DISCUSSION

In two surveys of nearly 500 nurses, we identified that critical care nurses are more likely to have symptoms of PTSD when compared with general medical/surgical nurses. Some of the traumatic events that are associated with symptoms of PTSD in ICU nurses are similar to the events reported by noncombat war veterans, including handling dead bodies and assisting with the care of traumatic casualty victims (20-22). Although there was no difference in symptoms of anxiety and depression between ICU and general medical/surgical nurses, the rates of these symptoms were higher than reported in senior and middle managers who work in the healthcare industry (19). The results of our study provide important information for nursing and hospital administrators to improve the general well-being and job satisfaction of their critical care nurses.

PTSD is the fourth most common psychiatric diagnosis in the United States (2, 23, 24). Individuals are more likely to develop PTSD after direct interpersonal violence, such as rape or assault. PTSD also occurs in individuals after indirect exposure to a traumatic event, such as witnessing the unnatural death of another person. PTSD may be the upper end of a spectrum of a stress-response continuum rather than a distinct pathologic syndrome (25, 26). It is unlikely that most of these critical care nurses would meet the formal diagnostic criteria for PTSD. However, individuals may experience some symptoms of PTSD after a traumatic event, and the distinction between normal and abnormal responses is controversial (25). Therefore, the concept of subthreshold PTSD is relevant for our study of ICU nurses (25, 27). The prevalence of subthreshold PTSD ranges from 3.7% in a community sample to 21.2% among female Vietnam veterans (25, 28, 29). The majority of our ICU nurses who tested positive on the PTSS-10 would meet the diagnostic criteria for subthreshold PTSD and therefore would yield similar rates to female Vietnam veterans (27).

There are some potential modifiers that may influence the interpretation of this study. We used the PTSS-10 and HADS questionnaires to identify psychological disorders in critical care nurses. Although these questionnaires have excellent internal validity and reliability, they do not definitively diagnose individuals with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for PTSD or depression. However, the results of both questionnaires clearly identify individuals who have symptoms that would likely affect their overall professional satisfaction. This study did not carefully delineate the specific stressors, such as coping with end-of-life issues or general burdens of the ICU environment, that can cause symptoms of PTSD. More specifically, we did not collect information regarding the involvement of nurses in end-of-life decisions among the different types of ICUs. These data may have helped identify the specific role of end-of-life care in the development of symptoms of PTSD in these nurses. Studies that perform exit interviews with ICU nurses who are leaving their position are necessary to determine the specific stressor and whether the development of symptoms of PTSD contributes to the ICU nursing shortage.

In conclusion, symptoms of PTSD are more prevalent in ICU nurses. Approximately 20% of ICU nurses had symptoms consistent with possible anxiety disorders, and nearly 30% of ICU nurses had symptoms of depression. These findings may have important implications regarding methods that could enhance job satisfaction for ICU nurses and improve nursing retention. Studies that determine the specific characteristics that predispose individuals to the development of symptoms of PTSD and identify specific interventions for these individuals are warranted.

Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

Acknowledgment: The authors thank Kim Ragan, Mike Vaughn, M.D., Kelly Skelton, M.D., and Susan Berel for their assistance with the in-depth telephone interviews, and Sue Odom and Marsha Burks for their assistance with the design of the study.

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Meredith L. Mealer1, April Shelton1, Britt Berg2, Barbara Rothbaum2, and Marc Moss1

1 Department of Medicine and 2 Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia

Supported by unrestricted funds from the Emory University School of Medicine.

Correspondence and requests for reprints should be addressed to Marc Moss, M.D., Division of Pulmonary Sciences and Critical Care Medicine, 4200 East 9th Avenue, C272 Room 5525, Denver, CO 80262. E-mail:

This article has an online supplement, which is accessible from this issue's table of contents at www.atsjournals.org

Am J Respir Crit Care Med Vol 175. pp 693-697, 2007

Originally Published in Press as DOI: 10.1164/rccm.200606-735OC on December 21, 2006

Internet address: www.atsjournals.org

Copyright American Thoracic Society Apr 1, 2007
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