Differentiating social environments of high-risk professionals and specialised nurses: a qualitative empirical study on social embeddedness

ABSTRACT

Objective: High-risk professionals and specialised nurses in hospitals are frequently exposed to potentially traumatic events. Psychotrauma researchers have extensively studied personal risk factors of traumatisation among high-risk professionals, but it is hard to understand psychological functioning when professionals are decontextualised from their social environment. Generally, it has been well documented that to reduce the risk of posttraumatic stress disorder (PTSD) or other mental health problems related to traumatisation, it is essential to be embedded in a supportive social environment. However, study results among and within these occupational groups show great variety and even inconsistencies as to what is a supportive social environment.

Method: This ethnographical research, including participant observation, in-depth interviews, and document analysis, explored the social environment of firefighters, police officers, ambulance paramedics, specialised nurses, and military personnel and aims to explore their social connections and embeddedness. We performed a thematic content analysis of data to identify themes related to social or emotional support, social relationships, and stress or traumatisation.

Results: An analysis of the observational field notes, which covered 332 h of participant observation and 71 evenly distributed formal in-depth interviews, identified four themes related to social connections and embeddedness: Family, Hierarchical relations versus autonomy, Group versus individual, and Conditional family ‘love’. Results revealed that the military, police, and professional firefighters have family-like hierarchical connections and highly value group unity. Paramedics and most specialised nurses, however, tend to value individuality and autonomy in their work relationships.

Conclusion: This research shows noticeable differences in the social environments and social connections of these professionals, which implicates that prevention and mental health treatment might also have to be differentiated among occupational groups.

HIGHLIGHTS

• It is of great importance for high-risk professionals or frontline professionals who are frequently exposed to potential traumatic events, to be embedded in a supportive social environment; to work with the conviction that others ‘have your back’. However, their social environments differ so much that we cannot lump them together in one category.

• The military, police, and professional or career firefighters have family-like hierarchical connections and highly value group unity. Ambulance paramedics and most nurses working in specialised departments, such as emergency rooms, operating rooms, and intensive care units, on the other hand tend to value individuality and autonomy in their work relationships.

• To be effective, programmes for preventions, such as professional support or formal peer support, as well as mental health treatments might have to be differentiated accordingly between occupational groups.

Objetivos: Los profesionales de alto riesgo y las enfermeras especializadas de los hospitales están expuestos frecuentemente a eventos potencialmente traumáticos. Los investigadores de psicotrauma han estudiado ampliamente los factores de riesgo personales de traumatización entre profesionales de alto riesgo, pero es difícil comprender el funcionamiento psicológico cuando los profesionales están descontextualizados de su entorno social. En general, está bien documentado que para reducir el riesgo de un trastorno de estrés postraumático (TEPT) u otros problemas de salud mental relacionados con la traumatización, es esencial estar integrado en un entorno social de apoyo. Sin embargo, los resultados de los estudios entre y dentro de estos grupos ocupacionales muestran una gran variedad e incluso inconsistencias en cuanto a lo que es un entorno social de apoyo.

Método: Esta investigación etnográfica, que incluyó la observación del participante, entrevistas en profundidad y análisis de documentos, exploró el entorno social de bomberos, agentes de policía, paramédicos de ambulancia, enfermeras especializadas y personal militar, y tiene como objetivo explorar sus conexiones sociales y su arraigo. Realizamos un análisis de contenido temático de los datos para identificar temas relacionados con el apoyo social o emocional, las relaciones sociales y el estrés o la traumatización.

Resultados: Un análisis de las notas de campo de observación, que cubrieron 332 horas de observación de los participantes y 71 entrevistas formales en profundidad, distribuidas uniformemente, identificó cuatro temas relacionados con las conexiones sociales y el arraigo: familia, relaciones jerárquicas versus autonomía, grupo versus individuo y el “amor” familiar condicional. Los resultados revelaron que los militares, la policía y los bomberos profesionales tienen conexiones jerárquicas similares a las de una familia y valoran mucho la unidad del grupo. Sin embargo, los paramédicos y la mayoría de las enfermeras especializadas tienden a valorar la individualidad y la autonomía en sus relaciones laborales.

Conclusiones: Esta investigación muestra diferencias notables en los entornos sociales y las conexiones sociales de estos profesionales, lo que implica que la prevención y el tratamiento de salud mental también podrían tener que diferenciarse entre grupos ocupacionales.

KEYWORDS:

• High-risk professionals
• social environment
• social embeddedness
• social connections
• support
• specialised nurses
• military
• firefighters
• police
• paramedics

PALABRAS CLAVE:

• Profesionales de alto riesgo
• entorno social
• integración social
• conexiones sociales
• apoyo
• enfermeros especializados
• militares
• bomberos
• policías
• Paramédicos

1. Introduction

High-risk professionals, such as firefighters, paramedics, police officers, and military personnel, along with frontline professionals in hospitals, such as specialised nurses working in emergency rooms (ERs), operating rooms (ORs), and intensive care units (ICUs), are frequently exposed to critical events. Various systematic reviews show that these professionals are at higher risk for development of (trauma-related) mental health problems than the general population (Jones, 2017; Lee et al., 2020; Matthews et al., 2022; Petrie et al., 2018; Wagner et al., 2020). Psychotrauma researchers have extensively studied personal risk factors of traumatisation among high-risk professionals. However, it is hard to understand psychological functioning when professionals are decontextualised from their social environment (Southwick et al., 2016).

It is of utmost importance for high-risk professionals to rely on and turn to others for social support and it is well-established as a major protective factor following potentially traumatic events (Calhoun et al., 2022; Wang et al., 2021). Studies focusing on social embeddedness and enacted social support show, however, that having social connections is not always sufficient. Although for firefighters, paramedics, and ER-nurses social connections at work are predominantly supportive, for police officers, OR-nurses, and ICU-nurses social connections at work are also often a source of stress. Furthermore, literature research shows that the preferred source of supportive relationships, at work versus at home, may also differ. For military personnel study results are inconclusive as to whether support at work or at home protects them against mental health problems (Geuzinge et al., 2020). Thus, the association between the social environment and support is complex, which could explain to some extent why psychological interventions for prevention are not equally effective among high-risk professionals (Alden et al., 2021).

This research aims to thoroughly explore the social environments of high-risk professionals and to understand the protective role of their environments regarding the risk of (trauma-related) mental health problems. Qualitative research is best suited to identify the role of social connections in the environment, as it can reveal important information about relevant phenomena such as, the feeling of belonging, felt emotional connection, or other qualitative aspects of social relationships.

2. Method

2.1. Aim, study design and analysis

The purpose of this research is to explore the social environments of firefighters, paramedics, police officers, and military personnel, along with specialised nurses working in emergency rooms, operating rooms, and intensive care units. We aim to deepen our understanding of their social connections and embeddedness.

An ethnographic research approach was employed consisting of the following data collection methods: participant observation, in-depth interviews, and document analysis. The primary researcher (RG) conducted the observational fieldwork and interviews. The research team (presented authors) performed a thematic content analysis of data to identify themes with functional relevance (Creswell & Creswell, 2023; Lindgren et al., 2020), i.e. themes related to social or emotional support, social relationships, and stress or traumatisation. We followed the Standards for Reporting Qualitative Research (SRQR) (O'Brien et al., 2014).

2.2. Researcher’s positionality

Qualitative research, such as this ethnographic research, acknowledges the positionality of the researcher who conducts the study. Self-reflexivity of the researcher is an important quality procedure to foster rigour and allow the reader to assess possible biases (van Wijngaarden et al., 2017). The primary researcher is a clinical psychologist-psychotherapist with knowledge and expertise in group dynamics and psychological trauma. Therefore, the holistic felt sense of a setting or situation stimulated the researcher to reflect on relationships, interactions, interaction patterns, and systems.

2.3. Settings

Extensive fieldwork (in a 12-month period) took place in organisations where firefighters, ambulance paramedics, police officers, and military personnel work. We included three distinct hospital units where specialised nurses work, i.e. emergency rooms, operating rooms, and intensive care units (Figure 1). In the selection of the settings, we sought maximum variation (purposive sample) (Luborsky & Rubinstein, 1995; Patton, 2015) and therefore choose organisations and hospitals that are evenly distributed over the regions of the Netherlands, as well as over city and rural regions.

Figure 1. Units and methods per setting. M = male; F = female; Ju = junior(0-2 work experiences); Me = mediator (2–5 work experiences); Se = senior (+5 work experiences).

Initial access to the settings was usually obtained quickly through the organisations’ administrators, who were requested to participate in research regarding the risk of traumatisation. After a first interview and their approval of the study, practical arrangements (e.g. uniforms, access codes/passes, and information about regulations or procedures governing work rules) were made with an assigned contact person at the department. To gain access to the police departments and their employees, investigation of antecedents and a 3-month screening process was required. The resulting ‘internship agreement’ with the Police Academy made all Dutch Police departments accessible and open to the researcher.

2.4. Data collection

2.4.1. Participant observation

Part of the data on which this article rests was collected with participant observation whereby the researcher participated and followed the professionals in their daily activities (Braun & Clarke, 2006). The researcher became part of the professionals’ work environments (Crang & Cook, 2007) as a means to acquire first-hand experience of naturally occurring events and to get an intuitive understanding of the social environment in the workplace. This allowed the researcher to develop a sense of what is relatively significant to look at in these settings, and to develop sufficient insight to identify informants and formulate relevant questions during the interviews (Wolcott, 2008).

Observational fieldwork at fire departments included 24-hour/3-day shifts, ‘ride alongs’ with firefighters, participation in the daily training, and informal interviews with several firefighters. Because 80% of the firefighters are volunteers, the researcher also conducted fieldwork at two volunteer firefighter stations in rural areas. In the Netherlands, the fire and ambulance departments are located at separate stations. Fieldwork was also conducted at several ambulance departments (cities and villages), including a mobile (helicopter) trauma team. Police department fieldwork included observations and informal interviewing of officers on the road. Military department observations were restricted to interviews. Paramedics, firefighters, and police officers were also observed in their daily routines at a regional dispatch centre. Two large hospitals were contacted to conduct fieldwork in an ER, several distinct ORs, and ICUs (Figure 1).

2.4.2. Interviews

In addition to the observational data, interviews were an integral part of the study. We selected senior persons in every distinct occupational group, such as chiefs, administrators, trainers on settings, and teachers in academies, who are involved in the socialisation of newcomers and had already reflected on the nature of the social environment. The invited persons all agreed to a formal in-depth interview, both before and after conducting participant observation. (Figure 1). The selection of interview participants was based on an iterative process, i.e. purposeful sampling (Creswell & Creswell, 2023). The data were enriched by carrying out some observations and interviews, performing preliminary analysis, and then selecting more respondents to fill in emerging questions (Kuzel, 1999). To maximise variation and even further enrich the data we also selected participants located at other settings than where fieldwork took place.

The interviewer invited the interviewed participants to express their ideas concerning the research topics: support, stress, and dealing with traumatising experiences. Because of the explorative nature of this research, questions were initially global and open, in which the interviewer had a non-directive attitude. For example: What do you think contributes to maintaining mental health? How do professionals deal with traumatising events? What do you do to support professionals in dealing with critical incidents? The researcher maintained focus on the original research question while, at the same time, permitting flexibility in the direction the interview might take. The iterative nature of this qualitative research process in which preliminary data analysis often coincided with interviewing new participants, often resulted in new (and altered) questions (Schlütz & Möhring, 2015). For example: I heard others say ‘x’, what is your opinion on that?

2.4.3. Document analysis

The study also included examining selected (non-confidential) documents, i.e. texts, autobiographies, and documentaries. Since no observational fieldwork was carried out in settings where active military personnel work, we included more data from these kinds of documents. Based on the idea that the professional socialisation process provides information about the social environment, we focused our selection on documents related to education and training.

2.4.4. Journaling and reflection

Formal interviews were recorded and transcribed by the interviewer. A continuously updated reflective journal was used throughout the entire fieldwork period for notetaking of feelings and thoughts, and to write down new insights to pursue or new questions to raise, e.g. questions about participant responses that needed further consideration or follow-up.

The researcher used the research aim and self-conscious reflection to guide the observations and analysis, and to discern what qualified as something of collective social significance. One example of this is the following reflection about an observation at a fire department station:

We are sitting in armchairs in a circle around the television. They are telling me, one after the other, stories about practical jokes they pulled out as a group, often on firefighters that eventually left the profession. We all laughed. I get the feeling of belonging, as if they made me an insider. It feels good, I feel the desire to belong to these folks. (Field note)

This activity, of observation and reflection, provided the primary researcher with insights into the context as well as the social and cultural conditions within organisations or departments. After eleven months we found that the iterative process of data collection and analysis provided similar rather than dissimilar information and was deemed to have reached a saturation point. We decided to continue the data collection, i.e. further observations and sampling of interview participants in every professional group, for another month to ensure data saturation was achieved. As no further insights were identified, data began to repeat, signifying the attainment of an adequate sample size. Consequently, further data collection became redundant (Hennink et al., 2017; Kuzel, 1999).

2.5. Ethical considerations

Formal approval of the study was obtained from the Ethics Review Committee (Institutional Review Board) of the University of Humanistic Studies in Utrecht. Administrators of all involved organisations or departments gave written permission to conduct this research. Employees were informed beforehand about the current study through a brief description of the research by email, assuring the voluntary nature of the participation in informal interviews. The email explained that the researcher, a clinical psychologist specialised in trauma, is interested in traumatisation risks for five different occupational groups. In some departments, the manager or chief required that the researcher give the team a brief presentation about the research goals, questions, methods, and ethics prior to the observation. If someone asked the researcher directly about the purpose of the observation, identity and purpose was openly stated.

Only the primary researcher had access to the raw data, i.e. the non-anonymized field notes and journals, in contrast to the de-identified data that was used for coding.

3. Results

The research team analysed the observational field notes, the reflective journal, which covered 332 h of participant observation, and 71 formal in-depth interviews. We initially identified meaning units which we thought might be related to the social environment and relevant to social connections and embeddedness. We generated the following initial codes: Camaraderie, Brotherhood, Family, Loyalty, Solidarity, The group, Hierarchical, Autonomy, Individuality, and Disillusionment. We then clustered these codes into four themes which we defined as follows: Family, Hierarchical relations versus autonomy, Group versus individual, and Conditional family ‘love’.

Illustrative quotes were selected primarily based on the clarity of the theme. In accordance with our participant confidentiality guarantee, direct quotes are attributed only to the occupation and with a fictitious name.

3.1. Family

In some occupations, working and living are so intertwined that co-workers are as much part of everyday life as family members. Career firefighters, for instance, engage not only in work-related tasks but also live together for extended periods. During uninterrupted 24-hour shifts, three consecutive days, they coexist and interact with co-workers with whom basic facilities are shared (e.g. eating, bathing, and sleeping). The concept of brotherhood or camaraderie is deeply rooted in firefighters. During formal and informal interviews, the word ‘family’ was often mentioned, and this analogy appears to go far back. Historically and traditionally, firefighters are characterised by an ideal of dedication, support, and respect for one another, and they live by a code of unspoken duty and trust. According to Martin, a firefighter commander, firefighters rarely leave their department ‘because you just don’t leave your family’ (Interview E03). The other side of this loyalty is that ‘issues are often covered with a cloak of charity.’ Volunteer firefighters, on the other hand, do not spend as much time with their co-workers and supervisors, and they score less on camaraderie or brotherhood.

Among military personnel, the sphere of living is also largely concentrated within the organisation. Documents show that soldiers worldwide have perished while running into a line of fire to save an injured brother-in-arms. Returning veterans often speak of the tight bond during a peace mission. A nineteen-year-old Corporal expresses this unique social bond: ‘I never had such a good friendship, such a comradeship, as in [country at war]. Since I returned, I never found what we had there’ (Document 01).

At police departments, the word ‘family’ is often mentioned in informal and formal interviews and typically referred to as belonging to the group ‘blue’ [referring to the colour of the Dutch police uniform]: ‘It means to have done the police academy and to belong to the family.’ Karen, the interviewed police officer in charge (OIC), points to the receptionist and states: ‘That one over there, for example, he’s not blue’ (Interview P09). Ron, an instructor at the police academy, explains that unity is emphasised during training; ‘that’s what you want them to be later on when they’re out on the street: one group’ (Interview P02).

3.2. Hierarchical relations versus autonomy

When socialised within the military, individuals get used to commands imposed on them. This is highlighted in the following quote of a volunteer firefighter reflecting on his time in the army and his deployment in a war zone:

When I [as a veteran] was sitting on the couch, home again with my parents, I had to think about what to do next. I did not have to do that in the army as everything was decided and organized for you. Now I suddenly had to think for myself. (Field note, informal interview during observation)

Hierarchical relations and top-down decisions socialise people for a specific organisation or environment. However, this socialisation can make individuals unfit for other settings, as the following remark of a trainer for perioperative nurses shows: ‘At this moment, we got this military student on the ward. Phew, we ran into some issues with this guy. He doesn’t take any initiative and is just waiting for orders’ (Interview SN06). This is all the more poignant, as perioperative nurses are not even expected to show much autonomy. Patricia remembers the sign that used to be on the wall of the OR: ‘Eyes open mouth shut’ [Verbal communication is kept to a minimum to prevent cross-infection and aid concentration]. Joy agrees and shares that her mother, who was also a perioperative nurse, talked about a surgeon removing the wrong kidney. After they discovered the error, he had said: ‘Oh well, that one wasn’t good anymore either’ (Field note, informal interview during observation). The sign on the wall had a double meaning.

These findings contrast starkly with ambulance personnel, as illustrated in a quote of an administrator of an ambulance department: ‘Ambulance personnel have an opinion about everything; it makes leadership challenging’ (Interview T01). Although someone in charge may make the final decision, paramedics are allowed to freely discuss and express their individual views.

It is interesting to compare perioperative nurses with nurse anesthetists in this respect. Whereas perioperative nurses work closely with a surgeon, nurse anesthetists assist an anesthetist. Nurse anesthetists seldom work for one surgical specialisation but rotate, sometimes daily. The anesthetist (physician) is often responsible for multiple operating theatres simultaneously, so nurse anesthetists execute their work almost independently and report afterward to the anesthetist. A coordinator responsible for the selection and training of nurse anesthetists, a nurse anesthetist herself, summarises the resulting differences bluntly: ‘Anesthesia is a better fit for people who wish to be autonomous. Surgery [perioperative nurses] don’t want to take responsibility’ (Interview SN03). Several training coordinators and mentors of nurse anesthetists emphasise the importance of enhancing autonomy during the socialisation process. ‘You don’t always know what happens in other ORs, the student is responsible’ [to tell if they need emotional support after an incident] (Interview SN08).

3.3. Group versus individual

Basic military training is meant to create unity between previously disparate, heterogeneous individuals. The focus in the military is on the team rather than the individual. When Roy, a veteran soldier, talks about his own training, he emphasises that all lessons and exercises were focused on working together, ‘You don’t make it on your own’ (Interview M5). The solidarity of a military platoon is deemed critical to their operational effectiveness and essential for the safety and welfare of fellow soldiers. Though not all military personnel are deployed, all enlisted personnel must undergo initial training. A psychologist responsible for the selection process of military recruits, who also followed this basic training, summarised her experience as: ‘You give up your individuality. The group comes first’ (Interview M4).

It is interesting to note a difference among specialised nurses and paramedics who do not indicate a strong focus on the group. Instead, we found remarks pointing in the opposite direction, i.e. individuality. An emergency nurse trainer: ‘We stopped with debriefing together [after an incident], it did not feel safe to share with the whole group’ (Interview SN24).

Another remarkable difference is seen among firefighters. Whereas several volunteer firefighters emphasised during observation that their training is identical to career firefighters, quotes from chiefs suggest less unity in volunteer groups: ‘Volunteers are hard to follow-up [after a critical incident]. You don’t see them that often. The professionals you’ll bump into after 3 days. For volunteers, it sometimes takes up to 14 days before there is another training night’ (Rob, Firefighter chief, Interview A02). Fire department chiefs emphasised the importance that volunteers be supported at home.

Individuality, however, has its downsides. Emergency nurses work separately and independently in a room with a patient. This seemed to undermine feelings of their connection with peer nurses, as shown in a distressing experience of a young emergency nurse. She talked about having ‘spent a whole night shift working on a two-year-old with an unexplained sudden death syndrome.’ Afterwards, her colleagues were given the opportunity to reflect on the experience and share their emotions. In contrast, she had remained with the body of the child and his family. It was only in the last 15 min of her shift that she was ‘given the opportunity to cry when someone asked her how she was doing.’ However, that was not enough for her to emotionally process what had happened and when at home, she could not sleep, had called her mother, and was unable to return to work the next day (Field note, informal interview during observation).

3.4. Conditional family ‘love’

We also identified a counter-effect, which concerns family. Among police officers, an employer’s degree of loyalty may fall short of an officer’s expectations. During a participated resilience training the researcher heard several officers pointed out the extremely stressful experience of an internal investigation (IID): ‘for months, without knowing, they [chiefs and peers] are monitoring you behind your back. And you can’t share it with your neighbors or friends’ (Field note, informal interview during observation).

In the military, the emotional involvement and loyalty of the employee towards the employer can lead to feelings of disillusionment. For example, Lieutenant Chris, who returned ill from his deployment and was notified that ‘his position had become excessive.’ Paralysed and angry at the same time, he proclaimed: ‘Is this all I get after thirty-three years of dedication?!’ (Document 01). The inconsistency of the employer’s loyalty is illuminated by the fact that, when a soldier visits the medical department, his primary care physician (general practitioner) is also his occupational health physician. The primary care physician will offer health care to the soldier. However, as soon as the soldier leaves, this same physician can assume the role of the occupational physician and walk over to the Commander to say: ‘This soldier is not fit for duty anymore’ (Document 01).

Some employees lose trust in their organisation’s loyalty, whereas others never lose their emotional commitment to the organisation. Joe, a soldier who was admitted to a psychiatric hospital after his deployment, has difficulty accepting his PTSD diagnosis. He struggles with aggression, alcohol misuse, and serious marriage problems. He states, however, that ‘The crazy thing is, if the military needs me tomorrow, I will be there’ (Document 01).

4. Discussion

To summarise, in exploring the social environment of firefighters, paramedics, police, military, and specialised nurses working in emergency rooms, operating rooms, and intensive care units, we found noticeable differences in the way these professionals are embedded in their social environment. Thematic content analysis identified four themes related to social connections and embeddedness: Family, Hierarchical relations versus autonomy, Group versus individual, and Conditional family ‘love’. We found that some occupational groups, such as the military, police, professional firefighters are family-like, and hierarchical. Among these professionals, the unity of the group is highly valued. This seems in contrast to the findings among paramedics and most specialised nurses who tend to value individuality and autonomy in their relationships at work. In this discussion, we contextualise these findings in light of related theories and research literature and suggest which implications these differences between occupational groups might have for prevention and treatment of (trauma-related) mental health problems.

The family-like structure, with hierarchical relationships and the high value of group unity, reminds us of the family structure as described by Minuchin (2012). Healthy family relationships are hierarchical, where children are lower ranked then parents. Minuchin’s other dimension is the amount of emotional involvement or cohesion among members of the family. When there is too much cohesion, called enmeshment, there is less differentiation among its members and less room for individuality and autonomy. This contrasts with families with low emotional involvement among its members, which Minuchin called disengagement. There is not enough emotional closeness among its members to offer a secure base in times of stress.

Other researchers pointed out the similarities of the family and the military. Both have been termed ‘a greedy institution’ (Coser, 1967; Vuga & Juvan, 2013) which demands a high level of ‘social integration’ (Braswell & Kushner, 2012; Hatch et al., 2013). This dense network of interpersonal connections in an enclosed environment (Goffman, 1961; Soeters, 2018) might achieve the military’s goal of strong internal group cohesion (Boyt et al., 2005). Groups with strong and dense ties have greater potential to offer social support from within than social networks with weak and loose-knit connections (Thoits, 2011). For example, it has been demonstrated that unit cohesion among military personnel has a buffering effect. Strong unit cohesion weakens the relationship between stress exposure in prior life and PTSD symptoms after deployment (Brailey et al., 2007).

However, strong versus weak social ties do not say much about the quality of those relationships. Just as in families, strong social ties can be very dysfunctional, as many social connections and dense, close-knit social networks may not always be antecedents of supportive relationships. In fact, interpersonal relations in these occupational groups can be a double-edged sword, with aspects of both support and conflict. The police, for example, demonstrate family-like dysfunctional behaviours, such as interpersonal conflicts, disruptive behaviours, and bullying (Geuzinge et al., 2020). Bullying appears to be particularly prevalent in environments where subordinate hierarchical relations dominate because of their strong reliance on power imbalances (Nielsen et al., 2022; Turney, 2003). Sexual harassment is prevalent within the military (Harris et al., 2018), which is a hierarchical and disciplinary environment (Soeters, 2018).

To whom might one turn to for support when the ‘family’ creates a hostile work setting, i.e. when the family is dysfunctional, and when perpetrators’ friends or bullies’ friends are close-knit? It is vital for professionals, who frequently face potentially traumatic events, to have access to non-conflictual relationships and access to people who care for their well-being. In this light, it is not surprising that Gershon’s quantitative research showed that police officers who are the subject of an IID investigation rated it as among the highest impact events, even when compared to chemical spills, violent crime scenes, and hostage events (Gershon, 2000). As trauma specialists know, experiencing both support and conflict from the same person, or from within a supportive group, is associated with higher levels of personal distress and might increase the risk of traumatisation (Lyons, 1991).

Borrowing and adapting research findings concerning prevention, such as workplace mental health literacy programmes or resilience trainings, from an apparently similar occupational group might seem time and cost-effective. Examples include the military borrowing training models from professional sports; the police force looking at what works for the military organisation (Chappell & Lanza-Kaduce, 2010); teams in the ER, OR and ICU finding comparisons in aviation (Buljac-Samardzic et al., 2020); and firefighters copying specific interventions from military organisations (Cooper, 1995). Our findings suggest that when preventing or treating mental health problems, it is important to be aware of differences in the social environments of these occupational groups. For example, if interventions are done on group level it is crucial to be aware of contextual factors that might undermine a positive effect, such as interpersonal conflicts and dysfunctional behaviours within the work setting. Additionally, mental health care professionals could take these findings into account when making treatment recommendations. For example, group psychotherapy might not feel safe enough for professionals who highly value individuality or autonomy (Nitsun, 2014). Whereas, for professionals socialised for an occupation where the group is highly valued, this group norm in psychotherapy might undermine the development of individual autonomy (Yalom & Leszcz, 2020).

5. Limitations

This research involved observing and interviewing professionals and organisations in the Netherlands, limiting the extent to which the findings may be relevant to other countries. Additionally, for practical reasons, we chose not to observe deployed military personnel, which might also limit the generalisations of the findings. However, several scholars of the military argue that military communities have similar basic social arrangements across cultures and throughout modern history (Braswell & Kushner, 2012), and, as shown in the discussion, other research findings from countries across the globe showed many similarities to our findings.

6. Conclusions

Firefighters, paramedics, police officers, and military personnel, along with specialised nurses working in emergency rooms, operating rooms, and intensive care units, are frequently exposed to potentially traumatic events. To prevent mental health problems, it is essential for high-risk professionals to be embedded in a supportive social environment. This research shows noticeable differences in the social environments and social connections, which implicates that prevention and mental health treatment might also have to be differentiated among occupational groups.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Owing to the nature of this research, the participants of this study did not agree for their data to be shared publicly, so supporting data are not available.