Increased Prevalence of Post-traumatic Stress Disorder Symptoms in Critical Care Nurses

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1 Increased Prevalence of Post-traumatic Stress Disorder Symptoms in Critical Care Nurses Meredith L. Mealer 1, April Shelton 1, Britt Berg 2, Barbara Rothbaum 2, and Marc Moss 1 1 Department of Medicine and 2 Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia Rationale: Intensive care unit (ICU) nurses work in a demanding environment where they are repetitively exposed to traumatic situations and stressful events. The psychological effects on nurses as a result of working in the ICU are relatively unknown. Objective: To determine whether there is an increased prevalence of psychological symptoms in ICU nurses when compared with general nurses. Methods: We surveyed ICU and general nurses from three different hospitals (n 351) and then surveyed ICU nurses throughout the metropolitan area (n 140). Measurements and Main Results: In both cohorts of nurses, we determined the prevalence of symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression using validated survey instruments. Within our hospital system, 24% (54/230) of the ICU nurses tested positive for symptoms of PTSD related to their work environment, compared with 14% (17/121) of the general nurses (p 0.03). ICU nurses did not report a greater amount of stress in their life outside of the hospital than general nurses. There was no difference in symptoms of depression or anxiety between ICU and general nurses. In the second survey of ICU nurses from our metropolitan area, 29% (41/140) of the respondents reported symptoms of PTSD, similar to our first cohort of ICU nurses. Conclusions: ICU nurses have an increased prevalence of PTSD symptoms when compared with other general nurses. These results may increase awareness of these symptoms in nurses and lead to future interventions that improve their mental health and job satisfaction and help retain ICU nurses in their profession. Keywords: intensive care units; post-traumatic stress disorder; depression; anxiety disorders; nursing The intensive care unit (ICU) is a stressful environment due to high patient mortality and morbidity, daily confrontations with ethical dilemmas, and a tension-charged atmosphere (1). After exposure to a traumatic event, individuals with post-traumatic stress disorder (PTSD) experience persistent recollections, avoid reminders of the events, and have symptoms of increased arousal (2). Critically ill patients who survive their ICU stay can have symptoms of PTSD that occur more frequently than United Nations soldiers who served in politically unstable regions (3). In addition, one-third of family members of ICU patients reported mild to moderate post-traumatic stress symptoms mostly related to their participation in end-of-life decisions and discussions (4). There are approximately 400,000 critical care nurses in the United States who work in this demanding ICU environment. (Received in original form June 1, 2006; accepted in final form December 21, 2006 ) Supported by unrestricted funds from the Emory University School of Medicine. Correspondence and requests for reprints should be addressed to Marc Moss, M.D., Division of Pulmonary Sciences and Critical Care Medicine, 4200 East 9th Avenue, C272 Room 5525, Denver, CO marc.moss@uchsc.edu This article has an online supplement, which is accessible from this issue s table of contents at Am J Respir Crit Care Med Vol 175. pp , 2007 Originally Published in Press as DOI: /rccm OC on December 21, 2006 Internet address: AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Intensive care unit nurses work in a demanding environment where they are repetitively exposed to traumatic situations and stressful events. What This Study Adds to the Field ICU nurses have an increased prevalence of post-traumatic stress disorder symptoms compared with general nurses. The vacancy rate for nurses in critical care positions is approximately 17%. Due to the increased demand for ICU beds in the United States, there will be an estimated 114,000 vacant critical care nursing positions in the United States by One component of the ICU nursing shortage is an increased exodus of critical care nurses from their profession. In a national telephone survey of 700 registered nurses, the most common reason nurses consider leaving their jobs is a desire for a less stressful position (5, 6). The psychological effects on critical care nurses related to their work environment are relatively unexplored (7 9). Critical care nurses are repeatedly exposed to work-related stresses in the ICU, including addressing specific needs at the end of life, performing cardiopulmonary resuscitation, postmortem care, and prolonging life by artificial support to critically ill patients (1). Repetitive exposure to extreme stressors and the inability to adjust to this environment may result in the development of significant psychological disorders, such as symptoms of PTSD or depression, in some critical care nurses. We hypothesized that critical care nurses may be at increased risk for developing symptoms of PTSD and other psychological disorders. Therefore, we surveyed critical care and other nurses throughout a metropolitan area and performed a more complete psychological assessment on a subset of the respondents. Some of the results of these studies have been previously reported in the form of an abstract (10). METHODS The survey questionnaire required about 10 minutes to complete and included questions regarding general demographic information about the respondent and general impressions about their work environment. Symptoms of PTSD were measured using the Post Traumatic Stress Syndrome 10 Questions Inventory (PTSS-10), a self-report scale based on the Diagnostic and Statistical Manual for PTSD. A total score of greater than 35 is associated with a high probability that the patient fulfills the diagnostic criteria for PTSD (3). This questionnaire is commonly used in a variety of patient populations and has excellent sensitivity and specificity for PTSD (3, 11, 12). In addition, the PTSS- 10 has high internal consistency reliability (Cronbach s 0.92) and stability (test retest reliability, r 0.89) (13). The questionnaire also included the Hospital Anxiety and Depression Scale (HADS), which

2 694 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL consists of two subscales that evaluate symptoms of depression and anxiety (14). The HADS is well accepted and validated in a variety of populations, including primary care patients, healthy subjects, and the spouses of patients (14 17). A score of 8 or greater is suggestive of the possible presence of anxiety or depression (16, 18, 19). Survey of Nurses within Our Hospital System We administered the questionnaire to nurses who were full-time employees presently working in an adult intensive care unit at one of three Emory University affiliated hospitals. Emory University Hospital is a 587-bed facility with 35 medical ICU beds and an additional 20-bed mixed medical/surgical ICU. Crawford Long Hospital is a 583-bed community hospital with 48 ICU beds. Grady Memorial Hospital is a 1,000- bed hospital with 70 ICU beds. To serve as a comparison group, we administered the questionnaire to nurses at these three hospitals who were full-time employees working on a general medical or surgical ward. All participants were told that the purpose of this study was to gain knowledge about the critical care environment and its effect on the nursing population. When answering questions concerning the questionnaire, we did not use the terms post-traumatic stress disorder, anxiety, or depression. The surveys were completed anonymously. Survey of Critical Care Nurses in the Metropolitan Atlanta Area The same overall questionnaire (that included the PTSS-10 and HADS questionnaires) was also mailed to 415 members of the American Association of Critical Care Nurses (AACN) who lived within a 100-mile radius of Atlanta. The AACN is the world s largest nursing specialty organization representing the interests of more than 400,000 nurses who care for critically ill patients. The questionnaire included a cover letter stating that the purpose of the study was to examine the critical care environment and its effect on the nurses. We included a prepaid telephone card with the mailing as an incentive to increase participation. The surveys were anonymous. If the respondent wanted to learn more about the study and their results, they were encouraged to check the appropriate box on the last page of the questionnaire and leave a contact telephone number or address. Assessors administered the 49- question comprehensive Post-Traumatic Stress Disorder Diagnostic Scale to participants during a 20-minute telephone interview. Individuals were compensated $40 for their time during the phone interview. Nurses with clinically relevant PTSD or depression were referred to mental health resources in the community if they were interested in treatment. This study was approved by the Emory University Institutional Review Board. Statistical Analyses Normally distributed data were analyzed with two-tailed t tests or chisquare analysis. Nonparametric analyses were used for data that were not normally distributed. A backward elimination modeling strategy for all multivariable logistic regression analyses was used to examine predictors separately for symptoms of PTSD (JMP; SAS Institute, Inc., Cary, NC). Individual interaction terms between the type of nurse (general medical/surgical and ICU) and a variety of other independent variables were entered into the initial model to assess for effect modification. Removal of any of the individual confounding variables was allowed if it resulted in no alteration in the odds ratio (OR) for the outcome variable yet improved the precision of the OR. We determined 95% confidence intervals (CIs) for each independent variable in all multivariable logistic regression analyses. An value of 0.05 was used for all statistical tests. RESULTS Between February and March of 2005, a total of 351 nursing employees (230 ICU nurses and 121 general medical or surgical nurses) at one of three Emory University affiliated hospitals completed the questionnaire. The nurses were evenly distributed among the three hospitals (98 [28%] worked at Emory University Hospital, 128 [36%] worked at Crawford Long Hospital, and 125 [36%] worked at Grady Memorial Hospital) and were representative of the age and distribution of the nurses in our system. The demographics of the participants stratified by general medical/surgical or ICU nurse are included in Table 1. On average, general medical/surgical nurses worked shorter shifts and more days per week than ICU nurses. The average patientto-nurse ratio for general medical/surgical nurses was significantly higher when compared with the ICU nurses (6:1 [range, 5:1 6:1] vs. 2:1 [range, 2:1 2:1]; p 0.001). The different types of units where the general medical/surgical and ICU nurses primarily worked are displayed in the online supplement (Table E3 of the online supplement). Overall, 44% of ICU nurses had the perception that most of the time they helped one another with patient care, compared with only 31% of the general medical/ surgical nurses (p 0.02). ICU nurses and general medical/ surgical had equivalent confidence in the nurses and doctors in their respective units. However, general medical/surgical nurses felt more strongly that the care they provided affected their patient s outcome (with a median score of 7 out of 7 compared with 6 out of 7 for ICU nurses; p 0.06). ICU and general medical/surgical nurses report an equivalent amount of stress in their life outside of the hospital ( vs on a scale of 1 7; p 0.7). Twenty-four percent (95% CI, 18 29) of the ICU nurses were positive for symptoms of PTSD, compared with 14% (95% CI, 8 20) of the general medical/ surgical nurses (p 0.03). While adjusting for differences in primary hospital of employment, gender, marital status, primary shift (day vs. night), or being responsible for the primary household income, being an ICU nurse was the only variable that remained significantly associated with positive symptoms of PTSD (OR, 1.45; 95% CI, ; p 0.02). There was no difference in the percentage of ICU or general medical/surgical nurses who had symptoms consistent with possible anxiety (18 vs. 22%; p 0.36), depression (31 vs. 27%; p 0.48), or anxiety or depression (35 vs. 35%, p 0.98) on the HADS questionnaire. The percentage of ICU or general medical/surgical nurses who had symptoms of possible anxiety and depression (14 vs. 15%; p 0.89) was not different. Subgroup Analysis of the 230 ICU Nurses We further examined the responses of the 230 ICU nurses who represented 38% of the 611 ICU nurses in our system. Overall, 21% recalled having nightmares, and 17% had severe anxiety or panic related to experiences while working in the ICU. The ICU nurses who tested positive for symptoms of PTSD had significantly higher scores in all 10 domains on the PTSS-10 when compared with the ICU nurses who tested negative for symptoms of PTSD (p for each domain). The symptoms that occurred most frequently in the ICU nurses who were positive for symptoms of PTSD were sleep problems, being irritable, agitated, annoyed, or angry, and muscle tension (Figure E1). There were several demographic differences between the ICU nurses with and without symptoms of PTSD. Regarding their work environment, ICU nurses with positive symptoms of PTSD were more likely to work evening or night shifts and were less likely to have taken the role as charge nurse (Table 2). There was no correlation between the overall mortality rate in the specific ICUs and the prevalence of symptoms of PTSD in the nurses who worked in those units. In a multivariable analysis, working on the evening/night shift was the only variable that remained significantly associated with having symptoms of PTSD (OR, 1.47; 95% CI, ; p 0.026). ICU Nurses in the Atlanta Area To determine whether these results were generalizable to other ICU nurses, questionnaires were mailed to 415 local AACN members in June A total of 195 (47%) of the questionnaires were returned. Fifty-four of the respondents did not complete

3 Mealer, Shelton, Berg, et al.: PTSD in ICU Nurses 695 TABLE 1. CHARACTERISTICS OF INTENSIVE CARE UNIT AND GENERAL MEDICAL/SURGICAL NURSES WITH THE OUR MEDICAL SYSTEM First Cohort of Second Cohort of General Med/Surgical Nurses ICU nurses ICU Nurses (n 121) (n 230) (n 140) p Value Sex, % female Age, yr (mean SD) Marital status, % Single 41 (50/121) 35 (79/230) 20 (28/140) Married 44 (53/121) 51 (118/230) 66 (92/140) Divorced 11 (13/121) 13 (30/230) 11 (16/140) Other 4 (5/121) 1 (3/230) 3 (4/140) Children living in household, % positive Responsible for primary household income, % Nursing experience, yr (mean SD) Primary working shift, % day shift Patient-to-nurse ratio at primary position, median (25 75% quartiles) 6:1 (5 to 6:1) 2:1 (2 to 2:1) 2:1 (2 to 2:1) Working hours per day, n (mean SD) Working days per week, n (mean SD) Definition of abbreviation: ICU intensive care unit. the questionnaire because most of them no longer worked in an ICU. The remaining 140 ICU nurses, who had worked in an ICU during the previous 12 months, were included in the final analysis (33.7% of those questionnaires that were originally mailed). The demographics of the nurses who did not complete the questionnaire were not significantly different regarding age, gender, marital status, race, number of children, or whether they provided the primary income for their family. The general demographics of these ICU nurses are displayed in Table 1. Of the 65 (46%) respondents who included the name of their primary hospital of employment, nurses who work in at least 16 different hospitals are represented in this cohort. Of the 114 (81%) respondents who listed the type of ICU where they primarily worked, a variety of ICUs are represented, including combined medical/surgical (24%), medical ICUs (14%), cardiac ICUs (18%), surgical ICUs (7%), and other (37%). Overall, 28% of these ICU nurses had nightmares, and 16% had severe anxiety or panic related to their experience working as a nurse. Twenty-nine percent (95% CI, 22 37) of these nurses tested positive for symptoms of PTSD. The median PTSD scores were higher in the metro-atlanta ICU nurses when compared with the first cohort of ICU nurses (24 vs. 19; p 0.014); however, the percentage of nurses that were positive for PTSD symptoms was not different between the two groups (29 and 24%; p 0.22). The distribution of symptoms in these ICU nurses who were positive for symptoms of PTSD was similar to the first cohort of nurses (Figure E2). The PTSS-10 maintained a high internal consistency reliability with a Cronbach s of 0.90 and 0.87 for each of the two ICU nursing cohorts, respectively. Using the HADS, 20% (28/140) of these ICU nurses had symptoms consistent with possible anxiety, and 26% (36/140) had symptoms consistent with depression. When compared with the ICU nurses who work at our affiliated hospitals, the HADS scores were not different (p 0.63 and 0.60, respectively). Subgroup Analysis of Nurses with Positive Symptoms of PTSD Of the 41 ICU nurses with positive symptoms of PTSD, 24 included contact information on their questionnaire. We were TABLE 2. DIFFERENCES IN INTENSIVE CARE UNIT NURSES WHO WERE POSITIVE AND NEGATIVE FOR SYMPTOMS OF POST-TRAUMATIC STRESS DISORDER Positive Symptoms of PTSD Negative Symptoms of (n 54) PTSD (n 175) p Value Age, yr (mean SD) Marital status, % married Children, % positive Responsible for primary household income, % Nursing experience, yr (median, 25 75% quartiles) 6 (3 12) 9 (3 19) 0.19 Primary working shift, % 0.02 Day shift Evening or night shift Patient-to-nurse ratio at primary position, median (25 75% quartiles) 2:1 (2 to 2:1) 2:1 (2 to 2:1) 0.37 Working hours per day, n (mean SD) Working days per week, n (mean SD) Nurses who work overtime or hold a second PRN position, % Takes position as charge nurse, % Works in a unit where charge nurse has additional primary patient responsibilities, % Definition of abbreviation: PTSD post-traumatic stress disorder.

4 696 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL able to contact and formally interview 18 of these nurses. The events that were listed as traumatic episodes related to their work as an ICU nurse are included in Table 3. Seventeen of the 18 (94%) nurses have been having symptoms consistent with PTSD for at least 1 month, and 13 (72%) have had symptoms for more than 3 months. DISCUSSION In two surveys of nearly 500 nurses, we identified that critical care nurses are more likely to have symptoms of PTSD when compared with general medical/surgical nurses. Some of the traumatic events that are associated with symptoms of PTSD in ICU nurses are similar to the events reported by noncombat war veterans, including handling dead bodies and assisting with the care of traumatic casualty victims (20 22). Although there was no difference in symptoms of anxiety and depression between ICU and general medical/surgical nurses, the rates of these symptoms were higher than reported in senior and middle managers who work in the healthcare industry (19). The results of our study provide important information for nursing and hospital administrators to improve the general well-being and job satisfaction of their critical care nurses. PTSD is the fourth most common psychiatric diagnosis in the United States (2, 23, 24). Individuals are more likely to develop PTSD after direct interpersonal violence, such as rape or assault. PTSD also occurs in individuals after indirect exposure to a traumatic event, such as witnessing the unnatural death of another person. PTSD may be the upper end of a spectrum of a stress-response continuum rather than a distinct pathologic syndrome (25, 26). It is unlikely that most of these critical care nurses would meet the formal diagnostic criteria for PTSD. However, individuals may experience some symptoms of PTSD after a traumatic event, and the distinction between normal and abnormal responses is controversial (25). Therefore, the concept of subthreshold PTSD is relevant for our study of ICU nurses (25, 27). The prevalence of subthreshold PTSD ranges from 3.7% in a community sample to 21.2% among female Vietnam veterans (25, 28, 29). The majority of our ICU nurses who tested positive on the PTSS-10 would meet the diagnostic criteria for subthreshold PTSD and therefore would yield similar rates to female Vietnam veterans (27). There are some potential modifiers that may influence the interpretation of this study. We used the PTSS-10 and HADS questionnaires to identify psychological disorders in critical care nurses. Although these questionnaires have excellent internal validity and reliability, they do not definitively diagnose individuals with the Diagnostic and Statistical Manual of Mental Disor- TABLE 3. LIST OF TRAUMATIC EVENTS RELATED TO WORK AS AN INTENSIVE CARE UNIT NURSE Post mortem care Seeing patients die Combative patients Involvement with end-of-life care Verbal abuse from family members Verbal abuse from physicians Verbal abuse from other nurses Open surgical wounds Massive bleeding Trauma-related injuries Performing futile care to patients Performing cardiopulmonary resuscitation Stress related to feeling overextended due to inadequate nurse to patient ratios Stress related to not being able to save a specific patient ders, fourth edition, criteria for PTSD or depression. However, the results of both questionnaires clearly identify individuals who have symptoms that would likely affect their overall professional satisfaction. This study did not carefully delineate the specific stressors, such as coping with end-of-life issues or general burdens of the ICU environment, that can cause symptoms of PTSD. More specifically, we did not collect information regarding the involvement of nurses in end-of-life decisions among the different types of ICUs. These data may have helped identify the specific role of end-of-life care in the development of symptoms of PTSD in these nurses. Studies that perform exit interviews with ICU nurses who are leaving their position are necessary to determine the specific stressor and whether the development of symptoms of PTSD contributes to the ICU nursing shortage. In conclusion, symptoms of PTSD are more prevalent in ICU nurses. Approximately 20% of ICU nurses had symptoms consistent with possible anxiety disorders, and nearly 30% of ICU nurses had symptoms of depression. These findings may have important implications regarding methods that could enhance job satisfaction for ICU nurses and improve nursing retention. 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