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Secondary traumatic stress and dissociative coping strategies in nurses during the COVID-19 pandemic: The protective role of resilience

  • George Tsouvelas
    Correspondence
    Corresponding author at: Department of Psychology, School of Philosophy, Zographou Campus, CP: 15784 Athens, Greece.
    Affiliations
    Department of Psychology, National and Kapodistrian University of Athens, Athens, Greece
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  • Argyroula Kalaitzaki
    Affiliations
    Department of Social Work, Laboratory of Interdisciplinary Approaches for the Enhancement of Quality of Life, Affiliated Researcher of the Research Centre ‘Institute of Agri-Food and Life Sciences’, Hellenic Mediterranean University, CP: 71004 Heraklion, Greece
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  • Alexandra Tamiolaki
    Affiliations
    Department of Social Work, Laboratory of Interdisciplinary Approaches for the Enhancement of Quality of Life, Hellenic Mediterranean University, CP: 71004 Heraklion, Greece
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  • Michael Rovithis
    Affiliations
    Department of Nursing, Laboratory of Interdisciplinary Approaches to the Enhancement of Quality of Life, Affiliated Researcher of the Research Centre ‘Institute of Agri-Food and Life Sciences’, Health Sciences Faculty, Hellenic Mediterranean University, CP: 71004 Heraklion, Crete, Greece
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  • George Konstantakopoulos
    Affiliations
    Department of Psychiatry, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece

    Department of Clinical, Education and Health Psychology, University College London, London, UK
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Published:August 30, 2022DOI:https://doi.org/10.1016/j.apnu.2022.08.010

      Highlights

      • High levels of STS were found for nurses during the first phase of the COVID-19 pandemic in Greece.
      • STS was positively predicted by denial and self-distraction coping strategies and inversely by resilience.
      • Findings confirmed the relationship between dissociation processes (captured using the dissociative coping strategies) and STS.
      • Resilience exhibited a protective effect on the strong relationship between the dissociative coping strategies and STS.

      Abstract

      During the COVID-19 pandemic, nurses are repeatedly exposed to acute stress at their workplace, and therefore, they are at high risk for developing mental health symptoms. The prolonged exposure of healthcare professionals may lead to Secondary Traumatic Stress (STS). STS is an aspect of “cost of care”, the natural consequence of providing care to people who suffer physically or psychologically. The purpose of this study was to investigate the levels of STS in nurses during the first phase of the COVID-19 pandemic in Greece and to detect aggravating and protective factors. Participants were 222 nurses (87.4 % women; mean age 42.3 years) who completed an online survey. The questionnaire comprised of the Secondary Traumatic Stress Scale, the Brief Resilience Scale, and the Brief Coping Orientation to Problems Experienced Inventory. Nurses had high levels of STS. The hierarchical regression analyses showed that STS and its dimensions Avoidance and Arousal were positively predicted mainly by denial and self-distraction coping strategies and inversely by resilience. Resilience exhibited a protective (partial mediation) effect on the strong relationship between the dissociative coping strategies (denial, self-distraction, venting and behavioral disengagement) and STS. Trauma-informed care psychosocial interventions are needed to support the already overburdened nursing staff during the coronavirus pandemic.

      Keywords

      Introduction

      The new coronavirus (COVID-19) began spreading in China at the end of 2019 and, to date, represents an international health emergency with major effects on health and economy (
      World Health Organization
      COVID-19 preparedness and response progress report 1 February to 30 June 2020.
      ). In Greece, the first COVID-19 case was diagnosed on February 26, 2020 (
      • Giannopoulou I.
      • Tsobanoglou G.O.
      COVID-19 pandemic: Challenges and opportunities for the Greek health care system.
      ). While the country was emerging from a long-lasting period of profound economic crisis, the COVID-19 outbreak brought the public healthcare system to the edge of collapse.
      Nurses are under extreme psychological pressure due to their prolonged workplace exposure to the deadly virus. Avoiding contact with their families because of fear of infecting them, experiencing heavy workloads and lack of adequate personal protective equipment and medication (
      • Arpacioglu S.
      • Gurler M.
      • Cakiroglu S.
      Secondary traumatization outcomes and associated factors among the health care workers exposed to the COVID-19.
      ) are aggravating factors for their mental health (
      • Xiang Y.T.
      • Yang Y.
      • Li W.
      • Zhang L.
      • Zhang Q.
      • Cheung T.
      • Ng C.H.
      Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed.
      ). According to
      • İlhan B.
      • Küpeli İ.
      Secondary traumatic stress, anxiety, and depression among emergency healthcare workers in the middle of the COVID-19 outbreak: A cross-sectional study.
      increased levels of STS, anxiety, and depression were observed among nurses during the pandemic. Furthermore, according to
      • Lin J.
      • Ren Y.-H.
      • Gan H.-J.
      • Chen Y.
      • Huang Y.-F.
      • You X.-M.
      Factors associated with resilience among non-local medical workers sent to Wuhan, China during the COVID-19 outbreak.
      nurses were found to have lower resilience when compared to doctors and other medical staff. Constantly suffering the threat of being exposed and infected by the virus, nurses are, therefore, at higher risk of developing dysfunctional coping strategies and behaviors.

      Secondary traumatic stress

      Secondary Traumatic Stress (STS) emerges from work-related secondary exposure to extremely stressful events (
      • Figley C.R.
      Compassion fatigue.
      ), as a consequence of caring for clients who are traumatized, in pain or suffering (
      • Mangoulia P.
      • Koukia E.
      • Alevizopoulos G.
      • Fildissis G.
      • Katostaras T.
      Prevalence of secondary traumatic stress among psychiatric nurses in Greece.
      ). Secondary exposure to trauma is now considered a DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD;
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ) and early detection of severe STS symptoms may be associated with PTSD. According to
      • Adriaenssens J.
      • de Gucht V.
      • Maes S.
      The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey.
      , symptoms of STS include intrusive recurring thoughts, fatigue, disturbed sleep, hyperarousal, physical symptoms, anxiety, depression, and emotional arousal.
      Τhe history of trauma experiences, adverse childhood experiences (
      • Butler L.D.
      • Maguin E.
      • Carello J.
      Retraumatization mediates the effect of adverse childhood experiences on clinical training-related secondary traumatic stress symptoms.
      ) and the coping style previously used to deal with these experiences (
      • Figley C.R.
      Compassion fatigue.
      ) are the major risk factors for developing STS.
      • Dutton M.A.
      • Rubinstein F.L.
      Working with people with PTSD: Research implications.
      have also stipulated that STS reactions by nurses were predicted by secondary exposure to traumatic events experienced at the workplace, use of coping strategies, and psychological and contextual characteristics. Self-efficacy in implementing the COVID-19 protocols has been inversely related to STS (
      • Cai H.
      • Tu B.
      • Ma J.
      • Chen L.
      • Fu L.
      • Jiang Y.
      • et al.
      Psychological impact and coping strategies of frontline medical staff in Hunan between January and March 2020 during the outbreak of coronavirus disease 2019 (COVID-19) in Hubei, China.
      ).
      There is a small number of studies showing that healthcare professionals during current pandemic experience moderate to high levels of STS (
      • Lee M.S.
      • Shin S.
      • Hong E.
      Factors affecting secondary traumatic stress of nurses caring for COVID-19 patients in South Korea.
      ;
      • Ranieri J.
      • Guerra F.
      • Giacomo D.
      Predictive risk factors for post-traumatic stress symptoms among nurses during the Italian acute COVID-19 outbreak.
      ;
      • Vagni M.
      • Maiorano T.
      • Giostra V.
      • Pajardi D.
      Coping with COVID-19: Emergency stress, secondary trauma and self-efficacy in healthcare and emergency workers in Italy.
      ). Contact with COVID-19 patients referred to as an aggravating factor for STS (
      • Orrù G.
      • Marzetti F.
      • Conversano C.
      • Vagheggini G.
      • Miccoli M.
      • Ciacchini R.
      • Gemignani A.
      Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak.
      .
      • Trumello C.
      • Bramanti S.M.
      • Ballarotto G.
      • Candelori C.
      • Cerniglia L.
      • Cimino S.
      • Babore A.
      Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: Differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals.
      ) while other studies found that nurses not working closely with COVID-19 patients experienced more severe symptoms compared with their frontline colleagues working in the emergency services (
      • Li Z.
      • Ge J.
      • Yang M.
      • Feng J.
      • Qiao M.
      • Jiang R.
      • Yang C.
      Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control.
      ) and
      • İlhan B.
      • Küpeli İ.
      Secondary traumatic stress, anxiety, and depression among emergency healthcare workers in the middle of the COVID-19 outbreak: A cross-sectional study.
      did not validate differences between two groups in nurses. Given the inconsistent findings, it would be useful to examine levels of STS in the Greek nurses in terms of their contact with COVID-19 patients.
      The relationship between dissociation and trauma has been well documented (
      • van der Kolk B.A.
      • Pelcovitz D.
      • Roth S.
      • Mandel F.S.
      • McFarlane A.
      • Herman J.L.
      Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma.
      ). Dissociation describes a complex process of detachment often experienced during a traumatic event (peritraumatic dissociation;
      • Marmar C.R.
      • Weiss D.S.
      • Metzler T.J.
      • Delucchi K.
      Characteristics of emergency services personnel related to peritraumatic dissociation during critical incident exposure.
      ), or else, one's unwillingness to be exposed to human suffering or trauma that often creates the strong desire to “walk out right now” (
      • Missouridou E.
      Secondary posttraumatic stress and nurses' emotional responses to patient's trauma.
      ). As suggested by
      • Samson T.
      • Shvartzman P.
      Secondary traumatization and proneness to dissociation among palliative care workers: A cross-sectional study.
      , medical personnel tend to develop a clinical level of dissociation that puts them at increased risk for STS. There are few studies available which, however, prove the connection between STS and peritraumatic dissociation in mobile crisis workers (
      • Plouffe K.A.
      The relationship of dissociation proneness to secondary trauma, burnout, and compassion satisfaction in mobile crisis workers.
      ), palliative care providers (
      • Samson T.
      • Shvartzman P.
      Secondary traumatization and proneness to dissociation among palliative care workers: A cross-sectional study.
      ), and social workers (
      • Lev-Wiesel R.
      • Goldblatt H.
      • Eisikovits Z.
      • Admi H.
      Growth in the shadow of war: The case of social workers and nurses working in a shared war reality.
      ;
      • Samson T.
      • Bachner Y.G.
      • Freud T.
      Thought patterns mediate the development of secondary traumatic stress in social workers.
      ). According to
      • Ozer E.J.
      • Best S.R.
      • Lipsey T.L.
      • Weiss D.S.
      Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis.
      , a crucial predictor of posttraumatic symptoms is a personal tendency toward dissociation during exposure to a stressful event that results in detachment experienced in the course of a traumatic event (
      • Samson T.
      • Bachner Y.G.
      • Freud T.
      Thought patterns mediate the development of secondary traumatic stress in social workers.
      ) and worsens the prognosis (
      • Levin A.P.
      • Kleinman S.B.
      • Adler J.S.
      DSM-5 and posttraumatic stress disorder.
      ). During COVID-19 pandemic, large percentage of nurses (61 %) evidenced significant peritraumatic dissociative experience (
      • Ranieri J.
      • Guerra F.
      • Giacomo D.
      Predictive risk factors for post-traumatic stress symptoms among nurses during the Italian acute COVID-19 outbreak.
      ) and showed the highest percentages peritraumatic dissociation among other healthcare workers (
      • Azoulay E.
      • Cariou A.
      • Bruneel F.
      • Demoule A.
      • Kouatchet A.
      • Reuter D.
      • Kentish-Barnes N.
      Symptoms of anxiety, depression, and peritraumatic dissociation in critical care clinicians managing patients with COVID-19. A cross-sectional study.
      ).

      Coping strategies and STS

      Coping strategies are the cognitive and behavioral efforts made to control, reduce, or tolerate the internal or external requirements that threaten or overwhelm the individual's response capacity (
      • Lazarus R.
      • Folkman S.
      Stress, appraisal, and coping.
      ).
      • Ehlers A.
      • Clark D.M.
      A cognitive model of posttraumatic stress disorder.
      model for trauma and PTSD suggests that the experience of a threat initiates a series of coping strategies (excessive precautions, maladaptive responses to intrusive memories and persistent dissociation) that intend to minimize the threat, albeit they maintain the trauma symptoms (e.g., PTSD) (
      • Beierl E.T.
      • Böllinghaus I.
      • Clark D.M.
      • Glucksman E.
      • Ehlers A.
      Cognitive paths from trauma to posttraumatic stress disorder: A prospective study of Ehlers and Clark's model in survivors of assaults or road traffic collisions.
      ).
      Study findings have shown either problem-focused (e.g., active coping) (
      • Howlett M.
      • Doody K.
      • Murray J.
      • LeBlanc-Duchin D.
      • Fraser J.
      • Atkinson P.
      Burnout in emergency department healthcare professionals is associated with coping style: A cross-sectional survey.
      ) or emotion-focused strategies (e.g., rumination, emotional expression,) (
      • Rodríguez-Rey R.
      • Palacios A.
      • Alonso-Tapia J.
      • Pérez E.
      • Álvarez E.
      • Coca A.
      • Llorente A.
      Burnout and posttraumatic stress in paediatric critical care personnel: Prediction from resilience and coping styles.
      ) or dysfunctional coping strategies (e.g., avoidance or self-blame) (
      • Maunder R.
      • Lancee W.
      • Balderson K.
      • Bennett J.
      • Borgundvaag B.
      • Evans S.
      • Wasylenki D.
      Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.
      ) be associated with increased levels of trauma-related stress or PTSD in the healthcare workers. Clusters of coping strategies (problem-focused, emotion-focused, dysfunctional) are associated with different outcomes (
      • Lazarus R.
      • Folkman S.
      Stress, appraisal, and coping.
      ). Therefore, through the present study we attempt to investigate the observed inconsistency in the findings regarding the association of coping strategies and trauma/PTSD-related situations during the COVID-19 period and we try to review the operation of coping strategies and its clusters. Researchers have proposed different clusters, such as problem-focused vs. emotion-focused (
      • Lazarus R.
      • Folkman S.
      Stress, appraisal, and coping.
      ), adaptive vs. maladaptive (
      • Meyer B.
      Coping with severe mental illness: Relations of the brief COPE with symptoms, functioning, and well-being.
      ).
      • Zuckerman M.
      • Gagne M.
      The COPE revised: Proposing a 5-factor model of coping strategies.
      and
      • Kalaitzaki A.
      • Tamiolaki A.
      • Tsouvelas G.
      From secondary traumatic stress to vicarious posttraumatic growth amid COVID-19 lockdown in Greece: The role of healthcare workers' coping strategies.
      have suggested that coping responses should not be a priori defined as adaptive or maladaptive, since context is significant in attributing the meaning of adaptiveness. What seems to be consistent in the relevant literature are the specific coping strategies that are most frequently used. Studies have shown the use of avoidance and minimization by emergency medical service personnel (
      • Kerai S.M.
      • Khan U.R.
      • Islam M.
      • Asad N.
      • Razzak J.
      • Pasha O.
      Post-traumatic stress disorder and its predictors in emergency medical service personnel: A cross-sectional study from Karachi, Pakistan.
      , avoidance or self-blame by healthcare professionals (
      • Maunder R.
      • Lancee W.
      • Balderson K.
      • Bennett J.
      • Borgundvaag B.
      • Evans S.
      • Wasylenki D.
      Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.
      ), behavioral disengagement and distraction by nurses (
      • Wong T.W.
      • Yau J.K.Y.
      • Chan C.L.W.
      • Kwong R.S.Y.
      • Ho S.M.Y.
      • Lau C.C.
      • Lit C.H.
      The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope.
      ), “Stop Unpleasant Emotions and Thoughts” by healthcare and emergency workers (
      • Vagni M.
      • Maiorano T.
      • Giostra V.
      • Pajardi D.
      Coping with COVID-19: Emergency stress, secondary trauma and self-efficacy in healthcare and emergency workers in Italy.
      ), and denial, self-distraction, and behavioral disengagement by healthcare professionals (
      • Kalaitzaki A.
      • Rovithis M.
      Secondary traumatic stress and vicarious posttraumatic growth in healthcare workers during the first COVID-19 lockdown in Greece: The role of resilience and coping strategies.
      ), all of which have an underlying dissociative feature. In this study we proposed and examined a new classification of the coping strategies based on our belief that shared dissociative features exist between self-distraction, venting, denial, and behavioral disengagement.

      Resilience and STS

      Most researchers have recently agreed that psychological resilience is a complex concept and can be considered as a dynamic process that leads to health, adaptation, and positive functioning (
      • Southwick S.M.
      • Bonanno G.A.
      • Masten A.S.
      • Panter-Brick C.
      • Yehuda R.
      Resilience definitions, theory, and challenges: Interdisciplinary perspectives.
      ;
      • Tsigkaropoulou E.
      • Douzenis A.
      • Tsitas N.
      • Ferentinos P.
      • Liappas I.
      • Michopoulos I.
      Greek version of the Connor-Davidson Resilience Scale: Psychometric properties in a sample of 546 subjects.
      ); thus, it is a modifiable factor (
      American Psychological Association
      Building your resilience.
      ). By definition resilience refers to one's continuing effort/battle to cope with a stressful situation before, during, or after the development of any potential psychopathology symptoms (e.g., PTSD) (
      • Kaye-Kauderer H.
      • Feingold J.H.
      • Feder A.
      • Southwick S.
      • Charney D.
      Resilience in the age of COVID-19.
      ).
      Nurses seem to be extremely vulnerable, exhibiting a less-resilient response to the COVID-19-related stress compared to doctors and other support staff (
      • Lin J.
      • Ren Y.-H.
      • Gan H.-J.
      • Chen Y.
      • Huang Y.-F.
      • You X.-M.
      Factors associated with resilience among non-local medical workers sent to Wuhan, China during the COVID-19 outbreak.
      ). Previous studies have found that resilience was negatively associated with STS (
      • Foster K.
      • Roche M.
      • Delgado C.
      • Cuzzillo C.
      • Giandinoto J.-A.
      • Furness T.
      Resilience and mental health nursing: An integrative review of international literature.
      ;
      • McGarry S.
      • Girdler S.
      • McDonald A.
      • Valentine J.
      • Lee S.L.
      • Blair E.
      • Elliott C.
      Paediatric health-care professionals: Relationships between psychological distress, resilience and coping skills.
      ;
      • Roden-Foreman J.W.
      • Bennett M.M.
      • Rainey E.E.
      • Garrett J.S.
      • Powers M.B.
      • Warren A.M.
      Secondary traumatic stress in emergency medicine clinicians.
      ;
      • Yu F.
      • Raphael D.
      • Mackay L.
      • Smith M.
      • King A.
      Personal and work-related factors associated with nurse resilience: A systematic review.
      ). On the other hand, resilience may play a protective role against trauma-related stress and the risk of developing STS in healthcare professionals during a pandemic (
      • Heath C.
      • Sommerfield A.
      • von Ungern-Sternberg B.S.
      Resilience strategies to manage psychological distress among healthcare workers during the COVID-19 pandemic: A narrative review.
      ;
      • Maiorano T.
      • Vagni M.
      • Giostra V.
      • Pajardi D.
      COVID-19: Risk factors and protective role of resilience and coping strategies for emergency stress and secondary trauma in medical staff and emergency workers—An online-based inquiry.
      ). According to
      • Rees C.S.
      • Breen L.J.
      • Cusack L.
      • Hegney D.
      Understanding individual resilience in the workplace: The international collaboration of workforce resilience model.
      based on the model of International Collaboration Work force Resilience (ICWFR) resilience mediates the relationship between coping and psychological adjustment. Given the aggravating effect of dissociative copings on STS, we expected that resilience could play a protective role against the development of STS, so we chose to consider his potential mediating role.

      The present study

      The aim of this study was threefold: (a) to determine the prevalence of STS in nurses and if contact with COVID-19 patients related to STS, (b) to examine if dissociative copings strategies and resilience predict STS above and beyond demographic and contextual factors and (c) to explore the mediation of resilience in the relationship between dissociative coping strategies and STS. Resilience was expected to mediate the relationship by reducing the effect of dissociative coping strategies on STS.

      Methods

      Participants

      After excluding four participants not residing in Greece and two participants due to missing values as suggested by anomaly index, a sample of 222 nurses participated in the present study. The participants' mean age was 42.3 years; the majority of them were graduates of university nursing education, were working in public hospitals, and had contact with COVID–19 positive cases (see Table 1).
      Table 1Sociodemographic characteristics of participants.
      N%
      Marital status
       Married13761.7
       Singles5424.3
       Divorced3114.0
      Children
       Yes14565.3
       No7734.7
      Education
       Graduates of 2 years nursing education5323.9
       University11451.4
       Master/Doctoral5514.8
      Work experience
       Up to 5 years3817.1
       6–10 years2612.2
       11–15 years5424.3
       16–20 years4018.0
       21–25 years3114.0
       More than 26 years3214.4
      Workplace
       Public hospitals14364.4
       University hospitals2511.3
       Private hospitals198.6
       Services of social welfare167.2
       Primary health care125.4
       Settings offering personalized services73.2
      Contact positive COVID 19 cases
       Yes15231.5
       No7068.5
      RangeMSD
      Age23–65 years42.39.83
      Self-efficacy of implementing the COVID-19 protocols1(not at all) – 5(a lot)3.320.96
      Note: Ν = Frequencies, M = Mean, SD = Standard Deviation.

      Procedure

      A descriptive correlational design was utilized. This study was conducted through an online survey during the period of the first lockdown in Greece (April 5–30, 2020), and it was approved by the Research Ethics Committee of the Hellenic Mediterranean University. Participants were recruited using a convenience and snowball mixed sampling procedure. All invitees completed the questionnaire online via google forms. The participants received a complete description of the survey and were asked to sign an online informed consent prior to data collection.

      Measures

      The online survey demographic questions such as age, gender, marital status, number of children, education, work experience, and city of workplace were initially asked. A number of questions asked about nurses' experience with COVID-19 (i.e., whether they had contact with confirmed COVID-19 cases, level of self-efficacy of implementing the COVID-19 protocols). In addition, the following questionnaires assessed the study variables:
      The Secondary Traumatic Stress Scale (STSS;
      • Bride B.E.
      • Robinson M.M.
      • Yegidis B.
      • Figley C.R.
      Development and validation of the secondary traumatic stress scale.
      ), consisting of 17 items, allocated in three subscales (Intrusions, Avoidance, and Hyperarousal), was used to measure the intensity of secondary stress experienced in the past 7 days. Items are scored on a five-point scale, ranging from 1 (never) to 5 (very often). The scale has been translated into the Greek language by
      • Kalaitzaki A.
      • Rovithis M.
      Secondary traumatic stress and vicarious posttraumatic growth in healthcare workers during the first COVID-19 lockdown in Greece: The role of resilience and coping strategies.
      . The reliability (Cronbach's α) in the current sample was acceptable: STS total score = 0.91, Intrusion = 0.78, Avoidance = 0.78, and Arousal = 0.82.
      The Brief COPE (Coping Orientation to Problems Experienced Inventory;
      • Carver C.S.
      You want to measure coping but your protocol' too long: Consider the brief cope.
      ), consisting of 28 items, allocated in 14 subscales (i.e., Active coping, Planning, Use of emotional support, Use of instrumental support, Positive reframing, Acceptance, Religion, Humour, Venting, Denial, Substance use, Behavioral disengagement, Self-distraction, Self-blame), was used to assess coping strategies. Scales 1 through 8 are regarded adaptive coping strategies, whereas scales 9 through 14 are presumably maladaptive (
      • Meyer B.
      Coping with severe mental illness: Relations of the brief COPE with symptoms, functioning, and well-being.
      ). The participants indicated how often they were using each strategy to deal with COVID-19 pandemic, using a 4-point scale ranging from 0 (not at all) to 4 (very much). The Greek version of the scale has been validated by
      • Kapsou M.
      • Panayiotou G.
      • Kokkinos C.M.
      • Demetriou A.G.
      Dimensionality of coping: An empirical contribution to the construct validation of the brief-COPE with a Greek-speaking sample.
      . Reliabilities of the two subscales in the current sample were acceptable: adaptive coping α = 0.80 and maladaptive α = 0.73.
      The Brief Resilience Scale (BRS;
      • Smith B.W.
      • Dalen J.
      • Wiggins K.
      • Tooley E.
      • Christopher P.
      • Bernard J.
      The brief resilience scale: Assessing the ability to bounce back.
      ), consisting of six items was used to measure resilience as self-perceived ability to bounce back or recover quickly from stress. Responses were rated on a five-point Likert scale. The scale has been translated into the Greek language by
      • Kalaitzaki A.
      • Rovithis M.
      Secondary traumatic stress and vicarious posttraumatic growth in healthcare workers during the first COVID-19 lockdown in Greece: The role of resilience and coping strategies.
      . The reliability in the current sample was acceptable (α = 0.70).

      Statistical analysis

      • Bride B.E.
      Prevalence of secondary traumatic stress among social workers.
      thresholds were used for the interpretation of the STS (percentiles: 75th = 37.00, 90th = 43.80, 95th = 48.40), Intrusion (percentiles: 75th = 11.00, 90th = 12.00, 95th = 13.00), Avoidance (75th = 16.00, 90th = 20.00, 95th = 22.00) and Arousal scores (percentiles: 75th = 11.00, 90th = 14.00, 95th = 16.00). Independent samples t-tests were performed to test the differences on STS between the nurses who had contact with confirmed COVID-19 cases and those who had not. Four regression analyses were performed for the prediction of STS total score and its subscales (Intrusion, Avoidance, and Arousal) by sociodemographic variables, coping strategies, and resilience. All analyses with a p-value < .05 were considered significant and were performed with IBM SPSS v23. A mediation analysis was conducted as Structural Equation Model with AMOS v20, using Maximum Likelihood estimation method. The Expectation-Maximization imputation algorithm was used to estimate missing values. Direct effects included the relationships between the latent variables Resilience and STS, whereas indirect effects included the relationships between resilience and STS accounting for the latent variable of dissociative coping strategies. Parametric bootstrapping of standard errors across 2000 samples was used for the estimation of indirect effect. Model fit indices were assessed (
      • Hooper D.
      • Coughlan J.
      • Mullen M.R.
      ‘Evaluating model fit: A synthesis of the structural equation modelling literature’.
      ): Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), and Incremental Fit Index (IFI) greater than 0.95, root mean square error of approximation (RMSEA) and standardized root-mean-square residual (SRMR) less than 0.08.

      Results

      Descriptive statistics

      Table 2 presents means and standard deviations for the STS and its subscales, the 14 coping subscales, and resilience.
      Table 2Descriptive statistics for STS, coping subscales and resilience.
      Descriptive statisticsMSD
      STS Intrusion13.754.62
      STS Avoidance17.245.65
      STS Arousal13.024.98
      STS Total44.0013.93
      COPE Self Distraction5.331.49
      COPE Active Coping5.821.43
      COPE Denial3.951.56
      COPE Substance Use2.290.90
      COPE Use Emotional Support4.821.75
      COPE Use Instrumental Support4.791.79
      COPE Behavioral Disengagement2.691.11
      COPE Venting4.381.34
      COPE Positive Reframing6.211.39
      COPE Planning6.121.50
      COPE Humour4.381.46
      COPE Acceptance6.261.37
      COPE Religion4.511.91
      COPE Self Blame3.861.41
      Resilience21.294.02
      Note: M = Mean, SD = Standard Deviation.

      Levels of STS

      Regarding cut off scores (
      • Bride B.E.
      Prevalence of secondary traumatic stress among social workers.
      ), 146 (65.8 %) of the participants presented moderate to high scores on STS. Moreover, regarding STS's dimensions 150 (67.6 %) presented moderate to high scores on Intrusions, 116 (52.3 %) presented moderate to high scores on Avoidance and 133 (59.9 %) presented moderate to high scores on Arousal.

      Contact with confirmed COVID-19 cases and STS

      Compared to the 70 participants who did not had contact with Confirmed COVID-19 cases, the 152 participants who had contact demonstrated significantly higher scores on Intrusion t(220) = 2.19, p = .030, d = 0.32, and a tendency for higher scores on the overall STS scale t(220) = 1.80, p = .074, d = 0.26. There were neither statistically significant difference for Avoidance t(220) = 1.30, p = .195, d = 0.19 nor for Arousal t(220) = 1.52, p = .129, d = 0.22.

      Regression analyses

      A series of hierarchical multiple regression analyses (using the stepwise method) were performed in order to investigate whether socio-demographic and contextual factors would predict STS and its subscales (see Table 3). In step 1, the demographic variables (gender, age, marital status, children) were introduced, in step 2 the contextual variables (work experience, specialization, working in the capital of Greece, contact with confirmed COVID-19 cases and self-efficacy of implementing the COVID-19 protocols) were introduced, and in step 3 the subscales of coping and resilience were introduced. Self-efficacy in implementing the COVID-19 protocols (inversely), denial, and self-distraction predicted STS total score and all three subscales (Intrusion, Avoidance, and Arousal). Marital status, with married people showing higher scores, predicted STS total score, Intrusion, and Arousal. Resilience negatively predicted STS total score, Intrusion, and Αvoidance. Positive reframing inversely predicted Arousal but no other STS score (see Table 3).
      Table 3Hierarchical regression analysis for predicting STS and its subscales by socio-demographic and contextual factors, coping strategies and resilience.
      STSIntrusionAvoidanceArousal
      Final step (ΔR2)βFinal step (ΔR2)βFinal step (ΔR2)βFinal step (ΔR2)β
      Gender
      Age
      Marital status1(0.03)0.17
      p < .01.
      1(0.05)0.23
      p < .001.
      1(0.02)0.15
      p < .01.
      Children
      Work Experience2(0.02)0.07ns
      Self efficacy procedures COVID-192(0.08)−0.21
      p < .001.
      2(0.03)−0.16
      p < .01.
      1(0.07)−0.19
      p < .001.
      2(0.10)−0.25
      p < .001.
      Specialization
      Work in the capital
      Self Distraction4(0.07)0.28
      p < .001.
      4(0.06)0.28
      p < .001.
      4(0.05)0.22
      p < .001.
      4(0.07)0.31
      p < .001.
      Active Coping
      Denial3(0.24)0.40
      p < .001.
      3(0.18)0.36
      p < .001.
      3(0.23)0.40
      p < .001.
      3(0.18)0.36
      p < .001.
      Substance Use
      Use Emotional Support
      Use Instrumental Support
      Behavioral Disengagement
      Venting
      Positive Reframing5(0.02)−0.13
      p < .05.
      Planning
      Humour
      Acceptance
      Religion
      Self Blame5(0.02)0.19
      p < .01.
      Resilience5(0.02)−0.14
      p < .05.
      6(0.02)−0.16
      p < .01.
      5(0.02)−0.16
      p < .01.
      R20.450.380.390.39
      Note ns not statistically significant. For marital status 0 is for single and 1 for married.
      low asterisk p < .05.
      low asterisklow asterisk p < .01.
      low asterisklow asterisklow asterisk p < .001.

      Mediation analysis

      A Structural Equation Model was conducted to test the mediating effect of resilience in the relationship between dissociative coping strategies and STS. The model demonstrated acceptable model fit: CMIN = 88.63, df = 58, p = .013; CFI = 0.97; IFI = 0.98; TLI = 0.97; RMSEA = 0.05 (LO = 0.02, HI = 0.07); SRMR = 0.06. Resilience partially mediated the dissociative coping - STS relationship. Coefficient for direct effect was 0.57, p < .001 and for indirect effect was 0.09, p < .05. In Fig. 1 the model and the standardized path coefficients are presented.
      Fig. 1
      Fig. 1Mediating effects of resilience in the relationship between dissociative coping strategies and Secondary Traumatic Stress.
      Note p < .05, ⁎⁎ p < .01, ⁎⁎⁎ p < .001; Dotted lines refer to indirect effects.

      Discussion

      Nurses are a vulnerable population subgroup who experience persistent and enduring challenges that disturb their working functioning and ability, especially during the COVID-19 outbreak. In line with other findings (
      • Marzetti F.
      • Vagheggini G.
      • Conversano C.
      • Miccoli M.
      • Gemignani A.
      • Ciacchini R.
      • Orru G.
      Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak. medRxiv.
      ), Greek nurses exhibited high levels of overall STS, and more specifically, moderate levels of avoidance and arousal symptoms and extremely high levels of intrusion symptoms. Nurses who were in frequent contact with confirmed COVID-19 patients showed more intrusion problems and a tendency for higher overall STS scores, compared to the rest of the nurses. This finding is in keeping with results of previous studies in healthcare professionals during the current pandemic (
      • Kalaitzaki A.
      • Rovithis M.
      Secondary traumatic stress and vicarious posttraumatic growth in healthcare workers during the first COVID-19 lockdown in Greece: The role of resilience and coping strategies.
      ;
      • Lai J.
      • Ma S.
      • Wang Y.
      • Cai Z.
      • Hu J.
      • Wei N.
      • Tan H.
      Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
      ;
      • Marzetti F.
      • Vagheggini G.
      • Conversano C.
      • Miccoli M.
      • Gemignani A.
      • Ciacchini R.
      • Orru G.
      Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak. medRxiv.
      ).
      The examination of the predictors of STS provided interesting findings. Consistent with
      • Von Rueden K.T.
      • Hinderer K.A.
      • McQuillan K.A.
      • Murray M.
      • Logan T.
      • Kramer B.
      • Friedmann E.
      Secondary traumatic stress in trauma nurses: Prevalence and exposure, coping, and personal/environmental characteristics.
      findings, both personal and contextual variables were associated with STS. Married nurses also showed higher overall STS, Intrusion, and Arousal scores. Our results regarding marital status, are in accordance with relevant findings (
      • Zhang J.
      • Wang X.
      • Xu T.
      • Li J.
      • Li H.
      • Wu Y.
      • Zhang J.P.
      The effect of resilience and self-efficacy on nurses' compassion fatigue: A cross-sectional study.
      ). It might be that married healthcare workers, particularly the frontline ones, are more considerate not to say stressed and frightened of the likelihood of transmitting the virus to their loved ones. Self-distraction and denial were the most significant predictors of STS and its dimensions. This finding is in line with other studies on the effect of coping strategies on STS before the pandemic (
      • Akinsulure-Smith A.M.
      • Espinosa A.
      • Chu T.
      • Hallock R.
      Secondary traumatic stress and burnout among refugee resettlement workers: The role of coping and emotional intelligence.
      ;
      • Hosaini S.S.
      • Ariapooran S.
      Secondary traumatic stress in nurses: The role of problem and emotion-focused coping styles.
      ;
      • Kellogg M.B.
      • Knight M.
      • Dowling J.S.
      • Crawford S.L.
      Secondary traumatic stress in pediatric nurses.
      ). Self-blame predicted intrusion symptoms. Self-Blame was strongly and positively associated with intrusion in trauma-related situations (
      • Berman Z.
      • Assaf Y.
      • Tarrasch R.
      • Joel D.
      Assault-related self-blame and its association with PTSD in sexually assaulted women: An MRI inquiry.
      ) and might enhance a feedback process of rumination that sustains intrusion.
      The proposed model of the relationship between dissociative strategies and STS was confirmed by regression and SEM model. Consistent with our hypothesis, coping strategies associated with maintaining dissociation functions appear to be strongly associated with STS. This is both theory and data-driven, as it was based on the theories of trauma therapies (
      • Foa E.
      • Hembree E.
      • Rothbaum B.O.
      Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide.
      ;
      • Schwarz L.
      • Corrigan F.
      • Hull A.
      • Raju R.
      The comprehensive resource model: Effective therapeutic techniques for the healing of complex trauma.
      ;
      • Shapiro F.
      Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures.
      ) and the findings of this study confirmed the relationship between dissociation processes (operated through the dissociative coping strategies) and STS. Resilience, as also expected, predicted inversely STS, which is in line with previous studies (
      • Foster K.
      • Roche M.
      • Delgado C.
      • Cuzzillo C.
      • Giandinoto J.-A.
      • Furness T.
      Resilience and mental health nursing: An integrative review of international literature.
      ;
      • Maiorano T.
      • Vagni M.
      • Giostra V.
      • Pajardi D.
      COVID-19: Risk factors and protective role of resilience and coping strategies for emergency stress and secondary trauma in medical staff and emergency workers—An online-based inquiry.
      ;
      • McGarry S.
      • Girdler S.
      • McDonald A.
      • Valentine J.
      • Lee S.L.
      • Blair E.
      • Elliott C.
      Paediatric health-care professionals: Relationships between psychological distress, resilience and coping skills.
      ;
      • Yu F.
      • Raphael D.
      • Mackay L.
      • Smith M.
      • King A.
      Personal and work-related factors associated with nurse resilience: A systematic review.
      ). Furthermore, it was shown that resilience functions as a protective factor against the impact of dissociative coping strategies on STS. The more available resources (resilience), the weaker the relationship between maladaptive (dissociation-focused) coping strategies and STS. Therefore, the analysis reveals the protective role of resilience in the robust relationship between dissociative coping and STS. The aim should be both to enhance the psychological resilience of nurses and to reduce the use of dissociative coping strategies in order not to be at risk for developing STS.
      It is plausible that a number of limitations may have influenced the results of this study. The first is that a convenient sample limits the generalizability of the findings. No definite conclusions regarding the effect of gender on the STS can be drawn since the sample mostly comprised of women. The web-based questionnaire survey is another limitation. A web-based questionnaire requires some basic IT skills, however, since nurse practitioners are familiar with health information systems, we do not consider it to be a significant limitation for our study. Furthermore,
      • Ekman A.
      • Dickman P.W.
      • Klint Å.
      • Weiderpass E.
      • Litton J.E.
      Feasibility of using web-based questionnaires in large population-based epidemiological studies.
      concluded that the bias associated with collecting information using web questionnaires was not greater than that of the paper questionnaires. Another limitation is that this was cross-sectional study. A longitudinal study would have allowed for a better interpretation of the phenomena, such as the development and the maintaining of symptoms of secondary trauma in nurses. Future research should examine the convergent validity of the proposed dissociative coping strategies and their predisposing, precipitating and maintaining role on STS.
      Despite its limitations, this study expanded our knowledge by providing insights on the risk and protective factors that are associated with nurses' STS. The findings of the present study also have important implications for the development of prevention programs and workplace mental health interventions for preventing post and peri-traumatic symptoms and dealing with secondary traumatization in healthcare professionals. Since avoidance/denial is a common response to trauma/traumatic experiences at the workplace and seeking help for psychological problems has been associated with stigma in many communities, interventions should be made even more public and widely accessible (
      • Kaye-Kauderer H.
      • Feingold J.H.
      • Feder A.
      • Southwick S.
      • Charney D.
      Resilience in the age of COVID-19.
      ). Such interventions should target at addressing the trauma-related factors (e.g., dissociative strategies) that jeopardize healthcare workers' ability to provide effective care (
      • Sabo B.M.
      Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work?.
      ), their mental health (i.e., STS), and internal assets (e.g., resilience). At the same time interventions should also activate or enhance protective factors, such as personal resources (e.g., resilience), help healthcare workers reprocessing stressful events and use of the most effective and functional long-term coping strategies to protect their mental health (
      • Tarquinio C.
      • Brennstuhl M.-J.
      • Rydberg J.A.
      • Bassan F.
      • Peter L.
      • Tarquinio C.L.
      • Tarquinio P.
      EMDR in telemental health counseling for healthcare workers caring for COVID-19 patients: A pilot study.
      ;
      • Tsouvelas G.
      • Chondrokouki M.
      • Nikolaidis G.
      • Shapiro E.
      A vicarious trauma preventive approach. The Group Traumatic Episode Protocol EMDR and workplace affect in professionals who work with child abuse and neglect.
      ) and mitigate or prevent the development of STS. Given the social distancing measures, digital interventions and tele-interventions could be effective during the COVID-19 pandemic, as suggested by
      • Peiró T.
      • Lorente L.
      • Vera M.
      The COVID-19 crisis: Skills that are paramount to build into nursing programs for future global health crisis.
      . Acknowledging the risk and protective factors early enough will safeguard nurses, reduce the risk of STS morbidity, and potentially enhance their working abilities and promote their personal growth (
      • Kalaitzaki A.
      Posttraumatic symptoms, posttraumatic growth, and internal resources among the general population in Greece: A nation-wide survey amid the first COVID-19 lockdown.
      ;
      • Kalaitzaki A.
      • Rovithis M.
      Secondary traumatic stress and vicarious posttraumatic growth in healthcare workers during the first COVID-19 lockdown in Greece: The role of resilience and coping strategies.
      ). These will ensure positive outcomes for the professionals, the patients, and the care they provide.

      Author's contribution

      GT contributed to the conception and design of the manuscript, literature search, writing of the manuscript and approval of the final version.
      AK contributed to the conception and design of the manuscript, literature search, writing of the manuscript and approval of the final version.
      AT contributed to the literature search, drafted and approved the final manuscript.
      MR contributed to the literature search and approval of the final version.
      GK contributed to literature search, writing of the manuscript and approval of the final version.

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