Chapter 2 from The Influence of Psychological Trauma in Nursing, published by Sigma, focuses on types of trauma that occur more often in nursing—including patient assault, incivility, and compassion fatigue.
Although nurses are one of the highest-regarded professions, our business is a risky one, leaving us vulnerable to trauma in myriad ways. From the long-term erosion of our spirits due to vicarious experiences with patients’ traumatic events to being treated by peers in mean-spirited/hostile ways, nurses are surrounded by trauma.
Trauma unique to nurses and caregivers
We want to start this chapter with a story about a nurse. This nurse was a role model for new nurses on the inpatient psychiatric unit. Although fairly young with two small children, she was articulate, solid as a leader, and had a calming influence over the other staff members. Yet, when it came time to pass medications, she needed a supervisor to watch her administer certain drugs. Later, she confided to Karen that her license was on probationary status for opioid diversion, in part due to “alarm fatigue” (Sendelbach & Funk, 2013).
Her story is one of secondary trauma. After working for years on a pediatric intensive care unit, she began to experience insomnia, anorexia, and hyperarousal due to a trauma trigger. Whenever an alarm or beeping noise would sound, she would be triggered into reliving a past trauma.
“You see,” she said, “the sound reminds me of a ventilator alarm, of something gone wrong and a young life in my care.” When she was discovered for drug diversion (taking medication that was meant for patients), she knew it was time to reclaim her life. Months of therapy ensued, and she agreed to a recovery monitoring agreement with the state board of nursing to save her nursing license.
Karen will always remember this nurse, one she looked to for guidance as a new nurse. She was someone whom Karen never would have guessed would be diverting substances. Yet the secondary trauma was too overwhelming for her, and her coping mechanisms were insufficient at the time. Fortunately, her story ends with peace after the crisis and reclaiming her career and personal life. Let’s discuss forms of trauma that are specific and relevant to nurses and other healthcare providers.
Trauma experienced by nurses as caregivers
Because of the seemingly unending barrage of needs presented by patients, nurses are particularly susceptible to a unique form of psychological fatigue that impacts the ability to provide emotional availability to their patients. This is called compassion fatigue. A similar but distinct form of trauma is secondary trauma or vicarious trauma—what the nurse who diverted substances experienced.
The nurse, through witnessing or living through others’ trauma, may begin to experience secondary posttraumatic stress symptoms (PTSS). In these instances, nurses are not experiencing firsthand trauma but experiencing the symptoms related to having gone through such stress. We believe nurses, and the nursing care that is rendered, create a unique context and even a vulnerability to experiencing compassion fatigue and secondary trauma.
Compassion fatigue and secondary trauma
As a nurse, you hear individuals speak in times of crisis about physical and emotional periods of vulnerability, which, over time, with repeated intensity, can leave a caregiver emotionally spent and unable to give to others. We discuss ways to assess for and combat compassion fatigue in Chapters 3 and 4, where we describe paths to restoration and healing. For now, it is important to understand the characteristics of compassion fatigue and the recurrent themes that appear through a description of the literature. A concept analysis serves to help us understand what the term means and what its attributes or characteristics are. In a concept analysis, Coetzee and Klopper (2010) defined compassion fatigue in nursing as:
a state where the compassionate energy that is expended by nurses has surpassed their restorative processes, with recovery power being lost. All these states manifest with marked physical, social, emotional, spiritual, and intellectual changes that increase in intensity with each progressive state. (p. 237)
The authors describe compassion fatigue as a cumulative process that may eventually exceed the nurse’s endurance and restorative abilities (Coetzee & Klopper, 2010). There is a multidimensional quality; compassion fatigue affects many areas of an individual’s functioning. We believe compassion fatigue is a possible outcome of secondary trauma, also referred to as vicarious trauma. Secondary traumas are “stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than from exposure to a traumatic event” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014, para. 2). Secondary trauma isn’t unique to nursing; rather, this exposure can be experienced by many in the health professions, as well as first responders and clergy (SAMHSA, 2014).
Compassion, according to Georges (2011), is a complex phenomenon that occurs within a biopower context. It is the “power over life” in healthcare (p. 131). Nondiscursive forms (values we may believe but not vocalize or express), carrying powerful influences, create the unspeakable in nursing: “the creation/maintenance of biopolitical spaces in which compassion—for oneself or one’s patients—is rendered severely diminished or impossible” (p. 131). Frequent, unrelenting elements such as social and market forces, conscious withholding of emotion toward patients and students, valuing evidence and empiricism over theoretical understanding, and other factors in today’s nursing care and academic environments result in an inability or unwillingness to show compassion to ourselves and others (Georges, 2011). The unspeakable is often assumed, ingrained into our way of thinking so that we forget to question the very foundations of our thoughts and beliefs.
In your career, you will see, smell, and touch reactions to those who have experienced trauma. The hand you are holding may squeeze yours so tightly you are not sure how much longer you can bear it. An utterance from a patient may catch you off guard, so unexpected that you are not sure you heard correctly.
You may be in the ED or on a medical/surgical unit or in a long-term care facility. The patient may be in a life-threatening state from an automobile accident, or hemorrhaging post-surgery, or have been placed in a skilled nursing unit after having lived in the same home for 30 years.
The individual may be cognitively aware, or part of the trauma may be intensified by confusion, delirium, or pain. In nursing, we are taught that caring and empathy are valued in our patient interactions. But if we don’t strategize to sustain and restore our psyches and souls, we are just as vulnerable as our patients.
Click here to read the rest of Chapter 2 and view supplemental materials from The Influence of Psychological Trauma in Nursing in the Virginia Henderson Global Nursing e-Repository of Sigma Theta Tau International Honor Society of Nursing (Sigma).
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Karen J. Foli, PhD, RN, FAAN, is an associate professor and the director of the PhD in Nursing Program at Purdue University School of Nursing.
John R. Thompson, MD, practices psychiatric medicine for Purdue University's Counseling and Psychological Services.