CILR

O R I G I N A L R E S E A R C H

Health-related quality of life and post-traumatic stress disorder

symptoms in accident and emergency attenders suffering from

psychosocial crises: a longitudinal study

Mette Senneseth, Kjersti Alsaker & Gerd Karin Natvig

Accepted for publication 26 April 2011

Re-use of this article is permitted in

accordance with the Terms and Conditions

set out at http://wileyonlinelibrary.com/

onlineopen#OnlineOpen_Terms

Correspondence to M. Senneseth:

e-mail: [email protected]

Mette Senneseth MSc RN

Psychiatric Nurse

Department of Public Health and

Primary Health Care,

University of Bergen, Norway and

Bergen Accident and Emergency Department,

Bergen, Norway

Kjersti Alsaker PhD RN

Senior Researcher

Uni Health, National Centre for Emergency

Primary Health Care, Bergen, Norway

Gerd Karin Natvig PhD RN

Professor

Department of Public Health and Primary

Health Care,

University of Bergen, Norway

S E N N E S E T H M . , A L S A K E R K . & N A T V I G G . K . ( 2 0 1 2 )S E N N E S E T H M . , A L S A K E R K . & N A T V I G G . K . ( 2 0 1 2 ) Health-related quality of

life and post-traumatic stress disorder symptoms in accident and emergency

attenders suffering from psychosocial crises: a longitudinal study. Journal of

Advanced Nursing 68(2), 402–413. doi: 10.1111/j.1365-2648.2011.05752.x

Abstract Aims. This paper is a report of a study of health-related quality of life and post-

traumatic stress disorder symptoms in patients attending an Accident and Emer-

gency department because of psychosocial crises.

Background. Psychosocial crises are commonplace globally, but there is little

knowledge about patients attending Accident and Emergency departments because

of psychosocial crises.

Methods. Data were collected at an Accident and Emergency department in

Norway from September 2008 to June 2009. A total of 99 adults participated in the

baseline study and 41 of these participated at 2 months follow-up. The Short Form-

36 Health Survey and the Post Traumatic Symptom Scale were used to obtain data.

Findings. Participants reported significantly lower scores in all health-related

quality of life domains at baseline compared with the general Norwegian popula-

tion. The mental health score was two standard deviations below the norm. Health-

related quality of life scores were improved and post-traumatic stress disorder

symptoms were reduced after 2 months. High levels of post-traumatic stress dis-

order symptoms were reported by 78% of the participants at baseline and 59% at

follow-up. Participants with high levels of post-traumatic stress disorder symptoms

at follow-up also reported low health-related quality of life scores.

Conclusion. This study suggests a need for an acute psychosocial intervention and

an opportunity to receive follow-up support at Accident and Emergency depart-

ments.

Keywords: Accident and Emergency department, acute psychosocial crisis inter-

vention, health-related quality of life, post-traumatic stress disorder symptoms,

psychiatric nurses, psychosocial crisis

402 � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

Introduction

People all over the world experience psychosocial crises in

their lives (Bonanno 2004). Some seek professional help at

Accident and Emergency departments (A&Es) (Keene &

Rodriguez 2007, Try et al. 2008, Zakariassen et al. 2010).

Psychosocial crises can be initiated either by psychosocial

problems (Kelleher et al. 2000) [e.g. mental health (MH)

problems, difficult social situations or severe family prob-

lems] or by traumatic life events (e.g. physical or sexual

assault or bereavement) that induce psychological symptoms.

Psychological symptoms frequently occur after traumatic life

events (Bisson et al. 2007). Most people do not develop a

problematic psychological response following trauma, or, if

they do, they recover without any professional help (Bonanno

2004, Bisson et al. 2007). However, some people develop

psychological difficulties that require therapeutic intervention

(Wang et al. 2005, Bisson et al. 2007, Roberts et al. 2009).

There is little knowledge internationally about the health of

people attending A&Es because of psychosocial crises and

their need for psychosocial support. Such knowledge may be

essential for the intervention that is offered these people.

Background

Over the past decades, people’s quality of life (QOL) has

become increasingly important in health care and health

research. The term ‘health-related quality of life’ (HRQoL)

narrows the focus to the effects of health, illness and

treatment on QOL (Ferrans et al. 2005). HRQoL is a

multidimensional concept that consists of physiological,

psychological and functional aspects of well-being as seen

from the individual’s own perspective (Kvarme et al. 2009).

A number of studies have shown that traumatic life events

have a negative impact on HRQoL, such as physical and

sexual assault (Sadler et al. 2000), exposure to domestic

violence (Alsaker et al. 2006), traffic-related injuries (Wang

et al. 2005), critical illness (Deja et al. 2006), sexual abuse

(Dickinson et al. 1999) and military combat (Schnurr et al.

2006, Richardson et al. 2008). In four of these studies (Wang

et al. 2005, Deja et al. 2006, Schnurr et al. 2006, Richardson

et al. 2008), poor HRQoL is associated with post-traumatic

stress disorder (PTSD), which is an anxiety disorder (Roberts

et al. 2009). Schnurr et al. (2006) found that changes in

PTSD symptoms are related to changes in HRQoL and a

negative correlation between PTSD and QOL was found by

Wang et al. (2005). Other psychosocial crises such as

partnership splits and exposure to non-domestic violence

have also been associated with poor MH and low QOL.

However, in these studies different health- and quality-of-life

questionnaires were used. Using the General Health Ques-

tionnaire (GHQ-12), Willitts et al. (2004) found that part-

nership splits had a negative impact on MH. In a Norwegian

study, Johansen et al. (2007) found that a high level of PTSD

symptoms in victims of non-domestic violence was associated

with low QOL, measured by the World Health Organiza-

tion’s Quality of Life questionnaire (WHOQOL-BREF).

Only four of these studies measured the acute effect of the

psychosocial crisis on MH (Willitts et al. 2004), QOL

(Johansen et al. 2007) and HRQoL (Wang et al. 2005,

Alsaker et al. 2006).

In a study of A&E contacts in Norway, diagnoses related

to psychiatric illness were found in 2Æ7% of all events and the

most frequently diagnosed subgroups were depression/sui-

cidal behaviour, anxiety and substance abuse (Johansen et al.

2009). In another study, psychosocial crises (psychiatric

illnesses and harmful events) were found in 3Æ7% (Zakariassen

et al. 2010). A study of a psychosocial crisis support team at

an Norwegian A&E reported that people contacted the team

because of life crises such as serious life events, worries about

others and interaction problem in the family in 65Æ5%

(n = 901) of the events and that symptom of psychiatric

illness (such as depression/suicidal behaviour, anxiety and

substance abuse) were found in 29Æ6% (Try et al. 2008).

However, we found no longitudinal studies that had exam-

ined HRQoL and PTSD symptoms in people suffering from

acute psychosocial crises attending A&E.

The study

Aim

The aim of the study was to examine HRQoL and PTSD

symptoms in people attending an A&E because of psycho-

social crises.

Design

This was an observational longitudinal study as stated by

Polit and Beck (2008).

We hypothesized that:

• People who seek help at A&E, suffering from psychosocial crises, have lower HRQoL than the general population at

presentation and they have improved HRQoL after

2 months.

• These people have high levels of PTSD symptoms at pre- sentation and they have reduced PTSD symptoms after

2 months.

• High levels of PTSD symptoms are linked to low HRQoL scores at follow-up.

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� 2011 Blackwell Publishing Ltd 403

Location

The location for this study was in a psychosocial crisis

support team at an A&E in the centre of a city in Norway

with approximately 240,000 inhabitants. The A&E has a

total of near 100,000 contacts annually (Bergen A&E Annual

report 2009). The psychosocial crisis support team at the

A&E has approximately 2000 contacts annually and about as

many patients contact the psychosocial support team by

telephone as by personal meeting (Try et al. 2008). The

psychosocial crisis support team is on duty 7 days a week and

is staffed with trained psychiatric nurses. The psychosocial

crisis support team is meant to give acute help in a crisis. The

personnel are meant to have competence in basic diagnostic

categories and half of staff is trained in cognitive behavioural

therapy (CBT). The psychosocial crisis support team consul-

tations at the A&E include information about normal

reactions to trauma, advice for coping with the situation,

motivation by focusing on the person’s own ability to cope

and emphasizing the importance of social support from close

family and friends, as recommended by Bisson et al. (2007).

Referral from the team to General Practitioner (GP) is

provided in more than 50% of contacts (Try et al. 2008).

Participants

People who attended the psychosocial crisis support team

were asked about participation immediately after their first

consultation with a psychiatric nurse in the team. The

inclusion criteria were people who, during the recruitment

period, were

• attending A&E because of a psychosocial crisis and who consulted a psychiatric nurse.

• 18 years or older. • able to read and understand Norwegian.

People were offered three to four consultations with the

support team. Persons with suicidal thoughts or psychiatric

illnesses in need of therapy, were in addition referred to the

medical department to see a doctor. Persons with psychotic

symptoms were not offered contact with a psychiatric nurse

in the team, but with a psychiatrist for immediate treatment.

A total of 113 people were asked to take part in the study.

Ninety nine participated in the baseline study and 41 also

participated in the follow-up study.

Data collection

Data were collected using a self-report questionnaire that

participants confidentially filled out at the A&E. A new

questionnaire was sent 2 months later to the participants who

had accepted participation in the follow-up study. Data were

collected from September 2008 to June 2009. Questionnaires

were treated confidentially and neither name nor date of birth

was recorded. Individual codes (birth year combined with the

first letter of the person’s parents’ first names) were used for

paired tests from baseline to follow-up. Reminders were sent

only once. Both the baseline and the follow-up studies

comprised questions about demographic data, PTSD symp-

toms and HRQoL.

Instruments

The SF-36 Health Survey

The SF-36 Health Survey is a 36 item self-report question-

naire that assesses eight domains of physical and MH ranging

from 0 to 100, where the highest score indicates optimal

HRQoL and the lowest score indicates the poorest HRQoL.

The eight domains are physical functioning (PF), role limi-

tations because of physical health problems (role-physical,

RP), bodily pain (BP), general health (GH) perceptions,

vitality (VT), social functioning (SF), role limitations because

of emotional problems (role-emotional, RE) and general MH

(Ware & Sherbourne 1992). The first four domains (PF, RP,

BP, GH) together constitute the physical health domains. The

other four domains (VT, SF, RE, MH) constitute the MH

domains. The SF-36 is widely used in health research and is

validated and tested for reliability by several studies (Loge

et al. 1998, Ware et al. 2002).

The PTSS-10

The Post-traumatic Symptom Scale (PTSS-10) is a 10 item self-

report questionnaire that assesses the presence and intensity of

PTSD symptoms (Mehlum & Weisæth 2002). Each of the 10

symptoms is rated on a 7-point Likert scale ranging from 1

(not at all/never) to 7 (very often) (Mehlum & Weisæth 2002).

The 10 symptoms are sleeping problems, nightmares, feeling

of depression, startle/jumpiness, isolation, irritation, mood

swings, feelings of guilt/lowered self-esteem, fear of places and

situations that remind the subject of the traumatic event and

bodily tension (Eid et al. 1999). The PTSS-10 has been found

to have good internal consistency and test–retest reliability

(Eid et al. 1999) and to be a responsive, valid and reliable

instrument in screening for PTSD (Stoll et al. 1999). The total

score ranges from 10 to 70. A score of 35 or more justifies a

PTSD diagnosis (Stoll et al. 1999).

Ethical considerations

People were given both oral and written information about

voluntary participation and that non-participation would

M. Senneseth et al.

404 � 2011 Blackwell Publishing Ltd

not influence their treatment at the clinic. The Regional

Committee for medical Research Ethics for Western Nor-

way and the Norwegian Data Inspectorate approved the

study.

Data analysis

Data were processed and statistical analysis performed using

SPSSSPSS 16Æ0 (Oslo, Norway) for Windows. SF-36 data were

recoded and missing data replaced using the SF-36 health

survey manual and interpretation guide (Ware et al. 2002).

SF-36 data for the general Norwegian population were

obtained from the Norwegian Coordinated Living Condi-

tions Survey, cross-section 2002 (n = 5131), received from

the Norwegian Social Science Data Services. The SF-36

results were then norm-based, meaning that results were

standardized for age and gender according to the score of

the general Norwegian population (2002), such that a value

of 50 is the mean of the general Norwegian population and

10 is the standard deviation (Gandek et al. 2004, Magerøy

et al. 2007, Alsaker et al. 2008). Norm-based scoring of SF-

36 scales is recommended by developers because of the

advantage of easily facilitating interpretation of results

across measures, as all measures have comparable means

and standard deviations (Gandek et al. 2004). A score of

<50 shows a lower mean score than people of the same age

and gender in the general Norwegian population. One-

sample t-tests with a test value of 50 were used to compare

means with the general Norwegian population, giving a P

value for significantly different means if equal or <0Æ05,

corresponding to the 5% significance level. A 95% confi-

dence interval (CI) was used as an estimated statistical

interval for the norm-based scores.

Paired samples t-tests were used to examine the changes

in the SF-36 norm-based scores from baseline to follow-up

(n = 41). The P value for change from baseline to follow-

up indicates a statistically significant change in the norm-

based SF-36 scores from baseline to follow-up if equal or

<0Æ05.

The size of the changes in the norm-based SF-36 scores

from baseline to follow-up was measured by the effect sizes

(follow-up score minus baseline score divided by the standard

deviation at baseline). Effect sizes were judged against

standard criteria: trivial (<0Æ2), small (0Æ2 to <0Æ5), mod-

erate (0Æ5 to <0Æ8) and large (‡0Æ8) (Cohen 1978). Post-traumatic Symptom Scale-10 scores, measuring PTSD

symptoms, were summarized for each participant both at

baseline and at follow-up. Paired samples t-tests were used

to examine the changes in the summarized scores from

baseline to follow-up (n = 41). The P value for change from

baseline to follow-up indicates a statistically significant

change from baseline to follow-up if equal or <0Æ05. In

addition, a cut-off score at 35 was used in accordance with

other studies (e.g. Stoll et al. 1999, Deja et al. 2006) to

categorize participants into two subgroups at 2 months

follow-up; ‘PTSS-10 low-scoring’ (range 10–34) and ‘PTSS-10

high-scoring’ (range 35–70). PTSS-10 subgroups at 2 months

follow-up were compared regarding the norm-based SF-36

mean scores reported by these participants, using indepen-

dent samples t-tests for each of the eight SF-36 domains.

Paired samples t-tests were used to find the change in norm-

based SF-36 scores from baseline in PTSS-10 subgroups at

2 months follow-up.

Findings

Participants

In the baseline study, 113 people were asked to participate

(Figure 1 flowchart). Ninety nine people were included,

comprising 77 women and 22 men. Two months later 41

of these were included in the follow-up study, comprising 35

women and 6 men.

Demographic data and reasons for attending A&E

The mean age (SDSD) was 33 years (13). More than half of

participants were single or divorced (Table 1). Participants

stated different reasons for attending the psychosocial sup-

port team at the A&E (Table 1). Severe difficulties related to

their partner or a family member was the most frequent

reason for attending the department (28Æ1%), followed by

MH problems (26Æ3%) and sexual or physical assault

(18Æ1%).

Lost to follow-up

Participants who were lost to follow-up (n = 58) did not

differ in any characteristics from the participants who were

followed-up (n = 41), neither in age (P = 0Æ8), gender

(P = 0Æ1), baseline PTSS-10 summarized scores (P = 0Æ2) nor

in baseline HRQoL scores (P = 0Æ2–0Æ9).

Number of consultations

At the follow-up after 2 months (n = 41), participants were

asked about the total number of consultations they had had

with a psychiatric nurse at the A&E. Twelve participants

(29%) reported to have had four or more consultations,

including the first consultation. Seventeen participants (42%)

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� 2011 Blackwell Publishing Ltd 405

reported to have had two or three consultations, and 12

participants (29%) reported to have had only the first

consultation.

Health-related quality of life

Baseline (n = 99)

In raw scores from 0 to 100 the mean results (SDSD) for each

domain were: PF 85Æ2 (21Æ9), RP 52Æ6 (42Æ2), BP 55Æ8 (27Æ6),

GH 63Æ1 (23Æ2), VT 31Æ8 (19Æ8), SF 43Æ4 (27Æ2), RE 26Æ2

(38Æ4) and MH 39Æ4 (20Æ1).

Through standardized SF-36 results (norm-based scores),

mean scores were compared with the mean of the general

Norwegian population (in 2002), such that the mean of the

general Norwegian population was 50 and 1 SDSD was 10.

Participants in this study had lower norm-based scores in all

eight HRQoL domains compared with the general Norwegian

population at baseline (Table 2). The lowest norm-based scores

were in MH (mean 26Æ9), SF (mean 30Æ9) and RE (mean 32Æ9).

Follow-up (n = 41)

After 2 months, the participants still had lower norm-based

scores than the general Norwegian population (Table 2).

However, the participants had improved their HRQoL in five

domains from baseline to follow-up, including the four MH

domains and BP (Table 2). On a standard scale consisting of

‘trivial, small, moderate and large’, the effect sizes show that

the change in BP is judged as small, while the changes in the

four MH domains are judged as moderate (Table 2).

PTSS-10 scores

Mean PTSS-10 summarized score at baseline (n = 99),

measuring the 10 PTSD symptoms: sleeping problems,

nightmares, feeling of depression, startle/jumpiness, isolation,

irritation, mood swings, feelings of guilt/lowered self-esteem,

fear of places and situations that remind the subject of the

traumatic event and bodily tension, was 44Æ7 (possible range

10–70; Table 3). Among the participants at baseline, 79%

had a PTSS-10 total score greater than or equal to the cut-off

score of 35 points, showing high levels of PTSD symptoms.

At 2 months follow-up (n = 41), the mean summarized

score for PTSS-10 was 37Æ2 (Table 3). PTSS-10 summarized

scores were reduced from baseline to follow-up (P = 0Æ003).

At follow-up, 59% of the participants had a PTSS-10 total

score greater than or equal to the cut-off score of 35 points,

showing high levels of PTSD symptoms, which can indicate a

risk of developing PTSD.

HRQoL and the PTSS-10 scores

Concerning the question if there is a link between PTSD

symptoms and HRQoL, we looked at the differences in SF-36

scores between PTSS-10 subgroups in the follow-up study.

Assessed for eligibility (n = 113)

Refused to participate at

baseline (n = 10)

Not meeting inclusion criteria

(n = 3)**

BASELINE Analyzed (n = 99)

Refused to participate at

follow-up (n = 8)

Accepted participation in

follow up (n = 91)

Not returned questionnaire

(n = 47)

FOLLOW-UP Analyzed (n = 41)

Excluded (n = 1)*

Excluded (n = 3)***

Accepted participation

(n = 103)

Figure 1 Flowchart. *One respondent was excluded because of almost blank questionnaire. **Three respondents completed ques-

tionnaire but were under 18 years of age and were excluded during

processing of the data. ***Three respondents stated unknown per-

sonal codes at follow-up questionnaires and follow-up data could not

be paired with baseline data.

Table 1 Demographic characteristics and reasons for attending A&E at baseline (n = 99)

N %

Female 77 77Æ8 Male 22 22Æ2 Marital status

Single 51 51Æ5 Married or living with partner 34 34Æ3 Girlfriend/boyfriend 7 7Æ1 Divorced 6 6Æ1 Not stated 1 1Æ0

Reasons to attend the A&E

Severe difficulties related to partner or family

member

28 28Æ1

Sexual or physical assault 18 18Æ1 Loss of loved one in sudden death or suicide 6 6Æ0 Other traumatic life event or psychosocial crisis 16 16Æ2 Mental health problems 26 26Æ3 Suicidal thoughts or plans 4 4Æ0 Not stated 1 1Æ0

A&E, Accident and Emergency department.

M. Senneseth et al.

406 � 2011 Blackwell Publishing Ltd

The PTSS-10 high-scoring and low-scoring subgroups at

2 months follow-up differed in all HRQoL domains in the

follow-up study (P < 0Æ001) (in PF P = 0Æ03). The PTSS-10

low-scoring people had improved HRQoL in six of eight

domains (P < 0Æ01) (Figure 2). There was no statistically

significant difference between the general Norwegian

population and the PTSS-10 low-scoring people in the four

MH domains and in GH after 2 months. PTSS-10 high-

scoring people at 2 months follow-up reported lower

HRQoL than the general Norwegian population in seven of

eight domains (P < 0Æ001). For PF, we found no statistically

significant difference (Figure 3). PTSS-10 high-scoring people

at 2 months follow-up reported no statistically significant

improvement in any HRQoL domain from baseline

(Figure 3).

Discussion

Study limitations

A limitation of this study is that these findings cannot be

generalized to people who experience psychosocial crises

but do not attend an A&E. There may be a difference

between people who attend A&Es because of psychosocial

crises and those who experience psychosocial crises without

seeking help. Another limitation is that we do not have data

on whether participants were on medication or had taken

alcohol, neither at presentation nor at follow-up. A previ-

ous study of people attending the psychosocial crisis

support team at the A&E because of psychosocial crises

showed that 4Æ9% reported substance abuse and 9Æ2%

reported depression (Try et al. 2008). Depression and

alcohol/substance abuse may have negative impact on

HRQoL (Piccinni et al. 2006, Lahmek et al. 2009), while

medications such as antidepressants can have a positive

effect on HRQoL (Caruso et al. 2010). These variables

should be included in further studies. A third limitation to

the study is that we cannot through the statistical analyses

used in this study measure the predictive value of the

PTSS-10 instrument on HRQoL. And finally, more research

is needed to be able to find reasons for the changes that

take place in HRQoL and in PTSD symptoms. A random-

ized controlled trial with a control group is needed to

investigate the effect of the psychosocial interventions that

are given to this group.

Table 2 Health-related quality of life mean scores at baseline and at 2 months follow-up compared with the general Norwegian population

SF-36 norm-based scores*

Baseline (n = 99) Follow-up (n = 41) P value for change

from baseline� Effect size§Mean (SDSD) P � Mean (SDSD) P�

Physical health domains

Physical functioning (PF) 46Æ8 (12Æ1) 0Æ01 50Æ4 (7Æ0) <0Æ01 0Æ18 0Æ2 Role-physical (RP) 41Æ5 (12Æ1) <0Æ001 44Æ0 (12Æ8) <0Æ01 0Æ40 0Æ2 Bodily pain (BP) 41Æ7 (10Æ7) <0Æ001 46Æ4 (11Æ0) 0Æ04 0Æ01 0Æ4 General health (GH) 42Æ2 (10Æ9) <0Æ001 43Æ7 (12Æ3) <0Æ01 0Æ71 0Æ1

Mental health domains

Vitality (VT) 37Æ3 (9Æ7) <0Æ001 44Æ0 (11Æ1) <0Æ01 0Æ001 0Æ7 Social functioning (SF) 30Æ9 (12Æ4) <0Æ001 39Æ4 (14Æ1) <0Æ01 0Æ001 0Æ6 Role-emotional (RE) 32Æ9 (11Æ9) <0Æ001 38Æ5 (13Æ2) <0Æ01 0Æ001 0Æ7 Mental health (MH) 26Æ9 (12Æ2) <0Æ001 36Æ2 (14Æ9) <0Æ01 0Æ001 0Æ7

*SF-36 results are standardized for age and gender according to the score of the general Norwegian population (2002), such that a value of 50 is

the mean of the general Norwegian population and 10 is the standard deviation, as described in Gandek et al. (2004). �P value for mean difference compared with the general Norwegian population found from one-sample t-test with a test value of 50. Significant

difference if P value is <0Æ05. �P value for change from baseline to follow-up (n = 41) found from paired samples t-tests. Significant change if P value is <0Æ05. §Effect sizes (the size of changes) are judged against standard criteria: trivial (<0Æ2), small (0Æ2 to <0Æ5), moderate (0Æ5 to <0Æ8) and large (‡0Æ8) (Cohen 1978).

Table 3 PTSS-10 summarized score (possible range 10-70) mea- suring post-traumatic stress disorder symptoms at baseline and at

2 months follow-up

PTSS-10 summarized score

Baseline mean

score (SDSD)

(N = 99)

Follow-up

mean score (SDSD)

(N = 41)

Change from

baseline to

follow-up* (N = 41)

44Æ7 (11Æ3) 37Æ2 (15Æ4) P = 0Æ003

*P value found from paired sample t-test.

PTSS-10, Post-traumatic Symptom Scale-10.

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� 2011 Blackwell Publishing Ltd 407

Health-related quality of life in A&E attenders suffering

from psychosocial crises

Concerning our first hypothesis, participants reported lower

HRQoL compared with the general Norwegian population in

all eight HRQoL domains at presentation. The greatest

differences were found in MH, SF and role limitations

because of emotional problems. Participants reported almost

as low scores in MH (mean 39Æ4) as abused women at

Norwegian women’s shelters, who had a mean score of 35Æ6

(0–100 raw scores) (Alsaker et al. 2006). A study of women

in the military who had experienced both sexual and physical

assault, reported a mean score of 58Æ6 in MH (Sadler et al.

2000). However, assaults could have happened more than

10 years before, thus showing long-term effects on HRQoL

(Sadler et al. 2000).

Wyrwich et al. (2005) emphasizes the importance of

estimating clinically significant differences in QOL out-

comes. In this study, the difference between participants and

the general Norwegian population was clinically significant

in the MH domain, with a difference of more than two

standard deviations. The low scores in the MH domain

reflect the persons feelings of nervousness and depression all

of the time (Ware & Sherbourne 1992). A high score would

reflect feeling peaceful, happy and calm all the time. These

clinically significant findings imply that participants’ feelings

of nervousness and depression, and the fact that they do not

feel peaceful, happy and calm, could represent a risk of

suicidal ideation (Wyrwich et al. 2005). This is supported

by other studies showing that individuals experiencing

negative and potentially traumatic life events are at

increased risk for suicidal thoughts and behaviours (Kaplan

et al. 1997, Dube et al. 2001). Concerning SF, it is well

documented that social support is essential in people’s lives

(Kendler et al. 2005). In personal crises, social support may

be an important factor to recover (Deja et al. 2006, Bisson

et al. 2007, McGrath et al. 2010). The low score in SF in

our study reflects that it can be difficult for these people to

apply for social support themselves. People suffering from

psychosocial crisis therefore may need outreach help, which

is suggested by other studies (Dyregrov 2001, McGrath

et al. 2010). However, it is essential that social support is

positive as negative social support may be harmful (Dyre-

grov 1990) and may increase the risk of developing PTSD

(Brewin & Holmes 2003).

60

50

40

30

95 %

C l

20

PF 1 PF

2 RP

1 RP

2 BP

1 BP

2 GH

1 GH

2 VT

1 VT

2 SF

1 SF

2 RE

1 RE

2 MH

1 MH

2

Figure 2 Health-related quality of life reported by participants with a Post-traumatic Symptom Scale (PTSS)-10 score below cut-off score

at 35 at 2 months follow-up (n = 17). This figure presents mean score

and 95% confidence interval (CI), based on approximate normal

distributions, for the norm-based scores at baseline and 2 months

later. The norm-based scores are the SF-36 scores standardized for

age and gender according to the score of the general Norwegian

population, such that the mean score of the general Norwegian

population is 50 and standard deviation is 10 for all scales. PF,

physical functioning; RP, role-physical; BP, bodily pain; GH, general

health; VT, vitality; SF, social functioning; RE, role-emotional; MH,

mental health; 1 = baseline; 2 = after two months.

50

40

30

95 %

C l

20

PF 1 PF

2 RP

1 RP

2 BP

1 BP

2 GH

1 GH

2 VT

1 VT

2 SF

1 SF

2 RE

1 RE

2 MH

1 MH

2

Figure 3 Health-related quality of life reported by participants with a Post-traumatic Symptom Scale (PTSS)-10 score greater than or

equal to cut-off score at 35 at 2 months follow-up (n = 24). This

figure presents mean score and 95% confidence interval (CI), based

on approximate normal distributions, for the norm-based scores at

baseline and 2 months later. The norm-based scores are the SF-36

scores standardized for age and gender according to the score of the

general Norwegian population, such that the mean score of the

general Norwegian population is 50 and standard deviation is 10 for

all scales. PF, physical functioning; RP, role-physical; BP, bodily pain;

GH, general health; VT, vitality; SF, social functioning; RE, role-

emotional; MH, mental health; 1 = baseline; 2 = after two months.

M. Senneseth et al.

408 � 2011 Blackwell Publishing Ltd

At 2 months follow-up, participants still reported lower

HRQoL scores when compared with the Norwegian popu-

lation in general. However, participants had higher scores at

the follow-up in five HRQoL domains, showing that their

MH and BP had improved from baseline. The improvements

from baseline in VT, SF, RE and MH are by effect sizes

judged to be clinically significant differences (Wyrwich et al.

2005). These improvements reflect that participants feel

happier, more peaceful and calmer (MH) and that they have

more energy (VT) after 2 months. In addition, they do not

have the same limitations because of SF and emotional

problems as they reported at baseline.

Post-traumatic stress disorder symptoms

Concerning our second hypothesis, participants in the present

study reported high levels of PTSD symptoms at presentation.

Mean PTSS-10 summarized scores, measuring PTSD symp-

toms, were more than twice as high in participants in this

study (44Æ7) as in Norwegian U.N. Peacekeepers (17Æ3)

(Mehlum & Weisæth 2002). PTSS-10 scores improved from

baseline to follow-up. These results show that PTSD symp-

toms decrease for people suffering from a psychosocial crisis

in the 2 months after attending the A&E. These findings are

supported by other studies that find that people can have

psychological and behavioural reactions to traumatic events

that diminish over time (Bonanno 2004, Bisson et al. 2007).

Brewin (2003) claims that it may take 6–12 months before

people who experience trauma no longer will have PTSD

symptoms. A two-month follow-up, as used in our study,

may according to this be a relatively short period of time to

measure the decrease in such symptoms. This might explain

why PTSS-10 mean scores still are relatively high at 2 months

follow-up. However, people with high levels of PTSD

symptoms after 3–4 months are likely to have chronic

symptoms that will not improve further without intervention

(Brewin 2003). A PTSD diagnosis cannot be given to

participants in this study based on the PTSS-10 scores. An

additional psychiatric evaluation is required and a specific

prior traumatic event is a criterion. Nevertheless, the high

PTSS-10 scores indicate severe psychological distress and

reflect PTSD symptoms which are associated with poor

HRQoL (Deja et al. 2006, Schnurr et al. 2006, Richardson

et al. 2008).

Health-related quality of life and the level of post-

traumatic stress disorder symptoms

Concerning the question if there is a link between the level of

PTSD symptoms and HRQoL in the follow-up study, we

found that a high level of PTSD symptoms after 2 months

was linked to lower HRQoL measures. These findings are

supported by other studies (Deja et al. 2006, Schnurr et al.

2006, Richardson et al. 2008). In our current study, 59%

of the participants at 2 months follow-up reported high

PTSS-10 scores and they reported no statistically significant

improvement in HRQoL from baseline. However, we do not

know anything about neither the post-traumatic symptom

scores nor HRQoL scores among participants in the time

before the study. This could mean that some participants

have had high post-traumatic symptom levels and low

HRQoL both before and throughout the study. Depression,

for example, can have a major negative impact on HRQoL

(Goldney & Fisher 2004).

Implications for practice and research

Findings in this study show that people attending an A&E

experiencing psychosocial crises because of severe family

problems, sexual or physical assault, bereavement or MH

problems, have statistically significant impairments with

respect to HRQoL and that they suffer from severe psycho-

logical distress. These findings suggest a need for an acute

psychosocial crisis intervention. In addition, this study

suggests that people who experience a psychosocial crisis

may need outreach social support. A point for nursing staff to

consider is to help these attenders to activate their social

network and to make sure that they are not left to themselves

when they leave the A&E.

In this study, participants had consultations with a

psychiatric nurse in a psychosocial crisis support team at

the A&E. We have not measured the effect of these

consultations in this study. However, other studies empha-

size the benefits of early psychosocial intervention (Dybdal

2001, Bisson et al. 2007, Dennis & Hodnett 2007) and

social support (Deja et al. 2006, McGrath et al. 2010) in

psychosocial crises. Findings in this study imply that many

A&E attenders who are suffering from psychosocial crises

will be in need of further therapeutic intervention. An

appropriate intervention could be that people are offered a

follow-up consultation with a psychiatric nurse 2 months

after first attending an A&E, which includes screening for

PTSD and secures the people adequate treatment. The

PTSS-10 can be a useful supplemental instrument in

identifying people who need further attention at presenta-

tion and in identifying people who are at risk of developing

PTSD. People with PTSD should be referred to Trauma

Focused CBT or eye movement desensitization and

reprocessing treatment, both of which have been shown

to be effective in treating this disorder (Bisson & Andrew

JAN: ORIGINAL RESEARCH HRQoL and PTSD symptoms in A & E attenders

� 2011 Blackwell Publishing Ltd 409

2007). However, a PTSD diagnosis should not be consid-

ered at presentation unless symptoms have lasted for at

least 1 month, but should be considered at a follow-up

consultation.

Another important issue is the low MH scores in these

people, which represent a possible risk of suicidal ideation.

Assessing suicide risk may therefore be of crucial importance.

Screening for suicide risk is provided by GP at A&E (Try

et al. 2008), however, nurses can provide an opportunity for

people to respond to this important question by asking, and

secure that this question also is raised by the GP. A recent

study (Hirsch et al. 2009) claims that suicidal outcomes in

people experiencing negative or traumatic events are not

inevitable, and finds that optimistic reframing of negative life

events is associated with reduced suicide ideation. This

suggests that early psychosocial interventions should be easy

to get in touch with, and that a low threshold at A&Es for

people experiencing a psychosocial crisis would be recom-

mendable, such one could more easily identify people who

need further psychological treatment. Nevertheless, further

methodological research is needed to investigate the effect of

early psychosocial crisis intervention on HRQoL and PTSD

symptoms in people experiencing psychosocial crises attend-

ing an A&E. Concerning the limitation of this study on

information about MH problems before presentation at

A&E, The Mini-International Neuropsychiatric Interview

(M.I.N.I.) which is a short but accurate structured psychiatric

interview (Sheehan et al. 1998) would be appropriate and

recommended in such research. Negative life events and poor

social support is also associated with seasonal affective

disorder (Michalak et al. 2003). These are interesting vari-

ables and may be included in further studies using Seasonal

Patterns Assessment Questionnaire, the List of Threatening

Experiences and the Oslo 3-Item Social Support Scale

(Michalak et al. 2003).

Conclusion

With regard to clinical implications, our results may be

useful informing accident and emergency staff about the

severe psychological distress psychosocial crises can lead to,

and that the assessment of suicidal risk in these attenders is

essential. One should ask these attenders if they have

suicidal thoughts and immediately refer them to a medical

doctor or a psychiatrist if they answer affirmatively to this.

It also seems to be important to have an opportunity for

follow-up to be able to identify people who need further

treatment. In addition, nurses should help these attenders to

activate their social network when leaving the A&E, as

social support may be essential in recovering from a

psychosocial crisis. The PTSS-10 may be a useful supple-

mental instrument to psychiatric nurses to identify persons

who are in need of further intervention at presentation and

those who are at risk of developing PTSD at follow-up. In

terms of implications for policy, one should consider the

need for an acute psychosocial intervention and an oppor-

tunity to receive follow-up support at A&Es. In terms of

recommendations for future research, it would be appropri-

ate to get more knowledge about the effect of acute

psychosocial crisis intervention on PTSD symptoms and

HRQoL given by psychiatric nurses to these attenders.

What is already known about this topic

• People suffering from psychosocial crises are commonplace globally.

• Nurses in Accident and Emergency departments often meet people suffering from psychosocial crises.

• Psychosocial crises may cause enduring mental health problems and impairments in health-related quality of

life.

What this paper adds

• Health-related quality of life scores among people attending an Accident and Emergency department

because of psychosocial crises are significantly low

compared with the general population and the low

mental health score is clinically significant.

• People attending an Accident and Emergency department because of psychosocial crises have high

levels of post-traumatic stress disorder symptoms at

presentation.

• High levels of post-traumatic stress disorder symptoms after 2 months are linked to low health-related quality

of life scores.

Implications for practice and/or policy

• This study suggests that acute and follow-up psychosocial support at Accident and Emergency

departments, that secures psychological treatment for

people when indicated, should be available.

• The suicidal risk in people who suffer from psychosocial crisis should be assessed.

• Post-traumatic Symptom Scale-10 may be a useful instrument for psychiatric nurses when it comes to

assessing post-traumatic stress disorder symptoms and

to identify people in need for treatment.

M. Senneseth et al.

410 � 2011 Blackwell Publishing Ltd

Variables such as mental disorder and social support should

be included in such research.

Acknowledgements

This study could not have been carried out without help and

financial support from Bergen Accident and Emergency

Department and National Centre for Emergency Primary

Health Care, Uni Health, Bergen, Norway.

Funding

Bergen Accident and Emergency Department and National

Centre for Emergency Primary Health Care, Uni Health,

Bergen, Norway have funded this study.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

MS, KA and GKN were responsible for the study conception

and design. MS performed the data collection. MS, KA and

GKN performed the data analysis. MS, KA and GKN were

responsible for the drafting of the manuscript. MS, KA and

GKN made critical revisions to the paper for important

intellectual content. KA and GKN provided statistical exper-

tise. MS obtained funding. MS provided administrative, tech-

nical or material support. KA and GKN supervised the study.

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