The Nurse-Patient Relationship and Victims of Violence

By Hartman, Carol R. Rn, Cs, DNSc | Scholarly Inquiry for Nursing Practice, January 1, 1995 | Go to article overview

The Nurse-Patient Relationship and Victims of Violence


Hartman, Carol R. Rn, Cs, DNSc, Scholarly Inquiry for Nursing Practice


Vicarious traumatization is a phenomenon that recognizes that the exposure of persons, other than the victim, to the specifics of trauma material or the reenactment of traumatic experiences transmits the emotionally laden aspects of the original violence and thus is a source of emotional arousal and distress for the nurse working with victims of violence. This source of emotional arousal shapes the underlying approach-avoidance dynamic of countertransference responses that strain the empathic connection necessary for a safe and constructive nurse-patient relationship. Case consultation and supervision are necessary to protect the integrity of the nurse-patient relationship. The current isolating changes in the work setting cut the nurse off from needed support and guidance in working with victims of violence. The emotional risks inherent in working with victims of violence require that the nurse seek professional support for the interpersonal aspects of practice.

A former patient enters a clinic and shoots to kill his therapist, a social worker, and another staff member. A 32-year-old woman, admitted because of a seizure disorder and back inj ury, screams at the nurses attending her. S he berates them, calls them incompetent, and is reduced to tears. A nurse in the emergency room receives the battered body of an 8-month-old child; he dies. His young parents are arraigned for sexual abuse and for beating the baby. The nurse finds it increasingly difficult to go to work on this unit and requests a transfer to another unit. A therapist who has worked long and hard with a patient informs the patient of her impending marriage. The patient becomes enraged and levels a law suit against the therapist, claiming sexual abuse and abandonment. After years of legal involvement, the therapist realizes she can no longer take patients with a history of sexual abuse.

Locations and length of the professional relationship vary in these examples; what does not vary is that in each situation the patient has a complex history of experiencing abuse and violent actions. Other commonalities are that professional nurses in these situations are privy to violent past experiences either through the behavior of the patient toward the nurse or because of the consequences of the violent behavior toward others.

The consequences of patients telling their trauma stories or their reenactment of these experiences with others are at the basis of what is known as secondary traumatization (Danieli, 1985; Figley,1988; Pynoos & Nader, 1988; Solomon, 1990) or vicarious traumatization. Vicarious traumatization was introduced into the clinical literature by McCann and Pearlman (1990) and avoids some of the confusion of meaning associated with the notion of retraumatization in the process of helping. For example, a rape victim is often 'secondarily' traumatized by the legal system when the victim is made out to be responsible for the rapist's behavior. What is specific to the concept of vicarious traumatization is the recognition that the exposure of persons, other than the victim, to the specifics of trauma material or the reenactment of traumatic experiences transmits the emotionally laden aspects of the original violence and thus is a source of emotional arousal and distress for those persons. In turn, this emotional arousal can have parallel effects on the biological processes of the receiver as the prolonged arousal has on the victim. Therefore, victims of violence who come to the nurse for various forms of help are also a source of potential distress for the nurse. Nurses' reactions to this trauma information on both biological and psychological levels result in nontherapeutic responses and patterns of interaction within the nurse-patient relationship. Nontherapeutic patterns are marked by behaviors that overinvolve the nurse or result in the nurse's withdrawal from the patient. These behaviors adversely affect the empathic connection necessary for the therapeutic outcome of the nurse-patient relationship. …

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