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Enhanced Risk of PTSD for Frontline Health Workers

April 13, 2021 by Alexa Hornbeck
Arlene Colom, a nurse from Premier Family Health, adjusts her PPE as she waits for a patient to test for COVID-19 in Wellington, May 13, 2020. (Allen Eyesstone/Palm Beach Post/TNS)

A new study, led by University of Utah Health scientists, suggests that more than half of doctors, nurses, and emergency responders involved in COVID-19 care could be at risk for one or more mental health problems, including acute traumatic stress, depression, anxiety, problematic alcohol use, and insomnia. 

“There is a lack of willingness to deal with the effects of trauma across all our culture, and this is a good time to make that a priority,” said co-author of the study, Dr. Andrew James Smith, the director of the occupational training program at the University of Utah Health. 

Researchers recruited 571 emergency and hospital personnel from the United States’ Rocky Mountain region to complete self-report surveys between April 1, 2020 and May 7, 2020. Researchers noticed that as positive cases of COVID-19 increased, anxiety for frontline workers decreased. 

“Before the pandemic hit, there were upticks in self-soothing, like alcohol consumption, to reduce the anxiety of the anticipated nightmare, but when the event came, we saw the inverse situation that as disease totals rose, the anxiety went down,” said Smith. 

According to the report, participants with an immunocompromised condition, or those who had a family member with an immunocompromised condition, were at increased risk for acute traumatic stress, anxiety, depression, and insufficient sleep. 

“Frontline workers have continually experienced the fear of transmitting the virus to family members, this aspect was paradoxically experienced as a perennial sense of guilt,” said Alessandro Russo, an associate professor of Infectious Diseases at Sapienza University of Rome. 

In January, Russo and his team examined the relationship between COVID-19 and occurrence of traumatic stress and found that risk factors such as, “young age, low work experience, female gender, heavy workload, working in unsafe settings, and lack of training and social support,” are often predictors of PTSD. 

“Health care workers were not adequately supported by the civil population and governments. They were forced to measure themselves against a disease that was risky for their own health. These specific populations, after one year of the pandemic, are affected by a continuous re-experiencing of the traumatic event, as during the first wave,” said Russo. 

Lisa Wolf, the director of emergency nursing research at the Emergency Nurses Association, has worked in nursing for over 25 years, but says nurses felt betrayed by their health care institutions with the onset of the COVID-19 pandemic. 

“We’ve been through all kinds of things, like SARS, and AIDS, but we always felt the institutions we worked for were committed to keeping up as safe as possible. But in this pandemic the lack of response from the government and institutions created this anxiety among health care workers I’ve never seen. No one is sure who to trust and no one is sure what information is good,” said Wolf. 

Wolf recalled an event from last April, when a team of seven night-shift emergency nurses at an emergency room at Sinai-Grace Hospital of Detroit Medical Center were instructed to oversee 130 critically ill patients. 

“There would have been nurses that had to watch up to 20 patients at a time, which is not safe,” said one of the emergency room nurses Salah Hadwan in an interview with the Detroit Free Press. 

The team led a sit-in at the break room, refusing to work until the hospital was able to provide more staffing and resources. Yet, the resources never came, and the hospital ordered the emergency nurses to go home. 

“I think the real challenge for emergency nurses is that there is no time to process,” said Wolf. 

Last September, Wolf and her team investigated the levels of traumatic stress among emergency nurses in a study titled, “Does your work environment feel like a war zone?” 

“I was told stories of nurses committing suicide in the hospital bathrooms…I don’t think people understood how deep and prevalent trauma was until we did this study,” said Wolf. 

Her current study uses language from emergency nurses and the secondary traumatic stress scale. 

“We looked at Twitter as a data set, using search phrases like “get us PPE, and get me PPE,” to try to link words and tweets to the secondary traumatic stress scale from people who are verbalizing some kind of trauma,” said Wolf. 

Wolf said there has been a, “mass exodus of nurses from the bedside,” as many emergency nurses have switched to nurse practitioner positions which do not require as much direct patient care. 

This is consistent with the Utah Health study, which recommends giving frontline workers alternative roles which could reduce anxiety, fear, and the sense of helplessness associated with becoming infected. 

“You could reorient a nurse into conducting portions of visits that are virtual only. Even if there is an in-person component, it would allow a person to continue to provide their expertise without having to come into contact with a person that will be more infected,” said Smith. 

For Wolf, providing more resources for frontline workers to cope with traumatic stress and build resilience is necessary to restore the trust between workers and health care institutions. 

“A lot of nursing organizations talk about self-care, but the recommendations are often individual solutions to what is a very systemic problem,” said Wolf. 

Wolf is incorporating the idea of trauma processing into the emergency nursing pediatrics course and residency training programs. That way newer nurses who have never experienced a traumatic event, such as witnessing a patient die, can learn from a veteran nurse with more coping experience. 

“We are weaving this idea that if you uncover and normalize the fact we all need to manage our stress, then perhaps we will see a decrease in dysfunctional behaviors,” said Wolf. 

Smith is working on a new study which will examine how engagement in social support prevents health care workers from developing PTSD over time, and informal ways for frontline workers to engage in friendships, family, and their communities to prevent burnout and stress. 

“Social connections and social support, it’s the most consistent and powerful predictor of recovery,” said Smith.

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