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A crisis like COVID-19 can put nurses at risk for a stress disorder not just after but in anticipation of traumatic events.

“Never seen anything like this,” wrote a Texas nurse with 17 years of ER experience. “Protocols change minute to minute if there are any at all. I can no longer trust the CDC. For the first time in my career I am scared to go to work.” A Pennsylvania nurse in a pediatric intensive care cited conditions that put “all the staff, other patients and my family at high risk.”

Their comments and others from nurses grappling with the pandemic were part of a private online document compiled by New Jersey nurse Sonja Schwartzbach and excerpted in The New York Times. 1,253 participants shared their experience treating patients over half of whom had COVID 19. Chilling anecdotes abounded. About 26% “weren’t sure” if their patients had the virus because of a lack of testing kits.

Anyone outside the profession only has to imagine being in such a situation to understand how it puts health care professionals (HCP) at high risk for Post-Traumatic Stress Disorder (PTSD). “My colleagues and I have discussed the potential for PTSD,” writes Lisa Masiello '20, a clinical nurse leader who has worked as a nurse for 23 years, 19 in intensive care. “I think there is a general awareness, but the particulars on symptoms and treatment are not in the forefront of information right now.” In addition to being a lower priority, Masiello believes that “nurses wouldn't freely admit to suffering with it due to social stigma.”

Prior to graduating from Regis, Katelyn Cooper '17, deployed to Kandahar, Afghanistan where she sustained injuries and was first diagnosed with PTSD. “I started treatment long before I became a nurse, but am still being treated to this day,” she recalls. “It is not a quick fix… Digging out of PTSD is much more difficult than getting ahead of it.”

As someone responsible for training nurse practitioners, Dr. Karen Crowley '10, DNP is also concerned about Pre-Traumatic Stress Disorder, “where individuals have similar signs and symptoms as Post-Traumatic Stress Disorder as they prepare and wait for the inevitable.”

In 1998, she joined Regis College where she is currently an Associate Dean and Associate Professor. Dr. Crowley played a pivotal role in the development of Regis’ online nursing programs. Here, she defines different stress disorders nurses are particularly susceptible to and their treatments.

"Our role in helping others is only protected by us helping ourselves first"  - Dr. Karen Crowley

 

There are two mental health conditions1 to consider in nurses who are on the frontline of the Covid-19 Pandemic: Post-Traumatic Stress (PTS) and Post-Traumatic Stress Disorder (PTSD).

Post-Traumatic Stress is frequently seen as an adaptive response in individuals put into a stressful situation. Any type of fear or threat can initiate the “fight or flight” response of the nervous system, but the response is typically less severe, self-limiting (usually lasting for a short duration) and commonly does not require any treatment.

However, severe or prolonged trauma subjects the individual to be at risk for developing PTSD, which does require a medical professional diagnosis and treatment. One of the key diagnostic criteria for PTS/PTSD is there must be a traumatic or stress producing event that occurred in the past. However, in pre-traumatic stress the impending trauma or stress caused from the impending trauma appear to illicit the same types of physical and emotional responses to healthcare providers.

The difference with the pandemic is that many nurses may have been or are experiencing fear of the threat/trauma as the outbreak began in the United States in January 2020 as a pre-traumatic stress response. As the virus branches out across the U.S., there is fear and anticipation of what is to come. With the prolonged exposure in preparing and caring for patients as well as preventing self-exposure and family exposure will put nurses and other HCP at risk for developing PTSD.

Although medical and nursing professionals are trained and experienced in caring for patients in emergency situations, such as terrorist attacks, fires, floods, hurricanes etc., pandemics and epidemics bring a different set of circumstances to the health care professionals.

Whereas in a pandemic/epidemic, in addition to HCP caring for patients, HCP become potential victims of the ongoing threat and this threat can last for days, weeks and months. It is the repetitive exposure to the actual or pending traumatic event that wears down the nurses’ ability to rebound as they normally would. The last pandemic seen in the U.S. was in 2009 related to the H1N1 influenza virus, which resulted in 12,500 deaths in the US from April 2009 - April 2010, (0.02% of those affected in the US). COVID-19 death rate is currently at 2% due to its highly contagious nature2 and its effects on vital organs. Nurses of today have never experienced a pandemic of this magnitude.

“I have seen many devastating things in my career, but I never really considered myself a person who would be at risk until now” - Lisa Masiello, ICU nurse at a Boston hospital.

As a nurse practitioner and associate dean/faculty of a large online nurse practitioner program, I have experienced changes within my NP office as well as participated in several conversation with NP colleagues and NP students. During these conversations, the stress level is palpable and crosses many factors that this pandemic has created. There are change in work environments, nurses are put in situations they are not trained for, they don’t have the correct protective equipment, there is a change in practice guidelines, there is fear of contracting the virus, fear of transmitting it to their family, there is financial challenges as loved ones lose their job, there is home stressors as children are home from school and implement virtual learning, there are a plethora of emails related to all of these changes in personal and employment accounts. Those nurse and students I have spoken to have increasing fear, anger, irritability, feeling isolated, overwhelmed and bombarded, resulting in difficulty sleeping and concentration. There is talk of the negative effects, such as “when do I decide not to go back to work because the risk is too high? Or “when do I decide not to go home after a shift as the risk of infecting loved ones becomes higher”. Nurses are aware that we have not reached peak in any state, that there is many more months of this work to be done and the negative outcomes that this virus will cause. From these conversations I see a direct connection to post-traumatic stress syndrome symptoms but occurring in a pre-traumatic time.

Nursing education programs typically will include emergency preparedness and crisis interventions related to traumatic events such as terrorism, national disasters and active shooter situations. During these sessions, students are provided with information on why these events take place, steps to follow if actively involved in any crisis situation and are usually taught using simulated experiences. For crisis management related to receiving victims of the traumatic event, students are provided with information related to managing and triaging the victims, providing emergent care and the importance of the debriefing exercises that take place after work shifts or resolution of the crisis. Although the education of nursing includes responses to traumatic events, there are a few if any that have addressed the trauma that results from impending crisis like seen in a pandemic/epidemic/nuclear accident/biological warfare, etc.

  1. DSM-5 (2013)
  2. CDC

Are You Experiencing PTSD? Here Are Eight of the Signs

In 2013, the DSM-5 revised the diagnostic criteria for Post-Traumatic Stress Disorder to include a Trauma response or stress-related response. There are eight criterion, seven of which are required in the diagnosis of PTSD and include the following:a

Criteria/Required number Exhibiting behavior - Post-Traumatic Stress response Pre-Traumatic Stress response with COVID-19
A: Stressor (1) Direct personal exposure including being an eyewitness of trauma, becoming aware that a relative or close family friend is exposed to trauma.
Indirect exposure consisting of learning of trauma details – usually seen with health care professionals and other frontline responders.
Indirect Exposure through learning and preparing for the health care needs of the community
Direct exposure through contact with patients and threatened serious injury/death
Direct exposure to patients affected and adverse health outcomes of patients
B: Intrusion Symptoms (1) Flashbacks, nightmares, bad memories, physical or emotional response resulting from trauma reminders Memories that are upsetting from setting up medical processes, caring for patients with insufficient PPE, trying to protect oneself, visitor restrictions and physical and emotional responses from caring for patients affected,
C: Avoidance (1) Suppressing thoughts, feelings and reminders of the trauma related stimuli. Suppressing thoughts to “prepare” to meet the needs of the organization, “call of duty”, maintain employment, meet the needs of the family finances
D: Negative Alteration in Mood and cognition (1) Memory loss of the traumatic event
Increase in negative thoughts about the world or oneself
Lack of interest in enjoyable activities
Feeling Isolated
Blaming self or others for trauma
Negative affect
Inability to experience joy
Pandemics affect the world, worry about this and how many individuals will be affected, will the HCP get sick, will they infect their family and loved ones.
Isolation due to shelter in place, social distancing, remote employment
caring for patients in isolation without family members present due to visitor restrictions
E: Alterations in Arousal and Reactivity Arousal and reactivity related to the trauma that began or increased after the trauma
Difficulty Sleeping
Difficulty concentrating
Increased startle reaction
High risk taking or destructive behaviors
Aggression
Irritability
Hypervigilance
Arousal and reactivity to the impending trauma that began or increased before/during the trauma, resulting in the same list of symptoms as PTSD.
F: Duration (required) Symptoms present for at least one month COVID 19 pandemic:b Exposure to crisis began in 12/31/19 with the announcement of the virus in Wuhan, China. First death in China 1/11/2020. First Case reported in US 1/20/2020. WHO announces a global state of emergency 1/30/2020. US travel restrictions 1/31/2020. First death in US 2/29/2020. US national emergency declared 3/13/2020. US surpasses any other country with cases and deaths 3/26/2020. A month has passed since the first Case announced in US, in addition, a month has passed since the first death in US. Most important is the virus has not reached peak in any US state as of yet.
G: Functional Significance (required) Symptoms cause distress or impairment in functional status Same
H: Exclusion (required) Symptoms are not due to medications, illnesses or any other substances Same
  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (5th ed.) Washington, DC,
  2. Taylor, D. (2020). "A Timeline of the Coronavirus Pandemic" The New York Times
  3. COVID-19 Cases in the US

How can I Prevent PTSD?

The most important recommendation to the nursing workforce is not to wait to initiate these preventative/therapeutic suggestions. Everyone is experiencing the stresses of this Pandemic and as nurses; our role in helping others is only protected by us helping ourselves first. Nurses need to take care of themselves and each other and the health care organizations (HCO) have a responsibility to take care of the frontline workers. Stand together, be an advocate for yourself, your patients and your families. Implement the strategies below that you will feel will work for you and ensure the HCO provides you and your HCP colleagues with the mental health resources needed for you to stay strong.

“As a nurse I have had a few incidents that have caused some worsening of my symptoms, and changes to what I re-experience,” recalls Katelyn Cooper. “However, when these things started I knew what it was and was already in treatment for existing PTSD, so I didn’t brush it under the rug.” Today, Cooper works as a dialysis nurse.

“I have seen many devastating things in my career, but I never really considered myself a person who would be at risk until now,” writes Lisa Masiello, now an ICU nurse at a Boston hospital.

“Considering what we are coming up against as we have started seeing a surge in patients, I am more aware that self-care is more important than ever. This is how I deal with managing the stress. I have always thrived during times of stress at work, I handle the pressures at work by being proactive. Being prepared for the worst and hope for the best.”

How Can I Treat Pre-Traumatic Stress Response?

Since Post-Traumatic Stress is less severe, self-limiting (usually resolving within a month) and has less effect on the functional ability of the individual when compared to PTSD, treatment for PTS is usually not required. However, individuals can benefit from treatment to reduce the responses identified in the table below. The modalities listed below can be presumed to be effective in treating those with Pre-Traumatic Stress Response.

Treatment Type Treatment Example
Self-Care
Knowledge
  • Obtain information from one reputable site such as the CDC or state Department of Public health.
  • Become knowledgeable about the Mitigation Process at CDC Mitigation procedures for COVID-19
  • Refrain from reading/watching several articles, emails, or news announcements during the day
  • Read health care organization emails once a day
  • Avoid Social Media
Socialization
  • Meet with friends and family virtually
    • Zoom - Free account – up to 40 minutes free for each meeting with several participants
    • FaceTime for MAC, iPhone and iPad owners
    • Skype - free
    • Netflix Party - synchronized movie and TV shows with your friends and family with Chat ability
    • Virtual Social Hour
    • Virtual Book Club - free accounts to create or join a book club
Debriefing
  • Start or attend a HCO virtual support group to talk about fears and concerns
  • Talk with a family member or friend after each shift to debrief
  • Access the Employee Assistance Program offered at your place of employment
  • Attend sessions with Licensed Social Workers or Mental Health Providers placed at your HCO to help you process this crisis.
  • Take Control
  • Rearrange the furniture
  • Begin home improvements that you can do (painting, spring-cleaning etc.)
  • Play Games with family member
  • Use the home mandates to learn something new, such as a second language, cooking, baking, and sewing
  • Register for an online college class that interests you
Professional Therapy
  • Cognitive Behavior Therapy
  • Prolonged Exposure Therapy