Walker and avant theory analysis

Crit Care Nurs Q Vol. 35, No. 4, pp. 388–395 Copyright c© 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Concept Analysis Compassion Fatigue and Effects Upon Critical Care Nurses

Belinda Jenkins, BSN, RN, CEN; Nancy A. Warren, PhD, RN

Walker and Avant’s method of concept analysis was used to delve into the initial understanding of compassion fatigue, a relatively new concept being explored with critical care nurses and other health care professionals. The term was originally used in 1992 involving research exploring burnout experienced by critical care nurses when a trend emerged where nurses appeared to have lost their “ability to nurture.” The term has since been used synonymously with secondary traumatic stress disorder. Two important goals exist for this article: First, theoretically to conduct a concept analysis of compassion fatigue, thereby providing information for critical care nurses to understand the concept as a universal human experience. Second, from a caring perspective, identifying the effects related to critical care nurses provides an opportunity to address physical and somatic consequences of compassion fatigue that will ultimately become important to nursing practice, education, and research. Key words: burnout, compassion fatigue, secondary traumatic stress

T HE PROCESS that will be followed withinthis article is the model developed and implemented by Walker and Avant.1 Eight stages are outlined within the model, and a brief explanation is provided of each. The first stage of the model is to select a concept. Con- cept selection is very important and should be one of interest to the authors or related to the actual work of the authors. This concept should be manageable yet not too broad. Sec- ond, the authors should determine the aims or purposes of the analysis. This section should answer the question why is this concept im- portant to the authors. Third, identification of the uses of the concept that you can discover

Author Affiliations: Belmont University, Nashville, Tennessee (Ms Jenkins); and Department of Nursing, University of Tennessee, Martin (Dr Warren).

The authors have disclosed that they have no signif- icant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Nancy A. Warren, PhD, RN, De- partment of Nursing, University of Tennessee, 136 H Gooch Hall, Martin, TN 38238 (nwarren@utm.edu or belinda.jenkins@pop.belmont.edu).

DOI: 10.1097/CNQ.0b013e318268fe09

in the literature supports the definition of the concept. During this stage, through available literature, dictionaries, thesauruses, and col- leagues, the authors will identify possible uses of the concept. The review of literature will provide the evidence-based foundation for the analysis. During the fourth stage, the defin- ing attributes will be determined. Through the literature reviews regarding the concept, all the similar characteristics emerge. Fifth, a model case is identified. The model case pro- vides the reader an example of the defining at- tributes of the concept; this can be provided in a borderline, related, contrary, invented, or illegitimate case. These are provided in the sixth stage. The seventh stage includes identification of the antecedents and conse- quences. Antecedents are defined by Walker and Avant as those events or incidents that must occur or take place prior to the occur- rence of the concept, and consequences are defined as those events or incidents that occur as a result of the occurrence of the concept. The last stage defines the empirical referents, which are defined as classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself. The goal of this article was

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Compassion Fatigue 389

2-fold: Theoretically, to conduct a concept analysis of compassion fatigue, thereby pro- viding an understanding of the concept as a universal human experience and, from a car- ing perspective, identifying the effects related to critical care nurses by addressing physical and somatic consequences of compassion fa- tigue that will ultimately become important to nursing practice, education, and research. Perhaps, an ongoing dialogue regarding com- passion fatigue and the effects upon nurses in the critical care unit may facilitate actions to identify and prevent compassion fatigue.

PERSONAL AIMS OF CONCEPT ANALYSIS

Reflecting upon the experiences of the au- thors personally gained throughout our nurs- ing career, we believe that we have felt the effects of compassion fatigue and witnessed nursing coworkers showing the effects as well. Past nursing experiences have included time in high-stress environments, where mo- ments in time were crucial, and decisions made immediately affected the outcome of the patient—life or death. Past intensive care unit experiences where seeing uncooperative patients, interstaff conflicts, dying patients, and those patients affected by massive trauma on a daily basis lead to those effects. Over time, fatigue takes a toll upon critical care nurses. The outcomes have involved sleepless nights and still visualizing the faces of the in- jured or dead when trying to sleep, particu- larly if the deceased were young and in the prime of life, or worse yet, a young child. But as one sees those faces of the injured, not in a haunting sense, one reviews one’s perfor- mance and wonders what more could have been done. What could have been done dif- ferently, and would different actions have led to a difference in the outcome of the patient becomes a consuming question. We have also felt emotionally and physically drained after a 12-hour work shift and still tired before arriv- ing at work the next night after resting all day. While feeling and living these emotions, a con- cept to identify with the emotions was nonex- istent. As health care professionals, while tak-

ing care of others, critical care nurses and health care staff tend to lose sight of taking care of themselves. In exploring compassion fatigue and the potential affect upon critical care nurses, perhaps an enhanced awareness and understanding of compassion fatigue can be gained or at least ignite the conversations of others who have had similar experiences.

LITERATURE REVIEW

Taber’s dictionary defines compassion fa- tigue as “cynicism, emotional exhaustion or self-centeredness occurring in a health care professional previously dedicated to his or her work and clients2(p499); compassion as deep awareness of the pain and suffering of oth- ers: empathy; and fatigue as an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level, and as the condition of an organ or tissue in which its response to stimulation is reduced or lost as a result of overactivity. This definition can cross the lines for many disci- plines and be used to describe compassion.

A phrase that does loosely describe compas- sion fatigue is feeling the pain of the world, with German philosophers addressing this state as “weltschmertz.”3 While compassion fatigue has risen in nursing research only re- cently, nurses have felt the concept world- wide. Some researchers noted that persons who work with the suffering end up suffer- ing themselves, particularly when working with the suffering over time.4,5 While com- passion fatigue is noted more in the litera- ture relating to health care workers, it crosses over into other disciplines. The concept has been addressed in social workers, paramedics, law enforcement personnel, and lawyers. A lack of empirical studies was noted; however, the “clinical” law literature has raised aware- ness of the responses of attorneys working with difficult or traumatized clients who be- gan to feel countertransference and identifica- tion with the victims who were being repre- sented. Increased awareness of this concept has prompted the need for additional train- ing in law schools to assist professionals to

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390 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2012

prepare for the intense, face-to-face, and highly personal relationships that evolve from the attorney-client relationships. Police offi- cers also reported a greater number of psycho- logical distress and posttraumatic stress symp- toms than mental health care professionals.3-6

Law enforcement officers face stress in vari- ous ways, from working shift work to the na- ture of the job itself as in continuous exposure to violence and suffering. Figley4 propounded that emergency responders and crisis work- ers were at great risk for compassion fatigue. Emergency workers and critical care nurses absorbed the traumatic stress of the victims who were being assisted, particularly if the outcome of the nursing interventions still re- sulted in death. Furthermore, the nurse’s pri- mary focus is on preserving the life of the patient at all costs, so addressing the ensu- ing reactions to death and the reaction of the family members may be distressing and at op- posite ends of the spectrum of preservation of life at all costs. Critical care nurses may suffer their own grief at losing a patient after giv- ing all of their self to the preservation of life, yet family members may require communica- tions regarding critical interventions provided by nurses and supporting health care work- ers. While family members are stressed by the critical care environment and fear related to the many tubes and monitors, the critical care nurses may be stressed and fatigued by family members’ presence and ensuing questions re- garding what happened. Because the nurses are so involved with the physical care of the patient, they frequently have inadequate time to response to family members’ emotional needs, thus adding more stress to a complex situation. Family members may have unrealis- tic goals and expectations of the critical care nurses and assign blame tacitly or overtly to the nurses for the loss of their loved one while in the trust of the nurses.

Compassion fatigue has been described as a natural consequence of caring between 2 people, one who has been traumatized (the critical care patient) and the other who is affected by the first’s traumatic experience (the critical care nurse). It can have a sud-

den onset compared with burnout, which is a gradual progression caused by repeated ex- posure to chronic stressors. Caregivers tend to focus most of the attention to the per- son who is directly involved in the incident and fail to pay attention to their own needs. Compassion fatigue may change the personal and professional lives of the most caring of health care workers, social workers, and per- sonal support workers alike. These changes were noted as difficulty concentrating, intru- sive imagery, loss of hope, exhaustion, and irritability, which many critical nurses seem to have experienced.7,8

In review of the literature, defining charac- teristics emerge repeatedly that describe com- passion fatigue. Dr Charles Figley, PhD, has studied the effects of compassion fatigue. In his studies, Dr Figley found many common characteristics that occur prior to compas- sion fatigue. In 2001, Figley developed an al- gorithm for compassion fatigue, which flows from left to right when printed. The algorithm is called the compassion fatigue process, with the left side of the chart presenting the care- giver exposed to suffering, empathic ability, and concern for the patients. These 3 charac- teristics lead the nurse to respond; however, the critical care nurse may feel detachment or, conversely, feel a sense of satisfaction with the care provided. Over time, this leads to a residual compassion stress. If this continues, then the repeated exposure can possibly lead to the caregiver feeling compassion fatigue from prolonged exposure to suffering and de- mands of caring for another person.

Whatever discipline, whether a critical care nurse, physician, social worker, emer- gency responder, law enforcement officer, or lawyer, the defining antecedent that is most evident is the continuous and repeated expo- sure to stressors. This repeated exposure can lead to emotional exhaustion. Working long hours, with gradual results and exposure to sensitive information can have an emotional toll on the caregiver.8,9 When caregivers ex- perience compassion fatigue, the end result can also be a loss of empathy and a deper- sonalization. Depersonalization refers to the

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process where the client is viewed as less than human. In a national study of persons experiencing compassion fatigue, one-third reported having experienced high levels of depersonalization. Whenever a person is ex- periencing depersonalization, a dramatically increased risk of incorrectly interpreting in- formation that is disclosed to the caregiver becomes apparent. Often when compassion fatigue is experienced, a change in ethical and clinical values appears. For critical care nurses, evidence of compassion fatigue can be lack of appropriate documentation in the chart, or noting that the patients’ best inter- ests are not readily apparent in the nursing care. Negative feelings toward the patient can lead to substandardization of care.

Compassion fatigue is a progressive and fi- nal end result that evolves over time. Empir- ical referents that are present after the nurse has prolonged, and continuous and intense, contact with patients will experience symp- toms both of mental and physical traits. The mental symptoms include feelings of burnout, absence of energy, accident proneness, and emotional breakdown feelings.9,10 Emotion- ally, the person with compassion fatigue will be irritable, emotionally overwhelmed, with desensitization and lack of enthusiasm for pa- tient care. The physical symptoms can in- clude weight loss/gain, loss of strength, re- duce output, diminished performance, loss of endurance, and an increasing in physical com- plaints such as stomach pains and headaches. Spiritually, the person with compassion fa- tigue will experience a lack of spiritual aware- ness or lethargy.

RELATED CONCEPTS

In the literature review, related concepts were often noted and should be presented within this article. Along with compassion fa- tigue, a term that is often used interchange- ably is secondary traumatic stress, which is secondary traumatic stress as the result of knowledge about a traumatizing event expe- rienced by another and the subsequent stress resulting from helping or wanting to help

the traumatized person. Secondary traumatic stress may be nearly identical to posttrau- matic stress disorder, where secondary trau- matic stress resulted from effects happening to those emotionally affected by the trauma of another person; posttraumatic stress disor- der only exists when the person is directly affected by trauma and by being in harm’s way.11,12

Burnout is another closely related concept that is often described within the same lit- erature as compassion fatigue. Shakespeare mentions burnout within the lines of the play The Passionate Pilgrim, written in 1599, as demonstrated by the words “She burn’d with love, as straw with fire flameth . . . . She burn’d out love, as soon as straw outbur- neth . . . .”13(p159) Burnout has been described as a prolonged response to chronic emotional and interpersonal stressors on the job and de- scribed with the term “burnout,” which en- compasses the physical, emotional, and men- tal exhaustion caused by long-term involve- ment in emotionally demanding situations. Burnout develops gradually over time and pro- gressively worsens, with symptoms includ- ing fatigue, illness, disillusionment, cynicism, anger, difficulty sleeping, and a sense of help- lessness and/ or hopelessness.

Emotional contagion is defined as an af- fective process in which an individual observ- ing another person experiences emotional re- sponses parallel to that person’s actual or anticipated emotion.4,13 “Vicarious trauma- tization” is a term closely related and of- ten used interchangeably with compassion fa- tigue. The construct of vicarious trauma states that the psychological distress that occurs over prolonged exposure to trauma actually changes the cognitive aspect of perspective of the caregiver related to such life issues as in- timacy, trust, safety, self-esteem, and control. Nurses experiencing vicarious traumatization no longer feel grounded in the world around them; they begin to question the meaning of life, risk losing a sense of purpose, and hope- lessness may ensue.

The above-mentioned related concepts were found in the literature and used

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392 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2012

interchangeably. The concepts are all used to across a continuum to address the effects upon the critical care nurses as well as the persons receiving the care.

DEFINING ATTRIBUTES

The repeated characteristics that occur de- scribing critical care nurses and compassion fatigue include the following attributes: • Depersonalization • Reduced output/endurance/diminished

performance • Loss of empathy • Poor judgment

ANTECEDENTS AND CONSEQUENCES

Antecedents were specifically defined as events or incidents that must occur or be in place prior to the occurrence of the concept.1

Antecedents that have been identified reflec- tive of critical care nurses and compassion fatigue include, but are not limited to: • Caregiver exposed to suffering • Continuous and intense contact with pa-

tients • High-stress exposure • High use of self within one’s work

Consequences as events or incidents that occur as a result of the occurrence of the con- cept are defined.1 The following were identi- fied as consequences directly resulting from compassion fatigue that effects critical care nurses: • Loss of empathy • Increase loss of work days due to physical

complaints, stomach pains, headaches • Weight gain/loss • Accident proneness • Emotional breakdown

MODEL CASE

The following is a model case regarding a critical care nurse that contains all the at- tributes:

Nurse A works in a critical care unit of a medium- volume clientele hospital. The critical care unit on average admits 5 to 6 patients a day and for the local area is known for the trauma care provided. Nurse A works as the weekend charge nurse and is currently working her sixth 12-hour shift due to a colleague who is currently out for medical leave and desperately needing to supplement her income. While the critical care is very busy, nurse A is attentive to her patients’ needs and serves each patient with her skills and attends to the emotional and physical needs of each. Three nights ago dur- ing nurse A’s shift, a motor vehicle collision (MVC) with multiple trauma victims arrived. Nurse A, be- ing the charge nurse, assisted in each of the unit rooms and provided additional support to the nurs- ing staff. The victims included a mother and her 3 younger children ranging in ages from 13 to 19 years. The 2 older children were from out of town and home from college for a visit with their mother and younger sibling. The mother and the 2 older children died, and the youngest child was in crit- ical condition and later sent by helicopter to an area trauma center. Nurse A listened to the younger child ask about the mother and about the 2 older siblings. Nurse A was empathetic to the questions and was feeling sadness and concern for the oth- ers involved in the MVC. Since that night, nurse A has had trouble sleeping, having nightmares, and replaying the night over in her head. Nurse A does not call her patients by name anymore, she refers to them as “belly pain in room 3” or as “drunk guy in room 4,” and she makes cynical remarks about her patients in the nurse’s station. Since that night, her work performance has been less than optimal. Nurse A has been making charting mistakes, writ- ing on the wrong chart, and caught herself before making a critical medication error. When assessing a patient during the early morning, nurse A told a 35-year-old patient who was having a myocardial infarction that he probably had indigestion from food slipped in by a family member. When she is off work, she cares for her elderly mother and is currently raising her grandchildren after taking custody from their mother who cannot stop her current drug habit.

The attributes in the aforementioned model case evidenced by nurse A represent traits of experiencing depersonalization. She is no longer calling her patients by their name but by “belly pain in room 3 or drunk guy in room 4.” She is working her sixth 12-hour

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Compassion Fatigue 393

shift, so her endurance levels are subpar. Her work performance is no longer optimal, as ev- idenced by charting mistakes and a near miss on a medication error. Nurse A is making poor judgment skills by dismissing the chest pain as indigestion.

The following is a borderline case, with an explanation to follow:

Nurse B also works in the same critical care unit as a relief charge nurse. Nurse B has worked for the past 4 nights and was working when the above- mentioned MVC case came in. Nurse B took care of the 13-year-old young teen who was flown to the area level 1 trauma center. Nurse B was very atten- tive in her care of the young patient and assisted the flight crew upon arrival. Nurse B has been off for 3 days now and is returning to work. Nurse B has stated that she is still tired and does not feel well and has a headache. She also states that she has not been sleeping well since the last night she worked. Upon arrival of her shift, she has taken re- port from the day shift nurse, and all her rooms are full. Nurse B’s charge nurse asks for report on her patients and she just says “all the same, just a differ- ent day.” Nurse B sticks her head in each room, not addressing the patient’s needs, and rolls her eyes when a family member wants to talk to her about her loved one. Nurse B then takes all her patients charts and finds a quiet area to review and evalu- ate what still needs to be done. Nurse B realized that some of her patients were missing laboratory work, and intravenous antibiotics have not been hung as of yet. Nurse B knows by hospital protocol that intravenous antibiotics must be hung within 4 hours of the doctor’s order, and she has less than 1 hour to get the medications hung. Nurse B settles in for the night and proceeds with her patient care.

This is a borderline case in that nurse B is experiencing depersonalization, by not giv- ing the report on each of her patient, just states “ all the same, just a different day.” Nurse B is performing at subpar work perfor- mance by not addressing her patients’ needs and by rolling her eyes at patient family mem- bers. Nurse B is not experiencing bad judg- ment skills or making mistakes in providing care. Not making mistakes is what defines this model as a borderline case.

The following is an example of a contrary case and will be discussed after the example:

Nurse C also works in the same critical care unit and works as a staff nurse. She has worked there for the past year after graduating from nursing school. Nurse C is exposed to the same working conditions but only works her three 12-hour shifts per week as scheduled. She is juggling the same workload and institutional requirements as nurse A but does not have the responsibilities of a charge nurse. Nurse C loves her job and feels tremendous satisfaction each day when she goes home. Nurse C feels a sense of rewardment, knowing that she has helped each of her patients improve in some way. Nurse C has a smile on her face; she calls each patient by his or her name and addresses him or her when she enters into the room. She does not mind spending extra time talking with family member present and writes down phone numbers and is willing to call family members if the need should arise. Nurse C has a connection with her patients, and she takes pride in sharing the pain that her patients have but sparks feelings of kindness, tenderness, and gen- tleness along with understanding of the patients’ direct needs. Nurse C feels an overwhelming sense of reward when a patient suffers less because of the selfless care she has provided during her shift. Nurse C feels that any negative experiences are far less than the positive experiences she has at work and feels a tremendous satisfaction with her job and looks forward to caring for the next patient.

While nurse C has the same repeated expo- sure as the model case, she is flourishing in the same environment. She is having mean- ingful experiences with her patients and fam- ily members and looks forward to assisting the next patient. In compassion fatigue, the nurses will gradually distance themselves; this is not the case in the contrary example pro- vided.

EMPIRICAL REFERENTS

In Dr Figley’s research, the lack of a mea- surement instrument for compassion fatigue became readily apparent and from that re- search a scale was developed. Originally, this scale was called the Compassion Fatigue Stress Test, but with noted close proximity to other concepts, a revision of the scale was de- veloped. Several revisions have taken place but the Professional Quality of Life Scale,

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394 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2012

Version 5 (ProQOL 5), is the final and most current scale. The ProQOL 5 is a questionnaire that includes 30 questions with the answers scaled to respond: 0 equals never and 5 equals very often. The questions in the ProQOL 5 range from “I believe I can make a difference in my work” to “because of my [nursing], I have felt ‘on edge’ on certain things.” The ProQOL 5 rates the participant as either com- passion satisfaction or compassion fatigue.10

All of the research indicated the importance of determining those critical care nurses who are vulnerable to compassion fatigue and to quickly address the symptoms. Knowing who is vulnerable can lead to preventing compas- sion fatigue among the critical care nurses.

NURSING IMPLICATIONS FOR CRITICAL CARE NURSES

Prolonged exposure that consists of contin- uous and intense contact with patients expe- riencing life or death trauma, serious illnesses, and sudden critical events in the critical care unit can lead to compassion fatigue. The criti- cal events require nurses to stay on guard and perform at optimal levels continuously for a minimum of 12-hour shifts and ensuring that patients have the best outcomes becomes a cumulative process. If the stress that follows is not addressed appropriately, then the nurses may evolve to a state where the results are be- yond the nurses’ endurance level, the energy expended has surpassed the restored reserve, and recovery power is lost.

Research clearly supports that working with patients who are in pain, suffering, at the end of life, or may have been coded and expired may take an added toll on the physical and mental health of nurses. The experiences of critical care nurses who have had a patient expire in the critical care unit may differ from the experiences of nurse who had a patient expire in other hospital settings.14 Unlike the typical medical-surgical settings, critical care unit nurses may experience death from se- vere, sudden, traumatic events, which require quick, yet thorough, interventions. Initially, family members may not be allowed to remain

in the room with the seriously injured patient. When allowed to visit, family members may see more sophisticated, intimidating equip- ment connected to the patient than would be seen in other areas of the hospital. Family members may be reluctant to touch or com- municate verbally with the patient because of the many tubes and monitors. Nurses, on the contrary, have the difficult task of overseeing the patient and equipment, while providing communications to the family. While the fam- ily members are stressed, the nurse maybe just as stressed, or more so, because of interacting with both the patient and family. Given the complexity of factors that may influence the outcome of the patient, especially if the out- come is death, nurses may feel compassion fatigue. While it is unrealistic to expect criti- cal care nurses to address every aspect of the family needs, when death occurs as the out- come, nurses may begin to respond by com- passion fatigue and return to the old nagging questions of “ What could I have done better?” Nurses began to second-guess their responses or become hypercritical of the care provided.

Native American’s have a saying that each time you heal someone, you give away a piece of yourself until, at some point, you will re- quire healing.13 When compassion fatigue is apparent in the critical care unit, chronic ab- senteeism, high workers’ compensation costs, high turnover rates, and interpersonal con- flicts between nurses are evidenced. Healing from compassion fatigue takes time and dedi- cation among the staff to recognize the effects of compassion fatigue. Employers should take time to educate themselves about compassion fatigue and its effects, teaching the staff by continuing education to overcome the every- day stressors that nurses in the critical care setting deal with routinely on a daily basis. Strategies should be introduced to help heal our healers.

Nurses at all levels must support each other, respect the contributions of all involved in patient care, and reach out to others, particu- larly nurses in need of nurturing and renewal. Evidenced-based practice is required to iden- tify the most pressing issues affecting the

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occurrence of compassion fatigue and iden- tify the association between personal stres- sors, professional stressors, and workplace stressors that contribute to specific negative behaviors. This valuable information may be used in educational programs both to pre- pare new graduates for the exposure to suf- fering and to provide treatment programs and supportive measures to prevent compassion fatigue. Positive beliefs about self, a healthy self-concept, understanding other people and their cultures, continuing to address needs, and listening to what the mind and body are telling one are just a few ways to begin to

avoid compassion fatigue. Self-awareness and balance are keys to maintaining health and the ability to assist in the healing of others.

In conclusion, the intent of the authors with this initial report is to provide an avenue of beginning dialogue in the hopes of finding an- swers. Critical care nurses may be reluctant to deal with the emotions associated with com- passion fatigue; perhaps, many may even find difficulty admitting they are suffering from the symptoms. Stressors associated with compas- sion fatigue may be reduced, perhaps, signifi- cantly if appropriate and timely interventions are identified and provided.

REFERENCES

1. Walker LO, Avant KC. Strategies for Theory Construc- tion in Nursing. 5th ed. Upper Saddle River, NJ: Pear- son Education Inc; 2011.

2. Venes D. Taber’s Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: FA Davis Co; 2005.

3. Thompson R. Compassion fatigue: the professional li- ability for caring too much. The Human Side of School Crises—A Public Entity Risk Institute Symposium Web site. http://www.riskinstitute.org/peri/content/ view/1103/5. Published 2003. Accessed September 16, 2011.

4. Figley CR. Compassion fatigue: an introduction. Gift From Within—PTSD Resources for Survivors and Caregivers Web site. http://www.giftfromwithin.org/ html/What-is-Compassion-Fatigue-Dr-Charles-Figley. html. Published 2003. Accessed September 16, 2011.

5. Levin AP, Greisberg S. Vicarious trauma in attorneys. Gift from Within—PTSD Resources for Survivors and Caregivers Web site. http://www.wisspd.org/htm/ ATPracGuides/Training/ProgMaterials/Conf2009/ KLMI%5CVTA.pdf. Published 2011. Accessed September 16, 2011.