RESEARCH
PREVALENCE OF SECONDARY TRAUMATIC
STRESS AMONG EMERGENCY NURSES
Authors: Elvira Dominguez-Gomez, RN, BSN, and Dana N. Rutledge, RN, PhD, Hemet and Fullerton, CA
Earn Up to 8 CE Hours. See page 273.
Introduction: Emergency nurses often care for persons exposed
to traumatic events. In the presence of empathetic caring, nurses
exposed to such stressors over time can suffer from Secondary
Traumatic Stress (STS), or Compassion Fatigue (CF). STS
symptoms (intrusion, avoidance, and arousal) may lead to job
dissatisfaction or burnout. The purpose of this study is to
investigate the prevalence of STS in emergency nurses.
Methods: Exploratory comparative design, with 67 emergency
nurses from three general community hospitals in California. Survey
instruments included a demographic tool and the STS Survey (STSS).
Results: Nurses were most likely to have Arousal symptoms
(irritability reported by 54% of nurses), followed by Avoidance
symptoms (avoidance of patients 52%), and Intrusion symptoms
(intrusive thoughts about patients 46%). The majority of nurses
(85%) reported at least one symptom in the past week. Utilizing
Bride’s algorithm to identify STS, 15% of nurses met no criteria,
while 33% met all. Nurse participation in stress management
activities was associated with less prevalence of STS symptoms.
Discussion: High prevalence of STS in our sample indicates that
potentially large numbers of emergency nurses may be experiencing
the negative effects of STS. Symptoms may contribute to emotional
exhaustion and job separation of emergency nurses. Subsequent
studies should be done to evaluate the association of CF/STS on
actual burnout and attrition among emergency nurses.
E
xposure to human suffering by nurses is common
in the emergency department. On any day, emer-
gency nurses care for an array of patients, varying
in age, injury, and disease process. They commonly see
patients with injuries sustained in motor vehicle crashes,
Elvira Dominguez-Gomez, Inland Empire Chapter, is Emergency Department
Nurse, Hemet Valley Medical Center, Hemet, CA.
Dana N. Rutledge is Associate Professor, Nursing, California State University,
Fullerton, CA.
For correspondence, write: Elvira Dominguez-Gomez, 4520 Cloudywing Rd,
Hemet, CA 92545; E-mail: e.dominguez-gomez@att.net.
J Emerg Nurs 2009;35:199-204.
Available online 15 July 2008.
0099-1767/$36.00
Copyright © 2009 by the Emergency Nurses Association. Published by Elsevier
Inc. All rights reserved.
doi: 10.1016/j.jen.2008.05.003
May 2009 35:3
assaults, rapes, and abuse and from gunshot wounds. Emer-
gency nurses may experience negative repercussions after
caring for these types of patients with the cumulative effect
of chronic exposure to patients in physical or psycho-
logical distress, in conjunction with an empathetic response.1,2
A potential consequence of such “caring” work is a
negative and profound effect on nurses’ health that is some-
times referred to as compassion fatigue (CF) or secondary trau-
matic stress (STS).1,3-5 CF was first described as “a unique
form of burnout,” where people in the caregiving profes-
sions are the most susceptible.6 The concept was further
developed as the emotional stress experienced (nurse) from
the trauma of another (patient)7 and has been described as
the “emotional residual” of working with people who are
suffering or traumatized.8 Both STS and CF refer to expo-
sure to a person or persons who are traumatized or suffer-
ing rather than exposure to a traumatic event itself. Sabo1
posits that CF has an acute onset and results from caring
for people who are suffering rather than a toxic work envi-
ronment. It may occur after multiple interactions with
“traumatized and troubled” patients, resulting from the
desire to help the traumatized persons.7
STS is a term that was used previously in non-nursing
disciplines, such as social work, and reflects the emotional
disequilibrium resulting from close contact with persons
who are victims of trauma.7,9 Defined as the presence of
post-traumatic stress disorder (PTSD) symptoms in the
caregiver, STS results from a combination of the caregivers’
own previous traumatic experiences and the experiences of
their patients.2,7 STS may occur after daily exposure to
traumas in conjunction with the empathetic response.10
In this study CF and STS disorder are used inter-
changeably, with persons suffering from symptoms identi-
cal to those in PTSD11,12 (but only differing by exposure),
based on the American Psychological Association’s defini-
tion of traumatic stress disorders.
Related terms are vicarious traumatization and burn-
out. Vicarious traumatization refers to an empathetic en-
gagement with trauma suffered by persons cared for that
alters providers’ “inner experience”5 and implies a negative
and potentially permanent impact over time. Burnout is
defined as a “syndrome of emotional exhaustion, deperson-
alization, and reduced personal accomplishment …,”13
JOURNAL OF EMERGENCY NURSING 199
 RESEARCH/Dominguez-Gomez and Rutledge

referring to a gradual wearing down of an individual provider

because of imbalance between expected and actual work ex- TABLE 1
periences.1 Nelson-Gardell and Harris imply that burnout is Demographic and professional characteristics of
the presence of symptoms such as fatigue, irritability, indif- emergency RNs responding to STSS survey (N = 67)
ference, and poor work performance related to organiza- n Mean SD %
tional issues.10 All of these terms reflect a potential impact Age 61 42.62 y 10.05 y
on nurses related to caregiving that comes from their em- Experience 57 13.96 y 10.38 y
pathetic interactions with suffering or traumatized patients. Time worked per week 61 41.03 h 7.07 h
Little is known about the effects nurses experience Gender
when caring for patients and their families who are expe- Female 52 77.6
riencing suffering or trauma, especially day after day. With Male 14 20.9
STS, health care providers may experience PTSD symp- Ethnicity
toms, a combination of caregivers’ own traumatic expe- White 50 74.6
riences and the experiences of their patients.2,7,14,15 STS Hispanic/Latino 9 13.4
is related to CF but does not have an acute onset, as Asian 5 7.5
described by Sabo.1 High levels of STS may lead to nurse Other 2 3.0
burnout and job turnover or separation from nursing.2,4 Primary position
There has been no quantitative exploration of STS in Direct patient care/staff 55 82.1
emergency nurses. Therefore the purpose of this study was Nurse manager 3 4.5
to explore the prevalence of STS in a group of emergency Clinical nurse specialist 2 3.0
nurses in Southern California. Other 1 1.5

Methods
An exploratory comparative study was conducted at a
health care system (3 general community hospitals located
in rural Southern California), after approval by health sys-
tem administration and the university institutional review
board was obtained. According to the Office of Statewide
Health Planning and Development, emergency cases for
each of the facilities ranged from approximately 19,873
to 38,164 in 2006.16 At these sites, 111 study packets were
distributed to mailboxes of registered nurses (RNs) em-
ployed in emergency departments. Nurses sought were
actively employed RNs with a minimum of 6 months’
experience in the emergency department. The basis for
the exclusion of inexperienced emergency RNs was that
they may not yet have experienced enough repeated expo-
sure to traumatic events that contribute to the development
of STS. To ensure anonymity, data submission was by mail
or to a designated ED mailbox.
During recruitment, posters with a description of the
study were posted in nurses’ lounges. Reminder postcards
were placed in the emergency nurse’s mailboxes at 2 and
4 weeks. Packets contained an invitation to participate, a
self-addressed stamped envelope, a demographic sheet,
and the Secondary Traumatic Stress Scale (STSS).
DEMOGRAPHIC SHEET
Created by the first author, this questionnaire provided
basic demographics: gender, age, ethnicity, educational
background/degree, years in nursing practice, typical work
hours, and primary employment position (Table 1). Addi-
tional items included whether the emergency nurse had
ever sought assistance for work-related stress or participated
in stress management/self-care activities.
SECONDARY TRAUMATIC STRESS SCALE
The STSS is a self-report tool developed to measure STS
in health care workers (Table 2).9 The STSS uses 17 items
to evaluate the frequency of symptoms among 3 subscales:
intrusion (5 items), avoidance (7 items), and arousal (5 items).
These 3 subscales and the 17 items correspond with cri-
teria B, C, and D in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV) (2000) nec-
essary for PTSD diagnosis.12,17 Criterion A is identified as
the moment of “exposure” to the event, where the person
“experienced, witnessed, or was confronted with an event
that involved actual or threatened death or serious injury”
and the subsequent response of the person was that of
“intense fear, helplessness, or horror.”12 Criterion B is
described as the person “re-experiencing” the traumatic
event (intrusion), whereas criterion C is the persistent
avoidance of stimuli related to the traumatic event or
“numbing” of the person’s usual interests (avoidance). Cri-
terion D is described as persistent symptoms of heightened
arousal or agitation (arousal). Bride et al9 used the criteria
identified in the DSM-IV and developed 3 subscales to

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 RESEARCH/Dominguez-Gomez and Rutledge

TABLE 2
Frequency of STS symptoms reported by emergency RNs (N = 67)
Never Rarely Occasionally Often Very often
Criterion (item No.) [n (%)] [n (%)] [n (%)] [n (%)] [n (%)] Mean SD
Criterion B: Intrusion symptoms
Intrusive thoughts about clients (10) 13 (19.4) 22 (32.8) 21 (31.3) 8 (11.9) 2 (3.0) 2.45 1.04
Disturbing dreams about clients (13) 33 (49.3) 16 (23.9) 14 (20.9) 2 (3.0) — 1.77 0.89
Sense of reliving clients’ trauma (3) 32 (47.8) 19 (28.4) 12 (17.9) 2 (3.0) — 1.75 0.87
Cued psychological distress (6) 15 (22.4) 33 (49.3) 15 (22.4) 3 (4.5) — 2.09 0.79
Cued physiological reaction (2) 27 (40.3) 27 (40.3) 9 (13.4) 2 (3.0) 1 (1.5) 1.83 0.89
Criterion C: Avoidance symptoms
Avoidance of clients (14) 11 (16.4) 20 (29.9) 18 (26.9) 13 (19.4) 4 (6.0) 2.68 1.15
Avoidance of people, places, and things (12) 32 (47.8) 17 (25.4) 7 (10.4) 9 (13.4) 1 (1.5) 1.94 1.13
Inability to recall client information (17) 30 (44.8) 23 (34.3) 9 (13.4) 3 (4.5) 1 (1.5) 1.82 0.94
Diminished activity level (9) 18 (26.9) 18 (26.9) 20 (29.9) 9 (13.4) — 2.31 1.03
Detachment from others (7) 25 (37.3) 23 (34.3) 13 (19.4) 4 (6.0) 1 (1.5) 1.98 0.98
Emotional numbing (1) 16 (23.9) 21 (31.3) 19 (28.4) 8 (11.9) 2 (3.0) 2.38 1.08
Foreshortened future (5) 19 (28.4) 24 (36.8) 14 (20.9) 7 (10.4) 2 (3.0) 2.23 1.08
Criterion D: Arousal symptoms
Difficulty sleeping (4) 10 (14.9) 21 (31.3) 15 (22.4) 15 (22.4) 5 (7.5) 2.76 1.19
Irritability (15) 10 (14.9) 19 (28.4) 19 (28.4) 10 (14.9) 7 (10.4) 2.77 1.21
Difficulty concentrating (11) 11 (16.4) 30 (44.8) 20 (29.9) 4 (6.0) 1 (1.5) 2.30 0.88
Hypervigilance (16) 19 (28.4) 26 (38.8) 15 (22.4) 5 (7.5) 1 (1.5) 2.14 0.97
Easily startled (8) 32 (47.8) 19 (28.4) 7 (10.4) 5 (7.5) 3 (4.5) 1.91 1.15

correspond with factors necessary for PTSD diagnosis,12 Results

with the exception of criterion A, which entails exposure.
Bride17 addresses the exposure element in the STSS by tai-
loring the wording and the involvement of “stressor-specific
items” in the survey to reflect that the traumatic stressor is
the exposure to clients. Using a Likert scale ranging from 1
(never) to 5 (very often), participants rate how often they
have experienced each symptom during the past week.
When a participant reported that a symptom was experi-
enced “occasionally,” “often,” or “very often,” this symp-
tom was interpreted as present. In earlier usage the
internal consistency of the STSS instrument, a measure
of stability, was excellent (0.93) for the full STSS and good
for the subscales: 0.80 for intrusion, 0.87 for avoidance,
and 0.83 for arousal.9,18 In this sample the Cronbach α
coefficients for the sample subscales were .92 for intrusion,
.92 for avoidance, and .92 for arousal, and the Cronbach α
coefficient for the total STSS was .91, indicating excellent
internal consistency.
Descriptive and inferential statistics were used for data
analysis by use of version 15.0 of the Statistical Package for
the Social Sciences (SPSS, Chicago, Illinois).
SAMPLE
Of the emergency nurses, 67 responded (response rate,
63%). The sample was primarily women (78%) and
of white ethnicity (75%); the mean age was 43 years
(SD, 10.5 years). The majority identified themselves as
Associate-degree RNs (58%) with the primary position
of staff nurse/direct patient care (82%). The mean length
of nursing experience was 14 years (SD, 10.39 years), and
the mean time worked per week was 41 hours (SD,
7.07 hours). The majority of nurses (92%) denied any his-
tory of seeking assistance for work-related stress. Over half
(52%) reported regularly participating in activities that
promote stress management and self-care.
INDIVIDUAL SYMPTOMS
Individual symptoms are reported by PTSD domain. The
most frequently reported symptom for intrusion was in-
trusive thoughts about clients, with 46% of participants
reporting that they thought about their work with clients
when they did not intend to do so. The second most com-

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 RESEARCH/Dominguez-Gomez and Rutledge

TABLE 3 TABLE 4
Frequency of diagnostic criteria of PTSD due to sec- Comparison of STSS scores in emergency nurses ac-
ondary exposure related to practice with trauma- cording to demographic characteristics (N = 67)
tized populations STSS score t Test P value
Criteria meta n % Gender 5.447 .023
None 10 14.9 Female 39.0
Intrusion (B) 40 59.7 Male 31.3
Avoidance (C) 32 47.8 Shift worked (12 h) 0.292 .962
Arousal (D) 36 55.7 Days 37.7
Intrusion + avoidance (B + C) 27 40.3 Nights 37.5
Intrusion + arousal (B + D) 26 38.8 Use of counseling 1.494 .226
Avoidance + arousal (C + D) 27 40.3 Yes 43.2
Intrusion + avoidance + arousal (B + C + D) 22 32.8 No 36.9
Use of stress 2.263 .138
a
In addition to the exposure criteria (criterion A).
management strategies
Yes 35.8
No 40.2
monly reported intrusion symptom was cued psychological Ethnicity 1.860 .146
distress, with 27% reporting that reminders of work with Asian 32.4
clients upset them. The remaining intrusion symptoms Hispanic/Latino 31.8
were reported less frequently. Among avoidance symptoms, White 39.2
the most commonly reported symptom was avoidance of Other 30.0
clients (52%). Next was diminished activity level and emo- Highest level of education 0.494 .668
tional numbing, both experienced by 43% of nurses. Other Diploma 36.5
avoidance symptoms were reported less frequently. For Associate degree 37.8
arousal, over half of all nurses reported that they were easily Baccalaureate 38.1
annoyed or had difficulty sleeping. Master’s 28.5
Other 29.0
DIAGNOSTIC CRITERIA
Diagnostic criteria for PTSD include 4 factors that cor-
respond to the 17 symptoms of the STSS.12 Bride17 formu-
lated an algorithm to identify cases of PTSD by mirroring nurse, who assumes the difficult task of consoling the fam-
STSS items with these diagnostic criteria. Consequently, ilies and survivors of the event.
study participants who reported at least 1 intrusion symp- Using these diagnostic criteria, we found that only
tom, at least 3 symptoms of avoidance, and at least 2 arousal 15% of participants met no criteria for STS (Table 3)
symptoms meet the criteria for PTSD and, thus, for STS. whereas 32.8% of participants met all 3 criteria. Over half
Criterion A (exposure) is assumed to be present based on of the participants (60%) reported experiencing at least 1
the population surveyed, experienced emergency nurses. intrusion symptom (criterion B), and 56% reported experi-
This criterion is implied, both by the design of the STSS, encing at least 2 arousal symptoms (criterion D).
where the care of patients is identified as the “traumatic SYMPTOM SEVERITY
stressor,”11 and by the nature of emergency nursing. Emer- The potential range of scores possible on the full STSS is
gency nurses care for various types of patients, who differ in from 17, which indicates no symptoms, to 74, which is the
the nature and severity of their injuries, which may com- highest reportable score. The mean STSS score was 37.4
prise a traumatic event to the nurse. A report released by (SD, 11.0), with a range from 17 to 74.
the Centers for Disease Control and Prevention (2005)
reported that injuries sustained by falls, being struck by a SUBGROUP ANALYSES
person or object, and motor vehicle accidents accounted Analyses using t tests with a Bonferroni correction to
for 41% of injury-related visits to the emergency depart- decrease the chance of type I error (P = .01) found no sig-
ment.19 The repercussions of these types of patients, such nificant differences among nurses based on demographic
as death or severe injury, are witnessed by the emergency groups (Table 4). However, white subjects reported higher

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 RESEARCH/Dominguez-Gomez and Rutledge

STS scores, whereas men, nurses who participate in stress graphic location. It also is limited by self-reported responses
management strategies, and nurses with graduate degrees by emergency nurses. Although the response rate is
had lower scores. Correlations between STSS scores and adequate, STS experiences of nonrespondents may differ
age (r = 0.78) were significant, whereas those with years from those of respondents. Respondents may be more—
in nursing and hours worked per week were not. or less—likely to have responded because of experiencing
STS. The STSS tool was developed for use with health care
Discussion providers, specifically social workers; it is based on the pre-
mise that STS resembles PTSD and that the health care
This study examined the prevalence of STS among emer-
workers being surveyed have had exposure to patients with
gency nurses. In this sample 85% reported at least 1 STS
trauma and suffering (a component of STS). We assumed
symptom in the past week. Very concerning is the fact that
this exposure in our sample but did not measure it.
33% of the sample met the criterion for a diagnosis of STS.
The most frequently reported individual symptoms were
irritability, avoidance of clients, difficulty sleeping, intru- Implications for Emergency Nurses
sive thoughts, diminished activity level, and emotional
This is the first study to document STS in emergency
numbing. Symptoms experienced by fewer nurses were
nurses using a reliable and valid tool. The findings of high
cued physiological reaction, inability to recall client infor-
levels of STS, as well as of individual symptoms, point to
mation, and a sense of reliving clients’ trauma.
the need for further research with emergency nurses. In
In describing how to interpret scores on the STSS,
addition, further examination of the potential differences
Bride17 recommends using a cutoff score of 38 as designat-
in scoring among nurses of different gender, ethnicity,
ing the presence of STS. By use of this criterion, half of the
and education, along with the differences in those who
sample would have met the criteria for STS. If the DSM-IV
used specific coping strategies and those who did not,
diagnostic criterion is used, where the sample reported at
needs to be explored. Nurses with STS may not be effec-
least 1 intrusion symptom, at least 3 symptoms of avoid-
tive with patients, because their symptoms may disable
ance, and at least 2 symptoms of arousal, the prevalence
optimal caregiving. Nurse managers should assume that
of STS is slightly higher.12
a minority of emergency nurses may be suffering from
Comparing the sample of emergency nurses to the
STS and, when appropriate, urge them to seek appropri-
282 social workers reported on by Bride17 suggests that
ate counseling or to use stress management techniques.
nurses may be more likely to demonstrate criteria of STS
Potential strategies identified in the literature include the
(33% vs 15%) than are social workers. Whereas 70% of so-
use of formal and informal debriefing, providing the nursing
cial workers reported experiencing at least 1 symptom in the
staff with increased education on CF/STS, burnout, and
week before being surveyed,17 85% of emergency nurses did
death education, specifically care of the dying patient and
so. This clearly indicates the need for further study. Are the
family.20-22 Other coping strategies identified include the
findings replicable among other groups of emergency nurses
use of organizational “team-building” activities, humor,
as well as among nurses in other specialties? Do nurses who
reading, and alternative therapies, such as exercise, massage,
report these symptoms risk becoming dysfunctional or suf-
and meditation.21
fering ill health because of these symptoms? Are these nurses
likely to suffer job burnout and then leave their positions?
Longitudinal studies are warranted to tease out these an- Conclusions
swers. If nurses suffering from symptoms of STS are likely
Working at the entry point to health care for many
to burn out and/or leave their jobs, effective strategies are
patients, emergency nurses play a critical role in ensuring
needed that nurse managers and organizations can use to
quality care. The high prevalence of STS in this sample
ameliorate the symptoms and prevent these sequelae.
indicates that large numbers of emergency nurses may
Subgroup analyses lead to further questions. Are men
be experiencing the negative effects of STS. Increased
and persons of ethnic diversity less at risk for STS? Are there
understanding of the concept of STS or CF, including its
self-management or stress reduction strategies that emer-
identifying symptoms, potential coping strategies, and orga-
gency nurses can use to help ameliorate symptoms of STS?
nizational interventions that may increase nurses’ abilities
to manage or prevent STS, is needed. Increasing the aware-
Limitations
ness of this phenomenon in the workplace may prevent
This study is limited in generalizability because the sample emotional exhaustion and potential job separation of emer-
was not randomly selected and comes from a specific geo- gency nurses who suffer from STS.

May 2009 35:3 JOURNAL OF EMERGENCY NURSING 203


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