Secondary Traumatic Stress in Nursing: A Walker and Avant Concept Analysis

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Advances in Nursing Science Vol. 44, No. 2, pp. 157–170 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Secondary Traumatic Stress in Nursing A Walker and Avant Concept Analysis Marni B. Kellogg, PhD, RN, CPN, CNE Nurses on the front lines of health care are impacted psychologically by their work and may experience secondary traumatic stress. The literature contains several different terms to explore concepts that describe the impact of traumatic patient experiences on the nurse, making it difficult to differentiate the concepts. Using the Walker and Avant method of analysis, the author reviewed nursing-specific publications within the last 10 years and seminal works to develop a purer meaning of secondary traumatic stress and distinguish it from other related terms. A more precise definition of secondary traumatic stress will allow for the advancement of research related to awareness and prevention in nursing. Key words: concept analysis, secondary traumatic stress

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T IS WELL KNOWN that nursing is a stressful profession; caring for and empathizing with patients can be demanding for the nurse. Nurses’ sense of caring and emotional involvement increase vulnerability to psychological distress.1 In their professional role, nurses frequently witness acute pain and suffering and listen to the fears of their patients and their patients’ families. Caring for patients who are critically ill or severely injured can be an upsetting experience for the nurse and may lead to secondary traumatic stress (STS).2,3 It is even more important to recognize the risk of STS today, as nurses are positioned to

Author Affiliation: University of Massachusetts Dartmouth. The author has no acknowledgments or disclosures. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.advancesinnursingscience.com). Correspondence: Marni B. Kellogg, PhD, RN, CPN, CNE, University of Massachusetts Dartmouth, 285 Old Westport Rd, Dartmouth, MA, 02747 (mkellogg@ umassd.edu). DOI: 10.1097/ANS.0000000000000338

experience exacerbated mental health effects from the COVID-19 pandemic. In addition to working with more critically ill patients, nurses are exposed to hazards that increase their real and perceived risk for COVID-19 infection, given close, frequent patient contact and long work hours, with a potential shortage of personal protective equipment.4 The pandemic will likely lead to more nurses needing assistance with STS, heightening the importance of proper recognition and intervention. Over the past 10 years, there have been many publications on STS and its effects on caring professionals. Nursing specialties such as labor and delivery,5 pediatrics,3,6 emergency care,7,8 intensive care,9-11 and oncology12,13 have explored the concept of STS. STS has implications for the nurse and the profession of nursing. Publications utilize many related terms when speaking of STS, including burnout, compassion fatigue, and vicarious traumatization. In addition, the symptoms of STS parallel the signs of the psychiatric diagnoses: acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Each of these terms differs in its meaning. Still, at times, the terms are used interchangeably, which confounds the 157

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Statements of Significance What is known or assumed to be true about this topic? The literature contains many different terms to explore concepts that describe the impact of traumatic patient experiences on the nurse. Nurses are impacted psychologically by their work and may experience STS. Publications utilize many related terms for STS, including burnout, compassion fatigue, and vicarious traumatization. In addition, the symptoms of STS parallel the signs of the psychiatric diagnoses, ASD and PTSD. Each of these terms differs in its meaning, yet the terms are frequently used interchangeably, which confounds the literature and the definition of the concept. What this article adds: Using the Walker and Avant19 method of analysis, the author reviewed nursingspecific publications within the last 10 years and seminal works from social work and psychology to develop a purer meaning of STS and distinguish it from other related terms. A more precise definition of STS will allow for the advancement of research related to its occurrence, treatment, and prevention in nursing.

literature and the definition of the concept of STS and related expressions.2,14-17 The lack of conceptual clarity hinders research, which is essential to the development of nursing knowledge and research and the advancement of appropriate interventions to aid the mental health of the nurse and the profession of nursing. Searches of the literature revealed only one concept analysis on STS utilizing Rodgers’ Evolutionary Model for analysis.18 The purpose of this article is to use the work of Walker and Avant19 to analyze the concept of STS to gain insight into this phenomenon as it applies to nursing. This article reviews

the uses of the concept of STS, its defining attributes, descriptions of cases, and the antecedents and consequences to form a current definition. A purer meaning of STS in nurses is needed to distinguish it from other closely related terms. Clarity will allow for the advancement of research related to its occurrence treatment and prevention in nursing. METHODS The Walker and Avant19 process of concept analysis requires that all applications of the concept are identified and are useful in informing future research. OVID, CINAHL, and PsycINFO online databases were searched for studies of nursing, which both define and measure STS or associated factors as well as concept analyses of similar concepts. Using the key words of “STS,” “compassion fatigue,” “vicarious trauma,” “burnout and nurse,” “nursing,” or “nurses,” existing definitions of STS in the literature were identified. Articles selected for this analysis were limited to nursing-specific publications in academic journals from the last 10 years (January 2010-May 2020) and those published in the English language. Articles that evaluated interventions for STS or related concepts were excluded. One hundred twenty-nine items were initially identified; all abstracts were reviewed. Forty articles were retained, having met the search criteria, with 34 defining STS in quantitative studies of nurses and 6 concept analyses (see Supplemental Table 1, available at: http://links.lww.com/ANS/A26 and Table 1). Additional literature reviewed for this analysis included dictionaries and seminal works from disciplines outside of nursing, describing the concepts associated with STS. USES OF THE CONCEPT STS does not appear as a term in either English or medical dictionaries. The words can be examined individually.

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2012

2018

Jenkins and Warren27

Peters51

Compassion fatigue

Compassion fatigue

Year 2010

Author

Coetzee and Klopper20

Compassion fatigue Compassion fatigue

Concept

Walker and Avant21

Walker and Avant21

Walker and Avant21

Method

“Compassion fatigue is the final result of a progressive and cumulative process that evolves from compassion stress after a period of unrelieved compassion discomfort, which is caused by prolonged, continuous, and intense contact with patients, the use of self, and exposure to stress.”20(p239) “Compassion fatigue include the following attributes: Depersonalization, reduced output/endurance/diminished performance, loss of empathy, poor judgment.”27(p392) “Preventable state of holistic exhaustion that manifests as a physical decline in energy and endurance, and emotional decline in empathetic ability and emotional exhaustion, and a spiritual decline as one feels hopeless or helpless to recover that results from chronic exposure to others’ suffering, compassion, high-stress exposure, and high occupational use of self in the absence of boundary setting and self-care measures.”51(p470) (continues )

Proposed Definition

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Table 1. Concept Analyses of STS and Related Concepts

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2020

Method

Rodgersʼ Evolutionary Model55

Walker and Avant21

Walker and Avant21

Abbreviations: PTSD, posttraumatic stress disorder; STS, secondary traumatic stress.

Arnold18

Secondary traumatic stress STS

2019

Year

2013

Cross14

Author

Posttraumatic stress disorder PTSD Mealer and Jones16

Compassion fatigue Compassion fatigue

Concept

“Secondary traumatic stress, characterized as a PTSD-like condition, is the constellation of physical and emotional symptoms that results from empathetic engagement with others who are undergoing traumatic experiences. STS has the potential to be life-altering, impacting future empathetic work resulting in an altered worldview and interpersonal difficulties.”18(p152)

“Essential attributes include intrusions, avoidance, and hyperarousal. The consequences include worldview changes, retention issues, sleep disruption, and social network disturbances.”16(p279)

“The result of compassion and empathy in the palliative care provider with chronic professional exposure to suffering and repeated exposure to stressors. It is the state where compassion and empathy are lost, demonstrated by emotional and psychological, intellectual and professional, physical, social, and spiritual characteristics that, if left unattended, result in disinterest, moral distress, burnout, and breakdown.”14(p26)

Proposed Definition

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Table 1. Concept Analyses of STS and Related Concepts (Continued )

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Secondary Traumatic Stress in Nursing

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Oxford English Dictionary59 defines secondary as “coming after, less important than, or resulting from someone or something else that is primary.” In chemistry, secondary is defined as having its functional group located on a carbon atom that is bonded to 2 other carbon atoms. In Merriam-Webster Dictionary,60 the definition of secondary states: (1) not first in order of occurrence or development, dependent, or consequent on another disease; and (2) occurring or being in the second stage. Oxford English Dictionary61 defines traumatic as (1) emotionally disturbing or distressing; (2) relating to or causing psychological trauma; and (3) relating to or denoting physical injury. In Merriam-Webster Dictionary,62 traumatic is defined as (1) an injury (as a wound) to living tissue caused by an extrinsic agent; (2) a disordered psychic or behavioral state resulting from mental or emotional stress or physical injury; and (3) an agent, force, or mechanism that causes trauma. Oxford English Dictionary63 defines stress as (1) pressure or tension exerted on a material object; (a) the degree of pressure exerted on a material object measured in units of force per unit area; (2) a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances; (a) something that causes mental strain; (3) physiological disturbance or damage caused to an organism by adverse circumstances; and (4) particular emphasis or importance. MerriamWebster Dictionary64 defines stress as (1) the force exerted when one body or body part presses on, pulls on, pushes against, or tends to compress or twist another body or body part; (2) the intensity of this mutual force commonly expressed in pounds per square inch; and (3) the deformation caused in a body by such a force, or a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation. As noted in Supplemental Table 1 available at http://links.lww.com/ANS/A26, the most common definition for STS cited in the nurs-

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ing literature is that of Dr Charles Figley, a psychologist, family therapist, and social work educator, and researcher. Figley states, STS is “the natural consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person.”23(p7) This definition of STS is commonly found in literature outside of nursing from examining experiences of social workers and respiratory therapists.65-67 In current nursing research, STS is most frequently measured with the Professional Quality of Life Scale (ProQOL), developed by Stamm.25 The ProQOL defines compassion fatigue as a phenomenon comprising burnout and secondary trauma; the phenomenon results from “work-related, secondary exposure to people who have experienced extremely or traumatically stressful events.”25(p13) The measure states STS as “a negative feeling driven by fear and work-related trauma.”25(p8) The ProQOL examines compassion fatigue, the emotional harm that comes from one’s work, and compassion satisfaction, the fulfillment that comes from one’s professional life over the last 30 days.25 Research outside of nursing, including investigations in family caregivers and direct support professionals, has utilized the ProQOL defining STS as a part of compassion fatigue.68,69 It is important to note, although the ProQOL is used frequently in occupational research, there are concerns regarding the convergent validity of the STS and burnout subscales.70 Nursing researchers using the ProQOL tend to agree that STS, along with burnout, is part of the concept of compassion fatigue; however, they utilize different terms or explanations of STS. Hinderer and colleagues9 and Jakimowicz and colleagues49 agree that STS is similar to PTSD, having arousal, avoidance, and intrusion symptoms. Further blurring the concept, Young et al17 state that STS is just another term for compassion fatigue, while Lee and Seomun41 explain STS as a fright response. Some researchers using the ProQOL explain STS as a work-related trauma.13,32,36

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Another frequent measure of STS utilized in recent nursing research is the Secondary Traumatic Stress Scale (STSS).2,3,7 Authors using the STSS typically define the phenomenon as described by the author of the STSS. STS is “intrusion, avoidance and arousal symptoms resulting from indirect exposure to traumatic events by means of a professional helping relationship with a person or persons who have directly experienced the events.”26(p28) The STSS is a valid and reliable measure, with studies verifying its psychometrics.71,72 The STSS is a self-reported 17-item instrument developed as a screening tool for STS, which consists of a Likert-style response format.26 The reliability of the STSS has been validated with several samples of nurses; the Cronbach α demonstrates strong internal consistency ranges, 0.92 in pediatric nurses3 to 0.94 in labor neonatal intensive care unit nurses.2 The STSS adequately describes the attributes of STS in nurses and is recommended as a measure of STS in nursing.73 Utilizing Rodgers’ Evolutionary Model to define the concept, Arnold defines STS as “a PTSD-like condition, it is the constellation of physical and emotional symptoms that results from empathetic engagement with others who are undergoing traumatic experiences. STS has the potential to be life-altering, impacting future empathetic work resulting in an altered worldview and interpersonal difficulties.”18(p152) Contrary to STS, burnout has been described in the literature for decades.74,75 Burnout is defined as physical and psychological exhaustion; symptoms of burnout are anger and ineffectiveness indifference, which are often accompanied by depression and anxiety, and, unlike STS, occur gradually in an individual over time.75 Burnout results in exhaustion, anger, frustration, and depression.25 Burnout was recently included in the International Classification of Diseases and Related Health Problems (ICD-11) by the World Health Organization.76 Congruent with the aforementioned characteristics, the World Health Organization defines burnout as:

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.76

Physical symptoms of burnout include headaches and anxiety; individuals also may feel a decreased sense of accomplishment, emotional exhaustion, helplessness, or hopelessness.75,77 Often caused by unbalanced workloads, workers suffering from burnout feel unsupported or inadequately prepared for the demands of their job.77 Burnout differs from STS in that it is progressive; one incident does not stand out as traumatizing, nor cause its occurrence.75-77 According to Joinson,74 compassion fatigue is a term used to describe burnout, specifically when it occurs in those persons working in caring professions. Joinson was the first to coin the term “compassion fatigue” in 1992 while studying nurses. Joinson states the symptoms of compassion fatigue follow classic stress patterns: You forget or lose things or have a shorter attention span. You’re exhausted and have frequent headaches or stomachaches. Your resistance is low, and you get sick more often. You’re depressed. One particular sign to watch for is anger, especially when it’s too frequent and too intense for the situation.74(p116)

Compassion fatigue results in a progressive loss of awareness of one’s own emotional needs, an inability to nurture, and ineffective caregiving.74 After conducting an informal survey of nurses, Figley23 first suggested that the terms “compassion fatigue” and “STS” could be used interchangeably. Figley23 found nurses preferred the use of the term “compassion fatigue” due to the possible stigma associated with the term “STS.” Years later, this suggestion may have blurred the meaning of each of the concepts and contributed to the need for conceptual clarity. The original

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Secondary Traumatic Stress in Nursing

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definition of compassion fatigue differs from that of STS. Another term, “vicarious traumatization,” is often found in STS literature. Vicarious traumatization was initially coined for use with psychotherapists.78 Vicarious trauma results from hearing the stories of traumatic events that occurred to others.78 While one may not observe or participate in the traumatic event, vicarious trauma also mirrors STS in that the symptoms parallel those of ASD and PTSD.78 Symptoms of vicarious traumatization include avoidance behaviors, intrusive thoughts, and arousal.78,79 Vicarious trauma purportedly causes a permanent change in a person’s beliefs, perspective, and emotional needs over time.75,79 According to Kunh,80 it is anticipated that one’s reactions, ideas, and expectations change according to his or her life experiences. Using the stated definition of vicarious traumatization and previous definitions STS, both STS and vicarious trauma are equivalent. According to the American Psychiatric Association (APA),81 ASD or PTSD can result from secondary exposure to traumatic events, including witnessing events that occurred to others or experiencing details of distressing events on repeated occasions. Symptoms of both ASD and PTSD are categorized into 4 types: intrusive symptoms, avoidance of painful thoughts or memories, adverse changes in thoughts and mood, or changes in emotional responses such as irritability, recklessness, or hypervigilance.81 In ASD, the symptoms last for 3 days to 1 month after the disturbing event, whereas PTSD occurs when the duration of symptoms is longer than 1 month.81 Mealer and Jones16 analyzed the concept of PTSD in nursing; attributes of PTSD were found to be similar to the symptoms cited by the APA81 and include intrusion, avoidance, and arousal. Mealer and Jones16 also note changes in worldview as a consequence of PTSD. Considering these criteria, STS may be a clear case of either ASD or PTSD, whereby the sufferer may or may not be formally diagnosed. Disturbing events can cause significant distress or impair

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an individual socially, affect his or her ability to work, or change the course of day-to-day functioning.81 Table 2 provides a comparison of the terms frequently used synonymously with STS. This table highlights the causes, attributes, and outcomes of these different terms. DEFINING ATTRIBUTES Defining attributes are the characteristics of the concept that appear over and over again.19 When examining the definitions of the phenomenon of STS through different sources, specific themes emerge and these themes provide the defining attributes of STS. A clear understanding of the defining attributes helps convey the meaning of the concept. Professional, caring relationship STS results from a professional, caring relationship where the individual has the desire to assist and care for the traumatized as part of his or her professional role.∗ Indirect exposure to a traumatic event STS results from indirect exposure to a traumatic situation.† The phenomenon in nurses can result from exposure to a traumatic event such as a patient death, participating in painful procedures, grieving families, or wondering whether they could have done more to help a patient.2,5 Intrusive behavioral and emotional reactions STS causes behavioral and emotional reactions similar to those of PTSD.2,9,16,18,27,42,49 These behaviors and feelings express themselves in a variety of ways, such as thinking of the disturbing event repeatedly, having trouble sleeping, or wishing to avoid situations ∗ References † References

6-8, 13, 30, 32, 36, 37, 44, 51, 52, 56. 2, 3, 6, 8, 9, 11, 18, 20, 23, 26, 27, 34, 37, 39, 41, 42, 44, 48, 49, 51, 52, 56.

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Empathizing with another’s traumatic experiences, after exposure to the traumatic situation of another.75,79

Personal exposure to a traumatic event or exposure to the traumatic situation of another.81

Personal exposure to a traumatic event or exposure to the traumatic situation of another.81

Overwhelming, work-related stress with gradual onset.74-76

Overwhelming, work-related stress with gradual onset applies to caring professionals.74

Vicarious traumatization

Acute stress disorder

Posttraumatic stress disorder

Burnout

Compassion fatigue

Progressive forgetfulness, shorter attention span, somatic symptoms, depression, helplessness, boredom inappropriate anger.74-76 Progressive loss of awareness of own emotional needs.74

Intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.81

Mental distress, avoidance arousal, and intrusion, and other emotional reactions such as sadness, anger, tension, or worry.26 Avoidance behaviors, intrusive thoughts, and arousal, permanent change in the persons’ beliefs, perspective.75,79 Intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.81

Attributes

Abbreviations: ASD, acute stress disorder; PTSD, posttraumatic stress disorder; STS, secondary traumatic stress.

Exposure to the traumatic situation of another as part of a professional, caring relationship.26

Cause

Secondary traumatic stress

Concept

Inability to nurture, ineffective caregiving.74

Change in worldview and beliefs, adaption, possibly PTSD, and sensory disruption, equivalent to STS.75,79 Psychological diagnosis. Intense fear, helplessness, and horror. Re-experience of the traumatic event, through thoughts, dreams, and continuous reminders for 3 d to 1 mo.81 Psychological diagnosis. Intense fear, helplessness, and/or horror. Reexperience of the traumatic event, through thoughts, dreams, and continuous reminders for greater than 1 mo.16,81 Mental distancing and reduced professional efficiency.76

Symptoms of ASD or PTSD.26,75

Outcomes

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Table 2. Comparison of Terms Used Synonymously With Secondary Traumatic Stress

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Secondary Traumatic Stress in Nursing

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that remind them of the traumatic event.2,5 Emotional reactions, such as sadness, nervousness, anger, tension, or worry, are also common.26 Similar to PTSD, these reactions may lead to a change in one’s worldview.16,18 CASES The next step in analyzing a concept is the construction of cases or exemplars of the concept of interest.19 The model case, a borderline case, a related case, and a contrary case allow for a clear definition of the attributes and characteristics of STS, as well as what behaviors and emotions do not constitute STS. Model case Walker and Avant19 describe a model case as an example, the concept where all of the defining attributes are present. The following narrative is a clear example of the concept of STS: Amanda is a nurse in a pediatric hospital. One day, her assigned patient unexpectedly became very ill; despite the best efforts of the medical team, the patient died. Everyone had tried their very best to save the patient; the resuscitation efforts were gruesome. The patient’s family was inconsolable. Amanda was distraught; she cried while at home, thinking about this patient and their family. She kept reliving the shift and her actions in her mind; she had visions of her patient during the code and had trouble sleeping. Amanda’s emotions fluctuated; at times, she often felt angry, sad, and nervous. At times, she had headaches and was nauseous. Amanda worried this would happen again the next time she went to work. Amanda needed to take some time off from work and had a tough time when she first returned.

This is a model case of STS as it contains all of the defining attributes of the phenomenon and serves as an underpinning for the concept. Amanda was exposed to her patient’s traumatic death. She cared for this patient and her family as a professional nurse. The experience intruded her life outside of work, causing her to feel sad about her patient and anxious for future shifts at work. Amanda

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wished to avoid situations that reminded her of this experience. Borderline case A borderline case contains most, but not all, of the defining attributes and demonstrates most, but not all, of the defining attributes of the concept.19 Sam is a nurse on a respiratory floor in a large urban pediatric hospital. A large number of patients that he cares for have a diagnosis of cystic fibrosis (CF). Over time and repeated patient admissions, Sam has developed relationships with many of his CF patients and their families. As CF has no cure, many of the patients that Sam has cared for have died of disease complications on his floor. Two patients, Sam has come to know and cared for, have passed away within the last week. Sam feels sad, down, and unusually tired. He noticed he has been forgetting things and is suffering from frequent headaches. He has a short fuse and has been easily upset with his children while at home.

This is an example of a borderline case; it contains the majority of the defining attributes of STS. Sam was exposed to his patients’ deaths as part of his professional role. As a result, he suffered some emotional and somatic symptoms, including headaches as well as forgetfulness, sadness, and anger. Sam was not suffering from the vital components of intrusive thoughts or wishing to avoid working. Sam’s symptoms were more representative of compassion fatigue, as coined by Joinson,74 than that of STS. Related case A related case demonstrates how the concept of STS is linked to similar concepts.19 Related to STS is that of burnout. Tracey works as a staff nurse on a busy medicalsurgical unit. Many nurses have recently resigned due to new administrative policies. The department is always short-staffed. Tracey feels as though she does not have enough time to meet her patients’ needs and feels frustrated with her patient assignments, knowing she will not be able to provide high-quality care to her patients. During her shift, there was a code, and a patient under her

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care passed away. Tracey felt exhausted at the end of her 12-hour shift; she left work late and went to bed as soon as arriving home to get some sleep. The next day she briefly considered calling in sick due to her negative feelings toward her job but went to work.

Tracey is feeling burnt out. Burnout involves exhaustion, pessimism, negative attitudes toward patients, and feelings of dissatisfaction related to work.9 Although Tracey was exposed to her patient’s death, the experience did not cause intrusion, avoidance, or arousal. Burnout does not include the critical attributes of STS and demonstrates a related case. Contrary case A contrary case is a clear example of what the concept is not and does not contain any of the defining attributes of the concept being analyzed.19 Rebecca has been a hospice nurse for many years. She enjoys knowing that she has helped others be comfortable at the end of their life. She feels sad for the families of her patients when they lose their loved ones but feels happy and at peace, knowing she cared for them and helped make them as comfortable as possible. Rebecca is often relieved for her patients and their families when they pass as their suffering has ended. Recently, she was assigned to a 31-year-old young mother with cancer; upon her death, Rebecca knew that the patient was comfortable, and although she empathized with the family, she knew she helped make the patient’s last moments as peaceful as possible.

Rebecca illustrates an example of a contrary case, as she did not display the attributes of STS. Rebecca loves her job; she left work feeling good, knowing that she made a positive difference for her patient and her family. Rebecca displays compassion satisfaction, the feeling of pleasure from being able to help one’s patients.25

for someone who has experienced a traumatizing event as part of his or her professional role. STS does not occur without trauma. Consequences are incidents that occur because of the occurrence of the concept.19 STS can cause symptoms identical to that of PTSD.23,53 STS may also lead to nurses choosing to leave the profession due to the trauma. EMPIRICAL REFERENTS “Empirical referents are classes or categories of actual phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself.”19(p179) Empirical referents explain how a concept can be measured or related to or identical to the defining attributes of the concept.19(p179) Empirical referent for STS is a caring professional relationship. If an individual does not feel concern or interest or attach importance to his or her patient, he or she is less likely to experience the intrusive and emotional reactions of STS. A NEW DEFINITION OF SECONDARY TRAUMATIC STRESS As a result of this analysis, a new definition of the concept of STS can be formed. The proposed definition for STS is an intrusive state of psychological tension resulting from witnessing the emotional or physical suffering of another as part of a professional helping relationship. This experience can lead to a variety of emotional reactions such as sadness, anger, anxiety, worry, or avoidance. STS is synonymous with vicarious traumatization and can result in a change in worldview and the psychological diagnoses of ASD or PTSD. This definition is close to that of STS as defined by Figley23 but more clearly describes the intrusiveness, possible emotions, and outcomes of this subjective experience.

ANTECEDENTS AND CONSEQUENCES DISCUSSION Antecedents are those events that are required to occur before the occurrence of the concept.19 For STS to occur, one must care

This is the first concept analysis on STS using the work of Walker and Avant.19 One

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Secondary Traumatic Stress in Nursing

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other concept analysis was found in the literature using Rodgers’ Evolutionary Model for analysis.18 In comparing the definition of STS by Arnold18 to this analysis, the definitions of STS are similar. This analysis brings to light more of the potential psychological outcomes of STS for the nurse and clarifies that vicarious traumatization is an appropriate synonym. STS is conceptually different from terms such as “burnout” and “compassion fatigue” that do not require the antecedent of caring for someone experiencing a traumatizing event. In addition, compassion fatigue and burnout do not have the mental health consequences of STS. Both PTSD and ASD differ from STS as they are more severe and can result from personal trauma. In addition, this analysis reveals STS is not a component of compassion fatigue; therefore, researchers should refrain from the use of the ProQOL for measurement of STS. This clarification of the concept of STS is essential for nurses, nursing administrators, and nurse educators. It is crucial to raise awareness of STS so that nurses can look for the signs of this work-related hazard in themselves and their colleagues. Nurse educators must also be aware of STS to help prepare the next generation of nurses for the possible mental health implications of this caring profession. Nursing researchers must take the next steps to develop appropriate interventions for nurses to help abate STS. There are no known interventions that directly target STS in nurses. Current approaches for addressing the condition tend to fall under the categories of education, wellness enhancement, and general health promotion.82 COVID-19 pandemic presents a durable and potentially harmful threat to the nursing workforce and its mental health. Preliminary evidence

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in Wuhan, China, where the pandemic began, suggests mental health monitoring and assistance are vital for nurses caring for patients with COVID-19.83 Nursing researchers should use this time to target appropriate psychological interventions to support these essential workers as they cope with mounting devastation from the pandemic.

LIMITATIONS As the aim of this analysis was STS in nursing, the literature search was limited to seminal works and studies of STS found in the nursing literature, which define and measure the concept. Other than seminal works, publications related to STS outside of nursing or studies published in languages other than English were not examined, which may have narrowed the scope of this analysis.

CONCLUSION Identifying the critical attributes and clarifying the definition of STS are vital for the advancement of research into the phenomenon in the discipline of nursing. Much of the current research is clouded because of confusion among related terms. STS has negative implications for nursing, effective interventions that provide nurses with strategies for coping with occupational stress, and its impacts are needed to promote emotional well-being and prevent psychological diagnoses in nurses. Awareness of the concept of STS and research into its prevalence can lead to the development of appropriate psychological interventions and educational programs that support nurses and help prevent its occurrence in nursing.

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