More than a decade ago, Meredith Mealer embarked on research that has only increased in relevance with the passing years.
The study focused on the prevalence of post-traumatic stress disorder (PTSD) among survivors of acute respiratory distress syndrome, a devastating lung disorder. Mealer, PhD, RN, was then a research coordinator, working on the study with Marc Moss, MD, a pulmonary/critical care physician leading the effort. As Mealer paged through the symptoms patients and families reported – nightmares, high stress, emotional numbing, anxiety attacks – some struck her close to home. Prior to shifting her focus to clinical research, Mealer had been an intensive care unit nurse.
“As a bedside nurse, I had some of those symptoms,” she recalled.
It sparked her curiosity, which led to her informally touching base with ICU nurses who had decided to leave the bedside. They spoke of nightmares, anxiety attacks, and sleep problems. They said things like, “I was so stressed out I had to get out of the ICU.”
She suggested to Moss that PTSD among ICU nurses might itself merit studying. After all, ICU nurses face the constant stresses of keeping the sickest of patients alive; of interacting with panicked, shocked, and despondent family members; and of watching patients die despite having cared for them day in and day out during 12-hour shifts.
That was in 2002, at Emory University. Fourteen years later, Mealer is the director of the Colorado Multiple Institutional Review Board (COMIRB) and assistant professor in the University of Colorado School of Medicine’s Department of Physical Medicine & Rehabilitation. Moss is the School of Medicine’s vice chair for Clinical Research and a professor of pulmonary sciences and critical care medicine. Mealer’s initial realization has yielded several path-breaking studies on the prevalence of PTSD as well as that of anxiety, depression, and burnout syndrome (BOS) among ICU nurses, including those at University of Colorado Hospital.
Moss and Mealer have played a big role in raising national awareness of ICU-related stress, and they’re not slowing down. Moss is lead author of what he describes as a major paper on BOS, to be published simultaneously this July by the four major critical-care societies under The Critical Care Societies Collaborative umbrella. The publication marks the addition of BOS as a primary interest of critical-care study, Moss said. Mealer is contributing an accompanying editorial in one of the journals.
The work has also led to an ongoing research program aimed at boosting ICU nurse resilience, to benefit themselves and, by extension, patients, hospitals and the health care system. Moss and Mealer’s goal is to develop an evidence-based program that ICUs everywhere can use to help nurses deal with on-the-job stressors. The next step will be a multi-center study focusing on mindfulness training and cognitive behavioral therapy. If all goes well with their National Institutes of Health grant proposal, the study will launch in 2017.
One in five
We typically associate PTSD with soldiers returning from war zones. And indeed, 20 percent of Iraq war veterans and nearly 31 percent of Vietnam veterans have been diagnosed with it. By comparison, about 7 percent of U.S. adults will experience PTSD sometime in their lives. Mealer and Moss’s studies have found the PSTD prevalence among ICU nurses to be around 20 percent, the same PTSD risk as fighting in a Middle Eastern war zone. The figure is consistent across nurses surveyed and studied at Emory, UCH, and other hospitals around the country.
There are 500,000 ICU nurses in the United States. They are the bedrock of critical care, spending far more time with critical-care patients than doctors and other providers, which leaves them particularly susceptible to the stresses of the environment. And while many nurses stay on the job for years, those stresses are among the reasons that ICU nursing teams see turnover rates averaging 13 percent to 20 percent annually, Moss said.
In addition to costing hospitals experienced talent, turnover puts more pressure on nursing teams who must integrate new hires or in-house transfers. It’s also expensive. It costs roughly $70,000 to hire and train a single ICU nurse, Moss said; for a hospital with 40 ICU beds, that adds up to about $1.2 million a year.
One can’t change basic truths of the ICU – that they host the sickest and most badly injured patients, or that the families at the bedside are enduring the worst days of their lives.
“People are going to die in the ICU. You can’t change that – any more than you can change the fact that people die in wars,” Moss said. “But you can change the way we adapt to this stressful work environment.”
That adaption can involve organizational changes – increasing staffing or minimizing the switching between day and night shifts, for example. But Moss and Mealer’s work has focused on increasing the resilience of individual nurses and determining what kinds of formal programs can help hospitals give ICU nurses the coping skills they need to sustain long careers in critical care.
For a sense of the sorts of tools and techniques that might work, they interviewed ICU nurses that up-front tests had identified as “highly resilient” and also nurses with PTSD, noting differences in terms of their world views, social networks, cognitive flexibility and self-care/work-life balance.
The resilient nurses, they found in a study published in 2012, did better along one or more of these lines, harnessing “spirituality, a supportive social network, optimism, and having a resilient role model” to enhance their ability to cope.
Having identified what might work, they followed up with a 12-week pilot program in late 2012 at UCH. Underlying the program was a conviction that managing stress is a skill that can be learned. The pilot included a two-day educational workshop, written exposure sessions, mindfulness-based stress reduction exercises, a prescribed aerobic exercise regimen, and event-triggered counseling sessions.
The last of these involved 30-minute to 60-minute one-on-one meetings with a licensed clinical social worker after a nurse experienced a patient’s death, participated in end-of-life family discussions, performed cardiopulmonary resuscitation, provided futile care with a terminal patient, or cared for a patient with massive bleeding or traumatic injuries.
Thirteen ICU nurses participated in the program (from the UCH medical, surgical and cardiac ICUs), with 14 serving as business-as-usual controls. Up-front questionnaires showed many of them to have symptoms of anxiety, depression or emotional exhaustion, and almost half showed symptoms of PTSD.
The study, published in 2014, found PTSD scores to have vastly improved among the 13 nurses involved in the pilot’s interventions when compared to the 14 controls. In addition, ICU nurses generally embraced the resiliency training intervention.
A wider net
Jessica Leiss, RN, BSN, an MICU nurse at UCH, participated in the study. She said the classes were a benefit, in particular the addition of cardiovascular exercises that came with the study’s three-month membership at the Anschutz Health and Wellness Center (she had been doing yoga already). But most helpful, she said, was the program’s role in helping nurses share their experiences and understand the importance of taking care of themselves as well as their patients.
“I don’t think people understand what we do here – how sick people can be and the things we do to essentially save their lives,” Leiss said. “We have not just the patient in the bed to care for; we have families who are in distress, who have poor coping skills.”
At UCH, awareness about the well-being of nurses is already improving, said Danielle Refvem, RN, BSN, also a MICU nurse at UCH. Refvem, who has worked in ICUs for six years, said little things, like taking an entire 30-minute lunch break or the occasional 10 minutes to walk down to the Garden View Café for a cup of coffee, can be crucial to relieving stress.
“We can’t take care of patients if we don’t take care of each other,” she said.
Like many of her MICU colleagues, Jana Palaia, RN, BSN, said getting to the mountains and elsewhere outdoors serves as a form of therapy for her – as does confiding in colleagues or her fiancée, going home and sitting in silence, or just going home and crying.
Palaia said she would welcome formal programs like the ones Moss and Mealer are studying, which can augment classes and seminars relating to reducing stress and avoiding the burnout already happening in the MICU (one recent example was a seminar on compassion fatigue led by a UCH chaplain).
Mealer said her passion for this work is rooted in a desire to provide ICUs the resources they need for a healthy work environment.
“I think that we rarely consider the caregivers and the impact that the environment has on them,” she said. With respect to PTSD, anxiety, depression and other manifestations of ICU workplace stress, she said, “I think the more information we get out about how common it is, the better. A lot of nurses have this, a lot of physicians have this, and it’s okay. There are things we can do to help them.”