International Emergency Nursing 23 (2015) 115–119
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Need for compassion in prehospital and emergency care: A qualitative study on bus crash survivors’ experiences Isabelle Doohan MSc (PhD Student) a,b,*, Britt-Inger Saveman RNT, PhD (Professor) a,b,c a b c
Department of Surgery and Perioperative Sciences, Section of Surgery, Umeå University, SE-90187 Umeå, Sweden Department of Nursing, Umeå University, SE-90187 Umeå, Sweden Affiliated to Arctic Research Centre, Umeå University, SE-90187 Umeå, Sweden
A R T I C L E
I N F O
Article history: Received 27 May 2014 Received in revised form 13 August 2014 Accepted 23 August 2014 Keywords: Compassionate care Emergency medical services Emergency nursing Experiences Interview Qualitative research Social support
A B S T R A C T
Aim: To explore the survivors’ experiences after a major bus crash. Background: Survivors’ experiences of emergency care after transportation related major incidents are relatively unexplored, with research involving survivors mainly focused on pathological aspects or effects of crisis support. Methods: Semi-structured telephone interviews were conducted with 54 out of 56 surviving passengers 5 years after a bus crash in Sweden. Interviews were analyzed using qualitative content analysis. Results: Prehospital discomfort, lack of compassionate care, dissatisfaction with crisis support and satisfactory initial care and support are the categories. Lack of compassion in emergency departments was identified as a main finding. Lack of compassion caused distress among survivors and various needs for support were not met. Survivors’ desire to be with their fellow survivors the day of the crash was not facilitated after arriving at emergency departments. Conclusions: Connectedness among survivors ought to be promoted upon arrival at emergency departments. There is a need for emergency department professionals to be sufficiently educated in compassionate care. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Major incidents regularly disrupt communities all over the world and affect the survivors, their relatives, and the society itself. Research on survivors’ experiences of major incidents and disasters mainly focus on the pathological reactions of survivors, e.g., psychopathological consequences of disasters (Fullerton and Ursano, 2005) and distress and sick leave after, for example, surviving a tsunami (Wahlström et al., 2009). Research concerning posttraumatic stress disorder (PTSD) is particularly in focus after disasters (Johannesson et al., 2009; Neria et al., 2008), and following major incidents such as bus (Arnberg et al., 2011) or train crashes (Hagström, 1995). Other studies on bus crash experiences primarily study psychopathological consequences, for example, symptoms of intrusion, avoidance, and distress among children involved in a bus crash (Winje and Ulvik, 1998). In addition to PTSD, traumatization can cause a variety of other problems, e.g. depression and anxiety disorders. On the other hand, the concept of resilience has been recognized as important in research on disaster victims (Bisson, 2007).
* Corresponding author. Tel.: +46 705 893 326; fax: +46 907 851 156. E-mail address: [email protected] (I. Doohan). http://dx.doi.org/10.1016/j.ienj.2014.08.008 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
Resilience is the capacity to maintain a healthy, symptom-free functioning after a potentially traumatizing event (Bonanno et al., 2006). Attention is rarely paid to survivors after a major incident with the intention to study aspects other than pathological. The exception is when a disaster occurs and extraordinary efforts are taken to offer the survivors help. An example of this was the Southeast Asian tsunami disaster in 2004, which generated thorough research involving the survivors’ mental health and their experiences (Keskinen-Rosenqvist et al., 2011; Råholm et al., 2008). Major incidents which occur more regularly, for example within public transportation, do not attract as much attention, with little research focusing on survivors’ experiences. In a study on bus crash survivors’ short-term experiences, sleep difficulties, travel anxiety and need for support were presented (Doohan and Saveman, 2014). A study on train crash survivors’ experiences showed that all benefitted greatly from informal social support (Forsberg and Saveman, 2011). Moreover, when evaluating a rescue operation one generally communicates with the rescue workers and volunteers involved in the response (e.g. Suserud and Haljamae, 1997). Seldom are the actual recipients of the help interviewed. There is a lack of empirical evidence on how survivors perceive the emergency care offered after transport related major incidents. In order to improve prehospital and emergency care further studies are needed. The aim
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of this study is to explore the survivors’ experiences after a major bus crash.
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2. Methods
12 2.1. Study design The study has a descriptive qualitative design and is based on content analysis of telephone interviews with survivors 5 years after a major bus crash in Sweden.
10 Women
8
Men
6 4
2.2. Study settings
2 In February 2007, two buses going in opposite directions collided nearly head on. Six of the 62 passengers died instantaneously due to massive injuries. A handful of passengers who sat in the adjoining area of the impact zones suffered moderate to serious injuries while most of the remaining passengers in both buses sustained minor injuries. Four off duty professionals from the emergency services stopped at the scene and initiated a rescue operation within minutes of the crash. Approximately 20 minutes later, official emergency professionals arrived. A majority of the passengers were sent to a nearby gathering place, while a few were transported directly to hospitals. Everyone was subsequently sent to three different emergency departments and the transport time from the gathering place to the emergency departments varied from 1 to 4.5 h (Swedish Accident Investigation Authority, 2008). 2.3. Sample The sampling was purposive and consisted of 54 of the 56 surviving passengers from the bus crash: 21 women and 33 men. The sample population included all survivors from the two buses that crashed, but two survivors were excluded because they were unreachable. Ages ranged from 23 to 69 years (mean 43) at time of interview. Data on the survivors’ injuries were collected from an official accident report completed by the Swedish Accident Investigation Authority (2008). The participants’ injuries are presented according to the abbreviated injury scale (AIS), where maximum AIS (MAIS) represents the person’s injury with the highest AIS value (International Injury Scaling Committee, 2005). Fortyfour participants sustained mild injuries (AIS 1), seven of the participants sustained moderate injuries (AIS 2), e.g., concussion and rib fracture, and three participants suffered from serious injuries (AIS 3), e.g., complicated fractures and internal injuries. The deceased passengers sustained thoracic, head, and abdominal injuries as well as multiple internal lethal injuries (AIS 5–6). The two excluded survivors sustained mild and moderate injuries respectively. See Figs 1 and 2.
0 18-29
30-39
40-49
50-59
60+
Fig. 1. Age and sex distribution among the passengers (n = 62).
considerable experience in interviewing patients. The interviews were anonymized before they were given to the researchers. Interview length varied from 8 to 75 minutes. The interviews were audio recorded and transcribed verbatim. Written text per participant ranged from 1 to 18 pages with a total of 226 pages. 2.5. Data analysis Data were analyzed using qualitative inductive content analysis (Graneheim and Lundman, 2004) with an intention to hold back author’s preunderstanding. The analysis focused on the manifest content in the material, representing what the text states through visible and observable components, not necessarily the underlying meanings (Graneheim and Lundman, 2004). The interviews were listened to, transcribed and later read through several times to achieve an overall understanding of the material. Text passages from the day of the crash were extracted and constituted the unit of analysis (Graneheim and Lundman, 2004). It resulted in 83 pages of plain text. The rest of the text will be analyzed and reported elsewhere. Meaning units were distinguished from the unit of analysis through a systematic approach. The meaning units were coded and classified by categories, which were developed as the work progressed (Malterud, 1996). The categories were discussed by both authors to ensure rigor. Throughout the analysis, the authors re-read the text and compared it to the original quotes to assure internal validation. Furthermore each quote was assigned a unique identifier to
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2.4. Data collection In 2007 the Swedish Accident Investigation Authority conducted interviews with all survivors 1 month after the bus crash. Data on the survivors were made available to the authors for a previous study (Doohan and Saveman, 2014) and the survivors were contacted again in spring 2012 for follow-up telephone interviews. Information letters were sent out to all survivors and 54 gave verbal informed consent. The authors compiled an interview guide with 19 semi-structured questions covering short and long term experiences of the prehospital response, the emergency care and the support, e.g., “What is your opinion of the care you were given after the crash?” and ”What help or support was the most important to you during the first few days after the crash?”. The interviewer for both telephone interview occasions was a registered nurse from Umeå University Hospital’s Emergency Department with
30 25 20
Women
15
Men
10 5 0 MAIS = 1 MAIS = 2 MAIS = 3 MAIS =4 MAIS = 5-6 Fig. 2. The participants’ injuries according to MAIS (n = 62). Adapted from the Swedish Accident Investigation Authority (2008) data.
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ensure the internal validity by making it possible to trace the extracts back to the original interview. The use of representative quotations from the interview participants adds transparency and trustworthiness to the findings and the data interpretation. Data have been analyzed, interpreted and inserted into the emergent categories. 2.6. Methodological considerations A well-known risk with retrospective studies is recall bias. Semistructured questions allowed the respondents to openly talk about experiences from the day of the crash up to 5 years after and they were not asked to recall anything in detail. When the interviews were transcribed, it became clear that many had chosen to thoroughly describe their experiences of the care they were given on the day of the crash. The ample interview material was divided into two studies, one covering the day of the crash and the other one covering the long term effects of the crash. It is important to note that described in the study are the survivors’ subjective experiences which serve as a source of knowledge, not as objective truth. In a study on disaster experiences it was concluded that the more critical phase of an emergency event is remembered the best and that time elapsed since the event had a small effect on what was recalled by the participants (Grimm et al., 2014). Research suggests that persons who feel bad tend to reflect over and remember possible reasons to why they feel bad to a greater extent, than those who have had no problems (Coughlin, 1990). We consider the study valid given the amount of data, the careful and thorough data analysis and having taken recall bias into consideration. 2.7. Ethical approval The study is approved by the Regional Ethics Committee in Umeå, Sweden (No 2012-61-31 Ö). Informed consent was obtained prior to the study. 3. Results There are four categories supplemented with four subcategories. Aspects perceived as dissatisfactory are presented in three categories: prehospital discomfort, lack of compassionate care and dissatisfaction with crisis support. They constitute the focus points in the present study. A fourth category, satisfactory initial care and support, summarizes aspects perceived as satisfactory and represents elements that need no improvement. The initial response was mostly characterized by competent professionals and helpful fellow passengers, however, the survivors’ experiences in the emergency departments illustrated several shortcomings. 3.1. Prehospital discomfort During the prehospital phase there were experiences of various discomforts, such as being cold, feeling pain, and lack of privacy. 3.1.1. Experiencing cold and unpleasantness The day of the crash was a cold winter day and severe cold was experienced before help was offered as well as during the transport from the crash site. Other forms of pain and unpleasantness included shock and loneliness. Interviewees described being brusquely carried out of the bus and not receiving pain medication despite being in excruciating pain. Transportation in a bus without seatbelts to a hospital hours away from the crash site was also perceived as unpleasant.
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“A gathering place after a collision is always a rather gruesome place to be at. /. . ./ We were pressed together /. . ./ I remember sitting across from two persons and one had a gash in his head, and those wounds always bleed a lot. The other one had bitten his lip /. . ./ There was a big puddle of blood on the floor in front of him and you could not do anything except to just sit there.” (6) 3.1.2. Feeling infringed upon Not all encounters with crisis support volunteers were comforting and there were volunteers who acted strangely, offered no support or invaded on the survivors’ privacy. The media presence was at times intrusive. Journalists and photographers showed little empathy as they photographed patients when exiting ambulances and showed no signs of respecting the survivors’ personal space. The journalists were perceived as the worst thing of all and survivors were greatly affected since they were not prepared to meet the media. For one survivor it took just as much energy to overcome the traumatic media encounters as the actual crash. “There was a person from this volunteer group who sat with me for a while /. . ./ I thought he was behaving a bit strangely. He wanted me to hold his hand and I thought it was a bit unpleasant. /. . ./ I had not asked him to sit there and my husband was there as well, so it felt a little, I do not know, he felt a bit redundant.” (3) 3.2. Lack of compassionate care Although many were satisfied with the care they received, there were experiences of negative encounters in the emergency departments and a lack of compassionate care. 3.2.1. Feeling mistreated Stressed emergency department professionals rushed in and out of examination rooms and insensitively disregarded patients’ worries and pains. “He had looked in old hospital records and seen that I had experienced pain in my back when I was in high school /. . ./ and when I said that something did not feel right in my back he just said ‘yes, yes, but you have had that before’ and rambled on and was very negligent and thought it was nothing to care about, though I was quite worried that it could have been something” (21) Being in a state of shock and being unable to process all of the information was described. There was a strong need for privacy and for emotional care while lying injured, but those needs went unmet. Negative and unpleasant experiences of the media presence in the emergency departments were also expressed. There was an overall lack of empathy among the journalists as they were intrusive and did not know when to back off. 3.2.2. Being left to fend for oneself There was a long wait in the emergency departments, e.g., being left on a bed in the hallway for a long time without receiving much help. When it was time to go home, patients were forgotten and given little or no attention, for example, not being notified that it was time to go home and not being able to meet up with fellow passengers. This lack of attention generated feelings of loneliness and emptiness, as if the crash had never happened. A sense of community had developed between the survivors after spending an entire day together and they wanted to see each other again. The lack of compassion was further evidenced when patients were told to take the bus home, something that understandably caused great distress and anger. There were various examples of this, e.g., ending
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up alone in the reception area, having to arrange a return trip despite being nearly incapable of calling a taxi. Not wanting to travel by bus because of injuries, shock, and having bloodstained clothes was expressed. These experiences had a strong impact and caused irritability and anger over the years. “What made me very upset that day was when I asked how I was going to get home, and they told me in the emergency room, ‘well, you’ll have to take the bus!’ /. . ./ I had to go home in my bloodstained shirt and the jacket I wore in the accident, and then to be told to take the bus home /. . ./ I had a bandage on my chin, a bruised face and bloodstained clothes. It was so terribly wrong.” (33) 3.3. Dissatisfaction with crisis support The importance of having as many people as possible around them, whom they could talk to was stressed as well as the opposite, i.e., privacy. To share a room with patients not from the bus crash and having to talk about the experience in their presence resulted in discomfort. Receiving inadequate professional support or being offered no support at all in the emergency departments caused disappointment as well as not receiving a second offer of support after leaving the hospital. For many, the need for formal support arose after a few days at home, not in the emergency department. Opportunities to spend time with fellow passengers and, thus, provide mutual support were limited. Being in shock and unreceptive to talk to anyone were also experienced. “I was very disappointed that I was not offered to talk to someone, it just kind of disappeared. It would have been good if they had a few routines /. . ./ I wished that I would have been given a second chance, after I had returned home and realized that I needed to talk.” (36) 3.4. Satisfactory initial care and support There were also many positive experiences regarding the prehospital initial care. The prehospital response was professional and well-organized; e.g. ambulances and helicopters arrived shortly after the crash, a bus for transportation was quickly arranged and blankets were handed out. All of the above enabled the survivors to feel efficiently cared for. Overall, the survivors were satisfied with the medical care and the crisis support offered in the emergency departments. Having someone close by the entire time was essential and families offered significant support. “It was a great set-up at the hospital when we got there, it was perfectly organized /. . ./ it went like clockwork, all of it, I have not experienced anything like it.” (27) Despite having physical scars reminding them of the crash, the majority of survivors stated, at the time of the interviews, that they felt good. The crash experience did however leave its mark in life and some of the survivors still felt a need to talk about the crash. 4. Discussion The individual’s experience of a traumatic situation is what determines how the person reacts. A majority of the survivors had mild to moderate injuries but were, nonetheless, strongly affected by the bus crash and the subsequent care they were offered. Three main findings represent nursing aspects that can be improved: experiences of prehospital discomfort, a lack of compassion in the emergency departments, and lastly, dissatisfaction with the crisis support. One of the main findings is a lack of compassionate care in the emergency departments. There is still no clear definition of
compassion, but it involves an awareness of another’s feelings, an appreciation of how they are affected by their experiences, and meaningful interaction with the other person (Dewar et al., 2011). Compassion can also be defined as a sympathetic consciousness of others’ distress and a desire to alleviate it (Fan and Lin, 2013). Our results show that a lack of compassion among professionals can affect a patient’s well-being to a degree where it remains one of the worst memories of the crash day. Survivors who had negative experiences spoke of stressed and indifferent professionals and of being belittled by physicians and that there was a remarkable lack of understanding regarding the survivors’ return trips. For an affected person it is of utmost importance to calm down and regain balance in the acute stage in order to stimulate recovery (Hobfoll et al., 2007). Emergency department professionals cannot assume that all patients possess the same resources, for example a family member who can pick them up or having money to pay for a taxi. Due to the uneven distribution of resources in society, there will always be holes in the fabric of the social safety net (Hobfoll et al., 2007). It appears as if some of the professionals did not fully understand that these survivors were not everyday patients. In extraordinary situations, there seems to be a greater need for compassionate care, which implies that the professionals may have to step outside of their role and recognize the needs of the whole person, as well as their family members. The inclusion of relatives is of importance because positive interactions between hospital professionals and family members can have a substantial effect on further interactions and can reduce the families’ suffering (Söderström et al., 2006). Our results support studies pointing toward “an erosion of caring and compassion” in nursing around the world (Darbyshire and McKenna, 2013). Likewise, an empathy decline in medical school is evident and the decline is threatening health care quality (Neumann et al., 2011). From a patient’s perspective, encounters in health care can, instead of alleviate suffering, actually cause or increase it. In a study on the alleviation of suffering, interviewees related experiences of good care to “being seen”. If patients were not seen as whole human beings and their existential suffering was not taken seriously, they experienced care as non-care (Arman and Rehnsfeldt, 2007). In a review of literature on patient experiences in the emergency department the lack of caring regarding the patients’ psychosocial and emotional needs were issues given the most emphasis (Gordon et al., 2010). A Great Britain study showed that both patients and professionals prioritized empathy, listening, a nonjudgmental attitude and individualized care above academic nursing and technical skills among nurses. Patients want nurses who communicate with them as fellow human beings and who bring care, compassion, and thoughtfulness into their encounters (Darbyshire and McKenna, 2013; Griffiths et al., 2010). In order to offer such care, it is important for all professionals to acknowledge compassionate care as a vital part of person-centered care (Lown et al., 2011). The survivors’ first encounters are with emergency prehospital and emergency department professionals who, therefore, should minimally possess some knowledge in how to properly approach survivors after major incidents. The hectic atmosphere surrounding prehospital and emergency care does not preclude acts of compassion. Not being alone during the day of the crash and sharing the experience with others seemed critical for the survivors’ early healing process. A sense of belonging evolved among the survivors during the day of the crash and they wanted to meet up with their fellow passengers after medical assessments, however, it was not facilitated. The sense of being left alone could have been prevented or counteracted by facilitating a connectedness among passengers who were in the same hospital. There is evidence of how valuable it is to spend time with others directly after a traumatic incident and how natural encounters can be of great importance for progress in existential health (Hobfoll et al., 2007; Rehnsfeldt and Arman, 2012). Allowing the survivors to stay together upon arrival in the
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emergency departments and afterwards could have allowed them to process the experience with one another. A formal gathering for all affected at a later stage can constitute an opportunity to promote a sense of community, share information and detect persons with signs of PTSD (Bisson, 2007; Wahlström et al., 2013). The diverse perceptions of both social support and formal support are consistent with previous research (Hobfoll et al., 2007; Wahlström et al., 2013). Flexibility is the key concept in contemporary crisis support and all survivors after major traumatic incidents do not and will not need formalized support from professionals. Immediately after a traumatic incident practical and pragmatic support offered in a sympathetic manner can alleviate the survivors’ distress (Arman and Rehnsfeldt, 2007). Informal social support and strong connections to relatives are highly important in combating stress and trauma (Norris et al., 2002). Strengthening connectedness between the affected passengers and their loved ones as early as possible is essential. A central issue is finding those who start off with weak social support (Hobfoll et al., 2007), because social support tends to fade over time. Dissatisfaction with social support is associated with psychological illness (Wahlström et al., 2013) and a perceived lack of social support is also recognized as a risk factor for developing PTSD (Bisson, 2007). A simple question regarding one’s family and social network can help identify those in need of special concern. Further research within this area is needed and is of great importance in our ongoing search for what are best practices in emergency care. 5. Conclusions and implications It is important to promote connectedness among survivors in order to enhance their recovery. Upon arrival at an emergency department, survivors with minor injuries can be treated as a group of people belonging together, rather than individual trauma patients. In addition, the survivors’ natural ties to close relatives should be facilitated as soon as possible, and if there are none, appropriate formal support ought to be provided. The results indicate a need for emergency care nurses, as well as emergency physicians, to be able to identify psychosocial and existential needs of survivors. Nurses should receive sufficient education in compassionate care in addition to evidence-based medical care for physical injuries. It would enable them to offer the best care possible to persons affected by mass casualty incidents or disasters. Acknowledgements The authors are grateful to all of the survivors for their willingness to share their experiences, to Mrs. Asta Strandberg, R.N., for interviewing the participants and to Mrs. Johanna Björnstig for transcribing the interviews. Funding: Umeå University. The funding source had no involvement in the study. References Arman, M., Rehnsfeldt, A., 2007. The ‘little extra’ that alleviates suffering. Nursing Ethics. 14 (3), 372–384, discussion 384–386. Arnberg, F.K., Rydelius, P.A., Lundin, T., 2011. A longitudinal follow-up of posttraumatic stress: from 9 months to 20 years after a major road traffic accident. Child and Adolescent Psychiatry and Mental Health. 5 (1), 8. Bisson, J.I., 2007. Post-traumatic stress disorder. Occupational Medicine (Oxford, England). 57 (6), 399–403. Bonanno, G.A., Galea, S., Bucciarelli, A., Vlahov, D., 2006. Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack. Psychological Science: A Journal of the American Psychological Society. 17 (3), 181–186. Coughlin, S.S., 1990. Recall bias in epidemiologic studies. Journal of Clinical Epidemiology. 43 (1), 87–91.
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Need for compassion in prehospital and emergency care: A qualitative study on bus crash survivors’ experiences Isabelle Doohan MSc (PhD Student) a,b,*, Britt-Inger Saveman RNT, PhD (Professor) a,b,c a b c
Department of Surgery and Perioperative Sciences, Section of Surgery, Umeå University, SE-90187 Umeå, Sweden Department of Nursing, Umeå University, SE-90187 Umeå, Sweden Affiliated to Arctic Research Centre, Umeå University, SE-90187 Umeå, Sweden
A R T I C L E
I N F O
Article history: Received 27 May 2014 Received in revised form 13 August 2014 Accepted 23 August 2014 Keywords: Compassionate care Emergency medical services Emergency nursing Experiences Interview Qualitative research Social support
A B S T R A C T
Aim: To explore the survivors’ experiences after a major bus crash. Background: Survivors’ experiences of emergency care after transportation related major incidents are relatively unexplored, with research involving survivors mainly focused on pathological aspects or effects of crisis support. Methods: Semi-structured telephone interviews were conducted with 54 out of 56 surviving passengers 5 years after a bus crash in Sweden. Interviews were analyzed using qualitative content analysis. Results: Prehospital discomfort, lack of compassionate care, dissatisfaction with crisis support and satisfactory initial care and support are the categories. Lack of compassion in emergency departments was identified as a main finding. Lack of compassion caused distress among survivors and various needs for support were not met. Survivors’ desire to be with their fellow survivors the day of the crash was not facilitated after arriving at emergency departments. Conclusions: Connectedness among survivors ought to be promoted upon arrival at emergency departments. There is a need for emergency department professionals to be sufficiently educated in compassionate care. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Major incidents regularly disrupt communities all over the world and affect the survivors, their relatives, and the society itself. Research on survivors’ experiences of major incidents and disasters mainly focus on the pathological reactions of survivors, e.g., psychopathological consequences of disasters (Fullerton and Ursano, 2005) and distress and sick leave after, for example, surviving a tsunami (Wahlström et al., 2009). Research concerning posttraumatic stress disorder (PTSD) is particularly in focus after disasters (Johannesson et al., 2009; Neria et al., 2008), and following major incidents such as bus (Arnberg et al., 2011) or train crashes (Hagström, 1995). Other studies on bus crash experiences primarily study psychopathological consequences, for example, symptoms of intrusion, avoidance, and distress among children involved in a bus crash (Winje and Ulvik, 1998). In addition to PTSD, traumatization can cause a variety of other problems, e.g. depression and anxiety disorders. On the other hand, the concept of resilience has been recognized as important in research on disaster victims (Bisson, 2007).
* Corresponding author. Tel.: +46 705 893 326; fax: +46 907 851 156. E-mail address: [email protected] (I. Doohan). http://dx.doi.org/10.1016/j.ienj.2014.08.008 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
Resilience is the capacity to maintain a healthy, symptom-free functioning after a potentially traumatizing event (Bonanno et al., 2006). Attention is rarely paid to survivors after a major incident with the intention to study aspects other than pathological. The exception is when a disaster occurs and extraordinary efforts are taken to offer the survivors help. An example of this was the Southeast Asian tsunami disaster in 2004, which generated thorough research involving the survivors’ mental health and their experiences (Keskinen-Rosenqvist et al., 2011; Råholm et al., 2008). Major incidents which occur more regularly, for example within public transportation, do not attract as much attention, with little research focusing on survivors’ experiences. In a study on bus crash survivors’ short-term experiences, sleep difficulties, travel anxiety and need for support were presented (Doohan and Saveman, 2014). A study on train crash survivors’ experiences showed that all benefitted greatly from informal social support (Forsberg and Saveman, 2011). Moreover, when evaluating a rescue operation one generally communicates with the rescue workers and volunteers involved in the response (e.g. Suserud and Haljamae, 1997). Seldom are the actual recipients of the help interviewed. There is a lack of empirical evidence on how survivors perceive the emergency care offered after transport related major incidents. In order to improve prehospital and emergency care further studies are needed. The aim
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of this study is to explore the survivors’ experiences after a major bus crash.
16 14
2. Methods
12 2.1. Study design The study has a descriptive qualitative design and is based on content analysis of telephone interviews with survivors 5 years after a major bus crash in Sweden.
10 Women
8
Men
6 4
2.2. Study settings
2 In February 2007, two buses going in opposite directions collided nearly head on. Six of the 62 passengers died instantaneously due to massive injuries. A handful of passengers who sat in the adjoining area of the impact zones suffered moderate to serious injuries while most of the remaining passengers in both buses sustained minor injuries. Four off duty professionals from the emergency services stopped at the scene and initiated a rescue operation within minutes of the crash. Approximately 20 minutes later, official emergency professionals arrived. A majority of the passengers were sent to a nearby gathering place, while a few were transported directly to hospitals. Everyone was subsequently sent to three different emergency departments and the transport time from the gathering place to the emergency departments varied from 1 to 4.5 h (Swedish Accident Investigation Authority, 2008). 2.3. Sample The sampling was purposive and consisted of 54 of the 56 surviving passengers from the bus crash: 21 women and 33 men. The sample population included all survivors from the two buses that crashed, but two survivors were excluded because they were unreachable. Ages ranged from 23 to 69 years (mean 43) at time of interview. Data on the survivors’ injuries were collected from an official accident report completed by the Swedish Accident Investigation Authority (2008). The participants’ injuries are presented according to the abbreviated injury scale (AIS), where maximum AIS (MAIS) represents the person’s injury with the highest AIS value (International Injury Scaling Committee, 2005). Fortyfour participants sustained mild injuries (AIS 1), seven of the participants sustained moderate injuries (AIS 2), e.g., concussion and rib fracture, and three participants suffered from serious injuries (AIS 3), e.g., complicated fractures and internal injuries. The deceased passengers sustained thoracic, head, and abdominal injuries as well as multiple internal lethal injuries (AIS 5–6). The two excluded survivors sustained mild and moderate injuries respectively. See Figs 1 and 2.
0 18-29
30-39
40-49
50-59
60+
Fig. 1. Age and sex distribution among the passengers (n = 62).
considerable experience in interviewing patients. The interviews were anonymized before they were given to the researchers. Interview length varied from 8 to 75 minutes. The interviews were audio recorded and transcribed verbatim. Written text per participant ranged from 1 to 18 pages with a total of 226 pages. 2.5. Data analysis Data were analyzed using qualitative inductive content analysis (Graneheim and Lundman, 2004) with an intention to hold back author’s preunderstanding. The analysis focused on the manifest content in the material, representing what the text states through visible and observable components, not necessarily the underlying meanings (Graneheim and Lundman, 2004). The interviews were listened to, transcribed and later read through several times to achieve an overall understanding of the material. Text passages from the day of the crash were extracted and constituted the unit of analysis (Graneheim and Lundman, 2004). It resulted in 83 pages of plain text. The rest of the text will be analyzed and reported elsewhere. Meaning units were distinguished from the unit of analysis through a systematic approach. The meaning units were coded and classified by categories, which were developed as the work progressed (Malterud, 1996). The categories were discussed by both authors to ensure rigor. Throughout the analysis, the authors re-read the text and compared it to the original quotes to assure internal validation. Furthermore each quote was assigned a unique identifier to
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2.4. Data collection In 2007 the Swedish Accident Investigation Authority conducted interviews with all survivors 1 month after the bus crash. Data on the survivors were made available to the authors for a previous study (Doohan and Saveman, 2014) and the survivors were contacted again in spring 2012 for follow-up telephone interviews. Information letters were sent out to all survivors and 54 gave verbal informed consent. The authors compiled an interview guide with 19 semi-structured questions covering short and long term experiences of the prehospital response, the emergency care and the support, e.g., “What is your opinion of the care you were given after the crash?” and ”What help or support was the most important to you during the first few days after the crash?”. The interviewer for both telephone interview occasions was a registered nurse from Umeå University Hospital’s Emergency Department with
30 25 20
Women
15
Men
10 5 0 MAIS = 1 MAIS = 2 MAIS = 3 MAIS =4 MAIS = 5-6 Fig. 2. The participants’ injuries according to MAIS (n = 62). Adapted from the Swedish Accident Investigation Authority (2008) data.
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ensure the internal validity by making it possible to trace the extracts back to the original interview. The use of representative quotations from the interview participants adds transparency and trustworthiness to the findings and the data interpretation. Data have been analyzed, interpreted and inserted into the emergent categories. 2.6. Methodological considerations A well-known risk with retrospective studies is recall bias. Semistructured questions allowed the respondents to openly talk about experiences from the day of the crash up to 5 years after and they were not asked to recall anything in detail. When the interviews were transcribed, it became clear that many had chosen to thoroughly describe their experiences of the care they were given on the day of the crash. The ample interview material was divided into two studies, one covering the day of the crash and the other one covering the long term effects of the crash. It is important to note that described in the study are the survivors’ subjective experiences which serve as a source of knowledge, not as objective truth. In a study on disaster experiences it was concluded that the more critical phase of an emergency event is remembered the best and that time elapsed since the event had a small effect on what was recalled by the participants (Grimm et al., 2014). Research suggests that persons who feel bad tend to reflect over and remember possible reasons to why they feel bad to a greater extent, than those who have had no problems (Coughlin, 1990). We consider the study valid given the amount of data, the careful and thorough data analysis and having taken recall bias into consideration. 2.7. Ethical approval The study is approved by the Regional Ethics Committee in Umeå, Sweden (No 2012-61-31 Ö). Informed consent was obtained prior to the study. 3. Results There are four categories supplemented with four subcategories. Aspects perceived as dissatisfactory are presented in three categories: prehospital discomfort, lack of compassionate care and dissatisfaction with crisis support. They constitute the focus points in the present study. A fourth category, satisfactory initial care and support, summarizes aspects perceived as satisfactory and represents elements that need no improvement. The initial response was mostly characterized by competent professionals and helpful fellow passengers, however, the survivors’ experiences in the emergency departments illustrated several shortcomings. 3.1. Prehospital discomfort During the prehospital phase there were experiences of various discomforts, such as being cold, feeling pain, and lack of privacy. 3.1.1. Experiencing cold and unpleasantness The day of the crash was a cold winter day and severe cold was experienced before help was offered as well as during the transport from the crash site. Other forms of pain and unpleasantness included shock and loneliness. Interviewees described being brusquely carried out of the bus and not receiving pain medication despite being in excruciating pain. Transportation in a bus without seatbelts to a hospital hours away from the crash site was also perceived as unpleasant.
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“A gathering place after a collision is always a rather gruesome place to be at. /. . ./ We were pressed together /. . ./ I remember sitting across from two persons and one had a gash in his head, and those wounds always bleed a lot. The other one had bitten his lip /. . ./ There was a big puddle of blood on the floor in front of him and you could not do anything except to just sit there.” (6) 3.1.2. Feeling infringed upon Not all encounters with crisis support volunteers were comforting and there were volunteers who acted strangely, offered no support or invaded on the survivors’ privacy. The media presence was at times intrusive. Journalists and photographers showed little empathy as they photographed patients when exiting ambulances and showed no signs of respecting the survivors’ personal space. The journalists were perceived as the worst thing of all and survivors were greatly affected since they were not prepared to meet the media. For one survivor it took just as much energy to overcome the traumatic media encounters as the actual crash. “There was a person from this volunteer group who sat with me for a while /. . ./ I thought he was behaving a bit strangely. He wanted me to hold his hand and I thought it was a bit unpleasant. /. . ./ I had not asked him to sit there and my husband was there as well, so it felt a little, I do not know, he felt a bit redundant.” (3) 3.2. Lack of compassionate care Although many were satisfied with the care they received, there were experiences of negative encounters in the emergency departments and a lack of compassionate care. 3.2.1. Feeling mistreated Stressed emergency department professionals rushed in and out of examination rooms and insensitively disregarded patients’ worries and pains. “He had looked in old hospital records and seen that I had experienced pain in my back when I was in high school /. . ./ and when I said that something did not feel right in my back he just said ‘yes, yes, but you have had that before’ and rambled on and was very negligent and thought it was nothing to care about, though I was quite worried that it could have been something” (21) Being in a state of shock and being unable to process all of the information was described. There was a strong need for privacy and for emotional care while lying injured, but those needs went unmet. Negative and unpleasant experiences of the media presence in the emergency departments were also expressed. There was an overall lack of empathy among the journalists as they were intrusive and did not know when to back off. 3.2.2. Being left to fend for oneself There was a long wait in the emergency departments, e.g., being left on a bed in the hallway for a long time without receiving much help. When it was time to go home, patients were forgotten and given little or no attention, for example, not being notified that it was time to go home and not being able to meet up with fellow passengers. This lack of attention generated feelings of loneliness and emptiness, as if the crash had never happened. A sense of community had developed between the survivors after spending an entire day together and they wanted to see each other again. The lack of compassion was further evidenced when patients were told to take the bus home, something that understandably caused great distress and anger. There were various examples of this, e.g., ending
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up alone in the reception area, having to arrange a return trip despite being nearly incapable of calling a taxi. Not wanting to travel by bus because of injuries, shock, and having bloodstained clothes was expressed. These experiences had a strong impact and caused irritability and anger over the years. “What made me very upset that day was when I asked how I was going to get home, and they told me in the emergency room, ‘well, you’ll have to take the bus!’ /. . ./ I had to go home in my bloodstained shirt and the jacket I wore in the accident, and then to be told to take the bus home /. . ./ I had a bandage on my chin, a bruised face and bloodstained clothes. It was so terribly wrong.” (33) 3.3. Dissatisfaction with crisis support The importance of having as many people as possible around them, whom they could talk to was stressed as well as the opposite, i.e., privacy. To share a room with patients not from the bus crash and having to talk about the experience in their presence resulted in discomfort. Receiving inadequate professional support or being offered no support at all in the emergency departments caused disappointment as well as not receiving a second offer of support after leaving the hospital. For many, the need for formal support arose after a few days at home, not in the emergency department. Opportunities to spend time with fellow passengers and, thus, provide mutual support were limited. Being in shock and unreceptive to talk to anyone were also experienced. “I was very disappointed that I was not offered to talk to someone, it just kind of disappeared. It would have been good if they had a few routines /. . ./ I wished that I would have been given a second chance, after I had returned home and realized that I needed to talk.” (36) 3.4. Satisfactory initial care and support There were also many positive experiences regarding the prehospital initial care. The prehospital response was professional and well-organized; e.g. ambulances and helicopters arrived shortly after the crash, a bus for transportation was quickly arranged and blankets were handed out. All of the above enabled the survivors to feel efficiently cared for. Overall, the survivors were satisfied with the medical care and the crisis support offered in the emergency departments. Having someone close by the entire time was essential and families offered significant support. “It was a great set-up at the hospital when we got there, it was perfectly organized /. . ./ it went like clockwork, all of it, I have not experienced anything like it.” (27) Despite having physical scars reminding them of the crash, the majority of survivors stated, at the time of the interviews, that they felt good. The crash experience did however leave its mark in life and some of the survivors still felt a need to talk about the crash. 4. Discussion The individual’s experience of a traumatic situation is what determines how the person reacts. A majority of the survivors had mild to moderate injuries but were, nonetheless, strongly affected by the bus crash and the subsequent care they were offered. Three main findings represent nursing aspects that can be improved: experiences of prehospital discomfort, a lack of compassion in the emergency departments, and lastly, dissatisfaction with the crisis support. One of the main findings is a lack of compassionate care in the emergency departments. There is still no clear definition of
compassion, but it involves an awareness of another’s feelings, an appreciation of how they are affected by their experiences, and meaningful interaction with the other person (Dewar et al., 2011). Compassion can also be defined as a sympathetic consciousness of others’ distress and a desire to alleviate it (Fan and Lin, 2013). Our results show that a lack of compassion among professionals can affect a patient’s well-being to a degree where it remains one of the worst memories of the crash day. Survivors who had negative experiences spoke of stressed and indifferent professionals and of being belittled by physicians and that there was a remarkable lack of understanding regarding the survivors’ return trips. For an affected person it is of utmost importance to calm down and regain balance in the acute stage in order to stimulate recovery (Hobfoll et al., 2007). Emergency department professionals cannot assume that all patients possess the same resources, for example a family member who can pick them up or having money to pay for a taxi. Due to the uneven distribution of resources in society, there will always be holes in the fabric of the social safety net (Hobfoll et al., 2007). It appears as if some of the professionals did not fully understand that these survivors were not everyday patients. In extraordinary situations, there seems to be a greater need for compassionate care, which implies that the professionals may have to step outside of their role and recognize the needs of the whole person, as well as their family members. The inclusion of relatives is of importance because positive interactions between hospital professionals and family members can have a substantial effect on further interactions and can reduce the families’ suffering (Söderström et al., 2006). Our results support studies pointing toward “an erosion of caring and compassion” in nursing around the world (Darbyshire and McKenna, 2013). Likewise, an empathy decline in medical school is evident and the decline is threatening health care quality (Neumann et al., 2011). From a patient’s perspective, encounters in health care can, instead of alleviate suffering, actually cause or increase it. In a study on the alleviation of suffering, interviewees related experiences of good care to “being seen”. If patients were not seen as whole human beings and their existential suffering was not taken seriously, they experienced care as non-care (Arman and Rehnsfeldt, 2007). In a review of literature on patient experiences in the emergency department the lack of caring regarding the patients’ psychosocial and emotional needs were issues given the most emphasis (Gordon et al., 2010). A Great Britain study showed that both patients and professionals prioritized empathy, listening, a nonjudgmental attitude and individualized care above academic nursing and technical skills among nurses. Patients want nurses who communicate with them as fellow human beings and who bring care, compassion, and thoughtfulness into their encounters (Darbyshire and McKenna, 2013; Griffiths et al., 2010). In order to offer such care, it is important for all professionals to acknowledge compassionate care as a vital part of person-centered care (Lown et al., 2011). The survivors’ first encounters are with emergency prehospital and emergency department professionals who, therefore, should minimally possess some knowledge in how to properly approach survivors after major incidents. The hectic atmosphere surrounding prehospital and emergency care does not preclude acts of compassion. Not being alone during the day of the crash and sharing the experience with others seemed critical for the survivors’ early healing process. A sense of belonging evolved among the survivors during the day of the crash and they wanted to meet up with their fellow passengers after medical assessments, however, it was not facilitated. The sense of being left alone could have been prevented or counteracted by facilitating a connectedness among passengers who were in the same hospital. There is evidence of how valuable it is to spend time with others directly after a traumatic incident and how natural encounters can be of great importance for progress in existential health (Hobfoll et al., 2007; Rehnsfeldt and Arman, 2012). Allowing the survivors to stay together upon arrival in the
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emergency departments and afterwards could have allowed them to process the experience with one another. A formal gathering for all affected at a later stage can constitute an opportunity to promote a sense of community, share information and detect persons with signs of PTSD (Bisson, 2007; Wahlström et al., 2013). The diverse perceptions of both social support and formal support are consistent with previous research (Hobfoll et al., 2007; Wahlström et al., 2013). Flexibility is the key concept in contemporary crisis support and all survivors after major traumatic incidents do not and will not need formalized support from professionals. Immediately after a traumatic incident practical and pragmatic support offered in a sympathetic manner can alleviate the survivors’ distress (Arman and Rehnsfeldt, 2007). Informal social support and strong connections to relatives are highly important in combating stress and trauma (Norris et al., 2002). Strengthening connectedness between the affected passengers and their loved ones as early as possible is essential. A central issue is finding those who start off with weak social support (Hobfoll et al., 2007), because social support tends to fade over time. Dissatisfaction with social support is associated with psychological illness (Wahlström et al., 2013) and a perceived lack of social support is also recognized as a risk factor for developing PTSD (Bisson, 2007). A simple question regarding one’s family and social network can help identify those in need of special concern. Further research within this area is needed and is of great importance in our ongoing search for what are best practices in emergency care. 5. Conclusions and implications It is important to promote connectedness among survivors in order to enhance their recovery. Upon arrival at an emergency department, survivors with minor injuries can be treated as a group of people belonging together, rather than individual trauma patients. In addition, the survivors’ natural ties to close relatives should be facilitated as soon as possible, and if there are none, appropriate formal support ought to be provided. The results indicate a need for emergency care nurses, as well as emergency physicians, to be able to identify psychosocial and existential needs of survivors. Nurses should receive sufficient education in compassionate care in addition to evidence-based medical care for physical injuries. It would enable them to offer the best care possible to persons affected by mass casualty incidents or disasters. Acknowledgements The authors are grateful to all of the survivors for their willingness to share their experiences, to Mrs. Asta Strandberg, R.N., for interviewing the participants and to Mrs. Johanna Björnstig for transcribing the interviews. Funding: Umeå University. The funding source had no involvement in the study. References Arman, M., Rehnsfeldt, A., 2007. The ‘little extra’ that alleviates suffering. Nursing Ethics. 14 (3), 372–384, discussion 384–386. Arnberg, F.K., Rydelius, P.A., Lundin, T., 2011. A longitudinal follow-up of posttraumatic stress: from 9 months to 20 years after a major road traffic accident. Child and Adolescent Psychiatry and Mental Health. 5 (1), 8. Bisson, J.I., 2007. Post-traumatic stress disorder. Occupational Medicine (Oxford, England). 57 (6), 399–403. Bonanno, G.A., Galea, S., Bucciarelli, A., Vlahov, D., 2006. Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack. Psychological Science: A Journal of the American Psychological Society. 17 (3), 181–186. Coughlin, S.S., 1990. Recall bias in epidemiologic studies. Journal of Clinical Epidemiology. 43 (1), 87–91.
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