Improving Resilience in Nurses Affected by PTSD

Post-traumatic stress disorder (PTSD) in nurses and other healthcare workers is one outcome of the COVID-19 pandemic

Post-traumatic stress disorder (PTSD) in nurses and other healthcare workers is one outcome of the COVID-19 pandemic (Dutheil et al., 2020). Proactive prevention measures, education, and early identification of symptoms will reduce effects of stress, and potentially reduce loss of life (Jun & Melnyk, 2020). The purpose of this article is to discuss PTSD and how it relates to healthcare professionals, particularly, nurses. Risk factors such as co-worker conflict, personal and professional obligations, moral injury, and gender differences are examined. Resilience strategies such as the Resilience in Stressful Events (RISE), MINDBODYSTRONG, and the Wellbeing Initiative with mood fit app programs are interventions which may prevent or treat pandemic-related stress. Additionally, the significance of administrative support will be emphasized.

PTSD

PTSD is a psychiatric illness that occurs in some people who have experienced traumatic events or have witnessed those events (Cho & Kang, 2017). Symptoms persist for at least a month and include headaches, intrusive thoughts, flashbacks of trauma, hypervigilance, and sleep disturbance that leads to considerable social, interpersonal, or occupational dysfunction (Levin, 2019). Over time, there has been controversy about the definition and diagnostic criteria of this condition, perhaps leading to confusion and lack of appropriate treatment. The DSM-IV defined PTSD as occurring when a “person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness, or horror" (U. S. Substance Abuse and Mental Health Services Administration [SAMHSA], 2016, para. 1). The newest edition, DSM-5, narrowed it down to “actual or threatened death, serious injury, or sexual violence” (American Psychiatric Association, 2017). This restricted definition of “trauma exposure” reduced the incidence of PTSD diagnosis. PTSD negatively affects nurses’ health and can result in poor outcomes.

Precipitating Factors of PTSD

PTSD negatively affects nurses’ health and can result in poor outcomes.

Co-workers
Relationships with coworkers and other team members play a substantial role in whether nurses develop PTSD or other ailments after traumatic events (Danella et al., 2017). Nurses experiencing burnout and or PTSD respond negatively when asked to describe their coworkers, team members, teamwork, and the impact of their work (Czaja et al, 2012). Similarly, nurses who obtain social support from nursing administration and colleagues after a traumatic event were less likely to experience PTSD and work-related fatigue. While patients themselves were not the precipitating factors of stress, the work environment appeared to create conflict that existed prior to the traumatic event (Czaja et al., 2012).

Professional and Personal Obligations
Exhausted providers during the recent pandemic felt the heavy burden of professional obligations, running thin on personnel and getting little rest without adequate time for recovery (Jun & Melnyk, 2020). Adding to the chaos was the lack of professional standards and evidence-based practice when healthcare agencies faced personal protective equipment shortages. Finally, the fear of acquiring the illness and spreading the disease to their families took a toll on the mental health of many providers. Early reports focused on asymptomatic transmission which intensified the anxiety of the workers fearing accidental spread (Chew et al., 2020). Providing disposable protective equipment decreased many healthcare workers’ anxiety about transmission of illness to their families at home but did little for the mental angst of continually managing those dying from this virus.

...the fear of acquiring the illness and spreading the disease to their families took a toll on the mental health of many providers

Caregivers are burdened with the task of maintaining employment while responding to the needs of their family at home (Levin, 2019). Childcare issues and personal affairs may leave many feeling torn between a sense of duty to their patients and their loved ones. Such prevailing thoughts and overwhelming worries may increase psychological stress and the rise in somatic symptoms (Chew et al., 2020). For example, during the pandemic, separation from family and friends as nurses worked long hours and/or self-quarantined to reduce the risk of infecting others resulted in isolation. Family members of nurses experienced stress as their loved ones worked to care for the patients with COVID-19 or were subjected to additional pressures that accompanied working during this pandemic.

Family members of nurses experienced stress as their loved ones worked to care for the patients with COVID-19...

Moral Injury
In traumatic or unusually stressful occurrences, individuals may perpetrate, fail to prevent, or witness events that contradict their own deeply held moral beliefs and expectations (Norman & Maguen, 2020). Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events such as commission or omission. A moral grievance can occur in response to acting or witnessing behaviors that go against individual values and moral beliefs. Having to make determinations regarding resources that affect the survival of others or in situations where all options will most likely lead to a negative outcome can exacerbate moral injury (Watson et al., 2022). An example of this may be treating terminal patients during the pandemic outbreak while not allowing family to be present.

A moral grievance can occur in response to acting or witnessing behaviors that go against individual values and moral beliefs.

For moral injury to occur (Watson et al., 2022), the individual must feel like a transgression occurred and that they or someone else “crossed a line” with respect to their moral philosophies. Guilt, shame, disgust, and anger are some of the trademark reactions of moral injury. Guilt involves feeling anguish and remorse regarding the morally injurious occurrence and shame is when the conviction about the occurrence generalizes to the whole person. Disgust may occur as a response to memories of an act of perpetration, and anger may occur in reaction to a loss or suffering betrayal. Other events that may lead to moral injuries include making decisions where no option will result in a positive outcome, witnessing events that go against the nurse’s moral compass, and experiencing a betrayal. Another hallmark reaction to moral injury is an incapacity to self-forgive, and consequently engaging in self-sabotaging behaviors (Watson et al., 2022).In some cases, a moral dilemma may occur like this mini-case study implies:

Guilt, shame, disgust, and anger are some of the trademark reactions of moral injury.

Nurse Jane was caring for a 29-year-old man dying of COVID-related respiratory failure, and because of visiting restrictions, his family was very distraught. She attempted to help the family by using her own phone to provide a video phone call so that the family could see and speak to their family member just before he died. Jane did not have policy to guide her on how to help in this difficult situation, and her improvised response, while helpful, left her feeling as if she had done something wrong. She was conflicted about having to be present at a time when families would normally have privacy. Being present during the video call had also required her to be a direct witness to the family’s distress, which proved to add a stressful experience during an already overwhelming pandemic.

Gender
Females are most vulnerable to PTSD (Sendler et al., 2016). Other risk factors are being single or divorced, diagnosis of anxiety and depression, and low social support. Psychiatrists and general surgeons are more likely to develop PTSD than other physicians. Because most nurses are female, screening for stress-related symptoms may be prudent. After a trauma, some may feel despondent, use alcohol or drugs, or develop PTSD (U. S. Department of Veterans Affairs, 2022). Females are more than twice as likely as men to develop PTSD (10% for women and 4% for men). There are a few explanations why women might develop PTSD more than men. Women with PTSD are more likely to feel depressed and anxious, while men with PTSD are more likely to have problems with alcohol or drugs. Both women and men who experience PTSD may develop physical health problems, thus meriting early treatment of this phenomena (Sendler et al., 2016).

Resilience

Females are more than twice as likely as men to develop PTSD

Resilience is adapting and responding positively to trauma and misfortune (American Psychological Assocaition [APA], 2022; Hendrickson, 2017) and recovering from unwarranted change (Corcoran, 2020). Resilient individuals experience fewer negative outcomes in response to traumatic events. The skill of resilience is not known to be hereditary, rather, it is a steady course, a conscious effort, a capacity that can be acquired through education or coaching (Cho & Kang, 2017). Resilience is a psychological act that mitigates the negative effects of trauma and promotes growth following the adverse events. Resilience is one of the most important factors that enhance post-traumatic adaptation and that having a moral compass, an internal system of values and ethics, facilitates higher levels of resilience (Cho & Kang, 2017).

Resilient individuals experience fewer negative outcomes in response to traumatic events.

Resiliency characteristics have been linked to cognitive reappraisal, social support, active coping strategies, and the use of humor (Cho & Kang, 2017). Interventions such as mindfulness, meditation, and yoga are methods that can build resilience and promote adaptation. Resilience can be compared to a muscle—if you work on it, it can increase in strength (Hendrickson, 2017). Professionals agree we all have resilience but in times of extreme stress, the ability to apply resiliency can be challenged.

Models to Increase Resilience

Interventions such as mindfulness, meditation, and yoga are methods that can build resilience and promote adaptation.

Resilience in Stressful Events (RISE)
Researchers at Johns Hopkins University in the Centers for Health Services and Outcomes Research, Baltimore, MD created the Resilience in Stressful Events (RISE) program to improve employee health related to traumatic events (Corcoran, 2020). This peer-to-peer program is designed to support nurses and other hospital staff during excessively stressful circumstances. Healthcare employees are provided with training related to peer support for those who experience emotional and physical stress after job-related traumatic events, such as disasters, poor patient outcomes, and medical errors. Peers are on standby to assist to employees when necessary. The focus is not therapy but providing support for emotionally stressed caregivers. The hallmark of the program is using volunteers from an interprofessional pool and increasing the levels of awareness during high-stress events (Corcoran, 2020).

The focus is not therapy but providing support for emotionally stressed caregivers.

MINDBODYSTRONG
The MINDBODYSTRONG (Sampson et al., 2020) intervention promotes acceptance, active coping, stress reducing strategies, and health coaching for nurses. The MINDBODYSTRONG program is adapted from the cognitive behavioral skill‐building intervention, Creating Opportunities for Personal Empowerment (COPE) program, developed by Bernadette Melnyk (Sampson et al., 2020). COPE has been shown to decrease depressive symptoms, anxiety, and stress while improving healthy lifestyle behaviors in children, adolescents, and college‐age youth (Buffington et al., 2016). The MINDBODYSTRONG series consists of eight weekly sessions that focus on three areas: caring for the mind, caring for the body, and skills building. Participants learn cognitive behavior therapy (CBT) concepts, establish weekly goals, and complete skill‐building endeavors. Educational interventions facilitate development of better habits related to mindfulness, healthier eating, positive self-talk, and physical activity (Sampson et al., 2020).

The MINDBODYSTRONG series consists of eight weekly sessions that focus on three areas...

Wellbeing Initiative and Mood Fit
As the extraordinary stresses confronting nurses during and after the COVID-19 pandemic take a toll on nurses’ mental health and wellbeing, they need authentic support systems and devices (American Nurses Association [ANA], 2020). Recognizing this critical necessity to support the mental wellbeing and resilience of nurses, the American Nurses Foundation partnered with organizations to develop a comprehensive mental well-being program that incorporates virtual support systems and a digital toolkit to enhance the current and long-term needs of America’s four million nurses (ANA, 2020).

The American Nurses Foundation has launched the National Well-being Initiative intended specifically for nurses across the United States (ANA, 2022; 2020). These resources will help nurses build resilience and take necessary steps to manage the stress and overcome the suffering caused by COVID-19 (ANA, 2020). Moodfit is a mobile app is customized for nurses to support them with wellness goals (ANA, 2022; 2020). Nurses can set goals using best-practice methods such as mindfulness meditation, breathing exercises, lifestyle tracking (e.g., sleeping and nutrition) and set up individualized reminders. The mobile app can be used in real time and in tandem with virtual chat rooms where one can support others while expressing concerns and bonding through shared experiences.

Administrative Support

Administrators may improve resilience by being attentive to and supportive of psychological, physical, spiritual, and psychosocial needs of healthcare providers (Levin, 2019). Individuals may experience or perceive betrayal from leadership, others in positions of power, or peers resulting in adverse outcomes or moral injury. Implementing techniques to address stress should be encouraged at the administrative level (Norman & Maguen, 2020).

Implementing techniques to address stress should be encouraged at the administrative level

Administrators can help by increasing communication with employees, particularly around changing policies and decision making (Watson et al., 2022). They can communicate that during times of extreme stress, high volume of cases, and changing circumstances, providers may experience guilt, shame, anger and difficulty functioning. Patience with oneself and others and check-ins—even brief ones—after particularly difficult days or cases may identify potential problems. Leaders may not be able to foresee what employees need during unusual times, but they should express praise and gratitude for the work employees are doing, particularly those in less senior positions, who often are less likely to seek support. When appropriate, remind employees who are performing appropriately that poor outcomes may happen and that challenging situations are appropriate times to seek help and assistance.

Workplace structure should be implemented to enhance relief and provide rest, so providers do not suffer burnout (American Psychiatric Nurses Association [APNA], 2022). Overtime tends to accumulate and deter rejuvenation, and should be limited. Incorporating resilience programs can help workers develop skill sets to use during times of increased stress. Workforce resilience and self-care programs should be publicized; teamwork and morale building activities should be included in addition to wellness breaks. Staff appreciation events and verbal acknowledgement of ongoing efforts should be continued to support employees. Strategies to address trauma include team support to discuss the challenges of providing care for patients, regular contact from supervisors, and briefing on moral injuries (APNA, 2022).

Conclusion

PTSD is widely associated with veterans, but frequently exists among caregivers, especially nurses (U. S. Department of Veterans Affairs, 2022). Colleagues have a role in the success or demise of a functioning organization and peer support is imperative to reduce negative effects of trauma. While gender appears to be a factor in developing PTSD, other factors may include moral injury, lack of collegiality, and perceived lack of administrative support. Fortunately, there are tools available to develop or improve resilience among nurses (Sendler et al., 2016) such as MINDBODYSTRONG (Sampson et al., 2020). Administrators can make a difference by being aware of the climate of the organization and understanding that healthcare workers need assistance during times of crisis. In doing so, they can be proactive in ameliorating far-reaching effects of stressful events such as the COVID-19 pandemic and prepare for future challenges.

Authors

Renee Bauer, PhD, MS, PMHNP-BC, RN
Email: Renee.Bauer@indstate.edu

Renee Bauer is the Community Coordinator of the school of nursing at Indiana State University. She has been in nursing for 26 years. She teaches at both the graduate and undergraduate levels. She is a member of Sigma Theta Tau International and her primary interests are psychiatry and research.

Emily Cannon, DNP, MS, RN 
Email: Emily.Cannon@indstate.edu

Emily Cannon has worked for Union Hospital in Terre Haute, IN as a medical-surgical float nurse (1995-1997) and later as an Infection Control Practitioner (1997-2003). From 2003-2012, she served as a nursing faculty member at Ivy Tech Community College until she began teaching in the Baccalaureate Nursing Program for Indiana State University. She is a member of Sigma Theta Tau International, Academy of Medical-Surgical Nurses, and the Emergency Nurses Association.

Robert Owegi, DNP, RN, CMSRN, CNE 
Email: Robert.Owegi@indstate.edu
ORCID ID: 0000-0002-6885-0015

Robert Owegi works at Indiana State University and teaches medical-surgical nursing in the undergraduate distance track. He has been a registered nurse for 15 years. His work history includes Indiana University Hospital and Methodist Hospital in Indianapolis. Robert is a member of Sigma Theta Tau International, Academy of Medical-Surgical Nurses, and National League for Nursing.