Emergency medical service (EMS) professionals have one of the most stressful occupations in health care (Cydulka et al, 1997). EMS responders are often exposed to tragic death, suffering patients, and dangerous environments. In comparison with hospital health professionals, emergency medical technicians (EMTs) and paramedics are more susceptible to occupational stress. This is as a result of their responsibilities to care for critical patients at unfamiliar scenes, and their increased exposure to traumatic events (Hammer et al, 1986; Cydulka et al, 1989).
While the focus of the present study was based on the United States (US), similar psychological concerns have been reported internationally. Approximately 72% of US EMS providers have suffered from a traumatic experience in their occupation (Oginska-Bulik and Kobylarczyk, 2015). In the UK, 87% of EMS workers have experienced poor mental health at some point in their careers (Clompus and Albarran, 2016); and in Canadian paramedics, 27–28% had considered suicide (Eric, 2014).
EMS professionals share common struggles, such as increased workload and pressure to perform. For example, three UK countries recently implemented standards to arrive on scene within 8 minutes of life-threatening calls 75% of the time (National Audit Office, 2017), and hand over patients within 15 minutes (NHS England, 2017). This limits any opportunity for the EMS crews to briefly reflect on the incident among their peers (Clompus and Albarran, 2016).
Despite the impact of traumatic experiences, EMTs and paramedics choose this career path because of the level of job satisfaction. One study looked at growth in EMS personnel and suggested that the experiences of occupational trauma act as a catalyst for positive post-trauma changes (Shakespeare-Finch et al, 2003). Vicarious post-traumatic growth (PTG) and vicarious dramatisation are two potential outcomes of working with trauma patients. Vicarious traumatisation, also referred to as secondary traumatic stress (STS), results from engagement with and exposure to traumatised patients and their experiences (McCann and Pearlman, 1990; Figley, 1995). Previous research has documented the detrimental effects of exposure to trauma victims; however, experiences working with trauma survivors have also been associated with positive outcomes (Tedeschi and Calhoun, 1996; Arnold et al, 2005). Stressful and traumatic events may serve as a trigger, directing internal changes towards a higher level of psychological functioning and personal development (Linley and Joseph, 2004).
Maladaptive traits previously reported in EMS that are associated with indirect trauma exposure include the following:
However, adaptive traits may include PTG and positive change in outlook (Tedeschi and Calhoun, 1996; Joseph et al, 2006; Oginska-Bulik and Kobylarczyk, 2015).
A large body of research on STS has been explored (Bentley et al, 2013; Duffy et al, 2015; Manning-Jones et al, 2016; Austin et al, 2017). However, there is a paucity of literature comparing specialties. Furthermore, there are inconsistent methodologies and mixed outcomes from studies evaluating secondary stress in health professionals (Manning-Jones et al, 2016). This study investigated the prevalence of secondary stress, evaluating both the positive and negative psychological impacts. In addition, the role of resilience was explored. Data from EMS providers were collected using four validated scales:
Hereafter, in the current article, they will be referred to as resilience, growth, secondary stress, and positive/negative outlook.
Brief Resilience Scale
The Brief Resilience Scale (BRS) assesses the ability to recover from stressful situations. The BRS is a validated self-report 6-item scale rating one of the highest levels of quality for measuring resilience (Windle, 2011). Each item is rated as 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree with a total score range of 6–30. Higher scores indicate higher resilience (Smith et al, 2008).
Post-traumatic Growth Inventory
PTG can be defined as developing positive changes following traumatic or stressful events (Tedeschi and Calhoun, 1996). The Post-traumatic Growth Inventory (PTGI) is a validated 21-item self-report scale which measures five factors:
Each item is rated on a 6-point scale from 0 (meaning ‘I did not experience’) to 6 (‘I experienced this change to a very great degree’), with a total score range of 0–105. A higher total score indicates a higher degree of PTG (Tedeschi and Calhoun, 1996; Arnold et al, 2005).
Secondary Traumatic Stress Scale
The Secondary Traumatic Stress Scale (STSS) measures the development of STS on an individual's professional relationships with traumatised patients (Bride et al, 2004).
The STSS is a 17-item self-report scale designed to measure three factors: intrusion, avoidance, and arousal. Each item is rated as 1=never, 2=rarely, 3=occasionally, 4=often, and 5=very often, with a total score range of 17–85 (Bride et al, 2004). The STSS has evidence of reliability, convergent and discriminant validity (Bride, 2007).
Changes in Outlook Questionnaire-Short
The Changes in Outlook Questionnaire-Short (CIOQ-S) assesses positive and negative changes in outlook in the aftermath of adversity. The CIOQ-S is a 10-item self-report instrument consisting of five questions measuring positive changes and five questions measuring negative changes. Each item is rated on a 6-point scale from 1= strongly disagree to 6=strongly agree, with a potential range of 5–30. Higher scores indicate greater positive and negative changes. Cronbach's alpha was .78 for Positive and .83 for Negative; CIOQ-S has proven internal consistency, reliability and convergent validity with the full CIOQ (Joseph et al, 2005; 2006).
Method
Participants and procedure
After receiving approval from the Institutional Review Board and Ethics Committee, EMS providers from ambulance centres within the US voluntarily and anonymously completed the four validated questionnaires. A cover letter was sent explaining the purpose and content of the study.
Data analysis
All statistical analyses were performed using R©—the statistical computing software. Demographic variables of the sample were summarised. One questionnaire was not completed and is reflected in the results. Continuous variables were summarised using mean (M) ± standard deviation (SD) and categorical variables were presented as relative frequencies; p-values less than 0.05 were considered statistically significant.
Results
Approximately 160 questionnaires were distributed with a return rate of 34% over 6 week. The questionnaires were made available via a department supervisor, which may have had an impact on return rate. This pilot study surveyed a convenience sample, resulting in disproportionate demographics; yet the study maintained statistical significance. Table 1 presents the basic characteristics of respondents. The majority of respondents were paramedics (61%), predominantly working full-time (80%) with an average of 10.6 years working in EMS. Over half (56%) expressed interest in participating in support groups or counselling for coping with work-related traumatic events; however, 70% of EMS respondents stated not having received education or training.
| Variable | n | Mean | SD |
|---|---|---|---|
| Employee position | 54 | ||
| Paramedic | 61% | ||
| Emergency medical technician | 39% | ||
| Employment status | 54 | ||
| Full-time | 80% | ||
| Part-time | 20% | ||
| Years in EMS service | 54 | 10.61 | 9.15 |
| Coping training or education received | 53 | ||
| Yes | 30% | ||
| No | 70% | ||
| Interest in participating support group | 52 | ||
| Yes | 56% | ||
| No | 44% |
EMS scale scores
Collectively, paramedic and EMT positive outlook and growth mean scores averaged within the moderate range. Of the five factors measuring PTG, ‘personal strength’ and ‘appreciation of life’ scored above average. STS and negative change in outlook appeared slightly lower than average, while resilience scores skewed positively higher than average. See Table 2.
| Attribute | n | Mean (%) | SD | Observed range |
|---|---|---|---|---|
| Secondary traumatic stress (STS) | 53 | |||
| Total | 33.94 | 14.24 | (17, 73) | |
| Intrusion | 9.23 | 3.91 | (5, 18) | |
| Avoidance | 14.25 | 6.26 | (7, 35) | |
| Arousal | 10.47 | 4.97 | (5, 23) | |
| Post-traumatic growth (PTG) | 52 | |||
| Total | 47.87 | 24.12 | (0, 100) | |
| New possibilities | 12.58 | 9.58 | (0, 33) | |
| Relating to others | 19.96 | 9.21 | (0, 38) | |
| Personal strength | 11.10 | 4.97 | (0, 20) | |
| Spiritual change | 2.15 | 1.83 | (0, 5) | |
| Appreciation of life | 8.42 | 4.11 | (0, 15) | |
| Change in outlook-short | 53 | |||
| Positive change | 19.51 | 6.16 | (5, 30) | |
| Negative change | 11.28 | 4.96 | (5, 29) | |
| Brief resilience | 53 | |||
| Total score | 22.85 | 3.96 | (14, 30) | |
| Average score | 3.81 | 0.66 | (2.33, 5) |
Note. Collectively, positive outlook and growth averaged within the moderate range while resilience scores skewed positively higher than average. STS and negative change in outlook appeared slightly lower than average.
SD=standard deviation.
Scores comparisons
EMTs had significantly higher (p=0.03) PTG than paramedics respectively (M=55.6, SD=24.4; M=42.6, SD=22.8). There was no significant difference in remaining attributes. Scores were statistically equivalent (p>0.05) between the two groups.
Correlations of scales
As a group of EMS, correlations between scales and their significance (p<0.001) is presented in Table 3. The strongest positive correlation was between Negative Outlook and Secondary Stress (r=0.70, p<0.001), closely followed by Growth and Positive Outlook (r=0.62, p<0.001). Resilience was negatively associated with both Secondary Stress and Negative Outlook, (r=-0.66, p<0.001) and (r=-0.65, p<0.001), respectively.
| Secondary traumatic stress | Post-traumatic growth | Positive change in outlook | Negative change in outlook | Resilience | |
|---|---|---|---|---|---|
| Secondary traumatic stress | … | ||||
| Post-traumatic growth | r = 0.67 |
… | |||
| Positive change in outlook | r = -0.02 |
r = 0.62* |
… | ||
| Negative change in outlook | r = 0.7* |
r = -0.11 |
r = -0.18 |
… | |
| Resilience | r = -0.66* |
r = -0.11 |
r = 0.22 |
r = -0.65* |
… |
Note. Correlations between scales and their significance
Expressed interest in training
The average growth score among those who expressed interest in receiving coping training was significantly higher (p=0.001) than the average growth score from respondents who were not interested. Likewise, the average resilience score among those who expressed interest in receiving training was significantly higher (p=0.02) than the average resilience score from respondents who were not interested. See Table 4.
| Attribute | Interest in training (mean) | Standard deviation | No interest in training (mean) | Standard deviation | p-value |
|---|---|---|---|---|---|
| Secondary traumatic stress | 35.97 | 15.56 | 30.09 | 11.59 | 0.14 |
| Post-traumatic growth | 57.62 | 22.36 | 36.24 | 20.30 | 0.001* |
| Changes in outlook, Positive | 20.17 | 5.09 | 18.73 | 5.30 | 0.32 |
| Changes in outlook, Negative | 11.24 | 5.42 | 11.00 | 4.32 | 0.86 |
| Brief resilience | 23.33 | 3.59 | 22.22 | 4.40 | 0.02** |
Note. The average growth and resilience score among those who expressed interest in receiving training was significantly higher than the average score from respondents who were not interested to receive similar training.
Full-time vs. part-time
In order to explore whether the amount of working hours had an impact on EMS, the authors compared the average scores for full-time and part-time respondents. For the purposes of this study, full-time and part-time are considered a minimum of 72 and 48 hours per 2-week pay period, respectively. Resilience was the only attribute which indicated a significant difference. The average BRS scores for respondents working part-time is significantly higher (p=0.005) than those working full-time, respectively (M=25.27, SD=2.94 and M=22.21, SD=3.97).
Coping skills training and education
Participants were asked, ‘In your current position, have you received any type of training or education on coping with traumatic events at work?’ Only 30% of EMS indicated they had received training or education on coping with traumatic events; however, no significant differences were observed (p>0.05; positively or negatively) among those who received and those who did not receive for this variable in each scale.
Years of experience
Next, the authors evaluated whether more or fewer years of experience was correlated to each attribute. Data were analysed two different ways.
No significant differences were detected for any attributes (p>0.05).
Discussion
STS and resilience
Overall, the group reported a moderate level of secondary stress with no significant difference between groups. STS was substantially correlated to the negative change in outlook and inversely related to resilience. Comparable to secondary stress, Newland et al (2015) examined the impact of ‘critical stress’ in over 4000 paramedics and EMTs. Critical stress was defined as:
‘the stress EMS undergo either as a result of a single critical incident that had a significant impact, or the accumulation of stress over a period of time’. (Newland et al, 2015).
The findings showed that 86% experienced critical stress; 37% had contemplated suicide; and 6.6% had attempted to take their own life (Newland et al, 2015). These numbers represent the intense emotional threat that work-related stress and exposure to traumatic events has on EMS providers. However, related literature has proven that post-traumatic stress and PTG are not mutually exclusive and may coexist in those working with a traumatised population (Shakespeare-Finch and Lurie-Beck, 2014).
The implications of this study reflect the importance of resilience, and of establishing coping skills early in an EMS career. This can foster positive adaptive changes to secondary traumatic stress instead of maladaptive consequences.
Positive adaptations in EMS
While secondary stress was experienced by this group of EMS providers, resilience, positive change in outlook, and PTG were still present. A review of 39 empirical studies documenting ‘adversarial growth’ (collective term referring to positive changes while struggling with adversity) found that, through hardship, a person can reach a higher level of functioning (Linley and Joseph, 2004).
Collectively, EMTs and paramedics demonstrated a moderate level of resilience, with resilience having an inverse relationship to secondary stress. Similar to the present results, Mealer et al (2017) also found that resilience mitigated symptoms associated with psychological distress caused by exposure to traumatic events in critical care work. EMS working part-time scored significantly higher in resilience than those working full-time. Given that resilience measures the ability to bounce back from stress, the time gap between work shifts may be a factor allowing part-time responders more sufficient time to recover. As evidenced by Alexander et al (2001), approximately 70% of EMS providers reported not having adequate time to emotionally recover between traumatic events. Also, severity of distressing symptoms in EMS professionals could be predicted by the frequency in which they experience traumatic incidents (Bennett et al, 2005).
Post-traumatic growth
The level of resilience in EMS is an important trait because it enables a more effective coping ability and fosters PTG (Oginska-Bulik and Kobylarczyk, 2015). This is in agreement with a European study evaluating 62 paramedics, identifying significant positive correlations between coping strategies and PTG (Jurisová, 2016). As a whole, this group of EMS providers scored a moderate level of PTG with above-average growth factors in ‘personal strength’ and ‘appreciation of life’.
EMTs vs. paramedics in PTG
When comparing the two groups, EMTs indicated significantly more PTG than paramedics. While the authors did not explore this further, a large cohort study of over 34 000 certified EMS professionals found that paramedics, compared with EMTs, were at increased odds for stress, anxiety, and depression (Bentley et al, 2013). This may help to explain why EMTs gain more potential for growth.
Recent studies found that predictors of PTG include female gender, older age, humour, self-care, peer support and spirituality (Ai et al, 2013; Kobylarczyk, 2015; Manning-Jones et al, 2016; Oginska-Bulik and Koutná, 2017). Of these factors, a large body of literature demonstrates the association between PTG and spirituality (Shaw et al, 2005). Interestingly, the result of trauma exposure has been reported to lead to deeper spiritual beliefs; subsequently, spirituality and religion have been shown to highly correlate with PTG (Shaw et al, 2005; O'Rourke et al, 2008).
Changes in outlook
As with Joseph et al (2006), the present results confirmed that PTG in EMS was significantly correlated to positive changes in outlook, respectively (r=0.46, p<00.05 and r=0.62, p<0.001). Overall, this group of EMS professionals indicated more positive outlook changes than negative. Respondents reported the highest scoring item as ‘I value my relationships much more now’ and the lowest scoring item as ‘My life has no meaning anymore’. Owing to the majority of the respondents being male, differences between genders were not analysed. However, a review of studies looking at gender and perceived changes following adversity either showed no difference or a higher positive growth in females (Linley and Joseph, 2004).
Participating in coping resources
EMS professionals who expressed interest in participating in some type of coping resource (e.g. counselling, support groups) demonstrated significantly higher resilience and growth scores compared with those who were not interested. Although coping resources have proven valuable, research suggests that a focus only on post-traumatic stress symptoms may limit or slow recovery and mask the potential for growth (Shakespeare-Finch and Lurie-Beck, 2014).
Years of experience
Years of experience showed no relationship to any of the attributes studied in this group of EMS. Previous data reported by EMS in national surveys have shown mixed results (Cydulka et al, 1997; Bentley et al, 2013). Notably, prolonged traumatic exposure can still result in long-lasting personal growth. One study evaluating 30 prisoners of war exposed to traumatic stress and adversity for several years found that duration of captivity was positively correlated to PTG (Feder, 2008).
What can we do?
A large body of literature reports the detrimental effects which impact EMS professionals (Cydulka et al, 1989; Figley, 1995; Cydulka et al, 1997; Bennett et al, 2005; Bentley et al, 2013; Newland et al, 2015). The traditional approach of restorative intervention focused on wellbeing has now shifted to preventative care. Fortunately, recent studies have proven effective strategies to offset the psychological effect of occupational stress by improving EMS culture and enhancing resilience skills (Peters, 2017; Romano et al, 2017).
Improving EMS culture
Studies have found that day-to-day organisational stress contributed just as much or more to psychological distress than the actual stress associated with trauma (Bennett et al, 2005). Eliminating secondary traumatic stress among EMS providers is unrealistic; however, reducing the organisational stress while enhancing resilience skills appears to be an effective strategy.
When trying to remedy stress among EMS, typical programmes like support groups, debriefing, and counselling are beneficial. However, the EMS culture is a more influential factor (Cydulka et al, 1997; Mildenhall, 2012). In a review of literature, most paramedics preferred to manage feelings of distress informally within their own work environment (Mildenhall, 2012). Likewise, findings from a 2016 UK study (Clompus and Albarran) reported that both formal and informal methods of support enhanced resilience; yet paramedics relied more heavily on peer networks to deal with everyday pressures as formal methods involving management and debriefing were less available. Furthermore, evidence suggests that post-traumatic support mechanisms should not be delivered by a managerial person responsible for employees or external mental health practitioners; rather, use of a peer-group risk-assessment strategy strengthens resilience (Jones et al, 2003).
Newland et al (2015) suggest that health professionals feel supported by management and peers to seek help without fear of being fired or mocked, rather than the type of help or access to resources. Likewise, the results of a recent study including 740 EMS workers found that despite routine exposure to traumatic events, a sense of workplace belonging was significantly associated with enhanced resilience and reduced distress (Shakespeare-Finch and Daley, 2017). Ideally, tailored occupational stress programmes should be developed.
Resilience training
Resilience in EMS providers is significantly associated with overall wellbeing and health (Gayton and Lovell, 2012). Fortunately, evidence-based research has shown that resilience is a learnable and multi-dimensional trait which can be successfully taught in a classroom setting. In recent years, workplace resilience programmes have been implemented for first responders including firefighters, police, EMS, and the military (Reed and Love, 2009; Gunderson et al, 2014; Hatch, 2016). Results demonstrate a significant increase in the level of resilience after education (Gunderson et al, 2014). Notably, studies evaluating UK paramedics suggest that efforts in establishing resilience need to be implemented early in EMS practice since coping strategies are often developed during the formative years (Clompus and Albarran, 2016).
Interestingly, findings from the current study indicate significantly higher resilience scores in those EMS professionals that merely expressed an interest in engaging in some type of coping resource. Indeed, self-awareness is one of the domains of practice in developing resilience (Green, 2017). That being said, implementing such resilience training may help sustain or elevate the level of resilience.
Limitations
The present study used self-reporting questionnaires, leaving interpretation open to the participants. Also, a convenience sampling method was employed, which may limit the generalisation of findings. The authors acknowledge this pilot study had a low number of respondents; yet preliminary data prove statistical significance for further research in a larger setting.
The sample of EMTs and paramedics was not equal, which may not allow for full representation of the comparison results. Although data collection was anonymous, some of the questionnaires were distributed by supervisors. Therefore, participants may have felt pressure to answer in a particular way (potentially impacting how genuine the results are), and may not have felt that participation was completely voluntary. To avoid possible bias, further qualitative research on a larger scale will involve the use of electronic survey programmes conducted via web-based access links designed for self-completion and the maintenance of anonymity.
Conclusions
STS in EMS is an inherent part of the job; therefore, enhancing resilience skills can help to transform the psychological processing of their experiences to facilitate a more positive outlook. The findings of this article provide evidence of significant correlations between STS, resilience, growth, and changes in outlook in EMTs and paramedics.
When comparing the two groups, EMTs demonstrated significantly more PTG than paramedics. Indeed, a larger multi-centre study is warranted to gain a better understanding of the psychological adaptations EMS professionals develop. While STS was experienced by EMS providers, PTG and positive changes in outlook was still present, proving that both positive and negative psychological adaptations can coexist. EMS providers with less resilience, or those working full-time, are more likely to be at risk of STS and negative changes in outlook. Learning how to build resilience and create a supportive culture among EMS is imperative in fostering a positive adaptation to adversity. The findings of this preliminary study provide evidence of significant correlations. Therefore, a larger multi-centre study is warranted to gain a better understanding of the psychological adaptations EMS crews develop.