Stress and Paramedics: Causes and Effects

Table of Contents

TOC o “1-3” h z u Abstract PAGEREF _Toc358761246 h 21.0Introduction PAGEREF _Toc358761247 h 32.0Literature Review PAGEREF _Toc358761248 h 43.0Methodology PAGEREF _Toc358761249 h 5Research Design PAGEREF _Toc358761250 h 5Sampling Method PAGEREF _Toc358761251 h 6Data Collection Method PAGEREF _Toc358761252 h 7Data Analysis & Presentation PAGEREF _Toc358761253 h 7Ethical Considerations PAGEREF _Toc358761254 h 84.0Results and Findings PAGEREF _Toc358761255 h 8Positive work effects PAGEREF _Toc358761256 h 9Stress factors PAGEREF _Toc358761257 h 9Effects of stress PAGEREF _Toc358761258 h 105.0Discussion PAGEREF _Toc358761259 h 106.0Recommendations PAGEREF _Toc358761260 h 127.0Conclusion PAGEREF _Toc358761261 h 13References PAGEREF _Toc358761262 h 14APPENDICES PAGEREF _Toc358761263 h 16Appendix 1: Interview Guide for the Respondents PAGEREF _Toc358761264 h 16Appendix 2: Thematic analyses PAGEREF _Toc358761265 h 19Appendix 3: Ethics Form A PAGEREF _Toc358761266 h 23Appendix 4: Face Sheets PAGEREF _Toc358761267 h 59Appendix 4a: Face Sheet 001 PAGEREF _Toc358761268 h 59Appendix 4b: Face Sheet 002 PAGEREF _Toc358761269 h 60Appendix 4c: Face Sheet 003 PAGEREF _Toc358761270 h 61Appendix 4d: Face Sheet 004 PAGEREF _Toc358761271 h 61

AbstractThis study aimed at establishing the effects that stress had on the motivation, morale and overall performance of Paramedics. It sought to establish the relationship that existed between these causes and the effects.

The study was descriptive in nature and aimed at exploration of experiences, views, perceptions and observations. Qualitative data collection methods were adopted and the researcher used one on one interviews. The population was defined as paramedic students in Flinders University who had worked in Saudi Arabia and involved a sample size of four respondents.

The study finds that though paramedics feel motivated by adequate training and service to people, a wide range of factors contributes to them getting job related stress. These factors include work overloads, long working hours and poor channels of communication among others. The research also established that stress causes reduced performance, low morale and increased rate of absenteeism among paramedics.

The study concludes that stress in paramedicine comes from many sources and all stakeholders are contributors as well as victims of the stress. It then goes ahead and suggests some ways in which stakeholders can reduce the causative agents of stress.

1.0IntroductionWork related stress is a well known phenomenon in many professions. However, some professions are more prone to it than others. Paramedicine, by its very nature, is among the professions with the highest risks of stress and its many manifestations. Extensive research has been carried out on stress, its characteristics and effects on paramedics.

This research aimed at addressing itself to the causes of stress in paramedics and the effects it has on their morale, motivation and performance.

The study approached the issue on a causal – effect theory with the aim of determining how the paramedics felt the various factors that they feel predispose them to stress would affect their overall on-the-job performance.

The study also sought to fill a gap left by other studies in that it did not draw its own recommendations but will sought to gather these from the paramedics themselves thereby emerging with home-grown solutions for Paramedics problems.

2.0Literature ReviewStress has been found to heavily affect the level of employee output. Stress and its resultant burn out have especially been found to negatively affect the operation of paramedics and their level of job satisfaction (Nirel et al. 2008; Blau et al. 2011). A 2002 research study done to follow up the health and stress in the Ambulance Services Victoria indicated the main causes of stress among paramedics in the unit to include issues that pose as a hazard to their personal safety and having to watch a colleague in serious pain or injury, or to witness his death. The level of stress was however found to have decreased as compared to that of 1993. The study that involved 52% of the Metropolitan Ambulance Service and Rural Ambulance Service’s paramedics indicated an improvement in stress management among the paramedics since 1993 (Robinson 2002).

Qualitative studies have identified the nature of the job (that entailing helping others and saving lives), passion, variety and to some, the pay and associated benefits as being the main motivations behind taking up the paramedics career (Nirel et al. 2008; Vettor & Kosinski 2000). The main pressures that arises in undertaking of the paramedics’ roles include the low level of support from the top management, long working hours with lots of time spent at work hence very little time left to attend to family and personal issues A further issue is demoralizing compensation that includes a low pay as compared to the amount and complexity of work done (Nirel et al. 2008; Blau et al. 2011).

Studies conducted have identified workload, poor health, burnout and stress as being the greatest contributors of job dissatisfaction among paramedics. Paramedics are at a high risk of stress and burn outs as their job exposes them to stressful situations and tragedies that include injuries, death and harsh working environments. These highly result into emotional and psychological exhaustion (Vicki et al. 2005), factors that result into stress and burn out, which in turn leads to an increase in rates of resignations, poor work attendance and demoralization (Vettor & Kosinski 2000).

Previously, no qualitative research had focused on the use of projection methods to fore cast the possibility of paramedics and Emergency Medical Technicians having stress and burn out. Vettor and Kosinsinki (2000) focused on the use of early recollections as a predictive method for stress assessment. The use of early recollections as indicated by the authors could be an effective way through which organizations can be able to identify paramedics and EMTs susceptible to stress and burnout. This would in turn reduce the incurrence of extra and unwanted costs related to replacement of resigned workers, treatment for employees, employees’ failure to attend work and sick leaves.

The most suitable theory for the undertaking of this research is the coping theory. This theory explains how organisms react to various situations and the means through which they are able to deal with any arising problem. In this case, the theory was important in answering the research question on how stress affects the operation of paramedics. It was useful in identifying how paramedics react to stress at work, how increased stress levels have affected their daily undertaking of duties and the various strategies put in place to reduce the level of stress as well as its effects.

3.0MethodologyResearch DesignThis study utilized descriptive design to gather relevant information in an explanatory manner (Mantri 2009). This research design was be constructive in the exploration of participants’ experiences, perceptions, views and observations from student paramedics from Flinders University. The design incorporated qualitative methods of data collection and research and involved one on one in-depth interviews with paramedics who have worked in Saudi Arabia.

Sampling MethodThe study participants included a purposively selected sample of n=4 Saudi paramedic students from Flinders University in their final year of study. The researcher used his contacts and membership in the Saudi Paramedic association to select students who would take part in the study. This was a form of purposeful sampling involves the selection of respondents based on a set of required characteristics (McBurney & White 2009). Once this group was identified, the researcher then used simple random sampling to come up with the sample of four respondents. The respondents were contacted through emails and requested to grant the researcher an interview. Luckily, none of those sampled turned down the request to be interviewed.

The participation in the survey was entirely voluntary and no incentives were offered. The following table summarises the profiles of the survey’s respondents.

Table 1: Participant profile

Participant ID Sex Work duration Comments

001 Male 7 Years Cooperative and resourceful

002 Female 6 Years Successful interview

003 Female 4 Years 6 Months Very informative interview

004 Male 12 Years Very Cooperative

Source: Researcher, 2013.

Data Collection MethodThis study deployed a qualitative data collection method. Data for the study was collected through one-on-one in-depth interviews. This data collection method was preferred over focus group interviews mainly because the study deals with sensitive personal issues that participants may not be willing to share in a group. The sample was also small; hence, conducting one on one interview was possible without taking too much time. An interview guide was constructed to aid in the collection of data (Appendix 1) (Mantri 2009). The design of the interview guide was aligned with the insights from the research question as well as the literature review so as to cover specific areas of interest relevant to this study (Grbich 1999). The interview entailed the use of open ended questions.

In order to test the credibility of the interview guide, a pilot interview was conducted to identify possible areas of difficulty in understanding, ambiguity and irrelevance with regard to the research question (Grbich 1999).

Data Analysis & Presentation

To analyse the research data collected, preliminary analysis and then thematic analysis (Appendix 2: Thematic analysis) approach were used. This involves studying the obtained patterns of responses or observations from the respondents (Grbich 1999). In this case, the obtained findings based on the responses given by the respondents were presented through the use of the descriptions given by the respondents during the interview and in response to the asked questions.

Thematic analysis is an important analysis tool in qualitative research since it identifies the implicit and explicit concepts captured in collected data. It puts its emphasis on the description and organisation of a data set. The method can be used inductively or deductively and the researcher opts on the application depending on the epistemology of their study (Boyatzis, 1998)

Ethical Considerations

It is important to note that the sampling process, piloting and actual data collection processes were conducted informally and with the verbal consent of participants. For the purpose of observation guidelines, the researcher sought the approval of the Social and Behavioural research ethics Committee (Appendix 3: Ethics form)

As the data collected during this study contains very sensitive and personal information, all participants were assured of total confidentiality, anonymity and guaranteed that the findings of this research shall not cause them any professional or reputational harm whatsoever (Mantri 2009; Grbich 1999). It was important for the researcher to identify the possible harm or damage, both personal and professional, which could be caused on the participants if any of the information given was traced back to them. Finally, the findings of this result were used and disseminated exclusively for academic purposes.

4.0Results and FindingsMajority of the participants in the research were practicing paramedics seeking further education in medical related fields. The data was organised into face sheets (Appendix 4). Four themes were identified in the description of the available data and labelled, positive work aspects, stress factors, stressor effects and possible solutions. The participants provided concise information for the different themes identified. They discussed their work experiences and identified numerous challenges which faced them when undertaking their duties as paramedics.

Positive work effectsThis theme aimed at capturing the specific elements inherent in the work that boosted the morale of the practitioners. The participants identified factors including adequate training which made feel them competent enough to offer the services required to them. The most prevalent motivation under this theme though was the service to the people angle with 75% of the respondents saying that they derive satisfaction from having saving lives or assisted a person in need of medical services. As Respondent number two put it,

“Most people in Saudi Arabia cannot access medical care . . . . . . . being able to serve people so desperately in need of medical care is inspiring.”

Stress factorsThe aim of this theme was to establish the various factors that paramedics consider as the major causes of job related stress. This was the main theme of the research. It emerged that a wide range of factors contribute to stress in the workplace. Huge workload was the most prevalently mentioned source of work related stress with 75% of the respondents mentioning it directly or mentioning some of its causes. The workload was said to be caused by understaffing, terrorism and violence. Another cause of stress which was mentioned by 50% of the respondents was long work hours which lead to burnout. Poor communication channels were also cited as a factor leading to stress. The respondents also mentioned Traffic congestion, lack of crowd control mechanisms and the ever increasing threat of malpractice litigation as factors that interfere with their work reducing efficiency which then interprets to frustration and stress.

Figure 1: Causes of stress among paramedic

Source: Researcher, 2013

Effects of stressThe respondents were unanimously (100%) agreed that the major result observed on stressed paramedics is reduced morale and motivation. This was also indicated to result in reduced efficiency and productivity by 75% of the respondents. 50% of the respondents said that a stressed paramedic was prone to errors. In the long run, the respondents (75%) indicated that stress takes its toll on the health of the individual which directly results in absenteeism and higher incidence of elongated sick leaves.

5.0DiscussionThe toll that work related stress and burnout takes on the psyche, motivation and morale of paramedics cannot be gainsaid. The daily encounters in their operations leave indelible marks on the paramedics’ psychological state (Clohessy and Ehlers, 1999). As enumerated by the previous studies analysed in the literature, this affects not only the paramedics but also the society in terms of resources needed to replace paramedics and the opportunity cost of losing one. McFarlane, Williamson and Barton (2009) draw a correlation between the factors to dissatisfaction, errors and decreased attention to patients. The characteristic responses to these factors as have been shown in the studies rhyme with those listed by Vettor and Kosninski (2000). These include emotional exhaustion, depersonalization and negative assessment of oneself.

Coping theory has been identified as the most effective way of dealing with the problem. The theory involves two broad types; problem and emotion focused coping. Problem focused coping involves exerting effort in the solution or management of the problem which resulted in the distress. Kilburn and Whitlock (n.d) explains that with this approach, the focus is in the assimilation relevant information to assist in planning and making decisions aimed at resolving the differences. On the other hand, emotional focused coping focuses on the alleviation of the emotional distress by adoption of cognitive processes like positive attitude, emotional support or stop gap measures like smoking and alcohol (Kilburn and Whitlock, n.d.).

The use of peer support in helping the victims has been identified as one of the most effective tools in dealing with affected workers. Okada et al (2007) has suggested that the individuals can be guided towards a positive coping mechanism like the adoption of beneficial hobbies like exercising rather than alcohol and smoking. Pre service training on stress management and coping has also been suggested as an essential tool to ward off possibilities of having to deal with adverse effects of stress in the future.

However, as shown by Robinson (2002), it is not all doom and gloom, the improvement in levels of stress management from the 1993 levels if well build upon can be enhanced. Further research is therefore necessary to identify the factors that have led to this improvement with an aim of capitalising on them. This would greatly benefit the paramedicine profession by retaining more employees and at a higher efficiency and motivation level. This would in turn ease the pressure on resources and also ease the resources for other improvement areas in the profession.

6.0RecommendationsStress and its causes are not quantifiable or easy to separate. It is thus recommended that the best way to deal with stress is to first and foremost tackle its causes. The researcher sough suggestions from the respondents on what they would recommend and the suggestions were as varied as were the causes. What emerges as the recurrent theme is that all stakeholders have a role to play in this. It is therefore recommended that the policy makers endeavour to make adequate staffing to ease the workload on paramedics, shifts should also be reviewed so as to make a balance between the available staff and fatigue levels. It would also help if proper communication channels were established through which two way information would flow swiftly. Civic education would also play a great role in avoiding crowd interference in scenes.

The government should also establish legal assistance programs for Paramedics against wrongful malpractice litigation. On the other hand, it is upon the paramedics themselves to change their attitudes towards some factors and ways of coping. As noted earlier, some people adopt proactive product focused coping mechanism which differs a lot from the reactive emotion focused mechanism. The management should also organise counselling sessions for the paramedics and make arrangements for debriefings after traumatising assignments and experiences.

7.0ConclusionThough the research cannot be said to be entirely indicative of the entire paramedicine field owing to its limited target population and the small sample size explored, it nevertheless points to a justifiable conclusion that stress is a formidable risk in the profession. The stress as described from the respondents emerges from many aspects of the field including the practice itself, the administration as well as personal attitudes of the paramedics themselves.

All stakeholders can therefore be said to be the source as well as victims of the effects of the stress with the authorities having to contend with increased pressure on resources needed to alleviate the effects on the paramedics and the patients. The wider population has also been shown to contribute to stress through frustration and as consumers of the services they become victims of the stress when the quality of services offered becomes compromised. The paramedics too contribute to stress through negative attitudes and coping mechanisms that are not proactive which end up complicating the matter further.

It is therefore not farfetched to say that the cyclic nature of stress factors could continue in perpetuity unless concerted efforts are made by all concerned to break the vicious cycle.

ReferencesBlau, G, Chapman, S & Gibson, G 2011, ‘Exploring the Importance of Different Items as Reasons for Leaving Emergency Medical Services Between Fully Compensated, Partially Compensated, and Non-Compensated/Volunteer Samples’, Journal of Allied Health, vol. 40, no. 3, pp.e33-e37.

Boyatzis, R. 1998. Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage.

Clohessy, S & Ehlers, A 1999, ‘PTSD symptoms, response to intrusive memories and coping in ambulance service workers’, British Journal of Clinical Psychology, vol.38, pp.251-265.

Grbich, C 1999, Qualitative Research in Health: An Introduction, Allen & Unwin, NSW.

Kilburn, E & Whitlock, J n.d., ‘Coping’, Cornell Research Program on Self Injurious Behavior in Adolescents and Young Adults, viewed on 6 September 2012, <http://www.crpsib.com/userfiles/File/Coping%20Lit%20Review.pdf>.

Kumar, R 2008, Research Methodology, APH Publishing Corporation, New Delhi.LeBlanc, V, MacDonald, R, McArthur, B, King, K, &Lepine, T 2005, ‘Paramedic Performance in Calculating Drug Dosages Following Stressful Scenarios, Prehospital Emergency Care, vol.9, no.4, pp.439-444.

Mantri, J 2009, Research methodology on data envelopment analysis, Universal Press, Florida.

McBurney, DH & White, TL 2009, Research Methods, Cengage Learning, London.McFarlane, A, Williamson, P & Barton, C 2009, ‘The Impact of Traumatic Stressors in Civilian Occupational Settings’, Journal of Public Health Policy, vol.30, no.3, pp.311-327.

Nirel, N, Goldwag, R, Feigenberg, Z, Abadi, D & Halpern, P 2008, ‘Stress, Work Overload, Burnout, and Satisfaction among Paramedics in Israel’, Prehospital and Disaster Medicine, vol. 23, no.6, pp.537-546.Okada, N, Ishii, N, Nakata, M & Nakyama, S 2005, ‘Occupational Stress among Japanese Emergency Medical Technicians: Hyogo Prefecture’, Prehospital and Disaster Medicine, vol. 20, no. 2, pp.115-121.

Robinson, R 2002, ‘Follow-up Study of Health and Stress in Ambulance Services of Victoria, Australia, Victorian Ambulance Crisis Counselling Unit, Report 1, pp.1-54.

Vettor, S & Kosninski, F 2000, ‘Work-stress burnout in emergency medical technicians and the use of early recollections’, Journal of Employment Counselling, vol. 37, no.4, pp.216-228.

APPENDICESAppendix 1: Interview Guide for the RespondentsTell me a little about your work as a paramedic prior to study in Australia?

Probe: How many years working

What was the most positive aspect of working as a paramedic in Saudi Arabia?

What do you see as the main causes of stress for Saudi paramedics?

How do these stressors effect the operation (efficiency) of paramedics?

Probes: days of sick leave?

Probes: morale?

What could the administration or management at the various Emergency Centres do to lower the levels of stress experienced and to deal with their resultant effects?

Has your study in Australia helped with how you can manage stress when you return to paramedic practice?

Appendix 2: Thematic analysesTheme 1

Name: positive work aspects

Description: elements providing morale to participants during work. Theme 2

Name: Stress factors

Description: The factors contributing to the development of work related stress. Theme 3

Name: Stressor effects

Description: effects of stress factors upon the participants Theme 4

Name: Proposed solutions

Description: changes participants think are necessary in improving working conditions.

Participant 1 The training offered to paramedics in Saudi Arabia remains the most positive aspect of working as a paramedic within the country. This training has significantly improved my working capability as a paramedic and offered me an opportunity to enjoy being a paramedic. Though the job has many challenges, training has significantly improved my capacity to handle the various challenges I face during my working period.

There are many stressing factors while working as a paramedic in Saudi Arabia. The cities are normally characterized with constant traffic congestions, which prevent paramedics from reaching their destinations quickly. During emergency response like ambulances, failure to reach patients in time could be seen as inefficiency of paramedics. The delays resulting from traffic congestion stresses paramedics greatly. Another stressing factor, applying to accident scenes, is the presence of crowds of people on accident scenes. These individuals make it difficult for paramedics to reach the people requiring medical assistance. When paramedics encounter these stressing factors, pressure normally increases on their side in offering sufficient services. Delays caused by traffic congestion, could reduce the time available for paramedics to attend to emergency calls. This might mean the paramedics work quickly and efficiency of their services could become compromised. Working under strict time deadlines within the profession becomes dangerous and the paramedics become prone to errors. The morale of paramedics working under these circumstances becomes immensely reduced because of the pressure and limited time available for attending patient. This remains so because paramedics remain aware of consequences which might follow erroneous operation. The paramedics can be held responsible if patient suffer damage as a result of delayed response The administration at various emergency centers should seek to change the methods applied in estimating the time required to make an emergency call response. Consideration should be undertaken based on various regions in order to cater for delays resulting from traffic congestion within city roads. The administration should seek to establish a government sponsored program aimed at informing the population about the necessary steps to take in accident scenes. With increased knowledge, people would not crowd around accident scenes in order to see paramedics perform their duties.

Participant 2 I could say the most positive aspect of working as a paramedic in Saudi Arabia is the fact that I have to handle many people who are critically sick. Most people in Saudi Arabia cannot get access to medical care. The people are often desperate to get medical attention. Being able to serve people who are so desperately in need medical care is positive aspect.

There are various causes of stress for paramedics in Saudi Arabia, and none of them can be pin pointed as being the main cause. Terrorism is one of the causes of stress for paramedics in working Saudi Arabia .The country has been associated with terrorist attacks in many occasions. Therefore, it becomes very difficult for paramedics working in Saudi Arabia to work comfortably as they often are afraid of terrorist attacks. Violence is another cause of stress for Paramedics in Saudi Arabia as they are afraid of eruptions of violence which are common in Saudi Arabia. They are afraid that the violence can occur as they are carrying out their day to day duties. These stressors have an impact on the paramedics in that they often extend the days of sick leave as they need time to deal with the stress. Stress is detrimental to the human body and it leads to increase in blood pressure. It also leads to decrease in the immune system and hence the paramedics can develop a weakness in their natural ability to fight bacteria and viruses. This leads to occurrence of sickness and they have more days of sick leave.

Stress leads to low morale especially stress caused by death since the paramedics consider themselves as being failures when patients die under their care.

The administration can come up with employee assistance programs which can make counselors and other specialists accessible for the employees. These specialists can assist the paramedics in the management of their stress. They can also provide debriefing sessions for the paramedics in cases of violence or traumatic events

Participant 3 Despite the many challenges, the most important aspect of the whole experience revolves around the fact that our paramedic services saved hundreds of lives. Working in Saudi Arabia was also a great source of inspiration seeing people appreciating our work and encouraging us to continue helping the society in providing healthcare emergency response.

The main causes of stress included overwhelming workload due to understaffing. On the other hand, the society has become excessively concerned with the issues of patients rights and ethical practice. Any slight mistake would be blown out of proportion in trying to qualify it as a matter of professional negligence or malpractice. While this remained the biggest cause of stress, withdrawing one’s services was not an option especially when bound by the moral obligation to save life, alleviate suffering and promote good health Owing to the fact that we work longer hours almost 7 days a week, most of us often develop fatigue and burnout. This reduces our productivity and sometimes sick leaves are inevitable when one of us is worn down by fatigue and burnout.

Threats of malpractice claims also demoralize some paramedics. Personally, this has often discouraged me from taking initiative to help a patient while off duty because of no proper legal protection accorded to use out of the ordinary course of duty. It is important for the management increase the number of paramedic staff. This will ease pressure on the current workforce since adequate staffing can allow paramedics to work on shifts and have time to rest. Moreover, stakeholders of the Emergency Centers should collaborate with the government to develop a balanced policy framework that protects paramedics from malpractice claims with clearly defined grounds of defense.

Participant 4 The practice of paramedics in Saudi gives the paramedics wide experience in the practice as well as in increasing mentoring and the opportunities for career development. In terms of service to the people, the practice has many positive aspects but the main one lies in the satisfaction one gets after having saved a life or after seeing that a patient has safely and efficiently been handed over to the hospital without any complications that a paramedic would have prevented. There is complete joy in being able to successfully undertake our various responsibilities.

Paramedics practice in Saudi could also be a cause of stress to the practitioners. One of the reasons for stress is the high number of emergencies that require the paramedics’ attention and long hours of work, aspects that make the job very pressurizing. Another challenge that could cause stress as a result of practicing paramedics in Saudi is the poor channels of coordination and communication within the medical departments. This causes the poor provision of medical resources as well as poor channels of presenting the grievances and issues that need to be addressed.

In cases of fatigue resulting from the increased stress, paramedics are offered sick leave for as long as their conditions have stabilized and they are able to resume their duties.

The morale and motivation of practicing paramedics in Saudi as relatively low as compared to other regions because of the stress related to the practice. One of the important measures that the administration and government could take to reduce the stress related to the practice is by putting in place effective channels where the paramedics can air their grievances and issues than need to be addressed. The government should also ensure adequate facilitation through provision with all the required medical facilities as well as human resources.

Appendix 3: Ethics Form AFlinders University

SOCIAL AND BEHAVIOURAL RESEARCH ETHICS COMMITTEE Office Use Only

Project No.

APPLICATION