psychological distress in emergency medical services
TRANSCRIPT
University of Calgary
PRISM: University of Calgary's Digital Repository
Graduate Studies The Vault: Electronic Theses and Dissertations
2017
Psychological Distress in Emergency Medical Services
Practitioners: Identifying and Measuring the Issues
Lefevre, Nicola Louise
Lefevre, N. L. (2017). Psychological Distress in Emergency Medical Services Practitioners:
Identifying and Measuring the Issues (Unpublished master's thesis). University of Calgary,
Calgary, AB. doi:10.11575/PRISM/27476
http://hdl.handle.net/11023/4181
master thesis
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UNIVERSITY OF CALGARY
Psychological Distress in Emergency Medical Services Practitioners:
Identifying and Measuring the Issues
by
Nicola Louise Lefevre
A THESIS
SUBMITTED TO THE FACULTY OF GRADUATE STUDIES
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF SCIENCE
GRADUATE PROGRAM IN MEDICAL SCIENCE
CALGARY, ALBERTA
SEPTEMBER, 2017
© Nicola Louise Lefevre 2017
ii
Abstract
This thesis investigates psychological distress in Emergency Medical
Services practitioners through three pieces of inter-related research. The first
examines the prevalence of compassion fatigue in all health care practitioners by
systematic review of literature. The second conceptualizes three manifestations of
distress (compassion fatigue, burnout, and post-traumatic stress disorder), places
them in the context of EMS work by describing practitioners’ experience, and
broadly strategizes ways to address them. The third measures the presence of
compassion fatigue, burnout, and post-traumatic stress disorder in a sample of
EMS practitioners through a survey based study. Overall, the research showed
that EMS practitioners are experiencing psychological distress as compassion
fatigue, burnout and PTSD, and that compassion fatigue has been identified across
diverse practitioner groups in health care. Recommendations are consistently
made that further research needs to be conducted to investigate root causes, and
that education and support programs would be of benefit to practitioners.
Keywords: Psychological distress, compassion fatigue, burnout, PTSD, Emergency
Medical Services.
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Table of Contents Abstract .................................................................................................................. ii
Table of Contents .................................................................................................. iii
List of Tables ......................................................................................................... vi
List of Figures ...................................................................................................... vii
List of Abbreviations .......................................................................................... viii
Chapter 1: Background and Summary ................................................................. 1
1.1 Overview of Thesis ......................................................................................... 5
1.2 Description of EMS ......................................................................................... 2
1.3 Personal Experience in EMS and Inspiration for Study ................................... 4
1.4 Original Research Questions and Revisions in Scope .................................... 7
1.5 Thesis Chapters .............................................................................................. 9
1.6 Chapter 2: Concept Paper ............................................................................ 10
1.7 Chapter 3: Systematic Review ...................................................................... 10
1.8 Chapter 4: Survey Study ............................................................................... 11
1.9 Authorship ..................................................................................................... 12
Chapter 2: Conceptualizing Psychological Distress in Emergency Medical Services Practice ................................................................................................. 14
1.1 Introduction ................................................................................................... 14
1.1.1 Figure 1: Recognizing psychological distress and developing a response ........................................................................................................................ 16
1.2 Conceptualizing and Clarifying Psychological Distress ................................. 16
1.3 The Phenomenological Experience of EMS Work and the Need for Resilience ........................................................................................................... 20
1.4 Identifying the Stressors ............................................................................... 24
1.5 Building Resilience: Suggested Educational and Organizational Strategies . 26
1.6 Conclusion .................................................................................................... 29
1.7 Bibliography .................................................................................................. 31
Chapter 3: Compassion Fatigue in Health Care Practitioners: A Systematic Review ................................................................................................................... 34
1.1 Introduction ................................................................................................... 34
1.2 Methods ........................................................................................................ 35
1.2.1 Data Sources and Searches ................................................................... 35
1.2.2 Inclusion Criteria ..................................................................................... 36
1.2.3 Data Extraction ....................................................................................... 36
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1.2.4 Data Synthesis and Analysis Method ..................................................... 37
1.3 Results .......................................................................................................... 38
1.3.1 Study Selection ....................................................................................... 38
1.3.2 Study Characteristics and Results .......................................................... 38
1.4 Discussion ..................................................................................................... 40
1.5 Limitations ..................................................................................................... 43
1.6 Conclusion .................................................................................................... 43
1.7 Bibliography .................................................................................................. 45
1.8 Tables and Figures ....................................................................................... 53
1.8.1 Figure 1: PRISMA diagram ..................................................................... 53
1.8.2 Table 1: Summary of Studies ................................................................. 54
1.8.3 Table 2: Summary of studies using ProQOL reporting all three sub-scales ........................................................................................................................ 63
1.8.4 Table 3: ProQOL cut-off scores .............................................................. 63
Chapter 4: Psychological Distress in Emergency Medical Services: A Survey Study of Practitioners .......................................................................................... 64
1.1 Background ................................................................................................... 64
1.2 Methods ........................................................................................................ 66
1.2.1 Sample ................................................................................................... 66
1.2.2 Design and Data Collection .................................................................... 67
1.2.3 Measures ................................................................................................ 67
1.2.4 Analysis .................................................................................................. 69
1.3 Results .......................................................................................................... 66
1.3.1 Relationship Between ProQOL, MBI, IES-R and Demographic Variables ........................................................................................................................ 70
1.3.2 Presence of Compassion Fatigue, Burnout, and PTSD ......................... 72
1.3.3 Relationships Between Self-Report Answers and Demographic Variables ........................................................................................................................ 72
1.3.4 Relationships Between Survey Scores and Self-Report Answers ......... 74
1.4 Discussion ..................................................................................................... 76
1.5 Limitations ..................................................................................................... 77
1.6 Conclusion .................................................................................................... 78
1.7 Bibliography .................................................................................................. 79
1.8 Tables and Figures ....................................................................................... 82
1.8.1 Table 1: Mean scores (SD) by demographic variables .......................... 82
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1.8.2 Figure 1: Overall results for ProQOL, MBI, and IES-R .......................... 83
1.8.3 Table 2: Prevalence of compassion fatigue, burnout, and PTSD .......... 83
1.8.4 Figure 2: Prevalence of compassion fatigue, burnout, and PTSD ......... 84
1.8.5 Table 3: Self-report percentage by demographic variables ................... 85
1.8.6 Table 4: Mean scores (SD) by self-report answers ................................ 86
Chapter 5: Review of Research and Future Opportunities ............................... 87
1.1 Purpose of Research and Original Contribution ............................................ 87
1.2 How the Research Was Conducted .............................................................. 87
1.3 What the Research Showed ......................................................................... 88
1.4 Future Opportunities ..................................................................................... 91
1.5 Limitations ..................................................................................................... 92
1.6 Conclusion .................................................................................................... 93
Bibliography ......................................................................................................... 94
vi
List of Tables
Chapter 3
Table 1: Summary of studies
Table 2: Summary of studies using ProQOL, reporting all three sub-scales
Table 3: ProQOL cut-off scores
Chapter 4
Table 1: Mean scores (SD) by demographic variables
Table 2: Prevalence of compassion fatigue, burnout, and PTSD
Table 3: Self-report percentages by demographic
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List of Figures
Chapter 2
Figure 1: Recognizing psychological distress and developing a response
Chapter 3
Figure 1: PRISMA diagram
Chapter 4
Figure 1: Overall results for ProQOL, MBI, and IES-R
Figure 2: Prevalence of compassion fatigue, burnout, and PTSD
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List of Abbreviations
BO Burnout
CF Compassion Fatigue
CS Compassion Satisfaction
EMR Emergency Medical Responder
EMS Emergency Medical Services
EMT Emergency Medical Technician
EMT-P Emergency Medical Technologist-Paramedic
IES-R Impact of Event Scale-Revised
MBI Maslach Burnout Inventory
PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses
ProQOL Professional Quality of Life Scale
PTSD Post-Traumatic Stress Disorder
STS Secondary Traumatic Stress
WHS Workplace Health and Safety
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Chapter 1: Background and Summary
1.1 Overview of Thesis
The stress associated with working in Emergency Medical Services has been
considered an unavoidable part of doing a fast paced and unpredictable job that
regularly deals with the trauma and distress of sick and injured people. People entering
the field may perceive EMS as an exciting way of helping people; they tend to be
attracted by the opportunity to provide emergency care outside of a controlled clinical
environment. Combining the practice of health care with the first response of public
safety makes EMS unique, and with that unique role has come some distinct challenges.
One of those challenges is in fully understanding, supporting and destigmatizing the
mental health and wellness of practitioners.
This project was developed in response to stories told by EMS practitioners about
the impact their work was having on them. It investigates the complex subject of
psychological distress in EMS in three ways: first by conceptualizing and differentiating
three manifestations of distress (compassion fatigue, burnout, and post-traumatic stress
disorder), placing them in the context of EMS work and experience, then broadly
strategizing ways to address them; next by examining the prevalence of the specific
issue of compassion fatigue in the larger field of all health care practitioners by
completing a systematic review and analysis of literature; and finally by conducting a
survey based study of EMS practitioners to identify the presence of, and further
understand, compassion fatigue, burnout, and post-traumatic stress disorder.
2
Evidence supports the notion that educational and organizational responses to
workplace psychological distress should be developed specifically for the field of
practice being targeted (1), and while this project was not intended to develop a detailed
response to the issues, it paints a comprehensive picture of the current state of mental
wellness for EMS practitioners that may help with future developments in the field.
1.2 Description of Emergency Medical Services
In order to contextualize the stress being discussed in this project, it is important
to understand the training, scope of practice, and work environment of Emergency
Medical Services.
Like other health professions, EMS practitioners are required to undertake a
specialized academic and practical education program that equips them with the
knowledge and skills required to assess and treat urgent health concerns and trauma.
The education consists of didactic training and field practicums, and can take up to 3.5
years to complete depending on the level of practice. There are three levels of training:
Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), and
Emergency Medical Technologist-Paramedic (EMT-P or Paramedic), with the skills of
the next building upon the last. Students are required to pass a provincial licensing
exam after each level in order to practice.
The first level of training is the EMR designation. Practitioners at this level have a
limited scope that includes basic patient assessment including vital signs and
glucometric testing, administration of oxygen, oral glucose and ASA, and skills such as
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CPR, placement of simple airway adjuncts, wound control and splinting (including spinal
immobilization), and use of an Automated External Defibrillator (AED). An EMR
program takes approximately 6 months to complete and there is no practicum. The next
level is EMT designation, for which students must complete an additional 12-month
program. In this program, they expand their scope to include more advanced
assessment skills such as cardiac monitoring and ECG interpretation, administration of
medications including salbutamol, nitroglycerin, and epinephrine, initiation and
maintenance of intravenous fluid therapy, and the use of additional adjuncts for airway
management. The most advanced level of practice is the EMT-P (Paramedic); the
scope of a Paramedic includes a number of advanced assessment skills such as
capnography and blood samples, treatments such as initiation of intraosseous lines,
intubation, and cardioversion, and administration of numerous medications including
morphine, dimenhydrinate, midazolam, and some antibiotics (2). The Paramedic
program is an additional two years of education made up of classroom training and 4
practicums. Though the full scope of practice for practitioners according to the
competency profile can be quite extensive, when they enter the field they will be
expected to work under the medical control protocols implemented by the medical
director of their employer. Protocols are algorithms to guide treatment decisions based
on standing orders. EMS practitioners use their assessment skills and clinical judgement
to determine which protocols are pertinent, and treat accordingly.
EMS is unique in health services in that it provides acute, unscheduled care in
non-clinical environments. Other services provide unscheduled or emergency care, such
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as the hospital emergency department and urgent care centres, and other services
provide care in non-clinical environments, such as community home care, but EMS is
singular in how it combines the services. As well, EMS acts as first response, similar to
police and fire departments, meaning practitioners frequently have limited information
about the situations they are responding to, and are required to make quick decisions
that can have a significant impact on their patient’s condition. Practitioners generally
work in partnerships, with two staff on an ambulance; this may be any combination of
practitioners (EMR, EMT, and/or Paramedic), and the patient’s condition will determine
which staff member acts as the attendant. Due to the potential for changes in patient
condition, care often ends up being deferred to the staff member with the higher level of
practice, which can sometimes result in an uneven workload between partners. The
work is fast-paced and EMS crews respond to many patients with wide-ranging
concerns in the course of a shift; however they also routinely end up waiting for long
periods with their patients in hospital emergency departments. There is little downtime
between calls or opportunity for socializing with colleagues during work. The work is by
12 hour day and night shifts. All of these factors combine for a physically and
emotionally demanding work and work environment.
1.3 Personal Experience in EMS and Inspiration for Study
The motivation for this project came from my experience working as an
Emergency Medical Technician in and around Calgary. After nine years working
frontline, I moved into a role developing a community health program that allowed EMS
practitioners to make referrals to continuing care services for their patients. It was in this
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role that I started to have conversations with colleagues, and it became evident through
their descriptions of interactions with patients and colleagues (both within and outside of
EMS), that psychological distress was being experienced. It seemed that practitioners
felt burdened by many aspects of their work, and it was impacting their ability to provide
care. Around the same time, I was asked to represent EMS on the Community Care
ethics committee, and was introduced to the concept of compassion fatigue by a fellow
member who was involved in research involving social workers. During this discussion I
was struck by similarity of the effects of compassion fatigue, described as a decreased
or inability to provide care due to constantly being required to provide care, and what I
was hearing at EMS. In particular, one story came to mind. A paramedic colleague, who
had decided to take some time off from EMS after 10 years of practice, told me about a
patient she responded to in the weeks leading up to her decision to leave. She said the
patient was a pregnant woman who was having severe back pain, and when she arrived
at the scene, she found her patient sitting on the floor of her home crying in pain. She
attempted to help her up of the floor, and it quickly became clear that the woman would
not be able to stand, let alone walk. As she sent her partner out to the ambulance to get
their stretcher, she became frustrated thinking that now she was going to be forced to
carry this patient, and she had been lifting and carrying people all night. She was
disproportionately angry that a pregnant woman experiencing pain could or would not
just walk, despite the pain being severe enough to result in tears. My colleague said
that was the moment she knew she didn’t care anymore, and could no longer do the job.
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This story was by no means unusual. Another colleague submitted a referral for
a patient frequently attended with the words “It’s pointless for us to go back to the
house” written in the comments; another was frustrated with having to treat their
patient’s nausea because they were already on overtime at the end of a shift. There
were other signs that people were not happy; some practitioners used demeaning
phrases to describe their patients, coworkers, and students, as well as colleagues in
other areas such as EMS dispatch or the hospital emergency department. Additionally,
there was a pervasive sense of “us against them” when it came to supervisors and
management. While it is reasonable that fast paced work that concerns people’s health
is stressful and that staff would need some way of venting about it, a practice not unique
to EMS, it seemed to me that the stakes here were high.
Based on the discussions we were having in the Community Care ethics
committee meetings about compassion fatigue and its tie to moral distress, and my own
background in bioethics, I applied for and received an award to study the ethical
perspectives of EMS practitioners. What I hoped to learn from the study was what kinds
of ethical points of view were common among staff, and how these views impacted their
decision making. One of the interesting findings of the study was that practitioners
prioritized their fiduciary duty to their patients above everything else, including their
employer and colleagues, and were risk averse when it came to the potential for causing
harm. As well, their decision making was contextual, in as such as there were not
universal principles determining decisions, rather decisions were made situationally.
These results led me to conclude two things: that EMS practitioners were constantly
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trying to balance and prioritize information, and that they cared deeply about providing
the best possible care. Considering this, it seemed likely that my colleagues’ negative
attitudes about their patients had more to with distress and fatigue from their job than
genuine disdain for the people they were serving.
1.4 Original Research Questions and Revisions in Scope
Expanding on the next steps outlined in the ethical perspectives study, this
project was primarily intended to explore the psychological distress experienced in EMS
by investigating the presence and impact of compassion fatigue in practitioners. While
issues such as post-traumatic stress disorder (PTSD), which result when a practitioner is
the primary subject of a trauma, had garnered attention (3), research into the effects of
cumulative stress and distress that may result from vicarious trauma was not as robust.
Compassion fatigue was being recognized as a distinct issue that required attention in
other health care fields (4), and there was a gap in the research for EMS. However, as
my work developed, it became evident that compassion fatigue did not exist in isolation,
and discussion only of that issue would not provide the full story of psychological
distress in EMS.
The two primary research questions initially were: (1) determine through
systematic literature review the prevalence of compassion fatigue in health care
practitioners, commonly used measurement tools, and current strategies for coping and
resiliency; and (2) determine the prevalence of compassion fatigue by surveying a
sample of EMS practitioners using a validated measurement instrument. Both questions
were revised during the course of the project; the first question was scaled back to focus
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on completing a systematic review of prevalence of CF in all health care practitioners,
and the second was increased in scope to include measurement and discussion of
burnout and PTSD. Consequently, a concept paper was added to the project to help
further define the issues in psychological distress, describe them in the context of the
EMS experience, and illustrate the need for an educational and organizational response.
The scope of the second research question was expanded because literature
showed that the development of compassion fatigue is closely linked to burnout (5),
which is another kind of cumulative stress and is acknowledged (6) as being
experienced by members of many health professions. Burnout contributes significantly
to the sufferer’s decreased effectiveness, practitioner error, and to attrition from
professions (7); similarly, it is evident that emotional distress and suffering associated
with CF is affecting practitioner health and patient care, as well as business operations
through absenteeism and decreased effectiveness (8). Both compassion fatigue and
burnout are identified in domains, and some overlap exists in the issues. Stamm (9)
identifies and measures compassion fatigue in three domains, burnout (the negative
feelings such as exhaustion and frustration related to operational and structural issues)
is one of three domains; the others are compassion satisfaction (the positive feelings
derived from being able to do your work), and secondary traumatic stress (the distress
resulting from being witness to the suffering of others). Burnout has itself been identified
by Maslach as multidimensional (10): emotional exhaustion (where a practitioner is
emotionally overextended and exhausted by work), depersonalization (where a
practitioner develops an unfeeling and impersonal response to the recipients of service
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or care), and personal accomplishment (a practitioner’s feelings of competence and
successful achievement in work.)
It is also important to acknowledge compassion fatigue and burnout as distinct
issues, as recognizing the variable factors that influence each helps with developing
strategies to mitigate them. The feelings associated with burnout (exhaustion,
frustration, anger) might be eased by adjustments to the work environment (scheduling,
workload, etc.), whereas compassion fatigue requires not only that burnout be
addressed, but also that practitioners are supported in coping with the experience of
vicarious trauma. There is no easy answer to the question of how one might mitigate the
risks intrinsic to a type of work (i.e. how to avoid absorbing trauma when caring for the
traumatized), however the working environment may be more easily managed. A
measure of PTSD was eventually included in our survey as it is an issue recognized to
also impact EMS providers. It provided an interesting point of comparison, as of the
three issues it is the only one that is related to primary trauma and considered as a
consequence of acute, rather than cumulative, stress. Overall, considering the three
issues together gave the most comprehensive description of psychological distress in
EMS practitioners.
1.5 Thesis Chapters
As mentioned, the research was undertaken in three inter-related pieces of work.
Each manuscript represents one chapter of the thesis, and all will be submitted for
publication.
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1.6 Chapter 2: Concept Paper
The concept paper was written to clarify, define and identify factors surrounding
psychological distress and make preliminary suggestions about a strategy for building
resilience. It was important to recognize that distress in EMS has multiple precipitating
factors, and that to develop EMS targeted strategies for resilience, the experience of
EMS practice needed to be described, and the specific stressors had to be identified. As
well, psychological distress (compassion fatigue, burnout, and PTSD) had to be defined
and differentiated, as psychological distress is a broad term and often the language
associated with these issues are used interchangeably when in fact distinct, though
related, issues are being discussed.
The subjective experience of the individual practitioner and how that relates to the
education they are given as students is emphasized in this paper. Many EMS education
programs in Alberta currently lack robust training in psychological resiliency, however
such training is required if students are to embrace and cope with the nature and
logistics of their work.
A future strategy calls for practitioners to be equipped for practice beyond clinical
skills; preparation for the operational reality of the work is suggested, as are teaching
strategies for coping that can be used when staff are impacted by stressors and trauma.
1.7 Chapter 3: Systematic Review
The purpose of the systematic review was to describe the reported prevalence of
CF among health care practitioners and potential correlations to personal and
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professional demographic variables; the review was not undertaken specifically to
address EMS, or even other emergency services, as compassion fatigue is still an
emerging topic in those fields and there is limited literature published. Data were
extracted from a total of 40 articles meeting inclusion criteria, which identified studies
specifically measuring CF in health care providers using a validated instrument the
Professional Quality of Life Scale (ProQOL.) Quantitative data that included basic article
characteristics, study strength and quality determination, measurements of CF, and
general findings were extracted. As there was a great deal of variability in the reporting
of the ProQOL, the results were not collated into a meta-analysis. The review showed
that CF was reported across all practitioner groups, including physicians, nurses, mental
health professionals, and audiologists, in fields such as emergency, cancer care,
palliative care, and family practice. Relationships to most demographic variables were
either not statistically significant or unclear. The review demonstrated that compassion
fatigue exists across many practitioner groups, and it provided an important comparator
for the data collected in the survey study of psychological distress in EMS (chapter 3 of
this thesis.) However reporting and prevalence of CF were variable, and the relationship
between CF and demographic, personal, and/or professional variables was unclear.
While it was not in the scope of this research to examine mitigation, important questions
were raised about how to respond to the CF experienced by healthcare providers.
1.8 Chapter 4: Survey Study
The objective of the study was to describe, using validated instruments in a
cross-section of EMS providers, the prevalence and extent of compassion fatigue,
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burnout and PTSD. A secondary objective was to report the difference between self-
reported psychological distress, and that measured by validated instruments.
The target population for this study was EMS staff (EMRs, EMTs, and
Paramedics) in the Alberta Health Services Calgary Zone who were licensed and
currently employed in EMS practice. The survey used a cross-sectional design that
involved completion of a paper-based survey package consisting of three validated
instruments and a demographic questionnaire. The instruments used were the
Professional Quality of Life Scale (ProQOL) to identify compassion fatigue, the Maslach
Burnout Inventory (MBI) to assess burnout, and the Impact of Event Scale-Revised
(IES-R) to screen for PTSD. As well, a self-report question asked participants if they felt
a description of CF, BO, or PTSD applied to them.
The results of this study showed that psychological distress as compassion
fatigue, burnout, and post-traumatic stress disorder was present, with issues related to
burnout most prevalent. The study also identified that overlap between the issues might
exist. Finally, there was some incongruence between self-reporting of PTSD and
measurement by validated instrument.
1.9 Authorship
Each of the manuscripts included in this thesis have been primarily authored by
me (Nicola Lefevre.) Chapter 2 (concept paper) includes co-author Grayson Cockett
who provided a portion of original research, and Chris McIntosh who provided review.
Chapter 3 (systematic review) includes co-authors Grayson Cockett and Christina
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Heinrich, who served as additional reviewers. Chapters 2 and 3 also included the
members of the supervisory committee (Dr. Ian Mitchell, Dr. Juliet Guichon, and Dr.
Stacy Page) as co-authors, all who provided scholarly input. All chapters include the
thesis supervisor (Dr. Christopher Doig) as co-author.
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Chapter 2: Conceptualizing Psychological Distress in Emergency Medical
Services Practice
A systematic review of the literature (presented in Chapter 3) was conducted as
the initial stage in this research. From that, it became evident that compassion fatigue
does not develop or exist in isolation, and discussing only that issue would not provide a
complete picture of psychological distress. Consequently, studying only compassion
fatigue would not be adequate background for any future resilience education and
support strategies. EMS is a unique field and the experience of the practitioner is likely
not well understood, though it is likely that something can be learned by studying similar
issues in other healthcare providers as well as related first response providers such as
Firefighters and Police. This concept paper was written to identify and to define the co-
existing issues, to discuss the EMS experience, and to make suggestions about
strategies for education and resilience building.
1.1 Introduction
The psychological distress associated with providing care to those in crisis, and
its impact on mental wellness, is an area of concern that is being studied in many areas
of health care, as well as with emergency services. Emergency Medical Services (EMS)
practitioners have a unique role as caregivers: they provide high intensity, episodic
emergency health services in unfamiliar and occasionally hazardous environments, they
are usually unaware of patient outcomes other than immediate survival, and as a mobile
service, they often lack the type of on-site peer social support network available within
more traditional healthcare settings such as hospitals and clinics. EMS practitioners
15
undertake a specialized academic and practical education program that equips them
with the knowledge and skills required to assess and to treat urgent health concerns and
trauma, as well as prepare them for the physical demands of working as first responders
at the scene of incidents (i.e. in non-clinical environments.) However, the experience of
providing emergent health care in this way includes numerous stressors that may result
in psychological distress, and a need exists to further equip practitioners also with
knowledge and skills that build resilience and enable them to cope with their
experiences.
There is a sense of urgency among practitioners and EMS operations to
investigate mental wellness and the causes of psychological distress (1, 2). A broad
online search of both grey and academic literature for reporting on EMS mental health
revealed a number of studies, media reports including calls to action from practitioners,
individual stories, and responses from employers (1, 2, 3). A position paper from the
Paramedic Chiefs of Canada on Operational Stress Injuries outlines the scope of the
issue, and identifies a number of mental health issues arising in EMS practice. The
paper also offers “seven core principles for creating effective responses to operational
stress”, which includes identifying the issues that are specific to frontline EMS work, and
adapting prevention and treatment programs for use in the EMS context (4). It is
important to recognize that the exhaustion and distress that can result from EMS work
have multiple precipitating factors, including the work environment, organizational policy
and practices and the nature of the work itself. In order to further develop an EMS
targeted program to help staff build the resilience required to practice effectively and for
16
a long term career, the potential distress must be conceptualized and differentiated, the
experience of EMS practice must be described and understood, and the specific
stressors associated with the work must be identified. This paper aims to build upon
existing work that has been undertaken to understand and respond to the issues of
psychological distress in emergency services (5, 6).
1.1.1 Figure 1: Recognizing psychological distress and developing a response.
1.2 Conceptualizing and Clarifying Psychological Distress: Compassion Fatigue,
Burnout, and Post-Traumatic Stress Disorder
As referenced above, the interest in further research and action related to mental
health and wellness has been established in EMS. As the work develops, it is important
to recognize that psychological distress is a broad term, and often the language
associated with these issues is used interchangeably when in fact distinct, though
related phenomena are being described.
17
Compassion Fatigue (CF) is described as the healthcare practitioner’s diminished
capacity to care that results from repeated exposure to the suffering of patients, as well
as from the knowledge of a patient’s traumatic experiences (7). This exposure is
referred to by Charles Figley as vicarious traumatization and secondary traumatic stress,
meaning that rather than being the primary subject of trauma, the practitioner is witness
to the trauma of those for whom they care. Compassion Fatigue tends to develop over
time (i.e. a cumulative stress); it is an erosion of the ability to show compassion and do
the work of caring and is often triggered by the continual use of empathy and emotional
energy, previous exposure to trauma, prolonged exposure to secondary trauma, and the
work environment (8). Figley, who has studied CF extensively over the last 20 years,
holds that compassion fatigue will often result when secondary traumatic stress and
burnout (which is generally caused by organizational stressors, discussed in more detail
later) exist together (9). In EMS, practitioners see many patients over the course of a
single shift, and no matter the acuity of the complaint, each patient has judged their
situation sufficiently emergent to call for EMS help. This belief often leads to high
intensity encounters regardless of the actual acuity of the medical issue, which are only
intensified when there is a true medical emergency or trauma. The combination of these
routinely intense encounters, with organizational and operational stresses, can
eventually result in compassion fatigue. While there is no assessment tool that will
definitively diagnose compassion fatigue, there exist several complimentary
measurements that can help predict whether a practitioner is at a high, average, or low
risk of developing CF. A commonly used measurement tool is the Professional Quality
of Life scale (ProQOL), a 30 question self-assessment survey that provides scores in
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the domains of Compassion Satisfaction, Burnout, and Secondary Traumatic Stress. A
typical pattern preceding the development of compassion fatigue is noted when
individuals report a lower score in the compassion satisfaction domain, and higher
scores in the burnout and secondary traumatic stress domains (9).
Burnout (BO) is defined as a “psychological syndrome that involves a prolonged
response to stressors in the workplace. Specifically, burnout involves the chronic strain
that results from an incongruence, or misfit, between the worker and the job.” (10)
Compassion fatigue and burnout are distinct in how they manifest, but burnout may
contribute to compassion fatigue. Burnout itself manifests in three dimensions:
“emotional exhaustion, in which overwhelming work demands deplete the individual’s
energy, depersonalization and cynicism, in which the individual detaches from the job;
and feelings of inefficacy, in which the individual perceives a lack of personal
achievement.” (11) Burnout is considered to be triggered primarily by work-related and
organizational characteristics (8). In EMS, the factors that could influence burnout are
numerous and could include a schedule of shifts that alternate between days and nights,
long waits in emergency departments that prevent practitioners from being available for
other patients, inadequate resources and equipment, and perceived isolation from both
other team members and management.
While compassion fatigue cannot be directly measured, burnout can be. Tools
used to measure burnout assess contributing domains to present an overall measure of
severity. One such tool is the Maslach Burnout Inventory, a reliable and validated self-
assessment tool often used to measure burnout levels, in which three sets of questions
19
related to the three domains described above (emotional exhaustion,
depersonalization/cynicism, and inefficacy) are scored individually and then interpreted
in combination to report low, average, and high levels of burnout (12). Just as with the
ProQOL, there are two negative domains and one positive (inefficacy is framed through
questions regarding personal achievement.)
Post-Traumatic Stress Disorder (PTSD) is closely associated with any type of
emergency work or sudden acute event. PTSD is a diagnosis with specific criteria
according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-IV), and must be diagnosed by a mental health professional, whereas CF and BO
do not have specific diagnostic criteria. PTSD results from direct exposure to a traumatic
event, and causes an inability to function socially or professionally (13). It is important to
recognize that while EMS practitioners likely experience vicarious trauma (through the
experiences of their patients), they can also find themselves as the primary subject of
traumatic experiences; both vicarious and primary trauma can combine to amplify the
effects a practitioner experiences. As first responders, EMS practitioners enter mostly
unknown situations, and provide care in often uncontrolled environments; this makes the
risk of exposure to and involvement in traumatic events, quite high. For example, EMS
practitioners may be witness to horrific examples of physical trauma to children
(vicarious trauma), or could be involved in events such as motor vehicle collisions while
responding to clinical emergencies (primary trauma.) While not all trauma will result in
PTSD, the combination of vicarious trauma, primary trauma and the cumulative nature
of EMS workplace stressors establish first responders at a higher risk of developing this
20
disorder. As mentioned above, PTSD must be diagnosed by a mental health
professional; however, there are a number of self-screening tools in use that can give an
indication that further investigation is necessary.
As described, compassion fatigue, burnout, and PTSD are distinct issues with
specific causes or contributing factors, signs and symptoms. Outwardly however, they
seem to overlap in their manifestation, causing a generally decreased ability to perform
job duties, poor mood, and difficulties functioning socially (8, 10, 15). As well, the issues
can co-exist; evidence suggests that the existence of burnout creates a “fertile ground”
for other types of occupational stress, including compassion fatigue (as previously
discussed, measurement of CF does include the domain of burnout.) (8) In EMS, a
practitioner can experience primary trauma as a participant in traumatic events, and
vicarious (also known as secondary) trauma through their role as a caregiver to multiple
patients over time, all while dealing with operational factors such as workload and shift
work. CF, BO and PTSD can be present or absent, and if present, in varying levels of
severity.
1.3 The Phenomenological Experience of EMS Work and the Need for Resilience
There are numerous reasons a person may be attracted to a particular type of
work. For those interested in EMS, perhaps it is a desire to care for people, a need for
excitement, or an interest in emergency medicine. For those entering any caring
profession, it is understood that formalized training is required to equip them with the
cognitive knowledge and technical skills essential for practice. EMS students are
expected to pass didactic courses and practicums over the course of approximately 3
21
years following a step-by-step set of courses starting with at the Emergency Medical
Responder (EMR), then the Emergency Medical Technician (EMT) level, and finally the
Paramedic level. They must also pass licensing exams after each level of training in
order to practice. Through their classroom education and practicum, they will learn how
to perform in the role of EMR, EMT or Paramedic, and while EMS programs ensure a
future practitioner is prepared through vocational training, there seems to be an
underlying assumption that a person is somehow naturally equipped to cope with their
future career simply by virtue of choosing it. In Alberta, many EMS education programs
lack specific training in psychological resiliency that equips students for the experience
of doing this type of work as a career. Other provinces have identified the need for
such, and there are programs in existence that could be explored for implementation in
other EMS organizations (14). EMS is unique among caring professions in both the
practice of it and the associated stressors, and it is false to assume that this resiliency
along with the phenomenological knowledge to cope is acquired exclusively through
experiential learning. It is short sighted to neglect the preparation and training that will
help build practitioner resilience. Indeed, resilience allows students to embrace and
cope with the nature of their work (15), rather than simply “playing the role” and “doing
the job” for as long as they can deal with the work.
As described above, to become a paramedic requires a significant commitment of
both time and resources. Practitioners entering the field expect to experience difficult
situations and distress (that is, they know “what they signed up for.”) However, they
have not yet experienced how the work will impact them as an individual. Intimately
22
witnessing the suffering of others while bearing the responsibility of providing care can
be profoundly distressing; organizational and operational demands compound the
stress. As well, particularly with the busy operational demands of an urban EMS
service, there is little opportunity for “time outs” after situational events that have a
likelihood of resulting in negative psychological impact. The maintenance of supportive
interpersonal relationships may be difficult due to the unique nature of the work (which
may be hard for a layperson to understand) and time pressures associated with a busy
EMS system (there is not always a spare moment to debrief with colleagues.) The
distress can also be subjective, and it is problematic to generalize about the types of
stress or situations that a practitioner may end up responding to negatively. For one
person, it may be performing a cardiac arrest resuscitation with a frantic family present;
for another it could be attending multiple low acuity (perhaps frequently seen) patients in
a shift. The moral distress that can result from being unavailable for another
emergency, and guilt of dehumanizing their patient through this judgment are all
contributors to a paramedic’s stress. Another may be worn down by the shiftwork and
the pace, thankful for an emergency department hallway wait as it provides a moment of
downtime to eat; and others may see their own family in the faces of those they are
trying to help. It is difficult to know how one will be impacted by negative stressors even
if there is an awareness of what they are, and identifying individual triggers for
psychological distress sometimes occurs only after specific events or many years of
work.
23
Practitioners know objectively the career they are entering will not be easy, but
the experience is a different phenomenon. Working as an EMT or Paramedic in an EMS
system and encountering patients and other interdisciplinary practitioners day after day
is subjective and visceral. Doing the work provides practitioners with knowledge of their
job, and of themselves in the role, that cannot be taught in a classroom or memorized
with protocols; it is how their work impacts them as a subject. As previously referenced,
psychological distress resulting from work is not unique to EMS, however there are
several unique factors that require a practice specific response. The operational issues
differ from those found in clinical settings, the system of peer and formal supports can
be less accessible (though this is changing, provinces such as Ontario now legislate
support for first responders with PTSD), and the personalities of persons entering the
field tend toward a certain type (16). Profoundly feeling the work is a part of what makes
a practitioner an empathetic and effective caregiver. The development of resilience is a
way to allow practitioners to function as people with a job to do as well as a life they
want to live. Whereas education surrounding distress is present in other programs such
as nursing, preparation is lacking in EMS training programs in Alberta. Evidence
suggest such programs will be required to sustain a healthy, knowledgeable and
effective workforce (17). Mental readiness and resilience-building education may not be
sufficient to make clear to practitioners the unique way they will experience their work,
but it will help them to manage the potentially resulting distress.
24
1.4 Identifying the Stressors
In a recent qualitative study (18), EMS practitioners were asked to identify the
stressors they experienced in their day-to-day work, as well as to describe how that
stress was manifested, and to suggest actions that could be taken to improve their work
environment. The stressors were numerous and varied; overall they could be
categorized broadly as ‘Intrinsic’ (stress resulting from a job duty), ‘Social’ (related to
personal, interpersonal and interagency relationships), and ‘Organizational’ (stress
resulting from the operation and organization of the EMS system.)
The greatest number of stressors were found in the ‘Organizational’ category
(18). Initially this finding may seem counterintuitive considering the perception of stress
in EMS has more to do with critical decision making in patient care than it does with the
system in which they operate. However, practitioners made it clear that that they
generally liked the work they did when they were allowed to do that work, and felt
strongly that factors such as lack of resources, lack of engagement, encouragement,
support and recognition from leadership, and a general feeling that they were not trusted
to do their work prevented them from performing effectively and feeling satisfied.
Closely related to these organizational stressors were ‘Social’ stressors, where
practitioners felt distress related to maintaining a work-life balance, feeling distrust
toward other agencies such as dispatch, and interpersonal relations with other
distressed practitioners. Of particular note with these types of stressors was the distress
caused by shift work. In the one EMS system studied, practitioners generally worked a
schedule of two 12 hour days, followed by two 12 hour nights, a rotation that proved
25
difficult for maintaining social contact with anyone other than those who worked the
same hours, and, due to the constant switching back and forth between days and nights,
did not necessarily provide the type of restful downtime required to recover from 48
hours of work. Combine this with the feeling that it was difficult to match up schedules
with family and often resulted in missing important holidays and events, and the inability
of non-EMS people to relate to the stresses of their job, and practitioners reported living
lives that could be quite socially isolated. Compounding this feeling is the
acknowledgement that fellow practitioners were feeling the same way; the distress felt
throughout the workforce made it difficult for practitioners to support one another
effectively and, in fact, became a stressor in itself for coworkers who must cover for
each other if the stress impacts job performance.
‘Intrinsic’ factors, i.e. those related directly to patient care or the nature of the
work, were also described (18), however these were the stressors that practitioners
were most often expecting and most willing to accept (this is not to say that they were
necessarily prepared to cope with these factors, just that they were aware they would
exist based on their conception of EMS work.) There was widespread awareness and
acknowledgement in this study of critical incident stress, and there seemed to be some
feeling that it was an unavoidable part of the job, though it was also noted that there was
only so much of this type of stress that was manageable, and other stressors made it
more difficult to manage.
In addition to identifying the stressors, the language that was used to describe
how the stress made practitioners feel is interesting. The word “frustrated” was often
26
used, particularly to describe feelings around the organizational stressors described
above. “Anxiety” seemed to apply mostly to interpersonal relations, particularly a feeling
of anxiety about other’s perception of them and how that could impact their reputation in
the field. Practitioners also used the phrase “burnout” to describe a general feeling for
themselves, but also to indicate what they perceived to be affecting their coworkers
which was then adding to their own distress. Additionally, words like “exhausted”,
“nervous”, “disheartened”, and “jaded” came up when talking about the impact of all
types of stressors.
1.5 Building Resilience: Suggested Educational and Organizational Strategies.
Considering the apparent gap in what practitioners are identifying as causing
distress (i.e. organizational factors) and what they are taught about the work while in
training (including practicums) (19), and the impact of subjective experience, it may not
be surprising that EMS systems are experiencing a high rate of attrition, shorter years of
service, depressed morale (20), and increased use of sick time for mental health related
issues. Diagnosed PTSD is seen as being prevalent in EMS (21). Recent reporting of
Workplace Health and Safety (WHS) claims in Alberta show that the number of claims
made related to anxiety and/or stress, or mental illness in EMS have increased 300% in
the last three years, totaling nearly 4000 lost days and costing just over $2 million (22);
these totals do not include daily sick calls that may be attributable to psychological
distress but are not necessarily reported as such. As well, the potential personal and
practice costs of ignoring psychological wellness for the individual, their patients, and
the organization are considerable (21, 23). Studies show that with increased distress
27
comes decreased effectiveness in both patient care and other job functions, as well as
decreased job satisfaction and personal happiness (7). Distress also causes erosion of
interpersonal relationships which, as discussed previously, are already difficult. Distress
can result from loss of confidence in equally distressed peers and the added burden of
attempting to cover for them (18); it can also cause bullying and harassment behaviors
(20). Consequently, some practitioners are personally and professionally unhappy,
which may result in them leaving EMS entirely and taking with them their wealth of
knowledge and expertise.
Safe, healthy, and inclusive workplaces are identified as a priority in many
organizations (24); recommendations have been made by researchers and an EMS
leadership organization that approaches to psychological wellness should address both
acute and cumulative stress through increased understanding (4), as well as practice
specific prevention and coping strategies, interventions, and treatments. Building on
work that is already underway and utilizes existing resources, a comprehensive,
effective and sustainable program should provide an approach to psychological wellness
that begins prior to entering the workforce, recognizes psychological distress as a
legitimate cause of illness, and provides both immediate and ongoing support once
employed.
Future practitioners must be equipped for practice in a way that goes beyond
clinical skills and protocol, they need to be prepared for the reality of the work and given
strategies for coping to be used when they are impacted by stressors related to their job.
This begins in EMS programs with a commitment to teaching about resiliency through a
28
process that does two things: provides education about the “logistical” aspects of EMS
work i.e. how an EMS system operates and how that operation impacts the practitioner’s
ability to provide patient care, and teaches hands on skills that can be used when
symptoms of distress are encountered. In Alberta, this type of education is not currently
well developed. The education should include an understanding of dispatch, emergency
departments and acute care so students are more comfortable with interagency
dependence. Such teaching should give information about the physiological and
psychological impact of shift work so students know what to expect and can be assisted
in preparing personal strategies to cope with potential social isolation and sleep
disruption. Teaching should discuss how to recognize symptoms of various types of
psychological distress and outline effective interventions. Teaching should emphasize
that while the individual’s experience of events is unique, the skills necessary to be
resilient are common. Students will not only benefit themselves from this knowledge
and training for resilience, but will also start to become part of an empathetic and
respectful culture of understanding in the workplace. In addition, education surrounding
basic ethical principles such as autonomy and justice will help the development of a
moral resilience (25), and provide a greater understanding of issues related to patient
care and resource allocation.
The responsibility of the employer is to help practitioners sustain psychological
wellness by allowing them to employ the resilience skills developed. This objective can
be achieved in part by ensuring that psychological wellness is prioritized and legitimized
in a way equal to physical health. Admittedly, a shift in culture will be required, and that
29
can be brought about by acceptance by leadership of the serious nature of the problem
and need for training to help alleviate it, and by ensuring that operational policies and
processes are not unnecessarily contributing to the types of stressors that have been
identified by staff. A second part of the sustainability may be to develop a collaborative,
practice specific response of peer support and professional intervention that is broadly
known and easily accessible when staff require it, such as those being developed in
Ontario. Finally, the organization must continue to build on a culture of empathy,
respect and understanding (25). There is a culture of toughness in the emergency
services. To sustain a healthy and satisfied workforce, the employer must continue to
work toward providing the appropriate support practitioners need to deal with the stress
of doing the job. This must be throughout their career.
1.6 Conclusion
The costs of failing to understand and support psychological distress in
Emergency Medical Services are clear. For practitioners, preparation for not only the
practice of skills, but also the reality of working in the field is crucial. For the EMS
organization, there are several consequences. The use of sick time and workplace
health and safety claims for issues related to distress cause increased costs in salary for
the staff who are off as well as for those who are required to replace them, a decrease in
morale exacerbates any issues that exist between staff and management as well as
negatively impact interagency relations, and there may be and increased rate of attrition
and drain of knowledge and experience from the field. Finally, psychological distress in
practitioners is an issue of patient safety, as its negative impact on care, and could
30
result in worse outcomes. The continued development of a comprehensive and
sustainable response is required. Ultimately, failing to respond appropriately will only
compound the issue, and prove to be a detriment to the practitioners, their patients, and
the EMS organization.
31
1.7 Bibliography
1. Code Green Campaign. http://codegreencampaign.org/category/stories.
Accessed 2015.
2. Crean F, Addo K, Orfanakos A, et al. Making the Strong Stronger: An
Investigation into how the Toronto Paramedic Services Address Staff Operational
Stress Injuries. Toronto Office of the Ombudsman; 2015.
3. Jones S. Describing mental health profile of first responders: a systematic review.
Journal of the American Psychiatric Nurses Association 2017; (23) (3): 200-214.
4. Operational Stress Injury in Paramedic Services: A Briefing to the Paramedic
Chiefs of Canada.
http://www.paramedicchiefs.ca/docs/bcs/PCC_Ad_hoc_Committee_on_Stress_In
jury_Report.pdf: Ad-hoc Committee on Operational Stress Injury; 2014.
5. Cocker F, Joss N. Compassion Fatigue among Healthcare, Emergency and
Community Service Workers: A Systematic Review. International Journal of
Environmental Research and Public Health. 2016; 13(6): 618.
6. Avraham N, Goldblatt H, Yafe E. Paramedics’ Experiences and Coping Strategies
When Encountering Critical Incidents Qualitative Health Research. 2014; 24(2):
194-208.
7. Nimmo A, Huggard P. A Systematic Review of the Measurement of Compassion
Fatigue, Vicarious Trauma, and Secondary Traumatic Stress in Physicians.
Australasian Journal of Disaster and Trauma Studies. 2013; 1:37-44.
8. Sabo B. Reflecting on the Concept of Compassion Fatigue. The Online Journal of
32
Issues in Nursing. 2011; 16(1).
9. Stamm B. The Concise ProQOL Manual. 2010; http://www.proqol.org. Accessed
February 2017.
10. Maslach C. Job Burnout: New Directions in Research and Intervention. Current
Directions in Psychological Science. 2003; 12(5):189-192.
11. Thomas N. Resident Burnout. JAMA. 2004; 292(23):2880-2889.
12. Maslach C, Jackson S, Leiter M. The Maslach Burnout Inventory Manual. 3rd ed.
Palo Alto, CA: Consulting Psychologists Press; 1997.
13. Diagnostic and statistical manual of mental disorders. 5th ed. Washington DC:
American Psychiatric Association; 2013.
14. Langara College Course Calendar (Vancouver, BC)
https://langara.ca/continuing-studies/programs-and-
courses/programs/resilience/index.html
15. Streb M, Häller P, Michael T. PTSD in Paramedics: Resilience and Sense of
Coherence. Behavioral and Cognitive Psychotherapy. 2014(42):452-463.
16. Mirhaghi A, Mirhaghi M, Oshio A, Sarabian S. Systematic Review of the
Personality Profile of Paramedics: Bringing Evidence into Emergency Medical
Personnel Recruitment Policy. Journal of Academic Emergency Medicine. 2016;
(15.3): 144-149.
17. McAllister M, McKinnon J. The Importance of teaching and learning resilience in
the health disciplines: A critical review of the literature. Nurse Education Today.
2009; 29(4):371-379.
18. Cockett A. Building Resilience to Occupational Stressors Amongst Alberta Health
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Services Emergency Medical Responders. Disaster and Emergency
Management, Royal Roads University; 2015.
19. SAIT School of Health and Public Safety. Emergency Medical Technology-
Paramedic Course Outline. 2016; http://www.sait.ca/programs-and-courses/full-
time-studies/diplomas/emergency-medical-technology-paramedic, 2017.
20. Guiding Minds at Work Overview Report. In: Guiding Minds at Work; 2015.
21. Wilson S, Guliani H, Boichev G. On the economics of post-traumatic stress
disorder among first responders in Canada. Journal of Community Safety and
Well-Being. 2016; (1)(2).
22. WHS Report-EMS. In: Alberta Workplace Health and Safety; 2016.
23. Newland C, Barber E, Rose M, Young A. Survey Reveals Alarming Rates of EMS
Provider Stress and Thoughts of Suicide. Journal of Emergency Medical
Services. October 2015
24. Our People Strategy: Because We Are Stronger Together.
http://www.albertahealthservices.ca/assets/about/msd/ahs-msd-ahs-people-
strategy.pdf: Alberta Health Services; 2016.
25. Hafferty F, Franks R. The Hidden Curriculum, Ethics Teaching, and the Structure
of Medical Education. Academic Medicine. 1994; 69(11):861-871.
34
Chapter 3: Compassion Fatigue in Health Care Practitioners: A Systematic Review
The purpose of this systematic review was to identify the presence of compassion
fatigue in health care practitioners. This study considered all disciplines of health care
practitioners, because little evidence exists concerning Emergency Services alone. The
review also provided a way of relating the issues within EMS to the broader context of
other health care practitioners.
1.1 Introduction
Compassion Fatigue (CF) can be described as a health care practitioner’s
diminished capacity to care that results from repeated exposure to the suffering of their
patients, as well as from the knowledge of their patient’s traumatic experiences (1).
Although not precisely interchangeable, compassion fatigue is very closely related to the
concepts of ‘Vicarious Trauma’ and ‘Secondary Traumatic Stress’, both of which also
result from exposure to the trauma experienced by patients, rather than to the actual
trauma itself (2). The concept is related also to, and often mislabeled as, “burnout.” CF,
as defined above, is a result of providing patient care, and could theoretically be
experienced suddenly after caring for a particularly traumatized patient, though it is more
often considered a process that results from many incidences. Burnout may contribute
to compassion fatigue, given that operational factors such as work hours and work
environment can have an impact (3).
Research has been undertaken to develop reliable measurement tools to
examine the prevalence of CF, but these could be used also to predict risk. One such
35
instrument is the Professional Quality of Life Scale (ProQOL) developed by Stamm. The
ProQOL began as the “Compassion Satisfaction and Fatigue Test” and was developed
in 1993 in order to measure both the positive and negative elements experienced by
persons who act as professional helpers (4). The instrument measures CF by using
three sub scales: Compassion Satisfaction (CS), Burnout (BO), and Secondary
Traumatic Stress (STS)/Compassion Fatigue (CF) (depending on the version.) The
scores are not considered cumulatively; instead combinations of high and low scores in
the sub scales indicate overall level of CF. The ProQOL does not have a scale specific
control value for use as a diagnostic instrument.
This systematic review sought to describe the prevalence of CF in health care
practitioners. Interventions and mitigation strategies were not examined in this review.
1.2 Methods
1.2.1 Data Sources and Searches
This systematic review was conducted consistent with recommendations from
“The Meta-analysis of Observational Studies in Epidemiology” guidelines (5). An
electronic search was conducted using the Medline, Pubmed and Ovid databases. The
MESH term “compassion fatigue” was used, with keyword searches for, “secondary
traumatic stress”, “secondary traumatization”, and “vicarious traumatization.” Articles
were included from their date of publication up to July 2016. The terms were then
combined using “or” resulting in an initial list of articles that were reviewed by applying
the inclusion criteria to the title, and then abstract. All articles returned with the keyword
“compassion fatigue” were reviewed by at least abstract. Citations from accepted
36
articles were also searched. Due to the heterogeneous nature of providers of interest for
the samples/journals where articles on compassion fatigue could be published, hand-
searching journals and conference abstracts was not considered feasible
1.2.2 Inclusion Criteria
In order to be included in this review, studies had to meet the following inclusion
criteria: English language studies containing data that specifically included a
measurement of “compassion fatigue”; using a validated measurement tool and
reporting mean or median scores; using a participant sample consisting of practitioners
from a professional health care discipline providing frontline patient care; and originating
from a peer reviewed scientific journal.
1.2.3 Data Extraction
All articles returned from the search were reviewed by title. Those articles that
met inclusion criteria were then reviewed by abstract (indicating that a measurement of
compassion fatigue was made during the study); full text review was undertaken on
appropriate articles. After the final list of articles for inclusion was identified, data was
extracted. A data extraction form was developed prior to study selection, pilot tested on
one of the included studies, and refined accordingly as other studies were abstracted.
Data abstraction was performed by two authors (NLL and GC) with all data
independently verified by each author, and discrepancies resolved by consensus. When
data were not clear, the reviewers interpreted the data together and came to a
consensus. Unclear data or areas where assumptions had to be made are highlighted.
37
Full text review of included articles resulted in a list of study characteristics for
extraction. These characteristics were used to develop an evidence table that included:
the study’s demographic details (source, year, country, number of participants);
information pertaining to the overall strength and design (population, total sample size,
sampling method, research design, level of statistical analysis, response rate, method of
assessment, and the measurement tools utilized.) Study results data were recorded as
quantitative results (scores, risk/incidence) and qualitative analysis; as well, general
findings were recorded.
1.2.4 Data Synthesis and Analysis Method
This study is reported in accordance with the PRISMA statement, following an
accepted method. (6) When extracting the data into an evidence table, it became clear
that there was a large amount of heterogeneity in the methods of reporting results of the
measurement tools, particularly the ProQOL. As previously described, the ProQOL is
measured on three sub-scales: Compassion Satisfaction (CS), Burnout (BO) and
Compassion Fatigue (CF)/Secondary Traumatic Stress (STS). The third scale is
sometimes measured as “Compassion Fatigue” and sometimes as “Secondary
Traumatic Stress”, and each is scored differently. The versions of the ProQOL used in
the reviewed studies varied (when reported) between versions III, IV and V, and both
“Compassion Fatigue” and “Secondary Traumatic Stress” were reported as the third
sub-scale.
The majority of studies using ProQOL measured risk based on a participant’s
questionnaire score on each of three sub scales, compared with established cut off
38
scores. Some of the studies reported only two of the sub-scales, usually the
Compassion Satisfaction and Burnout scales. The scores for each sub-scale must be
considered individually, and there is no accepted method of combining them to report an
overall score (4). Some studies reported a mean score on each of the sub-scales for
the overall sample. A few studies were detailed in the reporting, providing a mean score
and SD (or 95% CI) for each of the ProQOL sub-scales by demographic variables (age,
gender, years of experience, etc.)
A summary evidence table was created presenting the study results (Name, author,
year, country, sample population, measurement tools used, overall findings, quantitative
prevalence or risk measured by ProQOL.)
1.3 Results
1.3.1 Study Selection
1015 records were returned. 46 additional records were found through reference
searches. Application of the inclusion/exclusion criteria to titles and abstracts left 65
articles to be examined. After stringent full text review, 40 articles remained for this
study. See PRISMA diagram (Figure 1)
1.3.2 Study Characteristics and Results
Of the 40 articles from which data were extracted, 24 were studies from the USA
and 20 focused on nurses. The vast majority (N=37) of the studies used the
Professional Quality of Life Scale (ProQOL) to measure compassion fatigue; all studies
also included some form of demographic questionnaire and just over half used an
39
additional tool or tools to assess some domain of psychological distress. The majority of
the studies (N=25) were published in the last three years, indicating that interest in the
subject has increased recently (Figure 2.)
The reporting of the results varied, with only 18 studies reporting mean scores for
all three ProQOL sub scales, 22 studies reporting a percentage risk of the sub scales,
and a few using a combination of the measures. Though all studies found some level of
compassion fatigue in their sample population, correlation to demographic and work
variables was inconsistent. The most common variables showing some relationship with
compassion fatigue levels were a history of depression/anxiety/PTSD, a history of
previous trauma, age, years in practice, type of care being provided, gender, level of
managerial support, level of social support, length and timing of shifts, and level of
education. Table 1 presents a summary of the study characteristics and major
quantitative and overall findings.
Table 2 presents a summary of those studies that both used the ProQOL tool as
the primary measure of compassion fatigue, and reported mean scores for all three sub-
scales (compassion satisfaction, burnout, and secondary traumatic stress/compassion
fatigue.) The summary shows the scores between practitioner groups (nurses vs. other
health practitioners) to be homogeneous. It also shows that compassion fatigue existed
in all the studied samples. Though most of the studies concluded that compassion
satisfaction was in the average range for the participants, burnout and secondary
traumatic stress were seen to be on the high end of average. Using standard ProQOL
cut off scores (see Table 3), in order to conclude that compassion fatigue is NOT
40
present, compassion satisfaction scores would be high, and burnout/secondary
traumatic stress scores would be low. The results included in this review show that
even though the compassion satisfaction scores were not in the “low” range, the
combination with “average-high” burnout and secondary traumatic stress/compassion
fatigue equates with the existence of compassion fatigue in the sample.
1.4 Discussion
Compassion fatigue was prevalent across diverse practitioner groups, work
environments and specialties, and each study in this review reported at least some
compassion fatigue according to ProQOL scores. As shown in the results, there were a
number of personal and work related variables that might be related to compassion
fatigue, including history of depression/anxiety/PTSD, a history of previous trauma, age,
years in practice, type of care being provided, gender, level of managerial support, level
of social support, length and timing of shifts, and level of education. The evidence
supporting these relationships was varied, and when seen, the correlation rarely
reached statistical significance.
There was a demonstrated association between compassion fatigue and prior or
current distress. The most consistent personal factors contributing to increased levels of
CF were an existing diagnosis of anxiety or depression (7) (8), and prior negative life
events or trauma (3). Distress was also associated with factors related to the work
environment such as shift time and length (9) (11) (19) (20), and the type of caring work
being done (17), though it was not as clear how these factors impact CF levels. It was
also unclear how age and years of experience impact CF. Higher levels of compassion
41
fatigue and burnout were sometimes seen in those with less experience (12), but there
was also evidence that the opposite is true and that there is a higher level of
compassion satisfaction in the less experienced (11). There was little explanation as to
why this disagreement exists, though it is possible that years of experience in a specific
field results in varied impacts.
Compassion fatigue and burnout, as well as post-traumatic stress disorder and
other types of psychological/emotional distress, are often associated and sometimes
conflated in discussion. It is important to differentiate these concerns conceptually, as
well as to outline how they overlap because there is not one general approach to
mitigating and treating the issues, and the triggers vary. Compassion fatigue is a health
care provider’s diminished capacity to care that results from repeated exposure to the
suffering of their patients, as well as from the knowledge of their patient’s traumatic
experiences (1). This exposure is referred to as vicarious traumatization and secondary
traumatic stress, both of which are a consequence of being witness to the trauma of
others, and being in a position of having to care for those who are suffering, rather than
being the primary subject of the trauma themselves. Compassion fatigue develops over
time; it is an erosion of the abilities to show empathy and to do the work of providing
care. Compassion fatigue is triggered by the continual use of empathy and emotional
energy, previous exposure to trauma, prolonged exposure to secondary trauma, and the
work environment. (16) Burnout is defined as a “psychological syndrome that involves a
prolonged response to stressors in the workplace. Specifically, burnout involves the
chronic strain that results from an incongruence, or misfit, between the worker and the
42
job. (7) Burnout is primarily triggered by work-related and organizational characteristics,
with some personal characteristics. (16) Post-Traumatic Stress Disorder (PTSD) is a
diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (47) that results from direct exposure to a traumatic event, and causes an
inability to function socially or at work. The major difference between PTSD and
Compassion Fatigue is the direct (in the case of PTSD) or indirect (in Compassion
Fatigue) experience of trauma, as well as the time it takes to develop. Whereas PTSD
can develop as a result of one specific trauma, Compassion Fatigue often manifests
after repeated exposure. Many of the clinical signs and symptoms are the same.
Evidence (16) suggests that the existence of burnout creates a “fertile ground” for
other types of occupational stress, including compassion fatigue. Indeed, quantitative
measurement of compassion fatigue according to the validated and widely used
Professional Quality of Life Scale (ProQOL) is conducted in three domains: a measure
of burnout, of secondary traumatic stress, and of compassion satisfaction. High scores
in burnout and secondary traumatic stress, combined with a low score in compassion
satisfaction are indicative of compassion fatigue (4). Moreover, and particularly in fields
such as Emergency Medical Services where a practitioner can experience primary
trauma as witness to active scenes as well as secondary trauma attending to multiple
patients with multiple complaints over time, compassion fatigue can co-exist with PTSD.
The finding that compassion fatigue exists across diverse practitioner groups can
have a serious impact on professional practice and workforce. Nimmo and Huggard, in
a systematic review of compassion fatigue in physicians, report that issues are “often
43
reflected in outcomes of emotional distress, pain, and suffering, and may manifest in in
increased rates of absenteeism, reduced service quality, low levels of efficiency, high
attrition rates and eventually, workforce dropout.” (1) This raises an important question
with regards to mitigation strategies and programs. There are developed programs in
existence, and many of the studies in this review recommended there mplementation in
health care environments. The use of formal programs and treatments along side
general wellness programs that encourage self-care, and increased social and
managerial support which have been identified as protective factors (28), would
contribute to a comprehensive strategy. As well, education to practitioners, from
students to the most experienced, about the existence and impact of compassion fatigue
could assist with identification of the condition, which in turn could be an important part
of mitigation. However, it is important to note that prior to the implementation of
anything, organizations must ensure that the exact issues at play in their staff were
identified, and the response was tailored to meet those concerns.
1.5 Limitations
The samples in all studies were gathered using a convenience sampling method,
with voluntary completion of the questionnaires. All studies were cross sectional,
making generalization to populations more difficult. Because of the inconsistencies in
data reporting, a meta-analysis of the data was not possible.
1.6 Conclusion
Compassion fatigue exists across diverse practitioner groups and specialties and
can be successfully measured using the ProQOL. However CFs relationship to
44
demographic, personal and professional variables is mostly unclear and reporting in
studies on this topic is highly variable. Though more research should likely be
conducted into the root causes of CF, education and mitigation or support programs are
recommended from a professional practice standpoint
45
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20. Severn MS, Searchfield GD, Huggard P.Occupational stress amongst
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26. Whitebird RR, Asche SE, Thompson GL, Rossom R, Heinrich R. Stress,
burnout, compassion fatigue and mental health in hospice workers in Minnesota.
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27. Zeidner M, Hadar D, Matthews G, Roberts RD. Personal factors related to
compassion fatigue in health professionals. Anxiety, Stress and Coping 2013; 26:
595-609.
28. Ariapooran S. Compassion Fatigue and burnout in Iranian nurses: the role of
perceived social support. Iranian Journal of Nursing and Midwifery Research
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30. Hegney DG, Criagie M, Hemsworth D et al. Compassion satisfaction,
compassion fatigue, anxiety, depression and stress in registered nurses in
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32. Mason VM, Leslie G, Clark K, et al. Compassion fatigue, moral distress, and
work engagement in surgical intensive care unit trauma nurses: a pilot study.
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35. Amin AA, Vankar JR, Nimbalkar SM, Phatak AG. Perceived stress and
professional quality of life in neonatal intensive care unit nurses in Gujarat, India.
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37. Branch C, Klinkenberg D. Compassion fatigue among pediatric healthcare
providers.The American Journal of Maternal/Child Nursing 2015; 40: 160-66.
38. Dasan S, Gohil P, Cornelius V, Taylor C. Prevalence, causes and
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39. Hunsacker S, Chen H-S, Maughan D, Heaston S. Factors that influence the
development of compassion fatigue, burnout, and compassion satisfaction in
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40. Kelly L, Runge J, Spencer C. Predictors of compassion fatigue and
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of secondary traumatic stress among psychiatric nurses in Greece. Archives of
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45. Osland EJ.An investigation into the professional quality of life of dieticians
working in acute care caseloads: are we doing enough to look after our own?
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53
1.8 Tables and Figures
1.8.1 Table 1: PRISMA diagram of study selection.
Records identified through
database searching
(n = 1015 )
Scre
enin
g In
clu
ded
El
igib
ility
Id
enti
fica
tio
n Additional records identified
through other sources
(n = 46 )
Records after duplicates removed
(n = 922 )
Records screened
(n = 922 )
Records excluded
(From title n = 779
From abstract n=78)
) Full-text articles assessed
for eligibility
(n = 65 )
Full-text articles excluded
(n = 25)
Studies included in
quantitative synthesis
(n = 40 )
54
1.8.2 Table 1: Summary of studies.
Author
[Reference]
Year COUNTRY SAMPLE
n
MEASUREMENT
INSTRUMENTS
OVERALL
FINDINGS
QUANTITATIVE
FINDINGS
Abenroth &
Flannery
[7]
2006 USA Hospice
Care RN’s,
n=216.
ProQOL-III Overall sample at
risk for CF; 91%
scoring moderate
high risk for BO also
scored moderate
high risk for CF. No
correlation with
personal
demographics, some
correlation with work
related variables.
35% of those
diagnosed with
depression or PTSD
scored high risk.
26.4% high risk,
52.3% moderate
risk, 21.3% low
risk.
Adams, et al.
[8]
2006 USA Social
Workers
n=274
Compassion
Fatigue Scale
General Health
Questionnaire
Supported notion
that job burnout and
secondary trauma
were separate
contributors to
psychological
distress.
No scores
provided.
Benoit, et al
[9]
2007 USA Genetic
counsellors
n=12
Focus Group
questions
All participants
described experience
indicating CF.
Themes included
being overwhelmed
due to caring, feeling
responsible, not
being able to control
patient suffering.
Difficulty
differentiating
experience of CF
from BO. Delivering
bad news prevalent
trigger of CF.
Traumatic memories
also a trigger.
Emotional responses
from work interfered
with ability to cope in
personal life.
None reported.
Alkema, et al.
[10]
2008 USA Hospice
Health
Care
Practitioner
s
n=37
ProQOL
Self Care
Assessment
Worksheet.
Burnout and CF
negatively correlated
to all aspects of self-
care except physical
care. CS
significantly
positively correlated
to emotional care,
spiritual care and
work life balance.
As CF increased,
reported self-care
decreased.
Mean CS 40.5
(high),
BO 23.8
(average),
CF 17.5 (high)
SCAW showed
higher scores for
self-care activities.
55
Author
[Reference]
Year COUNTRY SAMPLE
n
MEASUREMENT
INSTRUMENTS
OVERALL
FINDINGS
QUANTITATIVE
FINDINGS
Yoder
[11]
2008 USA RN’s from
special
care units,
n=106.
ProQOL-IV
Narrative response
BO and CF scales
strongly correlated.
15.8% of sample fell
into area of risk for
CF. CS found to be
higher in those
working longer shifts,
ICU and with less
experience.
Mean overall
scores:
CS=40.3,
BO=19.2,
CF=12.3
Craig & Sprang
[12]
2009 USA Trauma
treatment
therapists,
n=532.
ProQOL-III
Trauma Practices
Questionnaire
Sample reported
significantly lower CF
than in other studies
of mental health
professionals.
Younger, less
experienced reported
higher burnout; more
experience had
higher CS.
32% above cut off
for CS
6% above cut off
for CF
12% above cut off
for BO
Meadors et al
[13]
2009 USA Pediatric
health care
providers,
n=167.
ProQOL (version
not specified)
Secondary
Traumatic Stress
Scale
Impact of Events
Scale-Revised
No statistically
significant
relationships
between professional
groups and
subscales. Higher
CF scores for those
who had experienced
a loss within the last
30 days.
1.2% of
participants
showed high BO
scores, 76%
scored low. 7.3%
scored high on
CF, 43% scored
low.
Hooper et al
[14]
2010 USA Emergency
dept RN’s,
n=114.
ProQOL-IV ED nurses found to
have lower levels of
CS compared to
other services. 82%
had moderate-high
levels of BO, 86%
had moderate-high
levels of CF.
Risk percentages:
20.2% low risk for
CS,
26.6% high risk
for BO, 28.4%
high risk for CF.
Potter et al
[15]
2010 USA Oncology
RN’s,
n=153.
ProQOL-IV Risk of CF relatively
equal between work
settings
(inpatient/outpatient
units.) Higher level of
BO for those on
outpatient units. Staff
with 11-20 years’
experience showed
highest risk scores
on all sub scales.
Mean overall
scores:
CS=38.3,
BO=21.5,
CF=15.2
Circenis &
Millere
[16]
2011 Latvia Acute care
hospital
RN’s,
n=129.
ProQOL-V
Workplace
questionnaire
Maslach Burnout
Inventory
53% of the sample
had higher than the
mean score for CS,
54% had higher than
the mean score for
BO, and 50% had
higher than the mean
score for STS.
Mean scores:
CS=37.42,
BO=23.5,
STS=19.59
56
Slocum-Gori et
al
[17]
2011 Canada Palliative
care
providers,
n=630.
ProQOL (version
not specified)
Practitioners
providing care for
psychological,
emotional and
physical distress had
significantly higher
levels of CF and BO.
Nurses reported
highest level of CF.
Those who worked
part time had higher
CS.
Mean scores:
CS=43.9,
CF=18.6,
BO=20.8
Young et al
[18]
2011 USA Cardiovasc
ular RN’s,
n=70.
ProQOL-V Statistically
significant
differences between
nursing units for CS
and BO subscales.
Mean scores
HVICU:
CS=36.6,
BO=24.82,
STS=21.88
HVIMC:
CS=41.84,
BO=19.48,
STS=19.44
Bhutani et al
[19]
2012 India Non-
physician
clinicians,
n=60
ProQOL-V
Questionnaire
including personal,
professional,
anthropometric and
metabolic profiles
CS highest for those
with most years of
practice or in private
practice. Those
reported “poor
working conditions”
had higher BO. No
significant correlation
between sub scales
and demographic
variables.
Mean scores:
CS=40.63,
BO=22.8,
STS=23.52
Rossi et al
[3]
2012 Italy Mental
health
providers,
n=260
ProQOL-III
General Health
Questionnaire
(GHQ-12)
Those with reported
psychological
distress had
significantly lower
CS. Distress and
prior trauma showed
higher BO and CF.
Mean scores:
CS=32,
BO=21.15,
CF=10.2
Severn, et al
[20]
2012 New
Zealand
Audiologist
s,
n=82
ProQOL-III
Audiology
Occupational
Stress
Questionnaire
(AOSQ)
Highest level of CS
in private practice.
Lower CS and higher
BO with increased
age. Stress
associated with
patient contact
strongest predictor of
CF.
25% high level
CS, 22% low.
20% high level
risk of BO, 26%
low.
22% high risk of
CF, 29% low.
El-Bar, N et al
[21]
2013 Israel Physicians
n=128
CFST CF most prevalent.
Sharp divide in risk
for CF, either
extremely high or
extremely low.
Immigration can
involve a great deal
of personal trauma,
which increases risk
for CF. Levels found
here significantly
higher than other
studies.
35.2% at
extremely high
risk for CF,
9.4% high risk for
BO, 21.1% at risk
for low CS.
57
Being born
abroad/having no
academic affiliation
increased CF risk.
No impact with other
variables.
Kim
[22]
2013 USA Liver and
kidney
nurse
transplant
coordinator
s,
n=14.
ProQOL-V No significant
correlation between
demographic
variables and sub
scale scores.
Majority of sample
had average levels of
CS, BO and STS.
Mean scores:
CS=40,
BO=24,
STS=23.
Michalec, et al
[23]
2013 USA Nursing
students,
n=436.
ProQOL-V
Maslach Burnout
Inventory (MBI)
Semi-structured
interview
Significantly lower
levels of BO in 1st
year students than
second year, but no
significant increase
in 3rd and 4th year.
Overall sample
categorization:
CS levels=high,
BO
levels=average,
STS levels=low.
Mizuno, M et al.
[24]
2013 Japan Nurses
Midwives
n=255
ProQOL
Frankfurt Emotional
Work Scale
ProQOL scores
significantly
associated with
stress factors and
emotion work.
Particularly making
value judgements,
and having to control
emotions. No
relationship seen
between scores and
work experience.
Negative feelings
about accepting
certain aspects of the
work significantly
associated with CF.
No significant
differences in
ProQOL scores
between
nurses/midwives. No
high risk for CF.
Mean CS: 33.5
Mean BO: 26.9
Mean CF: 21.3
Sodeke-
Gregson, et al.
[25]
2013 UK Trauma
therapists
n=253
ProQOL V
Coping Strategies
Inventory
Majority in average
range for CS and
BO, and high range
for STS. CS
negatively correlated
with BO, BO
positively correlated
with STS. Age,
managerial support
positive predictors of
CS.
Perceived
management support
and older age
significant negative
predictors of BO.
More self-care, past
trauma for self-
CS: 8% low, 53.2
% average
BO: 64.2%
average, 25.8%
high
STS: 70% high,
30% average
58
positive predictors for
STS.
Whitebird et al,
[26]
2013 USA Hospice
care
providers
of various
designation
s,
n=547
ProQOL-III
Short Form-12
Health Survey
Version 2 (SF-12)
Generalized
Anxiety Disorder
Scale (GAD-7)
Patient Health
Questionnaire
(PHQ-8)
Medical Outcomes
Social Support
Survey (MOS6)
Job Satisfaction
question
Coping Strategies
Higher levels of BO
than CF, both less
than average for
norms associated
with ProQOL. Both
were moderately
correlated with
anxiety and
depression.
Mean scores:
CF=9.9
BO=13.9.
Zeidner et al,
[27]
2013 USA Health
professiona
ls of
various
designation
s and
specialties,
n=182.
ProQOL-III
Schutte Self Report
Inventory
Emotion-
management
subscale of the
Mayer-Salovey-
Caruso emotional
intelligence test
Coping inventory
for stressful
situations-situation
specific coping
Mood subscales of
the Dundee stress
state questionnaire
Women reported
higher levels of CF.
No significant
difference between
professional groups.
No overall scores
provided.
Ariapooran
[28],
2014 Iran RN’s
n=164
ProQOL
Multidimensional
Scale of Perceived
Social Support
Inverse correlation
between social
support and BO; no
meaningful
correlation between
social support and
CF.
May indicate that
nurses working with
victims or survivors
could be at risk for
developing CF or
BO. Social support a
key variable in
determining risk for
CF and BO.
45.7% at risk for
CF
54.3% of ER and
35.4% on non-ER
nurses suffered
from CF;
15.03% at risk for
BO
19.2% of ER and
11.4% of non-ER
at risk for BO.
Bellolio, et al.
[29]
2014 USA Resident
physicians
n=188
ProQOL V No statistically
significant impact of
any demographic
variable in any of the
subscales. BO
scores higher when
more hours and night
shifts worked.
Found average
levels of CS, low
levels of BO and
CS: 59% average
level, 41% high
level.
BO: 57% low,
43% average.
STS: 77% low,
23% average.
59
STS in sample; no
difference in
comparison to other
specialties. Higher
risk of developing CF
with night shifts.
Hegney, D et al.
[30]
2014 Australia
RN’s
n=132
ProQOL V
DASS
Approx. 20% in
sample showed
potential risk and
higher CF. 12% high
risk, 7.6% very
distressed.
STS and BO related
and associated with
negative mood.
No significant
correlation with
variables. Lower
levels of CS in
nurses with less
experience.
Mean CS: 35.66
Mean BO: 23.66
Mean STS: 18.6
Positively
correlated with
age and years in
nursing.
Hinderer, K et
al.
[31]
2014 USA RN’s
n=128
ProQOL V
Penn Inventory
35.9% nurses scored
for high BO, 27.3%
for CF, more than
75% high for CS. CF
less prevalent than
BO. BO related to
longer shifts, work
relationships. CF
triggered by
challenging patients,
futile care,
environment,
personal experience.
High prevalence of
CS, particularly in
older nurses.
Mean BO: 20.56
(suggested higher
risk of BO)
Mean CF: 13.94
(reported by
27.3% of sample)
Mean CS: 37.96
(majority above
average CS)
Mason, V et al
[32]
2014 US RN’s
n=26
ProQOL V
Utrecht Work
Engagement Scale
Moral Distress
Scale
As work engagement
increases so does
CS. No other
relationships
between scores and
variables.
CS: 73.1%
average, 26.9%
high
BO: 42.3% low,
57.7% average
STS: 61.5% low,
38.5 average
Martin, L et al
[33]
2014 USA Abortion
providers
(range of
clinicians)
n=?
ProQOL
Ways of Coping
Questionnaire
Workgroup
Characteristics
Measure
People and
Organizational
Culture Profile
APSS
Significantly higher
CS and lower BO
than other healthcare
providers.
Compassion fatigue
in line with other
studies.
CS: 49% high,
30% average,
21% low
BO: 4% high, 21%
average, 75% low
CF: 46% average,
43% low
Smart, D et al.
[34]
2014 USA RN’s
Physicians
Nursing
assistants
n=139
ProQOL V Mean scores did not
differ between
departments.
General medical
workers showed
Mean CS: 39.1
Mean BO: 23.4
Mean STS: 19.0
60
evidence of higher
burnout.
Significant increase
in level of BO for
caregivers of non-
critical patients
(compared to those
in ED or ICU.)
Findings contrary to
other studies. Night
shifts associated with
higher BO, less CS.
Amin, et al.
[35]
2015 India NICU RN’s
n=129
ProQOL V
Perceived Stress
Scale 14
Perceiving high
stress experienced
prolonged distress,
may be higher risk of
BO, STS or low CS.
Weak to moderate
positive correlation
between perceived
stress and BO/STS.
Almost 25% positive
for BO and STS.
Similar to reports in
western lit.
Perceived stress;
most nurses
perceived
moderate stress
(47.3%), mild
stress in 29.5%,
and high stress in
23.2%.
High CS found in
19.4%, high BO in
23.3% and high
STS in 23.3%.
Berger, et al.
[36]
2015 USA Pediatric
RNs
n=239
ProQOL V
Two open ended
questions
STS due to frequent
traumatic patient
situations. End of life
situations particularly
difficult. Continually
caring for critical
patients frequent
trigger of CF and BO.
Respondents
reported decrease in
care and issues in
personal life.
Younger nurses had
lower CS, higher BO
and STS. Lower CS
with 6-10 years exp,
higher after 20 years
exp. Lower CS,
higher BO on
medical/surgical
units.
71.5% moderate
to high CS. Over
a quarter had low
CS, high BO and
high STS.
Branch and
Klinkenberg
[37]
n=
2015 USA
Pediatric
RN’s,
Social
Workers,
RTs, PTs,
OTs,
Psychologi
sts, Child
Life
Therapists,
PCAs.
n=296
ProQOL V Staff on units with
long periods of
stability and support
showed higher CS,
lower BO. Oncology
units avoid CF
through meaningful
interactions with
patients.
Significant score
differences by clinical
unit.
25% high risk for
CS, 30.9% high
risk for BO, 26.9%
high risk for STS.
Dasan, et al [38]
2015 UK
Emergency
Medicine
ProQOL
Potential impacts of
Levels of CF found to
be low. Those with
98% of
consultants were
61
consultants
in UK ED
n=681
CF questionnaire
Qualitative
interview
CF more likely to
report irritability and
reduced standards of
care, as well as
intent to retire earlier.
Mean CS reduced
marginally over first
10 years, increased
after 20 years. Job
demand, control and
support impacted
levels of satisfaction
or fatigue in
interviews.
average or high
for CS, only 2.3%
low. Of the 2.3%,
only 2 consultants
had high BO, and
one of those also
high STS.
Hunsaker, S et
al [39].
2015 USA Nurses
n=284
ProQOL V Overall low to
average level of CF
and BO among ED
nurses. CF less
prevalent with
increasing
age/experience.
Less CF and BO with
increased
managerial support.
Older nurses had
higher levels of CS,
younger nurses had
higher levels of BO.
More years nurse
had practiced, higher
the level of CS, lower
the level of BO.
Lower BO with
shorter shifts.
Mean CS: 39.77
CF: 21.57
BO: 23.66
56.8% average
CS; 65.9% low
CF; 54.1%
average BO.
Kelly, et al [40].
2015 USA RN’s
n=491
ProQOL V Nurses would be in
normal range for BO
and CS, low range
for STS.
Some findings
related to
demographics:
"millennial"
generation more
likely to be
experiencing higher
BO/STS and lower
CS than "Baby
boomer" nurses. As
nurses gained
experience,
increased CF and
lowered CS.
Overall mean
ProQOL scores:
BO: 25.63
STS: 20.86
CS: 40.51
Kim, K et al [41].
2015 Korea RN’s
n=488
ProQOL V
Ethical Dilemmas
Questionnaire
Professional
Nursing Values
Questionnaire
Significant
differences in CS
and BO by age,
marital status,
religion, educational
status, position and
number of years in
practice. Low CS
and high BO
associated with
Mean CS: 32.8
Mean BO: 29.0
Mean STS: 27.3
62
nurses with less than
3 years’ experience
Level of CS higher
than levels of BO
and STS. CS
increases as age
increases.
Lee, W et al [42] 2015 USA Genetic
Counsellor
s
n=467
ProQOL V
STAI
High CS found in
counsellors at high
risk for CF; both can
exist together.
Burnout a significant
predictor of CF.
Mean CS: 41.15
(4% low range)
Mean BO: 21.11
(19% high, 68%
average)
Mean STS: 19.37
(61% high, 39%
average)
Mangoulia, P et
al [43]
2015 Greece RN’s
n=174
ProQOL V Overall showed low
CS, high risk for BO
and CF. No
relationship shown
between previous
trauma and STS.
Knowledge powerful
protective factor.
Mean CS: 28.36
(low)
Mean BO: 25.17
(average)
Mean CF: 16.45
(borderline high)
Meyer RML, et
al [44]
2015 USA RN’s
starting
pediatric
residency
program
N=
ProQOL
Mueller McCloskey
Satisfaction Scale
Life Events
Checklist
CF 23.56+/-13.29
CS: 93.56+/-
16.77
BO: 24.01+/-
11.67
Osland, E.J [45]
2015 Australia Dieticians
n=87
ProQOL V Significantly higher
STS in those working
with pediatrics.
Overall showed
average CS, average
BO and low STS;
overall positive
professional quality
of life. Higher STS in
high risk areas (ICU,
mental health.) More
years of practice
showed higher
STS/BO.
CS: 78% average,
20% high
BO: 37% low,
63% average
STS: 66% low,
34% average
Sacco, T et al
[46]
2015 USA RN’s
n=221
ProQOL V Overall, nurses
scored in average
range for all three
sub-scales.
Suggested that age
has impact on
ProQOL, nurses over
50 had higher CS,
lower BO and STS.
Younger less
experienced nurses
higher risk for CF.
Significant difference
in CF by age, unit
acuity, and
management/practic
e change.
None reported.
63
1.8.3 Table 2: Summary of studies using ProQOL tool, reporting all
three sub-scales.
Study Author {Reference} Year Sample CS BO STS
16 Alkema et al, 2008 2008 Other 40.5 23.8 17.5
3 Yoder, 2008 2008 Nurses 40.3 19.2 12.3
4 Potter et al, 2010 2010 Nurses 38.3 21.5 15.2
15 Slocum-Gori et al, 2011 2011 Other 43.9 20.8 18.6
13 Bhutani, et al 2012 2012 Other 40.63 22.8 23.52
2 Circenis & Millere, 2012 2012 Nurses 37.42 23.5 19.59
14 Rossi et al, 2012 2012 Other 32 21.15 10.2
5 Young et al, 2011 2012 Nurses 36.6 24.82 21.88
1 Kim, 2013 2013 Nurses 40 24 23
11 Mizuno et al, 2013 2013 Nurses 33.5 26.9 21.3
9 Hegney et al, 2014 2014 Nurses 35.66 23.66 18.66
8 Hinderer et al, 2014 2014 Nurses 37.96 20.56 13.94
18 Smart et al, 2014 2014 Other 39.1 23.4 19
7 Hunsaker et al, 2015 2015 Nurses 39.77 23.66 21.57
6 Kelly et al, 2015 2015 Nurses 40.51 25.63 20.86
10 Kim et al, 2015 2015 Nurses 32.8 29 27.3
17 Lee et al, 2015 2015 Other 41.15 21.11 19.37
12 Mangoulia et al, 2015 2015 Nurses 28.36 25.17 16.45
Median Scores All 37.69222 23.37 18.90222
1.8.4 Table 3: ProQOL Cut-Off Scores
Compassion Satisfaction
Burnout Secondary Traumatic Stress/Compassion
Fatigue
High >42 >42 >42
Average 23-41 23-41 23-41
Low <22 <22 <22
64
Chapter 4: Psychological Distress in Emergency Medical Services: A Survey
Study of Practitioners.
This thesis is intended to contribute to the body of evidence surrounding the
psychological distress experienced by EMS practitioners. Now that the issues
have been defined in the EMS context conceptually as well as placed in the greater
context of healthcare providers, it is important to provide quantitative data to
describe the issues further.
1.1 Background
Emergency Medical Services (EMS) has long held a unique role in health
systems, and that role has evolved and expanded over the years. Traditionally,
EMS practitioners (Emergency Medical Responders, Emergency Medical
Technicians, and Paramedics) have provided care to patients in urgent or life-
threatening situations. EMS providers often provide high intensity episodic care, in
unfamiliar and occasionally hazardous environments, often without broad peer
support networks available in other traditional health care environments such as
hospitals. As such, EMS practitioners may be at particular risk from numerous
stressors which result in psychological distress. In the face of decreasing morale
and growing attrition from the field (1), understanding the stress and supporting the
psychological health and safety of practitioners has become a priority for EMS
organizations. For example, a recent position paper from the Paramedic Chiefs of
Canada (2) identified the need to explore mental health issues, and develop
appropriate prevention and treatment programs specific to EMS.
65
Psychological distress can be categorized into at least 3 major areas, each
which is not necessarily unique (i.e. factors may overlap), but whose definition and
primary contributing cause may be different. Compassion Fatigue (CF) is described
as the diminished capacity to care which arises from repeated exposure to the
suffering of patients, as well as from knowledge of the patient’s specific traumatic
experience (for example, motor vehicle collision, victim of domestic violence, life-
threatening anaphylaxis) (3). Compassion fatigue is considered a cumulative stress
in part due to the amassed expenditure of emotional energy (apart from other
factors). Burnout (BO) is defined as a “psychological syndrome that involves a
prolonged response to stressors in the workplace…and results from an
incongruence or misfit between the worker and the job.” (4) Burnout is triggered by
work-related and organizational characteristics. Whereas CF and BO are
behaviours which become manifest, Post-traumatic stress disorder (PTSD) is a
diagnosis with specific criteria applied by a mental health professional, and usually
arises from an exposure to a traumatic event (5). EMS providers are at risk of
exposure to traumatic events by virtue of their work.
Given the different types of psychological distress which may arise in EMS
providers, our study attempted to differentiate among CF, BO, and PTSD. Our
objective was to describe, using validated instruments in a cross-section of EMS
providers in Alberta, the prevalence and extent of these three areas of
psychological distress. Further, we wished to estimate any difference between self-
reported psychological distress, to that measured by validated instruments.
66
1.2 Methods
This study was approved by the Conjoint Health Research Ethics Board
which reviews proposed research on humans conducted by faculty, staff and
students at the University of Calgary. The study was also reviewed by the Alberta
Health Services Emergency Medical Services Research Committee.
1.2.1 Sample
The target population for this study was Emergency Medical Services staff in
the Alberta Health Services Calgary Zone. Participants were required to have a
valid, unrestricted Emergency Medical Responders (EMR), Emergency Medical
Technicians (EMT), and Paramedics (EMT-P) license to practice from the Alberta
College of Paramedics and be employed in EMS currently. Because this study
was chiefly concerned with the psychological distress that results from continually
interacting with and caring for patients while also coping with operational demands,
participant’s primary role was required to be front line patient care.
Participants self-identified. Informational posters were displayed in the EMS
rooms located in hospitals as well as at the Southgate Station. In addition, the
information was distributed by AHS email to all EMS Calgary Zone field staff.
There was not a summative value that could establish an a priori sample size
estimate, instead a convenience sample was used from potential participants
identified over distinct 24 hour periods during a four day schedule rotation.
67
1.2.2 Design and Data Collection
The study was a cross-sectional survey. Participants were asked to complete
a survey package made up of three validated tools and a demographic
questionnaire. Paper based survey packages were available in the EMS waiting
areas of the four adult acute care hospitals in Calgary (Foothills Medical Centre,
South Health Campus, Peter Lougheed Centre, and Rockyview General Hospital)
as well as the Southgate EMS Superstation, which serves as a shift start and end
point for approximately 11 emergency and 15 inter-facility transfer ambulance
crews.
Data was collected between December 21 and 30, 2016, and between
February 10 and 17, 2017. Survey packages were completed by practitioners and
left for pick up in the locations described above.
The primary outcomes and measurements are as follows:
1. Measure compassion fatigue, using the ProQOL version 5.
2. Measure burnout, using the Maslach Burnout Inventory.
3. Positive/negative screening for PTSD, using IES-R scale tool.
4. Self-reported prevalence of compassion fatigue, burnout, and PTSD.
1.2.3 Measures
Demographic Survey: A short questionnaire collecting demographic variables
was included with the survey package. Variables included age, sex, professional
68
designation (Emergency Medical Responder, Emergency Medical Technician or
Paramedic), and total years of service in EMS. Because the survey was
anonymous, participants were asked also to include their first initial to ensure no
duplicate responses.
Professional Quality of Life Scale version 5 (ProQOL V): is a 30 item self-
report instrument which identifies Compassion Fatigue through the measurement
of three domains. The domains are Compassion Satisfaction (the positive feelings
derived from being able to do the work), Burnout (negative feelings such as
exhaustion and frustration related to operational and structural issues), and
Secondary Traumatic Stress (distress resulting from being witness to the suffering
of others.) Analysis of the ProQOL is not based on a summative score, rather
each of the domains is scored individually. When interpreting the ProQOL,
compassion fatigue is identified when low compassion satisfaction scores are seen
in combination with higher burnout and secondary traumatic stress scores. Cut-off
scores can be used to classify results as ‘Low’, ‘Average’, or ‘High’ (6).
Maslach Burnout Inventory (MBI) is a 22 item self-report instrument which
measures burnout in the domains of: Emotional Exhaustion (being emotionally
overextended and exhausted by work); Depersonalization (an unfeeling and
impersonal response to the recipients of service or care); and Personal
Accomplishment (feelings of competence and successful achievement in work.)
Each question in the domains is assessed by frequency (i.e. respondents are
asked how often they experience a feeling, rather than how strongly they feel it.)
69
Burnout can be present dependent on responses within each separate domain (7).
Burnout is present when scores are high in emotional exhaustion and
depersonalization, and when a low score is recorded in personal accomplishment.
The domains are scored separately and cut-offs can be used to identify scores as
‘Low’, ‘Average’ or ‘High’.
Impact of Event Scale-Revised (IES-R): is a 22 item self-report tool used to
screen for the presence of post-traumatic stress disorder. Respondents are asked
to indicate how distressing each item has been on Likert-like scale of 1-4. A
cumulative score is calculated; scores over 33 are a positive screen for PTSD,
though the tool itself is not considered diagnostic (8).
In addition to completing the measurement instruments, respondents were
asked to report their own experience with compassion fatigue, burnout, and PTSD
by reading a description of each, then answering the question, “Do you feel you fit
the description of (compassion fatigue/burnout/PTSD)?” Respondents were given
the options ‘Yes’, ‘No’ or ‘Sometimes.’
1.2.4 Analysis
Data was analyzed using classic descriptive techniques: response rates,
demographics, and measures of central tendency, dispersion, and distribution of
responses within survey. There are ranges of responses within domains, and
variable combinations in both the ProQOL and MBI which help to define presence
or absence of CF and BO respectively. We defined CF as present when an
individual respondent scored in the high range (>42) for burnout or secondary
70
traumatic stress, and in the low range (<22) for compassion satisfaction. We
defined burnout as present when an individual respondent scored in the high range
in any of the three domains of the MBI (emotional exhaustion >30,
depersonalization >12, personal accomplishment <33.) We defined PTSD as
present when an individual respondent scored >33 on the IES-R. Self-reported
responses were compared against the validated instruments.
1.3 Results
All data was collected in Calgary, Alberta. A total of 73 responses were
received out of approximately 158 potential respondents who were scheduled on
shift over the collection period. All respondents were either Paramedics or EMTs,
the majority (n=54, 75%) were Paramedics. The mean (SD) years of service
worked in EMS was 12.7 (7.1), with a range of 2 years to 35 years. The sex of
participants was even, with 36 female and 37 male responses. Respondents
ranged in age from 24 to 58 years old, and the mean (SD) age was 35.6 (8.1)
years.
1.3.1 Relationship Between ProQOL, MBI, IES-R and Demographic Variables
Table 1 shows the overall mean scores for each of the measurement
instruments, as well as any bivariate relationships that may exist between the
demographic variables and the survey scores. Figure 1 presents the overall results
of each of each instrument and domain. The cut-off values for ‘high’ are indicated
on the results.
71
Analyzing the ProQOL, in our sample, mean (SD) results for compassion
satisfaction was 30.4 (7.2), for burnout 30.2 (6.6), and secondary traumatic stress
24.6 (7.3). No significant differences were seen when age, years of service, and
professional designation were considered. A difference was noted analyzing
secondary traumatic stress by sex, with the mean (SD) score for men of 21.7 (6.5)
significantly lower than that for women of 27.8 (6.9).
Examining the MBI, the overall mean (SD) scores by domain were 21.3
(11.7) for emotional exhaustion, 24.4 (11.0) for depersonalization and 30.5 (7.4) for
personal accomplishment. The MBI measures a level of burnout in each domain,
meaning average burnout exists in the domain of emotional exhaustion, very high
burnout in depersonalization, and high burnout in personal accomplishment. There
were no significant relationships seen between the variables and MBI scores,
though a small difference between paramedics (mean (SD) 22.6 (12.6)) and EMTs
(17.3 (7.3)) for the domain of emotional exhaustion was identified.
The overall mean (SD) score for the IES-R was 30.5 (23.2), below a cut-off
score of 33 used as determinant of a positive screen; 42.9% of respondents scored
33 or above. No significant correlations were identified with the variables except
for a notably lower mean (SD) score for men (25.6 (24.3)) than women (35.5
(21.2)). Only women and respondents over 40 (33.9 (24.4)) had mean scores over
the cut-off score.
72
1.3.2 Presence of Compassion Fatigue, Burnout and Post-Traumatic Stress
Disorder
Table 2 and Figure 2 shows the prevalence of compassion fatigue and
burnout through the domains of the ProQOL and the MBI respectively (as defined
in methods), as well as the percentage of respondents who had a positive screen
result for PTSD through the IES-R. The results of the ProQOL showed that only a
small percentage of respondents scored in the high range for any of the three
domains (11.8% for CS, 4.4% for BO, and 1.5% for STS) and only 1.5% scored in
the high range for 2 of 3 domains. There were no participants who scored high for
all three. The MBI showed more extreme results, particularly in the domain of
depersonalization (DP) where the vast majority of respondents were in the high
range (83.3%). The domains of emotional exhaustion (EE) and personal
accomplishment (PA) showed 30.6% and 69.4% in high range respectively. 100%
of respondents scored high in at least one domain, 38.9% in at least two, and
27.8% of the sample scored high in all three domains. Through the use of the IES-
R survey tool, it was identified that 42.9% of respondents had a score over 33,
indicating a positive screen for further investigation of potential PTSD.
1.3.3 Relationships Between Self-Report Answers and Demographic
Variables
Table 3 shows overall self-identification of each issue in the sample, as
well as bivariate analysis of the answers with the demographic variables. For the
entire sample, 57.5% of respondents self-reported compassion fatigue, 47.9%
73
burnout, and 20.5% PTSD. A much larger percentage of men (89%) than women
(52.8%) reported compassion fatigue, and respondents for each of the variables of
over 10 years’ experience, those over 40, and those who were paramedics
consistently reported more compassion fatigue, burnout and PTSD.
1.3.4 Relationships Between Survey Scores and Self-Report Answers
Analysis of the congruence between the survey scores and the self-report
answers for each of the issues is shown in Table 4. The ProQOL scores and
compassion fatigue self-report showed general agreement. For those who said
‘Yes’ to compassion fatigue, the mean compassion satisfaction score was below
the overall mean for CS, and the scores for burnout and secondary traumatic
stress were above the overall mean for these domains, which would indicate
potential compassion fatigue. For those who said no, the CS mean was higher
than the CS mean for the whole sample, and both the BO and STS were lower. A
similar result was seen with MBI scores; those who said ‘Yes’ to burnout had a
mean score for personal accomplishment that was lower than the overall PA mean,
with emotional exhaustion and depersonalization much higher. For those who said
‘No’, the reverse was seen. It should be noted that in all cases the mean score for
depersonalization remained in the high burnout range. There was some
incongruence between the self-report question for PTSD and the IES-R survey
scores. While the ‘Yes’ and ‘No’ answers agreed with the mean scores (a positive
screen score of 49.8 for ‘Yes’, and a negative screen score of 17.6 for ‘No’) the
mean (SD) for those who answered ‘Sometimes’ (36.6 (14.6)) was in fact in the
74
positive screen (above 33) range, suggesting that a number of respondents did not
accurately self-identify PTSD.
1.4 Discussion
The most significant finding in our survey data were the very high scores in
the depersonalization domain of burnout. Depersonalization is a
…distant or indifferent attitude toward work. It manifests as negative,
callous, and cynical behaviors or interaction with colleagues or patients in
an impersonal manner. Depersonalization may be expressed as
unprofessional comments directed toward coworkers, blaming patients for
their medical problems, or the inability to express empathy or grief when a
patient dies. (9)
According to Maslach, who developed the MBI instrument, it can develop in
response to emotional exhaustion and the two domains should be considered
together (7). There is only a small amount of information surrounding which factors
impact burnout in EMS, however studies examining other health professions
identify organizational and operational factors, such as working hours and
environment, perceived lack of support from and poor communication with
management, lack of autonomous decision making, overburden in workloads, and
insufficient resources (10). Preliminary research in EMS supports these factors as
significant risk factors, too (11). Burnout is a particular concern as it potentially
increases susceptibility to compassion fatigue. Experiencing burnout creates a
“fertile ground” for the development of psychological distress (12). An individual’s
75
continual exposure to the stress associated with operational factors, can deplete
resiliency and diminish the ability to cope with trauma, both primary and secondary,
and results in decreased compassion and positive feelings toward their patients.
Another significant finding was the incongruence between the rate of self-
report of PTSD and the scores of the IES-R; only 20% of respondents said ‘yes’ to
identifying with the description of PTSD, while 43% overall scored 33 or above
(considered a positive screen) on the survey instrument. There were two areas of
concern with this result. A further 30% of respondents reported ‘sometimes’
identifying with the description of PTSD, though the mean score for this group was
36.6 (above the cut-off) and the distribution showed the vast majority of the group
also above the cut-off. Additionally, the distribution for scores in the ‘yes’ group
identified approximately a third of these responses that were not actually above the
cut-off score. It should be noted that there was other congruence shown with the
instrument and the self-reporting; the vast majority (87%) of respondents who said
‘no’ to the self-report question scored under 33 on the IES-R which indicated a
negative screen. It is possible that while PTSD is recognized by the EMS
practitioner it is not well understood, which could account for those who answered
‘yes’ but did not screen positive. Considering that burnout was present in the
majority of the sample, it could be that practitioners are attributing other issues to
PTSD as PTSD is quite often discussed as a cause of psychological distress in
emergency services. However PTSD was also generally under reported in the
‘sometimes’ group, which may again speak to lack of understanding (i.e.
practitioners who do not fully recognize what their distress is a result of) but also
76
may be related to the stigma that is still attached to reporting PTSD and causes it
to be under reported in other demographics also (13). Of the three issues studied,
PTSD is the only one that results from primary trauma (i.e. a trauma of which the
practitioner is the subject); EMS is starting to take steps toward creating a
supportive culture where practitioners feel empowered to report their own trauma
rather than feeling compelled to stay quiet in order to be considered still competent
in their role.
It is important to recognize how compassion fatigue, burnout, and PTSD
coexist and build upon each other within EMS practitioners. Nearly 60% of
respondents identified as experiencing compassion fatigue, and the results of the
ProQOL showed the mean scores for the EMS practitioners in this study tended to
be lower for compassion satisfaction and higher for burnout and secondary
traumatic stress than other groups of healthcare practitioners (14, 15, 16, 17) as
well as when compared to the data bank associated with the ProQOL itself (6).
This suggests that compassion fatigue is present in EMS practitioners, however
the scores for all the instruments seem to support the idea that combinations of the
issues coexist in the same individual. Keeping in mind the high prevalence of
depersonalization seen on the MBI, addressing burnout, which is a domain of CF
and also appears to be the most pervasive issue overall, could bring about
improvement in secondary traumatic stress and increase compassion satisfaction,
as well as give practitioners the opportunity to build up resiliency in other areas.
Addressing burnout is an important strategy because nearly half of all respondents
self-reported both compassion fatigue and burnout, and 14% reported all of
77
compassion fatigue, burnout, and PTSD. Our study also suggests which
practitioners may need particular attention. Most significantly, more paramedics
self-reported ‘yes’ to all issues, and tended to have higher scores in the negative
domains of both the ProQOL and the MBI than the EMTs. Paramedics have a
larger scope of practice than EMTs, and when paramedics and EMTs are
partnered, it is often the paramedic who makes the care decisions and provides
treatment; the added burden of responsibility and stress could account for
increased burnout and compassion fatigue in paramedics. As well, traumatic
stress both primary (in PTSD) and secondary (in compassion fatigue) was
significantly lower in men, though men also reported compassion fatigue far more
often than women. The reason for this is unclear, though the masculine culture
found in EMS could cause men to feel that it is less permissible to admit to
experiencing trauma and being impacted by it, but more acceptable to be low in
softer emotion like compassion.
1.5 Limitations
There were a few limitations associated with this study. Participants self-
identified and it is possible that those who had the most interest in completing the
survey were those who felt they experienced a lot of stress. The cross sectional
design and relatively small sample size could make it difficult to generalize the
results across all EMS practitioners. Finally, there was no opportunity to examine
individual experiences and compare them against responses.
78
1.6 Conclusion
The results of this study identify that psychological distress is present in
EMS practitioners as compassion fatigue, burnout, and post-traumatic stress
disorder. The most prevalent issue was identified as burnout, specifically burnout
in the domain of depersonalization, which causes practitioners to develop negative
and cynical attitudes towards colleagues and patients. Coexisting with burnout is
compassion fatigue, which was self-reported in half of respondents and is likely a
result of the identified burnout that has remained unaddressed. PTSD was present
and under-reported by practitioners. Further investigation into the reasons for such
high scores in depersonalization is recommended. A comprehensive resilience
program ought to include training that would target burnout (specifically
depersonalization), enhanced screening for PTSD, and awareness of compassion
fatigue.
79
1.7 Bibliography
1. Guiding Minds at Work Overview Report. In: Guiding Minds at Work; 2015.
2. Operational Stress Injury in Paramedic Services: A Briefing to the
Paramedic Chiefs of Canada.
http://www.paramedicchiefs.ca/docs/bcs/PCC_Ad_hoc_Committee_on_Stre
ss_Injury_Report.pdf: Ad-hoc Committee on Operational Stress Injury;
2014.
3. Nimmo A, Huggard P. A Systematic Review of the Measurement of
Compassion Fatigue, Vicarious Trauma, and Secondary Traumatic Stress in
Physicians. Australasian Journal of Disaster and Trauma Studies. 2013;
2013-1:37-44.
4. Maslach C. Job Burnout: New Directions in Research and Intervention. .
Current Directions in Psychological Science. 2003; 12(5):189-192.
5. Diagnostic and statistical manual of mental disorders. 5th ed. Washington
DC: American Psychiatric Association; 2013.
6. Stamm B. The Concise ProQOL Manual. 2010; http://www.proqol.org.
Accessed February 2017.
7. Maslach C, Jackson S, Leiter M. The Maslach Burnout Inventory Manual.
3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1997.
8. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: A Measure of
Subjective Stress. Psychometric Medicine. 1979;41(3).
9. Moss M, Good V, Gozal D, Kleinpell R, Sessler C. A
Critical Care Societies Collaborative Statement: Burnout Syndrome in
80
Critical
Care Health-care Professionals. A Call for Action. American Journal of
Respiratory and Critical Care Medicine. 2016(194):106-113.
10. Paris, M., Hoge M. Burnout in the Mental Health Workforce: A Review.
Journal of Behavioral Health Services and Research. 2010; 37(4):519-528.
11. Cockett A. Building Resilience to Occupational Stressors amongst Alberta
Health Services Emergency Medical Responders. Disaster and Emergency
Management, Royal Roads University; 2015.
12. Sabo B. Reflecting on the Concept of Compassion Fatigue. The Online
Journal of Issues in Nursing. 2011; 16(1).
13. Hoge CC, CA., Messer S, McGurk D, Cotting D, Koffman R. Combat
Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care.
New England Journal of Medicine. 2004(351):13-22.
14. Alkema K, Linton JM, Davis R. A study of the relationship
between self-care, compassion satisfaction, compassion fatigue, and
burnout
among hospice professionals. Journal of Social Work in End-of-Life and
Palliative Care. 2008(4):101-119.
15. Kelly L, Runge J, Spencer C. Predictors of compassion fatigue
and compassion satisfaction in acute care nurses. Journal of Nursing
Scholarship. 2015(47):522-528.
16. Potter P, Deshields TL, Divanbeigi J, Olsen S. Compassion fatigue and
burnout: prevalence among oncology nurses. Clinical Journal of Oncology
81
Nursing. 2010(14):E56-62.
17. Yoder E. Compassion fatigue in nurses. Applied Nursing Research.
2010(23):191-197.
82
1.8 Tables and Figures
1.8.1 Table 1: Mean scores (SD) by demographic variables.
ProQOL V mean (SD) MBI mean (SD)
IES-R
mean
(SD)
Co
mp
assi
on
Sati
sfac
tio
n
Bu
rno
ut
Seco
nd
ary
Trau
mat
ic
Stre
ss
Emo
tio
nal
Exh
aust
ion
De
pe
rso
na
lizat
ion
Pe
rso
nal
Acc
om
plis
h
me
nt
Sco
re
Overall
30.36
(7.19)
30.18
(6.63)
24.63
(7.32)
21.31
(11.69)
24.43
(11.0)
30.5
(7.39)
30.47
(23.17)
Age
<40
29.82
(6.56)
29.96
(6.52)
24.47
(7.4)
21.06
(11.73)
25.11
(10.21)
30.15
(6.91)
29.2
(22.81)
>40
31.79
(8.69)
30.74
(7.05)
25.05
(7.28) 22 (11.85)
22.52
(13.07)
31.47
(8.7)
33.89
(24.42)
Sex
M
30.28
(7.57)
29.48
(7.53)
21.66
(6.47)
20.61
(12.44)
24.11
(11.32)
30.5
(7.47)
25.6
(24.31)
F
30.44
(6.91)
30.91
(5.54)
27.79
(6.91) 22 (11.01)
24.75
(10.8)
30.5
(7.4)
35.54
(21.2)
Yrs. of
Service
<10
30.71
(7.62)
29.23
(7.07)
25.59
(7.83)
20.54
(12.07)
24.22
(9.96)
30.11
(7.45)
30.78
(23.13)
>10 30 (6.83)
31.13
(6.11)
23.68
(6.75)
22.11
(11.38)
24.66
(12.15)
30.91
(7.42)
30.12
(23.57)
Professio
nal
Designati
on
EMT
31.63
(4.56)
28.28
(5.96)
23
(5.92)
17.33
(7.28)
23.5
(9.76)
31.06
(6.2)
30.67
(22.99)
Param
edic
29.88
(7.96)
30.86
(6.78)
25.22
(7.73)
22.63
(12.6)
24.74
(11.45)
30.31
(7.8)
30.4
(23.45)
83
1.8.2 Figure 1: Overall results for ProQOL, MBI, and IES-R
1.8.3 Table 2: Prevalence of Compassion Fatigue, Burnout, and PTSD
Compassion
Fatigue
Burnout PTSD
CS BO STS EE DP PA IES-R >33
% positive 11.8% 4.4% 1.5% 30.6% 83.3% 69.4% 42.9%
1/3 present 16.2% 100%
2/3 present 1.5% 38.9%
3/3 present 0% 27.8%
84
1.8.4 Figure 2: Prevalence of Compassion Fatigue, Burnout, and PTSD
85
1.8.5 Table 3: Self-report percentages by demographic variables.
Compassion Fatigue-
Self Report Burnout-Self Report PTSD-Self Report
YES NO
SOMETI
MES YES NO
SOMETIM
ES YES NO
SOMETI
MES
Overall 57.5% 13.7% 28.80% 47.9% 20.5% 31.50% 20.50% 49.3% 30.10%
Age
<40 54% 13% 32% 45.3% 22.6% 32.10% 13.20% 54.7% 32.10%
>40 65% 15% 20% 55% 15% 30% 40% 35% 25%
Sex
M 89% 21.6% 16.20% 45.9% 24.3% 29.70% 21.60% 59.5% 18.90%
F 52.8% 5.60% 41.70% 50% 16.7% 33.30% 19.40% 38.9% 41.70%
Yrs of
Service
<10
51.4% 18.9% 29.7% 43.3% 27% 29.7% 16.2% 48.6% 35.1%
>10 63.9% 8.3% 27.8% 52.8% 13.9% 33.3% 25.7% 51.4% 25.7%
Professio
nal
Designati
on
EMT 36.8% 21.1% 42.10% 31.6% 26.3% 42.10% 15.80% 47.4% 36.80%
Param
edic 64.8% 11.1% 24.10% 53.7% 18.5% 27.80% 22.20% 50% 27.80%
86
1.8.6 Table 4: Mean scores and SD by self-report answers.
Scores (mean/SD)
Tool Self-Report
Compassion
Satisfaction Burnout
Secondary
Traumatic Stress
ProQOL (CF)
Yes 28 (7.0) 33.3 (5.1) 26.5 (7.1)
No 35.5 (7.9) 20.8 (4.2) 16.1 (4.2)
Sometimes 32.5 (5.0) 29 (5.0) 25.4 (5.6)
Self-Report
Emotional
Exhaustion Depersonalization
Personal
Accomplishment
MBI (Burnout)
Yes 29.8 (8.9) 31.3 (9.1) 27.8 (6.9)
No 10 (7.7) 15.7 (7.7) 37.1 (6.4)
Sometimes 15.5 (5.9) 19.5 (8.2) 30.3 (5.4)
Self-Report Total score
IES-R (PTSD)
Yes 49.8 (26.5)
No 17.6 (17.33)
Sometimes 36.6 (14.57)
87
Chapter 5: Review of Research and Future Opportunities
1.1 Purpose of Research and Original Contribution
This thesis sought to explore and to describe the current state of workplace
psychological distress in Emergency Medical Services, as well as to make
preliminary suggestions for remediating the issue. The identification of, and
response to, practitioner distress is an emerging concern in EMS organizations,
and while the issue has been examined extensively in other health and public
safety fields (e.g. nursing and law enforcement) gaps remain in the research for
EMS. So far, organizations have focused mainly on the identification and
exploration of post-traumatic stress disorder (PTSD), an issue often associated
with professions that provide first response (e.g. police, fire, military), where staff
members have an increased likelihood of experiencing trauma. This study aimed
to provide a broader detailed description of psychological distress and its impact on
EMS practitioners. First the issue of compassion fatigue was examined across
health care practitioners through a systematic review of literature. Psychological
distress was defined and conceptualized in the context of EMS work. Finally, a
survey based study of EMS staff in Calgary was completed. Overall, the results of
each portion of this thesis shows that psychological distress is present in EMS, is
having a negative impact, and is not singular in how or why it develops.
1.2 How the Research Was Conducted
The thesis was separated into three projects, as described above, in order
to ensure the description of psychological distress in EMS was detailed and
88
comprehensive, and that each piece of the overall research was robust. Initially
two research questions were posed: first, to identify the prevalence of compassion
fatigue in health care practitioners, the most commonly used measurement tools,
and the current strategies for coping and resiliency; second, to identify the
prevalence of Compassion Fatigue in EMS practitioners.
As our work developed, our objectives modified slightly. First, we conducted a
systematic review of studies that measured prevalence of compassion fatigue
across diverse disciplines of health care practitioners, using a validated instrument.
In all 40 studies were included in the review. The second research question was
expanded in scope to include exploration and measurement of burnout and PTSD,
in addition to compassion fatigue. The study was designed to measure the three
issues by analyzing scores for three instruments: the ProQOL (for compassion
fatigue) the Maslach Burnout Inventory (MBI, for burnout) and the Impact of Event
Scale-Revised (IES-R, for PTSD). As well, it compared the scores with the
prevalence of the issues as measured by self-report. Because of this increase in
scope, a concept paper that described the three issues and discussed the
contributing stressors in the EMS context was drafted. This paper also served to
make suggestions regarding a broad response to the concerns.
1.3 What the Research Showed
Overall, the results of this research showed that EMS practitioners are
experiencing psychological distress as compassion fatigue, burnout and PTSD.
The systematic review revealed that compassion fatigue is not unique to EMS, as
89
compassion fatigue has been identified across diverse practitioner groups in health
care. From these studies are consistent recommendations that further research
needs to be done investigating root causes, and that education and support
programs would be of benefit. The other portions of the thesis began to respond to
those recommendations.
According to the survey study, the most prevalent issue in EMS is burnout, a
cumulative stress that results from operational and structural stressors, particularly
the domain of depersonalization which causes practitioners to develop negative,
callous attitudes about their patients and coworkers. That burnout exists in a high
stress job such as EMS is not surprising, however the reason for the high burnout
values reported in the depersonalization domain was not clear and would benefit
from further investigation. Nearly half of participants screened positive for PTSD,
but only 20% of all participants self-reported as experiencing PTSD. An analysis of
the scores against the self-report answers showed that a number of respondents
who answered that they ‘sometimes’ felt they identified with PTSD did in fact
screen positive. As well, some of those who answered ‘yes’ to the self-report
question screened negative. This incongruence suggests that practitioners may
have a difficult time identifying PTSD in themselves, alternatively they may not feel
comfortable reporting it. Compassion fatigue, which is a cumulative stress, was
not significant from the survey scores, however nearly 60% of participants self-
reported experiencing it. Additionally, though the scores did not meet our criteria
for compassion fatigue (high range score for the negative domains burnout and
secondary traumatic stress, with low range for the positive domain of compassion
90
satisfaction), they were considerably higher in the negative domains and lower in
the positive domain than the scores analyzed in the systematic review. In general,
paramedics reported psychological distress more often than EMTs, suggesting that
practitioners with a more advanced scope of practice, who are often deferred to for
treatment decisions may be at higher risk. Men reported more compassion fatigue
and significantly less PTSD than women, which may be a result of working in a
culture that seems to value stereotypically male traits like strength and stoicism.
An unspoken social expectation not to reveal one’s feelings could cause men to
under-report or not identify issues that may make them seem weak, yet be
comfortable with admitting an issue with a softer emotion such as compassion.
As outlined in the concept paper, the reasons for the development of
distress are varied, and the way practitioners subjectively experience their job must
be considered when identifying workplace stressors. Recognizing the specific
stressors is crucial because such recognition provides a way of targeting education
for students and better preparing them for the operational reality of EMS work.
However, it is not enough simply to identify the stressors because people are
impacted by them differently and to varying degrees; students need practical skills
for coping with whatever triggers stress for them. It is also important to define the
specific issues that fall under the broad concept of distress, and understand the
ways in which these issues overlap and where they divide. In the case of the three
issues investigated in this research, burnout is a domain of compassion fatigue as
well as its own distinct issue identified in three other domains (emotional
exhaustion, depersonalization, and personal accomplishment.) The development
91
of burnout creates a vulnerability that allows compassion fatigue also to develop.
An inclusive and effective response to psychological distress must include building
resilience through education prior to practice, and maintaining a supportive work
environment once practitioners are in the field.
1.4 Future Opportunities
Occupational stress and its impact on mental health in EMS had already
been identified as a major concern, so defining and quantifying the distress
remains important if an effective response is to be developed.
Next steps should begin with further investigation into the high prevalence of
measured burnout, in particular the domain of depersonalization, in order to
understand what factors (both personal and operational) impact the development
of this attitude, and to confirm that it is in fact common to the vast majority of
practitioners. Second, considerable focus has been directed towards PTSD.
However, PTSD is a specific psychological-psychiatric diagnosis which requires
expert evaluation. The reported number of practitioners who self-reported concerns
about PTSD, and the number that screened positive is worrisome. Consideration
should be given to a process of enhanced screening, and evaluation of those who
screen positive, to ensure that patient care is not compromised by practitioners
who are distressed and suffering, as well as to protect practitioner well-being.
Education and support programs would likely be of benefit for those individuals
who do not screen positive, but clearly are reporting distress.
92
There is an opportunity to build on work being undertaken in other provinces
and countries, as well as support resources currently available in Alberta. A
comprehensive educational program for resilience building that starts with in EMS
student skill training, and is maintained in the EMS organization through policy and
culture would be meaningful. Such a program should include learning about the
stressors expected in practice, the operational realities of the work, and practical
skills for coping. Once employed in the field, practitioners should have access to a
supportive work environment where the organization understands and prioritizes
mental wellness by eliminating stigma, providing widely accessible resources, and
where possible, reviewing operational policies and demands that can be seen as
contributing to burnout. Further research should begin with a review of resilience
education and programs that could be adapted for implementation in an Alberta
EMS context, as well as an environmental scan of the effectiveness of resources
already in place.
1.5 Limitations
There were some limitations in the research. First, there are several EMS
training programs that practitioners could have been graduates of, and while the
curriculum of these programs is mostly standardized, there are some variances in
teaching and content. The survey study sample, and the stories of firsthand
experience, was limited in size and a cross section of practitioners in one
geographic area (Calgary), so it is unclear how much can be generalized. As well,
there is a heightened awareness of PTSD within EMS, which could potentially
93
impact the self-reporting. Another consideration is that EMS in Calgary was
transferred to Alberta Health Services several years ago, after having been
managed and funded by the City of Calgary. With this transfer came a number of
changes to the work environment and practice (e.g. fewer resources and
equipment, revised protocols, expanded scope and responsibility, some centralized
deployment rather than “home base” halls.) These kinds of changes may be
contributing stressors, and the responses and solutions are not clear.
1.6 Conclusion
The research in this thesis helps to fill a gap in knowledge about the current
state of, and factors influencing, psychological distress in Emergency Medical
Services. The literature presented in this work shows that psychological distress
may results in negative outcomes: decreased staff morale and increased attrition
resulting in a knowledge drain and increased staffing costs, errors in patient
treatment and concerns about patient safety, and decreased quality of life for the
practitioner. In order to mitigate these risks, the issues identified, described and
measured here should be studied further and integrated into a comprehensive
resilience program that starts with students and is maintained throughout a
practitioner’s career. To care for patients we have to care for providers. Ultimately,
failing to address these issues will only allow them to continue to develop, to the
detriment of practitioners, the organization, and the people whom they serve.
94
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