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Caring for traffic accident victims: The stories of nine male police officers
International Emergency Nursing (2011) 19, 90– 95
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journal homepage: www.elsevierhealth.com/journals/aaen
Caring for traffic accident victims: The stories of nine male police officers Susann Backteman-Erlanson RNT, MSc, PhD (Student) *, ¨ ster RNT, PhD, Ann Jacobsson RN, MSc (Project Assistant), Inger O Christine Brulin RNT, PhD (Professor) ˚ University, SE-901 87 Umea ˚, Sweden Department of Nursing, Umea Received 2 April 2010; received in revised form 14 June 2010; accepted 25 June 2010
KEYWORDS Police; Experiences; Traffic accidents; Content analysis; Stress; Coping; Gender
Abstract Psychological strain due to the work environment is common, especially in those occupations which involve working in critical situations. Working as a police officer seems to increase the risk of psychological problems such as symptoms of stress and post traumatic stress disorders. The aim of this study was to describe male police officers’ experiences of traumatic situations when caring for victims of traffic accidents, and to reflect the results through the perspective of gender theories. Nine police officers were asked to narrate and reflect upon their experiences in taking care of people who had been severely injured in traffic accidents. The interviews were analysed with qualitative content analysis. The findings are presented in three themes: ‘‘being secure with the support system’’, ‘‘being confident about prior successful actions, and ‘‘being burdened with uncertainty’’. The officers’ descriptions showed that most of them had strategies that they used when they were first responders, developed on the basis of their own knowledge and actions and the support systems in their organization which enabled them to act in traumatic situations. When support systems, knowledge, and actions were insufficient, they sometimes felt insecure and ‘‘burdened with uncertainty’’. In this male-dominated context, there was a risk that the officers may not talk enough about traumatic situations, thus influencing their ability to cope successfully.
ª 2010 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: +46 907869859; fax: +46 907869169. E-mail address: [email protected] (S. BacktemanErlanson).
Psychological strain due to the work environment is common, especially in occupations which involve working in critical situations (Ben et al., 2006; Helps, 1997). Working as a police officer seems to increase the risk of psychological
1755-599X/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2010.06.001
Caring for traffic accident victims: The stories of nine male police officers problems such as symptoms of stress and post traumatic stress disorders (PTSD) (Anderson et al., 2002; Arrendondo et al., 2002; Gersons, 1989; Renck et al., 2002). Police work is characterized by sudden events, major and minor crimes, and the actions, individuals, and injuries associated with traffic accidents. Police officers are responsible for informing the victims’ relatives, and when they are the first to arrive at the scene of an accident, they have to start and continue critical medical care until the emergency team arrives (Orner, 2003). Thus, the job of a patrolling police officer is psychologically demanding. Police officers who have experienced traumatic events report memories in the form of visual, tactile, and olfactory sensations (Karlsson and Christianson, 2003). Lingering memories of traumatic events have been described as a risk factor for developing burnout in close working relationships (Schaufeli and Enzmann, 1998), and also among police personnel (Kop and Euwema, 2001; Renck et al., 2002). Unfortunately, most police systems have no organized coping strategies to prevent PTSD or burnout (Anshel, 2000). It is important, therefore, to develop programs focused on coping after an accident. However, the development of programs requires increased knowledge of the reactions among police personnel after caring for victims of accidents. Positive coping strategies have been used to prevent ill health since the mid-1980s (Folkman and Moskowitz, 2000). Police work often involves the ‘‘heroic feeling’’ of being first at the accident scene and saving lives (Elmqvist et al., 2009), and the experience and recollection of these situations and feelings are very important in improving skills related to taking care of severely injured people (Fullerton et al., 1992; Shakespeare-Finch et al., 2002). On the other hand, negative coping strategies such as avoidance behaviour increase the risk for discomfort and feelings of unease (Jeavons et al., 2000). Gershon et al. (2002) found that maladaptive coping behaviour such as heavy drinking or gambling was common in police work. In addition, those who reported maladaptive coping strategies also reported stress at work, which increased the risk of anxiety, depression, PTSD, and burnout (Gershon et al., 2002). Researchers have suggested the importance of further investigating the process of taking care of severely injured people during traumatic situations (Anshel, 2000; Renck et al., 2002). Aside from the fact that police personnel often work in demanding situations, police organizations are also dominated by men, as indicated by men being clearly signalled as the norm in language, stereotypes, and presumptions (Andersson, 2003; Kop and Euwema, 2001). Andersson (2003) pointed out that ‘‘real police work’’ (p. 91) may be seen in these organizations as the ‘‘nightly patrolling in cars’’ (p. 91) often performed by young men. A ‘‘macho cop culture’’ that idealizes a John Wayne-like image of masculinity has also been described (Kop and Euwema, 2001, p. 631; Schaufeli and Enzmann, 1998, p. 63), as has the use of a ‘‘code of silence’’ (Kingshott et al., 2004, p. 190). Experiences from critical situations, however, are not evaluated or talked about within these organizations (Kingshott et al., 2004; Rothwell and Baldwin, 2007), leading to negative, avoidant coping strategies (Alexander and Walker, 1996; Kingshott et al., 2004; McCafferty et al., 1992). According to Connell’s theory of hegemonic masculinity (Connell, 2005), this type of strategy may be seen to express the dom-
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inant way of being masculine, stressing strength and firmness. In Sweden as well as in other countries, the gender structure of police organizations changed after 1950 as women entered the occupation (Dahlgren, 2007). However, since women were not expected to perform ‘‘real’’ police work, they began to be seen as a threat, as they were promoted more rapidly in their administrative work than were their male colleagues (Dahlgren, 2007, p. 84). We have found no studies that illuminate police officers’ experiences of taking care of severely injured people after a traumatic situation. In order to develop effective coping strategies to prevent burnout among personnel, and to further improve the care of severely injured people, such knowledge is of the utmost importance. Furthermore, since the role of the male-dominated culture is prominent in police organizations, a gender perspective must be taken into consideration when analyzing and interpreting police officers’ narratives. This study is one of several qualitative and quantitative studies exploring experiences of traumatic situations. The aim of the present study was to describe male police officers’ experiences of working in traumatic situations when caring for victims of traffic accidents, and to reflect the results through the perspective of gender theories.
Methods In this study we used a qualitative approach, by using content analysis (Graneheim and Lundman, 2004).
Participants A convenience sample comprising nine policemen was used for this study. The participants were employed in a mid-sized police authority in northern Sweden. The inclusion criteria were being responsible for patrolling, having experience in the care of injured and deceased people in traffic accidents, being male, and being able to speak and understand the Swedish language. The participants were invited to take part in the study during their morning meeting at work, at which time the purpose of the study was presented. They received an information letter about the study, in which they were asked to contact the researcher to make an appointment for time and place of an interview. Nine male police officers notified the researcher of their interest, and willingly agreed to participate in the study. Their ages ranged from 27 to 40 years, and their experience of police work ranged from 1 to 9 years. All had undergone the 2 years full time studies of police education which is the norm in Sweden.
Data collection Narrative interviews lasting 30–45 min were conducted by the first author (SB); six in September 2003 and three in January 2008. In the interviews, the interviewees were asked to narrate and reflect upon their experiences in taking care of severely injured and dead people in traffic accidents. Initial questions were asked to open up topics and facilitate the informants’ narrations (Riessman, 2008). An interview guide was used, and the opening question was: ‘‘Please tell me
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about any accident when you have taken care of injured and dead people.’’ Several probing questions were then asked to prompt the interviewees to elaborate upon or to clarify information: ‘‘Tell me more; what did you feel then and what did you experience?’’, ‘‘What happened then?’’ and finally, ‘‘How did you reflect upon this?’’ The interviews occurred at a place and time that suited each participant, usually in a room at the local police station or the office of the first author. All interviews were audio-recorded and transcribed verbatim.
Research ethical considerations This study was approved by the Ethics Committee at the Medical Faculty, Umea ˚ University, Umea ˚, Sweden (dnr 03079). Identifying details were excluded from the audio recordings, and the participants were assured confidentiality and anonymity in the presentation and publication of results.
Data analysis The audio-recorded and transcribed interviews were analyzed using qualitative content analysis (Graneheim and Lundman, 2004; Polit and Beck, 2006). Qualitative content analysis is a process of identifying, coding, and categorizing primary patterns in qualitative data––in this study, narrative interviews (Riessman, 2008). The method can be used to describe meanings, intentions, and context and is useful in the analysis of individual or group experiences, thoughts, and attitudes (Graneheim and Lundman, 2004). The intent during the analytical process was to remain close to the words of the text. The analysis was performed in several steps. The first reading of the text was open, to allow the researchers to grasp the content and gain a sense of the whole interview text. Next, the text was read through several times before being divided into meaning units. This process was based on two questions: How do policemen experience the traumatic event? and What is it like, caring for people in traumatic incidents? The meaning units were then condensed into descriptions based on the text of the described experiences, and coded. The coded units relevant to the aims of the study were then abstracted into subthemes and themes. To increase trustworthiness, all authors participated in the process throughout the analysis by reading and reflecting upon the texts.
Results The narratives consisted of several different stories about experiences of taking care of seriously injured and someTable 1
times deceased people; reflections about the experiences were also expressed in the narratives. Three themes were formulated: being secure within the support system, being confident about prior successful actions, and being burdened with uncertainty (Table 1). The officers felt secure within the support system when the different strategies that had been developed over the years were supported by the organization. These strategies included resources to guide the policemen through the accident and to help them process their thoughts afterward. From the narratives it was obvious that a feeling of knowing and doing what was necessary made them confident in their own capacity, leading to a feeling of success in their actions. Feelings of inadequacy surfaced when support systems and their own knowledge were insufficient to enable them to act optimally. Uncertainty over what should have been done, coupled with an inability to improve the outcome, became a growing burden that negatively influenced further contributions in emergency situations. The themes and subthemes are thus highly interrelated. They are explained further below, with clarifying excerpts from the interviews.
Being secure within the support system This theme ran through almost all of the narratives about taking care of seriously injured or dead people. To achieve this feeling of security, the police officers combined different personal strategies, based not only on support from colleagues and spouses, but also on actual support from the organization in terms of using the uniform. The first subtheme, ‘‘having developed various strategies,’’ was characterized by problem-solving, which the officers said helped them focus on what they had to do: ‘‘It’s just doing your duty, no more complicated than that.’’ When they had to convey difficult information, they concentrated on the information and tried to push away their feelings. Another strategy was to distance themselves emotionally from the difficult incident, to separate their own problems from those of others. Several of the interviewees stressed that they had the ability to set aside and compartmentalize problems related to their work when they were off duty, describing how they left their thoughts about work with the uniform when they took it off. The officers also described the importance of having time to prepare themselves mentally on the way to the scene of the accident. Even a few minutes could mean a lot:
Overview of subthemes and themes.
Subthemes
Themes
Having developed various strategies Feeling supported Knowing and doing what is necessary Knowing one’s own capacity Uncertainty about what should have been done Feeling inadequate
Being secure within the support system Being confident about prior successful actions Being burdened with uncertainty
Caring for traffic accident victims: The stories of nine male police officers ‘‘You get some time to think it over, what to do next and so on, together with your partner.’’ In addition, they often planned for a worst-case scenario: ‘‘It’s better to be prepared for the worst, and then when you arrive it’s not as bad, instead of vice versa.’’ The other subtheme in this theme, ‘‘feeling supported’’ was expressed in terms of companionship with colleagues: ‘‘It gives you a feeling of security to go with someone you feel comfortable with, instead of going by yourself.’’ Time spent with colleagues after the incident was also valuable as a way to process the event. There was a difference between talking to spouses at home about the event and talking with colleagues: ‘‘It’s a special kind of culture, and it depends on who you’re going with, you can’t talk to every colleague.’’ The participants also described how the uniform helped them feel secure in traumatic situations: ‘‘We had to start by putting on all the pieces of the uniform in the car, so you look like a police officer. . . and you put on your formal mask, and then you do your job and nothing else.’’
Being confident about prior successful actions The police officers described how they felt confident about successful prior actions when they found themselves in new but similar difficult situations; they knew what to do, and they knew they were capable of doing it. Such knowledge was very valuable in handling difficult situations and made them feel competent and secure in their professions, which was in turn very important and useful in future similar situations. The first subtheme in this theme, ‘‘knowing and doing what is necessary’’ describes the officers’ feeling of acting in an optimal way in a specific traumatic situation. Discussing the event with colleagues and sharing experiences with each other was very important: ‘‘We felt that we had done a good job, we sat in the car going back to the station, we were pleased and satisfied.’’ This feeling was strengthened further by greetings from other professionals who had been involved in the traumatic situation; for example, the policemen had a thank you card at the station saying, ‘‘Thank you so much for your help in this special accident.’’ The other subtheme in this theme was ‘‘knowing one’s own capacity’’. It was clear that knowing one’s own capacity was important for performing successful actions, and being confirmed by colleagues and society was important for accurately judging this capacity: ‘‘He was very good, my colleague, with a lot of experience.’’
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Another important factor in judging one’s own capacity was being confirmed as an educated police officer with enough theoretical and practical knowledge to handle traumatic situations. One interviewee said that when he arrived first at the scene of an accident, ‘‘I realized I cannot do everything. I can only do my best under the conditions present at the time and my capacity on that day.’’ This sort of reasoning strengthened the police officers, and left them feeling good, and satisfied with their work.
Being burdened with uncertainty When the police officers‘ did not have sufficient time to prepare themselves before being faced with traumatic situations involving severely injured and sometimes deceased persons, they experienced feelings of inadequacy. These feelings lingered as thoughts of uncertainty about what should have been done, and sometimes became a burden. Not being able to control and handle traumatic situations caused feelings of powerlessness and inadequacy, and the interviewees expressed these feelings as if the experiences were still with them. The first subtheme in this theme, ‘‘uncertainty about what should have been done’’ was described by a number of officers who had encountered situations where they felt a lack of both support and knowledge. After these situations were resolved, they had ongoing thoughts about the event and their own contribution: ‘‘When you think about this [a particular event], there is really nothing to do about it, but still you wonder about it, it’s still there.’’ They asked themselves, ‘‘Did we do the right thing? Should we have done more? Could we have done more if we had had more equipment?’’ They also pointed out that the preparation time was often too short, and they were forced to deal with the accident without being mentally prepared. The second subtheme in this theme, ‘‘feeling inadequate’’, was described in terms of emotional reactions in different situations. At times, the ‘‘purely humane’’ pushed against the professional role: ‘‘It was heartbreaking and very tough; it’s so difficult when people cry. . . and their children were badly hurt, then it can be really hard for you.’’ One policeman, describing his emotional difficulties, said: ‘‘There were fifteen minutes when I felt so inadequate because I could not do anything; they [the spouses of the injured people] just sat there.’’ The informants also described how they tried to pull themselves together in order to tell the spouses of the injured people what had happened. Feelings of inadequacy could become so strong that the policemen delayed their arrival at the scene, to en-
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sure that other emergency team members would arrive before them. Such situations added to the burden of uncertainty: ‘‘Often it is really terrible accidents that you have in your memory for a couple of days; you think about [scenes] from here and there, sometimes you get to see really bad things.’’
Discussion The interviewees’ descriptions of their experiences of traumatic situations caring for victims of traffic accidents showed that in situations where they were the first responders, most of them used strategies that promoted feelings of security. Feelings of security came from support within the police organization, but also from their own ability to solve and sort out difficult situations. They focused on what to do, what to say, and what their special duties were, which can be considered a form of problem-focused coping (Folkman and Moskowitz, 2000). Focusing on task-oriented, situation-specific actions can contribute to the individual’s ability to feel effective and to experience situational mastery and control, which in turn can increase his or her well-being (Carver et al., 1989; Folkman and Moskowitz, 2000). The police officers in our study also explained that they knew and did what was necessary. This could be an example of the process suggested by Folkman and Moskowitz (2000), in which successful problem-focused efforts can explain reports of positive emotions in the midst of distress. Problem-focused coping also has other positive outcomes, such as focusing attention (Folkman and Moskowitz, 2000), which the policemen in our study expressed through their narratives. Another way that the interviewees maintained their professional role was to leave unpleasant feelings and thoughts with the uniform when they took it off and went home. As Gersons (1989) writes, this could be a strategy for deliberately differentiating their professional identities from their private lives or identities. Elmqvist et al. (2009) found that when first responders had the opportunity to retell the situation later, they could transform their experience through these narratives into useful knowledge that helped prepare them for unexpected encounters in the future. This also helped both themselves and other first responders to deal with unpleasant memories, as they could feel both personal and professional growth. The police officers in our study also expressed the importance of discussing with their colleagues the ways they had acted in difficult situations; this also strengthened them with knowledge that was useful when attending similar accidents. They described how working together with other professionals and being confirmed by them as doing a good job helped them in judging their own capacity. The participants in the study by Elmqvist et al. (2009) also expressed the importance of consultation and collaboration between professionals who deal with injured persons. Focusing on experiences from traumatic situations that worked out well is one strategy that can be used by those involved to help them cope more easily in other similar situations (Fullerton et al., 1992). The police officers in our
study noted that it was ‘‘not allowed’’ to talk about difficult situations with just anybody among their colleagues, and that usually depended on whom they worked with. Some previous studies have described this aspect of police culture; the ‘‘code of silence’’ which can mean that police officers do not speak out loud about their experiences, but rather keep their experiences to themselves (Kingshott et al., 2004; Rothwell and Baldwin, 2007). In a review, Anshel (2000) suggests a conceptual model for the process of coping with the stress experienced in police work, and offers suggestions for improvements, concluding that through training police officers can learn to select the appropriate cognitive appraisal for each specific situational demand. By learning to appraise their actions objectively, they could increase their knowledge and feel more secure in their abilities when taking care of victims of traffic accidents. The police officers in our study said that they sometimes felt uncertain about how they had acted, which left them feeling ambivalent about specific difficult situations. The work in which they were engaged could be divided into two categories (Andersson, 2003): the ‘‘real police work’’ (p. 91) done by the young men on night patrol, and the planning done by their middle-aged and older colleagues, who thus lost credibility due to not being out in the field. Our interviewees emphasized the difficulty of being in situations when people were crying or seriously injured, using expressions such as ‘‘couldn’t do anything.’’ This could relate to Andersson’s (2003) interpretation of doing ‘‘real police work’’ (p. 80) and the ‘‘macho culture’’ exemplified by the John Wayne image (Kop and Euwema, 2001, p. 631), which to a certain extent is still present within police organizations. Karlsson and Christianson (2003) found that vivid visual, tactile, and olfactory sensations from the scene of a traffic accident remain in memory years after a traumatic experience, and that often it was the memories from early in an individual’s career and his or her first experiences of traumatic incidents that made the deepest impressions. The police officers in our study also had vivid memories from traumatic situations, and could describe the events in detail. They further confirmed the results of Karlsson and Christianson, in reporting that talking about a traumatic experience with their colleagues was a way of working through it, and that the feelings of powerlessness and despair were especially acute in situations involving traumatized children. However, our findings differ from those of Karlsson and Christianson (2003) in that our interviewees not only emphasized the importance of getting support from superiors and the work organization in these situations, but also stated that they received this support, at least to a certain extent. The participants in the study by Karlsson and Christianson’s (2003) stated that they did not receive any support from the work organization.
Methodological considerations The strength of this study is that it illuminates the police officers’ own experiences of working in a traumatic situation. Furthermore, the narratives from the interviewees were rich and strongly focused on the topic, and did not differ due to content and length of the interview. The interviewees also gave detailed accounts rather than brief answers and general statements (Riessman, 2008). A possible weak-
Caring for traffic accident victims: The stories of nine male police officers ness is that five of the interviews were conducted in September 2003 and the remaining three were conducted over 4 years later, in January 2008. However, during this period there were no substantial changes in police education, the police work environment, the support system in prehospital care, the guidelines for handling traumatic situations, or the relevant victim protocols. The first author (SBE) collected all interviews in both 2003 and 2008, and the consistency was similar on both occasions. The interviews were read through and analyzed by all authors, and no discrepancies were found between the two groups of interviews.
Conclusions The male police officers in our study relied upon a combination of their own knowledge and action and the support systems in their organization to enable them to act in traumatic situations. They thus felt insecure and ‘‘burdened with uncertainty’’ when their support systems, knowledge, and actions were insufficient. In this male-dominated context, there is a risk that police officers will fail to talk enough about traumatic situations, which might influence their ability to cope successfully. This risk has previously been highlighted by Kop and Euwema (2001), who warn that police culture, which is often described as ‘‘macho’’, might not pay sufficient attention to emotional problems. Furthermore, Karlsson and Christianson (2003) found that few policemen had received support from their superiors. One limitation of this study is the relatively small number of participants, but our findings show similarities between the police organizations in Sweden and those in other countries. Additional research is still necessary; specifically, important knowledge in this area could be gained by interviewing female police personnel about their experiences.
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Connell, R.W., 2005. Masculinities. University of California Press, Berkeley and Los Angeles, California. Dahlgren, J., 2007. Kvinnor i polistja ¨nst. Fo ¨reningen Kamraterna, Svenska Polisfo ¨rbundet och kvinnors intra ¨de i polisyrket 1957– 1971 [Women in the police service. The Kamraterna Association, the Swedish Policemen’s Union and women’s entrance into the police profession 1957–1971]. Dissertation, unpublished. Department of Historical Studies, Umea ˚ University, Umea ˚. Elmqvist, C., Brunt, D., Fridlund, B., Ekebergh, M., 2009. Being first on the scene of an accident – experiences of ‘doing’ prehospital emergency care. Scandinavian Journal of Caring Sciences, September 1, 2009 (Epub ahead of print). Folkman, S., Moskowitz, J., 2000. Positive affect and the other side of coping. American Psychologist 55, 647–654. Fullerton, C., McCarroll, J., Ursano, R., Wright, K., 1992. Psychological responses of rescue workers: fire fighters and trauma. American Journal of Orthopsychiatry 62, 371–378. Gershon, R.R., Lin, S., Li, X., 2002. Work stress in aging police officers. Journal of Occupational and Environmental Medicine 44, 160–167. Gersons, B., 1989. Patterns of PTSD among police officers following shooting incidents: a two-dimensional model and treatment implications. Journal of Traumatic Stress 2, 247–257. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Helps, S., 1997. Experiences of stress in accident and emergency nurses. Accident and Emergency Nursing 5, 48–53. Jeavons, S., Horne, D.J., Greenwood, K.M., 2000. Coping style and psychological trauma after road accidents. Psychology, Health & Medicine 5, 213–221. Karlsson, I., Christianson, S., 2003. The phenomenology of traumatic experiences in police work. Policing: An International Journal of Police Strategies & Management 20, 419–438. Kingshott, B., Bailey, K., Wolfe, S., 2004. Police culture, ethics and entitlement theory. The Justice Professional 17, 187–202. Kop, N., Euwema, M.C., 2001. Occupational stress and the use of force by Dutch police officers. Criminal Justice and Behavior 28, 631–652. McCafferty, F., McCafferty, E., McCafferty, M., 1992. Stress and suicide in police officers: paradigm of occupational stress. Southern Medical Journal 85, 233–243. Orner, R., 2003. A new evidence base for making early intervention in emergency services complementary to officers‘ preferred adjustment and coping strategies. In: Orner, R., Schnyder, U. (Eds.), Reconstructing Early Intervention after Trauma. Innovations in the Care of Survivors. Oxford University Press, Oxford, pp. 143–153. Polit, D., Beck, C., 2006. Nursing Research: Principles and Methods. Lippincott Williams & Wilkins, Philadelphia. Renck, B., Weisaeth, L., Skarbo ¨, S., 2002. Stress reactions in police officers after a disaster rescue operation. Nordic Journal of Psychiatry 56, 7–14. Riessman, C., 2008. Narrative Methods for the Human Sciences. Sage Publications, Thousand Oaks, CA. Rothwell, G., Baldwin, J., 2007. Ethical climate theory, whistleblowing, and the code of silence in police agencies in the state of Georgia. Journal of Business Ethics 70, 341–361. Schaufeli, W., Enzmann, D., 1998. The Burnout Companion to Study and Practice: A Critical Analysis. Taylor & Francis, London, Philadelphia. Shakespeare-Finch, J., Smith, S., Obst, P., 2002. Trauma, coping resources, and family functioning in emergency services personnel: a comparative study. Work & Stress 16, 275–282.
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/aaen
Caring for traffic accident victims: The stories of nine male police officers Susann Backteman-Erlanson RNT, MSc, PhD (Student) *, ¨ ster RNT, PhD, Ann Jacobsson RN, MSc (Project Assistant), Inger O Christine Brulin RNT, PhD (Professor) ˚ University, SE-901 87 Umea ˚, Sweden Department of Nursing, Umea Received 2 April 2010; received in revised form 14 June 2010; accepted 25 June 2010
KEYWORDS Police; Experiences; Traffic accidents; Content analysis; Stress; Coping; Gender
Abstract Psychological strain due to the work environment is common, especially in those occupations which involve working in critical situations. Working as a police officer seems to increase the risk of psychological problems such as symptoms of stress and post traumatic stress disorders. The aim of this study was to describe male police officers’ experiences of traumatic situations when caring for victims of traffic accidents, and to reflect the results through the perspective of gender theories. Nine police officers were asked to narrate and reflect upon their experiences in taking care of people who had been severely injured in traffic accidents. The interviews were analysed with qualitative content analysis. The findings are presented in three themes: ‘‘being secure with the support system’’, ‘‘being confident about prior successful actions, and ‘‘being burdened with uncertainty’’. The officers’ descriptions showed that most of them had strategies that they used when they were first responders, developed on the basis of their own knowledge and actions and the support systems in their organization which enabled them to act in traumatic situations. When support systems, knowledge, and actions were insufficient, they sometimes felt insecure and ‘‘burdened with uncertainty’’. In this male-dominated context, there was a risk that the officers may not talk enough about traumatic situations, thus influencing their ability to cope successfully.
ª 2010 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: +46 907869859; fax: +46 907869169. E-mail address: [email protected] (S. BacktemanErlanson).
Psychological strain due to the work environment is common, especially in occupations which involve working in critical situations (Ben et al., 2006; Helps, 1997). Working as a police officer seems to increase the risk of psychological
1755-599X/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2010.06.001
Caring for traffic accident victims: The stories of nine male police officers problems such as symptoms of stress and post traumatic stress disorders (PTSD) (Anderson et al., 2002; Arrendondo et al., 2002; Gersons, 1989; Renck et al., 2002). Police work is characterized by sudden events, major and minor crimes, and the actions, individuals, and injuries associated with traffic accidents. Police officers are responsible for informing the victims’ relatives, and when they are the first to arrive at the scene of an accident, they have to start and continue critical medical care until the emergency team arrives (Orner, 2003). Thus, the job of a patrolling police officer is psychologically demanding. Police officers who have experienced traumatic events report memories in the form of visual, tactile, and olfactory sensations (Karlsson and Christianson, 2003). Lingering memories of traumatic events have been described as a risk factor for developing burnout in close working relationships (Schaufeli and Enzmann, 1998), and also among police personnel (Kop and Euwema, 2001; Renck et al., 2002). Unfortunately, most police systems have no organized coping strategies to prevent PTSD or burnout (Anshel, 2000). It is important, therefore, to develop programs focused on coping after an accident. However, the development of programs requires increased knowledge of the reactions among police personnel after caring for victims of accidents. Positive coping strategies have been used to prevent ill health since the mid-1980s (Folkman and Moskowitz, 2000). Police work often involves the ‘‘heroic feeling’’ of being first at the accident scene and saving lives (Elmqvist et al., 2009), and the experience and recollection of these situations and feelings are very important in improving skills related to taking care of severely injured people (Fullerton et al., 1992; Shakespeare-Finch et al., 2002). On the other hand, negative coping strategies such as avoidance behaviour increase the risk for discomfort and feelings of unease (Jeavons et al., 2000). Gershon et al. (2002) found that maladaptive coping behaviour such as heavy drinking or gambling was common in police work. In addition, those who reported maladaptive coping strategies also reported stress at work, which increased the risk of anxiety, depression, PTSD, and burnout (Gershon et al., 2002). Researchers have suggested the importance of further investigating the process of taking care of severely injured people during traumatic situations (Anshel, 2000; Renck et al., 2002). Aside from the fact that police personnel often work in demanding situations, police organizations are also dominated by men, as indicated by men being clearly signalled as the norm in language, stereotypes, and presumptions (Andersson, 2003; Kop and Euwema, 2001). Andersson (2003) pointed out that ‘‘real police work’’ (p. 91) may be seen in these organizations as the ‘‘nightly patrolling in cars’’ (p. 91) often performed by young men. A ‘‘macho cop culture’’ that idealizes a John Wayne-like image of masculinity has also been described (Kop and Euwema, 2001, p. 631; Schaufeli and Enzmann, 1998, p. 63), as has the use of a ‘‘code of silence’’ (Kingshott et al., 2004, p. 190). Experiences from critical situations, however, are not evaluated or talked about within these organizations (Kingshott et al., 2004; Rothwell and Baldwin, 2007), leading to negative, avoidant coping strategies (Alexander and Walker, 1996; Kingshott et al., 2004; McCafferty et al., 1992). According to Connell’s theory of hegemonic masculinity (Connell, 2005), this type of strategy may be seen to express the dom-
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inant way of being masculine, stressing strength and firmness. In Sweden as well as in other countries, the gender structure of police organizations changed after 1950 as women entered the occupation (Dahlgren, 2007). However, since women were not expected to perform ‘‘real’’ police work, they began to be seen as a threat, as they were promoted more rapidly in their administrative work than were their male colleagues (Dahlgren, 2007, p. 84). We have found no studies that illuminate police officers’ experiences of taking care of severely injured people after a traumatic situation. In order to develop effective coping strategies to prevent burnout among personnel, and to further improve the care of severely injured people, such knowledge is of the utmost importance. Furthermore, since the role of the male-dominated culture is prominent in police organizations, a gender perspective must be taken into consideration when analyzing and interpreting police officers’ narratives. This study is one of several qualitative and quantitative studies exploring experiences of traumatic situations. The aim of the present study was to describe male police officers’ experiences of working in traumatic situations when caring for victims of traffic accidents, and to reflect the results through the perspective of gender theories.
Methods In this study we used a qualitative approach, by using content analysis (Graneheim and Lundman, 2004).
Participants A convenience sample comprising nine policemen was used for this study. The participants were employed in a mid-sized police authority in northern Sweden. The inclusion criteria were being responsible for patrolling, having experience in the care of injured and deceased people in traffic accidents, being male, and being able to speak and understand the Swedish language. The participants were invited to take part in the study during their morning meeting at work, at which time the purpose of the study was presented. They received an information letter about the study, in which they were asked to contact the researcher to make an appointment for time and place of an interview. Nine male police officers notified the researcher of their interest, and willingly agreed to participate in the study. Their ages ranged from 27 to 40 years, and their experience of police work ranged from 1 to 9 years. All had undergone the 2 years full time studies of police education which is the norm in Sweden.
Data collection Narrative interviews lasting 30–45 min were conducted by the first author (SB); six in September 2003 and three in January 2008. In the interviews, the interviewees were asked to narrate and reflect upon their experiences in taking care of severely injured and dead people in traffic accidents. Initial questions were asked to open up topics and facilitate the informants’ narrations (Riessman, 2008). An interview guide was used, and the opening question was: ‘‘Please tell me
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about any accident when you have taken care of injured and dead people.’’ Several probing questions were then asked to prompt the interviewees to elaborate upon or to clarify information: ‘‘Tell me more; what did you feel then and what did you experience?’’, ‘‘What happened then?’’ and finally, ‘‘How did you reflect upon this?’’ The interviews occurred at a place and time that suited each participant, usually in a room at the local police station or the office of the first author. All interviews were audio-recorded and transcribed verbatim.
Research ethical considerations This study was approved by the Ethics Committee at the Medical Faculty, Umea ˚ University, Umea ˚, Sweden (dnr 03079). Identifying details were excluded from the audio recordings, and the participants were assured confidentiality and anonymity in the presentation and publication of results.
Data analysis The audio-recorded and transcribed interviews were analyzed using qualitative content analysis (Graneheim and Lundman, 2004; Polit and Beck, 2006). Qualitative content analysis is a process of identifying, coding, and categorizing primary patterns in qualitative data––in this study, narrative interviews (Riessman, 2008). The method can be used to describe meanings, intentions, and context and is useful in the analysis of individual or group experiences, thoughts, and attitudes (Graneheim and Lundman, 2004). The intent during the analytical process was to remain close to the words of the text. The analysis was performed in several steps. The first reading of the text was open, to allow the researchers to grasp the content and gain a sense of the whole interview text. Next, the text was read through several times before being divided into meaning units. This process was based on two questions: How do policemen experience the traumatic event? and What is it like, caring for people in traumatic incidents? The meaning units were then condensed into descriptions based on the text of the described experiences, and coded. The coded units relevant to the aims of the study were then abstracted into subthemes and themes. To increase trustworthiness, all authors participated in the process throughout the analysis by reading and reflecting upon the texts.
Results The narratives consisted of several different stories about experiences of taking care of seriously injured and someTable 1
times deceased people; reflections about the experiences were also expressed in the narratives. Three themes were formulated: being secure within the support system, being confident about prior successful actions, and being burdened with uncertainty (Table 1). The officers felt secure within the support system when the different strategies that had been developed over the years were supported by the organization. These strategies included resources to guide the policemen through the accident and to help them process their thoughts afterward. From the narratives it was obvious that a feeling of knowing and doing what was necessary made them confident in their own capacity, leading to a feeling of success in their actions. Feelings of inadequacy surfaced when support systems and their own knowledge were insufficient to enable them to act optimally. Uncertainty over what should have been done, coupled with an inability to improve the outcome, became a growing burden that negatively influenced further contributions in emergency situations. The themes and subthemes are thus highly interrelated. They are explained further below, with clarifying excerpts from the interviews.
Being secure within the support system This theme ran through almost all of the narratives about taking care of seriously injured or dead people. To achieve this feeling of security, the police officers combined different personal strategies, based not only on support from colleagues and spouses, but also on actual support from the organization in terms of using the uniform. The first subtheme, ‘‘having developed various strategies,’’ was characterized by problem-solving, which the officers said helped them focus on what they had to do: ‘‘It’s just doing your duty, no more complicated than that.’’ When they had to convey difficult information, they concentrated on the information and tried to push away their feelings. Another strategy was to distance themselves emotionally from the difficult incident, to separate their own problems from those of others. Several of the interviewees stressed that they had the ability to set aside and compartmentalize problems related to their work when they were off duty, describing how they left their thoughts about work with the uniform when they took it off. The officers also described the importance of having time to prepare themselves mentally on the way to the scene of the accident. Even a few minutes could mean a lot:
Overview of subthemes and themes.
Subthemes
Themes
Having developed various strategies Feeling supported Knowing and doing what is necessary Knowing one’s own capacity Uncertainty about what should have been done Feeling inadequate
Being secure within the support system Being confident about prior successful actions Being burdened with uncertainty
Caring for traffic accident victims: The stories of nine male police officers ‘‘You get some time to think it over, what to do next and so on, together with your partner.’’ In addition, they often planned for a worst-case scenario: ‘‘It’s better to be prepared for the worst, and then when you arrive it’s not as bad, instead of vice versa.’’ The other subtheme in this theme, ‘‘feeling supported’’ was expressed in terms of companionship with colleagues: ‘‘It gives you a feeling of security to go with someone you feel comfortable with, instead of going by yourself.’’ Time spent with colleagues after the incident was also valuable as a way to process the event. There was a difference between talking to spouses at home about the event and talking with colleagues: ‘‘It’s a special kind of culture, and it depends on who you’re going with, you can’t talk to every colleague.’’ The participants also described how the uniform helped them feel secure in traumatic situations: ‘‘We had to start by putting on all the pieces of the uniform in the car, so you look like a police officer. . . and you put on your formal mask, and then you do your job and nothing else.’’
Being confident about prior successful actions The police officers described how they felt confident about successful prior actions when they found themselves in new but similar difficult situations; they knew what to do, and they knew they were capable of doing it. Such knowledge was very valuable in handling difficult situations and made them feel competent and secure in their professions, which was in turn very important and useful in future similar situations. The first subtheme in this theme, ‘‘knowing and doing what is necessary’’ describes the officers’ feeling of acting in an optimal way in a specific traumatic situation. Discussing the event with colleagues and sharing experiences with each other was very important: ‘‘We felt that we had done a good job, we sat in the car going back to the station, we were pleased and satisfied.’’ This feeling was strengthened further by greetings from other professionals who had been involved in the traumatic situation; for example, the policemen had a thank you card at the station saying, ‘‘Thank you so much for your help in this special accident.’’ The other subtheme in this theme was ‘‘knowing one’s own capacity’’. It was clear that knowing one’s own capacity was important for performing successful actions, and being confirmed by colleagues and society was important for accurately judging this capacity: ‘‘He was very good, my colleague, with a lot of experience.’’
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Another important factor in judging one’s own capacity was being confirmed as an educated police officer with enough theoretical and practical knowledge to handle traumatic situations. One interviewee said that when he arrived first at the scene of an accident, ‘‘I realized I cannot do everything. I can only do my best under the conditions present at the time and my capacity on that day.’’ This sort of reasoning strengthened the police officers, and left them feeling good, and satisfied with their work.
Being burdened with uncertainty When the police officers‘ did not have sufficient time to prepare themselves before being faced with traumatic situations involving severely injured and sometimes deceased persons, they experienced feelings of inadequacy. These feelings lingered as thoughts of uncertainty about what should have been done, and sometimes became a burden. Not being able to control and handle traumatic situations caused feelings of powerlessness and inadequacy, and the interviewees expressed these feelings as if the experiences were still with them. The first subtheme in this theme, ‘‘uncertainty about what should have been done’’ was described by a number of officers who had encountered situations where they felt a lack of both support and knowledge. After these situations were resolved, they had ongoing thoughts about the event and their own contribution: ‘‘When you think about this [a particular event], there is really nothing to do about it, but still you wonder about it, it’s still there.’’ They asked themselves, ‘‘Did we do the right thing? Should we have done more? Could we have done more if we had had more equipment?’’ They also pointed out that the preparation time was often too short, and they were forced to deal with the accident without being mentally prepared. The second subtheme in this theme, ‘‘feeling inadequate’’, was described in terms of emotional reactions in different situations. At times, the ‘‘purely humane’’ pushed against the professional role: ‘‘It was heartbreaking and very tough; it’s so difficult when people cry. . . and their children were badly hurt, then it can be really hard for you.’’ One policeman, describing his emotional difficulties, said: ‘‘There were fifteen minutes when I felt so inadequate because I could not do anything; they [the spouses of the injured people] just sat there.’’ The informants also described how they tried to pull themselves together in order to tell the spouses of the injured people what had happened. Feelings of inadequacy could become so strong that the policemen delayed their arrival at the scene, to en-
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sure that other emergency team members would arrive before them. Such situations added to the burden of uncertainty: ‘‘Often it is really terrible accidents that you have in your memory for a couple of days; you think about [scenes] from here and there, sometimes you get to see really bad things.’’
Discussion The interviewees’ descriptions of their experiences of traumatic situations caring for victims of traffic accidents showed that in situations where they were the first responders, most of them used strategies that promoted feelings of security. Feelings of security came from support within the police organization, but also from their own ability to solve and sort out difficult situations. They focused on what to do, what to say, and what their special duties were, which can be considered a form of problem-focused coping (Folkman and Moskowitz, 2000). Focusing on task-oriented, situation-specific actions can contribute to the individual’s ability to feel effective and to experience situational mastery and control, which in turn can increase his or her well-being (Carver et al., 1989; Folkman and Moskowitz, 2000). The police officers in our study also explained that they knew and did what was necessary. This could be an example of the process suggested by Folkman and Moskowitz (2000), in which successful problem-focused efforts can explain reports of positive emotions in the midst of distress. Problem-focused coping also has other positive outcomes, such as focusing attention (Folkman and Moskowitz, 2000), which the policemen in our study expressed through their narratives. Another way that the interviewees maintained their professional role was to leave unpleasant feelings and thoughts with the uniform when they took it off and went home. As Gersons (1989) writes, this could be a strategy for deliberately differentiating their professional identities from their private lives or identities. Elmqvist et al. (2009) found that when first responders had the opportunity to retell the situation later, they could transform their experience through these narratives into useful knowledge that helped prepare them for unexpected encounters in the future. This also helped both themselves and other first responders to deal with unpleasant memories, as they could feel both personal and professional growth. The police officers in our study also expressed the importance of discussing with their colleagues the ways they had acted in difficult situations; this also strengthened them with knowledge that was useful when attending similar accidents. They described how working together with other professionals and being confirmed by them as doing a good job helped them in judging their own capacity. The participants in the study by Elmqvist et al. (2009) also expressed the importance of consultation and collaboration between professionals who deal with injured persons. Focusing on experiences from traumatic situations that worked out well is one strategy that can be used by those involved to help them cope more easily in other similar situations (Fullerton et al., 1992). The police officers in our
study noted that it was ‘‘not allowed’’ to talk about difficult situations with just anybody among their colleagues, and that usually depended on whom they worked with. Some previous studies have described this aspect of police culture; the ‘‘code of silence’’ which can mean that police officers do not speak out loud about their experiences, but rather keep their experiences to themselves (Kingshott et al., 2004; Rothwell and Baldwin, 2007). In a review, Anshel (2000) suggests a conceptual model for the process of coping with the stress experienced in police work, and offers suggestions for improvements, concluding that through training police officers can learn to select the appropriate cognitive appraisal for each specific situational demand. By learning to appraise their actions objectively, they could increase their knowledge and feel more secure in their abilities when taking care of victims of traffic accidents. The police officers in our study said that they sometimes felt uncertain about how they had acted, which left them feeling ambivalent about specific difficult situations. The work in which they were engaged could be divided into two categories (Andersson, 2003): the ‘‘real police work’’ (p. 91) done by the young men on night patrol, and the planning done by their middle-aged and older colleagues, who thus lost credibility due to not being out in the field. Our interviewees emphasized the difficulty of being in situations when people were crying or seriously injured, using expressions such as ‘‘couldn’t do anything.’’ This could relate to Andersson’s (2003) interpretation of doing ‘‘real police work’’ (p. 80) and the ‘‘macho culture’’ exemplified by the John Wayne image (Kop and Euwema, 2001, p. 631), which to a certain extent is still present within police organizations. Karlsson and Christianson (2003) found that vivid visual, tactile, and olfactory sensations from the scene of a traffic accident remain in memory years after a traumatic experience, and that often it was the memories from early in an individual’s career and his or her first experiences of traumatic incidents that made the deepest impressions. The police officers in our study also had vivid memories from traumatic situations, and could describe the events in detail. They further confirmed the results of Karlsson and Christianson, in reporting that talking about a traumatic experience with their colleagues was a way of working through it, and that the feelings of powerlessness and despair were especially acute in situations involving traumatized children. However, our findings differ from those of Karlsson and Christianson (2003) in that our interviewees not only emphasized the importance of getting support from superiors and the work organization in these situations, but also stated that they received this support, at least to a certain extent. The participants in the study by Karlsson and Christianson’s (2003) stated that they did not receive any support from the work organization.
Methodological considerations The strength of this study is that it illuminates the police officers’ own experiences of working in a traumatic situation. Furthermore, the narratives from the interviewees were rich and strongly focused on the topic, and did not differ due to content and length of the interview. The interviewees also gave detailed accounts rather than brief answers and general statements (Riessman, 2008). A possible weak-
Caring for traffic accident victims: The stories of nine male police officers ness is that five of the interviews were conducted in September 2003 and the remaining three were conducted over 4 years later, in January 2008. However, during this period there were no substantial changes in police education, the police work environment, the support system in prehospital care, the guidelines for handling traumatic situations, or the relevant victim protocols. The first author (SBE) collected all interviews in both 2003 and 2008, and the consistency was similar on both occasions. The interviews were read through and analyzed by all authors, and no discrepancies were found between the two groups of interviews.
Conclusions The male police officers in our study relied upon a combination of their own knowledge and action and the support systems in their organization to enable them to act in traumatic situations. They thus felt insecure and ‘‘burdened with uncertainty’’ when their support systems, knowledge, and actions were insufficient. In this male-dominated context, there is a risk that police officers will fail to talk enough about traumatic situations, which might influence their ability to cope successfully. This risk has previously been highlighted by Kop and Euwema (2001), who warn that police culture, which is often described as ‘‘macho’’, might not pay sufficient attention to emotional problems. Furthermore, Karlsson and Christianson (2003) found that few policemen had received support from their superiors. One limitation of this study is the relatively small number of participants, but our findings show similarities between the police organizations in Sweden and those in other countries. Additional research is still necessary; specifically, important knowledge in this area could be gained by interviewing female police personnel about their experiences.
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