Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Relationship Between Posttraumatic Stress Disorder and Compassion Satisfaction, Compassion Fatigue, and Burnout in Iranian Psychiatric Nurses

Batool Tirgari, PhD; Mansooreh Azizzadeh Forouzi, MSN; Mohammad Ebrahimpour, MSN

Abstract

Research is limited regarding post-traumatic stress disorder (PTSD) and professional quality of life (ProQOL) in Iranian nurses, especially nurses working in psychiatric units. The current study was conducted to determine the relationship between PTSD and ProQOL among psychiatric nurses in Kerman, Iran. This cross-sectional correlational study comprised 160 nurses working in three clinical settings supervised by Kerman University of Medical Sciences. Data were gathered using two questionnaires: PTSD Checklist and ProQOL Scale. Mean total PTSD score was 35.18 (SD = 10.92, range = 17 to 85), indicating nurses experienced moderate PTSD. Among ProQOL domains, burnout had the highest mean score and compassion fatigue had the lowest mean score. According to the Pearson correlation coefficient, PTSD score had a relationship with compassion satisfaction (r = −0.29; p < 0.001), compassion fatigue (r = 0.61; p < 0.001), and burnout (r = 0.36; p = 0.001). The current study results suggest that examining work-related PTSD, burnout, compassion satisfaction, and compassion fatigue in mental health nurses can help identify strategies to improve working conditions and quality of nursing care. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

Research is limited regarding post-traumatic stress disorder (PTSD) and professional quality of life (ProQOL) in Iranian nurses, especially nurses working in psychiatric units. The current study was conducted to determine the relationship between PTSD and ProQOL among psychiatric nurses in Kerman, Iran. This cross-sectional correlational study comprised 160 nurses working in three clinical settings supervised by Kerman University of Medical Sciences. Data were gathered using two questionnaires: PTSD Checklist and ProQOL Scale. Mean total PTSD score was 35.18 (SD = 10.92, range = 17 to 85), indicating nurses experienced moderate PTSD. Among ProQOL domains, burnout had the highest mean score and compassion fatigue had the lowest mean score. According to the Pearson correlation coefficient, PTSD score had a relationship with compassion satisfaction (r = −0.29; p < 0.001), compassion fatigue (r = 0.61; p < 0.001), and burnout (r = 0.36; p = 0.001). The current study results suggest that examining work-related PTSD, burnout, compassion satisfaction, and compassion fatigue in mental health nurses can help identify strategies to improve working conditions and quality of nursing care. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

The well-being of professionals in mental health settings has attracted considerable interest recently (Aadeyemo et al., 2015). Professional quality of life (ProQOL) refers to the positive and negative emotions an individual has about his or her job. Compassion satisfaction, burnout, and compassion fatigue are elements of ProQOL (Kim, Han, Kwak, & Kim, 2015). Compassion satisfaction refers to the sense of happiness or pleasure that comes with one's work or that one receives from others' actions. Compassion satisfaction relates to positive feelings derived from providing effective and helpful work (Aadeyemo et al., 2015). Burnout is defined as a psychological syndrome that involves a prolonged response to chronic interpersonal stressors of the job (Ray, Wong, White, & Heaslip, 2013). Compassion fatigue, also called secondary traumatic stress, is defined as a state of tension and preoccupation with traumatized patients by re-experiencing the traumatic events and persistent arousal associated with the patient (Ray et al., 2013).

According to the literature, ProQOL is influenced by clinical work environment characteristics (Aadeyemo et al., 2015; Ray et al., 2013). These characteristics include personal and situational factors that influence the development of burnout (Ray et al., 2013), compassion satisfaction, and compassion fatigue (Sacco, Ciurzynski, Harvey, & Ingersoll, 2015) among nurses.

Nurses in hospitals are often exposed to many stressors (Mealer, Burnham, Goode, Rothbaum, & Moss, 2009). Sources of major stress for psychiatric nurses include workload (Khankeh et al., 2014) and confrontation with suicidal and violent behaviors (Jacobowitz, Moran, Best, & Mensah, 2015; Sahraian, Davidi, Bazrafshan, & Javadpour, 2013; Skogstad et al., 2013). Khankeh et al. (2014) stated inadequate collaboration with other professionals and support and delivery of nursing care for individuals with psychiatric disorders are examples of areas that have been highlighted as major sources of stress for psychiatric nurses (Khankeh et al., 2014). As such, mental health nursing has been reported as a stressful nursing specialty with adverse consequences (Aadeyemo et al., 2015; Lauvrud, Nonstad, & Palmstierna, 2009; Needham et al., 2005), including burnout (Khankeh et al., 2014; Mealer et al., 2009), compassion fatigue (Franza, Del Buono, & Pellegrino, 2015), and posttraumatic stress disorder (PTSD) (Mealer et al., 2009).

PTSD is a psychiatric disorder caused by exposure to an extremely threatening or horrific event or series of events (Larsen & Pacella, 2016; Mealer et al., 2009). The criteria for PTSD according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) are:

Criterion 1: Exposure to a traumatic event; Criterion 2: Persistent re-experiencing of the event; Criterion 3: Avoidance of stimuli associated with the trauma and numbing of general responsiveness; Criterion 4: At least two symptoms of negative alterations in cognitions and mood associated with the trauma; Criterion 5: Marked alterations in arousal and reactivity; Criterion 6: The duration of symptoms is more than 1 month; Criterion 7: The disturbance causes clinically significant distress or impairment in functioning; Criterion 8: The disturbance is not attributable to the physiological effects of a substance or other medical condition.

Review of the literature showed that some studies have examined posttraumatic stress symptoms and ProQOL among nurses within different specialties. These studies indicated that the rates of secondary traumatic stress symptoms among nurses working in forensics, pediatrics, emergency medicine, hospice, intensive care units, and oncology departments ranged from 25% to 78% (Beck, 2011; Franza et al., 2015; Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010). A study of emergency department nurses found that approximately 86% had moderate to high levels of compassion fatigue (Hooper et al., 2010). Lauvrud et al. (2009) assessed the occurrence of posttraumatic stress symptoms and their relationship with ProQOL in nursing staff at a forensic psychiatric security unit. They found that the prevalence of posttraumatic stress symptoms was low. Low scores were also found for compassion satisfaction. The length of psychiatric nursing experience and low scores of compassion satisfaction were significantly correlated to increased posttraumatic stress symptoms (Lauvrud et al., 2009). Results of another study showed that 48% of psychiatric nurses reported that they experienced a traumatic event in their workplace (Registered Psychiatric Nurses Association of Saskatchewan [RPNAS], n.d.). According to this report, the overall incidence of PTSD (24.53%) found in the study sample was twice the rate expected in normal community-based samples (RPNAS, n.d.).

In a cross-sectional study comprising 234 participants at a federal neuropsychiatric hospital in Nigeria, Aadeyemo et al. (2015) concluded that the experience of violence in neuropsychiatric wards was significantly associated with secondary traumatic stress. Compassion satisfaction was negatively correlated with psychological distress (Aadeyemo et al., 2015). Mealer et al. (2009) indicated that psychological symptoms including PTSD, anxiety, and depression are common in nurses (Mealer et al., 2009). Franza et al. (2015) evaluated compassion fatigue in psychiatric nurses and showed a high level of job burnout and compassion fatigue in this population (39.3% and 28.6%, respectively).

There are few studies on ProQOL and PTSD in Iranian nurses, especially those working in general (Ariapooran, 2014), emergency, and trauma wards (Iranmanesh, Tirgari, & Bardsiri, 2013; Narimani, Zahed, & Basharpoor, 2010; Sheikhbardsiri et al., 2015). Yadollahi, Razmjooei, Jamali, Niakan, and Ghahramani (2016) studied the relationship between ProQOL and general health of staff in Rajaee Trauma Hospital, Shiraz, Iran. Staff members were found to have low burnout, secondary traumatic stress, physical dysfunction, social dysfunction, and severe depression as well as moderate levels of compassion satisfaction, anxiety, and sleep disorders (Yadollahi et al., 2016). Using the Mississippi Scale for Combat-Related PTSD, Iranmanesh et al. (2013) assessed the prevalence and level of PTSD in paramedics and emergency personnel supervised by Kerman University of Medical Sciences. Most (94%) paramedic and hospital emergency personnel reported moderate PTSD. The two groups had significantly different levels of PTSD on all subscales. Hospital emergency personnel had a higher mean PTSD score than paramedic personnel. Emergency workers are trained to manage medical emergencies and expect to encounter death and serious injury by the very nature of their jobs. Having to increase their emotional preparation and perceived control over these events puts them at risk for PTSD (Iranmanesh et al., 2013).

Using the ProQOL Scale (burnout and compassion fatigue subscales), Ariapooran (2014) determined the prevalence of compassion fatigue and burnout and the role of perceived social support in Iranian nurses. Results indicated that the prevalence of compassion fatigue and burnout was 45.3% and 15%, respectively. Therefore, the evaluation of mental health nurses' perceived burnout, compassion fatigue, and compassion satisfaction, and how these factors relate to PTSD, is a high priority for mental health organizations (Van Bogaert, Kowalski, Weeks, & Clarke, 2013). This evaluation can increase awareness about these symptoms in psychiatric nurses and possibly lead to future interventions to improve their mental health. Therefore, the current study was conducted to examine PTSD symptoms and ProQOL among Iranian psychiatric nurses.

Educational Preparation of Psychiatric Nurses in Iran

Generally, in Iran, psychiatric nurses' workplaces are psychiatric hospitals. Inpatient care is provided through hospitals that focus on rapid assessment and stabilization. Limited numbers of beds and high acuity of service users place pressure on nurses to develop new roles that essentially manage unmanageable situations.

Currently in Iran, after 4 years of formal nursing education, graduates become qualified, general nurses who work in clinical wards. Psychiatric nurses in Iran comprise nurses who hold a bachelor's degree (BSc) in nursing and who work in psychiatric settings (Karimollahi, 2012; Zarea, Nikbakht-Nasrabadi, Abbaszadeh, & Mohammadpour, 2013). The BSc nurses' curriculum contains only two theoretical courses and one practical course on mental health nursing. The short duration of theoretical and clinical education has been cited by some students as the factor that hinders them from achieving their learning objectives in regard to mental health nursing (Karimollahi, 2012). Therefore, the training of nurses on mental health is far from satisfactory in Iran (Zarea et al., 2013).

Undergraduate students often enter psychiatric courses with preconceived notions that patients are aggressive due to media representations and warnings from their families. Routine clinical experiences are also being used for training of therapeutic communication with patients (Karimollahi, 2012).

Self-images of Iranian psychiatric nurses are negatively influenced by the public's view of nursing, not only as a whole, but specifically in the care of individuals with mental illness. Working with individuals with mental illness increases the negative public perception of psychiatric nurses. In addition, psychiatric nurses are not required to pass an entrance examination for mental health nursing in Iran. Therefore, these nurses may not have sufficient skills necessary for working with individuals with mental illness (Zarea et al., 2013), which may lead to dissatisfaction and burnout.

The Iranian Nursing Organization (INO; 2010) reported that most psychiatric nurses do not have the appropriate qualifications for working in psychiatric wards, and most are forced into the sector by management or because of poor performance in other nursing sectors. Nurses must develop new skills, attitudes, knowledge, and roles in light of a growing body of evidence regarding the nature of effective practice in Iranian inpatient psychiatric units.

Method

Study Design and Setting

This cross-sectional correlational study examined the relationship between PTSD and ProQOL among psychiatric nurses. The study took place in three clinical settings situated in southeast Iran and was supervised by Kerman University of Medical Sciences (Shahid Beheshti Hospital, Sirjan's Emamm Reza Hospital, and Golestan Patient Rehabilitation Center).

Ethical Considerations

Before collecting data, approval for the study was obtained from the Ethical Review Committee of Kerman University of Medical Sciences. All study participants were provided and completed an informed consent form. Researchers explained voluntary participation, a guarantee of confidentiality, and freedom to withdraw from the study at any time.

Participants

Between June and October 2013, 160 psychiatric nurses who had worked for >1 year in the three clinical settings were recruited (Shahid Beheshti Hospital [n = 116], Sirjan's Emamm Reza Hospital [n = 19], and Golestan Patient Rehabilitation Center [n = 25]). Census sampling was used for data collection. This method of sampling is used when the entire population is small; data are gathered from every member of the population.

The settings were repeatedly visited to ensure eligible participants were provided an opportunity to participate in the study (all three shifts). Questionnaires were distributed by the third author (M.E.) along with information about the study aims.

Instruments

Demographic Data. The demographic questionnaire included variables such as age, gender, marital status, educational level, job experience, working hours per month, shift status, years of nursing experience, and experience managing traumatic events.

Professional Quality of Life Scale. The ProQOL Scale is a 30-item self-report measure that evaluates the positive and negative aspects of helping professions (Stamm, 2010). The scale comprises three subscales: (a) compassion satisfaction, (b) burnout, and (c) compassion fatigue. The compassion satisfaction subscale measures pleasure derived from being able to work well, with higher scores representing a greater satisfaction related to the ability to be an effective caregiver (e.g., I am happy that I chose to do this work). The burnout subscale is associated with feelings of hopelessness and difficulties in handling the job effectively, with higher scores related to higher risk for burnout (e.g., I feel trapped by my job as a helper). The compassion fatigue subscale relates to work-related secondary exposure to extremely stressful events, with higher scores indicating a higher degree of compassion fatigue. Each subscale comprises 10 questions that are rated on a 5-point Likert scale (1 = never to 5 = very often). Scores for each subscale are obtained by summing the scores of the 10 individual questions. High scores on each subscale signify a higher degree of the corresponding sub-factor. However, the three subscale scores are not summed to obtain the overall ProQOL score. Compassion satisfaction, burnout, and compassion fatigue scores are grouped into three categories: low (≤22 points), moderate (23 to 41 points), and high (≥42 points) (Stamm, 2010). The Pro-QOL Scale takes approximately 15 to 20 minutes to complete on paper in the workplace.

At the time of the ProQOL Scale development, Cronbach's alpha was 0.88 for compassion satisfaction, 0.71 for burnout, and 0.77 for compassion fatigue (Stamm, 2010). The validity and reliability of the ProQOL Scale was re-checked in the context of the current study. Ten faculty members at Kerman University of Medical Sciences reviewed the content of the ProQOL Scale and agreed that the scale was appropriate. To compute the content validity index (CVI), 10 experts used a 4-point Likert scale to assess the relevance, simplicity, and clarity of statements for each item of the questionnaire. The CVI of the ProQOL scale was 0.94. To reassess the reliability of the translated scale, alpha coefficient of internal consistency was computed, resulting in 0.89, indicating the scale was reliable and valid.

PTSD Checklist. The PTSD Checklist, which was developed and validated by Weathers, Huska, and Keane (1991), is an easily administered self-report rating scale for assessing DSM-IV-TR symptoms of PTSD. Using a 5-point Likert scale, responses ranged from strongly agree to strongly disagree. PTSD score was the sum of 17 items (range = 17 to 85 points), with higher scores indicating a greater level of PTSD. However, there is no defined PTSD cut-off score for this checklist (Weathers et al., 1991). The PTSD Checklist takes 10 to 15 minutes to complete on paper in the workplace.

The PTSD Checklist has been shown to have excellent test–retest reliability over a 2- to 3-day period. Internal consistency was very high for each of the three groups of items corresponding to the DSM-IV-TR, symptom clusters, and 17 items of the checklist. This checklist correlated strongly with other measures of PTSD, such as the Mississippi Scale for Combat-Related PTSD, Keane PTSD Scale of the Minnesota Multiphasic Personality Inventory, and Impact of Events Scale. The checklist was also moderately correlated with level of combat exposure (Weathers et al., 1991).

Validity and reliability of the PTSD checklist were re-checked in the context of the current study. Ten faculty members at Kerman University of Medical Sciences reviewed the content of the checklist, agreeing it was appropriate. To compute the CVI, 10 experts used a 4-point Likert scale to assess the relevance, simplicity, and clarity of statements for each item of the checklist. The CVI of the PTSD Checklist was 0.96. To reassess the reliability of the translated scale, alpha coefficient of internal consistency was computed, resulting in 0.86, indicating the checklist was reliable and valid.

Data Analysis

Data were analyzed using SPSS version 19. The Kolmogorov-Smirnov test was applied to assess the data from a population with a normal distribution. Descriptive statistics and Student's t test or one-way analysis of variance (ANOVA) and Pearson correlation coefficient were used for data analysis. Significance was set at 0.05.

Results

Participants

A descriptive analysis of background information revealed that participants were ages 30 to 39 (mean [SD] age = 33.01 [6.91] years). A total of 75.6% of participants were female, and 80% were married. Most participants had a BSc in nursing (81.8%) and 5 to 9 years of experience in nursing (33.1%). In addition, 78.8% of participants worked between 150 and 200 hours per month. Most respondents had moderate job experience (51.9%) and moderate interest in work (58.1%) (Table 1).

Demographic Characteristics of the Study Sample (N = 160)

Table 1:

Demographic Characteristics of the Study Sample (N = 160)

PTSD and ProQOL Scores

Table 2 shows total mean scores of participants' PTSD and ProQOL. Mean PTSD total score was 35.18 (range = 17 to 85), indicating nurses experienced moderate PTSD. Among the ProQOL domains (i.e., subscales), burnout had the highest mean score and compassion fatigue had the lowest mean score. Mean scores of ProQOL domains were categorized in three levels: weak, moderate, and high. Most participants had moderate levels of compassion satisfaction, burnout, and compassion fatigue (Table 3).

Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life (PROQOL) Scores in Iranian Psychiatric Nurses

Table 2:

Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life (PROQOL) Scores in Iranian Psychiatric Nurses

Professional Quality of Life Domain Scoresa in Iranian Psychiatric Nurses (N = 160)

Table 3:

Professional Quality of Life Domain Scores in Iranian Psychiatric Nurses (N = 160)

Correlation Between PTSD and ProQOL

Pearson correlation coefficient showed a significant correlation between PTSD and all ProQOL domains (Table 4).

Relationship between Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life Domains in Iranian Psychiatric Nurses

Table 4:

Relationship between Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life Domains in Iranian Psychiatric Nurses

Relationship Between PTSD and Demographic Variables

One-way ANOVA revealed a difference in PTSD scores according to nurses' age, interest in work, and experience in managing traumatic events. Nurses who were older (p = 0.001), had high experience managing traumatic events (p = 0.001), and had low interest in work (p = 0.001) were more likely to experience PTSD (p = 0.045). However, there was no significant relationship between PTSD and other demographic variables (Table 5).

Relationship between Posttraumatic Stress Disorder and Demographic Variables in Iranian Psychiatric Nurses

Table 5:

Relationship between Posttraumatic Stress Disorder and Demographic Variables in Iranian Psychiatric Nurses

Relationship Between ProQOL Domains and Demographic Variables

There were no significant differences in ProQOL domain scores according to demographic variables.

Discussion

The aim of the current study was to examine the relationship between PTSD and ProQOL among Iranian psychiatric nurses. The main results revealed that there was a significant relationship between PTSD and all domains of ProQOL.

Nurses in the current study experienced moderate PTSD. Lauvrud et al. (2009) found that the prevalence of PTSD was low in nursing staff at a forensic psychiatric security unit. Skogstad et al. (2013) stated that mental health professionals may be exposed to violence from patients and report high levels of PTSD symptoms. It could be said that nurses in general are especially vulnerable to stress and related problems because they can become too empathic due to the degree and duration of contact they have with patients, their emotional investments (Ariapooran, 2014), and managing stressful behaviors such as suicide and violence (Sahraian et al., 2013).

According to a study by Zarea et al. (2013), Iranian psychiatric nurses were not chosen to work in psychiatric wards based on appropriate qualifications. It was believed that inexperienced nurses who had been rejected by the health care system were sent to work in psychiatric hospitals. Nurses are sometimes forced by management to work within the psychiatric sector, even if they dislike working in that area. Despite the importance of having the communication skills necessary to build relationships with patients in these wards, most Iranian psychiatric nurses had not received any education and training in this important skill (Zarea et al., 2013).

For participants in the current study who were found to have PTSD, the research team recommended the nurse administrators of the research settings support their staff by regularly allocating time for nurses to discuss how they are coping with the stress of the care they give. Staff members were encouraged to practice good self-care, such as mindfulness meditation and self-compassion.

In the current study, burnout had the highest mean score and compassion fatigue had the lowest mean score. According to Konstantinos and Ouzouni (2008), psychiatric nurses were vulnerable to burnout because of less social support and less on- and offthe-job affirmation compared to nurses in other specialties. The authors went on to state that interpersonal relationships were the most frequent source of undesirable personal stress for psychiatric nurses, having a greater impact on them than nurses in other specialties (Konstantinos & Ouzouni, 2008). Regarding compassion fatigue, Boyle (2011) concluded that repeated exposure to others' emotions may lead to this condition.

In the current study, a significant correlation was found between PTSD and all ProQOL domains. Previous studies also showed a significant relationship between ProQOL domains (i.e., compassion satisfaction, burnout, and compassion fatigue) and PTSD (Aadeyemo et al., 2015; Kim et al., 2015; Lauvrud et al., 2009). Lauvrud et al. (2009) found that low scores on compassion satisfaction were correlated with increased posttraumatic stress symptoms. Aadeyemo et al. (2015) concluded that compassion satisfaction was negatively correlated with psychological distress. According to Kim et al. (2015), nurses are professionals who are more likely to experience compassion fatigue, which can negatively affect their mental and physical health as well as job performance.

The reverse correlation between PTSD and ProQOL domains among psychiatric nurses could possibly be explained by health-related experience and exposure to more emotional stressors than individuals in other jobs. Most problems stem from the nature of the job, as nurses spend a lot of time with patients with mental illness. In general, behaviors related to suicide and violent behaviors are the most stressful behaviors nurses confront (Sahraian et al., 2013). Individuals experiencing compassion fatigue can feel a loss of meaning and hope and can have symptoms associated with PTSD such as anxiety, difficulty concentrating, being jumpy or startled easily, irritability, difficulty sleeping, excessive emotional numbing, and intrusive images of another's traumatic experience (Portnoy, 2011).

According to Zarea, Nikbakht-Nasrabadi, Abbaszadeh, and Mohammadpour (2012), Iranian psychiatric nurses are confused about their main task and what it involves. Iranian psychiatric nurses were found to perform a number of non-specialized tasks, leading to weak therapeutic communication with patients. In addition, “in Iran, psychiatric supervision was mostly a type of observation carried out in such a way that nurses viewed themselves as either security guards without the need for much academic knowledge or secretaries with a mountain of paperwork” (Zarea et al., 2012, p. 700).

According to the findings of the current study, a positive correlation was found between experiences in managing traumatic events and PTSD. Nurses who had high experiences in managing traumatic events had higher levels of PTSD compared to nurses with low or moderate experience managing traumatic events. Elhai et al. (2012) reported that PTSD requires exposure to a stressful event or situation (either short or long lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost any individual. Therefore, determining the lifetime history of trauma exposure has important implications for predisposition to subsequent development of PTSD (Mealer et al., 2009). According to Jacobowitz (2013), psychiatric nurses are subject to a high rate of assault by patients. The stress of exposure to assault and the potential for assault appear to impact nurses' emotional states in the form of posttraumatic stress and PTSD (Jacobowitz, 2013).

Nurses' age was positively correlated with PTSD in the current study. This finding indicated that the PTSD score among older participants was higher than the score among their younger colleagues. Inconsistent with this finding, Mealer et al. (2009) reported that a nurse's age negatively correlated with the development of PTSD (Mealer et al., 2009). In addition, Iranmanesh et al. (2013) compared PTSD among paramedic and hospital emergency personnel in southeast Iran. They found that there was no significant correlation between PTSD and age. Skogstad et al. (2013) reported that senior nurses had fewer PTSD and burnout symptoms compared with junior nurses. Lauvrud et al. (2009) stated that long nursing experience leads to higher exposure to violence and higher rates of posttraumatic problems. The level of training or desire to work in the area may also lead to these issues.

Lack of interest in work was correlated with PTSD in the current study. Nurses with low interest in work had a higher level of PTSD than those with more interest in work. Similarly, Sheikhbardsiri et al. (2013) showed a negative association between interest in work and PTSD score. They showed that hospital emergency personnel, who had low interest in work, had higher rates of PTSD compared to those who had more interest in work (Sheikhbardsiri et al., 2013).

Limitations

The current study had several limitations. The sample of participants, which was not representative of all psychiatric nurses, affects generalizability of the findings. Furthermore, there was a risk of self-report bias, which may have led to an overestimation of some of the findings due to variance. Another limitation was the amount of time participants had to fill in the questionnaires. The second author (M.A.F.), therefore, asked participants to fill in the questionnaires whenever or wherever they preferred.

Implications for Practice

It is necessary to review the resources available in the workplace and provide employees with supportive counseling on work-related issues. Creating a reflective environment in which psychiatric nurses can express their feelings and experiences about stressful situations seems to be an effective approach in identifying factors that influence PTSD and ProQOL.

Empathetic caring and interpersonal skills are at the core of nursing. However, the cost of providing this empathic nursing care can contribute to caregivers' compassion fatigue. Talking about one's concerns and feelings with an appropriate individual can provide support and hope to the caregiver and assist him/her with the development of an action plan to address compassion fatigue. For nurses, the conversation represents recognition for deeper self-awareness and support to prevent and heal the effects of burnout, secondary traumatic stress, and compassion fatigue. Therefore, a continuous educational program on coping with work-related PTSD and improving ProQOL could be an effective step for nursing education.

Stress management programs may preserve the well-being of highly stressed nurses. Nursing schools should prepare nursing students through stress management training. Training in stress management is important for nurses who care for patients with psychiatric disorders. Hence, nurses become familiar with and learn to manage their own stress reactions.

It is important for nurses to identify replenishing strategies that can promote physical, emotional, and spiritual well-being. In addition, nurses may need encouragement to try a new approach to self-care, such as a yoga, massage, or meditation.

Conclusion

The results of the current study indicate moderate levels of PTSD, burnout, compassion satisfaction, and compassion fatigue among psychiatric nurses in Kerman, Iran. Prevention of work-related PTSD, burnout, and compassion fatigue and promotion of compassion satisfaction require appropriate interventions. Teaching coping strategies, providing training on adaptive self-care, participating in critical incident debriefing, and having routine structured debriefing meetings may play a role in helping nurses decrease the risk of burnout, compassion fatigue, and PTSD.

References

  • Aadeyemo, S.O., Omoaregba, J.O., Bushura, A., James, B.O., Blessing, U., Ezemokwe, C.O. & Vera, M. (2015). Experiences of violence, compassion fatigue and compassion satisfaction on the professional quality of life of mental health professionals at a tertiary psychiatric facility in Nigeria. Open Science Journal of Clinical Medicine, 3, 67–73.
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • Ariapooran, S. (2014). Compassion fatigue and burnout in Iranian nurses: The role of perceived social support. Iranian Journal of Nursing and Midwifery Research, 19, 279–284.
  • Beck, C.T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25, 1–10. doi:10.1016/j.apnu.2010.05.005 [CrossRef]
  • Boyle, D.A. (2011). Countering compassion fatigue: A requisite nursing agenda. The Online Journal of Issues in Nursing, 16. doi:10.3912/OJIN.Vol16No01Man02 [CrossRef]
  • Elhai, J.D., Miller, M.E., Ford, J.D., Biehn, T.L., Palmieri, P.A. & Frueh, B.C. (2012). Post-traumatic stress disorder in DSM-5: Estimates of prevalence and symptom structure in a nonclinical sample of college students. Journal of Anxiety Disorders, 26, 58–64. doi:10.1016/j.janxdis.2011.08.013 [CrossRef]
  • Franza, F., Del Buono, G. & Pellegrino, F. (2015). Psychiatric caregiver stress: Clinical implications of compassion fatigue. Psychiatria Danubina, 27(Suppl. 1),S321–S327.
  • Hooper, C., Craig, J., Janvrin, D.R., Wetsel, M.A. & Reimels, E. (2010). Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing, 36, 420–427. doi:10.1016/j.jen.2009.11.027 [CrossRef]
  • Iranian Nursing Organization. (2010). Mental sector nurses are not properly selected [website in Persian]. Retrieved from http://www.ino.ir
  • Iranmanesh, S., Tirgari, B. & Bardsiri, H.S. (2013). Post-traumatic stress disorder among paramedic and hospital emergency personnel in south-east Iran. World Journal of Emergency Medicine, 4, 26–31. doi:10.5847/wjem.j.issn.1920-8642.2013.01.005 [CrossRef]
  • Jacobowitz, W. (2013). PTSD in psychiatric nurses and other mental health providers: A review of the literature. Issues in Mental Health Nursing, 34, 787–795. doi:10.3109/01612840.2013.824053 [CrossRef]
  • Jacobowitz, W., Moran, C., Best, C. & Mensah, L. (2015). Post-traumatic stress, trauma-informed care, and compassion fatigue in psychiatric hospital staff: A correlational study. Issues in Mental Health Nursing, 36, 890–899. doi:10.3109/01612840.2015.1055020 [CrossRef]
  • Karimollahi, M. (2012). An investigation of nursing students' experiences in an Iranian psychiatric unit. Journal of Psychiatric and Mental Health Nursing, 19, 738–745. doi:10.1111/j.1365-2850.2011.01850.x [CrossRef]
  • Khankeh, H., Khorasani-Zavareh, D., Hoseini, S.-A., Khodai-Ardekandi, M.-R., Ekman, S.-L., Bohm, K. & Castren, M. (2014). The journey between ideal and real: Experiences of beginner psychiatric nurses. Iranian Journal of Nursing and Midwifery Research, 19, 396–403.
  • Kim, K., Han, Y., Kwak, Y. & Kim, J.-S. (2015). Professional quality of life and clinical competencies among Korean nurses. Asian Nursing Research, 9, 200–206. doi:10.1016/j.anr.2015.03.002 [CrossRef]
  • Konstantinos, N. & Ouzouni, C. (2008). Factors influencing stress and job satisfaction of nurses working in psychiatric units: A research review. Retrieved from http://www.hsj.gr/medicine/factors-influencing-stress-and-job-satisfaction-of-nurses-working-in-psychiatric-units-a-research-review.php?aid=3653
  • Larsen, S.E. & Pacella, M.L. (2016). Comparing the effect of DSM-congruent traumas vs. DSM-incongruent stressors on PTSD symptoms: A meta-analytic review. Journal of Anxiety Disorders, 38, 37–46. doi:10.1016/j.janxdis.2016.01.001 [CrossRef]
  • Lauvrud, C., Nonstad, K. & Palmstierna, T. (2009). Occurrence of post traumatic stress symptoms and their relationship to professional quality of life (ProQoL) in nursing staff at a forensic psychiatric security unit: A cross-sectional study. Health and Quality of Life Outcomes, 7, 31. doi:10.1186/1477-7525-7-31 [CrossRef]
  • Mealer, M., Burnham, E.L., Goode, C.J., Rothbaum, B. & Moss, M. (2009). The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depression and Anxiety, 26, 1118–1126. doi:10.1002/da.20631 [CrossRef]
  • Narimani, M., Zahed, A. & Basharpoor, S. (2010). Prevalence of posttraumatic stress disorder in hospital emergency nurses and fire department workers in Uremia city. Journal of Research in Behavioural Sciences, 8, 69–74.
  • Needham, I., Abderhalden, C., Halfens, R.J., Dassen, T., Haug, H.J. & Fischer, J.E. (2005). The impact of patient aggression on carers scale: Instrument derivation and psychometric testing. Scandinavian Journal of Caring Sciences, 19, 296–300. doi:10.1111/j.1471-6712.2005.00344.x [CrossRef]
  • Portnoy, D. (2011). Burnout and compassion fatigue: Watch for the signs. Health Progress, 92, 46–50.
  • Ray, S.L., Wong, C., White, D. & Heaslip, K. (2013). Compassion satisfaction, compassion fatigue, work life conditions, and burnout among frontline mental health care professionals. Traumatology, 19, 255. doi:10.1177/1534765612471144 [CrossRef]
  • Registered Psychiatric Nurses Association of Saskatchewan. (n.d.). Factors affecting post-traumatic stress disorders and depression in psychiatric nurses. Retrieved from https://www.rpnas.com/about/papers/ptsd-rpn
  • Sacco, T.L., Ciurzynski, S.M., Harvey, M.E. & Ingersoll, G.L. (2015). Compassion satisfaction and compassion fatigue among critical care nurses. Critical Care Nurse, 35(4), 32–42. doi:10.4037/ccn2015392 [CrossRef]
  • Sahraian, A., Davidi, F., Bazrafshan, A. & Javadpour, A. (2013). Occupational stress among hospital nurses: Comparison of internal, surgical, and psychiatric wards. International Journal of Community Based Nursing and Midwifery, 1, 182–190.
  • Seides, R. (2010). Should the current DSMIV-TR definition for PTSD be expanded to include serial and multiple microtraumas as aetiologies?Journal of Psychiatric and Mental Health Nursing, 17, 725–731. doi:10.1111/j.1365-2850.2010.01591.x [CrossRef]
  • Sheikhbardsiri, H., Sarhadi, M., Abdollahyar, A., Dastres, M., Sheikh Rabari, A. & Aminizadeh, M. (2015). The relationship between personality traits and post-traumatic stress disorder among EMS personnel and hospital emergency staffs. Journal of Critical Care Nursing, 8, 35–42.
  • Skogstad, M., Skorstad, M., Lie, A., Conradi, H., Heir, T. & Weisæth, L. (2013). Work-related post-traumatic stress disorder. Occupational Medicine, 63, 175–182. doi:10.1093/occmed/kqt003 [CrossRef]
  • Stamm, B.H. (2010). The concise ProQOL manual. Retrieved from http://www.proqol.org/uploads/ProQOL_Concise_2ndEd_12-2010.pdf
  • Van Bogaert, P., Kowalski, C., Weeks, S.M. & Clarke, S.P. (2013). The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care: A cross-sectional survey. International Journal of Nursing Studies, 50, 1667–1677. doi:10.1016/j.ijnurstu.2013.05.010 [CrossRef]
  • Weathers, F.W., Huska, J.A. & Keane, T.M. (1991). PCL-C for DSM-IV. Boston, MA: National Center for PTSD-Behavioral Science Division.
  • Yadollahi, M., Razmjooei, A., Jamali, K., Niakan, M.H. & Ghahramani, Z. (2016). The relationship between professional quality of life (ProQol) and general health in Rajaee Trauma Hospital staff of Shiraz, Iran. Shiraz E-Medical Journal, 17. doi:10.17795/semj39253 [CrossRef]
  • Zarea, K., Nikbakht-Nasrabadi, A., Abbaszadeh, A. & Mohammadpour, A. (2012). Facing the challenges and building solutions in clinical psychiatric nursing in Iran: A qualitative study. Issues in Mental Health Nursing, 33, 697–706. doi:10.3109/01612840.2012.698371 [CrossRef]
  • Zarea, K., Nikbakht-Nasrabadi, A., Abbaszadeh, A. & Mohammadpour, A. (2013). Psychiatric nursing as ‘different’ care: Experience of Iranian mental health nurses in inpatient psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 20, 124–133. doi:10.1111/j.1365-2850.2012.01891.x [CrossRef]

Demographic Characteristics of the Study Sample (N = 160)

Variablen (%)
Age (years)
  20 to 2961 (38.1)
  30 to 3971 (44.4)
  40 to 5028 (17.5)
Gender
  Female121 (75.6)
  Male39 (24.4)
Marital status
  Married128 (80)
  Single32 (20)
Educational level
  High school diploma26 (16.3)
  Bachelor's degree131 (81.8)
  Master's degree3 (1.9)
Job experience (years)
  High (≥20)36 (22.5)
  Moderate (10 to 19)83 (51.9)
  Low (≤9)41 (25.6)
Working hours per month
  100 to 14925 (15.6)
  150 to 200126 (78.8)
  >2009 (5.6)
Shift status
  Rotating113 (70.6)
  Fixed47 (29.4)
Interest in working
  High54 (33.8)
  Moderate93 (58.1)
  Low13 (8.1)
Years of nursing experience
  <550 (31.3)
  5 to 953 (33.1)
  10 to 1429 (18.1)
  15 to 196 (3.8)
  20 to 2416 (10)
  25 to 306 (3.8)
Experience with traumatic events
  High36 (22.5)
  Moderate76 (47.5)
  Low48 (30)

Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life (PROQOL) Scores in Iranian Psychiatric Nurses

VariableMean (SD) (Range)
PTSDa35.18 (10.92) (17 to 74)
ProQOLb
  Compassion satisfaction23.40 (6.20) (5 to 35)
  Burnout27.17 (4.63) (12 to 40)
  Compassion fatigue22.95 (6.32) (10 to 42)

Professional Quality of Life Domain Scoresa in Iranian Psychiatric Nurses (N = 160)

Variablen (%)
HighModerateLow
Compassion satisfaction53 (33.1)101 (63.1)6 (3.8)
Burnout0124 (77.5)36 (22.5)
Compassion fatigue086 (53.8)74 (46.2)

Relationship between Posttraumatic Stress Disorder (PTSD) and Professional Quality of Life Domains in Iranian Psychiatric Nurses

VariablePearson Correlation (p Value)
Compassion SatisfactionBurnoutCompassion Fatigue
PTSD0.61 (<0.001)0.36 (<0.001)−0.29 (<0.001)

Relationship between Posttraumatic Stress Disorder and Demographic Variables in Iranian Psychiatric Nurses

VariableMean (SD)Fp Value
Age (years)5.20.008
  20 to 2931.88 (9.7)
  30 to 3936.71 (12.04)
  40 to 5038.50 (8.70)
Interest in working8.020.001
  High32.81 (11.9)
  Moderate35.08 (9.81)
  Low45.76 (10.92)
Experience managing traumatic events7.430.001
  High40.7 (11.47)
  Moderate34.55 (10.27)
  Low31.63 (10.1)
Authors

Dr. Tirgari is Associate Professor, Nursing Research Center, and Ms. Azizzadeh Forouzi is Faculty Member, and Mr. Ebrahimpour is Master of Psychiatric Nursing Graduate, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was approved by the Health System Research Center of Kerman University of Medical Sciences. The authors thank all nurses who participated in this study.

Address correspondence to Mohammad Ebrahimpour, MSN, School of Nursing and Midwifery, Kerman University of Medical Sciences, Medical University Campus, Haft-Bagh Highway, 7616913555, Kerman, Iran; e-mail: mebrahimpour62@yahoo.com.

Received: April 11, 2018
Accepted: August 23, 2018
Posted Online: December 03, 2018

10.3928/02793695-20181023-02

Sign up to receive

Journal E-contents