During my time as a student, I was involved in the care of a child who suffered a traumatic brain injury believed to be the result of non-accidental trauma (NAT). Clinically, the case was an exceptional learning opportunity, a lesson in managing intracranial pressure; positioning; sedation; ventilation; perfusion; neuroprotection; and the constant vigilance required to protect a young, injured brain with little margin for error.
But the lesson that stayed with me did not come from the monitor, the ventilator, the treatment plan, or the procedures we performed. It came from the room.
The child’s parents were present. They eventually would be convicted of abuse, but in that moment, we could not treat them as suspects, only as family members at the bedside of a critically injured child. Our responsibility was to remain professional, therapeutic, and clear while the investigation was handled through the appropriate channels. We had to explain the treatment plan, answer questions, care for our patient, and protect them, while also managing the emotional gravity of what likely had happened.
At some point, the nurse looked at me and said, “You’re going to have to get used to it. This happens a lot here.”
I understood that she was not being callous or dismissing the horror of the situation. She was sharing what many clinicians learn only through untoward experience: Some rooms ask more from clinicians than clinical knowledge alone.
The hard truth is not that harm happens to children, but that the people who are involved in that harm may look ordinary. They can appear calm, tearful, attentive, and even polite. They may ask appropriate questions and seem indistinguishable from any concerned family member, frightened about their child’s condition. However, guilt is not determined at the bedside by the healthcare team, so they cannot judge. They are expected to care, document, communicate, provide reports through appropriate channels, and maintain a level of professionalism even when the story behind those injuries becomes unbearable.
That is the burden.
Why These Cases Feel Different
NAT comes with a unique emotional and ethical challenge that impacts the emotions of clinicians in the room. The patient may need airway management, seizure control, neuroprotective care, safe transfer, surgery, or intensive monitoring. At the same time, clinicians are navigating an incomplete patient history; the family’s presence; concerns from child protective services; involvement of law enforcement; and their own anger, grief, or disbelief.
According to the Centers for Disease Control and Prevention (CDC), child abuse and neglect are common, with at least 1 in 7 children within the United States experiencing abuse or neglect within the past year.1 The CDC also states that this is likely an underestimation, as many cases may go unreported. These are not rare occurrences or theoretical events—they are real injuries that arrive in emergency departments, pediatric care units, operating theaters, intensive care units, outpatient settings, transport environments, and forensic departments.
The challenge facing clinicians is a high-speed collision between compassion, suspicion, duty, and restraint. The process for reporting suspicions must be followed, and the investigation must not be compromised. Thus, the clinician must remain humane and objective and professional, without becoming naive, cold, or numb.
The American Nurses Association (ANA) Code of Ethics states that nurses promote, advocate for, and protect the rights, health, and safety of patients.2 The ANA also recognizes that public health–related mandatory reporting exists to protect individuals, families, and communities from abuse, neglect, and other safety issues. For the bedside clinician, this means that suspected abuse must be handled as both a clinical and ethical responsibility.
That responsibility can feel heavy.
Caring Without Judging
When it comes to suspected NAT, clinicians may feel an overwhelming desire to know what happened. That desire is understandable. The story may not make much sense. The injury pattern can conflict with the given explanation. The family’s behavior may seem too calm or too dramatic or too vague, or just too inconsistent. But suspicion is not certainty, and the bedside is not the place for an informal trial.
Under these circumstances, while the clinician’s primary role is to provide care, they also should observe the patient carefully, document their findings objectively, report their concerns following the proper channels as defined by policy and law, and communicate in ways that protect the patient and the integrity of the process involved.3
Objective documentation matters. Instead of writing that a caregiver “appears guilty” or “is acting suspiciously,” clinicians should record facts like who is present, what they have said, when those statements were made, what injuries they have observed, what interventions were performed, and which notifications have been made. The goal is to preserve accuracy, not to sanitize the concerns.
Language in this situation also matters. In an emotionally charged room, clinicians may be more reserved, afraid of saying the wrong thing. Silence may give a sense of safety, but families still need to be communicated with. So, clinicians should use language that is compassionate, factual, and bounded:
“Right now, our focus is keeping your child stable and supporting their breathing and circulation.”
“The team is still evaluating the injuries and determining what treatment is needed.”
“I know this is overwhelming. I’ll explain what I can as clearly as possible.”
“Some questions may need to be answered by other members of the care team, but my role right now is to focus on the care being provided.”
These statements do not assign blame, promise certainty, or interfere with reporting or investigation. They allow the clinician to remain present and therapeutic without stepping outside their professional role.
Moral Distress at the Bedside
NAT can create a sense of moral distress in clinicians who feel emotionally trapped by the circumstances that led to the child needing care. For example, caring for an injured child while having to interact professionally with someone who may have caused the injuries. A clinician may want to comfort the patient but is limited by time and the stability of their condition. A clinician may feel anger towards one of the child’s caregivers, along with guilt about having that anger.
A clinician may feel the system has failed the child even before they arrived at the hospital.
A study by Epstein and Hamric described moral distress, moral residue, and the “crescendo effect,” in which unresolved moral distress can accumulate over time. This is important because a single case may be difficult, but repeated exposure to morally painful situations can leave a mark.4
A study by Christodoulou-Fella and colleagues found that moral distress and secondary traumatic stress may be associated with compromised health among healthcare professionals. This matters in NAT because clinicians may not only witness physical injury, but also absorb the emotional meaning of the injury.5
Experiencing secondary traumatic stress is not a sign of weakness. The National Child Traumatic Stress Network described secondary traumatic stress as an occupational hazard for professionals who work with traumatized children. A clinician caring for an injured child and handling distressed families may be exposed to vividly traumatic details, visible injuries, grief, fear, anger, and uncertainty. The clinician may find themselves functioning well during the shift but later, when the world has slowed down, they experience intrusive distressing thoughts, disruption in sleep, emotional numbing, irritability, and social avoidance.6
These reactions do not mean the clinician is unfit for the work. They mean the work has weight.
Resilience Is Not Numbness
The nurse who told me, “You’re going to have to get used to it,” was right in one sense: Clinicians who work in emergency, pediatric, trauma, critical care, forensic, and transport environments will encounter cases that are emotionally difficult. They need composure and discipline. They need to function while upset and avoid saying anything harmful, accusatory, or misleading. They need to keep the patient at the center of care.
But “get used to it” is incomplete if it means becoming numb, unsupported, cynical, or alone.
Clinicians should be able to feel, function, recover, and return without being slowly hollowed out by the work. Healthcare has a long history of confusing silence with strength. We praise the clinician who moves from one devastating room to the next without blinking. Sometimes that clinician is coping well. Sometimes they have simply internalized that there is nowhere safe to set the burden down.
Resilience is the clinician’s ability to protect themselves without abandoning the patient. When emotions interfere with communication, this may involve a controlled breath before answering a difficult question, asking for assistance from a team member to allow a pause, or having to focus on the next necessary procedure.
After the case, resilience might look different: perhaps speaking with a trusted colleague, actively engaging in a debriefing, using an employee assistance program, reaching out to a peer support team, or even recognizing that the case is following you home. It can appear in many, subtle ways, like being more irritable with your loved ones, constantly replaying the child’s injuries over and over again in your mind, trading assignments to avoid similar cases, or becoming detached from those very patients you serve.7 Those signs, any of them, need attention.
This does not demonstrate fragility. It makes sure that, at the end of the day, they are still intact.
Psychological Safety After Difficult Care
Clinicians recover better from difficult cases when they work in environments where it is safe to speak honestly, ask for help, and acknowledge the emotional weight of care, rather than relying on individual toughness.
A study by Edmondson introduced the concept of psychological safety as the shared belief that a team is safe for interpersonal risk-taking. In clinical practice, this takes the form of a clinician being able to say, “That case affected me,” or “I really need to take a minute,” or “Can we do a debrief after what just happened?” without this being perceived as a defect or unprofessional.8
Psychological safety also does not require that someone disclose a personal emotion within a group setting. Everyone processes stress differently. Some clinicians may benefit from having a conversation, while others may need to be quiet. Some benefit from having a formal debriefing, while others prefer individualized support. The key is that the necessary level of support be made available, normalized, and free of shame.
After a case of suspected NAT, a useful team check-in need not be an overly long process. It can be simple questions:
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What went well clinically?
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Was communication clear?
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Were reporting and documentation steps completed?
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Was there anything about the family interaction that created concern or distress?
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Does anyone need follow-up support?
The best debriefings do not force vulnerability. They make room for it.
What Frontline Clinicians Can Do
For the individual clinician, preparation begins with accepting that emotional responses are predictable. Anger, grief, disgust, sadness, protectiveness, or disbelief may appear during care. It is impossible to eliminate those emotions, but if you recognize them early, they will have less control over tone, documentation, and clinical decisions.9
Frontline clinicians can take several practical steps. First, know the policy before the case. Understand your facility’s process for suspected abuse, mandatory reporting, chain of command, forensic documentation, photography if applicable, social work involvement, and law enforcement communication. A clinician should not have to learn the reporting pathway for the first time during a crisis.
Second, use objective language. In documentation and hand-off, describe what you saw, heard, did, and reported. Avoid labels that assign guilt. Accuracy protects the patient, the clinician, and the investigative process.
Third, communicate within the professional role. Families may ask painful questions: “Is my child going to die?” “Why are police here?” “Why won’t anyone tell me what happened?” Clinicians can be honest without overstepping. When uncertain, it is appropriate to say, “I don’t want to give you incomplete information, but I can tell you what we’re doing right now medically.”
Fourth, use the team. No clinician should feel they must carry the entire emotional and communication burden alone. Charge nurses, social workers, physicians, advanced practice providers, chaplains, child protection teams, forensic clinicians, and security personnel may all have appropriate roles.
Fifth, pay attention to the aftershock. If the case stays with you, that does not mean you failed. It may mean the case was humanly difficult. Seeking support is not a personal defect; it is a survival skill.
The Better Lesson
I still think about that nurse.
At the time, her words felt heavy, maybe even harsh, but I remember them as honest. She had likely seen many cases like the one I was just learning to process. She knew that if I was going to continue in critical care, transport, or emergency medicine, I would need to develop resilience: so that I could stand in rooms where the story may be unbearable, provide high-quality care without allowing suspicion to shape bedside behavior, and speak to people I did not fully understand about injuries I could not emotionally reconcile.
Instead of “get used to it,” the better lesson is “get prepared for it”—train for it, get support through it, get honest about it, get better at caring for the patient without abandoning yourself in the process.
NAT forces the clinician to manage far more than the physical injuries. They must also deal with uncertainty, emotion, the family, acting within professional boundaries, documentation, reporting, and the deeply painful knowledge that serious harm can appear in the most ordinary places.
The truth should not make a clinician into a cynic. It should make the professional more prepared. Children deserve clinicians who care for them with the highest skill and compassion. Families deserve professionals who do not mistake suspicion for a guilty verdict. And clinicians deserve teams that recognize resilience is not numbness, but the capacity to keep doing the work without throwing away your humanity.
Because the child should not be the only person in that room that we are determined to save.
Notes
Artificial intelligence—specifically a large language model (LLM)—was utilized in order to create an outline prior to writing the paper. This aided in organizing thoughts but was not utilized to write the paper or generate any of the content found within.
Disclosure
The author declares that they have no relevant or material financial interests.
About the Author
Patrick Horan (patrickdhoranjr@gmail.com) is a paramedic, healthcare simulation educator, and doctoral student with experiences in prehospital care, critical care transport, hazardous materials response, and clinical education. He currently works in healthcare simulation and training, with interests in patient safety, clinical resilience, and emergency preparedness, as well as high-risk clinical decision-making. His work has appeared in EMS1 as well as other healthcare education publications.