Current figures identify that sickness absence among United Kingdom (UK) ambulance staff is at an all-time high, with levels having exceeded those of other National Health Service (NHS) workers (NHS Information Centre, 2010). Indeed, reports suggest that many of these instances are attributable to stress, anxiety and depression (NHS Information Centre, 2010), particularly within pre-hospital workers; suggesting that stress may be inherent in the nature of the profession or organisation, rather than be an individual-specific problem (Hancock and Desmond, 2001; Okada et al, 2005; Smith, 2009).
While there are many conceptual definitions of ‘stress’, there appears to be a general consensus among academics that it is the physiological, psychological and behavioural response to a perceived imbalance between level of demand placed upon an individual and their perceived and actual ability to cope with these demands (Lazarus, 1966; Lazarus and Folkman, 1984; Moore, 2001; Jenner, 2007). Occupational stress is defined as ‘the adverse reaction people have to excessive pressures or to other types of demand placed upon them at work’ (Health and Safety Executive, 2010). Symptoms include feeling upset, irritableness and behaving out-of-character, not being bothered about things one would be normally be concerned with, and social withdrawal (Walker et al, 2002).
The ambulance service by its very nature is an unscheduled, emergency response organisation in which frontline employees often work in chaotic and unpredictable environments while making rapid clinical decisions, often under the observant eye of the general public (Sterud et al, 2008). As such, it is arguable that these demands are enough to place considerable stress upon the workers, let alone considering the increasing management pressures to achieve targets, the frustration from the increasing deficit in resources, and the long hours worked (Okada et al, 2005; Dollard et al, 2007; Jenner, 2007; Regehr and Millar, 2007; Nirel et al, 2008).
For employers, the cost of stressed workers is high. Public sector organisations such as the NHS have counted the economic impact with sick-leave costing £1.7 billion per year (Black, 2008; Boorman Report, 2009), with one ambulance service proposing that 8 312 double-crewed ambulances are lost each year within their area (South Central Ambulance NHS Trust, 2008). Furthermore, the absence of some frontline staff due to sickness adds greater pressure to remaining staff from rising workloads/increased emergency calls and uncovered shifts, while still there remains a necessity to meet response times and performance indicators as imposed by the Government (Gray, 2005; Price, 2006) and provide high-quality care for the patient.
For employees, the personal cost of feeling stressed can also be high—having financial and social implications, impinging on family life (Regehr, 2005) and on personal motivation, management and commitment to work (Jenner, 2007). The greatest cost of all, however, is undoubtedly the impact of self-inflicted lifestyle diseases such as myocardial infarction, stroke, hypertension, and depression (Lewis, 1994; Shelton and Kelly, 1995).
It is importantl for stress to be perceived before it is felt and a response initiated (Jenner, 2007). Every ambulance call-out has the potential to be felt as stressful—however the perception of seriousness directly correlates to the amount of stress experienced by the paramedic (Bounds, 2006). Recent worldwide attention to major incidents such as terrorist activities and natural disasters, has lead to a plethora of research investigating the impact of psychological trauma upon many categories of people, including those working for the emergency services. Thus, increasingly the focus appears to have been given to critical incident stress rather than daily occupational stressors (Alexander and Klein, 2001; Regehr et al, 2002a; Bounds, 2006).
Critical incidents are defined as events that have the potential to cause an individual or group of individuals to feel overwhelmed by, and unable to cope effectively with the experience (Mitchell and Bray, 1990; Flannery, 1999; Hammond and Brooks, 2001; Harris et al, 2002; Ward et al, 2006). Much of the critical incident research unsurprisingly focuses upon post-traumatic stress symptoms, psychopathology (Hammond and Brooks, 2001; Foa et al, 2005; Misra et al, 2009), post-traumatic stress disorder (PTSD), and formal stress management strategies such as critical incident stress debriefing (CISD) (Mitchell, 1983; Mitchell and Everly, 1995).
Importantly, Jenner (2007) clarifies that many paramedics do not have stressful reactions following exposure to potentially stressful incidents. This is due to individual differences such as personality, previous experiences, perceptions of stress and personal coping strategies. Jenner's (2007) work raises important questions that the studies mentioned have failed to ask—how do emergency workers actually cope with stress? What do they do to get by in day-today life? Very few ambulance staff access formal stress management support (Rose et al, 2001), so what happens within their environment to mediate this?
To date, very few studies have been undertaken to explore the specifics of occupational-related stress coping mechanisms (Lau et al, 2006) particularly from an ambulance service perspective (Bounds, 2006) and, as a consequence, little is known about the informal coping strategies used by paramedics.
The literature review
The present study is a review of the published research exploring the informal (personal) coping strategies employed by frontline ambulance workers in relation to perceived stressful experiences. The purpose of this review is to provide a summary of the existing literature and to provide suggestions for future research. To obtain a comprehensive understanding, this review will include both quantitative and qualitative research.
The articles used in this review were identified by various internet academic searches. Examples of databases used include; Allied and Complementary Health (AMED), Published International Literature on Traumatic Stress (PILOTS), and PsycInfo. Keywords such as ‘stress’, ‘burnout’, ‘ambulance’, ‘paramedic’ and ‘coping’ were selected. These search terms narrowed the list of articles to those of interest and which met a set inclusion criteria (for example; papers were only considered from 1990 onwards). Studies referring only to formal stress management techniques were excluded, as this study only considered informal coping strategies used by the individual. Other articles were excluded because of no relevant ambulance staff in their sample. The search yielded a total of 11 papers.
Every ambulance call-out has the potential to be felt as stressful
No randomised control trials (RCT) were found. This is not surprising given the subject matter—it would be highly unethical to propose an RCT to see how paramedics cope with stress! It is not uncommon to find a lack of RCT evidence within the sphere of medicine and health due to this nature (Bowling, 2002). One systematic review was found and included (Sterud et al, 2006).
Of the research papers included in this literature review, four were undertaken in Canada, one in the United Kingdom, one in Australia, one in Sweden, one in Italy, and two in America. One was a literature review. No papers were found originating from Africa or Asia—therefore one criticism of this review is that it only includes studies undertaken in the Western world, and therefore any results may not be culturally transferable to other areas of the world.
Categorising the content
Thematic analysis of the literature identified several key coping strategies used by frontline ambulance workers to mediate stressful experiences. These were:
Results and discussion
Overwhelmingly, the research literature suggests that rather than used independently, paramedics strategically and flexibly employ a synthesis of coping techniques to promote personal emotional processing and management to assist them in returning to a normative emotional state following a stressful experience (Alexander and Klein, 2001; Shakesphere-Finch et al, 2002). Studies indicate that during an emergency call, paramedics become highly task orientated, with immediate coping mechanisms taking the form of visualisation (becoming focused upon the patient or the practical procedure in hand) which serves to emotionally distance the paramedic from the patient and their relatives; thereby forming a psychological barrier, protecting the healthcare worker from experiencing the emotion while enhancing their ability to do the job (Regehr et al, 2002b).
Paramedics often pride themselves as ‘being able to cope with anything’ but research has identified that this belief is linked to the development of PTSD
Cognitive strategies
Analysis of the research indicates that paramedics frequently employ emotional suppression, as a coping strategy after the call has finished (Alexander and Klein, 2001). High prevalence rates were also recorded for the use of avoidance techniques such as refusing to think about the incident, which have found to be a significant predictor of burnout and compassion fatigue (Prati et al, 2009). Many of the studies found that despite being recognised as unhelpful, paramedics favoured these methods as they hide fear and vulnerability, and protect the professional identity of the ambulance worker as an emotionally strong individual. Paramedics often pride themselves as ‘being able to cope with anything’. This emotional toughness may be the result of a historical quasi-military culture. However, research has identified that this coping mechanism is strongly linked to the development of posttraumatic stress disorder (Wastell, 2002).
It is interesting that of the literature reviewed, none considered whether sickness absence is in-fact a behavioural response to the avoidance coping mechanism. Deery et al (2010) in their study of call centre workers, found that one method of coping with organisational stress is to avoid work through absenteeism. This enables the employee to revitalise their energy levels and cope better with job demands. Obviously this method has implications for organisational practice and is clearly something that those managing sickness absence need to be aware of and offer support with. Considering the well-documented concern regarding the high rates of sickness absence within the ambulance service, it seems strange that this connection has never been made before. It is certainly an area for future research.
Methodological challenges such as relatively small sample sizes and unclear sampling strategies reduce the validity of several of the studies in this review. While three studies report a good response rate of over 68 %, there remains an opportunity for sampling response bias (Bennett et al, 2004). Two of the studies failed to give enough detail to assess participant involvement levels. Halpern et al's (2009) study had a very low response rate of just 6 %. No explanation for this was given. Regehr et al's (2002b) study of paramedics had a lack of transparency in the use of recruitment techniques. This is a residing criticism of qualitative research (Mays and Pope, 2000). Indeed Higginbottom (2004) identified that many qualitative studies fail to clearly define all aspects of the methodological approach. However, Russell and Gregory (2003) argue that sound reasoning and justification regarding recruitment should be given to provide credibility.
One possibility is that of those invited, stress related avoidance techniques resulted in failure to participate, thereby continuing to ‘protect’ the worker from the vulnerability of emotional exposure, and the threat to an established professionalism. On the other hand, potential participants may not have suffered any stress/ coping difficulties, or failed to acknowledge that they had, and therefore saw no value in taking part (Bennett et al, 2004). Further concerns related to confidentiality and the perceived threats to career prospects.
Perhaps the most challenging criticism of these papers is the variance in the types of scale used to generate data. The studies in this review employed many different instruments to measure aspects of stress and coping. This can make the interpretation and generic synthesis of the results difficult.
Interestingly, despite this criticism comparable results regarding the use of cognitive coping strategies by paramedics were found from all the studies reviewed. Therefore, it seems appropriate to conclude that these workers frequently employ these techniques and this result is unlikely to have been infiuenced by the data collection methods. Furthermore, similar findings have also arisen from research on nurses (Callaghan et al, 2000) and police officers (Leonard and Alison, 1999). It is worrying that despite its high prevalence and documented negative outcomes, that regulatory and educational bodies pertaining to these occupations have failed to draw attention to this phenomenon.
Refection
A small study based upon a convenience sample in Canada reported the cognitive use of professional refection as a post-incident coping strategy among ambulance personnel. Regehr et al (2002b) found that contrary to avoidance, some paramedics actively reviewed the incident, positively reframing it as a professional learning experience to determine if they could have provided better care.
It is surprising that other, more contemporary studies in this review fail to consider refection as a coping mechanism. It is arguable that this method is relatively new to the ambulance service, and certainly within the UK has only been formally instigated since its affiliation with higher education and professional registration. Importantly, in practice, all grades of UK ambulance personnel are encouraged to develop this skill. Researchers must be aware that refection is considered an aspect of continued professional development and is a requirement of the UK paramedics registering body; the Health Professions Council (HPC).
While occupational awareness of refection is increasing—which represents a cultural ideological shift towards professional openness and responsibility—it is not required to be completed after every stressful event, and indeed it is arguable whether some ambulance clinicians only undertake professional refection when registering bodies and employers demand to see evidence of its completion. In terms of this literature review, it is also criticisable that this method fails to provide coping support for daily organisational stresses. However, unlike the coping mechanisms discussed so far, refection is contextualised as a learning opportunity within a pedagogical discourse. It is a culturally acceptable, problem solving approach allowing experiential interpretation and personal exploration. In doing so, it enhances professionalism. Therefore, it is likely that in future studies exploring coping strategies, this method will become more favourable.
None of the papers reviewed draw the conclusion that this emotional suppression may, in fact, be an emotional form of protecting the family from the trauma and stressors experienced by the paramedic.
Social support–family
Respondents from several of the studies reviewed indicated that the family is a consistent and important source of support enabling paramedics to cope with stress (Jonsson and Segesten, 2004; Regehr, 2005; Regehr and Millar, 2007). This interpersonal transaction between family members often creates positivity, and many respondents identified that talking with partners was a principal coping technique (Regehr et al, 2002b; Regehr, 2005).
Shakesphere-Finch et al (2002) on the other hand reported that paramedics often ‘compartmentalise’ the home and work environments—by not discussing work experiences with the family/spouse and keeping it to themselves when at home. None of the papers reviewed draw the conclusion that this emotional suppression may in-fact be an emotional form of protecting the family from the trauma and stressors experienced by the paramedic. With families already coping with the demands of shift-work, unpredictable late finishes, other daily organisational hassles and the impact this has upon lifestyle (Regehr, 2005), it is no wonder that paramedics attempt to burden their loved ones less in this way.
Indeed, Regehr (2005) and Regehr et al (2002b) identified that emotional suppression was frequently used, which consequentially has been shown to result in social and emotional disengagement by the individual; thereby significantly affecting family life. Subsequently, as seen in Vietnam veterans (Calhoun et al, 2002) uncharacteristic, explosive shows of anger, irritability and sleep disturbances may prevail as the stressful feelings become difficult to contain.
One paper notes another familial coping technique as becoming overprotective of the family in terms of safety concerns (Regehr, 2005). Furthermore, Regehr et al, (2002b) identified that some paramedics consciously use cognitive restructuring and reframing to accomplish a positive outcome. Making the most of life (because you don't know what's round the corner) and valuing family members is a meaningful product from a stressful experience.
The reduced availability for social and emotional integration and support from peers could be detrimental to the mental health of the employee
Following review of existing research, unfortunately it remains a criticism of employers that very little, if anything is in place to formally support paramedics’ partners and their families when times are emotionally difficult as a result of work (Regehr, 2005). In practice, it is often the support of ambulance colleagues and local managers who provide this service informally.
Social support–colleagues
By far, the most commonly used coping mechanism according to paramedics, is talking with colleagues—particularly crewmates (Alexander and Klein, 2001; Regehr et al, 2002b; Jonsson and Segesten, 2004; Regehr, 2005; Regehr and Millar, 2007; Essex and Benz-Scott, 2008; Halpern et al, 2009). Research has demonstrated that this method is favoured over talking with partners, and plays a significant role in defusing the emotional aftermath of stressful experiences. Those who experience low peer support show significantly worse stress symptoms (Alexander and Klein, 2001; Jonsson and Segesten, 2004; Regehr, 2005; Regehr and Millar, 2007; Essex and Benz-Scott, 2008; Halpern et al, 2009). Similar findings have been identified for police officers, nurses, firefighters and doctors (Alexander and Atcheson, 1998; Alexander and Klein, 2001; Jonsson and Segesten, 2003; Volkmann, 2003; Beaton et al, 2004).
These results suggest that it is of utter importance that following a stressful experience, staff are given the time to support each other (Alexander and Klein, 2001) to reduce stress and subsequently sickness absence in the long term. While it is in employer's best interests to facilitate and encourage this (Jonsson and Segesten, 2003), synthesis of the reviewed literature (and personal experience) suggests that in reality, the opposite is true.
Certainly within the UK, the demands for ambulances (as a result of increasing call volumes) and the rigid requirements for crews to ‘clear’ from hospital departments within fifteen minutes of handing over the patient (Gatling and Ansell, 2008), means that the opportunity for informal peer debriefing is limited. Furthermore, to meet imposed government response time targets, ambulance crews are strategically deployed across a geographical area. This often involves being mobile for most of the shift and/ or being based at single crew ‘stand-by’ points. Research has identified that as a result, crews often have prolonged isolation from other colleagues including supervisors and managers. The reduced availability for social and emotional integration and support from peers could be detrimental to the mental health of the employee.
Interestingly, the same must be true for those working alone (on a response car for example). Of the literature reviewed, none considers the significance of this in this context. Even papers exploring other emergency occupations appear not to acknowledge this. Lone working is not new, so it is unclear why relevant research has not been completed. This adds to the argument that the importance, value, and necessity for peer support needs to be highlighted throughout the profession, and awareness raised of its role in informal debriefing following calls/stressful experiences.
Social support–supervisors and managers
While talking with colleagues was rated highly, paramedics poorly rated talking with supervisors and managers as a method of coping. According to the literature, these senior employees were viewed as barely supportive or unsupportive (Alexander and Klein, 2001; Regehr and Millar, 2007). However, Alexander and Klein (2001) questioned whether these negative perceptions were emergent from an ‘absence of climate of care’, or whether blame was attributed to significant others because of the respondents inability to accept and admit their own ‘emotional vulnerability’.
Discontent may also be attributable to a lack of opportunity for face-to-face interaction between staff and supervisors/managers due to the ambulatory nature of the work and the need for stand-by. The rotating twenty-four hour shifts rarely complement the standardised ‘offce’ hours worked by managers. Subsequently, the net effect is that communications become more difficult, and manager's risk becoming disconnected from their staff (Carriere and Bourque, 2008).
Regehr and Millar (2007) identified that paramedics found supervisors/managers interrogational and critical at the time when they most needed support. Taking into account the points above however, one wonders whether good intentions by senior staff are in-fact miss-communicated and therefore miss-interpreted. Halpern et al (2009) found that staff were actually very keen to have their supervisor's support but were demoralised and dissatisfied when this failed to materialise or was insufficient. These points suggest that training is required for supervisors and managers to explain the importance of their role in providing organisational support, enhance communication skills, promote basic counselling skills, and to emphasise recognition of when an employee might need support. Furthermore, training could be extended to the entire ambulance workforce to promote a positive culture of stress awareness and openness to emotional vulnerability; thereby reducing the stigma associated with emotional display.
Interestingly, the views of supervisors/managers were not considered by the studies reviewed; rather the focus remained on paramedics. It would be useful to identify the perspective of these senior ambulance staff to counterbalance the current research findings.
Humour
This literature review has identified from both qualitative and quantitative research that black humour is employed by ambulance personnel, and is perceived as a useful moderator of stress— promoting a sense of control and an ability to cope (Alexander and Klein, 2001; Regehr et al, 2002b; Jonsson and Segesten, 2004; Essex and Benz-Scott, 2008; Halpern et al, 2009). The results suggest that camaraderie within the ambulance service increases teamwork, morale, forges a sense of ‘togetherness’ (group cohesion) and provides social support. Such positivity correlates with higher standards in quality of work performance (Bennett, 2003). Therefore, it is important that this coping technique is allowed to occur.
Interestingly, professional group rules govern the contextual element of joking. Although patients are sometimes drawn into the lightheartedness, most takes place ‘backstage’ out of public hearing (such as in the cab or crew room). Often, humour is not shared with family and ‘outside’ friends as they are unlikely to appreciate its coarse nature. Furthermore, Jonsson and Segesten (2004) observed that joking is never permitted when the call involves seriously ill or injured children.
From a cognitive perspective, the studies comment that the use of humour is a strategy employed to create emotional distance between the paramedic and the situation; thereby ‘protecting’ the professionalism of the worker from the vulnerability of exposing feelings, yet providing a socially acceptable form of anxiety release (Halpern et al, 2009). Others argue that it is a form of denial; a deliberate act of not wanting to address strong emotions, which allows individuals to hide or suppress their feelings (Moran and Massam, 1997). In these instances, the therapeutic value of humour appears to be negligible.
Story telling
Narrative telling as a coping strategy is only acknowledged by two of the studies reviewed, and one of these fails to discuss it in any detail (Regehr et al, 2002). However, it is arguable that this coping mechanism is rarely recognised as a separate entity, and in fact is deemed as a fundamentally inherent, strategic form of communication within other coping strategies such as social support, humour, and professional refection. For example; Tangherlini's (2000) observational ethnographical work highlights the intrinsic nature of storytelling. He identified that personal exploration and evaluating professional practice underlie EMS narratives.
While the two studies mentioned were of a qualitative, naturalistic methodology, many of the other studies used rigid coping scales which ask specific questions for specific known coping strategies such as humour. Therefore, there is a lack of opportunity to gather data on other coping mechanisms such as narrative telling.
Although Tangherlini's (2000) report is not without criticism for its lack of transparency (regarding participant selection and methods of data collecting) useful conclusions may be drawn, but with caution. Firstly, he identified that paramedics use storytelling for informally debriefing emergency calls and daily hassles. This enhances group cohesion, teamwork and social support. Secondly, he found that narrative telling creates an emotional distance between the paramedic and the incident/patient, helping them to cope with it. It also provides a culturally acceptable form for expressing concerns, fears and anxieties, and gives perspective to the situation.
Storytelling as a coping mechanism appears to be under-researched and under-rated. The significance of the spoken word as a window on personal emotions, thoughts and psychological coping/resilience cannot be overlooked. Much research into this area is required.
Risky behaviours
Using alcohol following stressful experiences was identified by five studies. It seems that many of the respondents (up to 50 % of participants in Essex and Benz-Smith's (2008) study) used alcohol as a short-term coping strategy despite being recognised by the respondents as unhelpful. Similar results were found from studies on firefighters (Boxer and Wild, 1993), military personnel (Gould and Greenberg, 2008), nurses (Callaghan et al, 2000) and police officers (Leonard and Alison, 1999). The latter study found that alcohol intoxication represented a form of denial of feelings, however, it is also likely that alcohol is used as a relaxation aid. Prati et al's (2009) study of Italian emergency workers found that substance abuse was one of the least used coping strategies, with cognitive and social support being more widely used.
Regehr et al (2002), Halpern et al (2009) and Regehr and Millar (2007) recognised from respondents that at times, alcohol use became more problematic. Each of the studies had one respondent who could personally identify with this, but also linked excessive alcohol intake with burnout. Interestingly, this conclusion is contradictory to those found by Ward et al (2006) who established from questioning 1 099 South African paramedics that there was no correlation between incident exposure and alcohol use. A later study by Sterud et al (2007) of 2 372 police officers and 1 096 ambulance personnel observed that there is no relationship between significant stress and excessive alcohol use in these emergency workers. However, they did find that drinking to cope was a risk factor for higher levels of alcohol related problems. So, perhaps a conclusion may be drawn that currently, there is no consensus as to whether alcohol misuse is associated with occupational stress in paramedics, however, further systematic research is needed.
With any study exploring personal habits, one has to be mindful that participants may refrain from disclosing, or may falsify information given on use or frequency of use, due to the severe occupational and social implications associated with this. Importantly, managers need to be aware that employee alcohol use/misuse might imply psychological distress and an inability to cope. Development and implementation of relevant policies which positively and sensitively respond to stress and stress-related behaviours are necessary to ensure the responsibilities of all parties are clear and promote the health and wellbeing of employees.
Review limitations
Apart from the limitations mentioned within the text, this review is potentially limited by the influence of the author's theoretical orientations, interest in social psychology and their professional experience as a frontline paramedic. While this can bring many enriching sources of information and potentially add phenomenological validity to the work, this influence can bias the active, interpretative process and decision-making about what material should be included, the data abstracted, critically analysed and synthesised. This refects the post-positivist perspective that subsequent knowledge construction may be a resulting blend of preconceived perceptions and unknown ideologies.
Some of the studies reviewed commented on gender differences and amount of professional experience as being a contributory factor in how effective coping strategies are. Unfortunately, it is a limitation of this study that these areas were not reviewed. Further academic exploration of these factors may provide some interesting and useful data.
Conclusion
Currently, there is very little quality research investigating the informal coping mechanisms paramedics use to manage occupational stress and their emotions in relation to daily hassles and incidents. Of that which is available, paramedics seem to use a holistic blend of humour, social support, cognitive behavioural methods, narrative telling, and professional refection.
From an academic perspective, understanding how paramedics cope informally could assist in understanding why formal methods are not as successful as they could be. Further research is required to gain a greater understanding of this.
It must be recognised that human resources singularly constitute the most expensive element of economic capital, and therefore there is a need to protect and support employees and management teams from both the physical and behavioural aspects of stress, and also the emotional and psychological ramifcations. Further training for managers, supervisors and employees is required, as is a shift in ambulance service culture to look ahead and be mindful that impingement to the practice of informal coping strategies will undoubtedly lead to increased stress levels within employees, which will consequently result in increased sickness absence and staff seeking alternative employment.
In the current climate of limited finances within the NHS and the constant drive towards achieving explicitly top-down targets and indicators of performance, arguably in reality, attention to employee wellbeing is likely to be some way down the ‘to do’ list—despite government initiatives to work towards improving the health of working people.