Coping Strategies and Professional Quality of Life Among Emergency

19/11/2010

Coping Strategies Among Emergency …

Coping Strategies and Professional Quality of Life Among Emergency Workers

The Australasian Journal of Disaster and Trauma Studies ISSN: 1174-4707 Volume : 2009-1

Coping Strategies and Professional Quality of Life Among Emergency Workers Gabriele Prati, Luigi Palestini and Luca Pietrantoni, Department of Education, University of Bologna, Italy. Correspondence should be addressed to Gabriele Prati, Dipartimento di scienze dell'educazione, Università di Bologna, via Filippo Re, 6 - 40126 Bologna, Italy; telephone: +3951 2091610; fax: +39 051 2091489; email: [email protected] Keywords: emergency workers; coping strategies; quality of life

Gabriele Prati, Luigi Palestini and Luca Pietrantoni Department of Education, University of Bologna, Italy

Abstract Emergency workers must cope with a wide range of critical incidents. Scientific literature is increasingly documenting the way emergency workers deal with these events and the relation of their coping responses to quality of life. This study found that Italian emergency workers (N=1200) were most likely to engage in the use of acceptance (M=3.72, SD=0.78), planning (M=3.44, SD=0.83), active coping (M=3.32, SD=0.87), instrumental support (M=2.94, SD=0.96) and positive reframing (M=2.81, SD=0.93) and less likely to resort to substance use (M=1.04, SD=0.35), denial (M=1.31, SD=0.60) and behavioral disengagement (M=1.57, SD=0.66). Additionally, we identified second order dimensions of coping that offer support for the empirically derived categories of coping (problem-focused coping, avoidance, meaning-focused coping and social support coping). Finally, avoidance coping emerged as risk factor for professional quality of life while problem-focused coping promoted compassion satisfaction.

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Coping Strategies and Professional Quality of Life Among Emergency Workers Introduction There is an increasing interest in the community and in the academic literature on emergency workers’ quality of life because of their repeated exposure to potentially traumatic events (Benedek, Fullerton & Ursano, 2007). Emergency workers are exposed to critical incidents in their line of duty, such as accidents involving children, mass incidents, major fires, road traffic accidents, burnt patients, violent incidents and murder scenes. A critical incident may be defined as any event whose impact is stressful enough to overwhelm an individual’s usual method of coping. The literature on emergency workers has usually focused on negative outcomes such as traumatic stress symptoms (e.g. Clohessy & Ehlers, 1999), secondary traumatic stress or compassion fatigue (e.g. Figley, 1995) and burnout (Alexander & Klein, 2001). However these are not the only possible emergency workrelated outcomes. For example, research findings evidenced that emergency ambulance personnel reported positive post-trauma changes (posttraumatic growth) as the result of the experience of occupational trauma (Shakespeare-Finch, 2003). Stamm (2005) introduced the concept of Compassion satisfaction, defined as the benefits that individuals derive from working with traumatized or suffering persons – i.e., positive feelings about helping others, finding meaning in one’s efforts and challenges, fulfilling one's potential, contributing to the work setting and even to the greater good of society, and the overall pleasure derived from being able to do one’s work well. We argue that the way emergency workers cope with the exposure to critical incidents plays a crucial role in the development of the aforementioned outcomes. For example, a recent meta-analysis revealed a clear, consistent and positive association between reliance on avoidance strategies to cope with trauma and psychological distress, while there was a small relation of strategies focused on solving the problem (e.g., planning how to resolve the stressor, seeking information about the stressor) to psychological distress (Littleton, Horsley, Siji & Nelson, 2007). Thus, we set to investigate the relationship between emergency workers’ coping strategies and quality of life. Emergency workers’ coping strategies Two primary conceptualizations of coping strategies have emerged in the literature. The first conceptualization, proposed by Lazarus and Folkman (1984), distinguished two major theory-based functions of coping: problem-focused coping and emotion-focused coping. The second conceptualization emphasized the distinction between approach and avoidance coping strategies (Moos & Schaefer, 1993). Besides conceptual approach, empirically derived categories of coping usually include four factors: problemfocused coping, avoidance, meaning-focused coping and social support coping (Folkman & Moskowitz, 2004). Emergency workers are a self-selected occupational group which faces unusual demands, and they may not be compared with the general population in term of coping strategies (Beaton, Murphy, Johnson, Pike, & Cornell, 1999). It is more difficult to determine on a priori grounds the coping strategies they use and which of these could be effective in facing stressors and improving quality of life. In their study on Protective Services Personnel, Burke and Paton (2006) identified two constructs, problem-focused coping (e.g. active coping, planning, acceptance) and emotion-focused coping (e.g. mental disengagement, denial, seeking support) which were respectively related to positive and negative work experience. In another study, Shipley massey.ac.nz/~trauma/…/prati.htm

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and Gow (2006) identified three dimensions that might underlie coping strategies among State Emergency Service (SES) volunteer members: adaptive coping (e.g. active coping, seeking support, planning, acceptance), maladaptive coping (e.g. denial, self-blame, behavioral disengagement) and coping through the use of humor. The participants were least likely to engage in maladaptive coping strategies while they were most likely to resort to adaptive coping abilities. Adaptive coping was also moderately correlated with general satisfaction with one's work. The complexity of the situations faced by rescue workers is paralleled by findings from the empirical literature. Results concerning the relationship between coping strategies and mental health in rescue personnel are quite contradictory (except for avoidance coping). Cognitive and behavioral avoidance and escape-avoidance coping have been found to predict greater psychological distress (Beaton, et al., 1999; Brown, Mulhern, & Joseph, 2002; Boudreaux, Mandry & Brantley 1997; Clohessy & Ehlers, 1999; Chang, Lee, Connor, Davidson, Jeffries, & Lai, 2003; Marmar, Weiss, Metzler, & Delucci 1996), but denial and behavioral distraction coping has been not related to mental health (Beaton et al., 1999; Clohessy & Ehlers, 1999). Problem-focused coping has been found associated both to high (Marmar et al., 1996) and low levels of distress (Brown et al., 2002). Emotion-focused coping has been associated to lower psychological distress (Brown et al., 2002) but seeking social support for emotional reasons and venting of emotions have not (Beaton et al., 1999; Clohessy & Ehlers, 1999). In their systematic review Sterud, Ekeberg, and Hem (2006) concluded that some studies identified maladaptive coping strategies but no studies have been able to identify any adaptive coping strategies. However, this review mainly focused on negative mental health outcomes. There is currently sufficient literature supporting the independence of positive and negative outcomes (Paton, Violanti, & Smith, 2003; Shakespeare-Finch, 2003) and the use of differential coping strategies in emergency service workers as an initial protective mechanism (McCammon, Durham, Jackson Allison, & Williamson, 1988). Finally, the literature evidenced that there are gender differences in coping strategies (Tamres, Janicki & Helgeson, 2002) and Hytten and Hasle (1989) findings suggested that job tenure is positively related to more adaptive coping strategies. Thus, length of services and gender need to be investigated. The purposes of this study are: 1) to investigate the use of coping strategies; 2) to identify second order dimensions that might underlie coping scales; 3) to investigate differences in coping strategies according to gender and length of services; 4) to examine which second order coping dimensions are related to quality of life.

Method This study included 1200 Italian emergency workers. They include firefighters, Civil Protection volunteers, different categories of emergency medical service personnel (medical first respondents, medical technicians, paramedics, nurses, ambulance personnel, ambulance drivers). The sample consisted of 852 males (71.0 %). The age of respondents ranged from 18 to 75, with a mean age of 35.77 years (SD 10.04 years). The length of service ranged from 0 year to 36 years (M = 9.49 years, SD = 7.43 years). In this sample, 822 (68.5%) were auxiliary (part-time, volunteer) and 361 (30.1%) were career (full-time) emergency workers, while the remaining (n = 17, 1.4%) did not answer to this question. A total of 141 participants (11.8 %) were firefighters and 1041 (86.8%) were emergency medical service personnel, while the remaining (n = 18, 1.4%) were civil protection volunteers. Level of education is medium: 193 (16.1%) of the sample completed compulsory education, 646 (53.8%) has a high school degree and the remaining 325 (27.1%) a university degree. A total of 36 participants (3.00%) did not provide education level. Procedure massey.ac.nz/~trauma/…/prati.htm

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Participants were recruited from emergency workers attending their regular service. A brief description of the study was sent to emergency workers organizations, in order to request members’ voluntary participation in the survey. Participants were given a choice between filling out an online version of the questionnaire on the web site of University of Bologna or a paper-and-pencil version of the same instrument. A total of 983 (81.9%) participants filled out the online version of the questionnaire. Materials The instrument consisted in a multipart questionnaire. Demographics included were questions on gender, age, position (volunteer or full-time emergency worker), length of service, and level of education. Coping strategies were assessed using the Brief COPE Inventory (Carver, 1997), including 28 items measuring 14 coping strategies (Self-distraction, Active coping, Denial, Substance use, Emotional support, Instrumental support, Behavioural disengagement, Venting, Positive reframing, Planning, Humor, Acceptance, Religion, Self-blame). Each strategy is assessed by means of two items. Participants were asked to think about the more recent stressful events occurred during their work activity and to indicate the extent to which they coped with them using the different strategies. Answers were provided on a five-point Likert scale (from “never” to “very often”). In order to develop scales that would assess relatively distinct aspects of coping, Carver (1989) suggests to conduct a second order factor analysis using scale totals as raw data. The internal reliability of this scale reports Cronbach alpha coefficients ranging from 0.50 to 0.90 (Carver, 1997). We derived the items from an Italian validation of the COPE scale (Sica, Novara, Dorz, & Sanavio, 1997). Quality of life was assessed by a version of ProQOL R-IV (Professional Quality of Life Scale. Compassion Satisfaction and Fatigue Subscales - Revision IV) (Stamm, 2005). We employed a revised version of this instrument (Palestini, Prati, Pietrantoni, Cicognani, in press) including 22 items corresponding to three scales: Compassion Satisfaction Scale, Burnout Scale and Trauma/Compassion Fatigue Scale. Participants were asked to specify how often, during the last month, they had experienced a series of emotional states as result of their rescue operations. Responses were given on a five-point Likert scale, ranging from “never” to “very often”.

Results Mean, standard deviation, skewness and kurtosis for each Brief COPE scale are shown in Table 1. The most used coping strategies were acceptance, planning and active coping. Substance use, behavioral disengagement and denial were the least used coping strategies. The values of skewness and kurtosis for substance use revealed a strong violation of normality assumption, therefore we dropped this scale from further analyses. Table 1. Mean, standard deviation, skewness and kurtosis for each Brief COPE scale

Mean

Std. Deviation Skewness Kurtosis

Acceptance

3.72

0.78

-0.62

0.57

Planning

3.44

0.83

-0.59

0.32

Active coping

3.32

0.87

-0.41

0.07


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Use of instrumental support

2.94

0.96

-0.18

-0.42

Positive reframing

2.81

0.93

-0.02

-0.36

Venting

2.58

0.96

0.20

-0.53

Humor

2.39

1.13

0.45

-0.64

Self-distraction

2.37

0.97

0.31

-0.64

Use of emotional support

2.31

0.89

0.35

-0.37

Religion

2.02

1.02

0.81

-0.21

Self-blame

1.98

0.81

0.66

0.10

Behavioral disengagement

1.57

0.66

1.22

1.39

Denial

1.31

0.60

2.49

7.00

Substance use

1.07

0.35

6.85

55.99

Note. Scores on the scales range from 1 to 5 To identify dimensions that might underlie coping strategies, we conducted a second order factor analysis. We used an oblique rotation (Oblimin rotation method) to allow for correlations among factors. This analysis yielded four factors with eigenvalues greater than 1. Visual inspection of scree plot confirmed four factors. Table 2 displays loadings and communalities for the Brief COPE scale. One factor (Emotion and support coping) was composed of seeking social support (both scales) and venting emotion. Another (Avoidance coping) was composed of denial, self-distraction, behavioral disengagement and self-blame. A third factor (Problem-focused coping) was composed of planning, active coping and acceptance. A fourth factor (Cognitive restructuring coping) incorporated humor and positive reframing. Only turning to religion failed to load substantially on any of these factors, with its highest loading (on the Avoidance factor) being .29. This coping strategy was therefore not considered in further analyses. Table 2. Exploratory factor analysis (Oblimin rotation method) loadings and communalities for the Brief COPE scale Factors Emotion and support Avoidance coping coping

Problemfocused coping

Cognitive restructuring coping

Communality

Venting

.826

-.072

-.063

.088

.669

Use of instrumental support

.762

-.064

.225

-.124

.677

Use of emotional support

.755

.151

-.054

.022

.635

-.217

.774

.105

-.070

.577

Self-distraction

.115

.569

.015

.136

.409

Behavioral disengagement

.219

.561

-.279

.164

.487

Self-blame

.270

.460

.112

.055

.397

Religion

.235

.299

.257

-.161

.288

Planning

.067

-.015

.825

.019

.718

Denial


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Active coping

.019

.080

.775

-.049

.621

Acceptance

.159

-.360

.435

.402

.526

Humor

.015

.039

-.149

.865

.756

-.059

.273

.367

.503

.507

25.7

12.6

9.1

8.5

55.9

.79

.69

.68

.68

Positive reframing % of variance Cronbach's Alpha

Male participants (M=2.45, SD=.71) tended to use less Emotion and support coping in comparison to females (M=2.98, SD=.74). This difference was significant t(1158)=-11.37, p.05. Table 3 displays intercorrelation between length of service, coping strategies and dimensions of professional quality of life. Most of the correlation coefficient are extremely low although they are significant. We considered negligible all correlation coefficients < .20. Emotion and support coping was positively correlated with Avoidance coping, Problem-focused coping and Cognitive restructuring coping. Cognitive restructuring coping was positively related to Avoidance coping and Problem-focused coping. Problem-focused coping was positively associated with Compassion satisfaction. Avoidance coping was positively related to Burnout and Compassion fatigue. Burn-out and compassion fatigue were also positively associated. Table 3. Intercorrelation Between Measures 1 1. Length of service

2 –

2. Emotion and support coping 3. Avoidance coping 4. Problem-focused coping 5. Cognitive restructuring coping

3

4

5

6

7

8

-.16**

.02

.07*

.01

.03

.10**

.13**

–

.36**

.36**

.26**

.11**

.13**

.11**

–

.14**

.26**

-.10**

.30**

.27**

–

.21**

.32**

.05

.03

–

.09**

.12**

.10**

–

-.11**

-.06*

–

.81**

6. Compassion satisfaction 7. Burnout 8. Compassion fatigue

– Note. ** p < .01; * p< .05. N range from 1095 to 1162

Table 4 shows the results of multiple regression analyses of coping strategies on the three quality of life outcomes. Avoidance coping was the only predictor of Burnout and Compassion fatigue. Compassion massey.ac.nz/~trauma/…/prati.htm

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satisfaction was predicted by Problem-focused coping and Avoidance coping. Table 4. Multiple Regression analysis of coping strategies on the three quality of life outcomes (standardized regression weights) Compassion satisfaction

Burnout

Compassion Fatigue

.046

.023

.009

Avoidance coping

-.173*

.276*

.263*

Problem-focused coping

.317*

.000

-.016

Cognitive restructuring coping

.052

.043

.032

R2

.126

.087

.072

F

42.404*

28.339*

23.409*

df

4,1149

4,1147

4,1148

Emotion and support coping

Note. * p