Continuing Nursing Education
Recalling Stress and Trauma in the
Workplace: A Qualitative Study of
Pediatric Nurses
Anna E. Kleis and Marni B. Kellogg
N
ursing 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
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PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1
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.
noted in the prevalence of secondary may cause secondary traumatic stress
traumatic stress or compassion in pediatric nurses.
fatigue, with mean scores ranging Qualitative studies in the literature
from low levels in nursing coordina- related to stress in pediatric nursing
tion (Kim, 2013), average levels in crit- are limited. McGibbon and colleagues
ical care nurses (Sacco et al., 2015), (2010) published an ethnography on
and moderate or high levels in pedi- pediatric nursing stress studying nurs-
atric nurses (Kellogg et al., 2018). es working in a pediatric intensive care
These results indicate the occurrence unit of a pediatric hospital in Canada.
of work-related stress or trauma is Results focused on causes of nursing
highly variable and should be further stress and revealed six themes: 1) emo-
investigated so appropriate interven- tional distress, 2) constant presence, 3)
tions can be implemented. Currently, the burden due to responsibility, 4)
little is reported in the literature about hierarchical power, 5) bodily care, and
experiences in pediatric nursing that 6) being mothers, daughters, aunts,
are most challenging emotionally and and sisters.
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.
5
 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.
6 PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1
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
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,
 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 16.0 Years of nursing experience 20.0
(n = 334) (n = 72)
Years of pediatric nursing 14.4 Years of pediatric nursing 17.7
experience (n = 333) experience (n = 72)
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

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
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.”
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

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

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
8 PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1
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-
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
 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
PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1
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
spaces for nurse respite and reflection,
recently demonstrated a decrease 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.
9

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PEDIATRIC NURSING/January-February 2020/Vol. 46/No. 1
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