By Patricia A. Rowell, PhD, RN
Expiration Date: December 31, 2008

Best version for printing (About PDF Files)Table of Contents

• Abstract
• Objectives
• Introduction
• Trust
• Primary Trauma
• Secondary Traumatization
• Physiology of Stress
• Predisposing Factors to Stress-Related Maladaptation
• Sequelae to Interpersonal Violence
• Immediate Care
• Prevention in the Workplace
• Worker Action Tips
• Summary
• References

Abstract

Of two major types of trauma – interpersonal and non-interpersonal – the most common, for most people, is interpersonal trauma. This trauma can come from being the recipient of actual violence from one person upon another, e.g., rape or beating, observing violent acts of one person upon another, e.g., fights or stabbings, or being demeaned and berated by someone of influence in one’s life. All of these actions can be a threat or perceived threat to one’s safety and well being. The target person’s physiology, behaviors, and thoughts can change so that the person may suffer from a variety of symptoms – some short- term, some chronic, or none at all. Why some persons suffer sequelae and others do not remains an unanswered question even though some hints are being identified.

Nursing can help make a difference in the outcomes of such events; however, the impact of such events on the nurse and other care providers is not insignificant. It is these helpers of the sick, angry, or traumatized who are often primarily or secondarily traumatized without their trauma being recognized by others. Without recognition of the impact of the trauma, the treatment they need and deserve is often not received. So often the nurses who are traumatized see violence as an everyday part of their jobs, therefore, it is not reported or the impact is not consciously recognized.

Due to the seriousness of the problems associated with primary and secondary trauma to nurses, this module will discuss the impact, prevention, and treatment relative to interpersonal violence.

Objectives:

On successful completion of this independent study module, the learner will be able to:

1. Describe secondary traumatization to care providers.
2. Describe the signs of stress and anxiety disorders associated with secondary traumatization.
3. Discuss interventions which assist the victim to deal with the sequelae of secondary traumatization.
4. Discuss prevention strategies.

Introduction

Violence has been and continues to be a major component of American society. “Work related violence, defined as violent acts, including physical assaults and threats of assault directed toward persons at work or on duty has been recognized as a major problem” (Gerberich, et al., p. 495). Research has found variance in nurse-based violence. One study found a 15% rate of physical violence against nurses (Gates, p. 649). Although reported less often than physical assault, non-physical assaults are associated with substantial negative consequences (Gates, p. 649). Basically, violence can be divided into two categories: interpersonal and non-interpersonal. Examples of interpersonal violence are rape, beating, and berating. Examples of non-interpersonal violence result from tsunamis, hurricanes, accidents, and earthquakes. Notice that the source of interpersonal violence comes from another human being; is usually personally oriented; and is a violation of trust between fellow human beings. Non-interpersonal violence is usually unpredictable, an act of nature, and not related to a violation of trust. Each type of violence can cause individuals to have significant reactions, either short-term or chronic. For a certain percentage of victims, reactions can change their lives.

“The overwhelming results of disaster (including violence) often bring about intense emotional feelings such as crying, feelings of sadness and depression, a sense of hopelessness, and feelings as if one cannot continue to function under such conditions. Other common reactions include fear, anxiety, inability to concentrate, sleep disturbances, irritability or anger, general distress, and a re-experiencing of the event such as with nightmares, dwelling on the event, and intrusive or obsessive thoughts.” (Walser, RD, et al. p.55).

Trust

As infants, one of the first tasks we have to master is that of developing trust in others. As infants when we cry, someone comes to comfort us. As we start to go to school, we learn our teachers will take care of us while at school. As we grow, we learn whether we can trust our peers, as well as adults. Not all persons are worthy of our trust but, hopefully, most are. We learn throughout our lifetime whom and whom not to trust. Professionally, we envision ourselves as care providers to people in need. Perhaps, if we even think of it, we consider ourselves safe from violence from the patient and/or their family whom we try to help. Much of our future development as humans is based on the establishment of trust. What happens when trust is betrayed? Anxiety may permeate one’s life.

Since September 11, 2001, health-care professionals have been concerned about the effects on the nation’s citizens of the three tragedies that struck the United States on that day – the Twin Towers (NY), the Pentagon (DC), and a field in Pennsylvania. There has been much research done with some of the disaster responders (firefighters, police officers, and construction workers) and with citizens in general; however, not as much has been done with the health-care professionals who cared for the terrorists’ victims or for those who waited for individuals who were either not found or were found dead.

In addition to the 9/11 disasters, health care providers are exposed every day to interpersonal violence in their workplace, their neighborhoods and, for some, resulting personal physical or psychological trauma. Considering almost one in four women and one in seven men will experience exposure to personal violence in their life time, it may be safe to say that either you or someone with whom you work is a victim of violence.

Primary Trauma

Primary traumatization occurs when an individual is the victim of violence. Nurses are potentially in more danger because of their 24/7 closeness and intimate relationship to patients and the intensity of their work relations with fellow care providers. For health- care providers, violence may take the form of hitting, kicking, choking, etc. Hospital and health-care workers are at high risk for violence, particularly nonfatal violence. Violence against nurses specifically is a major occupational health problem (Gerberich p.704). Certain areas of care are more prone to violence because of the illness of the patient (hospice, home health, ICU, psychiatry, medical units, and the ED); the drugs that are used in the patient (OR and post-anesthesia care units), and the level of emotion experienced by family (home health, pediatric ICU, neonatal intensive care), and other provider employees (nurses, physicians, physical therapists, et al). There is violence in all areas of health care; however, some areas seem to experience more than others. Patients are most commonly the perpetrators of physical violence, while other employees are most commonly the perpetrators of non-physical violence (Findorff, 2006, p. 298). Longer contact time with patients increases the chances for physical violence (Findorff, 2006, p. 299).

Secondary Traumatization

Secondary traumatization occurs when helpers, observers, or loved ones witness the excessive pain and anguish of the traumatized victim. This form of trauma is often not recognized, especially among health-care providers. Nurses are at great risk for secondary trauma because of the personal and emotional care they provide the victim. The likelihood of secondary traumatization increases when there is 1) exposure to the stories (images) of multiple victims; 2) one is empathically sensitive to their suffering; and 3) one has any unresolved emotional issues that relate (affectively or symbolically) to the suffering seen. One might think of the ED nurse who participates in the care of automobile victims or rape victims or the psychiatric nurse who works with rape victims or the ICU nurse who cares for the patient and family when there is great suffering and body damage. One can understand why the demands made of the nurse can cause emotional exhaustion or secondary traumatization. The emotional exhaustion is a psychological and physiological reaction to the stress.

Physiology of Stress

When an incident occurs that, from the individual’s perspective, threatens life or physical well being, the “fight or flight response” is elicited. There is a sudden engagement of the sympathetic branch of the autonomic nervous system to increase the heart rate, the respiratory rate, auditory sensitivity, and visual acuity. One perspires, the mouth goes dry, and terror engulfs one. One is ready to immediately fight or to remove oneself from the danger. If the danger continues over time or the victim feels helpless in the face of the danger, the longer the stress reaction may be prolonged. The more prolonged this reaction, the more likely changes in one’s physiology and anatomy occur.

Understanding the physiology a little deeper will help one understand what is happening and how to intervene more productively.

“In the “purest” sense, trauma involves exposure to a life-threatening experience. This fits with its phylogenetically old roots in life-or-death issues of survival and with the involvement of older brain structures (e.g., limbic system) in response to stress and terror… (Baldwin, p.3).

Several animal studies have suggested the possibility of permanent physical damage (including shrinkage) in the hippocampus and changes in the amygdala when severe or chronic trauma—and its symptoms----persist.” (Baldwin, p.4).

As one may remember, the limbic system is associated with emotional responses and the ability to focus or learn; the amygdala is associated with the direction of emotional responses; and the hippocampus regulates recall of recent experiences and new information (Kneisl, Wilson, Trigoboff, p.804). Additionally, norepinephrine-containing cells in the central nervous system become active (Kneisl, Wilson, Trigoboff, p.84). There is general sympathetic activation with mobilization of glucose, changes in circulation, and stimulation of the adrenal medulla to increase epinephrine and norepinephrine, so the heart and respiratory rate increase and the body cells are more efficient in energy use. The body prepares itself to remain viable by being ready to fight or flee.

If the stressors continue or the individual continues to feel helpless, the physiology becomes more complex and entrenched in an attempt to adapt to the abnormal situation of chronic stress. In the phase of long-term adjustment to stress, the brain brings about a general sympathetic activation with mobilization of renal tissue to produce more renin that results in increased angiotensin to affect the adrenal cortex to produce mineralcorticoids (aldosterone) and antidiuretic hormones that leads to the conservation of salts and water and loss of potassium and hydrogen ions. The adrenal cortex also stimulates the production of glucocorticoids that along with the pancreas produces glucagon that causes elevation of blood glucose concentrations while the liver produces additional glucose from other carbohydrates, glycerol, and amino acids. The glucocorticoids also help conserve glucose through the breaking down of peripheral tissue to obtain energy. Simultaneously, the brain produces growth hormone to mobilize remaining energy reserves through the release of lipids from adipose tissue and the release of amino acids from skeletal muscle. The brain also releases adrenocorticotropic hormone (ACTH) to participate in stimulation of the adrenal cortex (Kneisl, Wilson, Trigoboff, p.85).

With the long-term adaptation to ongoing stress, the body continues in survival mode long after the actual insult occurred. Eventually, the adaptation becomes maladaptation. The physiological and behavioral changes that were originally meant to protect the person can become major social, psychological, and physical barriers to a normal life.

Predisposing Factors to Stress-Related Maladaptation

The human body is “hard wired” to protect itself from death or injury (i.e., fight or flight response); however, too much of this life-preserving reaction can result in damaging, if not, life-threatening behaviors (i.e., suicide). A number of factors predispose a person to the risk of developing a stress-associated illness. Among the risk factors known at this time are: a history of prior traumatic exposure in childhood; prolonged or repeated abuse; pre-existing psychiatric disorders or a family history; high levels of restlessness, fatigue, and agitation that interfere with daily functioning; considerable loss of life during the traumatic event; serious financial loss; and human intent… (Walser, p. 55). Although the above predisposing factors have been identified, many other yet undiscovered factors are believed to affect the impact of trauma on an individual.

Sequelae to Interpersonal Violence

The ramifications of a life-threatening interpersonal event vary from person to person. Much research is underway to try to discern the predisposing factors for a pathological stress reaction. Most people have a significant reaction to a perceived life-threatening incident; however, some of those people will have an acute stress reaction while others have chronic stress reactions. The vast majority of persons have a short-term acute stress reaction and then are either symptom-free or have few enough symptoms to be considered without disease, while others are deeply and permanently affected by the trauma.

Symptoms of acute stress disorder include crying, feelings of sadness and depression, a sense of hopelessness, fear, anxiety, inability to concentrate, sleep disturbances, irritability or anger, nightmares, general distress, and feeling as if one cannot continue to function under such circumstances. These symptoms usually exist a few weeks and eventually subside over time. (Walser, p. 55)

Persons with chronic stress disorders may have the same symptoms as above but also experience recurrent intrusive thoughts of the incident, dwell on the event, experience flashbacks, avoid event-related stimuli, experience persistent symptoms of increased arousal, and demonstrate significant levels of distress or impairment (Baxter, p. 146). These symptoms usually need some psychiatric intervention to help the person deal with the symptoms’ personal and social effects on day-to-day life.

Immediate Care

After an interpersonal traumatic event occurs, recognition of the potential effect on the care providers is imperative. A comprehensive plan for intervention in such events should immediately be implemented.

There is currently debate as to whether immediate debriefing of the victim following the violent incident is helpful or not. Perhaps the immediate post-trauma decision regarding talking about the violence should be left up to the victim. Provide the victim support and an “empathetic ear”, as well as medical, psychiatric, or surgical care as needed. Be sure that the victim “feels safe” (a totally subjective feeling for the victim) by doing such things as providing her/him a comfortable room to sit or lie in; have someone the victim considers non-threatening stay with her/him; provide the victim “comfort food” if he/she asks for it; and take cues for other safety measures from the victim. Above all, let the victim control whether he/she wants to be touched as a comfort measure. Touch is something she/he may not be able to tolerate. Allow the victim to talk if she/he wishes to. People vary greatly in dealing with the trauma of victimization.

As noted earlier, persons exposed to trauma or traumatized respond differently. Support victims in seeing a mental-health provider to determine what kinds of assistance they may need and if they have a clinically diagnosable condition that will require more prolonged care. Psychiatric illness still carries a social stigma, so many persons will try to avoid seeing a mental-health provider, but kind, patient; understanding support may help the victim overcome this reluctance.

The usual first step with victims is to try to control their anxiety, help them feel safer, and start on ego building (Goodwin, p. 23). Most victims feel guilty for the violence used against them and/or feel that they “deserve what they got”. These feelings are ego destroying and must be addressed early and repeatedly in therapy.

Prevention in the Workplace

Violence against or between nurses and other health care providers is not part of nursing nor any other job. No one deserves to be the target of physical or non-physical violence or abuse. Although there is no mandate by the Occupational Safety and Health Administration (OSHA) or any other federal organization regarding workplace related violence prevention measures, there are recommendations from OSHA (Findorff, p.300).

Although emergency rooms, psychiatric units, waiting rooms, and geriatric units are recognized as the sites for the most violence, it can occur anywhere. The risk factors for violence include, but are not limited to:

• Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses,
• Working understaffed, especially during meal times and visiting hours,
• Transporting patients,
• Long waits for service,
• Overcrowded, uncomfortable waiting rooms,
• Working alone,
• Poor environmental design,
• Lack of staff training and policies for preventing and managing crises with potentially volatile patients,
• Drug and alcohol abuse,
• Access to firearms,
• Unrestricted movement of the public, and/or
• Poorly lit corridors, rooms, parking lots, and other areas (NIOSH, p. 6).

The National Institute for Occupational Safety and Health (NIOSH) offers a number of prevention strategies:

Environmental Designs

• Develop emergency signaling, alarms, and monitoring systems,
• Install security devices, such as metal detectors, to prevent armed persons from entering the hospital,
• Install other security measures, such as escorts to the parking lots at night,
• Design waiting areas to accommodate and assist visitors and patients who may have a delay in services,
• Design the triage area and other public areas to minimize the risk of assault:
  
  
  1. Provide staff restrooms and emergency exits,
  2. Install enclosed nurses’ stations,
  3. Install deep service counters or bullet-proof and shatter-proof glass enclosures in reception areas, and/or
  4. Arrange furniture and other objects to minimize their use as weapons.

Administrative Controls

• Design staffing patterns to prevent personnel from working alone and to minimize patient waiting time,
• Restrict the movement of the public in hospitals by card-controlled access,
• Develop a system for alerting security personnel when violence is threatened.

Behavior Modification

• Provide all workers with training in recognizing and managing assaults, resolving conflicts, and maintaining hazard awareness (NIOSH, pp. 5-7).

Worker Action Tips

Being alert for escalation of a situation into a potentially violent situation is imperative for all health care workers, regardless of their work setting. NIOSH identifies the following signals that may be associated with impending violence:

• Verbally expressed anger and frustration,
• Body language, such as threatening gestures,
• Signs of drug or alcohol use,
• Presence of a weapon.

Behavior on part of the health care provider that may help to diffuse violence includes:

• Present a calm, caring attitude,
• Don’t match the threats,
• Don’t give orders,
• Acknowledge the person’s feelings,
• Avoid any behavior that may be interpreted as aggressive.

Be watchful:

• Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor,
• Be vigilant throughout the encounter,
• Don’t isolate yourself with a potentially violent person,
• Always keep an open path for exiting--don’t let the potentially violent person stand between you and the door.

If you can not diffuse the situation, remove yourself from the situation, call security for help, and report any violent incidents to your management (NIOSH, pp. 7-8).

In 2004, OSHA published Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. These guidelines are very thorough and should serve as a major reference for making the health-care workplace safer. A major organizational tenet should be that violence must be reported and that the victim will not be held at fault for the incident. It is incredibly important that violence against or among providers be reported, so the predisposing factors can be corrected and learning needs met.

Summary

Violence against and between health-care providers is far too common and results in many adverse impacts on the workplace and the victim. Health-care organizations must set the expectation that interpersonal violence is common and to be expected. Every incident should be reported and the victim offered help both informally and formally. Violence must not be tolerated in the workplace. Planning ahead for prevention and treatment must be done now rather than later. Health-care workers deserve nothing less.

Author

Patricia A. Rowell, PhD, RN
Patricia.Rowell@ana.org

Pat Rowell is currently a Senior Policy Fellow in the Department of Practice and Policy at the American Nurses Association. She holds a PhD in Health Administration and Research, Master of Science in Nursing-Pediatric Nurse Practitioner, as well as Bachelor of Science degrees in Nursing and Biology and Chemistry. She is certified in Psychiatric Nursing and has clinical experience in working with victims of trauma.

References

Baldwin, D. About Trauma: Trauma Symptoms. (n.d.). Retrieved on March 13, 2006 from http://www.trauma-pages.com/pg2.htm

Baxter, A. (2004). Posttraumatic stress disorder and the intensive care unit patient. Implications for staff and advanced practice critical care nurses. Dimensions of Critical Care Nursing, 23(4), 145-150.

Findorff, MJ, McGovern, PM, Wall, M., Gerberich, SG and Alexander, B. (2004). Risk factors for work related violence in a health care organization. Injury Prevention 10, 296-302.

Gates, DM. (2004). The epidemic of violence against healthcare worker. Occupational and Environmental Medicine, 61: 649-650.

Gerberich, SG; Church, TR, McGovern, PM, Hansen, H, Nachreiner, NM, et al. (2005) . Risk Factors for Work-Related Assaults on Nurses. Epidemiology 16(5), 704-709.

Goodwin, JM. (2005). Redefining borderline syndromes as posttraumatic and rediscovering emotional containment as a first stage in treatment. Journal of Interpersonal Violence 20(1), 20-25.

Kneisl, CR, Wilson, HS, and Trigoboff, E. (2004). Contemporary Psychiatric-Mental Health Nursing. New Jersey: Pearson Prentice Hall.

National Institute of Occupational Safety and Health. (2002). Violence: Occupational Hazards in Hospitals. Retrieved on March 15, 2006 from http://www.cdc.gov/niosh/2002-101.

Occupational Safety and Health Administration/US Department of Labor. (2004). Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. (OSHA 3148-01R 2004). Washington, D.C.

Walser, RD, Ruzek, JI, Naugle, AE., Padesky, C., Ronell, DM, and Ruggiero, K. (2004). Disaster and Terrorism: Cognitive-Behavioral Interventions. Prehospital and Disaster Medicine 19(1): 54-63.

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