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Impact of war stress on posttraumatic stress symptoms in hospital personnel
General Hospital Psychiatry 29 (2007) 264 – 266
Short Communication
Impact of war stress on posttraumatic stress symptoms in hospital personnel Menachem Ben-Ezra, Ph.D.a,4, Yuval Palgi, M.A.a, Nir Essar, M.D.b a
Department of Psychology, Tel Aviv University, P.O. Box 39040, Ramat Aviv, Tel Aviv 69978, Israel b Department of Psychology, Derby University Branch in Israel, Ramat-Efal, Israel Received 6 January 2007; accepted 1 March 2007
Abstract Objective: This study examines the relationship between exposure to war stress and posttraumatic symptoms among nurses and physicians in a general hospital targeted by missiles. Method: Hospital staff who were exposed to missile attacks and casualties of war, both military and civilians (n = 80), were assessed for posttraumatic stress disorder (PTSD) symptoms a month after the war between Lebanon and Israel erupted (during the last days of the war). Results: High levels of PTSD symptoms were found in 10.5% of physicians and 35.7% of nurses. Logistic regression analysis showed that nurses had an increased risk for PTSD in comparison to physicians (odds ratio = 5.28). Conclusion: These findings show that nurses suffered from more severe posttraumatic symptoms compared to physicians after exposure to prolonged war stress. The gap between physicians and nurses warrants further study. D 2007 Elsevier Inc. All rights reserved. Keywords: Trauma; War stress; Hospital personnel; Impact of event scale
1. Introduction On July 12, 2006 at 0930 h, war erupted between Israel and Lebanon. Israel suffered 163 fatalities (44 civilians and 119 soldiers) and 2400 casualties (2000 civilians and 400 soldiers). During the war, the northern city of Haifa was targeted by hundreds of missiles. The Rambam Hospital is the largest and most important hospital in northern Israel and serves a population of 1 million people, with 75,000 hospitalizations and 500,000 admissions each year. A large proportion of civilians and military casualties were admitted to the hospital during the war. The hospital itself was also targeted, with 40 missiles landing in the hospital vicinity. Few studies have systematically examined the effect of hospital personnel’s exposure to extreme stress [1,2]. Prior studies have examined exposure to bombings, terror attacks and sniper shootings, which represented only a single trauma or indirect exposure to multiple traumas [3–6]. To the best of our knowledge, no earlier study has been conducted on hospital personnel exposed to war stress.
4 Corresponding author. Tel.: +972 3 6760285. E-mail address: [email protected] (M. Ben-Ezra). 0163-8343/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2007.03.001
Based on previous research [1,4], we hypothesized that physicians would show lower levels of posttraumatic stress disorder (PTSD) symptoms in comparison to nurses.
2. Methods A sample of hospital personnel was selected at random 1 month after the war begun (during the last days of the war). The hospital employs 1100 physicians and 800 nurses. The initial sample included physicians and nurses (n =109). The response rate was 80%. Those who declined were asked about their reasons for refusal. The most common reason for refusing was bno time.Q The final sample consisted of 80 participants: 38 physicians and 42 nurses (Table 1). There were no differences between respondents and nonrespondents in demographic data (age, gender, profession and exposure). The study took the form of a short screening interview and a survey conducted on the week of August 12. None of the participants had a history of mental disorder or prior exposure to war-related stress. All participants were under missile attacks, with immediate threat to life and exposure to war; casualties comprised both military and civilians.
M. Ben-Ezra et al. / General Hospital Psychiatry 29 (2007) 264 – 266 Table 1 Participant characteristics, by profession
Age in years (S.D.) Gender: female [n (%)] Marital status: married [n (%)] IES-R score [mean (S.D.)] Increased risk for PTSD (IES-R N 33) [n (%)] a b
Physicians (n = 38)
Nurses (n = 42)
Test statistics
P
36.34 (8.65)
33.92 (8.89)
t = 1.294
.199a
18 (47.4)
38 (90.5)
v 2 = 15.669
.001b
27 (71.1)
25 (59.5)
v 2 = 0.987
.320b
t = 3.533
.010a
v 2 = 6.902
.009b
265
associated with an increased risk for high levels of PTSD symptoms. With ANCOVA, the professional status as nurse was also associated with higher IES-R scores while controlling for age, gender and marital status ( F =6.93; df =1,80; P =.01). 4. Discussion
15.24 (11.41) 4 (10.5)
26.50 (16.38) 15 (35.7)
Groups compared using t test. Groups compared using chi-square test.
Demographic measures included age, gender, marital status and profession. The 22-item Impact of Event Scale — Revised (IES-R) [7] was used to assess PTSD symptoms in the past 7 days in response to war stress. Total scores N 33 indicate a clinical level of distress [8]. This measure has been shown to be reliable and valid [7,8] and has been previously used in studies of Israeli subjects [9,10]. The score was the sum of three subscale scores using the full 22item IES-R (range, 0–88). The reliability (Cronbach’s a) in our sample was .92. We used t tests and chi-square tests in order to compare demographic differences between professions. Logistic regression analyses with IES-R cutoff (N 33 vs. V 33) as dependent variable were performed to determine the degree to which demographic variables (age, gender, marital status and profession) were associated with high levels of PTSD symptoms. Odds ratio and 95% confidence intervals were determined. Analysis of covariance (ANCOVA) was used to assess the relationship between the total IES-R score and profession while controlling for age, gender and marital status. All analyses were conducted using SPSS program (version 11.5; SPSS, Chicago, IL). 3. Results There were no differences in age and marital status between nurses and physicians. A greater proportion of the sample comprised nurses. Nurses had higher IES-R scores; a greater proportion of nurses had an IES-R score of N 33 (Table 1). When profession, age, gender and marital status were entered into the logistic regression model, nurses were 5.28 times more likely to endorse high levels of PTSD symptoms (IES-R score N 33; odds ratio = 5.28; 95% confidence interval = 1.29–21.56; Wald v 2 = 5.373; df = 1,80; P = .02). No other demographic variable was
Almost one quarter (23.4%) of the hospital personnel sampled had symptoms of posttraumatic stress rising to the level of clinical concern. These results are comparable with earlier studies of hospital personnel in other trauma settings [2,4]. The relatively high levels of posttraumatic stress among hospital personnel indicate that, under some circumstances, medical personnel may not be as resilient as some studies have suggested [3,11]. Clearly, some of these differences may be due to the fact that, in addition to treating seriously injured or dying patients, hospital personnel were also concerned with their own safety and that of their family, both at work and during routine daily activities. Quantitative data also suggest that the effect of profession has a differential impact on hospital personnel. Compared to physicians, nurses had five times greater risk of having clinically significant symptoms of posttraumatic stress. Higher levels of symptoms among nurses have been found in other studies [1,4]. Our results are in line with earlier studies showing that even exposure to a single trauma affect nurses more than physicians [1,4,6]. There are two limitations to this study. First, no actual diagnosis was made, but studies [8] have shown that the IESR, using a cutoff score of 33, has the best diagnostic accuracy for predicting PTSD symptoms according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria [12]. A second limitation is the study’s cross-sectional design. Longitudinal studies are needed preferably with an assessment prior to severe events and with follow-up assessments to study the course of symptoms. Future studies should assess the nature of wartime exposures (patient contact vs. personal threat of injury or death) to assess the relative contribution of different exposures to the development of stress symptoms. Although exposure to prolonged war stress with actual threat to life is quite rare in hospital personnel, its consequences were severe. Since it is likely that those hospital personnel will be affected by crises such as this in the future, policies for preventing and reducing the prevalence PTSD should be accompanied by action to mitigate the effects of war stress on the mental health of hospital personnel who are generally under elevated stress in a hospital setting. References [1] Luce A, Firth-Cozens J, Midgley S, Burges C. After the Omagh bomb: posttraumatic stress disorder in health service staff. J Trauma Stress 2002;15:27 – 30.
266
M. Ben-Ezra et al. / General Hospital Psychiatry 29 (2007) 264 – 266
[2] Hodgetts G, Broers T, Godwin M, et al. Posttraumatic stress disorder among family physicians in Bosnia and Herzegovina. Fam Pract 2003;20:489 – 91. [3] Firth-Cozens J, Midgley SJ, Burges C. Questionnaire survey of posttraumatic stress disorder in doctors involved in the Omagh bombing. BMJ 1999;319:1609. [4] Grieger TA, Fullerton CS, Ursano RJ, et al. Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks. Psychiatr Serv 2003;54:1383 – 7. [5] Kerasiotis B, Motta RW. Assessment of PTSD symptoms in emergency room, intensive care unit, and general floor nurses. Int J Emerg Ment Health 2004;6:121 – 33. [6] Weiniger CF, Shalev AY, Ofek H, et al. Posttraumatic stress disorder among hospital surgical physicians exposed to victims of terror: a prospective, controlled questionnaire survey. J Clin Psychiatry 2006;67:890 – 6.
[7] Weiss DS, Marmar CR. The Impact of Event Scale — Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York7 Guilford; 1997. p. 399 – 411. [8] Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale — Revised. Behav Res Ther 2003;41: 1489 – 96. [9] Bonne O, Brandes D, Gilboa A, et al. Longitudinal MRI study of hippocampal volume in trauma survivors with PTSD. Am J Psychiatry 2001;158:1248 – 51. [10] Shalev AY, Freedman S. PTSD following terrorist attacks: a prospective evaluation. Am J Psychiatry 2005;162:1188 – 91. [11] Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet 2000;355:533 – 7. [12] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC7 Author; 1994.
Short Communication
Impact of war stress on posttraumatic stress symptoms in hospital personnel Menachem Ben-Ezra, Ph.D.a,4, Yuval Palgi, M.A.a, Nir Essar, M.D.b a
Department of Psychology, Tel Aviv University, P.O. Box 39040, Ramat Aviv, Tel Aviv 69978, Israel b Department of Psychology, Derby University Branch in Israel, Ramat-Efal, Israel Received 6 January 2007; accepted 1 March 2007
Abstract Objective: This study examines the relationship between exposure to war stress and posttraumatic symptoms among nurses and physicians in a general hospital targeted by missiles. Method: Hospital staff who were exposed to missile attacks and casualties of war, both military and civilians (n = 80), were assessed for posttraumatic stress disorder (PTSD) symptoms a month after the war between Lebanon and Israel erupted (during the last days of the war). Results: High levels of PTSD symptoms were found in 10.5% of physicians and 35.7% of nurses. Logistic regression analysis showed that nurses had an increased risk for PTSD in comparison to physicians (odds ratio = 5.28). Conclusion: These findings show that nurses suffered from more severe posttraumatic symptoms compared to physicians after exposure to prolonged war stress. The gap between physicians and nurses warrants further study. D 2007 Elsevier Inc. All rights reserved. Keywords: Trauma; War stress; Hospital personnel; Impact of event scale
1. Introduction On July 12, 2006 at 0930 h, war erupted between Israel and Lebanon. Israel suffered 163 fatalities (44 civilians and 119 soldiers) and 2400 casualties (2000 civilians and 400 soldiers). During the war, the northern city of Haifa was targeted by hundreds of missiles. The Rambam Hospital is the largest and most important hospital in northern Israel and serves a population of 1 million people, with 75,000 hospitalizations and 500,000 admissions each year. A large proportion of civilians and military casualties were admitted to the hospital during the war. The hospital itself was also targeted, with 40 missiles landing in the hospital vicinity. Few studies have systematically examined the effect of hospital personnel’s exposure to extreme stress [1,2]. Prior studies have examined exposure to bombings, terror attacks and sniper shootings, which represented only a single trauma or indirect exposure to multiple traumas [3–6]. To the best of our knowledge, no earlier study has been conducted on hospital personnel exposed to war stress.
4 Corresponding author. Tel.: +972 3 6760285. E-mail address: [email protected] (M. Ben-Ezra). 0163-8343/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2007.03.001
Based on previous research [1,4], we hypothesized that physicians would show lower levels of posttraumatic stress disorder (PTSD) symptoms in comparison to nurses.
2. Methods A sample of hospital personnel was selected at random 1 month after the war begun (during the last days of the war). The hospital employs 1100 physicians and 800 nurses. The initial sample included physicians and nurses (n =109). The response rate was 80%. Those who declined were asked about their reasons for refusal. The most common reason for refusing was bno time.Q The final sample consisted of 80 participants: 38 physicians and 42 nurses (Table 1). There were no differences between respondents and nonrespondents in demographic data (age, gender, profession and exposure). The study took the form of a short screening interview and a survey conducted on the week of August 12. None of the participants had a history of mental disorder or prior exposure to war-related stress. All participants were under missile attacks, with immediate threat to life and exposure to war; casualties comprised both military and civilians.
M. Ben-Ezra et al. / General Hospital Psychiatry 29 (2007) 264 – 266 Table 1 Participant characteristics, by profession
Age in years (S.D.) Gender: female [n (%)] Marital status: married [n (%)] IES-R score [mean (S.D.)] Increased risk for PTSD (IES-R N 33) [n (%)] a b
Physicians (n = 38)
Nurses (n = 42)
Test statistics
P
36.34 (8.65)
33.92 (8.89)
t = 1.294
.199a
18 (47.4)
38 (90.5)
v 2 = 15.669
.001b
27 (71.1)
25 (59.5)
v 2 = 0.987
.320b
t = 3.533
.010a
v 2 = 6.902
.009b
265
associated with an increased risk for high levels of PTSD symptoms. With ANCOVA, the professional status as nurse was also associated with higher IES-R scores while controlling for age, gender and marital status ( F =6.93; df =1,80; P =.01). 4. Discussion
15.24 (11.41) 4 (10.5)
26.50 (16.38) 15 (35.7)
Groups compared using t test. Groups compared using chi-square test.
Demographic measures included age, gender, marital status and profession. The 22-item Impact of Event Scale — Revised (IES-R) [7] was used to assess PTSD symptoms in the past 7 days in response to war stress. Total scores N 33 indicate a clinical level of distress [8]. This measure has been shown to be reliable and valid [7,8] and has been previously used in studies of Israeli subjects [9,10]. The score was the sum of three subscale scores using the full 22item IES-R (range, 0–88). The reliability (Cronbach’s a) in our sample was .92. We used t tests and chi-square tests in order to compare demographic differences between professions. Logistic regression analyses with IES-R cutoff (N 33 vs. V 33) as dependent variable were performed to determine the degree to which demographic variables (age, gender, marital status and profession) were associated with high levels of PTSD symptoms. Odds ratio and 95% confidence intervals were determined. Analysis of covariance (ANCOVA) was used to assess the relationship between the total IES-R score and profession while controlling for age, gender and marital status. All analyses were conducted using SPSS program (version 11.5; SPSS, Chicago, IL). 3. Results There were no differences in age and marital status between nurses and physicians. A greater proportion of the sample comprised nurses. Nurses had higher IES-R scores; a greater proportion of nurses had an IES-R score of N 33 (Table 1). When profession, age, gender and marital status were entered into the logistic regression model, nurses were 5.28 times more likely to endorse high levels of PTSD symptoms (IES-R score N 33; odds ratio = 5.28; 95% confidence interval = 1.29–21.56; Wald v 2 = 5.373; df = 1,80; P = .02). No other demographic variable was
Almost one quarter (23.4%) of the hospital personnel sampled had symptoms of posttraumatic stress rising to the level of clinical concern. These results are comparable with earlier studies of hospital personnel in other trauma settings [2,4]. The relatively high levels of posttraumatic stress among hospital personnel indicate that, under some circumstances, medical personnel may not be as resilient as some studies have suggested [3,11]. Clearly, some of these differences may be due to the fact that, in addition to treating seriously injured or dying patients, hospital personnel were also concerned with their own safety and that of their family, both at work and during routine daily activities. Quantitative data also suggest that the effect of profession has a differential impact on hospital personnel. Compared to physicians, nurses had five times greater risk of having clinically significant symptoms of posttraumatic stress. Higher levels of symptoms among nurses have been found in other studies [1,4]. Our results are in line with earlier studies showing that even exposure to a single trauma affect nurses more than physicians [1,4,6]. There are two limitations to this study. First, no actual diagnosis was made, but studies [8] have shown that the IESR, using a cutoff score of 33, has the best diagnostic accuracy for predicting PTSD symptoms according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria [12]. A second limitation is the study’s cross-sectional design. Longitudinal studies are needed preferably with an assessment prior to severe events and with follow-up assessments to study the course of symptoms. Future studies should assess the nature of wartime exposures (patient contact vs. personal threat of injury or death) to assess the relative contribution of different exposures to the development of stress symptoms. Although exposure to prolonged war stress with actual threat to life is quite rare in hospital personnel, its consequences were severe. Since it is likely that those hospital personnel will be affected by crises such as this in the future, policies for preventing and reducing the prevalence PTSD should be accompanied by action to mitigate the effects of war stress on the mental health of hospital personnel who are generally under elevated stress in a hospital setting. References [1] Luce A, Firth-Cozens J, Midgley S, Burges C. After the Omagh bomb: posttraumatic stress disorder in health service staff. J Trauma Stress 2002;15:27 – 30.
266
M. Ben-Ezra et al. / General Hospital Psychiatry 29 (2007) 264 – 266
[2] Hodgetts G, Broers T, Godwin M, et al. Posttraumatic stress disorder among family physicians in Bosnia and Herzegovina. Fam Pract 2003;20:489 – 91. [3] Firth-Cozens J, Midgley SJ, Burges C. Questionnaire survey of posttraumatic stress disorder in doctors involved in the Omagh bombing. BMJ 1999;319:1609. [4] Grieger TA, Fullerton CS, Ursano RJ, et al. Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks. Psychiatr Serv 2003;54:1383 – 7. [5] Kerasiotis B, Motta RW. Assessment of PTSD symptoms in emergency room, intensive care unit, and general floor nurses. Int J Emerg Ment Health 2004;6:121 – 33. [6] Weiniger CF, Shalev AY, Ofek H, et al. Posttraumatic stress disorder among hospital surgical physicians exposed to victims of terror: a prospective, controlled questionnaire survey. J Clin Psychiatry 2006;67:890 – 6.
[7] Weiss DS, Marmar CR. The Impact of Event Scale — Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York7 Guilford; 1997. p. 399 – 411. [8] Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale — Revised. Behav Res Ther 2003;41: 1489 – 96. [9] Bonne O, Brandes D, Gilboa A, et al. Longitudinal MRI study of hippocampal volume in trauma survivors with PTSD. Am J Psychiatry 2001;158:1248 – 51. [10] Shalev AY, Freedman S. PTSD following terrorist attacks: a prospective evaluation. Am J Psychiatry 2005;162:1188 – 91. [11] Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet 2000;355:533 – 7. [12] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC7 Author; 1994.