Strategies for Public Safety Organizations

Drivers

The National Framework organizes the drivers [link to drivers page] of burnout and moral injury into two primary categories: relational breakdown and operational breakdown. Relational breakdown - distrust, values conflict, lack of control, and inequities - are primarily addressed through relational repairs. Operational breakdown, on the other hand, relate to the experience of workers in the delivery of service or learners in the educational process. These include lack of safety, excessive demands, and inefficiencies.

Relational Breakdown

Evidence

Distrust: Distrust can be a lack of trust between workers and learners and their peers, teams, administration, patients, community, and society. It can relate to poor teamwork, communication, and ineffective leadership and governance, as well as system and society level factors. Toxic organizational culture has been studied in the public safety workforce. A survey of US firefighters found that toxic organizational culture can make it difficult for workers to address mental health issues and moral injury and lead to a bullying mentality that causes a reluctance to show emotion or vulnerability following traumatic events.1 A study of Canadian public safety workers found this culture puts pressure on staff to withdraw work-related complaints and recommendations.2 During COVID-19, lack of communication and transparency within policy development and with the public was shown to create issues between workers and institutions,3 and a lack of action by a trusted authority or colleague was associated with potential moral injury for public safety workers.2 During COVID-19, public safety workers also experienced stigma from the public, family, and friends associated with their work for being “virus carriers”.3

Values conflict: Values conflict arises when there is a disconnect between what workers and learners believe should be done and what they are asked to do. Public safety workers in Canada report experiencing values conflict in a variety of ways, including ethical conflicts and being compelled to provide treatment that they consider harmful or futile, such as backboarding when it causes severe pain for the patient; both of these experiences were associated with potential moral injury.2, 4 At a societal level, workers may experience values conflict when they feel compelled to provide unnecessary or artificial medical services to prevent legal repercussions (such as resuscitating a deceased patient), which, according to one study of Iranian EMS, may lead to moral distress.5 

Lack of control: A lack of control occurs when workers and learners have no voice in organizational decisions that impact public safety. This can result from a lack of mechanisms for workers to voice their concerns or from organizations actively silencing workers, creating an environment where workers fear retaliation for raising issues. In a study of moral injury in US firefighters, workers shared the experience of being coerced into submission by the organizational culture.1 Another study found that their belief that they have little role in organizational decision-making was related to concerning burnout scores among US firefighters.6  

Inequities: Inequities refer to situations where privileged individuals receive better services, health, and opportunities compared to those who are underprivileged. This can manifest through sexism or microaggressions perpetuated by paramilitary and hierarchical structures leading to potentially morally injurious events according to a study of Canadian public safety workers.4 Gender pay gaps, lack of maternity leave, and lack of pregnancy policies are also common among EMS in the US,7 which was theorized to be the cause of disparities in rates of burnout between men and women in another study of EMS workers in the US.8

References

  1. Dill J, Schimmelpfennig M, Anderson-Fletcher E. Wounds of the Spirit: Moral Injury in Firefighters. 2023.
  2. Rodrigues S, Mercier JM, McCall A, Nannarone M, Hosseiny F. “Against everything that got you into the job”: experiences of potentially morally injurious events among Canadian public safety personnel. European journal of psychotraumatology. 2023;14(2):2205332-2205332. 
  3. Xue Y, Lopes J, Ritchie K, et al. Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review. Front Psychiatry. 2022;13:863232. 
  4. Smith-MacDonald L, Lentz L, Malloy D, Brémault-Phillips S, Carleton RN. Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics. Int J Environ Res Public Health. 2021;18(22):12145.
  5. Jafari M, Hosseini M, Bagher Maddah SS, Khankeh H, Ebadi A. Factors behind Moral Distress among Iranian Emergency Medical Services Staff: A Qualitative Study into their Experiences. Nursing and Midwifery Studies. 2019;8(4). 
  6. Raposa ME, Mullin G, Murray RM, et al. Assessing the Mental Health Impact of the COVID-19 Pandemic on US Fire-Based Emergency Medical Services Responders: A Tale of Two Samples (The RAPID Study I). J Occup Environ Med. 2023;65(4):e184-e194.
  7. Rudman JS, Farcas A, Salazar GA, et al. Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review. Prehosp Emerg Care. 2023;27(4):385-397.
  8. Lu DW, Shin J, Wan C, et al. Burnout and Workplace Incivility Among Emergency Medical Services Practitioners: A Preliminary Report. Prehospital emergency care. 2023;27(4):413-417.

Operational Breakdown

Evidence

Lack of safety: A lack of safety entails situations where workers and learners are exposed to environments that increase stress, diminish their sense of security, and/or pose the risk of harm to their physical and/or mental health, including workplace violence. Studies have shown that public safety workers can experience a lack of safety in multiple ways, such as breaking traffic laws, time constraints for equipment checks, seeing patients without appropriate situational awareness, frequent exposure to traumatic events, and increased risk of contracting diseases such as COVID-19.1. 2, 3, 4 An unsafe workplace may lead to moral injury among EMS and firefighters. 5  

Public safety work is inherently stressful as it revolves around the well-being of others in circumstances that are often unpredictable, urgent, and emergent. A study in Iran found that laypersons’ interference in patient care that causes harm and the need to obtain consent in emergency situations can cause moral distress in EMS workers.4 This is exasperated by public safety workers feeling unprepared to work in an impaired social system that is not held accountable, according to a 2021 Canadian study.6 Studies have also shown that public safety workers may lack adequate mental health supports and training for appropriate coping strategies necessary for a high stress job.3, 7 and experience limited social support and communication with co-workers.8 Finally, research on public safety workers in Canada found that this mental health stigma was worsened by pressure to have a strong persona9 in some organizations, leading to fear of retribution by peers or administration for seeking professional services. 10, 11, 12 Barriers based on a study on public safety workers in the US include a lack of knowledge, an inability to show weakness, a fear of confidentiality breach, negative therapist experiences, and a lack of access/availability of mental health services.13

Excessive Demands: Excessive demands occur when workers and learners are asked to accomplish more than their typical work capacity will allow. Workers report distress when they perceive their work demands to be impossible, putting them at risk for moral injury, according to a study of public safety workers in Canada.6 The COVID-19 pandemic exacerbated these demands due to limited staff and increased demand, resulting in insufficient resources,2, 5, 6 lack of appropriate breaks,14 lack of necessary time to recover after shifts,8 high weekly call volumes,3 being overworked,15 and work-family conflict.16, 17 Additionally, underfunding often results in a shortage of available crews to respond to 911 calls, leaving many public safety workers under pressure to take on more hours, according to a Canadian study of public safety workers.14

Inefficiencies: Inefficiencies refer to work expectations that involve activities of little or no value but consume significant time and energy from workers and learners. For example, public safety workers in Canada report excessive wait times upon arriving in the emergency department14 and EMS workers in the U.S. have reported frequent protocol changes associated with burnout.1  

References

  1. Crowe RP, Bower JK, Cash RE, Panchal AR, Rodriguez SA, Olivo-Marston SE. Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehosp Emerg Care. 2018;22(2):229-236.
  2. Melnyk H, Di Tosto G, Powell J, Panchal AR, McAlearney AS. Conflict in the ems workforce: An analysis of an open-ended survey question reveals a complex assemblage of stress, Burnout, and pandemic-related factors influencing well-being. International Journal of Environmental Research and Public Health. 2023;20(10):5861.
  3. Dill J, Schimmelpfennig M, Anderson-Fletcher E. Wounds of the Spirit: Moral Injury in Firefighters. 2023.
  4. Jafari M, Hosseini M, Bagher Maddah SS, Khankeh H, Ebadi A. Factors behind Moral Distress among Iranian Emergency Medical Services Staff: A Qualitative Study into their Experiences. Nursing and Midwifery Studies. 2019;8(4).
  5. Xue Y, Lopes J, Ritchie K, et al. Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review. Front Psychiatry. 2022;13:863232.
  6. Smith-MacDonald L, Lentz L, Malloy D, Brémault-Phillips S, Carleton RN. Meat in a Seat: A Grounded Theory Study Exploring Moral Injury in Canadian Public Safety Communicators, Firefighters, and Paramedics. Int J Environ Res Public Health. 2021;18(22):12145.
  7. Díaz-Tamayo AM, Escobar-Morantes JR, García-Perdomo HA. Coping Strategies for Exposure to Trauma Situations in First Responders: A Systematic Review. Prehospital and Disaster Medicine. 2022;37(6):810-818.
  8. Raposa ME, Mullin G, Murray RM, et al. Assessing the Mental Health Impact of the COVID-19 Pandemic on US Fire-Based Emergency Medical Services Responders: A Tale of Two Samples (The RAPID Study I). J Occup Environ Med. 2023;65(4):e184-e194.
  9. Krakauer RL, Stelnicki AM, Carleton RN. Examining Mental Health Knowledge, Stigma, and Service Use Intentions Among Public Safety Personnel. Front Psychol. 2020;11:949.
  10. Karaffa KM, Koch JM. Stigma, Pluralistic Ignorance, and Attitudes Toward Seeking Mental Health Services Among Police Officers. Criminal Justice and Behavior. 2016;43(6):759-777.
  11. Wheeler, C., Fisher, A., Jamiel, A. et al. Stigmatizing Attitudes Toward Police Officers Seeking Psychological Services. J Police Crim Psych. 2021;36:1–7.
  12. White AK, Shrader G, Chamberlain J. Perceptions of law enforcement officers in seeking mental health treatment in a right-to-work state. Journal of Police and Criminal Psychology. 2016;31:141-154.
  13. Jones S, Agud K, McSweeney J. Barriers and Facilitators to Seeking Mental Health Care Among First Responders: "Removing the Darkness". J Am Psychiatr Nurses Assoc. 2020;26(1):43-54.
  14. Rodrigues S, Mercier JM, McCall A, Nannarone M, Hosseiny F. “Against everything that got you into the job”: experiences of potentially morally injurious events among Canadian public safety personnel. European journal of psychotraumatology. 2023;14(2):2205332-2205332.
  15. Kim R, Ha JH, Jue J. The moderating effect of compassion fatigue in the relationship between firefighters’ burnout and risk factors in working environment. Journal of Risk Research. 2020;23(11):1491-1503.
  16. Smith TD, DeJoy DM, Dyal MA, Huang G. Impact of work pressure, work stress and work-family conflict on firefighter burnout. Archives of environmental & occupational health. 2019;74(4):215-222.  
  17. Smith TD, Hughes K, DeJoy DM, Dyal MA. Assessment of relationships between work stress, work-family conflict, burnout and firefighter safety behavior outcomes. Safety science. 2018;103:287-292.