- Email: [email protected]
personnel (CE)
RESEARCH
Work Stress and Posttraumatic Stress Disorder in ED Nurses/Personnel Authors: Judith M. Laposa, MA, Lynn E. Alden, PhD, and Louise M. Fullerton, RN, MSc(A), Vancouver, BC Introduction: Work-related stress in the emergency department Judith M. Laposa is a doctoral student and Lynn E. Alden is Professor, Department of Psychology, University of British Columbia. Louise M. Fullerton is Operations Director, Vancouver, BC. Supported by a Social Sciences and Humanities Research Council grant to the second author and a National Sciences and Engineering Research Council scholarship and British Columbia Medical Services Foundation scholarship to the first author. For reprints, write: Judith M. Laposa, MA, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia, Canada V6T 1Z4; E-mail: [email protected]. J Emerg Nurs 2003;29:23-8. Copyright © 2003 by the Emergency Nurses Association. 0099-1767/2003 $30.00 + 0 doi:10.1067/men.2003.7
previously has been linked to depression and burnout; however, these findings have not been extended to the development of anxiety disorders, such as posttraumatic stress disorder (PTSD). Three sets of factors have been shown to contribute to stress in ED personnel: organizational characteristics, patient care, and the interpersonal environment. The current study addressed whether an association exists between sources of workplace stress and PTSD symptoms. Method: Respondents were 51 ED personnel from a hospital in
a large Canadian urban center. The majority of respondents were emergency nurses. Respondents completed questionnaires measuring PTSD and sources of work stress and answered a series of questions regarding work-related responses to stress or trauma. Results: Interpersonal conflict was significantly associated with
PTSD symptoms. The majority of respondents (67%) believed they had received inadequate support from hospital administrators following the traumatic incident and 20% considered changing jobs as a result of the trauma. Only 18% attended critical incident stress debriefing and none sought outside help for their distress. Discussion: These findings underscore the need for hospital
administrations to be aware of the extent of workplace stress and PTSD symptoms in their employees. Improving the interpersonal climate in the workplace may be useful in ameliorating PTSD symptoms.
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
23
RESEARCH/Laposa, Alden, and Fullerton
P
osttraumatic stress disorder (PTSD) is an anxiety condition that develops subsequent to traumatic events. The hallmark symptoms of the disorder are intrusive memories and images of the trauma and behavioral avoidance of cues that remind the person of the incident. PTSD is known to create significant life impairment, including occupational dysfunction. PTSD was first recognized among persons who had directly experienced trauma, such as war veterans and assault victims. More recently, researchers have demonstrated that PTSD can develop in persons who witness upsetting events in the workplace, such as ambulance attendants and firefighters.1,2 ED personnel also have been shown to be at increased risk of having PTSD develop, with up to one third of ED workers reporting PTSD symptoms and 12% meeting full criteria for the disorder.3,4 In addition, Laposa and Alden4 found that 27% of a sample of ED workers reported that their PTSD symptoms had interfered with their job performance. These findings point to the importance of unearthing factors that may contribute to PTSD in this population, which in turn would provide targets for interventions designed to prevent personal suffering and occupational impairment. One factor that may increase the likelihood of PTSD is work-related stress. Stress is defined as a psychobiological reaction of the body to physical or psychological demands that threaten or challenge the organism’s well-being.5 Some studies suggest that experiencing stressful life events increases vulnerability to PTSD.6,7 Most of those studies, however, assessed significant personal events, such as financial stress or loss of a loved one. The extent to which more routine work-related stress contributes to the development of PTSD remains to be determined. Studies of workplace stress in the emergency department have focused primarily on the contribution of stress to job burnout.8,9 There is reason to believe that stress also predisposes health care workers to clinical conditions, such as depression;10,11 however, no studies have addressed the relationship between stress and the development of anxiety disorders. Empirical studies indicate that 3 sets of factors contribute to stress in ED personnel: organizational characteristics, patient care, and the interpersonal environment.3,12-16 Organizational sources of stress include staffing and unit management; patient care encompasses events such as caring
24
for patients in critical condition and dealing with patients’ families; and the interpersonal environment includes conflict among coworkers and supervisors. The current study addressed whether an association exists between sources of workplace stress and PTSD symptom severity. We also assessed workers’ reactions to traumatic incidents. Our goal was to follow up on a recent study of violence against ED staff, which revealed that many emergency workers who were victims of violence took time off or even left the job because of the incident.17 This research also indicated that emergency workers looked for support from colleagues rather than from formal hospital crisis debriefing programs. We wanted to determine whether participants of this study would display similar reactions to other types of traumatic workplace events. Method
The current study is a secondary analysis of data previously reported.4 The purpose of the primary study was to establish the prevalence of PTSD in a sample of ED personnel and to examine several key tenets of a recently proposed cognitive model of PTSD. In the current study we go on to determine whether associations exist between symptoms of PTSD and sources of workplace stress, and how emergency personnel respond to workplace stress or trauma. RESPONDENTS
Respondents in this study were ED personnel who had participated in the study by Laposa and Alden.4 To summarize, 51 ED workers at a major hospital in a large urban center in British Columbia were recruited from staff meetings and by word of mouth. Ethical approval for this study was obtained from both the university and hospital research ethics boards. Sixty-seven percent of those who picked up a questionnaire package completed it, which represents approximately 44% of ED staff who had extensive patient contact. Respondents were primarily emergency nurses, single, women, and of European Canadian background (Table 1). The average age was 36.5 years, with an age range of 23 to 51 years. Respondents had been working in the emergency department of this hospital for an average of 7.5 years and in the health services profession for an average of 12.5 years.4
JOURNAL OF EMERGENCY NURSING
29:1 February 2003
RESEARCH/Laposa, Alden, and Fullerton
TABLE 1
TABLE 2
Demographic breakdown of participants
Diagnostic criteria for PTSD
Demographic variable
Gender Female Male Ethnic background European Canadian Asian Canadian Indo Canadian Other Marital status Single Married/common-law Separated/divorced/widowed Education level High school Some college/university College/university degree Graduate/professional degree Occupation Direct patient care (eg, nurses, physicians) Administrative clerks (eg, nursing unit clerks) Indirect support (eg, technicians, housekeeping)
%
90 10 57 14 4 25 47 43 10 6 12 61 20 73 21 6
A. Experiencing, witnessing, or confronting with a lifethreatening event to which person responded with intense fear, helplessness, or horror B. Reexperiencing the event (eg, upsetting thoughts/images or bad dreams about the event, feeling as if they are reliving the event, feeling emotionally upset when reminded of the traumatic event) C. Numbing and avoidance of things associated with the trauma (eg, avoiding talking about the event, avoiding things that remind them of the event, feeling distant from others or emotionally numb) D. Increased arousal (eg, trouble sleeping or concentrating) E. Duration of more than 1 month F. Clinically significant distress or impairment in important areas of life functioning Data from reference 26.
score. Cronbach’s alphas for the 3 factor and total scores were .63, .76, .71, and .81, respectively, which suggests that the scales had adequate internal consistency. To allow comparison across the 3 dimensions, each factor score was averaged across the number of items.
MEASURES
Posttraumatic Diagnostic Scale: PTSD was assessed with
Health Professionals Stress Inventory (revised version):
Stress was assessed with the Health Professionals Stress Inventory Revised (HPSI-R). The HPSI is a 30-item scale designed to measure stress in the health profession.18 Factor analysis of the original items revealed 4 underlying factors, or dimensions.19 Because one dimension was characterized by low internal consistency and item overlap with the other factors, for the purpose of this study we chose to focus on the 3 stable factors and selected only the items with high loadings on a single dimension. We refer to these 3 revised factors as organizational characteristics (8 items, eg, not being allowed to participate in making decisions about my job), patient care (7 items, eg, fearing a mistake will be made in the treatment of a patient), and interpersonal conflict (3 items, eg, experiencing conflict with coworkers). Respondents rated each item on a 1- to 5-point scale that reflected how stressful that aspect of the job was for them. The 3 sets of items were summed to create a total stress
the Posttraumatic Stress Diagnostic Scale (PDS).20 The PDS measures all 6 criteria from the Diagnostic and Statistical Manual of Mental Disorder, fourth edition, for PTSD (Table 2). Respondents completed the scale with reference to potentially traumatic work events. This list of events was based on situations identified in previous research as critical ED incidents, such as actual or threatened physical assault, death of a child, and dealing with multiple casualties at the same time.17,21 After indicating which events they have experienced on the job, respondents chose the event that upset them the most. The PDS provides scores for the 3 symptom clusters of PTSD: reexperiencing (eg, having intrusive thoughts or images about the event), avoidance and numbing (eg, avoiding thinking or talking about the event), and arousal (eg, being easily startled). The 3 cluster scores can be summed to produce a symptom severity score. Foa20 reports a Cronbach’s α of .92 for the severity score; in our sample it was .83, indicating adequate internal consistency.
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
25
RESEARCH/Laposa, Alden, and Fullerton
TABLE 3
The top six most upsetting events Event
%
Providing care to a patient who is a relative or close friend and is dying or in serious condition Threatened physical assault of self Multiple trauma with massive bleeding or dismemberment Death of a child Providing care to a traumatized patient who resembles yourself or family members in age or appearance Caring for a severely burned patient
15 15 13 13 8
8
Work-related responses to stress or trauma: Six items regarding reactions to stress/trauma were assessed, including workload reduction resulting from stress, and following the traumatic event, whether they (1) attended critical incident stress debriefing, (2) sought professional help elsewhere, (3) felt supported by their administration, (4) believed that the event affected their previous ability to interact with coworkers, and (5) considered changing jobs. The first 3 questions were asked in a Yes/No format. The latter 3 questions were rated on a scale from 1 to 5 (1 = strongly disagree; 5 = strongly agree). For descriptive purposes an answer of 1 or 2 was coded as “No,” 3 was coded as “Neutral,” and 4 or 5 was coded as “Yes.” Results
between the 3 factors or total stress score and age, number of years working at this hospital, number of years working in the health services profession, number of shifts per month, or number of overtime shifts per month. Pearson correlation coefficients computed between the HPSI-R factor and total scores and PTSD symptom severity revealed that interpersonal conflict was the only type of stress to significantly predict PTSD symptom severity (r = .36, P < .05).* Pearson correlation coefficients were computed between the HPSI-R scores and scores on the 3 PTSD symptom clusters to ascertain whether the HPSI-R was associated with some symptoms of PTSD more than others. Interpersonal conflict was significantly associated with the avoidance (r = .32, P < .05) and arousal (r = .37, P < .01) clusters. Respondents’ responses to the 6 workplace-related change questions can be seen in Table 4. Of particular importance were findings indicating that the majority of respondents believed they had received inadequate support from hospital administrators following the traumatic incident and that one fifth of respondents considered changing jobs as a result of the trauma. Despite those complaints, relatively few attended critical incident stress debriefing and none sought outside help for their distress. Discussion
These results point to a relationship between stress caused by interpersonal conflict in the workplace and PTSD symptoms. Interestingly, stress created by organizational factors and patient care was less problematic, suggesting that ED personnel can manage the work but that it was the job’s interpersonal environment that was more relevant to PTSD levels. Because of the correlational design of the current study, there are at least 2 ways to interpret the relationship between interpersonal conflict and PTSD severity. On one hand, interpersonal conflict may sensitize individuals, making them more vulnerable to experiencing symptoms of PTSD
Out of a possible total of 90, the average stress score (HPSIR) was 57.19 (SD = 10.15), with a range of 31 to 76. The average PTSD symptom severity score was 6.85 (SD = 5.58), out of a possible total of 51, with severity scores ranging from 0 to 25. Twelve percent of respondents met full criteria for a diagnosis of PTSD, and 20% met the criteria for the 3 symptom clusters (B to D). The 6 events chosen most frequently as the most upsetting are provided in Table 3. To determine whether any of the HPSI-R factors were rated as more stressful than the others, a repeated measures analysis of variance was conducted that compared the severity of stress caused by each factor. This analysis revealed that all 3 HPSI-R factors were rated as equally stressful (F [1, 49] = 0.73, P > .1). No significant relationships existed
*Although the total HPSI-R stress score was normally distributed, the PTSD symptom severity score was not. To normalize the data, a log transformation of the PDS severity score was performed. However, when the results derived from transformed and untransformed data were compared, the difference between the 2 was not large enough to warrant transforming the PDS score. Thus, the reported results are based on untransformed data, and consequently are conservatively biased.
26
JOURNAL OF EMERGENCY NURSING
29:1 February 2003
RESEARCH/Laposa, Alden, and Fullerton
TABLE 4
Percentage endorsement for work-related responses to stress or trauma % Neutral
Question
Yes
No
Did you reduce your work hours in the past year because of stress reasons? Following the most upsetting event did you: 1. Attend critical incident stress debriefing provided by the hospital? 2. Seek outside professional help for dealing with your stress reaction? 3. Feel adequately supported by your immediate hospital administration? 4. Believe the incident affected your ability to maintain the previous level of function/interaction with coworkers? 5. Consider changing jobs?
29
71
18 0 8 2
25 10
82 100 67 88
20
14
66
following a traumatic work event. Conversely, it may be that having PTSD symptoms makes it harder to get along with others. Eighty-eight percent reported that the traumatic event did not affect their interaction with coworkers, suggesting that the conflictual interpersonal environment existed before the PTSD symptoms. However, prospective studies using larger and broader samples are needed to determine the causal nature of this relationship. Studies on PTSD in other emergency service professions have only reported prevalences of those workers meeting the symptom criteria for PTSD (B to D), but not formal PTSD diagnostic criteria (ie, meeting criteria A to F). In comparison with these other studies, the finding that 20% met symptom criteria in this sample is, in general, very similar to the figure found with ambulance attendants, is somewhat lower than the figure found in firefighters, and is somewhat higher than the figure found in disaster workers.4 To our knowledge, this is the first study to examine the association between sources of workplace stress and PTSD symptoms in ED personnel. The results are consistent with the finding by Schwarz and Kowalski22 that following a school shooting, the positive attitudes of school personnel towards the workplace, particularly towards coworkers, were related to fewer symptoms of PTSD. Our finding of a specific link between interpersonal conflict and PTSD symptoms also parallels findings in other anxiety disorders, although these investigations did not focus on workplace stress per se. For example, Last et al23 and Doctor24 reported a strong association between relationship or interpersonal conflict and the onset of agoraphobia, a condition marked
by behavioral avoidance of situations that trigger panic attacks. The results are also consistent with earlier studies demonstrating that lack of social support may act as a risk factor for PTSD.25 The vast majority of respondents did not attend debriefing programs offered to them by the hospital, nor did they feel supported by their administration following a traumatic incident. Furthermore, many staff decreased their hours for stress reasons, and 20% of them indicated that the critical incident made them consider switching jobs. Together, these findings underscore the need for hospital administrations to be aware of the extent of workplace stress and PTSD symptoms in their employees. Interestingly, there were trends for those who attended critical incident stress debriefing. They tended to report feeling more supported by their hospital administration and to report less interpersonal conflict. However, studies specifically designed to test debriefing program effectiveness are needed to replicate these results. The implication of this study is that changes in the interpersonal climate, including enhancing administrative support, may be useful in ameliorating PTSD symptoms. A more positive interpersonal environment may make ED personnel less likely to be traumatized by the work they do. Supportive social relationships have been shown to buffer the impact of traumatic events, and this suggests that providing emotional support for traumatized workers would be beneficial. However, given that such a small percentage of individuals actually attended formal debriefing programs, employees may be doing more of their processing of the
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
27
RESEARCH/Laposa, Alden, and Fullerton
traumatic event among their peers. Creating a less conflictual work environment may provide coworkers with better access to defusing opportunities among themselves. This in turn may promote emotional processing of critical incidents and thereby decrease PTSD symptoms. Acknowledgments We would like to thank the hospital for supporting this study and the following people for their assistance in conducting this research and for providing comments on earlier versions of this manuscript: Charles Taylor, Dr Tanna Mellings, and Aaron Magney.
REFERENCES 1. Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol 1999;38:251-65. 2. Wagner D, Heinriches M, Ehlert U. Prevalence of symptoms of posttraumatic stress in German professional firefighters. Am J Psychiatry 1998;155:1727-32. 3. Helps SL. Experiences of accident and emergency nurses. Accid Emerg Nurs 1997;5:48-53. 4. Laposa JM, Alden LE. Posttraumatic stress disorder in the emergency room: exploration of a cognitive model. Behav Res Ther 2003;41:49-65. 5. Gatchel RJ, Baum A. Health Psychology. New York: Random House; 1983. p. 40-74. 6. Astin MC, Lawrence KJ, Foy DW. Posttraumatic stress disorder among battered women: risk and resiliency factors. Violence Vict 1993;8:17-28. 7. Bryant RA, Harvey AG. Initial posttraumatic stress responses following motor vehicle accidents. J Trauma Stress 1996;9:223-34. 8. Keller KL. The management of stress and prevention of burnout in emergency nurses. J Emerg Nurs 1990;16:90-5. 9. Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med 1989;18:7984. 10. Gallery ME, Whitely TW, Lonis LK, Anzinger RK, Revicki DA. A study of occupational stress and depression among emergency medicine physicians. Ann Emerg Med 1992;21:58-64. 11. Revicki DA, Whitely TE, Gallery ME. Organizational characteristics, perceived work stress, and depression in emergency medicine residents. Behav Med 1993;19:74-81. 12. Burns H, Kirillof L, Close J. Sources of stress and satisfaction in emergency nursing. J Emerg Nurs 1983;9:329-37. 13. Keller KH, Koenig WJ. Sources of stress and satisfaction in emergency practice. J Emerg Med 1989;7:293-9. 14. Scullion PA. An identification of stressors associated with student nurses in an accident and emergency department and comparison of stress levels. Accid Emerg Nurs 1994;2:79-86. 15. Walsh M, Dolan B, Lewis A. Burnout and stress among A & E nurses. Emerg Nurse 1998;6:23-30. 16. Hawley P. Sources of stress for emergency nurses in four urban Canadian emergency departments. J Emerg Nurs 1992;18:65-7.
28
17. Fernandes CMB, Bouthillette F, Raboud JM, Bullock L, Moore CF, Christenson JM, et al. Violence in the emergency department: a survey of health care workers. Can Med Assoc J 1999; 161:1245-8. 18. Wolfgang AP. The health professions stress inventory. Psychol Rep 1988;62:220-2. 19. Eells TD, Lacefield P, Maxey J. Symptom correlates and factor structure of the health professions stress inventory. Psychol Rep 1994;75:1563-8. 20. Foa EB. The Posttraumatic Diagnostic Scale (PDS) manual. Minneapolis (MN): National Computer Systems; 1995. 21. Burns C, Harm N. Emergency nurses’ perceptions of critical incidents and stress debriefing. J Emerg Nurs 1993;19:431-6. 22. Schwarz ED, Kowalski JM. Malignant memories: effect of a shooting in the workplace on school personnel’s attitudes. J Interpersonal Violence 1993;8:468-85. 23. Last CG, Barlow DH, O’Brien GT. Precipitants of agoraphobia: role of stressful life events. Psychol Rep 1984;54:567-70. 24. Doctor RM. Major results of a large-scale pretreatment survey of agoraphobics. In: DuPont RL, editor. Phobia: a comprehensive summary of modern treatments. New York: Brunner/Mazel; 1982. p. 203-14. 25. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clinical Psychol 2000;68:748-66. 26. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 1994.
JOURNAL OF EMERGENCY NURSING
29:1 February 2003
Work Stress and Posttraumatic Stress Disorder in ED Nurses/Personnel Authors: Judith M. Laposa, MA, Lynn E. Alden, PhD, and Louise M. Fullerton, RN, MSc(A), Vancouver, BC Introduction: Work-related stress in the emergency department Judith M. Laposa is a doctoral student and Lynn E. Alden is Professor, Department of Psychology, University of British Columbia. Louise M. Fullerton is Operations Director, Vancouver, BC. Supported by a Social Sciences and Humanities Research Council grant to the second author and a National Sciences and Engineering Research Council scholarship and British Columbia Medical Services Foundation scholarship to the first author. For reprints, write: Judith M. Laposa, MA, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia, Canada V6T 1Z4; E-mail: [email protected]. J Emerg Nurs 2003;29:23-8. Copyright © 2003 by the Emergency Nurses Association. 0099-1767/2003 $30.00 + 0 doi:10.1067/men.2003.7
previously has been linked to depression and burnout; however, these findings have not been extended to the development of anxiety disorders, such as posttraumatic stress disorder (PTSD). Three sets of factors have been shown to contribute to stress in ED personnel: organizational characteristics, patient care, and the interpersonal environment. The current study addressed whether an association exists between sources of workplace stress and PTSD symptoms. Method: Respondents were 51 ED personnel from a hospital in
a large Canadian urban center. The majority of respondents were emergency nurses. Respondents completed questionnaires measuring PTSD and sources of work stress and answered a series of questions regarding work-related responses to stress or trauma. Results: Interpersonal conflict was significantly associated with
PTSD symptoms. The majority of respondents (67%) believed they had received inadequate support from hospital administrators following the traumatic incident and 20% considered changing jobs as a result of the trauma. Only 18% attended critical incident stress debriefing and none sought outside help for their distress. Discussion: These findings underscore the need for hospital
administrations to be aware of the extent of workplace stress and PTSD symptoms in their employees. Improving the interpersonal climate in the workplace may be useful in ameliorating PTSD symptoms.
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
23
RESEARCH/Laposa, Alden, and Fullerton
P
osttraumatic stress disorder (PTSD) is an anxiety condition that develops subsequent to traumatic events. The hallmark symptoms of the disorder are intrusive memories and images of the trauma and behavioral avoidance of cues that remind the person of the incident. PTSD is known to create significant life impairment, including occupational dysfunction. PTSD was first recognized among persons who had directly experienced trauma, such as war veterans and assault victims. More recently, researchers have demonstrated that PTSD can develop in persons who witness upsetting events in the workplace, such as ambulance attendants and firefighters.1,2 ED personnel also have been shown to be at increased risk of having PTSD develop, with up to one third of ED workers reporting PTSD symptoms and 12% meeting full criteria for the disorder.3,4 In addition, Laposa and Alden4 found that 27% of a sample of ED workers reported that their PTSD symptoms had interfered with their job performance. These findings point to the importance of unearthing factors that may contribute to PTSD in this population, which in turn would provide targets for interventions designed to prevent personal suffering and occupational impairment. One factor that may increase the likelihood of PTSD is work-related stress. Stress is defined as a psychobiological reaction of the body to physical or psychological demands that threaten or challenge the organism’s well-being.5 Some studies suggest that experiencing stressful life events increases vulnerability to PTSD.6,7 Most of those studies, however, assessed significant personal events, such as financial stress or loss of a loved one. The extent to which more routine work-related stress contributes to the development of PTSD remains to be determined. Studies of workplace stress in the emergency department have focused primarily on the contribution of stress to job burnout.8,9 There is reason to believe that stress also predisposes health care workers to clinical conditions, such as depression;10,11 however, no studies have addressed the relationship between stress and the development of anxiety disorders. Empirical studies indicate that 3 sets of factors contribute to stress in ED personnel: organizational characteristics, patient care, and the interpersonal environment.3,12-16 Organizational sources of stress include staffing and unit management; patient care encompasses events such as caring
24
for patients in critical condition and dealing with patients’ families; and the interpersonal environment includes conflict among coworkers and supervisors. The current study addressed whether an association exists between sources of workplace stress and PTSD symptom severity. We also assessed workers’ reactions to traumatic incidents. Our goal was to follow up on a recent study of violence against ED staff, which revealed that many emergency workers who were victims of violence took time off or even left the job because of the incident.17 This research also indicated that emergency workers looked for support from colleagues rather than from formal hospital crisis debriefing programs. We wanted to determine whether participants of this study would display similar reactions to other types of traumatic workplace events. Method
The current study is a secondary analysis of data previously reported.4 The purpose of the primary study was to establish the prevalence of PTSD in a sample of ED personnel and to examine several key tenets of a recently proposed cognitive model of PTSD. In the current study we go on to determine whether associations exist between symptoms of PTSD and sources of workplace stress, and how emergency personnel respond to workplace stress or trauma. RESPONDENTS
Respondents in this study were ED personnel who had participated in the study by Laposa and Alden.4 To summarize, 51 ED workers at a major hospital in a large urban center in British Columbia were recruited from staff meetings and by word of mouth. Ethical approval for this study was obtained from both the university and hospital research ethics boards. Sixty-seven percent of those who picked up a questionnaire package completed it, which represents approximately 44% of ED staff who had extensive patient contact. Respondents were primarily emergency nurses, single, women, and of European Canadian background (Table 1). The average age was 36.5 years, with an age range of 23 to 51 years. Respondents had been working in the emergency department of this hospital for an average of 7.5 years and in the health services profession for an average of 12.5 years.4
JOURNAL OF EMERGENCY NURSING
29:1 February 2003
RESEARCH/Laposa, Alden, and Fullerton
TABLE 1
TABLE 2
Demographic breakdown of participants
Diagnostic criteria for PTSD
Demographic variable
Gender Female Male Ethnic background European Canadian Asian Canadian Indo Canadian Other Marital status Single Married/common-law Separated/divorced/widowed Education level High school Some college/university College/university degree Graduate/professional degree Occupation Direct patient care (eg, nurses, physicians) Administrative clerks (eg, nursing unit clerks) Indirect support (eg, technicians, housekeeping)
%
90 10 57 14 4 25 47 43 10 6 12 61 20 73 21 6
A. Experiencing, witnessing, or confronting with a lifethreatening event to which person responded with intense fear, helplessness, or horror B. Reexperiencing the event (eg, upsetting thoughts/images or bad dreams about the event, feeling as if they are reliving the event, feeling emotionally upset when reminded of the traumatic event) C. Numbing and avoidance of things associated with the trauma (eg, avoiding talking about the event, avoiding things that remind them of the event, feeling distant from others or emotionally numb) D. Increased arousal (eg, trouble sleeping or concentrating) E. Duration of more than 1 month F. Clinically significant distress or impairment in important areas of life functioning Data from reference 26.
score. Cronbach’s alphas for the 3 factor and total scores were .63, .76, .71, and .81, respectively, which suggests that the scales had adequate internal consistency. To allow comparison across the 3 dimensions, each factor score was averaged across the number of items.
MEASURES
Posttraumatic Diagnostic Scale: PTSD was assessed with
Health Professionals Stress Inventory (revised version):
Stress was assessed with the Health Professionals Stress Inventory Revised (HPSI-R). The HPSI is a 30-item scale designed to measure stress in the health profession.18 Factor analysis of the original items revealed 4 underlying factors, or dimensions.19 Because one dimension was characterized by low internal consistency and item overlap with the other factors, for the purpose of this study we chose to focus on the 3 stable factors and selected only the items with high loadings on a single dimension. We refer to these 3 revised factors as organizational characteristics (8 items, eg, not being allowed to participate in making decisions about my job), patient care (7 items, eg, fearing a mistake will be made in the treatment of a patient), and interpersonal conflict (3 items, eg, experiencing conflict with coworkers). Respondents rated each item on a 1- to 5-point scale that reflected how stressful that aspect of the job was for them. The 3 sets of items were summed to create a total stress
the Posttraumatic Stress Diagnostic Scale (PDS).20 The PDS measures all 6 criteria from the Diagnostic and Statistical Manual of Mental Disorder, fourth edition, for PTSD (Table 2). Respondents completed the scale with reference to potentially traumatic work events. This list of events was based on situations identified in previous research as critical ED incidents, such as actual or threatened physical assault, death of a child, and dealing with multiple casualties at the same time.17,21 After indicating which events they have experienced on the job, respondents chose the event that upset them the most. The PDS provides scores for the 3 symptom clusters of PTSD: reexperiencing (eg, having intrusive thoughts or images about the event), avoidance and numbing (eg, avoiding thinking or talking about the event), and arousal (eg, being easily startled). The 3 cluster scores can be summed to produce a symptom severity score. Foa20 reports a Cronbach’s α of .92 for the severity score; in our sample it was .83, indicating adequate internal consistency.
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
25
RESEARCH/Laposa, Alden, and Fullerton
TABLE 3
The top six most upsetting events Event
%
Providing care to a patient who is a relative or close friend and is dying or in serious condition Threatened physical assault of self Multiple trauma with massive bleeding or dismemberment Death of a child Providing care to a traumatized patient who resembles yourself or family members in age or appearance Caring for a severely burned patient
15 15 13 13 8
8
Work-related responses to stress or trauma: Six items regarding reactions to stress/trauma were assessed, including workload reduction resulting from stress, and following the traumatic event, whether they (1) attended critical incident stress debriefing, (2) sought professional help elsewhere, (3) felt supported by their administration, (4) believed that the event affected their previous ability to interact with coworkers, and (5) considered changing jobs. The first 3 questions were asked in a Yes/No format. The latter 3 questions were rated on a scale from 1 to 5 (1 = strongly disagree; 5 = strongly agree). For descriptive purposes an answer of 1 or 2 was coded as “No,” 3 was coded as “Neutral,” and 4 or 5 was coded as “Yes.” Results
between the 3 factors or total stress score and age, number of years working at this hospital, number of years working in the health services profession, number of shifts per month, or number of overtime shifts per month. Pearson correlation coefficients computed between the HPSI-R factor and total scores and PTSD symptom severity revealed that interpersonal conflict was the only type of stress to significantly predict PTSD symptom severity (r = .36, P < .05).* Pearson correlation coefficients were computed between the HPSI-R scores and scores on the 3 PTSD symptom clusters to ascertain whether the HPSI-R was associated with some symptoms of PTSD more than others. Interpersonal conflict was significantly associated with the avoidance (r = .32, P < .05) and arousal (r = .37, P < .01) clusters. Respondents’ responses to the 6 workplace-related change questions can be seen in Table 4. Of particular importance were findings indicating that the majority of respondents believed they had received inadequate support from hospital administrators following the traumatic incident and that one fifth of respondents considered changing jobs as a result of the trauma. Despite those complaints, relatively few attended critical incident stress debriefing and none sought outside help for their distress. Discussion
These results point to a relationship between stress caused by interpersonal conflict in the workplace and PTSD symptoms. Interestingly, stress created by organizational factors and patient care was less problematic, suggesting that ED personnel can manage the work but that it was the job’s interpersonal environment that was more relevant to PTSD levels. Because of the correlational design of the current study, there are at least 2 ways to interpret the relationship between interpersonal conflict and PTSD severity. On one hand, interpersonal conflict may sensitize individuals, making them more vulnerable to experiencing symptoms of PTSD
Out of a possible total of 90, the average stress score (HPSIR) was 57.19 (SD = 10.15), with a range of 31 to 76. The average PTSD symptom severity score was 6.85 (SD = 5.58), out of a possible total of 51, with severity scores ranging from 0 to 25. Twelve percent of respondents met full criteria for a diagnosis of PTSD, and 20% met the criteria for the 3 symptom clusters (B to D). The 6 events chosen most frequently as the most upsetting are provided in Table 3. To determine whether any of the HPSI-R factors were rated as more stressful than the others, a repeated measures analysis of variance was conducted that compared the severity of stress caused by each factor. This analysis revealed that all 3 HPSI-R factors were rated as equally stressful (F [1, 49] = 0.73, P > .1). No significant relationships existed
*Although the total HPSI-R stress score was normally distributed, the PTSD symptom severity score was not. To normalize the data, a log transformation of the PDS severity score was performed. However, when the results derived from transformed and untransformed data were compared, the difference between the 2 was not large enough to warrant transforming the PDS score. Thus, the reported results are based on untransformed data, and consequently are conservatively biased.
26
JOURNAL OF EMERGENCY NURSING
29:1 February 2003
RESEARCH/Laposa, Alden, and Fullerton
TABLE 4
Percentage endorsement for work-related responses to stress or trauma % Neutral
Question
Yes
No
Did you reduce your work hours in the past year because of stress reasons? Following the most upsetting event did you: 1. Attend critical incident stress debriefing provided by the hospital? 2. Seek outside professional help for dealing with your stress reaction? 3. Feel adequately supported by your immediate hospital administration? 4. Believe the incident affected your ability to maintain the previous level of function/interaction with coworkers? 5. Consider changing jobs?
29
71
18 0 8 2
25 10
82 100 67 88
20
14
66
following a traumatic work event. Conversely, it may be that having PTSD symptoms makes it harder to get along with others. Eighty-eight percent reported that the traumatic event did not affect their interaction with coworkers, suggesting that the conflictual interpersonal environment existed before the PTSD symptoms. However, prospective studies using larger and broader samples are needed to determine the causal nature of this relationship. Studies on PTSD in other emergency service professions have only reported prevalences of those workers meeting the symptom criteria for PTSD (B to D), but not formal PTSD diagnostic criteria (ie, meeting criteria A to F). In comparison with these other studies, the finding that 20% met symptom criteria in this sample is, in general, very similar to the figure found with ambulance attendants, is somewhat lower than the figure found in firefighters, and is somewhat higher than the figure found in disaster workers.4 To our knowledge, this is the first study to examine the association between sources of workplace stress and PTSD symptoms in ED personnel. The results are consistent with the finding by Schwarz and Kowalski22 that following a school shooting, the positive attitudes of school personnel towards the workplace, particularly towards coworkers, were related to fewer symptoms of PTSD. Our finding of a specific link between interpersonal conflict and PTSD symptoms also parallels findings in other anxiety disorders, although these investigations did not focus on workplace stress per se. For example, Last et al23 and Doctor24 reported a strong association between relationship or interpersonal conflict and the onset of agoraphobia, a condition marked
by behavioral avoidance of situations that trigger panic attacks. The results are also consistent with earlier studies demonstrating that lack of social support may act as a risk factor for PTSD.25 The vast majority of respondents did not attend debriefing programs offered to them by the hospital, nor did they feel supported by their administration following a traumatic incident. Furthermore, many staff decreased their hours for stress reasons, and 20% of them indicated that the critical incident made them consider switching jobs. Together, these findings underscore the need for hospital administrations to be aware of the extent of workplace stress and PTSD symptoms in their employees. Interestingly, there were trends for those who attended critical incident stress debriefing. They tended to report feeling more supported by their hospital administration and to report less interpersonal conflict. However, studies specifically designed to test debriefing program effectiveness are needed to replicate these results. The implication of this study is that changes in the interpersonal climate, including enhancing administrative support, may be useful in ameliorating PTSD symptoms. A more positive interpersonal environment may make ED personnel less likely to be traumatized by the work they do. Supportive social relationships have been shown to buffer the impact of traumatic events, and this suggests that providing emotional support for traumatized workers would be beneficial. However, given that such a small percentage of individuals actually attended formal debriefing programs, employees may be doing more of their processing of the
February 2003 29:1
JOURNAL OF EMERGENCY NURSING
27
RESEARCH/Laposa, Alden, and Fullerton
traumatic event among their peers. Creating a less conflictual work environment may provide coworkers with better access to defusing opportunities among themselves. This in turn may promote emotional processing of critical incidents and thereby decrease PTSD symptoms. Acknowledgments We would like to thank the hospital for supporting this study and the following people for their assistance in conducting this research and for providing comments on earlier versions of this manuscript: Charles Taylor, Dr Tanna Mellings, and Aaron Magney.
REFERENCES 1. Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol 1999;38:251-65. 2. Wagner D, Heinriches M, Ehlert U. Prevalence of symptoms of posttraumatic stress in German professional firefighters. Am J Psychiatry 1998;155:1727-32. 3. Helps SL. Experiences of accident and emergency nurses. Accid Emerg Nurs 1997;5:48-53. 4. Laposa JM, Alden LE. Posttraumatic stress disorder in the emergency room: exploration of a cognitive model. Behav Res Ther 2003;41:49-65. 5. Gatchel RJ, Baum A. Health Psychology. New York: Random House; 1983. p. 40-74. 6. Astin MC, Lawrence KJ, Foy DW. Posttraumatic stress disorder among battered women: risk and resiliency factors. Violence Vict 1993;8:17-28. 7. Bryant RA, Harvey AG. Initial posttraumatic stress responses following motor vehicle accidents. J Trauma Stress 1996;9:223-34. 8. Keller KL. The management of stress and prevention of burnout in emergency nurses. J Emerg Nurs 1990;16:90-5. 9. Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med 1989;18:7984. 10. Gallery ME, Whitely TW, Lonis LK, Anzinger RK, Revicki DA. A study of occupational stress and depression among emergency medicine physicians. Ann Emerg Med 1992;21:58-64. 11. Revicki DA, Whitely TE, Gallery ME. Organizational characteristics, perceived work stress, and depression in emergency medicine residents. Behav Med 1993;19:74-81. 12. Burns H, Kirillof L, Close J. Sources of stress and satisfaction in emergency nursing. J Emerg Nurs 1983;9:329-37. 13. Keller KH, Koenig WJ. Sources of stress and satisfaction in emergency practice. J Emerg Med 1989;7:293-9. 14. Scullion PA. An identification of stressors associated with student nurses in an accident and emergency department and comparison of stress levels. Accid Emerg Nurs 1994;2:79-86. 15. Walsh M, Dolan B, Lewis A. Burnout and stress among A & E nurses. Emerg Nurse 1998;6:23-30. 16. Hawley P. Sources of stress for emergency nurses in four urban Canadian emergency departments. J Emerg Nurs 1992;18:65-7.
28
17. Fernandes CMB, Bouthillette F, Raboud JM, Bullock L, Moore CF, Christenson JM, et al. Violence in the emergency department: a survey of health care workers. Can Med Assoc J 1999; 161:1245-8. 18. Wolfgang AP. The health professions stress inventory. Psychol Rep 1988;62:220-2. 19. Eells TD, Lacefield P, Maxey J. Symptom correlates and factor structure of the health professions stress inventory. Psychol Rep 1994;75:1563-8. 20. Foa EB. The Posttraumatic Diagnostic Scale (PDS) manual. Minneapolis (MN): National Computer Systems; 1995. 21. Burns C, Harm N. Emergency nurses’ perceptions of critical incidents and stress debriefing. J Emerg Nurs 1993;19:431-6. 22. Schwarz ED, Kowalski JM. Malignant memories: effect of a shooting in the workplace on school personnel’s attitudes. J Interpersonal Violence 1993;8:468-85. 23. Last CG, Barlow DH, O’Brien GT. Precipitants of agoraphobia: role of stressful life events. Psychol Rep 1984;54:567-70. 24. Doctor RM. Major results of a large-scale pretreatment survey of agoraphobics. In: DuPont RL, editor. Phobia: a comprehensive summary of modern treatments. New York: Brunner/Mazel; 1982. p. 203-14. 25. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clinical Psychol 2000;68:748-66. 26. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington: American Psychiatric Association; 1994.
JOURNAL OF EMERGENCY NURSING
29:1 February 2003