"Arts, Faculty of"@en . "Social Work, School of"@en . "DSpace"@en . "UBCV"@en . "Plante, Rodney S."@en . "2009-04-28T18:20:56Z"@en . "1997"@en . "Master of Social Work - MSW"@en . "University of British Columbia"@en . "The intensity and emotional demands of the health care environment place exceptionally\r\nhigh performance expectations and stress on hospital social workers. Critical Incident Stress\r\n(CIS), a specific type of stress associated with dramatic, emotionally overwhelming situations,\r\nknown as Critical Incidents (CIs), produce several emotional and physical reactions that can\r\nthreaten the well-being of the hospital social worker. CIS, as experienced by hospital social\r\nworkers, is absent from the literature and not well understood. The purpose of this study was to\r\ndescribe how hospital social workers appraised, reacted to, and coped with CIs in their work\r\nenvironment.\r\nLazarus and Folkman's (1984) theoretical framework of stress appraisal and coping was\r\nused to guide this descriptive study. A sample of 30 hospital social workers was recruited from\r\ntwo Vancouver tertiary care hospitals. Four instruments (Participant Information Sheet, Critical\r\nIncident Information Form, Emotional Appraisal Scale, and Ways of Coping Scale) were used to\r\ngain knowledge on how hospital social workers appraised, reacted to, and coped with CIs in their\r\nwork environment. Quantitative data were coded, qualitative data were subjected to content\r\nanalysis, and descriptive statistics calculated.\r\nData revealed that hospital social workers encountered CIs in their work environment and\r\nthat the majority of CIs centred on death-related events. The primary traits of events appraised as\r\nCIs were novelty, suddenness, and uncertainty. Respondents reacted to the CI with a variety of\r\nemotional (anxiety, fear, frustration, worry, anger) and physical reactions (feeling overwhelmed,\r\nfatigued, withdrawn, anxious, difficulty with sleeping), and although they experienced some\r\ndiscomfort, these reactions were not debilitating. Most hospital social workers indicated that\r\ntheir personal beliefs had been challenged by the CI and revealed that they were unsure as to\r\nwhat their social work role or function should have been during the event. However, despite this,\r\nrespondents remained confident and comfortable with the decisions they made. Hospital social\r\nworkers appeared to cope well with CIs, used a variety of emotion- and problem-focused coping\r\nstrategies, and reported few negative effects on their professional and/or personal lives. The top\r\nfour coping strategies utilized by respondents were seeking social support, planful problemsolving,\r\npositive reappraisal, and self-control.\r\nThe implications of the findings for hospital social work administration, social work\r\ntraining and education, hospital social work practice, and future research are discussed."@en . "https://circle.library.ubc.ca/rest/handle/2429/7654?expand=metadata"@en . "3187749 bytes"@en . "application/pdf"@en . "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 \u00C2\u00A9 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 \u00C2\u00A3tt/4i. u)r>ej 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 \u00E2\u0080\u00A2 anxiety \u00E2\u0080\u00A2 fear \u00E2\u0080\u00A2 worry HARM: 1.65 \u00E2\u0080\u00A2 anger \u00E2\u0080\u00A2 disappointment \u00E2\u0080\u00A2 disgust \u00E2\u0080\u00A2 frustration CHALLENGE: 1.43 \u00E2\u0080\u00A2 confidence \u00E2\u0080\u00A2 in control \u00E2\u0080\u00A2 security BENEFIT: .47 \u00E2\u0080\u00A2 eager \u00E2\u0080\u00A2 exhilaration \u00E2\u0080\u00A2 happiness \u00E2\u0080\u00A2 hopefulness \u00E2\u0080\u00A2 pleasure \u00E2\u0080\u00A2 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. Qualitative data could provide clearer insight and a more comprehensive understanding into the experiences of hospital social workers who encountered CIs in their work environment. 49 References Abramson, J.S., Donnelly, J., Ring, M.A., & iVlailick, M.D. (1993). Disagreements in discharge planning: A normative phenomenon. Health and Social Work. 18(0, 57-64. Appel, Y.H. (1988). Occupational stress in the care of the critically ill, the dying, and the bereaved (book review). Social Work. 33. 468. Appleton, L.A. (1992). Critical Incident Information Form. Unpublished manuscript. Appleton, L.A. (1993). Staff Nurses' Appraisals and Coping Strategies in a Critical Incident. Unpublished Master's Thesis, University of British Columbia, Vancouver, British Columbia, Canada. Appleton, L.A. (1994). What a Critical Incident? The Canadian Nurse. 4(2\ 23-26. Arches, J. (1991). Social structure, burnout, and job satisfaction. Social Work. 36, 202-206. Baldwin, K.M. (1993). Lazarus'theory of coping. In S.M. Ziegler (Ed.). Theory-directed nursing practice (pp. 128-152). New York: Springer Publishing Company. Beemsterboer, J., & Baum, B.H. (1984). 'Burnout': Definitions and health care management. Social Work in Health Care. 10(1). 97-109. Bell, J.L. (1995). Traumatic event debriefing: Service delivery designs and the role of social work. Social Work. 40(1). 36-43. Bergmann, L.H., & Queen, T.R. (1986). Critical incident stress. Fire Command. 53(5). 52-55. Canadian Association of Social Workers. (1995). Standards of Practice in Social Work. Ottawa: Author. Carlton, T.O. (1989a). Education for health social work: Opportunities and constraints in schools and hospitals. Health and Social Work, 14. 147-152. Chan, T.H., & Ward, S. (1993). Coping process theory. AAOHN.41(10\ 499-503. 50 Cohen, F. (1991). Measurement of coping. In A. Monat & R.S. Lazarus (Eds.), Stress and coping: An anthology (3rd ed.) (pp.228-244). New York: Columbia University Press. Cournoyer, B.R. (1988). Personal and professional distress among social caseworkers. Social Casework. 69. 259-264. Cushman, L.F., Evans, P., & Namerow, P.B. (1995). Occupational stress among AIDS social service providers. Social Work in Health Care. 21(3). 115-131. Davidson, K.W. (1985). Social work with cancer patients: Stresses and coping patterns. Social Work in Health Care. 10(4). 73-82. Davidson, K.W. & Foster, Z. (1995). Social work with dying and bereaved clients: Helping the workers. Social Work in Health Care. 21(4). 1-16. Donnelly, J.P. (1992). A frame for defining social work in a hospital setting. Social Work in Health Care. 18m. 107-119. Folkman, S., & Lazarus, R.S. (1980). An analysis of coping in a middle-aged community sample. Journal of Health and Social Behaviour. 21 (Sept.). 219-239. Folkman, S., & Lazarus, R.S. (1985). If it changes it must be a process: Study of emotion and coping during three stages of a college examination. Journal of Personality and Social Psychology. 48(1). 150-170. Folkman, S., & Lazarus, R.S. (1986). Stress processes and depressive symptomatology. Journal of Abnormal Psychology. 95(2). 107-113. Folkman, S., & Lazarus, R.S. (1988a). Coping as a mediator of emotion. Journal of Personality and Social Psychology. 54(3). 466-475. Folkman, S., & Lazarus, R.S. (1988b). The relationship between coping and emotion: Implications for theory and research. Social Science Medicine. 26(3). 309-317. Folkman, S., Lazarus, R.S., Dunkel-Schetter, C , DeLongis, A., & Gruen, R.J. (1986). Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology. 50(5). 992-1003. 51 Folkman, S., & Lazarus, R.S. (1991). Coping and emotion. In A. Monat & R.S. Lazarus (Eds.), Stress and Coping: An Anthology (3rd ed.) (228-244). New York: Columbia University Press. Greene, R. (1986). Countertransference issues in social work with the aged. Journal of Gerontological Social Work. 93(3). 79-88. Harrison, W.D. (1980). Role strain and burnout in child-protective service workers. Social Service Review. 50. 31-44. Himle, D.P., Jayaratne, S., & Chess, W.A. (1986). Gender differences in work stress among clinical social workers. Journal of Social Service Research. 10. 41-56. Jayaratne, S., & Chess, W.A. (1984). Job satisfaction, burnout, and turnover: A national study. Social Work. 29. 448-455. Jayaratne, S., Davis-Sacks, M.L., & Chess, W.A. (1991). Private practice may be good for your health and well-being. Social Work. 36(3). 224-229. Jayaratne, S., Himle, D., & Chess, W.A. (1988). Dealing with work stress and strain: Is the perception of support more important than its use? Journal of Applied Behavioral Science. 24(2), 191-202. Johnson, M., & Stone, G.L. (1986). Social workers and burnout: A psychological description. Journal of Social Service Research. 10. 67-80. Koeske, G.F., & Koeske, R.D. (1989). Workload and burnout: Can social support and perceived accomplishment help? Social Work. 34. 243-248. Lane, P.S. (1994). Critical incident stress debriefing for health care workers. Omega. 28(4), 301-315. Lazarus, S., & Folkman, S. (1984). Stress, Appraisal, and Coping. New York: Springer. Lazarus, R.S., Averill, J.R., & Opton, E.M., Jr. (1974). The psychology of coping: Issues of research and assessment. In G.V. Coelho, D.A. Hamburg, & J.E. Adams (Eds.), Coping and adaptation (249-279). New York: Basic Books Inc. 52 Lazarus, R.S., Kanner, A.D., & Folkman, S. (1980). Emotions: A cognitive-phenomenological analysis. In R. Plutchik, & H. Kellerman (Eds.), Theories of emotion Vol. 1. Emotion: Theory, research, and experience (189-217). New York: Academic Press. Loewenberg, E.M. (1979). The causes of turnover among social workers. Journal of Sociology and Social Welfare. 6. 622-642. McGee, R.A. (1989). Burnout and professional decision making: An analogue study. Journal of Counseling Psychology, 36(3), 345-351. Martin, K.R. (1993). To cope with the stress. Nursing. 5. 39-41. Mitchell, J.T. (1982). Recovery from rescue. Canadian Emergency Services News. 5(6), 34-36. Mitchell, J.T. (1983). When disaster strikes: The critical incident stress debriefing process. Journal of Emergency Medical Services. 8(11), 36-39. Mitchell, J.T. (1988a). Stress: The history, status and future of critical incident stress debriefing. Journal of Emergency Medical Services. 13(111. 47-52. Mitchell, J.T. (1988b). Development and functions of a critical incident stress debriefing team. Journal of Emergency Medical Services. 13(121. 42-46. Mitchell, J., & Bray, G. (1990). Emergency services stress: Guidelines for preserving the health and careers of emergency services personnel. Englewood Cliffs, New Jersey: Prentice Hall. Neuman, W.L. (1994). Social Research Methods (2nd ed.1. New York: Allyn and Bacon. Oktay, J.S. (1992). Burnout in hospital social workers who work with AIDS patients. Social Work. 37(51.432-439. Perrez, M., & Reicherts, M. (1992). Stress, coping, and health: A situation-behaviour approach - theory, methods, applications. Seattle: Hogrefe & Huber Publishers. Pines, A. (1981). Burnout: Current problems in pediatrics. Current Problems in Pediatrics. 11(81. 3-32. 53 Poulin, J., & Walter, C. (1993a). Social worker burnout: A longitudinal study. Social Work Research and Abstracts. 29(4). 5-12. Poulin, J., & Walter, C. (1993b). Burnout in gerontological social work. Social Work. 38(3), 305-310. Reamer, F.G. (1992). The impaired social worker. Social Work. 37. 165-170. Rubin, A., & Babbie, E. (1993). Research methods for social work (2nd ed.). Pacific Grove, CA: Brooks/Cole. Rubin, J. (1990). Critical incident stress debriefing: Helping the helpers. Journal of Emergency Nursing. 16. 255-258. Saleebey, D. (1992). The strengths perspective in social work practice. New York: Longman. Selye, H. (1956). The stress of life. New York: McGraw Hill. Siefert, K., Jayaratne, S., & Chess, W.A. (1991). Job satisfaction, burnout, and turnover in health care social workers. Health and Social Work. 16(3). 193-202. Snelgrove, T. (1988). Critical incident stress. Emergency Health Services Newsletter. 1(2), 4-6. Spitzer, W.J., & Burke, L. (1993). A critical-incident stress debriefing program for hospital-based health care personnel. Health & Social Work. 18(2). 149-156. Spitzer, W.J., & Neely, K. (1992). Critical incident stress: The role of hospital-based social work in developing a statewide intervention system for first-responders delivering emergency services. Social Work in Health Care. 18(1). 39-58. St. Paul's Hospital. (1995). Protocol: Critical incident stress debriefing. Vancouver, B.C.: Author. Taylor-Brown, S., Johnson, K.H., Hunter, K., & Rockowitz, R.J. (1981). Stress identification for social workers in health care: A preventative approach to burnout. Social Work in Health Care. 7(2). 91-100. 54 Vernon Jubilee Hospital. (1991). Critical incident stress debriefing program. 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 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\u00E2\u0080\u0094the 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 "@en . "Thesis/Dissertation"@en . "1998-05"@en . "10.14288/1.0099236"@en . "eng"@en . "Social Work"@en . "Vancouver : University of British Columbia Library"@en . "University of British Columbia"@en . "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en . "Graduate"@en . "Hospital social workers\u00E2\u0080\u0099 appraisal of, reaction to, and coping with a critical incident in their work environment: a descriptive study"@en . "Text"@en . "http://hdl.handle.net/2429/7654"@en .