Compassion Fatigue and Secondary Traumatic Stress Among Emergency Department Nurses

Introduction

Compassion fatigue, a construct encompassing both burnout and secondary traumatic stress arising from sustained professional exposure to the suffering of others, was originally conceptualized within the context of clinicians and caregivers working with traumatized populations, and has since been widely applied to nursing, and emergency nursing specifically, given the specialty’s routine exposure to trauma, sudden death, and acute suffering under considerable time pressure (Figley, 1995; Stamm, 2010). Secondary traumatic stress, one of compassion fatigue’s two component constructs, refers specifically to trauma-like symptoms, intrusive thoughts, hypervigilance, and avoidance, that develop as a consequence of indirect exposure to another person’s traumatic experience, distinct from burnout’s more general exhaustion and cynicism (Beck, 2011).

Prior research using the widely validated Professional Quality of Life (ProQOL) scale has consistently found that emergency department nurses report elevated compassion fatigue relative to nurses in many other specialty areas, with a substantial proportion scoring in the high-risk range for both burnout and secondary traumatic stress (Hooper et al., 2010; Adriaenssens et al., 2012). Prior work has identified several plausible contributing factors, including patient volume, frequency of exposure to critical or traumatic cases, and available social and organizational support, though comparatively few studies have examined the relative, independent contribution of these factors within a single regression model, limiting the ability to determine which specific, potentially modifiable exposure or support factor most strongly predicts secondary traumatic stress specifically, as distinct from burnout (Hunsaker et al., 2015; Kelly et al., 2015).

Understanding this relative contribution is particularly important given a common but empirically underexamined assumption that years of accumulated clinical experience naturally builds resilience to secondary traumatic stress; if experience is not, in fact, a strong independent predictor once specific exposure and support factors are accounted for, this would suggest that structured, exposure-responsive support strategies are needed regardless of nurse tenure, rather than relying on experience alone to protect more senior staff. The purpose of this cross-sectional descriptive-correlational study was to examine compassion satisfaction, burnout, and secondary traumatic stress among emergency department nurses using the ProQOL scale, and to evaluate the association of patient volume, frequency of death or trauma exposure, perceived social support, and years of experience with secondary traumatic stress.

Methods

Design. This study used a cross-sectional, descriptive-correlational survey design, appropriate for characterizing the current distribution of compassion satisfaction, burnout, and secondary traumatic stress among emergency department nurses, and for examining the relative strength of several hypothesized correlates of secondary traumatic stress within a single data collection point.

Setting and sample. A survey was distributed to registered nurses working in emergency departments across six hospitals within two regional health systems between March and August 2025. Eligible nurses had a minimum of six months of emergency department experience. Of 328 eligible nurses, 240 completed the survey (73.2% response rate).

Measures. Compassion satisfaction, burnout, and secondary traumatic stress were assessed using the Professional Quality of Life scale (ProQOL-5), a 30-item, well-validated instrument yielding three independently scored subscales (Compassion Satisfaction, Burnout, and Secondary Traumatic Stress), each ranging from 10 to 50, with established cutoff scores distinguishing low, moderate, and high-risk ranges (Stamm, 2010). Weekly patient volume was assessed as the nurse’s typical number of patients cared for per shift, averaged across a typical week. Frequency of death or trauma exposure was assessed using a single-item, five-point frequency scale asking how often the nurse was directly involved in the care of a patient who died or experienced severe trauma during a typical month. Perceived social support was assessed using an adapted 6-item scale (range 0–100) addressing both workplace and personal support availability. Years of emergency nursing experience was assessed as a continuous variable.

Statistical analysis. Descriptive statistics summarized ProQOL subscale scores and the proportion of nurses in each established risk category. Pearson correlation examined the bivariate association of death/trauma exposure frequency, weekly patient volume, perceived social support, and years of experience with Secondary Traumatic Stress score. Multiple linear regression, entering all four predictors simultaneously, examined their independent, adjusted association with Secondary Traumatic Stress score. A two-sided p value of less than .05 was considered statistically significant.

Results

Among 240 surveyed emergency department nurses (Table 1), mean scores across the three ProQOL subscales fell within the moderate range per established scoring conventions, as shown in Figure 1: Compassion Satisfaction 34.2 (SD 6.8), Burnout 26.8 (SD 7.1), and Secondary Traumatic Stress 29.4 (SD 7.9).

Applying established ProQOL cutoff scores at the individual level, as shown in Figure 2, 38.3% of nurses scored in the high-risk range for Secondary Traumatic Stress and 31.7% scored in the high-risk range for Burnout.

Secondary Traumatic Stress score was significantly correlated with frequency of death or trauma exposure (r = .48, p < .001), weekly patient volume (r = .41, p < .001), and perceived social support (r = −.37, p < .001); years of experience showed a weaker, non-significant correlation (r = −.09, p = .17). This same pattern was confirmed in multiple regression, shown in Figure 3.

Discussion

This cross-sectional study found that more than a third of emergency department nurses scored in the high-risk range for secondary traumatic stress, with mean subscale scores across compassion satisfaction, burnout, and secondary traumatic stress all falling in the moderate range, consistent with prior ProQOL-based research documenting elevated compassion fatigue risk among emergency nurses relative to many other nursing specialties (Hooper et al., 2010; Adriaenssens et al., 2012). The specific finding that frequency of death or trauma exposure was the strongest independent predictor of secondary traumatic stress, more influential than weekly patient volume, perceived social support, or years of experience, extends prior work identifying multiple general contributing factors (Hunsaker et al., 2015; Kelly et al., 2015) by clarifying the relative, independent weight of this specific, direct-exposure factor within a single regression model.

The finding that years of experience was not a significant independent predictor of secondary traumatic stress, despite its common assumption as a protective, resilience-building factor, is a particularly important and somewhat counterintuitive result. This pattern suggests that secondary traumatic stress risk in emergency nursing may not simply diminish with career longevity, and that senior nurses with substantial direct trauma and death exposure may remain, or even become increasingly, vulnerable rather than developing durable immunity through repeated exposure alone, a pattern broadly consistent with theoretical models of secondary traumatic stress as a cumulative, exposure-dependent phenomenon rather than a skill that straightforwardly improves with practice (Beck, 2011; Figley, 1995).

The significant, independent protective association of perceived social support is consistent with prior compassion fatigue literature identifying support availability as a key modifiable buffer against secondary traumatic stress (Sprang et al., 2007; Boyle, 2011), and, combined with this study’s finding that a large majority of nurses reported access to formal mental health or employee assistance support despite this substantial protective association, suggests that access to support resources alone may be insufficient; the specific quality, accessibility, and actual utilization of that support, rather than its nominal availability, may be the more consequential factor warranting further investigation.

These findings have direct, practical implications for occupational wellbeing programming in emergency nursing. Rather than distributing wellness resources uniformly across all staff regardless of individual exposure history, or assuming senior staff require comparatively less support, these findings suggest that structured, exposure-responsive psychological support, for example proactively offered following a shift involving a particularly high-acuity trauma or death, and scaled to actual patient volume and workload, would more directly address the specific risk factors identified as most consequential in this study.

Several limitations should be considered. This study’s cross-sectional design does not permit causal inference regarding the direction of the relationship between perceived social support and secondary traumatic stress; it remains plausible that higher secondary traumatic stress itself reduces a nurse’s perception of available support, in addition to or instead of the reverse direction examined as this study’s primary hypothesis. Frequency of death or trauma exposure was assessed using a single-item self-report measure rather than a more detailed exposure inventory, which may have introduced some measurement imprecision. Although the sample spanned six hospitals across two regional health systems, generalizability to emergency departments in other regions or with different patient acuity distributions should be considered carefully.

Future research should examine this relationship longitudinally, ideally alongside implementation of a structured, exposure-responsive psychological support intervention, to test whether proactively addressing high-exposure periods measurably reduces secondary traumatic stress over time relative to standard, uniformly available support resources. Further investigation into the specific quality and actual utilization, rather than nominal availability, of workplace mental health support would help clarify why formal support access did not appear sufficient to fully offset the risk identified in this study. Taken together, these findings underscore that compassion fatigue, and secondary traumatic stress specifically, among emergency department nurses is most strongly driven by direct exposure to death and trauma rather than by accumulated experience, supporting structured, exposure-responsive support strategies as a more targeted approach than generalized wellness programming alone.

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