Post-traumatic Stress Disorder: A Learning Module for Nurses

This course will provide nurses with a basic understanding of post-traumatic stress disorder (PTSD). It will review hospital-wide strategies and support services for nurses who are at risk of developing, or who have been diagnosed with, PTSD.

What is PTSD?

PTSD is a psychological condition associated with:

  • Negative changes in cognition, mood, or arousal, as well as symptoms of intrusion or avoidance, that may occur following a traumatic or stressful experience (Bowsfield & Samra, 2015).

Why are nurses at risk for PTSD?

Front-line nurses are often exposed to traumatic or stressful events, which increases their risk of developing PTSD (de Boer, van Rikxoort, Bakker, & Smit, 2014).

Many nurses report "reacting professionally" during such events, but then experience stress reactions at a later time (de Boer et al., 2014).

Having increased profession experience does not prevent nurses who experience traumatic or stressful events from developing PTSD (de Boer at al., 2014).

Nurses have described traumatic events as those that involved intimidation, high emotional involvement, were preventable, that involved substandard care due to miscommunication or unprofessionalism (de Boer et al., 2014).

Exposure to Traumatic or Stressful Events

Traumatic or stressful events include (Bowsfield & Samra, 2015):

  • Death (violent or accidental)
  • Death threats
  • Actual or threatened serious injury
  • Threatened serious injury
  • Actual sexual violence
  • Threatened sexual violence

Exposure means that the nurse experienced the stressful or traumatic event (Bowsfield & Samra, 2015):

 

  • Directly (e.g., receiving a death threat)
  • In-person (e.g., witnessing a co-worker receive a death threat)
  • Indirectly (e.g., learning that a co-worker received a death threat)
  • Repeated indirect exposure within the context of work (e.g., learning the details of multiple co-workers receiving death threats over a period of time)

Review!

Nurses are at increased risk to develop PTSD because they are often exposed to traumatic or stressful events.

  • Is this statement true or false?

More experienced nurses are less likely to develop PTSD than less experienced nurses.

  • Is this statement true or false?

Only nurses who directly experience traumatic events are at risk of developing PTSD.

  • Is this statement true or false?

The Stress Response

The Stress Response

It is normal to feel the effects of the stress response following a traumatic event (de Boer et al., 2014). Such responses include: 

  • Physical, such as shakiness, gastrointestinal upset, or increased heart rate
  • Behavioral, such as being hyper-reactive
  • Emotional, such as feeling irritated, sad or anxious
  • Cognitive, such as being forgetful or indecisive 

The Stress Response

When a person's coping mechanisms are ineffective, these initial stress reactions may persist and lead to PTSD (de Boer et al., 2014). 

Signs and Symptoms of PTSD

What are the signs and symptoms of PTSD?

  • Signs and symptoms of PTSD usually occur within the first three months following a traumatic event (Bowsfield & Samra, 2015).
    • However, sometimes signs and symptoms do not emerge until months or years later. This is known as delayed expression.

What are the signs and symptoms of PTSD?

There are 4 mains clusters of symptoms:

  • Intrusion
  • Avoidance
  • Negative changes in thinking and mood
  • Changes to arousal and reactivity

For a diagnosis of PTSD, symptoms must be present for at least one month, they must impair functional ability (e.g., ability to carry-out social, personal or professional responsibilities) and they cannot be attributed to other medical conditions (Bowsfield & Samra, 2015).

Symptom: Intrusion

The nurse persistently experiences the negative event through one or more of the following ways (Bowsfield & Samra, 2015):

  • Intrusive memories
  • Nightmares
  • Flashbacks
  • Pronounced distress following exposure to reminders of the event
  • Pronounced physiological reactivity to stressful and traumatic event

Symptom: Avoidance

The nurse persistently avoids:

  • Thoughts or emotions, and/or
  • Physical reminders (including other people involved, or the environment in which the event occurred) related to the traumatic event (Bowsfield & Samra, 2015).

Symptom: Negative Changes in Thinking and Mood

Two or more of the following occur (Bowsfield & Samra, 2015):

  • Dissociative amnesia – the nurse is unable to recall specific details of the event
  • Persistent negative beliefs about oneself or the external environment
  • Persistent distorted beliefs regarding own or other’s responsibility for the occurrence or outcome of the traumatic event
  • Persistent negative emotions
  • Feeling disconnected from others
  • Inability to experience positive emotions

Symptom: Changes to Arousal and Reactivity

Two or more of the following occur (Bowsfield & Samra, 2015):

  • The person experiences new or worsening irritability or aggression
  • The person experiences a new or worsening onset of self-destructive behavior
  • The person becomes hypervigilant
  • The person startles easily
  • The person has difficulty concentrating
  • The person experiences difficulty sleeping

Negative reactions from coworkers were found to contribute to long-lasting PTSD symptoms.

 These behaviours include (de Boer et al., 2014):

  • Being ignored
  • Being accused of over-reacting
  • Receiving accusatory remarks 

PTSD in the Workplace

Individuals with PTSD may (Ministry of  Labour Ontario, 2018):

  • Have difficulty concentrating
  • Exhibit fear/anxiety with tasks they previously performed independently, or avoid these tasks altogether
  • Overreact, be quick to anger
  • Appear overly fatigued
  • Miss work
  • Withdrawal from social situations
  • Increase their alcohol intake after work

Review!

Match the terms and the descriptions!

  • The stress response
    Physical symptoms such as elevated heart rate, cognitive symptoms such as hyper-reactivity, emotional symptoms such as irritability, and cognitive symptoms such as forgetfulness.
  • Intrusion
    Experiencing flashbacks, nightmares and intrusive memories.
  • Negative Changes in Thinking/Mood
    Experiencing persistent negative emotions and feeling disconnected from others.

Match the terms and the descriptions!

  • Avoidance
    Maintaining distance from thoughts, emotions or reminders related to the traumatic event.
  • Changes to Arousal and Reactivity
    Becoming hyper-vigilant, startling easily, and experiencing difficulty sleeping.

Supporting Ontario's First Responders Act (Posttraumatic Stress Disorder), 2016

Supporting Ontario's First Responders Act (Posttraumatic Stress Disorder), 2016

The purpose of this act is to assist first-responders diagnosed with PTSD as a result of workplace experiences to receive expedited access Workplace Safety and Insurance Board benefits (Ministry of Labor, 2016).

What does this mean for nurses?

In December 2017, the Ontario government announced its intention to amend Bill 163, Supporting Ontario's First Responders Act (PTSD), to include front-line nurses as "first responders" (Ministry of Labor, 2017).

The act also mandates that employers of first-responders implement PTSD prevention strategies (Ministry of Labor, 2016). These prevention strategies may include polices to reduce the incidents of traumatic events and to facilitate effective coping when such events occur (de Boer et al., 2014).

Michael Garron Hospital: Policies & Employee Supports

What policies does Michael Garron Hospital have in place to prevent PTSD in nurses?

MGH’s Physiological Health & Safety in the Workplace is a policy focused on promoting psychological health and preventing psychological harm of all employees (MGH, 2016).

  • Currently, MGH’s Psychological Health and Safety System is maintained by the Occupational Health & Safety System
  • Human Resources and Occupational Health & Safety are responsible to monitor and audit departments the effect psychological health and safety measures, and to assist departments to address concerns and psychological hazards

What policies does Michael Garron Hospital (MGH) have in place to prevent PTSD?

Responsibilities (MGH, 2016):

  • MGH is responsible for developing and monitoring procedures and guidelines to ensure “reasonably practical measures are taken to eliminate psychological illness” (p.1)
  • Senior team members and managers are responsible for considering employee psychological health during decision making, and for ensuring that psychological harm is not caused by negligence, intent or recklessness
  • Employees are responsible abiding by MGH’s relevant policies, including: Civil and Respectful Workplace, Codes of Conduct, Harassment Policy, Standards of Behaviour and Workplace Violence and Prevention Policy

Supports for Employees Affected by Workplace Violence (MGH, 2018b, p. 11)

  • Debriefing
  • Referrals to:
    • Community agencies
    • Treating practitioners
    • Trade Unions
    • Employee Assistance Program

Employee Assistance Program (MGH, 2018a)

  • A service which provides confidential counseling
  • Is available 24 hours a day, 7 days a week
  • Can be accessed via telephone, in-person or online
  • A series of session are free (long-term/specialized support may be subject to additional fees)
  • Can be used to seek support regarding workplace challenges (as well as other aspects related to personal well-being)
  • Contact information:
    • 1-844-880-9137
    • www.shepellfgi.com/ecounselling

Review!

How does the Ontario Government intend to amend Bill 163, Supporting Ontario's First Responders Act (PTSD), 2016?

  • To include front-line nurses
  • To include EMS workers
  • To include fire fighters
  • To include police officers

Who is responsible for promoting psychological health & safety at MGH?

  • Senior team members & management
  • Occupational Health & Safety members
  • Front-line nurses
  • All employees at MGH can promote psychological health & safety

Feedback!

This learning module...

  • Increased my awareness of PTSD, including risk factors, and signs and symptoms
  • Did not increase my awareness of PTSD

This learning module

  • Increased my knowledge of Bill 163, Supporting Ontario's First Responders Act (PTSD), 2016
  • Did not increase my knowledge of Bill 163, Supporting Ontario's First Responders Act (PTSD), 2016

This learning module...

  • Increased my awareness of MGH's polices to promote the psychological health and prevent psychological harm of its employees
  • Did not increased my awareness of MGH's polices to promote the psychological health and prevent psychological harm of its employees

This learning module...

  • Increased my awareness of supports available for MGH's employees
  • Did not increase my awareness of supports available for MGH's employees

Thanks for participating. Feel free to include any additional feedback below.

References

References

Bowsfield, M. L., & Samra, J. (2015). Post-traumatic stress disorder in a nursing context. Journal: The Official Publication of the Ontario Occupational Health Nurses Association, 34(2), 26-32. Retrieved from http://ezproxy.lib.ryerson.ca/login?url=https://search-proquestcom.ezproxy.lib.ryerson.ca/docview/1737518302?accountid=13631

de Boer, J., van Rikxoort, S., Bakker, A. B., & Smit, B. J. (2014). Critical incidents among intensive care unit nurses and their need for support: Explorative interviews. Nursing in Critical Care, 19(4), 166-174. doi:10.1111/nicc.12020

Michael Garron Hospital. (2016). Psychological health & safety in the workplace. Unpublished intranet document.

Michael Garron Hospital. (2018a). Employee assistance program. Unpublished intranet document

Michael Garron Hospital. (2018b). Workplace violence prevention. Unpublished intranet document.

Ministry of Labor. (2016). Backgrounder: Supporting Ontario’s First Responders Act (Posttraumatic Stress Disorder), 2016. Retrieved from https://news.ontario.ca/mol/en/2016/04/supporting-ontarios-first-responders-act-posttraumatic-stress-disorder-2016-1.html

Ministry of Labor. (2017). News release: Providing more support for nurses with PTSD. Retrieved from https://news.ontario.ca/mol/en/2017/12/providing-more-support-for-nurses-with-ptsd.html#

Ministry of of Labour Ontario. (2018). First responders first. Retrieved from http://www.firstrespondersfirst.ca/