The fast-paced, unpredictable environment of emergency nursing can lead to trouble. Safety is an ongoing concern, considering the increasing incidence of workplace violence and the continuous flow of patients with infectious diseases. But there is another kind of stress emergency nurses may be reluctant to discuss: that which results from exposure to others’ trauma.

Emergency nurses are ideally situated to experience this kind of stress, referred to as secondary traumatic stress (STS). If left unaddressed, STS can negatively affect mood, relationships, job satisfaction, and patient care.

“When you think about your average emergency nurse and the number of people who are experiencing trauma that come through the ED, that trauma kind of gets transferred in a way to people caring for them,” explains Lisa Wolf, PhD, RN, CEN, FAEN, the director of emergency nursing research for the Emergency Nurses Association (ENA).

Wolf and colleagues explored both the harmful effects of STS on emergency nurses as well as potential remedies that could alleviate these effects.1 The authors surveyed 125 emergency nurses and conducted in-person focus group discussions with 53 of these. Investigators observed participants demonstrated high levels of STS, and contended this is a problem of considerable concern to the emergency nursing community.

Consider Impact

While prevalence of STS was high among participants, investigators reported emergency nurses react to STS in different ways. The authors used an instrument called the Secondary Traumatic Stress Scale, a self-report instrument that characterizes the different symptoms of STS under several subheadings, including arousal, intrusion, negative connotations and mood, and avoidance.

“Some people, if they are manifesting avoidance symptoms, they don’t want to go to work. They may want to avoid a specific room in the department or a specific area where a traumatic event has happened to them or where they have cared for someone who has suffered through a traumatic event,” Wolf explains.

Nurses with symptoms categorized as arousal may feel anxious or jumpy. For instance, Wolf notes many study participants talked about how they were unwilling to let anyone stand between themselves and a door.

Those experiencing symptoms categorized as intrusion typically report they cannot seem to escape thoughts, feelings, or pictures stemming from a traumatic event that is constantly replaying in their heads, Wolf observes. Negative connotation in moods typically refers to feelings of depression related to the traumatic event that a nurse or the nurse’s patient has experienced.

How do emergency nurses manage STS? What investigators found seems to align with other published research. “Our participants told us ... that they did a lot of numbing — either with alcohol, sleep ... or disconnecting from not just work, but kind of themselves, which is not super functional,” Wolf explains. “People are working so hard to wall off these [traumatic] experiences that they end up being a little too successful. They are unable to re-engage with patients or their families.”

Further, Wolf notes the damage caused by STS is cumulative trauma. It often follows people as they move to different, higher-level positions in nursing. “People have these experiences throughout their careers at the bedside. Then, they bring them into management, and they bring them into administration,” Wolf says.

When these symptoms of STS are not addressed effectively in nurses who have risen to higher-level positions, they may have little patience for bedside nurses who are struggling with similar STS experiences.

“Part of the cumulative trauma is this idea that I have dealt with [STS], so you will, too,” Wolf observes. “It is this [expectation that nurses] toughen up and develop a thick skin that is driving a narrative for a lot of bullying behaviors in EDs.”

What investigators drew from the study in terms of potential management-level solutions to the problem of STS in emergency nursing is that “managers and directors really need to do the work of resolving their own trauma before they help their staff,” Wolf advises.

Provide Respite

While formalized, critical incident debriefings are not that helpful in addressing STS, Wolf and colleagues reported gathering with colleagues on a more informal basis after a traumatic event was beneficial. The participants also indicated taking periods of respite during their shifts also was a helpful way to alleviate STS symptoms.

For example, nurses who have just witnessed a pediatric death need time to process that experience.

“It is not healthy or safe for them to just go into the next room,” Wolf observes. “This all comes back to having adequate staffing, adequate experience, and adequate training [on the part] of charge nurses and preceptors to help newer nurses process these types of events.”

Wolf adds there are many potential options to address STS once the issue is seen as a real problem.

“Just about everybody has some degree of STS. It is not a weakness in any way. This is a byproduct of the job,” Wolf observes. “We really need to destigmatize these very appropriate reactions to traumatic incidents.”

For its part, ENA has conducted multiple studies that all point to STS as a critical factor in practice. The idea of trauma processing is becoming part of preceptor programs and other initiatives. “It has got to be really embedded into practice,” Wolf says.

Wolf underscores the point that effectively addressing STS is not just about easing the suffering of individual nurses. There also is a clear effect on patient care. “What our participants told us was that [the numbing behaviors they resorted to because of STS] meant that they could not see signs of patient behavioral escalation, which has an impact for violence. They also couldn’t see signs of patient decompensation,” she says. “They had become so task-oriented that they were not seeing their patients as people.”

Wolf says STS represents an opportunity for management to recognize that it is a problem. Administrators can make sure staff nurses understand that leadership is willing and eager to help nurses process any feelings or other symptoms they may experience resulting from a bad patient outcome or other trauma. Wolf adds management should make it clear they will not ask nurses to ignore STS in the service of performing their jobs.

“Programs that are set up on a unit level to help people process these events are going to go a long way toward improving patient care, improving nursing outcomes, and also decreasing bullying behaviors,” Wolf says. Another incentive for management to act is the fact that high levels of STS in nurses correlate with an intention to leave the profession.

Wolf and colleagues completed their data collection before the COVID-19 pandemic began. That ongoing health emergency has a shined a strong spotlight on the importance of healthcare worker well-being. Wolf is hopeful the issue of STS in nurses will receive the attention and reformative action it deserves.

“There is a component with COVID-19 of organizational violence that I think has not been as clearly delineated prior to [the pandemic] where we have, from the federal government on down, shifting rules and changing standards,” observes Wolf, describing the constant barrage of directives as producing a gaslighting effect on nurses.

“This kind of cumulative trauma will cause a mass exodus if we do not take steps to really revolutionize nursing as a profession, and really hold on to the practice autonomy and authority that nursing should have,” Wolf adds.


  1. Wolf LA, Delao AM, Perhats C, et al. Traumatic stress in emergency nurses: Does your work environment feel like a war zone? Int Emerg Nurs 2020;52:100895.