Post-Traumatic Stress Disorder in Nursing

Post-traumatic stress disorder (PTSD) has long been associated with soldiers returning from combat. Today, many nurses and other health care professionals experience trauma on a different front: the battle waged against the deadly coronavirus disease 2019 (COVID-19).

Coping with stress always has been a part of the nursing profession. The impact of the COVID-19 pandemic has caused unprecedented levels of PTSD in nursing:

• A survey conducted by the American Nurses Association (ANA) in December 2020 found that in the previous 14 days, more than half of all nurses reported feeling exhausted (72%), overwhelmed (64%), irritable (57%), and anxious or unable to relax (57%).
• Most nurses also experienced difficulty sleeping or slept too much (67%).
• Nearly two-thirds of the nurses surveyed had directly treated a COVID patient (66%), and another 26% were unsure whether they had direct contact with a COVID patient.
• A separate study published in the journal Nursing Open reported that 88.19% of nurses surveyed in China experienced late-onset PTSD (occurring one to six months after treating COVID-19 patients): 13.54% had severe PTSD symptoms, 33.1% had moderate PTSD symptoms, and 41.55% had low PTSD symptoms.

What Is PTSD?

The American Psychiatric Association (APA) defines PTSD as a psychiatric disorder that may affect people who have experienced or witnessed a traumatic event or who have been threatened with death, sexual violence, or serious injury.

• PTSD was first recognized in combat soldiers as “shell shock” during World War I and “combat fatigue,” or a combat stress reaction, in World War II.
• As many as half of all military discharges during World War II are estimated to have been the result of combat exhaustion.
• In 1980, PTSD was added to the third edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders as a result of research conducted on soldiers returning from the Vietnam War.

The Impact of PTSD

Despite the historical association of PTSD with combat soldiers, the condition can arise in any member of the population and is estimated to affect 3.5% of adults in the U.S. each year.

• The Department of Veterans Affairs estimates that 4% of men and 10% of women in the U.S. will experience PTSD in their lifetime.
• The trauma that precipitates PTSD symptoms includes being the victim of or witnessing a serious accident or natural disaster; suffering an assault; and being the victim of physical or sexual abuse, childhood abuse, or domestic abuse. PTSD can also occur after experiencing or witnessing a traumatic event at work.

Not everyone who experiences a traumatic event will suffer from PTSD, but the closer a person is tied to the event the more likely it will result in PTSD. Other significant factors include the duration and suddenness of the event.The condition is also more likely to occur if the event causes significant changes in the person’s life and if the person was already affected by depression.

Causes and Effects of PTSD Among Nurses

Work-related stress is a primary cause of PTSD among nurses because they are likely to witness many traumatic events while on the job: Patients dying, patients in life-threatening situations, and verbal and physical abuse by patients and visiting family members are all PTSD triggers for nurses.

Certain health care settings make nurses more prone to experiencing PTSD as a result of their work.

• A study published in the Journal of Heart and Lung Transplantation determined that as many as 48% of nurses working in intensive care units (ICUs) meet the criteria for PTSD.
• Emergency and psychiatric nurses had the highest occurrence of PTSD symptoms among emergency responders, according to a study published in Frontiers in Psychiatry.
• A 2021 survey conducted by the Centers for Disease Control and Prevention (CDC) found that more than half of all public health workers in the U.S. reported PTSD symptoms, a rate that was 10% to 20% higher than for front-line health care workers and the general public.

Signs and Symptoms of PTSD in Nursing

PTSD can affect people who have been directly or indirectly exposed to a traumatic event, such as learning about the unexpected death of a loved one. It also can occur cumulatively in nurses and others who are exposed to many traumatic events in the course of their work. Working in health care environments exposes nurses to PTSD triggers including resuscitating patients, controlling bleeding, and participating in other lifesaving and end-of-life procedures.

The four categories of PTSD symptoms are intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity.

Intrusion

Intrusive memories of the traumatic event come to mind involuntarily and recurringly. These include intrusive thoughts, nightmares, and flashbacks of the event. The thoughts and memories may come to mind soon after the traumatic event and persist long afterward. This is one of the most common PTSD symptoms.

Avoidance

Avoidance can occur when someone who has experienced trauma attempts tries to remove all reminders of the event. The person avoids people, places, activities, or situations that may trigger distressing memories of the trauma. Eventually, the person must face the potential triggers because they will continue to arise unexpectedly. If avoidance lasts too long, it can worsen PTSD.

Changes in Cognition

Negative alterations in cognition and mood are often the first PTSD symptoms in a person who has experienced a traumatic event. The person may block from memory hurtful aspects of the event or may have negative or distorted thoughts about the causes or consequences of the event. The person may lose interest in work, favorite activities, and social life.

Changes in Mood and Behavior

Alterations in arousal and reactivity occur when a person becomes jittery or hypersensitive to being touched and exposed to other stimuli. The person may have trouble sleeping, become irritable or aggressive, or find it difficult to focus. The person also may engage in reckless or self-destructive behaviors.

Resources on the Signs and Symptoms of PTSD in Nursing

• Nurse Trauma: Signs You May Suffer from PTSD, The Atlanta Journal-Constitution — The article points out that women may not recognize PTSD symptoms in themselves because the condition is associated primarily with combat soldiers.
• What Are the 17 Symptoms of PTSD?, Cumberland Heights — The symptoms described include self-isolation, casting blame, and an exaggerated startle response.
• Nurses Report PTSD Symptoms Due to the Pandemic — Here’s Why, The Conversation — Nurses are feeling unprecedented levels of stress as a result of treating patients who are critically ill due to COVID, as they witness patients dying without the support of loved ones and cope with multiple patients dying per shift.

Coping With PTSD for Nurses

Health care leaders and managers help nurses recover from traumatic stress centers by encouraging post-traumatic growth (PTG). For example, social support and self-efficacy can help nurses cope with PTSD and extremely high levels of stress.

The following are effective strategies nurses can apply to cope with work-related stress:

Deep Breathing

The simplest and fastest way to center oneself is by taking long, deep breaths that exercise the diaphragm and increase the amount of oxygen reaching the brain, muscles, and other organs. The following is  an example of a deep breathing exercise that can be done alone or with a partner:

• Find a comfortable position, close your eyes, and focus your attention on your body and breath.
• Place one hand on your lower stomach and the other on your upper chest.
• Breath through your nose, focusing on using your breath to raise your abdomen more than your chest.
• Take three deep breaths, focusing on raising your abdomen, and then allow your body to get into its own rhythm of deep, slow breaths.

Progressive Muscle Relaxation

Progressive muscle relaxation is a stress-busting relaxation technique that’s an extension of the deep breathing exercise. Progressive muscle relaxation involves getting into a comfortable position, and then focusing on relaxing one muscle group at a time. You first tense the muscle group, and then relax it, focusing on the release of tension from the muscle.

Practitioners recommend starting with lower extremities; moving through the body; and ending with the face, abdomen, and chest, cycling through the same order each time the exercise is performed. The technique can help people with insomnia fall and stay asleep when performed before bedtime.

Mindfulness

What should be a simple stress reduction technique can be difficult for some people to practice. Mindfulness focuses your attention on the current moment to the exclusion of everything else. The goal is to empty the mind of all unnecessary thoughts by observing your own thought process.

A traumatic event or the cumulative trauma of nursing can cause the brain’s amygdala to overreact, triggering the fight, flight, or freeze response long after the threat passed. Mindfulness is intended to “hijack” the amygdala to lessen its impact and establish more connections between the amygdala and the prefrontal cortex. The result is a more peaceful feeling and a reduction in anxiety after only a few moments.

Self-Monitoring and Self-Soothing

Nurses easily can become so focused on patients and work that they lose a sense of how they feel physically and mentally. Nurses who are new to the profession may find it particularly difficult to recognize and respond to the early symptoms of stress and PTSD. When they identify emotions, thoughts, and activities consistent with PTSD, nurses should reach out to each other and mental health professionals for support.

While often associated with infants and children, self-soothing can benefit people who are feeling overly stressed or exhibiting other PTSD signs. Below are mental exercises that help people overcome stress and anxiety:

• Imagine writing all of your worries on a piece of paper, placing the paper in a jar, and putting the lid back on the jar. This helps you “put away” your worries.
• Recite positive affirmations to ground yourself, refocus on the most important matters, and eliminate negative or unhelpful thoughts.
• Focus on a random object and make as many observations as possible about it, including how it feels and whether it smells.
• Use “box breathing” to recenter: Exhale while counting to four, keeping the lungs empty for the count, and then inhale while counting to four, keeping the lungs full for the count.  Repeat as necessary.

Social Support

A survey of medical personnel in Germany found that the three resources medical workers relied on most often to cope with the stress and trauma of treating COVID-19 patients were a sense of coherence, social support, and religiosity. People with a high sense of coherence have a strong concept of their role in a rational world. Social support entails close connections and communication with family and close friends. Religiosity can provide a person with a connection to a higher power.

Journaling

Many people with PTSD find that they cope more effectively with symptoms by writing about their thoughts and feelings. Journaling can be done anywhere, at any time, with just a pen and notebook (or the digital equivalent). Start by spending a few minutes thinking about specific emotions and then describe them in writing.

The key is to reread what you wrote and think about how you felt when you wrote it, trying to step outside of your own thoughts. Spend about 20 minutes writing at a time, and try to make journaling a daily activity.

Nurses who cope well with traumatic stress tend to adopt a strategy that emphasizes staying engaged with their feelings and reaching out to others, according to the International Journal of Environmental Research and Public Health. Conversely, nurses who are most prone to experiencing PTSD symptoms are more likely to adopt a coping strategy that avoids and disengages from the source of the stress. Approach Coping Characteristics: active coping, use of emotional support, use of instrumental support, positive reframing, planning, and acceptance. Avoidant Coping Characteristics: self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame,

Steps for Treating PTSD in Nurses

Because nurses are trained to help others in need, it makes sense that many nurses feeling symptoms of work-related stress and trauma initially turn to other nurses for help. However, nurses and other health care professionals who are suffering the effects of traumatic stress often hesitate to seek help, whether from their peers, employer, or a third-party mental health provider.

As awareness of the rise in mental health problems among nurses grows, many hospitals are implementing peer-led coaching programs for treating PTSD in nurses. These programs make it possible for nurses to get support for trauma-related symptoms while “in the moment” from a nurse coach who is not a member of their care team. While the  nurses serving as coaches are not trained therapists and often offer only comfort and support, they can connect nurses with mental health service providers when necessary.

Treatments for PTSD

Peer support has proven to be helpful in relieving nurses’ work-related stress due to trauma. However, in many instances, restoring a traumatized nurse’s health requires a formal, long-term treatment program devised and managed by a trained mental health therapist. Approaches for treating PTSD in nurses include cognitive behavioral therapy, cognitive processing therapy, narrative exposure therapy, and various medications.

• Cognitive behavioral therapy focuses on improving the connection between what a person thinks, does, and feels. People work with therapists to understand their issues and what changes they need to make to alleviate the problems. Patients are trained to eliminate negative and unhealthy thoughts.
• Cognitive processing therapy is a type of cognitive behavioral therapy that helps a person who suffered a trauma to identify and modify “maladaptive thoughts” related to the event. The goal is to reframe the person’s beliefs about the trauma in a more positive light via behavioral changes.
• Prolonged exposure therapy teaches the person about how the body and mind respond to traumatic events. It uses breathing retraining and detailed processing of the event to overcome avoidance and prepares the person to deal with reminders and triggers related to the trauma.
• Brief eclectic psychotherapy is a short-term form of therapy that borrows elements of many different therapeutic approaches, including psychodynamic and cognitive behavioral therapies. It typically addresses a single specific problem the person is having by helping the person better understand what happened and develop coping skills.
• Eye movement desensitization and reprocessing (EMDR) therapy treats PTSD by applying a set of protocols and procedures based on adaptive information processing (AIP). The AIP model posits that “maladaptively stored memories” of the trauma block rational thinking. In EMDR, the therapist guides the person through “memory reprocessing” to reestablish appropriate cognitive and emotional connections.
• Narrative exposure therapy was designed initially to treat people who suffered multiple and continuous traumas by talking the person through the traumatic experience step by step. The goal is to prevent the amygdala from firing fight, flight, or freeze responses whenever the memory of the event is triggered.
• Medications for treating PTSD include sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor). These selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) work by rebalancing the brain chemicals, or neurotransmitters, that have been scrambled as a result of the trauma.

Resources for Treating PTSD in Nurses

• The Pandemic Has Devastated the Mental Health of Public Health Workers, The Pew Charitable Trusts — An examination of the impact of COVID-19 on the mental health of nurses and others who serve in public health offices, who bear the brunt of the antagonism and resentment of a small part of the population to COVID prevention measures.
• PTSD from COVID? What You Should Know, Cedars-Sinai — A discussion of how the pandemic has impacted nurses and other front-line health care and the practices and approaches for overcoming COVID-related trauma.
• COVID-19 PTSD in Healthcare Workers Is Real — and Technology Can Help Mitigate the Impact, MedCity News — Topics covered include the use of software and smart devices to help reduce the levels of stress in nurses and health care workers by enhancing communication and tracking patients as they are moved from location to location in a hospital.

The Impact of the Nursing Shortage on PTSD in Nurses

The nursing shortage in the U.S. exacerbates the epidemic of PTSD among nurses. The American Association of Medical Colleges (AAMC) reports that the lack of available nurses has caused some physicians to perform duties usually done by nurses and medical assistants. Some health care providers are offering nurses signing bonuses of up to $25,000, while others have recruited nursing students to care for critically-ill COVID-19 patients.

The growing demand for nurses is driven in part by the retirement of many nurses from the baby-boom generation; the health care needs of an aging population; and faculty shortages at nursing schools, which prevent schools from increasing student enrollment. Finally, the pandemic has led to many working nurses choosing either to take positions that don’t involve direct patient care or leave the nursing field entirely.

Statistics on the Growing Nursing Shortage in the U.S.

A review of studies on appropriate nurse staffing conducted by the Patient Safety Network (PSNet) established a direct connection between adequate nurse staffing levels and patient safety. The less time nurses can spend at a patient’s bedside, the higher the risk to the patient. In addition to nursing shortages, a surge in COVID patients would increase work load for staff and decrease time spent with patients.

• The Associated Press reported that staffing at the emergency room (ER) of a hospital in Michigan was hampered by recent nurse departures, requiring that each of the five nurses on duty care for four patients at one time.
• A survey conducted by McKinsey found that 22% of nurses were thinking of leaving their current position. Of the nurses considering a job change, 60% said they were more likely to quit due to the COVID pandemic.
• The primary reason nurses gave for wanting to leave was inadequate staffing (59%), followed by the intensity of the workload and other demands (56%) and the emotional toll of the work (54%).
• The U.S. Bureau of Labor Statistics (BLS) estimates that there will be 194,500 openings for registered nurses (RNs) each year on average over the next decade.
• ANA reports that about 500,000 experienced RNs will retire in 2022, requiring about 1.1 million new RNs to replace those retiring as well as to fill new RN positions.

Efforts to Address the Nursing Shortage

Health care service providers, professional nursing associations, and the U.S. government are working together to meet the future need for nurses. Their efforts focus on increasing the number of qualified nursing candidates and discouraging nurses from leaving the field.

The Scrubb reports on the growing leadership role of nurses in reshaping how people receive health care. Technological innovations will continue to create opportunities to make nursing more efficient, reduce stress, and improve patient outcomes and the patient experience.

The following are some of the trends that will impact the demand for nurses in the U.S.:

• The Affordable Care Act (ACA) allows more people to access health care services.
• Health care providers increasingly emphasize primary care, wellness, prevention, and management of chronic conditions.
• An aging population will increase demand for geriatric and other aging-related services.
• Health care models are adopting community-based approaches and programs.
• More career opportunities are available in nurse informatics, care coordination, and other technology-related nurse specialties.

Training nurses with the skills needed to improve patient outcomes while working more efficiently becomes more difficult as more experienced nurses retire or leave the profession. New nurses are more likely to be placed in critical care units and ERs, where they experience higher levels of stress and lack the perspective and coping skills the work requires.

Efforts to increase the supply of nurses center on giving them a role in high-level decision-making, increasing nurses’ pay, providing more training opportunities for bedside nurses, and improving the level of teamwork among nurses.

Resources on the Impact of the Nursing Shortage on PTSD Among Nurses             

• State of the World’s Nursing Report 2020, World Health Organization — Among the report’s findings is that filling the expected nurse shortage in the world through 2030 will require an 8% annual increase in the number of nursing school graduates.
• Nurses Urge the HHS to Declare the Staffing Shortage a National Crisis, Healthcare Finance — ANA calls for an immediate, concerted response to the nurse staffing crisis, which has been made worse by the demands of the COVID-19 response.
• Understanding the American Nursing Shortage, Healthline — The article notes that the states where the nursing shortage is most critical are California, Texas, New Jersey, South Carolina, and Alaska.

Nursing During a Pandemic

Treating patients during the COVID-19 pandemic has contributed to the sharp increase in PTSD among nurses.

• A 2020 survey of health care workers in Turkey found that nearly half of the nonphysicians in the group experienced PTSD symptoms, and 36% of doctors reported PTSD symptoms.
• Nurses treating COVID patients at a hospital in California report that a single day’s caseload typically includes 35 patients and can be as many as 80 patients.
• An ICU nurse compares treating severely-ill COVID patients to “doing battle with a COVID monster.”

Pandemic’s Impact on Nurses’ Mental and Physical Health

ANA’s 2021 survey of U.S. nurses asked them about their overall health, their mental and emotional well-being, as well as other health-related matters, over the previous two weeks. 

• On a scale of 0 (not good at all) to 10 (very good), the nurses’ average response was 5.7.
• On the same scale, when asked how optimistic they were about the future, the nurses’ average response was 6.2.
• The feelings the nurses reported experiencing most often in the previous two weeks were exhausted (51%), overwhelmed (42%), irritable (37%), anxious or unable to relax (36%), and that their work had meaning (32%).
• When asked whether they had sought professional mental health support since the start of the pandemic, 24% of the nurses said they had.

Efforts to Reduce Stress Among Nurses

Programs intended to reduce the level of stress nurses feel and their need to seek treatment for PTSD focus on four distinct areas:

• Technology-based interventions (web-based programs and smartphone apps)
• Mindfulness programs and spiritual interventions
• Programs based on cognitive behavioral therapy
• Programs that focus on the body and physical health

The approaches that show the most promise in reducing stress are technology-based systems that include relaxation, and stress management interventions that teach self-care skills. To be both practical and effective, stress reduction programs need to be easy to access and use. They also must be evidence-based interventions that emphasize self-care.

How Nurses Are Adjusting to Maintain Their Health During the Pandemic

Resilience has become the buzzword for the nursing profession during the COVID-19 pandemic. Researchers have identified three themes in the response of nurses and other health care providers to the demands placed on all health care resources by the pandemic.

• Facing an emerging challenge caused cautiousness and alertness, conservation of medical supplies, and heightened sensitivity to the health of nursing team members.
• Struggling with uncertainty, fear, stigma, and workloads made nurses fear that their lives were threatened. It also added to their work by requiring that they wear protective clothing and equipment. Nurses also report being ostracized by others who feared contracting COVID from them.
• Learning and innovating to adapt to the work environment involved receiving the appreciation and support of the public, incorporating new hygiene practices in work processes, and being more willing to improvise.

Resources on Nursing During a Pandemic                                        

• Coronavirus (COVID-19) Resources, American Association of Critical-Care Nurses — Information for nurses newly assigned to treating COVID-19 patients, information on COVID-19 vaccines, and information on the ethical obligations of COVID-19 treatment.
• COVID-19 Resource Center: Ethical Considerations, American Nurses Association — Topics include COVID-19 self-care considerations, crisis standards of care (CSC), and guidelines for clinicians facing COVID-19 challenges.

From mid-June to early September 2020, researchers surveyed 73 critical care nurses who were treating COVID-19 patients. According to the Journal of Advanced Nursing, they identify five themes related to the psychological distress the nurses felt while treating the patients: 1. Anxiety, depression, guilt, and PTSD symptoms. 2. Overwhelming grief and loss: “Tsunami of death.” 3. Professional duties vs. personal/family safety. 4. Job dissatisfaction, intention to leave nursing. 5. Resiliency, professional camaraderie, and growth.

Nurses Supporting Nurses Through the Profession’s PTSD Crisis

Nurses are on the front line in the battle against COVID-19.  In addition,  they play many other important roles in helping communities, families, and individuals protect themselves and return to wellness. To meet the expectations others set for them and they set for themselves, nurses must perform at their peak. Doing so requires recognizing when stress and trauma are causing them to feel symptoms associated with PTSD.

Nurses and other health care professionals are responding to the epidemic of PTSD in the profession via education, treatment, and other support services. Nurses’ health is the key to improving patient outcomes, supporting the profession, and promoting the health of individuals and communities.