O’Sullivan. B (2012) Journal of Canadian Paramedicine – International Edition

This paper is intended as a source to stimulate reflection around the issues of stress and burnout for Practitioners, 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 Practitioner wherever they may find themselves on the spectrum of wellness to impairment.

The incidence of stress and burnout faced by Practitioners is well supported in the empirical literature, Alexander & Klien (2001) conclude, that 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 Practitioners. 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”

Whilst the incidence of stress and burnout is well documented. The sources of burnout may be less obvious. It appears that these sources can be broadly categorised into two headings, intrinsic and extrinsic. The intrinsic factors would include those aspects that one would normally associate with the role of a practitioner, 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 Practitioner, for example, the manner in which Practitioners are treated by superiors, nursing staff and medical staff (Glendon 1992).

Continuing with extrinsic factors, James & Wright et al (1991) consider organisational climate, management favouritism, inadequate recovery periods between difficult calls, poor communication and relationships with the management team and co-workers. 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 organisation’s future (Glendon 1991). Brough. P. (2004) concludes that organisational 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 Practitioner, with numerous intrinsic and extrinsic factors thrown in. 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 deterioration in the quality of the care provided”

Schaufeli & Enzmann(1998 p.36) describe burnout as a persistent, negative work related state of mind in normal individuals, that is primarily characterised by exhaustion which is accompanied by distress, a sense of decreased effectiveness, decreased motivation and the development of dysfunctional attitudes and behaviours at work.” Emotional exhaustion refers to the depletion and draining of emotional resources. Dysfunctional attitudes and behaviours refers 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, that burnout is characterised by the development of negative attitudes towards the patient, job and the organisation, whereas stress is not necessarily accompanied by these behaviours 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 characterised 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 internal locus of control, 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, behavioural, 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.

Behavioural 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 dehumanising of the patient. Spiritual characteristics refers to the loss of faith, loss of meaning and purpose, feelings of alienation, estrangement and despair.

Remedies that may be available to the Practitioner 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 Practitioners responsibility to be pro-active in managing their own stress. To function effectively as a practitioner we must be in good shape personally, physically mentally and emotionally.

In relation to the physical aspects. Stress is a pattern of physiological responses which are caused by specific events in peoples lives such responses include Hyperglycaemia, Hypertension and Tachycardia to name just a few, with such a complex set of events and the Practitioners 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 a 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 includes regular stress related responses.

In relation to mental health, Pearlman & Mc Ian (1995) point out that, “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 socialising with friends and family, discussions with fellow Practitioners and attending workshops. The list is endless.

If the Practitioner 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 Practitioner 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 Practitioner to recognise 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 bases which the practitioner may consider appropriate. These individuals have specific training in these roles and may prove helpful to the Practitioner. On occasion access to Psychotherapeutic and Counselling services may be appropriate. It is important to mention that utilising 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 counselling/psychotherapeutic practice.

It would seem that the Practitioner’s occupational environment is becoming increasingly stressful with greater professional and clinical expectations and 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 Practitioner in modern Pre-Hospital Emergency Care, to be incorporated into daily practice if the Practitioner is to reduce the possibility of progressing along the spectrum from wellness to impairment. Ultimately the care that practitioners 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 Organisational 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.

Pearlmann. 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 Organisational 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 Counselling. 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.