Stress factors for the emergency nursing team and coping strategies

Nurses and stress: nurses working in the emergency sector live in constant contact with people in critical situations

Patients and their relatives bring with them many problems, thoughts, anxieties, which they inevitably spill over to the nursing staff, precisely because they need to be listened to.

Such continuous requests can generate a state of chronic stress in the staff member, which can lead to mere emotional exhaustion, post-traumatic stress disorders or psychopathologies, acute or chronic (DG Personnel, Organisation and Budget: pursuant to art. 37 “Publication obligations concerning public works, services and supply contracts” of D. lgs. lgs. 33/2013 and art. 29, paragraph 1 of D.lgs 50/2016, we publish the determination of 09/09/2021 by which a procedure for the awarding of a contract by means of a Direct Purchase Order on the Consip platform for the service of “assessment of the risk of work-related stress” for employees of the Ministry of Health).


Stress is a syndrome of adaptation to stressors called ‘stressors’.

It can be physiological, but it can also have pathological implications.

Any stressor that disrupts the body’s equilibrium immediately evokes neuropsychic, emotional, locomotor, hormonal and immunological regulatory reactions (WHO: Illustrated Guide to Stress Management).

Predictability, knowledge and severity of events play a key role in the possibility of establishing adaptive strategies to manage this stress.

Conversely, adaptation is problematic in the case of exposure to sudden catastrophic events, such as in ambulance rescue.


Flashback: an intrusive experience of the event that comes to consciousness, ‘repeating’ the memory of the event

Numbing: a state of consciousness similar to dizziness and confusion

Avoidance: the tendency to avoid anything that is in any way reminiscent of, or related to, the traumatic experience (even indirectly or only symbolically)

Nightmares: which can make one relive the traumatic experience during sleep, very vividly.

Hyperarousal: characterised by insomnia, irritability, anxiety, generalised aggression and tension.

It is very difficult for an experienced and qualified nurse to immediately enter the situation with lucidity and clarity, immediately committing thoughts and actions to the acts required by the intervention.


(Cantelli G., 2008, Lo stress nell’operatore dell’emergenza. Emergency oggi)

  • Unpredictability: the operator does not know in advance when he will be called to intervene, how many exits he will have to make in a day, where he will have to go, how many people may be involved, the seriousness of the rescue, the outcome of his treatment. Once he has arrived at the scene of the event, the nurse who is only in possession of the information given by the operations centre, which is often fragmentary and brief, has to understand what the situation actually looks like. In the meantime, he also has to coordinate the work of the team, manage bystanders, communicate with the operations centre. This uncertainty, in the long run, can create discomfort and alienation.
  • Age of the person to be rescued: rescuing young victims, especially peers and children, are by far the most stressful situations found in studies. The first two incidents considered by nurses to be the most critical relate in particular to death and sexual abuse of children.
  • Psychiatric patients: especially when they are uncooperative. In this case, the patient feels threatened by everything around him, including the caregiver, so much so that his violent reaction is precisely a defence mechanism. Emotional control, calmness and security of the operator in this case are crucial, but not always easy to put into practice, since the tension is really high and the possibility of making mistakes in communication, compromising the success of the intervention, is very high.
  • Severely traumatised patients: even more so if they are young or if they have very serious body injuries (amputations, deformities) or are involved in scenic/severe accidents (imprisoned patient, overturned car, maxi-emergencies).
  • Responsibility: the nurse’s desire for autonomy, the gratification of being alone with the user to frame the clinical situation, to treat it and to choose the access code to the emergency room, is accompanied by the fear of the responsibility of the choice, which historically was delegated to the doctor.
  • Organisation: Situations that create anxiety among emergency personnel may be the insufficient number of human resources and the overload of work to which nurses are subjected especially in recent years and, not least, the inability to provide care according to the expected standards, again due to lack of resources, time and personnel. Furthermore, a frequent feeling reported by some nurses is that of being part of an assembly line.
  • Lack of feedback regarding the work being done: one does not know how one is progressing and this can result in a loss of motivation to work.
  • Identification with the victim: empathy is a necessary condition to be close to those who suffer, but if you do not learn to ‘educate’ them, it can be devastating.
  • Teamwork: working with always different or untrained colleagues and not trusting them.


(Monti M., Lo stress acuto negli operatori d’emergenza e sue complicanze. Description and criteria for intervention in personnel. AISACE conference report, 2011)

To avoid incurring even serious disorders such as post-traumatic stress disorder, burnout or physical somatisation, it is important to apply personalised and individualised strategies to manage this stress (first and foremost talking about it and debriefing, but also physical activity and/or psychological support.

Adaptation strategies may focus on the emotion, seeking to improve the person’s state of mind by decreasing the emotional stress experienced, or on the problem, strategies that aim instead to manage the problem that is causing distress. Usually, both strategies are activated in a stressful situation.

In an operational reality such as that of an out-of-hospital emergency, suspending one’s action and dedicating time to reflecting on what one is doing, may appear unusual and threatening if one does not also have a physical place, which may constitute a pause from the emergency, a space for just thinking, from which one can then resume action, in a more conscious manner.

In order to get rid of accumulated stress, it is necessary to gain understanding, to have the opportunity to be able to talk to someone about one’s experiences, thus being able to realise what has happened, what this has caused, and, in the case of a negative event, to reaffirm that one has acted in the right way, noting that one could not have done otherwise; in this way, one has the opportunity to overcome the feelings of guilt that arise from the failure of the mission.

Author of the article: Dr Letizia Ciabattoni


Cantelli G. (2008) Lo stress nell’operatore dell’emergenza. Emergency oggi; 6

Cudmore J. (2006) Preventing Post traumatic stress disorder in accident and emergency nursing (a review of the literature). Nursing in Critical Care; 1

American Psychiatric Association (2013). DSM-5 Manuale diagnostico e statistico dei disturbi mentali. Raffaello Cortina Editore.

Laposa J.M., Alden L.E., Fullerton L.M. (2013) Work stress and posttraumatic stress disorder in ED nurses/personnel (CE). Journal of Emergency Nursing; 29

Monti M. Lo stress acuto negli operatori d’emergenza e sue complicanze. Descrizione e criteri di intervento nel personale. Relazione convegno AISACE, 2011

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