INTRODUCTION
The consequences of a major disaster are not restricted to individual suffering but affect families and communities and cause national crises [
1]. Firefighters who are first responders in disasters not only experience direct trauma related to injuries and life threats but are also vulnerable to surrogate trauma [
2]. In addition, they experience urgency and danger, intense working conditions, such as waiting for dispatch 24 hours a day. As a result, they experience psychological difficulties working while experiencing mental stress due to co-workers' accidents and danger to their own lives [
3]. Moreover, they repeatedly exposed to field work even if they experience psychological difficulties after traumatic event [
2].
Firefighters are at high risk for mental health problems, including post-traumatic stress disorder (PTSD), depression, and alcohol abuse. As a result of Korean firefighters who received hospital treatment in 2016 and 2020, the number of firefighters suffering from depression nearly doubled from 364 in 2016 to 650 in 2020. There has also been a steady increase in the number of firefighters who have visited hospitals with PTSD symptoms, from 37 in 2016 to 67 in 2020[
4]. In the study of scoping review on prevalence of PTSD among firefighters, it was found that the prevalence rates of PTSD symptoms in firefighters also vary from 6.5% to 37%[
5]. Mental health issues in firefighters cause workplace injuries, family and co-worker conflicts, absenteeism, and turnover, which affect their work performance [
6]. Additionally, the individual problems of firefighters are directly related to socioeconomic losses [
6,
7]. However psychological difficulties are unavoidable for firefighters. As a result, it is very important to provide interventions to assist firefighters in overcoming trauma, leading to positive changes after traumatic experiences [
2,
3,
6].
Several diverse psychological interventions are available currently that recognize the importance of mental health management for firefighters [
2,
6]. Most of them are interventions based on cognitive and behavioral theories, such as mindfulness therapy, acceptance commitment therapy, and emotional freedom technique [
6]. Education, counseling, group therapy such as forest healing camp and music therapy are also provided [
8,
9]. However, most studies have developed generic interventions without accounting for firefighters' length of service, position, or job characteristics [
6]. Even if a firefighter is exposed to the same traumatic event, the prognosis is different depending on the function and location [
10], and the primary complaint varies according to the period after the traumatic event [
11]. Therefore, psychological interventions for firefighters should consider their trauma-related characteristics and job characteristics.
Psychological interventions for most firefighters in Korea to date have developed and standardized general interventions rather than targeted interventions. In particular, although the Fire Psychology Support Center has been in operation since 2015, effective intervention studies based on understanding of fire officials' duties, trauma characteristics are insufficient, and absence of systematic manuals lead to regional inequality [
6]. Moreover, given the hierarchical work culture, existing psychological support services cannot be used freely [
12]. Based on these points, it was felt that it was urgent to understand the perception and the demand for psychological intervention of firefighters. However, there have been few prior qualitative studies on firefighters' experiences or perceptions of psychological intervention programs. Therefore, existing research alone is not sufficient to determine the psychological intervention programs needed for firefighters.
Following the COVID-19 pandemic, firefighters are frontline workers who respond to transportation and treat sick patients. This has caused firefighters to fear exposure to COVID-19, which increases the stress on firefighters at work [
13]. As a result of the analysis of the national health survey of firefighters in 2021, 5.7% of those suffering from PTSD and 4.4% of firefighters with depressive symptoms were confirmed, which was a slight increase compared to last year. This is interpreted to have been influenced by the increased burden of additional work such as field visits due to the spread of COVID-19 [
14]. It is clear that the COVID-19 situation affected the psychological state of firefighters.
The focus group interview is an appropriate methodology for needs assessment and perceptions research. Focus groups can be used to determine program direction or needs, before beginning the program. The focus groups provide a wider range of information to the interview that participants' ideas continue to build on themselves and create synergy, giving way to the unexpected, frankly [
15]. Focus group interviews go a lot further in allowing for candor not found in individual interviews. This is because focus group participants are mutually empowering and share different opinions [
16]. Therefore, this study attempted to grasp the perception of firefighters on psychological intervention programs during the COVID-19 Pandemic using focus group interview. The findings of this study are expected to lay the foundation for the development of psychological intervention programs for firefighters.
DISCUSSION
Regarding the barriers preventing participation in intervention programs, participants indicated additional workload along with firefighting work. Particularly, participants stated that they could not afford to participate in psychological intervention programs due to quarantine measures and additional work caused by COVID-19. They found it burdensome that someone had to replace them while they attended the programs. In fact, for 3 months from March 1, 2020, 34.5% of firefighters in New York City were on sick leave due to a suspected or confirmed COVID-19 outbreak, which reduced the number of emergency medical services personnel to meet the surge since COVID-19 [
22]. This demonstrates that the absence of firefighters will inevitably increase the workload of other firefighters.
Additionally, the participants stated that most psychological interventions were conducted during working hours and at the workplace to increase the participation rate, but it was difficult to concentrate on counseling in a situation in which the call bell would ring anytime, and the atmosphere was formal. This is supported by previous studies showing that a comfortable and private therapy office facilitates counseling [
23]. Since hyperarousal, one of the main symptoms of PTSD, is caused by environmental factors such as exposure to situations, it is essential to provide a comfortable counseling place and situation for effective counseling by firefighters [
24].
Further, the number of consulting experts was too small compared to the number of firefighters, and special intervention programs were limited. In Korea, very few psychological counselors belong to the National Fire Agency, and this majorly involves employing external professional psychological counselors [
25]. As a result, the program quality ends up being poor, and it inevitably becomes a formal consultation. Similar situations have been experienced in Canada, as it is difficult to consult a professional counselor; therefore, the recommended alternative was to increase the access to other creative art therapies such as music, yoga, and drama [
26]. Therefore, it is needed to develop an online psychological support system that can replace the insufficient number of experts in Korea, and to provide special intervention programs useful to firefighters with limited experts. In addition, it is necessary to create a more friendly environment for psychological counseling to minimize peer stigma by participating in a psychological counseling program [
26].
The number of people who can participate in the programs is limited. For instance, In Korea, only 180 firefighters (9%) participated in the "Stress Relief Program", which was originally planned for 2,000 firefighters, and it was confirmed that only 14.9% of the KRW 1 billion budget was implemented [
27]. Moreover, among firefighters who are at risk for developing PTSD (n=1,995), very few (9.7%) received mental health treatment in the past month [
28]. In addition, recent psychological intervention programs observed an even lesser number of participants, due to COVID-19 concerns regarding the spread of infection. For facilitating benefits for a larger number of people, future research should develop programs with high accessibility amidst all conditions, and alternatives such as, group counseling, smartphone applications, and non-face-to-face programs.
Finally, if someone attends a special intervention program in Korea, someone else has to do their job. Therefore, participation requires assistance at the organizational level. Furthermore, participation in such psychological counseling programs should be treated as an official leave of absence, rather than as working hours so that participants can attend without experiencing any pressure.
Regarding the suggestions to develop effective intervention programs, participants said that such programs should focus on positive content. Academia and industry are now turning to new perspectives focused on practical solutions that improve the resilience of workers [
2] and the positive attributes of individuals and organizations [
29]. Despite experiencing traumatic incidents on the job, most firefighters overcome this shock and continue to take responsibility for people's lives and safety at disaster sites. Therefore, it is necessary to develop a program that promotes positive aspects such as post-traumatic growth of firefighters.
Psychological intervention programs for firefighters should in particular be provided by professionals familiar with the nature of firefighting work. This is because a person familiar with the characteristics of the job can give practical advice. In this regard, Henderson et al. [
30] state that consideration of organizational belonging and personal factors in firefighting culture is very important for firefighters' psychological management. Kitt [
23] found that firefighters were frustrated with advisors who did not understand the firefighters' culture and work. Many studies have recommended a counseling program involving experienced firefighters, possessing knowledge regarding firefighter duties [
26]. Alternatively, many firefighters prefer peer-led Critical Incident Stress Management, which improves adaptability and resilience and reduces stress [
26]. Future studies need to extend psychological support programs toward co-workers.
Since firefighters have different types of trauma according to their job characteristics, it is necessary to develop an intervention program that considers job characteristics such as fire suppression, first aid, rescue, and internal work rather than implementing a general program. In addition, these programs should consider personal characteristics as well. Novice firefighters were exposed to approximately nine potentially traumatic events during their first 3 years in the fire department, 66% of which occurred while on duty [Gulliver, 2021]. Furthermore, programs should be tailored to account for the differences in each individual's coping strategies. A recent Korean survey evaluated the psychological variables of all firefighters [Kim, Dager, 2018]. Subsequently, high-risk groups were identified and appropriate interventions were undertaken. However, there is a need for more systematic mental health management for firefighters.
The psychological intervention provided to firefighters should be a long-term, ongoing program, not a one-time intervention program. In Korea, psychological support programs hosted by the Fire Department are provided in the form of outsourcing contracts with new companies every year. Therefore, the program lacks continuity, quality control is difficult, and there are also significant regional differences. In Australia, since 2013, MAPS (Mental Agility and Psychological Strength) has been developed for the primary prevention of PTSD in firefighters and its effectiveness has been continuously reported [
7]. Similarly, Korea also offers psychological counseling programs for the past 6 years and strives to provide sustainable programs [
6]. However, the entity providing the program must be maintained continuously.
Moreover, participants stated that they needed intervention services that were available any time after a traumatic event without restrictions on working hours. Joyce et al. [
2] also reveal that a multifaceted approach across all levels of the organization is required for a mentally healthy work environment in a study that developed an Internet based resilience program for firefighters. Online psychological intervention programs are essential to improve accessibility.
Finally, participants emphasized that a supportive organizational atmosphere and institutional support were important for the effective implementation of psychological intervention programs. Firefighters do not often exhibit psychological difficulties in trying to maintain their image of "trust". Moreover, psychological issues within firefighter organizations are not well understood as they tend to hide a negative organizational culture. Consequently, good facilitation strategies are needed to overcome the silence and stigma associated with mental health in the firefighter culture [
23].
In summary, firefighters want "flexible, effective, positive aspects based, and tailored" psychological intervention programs. In other words, although various psychological interventions are provided, these programs must be flexible enough to fit the specific individual and professional characteristics of firefighters. Additionally, the programs must be of practical use to firefighters and should not be perfunctory programs. Finally, there is a need to concentrate on the positive content without continuing to reflect on the negative aspects of traumatic events.
In this study, focus group interview and qualitative content analysis were applied to examine Korean firefighters' perceptions of psychological intervention programs during the COVID-19 pandemic. The strength of this study is that it presents detailed and clear barriers and suggestions based on interviews of firefighters working in the field. Based on this, it is expected that practical mental nursing interventions for firefighters can be developed. In addition, as a domestic firefighting hospital is scheduled to be established in 2024, it is expected that the main research results will be used as basic data for firefighters' trauma management and holistic nursing. However, it is difficult to generalize the findings from this study because only limited subjects were involved in a city. In a future study, it will be necessary to investigate the perception of psychological intervention for firefighters who have other work than emergency medical services and administrative work.