Post Traumatic Stress Disorder

The art of nursing originated with the infamous Florence Nightingale. The services provided by her and her colleagues were on the most basic level of human care-giving to the fallen men during the Crimean War of 1853-1856.


The nursing profession has developed immensely into a vast encompassing role during war time; but the sights, sounds, and smells have changed little. The experience nurses endure during war can cause long-term psychological problems no matter what day and age we are in. Post Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur after experiencing or witnessing a life-threatening or overwhelming traumatic event such as military combat (Antai-Otong, 2007). A more specific statistic from the National Center for PTSD reveals 15.2% of Vietnam veterans and 30% of men and women in more recent war zones are likely to develop PTSD (Antai-Otong, 2007). Nurses may have developed PTSD following their war experience due to the lack of preparation for the perils they were faced with, clinical inexperience, and sleep deprivation.
Due to the sheer volume and severity of casualties during war, it is no wonder why many nurses developed psychological issues post war time. As in the Vietnam War, one soldier after another starved for medical attention. The nurse would have to mentally formulate in a matter of seconds who needed what and who is worth expending the limited amount of energy and supplies on with life saving interventions. There was a huge amount of guilt felt by the nurses when soldiers were put in the “expectant” category; expecting to die (Wynd, 2006). These patients were in need of emotional support while they lay to die, and even that was hard to accomplish due to time constraints and lack of nursing staff. In addition, there were only a few medical facilities all injured soldiers were sent to with minimal medical staff on duty. This caused less than desirable patient to nurse ratios. The casualties seen were also nothing short of horrific and the training provided to the nurses did not prepare them for what they would see out in the field.
During the enlistment phase of the Vietnam War, the majority of nurses were sent over straight out of nursing school. The minimum age requirements were 21, but some later reported being younger. The amount of clinical experience had by these nurses included their education at a three-year diploma school and basic training through the military. With this inexperience and immaturity came stress during the high volume and extent of casualties seen. Many nurses describe completing highly technical procedures and interventions without having the training necessary. One such nurse tells of opening a wound herself and clamping off a vessel which was bleeding out (Sorrin, 2006).
Compounding the lack of preparation and experience, nurses were deprived of sleep. Many nurses reported not being able to fall asleep, even if lucky enough to have the opportunity to do so in the first place. To fall asleep you have to be relaxed and in a state of comfort, both of which are lacking during war. One nurse recalls lying down in a dark room after a long period of work and having no room in her head to fall asleep; there was too much going on within her mind that she was unable to relax and fall asleep (Freedman and Rhoads, 1987). In addition, with the numerous amount of admits from the field there was little time to sleep. There are many accounts of working at full patient capacity with 12 hour work days, 6 days per week (Sorrin, 2006). That said, it is easy to see the discrepancy and impact the lack of sleep can have on nurses when it is estimated that 90% of people require 8 hours of sleep per 24 hours (Blachowicz & MariJo, 2006).
Many tools have been integrated by the Department of Defense since the Vietnam War in regards to PTSD. This includes virtual reality software and self assessments of mental status available with on-site computers and health reassessments completed after a tour is completed. This is for the family as well as the veteran (Brewin, 2007). Incorporated in military nurses training are regular drills, emergency response teaching, triage protocols, and having communication “roles and channels” in place (Wynd, 2006).
Treatment of PTSD may include cognitive behavior therapy, group therapy, eye movement desensitization and reprocessing, psychodynamic psychotherapy, and pharmacological management with Selective Serotonin Reuptake Inhibitors (Unknown, 2007).
In summary, PTSD can be caused by any stressful stimuli, specifically the jeopardy of war time. The dearth of mental, emotional, and physical preparation of war, clinical inexperience, and sleep deprivation all have negative compounding effects to a state of well being. This disorder may be relieved with more intense, war-like training before going to the battle field; longer clinical exposure with a preceptor period prior to deployment; and lastly, better nurse to patient ratios to help with the hectic environment (Scannell-Desch, 2005).

Works Cited
Antai-Otong, Deborah (2007).Pharmacologic Management of Posttraumatic Stress Disorder. Perspectives in Psychiatric Care. 43, 55. Retrieved July 5, 2007, from Research Library database. (Document ID: 1218669951).
Blachowicz, Ewa, & Letizia, M. (2006). The Challenges of Shift Work. Retrieved August 6, 2007, from MEDSURG Nursing. 15, 275.
Brewin, B. (2007).PTSD and Me. Federal Computer Week. 21, 26. Retrieved July 5, 2007 from Proquest. http://proquest.umi.com/pqdweb?did=1258999171&sid=2&Fmt=3&clientid=3236&RQT=309&VName=PQD
Freedman, D., & Rhoads, J. (1987). Nurses in Vietnam: The Forgotten Veterans.Austin: Texas Monthly Press, Inc..
Scannell-Desch, E. A. (2005).Lessons learned and advise from Vietnam war nurses: A qualitative study. Journal of Advanced Nursing. 49, 600-607. Retrieved July 5, 2007 from Academic Search Premier, CINAHL. http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2005081089&site=ehost-live
Sorrin, L. (2006). Military Nurses in Vietnam. Retrieved August 6, 2007, from All about Military Nurses in Vietnam Web site: http://www.illyria.com/vnwnurse.html
Unknown, (2007). National Center for Posttraumatic Stress Disorder. Retrieved August 6, 2007, from Treatment of PTSD Web site: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.html
Wynd, C. A. (2006, September 30). A Proposed Model for Military Disaster Nursing. OJIN: The Online Journal of Issues in Nursing, 11, Retrieved August 6, 2007, from http://www.nursingworld.org/ojin/topic31/tpc31_4.htm

Intervention 1: PTSD relieved with more intense, war-like training before going to the battle field.
Disadvantage 1: Depending on the level of training and experience each nurse had prior to their military training and combat-seen time makes a difference in how they may see a given situation and how they will manage it psychologically. One study, relating nurses with an undergraduate degree (RN1) with nurses holding the same degree but with an added 6-12 month full-time study within a specialized area (RN2) revealed several differences with the learning approach taken by each group. For example, RN1s placed more emphases on the training facilities used and the real-life scenarios involved than did the RN2s. For example, RN2 nurses desired relevant symptoms they may come across and RN1 nurses needed more concrete holistic scenarios. (A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education, 2007) This can be explained with the fact that experienced nurses draw upon their previous clinical experience and intuition to create a plan of care in a split second. This can help minimize PTSD by simply taking that added stress off decision making at the most basic level of nursing care to wounded soldiers. However, this would also mean that different military training curriculum would have to be created for these two types of nurses to get what each needed for war time. (A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education, 2007)
Disadvantage 2: Another disadvantage or barrier of providing war-like training during many wars in the past was simply not having the time to do so. At the beginning of WWII, medical military personnel were below desired levels and thus a draft was initiated. This was done for the majority of civilian medical personnel though, which meant these individuals were trained for combat situations in an accelerated timeframe. It was noted that approximately two-thirds of all American physicians under the age of 45, that were also physically fit, were enlisted in the armed forces by 1943 (Unknown). So not only were these individuals trained in a short amount of time, but they were also trained in war theory of which they had never experienced.

Intervention 2: PTSD relieved with better nurse to patient ratios to help with the hectic environment.
Disadvantage 1: Although in theory this would be the most desirable situation, there is a slim chance it would physically work. When you look at the numbers of armed forces during the Vietnam War it becomes quite evident that the odds are stacked against the nursing personnel. There were over 250,000 US military personnel wounded and 58,132 military men and women killed. These numbers far outweighed the approximate 7500 US military nurses. This number included Navy nurses on two hospital ships, Air Force flight nurses involved in the evacuation of wounded soldiers, and Army, Navy, and Air Force nurses located at hospitals. (Scannell-Desch, 2004) More nurses would need to be recruited in order to fulfill this intervention, which would lead to more needed military nurse training, and thus more time. Again, if this was something that was initiated prior to an anticipated war, it could possibly work. Assuming, however, that civilian nurses would want to transition into military nurses of course.
Disadvantage 2: Although the nurse-to-patient ratio is an important aspect in order to conduct safe nursing care out on the battle field, there is also the factor of the inability to predict how an individual will react to real war scenarios. Directly before WWII, pre-induction tests were administered to attempt to eliminate psychologically unfit military personnel and thus remove most possibilities of PTSD in the future. These tests could pick out the most frank of behavioral disorders, but it was in no way a perfect solution. (Unknown). Everyone, without a doubt, will have a different reaction to stressful situations and this will only be evident in those stressful combat situations themselves. This involves the unknown reaction a highly experienced civilian nurse may experience as well as a recently graduated nurse.

 
Works Cited

A Comparison of Experiences of Training Emergency Care in Military Exercises and Competences among Conscript Nurses with Different Levels of Education. (2007, October). Military Medicine .
Scannell-Desch, S. (2004, April). Lessons learned and advice from Vietnam war nurses: a qualitative study. Journal of Advanced Nursing , 600.
Unknown. (n.d.). Military Medicine During The Twentieth Century. Retrieved October 25, 2007, from http://www.au.af.mil/au/awc/awcgate/milmedhist/chapter3.htm