PTSD in Nurses

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Post-traumatic stress disorder (PTSD) gained its recognition from its association with military veterans returning home from war along with the emotional strain they felt as a result of the events they witnessed during their service. Phrases such as “shell–shocked,” or “combat fatigue” were used to describe them upon their return. In 1980, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders identified PTSD as a psychological disorder. Although anyone can experience the disorder, PTSD in nurses is increasing in prevalence, especially when considering the events that have occurred throughout the past year within the healthcare professions.  

Many people have lost their income, families, homes, and their sense of well-being. Emergency personnel, rescue workers, physicians, and nurses have all voiced how COVID-19 has had a terrible impact on humanity. The increase in hospitalization and death rates has caused a major increase in PTSD in nurses. In this course, we will discuss strategies that promote successful identification and coping mechanisms for PTSD in nurses. 

Introduction

Nursing can be highly stressful, demanding, and unpredictable. In some cases, nurses are exposed to potential physical, psychological, and mental hazards for upwards of 12-16 hours a day. Each person reacts and responds to extreme stress and trauma in various ways, and because there are so many variables to consider, it has been challenging to diagnose PTSD in nursing.  

It is natural for individuals to experience fear, heightened senses, and avoidance after experiencing a traumatic event. Nurses are aware of our body’s natural defense to danger or fear, commonly identified as the "fight or flight" response. There are many scenarios that define a traumatic event, and not everyone identifies them the same. For example, some may say losing a loved one is traumatic for them, whereas others may define life-threatening situations or witnessing one as being traumatic for them – all of which are valid.  

The question now stands, “when do these traumatic events turn into PTSD?”  

In order to fully answer this, we must first define PTSD.  

Definition 

Post-traumatic stress disorder is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event (1). 

The DSM-5 diagnostic criteria for PTSD include: 

A. Stressor (one required):  

• Personally experiencing trauma or watching someone endure it. 
• Learning that a traumatic event(s) may have occurred to a close family member or friend. 
• In cases of life-threatening instances, or the death of a family member/friend, the event(s) must have been violent or accidental.  
• Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. nurses working in critical care units, caring for COVID-19 patients, etc.) (2). 

B. Intrusion symptom (one or more required):  

• Recurrent and distressing memories or dreams of the trauma experienced. 
• A dissociative reaction in which the person is completely unaware of their surroundings.  
• Intense, prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
• Distinct physiological reactions of internal or external reminders that may represent any aspect of the traumatic event (2). 

C. Avoidance (one or both required): Avoiding any memories, thoughts, or feelings related to the traumatic event on a continuous basis.  

• Avoidance or efforts to avoid instances or items that resemble or remind the person of the traumatic event. Examples include (2): 
• People 
• Places 
• Activities 
• Conversations 
• Familial objects 

D. Negative alteration in cognition and mood (two required):  

• Inability to remember specifics of the traumatic event due to dissociative symptoms.  
• Persistent and over-exaggerated negative belief about oneself, others, or the world (e.g. “the world is completely dangerous” or “my whole nervous system is shot”).  
• Persistent negative emotional state (e.g. fear, anger, guilt, or shame).  
• Persistent distorted perception about the cause of the traumatic event leads an individual to blame themselves. 
• Distinctive or diminished interest or participation in any significant activities. Feelings of detachment from others. Continuous inability to experience positive emotions (2). 

E. Alterations in arousal and reactivity (two or more): 

• Angry outbursts and irritable behavior without provocation, leading to physical aggression toward people or objects.  
• Self-destructive reckless behavior. 
• Hypervigilance. 
• Exaggerated startle response. 
• Problems with concentrating. 
• Sleep disturbance (2). 

F. Duration of the disturbance (criteria B, C, D, and E required):  

• More than a month. 

G. Functional Significance (required): 

• Clinically significant distress caused by the traumatic event(s) or impairment in social, occupational, or other areas of functioning.  
• The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2). 

Case Study 

Laura is a 26-year-old nurse of five years who has decided to take a travel nursing assignment to help with the overwhelming demand to care for COVID-19 patients. She is given a wonderful opportunity to make a difference. The staffing agency offered Laura a critical care staff nurse position, where she is expected to care for two patients and work 36 hours weekly on night shift for 13 weeks. Her pay would be $5,000 per week plus a non-taxed stipend for lodging and meals.  

She accepts the assignment and immediately takes leave from her full-time position in Tennessee. She packs her belongings, says goodbye to her family, and begins her venture to California.  

Upon her arrival to the hospital, Laura reports to the critical care department to meet with the nurse manager. Following, she is told by her superior that her contracted assignment has changed and that she will now be taking care of at least seven COVID-19 patients due to short-staffing. Laura is confused and feels as though she cannot say no due to her being under contract, so she attempts to reach out to her agency; no one is available to take her call. She leaves a message in hopes that someone will get back to her as soon as possible, however, she is expected to start her first shift that same evening.  

Laura's first night is horrific; she is caring for seven COVID-19 patients that are all on ventilators, and she has no resources available to her if she has any questions. The environment is overwhelming; patients are lined against the wall, people are crying, a code blue is being called every 10-to-15 minutes, and most of the time, the patient dies. The morgue is overflowing, and some of the deceased patients are placed in body bags and lined against the wall or piled into a single room.  

After only three shifts, Laura decides she cannot fulfill this contract because she has no support, is experiencing nightmares, feels extremely agitated, anxious, and seems to be crying all the time. As a result, she reaches out to her agency and informs them of her decision to end the contract. 

The agency tells her that she will be reported to both the Tennessee (her home state) and California Board of Nursing for job abandonment, meaning she cannot practice if she breaks her contract.  

Upon receiving this ultimatum, Laura decides to stay to fulfill the contract.  

Over the next few weeks, Laura notices that some of her co-workers are manifesting a change in behavior. They have become increasingly sad, detached from others, displaying anger toward other staff members, and anxious. Laura feels as though her work environment is toxic, and she wishes she were anywhere else in the world but there, however, she cannot leave. 

This is a prime example of PTSD in nurses.  

Refer to this case study to answer some of the learner exercise questions throughout the course.

Sign and Symptoms of PTSD in Nurses 

There are many signs and symptoms of PTSD in nurses. Symptoms may develop immediately, or within three months of the traumatic event(s). On some occasions, a person can suppress their feelings for up to a year before remembering a traumatic event. Many of the signs and symptoms are grouped into four categories: intrusive memories, avoidance, negative changes in mood and thinking, and negative changes in physical and emotional reactions (3).  

Intrusive memories include: 

• Recurrent distressing memories of the traumatic event 
• Flashbacks 
• Nightmares 
• Severe emotional distress 
• A physical reaction to something that reminds the person of the traumatic event 
  

Avoidance: includes any memories, thoughts, or feelings related to the traumatic event on a continuous basis. For examples, see “The DSM-5 diagnostic criteria for PTSD include” section above.  

Negative changes in mood and thinking includes:

• Feelings of hopelessness about the future 
• Not remembering certain aspects of the traumatic event 
• Difficulty in maintaining close relationships 
• Feeling of detachment 
• Lack of interest in activities once enjoyed 
• Difficulty experiencing positive emotions 
• Feeling emotionally “numb” 
• Alcohol or drug abuse 
• Having negative thoughts about yourself, other people, or the world (3)   

Changes in physical and emotional reactions include: 

• Heightened senses, fight or flight 
• Insomnia, trouble concentrating 
• Overwhelming feelings of guilt or shame 
• Increased irritability, aggressive behavior, outbursts with no provocation 
• Chronic illnesses, gastrointestinal problems, sweating/shaking 
• Angina 
• Self-destructive behavior, depression, hallucinations, anxiety, and feelings of constant sorrow (3)

Types of PTSD 

Since we know that the American Psychiatric Association describes PTSD as a psychological disorder, we know there are different types and severity levels of PTSD. As previously mentioned, everyone can experience the various types, however, we are going to focus on the commonly diagnosed types of PTSD in nurses.  

Overall, there are five types of PTSD, which include: normal stress response, acute stress disorder, uncomplicated PTSD, complex PTSD, and comorbid PTSD (4). 

Normal Stress Response 

The normal stress response, the "fight or flight," is the precursor to PTSD in nurses, and it does not always lead to full-blown PTSD. Any event that causes our natural stress response, such as surgery, an injury or pending thoughts of danger, all initiate a normal stress response; the problem occurs when this response is not alleviated within a short amount of time. 

Acute Stress Disorder 

A life-threatening event such as job loss, illness, natural disaster, or death of a loved one can initiate this early form of PTSD in nurses. While the individual may experience this type of disorder, they will typically overcome the initial stressor. If it becomes prolonged and untreated, it can lead to full-blown PTSD. 

Uncomplicated PTSD 

This type of PTSD in nurses is associated with one major event, making it the easiest form of PTSD to treat. The individual will want to avoid everything that could remind them of the event. 

Complex PTSD 

Complex PTSD is just as the name implies. This type of PTSD in nurses is associated with multiple traumatic events and is usually associated with various types of abuse, violence, war, and traumatic losses. The unfortunate problem with diagnosing this type of PTSD is that some professionals confuse it with a borderline or antisocial personality disorder or dissociative disorders (4). 

Comorbid PTSD 

This type of PTSD in nurses is associated with a person with more than one mental health concern and substance or narcotic abuse issues at the same time. This condition is extremely common because most people have more than one problem. PTSD makes this more complicated to treat. Individuals may try to self-medicate because they are in denial, but this only leads to self-loathing and self-destructive behaviors (5). 

Phases of PTSD in Nurses 

There are four phases of PTSD identified by Pyramid Health. The phases are impact (emergency), rescue, intermediate recovery, and long -term reconstruction (5). 

Impact (Emergency) 

The impact phase consists of the initial reaction such as anxiety, helplessness, guilt, shock, or fear. This occurs immediately after the individual experiences the traumatic event. The duration of this phase depends on the severity of the event (5). 

Rescue

The rescue phase involves the individual being able to come to terms with what has happened. This is closely related to the acceptance phase in grieving. The individual may experience flashbacks, confusion, anxiety, denial, or feelings of despair. 

Intermediate Recovery

The intermediate recovery phase is associated with the individual making the adjustment to return to everyday life. In this phase, the individual can begin to look at other issues within their life. While addressing new issues, they may have the feeling of altruism, in which they feel the love and support from others, causing them to believe that they can also help others. 

Additionally, they may also develop the feeling of disillusionment, in which they feel overwhelmed because they are not receiving the love and support that they think they should, or they realize they are on their own when it ends.

This phase is closely related to the acceptance phase in grieving. As with the grieving phase, the individual may go back and forth between phases. 

Long-term Reconstruction

The long-term reconstruction phase is characterized by the individual being able to rebuild while continuing to deal with the trauma's aftermath. Their main concerns are about their future and how they can maintain healing. 

Causes of PTSD 

Defining the causes of PTSD in nurses can be quite tricky because physicians have not been able to determine why some individuals may have a different response to the same traumatic event. Many nurses have experienced stressful experiences that did not cause PTSD. Some causes or increased risk for developing PTSD in nurses could include inherited mental health risk, an individual's temperament, and how our brain regulates chemicals and hormones that release stress in our bodies. 

The hippocampus is a component of the brain that works to consolidate information from short- to long-term memory, links these memories to sensations, and enables our ability to navigate through spatial memory (6). The hippocampus is located under the cerebral cortex in the allocortex, and there are two hippocampi, one on each side of the brain that have very distinct roles.  

PTSD is associated with abnormal hippocampal activity (6). It has been noted that PTSD is mainly associated with functional and structural changes in the amygdala, medial prefrontal cortex, and the hippocampus (6). The main role of the posterior hippocampus is in memory retrieval and spatial cognition, whereas the role of the anterior hippocampus is mainly associated with the amygdala, hypothalamic-pituitary-adrenal (HPA) axis, and limbic prefrontal circuitry (6).  

The anterior hippocampal-amygdala connections are thought to underlie atypical memory processes in PTSD, including flashbacks, intrusive thoughts, and nightmares (6). There are current theories of PTSD that identify hippocampal dysfunction as a key contributor to hallmark symptoms of PTSD in nurses (7). 

One common denominator for causes of PTSD is the actual stress an individual goes through when they experience or learn about a life-threatening event, serious injury, sexual assault, childhood physical abuse, being threatened with a weapon, an accident, being exposed repetitively to death, violence, or sickness. 

The Effect on Nurses 

The COVID-19 outbreak has had a severe impact on the healthcare industry. Professionals are working tirelessly to care for patients who are experiencing health issues caused by COVID-19, leading to a significant spike in PTSD in nurses.  

Professionals in critical care, trauma, and emergency room departments are continuously witnessing death on top of working within a crowded, high-stress environment that often faces short-staffing. 

Factors relating to development of PTSD in nurses: 

• Age  
• Work experience  
• Previous psychiatric history  
• Marital status  
• Family support  
• Coping styles  

Prevalence of PTSD in Nurses 

Based on the current U.S. population (223.4 million), around 7 to 10 of every 100 people will have experienced some traumatic event in their lifetime. 20% of the population (44.7 million) suffer from PTSD. The chances of experiencing traumatic events and receiving a PTSD diagnosis within the nursing profession are very high (8).  

In most instances, nurses are trained to put their patients’ needs over their own when they walk in the door. When their shift starts, they attempt to suppress their emotions so they can get through their shift. A nurse may experience a rush of feelings such as anger, guilt, confusion, sadness, sorrow, and grief and sometimes, in extreme cases, suicidal or homicidal ideations. To mask their emotions, they may turn to drinking, drugs, or destructive behaviors to cope with the day-to-day trauma from their job. 

A 2009 nursing study covering depression and anxiety revealed a high prevalence of burnout syndrome and PTSD in nurses. The 810-person study revealed that 22% of participants experience symptoms of PTSD, and 18% met the diagnostic criteria for PTSD. Additionally, the results determined that while 86% met the criteria for burnout syndrome, 98% fulfilled the diagnostic criteria for PTSD and were positive for burnout syndrome. The study concluded that nurses with burnout syndrome and PTSD were significantly more likely to have difficulty in their outside life from work (13).  

An additional study that evaluates the results of over 24 publications regarding PTSD in nurses between 1999 and 2019 determined that a majority of nurses with PTSD had the following: 

• Leadership roles 
• Negative outlook on patient care 
• Lack of supportive relationships, staffing, and organizational support 
• Internalized both short- and long-term patient suffering 

As they continue to push through global pandemics, natural disasters, and continuous tragic events, PTSD in nurses is a prevalent issue that we must address.

Current Therapy

PTSD will continue to worsen without treatment. The Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) in 2017 each established treatment guidelines for PTSD (10). Both guidelines recommend the use of prolong exposure (PE), cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR) therapy (10).  

Non-trauma-focused treatments include medication, relaxation therapy, and stress inoculation training (SIT).

Trauma-focused:

Prolong Exposure (PE)

Prolong exposure (PE) therapy is strongly recommended by both the APA and VA/DoD as a successful treatment of PTSD. PE is based on the emotional processing theory, which stipulates that traumatic events are not emotionally processed at the time of the event. 

PE therapy consists of two main components: in vivo and imaginal exposure (10). 

Cognitive Processing Therapy (CPT) 

CPT utilizes the social cognition theory and the informed emotional processing theory. Following a traumatic event, usually, a survivor attempts to make sense of what has happened and leads to distorted cognitions regarding themselves, the world, and others. The main goal of CPT is to shift an individual's unhelpful beliefs related to their trauma toward more accommodating, positive and helpful beliefs to promote new learning (10). Sessions usually take 12 weeks, and they incorporate psychoeducation about the cognitive model and exploration of the patient's conceptualization of the traumatic event (10). 

Cognitive Behavioral Therapy (CBT)

Trauma-focused CBT is based on behavioral and cognitive models drawn from cognitive behavior theories, including PE and CPT. This type of therapy includes modifying negative appraisals, correcting the autobiographical memory, and removing the problematic behavior and cognitive strategies. 

It is believed that guilt-associated appraisals tend to evoke negative effects and are usually paired with images or thoughts of the trauma, thus causing a repeated and reconditioned memory of the trauma; Ultimately producing distress, leading to tendencies to suppress or avoid the trauma-related stimuli in individuals (10).  

The techniques associated with CBT include exposure and cognitive restructuring. The exposure technique for a traumatic memory utilizes imaginal exposure, writing about the trauma, and reading the traumatic memory out loud (10). The most important aspect of cognitive restructuring is teaching the patients to identify the various dysfunctional thoughts and erroneous thinking, replace them with rational alternative thoughts, and having them reconsider their beliefs about themselves, the trauma, and the world (10). 

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

EMDR therapy requires healthcare professionals to help a patient move their eyes back and forth while imagining or recalling their traumatic event. This technique allows the individual to reprocess the memory while addressing the past, present, and future aspects of the traumatic memory.  

Non-trauma-focused:

Medication Therapy

The current medication therapy recommended by the APA for PTSD treatment is sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor). Although all medications must be customized for each individual, it is important to note that Zoloft and Paxil are the only FDA-approved medications for the treatment of PTSD (11). 

In some cases, taking antidepressants in conjunction with PTSD medication treatments can serve as beneficial. Those medications include: 

• Clonidine and Guanfacine, Risperidone for agitation 
• Clonidine, Prazosin and Trazodone for trauma-related nightmares 
• Beta-blockers such as Propanol are used to decrease hyperarousal symptoms but it has not been approved by the FDA (12). 

Relaxation Therapy

Relaxation therapy is a form of psychotherapy that utilizes breathing techniques, progressive muscle techniques, and meditation to elicit a voluntary relaxation response of the individual. Sometimes, guided imagery is utilized to have the individual focus on positive images in their mind. This technique helps lower the individual’s blood pressure, relieves tension in their muscles, and lowers their stress. 

Progressive Muscle Relaxation has been utilized to help reduce fatigue and relieve PTSD in nurses. This technique involves sequential tensing of major muscles in the body. This form of relaxation therapy reduces feelings of tension, lowers perceived stress, and can be performed anywhere at any time. This technique has the positive effect of decreasing the pulse rates, increases the individual's oxygen saturation and is sometimes used in conjunction with other forms of psychotherapy (13). 

Stress Inoculation Training (SIT) 

SIT is a form of psychotherapy used for the treatment of PTSD. This training is a type of cognitive-behavioral therapy that teaches the individual coping skills and helps them find new ways to deal with their PTSD symptoms. SIT teaches individuals to react differently in stressful situations and is performed in phases (14).

In the first phase, the individuals learn about their PTSD symptoms, and they identify the traumatic stress that they experienced. Following, the individual learns how to monitor their stress level. In the second phase, they learn new problem-solving strategies and coping skills that help them relax their bodies, control their breathing, interrupt the upsetting thoughts, and help the individual stay in the current moment. Research shows that SIT is one of the most effective forms of therapy for PTSD (14). 

Coping Mechanisms 

It is sometimes difficult for individuals experiencing PTSD to cope with the mountain of symptoms that they may encounter. For nurses experiencing PTSD, it is critical that they seek treatment and develop coping mechanisms. If their symptoms go untreated, their work performance and quality of patient care may decrease. 

Nurses have resources available to help them cope with PTSD. Some workplaces have elicited the help of psychiatrists or psychologists to provide drop-in services at the worksite. Various positive coping mechanisms include:  

• Spiritual guidance in prayer 
• Having a strong support system to lean on such as a sponsor that the individual can call when feeling overwhelmed 
• Including their family in the healing process 
• Performing mindful meditation or yoga  
• Performing guided imagery to focus on positive thoughts when the stressors resurface 
• Prescription medication  
• Peer support at work 
• Professional counseling 
• Group therapy
  

Conclusion 

PTSD can be a very debilitating condition and affects millions of people every year. Nurses are on the front lines serving the public during a health crisis, and we now know that for them to do their jobs effectively, their mental health must be a priority.  

Many organizations now offer counseling, time off, peer support, and incentives for nurses to take care of themselves. With proper treatment, we can alleviate or control PTSD in nurses. Our goal for the future is to continue to make the physical, spiritual, and mental health of all health care workers a top priority so that they can continue to provide the best care to patients.  

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