First responders, such as police, paramedics and fire-fighters, are repeatedly exposed to distressing situations, violence, trauma and death. They can also face day-to-day workplace stresses, such as heavy workloads, tough shifts, sometimes discrimination and bullying, and simple things such as poor or inaccurate communication.
While these factors can have an immediate detrimental effect on some people, for others the potentially negative impact of their job builds up over weeks, months, even years. The effect of being exposed to challenging situations often compounds over time.
For some, it occurs after they leave their very disciplined employment, which if combined with the absence of the comradeship they enjoyed in their jobs, can have tragic results.
While many first responder agencies have commendable procedures in place to support employees in times of need, sadly, mental illness and suicides are too high with First Responders.
Purpose
The purpose of this paper is to talk about a good practice framework that aims to provide guidance to protect the mental health of First Responders, promote wellbeing and prevent suicide.
We will be looking at:
- strategic and integrated approaches to mental health
- evidence-based frameworks of preventative measures, as well as supportive interventions for first responders
- a positive approach to mental health, by encouraging organisations to actively promote wellbeing as a core part of business
- need for shared responsibility
- key principles for creating mentally healthy workplaces that are high performing and enable each first responder to achieve their best
- practical guidance on how to develop or check an existing strategy to promote the mental health and wellbeing of a first responder workforce
- a comprehensive set of actions across the first responder’s career to assist each organisation to examine their approach to mental health and wellbeing
- guidance about support that can be provided to first responders who develop a mental health condition
Understanding Mental Health
Everyone’s mental health varies during their life. Mental health exists on a broad continuum from positive, healthy functioning at one end through to severe symptoms or conditions that impact on everyday life and activities. Common mental health conditions such as anxiety and depression may be caused by a range of factors including:
* individual factors (e.g. genetics, personality, life experiences) and
* environmental factors (e.g. grief and loss, relationship difficulties, financial problems, job stress).
Mental health is not fixed or static – a person can move back and forth along their own personal range over time in response to different stressors and experiences.
Mental Health & the Workplace
In all occupations there are both protective and risk factors to the physical and mental health and safety of workers. Common risk factors that can affect the mental health of workers in any workplace include:
- heavy workloads
- demanding deadlines and targets
- unclear roles and responsibilities
- low control over how the job is carried out
- challenging work hours
- high emotional, mental or physical demands
- lack of recognition or feedback
- bullying and/or poorly managed behaviours
- discrimination
Personal factors can also affect people’s mental health at work:
* For some workers daily life pressures can accumulate and develop into severe stress
* For others, specific life events such as sudden financial loss or the breakdown of a relationship can act as a trigger and result in severe difficulties functioning at work.
A worker’s mental health and wellbeing at work may be influenced by:
* the job they do
* the environment they are in
* and the social supports and positive activities that exist for them outside work.
A mentally healthy workplace is one that:
* actively minimises risks to mental health
* promotes positive mental health and wellbeing
* is free of stigma and discrimination
* and supports the recovery of workers with mental health conditions, for the benefit of the individual, organisation and community
An Integrated Approach
Evidence indicates that an integrated approach to mental health and wellbeing in the workplace will lead to the greatest benefits for organisations and workers. Integrated approaches draw on the following three key areas of focus:
- Protection – protecting mental health by reducing work-related risk factors for mental health conditions and increasing protective factors
- Promotion – promoting mental health and wellbeing by developing the positive aspects of work as well as workers’ strengths and capabilities
- Intervention – addressing mental health difficulties and conditions among workers, regardless of whether the workplace was a contributing factor
The Mental Health of First Responders
The nature of emergency services work means first responders are likely to:
* be exposed to difficult situations and potentially traumatic events. They may be repeatedly exposed to death, violence, natural disasters, at risk of harm to themselves or their colleagues, or exposed to other challenging situations that may potentially cause indirect trauma. These experiences greatly increase the risk of developing a mental health condition, or can make an underlying issue worse.
* The first responder role comes with a range of organisational stressors. First responders regularly work long hours on shift-work schedules, and are rostered to work at times that others usually spend with family or friends, such as weekends, public holidays, birthdays and Christmas. This can significantly impact their ability to access the support and interaction they need outside of work. This can lead to social isolation and relationship difficulties, which can pose a significant threat to a first responder’s mental health.
*Physical health is closely linked to mental health. First responders can have prolonged periods of low activity or sitting, have trouble ‘switching off’ or experience inconsistent sleeping patterns. They may also have difficulty eating healthily due to the demands of their work making it difficult to take consistent breaks.
Model for Mental Health & Wellbeing
Four key principles:
- Shared responsibility: A strong organisation is a shared responsibility
A shared, collaborative approach to mental health and wellbeing is fundamental to the health of any organisation. Thinking about health, safety and wellbeing should be as natural for everyone in the organisation as thinking about operational business activities.
- Modifying risk and protective factors: Take action at the organisational, team and worker level
First responder organisations need to consider strategies to modify risk and protective factors at the organisational, team and worker level. This is particularly important considering some stressors (e.g. exposure to trauma) are an inherent part of the first responder role. Strengthening protective workplace factors, particularly at the organisational level, should be a priority.
- Strengths-based culture: Build organisational resilience
Mentally healthy first responder organisations take active steps to create and maintain a culture that focuses on worker and organisational strengths. First responder leaders are educated about the benefits of mentally healthy workplaces and contribute to a strong culture by demonstrating positive behaviours and leading by example. Through their words and actions, leaders show that they value all workers, including those who put their hand up to say they are struggling. This focus on strengths and positive relationships helps to build organisational resilience and overcome the challenges that will undoubtedly arise.
- Integrated, holistic approach: A broad focus to promote mental health
Organisations adopting a holistic approach recognise that poor mental health affects organisational productivity and performance, regardless of whether the workplace was a contributing factor. They therefore consider a broad range of risk factors for mental health (organisational, operational, non-work related), common mental health conditions (i.e. anxiety, depression, PTSD) experienced by first responders, and multiple complementary strategies (promotion, prevention, and intervention; organisational and worker directed strategies; and suicide prevention). A truly effective first responder organisation acknowledges the complexity around mental health. It provides a range of ways to promote mental health and wellbeing within the organisation to help workers thrive.
Areas of Action
Five key action areas relating to mental health and well-being that every Australian first responder organisation needs to address.
- Adopt a systematic approach to risk management:
Consider the following broad range of risk factors that affect the mental and physical health and safety of workers: − organisational (e.g. work demands, low levels of control, poor support, bullying, harassment, lack of communication and consultation) − operational (e.g. life-threatening situations, attending fatal road accidents or similar, occupational violence) − environmental (e.g. extreme temperatures when carrying out duties, crowd control and response at public events, hazardous chemicals) − individual (i.e. that people respond to stressors at work in different ways).
- Establish processes to specifically monitor exposure to trauma. Consider screening of workers for PTSD and other mental health difficulties that may potentially arise from exposure to trauma.
- Identify and draw on a broad range of sources to assess risks and develop mitigation strategies. This includes information and data on productivity, rates of absenteeism, separation rates/ turnover, exit interviews, staff engagement/morale, feedback from the public/clients, peak/seasonal demands, analysing incident reports, reviews, de-identified information on claims and Work Health and Safety (WHS) service usage.
- Consult directly with workers and middle/senior managers through surveys, formal consultative processes, regular team meetings, and focus groups to identify and assess risk and discuss and develop solutions. The outcome should be a clear picture of the greatest risks to the health of your organisation or workplace, and a clear understanding of the factors that influence each risk – i.e. your organisation’s risk profile.
- Develop a plan to control the risks identified in your organisation or workplace as much as reasonably practicable, that consists of interventions aimed at: − Primary intervention – addressing the workplace factors that are risks of psychological injury and promoting protective factors (e.g. enhancing leadership capability, increasing job control, enhancing organisational justice, building an environment of positive social and emotional wellbeing) − Secondary intervention – minimising the impact of stress on workers by responding to warning signs and intervening early − Tertiary intervention – implementing safe and effective rehabilitation and return to work plans.
Monitor and review the effectiveness of your risk management measures to ensure they are working as intended. Managing work-related risks to mental health and wellbeing is not a one-off exercise but rather a core component of effective ‘business as usual’ management of any organisation.
- Develop and implement a mental health and wellbeing strategy
- Develop a clear and overarching strategy based on an integrated approach to mental health and wellbeing, incorporating policies, programs and practices that address your organisation’s specific risk profile.
- Ensure front line workers are involved in the planning, development, implementation and evaluation of the strategy. A top down approach with no worker input will not be successful.
- Aim to include worker representatives in the development of the strategy.
- Within your overarching strategy, develop and communicate policies, programs and practices to promote mental health and wellbeing at each phase of the first responder’s career. They should address areas such as work health and safety, equal opportunity, bullying, privacy, stay at/return to work, educating and preparing the workforce at all stages and levels, responding to workers at risk, organisational values and code of conduct, suicide in the workforce and critical incident response, etc.
- Incorporate mental health into the regular risk assessments undertaken across the organisation.
- Conduct regular evaluations of the initiatives being implemented by the organisation. Ensure these include measures with a preventative focus (such as reduction of risk factors to mental health, audits and training) as well as traditional measures (e.g. worker’s compensation claims and costs). Feed the findings into regular review and improvement cycles of the overall strategy.
- Develop leadership capability
- Develop the leadership capability of leaders and managers by providing mandatory career progression training focusing on people management skills and mental health in the workplace (e.g. creating mentally healthy workplaces, preventing mental health conditions in the workplace, identifying workers at risk and supporting those with mental health conditions).
- Focus training and development on positive, proactive leadership practices such as: − providing constructive feedback on worker strengths and areas of improvement − giving clear direction and advice and clarifying role requirements and expectations − dealing with difficult situations (including conflict) proactively, decisively, promptly and objectively − offering formal and informal opportunities for learning and development − providing positive direction and assisting workers to identify opportunities during times of change promoting trust, honesty and fairness by making fair and just decisions as transparently as possible − promoting a sense of belonging and social wellbeing at work − enhancing the meaningful aspects of work by promoting the organisation’s mission statement and communicating how workers’ roles contribute to the organisation’s mission and purpose.
- Take action to reduce stigma
Include stigma-reduction activities within your organisation’s risk management strategy and mental health plan. Examples include the following:
- Invite people (ideally other first responders) with a personal experience of recovery and management of mental health conditions, self-harm and/or suicide, to share their stories in the workplace.
- Encourage senior leaders and line managers to speak openly about mental health in the workplace.
- Ensure senior leaders actively endorse and participate in activities aimed at reducing stigma.
- Have zero-tolerance for discrimination against first responders who seek assistance for a mental health difficulty or have been diagnosed with a mental health condition. Set clear expectations that behaviour which reinforces stigmas and stereotypes is not acceptable and outline how the organisation will respond.
- Establish a track record of supporting first responders with mental health conditions to stay at or return to work by providing reasonable adjustments (as required under anti-discrimination legislation).
- Regularly and through multiple channels, provide information to staff about available services and supports. Ensure volunteers and family members know where to access this information.
- Promote events such as R U OK? Day, World Mental Health Day and Movember, to affirm mental health is an important part of the workplace and encourage open conversations.
- Regularly update all staff on what the organisation is doing to promote mental health and wellbeing.
- Demonstrate visible, active commitment to mental health in the organisation (e.g. conduct regular worker surveys, promote work-life balance where possible, encourage social events that promote wellbeing and strengthen the culture of the workplace).
- Consider how family members can be included in all the above initiatives, including inviting them to attend events.
- Educate and prepare your workforce
Include mental health education and training from the recruitment stage through to transitioning to retirement. Training may cover a broad range of topics across worker and organisational levels.
- Worker-focused programs can include: − understanding signs and symptoms of common mental health conditions − suicide risk − psychological first-aid − self-care and positive coping strategies − resilience and positive psychology − leadership development − mentor programs − information about physical health such as sleep deprivation, poor nutrition, excessive alcohol and caffeine consumption, impact of changes in adrenaline, lack of exercise, etc.
- Programs that focus on building organisational capacity can include: − prevention of indirect trauma − suicide prevention − anti-bullying training and practical skills for managing conflict − skills development to ‘help your mates’ and have a conversation with someone who may be struggling or at risk − practical language and behaviours to use to reduce stigma in the workplace − anti-discrimination education − legal roles and responsibilities regarding mental health in the workplace.
- During recruitment, orientation and on-boarding, provide recruits with a well-considered preview of what they can expect from the job and how it may affect them. Ensure this is paired with support and debriefing.
- Review the organisation’s training calendar to ensure a range of mental health-related training is regularly included. Provide regular training courses and refreshers across the entire workforce, including volunteers and rural first responders.
- Provide education and training to match the different phases of the first responder’s career (see ‘Promotion and development’ in the next section).
- Wherever possible, include face-to-face or video contact with first responders with personal experience relevant to the new knowledge or skill-set being studied.
- Ensure all training reinforces key messages such as ‘everyone can experience ups and downs with their mental health’, and ‘it’s always better to take action early on rather than let a situation fester and worsen’.
Suicide Awareness & Prevention in First Responders
Between July 2000 and December 2012 death by suicide was attributed to 110 police officers, paramedics and fire-fighters in Australia.
There are many reasons why someone considers suicide, which can be quite complex, but there are certain factors that may help us determine whether a person could be at risk of suicide. These can include:
- mental health conditions – e.g. depression, anxiety, post-traumatic stress disorder (PTSD)
- severe life stresses – e.g. loss of job or high job stress
- relationship difficulties
- long-term problems associated with exposure to abuse or trauma
- chronic pain and/or illness
- loss, feelings of failure
- financial hardship
- alcohol and/or substance abuse
- physical disability
Suicide prevention starts with recognising the warning signs and taking them seriously. Having open conversations can make a real difference. It can be particularly powerful to encourage first responders who have experienced self-harm, suicidal thoughts and/or behaviours, and recovered, to share their stories with others. Encouraging these kinds of conversations is a powerful tool to reduce the fear and silence surrounding suicide and ultimately prevent deaths by suicide in the workforce.
- Promote mentally healthy workplaces that address risk and protective factors, prioritise mental health and safety, destigmatise mental health conditions and encourage help-seeking.
- Invite people (ideally other first responders) with a personal experience of recovery and management of self-harm and/or suicide, to share their stories in the workplace.
- Conduct suicide awareness and prevention campaigns to highlight the warning signs and the key resources available to workers at risk, or for colleagues looking out for one another.
- Provide specific suicide prevention training to all staff. This training should form part of induction, as well as regular refresher courses. Training should include mental health first-aid, warning signs of suicidal behaviour and knowing what to do and how to respond to colleagues at risk.
- Make suicide counselling services available if a death in the workforce occurs. It is important that workers are provided with support following the death of a colleague to help them with their grief and provide advice on how to manage the impact it may have on them at work
Stay at work/return to work
- First responders with a mental health condition may require extra support to stay at or return to work. Any stay at work/ return to work plan should be tailored to the worker’s needs, incorporate any reasonable adjustments to their job, and be developed in collaboration with the worker. Parties responsible must first understand the worker’s abilities at this point in time and the requirements of the job.
- Ensure managers are familiar with organisational protocols regarding training requirements upon returning to work – for example, inductions, re-training or refresher courses, or rostering with a supervisor. These can help people return to work more effectively.
- Promote a culture of recovery where improvement is considered likely in most cases, and temporary adjustments are highly unlikely to become permanent.
- Prepare an agreed return to work plan to provide clarity around expectations and timeframes.
- Provide flexibility, where possible, regarding work hours and tasks for people returning to work. This may include allowing time off to attend appointments and providing reduced work hours. A graduated return to work approach allows a person to transition carefully, while they prepare for the role/or move to the next phase of their working life.
- Identify opportunities for non-operational/alternative duties to reduce exposure to trauma, where this is a contributing factor.
- Ensure the manager of a first responder who have a stay at work or return to work plan regularly checks in to ensure any workplace stressors are being addressed properly and appropriate supports provided.
Peer Support
Peer support is worker support provided by a trained group of fellow workers, as part of a formalised peer support program. The relationship is not intended to be a therapeutic one. It is a contact, support and referral service with an emphasis on brief, practical interventions.
- Ensure the organisation has an integrated, coordinated peer support program in place. The program should be available to all staff at all stages of their career.
- Review the recruitment and selection process for peers, ensuring only suitable peer-nominated first responders are selected for the program.
- Ensure peers with a range of life experiences, including personal experience of mental health conditions and recovery, are included in the program. Peers with a personal experience are a powerful resource and can offer understanding and hope to colleagues who may be struggling to cope.
- Develop a code of conduct for peers to assist with role clarity and boundaries, including confidentiality and privacy.
- Provide comprehensive, high quality training for new peers, with regular refresher training and annual reviews of peer support officer competency. Training should include, but not be limited to, mental health first aid.
- Make special efforts to ensure peer support is available and accessible to volunteer and rural workforces as these groups may experience additional challenges due to their social and geographical isolation.
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