Int J Mental Health Nurs - 2021 - Isobel - Vicarious Trauma and Nursing An Integrative Review

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International Journal of Mental Health Nursing (2022) 31, 247–259 doi: 10.1111/inm.12953
R EVIEW A RTICLE
Vicarious trauma and nursing: An integrative
review
Sophie Isobel1 and Margaret Thomas2
1
Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, and 2Sydney Local Health
District Mental Health Service, Sydney, New South Wales, Australia
ABSTRACT: Nursing requires empathic engagement, within therapeutic relationships, to ensure

the delivery of compassionate care. Empathic engagement with people who have experienced
trauma is known to potentially lead to experiences of vicarious trauma occurring in the caregiver.
However, relatively little is known about the implications of vicarious trauma for nurses. This
integrative review aimed to explore what is known about vicarious trauma and consider its
implications for nursing. Twenty-two articles were included in the review, with findings
considering how vicarious trauma is conceptualized and applied to nursing in the literature, what
implications of vicarious trauma, specific to nursing, are identified in the literature, and what
vicarious trauma interventions are identified to apply to nursing. The findings highlight clear
articulation of the concept of vicarious trauma and its relevance to nursing, including its pervasive
and significant personal and professional effects. Vicarious trauma was identified to be a
workplace hazard for nurses working across settings, which also impacts upon organizations. The
review highlighted that at individual, team, organizational, and social levels, awareness and
preventative approaches are recommended. These approaches require systemic supports that foster
individual coping mechanisms, self-care and support networks for nurses, education about
vicarious trauma, screening for vicarious trauma, and formalized access to clinical supervision and
peer support for all nurses. With increasing awareness of trauma across health care settings, and
a move towards the delivery of ‘trauma informed care’, recognition of vicarious trauma amongst
nurses as a likely ‘cost’ of the delivery of compassionate care to trauma survivors, is essential.
KEY WORDS: compassion fatigue, secondary trauma, vicarious trauma.
experiences of others (Huynh et al. 2008). In many

BACKGROUND
fields of nursing, nurses and midwives are directly
Nurses work in demanding contexts, providing physical exposed to people’s experiences of trauma. This
and psychological care and often witnessing distress includes witnessing injuries, undertaking procedures,
and pain. To be a nurse requires emotional labour hearing patient stories, reading clinical notes and
(Delgado et al. 2017): managing one’s own emotions engaging in clinical handover. Nurses may also experi-
while also managing the suffering, vulnerability and ence moral distress in their roles as a result of institu-
tional limitations on the extent of care they can provide
Correspondence: Sophie Isobel, Faculty of Medicine and Health,
the University of Sydney, Camperdown, NSW, Australia. Email: so- (Burston & Tuckett 2013). Clinician experiences of
phie.isobel@sydney.edu.au moral distress have been suggested to negatively affect
Authorship statement: all authors meet the authorship criteria individual nurses, care, and health systems (Burston &
according to the latest guidelines of the International Committee
of Medical Journal Editors, and all authors are in agreement with Tuckett 2013; Epstein et al. 2020), with moral distress
the manuscript. SI: 70% MT: 30%. in nursing particularly highlighted by the COVID-19
Sophie Isobel, PhD, RN(BN), grad cert CFHN, CAMH, Res
Meth.
pandemic (Lake et al. 2021). However, moral distress
Margaret Thomas, RN(BN), MMHN, BSc. particularly arises from ethical conflicts within practice
Accepted November 04 2021.
© 2021 John Wiley & Sons Australia, Ltd

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248 S. ISOBEL AND M THOMAS
setting contexts (Epstein et al. 2020), rather than the Burnout can result in emotional exhaustion (Maslach &
therapeutic relationship itself. Jackson 1981) and can lead to decreased motivation,
Nursing relies on an empathic therapeutic relation- low mood, and poor delivery of care, but is unlikely to
ship to be effective (Gerace et al. 2018; Harris & Grif- alter core internal and personal belief systems of safety
fin 2015; Zugai et al. 2015). Within this relational and trust (Rosenbloom et al. 1995). Compassion fatigue
space, when nurses engage with people who have expe- is the reduced capacity of the nurse to be empathic,
rienced or are experiencing trauma, they vicariously usually due to prolonged exposure to clinical work
experience aspects of the traumatic effects themselves (Sansbury et al. 2015). Cumulative enacting of compas-
(Lloyd 2020). Originally identified in trauma therapists sion over time can lead to a process of emotional
and named by McCann and Pearlman (1990), vicarious exhaustion, resulting in decreased performance and
trauma (VT) describes a process of experiencing trau- motivation, avoidance of interpersonal engagement,
matic responses after being exposed to the trauma of professional dissatisfaction, and physical health issues
others. While VT can result in short-term symptoms, it (Harris & Griffin 2015). Like burnout, compassion fati-
is also thought to alter a person’s cognitive schemas, gue is a reaction to the work environment and role and
beliefs, and assumptions, beneath consciousness is unlikely to shift a person’s worldview at a deep and
(McCann & Pearlman 1990) leading to profound personal level. VT, however, can occur cumulatively or
changes in core aspects of the self (Pearlman & Saak- acutely and rather than a process of exhaustion, more
vitne 1995), understanding of the world, and interac- closely resembles a primary traumatic response, with
tions with others. key sustained impacts upon self, trust, safety, and regu-
Compassion is often considered an essential aspect lation (Pearlman & Saakvitne 1995). VT can also be
of nursing care. Compassion is a sense of connection to theoretically distinguished from other concepts such as
another person’s suffering, leading to care being deliv- secondary trauma, where the diminishing of, or failure
ered with comfort, dignity and morality (Frampton to acknowledge, a traumatic event leads to another
et al. 2013). Having compassion is positioned as an reactive trauma (Boulanger 2018); as well as counter-
inherent characteristic of a ‘good nurse’ (Harris & Grif- transference, where unconscious responses occur in
fin 2015; Schantz 2007; Tehranineshat et al. 2019). relation to specific individuals, rather than affecting all
Empathy is required, as it allows nurses to feel ‘with’ caregiving relationships (Kadambi & Ennis 2004).
the patient and validate their experiences (La Monica While distinctions are often made in the literature
1981; Sabo 2006), leading to care being able to be between all of these constructs, the importance of
delivered compassionately. However, VT occurs as a these distinctions in practice is less clearly articulated.
result of empathy (Pearlman & Saakvitne 1995). When In nursing literature, there is a noticeable emphasis
the ‘empathic nurse’ projects themselves onto the per- on compassion fatigue, likely linked to the positioning
spective of their patient as a part of therapeutic of compassion as an inherent nursing quality, with less
engagement and the enacting of compassion, they focus on VT. While both are individual processes, one
experience the emotions of the patient (Lloyd 2020). implies a personal loss of a key quality required to deli-
This can occur through listening to explicit details of ver the nursing role (compassion), arising from an indi-
trauma but also from bearing witness to its effects on vidual becoming personally ‘fatigued’; while the other
people’s lives (Jordan 2010). As such, empathy is a positions similar outcomes with more personal implica-
‘double-edged sword’ (Sabo 2006): it enables compas- tions, as arising from a neurobiologically expected
sionate ability to care for the physical and psychological response to a core component of the role (empathy)
traumas of others, while also leaving nurses vulnerable and occurring outside of the control of the individual
to being traumatized themselves (Hilfiker 1985). (Isobel & Angus-Leppan 2018). These subtle differ-
VT is, therefore, essentially a product of the thera- ences in the process, outcomes, and responsibility
peutic relationship (Boulanger 2018). Other adverse when considering exposure to workplace stress and dis-
effects of therapeutic nursing relationships include tress for nurses may have significant implications for
compassion fatigue and burnout. While commonly individuals and organizations.
referred to collectively, each are theoretically distinct. Nurses are in a privileged and trusted position of
Burnout is a psychological strain experienced from engaging with people across the lifespan. They work in
working with challenging populations or under difficult settings providing emergency, intensive, palliative,
conditions, related to feelings of frustration, powerless- acute, and sustained physical and psychological care to
ness or futility in the workplace or role (Figley 2002). people at the beginning, middle, and end of their lives.

VICARIOUS TRAUMA AND NURSING REVIEW 249
Often they are the health care workers who hear peo- 1990 (when VT was defined) and in English were
ple’s stories and witness their pain. These are defining included. Articles were excluded through preliminary
aspects of the nursing role and not rare workplace relevance screening using criteria (see Fig. 1). A modi-
events. Undoubtedly in the course of this work, nurses fied Preferred Reporting Items for Systematic Reviews
will bear witness to the traumatic experiences and sto- and Meta-Analyses (PRISMA) was used to document
ries of the people they care for, and through processes the process of the review (see Figure 1).
of empathy and the associated processes of neurobio- The initial search yielded 115 papers that met crite-
logical reciprocity or attunement (Isobel & Angus- ria and were reviewed in full. During secondary screen-
Leppan 2018), may experience VT. Subsequently, there ing, full text articles were independently read and
is a need to understand what is known specifically assessed by both members of the research team. Arti-
about VT, in the context of nursing. cles were required to specifically refer to nursing and to
position or examine VT, as distinct from related con-
cepts. Studies and articles of any design were included
AIM
(Whittemore & Knafl 2005). Articles were assessed by
This study reviewed the scholarly literature on vicarious both authors and included upon consensus using the
trauma in nursing using an integrative review process. criteria. The quality of included articles was assessed
The aim was to explore the state of knowledge related through a purpose-developed process informed by
to VT in nursing to answer the question ‘what is known Whittemore and Knafl (2005), which sought to better
about vicarious trauma and its implications for nurs- understand the nature of the included literature. This
ing?’. Three specific questions guided the review pro- process occurred by both authors reflecting on whether
cess: (1) How is vicarious trauma conceptualized and the article had a clear aim and method or theoretical
applied to nursing in the literature? (2) What implica- positioning and its perceived relevance to the topic.
tions of vicarious trauma, specific to nursing, are identi- Quality was not an inclusion criterion but was assessed
fied in the literature?, and (3) What vicarious trauma to add understanding to the nature of what is known
interventions are identified to apply to nursing? about the topic (Whittemore & Knafl 2005). Twenty-
two articles were included in the final analysis. (See
Fig. 1). The research questions guided the process of
METHOD
data extraction from each included article.
An integrative review was conducted to synthesize find-
ings from both quantitative and qualitative studies and
FINDINGS
provide a comprehensive understanding of knowledge
on VT in the context of nursing. An integrative review The details of all 22 articles are summarized in
was used as it allowed diverse theoretical and empirical Table 1. The articles were assessed to be of variable
literature to be examined to encompass the varied per- ‘quality’, that is, many were discussion papers or non-
spectives relevant to the phenomenon (Whittemore & systematic reviews.
Knafl 2005). Integrative reviews are the broadest type of Some referred directly to VT in nursing and were
review method and are used to refine concepts, and therefore considered ‘highly relevant’ but these were
review theory, practice, and evidence relevant to a topic commonly also the papers using less robust methods,
(Whittemore & Knafl 2005). Whittemore and Knafl’s for example, brief reviews, discussion papers, commen-
(2005) integrative review methodology guided the pro- taries, or non-systematic reviews. Many of the papers
cess. The sampling frame proposed by Whittemore and of higher ‘quality’ did not set out to explore VT in
Knafl (2005) allows for integration of varying forms of lit- nursing but their findings led to VT being highlighted
erature including discussion papers, commentaries, the- as a relevant concept. This further suggests the impor-
oretical papers, and research papers to comprehensively tance of VT in nursing and the need for discrete exami-
consider complex topics and their application to nursing. nation of the concept. The findings of the review are
Systematic searching commenced in the CINAHL synthesized under each research question.
database using the terms Nurs* AND Vicarious AND
Trauma*. These same search terms were also used to
How is VT conceptualized in nursing?
systematically search a further six databases: Embase,
Medline, PsycInfo, Emcare, PubMed, and PreMedline, Across the included articles, VT was conceptualized
yielding a total of 366 articles. Articles published since most commonly using McCann and Pearlman’s (1990)

250
Idenficaon S. ISOBEL AND M THOMAS
Records idenfied through Addional records idenfied

database searching through other sources
(n = 366) (n = 0)
Records aer duplicates removed

(n = 139)
Screening
Records screened * Records excluded

(n = 139) (n = 25)
Eligibility
Full-text arcles assessed Full-text arcles excluded

for eligibility ** (n = 92)
(n = 114)
Studies included in review

Included
(n = 22)
*criteria were: published article (not letter or conference abstract), full text available in English
**criteria were based on research questions: clear identification of VT AND clear identification of nursing
FIG. 1 PRISMA.
original definition (Hartley et al. 2019; Jahner et al. et al. 2020; Taylor et al. 2016) or Pearlman and Mac
2019; Lev-Wiesel et al. 2009; Little 2002; Maier 2011; Ian’s (1995) definition (Robinson et al. 2003), where
Van der Wath et al. 2016) about the effects of changes in core belief systems occur and affect trust,
empathic engagement with people who are traumatized power, esteem, and intimacy, were used. Articles
leading to disrupting effects upon the nurse. Alterna- also referred specifically to a ‘transformation’ occurring
tively, Pearlman and Saakvitne’s (1995) definition (Li in the nurse due to empathic engagement

TABLE 1 Summary of included articles
Article reference Method Time period Sample size Assessed quality Assessed relevance
Clark and Gioro (1998) Brief review of the 1974–1997 Amount of No clear method or research Highly relevant to topic,
literature articles not questions. Used lived synthesis of early
specified experience to develop clinical knowledge
scenarios with a focus on
prevention
Corcoran (2020) integrative review 1944–2020 Included 8 Clear research question, VT identified in findings
of psychological articles (4 documented method with not aim
first aid were grey PRISMA, no assessment of
literature) quality of included articles
Garner (2017) Opinion piece N/A N/A Non-empirical. Opinion piece Highly relevant
about potential intervention.
Includes lived expertise of VT
through first person reflections
Goldblatt (2009) Phenomenological 2005 22 nurses Phenomenological approach VT identified in findings
study focused on Lived Expertise of not aim
participants, clear research
questions and methods.
Hancock (2020) Literature review, Unclear 8 articles Broad research questions. No Specifically considers VT
non-systematic included PRISMA, didn’t assess quality for correctional nurses.
of articles in reviewed Relies on one article
(Tabor 2011) for VT
aspects
Harris et al. (2015) Qualitative study Unknown N27 (15 Clear aim and methods VT identified in findings
with Forensic nurses) not aim
Mental Health
nurses in Australia
Hartley et al. (2019) Discussion paper N/A N/A Discussion paper. Quality Very relevant to VT, less
uncertain by standard measures so to nursing
Jahner et al. (2019). Integrative review 2006-2017 9 articles Integrative review with clear VT identified in findings
of rural nurses were included aim, method and article not aim
scrutiny
Lev-Wiesel et al. (2009) Self-report 2009 n204 health Clear aim and methods VT identified in findings
questionnaire care (n76 not aim
nurses)
Li et al. (2020) Descriptive app- 2020 n740 (n526 Descriptive study using app- VT examined specifically
based nurses) based questionnaire, 5 day in the context of CoVID
questionnaire recruitment period
Little (2002) Discussion paper N/A N/A Discussion paper with no Highly relevant.
method or aim. Written by an Explores VT for
emergency department Nurse emergency department
Manager (Lived Expertise) nurses
Maier (2011) Qualitative study 2006–2007 40 Clear method VT identified in findings
using interview and participants not aim
observational data
Manning-Jones et al. (2017) Testing a model of Unknown 365 Clear method Difficult to extract VT
relationship participants from findings
between STS and (76 nurses)
VPTG
Manning-Jones et al. (2016) As above (same As above As above Clear aim, relationship of As above
research team) coping strategies to STS and
VPTG
Mollart et al. (2009) Descriptive 2009 18 midwives Developed out of experiences VT identified in findings
qualitative study observed clinically. Clear not aim
method
(Continued)

TABLE 1 (Continued)
Article reference Method Time period Sample size Assessed quality Assessed relevance
Raunick et al. (2015) Survey study unknown 340 nurse Clear method. Highly relevant:
analysed participants Specifically about nurses
quantitatively and specifically
measured VT
Robinson et al. (2003) Mixed methods 1999 295 responses Survey with validated tools and Highly relevant. Uses a
survey study from mental questions based on literature VT specific scale to
health nurses measure VT in nurses
Sinclair and Hamill (2007) Literature review 2006 (range Included Clear aim and search strategy. Clear literature review
of literature literature not Exclusions and inclusion not on VT broadly. Attempts
not known) specified. listed. Thematic analysis of to link to oncology
unknown articles nurses at the end
Tabor (2011) Concept analysis 1990-2007 23 resources, Concept analysis, searched for Highly relevant
with clear 12 journal burnout, compassion fatigue,
definitions of VT articles, two PTSD, secondary traumatic
and related terms; websites and stress, and VT to facilitate
also brief two books differentiation and clarification
discussion of VT included of the concept of VT. Robust
relevance to method
Forensic nursing
Taylor et al. (2016) Mapping review/ 2009-2014 6 articles Clear aim and methods, focuses Relevant to VT in
synthesis included on nursing research not nursing research context
practice
Van der Wath et al. (2016) Qualitative unknown 9 nurse Qualitative design and Directly relevant.
phenomenological participants descriptive phenomenological introduces VT upfront
study method. Findings grounded in but hard to extract VT
the words of participants from findings specifically
Wies and Coy (2013) Quantitative survey unknown n42 Surveys using validated tool Explores VT in a
method specific field of nursing
(Goldblatt,2009; Robinson et al. 2003), particularly et al. 2020), overwhelming helplessness (Mollart et al.
when nurses are exposed to repeated trauma (Corcoran 2009), or worry (Maier 2011), leading to distress (Li
2020) and become ‘unwitting partners’ in ‘unconscious et al. 2020). These emotions are expected to occur
re-enactments’ of the original trauma (Clark & Gioro through empathy and compassionate nursing care, but
1998). VT was positioned as a ‘natural response’ to the can also conflict with a nurse’s professional expecta-
highly specialized and demanding work of nurses (Lit- tions and role, or be institutionally discounted (Hartley
tle 2002) and described as pervasive, insidious, inevita- et al. 2019). This may leave nurses to have to privately
ble, cumulative, and permanent (Clark & Gioro 1998; recognize, interpret, and make sense of human suffer-
Jahner et al. 2019; Robinson et al. 2003; Tabor 2011); a ing, as well as capacity for cruelty, without support or
profound shift in worldview (Hartley et al. 2019; Mol- organizational recognition (Little 2002). In addition,
lart et al. 2009), altering and damaging fundamental nurses may witness experiences, such as unexpected
beliefs about the world (Mollart et al. 2009). death, which are not widely acknowledged or go
VT was understood to occur as a manifestation of against widespread social or moral expectations of life
workplace stress (Robinson et al. 2003) or due to indi- (Hartley et al. 2019). The need for professional bound-
rect exposure to traumatic events (Manning-Jones et al. aries (Hancock 2020) and the emotional labour
2017), including patient stories (Garner 2017). The required to manage the subsequent emotional disso-
repeated ‘bearing witness’ to traumatic acts (Hancock nance between professional expectations and personal
2020), empathic listening to narratives of trauma (Rau- emotions may contribute to nurses’ experiences of VT
nick et al. 2015) or ‘invasion’ of someone else’s trauma (Hartley et al. 2019).
into the nurse’s practice (Tabor 2011) is thought to The relationship of VT to other concepts in nursing
lead to emotions such as anger, helplessness, confusion, was described in varied ways. VT was described by
ambivalence, grief (Hartley et al. 2019), sympathy (Li Clark and Gioro (1998) as ‘the same as’ compassion

fatigue (CF), secondary traumatic stress (STS), and (Harris et al. 2015). The reasons for the risk of VT
empathic strain; simply, different labels given to similar being particularly identified for nurses in these settings
effects from indirect exposure to trauma (Clark & largely related to assumed levels of exposure to people
Gioro 1998). Alternatively, VT was positioned as a con- who have experienced trauma, including experiences of
sequence of CF (Corcoran 2020); similar but different physical injuries, sexual abuse, accidents, disasters
to CF and STS (Goldblatt 2009) or ‘overlapping’ with (Manning-Jones et al. 2016), death, dying, violence,
CF and STS (Jahner et al. 2019). A number of studies and abuse (Sinclair & Hamill 2007; Taylor et al. 2016).
identified that although the concepts of VT and CF Risks for VT for nurses in these settings were also
may differ in theoretical definition (Hancock 2020), in articulated to be related to disconnects between medi-
practice this difference may be indistinguishable (Mol- cal and humanistic discourses (Hartley et al. 2019),
lart et al. 2009), as both are characterized by gradual feelings of redundancy (Little 2002), exposure to feel-
processes of individual inner turmoil (Jahner et al. ings of shock or horror (Harris et al. 2015) and perva-
2019). At times VT was considered an antecedent to sive long-term stress and responsibility (Tabor 2011).
burnout which was positioned as a more severe out- The time point of contact in the patient journey was
come (Maier 2011) while others considered that experi- considered a potential risk associated within the work-
ences of VT can lead to two outcomes, either STS or place setting (Little 2002), along with the sustained,
vicarious posttraumatic growth (Manning-Jones et al. close, and empathic engagement with patients required
2017). Hartley et al. (2019) differentiated VT from STS across settings (Lev-Wiesel et al. 2009; Tabor 2011).
as although nurses experience traumatic responses in In comparison to other professions, nurses were
both, in VT they are not actively participating in the identified to be at increased risk of VT, and yet to also
traumatic events themselves whereas in STS the pro- conversely often be protected from its effects. VT risk
cess of care is traumatic. VT was proposed by Little in nursing was noted to be amplified by high demands,
(2002) to parallel the experience of post-traumatic low resources, and competing personal and professional
stress disorder (PTSD) and burnout but to be existen- demands (Jahner et al. 2019), with many nurses
tially different in its focus on meaning and adaptation, reported to experience some symptoms of VT even if
rather than the symptoms themselves (Little 2002). they did not meet all criteria or identify with the con-
The role and environment of the nurse is potentially cept (Wies & Coy 2013). Hancock (2020) suggested
directly related to which of these experiences an indi- that ‘all’ nurses are likely to experience ‘aspects’ of
vidual nurse may have and whether multiple traumatic burnout, CF, and VT. Within nursing, non-clinical
effects co-exist or are intermingled (Hancock 2020). nurses were identified to also be at risk of VT due to
responsibilities and indirect exposure to traumatic
material through supporting direct responders, and
What implications of vicarious trauma, specific
their workload (Li et al. 2020; Maier 2011).
to nursing, are identified?
Protocols that govern nursing practice and result in
As Tabor (2011) notes, a lack of research specifically clear role expectations may be protective for nurses
on nursing and VT hampers ability to garner an empiri- (Lev-Wiesel et al. 2009). Nurses were found to have
cal or theoretical understanding of its impact. How- lower rates of VT than psychologists (Manning-Jones
ever, across studies included in this review, a large et al. 2017) and more positive outcomes after exposure
variety of effects and implications for nurses were theo- to VT than social workers, possibly due to opportunities
retically and clinically described. for debriefing and collegial support, clear roles, and
VT was identified as particularly relevant to nurses ability to focus on actions and tasks (Lev-Wiesel et al.
working in a large amount of settings including emer- 2009). Similarly, mental health nurses were found to
gency departments (Little 2002; Van der Wath et al. not have higher rates of VT than other mental health
2016), mental health units, drug health services, hos- workers (Robinson et al. 2003). However, VT was also
pices or veteran services (Clark & Gioro 1998), surgical recognized to be ‘contagious’, with indirect exposure to
settings (Hartley et al. 2019), non-clinical roles (Li trauma able to be transmitted amongst health care pro-
et al. 2020), sexual assault services (Maier 2011; Rau- fessionals through re-telling of stories (Robinson et al.
nick et al. 2015; Wies & Coy 2013), midwifery (Mollart 2003), including through clinical handover.
et al. 2009), correctional settings (Hancock 2020), Individual nurse vulnerability to VT was reportedly
oncology, intensive care (Sinclair & Hamill 2007), influenced by exposure levels, self-efficacy, personal
research (Taylor et al. 2016), or forensic settings and professional support systems, and individual

meaning frameworks such as spirituality (Clark & nurses linked to negative patient outcomes (Hartley
Gioro 1998). A personal history of trauma was also rec- et al. 2019), and organizational impacts such as finan-
ognized to increase vulnerability (Maier 2011; Raunick cial burden due to increased sick leave (Raunick et al.
et al. 2015; Tabor 2011). Believing the individual nurse 2015). For nurses, VT can also lead to compromised
had the appropriate skills for the job was considered a workplace safety, job stress, and decreased support;
protective factor, along with access to continuing edu- experiences were amplified in rural settings due to iso-
cation, peer support (Robinson et al. 2003), good per- lation and lack of services (Jahner et al. 2019).
sonal coping skills, and professional experience (Tabor Identified implications of VT were not all negative,
2011). While training and qualifications were consid- with studies also identifying the potential for vicarious
ered important, equally so were the culture of organi- posttraumatic growth (VPTG) to occur (Manning-Jones
zations and the valuing of nursing staff within et al. 2016, 2017). VPTG was characterized by positive
workplaces (Little 2002). changes to self, relationships, and philosophy due to
When nurses experience VT this impacts on both the vicarious exposure to trauma (Manning-Jones et al.
their personal and professional lives (Clark & Gioro 2017). In contrast to the rest of the examined litera-
1998; Garner 2017; Manning-Jones et al. 2017; Wies & ture, Raunick et al. (2015) downplayed the effects of
Coy 2013). Personally, VT can result in feelings of VT in nursing, noting that, while the effects of vicari-
numbness, fearfulness, grief, rage, anger, sadness, anxi- ous trauma were different to that of primary trauma
ety, depression, helplessness, despair, and shame (Clark exposure, they were not outside the realms of ‘average’.
& Gioro 1998; Hartley et al. 2019; Li et al. 2020; Maier
2011). It can also result in fluctuations between numb-
What vicarious trauma interventions are
ness and overwhelming emotion (Little 2002). Nurses
identified to apply to nursing?
experience physiological effects such as sleep distur-
bance, tachycardia, nightmares, loss of appetite, fatigue, While there is relatively little known about the unique
physical decline, irritability, and inattention (Clark & relevance and effects of VT in nursing, even less is
Gioro 1998; Hartley et al. 2019; Jahner et al. 2019; Li clearly articulated about what interventions are
et al. 2020). As well as impaired judgement and trau- required. Identified approaches or strategies in
matic imagery (Sinclair & Hamill 2007), alongside response to VT can be broadly classified into those
social effects such as loneliness, withdrawal, and isola- related to individuals and those related to organizations.
tion (Clark & Gioro 1998; Jahner et al. 2019; Sinclair On an individual level, strategies are required for
& Hamill 2007). VT is thought to affect nurses’ sense nurses to ‘buffer against’ the effects of VT and preserve
of belonging, relationships, and perspective on life their sense of self (Garner 2017). This can occur through
(Tabor 2011), decreasing resilience and heightening individuals recognizing and maintaining their own
risk of other personal destabilizations (Hartley et al. boundaries, developing positive coping mechanisms, fos-
2019). Similar to any primary trauma, VT can distort tering social support networks and engaging in self-care,
nurses’ worldview of themselves and others, including pleasure activities, spirituality, humour, debriefing, and
their sense of trust and safety, control, self-esteem, and stress reduction (Goldblatt 2009; Maier 2011; Manning-
intimacy (Jahner et al. 2019; Manning-Jones et al. Jones et al. 2016, 2017). Accessing clinical supervision
2017). Changes can occur to nurses’ frame of refer- and training, ensuring balance between work and rest,
ence, self-capacity, ego-resources, psychological needs, and actively seeking emotional and social support, exer-
and cognitive schemas (Raunick et al. 2015; Sinclair & cise, and tension relieving activities may also aid individ-
Hamill 2007). ual nurses (Lev-Wiesel et al. 2009). Opportunities to
Professionally, VT is linked to decreased nursing process VT exposure through therapy may also be help-
work performance (Hartley et al. 2019; Wies & Coy ful (Manning-Jones et al. 2017). Garner (2017) proposes
2013). This may be in part due to reduced sleep and that creative activities may be an important form of ther-
impacts upon personal life (Mollart et al. 2009), but is apeutic self-care, which can lead to relaxation and
also likely due to reduced empathy (Raunick et al. decreased anxiety and buffer against VT.
2015), with increased emotional distance leading to Awareness is critical for nurses to recognize the
decreased capacity for nurses to respond therapeuti- need for individual intervention (Clark & Gioro 1998;
cally to patients (Harris et al. 2015). VT may shift Goldblatt 2009) and to support prevention. Prevention
nurses’ worldview such that they can begin to deny or at an individual level requires heightened awareness,
invalidate patient experiences (Maier 2011), with VT in self-evaluation, connection with colleagues and other

professionals, and talking about thoughts and feelings about VT and nursing. The review found evidence that
in safe places (Clark & Gioro 1998). Education is nurses experience profound and diverse experiences in
needed so nurses can be vigilant to the presence of VT response to vicarious exposure to trauma in their work.
in themselves and their colleagues (Mollart et al. 2009; The diverse literature base, inclusive of the application
Raunick et al. 2015), ideally commencing at an under- of VT knowledge to specific settings or personal experi-
graduate level (Clark & Gioro 1998). Education should ences by nurses, is suggestive that VT is of greater
be focused on awareness, tools, and strategies for importance to nursing than the empirical literature
screening and response, alongside self-awareness alone may indicate. It was not uncommon for included
(Tabor 2011). empirical studies to not intentionally aim to examine
Across the literature, emphasis was placed on the VT, but to find it of relevance once the data were anal-
responsibility of organizations in relation to VT and ysed. This integrative review highlights a need for ongo-
nurses. Organizations were required to provide sup- ing research focused specifically on VT and nursing.
portive environments, manage caseloads, provide sys- The majority of the 22 articles included relied on the
tematic support, organizational governance, clinical original VT definitions proposed by McCann and Pearl-
supervision, peer support, and debriefing, even for man in 1990 in relation to trauma therapists but
nurses who do not personally seek it out (Harris et al. adapted for the nurses providing care for people who
2015; Mollart et al. 2009; Sinclair & Hamill 2007; Tay- have experienced, or are currently experiencing, trauma
lor et al. 2016), as well as developing policies that con- in their lives or in the course of care. This suggests
sider prevention, response, and support in relation to some consistency of concept, despite theoretical overlap
VT (Raunick et al. 2015). Organizations were required with other aligned concepts of compassion fatigue, sec-
to foster cultures that value nurses and provide psycho- ondary traumatic stress and burnout. Many articles
logical resources for support (Little 2002), with preven- were excluded from the findings due to a lack of delin-
tative approaches considered the most effective and eation of VT from other related concepts. It may be that
positioned through a lens of maintaining staff and the difference between CF and VT is theoretical and
patient safety (Robinson et al. 2003; Taylor et al. 2016). not possible to determine in practice. However, the
Preventative approaches should target all nurses, while detailed and specific articulations of the possible per-
also recognizing those most ‘at risk’, aiming to support sonal and professional effects of VT for nurses suggest
coping, awareness, and peer support (Robinson et al. an urgent need for targeted examination of the unique
2003; Taylor et al. 2016; Van der Wath et al. 2016). implications of VT for nurses and nursing.
Research is also required to aid in identifying risk fac- This review highlighted that the processes of empa-
tors, effective interventional strategies, and screening thy and compassion upon which nursing is built are
for VT amongst nurses (Hancock 2020). also widely recognized as the facilitators for nurses
At a social and political level, there is a need to experiencing vicarious but significant effects from expo-
position VT not as a crisis of individuals but as a social sure to the trauma of their patients. To engage thera-
phenomenon related to nursing role expectations peutically with their patients, nurses are required to
(Hartley et al. 2019) and a lack of structural mecha- exercise empathy and engage in processes of compas-
nisms to support people accessing assistance for sionate care. VT is a side effect of empathic engage-
trauma-related experiences, including VT (Wies & Coy ment, meaning that when nurses are caring for patients
2013). When costing or considering the impacts of vio- who have had, or are having experiences of trauma, the
lence, trauma and abuse upon populations, recognition effects are empathically mirrored in the nurse, trigger-
of its vicarious effects upon caregivers of victims, ing complex emotions and leading to psychological,
including nurses, was proposed as essential (Wies & physiological, and social effects. In this way, VT is an
Coy 2013). Societal and cultural glorification of vio- expected component of ‘good nursing care’. Nurses are
lence and undervaluing of suffering were also seen to perceived in society to embody gendered stereotypes
be contributors to the lack of acknowledgement of VT (Girvin et al. 2016; Shields 2012) and often positioned
occurring within nursing (Little 2002). as vocationally driven to be caring, self-sacrificing, and
compassionate (Morris-Thompson et al. 2011). In
recent times, a hero discourse of nursing has also
DISCUSSION
emerged (Einboden 2020), encouraging individual,
This review examined diverse literature spanning social, and political normalization of nurses risking
31 years from 1990 to 2021, to explore what is known their own health and wellbeing by practising in

foreseeably hazardous environments, sustained by identifiable, in practice the ‘symptoms’ of VT such as

moral fortitude and public adulation (Mohammed et al. shifts in worldview and feelings of helplessness are
2021). Yet despite the perception of nurses as dutiful likely to occur gradually and without conscious aware-
heroes with endless capacity to care, research from the ness. Similar to understandings of compassion fatigue,
fields of neuroscience, psychology, and nursing science it is likely easier to recognize VT in others than your-
all indicate a likelihood that nurses will be affected by self (Mendes 2014) and as such, it is essential that all
their roles at least as much as any other direct care health care environments develop ways of talking about
provider, with VT a likely workplace hazard, not just and identifying VT amongst staff and ensuring access
for those with vulnerability but for all nurses. As such, to interventions to help individuals and services pre-
individual, team, organizational, and social responses vent, identify, and manage the effects.
are required. It is important to note that not all effects of expo-
The review highlighted that at individual, team, orga- sure to the trauma of others are negative. Many articles
nizational, and social levels, awareness and preventative screened for the review also referred to the concept of
approaches are recommended. These approaches vicarious posttraumatic growth (VPTG). VPTG refers
require systemic supports that foster individual coping to positive psychological changes that occur after expo-
mechanisms, self-care and support networks for nurses, sure to indirect trauma (Yaakubov et al. 2020). Both
education about VT, screening for VT, and formalized VPTG and post-traumatic growth (PTG) experiences
access to clinical supervision and peer support for all are preceded by a shock, an infringement or destruc-
nurses. Harris and Griffin (2015) identified that the first tion of basic assumptions about oneself and the world
step in reducing compassion fatigue is acknowledging it (Ogi nska-Bulik 2018). This can lead to positive changes
exists. The same is likely true of VT, as without aware- in self-perception, interpersonal relationships, and phi-
ness, the need for structurally inbuilt preventative losophy of life that occur not directly due to the expo-
strategies is not recognized. Positioning VT as an indi- sure or to resilience, but as a product of the ‘struggle’
vidual issue that requires individual vigilance and self- that occurs with trauma exposure (Tedeschi & Calhoun
care fails to acknowledge both the unconscious pro- 2004). Importantly, VPTG does not exclude the possi-
cesses of VT itself, as well as the context of systemic bility of concurrent negative effects of VT (Yaakubov
and organizational responsibilities to protect all staff et al. 2020) or remove the distress associated with the
from harm occurring in the course of work. With traumatic exposure (Beck & Casavant 2020), it may just
increasing awareness of trauma across health care set- be an alternative or concurrent component of the expe-
tings, and movements towards the delivery of ‘trauma rience. Social support, feeling professionally valued,
informed care’, recognition of vicarious trauma amongst and job satisfaction are positively correlated with VPTG
nurses as a likely ‘cost’ of the delivery of compassionate occurring (Beck et al. 2016). In VPTG, the adapting
care to trauma survivors may also be essential. and coping that occurs due to exposure to VT may lead
Although framing nurses’ experiences as traumatic is to greater development in aspects of self than occurred
important, the largely individualistic focus of traumatic pre-trauma, for example, Neonatal Intensive Care Unit
stress models limits recognition to individual experi- nurses exposed to VT report higher rates of apprecia-
ence, requiring individual intervention (McGibbon tion of life afterwards, which could be considered a
et al. 2010), sidelining the social and cultural context of VPTG response (Beck & Casavant 2020). Alongside ini-
experiences and shared responsibility for interventions. tiatives to raise awareness and prevent VT, there may
The term trauma refers to the sustained effects of be benefit in ensuring nurses are also working in
experiences and events, not the events themselves (Iso- VPTG-enabling environments that provide peer sup-
bel et al. 2017). While prevention of trauma should be port, professional recognition, and positive job
a social and political priority, it is not possible to pre- conditions.
vent all exposure; however, the ongoing effects of expo- Findings of this review highlighted that despite
sure to circumstances known to be traumatic can be experiential and theoretical awareness of VT in the lit-
buffered by strategies and awareness. The same is true erature, there is limited research focused on the effects
of vicarious experiences of trauma. The review high- of, or intervention strategies for, VT in nurses. How-
lighted that nurses are likely to be exposed to vicari- ever, studies on aspects of nursing care often identify
ously traumatic experiences, stories, and circumstances, VT as important in their findings, further emphasizing
which over time are likely to have personal and profes- the need for more targeted research to occur. While
sional effects. While these effects are theoretically research in this review focused on a number of settings

where VT may be more likely to occur, the diversity of populations known to have high rates of trauma, and
these settings suggests that rather than being areas of rely upon processes of empathic engagement to sup-
higher risk, these are areas where the concept has been port recovery. They are, therefore, highly likely to have
explored based on greater awareness of trauma, lived experiences of vicarious trauma across their careers.
expertise of nurse researchers, or acuity. More research The clarity of concept, effects, and interventions pre-
is urgently needed to understand the individual, envi- sented in this review directly informs the actions of
ronmental, and organizational risk and protective fac- individual nurses and services, in preventing, identify-
tors related to VT for nurses. ing, and responding to vicarious trauma across settings,
including mental health nursing.
Mental health nurses are often called upon to sup-
LIMITATIONS
port their colleagues working in general health settings
The review included articles of varying quality. While through education, supervision, or consultation. The
determining the quality of the literature was not findings provide clear guidance to facilitate awareness
deemed critical to exploring the emerging field, it raising, preventative education, workplace wellbeing
means that the findings gave equal weighting to articles initiatives, and clinical supervision to support the men-
that represented one person’s perspective as to those tal health of all nurses, regardless of setting of work.
which systematically examined larger populations.
While the overlap between CF and VT was discussed
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ABSTRACT: Nursing requires empathic engagement, within therapeutic relationships, to ensure

experiences of others (Huynh et al. 2008). In many

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

Records idenﬁed through Addional records idenﬁed

Records aer duplicates removed

Records screened * Records excluded

Full-text arcles assessed Full-text arcles excluded

Studies included in review

© 2021 John Wiley & Sons Australia, Ltd

TABLE 1 Summary of included articles

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

foreseeably hazardous environments, sustained by identifiable, in practice the ‘symptoms’ of VT such as

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

© 2021 John Wiley & Sons Australia, Ltd

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