Current literature suggests that PCPs might not have adequate knowledge of PTSD and might not be adequately screening individuals for PTSD symptoms (Meredith et al., 2009; Sonis, 2013). If PTSD is not identified in the primary care setting, individual outcomes may be worsened and healthcare costs may rise; therefore, PCPs’ PTSD knowledge, subjective norms regarding PTSD screening, self-efficacy in screening for PTSD, attitudes toward PTSD screening, and screening practices need further evaluation. The purpose of this study was to examine primary care APRNs’ PTSD knowledge, subjective norms, self-efficacy, attitudes, and PTSD screening practices.
Design and Methods
A descriptive cross-sectional study design was utilized to examine primary care APRNs’ PTSD screening knowledge, subjective norms, attitudes, self-efficacy, and screening practices. Prior to data collection, Institutional Review Board approval was obtained from the university where the study was conducted. An electronic anonymous educational needs assessment survey was administered to subjects, who were recruited through membership of a mid-southern statewide nursing organization.
The tool utilized for this study was a modified version of surveys that were developed by Brown and Weisler (2011) and Byrnes (2006). The survey contained four patient vignettes and 30 items. Subjects were asked questions to assess general PTSD knowledge and screening practices, along with questions that assessed subjective norms, self-efficacy, and attitudes toward PTSD screening. Demographic data was also collected. A panel of four expert primary care APRNs established content validity of individual items in the tool, with an item-level content validity index (CVI) of 1.00.
Results
There were a total of 128 subjects who participated in the study, and 69 of these subjects met inclusion criteria, including 61 family nurse practitioners and eight adult nurse practitioners. APRNs’ years of practice were measured from one to four years (34.3%), five to 10 years (32.8%), and 11 years or more (32.8%). The majority of subjects (98.5%) reported their patient population was family or adult, and 55.1% of subjects listed their practice location as rural, which was defined as an area with less than 50,000 residents. Approximately half of subjects reported not screening any patients for PTSD within the past six or 12 months. The majority of subjects (76.8%) did not have an EHR system within their practice that alerted them to screen patients for PTSD. None of the subjects had received education or training on PTSD screening within the four weeks prior to completing the survey.
When assessing general PTSD knowledge, there were subjects who incorrectly listed the following as symptoms of PTSD: psychosis (27 subjects), hyperactivity (26 subjects), and grandiosity (14 subjects). Only 32.4% of subjects were able to correctly identify recommended primary care PTSD screening tools, and only 10.8% of subjects knew that the Primary Care PTSD Screening (PC-PTSD) takes less than 2 minutes to administer. When presented with a vignette of military-related PTSD, 31.9% of subjects chose “no or unsure” regarding whether or not they would screen the patient for PTSD, and only 46.4% correctly identified a positive PTSD screening result. When presented with vignette of PTSD related to a natural disaster, 98.6% of subjects stated they would screen for PTSD. When presented with a vignette of PTSD related to sexual trauma, 21.7% of subjects replied “no or unsure” when asked if they would screen the patient for PTSD, and only 58% of subjects were able to correctly identify a positive PTSD screening result. When presented with a vignette of PTSD related to an automobile accident, 80.9% of subjects stated they would screen the patient for PTSD. For all vignettes, only a minority of subjects (18.8% to 29%) knew that a structured interview should be conducted to confirm a diagnosis of PTSD.
The majority of subjects had low confidence in their ability to screen for PTSD (85.5%) and their ability to distinguish between PTSD and Acute Stress Disorder (90%). Approximately 72% of subjects agreed that screening for PTSD was within their scope of practice, and the majority of subjects (90%) agreed that APRNs are responsible for identifying patients who should be screened for PTSD. Only 55% of subjects stated that screening for PTSD was a component of their practice, while 95.7% stated that a standardized tool should be used to assist in diagnosing PTSD. When assessing attitudes, only 39.1% of subjects felt that PTSD screening was important in their practice. Subjects identified numerous barriers that impacted their ability to screen for PTSD, including patients’ reluctance or refusal to discuss PTSD symptoms (75.4%), patients’ reluctance to discuss positive PTSD screening results (69.6%), patients’ perceived stigma associated with a PTSD diagnosis (83.8%), a lack of PTSD educational resources for patients (85.5%), insufficient appointment time to effectively screen patients for PTSD (87%), insurance reimbursement issues for PTSD services (81.2%), and a lack of mental health care referral sources for patients with PTSD (90%).
Reliability of survey items examining self-efficacy, subjective norms, and attitudes were measured using Cronbach’s alpha. The alpha coefficient was 0.83 for self-efficacy items and 0.79 for attitude items. The alpha coefficient for subjective norm items was 0.51, which indicates low reliability.
Discussion
This study indicates deficiencies in primary care APRNs’ knowledge of PTSD and PTSD screening practices. Results suggest that primary care APRNs may need additional education on the symptoms of PTSD, along with education on the various types of trauma that may warrant screening for PTSD. The majority of subjects did not know that a structured interview should be conducted after receiving a positive PTSD screening result (Brown & Weisler, 2011). If PTSD is not formally diagnosed, treatment of the disorder cannot be initiated. The majority of subjects were unaware of recommended primary care PTSD screening tools and over-estimated the amount of time it takes to administer the PC-PTSD. APRNs may be more likely to screen for PTSD if they are aware of these tools and understand that they can be administered in an efficient manner that will minimize disruptions in the flow of patient care.
The majority of subjects reported low confidence regarding their ability to screen for PTSD. Primary care APRNs’ confidence level may potentially be improved if they have increased knowledge of PTSD and tools that can assist them with screening. Most subjects also reported low confidence in their ability to distinguish between PTSD and Acute Stress disorder, which suggests that primary care APRNs need additional education on these disorders to ensure proper diagnosis. Although subjects report external pressure to screen for PTSD, and state that a standardized screening tool should be used in primary care, only slightly more than half of subjects stated that PTSD screening was part of their routine practice. Additional research is needed to understand the discrepancies between these reported subjective norms and PTSD screening practices. The majority of subjects reported that PTSD screening was not important in their practice, which indicates that more research is needed to understand factors that may be influencing primary care APRNs’ attitudes toward the importance of screening. Subjects reported numerous barriers when screening for PTSD, with the most significant barriers being insufficient appointment time to screen patients for PTSD and a lack of mental health referral resources for patients with PTSD. If these barriers were removed, primary care APRNs may be more likely to implement PTSD screening in practice. Limitations of this study include a small sample size and the use of a new survey tool. The results regarding subjective norms must be interpreted with caution, due to low reliability scores on these items.
Conclusions
The findings from this study suggest deficiencies in primary care APRNs’ knowledge of PTSD and PTSD screening practices. Additional education and training are needed to improve primary care APRNs’ PTSD knowledge and screening practices. Additional research is needed to better understand how self-efficacy, attitudes, and subjective norms may be related to primary care APRNs’ PTSD knowledge and screening practices.