First responders, law enforcement officers, firefighters, paramedics and emergency medical service (EMS) staff, emergency managers, security workers, military personnel and others are exposed on a daily basis to extreme stressors. These include life-threatening emergency scenes and “sensory-overload” with high levels of sights, odors, physical conditions and noises. Such stressors in combination might overwhelm the responders when they are called for several scenes consecutively. Such overstimulation might cause acute stress as a function of the levels of surprise and unfamiliarity, magnitude, duration, coping strategies and past experience of the first responder.1 Evidence shows stress effects the professional performance, the quality of the decision making and effectiveness of actions taken.1,2,3,4 LeBlanc et al. (2012) have shown in a clinical scenario experiment that higher levels of measured stress led to decreased clinical performance.5 In addition, such bursts of stress might also have negative consequences on the first responder6 such as post-traumatic disorders (PTSD)7 as well as other physical complications.8
For first responders, exposure to stress is inherent in their role and tasks9 and can have an immediate effect on their physical reaction, such as freezing.10 Such negative performance reactions have the potential to be devastating, especially in disaster scenarios. To combat this effect individualized countermeasures could be used to maintain and ensure quick, adaptive and effective responses. Successful training requires hands-on learning, evaluation of performance, assessment of quality decision making and accurate prioritization of tasks and contents. However, many current training programs do not accurately recreate real life situations with effective stressors. Without the appropriate level and variance of stressors, negative transfer or the lack of coping mechanisms may occur. This gap might have critical consequences during an emergency leading to an increase in errors resulting in loss of life, reduced effectiveness of the responder, and waste of critical resources.
New advancements in the area of virtual reality (VR) allow for a more adequate training for first responders. VR is a digital technology method that was designed to simulate a physical environment, which precisely reflects human interactions with an environment and so creates experiences not otherwise possible. It simulates a truer representation of real emergency scenarios with more accurate personalized sensory input coupled with more natural physical interaction with the virtual world. The sensory strength of VR can be leveraged in stress management training by better exposing the trainee, both qualitatively and quantitatively, to potential disturbances in the emergency scene. These stressors include visual, auditory, smell, tactile, proprioception, vestibular and the internal state of the body.
VR should activate and provoke all these senses simultaneously. The activated senses will stimulate emotions that have direct influence, likely negative, on the functioning and efficiency of the trainee. VR can be used to enable hands-on experiential learning for first responders in hazardous environments based on real emergency scenarios. Using such technology could lead to advanced mental and cognitive resilience of first responders, by allowing them to personally and collectively develop and practice various coping mechanisms to increase their psychological stamina, adaptability, functioning and resilience in any given emergency or disaster situation. The current paper will discuss the advantages of using VR simulations in first responder training for improved stress management and overall performance.
First Responders and Stress
First responders perform complex and stressful tasks in uncertain settings, which pose threat to others and/or to the rescuers themselves. During emergencies, stressors can appear in various forms, including physical (e.g., extreme temperatures, dehydration or life-threatening environment), psychological (e.g., anxiety, information overload or deficit, time pressure), job-related / organizational (being responsible for the life of other people, role overload) and psychosocial-related.
For example, responders might experience observation-anxiety and performance anxiety, when bystanders and the media are present at the scene and they feel under examination, assessed and even criticized. Such stressors were found to negatively affect cognitive performance (see Martin et al., 2019 for a systematic review of some of the stressors).1 At certain levels, however, stress might contribute to engagement, increased alertness and situational awareness such as low operational stress among police officers patrolling in neighborhoods.4 In addition, Folkman & Moskowitz (2000) suggest positive emotions and adaptive mechanisms can also arise during acute stress.11
A professional response demands powerful physical, physiological, emotional and cognitive capabilities. Stress, which is inherent in every emergency, crisis or disaster event, is expected, unavoidable and unpreventable, and can negatively affect the performance of first responders by disrupting their emotional and physiological processes.12,13 Therefore, there is a need to manage the stress, i.e. decrease its magnitude and duration of its effect on a person. Such stress management is a fundamental skill for first responders and could have an impact on the responder’s personal safety, performance and long-term mental state. Responding to a sudden stressful situation might cause arousal, “freeze,” “flight,” “fight,” tonic or collapsed immobility behaviors56, which have certain physiological characteristics.
For example, “freeze” behavior includes heart rate deceleration, which allows for situational awareness to the surroundings.10 Research has shown that experience, gained both by real-life experiences and training might decrease the basic responses to stress, minimizing the triple-F (freeze, flight and, fight) and allowing for a controlled, adaptive and faster response. Ly et al. (2017)10 found significant differences between experienced and inexperienced firefighters in freeze levels given exposure to unpleasant images. Also, according to the “Basement training model”14, training allows those who operate under uncertainties to shorten the time and magnitude of “being in the emotional basement” and regain awareness and mindfulness to self-abilities, procedures, expectations to perform adaptively to the new and extreme situation.15
Further, several mental preparedness techniques have been suggested to be integrated in first responder training including mindfulness, psychophysiological intervention, breathing control and visualization.12,16 Such stress management practices are important for developing resilience, which might allow an adaptive response to an emergency situation as well as increase self-awareness to the first responder’s abilities and difficulties in their reactions to the situation.12 This might lead to improved and specific training, in which the first responder will develop his/her coping abilities.
The Critical Role of Stress Management in First Responder Functioning
First responders are frequently exposed to stressful situations and emotional events, which have some level of impact on their overall performance and well-being, both on the immediate and/or long-term. Stress management might influence five dimensions in emergency response (Figure 1):
- First responder well-being: Emergency situations and extremely stressful conditions are a major cause of mental health difficulties that influence the well-being of first responders.17 Given the nature of their occupation, first responders are at higher risk of developing mental health disorders and illnesses such as anxiety, depression, alcohol abuse and PTSD.18,19,20,21
- The emergency organization: The mental health of first responders is a leading cause of work dissatisfaction, absenteeism and long-term disability.23,24 The stressful emergency situations are an important cause for occupational burnout.25,26 Poor social and organizational relationships were found to lead to elevated levels of PTSD and stress among EMS staff.21 Also, positive relationships were shown to be protective and helped coping among various first responders.27
- The end-users: First responders play a crucial role in providing critical services that sustain the health, safety and security of local communities. First responder end-users, be them victims, bystanders or the general public benefit from increased chances of life-saving. Professional response delivers positive outcomes which are expressed in improved rescue efforts, decreasing patient’s mortality and morbidity, decreasing suffering and loss, elevating public trust and increasing community resilience28.
- Economic costs: Economic costs of emergency organizations are generally divided to two main areas: human resources and operational/logistics. The staff costs include recruitment, training and salaries. The operational/logistics costs include equipment, materials, physical assets, etc. Training plays an important role in preventing injuries, which have significant direct and indirect costs, such as treatment, compensation, as well as the need for shift staffing and response time.29
- Lawsuits: Due to their sensitive function as rescuers in high-risk areas, first responders are prone to lawsuits in various domains. In the case of EMS it includes motor vehicle accidents, paramedic behavior, negligent treatment30 as well as late response, mechanical equipment failure, and patient-lifting injuries.31 Such claims leading to litigation or lawsuits might cause first responders to refrain from any diversion from the protocol even if the immediate medical need calls for it, or in the case of police officers effect their reaction.32 The consequences for the organization are financial with increased insurance rates as well as potential monetary losses in litigation, and loss of trust and reputation with the public. Therefore, efforts should be made to minimize such cases.
First responder training must include these considerations as means of protecting and enhancing their mental and physical health in order to achieve improved outcomes in all five dimensions.
Challenges of First Responder Training to Function Under Unique Psychological Stressors
Training is the ultimate way, along with hands-on experience, to prepare first responders to respond efficiently and effectively in emergencies and disaster scenes. Mossel et al (2019) summarize three classic training methods: training in classroom with instructors teach and demonstrate; (2) An asynchronous learning using modules on electronic websites; and (3) drills and tabletop exercises.33 Ashkenazi et al. (2010) highlights four types of drills for emergency responders:
- Focal exercise which trains for a response to specific tasks in mass casualty events;
- Table-top exercises for senior executives who are supposed to make connectivity decisions in the strategic level;
- Functional exercises for all personnel participating in the response, at the tactic level; and
- Large-scale drills, which imitate real emergency scene(s) that includes the participation of other parties, involved in the emergency response, such as hospital staff, community representatives, local authorities among other.34
These methods allow emergency responders to constantly learn and improve their skills, response techniques, do’s and undo’s, safety and security. However, such training processes are not optimal. First, they lack the ability to pose real stressors, in terms of their volume and diversity, and to practice actual response in various difficult environments. Second, some scenarios cannot be fully practiced in real-life as they pose high levels of danger to the trainee and are too complex to be practiced in real life, such as crowd emergency behavior, explosions, toxic gases, mass evacuations, epidemics, etc. Lastly, exercises and training are expensive. These expenses include both operational costs, such as the costs of drill materials and setting the drill surroundings, as well as organizational costs such as staffing shifts while other personnel attend the drills.
Consequently, first responders will not be prepared for a full range of disaster scenes, and they will lack important skills and emotional capacity which could affect their performance. Poor or inadequate training might lead to bad decisions during the emergency, which might cause medical complications to the victim, delayed response and risks to both the victim and the responder. Wilkerson et al. (2008) mention three failures or risks in first responder functioning: wrong, missing or partial compliance to treatment protocols, such as triage and overtreatment;35,36,37 Lack of coordination between first responder from different organizations38 and little or no attention to on-site hazards and risks39. These failures have significant impact on the overall response and must be trained and on and exercised in scenarios.
One major challenge is to provoke real stressors and create an authentic scenario in the training process that can elevate the levels of individual’s stress and allow them to experience these stressors in order to perform better. Such training can gradually balance the natural but undesired physiological and mental response to stressors by allowing the trainee to experience it in a secure, controlled, measured and repetitive setting.
Training as Moderator for Stress Management
Professional training is an important moderator in the relationship between first responder occupational-stress and performance. Training first responders for stress coping techniques in a non-stressful setting can reduce real-time stress and increase performance.40 Such training intends to develop and elevate the individual’s capacity to adapt positively to emergency multi-stress situations and to recover quickly to functional equilibrium. Stress management training programs are increasingly being adopted by emergency management systems for primary stress containment and resilience empowerment. Such programs are grounded, theoretically, in problem-focused coping or emotion-focused coping.41
However, there is a gap between actual real-life emergency scenes and the training scenario and conditions. Limiting factors such as time, safety and costs will determine the extent, depth and frequency of such training scenarios. This is particularly relevant during scenarios involving large-scale mobilization of population or deployment of multiple medical and public health resources. One solution for these limitations is embodied in VR technologies, which can simulate various scenarios and trainers can use their capabilities to bridge the limiting factors and gaps of other traditional training formats.
Stress Management Training Using Virtual Reality Technologies
Utilizing VR in first responder training might lead to improved results at both the individual and team levels. This technology has been used for exposure therapy (VRET), such as in cases of anxiety and phobia.42,43,44 Lackey et al. (2016) found that stress and workload perceptions were reduced after VR training in military personnel.45 Using VR in training for stress management will increase a first responder’s self-confidence and allow them to develop situational awareness more quickly.
Consequently, this might improve decision making process, performance, and the chances of saving lives. In addition, applying different stress levels will also allow the trainee to examine their emotions, reactions, and develop coping mechanisms for improved performance during emergencies. In terms of training, utilizing VR in learning processes was found to be cost-effective46 and has led to improved learning results47 in comparison with in-class learning.
Using VR technologies for first responders could improve performance especially through stress management. Bouchard et al. (2010) referred to the following stressors in a military VR training: seeing dead bodies or uncovering human remains; knowing someone being seriously injured or killed; receiving artillery fire; being unable to help ill or wounded civilians because of the rules of engagement; seeing destroyed homes and villages; clearing and searching homes, caves, or bunkers; receiving small-arms fire; and participating in demining operations.48 Jensen & Wrisberg (2014) added additional stressors which were found in soldier reviews after hand-to-hand combat training: “a fear of causing a threat to the mission as well as the possibility of (a) endangering their fellow soldiers, (b) being captured, (c) losing the support of local citizens in a combat zone, and (d) being isolated from comrades.”49
While Bouchard et al. (2010) stressors included experiences within a given reality, Jensen & Wrisberg (2014) related side-effect and other emotional and mental stressors that must be taken into consideration when developing first responder’s stress management training.48,49 Another important stressor group includes social and relational traumatic events such as severe injury, death of a colleague or a family member, and complex emergency scenes in which the first responder is rescuing a victim which they might know personally. Scenarios in which children are involved are also significant stressors.50
Wilkerson et al. (2008) describe the CAVE VR system for medical (EMS) personnel.35 Stressors in a simulation of an explosion during a sport event in a stadium included visualizations of casualties and patients in different conditions and sounds such as explosions, noises of bystanders and victims such as screaming and crying, alarms and sirens. Narciso et al. (2020) evoked presence emotions among firefighters in an experiment comparing VR simulation with a real world exercise.51
Advantages for using VR in training first responders are both educational and technical. VR training simulates stressors that are titratable within a given scenario. This allows for a gradual exposure of first responders to stressors which leads to the development of coping mechanisms due to the personal experience as well as the instructor’s feedback. VR creates, both technologically and psychologically, an illusion of being immersed in a real environment that imitates external threats and generates internal stress. VR technologies can be used at both initial and/or advanced stages of the training process. For example, trainees can experience and operate new equipment before it is being fully installed for operational usage.52 VR enables the trainee to experience a threatening emergency scenario in a safe and controlled zone while enhancing practical learning.53
The volume and type of the stress posed to the trainee can be optimized to fit exactly to the level of the trainee. Trainees can repeat the scenarios and enhance and upgrade their learning according to the training plan, trainee’s pace, timetable and professional needs. An important aspect that should be addressed, is the risk of triggering new or old psychological trauma among trainees. In this case, VR training offer a solid background to develop psychological stamina and resilience among first responders, given the controlled and gradual exposure to the stressors. Not as in traditional training or real-life events, in which exposure to stressors is built-in and had been considered by the individual once they chose to be part of such teams, using VR training allows for supervised and even tailor-made exposure, fitted to the capabilities and needs of the trainee.
Table 1 compares stress management dimensions between traditional training, VR training and real-life events. Quality VR training not only overcomes the shortcomings of traditional training, but it also poses new opportunities for handling real events because of the low risks to the first responder well-being, lowered costs and variability of scenarios.53
First responders perform complex tasks in extreme environments, which vary in their size, volume, characteristics and risks. Although acquiring basic and advanced professional skills are fundamental in the training process, stress management is also a major component in the first responder’s professional education and capabilities. Many and various stressors might appear simultaneously or emerge gradually and affect the first responder’s reaction.
As stressors activate the individual’s senses and challenge their cognitive abilities, even experienced first responders might not be resilient to a sensory overload, and in the case of first responders, errors or failures in their performance might be critical and dramatic. Training, including drills and exercises, are frequently used for simulating stressful environments. The challenge in effective training is twofold: first, simulating a real environment, without posing actual physical threat to the trainee. And second, how to measure successful training outcome, and especially improvement in comparison with prior exercises.
Advancements in VR technologies allow for bridging these gaps. A virtual environment will not only simulate an emergency or disaster scene, in terms of the physical conditions, but it will also allow exposure to various scenarios further contributing to the learning process itself. Using VR simulations will contribute to the following domains:
- Improved learning and development of professional skills: Training in VR environments will deliver feedback and performance evaluations to the trainee and the instructor, as well as collective feedback to the entire team. In terms of learning outcomes, VR is a cost-effective and efficient methodology at both the individual and team levels: VR simulations are not-geographically bounded, and can be performed in large or small scales, which contribute to its cost-effectiveness. Utilizing VR training reduces the amount of instructor time (limiting it to more discussion and one-on-one debriefing). It also creates a more efficient means of assessing readiness (thus reducing overall time in training reducing costs). Further, it can adapt to individual trainees needs (as training becomes individualized rather than by classroom cohort increasing effectiveness). Lastly, VR can equalize training opportunity and standardize certification (since the system would be available to both large and small departments). Specifically, in terms of costs, VR headsets and infrastructure are becoming much cheaper while maintaining high immersion capabilities. Additionally, while an initial development cost is needed to implement the initial VR software framework, the adaptation ability of the software allows for a significant lifecycle or use where updates and modifications to the training would be significantly less effort. Furthermore, over time, and with increasing numbers of trainees, costs are reduced.22
- Safety and security: The VR environment is safer for the trainees as the trainees are immersed in the simulation where there is no actual contact with hazards or threats which characterize disaster scenes.
- VR training could support staffing decisions, such as recruitment and promotion. VR simulations allow for measurement and monitoring of the actual functioning of the first responders, their strengths and weaknesses, and self-paced development of coping strategies. Given the specific and significant work-related stressors, personal risk as well as mental and physical demands, emergency organizations face recruiting and retention challenges of appropriate candidates. Using VR simulations and training will allow the examination of the mental and cognitive fit of candidates in three ways: (a) improved recruitment through efficient selection of candidates; (b) preparing first responders to respond in the most professional and effective way to various scenarios; and (c) achieve better performance outcomes by saving lives, decreased errors and failures, and decreased lawsuits and harm.
- 360degree training and inter-organizational information sharing: As described in this article, first responders from different organizations operate in the disaster scene under extreme conditions and uncertainty. Using these simulations can enhance inter-organizational cooperation and collaboration among firefighters, police officers and EMS as well as with medical command and control center (MCCC) and hospitals in the surrounding areas. In this sense, the VR simulations can not only validate current guidelines, regulations and working methods34 but can also contribute to the creation of such guidelines in case of needs.
- Complex unknown disaster scenarios: Various scenarios such as complex coordinated terrorist attacks (CCTA)54 and mass gatherings55 are extreme scenarios which might have a dramatic effect on first responders due to their complex, uncertain and dangerous nature. In CCTA events, although first responders were trained to function in certain events of a singular type, the combination of intense multiple events and the extreme stress which overflow and activate the senses, emotions and mental abilities at once all lead to critical errors and tragic consequences that could be mitigated or altogether avoided with appropriate training and preparedness.
Utilizing VR technologies for first responders would maximize their training and exposure to various environments and scenarios, as well as contribute to development of stress management capabilities. Such improved skills are invaluable for performing under extreme conditions and saving lives.
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