The Cost of Caring in Nursing

Laurie Scudder DNP, NP


February 15, 2011

Secondary Traumatic Stress in Nurses: A Systematic Review

Beck CT
Arch Psychiatr Nurs. 2011;25:1-10.

Study Summary

Background. The effect of exposure to traumatic stress has been well recognized for 30 years, but only more recently has it been recognized that the results of trauma are felt beyond persons directly affected by it and may result in detrimental effects in significant others and caregivers. This "cost of caring" for those who care for traumatized patients has been reported in social workers, child protection workers, clergy, and mental health professionals. More limited research has examined this phenomenon in emergency department, hospice, oncology, forensic, and pediatric nurses. The purpose of this study was to review this literature in order to derive clinical implications for nurses at risk for secondary traumatic stress.

Methods. Beck began by clarifying terminology, observing that a number of tangential conditions are discussed in the literature, including burnout and vicarious traumatization. For the purposes of this study, "secondary traumatic stress" and "compassion fatigue" are terms used interchangeably and represent the result of knowledge about a traumatizing event experienced by another and the subsequent stress resulting from helping or wanting to help the traumatized person. Empathy and exposure are the 2 central concepts in this reaction. Symptoms of secondary traumatic stress include difficulty separating work from personal life, lower tolerance for frustration, depression, ineffective and/or self-destructive self-soothing behaviors, diminished sense of purpose, loss of hope, lower level of functioning, and decreased feelings of competence. Secondary traumatic stress can develop very suddenly and can lead to a sense of isolation, helplessness, and confusion.

Following a review of a number of databases, Beck identified 7 studies that examined secondary traumatic stress in nurses. Although 5 of the studies involved nurses exclusively, 2 were larger samples of other healthcare professionals, including nurses. None of the sample populations were randomly selected; most consisted of women, and educational backgrounds and years of experience of the nurses varied. A variety of methodologies, ranging from telephone and mailed surveys to live seminars that included data collection, and a number of different metrics, such as validated scales and open-ended questions, were used to assess level of stress, making comparisons between studies difficult. No study conducted a power analysis, making it impossible to determine statistical significance of the results.

Results. All studies, regardless of nursing population studied or instrument used, concluded that large numbers of nurses either experienced compassion fatigue or were at risk for this phenomenon. One study of 110 sexual assault nurse examiners concluded that one fourth of these nurses experienced secondary traumatic stress. Another study of 67 emergency nurses practicing in 3 different community hospitals concluded that 33% met the criteria for elevated secondary traumatic stress symptoms. A similar percentage (38%) of 43 oncology nurses were found to exhibit elevated secondary traumatic stress levels. The highest levels of compassion fatigue were found in a study of 216 hospice nurses, in which high risk for compassion fatigue was evident in one quarter of the sample and moderate risk was found in an additional half of the sample.

Three studies of pediatric nurses (one descriptive qualitative study of a small sample of 20 nurses working with chronically ill children and the 2 other studies of healthcare providers including nurses working with hospitalized children) consistently reported elevated stress levels. The only study to use a validated scale for compassion fatigue found moderate to extremely high risk for compassion fatigue in 39% of a sample of 314 healthcare providers, 136 of whom were nurses.


Although the studies included in this review were of variable quality and their applicability was limited by nonrandom sampling of primarily white female nurses, the consistency of results is striking. Drawing from these studies as well as others that examined potential interventions, Beck offers a number of suggestions to protect nurses from secondary traumatic stress. These include:

  • Educating nurses about their vulnerability to this syndrome and the associated signs and symptoms;

  • Providing continuing education on ways to prevent secondary traumatic stress, including peer support, and particularly noting the role of older nurses in assisting younger nurses (who are more vulnerable) in developing coping mechanisms;

  • Educating administrators about ways to detect secondary stress and steps to take when they identify a nurse who is struggling;

  • Forming compassion fatigue support groups;

  • Sending the message to nurses in high-risk settings, such as emergency departments, of the importance of balancing personal and professional life;

  • Educating nurses about personal strategies to prevent or ameliorate compassion fatigue, including getting enough sleep, regular exercise, relaxation, and nutrition; and

  • Organizational strategies such as breaking the silence that often exists around this issue, providing comforting physical spaces for clinicians to meet, and creating support teams.

The need for well-conducted studies in wider samples of nurses is clear. Providing insight into the risks and presentation of compassion fatigue is essential. The nursing shortage mandates that we take care of this important group of providers.



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