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Post-Traumatic Stress Disorder and the Role of the Certified Nursing Assistant

Michael Mileski, DC, MPH, MHA, MSHEd, LNFA

Over the last two decades, we have seen an increase in the number of cases of Post-Traumatic Stress Disorder (PTSD).  Mainly, we see this particular disorder in Veterans of military service, but also in residents who have undergone severely stressful situations in their lives as well.  According to Gradus (2015), approximately 6.8% of Americans are expected to have PTSD at some time in their lives.  This equates to approximately 7.7 million Americans at any given time (National Institutes of Health, 2009).

What is PTSD?
PTSD is nothing new, and has been in existence for as long as war has.  We used to refer to it as many other things, including “shell shock,” “soldier’s heart,” or “combat fatigue.”  Today this has changed to a real diagnosis that physicians and caregivers can do something to address.  Furthermore, it extends outside the war arena to people who have experienced or witnessed distressing events, such as 9/11, tornadoes, earthquakes, hurricanes, or any other disaster you can imagine.  We can also see it in those who have experienced car accidents, life-threatening illnesses, child abuse, rape, torture, battery, and a whole host of other extraordinary circumstances which cause massive amounts of stress in their lives.

When we consider PTSD, it is important to understand some of the outward signs we might see in someone who is experiencing the illness.  We can look for any or all of the following which are signs or symptoms of PTSD:

  • Verbal outbursts
  • Anger outbursts
  • Insomnia
  • Depression
  • Anxiety
  • Experiencing the original trauma through flashbacks, nightmares, or other means
  • Refusal to go to places or engage in situations which remind them of the event

Considering each of these, think about how many times you worked with a resident who showed these exact signs and symptoms.  Consider how many of your current residents might also be experiencing these same things currently.  Also, consider how someone without the understanding of this disease might simply pass off these symptoms as something else.  Understanding where these signs and symptoms fit into the context of PTSD is also of importance as well.  Table 1 shows how all the different stages of PTSD exist with each other, and how the symptoms are clustered into stages.  Understanding this table allows you to understand the disorder and where your residents might be in the continuum.
Where does this all leave you?
As a caregiver, the resident with PTSD is something you might not have previously encountered.  However, if you have not, the probability is high that you soon will.  You need to be on the lookout for residents who exhibit severe hostility, major depression, self-destructive behavior, or are potentially violent (Anxiety and Depression Association of America, 2015). 
Obviously it is up to you to do what you can to not only protect the residents you work with, but also yourself as well.  The certified nursing assistant is the first line of care.  You see more than anyone else does within a facility.  This also makes it your responsibility to report even the smallest changes you see in a resident.  It are these small changes, identified early, that can make a huge difference in the future of the resident.  If we are able to identify changes quickly, we can do things to prevent them from getting out of hand.  This can help to prevent negative outcomes for everyone involved.  You can also consider it in this fashion, the more you do to prevent these negative behaviors and outcomes from occurring, the easier and safer your job will be.  It is a win-win situation for you and for the resident. 

One significant thing to keep in mind as you read this are the policies and procedures of the facility where you work.  It is important that you ensure you are following these, as they are in place to not only protect the residents, but also to protect you!  Be certain that you understand what you should do in a situation where residents might act out.  Be certain that you understand your reporting requirements, and what to do if when you report something, nothing gets done.  From experience, your Administrator wants to know if someone is undergoing changes that you are noticing.  If nurses do not seem to care, talk to your Director of Nursing or Administrator.  They will ensure the best things happen for the residents that are possible.

Something else you need to consider is that you cannot “fix” everything despite your desire to do so.  Your main obligation is to care for your residents in the best way possible.  This means that you should be doing right by them at each encounter.  However, if you are left in a situation where you are not safe yourself, you should do your best to stabilize the situation and get others involved immediately.  Sometimes, the best thing you can do is walk away and get assistance.  You should not ever leave a resident who is in some sort of crisis “alone,” however you can step outside the room and call for the assistance you need.  Your safety and the safety of the resident is of paramount concern.

What Can You Do?
First and foremost, understand that there is no “right answer” to every situation.  Every occurrence, even with the same resident, has different nuances and will transpire in a different fashion.  There are often some common things which you can do however that will assist you in dealing with this behavior, or slowing its progression so you can get the help you need.  Consider some of the following effective measures in dealing with behaviors, outbursts, or other situations you might see in someone with PTSD:

  • Before you interact with any resident, ensure you are doing your part to negate any problems.  Always be sure to knock on the door, introduce yourself, let them know why you are there, and be clear in your communication with them.
  • Do not hurry the resident, and understand it is often best to break tasks into small pieces.  Instead of giving them a list of things they need to do when they get out of bed, start small, one task at a time, unless you know that you do not need to do this.  Too much to do at one time can cause them anxiety or irritation, both can be triggers to a PTSD event.
  • Always remain calm, thoughtful, and reassuring to anyone who is experiencing PTSD symptoms.  Anything less can cause the event to get worse.
  • Never take it personally.
  • ALWAYS report the occurrence immediately.
  • Find a favorite caregiver to help with the resident (Texas Department of Aging and Disability Services, 2015).  This can assist you in mitigating the situation and can buy some time for others to appropriately deal with what is going on.
  • Try to distract the resident with something that they like or enjoy (Texas Department of Aging and Disability Services, 2015).  Perhaps you can bring up an enjoyable topic which will help to take their mind off of whatever has triggered their current situation.
  • Never show your own anxiety, as it can make the resident with the episode more upset or agitated (Dementia Today, 2015).
  • If the resident is agitated, give them plenty of space to deal with this.  Get other residents away so that they are not harmed.  Get yourself away as well.  Get the help of others as well when this happens.
  • Reflect upon the incident after it is over.  Do you understand what caused it to begin with?  Was there a trigger event?  Was it something in the environment?  A particular person? 
  • Is there a new medical cause to this situation?  This is one main reason it is so important to report ANY event to nursing, and that they act upon the report.
  • Be sure to deal with your OWN feelings regarding the event.  Keep your cool during, never be aggressive, complete your task, and step away to calm yourself down when it is over.

Understand, you are the one thing between the resident and them potentially acting in an unsafe manner.  Do what you can to help negate these situations as they come, and to prevent them in the future.  You can quickly ascertain what your part can be, and if you can intervene very quickly.  If you are unable to do so, enlist the assistance of others who can.  At the end of the day, understand that your job is a stressful one, and can cause you some of the same symptoms that you just saw with your resident.  Ensuring that you are doing what is necessary to maintain your own health, mental and physical, is one of the most important things you can do.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349

Anxiety and Depression Association of America. (2015). Symptoms of PTSD. 
Retrieved from http://www.adaa.org/understanding-anxiety/posttraumatic-
stress-disorder-ptsd/symptoms

Dementia Today. (2015). Dementia and aggressive behavior.  Retrieved from http://www.dementiatoday.com/dealing-with-aggressive-behavior/

Texas Department of Aging and Disability Services. (2015). Module 7—Appropriate
responses to resident behaviors.  Retrieved from https://www.dads.state.tx.us/providers/nf/credentialing/NATCEP/
feedingassistant/module7.html

Gradus, J.L. (2015).  Epidemiology of PTSD.  Retrieved from http://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp

National Institutes of Health. (2009). PTSD: A growing epidemic. NIH Publication,
(4): 1. 10-14.
Dr. Mileski is an Assistant Professor at the Texas State University School of Health Administration, where he teaches courses in staff and supervisory management, patient care/satisfaction, long term care administration, and quality assurance. He can be reached at mileski@txstate.edu.