The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey

Abstract

Background

Emergency Nurses are routinely confronted with work related traumatic events and hectic work conditions. Several studies report a high prevalence of post-traumatic stress disorder (PTSD) in these nurses. Coping and social support seem to play an important role in the development of PTSD.

Objectives

This study examines (1) the frequency of exposure to and the nature of traumatic events in Emergency Nurses, (2) the percentage of nurses that report symptoms of PTSD, anxiety, depression, somatic complaints and fatigue at a sub-clinical level, and (3) the contribution of traumatic events, coping and social support to PTSD symptoms, psychological distress, somatic complaints, fatigue and sleep disturbances.

Design

Cross-sectional data from 248 Emergency Nurses, from 15 Flemish (Belgian) general hospitals, were analyzed.

Results

Emergency Nurses were found to be confronted frequently with work related traumatic events. Death or serious injury of a child/adolescent was perceived as the most traumatizing event. Almost one out of three nurses met sub-clinical levels of anxiety, depression and somatic complaints and 8.5% met clinical levels of PTSD. Levels of fatigue were high but not directly related to the frequency of exposure to traumatic events. Emotional coping was related to an increase in all outcomes; avoidant coping was related to more somatic complaints; problem focused coping was related to a decrease in psychological distress and perceived fatigue. Social support from colleagues and supervisor (head nurse) was found to have a protective effect on the occurrence of PTSD symptoms.

Conclusion

Emergency Nurses are especially vulnerable to post-traumatic stress reactions due to repetitive exposure to work related traumatic incidents. This not only personally affects the nurses, but can also impact quality of care. Hospital management should act on the findings of this study and invest in supportive, communicative, empathic and anticipatory leadership, and provide time-out facilities, cognitive-behavioral interventions and psychological counseling for Emergency Nurses on demand.

Introduction

PTSD (Post-Traumatic Stress Disorder) is an anxiety disorder that occurs as a result of experiencing, witnessing, or being confronted with an emotionally traumatic event. A traumatic event is defined as a situation that is so extreme, so severe and so powerful that it threatens to overwhelm a person's ability to cope, resulting in unusually strong emotional, cognitive, or behavioral reactions in the person experiencing it (Meichenbaum, 1994). PTSD is characterized by three major symptom groups: (1) re-experiencing of the traumatic event, including intense fear, nightmares, horror and intrusive recollections of the event, (2) avoidance of trauma-related events and emotional numbing, and (3) chronic psychological arousal (American Psychiatric Association, 2000). The re-experiencing cluster is seen as the most important feature of the syndrome (Laposa et al., 2003). In addition, the symptoms must be present for more than one month and the disturbance should cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. According to DSM-IV, PTSD may develop in three ways: (a) directly, through personal and direct exposure to a traumatic event (e.g. victims of war, extreme violence or sexual abuse), (b) by witnessing a traumatic event that involves the death, injury or suffering of another person, and (c) by learning, second hand, about a traumatic event that has been experienced by a family member or a close friend (American Psychiatric Association, 2000, Kerasiotis and Motta, 2004).

The incidence of PTSD symptoms is found to be higher in Emergency Nurses than in other nursing specialties (Figley, 1995, Boudreaux and McCabe, 2000, Alexander and Klein, 2001). In a British study, almost one third of the respondents experienced symptoms, indicative of PTSD (Helps, 1997). Another British and a Canadian study both found that about 20% of a sample of Emergency Nurses met the criteria for PTSD (Clohessy and Ehlers, 1999, Laposa et al., 2003). In two American studies, respectively 25% (Gates et al., 2011) and 33% (Dominguez-Gomez and Rutledge, 2009) met clinical cut-offs for PTSD. These figures are much higher than a PTSD prevalence of 14%, found in a population of internal/surgical ward nurses (Mealer et al., 2007).

The difference in PTSD prevalence between Emergency Nurses and nurses from other wards may be explained by a difference in exposure to traumatic events. All nurses have to deal with potentially traumatizing situations (O’Connor and Jeavons, 2003), but Emergency Nurses are routinely confronted with severe injuries, death, suicide and suffering and are also frequently exposed to verbal and physical aggression (Crabbe et al., 2004, Bennett et al., 2005, McFarlane and Bryant, 2007). A systematic review showed that 82–100% of emergency personnel are frequently exposed to work related traumatic events (Donnelly and Siebert, 2009). Another study revealed that 75% of Emergency Nurses were confronted in the past year with aggressive behavior, compared with 43% nurses of internal medicine wards, 23% of surgical wards and 9.9% of pediatric wards and gynecology. Verbal aggression over the same period was reported by 75% of Emergency Nurses, compared with 39% of their colleagues in internal medicine wards, 25% in surgical wards and 12.4% in pediatric wards and gynecology (Winstanley and Whittington, 2004). In addition, Emergency Nurses often have to move from one traumatic event to another, leaving little time for recovery (Alexander and Klein, 2001, Gates et al., 2011, Kilcoyne and Dowling, 2007).

Although not every confrontation with traumatic events leads to PTSD, it is well known that exposure to traumatic events may have significant psychological consequences (Figley, 1995, Kerasiotis and Motta, 2004, Alden et al., 2008). Research has shown that emergency personnel reports symptoms of PTSD after professional confrontations with traumatic events, such as nightmares, recurrent images and thoughts, flashbacks, sleeping difficulties, irritability and depression, lack of interest in daily life, loss of hope in the future, amnesia, anger, loss of concentration and restlessness (Ravenscroft, 1994, Caine and Ter-Bagdasarian, 2003). These negative experiences may lead to increased absenteeism, and loss of productivity, due to a change in professional attitude. Moreover, even the quality of nursing care can be negatively altered (Donnelly and Siebert, 2009, Gates et al., 2011). One has thus to be aware that PTSD in emergency care providers can have wide-ranging effects, not only for the individuals themselves, but also for their work setting, as PTSD may lead to a decrease in job satisfaction and an increase in psychosomatic distress, sick leave and staff turnover (McIvor et al., 1997, Collins and Long, 2003).

Physiological and psychological responses to traumatic events should however be seen as a normal reaction and in most cases these responses diminish within a short period of time. In contrast, the repetitive exposure to significant stressors and/or the inability to cope effectively with the traumatic experience may result in the development of psychological disorders (Mealer et al., 2007). Repetitive exposure to traumatic events can thus be seen as an important risk factor for the development of PTSD in Emergency Nurses. From this perspective, confrontation with large scale events such as e.g. a mass collision, does not necessary have more impact than repeated, daily confrontation with small scale events. Marmar et al. (1996) compared Emergency Nurses who witnessed a “large scale” disaster with Emergency Nurses who were repetitively confronted with “small scale” events during their daily work. No differences were found between the two groups in anxiety, depression and post-traumatic stress reactions, suggesting that repeated exposure to small scale events can indeed have serious consequences (Marmar et al., 1996, Clohessy and Ehlers, 1999).

Several authors investigated the nature and impact of traumatic events, reported by Emergency Nurses (Kerasiotis and Motta, 2004, Bennett et al., 2005, De Clercq et al., 2011, Healy and Tyrrell, 2011). Research showed that Emergency Nurses are regularly confronted with a broad variety of traumatic events (De Clercq et al., 2011). The most distressing events, in decreasing order, were cot death; incidents involving children; dealing with patients’ relatives and family; confrontation with burn patients; dealing with psychiatric patients; and handling dead bodies. Furthermore, the hectic work environment and overcrowding can hinder the recovery process and have a negative impact on the Emergency Nurse (Kilcoyne and Dowling, 2007).

In addition to type and frequency of exposure, female gender, professional seniority and more time on the job have been found to be predictors of PTSD symptoms in Emergency Nurses (Ortlepp and Friedman, 2002, Laposa et al., 2003, Dominguez-Gomez and Rutledge, 2009, Lavoie et al., 2011). Inadequate coping and lack of adequate social support may contribute to aggravation and persistence of PTSD symptoms. As far as coping is concerned, two general types of strategies can be distinguished: a problem-solving strategy and an emotion-focused strategy. Problem-solving (task oriented) coping involves attempts to do something about the stressful situation itself. Emotion-focused coping involves efforts to regulate emotions experienced because of the stressful event (Folkman and Lazarus, 1985). Both coping strategies can be active or avoidant. In more recent literature, avoidant emotional and task oriented coping is often merged and called avoidance coping (LeBlanc, 2009). The effectiveness of coping strategies is time related. As a health professional, the Emergency Nurse is expected to have an active problem solving approach during an emergency care intervention. During confrontation with a traumatic event, an avoidant emotional coping strategy (e.g. distraction) can be important for the emergency care worker in order to be able to go on functioning, but in the longer term this may hinder the recovery process and can therefore lead to the development of PTSD symptoms (Clohessy and Ehlers, 1999).

Next to coping, social support can be seen as a buffer for the development of PTSD symptoms. Research showed that Emergency Nurses especially use informal resources of social support for coping with the strong emotions experienced after a traumatic event (Fernandes et al., 1999, Battles, 2007). Having a supportive social network and being able to talk things over with colleagues, was found to have a strong preventive effect on the development of PTSD (Lavoie et al., 2011). Lack of social support and poor team communication on the contrary has been found to be related to higher levels of fatigue, burnout and post-traumatic stress responses among emergency personnel (Van der Ploeg and Kleber, 2003).

The aim of the present study was: (1) to examine the frequency of exposure to and the nature of traumatic events in Emergency Nurses; (2) to examine what percentage report symptoms of post-traumatic stress, anxiety and depression, somatic complaints, sleep problems and fatigue reaching a sub-clinical or clinical cut-off; and (3) to study the contribution of frequency of traumatic events, coping and perceived social support to PTSD symptoms, psychological distress (anxiety and depression), somatic complaints, fatigue and sleep problems in Emergency Nurses.