Research for Evidence Based Practice

R E S E A R C H

Myung-Jung National Un

Dong-Hee K Yangsan-si, R 0003-2571-8

For correspo Pusan Nat

400 JO

FACTORS ASSOCIATED WITH SECONDARY

TRAUMATIC STRESS AMONG NURSES IN REGIONAL

TRAUMA CENTERS IN SOUTH KOREA: A DESCRIPTIVE CORRELATIONAL STUDY

Authors: Myung-Jung Woo, MSN, RN, and Dong-Hee Kim, PhD, RN, Yangsan-si, Republic of Korea

Contribution to Emergency Nursing Practice

� The current literature on secondary traumatic stress in- dicates moderate to severe levels in nurses, with limited information regarding influencing factors of affected nurses.

� This article identifies 5 key factors associated with sec- ondary traumatic stress; including personality type, coping styles, the desire for job rotation and social sup- port from supervisors. Nurses in this study reported moderate to severe levels of secondary traumatic stress.

� Key implications for emergency nursing practice found in this article are that secondary traumatic stress is not a problem that can be prevented or solved at the in- dividual level. Administrative support, along with devel- opment and application of management interventions based on factors associated with secondary traumatic stress are needed to mitigate the negative effects of this issue.

Abstract

Introduction: Trauma is a leading cause of death in South Ko- rea. This study aimed to identify the factors associated with sec- ondary traumatic stress of nurses working at regional trauma centers.

Methods: A survey-based cross-sectional design was uti- lized. Data were collected through a structured questionnaire

Woo is Master’s Student Graduate, College of Nursing, Pusan iversity, Yangsan-si, Republic of Korea.

im is Professor, College of Nursing, Pusan National University, epublic of Korea. ORCID identifier: https://orcid.org/0000- 900.

ndence, write: Dong-Hee Kim, PhD, RN, College of Nursing, ional University Beomeo-ri, Mulgeum-eup, Yangsan-si,

URNAL OF EMERGENCY NURSING

consisting of 5 rating scales and demographic data. Data were analyzed via descriptive statistics, t test, analysis of variance, Pearson’s correlation, and multiple regression.

Results: One hundred eighty-six nurses participated, and most (84.4%) reported moderate to severe secondary traumatic stress. Exposure to traumatic events averaged 34.33 (SD ¼ 6.25) out of 65 points. Average problem-focused coping was 3.00 (SD ¼ 0.37), emotion-focused coping was 2.57 (SD ¼ 0.26), and dysfunctional coping was 2.17 (SD ¼ 0.41) out of 4 points. Social support from family and friends averaged 5.85 (SD ¼ 0.75), social support from coworkers was 5.78 (SD ¼ 0.83), and social support from supervisors was 4.65 (SD ¼ 1.18) out of 7 points. The factors affecting the respon- dents’ secondary traumatic stress were type D personality (b ¼ 0.39, P < .001), dysfunctional coping (b ¼ 0.28, P < .001), problem-focused coping (b ¼ 0.19, P < .01), desire for job rotation (b¼ 0.17, P< .01), and social support from su- pervisors (b ¼ -0.12, P ¼ < .05). This regression model was statistically significant and the explanatory power was 46.7% (F ¼ 33.47, P < .001, Adj R2 ¼ 0.47).

Discussion: Along with a personal effort to engage in stress management programs, administrators, managers, and supervi- sors should prioritize developing practical strategies for reducing secondary traumatic stress of nurses.

Key words: Nurse; Social support; Stress; Trauma; Type D per- sonality

Gyeongsangnam-do, Republic of Korea 50612; E-mail: dongheekim@pusan. ac.kr. J Emerg Nurs 2021;47:400-11. Available online 21 November 2020 0099-1767

Copyright � 2020 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2020.08.006

VOLUME 47 � ISSUE 3 May 2021

Demographic factors

Work-related factors

Type D personality

Exposure to traumatic events

Stress coping styles

Social support

Secondary traumatic stress

FIGURE

Conceptual analytic framework for factors of secondary traumatic stress among nurses working in regional trauma centers.

Woo and Kim/RESEARCH

Introduction

The mortality rate from trauma in South Korea was 55.2 in 2016 and 53.0 in 2017 per 0.1 million population; trauma is the fourth leading cause of death after cancer, cardiovas- cular, and respiratory diseases in South Korea.1 The Korean government set up regional trauma centers in 2012 to reduce the preventable trauma mortality rate to less than 20% by 2025. As of October 2018, 17 trauma centers have been designated nationwide, and 13 centers have officially opened. Patients visiting the regional trauma centers suffered severe physical trauma such as accidents (including traffic), disasters, assaults, sexual assaults, falls, and trauma patients exposed to violent crimes. More than 30 000 patients were admitted at regional trauma centers annually.2

Secondary traumatic stress (STS) is a type of stress experienced by individuals exposed to others who have experienced trauma but were not exposed to the traumatic event themselves. Health care workers and caregivers can experience this STS caused by the continuous care of trauma patients.3,4 People with STS are similarly affected as those who had directly experienced traumatic events.3 The criteria for STS symptoms are arousal, avoidance, and intrusion. Nurses often report difficulty sleeping or being easily annoyed, caused by the effects of arousal.5

The traumatic events experienced by trauma center nurses are constant and may be considered occupational hazards.6,7 People suffering from STS experience sadness, depression, insomnia, anxiety, and a reduction in their ability to work as professionals that seriously affect their professional lives.8 Nurses caring for patients with traumatic injuries such as car accidents, violent crime, and other injuries are likely to be at an increased risk of developing posttraumatic stress-like syndromes.9 Thus, a study of STS of trauma nurses is necessary.

Studies of STS have been conducted on nurses working in the emergency department,10-13 an intensive care unit,14

a mental health unit,15,16 a cancer ward,17 and a trauma cen- ter.7,18 These studies reported that 7.0% to 74.5% of nurses were at a high risk of STS. However, there is limited litera- ture identifying factors associated with STS of nurses. Furthermore, to the best of our knowledge, no study has been conducted with nurses working in a regional trauma center in South Korea.

In addition, to mitigate STS in nurses, it is necessary to examine contributory factors. Factors affecting traumatic stress are demographic,19-22 work-related,7 distressed per- sonality type (Type D personality),23,24 frequency of

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exposure to traumatic events,25 stress-coping styles, and so- cial support.26 The type D personality reflects a relatively stable psychological characteristic and displays negative affectivity and social inhibition.27 Subjects with a type D personality are more likely to have chronic stress and STS than those who are not.27,28 Coping mechanisms can be categorized into problem-focused, emotion-focused, and dysfunctional coping.29,30 STS can vary not only during the experience but also in coping methods after the event. Moreover, high social support is reportedly a major factor in reducing STS.10,22

Most previous studies have focused on personal variables and less on work-related factors or social factors. Moreover, there is no agreement on factors that may influence STS. A recent systematic review of literature showed the need to examine STS in light of its personal, work-related and social context.31 Nurses working at a regional trauma center are continuously exposed to trauma patients and are at risk of secondary trauma stress. Through examining the degree of STS and the factors that influence such stress, a strategy for stress management can be developed. We aimed to examine the relationship between general and work characteristics, type D personality and exposure to traumatic events, stress-coping methods, social support, and STS (Figure).

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Methods

STUDY DESIGN AND ETHICAL CONSIDERATIONS

We used a survey-based cross-sectional study design. This research was approved by the Pusan National University institutional review board (PNU IRB/2019_40_HR) before data collection. Participants provided written informed con- sent for the offline survey, and taking the survey was consid- ered implied consent for the online survey.

PARTICIPANTS, SAMPLING, AND SAMPLE SIZE CALCULATION

The eligible participants were 227 nurses who worked in the trauma emergency room and trauma intensive care unit of 3 regional trauma centers for more than a month. Conve- nience sampling was used in this study. The number of par- ticipants was calculated using the G*Power 3.1.9.2 software program.32 For multiple regression analysis, the minimum number of participants was calculated at 171 at a signifi- cance level of 0.05, a median effect size of 0.15, power of 0.90, and 15 independent variables. The independent vari- ables of the multiple regression analysis were included as var- iables reported in previous studies to influence the STS of the nurse. Considering the dropout rate, we aimed to recruit a sample size of 205 nurses.

Setting and Participant Recruitment

The researchers contacted the nursing departments of all regional trauma centers nationwide in South Korea and explained the purpose and method of the research. Among the 13 regional trauma centers open at the time of data collection, only 3 hospitals participated. Recruitment notices with the survey URL were posted on bulletin boards of each regional trauma center for the participants to access.

DATA COLLECTION

Data were collected from June to August 2019 through a structured questionnaire consisting of questions on general characteristics, work-related factors, type D personality, exposure to traumatic events, stress-coping methods, social support, and STS. Data was collected through online and written surveys. For the online survey, SurveyMonkey. com was used. Written or online surveys were provided individually to prevent duplicate responses. Completed written questionnaires were collected by means of a collection box.

402 JOURNAL OF EMERGENCY NURSING

INSTRUMENTS

Before utilizing the instruments described below, all content of the translated tools was evaluated by 5 non-participating nurses for possible misunderstandings or errors. This group consisted of one nursing professor and 4 nurses, each with more than 5 years experience at a trauma center, intensive care unit, or emergency department.

Secondary Traumatic Stress

The STS scale developed by Bride et al33 was translated into Korean, and bilinguals fluent in English and Korean translated it to English. The content of the translated tool was evaluated by a group of non-participating nurses. Based on Lynn’s recommendation,34 all 17 items had a CVI 1.0. The tool consists of 17 questions, including 5 items of intru- sion, 7 items of avoidance, and 5 items of arousal. It was scored on a 5-point Likert scale ranging from 1 (“never”) to 5 (“very often’’). Scores ranged from 17 to 85; a higher score indicated higher levels of STS. Based on the criterion sug- gested by the tool developer,35 scores less than 28 indicate lit- tle or no STS; 28 to 37 indicate mild STS; 38 to 43 indicate moderate STS; 44 to 48 indicate high STS; and >_ 49 indicate severe STS. In Bride et al33 the total Cronbach’s a was 0.93, and the subcategories’ reliability were 0.80 for intrusion, 0.87 for avoidance, and 0.83 for arousal. In this study, Cronbach's a was 0.92 in total, and for the subcategories were 0.79 for intrusion, 0.79 for avoidance, and 0.81 for arousal.

Distressed Personality Type (Type D Personality)

The type D personality tool (DS14) developed by Denollet27 was translated into Korean by Lim et al36 This tool consists of 14 questions: 7 about negative affectivity and 7 about social inhibition. Each item is scored on a 5- point Likert scale ranging from 0 (“false”) to 4 (“true”). The negative affectivity and social inhibition scores range from 0 to 28 and are classified as a type D personality when the sum of scores of each domain is at least 10. Cron- bach’s a was 0.88 for negative affectivity and 0.86 for social inhibition.27 Lim et al36 reported that Cronbach’s a was 0.87 for negative emotion and 0.77 for social inhibition. In this study, the overall Cronbach’s a was 0.92, negative affectivity was 0.85, and social inhibition was 0.90.

Exposure to Traumatic Events

In this study, we used a tool developed by Kim and Choi37 to measure the nurse’s experience of subsequent traumatic events. The tool is composed of 13 questions. It is measured

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Woo and Kim/RESEARCH

on a 5-point Likert scale, ranging from 1 (“never”) to 5 (“very often”). The score ranges from 13 to 65, with a higher score indicating greater exposure to trauma. In their study, Cron- bach’s a of the instrument was 0.90, while ours was 0.80.

Stress-coping Styles

We used the brief Coping Orientation to Problems Experi- enced (the brief-COPE) tool developed by Carver.38 It was translated into Korean by Joo39 and a social welfare expert and bilinguals fluent in English and Korean translated it to English, comparing it to the original text. It is composed of 28 items across 3 areas: 6 items for problem-focused, 10 items for emotion-focused, and 12 items for dysfunctional coping styles. This tool measures the degree to which each stress-coping style is used on a 4-point Likert scale ranging from 1 (“I have not been doing this at all”) to 4 (“I have been doing this a lot”). The score is calculated by adding the scores of each subcategory, with a higher score indicating which stress-coping method is used more frequently. The overall Cronbach’s a was 0.90 in Carver’s38 study and 0.90 in Joo’s39 study. The overall Cronbach’s a in this study was 0.73, with problem-focused coping at 0.75, emotional- focused coping at 0.68, and dysfunctional coping at 0.77.

Social Support

The Crisis Support Scale developed by Joseph et al40 was used to measure social support. The original tool measured social support twice: at the time of the event and at present. However, in Ko’s41 study, there was no statistically signifi- cant difference between the 2 measurements. Due to the characteristics of the regional trauma center, exposure to traumatic events was continuous, so the current social support was measured. In addition, based on previous studies,42,43 this study measured social supporters by dividing them into support from family and friends, coworkers, and supervisors. There are 7 questions for each sub-supporter; thus, in total, 21 questions. Each item was measured using a 7-point Likert scale from 1 (“not at all”) to 7 (“always”). The score of each sub-supporter ranges from 7 to 49, with higher scores indicating higher levels of social support. Cronbach’s a was reported to range from .67 to .69 in Joseph et al40 study. In this study, Cron- bach’s awas 0.90 in total, with “family and friends” at 0.77, “coworkers” at 0.86, and “supervisors” at 0.90.

DATA ANALYSIS

Data were analyzed using SPSS version 22.0 (IBM Co., Armonk, NY, USA). Descriptive statistics analyzed general characteristics, work-related factors, type D personality,

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exposure to traumatic events, stress-coping styles, social support, and STS. The difference in the degree of STS ac- cording to the general characteristics, work-related factors, and type D characteristics of the participants were analyzed by t test or analysis of variance (ANOVA). Pearson’s corre- lation coefficients analyzed correlation among exposure to traumatic events, stress-coping styles, social support, and STS. A multiple regression model was fit with STS as the dependent variable, with independent variables selected from the significant results of the t test, ANOVA, or correlational analysis. As there are few studies exploring factors associated with STS, this analysis is justified as exploratory, but should not be interpreted as confirmatory hypothesis testing. Hence, factors affecting STS were analyzed by applying multiple regression. The significance level used for data analysis was P < .05.

Results

GENERAL AND WORK-RELATED CHARACTERISTICS OF PARTICIPANTS

Of the 202 nurses that participated in the study, 112 partic- ipated through online surveys and 90 completed written questionnaires. One hundred eighty-six participants were included in the final data analysis. Two hundred five nurses were targeted for recruitment, and 202 participated. Among these, 16 questionnaires were excluded due to missing data. Of the total participants, 88.7% were female, and 57.0% were 25 to 30 years old. Approximately 87.1% of partici- pants were unmarried and 79.0% were 4-year college grad- uates. Regarding clinical characteristics, 44.1% had been working at a regional trauma center for more than 2 years, and the average work experience was 23.30 (SD ¼ 14.77) months. 70.4% of the participants worked at a trauma intensive care unit, 31.7% preferred job rotation and 71.0% were satisfied with working at a trauma center.

STS, TYPE D PERSONALITY, EXPOSURE TO TRAUMATIC EVENTS, STRESS-COPING STYLES, AND SOCIAL SUPPORT

The mean score of the STS was 49.62 (SD ¼ 12.43) points out of 85 points. The mean scores of the subcate- gories were 3.02 (SD ¼ 0.84) for arousal, 3.00 (SD ¼ 0.74) for avoidance, and 2.70 (SD ¼ 0.82) for intrusion out of 5 points. A cutoff score of 38 or higher was the criterion used as evidence for the presence of STS.32 In total, 84.4% of participants indicated moderate to severe STS, 46.8% of participants had a type D person- ality, and exposure to traumatic events averaged 34.33

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TABLE 1 Secondary traumatic stress, type D personality, exposure to traumatic events, stress-coping styles, and social support (N [ 186)

Characteristics Mean (Item Mean) SD N %

STS 49.62 12.43 Arousal 3.02 0.84 Avoidance 3.00 0.74 Intrusion 2.70 0.82

Little or no STS 9 4.8 Mild STS 20 10.8 Moderate STS 37 19.9 High STS 27 14.5 Severe STS 93 50.0

Type D personality Yes 87 46.8 No 99 53.2 Exposure to traumatic events 34.33 6.25 Stress-coping styles 2.48 0.23 Problem-focused coping 3.00 0.37 Emotional-focused coping 2.57 0.26 Dysfunctional coping 2.17 0.41 Social support 5.42 0.72 Family and friends 5.85 0.75 Coworkers 5.78 0.83 Supervisor/manager 4.63 1.18

STS, secondary traumatic stress.

RESEARCH/Woo and Kim

(SD ¼ 6.25) points out of 65 points. The stress-coping style averaged 2.48 (SD ¼ 0.23) points out of 4 points. In the subcategories, the problem-focused coping was 3.00 (SD ¼ 0.37), the emotional-focused coping was 2.57 (SD ¼ 0.26), and the dysfunctional coping was 2.17 (SD ¼ 0.41) out of 4 points. Social support averaged 5.42 (SD ¼ 0.72) out of 7 points. Support from family and friends was 5.85 (SD ¼ 0.75), support from coworkers was 5.78 (SD¼ 0.83), and super- visor support was 4.63 (SD ¼ 1.18) points (Table 1).

STS ACCORDING TO GENERAL AND WORK-RELATED CHARACTERISTICS AND TYPE D PERSONALITY

The degree of STS according to general characteristics, work- related characteristics, desired place of work (t¼ -2.65, P < .01), work satisfaction (t ¼ -4.51, P < .001), desire for job

404 JOURNAL OF EMERGENCY NURSING

rotation (t ¼ 6.28, P < .001). Type D personality (t ¼ 9.19, P < .001) was statistically significant (Table 2).

CORRELATIONS AMONG STS, EXPOSURE TO TRAU- MATIC EVENTS, STRESS-COPING STYLES, AND SOCIAL SUPPORT

The STS was associated with frequency of exposure to traumatic events (r ¼ 0.17, P ¼ .02), problem-focused coping (r ¼ 0.21, P ¼ < .01), dysfunctional coping (r ¼ 0.45, P < .001), social support from family and friends (r ¼ -0.25, P ¼ .001), coworkers (r ¼ -0.21, P ¼ < .01), and supervisors (r ¼ -0.24, P ¼ < .01). Cor- relations among STS, exposure to traumatic events, stress- coping styles, and social support showed weak or moderate strengths (Table 3).

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TABLE 2 Secondary traumatic stress score according to general, work-related characteristics, and type D personality (N [ 186)

Characteristics Mean STS Score SD t/F P

Gender Male 48.05 12.36 -0.62 .54 Female 49.82 12.46

Age(y) <25 49.28 12.33 0.05 .95 25-29 49.59 12.33 >_30 50.15 13.19

Marriage status Single 49.77 12.32 0.41 .69 Married 48.70 13.67 Others 46.00 0.00

Religion Yes 50.88 12.61 0.81 .42 No 49.18 12.38

Education Diploma 49.40 8.33 0.20 .82 Bachelor’s 49.39 12.12 > Master’s 51.12 16.25

Total period of working as a nurse (mo) < 36 49.29 12.18 0.06 .94 36-71 49.99 11.61 >_ 72 49.58 14.72

Period of working at aregional trauma center (mo)

< 6 46.50 13.98 0.43 .73 6-11 50.55 15.20 12-23 49.82 11.55 >_ 24 49.91 12.17

Working place Emergency department for trauma patients

47.18 12.86 -1.70 .09

Intensive care unit for trauma patients 50.64 12.15 Desired place of work

Yes 47.01 12.74 -2.65 < .01 No 51.81 11.78

Satisfaction with working Yes 47.36 12.72 -4.51 < .001 No 55.15 9.75

Desire for job rotation Yes 56.73 9.65 6.28 < .001 No 46.31 12.21

Type D personality Yes 57.01 9.96 9.19 < .001 No 43.12 10.65

STS, secondary traumatic stress.

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Woo and Kim/RESEARCH

T A B LE

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406 JOURNAL OF EMERGENCY NURSING

RESEARCH/Woo and Kim

FACTORS INFLUENCING STS

A multiple regression analysis was conducted. We entered the following data: desired place of work, satisfaction with working, desire for job rotation, type D personality, exposure to traumatic events, problem-focused coping, dysfunctional coping, social support from family and friends, social support from coworkers, and social support from supervisors, chosen from the significant results of the t test, ANOVA, or correlational analysis as independent variables, and STS as the dependent variable. Among these factors, nominal scales of the desired place of work, satisfaction with working, desire for job rotation, and type D personality were converted into dummy variables. The multiple regression analysis confirmed relationships between variables. As a result of finding the standardized residuals, all the values were within 3 SD and the distribu- tion of the error term could be assumed as a normal distribution. The variance inflation factor ranged from 1.098 to 1.230; hence, there was no problem in multicollinearity between independent variables. Cook’s distance values for examining individual data points never exceeded 1.0.

The explanatory power of the regression model was 46.7% (F ¼ 33.47, P < .001, Adj R2 ¼ 0.47). To clarify, the model explained 46.7% of the variance in STS. The fac- tors affecting the STS of nurses working at a regional trauma center were type D personality (b ¼ 0.39, P < .001), dysfunctional coping (b ¼ 0.28, P < .001), problem- focused coping (b¼ 0.19, P¼<.01), desire for job rotation (b ¼ 0.17 P ¼ <.01), and social support from supervisors (b ¼ -0.12, P ¼ <.05). The STS was higher in those who had a type D personality, utilized the dysfunctional coping method frequently, utilized the problem-focused coping method frequently, had a desire for job rotation, and had less support from their supervisors (Table 4).

Discussion

This study identified 5 key factors that affect the STS of nurses working at regional trauma centers in South Korea. This study adds uniquely to the published literature by quantifying the levels of STS among nurses working in trauma centers in this country. The STS of the regional trauma center nurses averaged 49.62 points out of 85, with 84.4% in the moderate to severe range. The STS of the nurses in the study was higher than previously re- ported13,44 and moderate to severe levels also account for a high percentage. In a previous study by Ratrout and Hamdan-Mansour13 utilizing the same measurement tool, STS was measured at 46 points.

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TABLE 4 Factors influencing secondary traumatic stress (N [ 186)

Characteristics B SE b t P

Type D personality 0.57 0.09 0.39 6.72 <.001 Dysfunctional coping 0.50 0.10 0.28 4.84 <.001 Problem-focused coping 0.38 0.11 0.19 3.42 <.01 Desire for job rotation 0.27 0.09 0.17 2.88 <.01 Social support from supervisors/boss -0.07 0.04 -0.12 -2.01 <.05

Adj R2 0.47 F 33.47 P <.001

Woo and Kim/RESEARCH

74.5% of nurses working at emergency rooms were in the moderate to severe range. Duffy at al44 conducted a study with nurses working at the emergency room and reported 45.9 points on average and 70% were in the moderate to severe range. In terms of subcategories, arousal has scored the highest, followed by avoidance and intrusion. The STS of the nurses in the study is higher than previously reported. Moderate to severe groups accounted for a high percentage, indicating the need to develop and apply strategies to care for the STS of trauma center nurses.

This study indicated that type D personality, dysfunc- tional coping, problem-focused coping, desire for job rotation, and social support from supervisors were the factors influencing the STS of nurses at regional trauma centers. These factors were statistically significant and the most influential factor was the type D personality. This is similar to Cho and Kang’s45 study conducted at intensive care units.

TYPE D PERSONALITY

The percentage of respondents with a type D personality was 46.8%. Although difficult to compare due to the absence of type D personalities at the regional trauma center, there was a relatively high proportion of type D per- sonalities among other clinical nurses. Type D personality ranged from 23% in medical and surgical units up to 36% in pediatric units.46 People with a type D personality are more vulnerable to chronic stress than people with a non-type D personality.36 They are less likely to seek help or support from others, which may lead to greater traumatic stress.47 In this study, nurses with type D personality work- ing at regional trauma centers had higher STS.

Negative affectivity and social inhibition, which are subcategories of the type D personality, are broad and stable

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personality traits that affect not only everyday life but also life at work.27,48 Individuals with a type D personality were more likely to experience burnout, have a lower level of personal achievement, and be at higher risk of post- traumatic stress when faced with severe stressors at work than individuals with a non-type D personality.48 In addition, people with a type D personality may have worse physical and mental health such as less physical activity, inadequate checks, and fewer health activities, than people with a non-type D personality. This was because they were less likely to perform health-related activities. They spent less time outdoors, were less likely to eat healthily, failed to avoid letting things get them down, and were less likely to get regular medical checkups than people with a non-type D personality.49 Cognitive behavioral therapy, mindfulness-based cognitive therapy, relaxation and interpersonal therapy, self-assertive training, and a healthy lifestyle can help mediate negative affectivity and social inhibition.50 Therefore, participation in health care inter- vention programs and supportive resources, such as consultations with specialists and relaxation therapy, should be encouraged.

STRESS-COPING STYLE

Results showed that the dysfunctional and problem- focused stress-coping methods of regional trauma center nurses were significant factors of STS. The higher the use of dysfunctional coping or problem-focused coping, the higher the degree of STS. Our findings were similar to previous studies on the traumatic stress of trauma nurse specialists.51 However, in our study, dysfunctional coping showed moderate correlation (r ¼ 0.45), and problem- focused coping showed low correlation (r ¼ 0.21) with STS. Each stress-coping style is not entirely independent;

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RESEARCH/Woo and Kim

they are complementary52 and individuals use a variety of coping methods to deal with stress.53 The nurses attemp- ted to solve the problem using more problem-focused stress-coping in situations where they were constantly exposed to the stress source. However, the higher the use of problem-focused stress-coping, the greater the STS. This means that STS is not a problem that can be prevented or solved solely at the individual level. Individ- ual problem-focused stress-coping may not be adequate because personal decision-making opportunities can be limited caused by the nature of the working environ- ment.39,54

DESIRE FOR JOB ROTATION

The STS was higher in those with a need for job rotation than those who did not want to rotate. This is thought to be related to the characteristics of the nursing work, personal characteristics, and adaptation of nursing work in the regional trauma center that cares for trauma patients. It is not easy to create a workplace where every nurse’s need is met. However, the nursing administrator should decide the department most suitable for nurses considering individ- ual’s aptitude. When selecting a nurse to work in the trauma center, administrators can consider a person with a high acceptance of the trauma center’s job characteristics. The supervisor should check periodically whether there is any stress related to the work environment and continue to try to find strategies to decrease it.

SOCIAL SUPPORT FROM SUPERVISOR/MANAGER

STS was theorized to be associated with social support from family and friends, coworkers, and supervisors/managers. Of these, only supervisors’ support appeared to be a factor influencing STS in the present study. Unlike family, friends, and colleagues, the supervisor can empathize and support nurses with STS. Administrators, managers, and supervisors should be more engaged in developing practical strategies for reducing STS of nurses. They must engage nurses under stress in discussions on the consequences of such stress and how they cope with it. Management should engage in pro- fessional support teams and conduct regular mental health and well-being checkups.

Limitations

This is a cross-sectional study using convenience sampling. Under- or over-representation of the population with a response bias is possible. The results are impacted upon

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by the limited number of regional trauma centers that participated. Although 13 such centers were officially opened in 2018, they continually bolstered their systems to- ward effective patient care, with trauma specialists and trauma nurses being recruited. This allowed nurses to focus on training novice nurses in establishing nursing systems. This could have contributed to the low participation in this study. Thus, more cross-sectional studies with random sampling or longitudinal studies are recommended.

Some instruments used in this study reported less than 0.8 of Cronbach’s a scores. A low a value could be caused by a low number of questions, poor inter- relatedness between items, or various constructs. We believe the reason for the low Cronbach’s a scores is related to the number of items in the scales. For example, only 6 items are utilized to measure the problem-focused stress-coping style. In addition, translation may be a problem. Instruments were translated into Korean from English, and despite our controls for cross-cultural research of back-translation, some problems of equivalence in translation may exist, such as vocabulary, idioms, grammar and syntax, varied experience, and conceptual equivalences. Further studies may be required to analyze the reliability of the Korean versions of the instruments. The research tool utilized in this study did not reflect the degree of shock experienced by nurses due to the scoring method that calculates the total score by merely adding the frequency of each traumatic event. Each trauma case also differs in severity. Future measures will need to be developed to reflect the frequency and severity of traumatic events experienced by nurses.

However, this study is meaningful as it is the first study in Korea to investigate STS levels and the factors influencing it in regional trauma center nurses. Further studies consid- ering other possible factors, such as empathy or resilience, are needed to provide a better understanding of STS among nurses working in regional trauma centers.

Implications for Emergency Nursing

This study was conducted among nurses working in the emergency room and the intensive care unit of the regional trauma center. There was no difference in STS according to the workplace. The STS of the nurses in the study was higher than previously reported.13,43 Moderate to severe levels also account for a high percentage of participants (84.4% ) at or above the cutoff score of 38. This indicated that various interventions, including counseling andmedita- tion programs, should be implemented to promote the man- agement of nurses’ STS. Along with an individual approach

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to engaging in stress management programs, a mutually supporting workplace culture is required. In addition, the nursing administrators should consider regular mental health evaluations of those nurses exposed to traumatic events. As the Korean government is gradually increasing the number of regional trauma centers, it is necessary to continue to understand and mitigate STS of nurses for nursing workforce recruitment, retention, and well-being.

Conclusions

This study showed that type D personality, dysfunctional coping, problem-focused coping, desire to change jobs and social support from supervisors were the factors associ- ated with STS of nurses at regional trauma centers. Conse- quently, we suggest the development and application of STS management interventions based on the factors of STS. Per- sonality traits of individuals do not easily change. To reduce STS of trauma nurses, personal efforts to participate in con- sultations with specialists and relaxation therapy are needed to reduce negative affectivity and social inhibition. Along with personal efforts, it will also be necessary to build a workplace culture that encourages and supports participa- tion in these programs. Workplace culture promotion pro- grams maymitigate STS. Additionally, nurses in supervisory or administrative roles should support nurses’ requests for transfer to other departments. Enhanced social support from supervisors should also be considered. As trauma cen- ter services expand in South Korea, the importance of un- derstanding and mitigating nurse STS is imperative.

Author Disclosures

Conflicts of interest: none to report.

Acknowledgments

We would like to thank the nurses who participated in the study.

REFERENCES 1. Statistics Korea. Causes of death statistics in 2018. Published October 15,

2020. Accessed September 23, 2019. http://kostat.go.kr/portal/korea/ index.action

2. National Emergency Medical Center. Korean trauma databank statistical yearbook. Accessed April 4, 2020. https://www.e-gen.or.kr/nemc/ statistics_annual_report.do?brdclscd04

3. Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. In: Stamm BH, ed. Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators. The Sidran Press; 1995:3-28

May 2021 VOLUME 47 � ISSUE 3

4. Gale K, Flannelly KJ, Greene PB, Kudler T. Burnout, secondary traumatic stress, and social support. Pastoral Psychol. 2011;60(5):633- 649. https://doi.org/10.1007/s11089-011-0346-7

5. Missouridou E. Secondary posttraumatic stress and nurses’ emotional responses to patient’s trauma. J Trauma Nurs. 2017;24(2):110-115. https://doi.org/10.1097/jtn.0000000000000274

6. Mealer M, Jones J. Posttraumatic stress disorder in the nursing population: a concept analysis. Nurs Forum. 2013;48(4):279-288. https://doi.org/10.1111/nuf.12045

7. Von Rueden KT, Hinderer KA, McQuillan KA, et al. Secondary traumatic stress in trauma nurses: prevalence and exposure, coping, and personal/environmental characteristics. J Trauma Nurs. 2010;17(4):191-200. https://doi.org/10.1097/JTN.0b013e3181ff2607

8. Gentry JE, Baranowsky AB, Dunning K. The accelerated recovery program (ARP) for compassion fatigue. In: Figley CR, ed. Psychosocial Stress Series, No. 24. Treating Compassion Fatigue. Brunner-Routledge; 2002:123-137.

9. Crabbe JM, Bowley DM, Boffard KD, Alexander DA, Klein S. Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims. Emerg Med J. 2004;21(5):568-572. https:// doi.org/10.1136/emj.2003.008540

10. Manning-Jones S, de Terte I, Stephens C. The relationship between vicarious posttraumatic growth and secondary traumatic stress among health professionals. J Loss Trauma. 2017;22(3):256-270. https:// doi.org/10.1080/15325024.2017.1284516

11. Aisling M, Aisling D, David C. An assessment of psychological need in emergency medical staff in the northern health and social care trust area. Ulster Med J. 2016;85(2):92-98.

12. Morrison LE, Joy JP. Secondary traumatic stress in the emergency department. J Adv Nurs. 2016;72(11):2894-2906. https://doi.org/ 10.1111/jan.13030

13. Ratrout HF, Hamdan-Mansour AM. Secondary traumatic stress among emergency nurses: prevalence, predictors, and consequences. Int J Nurs Pract. 2020;26(1):e12767. https://doi.org/10.1111/ ijn.12767

14. Jakimowicz S, Perry L, Lewis J. Compassion satisfaction and fatigue: a cross-sectional survey of Australian intensive care nurses. Aust Crit Care. 2018;31(6):396-405. https://doi.org/10.1016/ j.aucc.2017.10.003

15. Christodoulou-Fella M, Middleton N, Papathanassoglou EDE, Karanikola MNK. Exploration of the association between nurses’ moral distress and secondary traumatic stress syndrome: implications for patient safety in mental health services. BioMed Res Int. 2017:1908712. https:// doi.org/10.1155/2017/1908712

16. Kintzle S, Yarvis JS, Bride BE. Secondary traumatic stress in military primary and mental health care providers. Mil Med. 2013;178(12):1310-1315. https://doi.org/10.7205/MILMED-D-13- 00087

17. Quinal L, Harford S, Rutledge DN. Secondary traumatic stress in oncology staff. Cancer Nurs. 2009;32(4):E1-E7. https://doi.org/ 10.1097/NCC.0b013e31819ca65a

18. Hinderer KA, von Rueden KT, Friedmann E, et al. Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma

WWW.JENONLINE.ORG 409

RESEARCH/Woo and Kim

nurses. J Trauma Nurs. 2014;21(4):160-169. https://doi.org/10.1097/ JTN.0000000000000055

19. Baird S, Jenkins SR. Vicarious traumatization, secondary traumatic stress, and burnout in sexual assault and domestic violence agency staff. Violence Vict. 2003;18(1):71-86. https://doi.org/10.1891/ vivi.2003.18.1.71

20. Creamer TL, Liddle BJ. Secondary traumatic stress among disaster mental health workers responding to the September 11 attacks. J Trauma Stress. 2005;18(1):89-96. https://doi.org/10.1002/jts.20008

21. Ewer PL, Teesson M, Sannibale C, Roche A, Mills KL. The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug Alcohol Rev. 2015;34(3):252-258. https://doi.org/10.1111/dar.12204

22. Hensel JM, Ruiz C, Finney C, Dewa CS. Meta-analysis of risk factors for secondary traumatic stress in therapeutic work with trauma victims. J Trauma Stress. 2015;28(2):83-91. https:// doi.org/10.1002/jts.21998

23. Kunst MJ, Bogaerts S, Winkel FW. Type D personality and posttrau- matic stress disorder in victims of violence: a cross-sectional exploration. Clin Psychol Psychother. 2011;18(1):13-22. https://doi.org/10.1002/ cpp.698

24. Rademaker AR, van Zuiden M, Vermetten E, Geuze E. Type D personality and the development of PTSD symptoms: a prospective study. J Abnorm Psychol. 2011;120(2):299-307. https://doi.org/ 10.1037/a0021806

25. Ivicic R, Motta R. Variables associated with secondary traumatic stress among mental health professionals. Traumatology. 2017;23(2):196-204. https://doi.org/10.1037/trm0000065

26. Adriaenssens J, de Gucht V, Maes S. The impact of traumatic events on emergency room nurses: findings from a questionnaire survey. Int J Nurs Stud. 2012;49(11):1411-1422. https://doi.org/10.1016/j.ijnur- stu.2012.07.003

27. Denollet J. DS14: standard assessment of negative affectivity, social inhi- bition, and type D personality. Psychosom Med. 2005;67(1):89-97. https://doi.org/10.1097/01.psy.0000149256.81953.49

28. Kim YH, Kim SR, Kim YO, Kim JY, Kim HK, Kim HY. Influence of type D personality on job stress and job satisfaction in clinical nurses: the mediating effects of compassion fatigue, burnout, and compassion satisfaction. J Adv Nurs. 2017;73(4):905-916. https://doi.org/10.1111/ jan.13177

29. Endler NS, Parker JD. Assessment of multidimensional coping: task, emotion, and avoidance strategies. Psychol Assess. 1994;6(1):50-60. https://doi.org/10.1037/1040-3590.6.1.50

30. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. Springer; 1984

31. Ratrout HF, Hamdan-Mansour AM. Factors associated with secondary traumatic stress among emergency nurses: an integrative review. Open J Nurs. 2017;07(11):1209-1226. https://doi.org/10.4236/ ojn.2017.711088

32. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res

410 JOURNAL OF EMERGENCY NURSING

Methods. 2009;41(4):1149-1160. https://doi.org/10.3758/ brm.41.4.1149

33. Bride BE, Robinson MM, Yegidis B, Figley CR. Development and validation of the secondary traumatic stress scale. Res Soc Work Pract. 2004;14(1):27-35. https://doi.org/10.1177/1049731503254106

34. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35(6):382-385. https://doi.org/10.1097/00006199- 198611000-00017

35. Bride BE. Prevalence of secondary traumatic stress among social workers. Soc Work. 2007;52(1):63-70. https://doi.org/10.1093/sw/52.1.63

36. Lim HE, Lee MS, Ko YH, et al. Assessment of the type D personality construct in the Korean population: a validation study of the Korean DS14. J Korean Med Sci. 2011;26(1):116-123. https://doi.org/ 10.3346/jkms.2011.26.1.116

37. Kim HJ, Choi HJ. Emergency nurses’ professional quality of life: compassion satisfaction, burnout, and secondary traumatic stress. J Korean Acad Nurs Adm. 2012;18(3):320-328. https://doi.org/ 10.11111/jkana.2012.18.3.320

38. Carver CS. You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med. 1997;4(1):92-100. https:// doi.org/10.1207/s15327558ijbm0401_6

39. Joo S. A Study of PTSD of the Subway Operators With the Experience of Per- son Under Train Incidents. Master’s thesis. 2009. Ewha Womans Univer- sity. Accessed May 10, 2019. http://dcollection.ewha.ac.kr/public_ resource/pdf/000000054326_20200514141350.pdf

40. Joseph S, Andrews B, Williams R, Yule W. Crisis support and psychiatric symptomatology in adult survivors of the Jupiter cruise ship disaster. Br J Clin Psychol. 1992;31(1):63-73. https://doi.org/10.1111/j.2044- 8260.1992.tb00968.x

41. Ko YB. The Influence Factors of Secondary Traumatic Stress of Child Protec- tive Service Workers. Master’s thesis. Ewha Womans University; 2008. Accessed May 10, 2019. https://dcollection.ewha.ac.kr/public_ resource/pdf/000000049663_20200514141925.pdf

42. Baruch-Feldman C, Brondolo E, Ben-Dayan D, Schwartz J. Sources of social support and burnout, job satisfaction, and productivity. J Occup Health Psychol. 2002;7(1):84-93. https://doi.org/10.1037//1076- 8998.7.1.84

43. Caesens G, Stinglhamber F, Luypaert G. The impact of work engagement and workaholism on well-being: the role of work-related social support. Career Dev Int. 2014;19(7):813-835. https://doi.org/10.1108/CDI-09- 2013-0114

44. Duffy E, Avalos G, Dowling M. Secondary traumatic stress among emergency nurses: a cross-sectional study. Int Emerg Nurs. 2015;23(2):53-58. https://doi.org/10.1016/j.ienj.2014.05.001

45. Cho GJ, Kang J. Type D personality and post-traumatic stress disorder symptoms among intensive care unit nurses: the mediating effect of resilience. PLoS One. 2017;12(4):1-10. https://doi.org/10.1371/journal.- pone.0175067

46. Geuens N, Braspenning M, van Bogaert P, Franck E. Individual vulner- ability to burnout in nurses: the role of Type D personality within

VOLUME 47 � ISSUE 3 May 2021

Woo and Kim/RESEARCH

different nursing specialty areas. Burn Res. 2015;2(2-3):80-86. https:// doi.org/10.1016/j.burn.2015.05.003

47. Williams L, Wingate A. Type D personality, physical symptoms and subjective stress: the mediating effects of coping and social support. Psychol Health. 2012;27(9):1075-1085. https://doi.org/10.1080/ 08870446.2012.667098

48. Mols F, Denollet J. Type D personality in the general population: a sys- tematic review of health status, mechanisms of disease, and work-related problems. Health Qual Life Outcomes. 2010;8:9. https://doi.org/ 10.1186/1477-7525-8-9

49. Williams L, O’Connor RC, Howard S, et al. Type-D personality mech- anisms of effect: the role of health-related behavior and social support. J Psychosom Res. 2008;64(1):63-69. https://doi.org/10.1016/j.jpsy- chores.2007.06.008

50. Pelle AJ, van den Broek KC, Denollet J. Interventions in the context of the distressed (Type D) personality. In: Dornelas EA, ed. Stress Proof

May 2021 VOLUME 47 � ISSUE 3

the Heart: Behavioral Interventions for Cardiac Patients. Springer Science þ Business Media; 2012:167-197.

51. Kim SJ, Yeo JH. Factors affecting posttraumatic stress disorder in South Korean trauma nurses. J Trauma Nurs. 2020;27(1):50-57. https:// doi.org/10.1097/JTN.0000000000000482

52. Dewe P. A closer examination of the patterns when coping with work-related stress: implications for measurement. J Occup Organ Psychol. 2003;76:517-524. https://doi.org/10.1348/ 096317903322591613

53. Tennen H, Affleck G, Armeli S, Carney MA. A daily process approach to coping: linking theory, research, and practice. Ann Psychol. 2000;55(6):626-636. https://doi.org/10.1037//0003-066x.55.6.626

54. Hamama-Raz Y, Minerbi R. Coping strategies in secondary traumatiza- tion and post-traumatic growth among nurses working in a medical rehabilitation hospital: a pilot study. Int Arch Occup Environ Health. 2019;92(1):93-100. https://doi.org/10.1007/s00420-018-1354-z

WWW.JENONLINE.ORG 411