Overview
This article focuses on the physiological, emotional and behavioural response that is fear and considers how it impacts clinical practice. It may have some benefits; for example, the release of the stress hormone cortisol which can increase cognitive function and short-term memory improving information handling. Equally, it poses significant risks, such as loss of perspective, damage to clinician-patient rapport and information bias. The author considers how fear can affect the individual response to a threatening situation in the prehospital care environment and explores ways in which it can be managed.
The human brain has been described as an ‘anticipation machine’—making future predictions is its most important purpose for survival (Gilbert, 2006). Data from our past experiences, current state and environment are analysed to predict the future by calculating the odds of desired outcomes and forming contingency plans for avoiding or adapting to future adversity (Grupe and Nitschke, 2013).
The prehospital healthcare environment is unpredictable and ever changing. This can make for a turbulent and occasionally volatile experience for any paramedic. Fear is a physiological, emotional and behavioural response to an immediate, perceived future or previous threat (Steimer, 2002). It is situational, personal and relative to the induvial who experiences it. Nevertheless, the words ‘fear’ and ‘paramedic’ appear almost as oxymorons. But what happens when clinicians experience fear and what are the implications for clinical practice?
Fear is thought to have adaptive functions in terms of both cognition and behavioural response. Unlike reflexes and fixed-action patterns, the relationship between stimuli and behaviours mediated by fear is highly flexible and context-dependent (Adolphs, 2013). Therefore, fear is subjective to individual preference.
When individuals encounter a fear stimulus, it triggers a physiological stress response. This is commonly referred to as the ‘fight, flight or freeze’ response. First introduced by Walter Cannon (1929), it describes the sympathetic nervous activation of the medulla which creates a hormone cascade of epinephrine and dopamine to ready the body to either fight a potential threat or flee from it (Cacioppo et al, 2014). Physiological processes of stress manifest as physical symptoms of anxiety, increased heart rate, blood pressure and perspiration (Willis and Dalrymple, 2014).
There are benefits to this process. During a heightened emotional state, the brain adapts to collect as much information from the environment as possible. Adrenaline triggers the release of the stress hormone cortisol which can increase cognitive functioning and short-term memory (Schonfield et al, 2017). In fact, adrenergic and noradrenergic neurons accelerate the speed at which information can be absorbed and processed by two to three times of a neutral emotional state (Lupien et al, 2009).
The more information a clinician can obtain about a situation, the safer the patient care is presumed to be. However, the accuracy of the information collected whilst in this heightened state is questionable. When we are faced with unpredicted threats, fear can often drive out rational perspective (McCabe and Castel, 2008). This can result in decisions purely founded on emotion.
Fear and decision making
Fear arousal can impede our decision making and influence the way we process information. Jung et al (2014) found that individuals in a negative emotional state were more likely to deviate from logical norms when completing tasks. It is thought that this is because emotions arise from representations in working memory that occupy the same sub-systems that are required for reasoning and problem solving (Oaksford et al, 1996). It is both accurate decision making and the speed of making these decisions which may be compromised during emotional arousal (Gable and Harmon-Jones, 2012). This is contested however as some believe that it is the extreme of emotion which impedes decision making; both positive and negative have been found detrimental (Blanchette and Richards, 2004).
When a fear response is triggered, an individual will seek environmental cues to support the physiological and psychological distress they feel. This is known as danger confirming reasoning strategy (De Jong et al, 1997) and represents a form of bias that fear can create. The main consensus of research suggests two principal information-processing bias characteristics of anxiety:
This means that when clinicians attend to incidents which trigger previous fearful experiences, they might exhibit information bias to negative or neutral stimuli. For example, if previously a clinician has had a frightening experience in an environment, when placed in a similar environment with a different patient, the clinician is more likely to interpret neutral language and behaviour as negative or threatening.
Alternatively, others would argue that this is the result of adaptive intuitive learning from clinicians' experience. Much research has focused on the benefits obtained from previous clinical experience. Rew et al (2000) found that actions based on intuition improved crisis management and gaining a positive resolve. Additionally, the use of initiation has been linked with detection of deteriorating patients (Odell et al, 2009) and reducing patient mortality (Baird and Miller, 2015).
Downside of experience
However, attentional bias also indicates that once identified as a threat, it is difficult to disengage attention from negative stimuli to neutral or positive stimuli (Cisler and Koster, 2010). If our fear response has been triggered and we have decided that an individual or an environment is threatening, even when presented with information to discredit this, we may be inclined to disregard or not even acknowledge it.
Fear can jeopardise positive rapport formation with patients. Emotional states affect an individual's motivation to solve complex cognitive tasks and how attention is allocated during said task (Jung et al, 2014). This can damage communication by causing inadequate listening and mixed messages in the interpretation of intent, leading to frustration and hostile reactions (Boyd and Dare, 2014).
Most of the communication arises through body language by providing clues about the intentions, emotions and motivations of others (Tipper et al, 2015). When experiencing an emotional response, it can subconsciously alter our body language. Fear causes an individual to adopt defensive behaviour (Amory, 2013).
Defensive behaviour can be defined as a behaviour when an individual perceives or anticipates a threat (Mortensen, 2017). As attention is divided between participating in communication and how to pacify or avoid the anticipated threat, defensive behaviour can become contagious. Perceived threat can alter posture, tone and language which inspire reciprocal changes (Mortensen, 2017).
Case study
The case study concerns a clinician who, with her colleague, was called to attend to a male found collapsed in the street.
‘Having attended many similar calls, I felt no initial apprehension. It was in a busy area and early evening so still quite light. Had it been early in the morning, in a secluded place, I may have been more cautious. The patient initially presented as unresponsive but roused quickly to painful stimulus. Immediately the patient became verbally aggressive, telling us to go away and asking what we were doing. He presented as heavily intoxicated and had drug paraphernalia on the floor next to his things. It wasn't possible to reason or explain as everything we said seemed to inflame the situation. I remember feeling annoyed and frustrated with the patient, especially when he zoned in on my colleague. I attempted to intervene by getting in between the two and trying to further reason with the patient. My colleague dropped back to radio for police assistance, the patient growing increasingly irate getting closer and closer. I tried to back away and realised I'd become cornered with a wall behind me.
‘In the midst of panic, a random memory sprung to the forefront of my mind. A few weeks earlier in a completely different world, whilst sat in the pub enjoying a gin and tonic, my partner had joked that getting punched in the face didn't hurt quite as much as you would expect. So instead of remembering perhaps more useful information from our mandatory conflict resolution session; the mantra “it wont hurt as much as you think” played on a loop in my head as a weak excuse of reassurance. “Step back please,” I said assertively while putting my hand on his chest, to which he responded by shoving me against the wall. At this point, my colleague shouted at the patient, distracting him and allowing me to duck past. We took refuge in the ambulance and paged control for an update on police assistance. The patient kicked the ambulance door several times before stumbling off down the street.
‘When my colleagues asked if I was okay, I brushed it off as an occupational hazard—a daily occurrence. Having attended many similar situations previously, I felt ashamed to admit how scared I had been. Afterwards playing it back, I remember feeling guilty that I had let myself get into such a position. I felt bad that I hadn't managed the situation or my safety better. I had worked on a frontline ambulance for several years and never felt so certain that I was in serious danger which really shocked me. Panic had filled my mind and there wasn't any room to consider my tone, body language or posture. This, I later realised, was the point. The time for conflict resolution and positive communication was from the onset of the interaction. It has definitely affected my current practice and made me much more cautious, perhaps even defensive.’
Using what we know
Mortensen (2017) advises building a supportive (as opposed to defensive) climate for communication. Supportive climates incorporate description, empathy and equality as opposed to evaluation, neutrality and superiority. He explains that when under threat, an individual can seek to fit others into categories of good or bad, and to question the motive of the speech they hear.
If a clinician was to ask a question in an evaluation style, such as ‘why have you called?’, the recipient will feel compelled to defend their need. In the case of a descriptive approach, ‘Can you tell me what's happened today?’ invites exploration of specific events and perception reducing tension. Another point that Mortensen (2017) makes is that when there is neutrality in speech, it can suggest no concern and cause reciprocated defensiveness.
Empathetic communication can reassure a patient that the clinician can identify with the problem and reduce hostility. Equality rather than superiority also promotes supportive communication (Mortensen, 2017). If a superior stance is adopted due to defensive communication, the patient is more likely to focus on the affect and tone of the message conveyed rather than the context. It can appear as though the superior party is reluctant to cooperate when problem solving. Defensiveness can be reduced when equality is emphasised through mutual trust and respect (Mortensen, 2017).
Identifying hazards and threats undoubtedly keeps clinicians safer in practice. Some suggest that a physiological state of fear is associated with a quicker response time when detecting threat stimuli (Bar-Haim et al, 2007; Cisler and Koster, 2010).
Standard 1.3 and 1.4 of the Health and Care Professions Council (HCPC) standards of proficiency for paramedic practice states the required ability to work safely in challenging and unpredictable environments, including taking appropriate action to minimise risk (HCPC, 2014). Therefore, if fear facilitates faster threat recognition, the clinician can adapt and remain in control of the situation, safeguarding themselves and the patient. Reiterating that fear has both protective and adaptive properties.
Uncertainty and emotion
While fear is associated with assessments of danger or threat, it can become compounded with low certainty and lack of situational control (Lerner and Keltner, 2001). Paramedics can often attend incidents with limited information and high levels of emotion from patients and the public. When a person experiences fear, it triggers their tendencies to adapt to that fear. Previous frightening experiences may continue to affect cognition, social interaction and decision making for future similar and unrelated events (Raghunathan and Pham, 1999; Lerner and Keltner, 2001).
Uncertainty exacerbates heightened emotion in the context of clinical decision making and the clinical environment is known to be strongly associated with stress and fear (Ghosh, 2004). Denial is the most common response used as a defence mechanism (Nevalainen et al, 2012). Exhibiting emotion can be negatively regarded, akin to a loss of control and a sign of weakness; whereas the restraint and abstinence of emotion is seen more positively and as a sign of strength (Harrison, 2014).
Strumska-Cylwik (2014) explains that anxiety and fear are regularly regarded as unsympathetic, hostile and indulgent. Yet this contrasts against their own definition of being classed as ‘innate emotions’. These are a group of emotions which emerge from the human psyche; they are not learned from social interaction, such as shame or hatred (Mason and Canitanio, 2012). Essentially, they are hardwired into the brain's circuit board.
Expressing emotions, particularly negative ones, is necessary for sound psychophysical health and acts as a cathartic release. Often it is that the emotion and its expression are not treated separately and are therefore viewed negatively (Kennedy-Moore and Watson, 2001). A negative attitude towards an emotion simulates a lack of consent to experience it freely. This denial of emotion spawns guilt and shame (Strumska-Cylwik, 2014). Depriving acceptance of emotion initiates vulnerability and emotional instability.
Choosing appropriate environments to explore these emotions away from our professional obligations will allow for this catharsis. The acknowledgement and mastery of the emotional aspect of clinical decision making has been suggested as a critical element to improving patient safety (Croskerry and Abbass, 2010).
Conclusion
Aspiring and qualified clinicians alike are expected to adhere to professional competencies which are mostly grounded in behaviour and conduct. Behaviour qualities that are expected of a professional include patience, benevolence, honesty and empathy (Larson et al, 2013). However, even the most refined professional is still human and susceptible to fear which can hinder the expression of patience, honesty and empathy. Personal emotional management is necessary when attending to patients, but there is an expectation that clinicians should be immune to the emotional challenges of their role (Harrison, 2014). Experiencing innate emotions should not conflict with our professional identity. Benevolence, honesty and empathy should not just be reserved for our patient care, but also our self-care.
The prehospital environment is the most unpredictable and varied field in medicine (Willis and Dalrymple, 2014). It is of the utmost importance that clinicians protect themselves so that they can continue to deliver care, especially in the presence of risk and harm. If we are to evolve our practice, we must move to acceptance and not shame of our human factors. Having higher personal emotional intelligence establishes understanding of the consequences for clinical practice. Additionally, it equips clinicians with the skills to relate and empathise with patients.
LEARNING OUTCOMES
After completing this module the paramedic will be able to: