RESEARCH REVIEW 1.0 ANCC Contact Secondary Posttraumatic Stress and Nurses’ Hours Emotional Responses to Patient’s Trauma Evdokia Missouridou , PhD, MSc, RN disciplines ( Curtis & Puntillo, 2007 ; Figley, 1999 ). Indeed, ABSTRACT nursing researchers report alarmingly high percentages Alarmingly high percentages of secondary posttraumatic of secondary PTSD in critical care nursing ( Karanikola, stress have been reported in several nursing domains such et al., 2015 ), emergency department ( Morrison & Joy, as critical care and emergency nursing, oncology, pediatric 2016 ), oncology ( Quinal, Harford, & Rutledge, 2009 ), nursing, mental health nursing, and midwifery. The purpose pediatric nursing ( Meadors, Lamson, Swanson, White, & of this review is to examine and describe nurses’ emotional Sira 2010 ), mental health nursing ( Lee, Daffern, Ogloff, & responses in the face of their exposure to patients’ trauma. Martin, 2015 ; Mangoulia, Koukia, Alevizopoulos, Fildissis, Lack of understanding of the dynamics of trauma may limit & Katostaras, 2015 ), and midwifery ( Beck & Gable, 2012). nurses’ ability to interact in a meaningful and safe way with Although the true magnitude of secondary posttrau- patients and their families. Spirituality can be a precious matic stress still remains unclear due to methodological compass in the long-term journey of resolving feelings of limitations and differences in study designs and instru- grief and loss at work and of building a strong professional ments employed, professional training, organizational identity. cultures, or organizational health care systems between countries ( Beck, 2011 ; van Mol, Kompanje, Benoit, Key Words Bakker, & Nijkamp, 2015 ), the risk of emotional dis- Compassion fatigue , Emotion work , Secondary traumatic tress implicated in working with traumatized clients has stress , Self-care , Trauma certainly been recognized. he concept of posttraumatic stress disorder (PTSD) THE DYNAMICS OF TRAUMA: CARING FOR arose in the wake of the Vietnam War (Trimble, THE PATIENT WITH TRAUMA AND HIS/HER 1985 ) whereas its formal introduction in the third FAMILY edition of the Diagnostic and Statistical Manual of Caruth (1996) described trauma as an “unclaimed” experi- TMental Disorders ( DSM-III ) came only in the 1980s. ence, an event “experienced too soon, too unexpectedly, Despite criticism relating to the social and political power to be fully known and … therefore not available to con- issues implicated in the medicalization of human suf- sciousness until it imposes itself again, repeatedly, in the fering, research on the psychological impact of trauma nightmares and repetitive actions of the survivor” (p. 4). and its treatment has flourished during the last decades The experience of trauma actually leads to deep psycho- ( Stein, Seedat, Iversen, & Wessely, 2007 ; Summerfield, logical injury at an unconscious level that entails loss of 2001 ; Yehuda & Farlane, 1995 ). Furthermore, interest has control, language, power, and self. Trauma is a wound recently been drawn on the pervasive effects that PTSD that “cries out,” a silent wound that is articulated through may have on professionals who try to address the needs re-enactments. As a result, traumatized individuals are of traumatized individuals ( Figley, 1999 ). vulnerable to repeating past traumas and remain in a cri- Secondary PTSD, compassion fatigue, and vicari- sis without being able to regain control over their current ous traumatization are the terms that are used almost lives. Getting to “know” their trauma overwhelms them interchangeably to describe the “cost of caring” for the emotionally to the extent of rendering its cognitive pro- traumatized individuals in nursing (Dominguez-Gomez cessing impossible. According to Caruth (1996) , recovery & Rutledge, 2009 ; Meadors & Lamson, 2008 ) and other from trauma entails that it is spoken in all its horror and violation to someone who can listen to it without being overwhelmed. To integrate trauma into their lives, trau- Author Affiliation: Nursing Department, Technological Educational Institute of Athens, Greece. matized individuals must find language and symbols to The author has no declared conflicts of interest or sources of funding. express the frustrations, helplessness, disempowerment, Correspondence: Evdokia Missouridou, PhD, MSc, RN, Eoleon 31, 11852, and humiliation they suffered. Fragmentation of identity Athens, Greece ( [email protected] ). caused by the rupture of trauma is healed through the DOI: 10.1097/JTN.0000000000000274 construction of a narrative. 110 WWW.JOURNALOFTRAUMANURSING.COM Volume 24 | Number 2 | March-April 2017 Copyright © 2017 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. Nonetheless, the prospect of conceiving trauma is in- memories of patient arrest or witnessing patient death, tolerable. Furthermore, the recovery of traumatic mem- especially during the first years of their career. Partici- ories may retraumatize the individual ( Gabbard, 2000 ). pants in their study also expressed guilt about not feel- This is why the National Institute for Health and Care ing certain emotions that they felt they “should” be feel- Excellence (NICE) guidelines (2005) recommend to avoid ing at the time of a patient’s death. single-session interventions (known as debriefing) during Oncology nurses are also repeatedly exposed to trau- the first month after a traumatic event. But even later on, matic experiences while caring for their patients and are, the recovery of traumatic memories does not constitute therefore, prone to secondary traumatic stress ( Quinal a goal of therapy. According to Gabbard (2000) when et al., 2009). Secondary traumatic stress is described as re- memories of trauma reemerge, they may disrupt the nor- sembling PTSD but is triggered from exposure to persons mally integrative functions of memory, identity, and con- who have experienced trauma and from giving care to sciousness. Dissociation constitutes a way of warding off such persons. Exposure to end-of-life issues, death, and negative affect. Such defensive strategies, however, nar- cumulative exposure to patient suffering are described row the individual’s field of awareness and may partly ex- as precipitating factors to the development of secondary plain why severely traumatized patients have a reduced traumatic stress. The symptoms of secondary traumatic ability to think reflectively about themselves and about stress are described as including sleep difficulty, intru- relationship experiences. Therefore, professionals having sive thoughts about patients, irritability, and a sense of a therapeutic relationship with severely traumatized in- a foreshortened future ( Quinal et al., 2009). Least com- dividuals should focus on enhancing patients’ ability to mon symptoms of secondary traumatic stress were avoid- reflect on their relationships to other people instead of ance of people, places, and things and disturbing dreams focusing on recovering memories ( Gabbard, 2000 ). about patients. As regards nursing care at emergency settings, partici- NURSES’ EXPERIENCES OF CARING FOR pants in the study by Wolf et al. (2016) described “being THE PATIENT WITH TRAUMA AND HIS/HER overwhelmed” by patient care as a source of moral dis- FAMILY tress, which in turn resulted in feelings of powerlessness, Pain, loss, disability, chronic illness, and failure to achieve guilt, fear, anger, and frustration. Interestingly, nurses in relief from symptoms constitute trauma dimensions that this study found even more distressing feelings of pow- nurses have to deal with in everyday practice. In the study erlessness to make systemic changes in order to provide by Mealer, Shelton, Berg, Rothbaum, and Moss (2007) on sufficient patient care. PTSD in intensive care unit, nurses described the situa- Finally, two concept analysis studies of secondary trau- tions triggering secondary traumatic stress. These includ- matic stress and compassion fatigue ( Coetzee & Klopper, ed seeing patients die, patient aggression, involvement 2010 ; Mealer & Jones, 2013 ) and a qualitative study on with end-of-life care, verbal abuse from family members, the latter ( Austin, Goble, Leier, & Byrne, 2009 ) attempt physicians and other nurses, open surgical wounds, mas- to describe in depth the experience of nurses in the face sive bleeding, trauma-related injuries, care futility, per- of trauma and the cumulative process of nurse’s suffer- forming cardiopulmonary resuscitation, feeling overex- ing in the landscape of continuous exposure to human tended due to inadequate nurse-to-patient ratios, and not tragedy. Indeed, nurses often feel overwhelmed, horri- being able to save a specific patient. Pediatric intensive fied, and helpless when they encounter traumatized pa- care nurses also describe feelings of frustration accompa- tients and their families. When being haunted by images nied by feelings of helplessness, especially when having of specific patient encounters, nightmares and intrusive to be involved in the resuscitation of extremely premature memories persist and anxiety and psychological distress infants (Molloy, Evans, & Coughlin, 2015). are enhanced to a point of experiencing hopelessness, Maytum, Bielski-Heiman, and Garwick (2004) in frustration, and meaninglessness. Moral distress may be a qualitative study of compassion fatigue in pediatric caused by the disturbing realization that one becomes nurses describe the emotional stress that nurses experi- gradually unresponsive, disregarding,