Wednesday 21 March 2018

ICU Nurses, Post-traumatic Stress Disorder (PTSD)

Focused research over more than a decade by Meredith Mealer, Ph.D., RN and others has shown that Post-traumatic Stress Disorder (PTSD) is as prevalent amongst nurses working in ICU as in war veterans – but also that greater resilience protects against burnout (BOS) and PTSD. Resilience is being able to adapt effectively to major stress, and it can be learned. This means that you can start developing your resilience now to strengthen your psychological make-up for your future career in nursing.

The research path 

While Mealer was involved in a study on PTSD in survivors of acute respiratory stress syndrome in 2002, she became aware that she had herself experienced many of the symptoms while working in ICU. During informal discussions with other ICU nurses who had left the bedside, she found that she was not alone in what she had felt.

The symptoms of PTSD which the nurses experienced included nightmares, sleeping problems, high stress, emotional numbing – especially towards people they were close to, as well as anxiety attacks. Further symptoms of PTSD include losing interest in things one used to enjoy, being easily startled, irritability and even aggression, as well as flashbacks relating to traumatic events.

ICU Nurses, Post-traumatic Stress Disorder (PTSD)
Meredith Mealer, RN, Ph.D. and Marc Moss, MD.
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Mealer discussed her observations with the lead researcher she was working with, Dr. Marc Moss, a pulmonary/critical care physician. This has sparked more than a decade of research studies with the aim of developing an evidence-based program that can be used everywhere to provide ICU nurses with the skills to cope with the stressful environment. “People are going to die in the ICU. You can’t change that – any more than you can change the fact that people die in wars,” Moss said. “But you can change the way we adapt to this stressful work environment.”

The studies  

The first study aimed to determine the prevalence of PTSD symptoms, anxiety and depression in groups of nurses. Compared with 14% of general nurses, 24% of ICU nurses had symptoms of PTSD related to their working environment, while the occurrence of symptoms of depression and anxiety were the same for both groups. This means that ICU nurses have the same risk of developing PTSD as the soldiers who fought in the middle- eastern wars. This is not surprising considering that these nurses are faced daily with traumatic events associated with severe illness and trauma, suffering and death.

The PTSD symptoms most often experienced by the ICU nurses were sleeping problems, irritability, agitation, and anger as well as muscle tension. Many also suffered nightmares, and severe anxiety or panic attacks. Working night shifts was also a factor significantly associated with symptoms of PTSD in ICU nurses.

Resilience is a personal characteristic that enables people to succeed despite adversity. The researchers’ next study was a survey in which a large sample of ICU nurses was asked to complete questionnaires related to their resilience and psychological health. The findings, published in 2012, showed that the presence of high resilience in ICU nurses was significantly associated with a lower incidence of symptoms of PTSD, BOS, anxiety, and depression.

The researchers then set out to identify the mechanisms used by highly resilient ICU nurses – those who thrive and remain employed in ICU’s for many years – to help guide the development of measures to prevent PTSD in ICU nurses. This was a qualitative study using telephone interviews with purposive samples of both highly resilient ICU nurses as well as those diagnosed with PTSD.

Differences between the two groups were identified in the areas of worldview, social networks, cognitive flexibility and self-care/balance. Highly resilient nurses indicated that they coped with their stress through spirituality, a supportive social network, maintaining optimism, and having a resilient role model. Those with PTSD generally had poor social networks, did not identify with a role model and reported disruptive thoughts, regret and lost optimism.

The researchers then went on to determine whether a resilience intervention program for ICU nurses would be feasible as well as acceptable. The 12-week pilot program, using treatment and control groups, included a workshop, written sessions, counseling, mindfulness training, and an exercise program. The results showed that there was a significant reduction in the PTSD symptom scores after the intervention and that most of the participants were positive about the value of the response.

The next step planned by the researchers is a multi-center study with a focus on mindfulness training and cognitive behavioral therapy.

How can you develop resilience?

The essence of building resilience is self-care by incorporating the techniques of stress management that we all read and learn about, into our own everyday lives.

Build social networks

Make time for social interaction. Strong connections with family, friends, and colleagues provide you with a safety net of people you can communicate with about issues, provide you with different perspectives and give you emotional support when you need it. Furthermore, talking about and sharing traumatic experiences with your colleagues, and learning that others have similar experiences and feelings, is comforting and leads to mutual support.

Maintaining a sense of humor has also been identified as one of the characteristics of resilient people – and generally, you can’t joke and laugh all by yourself.

Maintain optimism and work on reducing negative thinking patterns

There are a variety of techniques that you can use to get out of depression and repetitive negative thought patterns resulting from traumatic events. Most of these techniques are based on the principles of cognitive therapy, and the following are only two of the many available on the web.

◈ Cognitive restructuring – which entails an eight-step technique for understanding your negative thinking and feelings, and challenging the automatic beliefs (the lies you tell yourself), which underlie your habitual reactions to events.

◈ Expressive writing – this technique has been used effectively to heal trauma and to treat PTSD. In this exercise, trauma is actively confronted and changed from disturbing memories and sensory experiences into a consolidated and easy-to-understand story. It involves free-form writing about your deepest feelings and thoughts about the event for 20 minutes on four consecutive days.

Maintain a healthy lifestyle

We should practice what we teach our patients about maintaining physical, mental, emotional and spiritual health. Sufficient sleep is essential for mental alertness and helps us cope with daily stressors. Exercise not only keeps us physically fit but contributes to stress relief and emotional well-being on a physiological level as well. Meditation, prayer and mindfulness practices have a calming effect and contribute to spiritual well-being and connectedness.

The stress management techniques discussed here are for use in daily life to build personal resilience. You may find yourself in a situation where even applying these techniques does not relieve your deep depression, anxiety or the symptoms of PTSD you might be experiencing. If this is the case, self-care will be to seek out therapy by a qualified professional.


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