Post-traumatic stress disorder among hospital emergency personnel in South-East of Iran

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1 International Research Journal of Applied and Basic Sciences 2013 Available online at ISSN X / Vol, 4 (6): Science Explorer Publications Post-traumatic stress disorder among hospital emergency personnel in South-East of Iran * Hojat Sheikh Bardsi 1. amin saberini 2. Mohsen amini zadeh 3.abdollreza sabahi 4.fatemeh shirazi 5 1. Department of Emergency Medicine,Kerman University of Medical Sciences 2. Research Officer And emergency medical specialist training,kerman university of medicine sciences. 3. Research Officer And emergency medical specialist training,kerman university of medicine sciences. 4. Psychiatrist neurologist University of Medical Sciences 5. Student economic, Kerman University of Medical Sciences Corresponding Author mohsen.aminizadeh@gmail.com ABSTRACT: emergency personnel had direct encounter with many events that threat their own wellbeing during their daily work and may cause PTSD. In the Iranian context, there are limited numbers of studies that examine prevalence rate of PTSD among groups of emergency personnel. This study thus was conducted to fulfill this goal among groups in hospitals supervised by Kerman Medical University.Using Mississippi post-traumatic stress disorder PTSD prevalence rate of all emergency personnel's (n= 250) examined. Data analysis was done by using Kolmogorov-Smirnov test, chi-square, Independent T-test, Pearson correlation and One-Way ANOVA. personnel had different level of education, marital status, experience of traumatic events, work hours per month, and gender. Most of [94%] hospital emergency personnel reported moderate posttraumatic stress disorder. The study suggests health care managers to organize a very systematic and dynamic policies and procedures in order to assist group to deal with PTSD.there is no conflict of interest Key words: post-traumatic stress disorder, emergency personnel INTRODUCTION Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress(baxter,2004). According to the NIMH (National Institute of Mental Health), 7.7 million adults or 3.5 percent of adult populations suffer from PTSD(National Institute of Mental Health,2009). Nayback(2009), stated that PTSD may cause wide spectrum of symptoms including flashbacks and nightmares of the event, anger, anxiety, depression, irritability, and impaired concentration. He continued that it also causes difficulty sleeping, panic attacks, hyper vigilance and an exaggerated startle response(nayback,2009). Hospitals are stressful places due to the increased complexity and demands of most job descriptions, the unpredictable changes in one s daily work routine, unrealistic expectations from patients/their families, and common encounters with ethical as well as end of life issues(baxter,2004). Mealer et al.(2009) identified that psychological symptoms including PTSD, anxiety, and depression are common in nurses. They go on that nurses who work in the outpatient setting are significantly less likely to have a diagnosis of PTSD when compared to inpatient nurses(mealer et al.,2009). All of the nurses who met diagnostic criteria for PTSD endorsed being exposed to a traumatic event including seeing patients die, massive bleeding, open surgical wounds, trauma related injuries, and performing futile care to critically or terminally ill patients( Mealer et al.,2009). Earlier studies showed that emergency department health care workers have been shown to be at increased risk of PTSD(Laposa, Alden,& Fullerton,2003 ; Regehr, Goldberg, & Hughes,2010; Nurmi,1999). Of all of the various types of hospital employees, nurses are often exposed to many of these stressors and may be predisposed to develop work related psychological disorders such as symptoms of PTSD(Baxter,2004). According to Mealer et al.(2007) 25% of critical care nurses and 33% of emergency nurses had PTSD symptoms. They go on that critical care and emergency nurses had a higher incidence of PTSD symptoms compared to the others. earlier studies(mealer et al.,2009; Sorenson,2002; Kessler et al.,2005; Nayback et al.,2009; Bennett et al.,2004) reported that factors such as age, sex, being unmarried and earlier experience of violence correlated with development of PTSD. Mealer et al.(2009) found that years nursing experiences, the age of the nurse, and how often a nurse is the charge nurse significantly related with the prevalence of PTSD.

2 In Iran Narimani, Zahed, and Basharpoor(2009) conducted a study to examine the prevalence of PTSD among hospital emergency nurses and fire department workers in North-East of Iran. They reported that 14% of hospital emergency nurses and 8% of fire department workers diagnosed with posttraumatic stress.in the context no study was found to assess prevalence rate of PTSD among two groups of paramedic and emergency personnel. It seems that they provide a good population to be studied for prevalence rate of PTSD. emergency personnel experience workplace events that present a direct threat to their own wellbeing (e.g., threatened and actual assault), and they are also confronted with events that involve severe injury (Alden, Regambal,& Laposa,2008). This study thus was conducted to examine prevalence rate of PTSD among emergency personnel in South-East of Iran. METHODS Design There was an approval from Kerman University of Medical Science prior to the collection of data. The study employed a Descriptive cross sectional design. Sample and setting Hospital emergency personnel selected from emergency wards of four hospitals supervised by Kerman Medical University (n=250). Personnel were given the same questionnaire evaluating post-traumatic stress disorder. The instruments Background information First, a questionnaire was designed to assess participants' demographic data including: age, gender, marital status, education level, interest to work, job experience, direct encounter with the patient, experience of traumatic events, experience of loss of family members. Questionnaire Participants in groups completed standardized assessment instrument measuring post traumatic stress disorder. The Mississipi post-traumatic stress disorder (M-PTSD) is a 39- items questionnaire. The items divided into four components: frequently haunted by memoirs (10 items include 4,7,13,14,36,39,18,29,33,37 ), problem in personal relationship (10 items include 6,22,1,5,19,28,30,35,38) problem in controlling emotional feelings ( 10 items include 3,20,26,24,27,3116,23,25,32), lack of depression (10 items include 8,9,10,12,15,21,2,11,17,34). The responses rate of items ranged based on 5-point Likert scale (never true=1 entirely true =5). The responses rate of 10 items (2, 6, 11, 17, 19, 22, 24, 27, 30, and 34) ranged inverse (entirely true =1 never true =5). Total score valued between 0 and 195. The high score is indicative of sever PTSD. Total score ranged between mild and sever (lower than 65 = mild PTSD; = moderate PTSD, and higher than 130=severe PTSD). Validity and reliability The Mississippi Scale for Posttraumatic Stress Disorder (M-PTSD) was developed for and validated on male veterans of the Vietnam War (Keane, Caddell,& Taylor,1988). The M-PTSD has been considered a reliable ( Chronbach =0.94) and valid measure of PTSD in veterans exposed to combat( King et al.,1995). In Iran Goodarzi (2003) checked validity and reliability of M-PTSD. They reported an acceptable reliability and validity for this questionnaire (internal consistency= 0.92, external consistency=0.82 ). Data collection and analysis Approval for this study was obtained from the Kerman University of Medical Science. Ethical Committee centre of Kerman Medical approved the study. All participants signed informed consent. All information about the study were given to the participants orally and written. They asked to write no name or other personal information in the questionnaires in order to provide confidentiality. Participants filled in the questionnaire during their daily work hours. 85% of all questions answered. Data from the questionnaires were analyzed using the Statistical Package for Social Scientists (SPSS). Descriptive analysis was used to determine the characteristics of sample. A Kolmogorov-Smirnov test was conducted to indicate that the data were sampled from a population with normal distribution. To check the homogeneity of the categorized demographic data (e.g. level of education, experience of traumatic events, ) Participants, chi-square was used. The correlation between demographic data and PTSD mean score examined by Independent T-test and

3 One-Way ANOVA. Pearson correlation coefficient was used to identify the relationship between age and posttraumatic stress disorder. The difference was significant at level of P < RESULTS A Kolmogrov-Smirnov test indicated that the data were sampled from a population with normal distribution. Demographic information The participants' demographic characteristics are shown in table 1. The mean age of hospital emergency personnel was ± 6.33). In hospital emergency group, 68.4% were female. In hospital emergency group, the most participant were nurses with BSc. Among Participants 77% were single. In hospital emergency group, 44.8% worked hours per month. 88.4% of hospital emergency personnel had direct encounter with patients. Of hospital emergency personnel, 34% had moderate experience of traumatic events. Almost half of participants had moderate interest to work. Hospital emergency personnel analysis According to One-Way ANOVA, there was a correlation between participants' educational level and Post-traumatic Stress Disorder score, so that hospital emergency personnel who had bachelor degree were more likely to have PTSD (p= 0.01) compared to their colleagues in the other groups. The One-Way ANOVA also showed a correlation between job and Posttraumatic Stress Disorder score, so that physicians compared to other participants had higher score of PTSD (p= 0.04). Furthermore, a negative correlation was found between work hours per month and PTSD score. It means that those who work less than 100 hour per month, were more likely to have PTSD (p= 0.001) compared to those who work or more than 200 hours per month. The independent T-test showed a negative association between interest to work and PTSD score. This means that participants who had low interest to work, had higher rates of PTSD (p= ) compared to those who have more interest to work. Furthermore, a correlation was found between direct encounter with patient and PTSD score so that those who had direct encounter with the patient, had higher score of PTSD (p= 0.009) compared to those who had no direct encounter with patient. However, there was no significant correlation between PTSD score and gender, age, marital status, job experience as well as disaster experience. DISCUSSION The results indicate a high incidence (94%) of post- traumatic stress disorder among hospital emergency department personnel. This is almost similar to the reported incidence of post- traumatic stress disorder in earlier studies(mealer et al.,2009; Laposa, Alden,& Fullerton,2003; Regehr, Goldberg,& Hughes,2010; Nurmi,1999; Laposa &Alden,2003; Bennett et al.,2004). Bennett et al.( 2004) who used Post-traumatic Diagnostic Scale (PDS) found that among emergency medical technicians, the overall rate of PTSD was 22%. Using the post-traumatic stress symptoms (PTSS), Post-traumatic Diagnostic Scale (PDS), Mealer et al.(2009)found 22% of nurses had symptoms of PTSD, and 18% met diagnostic criteria for PTSD. Laposa,Alden,and Fullerton (2003) who used Post-traumatic Diagnostic Scale assessed PTSD in emergency room workers at a major hospital in a large urban center in British Columbia. They found that 20% of participants met formal diagnostic criteria for PTSD, and 20% met PTSD symptom criteria. In Iran Narimani, Zahed, and Basharpoor(2009) reported that 14% of hospital emergency nurses and 8% of fire department workers diagnosed with posttraumatic stress. Saberi, Marooji, and Ghoreishi (2008) assessed PTSD among emergency medical technicians in Iran. They found that considering DSM-IV criteria, 36.4% of participants have PTSD criteria. Using Impact of Event Scale (IES) they showed a trauma sever impact among 28.9 % of emergency personnel. According to (Alden, Regambal,& Laposa,2008). emergency workers are trained to manage medical emergencies and expect to encounter death and serious injury by the very nature of their jobs. They have to increase their emotional preparation and perceived control over these events, and therefore are at risk for PTSD. According to the results, PTSD prevalence rate is significantly higher than that in similar studies conducted in the other countries. One explanation could be that the instruments and sample size used by earlier studies are different from those used in following study, and the results subsequently become different. It could be related to the difference in organizational structures in different countries, the different level of integrity in response to questions, and the difference in method of their selection, amount of education, and work volume( Van der Ploeg & Kleber,2003). The sample selected from Kerman, center of province Kerman. The city is in South-East of Iran; an important transitional way within daily accidents with high frequency and

4 intensity occurred. Therefore Hospital emergency personnel are daily involved with a lot of accidental cases with severe trauma. We observed there was no significant correlation between hospital emergency personnel PTSD score and gender, age, marital status as well as employment status. This is consistent with the findings of (Palgi et al.,2009). study. He found that no demographic variable was significantly associated with increased risk for high levels of PTSD symptoms. Bennett et al.(2004) showed that levels of PTSD did not differ according to grade, but men had a higher prevalence rate than women (23% compared with15%) Laposa, Alden, and Fullerton (2003) also found no significant correlation between years of experience and PTSD symptom severity. Contradictively Lavoie, Talbot, and Mathieu (2011) found an association between age/ emergency room experience and the occurrence of traumatic events and PTSD symptoms. Based on the findings, a work hour per month was correlated with PTSD score. Hospital emergency personnel who worked less than 100 hour per month reported higher PTSD score compared to other groups, so that more working hours per month, the lower prevalence rate of post-traumatic stress disorder. This could be due to the amount of adaptation obtained by the personnel. Personnel who had more shifts and spend more time in emergency department gain more adaptation with PTSD compared to that among those who spend less time in such departments. The results of this study also indicated that hospital emergency personnel who were physicians compared to other participants had higher score of PTSD. Palgi et al.(2009) found that among hospital emergency personnel, Physicians and nurses had higher PTSD scores compared to other personnel. In contrast Ben-Ezra, Palgi,and Essar (2007) who used Impact of Event Scale-Revised (IES-R) and Center for Epidemiologic Studies-Depression scale (CES-D) indicated that profession has a differential impact on hospital personnel. They continued that compared to physicians, both nurses and administrative staff had a significantly higher risk for clinical symptoms of posttraumatic stress disorder. As it is mentioned above, working hours per month negatively correlated with prevalence rate of post-traumatic stress disorder. In the Iranian health care system physician have the least shifts compared to other personnel. This may cause less adaptation they obtain and the higher risk they have for PTSD. Based on the findings, emergency personnel who were nurses had higher score of PTSD compared to the other groups. Lavoie, Talbot,and Mathieu (2011) reported high risk of post traumatic stress disorder among nurses. Mealer et al.(2007) also showed critical care and emergency department nurses have a higher incidence of PTSD symptoms compared to others. They asserted that as many as 25% of critical care nurses and 33% of emergency nurses have screened positive for symptoms of PTSD. Of all of the various types of hospital employees, nurses are often exposed to many of these stressors and may be predisposed to develop work related psychological disorders such as symptoms of PTSD(Baxter,2004). CONCLUSION The results of this study indicate a high incidence of post- traumatic stress disorder among hospital emergency personnel in South-East of Iran. This required health care managers to organize a very systematic and dynamic policies and procedures in order to assist groups to deal with PTSD. Providing a systematic continuing educational program about adaptation with PTSD could be one way to provide this assistance. Designing a screening or specific selection method in order to recognize high-risk individuals, particularly those who want to work in emergency departments could be another way of assistance. Rotation and exchanging personnel between different wards may provide emergency staff an opportunity to experience the wards with a lower work load compared to the emergency wards, and therefore improve their strength. Giving some special rewards to the and emergency hospital personnel may also motivate them to find the ways to be adapted with their PTSD symptoms. Creating a reflective narrative environment in which emergency hospital personnel can express their own feelings and experiences about stressful situation seems to be as an effective approach to identify the influential factors on PTSD. Limitations Our study had several limitations which should be noted. The convenience sample of participants which is not the representative of all paramedic and emergency hospital personnel could deteriorate the generalization of the findings. Use of the self report questionnaires may have led to an overestimation of some of the findings due to variance which is common in different methods. Another limitation was limited time participants had (due to the high work load) to fill in the questionnaire. Dealing this limitation, the second author asked participants to fill in the questionnaire whenever and wherever they preferred.

5 ACKNOWLEDGMENTS The authors wish to thank Kerman University of Medical Science and hospital emergency department personnel of the Shaf, Bahonar, Shahid Beheshti and Afzalipoor Hospital in Kerman, Iran for their kind assistance to the present study. Table 1. Demographic characteristics of the research sample (hospital emergency personnel Variable Hospital emergency personnel n (%) Gender Female 171(68.4) Male 79(31.6) Level of Education Diploma 96(38.4) Technician 22(8.8) Bachelor 115(46) Post graduate 17(6.8) Marital status Never married 193(77.2) Married 57(22.8) Work hours per month <100 19(7.6) (35.6) (44.8) >200 30(12) Direct encounter with the patient Yes 221(88.4) No 29(11.6) Experience of traumatic events Small 29(11.6) Moderate 85(34) High 77(30.8) Very high 59(23.6) Interest to work Very small 10(4) Small 34(13.6) Moderate 125(50) High 81(32.4) Table 2. PTSD score of the research sample (hospital emergency personnel) scale subscales paramedic personnel M ± SD frequently haunted by 20.66±6.06 memoirs M-PTSD problem in personal 23.10±3.81 relationship problem in controlling 24.23±4.45 emotional feelings lack of depression 21.30±4.85 Total score 89.3±15.45

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