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Posttraumatic Growth Among Health Care Workers on the Frontlines of the COVID-19 Pandemic
Abstract
Background:
The COVID-19 pandemic has led to significant mental health consequences for frontline health care workers (FHCWs). However, no known study has examined the prevalence, determinants, or correlates of posttraumatic growth (PTG) in this population.
Methods:
Data were analyzed from a prospective cohort of FHCWs at an urban tertiary care hospital in New York City (NYC). Assessments were conducted during the spring 2020 pandemic peak (Wave 1) and seven months later (Wave 2). Multivariable logistic regression analyses were conducted to identify Wave 1 sociodemographic, occupational, and psychosocial factors associated with PTG at Wave 2, and the association between aspects of PTG with burnout and pandemic-related PTSD symptoms at Wave 2.
Results:
A total 76.8% of FHCWs endorsed moderate or greater PTG; the most prevalent domains were increased appreciation of life (67.0%), improved relationships (48.7%), and greater personal strength (44.1%). Non-White race/ethnicity, greater levels of positive emotions, pandemic-related PTSD symptoms, dispositional gratitude, and feelings of inspiration were independently associated with PTG. At Wave 2, endorsement of spiritual growth during the pandemic was associated with 52% and 44% lower odds of screening positive for pandemic-related PTSD symptoms and burnout, respectively; greater improvement in relationships was associated with 36% lower odds of screening positive for burnout.
Limitations:
Single institution study and use of self-report instruments.
Conclusions:
Nearly 4-of-5 FHCWs report pandemic-related PTG, driven largely by salutogenic factors assessed during the pandemic surge. Interventions to bolster these factors may help promote PTG and mitigate risk for burnout and pandemic-related PTSD symptoms in this population.
... According to PTG scores, measured with the PTG Inventory (PTGI) and the PTG Inventory Short Form (PTGI-SF), the identified PTG levels ranged from low for nurses in ORIGINAL ARTICLE VOLUME 36 • NUMBER 2 • 2024 AOTEAROA NEW ZEALAND SOCIAL WORK New South Wales (NSW), Australia from September to November 2020 (Aggar et al., 2022), to moderate for nurses in China in June 2020 (Zhang et al., 2021), to high for nurses in Hubei Province, China from February to April 2020 (Mo et al., 2022). A study by Feingold et al. (2022) during the Covid-19 spring peak in 2020 and six months thereafter found that four out of five healthcare workers at a hospital in New York City, USA experienced moderate to high levels of PTG. However, there remains a need for more qualitative research to better understand the trajectory of PTG as a lived experience and provide the depth and richness of knowledge that is needed to efficiently foster PTG in the healthcare workforce. ...
... Another is the knowledge of social work theoretical models to inform thinking (Cui et al., 2021), including models of meaning-making (Feingold et al., 2022) and trauma (Moreno-Jiménez et al., 2021). For example: "Carl Jung … the work he did was so powerful. ...
... Their identification with social work and its culture, values, and theoretical concepts, might have increased the likelihood for the sample to experience PTG. This aligns with the findings that a higher occupational self-identification (Mo et al., 2022), psychoeducation (Moreno-Jiménez et al., 2021), and meaning-making (Feingold et al., 2022) increase the likel ihood of experiencing PTG. ...
INTRODUCTION: The Covid-19 pandemic posed major challenges to healthcare workers working on the front line. Their risk for negative mental health outcomes is well established, and a high volume of research has been directed at the causes, as well as measures to increase workers’ coping and resilience. Further, holistic and salutogenesis-oriented research is emerging directed at the origins of wellness and opportunities to grow after experiencing adversity. We contribute to this evolving research by qualitatively exploring the experience of transformational growth for social workers who worked in healthcare in Aotearoa New Zealand during Covid-19.
METHODS: We conducted semi-structured, online interviews with a sample of six social workers. Their accounts were analysed using an explorative semantic and interpretative form of reflexive thematic analysis, and five main themes were identified. The lens for analysis was Tedeschi and Calhoun’s post-traumatic growth (PTG) theory.
FINDINGS: Participants identified PTG in the form of an increased sense of self and self-identity. They reported significant vocational stresses and deep caring for their patients. They shared a strong occupational self-identification with the social work profession, which might have increased their likelihood of experiencing PTG. Most identified a transformational shift toward paying attention to their own needs.
CONCLUSION: These findings contribute to a new and more holistic perspective for our future pandemic response strategies. Further investigation is suggested to explore the identified shift in the balance between care for others and self-care within the profession.
Keywords: Post-traumatic growth; social worker; healthcare; Covid-19; pandemic; qualitative
... It adopted the Likert 6-point scale with a score of 0-100. Six studies [28,32,36,37,43,44] used a 10-entry short version of the PTGI scale (PTGI-SF), adopting a Likert 6-point scale with a total score of 0 to 50 [59]. Tedeschi et al. [60] updated the list with four new items in the spiritual and existential change subscale to better capture spiritual and existential change in nonreligious cultures, comprising PTGI-X with 25 items scored from 0 to 125 with a 6-point Likert scale. ...
... Researchers have also discovered that PTG was negatively correlated with trauma [28] and PTSD symptoms [47]. Another study indicated that PTG was positively correlated with PTSD [36]. ...
... Additionally, HCWs with religious beliefs [32,33], married [29], with children [39], and working part-time [32] had higher PTG levels. PTG levels differed between physicians and nurse assistants [43], and whether they were white [36] or born locally also differed from PTG levels [33]. Disaster training, rescue, critical patient resuscitation, and infectious disease treatment experience contribute to a higher PTG level [51]. ...
Background
The COVID-19 pandemic has imposed unprecedented stress and challenges upon medical staff, potentially resulting in posttraumatic growth (PTG). This scoping review aims to synthesize the existing knowledge on PTG among medical staff during the pandemic by identifying its current status and potential influencing factors. The findings may provide a foundation for future research and interventions to enhance the medical staff’s psychological resilience and well-being.
Methods
Literature was systematically searched on PTG among medical staff during the COVID-19 pandemic from 01 January 2020 to 31 December 2022. The following databases were searched: PubMed, Web of Science, Embase, CINAHL, PsycINFO, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), and Wanfang Data. Eligibility criteria included: (1) medical staff as research subjects; (2) a focus on “posttraumatic growth” or “alternative posttraumatic growth” related to the COVID-19 outbreak and pandemic; (3) discussion of the situation and influencing factors of PTG; and (4) study types, such as qualitative, quantitative, and mixed methods. Two researchers independently selected and extracted study characteristics (study design, study population, region, measurement instruments, and primary outcomes) from the included literature. The data were synthesized qualitatively and descriptively.
Results
Thirty-six papers from 12 countries met the inclusion criteria. Moderate PTG levels were observed among healthcare workers during the COVID-19 pandemic, with emphasis on “interpersonal relationships,” “changes in life philosophy,” and “growth in personal competence.” Influencing factors included trauma exposure, sociodemographics, psychological characteristics (resilience and positive qualities), coping, and social support.
Conclusions
This review discovered moderate PTG levels among medical staff during the COVID-19 pandemic, with critical areas in interpersonal relationships, life philosophy, and personal competence. The identified influencing factors can inform future research and interventions to enhance healthcare workers’ psychological resilience and well-being.
... For example, after Hurricane Sandy, higher rates of PTSD symptoms were associated with greater posttraumatic growth [30]. Research has found that these ndings extend to survivors of interpersonal violence and cancer as well [32][33][34]. ...
... During the COVID-19 pandemic, studies indicated that healthcare workers under stress may have experienced moderate rates of posttraumatic growth, primarily in the areas of appreciation of life, improved relationships, and increased personal strength [34]. Studies conducted on posttraumatic growth during the pandemic in nurses, speci cally, offer similar ndings. ...
... The dependent variable for this study was PTG, measured by the Posttraumatic Growth Inventory Short-Form (PTGI-SF) [53] a validated (54,55) and widely used (30,56,57) measure assessing growth because of a stressful or traumatic event derived from the Tedeschi and Calhoun's original Posttraumatic Growth Inventory (PTGI) [58]. The PTGI-SF has been used with healthcare workers during the COVID-19 pandemic [34,59,60] and consists of ten items each with a 0-5 response scale. The PTGI-SF items were summed to create a sum score with a potential range of 0-50. ...
BACKGROUND – Few studies have assessed posttraumatic growth (PTG) in nursing populations during the pandemic. Literature is mixed regarding the moderating effect of support. The study's purpose was to evaluate the impact of negative occupational experiences (NOE) on posttraumatic growth and the potential moderating role of various supports among a sample of nursing staff during the COVID-19 pandemic.
METHODS – A self-report longitudinal survey was sent to nursing staff within a large health system. Only baseline data (Fall 2022) were analyzed for this study. Linear regression modeling was used.
RESULTS –816 nursing staff participated. After adjusting for covariates, NOE and organizational support were associated with a moderate increase in PTG. Resilience was found to moderate the relationship between NOE and PTG in a simple interaction model.
CONCLUSION – Given the association between NOE and PTG, fostering PTG in the context of occupational stress may be important to preserving mental health among nursing staff.
... A recent review [11] and our own search identified no studies quantitatively evaluating post-traumatic growth in response to the pandemic amongst healthcare staff in the United Kingdom, and no studies internationally assessing growth specifically in mental health or community healthcare workers. Whilst surveys of healthcare workers in the United States of America and China have identified high levels of post-traumatic growth during the pandemic [12,13], the United Kingdom workforce has faced specific challenges which may have led to a different experience. These include the widely critiqued delayed government response to the pandemic, largescale redeployment of staff within the nationalized public health system, and lower public compliance with measures than in Asian countries, in the context of a workforce already threatened by Brexit and the fourth-lowest number of hospital beds per 1000 population among the G-20 countries [14][15][16][17][18]. Additionally, the pandemic has brought specific challenges for community and mental healthcare staff which merit focus. ...
... The findings suggest that employee growth can be promoted by encouraging staff to undertake positive self-reflection activities, such as mindfulness and meditation, and providing access to regular guided teaching and prac-tice. Organisations should facilitate staff to reflect on how they have been affected by the pandemic, encourage viewing the pandemic as both a crisis and as an opportunity to improve on the status quo, and provide opportunities for reflective processing of traumatic memories and anxieties in a supportive context [12,71]. Specific interventions that are helpful for facilitating this type of reflective processing and a growth mindset may include the use of appreciative enquiry during supervision, which involves asking staff to share narratives about times when the organization and its people were successful and satisfied, together with questions about the future to help envision strategies and action towards positive change [72]. ...
... Corresponding with our findings, a number of studies conducted in the USA have found that non-white ethnicity predicts greater post-traumatic growth, including in flood survivors, cancers survivors, sexual assault survivors, military veterans, and older adults and frontline healthcare workers during the COVID-19 pandemic [12,[74][75][76][77][78]. Black and minority ethnic healthcare staff in our study were exposed to a wealth of evidence via the media that they were at higher risk of serious illness or death if they contracted COVID-19. ...
Experiences of adversity can generate positive psychological effects alongside negative impacts. Little research to date has evaluated predictors of post-traumatic growth in mental or community healthcare workers during the COVID-19 pandemic. Following a survey of 854 community and mental healthcare staff in the United Kingdom in July to September 2020, multiple linear regression was used to determine the association between hypothesised risk and protective factors (personal, organisational and environmental variables) and total scores on the Post-traumatic Growth Inventory–Short Version. Positive self-reflection activities, black and minority ethnic status, developing new healthcare knowledge and skills, connecting with friends and family, feeling supported by senior management, feeling supported by the UK people, and anxiety about the personal and work-related consequences of COVID-19 each significantly independently predicted greater post-traumatic growth. Working in a clinical role and in mental healthcare or community physical healthcare predicted lower post-traumatic growth. Our research supports the value of taking an organisational growth-focused approach to occupational health during times of adversity, by supporting staff to embrace opportunities for personal growth. Valuing staff’s cultural and religious identity and encouraging self-reflective activities, such as mindfulness and meditation, may help to promote post-traumatic growth.
... Despite the negative traumatic impact of the frontline experience on HCWs [66,67], the positive responses triggered by this experience should be considered [68]. To this end, PTG outcomes in HCWs who are engaged in the pandemic response have been examined extensively [35,67,[69][70][71][72][73][74]. Consistent with these studies, our survey showed greater PTG in the 'Appreciation of Life' dimension-i.e., in the redefinition of priorities and life value following the event-and in the 'New Possibilities' dimension, at the expense of 'Spiritual Change', which was the least represented dimension. ...
... Consistent with these studies, our survey showed greater PTG in the 'Appreciation of Life' dimension-i.e., in the redefinition of priorities and life value following the event-and in the 'New Possibilities' dimension, at the expense of 'Spiritual Change', which was the least represented dimension. However, in contrast to some surveys [35,67,73], 54% of our sample scored at or below the average of the normative sample in the "Personal Strength" dimension; thus, despite its presence, it highlights the perceived lack of growth of health professionals. In our sample, the "Relating to Others" dimension was not significant, in contrast to other studies [35,67] in HCWs who care for COVID-19 patients, perhaps because the study by Feingold and colleagues was conducted during the first wave of the pandemic, in 2020, when levels of social attention and consideration toward HCWs were high. ...
... However, in contrast to some surveys [35,67,73], 54% of our sample scored at or below the average of the normative sample in the "Personal Strength" dimension; thus, despite its presence, it highlights the perceived lack of growth of health professionals. In our sample, the "Relating to Others" dimension was not significant, in contrast to other studies [35,67] in HCWs who care for COVID-19 patients, perhaps because the study by Feingold and colleagues was conducted during the first wave of the pandemic, in 2020, when levels of social attention and consideration toward HCWs were high. We speculate that the initial state of fear and uncertainty, combined with the media and social impact, influenced growth with respect to the perception of solidarity and communal closeness, and that it decreased in the long term. ...
Background:
Although the COVID-19 pandemic had an impact on the general population, health care workers (HCWs) constituted one of the groups that were most adversely affected by the associated risks, owing to the significant consequences on their mental health. This study examined these psychological effects on HCWs who cared for COVID-19 patients who were admitted to the intensive care unit in an Italian hospital.
Methods:
Subjects were administered several self-reported questionnaires: Kessler 10 Psychological Distress Scale (K10), Perceived Stress Scale-10 (PSS), Impact of Event Scale Revised (IES-R), and Post-traumatic Growth Inventory (PTGI), as well as two open-ended questions oriented toward understanding their positive and negative emotional experience and differentiating between two phases of the emergency.
Results:
Overall, 45% of HCWs showed medium-to-high anxiety/depressive symptoms, whereas 60% presented with medium-to-high levels of perceived stress. In addition, 37% of subjects developed symptoms of PTSD and 50% showed post-traumatic growth in the "appreciation of life" and "new possibilities" dimensions. With regard to the open-ended questions, three themes were identified: quality of workplace relationships, sense of emotional-relational competence, and sense of clinical-technical competence. In addition, two macrocategories of responses were identified in the answers: growth and block.
Conclusions:
The mental health of HCWs who are involved in the front line of COVID-19 was significantly impacted by this experience, showing high levels of post-traumatic stress and anxiety and depressive symptoms more than 1 year after the emergency began. A qualitative analysis of staff experiences can be a useful guide for structuring interventions and prevention.
... People exposed to COVID-19 may also experience PTG. Empirically, researchers have examined the prevalence of COVID-19 related PTG and found moderate to high levels detected among healthcare workers Finstad et al., 2021;Lyu et al., 2021;Moreno-Jiménez et al., 2021;Yıldız, 2021;Feingold et al., 2022) and American veterans (Pietrzak et al., 2021) as well as low levels among adolescents (Jian et al., 2022;Ulset and Soest Von, 2022) and young adults (Hyun et al., 2021). ...
... Regarding the specific dimensions of PTG, spiritual change scored the highest, followed by appreciation of life, personal strength, relating to others, and new possibilities. Given that the total and subscale scores were non-normally distributed (all Shapiro-Wilk test p values <0.0001), scores were dichotomized so that responses of "moderate, " "great, " or "very great" growth indicated a positive endorsement of PTG (Pietrzak et al., 2021;Feingold et al., 2022). In the current sample, 65.4% endorsed at least moderate levels of PTG. ...
... These results were supported by a previous study, which found that 66.9% of Chinese college students had experienced PTG during the COVID-19 pandemic (Chi et al., 2020). Additionally, while the prevalence of the COVID-19 related PTG in the present sample is lower than the 77% rate reported among healthcare workers (Feingold et al., 2022), it is markedly higher than the previous prevalence observed among home-confined Chinese adolescents (20.6%; Jian et al., 2022), Norwegian adolescents (9.6%; Ulset and Soest Von, 2022), and American veterans (43.3%; ...
Despite considerable disruption of social order caused by the COVID-19 pandemic, it has also been said to contribute to positive psychological changes and influence on the perception of public life satisfaction. The present study aimed to explore the association between the COVID-19 related posttraumatic growth and life satisfaction and the mediating role of personal values. A two-wave longitudinal design was used. 226 self-quarantined Chinese college students (58.8% male) completed post traumatic growth inventory (Time 1), satisfaction with life scale (Time 2), personal values questionnaire (Time 2) between February 2020 and May 2021. Results showed that more than half of self-quarantined Chinese college students reported moderate to high levels of the COVID-19 related posttraumatic growth. A structural equation model revealed that COVID-19 related posttraumatic growth was positively associated to life satisfaction, and self-transcendence and self-enhancement values partially mediated this association. These findings shed light on whether and how pandemic-related posttraumatic growth influenced personal life satisfaction, supporting the outcome and process perspectives of posttraumatic growth as well as Schwartz’s value theory. Based on the findings, some positive psychology interventions, such as online rumination activities and mindfulness practice, were proposed to enhance self-quarantined college students’ posttraumatic growth and life satisfaction.
... Pietrzak et al. (2021), working with veterans who had screened positive for COVID-19 and associated PTSD symptoms, found post-traumatic growth and improvements in the categories of relating to others, personal strength, and appreciation of life [40]. Frontline healthcare workers have also experienced much greater incidences of mental health consequences, including burnout, emotional exhaustion, and moral injury with the onset of the COVID-19 pandemic [41,42]. However, Feingold et al. (2022) reported moderate or great post-traumatic growth in appreciation of life, improved relationships, and improved personal strength [41]. ...
... Frontline healthcare workers have also experienced much greater incidences of mental health consequences, including burnout, emotional exhaustion, and moral injury with the onset of the COVID-19 pandemic [41,42]. However, Feingold et al. (2022) reported moderate or great post-traumatic growth in appreciation of life, improved relationships, and improved personal strength [41]. Further, Menculini et al. (2021) report growth in the general population with females reporting greater levels of post-traumatic growth in the areas of appreciation of life and personal strength compared to males, with many participants reporting no growth [43]. ...
Moral injury is a psychological wound resulting from deep-rooted traumatic experiences that corrode an individual’s sense of humanity, ethical compass, and internal value system. Whether through witnessing a tragic event, inflicting injury on others, or failing to prevent a traumatic injury upon others, moral injury can have severe and detrimental psychological and psychosomatic outcomes that may last a lifetime. Post-traumatic experiences do not have to be a permanent affliction, however. From moral injury can come post-traumatic growth—the recovery from trauma in which personal betterment overshadows moral injury. Moral injury may lead to substantial personal growth, improved capacity and resilience. Based on these observations, it seems that from struggles and darkness, there can be positivity and hope. This review will summarize the current concepts of post-traumatic growth and consider potential mechanisms leading to resilience and recovery through post-traumatic growth. These considerations are gaining more importance in light of a growing number of existential threats, such as violent conflicts, natural disasters and global pandemics.
... It has been suggested that people enduring traumatic or challenging events may not only develop PTSD symptoms but also experience positive changes, referred to as post-traumatic growth (PTG), and entailing different dimensions of one's life (such as an increased appreciation for life, more meaningful interpersonal relationships, an increased sense of personal strength, changes in one's priorities, a richer spiritual life) [3,4]. To the best of our knowledge, the few studies considering the role of PTG during the COVID- 19 pandemic have only been conducted on specific HWs populations (e.g., nurses) [5][6][7], and none have been conducted in Italy so far. ...
... Secondly, spiritual growth, while being the PTGI-SF dimension with the lowest mean score, was found to reduce the odds for PTSD. This finding aligns with a recent study showing the lowest PTGI-SF domain endorsement in spiritual growth among HWs tackling the first wave of COVID-19 at an urban hospital in NYC [5]. Interestingly, the same study found an association between spiritual growth endorsement and lower odds of screening positive for pandemic-related PTSD symptoms 7 months after the first wave, suggesting that the positive effect of PTG may last across time or even arise at some point during the process of adjusting to trauma. ...
Post-traumatic growth (PTG) and specific traumatic events have been poorly explored in the literature focusing on post-traumatic stress disorder (PTSD) among healthcare workers (HWs) tackling the COVID-19 pandemic. In a large sample of Italian HWs, we investigated the kinds of traumatic events and whether PTG affects the risk of PTSD, along with its prevalence and features, during the first COVID-19 wave. COVID-19-related stressful events, Impact of Event Scale-Revised (IES-R) and PTG Inventory-Short Form (PTGI-SF) scores were collected through an online survey. Out of 930 HWs included in the final sample, 257 (27.6%) received a provisional PTSD diagnosis based on IES-R scores. Events referring to the overall pandemic (40%) and to a threat to a family member (31%) were reported as the most stressful events. Female sex, previous mental disorders, job seniority, unusual exposure to sufferance and experiencing a threat to one’s family significantly increased the provisional PTSD diagnosis’ risk, while being a physician, the availability of personal protective equipment and moderate/greater scores on the PTGI-SF spiritual change domain were found to be protective factors.
... Following the research, COVID-19 can be accepted as a traumatic work-related event experienced by HCWs (Finstad et al., 2021). In addition, a few researchers have focused on investigating the positive consequences of COVID-19 on HCWs Feingold et al., 2022). According to the related research findings, the HCWs who actively worked in COVID-19-related departments (e.g., intensive care units) can experience PTG Feingold et al., 2022;Peng et al., 2021). ...
... In addition, a few researchers have focused on investigating the positive consequences of COVID-19 on HCWs Feingold et al., 2022). According to the related research findings, the HCWs who actively worked in COVID-19-related departments (e.g., intensive care units) can experience PTG Feingold et al., 2022;Peng et al., 2021). There have been controversial findings on whether PTG is an independent construct from post-traumatic stress (Shand et al., 2015) or is significantly positively or negatively related to post-traumatic stress ( _ Ikizer et al., 2021). ...
The COVID‐19 pandemic threatens health‐care workers' (HCW) mental health and well‐being. Although traumatic life events may result in psychiatric disorders, occasionally they give rise to positive changes, such as post‐traumatic growth. Accordingly, the present study evaluated the traumatic stress, anxiety, and depression levels of HCWs and their post‐traumatic growth levels during the pandemic. In addition, the study aimed to assess the changes in psychological outcomes during the pandemic. For this aim, the data were collected in two different periods. The first data‐collection period was between May and July 2020, and the second period started in November 2020 and ended in January 2021. The sociodemographic data form, Impact of Events Scale‐Revised (IES‐R), Generalized Anxiety Disorder‐7 (GAD‐7), Patient Health Questionnaire‐9 (PHQ‐9), and Post‐traumatic Growth Inventory (PTGI) were used to collect data. Sixty‐six HCWs participated in the study. No significant differences appeared between the baseline scores and 6‐month follow‐up in the depression, anxiety, and traumatic stress levels of HCWs. Furthermore, the PTGI scores decreased significantly over time. Although the change in the psychological distress scores was not statistically significant, the depression and post‐traumatic stress scores increased over time. Previous research specified an inverse‐parabolic relationship between traumatic stress and PTGI. Our results support previous research; as the exposure to the stressors continues, individual traumatic stress levels increase, psychiatric disorders become frequent, and affirmative changes (like post‐traumatic growth) decline.
... Cui et al. also assert that nurses' PTG can be facilitated through individual and organizational intentional constructive reflection on work experience, identification of the significance of experiences, and mobilization of personal resources; again, these factors were part of the narrative responses of nurses in this study bolstering evidence of the relationship between resilience and PTG. However, the study highlights the need for further research into PTG, particularly its relationship to salutogenic factors such as positive cognitions and emotions, personal strengths, relationships, etc. (Feingold et al., 2022). ...
[This article represents an earlier extended version of the article, Blaney et al. (2024) of the same title in the journal, Adversity and Resilience Science.]
... Cui et al. also assert that nurses' PTG can be facilitated through individual and organizational intentional constructive reflection on work experience, identification of the significance of experiences, and mobilization of personal resources; again, these factors were part of the narrative responses of nurses in this study bolstering evidence of the relationship between resilience and PTG. However, the study highlights the need for further research into PTG, particularly its relationship to salutogenic factors such as positive cognitions and emotions, personal strengths, relationships, etc. (Feingold et al., 2022). ...
This study explored the effectiveness of targeted resilience education on the resilience scores of nurses. It is known that higher resilience scores are corelated to better mental health. This study measured changes in resilience scores before and after resilience education; statistically significant increases in resilience scores was noted immediately following resilience and sustained at 2 months post-education.
... The COVID-19 pandemic as a public health emergency could be considered a traumatic event closely related to medical staff. Previous studies have revealed that a total of 76.8% of medical staff at a tertiary care hospital in New York, USA, recognized moderate or higher PTG associated with COVID-19 pandemic (Feingold et al., 2022). In several other studies, it has been demonstrated that the COVID-19 pandemic also has a positive impact on medical staff, such as experiencing PTG (R. Chen et al., 2021). ...
In the context of the Corona Virus Disease 2019 (COVID-19) pandemic, medical staff have experienced traumatic stress events. Research on post-traumatic growth (PTG) was limited. We aimed to assess the relationship between perceived social support and PTG among medical staff 3 weeks after the policy opening of COVID-19 pandemic in Nanjing, China and explore the mediating roles of deliberate rumination. A multicenter study including a total of 842 medical staff was conducted at two general hospitals from December 10, 2022, to December 25, 2022, in Nanjing, China. SPSS was used for statistical description and univariate analysis, and AMOS was used for structural equation modeling (SEM) to analyze the medicating effect of deliberate social support on PTG. In the SEM, the total effect of perceived social support on PTG was significant (β = .332, 95% CI [0.259, 0.408], p < .001). In addition, deliberate rumination played a mediating role between perceived social support and PTG, and the indirect effect of deliberate rumination between perceived social support and PTG was −.036 (95 % CI [−0.059, −0.018], p < .001). Perceived social support has significant direct and indirect effects on PTG. In the context of major public health emergencies, providing medical staff with more social support and guiding them to reflect positively could help medical staff achieve PTG after experiencing a traumatic event.
... 2024; 4:923 6 growth and mitigate the risk of PTSD symptoms. (20) The COVID-19 pandemic and its impact on the mental health of diverse populations is an evolving area of research, and the factors that may be related to PTSD in healthcare workers are still being understood. ...
Introduction: post-traumatic stress is a potential psychological and behavioral consequence of exposure to a traumatic event, characterized by the inability to overcome an unpleasant experience. Medical students, especially during their internships, often encounter stressful situations and challenges.Objective: this study aims to investigate the psychological impact of the COVID-19 pandemic on medical interns and identify the clinical and epidemiological factors associated with PTSD.Methods: this cross-sectional observational study utilized the Posttraumatic Stress Disorder Symptom Severity Scale and a validated form for clinical and epidemiological factors. The study was conducted with medical students from the Universidad Privada San Juan Bautista and Universidad Nacional San Luis Gonzaga. Data analysis was performed using SPSS Version 25. Results: this study revealed that 47,1 % of medical interns experienced low levels of post-traumatic stress, 42,5 % experienced moderate levels, and 10,3 % experienced high levels. Clinical and epidemiological factors that showed a statistically significant correlation (p<0,05) with post-traumatic stress included working extra shifts, caring for COVID-19 patients, having infected relatives, and experiencing harassment or verbal aggression from patients, colleagues, or other hospital staff. Conclusion: this study suggests that clinical and epidemiological factors, such as caring for COVID-19 patients, working extra shifts, and experiencing harassment or verbal aggression from patients or colleagues, are associated with post-traumatic stress in medical interns
... Therefore, adaptive CER appears to potentially reduce the negative effects resulting from stress events, such as BO. Reflective rumination can reduce symptoms of depression, anxiety (39), and the risk of stressrelated symptoms and BO (40) by promoting the processing of information and meaning related to traumatic events. This aligns with previous findings suggesting that deliberate thinking about traumatic events can mitigate psychological distress by modifying pathological thought patterns (41,42). ...
Objective
The study aims to investigate factors that prevent burnout (BO) and symptoms of posttraumatic stress disorder (PTSD) while facilitating posttraumatic growth (PTG) among nurses combating the coronavirus disease 2019 (COVID-19) pandemic, with the purpose of validating the mediating effects of PTG.
Methods
A total of 247 nurses who provided patient care during the COVID-19 pandemic were enrolled, and a questionnaire was used to measure BO, PTSD, and PTG, data on deliberate rumination, emotional expression, adaptive cognitive emotion regulation (CER), maladaptive CER, and social support. The mediation path models for the effects of the predictors on BO and PS through the mediation of PTG were analyzed using the R Lavaan package.
Results
The results showed that deliberate rumination, emotional expression, and adaptive CER significantly increased PTG, while PTG significantly reduced BO and PTSD symptoms (PSs). However, maladaptive CER did not have a significant effect on PTG and only had significant direct effects on BO and PS. Bootstrapping confirmed that PTG significantly mediated the effects of all predictors. It partially mediated the effects of deliberate rumination and adaptive CER and completely mediated the effects of emotional expression.
Conclusion
Based on the results, it has been supported that deliberate rumination, emotional expression, and adaptive CER should be addressed as important variables in psychological interventions addressing nurses’ adversities during the pandemic. These variables can prevent BO and PS by facilitating PTG.
... Our findings also highlight altruism and moral commitment of healthcare providers during the pandemic, a finding consistent with existing literature. 22 COVID-19 pandemic also brought positive outcomes, such as self-reflection and greater awareness of family bonding. The pandemic underscores the human connections, as people yearned for social interaction and a sense of community. ...
Rapid communication describes the multifaceted impact of the COVID-19 pandemic on three stakeholder groups: family caregivers of COVID-19 patients, frontline health workers attending to COVID-19 patients, and hospital-discharged COVID-19 patients. This communication aims to provide a nuanced understanding of the challenges faced by each group and their experience during the critical period of the pandemic. Three descriptive qualitative studies were conducted between July 2020 and November 2021, using individual in-depth interviews and focus group discussions. Participants were selected purposively. The findings of the three studies were collated in this rapid communication to compare the unique perspectives of the different stakeholders. Thematic analysis led to categories of Varied challenges and family realities, Accepting risks, Support, and Unexpected positive outcomes. These findings emphasise the need for context-specific dissemination of public health messages, particularly in densely populated urban areas. Policymakers are urged to consider the diverse challenges faced by different groups when formulating pandemic response strategies. Overall, this study provides valuable insights into the intricacies of navigating public health crises, fostering a deeper understanding of human connections and resilience during challenging times.
... The high prevalence of PTG was in line with a study conducted among New York healthcare workers seven months after the first wave of the pandemic there. It showed that 76.8% of them had moderate to high PTG (Feingold et al., 2022). ...
The pandemic is a major public health crisis, which may bring post-traumatic stress disorder (PTSD) as well as post-traumatic growth (PTG) to healthcare professionals. The current study aimed to assess coexistence patterns of PTSD and PTG among healthcare workers during the first outbreak of Corona Virus Disease 2019 (COVID-19). It also explored whether social support and self-disclosure could predict group membership. The questionnaire survey was conducted among Chinese front-line healthcare workers three months after the first outbreak of COVID-19, and 500 valid responses were obtained. Latent class analysis (LCA) was used to analyze the data, and logistic regression was used to examine the predicting effect of social support and self-disclosure. Four latent classes were identified: low PTSD/high PTG (Class 1, 53.2%), moderate PTSD/high PTG (Class 2, 28.0%), moderate PTSD/moderate PTG (Class 3, 6.4%), and high PTSD/high PTG (Class 4, 12.4%). None of the demographic information predicted the membership. Members with “low PTSD/high PTG” were associated with high social support and high self-disclosure of distress. Meanwhile, social support and self-disclosure differentiated those with the same moderate level of PTSD but showed higher or lower PTG. The results of this study confirmed that PTSD and PTG coexist among frontline healthcare workers, and PTG is prominent among them. Social support and self-disclosure are protective factors for low-stress and high-growth combinations.
... Fourth, the results of this study confirming that that the total score for PTG represented a moderate growth level. This is consistent with findings from a 2020 study in the United States (Feingold et al.,2022). A study in China in the early days of the COVID-19 outbreak revealed high levels of PTG (Cui et al., 2021), and HCWs in Greece also reported moderate to low levels of PTG (Kalaitzaki et al.,2022). ...
To understand the level of post-traumatic growth (PTG) and influencing factors among front-line healthcare workers (HCWs) working in mobile cabin hospitals treating patients with Coronavirus Disease 2019 (COVID-19) under the Normalized Epidemic Prevention and Control Requirements adopted in China. A random sampling method was used to select 540 HCWs of the Chongqing-aid-Shanghai medical team from April to May 2022 as the study participants. Participants completed a general information questionnaire, the Post-traumatic Growth Inventory-Chinese version (PTGI-C), the Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) and the Chinese Event Related Rumination Inventory (C-ERRI). Among the 540 included HCWs, 83.15 % were nurses and 78.89 % were women. The average scores for PTG (62.25 ± 16.73) and psychological resilience (64.22 ± 15.38) were at moderate levels, and the average score for rumination was low (21.62 ± 10.77). Pearson correlation analysis showed that CD-RISC and C-ERRI scores were positive with the PTGI-C score (r = 0.528, 0.316, P < 0.001). Multiple linear regression analysis identified psychological training or intervention during the COVID-19 epidemic (β = 2.353, P = 0.044), psychological resilience (β = 0.525, P < 0.001) and deliberate rumination (β = 0.732, P < 0.001) as factors significantly associated with the PTG of front-line HCWs, which together explained 36.8 % of the total variance in PTG (F[5,539] = 63.866, P < 0.001). In general, psychological resilience and deliberate rumination can promote PTG among HCWs and can be improved by strengthening psychological training and interventions for HCWs working under the Normalized Epidemic Prevention and Control Requirements.
... Findings from this study showed that health care professionals commonly experience PTG related to the COVID-19 pandemic, which is consistent with findings from previous surveys that focused on PTG among health care workers during the same crisis (Feingold et al., 2022;N. Zhang et al., 2023). ...
Objectives: Research on the use of strengths has suggested that it can promote individuals’ psychological health and well-being. This study aimed to examine the relationship between strength use and posttraumatic growth (PTG) in the context of COVID-19 pandemic among health care workers, as well as the mediating role of psychological capital in this relationship. Method: A total of 740 health care workers completed the Strengths Use Scale, the Positive Psychological Capital Scale, and the Posttraumatic Growth Inventory. Descriptive, correlational, and multiple mediation analyses were performed to analyze the data. Results: Participants of 55.9% reported experiencing significant PTG during the COVID-19 pandemic. The study found a significant and positive correlation between strength use, psychological capital, and PTG. In addition, the study found that self-efficacy and optimism, but not hope and resilience, mediated the linkage between strength use and PTG linked to the COVID-19 pandemic. The results also indicated that self-efficacy and optimism had equal importance in the strength use—PTG link. Conclusions: The study concludes that strength use is positively related to PTG in the context of the COVID-19 pandemic through the mediating roles of self-efficacy and optimism.
... For example, social support and optimism have been associated with greater mental health and well-being among U.S. combat veterans, 9/11 responders and survivors, and COVID-19 frontline healthcare workers (Adams et al., 2019;Feingold et al., 2021;Jacobson et al., 2018;Pietrzak et al., 2014;Southwick et al., 2016). Further, the work of Bonanno and others has established a key role for emotional and cognitive flexibility in adapting to traumatic events (Galatzer-Levy et al., 2012;Sardella et al., 2021); and finding meaning in traumatic events has been linked to recovery from traumatic stress-related conditions (Feingold et al., 2022). All these factors have well-validated standalone scales with varying instruction prompts and response options, making direct comparisons of resilience-promoting factors challenging; thus, having a single scale that assesses many aspects of resilience simultaneously may ease comparisons within and across studies and samples. ...
Objective: The construct of psychological resilience has received increasing attention in the mental health field. This article describes the development and initial validation of a novel self-report resilience scale, which addresses gaps in the resilience measurement literature by assessing thoughts and behaviors that help promote resilience rather than traits, and simultaneously evaluating multiple factors previously associated with resilience. Method: Following consensus meetings focused on scale development, we conducted an online study (n = 1,864) of U.S. adults to develop and validate an initial version of the Mount Sinai Resilience Scale (MSRS). Results: An exploratory factor analysis in a random 50% of the sample suggested a seven-factor solution; this solution was then generally supported by a follow-up confirmatory factor analysis in the remaining 50% of the sample. After removing poor-fitting items, a revised 24-item scale correlated in the expected directions with established measures of perceived resilience and resilience-related constructs (e.g., social support and optimism). Conclusions: Collectively, the results of this study provide initial support for the convergent and discriminant validity of the MSRS and describe its factor structure.
... 9,10 On the other hand, spiritual growth was found to be the PTGI-SF dimension with the lowest mean score, accordingly to recent data from literature. 11 Albeit concerns have been raised about the contribution of COVID-19 in suicide risk among HWs, 12,13 no studies evaluated whether PTG stemming from COVID-19 pandemic may exert a protective effect against SI. Greater improvement in Relating to others significantly reduced the odd of SI in our sample. ...
Objective
The COVID-19 pandemic impacted mental health across different groups, including healthcare workers (HWs). To date, few studies focused on potential positive aspects that may follow the exposure to the pandemic. We investigated the prevalence of posttraumatic stress disorder (PTSD) in Italian HWs and whether posttraumatic growth (PTG) dimensions affected the risk of suicidal ideation (SI) during the first COVID-19 wave.
Methods
An online self-report survey was conducted between April and May 2020. Sociodemographic data, information about COVID-19-related stressful events, Impact of the Event Scale-revised, and Post-Traumatic Growth Inventory-Short Form (PTGI-SF) scores were collected and compared between participants. Patient Health Questionnaire-9 scores were also collected to assess SI through item 9. Multivariate logistic regression was used to assess the relationship between PTGI and SI.
Results
Among 948 HWs, 257 (27.0%) reported a provisional PTSD diagnosis. The median PTGI-SF score was 24. Participants reporting PTSD symptoms had higher scores in the Spiritual change , Appreciation of life , and New possibilities domains, and in the total PTG scale. A total of 100 HWs (10.8%) screened positive for SI. Improvements in Relating to others domain of PTGI-SF (odds ratioOR: .46; 95% confidence interval: .25–.85) were associated with lower odds of SI.
Conclusions
COVID-19 pandemic has been indicated as a risk factor for SI, also among HWs. PTG may have a protective role on suicide risk. Improvements in Relating to others domain reduced odds of SI, consistently with the role of loneliness and lack of connectedness with others in enhancing suicidal risk.
... However, mixed studies on the comparison of specialized medical personnel with nurses indicated a 76.8% odds ratio of developing PTG. [28] It is not clear why nurses and students had a higher odds ratio of developing PTG. The research factors could not explain this causality because, first, the three groups were similar in terms of PTSD and mental distress, and second, differences in demographic factors, mean age, or marriage could not explain the cause as the average age of specialists was higher than nurses, but the incidence of PTG was higher in nurses than both medical students and specialists. ...
Objectives
The present study compared the prevalence and psychosocial factors affecting posttraumatic growth (PTG), posttraumatic stress disorder (PTSD), and psychological distress in nurses, physicians, and medical students.
Materials and Methods
In a cross-sectional study, three groups of medical staff including nurses ( n = 57), physicians ( n = 40), and medical students ( n = 34) who were responsible for the care/treatment of COVID-19 patients admitted to a general hospital for 4 months responded to Posttraumatic Growth Inventory, Brief Symptom Inventory-18, Resilience Questionnaire, PTSD Screen, and Social Capital-Integrated Questionnaire.
Results
After the exposure of medical staff to at least 4 months of treatment/care of COVID-19 patients, PTG prevalence was higher than PTSD (38.2% vs. 14.6%), but they experienced some degrees of psychological distress (65.5%). The nurses had 8.33 (confidence interval [CI]: 2.5–26.7) times higher PTG rate than medical students ( P < 0.001). Physicists also experienced 5.00 (CI: 1.4–26.7) times higher PTG than medical students ( P < 0.001). PTG was aided by age, married status, strong resilience, and high social capital, but gender had no influence. Resilience played an important protective role to prevent the incidence of psychological distress in nurses, medical students, and physicians.
Conclusion
Despite the fact that the PTSD and psychological distress were same in the three groups of medical staff, the nurses had a greater rate of PTG than physicians and medical students.
... 16 . Both studies reported a higher mean score compared to the current finding A study comprising frontline HCWs from New York in the US during the second wave reported that 76% HSWs experienced PTG 23 . ...
Objective: To evaluate post-traumatic growth experienced by medical doctors who served coronavirus disease-2019 patients. Method: The cross-sectional study was conducted from December 1, 2021, to February 28, 2022, at the Civil Hospital, Karachi, and comprised medical doctors of either gender aged >22 years who directly provided care for at least one month to coronavirus disease-2019 patients. Other than demographic and professional profile of the subjects, data was collected using the Post-Traumatic Growth Inventory, with total score ≥60 indicating a positive post-traumatic growth. Data was analysed using SPSS 22. Results: Of the 166 subjects approached, 150(90.3%) finished the study. There were 90(60%) females, 88(58.7%) were aged 25-35 years, 55(36.7%) were married, 107(71.3%) were postgraduate trainees, 79(52.7%) had 1-3 family members in the vulnerable groups, and 43(28.7%) had received any sort of psychological training. The mean post-traumatic growth score was 64.81±20.27 and 87(58%) doctors scored ≥60. The odds of experiencing post-traumatic growth for doctors with the number of vulnerable family members were significant (p<0.05). Doctors who had received psychological training before providing care to coronavirus disease-2019 patients showed higher odds of experiencing post-traumatic growth (p<0.05). Conclusion: Coronavirus disease-2019 resulted in substantial positive psychological growth for frontline doctors. Psychological training showed a significant role in post-traumatic growth.
... Network analysis revealed a strong positive association between pandemic-related and worst event-related PTG, as well as associations between symptoms of worst event PTSD and PTG, and symptoms of pandemic-related PTSD and PTG, but not between worst event PTSD and pandemic-related PTG or pandemic-related PTSD and worst-event PTG. Thus, our findings corroborate previous evidence indicating that many individuals experience pandemic-related PTG (Asmundson et al., 2021;Feingold et al., 2022) and that prepandemic Fig. 1. Networks of veterans at prepandemic (shown on the left) and the network at peripandemic (shown on the right). ...
Increases of symptoms of posttraumatic stress disorder (PTSD), anxiety and depression have been observed among individuals exposed to potentially traumatic events in the first months of the COVID-19 pandemic. Similarly, associations among different aspects of mental health, such as symptoms of PTSD and suicidal ideation, have also been documented. However, studies including an assessment prior to the onset and during the height of the pandemic are lacking. We investigated changes in symptoms of PTSD, depression, anxiety, suicidal ideation, and posttraumatic growth in a population-based sample of 1232 U.S. military veterans who experienced a potentially traumatic event during the first year of the pandemic. Symptoms were assessed prior to (fall/winter 2019) and one year into the pandemic (fall/winter 2020). We compared changes in symptom interrelations using network analysis, and assessed their associations with pandemic-related PTSD and posttraumatic growth symptoms. A subtle increase in psychopathological symptoms and a decrease in posttraumatic growth was observed one year into the pandemic. The peripandemic network was more densely connected, and pandemic-related PTSD symptoms were positively associated with age, anxiety, worst-event PTSD symptoms, and pandemic-related posttraumatic growth. Our findings highlight the resilience of veterans exposed to a potentially traumatic event during the first year of a pandemic. Similarly, the networks did not fundamentally change from prepandemic to one year into the pandemic. Despite this relative stability on a group level, individual reactions to potentially traumatic events could have varied substantially. Clinicians should individualize their assessments but be aware of the general resilience of most veterans.
... 16 . Both studies reported a higher mean score compared to the current finding A study comprising frontline HCWs from New York in the US during the second wave reported that 76% HSWs experienced PTG 23 . ...
Objective:
To evaluate post-traumatic growth experienced by medical doctors who served coronavirus disease 2019 patients.
Methods:
The cross-sectional study was conducted from December 1, 2021, to February 28, 2022, at the Civil Hospital, Karachi, and comprised medical doctors of either gender aged >22 years who directly provided care for at least one month to coronavirus disease-2019 patients. Other than demographic and professional profile of the subjects, data was collected using the Post-Traumatic Growth Inventory, with total score ≥60 indicating a positive post-traumatic growth. Data was analysed using SPSS 22.
Results:
Of the 166 subjects approached, 150(90.3%) finished the study. There were 90(60%) females, 88(58.7%) were aged 25-35 years, 55(36.7%) were married, 107(71.3%) were postgraduate trainees, 79(52.7%) had 1-3 family members in the vulnerable groups, and 43(28.7%) had received any sort of psychological training. The mean post traumatic growth score was 64.81±20.27 and 87(58%) doctors scored ≥60. The odds of experiencing post- traumatic growth for doctors with the number of vulnerable family members were significant (p<0.05). Doctors who had received psychological training before providing care to coronavirus disease-2019 patients showed higher odds of experiencing post-traumatic growth (p<0.05).
Conclusion:
Coronavirus disease-2019 resulted in substantial positive psychological growth for frontline doctors. Psychological training showed a significant role in post-traumatic growth.
... This concept focuses more on the individual's transcendence in psychological function or life consciousness than the pre-traumatic adjustment level. In recent years, with the outbreak of COVID-19, research on PTG among front-line nursing staff has gradually increased, analyzing their PTG experience, factors that influence their PTG, intermediary effects of PTG, and other aspects (Yim and Kim, 2022;Feingold et al., 2022;Cui et al., 2021；Atay et al., 2022Lyu et al., 2021). Psychological resilience is a positive adaptation process in which individuals respond to adversity, trauma, threat, or other major stresses (American Psychology Association,2022). ...
Psychological resilience helps individuals to actively respond to various emergencies, but its mediating role between the rumination and post-traumatic growth (PTG) of nurses remains unknown. Our study aimed to explore the extent to which psychological resilience mediates the association between rumination and PTG among nurses working in mobile cabin hospitals. This cross-sectional survey was conducted on 449 medical team members working in mobile cabin hospitals to support the prevention and control of coronavirus disease 2019 in Shanghai, China in 2022. Pearson correlation analysis was applied to assess the correlation between rumination, psychological resilience, and PTG. Structural equation models were used to examine the mediating role of psychological resilience between rumination and PTG. Our study results showed that deliberate rumination directly promoted psychological resilience and PTG and had positive effects on PTG through the mediating effect of psychological resilience. Invasive rumination had no direct effect on PTG. However, it had a negative effect on PTG through the mediating effect of psychological resilience. Together the results of this study indicate that the mediating effect of psychological resilience was significant in the association of rumination and PTG among mobile cabin hospital nurses, with a higher individual psychological resilience level helping nurses to achieve PTG. Therefore, targeted interventions should be implemented to improve nurses' psychological resilience and guide their rapid growth.
... This growth has been higher among nurses than in other groups (Beck et al., 2016;Lev-Wiesel et al., 2009;Taubman-Ben-Ari & Weintroub, 2008). Two studies of health workers during the COVID-19 pandemic showed moderate to high PTG (Feingold et al., 2022;Mo et al., 2021). It is also mentioned to apply an active coping style helps to improve the level of PTG (Mo et al., 2021). ...
Aim:
The purpose of this research was to identify the perceived stress coping strategies, and Post-Traumatic-Growth (PTG) among Iranian healthcare professionals.
Design:
A cross-sectional study was applied.
Methods:
This study was conducted among 402 healthcare professionals in northwestern Iran. Participants completed demographic, perceived stress, stress coping strategies, and PTG questionnaires. Multiple linear regression was employed to identify the predictors of perceived stress and PTG.
Results:
The overall score of perceived stress was calculated 30.55 (6.18). The problem-oriented strategy was the most common stress coping by healthcare professionals (52.66 (8.72)). Also, the total score of PTG was calculated at 45.72 (30.42). Perceived stress, stress coping strategies (except problem-oriented), and PTG scores were significantly different between hospital and health centres participants (p-value < 0.05). Previous experience in critical situations, crisis-related course, degree, age, department, and stress coping strategies were related to the stress level. Moreover, workplace, department, work experiences, and employment status were the predictors of PTG.
... EMDR therapy is an empirically supported treatment for psychological trauma, endorsed by the World Health Organisation (2013), United Nations High Commission for Refugees (2022) and the International Society for Traumatic Stress Studies (2019). It is a psychological treatment for pathogenic (trauma) memories and their associated stress symptoms using a model of pathogenesis and change known as adaptive information processing (Hase et al., 2017;Hase, 2021;Farrell et al., 2022;Laliotis and Shapiro, 2022;Wippich et al., 2023). ...
Objective
Frontline mental health, emergency, law enforcement, and social workers have faced unprecedented psychological distress in responding to the COVID-19 pandemic. The purpose of the RCT (Randomized Controls Trial) study was to investigate the effectiveness of a Group EMDR (Eye Movement Desensitization and Reprocessing) therapy (Group Traumatic Episode Protocol—GTEP) in the treatment of Post-Traumatic Stress Disorder (PTSD) and Moral Injury. The treatment focus is an early intervention, group trauma treatment, delivered remotely as video-conference psychotherapy (VCP). This early intervention used an intensive treatment delivery of 4x2h sessions over 1-week. Additionally, the group EMDR intervention utilized therapist rotation in treatment delivery.
Methods
The study’s design comprised a delayed (1-month) treatment intervention (control) versus an active group. Measurements included the International Trauma Questionnaire (ITQ), Generalized Anxiety Disorder Assessment (GAD-7), Patient Health Questionnaire (PHQ-9), Moral Injury Events Scale (MIES), and a Quality-of-Life psychometric (EQ-5D), tested at T0, T1: pre—treatment, T2: post-treatment, T3: 1-month follow-up (FU), T4: 3-month FU, and T5: 6-month FU. The Adverse Childhood Experiences – International version (ACEs), Benevolent Childhood Experience (BCEs) was ascertained at pre-treatment only. N = 85 completed the study.
Results
Results highlight a significant treatment effect within both active and control groups. Post Hoc comparisons of the ITQ demonstrated a significant difference between T1 pre (mean 36.8, SD 14.8) and T2 post (21.2, 15.1) (t11.58) = 15.68, p < 0.001). Further changes were also seen related to co-morbid factors. Post Hoc comparisons of the GAD-7 demonstrated significant difference between T1 pre (11.2, 4.91) and T2 post (6.49, 4.73) (t = 6.22) = 4.41, p < 0.001; with significant difference also with the PHQ-9 between T1 pre (11.7, 5.68) and T2 post (6.64, 5.79) (t = 6.30) = 3.95, p < 0.001, d = 0.71. The treatment effect occurred irrespective of either ACEs/BCEs during childhood. However, regarding Moral Injury, the MIES demonstrated no treatment effect between T1 pre and T5 6-month FU. The study’s findings discuss the impact of Group EMDR therapy delivered remotely as video-conference psychotherapy (VCP) and the benefits of including a therapist/rotation model as a means of treatment delivery. However, despite promising results suggesting a large treatment effect in the treatment of trauma and adverse memories, including co-morbid symptoms, research results yielded no treatment effect in frontline/emergency workers in addressing moral injury related to the COVID-19 pandemic.
Conclusion
The NICE (2018) guidance on PTSD highlighted the paucity of EMDR therapy research used as an early intervention. The primary rationale for this study was to address this critical issue. In summary, treatment results for group EMDR, delivered virtually, intensively, using therapist rotation are tentatively promising, however, the moral dimensions of trauma need consideration for future research, intervention development, and potential for further scalability. The data contributes to the emerging literature on early trauma interventions.
Clinical Trial Registration:Clinicaltrials.gov, ISRCTN16933691.
... 11 Second, we found evidence of improvements in character & virtue from before the COVID-19 pandemic to January 2022. This finding aligns with studies that have reported evidence of adversity-related growth during the COVID-19 pandemic, 43 in which the process of navigating challenging life circumstances leads to positive change and personal growth. 44 However, this general trend was not entirely homogenous, with increases in delayed gratification from January 2020 to January 2022 limited to middle and older adults. ...
Objectives:
Examine differences in multidimensional well-being from before (January 2020) to three timepoints during the COVID-19 pandemic (June 2020, January 2021, January 2022).
Study design:
Repeated cross-sectional design.
Methods:
Nationally representative cross-sectional cohorts of US adults completed the Secure Flourish Index before (January 2020 cohort: N = 1010) and during the COVID-19 pandemic (June 2020 cohort: N = 3020; January 2021 cohort: N = 3366; January 2022 cohort: N = 2598). We estimated differences in indicators, domains, and composite well-being between the January 2020 cohort and each of the subsequent cohorts. We also explored whether changes in well-being between January 2020 and January 2022 varied based on age, gender, and race/ethnicity.
Results:
Initial declines in well-being observed by June 2020 were largely followed by a return to prepandemic levels in January 2022, with some exceptions. Notably, general declines in mental health have persisted through to January 2022. On the other hand, there was evidence of general improvements in character & virtue that exceeded prepandemic levels in January 2022. Young adults and racial/ethnic minorities reported lower financial & material stability in January 2022 compared to before the COVID-19 pandemic.
Conclusions:
Although there are promising signs that the well-being of US adults has mostly recovered to prepandemic levels, a coordinated response is urgently needed to support population mental health and the financial security of vulnerable groups. As society continues the journey toward postpandemic recovery, continued tracking of multidimensional well-being will be important for making informed decisions about public health priorities.
... A study [59] found that 39.3% of nurses experienced post-traumatic growth during COVID-19 surveyed through the Posttraumatic Growth Inventory-Short Form [13] subscales of relating to others, new possibilities, personal strength, spiritual change and appreciation of life. Similarly, healthcare workers in China [60 , 61] , Greece [62] and New York City [63] evinced post-traumatic growth. Despite their anxiety, CT radiographers could still praise their adaptability and acknowledge the support of their team during COVID-19 [29] . ...
Introduction
At the onset of COVID-19 diagnostic radiographers from Gauteng, South Africa, shared their experiences of the new workflow and operations, their well-being and their resilience during this time. They experienced emotional, physical and financial fatigue. It is now over two years later, and South Africa has experienced four waves of COVID-19. Therefore, this study explored diagnostic radiographers' experience of COVID-19 after two years and four waves.
Methods
A qualitative explorative, descriptive and contextual study was conducted collecting data through nine virtual individual in-depth interviews. Responses from the diagnostic radiographers in Johannesburg, Gauteng South Africa, underwent thematic analysis.
Results
Thematic analysis revealed two themes and related categories. Theme one: participants shared synchronistic experiences with the four COVID-19 waves, the heterogeneous vaccination ideologies and their support and coping skills. Theme two: lessons learnt and the way forward.
Conclusion
Participants shared feeling overwhelmed at the onset of COVID-19 and feared infecting their family, friends and colleagues. However, their anxiety and fear decreased with time. They experienced the Delta variant as the worst and felt supported by their colleagues more than by management. They recounted observations of vaccine hesitancy but acknowledged that vaccination had alleviated some of the fear and anxiety. Participants' coping skills varied, and reflecting on their experience, they shared the lessons learnt and the way forward.
... Greater improvement in mental health between P1 a was seen in our BME than the Caucasian population. Studies focused on P1 have tended to find either no effect or an increased risk of poor mental health in BME HCWs [22][23][24]. The greater drop in symptoms amongst BME HCWs might reflect alleviation of the stress on the BME community that resulted from disproportionate deaths of BME HCWs in P1, where initially two thirds of the HCWs who died were BME [25]. ...
Background: COVID-19 had a huge impact on the wellbeing of healthcare workers (HCWs). This is well documented during the first peak of the pandemic. With cases in the UK rising for a third peak, hospitalisations and deaths surpassing the first, there is very little known about the mental health of HCWs during this time.
Methods: Using a questionnaire, data was collected from patient-facing staff at Barking, Havering, and Redbridge University Trust to quantify and compare the period prevalence of symptoms of depression, anxiety, and PTSD during the first peak (P1: March-May 2020) and third peak (P3: December 2020-Feburary 2021) of the COVID-19 pandemic as well as wellbeing service use, demographics of responders and what they found most difficult during the peaks.
Results: Of 158 responders, only 22·4% felt they had enough access to wellbeing services during P1 and 21·5% in P3. Of those who used wellbeing services 34·4% found them useful in P1 and 34·6% in P3. 70·3% of responders felt that not enough was done for staff wellbeing. The median anxiety score decreased from P1 (10(range 5-17)) to P3 (8(range 4-16)) p=0·031. Under 30-year-olds’ depression and PTSD scores increased from P1 to P3 (depression: P1 7(1-11), P3 8(3-14), p=0·048, PTSD: P1 4(0-7) peak 3 5(2-9), p=0·037). Several groups showed a decrease in anxiety scores from P1 to P3 including; over 30-year-olds (P1 10(5-17), P3 7(3-15) p=0·002), BME responders (P1 8(3·75-15) P3 6·5(1-12) p=0·006), AHP (P1 14(7-19), P3 11(5-19) p=0·005), ITU workers (P1 15(8-18·25) P3 12(5·75-18·25) p=0·004), and those who were redeployed (P1 8(5-18·25), P3 5(2-14·75), p=0·032).
Conclusion: We have observed changes in mental health symptoms within the study population as the peaks of the pandemic continue. With the majority of responders reporting they felt not enough had been done for their wellbeing support - and of those who used the wellbeing services only around 1/3 felt they were useful - we hope that this paper can help inform wellbeing provision and identify groups at higher risk of developing mental health symptoms.
... PTG has been observed among parents with critically or terminally ill children or children with acute health crises (Cadell et al., 2014;Colville & Cream, 2009;D'Urso et al., 2017;Hungerbuehler et al., 2011;Kim, 2017;Ogińska-Bulik & Ciechomska, 2016;Picoraro et al., 2014;Rodríguez-Rey & Alonso-Tapia, 2019); people with a wide range of health concerns including coronary health issues (Bluvstein et al., 2013;Hegarty et al., 2021;Kearns et al., 2019), cancer (Bussell & Naus, 2010;Casellas-Grau et al., 2017;Cormio et al., 2017;Danhauer et al., 2013Danhauer et al., , 2015Gori et al., 2021;Jim & Jacobsen, 2008;Marziliano et al., 2020;Paredes & Pereira, 2018;Rider Mundey et al., 2019;Zwahlen et al., 2010), stroke (Gangstad et al., 2009), physical disability (L. D. Goldberg et al., 2018), HIV infection (Pięta & Rzeszutek, 2022;Rzeszutek et al., 2019;Rzeszutek & Gruszczyńska, 2018;Sawyer et al., 2010), and chronic illnesses (Tolleson & Zeligman, 2019;Zeligman et al., 2018); survivors of natural (Bernstein & Pfefferbaum, 2018;Cameron et al., 2022;Cryder et al., 2006;Shang et al., 2020) and man-made disasters (Iwasa et al., 2019;Palgi et al., 2020), including earthquakes (Amiri et al., 2021;García & Wlodarczyk, 2018;Kesnold Mesidor, 2019;Zhou et al., 2020), fires (Palgi et al., 2020), floods (Boullion et al., 2020;Zeligman et al., 2019), hurricanes (Manove et al., 2019), tornadoes (Weber et al., 2019), and tsunamis (Siqveland et al., 2012); victims of crime, including victims of intimate partner violence (Arandia et al., 2018;Cobb et al., 2006;D'Amore et al., 2021), sexual violence (Burt & Katz, 1987;Sinko et al., 2022) sexual abuse (Ha et al., 2019), and childhood physical or sexual abuse (Schaefer et al., 2018); people in professions where exposure to danger or to the trauma of others is high (Armstrong et al., 2014;Chen et al., 2021;Chopko et al., 2017;Chopko & Schwartz, 2009;Feingold et al., 2022;Hyatt-Burkhart, 2014;Manning-Jones et al., 2015;McLean et al., 2011), and survivors of other distressing events. ...
Background. Posttraumatic growth (PTG)—positive changes that people may experience in the aftermath of highly distressing experiences—has been observed in survivors of a variety of events but has not been previously studied among people who have caused accidental death or injury (PCADIs). In addition, questions remain about the role, in PTG, of changes in the assumptive world and the relationships between PTG and distress, personality, and social support. Methods. Participants (N = 528), included PCADIs (n = 44) and a non-trauma comparison group (n = 484), who completed the Primals Inventory and measures of personality, anxiety, and depression. PCADIs (n = 43) also completed measures of PTG, PTG behavioral changes, social support and life satisfaction. Results. Modest levels of PTG commensurate with survivors of other relevant forms of distress were observed. Results demonstrated significant differences between primal world beliefs Good, Safe, Enticing, Just, Regenerative, Funny, and Improvable in PCADIs and non-trauma survivors as well as significant positive relationships between PTG and the primals Good, Safe, Alive, Just, Regenerative, Funny, and Improvable and between PTG and reported behavior changes related to PTG, but no significant relationships were found between PTG and distress, PTG and social support, or PTG and personality traits Extraversion, Openness to Experience, Conscientiousness, or Agreeableness (though a significant negative relationship was observed between PTG and Neuroticism). Conclusions. PCADIs may experience PTG that both influences and is influenced by primal world beliefs, but the hypothesized relationships between PTG and distress, personality, and social support were not observed. Additional studies with larger PCADI populations may find these relationships exist at a statistically significant level. And future research should aim to develop interventions addressing the distress and growth potential of this population.
... feelings could be indications of imminent, or existing, conditions such as burnout, depression, and PTSD, as well as intensions to resign. These feelings and conditions were, amongst others, identified as being prevalent among COVID-19 health care workers (29)(30)(31)(32)(33) although not unknown prior to this pandemic. (34) It is important therefore for organisations and policymakers in LMICs to develop support structures after the pandemic to ensure recovery and retention of scare healthcare human resources. ...
In March 2020, the World Health Organisation declared COVID-19 a global pandemic. Shortly after the first case of COVID-19 was reported in South Africa, the Western Cape province experienced a rapid growth in the number of cases, establishing it as the epicentre of the disease in South Africa. The aim of this study was to explore emergency care personnel’s lived experiences and their perceptions thereof within the context of the COVID-19 pandemic in the Western Cape province. This study followed a longitudinal hermeneutic phenomenological approach. The convenience sample included prehospital and emergency centre medical personnel. Data were collected over a 4-month period using both one-on-one interviews and participant recorded voice recordings. Data were analysed following Ricoeur’s theory of interpretation. Four themes were generated during the data analysis: 1) In the beginning, waiting for the unknown; 2) Next, change and adaptation in the workplace; 3) My COVID-19 feelings; 4) Support and connection. Participants discussed the uncertainty associated with responding to an unknown threat and a need to keep up with constant change in an overburdened work environment. Results showed high levels of uncertainty, restriction, fear, anxiety, and exhaustion. Despite these difficulties, participants demonstrated resilience and commitment to caring for patients. A need for support was also highlighted. Results indicated that change, over time, resulted in adaptation to a new way of practising and keeping safe. Healthcare workers experienced intersecting consequences as frontline healthcare workers and members of the public, all of which impacted their well-being. The importance of compassion and encouragement as forms of support was highlighted in the study. Robust and sustained support structures in a time of change, low mood, and exhaustion are essential.
... However, there was no guidance to support redeployed healthcare workers in China. It is crucial to recognise that they will need sufficient measures in place to support this unique transition in order to provide the best care for patients and ensure a safe working environment [56,57]. ...
Introduction
Public health responses were triggered while COVID-19 was spreading. China redeployed healthcare workers to serve the most vulnerable populations and communities in the initial epicentre—Wuhan. However, it is not known how redeployment processes impacted on healthcare workers in a pandemic crisis.
Aims
To explore the experiences and needs of frontline healthcare workers who were redeployed to care for COVID-19 patients in Wuhan, China, and understand the long-term impacts of the redeployment experience on their work and life.
Methods
A qualitative study was conducted with redeployed healthcare workers using semi-structured interviews and thematic analysis. This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines.
Findings
A total of 20 redeployed healthcare workers (13 nurses and seven physicians) participated, and four themes were generated: (1) Initial feelings and emotions of redeployment—Participants experienced worries and concerns, a sense of isolation and loneliness on their arrival to the epicentre. (2) ‘It is like a war zone’—Healthcare workers faced a range of risks and challenges of caring for COVID-19 patients in Wuhan in the context of resource strain. (3) Uncertainty and coping strategies in patient care—Despite the hardships experienced, participants continued to deliver high-quality patient care including psychological care and palliative care, good communication and building mutual trusting relationships. (4) Reflection and far-reaching impacts of caring for COVID-19 patients—Participants felt motivated and encouraged as efforts were recognised by the government and wider society.
Conclusions
Redeployed healthcare workers shared their unique needs and experiences of coping with redeployment and challenges they faced in the context of resource strain, which has significant implications for policy and future practice. The reality of a pandemic may reduce healthcare workers’ willingness to work due to various reasons including inadequate preparedness of facilities and workplace safety. It is important to support frontline healthcare workers in order to maintain an adequate healthcare workforce in pandemic crises. Continuously evolving pandemic circumstances and uncertainty highlight the importance of an organized national pandemic response plan for subsequent waves of COVID-19 and future pandemics.
Although COVID-19 brought many negative psychological consequences, many people also experienced psychological growth. The present study investigated why this happened and hypothesized that self-determination theory’s (SDT’s) basic psychological needs (BPNs) may play a role in this explanation. Based on SDT, this cross-sectional study hypothesized that both the satisfaction and frustration of BPNs mediated the associations between fear of COVID-19, post-traumatic growth (PTG), and post-traumatic stress (PTS) symptoms. A sample of 391 Peruvian adults (70.6% women; Mage = 35.04, age range between 18 and 84) responded to several valid and reliable questionnaires: Fear of COVID-19 Scale (FCV.19S); Basic Psychological Needs Satisfaction and Frustration Scale (BPNSFS); Impact Event Scale-Revised (IES-R); Post-Traumatic Growth Inventory (PTGI). The results showed that need satisfaction mediated the negative association between fear of COVID-19 and PTG, and need frustration mediated the positive association between fear of COVID-19 and PTG. In addition, a direct effect was found from fear of COVID-19 toward PTS symptoms. The results showed the importance of considering SDT’s BPNs in explaining PTG and PTS after experiencing fear of COVID-19.
Medical social workers (MSWs) engage in complex and demanding work that inevitably affects their professional well-being. A public health disaster like coronavirus disease 2019 (COVID-19) exacerbates the effects. This study aims to classify the professional quality of life (ProQOL) of MSWs during COVID-19 in mainland China. It further examines the relationship between ProQOL classification, post-traumatic growth (PTG), and demographic characteristics. ProQOL comprises three domains: compassionate satisfaction, burnout and secondary traumatic stress. About 345 MSWs completed questionnaires that measured their levels of ProQOL and PTG. Through a k-mean cluster analysis, three clusters of ProQOL are identified. The first type is named as the Career Satisfied group, characterised by MSWs with the highest level of compassionate satisfaction and the lowest level of secondary traumatic stress and burnout amongst the three clusters. The second cluster is called the Trauma-Thriving group, consisting of MSWs with the highest level of secondary traumatic stress amongst all. They also had the highest score for PTG. The third cluster, the Compassion Fatigue group, comprised MSWs with the highest burnout and lowest compassion satisfaction levels. The results underscore the importance of tailored interventions for each type of MSW that emerges in a public health disaster.
The COVID-19 pandemic has brought unprecedented challenges and stressors for social workers, often at the forefront of responding to crises. The pandemic has disrupted their professional practices, increased their workload, and exposed them to health risks. As a result, the well-being of social workers has become a growing concern, especially in countries with limited resources. The present study used a cross-sectional web-based survey to assess the prevalence rates of anxiety, stress, sleep quality, and overall well-being in a sample of 216 social workers employed in public medical facilities in Egypt during the COVID-19 epidemic. It also investigated the factors that influence their well-being. The results showed that half of the social workers (51.4%) scored 10 or higher on the General Anxiety Disorder scale (GAD-7), 83.3% scored ≥ 14 on PSS-10, and the mean score for sleep quality was 7.24 (SD = 2.10). Over half (58.3%) scored 50 or lower on the World Health Organization Wellbeing scale (WHO-5). Multivariable logistic regression analysis showed that younger social workers and those who scored ≤ 9 on GAD-7 were more likely to report a higher level of well-being. A higher score on PSS-10 was associated with a decrease in overall well-being. Working with family members of COVID-19 patients and sleep quality were not associated with WHO-5. These findings highlight the significant impact of the COVID-19 pandemic on the mental health of social workers in Egypt, underscoring the importance of providing adequate support and resources to address their well-being.
Mental health officers (MHO) in the military often encounter soldiers expressing distress, manifested in threats and attempts at self-harm and suicide. While these behaviors are a significant stressor for therapists, they may also be an opportunity for posttraumatic growth (PTG). We aimed to examine whether the relatively frequent exposure of MHO to soldiers who report thoughts, intentions, and attempts at self-harm and suicide is related to their PTG, as well as tested the contribution of cognitive variables (the centrality of the event and the challenge to core beliefs), and a trait not previously considered in this context, i.e. self-compassion to PTG. Self-report questionnaires were completed by130 Israeli army MHO. Of these, 98.5% reported that they are exposed to self-harm. The questionnaires were collected between the years 2020-2021. The findings show a positive linear relationship, as well as a curvilinear relationship, between PTG and exposure to expressions of self-harm and suicide, the centrality of the event, and the challenge to core beliefs. In addition, self-compassion served as a moderator in the association between exposure and PTG. The study validates the PTG model in a population that has not previously been studied in this context, and may lead to a broader understanding of PTG in this context. They may help in designing dedicated training programs for therapists dealing with reports of self-harm and suicidal behavior.
This phenomenological qualitative study examined the lived experience of pediatric nurse residents’ transition to practice during the COVID-19 pandemic. The purposive sample included nine pediatric nurses, participating in a nurse residency program, who entered the nursing profession during the first year of the pandemic. The setting was a free-standing, Magnet-recognized, pediatric academic medical center in the Northeastern U.S. Individual interviews were audio recorded and transcribed. Narratives were analyzed using a hermeneutic phenomenological approach. Five themes emerged from the data: Our New Normal; The Rules Keep Changing; I’m Not Ready for This (transition to practice); The Toll of COVID; and Shattered Family-Centered Care. Sub-themes emerged in The Toll of COVID theme: COVID and the Nursing Care Environment, Emotional Toll of COVID, Burnout: A Universal Truth, and The Pandemic within the Pandemic. The nurse residents’ narratives uncovered the essence of their uncertainty, sorrow, growth, and resilience. Through the eyes of pediatric nurse residents, this study illuminated the experiences of these novices as they entered the nursing profession amid a pandemic.
The purpose of this study was to examine the relationship between control beliefs about stress and post‐traumatic growth among Chinese nurses during the COVID‐19 pandemic and to examine the mediating role of basic psychological needs satisfaction and optimism in this relationship. A total of 692 Chinese nurses participated in this online study, who completed the Beliefs about Stress Scale, Post‐Traumatic Growth Inventory, Positive Psychological Capital Questionnaire, Basic Psychological Needs Satisfaction Scale and demographic variables between September and October 2020. Results indicate that 48.8% ( N = 388) of nurses reported significant post‐traumatic growth related to the COVID‐19 pandemic. Moreover, control beliefs about stress were positively related to post‐traumatic growth ( r = 0.38, p < 0.001), basic psychological needs satisfaction ( r = 0.44, p < 0.001) and optimism ( r = 0.47, p < 0.001). In addition, basic psychological needs satisfaction and optimism were both independent and serial mediators of the relationship between control beliefs about stress and post‐traumatic growth. Nurses and hospital administrators should focus on increasing nurses' control beliefs about stress and thereby enhancing their post‐traumatic growth after experiencing events such as the COVID‐19 pandemic. To support this process, programs should be designed to meet nurses' basic psychological needs and increase their optimism.
Since the first reported outbreak in China, the Coronavirus disease 2019 (COVID‐19) has raised serious concerns globally. The COVID‐19 pandemic has caused a severe psychological impact on healthcare workers (HCWs), and especially nurses, who are the most numerous and exposed frontline group. This systematic review and meta‐analysis aims to summarise extant literature on the effects of the COVID‐19 pandemic on the psychological health of nurses, particularly concerning the prevalence and risk factors for post‐traumatic stress disorder (PTSD). A systematic search was conducted on PubMed , Embase and PsycInfo from March 2020 to July 2023. Articles were included/excluded on predetermined eligibility criteria. A random‐effect meta‐analysis was performed using proportions to determine the pooled prevalence for PTSD among nurses. Subgroup analyses were also performed, and heterogeneity across studies was analysed using meta‐regression. Relatively high prevalence rates of PTSD were reported among nurse populations during the COVID‐19 pandemic in twenty‐six different countries, globally. Risk factors associated with PTSD include having prior mental health co‐morbidities, being a female, having high exposure/contact with COVID‐19 patients, having insufficient protective conditions and having intensive workloads. The overall pooled prevalence was 29.1% (95% C.I. = 23.5%, 35.5%) using a random‐effects model in 55 studies. The regression test of funnel plot asymmetry indicated a significant level of publication bias among studies. The COVID‐19 pandemic is associated with significant levels of PTSD among frontline nurses globally. A high level of heterogeneity was observed across studies. Psychological, social and administrative interventions should be implemented to mitigate heavy psychological distress in nurses.
The COVID‐19 pandemic constituted tremendous traumatic stress among the frontline healthcare workers. In the present study, we investigated relationships of two types of rumination, namely brooding and reflection, with traumatic stress and post‐traumatic growth and the mediating role of recollective experience in these relationships. A total of 88 healthcare workers (75% female, M age = 54.91) actively providing service to COVID‐19 patients reported two memories of events that impacted them the most at the first peak of the pandemic and rated their recollective experience (i.e., phenomenological characteristics of memories). We used structural equation modelling to test whether recollective experience mediated the link of brooding and reflection with post‐trauma reactions of stress and growth. The findings showed that brooding and reflection were associated with higher levels of traumatic stress and post‐traumatic growth. Importantly, recollective experience mediated the relationship of rumination with traumatic stress but this differed for the type of rumination. Higher brooding was associated with greater traumatic stress and that relationship was independent of how well the memories were recollected, while for reflection, high reflection was associated with stronger recollective experience, which predicted higher traumatic stress and post‐traumatic growth. The present study shows the functional dimensions of reflective rumination and presents novel findings that demonstrates the discrete mnemonic mechanisms underlying the association between brooding, reflection, and post‐trauma reactions.
Drawing upon the social identity approach, the present study explored the interrelationships among perceived stigma (both group‐based and personal), post‐traumatic growth (PTG), and their underlying mechanisms. Cross‐sectional data were collected from 3100 residents (female: n = 1667, 53.77%; male: n = 1433, 46.23%) of Hubei Province, China, aged between 12 and 65 years. The PROCESS macro (Model 7) in SPSS was employed to examine the moderated mediation effect of Inside/Outside Wuhan status on perceived identity and its associations with perceived stigma and PTG. The measurements included a brief scale assessing COVID‐19‐related stigma, the Multigroup Measure of Ethnic Identity, and the short form of the Post‐Traumatic Growth Inventory. Results showed that perceived stigma was positively associated with PTG, which was mediated by perceived identity. The moderation analysis suggested that the mediating effect of perceived identity on the courtesy stigma–PTG linkage was more pronounced in the Outside Wuhan group compared to the Inside Wuhan group. However, such an effect was not observed when personal affiliate stigma was the antecedent. In conclusion, this study suggests that positive contact and interaction can help reduce discrimination and stigma. Enhancing the perceived identity of stigmatized individuals can ultimately contribute to the achievement of PTG.
Mental health issues among nursing professionals have been increasingly reported during the coronavirus disease (COVID-19) pandemic. However, there is a paucity of research on post-traumatic stress disorder (PTSD) among nurses working in Medical Alliances. In this study, we aimed to investigate the risk factors associated with PTSD in the Regional Medical Alliance (MA) in Shantou (China) during the COVID-19 pandemic. A total of 1286 nurses from four MA hospitals participated in the study from February to March 2020. Our findings revealed that the incidences of PTSD, depression, anxiety, and sleep disorders among nurses from MA were 15.6%, 35.5%, 18.3%, and 36.4%, respectively. Moreover, PTSD was positively correlated with depression, anxiety, and sleep disorders. In addition, the results of logistic regression analysis showed that working in a tertiary hospital, older age, more severe depression, more severe anxiety, and prevalent sleep disorders were independent risk factors for PTSD among nurses. Therefore, mental health interventions targeting high-risk nurses in MA with an incidence of PTSD are urgently needed.
Life presents us all with challenges. Most of us at some point will be struck by major traumas such as the sudden death of a loved one, a debilitating disease, or a natural disaster. What differentiates us is how we respond. In this important book, three experts in trauma and resilience answer key questions such as What helps people adapt to life's most challenging situations?, How can you build up your own resilience?, and What do we know about the science of resilience? Combining cutting-edge scientific research with the personal experiences of individuals who have survived some of the most traumatic events imaginable, including the COVID-19 pandemic, this book provides a practical resource that can be used time and time again. The experts describe ten key resilience factors, including facing fear, optimism, and relying on role models, through the experiences and personal reflections of highly resilient survivors. Each resilience factor will help you to adapt and grow from stressful life events and will bring hope and inspiration for overcoming adversity.
Little is known about the positive psychological changes or posttraumatic growth (PTG) in response to the pandemic as the COVID-19 vaccines has become widely available. This longitudinal study aimed to characterize changes in the prevalence of pandemic-related PTG, and to identify and quantify the relative importance of PTG correlates pre-pandemic, 1- year peri‑pandemic, and 2-years post-pandemic onset. A total of 2,441 U.S. military veterans completed Wave 3 assessment of the National Health and Resilience in Veterans Study. In the full sample, a significant decrease from peri‑pandemic to 2-years post-pandemic onset was observed in overall pandemic-related PTG (41.5% to 32.2%) and four domains of PTG (appreciation of life, relating to others, personal strength, spiritual changes). Among veterans who screened positive for pandemic-related posttraumatic stress symptoms, the prevalence of pandemic-related PTG was markedly higher and did not change from peri‑pandemic to 2-years post-pandemic onset (78.4% to 73.4%). Greater pre-pandemic PTG (personal strength and new possibilities) and greater worries about the effect of pandemic on one's mental health were the strongest correlates of pandemic-related PTG 2-years post-pandemic onset. Results suggest that psychosocial interventions to bolster PTG in relation to early life traumas may help facilitate PTG in response to the pandemic and related crises.
Background and aims: Emotional distress is widespread among individuals recovering from COVID-19. The present study examined the relationships between illness severity and emotional distress and the outcomes of a general and cognitive rehabilitation program. Methods: Participants were 61 post-acute COVID-19 patients who participated in a multidisciplinary rehabilitation program. Data were collected at admission and discharge, 6 months later. Medical evaluations and self-reported emotional, neuropsychological and functional measures were used. Results: Mild illness was associated with higher levels of self-reported anxiety and depression and with lower self-reported executive functioning. Elevated anxiety levels and lower cognitive profile at admission were significantly linked to poorer cognitive outcomes, but not to motor or general functioning level at discharge. Conclusions: The results of the study indicate the significance of monitoring emotional characteristics, particularly anxiety, in post-COVID-19 individuals during multidisciplinary rehabilitation.
The present study aims to investigate whether the COVID-19 pandemic has had a positive effect on Turkish society in terms of post-traumatic growth and the factors that may affect this situation. This quantitative, cross-sectional study employed the survey model. Prior to the research, all permissions were obtained, and the participants were informed. Participants were in the 19-76 age range. More than half of the participants stated that they felt worried due to the pandemic. Similarly, more than half reported that they had treated COVID-19 at home. Those who reported that they were unemployed, those who thought their mental health was affected, and those who reported that they felt worried due to the pandemic scored high on the post-traumatic growth inventory. Some sociodemographic characteristics led to differences in the participants’ scores from the post-traumatic growth inventory and its sub-dimensions.
The COVID-19 pandemic has had an unprecedented impact on the US health care system which was already experiencing higher levels of personal burnout among health care workers than the average US worker. Well-being efforts to support the workforce have become a critical countermeasure during the pandemic. This work was presented at the Thomas Jefferson University, College of Population Health Seminar Series: Clinical Lessons from the Northeast Surge, COVID-19: Spread the Science, not the Virus, held August 18, 2020. The entire series was held virtually from July 21 to September 29, 2020. The authors describe issues impacting health care workers during this early period of the pandemic with two examples of concrete strategies to approach well-being at the organizational level and lessons learned.
The adverse impact of the COVID-19 pandemic on mental health has been widely concerned, but the research on positive psychological factors is insufficient, this study aims to investigate the prevalence and factors of posttraumatic growth (PTG) among residents in the worst-hit areas of China (Hubei Province). We were conducted in three disaster areas with different severity in Hubei Province three months after the outbreak, and the data were from 575 respondents. Instruments included the simplified Chinese version of the Posttraumatic Growth Inventory (C-PTGI) and the public health emergency psychological questionnaire. Nonparametric tests, Spearman correlation analyses, and multiple linear regression equations were used to analyze the data. The results showed that three months after the outbreak of COVID-19, the PTG of Hubei residents was at a low level, and their sense of fear was the most prominent, with a positive detection rate of 82.09%. According to the results of this study, high PTG levels were associated with high levels of fear, married and healthcare providers, while low levels of PTG were associated with serious chronic diseases, males, good economic status, and poor prevention and control measures. Government departments should strengthen social support for residents, carry out necessary stress management training to help them correctly deal with negative emotions and promote their personal growth.
Background: Covid-19 remains a pandemic that most countries in the world are still
dealing with. This is study aims to report the psychological impact of Covid-19 over time
on the Spanish population.
Methods: A longitudinal study (N = 1041) was carried out with two measurements:
after 2 and 5 weeks starting from the declaration of the state of emergency in Spain. The
presence of depressive symptoms, anxiety, and posttraumatic stress disease (PTSD)
was evaluated by means of screening tests. Sociodemographic data, variables about
Covid-19, loneliness, spiritual well-being, social support, discrimination, and a sense of
belonging were collected.
Results: The data showed how depressive symptomatology increased significantly over
time, while anxiety and PTSD did not show statistically significant changes. Spiritual
well-being and loneliness were the main predictors of psychological impact. A younger
age was a significant predictor of depression and anxiety, while female gender was
associated with anxiety and PTSD.
Conclusions: The impact of the pandemic is sustained over time, even increasing in
depression, and vulnerable groups that need greater psychological health support could
be identified.
Objective: This study examined how best to identify modifiable protective and risk factors for burnout in healthcare workers in the face of the COVID-19 pandemic. Individual, occupational, organizational and social factors were investigated. The study also assessed the impact of these factors on post-traumatic stress disorder (PTSD), anxiety, and depression.
Methods: Healthcare workers in the Quebec (Canada) healthcare system were recruited between May 21 to June 5, 2020. Participants answered an electronic survey 3 months after the COVID-19 epidemic outbreak began in Canada. Using the Maslach Burnout Inventory, PTSD Checklist for DSM-5, and Hospital Anxiety and Depression Scale, we studied the prevalence of burnout, PTSD, anxiety and depression in this cohort. Multivariable logistic or linear regression models including resilience, social and organizational support, workload and access to mental health help, simulation techniques and protective personal equipment (PPE) as well as perception of PPE security were conducted for each outcome.
Results: In mid-June 2020, 467 participants completed the survey. We found that half (51.8%) of the respondents experienced burnout characterized by emotional exhaustion and/or depersonalization at least once a week. In total, 158 healthcare workers (35.6%) displayed severe symptoms of at least one of the mental health disorders (24.3% PTSD, 23.3% anxiety, 10.6% depression). Resilience (OR = 0.69, 95% CI: [0.55–0.87]; p = 0.002) and perceived organizational support (OR = 0.75, 95% CI: [0.61–0.93]; p = 0.009) were significantly associated with burnout and other outcomes. Social support satisfaction, perception of PPE security, work type and environment, mental health antecedents and reassignment were associated with PTSD and/or anxiety and/or depression, but not burnout.
Conclusion: Future studies should address primarily resilience and perceived organizational support to promote mental health and prevent burnout, PTSD, anxiety and depression.
Safety of healthcare workers in hospitals is a major concern during the COVID-19 pandemic. Being exposed for several working hours per day to infected patients, nurses dealing with COVID-19 face several issues that lead to physical/psychological breakdown. This study focused on burnout and its associated factors in nurses working in an Italian University Hospital during the first wave of COVID-19 pandemic. We designed a web-based cross-sectional study addressed to nurses working at the University Hospital in Foggia, Italy. The online questionnaire was organized in sections aimed at collecting demographic and occupational variables, including the Maslach Burnout Inventory (MBI) and the Oldenburg Burnout Inventory (OBI). Two hundred and ninety-three nurses agreed to participate. According to MBI, we reported moderate/high emotional exhaustion in 76.5%, depersonalization in 50.2%, and personal gratification in 54.6% of participants. COVID-19-related burnout measured by OBI resulted medium/high in 89.1% of participants. Among demographic and occupational factors, a multivariate regression analysis identified emotional support, consideration of leaving job, and workload as predictive of burnout in nurses. In conclusion, this study suggests that the improvement of employer and family support to nurses, as well as reduction of workload and job-related stress, would contribute to reducing burnout in nurses during COVID-19 pandemics.
Background
There is considerable evidence of widespread emotional distress associated with the COVID-19 pandemic. A growing number of studies have assessed posttraumatic growth related to the current pandemic; but, none have considered whether reported growth is real or illusory (i.e., characterized by avoidant or defensive coping that results in higher levels of distress). The purpose of this study was to extend this literature by assessing growth specific to the pandemic in people reporting high levels of COVID-related stress and estimating the extent of real and illusory COVID-19-related growth.
Methods
Participants were 893 adults from Canada and the United States with high levels of COVID-related stress who provided complete responses on measures of posttraumatic growth, disability, and measures of general and COVID-related distress as part of a larger longitudinal survey.
Results
Approximately 77% of participants reported moderate to high growth in at least one respect, the most common being developing greater appreciation for healthcare workers, for the value of one’s own life, for friends and family, for each day, as well as changing priorities about what is important in life and greater feelings of self-reliance. Consistent with predictions, cluster analysis identified two clusters characterized by high growth, one comprising 32% of the sample and reflective of real growth (i.e., reporting little disability and stable symptoms across time) and the other comprising 17% of the sample and reflective of illusory growth (i.e., reporting high disability and worsening symptoms). These clusters did not differ in terms of socially desirable response tendencies; but, the illusory growth cluster reported greater increases in alcohol use since onset of the pandemic.
Conclusion
Consistent with research regarding personal growth in response to prior pandemics and COVID-19, we found evidence to suggest moderate to high levels of COVID-related growth with respect to appreciation for healthcare workers, life, friends and family, and self-reliance. Findings from our cluster analysis support the thesis that many reports of COVID-related personal growth reflect ineffectual pandemic-related coping as opposed to true growth. These findings have important implications for developing strategies to optimize stress resilience and posttraumatic growth during chronically stressful events such as pandemics.
Aims
To examine the nurses' burnout and associated risk factors during the COVID‐19 pandemic.
Design
We followed the Cochrane criteria and the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines for this systematic review and meta‐analysis.
Data Sources
PubMed, Scopus, ProQuest, Cochrane COVID‐19 registry, CINAHL and pre‐print services (medRχiv and PsyArXiv) were searched from January 1 to November 15, 2020 and we removed duplicates.
Review Methods
We applied a random effect model to estimate pooled effects since the heterogeneity between results was very high.
Results
Sixteen studies, including 18,935 nurses met the inclusion criteria. The overall prevalence of emotional exhaustion was 34.1%, of depersonalization was 12.6% and of lack of personal accomplishment was 15.2%. The main risk factors that increased nurses' burnout were the following: younger age, decreased social support, low family and colleagues readiness to cope with COVID‐19 outbreak, increased perceived threat of Covid‐19, longer working time in quarantine areas, working in a high‐risk environment, working in hospitals with inadequate and insufficient material and human resources, increased workload and lower level of specialized training regarding COVID‐19.
Conclusion
Nurses experience high levels of burnout during the COVID‐19 pandemic, while several sociodemographic, social and occupational factors affect this burnout.
Impact
We found that burnout among nurses is a crucial issue during the COVID‐19 pandemic. There is an urgent need to prepare nurses to cope better with COVID‐19 pandemic. Identification of risk factors for burnout could be a significant weapon giving nurses and health care systems the ability to response in a better way against the following COVID‐19 waves in the near future.
This study addresses the gap in the literature regarding the impact of nurses’ personal religious and spiritual beliefs on their mental well-being and burnout. A model of the association between these factors was tested based on surveys of 207 nurses located in southeastern USA and analyzed to determine the association between religion/spirituality, mental well-being, and burnout. A path analysis supported a model in which, through its positive impact on mental well-being, religion/spirituality was negatively associated with emotional exhaustion and depersonalization and positively associated with personal accomplishment.
Background
This study sought to assess the magnitude of and factors associated with mental health outcomes among frontline health care workers (FHCWs) providing care during the Spring 2020 COVID-19 pandemic surge in New York City.
Methods
A cross-sectional, survey-based study over 4 weeks during the Spring 2020 pandemic surge was used to assess symptoms of COVID-19-related posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) in 2,579 FHCWs at the Mount Sinai Hospital. Participants were additionally asked about their occupational and personal exposures to COVID-19. Multivariable logistic regression and relative importance analyses were conducted to identify factors associated with these outcomes.
Results
A total of 3,360 of 6,026 individuals completed the survey (55.8% participation), with 2,579 (76.8%) analyzed based on endorsing frontline responsibilities and providing information related to the three outcomes. 1,005 (39.0%) met criteria for symptoms of COVID-19-related PTSD, MDD, or GAD. 599 (23.3%) screened positively for PTSD symptoms, 683 (26.6%) for MDD symptoms, and 642 (25.0%) for GAD symptoms. Multivariable analyses revealed that past-year burnout was associated with the highest risk of developing symptoms for COVID-19-related PTSD (odds ratio [OR] = 2.10), MDD (OR = 2.83), and GAD (OR = 2.68). Higher perceived support from hospital leadership was associated with a lowest risk of all outcomes [PTSD (OR = 0.75), MDD (OR = 0.72), and GAD (OR = 0.76).
Conclusion
In this large sample of FHCWs providing care during the 2020 NYC pandemic surge, 39% experienced symptoms of COVID-19-related PTSD, MDD, and/or GAD and pre-pandemic burnout as well as leadership support were identified as the most highly associated factors. These findings suggest that interventions aimed at reducing burnout and augmenting support from hospital leadership may be appropriate targets to mitigate the risk for developing further psychopathology in this population and others working in the midst of crisis.
Burnout is characterized by emotional exhaustion and caused by exposure to excessive and prolonged stress related to job conditions. Moreover, burnout is highly prevalent among health care professionals. The aim of this study is, first, to examine the mediating role of social support over the effect of burnout in health care professionals and, second, to explore potential gender differences. A convenience sample of 1,035 health professionals from Ecuador, including 608 physicians and 427 nurses (68% women, with and age M = 40 + 9 years old), was surveyed using the Maslach Burnout Inventory (MBI), Social Support Survey (MOS), and General Health Questionnaire (GHQ-28) as measures of burnout, social support, and general health, respectively. Social support was found to mediate the negative effects of burnout on health regardless of gender. Differences across the three dimensions of burnout and health are further discussed, along with their implications for designing effective burnout interventions for health care professionals in Ecuador.
Open Access: https://link.springer.com/article/10.1007/s10943-020-01174-6
Objective:
Several studies have raised doubts about the effectiveness of posttraumatic growth (PTG) as a mechanism that promotes functioning. This study explored this issue in several directions: First, it examined whether functioning is negatively associated with posttraumatic symptoms (PTS), dissociation, and depression. Second, it determined whether PTG is positively associated with functioning. Finally, the study investigated whether PTG moderates the relationship between functioning and PTS, as well as between functioning and dissociation and depression.
Method:
The participants were 301 residents of an area exposed to the 2006 war in northern Israel. A structured questionnaire assessing posttraumatic stress disorder, depression, dissociation, PTG, and functioning was used 6 years following the war.
Results:
Functioning was found to be negatively associated with PTS, dissociation, and depression. PTG was found to be positively associated with functioning. In addition, PTG was found to moderate the relationship between functioning and PTS, as well as between functioning and dissociation and depression.
Conclusions:
Contrary to the approach that considers PTG to be an illusion, and possibly even a mechanism that may hinder a return to efficient functioning, the findings of this research suggest that PTG may reflect a growth phenomenon that includes functioning, thus implying a characteristic of the individual's relation to the world. Therefore, it may be concluded that PTG is not an illusion-a process that occurs only in one's head-but rather reflects actual functioning. The theoretical and practical implications of these findings are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Background: Covid-19 remains a pandemic that most countries in the world are still dealing with. This is study aims to report the psychological impact of Covid-19 over time on the Spanish population.
Methods: A longitudinal study (N = 1041) was carried out with two measurements: after 2 and 5 weeks starting from the declaration of the state of emergency in Spain. The presence of depressive symptoms, anxiety, and posttraumatic stress disease (PTSD) was evaluated by means of screening tests. Sociodemographic data, variables about Covid-19, loneliness, spiritual well-being, social support, discrimination, and a sense of belonging were collected.
Results: The data showed how depressive symptomatology increased significantly over time, while anxiety and PTSD did not show statistically significant changes. Spiritual well-being and loneliness were the main predictors of psychological impact. A younger age was a significant predictor of depression and anxiety, while female gender was associated with anxiety and PTSD.
Conclusions: The impact of the pandemic is sustained over time, even increasing in depression, and vulnerable groups that need greater psychological health support could be identified.
Purpose of review:
We aim to provide quantitative evidence on the psychological impact of epidemic/pandemic outbreaks (i.e., SARS, MERS, COVID-19, ebola, and influenza A) on healthcare workers (HCWs).
Recent findings:
Forty-four studies are included in this review. Between 11 and 73.4% of HCWs, mainly including physicians, nurses, and auxiliary staff, reported post-traumatic stress symptoms during outbreaks, with symptoms lasting after 1-3 years in 10-40%. Depressive symptoms are reported in 27.5-50.7%, insomnia symptoms in 34-36.1%, and severe anxiety symptoms in 45%. General psychiatric symptoms during outbreaks have a range comprised between 17.3 and 75.3%; high levels of stress related to working are reported in 18.1 to 80.1%. Several individual and work-related features can be considered risk or protective factors, such as personality characteristics, the level of exposure to affected patients, and organizational support. Empirical evidence underlines the need to address the detrimental effects of epidemic/pandemic outbreaks on HCWs' mental health. Recommendations should include the assessment and promotion of coping strategies and resilience, special attention to frontline HCWs, provision of adequate protective supplies, and organization of online support services.
The pandemic caused by Covid-19 has been an unprecedented social and health emergency worldwide. This is the first study in the scientific literature reporting the psychological impact of the Covid-19 outbreak in a sample of the Spanish population. A cross-sectional study was conducted through an online survey of 3480 people. The presence of depression, anxiety and post-traumatic stress disorder (PTSD) was evaluated with screening tests from 14 March. Sociodemographic and Covid-19-related data was collected. Additionally, spiritual well-being, loneliness, social support, discrimination and sense of belonging were assessed. Descriptive analyses were carried out and linear regression models compiled. The 18.7% of the sample revealed depressive, 21.6% anxiety and 15.8% PTSD symptoms. Being in the older age group, having economic stability and the belief that adequate information had been provided about the pandemic were negatively related to depression, anxiety and PTSD. However, female gender, previous diagnoses of mental health problems or neurological disorders, having symptoms associated with the virus, or those with a close relative infected were associated with greater symptomatology in all three variables. Predictive models revealed that the greatest protector for symptomatology was spiritual well-being, while loneliness was the strongest predictor of depression, anxiety and PTSD. The impact on our mental health caused by the pandemic and the measures adopted during the first weeks to deal with it are evident. In addition, it is possible to identify the need of greater psychological support in general and in certain particularly vulnerable groups.
Exposure to work-related traumatic incidents in firefighters may result in positive psychological changes which are termed “posttraumatic growth”. This study aimed to construct structure equation modeling based on the model of posttraumatic growth in firefighters. Methods: A total of 226 firefighters who had experienced a work-related traumatic incident participated. The participants from three municipal fire departments and seven fire stations completed an anonymous survey asking about extraversion, optimism, calling in the workplace, problem-focused coping, deliberate rumination, and posttraumatic growth. The model fit indices were suitable for the recommended level. Seven of the 11 paths established in the initial hypothetical model were identified. The variables of deliberate rumination, problem-focused coping, and extraversion had a significant effect on the posttraumatic growth of firefighters, with an explanatory power of 38.7%. The findings show that it is important to develop strategies to enhance deliberate rumination and problem-focused coping for firefighters after work-related traumatic events.
Research on parental psychological effects related to a child’s critical illness has focused on studying negative outcomes, while the possibility of posttraumatic growth (PTG), defined as the perception of positive changes after a traumatic event, has been overlooked. This study explores the degree of parental PTG after a child’s hospitalization in a pediatric intensive care unit (PICU) and the role of resilience, emotions, perceived severity of the child’s condition and stress in predicting PTG. In the first 48 h after their child’s discharge from a PICU, N = 196 parents were assessed for resilience, emotions, perceived stress, and the degree to which they perceived their child’s condition as severe. 6 months later N = 143 parents were assessed PTG. 6 months post discharge, 37.1% of parents reported PTG at least to a medium degree. Path analyses with latent variables showed that the psychological variables assessed at discharge predicted between 20 and 21% of the total variance in PTG. Resilience affected PTG indirectly, through the bias of positive emotions. PTG is a frequent phenomenon. Psychological interventions aimed at encouraging parental PTG after a child’s critical admission should focus on boosting resilience and positive emotions.
Background. Many veterans experience significant compromised spiritual and mental wellbeing. Despite effective and evidence-based treatments, veterans continue to experience poor completion rates and sub-optimal therapeutic effects. Spirituality, whether expressed through religious or secular means, is a part of adjunctive or supplemental treatment modalities to treat PTSD and is particularly relevant to combat trauma. The aim of this systematic review was to
examine the relationship between spirituality and mental wellbeing in post-deployment veterans.
Methods. Electronic databases (MEDLINE, PsycINFO, CINAHL, Web of Science, JSTOR) were searched from database inception to March 2016. Grey literature was identified in databases, websites, and reference lists of included studies. Study quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool and Critical Appraising Skill Programme Qualitative Checklist.
Results. From 6555 abstracts, 43 studies were included. Study quality was low-moderate. Spirituality had an effect on PTSD, suicide, depression, anger and aggression, anxiety, quality of life, and other mental wellbeing outcomes for veterans. Negative spiritual coping was often associated with an increase mental health diagnoses and symptom severity; positive spiritual coping had an ameliorating effect.
Discussion. Addressing veterans’ spiritual wellbeing should be a routine and integrated component of veterans’ health, with regular assessment and treatment. This requires an interdisciplinary approach, including integrating chaplains post-combat, to help address these issues and enhance the continuity of care. Further high-quality research is needed to isolate the salient components of spirituality that are most harmful and helpful in veterans’ mental wellbeing, including the incorporating of veterans’ perspectives directly.
Objective: In order to increase the knowledge of rumination and its associations with stressful events, we explored the relationships between four types of rumination (brooding, reflection, intrusive and deliberate rumination) in a sample of 750 adult participants who experienced a highly stressful event. We also explored the predictive value of the different types of rumination on posttraumatic stress symptoms and posttraumatic growth six month after the highly stressful event occurred.
Method: Participants completed the Ruminative Responses Scale (RRS) and the Event Related Rumination Inventory (ERRI). Brooding and reflection rumination were obtained from the RRS, while deliberate and intrusive rumination were obtained from the ERRI. Confirmatory factorial analyses were conducted using the four types of rumination to test three different models: 1) four-factor model (brooding, reflection, intrusive and deliberate rumination), 2) two-factor model: adaptive rumination (reflection and deliberate) and maladaptive rumination (brooding and intrusive) and 3) two-factor model: depressive rumination (brooding and reflection) and posttraumatic rumination intrusive and deliberate).
Results: It was observed that the four-factor model showed the best goodness of fit indices. Moreover, six months later it was observed that the most significant predictor of posttraumatic symptoms was intrusive rumination, while deliberate rumination was the most significant predictor of posttraumatic growth.
Conclusions: Results indicate that the four types of rumination are differentiated constructs. Ruminative thoughts experienced after the stressful event predicted posttraumatic consequences six months later. Implications of these findings are discussed.
Background There is increasing recognition that, in addition to negative psychological consequences of trauma such as post-traumatic stress disorder (PTSD), some individuals may develop post-traumatic growth (PTG) following such experiences. To date, however, data regarding the prevalence, correlates and functional significance of PTG in population-based samples are lacking.
Method Data were analysed from the National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 3157 US veterans. Veterans completed a survey containing measures of sociodemographic, military, health and psychosocial characteristics, and the Posttraumatic Growth Inventory-Short Form.
Results We found that 50.1% of all veterans and 72.0% of veterans who screened positive for PTSD reported at least ‘moderate’ PTG in relation to their worst traumatic event. An inverted U-shaped relationship was found to best explain the relationship between PTSD symptoms and PTG. Among veterans with PTSD, those with PTSD reported better mental functioning and general health than those without PTG. Experiencing a life-threatening illness or injury and re-experiencing symptoms were most strongly associated with PTG. In multivariable analysis, greater social connectedness, intrinsic religiosity and purpose in life were independently associated with greater PTG.
Conclusions PTG is prevalent among US veterans, particularly among those who screen positive for PTSD. These results suggest that there may be a ‘positive legacy’ of trauma that has functional significance for veterans. They further suggest that interventions geared toward helping trauma-exposed US veterans process their re-experiencing symptoms, and to develop greater social connections, sense of purpose and intrinsic religiosity may help promote PTG in this population.
A short form of the Posttraumatic Growth Inventory (PTGI-SF) is described. A sample of 1351 adults who had completed the Posttraumatic Growth Inventory (PTGI) in previous studies provided the basis for item selection. The resulting 10-item form includes two items from each of the five subscales of the original PTGI, selected on the basis of loadings on the original factors and breadth of item content. A separate sample of 186 completed the short form of the scale (PTGI-SF). Confirmatory factor analyses on both data sets demonstrated a five-factor structure for the PTGI-short form (PTGI-SF) equivalent to that of the PTGI. Three studies of homogenous clinical samples (bereaved parents, intimate partner violence victims, and acute leukemia patients) demonstrated that the PTGI-SF yields relationships with other variables of interest that are equivalent to those found using the original form of the PTGI. A final study demonstrated that administering the 10 short-form items in a random order, rather than in the fixed context of the original scale, did not impact the performance of the PTGI-SF. Overall, these results indicate that the PTGI-SF could be substituted for the PTGI with little loss of information.
Positive psychological or personal changes in the aftermath of trauma, defined as the result of the struggle with highly stressful events, have recently elicited heightened attention by trauma researchers. This article aims at summarizing the most important theoretical models and conceptualizations of posttraumatic growth (PTG) and addresses the issue of the adaptive significance of this phenomenon. It further renders a thorough empirical review of the relationship between PTG and psychological adjustment. European findings are specifically incorporated. As a conclusion, a two component cognitive model of PTG will be proposed that may explain the contradicting empirical findings in regard to the relationship between mental health and PTG. The Janus-Face model of PTG [Maercker, A. and Zoellner, T. (2004). The Janus face of self-perceived growth: Toward a two-component model of posttraumatic growth. Psychological Inquiry, 15, 41-48.] incorporates a constructive and an illusory aspect. On this basis, findings regarding relevant cognitive factors as predictors of PTG are summarized and evaluated. The article ends with a discussion of fruitful future research directions and how PTG can add a new perspective into trauma therapy.
Longitudinal research designs involve data collection at multiple time points to measure change over time. Therefore, identification of the same respondents is essential at each time point so that data from the same respondents can be matched for comparison over time. Subject-generated identification codes permit an anonymous means to track respondents over multiple data collection points. This article describes the evolution of subject-generated identification codes, techniques to improve respondent match rates, and the authors' experience using this mechanism in a longitudinal study of staff registered nurses working in hospitals. Challenges, recommendations, and implications for using subject-generated identification codes are discussed.
COVID-19 is a unique disaster, which has placed extreme stress on Healthcare Workers (HCWs) and the systems in which they work. Eradicating the pandemic requires sustainment of the healthcare workforce through actions that mitigate stress, promote resilience, and enhance performance. A major barrier is the lack of organizational practices and procedures designed to sustain HCWs during prolonged crisis events, such as COVID-19. Adapting existing best practices from other high-risk occupations allows for a more rapid, efficient response to optimize workforce well-being and preserve healthcare organizational functioning. This paper discusses current and emerging literature on the unique impacts of COVID-19 on HCWs and provides actionable, evidence-informed recommendations for individuals, teams, and leaders to enhance sustainment of HCWs that is critical to the preservation of national and global health security.
Background
Military combat trauma is often associated with negative outcomes, including high rates of posttraumatic stress disorder (PTSD). Less is known, however, about whether military combat trauma may foster posttraumatic growth (PTG), which has been observed in relation to other trauma types, in representative samples of veterans.
Methods
We analyzed data from veterans who participated in the National Health and Resilience in Veterans Study who reported a military-related trauma (n=210). Participants completed measures of trauma history, combat exposure, PTSD symptoms, PTG, functioning, and quality of life (QOL). Bivariate correlations, regression analyses, analyses of covariance, and fit of linear and quadratic functions were used to examine relationships between PTSD symptom clusters, PTG and its subdomains, and functioning.
Results
Number of deployments (β=0.23) and lifetime PTSD symptom severity (β=0.19), particularly re-experiencing symptoms (β=0.37), were independently associated with greater PTG. An inverted-U-shaped quadratic function provided the best fit for the relationship between PTSD symptoms and PTG (R² =0.22). Greater PTG was associated with greater mental functioning (β=0.15) and QOL (β=0.24).
Limitations
The inability to make casual inferences in this cross-sectional study; possible bias related to self-report measures; and the lengthy time period between index trauma and assessment of PTSD and PTG.
Conclusions
PTG is relatively common among combat veterans, particularly among those with PTSD, and is associated with better mental functioning and QOL. Positive psychology interventions to bolster PTG may help promote functional outcomes in this population.
In light of the global crisis created by the outbreak of the coronavirus and the disease it causes, coronavirus disease 2019, the goal of the study was to detect factors that might enhance people's ability to experience positive psychological change during traumatic events. As such, this study examined the relationship between social participation and posttraumatic growth (PTG) during the coronavirus outbreak and tested the mediating role of hope, social support, and cognitive reappraisal in explaining this relationship. The sample consisted of 275 participants (21.8% male, and 78.2% female, with an average age of 33.42, SD = 13.63), subjected to social‐distancing regulations during this period. Results demonstrated a serial mediation model in which social participation predicted PTG directly and indirectly through hope (pathways and agency), social support, and cognitive reappraisal. The importance of social participation in nourishing personal resources and practical implications including the need for prevention programs are discussed.
The current study focused on pediatric nurses. It explored the direct link between posttraumatic growth as a coping resource and burnout and the indirect link between posttraumatic growth and burnout via secondary traumatic stress (mediating effect). Moreover, meaning in work was examined as a moderator variable in relation to the direct link and the indirect link. One hundred and thirty‐eight nurses working at a pediatric medical center filled out self‐report questionnaires regarding personal and professional data, burnout, posttraumatic growth, secondary traumatic stress, and meaning in work. Posttraumatic growth was found to be a coping resource that linked to pediatric nurses' burnout directly and indirectly. Directly, there was an inverse correlation between the two; indirectly, posttraumatic growth linked negatively to secondary traumatic stress, and secondary traumatic stress linked positively to burnout. Moreover, meaning in work played a dual moderating role. First, it moderated the relationship between posttraumatic growth and secondary traumatization. Second, it moderated the direct relationship between posttraumatic growth and burnout, namely, the negative link between posttraumatic growth and burnout became stronger as meaning in work increased. As such, we recommend enhancing personal and professional posttraumatic growth, as well as designing interventions that promote meaningful work among pediatric nurses.
A recent study published in the Journal of Traumatic Stress demonstrated that posttraumatic stress disorder (PTSD) rates in Ireland are as high as 17.7% and that this could be related to the COVID‐19 pandemic (Karatzias et al., 2020). However, this number is probably skewed, as the fundamental requirement for a PTSD diagnosis—namely, a life‐threatening or severely stressful event—was not fulfilled. In this comment, the consideration of COVID‐19–related PTSD to represent a diagnosis is questioned based on the definitions of PTSD in the ICD‐11 and DSM‐5.
Trauma survivors who suffer from posttraumatic stress disorder (PTSD) symptoms may be particularly vulnerable when facing the COVID-19 pandemic. Yet trauma exposure may also lead to salutogenic outcomes, known as posttraumatic growth (PTG). Nevertheless, the implications of PTG attributed to prior trauma, for trauma survivors’ adjustment when facing additional stressors, are unclear. Addressing this gap, 528 Israeli trauma survivors were assessed for PTG and PTSD symptoms attributed to prior trauma, as well as peritraumatic stress symptoms related to the pandemic, as part of an online survey. Analyses revealed that being younger, female, quarantined, negatively self-rating one’s health status, and suffering from PTSD symptoms were associated with elevated peritraumatic stress symptoms. Furthermore, PTG attributed to prior trauma made a significant contribution in explaining elevated intrusion, avoidance, and hyperarousal symptoms. The present results point to the need for clinicians to take into account reports of PTG attributed to prior trauma when treating trauma survivors during the current pandemic.
The outbreak of the coronavirus disease 2019 (COVID-19) and its rapid global spread have created unprecedented challenges to healthcare systems. Significant and sustained efforts have focused on mobilization of personal protective equipment, intensive care beds, and medical equipment, while substantially less attention has focused on preserving the psychological health of the medical workforce tasked with addressing the challenges of the pandemic. And yet, similar to battlefield conditions, healthcare workers are being confronted with ongoing uncertainty about resources, capacities, and risks; as well as exposure to suffering, death, and threats to their own safety. These conditions are engendering high levels of fear and anxiety in the short-term, and place individuals at risk for persistent stress-exposure syndromes, sub-clinical mental health symptoms, and professional burnout in the long-term. Given the potentially wide-ranging mental health impact of COVID-19, protecting healthcare workers from adverse psychological effects of the pandemic is critical.Therefore, we present an overview of the potential psychological stress responses to the COVID-19 crisis in medical providers and describe pre-emptive resilience-promoting strategies at the organizational and personal level. We then describe a rapidly deployable Psychological Resilience Intervention founded on a peer-support model (Battle Buddies) developed by the United States Army. This intervention-- the product of a multidisciplinary collaboration between the Departments of Anesthesiology and Psychiatry & Behavioral Sciences at the University of Minnesota Medical Center-- also incorporates evidence-informed "stress inoculation" methods developed for managing psychological stress exposure in providers deployed to disasters. Our multi-level, resource-efficient, and scalable approach places two key tools directly in the hands of providers: 1) A peer-support Battle Buddy; and 2) A designated mental health consultant who can facilitate training in stress inoculation methods, provide additional support, or coordinate referral for external professional consultation. In parallel, we have instituted a voluntary research data-collection component that will enable us to evaluate the intervention's effectiveness while also identifying the most salient resilience factors for future iterations. It is our hope that these elements will provide guidance to other organizations seeking to protect the well-being of their medical workforce during the pandemic. Given the remarkable adaptability of human beings, we believe that, by promoting resilience, our diverse healthcare workforce can emerge from this monumental challenge with new skills, closer relationships, and greater confidence in the power of community.
Background
. Posttraumatic growth (PTG) refers to positive psychological changes that may occur after experiencing a traumatic event. While cross-sectional studies have suggested that posttraumatic stress disorder (PTSD) is associated with greater PTG, few longitudinal studies have evaluated interrelationships between PTSD and PTG. Further, little is known about which specific symptom clusters of PTSD and coping mechanisms may drive PTG over time.
Methods
. We evaluated interrelationships between PTSD symptoms and PTG using data from a 4-year, nationally representative, prospective cohort study of 2,006 older trauma-exposed U.S. veterans.
Results
. Autoregressive cross-lagged panel regression analyses revealed that greater severity of PTSD symptoms was associated with greater PTG over time. Specifically, greater severity of the avoidance and anxious arousal (e.g., hypervigilance) symptoms at Wave 1 predicted greater PTG at Wave 2; and greater severity of avoidance and lower severity of dysphoric arousal (e.g., sleep disturbance) at Wave 2 predicted greater PTG at Wave 3. Engagement in active coping and religious coping were associated with greater subsequent PTG above and beyond autoregressive associations between PTSD and PTG.
Limitations
. The self-report nature of the assessments, discrete assessment periods assessed, and focus on older military veterans are study limitations.
Conclusions
. Greater severity of PTSD symptoms, particularly avoidance and hyperarousal symptoms, may contribute to and maintain PTG over time in older veterans. Interventions that promote deliberate, constructive attempts to manage chronic PTSD symptoms via active coping and religious coping may help veterans better manage PTSD symptoms and experience greater PTG in late-life.
Aim
This study aims to identify the role that spiritual climate has in reducing burnout and intentions to leave amongst clinical nurses.
Background
Both shortages and the high turnover of nurses are challenging problems worldwide. Enhancing the spiritual climate amongst nurses can enhance teamwork, organisational commitment and job satisfaction and can play a role in reducing burnout and turnover intention.
Methods
A total of 207 clinical nurses working at a tertiary university hospital were included in this cross‐sectional single site study. Independent‐samples T‐test and ANOVA, Pearson correlation analysis and hierarchical regression analysis were used to explore the relationships amongst related factors.
Results
Most clinical departments showed a moderate spiritual climate (60.24±0.82) with high job burnout (33.62±0.28) and turnover intention (2.37±0.57). A good spiritual climate was correlated with high job satisfaction (r=0.412, p<0.01), low burnout and turnover intention (r=−0.423, p<0.01 and r=−0.292, p<0.01, respectively). Spiritual climate could also indirectly influence nurses’ job burnout and turnover intention (R²=10.31%).
Conclusions
Different departments have different spiritual climate. The findings from this study indicate that spiritual climate may impact nursing burnout and turnover.
This article is protected by copyright. All rights reserved.
Posttraumatic growth (PTG) may exist in trauma survivors, especially adolescents, whereas rumination is a typical cognitive characteristic among traumatized individuals. However, there were mixed relationships between rumination (intrusive rumination, deliberate rumination) and PTG. The study aimed to increase understanding of the relationships between them by investigating the role of social support among adolescents after the Yancheng tornado. Four hundred forty-three middle school students in the core area of the tornado were administered a revised social support scale based on Furman and Buhrmester's Network of Relationships Inventory, Event-Related Rumination Inventory, and Posttraumatic Growth Inventory. Results showed a nonsignificant relationship between intrusive rumination and PTG, whereas a positive relationship was found between deliberate rumination and PTG. Moreover, social support did not moderate the relationship between intrusive rumination and PTG, but it significantly mediated the relationship between deliberate rumination and PTG. Clinical implications on trauma intervention and limitations as well as future research directions were discussed.
Background:
Posttraumatic growth (PTG) is positive psychological changes after encountering challenging events. The main purpose of this meta-analysis was to summarize the prevalence of moderate-to-high PTG in people who experienced traumatic events and to understand what social-demographic and trauma characteristics distinguish those who show a high rate of PTG from those of low level.
Methods:
Six electronic databases were searched. Loney's appraisal criteria were used to evaluate the quality of studies. Freeman-Turkey double arcsine transformation method was used to calculate the combined prevalence. Age, time since event, type of trauma and trauma form were analyzed as subgroup factors. According to the source of the trauma, the type of trauma was divided into three different categories: disease, accident and specific profession. Specific profession refers to firefighters, veterans, intensive care staff, etc. The complex working environment, irregular lifestyle, various unpredictable factors, as well as the frequently adverse stimuli from others contribute to great physical and mental pressure.
Results:
Twenty-six articles were deemed as qualified for this systematic review and meta-analysis. The level of PTG across studies ranged from 10% to 77.3%, and heterogeneity tests showed high heterogeneity (I2 = 92.3%, 95%CI = 90.1%-94.0%, p < 0.01). Random effect model was chosen to calculate the combined prevalence and the prevalence was 52.58% (95%CI = 48.66%-56.48%). People whose age was younger than 60,had shorter time since trauma,worked in a specific profession and suffered from direct trauma reported high rate of moderate-to-high PTG.
Limitations:
Because the included studies haven't provided adequate PTG-related information, these factors could not be used to performed subgroup analyses. In addition, some studies were excluded due to the different standard may lead to deviation of the combined prevalence.
Conclusions:
Nearly half of the investigated individuals reported moderate-to-high PTG after experiencing a traumatic event. Future research needs to further study the determinants of PTG to provide relevant interventions for the victims of trauma.
Objective:
This study examined the nature and determinants of predominant trajectories of posttraumatic growth (PTG) over time.
Method:
Using data from a prospective, nationally representative survey of 2718 US veterans assessed in 2011, 2013, and 2015, we used latent growth mixture modeling to identify PTG trajectories, and to examine key determinants of PTG trajectories from a comprehensive set of sociodemographic, military, health, and psychosocial variables.
Results:
Three PTG trajectories were identified, labeled as Low and Decreasing PTG (74.0%), Consistently Moderate PTG (12.0%), and High and Increasing PTG (14.0%). Greater severity of posttraumatic stress disorder symptoms, specifically re-experiencing and avoidance symptoms, at baseline predicted Consistently Moderate and High and Increasing PTG trajectories. Compared to the Low and Decreasing PTG trajectory, the High and Increasing PTG trajectory scored higher on baseline measures of gratitude, purpose in life, Spirituality, and social support.
Conclusion:
Posttraumatic growth is a dynamic process with divergent trajectories. Developing interventions that target certain psychosocial factors may help trauma survivors maintain PTG over time.
Background:
In the last three decades, there has been increased interest in studying the association between religion/spirituality (R/S), and mental health and functional outcomes.
Methods:
Using data from a contemporary, nationally representative sample of 3151 U.S. military veterans maintained by GfK Knowledge Networks, Inc., we evaluated the relation between R/S and a broad range of mental health, and psychosocial variables. Veterans were grouped into three groups based on scores on the Duke University Religion Index: High R/S (weighted 11.6%), Moderate R/S (79.7%) and Low R/S (8.7%).
Results:
A "dose-response" protective association between R/S groups and several mental health outcomes was revealed, even after adjustment for sociodemographic and military variables. High R/S was associated with decreased risk for lifetime posttraumatic stress disorder (odds ratio [OR]=0.46), major depressive disorder (MDD; OR=0.50), and alcohol use disorder (OR=0.66), while Moderate R/S was associated with decreased risk for lifetime MDD (OR=0.66), current suicidal ideation (OR=0.63), and alcohol use disorder (OR=0.76). Higher levels of R/S were also strongly linked with increased dispositional gratitude, purpose in life, and posttraumatic growth.
Limitations:
In this cross-sectional study, no conclusions regarding causality can be made. The study provides a current snapshot of the link between R/S and mental health. The study also cannot determine whether religious coping styles (negative vs positive coping) contributed to observed differences.
Conclusions:
Although the present study does not have treatment implications, our results suggest that higher levels of R/S may help buffer risk for certain mental disorders and promote protective psychosocial characteristics in U.S. military veterans.
Background:
Posttraumatic growth (PTG) is commonly observed among trauma survivors. However, few studies have treated PTG as multi-dimensional and examined how different PTG dimensions may be protective against the negative effects of future trauma.
Methods:
Using a nationally representative web-based survey of 1057 U.S. military veterans followed for two years, we examined whether different PTG dimensions had a protective effect on the severity and diagnosis of posttraumatic stress disorder (PTSD) in the face of new traumatic life events.
Results:
Greater scores on the Personal Strength domain of the PTG Inventory-Short Form at baseline was associated with reduced severity (β=-.05, p<.05) and incidence (OR=.68, 95% CI=.50-.93) of PTSD at a two-year follow-up.
Limitations:
Results are associational and causality cannot be inferred so replication is needed.
Conclusions:
This study highlights the multi-dimensional nature of PTG and demonstrates a salubrious effect of trauma-related gains in personal strength on incident PTSD.
The measurement of burnout among physicians is important because physician well-being has the potential to affect workforce stability and quality of care. In this study, a single-item measure of burnout was validated against the sub-scales of the Maslach Burnout Inventory (emotional exhaustion, depersonalization, and personal accomplishment). Survey items included the 22-item Maslach Burnout Inventory, a single-item measure of burnout, and other questions regarding demographics, practice characteristics, and occupational satisfaction. The surveys were mailed to Texas Tech University School of Medicine Alumni classes of 1980–1989. The response rate was 43 per cent (n = 307). Pearson correlation coefficients and ANOVA were used to determine the association between the Maslach Burnout Inventory scores and the single-item burnout question. The single-item was correlated at r = 0.64 (p < 0.0001) with emotional exhaustion and the ANOVA yielded an R2 of 0.5 (p < 0.0001). Hence, in surveys of physicians where emotional exhaustion is the primary sub-scale of interest, a single-item measure of burnout may be used as an alternative to the Maslach Burnout Inventory in order to abbreviate survey material and potentially increase response rates among physicians. Copyright © 2004 John Wiley & Sons, Ltd.
To extend the literature the present study aims to examine the interrelationships between resilience (defined by a lack of posttraumatic stress disorder following trauma) and posttraumatic growth. Two studies were conducted of Israeli: (a) adolescents exposed to terror (N = 2908), and (b) citizens and army personnel following the second Lebanon War (N = 588). Across studies the results showed that high levels of resilience were associated with the lowest posttraumatic growth scores. The results imply that although growth and resilience are both salutogenic constructs they are inversely related. The theoretical and clinical implications of these findings are discussed.
Target article: posttraumatic growth
- Tedeschi
Tedeschi, R., Calhoun, L., 2004. Target article: posttraumatic growth. Psychol. Inquiry
15, 1-18.
- F W Weathers
- B T Litz
- T M Keane
- P A Palmieri
- B P Marx
- P P Schnurr
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P., 2013.
The PTSD Checklist for DSM-5 (PCL-5), www.ptsd.va.gov.