The Sound of Silence: The Occurrence of PTSD in Nursing
It’s More Common Than Most Think
Nurses face immeasurable exposure to traumatic events in their roles as first responders and caregivers to the communities we serve. Those who work in specialty areas such as the emergency department (ED), intensive care (ICU), mental health services, and trauma are at particular risk for bearing witness to the human atrocities that can shake the psychological foundation of any person.
With care and compassion acting as the core of nursing fundamentals, who cares for the caregiver when the strain of trauma is too overwhelming?
Sadly, nurses themselves are failing to recognize the illness in themselves and seek treatment.
For many years in American history, the concept and diagnosis of post-traumatic stress disorder (PTSD) was reserved for those brave men (and only men) who witnessed the horrific shock of war. Historians point as far back to 1597 to Shakespearean plays where symptoms of traumatic experiences are described. Even Civil War nurse Walt Whitman describes terrifying nightmares and flashbacks of the war in many of his mid-1800 writings.
For men who directly experienced war, the symptoms were described as exhaustion, shellshock, combat fatigue, and “soldier’s heart.” It was not until the 1960s that researchers began studying the effects of trauma on the civilian population, and it wasn’t until the late 1970s that the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) included PTSD as a valid diagnosis.
The description for PTSD in the DSM lists, "The essential feature [of PTSD] is the development of characteristic symptoms following a psychologically traumatic event." Symptoms involve the "re-experiencing of the traumatic event, numbing of responsiveness to, or reduced involvement with, the external world, and a variety of autonomic, dysphoric, or cognitive symptoms."
The Development of PTSD and PTSD in Nurses Today
As the label has evolved, the diagnosis of PTSD now includes the aftereffects of trauma associated with domestic abuse, war-zone reporting, and vicarious trauma. Loss of sleep, nightmares of the event, irritability, and frequent startling to minor noises are all well-publicized symptoms, which, if lasting more than six months, are considered diagnosable as PTSD.
Other lesser-known and easily missed symptoms of nurses with PTSD can include a form of hyper-vigilance where the nurse is hyper-focused on stable patients, being irritable or frequently angry, and feeling detached from friends and family.
Another subtle symptom is the nurse with an exaggerated negative belief: "If I were a better nurse, then I would have caught that patient's decline." Difficulty concentrating, avoiding certain rooms where they experienced trauma, and non-specific somatic complaints such as body aches, headaches, and lack of overall energy. Nurses with PTSD may be calling out sick more often as a protective mechanism.
And with increasing reports of a nursing shortage in the US, American nurses are only going to have more pressure put on them.
There are very few studies that seek to show the rate or potential of traumatic stress disorders in nursing. However, one study published in Depression and Anxiety (2009) noted that as many as 22% of the 810 nurses who participated in the study had symptoms of PTSD with more than 18% meeting diagnostic criteria. Richard Avila, MBA, RN, is one such nurse that was diagnosed with PTSD long after he had moved into a less-stressful role as a corrections nurse:
"My first role as an RN was in correctional health... If there was a behavioral issue with the inmate, the deputies will step in and handle the patient. My next role changed everything. I was hired as the ‘muscle’ nurse for a high-acuity behavioral health hospital... where violence against the staff was a common occurrence. They paid well, and I worked a lot of overtime, which contributed to my burnout. I lasted a year there, but the constant stress from the patient violence got to be too much. I wasn't sleeping, I was reactive to my family and friends, and I had a hard time being in large crowds. It reminded me of how my dad described himself after coming back from Vietnam. I thought the symptoms would go away once I switched jobs, but they didn’t. I finally got help from a therapist I saw weekly and was diagnosed with PTSD. I’m much better now. I work 40 hours a week (compared to 60+) and take time for relationships and more self-care activities.”
Not all people who experience the same trauma event end up with symptoms of PTSD.
Patricia Pearson, RN, LMFT, who specializes in PTSD, states, "It is not just about the severity of the trauma experienced, but more about a person's experience of multiple traumas over time that can have a significant effect on a person with PTSD… Those nurses who have experienced complex trauma (multiple trauma's overtime), such as an abusive childhood, could be at a higher risk for PTSD."
PTSD in Nursing, What Can Be Done?
Nurses experiencing PTSD need an environment where they feel heard and understood by their peers and leadership. Unfortunately, many nurses believe their suffering is prolonged when nurse managers fail to recognize PTSD and don’t provide support beyond the Employee Assistance Program (EAP) referral.
Yet, most EAP clinicians aren’t trained to recognize and treat trauma. According to Pearson, Eye Movement Desensitization and Reprocessing (EMDR) and Brainspotting are the gold standards for helping those suffering from PTSD process the trauma and begin to heal. If nurses suspect they have PTSD, they should seek clinicians trained in trauma therapy.
One nurse, who wished to remain anonymous, stated that, in spite of numerous traumatic births in her Midwest labor and delivery unit, peers and managers advised her to "stop talking about it." She sought treatment from a psychiatrist and, in spite of therapy and medication, still had a challenging recovery and eventually left the specialty as she continued to have fear and anxiety during routine births:
“I chose to embrace this as an opportunity to bring about positive change, not only for myself but for the profession. My Master's Degree research project became focused on this area: ‘Burnout, Compassion Fatigue and Vicarious Trauma among Obstetric Nurses.’”
"PTSD is not a sign of weakness," Pearson states. "It's the brain's way of protecting us from harmful experiences. The brain encapsulates the event, similar to how the body encapsulates a tuberculosis spore, yet any of our five senses can trigger the nurse to re-experience levels of the event.”
While few studies validate the occurrence of PTSD in the nurses, shining a light of awareness into the dark corners of the nursing profession by openly discussing the probability and direct experiences of nurses -- whether they be of emotional, mental, or physical abuse -- is a start.
By remaining silent about their struggles, nurses add to the stigma or “shame” of admitting psychological challenges in managing traumatic experiences.
Through trusting relationships with managers who are willing to dig deeper with staff on a routine basis and offer substantial debriefing sessions after traumatic events in a department (and supportive peers), PTSD symptoms can be addressed and treated in a timelier manner.
Caring for those who provide care is essential to the longevity and mental endurance of our profession.