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University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, SwitzerlandPrivatklinik Meiringen, Meiringen, SwitzerlandDepartment of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
Address for correspondence: Ulrike Ehlert, PhD, Department of Clinical Psychology, University of Zurich, Binzmühlestrasse 14/26, CH-8050 Zurich, Switzerland.
Air rescue staff are subject to stressors, including frequent traumatic events, shift work, and unfavorable conditions during rescue missions. We investigated subjective well-being among employees of the Swiss Air-Rescue organization and the potential determining factors, such as sense of coherence, self-esteem, coping, stress, and mental health status.
Methods
All employees (N = 142) received a questionnaire battery composed of the Trier Inventory for the Assessment of Chronic Stress, the Salutogenic Subjective Work Analysis, the Stress Coping Questionnaire, the Health and Stress Questionnaire, the Sense of Coherence Scale 13-item scale, the Inventory for the Measurement of Self-Efficacy and Externality, the Brief Symptom Inventory, the 12-item General Health Questionnaire, and the Posttraumatic Stress Diagnostic Scale. A discriminant analysis was conducted (input: subjective well-being, output: potential determining factors). A total of 48 participants provided complete data.
Results
The discriminant analysis was significant (χ2 = 40.80, P < .001; correct classification: 89.4%) and revealed that sense of coherence (F1,45 = 40.46) and self-esteem (F1,45 = 36.20) were the most important discriminating factors for subjective well-being.
Conclusion
Sense of coherence and self-esteem play an important role in the subjective well-being of emergency and rescue personnel. Fostering these traits should be included in preventive programs.
A vast body of research has demonstrated that emergency and rescue personnel are at an increased risk of witnessing or being victims of traumatic situations.
However, research in this group of employees has a long tradition of examining negative incidents, such as frequencies and types of stressful or traumatic situations. For instance, previous studies have addressed traumatic events and resulting mental health problems, such as posttraumatic stress disorder (PTSD), compassion fatigue,
Emergency and rescue employees face particular challenges, including an unpredictable workload, exposure to traumatic events, and critical decision making often based on incomplete information.
Specifically, air rescue personnel are regularly exposed to a variety of stressful conditions, including vibration, humidity, noise, barometric pressure, decreased partial pressure of oxygen, thermal changes, and gravitational forces.
Accordingly, emergency rescue employees are at greater risk of developing PTSD or other trauma-associated mental health problems, such as depression or increased consumption of alcohol or other substances.
Notably, the risk of developing mental health issues applies not only to the rescue staff carrying out missions but also to the staff working in emergency centers who organize and oversee the missions.
The Rettungsflugwacht–Garde Aérienne (Rega) is the largest air rescue organization in Switzerland, consisting of 13 helicopter bases from which every point in Switzerland is reachable within 15 minutes. Additionally, the Rega organizes repatriation flights for Swiss citizens from other countries. Between 2000 and 2020, the Rega completed an average of 14,840 helicopter and jet missions per year.
Despite the stress associated with this work and the aforementioned study findings demonstrating increased mental health problems, many rescue employees manage to function successfully. To explain this, studies have begun to shift their focus to health-promoting variables in this population, in line with approaches such as Antonvsky's salutogenic model.
A multilevel study on the relationships between work characteristics, self-efficacy, collective efficacy, and organizational citizenship behavior: the case of Taiwanese police duty-executing organizations.
have been found to function as predictors of resilience, positive appraisal, and effective coping in stressful situations. Further findings attest to the importance of organizational resources at work and social support in promoting mental well-being and mental health.
In sum, despite study findings reporting that rescue employees are at high risk of mental health problems, the majority of these persons remain healthy. However, to date, the literature on rescue and emergency staff, specifically flight crews, has focused on stressors and psychopathology. By contrast, data on health, well-being, and resilience in air rescue employees are scarce even though evidence is accumulating that positive mental states may play an independent role in the outcomes and encompass more than merely the absence of symptoms.
Subjective well-being refers to happiness, the absence of negative affect and morbidity, and notions of life satisfaction.
Therefore, the present study applied this approach to the exposure and adaptation to stress in air rescue employees. Specifically, we measured psychological adaptation, operationalized as general subjective well-being (defined as life satisfaction, emotional well-being, and absence of morbidity).
Furthermore, we aimed to evaluate the influence of chronic stress; coping strategies; organizational resources at work; social support; and character traits such as SOC, self-efficacy, and self-esteem on subjective well-being. Hence, the overarching goal of the study was to identify individual characteristics and work-related determinants of positive and negative adaptation.
Methods
Procedure
Recruitment was performed in cooperation with the management of the Rega in 2004. A study package with instructions, information, and questionnaires was sent to every member's home address, and all questionnaires were completed at home. Upon completion of the questionnaires, the participants returned them to the authors’ address. No monetary incentives were offered. The study was approved by the Ethics Committee for Human Research of the University and Canton of Zurich.
Participants
All employees of the Rega (N = 142) received the study package, and 48 participants (35%), consisting of 21 women and 27 men, provided complete data. All participants were German speaking. There were no statistically significant differences between participants and employees who did not participate with regard to age, but women are slightly overrepresented in the sample. The population consisted of crews of fixed wing repatriation flights, operations center employees, and crews involved in helicopter missions.
Measures
Participants’ age, sex, living arrangement, educational background, professional experience, and crew membership were recorded. To assess the burden/reward of the missions, participants were asked to state the number of distressing missions they had been involved in during the month before assessment and the number of distressing and rewarding missions since beginning their job. Moreover, participants rated the professional challenge and psychological burden/reward of these missions on a scale ranging from 0 to 10, with high scores indicating high challenge or distress/reward, respectively.
Additionally, participants completed the Trier Inventory for the Assessment of Chronic Stress (TICS-2), a 62-item self-report scale for the assessment of chronic stress. The TICS-2 is composed of 10 subscales: work overload, social overload, overextended at work, lack of social recognition, work discontent, social tension, performance pressure at work, performance pressure in communication, social isolation, and worry propensity.
Trierer Inventar zur Erfassung von chronischem Sre (TICS): Skalenkonstruktion, teststatistische Überprüfung und Validierung der Skala Arbeitsüberlastung [The Trier Inventory for the Assessment of Chronic Stress (TICS). Scale construction, statistical testing, and validation of the scale work overload].
in: Strohm O Ulich E Unternehmen arbeitspsychologisch bewerten Ein Mehr-Ebenen-Ansatz unter besonderer Ein Mehr-Ebenen-Ansatz unter besonderer Berücksichtigung von Mensch, Technik und Organisation. vdf Hochschulverlag,
Zürich, Switzerland1997
which assesses the subjective perception of work characteristics. The SALSA contains 67 items. From a conceptual perspective, the SALSA scales comprise pathogenic and salutogenic descriptors of decision latitude, psychological job demands, and social support from coworkers and supervisors.
The Stress Coping Questionnaire was used to measure the tendency to apply specific stress coping strategies in stressful situations. For the present study, only the substance use subscale was applied. The 6 items of this subscale include items on smoking, drinking, and the use of medication such as tranquilizers or sedatives. Each item was rated on a Likert scale ranging from 1 to 4.
(German translation of Olson and Stewart's Health and Stress Profile) was used to assess self-esteem. Furthermore, we used the social support, physical activity, and recovery scales to assess social support and coping strategies.
To examine participants’ SOC, we used the short version of the 29-item Sense of Coherence scale, the Sense of Coherence 13-item scale,
consists of 32 items assessing the following personality traits on 4 primary subscales: self-concept of own competence, internality in locus of control, powerful others' control, and chance control. In addition to these primary scales, the I-SEE provides secondary and tertiary scales. In the present study, only the tertiary scale self efficacy versus externality was used.
is a 53-item self-report symptom inventory designed to assess the psychological symptom status of patients or the general population. Each item is rated on a 5-point scale of distress ranging from “not at all” to “extremely.” In the present study, only the Global Severity Index was used.
To detect participants with possible psychiatric disorders, we used the short version of the General Health Questionnaire (GHQ), the 12-item GHQ.
which consists of 52 items corresponding to the Diagnostics and Statistical Manual of Mental Disorders (Fourth Edition) criteria A-F for PTSD. The Freiburg Personality Inventory-Revised
is a 138-item self-report inventory. In the present study, we only used the standard scale life satisfaction, and the scale openness was used as a control for social bias.
Definition of the Target Variables
Subjective Well-Being
Subjective well-being was assessed with the following 4 measures: 1) the standard scale life satisfaction from the Freiburg Personality Inventory-Revised, 2) the emotional well-being scale from the HS, 3) the Global Severity Index of the BSI, and 4) the total score of the GHQ-28 (scoring method 0011).
Psychosocial Demands
We operationalized psychosocial demands using the total score of the TICS-2 and the scales external stressors and job demands of the SALSA and added 4 additional items: the number of distressing missions in the month before assessment, the number of distressing missions since starting the job, the psychosocial burden of distressing missions, and the professional challenge of distressing missions.
Psychosocial Resources
Psychosocial resources were assessed using the social support, physical activity, and recovery scales from the HS; the substance use scale from the Stress Coping Questionnaire; the organizational resources and social resources scales based on the SALSA; the total score of the 29-item Sense of Coherence questionnaire; the tertiary scale self-efficacy versus externality from the I-SEE; and 3 additional items assessing the rewarding effects of emergency missions (ie, the number of all rewarding missions since beginning the job, the psychological reward of rewarding missions, and the professional challenge in rewarding missions).
Statistical Analyses
Data are presented as means ± standard deviation (SD). All correlations were calculated using Pearson correlation coefficients, and the significance level was set at P < .05 (2-tailed). In case of multiple testing, we adjusted the alpha level accordingly using a Bonferroni correction. Comparisons between sex and the continuous variables were performed using 1-way analysis of variance. For discrete variables, sex was compared using chi-square tests. The alpha level was set at alpha = .05, and Bonferroni was corrected to alpha = .0125.
Subjective well-being is a composite index and was calculated using the following method: groups with high and low life satisfaction and emotional well-being were created using median splits. For the BSI and GHQ-28, groups with high and low levels were defined by commonly used threshold scores (BSI: 62/63, GHQ-28: 4/5). Only participants’ scores above the median and below the threshold were counted and added to form the subjective well-being score. Thus, the possible range of subjective well-being was 0 to 4.
A discriminant function analysis was conducted to determine the predictors that best distinguish between groups with high and low subjective well-being scores. Only demand and resource variables that correlated significantly (P < .05) with subjective well-being were entered into the discriminant analysis. All statistical analyses were performed using SPSS version 27 (IBM Corp, Armonk, NY).
Results
Demographic Results
A total of 48 complete data sets were received (21 women and 27 men). The mean age was 41.5 years (SD = 6.4 years). Men were significantly older (45.89 years [SD = 6.8 years] vs. 37.29 years [SD = 8.1 years], F1,47 = 20.385, P < .001) and had significantly more experience in the job than women (17.52 years [SD = 8.3 years] vs. 5.81 years [SD = 6.0 years], F1,46 = 28.755, P < .001). Additional demographic information is summarized in Supplemental Table 1.
Subjective Well-Being
On the BSI, 16.7% of the respondents scored above the threshold score, indicating psychiatric morbidity. On the GHQ, 18.8% scored above the threshold score. The discriminant analysis only included demands and resources variables, which correlated significantly with subjective well-being (29-item Sense of Coherence scale: rs = 0.725, P < .001; HS [self-esteem]: rs = 0.638, P < .001; Stress Coping Questionnaire [substance use]: rs = −0.662, P < .001; TICS-2: rs = −0.630, P < .001; SALSA [social resources]: rs = 0.354, P = .025; HS [social support]: rs = 0.47, P = .001; self-efficacy vs. externality: rs = 0.421, P = .003; SALSA [organizational resources]: rs = 0.394, P = .006). The discriminant function distinguished participants with high subjective well-being scores from those with low scores via median split. Table 1 shows the absolute correlation between each variable entered in the model and the discriminant function (pooled within-group correlations). The greater the F value, the greater the importance of a particular variable in predicting group membership. Therefore, participants reporting high subjective well-being were characterized by a higher SOC and greater self-esteem, showed a reduced likelihood of using drugs as a coping strategy, and reported less chronic stress. Moreover, these individuals described better social resources at work, experienced more support in their private life, showed higher self-efficacy, and reported better access to organizational resources compared with persons with lower subjective well-being values. Figure 1 depicts the discriminant values of the respective input variables.
Table 1Assessment of the Components of Subjective Well-Being (SWB)
Variables
N
M
SD
Range
% of Maximum
Cutoff Value
FPI-R: life satisfaction
48
9.0
2.68
1-12
75
10 (median)
HS: emotional well-being
48
3.75
0.50
3-4
75
3.83 (median)
BSI (GSI)
48
48.52
13.32
24-80
61
63
GHQ-28
48
1.73
2.97
0-14
6
5
SWB score
48
2.73
1.33
0-4
68
3 (median)
BSI = Brief Symptom Inventory; FPI-R = Freiburg Personality Inventory-Revised; GHQ-28 = 28-item General Health Questionnaire; GSI = Global severity index; HS = Health and Stress Questionnaire; SWB = subjective well-being.
Figure 1Factors that discriminate the 2 groups of subjective well-being. Note that the 29-item Sense of Coherence scale is reduced by factor 10 for visual purposes.
The overall discriminant function proved to be significant (χ2 = 40.80, P < .001). The function correctly classified 89.4% of all classes (eigenvalue = 1.705).
Psychosocial Demands and Resources
Performance pressure at work assessed by the corresponding TICS-2 subscale (15.85 [SD = 4.58]) proved to be the most frequent stressor followed by work overload (10.13 [SD = 4.49]), work discontent (7.83 [SD = 3.67]), social tensions (7.80 [SD = 3.42]), chronic worrying (7.29 [SD = 3.66]), and social isolation (6.52 [SD = 4.43]).
The most frequent demands were professional challenge and psychological burden of distressing emergency missions (Supplemental Table 2). Of the 6 SALSA subscales, responsibility/required qualification (4.79 [SD = 0.31]) was the most important demand, whereas qualitative demands (2.40 [SD = 0.86]), adverse behavior of colleagues (2.13 [SD = 0.65]), excessive workload (2.13 [SD = 0.46]), adverse behavior of superiors (1.89 [SD = 0.66]), monotony of working tasks (1.09 [SD = 0.80]), and external stressors were perceived as less important.
With regard to resources (Supplemental Table 3), participants showed high values on the scales addressing personality traits as well as for psychological reward of rewarding missions and on the social resources subscale of the SALSA. The most frequently reported resource at work was social support from the work partner (4.45 [SD = 0.74]) followed by social support from colleagues and superiors (4.08 [SD = 0.64]). All participants described that their job encompassed a high variety of tasks (4.19 [SD = 0.60]). Supplemental Tables 1 and 2 provide a comprehensive overview of the psychosocial demands and resources variables.
Number of Traumatic Missions and Possible PTSD
Only 17% of the participants reported that they had not been exposed to any traumatic events during missions. Thirty-one percent reported 1 traumatic event, and 51% mentioned between 2 and 8 traumatic events, which occurred during missions. The A criterion of PTSD was met by 48% of the participants. Only 6.3% (n = 3) of the participants met the criteria for possible PTSD. There were no differences between the crews on the Posttraumatic Stress Diagnostic Scale.
Discussion
Our study aimed to identify individual characteristics and work-related determinants of subjective well-being in air rescue employees. Overall, we found that air rescue employees with higher levels of subjective well-being were characterized by greater SOC, self-efficacy, and self-esteem and low levels of chronic stress. This group was further characterized by good access to social and organizational resources at work and social support at home and had a low likelihood of using drugs as a coping strategy. Approximately 19% of our sample had high GHQ-28 scores, and around 17% had BSI scores indicative of a possible mental health problem.
Specifically, we found that SOC was the factor discriminating most strongly between individuals with high and low subjective well-being. In recent literature, SOC was associated with good health, specifically mental health, and a high quality of life.
Higher sense of coherence is associated with better mental and physical health in emergency medical services: results from investigations on the revised sense of coherence scale (SOC-R) in rescue workers.
In addition, the present study revealed that self-esteem is an important factor of subjective well-being. This finding is in line with recent data indicating that self-esteem is associated with greater life satisfaction, positive affect, happiness, and subjective vitality.
Examining the exercise and self-esteem model revised with self-compassion among Hong Kong secondary school students using structural equation modeling.
Perceived self-efficacy, which also emerged as a factor of subjective well-being in the present study, reflects an individual's beliefs in his or her ability to achieve intended results. In line with our findings, previous studies have indicated that self-efficacy is an important determinant of subjective well-being.
Achieving one's goals and feeling that one is in control, in terms of self-efficacy, might improve mental strength, the effectiveness of recovery, and the sense of general satisfaction, all of which are cornerstones of subjective well-being.
Subjective well-being, general self-efficacy and coping with stress in former psychiatric patients preparing for the peer support role: an exploratory study.
Another important factor of subjective well-being found in the present study is a low likelihood of using drugs as a coping strategy. This is in line with a vast body of research indicating that drug use decreases quality of life in the long-term and has a negative impact on somatic and metal health, thus reducing subjective well-being.
correlated negatively with subjective well-being. It has been hypothesized that individuals suffering from chronic stress lack the normal adaptive stress reactions. As such, chronic stress is a major risk factor for mental illness.
reported that chronic stress negatively influences subjective well-being and physiological functioning. In emergency medical personnel, a clear correlation between chronic stress and types of coping was found, with avoidance-focused coping increasing the likelihood of stress being perceived as distress.
In the present study, organizational and social resources (ie, working conditions and support in one's private life) emerged as major factors contributing to subjective well-being. In accordance with recent research, our results demonstrate the importance of support from colleagues and superiors in order to cope with stress at work.
found that an assistance pursuit coping style had a positive impact on subjective well-being in police officers. Data suggest that perceived support from colleagues and superiors is a protective factor against developing burnout and vicarious traumatization in emergency workers.
Furthermore, interpersonal contact with other persons who are able to provide support has long been recommended as a way to alleviate occupational strain.
A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak.
In the present study, 9% of the participants had GHQ-28 scores and 17% BSI scores that were indicative of mental health problems, but only 6.3% of participants showed possible PTSD.
A survey of intensive care unit doctors identified 29% of participants as having a possible mental health problem according to the GHQ-12.
whereas the prevalence of PTSD in our sample seems to be comparable to the general population. Although our findings have to be interpreted with caution given the small sample size, one might speculate that the low prevalence may result from a positive selection process insofar as personnel with high resilience remain with the Rega.
Limitations
The present study is subject to several limitations. The main limitation is the rather low response rate of 34%, which might have led to systematic error in the sample. Reasons for this low response rate might include the tight time schedules of the helicopter crews, the demanding training with a new type of air ambulance jet, and the general reticence of pilots and air personnel to participate in studies because of the extremely strict medical prerequisites for these professional groups. Although data were collected in 2004, it should be noted that data on air rescue crews are extremely valuable, and the types of stressors in air medical rescue crews seem similar compared with the actual data.
Furthermore, the exclusive use of self-report questionnaires entails a risk of response bias, specifically because PTSD is still associated with a negative stigmata.
To indicate social desirability in participants’ responses, we included the openness scale of the Freiburg Personality Inventory. Openness scores were similar to the norm sample of the Freiburg Personality Inventory validation study (meannorm = 5.95, meansample = 5.48, SDnorm = 2.94, SDsample = 2.71), suggesting the validity of the responses.
Although evidence suggests that anonymous online surveys strongly reduce the tendency for socially desirable responding, it is not possible to definitively rule out bias in terms of social desirability. Because this assessment took place before the COVID-19 pandemic, our results do not reflect any additional stressors or factors on emergency and rescue personnel due to the pandemic. Further research should include clinical interviews and longitudinal designs to address hypotheses regarding causality.
Conclusion
Exposure to chronic and traumatic stress is an intrinsic part of the occupational practice of health care and rescue workers, but people working in these professions should not be reduced to their problems and limitations. Our findings confirm the importance of complementing the disease-oriented focus with an assessment of positive aspects of experiences and functioning. We identified SOC as an important factor of subjective well-being, opening up the possibility of effective primary preventive programs. In general, such programs should include strategies to enhance these factors, augment the likelihood of access to organizational resources, and promote social support at work and at home.
A multilevel study on the relationships between work characteristics, self-efficacy, collective efficacy, and organizational citizenship behavior: the case of Taiwanese police duty-executing organizations.
Trierer Inventar zur Erfassung von chronischem Sre (TICS): Skalenkonstruktion, teststatistische Überprüfung und Validierung der Skala Arbeitsüberlastung [The Trier Inventory for the Assessment of Chronic Stress (TICS). Scale construction, statistical testing, and validation of the scale work overload].
in: Strohm O Ulich E Unternehmen arbeitspsychologisch bewerten Ein Mehr-Ebenen-Ansatz unter besonderer Ein Mehr-Ebenen-Ansatz unter besonderer Berücksichtigung von Mensch, Technik und Organisation. vdf Hochschulverlag,
Zürich, Switzerland1997
Higher sense of coherence is associated with better mental and physical health in emergency medical services: results from investigations on the revised sense of coherence scale (SOC-R) in rescue workers.
Examining the exercise and self-esteem model revised with self-compassion among Hong Kong secondary school students using structural equation modeling.
Subjective well-being, general self-efficacy and coping with stress in former psychiatric patients preparing for the peer support role: an exploratory study.
A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak.
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