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The Relationship Between Secondary Trauma and Distress

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Secondary trauma is not uncommon in the healthcare industry and can seriously impact the health of providers, patients, and organizations. In fact, one-in-four nurses suffers from post-traumatic stress disorder (PTSD) during their career. A recent study found that in critical care units, up to 48% of nurses meet diagnostic criteria for the disorder. No healthcare worker is immune to the risks of workplace trauma, especially in intensive care settings.

"Nurses see people die. They work on resuscitating patients. They try to control bleeding. They have end-of-life discussions," says nursing professor Meredith Mealer.

Secondary traumatic stress can lead to a host of adverse consequences, including increased risk of clinician burnout, severe fatigue, medical errors, and even suicidal ideation. There's a clear link between trauma and increased turnover rates among healthcare workers, leading to even more distress. Secondary trauma is a serious issue which requires professional intervention. A culture with strategic wellness initiatives and trauma-informed leadership can mitigate the risk of nurses, physicians, and other healthcare providers suffering in silence.

What is Secondary Traumatic Stress?

The concept of secondary traumatic stress (STS) was first coined in 1995 by psychology professor Charles Figley. He defined STS as "the natural behaviors and emotions resulting from knowing about traumatizing events experienced by another." Healthcare workers, mental healthcare providers, social workers, and first responders are all at an increased risk of occupational STS. Additionally, individuals with strong compassionate or empathetic tendencies are at higher risk for absorbing secondary trauma.

Secondary trauma can have physical, mental, and emotional consequences in the individual healthcare worker. Individual response can vary, and providers may internalize many of the following symptoms:

Emotional Symptoms

Emotional symptoms include feelings of grief, anxiety, or sadness. Individuals may be irritable, distracted, or experience mood-swings.

Behavioral Symptoms

Isolation, substance abuse, sleep disturbances, and eating pattern irregularity are all examples of behavioral symptoms resulting from secondary trauma.

Physiological Symptoms

Individuals suffering from secondary traumatic stress may experience headaches, rashes, ulcers, heartburn, and other physical problems.

Cognitive Symptoms

Cognitive symptoms such as difficulty concentrating and making decisions along with altered memory may impact suffering providers.

Spiritual Symptoms

These can include feelings of hopelessness, loss of purpose, or feeling unworthy.

Secondary Traumatic Stress vs Compassion Fatigue

While secondary traumatic stress and compassion fatigue have similar symptoms and some areas of overlap, they're not identical. Compassion fatigue “generally sets in over time, hence the ‘fatigue’,” explains clinical social work professor Steve Hydon. In contrast,"secondary traumatic stress can set in almost immediately."

While both conditions can have serious impacts on healthcare workers' personal and professional lives, compassion fatigue is generally the result of prolonged exposure to multiple traumatic situations, whereas secondary trauma can be the result of a single experience.

Understanding Secondary Trauma and Distress

In order to fully examine the relationship between trauma and distress, we must be able to identify the differences and understand each concept comprehensively. The dimension of distress that is most commonly confused with secondary traumatic stress is burnout. According to the National Academy of Medicine, burnout is "a workplace syndrome that is characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work." In general, burnout is caused by a wide variety of system factors, while secondary traumatic stress is the result of working closely with trauma patients or experiencing a traumatic event. 

Although the conditions are defined differently and have different causes, researchers propose a two-way link between secondary traumatic stress and burnout, as well as other dimensions of distress such as severe fatigue and meaning in work. Both burnout and STS can deplete emotional resources, causing providers to be more vulnerable to experiencing the adverse consequences associated with each.

The solution is likely a trauma-informed approach to preventing burnout and distress.

A Trauma-Informed Approach to Preventing Distress

Trauma is a serious issue that doesn't get better on its own. Individuals suffering from post-traumatic disorders require treatment to avoid serious, lasting impact on physical and mental health. Suffering silently is a risk to the individual healthcare worker's well-being, workplace performance, and the organization as a whole.

Secondary trauma has been linked to mental health disorders like anxiety and depression. Those suffering may be withdrawn or disconnected at work and experience difficulties being empathetic toward patient needs. Clinical workers with STS or PTSD are at a higher risk of displaying unpredictable behaviors or poor workplace judgement, which can easily lead to poor quality patient care. In the most extreme cases, untreated trauma can lead to an increased risk of suicide or substance abuse.

A trauma-informed approach to creating a healthy culture can likely mitigate the risks of secondary traumatic stress, burnout, and other dimensions of debilitating workplace distress in healthcare. Trauma should be treated as a distinct issue. However, efforts to manage secondary trauma risks among healthcare workers can also be beneficial to burnout and workplace satisfaction.

1. Psychoeducation

Therapeutic interventions from a qualified mental health care provider are a critical part of recovery and well-being for individuals with secondary traumatic stress. Nurses and other clinicians who are at high risk of trauma exposure can benefit from psychoeducation interventions that focus on building individual strength, fostering a sense of personal control, and developing authentic relationships at work and at home.

2. Informed Leadership

Managers and administrators across the healthcare industry need to be aware of secondary trauma and its potential impact on the individual, the patient, and the organization. A first step to creating more trauma-informed leadership is to stop thinking of trauma as interchangeable with stress or compassion fatigue. Providers should be supported and prioritized by the organization.Trauma is a real issue which requires treatment and serious attention.

3. Ongoing Awareness Training

Organizations should provide education and encourage discussion of STS to help individuals increase their understanding and learn boundaries to manage trauma in the workplace as much as possible. Individual awareness training can teach clinicians to recognize warning signs of adverse trauma and stress reactions.

4. Surveys and Self-Reporting Systems

The healthiest cultures encourage individuals to self-report trauma risks and seek peer support, psychotherapy, and other professional interventions. Assessments play an important role in monitoring trauma risks across the workplace, and especially among providers at higher risk of STS.

5. Workplace Self-Care

A genuine culture of self-care in the workplace is highly-individualized and based on the individual's preferences and context, according to chaplain and occupational trauma specialist Alexandra Zareth Canales. This should be an ongoing practice.

6. Patient Caseload Management

Active workload management is an important component of distress and trauma-aware management. Nurses and other care providers should be given access to workload support and sufficient time to provide quality patient care.

7. Flextime Scheduling

Flexible work schedules are a crucial component of stress and trauma exposure recovery. Administrators should recognize the need to protect downtime, according to The Vicarious Trauma Toolkit, while staying aware of individual behaviors; withdrawal or isolation can be negative responses to trauma exposure.

Addressing Secondary Trauma

Trauma is an epidemic among healthcare providers, especially individuals in critical or intensive care specializations. The first step in protecting individuals, patients, and healthcare organizations is to recognize secondary trauma as a serious, unique issue that requires professional intervention.

Healthcare organizations need to foster awareness and recovery by creating a trauma-informed culture and leadership. Many of the same initiatives to mitigate workplace distress and burnout can foster well-being among individuals at the greatest risk of debilitating trauma. Listening actively and watching for individual signs and symptoms of secondary trauma can prevent the risks of suffering in silence.

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