INTRODUCTION:

Over the past two decades Iraq has endured three international wars; and 13 years of economic sanctions, dictatorship, foreign occupation, and acts of terrorism (Al-Hilfi, Lafta, and Burnham, 2013; Garfield and McCarthy, 2005).

For professional nurses practicing in Iraq, expectations have been for professional life to continue as usual; caregivers are to function as if the stress of political unrest and personal insecurity does not have psychological impact.

Effects of daily exposure to war and terror on health care providers have not been well documented in professional literature (Al Hifi, Lafta and Burnham, 2013; Shabila, Al-Tawil, Al-Hadithi, and Sondorp, 2012). Little is known about the impact of a perceived daily threat to personal safety on nurses, even if that threat no longer exists. In a limited of number studies, exploration of the long-term outcomes of psychological trauma arising from political conflicts and war has focused on soldiers and health care providers returning from war zones (Feczer and Bjorklund, 2009; Kolkow, Spira, Morse, and Grieger, 2007; Nayback, 2009). These studies presume that the source of threat, a war zone, has been left behind and the traumatized individual has entered a safe haven where personal safety is no longer an issue.

Healing from perceived threats to personal safety when one’s locus of comfort and support, home and country, are the source of danger requires acknowledging and understanding the lived experience. Therefore, gathering information is a valuable first step in determining how recovery or adaption can proceed. Results from a phenomenological study were obtained to inform “caregivers of caregivers” in healing the trauma of war and terror.

BACKGROUND:

Health care personnel practicing in modern warfare settings are at increased risk for developing post-traumatic stress disorder (PTSD) (Kolkow, Spira, Morse, and Grieger, 2007). PTSD makes up the largest part of published reports on psychological trauma suffered by health care responders in war and terrorist acts (Feczer and Bjorklund, 2009; Nayback, 2009). A small number of studies have examined the phenomena of Post Traumatic Growth (PTG) as a positive outcome of stressors usually associated with development of post traumatic syndromes (Galea et al., 2002; Lev-Wiesel, Goldblatt, Eisikovits, and Admi, 2009; Rieck, Shakespeare-Finch, Morris, and Newbery, 2005). PTG has been associated with an individual’s abilities to draw upon personal resources, such as resilience and agency, to reframe personal meaning of life (Galea et al., 2002; Lev-Wiesel, Goldblatt, Eisikovits, and Admi, 2009).

The effects of psychological trauma on health care personnel, and the effect of terrorism or war on health care systems have been the focus of a limited number of studies (AbuAlRub, Khalifa, and Habbib, 2007; Firouzkouhi, Zargham-Boroujeni, Nouraei, Yousefi, and Holmes, 2013; Elliott, 2012; Lev-Wiesel, Goldblatt, Eisikovits, and Admi, 2009; Scannell‐Desch and Doherty, 2010, 2012). Deployed military nurses and civilian nurses in countries in the midst of war or terrorist action described the psychological impact of stress, violence, and vulnerability. Research examining experiences of returning military personnel highlighted the dual nature of the soldier-nurse and difficulties of reintegration in a country far removed from a culture of war (Elliott, 2012; Scannell and Doherty, 2010). Studies of civilian nurses living in countries experiencing war or countries perceived to be under the threat of violence described efforts to create a “new reality” that minimized the untoward effects of their daily stress (AbuAlRub, Khalifa, and Habbib, 2007; Firouzkouhi, Zargham-Boroujeni, Nouraei, Yousefi, and Holmes, 2013; Lev-Wiesel, Goldblatt, Eisikovits, and Admi, 2009).

Results of this literature review emphasize that little is known about the experiences of nurses who live and practice in communities impacted by terrorism or war. A limited number of studies examined the experiences of military nurses deployed to war zones and the sequelae resulting from that exposure, but to date no parallels have been drawn between the experiences of deployed nurses and those whose community of work and practice is itself the war zone.

OBJECTIVE:

Guided by Watson’s Human Caring Science (2012), this phenomenological investigation describes the lived experiences of Iraqi nurses who experienced the realities of war or terrorist threat as both citizens and practitioners in Iraq.

METHODOLOGY AND POPULATION:

After securing university Institutional Review Board approval, purposive sampling was used to recruit 10 professional nurses from Iraq. Participants in this study were male, possessed a degree in nursing, spoke English or Arabic, had lived and practiced as professional nurses in Iraq since 2003, and held Iraqi citizenship. After obtaining informed consent, single session, hour-long face-to-face or technology facilitated (Skype) interviews were conducted over a one month period in 2014 by members of the research team. Interviews were audio-recorded with the participants’ consent and transcribed verbatim immediately following each interview. Once transcription accuracy was verified, the recordings were destroyed.

Data management and analysis were ongoing. Analysis of data was first conducted individually by each member of the research team in isolation using Giorgi’s approach to phenomenological analysis. Significant words, phrases, sentences, and paragraphs were extracted from each transcript and then grouped into conceptual units or themes; this included thoughts and feelings related to living with the ongoing trauma of war or terrorism. Thereafter, the researchers collectively shared individual analyses of transcripts, clarified themes, and composed the narrative text, using this as a forum for achieving inter-rater reliability.

Findings:

Two main themes and seven subthemes emerged from analysis of the data.

Theme 1. Living under the Shadow:

This theme served as an umbrella for five subthemes. Living under the Shadow illustrated the pervasive trauma experienced by nurses. In response to the question, “What was your experience as a professional Iraqi nurse living and working in a community exposed to the threat of war or terrorist action on a daily basis?” One participant answered:

From where [do] you want me to start? Shall I start from facing the inevitable death every single day, or… the flashbacks and nightmares of headless unknown human bodies, or… the stories of destroyed families that I provided care to after the crisis of sectarian violence, or… with horrible death traps that terrorists set for ambulance crews?

Five subthemes addressed specific effects of unabated stress on the individual nurse: Impact on Personal Life, Effects on Physical Well-Being, Influence on Mental Health and Emotional Well-being, Impact on the Delivery of Nursing Care, and Lost Sense of Personal Safety.

Impact on Personal Life:

The influence of the exposure to continual threat on the personal lives of the nurses in this study was exemplified by participant comments surrounding the unpredictable nature of each day. “Every morning I was asking myself, Will I be able to go to work this morning? Will I get killed today? Will I [be] exposed to explosions and die or [be] injured? Will I be able to get back home?” Another participant reflected:

Maybe that’s the reason behind postponing the marriage decision. Who would guarantee that if I would start a family that I’m not going to lose my life at the wedding day or maybe the second day? It was not a good time to start a family.

Effects on Physical Well-Being:

Nurse participants used medical terminology to discuss the effects of continual exposure to war and threat on their physical well-being in the second subtheme.

I experienced continuous headache, hyper and hypotension, arrhythmias, loss of appetite for days, and even some short-term gastro-intestinal tract disturbances related to that hard experience, since I was completely healthy before that.

Another participant added:

I started to feel sick and my blood pressure has been elevated due to the impact of stressors or as a result of post-traumatic stress disorders. This affected my sleep, caused palpitations, and continuous headache.

Influence on Mental Health and Emotional Well-being:

This subtheme was the most prevalent in describing the effects of continual exposure to war and terrorist threat:

Regarding the psychological side, I suffered for a relatively long time after I experienced trauma. Horrific nightmares and flashback memories about the explosion scenes, uncontrolled anger episodes, mood swings, and fear of unknown. They were some examples of the negative psychological effects of such a trauma.

Psychologically, I cried a lot and felt so sad. I was depressed and my behaviors changed with others. I became so nervous. Till now, when I remember these events (trauma) it makes me nervous.

I was fully aware that I was experiencing typical post-traumatic stress disorder or shortly known as PTSD. Flashbacks, imagining myself as a murder’s victim, unexplained anxiety, horrific nightmares, and sometime insomnia were examples of the PTSD symptoms that I suffered for a long time.

Impact on the Delivery of Nursing Care:

A fourth subtheme addressed the effect of continual threat on the delivery of nursing care.

I was not satisfied in terms of the quality of my work, I was less productive, and I was self-centered trying to focus on my personal safety first rather than my quality of work. I was less committed to achieving my organization’s goals. I was very confused doing my job.

That environment made me lose the confidence in my job, lose my professionalism, and become confused. I was not able to perform well or provide good care, I was doing my best to rescue people and maintain their lives only.

Lost Sense of Personal Safety:

The fifth subtheme for Living under the Shadow of War and Ongoing Violence described the vulnerability that persisted for participants whether at work or at home.

In one of my nights shift duties in the hospital, the hospital security personnel warned us that we needed to be prepared for any accident, because the gunmen and the terrorists in the area around the hospital planned to attack the hospital.

When I was going home returning from the hospital, I saw a dead body was thrown on the side of the road and about 50 meters from the dead body an armed group carrying their guns and we did not know who they were. Honestly I said the ‘shahada.’ Shahadais the Muslim declaration of faith in its shortest form, which is "There is no god but God, Muhammad is the messenger of God," and is said when in imminent danger and death is expected.

Theme 2. Shield of Adaptation and Resilience:

All of the nurses reported in their stories that the trauma impacted multiple aspects of their lives. Most of them have witnessed and/or experienced life threatening events and felt insecure. However, participants mentioned that they continued doing their job as nurses despite all of the threats they were facing every day. When nurses were asked about what made them continue working despite the threat circumstances, they mentioned some motivational factors that pushed them to continue, such as social and professional commitments; sense of pride; hope; moral issues; and the need for money. Iraqi nurses who lived and worked in communities where war and terrorist threats were a daily experience developed adaptation and resilience strategies that served as a source of strength and inspiration.

The explosion was very near to me and it threw me away due to its huge impact… After checking myself, I realized that it was just bruises. I went back to my home and changed my damaged clothes. My aunt was waiting for me and she was worried about me since she heard the explosion. She said, “What’s going on?” I said, “Nothing. It’s just another day of living in Iraq. It’s no big deal.” So I changed my clothes and went back to work and start doing my duty towards my clients.

If I leave my work and others leave their work, terrorists would win and achieve their goals. While, our goals are to provide nursing care for our people to display nursing as a strong discipline and achieve our duty toward others.

Two subthemes were identified that described the approaches used by participants in this study to combat the deleterious effects of repeated exposure to trauma and threats.

Faith-Based Hope:

This theme exhibited the primacy of spirituality expressed as adherence to Islamic practice in the lives of nurses interviewed in the current study.

I believe everything can change suddenly by God’s will. Therefore, I want to be patient through praying, reading Holy Qur’an, visiting the holy shrines of the Prophet Mohammed’s Ahl al-Bayt (peace upon him).

Because trauma was and still is a part of our daily lives, I used multiple ways to adapt with the trauma, such as praying, reading the holy Qur’an, listening to music, especially the soft music, visiting my friends and neighbors, sometimes go shopping from nearby places, and sometimes visiting the holy shrines.

Ethical and Professional Commitment:

The second subtheme illustrated the dedication and resiliency exhibited by participating nurses.

[What] pushed me to do my job was my responsibility and duty toward the people. I would be satisfied if I was killed doing my job because it is an honor. We were always in direct contact with patients and see that patients’ lives depend on God's mercy and our care as care providers. It always pushed us to put the physical and the psychological pressure aside and doing our job as nurses to save patients’ lives.

DISCUSSION:

Findings from this study highlight the consequences of living under threat of war and terrorism, where trauma becomes a part of daily life. While nurses are in a unique position as human advocates to help people in critical times, the responsibility of caring and advocating for traumatized individuals while also being subjected to the same conditions is an additional stressor. The first theme, living under the Shadow, supported and expanded previous findings (Jacoub, Al-Diwan, and Al-Dakhily, 2010; Palgi, Ben- Ezra, Langer, and Essar, 2009; Rivers, Gordon, Speraw, and Reese, 2013). Rivers et al. (2013) pointed out that the risk of psychological disorders is significant among nurses who experience the realities of war and/or terrorism. Palgi, Ben- Ezra, Langer, and Essar (2009) found that during wartime nurses experience multiple traumas from repeated exposure to the events of war. Similarly, Jacoub, Al-diwan, and Al-Dakhily (2010) confirmed that nurses were more likely to suffer high levels of workplace stress as a result of the repeated traumatic events present in the daily exposure to war. Jacoub et al. (2010) found a high risk of PTSD (64.5%) among healthcare professionals who worked as rescuers during wartime. The five subthemes that emerged illustrate that in political or sectarian violence, terrorism, and other large-scale armed conflicts, what has been reported concerning the extensive and long-lasting effects on involved societies and nurses, extends beyond psychosocial, economic, and professional aspects of human lives (Gaylord, 2006; Lev-Wiesel et al., 2009; Ramon, Campbell, Lindsay, McCrystal, and Baidoun, 2006).

The second theme in this study, Shield of Adaptation and Resilience, captured the unique concrete and metaphysical adaptation and resilience strategies used by Iraqi nurses who lived and worked in communities where war and terrorist threats are a daily experience. These nurses relied on faith-based hope and ethical and professional commitments to nursing to persevere in a potentially deadly environment. This finding added to previous discoveries highlighting that high resilience, strong will, and agency are natural extensions of PTG through which perseverance can be better understood (Jacoub, Al-Diwan, and Al-Dakhily, 2009; Lev-Wiesel et al., 2009).

Watson’s Human Caring Science served as the theoretical framework for this study. A Human Caring Science perspective incorporates attention to provider and patient caring-healing and acknowledges that effective and productive providers of care attend to self-care (Watson, 2012). Caring exchanges, known as transpersonal caring relationships and caring moments, cannot authentically occur if the nurse is in a state of distress. Awareness of and attention to the caregiver’s own experiences becomes a liberating expansion of human compassion, strengthening alliance with the moral imperative of nursing (Watson, 2012).

CONCLUSION:

Nurses who live and work in war-like conditions are at a greater risk for experiencing the physical, psychological, and social effects of trauma. This is congruent with the findings of earlier studies (Feczer and Bjorklund, 2009; Gates, Gillespiem, and Succop, 2011). While nursing personnel may continue to work, PSTD symptoms can serve to impair family, social, and employment relationships. Coping mechanisms, such as spirituality and resiliency, were frequently implemented to manage the sequelae of stress. Work was mentioned by participants to be a source of purpose and stability within the chaos of the violence surrounding them.

Recommendations for practice include initiating education programs in the workplace about the sequelae of trauma related stress and how to institute self-care practices, as well as providing key personnel that staff can access if they are experiencing distressing symptoms and group support. More emphasis should be placed on the need for life balance with rest, nutrition, exercise, a creative outlet, work, social contact, and a spiritual life.

Further research is needed to explore the experiences of female nurses, at present a silent presence in the experiences of Middle Eastern nurses living and working in areas of war or terrorist threat. Qualitative research with both men and women is recommended to explore the effects mutual trauma experiences exert on transpersonal caring relationships and the effect that self-care has on healing for both parties. Expanded work that takes a mixed methods approach is suggested to explore the depth and breadth of symptoms experienced by traumatized nurses, as well as research exploring what interventions are most effective in their healing process. Finally, expanded research is urged to move exploration of this phenomenon beyond the borders of the Middle East to all nurses experiencing war and unrest within their countries.

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Received on 02.04.2017 Modified on 27.04.2017

Research J. Pharm. and Tech. 2017; 10(7): 2058-2062.

DOI: 10.5958/0974-360X.2017.00359.6