METHODS

The survey questionnaire required about 10 minutes to complete and included questions regarding general demographic information about the respondent and general impressions about their work environment. Symptoms of PTSD were measured using the Post Traumatic Stress Syndrome 10 Questions Inventory (PTSS-10), a self-report scale based on the Diagnostic and Statistical Manual for PTSD. A total score of greater than 35 is associated with a high probability that the patient fulfills the diagnostic criteria for PTSD (3). This questionnaire is commonly used in a variety of patient populations and has excellent sensitivity and specificity for PTSD (3, 11, 12). In addition, the PTSS-10 has high internal consistency reliability (Cronbach's α = 0.92) and stability (test-retest reliability, r = 0.89) (13). The questionnaire also included the Hospital Anxiety and Depression Scale (HADS), which consists of two subscales that evaluate symptoms of depression and anxiety (14). The HADS is well accepted and validated in a variety of populations, including primary care patients, healthy subjects, and the spouses of patients (14-17). A score of 8 or greater is suggestive of the possible presence of anxiety or depression (16, 18, 19).

Survey of Nurses within Our Hospital System

We administered the questionnaire to nurses who were full-time employees presently working in an adult intensive care unit at one of three Emory University-affiliated hospitals. Emory University Hospital is a 587-bed facility with 35 medical ICU beds and an additional 20-bed mixed medical/surgical ICU. Crawford Long Hospital is a 583-bed community hospital with 48 ICU beds. Grady Memorial Hospital is a 1,000-bed hospital with 70 ICU beds. To serve as a comparison group, we administered the questionnaire to nurses at these three hospitals who were full-time employees working on a general medical or surgical ward. All participants were told that the purpose of this study was to gain knowledge about the critical care environment and its effect on the nursing population. When answering questions concerning the questionnaire, we did not use the terms "post-traumatic stress disorder," "anxiety," or "depression." The surveys were completed anonymously.

Survey of Critical Care Nurses in the Metropolitan Atlanta Area

The same overall questionnaire (that included the PTSS-10 and HADS questionnaires) was also mailed to 415 members of the American Association of Critical Care Nurses (AACN) who lived within a 100-mile radius of Atlanta. The AACN is the world's largest nursing specialty organization representing the interests of more than 400,000 nurses who care for critically ill patients. The questionnaire included a cover letter stating that the purpose of the study was to examine the critical care environment and its effect on the nurses. We included a prepaid telephone card with the mailing as an incentive to increase participation. The surveys were anonymous. If the respondent wanted to learn more about the study and their results, they were encouraged to check the appropriate box on the last page of the questionnaire and leave a contact telephone number or address. Assessors administered the 49-question comprehensive Post-Traumatic Stress Disorder Diagnostic Scale to participants during a 20-minute telephone interview. Individuals were compensated $40 for their time during the phone interview. Nurses with clinically relevant PTSD or depression were referred to mental health resources in the community if they were interested in treatment. This study was approved by the Emory University Institutional Review Board.