Instructional Protocol/Sensitivity during Interaction with PTSD Sufferers
By Carol Ware Duff RN MSN
University of Toledo School of Nursing
The purpose of this teaching program it to establish guidelines and teaching and learning objectives for positive interaction with veterans with Post Traumatic Stress Disorder (PTSD), which will ensure a positive experience for the person with PTSD and will encourage communication between patient and staff member. The veteran with PTSD will always be addressed with respect, compassion, and calmness. The teaching target group of learners (staff members) and learning theory employed are discussed. The objectives for this educational learning unit are listed. A teaching method for this program is designed and discussed.
The evaluation of the learner’s progress is discussed with its advantages and disadvantages. The process of developing and implementing the teaching project is discussed. Finally, a narrative of this learning program designing process is furnished. A handout for tips on providing positive interactions with veterans with PTSD is included at the end of this paper and the power point instructional tool for information about PTSD and positive interaction with veterans with PTSD and learner evaluation form is attached.
Description of Learners and Background on PTSD
The group of learners this teaching activity will address will be staff members who have contact with veterans with Post Traumatic Stress Disorder (PTSD). By nature of the job structure at the veteran’s facilities, the learners will be adults. Staff members may be current employees who need a refresher for maintaining competency in proper interaction techniques with veterans who have PTSD or new employees.
Post Traumatic Stress Disorder is a common psychiatric disorder with a lifetime risk in the general population of about 9% and more commonly in the veteran population where at least 30% of the veterans who served in Vietnam were affected by PTSD (Dieperink et al., 2005). Currently PTSD is defined as occurring after one experiences, witnesses, or confronts a traumatic event including actual or threatened death, serious injury, or a threat to body integrity of self or others that evokes fear, helplessness, or horror.
Traumatic events include physical assault, natural or man-made disasters, combat, and captivity (Cook & Mc’Donnell, 2005). Symptoms of PTSD include re-experiencing (flashbacks or visceral responses), avoidance activities (such as drinking or drug use), emotional numbing with social withdrawal, and arousal or hyper-vigilance. PTSD is acute if symptoms last less than three months and chronic if the symptoms continue for more than three months (Karner, 2008).
Trauma exposure has been associated with the dysregulation of the neuroendocrine, neurotransmitter, and autonomic and central nervous systems, which can cause considerable harm to health. Common responses of avoidance symptomatology of PTSD reduce the chance that the veterans affected will seek medical help. This reduces the chance of preventative or maintenance interventions. Those with PTSD may also have restricted social networks and social isolation, which is important because effective social support seems to be one of the most significant indicators of well-being and positively correlates with health (Lee, 1997).
Freud wrote of the narcissistic bubble of invulnerability or instinct of self-preservation that surrounds all humans and protects us from worrying about death as we go through life. While in a war zone, the bubble is burst and annihilation anxiety can become intense. Later, some veterans can reassemble the bubble but those with PTSD cannot (Garfield and Leveroni, 2000).
The emotional numbing symptoms of PTSD lead to withdrawal and difficulties in expressing emotion (Riggs, Byrne, Weathers, & Litz, 1998). Human responses to the disaster of war may prevent the individual from developing the healthy coping responses that are necessary for the individual to use to deal with feelings about combat, trauma, death, and war (Mullins, 1984).
The patient with PTSD may have issues and motivations that make it more difficult to interact with him or her. There is great need for the veteran with PTSD to feel comfortable, helped, respected, and calm in order for them to come to a facility for care. Veterans with PTSD will leave a facility without treatment, rather than to have confrontational interactions where they feel neglected and uncared about.
A veteran with PTSD may find it very difficult to leave his or her home to come to an appointment and that last thing that he or she should experience is a staff member who is rushing, brusque, or appears to be uncaring or even condescending. The person with PTSD is intuitive, quick to react, and will often have severe amounts of anxiety about all things and has little resource to deal with stressors of any nature. Patients with PTSD often express difficulties with concentration, attention and memory (Neylan et al., 2004).
The learning theory employed for this educational program will be social learning theory. The social learning theory works well for this educational module because the learner becomes the center (human agency) and the healthcare environment at a veteran outpatient clinic or facility is a social situation. Bandura observed that people learn by what happens to others and how they interpret the behaviors of others. Leaning is therefore a social experience (Bastable, 2008, pp. 67-77).
As noted by Bastable, role modeling is the vital idea of this theory. The staff members who are in tune with the veteran with PTSD will be good role models for others to emulate. Verbal and nonverbal interactions are often observed by others, even if the observer cannot hear specifically what is being said. Non-verbal clues from body language are an important part of this learning and communicating process. The gestures, facial expressions, and body position will also give messages, which can be understood from across a room.
Bastable (2008) also mentions vicarious reinforcement as another concept of social learning theory. Learners will watch how others are accepted or rejected to observe the acceptable way to act in a certain situation. The learner will tap into the constructivism information processing theory. He or she will build their knowledge by using older lessons and adding more and newer knowledge to perfect what is already known.
The parts of this information processing is that there is building from acquiring knowledge and skills, being able to plan a course of action, explore new roles, and come back to the world with a new view (Billings & Halstead, 2009, p, 197). The learner is open to new ideas, as new knowledge becomes known with continued research into evidence-based concepts about interactions with veteran who have PTSD. This educational instruction unit will become a basic class offered during the orientation of all new employees and will also be included in the competencies that all employees who interact with veterans with PTSD will be required to renew yearly.
Keeping the special communication skills needed in successful interaction with veterans with PTSD current and effectively using them will improve interaction with and cooperation from veterans who have PTSD.
Apply Learning Theory to Group
The learners will receive a refresher power point presentation with educator narrative on signs and symptoms of PTSD and how a veteran with PTSD may respond to various situations, he or she may encounter in the healthcare setting. The particular stressors that affect those with PTSD will be addressed and the presentation will conclude with ways to interact to avoid stressors for the veteran with PTSD.
This refresher will reinforce what the staff already has experienced with successful and effective interactions with veterans diagnosed with PTSD and; if measures have been forgotten or neglected, those measures can be relearned. The objectives of this teaching/educational unit are: (1) to define PTSD, (2) to identify potential situations for poor interactions and communication to develop between staff members and veterans with PTSD, and (3) to present an opportunity for role-playing between staff members to facilitate effective communication between staff members and the veteran with PTSD to encourage behaviors on the part of the staff members which will be reflected in positive interactions between staff members and veterans with PTSD.
Adult learners (staff members) usually posses the idea that they can be self-directed and responsible for their own actions. Teaching adults must be done in such a way that their internal motivation is intact. The learners will bring their own experiences to the task and better interaction measures should be introduced in addition to what the staff member may already now about how to deal with a veteran with PTSD (Billings & Halstead, 2009).
An adult learner, in this case the staff member, when faced with a problem, will put the problem in the center of the situation and will find ways to reduce the problem. The learners (staff members) can be offered reminders about how veterans with PTSD may act. For instance, a veteran with PTSD should not be seated with a crowd of people around him or her. From a personal account from a veteran with PTSD, being in a crowded room situation is described, “like lighting a fuse on a bomb.” The veteran feels stressed in close proximity with others.
Cell phone conversations, running children, and verbal conversations of those nearby are likely to provoke stress and anger. Stress levels will rise and with this other symptoms such as joint pain, elevated blood pressure, feelings of alienation, and paranoia. Two factors are at work here. Veterans are more comfortable with other veterans, but the general level of activity, exacerbated by long wait times, and waiting areas placed in busy areas of the hospital will cause great discomfort. It is necessary for the staff to do what they can to decrease waiting times, offer a waiting area that is free from cell phone use and loud or sudden noises.
Frequent checking back with the veteran, to let him or her know that status of his or her waiting process, will help to alleviate the feeling of being abandoned and let the veteran know that someone is interacting with him or her, remembers he or she is still there, and is doing what is possible to help make the healthcare facility visit as non-stressful as possible.
Implementation of Selected Teaching Strategies with Learner
Role-playing between staff members would be an effective mode of teaching for this type of learning activity. Billings & Halstead (2009) share that adult learners appreciate a comfortable physical and psychological environment in which to learn. The room can be made more comfortable with cushioned chairs and practicing interactions with those they work with may facilitate a feeling of well-being during the class instruction.
The learners could collaborate with each other to conduct the clinical experience. The staff members can divide into dyads and work as a team. They will compose their own dialog for interactions in front of the group. One student could be the veteran and the other, the staff member. The learners can bring situations that they have found themselves in to the group, play out the interaction with dialog and body language, and the group can analyze was has occurred.
There could be group discussion of what may make a better form of interaction and the new scenario then played out. Role-playing is particularly helpful for situations of developing or improving interpersonal relationships and the interaction between a veteran and staff worker is just that. Another plus for using role-playing is that there can be several endings for a scenario and the group can focus on what works best (Billings & Halstead, 2009). Role-playing is effectively used when the learners must evaluate their attitudes and behaviors and need to see an issue from another’s viewpoint. The educator must define the problem, set the climate, and determine the goals. This is part of the planning of the teaching program and can be time-consuming (Lewis, Heitkemper, & Dirksen, 2004).
Evaluation of Learners
Evaluation of the role-playing roles can be accomplished by the educator, learners (staff members), or a combination of the two. The combination of evaluation between educator and learners will create more chances of exploring what makes a good interaction scenario with a veteran with PTSD. Self-evaluation of scenarios can be helpful in that the situation can be revisited and reanalyzed and be given a different outcome.
The advantages of role-playing are that it offers the chance to practice peer review and the learners are more apt to be actively involved in the learning process when they are in a sense “performing.” The process can be easily and immediately replayed with changes if necessary (Billings & Halstead, 2009). The role-playing sessions can be videotaped for future use and to re-evaluate interactions. With such a visual and verbal activity, all who are involved in watching the scenario can offer input. The learner can see what mistakes he or she might be making in interacting with veterans and can self-correct. Role-playing is an effective method to change attitudes and perceptions (Bastable, 2003).
Disadvantages for this type of learning are that some may feel self-conscious about performing and the evaluation of role-playing performance could be viewed as subjective. No correct or incorrect answer may leave a gray area (Billings & Halstead, 2009 p. 426), but being able to discuss openly what has happened during the interactions between staff members and pretend veterans with PTSD will allow for a development of an appreciation for the ability to interact positively with the veterans.
A certain comfort level is required for role-playing to be a desirable learning method. To facilitate this point, members of the same nursing team or unit or work area, can be grouped so that can feel comfortable with those they are role-playing with. A specific disadvantage for this educational unit would be if the staff member has not had training in successfully communicating with and preventing confrontations with veterans or in being able to decrease the intensity of the confrontation.
For the situation of working with veterans who have a great probability of experiencing PTSD, the staff should have some prior knowledge of causes for, symptoms of, and potential pitfalls of not adequately addressing the needs of the veteran with PTSD. This knowledge and instructional unit would be addressed at orientation to the new job as well as during the yearly competency.
Process of Developing and Implementing Project
I felt that this learning project needed to be developed after being in a veteran hospital for my practicum and from personal experiences. PTSD is a very common result of experiencing traumatic events. PTSD is currently being more intensely addressed, as we continue to send men and women into war situations. With the vast influx of potential patients who will be diagnosed with PTSD, there will be a need to interact in a helpful and therapeutic fashion and to do so effectively to offer healthcare to the growing numbers. PTSD is an illness that can be acute or chronic in nature and will be a potential illness as long as humans suffer traumas.
Veterans are often negatively affected by the time they have spent in wars. I could see areas of frustration on the part of both the staff and patients and the ones who can more easily change the way they interact are the staff, who for the most part are not veterans and do not have the diagnoses of PTSD. As health care workers and providers, we are ethically responsible for insuring our patient’s well-being and must make the effort to offer the best care possible.
After investigating many articles on PTSD, in medical, nursing, psychological, and sociological, and research publications, personal observations, and speaking with veterans, I felt the need to develop this learning opportunity for those who interact with veterans who have PTSD. Veterans with PTSD are at a disadvantage with how they have reacted to the trauma in their lives. They often have sleepless nights, poor emotional ties, which leads to social isolation, trouble dealing with stress, increased response to stressors, poor employment history, have difficulty in controlling painful memories, irritability, difficulty concentrating, hypervigilence, depression, and feel guilt and shame (Iraq War Clinician Guide: National Center for PTSD Fact Sheet, 2004).
The continuing wars in Iraq and Afghanistan will create more opportunities for veterans to experience PTSD. Veterans returning from these wars will have difficulties with anger regulation, be hostile, aggressive, may be generally violent, have outbursts of anger, heightened arousal, hostile appraisal of events, loss of ability to engage in self-monitoring, or other inhibitory process, and respond to this as perceived threat (Iraq War Clinician Guide, Assessment and Treatment of Anger, 2004).
It is essential that staff who interact with veterans with PTSD be compassionate, calm, empathetic, efficient, respectful, and clear in what they are saying. People with PTSD do not need to be singled out as a threat, but are clearly members of a group of people who will be hypersensitive and likely on medications that will interfere with their ability to react in a cognizant manner. They may not respond quickly to having their name called, but hear it just the same. It is necessary for staff to be aware that they are dealing with a PTSD patient and to have an adequate “tool box” to prevent potential escalations which as noted previously can include aggressive behaviors in response to perceived threats or varying environmental stimuli.
A critical issue for a staff member is that the PTSD sufferer, who may often be the most challenging or demanding, is also the most fragile emotionally with an illness brought on by traumas as diverse as childhood abuse, sexual battery, or hand-to-hand combat in defense of their country. Common responses of the avoidance symptomatology of PTSD reduce the chance that people affected will seek medical help. This reduces the chance of preventative or maintenance interventions. Those with PTSD may also have restricted social networks and social isolation, which is important because effective social support seems to be one of the most significant indicators of well-being and positively correlates with health (Lee, 1997).
In summary, it will be necessary and helpful for the staff to play act situations so they will be prepared to handle actual situations and to understand what they can do to avoid confrontations. Basically, interacting with a veteran with PTSD is parallel to being polite, caring, empathetic, and human. PTSD is an illness that can be acute or chronic in nature and will be a potential illness as long as humans suffer traumas. Veterans are affected by the time they have spent in wars. Wars may end but will continue to come back into the lives of those who fought in them, the veterans.
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- Billings, D., & Halstead, J. (2009). Teaching in Nursing: A Guide for Faculty (3rd edition). St. Louis, MO: Sanders Elsevier.
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- Iraq War Clinician Guide, 2nd edition (2004). War-zone-related stress reactions: What families need to know. Assessment and Treatment of Anger. Walter Reed Army Medical Center.
- Karner, T. (2008). Post-traumatic stress disorder and older men: If only time healed all wounds. Generations: Older Men’s Health, June 2008, 82-87.
- Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th edition). St. Louis, MO: Mosby. Lee, L. (1997). Social support, reciprocity, and well-being. Journal of Social Psychology (137), 618-628.
- Mullis, M. (1984). Vietnam: The human fallout. Journal of Psychosocial Nursing 22 (2), 27-31.
- Neylan, T., Lenoci, M., Rothlind, J., Metzler, T., Schuff, N., Du, A., Franklin, K., Weiss,
- D., Weiner, M. & Marmar, C. (2004). Attention, learning, and memory in posttraumatic stress disorder. Journal of Traumatic Stress 17 (1), 41-46.
- Riggs, D., Byrne, C., Weathers, F. & Litz, B. (1998). The quality of intimate relationships of male Vietnam veterans: Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress 11, 87-101.
Handout for Interaction with Veterans with PTSD in the Healthcare Situation
- Introduce yourself and have a positive attitude, explain what is going to happen if the veteran is there for a procedure.
- Make eye contact.
- Be formal unless given permission to be informal.
- Use a quite tone of voice and speak while looking at the veteran (many have hearing deficits).
- Use the patient’s name, he or she is not a task or case.
- Let the veteran know that you appreciate the situation that he or she finds him or herself in.
- Listen carefully and make sure you understand.
- Acknowledge and express concern.
- Listen, clarify, use common language, avoid using rules as reasons to not help.
- What have you heard is a good question to ask.
- Offer respect.
- Appreciate what the veteran has gone through and will be going through.
- Offer choices when making appointments, try to coordinate all appointments on the same day.
- Look for the patient’s strengths.
- Welcome concerns and complaints.
- Do not hurry. Remain calm.
- The veteran is always right.
Learner Evaluation Form Instructional Protocol/Sensitivity during Interaction with PTSD Sufferers
A. How helpful did you find the role-playing exercise of the unit?
1.Not at all 2. Fairly helpful 3.Very helpful
B. Was the power point presentation informative?
1.Not at all 2.Fairly informative 3.Very informative
C. Was the information throughout the educational unit given in a clear manner?
1. Not at all 2.Fairly clear 3.Very clear
D. Did you gather new information and skills?
1.None at all 2. Some new information 3.Some new skills
E. Did the instructor allow enough time for questions?
1.No 2. Too much time 3.Enough time
6, How helpful did you find this educational unit in helping you to interact with veterans with PTSD?
1. Not at all helpful 2.Somewhat helpful 3.Very helpful and necessary
Any suggestions for changes to this class are welcomed
Thank you for taking the time to fill out this evaluation. I take your comments and suggestions seriously as I wish to offer a class that is both informative and useful.
ABOUT THE AUTHOR: Carol Duff is an RN/MSN Nurse Educator specializing in veterans issues. She also has a degree in Military History from Bowling Green State University.
Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.
She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – one daughter-in-law; Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with her husband Gordon Duff, many cats, and two rescues.