why we 360 - firefighters

Date:27March2019 WhyWe360

Aninvestigationofpsychologicaldistress,injuryandsuicidewithinFireandEmergencyNewZealand

2017/2018Firefighters’Scholarship

Presentedby:SeniorFirefighterJoshuaDarby

WhyWe360:Aninvestigationofpsychologicaldistress,injury,andsuicidewithinFireandEmergencyNewZealand

JoshuaDarby

TableofContentsAcknowledgements...........................................................................................................1

ExecutiveSummary...........................................................................................................2

Introduction......................................................................................................................7

Theresearcher:JoshuaDarby..............................................................................................7

FireandEmergencyhistory–Evolutionthroughtragedy....................................................8

Reportobjectives.................................................................................................................9

PartOne–ReportsofFire................................................................................................11

PartOnemethodology.......................................................................................................11

TheImportanceofa‘360’..................................................................................................11

Definitionsandconcepts....................................................................................................12

Psychologicalinjury/potentiallytraumaticevent..........................................................13Distress/eustress............................................................................................................13Criticalincidents.............................................................................................................14Workplacestressors.......................................................................................................14Homestressors..............................................................................................................14

Multiplestressors,cumulativeeffect.................................................................................15

‘A360’–Psychologicalinjuryandfirefighters...................................................................16

Personalandvicariousexperiences...............................................................................17

‘Fire’–psychologicalinjuries.............................................................................................19

Internationalandnationalprevalenceofpsychologicalinjury......................................19Post-traumaticstressdisorder.......................................................................................19Depressionandanxiety..................................................................................................21Suicide,suicidalideation,suicideattempts...................................................................22

‘Smoke’–indicatorsofpsychologicalinjury......................................................................24

Maladaptivecoping/behaviour......................................................................................24

‘Exposures’–Radiatingeffectofpsychologicalinjury........................................................26

Firefighters.....................................................................................................................26Family,colleagues,community......................................................................................27Workplace......................................................................................................................29

‘Ignitionsources’–causesofpsychologicaldistress..........................................................32

Medicalcalls..................................................................................................................33Fatalityexposure...........................................................................................................36Missionfailure...............................................................................................................37Emotionalaspectexposure............................................................................................38Preparedness.................................................................................................................40

Workplacestressors...........................................................................................................42

Effectofcultureandstigmawithinfireservices...........................................................44

Homestressors...................................................................................................................45

PartOneconclusion...........................................................................................................46


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PartTwo–ASize-Up........................................................................................................47

PartTwoobjectives............................................................................................................47

PartTwomethodology.......................................................................................................47

FireandEmergencypsychologicalwellbeingstrategy.......................................................48

Criticalincidentstressmanagement.............................................................................50Criticalincidentandpersonalstresssupport................................................................52Peersupport..................................................................................................................55Psychologicaldistressandinjuryeducation..................................................................57Preferredprovidernetwork...........................................................................................60

Variablescontributingtoresponseefficacy.......................................................................61

Governanceandresourcing...........................................................................................62Relationship-firefighterandtraumasurvivorengagement.........................................65

PartTwoconclusion...........................................................................................................68

PartThree–MakePumps................................................................................................69

PartThreeobjectives.........................................................................................................69

PartThreemethodology....................................................................................................69

Traumainformedcare........................................................................................................70

Principlesandassumptionoftraumainformedcare....................................................71Assumptionsoftrauma-informedcare..........................................................................71Principlesoftraumainformedcare...............................................................................72Implementationdomains..............................................................................................74

Recommendations...........................................................................................................77

Action.................................................................................................................................77

Monitoring.........................................................................................................................80

Research.............................................................................................................................80

Limitations.......................................................................................................................83

References.......................................................................................................................84

Abbreviations...................................................................................................................95

Appendix..........................................................................................................................97

CaseStudy..........................................................................................................................97


JoshuaDarby

AcknowledgementsIwouldliketothankFireandEmergencyNewZealand,theNewZealandFirefighter’sWelfareSociety,theNewZealandProfessionalFirefightersUnion,andtheFireSuperTrusteesfortheirsupportoftheFirefightersScholarship,whichhasassistedmystudyandresearchinrelationtothisreport.IwouldalsoliketothankZoeMounsey,theSeniorResearchProgrammeAdvisorforFireandEmergency,andBethPiggott,theFirefightersScholarshipCoordinator,fortheirsupportthroughoutthescholarshipprocess.

IwouldalsoliketothankWarwickPudneyandHelenCurreen,wholeadtheViolenceandTraumaprogrammeattheAucklandUniversityofTechnology,aswellasAssociateProfessorDavidNicholls,fortheirsupportandguidancethroughoutthecourseofmystudyandresearch.Additionally,IwouldliketorecogniseclinicalpsychologistStevenGreyforhissupervisionandcounselwithregardtothereport.IwouldalsoliketothankclinicalpsychologistsRogerShave,JasonHannett,DrIanLambieandresearcherSamuelHarveyfortheirfeedbackonthereportdraft.Furthermore,IwouldliketothankmembersoftheSafety,Health,andWellbeingteam,FireandEmergencymanagement,andotherFireandEmergencypersonnelwhoprovidedinsightsandfeedbackthathavehelpedshapethereport.

Finally,Iwouldliketothankthemanyfirefighterswhohavesharedtheirexperienceswithmeinrelationtopsychologicaldistressandinjury.Itistheseexperiencesthathavecatalysedandshapedthisreport.Ihopethatinreturnthisreportcanprovideavoicetothoseexperiences.

Pleasenotethattheinformationprovidedinthisreportisnotintendedasasubstituteforprofessionalmedicaladvice.Ifyouhaveanyconcernsaboutyourwellbeing,pleaserefertoaqualifiedhealthprofessionalsuchasadoctororpsychologist.Thefollowingpsychologicalsupportservicesareavailable24hoursadayand7daysaweek,toassistFireandEmergencypersonnel:

• ForRegion1,2or3-VitaeServiceson0508664981

• ForRegion4or5-EAPServiceson0800327669

• ForNHQ-EAPServiceson0800327669


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ExecutiveSummaryPsychologicaldistressandinjuryhavelongtakentheirtollonhumanity.Itisonlyinthelastcenturythatsocietieshavebeguntounderstandmoreclearlytheunderlyingcausesandfar-reachingeffectsofthesetypesofinjury.Theexaminationofpsychologicalinjurybegan,forthemostpart,withenquiriesintohysteriainthelate19thcentury,evolvingthroughanunderstandingofshellshockandcombatneurosisintheFirstandSecondWorldWars,andthediagnosisandtreatmentofVietnamWarveteransinthe1970s.Morerecently,thisexaminationhasextendedtothatofpsychologicaldistressandinjuryexperiencedbyfirstresponders.Theincreasedattentiononfirstresponderpsychologicalinjuryhasbeguntohighlightanareathathaslongimpactedfirstresponders,butwhichhasonlymorerecentlyledresearchersandhealthprofessionalstosoundanalarm.Thisalarmisdrawingattentiontowhatmaybethegreatestriskfacingthemodernfirstresponder–theriskofpsychologicalinjury,maladaptivebehaviour,andsuicide.

Anawarenessandresponsetotheriskofpsychologicalinjury,maladaptivebehaviour,andsuicidewithintheNewZealandFireService(NZFS),nowFireandEmergencyNewZealand,hasbeendevelopingsincetheearly‘90s.Overthistimetherehavebeenanumberofimportantstepsforwardtaken,thankslargelytotheworkofcommittedindividualswithintheorganisation,togrowawarenessandimplementinitiativesinrelationtofirefighterpsychologicalwellbeing.Thishasincludedthedevelopmentofaformalpeersupportprogramme,psychologicaleducationinitiatives,andprofessionalhealthsupportnetworks.Yetdespitethisimportantprogress,agrowingbodyofinternationalresearch,andnationalanecdotalevidencesuggeststhatpsychologicalinjury,maladaptivebehaviour,andsuicideremainaconsiderableriskwithinFireandEmergency.Forsometime,IhavebeenseekingtounderstandthepsychologicalrisksfirefightersfacesoImightbeofsomeassistancetoFireandEmergencyinensuringtheorganisationalcommitmentsrelatedtothesafety,health,andwellbeingoffirefightersaremet.In2017IsoughttofurtherthisunderstandingandassistancebyengaginginpostgraduatestudythroughtheViolenceandTraumaprogrammeattheAucklandUniversityofTechnology.InNovember2017IwasawardedtheFirefightersScholarshipbyFireandEmergencytosupportthisstudyandresearchandtoprovideareportexaminingpsychologicalwellbeingwithinFireandEmergency.

TheaimofWhyWe360istoassistFireandEmergencytoimprovetheirresponsetoidentifying,eliminatingand/orminimisingthepsychologicalrisksfacedbyfirefighters.ThereporthasbeennamedWhyWe360,asanofficer,uponarrivalatanincident,isexpectedtowalk360degreesaroundthatincidentaspartoftheirinitial‘size-up’.Thissize-upprocess,whichincludesidentifyingthescopeoftheincidentaswellasanypotentialhazards,haslongbeenrecognisedasessentialforthedevelopmentofaneffectivestrategyforachievingincidentgroundobjectivessuchasrescueandextinguishment.ThisfiregroundprocedurehasbeendrawnuponinWhyWe360asananalogyforaprocessbywhichpsychologicalriskscanbehighlightedandastrategyforaddressingthoserisksidentified.Consequently,WhyWe360hasbeendividedintothreeparts-PartOneinvolvesa‘size-up’ofthepotentialprevalenceofarangeofpsychologicalinjuriesandmaladaptivebehaviourswithinFireandEmergency,andthepotentialeffectsoftheseexperiencesonfirefighters,theirfamiliesand


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theFireandEmergencyorganisation.PartOneofthereportalsoidentifiesanumberofprobableunderlyingcausesofpsychologicaldistressandinjuryexperiencedbyfirefighters.PartTwofocusesonidentifyingthecurrentresponseofFireandEmergencytotheriskofpsychologicaldistressandinjury,whilealsoexaminingtheefficacyofthisresponse.Finally,PartThreeidentifiesarangeofrecommendations,baseduponthesize-upcarriedoutinPartOneandPartTwo,thatwouldassistFireandEmergencywithidentifying,eliminating,andorminimisingpsychologicaldistressandinjurywithintheorganisation.Itishopedthatthissize-up,andthesubsequentreportrecommendations,wouldassistFireandEmergencyinensuringsafety,health,andwellbeingcommitmentsmadetoFireandEmergencypersonnelareupheld.

AsthereisalackofFireandEmergencyspecificresearchinrelationtofirefighters’psychologicalwellbeing,anumberofmethodologieshavebeentriangulatedtoassistinensuringthefindingsandrecommendationsinthisreportareevidence-informed.InPartOnethismethodologicalapproachincludes:theidentificationandexaminationofrelevantquantitativeandqualitativeresearch;theidentificationandexaminationofrelevantmaterialfromexpertsinthefieldsofpsychology,trauma,post-traumaticstress,andorganisationalculture;thepresentationofpreliminaryfindingstoarangeoffirefighterstoassistinassessingtheexternalvalidityoffindings;anethnographicapproachinvolvingtheexaminationoftheresearcherspersonalexperiencesinclusiveofoperationalfireandemergencyexperienceof15years,peersupportexperiencesinceearly2016,andfeedbackfromCriticalIncidentandPersonalStressSupport(CIPSS)workshopspresentedinAreas3and4beginningin2016.PartTwo,whileincludingsomeofthemethodologicalapproachesofPartOne,alsodrawsuponfurthermethodsduetoalackofrobustandavailabledatawithregardtoFireandEmergency’ssafetyhealthandwellbeing(SHW)strategyandcontrolmeasures.TheseadditionalmethodsincludeananalysisofpersonalcommunicationprovidedbyFireandEmergencypersonnel,aswellasananalysisofaninterviewofafirefighterandofficerinrelationtotheirattendanceatacriticalincident.Finally,adraftofWhyWe360wassubmittedtoarangeofclinicalpsychologists,researchers,andFireandEmergencypersonnelforreviewpriortothepresentationofthefinalreport.

PartOnekeyfindings

1. Internationalresearchindicatesthatfirefightersareexperiencinganelevatedprevalenceofpsychologicalinjuries,maladaptivebehaviours,andsuicide.

2. Firefightersareanat-riskgroupforpsychologicalinjury,maladaptivebehaviour,andsuicide–due,inconsiderablepart,totheirhighlevelsofcriticalincidentexposure.

3. Firefightersmayexperienceapsychologicalinjuryacutely,astheresultofasinglecriticalincidentexposure,butalso,andpotentiallymorecommonly,asaresultofaculminationandcombinationofstressors,whichincludescriticalincidentstressbutalsoworkandhomestressors.

4. TheeffectsoffirefighterpsychologicaldistressandinjuryarelikelytobecompromisingfirefighterSHW,familialrelations,operationalefficacy,andFireandEmergencyorganisationalculture.


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5. Theimplementationstrategyinrelationtoa2014MemorandumofUnderstanding(MOU)withemergencyambulanceservicesislikelytohavebeenacontributortopsychologicaldistressandinjurywithinFireandEmergency.

PartTwokeyfindings

1. FireandEmergencyhaveidentifiedpsychologicaldistressandinjuryasoneoftencriticalrisksthatthreatenfirefighterSHW.FireandEmergencyhavealsoidentifiedastrategyandimplementedcontrolmeasuresinrelationtothiscriticalrisk.

2. ThereisevidencetosuggestthattheFireandEmergencystrategyandcontrolmeasuresidentifiedinthisreportdonotprovideasufficientresponsetothelevelofriskidentifiedinPartOneofthisreport.

3. ThereisevidencetosuggestthattherearesubstantialgapsbetweenpolicyandpracticeinrelationtotheSHWstrategyandanumberofidentifiedcontrolmeasuresrelatedtopsychologicaldistressandinjury.Contributorstothesegapsincludeinsufficientgovernanceandresourcingaswellasalackofsufficientconnectiontotheneedsoffrontlinestaff.

4. AreviewoftheSHWstrategyandcontrolmeasuresusingatrauma-informedcare(TIC)frameworkwouldlikelyimprovethecurrentresponseofFireandEmergencytopsychologicaldistressandinjuryrisksfacedbyfirefighters.

5. Firefightersoftendemonstrateconsiderableresiliencyintheirworkandalsoappeartounderstandthevalueofcamaraderieinrelationtothestressorstheyencounter.Moremustbedonetoidentify,understand,andtapintothesecapacities.

Recommendationssummary

Thefollowingisasummaryofrecommendations,basedonthefindingsofthisreport,whichFireandEmergencymightliketoconsider.AdetaileddescriptionofrecommendationscanbefoundintheRecommendationssectiontowardstheendofthereport(onpage77).

1. Traumainformedcare–ItisrecommendedthatFireandEmergencyimplementsaTICframework.

2. Careerandvolunteertraining–Itisrecommendedthatacomprehensivepsychologicalwellbeingeducationcomponentisincludedaspartofallcareerandvolunteerrecruits’courses,andasapartofcareerandvolunteerpromotionalprogressionandtrainingcourses.

3. Ongoingtraining–ItisrecommendedthatFireandEmergencyprovidesregular,person-to-person,psychologicaleducationinrelationto:psychologicaldistressandinjuryawareness,prevention,andtreatment;incidentemotionalaspectexposure;anddealingwithfamiliesatcriticalincidents.Additionally,itisrecommendedthatthistrainingisembeddedintotheOperationalSkillsMaintenance(OSM)system.

4. Wellnesschecks–ItisrecommendedthatFireandEmergencyprovidesregularpsychologicalwellnesschecks.


JoshuaDarby

5. Managerialresourcingandmandate–ItisrecommendedthatFireandEmergencyreviewsmanagementspansofcontrolandadministrationsupportresourcingineachRegion.Additionally,itisrecommendedthatFireandEmergencyprovideaclearmandateformanagerswithregardtotheprioritisationofworkerwellbeing.

6. Stigma–ItisrecommendedthatFireandEmergencyinvestigatestheutilityofanti-stigmainitiatives.

7. Supportservices–ItisrecommendedthatFireandEmergencyreviewsthegovernanceandresourcingofthepreferredprovidernetwork.

8. Peersupport–ItisrecommendedthatFireandEmergencyprovidesanationalmandatewithregardtothereinvigorationofregionalpeersupportprogrammes.

9. Governanceandresourcing–ItisrecommendedthatFireandEmergencycarriesoutanimmediatereviewofthecurrentnumberofFireandEmergencypersonnelemployedtoassistwiththepreventionandtreatmentofpsychologicalinjuries.

10. Collaboration–ItisrecommendedthatFireandEmergencyresourcesanannualfirefighterpsychologicaldistressandinjurysymposium.

11. RetiredFirefighters–ItisrecommendedthatFireandEmergencyinvestigatesandresourcesaprogramme,suchaslegacysupport,forthepurposesofsupportingretiredfirefighters.

12. Leadership–Itisrecommendedthatallpersonnelinapositionofleadershiparemadeawareoftheconnectionbetweenworkerwellbeingandperceivedorganisationalsupport(POS).

13. Datarecording–ItisrecommendedthatFireandEmergencytakesthefollowingthreeactionstoimprovedatagathering.

A. InvestigateandimplementchangestotheincidentreportingsystemthatwouldallowofficerstoincludeinformationwithregardtoidentifyingSHWrisks,inrelationtomedicalcallsandotherpotentiallytraumaticevents.

B. Createadatacatchmentforcareer,volunteer,andretiredfirefightersuicide.

C. Reviewthecurrentexitinterviewframeworktoestablishiftheseinterviewsprovidesufficientopportunityforfeedbackinrelationtopsychologicaldistressandinjuryinrelationtoworkerturnover.

14. Surveys–ItisrecommendedthatFireandEmergencydevelopsandcarriesoutasurveyforthepurposesofidentifyingworkplacestressorsandorganisationalcultureaspectsrelatedtopsychologicalwellbeing.

15. Regularreview–ItisrecommendedthatFireandEmergencyinitiatesaprogrammeofregularreviewwithregardtoassessingtheefficacyoftheFireandEmergencypsychologicalwellbeingstrategyandassociatedcontrolmeasures.

16. Perceivedorganisationalsupport–ItisrecommendedthatFireandEmergencysponsorsresearchexaminingPOSwithintheFireandEmergencycontext.


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17. Epidemiologicaldata–ItisrecommendedthatFireandEmergencysponsorsresearchtoestablishtheincidenceandprevalenceofpsychologicaldistress,injury,andmaladaptivebehaviourwithregardtocurrentandretiredFireandEmergencyfirefighters.

18. Frontlineconnection–ItisrecommendedthatFireandEmergencysponsorsresearchtoidentifytheobservations,needs,andrequestsoffirefightersinrelationtothecriticalincidentandworkplacestressorstheyareexposedto.

19. Resilienceandpost-traumaticgrowth–ItisrecommendedthatFireandEmergencysponsorsresearchexaminingresilience,adaptivecoping,andpost-traumaticgrowth(PTG)inrelationtoFireandEmergencyfirefighters.

20. Communityriskreduction–ItisrecommendedthatFireandEmergencysponsorsresearchinrelationtotheradiatingeffectsoffirefighters’psychologicalinjury.Further,thatFireandEmergencysponsorsresearchinrelationtoidentifyingmechanismsforreducingpsychologicaldistressforcommunitiesinvolvedincriticalincidentsthatFireandEmergencyrespondsto.


JoshuaDarby

Introduction

Theresearcher:JoshuaDarbyIamaSeniorFirefighterwithinFireandEmergencybasedinRegion1,Area4.IamcurrentlystationedatEllerslieStationonBlueWatch.Ihavebeenanoperationalfirefighterforover15years,withapproximately13yearsofserviceasacareerfirefighter,andtwoyearsofserviceasavolunteerfirefighter.Duringthistime,Ihavealsoservedintheareasofrecruitmentandpeersupport,aswellasassistingindeliveringaprogrammeofpsychologicalfirstaid(PFA)inRegion1.

IamalsoaresearchstudentattheAucklandUniversityofTechnologywhereIamengagedinthepostgraduateresearchpathwayofViolencePreventionandTraumaRecoveryundertheHealthSciencesfaculty.MyfocusforthisstudyandresearchispsychologicalwellbeingwithinFireandEmergency.

Mymovetopeersupport,thestudyofpsychology,andtheinvestigationoftraumaandpsychologicaldistresswithinFireandEmergencyhasbeencatalysedbybothpersonalandvicariousexperiencesofpsychologicaldistressandinjuryduringmytimeintheservice.Ihopethoseexperiences,andthesubsequentstudyandresearchsummarisedinthisreport,cancontributesomethingofvalueinassistingallthoseinterestedinensuringFireandEmergencyobjectivesaremetinrelationtotheSHWoffirefightersinNewZealand.


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FireandEmergencyhistory–Evolutionthrough tragedy“Wedonotlearnfromexperience,welearnfromreflectingonexperience.”JohnDewey

ThefollowingsectionwillprovideabriefhistoryofFireandEmergency,reflectingonhistoricallysignificantmomentsofchangeandseekingtoidentifyanunderlyingpatternofchangewithintheorganisation.

FireandEmergency,formerlyknownastheNZFS,haditsearliestfoundationslaidinthemid-1800s,withthefirstNZvolunteerfireserviceestablishedin1854,followedbythefirstpermanentlystaffedfireservicein1868(NZFSThroughtheDecades,2017).Fromthoseearlybeginningsofwaterbucketsand‘jumpingsheets’,theserviceoverthecourseof160yearshasevolvedintoanorganisationthatisnowcomprisedofcloseto14,000personnel,andrespondstoinexcessof80,000emergencycalloutsannually(FireandEmergencyNewZealand,2018b).Itisanorganisationthatstrivestoembodyprinciplesofskill,service,andintegrityand,indoingso,istrustedbyNewZealandersacrossthecountry.ThisisperhapsmostclearlydemonstratedinthelatestColmarBruntonSurveysthatseektoidentifyNZ’smostreputablepublicsectororganisation.TheNZFShasonanumberofoccasionstoppedallfourmeasuresofreputation–leadership/success,fairness,socialresponsibility,andtrust(ColmarBrunton,2017).

Thismodernandwell-respectedorganisationhasnotfounditselfinthispositionbychance,anditisindeedpossibletoobservethejourneyofchangeandgrowthtothispointbylookingbackatthelast160yearsoffireservicehistory.Indoingso,acatalystforchangeemergesaswellasapatternforgrowth.Thiscatalystistragicincidents:anunfortunatebutseeminglynecessaryexperiencethatbringsproblemsintofocus.Tragicincidentsappeartocreateafoundationofawarenessthatleadstocriticalreflection,withthiscriticalreflectionleadingtothedevelopmentofinsights.Theseinsights,whenactioned,helptoensureproblemsareidentifiedandtheneliminatedorminimised,whichpreventsfurthersimilartragicincidentsfromoccurring.Historicalexamplesofthispatternareapparentwithinfireservices.Forexample,in1901therewerethreeseriouscentralAucklandfires,includingablazeattheGrandHotelthattookfivelivesandledtoarestructuringoftheAucklandfireservice.AfireattheSeacliffMentalHospitalin1942,whichresultedinthedeathof37patients,consequentlysawarecommendationoffiredetectionsystemsandsprinklersbeinginstalledinallpsychiatrichospitals.In1947theChristchurchBallantynesFiretookthelivesof41people.ThistragicincidentcatalysedaRoyalCommissionofInquiry,whichfoundthatthefireservicehadnotreasonablyprovidedsafetyandescapemeasuresforpersonnelandthepublic.ThisledtotheintroductionoftheFireServicesAct1949,andthefirstfiresafetylegislation.Finally,betweentheyearsof1974and1975,onthebackofincidentsthatdemandedamorecoordinatedandeffectiveresponse,theNZFSCommissionwascreated,andtheNZFSwasformallyestablishedasanationalorganisation.Thishistorydemonstratesarecurringpatternofcontinuousimprovement:TragicIncident–CriticalReflection–

Action–Change.Itisapatternthathasassistedtheorganisationinpreventingmanyfurthertragicincidents.


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Withthedevelopmentofanationalorganisationin1975cametheeventualdevelopmentofanorganisationalmissionstatement:“Toreducetheincidenceandconsequenceoffireandtoprovideaprofessionalresponsetootheremergencies”(NewZealandFireServiceCommission,2003,p.2).Thismissionstatementwasclearlyaimedatreducingthetragiceffectsthatfireandotheremergenciescanhaveonthepublic’sSHW.However,firefighterSHWhashistoricallyreceivedmuchlessattention.

ThetragiceventsoftheAucklandICIChemicalWarehouseFirein1984servedtobringthislackofattentionintofocus.Asaconsequenceofattendingthisfire,manyfirefighterssufferedphysiologicalandpsychologicalinjuries(Maher,1999).AreportcommissionedbytheMinisterofHealth(Elias,1990)inresponsetotheseinjuriesnoted“itwasnotpossibletoviewsafetymanagementintheFireServicewithconfidence.WequestionwhethersafetyisgivenappropriateprioritywithintheentirecommandstructureoftheFireService”(p.114).Itwasconcludedthat“thismattershouldbeaddressedatthehighestlevels”(p.114).

Oncemoreatragicincidentandsubsequentreporthighlightedtheimportanceofcriticalreflectionandaction,aswellastheconsequencesthatresultfromindividualsororganisationsnotengaginginsuchanapproach.Thelackofareflectiveapproachpriorto,andduringtheincident,wasshowntohavebeenfoundationalintheeventualnegativeoutcomesforfirefighters.However,acriticallyreflectiveprocesspost-incidenthelpedtoilluminateblindspotsincludingshortcomingsinNZFSSHWpractices.Thisledtothedevelopmentofinsightsthatcatalysedactionsincludingchangestofiregroundprocedure,theintroductionofnewpersonalprotectiveequipment(PPE),andthedevelopmentofanoccupationalhealthservice(Elias,1990).

Itcanbeseenthatwhencriticalreflectionformsabasisforinsightsandaction,changesresultthat,attheirbest,assistinpreventingtragicincidentsfromoccurringand,attheirworst,minimisethenegativeoutcomesofsimilartragicincidentsforthepublicandforfirefighters.

ThereisagrowingbodyofevidenceindicatingthatasubstantialtimeofcriticalreflectionandactionisrequiredinrelationtotheriskspsychologicalstressorsposetotheSHWofFireandEmergencyfirefighters.Thisevidenceincludestheanecdotalexperienceoffirefighters,internationalquantitativeandqualitativeresearch,andinternationalexpertopinion.Itisonthebasisofthisevidencethatthefollowinghypothesiswillbeexaminedinthisreport:

PsychologicaldistressandinjuryareleadingrisksinrelationtotheSHWofFireandEmergencyfirefightersandresult,inconsiderablepart,fromexposuretoacombinationandculminationofcriticalincident,workplace,andhomestressors.

ReportobjectivesOnthebasisoftheaforementionedhypothesis,thefollowingresearchquestionswillformthefoundationofathree-partinvestigationexploringthepsychologicalrisksfacedbyFireandEmergencyfirefighters,aswellasFireandEmergency’sresponsetothoserisks.


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PartOne,‘ReportsofFire’,willexaminethefollowingresearchquestion:

Canfirefightersbeaffectedbypsychologicaldistressandinjury?

Ifitisconcludedthatfirefighterscanbeaffectedbypsychologicaldistressandinjury,thefollowingquestionswillbefurtherinvestigated:

• Whatistheprevalenceandseverityofpsychologicalinjurieswithinfirefightingcohorts,andcanthisbetranslatedtoFireandEmergency?

• Whatmightbeindicatorsofpsychologicaldistressandinjurywithinfirefightingcohorts?

• Whateffectsmightpsychologicaldistressandinjuryhaveonfirefighters,theirfamilies,andFireandEmergencyasanorganisation?

• WhataresomeofthelikelycausesofpsychologicalinjurywithinFireandEmergency?

PartTwo,‘ASize-Up’,willidentifytheresponseofFireandEmergencywithregardtothepsychologicalrisksidentifiedinPartOneandexaminetheefficacyofthisresponse.Thefollowingresearchquestionswillformthebasisofthisexamination:

• WhatisthecurrentstrategyofFireandEmergencywithregardtoidentifying,andeliminatingorminimisingpsychologicaldistressandinjury?

• GiventhefindingsofPartOneofthisreport,isthecurrentandproposedstrategyandresourcingofFireandEmergencysufficient?

PartThree,‘MakePumps’,willidentifyarangeofrecommendations,basedonthefindingsofPartOneandPartTwo,thatwouldassistFireandEmergencytoupholdSHWcommitmentsmadetofirefighters.Thefollowingresearchquestionwillformthebasisforidentifyingevidence-informedrecommendationsthatwouldassistwiththisobjective.

WhatwouldenhanceFireandEmergency’scurrentresponsewithregardtoidentifyingandeliminating,orminimisingpsychologicaldistressandinjury?


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PartOne–ReportsofFire

PartOnemethodologyIthasbeenestablishedthatthereisinadequateresearchtodrawuponinassessingthepresence,prevalence,andseverityofpsychologicalinjuriesspecifictofirefighterswithinFireandEmergency(Z.Mounsey,SeniorResearchAdvisorforFireandEmergency,personalcommunication,October13,2017).

ThisabsenceofnationaldataisofconsiderableconcernasitcreateschallengesinunderstandingtherealextentofpsychologicaldistressandinjurywithinFireandEmergency.ThisabsencemaybeabarrierforestablishinganappropriatelevelofprioritisationandresourcingnecessarytomeettheneedsofFireandEmergencyfirefighters.Consequently,thereportapproachwillinvolvethetriangulationofanumberofmethodsinanattempttoofferasoundanalysis,builtonasolidepistemologicalbase,despitethelackofNZfocusedresearch.Thisapproachshouldlendtobothanawarenessandminimisationofanypersonalbiases,therebyofferingahypothesisthatisevidence-informed.

Thesemethodsareoutlinedbelow:

1. PartOnewillincludetheidentificationandexaminationofrelevantquantitativeandqualitativeresearchthatisconnectedwiththeresearchquestions.

2. PartOnewillincludetheidentificationandexaminationofrelevantmaterialfromexpertsinthefieldsofpsychology,trauma,post-traumaticstress,andorganisationalculture.

3. PartOnewillincludeanethnographicapproachinvolvingtheexaminationoftheresearcher’sNZFSandFireandEmergencyexperiencesinclusiveof:operationalexperienceofover15years;peersupportworksinceearly2016;andfeedbackfromCIPSSworkshopspresentedinAreas3and4in2016/17.

4. PartOnewillincludepresentingpreliminaryfindingstoarangeoffirefighterssofeedbackcanbeprovidedinrelationtotheexternalvalidityofthefindings.

TheImportanceofa‘360’Giventhisreportseekstoengagetwodistinctaudiences–firefightersandacademics–itusesacombinationoflanguageandfirefightinganalogiesthatmightassistinreachingboth.Thefollowingsectionsetsouttoexplainandcontextualisetheseanalogies.

Anofficer,uponarrivalatareportedstructurefire,isexpectedtocarryouta‘360’walk-aroundofthestructureaspartofaninitial‘size-up’.Thisreflectiveapproachassiststheofficerinestablishingwhetherafireexists,andifso,whatthreatthatfireposestolifeinsidethestructureaswellaswhateffectradiatedheatandsmokemighthaveon


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exposuresoutsideofthestructure.Anassessmentofthesevariableswillhelptodevelopaneffectivestrategyforrescueandextinguishment.Itwillalsoassistinidentifyinghazardsthathavethepotentialtoaffectfirefighterorpublicsafety(FireandEmergency,2013,s.3.2.7).

Asecondaryobjectiveforofficersandfireinvestigators,post-extinguishment,istoattempttoestablishbothapointoforiginandthepotentialignitionsourceofthefire.Thisprocesscanleadtotheestablishmentofcausation,whichinturnmayassistinthedevelopmentoffiresafetystrategiesthatpreventtheoccurrenceoffurthersuchincidents(FireandEmergency,2008).

Thesecontemplativepracticeshavebeendevelopedasbestpracticefromtheattendanceoffireandotheremergencyincidentsovermanyyearsanddemonstratecriticalreflectioninaction.Theyexistasappropriateanalogiesforexemplifyinganapproachto:

• identifyingtowhatdegreepsychologicaldistressandinjurymaybepresentwithinFireandEmergency

• identifyingunderlyingcausesofpsychologicaldistressandinjury

• developinginsightsthatcanbeactionedtoreducetheincidenceandconsequenceofpsychologicaldistressandinjuryinthefuture.

Theconceptofa‘360’,andsubsequentfireinvestigation,willbeappliedasananalogyinrelationtopsychologicalwellbeinginthefollowingways.FireandEmergencywillrepresentastructure.Smokefromthestructureequatestosignsofmaladaptivebehavioursdevelopedasaresultofpsychologicaldistressandinjury.Firewillrepresentthevaryingformsofpsychologicaldistressandinjurywithinthestructure.Exposureswillbeinclusiveofindividualsandcommunitiesoutsideofthestructurethatmaybeaffectedbythesmokeandfirewithinit(duetotheirproximity).Ignitionsourceswillbeidentifiedvariablesthathavebeenshowntocausefire.

Theseanaologiesformthebasisofthechaptertitles,asthisreportundertakesa‘360’ofFireandEmergencyduetocurrentreportsandindicatorsoffire.

DefinitionsandconceptsThisreportincludesanumberoftermsthatcanhavecontestedordifferentmeaningsdependingonthecontext.Accordingly,thissectionwillprovidekeydefinitionswithinthecontextofemergencyresponders,suchasfirefighters.Itwillalsoincludeabriefdiscussionofkeyconceptsthatwillbeencounteredinlatersectionsofthereport.


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Psychologicalinjury/potentiallytraumaticevent

Theword‘trauma’inancientGreektranslatesto‘wound’inModernEnglish("Trauma,"n.d.).Inphysicalmedicine,traumacanbeunderstoodasdamagetothebiologicalorganism(humanbody)causedbyphysicalharmfromanexternalsource.Inpsychology,itcanbeunderstoodasdamagetothepsyche(mind,soul,spirit)asaresultofatraumaticevent,orculminationoftraumaticeventswhereby:

• anindividualisunabletointegratetheiremotionalexperienceduetobeingoverwhelmedbythetraumaticevent/s(Giller,1999);and/or

• anindividualexperiences(subjectively)thattheirlife,bodilyintegrity,orsanityisunderthreat(Pearlman&Saakvitne,1995).

GiventhesubjectivenatureofatraumaticexperiencenotedbyPearlmanandSaakvitne(1995),theterm‘potentiallytraumaticevent’(PTE)willbeusedfordescribingtheseexperiences.

McFarlaneandBryant(2007)notethataPTEmaycatalyse,throughsingleorcumulativeexposure,psychologicaldistressthatcanleadtothedevelopmentofpsychologicalinjuries.Furthermore,Skeffington,Rees,andMazzucchelli(2017)notedthecorrelationbetweentraumaexposureandpost-traumaticstressdisorder(PTSD)inWesternAustralianfirefighters.ThereportstatedthatitiswidelyacceptedthatfirefightersareathighriskforPTEexposureandthepost-traumapathologythatcandevelopasaresultofthisexposure.Inthisreporttheterm‘psychologicalinjury’willbeusedratherthantheterm‘mentalhealthdisorder’,indefiningpost-traumapathologyasthelatterterm,andotherslikeit,canhaveastigmatisingeffect.Thetermpsychologicalinjurywillencompassarangeofnegativepsychologicaloutcomesresultingfrompotentiallytraumaticeventsthatarecorrelativewithfirefightingcohorts.Examplesarelistedbelow:

• PsychopathologysuchasPTSDandacutestressdisorder(ASD)(Shave,2010)

• Negativepsychologicaloutcomes,suchasdepressionandanxiety(Skeffington,Rees,Mazzucchelli,&Kane,2016)

• Suicideideationandsuicideattempts(BeyondBlueLtd,2018).

Psychologicalinjurieswillalsobediscussedinrelationtomaladaptivebehavioursandsuicide.Maladaptivebehavioursarebehavioursthatdevelopasacopingmechanisminrelationtopsychopathologyandothernegativepsychologicaloutcomes.Examplesofmaladaptivebehaviourincludesubstanceabuseandavoidancecoping.(Skeffingtonetal.,2017).

Distress/eustress

Itshouldbenotedthat‘stress’isoftenusedasapejorativetermwheninfactstresscanbehelpful.Itisusefulthentohaveterminologythatdifferentiatesthepositiveandnegativeaspectsofstress.Forthisreportthepreviouslyestablishedtermsof‘eustress’and‘distress’willbeusedtoidentifydifferenttypesofstress.

• Eustressisatermthatkeynotespositiveeffectsasaresultofexposuretoastressor.


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• Thetermdistresskeynotesnegativeeffectsasaresultofexposuretoastressor(MarkLe,Jonathan,&Gregory,2003).

Additionally,itisimportanttonotethattheexperienceofdistressdoesnotnecessarilyindicateapsychologicalinjury.Distress,foramajorityofindividuals,isendurable,short-livedandconsiderablymorecommonthanapsychologicalinjury(MinistryofHealth,2016).Furthertothis,thoughbeyondthescopeofthisreport,whiletraumacanleadtoamultitudeofnegativeeffects,ithasalsobeenshownto,attimes,leadtopositivechangesinanindividual,sometimesknownaspost-traumaticgrowth(PTG)(Kehl,Knuth,Hulse,&Schmidt,2014).

Criticalincidents

Forthepurposesofthisreport,‘criticalincidents’willbeatermthatreferstoincidentsfirefightersattendthatmayleadtothedevelopmentofpsychologicaldistress,andinturnpsychologicalinjury.Criticalincidentdistressmayalsocontributetoworkplaceandhomedistress.Thesepotentiallytraumaticcriticalincidentsinclude(Jacobsson,Backteman-Erlanson,Brulin,&Hörnsten,2015):

• motorvehicleincidents,structurefires,hazardoussubstancecalls,andnaturaldisasters

• medicalcalls,suchaspaediatriccardiacarrests,drowning,suicides,andoverdoses

• knowingthevictim,failedrescueefforts,humanerror,andmissionfailure.

Workplacestressors

Forthepurposesofthisreport,‘workplacestressors’referstopotentialstressorsexperiencedintheworkplace,whichareseparatefromtheattendanceofemergencycalloutsandcriticalincidents.Itisworthnotingthatworkplacestressorsmaybeacontributingfactorwithregardtotheexperienceofbothcriticalincidentandhomedistress.Examplesofworkplacestressorsinclude:

• aworkerperceivingthattheirorganisationdoesnotvaluetheircontributionsand/orwellbeing(Miller,Unruh,Wharton,Liu,&Zhang,2017).

• workoverload,timepressures,theactualorthreatenedlossofjob,bullying,personalityconflicts(Lewis,2014).

Homestressors

Forthepurposesofthisreport,‘homestressors’referstostressorsthatoccurbeyondthescopeofthecriticalincidentandworkplaceenvironments.Thoughitshouldbenotedthathomedistressmightcontributetotheexperienceofworkplaceandcriticalincidentdistress.Examplesofhomestressorsareoutlinedbelow:

• maritalconflict,relationshipconflict,familialdisruption,financialdistress(Meyeretal.,2012).


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• personalsicknessandinjury,death,sicknessorinjuryofsignificantothers(Sattler,Boyd,&Kirsch,2014)

Multiplestressors,cumulativeeffectItisimportanttonotethatmembersofthegeneralpopulationarelikelytoencounterexposuretobothhomeandworkplacestressors.However,itisunlikelythattheywillalsoexperienceexposuretocriticalincidentsatratessimilartothatoffirefighters(Skeffingtonetal.,2016).Hereinliestheuniqueriskfirefightersface–giventhattheyencounternotonlytheday-to-dayworkplaceandhomestressorsoflife,butalsotherepeatedexposuretoPTEs,specificallyintheformofcriticalincidentexposure.

AlthoughexposuretoaPTEcanhaveanacuteeffectleadingtopsychologicalinjury,ithasalsobeenshownthatthecumulative,orchronic,effectofrepeatedexposuretotrauma(RET)canleadtoabuild-upofpsychologicaldistress,whichmaybecomeafoundationforpsychologicalinjury(Jahnke,Poston,Haddock,&Murphy,2016).ArecentstudycarriedoutonfirefightersintheUnitedStates(US)notedthatalthoughtherewereincidentsofspecificcriticalincidenttrauma,mostfirefightersdiscussedthenegativeimpactsofRETandthepsychologicalimpactsthishadonthem(Jahnkeetal.,2016).

ArecentreportonthementalhealthandwellbeingofemergencyrespondersinAustralianotedthat,comparedtothegeneraladultpopulationrates,emergencyrespondershadsubstantiallyhigherratesofpsychologicaldistress,probablePTSD,andsuicidalthoughts.Furthermore,emergencyresponderswhohadservedmorethan10yearshadsubstantiallyhigherratesofpsychologicaldistress,suicidalthoughts,andprobablePTSDcomparedtothosewithlessthantwoyearsofservice(BeyondBlueLtd,2018).Thesefindingsappeartoindicateadose-responserelationshipwithregardtoanumberofvariablesincludingtimeserved.ThesefindingsalsoappeartobecongruentwithfindingsfromanationalqualitativeresearchstudycarriedoutonFireandEmergencyfirefighterswithregardtotheimpactsofincidents.OneofthethemesoftheresearchbyAdams,Asiasiga,andMcManus(2018),onFireandEmergencyfirefighters,wasthatofthecumulativeimpactofdistress.Oneoftheparticipatingfirefightersdescribedthiscumulativeeffectinthefollowingway:

Idon’tlikelettingtheguysseestufftheydon’tneedtosee,thegirlhadbeendeadforquitesometimeandthecopsandtheambohadpulledthepinonitquitequickly,theysaid,‘noshe’sbeengoneforawhile’but,justyouknow,seeingayoungfemaleyouknow,andthenyougohome,andyoustartthinkingaboutit,you’rethinkingaboutwhydidshedoit?Youknow,couldwehavedoneanythingorifwehadgottoit,whatwouldwehavedone,youknow?So,allthesethingsIthinkthisisfromtheearliercriticalincidentsjobsI’vebeeninvolvedin,youknow,you’vegotajarandyou’reputtingalltheselittlerocksintothisandonedayyoucouldtipyourselfover.(Adamsetal.,2018,p.34).

Thus,itisimportant,inexaminingtheaetiologyofpsychologicalinjuryandsuicideinrelationtofirefighters,thatonenotfixatesolelyoncriticalincidentsorsingleevent


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exposure.Instead,onemustextendaviewtothepossibilityofchroniccriticalincidentdistress,whichmayalsoaccumulatewithhomeandworkplacedistress.Thisprovidesauniquebreedinggroundforpsychologicaldistressandinjuryforemergencyresponderssuchasfirefighters.Indeed,Harveyetal.(2016)noted,inarecentstudyonfirefightersfromNewSouthWalesAustralia,thatratesofpsychologicalinjuryincreasedwithcumulativetraumaexposuredespitepriorresearchfailingtofindacorrelation.Theresearchersconcludedthat:

Whileourfindingofincreasingratesofmentaldisorderamongthosewithgreatercumulativetraumaexposuremaynotbesurprising,previousstudieshadfailedtofindsuchanassociation(Meyeretal.,2012).Theabsenceofsuchanassociationcouldhavebeeninterpretedtosuggestthatpost-traumaticmentalhealthproblemsonlyaffectedagroupofvulnerableindividuals,andthatoncesomeonehadexperiencedacertainnumberoftraumaticeventswithoutdevelopingmentalhealthsymptoms,theycouldbeassumedtoberesilient.Ourresultssuggestthisisnottrue;theriskofPTSD,depressionandheavydrinkingcontinuedtoincreaseatthesamelinearratewitheachadditionaltraumaexposure.Firefighterswhohadexperiencedmorethan20traumaticincidentsinvolvingfatalitieshadmorethanfourtimestheratesofPTSDaslessexposedfirefightersandsubstantiallyincreasedlevelsofdepressionandheavydrinking.Anyintervention,suchasscreening,aimedathigh-riskgroupsmustthereforeconsiderthelevelofcumulativetraumaexposure.(Harveyetal.,2016,p.656)

Thus,theavenuesforpsychologicaldistresscontributingtoapsychologicalinjuryareencapsulated,atleastinpart,inthefollowingpossibilities:

• Exposuretoasingleacutecriticalincident

• Exposuretoasinglehomeorworkplaceeventthatisdistressing

• RETintheformofcriticalincidentsleadingtochronicdistress

• Repeatedexposuretoeventsathomeand/orwithinaworkplacecontext,whichcreateschronicdistress

• Exposuretoacombinationofcriticalincidents,home,andworkplaceeventsthatcreatechronicdistressoverthecourseofalifetime.

‘A360’–Psychologicalinjuryandfirefighters‘Thefirststeptowardschangeisawareness.Thesecondisacceptance.’NathanielBranden

Thesection‘PersonalandVicariousExperiences’consistsofashortrecollectionoftheresearcher’spersonalexperiences,aswellasthesharedexperiencesofotherfirefighters,duringtheirtimeintheNZFSandFireandEmergency.Theseanecdoteshavebeenincludedtodemonstrateandgroundaspectsofthepreviouslydefinedstressors,aswellasthecumulativecapacityoftraumavialivedexperience.Theseexperiencesalsoprovidea


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foundationfortheresearchquestionsthatareexaminedintheliteraturereviewaspartofthefollowingsections:

• ‘Fire–Psychologicalinjuries’:Here,anumberofpsychologicalinjuriesthathavebeencorrelatedwithemergencyservices,includingfirefighters,willbeexplored.

• ‘Smoke–Indicatorsofpsychologicalinjury’:Thiswillexaminebehavioursthatmayindicatethepresenceofpsychologicaldistressandinjurywithinafireservice.

• ‘Exposures-Radiatingeffectsofpsychologicalinjury’,willinvestigatetheeffectsofpsychologicaldistressandinjuryonfamilies,colleagues,communities,andworkplaces.

Personalandvicariousexperiences

Researchquestion:Canfirefightersbeaffectedbypsychologicaldistressandinjury?

Ihaveincludedthissectiondespitetheriskthatsomereadersmayfeelitdetractsfromtheobjectivityofthereport.Whileobjectivityisanessentialcomponentofthisreport,so,inmyestimation,isconnection.Consequently,Ihopethefollowingsectioncanassurethosereadingit,thoughtheirchallengesmaydifferinsomeways,thatIamnotindifferenttotheexperienceofpsychologicaldistressandinjury.Therefore,thefollowingisabriefarticulationofsomeofmyownexperienceswhileworkingintheNZFSandFireandEmergency.

IjoinedtheNZFSat16yearsofageasavolunteerfirefighter,laterbeingacceptedintothecareerserviceatage18.Forthemostpart,IhaverelishedthejourneyandopportunitiesworkingasafirefighterinNZhasaffordedme.Ifondlyrememberthechallengesandtrainingprovidedatrecruitandpromotionalcourses,thefeelingsofprideinrepresentingFireandEmergencyathomeandabroad,andthesenseofcamaraderieandsatisfactionthatcomesfromattendingandassistingatvariousemergencyincidents.

Fromayoungage,andthroughthecourseofmyservice,Ihaveattendedavarietyofemergencycallouts.Manyhavebeenminorandinconsequential,whileotherswouldfallintothecategoryofaPTE.Theseeventshaveincludedassistingathomicidescenes,motorvehicleincidentsinvolvingthedeathorsevereinjuryofchildrenandadults,medicaleventsinclusiveofsuicide,drugoverdose,andindustrialentrapment,andthedeathorinjuryofadultsatstructurefires.Ihavealsoencounteredhomeandworkplacestressorsinthistime.Thesestressorshaveincludedthelossoffriendsandcolleaguestobothcancerandsuicide,timesofpersonalsicknessandinjury,relationshipdifficulties,andinterpersonalconflictsatworkandathome.

IfIhadbeenaskedevensixyearsagoiftheseeventshadaffectedme,iftheyhadleftatrace,Iwouldhavesaidno.Thiswaslargelyduetoafeelingofinvulnerability.Itwouldtakeaculminationofeventsinmymid20’stochallengethisbeliefofinvulnerability,andwhatfollowedwasadifficulttimewhereIexperiencedanxiety,depression,andeventuallysuicidalideation.Ifoundmyselfisolatedinthemidstoftheseexperiences,fearingwhatothersmaythinkofme,andwhataskingforhelpmightmean.Fortunately,Iwasabletoseekhelp,largelyfromoutsideoftheNZFS,andwiththesupportoffriendsandfamily,the


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helpofapsychologist,andawilltosurviveandthriveoncemore,Isetoutonalong,challenging,andongoingjourneyofunderstandingwhattraumais,howitaffectsus,whatwecandotoavoidit,andhowwecanmosteffectivelyrecoverfromit.

ThemoreIwasabletorecognisepsychologicaldistressandinjuryinmyownlife,themoreIbecameawareofitspresenceinothers.IwassurprisedtofindthatanumberoffirefightersIknewhadexperienced,orwereexperiencingtimesofpsychologicaldistressandinjury.Whiletheunderlyingcausesvaried,(sometimescriticalincident,otherstimeshomeorworkplacerelated,andoftenacombinationandculminationofall)asharedrealityemerged;firefighterswerenotinvulnerable,wetoocouldfacepsychologicalinjury.Thisrealitywasbroughtintostarkfocuswiththelossofoneofmyrecruitcoursememberstosuicidein2013.

Ijoinedtheservicespeersupportteamin2016,motivatedtobepartofasolutiontotheproblemofpsychologicaldistressandinjurywithinthefireservice.Itwasduringthisrole,andinmyfurthertrainingandstudy,thatIbegantounderstandthemagnitudeofthe‘fire’thatcouldexistwithinFireandEmergency.LaterthatyearIjoinedateamtaskedwithrollingoutpresentationsonPFAtocareerandvolunteerfirefightersinAreas3and4(CentralandNorthAuckland)aninitiativeinstitutedbymembersofthethenNZFSHealthandSafetyteamwhorecognisedtheimpactscriticalincidentsandhomeandworkplacestressorswerehavingonpersonnel.Duringthesepresentations,anumberoffirefighterscourageouslysharedstoriesoftheirownexperiencesofpsychologicaldistressandinjury.Thesestoriesclarifiedanunderstandingthatmypersonalexperiences,andtheexperiencesofotherfirefightersIhadencounteredalongtheway,werenotisolatedphenomena.Firefighters,consciouslyorunconsciously,wereexperiencingpsychologicaldistressandinjury.

Giventhevolumeofanecdotalexperiencescongruentwithpsychologicaldistressandinjury,itwasevidentthattherewasapresenceofpsychologicaldistressandinjurywithinFireandEmergency.Indeed,FireandEmergencyRegion1ManagerandAssistantNationalCommander,nowDeputyChiefExecutiveServiceDelivery,KerryGregory,hasstatedthatoneoftheprimarychallengesfacinghisthenregion,comprisedofapproximately2700personnel,isthatofpsychologicaldistressandinjury(K.Gregory,personalcommunication,November09,2017).However,itisdifficulttoquantifytheseanecdotalfindings,aswellasassesstheirprevalenceandseverity,giventhedearthofresearchspecifictoFireandEmergencyfirefighters.Therefore,thissectionofthereportwillexploreinternationalresearch,andtheanalysisofrelevantexperts,toprovidesomesenseofthepotentialprevalenceandseverityofpsychologicaldistressandinjurywithinFireandEmergency.


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‘Fire’–psychologicalinjuriesResearchquestion:Whatistheprevalenceandseverityofpsychologicalinjurieswithinfirefightingcohorts,andcanthisbetranslatedtoFireandEmergency?

Thissectionofthereportwillexaminetheprevalenceofcommonpsychologicalinjuriesonaninternationalandnationalscale.Itwillthenexamineboththepresenceandprevalenceofasampleofpsychologicalinjurieswithinarangeoffirefightingcohorts,andsomeoftheeffectsoftheseinjuries.

Internationalandnationalprevalenceofpsychologicalinjury

Itisnowwellestablishedthatpsychologicalstressorsandsubsequentinjurieshaveasubstantialimpactonthegeneralpopulation.AdocumentreleasedbytheWorldHealthOrganisation(WHO)in2017estimatedthenumberofpeoplesufferingfromdepressionworldwideatover300million,withnearlythesameamountsufferingfromanxietydisorders.DepressionwasrankedbytheWHOasthesinglelargestcontributortoglobaldisability,withanxietydisordersrankedsixth.Thisdocumentalsohighlighteddepressionasthelargestcontributortosuicidedeathsintheworld,anumberthatatthetimewascloseto800,000peryear(WHO,2017).

ArecentmentalhealthinquiryinNZreportedthatpsychologicaldistressandinjuryarecommon.ItwasestimatedthateachyearoneinfiveNewZealanderswouldexperiencepsychologicaldistressorinjuryand50-80%wouldexperiencepsychologicaldistressoraddictionintheirlifetime.Inadditiontothehumancost,itwasnotedthattheannualeconomiccostforpsychologicaldistressandmaladaptivebehaviourswasapproximately$12billion(HeAraOranga,2018).Furthermore,TheNZMentalHealthFoundationnotedina2014reportthatpsychologicalinjuriesareacommonoccurrencewithinNZ.Psychologicalinjurywasfoundtobethethird-leadingcauseofhealthdisabilityforNewZealandersbehindonlycancersandvascularandblooddisorders,withanestimated582,000adultsdiagnosedwithacommonpsychologicalinjury(MentalHealthFoundation,2014).Itmaynotcomeasasurprisethen,giventhecorrelationofpsychologicalinjuryandsuicide,thattheannualprovisionalsuicidestatisticsforthe2017/18-yearinNZshowedthat668peoplediedbysuicide.Thisisthefourthconsecutiveyearthatthenumberhasincreased,whilealsomarkingthelargestnumberofdeathsviasuicideinayearsincethestatisticshavebeengathered(OfficeoftheChiefCoroner,2018).

Letusthenconsideremergencyrespondercohortssuchasfirefighters.Aretheysomehowimmunetotheglobalandnationaltrendsofpsychologicaldistress,injury,andsuicide?ThefollowingsectionconsidersthesequestionsbyexaminingexpertopinionandrelevantresearchonpsychologicalinjuriessuchasPTSD,depression,anxiety,suicidalideation,andsuicide.

Post-traumaticstressdisorder

PTSDisadebilitatingpsychologicalinjurythatiscausedbyexposuretooneormoretraumaticevents.ThediagnosticcriteriafromtheDiagnosticandStatisticalManualofMentalDisorders:DSM-5(DSM–V)(AmericanPsychiatricAssociation,2013)notesthatfor


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thediagnosisofPTSDtobeestablished,exposuretotraumaticevents,includingactualorthreateneddeath,orseriousinjury,mustbepresent.Thefollowingareexamplesofthesetypesofexposure(AmericanPsychiatricAssociation,2013,p.271):

• Directlyexperiencingthetraumaticevent

• Witnessing,inperson,theeventasitoccurredtoothers

• Learningthatthetraumaticeventoccurredtoaclosefamilymemberorclosefriend(Incasesofactualorthreateneddeathofafamilymemberorfriend,theeventmusthavebeenviolentoraccidental.)

• Experiencingrepeatedorextremeexposuretoaversivedetailsofthetraumaticevent(e.g.,firstresponderscollectinghumanremains;policeofficersrepeatedlyexposedtodetailsofchildabuse).

TheDSM-VnotesthatratesofPTSDarehigheramongvocationswithanincreasedriskoftraumaticexposuresuchasfirefightersandemergencymedicalpersonnel.Giventhenatureofcallsthatfirefightersrespondto,andtherelationshipbetweenseverity(doseoftrauma)andthedevelopmentofPTSD,itcanbeseenwhyfirefightersareidentifiedasanat-riskpopulation.

Offurtherconcernisthedebilitatingnatureofthispsychologicalinjury.PTSDisdefinedbyanumberofsymptoms,including(AmericanPsychiatricAssociation,2013,pp.271-272):

• Recurrentdistressingdreamsthatarerelatedtothetraumaticevent(s)

• Dissociativereactions,suchasflashbacks,wheretheindividualfeelsoractsasifthetraumaticeventwerereoccurring

• Persistentnegativeemotionalstate(e.g.,fear,horror,anger,guilt,orshame)

• Markedlydiminishedinterestorparticipationinsignificantactivities

• Feelingsofdetachmentorestrangementfromothers

• Persistentinabilitytoexperiencepositiveemotions(e.g.,inabilitytoexperiencehappiness,satisfaction,orlovingfeelings)

• Irritablebehaviourandangryoutbursts(withlittleornoprovocation)typicallyexpressedasverbalorphysicalaggressiontowardpeopleorobjects

• Recklessorself-destructivebehaviour

• Problemswithconcentrationandsleepdisturbance(e.g.,difficultyfallingorstayingasleeporrestlesssleep)

TheDSM-VnotesthatindividualswithPTSDcanbequick-tempered,andmayengageinaggressiveverbaland/orphysicalbehaviourwithlittleornoprovocation.Theymayalsoengageinrecklessorself-destructivebehavioursuchasdangerousdriving,andexcessivealcoholordruguse.PTSDcanalsoaffectanindividual’sabilitytoconcentrate,focus,andevensleep,whilealsoaffectinganindividual’sabilitytoregulateemotionsandmaintainstablerelationships.PTSDisalsoassociatedwithsuicidalideationandsuicideattempts(AmericanPsychiatricAssociation,2013).


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BecauseoftheobviouscorrelationsbetweenthediagnosticfoundationsofPTSD,suchasexposuretotraumaticevents,andthedebilitatingeffectsofthesymptomology,thereisclearcauseforexaminingtheratesofPTSDinanyfireservice.AnumberofstudieshavenowexaminedratesofbothPTSDandpost-traumaticstresssymptomswithinfirefightingpopulations.ArecentnationalsurveyoffirefightersinAustraliafoundthatcareerfirefightershadovertwicetheprevalenceofprobablePTSD(9.1%)whencomparedtotheAustraliangeneralpopulationestimate(4.4%).However,at4.7%,probablePTSDwasonlyslightlymorecommoninvolunteerfirefightersthanthatofthegeneralpopulation(BeyondBlueLtd,2018).ArecentstudybySkeffingtonetal.(2017),assessingtraumaexposureandPTSDwithinmembersoftheDepartmentofFireandEmergencyServicesinWesternAustralia,foundthattheirmemberswereexposedtotraumaatconsiderablyhigherratesthanthegeneralpopulation,andreportedelevatedratesofPTSDsymptomology.FurtherAustralianresearchidentifiedacorrelationbetweenincreasedexposuretofatalitiesandanincreaseintherelativeriskofPTSDforfirefighters.Firefighterswhohadbeenexposedto25fatalincidentshadoverfourtimestherelativeriskofPTSDwhencomparedwiththosewhohadbeenexposedtobetweenzeroandfivefatalincidents(Harveyetal.,2016).AlthoughotherreportsoftheexactlifetimeprevalenceofPTSDwithinfirefightingcohortshavevaried,ithasbeenestablishedthatdespitethesevariancesfirefightersexperiencePTSDatconsistentlyelevatedratescomparedtothatofthegeneralpopulation(Skeffingtonetal.,2017).

ThesestudiessupporttheviewthatthereisastrongfoundationofevidencethatFireandEmergencyfirefightersmayexperiencePTSDatconsiderablyelevatedratescomparedtothatoftheNZpopulation.

Depressionandanxiety

Ithasbeenestablishedthatpsychologicaldistresscanleadtothedevelopmentofpsychologicalinjuriessuchasdepressionandanxiety,andthattheseinjuriesarecommon(WorldHealthOrganization,2017).Giventhisassociation,researchershavespecificallyexaminedthecorrelationbetweendepression/anxietyandfirefightingcohorts(Tiesmanetal.,2015).DrWillBrooks,aformerCanadianfirefighterandpsychologistnotestheimpactofdepressiononfirefighterslives:

Likeatownhousefire,depressionmightappearsmallandmanageabletotheaverageperson.However,uponcloserinspection,onerealizesthatjustasatownhousefirespreadstotheneighbouringunits,depressionslowlycreepsintomultipleareasoffirefighters’lives,includingtheirjobs,marriages,relationshipswiththeirchildren,familiesandevenhobbiestheyusedtoenjoy(Avsec,2017,p.1).

Despitetheseverityofpsychologicalsymptomsandthepsychosocialimpactsofdepressionandanxiety,aswellastheirlinktothedevelopmentofsuicidalideationandsuicide,mostresearchspecifictofirefightershasfocusedsolelyonPTSD.Harveyetal.(2016)notedthatthisexclusivefocusonPTSDrisksunderestimatingthefullmentalhealthimpactoftraumaexposureamongemergencyworkerssuchasfirefighters.Theirreportalludedtostudiesof


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militarypersonnel,whoarealsoexposedtoelevatedlevelsofPTEs,andexperiencedisorderssuchasdepressionandalcoholmisuseconsiderablymorethanPTSD.

IntheirstudyofdepressionamongstcurrentandretiredfirefightersinNewSouthWalesAustralia,Harveyetal.(2016)foundapositivelinearrelationshipbetweenexposuretofatalincidentsandtherelativeriskofdepression.Firefighterswithanexposureto25fatalincidentshadovertwicetherelativeriskofdepressionthanthoseexposedtobetweenzerotofivefatalincidents.AsurveycarriedoutbyMindintheUnitedKingdom(UK)foundthatofthefirefighterssurveyed,61%hadexperiencedapsychologicalinjurywiththisincludinginjuriessuchasdepressionoranxiety(Mind,2016b).Anotherstudyof200Saudifirefightersfoundthat44.4%ofthosesurveyedreportedanxiety,while53.3%reporteddepression(Alghamdi,Hunt,&Thomas,2016).

TherecentBeyondBlueLtd(2018)surveycarriedoutinAustraliasoughttomeasurelevelsofpsychologicaldistressmeasuredprimarilybyidentifyingsymptomsofanxietyanddepression.Thesurveyfoundthatcareerfirefightershadtwicethelevelsofveryhighpsychologicaldistress(8%)andovertwicethelevelsofhighdistress(19%)thanthatoftheAustralianadultpopulationestimates(4%and8%).Ontheotherhand,volunteerfirefightershadasimilarrateofveryhighdistress(4%)butanelevatedlevelofhighdistress(14%)comparedtotheAustralianpopulationestimate.Offurtherconcern,alargestudycarriedoutonover3000firefightersfromalargeurbanfiredepartmentintheUSfoundthatdepressionwasoneofthestrongestpredictorsofbothsuicidalideationandsuicideattemptsinthedepartment(Martin,Tran,&Buser,2017).Thisdiscoverycorroboratedpreviousresearchfindingsthatdemonstratedalinkbetweenpsychologicalinjuries,suchasdepressionandanxiety,andanincreasedriskofsuicidewithinfirefightingcohorts(Stanley,Hom,Hagan,&Joiner,2015).

Consequently,thereisstrongevidenceforaconstellationoftraumaticdistresssymptoms,inclusiveofdepressionandanxietythatwhilenotmeetingthecriteriaforaPTSDdiagnosis,willposeasubstantialthreattotheSHWoffirefighters.Thus,thereisapossibilityofsimilarpsychologicalinjuriesbeingpresentandprevalentwithinFireandEmergency.

Suicide,suicidalideation,suicideattempts

AnumberofoperationalfirefighterswithinFireandEmergencyhaverecentlydiedbysuicide.Theexactnumberremainsdifficulttoquantify,astherearenorecordskeptoffirefightersuicideswithinFireandEmergency(J.Kingsbury,NationalSafety,HealthandWellbeingManagerforFireandEmergency,personalcommunication,November09,2017).ThesedeathshavehighlightedtheneedtoinvestigatetheconditionsforsuicidalideationandsuicideamongFireandEmergencyfirefighters.OnceagainitisnecessarytolooktosimilarinternationalorganisationsforindicatorsastothepotentialrisksfacedbyNZfirefighters.

Stanleyetal.(2015)carriedoutanationwidestudyexaminingthecareerprevalenceofsuicidalthoughtsandbehavioursamongstcurrentandretired,careerandvolunteer,firefightersintheUS.Thisresearchwascarriedoutonthepremisethatfirefightershaveauniqueexposuretotraumagiventhenatureoftheiroccupation,andthatthismayindicateelevatedriskforsuicidalthoughtsandbehaviours.Additionally,theynotedthatstudying


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suicideamongstfirefightersisimperativegiventhatpastresearchhasrevealedfirefightersexperienceelevatedratesofpsychologicalinjury,includingdepression,excessivealcoholandtobaccouse,sleepdisturbances,andPTSD.Amongthegeneralpopulation,thesevariablesconferanincreasedriskofsuicidalideationandsuicide.Theirsurveyofover1000firefightersnoted:

Moststrikingly,15.5%offirefightersreportedhavingmadeatleastonesuicideattemptduringtheirtimeinthefireservice,incontrasttothe1.9–8.7%ofUSadultsestimatedtohaveattemptedsuicideatsomepointintheirlives.Further,46.8%offirefightersinthisstudyreportedcareersuicideideation,comparedwiththe5.6–14.3%lifetimeprevalenceofsuicideideationfoundamongthegeneralpopulationofUSadults.(Stanleyetal.,2015,p.168)

Theirstudyconcludedthattherewascompellingempiricalvalidationforwhathasbeenspeculatedanecdotally–suicideideationandbehaviourareanimportantissueforfirefighters.

TheBeyondBlueLtd(2018)report,anAustralianstudythatincludedidentifyingtheproportionofcareerfirefighterswithsuicidalthoughtsorbehavioursinthelast12months,notedthatcareerfirefightershadthreetimestherateofsuicidalthoughts(6.9%)andalmosttwicetherateofsuicideattempts(0.7%)thanthatoftheAustralianadultgeneralpopulationrates(2.3%and0.4%).Firefightersalsohadoverfourtimestherateofsuicideplans(2.6%)asthatoftheAustraliangeneralpopulationrate(0.6%).WhiletheseratesarelowerthanthatoftheUSstudy,thisispotentiallytheresultofthemeasurementtimeframe– 12-monthprevalenceversuscareerprevalence.Finally,thereportnotedthatcareerfirefightershadthehighestratesofsuicidalthoughtsandattempts,andthesecondhighestrateofplans,incomparisontotheotherthreesectorssurveyed(Police,Ambulance,StateEmergencyServices).Thereportfindingsalsoindicatedapotentialdose-responserelationship,acrossallfouremergencysectors,withlongerlengthofserviceassociatedwithconsiderablyhigherlevelsofsuicidalthinking.

AstudyintoworkplacesuicideintheUSnotedthatfirefightershadratesofsuicideinexcessofthenationalaverage,specifyingworkplacesuicideforprotectiveserviceoccupations(includingfirefighters)at3.5timesgreaterthantheoverallUSworkerrate.Thestudyattributedthesehigherratestoanumberofvariablesincludingshiftwork,andhighstressworkexperiences(Tiesmanetal.,2015).AfurtherreportissuedbytheNationalFallenFireFighterFoundationnotedthat,comparedtothegeneralpopulationrates,afiredepartmentisthreetimesmorelikelytoexperienceasuicidethanaline-of-dutydeathinanygivenyear(NationalFallenFirefightersFoundation,2014).

In2016thementalhealthcharityMind(2016b)carriedoutasurveyofover1600emergencyserviceworkersintheUK,includingover200firefighters.Theirfindingsforfirefightersrevealedthat30%hadcontemplatedtakingtheirownlivesduetopsychologicaldistressandinjurywhileworkingfortheFireandRescueService.InAustralia,anarticleappearingin‘TheAge’notedthattheVictorianFireServicewasexperiencingacrisisofpsychologicalinjuries


24 27March2019

withthenumberoffirefighterstakingtheirownlivesdramaticallyincreasinginrecenttimes(May,2016).

ThissynopsisofresearchandexpertopinionhasestablishedacorrelationbetweenfirefightersandpsychologicalinjuriessuchasPTSD,depressionandanxiety,aswellasacorrelationbetweentheseinjuriesandsuicidalideation,andsuicide.Thisresearchformsanevidence-informedbasefortherecommendationthatFireandEmergencycarryoutresearchintothepresence,prevalence,andimpactsofpsychologicaldistressandinjuryexperiencedbyitsfirefighters.

‘Smoke’–indicatorsofpsychologicalinjuryResearchquestion:Whatmightbeindicatorsofpsychologicaldistressandinjurywithinfirefightingcohorts?

Theadage“wherethere’ssmoke,there’sfire”canbeattestedtobymanyfirefighterswhohaveusedthesightorsmellofsmoketoassistinguidingthemtoafire.Inmuchthesameway,certainbehaviourscanserveasindicatorsofunderlyingpsychologicaldistressandinjury.Havingone’ssensesattunedtothepresenceofthesebehaviourscanhelpto‘raisethealarm’andgethelpwhendealingwiththeunderlyingcausesofthesedamagingbehaviours.Thefollowingsectionwillinvestigateanumberofmaladaptivebehavioursandtheirrelationshiptofirefightingcohorts.

Maladaptivecoping/behaviour

Individualsexperiencingsubstantialpsychologicaldistressorapsychologicalinjuryarelikelytoseektocopewiththeirdistress,consciouslyorsubconsciously,throughanumberofcopingmechanisms.Thesemechanismsofcopingcanoftenbesplitintotwocategories:adaptivecoping/behaviour,maladaptivecoping/behaviour.Adaptivecopingincludesmethodsthat,despitesometimesproducingshort-termdiscomfort,ultimatelyassistanindividualinavoidingdistressand/oralleviatingdistressthatmayhaveotherwiseledtoapsychologicalinjuryinthelongterm.Skeffingtonetal.(2017)notedthefollowingadaptivecopingmechanismsintheirresearch:

• Activecopingplanning

• Positivereframing

• Acceptance

• Humour

• Religion

• Emotionalsupport

Maladaptivebehaviours,likeadaptivebehaviours,oftenariseoutofalegitimateneedtosootheoverwhelmingsymptomsofpsychologicaldistressandinjury.Unlikeadaptivecopingmechanisms,maladaptivecopingispreoccupiedwithavoidingtheevent,andtheintenseemotionsthatmaybeweldedtoit.Whilethisavoidanceandsoothingmayassistinarresting


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short-termdistress,itcanproducedamagingoutcomesfortheindividualandthosearoundthem,bothintheshortandlongterm.Examplesoftypesofmaladaptivebehaviourorcopingarelistedbelow(Skeffingtonetal.,2017):

• Alcoholanddrugmisuse

• Denial

• Venting

• Behaviouraldisengagement

• Self-blame

Indeed,studieshaveshownthattheuseofmaladaptivecopingmethodscanleadtohigherdistressorpost-traumaticstress(PTS)symptoms(Skeffingtonetal.,2017).Asanexample,self-blameandusingsubstancesasacopingstrategypredictedhighercompositesymptomscoresandhigheralcoholabusesymptomsinastudycarriedoutbyMeyeretal.(2012)oncareerfirefighters.

WhilethereisnoresearchintomaladaptivebehavioursspecifictoFireandEmergencyfirefighters,JulieMaher,previouslyanoccupationalnursefortheNZFS,notedtheprevalenceofmaladaptivecopingmethodsinherdealingwithfirefightersinthelate80’s:

ItwasduringthistimethatIbegantorecognisewhatIbelieveweretheeffectsofwork-relatedstress.Irecognisedahighincidenceofalcoholandsuspecteddrugabuse,ahigherincidenceofsmokingthaninthegeneralpopulation(whensmokingwasbeginningtoreduceinthegeneralpopulation)andaparticularlyhighincidenceofmarriagebreakdown.(Maher,1999,pp.21,22)

Maher’sobservationofmaladaptivecopingmethodsbeingusedbyfirefighters,andthesensethatthesemethodsofcopingwererelatedtounderlyingpsychologicaldistressandinjury,issupportedbymorerecentresearch.Asanexample,thereisagrowingbodyofresearchdemonstratingthatalcoholabuseisprevalentamongfirefighters.Thisresearchsuggeststhatfirefightersmayresorttodrinkinginordertocopewithjob-relateddistress,withonestudyoffirefightersfindingthatalcoholusewasoneofthemostfrequentlyreportedcopingstrategiesformanagingwork-relateddistress(Paulus,Vujanovic,Schuhmann,Smith,&Tran,2017).

Theconnectionbetweenpsychologicaldistressandmaladaptivecopingbehavioursmaygosomewaytoexplainingthehighratesofalcoholabuseinfirefightingcohorts.Studieshavereportedthatfireandemergencyserviceworkisassociatedwithnotablyelevatedalcoholuse,withPaulusetal.(2017)notingthefollowingfindingsasaresultoftheirsurveyofover2500USfirefighters:

• Nearlyonethirdofmalefirefightersscreenpositiveforalcoholdependence.

• Depressionisassociatedwithalcoholdependenceamongfirefighters.

• PTSisassociatedwithalcoholdependenceandconsumption.


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• DepressionandPTSinteractinrelationtoalcoholoutcomes.

• Firefightersmaybenefitfromtreatmentstargetingdepression,PTS,andalcoholuse.

Skeffingtonetal.(2017)alsohighlightedthelinkbetweenalcoholmisuseandpsychologicalinjuriessuchasPTSD.However,aspreviouslystated,alcoholmisuseisbutoneexampleofmaladaptivecoping,andfurtherresearchintomaladaptivecopingshouldseektoidentifyalltypesofcopingthatmayperpetuatenegativepsychologicalandsocialoutcomesforfirefighters.

Theabovefindingsservetodemonstratetheimportanceofkeepingone’ssensesattunedto‘smoke’(maladaptivebehaviour)initsvaryingformsasanindicatorof‘fire’(psychologicaldistressandinjury).Giventheinternationalresearchonthecorrelationbetweenfirefighters,thepresenceandprevalenceofmaladaptivecopingmechanisms,andtheconnectionofthesemechanismswithvaryingpsychologicalinjuries,FireandEmergencywouldbeadvisedtoconsideritsownresearchintothepresenceandprevalenceofmaladaptivebehaviourspresentwithintheorganisation.

‘Exposures’–RadiatingeffectofpsychologicalinjuryResearchquestion:Whateffectsmightpsychologicaldistressandinjuryhaveonfirefighters,theirfamilies,andFireandEmergencyasaworkplace?

RECEOisacommandandcontrolacronymusedbyofficersforprioritisingresourceswhenfacedwithanincident.FollowingthefirstpriorityofR-‘risktolife’,isthepriorityofE–‘exposureprotection’(FireandEmergencyNewZealand[FireandEmergency],2013).Dependingonthesizeanddevelopmentofanincidentsuchasastructurefire,otherstructuresincloseproximitymaybethreatenedthroughradiatedheatandsmoke.Afireinonestructurewillspreadtootherstructuresincloseproximityifnotenoughisdonetoextinguishthefireorprotecttheexposures.Thisanalogyservestodemonstratenotonlytheimpactofpsychologicaldistressandinjuryonfirefightersbutalsotheradiatingimpactthisdistressandinjurycanhaveonfamily,friends,communities,andworkplaces.Thefollowingsectionwillexploreanumberoftheseradiatingeffects.

Firefighters

Whilethisreporthashighlightedtheimpactpsychologicalinjuriescanhaveonafirefighter’spsychologicalhealth,itisalsoimportanttonotetheimpactpsychologicalinjuriesmayhaveonafirefighter’sphysicalhealth.Thisisespeciallynecessarygiventhephysicalnatureofafirefighter’scorework,whichwillofteninvolveprolongedperiodsofstrenuousphysicalactivity.Consequently,researchershavebeguntoexploretheimpactofpsychologicalinjuriesonfirefighters’physiologicalhealthincludinghowpsychologicalinjuriesmightcompromiseafirefighter’sabilitytocarryoutcorework.Forexample,researchbyMilligan-Savilleetal.(2017)notedthatfirefighterswithPTSDreportedconsiderablyincreasedsomaticsymptomsincludinggreaterlevelsofgastrointestinal,cardiorespiratoryandneurologicalsymptomscomparedtothosewhodidnothavePTSD.Thesefindingshighlightthedegreeofimpairmentapsychologicalinjurycanhavewithregardtotheday-to-day


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functionofafirefighter,notonlyasaresultofimpairedpsychologicalhealthbutalsoasaresultofimpairedphysiologicalhealth.Bothofthesefactorshavethepotentialtonegativelyaffectafirefighterexperiencingapsychologicalinjury.

Family,colleagues,community

Ithasbeendemonstratedthatthesocialsupportprovidedbyfamily,friends,andcommunitiesisvitalinreducingtheimpactofpotentiallytraumaticeventsandresultantpsychologicaldistressandinjuryonemergencyresponderssuchasfirefighters(Sattleretal.,2014).Forexample,socialsupporthasbeennegativelycorrelatedwithscoresonbothtraumasymptomanddepressionscales(Roberts,2005).Thereductionofsymptomology,asaresultofsocialsupport,hasalsobeencorrelatedwithareductioninstressleavetakenfromworkfollowingatraumaticevent(Regehr,2005).Itisevidentthenthatsocialsupportplaysavitalroleinassistingwiththereductionofpsychologicaldistress,andtherecoveryfrompsychologicalinjury.However,researchhasindicatedthatfamilymembersarenotimmunetotheradiatingimpactoffirstresponderpsychologicaldistressandinjury(Cheryl,Gina,Elaine,Sharon,&Joscelyn,2005).Forexample,aqualitativestudyontheimpactoftraumaonparamedics,andtheradiatingeffectontheirfamilies,notedthefollowingexperiencesofspouses(Regehr,2005):

“He’snotjustwithdrawingfromme,he’swithdrawingfromourchildrenaswell,it’saffectingus”.(p.105)

“He’snotaspatient…Ithinkhe’sbecomemoreaggressivedriving…andIjustnoticehis[lackof]patience.Hejustblowsupsometimes”.(p.105)

“It’salmostlikeabombgoingoff.Ithithimandjustlikeanaftershock,hitallofus”.(p.106)

Researchershaveshownthatjob-relatedstressorscouldbetransferredtofamilymemberswhenaffectedfirefightersreturnhome.Thistransferencehasbeenshowntonegativelyimpactmarriages,aswellasparentalinteractionswithchildren.Asanexample,astudyofpoliceofficersfoundthatemotionalexhaustionandnegativeaffectivestatesexperiencedbyofficerswereassociatedwiththeirspouse’sreportsoffamilyconflict(Regehr&Bober,2005).TheDSM-Valsonotesthatindividualswhoexperienceapsychologicalinjury,suchasPTSD,maysufferfromimpairedinterpersonalfunctioning,andpoorfamilyandsocialrelationships(AmericanPsychiatricAssociation,2013).

Furtherresearchhassuggestedthatemotionalnumbing(amechanismsometimesusedbyemergencyrespondersincopingwithdistress)isassociatedwithnegativefeelingsoffamilymembers.Thisnumbing,whichisoftencharacterisedbydetachment,disinterest,andemotionalunavailability,maydiminishparents’abilityandinclinationtoseekout,engage,andenjoyinteractionswiththeirchildren,leadingtocompromisedrelationships(Regehr,2005).Stillfurtherevidencesuggeststhattraumaticexposureencounteredinthecourseoffireandemergencyworkmayresultintraumasymptomsforspouses(Cheryletal.,2005),aconceptattestedtobypsychiatristandworldleadingPTSexpert,BesselvanderKolk,whonotesthepossibleflow-oneffectsofpsychologicalinjuriesforthefamilymembersofthoseinjured:


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Traumaaffectsnotonlytheindividual,butalsothoseclosetothem.ThewivesofmenwhosufferPTSDoftenbecomingdepressed,whichinturncanaffectherchildrenwhoaremorelikelytogrowupinsecureandanxious.(VanDerKolk,2014,p.1)

Additionally,astudyoffirefighterswhobattledthe1983AshWednesdayBushfiresinAustraliareportedthefollowingfigures(McFarlane&Bookless,2001):

• 80%offirefightersreportedbeingmoreirritablewiththeirfamilyeightmonthsaftertheevent.

• 50%offirefightersspentlesstimewiththeirfamily,weremorewithdrawn,andfoughtmorewithfamilymembers.

• 65%offirefightersreportedavoidingdiscussionoftheirproblems.

Afollowupstudyreportedthefollowingfindings(McFarlane&Bookless,2001):

• 37%offirefightersbelievedtheexperienceaffectedthewaytheygotalongwithothers

• 31%ofthosefirefighterswhoweremarriedindicatedthattheirsexualrelationshadbeenaffectedbytheexperience.

• ItwasfoundthattheabovevariableswerecorrelatedwiththosewholaterdevelopedPTSD.

Finally,thereisagrowingbodyofevidencethatindicatesthattheremaybenegativeoutcomesforthechildrenandeventhegrandchildrenoffirefighterswhosufferapsychologicalinjuryandengageincertaintypesofmaladaptivecopingtodealwiththatinjury.Forexample,theAdverseChildhoodExperiences(ACE)study,alandmarkstudyinvolvingover13,000participants,involvedexamininghowadversechildhoodexperiences,suchaslivinginahouseholdwheremembersofthathouseholdhadapsychologicalinjuryorwereengagedinmaladaptivebehaviour,mightcontributetoarangeofnegativeoutcomesforthechildrenofthathouseholdlaterinlife(Felittietal.,1998).Foreachidentifiableadverseexperiencethatachildwasexposedto,anACEscoreofonewouldbegiven.Thisstudyandnumerousfollow-upstudiesidentifiedagradeddose-responserelationshipwithregardtothenumberofACEsexperiencedbyachild,andtheincidenceofnegativehealthandwellbeingoutcomesoverthecourseofthatchild’slife.Theresearchrevealedthatwithoutappropriateintervention,ACEscouldleadtolong-termdisease,disability,chronicsocialproblems,andearlydeath.Forexample,achildwithanACEscoreoffourormorehadafourto12foldincreasedriskfordepression,drugabuse,alcoholism,andsuicideattemptslaterinlife.Withspecificregardtosuicideattempts,individualswithanACEscoreofonewerealmosttwiceaslikelytohavemadeasuicideattemptasthosewithanACEscoreofzero.IndividualswithanACEscoreoffourormorewereover12timesaslikelytohaveattemptedsuicidethanthatofanindividualwithanACEscoreofzero(Felittietal.,1998).Thisresearchhasconsiderableimplicationsinrelationtofirefightersandtheirchildren,giventheresearchpreviouslyidentifiedinthisreportthathasindicatedelevatedratesofpsychologicalinjuryandmaladaptivecoping,inclusiveofsubstanceabuse,infirefightingcohorts.Consequently,thechildrenoffirefighters,whoexperiencepsychological


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injuriesandengageinmaladaptivebehaviours,aremorelikelytohaveahigherACEscoreandthushaveincreasedvulnerabilityforarangeofnegativephysiological,psychological,andsocialoutcomes.

Psychologicaltraumamayalsoinduceepigeneticmodificationtoanindividual’sDNAthatmayhaveshortandlong-termeffectsonanindividual’sbrainfunction,thebody’sstressresponsesystem,andevenimmunefunction.Epigeneticmodificationscanbelikenedtoalightswitch.Alightswitchcanturnalightonandoffbutitdoesnotaltertheelectricalwiringsystemofthatlight.Inotherwords,epigeneticmodificationsdonotaltertheDNAstructurebuttheycanalterwhetherDNAisswitchedonoroff.Therehasalsobeensomeevidencethatsuggeststhattheseepigeneticmodificationscanbeinheritedacrosssubsequentgenerations(Yehudaetal.,2016).Thismayberelevanttofirefightersassomeoftheseepigeneticmodifications,whichareaccumulatedacrossalifetime,appeartobetheresultofpsychologicalinjury,andthereisthepossibilitythatthesemodificationsmaybepasseddowninter-generationally.Forexample,inastudyofHolocaustsurvivors,childrenofHolocaustsurvivors,whohadPTSD,appearedtoinheritspecificepigeneticmodificationsfromtheirparentsandthiswascorrelatedwithanincreasedriskofdevelopingPTSDthemselves(Yehudaetal.,2016).Itshouldbenotedthatepigeneticresearchremainsinitsinfancyandepigeneticmodificationsarenotfixed,meaningjustasaswitchmaybeturnedoffitmayalsobeturnedonagain.Yet,thereisstillcausetoconsiderfindingsthatmaysignalanintergenerationalepigeneticriskforthechildrenoffirefighterswithPTSD.

Consequently,itisevidentthatitisimportanttorecognisenotonlytheimpactofpsychologicalinjuryonfirefighters,butalsothepotentialradiatingimpactofsuchinjuriesonthefamilies,friends,andcommunitiesoffirefighters.

Workplace

Thereareanumberofreasonswhyanorganisation,suchasFireandEmergency,shouldseektoensuretheidentification,implementation,andresourcingofinitiativesthatwouldassistineliminatingorminimisingpsychologicaldistressandinjury.Theprimaryreasonormotivationforsuchactionisethical.Forthemostpart,individualsandsocietyvaluehumanlifeandassuchshouldseektominimisehumansufferingwhereverpossible,asitistherightthingtodo.However,othermotivationsforrespondingtofirefighterpsychologicaldistressandinjuryareapparentasresearchhasindicatedthatpsychologicaldistressandinjuryarefactorscontributingtohigherabsenteeism,increasedworkerturnover,higheraccidentandinjuryrates,higherhealthcarecosts,increasedlegalexposure,andlowerproductivity(MentalHealthFoundation,n.d.).Therefore,whileanethicalmotivationshouldbefoundationaltoactioninrelationtoimprovingworkerwellbeing,workplaceandlegalfactors,thathavethepotentialtonegativelyimpactworkplaces,mayalsocontributetoanorganisationtakingstepstoeliminateorminimisepsychologicaldistressandinjury.

Withregardtotheworkplaceramificationsofpsychologicaldistressandinjury,asfarbackas1990ithasbeennotedthatfirefightersinNZmaybeplacingthemselvesandothersatriskwhenawarenessandmanagementofpsychologicaldistressandinjuryisnotsufficient:


30 27March2019

Itseemstousthatitisnecessaryforfirefighters,theUnionandCommissiontoacknowledgethatfirefighting,asanoccupation,maytakeanenormousphysicalandemotionaltoll.Ifhealthproblemsarenotidentified,monitoredandtreated,individualhealthmaybeputatrisk,occupationalrisksmaynotbeproperlyappreciated(becausehealthtrendswillnotbeapparent),andfirefightersindangeroussituationsmaybeputatriskbyacolleaguewhoisnotfunctioningadequately.(Elias,1990,p.121)

Ithasbeenshownthatfirefightersexperiencingpsychologicaldistressaremorepronetodecision-makingerrors.Whenreflectingonthesymptomologycorrelatedwithpsychologicaldistressandinjury,thereislittlewonderastothisoutcome.Justasphysiologicalfatigueandoverloadcancauseabreakdowninphysicalandcognitivefunctioning,psychologicaldistresscanleadtoanoverloadthatattimesmaycausehazardousworkdecisionsandbehaviours(Kaplan,Bergman,Christopher,Bowen,&Hunsinger,2017).

Theeconomiccostsofpsychologicaldistressandinjuryonorganisationsarealsobecomingevident.DrRussNewman,theAmericanPsychologicalAssociationexecutivedirectorforprofessionalpractice,notedthatthecostofdistressishugetoemployers,withanestimatedUS300billiondollarsayearspentbyemployersonstress-relatedissuessuchasabsenteeism,turnover,loweredproductivity,anddirectmedical,legalandinsurancecosts;stating"Thelinkbetweenemployeehealthandwell-beingandorganizationalperformanceisclear"(AmericanPsychologicalAssociation,2007,para.6)InNZ,2014estimatesshowedthatapproximately6.7millionworkingdayswerelostduetoabsencewithaneconomiccostof1.4billiondollars(MentalHealthFoundation,n.d.).WhiletheHeAraOranga(2018)reportindicatedtheoveralleconomiccostofpsychologicaldistressandmaladaptivebehavioursinNZwasapproximately$12billion.Substantialeconomiccostsarealsolikelyforfireandemergencyserviceswithresearchindicatingthatburnoutamongstfirefighters,resultingfrompsychologicaldistress,hasbeenlinkedtoincreasedabsenteeism,andturnover(Kaplanetal.,2017).ThisfindingissupportedbytheDSM-VthatnotesthatPTSDisassociatedwithincreasedabsenteeismfromworkandloweroccupationalsuccessincommunityandveteransamples(AmericanPsychiatricAssociation,2013).ResearchcarriedoutbyMindintheUKonemergencyservicepersonnelfoundthat57%hadcontemplatedleavingtheirjoborvoluntaryrolebecauseofpsychologicaldistressandinjury,while51%statedtheyhadtakentimeoffworkasaresultofpsychologicaldistressandinjury(Mind,2016c).Thiscorrelateswithresearchthathasshownthat30-40%ofsicknessabsenceislinkedtowork-relateddistress,andisalsothereasonwork-relateddistressaccountsforthesecondlargestoccupationalhealthproblemintheUK,costingtheUK£3.6bneveryyear(FireBrigadesUnion,2016).Componentsofthedirectandindirectcostsoffirefighterinjury,includingthatofpsychologicalinjury,werereportedbyFrazier,Hankin,Schaenman,andStambaugh(2005),andincluded:

• Lostwagesofinjuredfirefightersthatexceededdisabilitypayments

• Overtimewages,abovethecostoftheinjuredfirefighter’swages,tofillinforthefirefighter

• Medicalcosts


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• Costsofpsychologicalcounsellingforpsychologicaldistressandinjurysufferedbythefirefighter,thefirefighter’sfamily,and(occasionally)thefirefighter’sco-workers

• Timespentbythefirefighter,supervisors,andothersinvestigatingtheincidentandwritingtheinjuryreport

• Costoftrainingforfirefightersafety.

Thisrangeofeconomiccoststoanorganisationmayaccountforresearchthathasindicatedanaveragereturnof$4.20forevery$1spentonpsychologicalwellbeingprogrammes(MentalHealthFoundation,2016).

Withregardtolegalramifications,psychologicaldistress,asaresultofcriticalincidentand/orworkplacedistress,thatleadstoafirefighterexperiencingapsychologicalinjuryordyingbysuicidemaynowalsohaveasubstantialeffectonorganisationssuchasFireandEmergency.AccordingtotheHealthandSafetyatWorkAct2015aPersonConductingaBusinessorUndertaking(PCBU),suchasFireandEmergency,hasaresponsibilityanddutyofcaretoitsworkerstoprotectthemfromharmtotheirphysicalandpsychologicalsafety,health,andwelfare.ThePCBUcanfacepenaltiesifitisshownthatthisdutyofcarehasnotbeentaken.TwoSubpartsoftheActhighlightthelevelofresponsibilityFireandEmergencyholdwithregardtothepsychologicalwellbeingofitsworkers.ThefollowingsectionsoftheHealthandSafetyatWorkAct2015,pp.32,33,highlightsomeoftheapplicableclauses.Accordingtotheseclauses,FireandEmergencyareresponsiblefor,amongotherthings:

Section36,Subpart2‘DutiesofPCBUs,PrimaryDutyofCare’

1(a)theprovisionandmaintenanceofaworkenvironmentthatiswithoutriskstohealthandsafety;and

2(f)theprovisionofanyinformation,training,instruction,orsupervisionthatisnecessarytoprotectallpersonsfromriskstotheirhealthandsafetyarisingfromworkcarriedoutaspartoftheconductofthebusinessorundertaking;and

3(g)thatthehealthofworkersandtheconditionsattheworkplacearemonitoredforthepurposeofpreventinginjuryorillnessofworkersarisingfromtheconductofthebusinessorundertaking.

FurtherresponsibilitiesareoutlinedinSection44,Subpart3‘DutiesofOfficers,Workersandotherpersons’.‘Officers’wouldtranslatewithinaFireandEmergencycontexttotheChiefExecutive(CEO),ExecutiveLeadershipTeamandtheOperationalLeadershipTeam.AccordingtotheHealthandSafetyatWorkAct2015,p.41,‘Officers’haveaduediligenceroletotakereasonablestepswithregardtothefollowing:

a) toacquire,andkeepuptodate,knowledgeofworkhealthandsafetymatters;and

b) togainanunderstandingofthenatureoftheoperationsofthebusinessorundertakingofthePCBUandgenerallyofthehazardsandrisksassociatedwiththoseoperations;and


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c) toensurethatthePCBUhasavailableforuse,anduses,appropriateresourcesandprocessestoeliminateorminimiseriskstohealthandsafetyfromworkcarriedoutaspartoftheconductofthebusinessorundertaking;and

d) toensurethatthePCBUhasappropriateprocessesforreceivingandconsideringinformationregardingincidents,hazards,andrisksandforrespondinginatimelywaytothatinformation;and

e) toensurethatthePCBUhas,andimplements,processesforcomplyingwithanydutyorobligationofthePCBUunderthisAct;and

f) toverifytheprovisionanduseoftheresourcesandprocessesreferredtoinparagraphs(c)to(e).

Onecanseethenthatanorganisation,especiallyonesuchasFireandEmergency,maybeimpactedlegallyasaresultofworkerswhoexperiencepsychologicalinjuryorwhodiebysuicideifitisshownthattheorganisationhadnottakenappropriatestepstoidentifyandeliminateorminimisetherisksassociatedwithsuchoutcomes.However,responsibilityfortheSHWofindividualsshouldneverbeframeddualisticallyandwhileFireandEmergencyhasadefiniteresponsibilitywithregardtotheSHWoffirefightersitisnot,andshouldnotbe,theirsoleresponsibility.Section45oftheHealthandSafetyatWorkAct,2015reflectsthisnotionofsharedresponsibilitynotingtheindividualresponsibilitiesworkershavewithregardtotheirown,andtheircolleagues’,SHW.

Thissectionofthereporthasprovidedabriefsynopsisoftheradiatingnatureofpsychologicaldistressandinjuryexperiencedbyfirefighters;byitsverynaturetheseexperiencesarelikelytohaveasubstantialimpactonfriends,family,communitiesandworkplacesoffirefighters.

‘Ignitionsources’–causesofpsychologicaldistressResearchquestion:WhataresomeofthelikelycausesofpsychologicalinjurywithinFireandEmergency?

TheFireandEmergencyFireandInvestigationtechnicalmanualstatesthatthemosteffectivewaytoachievefirepreventionisthroughlearningasmuchabouthowandwhyfiresstartinthefirstplace(FireandEmergency,2008).Thisstatementequallyappliestothenecessaryprocessofunderstandingwhatvariablescontributeto,andunderlie,psychologicalinjurysothatitmaybeprevented.

Thisreporthasestablishedacorrelationbetweenpotentiallytraumaticeventsandpsychologicaldistressandinjury.Additionally,ithasdemonstratedthecomplexitiesofacuteandchronicexposuretocriticalincidents,andhowhomeandworkplacedistresscancontributetothedevelopmentofapsychologicalinjury.Asthesepotentialignitionsourcesofpsychologicaldistressandinjuryhavealreadybeenidentified,thissectionwillfocusonanumberofaspectsuniquetotheFireandEmergencylandscapethatmaybefuellinganescalationofpsychologicaldistressandinjury.Thiswillincludeabriefinvestigationof


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medicalcalls,workplacestressors,andorganisationalculturespecifictoFireandEmergencyfirefighters.

Itshouldbenotedthatthisisnotanexhaustiveanalysisofcontributorstopsychologicalinjury,asitwasbeyondthescopeofthisreporttoexamine,forexample,personalfactorssuchaspre-employmenttraumaandpersonality.Furthermore,thefollowingsectionfocusingonmedicalcallsshouldnotdetractfromtherealityoftheothertypesofcriticalincidentsfirefightersattendsuchasfires,motorvehicleaccidents(MVA),andnaturaldisasters,whichcanalsocreatedistressthatmaycontributetoapsychologicalinjury.ThiscautionisperhapsbestsummarisedbyaFireandEmergencyfirefighterinterviewedaspartofaresearchreportconductedbyAdamsetal.(2018):

So,someofthestuffthathasaffectedmefromatraumaticpointofviewhasbeenfirerelatedbutyou’renotinterestedinthatbuttherehasbeenanumberoffiresovertheyearsthatI’veattendedwherewe’vehadunsuccessfulrescuesthatplaysuponyouemotionally,psychologically,itplaysuponyouquitealot,butI’llpushthatasideforthemomentandjustkindoffocusonthenon-fire.(Adamsetal.,2018,p.34)

Medicalcalls

Theperiodspanning1July2017to30June2018sawfirefightersinNZattend82,567incidents.Oftheseincidents,approximately10,000comprisedstructureandvegetationtypefiresandover2000wereduetonaturaldisastersandextremeweatherevents.Approximately10,000resultedfrommotorvehicleaccidentsandotherrescues,andcloseto1000weretheresultofhazardoussubstanceincidents.Perhapsmostnotably,firefightersattendedapproximately14,000medicalincidentsoverthistime,whichisconsiderablymorethantheamountofvegetationandstructurefiresincidentsattended(FireandEmergencyNewZealand,2018b).

Numerousfireservicesinternationallyrespondtomedicalcallsinafirstorco-responsecapacity,however,thiswasnotcommonpracticeinallpartsofNZpriorto2013.Untilthistime,theNZFShadanunderstandingwhereitwouldsupportanotheragency,suchasStJohn,ifarequestwasrecommended.Thiswasgenerallyknownas“MutualAid”andwasessentiallyacommitmenttohelpoutwhenrequired.However,2013sawthedevelopmentofaformalMOUbetweentheNZFS,StJohnandWellingtonFreeAmbulance,withmedicalcallresponsebeingsocialisedoverthatyear(G.Travers,NationalComcens&MedicalResponseManagerforFireandEmergency,personalcommunication,November09,2017).

In2014,therewasasubstantialincreaseinthenumberofmedicalcallstheNZFSrespondedto(seeFigure1),areflectionoftheimplementationoftheMOUbetweenStJohn,WellingtonFreeAmbulanceandtheNZFSinDecember2013(FireandEmergencyBusinessAnalystUnitdataonmedicalcallsbyregioninNZ,2011-2019,personalcommunication,February04,2019).Anexaminationoftheincreaseinresponsetomedicalcallspost2013ispertinentgiventherelationshipbetweendoseexposuretotrauma,andthedevelopmentofpsychologicalinjuriessuchasthosementionedinthepriorsection.


34 27March2019

Region1 Region2 Region3 Region4 Region5

20182017201620152014201320122011

12000100008000

6000

4000

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0

NumberofmedicalcallsbyRegion

AsaresultoftheMOUagreeduponbytheNZFS,StJohn,andWellingtonFreeAmbulance,firefightersweretoco-respondto‘purple’codedcallswithemergencyambulanceservices(EAS).Acodepurplecorrespondstocallsthatareimmediatelylifethreatening,suchascardiacarrestsandhangings(StJohn,2017).Formanyfirefightersthisrepresentedasubstantialadditiontotheirrole.ThisadditionhasseenexposuretoPTEsforsomefirefightersincreaseconsiderably,withFigure1demonstratingtheincreaseinresponsetomedicalcallsandpotentiallytraumaticeventsnationally.

Figure1.MedicalcallsattendedbyFireandEmergencyfirefightersaccordingtoyearandRegion.AdaptedfromFireandEmergencyBusinessAnalystUnit,personalcommunication,February04,2019.

BelowisasampleofanumberofAreaswithineachRegionthathavebeenimpactedbytheMOU(FireandEmergencyBusinessAnalystUnitdataonmedicalcallsbyregioninNZ,2011-2019,personalcommunication,February04,2019):

Region Area Name Medicalcalls

Year Number Year Number Increase

1 4 AucklandCity 2013 41 2018 706 1621%

1 5 Counties-Manukau

2013 389 2018 1193 206%

2 6 Waikato 2013 162 2018 495 205%

2 8 BayofPlentyCoast

2013 386 2018 689 78%

3 11 Hawke’sBay 2013 208 2018 393 88%

3 13 Whanganui 2013 84 2018 184 119%

4 21 ChristchurchMetro

2013 488 2018 673 37%

5 24 EastOtago 2013 276 2018 553 100%


JoshuaDarby 35

AqualitativeresearchstudycarriedoutonFireandEmergencyfirefighters,inrelationtotheimpactofthe2014MOU,notedfirefighter’sexperiencesofthisincreasedmedicalcalloutworkload,withonefirefighternoting:

Ifwelookatthejobswe’redoing,workingjobsthatwearedoing,it’s[medicalcalls]makingup,I’mjustguessing,butit’sprobablyathird,aquartertoathird,oftheworkingjobsthatwegotoaremedicalcalls,we’reprobablyaveragingacoupleaweekonmyshiftsooutoffourshiftswemightgettwoheartattackcallsifyoulike,twomedicalcalls,sometimesitcanbefourorfiveorsix,couldbeoneortwoadayonabusysetbutitaveragesaroundoneeveryseconddayandsomakesupasignificantpartoftheworknow.(Adamsetal.,2018,p.23).

Thisincreaseinmedicalresponseworkloadwasalsoreflectedinareport,releasedbyStJohn,notingthattheNZFShadattendedmorethan70%ofadultout-of-hospitalcardiacarrests(OHCAs)duringthereportingperiod(July01,2015toJune30,2016)whereanEASmadearesuscitationattempt.ThereportalsostatesthattheNZFSwasfirstonsceneat15%oftheseevents(Dicker&Davey,2016).

Thisincreaseinresponseoffirefighters,inaco-responsecapacity,hasseenpositiveoutcomesforthecommunitiesFireandEmergencyserveswiththesamereportreleasedbyStJohnnoting:

TheNewZealandFireServicehasbeenfundamentalintheearlydefibrillationof95adultpatientsincardiacarrestpriortothearrivalofStJohnEAS.Ofthesepatients,38%survivedtheevent(hadapulsesustainedtohospitalhandover)and28%survivedtohospitaldischarge.(Dicker&Davey,2016,p.25)

AmorerecentreportbyTurnerandRasmussen(2018)notedthatpatientoutcomesinNZwereimproving,asindicatedbyanincreaseinreturnofspontaneouscirculationfrom8%to12%.Thisimprovement,whichisleadingtomorelivesbeingsaved,isbelievedtobetheresultoftheFireandEmergencymedicalresponsecapability.ThesebenefitsextendbeyondthatofthecommunitytothatofindividualfirefighterswithinFireandEmergencywhobytheirverynaturewanttoassistthepublicwhereverpossible.QualitativeresearchcarriedoutonasampleofFireandEmergencyfirefightersnotedthebenefitthisrolecanhaveforsomefirefighters:

Imeanifyourespondforexampletomedicalemergenciesandyou’reabletoreviveorresuscitatesomeone’sfamilymember,there’sahugesenseofsatisfactionandasenseofachievementinhelpingsomeoneandimprovingthesituationtheywereattending(Adamsetal.,2018,p.23).

However,whileanincreaseinresponsetomedicalcallshasseenmeasurablebenefitsforthecommunity,andcontributedtoanelevatedsenseofmeaningforsomefirefighters,ithasalsopresentedaconsiderableincreaseinpsychologicalriskforFireandEmergencyfirefighters.Forexample,researchbyStanleyetal.(2015)foundthatfirefighterswhoweremembersoffiredepartmentsthatalsorespondedtoemergencymedicalcalloutswere


36 27March2019

2011 2012 2013 2014 2015 2016 2017 2018

Whangarei-KaiparaArea

WaitemataArea

MuriWhenuaArea

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AucklandCityArea

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800

600

400

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0

NumberofK41sTransmittedformedicalcalls

almostsixtimesmorelikelytoreporthavingmadeasuicideattempt.Thismayconferanelevatedriskforfirefighterswhoalsorespondtomedicalcallouts.Additionally,thenatureofpurplecalls,beingimmediatelylifethreatening,meansthattheyqualifyasaPTE.

Furthermore,thevolumeofcallsforsomestationshasincreasedsubstantially,seeFigure1,leadingtocumulativeexposurepossibilitiesdiscussedearlierinthisreport.Therefore,increasedpsychologicalriskislikelytobedue,atleastininpart,totherelationshipbetweenPTEexposure,RET,andtheexperienceofpsychologicaldistressandinjury(Harveyetal.,2016;Jacobssonetal.,2015;Richardson&James,2017;Sattleretal.,2014).Consequently,whileanincreaseinattendanceatmedicalcallshasundoubtedlyproducedbenefitsforthepublicandevenfirefighters,thereisevidencetosuggestthatitwillhavealsoincreasedriskstofirefighters.Thefollowingsectionwillexploreanumberofthesepotentialrisks.

Fatalityexposure

Giventhenatureofpurplecalls,therehasbeenadramaticincreaseinexposuretofatalitiesforaconsiderablenumberoffirefighters.ForExample,Figure2demonstratestheimpactoftheMOUinRegion1byshowingtheincreaseinexposuretofatalitiespostthe2014MOU.

Figure2.K41codestransmitted,formedicalcalls,attendedbyfirefightersaccordingtoyearandareawithinRegion1.AdaptedfromFireandEmergencyBusinessAnalystUnit,personalcommunication,January04,2019

K41isacodetransmittedbytheattendingfireofficertosignifyafatalityhasoccurredduringtheirattendanceatthecall.

Areas3,4,and5areexamplesofAreasthathaveseenaconsiderableincreaseinexposuretomedicalcallfatalities(FireandEmergencyBusinessAnalystUnitdataonmedicalcallsbyregioninNZ,2011-2019,personalcommunication,February04,2019)::

Region Area Name Medicalcallsinvolvingafatality

Year Number Year Number Increase

1 3 Waitemata 2013 26 2018 255 880%

1 4 AucklandCity 2013 5 2018 199 3880%

1 5 Counties-Manukau

2013 24 2018 317 1220%


JoshuaDarby 37

Thisincreasedexposuretofatalitiesisofsignificance,giventhatresearchhasshownacorrelationbetweenexposuretodeathandanincreaseintherelativeriskofpsychologicalinjuriesandmaladaptivebehaviours(Harveyetal.,2016).ResearchcarriedoutbyHarveyetal.(2016)foundthatincreasedexposuretofatalincidentsincreasedrelativeriskforPTSD,depression,andheavydrinking.AsdemonstratedinFigure3,afirefighterwhohadbeenexposedto25fatalincidentshadoverfourtimestherelativeriskofPTSD,andoverthetwicetherelativeriskofdepressionandheavydrinking,thanthatofafirefighterwhohadbeenexposedtobetween0–5fatalincidents.Thisappearstoindicateadose-responserelationshipwithregardtoexposuretofatalincidents.Itisimportanttonotethat,whilethesefindingsareconfronting,giventhehighlevelsofexposurepreviouslydemonstrated,theydonotindicatethatafirefighterwithhighlevelsofexposurewilldefinitelyexperienceapsychologicalinjuryorengageinmaladaptivebehaviour,onlythattheirriskwillincreaseinrelationtotheexperienceoftheseoutcomes.

Figure3.TheimpactofcumulativetraumaexposureonpsychologicalinjuriesandmaladaptivebehaviourinagroupofAustralianfirefighters(Harveyetal.,2016).

Theincreasedexposuretopurplecallshasalsoledtoanincreaseinexposuretocertaintypesoffatal,orpotentiallyfatal,incidentssuchassuicide,homicide,drowning,paediatriccardiacarrest,choking,anddrugoverdose.Thespecificityofthetypeoffatalincidentisimportanttonoteascertaintypesoffatal,orpotentiallyfatal,incidentsmayconferanelevatedriskforpsychologicaldistressandinjury.Forexample,researchhasindicatedthatfirefighters,whohadrespondedtoasuicideattemptordeath,weremorelikelytoexperiencesuicidalideationandweremorelikelytoreporthavingmadeasuicideattempt(Stanleyetal.,2015).Additionally,researchhasindicatedthatfirefighterswhoareunabletoresuscitateachildriskthelossofpsychologicalresources(Sattleretal.,2014).

Missionfailure

Whileambulanceofficersrespondtopurplecalls,theyalsorespondtocallsthatfallintolessseverecategorieswheretherecoveryofapatientismorelikely.Thismightincluderesponsetocallsinvolvingfractures,softtissueinjuries,hypothermia,andothersuchinjuries,whichlendtohighratesofrecovery.However,firefighterswhoco-respondseeconsiderablyfewercasesofrecoverygiventhenatureofpurplecalls.Tothisend,firefighterswilloftenmentionthenumberofconsecutivepurplecallsthattheyhaveattendedandthathaveresultedina


38 27March2019

fatality.ExamplesoftheseexperiencescanbefoundinthereportbyAdamsetal.(2018)onFireandEmergencyfirefighters:

SothemajorityofFireandEmergencyNewZealandbrigadesjustbackupStJohnorWellingtonFreeifyoulike,tothepurplejobs,whicharecardiacarrestandrespiratoryarrestssoitisalwaysthebadstuff,theydon’tgetthegoodstufflikeStJohndoaswell,likethefixingupacut,thegoodstories,likeninetimesoutoftenwhenweturnupatoneofthem,thepersonisdeceasedalready.(Adamsetal.,2018,p.30)

...ImeanIjusttoldyouthatofmymaybe50CPRsinthelastfewyears,Ihaven’tbroughtonepersonbackyet,soI’mworkingonthisperson,thisperson’slovedone,andchancesarethey’renotgoingtomakeit,andthesepeoplearefullofhopeandthey’rerelyingonustogetaresult,sothat’sprobablyoneoftheheavieraspectsforme...(Adamsetal.,2018,p.30)

Theseexperiencesmayindicateasenseof‘missionfailure’,whichhasbeencorrelatedwithpsychologicaldistressthatcanleadtoapsychologicalinjury(Jacobssonetal.,2015).Furtherresearchhasspeculatedthatfirefightersmayriskthelossofpsychologicalresources,suchasasenseofself-efficacy,iftheyareunabletosuccessfullyrescueacasualty,especiallyiftherescueattemptinvolvesachild(Sattleretal.,2014).Thissenseofalossofself-efficacyappearstoberevealedinthisstatementbyaFireandEmergencyfirefighter:

...we'regeareduptogotoanincident,likeahousefireforexample,torenderassistance,sowewalkawayfromthatkindofincidentwithafeelingoflikewedidsomething,weputthefireoutyouknow,we'vetriedourbesttosavethisperson’shouseandbelongings,andwhomeverwasinvolvedsoit'slikeapositive,whereasyouwalkawayfromaCPRjob,andmostofthetimeyou'renotgettingapositiveresult,soitaffectsyourpsyche,youkindofwalkawaywithlikeabitofanegative,notanegativefeelingbutjustabitofadownfeelingbecauseyouhaven'tbeensuccessful,andwe'resousedtothatwalkingawayandthinkingyeahwedidagreatjob,whereaswewalkawayfromtheCPR,it'snotnecessarilyanythingtodowithwhatwedidatthejob,it'sjusttheresultthatwasalwaysgoingtohappen,andthat'shardtodealwithbecauseit'snotinour,it'snotinourpsyche,andwedidn'thaveachancereallyto,topsychologicallyprepareourselvesforthat,asanorganization.(Adamsetal.,2018,p.30)

Emotionalaspectexposure

WhilefirefighterssometimescarryoutCPRaftertherescueofacasualtyfromastructurefire,orprovidemedicalattentionduringtheextricationofacasualtyfromaMVA,thiswillnotofteninvolvetheimmediacyofafamilyorrelativepresence,andtheassociatedadditionalemotionalintensity,pressure,and,attimes,aggressionthatcanoccur.Thisincreasedemotionalaspectexposurehasthepotentialtonegativelyimpactfirefightersinatleasttwoways.Firstly,familymembersorrelativesofacasualtymaybecomeaggressivetowardsfirefighters,puttingfirefightersatriskofphysicalinjury,astheyattempttoperform


JoshuaDarby 39

medicalduties.ThispotentialoutcomehasalreadybeenidentifiedbythereportbyAdamsetal.(2018,p.46)onFireandEmergencyfirefighters:

They[firefighters]getsometimesangry,hostileorverydistressedrelative[s],andapparentlythatissomeofthedifficultythattheyhave,andyouknowhowtohandlethat,andyouknowthey’rethereforalongerperiodoftime.

Furthertothisincreasedphysicalthreat,istherealitythatCPRcarriedoutinthefamilyhomewilloftenexposefirefighterstomembersofthefamilywhoareemotionallydistraught,whichmayaddanelementofemotionalintensitytotheeventforfirefighters,especiallygiventhisemotionalaspectisnotasprevalentinotherpartsoftheirjob.Forexample,atmotorvehicleincidentsandstructurefires,otheremergencyresponderssuchasambulanceorpoliceoftendealwithfamilymembersandthepublic,leavingfirefighterstocarryoutextinguishmentorextricationdutieswithouttheadditionofthesestressors.

Theexperienceofdiscomfortanddistress,inrelationtodealingwithemotionalaspectexposureatmedicalcalls,hasbeenreportedinstatementsprovidedintheAdamsetal.(2018)nationalreportonFireandEmergencyfirefighters,forexample:

...they'reeitherinthelounge,inthehallway[or]veryofteninthebedroom,sothesemostsortofintimateplacesofahome,that'swherewedothework,anddoingthetypeofmedicalcallsthatwedo,it'sverytactileso,it'snotlikesquirtingwaterataninanimatebuilding,orworkingwithparamedicsextricatingsomebodyfromamotorvehicleaccident,it'stactileandmorethanthat,wehaveto,youknowwehavetoundresspeople,todothejobsoweneverdoCPRoncladpeople,soit'sveryintimateinthatsenseaswell,soyou'vegottotakepeoples’topclothesoffand,it'sjustwhatitis,that'stheonlywayyoucandoitproperly,soyoucanunderstandit'sahugecontrastasIsaidwithtacklingafire,there'sjustnocomparison.(Adamsetal.,2018,p.32)

Aconsiderablenumberofcareerfirefighters,intheRegion1PFAroll-out,mentionedthattheyhadtodealwithemotionallychargedscenariosthattheyfeltuncomfortablewithandunpreparedfor.Inonecase,anofficerexplainedhowheandhiscrewwereleftwiththefamilyofaman,whohadbeentakenawaybyambulanceinaseriouscondition,breakingdowninthemiddleoftheroadoutsidethefamily’shome.Theofficernotedhowdistressingthishadbeenforhimandhiscrewandhowithadaffectedhiminthedaysthatfollowed.TheseexperiencesappeartobecongruentwithresearchbyJacobssonetal.(2015)thatfoundthatfirefightersfeltinadequatelytrainedincommunicatingwithfamilymemberswhoareatthesceneofmedicalcalls,suchasatasuicide.Thisadditionalemotionalaspectexposureisalsoofparticularrelevancetovolunteerfirefighterswhorespondtocallswithintheirowncommunities.Inthesesmall,oftentight-knitcommunities,thereisahighlikelihoodthatvolunteerfirefighterswillattendcallsinvolvingpeopletheyknowpersonally,includingfamilyandfriends.AnotherfirefighterintheAdamsetal.(2018)reportnotedhowconnectionstothescenecouldcontributetodistress:


40 27March2019

Ithinkwhatcreatesthesortofconnection,soI'mpartMāorisoanytimethere'saMāorifamilyinvolved,Istruggleabit,Ifeelalittlebitmoreemotionalaboutthesituation...IwouldassumeninetypercentoftheguysarehappydoingthechestcompressionsandtheCPR,inaquietroomwherenobodyisaround,butthat'snotthecase,it'sthescreamingfamilyandthefamilythatarethere,thatisthehardestpart.(Adamsetal.,2018,p.32)

Indeed,astudyoffirefightersintheUSrevealedthataprimecontributoroftraumaticexperiencewastheplacementoffirefightersinsituationsthatcalledthemtodotheirjobsinstoicways,whilesimultaneouslycompellingthemtorelateonanemotionallevelwithcomponentsoftheincident.Consequently,theresearchersnotedthattheseincidentsfundamentallychallengedfirefighters’notionsofwhatittakestosolveproblems,whilealsofeelingandexpressingemotion(Richardson&James,2017).

Preparedness

Sattleretal.(2014)foundintheirresearchexaminingoccupationalstressors,thatfirefightersrankedsubstandardequipmentandjobskillsascreatingmoredistressthancriticalincidentexposure.Thisindicatesthenecessityoftraining,andappropriateequipment,inreducingdistressexperiencedbyfirefightersincarryingoutanexpansiontotheirrole.Armstrong,Shakespeare-Finch,andShochet(2014)notedintheirstudythat,“itisawidelyheldtenetofstressliteraturethatanincreaseinstressors,withoutconcurrentincreasesinresources,overwhelmsanindividual’sabilitytocopewith,andeffectivelyrespondto,stressors”(p.43).Thisisofrelevancegiventhehandlingofthe2014MOUthatsawmanyfirefightersattemptingtonavigateasubstantialincreaseinmedicalcallsandresultingfatalities,withoutpriornotificationorfurthertraining.Anumberoffirefightersreflectedonthissituationaspartofthequalitativeresearchcarriedoutpostthe2014MOU:

Weweren'treally[preparedformedicalcallouts]itsortofgotsprungonus,andthatwouldbethegeneralconsensusfromthewordgo,therehasbeensomeresistancetoitinsomestationsinsomeareasinNewZealand,butyeahwefeltthatitwasquitesprungonus,wedidn'treallygetany,didn'tknowmuchaboutitatallpriortoithappening,itwasjustsortof,Imeanwewereattendingthesecallsandthatwasnewstoussortofthing,soitwasn'tcommunicatedverywellatall.(Adamsetal.,2018,p.24)

Ithinkthefactwejustweren’twarnedaboutthiswasgoingtohappensoandIthinkthat’sbeenmadeverycleartotheorganisationsthatitwasn’twelldone...(Adamsetal.,2018,p.24)

...thissoundsunbelievablebutit’sactuallytotallytrue,therewasnocommunicationtotheworkforcethatfirecrewswouldbeattendingmedicalcalls,andevensomeofthemanagersdidn’tknow.(Adamsetal.,2018,p.24)

Thislackofnotificationandpreparednessmayhavecontributedtofirefightersandofficersfeelingoverwhelmed,attimes,facedwithsituationstheyhadnotdealtwithcommonlybefore,andmayhavenotfeltsufficientlypreparedandtrainedfor.TheMinistryofHealth


JoshuaDarby 41

(2016)hasstressedtheimportanceofpromotingself-efficacyasaneffectiveinterventioninrelationtoemergencydistress.Preparationthatprovidesasenseofself-efficacyinthesesituationsneedstoextendbeyondthatofbasicmedicaltraininginrelationtothemechanicsofCPRortheoperationofadefibrillator,whichanumberoffirefightersfeelsufficientlytrainedin,totheneedtofeelconfidentindealingwithmorecomplexmedicalcallsandwithemotionalaspectexposureonscene.Again,thelattersentimenthasbeenreflectedinastatementbyaFireandEmergencyfirefighter:

Idon’tthinkweneedanymoremedicalsupporttraining,whatwedoneedishowtodealwiththosethingsaroundthesituationwe’representedwith,dealingwithfamilies,friends,violence,youknow,Idon’tknowwhattheanswerisbutweneedsomeonetohelpustobeabletodealwiththosethingsbetter,wedon’tevenhaveanytoolsforthose.(Adamsetal.,2018,p.47).

Alackofappropriatepreparationmayalsoaccount,atleastinpart,forreportsofsomevolunteerfirefightersrefusingtoattendmedicalcalls(Adamsetal.,2018).Giventhatself-efficacyhasbeenassociatedwithlowerlevelsofpsychologicaldistressandresultingpsychologicalinjuriesinfirefighters,itisreasonabletoexpectthatfirefightersmighthavedesirednotificationandfurthertrainingpriortotheimplementationoftheMOU(Cheryl,John,Theresa,&Bill,2003).

Anotherissuethathasbeenraisedintheresearchliteratureisthatofcollaborationbetweenemergencyresponders.Allfirefighters,inastudycarriedoutbyJacobssonetal.(2015),expressedadesireforimprovedcooperationwithambulancepersonneltoreducedelaysandfailures,aswellasexpressinganeedformoretraininginemergencycare.Itcouldbearguedthatthisdesireisbasedonaneedtoachieveasenseofself-efficacyandagency,withthebenefittofirefightersofareductionofpsychologicaldistressthatcouldresultfromsuchagency.

Inthesamewaythatitisnotpossibletoeliminateallphysiologicalrisksinvolvedwithenteringaburningbuildingtoeffectarescue,itisalsonotpossibletoeliminateexposuretoPTEs,suchasmedicalcalls,andthepsychologicaldistressandinjurythatcanfollow.Inbothcases,eliminationoftheriskwouldrequirenotresponding,andtodosowouldcomeatthecostofaconsiderablebenefittothecommunitiesthatFireandEmergencyserves.Furthertothis,itmightalsocomeatthecostofpsychosocialbenefitsfirefightersgarnerfromcarryingoutsuchduties–thisinitselfisarisk.However,whileeliminationofpsychologicalriskswouldnothavebeenpossibleinrelationtoasubstantialincreaseinmedicalcallresponse,identificationandminimisationofthepsychologicalrisksinvolvedinanincreaseinPTEexposurewascertainlypossible.Indeed,FireandEmergencyalreadyhasasystemfordealingwithincidentswherehazardscannotbeeliminated,whichensuresthelikelihoodandconsequencesofrisksassociatedwithcarryingoutfireandemergencyworkareminimised.Thisisknownasadynamicriskassessment(DRA),andisatoolusedformitigatingrisksassociatedwithvariousincidentsFireandEmergencyrespondto(FireandEmergencyNewZealand,2013).Inmuchthesameway,whileexposuretoPTEscannotalwaysbeeliminated,itispossibletominimisethelikelihoodandconsequencesof


42 27March2019

exposuresthatleadtopsychologicaldistressandpsychologicalinjury(BeyondBlueLtd,2018).

Morespecifically,certainexternalitiesrelatedtotheMOUimplementation,likelytohaveanegativeeffectonfirefighterwellbeing,shouldhavebeenidentifiedandminimised.Theseexternalitiesinclude,butarenotlimitedto:alackofsufficientnotificationwithregardtotheMOUimplementation;alackoffurtheradditionalfirstaidtraining;alackofsufficientpsychologicaltraining;alackofadditionalpsychologicalsupports;alackofsufficientfirefighterparticipationinthedevelopmentandimplementationoftheMOUitself.Theseexternalitiesmayhavecontributedtoanincreaseintheincidenceandprevalenceofpsychologicaldistressandinjuryforfirefighters(Gluckman,2011).AdifferentimplementationapproachcouldlikelyhaveassistedwiththeminimisationofpsychologicaldistressandassociatedinjuryriskstodowithanincreaseinPTEexposure.Examplesofinitiativescouldhaveincluded:clearcommunicationastotheproposedimplementationstructureandtiming;improvedfirstaidtraining;improvedpsychologicaltraining;trainingfordealingwithfamilies;agreateremphasisoninter-agencycommunicationandcooperation;andahigherlevelofsupervisionandsupport.ThesetypesofInitiativescouldhaveincreasedperceivedorganisationalandpeersupport,andprovidedagreatersenseofself-efficacyandagencyforfirefighters(Rhoades&Eisenberger,2002).

AtimeofcriticalreflectionisnecessarytoassistinensuringthatfutureinitiativesarecarriedoutinsuchawaythatFireandEmergencyprovidesessentialservicestoNZcommunities,whileatthesametimeeffectivelyidentifyingandtheneliminatingandminimisingthepotentialnegativeeffectofthatworkontheSHWoffirefighters.

WorkplacestressorsIndependentresearchcarriedoutbyMind,amentalhealthcharityintheUK,notedanumberofkeyfindingsincludingthatpoormentalhealthwascommonwithintheemergencyservices,andthatworkloadandmanagementpressureisamajorcontributingfactortothestateofemergencyservicementalhealth(Mind,2016a).Lewis(2014)notes,inhisstudyoftheimpactofdistressontheworkplace,thatworkplacedistresscanresultfromanumberofvariablesincluding:

• Interpersonalconflictswithcolleaguesandorsupervisors

• Roleconflicts

• Timepressuresandworkoverload

• Issuesrelatedtocareerdevelopmentandlackofjobsecurity,aswellasunder/overpromotion

• Lackofinvolvementindecision-making,ororganisationalclimateandstructure.

Astudyexaminingworkplacedistressinrelationtofirefightersfoundthatworkplacestressors,suchassubstandardequipmentandjobskills,aswellasmanagementconflictandwages,weremoresubstantialstressorsthanexposuretocriticalincidents(Sattleretal.,2014).Thesefindingcorrelatewithpreviousresearchthatfoundadditionallifestressors,


JoshuaDarby 43

homeorworkplace,wereamongthestrongestpredictorsofPTSDsymptomsamongsttrauma-exposedadults,andthatworkplacedistresswascorrelatedwithnumerousindicatorsofpsychologicaldistressandinjuryamongfirefighters.Thisstudyconcludedthatlevelsofoccupationaldistressmaybeaparticularlyimportantpredictorofmentalhealthoutcomesamongstfirefighters(Meyeretal.,2012).Similarly,Armstrongetal.(2014)notedthatacombinationofworkplacedistressandcriticalincidentdistresswasapredictorintheregressionmodel,whichsupportedresearchfindingsthatworkplacestressorscontributetosymptomsofPTSD.OneofthekeyfindingsoftherecentlypublishedBeyondBlueLtd(2018)reportwasthatpoorworkplacecultureandpracticesareequallyasdebilitatingforemergencyservicepersonnelasexposuretoPTEs.Ontheotherhand,thisreportfoundthatemergencyserviceworkplacesthathaveregulardiscussionsaboutdistressingevents,effectivelymanageemotionaldemandsonworkers,andareperceivedasbeingsupportive,haveaninoculatingeffectthatcorrelateswithlowerratesofPTSDandpsychologicaldistress.

Aprimaryfactorrelatedtothemediationoftraumaticdistressissupportfromsuperiorswithintheworkplace.Cheryletal.(2003)notedthat,“whenpeoplefeelsupportedandvalued,theyexperiencelowerlevelsofdistress.Inaddition,cognitiveappraisalofself-efficacyhasbeenreportedtobeanimportantfactorinamelioratingdistress”(p.189).Additionally,Stanleyetal.(2015)foundthatsocialsupportfromco-workersmaylessensuicideriskandgeneralpsychologicaldistressamongstfirefighters.Itseemsreasonabletoassumethatsituations,suchasthehandlingoftheMOUin2014,wherecommunicationandlackofinvolvementofworkersseemtobeapparent,thatanavenueoffurtherworkplacedistresswascreatedforfirefighters.Thishypothesisissupportedbyresearch,suchasthatofMeyeretal.(2012),whonotedthatamongfirefighters,perceivedaccessibilityofpersonalandorganisationalsupportwasnegativelyassociatedwithPTSDanddepressivesymptoms,whereasalienationwaspositivelyassociatedwithPTSDanddepressivesymptoms.

ThesefindingsareofparticularrelevancetoFireandEmergencygivenarecentreportbyShaw(2019)examiningFireandEmergencyworkplacepolicies,proceduresandpracticesinrelationtobullyingandharassment.ThereportfoundthatbullyingandharassmentarebothsubstantialfeaturesoftheFireandEmergencyworkplaceatalllevelsandacrossallregions.Thisisanimportantfindingwithregardtothecontextofthisreport,giventhatadditionaldistresscreatedbysuchbehaviourcanbeacontributingfactortocumulativeworkplacedistress.Additionally,workplacedistresscausedbybullyingandharassmentcanbeaconsiderablecontributortopsychologicalinjury,especiallywhencombinedwithcriticalincidentandhomedistress.ItisalsoworthnotingthatthatcriticalincidentandhomedistressmaybecontributingtotheprevalenceofbullyingandharassmentwithinFireandEmergency.Forexample,theDSM-5notesthatindividualswithPTSDmaydisplaysymptomsincludingirritablebehaviourandangryoutbursts(withlittleornoprovocation)whichmaybeexpressedasphysicalorverbalaggressiontowardpeople(AmericanPsychiatricAssociation,2013).Therefore,itwouldbeintheinterestsofFireandEmergencytoidentifyworkplacestressorsandhowtheymaycontributetopsychologicalinjurywithintheorganisation,whilealsoinvestigatinghowcriticalincident,workplace,andhomedistressmaycontributetobullyingandharassment.Suchaninvestigationwillbevitalinidentifying


44 27March2019

appropriateinitiativeswithregardtotheeliminationand/orminimisationofworkplacedistress.

Effectofcultureandstigmawithinfireservices

Itcouldbearguedthatfirefightersareoftenperceivedandportrayedasinvulnerableheroeswhocanalwaysbecalleduponforhelp,butarerarelyinneedofhelpthemselves.However,thisreporthasdemonstratedthatdespitetheheroicworkfirefightersdo,theyarenotimpervioustopsychologicaldistressandinjury,andattimeswillrequirehelpthemselves.Yet,apersistentcultureandstigmaaroundpsychologicalinjurywithinfireservicesisleadingtofirefightersnotseekinghelpwhentheyneedit(BeyondBlueLtd,2018;Mind,2016a).JeffDill,acounsellorandformerUSfirefighter,notedinaninterviewthatfirefighterssufferwhathecalls‘culturalbrainwashing’,wheremanybelievethatwearingtheuniformmeansyouaretoactstrong,bebrave,offerhelp,butneveraskforit.Inthesamearticle,colleaguesofMikeMauser,aUSfirefighterwhodiedbysuicide,notedthatitwastheseideasthathadledtotheirfriendconcealinghisownmentalhealthissues(Bah,2016).

The“FaultLines”articlebyBah(2016)statesthat,ininterviewswithmultiplefirefightersandparamedicsacrosstheUS,thepredominantcultureinthefireservicemeantthatpsychologicalstressorsandinjurieswereseenassignsofweakness.Stanley,Hom,andJoiner(2016)notedintheirresearchthatstigma,preventingtheutilisationofservices,andafocusonhelpingothersattheexpenseoffocusingonpersonalneeds,weretwoimportantfactorsinrelationtoemergencyservicesuicide.Whileithasalsobeennotedthatbeingpartofacrew,beinglabelledasheroesinthemedia,andhavingcolleaguesthatdependonthem,mayresultinfirefightersbeinglesswillingtodisclosebeingaffectedbytrauma(Kehletal.,2014).Indeed,researchcarriedoutbytheUKorganisationMindnotedthat,althoughmembersoftheemergencyservicesaremorelikelytoexperiencepsychologicaldistressandinjuryincomparisontothegeneralpopulation,theywerealsolesslikelytoseeksupportforsuchdistressandinjury.TheirresearchalsofoundthatstigmaiscommonwithinemergencyservicesthroughouttheUK:

Thescopingresearchrevealedthat,despitedisproportionatelyaffectingbluelightpersonnel,mentalhealthproblemsarestigmatisedwithinthebluelightcommunity.Personnelsaythatdiscussionofmentalhealthisnotencouragedwithintheirorganisations,andthereisawidelyheldsuspicionthatcolleagueswouldbetreateddifferentlybytheirpeersiftheydisclosedamentalhealthproblem.Attherootofthisisanoftenunstatedassumptionthatthepeoplewho‘fixproblems’cannotbeseentohaveproblemsthemselves.(Mind,2016a,p.6)

Interestingly,theBeyondBlueLtd(2018)reportnotedthatthemajorityofstigma,withinemergencyresponseorganisationsinAustralia,wasthatof‘self-stigma’–thelackofabilitytotalkopenlyaboutpersonalstrugglesorafearofwhatothersthink–ratherthanstigmaasaresultofwhatcolleaguesactuallysaidordid.Thesefindingsindicatethatthevastmajorityofemergencyrespondersweresupportiveandhadpositiveregardforcolleagues


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experiencingpsychologicaldistressandinjury.Thisfindingindicatedthattherewasasubstantialdisparitybetweenhowemergencyworkersregardtheircolleagueswhentheyarestrugglingandhowtheyseethemselveswhenstruggling.

Itisalsoworthnotingthatthestigmaandstoicculturecommoninemergencyresponseorganisationsmayleadtounder-reportinginpsychologicalhealthsurveysamongstemergencyservicepersonnel.Paulusetal.(2017)found,intheirpsychologicalhealthsurveyoffirefightersintheUS,thattheremayhavebeenunder-reportingduetoreasonssuchasmasculinity,self-reliance,orbeliefsregardingtheneedtobetough,orlackoftrust(e.g.,fearthatsurveyswerenotconfidentialandmaybemadeavailabletosupervisors).AworkingpaperintheUKreportedthat72%ofpeoplewhodiedbysuicideoverthelastdecadehadnotmadeanycontactwithahealthprofessionaltheyearpriortotheirsuicide(FireBrigadesUnion,2016).Itis,therefore,ofutmostimportancethatFireandEmergencyinvestigateitsowncultureandthepossibilitythatstigma,inrelationtopsychologicaldistressandinjury,mayarrestthereportingandtreatmentofpsychologicalinjuries.

HomestressorsGiventhecumulativecapacityofdistress,itstandstoreasonthateventsthathavethepotentialtocreatedistressinthehomeenvironment,suchasrelationshipandmaritalconflict,familialdisruption,sicknessandinjury,andfinancialdifficulties,mayallcontributetoanaccumulationofdistressthatincludesbothworkplaceandcriticalincidentdistress.Furthermore,researchbySattleretal.(2014)proposedthatfirefighterstress,resilience,andcopingwereaffected,inpart,bythepresenceandintegrityofwhattheytermedresourcecaravans.Theseresourcecaravans,previouslyestablishedintheconservationofresource(COR)theory,aremadeupoffourcategoriesandincludedvariablesspecifictothehomeenvironment.Havingtheseresourcesinplaceprovidedwhatcouldbethoughtofas‘psychologicalPPE’,providingaresiliencebufferinrelationtocriticalincidentexposureandpsychologicalinjury.Theseresourcecaravansincluded:

• Personalcharacteristicresources–suchasoptimism,self-efficacy,self-esteem

• Conditionresources–suchasorganisationalsupport,homesupport,camaraderie,advice,goodworkingconditions

• Energyresources–suchasphysicalhealth,time,money

• Objectresources–suchasacar,houseetc.

Sattleretal.(2014)foundthatpersonalcharacteristicresources,energyresourcesandconditionresources,werenegativelyassociatedwithpost-traumaticstresssymptoms.Itstandstoreasonthen,thatwhenfirefighters’physicalhealthisadverselyaffectedasaresultofpersonalsicknessorinjury(energyresource),ortheylosetheabilitytomakemortgageorrentpayments(objectresources),orhomesocialsupportislostasaresultofmaritalorrelationshipconflictorthesicknessorinjuryofachild(conditionresource),thatfirefightersmayexperienceadditionaldistresswhilealsolosinganimportantbufferwithregardtopsychologicalinjury.Furthermore,itispossiblethatbothcriticalincidentandworkplace


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distressmightcontributetothelossofanumberofresourcecaravans,whichinturncreatesthepotentialforelevatedhomedistress.

PartOneconclusionPsychiatristandtraumaspecialistBesselvanderKolknotesthathumanshaveanextraordinarycapacityforsurvivalandresilience.Thisisclearlyobservableinaglobalpopulationthathas,andcontinuesto,reboundfromlargecatastrophiceventssuchasnaturaldisastersandworldwars.Thisisalsotrueinrelationtoeventsexperiencedmorecommonlybyemergencyresponders,suchascriticalincidentsandworkplaceandhomestressors.However,vanderKolkalsoassertsthattraumaticexperiencesleavetraces–tracesonourmind,ouremotions,onourcapacityforintimacyandjoy;tracesthataffectourbiologyandimmunesystems,andindoingsoimpactnotjustourselves,butalsoourfamilies,workplaces,andcommunities(VanDerKolk,2014).Firefightershaveembodiedthisextraordinarycapacityforsurvivalandresilience.Oftenfacedwithstressorsthatfarexceedthoseexperiencedbythegeneralpopulation,theycontinuetoturnupandgivethemselvestotheserviceofthepublic.However,thisreporthasrevealedthatfirefightersarenotimmunetothetracesoftraumaandthat,overtime,potentiallytraumaticeventscanaccumulate,andcombinewithstressorsatworkandathome.Thisaccumulationandcombinationofstressors,unchecked,canleadtopsychologicalinjuriesandmaladaptivebehavioursthatnotonlynegativelyimpactfirefighters,butalsotheirfamilies,theircommunities,andFireandEmergency.

PartOneofthisreporthasidentifiedanumberofindicatorsandcausesofpsychologicaldistressandinjurywithinfireservicesinternationally,whilealsohighlightingtheprevalenceofthosepsychologicalinjuries.TheseconcerningglobaltrendsappeartosupportthehypothesisthataleadingSHWrisk,perhapseventheleadingSHWrisk,facingFireandEmergencyfirefightersisthatofpsychologicalinjury,maladaptivebehaviour,andsuicide.ThesefindingsshouldsignalanurgentalertforasubstantialandconcertedresponsefromallthosewishingtoensurethesafetyhealthandwellbeingoffirefighterswithinFireandEmergency.


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PartTwo–ASize-UpThe‘360’formspartofaninitial‘size-up’undertakenbyanofficeruponarrivalatastructurefiretoestablishthepresence,location,intensityandthepotentialspreadofafire.Thisinitialsize-upisalsousedtoidentifyanyadditionalpotentialhazardsthatmayplacefirefightingcrewsindanger.PartOneofthisreportdrewupontheconceptofthe360anduseditasanoperatinganalogywithregardtoastrategyforidentifyingthepotentialincidenceandprevalenceofpsychologicaldistressandinjurywithinFireandEmergency.Furthermore,thisstrategywasusedtoidentifypotentialcausesandrisksassociatedwithpsychologicaldistressandinjury.InPartTwoofthisreport,thesize-upprocesswillagainbeundertakentoidentifythestrategyandcontrolmeasurescurrentlyusedbyFireandEmergencyinrelationtofirefighterpsychologicalwellbeing,andassesstheefficacyofthisstrategyandcontrolmeasures.

PartTwoobjectivesThefollowingresearchquestionswillformthefoundationofaninvestigationintotheidentificationoftheFireandEmergencyresponsetopsychologicalwellbeingrisksandtheefficacyofthatresponse:

• WhatisthecurrentstrategyofFireandEmergencywithregardtoidentifying,andeliminatingorminimisingpsychologicaldistressandinjury?

• GiventhefindingsofPartOneofthisreport,arethecurrentandproposedstrategyandresourcingofFireandEmergencysufficient?

PartTwomethodologyThemethodologicalapproachusedtoexaminetheresearchquestionsinPartTwowilldifferinsomewaysfromthatofPartOne.Thisdifferenceinapproachisrequireddue,inpart,toalackofrobustandavailabledatawithregardtotheFireandEmergencystrategyandcontrolmeasures.Theselimitationswillhavesomeimpactinrelationtothedegreetowhichtheexaminationandfindingsarerepresentative.However,anumberofstepshavebeentakentoensuretheexaminationisofvalueandthattherecommendationsareevidence-informeddespitetheselimitations.Stepsthathavebeentakentoensuretheexaminationandfindingsareevidence-informedandofvalueincludethetriangulationofthefollowingmethodology:

1. PartTwowillexamineanddrawupontheReadytoRespondqualitativeresearchreportthatexploredtheimpactsofincidentsonFireandEmergencyfirefighters.

2. PartTwowillinvolvetheexaminationofacasestudyofFireandEmergencyfirefightersinrelationtoacriticalincident.

3. PartTwowillincludefeedbackfromarangeoffirefighterswhowerepresentedwiththefindingsofPartOneofthisreport.


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4. PartTwoincludestheidentificationandexaminationofrelevantmaterialfromexpertsinthefieldsofpsychology,trauma,post-traumaticstress,andorganisationalculture.

5. PartTwowillincludeanethnographicapproachthatincludesdrawingupontheresearcher’spersonalexperienceinclusiveofoperationalfireandemergencyworkofover15years,peersupportworksinceearly2016,feedbackfromCIPSSworkshopspresentedinAreas3and4in2016/17andresearchfeedbackgroupsin2018/19.

6. AdraftcopyofPartTwowillbesubmittedtoFireandEmergencySHWworkers,healthprofessionals,andassociatedagenciesforreviewandcommentbeforethefinalreportissubmitted.

FireandEmergencypsychologicalwellbeingstrategyResearchquestion:WhatisthecurrentstrategyofFireandEmergencywithregardtoidentifying,andeliminatingorminimisingpsychologicaldistressandInjury?

DuetothenatureofFireandEmergencyworkthereareconsiderableriskstotheSHWofFireandEmergencyfirefighters.Aspreviouslydiscussed,FireandEmergencyhavebothamoralandlegaldutyofcareinrelationtoensuringthattheserisks,includingpsychologicaldistressandinjury,areidentifiedandtheneliminatedorminimised.TheFireandEmergencystrategy,inrelationtoeliminatingorminimisingthesepsychologicalrisksandpromotingpsychologicalwellbeing,appearstobeencompassed,atleastinpart,bythecurrentCIPSSmanualandCIPSSreferenceguide,aswellastheFireandEmergencySHWmanualandFireandEmergencySHWstrategydocuments(FireandEmergencyNewZealand,2017b,2018d,2018e,n.d.;NewZealandFireService,2014,2017).Thefollowingsectionofthisreportwilldrawuponthesedocumentsinprovidingabriefexaminationofthisstrategy.

TheFireandEmergencySHWstrategyisintendedtoensurethatFireandEmergencyisabletomeetitslegalobligationsundertheHealthandSafetyatWorkAct2015(HSWA),anditsownSHWcommitmentsincludingthat“everyonegoeshomesafeandwelleverytime”(FireandEmergencyNewZealand,2017b;FireEmergencyNewZealand,n.d.).AnupdatedSHWstrategydocumentstates“thegoalofthestrategyistodevelopastrongsafety,healthandwellbeingculturetoeffectivelymanagecriticalrisksinanewandmorediverseorganisation”(FireandEmergencyNewZealand,2018e).Keyareasoffocus,intendedtoassisttheorganisationinmeetingitsSHWcommitmentsandlegalobligations,include:buildinganengagedlearningculture;developingSHWleadership;reducingharmandsupportingrecovery;enhancingcollaborativerelationships(FireandEmergencyNewZealand,2017c,2018e,n.d.).TheSHWstrategyalsoidentifiesthreeriskareasthatrequiremanagementinrelationtotheSHWgoal:physicalsafety;workrelatedhealth;psychologicalwellbeing(FireandEmergencyNewZealand,n.d.).Thesegeneralriskareasarebrokendownintoafurthertencriticalrisksareas,whichwereidentified,accordingtoSHWdocumentation,throughananalysisofinjuryandillnessdata,discussionswiththenationalSHWcommitteeandotheroperationalleaders,andanexaminationoftheHSWAexpectationsandguidelines(FireandEmergencyNewZealand,2018e).Amongthetencriticalrisksidentifiedistheriskof“Acute


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andpost-traumaticpsychologicalstressandrelatedconcernsandillnessfromoperationalexposuretosuddendeathandseriousinjury,orfromworkpressuresoroverload”(FireandEmergencyNewZealand,2018e,p.13).Thereappearstobearangeofplansandinitiativesinrelationtoensuringriskmanagementcontrolsareinplace,effective,andflexible(FireandEmergencyNewZealand,2018d).Theseinitiativesincludethefollowingleadandlagindicators,whichappeartobecorrelatedwithpsychologicaldistressandinjurypreventionandtreatment:

LeadIndicators:

• Learn–leadersparticipateinannualsafety,healthandwellbeingevents

• Talk–leadersengageinfrequentsafetyconversationswiththeirpersonnel

• Understand–allleadersandpersonnelhavetrainingandinformationaboutpsychologicalsupport

• Train–resilienceandsafety,healthandwellbeingtrainingforallrecruitsandnewpersonnel

Lead/LagIndicators:

• Support–increaseinsafeandtimelyreturntoworkandincreaseinuptakeofpsychologicalsupport

• Learningandcirculatinglessonsfromgoodincidentoutcomesandfrominvestigations

LagIndicators:

• >50%increaseinreportingofsignificantnearmissevents

• >25%(orgreater)reductioninseriousinjuries

• 10%(orgreater)reductioninallinjuries

Otherleadandlagindicatorsspecifictopsychologicalwellbeinginclude:measuringuptakeofpsychologicalsupportsthroughreferralnumbers;financialspendingonprofessionalsupport;roll-outoftheCIPSSprogrammetrainingandinformationthroughSHWadvisorworkshops;measuringrecruitsreceivinginformationonsupportingthemselvesandsupportavailable(FireandEmergencyNewZealand,2018e).Implementationoftheseindicatorsappeartobesupportedbythefollowingpsychologicalwellbeinginitiatives:recruitpsychologicalwellbeingtraining;CIPSSprogramme;psychologicalwellbeingeducationforleaders/workers;peersupport;preferredprovidernetwork(includingEmployeeAssistanceProgramme(EAP)/Vitaeservices)(FireandEmergencyNewZealand,2018e).

Therefore,itisclearthatFireandEmergencydohaveastrategy,andanumberofcurrentandproposedcontrolmeasures,thatarearesponsetothepresenceofarangeofpsychologicalriskswithintheorganisation.Yet,thepresenceofastrategyandcontrolmeasuresdoesnotnecessarilyindicateaneffectiveresponsetopsychologicalriskswithintheorganisation.Tounderstandtheefficacyofthecurrentstrategyandcontrolmeasuresthefollowingresearchquestionwillbeexplored.


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Researchquestion:GiventhefindingsofPartOneofthisreport,isthecurrentandproposedstrategyofFireandEmergencysufficient?

TheexaminationofthisresearchquestionwillbeginwithabrieforientatingdiscussiononthehistoryofpsychologicalsupportwithintheNZFS.ThiswillbefollowedbyaninvestigationofanumberoftheidentifiedeliminationandminimisationinitiativescurrentlyoutlinedinFireandEmergencySHWdocuments.Thisexaminationisnotintendedtobeexhaustiveandwillbelimited,giventheredoesnotappeartohavebeenanyepidemiologicalbenchmarkingestablishedinrelationtotheincidenceandprevalenceofpsychologicalinjuriesormaladaptivebehaviourswithinFireandEmergency.Thecurrentidentifiedmeasurementstrategies,includingidentifyingchangesinreferralnumbers,haveanumberofinternalvalidityissuesanddonotprovideanappropriatereplacementtoquantitativeepidemiologicalresearchorthequantitativeorqualitativereportingoffirefighterperceptionsofsupportefficacywithregardtomeasuringcontrolcomponentefficacy.

Criticalincidentstressmanagement

Socialsupport,oftenreferredtoascamaraderiewithinthefireservice,hasexistedwithinsocietysincetimeimmemorial.However,theneedforamorestructuredformofsocialsupportforNZFSfirefighterswasfirstrecognisedin1989byagroupofmotivatedindividualswithintheorganisation.Theirinterestinpsychologicalwellbeingandtheirunderstandingoftheimportanceofsocialsupport,inrelationtopsychologicaldistressandinjury,ledtoapeersupportprogrammebeingpilotedwithintheNZFSin1990(NewZealandFireService,2017).Thepilotwasdeemedsuccessful;consequently,itwasexpandedtoanationwidepeersupportservice,basedonamulti-componentprogrammeknownasCriticalIncidentStressManagement(CISM),withpeersupportteamsestablishedacrossthecountryandCISMcoordinatorslocatedineachRegion.TheCISMprogrammewasavailableforutilisationbyoperationalandnon-operational,careerandvolunteerpersonnelwithintheNZFS(NewZealandFireService,2014).

CISMisamulti-componentprogrammedevelopedbyProfessorJefferyMitchellwhoisanex-paramedic.ThegoalofCISMistoensurethatexposuretocriticalincidentsdoesnothavealong-termdetrimentaleffectonfirstresponders.ThecomponentsthatmakeuptheCISMprogrammearemeanttocoverthepre-,peri-,andpost-traumaphasesinrelationtocriticalincidentexposure.AnumberoftheCISMcomponentsarelistedbelow(NewZealandFireService,2014,p.6):

• Demobilisation–Aquickinformationandrestsessionimmediatelyfollowsamajorincident.Theyprovideatransitionfromthetraumaticeventtonormalroutineandfunctioningandreducetheintensityofimmediatestressreactions.

• Defusing–Informaldiscussionsareheldsoonafteracriticalincidenttohelpreducetheemotionalimpactofwhatfirefightershaveexperienced.

• Debriefing–Aformalgroupprocessallowspeopletoexploretheirphysicalandemotionalresponsetoanincidentthatmayhavehadaconsiderableimpactonthem.Therearestrictprotocolsaroundthewayadebriefingisrunandare(sic)onlyundertakeninthepresenceofCISMtrainedmentalhealthprofessionals.


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ThedebriefingcomponentofCISMisknownasCriticalIncidentStressDebriefing(CISD)andisperhapsthemostwell-knowncomponentoftheCISMprogramme.CISDincludesthefollowingsevenphases(NewZealandFireService,2014,p.7).

1. Introductionphase–Teammembersintroducethemselvesanddescribethedebriefingprocess.

2. Factsphase–Helpsparticipantstobegintalkingaboutwhattheydidattheincident.

3. Thoughtsphase–Participantsareaskedtosharewhattheythoughtwhentheyrealisedwhatwashappeningattheincident.

4. Emotionsphase–Thisreactionphaseistheheartofthedebriefing.Itfocusesontheimpactonthepeopleinvolvedandfeelingsofanger,frustration,sadness,lossandconfusionaresometimesdiscussed.

5. Assessmentphase–Peopleareaskedtoreflectontheirfeelingsatthetimeoftheincident,andtodescribeanysymptomsorsignsofstresstheyareexperiencing.

6. Teachingoreducationphase–Peopleareprovidedanopportunitytohelpthemunderstandthatanysymptomsexperiencedarecommonreactionstotheevent.

7. Re-entryphase–Participantsareabletoaskquestionsormakefinalstatements.Thereisasummaryofwhatwasdiscussedandanynextstepswereidentified.

TheimplementationofCISMrepresentedanimportantstepforwardinthepsychologicalwellbeingspacewithintheNZFS,asithelpedtoformalisesocialsupportandwasbasedonaprogressiveunderstandingofpsychologicaldistressandinjuryspecifictoemergencyresponders.Furthermore,itassistedtheNZFStomeetnewrequirementssetoutbytheHealthSafetyandEmploymentAct1992,requiringemployerstoprovideasafeworkplaceforemployees(NewZealandFireService,2014).Yet,itisdifficulttoexaminetheefficacyoftheCISMprogrammewithintheNZFSduetoalackofepidemiologicaldataandbenchmarking–aproblemthatcontinuestoexistwithregardtotheefficacyofthecurrentSHWstrategyandCIPSSprogramme.However,feedbackfrompeersupportwork,CIPSSpresentations,andtheattachedcasestudyindicatelimiteduptakeofCISMandCISDwithinsomeareasoftheNZFS,despitetheprogrammebeinginplacesincetheearly‘90s.

TheCISMprogrammedidexperiencenoteworthyuptakeinternationallyasawarenessofthepsychologicalrisksinherentintheworkoffirstrespondersgrew,andSHWworkersandorganisationssoughttorespondtotheserisks.However,theCISMprogrammeeventuallyfacedscrutinywithquestionsraisedabouttheefficacyofcomponentssuchasCISD(Shave,2010).AsaresultofthecontinuingdebatearoundCISMandCISD,theNZFSlauncheditsownreviewoftheCISMprogrammein2010.Thisreviewidentifiedthatinternationalbestpractice,withregardtothepromotionofthepsychologicalwellbeingofemergencyresponders,wasmovingawayfromtheMitchellmodelandtowardsconceptsofresilience,interpersonalsupport,andpracticalassistanceinherenttoPFA.ItappearsthesefindingswerebasedontheconcernsofsomeresearchersinrelationtopotentialweaknessesofCISMincludingtheuseofCISD.ConcernsinrelationtoCISDincludedthattherewasthepotentialforvicarioustrauma,re-traumatisation,interferencewithnormalpatternsofrecovery,andtheover-pathologisingofnormalstressreactions(NewZealandFireService,


52 27March2019

2017;Shave,2010).ItshouldbenotedthatresearchappearstobeconflictedwithregardtotheefficacyofCISDwithSattleretal.(2014)findingthatCISDattendancewaspositivelyassociatedwithPTGandnegativelyassociatedwithpost-traumaticstresssymptoms.However,theinitialfindingsoftherevieweventuallyledtotheCISMprogrammebeingreplacedbyanothermulti-componentprogrammeknownasCIPSSin2014.

Criticalincidentandpersonalstresssupport

CIPSS,whichisbasedontheprincipalsofPFA,remainsthecurrentandpredominateprogrammeofpsychologicalsupportimplementedbyFireandEmergency.ThepurposeofCIPSSisstatedasinforming,educating,andempoweringalreadyresilientfirefightersandotherpersonneltomanagethemselvesinchallengingsituationsandtoremainsafe,healthy,andwell(NewZealandFireService,2017).ThecurrentCIPSSprogramme,liketheinitialCISMprogramme,isalsointendedtoensurethatFireandEmergencymeetsitsresponsibilitiesoutlinedintheHSWA2015.Additionally,itisintendedtoassistinensuringFireandEmergencySHWcommitments,suchas“nothingismoreimportantthanourpeople”andthatFireandEmergencyis“committedtoensuringthateveryonegoeshomesafeandwellafteranyworktheyundertakeonbehalfoftheorganisation”,aremet(FireandEmergencyNewZealand,2017c,p.1).TheCIPSSmanualoutlinestheobjectivesoftheCIPSSprogrammethatalsoalignwithFireandEmergencySHWcommitments(NewZealandFireService,2017,p.53):

• Protectandpromotethepsychologicalwellbeingandresilienceoffirefightersandotherpersonnel

• ProvideanationallyconsistentprogrammeforNZFSpersonnelandtheirfamiliessoeveryone,regardlessoftheirgeographicallocation,rankorrolehasaccesstoevidence-informedstrategies

• Provideemotionalandpracticalsupportfollowingcriticalincidentsandintimesofpersonalandprofessionalneed.

IthasbeenstatedthatCIPSSincludesthephilosophyandcultureofsupportthatCISMencouraged.However,ithastakenadifferentapproachtotheoutworkingofthatsupport(NewZealandFireService,2014).Thosedifferencesinoutworkingappeartobebuiltuponthefollowinginsights(NewZealandFireService,2014,2017):

• Firefightersexperiencedistressasaresultofexposuretocriticalincidents,butalsoasaresultofpersonalandworkplacestressors.

• Firefightershavedifferentneedsanddealwithdistressindifferentways,oftenrequiringspaceandtimetoeffectivelyprocessanevent.

• Agreateremphasisneedstobeplacedonthecumulativeeffectoftraumaonfirefighters.

• Supportshouldnotbeforcedonfirefighterstoosoonafteracriticalincident.

• Supportshouldbeavailablefordifferentstressors,suchaspersonalandworkplacestressors.


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• Firefightersshouldnothavetoparticipateinstrategiestheydon’tthinkarerightforthem.

TheCIPSSprogrammeincludesanumberofcomponentsofthehistoricalCISMprogrammewhilealsoincludingsomenewandupdatedcomponents.CIPSSdocumentationoutlinesthesumofthecurrentcomponents(NewZealandFireService,2014,2017):

• Workereducation(MANERSmodelofPFA)

• Formalpeersupportnetwork

• Informalsupport

• Familialeducationandsupport

• Recruittraining

• Provisionofapreferredprovidernetwork(EAP,psychiatrists,psychologists,counsellors,chaplains,doctors,etc.)

• Policiesandprocedures

ThefollowinghumanresourcingisidentifiedwithinCIPSSdocumentationtoensurethedeliveryandefficacyofthesecomponents(NewZealandFireService,2014,2017):

• SeniorAdvisorCIPSSProgramme

• NationalPsychologicalAdvisor

• Subjectmatterexperts

• NationalSHWmanager

• RegionalSHWcoordinators

• InjuryManagementUnit(IMU)

• WelfareLiaisonOfficer

• IwiLiaisonOfficer

Anumberofadditionalinitiativeshavealsobeenundertaken.Theseinclude:apsychologicalwellbeingforleadersworkshop(settocommencein2019);LeadingPsychologicalWellbeingworkshopsprovidedbytheUnitedFireBrigadesAssociation(UFBA);aqualitativeresearchreportexaminingtheimpactofillness,injuryanddeathincidentsonfirefighterwellbeing(findingsmadeavailableinOctober2018);ahealthstandardsproject,whichincludesthedevelopmentofhealthchecksinrelationtopsychologicalwellbeing.

ItisevidentinreviewingCIPSSdocumentationthattheprogrammealignswithanumberofthekeyfindingsofPartOneofthisreport.Mostnotably,itiscongruentwithfindingsrelatedtothecumulativepotentialoftraumaandtheidentificationofworkplaceandhomestressorsasbeingpotentialcontributingfactorsinrelationtoapsychologicalinjury.ItisalsoevidentthattheprogrammeincludesanumberofcomponentsthathavethepotentialtoeliminateorminimisesomeofthepsychologicalrisksfacedbyFireandEmergencyfirefighters.However,internationally-recognisedbestpracticeguidelines,andformaland


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informalfeedbackfromFireandEmergencyfirefighters,suggestthattheremaybeimportantinitiativesmissingfromthecurrentSHWstrategyand,whereinitiativesdoexist,theremaybesubstantialgapsbetweentheimaginedandactualeffectofthoseinitiatives(SAMHSA,2014).Forexample,anumberofinternationalemergencyagenciesprovidea‘legacysupport’programmeforretiredpersonnelasanacknowledgementoftheirservice,andasaresultofunderstandingthatthispopulationmaybemostaffectedbythecumulativeimpactofexposuretoPTEs.Yet,FireandEmergencycurrentlyhasnosuchinitiative.WhileotherSHWcontrolmeasuresdoexist,thereisevidenceofalackofefficacy.Forexample,qualitativefeedbackfromAdamsetal.(2018)notedthattherearestillsubstantialbarrierswithinFireandEmergencyinrelationtohelpseeking.Theseincludedstigmatisationaroundpsychologicalinjuriesandtrustissuesrelatedtoconfidentiality.Additionally,FirefighterX(intheattachedcasestudy)hadneverpreviouslyexperiencedanofficercheck-inwiththeircrewonthewaytothecallwithtraumainmind,andOfficerYhadneverofferedsupportinthiswaybefore,despitebothhavingoveradecade’sserviceandCISMbeingestablishedin1990andCIPSSin2014(NewZealandFireService,2017).Finally,informalfeedbackfromfirefightersinFireandEmergencyindicatesapotentialgapbetweenpolicyandpracticewithregardtoidentifiedcontrolmechanisms:

FireandEmergencyacknowledgementandcommitmenttoFirefightersisthattheyaresayingtherightthingsinspeak,somesupportservicesofferedarefitforpurposebutitwouldappearthattherehasbeenlittleeffortintermsofaddressingtherootcauseofsomeissues.(SeniorStationOfficer,Region2,personalcommunication,December19,2018)

IspoketoanexperiencedSSOwhoneededachat.Hehadbeentosomeveryintensesituationsbothforhimandhiscrew(arookieIthink).Hehadconcernsforhiscrew(understandably)butseemedtobestrugglingwiththelackofrealgenuineheartfeltsupport.IrealisethismaysoundabitairyfairybutIgottheimpressionthatthecompanylineof“peersupportisthereforyouandfillintheH&Skiosk”etc.etc.didn’tcutitandheneededamorehuman,compassionate,genuineinterestinthissituationandhisexperiences.Itannoysmethatwecurrentlysitinthispositionaswehavebeendoingit[medicalcalls]forsometimenowandshouldhavegotouracttogether.Itupsetsmethatsomeofmypeers,friends,fellowOfficersaresayingthattheyarefeelingunsupportedintheirconcerns.(StationOfficer,Region1,personalcommunication,October21,2018)

ThoughitisevidentthattherehavebeenanumberofimportantstepsforwardinrelationtotheidentificationandeliminationorminimisationofpsychologicaldistressandinjurywithinFireandEmergency,thereisalsoevidencetosuggestthatcurrentcontrolmeasuresmaybeinsufficient.Asaresult,itislikelythatatrauma-informedcultureremains,perhapsseverely,underdevelopedwithinFireandEmergency.ThefollowingreportsectionswillinvestigatesomeofthecomponentpartsofthecurrentSHWstrategyandCIPSSprogramme.ThisinvestigationwillseektoidentifyissuesthatmaybeinhibitingtheefficacyofthecurrentSHWstrategyandcontrolmeasures,whilealsoidentifyingifothermeasuresarenecessary.


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Peersupport

FireandEmergencyhasaformalpeersupportprogrammethatformsoneofthemaincomponentsoftheCIPSSprogramme.Formalpeersupportisanevidence-informedinterventionandisrecommendedbyanumberoftraumaagencies(Phoenix,n.d.;SAMHSA,2014).OneofthestrengthsoftheformalpeersupportframeworkwithinFireandEmergencyisthatitisbasedonthePhoenixAustraliaguidelinesforpeersupport.Theseguidelinesarereflectedinawell-writtenCIPSSadministrationguideandpeerprobationarytrainingmanual(NewZealandFireService,2014,2017).PhoenixAustralia,acentreforpost-traumaticmentalhealth,comprisesacombinationofexpertsinthefieldoftraumawhohavedevelopedinternationally-recognisedprogrammesofresearchandevaluationwithregardtotrauma(Phoenix,n.d.).Thecentreisofobvioususeasaresource,thoughtheremaybelimitationsofexternalvalidity,givenitsisolationfromaFireandEmergencysettingandculture.Furthermore,thePhoenixguidelinesforpeersupportarenowsevenyearsold,andmaynotreflectsomeofthemorerecentresearchintopeersupportandtraumawithspecificitytofirefighters.SAMHSA,theleadgovernmentalagencywithregardtopublichealthintheUS,alsoidentifiespeersupportasakeycomponentofsupportprogrammes.SAMHSAidentifiespeersupportasoneofthesixkeyprinciplesofaTICapproach,recognisingpeersupportasakeyvehicleforestablishingsafetyandhopewithinindividuals,organisations,andsociety(SAMHSA,2014).

TheformalpeersupportprogrammewithinFireandEmergencyhasbeenidentifiedasahigh-levelcontrolinrelationtopsychologicalrisksoutlinedwithinthecurrentSHWstrategy(FireandEmergencyNewZealand,2018e).Thepeersupportprogrammeissupportedbywhatappearstobewell-writtenpolicyandproceduralguidelines.However,theefficacyofanypeersupportprogrammeismediatedbyanumberofimportantvariables(SAMHSA,2014).Forexample,thedevelopmentofaformalpeersupportnetworkintheNZFSbeganwithformaltraininginNZandAustralia,whichtotalledsixdays.OrganisationssuchastheQueenslandAmbulanceService(QAS)mirrorthisleveloftrainingwithtraineepeersupportersrequiredtoundertakeacomprehensivesix-dayliveintrainingprogrammethatisofferedtwiceayear.Recruittrainingisfurthersupplementedbyafour-daylive-inrefreshercourseofferedtwiceayear,alongwithannuallocalpeersupportworkshops(QueenslandAmbulanceService,2018).Thisleveloftrainingisofobviousbenefit,giventheresponsibilitypeersupportershave–oftenbeinganinitialcontactforthoseexperiencingpsychologicaldistress.Yet,despitepolicyoutliningitsnecessity,itappearsasthoughtherehasbeenlittleornosupplementarytrainingprovidedforapotentiallyconsiderableamountofpeersupporters,forupto25years–anumberoftwodaycourseshavebeenprovidedfornewpeersupportersinrecentyears(NewZealandFireService,2014).

AnotherpotentialissueforFireandEmergencypeersupportersisalackofappropriatesupervision.Supervisionisanessentialcomponentofanypeersupportprogrammeanditservestoprovidecriticalsupporttopeersintheworkthattheydo.Researchhasindicatedthatsupervisioncanreducetheriskofburnoutandvicarioustrauma,bothofwhichposeaconsiderablerisktopeersupporters(Bell,Kulkarni,&Dalton,2003).Supervisionalsoassiststoensurepeersupportersarepractisingsafelyandappropriately,andareofoptimalbenefittotheircolleagues.Yet,itisnotclearthatthecurrentFireandEmergencypeersupport


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supervisionprotocol(oneannualclinicalsupervisionsession)isbeingcarriedoutoratleastsufficientlymonitored.InRegionswheresupervisionappearstobeadequateitisnotclear,whencomparingtoanorganisationsuchastheQAS,thatonecompulsoryannualsupervisionsessionissufficienttoeliminateorminimisetherisksofburnoutandvicarioustraumatisation.QASrequirespeersupporterstoattendgroupsupervisionsessionsandaminimumoftwoindividualsessionswithinternalcounsellors.Furthertothis,theyalsohaveunlimitedaccesstointernal/externalcounsellorsatanytimeforsupportorsupervision(QueenslandAmbulanceService,2018).

ItshouldbenotedthatsomeRegions,inmorerecenttimes,havehadareinvigorationoftheirpeersupportprogrammesthathasledtoanincreaseintrainingandsupportforpeersupporters.However,theseinitiativesappeartobetheresultofanumberofcommittedandconcernedindividualswhohaverecognisedthelackofconsistencyinsupportandtrainingforpeersupportersintheirarea.Thesereinvigorationprogrammesareyettooccurasaresultofanationaldirective,andmayindicatealackofgovernanceatanationallevelandaconsiderablegapbetweenpolicyandpracticeinsomeRegions.Thesegapsmayberesultingintrainingandsupervisiondeficits,whichisaconcernasacoreskillofapeersupporteristheirabilitytorecognisethesignsandsymptomsoftraumaandconnectindividualsindistresswiththeappropriatesupportservice(NewZealandFireService,2014;SAMHSA,2014).Furthermore,alackoftrainingandagencywheninteractingwithpeoplewhomaybetraumatisedcouldbeharmfultoanindividualseekingsupport,butalsotothepeersupporter(Armstrongetal.,2014).ThisfindingissupportedbytheBeyondBlueLtd(2018)reportwhichfoundthat,amongcareeremergencyresponders,inadequatesupportwasassociatedwithincreasinglevelsofpsychologicaldistressandprobablePTSD.InthecasestudyofFirefighterX(seetheappendix),ifsymptomshadpersistedandapeersupporterhadbeencontacted,thepeersupporterwouldneedtohavebeenconfidentinidentifyingifFirefighterX’sstressresponseshadsurpassedwhatwouldbeconsideredanormalstressreaction.Ifthiswerethecase,theywouldthenhaveneededtobecapableofconnectingFirefighterXwiththeappropriatesupportsystems.Insufficientsupervisionandtrainingmayaccountfortheinabilityofapeersupportertocarryoutsuchactions.Thisiswhyappropriatesupportandtrainingisnecessary,andmustmovefrompolicytopracticeforallRegionpeersupportteams,fortheimplementationandsustainabilityofaneffectivenationalformalpeersupportprogramme(SAMHSA,2014).

WhilepeersupportisanimportantcomponentoftheCIPSSprogramme,andothersimilarprogrammessuchasTIC,therearelimitationstoitsuseasasupporttool.Aspreviouslymentioned,peersupportersmaylackappropriatetrainingandnecessarysupervision,limitingtheiruseasatraumaresource.Anotherlimitationisthatpeersupportersmaynotbeutilisedduetogeographical,personality,oridentityfactors.Consequently,organisationslikeSAMHSAhaverecommendedanapproachsuchasTICthat,whileincludingformalpeersupport,alsorequiresthatanorganisationprovidepsychologicaldistressandinjurytrainingforallmembersofanorganisation,fromthereceptionisttotheCEO.Inthisway,suchlimitationsareovercomeastraumainsightsandsupportareembeddedintheculture,andnotabstractedsolelytopsychologicalsupportstaff.Furthermore,TICmovestrainingtoafamilialandsocietallevel,promotingfurtheravenuesofsupportandunderstanding.Thisapproachassiststoensurethatthosewhoexperiencetraumahavethegreatestchanceof


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findingsupportandhope,asitisnotlefttooneindividualorevengrouptoprovide,butisevidentandavailableenmasse.ThecurrentCIPSSprogrammealsoincludestrainingandeducationcomponentsandthesewillbediscussedinthenextsection.

Theapparentincongruencebetweenpolicyandpracticewithinareasofpeersupportisconcerning.Yet,gapsbetweenpolicyandpracticearenotanewphenomenonandresearchershavediscussedtheneedtocreateresilientprogrammesthatminimisethedifferencebetweenwhatissometimesreferredtoasWorkAsImagined(WAI)andWorkAsDone(WAD)(deCarvalhoetal.,2018).WAIencompassespolicyandprocedureandwouldinclude,withregardtoaFireandEmergencycontext,operationalinstructions(OIs),CIPSSmanuals,andSHWcommitments.WAD,ontheotherhand,encompassesthetangiblemanifestation,oroutworking,ofsuchpolicyandprocedure.ResearchersnotetheimportanceofbothWAIandWAD,whilealsonotingthepropensityforagapbetweenthetwovariables.Asaresultofthepropensityforagapbetweenthetwo,researchersrecommendthatsuchgapsareidentifiedassoonaspossible,discussed,andresolvedtoensuremoreeffectiveoutcomes(deCarvalhoetal.,2018).ProgrammeswithlittleornogapbetweenWAIandWADcanbeassumedasresilient.However,programmeswithsubstantialgapsbetweenWAIandWADareunlikelytobesufficientlyeffectiveandmayinturnbeperceivedasanexercisein“box-ticking”,orcompliance,ratherthanagenuineefforttomeettheneedsofworkers.

Inconclusion,theFireandEmergencyformalpeersupportprogrammehasanevidence-informedbasisandhasclearpolicyandprocedurecreatingaframeworkforWAI.Nevertheless,thereappearstobealackofnationalconsistencyinrelationtothegovernance,support,andresourcingofRegionalpeersupportprogrammes.ThegapbetweenWAIandWADmayberesultingininsufficienttraining,supervision,andgeneralgovernanceofpeersupporters.Thisisofconcern,astheformalpeersupportprogrammehasbeenidentified,withintheSHWstrategy,asahigh-levelcontrolmeasurewithregardtopsychologicaldistressandinjury(FireandEmergencyNewZealand,2018e).ItisevidentthatareviewofpeersupportineachRegionisrequiredtoidentifygapsbetweenWAIandWADandtohelptoensureFireandEmergencypeersupportstaffexperienceasenseofself-efficacy,andarealsoofoptimalbenefittopersonnelwhoseektheirsupport.

Psychologicaldistressandinjuryeducation

TheFireandEmergencySHWmanualnotesthatFireandEmergencywillprovidebothappropriatetrainingandrelevantinformationsothatpersonnelareabletocarryouttheirdutiessafely.ItalsonotesthatthisSHWtrainingshouldbeintegratedwithothertrainingmaterialsandtrainingcourses,suchastheTrainingandProgressionSystem(TAPS),tosupportconsistentdeliveryandoptimaluptakeofrelevantinformation(FireandEmergencyNewZealand,2018d).Additionally,theSHWstrategyoutlineseducationinrelationtopsychologicalwellbeingasahigh-levelcontrolinitiativeinrelationtopsychologicalinjury(FireandEmergencyNewZealand,2018e).ThissectionofthereportwillexamineanumberofthetrainingandeducationinitiativesdevelopedandimplementedbyFireandEmergencyinrelationtotheaforementionedSHWobjectives.


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CIPSSroll-out

ASAMHSA(2014)documentfoundedontrauma-focusedresearch,practice-generatedknowledge,andlessonsarticulatedbytraumasurvivors,hasidentifiedongoingtrainingandworkforcedevelopment,inrelationtopsychologicaldistressandinjury,asanessentialcomponentinensuringtheembeddingoftraumaknowledgewithinanorganisation.Accordingly,theCIPSSprogrammeimplementedaneducationprogrammebasedontheMANERSmodelofPFA,developedbytheVictorianAmbulanceCounsellingUnit(VACU),whichbeganroll-outin2015.PFAalignswithcertainprinciplesofTIC,includingafocusonpersonalsupportandpracticalassistance(Phoenix,n.d.).Whilehavinglimitedempiricalvalidation,PFAencompassesanapproachthatissupportedbytheconsensusofexpertsinthefieldoftrauma(Litz,2008;Tessa,Inge,KoenVan,EmmyDe,&Philippe,2014).PFAmovesawayfromprescriptivestructuredsupport,suchasthatofCISD,andtowardsalessformalapproachthatincludestappingintoindividuals’naturalresilience,andreducingdistressthroughpersonalsupport(NewZealandFireService,2017).Litz(2008)notestheneedforPFAtobesimplifiedandstructuredforapublichealthsetting.ThisisoneofthestrengthsoftheMANERSmodelofPFAutilisedbyFireandEmergency,asMANERSbreaksdowntheconceptsofPFAintoamoreeasilyrememberedacronym.TheCIPSSpresentationincluded:abriefhistoryofpsychologicalsupportwithintheNZFS;reflectionsontheevolutionoftheworkfirefighterscarryout;abreakdownofthecomponentsofCIPSS;anexplanationoftheMANERSmodelofPFA.

WhiletheCIPSSroll-outrepresentedanothersubstantialstepforwardinattemptstominimiseandeliminatepsychologicalriskswithinFireandEmergency,theefficacyofthesepresentationsappearedtosuffer,atleastinsomecases,fromalackofprioritisation,supervision,training,andresourcing.Forexample,aroll-outoftheCIPSSpresentationsinRegion1tocareerandvolunteerpersonnelfacedanumberofchallenges.Initially,itwasdecidedthattheroll-outtocareerstaffshouldoccurviaSeniorStationOfficers(SSOs).PeersupportersintheRegionqueriedthisapproach,asSSOshadreceivednoformaltrainingintheprogramme,andanumberwerelikelytobeunfamiliarwiththematerialandmaywellhavefeltuncomfortabledeliveringsuchmaterial.Aftertheseconcernswereraised,adecisionwasmadetorolltheprogrammeoutthroughpeersupporters,thoughinitiallytherewasnoplantoprovidethemwithformaltraining.Peersupportersbelievedthattraining,providedbyaprofessional,wouldbeessentialtoaneffectiveroll-out.Eventually,aformalone-daytrainingcoursewasapprovedandprovided.However,despitetheroll-outbeginningin2016,inRegion1therehavebeenlimitedpresentationsmadetotheregion’svolunteersandthereareanumberofcareerstaffwhoareyettoreceivethepresentation.ThistimeframefordeliveryisofconsiderableconcerngiventhefindingsofPartOneofthisreport.Anonlinepresentationoftheprogrammewasdevelopedtoviewthroughtheintranet,potentiallytoensurethatalternativeaccesstothematerialwasavailable,giventhetimeframeitwastakingtoprovideaperson-to-personroll-out.Thisinitiative,whileofsomebenefit,doesnotappeartoreflectthespiritoftheSHWcommitmentsformerlysetoutbyFireandEmergencyindicatingSHWasaforemostpriority.Othertraininginitiatives,suchastherecentnationalincidentgroundcommunicationsradioreplacementroll-outandthecurrentfirstaidtrainingprogramme,appeartohaveamuchhigherlevelofgovernance,resourcing,andadministrationsupportthanthatoftheCIPSSroll-out.Asanexample,Fire


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andEmergencyrequireallstafftoattendperson-to-personphysiologicalfirstaidtrainingfacilitatedbytrainedmedicalprofessionals.Attendeesarerecorded,andfurthersessionsareprovidedtoensurestaffonleaveoroffworkalsoundergothetraining.Thisadministrationisaccountedfor,inpart,byanOSMsystemthatindicatesreal-timecompetencyinfirstaid.ThislevelofadministrationanddeliveryisanobviousstandardgiventheimportanceoffirstaidinFireandEmergencywork.Itisnotclear,then,whyacriticalcontrolmeasuresuchasCIPSSeducationwouldreceivelessergovernance,resourcing,andadministrationsupportthanotherorganisationalinitiatives.Finally,informalsupport,includinginformalworkmate,familial,andfriendsupport,isidentifiedasacomponentoftheCIPSSprogramme.Yet,thereappearstobebarrierstothetimelyprovisionofefficaciouspsychologicaldistressandinjuryeducationforfirefighters,letaloneeducationforfamilymembers.

Recruit,promotional,andstationpsychologicalwellbeingeducation

CareerfirefightershavehadaCIPSScomponenttaughtaspartoftheirrecruitcourseforanumberofyearsnow.However,thereiscurrentlynonationaldirectivewithregardtoCIPSS,oranyotherpsychologicalwellbeingtraining,onvolunteerrecruitcourses,despitethisgapbeingnotedina2017SHWdocument(FireandEmergencyNewZealand,2017b).Thereissomenon-directedtraining,recentlyinitiated,forvolunteerrecruitsattheMtWellingtontrainingcentreinRegion1.Thistraininghasoccurredasaresultofpeersupportersidentifyingthecurrentgapinvolunteertraining.However,thetraininginRegion1appearstobeisolatedwithnopsychologicaldistressorinjurytrainingcurrentlyprovidedforvolunteerrecruitsattheNationalTrainingCentre(NTC)ortrainingcentresinRegion4and5.Thisappearstoindicateacurrentlackofnationalconsistencywithregardtorecruits’psychologicaldistressandinjuryeducation.Furthertothis,NTCtrainershaveraisedconcernsastothedeliverymethodoftheCIPSScomponentcurrentlyprovidedoncareerrecruits’courses.Todate,itdoesnotappearasthoughtheirconcernshavebeenaddressed(NationalTrainer,personalcommunication,February07,2019)

FireandEmergencyhasanumberofsystemsforensuringtheembeddingofinformationandtrainingthroughouttheorganisation.Thisincludes:TAPS;OSMasapartoftheStationManagementSystem(SMS);andpromotionalexams.WithregardstoTAPS,asystemusedtoensurethetrainingdevelopmentoffirefighters,thereappearstobelittleornointegrationofpsychologicalwellbeingeducationatanylevelofthecareerorvolunteersystems.ComponentsthatdoexistappeartobealignedwiththeoutdatedCISMprogramme(NationalTrainer,personalcommunication,February07,2019).WithregardtoOSM,astationtrainingandmonitoringsystemthatprovidesknowledgecheckcapacity,thereappearstobenocomponentcurrentlyavailablerelatedtopsychologicaldistressandinjuryidentification,elimination,orminimisation.Thisisdespitepreviousreportrecommendations,publishedbyaFireandEmergencyfirefighterin2014,notingthattheNZFSshouldbemoreproactiveinmanagingdistress,andthatthiscouldbeachievedinpartthroughembeddingpsychologicalwellbeingcomponentswithinTAPSandSMS(Dudley,2014).


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Otherpsychologicaldistressandinjuryeducationprogrammes

FireandEmergencyhaverecentlydevelopedafurtherpsychologicalwellbeingeducationprogrammeknownasthePsychologicalWellbeingforLeadersworkshop.ThisworkshopisbeingdeliveredtoleaderswithinFireandEmergencyin2019.Whiletheprogrammehassomestrongcomponentparts,therehavebeenconcernsraisedinrelationtohowitwillbedeliveredtooperationalstaffthat,itcouldbeargued,areinneedofitthemost.Theseconcernsrelateto:thelackofcleartimeframesinrelationtotheroll-out;alackofoperationalandtraumasurvivorinputintopresentationdevelopmentanddelivery;thenecessityofsomeofthecomponentparts;howitistofitinwiththecurrentCIPSSpresentationandroll-outobjectives.OtherpsychologicalwellbeingeducationalcomponentsprovidedbyFireandEmergencyincludeaStayingWellhandbookandpamphlet,alinktopsychologicalwellbeingsupportsthrougha“HowDoI”tabonthePortalinternetsite,andLearningStationvideosonCIPSSandMANERS.(LearningStationisaFireandEmergencyonlinetrainingsystem.)However,theseinitiatives,includingthelearningvideos,canremainlargelyinactive,astheyarenotcurrentlylinkedtoOSMandrelyonundirectedorpromptedengagement.TheUFBAalsoprovideaoneandahalfday“LeadingPsychologicalWellbeing”workshop,whichurbanandruralfirefightersmayapplyfor(UnitedFireBrigades'Association,2018).However,itwasbeyondthescopeofthisreporttoassessthispsychologicaleducationinitiative.

GiventhestatedimportanceofpsychologicalSHW,itwouldappearimperativethatFireandEmergencyprovidesagoldstandardpsychologicaldistressandinjuryeducationprogramme.Suchprogrammesneedtoincludeevidence-basedcontentthatisgroundedintheappropriateorganisationalcontext.Furthermore,thismaterialneedstobedeliveredinanengagingmanner,fitforFireandEmergencyworkerconsumption.Itcouldbeimaginedthataneffectivedeliverystrategywouldincludetheuseofpresenters/trainerswho:haveoperationalexperienceoraresupportedandinformedbythosewithoperationalexperience;havepresentationandfacilitationskillsthatwillensurethepresentationisengaging;havesomesortoftraininginpsychologicalwellbeing;andhaveaccesstoregularsupervision.Finally,theseeducationalinitiativesshouldreceiveasimilarlevelofprioritisation,governance,administration,resourcingandsupportasthatofotheressentialareasoftraining,suchasfirstaidandincidentgroundcommunicationstraining.

Preferredprovidernetwork

FireandEmergencycurrentlyhaveanumberofcontractedexternalproviderswhomakeuptheirpreferredprovidernetwork.ThisincludesEAP/Vitaeservices,counsellors,clinicalpsychologists,andconsultantpsychiatrists.Theseservicesarebuiltintoafour-tieredmodelwithdifferingsupportrequirementscorrelatingwithdifferingsupporttiers(FireandEmergencyNewZealand,2018c).

TierOneofthissystemofsupportallowsFireandEmergencyfirefightersandtheirimmediatefamilymembersaccesstoEAP/Vitaeservices.Thislevelofsupportcanbegainedanonymouslyviaself-referral,throughamanager,orthroughamemberoftheSHWteam.FireandEmergencycoversthecostsinvolvedwithengagingwiththeseprofessionalsupportservices(FireandEmergencyNewZealand,2018c).Thereareobviousbenefitstothis


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system,includingtheabilitytoremainanonymousandtheremovalofapotentiallysubstantialcostbarriertoprofessionalsupport.Yet,thereareanumberoflimitationstothisservice,includingthepotentialforanexternalprovidertolackaclearunderstandingofaFireandEmergencycontext,whichmaybeanessentialunderstandinginrelationtodevelopingtrust–afoundationalelementoftherapy.ThisissuewashighlightedintheReadytoRespondreportwithakeyinformantnoting:

…they’veheardacoupleoffirefightershadbadexperiencesdealingwithpsychologists,andcounsellorsandsothat’sbeenfedback,andsoforexample,beentothepsychologist,didn’tunderstandtherole,orthejoborcouldn’trelateto,wasn’tatraumaspecialistpsychologist,sotheycouldn’thelp…(Adamsetal.,2018,p.57)

Thismayalsobeanissueatotherlevelsofsupport,includingreferraltoacontractedclinicalpsychologist(TierTwo)andreferraltoaconsultantpsychiatrist(TierFour).ThispotentialbarrierhasbeenovercomeinsomeareasasaresultofhavingcontractorswhohaveasubstantialhistorywithFireandEmergency,orwhohavebeenappropriatelyorientatedwithregardtothecultureandcontextofFireandEmergencywork.InRegion4,thispotentialbarriertoengagementappearstohavebeenovercome,atleasttoasubstantialdegree,asaresultofhavingadedicatedWelfareOfficerwhoworkscloselywithateamofpsychologiststodevelophealth-monitoringinitiatives,providereferrals,andimplementpsychologicaleducationinitiatives.Anumberofexternalprovidershaveindicatedtheirdesiretohaveasimilarsystemofcollaborationandreferraltooptimisetheefficacyoftheirservice.HawkesBay,anareainRegion3,appearstohaveasimilarapproach,withlocalpsychologistswhospecialiseintraumavisitingallcareerwatchesonaquarterlybasis(FireandEmergencyNewZealand,2018c).However,otherRegions(forexampleRegion1)lackanappropriateamountofclinicalpsychologiststoreferto,andalsodonothaveasufficientsysteminplaceforensuringcontractorsareappropriatelyorientatedandreferralsarehandledefficiently.Furthermore,itappearsthatsuboptimalgovernanceiscontributingtoissuesinrelationtoreportingbypreferredproviders.Specifically,thereisnotyetastandardisedreportingsystemforusebyproviders,whichmakesitdifficulttotrackworkerwellnessandidentifythemeswithregardtopresentingissuesacrossFireandEmergency(SafetyHealthandWellbeingcoordinator,personalcommunication,March19,2019).

Itisapparentthatanationallyconsistentprogrammewithregardtothepreferredprovidernetworkislacking.Thisisofconcerngiventheimportantrolethatprofessionalsupportplaysineliminatingorminimisingpsychologicaldistressandinjury.

VariablescontributingtoresponseefficacyWhileidentifyingallthevariablescontributingtoresponseefficacyinrelationtofirefighters’psychologicalSHWneedswouldrequireasophisticatedmultivariateanalysis,itisevidentthatcurrentgapsbetweenpolicyandpracticecontributeconsiderably.Thefollowingtwosections,governanceandresourcingandfirefighterandtraumasurvivorengagement,offersadiscussioninrelationtotworeasonablyevidentareasthatwouldassisttoclosethecurrentgapsbetweenpolicyandpractice.Improvementsinthesetwoareaswouldalso


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provideamorerobustSHWstrategy,andamoreeffectiveresponsetothepsychologicalSHWneedsoffirefighters.

Governanceandresourcing

CIPSSresourcingandspanofcontrol

SAMHSA(2014)notesthat,withtheexistenceofsufficientsupportsandinterventions,peoplecananddoovercometraumaticexperiences.However,difficultiesinrelationtoimplementinganeffectiveSHWstrategy,andthepropensityforgapstoarisebetweenpolicyandpractice,hasledSAMHSAtodevelopguidelinesfortheimplementationandsustainmentofeffectivetraumaprogrammes.Forexample,SAMHSA(2014)notestheimportanceofappropriategovernanceandfinancinginrelationtoensuringthesuccessfulimplementationandsustainabilityofaprogrammesuchasCIPSS.Withregardtogovernance,SAMHSA(2014)notestheimportanceofidentifyingandestablishingleaderswithintheorganisationwhoareresponsibleforleadingandoverseeingtraumaprogrammes.Withregardtofinancing,SAMHSA(2014)notesthatfinancingstructuresneedtobedesignedinsuchawayastosupportsufficientresourcingforareassuchas:stafftrainingontrauma;establishmentandsustainmentofformalpeersupport;provisionofevidence-informedtraumascreening,treatment,andrecoverysupports;andthedevelopmentandmaintenanceofcross-agencycollaborations(SAMHSA,2014).

AnoperationalperspectiveofappropriategovernanceandresourcingcanbegarneredfromtheFireandEmergencyNewZealand(2013)commandandcontrolmanual.Appliedasaanalogy,guidelinesfromthemanualcanprovidehelpfulinsightsinrelationtowhatmightberequiredtoensureacoordinatedresponsetoeliminatingorminimisingpsychologicaldistressandinjuryrisks.ThemanualnotesthatincreasesinthecomplexityorsizeofanincidentconsiderablydecreasesanIncidentController’sabilitytoeffectivelymaintaincommandandcontrol,noting“Escalationmustbemetwithdelegation”(FireandEmergencyNewZealand,2013,p.6).Largerandmorecomplexincidentsrequireanofficertorequestmoreresourcesanddelegatemoreresponsibility.Accordingly,IncidentControllershavetheabilitytoinitiatefurtherresourcingthroughactionssuchastransmittinggreateralarms,whichprovidesfurtherappliancesandpersonnel,and/orrequestingspecialistappliancesandagencies.Delegationisalsoimperativewithlargerormorecomplexincidents,tobenefitfromsectorisationandlogisticalandoperationalcommandresourcing.Failuretoimplementfurtherresourcingand/ordelegatetaskscanleadtoofficersontheincidentgroundworkingoutsideofoptimalspansofcontrol,whichcanhaveanegativeflow-oneffectwithregardtotheefficacyofrescueandextinguishmentefforts,aswellasincreasingrisksinrelationtotheSHWoffirefightingcrews.

Itispossibletoapplythesecommandandcontrolconcepts,inrelationtoresourcinganddelegation,tothe‘incidentground’ofpsychologicaldistressandinjury.Accordingly,thissectionofthereportwillidentifyandexaminethecurrentmanagementstructureandresourcingofCIPSS,whichappearstobetheprimarycontrolmeasureforrisksrelatedtopsychologicaldistressandinjury.CIPSSdocumentationindicatesthefollowingstructurewithregardtothegovernanceoftheprogramme(NewZealandFireService,2014,2017):


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• NationalSafetyandWellbeingCommittee–whoaretoprovidealevelofgovernancetoensuretheprogrammeisvisibleandsupportedacrosstheorganisation

• CIPSSSeniorManagementChampion–whohasaprimaryroleinpromotingtheprogrammeataseniormanagementlevel,aswellasprovidingongoingsupporttoleaderstoensuretheobjectivesoftheprogrammecanbemet

• NationalClinicalAdvisor–whoistoprovideclinicalskills,professionalinputandadvicetotheprogramme

• SeniorAdvisorCIPSSProgramme–whoisamemberoftheSHWteamandresponsiblefortheday-to-daymanagementoftheprogramme;andprovidesinformation,supportandresourcestotheRegionSHWcoordinatorsinorderforRegionalefficacywithregardtotheprogramme

• Subjectmatterexperts–whounderstandthesupportprogrammewithinFireandEmergencyandensurethattheprogrammeremainscongruentwithitsvaluesandprinciples

• WelfareLiaisonOfficer–whoworkswiththeRegionSHWcoordinatorstoensuredeliveryofthepeersupportprogramme

• RegionSafetyHealthandWellbeingCoordinators–whomanagethepeersupportteamsandtheCIPSSprogrammeintheirrespectiveregions

• RegionCIPSSAdvisor–whoimplementsCIPSSintoRegionsandappoints,trains,andprovidesday-to-daysupportofpeersupportteams

• PeerSupportTeamLeader–whoprovidesapeersupportteamcoordinationrole

• PeerSupportteams–whoarelocatedineachRegion

• ThePreferredProviderNetwork–whichincludescontractedproviderssuchascounsellors,EAP,clinicalpsychologists,chaplainsetc.

Itisobviousthatacleargovernanceframeworkisidentifiedandis,onfacevalue,providingareasonablespanofcontroltoassistinensuringgapsbetweenpolicyandpracticeareeliminatedorminimised.However,whenoneexaminesthedetailsofthesecomponentsandjuxtaposesthemwithotherprogrammes,thentheappropriatenessofthecurrentgovernanceandresourcingbecomeslessobvious.Forexample,theNationalClinicalAdvisorroleisnotsubstantive;instead,itappearsthatthereisanexternalcontractorwhoprovidesadviceintermittentlyasrequested.ThisisdifferentfromanorganisationsuchasVictoriaAmbulance(whohavelessthanathirdoftheworkersofFireandEmergency,andwhosecounsellingunitFireandEmergencyadoptedtheMANERSprogrammefrom)thathastwopsychologistsworkingfulltimeinadvisoryroles.Inadditiontothis,VictoriaAmbulancehavetwofull-timechaplainswhosupportthesepsychologists,andthereisfurthersupportfromtwopeersupporterswhoworkinapaidsupportroleonamonth-by-monthrotationbasis.Furthermore,AmbulanceVictoriahasthreefulltimecoordinatorsoverseeingtheirpsychologicalwellbeingprogramme,allowingforasuperiorspanofcontrol,includingafulltimeprojectcoordinatorandtwoadditionalfulltimecoordinators/counsellors(C.Laufale,


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ParamedicandpeersupporterforStJohn,personalcommunication,October12,2018).Incontrast,FireandEmergency,withapproximately14,000staff,currentlyhasonepart-timeCIPSScoordinator(twodaysperweek)forthecoordinationofthenationalCIPSSprogramme,andnointernalpsychologistsorcounsellors.

TheCIPSSprogrammeisimplementedandmanagedataRegionallevel,atleastinsubstantialpart,byRegionSHWcoordinators.However,itappearsthatthereareanumberofvariablesthatarenegativelyaffectingtheSHWcoordinators’abilitytoensureanefficaciousdeliveryofthisessentialservice.Thesevariablesappeartoincludecompetingdemandsasaresult,inpart,oflargespansofcontrol.SHWcoordinatorshavesubstantialresponsibilitieswithregardtoboththephysiologicalandpsychologicalsafetyofworkers;insomeRegions,thisresponsibilityextendstoinexcessof1000workers.Furthermore,SHWcoordinatorshaveidentifiedthatgovernanceandresourcingissuesarefurtherimpactingtheirabilitytoprovideanoptimalservice.Thesespan-of-control,governance,andresourcingissuesappeartobecontributingtoworkloadsthatattimescancompromisewhatshouldbeaprimarycontrolmeasurewithregardtothecriticalriskofworkerpsychologicalsafety,healthandwellbeing.ThecauseandeffectofthecurrentsituationhasbeenarticulatedbyoneoftheSHWcoordinators:

"Ourworkloadsarehugeandasagroupofworkerschargedwithsupportingothersandfacilitatingaccesstowellbeingservicesweare–despiteourbestintentionsanddesiretobeofservice-challengedandcompromisedinourcapacitytodeliver.Thisalsoaffectsourownwellbeingandstresslevels."(SafetyHealthandWellbeingcoordinator,personalcommunication,March19,2019)

FeedbackfromSHWcoordinatorsindicatesthatvariablesincludingsuboptimalgovernance,resourcingandspansofcontrolmaybenegativelyimpactingtheirabilitytodeliveranoptimalservice,whilealsopotentiallycompromisingtheirhealthandwellbeing.Consequently,itispossibletoidentifyparallelsbetweenfirefighterswhomayexperiencealossofasenseofself-efficacyasaresultofinadequatetraining,resourcing,andsupport,andSHWcoordinatorswhoarealsobeingaskedtoprovideanessentialservicewithwhatappearstobesuboptimalgovernance,resourcingandsupport.

Finally,whilesomeSHWcoordinatorshaveconsiderabletrainingandexperiencespecifictopsychologicalwellbeing,otherscoordinators’trainingandexperienceismorealignedwiththephysiologicalaspectsofpersonnel’sSHW.ThismaybewhydocumentationindicatesthattherearetobeCIPSSadvisorpositionsforeachRegion.ItislikelythattheadditionoftrainedCIPSSadvisors,and/orwelfareofficers,ineachRegionwouldleadtoanincreasedabilitytoidentify,eliminateorminimiseSHWmattersrelatedspecificallytopsychologicalwellbeing.TheseroleswouldalsoprovideincreasedsupporttoRegionSHWcoordinators,whichwouldlikelycontributetoimprovedservicedelivery(NewZealandFireService,2017).However,itappearsasthoughtheCIPSSadvisorpositionsarebeingassumedbySHWcoordinatorswho,insomecases,arealsoadoptingthepeersupportteamleaderrole.ItisalsoworthnotingthatthereiscurrentlyonlyoneWelfareOfficer,basedinRegion4,inFireandEmergency.Itappearsthatthisadditionalresource,uniquetoRegion4,hasledto


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noteworthybenefitsforthatRegion’sworkers,asarticulatedintheFireandEmergencyPsychologicalWellbeingforLeadersresource(FireandEmergencyNewZealand,2018c).

Managementresourcingandspanofcontrol

Thespan-of-controlissueappearstoextendbeyondjustthatoftheSHWpersonnel.ItappearsthatinsomeRegions,FireandEmergencyManagers,AssistantAreaManagers(AAM)andAreaManagers(AM)faceanumberofbarriersthatmakeitmoredifficulttoprioritiseinitiativesthatwouldlikelyleadtoanincreaseinPOS,e.g.regularlyvisitingstationsandprovidingface-to-facetimewithcrews.Thesebarriersappeartofallintotwomaincategorieswithonemanagernotingthatthesefactorsare,inpart,contributingtofirefightersmissingoutonwhattheydeserveandneed(AreaManager,personalcommunication,February22,2019):

1. Spanofcontrol–Managers,particularlyinmetrobrigades,canhavespan-of-controlissuesinrelationtothenumbersofpersonnelundertheirmanagement.Thisspan-of-controlissuecanbefurtheredcomplicatedbyfactorssuchasthegeographicalspreadofpersonnelandtrafficcongestion.Furthertothis,alackofappropriateadministrativesupport,streamlineadministrationandrecruitpostingprocessesandsystemscancontributetomanagershavingtoallocateconsiderabletimetoofficeduties,atthecostofface-to-facetimewithfirefighters.

2. Managementmandate–TheprioritisationoftheSHWofFireandEmergencypersonnelisoutlinedatanationallevelthroughSHWcommitmentsandSHWpolicy.However,itdoesnotappearasthoughthismandate,inrelationtotheprioritisationofworkerwellbeingandcare,isembeddedintoallRegionandAreabusinessplans,atleasttoanysubstantialdegree,thatrelatetomanagementperformanceasmeasuredbykeyperformanceindicators(KPI)andbusinessoutputtargets.

POSandperceivedsocialsupportarecatalysed,inpart,bymeaningfulpersonnel-focusedinitiativesthatrequireasubstantialinvestmentoftime.Undoubtedly,thereareotherissuesleadingtoalackofprioritisationofworkerwellbeinginitiatives,suchalackofunderstandingaroundpsychologicaldistressandinjury;however,theaforementionedvariables,individuallyorincombination,poseaconsiderablebarriertomanagershavingmeaningfulengagementwithworkersandthatmayberesultinginlowlevelsofPOS,whichwouldlikelyotherwisebeaprotectivefactorinrelationtofirefighterpsychologicaldistressandinjury(Rhodes&Eisenberger,2002).

Inconclusion,itislikelythatgapsbetweenSHWpolicyandpracticeareoccurring,inpart,asaresultofinappropriatespansofcontrol,governance,andresourcing.Unaddressed,thesegapswillbeacontributingfactorwithregardtotheinabilitytoensurecurrentSHWcommitmentsaremet.

Relationship-firefighterandtraumasurvivorengagement

FireandEmergencySHWdocumentationnotesthatthereis“verygoodsupportavailablewhenweknowaboutwellbeingissuesorconcerns”(FireandEmergencyNewZealand,2018c,p.12).Thereareanumberofpointstonoteinrelationtothisstatement.Firstly,previoussectionsofthisreporthaveidentifiedthatkeysupportservices,atleastinsome


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cases,mayhaveconsiderableshortcomingsthatareresultingintheneedsoffirefightersnotbeingmet,whichcontradictsthisstatement.Additionally,thesecondpartofthestatementindicatesaneedtoknowofwellbeingissuesorconcernssothatappropriatesupportcanbeprovided.Thisisimportanttonoteasastrongtheme,relatedtofeelingsofdisconnect,hasdevelopedasaresultoffeedbackfromfirefightersatCIPSSpresentations,feedbackgroups,andtherecentReadytoRespondqualitativeresearchstudy(Adamsetal.,2018).ThatistosaythatitislikelythataconsiderablenumberoffirefightersbelievethatFireandEmergencyareattimesdisconnectedfromtheissuesfrontlinepersonnelarecontendingwith,andthereforeareunabletoappropriatelyrespondwithsufficientsupportinitiatives.Forexample,theReadytoRespondreportnotedthatanumberoffirefightersfeltlikemanagementweredistantfromtheday-to-dayrealitiesofoperationalwork,andthestressorsthatcomewithsuchwork(Adamsetal.,2018).Whileotherfirefighters,whotookpartinfeedbackgroups,identifiedalackofunderstandingandempathyfrommanagementresultingfromalackofconnection.Forexample,oneofficerprovidedthefollowingfeedback:“Ifeelthereisadisconnectbetweenmanagementandthecrewsontheappliances.‘ThemandUs.’Howthisisaddressed,Ijustdon’tknow.Butmoreempathyandunderstandingisneeded.”(StationOfficer,Region1,personalcommunication,December21,2018).Thisperceptionofdisconnectionisconcerning,asitislikelytocontributetolowerlevelsofPOS,whilealsoaccountinginpartforgapsbetweenpolicyandpractice.Ontheotherhand,whenrelationshipandconnectionarepresent,positiveoutcomestendtofollow,asexemplifiedintheexperienceofFirefighterYintheattachedcasestudy.Inthiscase,connection,relationshipandtrustwerekeyvariablesinidentifyingapsychologicalriskandminimisingthatrisk,whilealsoprovidinganopportunityforempowerment,learning,andgrowth.

SAMHSA(2014)notestheimportanceofbeingconnectedtotheneedsofworkersandtraumasurvivors,ifanorganisationwishestodevelopandprovideaneffectiveresponsetopsychologicaldistressandinjury.SAMSHAalsonotesthatitisessentialtounderstandconnectionfromtheperspectiveoftheculturalcontextofanorganisation.Connectionisaconceptfamiliartofirefighters,ascamaraderiehaslongbeenavalueandfoundationoftheNZFS,nowFireandEmergency,organisation.Forthemostpart,firefightersbelieveinthiscamaraderieethicbothontheincident-groundandalsooutsideofit,oftengoingtotremendouslengthstosupporteachotherintimesofdifficulty.ThiscontextualunderstandingoftheimportanceoflookingaftereachothermaygosomewaytoexplaintheintensityofperceivedviolationthatoccurswhenfirefightersdonotbelievetheyarevaluedorcaredforbyFireandEmergency.TheimportanceofconnectionandrelationshipcanalsobeseeninthewiderculturalcontextofTeAoMāori.InaMāoricontext,theconceptsofwhakawhanaungatangaandwhanaungatanga,translatingroughlyastheformingandmaintainingofrelationship,areseenastranscendentvaluesthatMāorihaveusedtodetermine‘right’and‘wrong’conducttowardsoneanother(Quince,2007;"Whakawhanaungatanga,"n.d.).Itwasbelievedthatadherencetoprinciplesofwhanaungatangawouldleadtoastateofora(wellbeing),withinanindividualandwithinagroup.ForMāorifamiliarwiththeconceptofwhanaungatanga,itislikelythattheywouldseethegapsinaSHWstrategyandgapsbetweenSHWpolicyandpracticeasaresult(inpart)ofalack,orinabilitytomaintainappropriateconnectionwithfrontlineworkers.Itispossiblethatthislackofconnectionmanifestsinatleasttwoforms:


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1. Alackofsufficientconnectiontotheobservationsandneedsoffirefightersandotherpersonnelwhoareexperiencingpsychologicaldistressandinjury

2. Alackofsufficientconnectiontoavalueshierarchywheretranscendentvaluessuchasintegrityandthewellbeingofpersonnelareprioritisedaboveallelse,andthatthesevaluesmanifestnotonlyinwordsbutintangibleactionandbehaviour.

Whenanorganisationanditsleadersareconnectedtotheobservationsandneedsofworkers,andarecommittedtoaddressingthoseneedsinwaysthatarenotperceivedascomplianceor‘boxticking’,thenitcanbeassumedthatanaturaloutcomewillbetheformationandmaintenanceofarelationshipthatgrowstrustbetweenemployerandemployee,andfostersthewellbeingofall(Sinek,2014).ThisemphasisonrelationshipandconnectionisfurtherhighlightedinSAMHSA(2014)guidelinesforatrauma-informedapproachwithinanorganisation,suchasFireandEmergency,whichemphasisestheimportanceofengagementwithworkersandtraumasurvivors.Morespecifically,SAMHSA(2014)notesthatworkersshouldhaveasubstantialinvolvement,voice,andmeaningfulchoicewithregardtoareasrelatedtoSHWstrategyandcontrolmanagement,includingprogrammedesign,implementation,delivery,evaluation,andqualityassurance.Thereisclearcauseforsuchprocesses,astheyassisttoensurearelationshipismaintainedbetweenthosewhodevelopstrategyandinitiatives,andthosewhothestrategyandinitiativesareaimedat.FailuretoinvolveandgivevoicetofirefighterswhoareexperiencingincreasedlevelsofPTEexposure,andthosewhohaveexperiencedapsychologicalinjury,mayresultinastrategyandcontrolmeasuresthatdonotsufficientlymeettheneedsofFireandEmergencyfirefighters.Morerecently,FireandEmergencyhavetakenstepstoincreasethevoiceoffirefightersinrelationtopolicy,forexample:theReadytoRespondreport;Beacon(aFireandEmergencycrowdsourcinginitiative);andworkinggroupswithfirefighterrepresentation.However,itisevident,giventhefeedbackofaconsiderablenumberoffirefighters,thatmoremustbedone,especiallyintheareaofwellbeing,toidentifytheobservationsandneedsoffirefighters,andhavefirefightersinvolvedinthedevelopmentofinitiativesthatwouldmeettheseneeds.

AnexaminationoftheresearchquestionsestablishedinPartTwoofthisreporthasidentifiedthatFireandEmergencyhaverespondedtopsychologicaldistressandinjuryriskswithintheorganisation.Furthermore,anumberoftheinitiativesthatmakeupthisresponseareevidence-informedand‘astepintherightdirection’.However,PartTwoofthisreporthasalsoestablishedthatthereisevidencetosuggestthatthecurrentSHWstrategyandcontrolmeasureslackthescopeandsophisticationrequiredtoensureSHWcommitmentsandobjectivesaremet.Furthermore,thereisevidencethatsuggeststherearesubstantialgapsbetweenpolicyandpracticeinrelationtotheseobjectivesandcontrolmeasures.Whileamultivariateanalysiswouldberequiredtoidentifyallthevariablesaccountingfortheseissues,itisevidentthatalackofappropriategovernanceandresourcingandalackofconnectiontofrontlineworkersaretwosubstantialcontributors.


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PartTwoconclusionTheprioritisationofpeople,aboveallelse,issummedupintheMaoriproverb“Heahatemeanuioteao.Hetāngata,hetāngata,hetāngata”translated-“Whatisthemostimportantthingintheworld?Itispeople,itispeople,itispeople”(Caldwell,2015).ThisMāoriproverbhasbeenidentifiedbyFireEmergencyasakeyvalue,andhascontributedtothedevelopmentofSHWinitiativesthatformthecurrentresponsetopsychologicaldistressandinjuryrisksfacedbyfirefighters(FireandEmergencyNewZealand,2017c).However,PartTwoofthisreporthasidentifiedthatthiscurrentresponseisunlikelytobesufficientwithregardtoitsobjectivesofidentifying,eliminatingandminimisingpsychologicalrisksfacedbyfirefighters.AninsufficientresponsetotheserisksislikelytobecontributingtoanincreasedincidenceandprevalenceofpsychologicaldistressandinjurywithinFireandEmergency.Itisalsolikelytobecontributingtohigherratesofabsenteeismandworkerturnover,whilenegativelyaffectingproductivityandoperationalefficacy.ImprovingtheresponsetopsychologicaldistressandinjuryrisksfacedbyFireandEmergencyfirefighterswillinvolvearangeofinitiativesincludingimprovedgovernanceandresourcing,butmostlyitwillinvolveensuringmoreisdonetoidentify,connect,andrespondtotheneedsoffirefighters.Failuretorespondinatimelymannertotheseneedswilllikelybeseen,byaconsiderablenumberoffirefighters,asaviolationofpreviouslystatedSHWcommitmentsandthepreeminentvalueofFireandEmergency–theprioritisationofpeople’swellbeingaboveallelse.


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PartThree–MakePumpsInthecontextofastructurefire,thecompletionofa‘360’providesanofficerwithenoughinitialinformationtodecideonanappropriatestrategyforrescueandextinguishment,aswellasastrategyfortheeliminationorminimisationofanyidentifiedhazards.Furthermore,anofficerwillhaveafoundationofinformationthatwillallowthemtoidentifyandrequestwhatresourcestheywillrequiretoensuretheycanexecutetheirstrategyforeffectiverescue,extinguishment,andhazardcontrol.PartThreeofthisreporthasbeentitledMakePumps,asthistermcorrelatestoarequestforadditionalresourcesintheformoffurtherfireapplianceswhenanofficer,oncompletionoftheirsize-up,identifiesthattheywillrequirefurthersupportandresourcestoachievetheirincidentgroundobjectives.Drawingonthisanalogy,thefollowingsectionofthereportwillprovideabriefexaminationofanevidence-informedframework,TIC,thatwouldlikelyprovideamoresubstantialandsophisticatedresponsetopsychologicaldistressandinjuryrisksidentifiesinPartOneandPartTwoofthisreport.TICwillalsoassistinimprovinginitiativescurrentlyemployedbyidentifyingandclosinggapsbetweenpolicyandpractice.ThisanalysisofTICwillbefollowedbyrecommendationsbasedonthefindingsofPartOneandPartTwoofthisreport.

PartThreeobjectivesThefollowingresearchquestionwillformafoundationforidentifyingappropriaterecommendationsinrelationtothefindingsofPartOneandPartTwoofthisreport:

WhatwouldenhanceFireandEmergency’scurrentresponsewithregardtoidentifyingandeliminating,orminimisingpsychologicaldistressandinjury?

PartThreemethodology

Trauma-informedcare

Giventhescopeofthisreport,itwasnotpossibletoexamineallpsychosocialhealthframeworksforsuitabilitywithregardtoaFireandEmergencycontext.However,anassessmentwascarriedoutinwhichanumberofframeworkswereconsideredforfurtherexamination.Trauma-informedcare(TIC)wasselectedforprimaryexaminationafterconsultationwithanumberofhealthprofessionalsandasaresultofitsevidence-informedfoundationsanditsestablishedapplicationinanNZcontext.

Recommendations

RecommendationsinPartThreewerecompiledvia:ananalysisofthefindingsofPartOneandTwoofthereport;findingsfromtheReadytoRespondandBeyondBluereports;feedbackfromoperationalandSHWworkers;feedbackfromhealthprofessionals;andguidelinesprovidedbySAMHSA.


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TraumainformedcareResearchquestion:WhatwouldenhanceFireandEmergency’scurrentresponsewithregardtoidentifyingandeliminating,orminimisingpsychologicaldistressandinjury?

TheimplementationofaTICframeworkhasbeenidentified,asaresult(inpart),ofthefindingsofPartOneandTwoofthisreport.Consequently,TIChasbeenidentifiedasaframeworkthatwouldassistFireandEmergencytoimproveitsresponsetopsychologicalSHWrisks.

ThefollowingsectionofthisreportwillprovideanoutlineofthecoreprinciplesandassumptionsofTIC,astheTICphilosophyandframeworkwillcontributetothereportrecommendations.Theimplementationoftheover-archingframeworkofTICtoaFireandEmergencycontextwouldnotnecessarilybeintendedtoreplacethecurrentSHWstrategyandcontrolmeasures.Rather,itwouldbeusedtostrengthenandsupportthegoodexamplesofpolicyandpracticethatalreadyexist,whilealsosuggestingnewwaystoimprovetheorganisationalresponsetopsychologicaldistressandinjury.Accordingly,aTICapproachcouldbeadaptedtoaFireandEmergencycontexttoassisttheorganisationinthefollowingways:

• ContributetowardstheidentificationandeliminationorminimisationofpsychologicaldistressandinjurywithinFireandEmergency

• IdentifyandremedygapsbetweencurrentpsychologicalSHWpolicyandpractice

• EnsureSHWcommitmentsandlegalresponsibilitiesareupheld

• IncreasecurrentlevelsofPOS

• Reduceabsenteeismandworkerturnover

• ImproveservicetotheNZpublic.

TICiscongruentwithcurrentandproposedobjectivesofFireandEmergency,includingaligningwiththecurrentSHWcommitments,theproposedorganisationalvision,andtheproposedkeyareasofchange(FireandEmergencyNewZealand,2017a,2018a;FireEmergencyNewZealand,n.d.)

SAMHSAhasnotedthatitisevidentthataddressingtraumarequiresamulti-layeredapproachinclusiveof:earlydetectionforprevention;effectivetrauma-specificassessmentandtreatment;andpublicandorganisationaleducationandawareness.TICisanoverarchingframeworkthatassistsorganisationsandcommunitiestomaximisetheimpactsofpre-,peri-,andpost-psychologicaltraumainitiativesaimedatidentifying,preventing,andtreatingpsychologicaldistressandtrauma(SAMHSA,2014).AreportbytheBritishPsychologicalAssociationnotesanemergingbodyofevidencethatsuggeststhatinterventionsbasedontrauma-informedprinciplesareeffectiveinreducinglowmood,traumareactions,self-harm,suicidalityandre-victimisation.ThereportalsonotesthatthereisevidencethatTICmayhelpincreaseadaptivecopingskills,improvephysicalhealth,andreducegeneral‘mentalhealthsymptoms’(Johnstone&Boyle,2018).


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TheTICphilosophyinvolvesanevolutioninhealthpracticethatcentresonidentifyingwhathashappenedtopeopleratherthanwhatiswrongwithpeople.Thisisanimportantfocusshift,aspreviousphilosophiesthatfocusedonwhatwaswrongwithpeoplemayhavecontributed,inpart,tothestigmaissuesidentifiedearlierinthisreport.Thus,theTICapproachinvolvestheeducationandinvolvementofeveryoneinanorganisation,fromreceptionisttoCEO,inunderstandingthisphilosophyandhavinganactiveroleintraumapreventionandtreatment.TheimportanceofTICisnowrecognisedamongstmosthealthservices,asithasbecomeclearthattraumainterventionsarenotenoughinandofthemselves,andthatorganisationalandsocietalcultureplaysavitalroleinmaximisingtheimpactofspecificinterventions(SAMHSA,2014;Yatchmenoff,Sundborg,&Davis,2017).InNZ,TIChasbeenrecognisedandrecommendedbytheNZMinistryofHealthandorganisationssuchasTePouoteWhakaaroNui,anationalcentreofevidence-basedworkforcedevelopmentformentalhealthinNZ(TePouoteWhakaaroNui,2018).ThissectionofthereportwilldrawupontheSAMHSA(2014)TICimplementationguidelinesindemonstratinghowaTICframeworkcouldassistFireandEmergencyinachievingitsSHWobjectives.TheguidelinesforthedevelopmentofaTICapproachformasolidfoundationforimplementationhavingintegrated:trauma-focusedresearch;insightsarticulatedbytraumasurvivors;andpractice-generatedknowledgewithregardtotraumainterventions(SAMHSA,2014).

Principlesandassumptionoftraumainformedcare

TherearefourkeyassumptionsandsixkeyprinciplestoaTICframeworkthatcouldbeappliedtoFireandEmergency.ThefollowingsectionwillidentifyandapplytheseassumptionsandprinciplestoaFireandEmergencycontext:

Assumptionsoftrauma-informedcare

1. Realise–Atrauma-informedFireandEmergencywouldrealisethewidespreadimpactoftraumaandbeabletoidentifyprospectivepathstorecovery.

2. Recognise–Workerswithinatrauma-informedFireandEmergencywouldbeabletorecognisethesignsandsymptomsoftraumawithinthemselves,theircolleagues,theirfamilies,andthecommunitiestheyworkwithin.

3. Respond–Atrauma-informedFireandEmergencywouldrespondbyfullyintegratingtraumainsightsintoprocedures,policies,andpractices.

4. Resistre-traumatisation–Atrauma-informedFireandEmergency,havinginsightsintotheaetiologyofpsychologicaltrauma,wouldseektoactivelyresistre-traumatisation.


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Principlesoftraumainformedcare

ATICapproachinvolvesadheringtosixkeyprinciples,ratherthanaprescriptivesetofcheck-boxes,makingitsimplertoadaptforaFireandEmergencycontext.Thesixkeyprinciplesarelistedbelow,followedbyabriefexplanationofcongruenceandsuitabilityforaFireandEmergencysetting(SAMHSA,2014,p.10):

1. Safety

2. Trustworthinessandtransparency

3. Peersupport

4. Collaborationandmutuality

5. Empowerment,voiceandchoice

6. Cultural,historical,andgenderissues

Safety

RenownedpsychiatristandtraumaresearcherJudithHermanhasrepeatedlyemphasisedtheimportanceofestablishingafoundationofsafetyandsecurityintheinitialstagesofpsychologicaltraumarecovery(Herman,1992).InTIC,feelingsofsafetyarerecognisednotonlyasafoundationforrecovery,butalsoasafoundationforprevention.InTIC,itisrecognisedthatworkerswhofeelpsychologicallysafeandwellaremorelikelytocarryouttheirdutieseffectivelyandhavetheirriskofpsychologicaltraumaminimisedoreliminatedthanthosewhodonotfeelsafeintheirworkenvironment.ThisisimportanttonotegiventherecentfindingsoftheShaw(2019)reportintobullyingandharassmentwithinFireandEmergency.Furthermore,itnotesthatthedevelopmentofpracticesrelatedtoacultureofsafetyshouldbelargelyinformedbyworkers,whichprovidesanumberofbenefitsincludingincreasedbuy-infromworkers.TheconceptoftheestablishmentofsafetytoeliminateandminimiseinjurycanbeseenwithintheoperationalaspectsofFireandEmergencywhereappropriatePPE,training,policy,andprocedureforma‘preparedness’ethictoensurerisksassociatedwithexposuretoincidents,suchasmotorvehicleincidentsandstructurefires,areeliminatedorminimised.Inmuchthesameway,TICinsiststhattoolswithregardtopsychologicalsafetyareprovidedtoensurestafffeelsafeandthepreventionofpsychologicaldistressandinjuryismaximised(SAMHSA,2014).

Trustworthinessandtransparency

Oneofthefundamentalgoalsofthetrustworthinessandtransparencyprincipleistoensurethatworkersfeeltheycantrusteachother,theirmanagers,andtheorganisationitself.ResearchbySattleretal.(2014)notedthatsomefirefightersratedorganisationaldistressasbeinggreaterthanthedistresscreatedbyexposuretocriticalincidents.Variablesleadingtoorganisationaldistressincludecommunicationbreakdownsandthelackoffrontlinestaffinvolvementindecision-makingprocesses.InTIC,itisbelievedthattransparency,withregardtoorganisationaldecisionsandoperations,canhelptobuildafoundationoftrust.Fromthisfoundation,relationshipsoftrustcanbeformedandmaintained.ThisconceptisreflectedinTeAoMāoriwhereproperrelationshipissummedupintheconceptsof


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whanaungatangaandwhakawhanaungatanga,whichemphasisetheimportance,forthegroupandindividual,oftheformingandmaintainingofrelationshipthroughadherencetoprinciplessimilartothatoftrustworthinessandtransparency(Quince,2007;SAMHSA,2014).

Peersupport

InTIC,peersaredefinedasindividualswhohavelivedexperiencesoftrauma,andwhoareabletousetheirexperiencestohelpothers.Theselivedexperiencesareseenasvitalforcommunicatingamessageoftrust,safety,andhope.Itisbelievedthatcollaborationwithandthroughpeerscanleadtochangesinculturethathelptoensureatraumamessageisrelevantandthereforeeffective(SAMHSA,2014).Indeed,ithasbeenshownthatfirefightersvaluepeersupportasaresourceforcopingwithdistress(Sattleretal.,2014).

Collaborationandmutuality

ATICorganisationrecognisesthateveryonehasaroletoplayinminimisingandeliminatingtrauma.Thisinvolvesensuringthatrankandpowerareusedcreatively,inawaythatpromotesanenvironmentofcollaborationandrespect,wheredecision-makingisinformedbyreflectedexperiencefromarangeofareas–forexample,theinclusionofpeervoicesongroupstaskedwithidentifyinganappropriateorganisationalresponseinrelationtopsychologicalinjuries(SAMHSA,2014).Whilethiscanbemoredifficulttoachieveinparamilitaryorganisations,suchasFireandEmergency,itispossible.RecentpracticebyFireandEmergencyisevidenceoftheorganisation’scommitmenttoasophisticatedmodelofmanagementthatcanshiftgearsdependingonthesetting(FireandEmergencyNewZealand,2018a).

Empowerment,voice,andchoice

InaTICorganisation,workersareempoweredtodotheirworkaseffectivelyaspossiblebyensuringadequateorganisationalsupportisprovided.Thissupportwouldincluderecognisingthestrengthsandexperiencesofindividualswithintheorganisationandputtingthemtouse.InaFireandEmergencycontext,itwouldincludecommitmenttothedevelopmentandpromotionofresilienceandpost-traumaticgrowtheducationforfirefighters,FireandEmergencyasawhole,andthecommunitiesinwhichFireandEmergencyserves.SeniorstaffwithinFireandEmergencywouldhaveanawarenessofhowthemisuseofpowercancontributetoanoppressiveatmospherethatisnotcongruentwiththeprinciplesofsafetyandtrustworthiness.FireandEmergencywouldworktoempoweritspeoplethroughshareddecision-makingintheareaofpsychologicalwellbeing(SAMHSA,2014).

Cultural,historical,andgenderissues

InaTICorganisation,traditionalculturalapproachestowellbeing(suchasTeWhareTapaWha)areintegratedaspartofaresponsetotrauma(SAMHSA,2014).Thisassiststoensurethatareasimportanttomanycultures–suchasthephysical,mental,familial,andspiritual–areacknowledgedandcateredfor.Furthermore,historicalissuesareacknowledgedand


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addressedandtheorganisationactivelyseekstomovepastculturalstereotyping(SAMHSA,2014).

Implementationdomains

TheSAMHSA(2014)modelofTICgroundsthedevelopmentandimplementationofatrauma-informedapproachintotenimplementationdomains.ThesedomainscouldprovideafoundationformeasuringthecurrentFireandEmergencySHWstrategyandcontrolmeasuresinrelationtotheeliminationorminimisationofpsychologicaldistressandinjury.Thesedomainsarenottobethoughtofasaprescriptivestep-by-stepprocessorachecklist,butaguide–basedonorganisationalchangeliteratureandmodelsforestablishingtrauma-informedcare–thatcanprovideafoundationfortheestablishmentandmaintenanceofaTICFireandEmergency(SAMHSA,2014).Thefollowingsectionprovidesexamplesofinitiatives,basedontheassumptions,principles,andguidelinesforimplementationofTICprovidedbySAMHSA(2014),thatFireandEmergencycouldtake,andwhichwouldbelikelytoleadtoimprovementsinpsychologicalwellbeingforFireandEmergencyworkers.Thetenimplementationdomainsareoutlinedbelow(SAMHSA,2014,p.12):

1. Governanceandleadership

2. Policy

3. Physicalenvironment

4. Engagementandinvolvement

5. Cross-sectorcollaboration

6. Screening,assessment,treatmentservices

7. Trainingandworkforcedevelopment

8. Progressmonitoringandqualityassurance

9. Financing

10. Evaluation

Governanceandleadership

• IdentifyandresourceateamforassessingtheFireandEmergencySHWstrategyinrelationtoTICand,ifnecessary,implementingchangesthatwouldseecurrentpolicyand/orpracticesalignwithaTICapproach.

• IdentifyaFireandEmergencymanagertooverseeaTICassessment.ThisindividualwouldhaveoperationalexperienceaswellasanunderstandingoftheaetiologyofpsychologicaltraumaandtheTICapproach.

• IdentifyandinvestinanumberofworkersthatwouldshareresponsibilityfortheleadershipoftheTICapproachassessment.Theseindividualswouldhaveoperationalexperienceaswellasanunderstandingofpsychologicaltraumawithregardtofirefighters,andalsohaveaclearunderstandingoftheTICapproach.TheseindividualswouldreportdirectlytotheidentifiedmanagerandworkincollaborationwiththeminachievingtheTICassessmentandobjectives.


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• Identifyandinvestinaclinicalsupervisorwithappropriateclinicaltrainingandpracticewithregardtotraumawithinafirstresponsecontext.ThisindividualwouldprovidesupervisionandsupporttotheteamresponsiblefortheinvestigationandimplementationofTICwithinFireandEmergency.ItwouldbeusefulifthisindividualhadapriorunderstandingofTIC.

• IdentifyandengagetheassistanceofalocalresearchinstitutionoruniversitytoassisttheTICteamintheidentificationandapplicationofnecessaryresearchtoolsandprocesses.

GoalsoftheTICteamwouldthenincludealloftheremainingninedomains.

Policy

• SeektoensurethatcurrentnationalandlocalpolicyandpracticesarecongruentwiththeassumptionsandprinciplesofTIC.Investigateifthesepoliciesandproceduresincludecross-agencyprotocolsthatreflecttrauma-informedprinciplesandmovebeyondcompliancetointegratedpractice.

• ExamineifcurrentstaffingpoliciesadequatelydemonstrateacommitmenttoTICtraining,assumptions,policies,andpractice.

• Seektoidentifyandrectifygapsbetweenpolicyandpracticethatmayleadtoinefficacyandaperceptionof‘boxticking’.

Physicalenvironmentoftheorganisation

• Identifyifthephysicalenvironmentthatstaffinhabitpromotescollaborationandasenseofsafety.Identifyiffirefighters,managers,andsupportstaffbelievetheyareabletoworkcollaborativelyfromaplaceoftrust,openness,andtransparencywithinFireandEmergency.

• SeektoestablishabenchmarkofPOStomeasuretheperceptionofthephysicalenvironment.

Engagementoftraumasurvivors

• Identifyandinvolvefirefightersandotherstaffwhohaveexperiencedandrecoveredfromtraumainascertainingtheappropriatenessofcurrentandproposedpsychologicalwellbeinginitiatives.

• Investigatehowpeersupportcanbefurtherintegratedintoaservicedeliveryapproach.

Cross-sectorcollaboration

• Identifyanddeveloppotentialkeypartnershipswithotherfirstresponseorganisations,suchasStJohnandtheNZPolice.Identifythepotentialforsharedresourcing,research,andinterventions.

• Investigatethepotentialofcollaboratingwithalocalresearchinstituteoruniversitywithregardtopsychologicaltraumaresearch.


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Screening,assessment,andtreatmentservices

• Seektoidentifyifinternalandexternalpsychologicalsupportservicesaresuitableasmeasuredbyclientcenteredness,culturalappropriateness,andtrauma-informedcongruence.

• Seektoidentifyifgenderandculturespecifictraumaservicesandsupportsareavailable.

Trainingandworkforcedevelopment

• Ensureappropriateandongoingsystemsoftraumaeducationareinplaceandthathumanresourcesystemsincorporatetrauma-informedprinciplesinrelationtohiring,supervision,workaccidentandnon-workaccidentprocesses,andstaffevaluation.

• Identifyifappropriatetoolsandsystemsareinplacethatassistinaddressingemotionaldistressthatcanarisefromworkinginatraumaenvironment.

Progressmonitoringandqualityassurance

• Identifyalocalresearchinstituteoruniversitythatcouldassistinthedevelopmentofidentifyingappropriateevidence-basedtrauma-specificscreening,assessments,andtreatmentsaswellasdevelopingapsychologicalhealthsurveyforthepurposesofmeasuringtheincidentandprevalenceofpsychologicalinjurywithinFireandEmergency.

• InvestigateappropriatemeansforbenchmarkingtraumainterventionswithinFireandEmergencytoassistinensuringefficacy.

• InstigateacontinualreviewprocesstoensureaFireandEmergencyapproachtoTICreflectstheassumptionsandprinciplesofTICandfocusesonefficacyratherthancompliance.

Financing

• Reviewtheappropriatenessofcurrentfundingforensuringsupportofatrauma-informedapproach.Thiswouldinclude:assessingresourcingtoensureappropriatespansofcontrolforSHWworkers,assessingresourcingforstaffeducation;continuedsupport,supervision,andtrainingofpeersupporters;engagementofresearchforthepurposesofidentifyingincidenceandprevalenceratesofpsychologicalinjury;andthesupportofcross-agencycollaborationefforts.

Evaluation

• IdentifyifcurrentmeasuresandevaluationdesignsusedbyFireandEmergencyreflectanappropriateunderstandingoftrauma.

• IdentifyiftherearemeasuresinplaceforgatheringfeedbackinrelationtotheefficacyofFireandEmergencypsychologicalwellbeinginitiatives.


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RecommendationsResearchquestion:WhatwouldenhanceFireandEmergency’scurrentresponsewithregardtoidentifyingandeliminating,orminimisingpsychologicaldistressandinjury?

ThefollowingrecommendationsarebaseduponthefindingsofthisreportaswellasliteraturefromSAMHSAinrelationtoestablishingaTICorganisation,feedbackfromFireandEmergencyfirefighters,findingsfromtheBeyondBluesnationalstudy,andSection44oftheHSWA2015.

Therecommendationshavebeensplitintothefollowingsections:

• Action:The12recommendationsonactionprovidesomeimmediateoptionsavailabletoFireandEmergencythatarelikelytoassistinthepreventionandtreatmentofpsychologicaldistressandinjury.

• Monitoring:ThethreerecommendationsonmonitoringaddressanumberofavenuesavailabletoFireandEmergencytoimproveidentificationandmonitoringofpsychologicalhealthwithintheorganisation.Thissectionalsoprovidesavenuesformeasuringtheefficacyofinitiativesimplementedinrelationtopsychologicalwellbeing.

• Research:ThefiverecommendationsonresearchwillassistinbridgingthedatagapcurrentlypresentwithinFireandEmergencyinrelationtopsychologicalwellbeing,byprovidingadetailednationalpictureofpsychologicaldistressandinjurywithintheorganisation.ThisdatawillprovideamuchclearerpathwaytoanimprovedresponsetopsychologicalSHWrisks,whichwillassistFireandEmergencytoensureitismeetingitsSHWlegalobligationsandSHWcommitments.

Action1. Trauma-informedcare–ItisrecommendedthatFireandEmergencyimplements

TICasanevidence-informedoverarchingframeworktoassistFireandEmergencyinassessinggapsinthecurrentSHWstrategy,andgapsbetweencurrentSHWpolicyandpracticerelatedtopsychologicaldistressandinjuryrisks.Furthermore,TICmayassistFireandEmergencytoincreasePOSbystrengtheningcurrentandproposedpsychologicalwellbeinginitiatives,byimprovingorganisationalculture,andbyincreasingcollaboration.

2. Careerandvolunteertraining–Itisrecommendedthatacomprehensivepsychologicalwellbeingeducationcomponentbeincludedaspartofallcareerandvolunteerrecruits’courses,andasapartofcareerandvolunteerpromotionalprogressionandtrainingmaterialandcourses.Examplesofpsychologicaleducationcomponentsinclude:trainingtoimproveasenseofself-efficacyandagencyatcriticalincidents;psychologicaldistressandinjuryawareness,prevention,andtreatment;trainingrelatedtoincidentemotionalaspectexposure;trainingfordealingwithfamiliesatincidents;educationwithregardtohelpseeking;and


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trainingforthefacilitationofwitnesswelfare.Additionally,itisrecommendedthataspectsofCIPSS,PFA,andconceptssuchasresilienceandPTGbecoveredaspartofthesepsychologicaleducationcomponents.Itisalsorecommendedthatcurrentprogressionandtrainingliteraturebereviewedtoensureitreflectscurrentbestpractiseinrelationtopsychologicaldistressandinjury.Finally,itisrecommendedthatoperationalworkersandtraumasurvivorsplayaconsiderablepartinthedesignanddeliveryoftheseeducationcomponents.

3. Ongoingtraining–ItisrecommendedthatFireandEmergencyprovidesregular,person-to-personpsychologicaleducationinrelationtothecomponentsidentifiedinrecommendation2.Additionally,itisrecommendedthatthistrainingbeembeddedintotheOperationalSkillsMaintenance(OSM)system.Finally,itisrecommendedthattheseinitiativesbedevelopedincollaborationwithoperationalworkersandtraumasurvivors.

4. Wellnesschecks–ItisrecommendedthatFireandEmergencyinvestigateanationaldirectiveinrelationtotheprovisionofregularwellnesschecksasanearlydetectionandpreventativemeasurewithregardtopsychologicaldistressandinjury.Whilethereisworkunderwayinthisregard,itisrecommendedthatFireandEmergencyensureoperationalpersonnelandtraumasurvivorsplayaconsiderablepartinthedevelopmentofwellnesschecks.

5. Managerialresourcingandmandate–Itisrecommendedthatareviewofmanagementspansofcontrolandadministrationsupportbecarriedouttoassistinensuringmanagersareabletoprioritisepersonnelwellbeing.Additionally,itisrecommendedthatFireandEmergencyprovideaclearmandateformanagers,embeddedintoRegional/Areamanagementbusinessplans,withregardtotheprioritisationofpersonnelwellbeingaboveallotherduties.

6. Stigma–Thisreportrevealedthenegativeimpactthatself-perceivedstigmainrelationtopsychologicalinjuriescouldhaveonhelpseeking.ItisrecommendedthatFireandEmergencycarryoutaninvestigationwithregardtostigmainrelationtopsychologicalinjurywithintheorganisation.Thisinvestigationshouldbeusedtoinformacampaigntoaddressstigmainrelationtopsychologicalinjury,maladaptivebehaviourandhelpseeking.

7. Supportservices–Itislikelythatariseincriticalincidentexposureandanincreaseinawarenessoftheimpactofpsychologicalinjurywillplacepressureonexistingsupportservices.ItisvitalthatFireandEmergencyensuresthatanincreaseindemandforsupportcanbefullymetbyappropriatesupportproviders.Thiswouldincludeensuringthatenoughappropriatelytrainedpsychologicalsupportproviders,foreachofthefourtiersofsupport,areinplace,readilyavailable,andsupportedbyanintegratedandwell-managedsystemforreferrals.Furthermore,itisrecommendedthatthoseinvolvedinthepreventionandtreatmentofpsychologicalinjury,andthoseinvolvedinmonitoringandresearchingpsychologicalinjury,haveasufficientunderstandingoftheoperationalrealitiesfacingthemoderndayFireandEmergencyfirefighter.Itisalsoimportantthattheseprovidersareregularlybriefedonrelevanttrauma-relatedliterature.


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8. Peersupport–ItisrecommendedthatFireandEmergencyprovidesanationalmandatewithregardtothereinvigorationofRegionalpeersupportprogrammes.Thisshouldincludeensuringpolicyandpracticearealignedwithinternationalbestpractiseguidelinesandthatgapsbetweenpolicyandpracticeareidentifiedandminimisedoreliminated.Thiswouldincludereviewinggovernanceandpracticerelatedtotrainingandsupervision.

9. Governanceandresourcing–ItisrecommendedthatFireandEmergencycarriesoutanimmediatereviewofthecurrentnumberofFireandEmergencyworkersemployedtoassistwiththepreventionandtreatmentofpsychologicalinjuries.Asapartofthisreview,considerationshouldbegiventotheprovisionoffurtherRegion/Arearesourcessuchasinternalpsychologists,wellbeingofficers,andchaplains.ItisalsorecommendedthatareviewofcurrenthumanresourcingbecarriedouttoensurepersonnelinSHWpositionsarenotexceedingoptimalspansofcontrol,andthatsuccessionplanningisinplaceforthesepositions,asthesevariablesarelikelytohaveaconsiderableimpactonservicedelivery.Furthermore,itisrecommendedthatthegovernanceandresourcingofindividualRegions/AreasbereviewedtoensuretheyreflecttheuniquerisksandobstaclesfacedbyeachRegion/Areaindeliveringeffectivepreventionandtreatmentinitiativesinrelationtopsychologicaldistressandinjury.

10. Collaboration–Itisrecommendedthatanannualsymposium,relatedtofirefighterpsychologicaldistressandinjury,isprovidedforfirefighters,traumasurvivors,andSHWstaffasacatalystforanimprovedresponsetopsychologicalSHWriskswithinFireandEmergency.Thissymposiumwouldserveasanongoingcatalystforcollaboration,educationandactionwithregardtopsychologicaldistressandinjury.Thissymposiumwouldalsoprovideanopportunitytoinviteotheremergencyresponseorganisations,suchastheNZPoliceandStJohn,toidentifyhowwemightcollaborateonfutureinitiativesaimedatpreventingandtreatingpsychologicalinjury,maladaptivebehaviourandsuicidewithinourrespectiveorganisations.

11. Retiredfirefighters–Retiredandlongservingfirefightersappeartohaveanincreasedriskofpsychologicalinjuryasaresult,inpart,ofthecumulativepotentialofcriticalincidentexposureandthelossofresourcecaravans.Therefore,itisrecommendedthatFireandEmergencyinvestigatesandresourcesaprogramme,suchas‘legacysupport’,forthepurposesofsupportingretiredfirefighters.Thissupportshouldinclude:assistingwithtransitionoutofthefirefightingrole;ongoingmonitoringofpsychologicalhealth;andprovisionofpsychologicalwellbeingassistance.

12. Leadership–POSappearstobeasignificantfactorinrelationtotheresilienceandwellbeingofworkers.Consequently,itisrecommendedthatallworkersinapositionofleadershiparemadeawareoftheconnectionbetweenworkerwellbeingandPOS.ThereshouldbeaconcertedendeavourbyleaderswithinFireandEmergencytodemonstratethisunderstandinginthewaytheyinteractwiththeirworkersandinhowtheyapplythisunderstandinginorganisationaldecision-makingprocesses.


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Monitoring1. Datarecording–ItisrecommendedthatFireandEmergencytakesthefollowing

threeactionstoimprovedatagathering.

A. InvestigateandimplementchangestotheincidentreportingsystemthatwouldallowofficerstoincludeinformationwithregardtoidentifyingSHWrisks,inrelationtomedicalcallsandotherpotentiallytraumaticincidents.

B. Createadatacatchmentforcareer,volunteer,andretiredfirefightersuicide.

C. Reviewthecurrentexitinterviewframeworktoestablishiftheseinterviewsprovidesufficientopportunityforfeedbackinrelationtopsychologicaldistressandinjuryinrelationtopersonnelturnover.

2. Surveys–ItisrecommendedthatFireandEmergencydevelopsandimplementstwosurveysforthepurposesofidentifyingandbenchmarkingworkplacestressorsandorganisationalcultureaspectsrelatedtopsychologicalwellbeing:

A. Aworkplacehealthsurveythatseekstoidentifyworkplacestressorsthatmaycontributetopsychologicalinjury–resultingdatacouldthenbeusedtoidentifyandchangeaspectsoforganisationalfunctionthatcontributetopsychologicaldistress

B. Anorganisationalculturesurveyforthepurposesofidentifyingcurrentcatalystsandbarrierstotheuptakeofcurrentandproposedinitiativesrelatedtothepreventionandtreatmentofpsychologicalinjuries.

Itisimportantthatoperationalstaffandtraumasurvivorscontributesignificantlytothedesignanddeliveryofsuchsurveys.

3. Regularreview–ItisrecommendedthatFireandEmergencyinitiatesaprogrammeofregularreviewwithregardtoassessingtheefficacyoftheFireandEmergencypsychologicalwellbeingstrategyandassociatedcontrolmeasures.Thisshouldincludeensuringgapsbetweenpolicyandpracticearebeingidentified,eliminatedand/orminimised,andthatstrategyandcontrolmeasuresalignwithinternationalbestpractice.

Research1. Perceivedorganisationalsupport–ItisrecommendedthatFireandEmergency

sponsorsresearchexaminingPOSwithinaFireandEmergencycontext.ThisresearchshouldincludeidentifyingcontributorstoPOSwhilealsoprovidingameasurementofcurrentlevelsofPOSwithinFireandEmergency.Thisresearchcanthenbeusedasabenchmarktoensuretheidentificationandmonitoringofanimportantprotectivevariableinrelationtopsychologicaldistressandinjury.

2. Epidemiologicaldata–BoththeBeyondBlueLtd(2018)studyandtheSAMHSA(2014)TICimplementationguidenotetheimportanceofgatheringnationalepidemiologicaldatawithregardtoestablishingtheincidenceandprevalenceofpsychologicaldistressandinjurywithinapopulation.Therefore,itisrecommended


82 27March2019

thatFireandEmergencycapitaliseontheuniqueopportunitythatnowexiststocollaboratewiththeBeyondBlueLtd(2018)researchers,drawingupontheirexistingframework,toestablishtheincidenceandprevalenceofpsychologicaldistress,injury,andmaladaptivebehaviourwithregardtocurrentandretiredFireandEmergencyfirefighters.Thiswillhavetheadditionalbenefitsofprovidinganationalbenchmarkthatcanbeusedtoassesstheefficacyofcontrolmeasures,whileprovidingaconsiderablesavingofbothtimeandmoney.

3. Frontlineconnection–ItisrecommendedthatFireandEmergencysponsorsresearchtoidentifytheobservations,needs,andrequestsoffirefightersinrelationtothecriticalincidentandworkplacestressorstheyareexposedto.Additionally,thisresearchshouldincludeexaminingwhichcommunicationpathwaysarebestsuitedtoconnectinginsights,training,andsupportserviceswithFireandEmergencyfirefighters.

4. Resilienceandpost-traumaticgrowth–ItisrecommendedthatFireandEmergencysponsorsresearchexaminingresilience,adaptivecoping,andPTGinrelationtoFireandEmergencyfirefighters.

5. Communityriskreduction–ThisreporthashighlightedtheradiatingeffectsofpsychologicalinjuryandrevealedtheimportanceofunderstandingtheseeffectsonthefamiliesofFireandEmergencyfirefighters,ontheFireandEmergencyorganisation,andonthecommunitiesinwhichFireandEmergencyfirefightersserve.ItisrecommendedthatfurtherresearchspecifictoFireandEmergencyfirefightersidentifythepresence,prevalence,andeffectoftheseradiatingfactors.Furthermore,itisrecommendedthatFireandEmergencyinvestigateavenuesfortheorganisationtoreducepsychologicaldistressforcommunitiesinvolvedinacriticalincidentinwhichFireandEmergencyworkersareinattendance.


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LimitationsAswithmostresearch,thereareanumberoflimitationstothefindingsinthisreport.Thisreporthasbeenbasedontheconceptofa360whereanincidentisbrieflywalkedaroundaspartofaninitialsize-upprocess.Duetothebriefnatureofthisapproach,itshouldbenotedthatthisreportisnotexhaustivewithregardtoidentifyingpsychologicalSHWrisks,missingSHWstrategycomponents,orgapsbetweenSHWpolicyandpractice.Itshouldalsonotreplacein-depthscientificenquiryintothemanytopicscovered.Additionally,itwasbeyondthescopeofthisreporttoexaminevariablessuchassex,age,andethnicityinrelationtothefindings.

Furthermore,thisreporthasidentifiedanumberoffactorsthatcontributetoapsychologicalinjurysuchasexposuretocriticalincidents,aswellashome,andworkplacestressors.However,itwasbeyondthescopeofthisreporttoexaminepre-employmentfactorssuchasprevioustrauma,childhoodexperiences,andpersonality.

Thisreporthasrelied,inpart,uponinternationalresearchinexaminingthepotentialpresenceandprevalenceofpsychologicaldistressandinjury,whilenotfullyexaminingthelimitationsofeachresearchpiece.Furthermore,thereareanumberofuniquevariablesdifferentiatingtheexperiencesofFireandEmergencyfirefightersfrominternationalfirefightersandemergencyresponders.Additionally,thisreporthas,attimes,drawnupontheanecdotalexperiencesoffirefightersthatdonotaccountfortheviewsofallfirefighters.

Itisalsoworthnotingthatmedicalfiguresquotedinthisreportwerebasedondatafromfireincidentreporting.Thisdatahaslimitations,giventhatthereissomesubjectivityinvolvedinclassifyingacall.

Finally,thetransitionfromtheNZFStoFireandEmergencyincludedamalgamatingwithruralfireservices.Whileaconsiderableamountofthereportfindingswillapplytoruralfirefighters,itwasbeyondthescopeofthisreporttoexaminetheresearchquestionswithspecificitytoaruralfirefightingcontext.ThesesamelimitationsarealsotruewithregardtootherFireandEmergencypersonnel-suchasFireRiskManagementOfficersandCommunicationCentreStaff.FutureresearchshouldseektoexaminetheimpactsofpsychologicaldistressandinjuryonallFireandEmergencypersonnel.


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AbbreviationsACE–AdverseChildhoodExperience

ASD–AcuteStressDisorder

CIPSS–CriticalIncidentandPersonalStressSupport

CISD–CriticalIncidentStressDebriefing

CISM–CriticalIncidentStressManagement

DSM-V–DiagnosticandStatisticalManualofMentalDisorders:DSM-5

EAS–Emergencyambulanceservice

FireandEmergency–FireandEmergencyNewZealand

HSWA–HealthandSafetyatWorkAct2015

MOU–MemorandumofUnderstanding

MVA–MotorVehicleAccident

NZFS–NewZealandFireService

OIs–OperationalInstructions

OrgLT–OrganisationalLeadershipTeam

OSM–OperationalSkillMaintenance

PFA–PsychologicalFirstAid

PPE–PersonalProtectiveEquipment

PTE–PotentiallyTraumaticEvent

PTG–Post-traumaticGrowth

PTS–Post-traumaticStress

PTSD–Post-traumaticStressDisorder

QAS–QueenslandAmbulanceService

RECEO–Risktolife,Exposures,Containment,Extinguishment,Overhaul

RET–RepeatedExposuretoTrauma

SAMHSA–SubstanceAbuseandMentalHealthServicesAssociation

SFF–SeniorFirefighter


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SHW–Safety,HealthandWellbeing

SMS–StationManagementSystem

SSO–SeniorStationOfficer

TAPS–TrainingandProgressionSystem

TIC–TraumaInformedCare

UFBA–UnitedFireBrigadesAssociation

VACU–VictorianAmbulanceCounsellingUnit

WAD–WorkAsDone

WAI–WorkAsImagined

WHO–WorldHealthOrganisation


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Appendix

Case StudyAttendanceatPTEs,suchassuicidesandpaediatriccardiacarrests,arenowcommonplaceformanyfirefightersinNewZealand.Thefollowingcasestudyisaresultofinterviewscarriedoutwithafirefighterandanofficerwhoattendedthesamecriticalincidentduringthecourseoftheirduties.Thenamesofboththefirefighterandofficerhavebeenmaskedtoprotecttheiridentities.

FirefighterX

FirefighterXisacareerfirefighterwithover10yearsofservice.Inthecourseoftheirdutiestheyresponded,withtheircrew,toaPTEintheformofanattemptedsuicideinvolvinganadolescent.ThefollowingsectionincludesasummaryofthisPTE(FirefighterX,FireandEmergencyfirefighter,April29,2018,personalcommunication).

OfficerY

OfficerYisacareerfirefighterwithover10yearsofservice.OfficerYwasinchargeofthecrewandincidentrespondedtobyFirefighterX(OfficerY,FireandEmergencyofficer,May9,2018,personalcommunication).

Potentiallytraumaticevent

FirefighterX,aspartofacrewoffourfirefighters,respondedtoamedicalco-responsecallintheearlyhoursofthemorningduringaroutinenightshift.OnthewaytotheincidentOfficerY,whoisresponsibleforthecrewoffour,receivedfurtherdetailsfromthefirecommunicationcentrestatingthattheywouldbeattendinganattemptedsuicideviahanging.OfficerYpassedthisinformationontotheircrewatwhichpointFirefighterXrecallswhattheydescribedas“whitehotanxiety”goingthroughtheirbody,whilesimultaneouslyexperiencingnegativethoughtssuchas“thiswillbetoomuchforme”and“Ican’tdothis”.

OfficerY,afterpassingonthedetailsofthecalltothecrew,tookafurtherstepaskingifanyofthecrewwouldprefernottotakeanactiveroleintheincident.FirefighterXnotedthattheycouldnotrecallanothertime,intheircareer,whereanofficerhadverbalisedsuchanoption.FirefighterX,afterpausingmomentarily,vocalisedtotheirofficerandcrewthattheywereuncomfortablewithassistingatthiscall.AtthispointOfficerYandtheremainingcrewimmediatelyacknowledgedthatitwasokayforFirefighterXtotakealessactiveroleattheincident.FirefighterXnotedamarkeddecreaseinthedistressingphysiologicalandpsychologicalsymptomologythattheyhadbeenexperiencingtothispoint.ThisreductionoccurredimmediatelyafterthecombinationofFirefighterXvocalizingtheirdiscomfortatassistingatthecall,andtheacknowledgementbyOfficerYandtheremainingcrewthatthiswasacceptable.


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OnarrivalatthecallFirefighterXnotedtheyfeltalotcalmerasaresultofnolongerbeingrequiredtoassist.Asaresultofthisrelativesenseofcalm,theydecidedthattheywouldbeabletoprovideassistancetothecrew,knowingtheyhadpermissiontostepoutofthatassistanceifrequired.FirefighterXwasabletocarryoutCPRonthepatientasaresultofthis.FirefighterXnotedthatthroughouttheirCPReffortsboththeofficerandcrewcheckedinonthemtoseehowtheywerecoping.AfterbeingrelievedfromcarryingoutCPRbyafellowcrewmember,FirefighterXreturnedtotheapplianceandbegantodebriefandengagecopinginsightsthattheyfoundusefulincalmingtheresidualdistresstheywereexperiencing.WhentheothercrewmembersreturnedtotheapplianceFirefighterXwasabletohelpfacilitatea‘hotdebrief’.Duringthisdebrief,theothercrewmembers,asaresultofFirefighterX’sactions,feltcomfortablementioninghowintensethecallhadbeenforthemandeventhankedFirefighterXfortheirapproachtothecall.

LaterthatmorningFirefighterXandtheircrewwereturnedouttoafurthermedicalco-responsecall.FirefighterXnotedthatnotonlydidtheynotexperiencethesamedistressfulphysiologicalandpsychologicalsymptomology,theybelieved–nomattertheintensityofthecall–theywouldbeabletohandleit,giventhemutualcrewunderstandingthatwaspresent,andthemutualsupportthatwouldbeprovided.


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