SPECIAL ISSUE PAPER

Trauma-exposed Firefighters: Relationships among Posttraumatic Growth, Posttraumatic Stress, Resource Availability, Coping and Critical Incident Stress Debriefing Experience David N. Sattler1*†, Bill Boyd2,3 & Julie Kirsch1,4 1

Department of Psychology, Western Institute for Social Research, Western Washington University, Bellingham, WA, USA Bellingham Fire Department, Bellingham, WA, USA 3 Coastal Industrial Services, Ferndale, WA, USA 4 Department of Psychology, University of Wisconsin, Madison, WI, USA 2

Abstract This project examines protective factors associated with resilience/posttraumatic growth and risk factors associated with posttraumatic stress among firefighters exposed to critical incidents. The participants were 286 (257 men and 29 women) volunteer and paid firefighters in Whatcom County, Washington. Participants completed an anonymous survey asking about demographics, critical incident exposure, posttraumatic stress symptoms, posttraumatic growth, resource availability, coping, occupational stress and critical incident stress debriefing experience. Most participants had significant critical incident exposure, and about half had attended critical incident stress debriefing sessions. Posttraumatic growth was associated with being female, critical incident exposure, critical incident stress debriefing attendance, posttraumatic stress symptoms (negative association), occupational support, occupation satisfaction, occupational effort, problem-focused coping, emotion-focused coping and personal characteristic resources. Posttraumatic stress symptoms were positively associated with years of firefighting, burnout, occupational effort and disengagement coping and negatively associated with critical incident stress debriefing attendance, posttraumatic growth, social support, internal locus of control, personal characteristic resources, energy resources and condition resources. The findings support conservation of resources stress theory and show that the maintenance and acquisition of resources can offset losses and facilitate resilience/posttraumatic growth. Implications of the findings for enhancing firefighter resources, facilitating resilience and minimizing occupational stressors are discussed. Copyright © 2014 John Wiley & Sons, Ltd. Received 14 October 2013; Revised 21 February 2014; Accepted 5 August 2014 Keywords posttraumatic stress; posttraumatic growth; firefighters; resilience; social support *Correspondence David N. Sattler, Department of Psychology, Western Institute for Social Research, Western Washington University, Bellingham, WA 982259172, USA. † Email: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2608

Firefighters and other first responders are routinely exposed to traumatic and stressful events—critical incidents—as part of their responsibilities to save lives and property (Declercq, Meganck, Deheegher, & Van Hoorde, 2011). Critical incident exposure increases firefighters’ risk of traumatic stress reactions such as posttraumatic stress symptoms (Bryant & Harvey, 1996; Meyer et al., 2012). However, recent research suggests that firefighters also may be ‘uncommonly resilient’ and experience personal growth following critical incident exposure (Gist, 2007). Few studies 356

have examined both posttraumatic growth/resilience and posttraumatic stress among firefighters. Research is needed to examine in more detail the predictors associated with posttraumatic growth and posttraumatic stress following critical incident exposure and to inform employee assistance programs on how to best provide support and assistance to and promote resilience in firefighters. This project is guided by conservation of resources (COR) stress theory and posttraumatic growth theory, which each provide an important framework for Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

D. N. Sattler, B. Boyd and J. Kirsch

understanding firefighter resilience and stress following critical incident exposure. COR states that individuals strive to acquire, maintain and protect valued resources and can experience stress when resources are threatened or lost. Resources fall into four general domains: personal characteristic resources (e.g. self-efficacy and optimism), condition resources (e.g. tenure, status and employment), energy resources (e.g. money and time) and object resources (e.g. house and car). For firefighters, exposure to critical incidents may threaten personal characteristic resources (e.g. self-esteem), condition resources (e.g. social support) and energy resources (e.g. physical health). The COR theory suggests that a rich resource base can facilitate resilience to traumatic stressors by serving as a buffer against resource loss, assisting individuals in coping when resources are threatened or lost, and promoting resource gain. In contrast, individuals with a weaker resource base may be more susceptible to resource loss and less able to recover in a timely manner (Hobfoll, 2012). Firefighters may be especially vulnerable to stress when they lack key resources needed to cope with the psychological and physical demands of critical incident exposure (Bryant & Harvey, 1996). Resource caravans are central to COR and can impact posttraumatic growth as well as posttraumatic stress. Resource caravans occur when resources are gained or lost across more than one domain. A resource caravan promoting gains may occur, for example, when social support (a condition resource) provided by fellow firefighters enhances self-esteem (a personal characteristic resource). Similarly, camaraderie (a construct related to social support) encompasses feelings of belonging and trust for group members; can provide opportunities to obtain information, alternate perspectives and interpretations, and advice that can help individuals process the trauma and facilitate adaptive coping; and can enhance well-being (Cowman, Ferrari, & Liao-Troth, 2004; Huynh, Xanthopoulou, & Winefield, 2013; Lepore, 2001; McFarlane & Yehuda, 1996; Prati & Pietrantoni, 2010; Tuckey & Hayward, 2011). Such overlap in resource gains may be fundamental in promoting resilience/posttraumatic growth. Firefighters may be at risk of resource loss caravans following critical incident exposure. For example, exposure to critical incidents may threaten personal characteristic resources such as self-efficacy if a firefighter is unable to rescue a victim (especially if the victim is a child; cf. Bryant & Harvey, 1996) as well as energy resources if sleep is disturbed as a result of processing the event. Irregular shift schedules and long hours may threaten energy and condition resources if they result in physical and mental exhaustion and work–family conflict (Cowlishaw, Evans, & McLennan, 2010). Loss of co-worker support and occupational stress may threaten both personal characteristic resources and condition resources. In short, firefighters Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

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may be most vulnerable when they lack key resources needed to cope with the psychological and physical demands of critical incident exposure (Monnier, Cameron, Hobfoll, & Gribble, 2002). Posttraumatic growth theory complements COR and suggests that critical incident exposure may provide opportunities for personal growth and other positive outcomes (Tedeschi & Calhoun, 1996). For example, firefighters may experience increased awareness of life priorities and positive life changes as a result of thinking about the incident (Groleau, Calhoun, Cann, & Tedeschi, 2012). They may refine or learn new coping skills, gain an enhanced appreciation for life and experience new levels of self-efficacy (viz., gain new resources, Linley & Joseph, 2004; Sattler, Assanangkornchai, Moller, Kesavatana-Dohrs, & Graham, 2014). These positive outcomes may offset to some degree negative experiences (Groleau et al., 2012; Linley & Joseph, 2004). One process underlying growth may involve cognitive disequilibrium—challenges to idealism and service to community as a result of exposure to situations involving life threat and loss of life. Gist (2007) suggests that cognitive disequilibrium can serve as an impetus for growth and is a salutatory if sometimes discomforting factor that motivates people to reexamine their understanding of a situation or circumstance, embrace broader and alternative views, and emerge with a fuller understanding and appreciation of the matter at issue (cf. Mills & Keil, 2004) (Gist, 2007, p. 420). Woodall’s summary of interviews with firefighters underscores this perspective: It is the very nature of a firefighter’s journey, the seemingly endless exposure to human pain and suffering, that has afforded them the opportunity to appreciate the joys of life by knowing and understanding human tragedy. By experiencing, although most times vicariously, the emotional and physical pain of the sick, injured, and dying, they become capable of experiencing the true meaning of life. These resilient emotional skills serve them both at home and on the job. Their experiences afford them the emotional skills required to function in dangerous and tragic environments. By the same token, these skills also afford them the opportunity to take that little extra moment to appreciate the joys of life, understanding all the while just how fleeting these joys can be (1997, as cited in Gist, 2007, p. 420). Adaptive coping strategies may further promote resource gain caravans and posttraumatic growth. Firefighters and other first responders often engage in approach oriented coping strategies such as 357

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problem-focused coping rather than emotion-focused or avoidance coping (Chamberlin & Green, 2010; Wagner & Martin, 2012). Problem-focused coping involves taking direct action, emotion-focused coping involves managing stress by attempting to alter emotional responses to the situation (Folkman & Lazarus, 1985) and avoidance coping involves avoiding or disengaging from the situation or processing the event. Problem-focused coping may be associated with growth following stressful events (Linley & Joseph, 2004; Sattler et al., 2014). Emotion-focused coping may involve seeking emotional support and positive reframing. Purely passive and disengagement coping strategies are associated with increased stress among firefighters and other first responders (Brown, Mulhern, & Stephen, 2002; Kirby, Shakespeare-Finch, & Palik, 2011). Additional research is needed to examine the association of these strategies with stress and resilience among firefighters. Fire departments may use critical incident stress debriefing to prevent or minimize the development of stress reactions among firefighters. Debriefing involves sharing observations and facts about the event and discussing emotional reactions and thoughts about the incident with peers and facilitators immediately following the event. Although opinions regarding the efficacy of critical incident stress debriefing are mixed, because departments represented in this study employ it, we examined the association of critical incident stress debriefing attendance with growth and stress. We note that debriefing includes multiple components. It is likely that some components (e.g. peer involvement) overlap with other variables (e.g. social support and camaraderie). Jeannette and Scoboria (2008) report that firefighters value informal peer support following exposure to a critical incident regardless of incident severity, but more formal interventions are preferred as incident severity increases. Volunteer status may also influence risk and resilience to traumatic stress exposure. Two-thirds of firefighters in the USA volunteer and receive no financial compensation for their work (Karter & Stein, 2012) and must balance the demands of firefighting with their full-time job and family commitments. Volunteers may resign because of difficulties managing these demands and family strains (Cowlishaw et al., 2010). Volunteer as well as paid firefighters may experience burnout if the job demands tax personal characteristic, energy and condition resources. Additional research is needed to examine the experiences of volunteer firefighters on the job, such as occupational stress and burnout, and to identify variables associated with resilience and stress in comparison with full-time firefighters. Such information can assist departments in designing or redesigning employee assistance and support programs. Few studies have examined COR, posttraumatic growth theory or the protective factors associated with resilience/posttraumatic growth and risk factors associated with posttraumatic stress among firefighters 358

D. N. Sattler, B. Boyd and J. Kirsch

exposed to critical incidents. On the basis of COR, posttraumatic growth theory and past research, we examined how demographic variables, firefighter status (e.g. length of service, volunteer versus paid), critical incident exposure, critical incident stress debriefing experience, resource availability, social support, coping and occupational stress relate to stress and posttraumatic growth. The findings may assist theory development and the manner in which employee assistance programs provide support and assistance to firefighters.

Method Participants The participants were 286 (257 men and 29 women) firefighters from 13 of the 17 Whatcom County, Washington fire districts, including the Bellingham Fire Department and the Lynden Fire Department. Most participants were Caucasian (95%), followed by other (3%), Latino American (2%), Asian American (0.3%) and African American (0.3%). Most were married (70%), followed by single (25%) and divorced/separated/other (5%). The average age was 38 years [standard deviation (SD) = 11]. More than two-thirds were volunteer firefighters (71%), and about one-third were paid firefighters (29%). They worked as firefighters for an average of 11 years (SD = 9). Most held the position of firefighter/emergency medical technician (64%), followed by Lieutenant/Captain (18%), Chief Officer (9%), Firefighter paramedic (8%) and other (1%). Assessment instruments A cover letter introduced the study, presented informed consent information and indicated responses were anonymous and confidential. Given the number of measures included in the survey and the time constraints to administer it, the length of a few scales was shortened to reduce time to administer the survey. The assessment instruments were presented in the following order. Demographics Nine items asked for demographic information (e.g. gender and marital status), current position in the department and number of years as a firefighter. Participants checked their choices or wrote in a number to indicate their answers. Critical incident stress debriefing experience Nine items asked if participants believe critical incident stress debriefing is effective and if they were willing to participate should the need present itself. Examples of items include ‘If I ever needed it, I think critical incident stress debriefing would be helpful for me’ and ‘I think critical incident stress debriefing may actually increase stress for firefighters who experience a traumatic emergency incident’ (reverse coded). Participants used a five-point scale (1 = not at all to 5 = very Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

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much) to indicate their answers (α = 0.81). Two items asked for the number of debriefings they had attended and their stress level change 2 weeks after attendance. Critical incident exposure Participants indicated the number of times they experienced 15 critical incidents during their career as Table I. Traumatic emergency incident experience (N = 286) Incident

Percent

Treating one or more fatalities Incident involving possibility of child injury or death Violent situation on an incident-police assist Treating a friend or family member Treating a seriously injured child Body retrieval Fellow firefighter’s real possibility of duty-related injury/death Direct threat—verbal and/or physical while on scene Prolonged extrication of seriously injured patient(s) Real possibility of duty-related serious injury Close contact with mutilated/burned patient(s) Direct exposure to hazardous materials Child abuse incident Critical/negative media coverage Serious injury to self while on duty

88 76 75 67 67 67 61 60 54 53 50 45 39 34 5

a firefighter (adapted from Monnier, Cameron, Hobfoll, & Gribble, 2002; items were selected on the basis of their relevance to the fire agencies included in the study and their past incidents). Table I presents the items (α = 0.83). Occupational satisfaction, effort, attitudes about expressing emotions and social support We developed 57 items to assess occupational satisfaction and effort, job burnout, internal and external factors that influence stress on the job, attitudes about expressing emotions on the job and social support. The items were based on the second author’s experiences as a Fire Chief, situations relevant to the fire agencies included in the study and consultation with a sociologist who is an expert in lifesaving professions. Table II presents examples of items in the scales. Participants used a five-point scale (1 = not at all to 5 = very much) to indicate their answers (all items, α = 0.81). Coping Fourteen items asked about problem-focused, emotion-focused and disengagement coping styles (adapted from Carver, Scheier, & Weintraub, 1989) when dealing with stress. Examples of items include ‘Take action to solve a problem’, ‘Learn to live with the problem’ and ‘Admit I cannot deal with it and quit

Table II. Firefighter support, occupation satisfaction, burnout, effort and locus of control (N = 286) Item Occupational support My immediate supervisors care about my well-being. My immediate supervisors give me a lot of support. My fellow firefighters give me a lot of support. Social support My family/significant others are always there to help me if I need them. I have someone to talk with about my problems. Occupation satisfaction During a call, I like feeling in control over a hectic situation. I like the challenge of relying on mental ability to solve problems. I enjoy the unpredictability of an emergency call. I feel good about my job. Burnout Tragedy of victim’s lives has taken a toll on me. To see what I’ve seen has taken a toll on me. Severe time pressure of too many calls creates stress. Sometimes I feel burned out on the job. Occupational effort On some calls I push myself to the edge mentally and physically. Sometimes I worry my best efforts won’t be enough. Internal locus of control People can take measures to reduce their risk. I get what I want because I’m lucky. (Reverse scored) It is not wise to plan ahead because fortune determines future. (Reverse scored)

Cronbach’s α

M (SD)

0.84 3.92 (1.06) 3.73 (1.16) 4.14 (0.89) 0.77 4.38 (0.94) 4.23 (1.05) 0.62 4.08 3.50 3.57 4.36

(0.92) (1.18) (1.15) (0.71)

1.94 1.99 3.08 2.43

(1.00) (1.05) (1.20) (1.18)

0.77

0.47 3.40 (1.07) 2.96 (1.19) 0.47 3.87 (1.02) 4.27 (0.84) 4.28 (0.95)

SD: standard deviation. Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

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trying’. Participants used a five-point scale (1 = not at all to 5 = very much) to indicate their answers (problem-focused coping, α = 0.80; emotion-focused coping, α = 0.74; disengagement coping, α = 0.52). Items not directly relevant to these three coping styles were not included.

a regularly scheduled drill night. At the beginning of the session, participants reviewed the consent form and asked any questions. It took about 25 min to complete the assessment instruments. The response rate for each district and department was excellent and ranged from 98% to 100%.

Resource availability An 18-item scale assessed perceived availability of personal characteristic, condition and energy resources in the past 30 days (based on Freedy, Saladin, Kilpatrick, Resnick, & Saunders, 1994, and Sattler et al., 2002; six items were omitted because they were not directly relevant to the experiences of firefighters). Participants used a five-point scale (1 = not at all to 5 = very much) to indicate their answers (α = 0.92).

Results

Posttraumatic stress symptoms A 17-item scale assessed posttraumatic stress symptoms in the past 30 days (full 16-item scale from Sattler et al., 2002, with the addition of ‘Feeling irritable or on edge’). Examples include ‘Avoiding things that remind me of an emergency incident’, ‘Thinking about a stressful emergency incident when I don’t want to’ and ‘Having difficulty sleeping’. Participants used a five-point scale (1 = not at all to 5 = very much) to indicate their answers (α = 0.86). Posttraumatic growth Eight items from the posttraumatic growth inventory assessed growth (Calhoun & Tedeschi, 1998). Examples include ‘Having new priorities about what is important in my life’ and ‘Appreciating each day more’. This scale included all six items used by Sattler et al. (2006) and two additional items from the posttraumatic growth inventory. Participants used a seven-point scale (1 = significant decrease to 4 = no change to 7 = significant increase) to indicate their answers (α = 0.85). Procedure The project was approved by the Western Washington University Human Participants Research Committee and followed the American Psychological Association ethical guidelines. The sampling procedure involved contacting all 17 Whatcom County fire districts, Bellingham Fire Department and Lynden Fire Department to solicit participation and schedule a time when firefighters could complete the questionnaire. All districts agreed to participate, but four of the smallest districts did not participate because they could not schedule a meeting during the period in which we conducted the study. For departments with paid firefighters, the first two authors administered the assessment instruments during regularly scheduled training sessions or meetings. For departments with volunteer firefighters, the first two authors administered the instruments during 360

Critical incident exposure and critical incident stress debriefing attendance Almost all participants (94%) experienced exposure to critical incidents during their career, and exposure was variable (M = 102 separate incidents, SD = 325.8; Table I). About half (52%) had participated in critical incident stress debriefing following critical incident exposure. Of those who participated in critical incident stress debriefing, about two-thirds (64%) reported their stress decreased 2 weeks after attendance. Having a positive attitude toward critical incident stress debriefing was positively and weakly associated with posttraumatic growth (r = 0.15, p < 0.05) but was not associated with posttraumatic stress symptoms (r =- 0.05, p = ns). Firefighter support, occupation satisfaction, burnout, effort and locus of control Table II shows participants indicated they receive support from co-workers and their family. They were satisfied with their work, reported minimal burnout and indicated internal locus of control. Resource availability and coping factor analyses Resource availability A principal component factor analysis with varimax rotation was performed on the resource availability measure. Three factors with eigenvalues greater than one and factor loadings greater than 0.50 emerged. Factor 1 assessed personal characteristic resources (43% of variance), factor 2 assessed energy resources (7% of variance) and factor 3 assessed condition resources (6% of variance). Each factor had good to excellent reliability. Coping A principal component factor analysis with varimax rotation was performed on the coping measure. Three factors with eigenvalues greater than one and factor loadings greater than 0.50 emerged. Factor 1 assessed problem-focused coping (23% of variance), factor 2 assessed emotion-focused coping (13% of variance) and factor 3 assessed disengagement coping (11% of variance). Problem-focused coping and emotionfocused coping had good reliability, and disengagement coping had poor reliability. Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

D. N. Sattler, B. Boyd and J. Kirsch

Predicting posttraumatic growth and psychological distress Positively skewed variables (i.e. posttraumatic stress symptoms, critical incident exposure and family resources) were log transformed, and negatively skewed variables (i.e. general social support and internal locus of control) were reflected and log transformed (on the basis of procedures recommended by Judd, McClelland, & Ryan, 2009). Table III presents the correlations among posttraumatic growth, posttraumatic stress symptoms, demographics, critical incident stress debriefing experience, social support, burnout, locus of control, coping and resource availability. Two hierarchical linear regression analyses examined predictors of posttraumatic growth and posttraumatic stress symptoms. Demographic variables, employment status, critical incident exposure, critical incident stress debriefing attendance and attitudes, social support, occupation experience, locus of control, coping style and resource availability were entered in nine steps. Order of entry was based on the COR theory and previous research that suggests to first account for variables concerning individual characteristics such as demographics and past experiences and then situational variables (cf. Freedy et al., 1994; Hobfoll, 2011; Sattler et al., 2006, 2014). Posttraumatic growth Table IV shows that the predictor variables accounted for 23% of posttraumatic growth variance, F(19, 263) = 5.49, p < 0.001. Posttraumatic growth was associated with being female, critical incident exposure, critical incident stress debriefing attendance, posttraumatic stress symptoms (negative association), occupational support, occupation satisfaction, occupational effort, problem-focused coping, emotion-focused coping and personal characteristic resources. Posttraumatic stress symptoms Table IV shows that the predictor variables accounted for 51% of posttraumatic stress symptom variance, F(19, 263) = 16.38, p < 0.001. Posttraumatic stress symptoms were positively associated with years of firefighting, burnout, occupational effort and disengagement coping and negatively associated with critical incident stress debriefing attendance, posttraumatic growth, general social support, internal locus of control, personal characteristic resources, energy resources and condition resources.

Discussion The results show that firefighters were regularly exposed to critical incidents, and nearly half participated in critical incident stress debriefing sessions. Number of years firefighting, burnout, occupational effort and disengagement coping were positively associated Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

Posttraumatic Growth

with posttraumatic stress symptoms, whereas critical incident stress debriefing attendance, posttraumatic growth, general social support, internal locus of control, personal characteristic resources, energy resources and condition resources were negatively associated with posttraumatic stress symptoms. These variables accounted for 51% of posttraumatic stress symptom variance. Further, the vast majority reported posttraumatic growth. Being female, critical incident exposure, critical incident stress debriefing attendance, occupational support, occupation satisfaction, occupational effort, problem-focused coping, emotion-focused coping and personal characteristic resources accounted for about one-quarter (23%) of posttraumatic growth variance. The findings support COR and its application to firefighters who experience critical incidents as part of their job responsibilities and have several implications (Hobfoll, 2011; Huynh et al., 2013). The negative association of personal characteristic resources, energy resources and condition resources with posttraumatic stress and the positive association of personal characteristic resources with posttraumatic growth underscore their central role concerning mental health. These resources explained unique variance in posttraumatic stress symptoms and posttraumatic growth above and beyond the other predictors (e.g. coping and other situational predictors). These resources enable firefighters to tackle challenging traumatic incidents, give support to and receive support from others and keep the incidents in perspective. The finding that critical incident exposure was related to posttraumatic growth but not to posttraumatic stress symptoms supports prior work that found affective response to critical incident exposure, not frequency of exposure, predict stress response (Declercq et al., 2011). Despite the controversy surrounding critical incident stress debriefing, we found that critical incident stress debriefing attendance was negatively associated with posttraumatic stress symptoms and positively associated with posttraumatic growth. We note that critical incident stress debriefing includes many components (e.g. peer involvement and social support), and as such, it is difficult to determine what features may be driving the association. Given the small communities in which the departments represented in this study operate, we suspect that peer and social support play significant roles. The findings support Gist (2007), Woodall (1997, as cited in Gist, 2007), Tedeschi and Calhoun (1996) and others concerning the salutatory nature of critical incident exposure for firefighters. Bonanno, for example, reports the following: (a) resilience in the wake of critical incident exposure is common; and (b) most people are able to function at their usual level of functioning, even though they may experience mild to moderate temporary stress reactions (Bonanno et al., 2011). Positive reinterpretation and accommodation 361

362 — 0.19* 0.16† 0.11* 0.18† 0.04 0.06 0.10* 0.27‡ 0.01 0.47‡ 0.28‡ 0.36‡ 0.21‡ 0.21‡ 0.35‡ 0.54‡ 0.41‡ 0.41‡

— 0.15* 0.14* 0.02 0.09 0.08 0.16† 0.13* 0.19† 0.14* 0.20‡ 0.04 0.19† 0.12* 0.24‡ 0.34‡ 0.02 0.36‡ 0.17† 0.17†

1. Posttraumatic growth 2. Posttraumatic stress 3. Gender 4. Years as firefighter 5. Employment 6. Critical incident exp. 7. CISD attendance 8. CISD experience 9. Occupational support 10. Social support 11. Occupation satisfaction 12. Burnout 13. Occupational effort 14. Internal locus of control 15. Problem-focused coping 16. Emotion-focused coping 17. Disengagement coping 18. Personal char. resources 19. Energy resources 20. Condition resources — 0.16† 0.15† 0.11* 0.05 0.11* 0.11* 0.12* 0.06 0.13* 0.03 0.09 0.03 0.23‡ 0.01 0.05 0.11* 0.06

3

— 0.18† 0.57‡ 0.38‡ 0.04 0.07 0.17† 0.11* 0.28‡ 0.08 0.04 0.15† 0.17† 0.17† 0.11* 0.01 0.01

4

— 0.36‡ 0.07 0.15† 0.25‡ 0.11* 0.07 0.34‡ 0.05 0.04 0.05 0.08 0.05 0.02 0.03 0.02

5

— 0.34‡ 0.10* 0.16† 0.19† 0.01 0.39‡ 0.15† 0.06 0.07 0.18 0.08† 0.08 0.07 0.01

6

Notes: exp.: experience; CISD: critical incident stress debriefing; char.: characteristic. *p < 0.05. † p < 0.01. ‡ p < 0.001.

2

1

Variable

— 0.10* 0.05 0.05 0.09 0.10* 0.00 0.01 0.10 0.14† 0.12* 0.01 0.02 0.04

7

— 0.16† 0.12* 0.08 0.09 0.03 0.06 0.11* 0.23‡ 0.04 0.15† 0.16† 0.09

8

— 0.21‡ 0.10* 0.24‡ 0.01 0.10 0.10* 0.22‡ 0.02 0.23‡ 0.17† 0.08

9

— 0.00 0.20‡ 0.06 0.07 0.14† 0.33‡ 0.17† 0.39‡ 0.29‡ 0.47‡

10

— 0.09 0.15† 0.03 0.13* 0.20‡ 0.04 0.15† 0.06 0.05

11

— 0.24‡ 0.18† 0.09 0.14† 0.23‡ 0.21‡ 0.26‡ 0.11*

12

— 0.11* 0.02 0.05 0.22‡ 0.12* 0.03 0.06

13

— 0.19† 0.19† 0.29‡ 0.22‡ 0.11* 0.17†

14

— 0.36‡ 0.12* 0.3‡ 0.11* 0.17†

15

— 0.06 0.41‡ 0.21‡ 0.20‡

16

— 0.22‡ 0.08 0.12*

17

— 0.52‡ 0.56‡

18

Table III. Correlations among posttraumatic growth, posttraumatic stress symptoms, demographics, CISD experience, support, burnout, locus of control, coping and resource availability (N = 286)

— 0.42

19

Posttraumatic Growth D. N. Sattler, B. Boyd and J. Kirsch

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Table IV. Predicting posttraumatic growth and posttraumatic stress symptoms with demographics, critical incident experience, support, burnout, locus of control, coping and resource availability (N = 286) Posttraumatic growth B

SE B

β

0.04 0.00 0.02

0.02 0.00 0.02

0.09 0.14* 0.07

0.01

0.01

0.11

0.03 0.00

0.02 0.01

0.13* 0.12

0.02

0.01

0.14*

0.01 0.03

0.01 0.01

0.01 0.22††

0.16**

0.01

0.01

0.03

0.07 0.05

0.06 0.19**

0.06 0.03

0.01 0.01

0.42†† 0.19**

0.08

0.07

0.05

0.01

0.25††

0.01 0.00 0.03

0.01 0.01 0.01

0.10 0.01 0.16**

0.05 0.02 0.08

0.01 0.01 0.04

0.30†† 0.13* 0.12*

SD

B

SE B

β

11.00 11.19

— 8.90 —

0.34 0.00 0.14

0.16 0.01 0.13

0.13* 0.01 0.07

102.57

327.45

0.10

0.04

0.18*

53.00 3.59

— 0.67

0.24 0.12

0.11 0.07

0.15* 0.01

Step 4: For PT growth Posttraumatic stress

1.53

0.49

0.89

0.40

0.14*

Step 4: For posttraumatic stress Posttraumatic growth

5.37

0.82

— —

— —

— —

Step 5: Social support Occupational support General support

3.95 4.31

0.89 0.88

0.15 0.07

0.05 0.06

0.16** 0.08

3.88

0.68

0.19

0.07

2.35 3.17

0.85 0.90

0.06 0.18

4.14

0.64

0.08

Variable Step 1: Demographics Gender† Years as firefighter Employment status‡

M

Step 6: Occupation attitudes Occupation Satisfaction Burnout Occupational effort Step 7: Control Internal locus of control

ΔR

0.01*

Step 2: Critical incident exp. Step 3: CISD Attendance§ Experience

Posttraumatic stress symptoms 2

ΔR

2

0.03*

0.03*

0.03

0.05*

0.04*

0.07* 0.06* 0.09**

0.09**

0.16††

0.29††

0.35††

0.16 0.20††

Step 8: Coping Problem focused Emotion focused Disengagement

3.28 3.19 2.23

0.89 0.76 0.56

0.12 0.19 0.04

0.06 0.07 0.09

0.13* 0.18** 0.03

Step 9: Resource availability Personal characteristics Energy Condition

3.83 3.16 4.11

0.70 0.92 0.92

0.35 0.03 0.09

0.09 0.06 0.30

0.30†† 0.03 0.02

0.37**

0.23††

0.51††

Notes: exp.: exposure; CISD: critical incident stress debriefing; PT: posttraumatic; SD: standard deviation; SE: standard error. *p < 0.05. † Male = 0, female = 1. ‡ Volunteer = 0, full-time = 1. § No attendance = 0, attended = 1. **p < 0.01. †† p < 0.001.

as a result of cognitive disequilibrium may promote the use of acceptance and problem-focused coping strategies and facilitate posttraumatic growth (Updegraff & Taylor, 2000). As a result, firefighters may learn to be more resilient and effective in taking direct action to resolve distress and manage negative emotions (Calhoun & Tedeschi, 2001; Janoff-Bulman, 2006) and clarifying values and life priorities. Posttraumatic growth also may reflect a coping style in which firefighters who are routinely exposed to critical incidents learn to accommodate stressors Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

associated with their professional duties (Hobfoll, 2011; Sattler et al., 2006). The findings also support COR’s assertion that engagement—a positive affective-motivational state that persists in response to an enduring stressor or challenging event—may strengthen one’s resources (Hobfoll, 2011). To promote engagement, fire departments could offer firefighters opportunities to strengthen crew cohesiveness and support one another, and develop or revise employee assistance and support programs to instruct firefighters about ways to enhance personal 363

Posttraumatic Growth

characteristic resources and resilient skills development. These recommendations are underscored by the following: (a) the findings that critical incident stress debriefing attendance was associated with posttraumatic growth (e.g. receiving support from peers during the session); (b) the findings that occupational support, occupation satisfaction, occupational effort and personal characteristic resources were associated with posttraumatic growth; and (c) research and anecdotal evidence provided from firefighters that they appreciate social support and camaraderie during critical incident stress debriefing sessions. Support provided by co-workers, supervisory personnel and family members may be essential in helping promote and enhance personal characteristic and condition resources (Cowman et al., 2004; Huynh et al., 2013). These recommendations may assist firefighters in taking action to resolve feelings of distress, manage emotions, clarify values and life priorities (Calhoun & Tedeschi, 2001; Janoff-Bulman, 2006; Sattler et al., 2014), and offset— to some degree—negative outcomes. In previous research examining occupational stressors, firefighters ranked wages, management/labour conflict, substandard equipment and job skills as more significant stressors than critical incident exposure (Beaton & Murphy, 1993). We found that occupational stressors including burnout and occupational effort as well as disengagement coping are associated with posttraumatic stress symptoms. These findings have implications for departments working to minimize occupational stressors. Programs might identify key experiences within the department that are associated with stress, including the structure and functioning of the organization, job demands, daily hassles and opportunities for advancement. A job analysis could identify task demands associated with feelings of burnout and disengagement. Organizational structure as well as job tasks might be redesigned with the goal of reducing burdens on individual firefighters and promoting empowerment in daily activities (Gist, 2007). Departments might also offer or revise instructional programs to effectively teach ways of coping with occupational stressors and managing reactions to trauma, thereby improving firefighter preparation for handling dangerous situations (Gist, 2007; Karter & Stein, 2012). Most volunteer fire stations are located in rural communities that may lack the personnel and funds to provide adequate training and equipment. Career (non-volunteer) firefighters also face unique challenges that could potentially make them vulnerable to posttraumatic stress. Primarily, firefighting may offer limited opportunities for career advancement given that supervisory positions are limited. A few studies suggest that the longer career firefighters are employed, the lower their self-efficacy and perceived available support (Regehr, Hill, Knott, & Sault, 2003). This is especially concerning since both of these factors may 364

D. N. Sattler, B. Boyd and J. Kirsch

promote resilience to posttraumatic stress disorder. Future research is needed to examine how to maintain or increase self-efficacy and support throughout the career. As with most studies, there are several limitations. The findings may not generalize to firefighters in large urban fire departments or other regions. Items asking about critical incident stress debriefing were retrospective, and time since participation may have influenced perceptions of efficacy. Although the reliability of the vast majority of scales was good to excellent, it was weak for occupational effort, locus of control and disengagement coping. The weak reliability of the disengagement coping factor (0.52) is similar to that of the behavioural disengagement (range of 0.42 to 0.66 across samples) and mental disengagement (range of 0.45 to 0.58 across samples) factors reported by Carver et al. (1989). Low reliability for occupational effort and locus of control may be due, in part, to the need for additional items assessing the breadth of the concepts, and they likely do not capture the complete characteristics of these concepts. Future research exploring occupational effort and examining the validity and reliability of the adapted scales is warranted. Most participants were married, which likely is associated with increased availability of social support. Future research examining resilience/posttraumatic growth could implement prospective, longitudinal designs to examine resource gain caravans as a source of resilience/posttraumatic growth over time. Of particular interest is identifying actions that employee assistance programs can take to promote the acquisition or enhancement of resources associated with resilience/posttraumatic growth. Firefighters’ level of engagement may be an especially important moderator of resource availability in the face of chronic occupational and traumatic stress exposure. Future studies also are needed to examine the unique needs of firefighters in rural versus urban settings and what employee assistance programs can do to mitigate occupational stress and facilitate resilience.

Conflict of interest The authors have declared that they have no conflict of interest.

Acknowledgments We thank the firefighters and the fire districts in Whatcom County, Bellingham Fire Department and the Lynden Fire Department for their participation, and Jennifer Lois for her assistance with developing an attitude scale. This project is based on a project conducted by the second author for the Executive Fire Officer Program, US Fire Administration/National Fire Academy, with the assistance of the first author. Stress and Health 30: 356–365 (2014) © 2014 John Wiley & Sons, Ltd.

D. N. Sattler, B. Boyd and J. Kirsch

Posttraumatic Growth G.

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