Introduction

Post-traumatic stress disorder (PTSD) is a mental health condition that may result from direct, indirect, or repeated exposure to traumatic events1. Diagnosing PTSD requires exposure to a traumatic incident, or associated events1. Symptoms of PTSD are typically grouped into four categories; intrusive thoughts or re-experiencing (reliving the traumatic event), avoidance of reminders of the event, negative changes in thoughts and emotions, and hyperarousal or reactivity (overreaction to situations)1,2. PTSD is a global public health concern. On average symptoms persist for 6 years, and women are more likely to develop PTSD than men3. Although PTSD has historically been associated with military veterans, recent studies highlight its prevalence among healthcare workers, including nurses4. Nurses are at risk of developing PTSD owing to their frequent direct and indirect exposure to traumatic situations while caring for vulnerable patient populations. Driven by a strong sense of responsibility to protect their patients from suffering, nurses are repeatedly exposed to trauma experienced by patients and families, including sudden illness, overwhelming pain, and unexplained loss. Nurses may also directly experience trauma through workplace violence, an increasingly prevalent global issue5. Compared to other professions, nurses face a higher risk of experiencing workplace violence and abuse6,7. Such violence can negatively affect nurses’ physical and mental health, as well as their professional performance8. Emergency medicine remains an important component of hospital services, with patients often arriving in critical condition and requiring urgent and complex care. Emergency nurses typically face a heavy workload and are frequently subjected to verbal and physical aggression9,10. They are also regularly exposed to severe trauma, death, suicide, and other distressing events. Compared to nurses in other departments, emergency nurses are at greater risk of developing PTSD11,12. A high prevalence of PTSD among emergency medical personnel has been reported both in China and globally. Factors such as age, years of service, job title, health status, and level of social support influence PTSD occurrence in this population13,14.

Career resilience—the ability to cope with career-related stress, barriers, or adversity—plays a critical role in shaping attitudes, decisions, and behaviors at work15. Perceived organizational support refers to the extent to which employees feel supported by their organization16. Evidence shows that perceived organizational support enhances employees’ emotional well-being and promotes a more positive work environment17.

The current study investigated relationships between PTSD, career resilience, and organizational support. We also assessed the prevalence of PTSD among emergency department nurses, and examined the influences of career resilience and perceived organizational support on PTSD. Our findings are expected to inform interventions that reduce PTSD in nurses by enhancing career resilience, fostering organizational support, and promoting adaptive responses to traumatic events.

Setting and Sample​​

The study was conducted between April and August 2020 in the emergency departments (EDs) of six tertiary general hospitals in Wuxi and Suzhou. These urban hospitals serve high-acuity patient populations with 24/7 emergency services, reflecting typical high-volume tertiary ED settings in Eastern China.

Participants

A whole-group sampling method was used to recruit 213 emergency department nurses from the selected hospitals. The inclusion criteria were (1) more than 2 years of emergency nursing practice at the current hospital, as determined via hospital Human Resources records; and (2) provision of written consent after receiving a full study briefing. The exclusion criteria were (1) pregnancy or breastfeeding, self-reported via a confidential questionnaire and verbally confirmed during enrollment; (2) participation in clinical rotation or further training, determined via cross-referencing with departmental schedules; and (3) recent experience of serious personal life events. Such events were assessed using a structured interview (e.g., “Have you experienced a major life event in the last 3 months?”), to exclude those reporting events such as bereavement or divorce. Of 224 identified nurses, 11 were excluded; 2 declined consent, 3 were in rotational training, 4 reported relevant recent life events, and 2 did not meet the work-experience criteria. The final sample included 213 nurses, equating to a response rate of 95.1%.​.

Research tools

General information questionnaire

A self-designed questionnaire was used to collect demographic and professional data, including hospital affiliation, sex, age, marital status, education, years of work experience, professional and technical title, provincial specialty nurse status, job position, employment type, number of middle and night shifts, and monthly income.

Self-assessment scale for PTSD

The PTSD self-rating scale (PTSD-SS) developed by Liu Xianchen et al.18. was used with slight modifications (e.g., replacing the term “disaster” with “traumatic event”). This 24-item scale includes five dimensions; subjective evaluation of the traumatic event, recurrent re-experiencing, avoidance symptoms, increased alertness, and impaired social functioning. Each item is rated on a 5-point scale, reflecting the extent to which the traumatic event affected the respondent’s physical, psychological, and daily functioning. The total score ranges from 24 to 120, with scores ≥ 50 indicating a positive screen for PTSD. Higher scores reflect more severe symptoms. The reference delineation values for mild and moderately severe PTSD were set at 50 and 60 points, respectively. The scale demonstrated good reliability and validity, with a reported internal consistency coefficient (Cronbach’s ɑ) of 0.92, a split-half reliability coefficient of 0.95, and a retest reliability coefficient of 0.86. For the current sample, Cronbach’s α was 0.94.

Career resilience scale

The Career Resilience Scale, compiled by Grzeda and Prince and adapted by Zeng Hua19, was used to assess nurses’ career resilience. The scale comprised 11 entries across three dimensions; self-confidence, work initiative, and self-reliance. Each item was rated on a 5-point Likert scale as follows: 1 (Strongly Disagree), 2 (Disagree), 3 (Fairly), 4 (Agree), and 5 (Strongly Agree). Total scores ranged up to 55, with higher scores indicating greater career resilience. The scale has shown good reliability and validity (Cronbach’s ɑ 0.79). For the current sample, Cronbach’s α was 0.82.

Sense of organizational support scale

The Sense of Organizational Support scale, adopted by Zhixia20, includes two subscales: emotional support and instrumental support. It was later revised by Hongmei and Hui21 to better reflect the nursing context, based on interviews and expert opinions. The revised version comprises 14 items; 10 for emotional support and three for instrumental support. Each item on the scale was measured simultaneously from two perspectives, “actual situation” (perceived organizational support) and “personal expectation” (desired support)21. Each item was rated on a 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”), with higher scores indicating stronger perceived and required organizational support. Reported Cronbach’s ɑ coefficients of reliability for the modified scale were 0.92 for homogeneity, 0.83 for emotional support, and 0.75 for instrumental support. In the current sample they were 0.91 for homogeneity, 0.85 for emotional support, and 0.78 for instrumental support.

Survey method

Approval was obtained from the nursing departments of the participating hospitals. A trained investigator was assigned to each hospital to administer the survey using standardized instructions.Paper surveys were distributed on-site.The paper surveys were completed anonymously by the participants and collected by the investigators. Of the 224 questionnaires distributed, 213 were completed and deemed valid, resulting in a recovery rate of 95.1%.

Statistical analysis

After data verification and proofreading, SPSS version 17.0 software was used for data entry and statistical analysis. Categorical data were summarized using rates and percentages. A t-test or analysis of variance was used to compare PTSD scores in participants with different characteristics. Pearson’s correlation analysis was used to investigate relationships between career resilience, sense of organizational support, and PTSD. Stratified regression analysis was performed with PTSD as the dependent variable. Demographic data were used as first-level independent variables, and career resilience and sense of organizational support were used as second-level independent variables. Statistical significance was defined as p < 0.05 (two-tailed, with α = 0.05).

Results

Demographic characteristics

The sample included 213 emergency department nurses from tertiary hospitals in Eastern China. The majority (83.1%, n = 177) were female, reflecting the gendered nature of nursing. More than 75% (n = 163) of the nurses fell within the 26–35 years age range, indicating a cohort in early-to-mid career facing high clinical demands. A significant night shift burden was evident, with 83.1% of the nurses (n = 177) working 3 night shifts per week. Most nurses had 1–10 years of experience (72.77%, n = 155), and the majority held junior positions (Nurse Practitioners 57.75%, n = 123; Staff Nurses 80.28%, n = 171). Demographic characteristics are shown in Table 1.

Table 1 Demographic characteristics (n = 213)
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PTSD, career resilience, and perceived organizational support

The scores for each dimension are presented in Table 2. In Table 2 the mean is per-item, on a scale of 1–5. It interprets dimension severity (subjective evaluation = highest impact). The mean PTSD score was 1.98 ± 0.62. This reflects moderate symptom severity, though notably, 29.11% (n = 62) screened positive for PTSD (total score ≥ 50), indicating clinical relevance. Subjective evaluation of traumatic events was the most severe dimension (76 ± 0.80), suggesting that nurses acutely internalize workplace trauma. Avoidance symptoms were least reported (1.66 ± 0.35), implying that nurses continue engaging with trauma triggers despite distress.

Table 2 PTSD scores of emergency nurses (points, ±)
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Detailed dimension scores are shown in Table 3. The mean career resilience score was 3.49 ± 0.38 on a 5-point scale (1 = low resilience, 5 = high resilience). The mean perceived organizational support score was 3.32 ± 0.63. The scores for each dimension are presented in Table 4. Work initiative was identified as a strength, and self-confidence was identified as a weakness. Mean career resilience was 3.49 ± 0.38. This indicates moderate adaptive capacity, with “Work initiative” as the strongest dimension (Table 3; 3.68 ± 0.59), highlighting proactive coping. Self-confidence scored lowest (3.38 ± 0.60), signaling a key vulnerability. Resilience was unevenly distributed, in that work ethic persisted despite trauma (high initiative), but self-belief was compromised (lower confidence).

Table 3 Career resilience scores of emergency nurses (points, ±)
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Table 4 Scores for emergency nurses regarding perceived organizational support (score, ±)
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Table 4 (“Organizational Support”) highlights scale meaning, indicates that instrumental support scores were higher than emotional support scores, and indicates moderate overall scores. The mean perceived organizational support score was 3.32 ± 0.63 (scale 1–5; higher = better support). Instrumental support (tangible resources) scores exceeded emotional support scores (3.39 ± 0.60 vs. 3.29 ± 0.57). Both dimensions scored near the scale midpoint, indicating room for improvement.

Univariate analysis

Statistically significant differences in PTSD scores were observed based on age, years of work experience, provincial specialized nurse status, professional and technical titles, job position, and the number of middle and night shifts (p < 0.05; Table 5). As shown in Table 6, PTSD scores and subdimension scores were significantly negatively correlated with overall and dimension scores for career resilience, as well as the scores of each dimension of perceived organizational support (p < 0.05).

Table 5 One-way analysis of emergency nurses’ total PTSD-SS scores (score, ±)
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Table 6 Correlations between PTSD, occupational toughness, and perceived organizational support scores (r-value)
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Multifactorial analysis of PTSD in emergency nurses

A linear regression model was conducted using the total PTSD score as the dependent variable, occupational resilience and sense of organizational support as the independent variables (with the actual score values used for each factor), and demographic characteristics as covariates. The entry and removal values for the regression equations were set at 0.05 and 0.10, respectively. Self-confidence and self-reliance dimensions of occupational resilience, as well as the instrumental support and emotional support dimensions of perceived organizational support, were significant protective factors for PTSD in emergency nurses. The effect of instrumental support was the most prominent. Professional position may increase the risk of PTSD, whereas other demographic characteristics did not reach statistical significance. The significance levels for inclusion and exclusion from regression equations were set at 0.05. Results of multifactorial analysis of PTSD in emergency nurses are presented in Table 7. Regression analysis indicated that the self-confidence and self-reliance dimensions of occupational resilience affected PTSD in emergency nurses (Table 7). The self-confidence dimension had a significant negative effect (B = − 1.360, p < 0.001), indicating that higher levels of self-confidence were associated with less severe PTSD symptoms. This dimension had the strongest effect (i.e., the highest absolute β value) among all variables, and was highly statistically significant (p < 0.001), indicating that self-confidence is a key factor in alleviating PTSD. Emergency department nurses with higher self-confidence are adept at coping with that high-pressure environment, and can effectively manage the negative emotions associated with traumatic events, thereby reducing the occurrence of PTSD. The significant negative effect of the self-reliance dimension (B = − 1.001, p = 0.001) indicated that greater independent coping ability was associated with less severe PTSD symptoms. Although the effect was slightly lower than that of the assertiveness dimension, it remained highly statistically significant (p = 0.001). Nurses with high self-reliance are more likely to be proactive problem solvers rather than passive recipients of stress, thereby reducing the long-term negative effects of traumatic events. The results of the current study indicate that occupational resilience (assertiveness and self-reliance) constitutes a psychological protective barrier and significantly reduces PTSD symptoms, suggesting that psychologically resilient nurses are better able to adapt to the high-pressure environment of an emergency department. The effect of self-confidence was even greater (B = − 1.360 vs. B = − 1.001), suggesting that boosting self-confidence may be a higher priority for intervention.

Table 7 Stratified regression analysis of demographic characteristics, career resilience, and perceived organizational support among emergency nurses
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Discussion

PTSD status of emergency nurses

The detection rate of PTSD among emergency nurses in this study was 29.11%, based on the reference thresholds of 50 and 60 points, which denote mild and moderately severe PTSD, respectively. Specifically, twenty nurses (15.9%) scored above 50 points on the PTSD-SS, and nine (7.1%) scored > 60 points. These findings indicate that the PTSD status of emergency nurses needs to be addressed. The mean PTSD score in emergency nurses was 1.98 ± 0.62. Of the five PTSD-SS dimensions subjective evaluation ranked highest, followed by increased alertness, repeated reoccurrence of experience, impaired social functioning, then avoidance symptoms. The dimension with the highest score was “subjective evaluation of traumatic events,” indicating that emergency nurses are commonly affected by PTSD. This result also indicates that emergency department nurses are generally aware of the psychological and emotional impact of traumatic events encountered at work, consistent with the findings of Lin et al.11.

Emergency clinical work is inherently high-risk due to the unique nature of the occupational environment, including social prejudice, limited public understanding, and poor cooperation from patients and their families. Consequently, emergency department nurses frequently endure prolonged overload, irregular schedules, and a heavier burden of risks, tasks, and responsibilities compared to nurses in other departments22. Yonghui et al.23 noted that the high risk, intense workload, and persistent pressure in clinical settings expose nurses to prolonged psychological pressure which, if unrelieved, may diminish work enthusiasm. Consequently, emergency nurses are more prone to PTSD than those in other departments, as supported by previous studies11,12. Chen and Cui24 reported that interventions such as cognitive-behavioral therapy, exposure therapy, muscle relaxation, breathing regulation, and self-talk training can help alleviate PTSD symptoms, including recurrent re-experiencing, anxiety, and fear. These interventions may also reduce persistent hypervigilance, insomnia, and nightmares, especially when used in combination with pharmacological agents such as sedatives and tranquilizers.

To date, few studies have investigated targeted interventions for PTSD in nurses. In addition to treatment, establishing prevention mechanisms is crucial. The present study highlights the high detection rate of PTSD in emergency nurses, and provides evidence-based recommendations for hospitals to develop systematic intervention policies, as follows: (1) Develop a “Psychological Response Manual for Emergency Traumatic Events,” with a focus on cognitive restructuring related to the “Subjective Rating” dimension of PTSD, which yielded the highest mean score in this study. This manual should help nurses reframe traumatic experiences and distinguish between “occupational risks” and “personal failures” using case study learning. (2) Implement monthly “Stress Reduction Workshops” that integrate muscle relaxation training and positive breathing exercises to reduce stress levels and mitigate PTSD symptoms. (3) Establish a “mental load point system” whereby accumulated psychological stress is quantified, and mandatory leave is automatically triggered once a defined threshold is reached. (4) Introduce a “Trauma Exposure Allowance,” with cumulative financial compensation based on the severity of trauma exposure. Additionally, offer incentives, such as opportunities for overseas training, to nurses who have tested negative for PTSD for 5 years. (5) Create an “emergency clinic-outpatient clinic rotation channel” to allow high-exposure nurses to periodically rotate into lower-stress outpatient settings, thereby reducing sustained trauma exposure. (6) Destigmatize psychological distress by normalizing emotional responses to trauma. Hospitals can host anonymous “My Trauma Story” sharing sessions to provide peer support and reduce the stigma associated with the subjective evaluation of traumatic events. (7) Incorporate a “psychological safety indicator” into hospital performance evaluations, and allocate resources to departments that proactively report PTSD-related symptoms.

Influence of career resilience on PTSD

In the current study the mean total career resilience score in emergency nurses was 3.49 ± 0.38, indicating a moderate level consistent with the findings of Ting et al.25. This suggests that the career resilience of emergency nurses working in comprehensive tertiary care hospitals can be further improved. Among the three dimensions of career resilience, the mean score was highest for “work initiative,” followed by “self-reliance” then “self-confidence.” The high score for “work initiative” indicates that emergency nurses demonstrate high work initiative and a willingness to help others, reflecting strong teamwork awareness. In correlation analyses career resilience and its dimensions were significantly negatively correlated with overall PTSD. These findings suggest that enhancing the career resilience of nurses by positively shaping their attitudes, decisions, and behaviors towards their careers can enable them to cope more effectively with challenges in life and work, thereby reducing PTSD. This is consistent with results reported by Shouzhi et al.14. Lihua15 reported that optimism, internal control, and positive coping strategies positively influence career resilience. Streb et al.. [26] reported that high resilience lowered the risk of developing PTSD, therefore enhancing resilience may be a promising approach to reducing PTSD symptom severity in high-risk groups such as paramedics.

Career resilience refers to an individual’s ability to recover from changes in the work environment or career-related adversity. It plays a critical role in helping employees overcome work stress and maintain their physical and mental health15. Conversely, PTSD reflects an individual’s inability to cope with traumatic events, resulting in a mental disorder. This study highlights the importance of career resilience and confirms that its level significantly influences the prevalence of PTSD in emergency nurses—an issue that warrants serious attention from nursing managers. In the current study career resilience, particularly the dimensions of “self-confidence” and “self-reliance” significantly reduced PTSD symptoms in emergency nurses, with self-confidence having the strongest effect. This suggests that enhancing emergency nurses’ psychological toughness, particularly their level of self-confidence, may contribute to the prevention of PTSD. These findings provide key evidence to inform hospital-level policy development. Training programs should emphasize “self-confidence” and “self-reliance” as core competencies, reinforced through situational simulations, case studies, and other interactive modules. Resilience training should be incorporated throughout the nursing career trajectory. Initiatives may include regular anti-stress workshops, a real-time performance feedback system, and the enhancement of nurses’ sense of achievement through quantitative indicators such as patient satisfaction scores and team contributions. Hospitals should implement personalized career planning guidance, establish clear promotion pathways for emergency nurses, and incorporate resilience assessment into promotion evaluation. A dual-track communication system should be established between nursing managers and psychologists, supplemented by regular group-based stress reduction activities. To further cultivate career resilience, non-financial incentives such as a “Best Crisis Response Award” can be used to recognize exemplary cases of adaptability under pressure. Case-sharing sessions should be institutionalized to transform professional setbacks into collective learning resources and reduce the fear of failure. We also recommend establishing a “Resilience Development Committee” in conjunction with the Emergency Medicine and Psychology Departments to regularly evaluate the effectiveness of these interventions. These policy recommendations aim to directly reduce the incidence of PTSD, reduce team turnover owing to psychological trauma, improve the stability of the emergency team, and increase patient safety indicators by enhancing the adaptive capacity or “plasticity factor” of career resilience.

Effect of perceived organizational support on PTSD

The mean total score for perceived organizational support in emergency nurses was 3.32 ± 0.63. The mean scores for emotional support and instrumental support were 3.29 ± 0.57 and 3.39 ± 0.60, respectively, indicating a moderate level of perceived support. These findings are consistent with those reported by Jingjing and Hong27. Of the two dimensions, emotional support had the lowest mean score. This may be attributed to the fact that emotional support reflects employees’ perceptions of the organization’s recognition of their contributions and concern for their well-being. These results suggest that the overall level of organizational support perceived by emergency nurses needs improvement. Furthermore, perceived organizational support and its dimensions were negatively correlated with PTSD and its subdimensions, indicating that higher levels of perceived organizational support were associated with lower levels of PTSD.

Organizational support can serve as a supplementary measure with respect to PTSD prevention. The limitations of organizational support—which has significant effects but weaker effects than individual psychological toughness—suggest that it should be combined with individual psychological development to maximize protective impact. Future interventions should focus on cultivating individual psychological qualities and combining them with organizational environment optimization, to more effectively reduce the occurrence of PTSD. In regression analysis the instrumental and emotional support dimensions of organizational support significantly influenced PTSD in emergency nurses (Table 7). Instrumental support had a strong negative effect (B = − 0.835, p < 0.001), with an influence second only to the assertiveness dimension, suggesting that instrumental support is a the core factor associated with alleviating PTSD. The impact of instrumental support—defined as the actual provision of resources and assistance (e.g., manpower support, equipment security, scheduling optimization, etc.)—was significantly greater than that of emotional support (B = − 0.835 vs. B = − 0.175), suggesting that emergency nurses rely more on tangible improvements in working conditions to alleviate their psychological burden. Adequate instrumental support can reduce nurses’ sense of overload and helplessness, thereby decreasing the cumulative negative impact of traumatic events. Although emotional support had a weaker negative effect, it was still statistically significant (B = − 0.175, p = 0.039). The results of this study show that emotional support refers to psychological care, such as empathy, listening, and encouragement, which, although not as significant as instrumental support, can alleviate nurses’ feelings of isolation and emotional exhaustion. Regular group counselling or peer support groups were conducted to encourage nurses to share traumatic experiences. Managers need to be proactive in expressing recognition rather than focusing only on task completion. Emotional comfort alone may address the symptoms rather than the root cause, and needs to be coupled with improvements in actual working conditions.

Organizational support reduces the risk of PTSD in emergency nurses through a combination of instrumental support (practical help) and emotional support (psychological care), but the former is more effective. This finding may be explained by the fact that emotional support is mainly demonstrated through respect and attentiveness to employees, such as showing care for their well-being, acknowledging their contributions, and assisting with work-related and life-related concerns26. The present study reveals the key role of organizational support, particularly emotional and instrumental support, in reducing PTSD in emergency nurses. Based on these findings, we propose the following policy recommendations for hospital administrators: (1) Establish a regular “manager-nurse” talk system (once a month), focusing on listening to nurses’ demands for work value and professional dignity. Emotional feedback should be incorporated into managerial performance appraisals. (2) Implement a “48-h psychological intervention after traumatic events,” where a full-time psychological counselor and the head nurse jointly provide emotional guidance. (3) Create an electronic record of nurses’ positive contributions, including metrics such as resuscitation success rates and patients’ letters of appreciation in real time, and enhance recognition of nurses’ efforts through public announcements in the hospital and letters of appreciation from families. (4) Implement a “Peak Hour Administrative Support” system, deploying administrative staff to assist with non-technical tasks during high-demand periods. (5) Establish an “emergency childcare service” and a “commuting subsidy fund” to address nurses’ primary concerns. (6) Establish an “occupational exposure allowance” for nurses involved in major resuscitation or frequent night shifts.

The adoption of organizational support initiatives in hospitals can reduce the incidence of PTSD by optimizing the implementation of emotional support, which is of strategic significance with respect to the sustainable development of high-stress departments such as emergency departments.

Strengths and limitations

This study has several notable strengths. First, it represents one of the few investigations specifically examining PTSD among emergency department nurses, addressing a critical gap in the literature and providing much-needed evidence for targeted interventions in this high-risk group. Second, the research design incorporated data collection across six tertiary hospitals in Suzhou and Wuxi, enhancing the diversity of the sample and increasing the potential generalizability of findings to similar urban, tertiary care emergency settings in Eastern China. Third, we achieved an exceptionally high response rate of 95.1% (213 valid responses out of 224 eligible nurses). This high participation rate significantly reduces concerns about non-response bias and strengthens confidence that the results accurately reflect the experiences of the target population within these settings.

Our findings revealed that the PTSD status of emergency nurses warrants attention, while their career resilience and perceived organizational support were at moderate levels. Crucially, both career resilience and perceived organizational support demonstrated significant negative correlations with PTSD. Specifically, the dimensions of “self-confidence” and “self-reliance” (career resilience), along with “emotional support” and “instrumental support” (organizational support), were significantly negatively correlated with PTSD symptoms. These robust associations provide concrete evidence for nursing administrators to prioritize interventions enhancing these specific protective factors to alleviate PTSD, improve job satisfaction, and stabilize the emergency nursing workforce.

Conclusions

Both self-confidence and self-reliance dimensions of professional resilience significantly reduced PTSD symptoms in emergency nurses, with self-confidence having stronger effects. This suggests that enhancing emergency nurses’ psychological toughness (particularly their level of self-confidence) may contribute to the prevention of PTSD. Organizational support can serve as a supplementary measure. The limitations of organizational support—which had a weaker effect than individual psychological toughness, even though instrumental support had a significant effect—suggest that it should be combined with individual psychological development to maximize protective effects. Future interventions should focus on cultivating individual psychological qualities, and combining them with organizational environment optimization to more effectively reduce the occurrence of PTSD.