Emotional Freedom Techniques (EFT) Tapping for Pediatric Emergency Department Staff During the COVID-19 Pandemic: Evaluation of a Pilot Intervention

Abstract

Objective:

Emergency-department (ED) staff may experience psychologic distress due to the stressful nature of their work. The COVID-19 pandemic exacerbated this distress. Emotional Freedom Techniques (EFT) tapping, a somatic psychophysiologic intervention combining vibratory acupressure with elements of cognitive–behavioral and exposure therapies, can reduce psychologic distress. This study tested the short-term effect of 10-minute EFT tapping on the psychologic distress of pediatric ED staff responding to COVID-19.

Materials and Methods:

During the COVID-19 pandemic, diverse staff in the pediatric ED of a New York City teaching hospital participated in this single-group study. A licensed creative arts therapist led participants in 10-minute EFT tapping sessions. A self-report questionnaire with 7 items based on the Trauma Exposure Response framework was administered immediately pre- and postintervention. Standardized mean differences between both timepoints were calculated.

Results:

There were statistically significant reductions for 6 of the 7 items studied, including stress (3.32–2.14), obsessive and intrusive thoughts (2.50–1.85), feelings of pressure (3.20–2.17), loneliness (1.84–1.44), and emotional and physical pain (2.28–1.70); all P < 0.001. No significant changes in professional satisfaction were reported following the intervention.

Conclusions:

Despite the limitations of a single-arm study design, a 10-minute brief EFT tapping session was a promising way to reduce short-term psychologic distress in pediatric ED health care workers. Future studies, including rigorous randomized controlled trials, are needed to evaluate the effectiveness of brief EFT tapping interventions in other settings.

INTRODUCTION

The mental well-being of health care workers (HWs) is a significant public-health concern. Exposure to numerous occupational and patient-related challenges contributes to high levels of psychologic distress,¹ including nonspecific symptoms of stress, post-traumatic stress disorder (PTSD), anxiety, and depression² among HWs. Occupational challenges include heavy workloads, long working hours, responsibility for decision-making, and social expectations of HWs,^3–5 as well as organizational stressors, such as staff downsizing and increased administrative burdens.^4,5 Patient-related challenges include exposure to disease and suffering or death of patients.⁶ HWs in the emergency department (ED), a high-risk area in a hospital with acutely ill patients, are particularly susceptible to these challenges contributing to psychologic distress.³ Chronic exposure to such stressors resulting in psychologic distress can affect mental and emotional well-being negatively (e.g., burnout symptoms; stress-related mental disorders, such as depression, anxiety disorders, and PTSD; and sleep disorders).^7–13 Due to these stressors, HWs frequently report low compassion and job satisfaction and high secondary traumatic stress, especially in the ED.^7,14

With COVID-19 exacerbating these issues, the World Health Organization declared it a critical priority for health care leaders and governments to address the mental well-being of HWs during the pandemic.¹⁵ Throughout the pandemic, an increased load of critically ill patients, fear of contracting and spreading COVID-19, supply shortages, and perceived inability to provide adequate medical care all added to the stresses experienced by HWs.^5,16–19

Unsurprisingly, many studies, reviews, and meta-analyses of stress and the mental health of HWs have been conducted since the beginning of the COVID-19 pandemic.^1,11,17 HWs experienced increased psychologic symptoms of distress, including anxiety, depression, traumatic stress, and somatic symptoms.^{1,8,11,16–19} A 2022 meta-review by Chutiyami et al., involving 3,245,768 HWs across 1828 studies, identified a high pooled prevalence of multiple negative mental health conditions among HWs during the COVID-19 pandemic, including stress, distress, or PTSD (18.6%–56.5%), anxiety (16%–41%), depression (14%–37%), burnout (12%–45.6%), obsessive–compulsive disorder or obsessive thoughts (16.2%), phobias (35%), and somatization symptoms (10.7%).²⁰ Another review on traumatic stress response and acute stress symptoms related to COVID-19 reported a prevalence of trauma-related stress among HWs ranging from 7.4% to 35%, particularly among nurses and frontline workers.²¹ Failure to address these mental-health concerns will lead to significant consequences for HWs and may also affect patient care and safety negatively.

Context

In March 2020, pediatric ED staff of a large hospital in New York City were confronted with a high caseload of critically ill patients and the imminent threat of contracting COVID-19 without an available vaccine. As New York City was a global epicenter for COVID-19,²² hospitals had to quickly reorganize staff and reconfigure departmental spaces to manage the flow of patients with COVID-19; ED staff often had to work longer hours or extra shifts to meet increased patient-care demands.²³

Based on these conditions and considering the importance of implementing interventions to tackle mental health problems among HWs during the pandemic, from June 2020 to July 2021, pediatric ED staff were invited to 10-minute Emotional Freedom Techniques (EFT) tapping group sessions during day and night shifts. The group intervention targeted psychologic stress and negative responses to trauma exposure. EFT tapping and other brief stress-management interventions were novel to the pediatric ED staff, as they had not previously been provided in the department prior to this intervention.

EFT Tapping

EFT tapping is a psychophysiologic intervention for addressing psychologic distress. The technique combines vibratory acupressure with elements of cognitive–behavioral and exposure therapies. Due to this unique acupressure element, EFT is also commonly referred to as “EFT tapping.”²⁴ The basic premise of EFT tapping is to have participants recall a distressing emotional trigger or traumatic memory or event (an element of exposure therapy), verbalize and pair it with a reframing statement of self-acceptance (an element of cognitive–behavioral therapy), while tapping acupoints on the body that are thought to regulate energy flow and relax the body and mind (an element of vibratory acupressure).²⁵ As such, EFT tapping breaks the cycle of hyperarousal from emotional triggers or traumatic events.^26,27 The proposed mechanisms are that EFT simultaneously sends activating signals produced by recall of psychologic distress and deactivating signals produced by tapping to the brain.²⁵ With repeated rounds of tapping, continual deactivating signals start to take over, so psychologic distress is linked with relaxation techniques to create a new response that can be recalled without the previously evoked negative emotional response.^25,28

Compared to other interventions involving cognitive reprocessing or solely relaxation-focused interventions, the addition of acupoint tapping leads to faster reductions in negative mental-health symptoms.^26,27 Neurobiologic studies suggest that acupoint stimulation releases serotonin in the amygdala and prefrontal cortex to enable a rapid reduction in hyperarousal.^28–30 Additionally, EFT tapping helps regulate the stress hormone, cortisol,³¹ and releases opioids, serotonin, and γ-aminobutyric acid, overriding the fight-or-flight response, decreasing pain, and reducing anxiety-related symptoms.³⁰

EFT tapping can be used as an add-on to therapy or as a self-help technique.³¹ It is simple, easy to learn, and can be conducted with limited space and time. Multiple studies report significant results with a single guided session across a wide range of populations.^24,32–35 Systematic reviews and meta-analyses of EFT tapping interventions have demonstrated effectiveness in ameliorating a multitude of mental-health conditions,³⁶ reducing anxiety,³⁷ depression,²⁹ burnout, and PTSD,³⁸ each with large effect sizes (Cohen's ∂ or Hedge's ∂ > 0.8).³⁸ EFT tapping meets the American Psychological Association's Task Force on Evidence-Based Practice criteria for psychologic disorders, including anxiety, depression, phobias, and PTSD.³⁷

Evidence Base

Several studies investigated the mental health challenges of ED HWs during the COVID-19 pandemic and proposed various intervention methods to tackle stress and secondary trauma exposure.¹ However, to date and to the best of the current authors' knowledge, no previous studies evaluating the effectiveness of these interventions have yet been explicitly assessed in EDs.

Additionally, there is a dearth of synthesized evidence around the effects of EFT tapping on mental health symptoms among HWs. One study, conducted before COVID-19, evaluated a brief EFT intervention for HWs, including alternative-medicine practitioners, chiropractors, and physicians, and found a reduction in psychologic symptoms among those participants.³² Furthermore, a study investigating EFT tapping implemented for stress and burnout among HWs during COVID-19 found reductions in stress, anxiety, and burnout among nurses compared to a no-treatment control group.²⁴ However, no other known studies on EFT tapping have been carried out during the COVID-19 pandemic.

Therefore, this current study evaluated the impact of a brief EFT tapping intervention on stress and trauma-related responses among pediatric ED staff during COVID-19, and this article discusses the implications and future recommendations for EFT tapping interventions in similar settings.

MATERIALS AND METHODS

Study Design and Sampling

A secondary data analysis was performed with anonymous survey data collected from a pilot EFT tapping intervention which was part of ongoing wellness programming in the pediatric ED of a teaching hospital in NYC. The evaluation of anonymous secondary data was reviewed by the Columbia University Irving Medical Center institutional review board and was deemed to be not human subjects research (IRB # AAAT7507).

The pilot intervention used a single-group study design to evaluate the effectiveness of EFT tapping for reducing short-term trauma-related symptoms. All HWs having status on duty in the pediatric ED at the time were eligible to participate. Between July 2020 and July 2021, participants were recruited voluntarily through communications via e-mails, flyers, and face-to-face interactions in the pediatric ED. This recruitment yielded a sample of 50 participating pediatric ED staff. Before study participation, all individuals were informed about EFT tapping, the length of time required, and the voluntary and confidential nature of completing the intervention and surveys. The anonymous survey included descriptive characteristics, including participants' role in the ED and how many years they worked in their professions. Participants were asked to assess their current emotional states in a preintervention survey and, after the EFT tapping intervention, their new emotional states were reassessed via a postintervention survey.

Measures and Data Collection Procedures

Data were collected with a self-report paper survey completed immediately before and after the intervention. The research team developed the questionnaire to measure levels of short-term psychologic distress commonly experienced by HWs based on the Trauma Exposure Response framework.^39,40 The questionnaire comprised 7 items around psychologic distress, including (1) current level of stress, (2) professional satisfaction, (3) obsessive and/or intrusive thoughts, (4) feelings of pressure (professional, societal, family), (5) physical pain, (6) emotional pain, and (7) feelings of loneliness and isolation (see Box 1). Using a 5-point Likert scale, a score of 1 indicated that a participant felt “none” of the item, and a score of 5 indicated feeling an “extreme” level; 1 item—professional satisfaction—was reverse coded. As such, an increase in score indicated an increased level of psychologic distress. For the 7-item questionnaire, the Cronbach's α was 0.78, indicating high internal consistency.

Box 1.

7-Item Questionnaire based on the Trauma Exposure Response framework

In the current moment, please rate the following items on a scale of 1-5, where: 1 = None, 2 = Mild, 3 = Moderate, 4 = Very Much, & 5 = Extreme.
Item 1	Current level of stress
Item 2	Professional satisfaction
Item 3	Obsessive and/or intrusive thoughts
Item 4	Feelings of pressure (professional, social, familial)
Item 5	Physical pain
Item 6	Emotional pain
Item 7	Feelings of loneliness/isolation

Intervention

The EFT tapping intervention, offered during both day and night shifts, was facilitated by the ED's licensed creative arts therapist (LCAT), who was trained in EFT tapping. Each group intervention was held in an enclosed private space away from treatment areas of the pediatric ED. The EFT tapping intervention was conducted in 10-minute group sessions with 3–5 participants per group. As participants arrived, they were instructed to complete the survey, and then the session began with a brief overview of EFT tapping. The group was then asked to describe a theme of concern, such as work stress, tension, pain, or uncertainty. Identifying a theme, such as concern, is the first step in EFT tapping.²⁵ After the group established a shared theme, the facilitator guided the participants in an EFT tapping sequence (see Box 2) following the standard protocol using the 9 EFT tapping points (see Fig. 1).⁴¹ The 9 EFT points correspond to Traditional Chinese Medicine acupuncture points (Table 1).⁴² After completing the whole EFT tapping sequence, the members from all groups were instructed to complete the survey and then debrief about their experiences.

Box 2.

Emotional Freedom Techniques Tapping Session Sequence

1. Scan your body and identify a source of pain, discomfort, tension, or emotions associated with a specific traumatic event.

2. Take one cleansing inhale through the nose, and then exhale through the mouth.

3. Rate internally how your body feels on a scale of 0–10, where 0 is the least intense and 10 is the most intense.

4. Tap on the Karate Chop (KC) point shown in the figure^a while setting up a statement on the theme of concern (say aloud or silently). Repeat two more times.

5. Simultaneously tap on acupoints 2 through 9 shown in the figure,^a while verbalizing “thinking and feeling” statements (say aloud or silently). Repeat for two more rounds.

6. Take one cleansing inhalation through the nose, and exhale through the mouth.

7. Rescan your body and notice any changes in your body.

8. Rate how your body feels on a scale of 0–10, where 0 is the least intense and 10 is the most intense.

Figure 1 of this article is the figure viewed by the participants.

FIG. 1.

A sequence chart of the Emotional Freedom Techniques tapping points. This figure was created by Jodi Scharf, MPH and was adapted with permission from The Tapping Solution Foundation.⁴¹

Table 1.

Correlation of Emotional Freedom Techniques Tapping Points to Traditional Chinese Medicine Acupuncture points by point names in Sequence Order

EFT tapping point name	Chinese & English point name	Meridian name & #
Karate chop	Houxi (Back Stream) A push from behind a mountain stream^a	SI-3
Eyebrow	Zanzhu (Gathered Bamboo) The grasping of bamboo^a	BL-2
Side of eye	Tongziliao (Pupil Crevice) The bone of fresh innocent eyes^a	GB-1
Under eye	Sibai (Four Whites) The full white energy of the 4 directions^a	ST-2
Under nose	Renzhong (Man's Middle) Man standing between heaven & earth^a	GV-26
Chin	Chengjiang (Container of Fluids) Receiving the rich broth of life^a	CV-24
Collarbone	Shufu (Shu Mansion) A vital transfer to the palace treasury^a	KI-27
Underarm	Dabao (Great Wrapping) A vast & extensive containment or a big cuddling embrace^a	SP-21
Top of head	Baihui (Hundred Meetings) The meeting in grand unity^a	GV-20

Names from Kaatz D. Characters of Wisdom: Taoist Tales of the Acupuncture Points. Petite Bergerie Press: Soudorgues, France; 2005.⁴²

SI = Small Intestine; BL = Bladder; GB = Gallbladder; ST = Stomach; GV = Governing Vessel; CV = Conception Vessel; KI = Kidney; SP = Spleen.

EFT, Emotional Freedom Techniques.

Data Analysis

The IBM Statistical Package for Social Science (SPSS) for Windows (version 27.0, SPSS Inc., Chicago, IL, USA) was used to analyze the data. Descriptive statistics including mean, standard deviations (SDs), frequencies, and percentages, were used to characterize the study sample. Paired samples t-tests were used to determine the mean differences between pretest and post-test scores with an α of 0.05.

RESULTS

Participants

The research sample included 50 pediatric ED staff on duty in diverse medical and nonmedical roles, including nurses, doctors, interpreters, technicians, and workers in environmental services. A majority (67.6%) were registered nurses (RNs) or nurse–managers (Table 2). The mean years in their professions was 10.89 years (SD = 8.50; range: 2–29). The preponderance of respondents (84%) received the intervention during the day shift, and a majority (64%) participated during the early phase of intervention rollout (July 2020–December 2020) as opposed to the late phase (January 2021–July 2021).

Table 2.

Demographic Characteristics of the Full Sample (N = 50)

Variable	n	(%)
Years in profession
2–4	9	26.5
5–9	11	32.4
10–14	5	14.7
15–19	4	11.8
More than 20	5	14.7
(No response – n = 16)
Discipline
Nursing (RN, nurse manager)	25	67.6
Other medical (UA, ERT)	5	13.5
Nonmedical^a	7	18.9
(No response – n = 13)
Day/night shift
Day	42	84
Night	8	16
Early/late phase of study
Early^b	32	64
Late^c	18	36

Note: To minimize deductive disclosures, demographic characteristics such as gender, age, or race/ethnicity were not collected.

Nonmedical = administrator or environmental services.

July 2020 to December 2020.

January 2021 to July 2021.

UA, unit assistant; ERT, emergency room technician.

Psychosocial Measures

Statistically significant (P < 0.001) reductions at postintervention were observed for the overall score and for the items studied at P < 0.001 (mean differences in stress −1.18; feelings of pressure −1.06; obsessive and intrusive thoughts −0.65; emotional pain −0.60; physical pain −0.58; and loneliness −0.40), but not for professional satisfaction (P = 0.06; Table 3).

Table 3.

Psychologic Distress in Preintervention and Postintervention States of the Full Sample (N = 50)

Distress item	Pre mean (SD)	Post mean (SD)	Difference pre–post mean (SD)	P-value
Current level of stress	3.32 (1.15)	2.14 (0.89)	–1.18 (0.95)	P < 0.001^*
Feeling pressure	3.20 (1.13)	2.17 (0.88)	–1.06 (0.98)	P < 0.001^*
Obsessive and/or intrusive thoughts	2.50 (1.31)	1.85 (0.88)	–0.65 (0.93)	P < 0.001^*
Emotional pain	2.28 (1.20)	1.69 (0.80)	–0.60 (1.05)	P < 0.001^*
Physical pain	2.42 (1.28)	1.83 (1.04)	–0.58 (0.85)	P < 0.001^*
Feeling lonely/isolated	1.84 (1.02)	1.44 (0.80)	–0.40 (0.57)	P < 0.001^*
Professional satisfaction	3.60 (0.97)	3.24 (1.20)	–0.31 (1.06)	P = 0.06

P-values from paired samples t-tests.

Significance at P < 0.01 level.

SD, standard deviation.

DISCUSSION

This study found significant reductions in stress and trauma-related symptoms following a single 10-minute group EFT tapping session, consistent with prior research on EFT tapping interventions addressing stress²⁴ and psychologic distress in HWs.³³

Implications of EFT Tapping Post-COVID

There is a lack of studies on the impact of interventions to reduce psychologic stress among HWs.¹⁷ Psychologic distress and trauma-related symptoms are common and expected during stressful events such as COVID-19.¹⁷ While symptoms may become reduced over time for some individuals, a significant percentage of HWs are still predicted to meet diagnostic criteria for PTSD post-COVID.⁴³ Based on the psychologic burden HWs experienced during previous major epidemics, including Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), an estimated 10%–40% of HWs are expected to meet criteria for PTSD 1–3 years after the pandemic.⁴⁴ Given the prolonged timeline of COVID-19, a significant postpandemic effect on HWs' psychologic well-being is anticipated.¹⁷

HWs may be hesitant to seek mental-health care or participate in longer interventions due to time constraints and confidentiality concerns.¹ Proactive, self-administered, brief interventions such as EFT tapping will be needed to protect the mental health of the health care workforce after the pandemic.

Logistic Considerations and Feasibility

A 10-minute EFT tapping session was designed to accommodate shift timings (e.g., before and after day and night shifts) and limited available space within the ED. Time constraints comprise one of the primary sources of stress among pediatric ED staff³; this may be exacerbated if participation in an intervention is time-consuming. EFT tapping has been implemented as a rapid intervention in many settings where individual psychotherapy or longer programming is impractical, such as refugee camps, war-veteran retreats, and in locations after natural disasters and terrorist attacks.⁴⁵ The 10-minute EFT tapping sessions take little time and use few resources, especially when conveniently provided between day and night shifts, and can impact staff's well-being significantly.

The intervention is feasible with regard to facilitation. While an LCAT guided this intervention, specialized training or certification in EFT tapping is not required. Facilitators for EFT must follow an EFT manual that includes evidence-based standards defined by the American Psychological Association's (Division 12 Clinical Psychology) Presidential Task Force on Evidence-Based Practice,⁴⁶ including The EFT Manual,⁴⁷ volume 1 of The Clinical EFT Handbook,⁴⁸ or The EFT Mini-Manual.⁴⁹ Effectively, the low-resource requirement of this intervention adds to the overall accessibility of this intervention.

Limitations

These findings should be interpreted in light of several limitations of the current study. The single-arm study design limited internal validity. These results need to be confirmed through studies with comparison arms, ideally in randomized controlled trials. The validity and reliability of the scale developed from the trauma-exposure response framework have not yet been established. The survey—which was designed to be brief—included pertinent symptoms of psychologic distress delineated by the Trauma Exposure Response Framework,^39,40 which describes mechanisms of internal stress among HWs as a result of exposure to the suffering of patients and coworkers. The survey for the current study used questions from 3 different tests: the PTSD Checklist for DSM-5 (PCL-5) to measure PTSD symptoms,⁵⁰ the Center for Epidemiologic Studies Depression scale (CES-D)⁵¹ to assess depressive symptoms, and the Perceived Social Support Scale (PSSS) to estimate social support levels.⁵²

Self-reported descriptive characteristics were not collected for some characteristics and had high rates of missing data for others (16 of 50 responses were missing for “years in profession”; 13 of 50 responses were missing for “discipline”). It was, therefore, not possible to analyze effects by years of experience in the profession or discipline appropriately. The intervention was offered to everyone (APRNs, PAs, MDs/DOs, etc.); however, only 1 doctor participated. Reasons for declining participation were not collected, and results were collapsed for deductive disclosures.

Some participants may have attended more than 1 EFT tapping session, skewing the descriptive characteristics or masking a compounded effect across multiple sessions versus a single session. Finally, participation in the intervention declined over time as the adverse consequences of COVID-19 on the healthcare staff and system started to diminish. There are a number of explanations for these patterns that were not assessed in this intervention. To the current authors' knowledge, however, there was no other intervention in place for pediatric ED staff. Data were collected as part of wellness programming in the pediatric ED with the potential for self-selection bias that limits generalizability to other settings. Despite these limitations, the findings provide valuable information to inform future studies and interventions using EFT tapping for HWs.

Future Recommendations

The design of future studies should be strengthened by including randomized assignment to a control group and supplementing assessments with validated scales, including the PTSD Checklist for DSM-5 (PCL-5)⁵⁰ and the Potential Stressful Events Interview (PSEI),^51,53 and physiologic measures of stress, such as salivary cortisol levels. Future studies should investigate the dose–response of EFT tapping and include follow-up assessments to ascertain outcome durability to provide evidence of potential longer-term effects beyond immediately post-EFT tapping sessions.

The findings of this study have implications for application of EFT tapping specifically for ED staff during COVID-19, therefore, targeted EFT tapping interventions should be tailored to individual departments or hospital contexts. Future studies should also explore possible positive impacts on patients' well-being that are mediated through reduction of distress among pediatric ED staff.⁵⁴

Implications for ED Health Care Staff

This study contributes to a better understanding of the potential for a brief EFT tapping intervention addressing mental well-being among ED health care staff. These findings provide empirical evidence to substantiate the positive effects of EFT tapping for staff mental health during COVID-19. Given the importance of psychologic well-being for retention, and reduction of absenteeism and turnover rates among staff, patient satisfaction might improve when patients perceive accumulating cues about the levels of stress among ED staff caring for them and the ED as a whole.⁵⁴

CONCLUSIONS

ED staff are at risk of high levels of occupational stress, negative trauma-related symptoms, and compassion fatigue during and following the COVID-19 pandemic. A brief 10-minute, single-session intervention utilizing EFT tapping significantly reduced stress, obsessive and intrusive thoughts, emotional and physical pain, and loneliness reported by participants. Although this report is a preliminary look into this brief intervention and is subject to study-design limitations, the initial findings offer noteworthy information on the potential of EFT tapping for health care personnel.

Footnotes

ACKNOWLEDGMENTS

The authors acknowledge and thank: (1) Jodi Scharf, MPH for her assistance with the manuscript and designing ; (2) the study participants for generously donating their time for survey completion; and (3) the pediatric ED leadership and staff for their support with programming.

AUTHORs' CONTRIBUTIONS

This project was conceptualized by S. Bifano, C. Szeglin, and Dr. Gold. Drs. Garber and Gold supervised the work. S. Bifano and C. Szeglin were responsible for resources and conducting the investigation, and Dr. Garbers performed the formal analysis. All of the authors participated in reviewing and editing the article.

AUTHOR DISCLOSURE STATEMENT

Dr. Gold has been a member of the scientific advisory board of the Tapping Solution App since 2020 (an uncompensated role). No financial conflicts of interest exist for the other authors.

FUNDING INFORMATION

The authors received no funding for the project.

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