Is it possible you suffer from secondary trauma?
As an ED nurse, you witness the aftermath of tragic accidents, child abuse, domestic violence, and other traumatic events every day. This exposure can have a cumulative effect, according to Alice Kramer, MS, RN, CEN, clinical nurse specialist for emergency services at St. Luke’s Medical Center in Milwaukee.
"It’s a reality that ED nurses themselves become traumatized by listening and caring about the stories of so many victims of violence," says Kramer. "This is not an easy job to do, and it takes its toll on nurses."
The problem comes when you don’t just empathize but somehow "catch" a grief or trauma reaction, says Billie Z. Lawson, MSW, ACSW, associate director of the social work department at Harborview Medical Center in Seattle. "ED nurses are at high risk for this because they see enormous grief and trauma," she explains. "By hearing people’s stories, you can have your own reactions."
Lack of control is factor
ED nurses are at particularly high risk for those secondary reactions because you don’t have any control over who is going to walk in the door, Lawson notes. "You can’t say, I’m not going to do this one because my next-door neighbor just came in on a gurney,’" she says.
You also have no "down time," says Lawson. "You don’t have time to stop and process something, because the next person is already walking in the door."
Here are ways to avoid secondary trauma:
• Watch for signs.
Be the lookout for these signs and symptoms in yourself and your colleagues, recommends Kramer.
— cynicism;
— withdrawal from friends and family;
— low energy levels;
— feelings of despair and hopelessness.
ED nurses often have the attitude to "take it in stride," but you can avoid burnout by watching for those symptoms, says Kramer. (See related story about asking for help, p. 146.)
You can’t fix’ every situation
• Be realistic about what you can do.
In cases of child abuse or domestic violence, nurses should be educated about the process of change, Kramer advises. "That way, you don’t expect so much from yourself, and wind up feeling powerless as a result."
In the ED, it’s unlikely you will be able to "fix" a situation of domestic abuse, Kramer stresses. "Instead of trying to solve the entire problem, realize the impact you can have," she suggests. "Do case reviews so you can explore the ways you have contributed. Let go of unrealistic expectations about things you cannot do in the ED."
For example, simply asking a battered woman about abuse is an intervention, says Kramer. "A battered woman doesn’t expect you to fix their complex social situations," she says. "But they do have the right to expect that you will ask them about it, and be given an opportunity to tell about their situations in a confidential and respectful way." (For more information on domestic violence screening, see ED Nursing, August 2000, p. 121; ED Nursing, May 1998, p. 97; and ED Nursing, June 1998, p. 124.)
If you ask a victim of abuse, "was that a useful intervention?" most will say yes, says Kramer. "It’s important to realize that it doesn’t have to be a dramatic fix," she says. "Simply giving information and options that she may never have known about, whether she uses them or not, is valuable."
• Identify your own "triggers."
Certain scenarios will hit you harder if you can identify with the patients or family members, Lawson says. "One incident might blow you out of the water, and everybody else seems normal," she notes. "You will relate to other people’s stories differently based on your own areas of vulnerability."
You might have thought you’ve seen everything, but a case can come along that shatters that assumption, says Lawson. "It’s very disorienting when your world view is turned upside down," she says. "That can happen with certain kinds of abuse cases, anything inflicted on somebody that is horrifying, or accidental things, like somebody standing in their yard and a tree falls down and kills them."
• Use colleagues for support.
It’s helpful to discuss difficult cases with your co-workers, says Lawson. "Instead of bottling something up, ask another nurse, Did you see what happened?’ It’s not typically how you end a shift, but to the extent you can, it helps to talk at a deeper level about our value systems, or what a particular case meant to you," she says.
The hospital offers ongoing support groups, but ED nurses don’t participate, reports Lawson. "ED staff are much more task-focused."
Still, it’s key to acknowledge an incident that upsets you, says Lawson. "When you have a chance to quickly acknowledge that this was a big deal, you can pretty much let it go and get back to work," she explains.
For example, telling your colleagues, "that case reminded me of my younger brother who died when he was 8 years old," can get it off your chest, says Lawson. "You can do this in two seconds, and then you can get back to what you’re doing," she says. "Just acknowledging the impact can be helpful."
For more information about secondary trauma, contact:
• Alice Kramer, MS, RN, CEN, Emergency Services, St. Luke’s Medical Center, 2900 W. Oklahoma Ave., P.O. Box 2901, Milwaukee, WI 53201-2901. Telephone: (414) 649-6228. Fax: (414) 649-5708. E-mail: alice_kramer@ aurora.org.
• Billie Z. Lawson, MSW, ACSW, Harborview Medical Center, Social Work Administration, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 329-7166. E-mail: [email protected].
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