Post-traumatic stress among rescue workers after terror attacks in Norway

Abstract

Introduction

On 22 July 2011, Norway was struck by two terror attacks. A car bomb exploded in the government district of Oslo. Eight people were killed, 12 were admitted to hospital and ~80 were treated in the accident and emergency outpatient clinic [ 1 ]. The government district emerged as a war zone with ongoing fire and risk of collapsing buildings. About 2h later, there was a single terrorist shooting at a Labour Party youth camp on Utøya Island. Ambulance personnel were held back until the police had secured the area. In the meantime, civilians rescued victims from the water. About 500 adolescents and young adults were at the camp [ 2 ]. Sixty-nine were killed, and many were admitted to hospital or treated in outpatient clinics [ 1 , 3 ]. At Utøya, rescuers experienced ongoing shooting. For weeks, general health care providers treated patients with multiple gunshots or blast injuries, and psychosocial personnel treated survivors, next of kin and the bereaved.

First responders and health care providers experience traumatic events, witness suffering and perceive threat. With training and experience, they develop skills and become emotionally prepared [ 4 ]. Even so, they usually report more post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) than the general population [ 5 ]. Typical features include intrusive memories, detachment and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. A 10% prevalence of PTSD in rescue workers worldwide has been reported, but the prevalence differs between and within groups: such as police officers (<10%), firefighters, ambulance personnel and health care providers (up to 20% for all groups) [ 5 ].

Possible PTSD was found in ~12% of firefighters and emergency medical personnel, and 6% among police officers after the 2001 World Trade Center (WTC) terror [ 6 ], and in 1% of the policemen after the Madrid attacks [ 7 ], and in 4% of the ambulance personnel after the 2005 London bombings [ 8 ]. Female gender has been associated with PTSD in studies of civilian survivors of traumatic incidents [ 9 ], but not in police [ 10 ], combat veterans [ 9 ] or WTC rescue, recovery and cleanup workers [ 11 ]. One study of police officers working after the WTC terror [ 12 ] found a prevalence of possible PTSD in 14% of women and 7% of men.

There are contradictory findings about risk factors for PTSD in rescue workers, although high levels of exposure, assisting survivors and shortage of supplies and resources are predisposing factors [ 13 , 14 ]. Perceived personal threat is an additional risk factor [ 15 ]. There is also disagreement whether previous experience with disasters or repeated traumatic experiences [ 13 ], preparation and training [ 16 ], longer job experience and age [ 5 , 17 , 18 ] are risk or protective factors. Work-related/organizational factors such as lack of support [ 15 ], low degree of job security and role clarity have also been associated with post-traumatic distress.

Random untrained people who happen to be in the terror/disaster area may voluntarily try to perform similar tasks as professionals [ 19 ], but few studies of unaffiliated civilian people have been published. Significantly higher possible PTSD was found in student volunteers compared with professional rescuers after the Bam earthquake in Iran [ 20 ], in volunteers compared with professional rescue workers after a bus crash in Norway [ 21 ] and among unaffiliated volunteers after the WTC attacks [ 6 ]. A higher prevalence of PTSD has been found in volunteer firefighters compared with professionals. Training and experience were highlighted as protective factors [ 22 ]. A review showed PTSD prevalence between 24% and 46% in volunteers, quite similar to disaster victims [ 19 ]. Severity of exposure, lack of support after the event and identification with the victims were associated with mental health complaints.

Terrorism still occurs rarely in the Western world and few studies compare responses from different occupational groups with scores from unaffiliated volunteers. Large-scale disasters, like the terrorism in Norway, provide a unique opportunity to study stress reactions in different groups exposed to the same event. Thus, the main aims were to study firstly the level of PTSS 10 months after a terror attack in different professional rescue personnel and unaffiliated volunteers and secondly the associations between demographic, exposure and work-related variables and PTSS in these groups of rescue personnel.

Methods

This cross-sectional study concerned personnel involved in the rescue and health care service for victims and their next of kin after the terrorist attacks in Norway on 22 July 2011. Professional personnel and unaffiliated civilians involved in the rescue work from 22 July to 5 August 2011 were invited ( Tables 1 and 2 ). Questionnaires were distributed between March and June 2012, ~8–11 months after the terror attack (mean 10 months). A leader within each participating unit was appointed to distribute and collect the questionnaires. The completed questionnaires were dropped anonymously into a sealed box. To obtain an overview of the response rate, each leader was asked to keep records of the number of distributed and submitted questionnaires. A reminder was distributed after 1 month. Returning the questionnaire was taken as implied informed consent.

Personnel and volunteers from six groups participated: general health care providers (physicians, nurses/nurse assistants, paramedics, other personnel working in hospital); psychosocial health care providers (psychiatrists, psychologists, counsellors [priests, other employees of the church and imams], social workers, nurses); police officers; firefighters and affiliated volunteers (Norwegian Civil Defence, the Home Guard, Norwegian Search and Rescue Dogs and Norwegian People’s Aid). These affiliated volunteers are trained to assist in various rescue operations. Unaffiliated volunteers were people who happened to be at the campsite next to Utøya Island or working at the hotel hosting next of kin.

This paper presents the main findings from the study of Norwegian rescue personnel working after the terror attacks. Two papers have previously been published [ 23 , 24 ].

Previous occupational training and experience were assessed by three questions: (i) Have you had former working experience in similar tasks? (ii) Have you had former training based on simulation? and (iii) Have you ever participated in disaster drills before this mission? Response alternative was no/yes (see other response alternatives in Table 3 ).

Role clarity was assessed with two questions: (i) Were you acquainted with your job tasks/work responsibilities? and (ii) Did you perform work tasks with sufficient means and resources? A five-point Likert scale was used (1 = not at all – 5 = to a very high extent). In the regression analysis, a median split of 4.0 was used on Item 1, and a median split of 2.0 on Item 2.

Four items addressed organized support provided from employer: (i) debriefing, (ii) psychiatrist and psychologist, (iii) other/meetings and (iv) gatherings ( Table 3 ). The response alternative was yes/no. The items were collapsed into one item and then dichotomized into 0 = I have not received any offers of support and 1 = I have received support.

Appreciation was measured with three questions: from the organization, family/friends and authorities ( Table 3 ). The items were scored on a five-point Likert scale (1 = not at all–5 = to a very high extent). A one-factor solution was found.

Satisfaction with the rescue work was assessed with seven questions, such as: (i) It was a success, (ii) It was meaningful, (iii) You (or your colleagues) fell short regarding work tasks, (iv) You/your group was obstructed (e.g. bureaucracy, lack of equipment, unclear messages), (v) There was competition between you (or your team) and other participants, (vi) Did you get sufficient advice and support during the work and (vii) Did you stretch yourself too far because high effort was expected (e.g. no breaks, worked beyond your personal limits). A five-point Likert scale was used (1 = not at all–5 = very much). A two-factor solution was found: successful = Items a, b and f and obstructed = Items c, d, e and g.

Seven questions measured witnessing: (i) people who could not make contact with their next of kin, (ii) people in despair at the campsite, (iii) victims with major physical injuries, (iv) fatalities, (v) physical contact with fatalities, (vi) body parts and (vii) strong smells or other perceptions. A two-factor solution was found: witnessing (i) people in despair and (ii) people with major injuries/fatalities. One item assessed possible threat: Did you experience fear of explosion/shooting? Response alternatives were 0 = no, not experienced; 1 = yes, but not stressful; 2 = yes, moderately stressful and 3 = yes, very stressful. The variables were dichotomized (no, not experienced/yes, I have experienced this) ( Table 4 ).

The PTSD Checklist (PCL) is a widely used 17-item self-administered measure of symptoms needed for a possible PTSD diagnosis (range 17–85) [ 25 ]. In this study, the Norwegian version was used [ 26 ]. A cut-off score >31–38 seems to identify most PTSS cases [ 27 ], and a cut-off score of 50 has been used as an indicator of possible PTSD ( Table 4 ) [ 26 ].

The data are presented as means with 95% confidence intervals, or percentages. There were few missing data (0.5–5%). Where appropriate, the variables were dichotomized. Chi-square and Kruskal–Wallis tests were used to compare proportions, and analysis of variance compared means between groups. A linear regression analysis was performed with PCL sum score as outcome. SPSS (version 21.0, SPSS, Chicago, IL) was used.

The data protection officer at the Oslo University Hospital was contacted before the study began and replied that we did not need further approval from the regional ethics committee since the data were collected anonymously. The data were stored on the research server at the hospital.

Results

A total of 2922 questionnaires were distributed. The overall response rate was 61% ( N = 1790). Participants were general health care providers ( n = 858), psychosocial health care providers ( n = 214), police officers ( n = 253), firefighters ( n = 102), affiliated volunteers ( n = 307) and unaffiliated volunteers ( n = 56). The Norwegian Red Cross organization declined to participate. There were significantly different response rates between the groups ( Table 1 ).

For most rescue workers, the work started on 22 July. Ninety-seven per cent of the firefighters and 64% of unaffiliated volunteers worked at the site of terrorism but none of the psychosocial personnel ( Table 2 ). Most of the unaffiliated volunteers worked <24h, whereas a large number of health care providers and police officers worked for more than a week.

Approximately two-thirds of the professionals probably were able to handle the rescue work due to previous training, experience with similar work tasks and disaster drills, and more often than the psychosocial personnel ( Table 3 ). Unaffiliated volunteers, psychosocial personnel and police officers reported to a lower extent that they knew their work responsibilities (role clarity) compared with the other groups ( M = 3.1 versus 3.6 versus 3.9, respectively, versus the other groups M = 4.2, P < 0.001) ( Table 3 ).

Police officers and the unaffiliated volunteers reported that they had less adequate means and resources ( M = 2.8 and 2.9, respectively, compared with all other groups: M = 3.7 –4.1, P < 0.001). Unaffiliated volunteers rated their performance (satisfaction) during the rescue work as less successful compared with general health care personnel, firefighters and affiliated volunteers ( M = 3.6 versus M = 4.0, P < 0.001), and the police officers rated the rescue work to be more obstructed compared with the other groups ( M = 2.4 versus all other groups: M = 1.8–2.2) ( Table 3 ).

Unaffiliated volunteers had significantly more stress symptoms than the professional rescue workers (PCL score: unaffiliated volunteers, M = 32.4 versus all other groups, M = 20.5, P < 0.001) ( Table 4 ). About 15% of the unaffiliated volunteers had symptoms at a poss ible PTSD level (PCL > 50) compared with 0.2–2.0% among the professionals. More women had stress symptoms at a PTSD sub-threshold level (PCL 35–49) among police officers (female gender 6% versus men 1%), affiliated volunteers (female gender 3% versus men 2%) and unaffiliated volunteers (female gender 35% versus men 15%). The corresponding figures for possible PTSD level (PCL > 50) were police officers: 1% versus 0%; affiliated volunteers: 4% versus 0% and unaffiliated volunteers: 25% versus 9%. For all groups, P <0.05.

More psychosocial personnel and unaffiliated volunteers reported witnessing people in despair (59% and 96%, respectively). Of those, 7% of psychosocial personnel and 15% of unaffiliated volunteers reported this as very/extremely stressful. More general health care providers, firefighters and unaffiliated volunteers reported that they had witnessed people with major physical injuries/fatalities (78% versus 89% versus 81%, respect ively). Of those, 4% of general health care providers, 6% of firefighters and 16% of unaffiliated volunteers reported this as very/extremely stressful. Firefighters and unaffiliated volunteers also reported fear of explosion/shooting (62% versus 72%, respectively). Perceiving this as very/extremely stressful was reported by 9% and 33%, respectively.

In the unaffiliated volunteers (47%) and the affiliated volunteers (65%), a significantly smaller proportion reported that they had been offered/received support after the work was completed. The highest proportion of ‘offered assistance’ was found in firefighters (95%). There were no significant differences in PCL scores among those who received debriefing, had seen a psychiatrist/psychologist or had not been offered organized support.

As shown in Table 5 , 12 variables were bivariately associated with PTSS. The multivariate analyses showed that female gender (β = 1.7), witnessing physically injured/dead people (β = 2.0), witnessing people in despair (β = 0.6), fear of explosion/shooting (β = 1.1), perceiving the rescue work as obstructed (β = 1.6), being affiliated (β = 1.0) or unaffiliated (β = 8.4) volunteers were independently associated with PTSS. Previous work experience (β = −0.9) protected against PTSS.

We explored the gender differences using different PCL cut-off scores. A PCL cut-off score of 35 showed significant differences between police officers, affiliated and unaffiliated volunteers ( P < 0.05). A cut-off score of 50 showed a significant difference between gender ( P < 0.05) in affiliated volunteers.

Discussion

The levels of PTSS across professional groups were low except for the unaffiliated volunteers. Associations with PTSS were female gender, less preparation, more exposure, perceiving obstruction in work and being affiliated and unaffiliated volunteers. Most professionals were experienced and prepared, unlike the unaffiliated volunteers.

The low prevalence of PTSD in professional personnel is consistent with the findings after the tsunami in 2004 [ 16 ] and after the terror attacks in Madrid [ 7 ], somewhat lower than after the 2005 London bombings [ 8 ], and much lower than after the terror attacks in WTC [ 6 , 28 ]. The time points differed in the studies. In our study, most respondents started work on 22 July, while the destruction was ongoing. This is in contrast to the Thoresen study after the Indian Ocean tsunami. Compared with the WTC terror attacks, professional rescue workers in Norway had a shorter duration of exposure, no colleagues died and few were physically injured. In Norway, there was massive material destruction, but not to the extent seen after the WTC attacks or the Indian Ocean tsunami. The rescue workers in WTC may also have perceived a stronger threat to self, which may partly explain the high level of PTSD.

The PTSD level in unaffiliated volunteers in the present study (15%) is lower compared with unaffiliated volunteers after the WTC attacks (21%) [ 6 ], students volunteering after the Bam earthquake (34%) [ 20 ] and recovery and instrumental volunteers after the Swissair flight 111 disaster (46%) [ 29 ]. Still, unaffiliated volunteers had a markedly increased risk for post-traumatic stress when compared with professional rescue workers. Possible explanations could be high disaster exposure in combination with lack of training and experience [ 19 , 22 ]. Other explanations could be low degree of role clarity [ 30 ], little access to resources, perceived obstruction in work or limited work success. In fact, all these factors were associated with post-traumatic stress in our study. Nevertheless, adjusting for these factors in a multivariate analysis only led to a minor change in the differences between rescue groups, indicating that differences between rescue groups in the risk of PTSD may be independent of work-related factors examined in our study.

Comparing professional rescue workers and unaffiliated volunteers exposed to the same event is a strength of the study, as was the high number of participants. Even though a formal diagnosis of PTSD cannot be based on self-assessments, studies have shown a good relationship between PCL-S and other formal methods for diagnosing PTSD. Conducting interviews would probably not have changed our main finding that the level of post-traumatic stress was low among the professional groups and high among the unaffiliated volunteers.

We did not conduct a prospective study with at least two time points to study changes over time. It is likely that the levels of symptoms had been higher shortly after the event. By assessing the symptoms after almost 1 year, the long-term effects of the event were demonstrated. This could probably have influenced the response rate. The low response rate among unaffiliated volunteers (46%) is a limitation in terms of generalization for this group. The non-responders, particularly among the unaffiliated volunteers, may suffer from higher levels of PTSS and may have received insufficient support or counselling. We have no data to verify this. There were only minor differences between the professional groups with high or moderate response rates, so it is unlikely that the non-response rates influenced the main findings of the study. For the firefighters, we are more certain that the data can be generalized. For the other groups, the response rate was higher than in some studies [ 11 , 13 ], similar to some [ 16 ] and lower compared with other.

Few professionals reported high levels of PTSS, while unaffiliated volunteers were affected. Female gender was associated with more PTSS as well as less preparation, more exposure, perceiving obstruction in work and being affiliated and unaffiliated volunteers.

The unaffiliated volunteers were more vulnerable to post-traumatic stress than professional rescue workers. In planning and monitoring rescue work, this must be taken into account together with role clarity and sense of achievement. In addition, organizations should reinforce training and experience since preparedness has a significant impact on handling stressors.

Funding

The South-Eastern Norway Regional Health Authority funded the study (grant number 2012108). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Conflicts of interest

None declared.

References