Mohammad Qutishat,Aisha Al Shdefat,Kholoud Al Damery

1Lecturer, Department of Community and Mental Health, College of Nursing, Sultan Qaboos University, Sultanate of Oman;

2Lecturer,Department of Maternal and Child Health,College of Nursing,Sultan Qaboos University,Sultanate of Oman.

Abstract Background: Since the coronavirus outbreak (COVID-19) has been declared an emergency in public health and has drawn enormous attention worldwide, the number of infected cases and deaths increases.The psychological well-being of the citizens and the health team workers might be affected and lead to more anxiety and stress, such as Post Traumatic Stress Disorder. Aim: This paper aims to provide a holistic approach regarding nursing management of Post-Traumatic Stress Disorder concerning the COVID-19 outbreak and the consequences of lockdown, quarantine, or curfew.Methods:An extensive literature searchesCumulative Index of Nursing&Allied Health Literature (CINAHL), ProQuest Nursing & Allied Health Database, Google scholar PubMed, Ovid MEDLINE, Psych articles, and Psych Info,were conducted to achieve the objective of the study. Results:This paper highlights that the experiences of PTSD among patients in different age groups and health conditions,as well as health team workers as a result of the COVID-19 outbreak, can be affected by several factors including health and social stigmatization, media influences, and public health awareness.The result of this paper suggested that it is important for all nursing practices, concerning the treatment of patients with COVID-19 and its psychological symptoms, especially PTSD, to master their skills and knowledge to gather crucial information on the history of patient distress and to assess their existing levels of stress and anxiety-related the pandemic. Conclusion: The COVID-19 pandemic involves several possible causes of distress for particular people, such as experiencing a loved one's death or being terminally ill; this may lead to post-traumatic stress disorder (PTSD), which needs skilled and certified nurses to collaborate closely alongside other health.team members to identify, manage and support the health of such persons effectively.

Keywords:PTSD,COVID-19,Nursing management,Infectious disease

Introduction

Coronaviruses are a class of viruses that can cause the common cold, severe acute respiratory syndrome(SARS), and Middle East Respiratory Syndrome(MERS).Scientists have identified a new coronavirus as the source of a disease outbreak in China in 2019 and have retained global recognition[1].

The coronavirus outbreak (COVID-19) has been declared an emergency in public health and has drawn enormous attention worldwide.Under COVID-19,several governments took strict quarantine measures and implemented an immediate lockdown and curfew program to prevent further spread and contain infectious diseases worldwide [2].Global governments have stopped traveling between their nations, studying at university, and schools that have been suspended and turned into online later; people are forced to stay in their homes and keep their social distance as much as they can[3].

People who develop symptoms or have similar symptoms of COVID-19 were quarantined for 14 days[4].Other people are forced to curfew and staying home with minimum physical mobility in their hometowns; During that, they receive instructions about what to do and how they can help their family members [5].They also have to handle their work and look after their children and their families.Therefore,quarantine, lockdown, or curfew are not favorable decisions for most people,and they have emotions that are psychosocial,physical,and adverse effects[2].

As the number of infected cases and death are increasing, the shortage of health care providers and medical resources all over the world, the lack of clear and definite information of virus from the media, and lack of protecting supplies in the marketplace,suffering intense anxiety due to the uncertainty and insecurity are increasing and affecting the psychological well-being for citizens and health team workers as well and can lead to more anxiety disorder[6].Thus this paper aims to provide a holistic approach regarding nursing management of PTSD concerning the COVID 12 outbreak and the consequences of lockdown,quarantine,or curfew.

Methods

The following published research databases were searched: Cumulative Index of Nursing & Allied Health Literature (CINAHL), ProQuest Nursing &Allied Health Database,Google scholar PubMed,Ovid MEDLINE, Psycharticles, and PsychInfo.Search terms used were:(posttraumatic stress disorder or PTSD)and(anxiety related to COVID-19 among nurses) and(prevalence or incidence or occurrence or survey or cohort related to virus's outbreak), (nursing management of coronavirus),and (nursing management of PTSD).

These searches returned 232 unduplicated potential studies that were then assessed for the following inclusion criteria: (1) nurses and patients were included in the sample, (2) conducted in a relation to respiratory virus's outbreak,(3)studies of special circumstances and advanced care such as suicide and severe psychiatric problems), (4) PTSD prevalence rates were reported or calculable(5)reports from international health care organizations.Two reviewers independently searched for eligible studies and consensus decisions were reached after discussion.21 studies met all criteria and were included in this research synthesis.

A qualitative summary of evidence Post-traumatic Stress Disorder(PTSD)and Infectious Disease

Post-traumatic stress disorder(PTSD)follow traumatic events beyond the context of ordinary human experiences, such as violent physical attacks, abuse,injuries, harassment, natural catastrophes, and specific disease recovery,and are described by typical intrusion symptoms.The severity of the trauma, related stimuli avoidance, emotional numbing, and hyper-arousal activity.It has been estimated that up to 8% of people in the U.S.would develop PTSD at some stage in their lives; females are twice as likely to experience it than males[7].

Some studies have investigated the psychological consequences of epidemics, such as Extreme Acute Respiratory Syndrome (SARS) and H1N1.One study recorded that 9.6% of those or their friends and family who were quarantined or suspected of infection had psychological symptoms after the SARS[8].Mak et al.and Lam et al.reported that more than 40 percent of SARS patients confirmed having suffered PTSD at one point during the outbreak.Meanwhile, those respondents who were isolated, employed in high-risk workplaces such as SARS hospitals, or had friends or close relatives who contacted SARS were two to three times more likely than those who were not exposed to the virus to develop elevated rates of PTSD[9,10].

A recent study found that the prevalence of PTSS in China was 7 percent a month after the COVID-19 outbreak.Compared to earlier research that reported a prevalence of 3.7% during the post-SARS epidemic in Taiwan[8,11].

People with PTSD experience disturbing thoughts or emotions linked to a traumatic incident long after the event occurred.The traumatic event may be suffered or witnessed directly by someone or learned due to shared information of a traumatic event experienced by someone closed [12].PTSD is diagnosed after a person has experienced symptoms for at least one month after a traumatic event.Symptoms occur most often within three months of the event but can take years to emerge[13].

Clinician associates PTSD with a broad spectrum of signs, such as re-experiencing a traumatic experience that involves frequent recollections,flashbacks, and nightmares, avoiding trauma-related individuals, places, and activities, and increased arousal such as difficulty in sleeping and concentrating,becoming jumpy,and being anxious and annoyed[12].

Nursing Management of PTSD in a Relation of COVID-19

It is essential for all nursing practices that involve caring for patients with COVID-19 and its psychological symptoms, particularly PTSD, to master their communication skills to gather vital information on patient trauma history and measure their current stress and anxiety levels.Besides, they also requested to demonstrate empathy, compassion and validated emotional reactions.

Nurses should carry out a detailed examination and evaluation of a patient's physical well-being.Nurses should use the DSM-V criterion to determine these symptoms.By answering up-to-date questions regarding their background, general well-being, life experiences, coping strategies, social networking, and others, it will be better to assess whether their conditions are exacerbated or if an individual is under-reliant.It should be remembered.However, that PTSD misdiagnosis remains very easy given the fact that most patients do not show up when discussing their symptoms, partly because they do not understand what causes their symptoms and therefore fear that they will be perceived or diagnosed as “mentally ill”[14].Social networking platforms like Twitter and Facebook play a growing role in crises while providing forums for mutual grief, reflection, and conversation about traumas.Thus these platforms offer an opportunity to examine whether post-traumatic stress and anxiety can be easily detected.Using telemedicine,including telephone or video calls and social media platforms, required the nurses to be more aware that the pandemic is affecting countries with different cultural environments and various available resources to deal with it.

Post-traumatic stress disorder treatment can help the patients regain a sense of control over symptoms and life.Nurses should recognize that the primary treatment for PTSD is psychotherapy.However,medication can also be included.Combining these treatments can be more beneficial.Resistance may occur when a patient experiences a conflict during treatment.Confrontation is not the best approach.However, nurses should deescalate the situation,examine the patients' concerns, and guide him to identify his solutions[15].

With proper training, healthcare professionals in multiple disciplines can administer or assist in delivering primary PTSD therapies and treatments.Health team workers can utilize psychotherapy to treat children and adults with PTSD, such as psychoeducation, group therapy, cognitive therapy,exposure therapy,and systemic desensitization.

Nurses should assess the readiness of the patient of doing such treatments, they should also elicit and strengthen a patient's motivation for seeking help,discuss the opportunities available, that is convenient to the patient health condition,and other related factors,complete mental health assessment, a history of previous treatment and experiences, physical health and some needed lab investigation, consent for is a compulsory requirement [15, 16].If medications are prescribed, nurses should advise patients to take them according to the healthcare provider's instructions.They should also remember that PTSD treatment includes antidepressant and anti-anxiety medication;the combination can be adjusted and co-existed with other medical procedures.Nurses should remember to educate patients about expected benefits and potential adverse reactions, remind them how substantial is the medication compliance, in the early stage, establish suicidal precaution if the antidepressant is the choice,encourage them to express their feelings and their previous medication experiences, and collaborate with the multidisciplinary team to adjust the medication dose or medication schedule if needed.

Health Awareness and Anxiety Reduction Associated with PTSD and COVID-19

As a nurse, it is essential to provide psychoeducation with comprehensive knowledge on documented hazards and the physical and mental well-being effects of COVID-19.Psychoeducation may include the difficulties in managing the virus-related uncertainties that almost everyone is experiencing right now, which may be particularly challenging for some people with PTSD. Nurses should highlight the need for distractions, sleep hygiene, a healthy diet, medication compliance, mindfulness techniques, and exercise;Patients need to understand that this health crisis may persist for some time.

It is now a fact that some patients spend hours monitoring television and social media outlets,displaying information on newly identified cases,recovered cases, and even death, which can significantly worsen their PTSD and anxiety.Nurses should offer patients and their families with a balanced approach of these connections not to exceed, for example, one hour a day; making it twice or three times a day for a total of one hour as described above may also be crucial.Suggest reliable sources to avoid myths, rumors, and misinformation.These resources are the World Health Organization(WHO),the Centers for Disease Control and Prevention (CDC), Center for Health Security, and the National Health Service.Nurses can also give pieces of advice in a reasonable amount of time,listening to the news as a distraction to work or desired activities.They can provide awareness of anxiety and a healthy perspective on risk, discuss depression and loss of control and suggest hedonic activities such as baking, cooking, gardening,inventing a new game,or watching a film.

Patients under quarantine or curfew, staying at home under regional limits, or recovered from COVID infection are at high risk of disturbing circadian rhythms that might increase the anxiety and exacerbate the symptoms of PTSD.In contrast, standard circadian patterns and regular physical activity are essential to decrease stress or alarm thresholds and better control PTSD symptoms.Therefore, it is recommended that the nurse suggest a proper waking time and bedtime that can be easily observed daily and that some physical activity is done regularly in the morning or at any desired time.

Nurses should remember that the full eradication of PTSD may be more challenging for people with psychiatric disease co-morbidity and PTSD [17].It should also be noted that diagnosing PTSD can be much more difficult when other mental illnesses co-exist and mask some symptoms with PTSD,such as depression or anxiety.Patients and family members are often motivated to keep weight under control by developing new areas for home sports and incorporating physical exercise in their home routine.Besides, meditation and yoga can be beneficial to individual patients dealing with the pandemic's mental consequences.Online,some excellent videos are freely available on YouTube or other smartphone apps.

Stigma and COVID-19; Implications of PTSD Nursing Managements

Rumors and misinformation are rampant when a new virus causes the outbreak.Quickly, there are stereotypes about people who have or may have the disease.For example, Asian people have been treated with suspicion and blamed for COVID-19, people were also worried that after completing the quarantine,recovered individuals might stay contagious.Reports indicated that blaming and imprinting them with such stereotypes can be hurtful and dangerous.It makes people targets misplaced anger and hostility and makes them feel isolated and even abandoned[18].

Being a nurse can put you on the frontline in reducing Stigma and discrimination, this means that nurses should encourage people, families, and other health care providers not to imprint people with this condition as "COVID-19 cases," "victims,""COVID-19 suspect," or "suspected cases." that can trigger the incidence of PTSD or worsen its condition.Nurses should not repeat or spread unconfirmed rumors and avoid using hyperbolic language to generate insecurity, such as "plague" or "apocalypse."They should remember that using these terms gives the impression that people with the disorder have done something terrible or are less human than others.

COVID-19 has risen globally in many geographical areas and influenced people from many countries.The nurse should not match the disease to any particular ethnicity or nationality.Be empathetic towards all those in the active phase, recovery phase,and even death.Those affected by COVID-19 have done nothing wrong and deserve the support,sympathy,and kindness and if they spread out unintentionally within their families and neighborhood.Find opportunities to enhance positive and hopeful stories and positive images for people who have COVID-19.

Nurses and COVID-19

Earlier studies indicated that nurses are in the frontline for developing PTSD [19]; ICU nurses have a higher prevalence of PTSD symptoms than other nurses [20].As a result of COVID-19, these numbers will undoubtedly increase.The shortage of safety facilities for hospital personnel all over the world, the various risk to infections,death,concerns regarding interacting with fellow workers who may be a particular case to COVID-19, strict measures, and loss of medical staff that put further burden on this high-pressure job,raising the probability of anxiety and fear[21].

As cases of COVID-19 continue rising, nurses are requested to maintain their mental health and well-being during this period to ensure their overall health.They should make sure to bear in mind that the current situation will not go away immediately, so instead of frequent short-term crisis responses, they can concentrate on longer-term occupational roles.

Nurses are also requested to use helpful coping strategies such as having enough rest during work or between shifts, consume healthier food, engage in physical activity, and stay in contact with family and close friends.They should be aware that unhealthy coping mechanisms that are not effective, such as cigarettes, alcohol, or drugs that can make the condition also worsen, should be avoided [22].Sadly,some healthcare workers can experience avoidance because of Stigma or fear by their families or friends,which can make a situation that is already complicated even more difficult.Staying close to loved ones, even by digital means, is one way to keep in touch and obtain social assistance, sometimes with those who may have similar experiences[22].

Children and COVID-19, Implications of PTSD Nursing Managements

Nurses should pay more attention to children and help them to find meaningful ways to convey emotions like anxiety and sadness.Each child has his style of expressing feelings.Participating in a creative activity like playing or drawing may often promote the process.Nurses should Keep and encourage parents to formulate familiar routines as much as possible in everyday life, particularly when children have to stay at home.It should come to the nurse's mind to provide children with age-appropriate events, including learning experiences, and allow them to continue playing and socializing with others, even when instructed to limit social interaction during quarantine,curfew, and even hospitalization.It is usual for children to seek more bonding in times of stress and crisis, and to be more demanding on parents.Nurses and parents need to discuss COVID-19 frankly and in an age-appropriate way with the children representing the facts of infected cases, antecedents, consequences,and even death as they study the actions and feelings of adults in tough times to control their emotions[22].

Elderly and COVID-19, Implications of PTSD Nursing Managements

Older adults, particularly in isolation and those with cognitive and physical disabilities, may become more anxious, angry, stressed, agitated, and withdrawn during the COVID-19 outbreak,while in quarantine,or as being infected or recovered individual.It is meaningful that nurses need to provide practical and emotional support through informal networks and health professionals.They should share basic facts and straightforward details about what is happening and how infection risk can be what.Repeat the information where appropriate.Nurses should not be judgmental and keep sharing the directions in a simple, brief,respectful, and patient way.Nurses can use photos and writings for emotional expression.They can engage family members and other support systems to provide information and help people take preventive measures andlearn simple daily physical exercises to perform at home,in quarantine,isolation,or after recovery[22].

Suicide and COVID-19Implications of PTSD Nursing Managements

Recent studies have shown that certain patients are on the frontline of committing suicide, especially those with extreme obsessions, comorbid depression, bipolar disorder,impulse control disorders,drug use disorders,personality, and eating disorders [23].Nurses should bear in mind that suicide risk assessment should include the significant rise in frequency of PTSD, the history of suicide behavior, the patient's compliance with treatment, the social support, the life impairment,and the co-morbidity of other mental health issues [24,25].

For all patients with PTSD,nurses should actively evaluate the suicide ideation and warning signs of suicide; the assessment might include some valid tools and specific instruments such as The Nurses' Global Assessment of Suicide Risk (NGASR) [26].They should establish a safe environment and close observations whenever hospitalization is required [27,28].

Nurses must prioritize caring for patients with depressive symptoms; it is essential to remember that using supportive techniques is a critical element of care.However, the nurses should still try to find ways to help the patient develop resilience to his mind.Avoidance should be carefully assessed to determine whether it is proportionate to the current situation and correctly addressed to prevent flashbacks.It is highly recommended that nurses need to help isolated patients overcome loneliness associated with PTSD cases or these as a result of COVID-19, they should help the patient to build stability through increased communication with friends, family members, and loved ones.

Patients with PTSD usually feel guilty,powerless,hopeless, and helpless about their feelings.In COVID-19, they might blame themselves if someone is infected or health deterioration.Staff should motivate them to express their feelings by asking the proper questions to identify internal and external trigger points that deteriorate the patient's health.The main objective during this point is to enable the patient to develop a sense of dignity and gain control over their symptoms; nurses must understand how PTSD makes a patient feel and then build a communicative and trust-based relationship with empathy and respect[18].

Parents and children who suffer from these symptoms should be encouraged to maintain social interaction with their environment [29].Parents should not only concentrate on the issues relating to the current pandemic situation but should also be encouraged to participate in fun activities with their children.Especially in a quarantine situation, it is essential to clarify that the coronavirus does not define every aspect of life[30].

Conclusion

The COVID-19 pandemic involves several possible causes of suffering for particular people, such as experiencing the loss of a loved one or being terminally ill that may lead to post-traumatic stress disorder (PTSD).Skilled and certified nurses are expected to collaborate closely alongside other health team members to assess, treat, and promote the health of such persons comprehensively.