Running head: Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder in Psychiatric Nurses

Amanda Mathy
Ferris State University

Abstract
Post-Traumatic stress disorder is defined as a complex disorder in which a persons memory,
emotional responses, intellectual processes, and nervous system have been disrupted by one or
more traumatic experiences (Swan, & Hamilton, 2014). Many nurses, especially those who
work with psychiatric patients, experience PTSD symptoms. PTSD symptoms do not only affect
the personal life of the nurses but also impact overall patient care in the professional setting. This
issue analysis paper focuses on the prevalence of PTSD in psychiatric nurses while identifying
symptoms, risks, and preventative measures. The issue among nurses is addressed as well as
consequences on the nurse, patient, and workplace environment if the issue continues. Research

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on PTSD is guided by the use of nursing and psychological theories including Betty Neumans
Systems Theory and Maslows Hierarchy of Needs. Recommendations, including proper
assessments and debriefing meetings are made in order to prevent this issue from worsening.
American Nurses Association standards of professional practice and QSEN competencies are
used as additional research tools for PTSD effects on the healthcare system. Post-Traumatic
stress disorder is very common among nurses, but is not highly addressed when specifying to the
psychiatric field. PTSD in psychiatric nurses is a prevalent issue and needs to be addressed to
protect nurses and patients overall well-being.

Post-Traumatic Stress Disorder in Psychiatric Nurses

Post-traumatic stress disorder is an emergent healthcare issue that continues to be
unrecognized in all areas of health care. Dating back to 1980, PTSD was first recognized with
the Vietnam Veterans, which explains why PTSD is known as the Veterans disease. Three
decades later, this disease started to affect a more diverse population, specifically the nursing
staff. The overall nursing population affected by PTSD was marked at 14% estimating four times
higher than the general population. Nurses in all areas are affected by PTSD focusing most on
high stress level environments, such as the emergency department, critical care unit, and
psychiatric areas (Hood, 2011).
PTSD is often linked to compassion fatigue and STS, which is secondary traumatic stress
disorder. Although these disorders compare in symptoms, they differ by the level of exposure

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(Zerach, & Shalev, 2015). Whereas PTSD is personally experiencing a traumatic event, STS
results in being exposed to a patients traumatic event and experience. From witnessing trauma
experience, PTSD is highly associated with fatigue, irritability, insomnia, anger, anxiety,
depression, flashbacks, nightmares, and inability to concentrate (Swan, & Hamilton, 2014).
Having these symptoms as a nurse not only affects their personal lives, but also affects overall
patient care in the professional environment.
Events Leading to PTSD
According to the International Journal of Mental Health Nursing, 80-90% of
psychiatric nurses reported to verbal abuse and threats by the patient, 76% reported experiencing
mild physical violence, and 16% encountered severe physical violence (Lee, Daffern, Ogloff, &
Martin, 2014). These are all issues psychiatric nurses are faced with working in the stressful
environment.
Psychiatric nurses are exposed to many challenging events due to the stressful
environment they work in. They are at high risk of exposure of stressful incidents due to the high
rate of assault by patients (Jacobowitz, 2013). Assault by patients directly impact nurses because
it leads to personal safety and health concerns for both the nurse and the patient. Emotional and
physical abuse is two major factors that nurses are dealt with that consequently lead to personal
safety concerns. Psychiatric nurses are often verbally attacked by patients, who are frustrated or
have no filter, such as patients with manic bipolar disorder. Physical abuse occurs frequently
when patients are restrained or secluded because they are trying to escape the environment.
Aggression and violence results from fear of being trapped as well as paranoia. Patients, who are
paranoid, such as schizophrenic patients, often have hallucinations and delusions that can lead to
assaulting the nursing staff. Nurses develop PTSD symptoms frequently from witnessing a death

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or an attempted suicide by one of their patients while they are on watch. Patients with depression
and anxiety feel as if they will not recover from this disorder, so taking their own lives is the
only option. From these traumatic events, nurses are exposed to stress and distress that can affect
their emotional and physical well-being.
The Issue at Hand
With 33% of nurses screening positive for PTSD in the emergency department and 25%
in the critical care unit, the 9-10% of psychiatric nurses experiencing PTSD are often
overlooked (Hood, 2011). Due to poor assessment of these incidents, employers frequently
downplay the issue and lead nurses to cope by themselves. Nursing is a profession of strongwilled attitudes and personalities, so nurses keep these emotional and physical symptoms to
themselves, so they are not portrayed as weak nurses. Even with knowledge of the disorder,
psychiatric nurses often avoid seeking treatment if onsets of symptoms do occur because they do
not want others to view them having the inability to handle stress on the job. The inner emotions
and feelings affect the emotional and physical changes of nurses, which can lead to direct
negative impacts on the safety and quality of the nurses themselves, patient care, families, and
the workplace.
Effects on nurses
All nurses personal lives are affected by stress at work and trauma that occurs on a daily
basis. Specifically, nurses with PTSD have more of a negative impact on their home lives and
overall well-being. Besides feeling fatigued and having the inability to concentrate at work,
nurses have many negative alterations in their cognitions and mood. A lack of trust, dependence,
self-esteem, and self-confidence occurs because the nurse feels unstable and unable to control the
trauma from occurring. These negative feelings will lead the nurse to become less interested and

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passionate about normal activities as well as upholding lower expectations about self. A brief
period of blaming others for the cause of the incident may occur, but will ultimately lead to
blaming oneself because he or she could not prevent it. If it worsens, the nurse will detach
himself or herself from relatives and friends, ultimately leading to strains in those close
relationships. When isolation occurs, the nurse will solely focus on patient care but will create an
unsafe environment due to medical errors and decrease patience to care for others. (Swan, &
Hamilton, 2014).
Effects on patient care
Quality and safety is a priority when providing patient care. It is the nurses job to give
patients the most effective, safest, and proficient care to ensure their well-being and health in the
in-patient setting as well as the recovery at home. A few major symptoms of PTSD are fatigue,
inability to concentrate, and irritability. In a psychiatric unit, patients often do not have physical
symptoms but emotional symptoms that need to be cared for. To properly assess patients, nurses
need to be active listeners. Active listening requires the nurse to be patient and focused on the
verbal and non-verbal gestures the patient is using. If a nurse develops PTSD, they will either be
unable or have a difficult time focusing on what the patient, which may cause the patient to
become irritable and restless. The nurse will not have patience for sitting down to talk to one
patient because of increased irritability and fatigued as well. The lack of concentration will lead
to a higher risk of medication errors and infections, which decreases the patients safety. Overall,
the quality of care for the patient will be decreased if the nurse upholds these symptoms leading
to poor patient reviews and satisfaction (Swan, & Hamilton, 2014).
Effects on workplace

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Direct impact to the workplace occurs when nurses are unhappy with themselves and
impacting overall patient care. Patients, who are not satisfied, are more willing to talk poorly
about the institution and provide poor reviews. With poor reviews, there will be a decreased
number of patients going to the institution resulting in a cost deficit. Nurses being fatigued and
unhappy with themselves and their workplace lead to high burnout and turnover rates. With
fewer nurses staffed, there will be an increased patient workload for many nurses. The nurse-topatient ratios will increase, meaning there will be an increased risk for medication errors and
decrease in patient satisfaction.
Theory
Theories guide nursing practice to improve by the concepts and information provided.
Nursing theories and other theories often correlate by common principles. A nursing theory and
psychology theory that both can be applied to post-traumatic stress disorder are Betty Neumans
Systems Model and Maslows Hierarch of Needs. Both theories focus on stress factors and how
it affects the health, safety, and person specifically.
Betty Neumans Systems Model
In 1924, Betty Neuman developed this flexible and holistic model that focused on stress
and the effects it has on individuals stability. Neuman defines stability as a state of balance of
harmony requiring energy exchanges as the client adequately copes with stressors to retain,
attain, or maintain, an optimal level of health thus preserving system integrity (Current Nursing,
2012). Stability is affected whether known or unknown stressors occur because it causes some
kind of change for the individual. Every person handles stress differently, but it ultimately leads
to a change in stability whether the person is prepared for it or not. In order to maintain stability,
Neuman suggest that nurses have to fulfill that role by their interventions. Preventative measures

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are highly used in maintaining stability, so the nurse must be able to apply primary, secondary,
and tertiary preventions.
Stressors, which can include emotions, feelings, role expectations, and job or finance
pressure, are bound to occur in the psychiatric field. Although nurses are trained for this stressful
environment through primary prevention, unknown stressors still happen that can change the
nurses stability. This means that nurses must be able to recognize the stressors and use
secondary or tertiary preventative measures to ensure they achieve optimal level of health again.
The moment that nurses are unable to identify the stressors and intervene on these incidents,
PTSD symptoms can develop and cause more stress for the nurse (Current Nursing, 2012).
Maslows Hierarchy of Needs
In 1934, Abraham Maslow developed the psychological theory, Maslows Hierarchy of
Needs, which focuses on individuals motivation to fulfill certain needs (McLeod, 2014).
Maslow identified five aspects of his theory to create a pyramid, which include physiological,
safety, love and belonging, self-esteem, and self-actualization needs. In order to reach the
overarching goal of self-actualization, the individual must meet basic human needs and progress
up the pyramid. Although every individual can meet all five aspects of needs, progression is
often stopped by stressors.
Post-traumatic stress disorder is a stressor that ultimately stops the progression of
individuals needs. When nurses have PTSD, basic human needs are affected because of sleep
disturbances. If nurses are able to progress to the safety needs, they will be stopped because
PTSD symptoms will affect their own stability and also safety measures of the patients they are
caring for. Moving up towards self-actualization only gets harder for nurses with this disorder,
because it starts affecting their relationships, independence, dominance, and respect. This theory

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proves that nurses need to recognize the stressors in order to maintain their personal needs. Once
they achieve to the self-actualization level, they will find a resilience of stressors (McLeod,
2014).
Consequences/Implications
Lack of recognition and knowledge regarding post-traumatic stress disorder leads to
many consequences for the nurses, patients, and workplace. Besides physical and emotional
changes, social changes occur from PTSD symptoms as well. A nurse with PTSD symptoms
often times shows symptoms of anger, sympathy, depression, fear, worry, and guilt to their
family members. Isolation and avoidance might also occur as the individual feels as if he or she
is going through this traumatic experience alone.
The biggest concern is the safety aspect of nursing care and how it impacts the work
place. With a high rate of job dissatisfaction by the nurses, there is a high risk for burnout and
turnover rates. Due to lack of employees, nursing shortages in the psychiatric field are expected
to happen. According to Walden University, More than 75% of newly employed psychiatric
nurses leave employment within 6 months (Rollins, 2014). This impacts psychiatric nurse
retention tremendously and is an issue that needs to be recognized. Hospitals and other
institutions policies need to value these traumatic incidents, so there is a decrease in the number
of nurses quitting. The workplace needs to focus on debriefing and counseling and value the
thoughts and feelings of all staff members, especially when talking about post-traumatic stress
disorder.
Root Cause Analysis
In the end, post-traumatic stress disorder is not only a disorder that can affect the nurse
but also psychiatric nurse turnover rates. Traumatic incidents of patient violence or aggression

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towards the nurse first trigger the PTSD symptoms in the nurse. The nurse, working in a stressful
environment already, continues to deal with these symptoms which consequently make the PTSD
symptoms worsen. When emotional and physical changes impact the nurse directly, he or she
will have low self-esteem and self-confidence making patients behaviors unpredictable. The
nurse should not cope with this alone and instead should look to peers for help; however,
employers tend to look past this issue and give the nurse an inadequate support system.
Unfortunately the nurse will use self-coping strategies and bottle up emotions instead of
speaking out due to fear of being judged. Days, weeks, or months later, the nurse will be
unhappy with his or her job and will fall into the burnout or turnover rate.
Recommendations for Quality and Safety
In order to promote quality and safety in the psychiatric field, preventative measures by
the nurse, health care staff, and health care facility need to be implemented. Strategies and new
policies are discussed further in order to prevent PTSD becoming an enormous issue in the
health care setting.
Education
Continuous education is important for all nurses because it helps keep them up-to-date
with current research, evidence, knowledge, and skills regarding proper patient care. CEUs are
offered by every facility in order to provide more education to staff members. For psychiatric
nurses specifically, more CEUs on preventative measures to handle patients and the stressful
environment should be offered. Management of aggressive patients in case of choking, hitting,
biting, or kicking is important to have knowledge of so physical violence and traumatic incidents
do not occur. CEUs based on communication with psychiatric patients and how one should avoid

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verbal abuse should also be provided for all psychiatric staff. Once education is implemented, the
prevalence of post-traumatic stress disorder may decrease due to preventative measures.
Debriefing Meetings
Once traumatic incidents occur, debriefing and counseling is important for all staff
members to be a part of. There are not enough routine structured debriefing meetings provided
by the institutions, and that takes away communication from one staff member to the next.
Weekly debriefing meetings should be implemented due to the stressful environment that these
nurses are working in on a daily basis.
If a very traumatic incident occurred on the floor, a Critical Incidence Stress Debriefing
should be implemented. CISD is a supportive, crisis-focused discussion of a traumatic event in
a small group of people that is held by two to four leaders (Mitchel, 2015). Because these
leaders have to be professional trained, the psychiatric staff should provide training to more
nurse managers and registered nurses, so more discussion can happen. Also, CISD does not
normally occur until 2-3 days after the traumatic event because they want the nurses to have time
to reflect. Although this may work at times, some nurses need to seek guidance and help right
away. The time after a traumatic experience should be shortened to 24 hours to a maximum of 2
days for these nurses (Mitchel, 2015).
EMDR Therapy
The newest recommendation would be EMDR, which is eye movement desensitization
and reprocessing. This type of therapy involves a trained professional moving an object side to
side in front of the patient with PTSD. While the patient is following the objects, he or she is
thinking about the traumatic incident. When the traumatic incident first occurred, the nurses
brain was in shock and blocked the process to think about any other situation except for the

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traumatic one. This therapy works by the processes in the brain being re-opened when the eyes
are moving side to side (Maxfield, 2015).
American Nurses Association (ANA) Standards
Standard 11. Communication
The registered nurse communicates effectively in a variety of formats in all areas of
practice (American Nurses Association, 2010, p. 54). Nurses and the health care team must be
able to communicate effectively to each other during times of traumatic experiences. Staff
members should be able to recognize PTSD and be able to communicate with a nurse if he or she
is presenting with signs or symptoms. Nurses should also assess their own communication skills,
so if a traumatic incident occurs, they can use their conflict resolution skills to prevent PTS
(ANA, 2010). If PTSD does occur, they should seek help and speak about their feelings in a
professional manner. If communication between health care members was more efficient, nurses
would not go unnoticed if they developed PTSD and employers would not overlook the situation.
Standard 14. Professional Practice Evaluation
The registered nurse evaluates her or his own nursing practice in relation to professional
practice standards and guidelines, relevant statutes, rules, and regulations (ANA, 2010, p. 59).
Psychiatric nurses should provide self-evaluations in order to view strengths and improvements.
Certain strengths should be upheld by nurses such as their compassion and passion of helping
others. If nurses develop post-traumatic stress disorder, they are at risk of being irritable,
fatigued, and angry, which ultimately goes against every characteristic they should have for
proper patient care. If the nurse feels there are weaknesses or improvements, the nurse should
seek help or guidance in order to obtain professional growth. Nurses should also be familiar with

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the professional practice standards or guidelines for certain institutions, so they understand the
debriefing process after a traumatic experience (ANA, 2010).
Standard 16. Environmental Health.
The registered nurse practices in an environmentally safe and healthy manner (ANA,
2010, p. 61). Safety refers to the nurses emotional and physical being in the environment.
Nurses with PTSD symptoms, such as fatigue and inability to concentrate, are at a higher risk of
making medication errors as well as harming the patient. If nurses start to have these symptoms,
the nurse must self-assess and intervene in order to prevent errors. If errors do occur, the nurse
must also be responsible for his or her actions and report the errors. By being an own advocate,
nurses will prevent errors and provide a safe and healthy environment (ANA, 2010).
Quality and Safety Education for Nurses (QSEN) Competencies
Safety
Nurses must minimize risk of harm to patients and providers through both system
effectiveness and individual performance (QSEN, 2014). Nurses have a certain role to ensure
patient safety. Due to the stressful environment in a psychiatric unit, nurses should act on
preventative measures to decrease the stressors in psychiatric patients. If there are stressors, then
the nurse should intervene in order to prevent a traumatic incidence from occurring. This will
decrease the risk of PTSD in nurses resulting in a decreased risk of harm for both the nurses and
patients.
Conclusion
Post-traumatic stress disorder among nurses is a common issue that should not be
overlooked. It is an emergent situation that not only impacts the nurse personally and physically,
but also impacts patient care and the workplace. Preventative measures of PTSD need to occur

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from not only the nurse, but also other staff members and the institution because they all work
together to create a positive and safe environment. Evidence by nursing and psychological
theories and QSEN competencies will help guide preventative measures to be implemented.
Although nurses put their patients as a first priority, they also need to put themselves first at
times and meet basic needs to achieve optimal health. If nurses dont care for themselves, they
will never be able to achieve self-actualization.

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