The Cost of Caring

Submitted by Julie Givens RN, BSN and Cynthia Bain MSN, RN, CNE

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The Cost of Caring

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Nurses are the heart of healthcare. Nursing has been voted the number one most trusted profession in America thirteen times out of the past fourteen years in the annual Gallup Poll (Resources, 2013). It is considered both an art and a science. Administering medications and tending to a wound is the science of nursing, however, nurturing to a patient’s emotional and psychological needs is the art of nursing. It is this holistic approach of care that makes nurses vulnerable to injury themselves. “In traditional Native American teaching, it is said that each time you heal someone you give away a piece of yourself until, at some point, you will require healing” (Stebnicki, 2008, p. 3).

While in school, therapists and counselors are taught about the risks of experiencing negative psychological effects resulting from treating traumatized clients and how they can prevent it. Nurses, on the other hand, do not have much exposure to this material in their education and therefore do not know how to guard themselves against these negative effects so that they may continue to provide quality care. “One nurse stated that she was often left with a feeling of impotence and that she would go home feeling that she didn’t give the care that she wanted to, or became a nurse to give” (Austin, Goble, Leier, & Byrne, 2009, p. 205). It has been shown that job induced stress is linked to absenteeism, lower morale, and frequent turnover of staff (Annscheutz, 1999).

Compassion Fatigue, Secondary Trauma, Vicarious Traumatization, and Burn Out

There are a few conditions that describe negative consequences of caring for traumatized patients in health care professionals. These include burnout, compassion fatigue, vicarious traumatization, and secondary traumatization. While these terms are sometimes used interchangeably there are distinct differences between each of them.

Burnout is described as being worn out, or becoming exhausted by the excessive demands on one’s energy, strength, or resources. It is often accompanied by feelings of failure (Freudenberger, 1974). Burnout can often be resolved with a change in profession or lessened hours. Figley (1995) describes compassion fatigue as “natural and disruptive by-product of working with traumatized and troubled clients” (p. xiv). Secondary trauma has been equated with compassion fatigue but the phrase compassion fatigue is often used because it has been deemed “less stigmatizing” (Austin, Goble, Leier, & Bryne, 2009 p.197).

Figley (1995) describes secondary traumatization, or secondary traumatic stress, as the natural behaviors and emotions resulting from knowing about a traumatizing event experienced by another or- the stress from wanting to help or helping someone who has been traumatized or is suffering. Secondary stress can present with symptoms such as intrusive thoughts, nightmares, avoidance of certain patients or hyper-arousal when around them, and emotional numbing which all have a sudden onset.


Vicarious traumatization (VT) is the result of empathetic engagement with a client’s trauma material that changes the inner experience of the therapist or caregiver. It can manifest as seriousness, sadness, anxiety, and despair for humanity (McCann & Pearlman, 1990). VT causes a long-term, and sometimes permanent, change in attitudes and belief of one’s self and others. It can lead to disconnection from friends and family, social withdrawal, decreased sensitivity, despair, and hopelessness (Saakvitne, 1995). All of the above mentioned conditions will be explained in this paper. They will not, however, be used interchangeably.

Transference and Counter Transference

There are a few concepts to be understood that play a role in the development of vicarious traumatization. Transference and counter-transference are theories of how the patient and caregiver will affect each other. It is important for the caregiver to acknowledge these as inevitable reactions or responses. Transference is the relating of the caregiver to someone who played a significant role in the patient’s life. Counter-transference, on the other hand, is the reaction of the caregiver to the patient. It can be used to identify with the patient and understand what and how they are feeling. The danger, however, is that the caregiver can become emotionally entangled and loses objectivity or sense of oneself.

There are two main types of counter-transference reactions to be aware of. Counter-Transference Reaction Type I is an avoidance reaction. In this type of reaction the caregiver withdraws from the patient and distances themselves while maintaining a blank screen facade. They may even deny, ignore, or try to intellectualize a patient’s claim (Hartman, 1995). For example, a woman came into the emergency room after being raped on a date. The nurse caring for her showed little empathy or compassion while performing the assessment and hardly looked at the patient while asking questions about the incident. The woman expressed fear of returning to her apartment because her date knew where she lived. She was worried that he may come back. The nurse did not offer to contact a social worker or anyone that could help make other arrangements. Instead she brushed off the patient’s concern and simply said she doubted the man will return.

Counter-Transference Reaction Type II is an over identification reaction. The caregiver loses boundaries as they become over-involved with the patient. They often become emotionally entangled and dependent on the patient (Hartman, 1995). Using the example from above, the nurse experiencing a Type II reaction was very concerned for the patient’s emotional state and was very compassionate towards the patient. She spent more time tending to this patient than the others she was assigned to because she did not want to leave her alone. When the patient expressed fear about returning to her home the nurse not only got in touch with a social worker that could make arrangements for the patient, but she also gave the patient her personal phone number.

Constructivist Self Development Theory

The Constructivist Self Development Theory (CSDT) is an interpersonal theory that describes the effect that trauma can have on an individual’s psychological development and their sense of self. The CSDT is an interactive theory which takes into consideration the reactions of different people to the same trauma. It indicates that there will be a unique reaction based on the individual, the trauma they experienced, and the work setting (Pearlman & Saakvitne, 1995). This is the basis for understanding the effects that vicarious traumatization has on the caregiver. Vicarious traumatization causes disruptions in five categories: frame of reference, self-capacities, ego resources, psychological need, beliefs, relationships, and imagery.

A change to one’s frame of reference may be considered the most drastic and problematic change. An individual’s frame of reference maintains their self-identity, how they view the world, and their spirituality. Alterations to a caregiver’s frame of reference can make them feel disconnected or distant from others. The caregiver can be confused as their views of the world and things that happen in it are challenged, and despondent and helpless due to the disruption of their spirituality (Pearlman & Saakvitne, 1995).

Self-capacity entails the ability to maintain positive self-esteem and manage one’s feelings or emotions. Impairment of an individual’s self-capacity may result in them being intolerant to negative emotions or confrontations which can impair their relationships with others (Trippany, White Kress, & Wilcoxon, 2004). This can lead to the caregiver experiencing anxiety and being increasingly self-critical while starting to exhibit depressive symptoms (Pearlman & Saakvitne, 1995).

Ego resources include awareness of psychological needs, the ability to make judgment calls that are in the individual’s best interest, and working to attain goals that benefit the individual and allow for personal growth. If any of these abilities are hindered by vicarious traumatization it can result in the individual exhibiting maladaptive or self-destructive behaviors, ignoring their own needs, and having difficulty making decisions. Ultimately, it can lead to impairment of cognitive processes in the individual (Pearlman & Saakvitne, 1995).

Psychological needs, beliefs, and relationships include five areas that will be altered by the effects of vicarious traumatization: safety, trust, self-esteem, intimacy, and control. When one’s sense of safety is impeded they may have behavior changes such as doubting their instincts and mistrust of others around them due to fearfulness and increased vulnerability. Disruption of trust of oneself leads to an individual not trusting their impressions of others and lacking the confidence to be independent. When self-esteem is affected the individual’s self-esteem is lowered and, especially in caregivers, they may begin to doubt their ability to help others. However, this disturbance of one’s own self-esteem may be exhibited as a low esteem in other individuals which leads them to degrade differing interests and beliefs. If self-intimacy is disturbed or lost the individual may lose enjoyment in activities they normally take pleasure in. However, if the nurse loses intimacy with others they may avoid close or personal relationships. Ultimately, the nurse may lose a sense of control due to the trauma that they are treating in their patients which can cause distress if they feel they do not have any control over the events in their life (Pearlman & Saakvitne, 1995).

Imagery, which may be the most obtrusive if negatively affected by vicarious traumatization, can cause mental images formed from the patient’s trauma to intrude in the caregiver’s thoughts. This can cause distress in the caregiver and also trigger memories of their own personal trauma that may be painful (Sinclair & Hamill, 2007).

Recognizing the problem

There are a few tests or scales that can be used to diagnose some of the issues that can result from traumatic stress. The Secondary Traumatic Stress Scale (STSS) measures symptoms associated with exposure to working with traumatized patients. The person completing the survey is ranking how often in the previous week they had experienced each listed symptom. The symptoms are derived from three subscales: intrusion, avoidance, and arousal (Bride, Robinson, Yegidis, & Figley, 2004). Trauma and Attachment Belief Scale (TABS) is a self-test that assesses cognitive schemas. It addresses safety, trust, esteem, and intimacy in oneself and in others (Pearlman L. A., 2003).

The Compassion Fatigue Self-Test (CFST) for Helpers measures both negative consequences and satisfaction of compassion. There are sixty-six items broken into three subscales: compassion fatigue, compassion satisfaction, and job burnout (Figley, 1995b). The Compassion Fatigue Scale-Revised (CF-R) is a self-test engineered to assist caregivers in identifying symptoms of compassion fatigue in themselves. It includes thirty items that evaluate job burnout and secondary traumatic stress which are rated on a scale from one (rarely/never/NA) to ten (very often) (Adams, Figley, & Boscarino, 2008).

Effects of Trauma on Today’s Nurses

The term vicarious traumatization, which was identified two decades ago, was intended to describe a condition affecting psychotherapists. Over the years, however, it has been found that dealing with trauma negatively affects a wide array of professions. Several studies on how trauma affects nurses and other healthcare workers are listed. Twenty pediatric nurses were found to experience compassion fatigue after being interviewed (Maytum, Heiman, & Garwick, 2004). After two hundred sixteen hospice nurses took the Compassion Satisfaction and Fatigue Test 26.4 % were found to be at high risk for compassion fatigue. While 52.3% were at moderate risk for compassion fatigue, and 21.3% were at low risk for compassion fatigue (Abendroth & Flannery, 2006). One hundred eighty five health care providers, one hundred twenty five of which were nurses, took the Compassion Fatigue Questionnaire and it was concluded that personnel with higher levels of personal stress were prone to higher levels of compassion fatigue (Meadors & Lamson, 2008). Out of forty two oncology nurses, sixteen of the participants, or 38%, had moderate secondary traumatic stress according to the Secondary Traumatic Stress Scale (STSS) (Quinal, Stephanie, & Rutledge, 2009). According to the STSS 33% of the sixty seven emergency department nurses scaled met all criteria for Post-Traumatic Stress Disorder (Dominguez-Gomez & Rutledge, 2009). Of the one hundred ten sexual assault nurses who took the Compassion Fatigue Test, 25% indicated they experienced traumatic symptoms (Townsend & Campbell, 2009).

Addressing the Problem

As well as recognizing the problem, it is just as imperative that nurses have an understanding of how to treat and ideally prevent vicarious traumatization or any similar conditions resulting from traumatic stress. One approach to recovery is “ABC”, developed by Pearlman and Saakvitne (1995). A is awareness of one’s limitations and emotional needs. B stands for balance between work and leisurely activities. C is connection and communication so that one does not isolate themselves when they need help from others the most (Little, 2002). Similar to ABC is the acronym ACT. A stands for acknowledging that traumatic stress can have negative effects on the caregiver. C is connecting with others to form a support system. T is talking and sharing thoughts and feelings with others in a safe environment (Clark & Gioro, 1998).

Aside from the clever acronyms (interventions) there are other strategies for nurses to maintain themselves and for administrators and charge nurses to support their nurses. Rourke (2007) classified three strategies to prevent negative effects from caring for traumatized patients. Personal strategies include getting adequate sleep, exercise, and eating healthy. It is also important to make time for leisurely activities and maintaining a good social network. Professional strategies consist of setting personal boundaries between the caregiver and the patient, identifying what kind of cases might cause the caregiver to feel particularly stressed, and placing emphasis on the positive aspects of the job and patient interactions. Organizational strategies include having an open environment to talk about vicarious traumatization and similar issues, providing safe and comforting areas for caregivers to meet, maintaining an air of respect for the work done and encouraging a sense of teamwork among workers (Beck, 2011).

Awareness is the biggest factor in preventing nurses from being affected by vicarious traumatization or one of the related phenomena. An increased awareness of the emotional demands of a nursing career is of the utmost importance and this should start with integrating education into undergraduate and graduate programs as well as nursing orientation programs (Erickson & Grove, 2007). The healthcare system will fail without nurses so measures should be taken pre-emptively to protect them from the devastating effects that can otherwise be referred to as the cost of caring.


Teaching About Trauma without Traumatizing

One challenge educators face in teaching students about the negative effects of trauma is that the information itself might possibly traumatize the students and cause harm. The classroom needs to be a safe environment for students to learn how trauma experiences can affect them before they encounter it on the job. There are a few risk factors that increase the potential for the students at risk to be traumatized in the classroom. For instance, some students may have never been exposed to trauma material before which could cause them to become overwhelmed by the unfamiliar, and possibly disturbing, feelings that develop as a result of the exposure (Neumann & Gamble, 1995). Additionally, students who have a personal history of trauma are at higher risk for becoming traumatized while being taught about the effects of trauma (Cunningham, 2004).

Teaching students about vicarious traumatization prior to being introduced into the work field may aid students in developing a theoretical framework. Through this framework they can manage and understand not only their reactions to trauma but their clients’ as well. When presenting case material instructors should encourage the expression of honest responses and even “model” responses to support students in acknowledging feelings they may be struggling with. Once students acknowledge their reactions to the trauma material, instructors can provide resources for coping with trauma in the work setting, including reading material, supervision or a mentor relationship with a more experienced colleague, and self-care habits (Cunningham, 2004). This will teach students how to appropriately address struggles they face without allowing manifestation of harmful habits or emotions that could lead to the development of a traumatic stress related phenomena.

The case study methodology that is presented in class and the manner in which it is presented should also be premeditated and chosen with careful consideration to prevent traumatizing students. As previously mentioned one of the risk factors for students is having minimal exposure to or experience with trauma. If a gruesome case is shared with excessive graphic details it could cause students to feel overwhelmed. Summarizing cases and sharing only the information that is important can help reduce the risk of traumatizing students. Using cases that were highly covered by the media can also reduce the risk of students being traumatized as they have already been exposed to the material (Cunningham, 2004). In addition, the presenter needs to be cognizant of how they are presenting the material. If they speak without using the proper emotion it does not warn the listeners of graphic material that is about to be divulged (Cunningham, 2004).

The goal is to reduce the risk of developing vicarious traumatization, however, some emotional distress is beneficial for learning in the controlled and safe setting of the classroom. This will allow students to emotionally empathize with their clients when they become upset and instructors can guide the student and class through it and utilize it as a learning experience. Reassuring the student that their reactions are normal will help the student form a connection with future clients. It also allows the students to recognize which aspects of the situation can be changed and which cannot be. The instructor can then introduce therapeutic skills that can lead to the desired changes. Ultimately this will lead to students being able to anticipate responses so they can then normalize and form strategies to effectively deal with them (Cunningham, 2004).

Educational Content

An example of a course outline used at the University of New South Wales for their course “From Individual to Community Interventions: Therapeutic Responses to Trauma” is described below. Although this course is intended for social work students it could easily be adapted to implement into nursing curriculum. Unit one focuses on introducing trauma and conceptualizing it in relation to individuals and the community. Students are assigned to groups for debriefing sessions after each lecture and they discuss which self-care practices they believe will be most beneficial to them. Students are taught about the impact that trauma has on an individual’s neurobiology, psychology, and body. In the third week they are trained on identifying traumatized communities (Breckenridge & James, 2010). This unit would be most beneficial for nursing students to understand how caring for a traumatized population can affect them. It would be essential to emphasize symptoms of traumatic stress related phenomena to identify in themselves and reviewing self-care practices that can stave the development of such conditions.

Unit two focuses on interventions for individuals and communities that have been traumatized. These interventions support the clients and encourage healing and include skills such as taking a trauma history (Breckenridge & James, 2010). While this unit relates more to a social worker’s undertaking it is important for a nurse to be trained in interventions to care for traumatized patients. Especially in specialties such as emergency room, ICU, burn unit, and psychiatric nursing, nurses care not only for the patient but the patient’s significant others who face traumatic situations.

Unit three discusses domestic violence and child abuse. In this unit students are given the chance to apply the skills and interventions they have learned previously in the course in a simulation exercise (Breckenridge & James, 2010). Nurses of all specialties may encounter patients that are suffering some sort of abuse. It is critical that students are trained to not only recognize these patients but be able to approach them in a way that they feel safe to share their experience with the nurse so they can avoid future effects of the trauma.

Unit four concentrates on traumatic death, natural disaster, epidemics, and mass casualties. Students discuss the impact on the survivors surrounded by these incidences and what needs they might have. In addition they address what their role would be in the event of a natural disaster or mass casualty (Breckenridge & James, 2010).


Risking Connection

Risking Connection is another program used to train those who work with survivors of trauma. The resounding idea behind it is that “connection is the active ingredient in healing relationships” (Giller, Vermilyea, & Steele, 2006, p. 67). The basic principles include: “symptoms are meaningful, adaptive responses to traumatic stress, a RICH relationship (one that embodies respect, information, connection, and hope) is the key to healing from trauma, managing (and preventing) symptoms and crises requires building self-capacities, (or feelings skills) in both helpers and survivors”, “the helper’s internal responses are essential tools and must be noticed and used constructively, and trauma work affects the person of the helper” (Giller, Vermilyea, & Steele, 2006, p. 67).

Of caregivers who completed this course 97% agreed that the training improved their effectiveness as a care provider, 93% said the training boosted their enthusiasm and level of hope regarding working with trauma survivors, 90% stated the training helped them realize in new and more obvious ways how caring for trauma patients affects the person of the helper, 93% shared that the training gave them insight and direction about the necessity of self-care on the part of the helper and its critical role in preventing vicarious traumatization, and 87% agreed that they are better able to recognize and address the effect of vicarious traumatization because of this training (Giller, Vermilyea, & Steele, 2006, p. 80). This model of teaching appears effective for training those who care for survivors of trauma while emphasizing the need to care for both the survivor and the caregiver.

A Personal Perspective

The author started doing research on vicarious traumatization in nurses during her sophomore year of college for an assignment in an abnormal psychology class. The following semester in the early morning hours of her first day of nursing school clinical experience she was awoken by a car crashing through the wrought iron fence that enclosed her apartment complex at seventy miles an hour and stopping just three feet short of the apartment building directly below her bedroom window. The car caught fire and was soon engulfed in flames. She and her two roommates, who were also nursing students, worked quickly to help everyone that they could. Because of damage to the car, only two of the four passengers were rescued from the car. The two that were pulled from the car suffered severe injuries including a spinal fracture, skull and facial fractures, third degree burns, a broken wrist, and damage to internal organs. The two that were trapped in the car never made it out.

Later that day when the professors at their school found out what happened they set up a counseling session for all three to attend. Because the author had already started doing research over the negative effects trauma can have on caregivers she thought she would be able to heal from this traumatic experience. However, a few months later she was still suffering from bouts of insomnia and nightmares. As she continued reading about traumatic stress related phenomena and researching ways to educate nurses about them she found that she was experiencing many of the symptoms she read about. This reinforced the belief that nursing students should have exposure to this material and be familiar with the phenomena discussed prior to entering the profession.



Nurses are a valued part of our healthcare system. We owe it to them to prepare them and provide tools for maintaining their emotional, mental, and spiritual health when facing challenges in this line of work. There are strategies for protecting themselves including self-care practices. Introducing these phenomena and conceptualizing trauma to students prior to entering the profession will arm nurses with knowledge of what symptoms to be aware of, how to protect themselves, and how to therapeutically connect with patients that have experienced trauma. Nurses may become more confident, effective, and caring while serving the patients who experience trauma.