Increased Prevalence of Post Traumatic Stress Disorder Symptoms in Critical Care Nurses On-line supplement Meredith L. Mealer, R.N. April Shelton, R.N. Britt Berg, M.S. Barbara Rothbaum, Ph.D. Marc Moss, M.D. 1
Methods section: Questionnaires: PTSS 10 is a self-report scale based on the Diagnostic and Statistical Manual III criteria for PTSD (Table E1). This questionnaire has been shown to have a high sensitivity and specificity and records the presence and intensity of ten specific PTSD symptoms: sleep disturbance; nightmares; depression; hyperalertness; withdrawal (emotional numbing and inability to care for others); generalized irritability; frequent changes in mood; guilt; avoidance of activities, prompting recall of the traumatizing event; and increased muscle tensions. Patients rate their symptoms, using a scale from 1 (never) to 7 (always). A total score of >35 is associated with a high probability that the patient fulfills the diagnostic criteria for PTSD (E1). The Hospital Anxiety and Depression scale is a 14 item self administered questionnaire for detecting symptoms of anxiety (7 items) and depression (7 items) (Table E2). Each item is scored on a 4 point scale (0-3). This scale has been used to measure symptoms of anxiety and depression in family members of ICU patient. A score of 0 to 7 for either subscale is regarded as being in the normal range (E2). The Posttraumatic Stress Diagnostic Scale (PDS) is a 49 item self-report instrument that is designed to assist with the diagnosis of Post Traumatic Stress Disorder (PTSD). The PDS is based on the DSM-IV diagnostic criteria for PTSD (American Psychiatric Association, 1994). The PDS translates the DSM-IV s technical language into more common used language suitable for adults. In Part 1 of the PDS the respondents are asked to read through a list of traumatic 2
events and to checkmark any event they have witnessed or experienced. Part I of the PDS, which lists common traumas that individuals experience, was amended to include 14 additional potential traumas that ICU nurses might experience. The participants were asked to select the trauma(s) that were most distressing or caused the most interference in their life afterwards. In Part 2 the subjects are asked which of the events that most bothers them, and to briefly describe the traumatic event. The Symptom Severity Score ranges from 0 to 51. The cut-offs for the symptoms severity rating categories are: < 10 mild; >11 and < 20 moderate; >21 and < 35 moderate to severe; >36 severe (E3). Results: The nurses sampled in our study are representative of ICU nurses. There are a total of 429 ICU nurses at Emory and Crawford Long Hospitals. Their mean age is 38.94 years and 85% of female. At Grady Memorial Hospital, there are 182 ICU nurses and 86% are female. In addition, the age and gender distribution of the critical care nurses included in our study is very similar to the national averages for critical care nurses. Nationally, 90% of member of the American Association of Critical Care nurses are women, and the age distribution is 6% are 29 year of age or younger, 21% are between 30 and 39 years, 37% are between 40 and 49 years, 31% are between 50 and 59 years, and 5% are 60 years of age or older. 3
References: E1. Weisaeth L: Torture of a Norwegian ship's crew. Stress reactions, coping, and psychiatric after effects. In: International Handbook of Traumatic Stress Syndromes. Wilson JP, Raphael B (Eds). New York, London, Plenum Press, 1993, pp 743-750. E2. Pochard F, Darmon M, Fassier T, Bollaert PE, Cheval C, Coloigner M, Merouani A, Moulront S, Pigne E, Pingat J, et al. Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death. A prospective multicenter study. J Crit Care 2005; 20: 90-96. E3. Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self report measure of posttraumatic stress disorder: The posttraumatic diagnostic scale. J of Trauma Stress 1995; 8: 675-690. 4
Figure Legends for online supplement Figure E1: Distribution of PTSS-10 scores stratified by ICU nurses in our health system that tested positive or negative for symptoms of PTSD Figure E2: Distribution of PTSS-10 scores stratified by ICU nurses in the metropolitan area that tested positive or negative for symptoms of PTSD 5
TABLE E1 PTSS-10 questionnaire When I think about my experiences working as a nurse, I recall having: Nightmares No Yes Severe anxiety or panic No Yes Severe pain No Yes Trouble breathing, feelings of suffocation No Yes Presently (this means in the past few days) I suffer from 1. Sleep Problems. 2. Nightmares. 3. Depression. I feel dejected/down-trodden 4. Jumpiness. I am easily frightened by sounds or sudden movements 5. The need to withdraw from others. 6. Irritability, that is, I am easily agitated/annoyed and angry. 7. Frequent mood swings. 8. A bad conscience, blame myself, have guilt feelings. 9. A fear of places and situations, which remind me of the unit where I work. 10. Muscular tension. Never Always 1 2 3 4 5 6 7 6
TABLE E2 Hospital Anxiety and Depression Scale 1. I feel tense or wound up 2. I get a sort of frightened feeling as if something awful is about to happen 3. Worrying thoughts go through my head 4. I can sit at ease and feel relaxed 5. I get sort of frightened feeling like butterflies in the stomach 6. I feel restless as if I have to be on the move 7. I get sudden feelings of panic 8. I still enjoy the things I used to enjoy 9. I can laugh and see the funny side of things 10. I feel cheerful 11. I feel as if I am slowed down 12. I have lost interest in my appearance 13. I look forward with enjoyment to things 14. I can enjoy a good book or radio or TV program Most of the time A lot of the time From Time to Time/Occasionally Not at all 7
TABLE E3 Distribution of Primary Units where Critical Care and General Nurses were Employed General Med/Surgical Nurses (n=121) First Cohort of ICU Nurses (n=230) Second Cohort of ICU Nurses (n=114) Medical Intensive Care Unit 37% (84/230) 14% (16/114) Cardiac Intensive Care Unit 21% (48/230) 18% (20/114) Surgical Intensive Care Unit 23% (52/230) 7% (8/114) Combined Medical/Surgical 0% 24% (27/114) Intensive Care Units Other Intensive Care Units 20% (46/230) 37% (43/114) Medical Floor 43% (51/121) Surgical Floor 18% (22/121) Mixed Medical/Surgical Floor 36% (43/121) Other Non-ICU Floors 3% (5/121) 8
FIGURE E1 7 6 5 4 3 2 1 0 Sleep Problems Nightmares Depression Jumpiness Withdrawal Irritability Mood Swings Guilty Feelings F Wo 9
FIGURE E2 7 6 5 4 3 2 1 0 Sleep Problems Nightmares Depression Jumpiness Withdrawal Irritability Mood Swings Guilty Feelings Fear of Workplace 10