The role of psychological screening for emergency service responders

Noreen Tehrani (Noreen Tehrani Associates, Twickenham, UK)
Ian Hesketh (University of Manchester, Manchester, UK)

International Journal of Emergency Services

ISSN: 2047-0894

Publication date: 7 May 2019

Abstract

Purpose

The purpose of this paper is to examine the role that psychological screening and surveillance can take in improving the delivery of psychological support to emergency service responders (ESRs) at a time of increasing demands and complexity.

Design/methodology/approach

The study aims to present and discuss the use of psychological screening and surveillance of trauma exposed emergency service workers.

Findings

The evidence supports the use of psychological screening and surveillance using appropriate validated questionnaires and surveys.

Research limitations/implications

The findings suggest that emergency services should be using psychological screening and surveillance of ESRs in roles where there is high exposure to traumatic stress.

Originality/value

These findings will help emergency service organisations to recognise how psychological screening and surveillance can be used as part of a wider programme of well-being support. This approach can also help them meet their legal health and safety obligations to protect the psychological health and well-being of their ESRs.

Keywords

Citation

Tehrani, N. and Hesketh, I. (2019), "The role of psychological screening for emergency service responders", International Journal of Emergency Services, Vol. 8 No. 1, pp. 4-19. https://doi.org/10.1108/IJES-04-2018-0021

Publisher

:

Emerald Publishing Limited

Copyright © 2018, Emerald Publishing Limited


Introduction

UK Emergency Services have entered a period of unprecedented change, at a time of reduced budgets (National Audit Office, 2015a, b), reduced manpower (HMIC, 2016), increasing demands (National Audit Office, 2017) and changes to the terms and conditions for their workers (Hutton, 2011; Winsor, 2012). The pace of these changes makes organisational and operational adjustment difficult (Winsor, 2012; Berger et al., 2012, Simcock, 2015; National Audit Office, 2017). In addition, emergency service responders (ESRs) are dealing with mounting threats from terrorism, natural and man-made disasters at a level and intensity rarely experienced in the past. There are pressures to increase joint working between emergency services, both strategically (HM Government, 2016) and operationally (ESCWG, 2016), with firefighters, police and paramedics taking over aspects of each other’s roles. This move has not been without opposition (FBU, 2015), with firefighters and police finding the emotional labour of dealing with health-related emergencies, whilst surrounded by distressed and grieving families, difficult to handle. A freedom of information request to all the UK police forces (BBC, 2016) has shown that the combination of reduced resources, increased pressure and complex demands has led to higher levels of sickness absence and difficulties in the recruitment and retention of workers (National Health Executive, 2015).

The roles of those working in emergency services fall into three main categories (College of Policing, 2017). The first category is the frontline responders who are regularly involved in responding to incidents ranging from recovering stolen bicycles, transporting patients or checking smoke alarms, to dealing with murder, serious injuries, major fires, domestic violence, suicides and cot deaths. These same responders are often the first at the scene of major incidents such as terrorist attacks, rail crashes, riots and explosions. The main characteristic of traumatic exposure for the frontline responders is the unpredictability of the incidents they are required to handle. Emergency responders have little time to prepare to meet the operational and emotional demands of the incident, with the result that their ability to cope can become overwhelmed (Tehrani and Piper, 2011). The psychological impact of attempting to meet extreme physical, cognitive and emotional demands of a crisis can be the development of acute stress disorder, which may lead to post-traumatic stress (Halpern et al., 2009; Shakespeare-Finch, 2011).

The second category of ESRs includes those working in roles involving intense exposure to psychological hazards. These specialists ESRs use their technical skills in high psychological risk areas of work. In policing these may include online child abuse, domestic violence, firearms, undercover work, accident investigations or family liaison. In these specialist roles the psychological risks are inherent to the role, creating a responsibility on the organisation to meet its legal duty of care to protect the well-being of these workers. This duty requires the emergency service to have plans and procedures in place to identify, monitor, reduce and respond to psychological hazards (Management of Health and Safety Regulations, 1999). ESRs working in specialist roles may experience compassion fatigue due to emotional exhaustion created by the practical and emotional demands placed on them by distressed people. ESRs can also develop secondary trauma created by being exposed to victims of abuse or other forms of trauma. The symptom of secondary trauma is similar to those experienced by the primary trauma victim (Stamm, 2010). Compassion fatigue and secondary trauma can go unnoticed, unrecognised and untreated, culminating in the ESR finding themselves unable to cope due to the long-term psychological harm caused by their work (Weiss et al., 2010).

The third category is made up of response and specialist ESR deployed to deal with a major disaster. Emergency services are well versed in handling the operational and practical challenges of major fires, floods, transport collisions and terrorist attacks involving mass death and casualties (Slottje et al., 2008; Brooks et al., 2017). Comprehensive emergency preparedness guidance (Cabinet Office, 2012) sets the framework for civil protection dealing with preparation, management and prevention of emergencies. However, emergency services are less well prepared for dealing with the human impact of a disaster on their ESRs who are involved in disaster responses. Whilst most ESRs will handle the psychological impact of dealing with the demands of a major disaster, many will become affected, at least in the short term (Tehrani, 2016a).

This paper has four aims:

  1. to explain how physical and psychological screening and surveillance can be used in emergency response organisations;

  2. to provide an outline on meeting the needs of the response, specialist and disaster facing ESRs;

  3. to describe the range of tools available to be used in screening and surveillance; and

  4. to discuss the reasons for introducing psychological screening and surveillance into emergency services.

Use of screening and surveillance

Health surveillance and screening has been used in emergency services to provide evidence to assist in the assessment, monitoring and support of ESRs fitness for work. Surveillance adopts a systematic approach to the early identification of work-related ill health or injury (McFarlane and Bryant, 2007; Dantzker, 2011; Mouthaan et al., 2014; Carleton et al., 2017). The Management of Health and Safety at Work Legislation (1999) legislation provides the framework with a specific reference to the need for surveillance:

Every employer shall ensure that his employees are provided with such health surveillance as is appropriate having regard to the risks to their health and safety which are identified by the assessment

(Point 6).

Surveillance falls within the wider Risk Control and Management Cycle in which organisations are required by law to identify risks, establish who might be harmed, to evaluate the magnitude of the risk and to identify ways to mitigate or reduce the risks (IOSH, 2016). Occupational surveillance shares some of the features of clinical research, but is not designed to generate or create new scientific knowledge. Rather, it uses existing knowledge and research to prevent disease or injury, enhance resilience and increase well-being in employees who may become exposed to an identified health hazard (Otto et al., 2014). A review of the risks inherent in organisations (European Agency for Safety and Health at Work, 2011) identified a range of hazards found in emergency services, including physical exposures to radioactive, chemical and biological substances in addition to physical injuries caused by physical violence, needlesticks and injuries caused by knives and firearms. In addition to the physical hazards, the agency identified several psychological hazards. These include exposure to disasters, dealing with multiple deaths, body recovery, transport accidents, terrorism, fires, shootings and other threats to life. Psychometric testing is used for different purposes, in emergency services tests are often employed in pre-employment screening to assess a candidate’s psychological fitnessto carry out their roles. The College of Policing (2015) has established standards for pre-employment screening which include an assessment of physical and psychological fitness, together with tests of aptitude and mental capacity. ESRs are required to have regular in-post checks of their stamina, sight and hearing (e.g. College of Policing, 2014).

The use of screening in psychological surveillance is different to the psychometric testing that takes place pre-employment. In contrast to the one-off pre-employment tests, psychological surveillance is an ongoing process used to assist in the maintenance of a healthy workforce where the results allow for ESRs to be tracked over time, identifying those with signs or symptoms indicative of actual or imminent psychological difficulties.

The screening debate

The UK Psychological Trauma Society (2014) produced guidance suggesting that “there is no reliable evidence to support the use of any formal pre-enlistment screening processed based upon psychometric testing or profiling of candidates for trauma prone roles”. The UKPTS acknowledged that where a role required occupational health to surveillance the assessment should be carried out by a health care with an understanding of traumatic stress. Other researchers, mostly working with the UK military (Jones et al., 2003; Greenberg, 2015), suggest that pre-employment screening is ineffective in reducing or predicting PTSD. A study by Rona et al. (2006) found that in the military the pre-deployment screening was ineffective in predicting the post-deployment onset of mental health disorders or PTSD and that pre-deployment screening could adversely affect the career of those identified as vulnerable (Jones et al., 2003). Whilst the authors of this paper recognise the use of personality profiling to select candidates in terms of their future vulnerability to develop mental health problems is inappropriate, where screening identifies current symptoms of PTSD, anxiety, depression or burnout there would be a failing in the organisation’s duty of care to allow these candidates to proceed in the recruitment process without at the least a meeting with an occupational health professional to discuss the potential dangers. Whilst historic child abuse, neuroticism and introversion have been shown to be related to an increased incidence of clinical symptoms, most people can undertake their roles effectively and without causing themselves undue harm (Tehrani, 2016a, 2018).

The negative view of screening is challenged by US military researchers (Castro, 2014; Milliken et al., 2007), who utilise screening for the early identification of mental health problems, and in programmes of education and support. A study by Milliken et al. (2007) found that psychological screening identified 20.3 per cent of active soldiers required mental health treatment of which 60 per cent sought care within 30 days of screening. The US military are using screening to increase well-being and resilience by reducing psychological stigma and barriers to seeking support (French et al., 2004). Wright et al. (2007) described psychological screening as one of the most widely used ways to identify (US) military personnel who might need help for a mental health issue.

Meeting the needs of emergency service responders (ESRs)

Frontline responders

The largest group of ESR is the frontline responders. For this group the nature and frequency of the traumatic exposure is difficult to predict. However, the types of the traumatic events causing trauma responses together with the organisational and personal factors that increase vulnerability are largely understood (Skogstad et al., 2013; Skeffington et al., 2017). As frontline responders do not face predictable traumatic events it is inappropriate for them to be part of a surveillance programme, as their results can provide data which can be misleading and costly (HSE, 1999). Therefore, the responsibility for the psychological well-being of frontline responders falls to their line manager and the ESRs themselves. The line managers of frontline responders need to be trained in identifying the signs of mental health problems (including traumatic stress), to have the skills to talk to their team about any personal difficulties, personal resilience and to create an environment where open discussion of work-related problems is seen as a strength rather than a weakness (Hesketh and Cooper, 2017a). The frontline responders need comprehensive induction training to prepare them for the nature of their role and the incidents that may cause a trauma response (Castro et al., 2006), they also need to be able to recognise symptoms of trauma in themselves and others. A study undertaken for the Health and Safety Executive by Mitchell and Stevenson (2000) found that supportive supervisors with a positive management approach, a workforce educated in the recognition of psychological signs and symptoms, together with flexible psycho-social support, reduced the likelihood of psychological problems. When a frontline responder returns from a shift it is important that time is made available for them to be demobilised by their line manager. The demobilising process takes between 5 and 10 min (Tehrani, 2014). If the team leader recognises that a responder has been seriously affected by an incident there may be a need to arrange a longer demobilising session, which provides the responder with an opportunity to talk about the incident that has caused the difficulty, and to be provided with helpful psycho-education and advice (Tehrani, 2014). Where responders continue to struggle, their line manager should make a referral to occupational health, who can refer the ESR for psychological screening to identify if there is a need for a psychological assessment or other supportive intervention. The provision of organisational demobilisation and defusing following a traumatic incident has been shown to meet several needs for teams, by providing support that is highly valued by workers; an opportunity to identify workers requiring clinical support; an increase in level of social cohesion; a reduction in harmful responses, e.g. alcohol abuse; a reduced levels of sick-leave; and increased performance (Creamer et al., 2012).

Specialist responders

There is a relatively small group of ESRs, who are employed in roles which continually expose them to psychologically distressing or demanding conditions. Risk assessments have identified the roles which carry the highest psychological burden. In policing, for example, these include: family liaison, call handling, undercover investigations, public protection, viewing online images of child abuse, firearms, hostage negotiators and body recovery. Emergency services have to respond to the needs of these ESRs by introducing mandatory risk assessments, psychological screening and support to meet their duty of care (Management of Health and Safety Regulations, 1999). Craun et al. (2014) undertook research to examine the level of secondary traumatic stress in law enforcement officers involved in the investigation of sex offences, and found that the development of PTSD, secondary trauma and compassion fatigue was reduced where there was positive supervisor support, and increased where there were high levels of denial. Research by Carleton et al. (2017) involving the screening of 5,813 Canadian ESRs (police, paramedics, firefighters and prison officers) for PTSD, anxiety, depression, social anxiety, panic disorder and alcohol abuse found that there was an indication of at least one of the disorders in 44.5 per cent of the ESRs. Wortley et al. (2014) studied internet child abuse investigators. This study used a combination of screening questionnaires and interviews which showed that whilst the majority had no clinically significant symptoms, there were a number experiencing significant levels of PTSD, a risk that appeared to increase over time. Whilst these research projects on the psychological impact of the roles undertaken by ESRs provides vital information on the nature of psychological exposure and distress, they should not be confused with psychological surveillance.

The case for a national screening and surveillance programme of workers exposed to traumatic incidents was proposed by Dollard et al. (2007), who supported the use of surveillance for monitoring and tracking how the nature and management of work creates challenges for the occupational health and safety of workers. Essential to the introduction of surveillance programmes is the development of screening tools, with clearly defined cut-off levels which can be used to identify those ESRs needing further psychological support and assessment (McFarlane and Bryant, 2007). The need for psychological surveillance in ESRs was identified in the late 1990s, online screening and surveillance for specialist roles has made this more feasible (Price et al., 2016). The surveillance programme measures a range of clinical symptoms, including anxiety, depression, PTSD, burnout and compassion fatigue; with ESRs being screened pre-deployment and at regular intervals throughout their specialist deployment. Initial screening shows that around 80 per cent of ESRs in specialist roles are fit and have no significant symptoms of trauma, 15 per cent have scores which are concerning and 5 per cent have clinically significant symptoms of PTSD (Tehrani, 2016b). The screening results do not halt deployment, but rather they trigger a psychological assessment which can be used to provide psycho-social education and advice, a referral for trauma therapy and occasionally a redeployment to an alternative role (College of Policing, 2018). Surveillance of child protection officers (Tehrani, 2018) examined the results from 2,289 officers and showed that attitudes to health, tenure and adverse childhood experiences were associated with increased clinical scores. In another surveillance report involving 126 internet child abuse investigators (Tehrani, 2016a), it was found that there were higher levels of secondary traumatic stress in female investigators, and in investigators who had high levels of introversion or neuroticism. The role of surveillance is not, in itself, to reduce the incidence of mental health problems. Rather, it is a supportive measure to identify risk and resilience factors within the working environment, and to identify where an individual ESR requires support or further assessment. As with the frontline responders, the line manager’s role is important in providing a supportive environment in which it is acceptable for ESRs to discuss their work and the challenges it creates in personal and working life. The line manager should also make a referral to occupational health where there is a need for additional assessment and support.

Disaster responders

Large numbers of frontline and specialist ESR are needed to deal with major incidents and disasters, and depending on their level of exposure, many will require psychological support (BPS, 2017). As with the frontline responders, it is important to provide immediate practical support at the time of the disaster, and to ensure that ESRs are demobilised at the end of each shift. Although debriefing is not designed to prevent or treat PTSD (Regal and Dyregrov, 2012; Ruck et al., 2013), these interventions are highly valued in building social cohesion and support (Dyregrov, 2002). Debriefing meets the needs of ESRs to have their experiences recognised in a familiar setting, where they can be provided with psycho-education, support and the opportunity to reflect on their experiences with their colleagues. Although the use of debriefing has been challenged as a treatment for PTSD (Bisson et al., 2000), this does not detract from the role debriefing can play in providing an early indication of those requiring further assessment and support (Arendt and Elklit, 2001).

There is mounting evidence to show that undertaking brief screening can be helpful in identifying ESRs who are likely to require psychological support (Brewin, 2005; Momsen et al., 2017). It is recognised that in the immediate aftermath of a disaster most people will have experienced heightened physiological and psychological responses (Sijbrandij et al., 2008), and that these responses will rapidly decline over time. However, for some ESRs the symptoms do not decline, and may become more intense (Pietrzak et al., 2014). There has been some success in developing brief post-trauma screening tools which have a high level of sensitivity and specificity in accurately identifying people likely to develop PTSD (Brewin et al., 2008; Mouthaan et al., 2014). The screen and treat approach has the benefit of identifying ERSs who need to be referred to occupational health for a more comprehensive screening and psychological assessment.

Screening and surveillance tools

An important issue for screening and surveillance programmes is the choice of screening questionnaires. Psychological screening questionnaires need to be reliable and valid (Mouthaan et al., 2014). Psychological test developers need to demonstrate that their questionnaires accurately measure the magnitude of a psychological condition or feature over time and population. In addition, these tools need to be able to differentiate between ESRs experiencing significant early signs of psychological distress from those within a normal range of emotional expression. A benefit of a surveillance approach is that it allows for the sensitivity of the cut-off levels to be adjusted informed by organisational feedback on levels of sickness absence and occupational health referrals together with the proportion of ESR referrals deemed appropriate at clinical assessment. The surveillance approach recognises that mental health is a continuum, where the boundary between coping and not coping with pressures of emergency work may be very narrow.

There are hundreds of psychological questionnaires which could be used in screening and surveillance in emergency services. The most important are the clinical measures which measure levels of PTSD together with the associated symptoms of anxiety and depression (Briere, 2004; Wilson and Keane, 2004). The second group of measures is those that identify risk and vulnerability factors including personality, support and early life abuse (Ozer et al., 2008). The third group of measures looks at resilience factors including coping skills, organisational support, attitudes to work and post-trauma growth (Mitchell et al., 2013). It would be impossible to name all the hundreds of potential screening questionnaires that could be used in emergency services; however, a description of the questionnaires that were employed by the Child Exploitation and Online Protection Command provides some helpful information on the selection of measures (ACPO, 2007). In order to assist the reader, we have put together Table I which provides suggestions on questionnaires and tools can be used for screening and assessment. We emphasise that there may be other questionnaires which are also useful which may have been missed off our table. The list of tools has been divided into four main groups: critical incident screening; clinical indicators; risk and resilience factors; and clinical assessments:

  1. Critical incident screening.

    Post-incident or critical incident screening is a way of finding out how an individual or group of individuals has responded to a traumatic exposure. This screening can be undertaken as part of a post-incident debriefing (Tuckey and Scott, 2013; Whybrow et al., 2015) or using self-report questionnaires as a way of identifying ESR who needs to be referred for further investigation. It needs to be recognised that during the first month some post-trauma responses are to be expected and an illustration of the way the mind adapts to being placed in a life-threatening situation. The aim of screening during the first few weeks is to identify those with pre-existing mental health conditions; provide tailored psycho-education; and identify those most likely to need further monitoring and follow up. All of the suggested post-incident tools have been used for at least 10 years and are widely used by clinicians and researchers. The sensitivity and specificity of the shorter tools have been shown to be high (Sijbrandij et al., 2008), therefore it would seem appropriate to use the shorter tools as these are more likely to be completed. There is a growing tendency for these questionnaires to be completed on smartphones (Van der Meer et al., 2017).

  2. Clinical indicators.

    These clinical questionnaires are also self-report tools and are often completed online for ease of scoring and analysis. It is important that as the diagnostic criteria for defining and assessing PTSD are refined the questionnaires used in screening reflect these changes. The PCL-5 and PSS-5 are similar in terms of their item content. They both include 20 items and are based on the latest version of the Diagnostic and Statistical Manual’s criteria for PTSD (APA, 2013). The Impact of Events-Extended questionnaire is included because it has been validated using a working rather than a clinical population (Tehrani et al., 2002). Research has found that in addition to trauma symptoms many of those exposed to trauma develop clinical levels of anxiety, depression, burnout and secondary trauma (Shalev, 1996; Carmassi et al., 2016), it is therefore important to include tools which measure these conditions as part of any screening/surveillance programme. The GAD-7 is a short measure and Goldberg Anxiety/Depression Scale has been validated on an occupational group. Dissociation is a common state following a traumatic exposure and can be useful in identifying people likely to go on to develop full-blown PTSD. The tools to measure post-trauma dissociation (DESII) and peritraumatic dissociation (PDEQ) are widely used clinically and in research. Finally, we have included measures of burnout, compassion fatigue and compassion satisfaction. Although these conditions are not recognised in the diagnostic criteria they are useful in identifying people who may be struggling following a traumatic exposure. The ProQOL-R (Stamm, 2010) was based on the work of Charles Figley (2002) and looks at the positive outcome of working in trauma exposed roles which was named compassion satisfaction, together with the negative outcomes of burnout and compassion fatigue. An alternative measure which can be used to measure burnout was developed by Christina Maslach (Maslach and Jackson, 1981) but this does not have the utility of measuring compassion satisfaction, compassion fatigue or secondary trauma.

  3. Risk and resilience factors.

    An assessment of associated personal and work-related factors should also be included in a surveillance programme as these provide some indication of what makes some ESRs more vulnerable to becoming affected by traumatic events. This additional information that these questionnaires provide is useful in designing interventions to be used to increase resilience and help to develop training and education programmes. One of the most important screening tools is the Adverse Childhood Experiences Survey (Felitti et al., 1998), this tool is becoming more widely recognised as a way of identifying people who may be vulnerable to a wide range of physical and psychological conditions (Bellis et al., 2013), personality, sense of purpose, coping styles and work engagement have all been found to be related to the magnitude of trauma symptoms. The EPQ-R (Eysenck et al., 1985) is rather old but it is well validated and useful for assessing levels of introversion, neuroticism and risk-taking behaviour. It is also useful in that it also includes a “lie scale” which can be used as a more general check on the veracity of the screening results. The COPE questionnaires look at active and passive coping styles. It has been shown that active coping improves resilience whilst passive coping is unhelpful (O’Connor and Elklit, 2008). The SoC questionnaire is widely used by researchers and clinicians as a way of establishing how individuals look on their life and work, how easy it is to understand what is expected of them and whether they can manage the volume or content of their work (Streb et al., 2014). There is the UWE that is used in occupational settings to measure how draining work can be where people become over-engaged (Schaufeli and Bakker, 2003) and the WAS is a very powerful tool for measuring attitudes toward health and well-being which has been shown to predict ability to remain working in the future (Ilmarinen, 2007).

  4. Diagnosis and formulation tools.

    For the small number of ESRs that require trauma treatment it is important to have suitable diagnostic tools. The CAPS-5 (Weathers et al., 2014 is regarded as the gold-standard tool for diagnosis. The administration of CAPS-5 involves a face-to-face interview with a clinician qualified in administering and interpreting this scale. The interview will take between 1 and 2 h depending on the complexity of the case. The PSS-I-5 (Foa and Capaldi, 2013) can be used for a similar function but has fewer questions but generally will take a similar length of time for completion. Both the CAPS-5 and the PSS-I-5 are resource intensive and only suitable for occasions where a formal diagnosis is required such as in a medical retirement or litigation. However, for trauma psychologists and therapists formulation and psychological assessment are more appropriate tools. The focus here is the development of treatment plans. The model developed by Ehlers and Clark (2000) was designed to be used by practitioners and involves recognising the perceptions and beliefs that maintain the trauma symptoms and identifies targets for intervention. The psychological assessment (Tehrani et al., 2007) involves a structured interview which explores current psychological, physical and social well-being, looks at personal history and attachments, and identifies strengths and capacities. After the assessment the psychologist provides feedback and psycho-education on the nature of trauma based on the results of their psychological screening. It is important to be aware that all the psychological screening and surveillance tests described are protected, and the disclosure of test materials is prohibited, as the unauthorised access to psychometric test material erodes their validity and reliability. It is also important that anyone involved in the administration or interpretation of screening results to be appropriately qualified and there are strict rules relating to the confidentiality of the results and the protection of these data from unauthorised access.

Discussion of benefits of screening and surveillance as part of a larger well-being programme

It is recognised that there are increasing pressures being placed on emergency services to deal with the trauma of terrorism, natural and man-made disasters, interpersonal violence and personal tragedies. Alongside, there is a continual reduction in funding and an increase in workload, challenging the ability of the ESR to remain resilient and cope with the psychological burden. More frequently, internal support resources are stretched to their limits, with precious occupational health resources needing to be targeted effectively. Psychological screening can help by the more effective targeting of support and the provision of management information based on the screening results. Psychological screening can identify risk and resilience factors and develop psycho-social support and education to create trauma informed organisations (Bloom, 2011). To be successful there is also a need for the development of trauma informed organisational policies and procedures for dealing with disasters and other critical incidents, and for providing support to those affected (Bloom, 1997). Management and ESRs need to become emotionally aware, and to have the knowledge and training to identify the signs and symptoms of stress and trauma in themselves and their colleagues. If society is to be kept safe, emergency services must maintain their capability for dealing with emotionally challenging, complex and traumatic work, and introduce organisational systems and processes which meet the organisational, operational and personal needs of ESRs. Emergency services need to deliver trauma awareness training and education to supervisors and their teams. This is critical when recognising and responding to signs and symptoms of traumatic stress and is needed to provide evidence-based early interventions and regular screening and support to identify those who are struggling, as a means of reducing stigma and building well-being and trauma resilience (McFarlane and Bryant, 2007). This approach is being supported by Blue Light Framework (Hesketh and Williams, 2017), which aims to improve the psychological well-being of ESRs. There is guidance on risk assessment and screening in emergency services to promote a systematic approach to supporting ESRs (Hesketh et al., 2017) and on managing trauma in high-risk organisations Hesketh and Tehrani, 2018).

Psychological screening and surveillance of ESRs provides a simple and economic mechanism to identify ESRs in need of psychological support, and an opportunity to examine and quantify the impact of personal and organisational factors, influencing the level of trauma resilience. The aim of the approach is to create a workforce which is trained and equipped to recognise and build their psychological well-being and emergency services that are able to meet their duty of care by proactively developing and promoting a trauma informed workforce.

Examples of some screening and surveillance tools available for assessing post trauma responses

Post-critical incident screening tools Developer Features Cut-off score
Traumatic Stress Symptom Checklist (TSSC) Basoglu et al. (2001) 23 items: 17 trauma items and 6 depression items. Four-point scale 25 or higher
The Impact of Events Scale-Revised (IES-R) Weiss and Marmar (1997) 22 items which measure intrusion, avoidance and hyperarousal. Five-point scale Varied
The Trauma Screening Questionnaire (TSQ) Brewin et al. (2002) 10 items: 5 intrusion items and 5 hyperarousal items. Yes/No scale 6 or higher
The Davidson Trauma Scale (DTS) Sijbrandij et al. (2008) 17 items rated for frequency and severity during the previous week. Five-point scale 20 or higher
SPAN (short form of DTS) Sijbrandij et al. (2008) 4 items: startle, physiological arousal, anger and numbness. Five-point scale 5 or higher
Clinical indicator tools Developer Features Cut-off score
PTSD Checklist 5 (PCL-5) Weathers et al. (2014) 20 items: 5 re-experience, 2 avoidance, 7 neg. self-belief, 6 arousal. Five-point scale 33 or higher
PTSD Symptom Scale (PSS-5) Foa and Tolin (2000) 20 items: 5 re-experience, 2 avoidance, 7 neg. self-belief, 6 arousal. Five-point scale 33 or higher
Impact of Events Scale-Extended (IES-E) Tehrani et al. (2002) 23 items which measure intrusion, avoidance and hyperarousal. Five-point scale 50 or higher
General Anxiety Disorder-7 (GAD-7) Spitzer et al. (2006) 7 items which measure anxiety. Four-point scale 10 or higher
Goldberg Anxiety/Depression Scale Goldberg et al. (1988) 9 items anxiety items and 9 depression items. Yes/No scale 5 or more both items
Peritraumatic Dissociative Experiences (PDEQ) Marmar et al. (2004) 10 items. Five-point scale 12 or higher
Dissociative Experiences Scale II (DESII) Carlson and Putnam (1993) 28 items scored on % of time symptom experienced 30% or higher
Professional Quality of Life-Revised (ProQOL-R) Stamm (2010) 30 items: 10 compassion satisfaction (CS), 10 burnout (BO), 10 compassion fatigue (CF). Six-point scale CS: 30 or lower, BO: 31 or higher, CF: 15 or higher
Risk and resilience assessment tools Features
Adverse Childhood Experiences (ACE) Felitti et al. (1998) 5 items measure adverse childhood experiences and 5 items measure childhood adversity. Yes/No scale (score of 4 or more is significant)
Sense of Coherence (SoC) Antonovsky (1996) 13 items: 4 meaningfulness, 5 comprehensibility, 4 manageability. Seven-point scale
Eysenck Personality Questionnaire-Revised (EPQ-R) Eysenck et al. (1985) 60 items: 5 subscales, extraversion/introversion, sensitivity (neuroticism), tough-mindedness (psychoticism), social desirability and impulsivity
Cope Inventory Carver et al. (1989) 13 coping subscales some are active and others passive. This measure is useful when taken together with data from other measures where it can identify coping styles and tendencies
Utrecht Work Engagement (UWE) Schaufeli and Bakker (2003) 3 engagement scales: vigour, dedication and absorption. The UWE has shown that some people can be engaged in their work and become burnt out due to being over conscientious or driven to succeed
Work Ability Score (WAS) Ilmarinen (2007) A single item measures work ability. It has been taken from the Work Ability Index and has similar predictive qualities for physical and psychological well-being
Diagnosis/Formulation tools Developer Features
Clinician Administered PTSD Scale-5 (CAPS-5) Weathers et al. (2014) CAPS-5 is a 30-item structured interview (gold standard for trauma diagnosis)
PTSD Symptom Scale (PSS-I-5) Foa and Capaldi (2013) PSS-I-5 is the 20-item structured interview version of the PSS-5 using the same questions
PTSD Formulation Ehlers and Clark (2000) Formulation based on cognitive model of trauma by Ehlers and Clark
Psychological Assessment of PTSD Tehrani et al. (2007) Structured interview and assessment process which builds on access to a comprehensive psychological screening

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Further reading

Hesketh, I. and Cooper, C. (2017b), “Measuring the people fleet: general analysis, interventions and needs”, Strategic HR Review, Vol. 16 No. 1, pp. 17-23.

Price, M., Kuhn, E., Hoffman, J.E., Ruzek, J. and Acierno, R. (2015), “Comparison of the PTSD Checklist (PCL) administered by mobile device relative to paper form”, Journal of Traumatic Stress, Vol. 28 No. 5, pp. 480-483.

Schaufeli, W.B. and Bakker, A.B. (2006), “The measurement of work engagement with a short questionnaire”, Educational and Psychological Measurement, Vol. 66 No. 4, pp. 701-716.

van der Meer, C.A.I., Bakker, A., Schrieken, B.A.L., Hoofwijk, M.C. and Oliff, M. (2016), “Screening for trauma related symptoms via a smart phone app: the validity of smart assessments on your mobile in referred police officers”, International Journal of Methods and Psychiatric Research, Vol. 2, pp. 87-92, available at: https://doi.org/10.1002/mpr.1579 (accessed 25 June 2018).

Corresponding author

Ian Hesketh can be contacted at: ian.hesketh-2@manchester.ac.uk