Workplace Programs to Reduce Post-traumatic Stress Injuries Work Disability: First Responder Experiences

Abstract

Purpose

First responders (FR—police, firefighters, paramedics) are exposed to trauma which can result in post-traumatic stress injuries (PTSI). Despite a lack of strong evidence on interventions to address PTSI work disability, workplace PTSI programs and policies are necessary to prevent work disability. The study objective was to examine experiences and perspectives about workplace programs, policies, and experiences related to the prevention of PTSI work disability among FR in Alberta, Canada.

Methods

This qualitative study collected the perspective of police members, firefighters, and paramedics in Alberta, Canada regarding current workplace PTSI programs and policies. Qualitative interview data underwent descriptive thematic analysis.

Results

Interviews were conducted with 47 FR members from police (16), fire (16), and paramedic (15) services who shared their experience with PTSI and workplace programs and policies. Three key themes emerged: improving culture, programs under development, and trusted communication. Three additional themes related to recommendations to improve programs and policies in the workplace were also identified: streamlined processes, better resources, and continue to reduce stigma. The themes and recommendations from participants provide practical information about how programs and policies can be improved.

Conclusion

Interviews provided rich descriptions of current FR workplace PTSI practices and policies. While participants noted that awareness about PTSI and the culture of FR workplaces has improved, more needs to be done. Paramount were recommendations regarding the need for streamlined processes and better resources to reduce PTSI work disability. Study findings suggest that the development and implementation of workplace PTSI programs have a positive impact on FR organizations and on the mental wellbeing of the FR workforce. Future research should examine FR workplace program and policy development as well as implementation.

Background

First responders (FR) or public safety personnel (PSP) including police, firefighters and paramedics have challenging jobs and encounter various hazards that can lead to occupational injuries [1–3]. Exposure to potentially psychologically traumatic events (PPTE) in the course of their work can result in post-traumatic stress injuries (PTSI) [1, 3, 4], described as “mental health conditions that a person may experience as a result of exposure to one or more PPTE [5]. PTSI encompass symptoms of anxiety-, mood- or trauma-related disorders, such as generalized anxiety disorder (GAD), major depressive disorder (MDD), panic disorder and post-traumatic stress disorder (PTSD). Carleton et al. [6] reported a PTSI prevalence rate of 23% among PSP, which is notably higher than that among the general population (5–10%). Cherry et al. [7] found the prevalence of PTSD among firefighters who attended the 2016 Fort McMurray fire in Alberta, Canada, to be 21.4% and noted that anxiety disorders and depressive disorders were also high. A recent systematic review by Hoell et al. [8] found the prevalence of the one-year work-related PTSD among paramedics is 20%. The high prevalence and complex nature of PTSI symptoms make it challenging for PSP workplaces to prevent work disability related to PTSI.

Occupational stressors can play a significant role in the development of PTSI. Carleton’s [9] cross-sectional survey study of over 4400 PSP explored and highlighted the association of occupational stressors (i.e., organizational factors such as leadership style and staffing, as well as operational factors such as shift work) and PPTE. Occupational stressors were also associated with other anxiety and mood- related disorders (even when PPTE was adjusted for in the analysis). This research points to the importance of workplace organizational factors for mental health disorders such as PTSI. Carleton [9] identified the need to consider organizational and operational changes for PSP organizations. While the impact of organizational and operational stressors was not identical across PSP, it was clear that addressing these stressors would be beneficial.

Research suggests that evidence-based interventions are needed to address PTSI among PSP. A systematic review by Lees [10] exploring interventions for anxiety, PTSI, fatigue/sleepiness with law enforcement officers found that the majority of PTSI intervention studies examined individual treatment options with a focus on resilience [11–13]. Interventions focusing on unique work environments of PSP are also needed [14, 15], including a broad range of support services (e.g., alcohol abuse treatment, wellness training, mental health services) with coordination with the work environment specifically regarding shift length and schedules [16], as are prevention and early intervention programs for PSP mental ill health and suicide prevention [17]. Overall, the existing research suggests a lack of evidence of effectiveness of the PTSI programs evaluated. Despite the lack of strong evidence for workplace-based PTSI interventions, Canadian employers have a responsibility to protect workers from injury and the disability that may result in the workplace [18]. McCreary [17] noted that PSP organizations were challenged in balancing job requirements and protecting workers and identified the need to further examine workplace programs and policies in PSP organizations.

Furthermore, FR services have reported challenges in recruiting [18, 19]. Combining this decrease in new staff with the increased work disability from PTSI resulting from increases in OSI and long-term exposure to PPTE results in less FR available to protect the public. This suggests a need to better prevent work disability among FR [4].

However, a knowledge gap exists regarding the prevention of PTSI work disability for PSP [17] and current PTSI programs and policies in PSP organizations. An examination of organizational policies and practices is important to help prevent work disability associated with PTSI [9]. Stronger connections to the workplace are also needed to help reduce PTSI related work disability [20]. Moreover, proactive workplace strategies also need to be developed and improved, especially for violence-related injuries [21]. Studies have shown that PSP were less likely to seek supports from professionals, such as physicians and therapists, possibly due to feelings of reluctance or seeking non-professional supports instead [9, 22–25]. Rikkers and Lawrence [26] reported that over 60% of FR participants felt they needed help for their mental health issues, yet less than 50% of them seek the help needed. Programs in the workplace, therefore, may be more accessible to FR and reduce the barriers to seeking support.

To address this gap, the objective of this study was to examine experiences and perspectives about workplace practices (policies and programs) for the prevention of work disability related to PTSI in FR organizations from those with experience of PTSI either directly or having supported someone with PTSI. Our focus was the prevention of disability related to PTSI. A qualitative thematic approach was used to explore the experiences and practices being used in FR organizations in Alberta, Canada.

Methods

This study employed an interpretive qualitative approach, with interview data collected from police members, firefighters, and paramedics in Alberta, Canada. Semi-structured interviews focused on the experiences and perspectives on current programs, policies, practices and priorities related to the prevention of PTSI work disability in police, fire and paramedic organizations in Alberta. The study received ethics approval from the University of Toronto’s Research Ethics Board (41068) and the University of Alberta (Pro00111904).

Stakeholder Advisory Committee

We assembled a stakeholder advisory committee comprised of representation from FR organizations and associations in Alberta, who offered input about the project. Based on their experience working in FR organizations, committee members contributed to all research stages, including recruitment, use of correct terminology during data collection, and framing of research messages for broader dissemination. This integrated knowledge transfer and exchange (KTE) strategy [27] allowed the research team to describe indicators of success so that FR organizations in Alberta might better implement and manage the programs, policies, and practices directed at preventing PTSI work disability.

Sample and Recruitment

We used purposive sampling to recruit a representative sample of police members, firefighters, and paramedics in Alberta that included men and women of various ages and different job responsibilities. Individuals who experienced PTSI either directly or through having supported someone with PTSI (supervisor or health and safety/disability management role) were included in this study).

The stakeholder advisory committee assisted with recruitment by reaching out to potential study participants via emails, newsletters and e-blasts that included a link to an online recruitment survey. Interested participants completed the recruitment survey, providing their contact information and details about their current role. Interested candidates and interview participants were encouraged to forward the invitation to participate to other FR.

Data Collection

An experienced research associate and qualitative interviewer (JV) conducted 45–60 min, one-on-one semi-structured interviews via phone or online meeting platform (Teams or Zoom). Informed consent was provided by all participants prior to the interview. An interview guide with questions and prompts was developed by the research team and reviewed by the members of the stakeholder advisory committee. Participants were asked about their experiences/perspectives with PTSI including work absence, return- to work (RTW) or reintegration programs, policies, practices, PTSI programs, policies, and practices and facilitators/barriers related to existing programs and practices. Participants were also asked for recommendations about ways to improve workplace PTSI programs and policies.

Data Analysis

Interview data were anonymized, transcribed and thematically analyzed (DVE, JV, EI, SR) using reflexive methodology outlined by Braun and Clarke [28, 29]. We developed a codebook using the interview questions and prompts, as well as findings from three relevant systematic reviews [42, 43, 45]. NVivo software (NVivo, released in March 2020 by QSR International Pty Ltd) was used to support data organization, coding and thematic analysis. Numerous discussions related to the deductive (understanding programs and program elements) and inductive (concepts and developing themes) analysis resulted in identification of key insights and divergent perspectives regarding workplace PTSI programs, policies, and practices from the perspective of those supporting workers with PTSI or those experiencing PTSI symptoms. Discrepancies were resolved through discussion until consensus was reached. The anonymous analyzed content and illustrative examples were presented to the stakeholder advisory committee for review and feedback.

Results

Participant characteristics: Interviews were conducted with 47 members of police (n = 16), firefighter (n = 16), and paramedic (n = 15) services in Alberta between September 2021 and December 2021. Characteristics of the participants are shown in Table 1. Data saturation was achieved since no new details about programs or experiences were detected as we completed the final interviews.

Table 1.

Characteristics of study participants

	Role		Age (years)		Gender
	Support	Worker	18–44	45 and above	Male	Female	Total
Firefighter	5	11	6	10	14	2	16
Paramedic	5	10	8	7	9	6	15
Police	7	9	8	8	9	7	16

Overarching themes: Through thematic analysis we identified three overarching themes regarding PTSI programs and policies in FR organizations: improving culture; programs under development; and trusted communication. While the themes are inter-related, they each highlight different aspects of addressing PTSI in the workplace. Three additional themes also emerged regarding participant recommendations to better support PTSI in their workplaces: streamlined processes; better resources; and continued reduction of stigma. These themes were consistent across firefighter, police and paramedic participants.

Improving Culture

Within this theme, we heard that there were improvements in organizational culture which reduced barriers to seeking support for PTSI. However, some participants noted that not all (the ‘old guard’ in leadership roles) were onboard with improved culture and awareness of mental health concerns. Also related to concerns about the ‘old guard’ some reflected that there may be fear associated with seeking PTSI treatment and impacts on career and job opportunities.

Participants consistently remarked that the culture in their service/organization has improved over time. The culture shift, described as occurring slowly and often over decades, was demonstrated by more knowledge about PTSI and less stigma associated with mental health and psychological injury. Participants noted that even when there was an absence of formal PTSI programs, a positive workplace culture allowed members to come forward and seek help when needed. A support staff from a police service, for example, described the importance of a positive work culture:

Just a really good culture within the office so that members are comfortable to identify whether or not they’re having issues. And members trust that they will be taken care of and respected through the process. Once you’ve established that trust and that culture, I think you’re far more likely to see a member come forward and say, ‘Look, I’ve got problems and I need help with them’. <S-PL-38>

In general, the trend of improving culture was making it easier to seek help for PTSI. However, members reflected that to get help or support for PTSI an individual had to realize they needed it. Some also observed that more work was needed to support individuals to make the decision to come forward and ask for support. Some participants also spoke about being exhausted by trying to hide their condition as well as often attempting to locate and access supports outside of their work environment due to fear of disclosure. Participants related that further efforts are required to reduce the stigma of having a psychological injury, end the narrative that reducing one’s workload equates to laziness or “loafing”, encourage the use of available resources, and support staff to come back “when they were ready” and not cut corners. Often the stigma and reticence to make it known that a FR was struggling delayed seeking support (see quote above). Also, a worker from a fire service mentioned:

Lots of guys and girls just don’t even know that they’re struggling. They don’t realize that these are symptoms, or they’re suffering from chronic sleep deprivation, or if they do know they don’t know what to do or what the cause. The biggest thing is the stigma. So if they are struggling, they don’t want to make it known, so that makes it hard to access resources. <W-FF-43>

Despite noting an improvement in workplace culture over time, some raised concerns about the “old guard” in some services. Participants felt that some in leadership positions were a barrier to continued improvement of culture and reduction in stigma related to PTSI. The rank and file were adapting more quickly to addressing mental health than management, leading to mistrust of the “old guard”. Participants suggested that the old guard lacked empathy and tended to be judgemental, which perpetuated stigma related to PTSI and prevented or delayed members to seek support for their PTSI. A support staff from a fire service related:

Buy-in from the top, I think is a change culture that will happen as you see new leadership come in. The old leadership requires education and a little bit of a call to action. You say that you promote mental health in your workplace, what does it look like and what have you personally done, and what can you do to make it easier on the guys, and do you joke about it not realising that you’re ostracising some of the people that might be actually feeling that way? <S-FF-23>

Participants commented on the importance of buy-in from leadership. Leadership buy-in included actively promoting mental health, implementing policies and procedures fairly and consistently, staffing for reintegration teams as well as ensuring there was adequate staffing should team members require time off. Even with an improved culture, a sense of mistrust and concern prevailed about seeking treatment or accommodation for PTSI or mental health issues due to a possible negative career implications.

Concerns raised about the repercussions of PTSI treatment or time off included “fear” of being singled out, opening up, or disclosing an injury to others in the workplace. Others noted fear associated with potential negative impacts on their career advancement/promotions, current pay, and the ability to make a living. Some expressed a fear of “being on their own” to deal with PTSI when they felt that the workplace would not be supportive. A support staff from a police service described:

They don’t know how that’s going to affect them, how it’s going to affect their career, how it’s going to affect their family… at the end of the day, everybody thinks in the back of their mind is this going to stigmatize me, or are people going to think differently about me? Could this affect promotion in the long run? I think that’s probably the biggest thing. I’ve seen tons of members struggle with this for a year. <S-PL-40>

Programs Under Development

Participants often noted that workplace PTSI programs and policies were under development, positively viewing such efforts even when they were not yet fully implemented. Program development was facilitated by an improving culture, particularly the reduction in the stigma related to mental health, operational stress injury (OSI) and PTSI. Participants noted that training, reintegration, and peer-support programs were being updated or newly developed but also indicated the need for flexible procedures and practices within programs to best address the varying needs of members with PTSI since the “cookie-cutter” or “one-size-fits-all” approaches had not worked in the past.

Participants also reflected on many types of existing external supports such as such as private, provincial, and community based as well as from insurance providers (e.g., Employee [and Family] Assistance Programs (EAP/EFAP)). However, participants also noted that these were not uniformly available to all members in all jurisdictions. The concept of “under development” was extended to these formal supports even though they were already in place. Here participants noted that these supports did not meet the needs of FR with PTSI. Therefore, they felt that further development was required to ensure that the number of visits was sufficient to address PTSI, that the therapists were trauma-trained and that long delays to access supports were eliminated. Participants noted that once FR decided to get support they needed access quickly and that the support was helpful, or they would stop seeking the support. Many interviewees noted that these barriers were part of the reason to create specific accessible workplace programs.

While specific organizational PTSI programs and policies were described as often being simultaneously developed, policy development was considered more time consuming because there was more pressure to “get it right”. Some noted that delays in developing policies were purposeful to ensure the resulting programs and practices could maintain a level of flexibility that was needed to be effective. For example, a worker from a fire service described where they were with program development:

So we’re just developing this committee right now type thing and seeing what it’s going to look like, developing terms of reference and what kind of things we’re going to be able to provide and what kind of budgets we’re going to have for members. <W-FF-43>

Specific workplace-based programs were described as training about PTSI and were often the only thing available in their service. Respondents felt that it was still “early days” for PTSI or mental health training programs, suggesting that further development and modification was ongoing or needed. A concern about available training programs was that they were often only delivered at orientation or onboarding for frontline workers. There were also suggestions to expand PTSI training to include supervisors and human resource (HR) professionals as they should be better educated about PTSI, and more trauma informed. There was a strong sense that there was a lack of understanding and/or appreciation of the unique nature and challenges faced by frontline FR. For instance, a support staff in a fire service said:

The first year was just figuring out what we have, what we don’t have, and what we need. And so, bringing these types of training and services to the volunteer members is part of our process we’re looking at. <S-FF-15>

Despite PTSI programs being developed, participants often described uncertainty about the existence of PTSI programs or policy in their service. Responses related to PTSI policy reflected a continuum where some mentioned ‘there is no policy’, others said, ‘not that I am aware of’ or ‘not specifically’, with yet others responded with ‘I am sure that there is’, or confidence that programs existed. These responses reflect the varying levels of knowledge about existing workplace PTSI policies, as mentioned by a worker in a fire service:

I want to say that there is because of the amount training certain individuals and the chief officers have taken with regards to that. I want to say, again, that there is a policy in place that will dictate and direct how that process works. But, again, it’s been a while since I’ve broken out our SOPs and SOGs environment, so I would potentially be misspoken if I stated what I thought would be fact. <W-FF-10>

Some of the uncertainty related to the existence of several different types of programs that could be linked to PTSI disability prevention, but that may not be available to all members. Some programs were considered specific to PTSI (such as reintegration, resilience, and psychological services), while others were more general (such as RTW, wellness, or HR programs). Those in support positions were often aware of the variety of programs but noted they were not well integrated in the workplace. Some workers described their experiences with one workplace program but realized later that there were others available. Participants also expressed confusion about the variety of programs available. Specifically, they were not certain about differences between programs, and which one was best for them. A support staff in a police service mentioned:

… HR works out of a different system. And then Reintegration [program] works out of a different system. Psych Services works out of a different system. So, each of these systems can have the same person with different bits of information. So, that’s where we really need to collect data a lot better with a system from 2021. … We need to put our people first and put our resources to be able to help our people. We just haven’t gotten there. We’ve been told it’s coming. <S-PL-47>

Participants commented on the need for easy access to information about PTSI programs and resources. While information about programs and policies was usually presented during onboarding or orientation, participants noted that finding it when needed was more important. Many felt that accessibility to information and programs was a concern because of delays and red-tape experienced in getting needed support. They felt it took too long to get access and often described barriers as coming from inside as well as outside the service at the county, municipality, or provincial level. In addition, there were concerns that while policy might be in place ‘on paper’ it was not necessarily so in practice or that the existing practices were too reactive. The perceived lack of procedures/practices resulted in delays in seeking support which was detrimental to recovery and working productively. A support staff in a paramedic organization spoke about the impact of information not being easily accessible to members:

… you have to get that knowledge and get that information out there and make it more accessible. … if that webpage where peer support is … incomplete. The people go to access it and they’re like, that didn’t answer my question so now what I do, and they’re left in that tailspin and going, I guess I’ll just go back to work. And they are coming back to work and injuring themselves even more, you can’t control the call volume, you can’t control the types of calls that we’re getting. It’s compounding it. <S-PR-24->

Trust and Communication

Trust was often mentioned in relation to communication to spread information about PTSI programs within FR organizations. Informal communication or ‘word of mouth’ about PTSI was considered a useful method of spreading awareness about PTSI programs/practices, especially when it comes from a trusted person, as mentioned by a worker in a police organization:

Yeah, word-of-mouth has been the biggest seller for the resources that are available. When people go and they have an experience, and life gets better because they went to psychological therapies, or talked to Peer Support, or involved in Reintegration, then usually that word-of-mouth within the service is really what sells things. <W-PL-30>

Trust was a key factor for members to feel safe to communicate about their PTSI experiences with workplace colleagues, whether supervisor or co-worker. Participants felt better communicating with colleagues who had similar experiences. In addition, there was significance attached to creating an environment where FR (and their families) felt safe disclosing difficulties or diagnoses. When a member lacked trust in the workers compensation board or the employer, or did not feel supported, they were less likely to communicate with them about PTSI or mental health concerns.

Participants spoke about the value of trust and a sense of community in the workforce with respect to supporting those with PTSI and implementing relevant policy and programs. Access to trusted and knowledgeable individuals who can understand the experience of PTSI was extremely important for members. “Watching out for each other” was an important informal PTSI workplace support that nearly all participants described. Doing so did not only relate to PTSI but was described as being part of the job when in dangerous situations and an extension of the everyday aspect of protecting each other. This included identifying when someone needed help or appeared to be “in trouble” and required a great deal of trust as it went beyond performing duties safely. Participants often differentiated between formal peer-support programs and the type of informal support they had with trusted colleagues. Trust was also noted when participants recounted their experiences with informal support outside of the workplace, often speaking of connecting with family and friends as “individuals you trust”. A worker participant from a fire service, for instance, recalled the informal support they received:

With all the symptoms, I struggled to even leave my house. I was lucky enough to have a few members reach out and trying to get me out of the house, go for a walk or whatever but nothing formal I think. There’s a lot of uncertainty in how to interact with someone that’s struggling so hard with big emotions and uncertainty … it was just peer support basically. <W-FF-43>

Communication from trusted sources was also considered an important element of workplace PTSI programs and policies. Participants reported that information about PTSI programs, policies, and practices was communicated at various times during their working life. They most often spoke about information regarding PTSI being presented at orientation, and after an intense incident. Participants highlighted the importance of having refreshers about PTSI programs, policies, and practices so members can identify and access existing programs as well as get help if needed. A support staff in a police service said:

Yeah, I believe as part of their onboarding they would be learning about it. Of course, you forget about it after you’ve been there for a while. The supervisor should be the first point of support to our members and they should have some of that information available to them. But if the supervisor doesn’t know then they can always reach out to other return to work coordinators. <S-PL-32>

Contacting a member when they were off work due to PTSI was another element of communication described. Participants shared that there were personal preferences around the extent of communication when a member is off work and while discussing their own RTW plan. If a member experiencing PTSI is more private, there could be less communication with the employer or anyone at the workplace. Concerns about privacy and confidentiality were also raised by participants when discussing communication. For example, a worker from a police service said:

Because I’m a private guy, doing the peer-to-peer thing isn’t something that I would really want to talk to somebody about. <W-PL-22>

Recommendations for Improving PTSI Programs

When asked about recommendations regarding how to improve workplace PTSI programs and policies, three themes that build upon the overarching themes above emerged from participant interviews. A description of each, including supporting quotes, follows.

Streamlined Processes

Participants stressed that having a “streamlined process” was necessary to improve PTSI programs. Participants expressed the need for programs with less ‘red tape’ and paperwork. Many also noted the need for proactive approaches to further reduce stigma and delays. The emphasis on ease was related to getting faster access to support and treatment as participants noted the negative consequences of delays they experienced.

Access to relevant information about PTSI in one designated place was identified as one aspect of streamlining. Participants suggested that information about workplace supports as well as external treatment options be easily accessible and use simple language that all members can understand. They also noted that it is helpful when information is accessible on multiple devices (e.g., phone, tablets, desktop) or through different sources (e.g., supervisors, bulletin, intranet).

Better coordination across different programs for PTSI, particularly for RTW and reintegration, was also identified as a need. Participants noted silos where different helpful programs were not always available to all members. For instance, a worker from a fire service mentioned:

I just think it would make it a lot easier if there’s … one clear, concise point of entry into that system instead of a million different websites. … There’s a joke in the fire service about firefighters not being able to tie their own shoes that’s why we have big rubber boots. So trying to have a firefighter sit down and search through a million websites trying to find the right one, firefighters are just going throw their hands up in the air and say I’m done. I’ve wasted so much time. - <W-FF-45>

More and Better Resources

The need for’more and better resources’ for PTSI was also noted among participant recommendations. Predominant among this theme was the need for trauma-trained therapists, whether they were part of EAP/EFAP, the service, or in the community. Access to more sessions with an EAP/EFAP that is more tailored to FR who typically experience more trauma than workers in other sectors was also encouraged, as was access to better online programs that could be accessed at home, allowing for quicker access to support as well as reducing the stigma of seeking mental health support.

Within the workplace, interviewees mentioned that peer support should be provided by ‘informed’ peers (i.e., those with experience in dealing with trauma). There were also calls for more personnel resources available to allow staff adequate time off work for recovery and for reintegration teams to assist with the RTW process. Increasing supervisors’ training about mental health and awareness of available programs and resources to recommend for workers with PTSI was also endorsed. For example, a support staff in a police service mentioned:

We need a better HR department, with HR professionals, who are trauma informed and who work closely with our psychological services and take into account the injured employee, you know, what’s going to benefit them and what’s going to help them to get better or to at least be in meaningful work. <S-PL-42>

Particularly important for those in rural areas was the recommendation to enhance the level of awareness and knowledge among policy makers at municipal and provincial levels.

Continue to Reduce Stigma

Participants consistently reported that the culture in FR workplaces was improving with less stigma regarding mental health/PTSI (see improving culture theme above). However, participants recommended continued stigma reduction was required in their workplaces. Many felt that reducing stigma was important to promoting self-awareness so that individuals could identify their need for help/support. Participants also expressed a need for broader education about PTSI and mental health. Given the impact of PTSI on workplace members and their families, it was suggested that PTSI needed to be better understood at a societal level and should be taught in school.

The perceived link between promotions or job security and PTSI (or mental health or even taking time off work with an injury) was also identified. Participants recommended that there be clarification about the existence of a link, speaking to the need for trust within the service as noted above. A support staff in a police service, for instance, said:

If you’re going to decrease stigma, if you’re going to make the return-to-work process easier, your advocates have to have a lot of organizational credibility. Truly. That’s how you shift conversations is people who a lot of others look up to. <S-PL-01>

Discussion

The aim of this qualitative study was to examine experiences and perspectives about workplace practices (programs and policies) for the prevention of work disability related to PTSI in FR organizations. This study is one of the first to focus on the experiences about workplace programs and policies for the prevention of work disability related to PTSI. Members from police, fire and paramedic services in Alberta Canada who either had PTSI symptoms or supported others with PTSI symptoms in the workplace provided rich insights into PTSI programs, policies and recommendations. A thematic analysis of interview data revealed three overarching themes: improving culture; programs under development; and trusted communication. In addition, three themes emerged regarding recommendations: streamlined processes; better resources; and continued reduction of stigma. These inter-related themes revealed current FR experiences and challenges, regardless of role or service type.

Our findings offer direction to FR workplaces in how to develop programs and policies to reduce the work disability from PTSI. Continued efforts are needed to improve the organizational culture of FR workplaces to reduce stigma associated with PTSI and mental health is necessary. Study participants felt an improving culture was an important to reducing PTSI work disability. Research examining the experiences of PSP related to PTSI or RTW reveal mixed findings about workplace culture. Many studies suggest improvements are still required [30–32], including in those that suggest that PSP culture around mental health has improved [33]. Improvement in culture requires that the leadership buy-in to the need for PTSI programs and lead by example. In addition, work must be done to reduce the fear of repercussions related to making a mental health claim or going off work with an injury. Testa et al. [34] found FR were concerned that their career progression would be impacted if they had a history of mental health problems or if they sought mental health treatment. This fear often leads to delays in seeking treatment or going off work which is detrimental to successful rehabilitation [3, 20, 31, 35]. Some FR reported that they also had to recognize when they needed support and actively seek it. MacDermid [33] reported similar experiences in firefighters who felt they could use training to better recognize mental health problems.

Workplace PTSI programs and policies were reported to be under development in FR organizations with training, reintegration, or peer-support programs in various stages of development. The variability in program/policy development led to uncertainty among members regarding the existence of PTSI program in their workplace. Compounding this was the sense that there was inadequate communication about programs. Some frustration was noted about challenges finding information about PTSI programs when members needed it which often delayed getting support. There were also often further delays due to ‘red tape’ or the sense that a policy only existed on paper. A delay in getting support or treatment for PTSI has been linked with poorer work disability outcomes [20, 30, 36].

Overall communication was a key element required so members were informed about existing programs as well as for general information and awareness of mental health. Most importantly, the communication had to come from trusted sources whether through formal or informal channels. Word-of-mouth for those who had experience directly with existing programs was highly valued by members. Many studies have reported on the importance of communication in reducing work disability in PSP [30, 32, 37–39]. An important challenge for workplaces is how to ensure that communication is timely and updated to support members with mental health challenges. This includes when members are off work, where frequency and mode of communication may require flexibility depending on the nature of injury.

A call for more and better resources for PTSI was also highlighted. This call was often directed at external resources such as EAP/EFAP that were not trauma-trained or difficult to access. Within the workplace, it was recommended that leadership and human resources personnel receive mental health training to better support FR. Previous studies [40, 41] have also suggested the need for training in active listening, crisis management, being trauma informed, and recognizing signs and symptoms of PTSI among FR. Supervisors and managers may also benefit from training about work accommodations, RTW strategies, psychological health and safety, and conflict management [41]. Concerns about workplace peer support or RTW programs were also raised, with participants stressing the need for these to be effective. This highlights both the need for evidence-based approaches for reducing work disability related to PTSI symptoms [42–45], and the challenges of implementing programs that may require coordination with outside agencies including EFAP/EAP or other community partners [30, 37, 46].

Overall, this study identified that most workplace PTSI programs and policies were not fully implemented. While some programs were described as ‘being delivered’ often in an informal fashion, there was less attention to the implementation of the programs, and greater focus on developing programs to address PTSI and effectively support members. Recent studies on PSP organizations have noted there are challenges with implementation of PTSI and RTW programs [30, 33, 37]. More applied research is clearly needed to address the implementation challenges in PSP organizations.

Strengths and Limitations

A key strength of this study is that we gathered perspectives about PTSI workplace programs and policies directly from workplace personnel in FR organizations. Conducting interviews with both injured workers in FR services and those who offer support to them provided a comprehensive view of how PTSI is addressed at the workplace. The interviews yielded rich data about the current PTSI practices and experiences of FR in Alberta. Another strength was having an engaged stakeholder advisory committee that aided in recruitment, helped refine messages from the results, and assisted with dissemination.

A potential limitation of our study was the use of a convenience sample of FR in Alberta. The purposive sampling approach, however, helped to ensure our sample reflected a balance of service types, sizes, and geographical locations. Future research needs to replicate the findings with samples in other jurisdictions. Longitudinal research would also be welcome to follow those with PTSI over time to determine program and policy effectiveness. It is also possible that those who volunteered to be interviewed may have different experiences related to PTSI than those who did not. Specifically, people with more difficult or challenging experiences may have been more inclined to volunteer for the study and share their experiences than those with relatively minor concerns. Finally, this study was conducted during the COVID-19 pandemic. This lengthened recruitment may have narrowed the potential individuals interested in participating and eliminated the possibility of conducting in-person interviews. The study nonetheless included rich descriptions of experiences with PTSI practices.

Conclusion

The findings from this study show that FR organizations in Alberta are developing workplace programs and policies to address work disability resulting from PTSI. An improvement in organizational culture in the past few years has facilitated the PTSI program development. Despite the positive findings regarding culture and program development, challenges remain regarding program implementation. More research is necessary to evaluate the implementation needs of FR organizations given the nature of PTSI, the need for coordination among workplace, and community as well as provincial or national services. Our findings suggest this is an opportune time to conduct this type of implementation research. Furthermore. the findings suggest that the development and implementation of workplace PTSI programs have a positive impact on FR organizations to help ensure the mental wellbeing of the FR workforce.

Author Contributions

DVE, EI and ET contributed to the study conception and design. Material preparation, data collection and analysis were performed by DVE, SR, EI, JV, MM, and SBP. The first draft of the manuscript was written by DVE and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

Funding for this research was from a Supporting Psychological Health in First Responders grant (Grant Ref #: 20SPHIFR39-2) from the Alberta Government.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.