UBC Reports | Vol. 50 | No. 3 | Mar. 4, 2004

Shell Shock in the Emergency Room

Not the patients... the staff

By Erica Smishek

A child the same age as your own bleeds profusely from a wound; her leg has been dismembered. A severely burned patient stares into your eyes before dying. An irate member of a patient's family physically accosts you in a moment of rage and despair.

Every day, nurses, doctors and other emergency department personnel face these and other upsetting events.

It's part of the job -- and for some, it's leading to post-traumatic stress disorder (PTSD).

"When nurses talk about the things they see, you wonder, ‘how does anyone do this work without emotional damage,'" says UBC psychology professor Lynn Alden. "Their descriptions about events are horrible -- treating children that have been charred, children that have been injured, routinely watching people die. It's very hard emotionally."

PTSD is an anxiety condition that can develop subsequent to traumatic events. Symptoms include intrusive memories and images of the trauma, and behavioural avoidance of cues that remind the person of the incident. PTSD is known to create significant life impairment, including occupational dysfunction.

PTSD was first recognized in people who had directly experienced trauma, such as war veterans and assault victims. But more recently, researchers have demonstrated that PTSD can develop in individuals who witness upsetting events in the workplace, such as ambulance attendants and firefighters.

In the first study of its kind, Alden and doctoral student Judith Laposa are examining the relationship between work-related stress and the development of PTSD in emergency department personnel.

Preliminary findings suggest that as many as 20 per cent of emergency department workers surveyed report clinically significant levels of PTSD symptoms and 12 per cent meet the full criteria for the disorder -- more than double the rate found in the general population.

"There is almost a macho attitude. Health care professionals think they should be tough enough to deal with it," says Alden. "It comes as a shock to learn that they're human, that to be subjected to traumas that others do not normally encounter can have a significant impact on their work and their lives."

In the first of two studies supported by the Social Sciences and Humanities Research Council, the Natural Sciences and Engineering Research Council and the B.C. Medical Services Foundation, 51 emergency department workers at a major hospital in a large urban B.C. centre completed a questionnaire that measured sources of stress (organizational characteristics, patient care and interpersonal conflict) as well as reactions to traumatic work events, including how they interpreted the cause of events as well as their state when the events happened.

At least half of the participants reported dissociation -- some degree of going on automatic pilot and feeling unreal at the time of the traumatic incident.

"They can feel like they're in a dream when these bad things happen," says Alden. "They process information about the event differently because of the anxiety."

The majority of participants reported feeling emotionally upset when reminded of the event, trying not to think, talk or have feelings about the event and having upsetting thoughts or images about the event that came into their heads when they didn't want them to.

Some participants reported a more negative belief system about the world ("the world is a more dangerous place") and themselves following a traumatic event.

In a second study, the researchers examined factors that would increase the likelihood of PTSD. They found an association between interpersonal conflict and PTSD symptoms.

"After a very difficult incident, you often need to share the experience. You all go for dinner or a drink and try to laugh, maybe using black humour to help cope with what you've just been through," Alden explains. "But if you can't do that, if you don't feel that sense of support from your colleagues and hospital administration, traumatic events can be harder to process."

With funding from the Workers' Compensation Board of B.C., the pair has embarked on a third, more comprehensive study in partnership with several B.C. hospitals. It will include questionnaires and interviews with full-time nurses and will examine what impact factors like the density of traumatic experiences and the down time away from traumatic events have on the development of PTSD.

Ultimately, they hope their findings will help hospital administrations not only be aware of the extent of workplace stress and PTSD symptoms in their employees but help them improve the workplace climate to support employees following traumatic events.

"According to the literature, we haven't hit upon a way to prevent PTSD," says Alden, "but there are ways to treat it once it develops."

They would also like to work with educators to develop programs that prepare nursing students for what they will inevitably experience in the workplace.

"I've always been fascinated by the resiliency of the human spirit," says Laposa, who has studied clinical psychology for four and a half years. "Ultimately, I am interested in developing strategies that medical personnel can use to minimize and deal with any negative emotional impact of assisting patients through medical crises."