Does Helping Hurt?

           O'Sullivan. B. (2012) Does Helping Hurt, Canadian Paramedicine (35) 1,pp. 25-27. 

This paper is intended as a source to stimulate reflection around the issues of Stress and Burnout for Paramedics, as they go about their daily practice within modern Pre-Hospital Emergency Care. It is also an attempt to raise awareness of impairment risks and introduce for consideration, the resilience strategies that may be available to the Paramedic wherever they may find themselves on the spectrum of wellness to impairment.

The incidence of stress and burnout faced by Paramedics is well supported in the empirical literature, Alexander & Klien (2001) conclude  the mental and emotional well being of  EMS personnel appears to be compromised by accident and emergency work. In addition the Association of Chief Ambulance Officers (U.K.1990) observed, there are too many incidents of premature retirement and death due to stress related illness. They further draw attention to the increased incidence of burnout among Paramedics. Another recent paper provided by the Critical Incident Stress Management Committee (Ireland 2008) concluded "Clearly Paramedics put themselves at significant psychological risk when compared to the general population"

The incidence of stress and burnout is well documented however the sources of burnout may be less obvious. It appears that these sources can be broadly described under two headings, intrinsic and extrinsic. The intrinsic factors would include those aspects that one would normally associate with the role of the Paramedic, for example the frequent contact with people who are in pain and distress or the routine contact with injury, mutilation and death (Vettor & Kosinski 2000). The extrinsic factors include those aspects that one would not normally  associate with the role of the Paramedic, for example, the manner in which Paramedics are treated by superiors, nursing staff and medical staff (Glendon 1992). Continuing with extrinsic factors, James & Wright et al (1991) consider organizational climate, management favoritism, inadequate recovery periods between difficult calls, poor communication and relationships with the management team and co-workers to be significant factors. Some other examples identified include non emergency work (Sparrious 1992), certain shift patterns, being with bad drivers at high speed, the promotion of incompetent people, insufficiently low retirement age and a lack of information about the organization's future (Glendon 1991).  Interestingly  Brough. P. (2004) concludes that organizational factors are more frequently the sources of stress rather than operational duties.

In a profession where human relationships are so intrinsically related to the role of the Paramedic.  It is sometimes inevitable to experience distress and burnout. Maslach (2003) notes, "stress over a period of time can result in burnout leading to a reduction in the quality of the care provided"

Schaufeli & Enzmann(1998 p.36) describes burnout as a persistent, negative work related state of mind in normal individuals, that is primarily characterized by exhaustion which is accompanied by distress, a sense of decreased effectiveness, decreased motivation and the development of dysfunctional attitudes and behaviors at work." Emotional exhaustion refers to the depletion and draining of emotional resources. Dysfunctional attitudes and behaviors refer to the development of negative, callous, indifferent and cynical attitudes towards the patient. "Normal" refers to individuals who do not suffer from psychopathology (Cozens & Payne 1999, p.20)

Schaufeli & Van Dierendonck (1993) argue the biggest difference between stress and burnout is, burnout is characterized by the development of negative attitudes towards the patient, job and the organization, whereas stress is not necessarily accompanied by these behaviors and attitudes. One concept put forward is that everyone can experience stress while burnout can only be experienced by those who enter their profession enthusiastically with high expectations and goals (ibid). Pines (1993) concludes individuals who expect a sense of significance from their work are susceptible to burnout whereas those individuals without such expectations experience job stress. Maslach et al (2001) argues certain personality traits may predispose an individual to a greater risk of  burnout for example, personalities characterized by poor self esteem, an avoiding non-confrontational coping style and an external locus of control (where events and achievements are attributed to "powerful others" and chance). In contrast burnout is less common among personalities with a well developed internal locus of control for example, where they attribute events and achievements to their own effort and ability.

Gorsch et al (1994) identifies five characteristics of burnout. They are physical, psychological, behavioral, interpersonal and spiritual.

Physical characteristics refer to exhaustion, sleep difficulties, fatigue, headaches and gastrointestinal disturbances. Psychological refers to depression, irritability, guilt, anxiety, helplessness, and hopelessness.

Behavioral refers to aggressiveness, pessimism, defensiveness, cynical attitudes and substance abuse. Interpersonal refers to an inability to concentrate with patients, a withdrawal from patients and co-workers and the dehumanization of the patient. Spiritual characteristics refer to the loss of faith, loss of meaning and purpose, feelings of alienation, estrangement and despair.

Remedies that may be available to the Paramedic should they find themselves progressing along the spectrum from wellness to impairment can be identified under three broad headings. They are physical, mental and strategic. Firstly we must accept that stress will occur and in the first instance it is the Paramedics responsibility to be pro-active in managing their  stress. To function effectively as a Paramedic we must be in good shape personally, physically mentally and emotionally.

In relation to physical aspects, stress is a pattern of physiological responses which are caused by specific events in people's lives such responses include Hyperglycemia, Hypertension and Tachycardia to name a few, with such a complex set of events and the Paramedics predisposition to these events. It is reasonable to assume that maintaining good physical health will reduce the incidence of undesired stress. In short a healthier body is far more capable of dealing with excessive stress than an unhealthy body. Improvements to physical health can occur as a result of increasing physical exercise, proper rest periods and sleep patterns. A balanced diet ensures that the body has all of the necessary nutrients to perform daily activities which would include regular stress related responses.

In relation to mental health, Pearlman & Mc Ian (1995) point out, "any mental health exercise that draws attention away from events and provides a relaxed state to the individual is helpful in this regard." Some examples might include imagery, meditation, music, breathing techniques, vacations, hobbies, movies, walking pets, increased socializing with friends and family, discussions with fellow Paramedics and attending workshops. The list is endless.

If the Paramedic finds that he or she is taking responsibility for anything that goes wrong to such an extent that feelings of powerlessness and hopelessness continue to be obstacles to maintaining a healthy lifestyle balance, it may be worthwhile for the Paramedic to re-assess his or her own perception towards certain events to re-establish a healthy balance between their personal and professional lives.

With regard to strategic thinking, this allows the Paramedic to recognize their personal and professional limitations and to work effectively within those limitations, for example the setting of achievable goals.

One resource worth a mention is the Peer Support Workers in stations.   The Paramedic may consider this resource appropriate. These individuals have specific training in these roles and may prove helpful to the Paramedic. On occasion access to Psychotherapeutic and Counseling services may be appropriate. It is important to mention that utilizing these services is not a sign of weakness rather it is a pro-active approach to self care. These services are accessible through the Occupational Health Department of The Health Service Executive. They are self referring and confidentiality is a legal and ethical part of any professional counseling/psychotherapeutic practice.

It would seem that the Paramedic's occupational environment is becoming increasingly stressful with greater professional and clinical expectations with increased accountability measures being placed on him or her. It would seem that self care is an intrinsic, continuous and highly important activity to be performed by any Paramedic in modern Pre-Hospital Emergency Care, to be incorporated into daily practice if the Paramedic is to reduce the possibility of progressing along the spectrum from wellness to impairment. Ultimately the care that Paramedics provide to others will only be as good as the care that they provide to themselves.  

 

 

REFERENCES.                             

Alexander & Klien (2001) Ambulance Personnel and Critical Incidents British Journal of Psychiatry:178:76-81.

Ambulance 2000 (1990) Proposals for the Future Development of the  Ambulance Service, Association of Chief Ambulance Officers (U.K.)     In Stress, Workload and Fatigue, Hancock. P. & Desmond.  P. (2001),Mahwah, New Jersey.           

Brough. P. (2004). Comparing The Influence Of Traumatic and  Organizational Stressors On The Psychological Health Of Police, Fire And Ambulance Officers, International Journal Of Stress Management: 11 (3) 227-244.

Cozens. J.F. & Payne. R. (1999) Stress in Health Professionals, Psychological, and Occupational Causes And Interventions. J. Wiley & Sons.      

C.I.S.M. (2008) the National Ambulance Service Stress Survey, Executive Summary and Action Recommendations. Department Of Psychology, Royal College Of Surgeons, Ireland. 

Glendin (1992) Chronic Stress in Ambulance Crews, Unpublished Masters Thesis, Dept, Of Occupational Psychology, Birbeck College,University Of London.

Gorsch et al (1994) When Helping Starts To Hurt, A New Look At Burnout Among Psychotherapists. Norton, New York.

James & Wright (1991) Occupational Stress In The Ambulance Service, Health Manpower Management 17 (4).

Maslach. C. (2003) Professional Burnout, Recent Developments in Theory and Research, Taylor & Francis, Washington.

Pearlman. L.A. & Mc Ian. P.A. (1995) Vicarious Traumatisation, An   Empirical Study Of The Effects Of Trauma Work. Professional Psychology Research and Practice 26 (6) 558-565.

Pines.A.M. (1993) Burnout in Glodenberger. L. & Brenitz, Handbook of Stress, Theoretical And Clinical Aspects, 2nd Edition, p.386-402. New York: Free Press

Schaufeli. W.B. & Enzmann. D. (1998) The Burnout Companion to Study And Practice, A Critical Analysis.Taylor & Francis, London.

Schaufeli Van Dierendonck (1993) The Construct Validity Of Two Burnout Measures, Journal Of Organizational Behaviour, 14:631-647.

Spurious (1992) Occupational Stress among Ambulance And Rescue Service Workers, South African Journal Of Psychology, 22 (2) 87-91.

Vettor.S.M. & Kosinski. F.A. (2000) Work Stress Burnout in Emergency Medical Technicians And The Use Of Early Recollections, Journal Of Employment Counseling. 37 (4) 216-228. In Nurit. N. (2008), Stress, Work Overload, Burnout and Satisfaction among Paramedics In Israel. Pre- Hospital and Disaster Medicine, 23 (6) 537-546.                            

 

Author                          Brian O Sullivan.

Email.                           brian@changes.ie

Full Quote.                    O'Sullivan. B. (2012)  Does Helping Hurt? Canadian Paramedicine,

                                    35:1:25-27.