Final research paper

Running head: FIRST RESPONDERS RISK FOR PTSD

Do First Responders Have an Increased Risk of Developing Post Traumatic Stress

Disorder?

Student Name

Do First Responders Have an Increased Risk of Developing Post Traumatic Stress

Disorder?

Introduction

This topic is important to me, my husband was a first responder, many of his former crew members have suffered from PTSD, are currently suffering, and have even taken their own life since his line of duty death. I would like to research if mandatory counseling or if a critical stress debriefing after a traumatic incident could lessen the effects of PTSD however, there was not an ample amount of research.

First responders are those that respond to any emergency event. They can be firefighters, paramedics, emergency medical technicians (EMTs), law enforcement officers, trauma nurses, etc. With first responder suicides on the rise and the number of first responders suffering from posttraumatic stress disorders (PTSD) on the upswing (Kimbrel, Steffen, Meyer, Kruse, Knight, Zimering, and Gulliver, 2011) it seemed of importance to research if first responders do have a higher risk of development for PTSD. Proving that the risk of PTSD is higher in those occupations, could lead to programs for first responders to combat posttraumatic stress disorder.

Literature Review:

In the Chopko, Palmieri, and Adams 2018 path analysis there really was not a specific claim as to what they thought the outcome would be because they were trying to determine the relationships between traumatic experience, posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) for police officers. In this cross-sectional study, the authors conducted their research with a goal to better understand and help police officers experiencing

PTSD (Chopko, Palmieri, & Adams 2018).

The methods used were pretty straightforward, the first author Brian A. Chopko attended roll calls at three different police departments and training sessions at the state training center, he invited 364 officers to participate in the anonymous survey only 53% of those asked, accepted and returned their surveys (Chopko, Palmieri, & Adams 2018). The participants were of varying levels of ranks including patrol officers, detectives, administration, and other positions. The subjects were predominately white males and mostly married (Chopko, Palmieri, & Adams

2018, p.183).

The subjects were given a self-assessed questionnaire to measure Posttraumatic Growth

Inventory with 21 questions, 10 questions on behavioral growth and 11 for cognitive growth (Chopko et al, 2018). They responded to the Posttraumatic Stress Disorder checklist, and also the Critical Incident History Questionnaire that assesses 34 incidents that are commonly experienced by officers in the field 19 of those questions ask about direct involvement ( shooting at someone/being shot at) and 15 items about indirect involvement for example:

encountering a child that was beaten or sexually abused, and one question on personal relationship stress was asked(Chopko et al, 2018)

The research design helped gather the correct information needed to assess relationships among traumatic experiences. I am not sure that the research was ethical, it is not clear how secure the anonymity was. Also, if the researcher was at role calls and classes asking those to participate who is to say they did not feel coerced into participating if their supervisors were on board.

Schutt and Marotta’s “Personal and Environmental Predictors of Posttraumatic Stress in

Emergency Management Professionals” they claim emergency management professionals

(EMPs) relationship with PTSD could be influenced by personality, context, burn out, and compassion satisfaction (Schutt and Marotta, 2011). Some of their claims seemed to be substantiated by their research as ethnicity identity showed a significant correlation with PTSD, as did neuroticism (personality) and burnout (Schutt and Marotta, 2011).

In this longitudinal study Schutt and Marotta recruited the population from four different emergency management associations through email, they found 269 participants 175 men and 94 women with an average age of 46, a little over half participants were married and mostly white (Schutt and Marotta, 2011). Personality was measured with the NEO Five Factor Inventory to measure their traits, the multigroup ethnic identity measure – revised was used to measure ethnicity, they used a trauma history questionnaire to determine if the types of traumatic events encountered, the PTSD Checklist- civilian version to determine presence and severity of PTSD and finally a demographic questionnaire (Schutt and Marotta, 2011). There was a contact person at each management facility that distributed the email to participants with the surveys.

The experiment seems to be conducted in an ethical manner, informed consent was given when surveys were returned and there is a social and clinical value to this test . One must question the article as it reports in one paragraph 175 men and 94 women which totals only 269 but two paragraphs later Schutt and Marotta write “Two hundred eighty-four individuals completed the full or partial survey” (p.10). Also, it is looking for ethic diversity having an impact yet the majority of the respondents are white.

In Skogstad, Fjetland, and Ekeberg 2015 correlational study about exposure and PTSD symptoms of first responders of terror attacks in Norway they hoped to “investigate the degree of perceived peritraumatic strain as well as the prevalence and predictors of PTSS among first responders” (np). It was thought that since victims of traumatic events, victims and victim’s families of terror attacks have an increased risk of developing PTSS or PTSD that first responders responding to the terror attacks would have an increased chance of developing PTSS and PTSD as well (Skogstad, Fjetland, & Ekeberg, 2015).

The 2015 Skogstad, Fietland & Ekeberg study they found there were low rates of PTSD and PTSS. The study was done ethically and the “Oslo University Hospital’s Privacy Protection Supervisor approved the study” (Skogstad, Fjetland, & Ekeberg, 2015).

The methods used were as follows, an anonymous questionnaire was sent to police, fire, and ambulance personnel directly involved with the terror attacks that occurred in Norway on July 22, 2011 this study sent the questionnaire from 8-11 months after the attacks with an information letter and if questionnaire was returned that implied consent (2015). The questionnaire questioned sociodemographic such as age, sex, and occupation, there were also questions to determine how greatly the attacks were witnessed respondents would circle yes or no then chose to which degree they witnessed the events, ie. Viewing dead bodies, smelling strong odors, seeing body parts, etc. (Skogstad, Fjetland, & Ekeberg, 2015). The study also asked 4 questions regarding perceived threats measured on a Likert scale. The participants were all male, police officers, firefighters and ambulance personnel most between 30-49 years of age with the majority of participants having over 5 years of work history (Skogstad, Fjetland, & Ekeberg, 2015).

Boyd, Protopopescu, O’Connor, Neufeld, Jetly, Hood, Lanius, and McKinnon’s 2018 study they “sought to identify trauma related symptoms most strongly associated with functional impairment in a sample of military members, veterans, and first responders” (Boyd et al., 2018, np). The study hypothesized that the dissociative symptoms would mediate the PTSD symptoms and functional impairments (Boyd et al., 2018). It concluded that military members and veterans had higher levels of trauma related symptoms than first responders.

In this correlational study, the researchers reviewed eighty- one charts retrospectively of patients that were in an inpatient treatment for PTSD recovery of those eighty-one charts only sixty-two subjects were found to be satisfactory for the study. The methods used in the study was the World Health Organization Disability Assessment Schedule 2.0 (WHODAS) it is a selfreport inventory as is the PTSD Checklist for DSM-5 that was used. The Multiscale Dissociation Inventory is used to measure the frequency that individuals experience the dissociative symptoms, the Difficulties in Emotion Regulation Scale was used to assess the six dimensions of difficulties in emotional regulation, the Toronto Alexithymia Scale is a 20 item self-report that measures difficulties naming or recognizing ones emotions, the Depression Anxiety Stress Scale was used to measure symptoms of depression, stress, and anxiety and finally the Adverse Childhood Experience Questionnaire was used to assess 10 commonly experienced adverse experiences (Boyd et al., 2018).

The study seems to have been conducted ethically and with proper permission it was approved by the Homewood Health Centre Research Ethics Board.

In the longitudinal 2011 study performed by Kimbrel, Steffen, Meyer, Knight,

Zimering, & Gulliver the researchers questioned the validity of the Sources of Occupational Stress scale (SOOS) and if it was the best instrument to measure the occupational stress of first responders. The first responders and clinicians treating them have objected to the SOOS for being too long and redundant. The goal of Kimbrel et al was to improve and shorten the SOOS. (Kimbrel et al., 2011). The researchers found that while the SOOS 14, the abbreviated version exhibited good internal consistency, and good validity across two independent samples there needs to be additional studies to replicate.

The first study was with firefighters from large cities across the United States, mostly male and an average of 42 years the majority had served in fire service for greater than 7 years and over half were non-Hispanic Caucasian with African Americans making up 12 % it aimed to prove a shortened SOOS could work (Kimbrel et al., 2011). The subjects took both the SOOS and the SOOS 14 along with other tests. Study 2 used different participants all active duty fire personnel from large urban fire departments. The average age was 41 and while half were non- Hispanic white there was a larger number of African Americans 32%. Informed consent was obtained and the same tests were given which helps to determine the testing as ethical.

In conclusion of the literature review, I still feel there is further research necessary to determine if first responders are at an increased risk of PTSD. While there are plenty of studies and research, I feel a more comprehensive study can be done. I believe I would use the full SOOS even though Kimbral et al., 2018 showed that the SOOS 14 could work it does not have enough testing and I would want a full range of testing. I feel as though a large sample size that is much more diverse would be beneficial to any study. Some of the research such as Shutt and

Marotta’s 2011 study have been largely dominated by white males and while this might be representative of the field, I would further research the field and try to take a more diverse slice of population. I also would make sure to use only members that are active duty.

Methodology

Research design:

I have chosen the quantitative approach for the research. I felt quantitative would be the best since I am planning to study a larger more diverse population of first responders. The independent variable will be the first responders and the dependent variable will be to what degree the first responders develop posttraumatic stress disorder. Since I would like to measure possible PTSD in the first responder field across the country it is impossible to find first responders that have been on the same degree of traumatic calls.

Participants:

· I will be gathering participants from stations chosen from four categories at random in every state; included in the first category will be the largest/EMS police stations, the second category are medium size/medium call volume EMS and police stations, the third category will be the smallest/slowest EMS and police station in every state. For the fourth category I would like to add in a large/busy private ambulance from each state as well to make sure all areas of first response are represented in the study. I would obtain the information necessary for determining station selection by using data collected from the National Fire Protection Agency and The National Association of Police officers. Once the stations are chosen in each state, I would contact the public liaison for each department and ask to have the questionnaires distributed to all first responders at those stations. I anticipate having at least 300 surveys returned from each state with a total of 15,000 participants.

· The cluster sampling will be employed in this experiment since it seems to be the best fit for a full random sample of the first responder community.

· There will be groups assigned but only assigned by professional title for example, the groups will be broken into Fire, Police, Paramedic, and Emergency Medical Technicians (EMTs). The groups could determine if some professions develop PTSD easier than others and if those groups are recognized as having higher probability for PTSD the preventative measures could be concentrated on them.

· The demographics of the study will more than likely be predominately male and predominately white. According to the National Fire Protection Agency’s (NFPA, 2019) and the National Police Officer Association’s (NPOA, 2019) statistics, both fields are predominantly made up of white males between the ages of 20-49 years of age. The

National Fire Protection Agency’s 2017 United Fire Department Profile Report 7% of firefighters are women, Data USA is currently reporting that 21% of police officers are female.

Procedures:

· I plan on conducting this study online through a portal that has an access code given to participants. I think this would be the easiest way to have the data returned and the most cost-effective way to collect it. The date will however, be analyzed at a

University and only approved researchers will have access to it.

· I would give the participants 60 days to complete the surveys.

Measures:

· This will be a self-report study

· As in Kimbrel et al 2011 study I would like to use the PTSD Checklist (PCL-5

Weathers, Lita, Herman, Huska, & Keane, 1993) and also the Critical Incident History Questionnaire that assesses 34 incidents that are commonly experienced by officers in the field 19 of those questions ask about direct involvement (shooting at someone/being shot at) and 15 items about indirect involvement for example:

encountering a child that was beaten or sexually abused (Chopko et al, 2018). I would also like to use the Sources of Occupational Stress (SOOS) even though the 2018 study by Kimbrel et al showed the abridged 14 question SOOS was valid I would like to go more in depth. Unfortunately, I was only able to find one example of the tests I would like to administer the PTSD Checklist by Weathers et al, 1993 is attached.

· The PTSD Checklist (PCL-5 Weathers et al, 1993) “is a 17-item self-report measure designed to assess PTSD symptom severity that has demonstrated excellent reliability and validity” (Kimbrel et al, 2011. np).

· I will include all surveys on the portal in different sections, breaks may be taken and they can work at their own pace (save and come back later).

· The above-mentioned surveys will all be done through self-reporting questionnaires

Ethical:

· I plan on keeping the study ethical by conferring and receiving permission by our IRB at the University, obtaining a properly written informed consent, and protecting the anonymity of the subjects. It will also be stated on the informed consent that participation is voluntary.

PTSD Checklist by Weathers et al, 1993

Discussion:

The findings of this research prove that first responders do have a higher risk of developing Post traumatic stress disorder (PTSD). The findings would be of great importance to help implement programs to lessen the chances of PTSD in first responders. It is also in the findings of this report that the amount of trauma witnessed, long hours, and anxiety of being harmed have caused an increase in severity of PTSD in first responders. This information will help a great deal in the first responder community to find preventative measures, whether limiting hours worked, mandating clinical debriefing after severe calls, or helping new first responders during training to prepare better mentally for the job.

Even though great measures were taken to ensure a large number of diverse first responders and departments were taken into account I believe the same research with the same number of participants from different areas should be conducted again to add a larger sample. I would also like to see results from a study done after additional mental health training has occurred with new recruits and trainees cope mentally with the stressors of the job.

The possible limitations to this study could lie in the differences between urban and rural departments that see different types of calls. I also see limitations in the fact that all participants were given the same questionnaires. It might have been beneficial to give the first responders different job specific questions since they were already broken into groups. Also, fish and wildlife and forest ranger were not included. I would also like to see highway patrols included into the law enforcement group in future studies.

I did not see any ethical issues that were encountered. The voluntary surveys were given through a password protected website identifying only the test not the participant by number.

There is no way of knowing which participant took the test. Informed consent was given.

Permission was granted through the University’s review board.

Validity:

The internal validity is the extent to which we can say that only the independent variable caused the changes in the dependent variable (Cozby & Bates, 2018). I believe history is a threat to this study. Who is to say the participants did not have a previous history that we did not ask about, and therefore was not taken into consideration? I did not ask how many were veterans and if the PTSD came from their time in active duty military. Also, what happened to them before becoming a first responder? Were they involved in a tragedy that caused PTSD symptoms to be easily triggered?

Construct validity of refers to the accuracy of measurement (Cozby & Bates, 2018). I did wonder about reactivity to the experiment by the participants. Did the participants feel that they could be matched with their answers so they did not necessarily answer truthfully? It would be suggested that a survey is given to participants from this experiment about how anonymous they thought the survey was. One can also wonder if cues from the experimental questions caused the participants to answer higher or lower on the PTSD scale since they knew from the material that was being tested.

In conclusion I feel that the study is valid, ethical, and will prove to be very helpful in the future. If the findings of this research are shared with the community it could make our first responders healthier and proved for a stronger mental health in the community.

References

Boyd, J. E., Protopopescu, A., O’Connor, C., Neufeld, R. W., Jetly, R., Hood, H. K., . . . Mckinnon, M. C. (2018). Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with

PTSD. European Journal of Psychotraumatology, 9(1), 1463794. doi:10.1080/20008198.2018.1463794

Chopko, B. A., Palmieri, P. A., & Adams, R. E. (2018). Relationships Among Traumatic

Experiences, PTSD, and Posttraumatic Growth for Police Officers: A Path Analysis.

Psychological Trauma: Theory, Research, Practice, and Policy, 10(2), 183-189.

doi:10.1037/tra00

Cozby, P. C., & Bates, S. (2018). Methods in behavioral research. New York, NY: McGraw-Hill

Education.

Kimbrel, N. A., Steffen, L. E., Meyer, E. C., Kruse, M. I., Knight, J. A., Zimering, R. T., & Gulliver, S. B. (2011). A revised measure of occupational stress for firefighters: Psychometric properties and relationship to posttraumatic stress disorder, depression, and substance abuse.

Psychological Services, 8(4), 294-306. doi:10.1037/a0025845

National Police Officer Association. 2019

National Fire Protection Agency. 2019

Schutt, J. M., & Marotta, S. (mar. 2011). Personal and Environmental Predictors of Posttraumatic

Stress in Emergency Management Professionals. Pyschological Trauma: Theory, Research,

Practice, and Policy, 3(1), 8-15. doi:10.1037/e517292011-473

Skogstad, L., Fjetland, A. M., & Ekeberg, Ø. (2015). Exposure and posttraumatic stress symptoms among first responders working in proximity to the terror sites in Norway on July 22, 2011 – a cross-sectional study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine,

23(1). doi:10.1186/s13049-015-0104-4

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FIRST RESPONDERS RISK FOR PTSD 2

FIRST RESPONDERS RISK FOR PTSD 2

Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD PCL-5 (8/14/2013)