Published ahead of print on December 21, 2006, doi:10.1164/rccm.200606-735OC
© 2007 American Thoracic Society doi: 10.1164/rccm.200606-735OC
Increased Prevalence of Post-traumatic Stress Disorder Symptoms in Critical Care Nurses1 Department of Medicine and 2 Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia 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 80262. E-mail: marc.moss{at}uchsc.edu
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.
Key Words: 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. 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 2015. 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).
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 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
Survey of Critical Care Nurses in the Metropolitan Atlanta Area
Statistical Analyses
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 patient-to-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 (3.8 ± 1.6 vs. 3.9 ± 1.6 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, 1.24–1.72; 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 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, 1.23–1.71; 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 2005. A total of 195 (47%) of the questionnaires were returned. Fifty-four of the respondents did not complete 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
Subgroup Analysis of Nurses with Positive Symptoms of PTSD
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 Disorders, 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. Studies that determine the specific characteristics that predispose individuals to the development of symptoms of PTSD and identify specific interventions for these individuals are warranted.
The authors thank Kim Ragan, Mike Vaughn, M.D., Kelly Skelton, M.D., and Susan Berel for their assistance with the in-depth telephone interviews, and Sue Odom and Marsha Burks for their assistance with the design of the study.
Supported by unrestricted funds from the Emory University School of Medicine. This article has an online supplement, which is accessible from this issue's table of contents at www.atsjournals.org Originally Published in Press as DOI: 10.1164/rccm.200606-735OC on December 21, 2006 Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. Received in original form June 1, 2006; accepted in final form December 21, 2006
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