Nurses and Secondary Trauma

When I started nursing school, I had a fascination with being in the thick of the really 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, part of the team. I wanted to fill the role of a smart, dependable nurse. The one who the doctor trusted, and the one with whom the family felt safe.  I still desire this to some degree, but after working in cardiac stepdown and neurocritical care, my mentality has shifted quite a bit.

While we say it’s really cool to see those kinds of things and be on the front lines, the actual reality of it 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, or 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 at the time was 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 and is faculty at Boston College about vicarious trauma and nursing.  She states that “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.”

Dr. Shaw goes on to mention that, “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.”

Sound familiar, anyone?

How do you know you’ve experienced it?

Dr. Shaw discusses how important it is to differentiate between burnout and vicarious trauma.  Burnout is quite the buzzword in our profession as we struggle with a higher nurse to patient ratios, increasing demands at work, constantly evolving technology, all accompanied by sicker and sicker patients. Here is a great article that really dives deeper into a definition of burnout, which essentially outlines burnout by three components; extreme exhaustion, alienation from work activities, and reduced performance.

“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,” mentions Dr. Shaw.

I don’t know about any of you out there, but what she said really 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. (I talk about this a bit more in depth in the FreshRN Podcast, Dealing With Patient Deaths.)  Every joyful moment 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… and since I am a nurse, I can paint a pretty accurate picture in my mind of what that would look like.  Those worst-case scenarios were very, very real to me.  I was having a tough time really being mentally present because I was constantly holding back fear.

What do you 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. (A self-care care plan, perhaps?  No?  Not so much? I’ll show myself out…)

I’ll let her take it from here…

Context

“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.

Practice self-awareness

When you feel some kind of way, don’t just ignore it, but 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 in how you’re feeling, the values that contribute to those emotions, and reminding 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 each do not need to carry this load alone.

Set boundaries

Create physical spaces or set times in which work, and your cumulative trauma exposure does 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 and Laura’s book, Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others

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 available with trained counselors at no cost to the employee. Ask your manager if your facility has this benefit.

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

Here is Laura’s TED Talk… and guys, it’s wonderful. She outlines this in much more depth than I have here.  One of the the things she said in how you can identify one of the various ways if you’re experiencing this is, “when the best part of the workday is when you don’t have to do your job.”

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 back?

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

Self-Compassion: The Proven Power of Being Kind to Yourself

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

Braving the Wilderness: The Quest for True Belonging and the Courage to Stand AloneRising Strong: How the Ability to Reset Transforms the Way We Live, Love, Parent, and LeadDaring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and LeadThe Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You AreI Thought It Was Just Me (but it isn’t): Making the Journey from

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,” stated Dr. Shaw.

Even more resources

A great nurse burnout resource is Elizabeth Scala’s blog and books.

Nursing from Within: A Fresh Alternative to Putting Out Fires and Self-Care WorkaroundsStop Nurse Burnout: What to Do When Working Harder Isn’t Working

I hosted a webinar with Nurse.com entitled Empathy 101 For Nurses: How to Care for Yourself While Emotionally Supporting Others

Dr. Brene Brown – she has a great website with lots of information about empathy

Dr. Kristin Neff – resources related to self-compassion

Trauma Stewardship Institute

Jessica Shaw, Ph.D., is a community psychologist and is currently faculty at Boston College. 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.