Prevention of Health Care Workers* Health Problems after Work Related Critical Incidents: A Randomized Controlled Trial

Only recently researchers have started to examine the impact of acute stressors
(critical incidents) in the workplace, next to chronic job stressors. High
rates of (symptoms of) Post Traumatic Stress Disorder (PTSD) have been reported
among health care workers in acute settings, which negatively impact their well
being and their attitude towards the job. Chronic job demands (e.g. demanding
contacts with patients, time constraints, poor communication) are positively
related to burnout (exhaustion and disengegement). With regard to the expected
shortage of health care workers in the Netherlands in the near the future,
impaired well being and disengagement may lead to serious problems; not only
for the individual health care worker, but also for the organization, and for
society. Preventive programs should protect and support health care
professionals after work-related critical incidents (Arbo-wet, 1994). Until now
however, no consensus exists with regard to the content of preventive
intervention after critical incidents.
Job resources (e.g. autonomy, social support, relationship with supervisor) are
considered health-protecting factors, that buffer the impact of high job
demands on burnout. Lack of resources leads to disengagement and indirectly to
short-term absenteeism. The impact of critical incidents on outcomes, like
posttraumatic responses, exhaustion, and absenteeism may also be buffered by
job resources (i.e. psycho education, social support, autonomy, support from
co-workers, and supervisor support). Besides, job resources may exert their
effect (partly) via personal resources (e.g. self-efficacy, self esteem,
resilience, optimism; see work model, page 21).
Neuro-endocrine response: In this study, the neuro-endocrine response to stress
(i.e. cortisol, and dehydroepiandrosterone/DHEA) is included as the more
objective measure of stress (next to self report questionnaires). Although, in
PTSD, hyper-regulated stress systems (low cortisol baseline level in
combination with over reactiveness to stress), as well as the opposite have
been found, DHEA to cortisol ratio may index the degree to which an individual
is buffered against the negative effects of stress.
Also in burnout-patients mixed results with respect to cortisol levels have
been found. However, when hormone levels and exhaustion symptoms were
simultaneously assessed (in a diary study), more severe burnout symptoms were
consistently associated with lower levels of cortisol, smaller Cortisol
Awakening Rise, and smaller cortisol to DHEA ratios.

Primary objective of the study is to test the effectiveness of two
interventions (by comparison with a control intervention and by mutual
comparison) in preventing the negative effects of critical incidents and
chronic job demands on the outcomes: posttraumatic responses, exhaustion,
(dis)engagement, absenteeism, and satisfaction with help after critical
incidents.

Secondary objectives are:
a) to examine inter-correlations of critical incidents, chronic job demands,
job resources and personal resources, in inducing ASD/PTSD symptoms, general
health problems, depression, anxiety, substance abuse (tobacco, alcohol,
medication), exhaustion, disengagement, and absenteeism; across time, for the
three conditions (see model 1, p. 21).
b) to determine stress hormone levels in saliva, to explore associations
between DHEA to cortisol ratio in saliva and ASD/PTSD, burnout symptoms,
cognitive appraisal and coping (by simultaneous registration in a diary, thus
capturing states instead of constructs).

The study is longitudinal, randomized, *placebo* controlled (for flow chart,
see p. 25-26).

The Controlgroup receives a *placebo* intervention (watchful waiting).
Interventiongroup-1 receives watchful waiting + psycho-education.
Interventiongroup-2 receives watchful waiting + psycho-education + incident
focussed social support from trained colleagues (see flow chart p 26, and
teratment of subjects section, page 26-37).

The expected burden mainly originates from completing the questionnaires
(appendices 1, 4, 5, 6), keeping a diary, and saliva sampling (appendix 9a -
9f). The risks associated with participation consist of extra workload for the
colleague-supporters. There may be a risk of initially having more instead of
fewer complaints, induced by higher awareness (as a result of psycho-education
and questionnaire-items). Although in the intervention groups, this is not what
we expect, as we explicitly label possible responses as normal reactions to
abnormal situations that will probably disappear in a few days to weeks.