Post-traumatic stress disorder (PTSD) is a growing concern among nurses in inpatient settings, according to a recent review of studies published in the Journal of Clinical Nursing.
Nurse authors analyzed 24 articles for the May 5 review in literature published pre-COVID-19. They found PTSD occurs in nurses worldwide. They also identified factors associated with PTSD in nurses. "Many people understand that PTSD can happen in those not connected to the military. Literature has noted that PTSD is a growing concern for the nursing professional, as it requires exposure to trauma and suffering," said Regina D. Owen, DNP, PMHNP-BC, a speaker for Nurse.com's continuing education courses Post-traumatic stress disorder: Part 1 an Overview and Post-traumatic stress disorder, Part 2: Interventions.
Defining PTSD in nurses
PTSD results from repeated direct and indirect exposure to traumatic events.
Telltale symptoms include intrusive thoughts or reliving events, avoiding situations that remind one of an event, negative changes in thoughts and feelings, as well as hyper-arousal and overreacting to situations, according to the review.
Ongoing exposure to trauma and suffering can lead to symptoms of PTSD and have short- and long-term negative physiological impacts on nurses, according to Owen, who is an assistant professor for the Psychiatric Mental Health Nurse Practitioner Program at Uniformed Services University of the Health Sciences, Bethesda, Md. PTSD's actual prevalence in nursing, however, remains unclear. The authors hoped to help define PTSD prevalence in inpatient nursing specialties worldwide, instead finding that PTSD prevalence, depending on the study and how it was done, was all over the board. For example, while more than 95% of psychiatric nurses met the criteria for exposure to PTSD in one study, in another study, 24% of ICU and general acute care nurses reported PTSD symptoms. In still another study, 17% of emergency department nurses had a probable PTSD diagnosis. PTSD among nurses could be considerably worse, given the authors examined studies from 1999 to 2019, before COVID-19 was on researchers' radars, according to review author Michelle Schuster, MSN, RN, CPHON, a staff nurse in the inpatient hematology/oncology unit at Boston Children's Hospital.
Why are nurses at risk?
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Michelle Schuster, RN[/caption] Schuster experienced PTSD at her first nursing job. "At the time, I had no idea what it was," she said. "For a long time, I thought this is just what nursing is like, and I have to get through. But it wasn't until I started a new job in the same field of pediatric oncology that I then became aware that I was affected so deeply by my past experience." Schuster said she and her mentor and coauthor Trisha Dwyer wanted to get the message out and help acknowledge that PTSD is occurring in nurses internationally. "We really want to help people be more aware that this is happening because once those conversations start, we feel like more effort will be geared toward helping to find or develop and promote interventions that can best support nurses' well-being, overall," Schuster said. The coauthors found four common themes influenced PTSD risk in nurses: "Workplace matters," "Relationships matter," "It hurts to care," and "Interpersonal strengths." "These overarching themes captured a multitude of factors that occur across three levels of influence: organizational, interpersonal and intra-personal," the authors wrote. Schuster started seeing a therapist and learned she had PTSD with organizational origins.
"That was the first time that I really heard about or considered that PTSD could possibly occur in somebody that's not deployed or not associated with the military," Schuster said. "I wanted to learn more because I feel like if this is something that I am experiencing, maybe somebody else is, too."
Workplace matters
Certain factors, such as years of experience, seem to affect the risk of PTSD in nurses. But it isn't clear whether they have a protective or detrimental effect. One study suggested evening and night shift nurses were more likely to have PTSD symptoms than nurses working during the day.
Nurses who are exposed to disconcerting experiences, such as workplace violence, are more likely to develop PTSD symptoms, according to research. And workplace frustrations, such as feeling overextended or lacking resources to provide adequate patient care, contribute to traumatic stress, according to the review.
Other influences that can impact PTSD in nurses in the workplace include nurses' perceptions of care to patients and how nurses feel supported in an organization. "By making everybody more aware of what contributes to PTSD, maybe more policies or structures can be set up so we can protect nurses," Schuster said.
Relationships matter
Researchers have found having supportive relationships in the work environment with peers and supervisors protects against PTSD, while conflicts with colleagues and workplace bullying make PTSD more likely. Relationships at work are not the only things that matter when it comes to PTSD risk. Relationships at home, with friends and family, also impact the risk.
Interpersonal strengths
Some coping strategies, it turns out, are protective against PTSD, while others might increase PTSD development. Researchers have found active problem-focused coping strategies, as well as seeking social support and problem solving, tend to reduce psychological distress. Nurses who respond with emotional coping strategies and avoidance were more likely to have PTSD symptoms. Highly resilient ICU nurses in one study engaged in positive coping strategies, including getting good sleep, fostering spirituality and engaging in interpersonal relationships, according to the review.
It hurts to care
Nurses witness suffering and death, which can lead to PTSD. Nurses exposed repeatedly to children's suffering or death can be particularly stressful and traumatic. While this review does not take COVID-19 into account, caring for patients during a pandemic might add to the list of reasons for PTSD in nurses. "During this pandemic, we are asking nurses to 'keep going' and defer their grieving and processing of emotions they are experiencing, often causing a negative impact on their support system that is much needed," Owen said. The pandemic likely impacts all the themes in the paper, according to Schuster. "Nurses are witnessing the suffering," Schuster said. "They're witnessing these horrible traumatic events, and we definitely need to have awareness that PTSD can occur. We need to be able to really support nurses through this, not only currently but after COVID-19."
How to heal
Most nurses will heal naturally from the mental and physical toll their profession has asked of them, however a small minority will not, according to Owen. Nurses need to know they're not alone, according to Schuster. There is help, she said, whether nurses look to their employers for the resources they might provide or seek out therapy.
"As the saying goes, 'It takes a village,'" Owen said. "There are numerous proactive steps that an organization can take and prevent further damage to nurses' mental and physical well-being. This is an opportunity for organizations to provide a strong well-being program for the health professional staff, incorporating wellness activities and support avenues, which are available around the clock."
Owen said this is an important opportunity to begin important dialogue aimed at awareness and acknowledgment of the huge toll this has taken on their staff. "The goal is to provide a safe and supportive workplace in which nurses can seek early intervention to prevent the occurrence of PTSD," she said.
Take these courses on PTSD and anxiety disorders:
Post Traumatic Stress Disorder, Part 1: An Overview (1 contact hr) Post-traumatic stress disorder was once associated mainly with the survivors of wars, but today it is used to describe symptoms seen in a wide range of trauma survivors. The U.S. Department of Veterans Affairs National Center for PTSD indicates that at some point in their lives, 7% to 8% of the U.S. population will suffer from post-traumatic stress disorder, although more than half will experience a trauma. This educational activity will address causes, symptoms, and management of this disorder. Post Traumatic Stress Disorder, Part 2: Interventions (1 contact hr) During any given year, about 8 million adults are diagnosed with PTSD. Trauma -- whether resulting from a natural disaster (such as floods and fires) or human-made catastrophes -- produces psychological as well as physical wounding. This educational activity will discuss management of PTSD-related symptoms. Anxiety Disorders (1 contact hr) Anxiety can be mild, moderate, severe, or even escalate to panic. With PTSD, recurring intrusive memories of a traumatic event, troubling nightmares, and even flashbacks occur in which the person feels that he or she is reliving the event. The goal of this continuing education program is to update healthcare professionals' clinical knowledge about screening, identifying, and treating the most common types of anxiety disorders through a variety of medications and therapeutic modalities.
