Factors Associated with Secondary Traumatic Stress among Emergency Nurses: An Integrative Review

Background: Emergency nurses are exposed to traumatized patients as part of their job. Secondary exposure to trauma may lead to traumatic stress similar to those experienced by the primary victim. Emergency nurses develop secondary traumatic stress symptoms more than other nurses due to nature of emergency departments. The consequences of secondary traumatic stress can be noticed at personal, interpersonal, or organizational level. Objectives: This integrative review aimed to explore the literature on the factors attenuate or enhance occurrence of secondary traumatic stress among emergency nurses, to identify these factors, and to provide recommendations for research in the field. Method: An integrative literature review of quantitative and qualitative studies on secondary traumatic stress in emergency nurses were published in English language between 2000 and 2017 through the following data bases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest, Medline, PubMed, Google Scholar, SAGE Journals, Wiley on Line Library, Science Direct and EBSCOhost Sources. Results: The review identified that factors associated with secondary traumatic stress can be classified into personal and organizational factors. Findings on personal factors such as age, gender, and experience are controversial, whereas organizational factors such as trauma case load and perceived organizational support were found to predict traumatic stress more than the personal factors. Conclusions: Emergency nurses are at risk to develop traumatic stress and need to be aware to the contributing factors in order to maintain their well being. Further research is required to explore the factors enhance or attenuate occurrence of secondary traumatic stress.


Introduction
Emergency department (ED) is generally viewed as an emotionally charged area.
The ED, eventually, is described as physically and psychologically overwhelming area for both health professionals and nurses. However, the ED nurses are the key personnel, and act as the front line in dealing wounded and hemorrhaging victims, caring of traumatized victims, and seeing dying patients on daily basis [1]. This makes ED nurses subject to various forms of burden and psychological disturbances such as stress, dissatisfaction, and burnout [2]. The ED nurses suffer psychological disturbances due to caring of traumatized patients reaching unpleasant outcomes such as deaths and losses proposing a connection between caring of traumatized patients and psychological disturbances among ED nurses [3]. An increased concern about trauma is noted in the last decades due to increased rates of traumatic events caused by natural and man-made disasters [4]. Therefore, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has extended the conceptualization of trauma to include indirect exposure to trauma through hearing, witnessing, and learning about traumatic events. This infers that the concept of trauma is no more limited to direct experience of threatening assault, but also includes secondary exposure to traumatic events [5]. The reconceptualization of trauma has called for reconsidering the experiences of ED nurses whose main responsibility is to provide care to psychologically and physically traumatized patients. Thus, the term "traumatic stress" is emerging and been introduced in nursing literature to understand the nature of experience for nurses providing care for traumatized patients. Traumatic stress is a term used to describe the negative impacts experienced by healthcare professionals caring of traumatized patients [6]. Trauma and its related effects may be transferred secondarily to health professionals interacting with victims. Thus, stress encountered due to indirect exposure to trauma is called Secondary Traumatic Stress (STS). This type of stress has been recognized by McGibbon, et al. as one of the major types of stress encountered by nurses [7]. An increasing concern is noted about the indirect effect of trauma on ED nurses due to its serious consequences on their psychosocial wellbeing and their quality performance [8]. The literature has marked numerous factors that may enhance or attenuate occurrence of STS among helping professionals, however; little is known about factors associated with STS among ED nurses. It is imperative for both the quality care managers to ameliorate factors lead to development of STS among ED nurses [9].
The overall purpose of this integrative review is to explore the theoretical and empirical literature discussing the factors associated with development of STS among health professionals, in general, and among ED nurses, in particular. The specific aims are: to summarize and identify these factors, to provide evidence-based recommendations for future research and instrument development in the field, and to inform the priorities for future research evidence in this area.
Understanding these factors may help ED nurses maintaining their ability to H. F. Ratrout

Methodology
Literature search followed Whittemore and Knafl's framework of integrative review process [10]. This framework was consulted as it facilitates inclusion of a  [11]. The procedure used to locate the literature included in this review is illustrated in Figure 1. Whittemore and Knafl's framework was applied to extract data from the primary articles. Significant data were  [10]. A data matrix was developed to display the extracted data from each article. The facilitated extraction of data from articles subscribed to various methodologies. Constant comparison procedure was also used to extract the data from the qualitative studies to ensure distinction of emerged themes and relationships. Extracted themes were compared to each other so that similar themes were grouped together to reduce the extracted data.

Theoretical Perspectives
Trauma Transmission Model is one of the early models attempted to explain the process by which the trauma effect is transmitted from victim to helper. This model asserts that empathy is the core concept in development of compassion stress. It assumes that trauma workers who share empathy with traumatized victims may experience compassion stress. The prolonged compassion stress may result in STS [12].  [13]. Another model is the Nurse as Wounded Healer theory. This theory addressed the secondary exposure to trauma among nursing population, and acknowledges that nurses working in stressful environment such as emergency care unit may experience personal trauma, professional trauma, or both. This theory assumes that nurse who exposed to trauma will either become walking wounded and remain restricted to traumatic experience, or become a wounded healers who transcendence the trauma experiences. The concept of walking wounded describes the impact of working in traumatic environment such as emergency care area [14].
Accordingly, the ED nurses are viewed as wounded healers who require transcending the traumatic experiences successfully to be able to provide optimum.
These models are commonly having little empirical research evidence to suggest that they are either effective or appropriate to explain this process. Also, each of these models explained one or more aspects of the construct of secondary exposure to others' trauma, but each one of them failed alone to capture the whole aspects of this construct.

Prevalence of STS in ED Nurses
Previous studies from different geographic areas showed that prevalence of STS  [1]. In a very recent study in Scotland, Morrison and Joy found that 75% of a sample of emergency nurses reported at least one symptom of STS during the time of the study, and 39% of them met the whole criteria of STS [16]. These rates are alarming and require attention of stakeholders. Differences in characteristics of health care systems across countries and regions in which these studies have been conducted may explain the variation in the reported rates of STS. Also the methods and measurement issues vary as the criteria of STS have been changed after the year 2013 with release of DSM-5 [5]. For example, some researchers reported the incidence rate of STS symptoms in term of occurrence of the three symptoms of STS (intrusion, avoidance, and hyper-arousal), while, other researchers reported occurrence of any of these symptoms. However, it is recommended that researchers need to follow Bride's guidelines to report the incidence and prevalence of STS [17]. Moreover, variation in rates is also attri-

Risk Development
Emergency unit is a stressful, fast-paced, and demanding environment [16]. The ED nurses are routinely caring of traumatized patients and life threatening. Such daily scenarios place nurses at an increased risk for occurrence of STS symptoms [2]. Psychological responses to traumatic events often seen as normal, and usually diminishes within short period of time. However, repetitive exposure to traumatic events may hinder the normal recovery process and may result in the development of psychological disorders [20]. Consequently, the ED nurses are at risk and tend to develop STS more than others due to nature being repetitively exposed to traumatized individuals [21]. Another factor may contribute to STS among the ED nurses is being involved in a high level empathetic relationship with the traumatized individuals [22]. Sharing empathy is a central concept and key component in the process of developing STS among nurses [21]. Although empathy is a core therapeutic technique in nursing care, however, empathy may transfer trauma feelings from victims to nurses. Consequently, nurses either have positive feelings about their ability to help others which is known as compassion satisfaction, or have negative feelings that may precipitate for STS [3].
Furthermore, imminence, nature, and increased frequency of traumatic events confronted by nurses in ED departments have also contributed to development of STS among ED nurses. The repetitive exposure to such events is assumed to be associated with serious psychological and physical consequences on nurses in ED departments and can contribute to high risk of STS among them [15].

Consequences of STS on ED Nurses
Engaging in caring relationship with traumatized victims represented a source of stress that has an impact on the physical and mental integrity of the trauma workers [23]. Secondary exposure to trauma affects the ED nurses physically and mentally [24]. Studies showed that nurses in ED reported high levels of traumatic stress, anxiety, depression, and somatic complaints [15]. The consequences of untreated STS among ED nurses found to influence nurses' capacity, quality of care provided, and organizational outcomes [3]. Each of the STS symptoms can be linked to group of negative consequences that can be noticed at personal, interpersonal, or organizational level [25]. At personal level, STS can disrupt normal life and leads to difficulty in enjoying life [25]. Intrusive thoughts may produce tactile sensations, thought distortion, flashbacks, and nightmares [2].
Moreover, reckless and risk-related behaviors were observed among ED nurses.
For example, Donnelly and Siebert reported that 40% of the emergency care personnel, including nurses, use drugs and alcohol to cope with traumatic stress [26]. Moreover, Duffy et al. found that ED nurses who reported high levels of STS symptoms use alcohol as coping strategy to manage the STS symptoms [1].  [2]. Rainville maintained that hyper-arousal symptoms cause nurses to perceive colleagues and patients as threat leading to violent and nonprofessional relationships [26].
At the organizational level, the STS symptoms may influence nurses' performance and the care they provide [15]. Mealer and Jones concluded that STS negatively impact the quality of life among nurses and their patients causing dissatisfaction and poor health care outcomes [2]. Moreover, the analysis of literature showed that STS is linked to job dissatisfaction, retention, burnout and tendency to leave nursing. Bride and Kintzle (2011) investigated the relationship between job satisfaction and STS among substance abuse counselors. Findings indicated that lower level of job satisfaction was associated with higher level of STS [27].
This finding was supported by Cieslak and colleagues who found similar findings in their analysis of the relationship between job burnout and STS among trauma workers [28]. Another issue is the consequences of avoidance. Rainville reported higher levels of arriving late, absenteeism, leaving workplace early, and episodes of sick leave among nurses experience high level of STS symptoms [25].
Avoidance among nurses has been observed in terms of avoiding taking care of patients who remind them with previous traumatic situations [2] [29]. In addition, Duffy et al. have also found that ED nurses who reported high levels of STS symptoms have higher tendency to change their career in comparison with nurses who did not report high level of STS symptoms [1]. These ramifications might lead to deterioration in the quality of patient care and patient health status [29]. With high prevalence of STS among ED nurses and its devastating effects, the STS become an area of concern that needs attention and further investigation. Despite the salience of STS consequences, less research has been directed to investigate the impact of secondary exposure to trauma on ED nurses in comparison with those studies examined the prevalence of STS and its predicting factors. One of the possible explanations is lack of conceptualization for the relationship between STS and these proposed consequences. Moreover, the models explain the STS ignored addressing effects of secondary exposure on nurses, and rather, focused prevalence and contributing factors.  [22], gender, years in nursing profession, professional seniority [31], educational level [32], history of sexual assault [30], trauma training, social support, personal trauma history [22], and spirituality level [2]. While the organizational factors identified in the literature are: trauma case load [22], organizational support [33], clinical supervision, and relationship with colleagues [30]. The following sections will explore and discuss the literature found on a selected group of these factors in details and combine findings from both the quantitative and qualitative literature. The key findings of reviewed studies are summarized in Table 1.  [34], Dominguez and Rutledge found that female nurses were more vulnerable to STS than male nurses [31]. In contrast, Petleski found that male nurses reported higher levels of STS symptoms than female nurses [35]. Differences in report and variation in years where studies conducted might speculate using different criteria to investigate STS resulting in variation in reported findings. Variation among these findings implies that gender does not relate STS, but these findings must be interpreted cautiously for three reasons: majority of ED nurses are females [16], female nurses had higher level of stress than male nurses [36], and female nurses had higher level of compassion fatigue than male nurses [37]. These inconsistent findings caused Hensel et al. to suggest the need for more research and further investigation to elucidate this relationship and the role of gender in STS [22]. Therefore, studies needed to investigate role of gender on developing STS considering feminism and maleness in nursing.  [8]. This finding clearly suggests that junior nurses have greater rates of STS, and as nurses gained experience, their vulnerability to develop STS is decreased. Thinking broadly, experience in nursing is similar to age and, therefore; results have to be interpreted cautiously.

Personal Factors
Coping capacity has been also identified as predictor for STS among helping professionals. Theoretically, coping has been conceptualized as protective factor against STS [2]. Probably, coping strategies assumed by ED nurses can mitigate the psychological impact of their exposure to traumatic stress in their every-day practice. This notion was empirically supported by Buurman et al. and Adriaenssens, et al. who found that coping is a significant predictor of STS development among ED nurses [6] [15]. Given that more stress is associated with reduced physical and mental health [38], Buurman et al. demonstrated that coping capacity explained one third of STS among nurses [6]. Studies found that nurses used drugs and alcohol as coping mechanism in response to the STS [1]. Von Rueden et al. have also found that ED nurses used medication to cope in response to STS [8]. It is believed that using more negative coping strategies would have worsened outcomes on ED nurses and deteriorates their status. There is a need to investigate nurses' perception of effective coping strategies to manage Empathy is an important mechanism to develop STS symptoms among caring professionals [3]. However, Empathy was investigated in the literature and few studies found connection between empathy and STS. A study by MacRitchie, and Leibowitz investigated the relationship between level of shared empathy and STS among 64 trauma workers, and reported that empathy is a significant moderator between exposure to traumatic events and STS development [39]. This connection was sustained by Sheen et al. who reported that empathy was identified as a risk factor for STS in both quantitative and qualitative literature [40].
However, Crumpei and Dafinoiu investigated 77 medical workers from emergency and intensive care units including nurses and found no relationship between STS and empathy [41]. Despite the facts that empathy in nurses is viewed to enhance the positive outcomes of provided care [42], this relationship needs further scrutiny because of its negative effect on the ED nurses. Being involved in high empathetic relationship with traumatized patients may transfer trauma feelings from the patient to nurses and consequently place them at risk for developing STS.
Another assumed to play a role in development of STS is the amount of perceived social support. Social support is a broad, complex, and may have various forms [43]. Relationship between perceived social support and STS has been established in several studies. Studies demonstrated that nurses and trauma workers who received high levels of social support found to have less STS symptoms [22]. The qualitative literature also identified that ED nurses viewed social support as preventive and beneficial tool for the management of STS [16]. It can be said that there is a consensus in the literature to recognize social support as a protective factor against developing of STS among ED nurses. Social support reduces the effect of work stress on the nurses who are exposed to stressful situations such as helping patients who scrimmage with death. Thus, reduce the occurrence of STS symptoms [44]. However, it may be more helpful to determine which social supportive behaviors and which sources of support would help ED nurses more to protect them from STS.

Organizational Factors
The characteristics of an organization may play a role in prevention or occurrence of STS among its professionals [45]. Work related conditions have been found to associate STS among healthcare professionals [40]. Dworkin et al.  [22]. Work load is also one of the organizational characteristics suggested to contribute to STS among ED nurses [45]. Theoretically, Mealer and Jones described exposure to traumatic events through direct patient care as the main antecedent to develop STS among nurses [2]. This notion was empirically supported by several studies. High trauma case load has been found to relate development of STS symptoms among ED nurses [15] [47]. The qualitative literature also concluded similar findings. Morrison and Joy reported that junior nurses viewed exposing to traumatic events in workplace as a contributing factor for development of STS [16]. Studies from other disciplines also reported similar findings. It has been found that higher case loads accounted for unique variance of STS among providers working with survivors of sexual assault [30].

Discussion
The literature that has been reviewed for this study highlights the extent of the work that has been undertaken in this field. Much of the work has emphasized prevalence and factors associated with STS, however; studies were controversial in terms of rates and factors predicting STS among nurses in emergency units.
There were also efforts that attempted to explain occurrence of STS and consequences of STS on nurses and quality of care. Nevertheless, little work concerned with sociodemographic and organizational factors that may predict or result into The current review raised a concern about the factors investigated in the pertinent studies and thought to be related to STS. Studies have repetitively measured almost same list of variables conceptualized as predictors for STS symptoms. However, rational behind selecting these variables was not clear and never been linked to theoretical framework. Therefore, it is thought that these studies failed to capture all predictors of STS and a number of personal and organizational factors that are probably predicting STS have been ignored.
On the other hand, STS theories addressed the role of the personal factors in the development of STS. However, the empirical literature did not find this notion as true for all proposed personal factors. We have also found that reports regarding age, gender, education, and professional experience are contradicting.
Other personal factors; coping capacity, empathy, and social support were empirically supported as predictors of STS among ED nurses. This review is supporting previous reports that personal factors have very little influence on STS [30], some, but not all personal factors were associated with STS [22]. This review also support the conclusion reached by Morrison and Joy that nurses in ED had a perception that personal characteristics are not related to STS symptoms [16]. In conclusion, demographic factors are not definitely related to STS development among nurses, while other personal factors may have buffering role in this process. More work is needed to examine the role of personal factors in STS to better understand for the process by which STS is developed. Researchers have to build a rational for including the personal factors in the future studies.
Overall, the current review proposes that there are group of personal and organizational factors that attenuate or enhance occurrence of STS among ED nurses. However, it was not easy to make comparisons between the findings and draw conclusions for many reasons due to contradicting findings and inconsis-

Conclusion
Nurses in ED are at high risk for STS and are under investigated in terms of predictors and consequences compared to other vulnerable groups such caregivers.
It is obvious that nurses working in ED are likely affected by exposure to trau-H. F. Ratrout, A. M. Hamdan-Mansour Open Journal of Nursing matic events in encountered in their practice. Exposure to traumatic events could adversely affect ED nurses' well-being, organizational outcomes, and quality of care provided. Nurses need to be aware about factors contribute to STS, and training for such groups is a priority at this field. The literature tested empirically some factors, whereas some factors still require further investigations.
Longitudinal and qualitative approach need to be adopted to better understand the phenomenon. In addition, quality care manager and policy maker should observe consequences of STS in ED nurse as part of their quality improvement protocols.