There is a growing body of literature examining the physical, psychological and emotional pressures of day-to-day life as a paramedic. This qualitative study was undertaken in Israel using a phenomenological approach as the researchers wanted to explore how paramedics experience and cope with critical incidents (CIs). They wanted to find out what impact these CIs had on the work and personal lives of paramedics and how these individuals managed their feelings and thoughts after the CIs.
The authors cite Mitchell's (1983) construction of a ‘critical incident’ as a framework, where it is identified that a CI is any event that causes strong emotional reactions in the clinician which may impact on their ability to function effectively either on scene or afterwards. Clearly what actually constitutes a critical incident may vary according to individual interpretation.
Through processes of purposive sampling, 15 paramedics working for a large emergency service were recruited. The sample comprised 10 males and five females between 23 and 51 years of age. Their time in service spanned from 12 months to 26 years. In the six months prior to their interviews, their exposure to critical incidents ranged from a minimum of 20 through to a maximum of 150 events.
The semi-structured interviews lasted between one and three hours and included topics such as understanding the encounter with critical incidents, exploration of how these CIs impacted on personal and professional areas of the participants’ lives, and what coping mechanisms they had developed in response to these CIs.
All interviews were audio-recorded and transcribed word-for-word in preparation for analysis. Thematic content analysis facilitated identification of two overarching themes: A) ‘between connection and detachment’ describing participants’ experiences on the way to an emergency call, at the event itself, and after the event with a specific focus on participants’ emotional, cognitive and physical detachment/attachment to the patients and/or their families and/or the situation; B) ‘between control and lack of control of the situation’ relating to participants’ feelings of a sense of control (or otherwise) of the critical incident and the subsequent development of coping strategies.
The authors should be commended for their provision of rich, deep description related to the findings (which cannot be completely depicted in this review). Overall, they highlight the variety and complexity of actions and reactions that participants discussed in relation to their management of critical incidents including feelings of powerlessness, frustration, self-blame and, on occasion (especially in situations associated with poor patient outcomes) attribution of blame to other staff who were first on-scene. The authors suggest that the latter action is a coping mechanism which increases detachment and alleviates the individual's own personal distress in those instances.
In situations where participants felt in control and where they achieved positive patient outcomes, there was evidence of feeling ‘good’ and having high levels of self-worth and empowerment.
In cases where people described experiencing a lack of control, for example having limited resources or insufficient knowledge, this, perhaps unsurprisingly, evoked negative feelings challenging the participant's professional confidence. Examples of coping strategies when participants sensed a lack of control included: doing anything at all to keep busy rather than just doing nothing; reflecting on the CI after it was over to maximise on the learning potential of these events; making themselves available quickly to take the next emergency call and get on with work (similar process to distraction techniques).
The authors caution against trying to generalise from the findings of this study (and of course generalisation is rarely the purpose of qualitative research) as the report includes findings from a group of just 15 paramedics. Nonetheless, it provides a compelling account of the complex and diverse dynamics of situations increasingly referred to as critical incidents.
Although this study was undertaken in Israel it is likely that the findings have elements of transferability to a UK setting. Striking a balance between attachment and detachment with each individual patient and/or their families requires constant thought and negotiation but in order to maximise ambulance staff's functioning and minimise trauma post CIs, it would appear to be an important activity. Perhaps further research is needed to ascertain whether this is an area that requires more attention in both pre-registration pathways and post-registration education to enable professional growth and development whilst learning about strategies which may protect ambulance staff's emotional and psychological health in the future.