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Posttraumatic stress disorder in critical care nurses

Danella, Nicole BSN, RN; Hamilton, Sharece MSN, APRN, FNP-C; Heinrich, Chelsea BSN, RN

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doi: 10.1097/01.CCN.0000515980.94246.40
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Posttraumatic stress disorder (PTSD) develops after direct or indirect exposure to an extreme traumatic stressor.1 This stressor could be an actual or threatened death, serious injury, or sexual violence. In nursing, the stressor might be an actual or threatened assault, or witnessing the death or injury of another person.1 PTSD can develop after learning about the violence or unexpected trauma of a close family member or friend.1 Finally, PTSD can be triggered by exposure to the details of a traumatic event; for example, in first responders repeatedly handling human remains.1

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies PTSD based on its etiology.1 Characteristic signs and symptoms that result from the precipitating event fall into clusters: intrusion symptoms, avoidance, negative changes in cognition and mood, and/or alterations in arousal and reactivity (see PTSD diagnostic criteria).1 The full clinical symptoms must be present for more than 1 month, and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.1

This article examines PTSD in critical care nurses to bring awareness to the fact that they can be and often are directly affected by PTSD that results from the strenuous demands of the profession. Critical care nurses in particular are repeatedly exposed to traumatic stressors with the potential to lead to the development of psychological disorders such as PTSD. Studies that have examined PTSD in nurses show that PSTD has a large impact on nurses' well-being, nursing retention, and quality of patient care.2 Hospital administrators and nurse managers must recognize this risk so they can better support nurses who experience traumatic events and repeated stress. Facilities must be aware of this risk and work to provide more support for nurses after traumatic events to improve retention and quality of care.

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Table:
PTSD diagnostic criteria1

Precipitating factors

Research has found that relationships with coworkers and other team members play a significant role in whether nurses develop PTSD or other anxiety disorders after traumatic events.2-5 In a study by Czaja and colleagues, nurses who experienced burnout and/or PTSD responded negatively when they were asked to describe their coworkers, team members, teamwork, and the impact of their work.2 In addition, prior research has shown a link between the appearance of PTSD symptoms and interpersonal conflict in ED nurses and other critical care personnel.3 Similarly, Lavoie and colleagues found that nurses who encountered situations involving conflicts with fellow nurses and other healthcare providers were more likely to develop PTSD.5 However, critical care nurses who received more social support from nursing supervisors and colleagues after a traumatic event were less likely to experience PTSD and work-related fatigue.4

Laposa and colleagues found that stress was caused by organizational factors; patient care did not cause nurses and other healthcare professionals working in the ED either anxiety or stress. This lends further support to staff reports that interpersonal conflict is a more relevant contributing factor to increased PTSD levels than workload. Moreover, increased interpersonal conflict may sensitize nurses and increase their vulnerability following traumatic work events, causing them to become more susceptible to psychological disorders.3 These interpersonal conflicts often exist before traumatic events occur; a majority of critical care nurses reported that it was not the event itself that led to the development of interpersonal conflict, but the conflict in their work environment that existed prior to the traumatic event.3

Lateral and horizontal violence

Another factor that precipitates the development of PTSD in nurses is workplace violence.2,5,6 The most frequently reported stress-inducing incident for nurses was violence directed toward them from patients, patients' family members, and other staff members.6 Nurses are more likely to experience stress after receiving direct threats and verbal abuse from combative patients and their family members than from witnessing violent trauma.2 In addition, nurses report that awareness of violent acts involving children, such as sexual abuse or death, cause the most stress and anxiety.6

Horizontal or lateral violence and hostility occur when individuals working within the same “power level” display aggression toward each other.7 Unfortunately, nurses often suffer from horizontal violence, also known as peer bullying, which has negative psychological effects and diminishes the quality of patient care.8-10 Nurses may experience emotional abuse from their peers on a daily basis during their career.8,9

Research has found that nurses feel unsupported by their managers and hospital administration on this issue and, as established in the preceding section, increased social support is a key factor in how nurses are able to cope with the negative effects of bullying.8-10

Signs and symptoms

It is important to recognize how the signs and symptoms of PTSD will present in critical care nurses in order to properly assess, diagnose, and treat this disorder in affected professionals. Working in a hostile environment can impact nurses socially, emotionally, physically, and psychologically; notable signs and symptoms include decreased morale, migraines, reduced concentration, anxiety, and nightmares.7

A higher percentage of women than men are affected by PTSD, by some reports at a ratio of 2:1.7,11,12 It often presents with other psychiatric disorders, including depression and anxiety, as well as medical disorders such as arthralgias and headaches.7,11-13 Similar to other psychiatric disorders, PTSD often impairs activities of daily living or occupational processes, which may first be evident at the nurse's place of work. PTSD may result in nurses feeling that they could or should have saved someone who died.14 They may become cold toward or avoid patients who remind them of the traumatic event. They may show loss of hope for the future, diminished interest in work, or a lack of concentration.14

PTSD is diagnostically defined by a triggering traumatic event, followed by clusters of signs and symptoms.1 Nurses report that these signs and symptoms relate to the trauma the primary victim experienced, in addition to their caregiving experience.14 Nurses who work in critical care settings may jump from crisis to crisis without resolving the emotional stresses that follow a traumatic event. This provides further incentive for emotional avoidance if the crises cannot be processed and recovered from in a healthy way.11 Jumping from crisis to crisis can leave nurses feeling overextended, fearing future trauma, and eventually lead to burnout or career change.

PTSD may negatively impact nurses' ability to provide effective care.15 The additional stress that PTSD causes in nurses often leads to a career change; nurses who experience both burnout and PTSD symptoms are more likely to feel that their symptoms interfered with their careers and are twice as likely as nurses without either diagnosis to consider leaving the nursing profession.2,15 Laposa and colleagues found that one-fifth of the nurses and healthcare workers in their study considered changing careers as a result of trauma experienced at work and a resulting lack of support from hospital administrators.3

Diagnosis

PTSD is diagnosed following exposure to a traumatic event as outlined in column A of the PTSD diagnostic criteria table. Furthermore, the symptoms listed in columns B through E must be present for at least 1 month.1 The disturbance must cause clinically significant social or occupational distress and impairment, and must not be due to any physiologic substance or other medical disorder.1

The diagnosis no longer differentiates between acute and chronic PTSD, as indicated in the previous DSM-IV-TR. Instead, PTSD is now diagnosed if symptoms last 1 month or longer. Symptoms lasting between 3 days and 1 month comprise acute stress disorder.1 Delayed-expression PTSD (previously called “delayed onset”) is diagnosed if signs and symptoms do not appear until at least 6 months after the traumatic event.1 Two subtypes of PTSD are newly outlined in the DSM-5: PTSD with presence of dissociative symptoms, such as depersonalization (feeling detached from one's mind or body) and derealization (one's surroundings seem distorted or dreamlike), and PTSD in children under age 6 years.1

Treatment and prevention

Timely recognition of a stressful event is the first step in assessing nurses with possible PTSD. With proper preventive care, social and occupational impairment may be avoided.5 It is best for both nurses and patients if the healthcare community provides holistic, effective treatment that includes prevention, symptom management, and career-long mental health and wellness promotion.

Nursing administrators can attend workshops on detecting signs and symptoms of PTSD and measures to help nurses who report them.15 They should encourage nurses who experience PTSD to seek appropriate counseling and utilize stress management techniques; attend seminars to increase their awareness of PTSD; and pursue continuing education about caring for terminally ill patients and their families.15 Continued assessments are needed to identify the greatest sources of stress for nurses and potential coping strategies associated with these stressors.

Hospital administrators should include nurses when developing strategies to reduce lateral or horizontal violence.9 Previous research has shown that nurses who attend workshops on this issue strengthen communication skills and raise their awareness about lateral and horizontal violence.10 These workshops focus on teaching nurses healthy ways to solve conflicts and improving communication in order to eliminate the “culture of silence” around workplace violence.10 Furthermore, nurses who attend these workshops can progress from feeling defenseless to empowered about their ability to solve problems.10

Studies have also demonstrated that cognitive behavior therapy can help nurses share their experiences and control related stress.16 Support groups and open discussions are also beneficial. Nurses who attend debriefing sessions after critical incidents may experience fewer interpersonal conflicts with coworkers and feel more supported by hospital administrators, leading to reduced negative impact.3 Nurses need to be educated about their vulnerability when working with trauma patients and be able to recognize the signs, symptoms, and potential risk factors associated with PTSD.17 Hospitals should create more debriefing programs as well as raise awareness of available resources and hospital counseling available to employees.2

PTSD and the military

Research from the U.S. military is relevant to professional nurses experiencing PTSD or traumatic events. There is a documented history of combat and noncombat veterans returning from tours of service with PTSD.11 While 7% to 8% of the U.S. general population has been diagnosed with PTSD, the numbers may be as high as 14% to 16% in military personnel and veterans.18 A 1988 study specific to Vietnam veterans showed 27% to 31% experienced PTSD.12

Similarities between noncombat war veterans and critical care nurses include the handling of dead bodies and caring for trauma victims.19 This population provides a resource from which the healthcare community can reference successful studies on screening and treatment.18

Knowledge gained from the study of military personnel includes the importance of effective treatment in prevention of chronic, long-term impairment.20 It is essential to identify preexisting or concurrent occupational, personal, and situational stressors that may differ from traumatic or posttraumatic stressors.13 Military PTSD research has also reinforced the value of a strong support system throughout one's work experience and access to effective mental health services after a stressful event.14,20 A lack of social interactions and support is an important determinant of distress after traumatic events.16

In military personnel, the most effective treatment for PTSD includes long-term intensive group therapy, which can be provided to nurses.16 Researchers have found that community team involvement is a feasible treatment option. Jonsson and Halabi showed that the community team “absorbs” the traumatic experience that the nurse is undertaking and thus can help convert any negative energy through different releasing techniques such as open discussion and support groups.16 Many nurses could leave stressful events behind using this technique. It is important for them to have the opportunity to talk with coworkers and other individuals about their traumatic experiences. In nursing, this can be accomplished via mentoring, daily debriefing, and other social support networks.16

Relevance and impact

PTSD has a negative impact on quality of care and the healthcare industry's finances. Cimiotti and colleagues showed that increased workload and burnout in nurses increase infection rates in the patients they care for.21 Reducing nursing burnout by 10% could prevent approximately 4,160 hospital-acquired infections and save $41 million annually.21 Conversely, statistical models indicate increasing nurse workload by just one patient per RN will increase the rate of urinary tract infections by 1 per 1,000 patients and the rate of surgical site infections by 1 to 2 per 1,000 patients.21

Presenteeism is a reduction of on-the-job productivity as a result of a health problem such as PTSD. It is measured by self-report scoring instruments, and the condition has a considerable adverse effect on the quality of patient care delivered by affected nurses.22 Health problems not only affect job productivity but may also increase a nurse's tendency to make errors and have accidents due to impaired concentration. The demonstrated significant performance deficits include time management and completion of physical tasks.22 One study by Letvak and colleagues shows this impairment is clearly raising healthcare costs; the estimated total cost for all absenteeism and presenteeism ranged from $36.6 to $51.8 billion per year.22

Future studies and opportunities

The high incidence of PTSD supports the need for further research in this area. Studies should explore PTSD prevalence among nurses of different races, ethnicities, gender, and education levels. Research is needed on the use of different coping strategies and their success rates in nurses with diagnosed PTSD.

Future studies should also explore whether nurses with certain personality characteristics and professional goals are less prone to PTSD diagnosis following exposure to a traumatic event. For example, Adriaenssens and colleagues found that nurses with certain personality characteristics, such as a strong stress resistance, a high level of autonomy and independence, and good multitasking skills, might show more resilience after traumatic events.4 Research should also be conducted in nurses who have been previously exposed to abusive relationships or have a family psychiatric history because preexposure to these levels of distress can facilitate the relationship between traumatic events in the workplace and PTSD.23

Conclusion

Critical care nurses are at increased risk for PTSD because of interpersonal work conflicts and exposure to daily work stressors. Providing emotional support and furthering research on the effects of PTSD in nurses can lead to increased job satisfaction, decreased burnout, and decreased turnover.

REFERENCES

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Keywords:

burnout; critical care nurses; horizontal violence; lateral violence; posttraumatic stress disorder; PTSD; trauma

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