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). Significant variance is

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.

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.

Instructions for CNE Contact Hours

PNJ 2001 Continuing nursing education (CNE)

contact hours can be earned for completing the learning activity

associated with this article. Instructions are available at pediatricnursing.net

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

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 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.

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.”

Table 1. Description of Sample

Full Survey Results (Kellogg, et al., 2018) Individuals with Written Response

Variable M Variable M

Age (n = 333) 41.3 Age (n = 72) 45.7 Years of nursing experience (n = 334)

16.0 Years of nursing experience (n = 72)

20.0

Years of pediatric nursing experience (n = 333)

14.4 Years of pediatric nursing experience (n = 72)

17.7

Hours worked per week (n = 326) 38.2 Hours worked per week (n = 72) 37.4 Variable n % Variable n %

Gender (n = 334) Gender (n = 72)

Male 6 1.8 Male 3 4.2 Female 328 98.2 Female 69 95.8

Nurse Education (n = 334) Nurse Education (n = 72)

Diploma 10 3.0 Diploma 4 5.0 Associate’s 40 12.0 Associate’s 10 13.9 Bachelor’s 211 63.2 Bachelor’s 41 56.9 Master’s 61 18.3 Master’s 15 20.8 Doctorate 12 3.6 Doctorate 2 2.7

Pediatric Clinical Focus (n = 334) Pediatric Clinical Focus (n = 72)

Medical-Surgical 114 34.1 Medical-Surgical 23 31 Intensive Care 44 13.2 Intensive Care 9 12.5 Primary/Outpatient Care 41 12.3 Primary/Outpatient Care 9 12.5 Oncology 25 7.5 Oncology 5 6.9 Emergency Department 24 7.2 Emergency Department 8 11.1 Operating Room 5 1.5 Operating Room 0 0 Home Health 8 2.4 Home Health 2 2.7 Other 73 21.9 Other 16 22

Secondary Traumatic Stress Level (n = 338) Secondary Traumatic Stress Level (n = 72)

Severe 60 17.8 Severe 22 30.6 High 44 13.0 High 4 5.6 Moderate 66 19.5 Moderate 12 16.7 Mild 90 26.6 Mild 15 20.8 None 78 23.1 None 19 26.4

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

bedside nursing to academia primari- ly because of no support of manage- ment.” When nurses feel unsupport- ed by their supervisors, it can be stressful and emotional for the nurse. For example, one respondent said:

Hospitals (are) allowing families to verbally abuse us; it makes dealing with them quite difficult at times. There are days I’m afraid I’m going to lose my professionalism and tell a family I’m not their punching bag. Management is afraid to address this because they are too concerned with patient satisfac- tion rates! Another pediatric nurse stated:

“My manager and my employer have increased my stress with the push to make families happy, to be constantly perky and uplifting.” Nurses do not always feel administrators recognize the stress of staff nurses. As one nurse stated: “I think I would feel more sup- ported and less stress[ed] if nursing administration were more supportive of staff nurses.” Another explained: “Leadership needs to be more sup- portive of nursing, especially given the increased demands and limited resources. This would prevent high attrition rates!”

In addition to feeling unsupport- ed, some nurses reflected on corpo- rate finance creating job dissatisfac- tion. This is exhibited in one response: “We have just completed a difficult negotiation with our hospital and ratified a new union contract which has left me feeling that corpo- rate greed is undermining everything we try to do to improve health care.” Additionally, one nurse wrote:

I honestly love being a pediatric nurse; unfortunately, the hospital I work for is a disgraceful mess due to being owned by a for-profit cor- poration. But we are located in a fairly “rough” part of the city, and I know that these kids need me and that [I do occasionally] make a difference in someone’s life. That is what keeps me going, striving for more times when I can feel like that.

Inability to Separate Traumatic Experiences from Personal Life

A third major theme found among responses was the inability to separate their patients from children in their

ference in telling a family their child has passed than telling a fam- ily an adult elderly patient has passed, as well as pronouncing death on the pedi patient. There’s a difference in discussing palliative care with a family of a 1-week-old then a 100-year-old. As pedi nurs- es, we see it all: accidental trauma, non-accidental trauma, drown- ings, child abuse, shaken baby, genetic disorders with no known cure, degenerative diseases, and even Munchausen by proxy. Pedi nurses see the worst of the worst as nothing should ever happen to a child as they are the essence of innocence. The stress that comes from not saving each child or caus- ing pain can be awful. Another nurse explained differ-

ences in this specialty: “You give of yourself every day you try to encour- age your patient and family even when you know there is no hope. At times I feel I am such a liar.”

Children may not understand the necessity of what is going on in the hospital setting. Any amount of pain or injury that a nurse may feel they caused in a child can cause guilt. One respondent reflected on this idea: “The stress that comes from not sav- ing each child or causing pain can be awful.” Even if it is from a necessary procedure, such as an intravenous line insertion for a child to receive flu- ids, it still seems as though harm is being inflicted upon the child:

Most of my trauma comes from losing a little one. Usually, we are able to help our patients, but sometimes our best is not good enough. It is those times I find dif- ficult. I also find having to repeat- edly do IVs or other painful proce- dures can be traumatizing (for) everyone involved as well.

Using Positivity to Cope Although there are mostly nega-

tive connotations associated with work-related stress, many nurses remain positive. One nurse shed light on this in a thoughtful response:

I work in Pediatric Oncology, which is very rewarding and very sad at times. I gain great strength from my faith and coworkers. I am blessed to work with great people. The job can consume you, but I

own lives. Ten percent of respondents mention their children and families in their responses. They may envision their patients as their children, as one respondent stated: “I began to cry because the little boy was the same age, size, and weight in my arms as my daughter at the time…all I could think about is what it would feel like to lose my daughter right now.” Another respondent stated: “Working in the PICU and PEDS ER as a staff nurse has triggered a lot of anxiety and stress for me surrounding raising my own children.” Another nurse reiterated: “I feel as if pediatric nurs- ing is more difficult and anxiety-pro- voking now that I have children of my own that I worry about.” Even nurses without children voiced how caring for children affects their per- sonal life: “I care for…patients with complex care needs. I do not have any children, but working in the spe- cific field that I am has made me worry/concerned about having chil- dren in the future. It is not a constant concern, but it is definitively in the back of my mind.” These responses highlight the anxiety and stress that burden pediatric nurses’ everyday life because of the tragedies they have faced while at work. One nurse reported her family sees the effects of working in a caring profession: “My children say I have PTSD from being a pediatric emergency room nurse.”

Consumption by Traumatic Experiences

An additional prevalent theme throughout the responses entailed the nurses experiencing guilt from trau- matic occurrences, eventually con- suming their thoughts. The content in these responses reveals deep emo- tion. One nurse stated: “There are patients and situations over the years that haunt me and cling to me like a shadow. No one discusses the effects of nursing on mental health.” Another stated: “It continues to weigh heavy on my heart.”

Many of these responses implicate that pediatric nursing is unlike any other type of nursing; one nurse explained it can be harder:

I feel that pediatric nursing has a different kind of stress that not many other specialties of nursing can truly understand. There’s a vast difference in removing the ventilator from a 5-month-old than a 95-year-old. There is a dif-

PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1 9

have found over the years to find people and activities that focus on the positive things in life, and to take time for yourself. Laughter, faith, and meditation are keys to staying positive and finding joy in whatever circumstances you face. Respondents who discussed posi-

tivity emphasized different factors in their life. While some credited their religion and God for giving them guidance and a positive outlook on life, some credited their fellow staff and even those they are caring for, the children and parents, to get them through:

Some of the children on my floor are complex. The vent-dependent kids and some of the neuro patients can go bad with little warning. Our staff is mostly very cohesive. The doctors, respiratory therapists, child life are approach- able and respectful to nursing. The children and parents make the tough work rewarding. My job is stressful, but my colleagues and the kids make it worth the effort. Despite the challenging nature of

the job, 19% of respondents men- tioned loving their work in pediatric nursing. Many stated they find much of the work rewarding, enjoy forming relationships with patients and their families, and feel lucky to make a dif- ference in the life of a family.

Need for Further Research For the sixth theme, some pedi-

atric nurses who responded to the sur- vey advocated for further research on the topic of secondary traumatic stress. Eleven percent of participants leaving comments wrote ‘thank you’ in their responses. One pediatric nurse said: “Thank you for doing this study! People don’t understand the emotional turmoil pediatric nurses face, especially dealing with intensive care and chronic ESRD population.” Another echoed this message: “No one discusses the effects of nursing on mental health, and I am so glad you are doing this research. It needs to be brought to light. Thank you!”

Discussion Pediatric nurses responding to this

survey have experienced a significant amount of stress and trauma in their workplace. However, this did not stop

spaces for nurse respite and reflection, recently demonstrated a de crease in compassion fatigue scores in pediatric oncology nurses (Sullivan et al., 2019). Additionally, supporting a cul- ture of self-care through breaks during a shift and promoting nurses’ achievements can minimize compas- sion fatigue (Meadors & Lamson, 2008).

Limitations Limitations of the initial cross-sec-

tional survey have been previously published (Kellogg et al., 2018). Other limitations result from the method of data collection; those more impacted by secondary traumatic stress were more likely to leave a written response. Additionally, more informa- tion could have been gathered through interviews with nurses to determine more about the events and stressors that pediatric nurses experi- ence at work that may lead to the development of secondary traumatic stress.

Implications for Nursing Working in pediatric nursing can

lead to stress or secondary traumatic stress. Despite publication of several studies on this topic, findings from this analysis of nurses working in multiple pediatric specialties suggest that nurses need more support in their workplaces to deal with their stress. It is important that nurses rec- ognize the symptoms of secondary traumatic stress and the practice posi- tive self-care because these actions help reduce compassion fatigue and secondary traumatic stress (Meadors & Lamson, 2008). Educational ses- sions on stress management and sec- ondary trauma is an excellent first step to assist nurses in dealing with work-related stressors (Meadors et al., 2009). Nurses should be encouraged to take breaks throughout their work- day, and minimize personal stress to help to decrease the effects of second- ary trauma and compassion fatigue (Meadors & Lamson, 2008). These simple steps may help protect the mental health of pediatric nurses. Further research is needed to deter- mine which experiences are most traumatic for pediatric nurses, nega- tive effects of secondary traumatic stress for patients, and interventions that best reduce secondary traumatic stress in nursing.

many from illuminating reasons why they love their job. As one nurse exclaimed: “I believe that pediatric nursing is a passion that is shared among the people who are meant to do it. If this is your calling, then there is nothing else you would rather do.” Despite the stress and pressure result- ing from their work, their desire to help children and their families is notable. However, these nurses need to take care of themselves with the same ability they care for their patients.

Ten percent of responses indicated some nurses’ inability to separate traumatic situations in the clinical setting from affecting their at-home lives. This is a common finding of qualitative studies of pediatric nurses. Pediatric nurses who experience trau- matic events frequently relate these experiences to their families, which increases their distress (Lima et al., 2017; McGibbon et al., 2010).

Debriefing sessions and support groups would benefit nurses dealing with traumatic patient situations and reduce the feeling of the pressure to perform. Nursing support groups for gynecologic oncology nurses were found to be successful in helping these nurses deal with secondary trau- matic stress (Absolon & Krueger, 2009). Peer or social support was voiced as a helpful method of coping with secondary trauma by pediatric nurses in several studies (Berger et al., 2015; Günüşen et al., 2018; Kellogg et al., 2014).

Management should recognize work-related stress in pediatric nurs- ing and promote awareness of this stress. Nurses should be aware of the signs of secondary traumatic stress to aid in the recognition and early treat- ment for affected nurses (Beck, 2011). Educational sessions on stress man- agement and secondary trauma increase awareness of the conditions as well as the use of strategies for deal- ing with work-related stressors (Meadors & Lamson, 2008). Secon – dary traumatic stress has a negative impact on patients, on the psycholog- ical well-being of the nurse, and the profession of nursing. Furthermore, patient safety can be adversely affect- ed by nurse stress. Nurses who experi- ence symptoms of secondary trau- matic stress may not be able to func- tion optimally in their role. Inter – ventions piloted within one pediatric hospital, including education, pro- moting exercise and nutrition, bereavement support, and physical

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

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