Secondary traumatic stress can be described as a vicarious trauma experienced by witnesses to traumatic events (Graham et al, 2005; Zerach, 2013). It is particularly prevalent in emergency service workers but is also frequently described by nurses working in the hospital setting (Da Rosa et al, 2021).
Mutual suffering is a term used to describe the pain and emotional burden of empathising with one's patients or their relatives. Some nurses have identified a shared sense of emotional pain (Zerach, 2013) when caring for particular patients in the hospital setting and this is often more prevalent where a nurse experiences the effects of secondary trauma (Zerach, 2013). Nurses and other health professionals may be at an increased risk of emotional disturbance associated with caring for people who are experiencing distress, illness or disease or who are at the end stage of their life (Potter et al, 2010, Frank, 2018, Da Rosa et al, 2021) and it is this experience which is related to the term ‘mutual suffering’.
This short article aims to highlight the concepts of secondary traumatic stress and mutual suffering in the context of nursing practice and generate opportunities for the reader to reflect on how these phenomena influence their own practice. Readers are invited to examine the discussion from the literature and consider how secondary traumatic stress might contribute to mutual suffering within their own areas of practice.
It should be noted that much of the literature is now several years old and it is likely that new research will become available in light of the COVID-19 pandemic and a follow-up article will be produced in due course. Ongoing research should be considered with a view to devising strategies to combat the effects of these issues.
Discussion
Those working with the acutely unwell are at increased risk of suffering emotional disturbance resulting from prolonged patient contact and their empathetic relationships with them in an acute or end stage of suffering, distress, illness or disease (Potter et al, 2010; Zerach, 2013; Da Rosa et al, 2021). Nurses might not be suffering with the same physical or pathological insults as their patients; however, they are affected by continued exposure to the suffering of others. In a qualitative study of nurses' experiences of trauma, Baird and Kracen (2006) demonstrated a deeply traumatic impact on care providers that influenced their ability to continue nursing.
Secondary traumatic stress
Secondary traumatic stress, also referred to as vicarious trauma, is defined by Zerach (2013) as the experience of trauma in the absence of personal injury. Figley (1995; 2002) suggested that secondary traumatic stress is an empathetic response and is the manifestation of emotional stress from witnessing patients' traumatic experiences or the uncertainty of their prognosis. Baird and Kracen (2006) concurred with this definition, suggesting that it results from continued exposure to emotionally traumatic, physical events in others. Empathy is a central component of nursing (Nursing and Midwifery Council, 2018) and so it is conceivable that nurses may be predisposed to develop secondary traumatic stress.
Graham et al's study (2005) suggested that nurses with prolonged exposure to patients can develop entangled relationships with them that may cause nurses to experience detrimental emotions that influence their own perceived health and wellbeing. Nurses in the study reported experiencing anxiety and health fears. It is possible that this entanglement might involve an ‘osmotic’ effect, with the transference of emotion, both consciously, and unconsciously, which could impact on how nurses perceive their own health and wellbeing. Graham et al (2005) also recognised the potential positive effects arising from secondary traumatic stress, such as staff requiring increased clinical supervision opportunities and the need for reflective practice. They reported that secondary traumatic stress may occur immediately while caring for the patient, later, when the caring period is over, or develop throughout the caring period and beyond. Whenever it occurs, there is always a cost to the carer (Figley, 1995; 2002; Figley and Roop, 2006; Craigie et al, 2016). This is supported in the wider literature with Henderson (2001) and Dowling (2008) reinforcing the notion that decisions to emotionally engage with patients expose nurses to professional and personal emotional costs. This has more recently been discussed by Bruce and Beuthin (2020) although this is in the context of expected deaths and not acute trauma.
Secondary traumatic stress has been shown to create suffering for nurses witnessing traumatic events; however, the idea of suffering alongside patients can be seen in wider practice. According to Graham et al (2005), caring for the dying and for patients whose prognosis may be uncertain can cause significant discomfort. This gives rise to the concept of mutual suffering.
Mutual suffering
Graham et al (2005) sought to understand nurses' lived experience of mutual suffering when caring for the acutely ill or dying and suggested that mutual suffering is a uniquely personal experience resulting from being placed in a situation in which emotionally challenging care must be delivered. Detailed analysis of participant responses led Graham et al (2005) to report nurses experiencing feelings of guilt, impotence and anger at these situations.
Mutual suffering is both an acute and chronic response and a triggering event where the nurse experiences a range of negative emotions (Da Rosa et al, 2021). These can lead to an acute sense of suffering, either immediately or following the cumulative effect of continued regular negative experiences, leading to chronic elements of mutual suffering, such as health anxiety, fear for one's own health and an increased propensity to burnout (Zerach, 2013). According to Graham et al (2005) in the acute phase nurses push against the negative feelings but later create new ways of thinking or behaving. Participants in Graham et al's study declared an acceptance that, ‘as we give care, we also give a little of ourselves’. Clemens (1993) also concluded that caring for the acutely ill can have a profound impact upon the personal wellbeing of carers. Graham et al (2005) reported that a sense of failure is a permanent feature of nursing, going on to describe reports of guilt, low self-esteem and anxiety caused by uncertainty that all contribute to the experience of chronic mutual suffering. This may seem like an entirely negative perspective but there are opportunities for nurses to consider the challenges and complexities of care giving and to adopt a more reflective approach to care delivery.
Wilson and Daley (1999) and Sen (1988) described paradoxical experiences in which the carer is torn away from a patient or loved one while simultaneously united with and bonded to others who have shared similar experiences. Sen (1988) recognised the anxiety this separation caused carers but did not examine the nature of newly created bonds, whereas Wilson and Daley (1999) reported that these form an important part of the coping mechanisms of nurses.
Mutual suffering has been described as a negative experience in which carers experience a detachment from patients, which can ultimately lead to a degradation in care delivery (Clemens, 1993; Graham et al, 2005). However, Maeve (1998) reflected on how nurses were able to draw on the dilemmas of their patients' lives and suffering to amend their own lives for the better. Maeve (1998: 1138) described this process as ‘weaving a fabric of moral meaning’, reporting that where this was achieved, a sense of a positive outcome could arise that might reduce the negative effects of mutual suffering and lead to a degree of re-engagement. This was not found in the wider literature and may have been a process unique to the participants in Maeve's study. These views should be considered with interest but may not be a true representation of how nurses experience mutual suffering.
The earliest study discussing detachment and re-engagement appears to be by Kralik et al (1997) who claimed the engagement between nurse and patient is a significant determinant of the quality and standards of care. Much like the later studies conducted by Wilson and Daley (1999) and Graham et al (2005), Kralik et al (1997) concluded that when engagement suffered, so did patient and carer. For patients, the standard of care was compromised and, for nurses, there was a sense of failure, frustration and trauma.
Conclusion
This article has offered a brief overview of the literature pertaining to secondary traumatic stress and mutual suffering and has demonstrated how these phenomena can impact upon nurses' ability to provide patient care when allowed to go unmanaged.
The article calls on nurses to consider the impact of secondary traumatic stress and mutual suffering in their own practice areas and to reflect upon their own experiences of these phenomena.
It is hoped that, by raising awareness of secondary traumatic stress and mutual suffering in the hospital setting, strategies can be developed and implemented to assist practitioners to recognise and manage the potential negative impact that these phenomena cause.