Posttraumatic stress disorder - in nurses caring for patients with COVID-19
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Posttraumatic stress disorder
in nurses caring for patients
with COVID-19
BY RICHARD HILL, RN, CWCN, FACCWS
Abstract: Little is known about the psychological impact of trauma from pandemics
such as the COVID-19 pandemic. This article explores a descriptive study on the impact
of COVID-19 and the prevalence of posttraumatic stress disorder among RNs caring for
patients with COVID-19.
Keywords: burnout, compassion fatigue, COVID-19, posttraumatic stress disorder, PTSD,
secondary stress disorder
DESPITE INCREASED research on stress.1,4 Occupational burnout re-
the effects of repeated exposure to fers to a syndrome related to chronic
complex psychological trauma, little stressors that manifests as mental
is known about the psychological distancing, increased negativism or
effects of exposure to traumas such cynicism, and/or reduced profession-
as pandemics or natural disasters, alism. Compassion fatigue is similar
even though the 2003 outbreak of in that emotional or physical exhaus-
severe acute respiratory syndrome tion can manifest as a diminished
revealed an increased prevalence of capacity for compassionate care, and
posttraumatic stress symptoms this exhaustion is typically brought on
among healthcare workers.1-3 The by secondary traumatic stress. Nurses
COVID-19 pandemic has provided may experience secondary traumatic
another opportunity to assess the stress due to exposure to and the
psychological impact of a pandemic compartmentalization of trauma ex-
on healthcare professionals. This ar- perienced by patients or colleagues.2,4
ticle explores a descriptive study on Posttraumatic stress disorder
the impact of COVID-19 on RNs and (PTSD) is characterized as a mental
the prevalence of posttraumatic health disorder triggered by experi-
symptoms in those caring for pa- encing or witnessing a traumatic
tients who have or are presumed to event.5 According to the Diagnostic
have COVID-19. and Statistical Manual of Mental Disor-
ders, 5th edition (DSM-5), signs and
Background symptoms of acute PTSD typically
Recent trends in the literature have occur within 3 months of exposure
shed light on the various ways in to a traumatic event and last longer
which healthcare settings can be psy- than a month.6 In chronic PTSD,
chologically challenging workplaces, symptoms typically last 3 months or
with a focus on compassion fatigue, longer.7 Symptoms of delayed-onset
burnout, and secondary traumatic PTSD typically begin 6 months
52 l Nursing2021 l Volume 51, Number 7 www.Nursing2021.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.R.CLASSEN/SHUTTERSTOCK
or more after an exposure to a trau- with a few changes to the wording of involvement in the care of pa-
matic event.7 and a focus on COVID-19.6,8 Thirty- tients with COVID-19 based on
one RNs completed the survey for a their percentage of time spent car-
Methods response rate of 62%. ing for patients with positive and/or
This descriptive cross-sectional study The PDS-5 is a 20-item question- presumptive COVID-19 results.
assessed active RNs at two acute care naire that examines a participant’s Similarly, they were asked to report
hospitals in north Louisiana in June reaction to an experience on a only new symptoms within the pre-
2020. Convenience sampling was 5-point Likert scale of 0 to 4, with 0 vious 6 months that had persisted
conducted on volunteer participants, indicating a less significant reaction for more than a month. They could
targeting those who worked full time. and 4 indicating a more significant also elaborate on any traumatic
The participants were asked to iden- reaction. The severity of PTSD is de- events related to caring for these
tify their daily level of exposure to termined by assessing the total scores patients via a free-form, optional
patients with COVID-19 as either of 20 symptom ratings ranked by field added to the end of the PDS-5.
“greater than 75%” or “less than severity as follows.8 Free counseling was provided to
25%” of their patient load, or indicate • 0 to 10: minimal participants via virtual sessions with
that they had “no exposure” to these • 11 to 23: mild a licensed therapist.
patients. Based on their answers, re- • 24 to 42: moderate
spondents were sorted into “high- • 43 to 59: severe Analysis and results
exposure,” “low-exposure,” and “no • 60 to 80: very severe. In total, 31 RNs completed the
exposure” categories. A total score of 28 or more repre- PDS-5. Of those, 18 (58.0%) were
A survey modeled after the Post- sents a probable PTSD diagnosis.8 classified as high-exposure, 7
traumatic Diagnostic Scale (PDS-5) To quantify their level of daily (22.6%) were classified as low-expo-
in the DSM-5 was utilized and dis- exposure, the study participants sure, and 6 (19.4%) were classified
seminated to 50 RNs online via email were asked to define their level as no exposure based on descrip-
www.Nursing2021.com July l Nursing2021 l 53
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.tions of their daily exposure to pa- of the participating RNs, there was quantifiable symptoms (standard
tients with COVID-19. Demographic uncertainty about whether deviation [SD] ±5.96), and 9 (50%)
data were compiled and analyzed their PTSD symptoms could be met the conditions for probable
according to years of experience. Of characterized as acute, chronic, PTSD diagnosis based on their expe-
all the participating RNs, 26 (83.8%) and delayed-onset. riences. (See PTSD symptom break-
were White, 3 (9.7%) were His- Descriptive statistical analysis was down in the high-exposure group.)
panic, and 2 (6.4%) were Black. Ad- performed on data from the high- Twelve participants in the high-
ditionally, 25 (80.6%) participants exposure group and gathered in a exposure group (66.7%) had symp-
identified as female and 6 (19.4%) spreadsheet. Of these 18 individuals, toms ranging from moderate to se-
identified as male. 2 (11.1%) had minimal symptoms, 4 vere. The most common symptoms
In total, 12 participants (38.7%) (22.2%) had mild symptoms, 8 experienced by the participating RNs
provided free-form descriptions of (44.4%) had moderate symptoms, were intrusive thoughts, emotional
their experiences, all from the high- and 4 (22.2%) had severe symptoms. upset when reminded of the event,
exposure group. Due to difficulty On average, the participants in the persistent negative emotions, detach-
identifying the symptom timelines high-exposure group reported 9 ment from others, and sleep difficul-
ties. The least common symptoms
reported by the participants were
dissociative amnesia and reckless or
PTSD symptom breakdown in the high- self-destructive behavior.
exposure group6 The low- and no-exposure groups
Below are statistics related to responses from 18 high-exposure participants. included 13 participants (42.0%). Of
The RNs responded on a Likert scale of 0 to 4, with 0 indicating a less significant those, only 1 reported detachment
reaction and 4 indicating a more significant reaction. The 20 items were numbered from others, whereas the other par-
based on their order in the PDS-5 and correspond to specific DSM-5 criteria. ticipants experienced none. None of
the participants from either group
Item/symptom Mean SD
met the conditions for probable
1. Intrusive thoughts 2.11 1.23 PTSD diagnosis.
2. Bad dreams/nightmares 1.39 1.33
3. Flashbacks 1.28 1.07
Self-reporting
Two distinct trends were noted when
4. Emotional upset when reminded of event 2.06 1.21 the author analyzed self-reported
5. Physical reactions when reminded of event 1.72 1.18 traumatic experiences among the
6. Avoidance of thoughts/feelings 1.72 1.60 participating RNs: emotional distress
due to patient isolation and feelings
7. Avoidance of situations 1.22 1.21
of helplessness (see Trends in partici-
8. Dissociative amnesia 0.44 0.70 pant responses). A larger sample size
9. Persistent negative expectations of self or others 1.28 1.32 may yield more concrete themes and
10. Persistent distorted blame 1.17 1.38
allow for more thorough data extrac-
tion in the future.
11. Persistent negative emotions 2 1.33
• Emotional distress related to
12. Loss of interest 1.72 1.41 patient isolation. The first theme
13. Detachment from others 2.39 1.24 noted involved secondary trauma
related to the negative experiences
14. Emotional numbness 1.44 1.20
encountered in patient care, which
15. Irritable/aggressive behaviors 1.44 1.20 may be related to the emotional
16. Reckless or self-destructive behaviors 0.5 0.71 burden carried by nurses.9 Patient
17. Hypervigilance 1.22 1.21 isolation and the disruption of a
family’s grieving process appeared
18. Exaggerated startle response 1 1.14
to take a toll on the participating
19. Troubled concentration 1.55 1.29 RNs, who described moving from
20. Sleep difficulties 2.05 1.16 one code to the next and families
who were unable to mourn at the
54 l Nursing2021 l Volume 51, Number 7 www.Nursing2021.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.patient’s bedside. Additionally,
some traumatic experiences seemed Trends in participant responses
related to the participating RNs’ Below are examples of direct feedback from the participating RNs related to the
feelings of not having fulfilled their two trends found in the authors’ analysis:
role as a patient advocate.9 They Emotional distress due to patient isolation:
described patients who died with-
• “A patient death is difficult as is. But some days, we were having to just move on
out seeing their families and others
from one code to the next. And just moments before all of this, these patients
kept alive with machines despite
had to say their goodbyes to family that can’t even mourn at their bedside.”
poor prognoses.
• “People [were] dying without seeing their families or being kept alive with
• Feelings of helplessness. This
machines with a very poor prognosis.”
was the most prevalent theme ex-
pressed in the participating RNs’ self- • “We ran repeated codes on patients who medically and ethically should be
DNR.”
reported experiences. They noted
feelings of inadequacy and failure Feelings of helplessness:
from being unable to treat patients • “With this virus, the patients deteriorate swiftly. You can do everything you can
with COVID-19 effectively due to think of and the patient still deteriorates. It’s hard to be a caregiver and be
limited understanding of the disease, unable to help your patient no matter how hard you try.”
which often resulted in patient dete- • “[I have] feelings of inadequacy and failure due to our COVID [patients] not
rioration. receiving the care they deserve (mainly due to having to cluster care). Also
This theme may also go hand-in- feeling like we’re doing things to them rather than for them because we
hand with insufficient trauma re- really don’t know how to treat this disease.”
sources, a new concept in which
resources such as staffing, knowl-
edge of duties, access to healthcare Previous research has attempted ameliorating factor that may merit
professionals from other disciplines to quantify the prevalence of PTSD further study.7,14
and fields, and tangible supplies among healthcare workers. One study
such as personal protective equip- identified a 19.6% prevalence of Limitations
ment (PPE) are limited. This lack of PTSD symptoms among workers who Descriptive research has inherent
access can contribute to stress and had been exposed to biological mate- limitations because a problem cannot
worsen traumatic working condi- rial such as infectious body fluids.12 be tested or verified inferentially. It
tions.9 Early in the pandemic, many Another examined nurses in a trans- allows researchers to summarize the
healthcare facilities had to either plant ICU and noted a prevalence of characteristics of the study group,
reuse or ration PPE. This increased PTSD symptoms ranging from 17% to but it does not necessarily assess
anxiety and uncertainty among 48%.13 Similarly, earlier research dem- whether the findings would apply to
healthcare staff and contributed to onstrated a 22% prevalence of PTSD a broader population. This limitation
a heightened fear of contagion and symptoms among ICU nurses. may have been compounded by this
infecting loved ones.10 Using these prevalence rates as a study’s relatively small sample size
guide, the author was surprised by and minimal variation in region.
Discussion how many of the 18 high-exposure Another limitation was that data
A study of secondary traumatic RN participants experienced PTSD were not gathered regarding the
stress among nurses demonstrated symptoms in the present study, with hours worked by each participating
that age and experience were not 9 (50%) identified as having probable RN. Future research should assess
predictors.11 Analysis of variance PTSD. Of these responses, 5 (56%) possible correlations between hours
and two-tailed t-testing were con- had low-rated Likert responses re- worked and experienced symptoms.
ducted, and neither age nor experi- garding their detachment from oth- Additionally, due to high rates
ence was a statistically significant ers. These findings somewhat mimic of COVID-19 infection per capita
predictor of PTSD among the study previous research, which has corre- in Louisiana, there was a risk for
participants. Similarly, nurses’ years lated emotional support to decreased oversampling of nurses in the high-
of experience, which ranged from secondary traumatic stress and could exposure group.
1 to 28 years, did not correlate with indicate propinquity, or the physical Aside from the possible bias re-
exposure to traumatic events or re- and/or psychological proximity be- lated to the absence of statistical
ported symptoms. tween individuals, as a protective or analysis noted above, response bias
www.Nursing2021.com July l Nursing2021 l 55
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.was possible due to the online-only 3. Wu P, Fang Y, Guan Z, et al. The psychological 10. Xiang Y-T, Yang Y, Li W, et al. Timely mental
impact of the SARS epidemic on hospital employees health care for the 2019 novel coronavirus
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302-311.
tations, however, the author feels this 11. Kellogg MB, Knight M, Dowling JS,
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Richard Hill is an inpatient wound care nurse at
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56 l Nursing2021 l Volume 51, Number 7 www.Nursing2021.com
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