No one should learn about STS the way I did—after the fact. Part 1 of two parts.
She left nursing because of secondary traumatic stress (STS), also known as compassion fatigue. Now she works to inform others and promote awareness.
In 2005, I made the life-altering decision to leave a 22-year career in nursing. I will never forget the turmoil, shame, and confusion. I didn’t know I was experiencing secondary traumatic stress, or STS.
The concept has been around for decades, but knowledge of the full impact that STS can have on nurses and other healthcare professionals has not been well-disseminated. Perhaps the primary reason for the slow dissemination is lack of clarity in terminology. Is it compassion fatigue, vicarious trauma, or post-traumatic stress disorder (PTSD)? For years, burnout was the go-to descriptor for identifying what nurses experience when they feel emotionally depleted by their jobs. Unfortunately, the imprecise terminology only served to undermine recognition that something much more insidious might be going on.
In much the same way that describing what soldiers with PTSD experience, spreading the word about STS has had its challenges. Veterans of World War I who had PTSD were labeled as malingerers and shamed into believing they didn’t have what it took. Early on, it was diagnosed as “soldier’s heart” but was later changed to “battle fatigue” and “shell shock.” Eventually, the accepted terminology became post-traumatic stress disorder, or PTSD.
Ambiguity isn’t helpful
Similar ambiguity has been associated with STS. Added to the physical and emotional pain of those who suffer from STS is healthcare’s all-too-frequent “suck it up and carry on” expectation. No one wants to be perceived as not having what it takes, so the emotional distress that often comes with the job is continually dismissed and suppressed.
Secondary traumatic stress can be caused by witnessing the suffering of others or providing care for those who have been traumatized. According to Charles Figley (1995), a pioneer in the field of traumatology, STS is synonymous with compassion fatigue. Many definitions of secondary traumatic stress omit the term “trauma” but use phrases such as stress, emotional distress, duress, or critical incident stress. Yet, the symptoms often associated with STS are very similar to those of PTSD (Figley, 2002).
Thanks to advances in neuroscience and image scanning, evidence of the effects of trauma on the brain has been well-documented (Bremner, 2006). For example, the amygdala, which responds to fear and threats, sometimes exhibits overactivity—even enlargement—in people with PTSD. This can affect perception, causing states of hyperarousal and hypervigilance, both of which are symptoms associated with STS. The hippocampus, the brain’s memory processor, becomes rewired, thus changing how memories are stored. Instead of being processed as short-term and then stored as long-term, memories become trapped in a circuitous pattern where any trigger can recall them—another symptom of STS.
T is for trauma
So why do we avoid the T-word—trauma? In caring for those experiencing life-threatening situations or other devastating circumstances, why are we so careful not to call our own reactions trauma? If we think we are experiencing stress rather than trauma, we are less likely to seek professional help. Without treatment, symptoms can worsen and eventually affect both our professional and personal lives.
In addition to hypervigilance and intrusive, recurring thoughts, symptoms of STS include physiological reactions, such as increased reactivity to fear and stress; increased stimulation of the fight-or-flight response; sleep disturbances; exhaustion; and physical ailments. These symptoms contribute to changes in perception, less objectivity, and avoidance. Emotions such as anger and grief become more difficult to manage.
What do these symptoms look like in real life? For me, they have manifested in two distinct ways: 1) becoming hardened and cynical and 2) feeling crippled when confronted again by suffering.
Neither outcome is beneficial, and both need to be addressed. With regard to the latter—feeling crippled—it doesn’t take long after encountering suffering for feelings of hopelessness, withdrawal, and lack of self-esteem to set in. If one is unaware of what is at play, coping mechanisms—going silent, for example—can occur. Redirecting, shutting down, minimizing, or ignoring the experiences of patients are some of the ways that coping mechanisms can exhibit themselves, says Anna Baranowsky (2002), and their negative impact on patient care is obvious.
Secondary doesn’t mean insignificant
What aren’t as obvious are the feelings of shame and guilt that accompany delivery of less-than-optimal care. As a result, nurses and other healthcare professionals are more likely to develop nontherapeutic coping patterns, such as addictions. Studies show that development of STS is often a predictor of an early exit from nursing. How many nurses do we have to lose before we recognize how significantly STS can affect them and other healthcare personnel?
Because nurses are on the front lines of caring for the sick and frail, secondary traumatic stress is often viewed as an occupational hazard for the profession. Daily, nurses are confronted by heart-wrenching and tragic situations that have the potential to induce trauma. Studies indicate that 85 percent of emergency department nurses experience symptoms of STS (Dominguez-Gomez & Rutledge, 2009). Similar numbers are found among hospice nurses.
Response to trauma is highly individual—what may affect one may have little to no effect on another. Personality traits, such as increased empathic response, can increase susceptibility to STS. On the other hand, a nurse with greater resilience is less likely to be susceptible. The profession of nursing attracts caring, nurturing people, so it seems logical that we should inform all nurses about symptoms and treatments of secondary traumatic stress and ways to prevent it.
STS can be treated, but professional help is required. Trauma therapists may choose techniques such as cognitive behavioral therapy (CBT) and eye movement desensitization reprocessing (EMDR), both of which are very effective. Accelerated recovery programs are available. Resilience training and mindfulness-based stress reduction courses are also making headway.
At the crux of prevention is self-care. A depleted person cannot give to others. One might think that nurses wouldn’t need a reminder about the importance of proper rest, nutrition, and exercise. But life with all its busyness has a way of interfering with those good intentions. Add the stress of increased patient acuity, higher nurse-patient ratios, and staffing shortages, and we have the makings of a perfect storm.
Knowledge is key. No one should have to learn about STS the way I did—after the fact. No one should confuse STS with depression or wonder why he or she no longer feels competent, despite years of experience. To ensure that symptoms are recognized and the disorder is treated early, all nursing curricula should include STS education. The benefits are cumulative. It’s more effective to seek help sooner than later. Caring for self, balancing work with leisure, employing reflective practices, and managing stress levels are crucial components in preventing STS. Many studies have been done on nurses eating their young. Maybe it’s time to make sure nurses nurture their young by equipping new nurse graduates with knowledge about and skills for preventing secondary traumatic stress.
Efforts to spread the word on STS will not be effective until nurses and administrators everywhere become aware of its ramifications. That will never happen if we continue to refer to it as stress reaction or “the cost of caring.” Yes, we are nurses, but we are also sons, daughters, spouses, parents, and friends, and our loved ones should not be negatively impacted by our decision to have a career in healthcare. Finally, nurses owe it to themselves to recognize that nursing is emotionally trying and has the potential, if careful steps aren’t taken, to significantly alter who they are. RNL
Part 2: "Recognizing secondary traumatic stress in others"
Dorothy B. Wright, BScN, a resident of Springfield, Manitoba, Canada, is a freelance writer (click here to access her website and blog) and author of Side Effects: A Journey Through Secondary Traumatic Stress.
Baranowsky, A. B. (2002). The silencing response in clinical practice: On the road to dialogue. In C. R. Figley (Ed.), Treating compassion (pp. 155-170). New York, NY: Brunner-Routledge.
Bremner, J. D. (2006, December). Traumatic stress: Effects on the brain, Dialogues in Clinical Neuroscience, 8(4), 445-461.
Dominguez-Gomez, E., & Rutledge, D. N. (2009). Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing, 35(3), 199-204. doi: 10.1016/j.jen.2008.05.003
Figley, C. R. (Ed.). (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner-Routledge.
Figley, C. R. (Ed.). (2002). Treating compassion fatigue. New York, NY: Brunner-Routledge.