Avoiding Retraumatization: Why You Shouldn’t “Friend” Your Patients on Social Media

Avoiding Retraumatization: Why You Shouldn’t “Friend” Your Patients on Social Media

Burnout and compassion fatigue can be found as a topic in numerous publications and hospitals are beginning to look at strategies for individual nurses to recognize burnout and compassion fatigue. The nursing profession requires a great deal of empathetic work from nurses, which can result in empathetic strain.  Recognition of this is important for the development of compassion satisfaction, or positive feelings related to work, in the nursing workforce.

A lesser known aspect of the “burnout spectrum” is secondary traumatic stress disorder (STSD), according to Nancy Jo Bush, RN, MN, MA, AOCN and Deborah A. Boyle, RN, MSN, AOCN, FAAN, coauthors of Self-Healing through Reflection: A Workbook for Nurses. Much of the literature uses STSD and compassion fatigue (CF) interchangeably, but Bush and Boyle examine it as one facet of a spectrum of issues nurses face that causes burnout, or chronic stressors on the job. This spectrum includes CF, vicarious traumatization, and STSD.

What is STSD?

STSD is described by Bush and Boyle as the result of unresolved vicarious traumatization, a process of exposure to a patient’s trauma vicariously and taking in a patient’s suffering. The manifestation of STSD in a nurse is similar to the manifestation of PTSD. Nurses can experience hyper-arousal, nightmares, flashbacks, feelings of detachment, irritability, and more. Those at risk for STSD include nurses who work with intense patient populations, such as trauma emergency rooms, critical care units, pediatrics, and oncology. The risk for STSD is affected by time, coping, and personal characteristics. According to R. Adams Cowley, MD, time includes years in direct patient care, hours per week, and hours per shift. Coping refers to supports used by nurses, interpersonal relationships with coworkers, and stress relief strategies. Additionally, personal experiences with trauma (child abuse, unresolved grief, etc.) increase the risk of developing STSD.

John P. Wilson, PhD, and Rhiannon Brywnn Thomas, PhD, authors of Empathy in the Treatment of Trauma and PTSD, developed five factors that reflect empathetic strain which demonstrate key behaviors identified in therapists who work with trauma and those behaviors can be applied to nurses. One of these behaviors includes over-involvement and identification with the patient.

Social Media and Setting Boundaries

The increasingly high use of social media has affected all aspects of society. It has also affected the relationship between nurses and patients. Examples of this include news stories of nurses posting to social media about work and losing their jobs and viral posts illuminating the situations nurses face in their job. Social media has become a place for marketing to nurses, for supporting nurses, and for educating nurses.

Patients also use social media to document their experiences in the health care setting, including their experiences with their caregivers. Patients post videos of their chemotherapy infusions and more. In one study, 32% of U.S. users post about their friends’ and family’s health experiences on social media. In health care settings where nurses care for chronically ill patients, they often see patients repeatedly over time and as a result, form strong relationships with them and their families. Those patients and families at times send friend requests to nurses or ask nurses to connect on social media. According to the American Nurses Association’s social networking principles, nurses need to separate the professional and personal information online. One important reason related to separation of the personal and professional is to establish appropriate boundaries to avoid over-involvement in patient’s lives and retraumatization.

When nurses care for patients and then witness patients suffering and trauma in the professional setting, being connected to a patient’s social media can include repeated exposure to the event in their personal social media feeds. This repeated exposure can include reading messages from friends and families expressing various emotions about the patient. If the patient died, social media feeds could include repeated messages of mourning, grief, and loss. This isn’t to say nurses should avoid remembering or mourning; however, nurses need to rest and recover their empathetic muscle. Balanced empathy is important to sustain nurses throughout their careers.

Avoiding Retraumatization

Social workers Patricia Shelly, Shelley Hitzel, and Karen Zgoda define retraumatization as “a conscious or unconscious reminder of past trauma that results in a re-experiencing of the initial trauma event.” Interventions for vicarious traumatization and STSD include separating the professional from the personal. A healthy barrier is a helpful part of self-care for nurses. They need to engage in self-restorative work to be able to care for the needs of the patients they care for at work. Even though nurses develop bonds with patients and families, using self-protective strategies are important in being resilient. Nurses should avoid personal social media connections with patients.

Meeting the Needs of the New Graduate Nurse: Self-Care Education

Meeting the Needs of the New Graduate Nurse: Self-Care Education

New grad training programs have been recognized over the years as a necessity to help new nurses transition successfully from the role of student to professional nurse. These new grad training programs provide a structured curriculum to acclimate nurses into the organization and the nursing profession. These programs provide a foundation for the nurses’ career. This foundation would be strengthened with the addition of self-care education.

In order to prepare new nurses to use advancing technologies, to provide safe care, and reduce employee turnover, structured new grad training programs were developed at number of ANCC Magnet designated and/or University-affiliated hospitals. In 2011, the National Council of State Boards of Nursing (Chicago, Illinois) conducted a multi-site study of nurses transitioning to practice at hospitals and the results supported the previous research and recommendations. Based on their study, they recommended that new graduate programs have the following essential components:

  • 9-12 months in length
  • Trained preceptors
  • Institution based orientation
  • Opportunity for feedback and reflection
  • Institutional support
  • Safety and critical reasoning focus in the program
  • QSEN core competencies of patient-centered care, teamwork and communication, evidence-based practice, quality improvement, and informatics

What was not included in their recommendations, were core competencies in self-care strategies. These include prevention of burnout, compassion fatigue, or secondary trauma, all of which are experienced by nurses engaged in increasingly complex care. Self-care is an essential skill that new grads need and something that the large percentage of new grads, millennials, are looking for.

Who are Millennials?

There are a lot of articles that talk about who millennials are, and they are typically described as those born between 1980 and 2000. These nurses are on their way to becoming the largest generation in the nursing workforce. They are also usually described as tech savvy, highly educated, highly engaged employees who are well suited for the diverse, global world. Some other generalizations about millennials include a desire for flexibility and higher turnover rates. Millennials did not grow up with a belief in job security in the same way that previous generations did. Milennials are looking for a job that provides work-life balance, an emphasis on social relationships, and opportunities for growth that aren’t based on hierarchy. Obviously these are generalizations and individuals vary, but taking into account the characteristics of a large portion of a workforce are important to designing a training program.

Reality Shock

New graduates hired into hospital training programs, even when well structured, experience high levels of stress. In fact, the NCSBN study results showed that new grad participants had the highest reported stress during months 6-9 after starting as a new nurse. In a 2013 article by Elaine Riegel, RN, MSN, the period of transition new grads experience is “a time of stress, role adjustment, interpersonal conflict, and reality shock.” School programs haven’t prepared students for that intense period of adjustment and many new graduates did not anticipate the difficulties they would face.” New grads report feeling overwhelmed, anxious, and disillusioned when facing the reality versus expectations. In addition, new grads hired into high acuity or specialty areas need extensive emotional support.

Facing this reality shock and role transition is what contributes to the high stress that new grads report. However, these stressors are not over once they have successfully transitioned into the professional role. This is why incorporating self-care content into the new graduate program will allow new nurses to develop skills to sustain them throughout the entirety of their career. Nurses need essential training in preventing burnout and compassion fatigue, while practicing skills that maintain their compassion satisfaction. They don’t need self-care skills defined by commercial media who focus on facials and massages (although who doesn’t love a facial), but with evidence-based education that looks at self-care through the mental, emotional, spiritual, and physical domains. This education is essential for creating a work-life balance that milennials desire while managing the unique stressors of the nursing profession.

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