SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES 8
Secondary Traumatic Stress in Emergency Room Nurses
Jenna Ruimveld
Ferris State University
SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES 8
Abstract
Secondary traumatic stress (STS) is defined as “the emotions and behaviors that a person experiences as a result of being exposed to another person’s traumatic experience” (Von Rueden et al., 2012, p. 191). Many nursing staff experience STS, especially in those who work closely with trauma victims. The symptoms associated with STS can affect the personal and professional lives of nurses, influencing the quality and safety of patient care. This paper summarizes research regarding secondary traumatic stress; prevalence, risks, and prevention. Theories relating to secondary traumatic stress are described including Betty Neuman’s Systems Theory and Maslow’s Hierarchy of Needs. The healthcare environment is assessed, including current policies as well as consequences at a multidisciplinary level if this issue continues to occur. Recommendations are then made, guided by research as well as the American Nurses Association (ANA) standards of professional practice, as well as QSEN competencies; Knowledge, Skills, and Attitudes. Secondary traumatic stress is not a well known topic among healthcare workers and it needs to be addressed at all levels of care, in order to improve not only patient care but to protect nurses as well.
SECONDARY TRAUMATIC STRESS IN EMEREGENCY ROOM NURSES 8
Secondary Traumatic Stress in Emergency Room Nurses
The issue of secondary traumatic stress and the effects it can have on healthcare is a significant, yet understated topic. Secondary traumatic stress differs from posttraumatic stress disorder (PTSD) in that STS is a result of being exposed to a person’s traumatic experience, whereas posttraumatic stress disorder is caused by personally experiencing a traumatic event (Von Rueden et al., 2012). Similar to post-traumatic stress disorder, STS is associated with a range of physical and mental symptoms including insomnia, avoidance, anxiety, anger, inability to concentrate, irritability, and distressing dreams (Czaja, Moss, & Mealer, 2012). These symptoms have a direct impact on the personal and professional lives of nurses, putting not only themselves, but patients at risk as well.
Laposa, Alden, and Fullerton (2003) identified the events that most often lead to the development of STS in ER nurses:
(1) Providing care to a patient who is a relative or close friend and is dying or in serious condition, (2) Threatened physical assault of self, (3) Multiple trauma with massive bleeding or dismemberment, (4) Death of a child, (5), Providing care to a traumatized patient who resembles yourself or family member in age or appearance, (6) caring for a severely burned patient (p. 26, table 3).
Secondary traumatic stress affects emergency room (ER) nurses more frequently than other areas of nursing due to the high volume of traumatized patients. However it is not limited to ER nurses; STS can be seen in many of the different units and specialties within nursing such as critical care, oncology, pediatrics, neonatal intensive care units, surgery, and labor and delivery (Beck, 2011). Looking beyond just nursing, STS also has the potential to effect social workers, doctors, managers, and nursing aides, meaning that it is a problem that occurs in all realms of healthcare and therefore needs to be addressed with a multidisciplinary approach. The purpose of this paper is to analyze literature regarding secondary traumatic stress and the issues that it poses to nursing as a profession, and to provide recommendations to reduce the impact of STS.
Theory Base
Theories are the foundation for nursing practice driving the profession to constantly improve. Nursing theories are not only applicable to nurses, just as psychology theories are not just relevant to psychologists. Rather there is a sharing of information, theories, and ideas between professions. Neuman Systems Model and Maslow’s Hierarchy of Needs both can be applied to secondary traumatic stress. They have shared principles regarding stress and health as well as values in self-care and understanding the important role that health plays in life.
Newman Systems Model
Newman Systems Model, a nursing theory developed by Betty Neuman, focuses on an individual’s response to stress and stressful environments (Toto, Peters, Blackman, & Hoch, 2009). Like thumbprints, no two people are the same. A person’s stress is a constant changing state and the responses and reactions to stress are subjective to the one experiencing them. Stability is a term used in this theory, defined as “a state of balance of harmony requiring energy exchanges as the client adequately copes with stressors to retain, attain, or maintain an optimal level of health thus preserving system integrity” (Current Nursing, 2014). In order to maintain this stability, Neuman’s Systems Model suggests that this role falls upon that of the nurse, “…nurses can assist in preventing a stress response through primary prevention or help in adjusting to the stress response through secondary and tertiary prevention” (Gunusen, Ustun, & Gigliotti, 2009, p. 200).
The threat to one’s stability or a stress response can be normal or abnormal. Emergency room nurses who frequently work with traumatized patients work in a stressful environment; because of this they are already at risk for deviating from stability. Nurses suffering from secondary traumatic stress have surpassed their capacity for stress and their needs are to be addressed with secondary and tertiary prevention methods. “The desired outcome of a primary, secondary, and tertiary intervention is to retain, attain, and maintain balance and stability in the client system” (Toto et al., 2009, p. 111). In summary, the Neuman Systems Model applies to secondary traumatic stress in that it correlates environmental stress and stress response; for example symptoms of STS. It also discusses the different levels of prevention and treatment, primary, secondary, and tertiary, when caring for clients in whom a stress response can be identified.
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs is a psychology-based theory created by Abraham Maslow (Poston, 2009). Like many theories, it is applicable to more than one discipline, but most importantly in healthcare and the assessment of a patient’s needs. There are five main aspects of his theory that make up stages of needs in the form of a pyramid: physiological, safety, love and belonging, self-esteem, and self-actualization (Poston, 2009). Basic human needs must be met in order for someone to rise higher and towards self-actualization. When the stage of self-actualization has been reached, resilience to stress and stressors will also have formed.
STS is a stressor that potentially affects the needs and stage in which a person is located. When there is a threat to safety, emotional and physical safety needs are not being met. The ability to recognize this need internally requires reflection and self-assessment. Nurses who are experiencing symptoms of STS need to recognize their personal needs in order to move towards self-actualization and constantly strive towards the top of the pyramid.
Health Care Environment Assessment
The healthcare environment is not simply the context in which a nurse works. Like any environment, a healthcare environment is influenced by numerous factors and when assessing it, policies (governmental and institutional), resources, and quality and safety issues, must be considered. Secondary traumatic stress is a product of a poor healthcare environment, leading to personal and professional mishaps in nurses.
Secondary traumatic stress is prevalent in many ER nurses;“…85% reported at least 1 STS symptom in the past week. Very concerning is the fact that 33% of the sample met the criterion for a diagnosis of STS” (Dominguez-Gomez & Rutledge, 2009, p. 203).
Systems Framework
Government . Government support is a need for many issues in nursing; it is needed most to protect healthcare workers. Currently, there are many policies and governmental aids for those who have undergone a traumatic event, but no support for those who are treating them. The Employee Assistance Program (EAP) is a federal program that provides assistance such as counseling, legal and financial services, and more, to workers when facing troubling times (U.S. Department of Health and Human Services, 2014). These services are limited to federal employees only.
The Occupational Safety and Health Administration (OSHA), a governmental agency aimed at enforcing occupational health and safety laws, does not have any enforceable regulation or protocol for hospitals to follow after a traumatic event has occurred. Instead, they provide educational guides for supervisors and managers to follow after a crisis or traumatic event has occurred (OSHA, 2014).
Healthcare Organization . The healthcare organization is responsible for its staff and protecting their safety should be a priority. Magnet hospitals are becoming more of a trend through the United States. Magnet hospitals are organizations that have been recognized for their outstanding efforts towards patient and nursing care; “The Magnet Recognition Program recognizes health care organizations for quality patient care, nurse excellence and innovations in professional nursing practice” (American Nursing Credentialing Center [ANCC], 2014). According to the ANCC (2014), Magnet recognized hospitals follow the Forces of Magnetism, which are 14 characteristics the hospital has including “organizational structure and interdisciplinary relationships”. Because of these characteristics Magnet hospitals possess, they have a greater value of their nursing staff and are dedicated to constantly improve.
Organizations do not always have to be required by accreditation to put the needs of their nursing staff first. Bronson hospital a local hospital in Kalamazoo, Michigan, also puts the needs of the hospital staff following a crisis. According to Liz Colson, a Bronson Staff member, Bronson has a crisis debriefing services for staff that is delivered by the Bronson Crisis Debriefing Team. Staff volunteers from different areas of the hospital provide this service. The Crisis Debriefing Team consists of 25 employees trained in Critical Incident Stress Management and all of the services they provide are available at all times and dates to all units or departments. The debriefings are confidential and voluntary (L. Colson, personal communication, June 12, 2014).
Quality and Safety Issues
Secondary traumatic stress affects all aspects of life, both professionally and personally. These affects can have significant outcomes in quality and safety of both nursing and patient care. It is important for nurses to understand secondary traumatic stress and take action if or when symptoms begin to arise. This is assumption can be made regarding this topic; that nurses have an understanding of secondary traumatic stress and how to cope with traumatic events in the ER, however this is not the case. In fact many nurses have not even heard about secondary traumatic stress or how it can affect their lives.
Personal effects of STS. Work stress and trauma can overflow into the personal lives of nurses, especially those suffering with STS. Secondary traumatic stress can cause a range of symptoms all having an impact on the home lives of nurses, not just related to sleep, “... include an altered worldview and changes in psychological and emotional needs, trust and dependence, control, intimacy self esteem, altered beliefs and cognitions, and sense of safety that parallel those of post traumatic stress disorder (PTSD)” (Tabor, 2011, p. 203). Strains in personal relationships may begin to form, ultimately completing the circle and affecting job performance.
Patient c are. Quality and safety is a major aspect of patient care. It is the role of the nurse to provide each patient with the highest standard of care possible and in the safest way possible. One of the main symptoms of secondary traumatic stress is the inability to concentrate. In the emergency room, or a nursing setting, concentration and focus is key. Lack of concentration can lead to medication errors, higher risk of infections, and ultimately putting the lives of patients at risk as well as increase hospital costs.
Inferences/Implications/Consequences
Assessment of the healthcare environment initially may lead to believe there is adequate support and knowledge regarding secondary traumatic stress in nursing. There are specific examples of hospitals supporting their employees through difficult times however this is not a common trait among all organizations. The lack of legislative policy regarding the protection and prevention of secondary traumatic stress in nursing is potentially putting many staff at risk for this stress disorder. Healthcare is such a consumer driven product that nurses get lost in the numbers. Magnet hospitals clearly value nursing as a profession and are dedicated to support their staff, as well as hospitals that offer debriefing and counseling following a traumatic event. The healthcare environment needs to be positive and uplifting, with support from peers as well as management. All of these things can lead to a work environment of caring, which is what the nursing profession is about.
Consequences
If there is a continuation of lack of support and education for staff following a traumatic event, significant outcomes or complications may occur. Secondary traumatic stress can lead to many work related issues for many nurses. Czaja et al. (2012) concluded that the presences of PTSD and STS can lead nurses to feeling symptoms related to compassion fatigue, burnout, job dissatisfaction, and even be the cause of nursing turnover rates in many emergency rooms. Nursing turnover can cost the hospitals and nursing staff as a whole. A quick turnover rate can lead to a decrease in staff, ultimately resulting in increased patient workload for many nurses leading way to medication errors, increased risk for falls, and a decrease in patient satisfaction.
The entire system is a constant balance and shift; all of the factors are dependent upon one another. Patient satisfaction is dependent on nursing care, nursing care is dependent on job satisfaction, and job satisfaction is dependent on work environment and so on. It can be assumed with an equal balance between the factors associated with secondary traumatic stress, increased resilience and better patient outcomes can be achieved.
Recommendations for Quality and Safety
Secondary traumatic stress directly and indirectly affects patient quality and safety. The prevention and treatment of secondary traumatic stress does not just fall upon the nurse, but the environment and organization as well. Strategies to implement within the healthcare environment are discussed.
Debriefing
Critical Incident Stress Debriefing is a tool that can be utilized in all professions after a crisis. During debriefing, which is usually voluntary, members of the group meet and share their experiences and inform one another about the situation (Hanna & Romana, 2007). Hanna and Romana (2007) also describe the role of the group leader as gathering facts and staff reaction as well as the symptoms staff are experiencing or exhibiting. The leader also educates group members about positive coping strategies and at the end of the meeting recommendations for follow up and individual counseling are made to those who show obvious signs of secondary traumatic stress (p. 41). Research has shown it can have a positive effect on nursing. “There were trends for those who attended critical incident stress debriefing. They tended to report feeling more supported by their hospital administration and to report less interpersonal conflict” (Laposa, Alden, & Fullerton, 2003, p. 27).