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Hospital social workers’ appraisal of, reaction to, and coping with a critical incident in their work… Plante, Rodney S. 1997

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HOSPITAL SOCIAL WORKERS' APPRAISAL OF, REACTION TO, A N D COPING WITH A CRITICAL INCIDENT IN THEIR WORK ENVIRONMENT: A DESCRIPTIVE STUDY by RODNEY S. PLANTE B.S.W., The University of Victoria/1996 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in THE FACULTY OF GRADUATE STUDIES (The School of Social Work) We accept this thesis as conforming to the required standard The University of British Columbia October 1997 © Rodney Stephen Plante, 1997 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. SCttooJL Derjarfment of £tt/4i. u)r>ej<L The University of British Columbia Vancouver, Canada Date j. DE-6 (2/88) ABSTRACT The intensity and emotional demands of the health care environment place exceptionally high performance expectations and stress on hospital social workers. Critical Incident Stress (CIS), a specific type of stress associated with dramatic, emotionally overwhelming situations, known as Critical Incidents (CIs), produce several emotional and physical reactions that can threaten the well-being of the hospital social worker. CIS, as experienced by hospital social workers, is absent from the literature and not well understood. The purpose of this study was to describe how hospital social workers appraised, reacted to, and coped with CIs in their work environment. Lazarus and Folkman's (1984) theoretical framework of stress appraisal and coping was used to guide this descriptive study. A sample of 30 hospital social workers was recruited from two Vancouver tertiary care hospitals. Four instruments (Participant Information Sheet, Critical Incident Information Form, Emotional Appraisal Scale, and Ways of Coping Scale) were used to gain knowledge on how hospital social workers appraised, reacted to, and coped with CIs in their work environment. Quantitative data were coded, qualitative data were subjected to content analysis, and descriptive statistics calculated. Data revealed that hospital social workers encountered CIs in their work environment and that the majority of CIs centred on death-related events. The primary traits of events appraised as CIs were novelty, suddenness, and uncertainty. Respondents reacted to the CI with a variety of emotional (anxiety, fear, frustration, worry, anger) and physical reactions (feeling overwhelmed, fatigued, withdrawn, anxious, difficulty with sleeping), and although they experienced some discomfort, these reactions were not debilitating. Most hospital social workers indicated that their personal beliefs had been challenged by the CI and revealed that they were unsure as to what their social work role or function should have been during the event. However, despite this, respondents remained confident and comfortable with the decisions they made. Hospital social workers appeared to cope well with CIs, used a variety of emotion- and problem-focused coping strategies, and reported few negative effects on their professional and/or personal lives. The top four coping strategies utilized by respondents were seeking social support, planful problem-solving, positive reappraisal, and self-control. The implications of the findings for hospital social work administration, social work training and education, hospital social work practice, and future research are discussed. iii TABLE OF CONTENTS Abstract ii Table of Contents iii List of Tables vii Acknowledgments viii CHAPTER ONE: INTRODUCTION 1 Purpose of the Study 1 Background to the Issue 1 Stress 1 Critical Incident and Critical Incident Stress 2 Hospital Social Work 3 Significance of the Study 3 Theoretical Framework 4 The Appraisal Process 4 Cognitive Appraisal 5 Primary Appraisal • 5 Secondary Appraisal 6 Reappraisal 7 The Coping Process • 8 Emotion-Focused Coping 9 Problem-Focused Coping , 10 Factors Affecting the Coping Process 10 Outcomes of Coping 10 Potential Value of the Study 11 iv CHAPTER TWO: REVIEW OF THE LITERATURE 13 Critical Incident Stress and Hospital Social Work 13 Research on Hospital Social Work 13 Social Work with Death and Dying 14 Social Work with HIV/AIDS 16 CIS and other Health Care Professions 17 Summary 18 CHAPTER THREE: METHODOLOGY 19 Sample Selection 19 Subject Recruitment 19 Measures 20 Participant Information Sheet 20 Critical Incident Information Form 20 Emotional Appraisal Scale ..21 Ways of Coping Scale (Revised) 22 Data Analysis 23 Ethical Considerations 24 CHAPTER FOUR: PRESENTATION OF THE FINDINGS 25 Response Rate 25 Demographic Characteristics of the Sample 25 Nature of Critical Incidents Reported 28 Traumatic (Unplanned) Death 29 Suicide 30 Terminal/Critical Illness 30 Violence toward Social Workers 31 V Other Critical Incidents 31 Primary Characteristics of Critical Incidents Reported 32 Reactions to Critical Incidents 33 Physical Reactions 33 Emotional Reactions 33 Coping with Critical Incidents 35 Impact on Professional and Personal Lives 36 Summary of Findings 37 CHAPTER FIVE: DISCUSSION 38 Overview 38 Findings in Relation to Theoretical Framework 39 Comparison of Findings with other Literature 41 Nursing and Hospital Social Work 41 Death, Dying and Hospital Social Work 43 Limitations 44 Implications 45 Hospital Social Work Administration 45 Social Work Training & Education 46 Hospital Social Work Practice 47 Recommendations for Future Research 47 REFERENCES 49 vi APPENDICES 55 Appendix A: Participant Introductory Letter 55 Appendix B: Participant Information Sheet 58 Appendix C: Critical Incident Information Form 60 Appendix D: Emotional Appraisal Scale 65 Appendix E: Ways of Coping Scale 67 Appendix F: Resource Information 72 LIST OF TABLES vii Table 1: Description of Coping Strategies... 9 Table 2: Ages of the Subjects 26 Table 3: Years of Experience as a Social Worker 27 Table 4: Number of Years in Present Position 28 Table 5: Physical Reactions to a CI 33 Table 6: Emotional Reactions to a CI 34 Table 7: Scores on Emotional Appraisal Scale 35 Table 8: Scores on Ways of Coping Scale 36 Vl l l ACKNOWLEDGMENTS This project reflects an important achievement in my academic, personal, and professional life. I am fortunate for and grateful to many individuals all of whom have helped me in my quest to "discover and explore that which really matters". My appreciation is extended to my committee members, Dr. Brian O'Neill, Dr. Mary Russell, and David Conlin for their direction and encouragement throughout this process. I would like to thank my family, especially my father who believed in me, supported and encouraged me during this challenging experience. To Kyle for his friendship and understanding, both of which I have come to value. I am also grateful to my friends Tana, Harvey, Judy, Trish, Marlene, Aurelio and Cheryl for their ongoing support, and especially Winnie for "going above and beyond the call of duty". Finally, I am indebted to each of the 30 hospital social workers who shared their Critical Incident experiences. 1 CHAPTER ONE INTRODUCTION Purpose of the Study The purpose of this study was to determine how hospital social workers appraised, reacted to, and coped with CIs encountered in their work environment. A questionnaire package was distributed to a convenience sample of hospital social workers at two different Vancouver area hospitals. The questionnaire sought to answer four research questions: (1) What events do hospital social workers appraise as CIs, (2) What are hospital social workers' reactions to an event appraised as a CI, (3) How do hospital social workers cope with a CI, and (4) What impact has the CI had on hospital social workers' professional and personal lives? Background to the Issue Stress. Stress is generally considered an inevitable and complex aspect of everyday life. In recent decades, research has determined that differences in human reactions may be related to the variations in how people appraise and cope with a stressful incident (Lazarus & Folkman, 1984). Despite an abundance of literature, the lack of a single operational definition and a clear set of criteria has hindered the appreciation and understanding of stress (Beemsterboer & Baum, 1984). Stress is often referred to as being either a stimulus or a response. The former focuses on events in the environment such as natural disasters, noxious conditions, or illness. This approach acknowledges that certain events are understandably stressful but does not recognize individual differences in the evaluation of events. Response definitions refer to a state of stress (i.e.: the person is spoken of as "reacting with stress" or being "under stress"). Stimulus and response definitions have limited utility, because a stimulus gets defined as stressful only in terms of a 2 stress response. Lazarus and Folkman (1984) suggest that adequate rules are required in order to indicate which situations are evaluated as stressors and which are not. Studies have shown that when physical, cognitive, emotional, and behavioural responses occur within the body individuals experience a stressful event (Bergmann & Queen, 1986; Mitchell, 1982; 1983; Selye, 1956; Snelgrove, 1988). Prolonged or repeated exposure to stress is believed to cause a wide range of mild to severe mental and/or physical health problems (Bell, 1995; Martin, 1993; Mitchell, 1988a; Selye, 1956). Much of the literature on stress in the social work profession is limited to job satisfaction, burnout, and turnover (Arches, 1991; Cournoyer, 1988; Harrison, 1980; Himle, Jayaratne, & Chess, 1986; Jayaratne & Chess, 1984; Jayaratne, Davis-Sacks, & Chess, 1991; Jayaratne, Himle, & Chess, 1988; Johnson & Stone, 1986; Koeske & Koeske, 1989; Loewenberg, 1979; McGee, 1989; Poulin & Walter, 1993a; Reamer, 1992; Siefert, Jayaratne, & Chess, 1991). The majority of these reports studied social workers in child protection agencies and few describe the specific stress stimuli that hospital social workers can experience (Beemsterboer & Baum, 1984; Oktay, 1992; Perrez & Reicherts, 1992; Poulin & Walter, 1993b; Siefert, Jayaratne, & Chess, 1991; Taylor-Brown, Johnson, Hunter, & Rockowitz, 1981). Critical incident and critical incident stress. Stress associated with a dramatic, emotionally overwhelming situation, known as a "Critical Incident", may cause unusually strong emotional reactions that can overcome an individual's ability to cope and function (Martin, 1993; Mitchell, 1988a; 1988b; St. Paul's Hospital, 1995; Vernon Jubilee Hospital, 1991). Situations may include severe injury or death, loss of life after extraordinary and prolonged professional interventions, actual or potential threats to the professional's well-being, or emotionally charged crises such as sudden or pediatric deaths (Mitchell, 1982; 1983; Mitchell & Bray, 1990). CIs are self-defined and these reactions can have multiple definitions 3 because individual appraisals of what constitutes a CI often vary (Bergman & Queen, 1986a; Mitchell, 1982; 1983; 1988a; Snelgrove, 1988). Hospital social work. Hospital social work usually involves dealing with patients' intense emotions such as anger, despair, fear, and hopelessness, and places heavy demands on the worker for compassion, empathy, and sympathy (Pines, 1981) Hospital social workers are at risk to experience CIs and CIS because of their close involvement with human trauma, death, disease, terminally and critically ill patients and other emotional and social suffering. With notable increases in patient acuity and decreases in hospital beds and community resources, hospital social workers are seeing patients who are more acute and who present more complex discharge planning issues (Abramson, Donnelly, King, & Mailick, 1993). An underlying expectation for hospital social workers is to do more with significantly reduced resources and personnel to adequately meet the demands (Donnelly, 1992). Significance of the study. Hospital social workers are prone to experience stress in their daily practice because the intensity and emotional demands of the health care environment place exceptionally high performance expectations on them. However, what is not known is to what extent they experience CIS. Mitchell (1983) suggested that the physical, cognitive, emotional, and behavioural responses to a CI, if not attended to, could lead to reduced work performance, negative physiological and emotional reactions, as well as personal, professional, and family distress. Therefore, it is this author's belief that an investigation of how hospital social workers appraise, react to, and cope with CIs is a vital first step to understand their emotional responses to CIs, their coping strategies, and the impact of the incidents on their professional and personal lives. Findings from this study will be used to generate implications for social work administration, education, research and ultimately, social work practice. 4 Theoretical Framework As CIS is a specific kind of stress, I believe that Lazarus and Folkman's 1984 theoretical framework of stress appraisal and coping will assist in the understanding of how hospital social workers appraise, react and cope with CIs, and how this particular type of stress affects their personal and professional functioning. The appraisal process. Lazarus and Folkman (1984) suggest that, in order to understand why there are variations among individuals in how they experience comparable conditions, one must consider the cognitive process that occurs after experiencing an event and before reacting to it. According to the authors, this is a transactional model because there is a mutually reciprocal, bi-directional relationship between the person and the environment. A transactional model is concerned with process and change and is neither static nor structured. It assumes that stress is neither in the environment nor in the person but rather a product of their interplay. People are not regarded as passive recipients of environmental demands; rather they actively select and share the environments of their lives to a greater or lesser extent (Folkman & Lazarus, 1988b; Lazarus & Folkman, 1984). Lazarus and Folkman consider stress a particular relationship between the person and the environment that is appraised by the individual as taxing or exceeding their coping resources and endangering their well-being (1984; Baldwin, 1993). The environment is referred to as either, or both, the external and internal demands that exceed an individual's resources. The literature suggest that stress results from the interaction between individual personal characteristics and an environmental event (Baldwin, 1993; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). Although certain environmental demands and pressures produce stress in a population, individual and group variances in the degree and type of reaction are usually evident. People differ in their sensitivity and vulnerability to certain types of events, as well as in their interpretations and reactions. In order to understand what causes variations in stress among 5 different persons under comparable conditions, Lazarus and Folkman (1984) believe that one must consider the cognitive processes that intervene between the encounter and the reaction, as well as the factors that affect the nature of this mediation. Lazarus and Folkman's theory has identified two processes that mediate this relationship and are critical when dealing with stress: cognitive appraisal and coping. Cognitive Appraisal Cognitive appraisal is the process of categorizing an encounter, and its various effects, with respects to its significance for well-being (Lazarus & Folkman, 1984). More than just information processing, it is largely a continuous, evaluative process that determines why and to what extent a particular transaction or series of transactions between the person and the environment is stressful (Folkman et al., 1986; Lazarus & Folkman, 1984). Three types of cognitive appraisals have been identified: Primary Appraisal, Secondary Appraisal, and Reappraisal, however, the authors caution that these names are not meant to suggest rank order (Folkman et al., 1986; Lazarus & Folkman, 1984; Baldwin, 1993). Primary appraisal. Primary appraisal involves an evaluation of what is at stake in a particular encounter. Three outcomes of primary appraisal can be distinguished: irrelevant, benign-positive, and stressful (Baldwin, 1993; Folkman et al., 1986; Lazarus & Folkman, 1984). A stressor is deemed irrelevant when the individual determines that there is no threat to their well-being and therefore have no investment in the possible outcomes. Benign-positive outcomes occur if the appraised encounter is viewed as positive, that is, if it preserves or enhances well-being or suggests to do so. These appraisals are highlighted by pleasurable emotions such as joy, love, happiness, exhilaration, or peacefulness. Stress appraisals include harm/loss, threat, challenge and benefit. In harm/loss, some damage to the individual has already 6 been sustained, as in an injury or illness, recognition of some damage to self- or social esteem, or loss of a significant person (Lazarus & Folkman, 1984). Threat concerns harms or losses that have not yet occurred but are anticipated such as a critical illness or an expected death. A harm/loss outcome is usually fused with threat because every loss carries with it negative implication for the future. The adaptational significance of threat is that it permits anticipatory coping and allows people to prepare for and work through some of the difficulties in advance. Challenge outcomes have a great deal in common with threat outcomes; however, the main difference is that challenge appraisals focus on the potential for gain or growth inherent in an encounter. They are often characterized by emotions such as eagerness, excitement, and exhilaration, whereas threat centers on the potential for harm and is associated with negative emotions such as anger, anxiety, and fear. Exhilaration, happiness, relief, pleasure, eagerness, and hopefulness correspond to benefit emotions. Lazarus and Folkman emphasize that threat and challenge are not necessarily mutually exclusive (1984). The relationship between threat and challenge appraisals can shift as an encounter unfolds. A job promotion may be appraised as having the potential for gains in knowledge and skills, responsibility, recognition, and financial reward. At the same time there is a risk of the individual being swamped by new pressures and not performing to expectations. Therefore, the promotion is likely to be appraised as both a challenge and a threat as both are occurring simultaneously. Secondary appraisal. Secondary appraisal involves the evaluation of the various available coping options. Secondary appraisal is a crucial feature of every stressful encounter because the outcome depends on what, if anything, can be done to alleviate the stress, as well as what is at stake. Secondary appraisal is more than an intellectual exercise in spotting all the things that could be done; it is a complex evaluative process that considers which coping options are available, the likelihood that a given coping option will accomplish what it is expected to, and the likelihood that one can apply a specific strategy or set of strategies effectively (Baldwin, 7 1993; Lazarus & Folkman, 1984). Examples of individual coping resources include health and energy, spiritual beliefs, or general beliefs (about control), commitments, problem-solving skills, social skills, social support and material resources. Lazarus and Folkman (1984) believe that specific constraints may prevent the use of these resources in certain situational contexts, therefore distinguishing coping options from coping resources. Coping options are actions such as changing the situation, accepting it, seeking more information, or holding back from acting impulsively. Coping resources, on the other hand, refer to specific personal and environmental resources an individual draws on in order to cope. Lazarus and Folkman (1984) maintain that primary and secondary appraisals should not be considered separate processes. Even though they derive from different sources within the same encounter, they are interdependent, with each influencing the other. An individual is only able to classify an event as being harmful, a challenge, or a threat based on a convergence of information from both the primary and secondary appraisals. For example, an individual who appraised an event as a threat and can identify adequate coping resources may appraise the threat as minimal. On the other hand, an individual may appraise a situation as a challenge, but determine that insufficient resources are available to cope. The event may then be reappraised as threatening. Reappraisal. Reappraisal involves changing the meaning of an appraisal based on new information received about the stressor from the environment and/or individual. Simply put, it is an appraisal that follows an earlier appraisal in the same encounter and modifies it (Lazarus & Folkman, 1984). Reappraisal is divided into two types: defensive and non-defensive. A reappraisal that is non-defensive is viewed as virtually synonymous with a primary appraisal, the only difference is it occurs after the initial appraisal (Baldwin, 1993). Defensive reappraisal is a self-generated process that attempts to reinterpret past events more positively. Lazarus and Folkman (1984) identified personal and situational factors which influenced the reappraisal. Personal factors influencing appraisal are an individual's commitments and beliefs. Situational 8 factors influencing appraisal include novelty, predictability, event uncertainty, temporal factors (imminence, duration, and temporal uncertainty), and ambiguity. The Coping Process According to Lazarus and Folkman (1984), coping is determined by the individual's primary and secondary appraisals and is viewed as the constantly changing cognitive and behavioural efforts in order to manage specific external and/or internal demands that have been appraised as taxing or exceeding the resources of the individual (Baldwin, 1993; Chan & Ward, 1993; Folkman & Lazarus, 1988a; Lazarus & Folkman, 1984). Such a definition emphasizes the importance of the emotional context in coping, allows for the inclusion of both the negative or stress side of emotion, as well as the positive side of potential fulfillment and gratification, recognizes the overlap between problem-solving and coping, and emphasizes adaptive tasks that are not routine or automatic (Lazarus, Averill, & Opton, Jr., 1974). There are three key features of this definition of coping (Cohen, 1991). First, it is process-oriented, and focuses on what the person actually thinks and does in a specific stressful encounter, and how this changes as the encounter unfolds. Second, coping is regarded as contextual, meaning it is influenced by the individual's appraisal of the demands in the encounter and the resources for managing them. The emphasis on context means that particular individual and situational variables will together shape coping efforts. Third, there is no a priori assumptions about what constitutes good or bad coping; coping is simply an individual's efforts to manage demands, whether or not those efforts are successful (Folkman, et al., 1986; Lazarus & Folkman, 1984). Folkman and Lazarus (1991) identify two forms of coping - problem-focused coping and emotion-focused coping (see Table 1). The authors posit that both forms of coping not only influence one another during the coping process, but can also impede or facilitate each other (1991). Table 1 Description of the Coping Strategies 1) EMOTION-FOCUSED COPING: a) Accepting Responsibility b) Distancing c) Escape-Avoidance d) Positive Reappraisal e) Self-Controlling 2) PROBLEM-FOCUSED COPING: a) Confrontative Coping b) Planful Problem-Solving c) Seeking Social Support Acknowledges one's own role in the problem with a concomitant theme of trying to put things right Describes cognitive efforts to detach oneself and to minimize the significance of the situation Describes wishful thinking and behavioural efforts to escape or avoid the problem. Items on this scale contrast with those on the Distancing scale, which suggest detachment Describes efforts to create positive meaning by focusing on personal growth. It also has a religious dimension Describes efforts to regulate one's feelings and actions Describes aggressive efforts to alter the situation and suggests some degree of hostility and risk-taking Describes deliberate problem-focused efforts to alter the situation, coupled with an analytic approach to solving the problem Describes efforts to seek information support, tangible support, and emotional support Emotion-focused coping. Coping that is directed at regulating emotional response to a stressor is referred to as emotion-focused coping (Lazarus & Folkman, 1991; Baldwin, 1993). Emotion-focused coping consists of cognitive processes directed at lessening emotional distress and includes strategies such as avoidance, minimization, distancing, selective attention, positive comparison, and identifying positive value from negative situations (Lazarus & Folkman, 1984). Emotion-focused forms of coping are more likely to occur when there has been an appraisal that nothing can be done to modify harmful, threatening or challenging environmental conditions (Folkman & Lazarus, 1988a; 1988b; Lazarus & Folkman, 1984). 10 Problem-focused coping. With problem-focused coping, attempts are made to alter or manage a stressor. Efforts are often directed at defining the problem, generating alternative solutions, weighing the alternatives in terms of their costs and benefits, choosing among them, and responding. Problem-focused coping includes strategies that are directed inward as well as at the environment and are more probable when such conditions are appraised as receptive to change. Factors affecting the coping process. Resources that assist with the coping process and constraints which impede it, are two factors identified by Lazarus and Folkman (1984), which affect the coping process. Coping resources include health and energy, positive beliefs, problem-solving skills, social skills, social support, and material resources. Constraints against using coping resources include personal constraints, environmental constraints, and a perceived level of threat. However, appraisal and coping are interdependent throughout an encounter. For example, an appraisal of harm/loss, threat, or challenge stimulates coping efforts that change the person-environment relationship by altering the relationship itself (problem-focused coping) and/or by regulating emotional distress (emotion-focused coping). The changed relationship leads to new appraisals or reappraisals, which in turn engender further coping efforts, and so on. The identification of appraisal as a determinant of coping, or coping as a determinant of appraisal, is thus provisional depending on where one happens to interrupt the continuous, dynamic relationship between the two (Folkman & Lazarus, 1980). Outcomes of coping. According to Lazarus and Folkman (1984), the prime importance of appraisal and coping processes is that they affect three adaptational outcomes: social functioning, morale, and somatic health. Social functioning refers to an individual's degree of satisfaction with interpersonal relationships or degree of fulfillment in various roles, 11 for example, as a colleague, a partner, and a friend. Morale refers to how individuals feel about themselves. An individual's emotional reactions and coping strategies are also seen to have an effect on health and illness; this is referred to as somatic health. These three outcomes are closely interrelated. Good functioning in one area does not necessarily mean that an individual is functioning well in other areas. For example, a social worker can be satisfied with their relationships with family and friends, but if they experience additional stress at work they may become dissatisfied with their professional role. After an individual appraises and copes with a specific event an interpretation is made on the extent to which the encounter was resolved effectively (Folkman et al., 1986). This judgment considers the individual's values, goals, commitments, beliefs and expectations concerning the stressful event. For instance, even though an individual may not be able to resolve the stressful event, there may be positive adaptational outcomes (increase morale, and positive interpersonal relation). In such instances the individual may feel that the demands of the event were managed as well as could be expected. On the other hand, an individual may recognize that even when a stressful event is resolved, there may be negative outcomes. This can occur when the resolution of a stressful encounter is inconsistent with an individual's values, beliefs and expectations; an inconsistency may create additional conflicts for the individual (interpersonal difficulties, low morale, and health problems) (Folkman et al., 1986). Potential Value of the Study This study will contribute to the body of knowledge in relation to social work and occupational stress: as well, it will describe and highlight those events or situations hospital social workers appraised as CIs and how they reacted and coped. Findings from this study will generate useful implications and practice for hospital social work administrators, social work education, and further social work research. Social work administrators, with increased understanding of the stressors in a hospital setting, may implement specific interventions that 12 will emotionally and professionally support social workers, and in turn, decrease sick-time and improve the health of the social worker and the efficiency of their practice. 13 CHAPTER TWO REVIEW OF LITERATURE This chapter examines the CIS and hospital social work literature in order to better understand why CIs occur and under what conditions. A study of nurses' experiences with CIS is presented for comparative reasons. Critical Incident Stress and Hospital Social Work Research on CIS is in its infancy. Research has focused on the benefits of using hospital social workers as Critical Incident Stress Debriefers (CISD) as a result of the profession's unique perspectives on education, training, and practice methodologies (Bell, 1995; Lane, 1994; Spitzer & Burke, 1993; Spitzer & Neely, 1992). Few studies exist that study other professions' experiences with CIS. Recently, research has been expanded to include other health care professions such as nursing (Appleton, 1994). CIS, as experienced by hospital social workers, is absent from the literature and is not well understood. Despite widespread concerns about job-related stress among hospital social workers, there is no empirical research on their experiences with CIs. Existing studies concentrate mainly on stress and burnout in social work and were conducted in either child protection settings, or sampled a "mixed bag" of social workers from various fields of practice (Arches, 1991; Jayaratne & Chess, 1984). Research on Hospital Social Work In 1989, Siefert, Jayaratne and Chess (1991) surveyed 882 health care social workers and investigated factors associated with job satisfaction and burnout. The majority of social workers (75%) reported being highly satisfied with their job and experienced little depersonalization within their practice. However, a number of respondents (25%) indicated that they felt 14 emotionally exhausted with their job. Other findings suggested high levels of job satisfaction and a high sense of personal accomplishment were associated with less likelihood of social workers leaving their position. Social workers reported that high challenge, satisfaction with salary, and minimal conflict with professional values were all significant predictors of job satisfaction. Role conflict, role ambiguity, and lack of comfort were significant predictors of emotional exhaustion while high role conflict, minimal challenge, and decreased satisfaction with salary were predictors of depersonalization. Personal accomplishment was reported to be achieved by increased challenge and workload, greater satisfaction with financial rewards as well as minimal conflicts with role and professional values. These findings are consistent with Lazarus and Folkman's (1984) assumption that a sense of competence and mastery, under stressful conditions, is a critical element for successful coping and adaptation. Achieving a sense of competence and mastery is especially important considering the role and value conflicts that seem to plague today's hospital social workers. Social work with death and dying. Hospital social workers are frequently consulted to provide supportive counselling and educational services to terminally ill and bereaved individuals. Such social work is believed to be stressful and have emotional consequences for the practitioner (Appel, 1988). Davidson and Foster (1995) studied the stress and satisfaction experienced by health care social workers who worked with terminally ill and bereaved individuals. They found that these health care social workers viewed their work as both emotionally exhausting as well as professionally rewarding. They further discovered that the self-recognition of the emotional intensity, stress and value associated with social work with the terminally ill was an important factor in determining the level of experienced job satisfaction. The social workers in their study were more likely to find their work stressful and less satisfying if that recognition was absent. Respondents experienced considerable strain between the patients' needs and the competing needs of the hospital. Cutting clients off and providing 15 insufficient services were responses reported by a number of social workers who were stressed and had worked with terminally ill and bereaved individuals for some time. In an exploratory study of 36 hospital social workers, Davidson (1985) examined the nature and level of stresses experienced by social workers who work with terminally ill cancer patients and their families. She found that social workers not only experienced their work as stressful but that they also lacked adequate and available support to help them cope with the overwhelming emotions. Davidson's study identified a number of stressors including identification with the patient, fear of the illness, fear of death, feelings of loss and isolation, workload, and anxiety about lack of experience. Social workers coping with job stress varied between the use of team and peer support and denial and withdrawal from clients. Poulin and Walter (1993b) conducted a random sample survey of 1,196 gerontological social workers that examined their experiences with job stress and burnout. Findings suggested that social work with elderly clients produced significant emotional stress resulting from confronting loss, deterioration in health and death. Greene (1986) found that geriatric social workers experienced higher levels of death anxiety than did other social workers. In his study, slightly more than 60% of the social workers surveyed experienced moderate to high levels of emotional exhaustion. Additional results were: the higher the workers' satisfaction with their clients, the lower their depersonalization and emotional exhaustion and the higher their sense of personal accomplishment. Workers with higher self-esteem had lower depersonalization and emotional exhaustion and higher personal accomplishment than those with lower self-esteem. Older respondents tended to experience lower levels of burnout than did younger respondents. Supervisors played a critical role in helping workers deal with the emotional strains of their job. Workers who rated their supervisors high in terms of providing emotional and instrumental support had lower emotional exhaustion scores than did those who rated their supervisors low in this area. 16 Social work with HIV/AIDS. Further research on hospital social work with patients who are dying includes studies on HIV/AIDS. In an exploratory study, Oktay (1992) surveyed 128 hospital social workers to determine their susceptibility to burnout as a result of their work with AIDS patients and their families. The most cited stressful tasks that respondents reportedly performed were intervening with a patient's family and friends, supporting patients through medical interventions, dealing with practical matters such as housing and funeral arrangements, and death and dying counseling. Additional findings indicated that HIV/AIDS social workers reported higher levels of emotional exhaustion and depersonalization, but also higher levels of personal satisfaction, than did other hospital social workers. This study also demonstrated that burnout among AIDS social service providers was most common among younger workers, those with low levels of autonomy in the implementation of their work, and those who did not belong to a support group. Cushman, Evans, andNamerow (1995) surveyed 103 HIV/AIDS social workers, health educators, and counsellors to investigate the job stress in their work environments. More social workers (65%) reported feeling a great deal of stress on the job than did counsellors (38%) or health educators (29%). This may be explained by the fact that social workers have more exposure to the full range of issues/concerns faced by their clients and their families. Fifty percent of the sample surveyed by Cushman et al. 91995) stated they experienced a great deal of stress on the job which was not only associated with the severity of AIDS as a disease, but with several organizational characteristics of their job. Stressors were related to death and dying, as well as the severe physical illness experienced by AIDS patients. Thirty-three percent of the sample cited these as the most commonly mentioned stressors. Other reported stressors included youth of patients, multiple challenges caused by AIDS, inability to find a cure or solution to AIDS, giving HIV test results, neurological aspects of AIDS, and the unpredictability of illness progression. Organizational stressors were investigated and results indicated that HIV/AIDS workers felt overwhelmed by their jobs, primarily due to heavy caseloads, understaffing, lack of support (from co-workers, supervisors, and administration), bureaucratic difficulties, and an overabundance of paperwork. Nearly two-thirds reported that 17 working in a bureaucratic environment, personnel shortages and lack of funding were structural barriers which impeded their job performance. Overall, the findings from Cushman et al. 91995) suggested that the majority of all respondents, even though they experienced job stress, were satisfied with their job. Increased satisfaction was clearly associated with lower stress levels. The majority of participants found that on-site stress-reduction services (e.g. workshops, support groups, and rotations away from direct service provisions) were useful in reducing job-related stress. CIS and other health care professions. One study that investigated CIS outside the parameters of rescue personnel was a descriptive study of medical and surgical nurses. Using a sample of 50 nurses, Appleton (1993) sought to describe those situations or events nurses appraised as CIs, their emotional responses, their coping strategies, the impact of the incidents on nurses' professional and personal lives, and the role others played in assisting nurses manage their stress. Data were gathered using four instruments: Participant Information Sheet, Critical Incident Information Form, Emotional Appraisal Scale, and Ways of Coping Scale. The events appraised by the nurses as CIs were grouped into six categories: moral distress, lack of responsiveness by a health care professional, violence toward a nurse, emergency situations, patient death and actual or potential contact with infectious body fluids (Hepatitis B or HIV). Nurses reportedly felt morally distressed as a result of their role as patient advocates, felt guilty that their interventions were ineffective or futile, experienced CIS when a patient did not receive adequate response or intervention from members of the health care team, experienced violence which included threats of verbal and physical abuse, or cared for a dying, particularly young, patient. Physical and emotional reactions were also studied. The findings indicated that a large percentage of nurses suffered from insomnia, felt angry, fatigued, disappointed, frustrated, disgusted, fearful, anxious, and worried. The most commonly cited coping strategies used by the respondents were: seeking out social support, self-control, positive reappraisal, and problem-18 solving. The study did not identify which coping strategies were most beneficial or the strategies that may have contributed to negative effects. Findings from the study raised questions about a hospital's responsibility for the well-being of their employees. Recommendations included making debriefing teams (group and/or one to one sessions), peer support groups and counselling available in all hospitals in an attempt to lower staff turnover, reduce sick leave and decrease costs associated with both. Summary Literature was first reviewed that linked job stress, job satisfaction, high turnover, and burnout among health care social workers. Secondly, a study that described nurses' experiences with Critical Incident Stress was presented. Despite the expressed concerns, no studies have been found that examined hospital social workers' experience with CIs and CIS in their daily practice. Although the scope of this study was not to investigate job satisfaction or burnout, the author believed it was important to present these issues as they offered insight into the occupational stress and strain associated with certain social work practices and could become a CI experience. Reviewing these findings raised questions as to whether hospital social workers were more susceptible than other social work practitioners to experience CIS because of the traumatic and emotionally challenging situations they encounter, and whether CIs had been embedded within the context of the numerous stress studies reviewed. Hospital social workers' experiences with CIS is absent from the literature. Therefore, it was warranted to investigate and describe hospital social workers' experiences in order to understand what situations and/or events they appraise as being CIs, how they react to a CI, how they cope with a CI, and the impact of the event on their personal and professional lives. The following chapter will discuss the methodology procedures undertaken for this study. 19 C H A P T E R T H R E E M E T H O D O L O G Y This chapter will present the methodological procedures taken for this study and include sample selection, subject recruitment, measures, data analysis, and ethical considerations. A descriptive research design was used in this study to develop an understanding of how hospital social workers appraised, reacted to, and coped with CIs encountered in their work environment (Neuman, 1994). This design was selected as it allowed for description of phenomena about which very little is known. Sample Selection A convenience sample of 85 hospital social workers was selected from two tertiary care teaching hospitals within Vancouver, British Columbia. Criteria for participation in the study were the following: a) holding a BSW and/or MSW degree, b) current employment as a social worker at either hospital, and c) experience with and ability to recall a CI. As this was a study of hospital social workers, the investigator felt it was important to define a social worker as someone who has earned either a BSW and/or MSW degree. One individual was excluded from the study for not holding either degree. Subject Recruitment Following the approval of the University of British Columbia Sciences Screening Committee for Research and other Studies Involving Human Subjects and both of the hospital research committees, subject recruitment commenced. Participant Introductory Letters along with the questionnaire packages were distributed to each social worker via their social work department mailbox (Appendix A). The investigator made brief presentations during social work 20 department staff meetings, left messages on each social worker's voice-mail, and discussed the study informally with social workers individually and in small groups of two or three in order to explain the study, emphasize the benefits of participation, answer questions and solicit participation. Participants were instructed to place completed questionnaires in a sealed envelope and return to the investigator's mailbox or deliver them to the social work receptionist for the investigator to collect. February 28,1997 was the final day completed questionnaire packages were collected. Measures Participant information sheet. A general information sheet was constructed by the investigator to record demographic information such as: age, gender, number of years experience as a social worker, number of years in present position, and highest degree received (BSW/MSW) (Appendix B). Critical incident information form. This instrument was adapted from Appleton's (1992) study that investigated nurses' appraisals and coping strategies in a Critical Incident. The C.I.I.F. was selected because it required participants to respond to a variety of yes/no and open-ended questions concerning appraisals of and physical reactions to CIs and their impact on their personal and professional lives (Appendix C). Some of the information obtained from this instrument related to whether the CI occurred suddenly, if it involved dealing with something new, if it challenged the respondent's personal beliefs, the respondent's physical and emotional reactions, the CIs' effect on the respondent's interpersonal relationships, and if the respondent considered leaving their position because of the CI. 21 The instrument was pilot tested and minor revisions related to grammar, sentence structure and format were implemented. Question Number 2, which asked how long ago the CI had occurred, was changed to allow the participant to select a grouped time period. Question Number 3, was altered to allow for an "other" category for social workers who may have experienced a work-related CI outside their usual working hours. Question Number 11, which asked respondents to indicate if they had experienced any physical reactions post-CI experience, had more physical reaction options added. In addition, when measuring the respondents' recollection of physical reactions after a CI, the time was limited to 48-72 hours post-CI. According to the literature, most post-CI symptoms would have had an opportunity to evidence themselves within this time. Finally, the definition of a CI was reworded to help clarify the meaning. The C.I.I.F. was not tested for reliability or validity. There was some overlap in the information collected in the C.I.I.F. and the Emotional Appraisal Scale. The former solicited information on the physical reactions experienced by hospital social workers following their CI whereas the latter measured hospital social workers' emotional reactions. Some of the reactions reported, such as anxiety, were reported in both measures. Emotional appraisal scale. Folkman and Lazarus' (1986) 16-item Emotional Appraisal Scale (Appendix D) was chosen because one of the study's objectives was to measure hospital social workers' reactions to CIs. The instrument is a 16-item checklist with a 5-point Likert scale (0=not at all --> 4=a great deal). The 16 items are categorized, as a result of a factor analysis based on a much broader community sample and a variety of stressful encounters, into 4 emotional scales: threat emotions, challenge emotions, harm emotions, and benefit emotions. Threat emotions include fear, anxiety and worry, whereas challenge emotions include confidence, security, and control. Anger, disappointment, frustration, and disgust refer to harm emotions; and exhilaration, happiness, relief, pleasure, eagerness, and hopefulness correspond to benefit emotions. 22 Scores range from 0 to 12 for threat emotions, 0 to 12 for challenge emotions, 0 to 16 for harm emotions, and 0 to 24 for benefit emotions. The maximum score is 64 and the higher the scores for each of the categories, the higher the intensity of emotion. The instrument was developed from the cognitive-phenomenological theory of emotion (Lazarus, Kanner, & Folkman, 1980). This theory evidenced credibility as a result of empirical research within different populations and in different contexts (Lazarus, et al. 1980). The quality and intensity of emotions (including both positive and negative emotions) such as anxiety, disgust, relief, happiness, and anger are dependent upon the appraisal process. The authors emphasized that several of these positive and negative emotions occurred concurrently (challenge, benefit, harm/loss, and threat) and will intensify or weaken over the course of cognitive appraisals and reappraisals. In a study of exam-writing students, threat and challenge emotions were experienced concurrently. Alpha coefficients, measuring internal consistency, ranged from .59 to .84 (Folkman & Lazarus, 1985). Internal consistency was also evidenced in a study of 75 husbands and wives' most stressful encounter, where alphas ranged from .80 to .87 (Folkman & Lazarus, 1986). Ways of coping scale (revised). The Ways of Coping Scale (Appendix E) is a 66-question four-point Likert scale which assigns a maximum score of three for each question. The scale has eight categories comprised of four to eight items with the maximum possible score for each category ranging from 12-24 (Folkman, et al., 1986). This instrument was developed based on Lazarus and Folkman's (1984) theoretical framework which emphasized that throughout the changing person-environment interaction, a person copes with stressful events through the use of both problem-focused and emotion-focused coping. It was selected as one of the instruments for the study because it measures the behavioral and cognitive coping strategies used to deal with a stressful situation. 23 The 66 items are categorized as either emotion-focused or problem-focused methods of coping. The minimum score for all emotion- and problem-focused coping categories is zero with maximum scores of 18 for confrontative-coping, 18 for distancing, 21 for self-controlling, 18 for seeking social support, 12 for accepting responsibility, 24 for escape-avoidance, 18 for planful problem-solving, and 21 for positive reappraisal. The maximum score is 150 and the higher the scores for each of the categories, the greater the degree of use of a specific coping strategy. In the 1985 Folkman and Lazarus study, reliability alpha coefficients were: .85 for problem-focused coping, .84 for wishful thinking, .71 for distancing, .81 for seeking social support, .65 for emphasizing the positive, .75 for self-blame, .56 for tension reduction, and .65 for self-isolation. Further evidence of internal consistency is provided by another study conducted by Folkman, et al. (1986). In this study, the sample consisted of 75 husbands and wives, and they reported the most stressful encounter that they had experienced during the previous week. The participants were interviewed once a month for six months. Reliability alpha coefficients were .70 for the confrontative coping scale, .61 for the distancing, .70 for self-controlling, .76 for seeking social support, .66 for accepting responsibility, .72 for escape avoidance, .68 for planful problem-solving, and .79 for positive reappraisal. Data Analysis Quantitative data from the instruments were analyzed using the Microsoft SPSS Windows Statistical Package and descriptive statistics such as means, ranges, frequency distributions, and standard deviations were calculated. Open-ended questions in the Critical Incident Information Form were subjected to content analysis and categories were established for the CI responses (Rubin & Babbie, 1993). The investigator reviewed all 30 CIs two times looking for mutually exclusive themes that would capture them (Neuman, 1994). Five categories were selected and criteria for each were established. One category, traumatic (unplanned) death, involved situations in which social workers either notified the next-of-kin of a deceased patient, provided crisis/bereavement 24 counselling, or were disturbed by the specific details of the death. Suicide was identified as a second category and included CIs in which a patient or colleague, known to the social worker, committed suicide. Terminal/critical illness was another category and criteria for the selection of CIs involved social workers who provided counselling for patients who were near death and for grieving individuals. Violence toward social workers was conceptualized as another category and encompassed CIs in which social workers experienced verbal abuse, verbal threats, and physical abuse by a patient. Finally, a category labelled as Other was identified because three of the CIs were unique and could not be placed within the established categories. The investigator reviewed the CI responses a total of two times in order to ensure consistency in grouping the CI. Because the CIs were categorized without difficulty, no external reviewers were sought. Ethical Considerations The study met the ethical criteria, established to ensure the human rights of participants were protected, set forth by the British Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects and both hospital research committees. The possibility that participants may have experienced emotional discomfort from their recollection of an event or situation that was particularly disturbing or traumatic was acknowledged. The investigator included a list in the questionnaire package of several community resources that could provide supportive assistance (Appendix F). Participants were informed in the Introductory Letter of measures taken to ensure anonymity and confidentiality. 25 CHAPTER FOUR PRESENTATION OF THE FINDINGS This chapter is organized into two sections. The first section presents the response rate, the demographic data, the number of years of experience for social workers in the sample, and the number of years in present social work position. The second section includes the results and discussion in relation to the following four research questions: what events do hospital social workers appraise as CIs, what are their reactions to an event appraised as a CI, how do they cope with a CI, and what impact has the CI had on their professional and personal lives? Response Rate Questionnaires were completed by hospital social workers who were able to recall a CI they had experienced. A total of 30 out of 85 questionnaires was returned, yielding a response rate of 35.0%. Demographic Characteristics of the Sample The sample consisted of 30 hospital social workers, of whom 25 (83%) were female and 5 (17%) were male. Although there was a range in ages, the majority were between the ages of 40-49 (see Table 2). 26 Table 2 Ages of the Subjects AGE FREQUENCY PERCENT (%) 20-29 2 7.0 30-39 9 30.0 40-49 16 53.0 50-59 3 10.0 60-+ 0 0.0 Total 30 100.0 The majority of social workers within this sample (57%), as shown in Table 3, had more than 10 years of social work experience. A smaller portion of social workers, 27%, had less than three years of social work experience. Table 3 Years of Experience as a Social Worker 27 YEARS FREQUENCY PERCENT (%) <1 2 6.5 1-3 6 20.0 4-6 3 10.0 7-9 2 6.5 >10 17 57.0 Total 30 100.0 As shown in Table 4, over half of the social workers surveyed (53%) indicated they had been in their present position for at least four years. Forty-seven percent said they had worked in their present position for under three years. The majority, 63%, had a BSW degree with 37% indicating they had both BSW and MSW degrees. 28 Table 4 Number of Years in Present Position YEARS FREQUENCY PERCENT (%) <1 1-3 4-6 7-9 >10 4 10 6 7 3 13.0 34.0 20.0 23.0 10.0 TOTAL 30 100.0 Nature of Critical Incidents Reported Of the 30 CIs reported, nearly half of them (47%) had occurred within the Emergency Department of the hospital. Respondents also indicated they had experienced CIs within other parts of the hospital which included: a general medical ward (5); intensive care unit (3); psychiatry (2); palliative care unit (1); bum unit (1); and the social work department (1). Some social workers (3) recalled CIs that had occurred while they were employed outside a hospital setting and therefore these responses were not analyzed. Forty-seven percent of the hospital social workers recalled CIs that had occurred in the year previous to this study. Most of the CIs (63%) occurred during the day shift (0800-1600) with 17% having occurred during both the evening (1600-2400) and night shifts (2400-0800). One respondent experienced a CI outside of her usual working hours when she responded to a patient in crisis. Even though the nature of the respondents' experiences with their CIs varied, findings from the qualitative data revealed some common CI categories. The hospital social workers' descriptions of CIs were subject to content analysis and categorized within the following five categories: traumatic (unplanned) death, suicide, terminal/critical illness, violence toward social workers, and other. Although a significant number (n=20) of the reported CIs involved death and/or dying, in some way, the investigator believed it was important to describe specific events in order to capture the full essence of the CI. As a result, for each of the categories, examples 29 have been extracted to illustrate the different types of CIs experienced by the hospital social workers. Traumatic (unplanned! death. This category captured the events in which social workers were confronted with an unplanned, traumatic death. Interestingly, all of the traumatic deaths (n=8) occurred within the Emergency Department and involved motor vehicle accidents (MVA). The following example involved a social worker who was working the nightshift (2400-0800) in the Emergency Department: I was a relatively new social worker working by myself at night. I got a page requesting the trauma team to gather in the trauma room for an incoming trauma. Five teenage boys were involved in a single MVA and four out of the five boys had died as a result of their injuries. They were trying out a friend's new Mustang when the car ran off the road and hit a tree. Alcohol and speed were not factors in the accident. One family lost two of their children. The emergency waiting room was very chaotic, people were crying uncontrollably. I was the only social worker to deal with over 60 family members and friends. Another respondent recalled the following experience as a CI: A patient had died in the emergency room trauma room and I was consulted to locate his next-of-kin. I had recently completed a social work practicum in the ER and this was one of my first days working on my own. I eventually located the deceased patient's daughter who was 22 years old and told her that the patient had died and asked if she could come to the hospital. She began to scream very loudly and cry into the phone. I was so scared...it was painful to listen to. I got chills throughout my body and felt like hanging up on her. When she arrived at the hospital I had arranged for her to spend time with her father's body. I offered her grief and supportive counselling. This experience has left a definite impression on my social work practice. 30 Suicide. Seven out of the 30 CIs were grouped within this second category. Situations within this category occurred when either a patient or colleague known to the respondent committed suicide. Such situations were associated with respondents feeling anxious, frustrated and overwhelmed. The following two examples illustrate this. One social worker reported: A depressed patient with whom I had worked closely (she attended many of the therapy groups I was involved with as the therapist) and who appeared to be getting better, committed suicide while on a pass outside the hospital. I felt somewhat inadequate - like there must have been something I could have done differently. This next example involved a suicide of a colleague. The social worker wrote: I was not present when this incident occurred but hearing about it made me feel like I was there...a colleague in the hospital took her own life by hanging herself in the garage of her apartment building. I was shocked and not prepared when I heard this. I was haunted by the image of her hanging and had intrusive thoughts about her action. Terminal/critical illness. Social work with the terminally and/or critically ill was another category that social workers described as being a CI (n=5). Social workers who work with patients and their significant supports around terminal and critical illness often find themselves confronting strong emotional reactions, not only from their clients, but from within themselves. The CI for one social worker related to her provision of supportive counselling to a patient's mother: A 10 year old boy was flown down from Prince George, BC with severe third degree burns to his body. His mother accompanied him. I provided support to his mother throughout the night. The doctors had eventually decided that there was nothing that they could do to save him - they ordered morphine. Mom and I sat at his bedside waiting for him to die. I spent 4-5 hours with her. I was completely emotionally drained. It was so difficult to see the pain the 31 mom experienced in losing her child in such a terrible way. I was not sure if I should be doing more to help her. Violence toward social workers. Four of the CIs fit into this category. Violence encompassed verbal abuse, verbal threats, and physical abuse toward a social worker by a patient. Respondents described feelings that were associated with fear and worry. One social worker experienced the following assault: A male patient, unknown to me, ventured into my office after being informed of his discharge that day. It was not possible to provide him with the services and goods that he wished to have. When I explained this to him he proceeded to attack me with his fists. A second social worker reported: I was working in the Emergency Department, attempting to secure accommodations for a male patient. Patient had been barred from several places and it was becoming more difficult to find him shelter for the night. He was very agitated and belligerent towards me. I was walking the previous shift's social worker out to her car when he began screaming at me and chased after us. We had to run and hide in some bushes - when he was gone I returned to the social work office. I was upset and felt very vulnerable. Other critical incidents. Three of the CIs in this study were grouped into a miscellaneous category that included a child placed into foster care, a visual trauma, and a riot. CIs reported by these respondents were: A woman in her 30s with two young children came to the Emergency Department twice in the same day with two young children complaining of flu-like symptoms. She was advised to take some Tylenol and get some rest. Social work had not been involved in either visits. The woman returned with her id for a third time during the same day with the same 32 complaint. I observed both her and her kids to be very tired...social work interviewed her privately and she confessed that the real problem was that she was attending university and it was exam time. She said she had no money, no family, no friends and could not take care of her kids. The end result was that with the mother's permission, the kids were placed into Ministry care. The mother was very tearful throughout the entire time. I imagined no matter how busy or stressed out I was, that I could never leave my children with complete strangers for temporary custody. For one social worker, the sight of a seriously injured patient was a CI: I was the Emergency Department social worker and was involved with a trauma patient who had been crushed by a plate of glass from a high ceiling. I had never seen anyone crushed before -1 was amazed at how much blood there was. I felt helpless to control the situation. I assisted the patient's friend in calling the patient's sister and told her over the phone. Afterwards I felt I should not have assisted with this. One social worker experienced a CI as a result of a riot: It was the Stanley Cup riots...it was a very stressful, and long night with much chaos. Primary Characteristics of Critical Incidents Reported The suddenness of the CI experienced was reported by a significant number of hospital social workers (n=25). Eighty-three percent said that their CI had occurred suddenly and without any warning. The majority of respondents in this study (63%) recalled that their CIs involved dealing with something new to them. Among these experiences were: confronting end-of-life issues, encountering an aggressive patient, dealing with discrimination, patient advocacy within an interdisciplinary team, and patients with complex social issues. Fifty percent of the hospital social workers indicated that their CI had an element of uncertainty with respects to their professional role and/or function. Having their personal beliefs challenged by their CI was experienced by 37% of the hospital social workers. Despite the 33 suddenness, novelty, uncertainty, and challenge, most hospital social workers (87%) were comfortable with the decisions they made during their CI. Reactions to Critical Incidents Physical reactions. Using the Critical Incident Information Form (Appleton, 1992), information was gained about the physical reactions that hospital social workers experienced 48-72 hours following the CIs. Participants were able to select one or more physical reaction. They reported a variety of physical reactions that included feeling overwhelmed, fatigued, withdrawn and insomnia, and anxiousness. Full results are reported in Table 5. In addition to these, 27% of the social workers reported several other physical reactions, such as confusion, depression, headaches and nausea. Table 5 Physical Reactions to a C I PHYSICAL REACTION FREQUENCY PERCENT Feeling Overwhelmed 20 67.0 Fatigue 15 50.0 Sleep Disturbance (Insomnia) 15 50.0 Anxious 13 43.0 Withdrawn 6 20.0 Others 8 27.0 Emotional reactions. Emotional reactions experienced by social workers during the first 48-72 hours following their CI were measured using Folkman and Lazarus' (1986) Emotional Appraisal Scale (EAS). Participants indicated on this five-point scale the degree to 34 which they experienced an emotional reaction (0=not at all --> 4=a great deal). Table 6 shows the mean scores and indicates that hospital social workers experienced a variety of emotional reactions following their CI. Table 6 Emotional Reactions to a CI EMOTIONAL REACTION MEAN (X) SD Anxiety 2.48 1.15 Frustrated 2.28 1.49 Worried 1.97 1.27 Fearful 1.72 1.28 In Control 1.70 1.04 Angry 1.59 1.38 Disappointed 1.55 1.40 Confident 1.45 1.10 Disgusted 1.17 1.56 Secure 1.14 1.16 Relieved .76 1.30 Hopeful .72 .96 Pleased .59 1.05 Critical .48 1.24 Sad .45 1.15 Exhilarated .45 .95 Threatened .34 1.08 Happy .17 .47 Eager .14 .44 Table 7 indicates the average item score (AIS) for each of the four stress appraisal categories in the EAS. The AIS for each category was calculated by adding up the scores for each item in each category and then dividing that amount by the number of items in each category. The higher the AIS the more often the category of emotions was experienced. In this study, hospital social workers experienced primarily threat, harm, and challenge emotions with benefit emotions experienced by very few social workers. Table 7 Scores on Emotional Appraisal Scale (4) 35 EMOTION AVERAGE ITEM SCORE (M) THREAT: Io6 • anxiety • fear • worry HARM: 1.65 • anger • disappointment • disgust • frustration CHALLENGE: 1.43 • confidence • in control • security BENEFIT: .47 • eager • exhilaration • happiness • hopefulness • pleasure • relieved Coping with Critical Incidents Hospital social workers' coping strategies following a CI were measured using the Ways of Coping Scale (WCS) (Folkman, et al., 1986). Table 8 presents the AIS for each of the eight coping strategies in the WCS. The AIS for each strategy was calculated by totaling the scores of each item within each strategy and then dividing by the number of items in that strategy. The higher the AIS the more often that coping strategy was used. 36 Table 8 Scores on Ways of Coping Scale (8) COPING STRATEGY AVERAGE ITEM SCORE Seeking Social Support (P) Planful Problem-Solving (P) Positive Reappraisal (E) Self-Controlling (E) Distancing (E) Confrontative Coping (P) Accepting Responsibility (E) Escape-Avoidance (E) 1.33 1.10 .90 .85 .56 .47 .33 .31 P=problem-focused coping E=emotion focused coping Results from this study indicated that during the first 48-72 hours following a CI hospital social workers used a variety of emotion- and problem-focused coping strategies. As discussed earlier, emotion-focused coping are attempts made to regulate emotional responses such as: accepting responsibility, distancing, escape-avoidance, positive reappraisal, and self-controlling. Problem-focused coping are attempts made to alter/manage the stressor such as: confrontative coping, planful problem-solving, and seeking social support (Lazarus & Folkman,'1984). Impact on Professional and Personal Lives Participants in this study were asked if they had participated in a debriefing session in order to express their feelings and experiences about the incident. Although 68% of the social workers had not participated in a debriefing session, 70% said that they would have welcomed the opportunity. In this study, 23% of hospital social workers indicated that their CI did have a negative impact on their interpersonal relationships with their colleagues at work. Ten percent acknowledged that the CI had a negative impact on their interpersonal relationships with family 37 and/or friends. When asked if they had considered leaving their position/practice area because of this incident, 17% of the respondents indicated "yes". Summary of Findings Within this chapter the major findings were presented. The response rate, demographic characteristics of the sample along with information related to the nature of CIs reported, reactions to CIs, coping strategies with CIs, and the impact on professional and personal lives were also presented. The majority of hospital social workers (56%) had more than 10 years of social work experience and 53% had been in their present social work position for at least four years. Most of the CIs occurred in the Emergency Department. Through the use of content analysis, five CI categories were identified: traumatic (unplanned) death, suicide, terminal/critical illness, violence toward social worker, and other (child removal, visual trauma, and riot). Respondents recalled experiencing a variety of physical as well as emotional reactions, and primarily used four different types of emotion- and problem-focused coping strategies to cope with the CIs. A significant number of respondents identified debriefing as a supportive resource that might have been helpful in coping with the CIs. 38 CHAPTER FIVE DISCUSSION This chapter presents an overview of the research findings along with a discussion of their significance in relation to the theoretical framework and other studies. Limitations of the study along with implications for social work administration, education, practice and future research are discussed. Overview The purpose of this study was to describe how hospital social workers appraised, reacted to, and coped with CIs in their work environment and what impact the CIs had on their professional and personal lives. Data revealed that hospital social workers encountered CIs in their work environment and experienced a variety of emotional and physical reactions. The CIs identified by respondents centred on violence and death-related events, and although respondents reacted with some discomfort, these reactions were not debilitating. Respondents utilized various coping strategies in order to alter or manage the CI or to lessen the amount of emotional distress they experienced. Events that respondents appraised as CIs included traumatic (unplanned) deaths, suicides, critical/terminal illnesses, violence toward social workers, a visual trauma, a child protection issue, and a riot. Nearly half of the CIs occurred in the Emergency Department while others occurred on a general medical ward, ICU, psychiatry, PCU, a burn unit, and in the social work department. The primary traits of events appraised as CIs by respondents were novelty, suddenness and uncertainty. Not surprisingly, most indicated that their personal beliefs were challenged and said that they were unsure as to what their social work role or function should have been during the CI. This may be explained by the fact that most of the CIs had occurred suddenly, without 39 warning, and involved dealing with something new, and therefore hospital social workers may have been unable to immediately prepare themselves for an objective appraisal of the event. However, despite this, respondents remained confident and comfortable with the decisions they made. Within the first 48-72 hours following the CI, respondents experienced physical reactions which included feeling overwhelmed, fatigued, anxious, withdrawn and insomnia. Primary emotional reactions to the CI were anxiety, fear, frustration, worry and anger. Despite these reactions, hospital social workers appeared to cope well, even though some reported that their professional and/or personal lives had been negatively affected by their CI experience. The top four coping strategies utilized by respondents were seeking social support, planful problem-solving, positive reappraisal, and self-control. Data reflected the importance respondents gave for the need for support in order to facilitate positive ways of coping. Findings in Relation to the Theoretical Framework Although Lazarus and Folkman's (1984) theory provided a useful framework to understand how hospital social workers appraised and coped with CIs, it was more descriptive and less prescriptive with respect to suggestions for interventions. The basic tenet of this theoretical framework was that individuals reacted and coped with stressful events based on their own appraisal of the event. Differences in reactions and coping reflected individual differences in appraisals. The findings from this study not only revealed that respondents used primary appraisals when confronted with stressful encounters but also indicated that individuals experienced several emotions that corresponded with this theory's threat, harm, and challenge emotions. These findings support Lazarus and Folkman's (1984) theory. Respondents also used benefit emotions but to a lesser degree than those above which was understandable given the CIs were appraised as being stressful and most involved events related to death. 40 Folkman and Lazarus (1988a) believed that effective coping consisted of the use of six to seven different coping strategies and that an association existed between problem-focused coping and one type of emotion-focused coping which emphasized the positive. Those respondents who used problem-focused coping employed positive reappraisal coping (emotion-focused) more readily. This tenet was supported by the data from this study as hospital social workers utilized a variety of emotion- and problem-focused coping strategies. The use of positive reappraisal by hospital social workers as a mechanism to cope did not seem surprising given that a basic social work practice perspective is to create positive meaning by being focused on personal growth (Saleebey, 1992). This perspective differs from the traditional medical model where pathological deficiencies in the individual are emphasized. Although most hospital social workers are subjected to such an environment their professional education towards the strengths perspective may have caused them to appraise situations differently than other heath care professionals (Weick, Rapp, Sullivan, & Kisthardt, 1989). Lazarus and Folkman (1984) posited that individuals who are confronted with inadequate access to coping resources, such as those who worked evening and/or night shifts, may be more susceptible to stress. However, data from the hospital social workers did not support this assumption, and, in fact, revealed opposite findings. The majority of the reported CIs occurred during the day shift when respondents would have had the greatest access to coping resources. This contradiction could be understood in two ways. The majority of hospital social workers did not work shift work and therefore the respondents who recalled CIs were mainly those who worked day shifts. Another explanation may be that it is the nature of the CI (traumatic death) rather than access to coping resources (CISD team) that defined the event as critical/stressful. Coping resources appeared to be of greatest value once the event had actually occurred as the data had not indicated that merely having access to coping resources moderated the impact against the effects of CIS. Comparison of Findings with other Literature 41 Nursing and hospital social work. One of the unique features of this study was that it investigated hospital social workers' experiences with work-related CIs. No other research was located that connected this issue with this population. CIS research has only recently expanded into other health care professions such as nursing. As described earlier, Appleton (1993; 1994) investigated staff nurses' appraisals and coping strategies in relation to a CI using a descriptive research design and a sample of 50 medical/surgical staff nurses. According to Appleton (1993; 1994), events nurses appraised as CIs included moral distress, lack of responsiveness by a health care professional, violence toward a nurse, emergency situations, patient death, and actual or potential contact with infectious body fluids. Violence and death of a patient were CIs experienced as stressful by both hospital social workers and nurses which is not surprising as both professions work closely with patients who are often agitated, anxious, or near death. However, the reactions to these events appeared to vary somewhat between nurses and hospital social workers. Data from Appleton's study (1993; 1994) revealed that nurses responded to their CIs with anger, disappointment, frustration, and disgust (harm emotions) whereas hospital social workers in the current study responded with anxiety, fear, and worry (threat emotions). Although physical reactions were not that dissimilar between the two groups (both reported feeling fatigued and experienced insomnia), hospital social workers primarily felt overwhelmed. This finding was somewhat of a surprise. It seemed that nurses would be more susceptible to feeling overwhelmed because they worked 12 hour rotating shifts, did not have the flexibility of taking unscheduled breaks, and depending on the unit, could be responsible for eight to twelve patients at a time. However, the fact that hospital social workers reportedly felt more overwhelmed than nurses can be understood when viewed in the context that many of their CIs involved, in some way, death. It could be expected that nurses confront death issues more frequently than hospital social workers and therefore may have reacted to events differently than social workers would have. 42 Appleton (1993; 1994) found that nurses used a variety of emotion- and problem-focused coping strategies when confronted with a CI. The top four coping strategies, in descending order, were: seeking social support, self-control, positive reappraisal, and planful problem-solving. In contrast, hospital social workers also used a variety of coping strategies and reported the same top four as the nurses in Appleton's study but in a slightly different order (seeking social support, planful problem-solving, positive reappraisal, and self-control). Both populations utilized seeking social support as their primary coping strategy which involved efforts to obtain information support, tangible support, and emotional support (Folkman & Lazarus, 1991). CISD was one intervention that both studies indicated would have been welcomed in order to assist respondents with their coping following a CI. These findings are important because both hospital social workers and nurses appeared to have recognized the value of supportive psychological and educational interventions aimed at softening the impact of stress from CIs. This data also supported the benefits of CISD presented earlier by Lane (1994) and Rubin (1990). Similar findings with respect to the impact CIs had on their professional and personal lives were reported by both studies. Data from Appleton's study (1993; 1994) and this study revealed that, for the majority of respondents, the CI did not have a negative effect on their relationships with colleagues, family, and/or friends. This suggested that participants may have used successful coping strategies and were able to leave "work issues at work" and prevented the frustration and stress from affecting their personal lives. For the most part, differences between nurses' appraisals, reactions, and coping strategies with a CI and those of hospital social workers were slight. However, in order to better understand these differences it is necessary to look at the uniqueness of the two professions and consider the possibility that differences in their philosophical approach, training, and practice values may contribute to differences in appraisals, reactions, and coping with CIs. Hospital social workers often deal with situations that are not only morally difficult but unfixable. Autonomy, non-judgmentalness, self-determination, and unconditional acceptance are a few of the professional values promoted in social work (Canadian Association of Social Workers, 43 1995). Hospital social workers, in their daily practice, avoid becoming too involved in patients' issues out of respect for these values. Instead, they support patients to seek healthy solutions to their expressed concerns. As a result, a patient's independence and self-determination are increased which creates more realistic expectations between the patient and the social worker with respect to the desired outcome. Because hospital social workers acknowledge medical intervention is not within their area of professional expertise they are able to remove themselves from personal responsibility. In contrast, nursing, which usually subscribes to the medical model, can be task-oriented in its professional functions and roles. Consequently, nurses may act on or address patients' concerns in a more intrusive manner and, on a personal level, feel directly responsible if the desired outcome is not achieved. Although further research is needed, data from this study suggested that professional values may actually influence how CIs are experienced. Death, dying and hospital social work. A significant finding in this study was the prevalence of hospital social workers who appraised events related to death and dying as CIs. Three of the CI categories identified (traumatic death, suicide, and critical/terminal illness) related to death, dying, and end-of-life issues. Data indicated that, for many hospital social workers, involvement with a death was emotionally challenging and difficult work. Davidson and Foster (1995) suggested that social work with terminally ill patients exacted a heavy emotional toll on social workers who frequently experienced feelings of fear and loss. These reactions were similar to the threat reactions reported by the respondents in this study. Furthermore, social workers experienced considerable strain and stress as they recognized their own mortality. Despite feeling emotionally exhausted, Davidson and Foster (1995) revealed that social workers who worked with dying patients found this practice to be very rewarding. Even though hospital social workers experienced a CI, most felt comfortable with the decisions they made at the time and few considered leaving their present position. Findings from this study, 44 with respect to social work with death-related issues, appear to be valid as they replicated findings from Davidson and Foster's study. Most respondents acknowledge that death, dying, and other end-of-life issues are inevitable aspects of hospital social work. Most often, social workers are educated to deal with serious emotional and relationship issues and therefore may be prepared to deal with loss and other developmental issues in life. Dealing with such issues may make the social worker feel fulfilled, needed, or significant, and thus appraise their work as rewarding. However, from time to time, unusual situations occur that make a "typical" event seem extraordinary and a potential CI. Limitations The findings from this study cannot be generalized to-social workers in other hospitals, contexts, or clinical settings because of the convenience sample used. A convenience sample is not always representative of the population, therefore, I would recommend using a random sample to yield a sample that truly represented the population (Neuman, 1994). Another method that could have improved the generalizability and strength of the study would have been to replicate it in various settings. The study only examined how hospital social workers reacted and coped with a CI at one point in time (the first 48-72 hours following the event). Since participants recalled CIs retrospectively, the quality of data gathered depended on their recollection of the events. Potential threats to validity in the study may be related to a number of factors. First, most of the data were collected during the month of December when many social workers were absent from work on holidays. Second, because a convenience sample was used, only those social workers who were interested in the study and volunteered their time actually participated. Third, a number of social workers indicated they chose not to participate in the study because the questionnaire appeared too long and time-consuming. Finally, even though the investigator reviewed the definition of a CI with prospective participants, there were still some who were 45 confused about what events and/or situations constituted a CI. As a result there was no assurance that social workers were able to recall or identify a CI experience. Appleton (1993; 1994) noted in her study a similar response rate and identified similar factors to explain it. This investigator attempted to deal with some of the limitations identified in Appleton's study by editing some of the questions in the C.I.I.F., reformatting the C.I.I.F. to reduce its length, and pilot-testing the instrument to address any concerns or questions. However, not all of the limitations identified could be corrected. Appleton indicated that collecting her data during the month of December, a busy holiday time of the year, may have contributed to a low response rate. Nonetheless, this investigator still chose to administer questionnaire packages in December in order to meet a research deadline. I believed this decision may have been somewhat responsible for the low response rate. In hindsight I would recommend a less hectic time of year to collect data. Several hospital social workers seemed to prefer to discuss their CI experience in person with the investigator rather than complete the questionnaire package and participate in the study. This raised the question as to whether a higher response rate would have been achieved if the data collection had been more qualitative. Implications Hospital social work administration. Social work administrators may find it useful to know that "Critical Incident Stress" does not occur only within a critical care setting. Findings revealed that social workers experienced CIs in a variety of settings and that all social workers may be susceptible to CIs. Hospital administrators must recognize that CIs may occur within the hospital and, as a result, hospital staff may experience CIS. Hospital policy should read that the employer is accountable to protect their employees and ensure their physical safety and emotional well-being. 46 Data further revealed that social workers either sought support or wished to have received support following a CI. Numerous studies existed that described the positive impact supportive supervision had on mitigating the effects of stress, preventing bumout, and mobilizing the emotional energy needed for effective job performance. Even though the data suggested that hospital social workers managed their CI encounter well, they did react with and experience threat emotions. Therefore, in order to address these negative emotions, hospital social work administrators should make regular supervision with their social work staff a priority. Another mechanism to support social workers following a CI would be to have a C.I.S.D. program implemented within the hospital. C.I.S.D. was designed to reduce distressing negative emotional and physical reactions, lessen the negative physiological impact often experienced following a CI, facilitate emotional venting and closure on the incident. Debriefers in hospitals should make themselves aware of the findings in this study in order to better understand the CIs specific to hospital social work. Such a program may provide alternative or new coping resources and/or coping strategies. Although further research is warranted, such interventions may reduce cost associated with increased sick leave and employee turnover, resulting in budgetary savings. Social work training & education. Hospitals need to incorporate programs that educate hospital social workers about CIS. In-service training should include programs that are designed to support social workers following a CI. Such practices may include training centred on end-of-life issues, crisis intervention, and interdisciplinary seminars. Hospital social workers would not only be able to share their CI experiences but collaborate in the development and implementation of supportive resources for all health care professionals to access. Social work curricula at the undergraduate and graduate levels should include specific content on occupational stress associated with hospital/medical social work (Carlton, 1989a). Content should include education on social work with critically/terminally ill patients, social work in the Emergency Department, and social work with aggressive patients. Such content may 47 assist students with recognizing events that may be potential CIs thus allowing them to adapt their appraisal of the event accordingly. Hospital social work practice. The Standards of Practice in Social Work, developed by the CASW, highlighted several practice standards expected of social workers. Among them is: "establish professional expectations so that social workers can monitor, evaluate and improve their own practice" (1995). Hospital social workers should recognize the types of events that have been appraised as CIs and expect that these events may require emotional support in order to lessen the effects of CIS on the social worker. Hospital social workers should be encouraged to continue to seek support in order to evaluate their practice strengths and limitations. Seeking support from colleagues and/or social work administrators may not only improve social work practice but ensure healthy coping strategies, such as positive reappraisal and problem-solving, continue to be selected. Consequently, anxiety and frustration levels could be decreased, along with departmental pressure and absenteeism due to stress. Recommendations for future research. As research on CIS within social work is in its gestation period, it is important that future studies focus on helping to better understand the complexities of this type of stress. Some recommendations for future research would be to compare the coping strategies of hospital social workers who had participated in a CISD program with those who had not to determine the effectiveness of a CISD program in facilitating healthy coping. Longitudinal studies on individuals who experienced CIs could provide insight into the cumulative costs associated with absenteeism due to stress and other related leaves and may be beneficial in monitoring the effectiveness of in-service training programs and social work university curricula. 48 Research that investigates the relationship between age, years of social work experience, and level of education with CIS is warranted to determine if younger and less experienced hospital social workers are, in fact, more susceptible to CIs than their senior colleagues with more social work experience and education. This data could possibly influence the hiring of social workers for a hospital environment. Cross-cultural and gender research aimed at investigating the appraisals, reactions, and coping strategies with CIs may be useful to implement inclusive workplace interventions and resources. Different cultures and genders may appraise events differently and knowledge of these differences may improve the quality of workplace interventions. Studies that compare how social workers in other settings (i.e.: child protection) appraise, react, and cope with CIs could highlight those environments, social contexts, and occupations that have the greatest susceptibility to CIs and CIS. Further, research could investigate if and how professional values influence individuals' selection of coping strategies or determine how they react emotionally and/or physically. Finally, future research on hospital social work and CIS may want to use qualitative data gathering techniques to gain more detailed and succinct accounts of their experiences with CIs. 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Vernon, B.C.: Author. Weick, A., Rapp, C , Sullivan, P., & Kisthardt, W. (1989). A strengths perspective for social work practice. Social Work. 34. 350-354. APPENDIX A: Participant Introductory Letter A P P E N D I X B : Participant Information Sheet PARTICIPANT INFORMATION SHEET 59 AGE: GENDER: 20-29 Female 30-39 Male 40-49 50-59 60-+ YEARS OF EXPERIENCE AS A YEARS IN PRESENT POSITION: SOCIAL WORKER: <1 Year 1-3 4-6 7-9 >10 <lYear 1-3 4-6 7-9 >10 HIGHEST DEGREE RECEIVED (please check one) BSW MSW (without BSW) MSW (with BSW) 60 A P P E N D I X C : Critical Incident Information Form 61 CRITICAL INCIDENT INFORMATION FORM Please read the following definition, and then proceed. A Critical Incident refers to an event or situation that you define as traumatic and causes you to have unusually strong emotional responses which may compromise your usual coping skills (i.e.: an exceptional incident that is above and beyond what you would regard as everyday stress). 1. Describe in 50-75 words a Critical Incident that you have experienced. Please include a description of who was involved (do not list names), where it occurred, a brief description of what happened and what role you played in the situation. 2. How long ago did this Critical Incident occur? (check one) <1 year 2- 3 years 3- 4 years 4< years 1-2 years 3. Can you recall during what shift this Critical Incident occurred? (check one that is closest) Day Shift (0800-1630) Evening Shift (1600-2400) Night Shift (2400-0800) _ Other (indicate) 4. What do you feel was the worst part of this Critical Incident for you? 62 5. Did this situation occur suddenly/without warning? (check one) a) yes b) no 6. Did this incident involve dealing with something new to you? (check one) a) yes b) no If yes please explain: 7. Do you remember if there was an element of uncertainty in this incident with your professional role and/or function? (check one) a) yes b) no If yes please explain: 8. Do you remember this incident challenging your personal beliefs? (check one) a) yes b) no -Elaborate i f you wish: 9. Were you comfortable with the decisions that you made during the incident? (check a) yes b) no Elaborate i f you wish: 63 10. Do you remember experiencing other stresses in your life during the time of this Critical Incident? (check one) a) yes b) no If yes please indicate: a) personal stress b) professional stress c) other (indicate) 11. After the Critical Incident (within the first 48-72 hours following this event) do you remember if you experienced any of the following reactions? (check the relevant reactions) a) nausea e) insomnia/sleep disturbance i) anxious b) confusion f) feeling overwhelmed j) if others, please c) headache g) withdrawal indicate: d) fatigue h) diarrhea 12. Do you remember the Critical Incident having a negative impact on your interpersonal relationships with your colleagues at work? (check one) a) yes b) no with your friends and/or family? (check one) a) yes b) no 13. Did this incident occur while you were working in your present position/area? (check one) a) yes b) no. If yes please answer question 15. If no go to question 14. 14. Did you consider leaving your position/area because of this incident? (check one) a) yes b) no 64 15. Have you considered leaving your present position/area because of this incident? (check one) a) yes b) no 16. Please read the following (prior to answering this question): Debriefing is defined as a formal psychological and educational group process aimed at softening the impact of stress as a result of experiencing a CI, through "talking it out". This is different from an informal talking to a colleague about the event or situation. Did you participate in a debriefing session following the Critical Incident that you have just described? (check one) a) yes b) no If you answered yes go to question 18. If you answered no go to question 17. 17. Would you have liked a debriefing session following your CI? (check one) a) yes b) no 18. Are there specific reasons that would prevent you from seeking follow-up guidance or support after a CI? (check one) a) yes b) no If yes please explain: 19. If there is anything you wish to add regarding this Critical Incident, please do so in the space provided: APPENDIX D: Emotional Appraisal Scale Folkman and Lazarus (1986) 66 E M O T I O N A L A P P R A I S A L S C A L E As best you can, describe how you felt after experiencing this Critical Incident (within the first 48-72 hours following this event or situation). To do this, it is important that for each item you circle the number that best describes the extent of that feeling. Not At All A Little Somewhat Quite A Bit A Great Deal 1. angry 0 1 2 3 4 2. worried 0 1 2 3 4 3. exhilarated 0 1 2 3 4 4. disappointed 0 1 2 3 4 5. secure 0 1 2 3 4 6. confident 0 1 2 3 4 7. in control 0 1 2 3 4 8. fearful 0 1 2 3 4 9. pleased 0 1 2 3 4 10. hopeful 0 1 2 3 4 11. disgusted 0 1 2 3 4 12.eager 0 1 2 3 4 13. frustrated 0 1 2 3 4 14. anxious 0 1 2 3 4 15. happy 0 1 2 3 4 16. relieved 0 1 2 3 4 17. other 0 1 2 3 4 (please specify) A P P E N D I X E: Ways of Coping Scale (Revised) Folkman et al. (1986) 68 WAYS OF COPING SCALE (REVISED) Please read each item below and indicate, by circling the appropriate category, to what extent you used it after experiencing the Critical Incident (the first 48-72 hours following the event or situation). Simply circle the "not used" column if an idea is not applicable. Not Used Used Used Used Somewhat Quite A Great A Bit Deal 1. Just concentrate on what I had to do~ 0 1 2 3 the next step. 2.1 tried to analyze the problem in 0 1 2 3 order to understand it better. 3. Turned to work or substitute activity 0 1 2 3 to take my mind off things. 4.1 felt that time would make a 0 1 2 3 difference—the only thing to do was to wait. 5. Bargained or compromised to get 0 1 2 3 something positive from the situation. 6.1 did something which I didn't think 0 1 2 3 would work, but at least I was doing something. 7. Tried to get the person responsible to 0 1 2 3 change his or her mind. 8. Talked to someone to find out more 0 1 2 3 about the situation. 9. Criticized or lectured myself. 0 1 2 3 10. Tried not to bum my bridges, but 0 1 2 3 leave things open somewhat. 11. Hoped a miracle would happen. 0 1 2 3 12. Went along with fate; sometimes I 0 1 2 3 just have bad luck. 13. Went on as if nothing had 0 1 2 3 happened. 14.1 tried to keep my feelings to myself. 0 1 2 3 69 15. Looked for the silver lining, so to speak; tried to look on the bright side of things. 16. Slept more than usual. 17.1 expressed anger to the person(s) who caused the problem. 18. Accepted sympathy and understanding from someone. 19.1 told myself things that helped me to feel better. 20.1 was inspired to do something creative. 21. Tried to forget the whole thing. 22.1 got professional help. 23. Changed or grew as a person in a good way. 24.1 waited to see what would happen before doing anything. 25.1 apologized or did something to make up. 26.1 made a plan of action and followed it. 27.1 accepted the next best thing to what I wanted. 28.1 let my feelings out somehow. 29. Realized I brought the problem on myself. 30.1 came out of the experience better than when I went in. 31. Talked to someone who could do something concrete about the problem. 32. Got away from it for awhile; tried to rest or take a vacation. 33. Tried to make myself feel better by eating, drinking, smoking, using drugs or medication, etc. 34. Took a big chance or did something very risky. Not Used Used Used Used Somewhat Quite A Great A Bit Deal 0 1 2 3~~ 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 70 Not Used Used Used Used Somewhat Quite A Great A Bit Deal 35.1 tried not to act too hastily or follow my first hunch. 36. Found new faith. 37. Maintained my pride and kept a stiff upper lip. 38. Rediscovered what is important in life. 39. Changed something so things would turn out all right. 40. Avoided being with people in general. 41. Didn't let it get to me; refused to think too much about it. 42.1 asked a relative or friend I respected for advice. 43. Kept others from knowing how bad things were. 44. Made light of the situation; refused to get too serious about it. 45. Talked to someone about how I was feeling. 46. Stood my ground and fought for what I wanted. 47. Took it out on other people. 48. Drew on my past experiences; I was in a similar situation before. I knew what had to be done, so I doubled my efforts to make things work. Refused to believe that it had happened. 51.1 made a promise to myself that things would be different next time. 52. Came up with a couple of different solutions to the problem. 53. Accepted it, since nothing could be done. 49 50 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 71 Not Used Used Used Used Somewhat Quite A Great A Bit Deal 54.1 tried to keep my feelings from 0 1 2 3 interfering with other things too much. 55. Wished that I could change what 0 1 2 3 had happened or how I felt. 56.1 changed something about myself. 0 1 2 3 57.1 daydreamed or imagined a better 0 1 2 3 time or place than the one I was in. 58. Wished that the situation would go 0 1 2 3 away or somehow be over with. 59. Had fantasies or wishes about how 0 1 2 3 things might turn out. 60.1 prayed. 0 1 2 3 61.1 prepared myself for the worst. 0 1 2 3 62.1 went over in my mind what I 0 1 2 3 would say or do. 63.1 thought about how a person I 0 1 2 3 admire would handle this situation and used that as a model. 64.1 tried to see things from the other 0 1 2 3 person's point of view. 65.1 reminded myself how much worse 0 1 2 3 things could be. 66.1 jogged or exercised. 0 1 2 3 APPENDIX F: Resource Information 

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