STS among medical personnel

Medical personnel representatives—nurses, doctors, paramedics, that is people who have direct contact with patients and those who suffer because of their conditions or injured in accidents—are subject to negative consequences of exposure to trauma [8–13]. As underlined by Beck [14], STS is perceived as a professional risk factor among health care professionals. Research carried out within this scope confirms the high risk of STS occurrence in this professional group.

The studies conducted among paramedic personnel, the majority of which consisted of doctors, in 10 hospitals of one of the States in the USA shows that nearly 13% meet the STS criteria and almost 34% presented at least one symptom included in the scope of each of three STS categories, that is an intrusion, arousal and avoidance [15]. One of the studies mentioned by Nimmo and Huggard [12] shows that more than half (54%) of doctors who participated in the study met the criteria of compassion fatigue or STS. Yet, it results from other studies presented by the authors that the intensity of STS among doctors was low. Symptoms of secondary traumatic stress were also revealed by ambulance personnel in the study of Argentero and Setti [16].

Research carried out among nurses working in emergency rooms in Scotland shows that 75% of them presented at least one symptom included in the STS scope [17]. According to studies [18], 64% of Irish nurses working in emergency medical services met the STS criteria Similarly, 52.3% of emergency nurses in Jordan revealed a high or severe level of secondary traumatic stress [19]. High risk of the occurrence of secondary traumatization in this professional group is confirmed by study results which show that 86% of nurses participating in the study presented a moderate or high level of compassion fatigue [20]. Other studies mention frequent STS symptoms occurrence among oncology and critical care nurses [21–23]. High risk of STS symptoms occurrence is also observed among nurses who work in palliative care and cancer wards. Nurses who deal with the seriously ill, wounded, and those facing the end-of-life over extended periods of time are at particular risk of negative effects of indirect trauma [11, 20, 24]. It is confirmed by the literature review by Ortega-Compos et al. [25] which shows that 19% of cancer ward nurses present low compassion satisfaction, 56% moderate or high level of burnout, and 60% moderate or high level of compassion fatigue.

Polish studies confirm the high risk of STSD occurrence among the medical personnel. In research concerning nurses working in palliative care [26] escalation of STS symptoms (measured by means of Secondary Traumatic Stress Scale) was reported in 38.9% of participants. Moderate STS symptoms were observed in 23.6% and 37.5% of participants showed low levels of STS symptoms. In studies in which Posttraumatic Checklist—PCL-5 was applied to evaluate STS symptoms [13] it was reported that among 5 professional groups (therapists, paramedics, nurses, social workers, and probation officers) the highest level of STS symptoms was presented by medical personnel and high probability of STSD occurrence was noted in 45.8% of paramedics and 40% of nurses employed in posttraumatic and palliative care wards.

Professional load, work satisfaction, social support and cognitive trauma processing versus secondary traumatic stress

Several theoretical models have been developed to explain the nature of secondary traumatization and describe the factors that determine the occurrence of secondary traumatic stress. One of the most important concept that directly relates to secondary trauma is Ecological Framework of Trauma by Dutton and Rubinstein [27]. The authors distinguished several elements of the model such as: (1) traumatic events experienced by the victim, (2) coping strategies understood as cognitive and behavioural efforts undertaken by the helper, (3) posttraumatic reactions of the helper, (4) subjective factors that include personal resources (especially high self-esteem), professional resources (experience, training), vulnerability (own trauma history), satisfaction levels, both in life and at work, and environmental factors that include social support and working environment; the context of trauma worker works. The authors paid attention mostly to personal and environmental factors. These factors influence the emotional reactions of those helping people working with trauma victims that may be reflected as secondary traumatic stress. Coping strategies are also important, due to the fact that coping activity is aimed to master the requirements of an individual’s traumatic situation. Another notable concept is Constructivist self-development theory by McCann and Pearlman linked to previously described phenomenon of Vicarious Traumatization [5]. The theory evokes changes in cognitive patterns or beliefs, and therefore may be relevant to secondary trauma. It is worth mention that models developed for PTSD, i.e., the Cognitive shattered assumptions theory by Janoff-Bulman [28], PTSD Development model [29] and Emotional processing model [30] may also be used to explain mechanisms of secondary traumatization. The applicability of these models to STS symptoms results primarily from symptomatic similarity between STS and PTSD (as indicated by Figley) and analogical factors that influence the occurrence of these two-side consequences of trauma. These models treat posttraumatic disorders as errors in cognitive trauma processing which leads to the occurrence of distorted beliefs concerning the world and self. Such distortions entail intensive emotional reactions, mostly in the form of anxiety and foster the occurrence and sustainment of trauma symptoms.

Taking into account the assumptions of above models and studies conducted in the field of secondary trauma [13, 31, 32], it can be pointed out that special attention is focused on factors connected with work environment including occupational load, job satisfaction, social support as well as individual characteristic including cognitive trauma processing skills.

Participants

The research project was specifically approved by the Bioethics Committee of Opole Medical School (no 81/P1/2019). Informed consent (oral before, and written during filling the questionnaires) was obtained from all participants included in the study. 430 representatives of medical personnel who provide medical help to trauma victims were included in the study (the sample consists of individuals who were exposed to secondary trauma). The questionnaires were delivered to medical staff who had previously consented (written) to participate in the project. The study was anonymous and voluntary, and conducted in the period from November 2019 to February 2020 in 12 units and included voivodeship rescue stations, emergency medical teams, emergency wards in several Polish hospitals as well as cancer wards, intensive care units, and hospices. The questionnaires were delivered to and collected by the authors or persons trained by the authors during medical staff working hours. The study inclusion criterion was performing the profession of a paramedic or nurse and work with people who had traumatic experiences (struggling with illness. i.e., stroke, heart attack, cancer or after an accident).

The analysis included the results of 419 (11 questionnaires were dropped out due to the missing data; only participants with complete questionnaires were included in the analyses) people in the age from 19 to 65 years (M = 39.60, SD = 11.03). Among study participants, there were 137 (32.7%) men and 282 (67.3%) women. The studied group included paramedics (n = 201) where 60.2% were men and nurse staff (n = 218) in which there was a significant majority of women (92.7%). The majority of paramedics provide help for people who experienced various accidents, especially road accidents (57.2%) but also after traumatic events such as strokes and cardiac infarction (42.8%). Nurse staff included people working with cancer patients (87.7%) and accident sufferers (18.3%). Work experience of the medical personnel who participated in the study amounted at from 1 year to 43 years (M = 12.18, SD = 9.75), the number of work hours devoted to helping injured patients amounted at 2 to 90 (M = 38.24, SD = 15.65), and workload expressed by a percent of work devoted directly to providing help to patients in relation to the whole performed work from 2 to 100% (M = 69.11, SD = 31.89).

Measures

The survey developed for the research was used. It included questions about age, types of events which were experienced by patients, work experience as a paramedic/nurse, number of work hours per week devoted to working with patients, workload expressed in the percentage of work devoted to providing direct help for patients in relation to the whole performed work as well as four standard assessment tools described below.

Secondary Traumatic Stress Inventory—STSI is a modified version of the Posttraumatic Stress Disorder Checklist—PCL-5 developed by Weathers et al. [62]. The inventory is a self-assessment tool intended for testing people who provide help for trauma victims. Similarly to PCL-5 which was adapted to Polish conditions [63], it consists of 20 statements/accounts of traumatic events (range = 0–80; “Repeated, disturbing, and unwanted memories of the stressful experience”) referring to symptoms included to 4 criteria of PTSD, that is B. Intrusion; C. Persistent avoidance of stimuli connected to trauma; D. negative alterations in cognitions and mood; E. alterations in arousal and reactivity. The modification of the tool consisted of completing the instructions with the information about the occurrence of mentioned reactions in connection to the help provided to trauma victims. Some statements were completed with the phrase “of my patients”. According to the instruction the study participant shows to what extent the mentioned reactions occurred to them within last month in connection to the provided help and evaluates it using a five-level scale from not at all (0); slightly (1); moderately (2); significantly (3) to very much (4). Cronbach’s alpha indicator for Secondary Traumatic Stress Inventory amounts at 0.90 and is following for particular factors: 0.71; 0.85; 0.89; 0.87.

Job Satisfaction Scale is a modified version of Diener’s Satisfaction with Life Scale [64], designed to evaluate the general life satisfaction, developed by Zalewska [65]. The tool consists of 5 items. After the alterations, the statements refer to the evaluation of work (“In many aspects my work is almost perfect”). The study participant uses a seven-point scale of responses from 1 –“I certainly agree” to 7 –“I certainly disagree”. All statements are a part of one dimension (range = 7–35) and are internally highly consistent in a heterogeneous sample of employees and particular professional groups. Cronbach’s alpha for scale is 0.86.

Social Support Scale—What Support Can You Expect is a part of the Psychosocial Work Conditions questionnaire [66] and allows to evaluate the support received from the work environment, i.e. supervisors and coworkers as well as support outside of work, i.e. from family and friends (score range for each subscale = 8–40; “To what extent can you expect that someone helps you in a certain way?”). The tool consists of 8 statements for which participants answer on a 5-point scale from 1 (very small extent) to 5 (very large extent). Psychometric properties of the scale are satisfactory (support from supervisors: α = 0.94, coworkers: α = 0.92, friends outside of work: α = 0.89 and family: α = 0.89).

Cognitive Processing of Trauma Scale (CPOTS) by Williams, Davis and Millsap [60] was adapted to Polish conditions by Ogińska-Bulik and Juczyński [67]. A version adjusted for the study of people indirectly exposed to trauma was applied in the research. The tool consists of 17 statements (“Overall, there is more good than bad in this experience”) and measures five aspects of cognitive processing: positive cognitive restructuring (3 items; score range = 0–18), downward comparison (3 items; score range = 0–18), resolution/acceptance (4 items; score range = 0–24), denial (4 items; score range = 0–24), and regret (3 items; range = 0–18). Study participants address each statement on a seven-point scale from 0 (I certainly disagree) to 6 (I certainly agree). The result of each scale is calculated separately. The reliability of the Polish version of CPOTS evaluated by means of Cronbach’s alpha coefficient is satisfactory. The coefficients are 0.84 for positive cognitive restructuring, 0.89 for downward comparison, 0.82 for resolution/acceptance, 0.56 for denial and 0.72 for regret.

Statistical analyses

The IBM SPSS, version 25 software was used to verify the obtained data. The two-tailed probability value of < 0.05 was considered to be statistically significant. The first step of data analysis consisted of the calculation of descriptive statistics that included mean and standard deviation for secondary traumatic stress, occupational characteristic, job satisfaction, source of social support and cognitive coping strategies. Additional for demographic characteristic frequency and percentage were computed. T-Student’s test was implemented to compare the differences in the prevalence of secondary traumatic stress between nurses and paramedics as well as between men and women. Pearson’s correlation coefficients were applied to analyze the relations between the variables. The Benjamini-Hochberg procedure was done for multiple comparisons. A multivariable stepwise regression analysis was used in order to find a dependent variable (STS) predictors among independent variables (occupational load characteristic, job satisfaction, cognitive trauma processing, and social support). To assess model fit, R² was used. Moreover, regression analysis provided data that include adjusted R^2, R²-changes, standardized regression coefficient (β), unstandardized regression coefficient (B), F-statistic, confident intervals for B, and p-value. Multicollinearity was checked by using tolerance (> 0.10) and variance inflation factor (< 5). The effect size for multiple regression analysis was > 0.35.

Limitations of the study

There are certain limitations to the conducted research. It was a cross-sectional study which does not allow to draw conclusions related to the cause and effect dependencies. Subjective indicators of indirect exposure to trauma e.g., in the form of evaluation of the size and meaning of the influence of the events experienced by patients treated as the severity of the perceived trauma were also not taken into account. The influence of personal traumatic experiences that could affect the level of STS symptoms was also not analyzed. The analyses did not include a certain place of work (hospital, ward) because of the possible simultaneous employment of study participants in multiple places. It should be underlined that the study group was not homogeneous. Men constituted the majority of the group of paramedics while the group of nurses included mainly women. Age, gender and occupational group were not taken into account in further analysis. Due to the complexity of the social support variable and possible overpowering of the study, the results should be interpreted with caution.

Despite the indicated limitations, the results of the conducted study contribute new information within the conditioning of negative consequences of indirect exposure to trauma among the medical personnel. It shows that the cognitive models developed for PTSD may be applied to STS. Moreover, the research in this topic available in the literature referring to the medical staff include first and foremost nurses, therefore, the additional advantage of the conducted study was the extension of the sample by the group of paramedics.

The conducted study may also inspire further research in which other indicators of cognitive trauma processing, such as disruptions in basic convictions or ruminating the events experienced by the patients as well as personal features of helpers including the feeling of self-sense of self-efficacy in coping with trauma experienced by others should also be included. The analyses indicating the mediational role of job satisfaction, social support, and cognitive trauma processing in the relationship between occupational load and STS symptoms would also be useful. Longitudinal study that allow capturing the changes in the range of STS symptoms is also necessary. It should be remembered that the indirect exposure to trauma leads not only to negative consequences but it also may be a source of positive posttraumatic changes in the form of vicarious growth after the trauma.

Implications for practice

The conducted research may also have the practical implications for the development of prevention programs aiming at the decrease of levels of STS symptoms and lowering the risk of STSD occurrence among medical personnel, nurses and paramedics. The procedures designed to increase the level of satisfaction with work seems to be important. These interventions should focus on improving the source of job satisfaction such as the perceived ability to deliver good patient care, good relationships, respect from the superiors, supportive leadership, good salary, competitive pay and bonuses, participation in developing own work schedule, job security, self-growth in the form of professional training and job promotion, job autonomy, opportunity to decision-making and develop multidisciplinary actions in the context of health [73–76]. Nikić et al. [77] also point out the need for improving the communication skills and health as interventions that may lead to increase job satisfaction among health care workers. It should also be taken into consideration that high job satisfaction may favour the occurrence of secondary posttraumatic growth (SPTG). This is indicated by the research of Ogińska-Bulik and Juczynski [13] which informs about a positive relationship between job satisfaction and SPTG in a group of therapists and nurses working with trauma victims. Moreover, the development of competences of coping with trauma considering the alteration of cognitive coping strategies from negative to positive as well as encouragement to use of various self-care practices is also advisable. The significance of such practices is mentioned by Molnar et al. [78]. Encouraging to search and use not only social support from the close ones but also various forms of support like participation in workshops, training, supervision, or debriefing is also recommended. According to Calderón-Abbo et al. [79] these forms of support may significantly contribute to the prevention of negative results of indirect exposure to trauma. A significant role for the reduction of STS symptoms is also attributed to psychoeducation aimed at providing and broadening the knowledge about STS and developing coping skills. Molnar et al. [78] underline their importance and efficiency in lowering the intensity of STS symptoms in pediatric nurses. It may also be useful for professional competences. Several studies mentioned by Molnar et al. [78] show that the development of such competencies contributed to the reduction of STS symptoms in professionals who work with trauma victims. Med-Stress program developed by Smoktunowicz et al. [80] and aimed at counteracting the occurrence of secondary traumatization among medical personnel is used in Poland.