in the moderate STS category, 7.2% - 14.5% scored in the high

STS category, and 40.1% - 56.5% scored in the severe STS category (Erkin et al., 2021; Ratrout

& Hamdan-Mansour, 2020; Wolf et al., 2020; Woo & Kim, 2021). One study reported how

participants scored according to cutoff scores determined by the IES-R: 35.7% of participants

scored in the low STS category, 26.3% of participants scored in the medium STS category, and

38% of participants scored in the high STS category (Jobe et al., 2021).

In studies that reported STS using the ProQOL5, 21.6% - 31.4% of nurses reported low

STS levels (Nilan et al., 2019; O'Callaghan et al., 2020), 25% - 68.6% of nurses experienced

average amounts of STS (Nilan et al., 2019; O'Callaghan et al., 2020; Wijdenes et al., 2019) and

20.3% - 60% experienced moderate to high levels of STS (Cantu & Thomas, 2020; Flarity et al.,

2013; Nilan et al., 2019).

In studies that examined STS in other departments, nurses working in the ER experienced

significantly higher levels of avoidance and arousal than nurses working in other departments of

the hospital (Măirean et al., 2014). Nurses working in the ED reported higher levels of STS than

nurses working in the post anesthesia care unit (PACU) and the operating room (OR), although

nurses in psychiatric unit and labor and delivery scored higher than those working in the ER

(Wijdenes et al., 2019).

Aisling et al. (2016) examined STS in other healthcare providers in the hospital. Nurses

reported mean STS symptoms of 42.05, compared to doctors, nurse practitioners, and emergency

medical providers, who report mean STS scores of 39.58, 43.00, and 36.86 respectively (Aisling

et al., 2016). Cantu and Thomas (2020) found that ED technicians reported higher levels of STS

compared to RN’s, while Yaakubov et al. (2020) found that physicians scored a mean of 40.79 in

STS while nurses scored 49.56 in STS. This difference was not considered statistically

significant, and attributed to the fact that in the ER, nurses and doctors are exposed to the same

traumatic experiences and difficult patients in a similar manner (Yaakubov et al., 2020)

There is inconsistency in the literature as to which of the three subcategories associated

with STS is experienced most often by ER nurses. Three studies showed the subcategory of

avoidance was experienced most frequently by ER nurses (Aisling et al., 2016; Duffy et al.,

2015; Erkin et al., 2021). Of this category, the most reported symptom was feelings of

discouragement about the future. Three studies identified the subcategory of arousal as having

the most frequently experienced symptoms (Ratrout & Hamdan-Mansour, 2020; Wolf et al.,

2020; Woo & Kim, 2021). Symptoms that scored the highest were feelings of impending doom

and feelings of jumpiness, while other participants expressed feelings of paranoia, anxiety, and

palpitations. Intrusion symptoms scored the highest in two studies (Dominguez-Gomez &

Rutledge, 2009; Morrison & Joy, 2016). Of this category, the highest reported symptoms were

intrusive thoughts about patients outside of work, followed by feelings of anger and frustration

when thinking about patients.

Identification of Causes of STS

The fast-paced nature of the ER, combined with the acuity of patients seen, has been

reported to be a contributing factor in the development of STS. (Aisling et al., 2016; Cantu &

Thomas, 2020; Morrison & Joy, 2016; Wolf et al., 2020). Nurses in one study expressed that

while traumatic situations occur for patients and their families, nurses witness these traumatic

events on a regular basis, exposing them to an abundance of negative stimuli (Morrison & Joy,

2016).

Caring for patients with infectious diseases, such as SARS-CoV-2, the virus that causes

COVID-19, has contradictory evidence in the literature. In a study by Erkin et al. (2021), nurses

who care for patients with COVID-19 reported a high rate of STS compared to prior studies

conducted before COVID-19. However, in a study by Ilhan and Kupeli (2022), researchers

concluded that caring for patients with COVID-19 was not associated with an increase in STS.

Another reported cause is caring for patients who have experienced intimate partner violence:

van der Wath et al. (2013) found that after seeing physical injuries and hearing the stories of

victims of intimate partner violence, ER nurses reporting feelings of emotional detachment,

disempowerment, and extreme anger.

Risk Factors

Nursing Experience

The relationship between years of experience and STS has contradictory evidence in the

literature. Some studies found that experience was not a contributing factor in the development

of STS (Cantu & Thomas, 2020; Dominguez-Gomez & Rutledge, 2009; İlhan & Küpeli, 2022;

Măirean et al., 2014; Ratrout & Hamdan-Mansour, 2020). This contradicts the findings by

Wijdenes et al. (2019) who found that STS was highest in nurses with between 1-5 years of

experience. This is also contradicted by a study that found STS was highest in individuals with

5-15 years of experience (Nilan et al., 2019).

Workplace Factors

Low morale in the workplace has been reported as a risk for exacerbating STS symptoms

(Aisling et al., 2016; Morrison & Joy, 2016; Wolf et al., 2020). Decreased moral has been

attributed to media coverage (Wolf et al., 2020), lack of support from colleagues (Morrison &

Joy, 2016), Nurses commented that traumatic events in their unit impacted them more when they

did not feel supported by their co-workers and unable to have a support to lean on (Wolf et al.,

2020). Inexperienced nurses rely on their senior co-workers and managers to help guide them,

mentor them, and help them process what happened so they can continue to learn and grow

(Morrison & Joy, 2016; Wolf et al., 2020). Feelings of fear of the stigma of being weak and

unable to cope with workplace stressors have been reported as a part of the nursing culture that

contributes to the STS experience (Morrison & Joy, 2016).

Personal Characteristics

Individuals who have a high empathetic personality are at an increased risk of developing

STS symptoms (Dominguez-Gomez & Rutledge, 2009). However, in a study by Ratrout and

Hamdan-Mansour (2020), empathy showed a negative association with STS, indicating that low

levels of empathy are seen with higher levels of STS.

Individuals who report dysfunctional coping or problem-focused coping skill have a

higher risk of developing STS (Woo & Kim, 2021). Ratrout and Hamdan-Mansour (2020) report

that nurses with increased levels of coping demonstrated increased STS. Nurses in the study

reported increased rates of coping; however, their coping mechanisms were not effective and

described as dysfunctional (Ratrout & Hamdan-Mansour, 2020). Another reported consideration

is that nurses who demonstrate high coping skills may be given more stressful and traumatic

patients (Ratrout & Hamdan-Mansour, 2020).

Personal History

Nurses who have experienced personal trauma are at an increased risk of STS (Badger,

2001; Morrison & Joy, 2016). When a nurse cares for a patient experiencing a specific event that

has personal meaning to the nurse, the nurse may have a higher stress response (Cantu &

Thomas, 2020). Nurses who expressed job dissatisfaction, or a prior consideration to change

jobs, reported higher rates of STS (İlhan & Küpeli, 2022). Financial difficulties were also shown

to be an important predictor in the development of STS (İlhan & Küpeli, 2022).

Consequences of Secondary Traumatic Stress

Workplace Factors

Workplace productivity in the hospital is defined as the ability of the nurse to provide

safe and compassionate care to clients and families (Jobe et al., 2021). Workplace productivity is

related to STS levels; nurses who experienced mild STS symptoms were shown to have a

slightly higher level of workplace productivity (Jobe et al., 2021). This was attributed to positive

effects of stress, such as increased attentiveness and awareness, resulting in more efficient care

and attention to tasks. However, nurses who experienced high levels of STS were shown to have

decreased work productivity (Jobe et al., 2021).

Absenteeism, or avoiding/missing work, is positively correlated with STS (Jobe et al.,

2021; Ratrout & Hamdan-Mansour, 2020). Intent to leave the place of employment, transfer to

another unit, or leave the nursing practice completely has been seen with elevated scores of STS

(Duffy et al., 2015; İlhan & Küpeli, 2022; Ratrout & Hamdan-Mansour, 2020; Wolf et al., 2020).

Nurses who scored high on the avoidance subscale may have an even higher rate of job

dissatisfaction and/or burnout (Erkin et al., 2021).

In one study, nurses stated that their experience with STS has impacted the way they care

for their patients (Wolf et al., 2020). Nurses can reach a point of exhaustion which can decrease

their ability to provide safe and effective care (Wolf et al., 2020). At that point, nurses may stop

thinking critically and just do the bare minimum to get through their shift, increasing the risk of

medical errors and causing harm to the patients’ care (Jobe et al., 2021; Wolf et al., 2020).

Psychological Effects

STS has a demonstrated negative effect on nurses and exacerbates compassion fatigue

and burnout (Erkin et al., 2021; van der Wath et al., 2013; Wijdenes et al., 2019). Emotional

detachment and feelings of losing touch with reality have been reported (van der Wath et al.,

2013). Some nurses reported feelings of self-harm related to the experience of STS (Aisling et

al., 2016; Wolf et al., 2020). Nurses have committed suicide, some even in the hospital they

work at, because of the experiences of STS (Wolf et al., 2020). The stigma of mental health has

been identified as a reason nurses do not ask for help when they are feeling anxious, depressed,

or suicidal (Morrison & Joy, 2016; Wolf et al., 2020). Feelings of depression, sadness, anger, and

fear were reported by ER nurses (Bride et al., 2004; van der Wath et al., 2013). Nurses reported

their feelings arose from a combination of seeing the physical and emotional symptoms in their

patients as well as listening to their stories and experiences (van der Wath et al., 2013).

Nurses expressed that the STS had a negative impact on their relationship with their

partners and/or families (Aisling et al., 2016; Jobe et al., 2021; van der Wath et al., 2013; Wolf et

al., 2020). They stated that they are unable to discuss work related situations at home because

their family/partners do not understand how the events impact them (Wolf et al., 2020). Other

nurses reported that they were unable to devote their full attention to their family, because they

were constantly thinking of their patients (van der Wath et al., 2013).

Physical Effects

Difficulty sleeping and sleep alterations have been mentioned as side effects of the work-

related trauma and feelings of STS (Aisling et al., 2016). In a qualitative study designed to

investigate the prevalence and impact of STS on ER nurses, nurses expressed feelings of

sleeplessness due to memories and flashbacks of traumatic situations with patients (Wolf et al.,

2020). Nightmares would cause participants to wake and be unable to return to sleep, due to

continued thoughts of details of certain cases (Wolf et al., 2020). Other nurses expressed

sleeping for extended periods of time, and attribute it to a coping mechanism. However, those

nurses state that due to nightmares, they wake up feeling as though they had not slept at all (Wolf

et al., 2020).

Some nurses explained that their STS symptoms, anxiety, sleep disturbances, and heart

palpitations, were delayed until the nurse left work (Wolf et al., 2020). The delay has been

identified as a day or two, sometimes months or years later, depending on the situation (Morrison

& Joy, 2016; van der Wath et al., 2013; Wolf et al., 2020). This was attributed to nurses being

unable to have time during the shift to process the experience, requiring them to

compartmentalize and move on to the next patient (Morrison & Joy, 2016).

Substance Use

Increased use of substances has been seen in nurses who have experienced increased rates

of stress in the workplace. Increased alcohol use was seen in nurses experiencing elevated levels

of STS (Aisling et al., 2016; Duffy et al., 2015; Wolf et al., 2020). Nurses have stated they drink

nightly to “get rid of the monsters” that remain from repetitive trauma exposure (Wolf et al.,

2020) Some nurses also reported turning to drug use as a coping mechanism to try and self-

manage the symptoms from the trauma experienced (Wolf et al., 2020)

Protective Factors

Only one interventional study was found in the literature; however, it was implemented to

help prevent and treat compassion fatigue (Flarity et al., 2013). Because STS is a component of

compassion fatigue and is measured in the Professional Quality of Life Scale, it was included in

this study. A 4-hour group seminar was developed, using a documentary video, slides, lectures,

and group discussions/exercises. The focus of the seminar was to provide information about

compassion fatigue, burnout, and STS symptoms, causes, and risk factors (O'Callaghan et al.,

2020). After the seminar, participants were given access to resources that include printed

handouts, videos, guided imagery and music, and a website with additional resources and

published articles. After participating in the seminar, the researchers noted a statistically

significant decrease in the reported STS symptoms, from a mean STS score of 23.5

preintervention to a mean STS score of 21.4 postintervention (Flarity et al., 2013).

Positive Self-Care Strategies

Self-reflection has been identified as a positive exercise to reduce the effects of STS

(Badger, 2001). This allows nurses to reflect on how the experience has affected them and

address any negative emotions. Self-reflection also allows the nurse to reflect on positives from

the experience, such as increased team-building and self-resilience (Jobe et al., 2021). By

focusing on positives, it allows the nurse to dedicate energy and thoughts on positives instead of

negatives, which could decrease the risk of intrusive thoughts, which are seen in STS (Badger,

2001; Jobe et al., 2021).

Positive coping strategies have been shown to reduce levels of STS (İlhan & Küpeli,

2022; Jobe et al., 2021). Examples of these beneficial coping strategies are engaging in hobbies

such as exercise or sports, as well as reading (İlhan & Küpeli, 2022). However, this contradicts

Duffy et al. (2015) who found that there was no statistically significant difference between STS

in nurses who did and did not participate in exercise and engage in recreational hobbies.

Informal Support

Strong social support has been shown to have a significant impact on the reduction of

STS (Badger, 2001; Duffy et al., 2015; Jobe et al., 2021; Woo & Kim, 2021). Having a colleague

with whom the nurse has a strong bond may allow the nurse to share thoughts and experiences

surrounding the experience. This is recommended, as it allows the nurse the opportunity to talk

through the experience and voice both concerns and clinical perspectives with someone who

shares professional experiences (Badger, 2001; Jobe et al., 2021; Morrison & Joy, 2016; Wolf et

al., 2020). Informal support is beneficial when it comes from the workplace; support from family

and friends has been shown to be insignificant or even increase the rates of STS (Duffy et al.,

2015). Supportive management who will talk things out with nurses and allow them to verbally

process their feelings and emotions following a traumatic event, either in an informal or a formal

setting, is beneficial in helping prevent the negative outcomes associated with STS (Wolf et al.,

2020).

Formal Debriefing

Debriefing is a process that allows individuals who shared an experience to come

together and discuss the situation, feelings, responses, and overall impact (Badger, 2001). Formal

debriefing has been shown to be beneficial for nurses experiencing traumatic situations in the

workplace (Badger, 2001; Morrison & Joy, 2016). For maximum benefit, debriefing sessions

should be conducted within 72 hours of the event and be led by a trained specialist who was not

involved in the event (Badger, 2001). Nurses who participated in critical incident stress

debriefing (CISD) reported that it helped their mental well-being (Cantu & Thomas, 2020).

However, researchers are conflicted as to the benefit of formal debriefing. CISD may exacerbate

stress responses, as it forces individuals to re-experience the event and can cause further

traumatization (Badger, 2001; Cantu & Thomas, 2020).

Recommendations for Future Research/Practice

Providing training sessions to help teach nurses the signs/symptoms of STS can be

beneficial in helping nurses identify early stages of STS (Erkin et al., 2021). Providing

supportive psychological interventions to help nurses cope and overcome the negative impacts of

STS is vital to keep nurses at the bedside (Duffy et al., 2015; Erkin et al., 2021). Psychological

interventions are most beneficial when screening is done early and routinely. By screening early

and routinely, STS symptoms may be detected prior to becoming detrimental to the individual’s

physical and mental health (Duffy et al., 2015; Măirean et al., 2014)

Gap of Research

Minimal qualitative research has been done to examine STS in ER nurses. In the current

published literature, only five studies used qualitative methods: one utilizing interviews (van der

Wath et al., 2013) and four utilizing mixed methods with focus groups (Morrison & Joy, 2016;

Wolf et al., 2020) and open-ended questions at the end of a quantitative survey (Aisling et al.,

2016; O'Callaghan et al., 2020). Of the five studies using qualitative methods, only one study

was conducted in the United States, while the others were conducted in other countries, such as

Australia, Scotland, and South Africa. Existing literature focuses on the prevalence of STS but

does not go farther to examine the experiences of that stress on nurses. This paucity in the

research prevents researchers from fully understanding the experiences and consequences of STS

in ER nurses. Without understanding how STS affects the lives, relationships, and work

environments of this population, interventions may not be as effective as intended. Through an

extensive review and synthesis of the literature, the above gaps in knowledge were identified.

The previous findings were used as a guide for the development of this study.

Chapter III: Methodology

Purpose

The purpose of this study was to answer the research question ‘What is the lived

experience of secondary traumatic stress (STS) in emergency room (ER) nurses, and what coping

strategies are being used in response to the secondary traumatic stress?’ There are four specific

aims of this study:

1. to examine the relationship between experience levels, education levels, employment

status, shift worked, hospital trauma levels, change in reported stress, and reported coping

level with reported STS levels in ER nurses.

2. to describe STS experiences in ER nurses from the nurses’ perspectives.

3. to examine coping strategies, described by ER nurses, in response to STS.

4. to compare individual participant interview responses with corresponding survey

responses to identify similarities and differences in reported stress level and coping

techniques.

Design

This study was done using a cross-sectional, convergent mixed-methods approach. A

convergent design allowed the researcher to analyze the qualitative and quantitative data at the

same time and compare the results for similarities and differences (Creswell & Clark, 2018).

The quantitative portion of this study included a demographic survey as well as a 47-

question survey consisting of the Secondary Traumatic Stress Scale, the Brief-COPE inventory,

and a visual analog scale where participants rate their perceived level of stress on a 0 – 10 scale.

The qualitative portion of the study included a semi-structured interview with participants,

examining their lived experiences regarding secondary traumatic stress, impacts of STS on

registered nurses’ (RN) lives, what coping strategies are implemented, and how effective are

those coping strategies at mitigating the negative effects of stress.

Phenomenological Design

To answer the research question, ‘what is the lived experience of secondary traumatic

stress on ER nurses, and what coping strategies are being used in response to the secondary

traumatic stress?’ a quantitative survey is not enough. To thoroughly examine the research

question and to capture the question’s complex nature, a phenomenological design was used.

This approach allows the researcher to examine the meaning of a human’s experience (Crowther

et al., 2017). Individuals have a unique experience, even when presented with the same

phenomenon (Smith et al., 2022; Starks et al., 2007). Unlike other qualitative methods,

phenomenology seeks to explore and understand the lived experiences of a phenomenon (i.e.

secondary traumatic stress) by an individual or group of individuals (e.g., nurses who work in an

emergency room) who go through similar situations (Creswell & Poth, 2018).

By examining the experience of secondary traumatic stress from the perspective of ER

nurses, the researcher hoped to gain insight into the personal meaning of STS, the impact that

STS had on both the professional and personal lives of ER nurses, as well as how the experience

of STS affected relationships between the ER nurse and colleagues, patients, families, and

friends. This follows Heidegger’s concept of Dasein: a living being whose existence is not being

alone but is with world, meaning being with others (Burns et al., 2019; Horrigan-Kelly et al.,

2016).

The qualitative portion of this study involved one-on-one, semi-structured recorded

interviews with ER nurses, exploring their experiences with STS as well as coping strategies

used inside and outside of the hospital setting in response to self-reported stressors. The

researcher informed the participants during the initial survey collection that the interviews would

be recorded and reminded them immediately prior to starting the interview. These interviews

allowed each participant to express their experiences with STS, including impacts that it may

have on their professional and personal lives. The semi-structured nature of the interview guide

allowed for flexibility on the part of the researcher to inquire further into comments/statements

made by the participant, as well as ask clarification if needed during the interview. Individual

audio files were uploaded and transcribed using the Otter.ai program. The transcriptions were

checked by the researcher as well as another member of the research team to ensure accuracy.

Errors were identified and corrected on the transcription prior to analysis.

The interviews were analyzed using the seven-step guideline for interpretive

phenomenology, outlined by Smith et al. (2022). First, the researcher read and re-read the

interview, as well as listened to each audio-recording, ensuring that the participants are the center

of the analysis (Smith et al., 2022). Following that step, the second step was to explore the

transcript using noting within the transcript, with the intention of being comprehensive and

detailed in the notes (Smith et al., 2022). Many details and notes tend to be present in this step,

which is considered to be strong, as more detail is preferred at this stage (Smith et al., 2022).

This was followed by step three: analyzing the transcripts and notes with the intention to develop

experiential statements (statements that relate directly to the participant’s shared experiences;

Smith et al., 2022). During this step, the researcher developed a concise summary of important

points illustrated throughout the transcript, with the researcher’s interpretation reflected in these

summary points (Smith et al., 2022). Once the experiential statements were identified, the

researcher moved to the fourth set: searching for connections (Smith et al., 2022). During this

stage, the researcher separated each experiential statement from the transcript and examined

them as a group, clustering them to show different interconnections (Smith et al., 2022). This

process was very fluid, as the clusters changed throughout the process as the researcher saw

different relationships form throughout the statements. This worked closely with step five of

Smith’s process: organizing and naming the experiential themes that were clustered together in

the previous step into Personal Experiential Themes (PET’s; Smith et al., 2022). Step six

repeated steps one through five with every additional interview and transcript. During this step,

the researcher was aware that being influenced by identified exploratory notes, experiential

statements, and clusters from previous transcripts was a possibility. Although this became an

inevitability, the researcher treated each transcript on its own merit (Smith et al., 2022). After all

transcripts were analyzed independently, step seven involved looking at patterns across all PETs

and generated a set of Group Experiential Themes (GETs; Smith et al., 2022). Throughout this

step, the researcher examined the PETs from each individual interview, looking for similarities

and differences as to how each participant experienced stress, coped with stress, and how the

stress impacted their lives inside and outside the hospital. These similarities and differences

formed the GETs. This process was also very fluid, as the GETs changed based on new

introduction of the PETs. It was important that based on the phenomenological approach, the

GETs did not present a group normal of the experience, but rather examined shared features as

well as unique experiences of the participants (Smith et al., 2022). Throughout this process, it

was important that the researcher had a way to identify the participant where the PET originated

to reference back to if needed. As additional PETs were added to the GETs, statements were

examined to identify if new information was being identified. In accordance with qualitative

research, saturation was achieved when no new information was learned from the interviews.

Mixed Methodology

Mixed methodologies combine quantitative and qualitative research approaches. This

study will be conducted using a convergent mixed-methods approach. The main goal of the

mixed methodology portion of this study was to get a more complete picture of secondary

traumatic stress in emergency room nurses. A convergent mixed-methods design allows the

researcher to examine the qualitative and quantitative results side by side to examine for any

consistencies or inconsistencies in either the qualitative set of data or the qualitative set of data

(Creswell & Clark, 2018). Data will be collected simultaneously; quantitative responses will be

collected simultaneously as qualitative interviews. A quantitative survey was given, including

demographic information, the Secondary Traumatic Stress Scale, the Brief-COPE Inventory, and

a Visual Analog Scale (VAS) for perceived stress. The visual analog scale for perceived stress is

a researcher created scale, examining perceived stress at the beginning of a shift and the

perceived stress at the end of the corresponding shift. This will provide the researcher with the

prevalence and severity of STS in ER nurses, the type of coping utilized by participants, and the

perceived stress that the participant self-reports. Participants were also given the opportunity to

engage in a one-on-one interview following completion of the survey. This was done using semi-

structured interviews, allowing the participant to describe stressful experiences they have had in

the ER, describe how the stress has impacted them and their relationships inside and outside of

the hospital, describe coping strategies that they utilize, and discuss how effective those coping

strategies are at mitigating their stress response.

Having both sets of data (quantitative results and qualitative experiential themes) will

allow the researcher to examine complementary and contradictory perspectives between self -

reported secondary traumatic stress, perceived stress levels, and coping strategies and

experiential stories and examples of stress and coping. Analysis will be done using a convergent

design, allowing the researcher to validate one set of data with the other.

Sample and Setting

The setting for this study was Missouri and Illinois emergency rooms in the United States

of America. Inclusion criteria included adult RN’s who are working in an ER in Missouri or

Illinois and who speak English. An a priori power analysis was conducted using G*Power 3.1 to

determine the required sample size to achieve a power of 0.80 under an ANOVA test with an

alpha of .05. Existing literature has used an effect size of 0.15 when measuring STS in nurses

(Ratrout & Hamdan-Mansour, 2020; Woo & Kim, 2021). This researcher used an effect size of

0.20, which is slightly higher than that used in existing literature, to increase the significance in

the relationships. The required sample size was 150; however, throughout early recruitment, the

researcher noticed that a higher number than expected were being submitted incomplete. The

decision was made, at the approval of the IRB, to increase the minimum sample size by 40% to

account for attrition rates and/or incomplete surveys, bringing the recommended sample size to

215.

In the existing literature, studies examining STS qualitatively through interviews had

sample sizes of 10 and 11 (Morrison & Joy, 2016; van der Wath et al., 2013). A minimum

sample size was not set for the qualitative portion of the study; rather, once saturation of the data

had been achieved, recruitment for qualitative interviews stopped, as no new information was

gathered at that point and saturation was achieved.

Of those 215 surveys collected, 46 surveys were incomplete and were excluded from the

analysis, resulting in a total of 169 completed surveys. Of the 46 surveys that were thrown out,

five stated they were not an RN working in an ER in Missouri or Illinois, 26 did not complete the

STSS or Brief-COPE Inventory, and 15 did not complete the demographic survey, the STSS, and

the Brief-COPE Inventory. Failing to complete a few questions within each scale was not a

reason for removing the surveys for total counting. A total of 67 participants indicated an interest

in an interview by providing contact information when completing the survey. Thirty-two

(47.76%) participants never responded to the initial email, text message, or phone call. Four

reminder emails, text messages, and phone calls were sent to each participant (depending on

what contact information was provided: phone number vs email address). Thirty-five participants

agreed to an interview. Of those 35, five (14.3%) did not log onto the virtual meeting or did not

answer the phone call, four (11.4%) experienced technical difficulties and did not reschedule,

and three (8.6%) reached out prior to the interview to reschedule but never responded with a

date/time. Twenty-three interviews were collected, with each interview lasting between 28 – 55

minutes.

Recruitment

Using convenience sampling, participants were recruited directly from three Missouri

hospitals, the Missouri Emergency Nurses Association, as well as through the social media

platform Facebook. The researcher reached out to the manager/director of the Emergency Room

(ER) at three Missouri hospitals, as well as the president of the Missouri Emergency Nurses

Association, and emailed them an electronic copy of the recruitment letter, flyer, and list of

mental health resources to disseminate to their staff via their internal listserv email, as well as

posting the recruitment flyer in break rooms in their ERs. The recruitment flyer included a URL

link, as well as a QR code, to a Qualtrics survey. Initially, only Missouri ERs were used in

recruitment. However, halfway through the recruitment period, recruitment was opened to

Illinois due to lack of participation after approval for amendment was received from the IRB.

The researcher reached out to managers and directors in the ERs in five Illinois hospitals as well

as revised the recruitment flyer that was available on Facebook to account for the change in

recruitment.

Each participant who completed the quantitative survey was given the opportunity to win

one of 15 $15 Amazon Gift Cards. Each participant who completed an interview received a $20

Amazon Gift Card.

Ethical Considerations

Prior to conducting this study, the researcher obtained approval from the institutional

review board (IRB) and hospital IRBs. Electronic surveys were kept on a website that could be

accessed through a secure log-in and password that was only known by the research team. All

recorded interviews, transcriptions, field notes, and coding were kept both on a lockable

computer as well as in a locked cabinet, in a locked office, with access only available by the

research team. No identifiable information, such as names or addresses, was collected. Contact

information was collected for those who agreed to participate in an interview, however this

information was not attached to any interview or transcript, and each participant was assigned a

Research Participant ID # upon agreeing to complete the interview.

One risk of participating in this study was emotional triggering of the topic of traumatic

events. To mitigate this, participants were allowed to skip any questions they did not feel

comfortable answering in the surveys, and participants who agreed to an interview were

informed that they could decline to answer any question asked. Attached to each quantitative

survey link, as well as provided to every participant engaging in an interview, was a list of

resources for mental health support (Appendix C). The topic of STS may trigger some emotional

responses and cause additional stress for the participants. To help accommodate for that

possibility, each participant, whether they inquired about resources or not, was provided with the

information. Resources included financial options, some services were offered for free while

others were offered on a sliding scale, along with multiple delivery modalities: in-person, over-

the-phone, and texting.

Data Collection

At the start of the electronic survey, participants were given the option to complete the

quantitative survey only, or the option to provide contact information for participation in an

interview as well as completing the quantitative survey.

Demographics

The demographic survey consists of questions related to age, gender, experience in the

ER in years, experience as an RN in years, employment status, shift worked, education level, and

current hospital’s trauma level (Appendix D).

Secondary Traumatic Stress Scale

The STSS is a 17-item self-reporting instrument, designed to determine the level of STS

experienced by an individual who works with traumatized clients (Bride et al., 2004). The

participants are to examine each statement and indicate how frequently each statement was true

for them in the past seven days. Each item is scored using a 5-point Likert scale, with 1 being

never and 5 being very often (Appendix E). The STSS includes items that address the three

subscales of STS: intrusion (items 2, 3, 6, 10, 13), avoidance (1, 5, 7, 9, 12, 14, 17), and arousal

(4, 8, 11, 15, 16; (Bride et al., 2004). To score the STSS, each item’s score is added together for

a total. Possible scores for the STSS range from 17 to 85. Interpretation of the scores is as

follows: scores less than 28 are interpreted as little to no STS, scores of 28-37 are interpreted as

mild STS, scores of 38-43 are interpreted as moderate STS, scores of 44-48 are interpreted as

high STS, and scores of 49 or higher are interpreted as severe STS (Bride, 2007).

Scores on the STSS have demonstrated strong psychometrics across the literature.

Cronbach’s alpha is used to measure the internal consistency reliability for an instrument and can

range from .00 to 1.00, with higher numbers indicating higher internal consistency (Polit &

Beck, 2012; Warner, 2013). In a study examining 287 social workers, Bride et al. (2004)

identified that scores from the full STSS demonstrated a Cronbach’s alpha of α = .93. Bride et al.

(2004) also measured the Cronbach’s alpha for each of the subscales: intrusion α = .80,

avoidance α = .87, and arousal α = .83. Dominguez-Gomez and Rutledge (2009) examined 67

RN’s and found that scores for the full STSS demonstrated a Cronbach’s alpha α = .91 and found

the scores for the 3 subscale: intrusion α = .92, avoidance α = .92, and arousal α = .92. Scores on

the full STSS also showed a strong Cronbach’s alpha in a group of 227 Korean nurses of α = .92

(Woo & Kim, 2021). Woo and Kim (2021) also measured the Cronbach’s alpha for the 3

subscales: intrusion α = .79, avoidance α = .79, and arousal α = .81 (Woo & Kim, 2021). İlhan &

Küpeli, (2022) found that scores of the full STSS demonstrated a Cronbach’s α = .91 in 334

healthcare workers in Turkey.

STSS scores have exhibited adequate structural, convergent, and discriminant validity

(Bride et al., 2004). However, it is worth noting that the magnitude of the correlations is

relatively low, although they are statistically significant, meaning that not all individuals who are

exposed to secondary traumatic stressors will develop symptoms of STS (Bride et al., 2004).

Permission has been received to use the Secondary Traumatic Stress Scale (STSS) by the

developer, Dr. Bride, for this dissertation study (B. Bride, personal communication, March 17,

2022).

Brief-COPE Inventory

The Brief-COPE Inventory is an abbreviated version of the full 60-item COPE (Coping

Orientation to Problems Experienced) inventory (Abdul Rahman et al., 2021; Carver, 1997). The

Brief-COPE Inventory is a 28 item self-reporting instrument, designed to examine coping

responses to stress (Appendix F). Participants are asked to rate the frequency with which they

use each coping strategy on a 4-point Likert scale, with 1 being I haven’t been doing this at all

and 4 being I’ve been doing this a lot. The Brief-COPE has 3 subscales and 14 facets: problem-

focused coping (facets including active coping, use of informational support, planning, and

positive reframing), emotion-focused coping (facets including venting, use of emotional support,

humor, acceptance, self-blame, and religion), and avoidant coping (facets including self-

distraction, denial, substance use, and behavioral disengagement). To score the Brief-COPE,

each subscale is totaled. Higher scores in the problem-focused subscale indicate psychological

strength, coping strategies that are aimed at changing the situation, and can be predictive of a

positive outcome; higher scores in emotion-focused subscale indicate an aim to regulate

emotions associated with the situation; and higher scores in the avoidant subscale indicate a

cognitive or physical effort to attempt to disengage from the stressful situation (Coping

Orientation to Problems Experienced Inventory, 2021).

The Brief-COPE Inventory has shown strong psychometrics across the literature. Abdul

et al. (2021) examined 423 nurses and found that the Brief-COPE Inventory scores demonstrated

a Cronbach’s alpha of α = 0.81 (Abdul Rahman et al., 2021). Snell et al. (2011) examined 147

individuals with traumatic brain injury in whom the Brief-COPE Inventory demonstrated a

Cronbach’s alpha of α = 0.77. Hagan et al. (2017) examined 350 cancer patients using the Brief-

COPE Inventory and noted a Cronbach’s alpha of 0.563. The Brief-COPE Inventory has also

demonstrated convergent and discriminate validity (Rodrigues et al., 2022).

Visual Analog Scale for Perceived Stress

The Visual Analog Scale (VAS) for Perceived Stress is a self-reporting item used to

measure perceived stress on a scale from 0 – 10 (0 being no stress, 10 being the worse stress in

your entire life). This scale was chosen over other perceived stress scales due to the ease of use

and familiarity with visual analog scales. Participants were asked to rate their perceived stress at

the start of a typical shift, and then rate their perceived stress at the end of that particular shift.

The researcher then subtracted the pre-shift perceived stress level from the post-shift perceived

stress level to obtain the change in perceived stress level. If this number was positive, it indicated

that the participant had a higher stress after the shift than before the shift, and if the change in

perceived stress was negative, it indicated that the participant had a lower level of stress at the

end of the shift.

The VAS for Perceived Stress is a single item measurement. This has been used to

examine perceived stress in periodontal patients (Barre et al., 2018) as well as occupational

health practitioners (Lesage et al., 2012). This scale has shown similar results to other validated

stress scales, such as the Perceived Stress Scale and the Brief Stress Assessment Scale, when

examining perceived stress (Barré et al., 2018). Lesage et al. (2012) found that the VAS for

Perceived Stress discriminates as well as questionnaires to determine stress level.

Interview

Each participant who consented to an interview was contacted by the researcher within a

few days of completion of the qualitative survey and scheduled for a single interview, lasting

between 30-60 minutes. Interviews were conducted after the quantitative survey was complete.

Interviews were conducted either virtually, using a platform such as ZOOM or Microsoft Teams,

or over the phone, at the discretion of the participant.

A semi-structured interview guide (Appendix G) was developed with the Revised

Transactional Model of Occupational Stress and Coping in mind. Initial questions include those

related to patients that are deemed extra stressful by the participant. This addressed the concepts

of primary as well as secondary appraisal. Coping strategies were specifically asked about, and

the open-ended questions allowed for the participants to discuss how they chose to cope with the

stressors. The researcher continued with the questions related to the effectiveness of coping

strategies. This alluded to the concept of residual stress. Six questions were created, and prompts

were added to help the researcher probe for additional details if not provided by the participant.

The open-ended questions provided a guide for the interview to ensure that all questions were

asked and help the researcher stay on track with the questions. The flexibility of a semi-

structured interview guide allowed for the participant responses to prompt additional questions

by the researcher. The questions were also developed based on the concept of STS, the expertise

of the researcher regarding working in an emergency department, as well as the theoretical

framework that guided this study which prompted questions examining coping strategies. Each

interview was audio recorded and transcribed verbatim. Interviews and transcripts were reviewed

for accuracy by a second member of the research team. Participant recruitment for the interviews

lasted until data saturation was achieved based on transcriptions and group experiential

statements. Data saturation was achieved when no new information was heard through

experiential statements.

Data Analysis

Quantitative Analysis

In order to answer specific aim 1, the researcher examined 10 relationships: the

relationship between experience in nursing and the level of STS self-reported, the relationship

between experience in the ER and the level of STS self-reported, the relationship between

education levels and the level of STS self-reported, the relationship employment status and the

level of STS self-reported, the relationship between shift worked and level of STS reported, the

relationship between hospital trauma level and the level of STS self-reported, the change in

perceived stress, and the relationships between three subscales of reported coping levels and the

level of STS self-reported. The researcher used SPSS version 28 to run the statistical tests. Data

was screened for missing responses or incomplete surveys, as well as any major outliers.

Relationships with a p < .05 were considered statistically significant (Warner, 2013).

Data analysis for the quantitative survey was conducted using three statistical tests:

independent samples t-test was utilized to examine the relationship between STS score and

hospital trauma level, the relationship between STS score and employment status, and the

relationship between STS score and shift worked. This was the test of choice because the

dependent variable is continuous, and the independent variables were nominal with two levels

(level 1 trauma center and non-level 1 trauma center, full time and non-full time, day shift and

not day shift, graduate, and undergraduate education; Warner, 2013).

Spearman’s rho was used to examine the relationship between STS and years’ experience

as an RN and the relationship between STS and years’ experience in the ER. This was the test of

choice because the dependent variable is continuous, and the independent variable is continuous,

however there was non-normality in years’ experience for both relationships, which was why

Pearson’s Correlation was not used (Warner, 2013). Spearman’s rho was also used to examine

the relationship between the Brief-COPE Inventory subscales and reported STS scores. This was

the test of choice because the three subscales in the Brief-COPE Inventory are ordinal ranked

data using a Likert scale, and the assumption of normality was not met.

The dependent samples t-test was used to examine change in perceived stress. This was

the test of choice because the VAS of Perceived Stress is a single item measurement, that waws

asked the participant to answer twice: perceived stress at the beginning of an average shift and

perceived stress at the end of that particular shift. The change was calculated based on the

difference between post-shift and pre-shift. Positive values indicate an increase in stress

throughout the shift, negative numbers indicate a decrease in stress throughout the shift.

Qualitative Analysis

To answer specific aims 2 and 3, the researcher collected 23 semi-structured interviews.

During all recorded interviews, the researcher took field notes which included facial expressions

if the interview was conducted via video conferencing, speech patterns and pauses, and any

distractions occurring during the interview. The researcher also journaled throughout the

collection of interviews to document personal feelings and perspectives. While phenomenology

does not bracket, it is important for the researcher to be aware of their own bias and how that

impacts the interview and analysis.

Transcription of each audio recording was conducted through the online transcription

application Otter.ai. The primary researcher listened and reviewed each recording and

transcription to verify accuracy, and this was double-checked by another member of the research

team. Once the interviews were transcribed and verified with a secondary researcher, data

analysis began immediately after completion of the first interview.

The researcher analyzed the data using the seven-step method described by Smith et al.

(2022). The researcher read the transcripts and listened to the corresponding audio multiple

times, as well as reviewing each field note, to become intimately familiar with the experiences of

each participant. Exploratory noting was written on each transcript, and then experiential

statements were identified from each transcript. The experiential statements were examined

independently of the transcript, by writing each statement on a separate piece of paper, and then

examining the statements together. The researcher then clustered them into groups, based on

identified interconnections. Once clustered, the researcher named the groups into Personal

Experiential Themes (PETs). This process was repeated for each of the 23 interviews conducted.

Once each interview was examined, noted, and clustered, the PETs were compared across the

transcripts. The researcher looked for similarities and differences at a broader level, creating the

Group Experiential Themes (GETs).

Mixed Methods Analysis

To get a holistic understanding of the impact of secondary traumatic stress in ER nurses,

qualitative and quantitative data were compared using a convergent design (Creswell & Clark,

2018). The results of each interview were compared to the results of the Secondary Traumatic

Stress Scale, Brief-COPE Inventory, and the visual analog scale for perceived stress. A table was

created to compare each survey to qualitative comments for each participant. This allowed the

researcher to assess convergence and divergence between reported stress levels and coping

strategies (specific aim 4). This can be beneficial in identifying aspects of STS that are not

identified in the STSS, or the efficacy of coping mechanisms identified in the Brief-COPE

Inventory to the stressors discussed in the interview.

Validity

Internal validity addresses how the interactions between the independent and dependent

variables are related and not caused by other factors (Gray & Grove, 2021). Threats to internal

validity that could affect this study include selection and attrition. Unfortunately, random

recruitment is not plausible in this study as participants have the option of refusing to participate

or dropping out/withdrawing after the study begins. Attrition, or the participants who drop out or

fail to complete the survey, was addressed by increasing my sample size for data collection.

Trustworthiness and Rigor

To demonstrate rigor and trustworthiness, the researcher used reflexivity, triangulation,

peer debriefing, member checking, and audit trails. Reflexivity is operationalized as self -

reflection on the part of the researcher (Creswell, 2016). The researcher acknowledged their own

experiences related to a given phenomenon to help understand how they perceive the findings of

the study. This was done on a continual basis during the study: after each interview, during each

transcription, and throughout the analysis experience. Using multiple data sources to establish

themes helped to increase the dependability of this study through the process known as

triangulation (Creswell, 2016; Streubert & Carpenter, 2011). This was achieved in this study by

using multiple sources of data collection, such as interviews, observations/field notes, and

quantitative surveys. Members of the research team independently reviewed each transcript to

identify experiential statements and met to discuss their findings. Disagreement occurred in three

of the reviewed transcripts, however the team was able to reach an agreement after discussion on

all three transcripts. The researcher reached out to the participants and provided them with a

copy of the researcher’s notes and personal experiential themes for their respective interviews.

Participants were asked to review the documents for accuracy of the researcher’s interpretation

of the data. Eighteen of the twenty-three participants responded to the researcher, validating the

transcript accuracy, exploratory notes and experiential statements written by the researcher.

Detailed descriptions and records were maintained throughout each stage of the study process

using an audit trail. This clearly outlined decisions that were made during the study, as well as

the process of identifying both personal and group experiential themes from the data.

Chapter IV: Results

Secondary traumatic stress (STS) is the negative emotional, physical, or psychological

reaction experienced by someone who had an indirect exposure to trauma (Beck, 2011; Erkin et

al., 2021; İlhan & Küpeli, 2022; Jobe et al., 2021; Măirean et al., 2014; Rauvola et al., 2019).

Symptoms of STS mirror those of post-traumatic stress disorder (PTSD): avoidance of

places/individuals that remind of the trauma, arousal, intrusive thoughts of the trauma, and re-

experiencing of the event (Măirean et al., 2014; Wolf et al., 2020). The purpose of this study was

to answer the research question ‘What is the lived experience of secondary traumatic stress in ER

nurses, and what coping strategies are being used in response to the secondary traumatic stress?’

There are four specific aims of this study:

1. to examine the relationship between experience levels, education levels, employment

status, shift worked, hospital trauma levels, change in reported stress, and reported coping

level with reported STS levels in ER nurses.

2. to describe STS experiences in ER nurses from the nurses’ perspectives.

3. to examine coping strategies, described by ER nurses, in response to STS.

4. to compare individual participant interview responses with corresponding survey responses

to identify similarities and differences in reported stress level and coping techniques.

Two-hundred and ten surveys were collected in this study. Of those 210, two surveys

were removed because the participants indicated that they did not work in an ER in the states of

either Missouri or Illinois, therefore not meeting the inclusion criteria. Twenty-six surveys were

excluded because the participants completed the demographic survey but did not complete both

the Secondary Traumatic Stress Scale and the Brief-COPE Inventory. Thirteen surveys were

excluded because the survey was incomplete upon submission (no data was collected). One

hundred and sixty-nine completed surveys were included in the data analysis. The majority of the

sample identified as female (76.9%), aged between 30-39 (48.2%), and held a bachelor’s degree

(58.9%). The median age was 36 years (range of 23 – 77), the majority of the sample had

between zero- and nine-years of experience (62.58%) with a median of seven years of experience

in an ER, and the majority had between 0-15 years of nursing experience (75%) with a median of

10 years of experience as an RN. Demographic characteristics of the sample are illustrated in

Table 1.

Table 1: Demographics of the Sample

Characteristic n (percentage) Median (range) Characteristic n (percentage)

Age

• 20 – 29

• 30 – 39

• 40 – 49

• 50 – 59

• 60 – 69

• 70 – 79

158

• 28 (17.7%)

• 76 (48.2%)

• 38 (24%)

• 12 (7.5%)

• 2 (1.3%)

(23 – 77)

Education Level

• Diploma

• Associate Degree

• Bachelors Degree

• Masters Degree

• Doctor of Nursing

Practice

163

• 1 (0.6%)

• 27 (16.6%)

• 96 (58.9%)

• 23 (14.1%)

• 15 (9.2%)

Experience in ER

• 0 – 4 years

• 5 – 9 years

• 10 – 14 years

• 15 – 19 years

• 20 – 24 years

• 25 – 29 years

• ≥ 30 years

167

• 49 (29.34%)

• 56 (33.54%)

• 32 (19.16%)

• 13 (7.78%)

• 6 (3.59%)

• 4 (2.4%)

• 7 (4.19%)

(0 – 39)

Gender

• Female

• Male

• Nonbinary

• Transgender

169

• 130 (76.9%)

• 35 (20.7%)

• 3 (1.8%)

• 1 (0.6%)

Experience as RN

• 0 – 4 years

• 5 – 9 years

• 10 – 14 years

• 15 – 19 years

• 20 – 24 years

• 25 – 29 years

• ≥ 30 years

168

• 32 (19.05%)

• 51 (30.36%)

• 43 (25.59%)

• 16 (9.53%)

• 10 (5.95%)

• 7 (4.17%)

• 9 (5.35%)

(0 – 52)

Trauma Center

• 1

• 2

• 3

• 4

• 5

169

• 46 (27.2%)

• 25 (14.8%)

• 51 (30.2%)

• 21 (12.4%)

Employment

Status

• Full time

• Part time

• PRN

169

• 127 (75.1%)

• 18 (10.7%)

• 24 (14.2%)

Shift Worked

• Day

• Mid

• Night

• Variable

169

• 77 (45.6%)

• 28 (16.6%)

• 32 (18.9%)

Research Aim 1

Research aim 1 was examined quantitatively by reviewing ten different relationships: the

relationship between experience level as an RN, experience level in an ER, education level,

employment status, shift worked, hospital trauma level, change in reported stress, and reported

coping level with reported STS levels in ER nurse. This specific aim relates back to the Revised

Transactional Model of Occupational Stress and Coping, as it addresses the negative stress

response experienced by the ER nurses. The Secondary Traumatic Stress Scale, Brief-COPE

Inventory, Visual Analog Scale of Perceived Stress, and a demographic survey were used to

collect data from 169 participants.

Table 2: Secondary Traumatic Stress, Brief-COPE, Change in Perceived Stress

Characteristics Mean SD N % Cronbach α

STS

• Little to no STS

• Mild STS

• Moderate STS

• High STS

• Severe STS

50.02

14.24 10 25 21 19 94

5.9%

14.8% 12.4% 11.2% 55.6%

.94

STS Avoidance 2.95 0.88 169 .86 STS Arousal 3.06 0.93 169 .83 STS Intrusion 2.82 0.91 169 .83 Avoidance Coping 2.12 0.71 164 .84 Emotion Focused Coping 2.94 0.71 156 .81 Problem Focused Coping 2.36 0.73 158 .90 Change in Perceived Stress 2.30 3.21 167

The relationship between experience level as an RN and reported STS level was

examined using Spearman’s rho. The null hypothesis was that there is no relationship between

experience level as an RN and reported STS level, and the alternative hypothesis was that there

is a relationship between experience level working as an RN and STS level. Years of experience

as an RN and reported STS level are continuous variables, and the initial choice was to run a

Pearson correlation. However, the number of years of experience as an RN did not follow the

normal distribution, and it did not follow the assumption of linearity. Therefore, the decision was

made to change to a Spearman’s rank correlation coefficient, which yielded rs = -.028, t(167) = -

0.362, p = .714. Based on the results of Spearman’s rho, I have failed to reject the null

hypothesis.

The relationship between experience level in an ER and reported STS level was

examined using Spearman’s rho. The null hypothesis was that there is no relationship between

experience level working in an ER and reported STS level, and the alternative hypothesis was

that there is a relationship between experience level working in and ER and STS level. Years of

experience working in an ER and reported STS level are continuous variables, and the initial

choice was to run a Pearson Correlation. However, years of experience working in an ER did not

follow the normal distribution, and it did not follow the assumption of linearity. Therefore, the

decision was made to change to a Spearman’s rank correlation coefficient, which yielded rs =

.063, and t(167) = 0.813, and p = .416. Based on the results of Spearman’s rho, I have failed to

reject the null hypothesis.

The relationship between education level and reported STS level was examined using the

independent samples t-test. The null hypothesis was that there is no relationship between

education level and reported STS level, and the alternative hypothesis was that there is a

relationship between education level and STS level. Education level was dichotomized to

undergraduate education (to include diploma, associate degree, and bachelor’s degree) and

graduate education (to include master’s degree, Doctor of Nursing practice, and Doctor of

Philosophy). Initially, the intention was to run a one-way analysis of variance (ANOVA), but the

decision was made to dichotomize the data based on the small size of the individual groups. The

mean STS of RNs with an undergraduate degree (n = 127) was 48.43, indicating severe STS,

while the mean STS of RNs with a graduate degree (n = 42) was 55.76, indicating severe STS.

Based on the results of the Welch’s t-test, the average reported STS level between education

levels is statistically different: t(166) = -2.790, p = .004, d = 0.487. Cohen’s d value of 0.487 is

above 0.4, indicating a moderate effect size. I have rejected the null hypothesis.

The relationship between employment status and reported STS level was examined using

the independent samples t-test. The null hypothesis was that there is no relationship between

employment status and reported STS level, and the alternative hypothesis was that there is a

relationship between employment status and STS level. Initially at data collection, employment

status was presented as three different values (Full time, part time, per diem – PRN). However,

based on the small sample size among the various levels, the decision was made to dichotomize

the variable to full time and not-full-time level. The mean STS of RN’s working full time (n =

127) was 50.07 (sd = 14.65), indicating severe STS, while the mean STS of RN’s working less

than full time (n = 42) was 49.86 (sd = 13.09), indicating severe STS. There is no statistically

significant difference in STS between employment status. Based on the results of the Welch’s t-

test, the average reported STS level between employment status is not statistically significant:

t(167) = .084, p = .467, d = 0.016. Cohen’s d value of 0.016 is less than 0.2, indicating a very

small effect size. I have failed to reject the null hypothesis.

The relationship between shift worked and STS level was examined using the

independent samples t-test. The null hypothesis was that there is no relationship between shift

worked and reported STS level, and the alternative hypothesis was that there is a relationship

between shift worked and STS level. Initially at data collection, shift worked was presented as

four different values (Dayshift, Midshift, Nightshift, and variable shift). However, based on the

small sample size among the various levels, the decision was made to dichotomize the variable to

day shift and non-day shift. The mean STS of RN’s working day shift (n = 77) was 48.19 (sd =

15.504), indicating severe STS, while the mean STS of RN’s working shifts other than day shift

(n = 93) was 51.53 (sd = 12.969), indicating severe STS. Based on the results of the Welch’s t-

test, the average reported STS level between shifts worked is not statistically significant: t(167)

= -1.524, p = .136, d = 0.2573. Cohen’s d value of 0.2573 is around 0.2, indicating a small effect

size. I have failed to reject the null hypothesis.

The relationship between hospital trauma level and STS level was examined using the

independent samples t-test. The null hypothesis was that there is no relationship between hospital

trauma level and reported STS level, and the alternative hypothesis was that there is a

relationship between hospital trauma level and STS level. Initially at data collection, hospital

trauma level was presented as five different values (level 1, level 2, level 3, level 4, level 5).

However, based on the small sample size among the various levels, the decision was made to

dichotomize the variable to level one trauma and non-level one trauma level. The mean STS of

RN’s working at a level one trauma center (n = 46) was 48.22 (sd = 13.325), indicating severe

STS, while the mean STS of RN’s working at a non-level one trauma center (n = 118) was 51.19

(sd = 14.35), indicating severe STS. Based on the results of the Welch’s t-test, the average

reported STS level between hospital trauma level is not statistically significant: t(166) = -1.214,

p = .107, d = 0.2069. Cohen’s d value of 0.2069 is around 0.2, indicating a small effect size. I

have failed to reject the null hypothesis.

The perceived stress change at the end of shift from the beginning of the shift was

examined using a dependent samples t-test. The null hypothesis is that the perceived stress at the

start of a shift is not different than the perceived stress at the end of a shift, and the alternative

hypothesis was that the perceived stress at the start of a shift is different than the perceived stress

at the end of a shift. The choice was to run a dependent samples t-test. The measurement

(perceived stress) was collected by the same participant on two occasions (preshift, postshift).

The change was calculated based on the difference between post-shift and pre-shift. Positive

values indicate an increase in stress throughout the shift, negative numbers indicate a decrease in

stress throughout the shift. The mean value of the change in stress was 2.2952 (sd 3.20845).

Based on the results of the dependent samples t-test, t(165) = 9.217, d = -0.7154, and p < .001, I

will reject the null hypothesis.

The relationships between reported coping level (problem focused, emotion focused, and

avoidant focused) with reported STS level was examined using Spearman’s rho. The null

hypothesis is that there is no relationship between reported coping level and reported STS level,

and the alternative hypothesis was that there is a relationship between reported coping level and

STS level. Self-reported STS is a continuous variable, however the coping level is ordinal, but

ranked. A Pearson’s Correlation test would not be indicated, as two continuous variables are

required. Scoring for the Brief-COPE Inventory indicates that each subscale is measured

independently, so the researcher examined the relationship between each subscale with the

reported STS level. The problem focused brief-COPE subscale yielded a correlation of rs = .113,

t(153) = 1.398, and p = .163. We have failed to reject the null hypothesis. The emotion focused

brief-COPE subscale yielded a correlation of rs = .454, t(159) = 10.890, and p < .001. We will

reject the null hypothesis. The avoidant focused brief-COPE subscale yielded a correlation of rs

= .656, t(159) = 6.323, and p < .001. I have rejected the null hypothesis. See Table 3 for the

analysis of factors related to STS and coping.

Table 3: Analysis of Factors Associated with Secondary Traumatic Stress

Variables STS p Hospital Trauma Level

• Level 1

• Non-Level 1

• 48.22

• 51.19

• .107

Employment Level

• Full time

• Not Full time

• 50.07

• 49.86

• .465

Education Level

• Undergraduate

• Graduate

• 48.43

• 55.76

• .004

Shift worked

• Day shift

• Other shift

• 48.19

• 51.53

• .136

Years experience as RN • .714 Years experience in ER • .416 Brief-COPE

• Problem Focused

• Emotion Focused • Avoidant

• .163

• < .001

Change in Perceived Stress • < .001

Research Aim 2

Research aim 2 – to describe STS experiences in ER nurses from the nurses’ perspectives

– was examined through qualitative interviews. This specific aim relates back to the Revised

Transactional Model of Occupational Stress and Coping, as it addresses the negative stress

response experienced by the ER nurses. This specific aim addresses the experience, rather than

the prevalence, of STS in ER nurses. Twenty-three interviews were conducted via phone

interviews and video conferencing platforms (ZOOM and Microsoft Teams). To protect

confidentiality, each participant was assigned a Research Participant (RP) number upon

agreement to participate in an interview. Interviews lasted between 28 – 55 minutes, guided by

the semi-structured interview guide developed by the research team. Five GETs were identified

through data analysis: patient care suffers, relationships at work are impacted, life continues

outside the hospital, impacting me on a personal level, and residual stress remains despite coping

attempts. The last theme, residual stress remains despite coping attempts, relates to the last facet

of the Model: residual stress. Participants were able to identify the effectiveness of their coping

strategies on residual stress they experienced.

Patients affect nurses differently, based on many different factors: past experiences,

personal history, outlook on life, among others. Stress inducing patients include pediatrics,

psychiatric patients, substance abuse/overdoses, motor vehicle accidents, high acuity patients,

and chronic disease. Some participants identified multiple patient complaints as being triggering

for a high stress response.

Patient Care Suffers

Nurses are usually very empathetic and caring. They are trusted to provide safe, efficient,

and compassionate care and treatment to their patients. However, many participants in this study

identified that the effects of STS have had a direct impact on their ability to safely care for their

patients. That impact was brought to light through two subthemes by statements from

participants: lack of engagement with patients and patients’ and nurses’ safety are both at risk.

Lack of Engagement with Patients

Many participants discussed how their experiences with STS created a barrier between

themselves and their patients, leading to disengagement and less meaningful interactions.

Participants described this lack of engagement in multiple ways: putting a physical distance

between themselves and the patients, an unintentional disengagement by feeling too distracted to

provide effective and meaningful interactions, and intentional disengagement by mentally

disengaging from the patients.

Several participants reported feeling a physical distance between themselves and patients

following a traumatic experience. For RP 22, RP 29, and RP 31, the distancing occurred with the

patient themselves, while RP 35 reported a distancing between future patients who reminded RP

35 of the traumatic patient.

• RP 22 “I wouldn’t put myself, I didn’t want to step too far into their room, I didn’t want

to get too close to them to interact. I couldn’t focus on them very well”

• RP 29: “I try to avoid them if at all possible”

• RP 31: “I just wanted to be done, I didn’t want any continued interaction with that patient

because of what happened with their visitors. I remember I was just over it completely”

• RP 31: “I couldn’t give this patient as much of my time as they really should have had

• RP35: “Before I had the four-month-old patient, I always thought I’d end up in

peds…After that, absolutely not. Will not. Not even anywhere on the radar”

Some participants, like RP 6, attributed this disengagement to the busy nature of the

Emergency Room (ER) where they are not able to spend sufficient time with their patients:

• RP 6: “You do just go on right to the next thing, you’re not even processing that. And

you’re like, ‘Ok, now I gotta do this. And now I gotta call the family, and now we got to

take care of this body, and we got to do things and that and that.’ And it was all about the

tasks”

Seeing the patient in a mechanistic, Cartesian way, was one way that participants approached

patients when they were feeling overwhelmed and stressed, instead of seeing the patient as a

living being who was important to someone. That was how RP 24 reacted during those patient

interactions:

• RP 24: “it’s easier to compartmentalize when it’s just, this is a patient, and my job is to

fix this machine of a human. Versus: oh yeah, this is someone who has a life and all these

people care about them”

RP 24 also explained this process as labeling the patients as their chief complaint, to

depersonalize the patient and mentally disengage.

• RP 24: “it’s easy to kind of think of them as their chief complaint, which is ‘oh this is the

SI [suicidal ideation], or this is the person who is off of their, basically having a bipolar

episode because they wouldn’t take their medicine.’ And you forget, a lot of times, it’s

like ‘oh what is this like for you and your family?’”

Other participants expressed that they looked at the patient as a checklist and a set of tasks that

had to be completed. This allowed for some emotional detachment, preventing the nurse from

becoming emotionally invested in the patient. RP 3 and RP 25 stated that this was the way they

approached patients during times of increased stress:

• RP 3: “I dissociate quite a bit. I’m able to separate myself from what’s going on in front

of me and I can just kind of, focus on tasks and things I need to do, as opposed to the

individual that’s in front of me.

• RP 25: in that moment, it’s that adrenaline and you’re just like, okay, it’s all very

business. This is what we need to do”

This emotional detachment occurred not only with that specific traumatic/stressful

patient, but some participants explained that they felt emotionally detached from their patients

for the remainder of that shift. This was a more frequent theme that was brought up by multiple

participants:

• RP 1: “you don’t actually attend to other patients effectively”

• RP 2: “I wasn’t really able to carry out my job with patients so comfortably as I would

because of my level of frustration”

• RP 7: “this kind of slowed down my participation as well as my interactions with my

patients, and I, in general, would say I was unable to offer my best to them”

• RP 16: “just try to get through the day. I felt really quiet that day…where it was kind of

going for as little bit of conversation there was to have with”

• RP 22: “it’s like your brain is elsewhere. I don’t know how to describe it…you’re doing

the minimum that you have to do, your heart is just not in it the rest of the day”

• RP 30: “You’re gonna slow down a bit because you’re sad, you’re stressed, you’re

dealing with, I mean you physically absorb a whole lot of negative energy.”

Some participants even stated that their relationships with future similar patients caused a

resurgence of emotions and they had less interactions with those patients as a result of their past

experiences:

• RP 8: “I started having flashbacks of other patients who actually reacted like him. So it

was like, I was scared. I literally froze for a minute”

• RP 29: “moving forward, with any other assault patient that I have had, her face usually

kind of popped in”

• RP 35: “I remember being a little bit unnecessarily hostile to one patient who came in

who was a drug overdose”

One participant discussed how he did not have decreased engagement with patients, but had an

inappropriate interaction with that patient as the result of a stressful emotional response:

• RP 8: “I might have reacted poorly…I had this patient. I actually screamed at him. I was,

I was pissed off. So I screamed at him.”

Patients’ and Nurses’ Safety are at Risk

Several participants described how safety is a concern for both themselves as well as their

patients. Patients rely on nurses’ ability to provide safe care to themselves and their loved ones,

and nurses rely on the patients to be civil and not a safety threat to themselves and their nursing

staff. This coincides with the lack of engagement with patients, as physical and emotional

distancing can lead to errors or not recognizing changes in patient status. For some, like RP 6,

the traumatic response was so severe that there is no memory of patients for that shift. This

drastic mental block makes the participant unaware if mistakes were made, increasing the risk to

patients:

• RP 6: “I don’t remember any other patient from those two days at all”

• RP 8: “my hands were straight but my body was shaking. I couldn’t move. I kept on

looking at him, I didn’t know what to do. In that case, I was trying to think of what

actions to take…there was nothing coming to my head in a particular moment”

For others, like RP 27, triggering stimuli forces the participant to walk away from a patient. This

abandonment, even if only temporary, could lead to high safety concerns and put both the patient

and the institution at risk:

• RP 27: “There's certain smells that will put me back into almost like a panic attack, where

I have to step away from the current patient that I'm working on”

RP 7 and RP 27 explained that they were concerned that their lack of patient engagement would

cause them to make a mistake or perform a task that could negatively impact the patient safety

and condition:

• RP 7: “I was, at the same time, scared that I might do something that might, you know,

make the condition severe or increase the severity of the situation”

• RP 27: “some of them didn’t, I feel like they didn’t get the best care that I could have

given them.”

For some participants, the stress response that they went through posed a risk to patient safety.

They were unable to focus on their care, increasing the risk of making an error. Participants like

RP 21 were self-aware of this risk to patient safety and RP 21 explained how she made a

conscious effort to recognize this in her own behavior:

• RP 21: “it’s allowing yourself to say ‘look, I can be really pissed off, and I can be really

upset, but I gotta go give some insulin now. And I can’t be fucked up and push insulin,

because I’m gonna make a mistake. So I gotta reel it in here.’ But how many times a day

can you reel it in?”

• RP 21: “I’m trying to be mindful and increase my awareness of ‘I am on fire right now’

and when I’m on fire, I am setting myself to fail again, I’m gonna miss something, I’m

gonna make a med error”

• RP 35: “I was a mess…I was basically unusable. Like I couldn’t, I could not go back to

work. It was as if that kid was mine. Audibly wept and sobbed throughout the rest of that

shift.”

For other participants, the fear of violence was overwhelming. This fear was sometimes initiated

by the patient. RP 16 explains that even though patients who have a history of violent actions

come to the hospital for care, nurses must care for them and put themselves at risk of bodily

harm:

• RP 16: “occasionally we have had patients where they have attacked people…certain

patients have pulled out hair…another one bit a nurse…had broke the doctor’s thumb in

an altercation”

• RP 27: “I’m like, am I gonna get hurt today? Am I going to, is this going to be the point

where it’s going to put me in the hospital”

• RP 31: “it can be really frustrating as an ED nurse because you’re just not quite sure

what’s going to happen next: are they going to try to hurt you? Are they going to try to

hit you? Are they going to try to hurt themselves?”

• RP 31: “he has assaulted multiple employees: one so bad to the point that they had to

have surgery and like were our for 10 weeks recovering from it”

• RP 31: “at what point does it get so out of control that it’s like, physical violence is the

only option for families in the ED?”

• RP 32: “the patient ended up eventually escalating and getting physical with me and

cornering me”

For some participants, violence was not expected. Visitors, and even strangers, posed this threat

without warning. This happened to RP 24 and RP 31:

• RP 24: “He [patient husband] got really sort of, like charging up to me and getting in my

face. So I asked him to step back, he didn’t…and then they started throwing things that

were in the room at me”

• RP 31: “slammed her body into me and like, pinned me up against the stretcher. I think

because she was so frustrated, like she felt like physical assault was the only option that

could happen in that moment. And then she did it again. And it’s one of those things that

I will always remember, feeling just what is happening right now. And being literally

pushed into the stretcher…I was trying not to have a complete emotional response of like,

you just assaulted me in this room. And that’s an experience that has always stuck with

me”

RP 26 explained that violence was a concern while caring for victims of gunshot wounds or other

violent traumas. They explained that this fear was in the unknown if someone was going to come

to the hospital to inflict more harm on the patient and/or those caring for them:

• RP 26: “they put our hospital on lockdown for a while because we didn’t know if...if it

was gang related or just violence related, they don’t want whoever caused this issue to

come and try to hurt them more or hurt the ER staff”

Participants also expressed that this fear of violence, patient safety concerns, and personal safety

concerns were just “par for the course” and a normal part of ER nursing. They have no choice

but to accept it and continue caring for their patients:

• RP 24: “the highest stress things are when there’s the patients or the families who are just

being mean. And it happens a lot”

• RP 31: “I just felt helpless, because it was, like there was nothing that could be done…I

essentially just have to suck it up and keep taking care of this patient”

• RP 32: “I feel like if you talk to an ER nurse there is a very likely chance that they’ve

been in an unsafe situation with a psych patient”

Relationships at Work are Impacted

Nurses rely on their ability to work together to care for patients. Nurses, technicians, aids,

doctors, practitioners, ancillary staff and others work together to provide holistic, efficient, and

collaborative care for patients to have the best outcome possible. However, participants in this

study expressed that the secondary stress of caring for their patients has an impact on their

relationships with these coworkers. The participants identified that the experiences made their

workplace relationships stronger and better, while others expressed how the experiences caused

division and distancing from their coworkers.

Stronger and Better

Many participants identified that the stress response actually helped bring them closer

and develop stronger bonds with their coworkers. These stronger relationships were attributed to

the teamwork and the ability of their coworkers to help carry additional responsibilities, allowing

the participant to have a moment to process or have time to dedicate to their critically ill patient.

• RP 6: “I think that [traumatic patient interaction] helped our [coworkers] relationship a

lot. And it helped me know what to ask for”

• RP 8: “I simply asked the next nurse to take over because I knew I was having a mental

breakdown. I think I needed time”

• RP 28: “We all understand where we’re coming from. So we all know if we’re having a

bad day, you know, we can lean on each other”

• RP 33: “as coworker and friends together, like that’s why it’s our second family, we just

take care of each other”

Other participants explained the invaluable nature of shared experiences as a key factor in the

development of strong relationships with coworkers. These bonds were referred to as the “work

family” and stated that no relationship was quite like that between two ER RN’s.

• RP 11: “You develop a relationship with your coworkers that’s unlike anything else. It is

rooted in deep trust, understanding, and empathy”

• RP 16: “the ones who were there for the code, like who were in the ER at that time, that

was easier to work with them”

• RP 28: “They all know what you’ve been through, and what each other has been through.

And so you, you can lean on each other a lot easier. And you just help carry each other,

you pick each other up. You cover each other’s team if you need to step away for a

minute. You become a closer knit family and team”

• RP 30: “you’re sharing that experience with a coworker elbow to elbow, whether they

were friends before or you know, a newbie that you’re sharing a new experience with

them. There’s a bond, you know?”

Within those shared experiences is the benefit of having someone to talk to. Participants

expressed that they do not have an outlet outside of work to offload some of the mental turmoil

they’re experiencing, due to lack of understanding outside of their coworkers.

• RP 11: “It’s you know, really not conversation for polite society when we think about

what we do. And so it has to be done with your colleagues”

• RP 21: “sometimes I will seek out the opinion of somebody else and just say ‘hey you

know, this just happened’.

• RP 24: “we were able to kind of talk through it amongst ourselves, and that helps: talking

with coworkers. And just being able to kind of express how we’re feeling”

• RP 31: “they’re the people that I’m friends with, that I got to know from there, like

lifelong friends, because you’re in the trenches with them. And like, even on the worst

shifts, you’re still laughing, you’re still having fun, you’re still doing it together"

• RP 32: “I have friends at work that I can talk to. Because they, I feel like they can

understand my work stress more than anyone. So they’re very supportive about it,”

Divided and Distant

Unfortunately, not all the discussions related to relationships at work were positive. Some

patient interactions and the corresponding stress response resulted in a barrier between the

participants and their coworkers. Several participants expressed these experiences throughout

their interviews, and explained that they began feeling distant and disengaged from their

coworkers following a stressful patient interaction:

• RP 1: “I wasn’t able to communicate frequently with my coworkers… we tend to lose

focus with each other”

• RP 7: “I wasn’t so involved with my colleagues…my mood was down. I found I really

had a hard time communicating with my colleagues.”

• RP 16: “just try to get through the day. If felt really quiet that day…where it was kind of

going for as little bit of conversation there was to have with”

• RP 25: “if anyone was like ‘oh, you know, how are you’ or anything like that, I would

just be like ‘oh I'm fine.’ I couldn’t start talking about it without starting to tear up”

• RP 31: “I don’t remember talking about it a lot with the other nurses because there just

like, wasn’t time and then by the time the shift was over, we’re all so tired we just wanted

to go home”

• RP 34: I put myself in almost a silo, and try to get rid of as much of the outside factors

playing into my emotions so that I could really just concentrate on my patients”

• RP34: “I wouldn’t delegate things to other people, because I didn’t know how they would

do it…I got to the point of ‘you want it done the best, you do it yourself.’”

Some participants explained that they began having difficulty with the doctors who were also

caring for the same patient. While one of the participants explained that the distancing only

lasted for a single shift, as seen in RP 26, RP 22 discussed how the difficulty lasted for many

months and actually felt retaliatory in nature:

• RP 22: “and for the next probably six months, I got harassed by the attending. Every

patient that I would pick up to take to be the nurse he would say ‘oh, I’m not taking that

one. She has that one. She’s the nurse. I’m not working with her’”

• RP 26: “I kind of hid from the doctors for a little while...I could tell that one of them was

very much not in the mood to be interacted with after this happened...he’s a fantastic

provider, but he kind of has a short fuse sometimes. And I did not want to be on the

receiving end of that while I was already kind of in a mood”

One participant expressed feelings of abandonment by another nurse. While caring for a trauma

victim, the participant was left alone with no support to turn to:

• RP 22: “this child was dying in front of us. And all of a sudden the nurse, the primary

nurse that was supposed to be taking care of this baby looked at me and goes ‘I’m done, I

can’t’ and he walked out of the room. Which left me then with the residents who were

screaming at this kid and no other nurse to take care of this baby who was screaming and

dying in front of me”

Another participant described that the relationship between manager and participant was strained

after two different patient encounters:

• RP 32: “the focus wasn’t even on that he cornered me or got physical with me or was

verbally abusive to me. The focus was on how I let him fall”

• RP 32: “my manager came in and said ‘you don’t have time to cry. You have patients to

take care of, and if you’re crying you’re gonna make people think you did something

wrong.”

Life Continues Outside the Hospital

The majority of participants discussed how, even though the patient interaction occurred

within the walls of the hospital, the emotional response carried over into their personal lives.

This GET was divided into two subthemes: distancing from family and friends and altered

thoughts and behaviors.

Distancing from Family and Friends

The overwhelming majority of discussion in this subtheme was the lack of understanding

from friends and families regarding what the participants see on a daily basis. This led to

decreased discussions about work at home. For RP 32, she attempted to discuss patient

interactions and her feelings regarding them but was met with pushback when her support system

refused to listen.

• RP 32: “my husband had that talk about ‘don’t, you have to stop bringing your work

home with you.’ It really upset me and I called my mom…she was like ‘what do you

think it does for his day to hear about how hard or how awful, how much you hate your

job? Does it do anything good for him?”

• RP 3: “I’m reluctant to share some things with my husband, sometimes just because of

the nature of what I see. I don’t think it’s appropriate for me to talk about it all the time”

• RP 3: “I think you kind of are able to joke about it with people at work, and then you

kind of just don’t talk about it at home”

• RP 11: “it separates us from our loved ones and our friends, because they don’t

understand what it’s like to be in an emergency room. They don’t understand what it’s

like to be present when people die…they don’t have that base of knowledge to draw

from”

Other participants explained that their family and/or friends noticed changes in the participants’

lack of participation in home activities. This caused tension within those relationships.

• RP 3: “I separated myself a lot from my family”

• RP 7: “I’ve got a lot of things cluttering in my mind that kept my mind racing. And I

really had a hard time focusing on what needed to be done [at home].”

• RP 7: “members of my family were really concerned about what was going on, and why I

was in such a mood. I was unable to communicate with them. I needed some time to clear

up my mind…I really felt isolated from activities that day”

• RP 8: “I have these flashbacks to whatever happened in the ER. Then, most times my

family, they do get worried about me. They check up on me to make sure I’m doing ok.”

• RP 16: “It the point where I didn’t really want to do anything at home. Like I pretty much

was done, I don’t want to do anything…I just want to sit here and wait until I have to go

back to work’”

• RP 16: “she’s really upset with me because I was pretty much rude…and I was like ‘I’m

worried that I’m gonna get more patients who are just going to sit there and slowly

deteriorate and it’s hard to see’”

• RP 21: “you’re edgy…you’re not, you can’t engage with your parents and your

significant others…maybe you stuff it down for a while, but it comes back up and in

some way, shape, or form you distance yourself.”

Some participants stated that because of the lack of understanding, they did not see the benefit of

forming relationships with anyone who was not in a similar field of work. These relationships

were deemed to be too difficult and not worth the time and energy.

• RP 11: “because our relationships are so strong and secure in the hospital with our team

that we don’t put the effort into having outside relationships much because it’s just too

hard to explain to them, like what you do and what you see”

• RP 21: “then you go out with your friends who are accountants and teachers and they’re

like ‘oh how was your day?’ and so you say ‘oh, it was fine’. But it wasn’t. You saw, just

raw human tragedy, but it’s too difficult to explain to them”

• RP 26: “I struggle with having relationships that aren’t related to healthcare...pretty much

anybody that I spend time with extensively is in healthcare, because I can’t do non-

healthcare. They don’t necessarily understand the stuff that we deal with on a day-to-day

basis.”

• RP 32: “I see so many things that normal people don’t have to see or deal with”

• RP 33: “people say ‘what’s the worst thing you’ve ever seen?’ and you just, you don’t

even want to say it. Because it’s like, are they asking to see like, what’s the worst thing

you’ve seen? Or what’s the worst thing you felt? Because you want to save people from

that. Because that’s a terrible thing that I ask, you know?”

• RP 35: “I had ‘so few spoons’ for lack of a better reference that I just didn’t call people

or try and hang out because I just didn’t have the energy to deal with people and was too,

too drained”

Some participants described how they had fractured relationships because of what they

experienced in the ER. While some were temporary, others were permanent resulting in the

ending of long-term relationships. RP 22 and RP 32 experienced a negative effect with

relationships with their respective husband, while RP 27 had an impact with her relationship with

her children and even lost a long-term friend.

• RP 22: “I have found that trying to talk over situations with my husband, because our

viewpoint on things is so different, is actually increasing my stress”

• RP 27: “there have been times where I've not been able to get close to my kids until after

I have, until I have been able to appropriately decompressed. Have I yelled? Have I

screamed? Yes: at the kids, at a boyfriend”

• RP 27: “I did lose a best friend because I couldn’t, I couldn’t deal with the, I couldn’t

deal with the trauma”

• RP 27: “I was so emotionally upset that I couldn’t care of my kids...and I lost one of my

biggest support systems.”

• RP32: “I was kind of getting distant because I was seeing so much loss at work…my

interactions with my husband were just, so dented and sad”

Participants described how their family and/or friends had an altered opinion of the participants

after hearing stories and experiences from the hospital.

• RP 11: “then you have to explain to them [family] that you’re not a monster. I’m not a

monster”

• RP 21: “what we see, it’s our normal but it’s not normal”

• RP 22: “my husband thinks I’m crazy”

• RP 24: “sometimes I have to forget, they’ll just be repulsed. And whether it’s the gory

stuff, or just the social stuff, they’re like ‘you’re just talking about this like it’s normal’.

‘no, that’s not a normal thing to think is interesting…that’s traumatizing’”

Altered Thoughts and Behaviors at Home

Not only are relationships affected outside of the hospital, but personal attitudes,

thoughts, and behaviors change in the majority of participants as well. Parenting strategies were

the primary topic for discussion. Lack of trust with non-family members was discussed by

several participants. This lack of trust was directed at caregivers of children as well as at

strangers. RP 22 talked about the lack of trust with medical providers as well as childcare

providers, while RP 24 disclosed that he has changed his trust of strangers in the community due

to his experience with violent patients:

• RP 22: “because of that, as my children grew, I would never leave them alone with any

physician in a hospital anywhere for any length of time for any reason”

• RP 22: “then when you go to take your baby to the babysitter, it’s a whole other panic

because again, they trusted that person. They didn’t know that person was behaving

irresponsibly. And so, how well do I really know my babysitters? And what if something

like that happens?”

• RP 24: “in the past, if people came up to me, I’d stop and have a conversation, whatever.

And now it’s like ‘no, I don’t know who you are. I kind of have first-hand experience that

people can flip like that…it’s not worth my safety to risk this”

• RP 24: “before, I would leave the door unlocked if we were home. And so you just come

and go. And now I lock it every time. We have a big dog. We got one of those security

cameras…I know statistically the odds of that happening are almost zero. But I’ve seen it

happen.”

RP 6 and RP 22 acknowledged that they were becoming more restrictive with their

children, and stated it was important to make a conscious effort to combat that feeling with the

understanding that not everything can be controlled:

• RP 6: “Then that impacts my parenting. And I have to be real mindful of that to make

sure I’m not getting too fear based”

• RP 22: “I’ve had to kind of rein that in a little bit. You know, they’re boys. They’re

gonna do stupid things. They’re going to be daredevils. And I do kind of have to just sit

back and wait and see…I can’t be a helicopter parent and prevent everything that’s going

to happen just because I know it can”

Some participants believed that they became more safety conscious after caring for

patients in the ER. While they do not believe they were hindering their children’s activities, they

were more aware of possible dangers and then implemented practices that would keep them as

safe as possible:

• RP 30: “I learn from their dumb mistakes and I take it home and I say ‘okay, now we’re

not gonna keep the charcoal lighter next to that fire pit’…’I’m not gonna roll my lawn

mower on that hill because I know what happens when you roll a lawn mower on hills.

I’m gonna wear my helmet every time I get on my motorcycle”

• RP 33: “I’m much more aware of the dangers of things. So I have a heightened sense of

awareness of you know, if my son is climbing up a, he’s almost two so if he’s climbing

up on the slide, I’m thinking ‘well the height of this is trauma high, so you know, I’ve got

to be over there with him.’ Or if he’s in the front yard, I’m aware that there’s no fence

around our neighbor’s yard and we have a pond in the backyard. So I know he’s safer in

our backyard. Those kind of things”

Seeing tragic patient outcomes in the hospital made some participants believe that it

would happen to their own children. This led to a constant state of worry that their children

would be the victims of tragedy at every turn:

• RP 3: “when they [children] were babies, I would constantly worry that they wouldn’t

wake up. Because I see these things. And sometimes it would be intrusive”

• RP 11: “it made me a more fearful parent. And less apt to let my child go to friends'

houses, places where I don’t know the family that well”

• RP 11: “it’s [fearful parenting] never going away. If anything, it gets stronger and

stronger every year”

• RP32: “I didn’t let my son go swimming that whole summer”

• RP 32: “I had a kid that had a really bad reaction to Vicks Vapor Rub, and I cleaned it out

of my house. I don’t let them [kids] use it. I don’t let them swim. I don’t let them be

around big dogs”

Experiencing an altered perception of severity was something that was mentioned by a

few participants. RP 25, RP 31, and RP 33 all discussed that because of the severe nature of what

they see in their departments, they perceive things that others might perceive as significant as not

a big deal. This can lead to discord between family and friends:

• RP 25: “i think sometimes I feel like I have a more callous view of things...to me, that’s

not a big deal because I've seen much worse”

• RP 31: “she [mother] would get really frustrated with me because she’s like ‘you just,

you just act like you don’t care’ and I was like ‘it’s not that I don’t care. It’s that there’s

nothing to panic over. You need to calm down, it’s fine.”

• RP 31: “being an ED nurse has very much changed me, and I feel like I’m much less

emotional than I used to be…Because it’s like, you can’t do this job and feel all the

things all the time. You’ve got to turn it off”

• RP 33: “I’ve been told I used to show emotion. I would cry very easily, that kind of thing.

But it’s hard for me to show that now. I have a harder time showing emotions, and I think

that’s because so many, I think it might have to do with being in circumstances and

having to feel like you have to stop feeling to go into the next circumstance.”

One participant disclosed she completely avoids a specific place, because it was the

location of a particularly severe patient traumatic event:

• RP 35: “we had one patient who got stabbed at a bar that I used to frequent…quite a few

of us, we would go there for drinks after work, or like before the next shift…we stopped

going to that bar all together”

This same participant also mentioned experiencing a crisis of faith:

• RP 35: “it really made me question a lot of religion in general. Just, if there is a higher

power, why? Why would this be ok? Why would they think this is okay? What would

they do that?”

Impacting Me on a Personal Level

Not only did participants discuss how the secondary traumatic stress affected their

relationships with patients, coworkers, and family/friends, participants also spent time discussing

how those traumatic patient experiences affected their mental health during that shift. Participant

comments fell into two subthemes: mental anguish and self-doubt/self-blame.

Mental Anguish

Nurses help people. They provide treatment and support to help improve patient health

and get them back to a functioning level in their lives. When nurses are unable to do this, a sense

of helplessness occurs. Participants describe how they are impacted by seeing traumatic patients

but feeling unable to help:

• RP 6: “The biggest stress piece was really just watching this person decline. And it

actually went on for two or three shifts…they just kept getting worse...and I spent that

time just watching this person die”

• RP 6: “I think that maybe, it was more helplessness versus overwhelmed feeling”

• RP 8: “I just feel mentally broken. I feel depressed. I physically can’t do anything right,

like I can’t get my head straight.”

• RP 11: “having a three-year-old die from a gunshot wound to the abdomen in front of you

is probably one of the worst things I've ever seen in my life.”

• RP 22: “so when they pronounced him, I just burst into tears, even though I knew that’s

what was coming”

• RP 22: “he said ‘I’m gonna die right here’ and the old nursing thing is when the patient

says they’re gonna die, they’re gonna die. And so at that point, I started shaking”

• RP 25: “my first infant code…having the coroner come to the hospital, and assisting with

the initial autopsy photos and carrying him down to x-ray, and then carrying him

eventually to the morgue and being with their parents for a couple of hours…That one hit

me really, really hard. I think I was pretty upset for like, three days, I couldn’t even talk

about it without starting to cry”

• RP 27: “probably one of the worst cases of elder abuse and neglect that I've ever seen:

maggots, feces, smell, skin rotting off. I had to make a DCFS claim to the elder abuse.

That will trigger me: there’s certain smells that will put me back into almost like a panic

attack”

• RP 30: “the thing that tugged on my heartstrings the most but I take home the most times

is when somebody dies in my ER especially if I’ve talked to them before they died, you

know, or got a relationship with them”

• RP 33: “when they were bagging him, his face had subcutaneous air in his face because

he had so many facial fractures. And I will never forget that”

• RP 35: “We did an open thoracotomy in the trauma bay. I had my fingers plugging the

hole…there was so much blood all over the floor that we were sliding around.”

Some participants discuss that they compartmentalize their patient

experiences/interactions in the hope of putting it in a box and not focusing on it:

• RP 11: “you have to develop an unhealthy habit of boxing it up and sticking it on a shelf

until you can discuss it later. If you ever get to discussing it”

• RP 11: “I’ve developed a way to disassociate from the reality of what is happening

around me in order to get my tasks done.”

• RP 22: “in the moment you can’t really, you can’t really do feelings. It has to just be do

it, you have to work and then afterwards you just, you get this, you get this adrenaline

dump, shaking, racing thoughts”

• RP 28: “I just learned to deal with it...i pushed the feelings completely aside and did what

I had to do”

• RP 29: “what we see is something you don’t want to continue to think about”

• RP 30: “I mean, it’s a traumatic experience, but we’re programmed to move on, I guess.

There’s a necessity to move on”

• RP 33: “we kind of pushed the feelings aside and aren’t as emotional…I don’t know how

to name it. We don’t feel as much. We feel it, but we don’t know, you treat it, you do it,

and then you just go to the next patient and you’re expected to just continue on”

Several participants describe that personalizing the patient, or picturing themselves

and/or loved ones, makes the distress more significant:

• RP 4: “you try and put yourself in the patient's shoes, and you find out that’s when you

get emotionally depressed”

• RP 4: “I’m actually feeling what patients are actually feeling. Like, I get this thought that

‘what if this was actually me?’ Just those kind of thoughts

Patient family dynamics played a role in the mental anguish experienced by the participants.

They describe that they were able to maintain their composure until they encountered the family

and loved ones of the patient.

• RP 16: “it wasn’t until after working every effort there was that the doc said ‘okay, we’re

gonna have to call it’ and then the mom broke down. That point then I was like ‘oh my

gosh’ that kind of hurt to see”

• RP 24: “we have a cardiac arrest who comes in, and family is brought in and they start

crying. That is emotionally very difficult.”

• RP 25: “I’m going to cry about it again...just the way he [father] said it and the way he

was holding him, me and the other nurse just like, we started crying in the room. We

couldn’t help it”

• RP 30: “when a family breaks down and starts crying, that knocks me down…grief is the

sad part”

• RP 32: “even though you have a critical child, you have to stand between a dad or mom

seeing their child, maybe for the last time. So that was hard.”

• RP 32: “I could tell you his name. I could hear his family member, his aunt, screaming at

him to wake up and come play”

• RP 32: “I was so high stress, so high strung, so anxious…it scared me. Like, I didn’t want

to be that aunt, screaming over a child.”

• RP 33: “They’re [police] pulling this mom in this room questioning her about stuff, and

she’s accidentally killed her child trying to help her other one. And then you’re just like,

oh my god, the empathy you feel for this mom, and the sadness for this child. And then

the dad sitting there and you feel for him too. And then you look down and there’s a little

three-year-old’s shoe on the floor. It was just a lot”

• RP 34: “The doctor walked out to tell the parents ‘hey, I don’t think this is going to end

well. We should probably end now.’ And I could hear the parents out there, you know,

the uncontrollable sobbing.”

• RP 35: “Utter disbelief at how nonchalant the mom was at, and how horribly I felt that

that baby did not feel what a baby should have been feeling: utmost love, care,

safety…I’ve never been as sad as I was there. True sadness”

RP 21 explains how repetitive exposure to the same traumatic experience over and over led to

feelings of emotional exhaustion and frustration:

• RP 21: “I mean, you’re just getting beat up emotionally by somebody, just every single

interaction and like I said, this was going on for like, 8-10 hours and it altered my

psyche”

• RP 21: “you bag them and you tag them and then you’re on to the next one. And that is

fucked up. And I, I’m worried”

Self-Doubt and Self-Blame

Nurses undergo many years of schooling and training to learn how to effectively care for

patients. Sometimes the effort is not enough, and the patients have an increased morbidity or

mortality rate. Participants in this study discussed how their patient interactions led to feelings of

self-doubt and blame that they were not good enough to successfully keep the patient alive and

well. Some comments were not patient specific, but rather a more existential concern:

• RP 6: “that scares me, because I’m like ‘what if I can’t get the IV?’ and like, I’m trying

to struggle with that but really I need to be doing something else”

• RP 27: “I blamed myself”

Some participants focused on their actions on specific patient outcomes:

• RP 16: “I just kept questioning myself on everything I gave, just like thinking ‘was that

the right amount? Did I do the right thing?’ and then double checking …”

• RP 26: “I’m laying in bed, like, what did I miss, what could I have done better? What

else could have been done in general? Why couldn’t we fix them?”

• RP 27: “you live those traumatic events thinking ‘is there something else I could have

done? Is there something that I would have caught sooner?”

• RP29: “did I do it well enough? Did I give the medicine at the right time? Did I do

everything that I could have that would have changed the outcome?”

Residual Stress Despite Coping Attempts

Participants identified how the stress response has lingered throughout their lives, despite

their attempts at coping. These symptoms, both physical and psychological/emotional, impacted

their lives for an extended period of time.

Physical Symptoms

Participants discussed how the stress response of caring for patients impacted their lives

in a physical manner. The two common physical symptoms were categorized as either sleep

disturbance or changes in eating habits. Some participants explained that they had difficulty

sleeping in the nights following a particularly stressful patient interaction. For some participants,

this manifested through difficulty falling asleep:

• RP 2: “I wasn’t able to sleep…because my head kept on ringing and thinking about this

stressful experience. As well as from time to time I just wake up from sleep”

• RP 4: “You know, most of the times you want to sleep, close your eyes, and just these

flashes, you know, about the experience that could actually spoil your night. Or just if

you were feeling sleepy, you don’t feel sleepy anymore for some time.”

• RP 7: “I find it really difficult to fall asleep. And even when I do fall asleep, you find it

difficult to stay asleep. Because my mind keeps racing and recording this stressful

experience that I had at work. And it just keeps repeating itself in my head”

• RP 11: “sleep is fragmented at best”

• RP 27: “You get the nightmares afterwards. You get the restlessness, you get the loss of

sleep, loss of appetite”

• RP 22: “maybe indirectly, maybe they impact my depression, anxiety. And that impacts

my sleep”

Some participants discussed waking up in the middle of the night and not being able to return to

sleep:

• RP 11: “sleep isn’t often the hard part, it’s staying asleep. And so there’s frequent times

when we wake up and then can’t fall back asleep…so there’s a lot of ruminating that

happens at nighttime when you get the opportunity to kind of be alone with your

thoughts”

Other participants discussed that they continued to relive the experience through nightmares:

• RP 1: “I’ll have nightmares…that affect my mental health.”

• RP 1: “to see a human present with such blood…I wasn’t able to sleep. I had terrible

nightmares”

• RP 21: “you second guess yourself, you ruminate it in your head, you’re going over and

over, you have trouble falling asleep, you may wake up and you’re gonna go through it,

and you beat yourself up”

• RP 27: “I’ve been having nightmares. I can’t get this out of my head. And the

traumaticness of the event. If that smell, I smell, I have to give that patient up for the

most part because I can’t. It all comes flooding back”

• RP 27: “you try and disassociate with that event so you can continue to do your job but

sometimes it doesn’t work. You get the nightmares afterwards. You get the restlessness,

you get the loss of sleep, loss of appetite”

• RP 32: “My mind is just racing for hours after everyone else is asleep. it takes me forever

to fall asleep…and I replay scenarios in my nightmares…who knows what I’m going to

dream about tonight? Probably not going to be pleasant.”

• RP 34: “I have had some gnarly, gnarly, horrible, like fighting demons kind of thing in

my sleep…I’m sure some of it has to do with the trauma”

• RP 35: “As I get closer to anniversary dates of when that happened, I’ll have a harder

time sleeping. I’ll have basically nightmares where it’s, revisit where it’s basically like a

movie of it happening again”

Two participants, RP 16 and RP 35, even resorted to taking medication to help increase the

likelihood of sleep, although it was not as beneficial as he had hoped:

• RP 16: “It took a lot of work to go to sleep…I do take Buspar as needed for anxiety. I’m

supposed to take three a day. And I took three…hour after hour. I also took melatonin to

go to sleep to try and help me go to sleep and then I still was up at two o’clock in the

morning”

• RP 35: “definite sleeping issues. Had to take a lot of different sleeping medications:

melatonin, zolpidem, all that different stuff. Tried a bunch of things to try and improve

sleep or try and fall asleep because I’d be so focused on what just happened and what I

just saw that I couldn’t unwind”

Some patients experienced changes in their eating habits. RP 7 was hungry all throughout

his shift, but when he arrived at home, his appetite disappeared

• “I can actually recall one time when I had a really disturbing experience at work. And

when I got home, I can recall I was really hungry. But then, I didn't, I was unable to

develop an appetite to eat.”

• RP 29: “I got sick to my stomach thinking about it”

• RP 29: “I found myself thinking back to her story and how she was telling me how

terrified she was. And then I found like, it was already time to pick up my kids from

school. And I'm like ‘oh I didn’t eat lunch today’ and ‘oh I'm really kind of nauseous’

and I think I felt physically ill”

• RP 29: “I made myself kind of physically ill thinking about it. Like, I think it was about

after three days”

Psychological Symptoms

While participants have thoroughly described the reactions they experienced during their

interactions with their patients, they have also discussed how these interactions have affected

their mental health for a prolonged amount of time. This is manifested through fear, recurring

images, and the feeling that they will forever remember this incident.

• RP 1: “I’m living with fear after what I’ve seen”

• RP 2: “I was unable to cope for the fact that it kept on ringing and coming into my head.

And it was like, I needed to get some time off. I needed some time for myself”

• RP 2: “I got to see loads and loads of disturbing stuff that I wouldn’t want to think about

on a normal basis”

• RP 3: “It still affects me now, like I can, I can see the baby…so it’s still a traumatic

situation”

• RP 4: “having recurring images about the victim, you know, maybe the victims being,

how the victim felt, stuff like that. That puts me down for time, or later overnight.

• RP 6: “I noticed that when I’m done with my chunk of days, it takes a little while for me

to like, recover physically and mentally”

• RP 22: “imprinted in my brain for life”

• RP 25: “it’ll be a long time before I get the sound of the mom screaming and sobbing

next to me as I was doing compressions on her kid out of my head”

• RP 27: “I’m still reliving that one. I've gone on Paxil...that one still is recurring. So there

have been times where there’ve been triggers that have put me back into it”

• RP27: “I’ve been diagnosed with Post Traumatic Stress from it”

• RP27: “I have to go in the supply room and basically kind of breathe through it so I don’t

end up having a panic attack or PTSD episode”

• RP28: “You never get that out of your head. Even to this day, it never goes away. You

still think about those patients”

• RP 32: “sorry I get so emotional, and it happened like three years ago, and I still…”

• RP 34: “I definitely had flashbacks later on in my career. Like that time at [hospital], I

had that exact same flashbacks…I had those flashbacks of those parents crying and being

there”

• RP 32: “I didn’t have anxiety. Then I had kids and my anxiety grew a little bit. Then I

became a nurse. And now I just live drowning in anxiety, all the time”

• RP 34: “As soon as I grabbed the door handle of my house, I just uncontrollably started

sobbing. And I just remember saying to myself, ‘what is this? This is not me. I don’t cry

over patients. What’s going on?”

• RP 35: “any pediatric patient is just immediate elevation for stress level. Immediate, I can

go from not at all stress to at least a six or seven”

• RP 35: “I still remember their birthday, their full name, the day this happened, and think

about them probably more frequently than I should.”

• RP 32: “it was hard to go into that career that I thought for so long, I would love but

really it just turned me into such a depressed person”

Table 4: Breakdown of Theme Responses by Participant

Participant #

Patient Care

Suffers

Impacting

Work

Relationships

Life Continues

Outside

Hospital

Impacting on

a Personal

Level

Residual

Stress

1 X X X

2 X X

3 X X X

4 X X

6 X X X X

7 X X X X X

8 X X X X

11 X X X X

16 X X X X X

21 X X X X X

22 X X X X X

24 X X X X X

25 X X X X

26 X X X X

27 X X X X

28 X X X

29 X X X

30 X X X X

31 X X X X

32 X X X X X

33 X X X

34 X X X

35 X X X

Research Aim 3

Research aim three – examine coping strategies, described by ER nurses, in response to

STS – was examined through qualitative interviews. Coping strategies are an integral part of the

Revised Transactional Model of Occupational Stress and Coping, as it addresses the transition

between negative stress response and residual stress. Personal experiential statements were

organized into three group experiential themes: positive coping strategies, dysfunctional coping

strategies, and debriefing as a coping strategy. See Table 5 for the organization of coping

statements.

Positive Coping Strategies

Participants responded with a wide variety of coping strategies. Positive coping strategies

were sorted by those that provided relief for the participant without providing them either

physical or emotional harm. Participants discussed the benefits of speaking to a mental health

professional:

• RP 6: “I would say talking about things is probably my number one coping strategy”

• RP 8: “some advised me to go see a therapist. A therapist was actually provided by the

hospital for me.”

• RP 8: “Actually speaking to someone about it. Letting, it’s actually nice, letting the

person [therapist] know my perspective of what’s actually happening in our walls”

Some participants attributed their positive coping to their colleagues and their managers in the

department. Having the ability to go and speak with someone who understands and has a shared

experience provided them the opportunity to decompress. Religious support was also a helpful

opportunity for some participants:

• RP 24: “we were able to kind of talk through it amongst ourselves, and that helps: talking

with coworkers. And just being able to kind of express how we’re feeling”

• RP 25: “they were checking in and they actually sent a nun to come talk to me...she

looked at me with those very, kind of, pathetic eyes, you know, and I'm like ‘I super

appreciate it”

Other participants discussed how making a job or career change was beneficial for their

mental health. Participants disclosed that they switched from full time to per-diem (PRN), while

others left the hospital for another position. For RP 35, the decision was made to leave the

bedside completed. For some, this was an independent decision, while for others it was a

decision that was initiated by family.

• RP 3: “I think the biggest thing for me was switching hospitals, quite honestly”

• RP 24: “Another big one, I recently switched to PRN. And it’s great, because if I felt like

I’m stressed, I take a step back. I just won’t work”

• RP32: “that’s why I went PRN”

• RP 35: “I purposely, I’ve always known that I don’t really do well with pediatric patients.

So I’ve always purposely picked hospitals that don’t do direct pediatric care…I always

thought I’d end up in peds…after that, absolutely not. Will not, not even anywhere on

the radar”

• RP 35: “I actually did a good two and a half, three year sabbatical from being in an ER

just because I would come home so fried and so stressed and so emotionally drained for

lack of a better word that I just didn’t have it in me to give any more of myself”

Some participants explained that taking time to enjoy their home life and be intentional about not

thinking about work outside of work hours was beneficial for them:

• RP29: “I try to keep a good balance between when I clock out I have to not think about

it.”

• RP 29: “I will go home and cuddle my kids a little bit more, or you know, call my mom

or call my friends”

Dysfunctional Coping Strategies

Not all identified coping strategies were considered to be beneficial. These coping

strategies, even if they were identified as effective by the participants, posed a risk to the health

(physical and/or psychological) of the participants. Some of the dysfunctional coping included

using tobacco, prescription medications, recreational drugs, and/or alcohol:

• RP 2: “I took up my cigarette and I felt that was what I needed to keep myself off of

those thoughts”

• RP 3: “I started drinking more than I had before”

• RP 11: “we managed it through drinking, you know? We would go out drinking and

using alcohol after shifts to decompress and talk with each other”

• RP 30: “we all ended up at a local bar here in town and we had our own debriefing.

Which is way more therapeutic, being able to talk in an environment that you’re

comfortable.”

• RP 34: “up until a couple months ago, I was almost a daily marijuana user. And it was all

to suppress all this trauma and the feelings that I never wanted to deal with.”

• RP 35: “”my drinking had gone up, a lot”

Compartmentalizing was considered to be a dysfunctional coping mechanism, as participants

would push down their emotional response and not deal with the emotions. This was

dysfunctional because these participants were at risk of having the emotions come back up to the

surface at an inopportune time, as discussed by RP 21:

• RP 21: “you’re edgy…maybe you stuff it down for awhile, but it comes back up and in

some way, shape, or form, you distance yourself.”

• RP 21: “eventually you build up a wall. And because you, it’s about survival”

• RP 31: “I’ve been doing this so long that I’ve gotten pretty good at kind of like,

compartmentalizing and just disconnecting from the emotion of all of it.”

One participant stated that the traumatic stress caused her to call off in her upcoming shifts:

• RP 32: “I called into my shift for my next two shifts after that for like a week”

RP 6 described how she felt embarrassed by having an emotional response of crying in

the workplace. This feeling of “emotions at work are something to be shameful for” is a

dysfunctional perception of coping:

• RP 6: “I’ve, twice I’ve cried. Not my proudest moments, but whatever. That’s just the

way it was, like, I can’t sometimes. I just can’t help it, the tears just leak out”

Debriefing as Coping

Many participants felt that debriefings were helpful. They believed that it made them

stronger as a team. They praised their management team for offering debriefings:

• RP 3: “there was a department wide debrief session where the hospital response I thought

was really great. They brought in counselors. They made it very clear that anytime

anybody needed to speak about the situation that happened there, management’s door

was always open”

• RP 3: “It was really helpful to come together”

• RP 3: “Ultimately it [debriefing] helped us, I think, become a better team together,

because we went through it together”

• RP 24: “then afterwards, like the physician at the end of the shift...do you want to do a

quick debriefing?...being like ‘how are you feeling? Are you good?’...it was nice, because

it’s just basically checking in”

• RP 27: “i’ve been offered a debrief, had an open door policy with my manager...but at

[hospital] they don’t do very well with that...it’s like, sometimes it seems like the bigger

the hospital, the less the aftermath and the help is”

• RP 29: “coordinator is wonderfully amazing, that usually can walk through and say, you

know, ‘here’s what happened. Here's what we did.’ and then everyone is allowed to speak

if they need to. It's just a nice way of kind of talking it out and talking about that

happened and how we felt about what happened”

• RP28: “It makes you feel a little better to know that, you know, usually nobody’s got any

other ideas.”

• RP 34: “during the debrief, it was great and I tell you, the people that were in the debrief

with me, we had a much better rapport on patients that were, we worked together and

handed off”

• RP 34: “they [debriefing leaders] concentrated on what went right…the really tried to

stay on a positive note”

A few participants identified that the debriefing was beneficial, not only for the understanding of

skills that could have improved, but for the emotional outlet. It provided an opportunity for

validation and to know that they are not alone in their feelings or experiences:

• RP 7: “I would say it’s really supporting to get to learn new techniques as well as

strategies that healthcare providers such as myself need to know…as well as getting

involved with other experienced healthcare providers. So I feel it was really educating for

me”

• RP 11: “it provided a space for us to be sad, be angry, it was very non-judgmental. It was

just an opportunity for the people involved to acknowledge what happened, and

acknowledge how it affected us”

• RP 11: “I think it allowed us to kind of take everything down a notch and be a little more

calm. But it didn’t, it didn’t change the feelings…it really made us feel not alone”

• RP 16: “debriefing really helps. An actual sit down, let’s take a minute and go over what

we did, what we felt we did, and what we felt we could have done better. That is one

thing that I really wanted to do”

• RP 16: “I guess it did give us a little point where we all accepted the result, as best we

could”

• RP 16: “it made me feel better. It felt like a closing of the situation”

• RP 25: “being able to hear everyone else’s experiences...even though it didn’t hit me as

hard, you can see how it affected everybody else”

• RP 26: “Informal debrief at the end of everything, once stuff had kind of settled down to

talk...it kind of helped, because I know a lot of people were feeling it”

• RP 26: “I feel like the debriefing helped a lot because codes are kind of chaotic

anyway…being able to hear what you did wrong, but it’s something that we need to hear

to be able to learn…this is how everybody’s feeling after this. This is how we can move

forward”

• RP 31: “I remember seeing some of the providers showing emotion in that debrief that

you’d never seen that before…it was almost like validating to know like, well, if they’re

feeling that, then it’s ok that I’m feeling that.”

• RP 31: “I remember we just like, went back and one of the rooms in the back of the

department it was so quiet, like you could hear a pin drop. It was so quiet and knowing

anything about an ED and people who work in the ED they’re never quiet, right? And

that debrief was one of the most impactful, it think, because it impacted everyone.”

Some participants did not appreciate the benefit of the debriefing until after it was

completed. Prior to the debrief, they believed it would not be beneficial, but identified positive

experiences following the conclusion of the debriefing:

• RP 27: “before, I was traumatized. Some of the debriefings helped lessen that feeling of

‘you didn’t do everything you could’ or ‘you should have done it this way’. So

sometimes those debriefings will pick you back up, will help”

• RP 31: “I’m not interested. I don’t want to do it. It’s like, I wanted to just

compartmentalize it and put it away like I did everything else. But I was dreading it to be

completely frank about it. I didn’t want to do it at all. But, after we got in there, and I

started to de-compartmentalize a little bit, and allow myself to feel things and see that

other people are feeling things, it felt good”

• RP 35: “before, I felt confused. I was like ‘this sounds stupid’…so it didn’t seem

purposeful or useful. It just seemed like a waste of my time before I did it. But after I was

like, ‘oh that made sense. That was really good. There was good feedback.’ You know,

we got reassurance, I mean. But it was nice”

However, some participants did not see the benefits of debriefing identified by fellow

participants. One participant found that participating in a debriefing only ended with reliving the

experience, which was a major concern:

• RP 1: “It tends to repeat the same thing over and over again, so I decided not to join the

debriefing”

One participant felt as though the debriefing was an interrogation, where the nursing staff was

under criticism for the outcome, instead of finding ways for improvement:

• RP 4: “We had a quiet debriefing…It was a really stressful experience…Interrogation

mostly”

Other participants expressed feelings of perceived lack of value. For these participants,

management did not stress the importance and value of a debriefing, so the participants felt as

though it was not beneficial:

• RP 32: “that debrief, it was very quick. It was basically just what we could have done

better. And telling us not to show any emotion, because someone’s gonna think we did

something wrong. And that was it.”

• RP 32: ““we just kind of went over it the five minutes we had before we had to go back

and get back our other patients”

• RP 34: “it’s an unknown feeling. Is this really going to help? What are we going to talk

about? Are they going to try to pick apart what we did wrong and point at things that we

did wrong and make us feel bad?”

There was some discussion related to specifics of the debriefings: formal versus informal

and immediate versus delayed.

• RP 24: “it was more formal, but a little more stiff. Because, everyone’s in the room, and

not everyone feels comfortable with everyone. So I think everyone was a little more

guarded”

• RP 29: “I think that like, for me to step out of a traumatic arrest and go into a debriefing,

I haven’t had a chance really to think about everything that already had happened. And it

doesn’t affect me until later.”

• RP 30: “they’ve got those programs, but you know, it’s always next week on Saturday at

two o’clock, nobody can make it…nobody’s got time for that”

• RP 30: “it’s always a few days later. And you know, but then we’re over it, you know?

We’ve vented, we dealt with it on our own…the benefits of those are just really not in the

way they’re supposed to be, I guess”

• RP 30: “they had to schedule it and it was about three or four days later. And they had it

at a tertiary facility, which the event happened out here in the sticks…they scheduled the

class 30 miles down the road. You know, three days later with a chaplain nobody

knows… and we all look at each other like ‘okay, we just wasted our Saturday

afternoon’”

• RP 30: “I feel like they should swoop in, replace the staff, and take all that staff that just

experienced the problem, and bring them away and talk to them, let them vent it out. So

they don’t want to take it home, they can get back to work quicker. And the purpose of

that debriefing is, I think, it would be more effective if it happened immediately , you

know, as soon as possible, not days later and not in another place.”

• RP 34: “your emotions are real and raw. If there’s been some time, you’ve already started

to cope with that. No matter what that coping is, you’ve started coping with it and then

you’ve got to go back into those emotions and then you’ve got to re-cope with those

emotions a second time. So it’s almost like a you know, a double traumatic experience”

• RP35: “we would do our own little non formal, like informal ones. But management was

never involved, the doctors weren’t involved”

Some participants were unable to express if a debriefing was beneficial or not for them,

as they were never offered a debriefing session:

• RP 6: “I don’t think I’ve ever been offered, like a debriefing…I’ve been told that we do

debriefing, but I’ve never seen it happen”

• RP 6: “I guess nothing that I’ve been a part of has qualified for that, I don’t know. I’ve

never seen that happen, and nobody’s really ever talked to me about it”

• RP 27: “I have asked for formal debriefings, I've asked for informal debriefings. I’ve

asked. And a lot of times we don’t get it. Or they say ‘we don’t feel like it’s something

that we need to do’.”

• RP 35: “we had a really, really bad pediatric case: cardiac arrest case that there was not

proper debriefing measures put in and there was not proper aftercare.”

• RP 35: “there was no time off. No ‘hey, how are you doing?’ No, ‘we should debrief after

this hard, failed resuscitation attempt’ and just kind of hanging out there by yourself”

• RP 35: “now, having gotten to experience that [debriefing] it’s like, oh this would have

been really nice when I actually saw like, horrifying things”

Table 5: Coping Strategies

Coping Strategies (participant #)

Positive coping strategies

• Speaking with family/friends (2, 3, 6, 7, 8, 24, 25, 26, 27, 28, 29, 31, 32)

• Exercise (2, 6, 7, 8, 16, 21, 24, 26, 27, 29)

• Take moment to breath and calm (4, 7, 8, 21, 22, 26, 29, 32)

• Seek help from professionals (2, 6, 8, 11, 21, 34, 35)

• Humor, play jokes/pranks (16, 25, 30, 31, 33, 35)

• Employment change (3, 21, 24, 29, 35)

• Go to the movies/watch TV (1, 7, 22, 26, 31)

• Spending time with family (22, 25, 27, 28)

• Alternative peer-based support (6 – Heal Team, 35 – Care for the Caregiver, 22 – Counseling Services, 28 –

Wings Program,)

• Formal not as beneficial as informal (24, 30)

• Listen to music (3, 4, 29)

• Take a nap (7, 8)

• Taking prescribed medications (11, 16)

• Prayer, church (22, 27)

• Eating well (24)

• Hobbies

• Reading (8, 21, 22)

• Drawing/coloring (26, 29)

• Crocheting (35)

• Journaling (6)

• Gardening (30)

• Housework (30)

Dysfunctional coping strategies

• Drinking alcohol (3, 8, 11, 30, 33, 35)

• Dissociate (3, 11, 16, 30)

• Smoking (2, 11, 27)

• Taking medication/drugs outside of prescription (16, 35)

• get myself sedated so I could sleep (2)

• Excess sleeping (3)

• Crying (6)

Debriefing as Coping

• Helpful to share emotions (4, 8, 11, 16, 25, 27, 29, 31)

• Validating to hear others’ experiences (8, 11, 16, 24, 25, 27, 29)

• Helpful to find more information (4, 7, 8, 16, 25, 28, 31)

• Never been offered formal debriefing (6, 16, 22, 26, 27, 33, 35)

• Voluntary (3, 7, 11, 25, 28)

• Promote strong bonds with colleagues (3, 11, 16, 31)

• Immediate practice (3, 16, 28, 35)

• Mandatory (8, 11, 35)

• Negative

• Not worth going, don’t want to relive (1)

• interrogation (4)

• emotions are dismissed (32)

• rushed (32)

• Debriefings were informal (24, 26, 35)

• What I've experienced doesn’t warrant formal debrief (26, 27)

• Initially didn’t see benefit, but proved to be beneficial (31, 35)

• Immediate debrief not as helpful, haven’t processed emotions (29)

• Formal debriefing is not convenient (30)

• Not perceived as helpful, even though never attended (2)

Research Aim 4

Research aim four was to compare individual participant interview responses with

corresponding survey responses to identify similarities and differences in reported stress level

and coping techniques. After analyzing the datasets independently, interpretation began, and the

results were compared to identify areas of convergence (similarities) and divergence

(differences). The researcher created a table, consistent with a convergent mixed methods

analysis design, which included both quantitative and qualitative data for each participant. See

Appendix H for the sample table created to compare individual scores and qualitative statements,

comparisons and contrasts. Table 6 illustrates the convergence and divergence identified for

each participant between the quantitative and qualitative data.

Convergence

The qualitative and quantitative data converged when similarities were noticed between

the sets. Convergent data analysis revealed that participants who scored high STS or severe STS

gave very vivid recollections of their stressful experiences. They were generally able to describe

the patient experience in detail, as well as providing specifics on how it has impacted their lives

both in and out of the hospital. Some of these qualitative statements include RP 3’s comments of

“I would constantly worry that they [RP 3’s children] wouldn’t wake up”, and RP 26’s statement

regarding an unsuccessful pediatric resuscitation attempt “it’ll be a long time before I get the

sound of the mom screaming and sobbing while I do compressions on her child out of my head.”

There was convergence related to the Brief-COPE inventory with the qualitative data set

as well. Participants who had overall high scores on the Brief-COPE Inventory, as seen with RP

1, commented that they do not feel as though they have any residual stress related to interactions

with patients in the hospital. Participants who scored higher in the emotion-focused subscale

verbalized intentionality with regards to finding ways to regulate their emotions they experience

for stressors they encounter. This was seen in RP 21, who discussed how she was deliberate in

her awareness of her mental health. She identified that “when I am on fire, I am setting myself up

to fail again. I’m gonna miss something. I’m gonna make a med error.” Convergence was also

seen within the facet of substance use. Participants discussed using tobacco, drugs, and/or

alcohol following periods of increased stress for the ER. Some turned to illegal drugs, such as RP

34 who stated “I was almost a daily marijuana user…to suppress all this trauma and the feelings

that I never wanted to deal with,” while others used prescriptions drugs outside of the medication

indications. RP 16 stated “I do take Buspar as needed for anxiety. I’m supposed to take three a

day. And I took three…and then I still was up at two o’clock in the morning.”

Convergence also was seen in the Visual Analog Scale of Perceived Stress at the start of

the shift and the end of the shift. Many participants who had an increase in perceived stress at the

end of the shift compared to the beginning of the shift were able to discuss how their stress

increased and affected them throughout their shift. RP 7 explained that he felt more disconnect

and had fewer substantial interactions with his coworkers as well as with his patients. For RP 11,

who had an increase in end of shift stress, sleep quality was disrupted due to waking up

throughout the night as well as reliving the events through nightmares.

Divergence

Some divergence was seen among participants. One is the discrepancy between STS

scores and qualitative statements. One example is the lack of perceived residual stress, as seen

with RP 1, who stated that he did not feel any residual stress, but his STS score was a 63,

indicating severe STS. Another example is RP 25, who reported a moderate STS but cried during

the interview while discussing her memories of her traumatic patient interactions in vivid detail.

There was divergence with qualitative statements and the Brief-COPE Inventory. Some

participants reported the minimum score in a category but spent time in the interview discussing

how that category is significant for them. RP 35 reported the minimum score for religion but

discussed how they began developing a crisis of faith regarding what they have seen and

experienced in the ER. RP 34 reported the maximum score for religion but never mentioned any

religious support or religious coping mechanisms that were utilized in response to the stressful

response. RP 31 had divergence with their low avoidant subscale in the Brief-COPE, however

they discussed comments of dissociation and stuffing feelings down. Other participants scored

low in substance use but discussed using drugs and/or alcohol in response to the stress response

experienced. This happened with RP 27, who discussed visiting the bar to drink after work with

colleagues to talk through the events of the shift.

Other divergence existed when participants reported a decrease in their stress from the

end of the shift compared to the beginning of the shift. This was the case with RP 6, who

reported a 7/10 at the start of the shift and a 4/10 at the end of the shift (change in shift of –3).

RP 6 reported feeling that “my brain is on fire”, “that impacts my parenting”, and “it takes a little

while for me to recover physically and mentally.”

Table 6: Convergence and Divergence of Participants’ Responses

RP #

Convergence Divergence

1 Severe STS on STSS, mimics his words: hard to listen to

patients screaming in fear, reliving the experience through

nightmares and disturbing images

Higer scores in coping matches the statement of no

residual stress

Surprising that RP1 says there is no residual stress, but the STS score

is so high. Lists multiple indicators that has STS from work, but all

coping strategies are effective?

2 n/a Moderate to high score in the problem focused Brief-COPE indicates

an intention to change the situation, but none of comments in interview

mention this

Interview discusses “unable to cope” “I can’t sleep” “I can’t care for

my patients”, would have expected a low emotional Brief-COPE

Moderate to high avoidant subscale indicates desire to disengage, but

no comments in interview analysis discussing wanting to physically or

cognitively disengage

3 High STSS matches comments: get numb, escape the

situation, I would constantly worry that they [children]

wouldn’t wake up

States “I think I cope with these well. I, it doesn’t really affect me

much” referring to substance use patients. Identified those as higher

stress initially but then says they don’t affect much.

4 High STSS score matches the vivid statements Self-blame and religion were high on Brief-COPE, but never mentioned

in statements

States that coping strategies are always helpful in interview, but Brief-

COPE is high in avoidant subscale

6 Higher scores on the “problem focused” brief-COPE align

with statements that can process stress well

Lower brief-COPE “avoidant” scores align with

discussions of healthy coping strategies

Mild STS score, but makes profound statements of “my brain is on fire”

7 Severe STS score supported by statements of

disengagement, increased stress, physical symptoms

Discusses disengagement and distancing between

family/friends/coworkers, but moderate scores on emotional and

avoidant brief-COPE

Brief-COPE has moderate score for substance use, but no discussion in

interview on using substances for coping

8 Physical, psychological, emotional experiences match

severe STS

Avoidant brief-COPE congruent with “leaving work”

Moderate/high emotional brief-COPE not congruent with negative

emotional response of “mental breakdown”, “mentally broken”,

“screaming at patient”

11 Physical (lack of sleep) and psychological (anxiety,

depression) impact stated in interview corresponds to high

STS and increase in perceived stress

Nothing in the quantitative scales address the relationships with

coworkers or friends/family that the participant spends time speaking

Avoidant category is low in substance abuse, but interview statements

mention using alcohol and going to a bar after shifts

16 Emotion focused brief-COPE and interview statements

correlate with each other

Brief-COPE scored high on emotional support, but minimal mention

during interview to corroborate.

Low avoidant brief-COPE, but in interviews mentions dissociating,

disconnecting, and disengaging

21 High problem focused brief-COPE matches comments in

interview about being deliberate with making changes to

cope

High emotion focused brief-COPE matches interview

comments about understanding and being aware of

emotional response and attempting to compensate

High STS corresponds to vivid recollections of the

interview

n/a

22 High response on acceptance and self-blame for brief-

COPE corresponds with interview comments

Scored 8/8 on religion as a coping strategy, but doesn’t mention at all

in interview

Makes comments about suppressing emotions but scored low on the

disengagement for brief-COPE

24 Moderate/high problem focused agrees with interview statements of being intentional about trying to fix the stress response

n/a

Table 6. Continued

RP #

Convergence Divergence

25 While someone was available to talk with, participant

didn’t mention utilization of that resource. This agrees

with brief-COPE about infrequent emotional/instrumental

support from others

Scored lowest possible on disengagement, but has various comments

about dissociating and disengaging

Reported STS is not as high as anticipated based on reading transcript

of interview

Moderate STS but interview is so powerful, participant is crying at

memories. Would have anticipated a higher STS score

26 Severe STS matches interview comments “it’ll be a long

time before I get the sound of the mom screaming and

sobbing out of my head”

High emotional support in brief-COPE matches comments

of helping and benefits of debriefing

Self-blame of brief-cope matches comments in interview

n/a

27 Higher self-blame brief-COPE matches statements

Minimal score (2/8) on substance use, but discusses use of tobacco and

medications to mitigate the stress response

Expected higher intrusion score based on the interview statements:

nightmares, triggering --> symptoms returning, etc.

28 Little to no STS agrees with statements about no residual

stress

Scored lowest on disengagement (2/8) but states “you never get that out

of your head...you still think about those patients”

Discusses how supportive coworkers are, but reported lowest emotional

support (2/8) on brief-COPE

29 High avoidant STS category agrees with statements in

interview: “avoid them if at all possible”

Statements of avoiding all future patients of similar characteristics

doesn’t match the low avoidant brief-COPE

Low intrusion STS score doesn’t match comments about thinking about

patients during the day, face popping up while caring for other assault

victims

30 Planning portion of brief-COPE matches the intentionality

of changing behavior at home to prevent injury

Scored minimum (2/8) on disengagement but comments during

interview mention “grief is the sad part”, ‘you’re not as perky, you

move slower”, “we’re programmed to move on”

Scored minimum on substance use but discusses using alcohol after

shifts to discuss events with coworkers

31 Severe STS congruent with interview

Increase in stress post-shift congruent with statements of

experiences during shift

Scored low on behavioral disengagement on avoidant brief-COPE, but

makes numerous comments on dissociating, compartmentalizing, and

stuffing feelings down

32 Severe STS score congruent with interview quotes ‘called

into work’ ‘I still get so emotional’, etc.

n/a

33 n/a Mild STS but states “I don’t really feel stressed”

and has vivid recollections of stressful experiences

Hyperawareness discussed several times in interview, but doesn’t

follow low “arousal” category in the STSS

34 Scored high on substance use on Brief-COPE, matches

interview statements of using marijuana

High STS score matches comments of “uncontrollable

sobbing” and “flashbacks”

Scored 8/8 on religious support on Brief-COPE, but no comments of

any type of religious coping strategies during interview

Avoidant subscale on Brief-COPE is low, but during interview

mentions disengagement and detaching from other

35 Moderate problem focused coping validated by changing

employment to change situation

High STS score corresponds to comments in interview –

using medication/alcohol, emotions flowing into work

(hostility, crying)

Comments of “dark humor” matched non-verbal cues

during interview: laughing at inappropriate times while

talking about stressful and traumatic patient experiences

Only scored 1/8 on religion for brief-COPE, but in interview mentioned

crisis of faith

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Chapter V: Discussion

Summary of the Study

STS is the negative emotional, physical, or psychological reaction experienced by

someone who had an indirect exposure to trauma (Beck, 2011; Erkin et al., 2021; İlhan &

Küpeli, 2022; Jobe et al., 2021; Măirean et al., 2014; Rauvola et al., 2019). Symptoms of STS

mirror those of post-traumatic stress disorder (PTSD): avoidance of places/individuals that

remind of the trauma, arousal, intrusive thoughts of the trauma, and re-experiencing of the event

(Măirean et al., 2014; Wolf et al., 2020). The purpose of this study was to answer the research

question ‘What is the lived experience of secondary traumatic stress in emergency room (ER)

nurses, and what coping strategies are being used in response to the secondary traumatic stress?’

There are four specific aims of this study:

1. to examine the relationship between experience levels, education levels, employment

status, shift worked, hospital trauma levels, change in reported stress, and reported coping

level with reported STS levels in ER nurses.

2. to describe STS experiences in ER nurses from the nurses’ perspectives.

3. to examine coping strategies, described by ER nurses, in response to STS.

4. to compare individual participant interview responses with corresponding survey

responses to identify similarities and differences in reported stress level and coping

techniques.

The study was conducted using a convergent, mixed methods design. One hundred sixty-

nine quantitative surveys were collected from emergency room (ER) nurses across Missouri and

Illinois: data collected included a demographic survey, Secondary Traumatic Stress Scale, Brief-

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COPE inventory, and Visual Analog Scale of Perceived Stress. Twenty-three qualitative

interviews were conducted from February through June of 2023 and analyzed using an

interpretive phenomenological design.

This chapter will provide a review and interpretation of the findings, including the

relationship to existing literature and the connection to the theoretical framework (The Revised

Transactional Model of Stress and Coping), and recommendations for future research.

Research Aim 1: Summary and Discussion

Research aim 1 was to examine the relationship between experience levels, education

levels, employment status, shift worked, hospital trauma levels, change in reported stress, and

reported coping level with reported STS levels in ER nurses. This study found four statistically

significant relationships: the relationship between STS and the avoidant focused Brief-COPE, the

relationship between STS and emotion focused Brief-COPE, the relationship between STS and

education level, and the change in perceived stress from the beginning of shift to the end of the

shift.

Individuals who score high on the avoidant focused items in the Brief-COPE demonstrate

a cognitive and/or physical attempt to disengage from the situation, while individuals who score

high on the emotion focused facet in the Brief-COPE demonstrate an attempt to regulate their

emotional response. Participants who reported high levels of STS also reported high levels on

avoidant focused facet of the Brief-COPE Inventory. This indicates that high levels of STS

correspond to feelings of needing to disconnect from stressful situations. Participants who

reported high levels of STS also reported high levels on emotion focused facet of the Brief -

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COPE Inventory. This indicates that participants with high levels of STS would have a higher

emotional response, either positive or negative, to the stressful situation.

The relationship between education level and reported STS was also statistically

significant. Participants who held a graduate degree experienced significantly more STS than

their counterparts who held an undergraduate degree. This relationship has not been examined in

the literature. This could be because those who hold higher degrees have more experience. While

experience was not statistically significant in this study, it has been shown to be significant in

previous research. This could also be that those with higher education hold more senior roles

within the ER: charge nurse, supervisor position, etc. This new relationship will add to the

science of what is known about STS.

This study aligns with research about prevalence of STS using the STSS (Duffy et al.,

2015; Erkin et al., 2021; İlhan & Küpeli, 2022; Morrison & Joy, 2016; Ratrout & Hamdan-

Mansour, 2020; Wolf et al., 2020). Over 94% of participants in this study reported mild to severe

STS, with only 10 (5.9%) participants reporting little to no STS and 94 (55.6%) reporting severe

STS. The mean STS score was 50.02, which is in the severe STS category. This supports what

has been shown in the literature: Erkin et al. (2021), Wolf et al. (2020), and Woo and Kim (2021)

found the mean STS score to be in the severe STS category. Of the three subcategories of STS

(arousal, avoidance, intrusion), arousal scored higher than avoidance or intrusion with a value of

3.06. The literature does not show consistency with regards to which subcategory was reported

with higher values. The results of this study are consistent with the findings of Ratrout and

Hamdan-Mansour (2020), Wolf et al. (2020) and Woo and Kim (2021), who all found that

arousal symptoms scored higher than intrusion and avoidance symptoms.

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There was no statistically significant relationship between trauma center and shift worked

with reported secondary traumatic stress score in this study. Previous research has not shown

consistency with the relationship in years of experience and STS score. While Wijdenes et al.

(2019) and Nilan et al. (2019) identified that experience does have a relationship with the

development of STS, this study is consistent with the research that experience is unrelated to the

development of STS (Cantu & Thomas, 2020; Dominguez-Gomez & Rutledge, 2009; İlhan &

Küpeli, 2022; Măirean et al., 2014; Ratrout & Hamdan-Mansour, 2020). This study will add to

the body of literature that shows no relationship between years of experience (as an RN or in an

ER) and reported STS score. The relationships between reported STS score and employment

status as well as between reported STS score and education level have not been examined in the

literature. This study will add to the knowledge base of these two relationships, but needs to be

further examined in other groups of ER nurses to see if these results are generalizable to the

population of ER nurses.

Research Aim 2: Summary and Discussion

Research aim 2 was to describe STS experiences from the ER RN’s perspective.

Participants discussed the types of patients that they found to be more stressful and/or traumatic.

The most frequently reported stressful patient population was pediatric patients. This was

followed by psychiatric patients and then traumatic patient accidents. Existing literature does not

demonstrate consistency regarding what patient complaints nurses find to be more stressful.

Wolf et al. (2020) identified that pediatric trauma was a significant contributor to their

experience of stress, matching what was seen in this study. However, Erkin et al. (2021) reported

communicable diseases, specifically COVID-19, were more stressful, while van der Wath et al.

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(2013) reported caring for victims of intimate partner violence. Neither of those patient

populations were identified during interviews as contributing to the experience of stress

In this study, participants described four areas of their lives that they felt were affected by

secondary traumatic stress: personal life, patient care, relationships at work, and relationships at

home. This study also examined the coping strategies utilized in an attempt to mitigate the

negative effect of STS. To maintain consistency with the concept of STS, the findings are

summarized below according to how they fell into the three categories of STS: arousal, intrusion,

and avoidance.

Arousal

Arousal symptoms include feelings of irritability, difficulty concentrating, difficulty

sleeping, hypervigilance, and/or feeling jittery and jumpy (Bride et al., 2004). Many participants

reported sleep disturbances. While many disclosed nightmares, which is categorized as an

intrusion symptom, other sleep disturbances included difficulty falling asleep. Participants stated

that they would replay scenarios in their minds throughout the evening and night, hindering their

ability to fall asleep. Others stated that they would wake up throughout the night and be unable to

return to sleep. Other participants turned to drugs and/or alcohol to help them fall asleep. One

participant revealed that he had to sedate himself in order to get sleep. This dependency on using

harmful, sedative substances to get sleep is not healthy, and indicates that residual stress is being

experienced and having a negative impact in the lives of the participants.

Several participants expressed that they felt detached and had difficulty concentrating

while caring for their patients. This led to patient safety concerns that were discussed in Chapter

IV. Without being able to focus on the task at hand, or without discussing a patient’s history

thoroughly enough, it could lead to an error which could have catastrophic consequences on the

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patients. Other participants discussed lack of focus at home, leading to feelings of disengagement

from family and/or friends. This residual stress can lead to more long-term consequences.

Avoidance

Avoidance symptoms include feelings of emotional numbness, losing interest in prior

activities or the future, memory disruptions about patient situations, and/or avoiding working

with or being around people or places that are reminders of the traumatic experience (Bride et al.,

2004).

Loss of interest in previously enjoyed activities was not discussed during this study.

However, participants did explain that they felt disengaged from family/friends outside of work.

This loss of interest in their home life led to a distancing between themselves and their

family/friends. Part of this was attributed to the lack of shared experience, so the participants

were unable to have the emotional outlet of a support system. One participant stated that he was

at a family gathering and told his wife during a get-together that he just wanted to sit around and

wait until he had to return to work and continue to watch people die.

Avoiding working with certain patients was verbalized by several participants. For some,

like RP 26 and RP 29, they did not want to work with a specific patient population – domestic

violence victims. Other participants made the decision to leave that hospital completely. One

participant, RP 35, stated that because of a single incident of a victim involved in a bar fight and

was stabbed, she no longer is able to visit that bar, even though she had frequented that bar

previous to the patient interaction.

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Intrusion

Intrusion symptoms include feelings of re-experiencing the event, including disturbing

dreams/nightmares; thinking about patients outside of work; physical symptoms, such as an

increased heart rate, when thinking about patients; and/or psychological symptoms, such as

flashbacks and frustration, when thinking about patients (Bride et al., 2004).

The most disclosed intrusion symptom was nightmares and flashbacks. RP 1, 27, 32, 34,

35 all discussed how they experienced nightmares following their patient experiences. Some

participants stated that their nightmares only lasted a short time, while others say it lasted longer,

getting more frequent and severe during anniversaries of the event. Another physical symptom

that was reported was gastrointestinal (GI) symptoms: nausea, feelings of being-ill and having a

decreased appetite. One patient stated she felt ill for 3 days in a row, while another participant

stated that he felt hunger during work, but when he arrived at home his appetite was gone.

Flashbacks were a symptom expressed by several participants. These flashbacks had an

impact on sleep, which is discussed in the arousal category. For other participants, these

flashbacks happened while doing patient care. Patients who have similar symptoms or stories as

previously traumatic patients brought on flashbacks and memories. Some participants were able

to continue moving on caring for their patients, while others had to walk away from the bedside

for a moment to regain their composure. This could put patients at risk, as no one cared for them

during those times when the nurse stepped away.

Sometimes, stress responses can be beneficial. One participant shared a patient

experience where hypervigilance was beneficial. Hypervigilance, or the state of being highly or

overly alert to dangers and threats around you, helped the participant catch a potential lethal

mistake. Her patient was receiving medication that would harm the patient if precipitate formed.

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Because the participant was afraid of making a mistake, due to her patient’s critical condition,

she caught a slight precipitation forming in the bag of the medication. If the participant was not

hypervigilant and the precipitate was not caught, it could have had severe consequences to the

patient. This supported the findings of Jobe et al. (2021) who found that stress can increase

attentiveness and awareness and have more attention to detail.

Several previous articles identified physical effects of STS on nurses in the form of

difficulty sleeping due to nightmares and insomnia. This study adds to that existing literature as

these participants discussed feelings of nausea, ill-feeling, and lack of appetite.

Literature reports that nurses who report high levels of STS also demonstrated a higher

rate of absenteeism (Jobe et al., 2021; Ratrout & Hamdan-Mansour, 2020). This was seen in this

study: nurses reporting calling off work and even going in late to work as a result of a

particularly traumatic patient experience. Some nurses even reported leaving the department or

the hospital completely because of their experiences. This supports the findings from Duffy et al.

(2015), İlhan and Küpeli (2022), Ratrout and Hamdan-Mansour (2020), and Wolf et al. (2020).

By leaving the workplace, nurses are putting the hospitals at a disadvantage, requiring them to

spend more time and money into hiring replacement staff. This also puts an additional strain on

the remaining nurses to cover for the shifts that are empty.

This study will add to the literature with the following additional data: changes in

parenting strategies, changes in work relationships, and patient safety implications. These

concepts have not been well examined in the literature, due to lack of qualitative studies. Few

articles identified that nurses experienced a negative impact on relationships with families due to

lack of understanding and constant distractions (van der Wath et al., 2013; Wolf et al., 2020).

This is consistent with what was seen in this study. These effects are important because nurses

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do not spend 100% of their time in the hospital: they are people with families, friends, and

relationships. Experiences with STS has an effect on these relationships, which can have

additional consequences on the mental health of the nurses. This needs to be further examined in

future research. By understanding how these relationships are affected, we can implement

interventions to help mitigate these effects.

Revised Transactional Model of Occupational Stress and Coping

The Revised Transactional Model of Occupational Stress and Coping is a linear model to

help explain how individuals react and respond to a stressful situation. The five aspects are

primary appraisal (individual determination of a situation if is threat or benign), secondary

appraisal (individual considers what can be done), negative stress response (experiencing STS),

coping strategies used (implement coping strategies to mitigate stress), and finally residual stress

(experience of residual stress unrelieved by coping strategies or lack of residual stress resulting

from effective coping). This study examined all five stages of this model. Initially, the

participants were asked what types of patient interactions they found to be most stressful:

examining the primary appraisal. Participants shared patient characteristics and specific patient

interactions that they found as a threat or a challenge. Secondary appraisal was examined by the

participants talking through their patient interactions. Some participants explained how they

cared for the patients throughout the shift, while others mentioned feelings of self -doubt or

feelings of inadequacy to care for that patient. Participants continued to provide information on

how that experience affected various aspects of their lives: personal, sleeping habits, work

relationships, relationships with patients, relationships at home, and altered thought processes.

This addresses the negative stress response. Coping strategies were asked regarding daily

stressors, in the hospital stressors, and consideration of changing coping strategies during periods

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of high stress. Finally, residual stress was examined by asking if the participants felt as though

their coping strategies were effective for their particular stressors.

Some participants reported having no residual stress. They made comments such as “I

don’t have any residual stress” or “my coping strategies are typically effective enough.” These

participants tended to have healthier coping strategies: talking with family/friends, seeking help

from a medical professional, exercising, and distracting themselves through engaging in hobbies.

However, some participants stated that they did not feel as though they had any residual stress

but discussed very vivid recollections and specifics about patient interactions, including having

recurring nightmares about the experience. This was not a common theme, but it was worth

noting that there was a discrepancy.

Other participants expressed feelings of residual stress. Although other participants may

not have explicitly stated they had residual stress, it was categorized as residual stress if they

disclosed symptoms such as nightmares, flashbacks, or requiring drugs/alcohol long term. This

was done because their negative stress response lingered for an extended period of time.

Participants who were identified as having residual stress disclosed more negative coping

strategies, such as drug/alcohol use, taking medications outside of their prescription, and

dissociating from the situation, as that leads to delayed coping.

Residual stress was also seen in participants who discussed altered thinking

patterns/behaviors and altered relationships at home. Some participants discussed how their

parenting strategies changed to be more fear-based and guided by the negative possibilities that

could happen. This was labeled residual stress as it has long term implications and continued

presence in their lives. This study supports the use of the Revised Transactional Model of

Occupational Stress and Coping related to secondary traumatic stress in ER nurses.

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Research Aim 3: Summary and Discussion

Research aim 3 was to examine coping strategies, described by ER nurses, in response to

STS. Coping strategies were categorized into positive coping strategies (those that do not cause

harm to participants and/or others and provide satisfaction to the participants) and negative

coping strategies (those that cause harm or discomfort to the participant, even if it provides

temporary satisfaction). Debriefing was discussed separately from coping strategies, but it was

discussed as a specific coping strategy. This was decided because debriefing was shown in the

literature to be an effective coping strategy following traumatic patient interactions.

Positive Coping

Participants disclosed a variety of positive coping strategies. The most frequently

reported coping strategy was speaking with family and/or friends. However, participants

specified that the most benefit was when the family/friends were also in the healthcare field.

Family/friends who had shared experiences with the participants were able to listen and speak in

an understanding and non-judgmental manner. Spending time exercising was another commonly

reported coping strategy. Activities that were categorized as exercising were going to the gym,

working out at home, going for a walk with the dog, or statements of being active.

While it was not reported as commonly as others, making an employment change was

considered to be a positive coping strategy reported by some participants. While this has

negative consequences for the institution (increases turnover, leads to vacancies, requires

time/money spent on recruitment, hiring, and training), it has benefits for the participant. Some

participants altered their schedule from full time to per-diem (PRN), attributing the flexibility as

the main reason for switching. They reported that they felt more in control of their schedule, as

well as having less exposure to traumatic patient interactions. Other participants switched

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hospitals, allowing them a new environment with a different patient population. A few stated

they completely left nursing for a period of time, but then returned to the bedside when they felt

comfortable.

Some participants discussed support groups that were offered by their facility. While

these had different names, the general concept was the same across participants: peer-led

support. These programs offered staff the opportunity to meet with other nurses in the hospital on

a personal level, offering them an outlet to discuss any stressors or emotional responses they may

be feeling. One participant engaged in this program as a peer volunteer and met with another

nurse from the hospital on a different floor. They met for coffee outside of work hours and

discussed events that happened, keeping HIPAA laws in mind. The participant stated that she felt

that even though she was the peer volunteer, she saw the benefit in this peer support group.

Other coping strategies discussed were hobbies (reading, drawing, crocheting, journaling,

gardening, housework), meditating, seeking help from mental health professionals, and many

others. This wide variety in positive coping strategies gives researchers a deeper understanding

of a multitude of possibilities that could be used to help nurses have an effective way to help

mitigate the negative stress response of STS.

These positive coping strategies support the existing literature. Badger (2001) and Jobe et

al. (2021) found that self-reflection and self-care reduced the stress responses experienced by the

nurses. İlhan & Küpeli (2022) found that engagement in hobby activities, such as reading and

exercise, was beneficial in decreasing levels of STS. This study supports those results, as many

participants shared exercise, meditating, and reading as ways to cope with stress.

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Dysfunctional Coping

Nurses did not report as many negative coping strategies as positive coping strategies.

The most commonly reported strategy was using drugs/alcohol to help cope, and some of those

participants discussed using both drugs and alcohol. Drug usage included marijuana, tobacco,

and prescription medications that were used outside of the intended order. Misused prescription

medications were all reported in an attempt to aid in sleeping. The use of substances was briefly

mentioned in the previous research. This study supports the data that shows some nurses turn to

drugs and alcohol in an attempt to cope and get through their feelings (Aisling et al., 2016; Duffy

et al., 2015; Wolf et al., 2020). Participants in this study did identify that their use of drugs and

alcohol were not productive, and some actively sought counseling. While this dysfunctional

coping is harmful, participants did not disclose any thoughts of physical self-harm or

suicidal/homicidal ideation, which were topics identified in prior literature (Aisling et al., 2016;

Wolf et al., 2020).

Other dysfunctional coping strategies reported were dissociating and excessive crying.

Dissociating prevented the participants from coming to terms with the trauma and their response

to it. Most participants who reported dissociating also reported that they experienced more

nightmares and more triggering of events and memories. Participants who reported excessive

crying discussed that they felt embarrassed by crying at work or they left the patient care area to

cry, leaving their patients unattended. This concern for patient safety was discussed as a

consequence of STS in the literature (Jobe et al., 2021; Wolf et al., 2020). Wolf et al. (2020)

found that nurses felt exhausted and unable to provide safe and effective care for their patients.

This was mentioned by several participants in this study. This is a concern, as patient safety and

care are pivotal parts of nursing care. Jobe et al. (2021) also found that nurses began feeling

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disconnected from their patients and did the bare minimum to finish out their shift and stopped

critically thinking. This will also impact patient safety as the risk for medication errors increases

with a decrease in crucial thinking (Jobe et al., 2021)

Debriefing as Coping

Debriefing as a coping mechanism yielded conflicting data. Some participants found

debriefing to be helpful, while others found it to be more harmful. Some participants believed

that an immediate debriefing would be a better option, because the emotions are raw, the events

are fresh in the brain, and the staff is already on site. Others, however, felt as though they would

not benefit from an immediate debriefing as they needed time to process what happened and how

they were reacting. Delayed debriefings offered that chance to process the events, but one

participant specifically stated that delayed debriefings can be more triggering and cause another

layer of trauma. Another disadvantage that was discussed to delayed debriefings is that not all

staff can attend. One participant was unable to attend a formal debriefing because she was

working and could not find coverage for the time of the debriefing. Another participant attended

a delayed debriefing but stated it was not in the same hospital or even the same county as the

incident and it was led by someone who the staff did not know, which led to feeling

uncomfortable and devalued.

Formal versus informal debriefing was also discussed. The majority of participants stated

that they had never participated in a formal debriefing. This was for a variety of reasons: it was

never offered, they could not attend due to scheduling conflicts, or just were not interested in

attending. Informal debriefings were ideal for some participants. These participants stated that

the informal debriefings strengthened their relationships with their coworkers. One drawback to

informal debriefings that was mentioned was that because they occurred during the time of the

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incident, the debriefing session felt rushed. One participant stated that they did not f ind the

debriefing beneficial because she felt that her emotions were dismissed as unimportant and not

worthy of recognition. The informal debriefings addressed the emotional feelings and reactions

of the participants, while formal debriefings focused on the skills and things that went well and

did not go well. One participant stated that he felt as though he was in an interrogation during a

debriefing. He stated after that experience, he never wanted to return to a debriefing.

Informal debriefings and informal support through management and colleagues has been

identified as beneficial to help nurses work through their experiences. Wolf et al. (2020) found

that nurses who have supportive management have less negative outcomes associated with STS

when they can talk things out. Duffy et al. (2015), Jobe et al. (2021), and Woo and Kim (2021)

found that having colleagues with shared experiences help nurses form strong bonds and allow

nurses to talk though their experiences without judgement.

Some participants disclosed that they did not see the value in the debriefing until after

they participated in a session. They expressed feelings of anxiety over being critiqued, believing

it was a waste of time, or that they had more important things to do. However, after they finished

the debriefing session, they were surprised to see the benefit. The benefits they discussed were

seeing the emotions from their coworkers and feeling validated in their personal feelings.

Exploring the benefits of formal debriefing is not extensively studied in the literature in

emergency room nurses related to secondary traumatic stress. Some researchers found that

debriefing sessions can help improve mental well-being (Morrison & Joy, 2016), while others

found that it can cause re-traumatization by forcing nurses to re-experience the events (Cantu &

Thomas, 2020). This study does not support one particular style of debriefing: formal/informal,

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immediate/delayed, on site/off site, or voluntary/mandatory. Further research needs to be done to

examine the effectiveness of debriefing practices.

Research Aim 4: Summary and Discussion

Research aim 4 was to compare individual participant interview responses with

corresponding survey responses to identify similarities and differences in reported stress level

and coping techniques. In this study, many similarities and differences were identified. The

biggest consideration is that the STSS does not address all of the aspects of STS that were

brought to light through this study: impacts on family life, home life, and patient care. Overall,

participants who reported a high or severe STS score were able to provide detailed recollections

of information and memories from traumatic patient interactions. The patients who scored little

to no or mild STS had stories to share but the details were not as vivid. Those participants also

reported feeling less overall stress from work when discussing coping strategies and stress

management techniques. However, there were a few outliers who self-reported low STS score

but gave very specific details and even became emotional at remembering the event. This

discrepancy was not the majority, however.

The items within the STSS were consistent with the qualitative comments discussed by

the participants. Arousal symptoms scored higher than the other two subcategories (intrusion,

avoidance), and this was consistent with statements made during the interviews. Participants

discussed sleep disturbances, difficulty concentrating and focusing both in the workplace as well

as at home with family and friends, and some even identified feeling easily annoyed by patients

and patient visitors. Those above topics are all included in the subcategory of arousal.

The STSS focuses on the concepts of avoidance, intrusion, and arousal, but were all

primarily centered around the participants’ mental health. However, participants discussed

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aspects of their lives that were affected by their experience with STS. These other areas that were

impacted included relationships between coworkers, family/friends, and their patients. These are

not addressed or considered in the STSS. This is an area of opportunity for future research.

The Brief-COPE Inventory showed a variety of convergence and divergence when

compared to the qualitative data. This was not surprising, as there are 28 questions, three

subscales, and 14 facets within the scale. The Brief-COPE Inventory examines coping through

several different lenses: problem focused, emotion focused, and avoidant. This comprehensive

approach to examining coping strategies puts the individual facets at a higher risk of being

contradicted by statements in a qualitative interview.

The Visual Analog Scale showed more convergence than divergence when compared to

the qualitative data. Participants who reported an increase in stress post-shift compared to pre-

shift discussed relying on the drive home to decompress and be alone with their thoughts before

arriving at home and being engaged with their family life. Higher changes in perceived stress

from pre-shift to post-shift were seen in participants who discussed dysfunctional coping

strategies and a more significant impact in life outside of the hospital. Only one participant had a

negative change in perceived stress, meaning they reported a higher pre-shift stress and a lower

post-shift perceived stress. This contradicted her qualitative statements, as they were more

impactful in describing how STS negatively affected her mental health, her parenting styles, as

well as her disclosing that she was embarrassed for crying during work.

There is no existing literature that has looked at education level, trauma level, years of

experience, change in perceived stress, coping, shift worked, and employment status with

secondary traumatic stress together in addition to qualitative interviews. This study will increase

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what is known about secondary traumatic stress, coping strategies, and the lived experience of

STS for ER nurses.

Recommendations for Future Research

More research needs to be done to examine the convergence and divergence of

qualitative data and the Secondary Traumatic Stress Scale (STSS). Through this study, the

researcher identified aspects of secondary traumatic stress that were not assessed in the STSS.

The STSS addresses the personal symptoms specific to the three subconstructs of STS (arousal,

intrusion, and avoidance) but does not address other aspects of STS: family life, work life, and

patient care. The STSS can be helpful in identifying STS in a population, but it does not address

how STS affects the nurse in other aspects of their lives. Without understanding the lived

experience, interventions cannot be developed to help mitigate the effects. This is an area that

needs to be examined more extensively.

This study found that STS affects the mental health of the individual but can also

significantly affect other aspects of the individual’s lives. By conducting more research in this

study, a new measurement tool may be developed, or the STSS may be modified to include

questions regarding those other aspects of the STS impact. Future research in this area should

focus on interventions to help mitigate the stress response experienced by the nurses. Debriefing

has been shown to be beneficial in literature (Badger, 2001; Cantu & Thomas, 2020; Morrison &

Joy, 2016), however in this study, debriefings were met with mixed experiences by the

participants in this study. Some found that debriefings were helpful to process their emotions and

identify weaknesses, while others have found that debriefings are more harmful as they require

the participants to relive their experiences and feel more attacked than supportive. Future

researchers should examine the effectiveness of standardizing debriefing sessions that are offered

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at the end of every shift. By researching debriefing practices following traumatic patient

experiences, researchers can provide guidance on best practices to hospitals regarding how to

conduct debriefing sessions.

Recommendations for Future Practice and Policy

Strong management support was identified as a beneficial piece to effective coping.

Having a supportive management team (manager, director, charge RN) empowered the

participants to take breaks, practice self-care, and allowed the participants to have an outlet to

discuss feelings and emotions in response to their experiences. Hospitals can benefit from this

information by relaying the information to their management teams and supporting them to be

the best support system possible for their nurses. Management needs to be visible on the units to

support their staff: offering to assume care for patients to allow the RN a few moments of a

break, having an open-door policy to staff to allow them the space and opportunity to discuss

their feelings and experiences about situations experienced throughout their shifts, and allow

RNs the opportunity to take time away from the hospital to decompress and process situations

without punitive consequences.

Researchers also found that debriefing is not a standard practice among these

participants. This needs to be addressed in practice. Debriefing has multiple facets that may be

different based on the situation: immediate versus delayed, on site versus off site, mandatory

versus voluntary, and who initiates or conducts the debriefing. This study identified a mix of all

the different variables listed above; there was not enough consistency to put a recommendation

forward. However, this tells the researcher that more information needs to be learned to address

the ideal way to debrief following a traumatic situation.

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Policy implications from this study include adequate mental health support to mitigate the

long-term effects of STS for ER nurses. One way to do this is to allow nurses the opportunity for

time off following a traumatic patient experience, which will provide them with necessary time

to process and come to terms with what they just endured. This requires hospitals to have

adequate staff and resources in place. Failing to do so will force nurses to turn to dysfunctional

coping strategies. Participants in this study disclosed turning to drugs and alcohol to cope with

their emotional and psychological reactions to the experiences. These negative coping techniques

caused participants to miss work and/or call off due to inability to safely care for pat ients

following the use of drugs and/or alcohol. This puts additional strain on remaining nurses as well

as the hospital being short-staffed, which also directly impacts patient safety.

Hospitals should introduce the concept of STS in their orientation for new employees.

This could include descriptions of what STS may look like, as well as a measure to examine

current stress levels and coping strategies. By identifying signs of STS early, nurses may be able

to implement coping strategies before the emotional, physical, or psychological toll gets to be

overwhelming.

Limitations

One limitation of this study is that it is cross-sectional. Cross-sectional studies examine

the phenomenon/variable of interest at one point in time (Gray & Grove, 2021). Future research

will benefit from longitudinal studies, which can examine how STS can change over time.

Another limitation is using a purposive sample instead of random sampling. Random sampling

allows for a more heterogeneous population, whereas purposive sampling can increase bias

related to numerous demographic factors.

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Another limitation is the use of the measurement tool: Visual Analog Scale for Perceived

Stress. While the Visual Analog Scale is typically used to rate pain, the researcher adapted it to

examine perceived stress. Participants were asked to rate their perceived stress on a 0 (no stress)

– 10 (highest stress) at the beginning of an average shift and again at the end of an average shift.

This could lead to bias, as participants may focus on a particularly traumatic day. This impacts

the representativeness of this value and should be examined further in additional studies.

Another limitation is that recruitment was primarily done electronically. Nurses who do

not have access to the internet were not able to participate in this study. While some nurses were

able to access this survey through their work email, some nurses were recruited through a

professional organization (Missouri Emergency Nurses Association) as well as through the social

media platform Facebook. Nurses who do not have a Facebook account or did not check their

email account during the recruitment period did not see this opportunity.

While the majority of interviews were conducted online through a video platform, such as

ZOOM (13/23) or Microsoft Teams (1/23) which require a strong internet connection, some

interviews were conducted over the telephone (9/23). This limited the researcher’s ability to see

non-verbal cues that could be valuable in data analysis: facial expressions, background

distractions, determining if pauses in responses were due to an emotional response or due to

contemplating the response.

A limitation for the convergent design was that the quantitative sample and qualitative

sample did not include equal numbers of participants; those who completed the quantitative

survey had the choice to decline the qualitative interview aspect of the study. Having a smaller

qualitative sample size offers the researcher the opportunity to have a more rigorous, in-depth

understanding of the phenomenon, while a larger quantitative sample offers higher power and

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rigor for the required statistical tests. However, having differing sample sizes is a weakness for a

convergent design. Examining two datasets that are not equal has implications for the validity

and reliability of the results. This was addressed by only comparing the quantitative results of

those who participated in the qualitative portion of the study with their qualitative responses.

Conclusion

This study examined secondary traumatic stress in emergency room nurses through a

convergent mixed methods approach. Four statistically significant relationships were identified:

education level and reported STS level, the emotion-focused facet of the Brief-COPE Inventory

and reported STS level, the avoidant facet of the Brief-COPE Inventory and reported STS level,

and the change in self-reported stress between pre-shift and post-shift. Five group experiential

themes were identified through the 23 interviews: patient care suffers, relationships at work are

impacted, life continues outside the hospital, impacting me on a personal level, and residual

stress remains despite coping attempts. It was clear through the interviews that STS had an

impact on the individual beyond the physical, emotional, and/or psychological impact. The effect

of STS impacted relationships with patients, coworkers, family, and/or friends. This aspect of

STS has not been quantitatively measured, and consideration should be taken to develop a

measurement tool that can examine this. This study strengthens existing literature which

identifies the prevalence of severe STS in ER nurses and adds additional understanding of the

impact of STS on the lives of the ER nurses.

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Appendix A: Permission for Revised Transactional Model of Occupational Stress and

Coping

123

124

Appendix B: PRISMA Diagram

Figure 2: PRISMA Diagram

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Appendix C: Community Resources for Mental Health Concerns

These are a few resources in the area that can help if you are experiencing any mental or

emotional distress

• National Suicide Prevention Lifeline:

o Call the Lifeline for confidential 24 hour support. 9-8-8 or 1-800-273-8255.

o www.suicidepreventionlifeline.org/

• Crisis Text Line

o Text “GO” to 741-741

o www.crisistextline.org

o Crisis Text Line serves young people (and others) in any type of crisis, providing

access to free, 24/7, emotional support and information. A live, trained specialist receives the text and responds quickly.

• Avenues Counseling

o 1612 S. Big Bend Blvd. 63117

o www.avenuescounselingcenter.org 314-529-1391

o Provides a full range of counseling services, regardless of ability to pay. Fees

based on a sliding scale are available. Articles and information regarding

behavioral health topics may be found on their website.

• Walter’s Walk

o 737 Dunn Road, Hazelwood, MO 63042

o www.walterswalk.com 314-731-2433

o Provides integrated mental health services to children and adults who have

experienced trauma, depression and anxiety, regardless of ability to pay.

http://www.suicidepreventionlifeline.org/

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Appendix D: Demographic Survey

1. To be eligible to participate in this study, you must be a registered nurse (RN), working in an

emergency department (ED) in the state of Missouri or Illinois. Are you an RN working in a

Missouri or Illinois ED?

a. Yes

b. No

2. What is your age?

a. __________

3. To which gender do you most identify?

a. Female

b. Male

c. Transgender

d. Nonbinary

e. Other ______________________

f. Prefer not to say

4. How many years of experience do you have as a nurse?

a. __________

5. How many years of experience do you have in an emergency room?

a. __________

6. What is your employment status?

a. Full time

b. Part time

c. Per-diem (PRN)

7. What shift do you work?

a. Day Shift

b. Mid Shift

c. Night Shift

d. Varies

e. Other: ___________________

8. What is your highest education level?

a. Diploma in Nursing

b. Associate’s Degree in Nursing (ADN)

c. Bachelor’s Degree in Nursing (BSN)

d. Master’s Degree in Nursing (MSN)

e. Doctor of Nursing Practice (DNP)

f. Doctor of Philosophy (PhD)

9. What level trauma center is your hospital?

a. Level 1

b. Level 2

c. Level 3

d. Level 4

e. Level 5

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Appendix E: Secondary Traumatic Stress Scale

Table 7: Secondary Traumatic Stress Scale

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Appendix F: Brief-COPE Inventory

Table 8: Brief-COPE Inventory

Coping Statement I haven't

been

doing this

at all

A little bit

A medium

amount

I’ve been

doing

this a lot

I've been turning to work or other activities to take my mind off

things.

1 2 3 4

I've been concentrating my efforts on doing something about the situation I'm in.

1 2 3 4

I've been saying to myself "this isn't real". 1 2 3 4

I've been using alcohol or other drugs to make myself feel better 1 2 3 4

I've been getting emotional support from others. 1 2 3 4

I've been giving up trying to deal with it. 1 2 3 4

I've been taking action to try to make the situation better. 1 2 3 4

I've been refusing to believe that it has happened. 1 2 3 4

I've been saying things to let my unpleasant feelings escape. 1 2 3 4

I’ve been getting help and advice from other people. 1 2 3 4

I've been using alcohol or other drugs to help me get through it. 1 2 3 4

I've been trying to see it in a different light, to make it seem more positive.

1 2 3 4

I’ve been criticizing myself. 1 2 3 4

I've been trying to come up with a strategy about what to do. 1 2 3 4

I've been getting comfort and understanding from someone. 1 2 3 4

I've been giving up the attempt to cope. 1 2 3 4

I've been looking for something good in what is

happening.

1 2 3 4

I've been making jokes about it. 1 2 3 4

I've been doing something to think about it less, such as going to

movies, watching TV, reading, daydreaming, sleeping, or shopping.

1 2 3 4

I've been accepting the reality of the fact that it has happened. 1 2 3 4

I've been expressing my negative feelings. 1 2 3 4

I've been trying to find comfort in my religion or

spiritual beliefs.

1 2 3 4

I’ve been trying to get advice or help from other people about what to do.

1 2 3 4

I've been learning to live with it. 1 2 3 4

I've been thinking hard about what steps to take. 1 2 3 4

I’ve been blaming myself for things that happened 1 2 3 4

I've been praying or meditating 1 2 3 4

I've been making fun of the situation. 1 2 3 4

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Appendix G: Interview Guide

The purpose of this mixed methods study is to examine the phenomenon of secondary traumatic

stress in emergency room nurses. I am interested in understanding stressful experiences you have

had, how they impacted you on a professional and personal level, as well as identifying and

understanding any coping strategies you have used to help with your stress. There are four

specific aims of this study: (1) examine the relationship between experience levels, education

levels, employment status, shift worked, hospital trauma levels, and reported coping skills with

secondary traumatic stress (STS) in ED nurses; (2) to describe the meaning of secondary

traumatic stress in emergency room nurses from the nurses’ perspective; (3) to examine coping

strategies, reported and described by emergency room nurses in response to secondary traumatic

stress; and (4) to compare individual participant interview responses with corresponding survey

responses to identify similarities and differences in reported stress level and coping techniques.

Secondary traumatic stress is defined as the negative emotional and physical reaction

experienced by someone who had an indirect exposure to trauma, typically resulting from caring

for ill and injured victims.

• What does a typical shift look like?

o Time frame, typical patients seen (acuity, number, common complaints), staffing,

breaks

• Tell me about a specific patient interaction that was difficult, stressful, or traumatizing

for you?

o How did it make you feel at that moment?

o How did that experience affect your other patients during the shift?

130

o How did that experience affect your interactions with colleagues (nurses, doctors,

UAP’s, etc.) during the rest of the shift?

• What specific patient condition do you find more stressful than others? (Such as MVC’s,

MI’s, assault/abuse, pediatrics, etc.)

o What about these scenarios do you find more stressful?

o How often do you experience these situations?

• How has a traumatic patient event affected your life outside of work?

o Relationships with family/friends

o Sleep

o Thought patterns

• How do you typically manage your daily stress?

o Are these coping strategies effective after a day of increased stress at work?

o Do increased stress days require you to use different coping strategies?

• Tell me about a time you participated in a debriefing session following any traumatic

events at work.

o How did you feel prior and after?

o Is this formal or informal?

o Who was involved in the debriefing?

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Appendix H: Mixed Methods Table

Table 9: Mixed Methods Table

RP #

STSS Brief-COPE VAS Personal Experiential Statements

STSS

Interpretation

Brief-COPE Interpretation Change in

Stress:

Quotes:

Convergence Divergence

132

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Vita Auctoris

Mary Frazier was born in Kettering Ohio and grew up in Edwardsville, Illinois. She

earned her Bachelor of Science in Nursing from Southern Illinois University, Edwardsville in

2011. She began her nursing career in the emergency department at Anderson Hospital. Through

precepting, she found her love of teaching and returned to Southern Illinois University,

Edwardsville to earn her Master of Science in Nursing Education in 2017. Mary currently works

as a faculty member at Southern Illinois University, Edwardsville. She works with undergraduate

students in the classroom as well as in the clinical setting. She has been honored for her

leadership in the School of Nursing, receiving the Outstanding Leader award in 2019, as well as

honored for her work as an emergency room nurse, receiving the Hero in Action for

Emergency/Critical Care at the March of Dimes banquet in 2023. Mary is a member of the

Epsilon Eta chapter of Sigma Theta Tau Honors Society.

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List of Tables
List of Figures
Chapter I: Background of the Problem

Significance of the Study
Conceptual Definitions
Theoretical Framework
Philosophical Underpinnings
Purpose of Study

Chapter II: Literature Review

Method
Study Characteristics
Demographics of Study Participants
Measurements Used
Prevalence of Secondary Traumatic Stress
Identification of Causes of STS
Risk Factors

Nursing Experience
Workplace Factors
Personal Characteristics
Personal History

Consequences of Secondary Traumatic Stress

Workplace Factors
Psychological Effects
Physical Effects
Substance Use

Protective Factors

Positive Self-Care Strategies
Informal Support
Formal Debriefing

Recommendations for Future Research/Practice
Gap of Research

Chapter III: Methodology

Purpose
Design

Phenomenological Design

Mixed Methodology
Sample and Setting
Recruitment
Ethical Considerations
Data Collection

Demographics
Secondary Traumatic Stress Scale
Brief-COPE Inventory
Visual Analog Scale for Perceived Stress
Interview

Data Analysis

Quantitative Analysis
Qualitative Analysis
Mixed Methods Analysis
Validity
Trustworthiness and Rigor

Chapter IV: Results

Research Aim 1
Research Aim 2

Patient Care Suffers
Relationships at Work are Impacted
Life Continues Outside the Hospital
Impacting Me on a Personal Level
Residual Stress Despite Coping Attempts

Research Aim 3

Positive Coping Strategies
Dysfunctional Coping Strategies
Debriefing as Coping

Research Aim 4

Convergence
Divergence

Chapter V: Discussion

Summary of the Study
Research Aim 1: Summary and Discussion
Research Aim 2: Summary and Discussion

Arousal
Avoidance
Intrusion
Revised Transactional Model of Occupational Stress and Coping

Research Aim 3: Summary and Discussion

Positive Coping
Dysfunctional Coping
Debriefing as Coping

Research Aim 4: Summary and Discussion
Recommendations for Future Research
Recommendations for Future Practice and Policy
Limitations
Conclusion

Appendix A: Permission for Revised Transactional Model of Occupational Stress and Coping
Appendix B: PRISMA Diagram
Appendix C: Community Resources for Mental Health Concerns
Appendix D: Demographic Survey
Appendix E: Secondary Traumatic Stress Scale
Appendix F: Brief-COPE Inventory
Appendix G: Interview Guide
Appendix H: Mixed Methods Table
References
Vita Auctoris