The relation of clinical empathy to secondary traumatic stress

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1 Procedia - Social and Behavioral Sciences 33 (2012) PSIWORLD 2011 The relation of clinical empathy to secondary traumatic stress Irina Crumpei a*, Ion Dafinoiu a a Facultatea de Psihologie i tiin e ale Educa iei, Universitatea Al. I. Cuza, Str. Toma Cozma, nr. 3, Ia i,700554, Romania Abstract A growing body of empirical research shows that health professionals working with survivors of traumatic events may develop traumatic symptoms themselves. Empathy is one of the main risk factors associated with clinical competence and patient outcome. Seventy seven medical workers from emergency and intensive care units were surveyed to determine the presence of secondary traumatic stress and explore the distinct relations to sympathy and empathy. Sympathetic health professionals are most vulnerable. On the contrary, clinical empathy is not significantly related to traumatic symptoms Published by by Elsevier Ltd. B.V. Selection and and/or peer-review peer-review under responsibility under responsibility of PSIWORLD of PSIWORLD2011 Open access under CC BY-NC-ND license. Keywords: Secondary traumatic stress; empathy; sympathy; medical staff, trauma. 1. Introduction The past few years have brought about the development and increased attention of the traumatology field and the concept of traumatic stress. In the context of the studies naturally focused on reactions of the direct victim after the traumatic event, it was gradually discovered that the victims can multiply over time, even long after the event ended (Joinson, 1992; Figley, 1993; Hodgkinson & Shepard, 1994; Schauben & Frazier, 1995; Kassam-Adams, 1995; Pearlman & Mac Ian, 1995; Steed & Bicknell 2001 ). Joinson (1992) was the first to use the term compassion fatigue to describe the medical assistants experience when exposed to trauma in their work. The term has gained recognition by describing the effects of working with survivors of trauma on clinicians and mental health specialists. Victims of traumatic events might develop posttraumatic stress disorder showing intrusive, avoidance and arousal symptoms. Family members, clinicians, emergency professionals or co-workers who are exposed to the traumatic material of others put themselves at risk for developing similar symptoms (Figley, 1993). * Corresponding author. Tel.: ; address: irina_crumpei14@yahoo.com Published by Elsevier B.V. Selection and/or peer-review under responsibility of PSIWORLD2011 Open access under CC BY-NC-ND license. doi: /j.sbspro

2 Irina Crumpei and Ion Dafinoiu / Procedia - Social and Behavioral Sciences 33 (2012) Because of the indirect exposure to the traumatic material, the syndrome was called secondary traumatic stress (STS). In fact, the revised fourth edition of the Diagnostic and Statistic Manual of Mental Disorders includes posttraumatic stress syndrome diagnostic criteria for situations where the person faces a traumatic event or events that involved death threats or death or serious injury or threat of its own or other s body integrity. Considering that some professional groups are systematically confronted with traumatic experiences of others, it s not surprising that they experience symptoms of secondary traumatic stress. Medical workers are one of the vulnerable professional groups. Emotional involvement and patients suffering are among the most reported sources of stress by medical workers (Bratt et al., 2000). Mealer et al (2007) explained the high traumatic symptomatology rates experienced by both medical assistants and Vietnam War veterans pointing out that some of the tasks performed by medical personnel included looking after corpses and providing assistance to traumatized victims as it happens in combat. Figley (1993) argues that professionals who have a great capacity to feel and express empathy tend to be more vulnerable to symptoms of STS resulting from the care of one traumatized or suffering person. At the same time numerous studies show the importance of the medical workers empathy towards the patient (Suchman et al., 1997; Stephan & Finlay, 1999; Halpern, 2001). Consequently, medical specialists face a paradox. Omdahl & O Donnell (1999) define empathy as empathic concern, willingness to communicate and emotional contagion. Emotional contagion is the most controversial factor of the three. On one side it is most valued by patients who feel appreciated and understood, on the other side it threatens the specialist s objectivity and health. Other definitions of empathy argue that emotional contagion is rather part of compassion, while empathy means understanding patient s emotions and communicating that understanding (Bertakis et al; 1991; Hojat et al, 2001). Firstly, the present study aimed to assess the impact of working with traumatized persons on the medical workers of emergency and intensive care units. Secondly, considering the distinction between compassion and empathy, we wanted to explore how the two concepts relate to secondary traumatic stress. 2. Method The research took place in several hospitals in the city of Iasi, Romania. A preliminary qualitative study was conducted to identify the main sources of stress for different medical specialties. The results were consistent with other research showing patient suffering as an important stress source (Healey & McKay, 1999; McGowan, 2001; Stordeur et al., 2000). Therefore, the participants in this study are 77 medical workers from the Emergency and the Intensive Care units. 35 were physicians and 42 were nurses. In order to observe the presence of STS among medical personnel, we also used a control group, with similar characteristics formed from 60 pharmacists. All participants answered a set of questionnaires, after signing a confidentiality contract. The Professional Quality of Life Scale (Stamm, 2005) is a revised version of Figley s self-administrated test, developed in 1995 to measure secondary traumatic stress. It contains 3 sub-scales of 10 items each, which offer independent scores measuring different concepts: compassion satisfaction ( =.83), burnout ( =.66) and secondary traumatic stress ( =.73). The Impact of Events Scale (Horowitz, Wilner and Alvarez, 1979) initially measured symptoms of direct trauma and not of secondary trauma. In spite its original purpose, the scale is most frequently used to measure and survey secondary traumatic stress symptoms. It has two subscales that measure avoidance with 8 items ( =.71) and intrusion with 7 items ( =.89) and can be added to generate a total score ( =.84). The factors of the IPIP-NEO model described by Goldberg et al. (2006), represented the basis for operating the Big Five plus questionnaire. To measure compassion we used the specific facet from the factor agreeability ( =.73). The Jefferson Scale of Physician Empathy (Hojat et al., 2001) used in the present

3 440 Irina Crumpei and Ion Dafinoiu / Procedia - Social and Behavioral Sciences 33 (2012) study is the final form, designed to measure physicians empathy toward their patients and consists of 20 items ( =.75). 3. Results Independent Samples T Tests were conducted to compare the level of secondary traumatic stress in medical workers and pharmacists. Both physicians and nurses had significantly higher scores for all the subscales of the dependent variable. Even if medical workers (M = 35.64, SD = 6.85) have a significantly higher level of compassion satisfaction in comparison to pharmacists (M = 31.41, SD = 6.56; t(135) = 3.65, p <.001 ), they also suffer from a higher level of secondary traumatic stress (t(135) = 6.058, p <.001). The Impact of Events Scale indicates that the medical professionals (M = 33.25, SD = 12.10) experience intrusive and avoiding symptoms which generate a significantly higher level of total distress as compared to the pharmacists control group (M = 18.48, SD = 14.93; t(135) = 6.23, p <.001 ). These results confirm our hypothesis. Medical personnel experience a significantly higher level of secondary traumatic stress in comparison to other professionals who do not systematically interact with victims of traumatic events. Pearson correlation coefficients were computed to assess the relationship between secondary traumatic stress, empathy and compassion. None of the dependent variables correlated significantly with clinical empathy. Table 1. Pearson correlation: STS and Clinical Empathy Compassion satisfaction Burnout STS Intrusive Symptoms Avoidance Symptoms Total Distress Clinical Empathy Note. * = p.05, ** = p.01. N = 77 for all analysis. However, the analysis indicates a significant positive correlation between reported levels of secondary traumatic stress and compassion in medical staff. The Impact of Events Scale shows that more compassionate medical workers report higher levels of intrusive symptoms (r =.342, N = 77, p <.01). On the other hand, there is no significant relation between avoidance symptoms and compassion. More compassionate professionals report being more burned-out. There is no significant correlation between compassion satisfaction and compassion. Table 2. Pearson correlation: STS and Compassion satisfaction Compassion satisfaction Burnout STS Intrusive Symptoms Avoidance Symptoms Total Distress Compassion *.511**.342** ** Note. * = p.05, ** = p.01. N = 77 for all results. 4. Discussions The present paper had two main objectives. Firstly, we wanted to assess the level of STS in Romanian medical workers. Therefore we compared the medical workers STS scores to those of the control group consisted of pharmacists. We found significant differences in all of the subscales of the dependent variable, both in relation to nurses and physicians. Other studies concerned with this issue reached similar

4 Irina Crumpei and Ion Dafinoiu / Procedia - Social and Behavioral Sciences 33 (2012) conclusions. Dominguez-Gomez & Rutledge (2009) noticed that medical assistants working in the emergency department are characterized by a significantly higher degree of risk of experiencing secondary traumatic stress in comparison to social workers. Mealer et al. (2007) compared the intensity of posttraumatic symptomatology experienced by medical assistants in the intensive therapy and general practice departments. The first category is characterized by significantly higher scores. In addition, both specialties report significantly higher levels of risk in comparison to managers working in the health industry. These conclusions are not surprising. The amount of work, lack of support and traumatic stress are burnout triggers identified by the medical assistants performing activities in the emergency, intensive therapy and oncology departments. (Kash et al., 2000; Schwam, 1998, Maytum, Heiman, & Garwick, 2004). The problem is even greater in Romania, where the economic difficulties raise new challenges for the medical system and the medical staff. Therefore, the relationship established with patients increases the results on the compassion satisfaction scale. However, the professional achievements cannot counterbalance the chronic exposure to pain and trauma. Secondly, we tried to find a possible solution for the paradox of the clinical relationship. On one hand, empathic medical professionals have better results in treatment, recovery and patient satisfaction, on the other hand emotional involvement threatens decision objectivity and exposes the specialist to STS symptoms (Figley, 1995). This study suggests that while compassionate medical workers report more intrusive and avoidant symptoms, there is no relationship between clinical empathy and STS. Clinical empathy was defined in this study as the ability and the willingness to understand the patient s emotional reactions, to see the situation through the patient s eyes and to communicate this understanding (Hojat et al., 2002). Emotional contagion refers to compassion and is separated from empathy. This operationalization separates the cognitive side that refers to the understanding of the patient from the affective side that implies emotional contagion. Figley (1995) uses the term compassion fatigue as synonym to secondary traumatic stress showing that compassion rather than empathy could endanger the specialist. To conclude, these results could be used in STS prevention among the medical staff. Teaching specialists to show their patients empathy while voiding compassion and emotional contagion could reduce the STS incidence. Further research is needed to clarify the effects of such interaction on the relationship between the medical specialist and the patient. References Bertakis K.D., Roter D, Putnam SM. (1991). The relationship of physician medical interview style to patient satisfaction. Journal of Family Practice.;32: Bratt M.M., Broome M., Kelber S. & Lostocco L. (2000) Influence of stress and nursing leadership on job satisfaction of paediatric intensive care unit nurses. American Journal of Critical Care 9, Dominguez-Gomez, E., Rutledge, D. N. (2009): Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing. 353: Figley, C. R. (1993). Compassion stress and the family therapist. Family Therapy News, 2-8. Figley, C.R. (1995). Compassion fatigue as secondary stress disorder: An Overview. In C.R. Figley (Ed.) Compassion fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatised (1-20). New York: Brunner Routledge. Goldberg, L. R., Johnson, J. A., Eber, H. W., Hogan, R., Ashton, M. C., Cloninger, C. R., et al. (2006). The international personality item pool and the future of public-domain personality measures. Journal of Research in Personality, 40 (1), Healy C. & McKay M.F. (2000) Nursing stress: the effect of coping strategies and job satisfaction in a sample of Australian nurses. Journal of Advanced Nursing 31: Hodgkinson, P. E., & Shepherd, M. A. (1994). The impact of disaster support work. Journal of Traumatic Stress, 7, Hojat M., Mangione S., Nasca T.J., Cohen M.J.M., Gonnella J.S., Erdmann J.B., Veloski J.J., Magee M. (2001). The Jefferson Scale of Empathy: development and preliminary psychometric data. Educational and Psychol Measurement; 61:

5 442 Irina Crumpei and Ion Dafinoiu / Procedia - Social and Behavioral Sciences 33 (2012) Hojat M., Gonnella J.S., Nasca T.J., Mangione S., Vergare M., Magee M. (2002). Physician empathy: definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry; 159: Horowitz, M., Wilner, N. & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 4l, Joinson, C. (1992). Coping with compassion fatigue. Nursing, 22, Kash, K. M., Holland, J. C., Breitbart, W., Berenson, S., Dougherty, J., Ouellette-Kobasa, S., et al.(2000). Stress and burn-out in oncology. Oncology, 14, Kassam-Adams, N. (1995). The risks of treating sexual trauma: Stress and secondary trauma in psychotherapists. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp ). Lutherville, MD: Sidran Press. Maytum J. C., Heiman M. B., Garwick A. W. (2004). Compassion fatigue and burnout in nurses who work with children with chronic conditions and their families. Journal of Pediatric Health Care;18: McGowan B. (2001) Self-reported stress and its effects on nurses. Nursing Standard 15: Mealer, M. L., Shelton, A., Berg, B., et al. (2007) Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med 175: Omdahl, B. L., & O'Donnell, C. (1999). Emotional contagion, empathic concern and communicative responsiveness as variables affecting nurses' stress and occupational commitment. Journal of Advanced Nursing, 29(6), Pearlman, L. A. & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26, Schauben, L., & Frazier, P. (1995). Vicarious trauma: The effects on female counsellors of working with sexual violence survivors. Psycholom of Women Quarterly, 19, Schwam, K. (1998) The phenomenon of compassion fatigue in perioperative nursing. AORN J.;68: Stamm, B. H. (2005). The ProQOL Manual. The Professional Quality of Life Scale: Compassion Satisfaction, Burnout, and Compassion Fatinue/Secondary Trauma Scales. Lutherville, MD : Sidran Press. Steed, L. & Bicknell, J. (2001). Trauma and the therapist: The experience of therapists working with the perpetrators of sexual abuse. Australian Journal of Disaster and Trauma Studies, 1, 3. Stephan W.G., Finlay K.A. (1999). The role of empathy in improving inter-group relations. J Soc Issue; 55: Stordeur S., D Hoore W. & Vandenberghe C. (2001) Leadership, organisational stress and emotional exhaustion among hospital nursing staff. Journal of Advanced Nursing 35: Suchman A., Markakis K., Beckman H., Frankel R. (1997). A model of empathic communication in the medical interview. Journal of the American Medical Association; 277:

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