Coping Strategies and Professional Quality of Life Among Emergency Workers

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

Coping Strategies and Professional Quality
of Life Among Emergency Workers

Gabriele Prati, Luigi Palestini and Luca Pietrantoni

Department of Education,
University of Bologna,
Italy

Abstract

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

Coping Strategies and Professional Quality
of Life Among Emergency Workers

Introduction

The literature on emergency workers has usually focused on negative outcomes such as traumatic stress symptoms (e.g. Clohessy & Ehlers, 1999), secondary traumatic stress or compassion fatigue (e.g. Figley, 1995) and burnout (Alexander & Klein, 2001). However these are not the only possible emergency work-related outcomes. For example, research findings evidenced that emergency ambulance personnel reported positive post-trauma changes (posttraumatic growth) as the result of the experience of occupational trauma (Shakespeare-Finch, 2003). Stamm (2005) introduced the concept of Compassion satisfaction, defined as the benefits that individuals derive from working with traumatized or suffering persons – i.e., positive feelings about helping others, finding meaning in one’s efforts and challenges, fulfilling one's potential, contributing to the work setting and even to the greater good of society, and the overall pleasure derived from being able to do one’s work well.

We argue that the way emergency workers cope with the exposure to critical incidents plays a crucial role in the development of the aforementioned outcomes. For example, a recent meta-analysis revealed a clear, consistent and positive association between reliance on avoidance strategies to cope with trauma and psychological distress, while there was a small relation of strategies focused on solving the problem (e.g., planning how to resolve the stressor, seeking information about the stressor) to psychological distress (Littleton, Horsley, Siji & Nelson, 2007). Thus, we set to investigate the relationship between emergency workers’ coping strategies and quality of life.

Emergency workers’ coping strategies

Two primary conceptualizations of coping strategies have emerged in the literature. The first conceptualization, proposed by Lazarus and Folkman (1984), distinguished two major theory-based functions of coping: problem-focused coping and emotion-focused coping. The second conceptualization emphasized the distinction between approach and avoidance coping strategies (Moos & Schaefer, 1993). Besides conceptual approach, empirically derived categories of coping usually include four factors: problem-focused coping, avoidance, meaning-focused coping and social support coping (Folkman & Moskowitz, 2004).

Emergency workers are a self-selected occupational group which faces unusual demands, and they may not be compared with the general population in term of coping strategies (Beaton, Murphy, Johnson, Pike, & Cornell, 1999). It is more difficult to determine on a priori grounds the coping strategies they use and which of these could be effective in facing stressors and improving quality of life. In their study on Protective Services Personnel, Burke and Paton (2006) identified two constructs, problem-focused coping (e.g. active coping, planning, acceptance) and emotion-focused coping (e.g. mental disengagement, denial, seeking support) which were respectively related to positive and negative work experience. In another study, Shipley and Gow (2006) identified three dimensions that might underlie coping strategies among State Emergency Service (SES) volunteer members: adaptive coping (e.g. active coping, seeking support, planning, acceptance), maladaptive coping (e.g. denial, self-blame, behavioral disengagement) and coping through the use of humor. The participants were least likely to engage in maladaptive coping strategies while they were most likely to resort to adaptive coping abilities. Adaptive coping was also moderately correlated with general satisfaction with one's work.

The complexity of the situations faced by rescue workers is paralleled by findings from the empirical literature. Results concerning the relationship between coping strategies and mental health in rescue personnel are quite contradictory (except for avoidance coping). Cognitive and behavioral avoidance and escape-avoidance coping have been found to predict greater psychological distress (Beaton, et al., 1999; Brown, Mulhern, & Joseph, 2002; Boudreaux, Mandry & Brantley 1997; Clohessy & Ehlers, 1999; Chang, Lee, Connor, Davidson, Jeffries, & Lai, 2003; Marmar, Weiss, Metzler, & Delucci 1996), but denial and behavioral distraction coping has been not related to mental health (Beaton et al., 1999; Clohessy & Ehlers, 1999). Problem-focused coping has been found associated both to high (Marmar et al., 1996) and low levels of distress (Brown et al., 2002). Emotion-focused coping has been associated to lower psychological distress (Brown et al., 2002) but seeking social support for emotional reasons and venting of emotions have not (Beaton et al., 1999; Clohessy & Ehlers, 1999). In their systematic review Sterud, Ekeberg, and Hem (2006) concluded that some studies identified maladaptive coping strategies but no studies have been able to identify any adaptive coping strategies. However, this review mainly focused on negative mental health outcomes. There is currently sufficient literature supporting the independence of positive and negative outcomes (Paton, Violanti, & Smith, 2003; Shakespeare-Finch, 2003) and the use of differential coping strategies in emergency service workers as an initial protective mechanism (McCammon, Durham, Jackson Allison, & Williamson, 1988).

Finally, the literature evidenced that there are gender differences in coping strategies (Tamres, Janicki & Helgeson, 2002) and Hytten and Hasle (1989) findings suggested that job tenure is positively related to more adaptive coping strategies. Thus, length of services and gender need to be investigated.

The purposes of this study are: 1) to investigate the use of coping strategies; 2) to identify second order dimensions that might underlie coping scales; 3) to investigate differences in coping strategies according to gender and length of services; 4) to examine which second order coping dimensions are related to quality of life.

Method

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

Procedure

Participants were recruited from emergency workers attending their regular service. A brief description of the study was sent to emergency workers organizations, in order to request members’ voluntary participation in the survey. Participants were given a choice between filling out an online version of the questionnaire on the web site of University of Bologna or a paper-and-pencil version of the same instrument. A total of 983 (81.9%) participants filled out the online version of the questionnaire.

Materials

The instrument consisted in a multipart questionnaire. Demographics included were questions on gender, age, position (volunteer or full-time emergency worker), length of service, and level of education.

Coping strategies were assessed using the Brief COPE Inventory (Carver, 1997), including 28 items measuring 14 coping strategies (Self-distraction, Active coping, Denial, Substance use, Emotional support, Instrumental support, Behavioural disengagement, Venting, Positive reframing, Planning, Humor, Acceptance, Religion, Self-blame). Each strategy is assessed by means of two items.

Participants were asked to think about the more recent stressful events occurred during their work activity and to indicate the extent to which they coped with them using the different strategies. Answers were provided on a five-point Likert scale (from “never” to “very often”). In order to develop scales that would assess relatively distinct aspects of coping, Carver (1989) suggests to conduct a second order factor analysis using scale totals as raw data. The internal reliability of this scale reports Cronbach alpha coefficients ranging from 0.50 to 0.90 (Carver, 1997). We derived the items from an Italian validation of the COPE scale (Sica, Novara, Dorz, & Sanavio, 1997).

Quality of life was assessed by a version of ProQOL R-IV (Professional Quality of Life Scale. Compassion Satisfaction and Fatigue Subscales - Revision IV) (Stamm, 2005). We employed a revised version of this instrument (Palestini, Prati, Pietrantoni, Cicognani, in press) including 22 items corresponding to three scales: Compassion Satisfaction Scale, Burnout Scale and Trauma/Compassion Fatigue Scale. Participants were asked to specify how often, during the last month, they had experienced a series of emotional states as result of their rescue operations. Responses were given on a five-point Likert scale, ranging from “never” to “very often”.

Results

Note. Scores on the scales range from 1 to 5

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

Table 2. Exploratory factor analysis (Oblimin rotation method) loadings and communalities for the Brief COPE scale

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

Table 4 shows the results of multiple regression analyses of coping strategies on the three quality of life outcomes. Avoidance coping was the only predictor of Burnout and Compassion fatigue. Compassion satisfaction was predicted by Problem-focused coping and Avoidance coping.

Note. * p <.001

Discussion

The present study addressed the coping strategies of emergency workers. The literature focused extensively on the risk and protective factors for mental health symptoms following exposure to critical incidents. The processes by which emergency workers cope with stress could be considered essential. The results showed that the most used coping strategies were acceptance, planning, active coping, instrumental support and positive reframing. Substance use, denial and behavioral disengagement were the least used coping strategies. These findings are in line with previous studies in Protective Services Personnel (Burke & Paton, 2006) and State Emergency Service (SES) volunteer members (Shipley & Gow, 2006). Thus, we can infer that emergency workers tend to engage in approach coping strategies rather than avoidance coping strategies. Since emergency workers are a self-selected occupational group which faces unusual job demands, they may not be compared with the general population in term of coping strategies.

Exploratory factors analysis revealed four dimensions: Emotion and support coping, Avoidance coping, Problem-focused coping and Cognitive restructuring coping. This partially confirms the problem-focused/emotion-focused and the approach/avoidance conceptualization. We found a problem-focused coping factor but not the emotion-focused because it includes strategies (e.g. venting, self-distraction and positive reframing) that loaded on different factors. In the same way, we found an avoidance coping factor but not a single factor including approach coping strategies (e.g. reframing, instrumental support and planning). Moreover, our results differ from those of Burke and Paton (2006) and Shipley and Gow (2006). We found slightly different dimensions: Emotion and support coping did not group with Avoidance coping, and positive reframing did not group with Problem-focused coping as did in Burke and Paton’s (2006) study. The Maladaptive Coping dimension found in Shipley and Gow’s (2006) study is similar to Avoidance coping but it did not include self-distraction. Instead of loading on adaptive coping factor, self-distraction loaded on Avoidance coping factor in our study. Moreover, Emotion and support coping did not group with Problem-focused coping as did in Shipley and Gow’s (2006).

Finally, we found a new dimension named Cognitive restructuring coping which includes humor and positive reframing and appears similar to the Foster Positive Attitudes component found by Beaton et al. (1999) using the Coping Responses of Rescue Workers Inventory (McCammon, Durham, Jackson Allison, & Williamson, 1988). This dimension also recalls the conceptualization of “meaning-focused coping” (Folkman & Moskowitz, 2004) in which cognitive strategies are used to manage the meaning of a stressful situation. These results seem to offer support for the empirically derived categories of coping that include four factors: problem-focused coping, avoidance, meaning-focused coping and social support coping (Folkman & Moskowitz, 2004). Given the number of participants involved in this study and the fact that larger sample sizes are related to more reliable factorial solutions, we also suggest that the differences we found could be referred to a diverse cultural and organizational context between Italy and Australia.

Avoidance coping was a significant predictor of lower compassion satisfaction and higher compassion fatigue and burnout. This finding confirms the validity of previous studies (Beaton, Murphy, Johnson, Pike, & Cornell, 1999; Brown, Mulhern, & Joseph, 2002; Boudreaux, Mandry & Brantley 1997; Clohessy & Ehlers, 1999; Chang, Lee, Connor, Davidson, Jeffries, & Lai, 2003; Marmar, Weiss, Metzler, & Delucci 1996). Thus, it seems plausible that the avoidance coping dimensions represents maladaptive coping strategies that lead to a variety of adverse mental health outcomes among emergency workers.

Problem-focused coping was a good predictor of compassion satisfaction but not of compassion fatigue or burnout. This study confirms the conclusion of Sterud, Ekeberg, and Hem (2006): it is easier to identify maladaptive coping strategies than adaptive coping strategies. However, the explained variance was much higher for compassion satisfaction than for compassion fatigue and burnout. We suppose that coping strategies are more important for positive indicators of professional quality of life than for negative indicators.

Emotion and support coping was not related to professional quality of life as found by Beaton et al., (1999) and Clohessy and Ehlers (1999). It is possible that this coping strategy is related to the quality of support provided by the social network: probably it was sometimes good but bad at other times.

The fourth factor, Cognitive restructuring coping, was not related to professional quality of life. This finding confirms the results of previous studies concerning Foster Positive Attitudes (Beaton et al., 1999; Clohessy & Ehlers, 1999).

The results evidenced gender differences in coping strategies: men were less likely to engage the use of Emotion and support coping and Avoidance. These findings resemble those of a meta-analysis by Tamres, Janicki & Helgeson (2002): women were more likely to use strategies that involved verbal expressions to others or the self—to seek emotional support, ruminate about problems, and use positive self-talk.

Finally, length of service was positive related to Problem-focused coping and negatively related to Emotion and support coping. These results offer support for Hytten and Hasle (1989) findings in which experienced emergency workers were "better able to cope" with critical incidents. Alternatively, these findings suggest that there could be inter-generational differences: seasoned emergency workers seem to be paying more attention to the occupational demands and less attention to the emotions and to the need for support. We should otherwise note that length of service may be a confounded variable in this context, since volunteer emergency workers could opt out of the service if they are not able to cope (the same cannot be said for career emergency workers).

Limitations and Directions for Future Research

In terms of methodological limitations, self report instruments are vulnerable to retrospective distortion by participants. Another limitation was the use of cross-sectional research design. An objective for further research would be to further explore the impact of coping strategies prospectively.

Finally, coping strategies are not inherently good or bad but their adaptive qualities depend on the controllability of the situation (Folkman & Moskowitz, 2004; Lazarus & Folkman, 1984). Since emergency workers are not necessarily exposed to controllable stressful situations, we propose that coping strategies should be investigated further taking into account the specific context in which they occur.

Conclusion

This study found that Italian emergency workers were most likely to engage in adaptive coping strategies. Additionally, we identified second order dimensions of coping scale that offer support for the empirically derived categories of coping. Finally, avoidance coping emerged as risk factor for professional quality of life while problem-focused coping promoted compassion satisfaction.

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