International Emergency Nursing 23 (2015) 100–104
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Experiences of critical incidents among female and male firefighters Ann Jacobsson RN, MsC (PhD student), Susann Backteman-Erlanson RNT, MSc, PhD (Lecturer) *, Christine Brulin RNT, PhD (Professor), Åsa Hörnsten RN, PhD (Ass. Prof) Department of Nursing, Umeå University, SE-901 87 Umeå, Sweden
A R T I C L E
I N F O
Article history: Received 17 January 2014 Received in revised form 12 June 2014 Accepted 16 June 2014 Keywords: Experiences Critical incidents Firefighters Gender patterns Content analysis
A B S T R A C T
Background: A critical incident is defined as an event stressful enough to overwhelm the usually effective coping skills of an individual. Firefighters are frequently exposed to critical incidents that might have consequences for individuals and their performance in organization. Aim: The aim of this study was to describe experiences of critical incidents among female and male Swedish firefighters. Method: In all 180 participants (16 women, 164 men) who had been involved in up to 25 critical incidents during the last year responded to a survey describing critical incidents experienced in the past year. A qualitative content analysis identified several areas for improvement in firefighters’ working conditions. Results: Female firefighters were terse in describing their experiences, while the men described their experiences of critical events more vividly. The critical incidents described by the firefighters concerned such overwhelming situations as traffic accidents, huge fires, and other fatal incidents such as drownings and suicides. Risk of delay due to lack of equipment training and lack of medical education was mentioned. Lack of resources and organizational problems was mentioned as causing risks of failure. Several firefighters expressed frustration over being assaulted and threatened, or exposed to other kinds of violence. Not knowing how close, physically or mentally, one can get to people during ongoing rescue can lead to unsuccessful operations. Conclusions: Gender patterns should always be taken into account, making it possible for all firefighters to express and reflect on existentially tough experiences. Education needs to focus more on medical and mental health issues. Firefighters were sometimes exposed to the difficult challenge of violence and assault during rescue operations. The complexity of this problem needs to be highlighted, not only in firefighter organizations, but also in society in general. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Because firefighters are frequently exposed to critical incidents (Beaton et al., 1999) that might have consequences for them as individuals and for their performance in the organization, they are of interest in highlighting experiences of incidents described as severe or critical. This study will give special attention to experiences of critical incidents among Swedish firefighters. The profession of firefighting is gendered; in Sweden and many other countries it has traditionally been an arena for white workingclass men to attain significant social status without completing higher education (Baigent, 2001; Chetkovich, 2004; Ericson, 2004; Glans and Rother, 2007). Recent efforts to recruit women and culturally diverse personnel aim to make the work more egalitarian
* Corresponding author. Fax: +469058041. E-mail address: [email protected] (S. Backteman-Erlanson). http://dx.doi.org/10.1016/j.ienj.2014.06.002 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
(Ministry of Industry, 2005, Proposition 2005/06:155). In their daily work, Swedish firefighters are expected to rescue people, property, and animals in various situations, to give first aid to patients at the site of accidents, to perform conventional fire extinction, and sometimes to be exposed to smoke and heat (Glans and Rother, 2007). Physical exercise, equipment checks, and team training are common in their daily work, and they are increasingly engaged in fire prevention work in cooperation with others (Swedish Parliament, 2003, p. 778). New demands for diversity among operational staff, such as employing more women and people with various ethnic backgrounds, have been met with resistance and suspicion among many firefighters (Ericson, 2004; Häyrén Weinestål et al., 2011). Repeated and varied attempts to meet these new demands and requirements have not produced lasting results and progress has been slow (Ericson, 2004; Glans and Rother, 2007). The demands for increased diversity among fire personnel and other changes call for individual as well as team development in operating rescue teams and departments, which may result in increased uncertainty and
A. Jacobsson et al./International Emergency Nursing 23 (2015) 100–104
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stress in addition to the daily stress firefighters experience from critical incidents in rescue situations. A critical incident can be defined as an abrupt and powerful event that falls outside the range of ordinary human experiences and is stressful enough to overwhelm the usually effective coping skills of an individual (Mitchell, 1986; Mitchell and Everly, 1993). Critical incidents in emergency services are defined as personal loss or injury, traumatic stimuli, mission failure, or human error, and often imply contact with dead or severely injured children (Harris et al., 2002). Critical incidents faced by firefighters include motor vehicle accidents, burned bodies, chemical hazards, life-threatening situations, suicides, failed rescue efforts, dangerous fire suppression scenarios, knowing the victim, and witnessing the death of a coworker (Beaton et al., 1999; Lim et al., 2000). Critical incidents are stressful, and people involved in such situations may need support to minimize the risk of burnout. These events can have a strong emotional impact on even the most experienced rescue personnel (Bryant and Harvey, 1995; Burns and Rosenberg, 2001; Lim et al., 2000). Posttraumatic stress and psychological dissociation have frequently been reported among rescue personnel. Post-traumatic stress disorder (PTSD) is an emotional illness classified as an anxiety disorder involving intense fear, helplessness, or horror that usually develops as a result of a terribly frightening, life-threatening, or otherwise highly unsafe experience (American Psychiatric Association, 2000). A study of 358 rescue workers from California reported that younger people and those who reported greater exposure to critical incidence stress and felt greater threat were at higher risk for peritraumatic dissociation and posttraumatic stress disorders. They also scored lower on adjustment, identity, ambition, and prudence on a personality inventory. External locus of control, greater feelings of perceived threat, and use of avoidant coping strategies were more significantly associated with dissociation than age and exposure to stress (Marmar et al., 1996). Critical incidents are common and stressful in firefighting and increase health risks such as PTSD among emergency personnel. To improve efficiency in critical situations, education is mainly focused on team training, and little attention has been paid to individual and gendered experiences prior to, during, and after incidents. In order to improve the preparation of firefighters, we need more knowledge about women’s and men’s experiences of critical incidents. The aim of this study was to describe experiences of critical incidents among female and male Swedish firefighters.
sponded after four reminders. Mean age for the total group 40.9, sd 12.8 and the length of employment was 11.6 years, sd 10.2. For the purpose of this study, respondents were asked to answer an open question about their experiences of critical incidents in the past year. In all, 180 participants (44%; 164 men, 16 women) answered the question and estimated that they had been involved in critical incidents 1–25 times during the previous year. The mean age was 40.7 years, sd 10.2 and the length of employment was 12.8 years, sd 10.4 (n = 119). Notably the dropout rate when calculating mean age is 34% (n = 61) due to missing data regarding age and length of employment.
2. Method
The answers to the latter part of this particular question were analyzed using qualitative content analysis (Graneheim and Lundman, 2004; Krippendorff, 2004). Qualitative content analysis moves back and forth from data to analysis, as researchers compare, discuss, and come to agreement about the findings in a process intended to strengthen the credibility of the analysis. We conducted an initial, thorough reading of the written answers and then divided the text into domains based on the sex of the participants. We identified meaning units responding to the aim, condensed them while retaining the core content, labeled them with a code describing the content, and organized the codes into categories based on their similarities and differences. To ensure trustworthiness, we discussed findings and interpretations through all steps in the process.
2.1. Setting The Swedish Civil Contingencies Agency is responsible for organizing the Swedish fire and rescue sector and for developing both individuals’ and society’s abilities to prevent and deal with emergencies and crises. Firefighters work in full-time, part-time, and volunteer positions. Full-time firefighters have two years of postsecondary training. In Sweden about 2% of firefighters are women, and firefighters from ethnic minority groups are too few to be measureable as a percentage.
2.3. Procedure Data collection began in January 2010 and ended in June 2011. A package including an invitation letter, information about the study, and the self-administered questionnaire was sent to 882 firefighters in Sweden. Participants sent the questionnaire back to the authors in a prepaid envelope. The study was approved by the Regional Ethics Review Board in Umeå, Sweden (No 08-186M). Participants were told about confidentiality, and informed consent was obtained from each of them. This study was part of a comprehensive research project (Nordic Safety and Security) concerning emergency personnel’s work environment throughout the European Union. The study was supported by grants from the European Union (Dno: 41 952). 2.4. Data collection In the overall study, the participants were asked to complete a set of well-evaluated scales, consisting of established and tested instruments regarding mental health and psychosocial work environment. For the purpose of this study we included one open question asking participants to describe in detail critical incidents experienced during the previous year. The question had two parts:
• •
How many times during this past year have you in your profession experienced situations that you characterize as critical incidents? Could you please describe such situations?
2.5. Analysis
2.2. Sample 3. Results This study is part of a larger survey focused on the health and work environment of firefighters in Sweden. A total of 882 randomly selected Swedish male firefighters working full time and all women working full time as firefighters in Sweden (n = 60) were invited by letter to answer a questionnaire. The participants were identified through trade association records and through direct contact with those rescue stations not represented in the registry. Of those invited, 476 firefighters (54%; 418 men, 58 women) re-
The results are presented first with an overall introduction of the gender patterns in the answers. The contexts of various critical incidents are then described and labeled according to the codes and categories shown in Table 1. Overall, we found that male firefighters generally expressed a more private and existential experience of critical incidents, while women gave a somewhat more distanced, descriptive, and ab-
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Table 1 Overview of codes and categories. Codes
Categories
Traffic accidents, huge fires, drowning accidents, and suicides Equipment failures, defective training, and education Lack of resources and organizational problems Threats, assaults, or violence during rescue
Overwhelming critical situations Risks of delay Risks of failure Risks to oneself
stracted account, such as “a time-consuming rescue operation” or “a traffic accident with three persons trapped.” Men gave more specific, detailed, and often macabre descriptions of death and death anxiety from their experiences of participation in rescue operations: “I came to a workplace accident where a person had been torn into pieces by a giant drill.” Men also expressed more empathy in their stories about injured and suffering people and their families, “difficult when comforting spouses in situations where they suddenly had lost husband/wife”, while women were more descriptive. Men also more frequently expressed how they were affected by these experiences in their private lives, while women did not. One man wrote, “I was fire officer. I approached my son’s car and saw a dead person on the side of the car. But the car appeared to be stolen and the dead person was not my son, so I could breathe out.” Men were more critical than women of problems in the organization and among executives. Both men and women wished better debriefing to process emotionally difficult experiences. Men and women identified the following critical incident experiences. 3.1. Overwhelming critical situations – traffic accidents, huge fires, drowning accidents, and suicides Traffic accidents, huge house and apartment fires, drownings, and attempted or successful suicides were the most stressful incidents firefighters responded to. The most stressful traffic accidents were those in which many people were injured or people were trapped and difficult to rescue, was expressed like this “traffic accident with many injured and dead victims, situations where my knowledge is not enough”. Experiences of huge fires focused on firefighters’ feelings of inadequacy and the perception of understaffing. Participants commented on the overwhelming heat and the lack at critical points of firefighters specially educated in the use of breathing equipment. Knowing people and animals were suffering and hearing their cries during impossible rescue situations was a heavy emotional burden: “An apartment is on fire and people are still shut in. The neighbours are standing on their balconies and are shouting and directing us, but the stairwell is filled with smoke and it is too hot to enter.” Drowning accidents with drawn-out searches for missing people were hard, and the firefighters felt that they were not well enough equipped or staffed during such missions. Suicide attempts were also hard, as the firefighters felt insufficiently educated in communicating with people in crises: “I felt that I was not prepared enough when a man jumped in front of the metro and died, and a close relative was inconsolable.” 3.2. Risks of delay – equipment failures, defective training, and education Material or vehicle failures were mentioned as leading to delayed responses. Insufficient initial and ongoing training on equipment was frustrating and stressful, and was described as leading to unnecessary costs and suffering: “Technical problems and lack of experience with the computer in the rescue vehicles delayed starting the water pump which in turn delayed the rescue. The monitor is hard to read in daylight.” Another firefighter expressed it like this “insufficient skills due to lack of training causing inefficient rescue operation”.
Participants cited lack of training in placing the lever arm to get the best position possible for the vehicle and its equipment. Lack of medical education was a commonly mentioned problem, as was lack of education and training in dealing with people with mental illness. Lack of equipment was another commonly mentioned problem: “We arrived at a nursing home, and the personnel had initiated CPR [cardiopulmonary resuscitation], but since we lack medical equipment in the car, we could not perform any defibrillation and were therefore powerless.” 3.3. Risks of failure: Lack of resources and organizational problems Lack of resources (too few personnel in the initial phase or too many people injured or in need of rescuing for the available personnel and resources) was devastating, since it sometimes made rescuing impossible and increased suffering. Some firefighters described experiences of houses burning down or people dying unnecessarily when they could have rescued the person or the building had there been more firefighters on duty: “It was a private house fire and we felt that we should and could have saved the house, but did not manage it, since we are too few on duty nowadays.” Rescuing severely injured people and waiting for ambulance personnel or firefighters occupied with other missions were cited as other stressful situations with an ethical character: “It was a fire in an apartment, and half of us were occupied with another rescue mission, and according to laws, we were not allowed to start lifesaving in the smoke, since we were too few left.” Another organizational problem was lack of follow-up information. Although firefighters may have spent hours rescuing people and have been relieved when the ambulance arrived, they were given no information about the outcome or recovery of the rescued people. This was experienced as frustrating and depreciating: “We are not included in the health care staff and therefore not informed about the consequences for the patients we have tried to rescue for hours in a drowning accident.” 3.4. Risks toward oneself – threats, assaults, or violence during rescue Many firefighters expressed frustration over being assaulted, threatened, or exposed to other kinds of violence such as stone throwing, snowballs to the head, and public verbal threats. Being disrespected in their duty was described as very provoking. Some respondents described a lack of support from executives and society for such concerns. Threats and bodily harm from alcoholics and drug addicts during rescue operations were another reason for frustration, as were threats during family disputes or in dealing with arsonists: “We were involved in a family battle where the son unfortunately jumped from the third floor when we came in.” Not knowing how close, physically or mentally, one can get to people during ongoing violent situations was a problem that could lead to unsuccessful rescues: “We find that some ethnic groups commonly jeer at us, throw stones, launch rockets, or assault us verbally, and in general we are not kindly received.” 4. Discussion The results highlight areas for improvement in firefighters’ working conditions related to gender, emotional burden and stress in critical situations, and understaffing and organizational problems, with risks for delay, ethical dilemmas, and failures. Physical and psychological risks, such as threats and violence during rescue missions, were highlighted as problem areas. Women’s entrance into traditionally male-dominated occupations might be perceived as a threat to the existing hegemonic masculinity (Connell, 2009). Such hegemony was prevalent within the Swedish Police Organization at the end of the 1950s (Dahlgren, 2007). From a “doing gender”
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perspective (Connell, 2009) women working as firefighters could need to be even tougher than men and display no weakness in order to fit into this traditionally male-dominated profession. Participants, male and female, highlighted the emotional burden of being involved in critical incidents in rescue situations. It is important to decrease this burden through debriefing. Psychological debriefing was developed in the 1980s (Mitchell, 1986) to help people exposed to stressful incidents through their work to process thoughts and emotions. In a Cochrane review of debriefing (Rose et al., 2002), 15 randomized controlled trials were identified: three found debriefing associated with a positive outcome, nine found no effect, and two reported a negative outcome. One study found immediate debriefing to be more effective than delayed debriefing. The two negative reports have led to recommendations not to offer brief, single-session debriefing to an individual alone as routine service (National Institute of Clinical Excellence [NICE, 2005]). Sufferers of post-traumatic stress disorder re-experience the traumatic events and tend to avoid stimuli such as places and people or other things that remind them of the trauma. Other effects are numbing of general responsiveness and persistent symptoms of increased arousal. PTSD has been a formal diagnosis since 1980 (American Psychiatric Association, 2000). Some of the firefighters in our study had terrible memories of rescue situations, and post-traumatic stress may be under-diagnosed in this group. Elmqvist et al. (2010) and Backteman-Erlanson et al. (2011) found similar results in interviews about critical incidents among firefighters and police officers. In those studies the interviewees expressed the need to discuss critical incidents with their colleagues. In an American study of PTSD symptoms among firefighters, Ben et al. (2006) found that a majority of the respondents described their worst experience as the death of another person, followed by being injured or nearly killed themselves. Meeting screaming victims or unexplained fires were other traumatic experiences. Firefighters felt their units were understaffed and not optimally organized, leading to risks for delayed rescue. They found this very frustrating and an area for improvement. Ethical dilemmas were also identified in firefighters’ perceptions about responsibility, opportunities to rescue, and lack of resources. The firefighters wished improved cooperation with ambulance nurses and paramedics and expressed their own need for extended training and education in medical and mental health issues. Risks aside from the work itself, such as assault and violence during rescue operations were overwhelming, and it is vital that they be solved to reduce stress among firefighters in the future. A research group from Malmö, Sweden, has analyzed reasons for conflicts between police/rescue personnel and teenage boys in immigrant-dense areas in Sweden (Hallin et al., 2010). Boys explained their spitting and throwing of stones at policemen and firefighters as expressions of their hatred of police, who they believed had used violence against them earlier. It was also a way of demonstrating power and control, and the higher status of the older teenagers was manifested by such deeds. The report concludes that lack of living space, poverty, idleness, and other tensions result in violence against police officers. The parents of the teenagers state that the teens’ violence was intended for police, not firefighters, but the teenagers view police and rescue personnel as similar, and use arson to lure police to the area in order to assault them. Violence against police and firefighters was also seen by fathers not only as a way to protest inequality and hopelessness, but also as a way of developing masculinity and gaining respect (Hallin et al., 2010). Connell (2009) stated that masculinity is formed in relation to others, and particular language use and actions target those people one wants to distinguish oneself from, as confirmed by the study by Hallin et al. (2010). Mothers in that report attributed their teenage boys’ actions to peer pressure and inadequate parental supervision. The overwhelming feeling of firefighters assaulted during their rescue com-
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mitments was expressed by an interviewed firefighter: “It is not the stones that hurt. They are quite small, and eggs and spit do not hurt, but it is the humiliation that hurts.” (Hallin et al., 2010). Although there may be explanations for these attacks, firefighters need to be secure, because the attacks prolong rescue operations and increase suffering among both victims and firefighters. To reduce similar problems in the police force, recruitment in recent years has focused on admitting applicants with multicultural backgrounds, thereby counteracting the homogeneity of the professional group (Skeggs, 1997); this could also be useful among rescue personnel such as firefighters. The training and admission for training for firefighters could perhaps be better designed to solve some of these problems. Another important mission is to better educate and prepare firefighters for threatening and violent situations. More than half of invited participants declined, even after four reminders, although most of the women responded. Although the participation rate was under 50%, we considered that the study group represented firefighters quite well. Data collection for this paper was conducted within a larger study using valid and reliable questionnaires. The data for this study consist of responses to one twopart open question. Sometimes the responders wrote down only one or two sentences, and sometimes they continued to write on the back of the paper to give the whole story. It is important in a questionnaire allowing open answers to invite the participants to answer the question in greater depth, not superficially. In interviews, there is the opportunity to probe with open-ended encouragements, such as “tell me more.” An open question in a questionnaire does not give that probing opportunity, but respondents were instructed to use the back of the paper if needed. It might have been better to interview these people in depth, but we were fortunate to have the opportunity to conduct this survey along with the larger project and to reach a large number of Swedish firefighters, many of whom generously shared their experiences of critical incidents in writing. It is also possible that some of the firefighters who responded in writing would have declined an individual interview, and therefore, we may have reached a more diverse sample this way. 5. Conclusions The critical incidents described by the firefighters concerned such overwhelming situations as traffic accidents, huge fires, and other fatal incidents such as drownings and suicides. No matter how much preventive work is undertaken to reduce such incidents, they will always occur. The negative experiences of those involved in rescue operations, however, could be alleviated by extra efforts directed toward reducing risks of delay and failure. Gender patterns should always be taken into account, making it possible for all firefighters to express and reflect on existentially tough experiences. Female firefighters were terse in describing their experiences, while the men described their experiences of critical events more vividly. All firefighters expressed a need for a better cooperation with ambulance personnel to reduce delays and failures. They also expressed a need for more training in emergency care and dealing with mental health issues while waiting for ambulance staff. The firefighters further expressed concerns about problems with their organization, staffing, and equipment, which led to risks of delay. Finally, first responders are sometimes exposed to the difficult challenge of violence and assault during rescue operations. The complexity of this problem needs to be highlighted, not only in firefighter organizations, but also in society in general. References American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM-IV). Revised, American Psychiatric Association, Washington DC.
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Backteman-Erlanson, S., Jacobsson, A., Öster, I., Brulin, C., 2011. Caring for traffic accident victims: the stories of nine male police officers. International Emergency Nursing. 19, 90–95. Baigent, D. One more last working class hero: a cultural audit of the UK fire service. Fitting-in. 2001. Available from: http://www.fitting-in.com/baigent.pdf accessed 28/5/2014. Beaton, R., Murphy, S., Johnson, C., Pike, K., Corneil, W., 1999. Coping responses and posttraumatic stress symptomatology in urban fire service personnel. Journal of Traumatic Stress. 12, 293–308. Ben, K.S.D., Scotti, J.R., Chen, Y.-C., Fortson, B.L., 2006. Prevalence of posttraumatic stress disorder symptoms in firefighters. Work and Stress. 20, 37–48. Bryant, R.A., Harvey, A.G., 1995. Posttraumatic stress in volunteer firefighters: predictors of distress. The Journal of Nervous and Mental Disease. 183, 267–271. Burns, C., Rosenberg, L., 2001. Redefining critical incidents: a preliminary report. International Journal of Emergency Mental Health. 3, 17–24. Chetkovich, C., 2004. Women’s agency in a context of oppression: assessing strategies for personal action and public policy. Hypatia. 1, 122–143. Connell, R., 2009. Chapter 6. Gender in personal life, in: Gender, Polity Short Introductions, Malden. Available from: http://www.polity.co.uk/ shortintroductions/connell-contents.asp accessed 05/06/2014. Dahlgren, J., 2007. Kvinnor i polistjänst. Föreningen Kamraterna, Svenska Polisförbundet och kvinnors inträde i polisyrket 1957–1971 [Women in the police service. Comrades Association, the Swedish Police Union and women’s entry into the police force 1957–1971]. Dissertation. Umeå University, Department of Historical Studies, Umeå; 2007. Elmqvist, C., Brunt, D., Fridlund, B., Ekebergh, M., 2010. Being first on the scene of an accident – experiences of ‘doing’ prehospital emergency care. Scandinavian Journal of Caring Sciences. 24, 266–273. Ericson, M., 2004. Brandman och man. Om aktualiseringen av kön i brandmannayrket. [Firefighter and Man. About Gender in the Firefighter Profession], Räddningsverket, Karlstad. Institutionen för genusvetenskap, Gothenburg University. Glans, H., Rother, B., 2007. Bära slang som en man? En bok för aktivt jämställdhetsarbete i räddningstjänsten. [Wearing Hose Like a Man? A Book for Actively Promoting Gender Equality in Civil Protection], Räddningsverket, Karlstad. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. 24, 105–112.
Hallin, P.-O., Jasharil, A., Listerbom, C., Popoola, M., 2010. Det är inte stenarna som gör ont [It is Not the Stones that Hurt], MAPIUS 5, Malmö. Malmö University publications in urban studies. Harris, M.B., Baloğlu, M., Stacks, J.R., 2002. Mental health of trauma-exposed firefighters and critical incident stress debriefing. Journal of Loss &Trauma. 7, 223–238. Häyrén Weinestål, A.F., Bondestam, F., Berg, H., 2011. From novice to Nestor Masculinity Organisation and Risk in Emergency Services, Swedish Civil Contingencies Agency, Karlstad. An action research. Krippendorff, K., 2004. Content Analysis: An Introduction to Its Methodology, Sage Publications, Los Angeles. Lim, J., Childs, J., Gonsalves, K., 2000. Critical incident stress management. AAOHN: Official Journal of the American Association of Occupational Health Nurses. 48, 487–497. Marmar, C.R., Weiss, D.S., Metzler, T.J., Delucchi, K., 1996. Characteristics of emergency services personnel related to peritraumatic dissociation during critical incident exposure. The American Journal of Psychiatry. 153 (7S), 94–102. Ministry of Industry, 2005. Makt att forma samhället och sitt eget liv – nya mål i jämställdhetspolitiken. [Power to Shape Society and their Own Lives – New Gender Policy Objectives], Ministry of Industry, Stockholm. Proposition 2005/ 06:155. Mitchell, J., 1986. Teaming up against critical incident stress. Chief Fire Executive. 1, 24,36,84. Mitchell, J.T., Everly, G.S., Jr., 1993. Critical Incident Stress Debriefing: An Operations Manual for the Prevention of Trauma Among Emergency Service and Disaster Workers, Chevron, Baltimore, MD. National Institute of Clinical Excellence (NICE), 2005. Post-Traumatic Stress Disorder – The Management of PTSD in Adults and Children in Primary and Secondary Care. National Clinical Practice Guideline, Gaskell and the British Psychological Society, London. Rose, S.C., Bisson, J., Churchill, R., Wessely, S., 2002. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews. (2), Art. No.: CD000560, doi:10.1002/14651858.CD000560. Skeggs, B., 1997. Formations of Class and Gender: Becoming Respectable, vol. 51. Sage Publications, London. Swedish Parliament, 2003. Civil Protection Act (SFS 2003:778), Sveriges Riksdag, Stockholm.
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Experiences of critical incidents among female and male firefighters Ann Jacobsson RN, MsC (PhD student), Susann Backteman-Erlanson RNT, MSc, PhD (Lecturer) *, Christine Brulin RNT, PhD (Professor), Åsa Hörnsten RN, PhD (Ass. Prof) Department of Nursing, Umeå University, SE-901 87 Umeå, Sweden
A R T I C L E
I N F O
Article history: Received 17 January 2014 Received in revised form 12 June 2014 Accepted 16 June 2014 Keywords: Experiences Critical incidents Firefighters Gender patterns Content analysis
A B S T R A C T
Background: A critical incident is defined as an event stressful enough to overwhelm the usually effective coping skills of an individual. Firefighters are frequently exposed to critical incidents that might have consequences for individuals and their performance in organization. Aim: The aim of this study was to describe experiences of critical incidents among female and male Swedish firefighters. Method: In all 180 participants (16 women, 164 men) who had been involved in up to 25 critical incidents during the last year responded to a survey describing critical incidents experienced in the past year. A qualitative content analysis identified several areas for improvement in firefighters’ working conditions. Results: Female firefighters were terse in describing their experiences, while the men described their experiences of critical events more vividly. The critical incidents described by the firefighters concerned such overwhelming situations as traffic accidents, huge fires, and other fatal incidents such as drownings and suicides. Risk of delay due to lack of equipment training and lack of medical education was mentioned. Lack of resources and organizational problems was mentioned as causing risks of failure. Several firefighters expressed frustration over being assaulted and threatened, or exposed to other kinds of violence. Not knowing how close, physically or mentally, one can get to people during ongoing rescue can lead to unsuccessful operations. Conclusions: Gender patterns should always be taken into account, making it possible for all firefighters to express and reflect on existentially tough experiences. Education needs to focus more on medical and mental health issues. Firefighters were sometimes exposed to the difficult challenge of violence and assault during rescue operations. The complexity of this problem needs to be highlighted, not only in firefighter organizations, but also in society in general. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Because firefighters are frequently exposed to critical incidents (Beaton et al., 1999) that might have consequences for them as individuals and for their performance in the organization, they are of interest in highlighting experiences of incidents described as severe or critical. This study will give special attention to experiences of critical incidents among Swedish firefighters. The profession of firefighting is gendered; in Sweden and many other countries it has traditionally been an arena for white workingclass men to attain significant social status without completing higher education (Baigent, 2001; Chetkovich, 2004; Ericson, 2004; Glans and Rother, 2007). Recent efforts to recruit women and culturally diverse personnel aim to make the work more egalitarian
* Corresponding author. Fax: +469058041. E-mail address: [email protected] (S. Backteman-Erlanson). http://dx.doi.org/10.1016/j.ienj.2014.06.002 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
(Ministry of Industry, 2005, Proposition 2005/06:155). In their daily work, Swedish firefighters are expected to rescue people, property, and animals in various situations, to give first aid to patients at the site of accidents, to perform conventional fire extinction, and sometimes to be exposed to smoke and heat (Glans and Rother, 2007). Physical exercise, equipment checks, and team training are common in their daily work, and they are increasingly engaged in fire prevention work in cooperation with others (Swedish Parliament, 2003, p. 778). New demands for diversity among operational staff, such as employing more women and people with various ethnic backgrounds, have been met with resistance and suspicion among many firefighters (Ericson, 2004; Häyrén Weinestål et al., 2011). Repeated and varied attempts to meet these new demands and requirements have not produced lasting results and progress has been slow (Ericson, 2004; Glans and Rother, 2007). The demands for increased diversity among fire personnel and other changes call for individual as well as team development in operating rescue teams and departments, which may result in increased uncertainty and
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stress in addition to the daily stress firefighters experience from critical incidents in rescue situations. A critical incident can be defined as an abrupt and powerful event that falls outside the range of ordinary human experiences and is stressful enough to overwhelm the usually effective coping skills of an individual (Mitchell, 1986; Mitchell and Everly, 1993). Critical incidents in emergency services are defined as personal loss or injury, traumatic stimuli, mission failure, or human error, and often imply contact with dead or severely injured children (Harris et al., 2002). Critical incidents faced by firefighters include motor vehicle accidents, burned bodies, chemical hazards, life-threatening situations, suicides, failed rescue efforts, dangerous fire suppression scenarios, knowing the victim, and witnessing the death of a coworker (Beaton et al., 1999; Lim et al., 2000). Critical incidents are stressful, and people involved in such situations may need support to minimize the risk of burnout. These events can have a strong emotional impact on even the most experienced rescue personnel (Bryant and Harvey, 1995; Burns and Rosenberg, 2001; Lim et al., 2000). Posttraumatic stress and psychological dissociation have frequently been reported among rescue personnel. Post-traumatic stress disorder (PTSD) is an emotional illness classified as an anxiety disorder involving intense fear, helplessness, or horror that usually develops as a result of a terribly frightening, life-threatening, or otherwise highly unsafe experience (American Psychiatric Association, 2000). A study of 358 rescue workers from California reported that younger people and those who reported greater exposure to critical incidence stress and felt greater threat were at higher risk for peritraumatic dissociation and posttraumatic stress disorders. They also scored lower on adjustment, identity, ambition, and prudence on a personality inventory. External locus of control, greater feelings of perceived threat, and use of avoidant coping strategies were more significantly associated with dissociation than age and exposure to stress (Marmar et al., 1996). Critical incidents are common and stressful in firefighting and increase health risks such as PTSD among emergency personnel. To improve efficiency in critical situations, education is mainly focused on team training, and little attention has been paid to individual and gendered experiences prior to, during, and after incidents. In order to improve the preparation of firefighters, we need more knowledge about women’s and men’s experiences of critical incidents. The aim of this study was to describe experiences of critical incidents among female and male Swedish firefighters.
sponded after four reminders. Mean age for the total group 40.9, sd 12.8 and the length of employment was 11.6 years, sd 10.2. For the purpose of this study, respondents were asked to answer an open question about their experiences of critical incidents in the past year. In all, 180 participants (44%; 164 men, 16 women) answered the question and estimated that they had been involved in critical incidents 1–25 times during the previous year. The mean age was 40.7 years, sd 10.2 and the length of employment was 12.8 years, sd 10.4 (n = 119). Notably the dropout rate when calculating mean age is 34% (n = 61) due to missing data regarding age and length of employment.
2. Method
The answers to the latter part of this particular question were analyzed using qualitative content analysis (Graneheim and Lundman, 2004; Krippendorff, 2004). Qualitative content analysis moves back and forth from data to analysis, as researchers compare, discuss, and come to agreement about the findings in a process intended to strengthen the credibility of the analysis. We conducted an initial, thorough reading of the written answers and then divided the text into domains based on the sex of the participants. We identified meaning units responding to the aim, condensed them while retaining the core content, labeled them with a code describing the content, and organized the codes into categories based on their similarities and differences. To ensure trustworthiness, we discussed findings and interpretations through all steps in the process.
2.1. Setting The Swedish Civil Contingencies Agency is responsible for organizing the Swedish fire and rescue sector and for developing both individuals’ and society’s abilities to prevent and deal with emergencies and crises. Firefighters work in full-time, part-time, and volunteer positions. Full-time firefighters have two years of postsecondary training. In Sweden about 2% of firefighters are women, and firefighters from ethnic minority groups are too few to be measureable as a percentage.
2.3. Procedure Data collection began in January 2010 and ended in June 2011. A package including an invitation letter, information about the study, and the self-administered questionnaire was sent to 882 firefighters in Sweden. Participants sent the questionnaire back to the authors in a prepaid envelope. The study was approved by the Regional Ethics Review Board in Umeå, Sweden (No 08-186M). Participants were told about confidentiality, and informed consent was obtained from each of them. This study was part of a comprehensive research project (Nordic Safety and Security) concerning emergency personnel’s work environment throughout the European Union. The study was supported by grants from the European Union (Dno: 41 952). 2.4. Data collection In the overall study, the participants were asked to complete a set of well-evaluated scales, consisting of established and tested instruments regarding mental health and psychosocial work environment. For the purpose of this study we included one open question asking participants to describe in detail critical incidents experienced during the previous year. The question had two parts:
• •
How many times during this past year have you in your profession experienced situations that you characterize as critical incidents? Could you please describe such situations?
2.5. Analysis
2.2. Sample 3. Results This study is part of a larger survey focused on the health and work environment of firefighters in Sweden. A total of 882 randomly selected Swedish male firefighters working full time and all women working full time as firefighters in Sweden (n = 60) were invited by letter to answer a questionnaire. The participants were identified through trade association records and through direct contact with those rescue stations not represented in the registry. Of those invited, 476 firefighters (54%; 418 men, 58 women) re-
The results are presented first with an overall introduction of the gender patterns in the answers. The contexts of various critical incidents are then described and labeled according to the codes and categories shown in Table 1. Overall, we found that male firefighters generally expressed a more private and existential experience of critical incidents, while women gave a somewhat more distanced, descriptive, and ab-
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Table 1 Overview of codes and categories. Codes
Categories
Traffic accidents, huge fires, drowning accidents, and suicides Equipment failures, defective training, and education Lack of resources and organizational problems Threats, assaults, or violence during rescue
Overwhelming critical situations Risks of delay Risks of failure Risks to oneself
stracted account, such as “a time-consuming rescue operation” or “a traffic accident with three persons trapped.” Men gave more specific, detailed, and often macabre descriptions of death and death anxiety from their experiences of participation in rescue operations: “I came to a workplace accident where a person had been torn into pieces by a giant drill.” Men also expressed more empathy in their stories about injured and suffering people and their families, “difficult when comforting spouses in situations where they suddenly had lost husband/wife”, while women were more descriptive. Men also more frequently expressed how they were affected by these experiences in their private lives, while women did not. One man wrote, “I was fire officer. I approached my son’s car and saw a dead person on the side of the car. But the car appeared to be stolen and the dead person was not my son, so I could breathe out.” Men were more critical than women of problems in the organization and among executives. Both men and women wished better debriefing to process emotionally difficult experiences. Men and women identified the following critical incident experiences. 3.1. Overwhelming critical situations – traffic accidents, huge fires, drowning accidents, and suicides Traffic accidents, huge house and apartment fires, drownings, and attempted or successful suicides were the most stressful incidents firefighters responded to. The most stressful traffic accidents were those in which many people were injured or people were trapped and difficult to rescue, was expressed like this “traffic accident with many injured and dead victims, situations where my knowledge is not enough”. Experiences of huge fires focused on firefighters’ feelings of inadequacy and the perception of understaffing. Participants commented on the overwhelming heat and the lack at critical points of firefighters specially educated in the use of breathing equipment. Knowing people and animals were suffering and hearing their cries during impossible rescue situations was a heavy emotional burden: “An apartment is on fire and people are still shut in. The neighbours are standing on their balconies and are shouting and directing us, but the stairwell is filled with smoke and it is too hot to enter.” Drowning accidents with drawn-out searches for missing people were hard, and the firefighters felt that they were not well enough equipped or staffed during such missions. Suicide attempts were also hard, as the firefighters felt insufficiently educated in communicating with people in crises: “I felt that I was not prepared enough when a man jumped in front of the metro and died, and a close relative was inconsolable.” 3.2. Risks of delay – equipment failures, defective training, and education Material or vehicle failures were mentioned as leading to delayed responses. Insufficient initial and ongoing training on equipment was frustrating and stressful, and was described as leading to unnecessary costs and suffering: “Technical problems and lack of experience with the computer in the rescue vehicles delayed starting the water pump which in turn delayed the rescue. The monitor is hard to read in daylight.” Another firefighter expressed it like this “insufficient skills due to lack of training causing inefficient rescue operation”.
Participants cited lack of training in placing the lever arm to get the best position possible for the vehicle and its equipment. Lack of medical education was a commonly mentioned problem, as was lack of education and training in dealing with people with mental illness. Lack of equipment was another commonly mentioned problem: “We arrived at a nursing home, and the personnel had initiated CPR [cardiopulmonary resuscitation], but since we lack medical equipment in the car, we could not perform any defibrillation and were therefore powerless.” 3.3. Risks of failure: Lack of resources and organizational problems Lack of resources (too few personnel in the initial phase or too many people injured or in need of rescuing for the available personnel and resources) was devastating, since it sometimes made rescuing impossible and increased suffering. Some firefighters described experiences of houses burning down or people dying unnecessarily when they could have rescued the person or the building had there been more firefighters on duty: “It was a private house fire and we felt that we should and could have saved the house, but did not manage it, since we are too few on duty nowadays.” Rescuing severely injured people and waiting for ambulance personnel or firefighters occupied with other missions were cited as other stressful situations with an ethical character: “It was a fire in an apartment, and half of us were occupied with another rescue mission, and according to laws, we were not allowed to start lifesaving in the smoke, since we were too few left.” Another organizational problem was lack of follow-up information. Although firefighters may have spent hours rescuing people and have been relieved when the ambulance arrived, they were given no information about the outcome or recovery of the rescued people. This was experienced as frustrating and depreciating: “We are not included in the health care staff and therefore not informed about the consequences for the patients we have tried to rescue for hours in a drowning accident.” 3.4. Risks toward oneself – threats, assaults, or violence during rescue Many firefighters expressed frustration over being assaulted, threatened, or exposed to other kinds of violence such as stone throwing, snowballs to the head, and public verbal threats. Being disrespected in their duty was described as very provoking. Some respondents described a lack of support from executives and society for such concerns. Threats and bodily harm from alcoholics and drug addicts during rescue operations were another reason for frustration, as were threats during family disputes or in dealing with arsonists: “We were involved in a family battle where the son unfortunately jumped from the third floor when we came in.” Not knowing how close, physically or mentally, one can get to people during ongoing violent situations was a problem that could lead to unsuccessful rescues: “We find that some ethnic groups commonly jeer at us, throw stones, launch rockets, or assault us verbally, and in general we are not kindly received.” 4. Discussion The results highlight areas for improvement in firefighters’ working conditions related to gender, emotional burden and stress in critical situations, and understaffing and organizational problems, with risks for delay, ethical dilemmas, and failures. Physical and psychological risks, such as threats and violence during rescue missions, were highlighted as problem areas. Women’s entrance into traditionally male-dominated occupations might be perceived as a threat to the existing hegemonic masculinity (Connell, 2009). Such hegemony was prevalent within the Swedish Police Organization at the end of the 1950s (Dahlgren, 2007). From a “doing gender”
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perspective (Connell, 2009) women working as firefighters could need to be even tougher than men and display no weakness in order to fit into this traditionally male-dominated profession. Participants, male and female, highlighted the emotional burden of being involved in critical incidents in rescue situations. It is important to decrease this burden through debriefing. Psychological debriefing was developed in the 1980s (Mitchell, 1986) to help people exposed to stressful incidents through their work to process thoughts and emotions. In a Cochrane review of debriefing (Rose et al., 2002), 15 randomized controlled trials were identified: three found debriefing associated with a positive outcome, nine found no effect, and two reported a negative outcome. One study found immediate debriefing to be more effective than delayed debriefing. The two negative reports have led to recommendations not to offer brief, single-session debriefing to an individual alone as routine service (National Institute of Clinical Excellence [NICE, 2005]). Sufferers of post-traumatic stress disorder re-experience the traumatic events and tend to avoid stimuli such as places and people or other things that remind them of the trauma. Other effects are numbing of general responsiveness and persistent symptoms of increased arousal. PTSD has been a formal diagnosis since 1980 (American Psychiatric Association, 2000). Some of the firefighters in our study had terrible memories of rescue situations, and post-traumatic stress may be under-diagnosed in this group. Elmqvist et al. (2010) and Backteman-Erlanson et al. (2011) found similar results in interviews about critical incidents among firefighters and police officers. In those studies the interviewees expressed the need to discuss critical incidents with their colleagues. In an American study of PTSD symptoms among firefighters, Ben et al. (2006) found that a majority of the respondents described their worst experience as the death of another person, followed by being injured or nearly killed themselves. Meeting screaming victims or unexplained fires were other traumatic experiences. Firefighters felt their units were understaffed and not optimally organized, leading to risks for delayed rescue. They found this very frustrating and an area for improvement. Ethical dilemmas were also identified in firefighters’ perceptions about responsibility, opportunities to rescue, and lack of resources. The firefighters wished improved cooperation with ambulance nurses and paramedics and expressed their own need for extended training and education in medical and mental health issues. Risks aside from the work itself, such as assault and violence during rescue operations were overwhelming, and it is vital that they be solved to reduce stress among firefighters in the future. A research group from Malmö, Sweden, has analyzed reasons for conflicts between police/rescue personnel and teenage boys in immigrant-dense areas in Sweden (Hallin et al., 2010). Boys explained their spitting and throwing of stones at policemen and firefighters as expressions of their hatred of police, who they believed had used violence against them earlier. It was also a way of demonstrating power and control, and the higher status of the older teenagers was manifested by such deeds. The report concludes that lack of living space, poverty, idleness, and other tensions result in violence against police officers. The parents of the teenagers state that the teens’ violence was intended for police, not firefighters, but the teenagers view police and rescue personnel as similar, and use arson to lure police to the area in order to assault them. Violence against police and firefighters was also seen by fathers not only as a way to protest inequality and hopelessness, but also as a way of developing masculinity and gaining respect (Hallin et al., 2010). Connell (2009) stated that masculinity is formed in relation to others, and particular language use and actions target those people one wants to distinguish oneself from, as confirmed by the study by Hallin et al. (2010). Mothers in that report attributed their teenage boys’ actions to peer pressure and inadequate parental supervision. The overwhelming feeling of firefighters assaulted during their rescue com-
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mitments was expressed by an interviewed firefighter: “It is not the stones that hurt. They are quite small, and eggs and spit do not hurt, but it is the humiliation that hurts.” (Hallin et al., 2010). Although there may be explanations for these attacks, firefighters need to be secure, because the attacks prolong rescue operations and increase suffering among both victims and firefighters. To reduce similar problems in the police force, recruitment in recent years has focused on admitting applicants with multicultural backgrounds, thereby counteracting the homogeneity of the professional group (Skeggs, 1997); this could also be useful among rescue personnel such as firefighters. The training and admission for training for firefighters could perhaps be better designed to solve some of these problems. Another important mission is to better educate and prepare firefighters for threatening and violent situations. More than half of invited participants declined, even after four reminders, although most of the women responded. Although the participation rate was under 50%, we considered that the study group represented firefighters quite well. Data collection for this paper was conducted within a larger study using valid and reliable questionnaires. The data for this study consist of responses to one twopart open question. Sometimes the responders wrote down only one or two sentences, and sometimes they continued to write on the back of the paper to give the whole story. It is important in a questionnaire allowing open answers to invite the participants to answer the question in greater depth, not superficially. In interviews, there is the opportunity to probe with open-ended encouragements, such as “tell me more.” An open question in a questionnaire does not give that probing opportunity, but respondents were instructed to use the back of the paper if needed. It might have been better to interview these people in depth, but we were fortunate to have the opportunity to conduct this survey along with the larger project and to reach a large number of Swedish firefighters, many of whom generously shared their experiences of critical incidents in writing. It is also possible that some of the firefighters who responded in writing would have declined an individual interview, and therefore, we may have reached a more diverse sample this way. 5. Conclusions The critical incidents described by the firefighters concerned such overwhelming situations as traffic accidents, huge fires, and other fatal incidents such as drownings and suicides. No matter how much preventive work is undertaken to reduce such incidents, they will always occur. The negative experiences of those involved in rescue operations, however, could be alleviated by extra efforts directed toward reducing risks of delay and failure. Gender patterns should always be taken into account, making it possible for all firefighters to express and reflect on existentially tough experiences. Female firefighters were terse in describing their experiences, while the men described their experiences of critical events more vividly. All firefighters expressed a need for a better cooperation with ambulance personnel to reduce delays and failures. They also expressed a need for more training in emergency care and dealing with mental health issues while waiting for ambulance staff. The firefighters further expressed concerns about problems with their organization, staffing, and equipment, which led to risks of delay. Finally, first responders are sometimes exposed to the difficult challenge of violence and assault during rescue operations. The complexity of this problem needs to be highlighted, not only in firefighter organizations, but also in society in general. References American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM-IV). Revised, American Psychiatric Association, Washington DC.
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