Hospital Social Workers and Indirect Trauma Exposure: An Exploratory Study of Contributing Factors

Karen Badger, David Royse, and Carlton Craig This article explores the predictive ability of empathy (measured by the Interpersonal Reactivity Index), emotional separation (measured by the Maintenance of Emotional Separation Scale), occupational stress (measured by the Work-Related Strain Inventory), and social support (measured by the Multidimensional Scale of Perceived Social Support) on secondary traumatic stress (STS) (measured by the Secondary Traumatic Stress Scale) in hospital social workers. This cross-sectional study used a sample of 121 trauma center social workers who were predominantly master's-level prepared women with an average of 15.8 years' experience. Emotional separation and occupational stress were the strongest predictors of STS, explaining 49 percent of the variance, which suggests that hospital social workers need to be able to emotionally differentiate during work with patients and families and manage organizational stressors to minimize indirect trauma reactions.
KEY WORDS: compassion fatigue; emotional separation; hospital social work; occupational stress; secondary trauma

n stressful hospital organizational cultures, social workers often experience high-volume and high-acuity caseloads, quick patient turnaround (leaving little time for intervention and planning), devaluation and challenging of social work within a medical model, and professional territory and responsibility disputes (Dane & Chachkes, 2001; Gregorian, 2005; Pockett, 2003). Hospital social workers are also exposed to patients who have experienced traumatic events or illnesses (Dane & Chachkes, 2001; Pockett, 2003) and need to address their patients' pain and trauma as well as their own reactions and feelings.This can be difficult in a hospital environment that allows little time for processing these reactions ( Pockett, 2003) and frequently precludes meeting personal needs because of the fast pace of the job (Dane & Chachkes, 2001). Helping professionals indirectly exposed to trauma have reported symptoms such as intrusive secondary trauma-related thoughts or memories (flashbacks), avoidance behaviors, sleep disturbances, irritability, and dissociation (Bride, 2004; Dane & Chachkes, 2001; McCann & Pearlman, 1990). Stress reactions resulting from indirect trauma exposures that occur during work activities of professional caregivers are

commonly described as secondary traumatic stress, compassion fatigue, or vicarious traumatization (Bride, 2004; Collins & Long, 2003). In this study, this
phenomenon is referred to as secondary trattmatic stress

(STS) and is conceptually defined as "the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other [or] the stress resulting from helping or wanting to help a traumatized or suffering person" (Figley, 1995, p. 10). The indirect exposure to trauma inherent in social work is a concern because the social worker's self is in establishing a healing therapeutic alliance in every client interaction. The consequences of indirect trauma exposure may negatively affect the health and functioning of the social worker. Bride (2007) found social workers in general to be frequently exposed to client trauma when he examined the pervasiveness of STS reported by social workers. He found that 97.8 percent of the study respondents reported that their patients have experienced trauma, and 88.9 percent reported that they address trauma-related concerns during direct practice with their patients. Although only 15.2 percent met the primary criteria of the formal diagnosis of

CCC Code: 0360-7283/08 $3.00 O2008 National Association of Sociai Woricers

63

posttraumatic stress disorder (PTSD),5 percent met the criteria for at least one ofthe core symptom clusters (re-experiencing, avoidance, and hyperarousal), and approximately 20 percent of respondents met two ofthe measured PTSD criteria. Despite the potential negative consequences resulting from indirect trauma exposure, little research has been conducted in this area involving social workers generally (Bride, 2007) or hospital social workers specifically (Cunningham, 2003; Dane & Chachkes,2001;Pockett,2003).Bride (2004) noted that much of the literature that discusses STS or vicarious traumatization is based on anecdotal experience or conceptual ideas. Empirical researchers have just recently begun to investigate the impact of indirect trauma exposure on professional helpers relative to STS, and their findings have yielded mixed results (Bride, 2004). More research is necessary to further our understanding of variables contributing to the development of STS, particularly in hospital social workers for whom the patient population, their complaints and circumstances, and the characteristics of the medical setting create many challenges. This study explores some ofthe factors that may contribute to the development of STS in hospital social workers.The predictive independent variables (empathy, emotional separation, occupational stress, and social support) were chosen on the basis of theoretical significance, health care environmental characteristics, and support in the existing literature.
LITERATURE REVIEW Conceptual Model

cluded in this study's conceptual model to further the understanding of the ability of organizational and contextual factors to mitigate STS in hospital social work. Results of this study may assist in the refinement ofthe theoretical understanding of this problem and may influence thinking about prevention and remedial interventions. Empathy as a Gateway of Vulnerability STS (or compassion fatigue) has been described as a consequence for the professional helper engaged in work with those experiencing pain (Figley, 1999). Empathy, defined as a personality characteristic that describes the ability to affectively and cognitively respond to others with objectivity (Williams, 1989), is theoretically considered to place the professional at risk of indirect trauma exposure reactions (Figley, 1995).This is an important observation because of the centrality of empathy to the therapeutic alliance. Wilson andLindy (1999) have discussed the necessity of maintained empathy in trauma work, the achievement of which requires the social worker to listen to patients with openness and to experience their circumstances in a phenomenological or imaginative way (Williams, 1989; Wilson & Lindy, 1999). The assumptions of an etiological model of compassion fatigue developed by Figley (2002) suggest that this empathic ability and empathic concern, the ability to perceive pain in others and subsequently respond to suffering, not only are key to effective therapeutic work, but also create the risk of compassion fatigue; the risk is thought to increase relative to empathic aptitude (Figley, 1995). The connection between empathy and STS has not yet been empirically researched; little is known about how and if empathy acts as the gateway of vulnerability (Jenkins & Baird, 2002). However, empathy has been minimally explored relative to burnout. Study findings show that emotional empathy is a significant predictor for personal accomplishment and the depersonalization associated with burnout (Gross, 1994) and is positively correlated with emotional exhaustion and professional accomplishment (Williams, 1989), thus suggesting that professional caregiving is a source of depletion and satisfaction. These findings warrant further investigation of the contribution of empathy as part of this study. Empathy and Emotional Separation Among the factors included in Figley's (2002) etiological model thought to influence the development

Theoretically, empathy is considered to represent the channel of vulnerability for STS (Figley, 1995). Emotional separation refers to the social worker's ability to modulate emotional reactions to patient material to maintain appropriate distance and objectivity (Corcoran, 1983). It is possible that the ability to differentiate, or emotionally separate, from the patient while being empathic may more precisely protect against syndromes such as STS (Corcoran, 1983). Because empathic engagement is crucial to the therapeutic alliance, a better understanding of the roles of empathy and emotional separation on the development of STS is essential. Both occupational stress, which is very common in the hospital environment, and social support, which is consistently endorsed in the literature as influential in protecting the social worker against STS, are in-

64

Health & Sodal Work VOLUME 33, NUMBER I

FEBRUARY ZOO8

of compassion fatigue are the professional's emotional experiences of client suffering and disengagement from the patient. The social worker's ability to regulate his or her emotional responsiveness to the patient is important to the concept of empathy (Corcoran, 1989) .The capacity to establish boundaries between one's self and others while remaining empathically engaged is an important feature in selfregulation, and failure to adequately do so decreases emotional distance between the social worker and the patient (Wilson & Lindy, 1999), thus potentially decreasing one's ability to self-protect (Corcoran, 1983;Wilson & Lindy, 1999).This idea suggests that the inability to modulate emotional proximity to the client's situation and the failure to emotionally differentiate may contribute to a social worker's vulnerability for STS and may represent a critical pathway for development of STS reactions. Corcoran (1989) conducted a study exploring emotional separation and empathy relative to burnout in a sample of certified, master's-prepared social \vorkers. He found that increased empathy and decreased emotional separation were both significantly associated with increased burnout, but the correlation between empathy and burnout became insignificant after statistically controlling for emotional separation. Conversely, the partial correlation between emotional separation and burnout continued to be significant while controlling for empathy. Corcoran concluded that his findings did not support the theoretical link of empathy precipitating burnout in caregiver professionals. Similarly, Wertz (2000) found that absorption level (the ability to experience clients'feelings or stories), along with empathy, were both significant predictors for the PTSD symptoms reported by a sample of psychotherapists. Therapists who had high levels of phenomenological absorption in their client's stories had higher levels of reported symptoms; absorption in this study could be interpreted as the professional's degree of affective differentiation from the client, much like the objective component that accompanies empathy. These findings also suggest the need to explore emotional separation as a potential contributor to STS. Occupational Stress Occupational stress concerns the worker's strain that occurs in response to exposure and interaction with organizational stressors (Revicki, May, & Whitley, 1991) and is a major contributor to emotional

exhaustion and retention difficulties in employees, particularly in the health care environment (DoanWiggens, Zun, Cooper, Meyers, & Chen, 1995; Revicki & Gershon, 1996). Occupational stress has received some attention in the literature as a variable that contributes to the propensity for traumatic stress in professionals. One study that examined occupational stress in relation to trauma in social services professionals reported organizational factors as the strongest predictor of PTSD in child welfare workers as compared with the contributions of individual and incident factors (Regehr,Hemsworth,Leslie, Howe,& Chau,2004). An additional study found lack of work group support, role ambiguity, and poor supervision were positively correlated with occupational stress, which was, in turn, associated with greater general psychological distress in a sample of emergency medical technicians (Revicki & Gershon, 1996). Boudreaux and colleagues (1997) also found a positive association of occupational stress and psychological stress. These findings are consistent with those of a qualitative study that examined the impact of hospital work on social workers; the predominant themes that emerged from the data were occupational stress in the hospital environment (Dane & Chachkes,2001) and"both the cognitive and emotional reactions that the work triggers" (pp. 39-40). Such stressors often interfered with social workers' abilities to meet their own basic needs (that is, self-care), and participants unanimously related feelings of emotional depletion and of being overwhelmed. Participants reported changes in coping and emotional stress over time, which included increased intrusions of thoughts, trauma material, and patient concerns into personal time. They described feeling physically exhausted and emotionally drained in response to hearing and processing patients' stories and tragedies. Occupational stress appears to be a relevant variable both in this setting and for inclusion in this study. Social Support A review of the literature exploring social support in relation to trauma recovery found it to be a strong and critical component of adjustment (Lerias & Byrne, 2003). In a study of paramedics investigating PTSD symptoms, Regehr, Goldberg, Glancy, and Knott (2002) found that decreased perceived social support was significantly associated with increased use of mental health leave following exposure to a traumatic incident. Other studies showed a negative

BADGER, ROYSE, AND CRAIG / Hospital Social Workers and Indirect Trauma xposure

65

correlation between perceived social support and trauma-related symptoms and depression (Regehr, Hill, Knott, & Sault, 2003) and STS (Ortlepp & Friedman, 2002). The importance of social support in assisting social workers in hospital environments was also noted by Dane and Chachkes (2001);social support was highlighted as an aid in managing work and trauma-related stress during focus group discussions. Social support has been described as a viable coping method (Bride, 2004) and a factor that influences worker retention in stressful environments (Barak, Nissly, & Levin, 2001). Because of the consistency of the fmdings in the literature, social support was also included in this study as a predictive independent variable.
METHOD

This study explored the predictive contributions of empathy, emotional separation, occupational stress, and social support for producing STS in hospital social workers through the use of a descriptive, cross-sectional survey design and a sampling frame of social workers employed in one of five trauma centers located in the Midwest. All hospitals offered a range of medical and psychiatric services and collectively served both children and adults. Following receipt of approval or a waiver from the institutional review boards at all involved institutions, the investigator provided an explanation of the study at a staff meeting at each hospital.The hospital social work administrator extended the invitation to participate in the study and distributed the survey introductory letters and instruments at other team meetings. All social workers scheduled to work during data collection were invited to participate, yielding a possible sample size of 166. It was stressed that participation in the study was voluntary and anonymous, and survey measures did not request any personal identifiers. Surveys were placed in the hospital mailboxes of those eligible social workers absent from team meetings. Social workers who completed the surveys sealed them in the provided envelopes, which were either placed in centrally located sealed collection boxes or mailed in a postage-paid envelope to the investigator. Measures Questionnaire. A questionnaire was developed to collect information such as the following: years of social w^ork experience, years of hospital social work

experience, full-time or part-time status, area of practice (inpatient, emergency, or outpatient), and percentage of time spent working with pediatric and adult patients. Participants were not asked about gender (the sampling frame was mostly women), education level (few of the potential respondents were not master's prepared), or age (social work experience replaced this variable). Empathy. Empathy was defined as cognitive and affective dispositional empathy and was measured by the Interpersonal Reactivity Index (IRI) (Davis, 1983). The IRI is a 28-item, self-report measure representing cognitive and affective dispositional empathy. Davis tested the IRI for validity and found it to be a multidimensional measure of empathy. Cronbach's alpha coefficients ranged from .71 to .77 on the subscales, demonstrating adequate internal reliability (Davis).This study used the overall measure score as an indicator for the independent variable of empathy. The alpha level obtained for the overall scale was .75, which is acceptable for basic research.
Emotional Separation. Emotional separation was

defined as the degree to which one person is able to emotionally differentiate from another while being empathic (Corcoran, 1982) and was measured by the Maintenance of Emotional Separation Scale (Corcoran, 1983). Corcoran (1983) tested the sevenitem self-report scale for construct validity with acceptable results.The Cronbach's alpha coefficient for this study was .78, which is an indicator of acceptable internal consistency.
Occupational Stress. Occupational stress was defined

as the stress produced in response to exposure and interaction with work environment stressors and was measured by the Work-Related Strain Inventory (WRSI) (Revicki et al., 1991). This 18-item self-report scale was developed with an interdisciplinary sample of health care professionals, and tests for internal consistency produced an average Cronbach's alpha coefficient of .84 (Revicki et al.). The alpha coefficient for this study was .80, which is acceptable. The authors of the scale also tested it for convergence and discriminant validity by using comparisons with several measures of depression and burnout (Revicki et al.). Results showed that the WRSI measured a separate and independent construct.
Social Support. Social support was defmed as the

subjective assessment of the quality and sufficiency of social support reported by the hospital social

66

Health & Social Work VOLUME 33, NUMBER i

FEBRUARY 2008

workers and was measured by the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet, Dahlem, Zimet, & Farley, 1988). The MSPSS is a self-report measure consisting of 12 items and three subscales (Family, Friends, and Significant Other), and the overall measure score was used to operationalize social support in this study. The scale authors tested it for construct validity with good results. The Cronbach's alpha coefficient obtained for this study also demonstrated excellent internal reliability (a = .94). STS. STS was defined as the emotional and behavioral symptoms associated with work-related indirect trauma exposure and was measured by the Secondary Traumatic Stress Scale (STSS) (Bride, Robinson,Yegidis,& Figley, 2004) .The authors created this self-report scale with subscales measuring intrusion, avoidance, and arousal, aU considered to be symptoms correlated with exposure to indirect trauma (Bride et al., 2004).The authors of the scale tested it for reliability and obtained a Cronbach's alpha coefficient of .93 for the overall scale; convergent, discriminant, and factorial validity were also tested, with excellent results.The alpha coefficient obtained in this study duplicated that reported by the scale's authors in the original study (a = .93).
RESULTS

satisfactorily screened for multivariate outliers using a p < .001 criterion for Mahalanobis distance (Tabachnick & FideU, 2001). Associations among the independent variables used in the multivariate analysis were assessed for coUinearity, with satisfactory results. Descriptive Statistics A total of 121 surveys of a possible 166 were returned from aU hospitals included in the study, yielding a response rate of 73 percent. Study participants reported a range of six months to 43 years of social work experience, with an average of 15.8 years' {SD = 9.76) general experience. An average of 9.3 years {SD = 8.36) of this experience represented hospital social work. Sixty-nine percent of the social workers worked fuU-time as hospital social workers. The overall sample reported working with adult patients 73 percent of their work hours.The sample of social workers reported spending an average of 26 percent of their time in emergency departments, 45 percent of their time in inpatient units, 16 percent of their time in outpatient clinics, and approximately 10 percent of their time in a combination of areas or working in the community. Correlations of Independent Variables with STS Emotional separation (r = .63,/) < .001) and occupational stress (r = .60, p <.OO1) were strongly correlated with an increased likelihood of STS in hospital social workers. Perceived social support was weakly and negatively correlated with STS in this sample (r= .29,p < .001).Higher levels of empathy were weakly and positively associated with reported symptoms of STS (r = . 1 9,;J < .05). A greater number of years of experience in social work was weakly associated with fewer reported symptoms of STS (r = .'[9,p < .05), whereas the correlation between the years of experience in hospital social work and STS was not significant. Correlations among all variables are displayed in Table 1. Multivariate Analyses A stepwise regression analysis was conducted to explore the predictive ability of empathy, emotional separation, occupational stress, and social support on STS. These variables, in addition to the control variable ofyears worked in social work, were entered into the regression model.

Data Screening Variables in this study were screened for entry errors and outliers and tested for normal distribution through examination of skewness and kurtosis, yielding no problematic indexes. The independent variables had responses with distributions that approximated normality; the dependent variable, STS, had two outlier responses, but these were not considered problematic for bivariate analysis as the sample size was large enough to absorb their effects (Mertler &Vannatta, 2005). However, this variable underwent a square root transformation to create a new variable for use in multivariate analysis because this type of analysis is more sensitive to the presence of outliers (Tabachnick & FideU, 2000). The correlation matrix constructed for data analysis was examined for bivariate multicoUinearity, and no difficulties were discovered. All variables were found to be adequately homoscedastic and linear through the examination of scatter plots, histograms, and normal Q-Q plots (Mertler &Vannatta, 2005; Tabachnick & FideU, 2001). Variables were also

BADGER, ROYSE, AND CRAIG / Hospital Social Workers and Indirea Trauma Exposure

67

Table 1: Correlation Matrix of Independent Variables with Secondary Traumatic Stress

Variable
STS -.63** .60** -.29** .19* -.19* 1. Emotional separation -.50** .36** -.15 .06 2. Occupational stress -.43** .06 -.01 3. Social suppon 4. Empathy 5. Years in social work
*p < .05. p< .001.

-.02

-.05 -.07

Results of this analysis yielded three regression models, which are displayed in Table 2. Model 1 was significant [F(l, 110) = 10.151,p < .001], with emotional separation (|3 = -.626,;j < .001) explaining approximately 39 percent of the variance in STS (adjusted B} = .386). Model 2 was significant [F(2, 109) = 56.292, p < .001], with emotional separation (P = .433,/) < .001) and occupational stress (P = .2>92,p < .001) accounting for approximately 50 percent of the variance in STS (adjusted R} = .499). Model 3 was significant [F(3,108) = 41.151, p < .001], with emotional separation (P = -.418,p < .001), occupational stress (P = .396,p< .001),and years worked in social work (P = -.160,p = .017) explaining approximately 52 percent of the variance (adjusted R^ = .52).Empathy and social support were not significant in this regression analysis. Occupational stress and emotional separation (the two strongly significant variables in the regression model) were further analyzed to investigate whether the reported findings were a result of a statistical interaction between the two variables rather than representative of a main effect. STS was regressed

onto the centered variable of emotional separation and occupational stress, the results of which were not statistically significant [t( 117) = -.629,p= .531]. Social support has also been examined in other studies as a potential moderator for STS.Therefore, additional analysis was conducted to examine for interaction between social support and emotional separation and between social support and occupational stress. AH variables were centered, and STS was regressed on the resulting interaction variables. Neither social support and emotional separation [t(117) = .333, p = .740], nor social support and occupational stress [^(117) = -1.3, p = .197], were significant in this equation.These results suggest that the findings reported do represent main effects. Study Limitations The nature of this study limits generalizability, and causality cannot be assumed because of its crosssectional design.The self-selection sampling method has the potential of selection bias. Data coOection instruments used self-report, which is vulnerable to distortion and memory limitations of respondents. Empathy performed weakly in this study, raising concern that the data collection instrument may have lacked sensitivity in detecting this construct. Because of time constraints and the need to limit the variables included in the study, only a portion of potential predictors were examined. DISCUSSION Empathy, Emotional Separation, and STS Empathy has been theoretically assigned an important role as a conduit for STS reactions (Figley, 1995, 2002; Pearlman & Mac Ian, 1995). However, dispositional empathy lacked explanatory potency

Table 2: Regression Results: Predictors of Secondary Traumatic Stress in Hospital Social Workers
Model
1 (adjusted I? = .39) Emotional separation 2 (adjusted K' = .49) Emotional separation Occupational stress 3 (adjusted R^ = .53) Emotional separation Occupational stress Years in social work -.121 -.084 .047 -.081 .047
-.016

SE
.014

P
-.626

t
-8.41

P
<.OO1

Bivariatilr
-.626 -.433 .605 -.626 .605 -.204

.015 .009

-.433

-5.61

<.OO1 <.OO1

.392

5.08

.015 .009 .007

-.418

-5.52

<.OO1 <.OO1

.396
-.160

5.24
-2.42

.017

68

Health & Social Work VOLUME 33, NUMBER i

FEBRUARY 2008

in this study. Instead, these findings suggest that emotional separation, or the component of empathy representing differentiation from the patient, may more precisely represent professional vulnerability in the development of STS, which is consistent with those of Corcoran (1989), who found emotional separation rather than empathy to be significantly associated with burnout. Emotional separation was a very powerful variable in the regression model; however, on the basis of this study it cannot be determined whether this finding represents a protective characteristic that preempts STS or whether emotional separation is a by-product of incurring STS. It is possible that social workers attempt to modulate the impact of exposure to patient trauma by emotionaUy distancing and numbing reactively (Clark & Gioro, 1998). StiU, regardless of the order of events, emotional separation seems to be associated with a reduction in STS; it seems that the protective mechanism and regulatory function that emotional separation may provide may assist with maintaining a balance and centeredness when working with patient trauma. The danger of it occurring as a reaction to exposure rather than preemptively is that emotional separation could compromise compassion and empathy in interactions with the patient. Therefore, teaching social workers how to differentiate from their patients and maintain the balance of emotional distance and empathy at the onset of their work may help with the provision of caring interventions and may provide protection for hospital social workers. It is important for social workers to develop selfawareness, to construct professional boundaries, and to learn to establish a therapeutic connection with patients that is grounded in objectivity.
Occupational Stress and STS

It is important for social workers to develop self-awareness, to construct professional boundaries, and to learn to establish a therapeutic connection with patients that is grounded in objectivity.

resources, which could negatively affect their ability to adequately emotionaUy separate.This supposition is supported by the inverse correlation between occupational stress and emotional separation (r = .497, jj < .001) found in this study. The significance and strength of occupational stress in explaining the variance in STS suggests the need for the conditions of the hospital social workers' work environments to be evaluated. Environmental characteristics such as high volume and homogeneity of workload, fear and personal safety concerns, lack of education about the means to minimize STS, hospital administrators' lack of awareness of such risks, and hospital cultures that are unsupportive of processing exposure or practicing self-care activities aU increase social workers' vulnerability for stress reactions (BeU, Kulkarni, & Dalton, 2003). Reducing this stress appears important to protect hospital social workers.
Social Support and STS

Occupational stress was found to be a significant predictor of STS in this sample, a finding consistent with those of other studies. Workers already depleted and weakened by stress in their work environment may react with greater intensity to trauma exposure (Regehr et al., 2004). Although no statistical interaction was found between occupational stress and emotional separation, the trend of the data suggested higher levels of occupational stress were associated with lower levels of emotional separation. It appears possible that high levels of occupational stress may contribute to subsequent depletion of social workers' internal

Despite its prominence in existing literature, social support was not a significant predictor of STS in this analysis. This finding may be associated with how respondents use support. It is also possible that the characteristics and structure of health care facilities create a unique and powerful set of organizational stressors that may be difficult to offset with social support.The organization's response to stress management may be just as or more important than the assistance obtained from a social support network in decreasing occupational stress and thereby predicting STS. These findings introduce a cautionary note: It appears to be inaccurate to assume that hospital social workers with high levels of perceived social support are inoculated from STS; they are stiU in need of interventions to prevent and minimize STS reactions. Implications The nature of hospital social work brings social workers in contact with the tragedies of others on a

BADGER, ROYSE, AND CRAIG / Hospital Social Workers and Indirect Trauma Exposure

69

daily basis. Building an effective therapeutic alliance and providing high-quality services requires social workers to be emotionally available and responsive to patients. However, social workers are faced with the challenge of walking an internal tightrope between empathic connection with patients and families and emotional separation. Social workers need to find ways to proactively differentiate and separate enough from the patient's experience to self-protect, while continuing to engage with compassion. The practices of ongoing self-assessment and continued development of self-awareness are indicated in response to this dilemma (Clark & Gioro, 1998). It may also be helpful to increase the amount of clinical supervision and therapeutic debriefmg as opposed to the use of administrative supervision. The findings also suggest that hospital social workers ought to approach their work with a conscious commitment to monitor and tend to their own well-being despite the demands of the work and the environment. Suggested preservation methods include maintaining an awareness of the exposure to trauma inherent in the work and its potential impact and methods by which such stress reactions can be recognized and mitigated (Clark & Gioro, 1998). Establishing and regularly using forums in which processing and discussion can occur may be helpful (Bell et al., 2003; Clark & Gioro, 1998; Dane, 2000). Also, tending to basic self-care, such as physically caring for one s self, and maintaining a balance in life activities are important for the prevention of STS and efforts in self-preservation (Yassen, 1995). Social workers need to communicate to hospital administrators and policymakers the impact of their exposure to STS and the hospital environment on their well-being and quality of work (Randolph & Stamm, 1999). Social workers can advocate for themselves by asking the organization to provide fuU disclosure of risks of indirect trauma exposure during the hiring process (Munroe, 1999), by asking for the resources to minimize such risk, and by requesting that administrators assess the structure and characteristics of the work environment itself for contributory risk factors (Bell et al., 2003). Hospital social workers need to recognize that hospital administrators are removed from the social workers' day-to-day experiences and may not realize the impact of the work stress.Therefore, it is important for administrators to hear from social workers

about STS and the impact that their decisions and policies have on service quality and personal wellbeing so that management has the opportunity to be responsive to their employees. Organizations have a responsibility to minimize the effects of indirect trauma exposure. Continued research is necessary to further our understanding of the risks that accompany hospital social work. Preparing social workers to expect indirect trauma exposure and to manage their reactions is important; preservation of their weD-being is necessary to support the quality of their work and longevity in the social work profession. \iSmi
REFERENCES
Barak, M. M., Nissly,J.A., & Levin,A. (2001). Antecedents to retention and turnover among child welfare, social work, and other human service employees: What can we learn from past research? A review and metaanalysis. Social Service Review, 15, 625661. Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society, 84, 463-471. Boudreaux, E., Mandry, C , & Brandey, P.J. (1997). Stress, job satisfaction, coping, and psychological distress among emergency medical technicians. Prehospital and Disaster Medicine, 12, 242-249. Bride, B.E. (2004).The impact of providing psychosocial services to traumatized populations. Stress, Trauma, and Crisis, 1, 29-46. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52, i>i-l<i. Bride, B. E., Robinson, M. M.,Yegidis, B., & Figley, C. (2004). Development and validation of the Secondary Traumatic Stress Scale. Research on Social Work Practice, 14, 27-35. Clark, M. L., & Gioro, S. (1998). Nurses, indirect trauma, and prevention. Image: The Journal of Nursing Scholarship, 30, 85-87. Collins, S., & Long, A. (2003). Working with the psychological effects of trauma: Consequences for mental health-care workers. A literature leview.Journal of Psychiatric and Mental Health Nursing, 10, 417-424. Corcoran, K.J. (1982). An exploratory investigation into selfother differentiation: Empirical evidence for a monistic perspective on empathy. Psychotherapy: Theory, Research and Practice, 19, 63-68. Corcoran, K.J. (1983). Emotional separation and empathy. Journal of Clinical Psychology, 39, 667671. Corcoran, K.J. (1989). Interpersonal stress and burnout: Unraveling the role of empathy. Jowraa/ of Social Behavior, 4, 141-144. Cunningham, M. (2003). Impact of trauma work on social work clinicians: Empirical fmdings. Social Work, 48, 451-459. Dane, B. (2000). Child welfare workers: An innovative approach for interacting with secondary trauma.Jowma/ of Social Work Education, 36, 27-39. Dane, B., & Chachkes,E. (2001). The cost of caring for patients with an illness: Contagion to the social worker. SoeialWork in Health Care, 33, 31-50. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach.
Journal of Personality and Social Psychology, 44, 113126.

Doan-Wiggens, L., Zun, L., Cooper, M. A., Meyers, D. L., & Chen, E. H. (1995). Practice satisfaction, occupational

70

Health & SoeialWork VOLUME 33, NUMBER I

FEBRUARY 2008

stress, and attrition of emergency physicians. Academic Inventory among health professionals. Behavioral Emergency Medicine, 2, 556563. Medicine, 17, 111-120. Figley, C. (1995). Compassion fatigue as secondary Tabachnick, B. G., & Fidell, L. S. (2000). Using multivariate traumatic stress: An overview. In C. Figley (Ed.), statistics (4th ed.). Needham Heights, MA: AUyn & Compassion fatigue: Coping with secondary traumatic stress Bacon. disorder in those who treat the traumatized (pp. 120). Wertz, C. A. (2000). Vicarious traumatization:Tlw relationship NewYork: Brunner/Mazel. of absorption, emotional empathy and exposure to traumaFigley, C. (1999). Compassion fatigue:Toward a new tized clients to PTSD symptom-tike behavior in therapists. understanding of the costs of caring. In B. H. Stamm Unpublished doctoral dissertation, Clark University, (Ed.), Secondary traumatic stress: Self-care issues for Worcester, MA. clinicians, researchers, & educators (pp. 328). Baltimore: Williams, C. (1989). Empathy and burnout in male and Sidran Press. female helping professionals. Research in Nursing and Figley, C. (2002). Compassion fatigue: Psychotherapists' Health, 12, 169-178. chronic lack of self-care. Psychotherapy in Practice, 58, Wilson,J. P, & Lindy,J. D. (1999). Empathic strain and 1433-1441. countertransference. In M.J. Horowitz (Ed.), Essential Gregorian, C. (2005). A career in hospital social work: Do papers on posttraumatic stress disorder (pp. 518544). you have what it takes? Social Work in Health Care, NewYork: NewYork University Press. 40(3), 1-14. Yassen,J. (1995). Preventing secondary traumatic stress Gross, P. R. (1994). A pilot study of the contribution to disorder. In C. Figley (Ed.), Compassion fatigue: hurnout in Salvation Army Officers. Work & Stress, Coping with secondary traumatic stress disorder in those 8, 68-74. who treat the traumatized (pp.1178-1208). NewYork: Jenkins, S. R., & Baird, S. (2002). Secondary traumatic Brunner/Mazel. stress and vicarious traumatization: A validation study. Zimet, G. D., Dahlem, N.W., Zimet, S. G., & Farley, G. K. International Society for Traumatic Stress Studies, 15, (1988).The Multidimensional Scale of Perceived 423-432. Social Support. JoMrna/ of Personality Assessment, 52, Lerias, D., & Byrne, M. K. (2003).Vicarious traumatiza30-41. tion: Symptoms and predictors. Stress and Health, 19, 129-138. Karen Badger, PhD, is assistant professor, David Royse, McCann, I. L., & Pearlman, L. A. (1990).Vicarious PhD, is professor, and Carlton Craig, PhD, is assistant protraumatization: A framework for understanding the fessor. College of Social Work, University of Kentucky. Address psychological effects of working with victims._/0Hma/ of Traumatic Stress, 3, 131-149. all correspondence concerning this article to Dr. Karen Badger, Mertler, C.A.,&Vannatta, R. A. (2005). Advanced and multiCollege of Social Work, University of Kentucky, 625 Patterson variate statistical methods. Glendale, CA: Pyrczak. Office Tower, Uxington, KY 40506-0027; e-mail: kbadger@ Munroe,J. F. (1999). Ethical issues associated with secondary trauma in therapists. In B. H. Stamm (Ed.), uky.edu. Secondary traumatic stress: Self-care for clinicians, researchers, & educators (pp. 211229). Baltimore: Sidran Press. Original manuscript received Juiy 18, 2006 Finai revision received March 27, 2007 Ortlepp, K., & Friedman, M. (2002). Prevalence and corAccepted August 9, 2007 relates of secondary traumatic stress in workplace lay trauma counselors.Jowma/ ofTraumatic Stress, 15, 213-222. 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, 558-565. Pockett, R. (2003). Staying in hospital social work. Social Work in Health Care, 36(3), 1-24. Randolph,J. M., & Stamm, B. H. (1999). Maximizing human capital: Moderating secondary traumatic stress through administrative and policy action. In B. H. Stamm, (Ed.), Secondary traumatic stress: Self-care for clinicians, researchers, & educators (pp. 277-292). Baltimore: Sidran Press. Regehr, C , Goldberg, G., Glancy, G. D., & Knott,T. (2002). Posttraumatic symptoms and disability in paramedics. Canadian Journal of Psychiatry, 47, 953-959. Regehr, C , Hemsworth, D., Leslie, B., Howe, P, & Chau, S. (2004). Predictors of posttraumatic distress in child welfare workers: A linear structural model equation. Children and Youth Services Review, 26, 331-346. Regehr, C , HiU,J., Knott,X, & Sault, B. (2003). Social support, self-eff^icacy and trauma in new recruits and experienced firefighters. Stress and Health, 19, 189-193. Revicki, D. A., & Gershon, R.R.M. (1996). Work-related stress and psychological distress in emergency medical technicians, jowraa/ of Occupational Health Psychology, 1, 391-396. Revicki, D. A., May, H.J., & Whitley,T.W. (1991). Rehabihty and validity of the Work-Related Strain

BADGER, ROYSE, AND CRAIG / Hospital Social Workers and Indirect Trauma Exposure

71