Nursing can be a stressful pro-fession; caring for children can cause secondary trau-matic stress in the pediatric nurse (Kellogg et al., 2018). Secondary traumatic stress has been defined as “intrusion, avoidance and arousal symptoms resulting from indirect exposure to traumatic events using a professional helping relationship with a person or persons having directly experienced the events” (Bride et al., 2004, p. 28). Several pub- lications can be found in health care literature exploring work-related stress and trauma. Terms used to describe the occurrence vary and include secondary traumatic stress, compassion fatigue, burnout, and vicarious traumatization. Studies of work-related stress in nursing explore many specialties, including labor and delivery (Beck & Gable, 2012), emer- gency care (Dominguez-Gomez, & Rutledge, 2009; Flarity et al., 2013; Jeon & Ha, 2012; van der Wath et al., 2013), oncology (Günüşen et al., 2019), trauma and critical care (Hinderer et al., 2014; Mason et al., 2014; Sacco et al., 2015; Salimi et al., 2019; Von Rueden et al., 2010; Young et al., 2011), hospice and palliative care (Melvin, 2015; Sullivan et al., 2019), and nursing coordination roles (Kim, 2013)Nursing Article Paper. Significant variance is

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Continuing Nursing Education

Recalling Stress and Trauma in the Workplace: A Qualitative Study of

Pediatric Nurses Anna E. Kleis and Marni B. Kellogg

Anna E. Kleis, BSN, RN, is a Graduate, the University of Massachusetts Lowell, Lowell, MA; and Staff Nurse, Mount Auburn Hospital, Cambridge, MA.

Marni B. Kellogg, PhD, RN, CPN, CNE, is an Assistant Professor, the University of Massachusetts Dartmouth, Dartmouth, MA.

noted in the prevalence of secondary traumatic stress or compassion fatigue, with mean scores ranging from low levels in nursing coordina- tion (Kim, 2013), average levels in crit- ical care nurses (Sacco et al., 2015), and moderate or high levels in pedi- atric nurses (Kellogg et al., 2018). These results indicate the occurrence of work-related stress or trauma is highly variable and should be further investigated so appropriate interven- tions can be implemented. Currently, little is reported in the literature about experiences in pediatric nursing that are most challenging emotionally and

may cause secondary traumatic stress in pediatric nurses.

Qualitative studies in the literature related to stress in pediatric nursing are limited. McGibbon and colleagues (2010) published an ethnography on pediatric nursing stress studying nurs- es working in a pediatric intensive care unit of a pediatric hospital in Canada. Results focused on causes of nursing stress and revealed six themes: 1) emo- tional distress, 2) constant presence, 3) the burden due to responsibility, 4) hierarchical power, 5) bodily care, and 6) being mothers, daughters, aunts, and sisters Nursing Article Paper.

Kleis, A.E., & Kellogg, M.B. (2020). Recalling stress and trauma in the work- place: A qualitative study of pediatric nurses. Pediatric Nursing, 46(1), 5-10.

Problem: Secondary traumatic stress has been identified as a problem in the nurs- ing workforce, leading to adverse effects on mental health and job dissatisfaction.

Purpose: The purpose of this study was to begin to discover more about the events and stressors pediatric nurses experience that may lead to the development of sec- ondary traumatic stress.

Results: Content analysis was performed with the open-ended responses from a cross-sectional survey asking, “Is there anything else you would like to share?” Seventy-two responses were analyzed and six prevalent themes were identified: pressure to perform despite emotion, feeling unsupported, inability to separate trau- matic experiences from personal life, consumption by traumatic experiences, using positivity to cope, and the need for further research.

Conclusion: Pediatric nursing is stressful, yet many nurses also find it rewarding. Measures to improve the nurse’s awareness of work-related stress, including edu- cation and breaks during the workday, should be encouraged. Further research is needed to determine which experiences are most traumatic for pediatric nurses, negative effects of secondary traumatic stress for patients, and interventions that best reduce secondary traumatic stress in nursing.

Key Words: Secondary traumatic stress, pediatrics, coping.

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Deadline for submission: February 28, 2022 1.1 contact hour(s) Nursing Article Paper

6 PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1

More recently, Lima and colleagues (2017) explored critical care nurses in a mixed-methods study conducted in Portugal. Lima and colleagues (2017) focused their research on reactions to sudden pediatric deaths. Qualitative results revealed nurses experienced symptoms of secondary traumatic stress after sudden patient deaths; responses were influenced by the cause of death, the patient’s age, and the fam- ily’s reaction to the situation (Lima et al., 2017). Personal experiences of the nurse, such as parenthood, feelings, lack of institutional support, or inade- quate preparation to deliver difficult patient information, were also cited as reasons for a more intense reaction by the nurse (Lima et al., 2017).

A Turkish mixed-methods study of pediatric nurses who care for chroni- cally ill children found caring for this population is an emotional experi- ence. Nurses reported feeling sad and often uncomfortable, and feared their patients would die (Günüşen et al., 2018). Professional consequences of caring for this population included nurses considering leaving their posi- tion due to emotional burden (Günüşen et al., 2018). These nurses reported coping using social support and prayer, and tried to distance themselves from their patients emo- tionally to avoid attachment (Günüşen et al., 2018).

Only one mixed-method study investigated compassion fatigue and burnout in pediatric nurses in the United States. Berger and colleagues (2015) surveyed pediatric nurses working in one health care system and analyzed comments at the end of a survey exploring compassion fatigue. Researchers asked participants to recount a specific time they felt compassion fatigue and how they coped with the event (Berger et al., 2015). The most challenging experi- ences included patient deaths, child abuse cases, and shifts with low staffing/high workload (Berger et al., 2015). To cope with these stressors, some nurses ignored their feelings, some cried, others overindulged with food or spent money; positive coping occurred through peer support, prayer, religion, or exercise (Berger et al., 2015). This study explored pedi- atric nurses from across the United States working in many different loca- tions and sub-specialties, thus provid- ing a broader view than that of previ- ous research of the stress and trauma experienced as a pediatric nurse. Nursing Article Paper

nursing experience, pediatric special- ty, and average hours worked each week between the two groups are comparable. Those with severe sec- ondary traumatic stress as defined by Bride and colleagues (2004) using the Secondary Traumatic Stress Scale are noted to be more likely to write an open-ended response.

Data Analysis Data analysis and result extraction

were completed manually, following the process suggested by Bengtsson (2016). First, decontextualization was completed. Responses were read over by two researchers to obtain a general feel of the data. Next, responses were read again, and meaning units were coded. Key words related to secondary traumatic stress or the coping that emerged as comments were highlight- ed in each response. The words cope, stress, fear, traumatic, and guilt, along with rewarding, love, and comfort were found in many responses. The text was then recontextualized as respons- es were read to determine which responses fit into meaning units and which replies not related to secondary traumatic stress were determined. Responses were then categorized by homogeneous words and ideas, and were grouped by composing themes. Manifest analysis was used, staying close to the words of participants. Compiling the data, six themes emerged; two researchers reviewed the responses separately and reached consensus, demonstrating triangula- tion of the themes and increasing validity.

Results A total of six themes were identi-

fied throughout the responses. The themes found related to workplace stress in pediatric nurses were 1) pres- sure to perform despite emotion, 2) feeling unsupported, 3) inability to separate traumatic experiences from personal life, 4) consumption by trau- matic experiences, 5) using positivity to cope, and 6) the need for further research.

The Pressure to Perform Despite Emotion

One common theme was the feel- ing of pressure either by lack of time or the need to take care of as many patients as possible. Frequently, respondents stated they were required to move from one patient to the next,

Methods

Study Design This study is a qualitative analysis

of “open-ended” responses from a cross-sectional survey of pediatric nurses distributed by the author. Participants in the original study were recruited to complete a survey meas- uring secondary traumatic stress, cop- ing measures, anxiety, and job satis- faction. A random sample of Certified Pediatric Nurses (CPNs) certified by the Pediatric Nursing Certification Board (PNCB) was contacted via email with an invitation to participate. The sample was randomized using a ran- dom number generator. Of the 6,000 emails sent, 350 responses were received. Quantitative data revealed the majority of respondents suffered from moderate, high, or severe sec- ondary traumatic stress (n = 170, 50.3%) as a result of their work (Kellogg et al., 2018). This article fur- ther examines the traumatic or stress- ful experiences of these nurses by investigating the qualitative respons- es of participants from the original survey using content analysis Nursing Article Paper.

In total, 72 nurses responded to the open-ended question, “Is there anything else you would like to add?” Content analysis was used to explore the experiences of pediatric nurses related to secondary traumatic stress. Content analysis uses specific steps to determine themes, as well as basic quantitative methods such as fre- quencies to summarize characteristics within previously collected written qualitative data (Hays & Singh, 2012). IRB approval was obtained for this analysis.

Participants Of the 350 surveys returned, 326

completed all measures. Twenty-two percent of respondents elected to leave a written comment at the end of the survey. Comments ranged from two words to over 400 words; the majority wrote several sentences about traumatic or stressful work experiences. Demographics of pedi- atric nurses completing a survey relat- ed to secondary traumatic stress, cop- ing measures, anxiety, and job satis- faction compared to those respon- dents who elected to leave a written comment at the end of the survey are summarized in Table 1. Age, gender, highest degree earned, years of nurs- ing experience, years of pediatric

PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1 7

unable to recover from their previous patient experience. This concept is highlighted in one nurse’s response:

Management expects nursing/ techs to go on with their day as if nothing happened, as if a patient didn’t just pass away. It is hard to deal with the emotions of having a patient pass in a particular room and then immediately filling it with another patient. There needs to be time to reflect on what just

Feeling Unsupported The second theme found among

respondents of the survey was feeling unsupported. Responses describe nurses feeling unable to continue with their jobs and help children without more support from manage- ment. One respondent exclaimed: “I had an incident of PTSD of a 14-year- old hanging victim who survived [who] I needed to obtain psychologi- cal counseling for. I have left primary

happened. We are all humans; we have emotions. These kids become family. We are more upset than people realize when there are bad outcomes.

This feeling was echoed by another study participant: “It seems like there is more of a rapid-fire succession of difficult situations; you don’t have time to recover from one situation before another one arises Nursing Article Paper.”