Empathy’s Toll: The Reality of Nurses and Secondary Trauma

by | Feb 7, 2024 | Professional Development for Nurses | 7 comments

Empathy's Toll: The Reality of Nurses and Secondary Trauma

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When I started nursing school, I was fascinated with being in the thick of the intense medical situations that frequently accompany working in an acute care facility. The more intricate and gory the story or predicament, the better.  I wanted to be in the middle of the action and part of the team. I romanticized what it would be like to be a smart, dependable nurse. The one the doctor trusted and the one with whom the family felt safe.  

I still desire this to some degree, but after working in cardiac step-down and neurocritical care, my mentality has shifted quite a bit as I have learned more about nurses and secondary trauma.

While we say it’s cool to see those kinds of things and be on the front lines, the actual reality is… well, not. It’s not cool or interesting to remove the breathing tube from a young father of three and watch him take his last breath, perform CPR on a 30-year-old nurse, or pronounce an elderly woman deceased when she was the only person her daughter had left in this world. It wasn’t interesting to see a man who was already struggling with severe depression suffer a devastating stroke, nor was it fascinating to care for the man who tried to kill himself with Tylenol.

At first, I was excited to jump into that role as the nurse caring for these patients as they walked through arguably the worst moments of their lives.  What I didn’t realize then was that the empathy I provided in those situations was at a great cost to myself.

What is Secondary Trauma?

I had the opportunity to speak with Jessica Shaw, Ph.D., who is a community psychologist, about vicarious trauma and nursing.  

Vicarious trauma, also known as secondary trauma or indirect trauma, can result from being indirectly exposed to trauma through the firsthand accounts of others’ traumatic experiences. As individuals are exposed to story after story of others’ traumatic experiences, and those individuals are tasked with being a witness to each, they build up and accumulate. These individuals then carry the accumulated, collective weight of these traumatic experiences.”

Jessica Shaw, Ph.D.

Nursing Burnout vs. Secondary Trauma

Dr. Shaw discusses how important it is to differentiate between burnout and secondary trauma. Let’s first define nurse burnout.

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Nurse Burnout

Nurse burnout, a phenomenon quite familiar in the nursing profession, represents a state where a nurse feels overwhelmed, emotionally drained, and unable to meet constant demands. It’s like hitting a wall where the compassion and dedication that once fueled their care become overshadowed by exhaustion, both mental and physical. This is often the result of prolonged stress and emotional fatigue stemming from the intense nature of nursing work.

When a nurse experiences burnout, they may feel detached and disinterested and find it challenging to connect with patients on the empathetic level that is so integral to nursing. It’s not merely a bad day or a rough patch; it’s a deeper, more chronic kind of fatigue that doesn’t just disappear with a good night’s sleep. Burnout can affect a nurse’s ability to provide quality care and can lead to errors, negatively impacting both the nurse and their patients. It signals that something in the nurse’s work environment, schedule, or personal self-care routine needs attention and change.

Nurses and Secondary Trauma

To offer a definition, I will let Dr. Shaw explain it.

“Vicarious trauma is different [from burnout] in that it persists even when we shift to new contexts. We continue to be in a state of high arousal, thinking of the worst-case scenario in every context we find ourselves in, feeling irritable or defensive, as though we can’t do enough or aren’t doing enough, and so on. These thoughts and feelings are intrusive and persistent.”

I don’t know about any of you, but what she said hit home for me.  After working in critical care, with my every day as someone else’s worst-case scenario, that mentality started spilling into my personal life. Joyful moments seemed to be overshadowed by a worry that my husband would suffer a major stroke, my daughter would get cancer, my father would be diagnosed with a brain tumor… Since I am a nurse, I can paint a pretty accurate picture of what that would look like.  Those worst-case scenarios were very, very real to me.  I was having a tough time being mentally present because I was constantly holding back fear.

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What Should Nurses Do?

Now that we’ve defined vicarious trauma and differentiated it from burnout, let’s chat about what someone who feels that they may be experiencing this should do.

Dr. Shaw outlines some steps below.

Context Matters

Before discussing what an individual should do, it is important to remember that the individual is embedded in a larger context–the organization for which they work and the broader systems in which that organization is embedded. It is this broader context that engenders vicarious trauma. Thus, if we want to prevent or treat vicarious trauma, it is this broader context that will need to undergo some changes. The Vicarious Trauma Toolkit from the Office of Victims of Crime discusses what organizational changes may need to be made to create and foster a supportive environment for its members.

Of course, though, when we are dealing with vicarious trauma, we cannot sit back and wait for organizational change. So, while reminding ourselves that change is needed at levels beyond our direct control, we can take steps to take care of ourselves right now.

(Kati’s translation ➡️ Some units have secondary trauma baked into the experience of working in that specialty. For example, there’s no way to work in an ICU without observing trauma. However, some organizations are much better equipped to support their nurses.)

Practice Self-Awareness

When you feel this way, don’t just ignore it. Take time to reflect on what you are feeling and why you are feeling that way. What underlying values in your life contribute to such feelings (e.g., compassion, integrity, justice, healing), and why are those values important?

Center yourself by giving yourself deliberate space to reflect on how you feel and the values that contribute to those emotions, and remind yourself that such values should inform all aspects of your life, including how you take care of yourself.

Find Supporters

Find others, perhaps at work, perhaps elsewhere, with whom you can process how you are feeling and why you might be feeling that way. Validate one another’s experiences to let one another know that each person is not alone in this work and that you do not need to carry this load alone.

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Set Boundaries

Create physical spaces or set times in which work and your cumulative trauma exposure do not enter. Use these spaces to engage in activities and with others that bring you joy. If you find work or other intrusive thoughts creep in, acknowledge them, perhaps even out loud. Then, tell yourself that you do not need to think of that now, as you will set aside time to attend to such feelings later. By acknowledging the thought briefly, you are better equipped to set it aside.”

Use Your Resources

Dr. Shaw highly recommended the Trauma Stewardship Institute, which Laura van Dernoot Lipsky established. Laura’s book, Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others , is currently sitting on my bookshelf, full of highlighted passages.

Dr. Shaw also recommends the Vicarious Trauma Toolkit from the U.S. Department of Justice, Office for Victims of Crime, for organizational change strategies.

Also, many healthcare facilities have Employee Assistance Programs (EAP) available with trained counselors at no cost to the employee. Ask your manager if your facility has this benefit. (I have used this benefit before, and it was immensely helpful!)

Hospital chaplains are also a great resource. They aren’t there just for the patient; they are also there to care for the employees, and many are trained to support people through these experiences.

Going back to Laura van Dernoot Lipsky; she has a very popular TED Talk that I think you will appreciate. One of the things she said about how you can identify one of the various ways you’re experiencing this is “when the best part of the workday is when you don’t have to do your job.”

Is anyone out there watching the clock? Counting down the minutes until the next break? Can’t wait for 5 days off in a row, but can’t really enjoy that last day because you know you have to return?

Please watch this video. It is incredibly powerful and applicable to our profession.

Self-compassion is a key aspect of providing empathy and compassion sustainably.  I highly encourage you to check out Dr. Kristin Neff and her plethora of resources on self-compassion.

I also have experienced profound personal and emotional benefits from Dr. Brene Brown and her books on empathy and imperfection.

Remember, “this is not simply the cost of caring, and that exhaustion and sacrifice should not be worn as a badge of honor. We cannot take care of others if we do not take care of ourselves,”

Dr. Jessica Shaw

More About Our Guest

Jessica Shaw, Ph.D., is a community psychologist and faculty at the University of Illinois at Chicago. Her work focuses on examining and improving community and system responses to sexual assault. She partners with a range of stakeholders in her work, including sexual assault nurse examiners.

FAQ of Nurses and Secondary Trauma

What are the ABC’s of secondary trauma?

Awareness, balance, and connection.

Source: Saakvitne, K. & Pearlman, L. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization for Helping Professionals who Work with Traumatized Clients. New York, New York: W.W. Norton and Company.

Is there PTSD for nurses?

Absolutely. Post-traumatic stress disorder (PTSD) can indeed affect nurses, much like it does individuals in other high-stress professions. Nurses are routinely exposed to highly emotional and traumatic situations, from witnessing patient suffering and death to experiencing verbal or physical abuse. These experiences can accumulate over time, leading to significant emotional distress. What’s particularly challenging in nursing is the expectation to swiftly move from one patient care scenario to another, often without the opportunity to process the emotional impact of these experiences adequately. This can leave nurses feeling isolated with their feelings, exacerbating the risk of developing PTSD.

What are common warning signs of secondary trauma in nurses?

– Difficulty in maintaining professional boundaries with patients
– Being preoccupied with thinking about patients during your time off from work
– Loss of hope, feeling pessimistic
– Feeling numb, disconnected, or detached
– Staying busy so you’re mind doesn’t have time to think
– Lingering feelings of anger, resentment, or sadness regarding the patients’ situation; rumination on this
– Unable to separate your reality from that of your patient
– Overidentifying with the patient’s pain or experiences (daydreaming about how you would have saved them or what they went through and how it must have felt)

Source: British Medical Association

How can nurses reduce their risk for secondary trauma?

Let’s go through some things you can do to reduce your risk proactively. You will see that a lot of this is based on awareness. While having an action list of things to do to protect you at all times that’s just not feasible. One of the most powerful things we can do is to pay attention to ourselves to notice when we’re suffering early. We assume it’ll be painfully obvious if work is negatively impacting our mental health, but it’s often very subtle. The hospital is a building where all of the traumatized people come to get medical care; naturally, trauma will be normalized to some extent. It is on the healthcare worker to notice when it is encroaching on their mental health and take action.

– Notice how you’re feeling (physically, mentally, and emotionally) while you’re taking care of patients and after. Are you tense? Is your jaw clenched? Are you taking short and frequent breaths? Are you ruminating on what your patient told you or what you saw? This is a slow-burn situation and takes time to identify.
– Consider journaling what you’re noticing about yourself (even a quick note in your phone helps) so that you can sit back and notice how frequently these feelings occur. Context helps establish a balanced perspective!

Notice when you’re having difficulty keeping healthy empathy boundaries with patients. A healthy emotional distance is necessary for those of us caring for many people who endure trauma. We want to provide the connection the patient needs in the moment but not go deep into the depths of their trauma.

– It’s important to remember that while you play a crucial role in your patient’s journey to wellness, their well-being isn’t your responsibility alone. As a nurse, your ethical obligation is to offer safe, comprehensive, and suitable care, but it’s beyond your scope to ensure patients prioritize their health as you do. Our goal is to equip our patients with the necessary tools and knowledge to encourage them to take charge of their own health and well-being. This empowerment allows them to become active participants in their care, rather than us assuming control over their health decisions.

Balance out your assignments. Notice if you’re caring for many severely traumatized people at once and advocate for yourself to be assigned less complex patients to balance out your care. (And try to notice this if you’re the charge nurse who is making assignments.)

Seek help. We call the doctor when we notice signs and symptoms of various issues with our patients. Call a therapist if you notice signs and symptoms of vicarious trauma. (Your hospital likely offers free counseling through EAP – check to see if you get those benefits!) Seeking help early reduces the risk for more serious issues later on that become increasingly difficult to address (kind of like waiting until the patient is coding when a rapid response should have been called three hours earlier).

– Remember that suffering is not a competition where the one with the worst experiences earns compassion and care. Regardless of if someone else has it worse has nothing to do with you. Notice if you have signs and symptoms and get help. There is enough compassion and care to go around. You do not have to earn it.

Do not isolate yourself. Isolation amplifies suffering. We are more inclined to ruminate and catastrophize when we are alone. Stay in connection with loved ones and friends.

How can nurses manage the emotional impact of witnessing suffering without losing their sense of self and connection to their lives outside of work?

It’s easy to become deeply absorbed in our patients’ suffering to the point where it can overshadow our connection with ourselves and our lives beyond the hospital walls. It can happen so slowly over time that we don’t even realize it’s happening until these signs of secondary trauma manifest.

The intense focus on the pain our patients experience can make it challenging for us to process and heal from the trauma we witness, leading us to mistakenly believe that by sharing in their suffering, we might somehow alleviate it. However, it’s crucial to recognize that our duty does not extend to over-identifying with our patients’ experiences. Instead, maintaining our well-being necessitates nurturing our lives outside of work.

Engaging with family, friends, and activities unrelated to our professional duties helps us maintain a healthy perspective and remember our identities beyond our roles as caregivers. Creating a balance between compassion for others and self-care allows us to be present and effective in both our personal and professional lives without losing ourselves in the process.

Isn’t becoming jaded and grumpy a normal part of becoming more experienced?

While it’s a common belief that becoming more seasoned in nursing—or any profession fraught with high stress and emotional intensity—might naturally lead to becoming jaded or grumpy, it’s crucial to challenge this notion. Yes, with experience comes a deep understanding of the realities and often harsh truths of healthcare, which can sometimes lead to feelings of disillusionment or burnout. However, these feelings aren’t inevitable rites of passage but rather signals that we might need to reassess and recalibrate our approach to work and self-care.

Embracing experience doesn’t have to mean sacrificing our compassion, empathy, or joy for the job. Instead, it offers us an opportunity to deepen our connection to ourselves by learning our unique boundaries with empathy, refining our coping mechanisms, and seeking out the joy and fulfillment that drew us to nursing in the first place. It’s about finding balance, setting boundaries, and staying connected with the reasons we became nurses. Staying mindful of our well-being and actively engaging in self-care can help prevent the onset of cynicism, keeping our hearts open and our spirits uplifted even amidst the challenges. Remember, becoming more experienced should enhance our capacity for empathy and care, not diminish it.

More Resources on Nurses and Secondary Trauma

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    Hi, I’m Kati.

    Kati Kleber, MSN RN is a nurse educator, author, national speaker, host of the FreshRN® Podcast, and owner of FreshRN® – an online platform created to educate, encourage, and motivate newly licensed nurses in innovative ways.

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    1. Padma Dyvine

      Great Post! I have worked with hospice, prison and labor and delivery nurses who experience secondary trauma: hospice nurses dealing with loss after loss and L&D nurses after traumatic deliveries. We are all at risk. Nurses can for free measure Compassion Satisfaction/Secondary Trauma by completing a PROQOL (Professional Quality of Life scale) which is on line: http://proqol.org/uploads/ProQOL_5_English_Self-Score_3-2012.pdf
      You may be interested in a post from a couple of months ago that I did distinguishing among burnout, vital exhaustion and compassion fatigue: http://integralnursingsolutions.com/compassion-satisfaction-%E2%89%A0-vital-exhaustion-burnout-or-compassion-fatigue/

    2. Tracy

      Thank you! I love reading your posts! They have a wealth of information and resources specific to us.

    3. Kit

      This is a fabulous post. I wrote a similar post about “secondary trauma” recently although i didn’t know that was even the term when I wrote it

    4. Diane

      Thank you for an excellent post. While I’ve read tons of articles about nursing burnout, I’ve never before heard about the concept of secondary trauma. I agree with Padma Dyvine’s comment that “We are all at risk.” The majority of my experience is in geriatric nursing, and I can see where secondary trauma could be an issue here, too.

    5. Stephanie

      This is so on point! Thank you so much for putting it out there.

    6. Moira

      What I see here is really beautiful. Thank you for this. I supervise public health nurses who work in communities of profound poverty and violence. I want to put together a five slide PowerPoint for the nurses to get this conversation started. Once we start, it will never stop! (39 years of nursing experience).

      How do I get permission to quote the author?

      • Kati Kleber

        Hi Moira! If you’d like to cite the blog post, just make sure you include myself (Kati Kleber) as the author and a link back to the article. If you’d like to cite a quote from the person I interviewed, simply cite Dr. Jessica Shaw. Excited that this will be shared!


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