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Swedish Ambulance Managers’ Descriptions of Crisis Support for Ambulance Staff After Potentially Traumatic Events

Published online by Cambridge University Press:  10 October 2014

Karin Hugelius ,
Sara Berg ,
Elin Westerberg ,
Mervyn Gifford  and
Annsofie Adolfsson
Karin Hugelius*
Affiliation:
School of Health and Medical Science, Örebro University, Örebro, Sweden Department of Anaesthesia, Karlskoga Hospital, Karlskoga, Sweden
Sara Berg
Affiliation:
School of Health and Medical Science, Örebro University, Örebro, Sweden Ambulance Department, Värmland County Council, Karlstad, Sweden
Elin Westerberg
Affiliation:
School of Health and Medical Science, Örebro University, Örebro, Sweden Ambulance Department, Värmland County Council, Karlstad, Sweden
Mervyn Gifford
Affiliation:
School of Health and Medical Science, Örebro University, Örebro, Sweden
Annsofie Adolfsson
Affiliation:
School of Health and Medical Science, Örebro University, Örebro, Sweden
*
Correspondence: Karin Hugelius, RN, MSc School of Health and Medical Science Örebro University 70281 Örebro, Sweden E-mail karin.hugelius@oru.se
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Abstract

Introduction

Ambulance staff face complex and sometimes stressful or potentially traumatic situations, not only in disasters but also in their routine daily work. The aim of this study was to survey ambulance managers’ descriptions of crisis support interventions for ambulance staff after potential traumatic events (PTEs).

Methods

Semistructured interviews with a qualitative descriptive design were conducted with six ambulance managers in a health care region in central Sweden. The data was analyzed using content analysis.

Result

Five categories were found in the result: (1) description of a PTE; (2) description and performance of crisis support interventions; (3) impact of working in potentially traumatic situations; (4) the ambulance managers’ role in crisis support interventions; and (5) the ambulance managers’ suggestions for improvement. Ambulance managers described crisis support interventions after a PTE as a single, mandatory group meeting with a structure reminiscent of debriefing. The ambulance managers also expressed doubts about the present structures for crisis support and mentioned an alternative approach which is more in line with present evidence-based recommendations.

Conclusion

The results indicated a need for increased understanding of the importance of the managers’ attitudes for ambulance staff; a need for further implementation of evidence-based recommendations for crisis support interventions was also highlighted.

HugeliusK , BergS , WesterbergE , GiffordM , AdolfssonA . Swedish Ambulance Managers’ Descriptions of Crisis Support for Ambulance Staff After Potentially Traumatic Events. Prehosp Disaster Med. 2014;29(6):1-4.

Keywords

ambulancemanagementstress
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 29 , Issue 6 , December 2014 , pp. 589 - 592
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2014 

Introduction

Ambulance staff face complex and sometimes stressful or potentially traumatic situations, not only in disasters but also in their routine daily work. The term “potentially traumatic event” (PTE)Reference Norris 1 , Reference Bonanno 2 is used to address the individual perspective of what might be experienced as a traumatic event. Work-related situations identified by ambulance staff as potentially traumatic include severely injured or dead children, traumatic or tragic deaths, threats or violence against the ambulance staff, situations when the prehospital care failed or did not work as planned, situations highlighted by media, and situations where the ambulance staff identified with the victims or family.Reference Declereq, Meganck, Deheegher and Hoorde Van 3 – Reference Halpern, Gurevich, Schwartz and Brazeau 5 Studies show that ambulance staff experience between one and five self-assessed traumatic events during their careersReference Halpern, Gurevich, Schwartz and Brazeau 5 and that there is a risk for acute stress reactions, posttraumatic stress syndrome, and other kinds of emotional disturbances.Reference Jonsson and Segersten 4 – Reference Jonsson and Segersten 7

Individual coping strategies among ambulance staff and expressed desire for support have been described.Reference Halpern, Gurevich, Schwartz and Brazeau 5 , Reference Jonsson and Segersten 7 Traditionally, various debriefing methods have been used to reduce stress and to promote natural recovery among professional rescue personnel.Reference Rose, Bisson, Churchill and Wessly 8 However, studies have shown that psychological debriefing may not reduce psychological stress or improve recovery from PTE,Reference Rose, Bisson, Churchill and Wessly 8 , Reference Van Emmerik, Kamphuis, Hulsbosch and Emmelkamp 9 and single-session debriefing is no longer a recommended standard intervention for stress reduction after a PTE in Sweden.Reference Rose, Bisson, Churchill and Wessly 8 , 10 Evidence-based recommendations have been formulated.Reference Brymer, Jacobs and Layne 11 – Reference Hobfoll, Watson and Bell 13 Additionally, the leadership, attitudes, and management from the nearest manager, and from peers, have been described as important factors for recovery for ambulance staff exposed to a PTE.Reference Halpern, Gurevich, Schwartz and Brazeau 5 Given that implementation of crisis support interventions are most often the responsibility of the ambulance manager, the ambulance managers’ attitudes and views of crisis support interventions are important factors to consider when addressing the problem of mental illness among ambulance personnel. This study aimed to survey ambulance managers’ experiences of crisis support interventions for ambulance staff after PTEs.

Method

A qualitative descriptive designReference Polit and Beck 14 was used to survey the ambulance managers regarding crisis support interventions for ambulance staff after PTEs. Participants were recruited from six ambulance stations in a region in Sweden covering both urban and rural areas. The study was conducted according to standards and requirements described in the Helsinki declaration 15 and the senior medical manager and the head of health care division in the region approved the study. The informants were contacted and informed by telephone about the purpose of the study and asked if they wanted to participate. Participation was voluntary and informants were told that they could cancel their participation at any time. An interview guide with 13 questions was developed by the authors based on experience from prehospital medical care and on the literature. The interview guide began with questions relating to background information and present conditions of the ambulance managers’ areas of responsibility. The other questions asked were:

  • • Can you describe crisis support?

  • • What kind of situations can indicate the need for or initiate crisis support interventions?

  • • Can you give some examples of when crisis support interventions have been used at your ambulance station in recent years?

  • • How are crisis support interventions initiated at your station?

  • • Tell us about how crisis support is conducted at your station

  • • Tell us about your role in crisis support

  • • Do you consider crisis support to be an easy or difficult part of your responsibilities/role as manager?

  • • How is crisis support seen by your manager (the head of ambulance department in the county)?

Semi-structured interviewsReference Polit and Beck 14 were conducted with six ambulance managers of seven available in the region covered. The ambulance managers had experience in their positions ranging from 1-13 years and the number of staff ranged from 8-53 ambulance staff at each station. The number of ambulances ranged from two ambulances (80 alarms per year) to six ambulances (12,000 alarms per year) for each station. All interviews were held at the workplace of the ambulance managers, according to their own wishes stated when the interviews were agreed to. Two investigators (SB, EW) were present during all the interviews. One of the investigators conducted the interview and the other supplemented with follow-up questions. Both investigators took literal notes which were combined into one text document after the interview. The interviews lasted 45-90 minutes.

The data were analyzed according to content analysis as described by Polit and Beck.Reference Polit and Beck 14 The texts from the entire interviews were first read thoroughly by the investigators, separately at first and then together. In the second step, quotes central to the aim of the study were identified, color marked, and categorized into themes covering topics or examples given in the interviews. In that way, important findings were not lost during the analysis process. Then, the themes were formulated into categories. All authors were involved in the formulation of themes and categories. Finally, the entire interviews were read through again to validate the categories found and the result as a whole. Quotes from the interviews were used to illustrate the results.Reference Graneheim and Lundman 16

Results

The analysis of the interviews resulted in five categories. These were: (1) description of a PTE; (2) description and performance of crisis support interventions; (3) impact of working in potentially traumatic situations; (4) the ambulance managers’ role in crisis support interventions; and (5) the ambulance managers’ suggestions for improvement.

Quotes are used to illustrate examples given in the interviews by the informants.

Description of Potentially Traumatic Events

All the ambulance managers gave examples of PTEs that in their opinion had, or should have, indicated a mandatory need for crisis support. Examples of situations when crisis support interventions had been implemented during the recent years were suicide by a young person, sudden death of an infant, an aircraft accident, a person who was hit by a train, and situations involving violence or threats against the ambulance personnel.

It doesn't have to be traffic accidents or sudden infant deaths.

The managers stressed the importance of an individual perspective and of an awareness that a specific situation might be experienced as a traumatic event for one individual but not for others.

Description and Performance of Crisis Support Interventions

All ambulance managers described crisis support interventions as single-session group meetings with all involved staff, where the participants could express how they acted at the scene as well as their feelings and emotions about the situation. The meetings followed a predefined structure and were led by a designated leader, most often the ambulance manager or a senior colleague. The opinion on when to perform this crisis intervention session ranged from as soon as possible after the PTE to later on the same day, or the morning after. All ambulance managers stated that it was mandatory for all staff involved in the situation to participate in the sessions, but it was voluntary as to whether or not they said anything. Some of the managers described situations when they had to force staff to attend the sessions.

You have to attend for other colleagues; that has never been a problem, you participate, and that's about respect.

All ambulance managers stated that the best option for the staff involved was to stay at the workplace after participation in the crisis support intervention. A few ambulance managers also mentioned practical support as a kind of crisis support intervention, such as the provision of new clothes, or getting in contact with family or friends.

Impact of Working in Potentially Traumatic Situations

The overall opinion among the ambulance managers was that working as ambulance personnel included facing potentially stressful events and that regularly exposure to traumatic situations could make the ambulance staff inured or irritable.

We have to resist some things in this work as well. You can't cry over everything. People who do usually don't stay very long.

Reactions such as reduced compassion or ambulance staff losing their tempers were also mentioned. According to the ambulance managers, these reactions were associated with the lack of crisis support interventions after traumatic events and the ambulance staff “collecting” negative emotions and experiences with a limited possibility for mental health recovery.

Ambulance Manager's Role in Crisis Support Interventions

Ensuring appropriate crisis support interventions after a PTE was seen as an important part of the ambulance manager′s role. The challenges described were to identify when and for whom crisis support interventions were needed. The ambulance manager should also promote a generally positive climate at the workplace.

Once a year all people trained to lead crisis support meetings gather together with the head of ambulance services to discuss good and bad experiences, and that can be a slap in the face for stations with less adequately- functioning crisis support.

The interest in crisis support interventions at a higher strategic level in the ambulance services organizations was fragmented; some managers thought that the issue was a high priority and others found it difficult to find time and money to perform crisis support interventions.

Ambulance Managers’ Suggestions for Improvements

All ambulance managers discussed the current local routines which require mandatory crisis support meetings after PTE and they expressed doubts about whether or not these guidelines were always the best way of supporting their staff.

Strong emotions might be aroused with crisis support.

The ambulance managers had their own experiences and suggestions of how “an ordinary cup of coffee and a chat” could be just as good as a structured crisis support meeting. Some ambulance personnel had also requested less structured crisis support and they questioned the need for such support to be mandatory. The ambulance managers expressed a fear of “overdoing” the supportive approach and of overdramatizing the reactions among the ambulance personnel, which could lead to nonsupportive interventions.

Discussion

The overall impression from this study was that crisis support was seen as an important part of the ambulance managers’ responsibilities and that concern for the health of their staff and wellbeing was evident. The study also confirmed the experience that ambulance personnel are sometimes exposed to PTEs and that the situations described as being PTEs for ambulance personnel are in line with previous studies.Reference Declereq, Meganck, Deheegher and Hoorde Van 3 – Reference Alexander and Klein 6 The optimal type of crisis support interventions for professional rescue personnel is still not confirmed, but several studies indicate that opportunities for social support and voluntary expression, and sharing of feelings after working in a PTE, can serve to assist healing from the stress experienced and can also serve to increase the team performance.Reference Halpern, Gurevich, Schwartz and Brazeau 5 , Reference Hobfoll, Watson and Bell 13 , Reference Tuckey and Scott 17 – Reference Arnberg, Hultman, Michel and Lundin 20 This was confirmed by managers’ spontaneous impressions that collegial support was an important form of crisis support. Given that a cautious approach to individuals in the immediate aftermath of a traumatic event is recommended,Reference Brymer, Jacobs and Layne 11 it is interesting to note that all the ambulance managers considered crisis support meetings mandatory. This might indicate overconfidence among the ambulance managers in the recovery effects of single-session group meetings or in interventions similar to debriefing. Another finding was that the ambulance managers at the same time expressed concerns and doubts about their present structures for crisis support and spontaneously described alternative approaches that were more in line with present evidence-based recommendations. 10 – Reference Hobfoll, Watson and Bell 13 This indicates potential for the improvement of the current guidelines and the structure of crisis support interventions in the ambulance services organization described in this paper.

The ambulance managers suggested that exposure to PTEs and stressful events caused long-term emotional or behavioral effects. DonnellyReference Donnelly 21 showed that there is a significant risk for development of posttraumatic stress disorder among paramedics, which could be related to both exposure to critical incidents as well as day-to-day stress experiences. Ambulance managers should therefore be aware of the risk factors and indicatorsReference Halpern, Maunder, Schwartz and Gurevich 22 for long-term consequences after exposure to PTEs, and programs for crisis support at the workplace should include long-term follow ups and screenings. 10 The leadership before, during, and after working in a stressful situation has been shown to be of importance in relation to how professionals experience their work situation and their recovery from stress.Reference Halpern, Gurevich, Schwartz and Brazeau 5 , 10 , Reference Halpern, Maunder, Schwartz and Gurevich 22 – Reference Polit and Beck 25 In the interviews, no ambulance managers mentioned their own attitudes or daily leadership as being relevant factors when considering crisis support interventions. This might indicate a need for increased understanding of the managers’ role and their leadership for the recovery of individual staff exposed to a PTE.

Limitations

This study presents results from one health care region and there are limitations as to how the data can be interpreted and generalized. The goal in qualitative research is not to generalize, but to create an understanding of human experiences.Reference Polit and Beck 25 The consensus among the ambulance managers interviewed was high and the variation in the answers was limited, which might indicate a degree of transferability.Reference Polit and Beck 14 Using a larger sample of interviewed persons might add more valuable dimensions to knowledge in this field. The interviews were carefully transcribed during the interviews by two authors individually. Complete recordings and transcriptions might have increased the validity of the study.

Conclusion

The results of this study show an overall strong desire on the part of the ambulance managers to protect and support ambulance personnel who are exposed to work-related PTEs. The need for further implementation of evidence-based recommendations to ensure appropriate and optimal support to ambulance staff before, during and after working in a PTE was also shown.

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