POST-TRAUMATIC STRESS DISORDERS AND BURNOUT SYNDROME AMONG COMMUNITY PARAMEDIC STAFF
Doaa Abd El Salam Amin Yacout1, Neama Yousef Mohamed2*, Hanan Hosni El Sherbini3
1Community Health Nursing, Faculty of Nursing, Damanhour University, Egypt
2,3Community Health Nursing, Faculty of Nursing, Alexandria University, Egypt
*Corresponding Author;S Email : rahma_fathy2003@yahoo.com
ABSTRACT
Background: Community health nursing specialties have continuously changed and updated according to the community needs. Ambulance paramedics staff is one of the specialties in community health nursing, and they play a vital role in emergency situations even at home. They play a role in advancing home care which reduce the cost in health care system, they deal with serious conditions such as pandemic situation as in case of COVID-19 pandemic nowadays. So, this group of staff must be studied to understand the occupational problems that they might face and help them to deal with. Aims of study: The current study aimed to assess the post-traumatic stress disorders among paramedic staff, and to evaluate the burnout syndrome severity among paramedic staff as a community paramedic. Methods: A descriptive exploratory research design was used. Settings: The study was carried out at one out of the seven regions served by the Egyptian Ambulance Organization (EAO) namely Alexandria region which serve three Egyptian governorates (Alexandria, Matrouh and Beheira governorate). Subjects: All paramedic staff were working at the chosen settings and meet the inclusion criteria (68) were recruited in the study. Tools: Data was collected using three tools namely “Paramedic Staff Health Profile and Sociodemographic Assessment Tool, Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS) Tool and the Clinician-administered Post Traumatic Stress Disorder Scale for DSM-5 (CAPS-5) Past Month Version. Results: The current study indicate that the studied paramedic staff has different degree of burnout syndrome and post-traumatic stress disorder with a significant association with multivariable such as age, marital status level of education, years of experiences, working hours per week, sleeping hours and their evaluation for their health condition. Conclusion and Recommendations: The paramedic staff burnout inventory scale indicate that around one third of them have high emotional exhaustion level. Whereas, more than two fifths of them have low level of personal accomplishment. Around one third have high level of depersonalization. Furthermore, three quarters of the studied paramedic have mild, minimal distress or disruption of activities followed by moderate, distress clearly present but still manageable. Regular screening of paramedic staff should be done for evaluating stress, depression and anxiety. Proper management must be done for detection of early stage symptoms of BOS and PTSD. Inservice stress management training especially for invoice community paramedic staff must be executed to raise their awareness regarding the possibility of PTSD and BOS and their management.
Keywords: Ambulance Team; Stressors; Emotional Exhaustion; Distress; Community Health Workers
INTRODUCTION
Community paramedic is an evolving field that involves paramedics above emergency care and transport. It reduces emergency room visits and filling gaps in health care delivery by reducing the burden on primary care physicians. Additionally, it’s being used to improve access to appropriate care for patients who are unable to reach the health care facilities especially when they call the emergency service. According to Zavadsky (2014), Community Paramedic staff provide in-home and telephone based support to patients who call the emergency service and work as a part of mobile integrated health care practice as they conduct an in-depth patient’s assessment, develop customized plan of care, and provide needed support for patients and their family. Raynovich (2014) added that the Emergency Medical Services Professionals also participate in disease and injury prevention and they accurately assess both the patient’s clinical condition and the environmental context in which they live. Community paramedics are trusted members of the community who focus on outreach, education, and informal counseling, contribute to improved health care outcomes for the underserved populations they serve. There is growing interest in bringing the skills of these workers to specific condition-focused initiatives or patient-centered medical homes (Wingrove, 2014; Reforming States Group, 2014). World Health Organization (2011) recommend different training program for community paramedic staff who served population under difficult circumstances.
Community Paramedics face different occupational hazards at their work which are either physical, mechanical, biological or psychological hazards, they face unique mental health challenges, like no other job. One of the main challenges are the lacking human resources which make the care provision difficult and put extra load among in providing safe high-quality care for those in casualty or at home especially in remote marginalized and unserved area. Additionally, paramedic staff are forced to work in critical situations, and they must sustain commitment to disaster preparedness and planning since they deal with major casualty and must save victim’s life. They experienced traumatic events at work that makes them unable to deal the situation effectively and leads to the exposure to post traumatic stress disorders and burnout syndrome (Viswanathan, Wizemann & Altevogt, 2011). A study done at Mansoura city, Egypt concluded that Emergency Medical Responders (EMRs) group had more frequent exposure to both acute and chronic work-related stressors than comparative group. Also, community EMRs had higher levels of Emotional exhaustion (EE), depersonalization (DP), and PTSD than comparative group. EMRs are in need for stress management program for prevention of stress related hazards on health and work performance (Khashaba et al., 2014). Further, working as a community paramedic can be demanding psychologically and physically, setting a high pressure on community paramedic in prehospital care all over the world (IDSC, 2020). This pressure may cause a higher risk for them to develop burnout and stress (Auvinen & Lisitsyn, 2017). Emergency service workers (Paramedics) are already at high risk of burnout especially due to many occupational hazarders as coronavirus stress now days (Saxena, 2020). Paramedics are often the first on the scene of major accidents. People’s lives depend on their quick reaction and care. Added to this the physical stress of the job. So, paramedics need to be proactive about their own health both mental and physical. All these variables are contributing to burnout and stress among them (Emergency Service Health Team, 2020).
Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties, among them the emergency department and the pre-hospital healthcare services which are highly stressful environments (Cicchitti et al., 2014). Burnout has been typically described as a mental health problem that has three key components “personal accomplishment, emotional exhaustion and depersonalization” according to Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS). Burnout has also been described as a stress related illness which can manifest itself physically with typical stress responses leading to serious health and safety concerns. Thus, it is important to minimize risks among the frontline care providers. Burnout due to workload in general in community paramedics emergency services in major accidents may lead to serious consequences among the frontline care providers and the paramedic staff (Dubale et al., 2019; Shah et al., 2020). The paramedic health team always complain from variant level of anxiety and stress according to workplace variables and work overload as was found to have a positive correlation with Maslach burnout inventory scores (Shah et al., 2020; Patel et al., 2018; Christine, Emilie & Martine, 2019)
Burnout is not occurred alone; it mainly has another side like the coin. The other phenomena is post- traumatic stress disorders (PTSDs). The co-existence of PTSDs and BOS is associated with altered perceptions of work and nonwork-related activities affecting the paramedics health and their productivity and working performance. The extreme effect of PTSDs and BOS among these workers including loss of their life due to exhaustion and stress (Mealer et al., 2009).
The Clinician-administered Post Traumatic Stress Disorder Scale for DSM-5 (CAPS-5) was used to assess PTSDs related intrusion symptoms, avoidance symptoms, cognitions and mood symptoms, and arousal and reactivity symptoms. Also, it used to assess the disturbance characteristics of PTSD “onset, duration, associated distress or impairment, subjective distress, impairment in social functioning, impairment in occupational or other important area of functioning. And finally, it assess incidence of dissociative symptoms (Depersonalization, Derealization); where depersonalization is known as persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).While, derealization indicates persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Until recently, occupational health as one of community health nursing specialties within the ambulance services has received relatively little attention from researchers. In the past few years, researchers have become increasingly aware that ambulance personnel may be at risk of developing work-related health problems. So, the current study aimed to assess the PTSDs and BOS among paramedic staff working as a community paramedics in Egypt.
Aim of the Study
The current Study Aims to
Assess the post-traumatic stress disorders among paramedic staff as a community paramedic.
Evaluate the burnout syndrome severity among paramedic staff as a community paramedic.
MATERIALS AND METHOD
Study Design:
A descriptive exploratory research design was used.
Study Setting:
Egyptian Ambulance Organization (EAO) is government affiliated to the Egyptian Ministry of Health and Population (MOHP). It is one of the most important organizations affiliated to the Egyptian Ministry of Health. Since 1902 it provides responsive, quality emergency clinical care and support for patient transport, rescue and retrieval services that aimed to meet the community needs. The EAO serve seven regions covering the whole country; which are Greater Cairo region (Cairo, Giza, October, Helwan, and Qalyubia governorates), Alexandria region (Alexandria, Matrouh and Beheira governorates), Delta region (the governorates of Menoufia, Dakahlia, Damietta, Kafr El-Sheikh and Gharbia), Canal region (Suez, Ismailia, Eastern, Port Said, North Sinai, and South Sinai governorates), North Upper Egypt region (Beni Suef, Minya, and Fayoum governorates), Central Upper Egypt region (Assiut, Sohag and New Valley governorates), and South Upper Egypt region (Aswan, Luxor, Qena and Red Sea governorates). The current study was carried out at Alexandria region which serve three Egyptian governorates.
Study Subjects:
All working paramedic staff, meeting the inclusion criteria were included in the study. The total number of the selected paramedic are 68 members (30 members working at Alexandria governorate, 30 members working at Beheira governorate and 8 members working at Matrouh governorate). They were selected according to the following inclusion criteria:
Working at the EAO since at least one year.
Those who accept to participate in the study.
Tools:
In order to collect the necessary data for the study, the following tools were used:
Tool I: Paramedic Staff Health Profile and Sociodemographic Assessment Tool:
This tool was developed by the researchers after reviewing recent literatures in order to collect data about paramedic staff’s health profile, sociodemographic data, occupational history (job description, duration of employment, shift work hours, working experiences in addition to their lifestyle pattern. Also, weight, height and blood pressure were assessed.
Tool II: Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS):
It is a self-reported instrument used to measure the frequency of the three aspects of burnout syndrome namely: emotional exhaustion, depersonalization, and personal accomplishment (Maslach, Jackson & Leiter, 1996; Maslach & Jackson,1981; Maslach, Schaufeli & Leiter, 2001; Lheureux et al., 2017). It contains 22 items grouped into three subscales according to the following; emotional exhaustion (9 items) which allows subjects to describe feelings of being emotionally overextended and fatigued; depersonalization (5 items) which measures the extent of unfeeling and impersonal attitudes toward clients, and personal accomplishment (8 items) which describes feelings of competence and successful achievement in relation to working with clients. The responses are 6-point Likert- type scale ranging from never = 0 to every day= 6. The total score of burnout scale is 132. The classification of scores on subscales of the Maslach Burnout Inventory (MBI) was divided into the following:
-Emotional Exhaustion (EE): The maximum allowed score was 54 point which categorized into: Low EE (0-18 point), Moderate EE (19-26 point), and High EE (27 point and more)
-Personal Accomplishment (PA): The maximum allowed score was 48 point which categorized into: Low (40 point or more), Moderate (34-39 point), and High (0-33 point)
-Depersonalization (DP): The maximum allowed score was 30 point which categorized into: Low DP (0-5 point), Moderate DP (6-9 point), and High DP (10 point or more)
Tool III: Clinician-administered Post Traumatic Stress Disorder Scale for DSM-5 (CAPS-5) Past Month Version:
The Clinician-administered Post Traumatic Stress Disorder Scale for DSM-5 (CAPS-5) was used to assess the current PTSDs among the clinicians. The past month version of the CAPS-5 was used to evaluate PTSD symptoms over the past month (Weathers et al., 2018). The CAPS-5 is a 30-item structured interview questions, each question was scored (0) if the respondents didn’t have the symptoms or (1) if the respondents have the symptom. CPTSD total score was divided into four levels of distribution which are:
-None, who reported no symptoms of distress.
-Mild, minimal distress or disruption of activities (1-10 points).
-Moderate, distress clearly present but still manageable disruption of activities (11-20 points).
-Severe, distress clearly present with unmanageable disruption of activities (21-30 points).
METHODOLOGY
Official letters from the faculty of Nursing, University of Alexandria were directed to Egyptian Ambulance Organization at Alexandria, Beheira and Matrouh governorate to obtain their permission to collect data from the selected settings.
Tools I was developed by the researchers after reviewing of the recent literature.
Tool II and III were translated into Arabic language and revised extensively by expertise in language translation.
The content validity of the study tools was tested by a group of (5) experts in the field and their opinions and their suggestions were taken into consideration.
The reliability of the tool II and III was ascertained using the Cronbach Alpha test, where both were more than 80% reliable.
A pilot study was carried out on 5 paramedic staff to test the clarity, feasibility and applicability of the study tools. The necessary modifications were done. These staff were excluded from the total study subjects.
Data was collected individually from the paramedic staff after receiving their written approval to participate in the study.
An individual interview was carried out in order to collect the necessary data from each subject. The interview took around 20-30 min.
Weight and height were measured to calculate Body Mass Index (BMI) according to WHO standard. Blood pressure was measured also using mercury sphygmomanometer, while the paramedic staff was setting at a relaxed atmosphere.
Data was collected since the beginning of October 2019 till the end of January 2020.
The collected data was coded and feed into the PC using IBM-SPSS version 25.
Data was analyzed using the suitable statistical analysis and considering that the statistically significant p value equal to or less than 0.05.
Ethical Considerations
Written consent was obtained from every participant included in the study after explanation of aims and with the assurance that the collected data will be used only for the study purpose.
The study subjects were treated respectfully regardless of their age, sex, religious and their socioeconomic status.
Confidentiality and anonymity of individual’s response was ensured by statement in the cover page of the tool, and a code number was used instead of names.
Participation was maintained on a voluntary basis.
The study subjects assured that they have the right to withdraw at any time.
The researchers credited the study subjects and everyone who assisted in the study in the research acknowledgment statement.
RESULTS
Table 1: Distribution of the Studied Paramedics According to Their Socio-Demographic Data and Working Experiences
Socio-Demographic Data and Working Experiences
No. (68)
%
Age
Less than 30
10
14.7
30 to less than 40
25
36.8
40 to less than 50
26
38.2
50 and more
7
10.3
Mean±SD
39.6±9.0
Marital Status
Single
5
7.4
Married
61
89.7
Divorced
2
2.9
Level of Education
Secondary level of education (Diploma)
17
25.0
Above average education (Technical Health Institute)
35
51.5
High level (Bachelor)
9
13.2
Post-graduate (Diploma and Fellowship in Emergency)
7
10.3
Years of Experience
5 to less than 10 years
21
30.9
10 to less than15 years
22
32.4
15 to less than 20 years
12
17.6
20 years and more
13
19.1
Mean±SD
16.4±9.3
Working Shift
Morning
10
14.7
Socio-Demographic Data and Working Experiences
No. (68)
%
Evening
4
5.9
Long day
54
79.4
Number of Working Hours a Week
36.00
24
35.3
48.00
37
54.4
72.00
7
10.3
Mean±SD
46.2±10.4
Deal with Victim Directly
No
6
8.8
Yes
62
91.2
Work Satisfaction (Self-rating scale)
Satisfied
8
11.8
Partially satisfied
25
36.8
Dissatisfied
35
51.5
Desire to Change the Career (Career shift desire)
No
49
72.1
Yes
19
27.9
Table 1 shows that less than two fifths of the studied subjects aged 30 to less than 40 years and 40 to less than 50 years old (36.8% and 38.2% respectively) with the mean age was 39.6±9.0. The majority (89.7%) of them were married. A quarter of them have finished secondary education and just half (51.5%) of them finished above average education (technical health institute), compared to around one tenth of them who have bachelor degree or diploma and fellowship in emergency (13.2% and 10.3% respectively). Regarding mean years of experience, it was 16.4±9.3 years. More than seventy percent (79.4%) of them were working at long day shift. In this regard, it was noticed that they were working around 46.2 hours per week since 35.3% of them work for 36 hour, 54.4 % work for 48 hour and 10.3% worked for 72 hour as they work as a block working hours and be on call. The majority (91.2%) of them deal with victim directly. Only 11.8% of the paramedic staff was satisfied by their work compared to 51.5% were dissatisfied. Finally, more than a quarter (27.9%) of them has a desire to change their career.
Table 2: Distribution of the Studied Paramedics According to Their Lifestyle Pattern and Health Profile
Lifestyle Pattern and Health Profile
No. (68)
%
Number of sleeping hours
Inadequate (less than 6hours)
23
33.8
Adequate (6hours and more)
45
66.2
Mean ±SD
7.0±1.0
Smoking Habit
No
33
48.5
Yes
35
51.5
Regular Eating of Meals
No
22
32.4
Yes
46
67.6
Health Complain #
None
7
10.3
Headache
50
73.5
Low back pain
27
39.7
Insomnia
8
11.8
Hypertension
6
8.8
DM
3
4.4
Blood Pressure Assessment
Mean ±SD of Systole blood pressure
127.6±15.0 mm/hg
Mean ± SD of Diastole blood pressure
82.2±8.0 mm/hg
BMI
Average weight
35
51.5
Overweight
18
26.5
Obese class I
15
22.1
Self-evaluation for Health Condition (Self-rating scale)
Good
4
5.9
Fair
46
67.6
Poor
18
26.5
# Multiple response
Table 2 presents that only around one third (33.8%) of the paramedic staff has adequate sleeping hours with a mean sleeping hour 7±1 hours a day. Slightly more than half (51.5%) of them were smokers. It was observed that slightly more than two thirds (67.6%) of them eat regular meals per day. Only 10.3% didn’t complain of any health problems, compared to less than three quarters (73.5%) who suffered from headache, followed by less than two fifths (39.7%) who have low back pain, and the minorities who have insomnia, hypertension and DM (11.8%, 8.8%, and 4.4% respectively). Regarding blood pressure measurements findings, it was noticed that the mean systolic blood pressure is 127.6±15 mmHg, while the diastolic blood pressure is 82.2±8 mmHg. Body mass index (BMI) classification of them revealed that more than a quarter (26.5%) were overweight, while more than one fifth (22.1%) of them classified as obese class I. Finally, according to their self-evaluation for their health condition self-rating scale it was noticed that only 5.9% of them have good health condition, two thirds (67.6%) stated that they have fair health condition and slightly more than a quarter (26.5%) of them have poor health condition.
Table 3: Distribution of the Studied Paramedics According to Their Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS)
Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS) Domains
No. (68)
%
Emotional Exhaustion
Low (0-18)
26
38.2
Moderate (19-26)
19
27.9
High (27 and more)
23
33.8
Mean ± SD (Maximum allowed score is 54 point)
23.2±10.3
Personal Accomplishment
Low (40 or more)
30
44.1
Moderate (34-39)
14
20.6
High (0-33)
24
35.3
Mean ± SD (Maximum allowed score is 48 point)
37.0±8.0
Depersonalization
Low (0-5)
34
50.0
Moderate (6-9)
11
16.2
High (10 or more)
23
33.8
Mean ± SD (Maximum allowed score is 30 point)
6.6±6.3
Table 3 portrays the paramedic staff burnout based on Maslach burnout inventory-human services survey for medical personnel (MBI-HSS) findings. Regarding emotional exhaustion domain, it was found that around one third (33.8%) of them have high emotional exhaustion level and more than a quarter (27.9%) of them have moderate emotional exhaustion level with a mean of 23.3±10.3 point. Whereas, more than two fifths (44.1%) of them have low level of personal accomplishment followed by one fifth (20.6%) who have moderate level of personal accomplishment, with a mean of 37±8 points. Finally, around one third (33.8%) have high level of depersonalization with a mean of 6.6±6.3 points.
Figure 1: Distribution of the Studied Paramedics According to Their CPTSD Total Score Based on Clinician-administered Post Traumatic Stress Disorder Scale for DSM-5 (CAPS-5) Past Month Version
Figure 1 portrays that three quarters (70.6%) of them have mild, minimal distress or disruption of activities followed by moderate, distress clearly present but still manageable, some disruption of activities among less than a quarter (23.5%) of them according to the CPTSD total score based on clinician-administered post-traumatic stress disorder scale for DSM-5 (CAPS-5) past month version.
Table 4: The Association between the Studied Paramedics Socio-Demographic Data and Working Experiences and Their Emotional Exhaustion
Variables
Emotional exhaustion
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Age
Less than 30
1
10.0
3
30.0
6
60.0
FET:43.794
P˂0.001*
30 to less than 40
18
72.0
4
16.0
3
12.0
40 to less than 50
0
0.0
12
46.2
14
53.8
50 and more
7
100.0
0
0.0
0
0.0
Marital Status
Single
0
0.0
5
100.0
0
0.0
FET:16.961
P˂0.002*
Married
24
39.3
14
23.0
23
37.7
Divorced
2
100.0
0
0.0
0
0.0
Level of Education
Secondary level of education (Diploma)
0
0.0
12
70.6
5
29.4
FET:39.861
P˂0.001*
Above average education (Technical Health Institute)
21
60.0
7
20.0
7
20.0
High level (Bachelor)
1
11.1
0
0.0
8
88.9
Post-graduate (Diploma and
Fellowship in Emergency)
4
57.1
0
0.0
3
42.9
Years of Experience
5 to less than 10 years
1
4.8
3
14.3
17
81.0
FET:53.668
P˂0.001*
10 to less than15 years
18
81.8
4
18.2
0
0.0
15 to less than 20 years
0
0.0
8
66.7
4
33.3
20 years and more
7
53.8
4
30.8
2
15.4
Working Shift
Morning
7
70.0
3
30.0
0
0.0
FET:24.756
P˂0.001*
Evening
0
0.0
4
100.0
0
0.0
Long day
19
35.2
12
22.2
23
42.6
Variables
Emotional exhaustion
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Number of Working Hours a Week
36.00
20
83.3
4
16.7
0
0.0
FET: 34.655
P˂0.001*
48.00
6
16.2
12
32.4
19
51.4
72.00
0
0.0
3
42.9
4
57.1
Work Satisfaction
Satisfied
4
50.0
4
50.0
0
0.0
FET: 15.022
P˂0.005*
Partially satisfied
15
60.0
3
12.0
7
28.0
Dissatisfied
7
20.0
12
34.3
16
45.7
Sleeping hours
Inadequate
5
21.7
11
47.8
7
30.4
X2: 7.510
P˂0.023*
Adequate
21
46.7
8
17.8
16
35.6
Self-evaluation for Health Condition
Good
4
100.0
0
0.0
0
0.0
FET: 14.044
P˂0.007*
Fair
18
39.1
16
34.8
12
26.1
Poor
4
22.2
3
16.7
11
61.1
Variables
Emotional exhaustion
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Number of Working Hours a Week
36.00
20
83.3
4
16.7
0
0.0
FET: 34.655
P˂0.001*
48.00
6
16.2
12
32.4
19
51.4
72.00
0
0.0
3
42.9
4
57.1
Work Satisfaction
Satisfied
4
50.0
4
50.0
0
0.0
FET: 15.022
P˂0.005*
Partially satisfied
15
60.0
3
12.0
7
28.0
Dissatisfied
7
20.0
12
34.3
16
45.7
Sleeping hours
Inadequate
5
21.7
11
47.8
7
30.4
X2: 7.510
P˂0.023*
Adequate
21
46.7
8
17.8
16
35.6
Self-evaluation for Health Condition
Good
4
100.0
0
0.0
0
0.0
FET: 14.044
P˂0.007*
Fair
18
39.1
16
34.8
12
26.1
Poor
4
22.2
3
16.7
11
61.1
FET: Fisher Exact Test X2: Chi square test
P: P value of test of significance *Significant at P value ≤0.05
Table 4 shed the light on the significant association between age and emotional exhaustion status of the studied paramedic staff where the high level of exhaustion is prevalent among the older one with p value ˂0.001. Regarding marital status it was observed that around one third (37.7%) of the married have high level of emotional exhaustion with a significant association between marital status and emotional exhaustion, with p value 0.002. The majorities (88.9%) of those who have bachelor’s degree of education have high level of emotional exhaustion followed by 42.9% among those who have diploma and fellowship in emergency with a significant association (p value ˂0.001). Furthermore, the majority (81%) of those who have 5 to less than 10 years of experiences have high level of emotional exhaustion compared to 15.4% with 20 years of experience and more with a significant difference (p value ˂0.001). it also observed that less than half (42.6%) work for long day shift, have high level of emotional exhaustion, with a significant association between working shifts and emotional exhaustion with p value ˂0.001. Moreover, around half of those working for 48 and 72 working have high level of emotional exhaustion (51.4% and 57.1% respectively) with a significant association between working hours per week and emotional exhaustion with p value ˂0.001. More than two fifths (45.7%) were dissatisfied at their work with high level of emotional exhaustion (p value 0.005). Slightly less than half (46.7%) have adequate sleeping hours with low emotional exhaustion compared to 30.4% of those who have inadequate sleeping hours who have high emotional exhaustion with a statistically significant association between sleeping hours and emotional exhaustion with p value 0.023. Finally, it was noticed that 61.1% evaluate his health condition as poor condition have high level of emotional exhaustion with p value 0.007.
Table 5: The Association between the Studied Paramedics Socio-Demographic Data and Working Experiences and Their Personal Accomplishment
Variables
Personal accomplishment
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Age
Less than 30
4
40.0
3
30.0
3
30.0
FET: 34.027
P˂0.001*
30 to less than 40
8
32.0
0
0.0
17
68.0
40 to less than 50
18
69.2
8
30.8
0
0.0
50 and more
0
0.0
3
42.9
4
57.1
Marital Status
Single
5
100.0
0
0.0
0
0.0
FET:10.311 P˂0.035*
Married
25
41.0
14
23.0
22
36.1
Divorced
0
0.0
0
0.0
2
100.0
Level of Education
Variables
Personal accomplishment
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Secondary level of education (Diplome)
14
82.4
3
17.6
0
0.0
FET:54.545
P˂0.001*
Above average education (Technical Health Institute)
15
42.9
3
8.6
17
48.6
High level (Bachelor)
1
11.1
8
88.9
0
0.0
Post-graduate (Diploma and
Fellowship in Emergency)
0
0.0
0
0.0
7
100.0
Years of Experience
5 to less than 10 years
4
19.0
11
52.4
6
28.6
FET: 38.734
P˂0.001*
10 to less than15 years
8
36.4
0
0.0%
14
63.6
15 to less than 20 years
12
100.0
0
0.0
0
0.0
20 years and more
6
46.2
3
23.1
4
30.8
Working Shift
Morning
0
0.0
3
30.0
7
70.0
FET:21.817
P˂0.001*
Evening
4
100.0
0
0.0
0
0.0
Long day
26
48.1
11
20.4
17
31.5
Number of Working Hours a Week
36.00
8
33.3
0
0.0
16
66.7
FET: 27. 748
P˂0.001*
48.00
22
59.5
11
29.7
4
10.8
72.00
0
0.0
3
42.9
4
57.1
Work Satisfaction
Satisfied
4
50.0
0
0.0
4
50.0
FET: 16.086
P˂0.003*
Partially satisfied
7
28.0
3
12.0
15
60.0
Dissatisfied
19
54.3
11
31.4
5
14.3
Sleeping Hours
Inadequate
13
56.5
0
0.0
10
43.5
FET: 9.027
P˂0.011*
Adequate
17
37.8
14
31.1
14
31.1
Self-evaluation for Health Condition
Good
0
0.0
0
0.0
4
100.0
FET: 31.477
P˂0.001*
Fair
26
56.5
3
6.5
17
37.0
Poor
4
22.2
11
61.1
3
16.7
FET: Fisher Exact Test P: P value of FET *Significant at P value ≤0.05
Table 5 shed the light on the significant association between age and personal accomplishment status of the studied paramedic staff where the high level of accomplishment is prevalent among the older one with p value ˂0.001. Regarding marital status it was observed that around one third (36.1%) of the married have high level of accomplishment compared to 41% who have low accomplishment level with a significant association between marital status and personal accomplishment, with p value 0.035. The majorities (88.9%) of those who have bachelor degree of education have moderate level of accomplishment compared to 82.4% of those who have nursing diploma, while all of those who have diploma and fellowship in emergency have high level of accomplishment with a significant association (p value ˂0.001). Furthermore, less than two thirds (63.6%) of those who have 10 to less than 15 years of experiences have high level of accomplishment with a significant difference (p value ˂0.001). It also observed that around one third (31.5%) of those who working long day shifts have high level of accomplishment, with a significant association between working shifts and personal accomplishment with p value ˂0.001. Moreover, more than two thirds (66.7%) of those who work for 36 hours have high level of accomplishment with a significant association between working hours per week and accomplishment with p value ˂0.001. More than half (54.3%) were dissatisfied at their work have low level of accomplishment with a significant association (p value 0.003). Slightly more than half (56.5%) of those who have inadequate sleeping hours have low personal accomplishment with a statistically significant association between sleeping hours and personal accomplishment with p value 0.011. Finally, it was noticed that all of those who evaluate his health condition as good condition have high level of accomplishment with p value ˂0.001.
Table 6: The Association between the Studied Paramedics Socio-Demographic Data and Working Experiences and Their Depersonalization
Variables
Depersonalization
Low
Moderate
High
Sig.
No.
%
No.
%
No.
%
Age
Less than 30
0
0.0
1
10.0
9
90.0
FET: 39.929
P˂0.001*
30 to less than 40
11
44.0
10
40.0
4
16.0
40 to less than 50
16
61.5
0
0.0
10
38.5
50 and more
7
100.0
0
0.0
0
0.0
Marital Status
Single
3
60.0
0
0.0
2
40.0
FET: 11.420
P˂0.022*
Married
31
50.8
9
14.8
21
34.4
Divorced
0
0.0
2
100.0
0
0.0
Level of Education
Secondary level of education (Diploma)
8
47.1
0
0.0
9
52.9
FET: 23.659
P˂0.001*
Above average education (Technical Health Institute)
11
31.4
10
28.6
14
40.0
High level (Bachelor)
8
88.9
1
11.1
0
0.0
Post-graduate (Diploma and Fellowship in Emergency)
7
100.0
0
0.0
0
0.0
Years of Experience
5 to less than 10 years
11
52.4
1
4.8
9
42.9
FET:21.624
P˂0.001*
10 to less than15 years
8
36.4
10
45.5
4
18.2
15 to less than 20 years
8
66.7
0
0.0
4
33.3
20 years and more
7
53.8
0
0.0
6
46.2
Working Shift
Morning
7
70.0
0
0.0
3
30.0
FET:11.339
P˂0.078
Evening
0
0.0
0
0.0
4
100.0
Long day
27
50.0
11
20.4
16
29.6
Number of Working Hours a Week
36.00
12
50.0
8
33.3
4
16.7
FET: 16. 792
P˂0.002*
48.00
21
56.8
3
8.1
13
35.1
72.00
1
14.3
0
0.0
6
85.7
Work Satisfaction
Satisfied
4
50.0
0
0.0
4
50.0
FET: 25.417
P˂0.001*
Partially satisfied
6
24.0
11
44.0
8
32.0
Dissatisfied
24
68.6
0
0.0
11
31.4
Sleeping Hours
Inadequate
15
65.2
1
4.3
7
30.4
FET: 4.734
P˂0.094
Adequate
19
42.2
10
22.2
16
35.6
Self-evaluation for Health Condition
Good
4
100.0
0
0.0
0
0.0
FET: 7.410
P˂0.116
Fair
19
41.3
10
21.7
17
37.0
Poor
11
61.1
1
5.6
6
33.3
FET: Fisher Exact Test P: P value of FET *Significant at P value ≤0.05
There was significant association between age and depersonalization status of the studied paramedic staff where the low level of depersonalization is prevalent among all of those aged 50 years and more compared to the majority (90%) of those aged less than 30 years who have high depersonalization with p value ˂0.001. Regarding marital status it was observed that around one third (34.4%) of the married have high level of depersonalization compared to 40% of single individual with a significant association between marital status and depersonalization, with p value 0.022. The majority (88.9%) of those who have bachelor degree of education have low level of depersonalization compared to 47.1% of those who have nursing diploma, while half (52.9%) have nursing diploma have high level of depersonalization with a significant association (p value ˂0.001). Furthermore, more than half (53.8%) of those who have 20 years of experiences and more have low level of depersonalization compared to 46.2% of them have high level depersonalization with a significant difference (p value ˂0.001). Moreover, majority (85.7%) of those working for 72 hours have high level of depersonalization with a significant association between working hours per week and depersonalization with p value 0.002. Less than one third of them were dissatisfied and partially satisfied at their work have high level of depersonalization (31.4% and 32% respectively) with a significant association (p value ˂0.001). Finally, there is no statistically significant association between working shift, sleeping hours, and self-evaluation of health condition and depersonalization (Table 6) .
Table 7: The Association between the Studied Paramedics Socio-Demographic Data and Working Experiences and Their CPTSD Total Score
Variables
CPTSD Total Score
None
Mild
Moderate
Sig.
No.
%
No.
%
No.
%
Age
Less than 30
0
0.0
4
40.0
6
60.0
FET: 45.635
P˂0.001*
30 to less than 40
0
0.0
21
84.0
4
16.0
40 to less than 50
0
0.0
20
76.9
6
23.1
50 and more
4
57.1
3
42.9
0
0.0
Marital Status
Single
0
0.0
5
100.0
0
0.0
FET: 3.251
P˂0.517
Married
4
6.6
41
67.2
16
26.2
Divorced
0
0.0
2
100.0
0
0.0
Level of Education
Secondary level of education (Diplome)
0
0.0
12
70.6
5
29.4
FET: 41.686
P˂0.001*
Above average education (Technical Health Institute)
0
0.0
24
68.6
11
31.4
High level (Bachelor)
0
0.0
9
100.0
0
0.0
Post-graduate (Diploma and
Fellowship in Emergency)
4
57.1
3
42.9
0
0.0
Years of Experience
5 to less than 10 years
0
0.0
15
71.4
6
28.6
FET: 19.212
P˂0.004*
10 to less than15 years
0
0.0
18
81.8
4
18.2
15 to less than 20 years
0
0.0
8
66.7
4
33.3
20 years and more
4
30.8
7
53.8
2
15.4
Working Shift
Variables
CPTSD Total Score
None
Mild
Moderate
Sig.
No.
%
No.
%
No.
%
Morning
4
40.0
6
60.0
0
0.0
FET: 38.952
P˂0.001*
Evening
0
0.0
4
100.0
0
0.0
Long day
0
0.0
38
70.4
16
29.6
Number of Working Hours a Week
36.00
4
16.7
16
66.7
4
16.7
FET: 9.302
P˂0.054*
48.00
0
0.0
28
75.7
9
24.3
72.00
0
0.0
4
57.1
3
42.9
Work Satisfaction
Satisfied
0
0.0
4
50.0
4
50.0
FET: 7.286
P˂0.122
Partially satisfied
0
0.0
20
80.0
5
20.0
Dissatisfied
4
11.4
24
68.6
7
20.0
Sleeping Hours
Inadequate
4
17.4
15
65.2
4
17.4
FET: 8.525
P˂0.014*
Adequate
0
0.0
33
73.3
12
26.7
Self-evaluation for Health Condition
Good
0
0.0
0
0.0
4
100.0
FET: 15.768
P˂0.003*
Fair
4
8.7
33
71.7
9
19.6
Poor
0
0.0
15
83.3
3
16.7
FET: Fisher Exact Test P: P value of FET *Significant at P value ≤0.05
Table 7 shows the significant association between age and CPTSD total score of the studied paramedic staff where the high level of CPTSD is prevalent among the younger one was withn p value ˂0.001. No one of those who have bachelor’s degree of education and who have diploma and fellowship in emergency and those working as physician and paramedic have high level of CPTSD with a significant association between level of education and CPTSD total scores (p value ˂0.001). Furthermore, around one third (33.3%) of those who have 15 to less than 20 years of experiences have high level of CPTSD with a significant difference where p value 0.004. It also observed that less than three quarters (70.4%) of those who working long day shifts have high level of CPTSD, with a significant association between working shifts and CPTSD with p value ˂0.001. Moreover, more than two fifths (42.9%) of those who working 72 hours have high level of CPTSD followed by a quarter (24.3%) of those who working 48 hours per week with a significant association between working hours per week and CPTSD with p value 0.054. Slightly more than a quarter (26.7%) of those who have adequate sleeping hours have high CPTSD compared to 17.4% of those who have inadequate sleeping with a statistically significant association between sleeping hours and CPTSD with p value 0.014. one of the surprising findings revealed that all of those who evaluate his health condition as good condition have high level of CPTSD with p value 0.003. Finally, there is no statistically significant association between marital status, work satisfaction and CPTSD total score.
DISCUSSION
Despite the authority’s efforts to fight the accidents and its consequences, the front-line paramedics involved directly in handling these patients are at greater risk than others. Consequently, they may suffer from the psychological consequences due to the type of care they provide and the type of victim’s problem they deal with. The reasons for such adverse psychological outcomes range from excessive workload/work hours, inadequate personal protective equipment, young age or lack of experience, over-enthusiastic media news, and inadequate support. The mental health issue must not be underestimated during this critical phase (Spoorthy, Pratapa & Mahant, 2020).
The number of medical and paramedic staff suffering from burnout and stress has increased over the years, possibly causing negative effects on patient care, working environments and staffing shortages (Holdren, Paul & Coustasse, 2015). Furthermore, Czaja, Moss & Mealer, (2012) identified that PTSD and BOS are common in nurses and those with PTSD will almost uniformly have symptoms of BOS. Co-existence of PTSD and BOS has a dramatic effect on work and nonwork-related activities and perceptions. Creating a healthy work environment in which nurses feel supported by their coworkers and management in addition to stress management programs that address symptoms of burnout and assure safe nurse staffing patterns are important in minimizing BOS and PTSDs (Holdren, Paul & Coustasse, 2015). The current study confirmed that, only one tenth of the paramedic staff were satisfied by their work and more than a quarter of them has a desire to change their career. These findings go in line with Duffy, Avalos & Dowling (2015) who study the secondary traumatic stress among emergency nurses and reported that they have strong desire to change their carrier.
Regarding health profile and lifestyle pattern of the studied paramedic staff in the current study, only around one third of the paramedic staff has adequate sleeping hours. Slightly less than half of those who have adequate sleeping hours with low emotional exhaustion compared to one third of those who have inadequate sleeping hours who have high emotional exhaustion with a statistically significant association between sleeping hours and emotional exhaustion. Slightly more than half of those who have inadequate sleeping hours have low personal accomplishment with a statistically significant association between sleeping hours and personal accomplishment. slightly more than two thirds of them eat regular meals per day. Less than three quarters of them suffered from headache, followed by less than two fifths have low back pain, and the minorities have insomnia. In contrast Belotto (2017) indicated that their qualitative study among the EMS providers revealed that they have adequate sleeping especially at night without any sleeping disturbance and they eat well with no problems. This discrepancy may be due to other factors affecting sleeping hours of research subjects as worrying about their life, lack of protective measures used or due to working multiple shifts especially night, which may affect their circadian rhythm and sleep quality. According to the studied paramedic self-evaluation for their health condition it was noticed that only 5.9% of them have good health condition. In this regard, Blau (2011) indicate that sleep deprivation affects the general health perception of the emergency medical service (EMS) providers. Moreover, Nayback (2009) stated that PTSD may cause a wide spectrum of symptoms including flashbacks and nightmares of the event, anger, anxiety, depression, irritability, and impaired concentration. It also causes difficulty in sleeping, panic attacks, hyper vigilance and an exaggerated startle response.
Paramedic’s healthy lifestyle and positive health status perception mainly affecting their responses in critical situations. A relaxed paramedic staff who sleep well and have good health condition can control the psychological and emotional outburst necessary for dealing with stressful conditions like major accidents and catastrophe. The current study portrayed the paramedic staff burnout based on Maslach burnout inventory-human services survey for medical personnel (MBI-HSS) findings. Regarding emotional exhaustion domain, it was found that around one third of them have high emotional exhaustion level. Whereas, more than two fifths of them have low level of personal accomplishment. Finally, around one third have high level of depersonalization. These findings confirm Cicchitti et al., (2014) findings who declared that, BOS-related symptoms have been identified in at least half of the nurses, half of them suffered a medium-high emotional exhaustion, there quarters had a medium-high depersonalization and the majority had a medium–high reduced professional accomplishment.
The current study documented that three quarters of the paramedic staff have mild minimal distress or functional impairment of the global severity of symptoms. Also, three quarters of them have mild, minimal distress or disruption of activities followed by moderate, distress clearly present but still manageable. This may be attributed to the ever-increasing number of casualties, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these workers as reported by Lai et al., (2020). The same findings are reported at the previous researches conducted at the similar situations (Maunder et al., 2003; Bai et al., 2004; Lee et al., 2007). These findings were confirmed by Carmassi et al., (2018) and Aisling, Aisling & David (2016) and findings as they indicate that improved resources and psychoeducation will decrease distressing dreams and psychological distress among EMS.
The current study shed light on the significant association between age and emotional exhaustion status, level of accomplishment and depersonalization of the studied paramedic staff where the high level of exhaustion and high level of accomplishment and low level of depersonalization is prevalent among the older one. It was observed that around one third of the married have high level of emotional exhaustion and have high level of accomplishment, around one third of the married have high level of depersonalization with a significant association. The majorities of those who have bachelor’s degree of education have high level of emotional exhaustion and have moderate level of accomplishment and have low level of depersonalization with a significant association. Furthermore, the majority of those who have 5 to less than 10 years of experiences have high level of emotional exhaustion and have high level of accomplishment, whereas, more than half of those who have 20 years of experiences and more have low level of depersonalization with a significant difference. It also observed that less than half those who working long day shifts a day have high level of emotional exhaustion with a significant association. Moreover, around half of those who working 48 and 72 working have high level of emotional exhaustion and high level of accomplishment with a significant association. More than two fifths of dissatisfied at their work have high level of emotional exhaustion and have low level of accomplishment, and less than one third of dissatisfied and partially satisfied at their work have high level of depersonalization with a significant association. Finally, it was noticed that around two thirds of those who evaluate their health condition as poor condition have high level of emotional exhaustion and it was noticed that all of those who evaluate his health condition as good have high level of accomplishment. Theses finding may be attributed to lack of experience of those who young or had bachelor’s degree because of the fear of risk is high among knowledgeable than other or those who work for long period the level of stress and exhaustion effect on their emotional reaction in advance.
The same findings were reported by Vidotti et al., (2018) as they declared that levels of burnout syndrome were significantly higher among those working the day shift and associated factors included high demand; low control; low social support; dissatisfaction with sleep and financial resources. Professionals working the night shift, having low social support, being dissatisfied with sleep, having children, not having a religion, having worked for a short period in the institution, and being a nursing technician or aid were significantly more likely to experience high levels of the syndrome. The same results were reported by Iranmanesh, Tirgari & Bardsiri (2013). Additionally, according to a study done in Colombia, the professional staff may suffer from depersonalization. It is evident that greater emotional exhaustion occurs within the first 10 years of work, with the increasing link up time the risk decreases. The night work schedule is a risk factor that determines the appearance of burnout (Álvarez & Prieto, 2013).
The global impact of post-traumatic stress disorder and burnout syndrome has been profound, and the public health threat due to this is the most serious seen since the significant association between CPTSD and different variables as age, working experiences as well as different lifestyle pattern (Kar et al., 2020). In this regard, the current study shed the light on the significant association between age and CPTSD total score of the studied paramedic staff where the high level of CPTSD is prevalent among the younger one. Furthermore, around one third of those who have 15 to less than 20 years of experiences have high level of CPTSD with a significant difference. It also observed that less than three quarters of those who working long day shifts have high level of CPTSD. Moreover, more than two fifths of those who working 72 hours have high level of CPTSD with a significant association. Slightly more than a quarter of those who have adequate sleeping hours have high CPTSD with statistically significant association between sleeping hours and CPTSD. One of the surprising findings revealed that all of those who evaluate his health condition as good condition have high level of CPTSD.
Community health nurse have a significant role in protecting the community paramedic staff against PTSDs and BOS when preparing them to fight such situations and help them to be positive and try to isolate themselves from inclusion in drastic situation and also train them through proposing training program for ambulance paramedic staff to prevent or decreases feeling of burnout or stress as occupational hazards, and to maintain their physical and mental health intact. Application of the three levels of prevention model; primary, secondary, and tertiary level are highly important.
CONCLUSION
The findings of the present study concluded that,
The paramedic staff burnout based on Maslach burnout inventory-human services survey for medical personnel (MBI-HSS) findings indicate that around one third of the studied paramedic staff have high emotional exhaustion level. Whereas, more than two fifths of them have low level of personal accomplishment. Around one third have high level of depersonalization.
Furthermore, three quarters of the studied paramedic have mild, minimal distress or disruption of activities followed by moderate distress but still manageable, some disruption of activities among less than a quarter of them according to the CPTSD total score based on clinician-administered post-traumatic stress disorder scale for DSM-5 (CAPS-5) past month version. There are a statistically significant association between the PTSD and BOS and different variables as age, educational level, working experiences, marital status, sleeping pattern and work satisfaction level.
RECOMMENDATIONS
Based on the findings of the current study, the following recommendations are suggested:
Regular screening of paramedic staff involved in emergency care should be done for evaluating stress, depression and anxiety by using multidisciplinary psychiatry teams.
Proper management must be held at early stage of symptoms of BOS and PTSD.
Development of policy that support the human resources availability to decrease the workload among the paramedic staff.
Establish a PTSD and BOS high risk centers in order to deal with crisis effectively.
Form a rehabilitation hotline in order to help community paramedic staff to deal with any BOS or PTSD properly.
Develop a special guideline to describe essential interventions to promote mental well-being in community paramedic staff.
Inservice stress management training especially for invoice community paramedic staff must be executed to raise awareness regarding the possibility of PTSD and BOS and to deal with such conditions.
Conflict of Interest
The authors declared that they have no conflict of interest.
ACKNOWLEDGEMENT
The authors would like to express their appreciation to the studied paramedic staff who devote their time to participate in this research.
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