Healing the healers: A systematic review on the burden of secondary traumatic stress among healthcare providers

Abstract

Healthcare professionals (HCPs) are exposed to the traumatic and painful experiences of others as a part of their caring profession, which leaves them vulnerable to developing secondary traumatic stress (STS). It is an occupational hazard for those who provide direct patient care. Systematic review of quantitative studies on secondary traumatic stress among healthcare professionals was published in English between 2013 and 2023, using electronic databases: CINAHL, PubMed, MEDLINE, Global Health, PsychoInfo, and Google Scholar. The search produced 18 studies that explored secondary traumatic stress (STS) among healthcare professionals (HCPs) in the past 10 years (2013–2023). Most studies identified a high level of STS among HCPs. The Secondary Traumatic Stress Scale is the tool widely used to measure STS. Emotional exhaustion, exposure to patients’ deaths, multiple exposures to trauma, and a lack of job satisfaction predicted STS, whereas self-care, sports, social support, and debriefing remained protective factors. There has been evidence of secondary traumatic stress in healthcare professionals. The synthesis of data that are currently available highlights the emotional and psychological costs that care providers may incur from ongoing exposure to traumatic situations, underscoring the necessity of taking preventative action to address and lessen the effects of secondary traumatic stress.

Introduction

According to Dr. Charles Figley, secondary traumatic stress disorder is “the natural consequent behaviors, resulting from knowledge about a traumatizing event experienced by a significant other. Secondary traumatic stress (STS) is a set of behaviors and feelings that develop after being exposed to a traumatic incident that another person has gone through. STS is triggered by assisting someone who is in pain. Arousal, intrusion, and avoidance are the main signs of STS.[1] These STS symptoms resemble those of posttraumatic stress disorder.[2] Although STS may occur from indirect exposure in a professional setting such as attending to a traumatized patient, PTSD is caused by a direct traumatic event.[3]

Compared with other occupations, healthcare workers are more likely to have work-related health issues.[4] Secondary traumatic stress (STS), among other things, is a risk for those who work in direct patient care. Because of the nature of their employment, healthcare professionals who deal with traumatized or suffering patients are at risk of STS.[5]

Healthcare workers’ emotional and psychological well-being would suffer as a result of working in a healthcare setting.[6,7,8] After hearing about patients’ suffering, sorrow, and concerns, medical personnel who provide treatment for trauma victims may experience similar emotions.[9,10,11] According to a study on the connection between secondary traumatic stress (STS) and occupation, 67.7% of doctors, 59.3% of emergency medical technicians, 53.8% of paramedics, 62.5% of health officers, 30% of nurses, and 80% of anesthesia technicians were affected by a trauma that someone they treated or cared for had experienced.[12] These statistics revels the magnitude of the issue, and it is important that the professionals, administrators, and policymakers be aware of the impact of secondary exposure to trauma in the mental health of the healthcare professionals.

Professionals in the field of trauma management, such as mental health professionals dispatched to disaster areas,[13,14] individuals specializing in child sexual abuse,[15,16] domestic violence,[17,18] sexual assaults, and sexual violence,[19,20] are most vulnerable to subsequent trauma.

The traumatic events that affect healthcare personnel indirectly include physical harm, rape and sexual abuse, traffic accidents, and natural catastrophes.[21] According to studies, there may be both advantageous and detrimental psychological effects[22] to vicarious traumatic exposure, which is when a person is exposed to the specifics of a terrible incident while interacting with a direct trauma victim.[23]

The 17-item Secondary Traumatic Stress Scale (STSS) was created to assess the detrimental effects of indirect exposure to traumatic events in HCWs caring for distressed or traumatized patients.[3] A self-administered 22-item questionnaire called the Impact of Events Scale-Revised (IES-R) is based on three symptom clusters: intrusion, avoidance, and hyperarousal.[24]

Need of the study

Healthcare professionals are comparatively more vulnerable to work-related health problems because of the nature of their work.[4] Since the HCPs are involved in the care of people who undergo trauma and pain, they are constantly exposed to emotionally challenging experiences. Hence, they must be aware of the negative impact this exposure can have on their mental health. Understanding the factors contributing to STS can help in planning preventive and health-promoting interventions. Those factors that accelerate the development of STS can be consciously and selectively avoided to protect the mental health of the HCPs.

Vicarious exposure to trauma can also lead to a growth of the healthcare professional. Professionals described changes in the way they view themselves, the value they place on their relationships, and their appreciation for life.[25] Understanding this phenomenon can help us in promoting the well-being of our professionals. Since this study aims to summarize the data from quantitative studies performed in the past 10 years, it gives a holistic picture of the phenomenon.

Statement of problem

Healing the healers: A systematic review on the burden of secondary traumatic stress among healthcare providers.

Objectives

• To systematically review the current literature on the burden of secondary traumatic stress, tools used in measurement of STS, and the predictive and protective factors of STS.

• To draw conclusion based on the findings of the necessary investigations to support review studies

Research question

• What are the predictive and protective factors of secondary traumatic stress among healthcare professionals?

• What is the prevalence of STS among HCPs according to current literature?

Materials and Methods

PRISMA incorporates evidence-based reporting requirements for meta-analyses and systematic reviews. PRISMA provides guidelines on how to report systematic reviews and meta-analyses in a full and objective manner.[26] Study was performed in May–August 2023. When creating the standards for assessing the literature, P.I.C.O. was taken into account Table 1.

Table 1.

Criteria for PICO

Participants		Studies related to secondary traumatic stress among healthcare professional
Intervention		Predictive and protective factors of secondary traumatic stress
Comparison/Control		Secondary traumatic stress among healthcare professional
Outcome		Burden of secondary traumatic stress among healthcare professionals

Inclusion/exclusion criteria

Studies from the past 10 years (from the year 2013 to 2023) were considered, and because of the investigators’ limited knowledge and the potential for an erroneous translation, articles that were initially published in English were chosen. Peer-reviewed journal publications were used, as well as freely accessible materials. Studies that discussed primary research were incorporated.

Case studies and preprinted articles on secondary traumatic stress were omitted. We eliminated theoretical, modeling, and review works. Interventional and qualitative research was dismissed.

Search strategy

Title, abstracts, and keywords were the search criteria. Different combinations of keywords were used to search the well-known databases. CINAHL, PubMed, MEDLINE, Google Scholar, Global Health, and PsychoInfo were selected for this systematic review. The search was conducted from May to June 2023. To avoid oversaturating the data, Boolean operators (AND OR) and keywords were used in the search.

Keywords used as per MeSH

Secondary traumatic stress, secondary traumatic stress disorder, burnout, compassion fatigue, emotional burnout, emotional exhaustion, empathy fatigue, second victim syndrome, vicarious trauma, healthcare professionals, primary care provider, and healthcare providers.

The following search terms formed the search strategy, which was used in various combinations (“Secondary traumatic stress” OR “Secondary traumatic stress disorder” OR “burnout” OR “compassion fatigue” OR “emotional burnout” OR “emotional exhaustion” OR “empathy fatigue” OR “second victim syndrome” OR “vicarious trauma”) AND (“healthcare professionals” OR “primary care provider” OR “healthcare providers”)

Search criteria

The timeframe of the search was limited from the year 2013-2023.

Study selection

Coauthors extracted the data independently using MeSH terms and compared the results. The entire texts of the studies chosen in level one were obtained, and the same two writers independently assessed each one to determine its eligibility. The grounds for exclusion were meticulously classified and recorded.

Data extraction

Two reviewers collected data and worked independently. A consensus was obtained after discussing any differences of opinion. The coauthors then separately extracted the data and compared the findings. Following data were extracted from each study: author year and country, study design, population, instrument used, and key findings. The following phase was to evaluate the selected papers that matched the inclusion criteria for potential methodological bias. See PRISMA flow diagram, Figure 1.

Figure 1.

PRISMA Flow chart

Eighteen studies were included in the search when the predefined inclusion and exclusion criteria were applied.

Quality and bias assessment

The Newcastle-Ottawa Quality Assessment Scale[27] quantitatively evaluates publications by assigning as rating based on the selection, comparability, and exposure categories. The Cochrane risk of bias was used to analyze randomized controlled trials (RCTs), which were focusing on various aspects of trial design, conduct, and reporting. Joanna Briggs Institute instrument used to assess the qualitative and quasi-experimental studies based on checklist.[28]

Result

Table 2 Total number of healthcare professionals participated in the 18 studies were 6,844. Healthcare professionals included physicians, surgeons, nurses, psychologists, health technicians, medical secretaries, emergency medical technicians, laboratory assistants, disaster relief workers, social workers, counselors, and physiotherapists. According to a comparison research, psychologists had the lowest risk of developing STS, whereas social workers had noticeably higher levels of the condition.[35] Eight studies had only nurses as participants, of which five studies included nurses working in the emergency department,[5,32,38,41,42] one study was conducted among pediatric nurses,[44] and one study was conducted among disaster respondents.[37] Among the 18 studies reviewed, 12 were cross-sectional studies, 3 were descriptive correlational studies, and one was comparative study. One study used triangulation method, and one study used mixed method. Secondary Traumatic Stress Scale (STSS) was used to assess the level of secondary traumatic stress in 11 studies. Two studies used self-report questionnaires, and two studies used Impact of Events Scale.

Table 2.

Study findings

Author, year, country		Study design population		Instrument used		Key findings
Orrù et al.[29] (2021) Italy		cross-sectional study, 184 HCWs from 45 different countries		Secondary Traumatic Stress Scale (STSS)		41.3% of HCWs had moderate-to-severe secondary traumatic stress symptoms. Although HCWs working in other units had a lower percentage (30.3%), the frequency of STS was 47.5% in frontline HCWs. Exposure to patient death, emotional weariness, and perceived stress persisted as important predictors.
K N et al.[30] (2021) India		Cross-sectional study 2,008 HCPs from India.		Secondary Traumatic Stress Scale (STSS)		1548 (77%) of the HCPs reported having STS. The prevalence of STS was reported to be 88.2% in physicians, 79.2% in nurses, and 58.6% in allied healthcare professionals. In the category of severe STS, there were disproportionately more females.
İlhan and Küpeli[31] 2021 Turkey		Prospective cross-sectional study 363 emergency HCW		Secondary Traumatic Stress Scale (STSS)		Financial troubles were the primary cause of the development of anxiety, depression, and STS in 261 (71.9%) of the subjects. Low levels of depression and STS were shown to be connected with hobbies, a balanced diet, reading, exercise, and sports.
Duffy et al.[32] 2013 Ireland		Cross-sectional study, all of the 117 registered nurses (n) working in three emergency rooms		STSS		The prevalence of subsequent traumatic stress was 64%. Alcohol was reportedly useful for nurses in the research in reducing work-related stress.
Shalabi et al.[33] (2022) Saudi Arabia		Cross-sectional study 78 healthcare workers		The Secondary Traumatic Stress Scale (STSS)		12.8% of people reported experiencing extreme stress, and 28.2% indicated just light stress, whereas 52.6% experienced considerable stress.
Pappa et al.,[34] (2021) Greece		Cross-sectional study 464 HCWs		Impact of event scale		33% of HCWs reported having moderate or severe STS symptoms.
Manning-Jones et al.[35] (2022) New Zealand		Comparative study. 365 healthcare professionals 44 doctors, 103 social workers, 76 nurses, 72 therapists, 70 psychologists, and 72 counselors		The Secondary Traumatic Stress Scale (STSS; Bride et al., 2004)[3]		Social professionals had a considerably greater rate of STS., whereas psychologists had the lowest risk of any psychiatric complication from vicarious traumatic exposure. Peer support, support from superiors, and support from close friends and family all had a strong negative correlation with STS.
Chaudhry et al.,[36] (2022) Pakistan		Cross-sectional study 170 healthcare professionals		STSS		55.3% and 41.7% of HCP had mild to moderate STS, respectively. Multiple exposures to trauma were significantly associated with STS. Healthcare practitioners’ emotional stability as a personality attribute was indirectly correlated (r = -0.46) with the emergence of STS symptoms.
Beckmann[37] (2015) United States		Cross-sectional study participants (N=92) who had assisted in a national catastrophe during the previous five years were drawn from the American Red Cross.		demographics questionnaire; Secondary Traumatic Stress Scale		A master’s degree, being a young adult, being unmarried, and having responded to a crisis 7 to 12 months ago are risk factors for secondary traumatic stress and burnout. those who work with trauma survivors as volunteers, those who are jobless, and those who regularly or sporadically engage in self-care are protective characteristics that lower the incidence of secondary traumatic stress in disaster relief workers.
Machado,[38] 2018 United States		Mixed-methods design 150 RNs working in the adult emergency department.		Secondary Traumatic Stress Scale (STSS)		In the emergency department, secondary traumatic stress symptoms are mild to severe for nurses. All research participants had at least one of the intrusion, avoidance, or arousal symptoms of post-traumatic stress disorder while working in the emergency department.
Yörük et al.[39] 2022 Turkey		Cross-sectional study included 1416 healthcare workers		STSS		HCWs who met the following criteria had significantly higher mean STS scores: they were female, had a chronic illness, had a poor perception of their health, worked as a front-line healthcare provider in a public hospital, cared for a family member who had COVID-19, or had a relative pass away from COVID-19.
Khalid et al.[40] 2021 Pakistan		Descriptive correlational study 100 doctors		Secondary Traumatic Stress Scale Bride et al.[3]		Relationships between psychological resilience and 03 secondary traumatic stress disorder subscales (intrusion, avoidance, and arousal) are unfavorable. This implies that the risk of subsequent traumatic stress declines as psychological resilience rises. Secondary traumatic stress was shown to be significantly positively correlated with burnout.
Jobe et al.[41] 2021 United States		Cross-sectional survey design 255 emergency nurses		Impact of Events Scale-Revised (IES-R).		High secondary traumatic stress was indicated by 38% of responders.
Morrison and Joy[42] 2016 Scotland		Triangulation method		Questionnaire		Emergency nurses identified acute work pressures including death and resuscitation as the driving forces behind this. The management of secondary traumatic stress has been credited with the benefits of formal debriefing and social assistance;
Ratrout and Hamdan-Mansour[5] 2020 Jordan.		descriptive correlation design. 202 nurses working at eight emergency departments		Self-report questionnaires		According to the study, high to severe levels of secondary traumatic stress were reported by over half of the sample participants. The results revealed that nurses with higher coping skills and lower empathy likely to experience secondary traumatic stress more frequently.
Bock et al.,[43] 2020 Germany		Cross-sectional study 320 nurses		Freiburg PTSD screening		74 (25.3%) people claimed that these experiences trigger persistent ruminating and/or flashbacks.
Kellogg et al.,[44] 2018 United States		Cross-sectional study using a predictive correlational design Pediatric nurses (n=338)		STSS		There was moderate, high, or severe secondary traumatic stress in 50.3% of pediatric nurses (n=170).
Tsouvelas et al.,[45] 2022 Greece		Descriptive correlational design 222 nurses		STSS		65.8% (146) of the nurses had STSS denial, self-distraction, and marital status scores that were moderate to high, with married persons scoring higher and greater STS scores being anticipated. Resilience correlated negatively with STS score

Prevalence of secondary traumatic stress among healthcare professionals

The included studies had a range of STS levels, from 25.3% to 77%. More than 50% of the population tested in seven studies were found to have moderate-to-severe secondary traumatic stress.[30,31,32,33,42,44,45] However, five others found a prevalence below 50%.[29,34,36,41,43]

The percentage of HCPs with the highest levels of STS was 77%. The prevalence of STS was reported to be 88.2% in physicians, 79.2% in nurses, and 58.6% in allied healthcare professionals.[30] Morrison LE and Joy noticed that in the preceding week, at least one indicator of secondary traumatic stress had been experienced by 75% of the emergency nurses sampled.[42] Among emergency healthcare personnel amid the COVID-19 outbreak, STS was found in 71.9% (261) of the participants.[31] About 65.8% (146) of nurses had STSS ratings that were moderate to high.[45] The secondary traumatic stress criteria were satisfied by 64% of the emergency nurses.[32] Healthcare employees had mild stress 28.2% of the time, moderate stress 52.6% of the time, and severe stress 12.8% of the time.[33] About 50.3% of pediatric nurses (n = 171) reported having secondary traumatic stress of moderate to high intensity.[44] Maryam Chaudhry identified that 55.3% and 41.7% of HCP had little and mild to moderate level of STS.[36] Secondary traumatic stress disorder symptoms ranged from moderate to severe in 41.3% of HCWs. A lower percentage (30.3%) of STS was found in HCWs working in other units, compared with a frequency of 47.5% in frontline HCWs. In comparison with male HCWs, female HCWs scored considerably higher on the STSS Intrusion subscale.[29] High secondary traumatic stress was indicated by 38% of responders.[41] The proportion of HCWs with symptoms of moderate/severe STS was 33%.[34] Continuous rumination and/or flashbacks were experienced by 25.3% of nurses, according to their reports.[43]

Predictive factors of secondary traumatic stress

The major predictive factors identified by the researchers in the studies surveyed are perceived stress, emotional exhaustion, exposure to patients’ death,[29] lack of job satisfaction, financial difficulties,[31] considering change of career,[31,32] multiple exposure to trauma,[36] being a young adult, being single,[37] and acute work-related pressures such as death and resuscitation.[42] Nurses with higher coping skills and less empathy tended to experience secondary traumatic stress more frequently. Secondary traumatic stress was not significantly predicted by organizational characteristics.[5] Denial, self-distraction, and marital status, with married people showing higher scores, predicted high STS score.[45] Severe STS sufferers tended to be women more often than men.[30]

Protective factors of secondary traumatic stress

Participants who reported using hobbies, a balanced diet, and reading as coping mechanisms had significantly lower levels of STS. Sports and exercise were also discovered to be linked to lower levels of STS.[31] Peer support, support from superiors, and support from close friends and family all had a strong negative correlation with STS.[35] The development of STS symptoms correlated negatively with the healthcare professionals’ emotional stability of personality.[36]

Self-care activity was discovered to be a protective factor. Emergency nurses might benefit from peer support and guidance from a best friend or mentor.[37] According to two research, debriefing soon after a stressful experience would be most helpful in easing traumatic stress symptoms.[38,42] The benefits of debriefing, peer support, departmental programs, and therapy, as well as being allowed some time to gather one’s thoughts after a stressful occurrence, were proven.[38]

Discussion

The current study was intended to review the burden of STS as well as its predictive and protective factors. Among these, 12 studies gave a prevalence rate of STS, one study compared the level of STS among different professionals, and five studies identified predictive and protective factors.

The high levels of STS among HCPs in the reviewed articles were explained by emotional exhaustion, exposure to patients’ death,[29] and multiple exposure to trauma.[36] The highest level of STS identified was 77%.[30] The varied professions, various working locations, various working schedules, and variable working loads, however, can account for the varying levels of STS in the research under consideration. For instance, only emergency nurses were included in five studies, whereas pediatric nurses were the subject of one. Respondents were included in research about disasters.

Results of the current review are consistent with the systematic review of secondary traumatic stress in nurses conducted by Beck C. T. According to him, between 25% of forensic nurses and 78% of hospice nurses reported having higher secondary traumatic stress symptoms.[46] Therapists go through an internal process as they try both to make sense out of the stories they hear from clients and to integrate those stories into their own existing cognitive schemas.[47]

A qualitative study conducted among mental health therapists revealed nine protective factors to vicarious traumatization such as countering isolation (in professional, personal, and spiritual realms); developing mindful self-awareness; consciously expanding perspective to embrace complexity; active optimism; holistic self-care; maintaining clear boundaries; exquisite empathy; professional satisfaction; and creating meaning.[48] Current systematic review also identifies similar protective factors against STS. good training specific to trauma work, a personal history of trauma, and the interpersonal resources of the worker were identified as major mitigating factors in the development of STS among professionals working with survivors of traumatic events.[49]

A study focused on occupational stress and burnout among physiotherapists concluded that lack of rewards at work, social interaction, and the lack of support intensified occupational stress among them.[50] The HCPs must be provided with mental health services including periodic screening for PTSD, expanded social support, and, when necessary, psychotherapy and psychopharmacological treatment.[51]

Implications

The study has the potential to make meaningful contributions to healthcare practice, research, policy, and education by raising awareness, informing interventions, influencing policies, and shaping educational initiatives for healthcare professionals.

Practice

Help nurses and other healthcare professionals become more knowledgeable about secondary traumatic stress disorder and its effects. Nurses can seek appropriate assistance and self-care by recognizing the symptoms and indicators of this stress. Study findings can direct the development of focused intervention plans aimed at reducing secondary traumatic stress in medical professionals. This might involve putting counseling services, stress-reduction plans, and other forms of support into place in hospital environments.

Research

This can help direct future research projects by pointing up regions that require further investigation. Through the process of synthesis and summarization, the systematic review adds to the body of knowledge about the impact of secondary traumatic stress. Researchers interested in studying connected subjects can use this foundation as a reference.

Policy

The results of the systematic study may help shape new rules for the workplace that address and avoid secondary traumatic stress. It may be possible to put policies in place to help healthcare professionals manage their stress and foster a better work environment. Advocates promoting the availability of mental health resources and therapy within healthcare facilities may find themselves encouraged to open up. This may enhance healthcare teams’ general well-being.

Education

The creation of healthcare program curriculum could be influenced by the systematic review. Incorporating secondary traumatic stress knowledge into training curricula might enhance the capacity of aspiring healthcare providers to identify, treat, and avoid secondary traumatic stress. Healthcare professionals and practicing nurses may use the systematic review’s findings in their continuing education programs. This can help people advance professionally by giving them the skills and information they need to deal with the difficulties brought on by secondary traumatic stress.

Strengths of the study

The study could present the findings from 18 relevant studies on the topic in a systematic manner, which will help the readers to understand the depth and breadth of secondary traumatic stress among healthcare professionals.

Limitation of the study

The study could not include the qualitative studies performed in the field because the objective was to identify the predictive and protective factors.

Suggestion for future study

Future studies should focus on prevention of STS and promoting resilience among HCPs. Interventional studies involving promotion protective factors will be of great significance.

Conclusion

There has been evidence of secondary traumatic stress in healthcare professionals. Varying levels of STS were found across the included studies, ranging from 25.3% to 77%. However, it was difficult to compare research and draw conclusions because of the use of various techniques to detect secondary traumatic stress symptoms and diverse sample sizes. The synthesis of data that are currently available highlights the emotional and psychological costs that care providers may incur from ongoing exposure to traumatic situations, underscoring the necessity of taking preventative action to address and lessen the effects of secondary traumatic stress. Emotional exhaustion, exposure to trauma and death, perceived stress, and lack of job satisfaction remained the major predictive factors of secondary traumatic stress. By putting mental health first, we can build a more resilient and long-lasting healthcare workforce, which will improve patient care and promote a better healthcare ecosystem.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.