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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:
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.
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.
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.
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.
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.
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 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.
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.
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.
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:
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:
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.
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.
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:
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.
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,
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.
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.
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.
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.
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.:
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.
Treating patients during the COVID-19 pandemic has contributed to the sharp increase in PTSD among nurses.
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.
Programs intended to reduce the level of stress nurses feel and their need to seek treatment for PTSD focus on four distinct areas:
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.
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.
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 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.