Identify Stress and Vicarious, Secondary, Indirect Trauma in Nurses


Published: 18 April 2020

The relationship between a healthcare professional and their patient is often very close, and this proximity can expose staff to the distress and trauma experienced by patients. Caseloads can often include patients who have been affected by trauma, violence, abuse, death and fear, combined with a myriad of other physical and mental health issues.

Empathy and the desire to alleviate the pain and suffering of patients can dramatically enhance the connection between patient and worker. Unfortunately, this connection can have a serious psychological impact on the worker, with long-term consequences if left untreated (Upton 2018).

Empathic behaviour is associated with the mirroring of emotions and body movements between people (e.g. how laughing and yawning is considered to be contagious). In cases of trauma, the result is the mirroring of negative psychological issues in the healthcare worker.

trauma empathy
Empathy can dramatically enhance the connection between patient and worker, but this connection may have a serious psychological impact on the worker, with long-term consequences if left untreated.

Stress and Trauma Terminology

There is a great debate on the correct terminology for this type of trauma, with a range of descriptions that are often confused with each other. Vicarious trauma, secondary traumatic stress, compassion fatigue and burnout are often used interchangeably (albeit incorrectly) (Tabor 2011).

Although there is some discrepancy in the definitions, and these feelings may co-exist, it is important to be able to differentiate between the terms (Blue Knot Foundation 2018). This will help how we identify, respond and prevent the emotional impact of stress and trauma at work.

Vicarious Trauma

Vicarious trauma occurs from repeated exposure to other people’s trauma. Over time, workers begin to mirror the bio-psychosocial effects shown by the victims of trauma (Tabor 2011; The Lookout 2017).

Vicarious trauma can be described as a cumulative ‘negative transformation’ that impacts the physical and mental health of a healthcare worker, permeating all aspects of work and home life. It builds up over time, intruding on everyday life, and has the potential to drastically alter an individual’s character and belief systems (The Lookout 2017; Dragon 2019).

Secondary Traumatic Stress

Secondary trauma is the development of PTSD-like symptoms without directly witnessing or having being involved in a traumatic event. In healthcare, the traumatising event of a patient can become a traumatising event for the healthcare worker (Sudden 2019).

Unlike vicarious trauma, which accumulates over time, secondary trauma can occur unexpectedly and suddenly (Sudden 2019).

trauma distress
Secondary trauma is the sometimes sudden development of PTSD-like symptoms without directly witnessing or having being involved in a traumatic event.

Compassion Fatigue

Compassion fatigue is a type of indirect trauma specific to healthcare professionals, caused by the emotional ‘residue’ of working with those who have experienced trauma. It may cause emotional exhaustion and lack of empathy towards clients (Sudden 2019; AIS 2017).


Burnout is motivation-based, causing emotional and psychological exhaustion related to an individual’s work. It is not a form of trauma (Sudden 2019; The Lookout 2017).

Traumatic Countertransference

Traumatic countertransference is when a healthcare worker relates to a patient in such a way that they unconsciously connect the patient with an existing relationship in their own life. This can occur in many situations (not just in a medical setting) where there is a connection between people based on empathy (Good Therapy 2019).

This can be harmful in more ways than one because as a healthcare worker, the relationship should be professional and not because the patient reminds you of your mother, for example.

Behaviour and Symptoms

The human response to stress and trauma is autonomic, but the chemical and biological process that causes a person to experience vicarious or secondary trauma are the same. This stress response is not subject to cognitive or rational processing, and therefore two individuals will likely perceive and react in a different manner to the same event.

Healthcare workers who are experiencing vicarious or secondary trauma may experience:

  • Headaches, heartburn or rashes;
  • Emotional volatility;
  • Irritability, grief, anxiety and anger;
  • Social withdrawal;
  • Disrupted personal relationships;
  • Addictive behaviours; and
  • Feelings of disconnect, loss of purpose or hope etc.

(Good Therapy 2016)

If left untreated, these symptoms can develop into serious consequences including mental health disorders, detachment, emotional distress and substance abuse (Olga Phoenix 2015).

Prevention and Protection

Exposure to stressful working conditions can have a direct influence on a healthcare worker’s health and safety. Coping with these stresses requires protective measures that not only stem from the individual but also from the professional organisation that they work for.

Individual Strategies

Individual strategies to avoid stress and trauma can include:

  • Improved self-awareness;
  • A good work/life balance;
  • Maintaining personal and social connections;
  • Pursuing hobbies;
  • Motivation to learn and grow professionally and emotionally; and
  • Reflective practices such as mindfulness and yoga.

Many healthcare workers will experience compassion satisfaction, which refers to positive feelings associated with the belief that they have contributed or helped in some way (ProQOL 2018). Individual and organisational processes that enhance compassion satisfaction can significantly help protect an individual from work-related stress and trauma.

trauma yoga
Reflective practices such as mindfulness or yoga can help healthcare workers reduce stress.

Organisational Strategies

From an organisational level, there should be policies and procedures that recognise and prevent risk factors for vicarious and secondary trauma. Notably, this should include the provision of educational material about mental health disorders and the support systems that are available to all staff.

Organisations can also make sure that managers encourage professional development as well as making sure staff maintain a proper work/life balance. Finally, even positive encouragement and the continuing appreciation of work can be beneficial in promoting a supportive and safe workplace for all.

Additional Resources


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True or false? The terms 'vicarious trauma', 'secondary traumatic stress', 'compassion fatigue' and 'burnout' can be used interchangeably.

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