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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.

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Lisa LaBrie, RN, BSN

Lisa LaBrie, RN, BSN, is a nurse, educator, and speaker who promotes self-care for caregivers at and

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